Every finding on record at Littleton Care and Rehabilitation Center

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of diseases and infection for one of two units reviewed. Specifically, the facility failed to:-Ensure staff wore the appropriate personal protective equipment (PPE) for Resident #11, who was on enhanced barrier precautions (EBP);-Ensure proper infection control practices were followed during wound care;-Ensure hand hygiene was appropriately performed during wound care; and,-Ensure hand hygiene was appropriately performed during medication administration. Findings include:I. EBP failuresA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Home to Prevent Spread of Multidrug-resistant Organisms (MDROs), updated 4/2/24, retrieved on 2/23/26 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html: Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities. Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when Contact Precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (ex. central line, urinary catheter, feeding tube, tracheostomy/ventilator), or wound care (any skin opening requiring a dressing). In general, gown and gloves would not be required for resident care activities other than those listed above, unless otherwise necessary for adherence to standard precautions. Residents are not restricted to their rooms or limited from participation in group activities. Because enhanced barrier precautions do not impose the same activity and room placement restrictions as contact precautions, they are intended to be in place for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk.B. ObservationsOn 2/17/26 at 11:16 a.m., a sign on the back of Resident #11's room door indicated the resident was on EBP. The sign indicated a gown and gloves must be worn for high-contact resident care activities, including: dressing, bathing/showering, transferring, changing linens, changing briefs or assisting with toileting, and device care or use, such as central lines, urinary catheters, feeding tubes, tracheostomies, and wound care. Resident #11 had open wounds to his left buttocks and left heel.On 2/18/26 at 3:07 p.m., registered nurse (RN) #3 was observed performing wound care on Resident #11. The following observations were made:At approximately 3:10 p.m. RN #3 entered Resident #11's room. Upon entering the room, RN #3 donned (put on) on a pair of gloves, and began performing wound care on Resident #11's left buttocks wound. -RN #3 failed to don a gown after entering Resident #11's room and before beginning the resident's wound care. II. Wound care failuresA. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 2/23/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html: Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal.Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings, always clean your hands after removing gloves, remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil your hands.B. Facility policy and procedureThe Clean Dressing change policy and procedure, revised April 2025, was provided by the nursing home administrator (NHA) on 2/19/26 at 10:00 a.m. It read in pertinent part, Policy: It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. Physician's orders will specify type of dressing and frequency of changes. Compliance Guidelines: Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application:-If the table is soiled, wipe clean.-Place a disposable cloth or linen saver on the overbed table.-Place only the supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape).-If performing photo documentation, label measuring guide with patient identifier and date.-Use no-touch techniques to remove ointments and creams from their containers (use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. Establish area for soiled products to be placed (Chux or plastic bag). Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. Loosen the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. Wash hands and put on clean gloves. Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (clean outward from the center of the wound). Pat dry with gauze. Measure wound using disposable measuring guide. This is done weekly with wound rounds. Wash hands and put on clean gloves. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. Secure dressing. [NAME] with initials and date. (Add time if dressing is more than once daily.) Discard disposable items and gloves into appropriate trash receptacle and wash hands.B. ObservationsOn 2/18/26 at 3:07 p.m. RN #3 was performing wound care on Resident #11's left buttocks wound. The following observations were made:RN #3 walked to the wound cart, and retrieved one normal saline bullet (single-use vials used in wound care), one calcium alginate dressing, and one bordered gauze dressing. RN #3 placed supplies on top of the wound cart. RN #3 said she needed to verify Resident #11's wound care orders. RN #3 picked up the supplies and placed them on top of her medication car. After verifying Resident #11's wound care orders, RN #3 went into the medication storage room, grabbed two packages of two inch by two inch gauze, exited the storage room, picked up Resident #11's wound supplies on top of her medication cart, and walked to Resident #11's room.RN #3 entered Resident #11's room, performed hand hygiene upon entering the room, and grabbed a pair of gloves. Resident #11 was sitting in his wheelchair with his back to RN #3. RN #3 placed wound care supplies on the edge of Resident #11's dresser then donned her gloves. Resident #11 stood up and pulled down his shorts and underwear to expose a previous dressing.-RN #3 failed to establish a clean wound care field for wound supplies on top of Resident #11's dresser. RN #3 removed the dressing from Resident #11's left buttocks wound, walked into the resident's bathroom, and discarded the dressing. RN #3 opened both two by two gauze packages and the normal saline bullet, and squirted the normal saline onto the gauze. RN #3 wiped the surface and perimeter of the wound approximately 11 times, using the same side of the gauze each time. RN #3 walked to Resident #11's bathroom and discarded the gauze and her gloves in the trash can. -RN #3 failed to discard and replace her gloves, or perform hand hygiene, after removing Resident #11's old dressing and before cleansing the resident's left buttocks wound. RN #3 retrieved and donned a new pair of gloves, reached into her left scrub pants pocket with her left hand, and removed a Sharpie from her pocket. RN #3 opened the bordered gauze dressing and dated and initialed it with the Sharpie. RN #3 opened the calcium alginate dressing. Using her left hand, RN #3 placed the calcium alginate dressing on top of Resident #11's wound and held it in place. Using her right hand, RN #3 placed the bordered gauze over the calcium alginate dressing and adhered it to Resident #11. RN #3 gathered the wound care supply trash and discarded it into Resident #11's bathroom trash can. RN #3 removed the trash bag and placed a new bag in Resident #11's trash can. RN #3 removed the glove from her right hand, discarded it into the trash bag, and tied the bag closed. RN #3 exited Resident #11's room carrying the trash bag with gloved left hand, and disposed of the bag in the dirty utility room. -RN #3 failed to perform hand hygiene before donning a new pair of gloves and continuing Resident #11's wound care. RN #3 failed to maintain a clean field by reaching into her scrub pants pocket and retrieving a marker to sign and date Resident #11's bordered gauze dressing. RN #3 failed to discard her gloves, perform hand hygiene, and don a new pair after dating the dressing and before continuing wound care on Resident #11. II. Medication administration failuresA. Facility policy and procedureThe Medication Administration policy and procedure, dated May 2016, was provided by the NHA on 2/19/26 at 10:00 a.m. It read in pertinent part, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.The Hand Hygiene policy and procedure, revised April 2025, was provided by the NHA on 2/19/26 at 10:00 a.m. It read in pertinent part, It is the policy of this facility to provide the necessary supplies, education, and oversight to ensure healthcare workers perform hand hygiene, which is one of the most effective measures to prevent the spread of infection, based on accepted standards. Residents, family, and visitors will be encouraged to practice hand hygiene. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations:-Before and after coming on duty;-Before and after direct contact with residents; -Before preparing or handling medications;-Before performing any non-surgical invasive procedures;-Before and after handling an invasive device (e.g., urinary catheters, IV access sites);-Before donning sterile gloves;-Before handling clean or soiled dressings, gauze pads, etc.;-Before moving from a contaminated body site to a clean body site during resident care;-After contact with a resident's intact skin;-After contact with blood or bodily fluids;-After handling used dressings, contaminated equipment, etc.;-After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident;-After removing gloves;-Before and after entering isolation precaution settings;-Before and after eating or handling food;-Before and after assisting a resident with meals; and-After personal use of the toilet or conducting your personal hygiene.-After removing and disposing of personal protective equipment.B. ObservationsDuring a continuous observation, on 2/19/26, from 7:22 a.m. to 7:57 a.m., licensed practical nurse (LPN) #1 was observed administering medications to residents on the south hallway. The following observations were made: At 7:22 a.m. LPN #1 was at Resident #7's bedside administering her oral medications. Resident #7's tube feeding was running, via pump, per order and connected to her PEG tube. LPN #1 said it was time to disconnect Resident #7's tube feeding. LPN #1 donned a pair of gloves and raised Resident #7's shirt, exposing the PEG tube connection site. LPN #1 disconnected the tube feeding from Resident #7's PEG tube, secured the PEG tube cap in place, lowered Resident #7's shirt, and hung the tube feeding cord on the medication pole in the resident's room. -LPN #1 failed to perform hand hygiene after administering Resident #7's medications and before donning gloves. LPN #1 lowered Resident #7's shirt a second time, repositioned the resident's bedside table closer to her, grabbed the plastic box of glucometer supplies, exited Resident #7's room, unlocked and stored the plastic box in the bottom drawer of the medication cart, discarded his gloves, then walked into room [ROOM NUMBER].-LPN #1 failed to perform hand hygiene after exiting Resident #7's room, storing her glucometer and supplies, and before entering room [ROOM NUMBER]. At 7:27 a.m. LPN #1 exited room [ROOM NUMBER], returned to his medication cart, and began preparing medications for Resident #18. LPN #1 donned a pair of gloves, retrieved a medication cup from the medication cart, and dispensed medications from blister pill packets into the cup. LPN #1 removed a plastic box from the bottom of the medication cart, individualized with the resident's name and room number, and placed it on top of the medication cart. LPN #1 opened the box, grabbed the glucometer, opened an alcohol pad, and wiped all sides of the glucometer with the alcohol pad. LPN #1 poured a cup of water, picked up the plastic box and medication cup, and walked into Resident #18's room. -LPN #1 failed to perform hand hygiene after exiting room [ROOM NUMBER] and before donning gloves and preparing Resident #18's medications.At 7:33 a.m. LPN #1 entered Resident #18's room, wearing the same gloves he donned before preparing her medications. LPN #1 repositioned Resident #18's bedside table so he was able to stand right next to the resident's bed. LPN #1 checked Resident #18's glucose using a disposable lancet. LPN #1 obtained an alcohol pad, wiped all surfaces of the glucometer, and placed it in the plastic box. LPN #1 removed gloves and handed Resident #18 her oral medications. After verifying Resident #18 took her medications, LPN #1 repositioned Resident #18's bedside table closer to her and exited the resident's room. LPN #1 performed hand hygiene upon return to his medication cart.-LPN #1 failed to change gloves and perform hand hygiene before checking Resident #18's blood sugar and administering the resident her medications.At 7:40 a.m. LPN #1 opened a cart drawer, retrieved a plastic box labeled with Resident #32's name and room number, and placed it on top of the cart. LPN #1 donned a pair of gloves, opened the box, opened an alcohol pad, and wiped all sides of the glucometer. LPN #1 retrieved a bottle of liquid protein from a drawer in the cart and poured Resident #32's prescribed amount into a separate medication cup. LPN #1 placed the liquid protein back in the cart drawer, poured a cup of water, picked up the two medication cups, the water, and the glucometer kit, and entered Resident #32's room. At 7:44 a.m. LPN #1 entered Resident #32's room wearing the same gloves he used to prepare the resident's medications. LPN #1 placed the water, medications, and glucometer on Resident #32's bedside table. After obtaining and wiping one of Resident #32's fingers with an alcohol pad, LPN #1 used a disposable lancet to check Resident #32's blood glucose level. LPN #1 obtained an alcohol pad and wiped all sides of the glucometer before placing it back in the resident's glucometer box. LPN #1 removed and discarded his gloves, and handed Resident #32 her oral medications. After verifying Resident #32 took her medication, LPN #1 picked up the resident's glucometer, exited Resident #32's room, returned to the medication cart, and placed the glucometer back inside. -LPN #1 failed to change his gloves and perform hand hygiene after preparing Resident #32's medications, after he entered the resident's room, and before he checked Resident #32's blood sugar. Additionally, LPN #1 failed to perform hand hygiene upon returning to the medication cart after exiting Resident #32's room. At 7:48 a.m. LPN #1 began preparing medications for Resident #11. LPN #1 retrieved a medication cup from the cart and retrieved and dispensed 11 medications into the medication cup, opening and closing multiple drawers in the cart to obtain the medications. Resident #11 self-propelled himself to the side of the medication cart while LPN #1 prepared his medications. LPN #1 poured a cup of water and placed it on top of the medication cart. LPN #1 opened a cart drawer, opened and measured out the prescribed amount of a dissolvable medication, and poured the medication into the cup of water. LPN #1 obtained a plastic spoon from the medication cart and mixed the dissolvable medication into the cup of water, then discarded the spoon. LPN #1 handed the medication cup and the cup of water to Resident #11, and verified Resident #11 took his medications. LPN #1 asked to check a patch, located on Resident #11's right chest, and pulled Resident #11's shirt to the side to visualize the patch after approval was given. LPN #1 turned back to the medication cart and began documenting medication administration. -LPN #1 failed to perform hand hygiene before he began preparing Resident #11's medications, before he gave the resident his medications, and after completing medication administration. III. Staff interviewsRN #3 was interviewed on 2/18/26 at 3:15 p.m. RN #3 confirmed Resident #11's left buttock wound was open. RN #3 said EBP should be worn when treating open wounds. RN #3 said there was a recent facility in-service,, which discussed when EBP should be used. RN #3 said she did not think to wear a gown while performing Resident #11's wound care due to the small size of the wound. RN #3 said wearing EBP during resident care was important to help prevent cross-contamination and potential splashback of bodily fluids. RN #3 said hand hygiene should be performed when entering or exiting a resident's room, or when hands were visibly soiled. RN #3 said she should have performed hand hygiene when discarding her old gloves and before applying new ones. RN #3 said appropriate hand hygiene was important to help decrease the spread of infection. LPN #1 was interviewed on 2/19/26 at 7:57 a.m. LPN #1 said hand hygiene should be performed before and after every medication administration. LPN #1 said proper hand hygiene was important to help protect residents from exposure to pathogens. LPN #1 was interviewed a second time on 2/19/26 at 10:40 a.m. LPN #1 said EBP should be utilized during resident care and medication administration. LPN #1 said using appropriate PPE was important to help prevent introducing pathogens to residents. LPN #1 was unable to state why he failed to perform proper hand hygiene during medication administration. The assistant director of nursing (ADON) and director of nursing (DON) were interviewed together on 2/19/26 at 11:05 a.m. The ADON said hand hygiene should be performed before/after administering medications, before/during/after resident treatments, and upon exiting a resident's room. The ADON said it was important for infection control and preventing the spread of organisms. The ADON said EBP signs were placed on the back of resident doors throughout the facility due to facility residents requesting discretion. The DON said facility staff were given routine training on EBP use and appropriate hand hygiene during annual skills fairs and monthly staff meetings. The ADON said facility staff should wear a gown when performing wound care on any sized wounds that were open and producing discharge. The ADON said staff should change gloves and perform hand hygiene after removing the old dressing, before completing the remainder of wound care, and after wound care was completed.The ADON said facility staff should establish a clean wound care field by placing a Chux pad on top of a surface before wound care supplies. The DON said if a Chux pad was not used, she expected facility staff to cleanse the surface using an antimicrobial wipe to establish a clean field. The DON said performing appropriate hand hygiene, glove changes, and establishing a clean field were important to decrease potential infection risk and the transmission of germs to residents.

