Every finding on record at Lynwood Manor Healthcare Center

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment affecting 70 residents who consume food products, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased interior food service equipment illumination.Findings include: On 08/05/2026 at 10:00 AM, an initial tour of the food service was conducted with Dietary [NAME] G. The following items were noted:On 08/05/2026 at 10:03 AM, the hand sink faucet goose neck was observed leaking water, adjacent to the collar nut. Dietary [NAME] G was asked how long it had been leaking, Dietary [NAME] G stated: A few days. Dietary [NAME] G also stated: We use handwritten maintenance request forms for concerns. On 08/05/2026 at 10:04 AM, the microwave oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue.On 08/05/2026 at 10:06 AM, the juice machine (undersplash, dispensing spouts, drip tray assembly) was observed soiled with accumulated and encrusted food residue. Dietary [NAME] G was queried: How often is the juice machine cleaned? Dietary [NAME] G stated: Daily at night.On 08/05/2026 at 10:13 AM, the Walk-In Cooler entrance door gasket was observed worn and torn in two separate sections. Each damaged section measured approximately 6-8 inches long.On 08/05/2026 at 10:15 AM, the Walk-In Cooler entrance door and gasket were observed soiled with accumulated and encrusted dust/dirt/food residue.On 08/05/2026 at 10:17 AM, the two-door reach-in cooler interior light assembly was observed non-functional.On 08/05/2026 at 10:31 AM, the can opener assembly (cutting blade) and mounting bracket were observed soiled with accumulated and encrusted food residue.On 08/05/2026 at 10:33 AM, the meal plate warmer door gaskets (2) were observed (worn, torn, brittle, missing).On 08/05/2026 at 10:34 AM, the meal plate warmer interior door surfaces were observed soiled with accumulated and encrusted food residue.On 08/05/2026 at 10:40 AM, the commercial toaster air intake grill was observed soiled with accumulated and encrusted dust/dirt deposits.On 08/07/2026 at 10:00 AM, record review of the Policy/Procedure entitled: Dietary Department Guidelines dated 1/15/2025 revealed under Policy: The facility must store, prepare, and distribute food under sanitary conditions. Additionally, under The Facility: (1) The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness. and under Equipment: (1) All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner and used and repaired according to manufacturer's recommendations.On 08/07/2026 at 10:15 AM, record review of the Policy/Procedure entitled: Maintaining Food Service Equipment, undated, revealed under Policy: Maintaining food service equipment in a nursing home is essential for ensuring food safety, operational efficiency, and compliance with health regulations.The 2022 FDA Model Food Code section 5-205.15 states: A plumbing system shall be: (A) Repaired according to LAW; and (B) Maintained in good repair.The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened.The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris.The 2022 FDA Model Food Code section 6-303.11 states: The light intensity shall be: (A) At least 108 lux (10 foot candles) at a distance of 75 cm (30 inches) above the floor, in walk-in refrigeration units and dry FOOD storage areas and in other areas and rooms during periods of cleaning; (B) At least 215 lux (20 foot candles): (1) At a surface where FOOD is provided for CONSUMER self-service such as buffets and salad bars or where fresh produce or PACKAGED FOODS are sold or offered for consumption, (2) Inside EQUIPMENT such as reach-in and under-counter refrigerators; and (3) At a distance of 75 cm (30 inches) above the floor in areas used for handwashing, WAREWASHING, and EQUIPMENT and UTENSIL storage, and in toilet rooms; and (C) At least 540 lux (50 foot candles) at a surface where a FOOD EMPLOYEE is working with FOOD or working with UTENSILS or EQUIPMENT such as knives, slicers, grinders, or saws where EMPLOYEE safety is a factor.

Based on observations, interviews, record reviews, and 4 (R4, R5, R10, R28) of 16 sampled residents, the facility failed to provide palatable food products affecting 70 residents who consume food, resulting in the increased likelihood for resident decreased food acceptance and nutritional decline.Findings include: Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] with diagnoses that included depression and chronic obstructive pulmonary disease (a long-term lung problem that makes it hard to breathe). The Minimum Data Set (MDS) dated [DATE] revealed R6 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 8/5/26 at 11:15 AM, R5 was observed sitting up in a manual wheelchair with oxygen on via nasal cannula, hair was combed and clothes were observed to be clean. R5 reported that most of her meals are served cold and that staff refuse to reheat them. R5 reported that food concerns are common among the residents. Additionally, R5 reported that she doesn't eat much of the meat because it doesn't look that great. Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/3/26 revealed R10 scored 13 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). On 08/05/2026 at 1:09 PM, R10 was observed sitting in a chair in his room. R10 reported the taste of the facility's food was bad. Resident #4 (R4) Review of the medical record revealed R4 was admitted to the facility on [DATE]. The MDS with an ARD of 5/25/26 revealed R4 scored 15 out of 15 (cognitively intact) on the BIMS. On 08/05/2026 at 11:44 AM, R4 was observed sitting in his wheelchair in his room eating a granola bar. R4 reported the facility's food was too greasy, too spicey, and not good. R4 reported that was why he kept granola bars on hand. Review of the Resident Council Meeting Minutes dated 1/7/26, 2/4/26, 3/4/26, and 4/2/26 revealed Dietary-Dining room committee mtg [meeting] to follow. The Resident Council Meeting Minutes dated 5/7/26 revealed Dietary-Dining room Committee Meeting to be rescheduled. On 08/06/2026 the Dining Room Committee Meeting Minutes for the last six months were requested. On 08/06/2026, Nursing Home Administrator (NHA) A reported June 2026 were the only minutes available. Review of document provided as the Dietary meeting minutes dated 6/4/26 revealed 13 residents were in attendance. The notes revealed, Issues: 1: French fries and carrots not cooked completely. 2: Often food, especially soup, arrives cold. 3: Often the food is too salty and too spicy to eat. 4: There often is not enough food to go around on the HS [bedtime] snack cart. Some residents have observed other residents grabbing several snacks off the HS snack cart when it is taken to the hallway. Sometimes they take a bite of something and throw it back on the cart. Could the cart be covered? We have been served chicken and some vegetables 4-5 times a week. [Dietary Manager] replied that's what is on (name of facility food supplier) Food schedule and that's what she follows. [Dietary Manager] told residents there is a new part-time cook in the kitchen. R28 On 08/05/2026 at 3:17 P.M., An interview was conducted with R28 regarding facility food products. R28 stated: I don't receive the food and amount of food requested. R28 also stated: The menu items selected are wrong 95% of the time. On 08/06/2026 at 8:26 A.M., An interview was conducted with Registered Dietician (RD) H regarding food choices and portion size requests. (RD) H stated: We honor resident requests for additional food items and portions if warranted. (RD) H also stated: The meal card would indicate if the resident were on a carb (carbohydrate) consistent diet, no sugar diet, or no salt diet. On 08/06/2026 at 11:38 A.M., An interview was conducted with Dietary Aide (DA) I regarding the resident meal tray delivery schedule. (DA) I stated: 1st Dine, 2nd Dine, B-Hall, A-Hall. On 08/06/2026 at 11:50 A.M., 1st Dine lunch meal food trays (14) were observed leaving the food production kitchen, within an open stainless steel non-insulated food transport cart. On 08/06/2026 at 11:51 A.M., 1st Dine lunch meal food trays (14) were observed arriving at the Main Dining Room, within an open stainless steel non-insulated food transport cart. On 08/06/2026 at 12:02 P.M., 2nd Dine lunch meal food trays (7) were observed leaving the food production kitchen, within an open stainless steel non-insulated food transport cart. On 08/06/2026 at 12:03 P.M., 2nd Dine lunch meal food trays (7) were observed arriving at the Main Dining Room, within an open stainless steel non-insulated food transport cart. On 08/06/2026 at 12:19 P.M., B-Hall lunch meal food trays (18) were observed leaving the food production kitchen, within a stainless steel non-insulated food transport cart. On 08/06/2026 at 12:20 P.M., B-Hall lunch meal food trays (18) were observed arriving at B-Hall, within a stainless steel non-insulated food transport cart. On 08/06/2026 at 12:34 P.M., A-Hall lunch meal food trays (14) were observed leaving the food production kitchen, within a stainless steel non-insulated food transport cart. On 08/06/2026 at 12:36 P.M., A-Hall lunch meal food trays (14) were observed arriving at A-Hall, within a stainless steel non-insulated food transport cart. On 08/06/2026 at 12:42 P.M., Food product temperatures were monitored utilizing a digital thermometer. The following food product temperatures were recorded for R5's lunch meal tray: Herb Garlic Cod - 135.1Roasted Potato Medley - 119.2*Garden Seasoned Carrots - 127.5*Wheat Bread - Room TemperaturePeach Cake - Room TemperatureBeverage (Lemonade) - 64.2* On 08/06/2026 at 12:50 P.M., Food products were monitored for palatability concerns. The following items were noted: (1) The Herb Garlic Cod was observed to be somewhat dry and tough. (2) The Roasted Potato Medley was observed to be overcooked, somewhat dry, and shriveled in shape. (3) The Garden Seasoned Carrots were observed tender and flavorful. (4) The Wheat Bread was observed to be moist and supple. (5) The Lemonade beverage was observed to be warm (64.2 degrees Fahrenheit) and somewhat flavorful. (6) The Herb Garlic Cod was also observed to be overcooked, somewhat dry, and tough. On 08/06/2026 at 3:59 P.M., An interview was conducted with Nursing Home Administrator (NHA) A regarding food product temperature and quality monitoring. (NHA) A stated: We started a QAPI (Quality Assurance Performance Improvement) for food temperatures on July 8th. (NHA) A also stated: We have had three Dietary Manager's within the last 14 months. (NHA) A further stated: We are now attempting to address food related concerns with the QAPI process. On 08/07/2026 at 9:00 A.M., Record review of the Policy/Procedure entitled: Maintaining a Sanitary Tray Line dated 1/6/2025 revealed under Policy: This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause food borne illness. (*) The 2022 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under 3-501.19, and except as specified under ¶ (B) and in ¶ (C) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 degrees C (135 degrees F) or above, except that roasts cooked to a temperature and for a time specified in ¶ 3-401.11(B) or reheated as specified in ¶ 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; or (2) At 5 degrees C (41 degrees F) or less.