Based on record review and interviews, the facility failed to ensure two (#1 and #5) 11 residents out of 12 sample residents were kept free from abuse. Resident #1, who had limited mobility and required staff assistance with bed mobility and transfers due to a recent hip surgery, was admitted to the facility on [DATE]. On the night of 7/21/24, Resident #1 used her call light to request staff assistance with being repositioned in bed. The resident later used her call light to request staff assistance with going to the bathroom. Both times, when staff had not responded to the resident's call light in over one hour, the resident called her legal representative. Both times, the resident's representative called the facility and staff eventually answered Resident #1's call light. Early in the morning on 7/22/24, Resident #1 again called her representative. The resident was crying and scared and wanted to leave the facility. Resident #1 reported that registered nurse (RN) #1 had come into her room, got close to her face and yelled at her to stop using her call light. According to Resident #1, RN #1 told her if she did not stop using her call light, staff would not come to assist her. Resident #1's representative arrived at the facility after receiving the phone call and removed Resident #1 from the facility due to the resident crying hysterically, being scared and not wanting to remain in the facility. The resident's representative reported the incident to the local police department on 7/22/24. Certified nurse aide (CNA) #1, who witnessed the incident between RN #1 and Resident #1, wrote a statement on 7/22/24 which documented RN #1 had spoken sternly to the resident and told her to stop using her call light and nobody was going to answer the call light. The facility completed a grievance related to the allegation but failed to investigate the incident until 9/12/24, over one month later, when the facility was alerted by the state board of nursing that RN #1's nursing license was being investigated for an allegation of abuse. The facility failed to conduct a complete investigation of the incident or report the allegation to the State Agency on 9/12/24 and RN #1 continued to work at the facility. Additionally, on 10/3/24, during a group interview during the survey, Resident #5, who also required staff assistance, reported he waited for 45 minutes to answer his call light. When nobody came, Resident #5 began yelling for help. He said RN #1 came to the doorway of his room and yelled at him to shut up and quit using his call light. Resident #5 said he was angry at being treated that way by RN #1. Due to the facility's failures to ensure residents were kept free from abuse, Resident #1 and Resident #5 experienced psychosocial harm when RN #1 yelled at the residents for using their call lights and threatened that staff would not answer their call lights if they continued to use them. Findings include: I. Facility policy and procedure The Abuse Investigation and Reporting policy, revised August 2024, was provided by the nursing home administrator (NHA) on 10/3/24 at 8:39 a.m. It read in pertinent part, It is the policy of this facility that reports of abuse, neglect, misappropriation of property and exploitation are promptly and thoroughly investigated. The investigation process will consist of at least the following: -A review of the completed complainant report; -An interview with the person(s) reporting the incident; -Interviews with any witnesses to the incident; -An interview with the resident, if possible; -A review of the resident's medical record; -An interview with staff members having contact with the resident during the period/shift of the alleged incident, if applicable; -Interviews with resident's roommate, family members, and visitors, if applicable; and, -A review of all circumstances surrounding the incident. Employees of this facility accused of resident abuse shall immediately be barred from any further contact with the residents of the facility, pending the outcome of further investigation, prosecution or disciplinary action against the employee. The summary of the investigation will be recorded and attached to the report. Should the investigation reveal that the abuse occurred, the administrator would report such findings to the State Licensing Agency, as necessary, health department within (24 hours) and police department within two (2) hours as necessary with the results of the completion of the investigation. The administrator or designee will complete a copy of the Resident Abuse Investigation Report Form within five (5) working days of the reported incident. II. Incident of verbal abuse on 7/22/24 between Resident #1 and RN #1 A. Facility investigation The facility's investigation of the incident was provided by the NHA on 10/2/24 at approximately 2:00 p.m. A statement written by CNA #1 on 7/22/24 revealed resident #1 was admitted to the facility on the afternoon of 7/21/24. CNA #1 said the resident was using her call light throughout the day and night (on 7/21/24 into 7/22/24). CNA #1 said resident #1 requested assistance with the television, toileting assistance, retrieving food and repositioning in bed. CNA #1 reported RN #1 went into Resident #1's room and sternly told her she needed to stop taking advantage of her call light because the staff had had other residents to attend to. CNA #1's written statement further documented the resident's daughter arrived and removed Resident #1 from the facility. -Despite CNA #1's written statement of the incident, the facility completed a grievance for Resident #1's call light not being answered timely but failed to initiate an investigation for potential verbal abuse until 9/12/24 (see below). On 9/12/24, the facility was notified by the state board of nursing that RN #1 was being investigated for potential abuse. Upon receiving the notification from the state board of nursing, the facility spoke to CNA #1 and reviewed a written statement from RN #1 to the state board of nursing. A statement written by the NHA on 9/12/24 dated 9/12/24 documented his conversation via phone with Resident #1. The statement documented Resident #1 was asked if she recalled an incident with RN #1. The resident responded RN #1 had asked her to stop ringing the call light so frequently and had leaned over the bed and spoken loudly to her. Resident #1 reported she did not remember where or why she was at the facility because she had been on strong antibiotics and was having hip issues. Resident #1 said that she currently lived with her representative and had memory issues. According to the written statement, the NHA asked Resident #1 if she had planned to report RN#1 to the state or get her in trouble. Resident #1 indicated that was not her intention and she just wanted to get out of the facility. -The facility's investigation of the incident failed to include additional interviews with other staff members or residents and the incident was not reported to the State Agency (see interviews below). B. Resident #1 1. Resident status Resident #1, age greater than 65, was admitted on [DATE] and discharged home with her representative on 7/22/24. According to the July 2024 computerized physician's orders (CPO), diagnoses included unilateral primary osteoarthritis, right total hip arthroplasty (hip replacement surgery), depression, unspecified and anxiety disorder. The 7/21/24 nursing admission assessment and functional performance assessment documented the resident was alert and oriented to person, place and time. The resident had limited range of motion of leg including hip and knee, used a walker for mobility and was unable to be evaluated for transfers due to a medical condition or safety concerns. She required substantial to maximum assistance for all other activities of daily living (ADL). The assessment indicated the resident did not have any behavior issues. C. Resident representative interview The resident's representative was interviewed on 10/2/24 at 4:27 p.m. The representative said Resident #1 was admitted to the facility for rehabilitation after a hip surgery. She said the resident arrived at the facility on the afternoon of 7/21/24. She said Resident #1 called her in a panic around 6:00 p.m. (on 7/21/24), because she needed to be repositioned in bed and staff was not answering her call light. The representative said Resident #1 called her again an hour later, still needing assistance.The representative said she called the facility to request assistance for Resident #1. The resident's representative said Resident #1 called her again at approximately 9:00 p.m. (on 7/21/24), when her call light was again not answered for over an hour and she needed to use the bathroom. The representative said she called the facility a second time to request help for Resident #1. The representative said, at 1:21 a.m. on 7/22/24, she received a hysterical phone call from Resident #1. She said the resident was crying and was scared and terrified. She said the resident wanted to call the police. She said Resident #1 told her that RN #1 got into her face, within two inches, and yelled at her to stop using the call light and that she was not allowed to use the call light. The representative said the resident reported RN #1 told her if she continued to use her call light, nobody was going to answer it. The resident's representative said she immediately went to the facility and found Resident #1 scared and terrified and she did not want to stay in the facility. She said because Resident #1 was scared and hysterically crying, she could not leave her at the facility and she took her out of the facility. She said a CNA helped carry the resident's belongings out of the facility and she told the CNA the reason she was taking Resident #1 out of the facility. The representative said the facility wanted her to sign an Against Medical Advice form (AMA), but she refused. The resident's representative said she did not receive any phone calls from the facility after the incident. She said she called the police on 7/22/24 to report the abuse. The representative said the police substantiated the allegation as abuse. D. Police interview The police officer who investigated the incident on 7/22/24 was interviewed on 10/3/24 at 9:56 a.m. The police officer said he was the investigator on the reported abuse of Resident #1. He said the resident had been threatened and yelled at by RN #1 to not use her call light. He said he had attempted to call RN #1 three times during his investigation of the incident and never received a call back. He said,through secondary interviews, he was able to substantiate the abuse and he reported RN #1 to the state board of nursing. E. Staff interviews The NHA and the director of nursing (DON) was interviewed on 10/2/24 at 3:32 p.m The NHA said he did not have a full investigation of abuse involving Resident #1. The DON said he recalled Resident #1 was at the facility for about eight hours and the resident's representative picked her up in the middle of the night. He said the resident's representative requested that CNA #1 help her get the resident into her car. He said while CNA #1 was helping transfer Resident #1 to the representative's car, CNA #1 requested that the representative sign a form to have the resident leave AMA but the representative refused to sign the AMA form. The DON said CNA #1 informed him the representative was not happy with RN #1 and her response to Resident #1 using her call light. The DON said a grievance was filed due to the concerns of call light response time. He said a call light tracking was completed as part of the follow-up to the grievance filed. The NHA said he was not employed at the facility in July 2024. However, he said he had received notification from the state board of nursing in regards to RN #1's involvement in an abuse allegation. The NHA said he had not conducted a complete investigation which included other residents and staff or reported the abuse allegation to the State Agency. He said because the state board of nursing letter was on state letterhead, he thought the State Agency was aware of the incident. The NHA said, after receiving the letter, he contacted Resident #1 on 9/12/24 to get information related to the incident. He said the resident said she vaguely recalled the incident. The NHA said he attempted to contact Resident #1's representative twice on 9/12/24 with no response. The corporate consultant (CC) was interviewed on 10/3/24 at 8:49 a.m. The CC said the abuse policy was reviewed with both the NHA and the DON were educated on 10/2/24 (during the survey) regarding how to timely investigate abuse allegations. 51710 III. Incident of verbal abuse between Resident #5 and RN #1 A. Resident #5 1. Resident status Resident #5, age 82, was admitted on [DATE]. According to the October 2024 CPO, diagnoses included hemiplegia (paralysis of one side of the body) and hemiparesis (one-sided muscle weakness) following unspecified cerebrovascular disease (stroke) affecting the left dominant side. The 8/28/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required up to two-person assistance with bed mobility, transfers and all ADLs. The assessment indicated the resident did not have any behaviors. B. Resident interview Resident #5 was interviewed on 10/3/24 at 9:30 a.m. Resident #5 said the other night (no date specified) he had his call light on in the evening and he waited for 45 minutes for someone to answer it. He said no one showed up or looked in the door which led to him screaming for help. He said RN #1 came to his room, stood in the doorway and started yelling at him from the door, telling him to shut up and quit calling on his call light. Resident #5 said he had not reported the incident to anyone at the facility. He said the treatment he received from RN #1 made him pissed off that he was treated in this manner. The NHA was informed of the abuse allegation on 10/3/24 at 10:20 a.m. C. Facility follow-up On 10/3/24 at 11:48 a.m., the NHA provided an update regarding Resident #5's abuse allegation. The NHA said the police were notified of the allegation, the interdisciplinary team (IDT) were conducting staff and resident interviews and RN #1 had been removed from the facility's schedule pending the facility's investigation of the allegation.

Based on observations, record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings regarding resident care and life in the facility. Findings include: I. Facility policy The Grievance Policy, dated 10/3/24, was provided by the social services consultant (SSC) on 10/3/24 at 11:47 a.m. It read in pertinent part, To address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. To make prompt efforts to resolve grievances the resident may have. The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facility. The Grievance Official or designee responds to the individual expressing the concern within three (3) working days of the initial concern to acknowledge receipt and describe steps taken toward resolution. The Grievance Official/Designee completes the Grievance Resolution Forms, takes appropriate corrective action in accordance with State law if the alleged violation of resident's right is confirmed by the facility or an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency within its area of responsibility. The Grievance Official or designee will contact all parties with the outcome. The grievance log is maintained by the Grievance Official and reviewed by the Quality Assessment & Assurance Committee and shall not become part of the medical record. Results of grievance will be maintained no less than 3 years from issuance of the grievance decision. II. Observations On 10/2/24 at 9:55 a.m. the north and south hallways were observed to be cluttered with wheelchairs, oxygen concentrators, bedside commodes, empty boxes near the storage room and medication carts with computers. The floors of the hallways and the dining room had bits of trash and food on them. III. Resident Interviews Resident #6 was interviewed on 10/2/24 at 2:38 p.m. Resident #6 said the staff took a long time to answer the call lights in the evenings and at night. Resident #4 was interviewed on 10/2/24 at 2:59 p.m. Resident #4 said there were not enough staff to take care of everyone without having to wait a long time for call lights to be answered. She said the rooms were not cleaned daily. IV. Resident group interview The resident group interview was conducted on 10/3/24 at 9:30 a.m. The group consisted of seven residents ( #5, #6, #7, #8, #9, #10 and #11) who were interviewable based on assessment and the facility. The residents all said they continued to have concerns with the facility's follow-up on grievances. The concerns were as follows: -The facility failed to act upon grievances; -The facility had a lot of turnover and therefore the grievances were not acted upon; -The facility did not listen to the resident council group in order to help resolve issues; -The residents did not hear back from staff in regards to any grievances filed; and, -The facility continued to have complaints regarding staffing issues, call lights not being answered, clutter in the hallways and cleanliness of the building. V. Resident council meeting minutes The resident council meeting minutes for July 2024, August 2024 and September 2024 were provided by the director of nursing (DON) on 10/2/24 at 10:37 a.m. The 7/22/24 resident council meeting minutes documented the following resident concerns: The old business section (from June 2024) documented resident concerns of trash not being emptied, the utilization of agency staff during night of care (NOC) and not enough towels or washcloths for residents. The status update documented by the interdisciplinary team (IDT) said they were trying to minimize using agency staff. Resident concerns for the month of July 2024 included call light times were too long at night, there were too many wheelchairs and equipment in the hallways, and staff left wet towels in resident rooms and were not cleaning the toilet stools after use. -There was no documentation in the minutes which indicated how the facility planned to follow up on the resident concerns. The 8/19/24 resident council meeting minutes documented the following resident concerns: Hallways were cluttered with wheelchairs, commodes and supplies when the delivery trucks came and the residents did not have enough towels or wash cloths. -There was no documentation in the minutes which indicated how the facility planned to follow up on the resident concerns. The 9/23/24 resident council meeting minutes documented the following resident concerns: The old business section (from August 2024) documented resident concerns that hallways and shower rooms were cluttered, that all wheelchairs and bedside commodes be moved and that call lights were not being answered on time. -There was no documentation in the minutes which indicated how the facility had followed up on the resident concerns. VI. Staff interviews The activity director (AD) was interviewed on 10/3/24 at 10:37 a.m. The AD said resident council meetings were held once a month. She said all administrative team members were present and the residents and staff discussed resident concerns during the meetings. She said she was responsible for writing down meeting minutes. She said she provided the meeting minutes to the social services director (SSD), who was also the facility's grievance official. The AD said the SSD was responsible for filling out grievance forms based on the grievances voiced in the resident council meetings. The SSD was interviewed on 10/3/24 at 11:00 a.m. The SSD said she was the grievance official for the facility. She said she received the resident council meeting minutes from the AD. She said she filled out grievance forms based on the resident concerns brought up in the meetings. She said she would give the grievance forms to the appropriate department head to resolve the issue. The SSD said grievances were to be resolved within 48 hours of receiving the grievance form. She said she was supposed to follow up on grievances if the form was signed as resolved and a resolution was not actually obtained. After reviewing her grievance log, the SSD said she had two grievances filed from July 2024, however, she said they were not followed up on appropriately to ensure an actual resolution was obtained. She said she had no grievance forms filled out for the resident concerns brought up in the August 2024 and September 2024 resident council meetings.