This citation pertains to intake 2988521. Based on interview and record review, the facility failed to provide a written notice of transfer for three (R3, R6, and R79) of five reviewed. Findings include: Resident #3 (R3) Review of the medical records reflected that R3 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), acute respiratory failure (sudden, life-threatening condition where the lungs cannot provide enough oxygen to the blood or remove [NAME] dioxide efficiently), congestive heart failure (where the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), abnormalities of gait and mobility (any unusual or unexpected patterns of walking or movement), atherosclerotic heart disease (also known as coronary heart disease or ischemic heart disease is the most common type of heart disease), occlusion and stenosis of bilateral carotid arteries (narrowing of both carotid arteries, due to plaque buildup reduces blood flow to the brain, face and head), myopathy (a group of diseases that primarily affects the skeletal muscles, which are connected to the bones and responsible for voluntary movements) and tobacco use. The most recent Minimum Data Set (MDS) with ARD/Target Date of [DATE] revealed R3 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Record review of an admission/readmission progress note revealed R3 arrived back from the hospital on [DATE] at 4:50 PM via private wheelchair van. Reported R3 was alert and oriented times three and was able to make needs known. Vital signs were stable and R3 requested for his oxygen to be placed on him. R3 was admitted to the hospital for urinary tract infection (UTI) and a skin infection. Foley catheter was patent and intact draining clear yellow urine. Physician notified and medications verified. Call light within reach. Record review did not reveal a bed hold policy/transfer/discharge paperwork for hospitalization on [DATE]. During an interview on [DATE] at12:15 PM, via email the NHA A and DON B was asked for bed hold policy/transfer/discharge paperwork on hospitalization for R3 on [DATE]. During an interview on [DATE] at 1:04 PM, staffing coordinator/med records staff J stated she uploads the bed hold's after reviewed by DON B and added she hasn't had any transfers or discharges to do yet. Record review revealed census reported stop billing on [DATE] and start billing again on [DATE] for R3. During an interview on [DATE] at 2:42 PM and on [DATE] at 9:28 AM, requested transfer/discharge paperwork for R3. During an interview on [DATE] at 12:43 PM, DON B stated R3 went from an appointment at the podiatrist to the hospital. DON B stated they did not have anything on R3 for a bed hold or transfer/discharge paperwork on R3. Resident #6 (R6) A review of the medical record revealed R6 was admitted to the facility on [DATE] with diagnoses that included weakness and type 2 diabetes mellitus. The Minimum Data Set (MDS) dated [DATE] revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). A review of the Nurses Note dated [DATE] indicated that R6 was transferred to the hospital for difficulty breathing. A review of the medical record revealed no record of a written notice of transfer/discharge was provided to R6. On [DATE] at 1:20 PM, during an interview with DON B, she reported that R6 was provided with a bed hold policy and transfer notice. A copy of the bed hold policy for R6 was provided by the facility; however, no written notice of transfer was provided. On [DATE] 1:49 PM, DON B reported that the transfer notice was in the medical record under the Assessments tab. DON B reviewed what was available in the electronic record under the Assessments tab and confirmed there was no transfer notice in R6s medical record. Resident #79 (R79) Review of the medical record revealed R79 admitted to the facility on [DATE] with diagnoses that included congestive heart failure, type 2 diabetes mellitus, and hypertension. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] revealed R79 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). Review of the Nurses Note dated [DATE] revealed R79 was transferred to the hospital due to an increase in lethargy, shortness of breath, and functional decline. Review of the Discharge Return Anticipated MDS with an ARD of [DATE] revealed R79 had an unplanned discharge to the hospital. Review of the medical record revealed no record of a written notice of transfer/discharge was provided to R79. R79 readmitted to the facility on [DATE] and died in the facility on [DATE]. In an interview on [DATE] at 3:44 PM, Director of Nursing (DON) B reported a written bed hold policy was provided to the resident upon transfer to the hospital. When asked if a written notice of transfer was provided, DON B reported the resident was updated verbally, but nothing was provided in writing. Review of the facility's Transfer and Discharge policy dated [DATE] revealed 3. The facility's transfer/discharge notice will be provided to the resident and resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided:a. The specific reason and basis for transfer or discharge.b. The effective date of transfer or discharge.c. The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is to be transferred or discharged .d. An explanation of the right to appeal the transfer or discharge to the State.e. The name, address (mailing and email) and telephone number of the State entity which receives such appeal hearing requests.f. Information on how to obtain an appeal form.g Information on obtaining assistance in completing and submitting the appeal hearing request.h. The name, address (mailing and email), and phone number of the representative of the Office of the State Long-Term Care Ombudsman.i. For nursing facility residents with intellectual and developmental disabilities (or related disabilities) or with mental illness (or related disabilities), the notice will include the name, mailing and e-mail addresses and phone number of the state agency responsible for the protection and advocacy of these populations . 1. Emergency Transfers to Acute Care . a. Provide a notice of transfer and the facility's bed hold notice policy to the resident and representative as indicated.

Based on observation, interview and record review, the facility failed to ensure accurate and thorough completion of a do-not-resuscitate (DNR) document for one (R11) of two residents reviewed. Findings include:On 8/05/26 at 1:55 PM, R11 was observed asleep on his back with nasal cannula in place, and resident was well groomed. A review of the clinical record revealed R11 was admitted into the facility on 6/10/26 with diagnoses that included: malignant neoplasm of prostate (prostate cancer) and pneumonia. According to the Minimum Data Set (MDS) assessment dated [DATE], R11 scored 7/15 (severely impaired cognition) on the Brief Interview for Mental Status exam (BIMS-a cognitive screening tool). A review of R11's (Name of State) General Procedures DO-NOT-RESUSCITATE form revealed R11 signed the form as the Guardian (instead of the spot designated for Declarant) on 6/10/26, there is a physician signature on the form but no associated date next to it, the entire first page of the form was not filled out, including the line This do-not-resuscitate order is issued by (followed by a blank space for the physicians name to be typed or printed), attending physician for (followed by a blank space to type or print declarant or ward's name). Also left blank on the first page were the sections for declarant consent which included, lines for declarant signature and date, Because the resident signed as the guardian, the remainder of the first page of the form remained blank with exception of his first initial and last name being handwritten on the bottom right-hand side. On 8/07/26 at 11:15 AM, during an interview with Director of Nursing (DON) B, when asked if Advanced Directives were audited for accuracy and completeness, she reported that they are audited by nursing and by medical records prior to uploading to the electronic medical record. When asked to review the Advanced Directive on file for R11, DON B agreed that the top portion of the form should have been filled out (to clearly identify who the form was for), that the resident shouldn't have signed as a guardian and that the physician's signature should have been dated.

Based on observation, interview, and record review, the facility failed to provide physical and occupational therapy services as ordered for one resident (R35) of one reviewed.Findings include: On 8/05/26 at 10:50 AM, R35 was observed sitting up in a recliner, crocheting. R35 appeared clean and without odor. R35 reported wanting to be seen by therapy services and feels like she is stronger than she was when she last received therapy services. R35 further reported that she would like to be able to use her walker again and pointed to a walker folded up in a corner of her room. R35 reported that she currently gets around using a wheelchair. R35 reported that the facility physician had asked her how rehab was going to which the resident reported that she had not had any rehab since before she developed vertigo.Review of the medical record revealed R35 was admitted to the facility on [DATE] with diagnoses that included congestive heart failure, type 2 diabetes mellitus, and hypertension with recent readmission [DATE]) following hospitalization (6/3/26-6/5/26). The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/24/26 revealed R79 scored 14 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool).A review of R35's Kardex (document used by facility staff to know residents' current level of assistance/basic care needs) revealed R35 was a partial assist for transfers and supervision for toilet use.A review of R35's MDS assessment, section GG-Functional Abilities, dated 7/24/26 indicated that resident used both a walker and a wheelchair and was not evaluated for walking 10 feet with the following response not attempted due to medical conditions or safety concerns.A review of R35's Physician progress notes revealed that Facility Physician (FP) L requested Physical therapy to evaluate and treat. Occupational therapy to evaluate and treat. Permission to use standing orders. on 6/8/26, 7/8/26 and 8/5/26.A review of the most recent physical therapy notes provided by the facility revealed resident was discharged from physical therapy (PT) with a discharge reason listed as discharged to Hospital. A review of the most recent occupational therapy noted provided by the facility revealed resident was discharged from occupational therapy (OT) with a discharge reason listed as discharged to Hospital. On 8/07/26 at 11:09 AM, during an interview with Certified Nursing Assistant (CNA) O, she reported that R35 requires contact guard assistance with transfers. When asked if R35 ambulates with her walker at all, CNA O reported that she has not seen that and that the resident uses a wheelchair to get around.On 8/07/26 at 10:08 AM, during an interview with Occupational Therapy (OT) M, it was reported that R35 was not currently on therapy case load but had been receiving services with both PT and OT in June 2026. OT M confirmed that the reason services ended were due to resident being hospitalized and reported that residents are generally seen by therapy following a hospitalization of several days or more. When asked when R35 would be due for a therapy evaluation OT M reported they are completed quarterly and she would be due in the next few weeks. When asked about the 3 physician notes that requested resident be evaluated and treated by PT and OT, OT M reported she would have to look into that. No additional follow-up was provided from OT M prior to survey exit. On 8/07/26 at 10:17 AM, during an interview with Unit Manager (UM) N, when asked how therapy services are alerted to restart services following a return from the hospital, she reported they would be considered a readmission and it would be the responsibility of the admitting nurse to enter the orders to alert therapy. UM N reviewed the physician notes that indicated R35 should be evaluated by PT/OT and reported that she would follow up with what she is able to find out. On 8/07/26 at 10:53 AM, UM N reported that in the PT/OT notes from the hospital they indicated that the resident was at her baseline level of function and that could have been why therapy did not move forward with an evaluation. When asked if that was documented in the medical record anywhere UM N reported it was not.On 8/07/26 at 11:29 AM, during an interview with Nursing Home Administrator (NHA) A, she reported that she believed a resident that was on therapy services prior to a hospitalization would be screened prior to a full evaluation to determine if they still require services or they should be started right off the bat if the doctor orders an evaluation/treatment. When asked about the statement indicating the resident wasn't evaluated due to the hospital PT/OT notes indicating that the resident was at her baseline level of function, NHA A reported we just laugh at that and indicated that she would have therapy evaluate R35 as soon as possible. A review of the facilities policy, titled Therapy Evaluation updated 12/16/25, documented in part The licensed therapist will perform an initial resident evaluation upon physician referral and any re-evaluation where indicated. The rehabilitation department will be notified when a physician order is written for therapy evaluation and treatment. The licensed therapist will perform a chart review and initiate the evaluation.

Based on observations, interviews and record review, the facility failed to develop a policy and procedure to ensure one resident (R3) of one resident reviewed, could safely use a vaping pen device also known as an e-cigarette inside of the facility in his room. Findings Include;Resident #3 (R3)Review of the medical records reflected that R3 was admitted to the facility on [DATE]. Diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe), acute respiratory failure (sudden, life-threatening condition where the lungs cannot provide enough oxygen to the blood or remove [NAME] dioxide efficiently), congestive heart failure (where the heart muscle is unable to pump enough blood to meet the body's need for blood and oxygen), abnormalities of gait and mobility (any unusual or unexpected patterns of walking or movement), atherosclerotic heart disease (also known as coronary heart disease or ischemic heart disease is the most common type of heart disease), occlusion and stenosis of bilateral carotid arteries (narrowing of both carotid arteries, due to plaque buildup reduces blood flow to the brain, face and head), myopathy (a group of diseases that primarily affects the skeletal muscles, which are connected to the bones and responsible for voluntary movements) and tobacco use. The most recent Minimum Data Set (MDS) with ARD/Target Date of 07/24/2026 revealed R3 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15.During an observation and interview on 08/06/2026 at 7:42 AM, Registered Nurse (RN) K administered morning medications to R3. It was observed that R3 had a vaping pen device in his left hand and would use it as he wished while lying in his bed, wearing O2 at 2 lpm per nc continuously.During an interview on 08/06/26 at 15:34 PM, writer requested a vaping pen device policy via email to HNA A and DON B. During an interview on 08/07/2026 at 7:36 AM, writer emailed HNA A and DON B for smoking policy, and it was uploaded into Egress at 7:56 AM. During an interview on 8/07/2026 at 7:50 AM, writer received email response from HNA A, that they did not have a vaping pen device policy. Record review revealed R3 had smoking assessments related to smoking cigarettes but not a vaping pen device that could be used inside the facility. During an observation and interview on 08/07/2026 at 10:06 AM, R3 stated he used to smoke cigarettes until about 6 months ago, he switched to using a vaping device. R3 stated he smoked cigarettes when he was admitted to the facility. R3 observed wearing oxygen (O2) at 3 liters per minute (lpm) per nasal canula (nc) continuously at that time with a vaping pen device in his left hand. No observation of a designated smoking area sign in R3's room.During an interview on 08/07/2026 at 12:27 PM, DON B was asked if an assessment was completed when R3 went from smoking cigarettes to using a vaping pen device. DON B stated there was a point when he needed an eye surgery and they wouldn't do it because he had nicotine in his blood. In December 2026 they completed a smoke assessment on R3. DON B stated she was not aware of vaping pen device being an e-cigarette and needed its own policy. Record review of the facilities Smoking Policy revealed.Resident smoking is permitted only in places where it is designated.Smoking is prohibited in any area where oxygen is being used or stored, in any area that bears a No-Smoking sign, or in any area that would create a hazardous or unsafe condition.Smoking is prohibited anywhere indoors, and outdoors in public areas or where groups of people frequently gather.Per the State Operations Manual (SOM). Residents who wish to use e-cigarettes should be assessed for their ability to safely handle the device. Concerns related to resident safety with use of e-cigarettes should be investigated using the guidance at 42 CFR 483.25(d), Accidents and Supervision.consider how facilities balance resident safety with a resident's right to use these devices while also considering the rights of residents who do not want to be exposed to second-hand aerosol. For concerns related to resident choice to use e-cigarettes in facilities where the devices are permitted and for residents who do not wish to be exposed to second-hand aerosol.