Based on observations, record reviews, and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to: -Ensure nurse staffing data was posted on a consistent daily basis; -Ensure when nurse staffing data was posted, that it was posted in a prominent location, readily accessible to residents and visitors; and, -Ensure records of nurse staffing data were retained for 18 months. Findings include: I. Observations Observations in the facility on 10/2/24 at 9:55 a.m. revealed that the nurse staffing hours were not posted for the day. Observations in the facility on 10/3/24 at 10:03 a.m. revealed the nurse staffing hours were posted for 10/3/24, however, they were posted behind the main nurse's station and were not easily accessible to residents and visitors. II. Staff interviews The facility's scheduler was interviewed on 10/3/24 at 11:35 a.m. The scheduler said she was responsible for scheduling the nursing staff. She said she was responsible for posting the nurse staffing hours daily and that she was not sure why the nurse staffing hours information had not been posted on 10/2/24. The scheduler clarified the facility's director of nursing (DON) was responsible for posting nurse staffing hours and she was responsible for posting the schedule. The DON was interviewed on 10/3/24 at 1:15 p.m. He said during the week he would print the staffing information and post it, however, for the weekends, he said he would print the nursing staff data and the facility staff were responsible for hanging it. He said the information was not posted on 10/2/24 because he forgot to post it due to the arrival of the survey team. The DON said he did not keep the printed versions or the electronic copies of the nurse staff postings. He said he was not aware copies of the nurse staffing data needed to be retained for 18 months.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Ensure resident restrooms were cleaned appropriately; -Ensure surface disinfectant times were followed; and, -Ensure high touch surfaces were cleaned. Findings include: I. Professional reference According to the Environmental Cleaning procedures (reviewed 5/4/23) retrieved on 1/10/24 from: https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html, documented in part, common high touch surfaces include: sink handles, bedside tables, call bells door knobs, and light switches. High touch surfaces and floors were cleaned at least once daily (24 hour period). At least once daily or every 24 hours high touch surfaces were to be cleaned. II. Facility policy and procedure The Housekeeping Services Infection Control policy and procedure, revised January 2009, received from the nursing home administrator (NHA) on 1/9/24 at 10:39 a.m. It revealed in pertinent part, It was the policy of this facility to require effective environmental sanitization to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other formities. Frequent cleaning of the facilities interior will aid in physically removing and reducing microorganisms potential contribution to the incident of health-associated infection (HAI). The Environmental Service Fact Sheet: 7 Cleaning Process, reviewed February 2020, received from the NHA on 1/9/24 at 10:39 a.m. It revealed in pertinent part to clean the toilet: clean inside the toilet with johnny mop and an environmental protection agency (SPA) registered hospital grade disinfectant, paying special attention to the underside of the flush rim. Clean and disinfect all exterior surfaces with a cleaning cloth that has been soaked in an EPA registered hospital grade quaternary disinfectant, going from the cleanest part to the dirtiest. III. Disinfectants used in the facility Western Paper Distributors Chemical guide, undated, received from the NHA on 1/9/24 at 10:39 a.m. revealed in pertinent part Spic & Span (surface disinfectant) time ten minutes to complete total kill claim. Comet bathroom disinfectant had five minutes to complete the total kill time. The [NAME] and Gamble Professional Techincal Bulletin: Concentrated Spic and Span All Purpose Spray and Glass Cleaner, undated, received from the NHA on 1/9/24 at 10:39 a.m. revealed in pertinent part, treated surfaces must remain visibly wet for the time indicated for each organism listed. The [NAME] and Gamble Professional Technical Bulletin: Comet Disinfecting-Sanitizing Bathroom Cleaner, undated, received from the NHA on 1/9/24 at 10:39 a.m. revealed in pertinent part Thoroughly wet hard, non porous surfaces for five minutes, then rinse or wipe clean. Spray the product on the surface and let it stand for five minutes. Toilet bowls and urinals spray on the exposed surface. Brush thoroughly. Let stand for five minutes, then flush. IV. Observations On 1/9/24 at 8:34 a.m. housekeeper (HSK) #1 was cleaning room [ROOM NUMBER], a single occupancy resident room. HSK #1 entered the resident room and sprayed Comet cleaner to the bathroom sink and toilet at 8:36 a.m. HSK #1 collected dry cloth, sprayed it with Spin & Span then wiped down door handles and wardrobe handles. HSK #1 applied more Spic & Span to the same cloth and wiped the cord to the light over the bed. At 8:39 a.m. HSK #1 collected dry cloth and sprayed it with Comet cleaner and collected toilet bowl brush in a small red bucket. HSK #1 poured solution from the red bucket into the toilet bowl. HSK #1 brushed the toilet bowl, the toilet seat with a toilet brush at 8:40 a.m. There was visible brown matter in the toilet bowl and on the toilet seat. HSK #1 flushed the toilet and scrubbed the toilet bowl and seat a second time to remove the remaining brown matter with the toilet brush. HSK #1 took a cloth sprayed with Comet wiping down the toilet seat, handle, rim and the outside of the toilet to the floor. HSK #1 completed the room at 8:45 a.m. -HSK #1 failed to sanitize high touch areas like call light, bed control and television remote. HSK #1 failed to clean the toilet in a hygienic manner by using a toilet brush on areas other than the bowl. HSK #1 failed to wait the recommended surface disinfectant time for the Comet cleaner in the bathroom and the surfaces cleaned with Spic & Span (see disinfectants used in the facility above). At 8:46 a.m. HSK #1 was cleaning room [ROOM NUMBER], a double occupancy resident room. At 8:47 a.m. HSK #1 applied Comet to the bathroom sink and toilet. HSK #1 collected dry cloth and sprayed it with Spic & Span then wiped door handles and wardrobe handles. HSK #1 went to B side of the room and wiped the bedside table down. HSK #1 collected Comet spray , a dry towel, red bucket with Comet solution and the toilet brush. At 8:51 a.m. HSK #1 poured Comet solution from the red bucket into the toilet, scrubbed the toilet bowl and used the brush to scrub the toilet seat. HSK #1 then took a dry cloth and sprayed Comet on it to wipe the toilet seat, the toilet handle and last the outside of the toilet from top to the bottom. HSK #1 room was done at 9:00 a.m. -HSK #1 failed to allow Comet cleaner to stay wet on the surface per the surface disinfectant time recommended for disinfection in the bathroom, she cleaned the toilet from dirty to clean areas and failed to clean high touch areas for both bed A and B like call lights, remotes and light switches and the handrail in the bathroom. V. Staff interviews HSK #1 was interviewed on 1/9/24 at 9:01 a.m. She said the surface disinfectant time for the Comet cleaner was 10 minutes and she was unsure if the cleaner had to stay wet for that long on the surface. HSK #1 was not sure if Spic & Span cleaner had a surface disinfectant time, after reviewing the bottle she said had a 10 minutes surface disinfectant time. HSK #1 said she did not time her cleaning so she was not sure if either cleaner achieved the recommended 10 minute surface disinfectant time. HSK #1 said cleaning a resident's rooms and bathroom from cleanest areas to dirtiest areas was best practice and she should not have cleaned the toilet seat with the toilet bowl brush as the bowl was considered dirtier than the seat and could lead to increased infection risks. HSK #1 said high touch areas were door handles, wardrobe handles, bedside tables, light cord/switches, call lights and should be cleaned daily to prevent infection. The housekeeping and laundry manager (HLM) was interviewed on 1/9/24 at 9:53 a.m. He said rooms were to be cleaned daily with Comet or Spic & Span and both cleaners had a 10 minute surface disinfectant time and the dry time was included in the surface disinfectant time. The HLM said high touch areas were handrails, remotes, bedside tables, call lights, door handles, bed control remotes and needed to be cleaned daily to prevent infection. The HLM said toilet cleaning should be done with Comet cleaner by cleaning the outside areas of the toilet with cloth and the toilet bowl should be cleaned with the toilet brush. The HLM said the toilet seat should not be cleaned with a toilet brush. The infection preventionist (IP) was interviewed on 1/9/24 at 10:10 a.m. She said high touch areas were handles, call lights and light switches and should be cleaned daily for infection prevention. The IP did not know the surface disinfectant times for Comet or Spic & Span, but said cleaning should occur from cleanest areas to dirtiest areas.

Based on observations, record review and staff interviews, the facility failed to ensure one (#13) resident was free from physical restraints out of 21 sample residents. Specifically, the facility failed to: -Use the least restrictive device for the least time possible, when using a wander guard on Resident #13; -Have a physician's order in place to check for placement and functioning of Resident #13's wander guard; and, -Identify the wander guard as a restraint on Resident #13's minimum data set (MDS) assessment. Findings include: I. Facility policy and procedure The Alarms policy, dated October 2023, was provided by the director of nursing (DON) on 1/8/24 at 2:24 p.m. The policy read in part, It is the policy of this facility to utilize alarms in limited circumstances, in accordance with the resident's needs, goals, and preferences, so the resident will be able to attain or maintain his or her highest practicable level of physical, mental, and psychosocial well-being. The facility shall establish and utilize a systemic approach for the safe and appropriate use of resident alarms, including efforts to identify risk, evaluate and analyze risk, implement interventions to reduce risk and monitor the effectiveness of the interventions and modify interventions when necessary. Supervision and other resident-specific interventions shall be implemented and documented prior to the use of alarms. When alarms are utilized, additional monitoring shall be provided, including but not limited to: -Verifying alarms are used in accordance with the resident's care plan; -Verifying alarms are working properly; and -Monitoring for adverse consequences associated with the use of the alarms, including psychosocial harm. The Wander System Monitoring Program policy, revised January 2024, was provided by the DON on 1/8/24 at 2:25 p.m. It read in part, Each monitoring wristband will be tested daily for placement and function and replaced as per manufacturer's recommendations. II Resident #13 Resident #13, above the age of 65, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included Alzheimer's disease, difficulty in walking, unsteadiness on feet, heart failure, dizziness and giddiness (lightheadedness) and muscle weakness. The 12/12/23 MDS assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of five out of 15. He had no behaviors and did not reject care. He required supervision or touching assistance when walking. -It did not identify the wander guard or wandering behaviors. III. Observations On 1/3/24 at 2:23 p.m. Resident #13 was observed walking with the certified nurse aide (CNA) to his room with a wander guard bracelet on his right wrist. IV. Record review A wander guard consent was signed by the resident's representative on 8/26/2020. The targeted behavior identified for the use of the restraint was the resident was exit seeking and had a diagnosis of dementia. The January 2024 CPO revealed no physician's order for the placement of the wander guard nor an order in place to check for placement and functioning of the wander guard. An elopement/wandering evaluation dated 9/6/23 identified the resident as a low risk behavior. The assessment documented that the resident had no history of elopement; the resident made no statements about a desire to leave the facility; the resident had not exhibited wandering behavior; and his wandering behavior had improved compared to the prior evaluation. An elopement/wandering evaluation dated 12/12/23 identified the resident as a high risk for the behavior. However, the assessment documented the resident had no history of elopement; the resident made no statements about a desire to leave the facility; the resident had not exhibited wandering behavior; and his wandering behavior had improved compared to the prior evaluation. The comprehensive care plan, initiated on 10/14/19 and revised on 1/8/24, revealed the resident was an elopement risk/wanderer related to a history of attempts to leave the facility unattended. The interventions initiated 1/8/24 included: -Document wandering behavior and attempted diversional interventions; -Identify pattern of wandering; -Monitor wander guard placement; and, -Provide structured activities. A nursing progress note dated 12/12/23 at 3:09 p.m. revealed the resident triggered as high risk for elopement. The resident was triggered as a high risk due to a diagnosis of dementia and a history of wandering and ambulating as desired. The resident has no longer attempted to exit or state that he wanted to leave the facility. -There were no progress notes in his medical record of elopement attempts or exit seeking behaviors. -There was no evidence of any attempts to use less restrictive alternative measures. V. Staff interviews CNA #2 was interviewed on 1/8/24 at 9:14 a.m. She said it was her first day working at the facility and that she was an agency CNA. She said she did not know if Resident #13 wandered or was an elopement risk. CNA #1 was interviewed on 1/8/24 at 9:38 a.m. She said Resident #13 did not wander or exit seek. She said he did not leave his room unless a staff member invited him to the dining room for meals or activities. She said she did not know why he had a wander guard. Licensed practical nurse (LPN) #1 was interviewed on 1/8/24 at 9:52 a.m. She said on occasion the resident did exit seek and wander, so a wander guard was placed on his ankle. However, he kept removing the wander guard from his ankle and it was placed on his wrist. She said there was not an order to check the placement and functioning of the wander guard daily. She said he wandered up and down the hall. She said she was not aware of any actual elopement attempts to leave the building. The social services director (SSD) was interviewed on 1/8/24 at 9:56 a.m. She said there should be orders in place to check the placement and functioning of the wander guard and it should have been triggered on the MDS assessment. The DON was interviewed on 1/8/24 at 12:49 p.m. She said there should have been an order to check for the placement and functioning of the resident's wander guard; and the use of the wander guard should have been identified on the resident's MDS assessment. The DON said the resident had no elopement attempts and she would have to review the facility policy to see what criteria should be met for the placement of a wander guard alarm. VI. Facility follow-up On 1/8/24 at 10:15 a.m. an order was received from the physician to monitor the wander guard for placement every shift. On 1/8/24 at 10:15 a.m. an order was received from the physician to check the wander guard function every Monday on the night shift. -However, the facility did not assess the need for Resident #13 to continue to use the wander guard and why its continued use was needed.

Based on record review and interviews, the facility failed to ensure one (#7) two out of 21 sample residents with a pressure ulcer received the necessary treatment and services according to professional standards of practice. Specifically, the facility failed to follow physician orders for wound care and follow recommendations for linen on air mattresses for Resident #7. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), Elsevier, St. Louis Missouri, pg 1262. A health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. According to low air loss mattress system: your top questions answered retrieved on 1/10/24 from: https://homecarehospitalbeds.com/low-air-loss-mattress-systems-your-top-questions-answered/#:~:text=Fitted%20sheets%20should%20not%20be,through%20and%20prevent%20moisture%20buildup, Fitted sheets should not be used over low air loss mattresses because they compress the air cells and restrict air flow. Thin knit or jersey material flat sheets should be used instead. Low air loss mattress covers were specially designed to allow airflow to pass through and prevent moisture buildup. This creates a microclimate between the skin and mattress to keep the user comfortable and prevent skin breakdown. II. Facility policy and procedure The Skin and Wound Monitoring and Management policy and procedure, revised January 2022, was received from the nursing home administrator (NHA) on 1/9/23 at 10:10 a.m. It revealed in pertinent part, a resident having a pressure injury receives necessary treatment and services to promote healing, prevent infection, and prevent new avoidable pressure injuries from developing. Treatments per physician order should be documented in the resident's clinical record. Prevention: In order to prevent the development of skin break down or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with residents plan of care: use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattress, wedges, pillows). Licensed nurse to document presence of pressure reducing devices on treatment administration records as ordered. III. Resident status Resident #7, older than [AGE] years old, was admitted on [DATE]. According to the January 2024 computerized physician orders (CPO), the diagnoses included sepsis (systemic infection), muscle wasting with atrophy (muscle deterioration), moderate protein-calorie malnutrition, depression, congestive heart failure (fluid overload affecting the heart function) and chronic respiratory failure with hypoxia (decreased oxygenation). The 11/14/23 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status (BIMS) score of three out of 15. She required maximal physical assistance with dressing and transfers. She required supervision for personal hygiene and eating. The resident was incontinent of bowel and bladder. It documented one stage 3 pressure injury needing pressure reduction devices for chair and bed. IV. Observations On 1/3/24 at 1:50 p.m. Resident #7's bed was observed to have a fitted sheet over the air mattress. -According to the manufacturer's recommendations, fitted sheets should not be used (see above). On 1/8/24 at 10:00 a.m. Resident #7 was lying in her bed resting. Resident #7's bed was made with a fitted sheet over the air mattress. At 10:48 a.m. Resident #7 wound care was being completed by registered nurse (RN) #1. RN #1 collected alginate, border gauze and gloves. RN #1 dated and initialed the new dressing and removed the old dressing from the resident's coccyx. RN #1 checked skin around the wound. RN #1 placed the alginate over the open wound and covered with a border dressing. -RN #1 failed to clean the wound prior to applying the new dressing and used a bordered gauze instead of a foam dressing per wound physician order (see record review below). V. Record review The January 2024 CPO documented the following physician order: Wound care: coccyx, apply alginate and cover with bordered gauze daily and as needed ordered on 12/26/23; Pressure reducing mattress ordered 11/11/23; and, Late entry since 11/11/23 air mattress check placement and function ordered on 11/27/23. The 12/22/23 comprehensive care plan documented Resident #7 had a stage 3 to sacrum initiated on 7/7/23. Interventions administer treatments as ordered, monitor for effectiveness and air mattress placed. The 12/26/23 wound physician progress note documented wound orders as sacral cleanse with normal saline apply alginate cover with foam, change daily. VI. Staff interviews RN #1 was interviewed on 1/8/24 at 1:31 p.m. She said she did not clean the wound prior to applying the new dressing but if it had been soiled with bowel she would have cleaned it. RN #1 said not cleaning a wound placed a resident at increased risk for infections. Certified nurse aide (CNA) #3 was interviewed on 1/8/24 at 2:21 p.m. She said air mattresses were not to have fitted sheets on them. CNA #3 said flat sheets and disposable incontinence pads were to be used on air mattress so linen did not interfere with the offloading mechanism the air mattress was providing. RN #1 was interviewed again on 1/8/24 at 2:25 p.m. She said she was not aware Resident #7 had an air mattress and she did not know if there were special considerations for linen use on air mattresses. RN #1 went to the room and said Resident #7 had an air mattress in use that was made with a fitted sheet. The director of nursing (DON) was interviewed on 1/8/24 at 2:36 p.m. The DON said it was the responsibility of the assistant director of nursing (ADON) to update new orders for wound care and then she would double check the orders. The DON said a wound care order should include what it should be cleaned with like normal saline or if the wound physician had another preference. The DON said not cleaning a wound prior to adding the treatment increased the residents' risk for infection or worsening of the wound. The DON reviewed Resident #7's CPO and said the order did not indicate to clean the wound despite the wound physician order (see record review above) indicated the wound to be cleaned with normal saline. The DON said Resident #7 did have an air mattress due to her skin condition. The DON said she was not aware of the recommendation of not using fitted sheets.