This citation pertains to intake 2747712Based on observation, interview, and record review the facility failed to implement interventions to prevent accidents for one resident (#1) of three resident reviewed for accidents.Findings Included: Resident #1 (R1)Review of the medical record demonstrated that R1 was admitted [DATE] with diagnoses that included pain left knee, diverticulosis (the formation of small bulging pouches in the lining of the colon), disorder of bone density, epilepsy (chronic neurological disorder), hyperlipidemia (high fat content in blood), hypertension, type 2 diabetes, weakness, difficulty walking, lack of coordination, and fracture of the sacrum. Review of the most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/12/2026, revealed a Brief Interview for Mental Status (BIMS) of 15 (cognitively intact) out of 15.Review R1's medical record revealed that 01/30/2026 she was discharged from the facility because of an incident that occurred while being transported back to the facility from an appointment. R1's medical record also revealed that she was readmitted on [DATE] with new diagnoses that included distal femur fracture, fibula fracture, and bimalleolar ankle fracture.Review of a facility investigation file provided revealed that on 01/30/2026 at approximately 04:00 p.m. R1 was picked up by [NAME] Manor Driver C, to return to the facility from the outside appointment. At approximately 04:49 p.m., while being transported back the facility, [NAME] Manor Driver C was required to make a sudden stop. As a result of this sudden stop, R1 came out of her wheelchair and landed on the floor of the facility van. R1 was transported to the local emergency department by an area ambulance. Review of the facility investigation file [NAME] Manor Driver C had not applied the van seat belt to R1 prior to returning to the facility.On 02/20/2026 at 09:56 a.m., during an interview, [NAME] Manor Driver (LMD) C explained that on 01/20/2026 at approximately 04:00 p.m. he arrived with the facility van to transport R1 from an appointment back to the facility. LMD C explained that he placed R1 into the van and anchored her wheelchair to the floor of the van using the appropriate strap devices. LMD C explained that he could not recall if he had placed the van seatbelt around R1. LMD C explained that while driving back to the facility, he had encountered a location on the road which contained backed up traffic. LMD C explained that this occurred as the facility van was going around a corner with a significant blind spot. LMD C explained that it was necessary for him to apply the van brakes in a hard manner. LMD C explained that when this occurred R1 came out of her wheelchair and landed on the van floor. LMD C explained that he pulled into an area business parking lot and assessed R1. LMD C explained that he could not move R1 and contacted the facility and the was directed to contact 911. LMD C explained that R1 was transported to the area hospital by an ambulance. LMD C was asked why the van seat belt had not been applied to R1 prior to transportation. LMD C explained that he had thought the seat belt had been applied but apparently, he had forgotten to apply the seat belt. LMD C explained that he had received education on the use of an updated Transportation Driver Check List for Wheelchair Transport document on 01/30/2026, after the incident and again on 02/02/2026. On 02/20/2026 at 10:37 a.m. during and interview Nursing Home Administrator (NHA) A explained that on 01/30/2026 at approx. 04:30 p.m. she was notified of the above incident with R1. NHA A explained that an investigation was initiated immediately on 01/30/2026. NHA A explained that as a result of the investigation it was determined that [NAME] Manor Driver C had failed to apply the seat belt to R1 upon transportation. NHA A explained that following actions were initiated:A new form entitled Transport Driver Checklist for Wheelchair transport was developed and initiated. The new checklist included- wheelchair properly placed, wheelchair secured/brakes locked, 4-point anchors, seatbelt secured properly. Check list was to be completed on each transport.All Van Drivers were re-educated by 02/03/2026 for safety training and use of the new Transportation Driver Checklist for Wheelchair transport.An Ad Hoc Quality Improvement Council Meeting was conducted on 02/02/2026.Visual Audits will be completed no less than 2x per week for 4 weeks of driver securing passenger in van, and then weekly x 4 weeks. Audits will be done by NHA or designee. Audit reviews of the document Transport Driver Checklist for Wheelchair transport will be completed weekly for 4 weeks. During an interview on 02/20/2026 at 11:10 a.m. R1 was observed lying down in bed and it was observed that her left leg was elevated and covered by bedding. R1 explained that on 01/20/2026 that she had gone to an appointment outside of the building. R1 explained that once the appointment was completed her sister had called the facility requesting transportation to return. R1 explained that when the facility van arrived, she was assisted into the van by the driver. R1 explained that the van driver secured the wheelchair to the floor of the van but did not place a seat belt around her. R1 explained as the van was returning to the facility the van driver stopped suddenly at which time she was thrown out of her wheelchair and landed onto the floor. R1 explained that she was then transported to the hospital by an ambulance. R1 explained that she had broken her left leg and broken her left ankle. R1 explained that both fractures required surgery. R1 explained that her pain had not increased due to the fractures and her level of function for activities of daily living had not changed due to the new fractures. R1 explained that she was originally admitted after a fractured pelvis so the pain was no different and that her level of function for activities of daily living had not changed because of the new fractures to her left leg and ankle.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:A new form entitled Transport Driver Checklist for Wheelchair transport was developed and initiated. The new checklist included- wheelchair properly placed, wheelchair secured/brakes locked, 4-point anchors, seatbelt secured properly. Check list was to be completed on each transport.All Van Drivers were re-educated by 02/03/2026 for safety training and use of the new Transportation Driver Checklist for Wheelchair transport.An Ad Hoc Quality Improvement Council Meeting was conducted on 02/02/2026.Visual Audits will be completed no less than 2x per week for 4 weeks of driver securing passenger in van, and then weekly x 4 weeks. Audits will be done by NHA or designee. Audit reviews of the document Transport Driver Checklist for Wheelchair transport will be completed weekly for 4 weeks.The facility was able to demonstrate monitoring of the corrective action and maintained compliance.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain food service equipment effecting 71 residents, resulting in the increased likelihood for cross-contamination and bacterial harborage. Findings include: On 06/02/25 at 09:40 A.M., An initial tour of the food service was conducted with Dietary Director (DD) G. The following items were noted: The Scottsman ice machine entrance door (misaligned) and front panel cover plate were observed broken. (DD) G stated: I will contact maintenance for repairs. The 2022 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. The Scottsman ice machine ice scoop clear plastic caddy was observed soiled with accumulated and encrusted mineral (calcium and lime) deposits. (DD) G stated: I will have staff clean the caddy now. The Vulcan convection oven interior and exterior surfaces were observed soiled with accumulated and encrusted food residue. (DD) G indicated he would have staff thoroughly clean and sanitize the oven interior and exterior surfaces as soon as possible. The can opener assembly was observed soiled with accumulated and encrusted food residue. The can opener mounting bracket assembly was also observed soiled with accumulated and encrusted food residue. (DD) G indicated he would have staff thoroughly clean and sanitize the can opener and mounting bracket assemblies as soon as possible. The Vulcan griddle backsplash and corner edges were observed with accumulated and encrusted food residue. (DD) G indicated he would have staff thoroughly clean and sanitize the griddle surfaces as soon as possible. The CPG (Cooking Performance Group) oven interior and exterior front burner panel was observed with accumulated and encrusted food residue. (DD) G indicated he would have staff thoroughly clean and sanitize the exterior oven surfaces as soon as possible. The 2022 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. The mechanical dish machine wash temperature gauge was observed to read 115 degrees Fahrenheit during the operational cycle. (DD) G stated: I will contact maintenance for repairs. The 2022 FDA Model Food Code section 4-501.110 states: (B) The temperature of the wash solution in spray-type warewashers that use chemicals to SANITIZE may not be less than 49oC (120oF). The wash solution temperature in mechanical warewashing equipment is critical to proper operation. The chemicals used may not adequately perform their function if the temperature is too low. Therefore, the manufacturer's instructions must be followed. The temperatures vary according to the specific equipment being used. Record review of the Policy/Procedure entitled: Dietary Department Guidelines dated 01/15/2025 revealed under The Facility: (1) The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness. Record review of the Policy/Procedure entitled: Dietary Department Guidelines dated 01/15/2025 further revealed under Equipment: (1) All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner, used and repaired according to manufacturer's recommendations. Record review of the Policy/Procedure entitled: (Facility Name) dated (no date) revealed under Policy Statement: (Facility Name) will maintain food service equipment to ensure food safety, operational efficiency, and compliance with health regulations.

Based on observation, interview, and record review the facility failed to ensure for four out of four residents (Resident #14, 18, 35 and 37) cigarettes, lighters, and vaps were stored in a secured manner. Findings Included: Resident #14 (R14): Review of a SMOKING-SAFETY SCREEN dated 2/20/2024, revealed R14 was screened to be safe to smoke independently and without supervision. The screen also revealed R14 did not require the facility to store his light or cigarettes. Review of a care plan that was in place with a Focus of (R14) is a smoker dated 2/20/24 and revised on 4/23/2024, revealed under the interventions, (R14's) smoking supplies are stored with (R14). The care plan did not include how R14 was to safely store the cigarettes and lighter to prevent other residents from obtaining the cigarettes and/or lighter while the products were stored in R14's room. Resident #35 (R35): Review of a SMOKING-SAFETY SCREEN dated 12/9/2024, revealed R35 was screen to be an independent smoker, could light cigarette, and dispose of cigarette. The screen revealed R35 also used a [NAME], and did not need the facility to store lighter and cigarettes for him. Review of a care plan in place with a Focus of (R35) is a smoker revealed an intervention of, (R35) smoking supplies are stored with (R35). The care plan did not include how R35 was to safely store the cigarettes and lighter to prevent other residents from obtaining the cigarettes and/or lighter while the products were stored in R35's room. In an observation on 6/03/2025 at 8:38 AM, it was observed, that a pack of cigarettes and two lighters were inside of a baseball cap on R35's over the bed table. R35 stated that he did not have to keep the cigarettes and lighters locked up or secured, and was able to go smoke at his leisure. During an interview on 6/04/2025 at 12:13 PM, Director of Nursing (DON) B was asked if residents were to secure/lock up smoking items if the items were stored in the resident's room. DON B stated the residents did not like having to wait for a nurse to unlock the medication cart, and get their cigarettes and lighter for them. DON B was asked if she knew how many lighters, vaps, and packs of cigarettes were being stored in resident rooms in order to assure items were not coming up missing, in which DON B stated no. Review of the facility policy and procedure titled Smoking Policy-Residents dated 5/4/2022, revealed no language regarding securing/locking up cigarettes, lighters, or vaps when a resident was able to keep those items in their rooms. The policy did not speak to residents having the ability to keep the items in their rooms. 45135 Resident #18 (R18) Review of the medical record reflected R18 was an initial admission to the facility on [DATE] and readmitted after a hospital stay on 03/24/2023. Diagnoses of heart failure, Dysphagia (difficulty swallowing), Aphasia (difficulty communicating due to stroke), muscle weakness, abnormal gait and a history of a stroke. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025 revealed R18 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R18 requires assistance with personal care and uses a wheelchair as an assistive device. During an interview on 06/03/25 at 12:03 PM, R18 could answer questions by nodding her head or pointing to the item. Writer asked R18 if she was a smoker, and she nodded her head yes. Writer asked where she kept her cigarettes and lighter, she pointed to her top drawer, writer asked permission to open the drawer, and she nodded her head yes. No cigarettes or lighter visible in her drawer. Writer asked if she had to keep her cigs and lighter locked up, she nodded her head yes and pointed out in the hallway, writer asked her if she kept them in the medication cart and she nodded her head yes. During an interview on 06/03/25 at 12:07 PM, DON B stated all the smoking residents keep their cigarettes, lighters, and vape devices in their rooms. DON B stated they did a smoking assessment and determined if they could smoke independently or not and if so, they could keep their supplies in their room. DON B also stated the residents could store smoking supplies in their rooms as it is their property. Record review revealed R18 had a previous smoking assessment dated [DATE], it was a smoking agreement that was signed by R18. R18 was no longer able to smoke independently as documented on her smoking letter dated 06/25/24 and signed by LNA A. This smoking document stated R18 was non-compliant with the smoking agreement, so her smoking devices needed to be always locked up with the nursing staff. This same document had the date crossed out and dated 06/25 with staff initials. During an interview on 06/03/25 at 3:54 PM, Licensed Practical Nurse (LPN) F stated R18 had her cigarettes and lighter in her room. LPN F also stated she could keep them with her in her room. During an interview on 06/04/25 at 12:13 PM, DON B stated only the smokers got the smoking assessment. Shows how often they smoke, what they smoke, care planned yes/no, and if nursing staff had to keep items locked up. DON B also stated they look at how they light it, do they need assistance, can they smoke on their own, can they put out the cigarette themselves. DON B also stated the smoking assessment form shows dependent or independent outside in the courtyard. DON B stated residents with supervised smoking is someone who needs assistance with lighting the cigarette, holding of the cigarette, and they would have certain smoking times. DON B stated they currently do not have anyone that needs help/supervising while smoking. DON B stated residents smoking unsupervised, means they can smoke when they want to, could go in and out of the courtyard as they want to, no set times. DON B added there is no need for any staff to be out there with them because of their smoking agreement. They can keep their own smoking parafunctional in their room in their possession. DON B stated they look at residents Brief Interview for Mental Health (BIMS) score so if they are over a 11-12 and above can keep items in their smoking paraphernalia in their room. Writer asked if she had any concern with fire risk at the bedside, DON B stated no. Writer asked if the smoking paraphernalia was secured in their room? DON B stated no, it is in their room or in their pockets. Writer asked DON B how she assured other residents did not get a hold of these. DON B stated they had not had that problem before. Writer asked DON B if she was aware the smoking residents were leaving their paraphernalia sitting out on the over the bed table. DON B stated she was not aware of any residents leaving their smoking items out in the open. Writer asked DON B if R18 was a supervised smoker, due to the smoking letter that stated she was non-compliant and no longer allowed to smoke independently. DON B stated this resident was an independent and could keep her smoking items in her room. Writer asked DON B why R18 had a smoking agreement that documented that she was non-complaint with the smoking agreement and was now supervised as of 06/24/2024 and that date is crossed out with 06/25 written through it and it was initialed. DON B stated R18 was independent, and she was unaware of the letter stating she was no longer independent. Resident #37 (R37) Review of the medical record reflected R37 was an initial admission to the facility on [DATE] and admitted to hospice on 01/16/2025. Diagnoses of Chronic Obstructive pulmonary Disease, Non-ST Elevation (NSTEMI) Myocardial Infarction, Acute Kidney Failure and lack of Coordination. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 04/22/2025 revealed R37 had a Brief Interview of Mental Status (BIMS) of 14 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R37 requires assistance with personal care and uses a walker or wheelchair as an assistive device. During an observation on 06/02/25 at 2:06 PM, R37 had a pack of cigarettes and 2 lighters (1 blue and 1 red) sitting on his over the bed table, a blue plastic bowl sitting on his heat/cooling register with 1 single cigarette and a green lighter, and an inhaler. R37's oxygen was turned off and his nasal cannula was draped over the O2 concentrator. Record review revealed R37 did not have an updated smoking safety screen since his admission. One was completed today while this survey was in progress at 2:20pm. During an interview on 06/03/25 at 11:51 AM, R37 stated he kept his smoking paraphernalia in his dresser drawer. R37 stated there was no limit on the number of cigarettes or lighters they can have. R37 stated they were expected to manage their own cigarettes and lighters. Writer asked R37 if he had had any incidents of other residents coming in his room trying to take his lighters or cigarettes, he stated not really. During an interview on 06/03/25 at 12:07 PM, DON B stated all the smoking residents keep their cigarettes, lighters, and vape devices in their rooms. DON B stated they did a smoking assessment and determined if they could smoke independently or not and if so, they could keep their supplies in their room. DON B also stated the residents could store smoking supplies in their rooms as it is their property. During an interview on 06/03/25 at 3:54 PM, Licensed Practical Nurse (LPN) F stated R37 had his cigarettes and lighter in his room. LPN F also stated he could keep them with her in her room. During an interview on 06/04/25 at 12:13 PM, DON B stated only the smokers got the smoking assessment. Shows how often they smoke, what they smoke, care planned yes/no, and if nursing staff had to keep items locked up. DON B also stated they look at how they light it, do they need assistance, can they smoke on their own, can they put out the cigarette themselves. DON B also stated the smoking assessment form shows dependent or independent outside in the courtyard. DON B stated residents with supervised smoking is someone who needs assistance with lighting the cigarette, holding of the cigarette, and they would have certain smoking times. DON B stated they currently do not have anyone that needs help/supervising while smoking. DON B stated residents smoking unsupervised, means they can smoke when they want to, could go in and out of the courtyard as they want to, no set times. DON B added there is no need for any staff to be out there with them because of their smoking agreement. They can keep their own smoking parafunctional in their room in their possession. DON B stated they look at residents Brief Interview for Mental Health (BIMS) score so if they are over a 11-12 and above can keep items in their smoking paraphernalia in their room. Writer asked if she had any concern with fire risk at the bedside, DON B stated no. Writer asked if the smoking paraphernalia was secured in their room? DON B stated no, it is in their room or in their pockets. Writer asked DON B how she assured other residents did not get a hold of these. DON B stated they had not had that problem before. Writer asked DON B if she was aware the smoking residents were leaving their paraphernalia sitting out on the over the bed table. DON B stated she was not aware of any residents leaving their smoking items out in the open.

Based on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #2) out of five reviewed for unnecessary medications. Findings include: Resident #2. (R2) Review of the medical record reflected R2 was an initial admission to the facility on [DATE] and admitted to hospice on 05/16/2025. Diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Acute Kidney Failure, Chronic Kidney Disease, Stroke and unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 11 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 is dependent with all care and uses an electric wheelchair as an assistive device. Record revealed R2 had Ativan oral tablet 0.5mg, give 1 tablet by mouth every 4 hours as needed for anxiety, start date of 05/16/2025 with no end date. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025 with no end date. Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 with no end date. Record review of the Medication Administration Record (MAR) for the month of May 2025 showed R2 did not receive any Ativan 0.5mg tablets. R2 requested Hydrocodone 5/325mg tablet three times for a pain rated 5-7 on a scale of 0-10. R2 did not request any Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, or shortness of breath. Record review of the MAR for the month of June 2025 showed R2 did not receive any Ativan 0.5mg tablets. R2 requested Hydrocodone 5/325mg tablet three times for a pain rated 5-7 on a scale of 0-10. R2 did not request any Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, or shortness of breath. During an interview on 06/04/2025 at 8:21AM, SWD C stated his role is to get the consents for the use of these medications and nursing is the one who addresses them. SWD C added they do not like prn's, they do a 14-day trial and see how often they use it, they try to use non-pharmacal first. During an interview on 06/04/25 at 8:37 AM, DON B stated there would be a 14 day stop date and provider had to write a note. Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 with no end date. DON B added providers just leave that as needed, if pharmacy had not caught it, they usually do. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025 was ordered from hospice and Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 was ordered prior. DON B stated they would not stop the as needed medications or give an end date. These as needed orders were written by DON B. Per the State Operation Manual (SOM) . PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication . Record review of all discipline progress notes revealed no pain or anxiety re- assessments following the addition of Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025, Ativan oral tablet 0.5mg, give 1 tablet by mouth every 4 hours as needed for anxiety, start date of 05/16/2025 with no end date. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025, within the 14 days following the starting of these medications as recommended by the SOM. There was no documentation that these medications were still needed or not.