Based on record review and interviews, the facility failed to ensure notification of change for one (#1) of three residents reviewed out of four sample residents. Specifically, the facility failed to make a timely notify of Resident #1's when the resident had a change in medical condition and physical function; when the resident first complained of new symptoms of numbness in the left leg to the resident's physician. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 9/6/23 to 9/7/23, resulting in the deficiency being cited as past noncompliance with a correction date of 5/26/23. I. Facility Policy The Change of Condition Reporting policy, revised May 2023, was provided by the director of nursing (DON) on 9/7/23 at 2:49 p.m. It read in pertinent part: It is the policy of the facility that all changes in resident condition will be communicated to the physician. Any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. -All symptoms and unusual signs will be communicated to the physician promptly. Routine changes are a minor change in physical and mental behavior, abnormal laboratory and x-ray results that are not life threatening. The nurse in charge is responsible for notification of the physician prior to the end of assigned shift when a significant change in resident's condition is noted. -Document resident change of condition and response in nursing progress notes, on 24- Hour Report or Dashboard and update resident Care Plan, as indicated in clinical meeting. -All attempts to reach the physician and responsible party will be documented in the nursing progress notes. Documentation will include time and response. -The licensed nurse responsible for the Resident will continue assessment and documentation every shift for at least seventy-two (72) hours or until condition has stabilized. -Residents with acute medical changes (and some routine changes), will be listed on the 24 Hour Report or Dashboard and have progress and needs clearly communicated to each shift. II. Resident status Resident #1, age under [AGE] years old, was admitted on [DATE] and discharged to the hospital on 3/16/23. According to March 2023 computerized physician orders (CPO), diagnoses included femur fracture, pain in the hip, anemia, and metastatic prostate cancer: spread to the bone, brain, lung with malignant pleural effusion, lymph node and possibly liver. The minimum data set (MDS) assessment had not yet been completed due to new admission. The hospital admission referral dated 3/8/23 revealed Resident #1 was cognitively intact. The resident was able to walk and was independent with activities of daily living (ADL) prior to 3/7/23 when the resident sustained a non-displaced femur fracture of the top end of the bone at the hip near the pelvic bone and a rib fracture. The fracture related to The break was inoperable . The hospital referred the resident to the facility for rehabilitation services. The goal was for the resident to participate in rehabilitative services, strengthen his fractured leg and restore as much independence as possible to be able to return home with family. III. Record review Hospital assessment and care plan dated 3/7/23, read in pertinent part: Patient is denying .abdominal pain, numbness and tingling in extremities. (Resident name) with a past medical history significant for metastatic (cancer that has spread) prostate cancer that presented with left hip pain . severe and extensive mixed lytic and sclerotic widespread osseous metastatic disease throughout the bony pelvis (cancer that has spread to the bone). Orthopedics consulted - (recommended) non-operative management. Hospital physical therapy (PT) assessment dated [DATE], read in pertinent part: Discharge recommendations: Facility based rehab (can tolerate 1-2 hours of therapy per day). Patient seen for PT treatment session and continues to present with decreased independence in functional mobility due to decreased mobility, generalized deconditioning, decreased activity tolerance, balance impairments, strength deficits, and pain issues. Patient is continuing to have difficulty with overall strength and ability to mobilize the left lower extremity (LLE) (leg) due to pain. The resident needed total assistance to reposition in bed this morning .Barriers to discharge: disease process, current level of function, and pain. Hospital occupational therapy (OT) assessment dated [DATE], read in pertinent part: Discharge recommendation: Facility-based rehab (can tolerate 1-2 hours of therapy/day). Patient present with deficits in the areas of pain, ROM, strength, generalized deconditioning, and activity tolerance resulting in decreased independence for ADLs, . decreased independence for functional mobility required for ADL completion, and decreased safety during daily activities as compared to prior level of function . Today he is able to participate in limited sessions secondary to pain. Pt is NWB (non-weight bearing) on his LLE. OT will continue to follow and treat patient per his plan of care to work on bed mobility and activity tolerance. -Neither the PT or OT assessment document the resident was having numbness in the LLE or inability to move the LLE (see more below). Social services note dated 3/10/23 at 5:54 p.m. read in part: Resident was admitted to the hospital for rib and hip fx (fracture) that was not a result of a fall. (Resident name) was admitted to (facility name) on 3/10/23 for skilled services for his decrease in independence and mobility. (Resident) scored 15/15 on BIMS (brief interview for mental status) (intact cognition) which does not trigger any cognitive concerns. Nurse's note dated 3/11/23 at 6:19 p.m., written by licensed practical nurse (LPN), read in pertinent part: Resident complained of some numbness to the left outer leg and hip. States this is new for him. Staff will monitor. -There was no documentation that the resident's physician was notified of the resident newly reported symptoms of numbness to he left leg and hip and no nursing notes documenting the nurse were monitoring and assessing the resident symptoms over the next 72 hours. The resident's complaints of numbness were not mentioned again in the nursing progress notes until 3/16/23, five days later when the resident again reported symptoms of numbness. Care conference note dated 3/16/23 at 10:58 p.m. read in pertinent part: Concern: (resident's name) feels he is not getting enough therapy due to the amount he believes insurance will allow. Therapy: would like to get resident up and out of his bed with reports that resident not wanting to get out of bed due to level of pain he was feeling. Resident would like to get out of the bed and therapy would like to see him out of bed in a wheelchair for 1-2 hours a day or the amount he is able to tolerate. Nursing: would like to see if they can increase Gabapentin (medication for neurological pain) to help with the level of numbness he is feeling. Change in condition note dated 3/16/23 at 6:05 p.m. read in pertinent part: Symptoms or signs noted of condition change: Increased numbness to both lower extremities. Refer for full evaluation. Physician note dated 3/16/23 read in pertinent part: Today his hip pain is manageable and he states it is anywhere from a level 2-3/10 depending on when he has last taken his pain medication. Today he is concerned because he has increased numbness in bilateral lower extremities that has increased over the last two days. He also reports a new onset of significant weakness in bilateral lower extremities. States that yesterday he was 'at least able to wiggle toes', but since this morning is completely unable to move bilateral lower extremities. He is incontinent but has not noticed saddle anesthesia (a loss of sensation to the area of the buttocks, perineum /groin and inner surfaces of the thighs). He denies fevers/chills. He endorses pain around left hip. New weakness and numbness on exam likely related to prostate cancer metastasis. Contacted on- call line to speak to the patient's oncologist, discussed worsened neurologic findings (oncologist name) recommends patient be evaluated for possible cauda equina (dysfunction of multiple lumbar and sacral nerve roots) given new motor/sensory changes and continued incontinence. emergency room (ED) attending contacted who is aware that the patient will be transported to the ED for imaging. This plan was discussed at length with the patient and the family who state they 'just want to know' why weakness has increased. -Per the above note the physician documented the resident symptoms started two days prior when in fact the resident's symptoms started on 3/11/23 see nursing note above. Nursing note dated 3/16/23 at 9:10 p.m. read in pertinent part: At approximately 6:45 p.m. Patient spoke with (medical provider name) who gave orders to send patient to (hospital name) due to patient's ongoing complaints of numbness to both lower extremities. IV. Interviews LPN #1 was interviewed on 9/7/23 at 1:30 p.m. LPN #1 said remembered the resident complaining of numbness in his left leg and hip, but she was not able to recall details of the resident's complaints. LPN #1 said she called the resident physician's office but could not recall whom she talked to at the physician's office and said she did not write a note to document the notification because the physician she spoke to said it was taken care of. LPN #1 was not able to explain what was meant by it was taken care of and the LPN said she did not ask the physician what it was taken care of meant LPN #1 said she wrote a progress note but did not pass the information along to the oncoming nurse at change of shift. LPN #1 said following the resident's discharge the facility provided her education on requirements to report a change in a resident's change of condition to the resident's physician and nursing staff including leadership staff. LPN #1 said going forward she was instructed that she needed to make immediate notification to the resident's physician of a change in a resident's condition so the physician could assess the resident nn make appropriate treatment recommendations. In addition, she was expected to document the communication; document the physician's response and treatment orders. In addition, the details of the resident's change in condition was to be documented on the nursing 24-hour report. Following a change of condition the resident was to be monitored by nursing for at least the next 72 hours; and that monitoring was to be documented in the resident's record. The DON was interviewed on 9/7/23 at 2:55 p.m. The DON said the facility resident's family expressed concern that the facility failed to report the resident's change of connection to the resident's physician in a timely manner. The resident physician was contacted as a part of an investigation and their response was documented in the investigative report. (Per the investigation documentation the resident's physician and physician's assistant both said they were not notified of the resident change in condition as documented by LPN #1 on 3/11/23). The DON said as a result, to the investigation the facility reviewed the change of condition policy and revised the policy and procedures for identifying and reporting a change in a resident's condition. All nursing and therapy staff were educated on the policy and procedure. V. Facility interventions The facility made changes to the policy and procedures for identifying and reporting a change in resident condition. The DON said an investigation into Resident #1 care, started 5/22/23. The facility reviewed Resident #1's record for a timeline of reporting the resident's condition of the resident's physician. The facility conducted a full in facility audit of all resident's to see if any resident had similar concerns that the had a change in condition where one of the resident's and/or their representative felt the facility was not addressing their medical concerns. They found no similar concerns. On 5/23/23, LPN #1 received disciplinary coaching and education related to expectations for identifying a change in a resident's condition and reporting and documentation procedures. Facility leadership reviewed the change of connection reporting policy; revisions were made to the policy and procedure May 2023. The leadership staff developed and revised the change of condition assessment forms and all nursing and therapy staff were provided education in relation to identification of change in condition and neurological concerns; completed by 5/26/23. Resident #1 was not in the facility at the time of the investigation from 9/6/23 to 9/7/23 and current deficient practice in this area was not found with any of the sample residents.

Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Specifically, the facility failed to develop a system to maintain sanitary food storage for Resident #3's personal refrigerator. Findings include: I. Facility policy The Foods Brought by Family or Visitor/ Personal Food Storage, was provided by the nursing home administrator (NHA) on [DATE] at 1:57 p.m. included, Policy: Food or beverage brought in from outside sources for storage in facility pantries, refrigeration units, or personal room refrigeration units or designated resident public refrigerators will be monitored by designated facility staff for food safety. Designated facility staff will be assigned to monitor individual room storage and refrigeration units for food or beverage disposal at least weekly. Designated facility staff will monitor cleanliness of individual refrigeration units and ensure cleaning is completed as needed. II. Resident #3 A. Resident status Resident #3, age 65, was admitted on [DATE]. According to the [DATE] computerized physicians orders (CPO), diagnoses included [CONDITION(S)], type 2 diabetes mellitus with diabetic [CONDITION(S)], and heartburn. The [DATE] minimum data set (MDS) assessment revealed the resident's cognitive status was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She had no identified behaviors or rejections of care during the assessment period. B. Observation and interview The refrigeration unit in Resident #3's room was observed on [DATE] at 1:30 p.m. She said the unit was only cleaned out when she would ask staff to clean it out. In the refrigeration unit, there were several containers of food with no dates on them, several yogurt containers, and three cans of soda in the door. There was a strong odor inside the unit. C. Interviews Housekeeping (HSKG) #1 was interviewed on [DATE] at 11:48 a.m. She said the certified nurse aides were responsible for cleaning out the refrigeration units in residents' rooms. Certified nurse aide (CNA) #1 was interviewed on [DATE] at 12:15 p.m. She said the housekeeping department was responsible for the personal refrigeration units. Social services assistant (SSA) #1 was interviewed on [DATE] at 12:46 p.m. She said each resident had an ambassador. She said the ambassador should offer Resident #3 a refrigeration unit cleaning during their rounds. She said Resident #3 often refused to allow the refrigeration unit to be cleaned out. -However, there was no documentation of a system to show the resident's refrigerator was cleaned and food labeled, dated and discarded when expired, nor which department/ambassador was responsible for this task. The director of nurses (DON) was interviewed on [DATE] at 12:46 p.m. She said the dietary staff maintained the temperature logs for the refrigeration unit. She said the resident had just allowed the NHA to clean out her refrigeration unit. She said there should have been a system in place to clean out the refrigerator and discard expired foods.

Based on record review and interviews, the facility failed to provide the assistance needed to maintain an ability to complete activities of daily living (ADLs) for one (#131) out of 18 sample residents. Specifically, the facility ailed to identify and develop a communication system due to the resident's [CONDITION(S)] (loss of ability to understand or express speech) and develop interventions for the staff to communicate effectively. Findings include: I. Resident #131 A. Resident status Resident #131, age 78, was admitted on [DATE]. According to the September 2022 computerized physicians orders (CPO), diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 6/8/22 minimum data set (MDS) assessment revealed the resident's cognitive status was moderately impaired with a brief interview for mental status (BIMS) score of seven out of 15. She had no identified behaviors. B. Record review The resident did not have a person-centered individualized care plan to address the resident's [CONDITION(S)] identified on the baseline care plan and/or comprehensive care plan. Review of speech therapy notes: -The noted dated 9/7/22 (eight days after the resident's admission) included the medical doctor inquired about communication strategies for the resident due to expressive [CONDITION(S)]. The speech language pathologist provided the resident with a low tech augmentative and alternative communication (AAC) board. -The note dated 9/8/22 included the speech therapist added a pain scale to the AAC at bedside. -The note dated 9/12/22 included the patient was able to use the pain scale on her AAC board. C. Observations and interview Resident #131 was observed in her room on 9/11/22 at 5:23 p.m. On the nightstand next to her bed was a picture board under a gait belt. On 9/13/22 at 9:15 a.m. she said staff did not use the picture board when working with her. -Due to the resident's [CONDITION(S)], this made it hard for her to communicate her needs to the staff. D. Interviews Certified nurse aide (CNA) #3 was interviewed on 9/13/22 at 9:37 a.m. She said she had not received training on interventions specifically addressing Resident #131's [CONDITION(S)]. Registered nurse (RN) #1 was interviewed on 9/13/22 at 9:43 a.m. She said she had not received training on Resident #131's [CONDITION(S)] or a communication board. The speech therapist (ST) was interviewed on 9/13/22 at 11:11 a.m. She said Resident #131 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the therapy department had just started to use the AAC board to include training the resident how to utilize it. She said she had not provided training to the staff yet because she wanted to train the resident first. She said the resident was more alert the past couple of days due to medication changes. At 11:52 a.m. the ST said the plan moving forward was training staff on the AAC board if verbal communication was not successful. The DON was interviewed on 9/13/22 at 11:19 a.m. She said Resident #131 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said the resident did not have a person-centered individualized care plan addressing [CONDITION(S)] to include communication techniques for the staff to utilize to know the resident's care needs. She said the facility would develop a care plan to improve communication techniques for Resident #131.