Based on observation, interview, and record review the facility failed to ensure two (Resident #18 and Resident #2) residents reviewed for care plans, had a comprehensive care plan that was revised for resident care needs, resulting in the potential for all care needs not being met. Findings Include: Resident # 18 (R18) Review of the medical record reflected R18 was an initial admission to the facility on [DATE] and readmitted after a hospital stay on 03/24/2023. Diagnoses of heart failure, Dysphagia (difficulty swallowing), Aphasia (difficulty communicating due to stroke), muscle weakness, abnormal gait and a history of a stroke. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/20/2025 revealed R18 had a Brief Interview of Mental Status (BIMS) of 13 (cognitively intact) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R18 requires assistance with personal care and uses a wheelchair as an assistive device. During an interview on 06/03/25 at 12:03 PM, R18 could answer questions by nodding her head or pointing to the item. Writer asked R18 if she was a smoker, and she nodded her head yes. Writer asked where she kept her cigarettes and lighter, she pointed to her top drawer, writer asked permission to open the drawer, and she nodded her head yes. No cigarettes or lighter visible in her drawer. Writer asked if her if she had to keep her cigs and lighter locked up, she nodded her head yes and pointed out in the hallway, writer asked her if she kept them in the medication cart and she nodded her head yes. During an interview on 06/03/25 at 12:07 PM, DON B stated all the smoking residents keep their cigarettes, lighters, and vape devices in their rooms. DON B stated they did a smoking assessment and determined if they could smoke independently or not and if so, they could keep their supplies in their room. DON B also stated the residents could store smoking supplies in their rooms as it is their property. Record review revealed R18 had a previous smoking assessment dated [DATE], it was a smoking agreement that was signed by R18. R18 was no longer able to smoke independently as documented on her smoking letter dated 06/25/24 and signed by LNA A. This smoking document stated R18 was non-compliant with the smoking agreement, so her smoking devices needed to be always locked up with the nursing staff. This same document had the date crossed out and dated 06/25 with staff initials. During an interview on 06/03/25 at 3:54 PM, Licensed Practical Nurse (LPN) F stated R18 had her cigarettes and lighter in her room. LPN F also stated she could keep them with her in her room. During an interview on 06/04/25 at 12:13 PM, DON B stated only the smokers got the smoking assessment. Shows how often they smoke, what they smoke, care planned yes/no, and if nursing staff had to keep items locked up. DON B also stated they look at how they light it, do they need assistance, can they smoke on their own, can they put out the cigarette themselves. DON B also stated the smoking assessment form shows dependent or independent outside in the courtyard. DON B stated residents with supervised smoking is someone who needs assistance with lighting the cigarette, holding of the cigarette, and they would have certain smoking times. DON B stated they currently do not have anyone that needs help/supervising while smoking. DON B stated residents smoking unsupervised, means they can smoke when they want to, could go in and out of the courtyard as they want to, no set times. DON B added there is no need for any staff to be out there with them because of their smoking agreement. They can keep their own smoking parafunctional in their room in their possession. DON B stated they look at residents Brief Interview for Mental Health (BIMBS) score so if they are over a 11-12 and above can keep items in their smoking paraphernalia in their room. Writer asked if she had any concern with fire risk at the bedside, DON B stated no. Writer asked if the smoking paraphernalia was secured in their room? DON B stated no, it is in their room or in their pockets. Writer asked DON B how she assured other residents did not get a hold of these. DON B stated they had not had that problem before. Writer asked DON B if she was aware the smoking residents were leaving their paraphernalia sitting out on the over the bed table. DON B stated she was not aware of any residents leaving their smoking items out in the open. Writer asked DON B if R18 was a supervised smoker, due to the smoking letter that stated she was non-compliant and no longer allowed to smoke independently. DON B stated this resident was an independent and could keep her smoking items in her room. Writer asked DON B why R18 had a smoking agreement that documented that she was non-complaint with the smoking agreement and was now supervised as of 06/24,2024 and that date is crossed out with 06/25 written through it and it was initialed. DON B stated R18 was independent, and she was unaware of the letter stating she was no longer independent. Care plan initially included: *Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Date Initiated: 09/16/2021 Revision on: 02/18/2024. o Instruct resident about the facility policy on smoking: locations, times, safety concerns. Date Initiated: 09/16/2021. Revision on: 02/07/2024. o Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. Date Initiated: 09/16/2021. Revision on: 12/02/2022 o Observe clothing and skin for signs of cigarette burns. Date Initiated: 09/16/2021. Revision on: 12/02/2022 o The resident's smoking supplies are stored are with her. Date Initiated: 04/14/2023 Revision on: 06/02/2025 (during this survey) The resident can smoke: Timed smoker. Date Initiated: 09/16/2021. Revision on: 07/10/2024 Record review revealed R18 had her independence of smoking unsupervised taken away on 04/24/2024, however the care plan was not updated to reflect she needed supervision with smoking and all her smoking parafunctional was to be locked up with nursing staff. Record review also noted that R18 was allowed to smoke unsupervised after deeming her unsafe to do so. Her care plan was not updated or revise to maintain her safest as well as others. Resident #2 (R2) Review of the medical record reflected R2 was an initial admission to the facility on [DATE] and admitted to hospice on 05/16/2025. Diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Acute Kidney Failure, Chronic Kidney Disease, Stroke and unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 11 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 is dependent with all care and uses an electric wheelchair as an assistive device. Record review revealed R2 was admitted to hospice on 05/16/25 with Hospice Agency. Admission paperwork was under the miscellaneous tab, with minimal information included. Record review revealed there was minimal coordination of care between facility and hospice team upon admission only. Facilities care plan did not include hospice services. There was no comprehensive care plan for hospice. There was no visit notes uploaded in the Electronic Medical Record (EMR). No filled in calendar to reflect on which days the hospice staff would be making visits, nor did it reflect what care the hospice Certified Nursing Assistant (CNA) would provide above and beyond what the facility CNA would be providing. Record review of the hospice binders behind the nurse's station on hall 200, there was no hospice binder for R2 to aid in the facility staff knowing when the disciplines were coming to the facility and what services they would be providing above and beyond what services the facility was providing. Also missing a comprehensive care plan. During an interview on 06/04/25 at 8:18 AM, Social Work Director (SWD) C stated that after checking with the Director of Nursing (DON) B the hospice notes are in the EMR under the miscellaneous tab. During an interview on 06/04/25 at 8:36 AM, DON B stated some of the hospice documents were under the miscellaneous tab in the EMR. DON B stated if we (surveyors) were not there, she would have uploaded these documents into EMR. Record review revealed no hospice comprehensive care plan had been uploaded into the EMR under the miscellaneous tab as stated by DON B.