Based on record review and interviews, the facility failed to ensure the discharge needs of each resident were identified and resulted in the development of a discharge plan for one (#1) out of three residents reviewed for discharge out of seven sample residents. Specifically, the facility failed to develop and implement a complete discharge plan for Resident #1 that included home health care nursing for care of a stage 3 pressure injury the resident had upon discharge. I. Facility policy and procedures The Discharge or Transfer policy, revised August 2020, was provided by the clinical resource (CR) on 11/3/2020 at 1:37 p.m. It read, in pertinent part: It is the policy of this facility to provide the resident with a safe organized structured transfer and or discharge from the facility to include, but not limited to, hospital, another healthcare facility, or home that will meet their highest practicable level or medical, physical, and psychosocial well-being. The Discharge Planning policy, revised December 2019, was provided by the CR on 11/3/2020 at 1:40 p.m. It read, in pertinent part: It is the policy of this facility that discharge planning and evaluation will be provided by the social services staff for each resident. The discharge planning process focuses on the resident's discharge goals, the preparation of the resident to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions. Discharge planning involves the resident, family or responsible party, interdisciplinary team (IDT), and others involved in the resident's care plan. -Monitoring of the discharge planning program is the responsibility of the social services staff. The social services staff will ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. Referrals for discharge planning may be made by the physician, resident, family or responsible party, or staff member. It is essential to ensure that there is a planned program of continuing care to meet each resident's discharge needs. -Social services or designee shall involve the IDT in the ongoing process of developing the discharge plan. -Social services or designee will document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. -When discharge is anticipated, an IDT meeting with the resident and their family to assist with the adjustment to his/her new living environment. II. Resident status Resident #1, age 82, was admitted on [DATE] and discharged to her prior memory care assisted living facility on 10/7/2020. According to the October 2020 computerized physician orders [REDACTED]. -The resident failed to have a medical [DIAGNOSES REDACTED]. The 9/25/2020 minimum data set (MDS) assessment revealed the resident was cognitively impaired with a brief interview for mental status score of zero out of 15, the staff assessment for mental status revealed the resident had short and long term memory problems, severely impaired decision making skills and she did not exhibit any behaviors. She required extensive assistance of two staff members with her transfers and mobility and extensive assistance of one staff member with her activities of daily living (ADLs). She had a stage 3 pressure injury present upon admission to the facility and was using pressure reducing devices in her chair and bed. III. Home health representative interview A home health care nurse was interviewed on 11/2/2020 at 3:45 p.m. She stated the resident was discharged back to her assisted living facility with a significant pressure injury without nursing services being arranged for the care of the pressure injury. She stated the pressure injury was discovered and evaluated by the physical therapist (PT) on 10/8/2020 and the PT called and arranged for nursing services to evaluate and treat the wound. IV. Representative interview A representative for the resident was interviewed on 11/2/2020 at 4:42 p.m. She stated she was the owner of the resident's memory care facility and acted as the resident's representative often due to the resident's power of attorney living out of state and not being very involved. She stated she was not aware and had not been informed the resident had a pressure injury that required care prior to the resident's discharge. She stated the pressure injury was discovered by the staff at the memory care facility on 10/7/2020 upon assessment when the resident arrived home. She stated the memory care facility was not prepared for the presence of a pressure injury and could not care for it as they did not provide skilled nursing services. She stated they called the home health agency to arrange for care of the pressure injury when it was discovered as nursing services were not arranged prior to discharge. She stated she had made contact with the nursing facility prior to discharge since they could not come onsite to perform an assessment, though the pressure injury was not discussed. Cross-reference F580 Notification of Changes. V. Record review On 9/20/2020 a nursing note revealed Resident #1 was admitted and an open wound to her coccyx was identified during the admission assessment. On 9/20/2020 an admission skin assessment was completed and revealed the resident had a three inch by three inch stage 3 pressure injury to her coccyx with treatment orders put into place as well as pressure reducing devices were added to her bed and her wheelchair. On 9/21/2020 an order was written to treat the open area to the resident's coccyx by cleaning the area with normal saline, apply medi-honey to the wound bed and cover with a dry dressing daily and as needed until resolved. On 9/21/2020 a skin care plan was initiated, it read: The resident has an actual impairment to skin integrity related to surgical incision and pressure ulcer to coccyx upon admission. Interventions initiated on 9/21/2020 for the care plan included: Educate resident, family, and caregivers of causative factors and measures to prevent skin injury; Administer treatments as ordered and monitor for effectiveness; Air mattress; Monitor nutritional status; Notify nurse immediately of any new areas of skin breakdown; and weekly head to toe skin assessment. On 9/21/2020 a discharge care plan was initiated, it read: The resident wishes to return/be discharged to her previous group home assisted living facility after her skilled stay. She receives memory care and support there from the owner (of the assisted living facility). Interventions initiated 9/21/2020 included: Determine gaps in abilities which will affect discharge, address gaps by community referrals for services such as home health services, therapy, and nursing for medication management; Establish a pre-discharge plan with the resident, family/caregivers and evaluate progress and revise the plan; and make arrangements with required community resources to support independence post discharge. On 9/22/2020 a physician admission note revealed the resident had a three by three inch stage 3 ulcer to her coccyx. On 9/23/2020 a weekly skilled review note revealed Resident #1 was reviewed in the interdisciplinary team (IDT) meeting with the nursing home administrator (NHA), social worker (SW), assistant director of nursing, rehab director, occupational therapist, and physical therapist were in attendance. The review included barriers to a safe and effective discharge included: poor standing tolerance; potential to transfer with a walker; poor safety awareness; limited ability to communicate her needs; and current transfer status with a mechanical lift or maximum assistance of two staff members. The note revealed the resident was being monitored for wounds or pressure points, though did not reveal the resident had a current pressure injury. On 9/24/2020 the resident was seen by the wound care nurse practitioner (WCNP) and orders were written to treat the open area to the coccyx with santyl and cover with a dry dressing daily and as needed until resolved. On 9/24/2020 a nutritional summary note revealed the resident was seen by the wound nurse practitioner for a wound to her coccyx. On 9/24/2020 a social services summary note revealed the resident was supported by her POA who was her former boss and the owner of her assisted living facility, where she planned to return after her skilled stay in the facility. On 9/29/2020 a weekly skilled review note, written by the SW, revealed the resident was reviewed, though the note did not list attendees. The review included barriers to a safe and effective discharge including: admitted (to the facility) with a sacral wound; and concerns with mobility out of bed. The note revealed the resident would continue to work on safe transfer training to be able to safely return to her group home. On 10/1/2020 the resident was seen by the wound care nurse practitioner and orders were written to treat the open area to her coccyx by cleaning with normal saline, apply [MEDICATION NAME] to the wound bed and cover with a dry dressing daily and as needed. The WCNP note revealed the resident's wound was improving. On 10/1/2020 a skin/wound note revealed the resident was being treated for [REDACTED]. On 10/4/2020 a care plan review meeting note revealed a care plan meeting was held with the resident's representative POA in attendance via phone, also in attendance were the owner of the resident's assisted living facility, resident's physician, a registered nurse, a certified nurse aide, a therapy representative, the SW, and the dietary manager. The note revealed the attendees discussed the resident's psychoactive medications, mental status, poor meal intakes, progress made in therapy, and discharge plans. -There was no indication the presence or treatment of [REDACTED]. On 10/5/2020 a physician discharge progress note revealed the resident was discharging back to her group home on 10/7/2020 with home health services. -The note did not reference the presence or treatment of [REDACTED]. On 10/5/2020 orders were written for the resident to discharge home on 10/7/2020 with home health care services for physical and occupational therapy. On 10/5/2020 a discharge summary assessment was initiated and revealed the resident would return to her previous memory care group home as she had improved sufficiently and no longer needed the services of the facility. The assessment revealed the resident had a pressure injury to her coccyx with treatment orders in place and the need for the resident to be turned every two hours. The assessment revealed home health therapy services had been arranged. The discharge summary assessment was finalized and signed by licensed practical nurse (LPN) #1 on 10/7/2020 and was physically signed by the group home staff member on 10/7/2020. While home health therapy was arranged for the resident, no home health nursing was arranged related to wound care and treatment. On 10/7/2020 a discharge note revealed the resident discharged to her group home at 11:45 a.m. and was accompanied by group home staff members in a private car. All paperwork was reviewed and signed by the staff member and originals were sent with the staff member. The resident had no personal belongings while at the facility, signed orders and prescriptions were sent with the resident as well. Review of Resident #1's treatment administration record (TAR) throughout her stay in the facility revealed the resident received wound treatments as ordered to her coccyx. Review of the resident's progress notes revealed no additional social services or nursing notes describing coordination of discharge plans or discussions with the resident's POA or the representative/owner from the assisted living facility related to discharge plans, discharge needs, or the resident's pressure injury. VI. Staff interviews The social worker (SW) was interviewed on 11/2/2020 at 5:30 p.m. She stated she was responsible for all aspects of resident discharges. She stated she did handle the discharge plans for Resident #1. She stated she did not know about the resident's pressure injury prior to her discharge and was not aware the resident would need home nursing services. She stated the wound care needs of Resident #1 were not discussed, to her memory, in any IDT meetings where she was in attendance and in the resident's care plan review meeting held on 10/4/2020. She stated she had spoken at length with the resident's POA and representative from her memory care facility related to the resident's progress in therapy, general disposition, discharge plans, and the wound was not discussed as she was not aware of it. She stated she kept her own record of conversations with the POA and assisted living facility representative, but did not always document the conversations in the resident record. She stated she arranged for the resident to receive home health physical and occupational therapy (PT/OT), and did not arrange for home nursing as she was not aware the resident had wound care needs. She stated she did not become aware of the resident's wound care needs until 10/9/2020, when a representative from the home health agency called to inquire about wound care treatments the resident was receiving in the facility. The resident services resource (RSR) was interviewed on 11/2/2020 at 5:39 p.m. She stated once the facility became aware of the mistake made with Resident #1's discharge, she immediately provided additional education to the SW to ensure this type of situation did not happen again. She stated the SW was directed to review resident records, skin assessments, nursing notes, and other documentation as well as ask nursing and therapy staff specific questions related to the resident's needs and condition to ensure the proper services are arranged for a resident prior to discharge from the facility. The director of nursing (DON) and CR were interviewed on 11/2/2020 at 5:43 p.m. They stated they became aware of the problem with the resident's discharge on 10/9/2020. They stated they investigated the issue and had put plans into place with both SW and nursing education related to preventing this situation for any future discharges. They stated the whole IDT team should be involved with resident discharges and all resident care needs should be discussed in daily, weekly and care plan meetings so all team members are aware of all resident care needs. The DON stated that upon review, the discharge summary and description as well as interview with the nurse who actually discharged the resident revealed Resident #1 was picked up by three staff members from the memory care facility, one staff member received and went over the resident's orders including the wound care orders and the staff member signed receipt and understanding of the orders. Licensed practical nurse (LPN) #1 was interviewed on 11/3/2020 at 1:15 p.m. She stated she discharged Resident #1 on 10/7/2020 and remembered it well. She stated the resident was picked up and accompanied from the facility by three staff members from the memory care facility. She stated she explained and discussed all of the resident's orders and conditions with the staff member as well as the wound care orders. She stated medications and treatment supplies were sent with the staff member upon discharge from the facility and the staff member signed off on the discharge paperwork and did not ask any questions. The nursing home administrator (NHA) was interviewed on 11/3/2020 at 2:38 p.m. He stated became aware of the situation with Resident #1's discharge on 10/9/2020 when the home health agency contacted the facility. He stated all relevant staff should be aware of resident needs prior to discharge. He stated all aspects of resident care should be discussed as a team during discharge planning discussions to ensure all needed services were arranged for a resident prior to their discharge from the facility.

Based on record review and interviews, the facility failed to ensure a discharge summary was in place for one (#2) out of three sample residents reviewed for discharge out of seven total sample residents. Specifically, the facility failed to ensure a discharge summary including a recapitulation of the resident's stay, a final summary of the resident's status, and a post discharge plan of care was in place for the resident upon discharge from the facility. Findings include: I. Facility policy and procedure The Discharge Planning policy, revised December 2019, was provided by the clinical resource (CR) on 11/3/2020 at 1:40 p.m. It read, in pertinent part: Social services or designee will document, complete on a timely basis based on the resident's needs and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation will be discussed with the resident or the residents representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. Prior health status of the resident; current level of care required; caregiver/support person availability and the resident's or caregivers capacity and capability to perform required care; resident goals of care and treatment; projected level of functioning following rehabilitation and recovery process; projected timeframe for involvement to lower level of care; therapies and education required to accomplish care plan goals; and availability of support system and community resources necessary to meet the resident's goals. A post discharge plan of care or discharge summary is developed with the participation of the resident and, with the resident's consent, the resident representative which will assist the resident to adjust to his or her new living environment. The post discharge plan/discharge summary will indicate where the individual plans to reside, any arrangements that have been made for the resident's follow up care and any post discharge medical and non-medical services. All transfers and discharges are coordinated by the social services staff and implemented in accordance with the following steps: -Provide discharge counseling and planning to the resident and family -Inform appropriate persons including the charge nurse. Resident, family, or responsible party, and other staff involved who participate in discharge planning. -Ensure that nursing contacts the physician, the discharge is discussed and necessary orders are obtained. -The resident's physician must also document the basis for discharge. II. Resident #2 A. Resident status Resident #2, age 83, was admitted on [DATE] and discharged home on[DATE]. According to the October 2020 computerized physician orders [REDACTED]. The 10/4/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. He required supervision with his activities of daily living and mobility. B. Record review Review of the resident's record revealed the resident discharged home on[DATE], though no progress notes were written related to discharge planning, no discharge summary or assessment was completed, and the only record of the resident's discharge was the discharge date entered into the electronic health record. An order, dated 10/5/2020, read the resident planned to discharge home on 10/4/2020 with home health services. The order was written and entered on 10/5/2020 when the resident had discharged on [DATE]. On 11/3/2020 a late entry note was written by the social worker (SW) for 10/5/2020, it read the resident discharged home with home health services of physical and occupational therapy (PT/OT), certified nurse aide (CNA), and social worker for assistance with assisted living facility (ALF) transition. SW will continue to follow the resident to connect him with resources to aid in the transition to ALF from his home. There were no other notes in the resident record related to his discharge home. There was no discharge summary in the resident's record from the facility or from the resident's physician. Upon request, an undated physician discharge summary was provided by the CR on 11/3/2020 at 12:30 p.m. It read the resident's health had improved to the extent the discharged resident no longer needed the services of the facility. It listed the resident's past medical history, a list of comprehensive care plan goals, and notes from the resident's most recent physician visit dated 9/9/2020. The discharge summary did not include a recapitulation of the resident's stay in the facility, where the resident would reside, or a description of or directions for the resident's care needs post discharge. III. Staff interviews The social worker (SW) was interviewed on 11/3/2020 at 10:13 a.m. She stated, every resident should have a discharge summary assessment from facility staff and a note from the nurse on the day of discharge describing the discharge process. She stated the resident discharged unexpectedly on a weekend and she made the call to the home health agency when she returned to work on Monday to resume services for the resident. She stated the nurse who discharged the resident should have ensured physician orders [REDACTED]. The director of nursing (DON) was interviewed on 11/3/2020 at 12:30 p.m. She stated when a resident discharges from the facility, even if the discharge was unplanned, the nurse should obtain physician orders, write a note, and initiate a discharge summary assessment. She stated the nurse who discharged Resident #2 did not follow the facility protocol and had been educated since the resident discharge. She stated the physician discharge summary was requested and the physician office stated they had trouble uploading the summary to the system. She stated upon review it was discovered the summary did not contain the required information. The nursing home administrator (NHA) was interviewed on 11/3/2020 at 2:38 p.m. He stated he would expect the staff of the facility to follow policies and procedures for resident discharges. He stated a discharge summary from facility staff and from the resident's physician should be done and in the resident record. He stated the nurse who discharges the resident should also write a progress note to describe the discharge.

Based on record review and interviews, the facility failed to provide one (#1) of five residents, out of 13 sample residents, adequate supervision and an environment as free from accident hazards as possible, contributing to an accident involving self-harm. Resident #1, a new admission to the facility on [DATE], expressed to social services on [DATE] that he felt down, depressed and hopeless seven out of 11 days. He told a daughter the evening of [DATE] that he wanted to kill himself by placing a bag over his head. The resident was found expired with a bag over his head in the early morning hours on [DATE]. The facility failed to provide Resident #1 with either the supervision or the environment necessary to keep him safe from self-harm following his suicidal thoughts. Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on ,[DATE]-[DATE], resulting in the deficiency being cited as past noncompliance. Findings include: I. Immediate jeopardy for serious harm A. Situation of Immediate Jeopardy Resident #1, a new admission to the facility on [DATE], expressed to social services on [DATE] that he felt down, depressed and hopeless seven out of 11 days. No plans were developed to address his psychosocial distress. Two days later, on [DATE], he told a daughter he wanted to kill himself by placing a bag over his head, suicidal thoughts that another daughter reported to the director of nursing (DON). Hours later, the resident was found expired, with a bag over his head in the early morning on [DATE]. The facility failed to provide Resident #1 either the supervision or the environment necessary to keep him safe from self-harm following his suicidal thoughts. The DON, upon interviewing the resident on [DATE], determined the resident did not have an active plan to harm himself; however, neither she nor social services, who was aware of the resident psychosocial distress as of [DATE], conducted a lethality assessment to evaluate the resident's level of risk for self-harm. Further, while a plan to check on the resident that night was communicated to staff, the plan was informal and undefined, and any checks that occurred were undocumented. Finally, the DON's search of the resident's room for objects of concern was incomplete; she did not remove the plastic bags, call light cord, window blinds cord, or any other items potentially harmful agents from the room. The nursing home administrator (NHA) was notified of the immediate jeopardy on [DATE] at 11:43 a.m. He was further notified on [DATE] at 11:45 a.m. that record review and interviews during the complaint investigation confirmed the deficient practice had been corrected and the facility was in substantial compliance with F689 at the time of survey. B. Facility plan to remove the immediate jeopardy situation The facility developed the following immediate plan: Investigative Action: the facility initiated an immediate investigation which included staff interviews, a review of medical records and a QAPI (Quality Assurance Performance Improvement) analysis of the situation. - Every resident of the facility was interviewed and their medical record reviewed to assess their current emotional state and screen for [MEDICAL CONDITION]. - Information received from this assessment and review was acted upon, with care plan updates and interventions applicable to a single resident who was identified through this process. Further, residents who presented with mood problems secondary to this full house review were offered the assistance of a psychologist. Interventions to prevent recurrence: - Educated staff on policy in regards to suicide prevention and the lethality assessment; - Facility will initiate review of the residents when a resident expresses [MEDICAL CONDITION]; - Facility will offer services of psychologist or psychiatrist to any resident with identified mood problems; - In-service on identification and proper documentation of s/s of depression and reporting of resident's verbalization to hurt self ([DATE]); - Reviewed and updated the suicide precaution policy and procedure to include if the suicide lethality assessment score was low, but has a history of depression, will have a 24 hour sitter for 72 hours; if the suicide lethality assessment score was high, the resident will be sent to the hospital and put on a 24 hour sitter for 72 hours upon re-admission to the facility; - Facility posted posters about mental health resources in common areas for residents and staff ([DATE]); - Mental awareness to be added to the resident council agenda on an ongoing basis (September resident council meeting); - Ongoing PHQ-9 assessment and review for psychosocial support of high risk residents with depression every quarter and as needed by SS; random staff interviews on suicide precaution policy x4 weeks; - ED (Executive Director) to verify compliance monthly with psych services for those who require them; - In-service documentation reviewed; - QAPI plan reviewed. C. Removal of immediate jeopardy The immediate jeopardy situation was removed prior to the onsite investigation on ,[DATE]-[DATE]. Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction. Therefore, the deficient practice was corrected prior to the onsite investigation and represented past noncompliance at G level, actual harm that is isolated. II. Facility failure to provide Resident #1 either the level of supervision or the environment necessary to keep him safe from self-harm following his suicidal thoughts and prevent a successful suicide attempt. A. Resident #1 1. Resident status Resident #1, age 92, was admitted to the facility on [DATE] for physical and occupational rehabilitation services. According to the [DATE] computerized physician orders [REDACTED]. The minimum data set (MDS) assessment, dated after the resident expired on [DATE], revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. He required extensive assistance of two people with bed mobility, transfers, dressing, toileting and personal hygiene. It documented the resident felt down, depressed and hopeless for seven to 11 days of the assessment period. The resident had a care plan for impaired cognitive function care plan, initiated on [DATE]. It read the resident had impaired cognitive function, thought process and decision making. It indicated the resident was generally oriented to place and situation and did best when his needs were anticipated. The interventions included: to communicate with the family regarding the resident's capabilities and needs, provide a program of activities that accommodates his abilities, and social services to provide psychosocial support as needed. The care plan was created by the social services director (SSD). 2. Record review of Resident #1 mood status and lack of the facility response to his report of feeling down, depressed and hopeless contributed to the facility's failure to provide the resident adequate supervision and a safe environment. a. Resident representative interview Resident #1's daughter was interviewed on [DATE] at 8:54 a.m. She said the resident had fallen a few times at the assisted living where he resided. His final fall resulted in a [MEDICAL CONDITION] that ultimately sent him to the facility for physical and occupational therapy. -She said the resident had become hopeless since the start of the COVID-19 pandemic. She said he lived alone at an assisted living and prior to the pandemic, the resident was attending activities and got involved in the assisted living community. With the pandemic, the resident was not able to attend activities or see his friends and family. She said he told her he felt he was only living for his next meal. She said she would speak with him every day in an attempt to elevate his mood, and said she had visited him through the window earlier on [DATE] with his grandchildren. She said he looked sad. -She said the night of [DATE], the resident called her sister and said he wanted to kill himself. She said he told her sister he was going to place a bag over his head. She said she called the facility immediately and spoke with the head nurse (DON). She said she informed the facility staff the resident said he wanted to kill himself by placing a bag over his head and had told her sister he had attempted it earlier that day. She said she asked the facility staff to go check on the resident and asked to have him evaluated for depression. -She said she received a call back from the DON, stating the facility staff would keep an eye on him and they felt there was nothing to worry about. She said she did not understand why the facility staff did not remove the bags from the resident's room after she called and informed them of the resident's plan. -She said she never received a call from the facility staff to inform her the resident felt lonely and isolated. She said facility staff did not call her to ask about different things they could do to assist the resident with his down and depressed mood. b. Failure to respond to knowledge of the resident's psychosocial distress (feelings of hopelessness, loneliness, isolation, and depression) The [DATE] social services progress note revealed, as the MDS assessment above, that the resident exhibited mild to moderate cognitive impairment, short-term and long-term memory loss and poor insight. The note indicated the resident scored a 2 out of 27 on the depression screening (PHQ-9). The SSD wrote the score did not trigger for depression and indicated minimal signs and symptoms of depression, although the SSD noted during the assessment, the resident said he felt down, depressed and hopeless seven to 11 days out of the assessment period of 14 days. A review of the resident's medical record on [DATE] at 11:30 a.m. did not disclose the facility put interventions in place following the interview conducted by the SSD on [DATE], during which the resident stated he felt down, depressed and lonely. A care plan identifying the resident's potential for psychosocial problems related to the resident's admission to the facility was initiated on [DATE], the day the resident was found expired in his room. (The care plan did not document any goals or interventions.) The SSD was interviewed on [DATE] at 12:30 p.m. and again on [DATE] at 10:54 a.m. - She said the PHQ-9 depression screening was conducted for every resident upon their admission to the facility and quarterly thereafter. She said each question is asked to the resident and their response recorded. She said the social worker should ensure follow-up questions are asked of the resident if they indicate they are depressed. She said she conducted the PHQ-9 depression screening for the resident on [DATE], two days after he was admitted to the facility. -She confirmed when she conducted the PHQ-9 with Resident #1, he said he felt down, depressed and hopeless. She said his answer to her follow-up question was he felt isolated and lonely. She said she offered the resident information regarding window visits and would have staff come in to visit with him more frequently. She said she did not document these interventions. She also said she alerted the activities team to check in with the resident but did not have any documentation the activities staff was informed the resident felt isolated and lonely or of any one-to-one visitation completed by the activities staff following her interview with the resident. -She also confirmed she did not create a care plan to address the resident's statements of feeling depressed, lonely and isolated. She said she did not know why she created the cognitive impairment care plan instead of ensuring his mood and emotional needs were addressed following the interview with the resident. She also said she did not contact the resident's daughter to gain insight as to the resident's mood history or background following the interview. -She said it was standard procedure to create a care plan to address the resident's feeling of loneliness and isolation. She said she did not create a care plan because the comprehensive care plan was not due yet prior to the resident taking his life. However, she agreed she did not identify the resident's hopelessness, feelings of isolation and loneliness on the baseline care plan that was created within 48 hours of the resident's admission to the facility. -She said she should not have waited 14 days to develop the resident's psychosocial care plan and should have been developed following the interview with the resident. 3. Failure to provide Resident #1 the level of supervision and the environment necessary to keep him safe from self-harm following his suicidal thoughts. a. Record review A [DATE] nursing progress note was written by the DON on [DATE] at 7:28 a.m., two hours after the resident was found in his room expired. It read the DON received a phone call from the resident's daughter indicating the resident said he wanted to kill himself. The DON entered the resident's room and spoke with the resident. The note read the resident did not verbalize to the DON that he intended to harm himself or that he had a plan to harm himself. It indicated the resident was in a pleasant mood. The DON called the resident's daughter and informed her the resident did not plan to harm himself and stated he wanted to go home. Another [DATE] nursing progress note written by a RN after the DON note above. revealed: -At approximately 4:40 to 5:00 a.m., the certified nurse aide (CNA) called the nurse into the resident's room. When the nurse entered the resident's room, the resident was in bed, lying supine (lying face upward), pale in color with no noted respirations. A plastic bag was found on top of his head. The CNA pulled the bag up and away from the resident's face to check for respirations. -The note read the nurse checked on the resident between 3:00 and 3:30 a.m. and the resident was resting quietly in his bed. The nurse stated she walked down the hallway about every hour while he was sleeping, however the resident's medical record did not reveal documentation of these checks. -The note further read the DON contacted the police at 5:55 a.m. The fire department entered the facility and pronounced the resident's death at 6:13 a.m. The resident's body was released to the coroner at 8:00 a.m. The resident's medical record was reviewed on [DATE] at 11:30 a.m. It did not reveal documentation to indicate the resident had been placed on safety monitoring following the phone call received from the resident's daughter that he wanted to kill himself by putting a bag over his head. The record did not reveal the facility staff had conducted frequent monitoring of the resident or that any further interventions were put into place following the resident's daughter's phone call to the DON. The facility's investigation of the events ,[DATE] and [DATE] read: -The DON asked the resident if he planned to harm himself and she checked the room for any objects of concern and did not find any. It read it was the DON's impression that following the interview, the resident did not have a present plan to commit suicide. The DON called the resident's daughter back and then instructed the staff to check on the resident frequently. -Finally, the investigation indicated the charge nurse checked on the resident every hour along with the CNA over the course of the night and into the morning. However, the resident's medical record did not reveal documentation of any safety checks conducted for the resident following the resident's statement to his daughter that he wanted to kill himself and the DON's visit. b. Interviews Staff interviews confirmed the facility failed to provide Resident #1 the level of supervision and the environment necessary to keep him safe from self-harm after expressing a plan that he wished to kill himself. Specifically, the interviews revealed a failure to assess the level of Resident #1's risk for self-harm, a failure to conduct a complete room search and failure to document the resident received adequate supervision. The SSD and the social services consultant (SSC) were interviewed on [DATE] at 12:30 p.m. -The SSD said if a resident expressed suicidal thoughts, facility staff should keep the resident within line of sight until a suicide lethality assessment could be completed. She said based on the score of the lethality assessment, the resident would be sent to the hospital or placed on frequent safety checks. She said the frequent safety checks should be documented on a list indicating the location of the resident, the resident's activity and which staff member conducted the safety check. -The SSC said prior to the incident with Resident #1, safety checks were documented in the progress notes of a resident's medical record. She said following the incident with Resident #1, the facility initiated a frequent safety check form in conjunction with the suicide lethality assessment. The SSD said she did not remember if the resident's medical record revealed documentation of frequent safety checks by the facility staff following the resident's suicidal thoughts. -The SSD said on [DATE], that a lethality assessment was not filled out for Resident #1 until the following day, after the resident had already taken his life. She said the suicide lethality assessment was not readily available to the nursing staff prior to the incident with Resident #1; the assessment was locked up in the social services office. She said since the incident, the assessment has been moved to the nursing station and has been made readily available. The SSD was interviewed again on [DATE] at 10:54 a.m. She said she conducted an in-service for all staff, including the DON, on how to conduct a thorough sweep of a resident's room for self-harm objects. She said objects such as trash bags or anything else that could assist with suffocation, call light cord, sharp objects, the window blinds cord were some of the items considered self-harm agents and should be removed from the room of a resident who expressed suicidal thoughts. She said a plastic trash bag was considered a self-harm agent. She said she did not know if the call light cord was removed when the DON conducted a search of Resident #1 room on [DATE]. The DON was interviewed on [DATE] at 12:46 p.m. She agreed that since the incident involving Resident #1, the facility has ensured the suicide lethality assessment is readily available at the nursing station along with a frequent safety check form. -She said the night of [DATE], Resident #1's daughter called her and said she had just gotten off the phone with Resident #1 and he said he was going to kill himself. She said the resident's daughter was panicked and was worried about him. She said when she entered Resident #1's room, he was sleeping and she woke him up. She said she made small talk with the resident and then asked him if he wanted to or had any plan to harm himself. She said Resident #1 said no, and said he wanted to go home. She said his dinner was still sitting in the room, so she offered to assist him, to which he replied he was not hungry and wanted to go back to sleep. She said before she left the room, she searched for any sharp objects, such as a knife and pills in the drawers. She said she did not find anything and left the room. -She said she told the nurse to make sure to keep a close eye on him throughout the night. She said she did not instruct the staff to document safety checks for the resident, but just to provide the resident with more attention because the resident's daughter was concerned. She said safety checks should include the location of the resident, the activity the resident was doing and the staff member name who conducted the check and she confirmed she did not instruct the staff to conduct formalized frequent safety checks on the resident. She said she did not have any documentation to show safety checks were completed for Resident #1. -She said in the early morning on [DATE], the nurse contacted her and informed her the resident had been found not breathing and with a bag over his head. She said she immediately went into the facility and made the appropriate notifications. The DON was interviewed again on [DATE] at 9:33 a.m. -She said she did not remember the entire conversation with the resident's daughter the night the daughter called to say the resident wanted to kill himself. She said she did not remember if the resident's daughter mentioned him using a bag to suffocate himself. She said the resident's daughter was panicked during the conversation. -She said she searched his room out of habit after speaking with him. She said he did not tell her he had a plan to harm himself. She said she did not think plastic bags were considered a self-harming agent, but since the incident, the SSD had given an in-service on how to conduct a proper sweep of a room and what items are considered self-harming agents. She now considers a plastic bag to be a self-harming agent. She said she did not remove the call light cord from the room and did not shorten the cord for the window blinds. She said she did not think to do those things; she did not feel the resident was able to scoot himself to the end of the bed to use the call light cord to harm himself. However, she acknowledged the resident was able to bend over the side of the bed and grab the bag out of the trash can. -She said the resident stating he wanted to harm himself to his daughter was considered a suicidal ideation. She said looking back on it now, she would have considered him to score high on the lethality assessment and would have sent him to the hospital to be evaluated. 4. Facility correction Interview and record review during the complaint investigation revealed corrective actions to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction. See above facility plan plan to remove immediate jeopardy. Corrective actions identified in the plan to identify the resident and other residents having the potential to be affected by the deficient practice, systematic changes to prevent its recurrence, and monitoring to ensure sustained correction were reviewed during the complaint investigation. Interviews with the NHA and DON confirmed the corrective actions and therefore, the facility's substantial compliance with F689 at the time of the complaint investigation. The NHA and DON were interviewed on [DATE] at 11:35 a.m. -The NHA said following the incident, the facility conducted a QAPI (quality assurance and performance improvement) meeting with the facility medical director on [DATE]. He said the QAPI plan was voted on and put into place on that day. -He said on [DATE], once the resident's body was found, they conducted an immediate investigation of the incident. He said the state agency, family and police were notified. -He said they started doing a full house audit of the psychosocial needs of each resident. He said they began education for the staff on [DATE]. -He said, during the QAPI meeting, the monitoring process was approved on [DATE]. He said a PHQ-9 depression screening assessment would be done for each resident and an ongoing review and psychosocial support every quarter and as needed. He said random staff interviews were conducted weekly starting [DATE] regarding the facility's process and changes to the policy. -He said another QAPI meeting was held on [DATE] to discuss the changes to the facility's policy and procedure. He said if a resident scored low on the suicide lethality assessment and had a history of [REDACTED]. If the resident scored high, then the resident would be placed with a 24 hour sitter until the resident could be transferred to the hospital for an evaluation. Upon their return, the resident would be placed with a 24 hour sitter for 72 hours.

Based on observations, record review, and interviews, the facility failed to properly maintain an infection control program designed to prevent the spread of COVID-19. Specifically, the facility failed to: -Ensure resident supplies and durable medical equipment (DME) was stored appropriately; -Ensure necessary PPE was worn by staff while cleaning an isolation room; -Ensure Resident #13 was placed in quarantine after he was hospitalized and returned to the facility; -Encourage, assist, and provide Resident #1, (a resident who was coughing and sneezing), with a protective mask to cover his nose and mouth when in the dining room; -Encourage, assist to properly wear, and/or provide residents with, protective masks when in common areas, or tissue to cover their nose and mouth while within less than six feet; and, -Perform hand hygiene with the alcohol based hand rub (ABHR) for at least 20 seconds. Findings include: I. Professional reference According to the Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance April 2, 2020, if possible, isolate all admitted residents (including readmissions) in their room for 14 days if their COVID-19 status is unknown. According to the Centers for Disease and Prevention (CDC), Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings, 4/13/2020, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html read in part, Current data suggested person-to-person transmission most commonly happened during close exposure to a person infected with [MEDICAL CONDITION] that causes COVID-19, primarily via respiratory droplets produced when the infected person speaks, coughs, or sneezes. Droplets could land in the mouths, noses, or eyes of people who were nearby or possibly be inhaled into the lungs of those within close proximity. Transmission also might occur through contact with contaminated surfaces followed by self-delivery to the eyes, nose, or mouth. -Unrecognized asymptomatic and pre-symptomatic infections likely contributed to transmission in these and other healthcare settings. Source control, which involved having the infected person wear a cloth face covering or facemask over their mouth and nose to contain their respiratory secretions, might help reduce the risk of transmission of [DIAGNOSES REDACTED] CoV-2 from both symptomatic and asymptomatic people. According to the Centers for Disease and Prevention (CDC) Transmission-Based Precautions, 1/16/2016, retrieved from: https://www.cdc.gov/infectioncontrol/basics/transmission-based-precautions.html read in part, In settings where Airborne Precautions cannot be implemented due to limited engineering resources, masking the patient and placing the patient in a private room with the door closed would reduce the likelihood of airborne transmission. According to the Centers for Disease and Prevention (CDC) Hand Hygiene in Healthcare Settings, last up updated 1/31/2020, retrieved from: https://www.cdc.gov/handhygiene/providers/index.html, the recommendations were: Hand hygiene helped prevent the spread of viruses. When ABHR was used, put the product on hands and rub hands together, cover all surfaces until hands feel dry; this should take around 20 seconds. II. Observations and interviews Tour of the facility on 5/7/2020 at 8:22 a.m. revealed it had two hallways North and South with resident rooms, down the north hallway there were six doorways with isolation carts observed outside the door. There were residents observed in the dining room, several residents were observed without facial coverings or masks. Several boxes of supplies on the floor stacked along the wall was observed at the front of the north hallway, (briefs, personal cleaning cloths and oxygen tubing). There was an oxygen concentrator in the hall outside of room [ROOM NUMBER]. -At 8:33 a.m. housekeeper (HSK) #1 was down the north hallway cleaning rooms, she pushed her cart next to room [ROOM NUMBER] (a room with an isolation cart at the doorway), used alcohol based hand sanitizer (ABHS) and donned gloves. She knocked on the door and entered, she did not donn an isolation gown prior to entering. She proceeded to clean the resident's room. -At 8:39 a.m. the maintenance services director (MSD) came down the hallway and approached the room in which HSK #1 was in, he told the housekeeper she needed to donn an isolation gown, which she did after she was instructed. -At 8:40 a.m. the assistant director of nursing (ADON) was observed cleaning the oxygen concentrator and removed it from the hallway. III. Staff interviews Licensed practical nurse (LPN) #2 was interviewed was interviewed on 5/7/2020 at 8:40 a.m. She said all the residents she was caring for were on isolation because they were new admissions with the exception of one resident who was on contact isolation. HSK #1 and the nursing home administrator (NHA) was interviewed on 5/7/2020 at 10:10 a.m. HSK #1 said that she had not received any training related donning PPE or what precautions to use in an isolation room, nor was she trained on transmission based precautions (droplet, contact, or airborne). The NHA said HSK #1 was new and it was her fourth day working at the facility. He said the MSD had been showing HSK #1 how to clean resident rooms and observed her to ensure she was following isolation precautions. He had no response if any training had been provided to ensure HSK #1 had been following infection control policies and procedures. Certified nurse aide (CNA) #2 was interviewed on 5/7/2020 at 10:17 a.m. She said residents were allowed out of their rooms with a facial coverings (mask). She said some of the residents refused to wear masks. She said she was not sure who was supposed to encourage residents to wear a mask when they came out of their rooms. The MSD was interviewed on 5/7/2020 at 10:41 a.m. He said he had been training housekeeper #1 and been shadowing her since Monday 5/4/2020 to ensure she was following infection control practices. He said he verbally educated HSK #1 on procedural isolation precautions related to Covid-19, but had nothing in writing. He provided a copy of HSK procedures which he said was always available on the housekeeping cart. He said officially his staff would check off competency of proper isolation techniques including using PPE by nursing staff which had not been done until that morning. -At 10:37 a.m., the director of nursing (DON) provided a copy of immediate skills checklist (donning and doffing PPE) training based on the level of precautions required (standard, droplet, contact or airborne infection isolation) which was completed with HSK #1. IV. Failure to ensure Resident #13 (a readmission) was placed on isolation/quarantine for the required 14 days. 1. Family interview Resident #13's family was interviewed on 5/8/2020 at 11:00 a.m. He said on 4/18/2020 he visited his father and the staff assisted the resident outside on to the patio. He said his father was not responding to him and he was unable to get Resident #13 to speak or respond to him verbally. He said his father did not have on a mask or any facial covering. He said his father did not look well so he took Resident #13 to the hospital and he tested positive for Covid-19 two days later. 2. Record review Resident #13 was admitted to the facility on [DATE]. He was discharged to the hospital on [DATE] and readmitted to the facility on [DATE]. Review of progress notes 4/15/2020-4/18/2020 revealed Resident #13 had a decline and was not eating or drinking. Resident #13's son was notified and he was supposed to discharge to the son's home on hospice care. The nurse's note dated 4/18/2020 at 1:15 p.m., revealed Resident #13 was brought out to the patio to visit with his son around 12:15 p.m. Resident #13 was not smiling or talking to his son and Resident #13's son wanted him transported to the hospital. V. Administrative interview The director of clinical services (DCS), NHA, DON, and ADON were interviewed on 5/8/2020 at 3:10 p.m. They said Resident #13 was tested for Covid-19 in the hospital prior to his readmission 4/3/2020 and later found to be negative. They said this was one of the reasons the resident was not isolated. The DON confirmed Resident #13 was not placed in quarantine for the recommended 14 days per CMS (see above). They said the resident had a change in condition in which he was monitored. They said he had been declining since the end of March 2020 and this was his normal behavior (not eating, wanting to be left alone and wanting to sleep a lot). They said he would push his food away and he did not want to talk on the phone with his family. They said they were treating Resident #13 urinary tract infection [MEDICAL CONDITION] and he just did not respond positively. The NHA said they did not consider testing the resident for Covid-19 because he had just been tested in the hospital prior to admission and he tested negative. The DON said oxygen tanks were usually cleaned by housekeeping and should not have been left in the hallway but stored in the clean utility area for new admissions. She said they completed infection control training upon hire to include standard precautions after they had completed basic training in their dedicated area. She said the staff member's manager would send them to either her or the ADON for specific training (to include transmission based precautions). She said they had not completed specific infection control training with HSK #1 because she would be shadowed for a week or so and then the MSD would inform them she was ready for the training. She said they immediately trained HSK #1 on transmission based precautions that morning. They acknowledged residents should be offered facial coverings/mask while out of their rooms, and new admissions or readmissions should have been in quarantine for the recommended 14 days to prevent the spread of Covid-19. VI. Observations A. Lack of prompting use of appropriate PPE A continuous observation which began on 5/7/2020 at 8:29 a.m. revealed LPN #1 did not offer Resident #1 a mask to cover her nose and mouth when she coughed and sneezed in the dining room. LPN #1 said to her I see you're still coughing and sneezing. Resident #1 said Yes (as she continued to cough and sneeze). LPN #1 did not provide, encourage, or assist Resident #1 to cover her mouth and nose with a mask. Resident #2 with her mask worn under her chin, which exposed her mouth and nose, self-propelled in her wheelchair within three feet of LPN #1 and Resident #1. Resident #1 continued to cough and sneeze as Resident #2 passed by her. LPN #1 did not encourage Resident #2 to cover her nose and mouth with her mask as she passed Resident #1. LPN #1 did not offer Resident #1 the ability to sanitize her hands after Resident #1 repeatedly coughed and sneezed into her hands. Although Resident #1 had a tissue in her hand, it was balled up and did not cover her mouth, it remained that way as she repeatedly coughed and sneezed into her hands. LPN #1 did not offer her another tissue or a mask to cover her nose and mouth as she coughed and sneezed. LPN #1 assisted Resident #1 to stand with her walker she did not offer the resident to sanitize her hands. LPN #1 did not perform hand hygiene after she touched Resident #1's walker. Resident #1 coughed and sneezed while she walked to her room. LPN #1 did not offer Resident #1 a mask to cover her nose and mouth when she coughed and sneezed along the hallway. Resident #1 and Resident #2 were roommates and they were not in isolation. As Resident #2 entered their room, she passed LPN #1 who stood by Resident #1; Resident #1 continued to cough as Resident #2 passed by her. Resident #2 said as she passed LPN #1 I have chills. LPN #1 left their room without sanitizing her hands nor assisting Resident #1 to sanitize her hands. LPN #1 did not disinfect Resident #1's walker. An observation on 5/7/2020 at 8:58 a.m. revealed Resident #2 self-propelled along the hallway in her wheelchair with her mask under her chin and passed by unidentified staff. Staff did encourage Resident #2 to cover her nose and mouth with her mask. An observation on 5/7/2020 at 9:25 a.m. revealed Resident #6 self-propelled passed the dietary aide (DA) and then self-propelled past Resident #7 (less than three feet), while in the dining room; neither resident wore a mask. The DA did not provide, encourage, or assist either resident to cover their mouth and nose with a mask. An observation on 5/7/2020 at 9:32 a.m. revealed Resident #7 self-propelled passed CNA #1 in the hallway; Resident #7 did not wear a mask. CNA #1 did not provide, encourage, or assist her to cover her mouth and nose with a mask. An observation on 5/7/2020 at 9:40 a.m. revealed Resident #7 was in the dining room and did not wear a mask. The occupational therapist (OT) approached Resident #7, this was less than three feet from her, and she did not provide, encourage, or assist her to cover her mouth and nose with a mask. An observation on 5/7/2020 at 10:05 a.m. revealed Resident #8 stood at the nurse's station with his mask under his chin, less than three feet from LPN #1; he spoke to LPN #1 and she did not encourage, or assist him to cover his mouth and nose with his mask. There were other unidentified staff at the nurse's station as well. After their interaction, he continued to keep his mask under his chin and sat down, within view of the nurse's station. LPN #1 nor the other unidentified staff did not encourage, or assist him to cover his mouth and nose with his mask. An observation on 5/7/2020 at 10:21 a.m. revealed the OT was providing care to Resident #10 in her room. She exited the room with the vital sign cart and then performed hand hygiene with ABHR for less than 20 seconds. An observation on 5/7/2020 at 10:28 a.m. revealed Resident #8 stood in the hallway with his mask under his chin, unidentified staff passed him and did not encourage, or assist him to cover his mouth and nose with his mask. An observation on 5/7/2020 at 10:30 a.m. revealed the OT was in the dining room, interacted with Resident #7 at a distance of less than three feet, and Resident #7 did not have a mask on. The OT did not provide, encourage, or assist her to cover her mouth and nose with a mask. An observation on 5/7/2020 at 10:43 a.m. revealed Resident #7 was in the dining room and did not wear a mask. Three unidentified staff were in the dining room, Resident #7 was within their view, none of the staff tried to provide, encourage, or assist her to cover her mouth and nose with a mask. B. Open doors to isolation rooms An observation on 5/7/2020 at 8:45 a.m. revealed Resident #3 had an isolation cart outside of her room which contained gloves and gowns; the door to her room was open to the main hallway. Resident #4 had an isolation cart outside of his room which contained gloves and gowns; the door to his room was open to the main hallway. An observation on 5/7/2020 at 8:48 a.m. revealed the physical therapist (PT) entered the open door of Resident #3's room to provide treatment. The PT did not shut her door. She sat down less than three feet across from Resident #3 and began to type on her computer. She did not provide, encourage, or assist Resident #3 to cover her mouth and nose with a mask. An observation on 5/7/2020 at 8:50 a.m. revealed ADON stood at Resident #3's open doorway, did not shut it, then walked away. An observation on 5/7/2020 at 9:08 a.m. revealed Resident #4 had an isolation cart outside of his room which contained gloves and gowns; the door to his room was open to the main hallway. An observation on 5/7/2020 at 9:21 a.m. revealed the door to Resident #3 and Resident #4's rooms remained open. C. Failure to sanitize multiuse activity game and puzzle pieces An observation on 5/7/2020 at 9:15 a.m. revealed the activity assistant (AA) took a scrabble game into Resident #5's room, sat less than three feet across from her, and proceeded to play scrabble with her. She did not provide, encourage, or assist Resident #5 to cover her mouth and nose with a mask. An observation on 5/7/2020 at 9:38 a.m. revealed AA exited Resident #5's room with the scrabble game and did not sanitize the game board and its pieces. She stored the game in a cabinet which contained other games and puzzles; she did not perform hand hygiene afterwards. An observation on 5/7/2020 at 10:42 a.m. revealed Resident #2 was putting a puzzle together with AA in the dining area. Resident #2 started to cough. AA continued to put the puzzle together with Resident #2 and did not ask about her cough nor stop putting the puzzle together with her to have a nurse evaluate her cough. D. Resident interview Resident #2 was interviewed on 5/7/2020 at 10:40 a.m. She said she had chills since this morning and had a cough. She said she told the nurse about it. E. Staff interviews LPN #1 was interviewed on 5/7/2020 at 10:06 a.m. She said residents were to wear masks when out of their rooms to help protect themselves and other residents and to prevent the spread of viruses. If residents were in the dining room and not eating they should have their masks on for the same reason. She said the facility had not told us about having residents cover their nose and mouth with a mask when we are providing care for them; or when less than three feet from them. She said doors to isolation rooms should be closed to prevent the potential spread of virus while in quarantine. She said Resident #1 had an itchy cough and she complained of being tired and sneezing a lot, and always wanting to lay down. She said she hadn't taken care of her before today, and did not know why she was coughing and sneezing, I don't know what her baseline is. (Resident #2) said she felt cold today, she said she had chills. She was in isolation because her husband passed due to COVID-19. I have seen other residents play with the Scrabble game before. CNA #1 was interviewed on 5/7/2020 at 10:30 a.m. She said residents were to wear masks when out of their rooms to help protect themselves and other residents and to prevent the spread of viruses. She said the facility had not told them about having residents cover their nose and mouth with a mask when they were providing care for them; or when less than three feet from them. She said doors to isolation rooms should be closed when on quarantine and staff were to sanitize their hands for 20 seconds. The DON was interviewed on 5/7/20 at 11:03 a.m. She said all residents were placed on 14 day isolation if presumed positive for COVID-19. All residents were screened every eight hours for COVID-19. Resident #2 was in isolation in March because she was presumed positive for COVID-19 and because her symptoms included a lingering barking cough, the facility kept her in isolation longer than 14 days. Her cough had since resolved and she was removed from isolation and was not in isolation now. Resident #1 always had a cough, but had not been sneezing. Resident #1 was in isolation before her former roommate passed due to COVID-19. The DON was interviewed a second time on 5/7/20 at 11:43 a.m. She said residents were to wear masks while out of their rooms; staff were to encourage them to use one to protect and prevent them from COVID-19. She said she would re-educate staff to continue to encourage residents to wear masks when out of their rooms due to their cognitive deficits. She said staff were to use ABHR for at least 20 seconds and she would re-educate them on that as well. She said LPN #1 had not reported to her that Resident #2 had chills, and Resident #1 was coughing and sneezing. She and the ADON would complete full assessments on Resident #1 and Resident #2, and notify their families. She said AA had not reported to her that Resident #2 coughed while putting a puzzle together. She said Resident #2's cough had gotten better than it was before. She said the facility removed board games and puzzles from access due to COVID-19. She said she was not aware the activity department continued to use them with residents. She said she planned to remove all board games and puzzles from access to protect residents. She said doors to residents on isolation should remain closed to prevent and protect other residents from COVID-19. She said she would educate staff to keep their doors closed until they are off of isolation. She said staff should offer residents a mask to cover their nose and mouth when they were providing care for them in their rooms. She said she would educate her staff to offer and document if they refused; staff should social distance (as best as possible) when providing care to residents without masks; to protect the residents and themselves.

Based on observation and interview, the facility failed to maintain a safe, clean and comfortable environment in one out of one shower rooms. Specifically, the facility failed to: -Maintain comfortable temperatures in the shower room; -Keep the shower room clean; -Repair a toilet that was not secured to the floor which created a potential hazard to residents; -Repair a hole in the wall which exposed piping; and -Replace missing tiles. Findings include: Facility policy and procedure The Physical Plant Hazards policy, revised (MONTH) 2019, was provided by the consultant registered nurse (CRN) on 10/30/19 at 1:50 p.m. It revealed in pertinent part, Temperature levels should be maintained at a range of 71-81 degrees Fahrenheit (F). The Checklist of Deep Clean After a Discharge procedure, undated, was provided by the nursing home administrator (NHA) on 10/30/19 at 1:40 p.m. It read in pertinent part, that all surfaces should be disinfected with appropriate surface contact times for proper sanitation, garbage should be removed and that any maintenance issues should be reported to the maintenance supervisor (MS). Group resident interviews Three residents (#6, #20 and #15) participated in a group resident interview on 10/29/19 at 2:04 p.m. During this interview, all three residents voiced their concern that the shower room was too cold. Observations of the shower room The following was observed on 10/30/19 at 11:28 a.m: -The temperature of the shower room was 66.1F; -The base of the toilet was not secured to the floor and shifted upon weight distribution; -There was a hole beneath the vanity counter which exposed sink pipes; -Sections of the tiling were missing around the trim of the shower room; -The garbage can was filled beyond the brim; and -Toothpaste and residue was in the sink. Staff interviews The certified nurse aide (CNA) was interviewed on 10/30/19 at 11:34 a.m. She said she provided showers to her assigned residents. The CNA was in the shower room and said the room felt cold to her. She said there was a heater in the room so she did not understand the reason for the shower room to feel cold. She said no residents had reported to her that the shower room was cold. The licenced practical nurse (LPN) was interviewed on 10/30/19 at 11:40 a.m. She was in the shower room and confirmed the room felt cold. She confirmed the toilet was not secured to the floor and said some residents used the toilet. The MS was interviewed on 10/30/19 at 11:47 a.m. He said he received work orders typically via phone call, text or an application on his phone. He said the application allowed staff to put in orders for needed repairs. He confirmed the toilet had required frequent repair and had not been secured to the floor since he started in (MONTH) of 2019. He said he had regularly tried to secure the toilet but it would become unsecured due to people pushing or sitting on it. He said the shower room had required frequent repairs. He said the missing tiles were not an issue because it was only cosmetic and did not create any leaks. He said he was not aware of the hole in the wall beneath the vanity where pipes were exposed and said he would fix it. He said the temperature in the shower room was set for 78 F and he was not sure why the room had not maintained that temperature. The NHA and the CRN were interviewed on 10/30/19 at 11:53 a.m. The NHA and CRN were in the shower room. The NHA said it felt somewhat cold to him in the room. He said he was unaware the shower room needed repairs for the toilet, the hole in the wall and the missing tiles. The CRN said that the shower room was cold to her. The director of nursing (DON) and NHA were interviewed on 10/30/19 at 1:29 p.m. The DON said she had not been in the shower room since the summertime. She said she had not heard any reports from staff or residents regarding the temperature of the shower room. She said she was unaware the toilet needed to be repaired or of any other needed repairs in the bathroom. The DON said the unsecured toilet created a hazard for residents because it was not a stable surface and could tip over and/or move. The NHA said that staff had access to the application for the creation of work orders for any needed repairs. The NHA said the unsecured toilet presented a fall risk to residents. The NHA said the housekeeper cleaned the bathroom every morning and that it was possible the garbage would overfill within a few hours. He said the thermostat for the shower room was set at 74 F and he was not sure why the temperature was not maintained.

Based on observations, record review, and interviews the facility must post the following staffing information on a daily basis: the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff responsible for direct resident care per shift; registered nurses (RN), licensed practical nurses (LPN) or licensed vocational nurses (LVN), certified nurse aides (CNA), and resident census. Specifically, the facility failed to post the nurse staffing information, on a daily basis, that included the census, the total number and actual hours worked, per shift, by registered nurses (RNs), licensed practical nurses (LPNs), and certified nurse aides (CNAs) directly responsible for resident care. Findings include: I. Facility policy The Staff Posting Policy/Procedure, dated 10/2018, provided by the director of nursing (DON) on 10/30/19 at 12:36 p.m., read in pertinent part: It is the policy of this facility to post nurse staffing daily. Posting will be in a visible area for all residents and resident families. Place out staffing calculator with hours per patient day (PPD). II. Observations Observation of the staff posting on the following dates: 10/28/19 at 11:43 a.m., 10/29/19 at 10:17 a.m., and 10/30/19 at 8:41 a.m., revealed the form the facility used was the Daily Staff Schedule and the following documentation was missing, three required components: the census, the total number and hours worked by RNs, LPNs, and CNAs. III. Record review Review of the daily documents that were used for staff postings for August, September, and (MONTH) 2019 revealed, the documents were the staff schedules and did not contain the total number and hours worked by RNs, LPNs, and CNAs and the census was missing on eight days in August, eight days in (MONTH) and 19 days in October. IV. Interview The DON was interviewed on 10/30/19 at 11:57 a.m. She said she was responsible for completing and posting the staffing information each day. She said she was unaware of the regulation requirement for the staff posting. V. Facility follow-up On 10/30/19 at 12:28 p.m. the DON and the consultant registered nurse (CRN) said the correct format for the staff posting was available in their computer but the DON was not aware of it and was posting the nursing schedule everyday that did not have the required components. On 10/30/19 at 1:29 p.m. the DON provided a copy of the staffing calculator form that she said was the correct form to be posted each day for staffing. She then replaced the nursing schedule with the staffing calculator form immediately.

Based on record review and interview, the facility failed to inform two (#181 and #182) of three residents reviewed for beneficiary protection notification out of 22 sampled residents about changes to the Medicare covered services. Specifically, the facility failed to provide a skilled nursing facility-advanced beneficiary notice (ABN) for two residents who had remained in the facility after their Medicare coverage had ended. Findings include: Facility policy and procedure The Advanced Beneficiary Notice (ABN) of Non Coverage (Part A) Policy, revised (MONTH) (YEAR), was provided by the director of nursing (DON) on 10/30/19 at 10:20 a.m. It revealed in pertinent part, (The facility) must issue a liability notice to original Medicare beneficiaries before the facility provides an item or service that is usually paid for by Medicare, but may not be paid for. Failure to provide the ABN may result in the facility being unable to bill the beneficiary directly for the subject services. The ABN must be verbally reviewed with the beneficiary and/or his/her representative and any questions raised during that review must be answered before it is signed. The ABN must be delivered far enough in advance that the beneficiary or representative has time to make an informed decision. Record review Resident #181 Review of the medical record revealed Resident #181 was discharged from Medicare funded therapy services on 6/6/19. The resident was issued a Notice of Medicare Provider Non-Coverage (NOMNC), however, an ABN/denial letter was not provided. The resident remained in the facility and paid privately for services. Resident #182 Review of the medical record revealed Resident #182 was discharged from Medicare funded therapy services on 5/20/19. The resident was issued a NOMNC, however, an ABN/denial letter was not provided. The resident remained in the facility while pending coverage through Long-Term Care Medicaid. Staff interviews The social services director (SSD) and social services consultant (SSC) were interviewed on 10/30/19 at 10:27 a.m. The SSD said she started in her current position in (MONTH) 2019. She reported that her process was to review the resident's insurance coverage daily. She would review the coverage in a group meeting, with staff from the business office and rehab on Wednesday mornings. She said she issued NOMNC to the residents at least three days prior to the resident's insurance coverage end date, or as soon as possible. She said if the resident elected to stay in the facility after the insurance coverage ended then she would issue the ABN with the resident and/or their family/representative. She said she would make copies for the resident and/or family if requested and would place another copy in the chart. The SSC said the residents had been discharged from the facility prior to the current SSD starting at the facility. She said the previous SSD had not issued the ABNs as required.

Based on record review and interviews the facility failed to develop and implement a comprehensive, person centered plan of care for one (#1) out of five sampled residents. Specifically, the facility failed to: Develop a smoking care plan after learning that the resident was a smoker; and Develop and implement a proper care plan for elopement after the resident eloped from the facility. Cross Reference F689: failure to keep safe from accidents. Findings Included: I. Facility Policy The facility Care Planning policy was provided by the clinical nurse resource (CNR) on 7/18/19 at 11:30 a.m., it read in pertinent part: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive care plan for each resident. II. Resident Status Resident #1, under the age of 55, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15 and exhibited no behaviors. He required supervision with his activities of daily living and assistance of one staff member with set up help only. III. Record Review a. Care Plans There was no smoking care plan developed for the resident, though the facility knew he was a smoker. An activity care plan was initiated on 5/13/19 included an intervention to assist the resident outside as needed and requested. An elopement care plan was initiated on 5/27/19 after the resident had eloped, it read: Resident is at risk for elopement related to impaired safety awareness. The goal for the care plan read Resident will not leave the facility unattended through the review date. Interventions for the care plan included: Document wandering behavior and attempt diversional interventions; increased staff rounding when resident is sitting on the patio; and patient education provided on the process for therapeutic pass. Review of the resident ' s records showed no evidence that the facility implemented any of the interventions for preventing elopement for the resident. There was no evidence of attempting to divert the resident when going outside, that staff rounded or checked on the resident when he did go outside, or that education was provided to the resident regarding pass privileges. b. Progress notes A Physician admission progress note dated 5/2/19 read that the resident was a smoker. A weekly skilled review dated 5/15/19 read that the resident needed smoking cessation. A nursing note dated 5/17/19 read that the resident had been going outside of the facility and into the back smoking area taking cigarette butts to smoke. The resident had a lighter in his possession that he gave to the nurse to lock in the medication cart. A nursing note dated 5/18/19 read that the resident approached the medication cart and demanded his lighter so he could go out and smoke. The nurse told him he did not have permission from the administrator to smoke. The resident became angry and walked away cursing that it was not fair that everyone else got to smoke. A nursing note dated 5/21/19 read that the resident came out of his room walking and that nursing reminded him that he was non weight bearing on his right leg. The resident stated that he could walk and proceeded to go out the south entrance of the facility. A nursing note dated 5/27/19 read: Resident left building just before midnight. Walked by this nurse with his coat on and out the side patio door. Has been doing this for the past two weeks-goes out and gets cigarette butts and smokes them on the patio and then comes back in. He is usually gone only 15 minutes. After one hour, called the director of nursing to see what this nurse should do. A nursing note dated 6/10/19 read that the resident was found just off the property in the back of the building smoking, when approached about coming back onto the property, he refused. Resident did come back to the facility a few minutes later on his own. IV. Interviews The CNR was interviewed on 7/18/19 at 12:30 p.m. and stated that a smoking care plan should have been developed for the resident and should have explained what was being done regarding the resident ' s smoking behaviors. She went on to state that the elopement care plan should have been more descriptive and there should have been evidence of the interventions being implemented and that the care plan should have been updated when the resident when the resident left the property again.

Based on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (#1) of five sampled residents. Specifically, the facility did not communicate or document communication with the resident or the resident ' s family regarding the plan to discharge immediately after intravenous (IV) antibiotics were discontinued. Findings Include: I. Facility Policy The facility Discharge Planning policy, revised 12/2016 was provided by the clinical nurse resource (CNR) on 7/18/19 at 12:00 p.m. it read in pertinent part: It is the policy of this facility that discharge planning and evaluation will be provided by the Social Services staff for each resident. Discharge planning involves the resident, family or responsible party, ID, and others involved in the resident ' s care plan. Social Services or designee shall involve the resident and the resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. Social Services or designee will document, complete on a timely basis based on the resident ' s needs, and include in the clinical record, the evaluation of the resident ' s discharge needs and discharge plan. The results of the evaluation will be discussed with the resident of the resident ' s representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident ' s discharge or transfer. When discharge is anticipated, an IDT meeting with the resident and their family to assist with the adjustment to his/her new living environment. The social services staff will provide preparation and orientation to the resident regarding their new environment to help ensure that the transition is as anxiety free as possible. A post-discharge plan of care or discharge summary is developed with the participation of the resident and with the resident ' s consent, the resident representative which will assist the resident to adjust to his or her new living environment. The post discharge plan/discharge summary will indicate where the resident plans to reside, any arrangements that have been made for the resident ' s follow up care and any post-discharge medical and non medical services. II. Resident Status Resident #1, under the age of 55, admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15 and exhibited no behaviors. He required supervision with his activities of daily living and assistance of one staff member with set up help only. III. Record Review a. Care Plan The discharge care plan, initiated on 5/6/19, documented the resident was admitted to the facility for skilled services and was on IV antibiotic treatments. He wished to return to his group home at the end of his stay. The resident received additional support and services through a community agency which assisted individuals with developmental disabilities. The resident was supported by his mother and step-father who were both the resident ' s medical durable power of attorney (MDPOA). The goal for the resident was to verbalize and communicate an understanding of the discharge plan and describe the desired outcome by the review date. Interventions included encourage the resident to discuss feelings and concerns with impending discharge and monitor for episodes of anxiety fear and distress; establish a pre-discharge plan with the resident and family and evaluate progress and revise the plan. Prepare and give the resident, family, and care giver contact numbers for all community referrals. b. Assessments An IDT Care Plan Review dated 5/6/19 indicated the social services plan of care documented the resident was alert and oriented, had a [DIAGNOSES REDACTED]. The resident was able to communicate his needs verbally, and denied signs and symptoms of depression. His mood and behavior were stable and the resident did not receive [MEDICAL CONDITION] medications. The special treatment, procedures and devices section of the assessment read that the resident was seeing a podiatrist, receiving IV antibiotics finishing on 5/11/19 or 5/12/19, and that the resident needed a follow up appointment with the infectious disease doctor. The discharge plan summary section of the assessment read that the resident would return to the community agency group home where meals were provided and medications were managed by a nurse and that the resident may not require home health services upon discharge. The resident and his mother were present at the care plan review meeting held on 5/7/19. A Social Services Assessment was completed on 5/13/19 and the discharge section of the assessment read that the resident was planning to return to the DDRC group home where he previously resided. His discharge needs read Home Health Services? IV antibiotic treatments? The summary section read that the resident would return to his group home, he was supported by his mother and stepfather and that social services would continue to provide support and resources as needed. c. Progress Notes A weekly skilled review dated 5/8/19 read the resident ' s estimated length of stay was discharge pending IV antibiotics and home health care, barriers to a safe discharge included fall risk, safety awareness, cognition, and decreased motivation. Care conference was held on 5/7/19 to discuss plan of care and discharge plan and to continue discharge planning with the resident and family and the resident receives services through DDRC. A weekly skilled review dated 5/15/19 read that the resident ' s estimated length of stay was pending for home health for IV antibiotic and group home assessment. Barriers to a safe discharge included: non weight bearing to right lower extremity, poor safety awareness, non-compliance with weight bearing restrictions, smoking cessation, and wound care to right outer ankle. Social services were to continue discharge planning for safe discharge to group home, coordinate home health services for a nurse to manage IV antibiotics. Additional information included that nursing documentation supports the need for skilled services for both IV antibiotics and wound care management. A weekly skilled review dated 5/22/19 read that the resident ' s estimated length of stay was pending IV antibiotic stop date and home health services. Hoping to send resident home with home health care, however; under certain IDD waiver plans, resident can not receive home health services. Facility to try to set up discharge plan back to group home after IV ' s decrease to one. Barriers to safe discharge included: infection, multiple IVs throughout the day, wound, non-adherence to recommended plan of care, and developmental disability. Social services to continue discharge planning, working with DDRC on possible home health care options. A weekly skilled review dated 5/30/19 read that the resident ' s estimated length of stay was pending IV antibiotic stop date, the resident ' s last covered day would be 6/1/19 with discharge back to group home on 6/2/19. Social services to continue with discharge planning and assist the resident and family with discharge planning. Plan to continue IV antibiotics until further notice. Additional information read that nursing documentation supported the need for skilled services. A Notice of Medicare Non-Coverage (NOMNC) was issued to the resident and signed on 6/3/19 and read that the resident ' s Medicare coverage would end on 6/6/19. A weekly skilled review dated 6/6/19 read that the resident ' s estimated length of stay was pending the discontinuation of IV antibiotics on 6/19/19. Social services to continue discharge planning with resident and family and that the resident was Medicaid pending as of 6/3/19 and was no longer under a Medicare stay. An infection progress note dated 6/19/19 read that the resident returned from an appointment with the infectious disease doctor with orders to extend the IV antibiotics until 6/26/19. An e-interact nursing home to hospital transfer form dated 6/20/19 read that the resident was transferred to the hospital upon physician orders [REDACTED]. There was no progress or nursing note related to the resident ' s transfer to the hospital and the resident did not return to the facility after the transfer to the hospital. d. Physician orders Review of the physician orders [REDACTED].>-A verbal order was obtained on 5/30/19 for the resident to discharge home on 6/2/19 -A verbal order was obtained on 6/4/19 for the resident to discharge home on 6/7/19 -A verbal order was obtained on 6/20/19 for the resident to discharge home on 6/20/19 Review of the resident ' s progress notes revealed no indication or documentation that the resident, family or caseworkers were aware or informed of any of the plans to discharge the resident on any of the above dates, nor was there documentation of any specific dates or times of the continued discharge planning referenced in the weekly skilled reviews. IV. Interviews a. Family Interview The resident ' s mother was interviewed on 7/17/19 at 10:30 a.m. and stated she was not aware the resident was going to be discharged from the facility. She stated she was not informed that the resident would be discharged immediately after IV antibiotics were stopped and there were no plans made. She continued to say the resident was still receiving IV antibiotics on the date that he was transferred to the hospital so there would have been no reason to discharge him. b. Staff Interviews The resident services resource (RSR) was interviewed on 7/18/19 at 12:30 and stated she believed that the social worker at the time was working very diligently to arrange the resident ' s discharge because he was no longer covered under Medicare. She stated referrals were made to other facilities. She said she believed the resident, his mother and his caseworkers were made aware of the plans to discharge, though there was no documentation of conversations or specific plans. The nursing home administrator (NHA) was interviewed on 7/18/19 at 12:30 p.m. and stated that the physician had written orders to discontinue the IV antibiotics on 6/19/19 and that the resident was set to discharge home on 6/20/19. He stated he could not explain why there was no documentation of communication with the resident, his family or his caseworkers related to specific discharge plans.

Based on record review and interviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (#1) out of five sampled residents. Specifically, the facility failed to follow up with the pharmacy regarding an ordered medication that was not delivered resulting in the resident not receiving ordered medication and suffering from nausea and stomach pains for an extended period of time. Findings Include: I. Facility Policy The Ordering and Receiving Non-controlled Medications policy, dated 9/10, was provided by the clinical nurse resource (CNR) on 7/18/19 at 11:30 a.m. It read, in pertinent part: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. Timely delivery of new orders is required so that medication administration is not delayed. If available, the emergency kit is used when the resident needs a non-controlled medication prior to pharmacy delivery. Emergency/STAT medication order when a medication is not available in the emergency kit: An emergency /STAT order is placed with the provider pharmacy, which will be delivered in a timely manner. II. Resident Status Resident #1, under 55, was admitted on [DATE] and discharged on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. The 5/31/19 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15 and exhibited no behaviors. He required supervision with his activities of daily living and assistance of one staff member with set up help only. III. Record review a. Physician orders Review of the resident ' s (MONTH) 2019 CPO revealed an order written [REDACTED]. Give one tablet by mouth two times a day for GERD. b. Medication Administration Record [REDACTED] Review of the resident ' s (MONTH) 2019 MAR indicated [REDACTED]. c. Progress notes A nursing note dated 6/16/19 at 8:30 a.m. read that the resident refused his IV antibiotics because they were making him sick. A nursing note dated 6/16/19 9:14 p.m. read that the resident continued to refuse IV antibiotics because they were hurting his stomach and causing diarrhea. A nursing note dated 6/17/19 at 3:18 p.m. read that [MEDICATION NAME] was unavailable and had been ordered from the pharmacy. A nursing note dated 6/17/19 8:39 p.m. read that the resident had complaints of upset stomach, but was able to eat his meal. A nursing note dated 6/18/19 at 8:28 a.m. read that [MEDICATION NAME] was unavailable and facility was awaiting the delivery from the pharmacy. A nursing note dated 6/18/19 at 6:18 p.m. read that [MEDICATION NAME] was unavailable. A nursing note dated 6/18/19 at 9:11 p.m. read that the resident was complaining of stomach upset and diarrhea. The nurse contacted the pharmacy regarding the missing medication and it was discovered that the order was sent to the wrong pharmacy. The pharmacy took the order and would deliver the medication with the next delivery. A nursing note dated 6/19/19 at 12:37 a.m. read that the resident had been complaining of nausea and diarrhea and that the [MEDICATION NAME] order had been placed. A nursing note dated 6/19/19 at 8:29 a.m. read that the [MEDICATION NAME] was unavailable and the facility was awaiting delivery. A nursing note dated 6/19/19 at 3:48 p.m. read that the [MEDICATION NAME] was unavailable. IV. Interviews The CNR was interviewed on 7/18/19 at 12:30 p.m. and stated that the staff should have been more proactive regarding the order for the resident ' s medication especially with the resident complaining of stomach upset and refusing his IV antibiotics due to stomach upset. The staff should have called the pharmacy sooner, called the physician for additional orders, or called in a STAT order for the medication. She stated that the facility/corporation switched pharmacies on 7/1/19 and hopes for better communication, deliveries, and medication availability.