Based on observation, interview and record review, the facility failed to ensure proper communication/documentation of Hospice services provided to two (Resident #42 and Resident R2) of two resident reviewed for Hospice services, and the facility failed to follow physician orders and properly complete catheter care for one resident (Resident #38) of three residents reviewed for quality of care. Findings include: Resident #42 (R42) Review of the medical record reflected R42 was an initial admission to the facility on [DATE] and admitted to hospice on 03/26/2025. Diagnoses of Neurocognitive Disorder with Lewy Bodies, Dementia, Osteoarthritis, Stroke, Depression and Anxiety. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/28/2025 revealed R42 had a Brief Interview of Mental Status (BIMS) of 02 (severe impairment) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R42 requires assistance with personal care and uses a walker or wheelchair as an assistive device. Record review revealed there was no coordination of care between facility and hospice team. Facilities care plan was not updated to include hospice services. There was no visit notes uploaded in the Electronic Medical Record (EMR). No calendar to reflect on which days the hospice staff would be making visits, nor did it reflect what care the hospice Certified Nursing Assistant (CNA) would provide above and beyond what the facility CNA would be providing. Record review of the hospice binder behind the nurse's station on hall 200, contained the admission paperwork, blank monthly calendars, no care plan for disciplines. No medication list, no coordination of care provided on the facility care plan. During an interview on 06/04/25 at 8:18 AM, Social Work Director (SWD) C stated that after checking with the Director of Nursing (DON) B the hospice notes are in the EMR under the miscellaneous tab. During an interview on 06/04/25 at 8:36 AM, DON B stated some of the hospice documents were under the miscellaneous tab and hospice nurse's notes could document in EMR. DON B stated if we/surveyors were not there, she would have uploaded these documents into EMR. Record review revealed no hospice documentation was uploaded into the EMR under the miscellaneous tab as stated by DON B. Resident #2 (R2) Review of the medical record reflected R2 was an initial admission to the facility on [DATE] and admitted to hospice on 05/16/2025. Diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Acute Kidney Failure, Chronic Kidney Disease, Stroke and unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 11 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 is dependent with all care and uses an electric wheelchair as an assistive device. Record review revealed R2 was admitted to hospice on 05/16/25 with Hospice Agency. Admission paperwork was under the miscellaneous tab, with minimal information included. Record review revealed there was minimal coordination of care between facility and hospice team. Facilities care plan was no updated to include hospice services. There was no visit notes uploaded in the Electronic Medical Record (EMR). No filled in calendar to reflect on which days the hospice staff would be making visits, nor did it reflect what care the hospice Certified Nursing Assistant (CNA) would provide above and beyond what the facility CNA would be providing. Record review of the hospice binders behind the nurse's station on hall 200, there was no hospice binder for R2 to aid in the facility staff knowing when the disciplines were coming to the facility and what services they would be providing above and beyond what services the facility was providing. Also missing was a care plan, visit notes, medication list, coordination documents and a copy of the signed admission certification period document. During an interview on 06/04/25 at 8:18 AM, Social Work Director (SWD) C stated that after checking with the Director of Nursing (DON) B the hospice notes are in the EMR under the miscellaneous tab. During an interview on 06/04/25 at 8:36 AM, DON B stated some of the hospice documents were under the miscellaneous tab and hospice nurse's could document in EMR. DON B stated if we (surveyors) were not there, she would have uploaded these documents into EMR. Record review revealed no hospice documentation was uploaded into the EMR under the miscellaneous tab as stated by DON B. 49272 A review of the medical record revealed R38 was admitted to the facility on [DATE] with diagnoses that included: uninhibited neuropathic bladder, weakness, difficulty walking, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke) affecting left non-dominant side. On 6/2/25 at approximately 10 AM, R38 was observed in the hallways self-propelling in a manual wheelchair. R38 was observed to have a urinary catheter collection bag hanging from the arm rest of his wheelchair (above the level of his bladder), staff were observed to walk past R38. On 6/2/25 at 10:58 AM, resident was observed lying in bed with foley catheter tubing wrapped around his right leg. R38 reported having a urinary catheter for the entire time that he had been in the facility, that he wished he did not have it and that it burns. When R38 was asked about how/where his catheter collection bag should hang, he reported that when he is in his wheelchair it normally hangs from either the handrail or the side of the frame of the wheelchair and that no one has told him where it should hang in regards to his bladder. On 6/3/25 at 3:44 PM R38 observed in bed, urinary catheter leg bag in place. When asked if the staff exchange the traditional collection bag for a leg bag each day R38 reported they do it when it is possible. When asked for clarification R38 reported it is not possible for staff when they are too busy and that the big bag hold more urine. R38 confirmed he did not have a leg bag on the day prior (6/2/25). R38 reported he gets pushed to the side and that most days the staff do not exchange the traditional collection bag with a leg bag. When asked what his preference was, he reported without a doubt I would prefer a leg bag, reporting that the traditional bag/tubing gets pulled and wrapped around his leg and the bag has popped twice. When asked how often they clean his penis he reported that he didn't recall them doing it at all. On 6/4/25 at 11:30 AM R38 was observed in the dining room, awaiting his lunch. He was observed to have a traditional catheter collection bag that was attached under his wheelchair, catheter tubing was noted to be resting on the floor. It should be noted that R38 did not have a leg bag in place. On 6/4/25 at 1:07 PM, during an interview with LPN F, when asked what interventions were in place related to his urinary catheter, stated there is a securement device in place on R38's thigh and catheter care should be completed once per shift. She reported that catheter care had not been completed during her current shift. When it was reported that R38 still had a traditional urinary catheter collection bag in place and if that was typical, LPN F reported that R38 should be switched to a leg bag once he is out of bed for the day. LPN F reported that she had not seen R38 get out of bed yet. R38 had been to therapy and to the dining room for lunch that day. At 1:15 PM, LPN F was observed performing catheter care for R38. A clean towel was placed on R38's bedside table, LPN F used warm water and antibacterial soap to clean the catheter tubing at the insertion point only. LPN F did not clean any portion of the penis. R38's penis was noted to be red at the head and had a vertical tear from the urethral opening to the end of the penile head. On 6/4/25 at 1:57 PM, LPN F was asked if she knew how R38's penis got the tear, she reported that she didn't think they were able to determine the cause but that she knew that was the reason he got the order for the leg bag, because he would stand up with his catheter attached to stuff. When asked what areas she would normally clean during catheter care LPN F reported she would clean just the catheter tubing. On 6/4/25 at 2 PM, during an interview with the director of nursing (DON), when asked what she would tell me about the injury to R38's penis she reported that she was not familiar with it and began to look in his electronic chart. When asked what the expectation is for catheter care DON reported that staff perform it correctly, per policy. When asked what areas should be cleaned during urinary catheter care, DON reported meatus, foreskin, length of the penis as well as the catheter tubing. A review of R38's physicians orders revealed: 4/5/25 Change from leg bag to regular bag at HS (bedtime). 4/23/25 Change Foley to leg bag, one time a day. 5/12/25 Foley cath care every shift. A review of R38's skin assessments since his admission revealed no documentation of a penile tear. A review of the R38's progress notes revealed: 5/28/25 at12:14 PM, NP (nurse practitioner) Narrative (age redacted) male seen today for worsening genital burning. Pt. (patient) was up in w/c (wheelchair) propelling self .Pt seen and examined in room; indwelling catheter present and noted with lg (large) penile tear extending from glanular to shaft from long term use; catheter is secured to lt (left) thigh .current position was taunt not allowing much freedom with movement . Around top of shaft noted with redness; unsure if powder or cream applied prior; small amount of remnants remained .DERM (dermatology/skin): Skin warm and dry, lg penis tear; underside; rash to penile head and distal shaft .Assessment/Plan: Cutaneous Candidiasis (fungal infection): Mycolog Cream (antifungal cream); cleanse penis daily; pat dry. Apply cream topically BID (twice per day) and PRN (as needed) .Penile Tear: Be mindful of positioning of Grip-Lok Securement tape to lessen potential worsening of penile tear . 5/25/25 at 8:33 PM Nurses Notes: Resident complained of burning sensation related (to) his urinary catheter. Output appears large and clear . 4/17/25 at 10:12 AM Nurses Notes: (Residents name redacted) frequently moves his foley bag on back of w/c or places on w/c seat while in w/c. Education provided. 4/8/25 at 2:15 PM Nurses Notes: PT c/o (complains of) painful penis, write did assessment, PT has white discharge around head of penis, PT went to appointment with Urologist, new order for nystatin cream . 4/8/25 at 12:37 PM Nurses Notes: Received paperwork from appointment on urology. Orders received to cont. (continue) Flomax (medication to treat enlarged prostate), nystatin cream bid to tip of penis, recheck in 1 year, cont. indwelling catheter . 3/31/25 at 1:53 PM Physician Progress Note: Pt asked to be seen secondary to painful urination. Staff had a foley catheter and pulled it out . 3/31/25 at 1:47 PM Nurses Notes: Resident c/o painful urination, flank pain . 3/25/25 at 1:41 PM Nurses Notes: Resident complains of burning from catheter. Upon assessments residents tip of penis is spit (split). Updated MD. 3/25/25 at 6:40 PM Nurses Notes Resident pulled foley out, writer updated PCP (Primary care provider) and replaced foley . 3/5/25 at 9:09 AM Nurses Notes: .Resident continues to have burning in penis with yellow crusted discharge. 2/28/25 at 6:12 PM Nurses Notes: Pt c/o burning sensation, flank pain, and urine is cloudy w/ sediment present . 2/28/25 at 6:12 PM Nurses Notes: Pt c/o burning sensation, flank pain, and urine is cloudy w/ (with) sediment present . 2/7/25 at 3:16 AM Nurses Notes: Resident returned from (emergency room name redacted) via ambulance transport at 0300. Resident had a foley placed, 14 fr 10cc balloon. Catheter is patent and draining yellow urine. Output at the hospital was 1000ml. Resident states he feels better, denies any pain and is resting comfortably in his bed . 2/5/25 at 10:30 PM Admission/Readmission Note: Pt arrived at 1730 on previous shift via ambulance .Admission assessment completed by write and documented .Skin intact, normal color for ethnicity, warm and dry. Discoloration on bilateral lower legs A review of a Urology office visit note dated 4/7/25 revealed, (R38) is an (age redacted) male here for urinary retention. Patient has a Hx (history) of enlarged prostate and was self cathing for many years/states over 10. Patient has a foley cath that was placed a few months ago after stroke/left sided weakness and is changed monthly at (facility name redacted). Patient has discomfort when standing at the tip of penis and in urethra. Urine is clear no blood in bag .Genitals circ (circumcised) (appears in last few years-wife confirms but unsure where), foley clear, testes 3/3 bil (bilateral) .Discussed plan of care with pt and wife. Went over history, exam, plan of care. Hopefully would be able to go back to straight cathing in the future but for now it does not feel like his left arm is strong enough and patient is confused even though as to where he lives right now so I do not think having him do it twice a day is a good option. In the future if he goes home and has visiting nurses come he may be able to do the cathing again but for now I think the best option would be to do the indwelling catheter with changes monthly. We talked about nystatin cream for his penis as it is slightly irritated but many need to change this if it is not helpful in the future . It should be noted that there was no mention of a penile tear in the details of the urology report from 4/7/25. A review of the facilities policy, titled Catheter Care. Documented in part .Male: Gently grasp penis, draw foreskin back if applicable, using circular motion, cleanse the meatus moving down, cleanse the shaft of the penis, with a new moistened cloth, starting at the urinary meatus outward, wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter, dry area with towel . A review of the facilities policy, titled Indwelling Catheter Use, documented in part Additional care practices include: .Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears of dislodgement of the catheter, and Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder .

Based on interview and record review, the facility failed to limit the duration of a PRN (as needed) psychotropic medication to 14 days and/or ensure the physician documented rationale to extend the duration of use for one (Resident #2) out of five reviewed for unnecessary medications. Findings include: Resident #2. (R2) Review of the medical record reflected R2 was an initial admission to the facility on [DATE] and admitted to hospice on 05/16/2025. Diagnoses of Chronic Obstructive Pulmonary Disease, Diabetes, Acute Kidney Failure, Chronic Kidney Disease, Stroke and unsteadiness on feet. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/22/2025 revealed R2 had a Brief Interview of Mental Status (BIMS) of 11 (moderately impaired) out of 15. Under section G0100, Activities of Daily Living (ADL) Assistance reveals R2 is dependent with all care and uses an electric wheelchair as an assistive device. Record revealed R2 had Ativan oral tablet 0.5mg, give 1 tablet by mouth every 4 hours as needed for anxiety, start date of 05/16/2025 with no end date. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025 with no end date. Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 with no end date. Record review of the Medication Administration Record (MAR) for the month of May 2025 showed R2 did not receive any Ativan 0.5mg tablets. R2 requested Hydrocodone 5/325mg tablet three times for a pain rated 5-7 on a scale of 0-10. R2 did not request any Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, or shortness of breath. Record review of the MAR for the month of June 2025 showed R2 did not receive any Ativan 0.5mg tablets. R2 requested Hydrocodone 5/325mg tablet three times for a pain rated 5-7 on a scale of 0-10. R2 did not request any Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, or shortness of breath. During an interview on 06/04/2025 at 8:21AM, SWD C stated his role is to get the consents for the use of these medications and nursing is the one who addresses them. SWD C added they do not like prn's, they do a 14-day trial and see how often they use it, they try to use non-pharmacal first. During an interview on 06/04/25 at 8:37 AM, DON B stated there would be a 14 day stop date and provider had to write a note. Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 with no end date. DON B added providers just leave that as needed, if pharmacy had not caught it, they usually do. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025 was ordered from hospice and Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025 was ordered prior. DON B stated they would not stop the as needed medications or give an end date. These as needed orders were written by DON B. Per the State Operation Manual (SOM) . PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication . Record review of all discipline progress notes revealed no pain or anxiety re- assessments following the addition of Hydrocodone/acetaminophen oral tablet 5/325mg, take one tablet by mouth every 6 hours as needed for pain, maximum daily amount 4 tablets a day, start date of 04/27/2025, Ativan oral tablet 0.5mg, give 1 tablet by mouth every 4 hours as needed for anxiety, start date of 05/16/2025 with no end date. Morphine Sulfate (Concentrate) Oral Solution100 MG/5ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for pain 7-10, shortness of breath, start date of 05/16/2025, within the 14 days following the starting of these medications as recommended by the SOM. There was no documentation that these medications were still needed or not.

This citation has two Deficient Practice Statements (DPS), A and B: DPS A: This citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to ensure hot liquid was served at a safe and appropriate temperature for one (Resident #28) of three reviewed for accident hazards, resulting in Immediate Jeopardy when R28 received coffee of an unknown temperature, which spilled, causing R28 to sustain a second-degree thermal burn (damage to outer and second layer of skin, causing blisters, pain and discoloration) on his left outer thigh and increased pain. Findings include: Resident #28 (R28): Review of the medical record reflected R28 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included multiple sclerosis and unspecified severe protein-calorie malnutrition. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for second or third degree burns. During an interview and observation on 07/09/24 at 2:17 PM, R28 reported about three to four months prior, hot coffee fell over and was super hot. He reported having a fourth-degree burn on his leg. He lifted the left leg of his shorts and showed a darkened area, several inches long, on the lateral (outside) aspect of his left leg. R28 reported there was a lid on his cup, which he had next to him, in his wheelchair. According to R28, the lid did not seal good enough, causing the hot coffee to leak out of the side of the cup. R28 reported when the coffee spilled on him, he told staff right away, and they put stuff on to make it heal. A Progress Note for 4/18/2024 at 11:28 AM reflected, .Resident came up to writer stating that they spilled coffee from the kitchen on themselves and the floor. Writer took a look at the left thigh and measured burn. Writer cleaned burn and iced for 20 minutes. After the ice, writer applied medihoney to burn and wrapped with abd [dressing]. Writer educated the resident on safety while drinking hot beverages and also educated the kitchen staff on importance of temping foods and drinks before serving to residents . A late entry Progress Note for 4/18/2024 at 12:00 PM reflected, .Dietary staff temped coffee prior to giving to [R28], Temp in normal range, [R28] stated he placed his coffee cup on the L [left] side of his w/c [wheelchair] and as he was self propelling w/c the coffee cup tipped over. He did not alert staff and went to smoke. Offered [R28] a cup holder to his w/c. [R28] declined at this time. There was no documentation in R28's medical record or on the facility's April 2024 Coffee Temperature Log to support that the coffee temperature was checked and in a safe range prior to serving it to R28. The facility's investigation into the incident was reviewed and included an incident report for 4/18/24 at 11:17 AM, which reflected R28 came up to the nurse, stating he had spilled coffee on himself and the floor. His left thigh was assessed and noted to have blisters and a raised, red area. The immediate action taken reflected the burn was cleansed, then iced for 20 minutes. Once the ice was off, medihoney (wound and burn treatment) was applied to the wound, then covered with an ABD dressing. R28 was educated on safety precautions while drinking hot beverages, such as a lid, sitting at the table and not roaming around with drink in hand. The report reflected, .Writer also educated kitchen staff on appropriate coffee temperatures to prevent further accidents of this nature . The facility's investigation included a sign in sheet for education provided by Registered Dietitian (RD) I on 4/18/24, which reflected: -Temperatures of hot beverages must be done prior to and during meal service -Temperatures of hot beverages must be taken prior to any request by residents in between meals -Hot beverages must be below 135 degrees (Fahrenheit) prior to serving to residents -All hot beverages must have a lid on prior to serving to the resident The education was signed by seven dietary staff. The facility's investigation did not indicate a root cause analysis, nor an identification of which staff member provided the coffee to R28 on 4/18/24. During an interview on 07/12/24 at 12:32 PM, Director of Nursing (DON) B reported Dietary Aide (DA) T provided R28 with the coffee that burned him on 4/18/24 and verbalized putting three ice cubes in it. When asked why ice was placed in the coffee, DON B reported she (personally) did not document the coffee temperature at the time she looked into the incident because it was within normal limits. DON B believed the coffee temperature was in the range of low 140's (degrees Fahrenheit) and reported it may have been 144 degrees Fahrenheit. According to DON B, the temperature of the coffee that was provided to R28 was under 150 degrees Fahrenheit, and she was not concerned. DON B reported R28 sat outside to smoke two cigarettes after the coffee spilled on him. Review of the facility's staff education pertaining to hot liquids on 4/18/24 did not reflect that DA T had signed the education. On 07/10/24 at 02:20 PM, DA T reported coffee was temped after drawing it from the machine and before sending out the tray. DA T stated, The coffee temperature is usually around 160 degrees Fahrenheit from the machine and about 145 degrees Fahrenheit when delivered. The April 2024 Coffee Temperature Log reflected a coffee temperature of 180 degrees Fahrenheit on 4/18/24 at 7:30 AM. The recheck temperature was 148 degrees Fahrenheit. At 11:30 AM on 4/18/24, the coffee temperature was 178 degrees. The recheck temperature was 147 degrees Fahrenheit. The 4:30 PM coffee temperature on 4/18/24 was 135 degrees Fahrenheit. An undated Hot Liquid Safety policy reflected, .2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature . On 07/10/24 at 3:24 PM, Nursing Home Administrator (NHA) A reported the undated Hot Liquid Safety policy was the policy that was current as of 4/18/24 (when R28 sustained the burn). Further review of the April 2024 Coffee Temperature Log reflected each initial and recheck coffee temperature exceeded 140 degrees Fahrenheit until the 4:30 PM coffee temperature on 4/18/24. During an interview on 07/10/24 at 2:59 PM, Licensed Practical Nurse (LPN) L reported being R28's nurse at the time he sustained the coffee burn. R28 came to her and reported receiving coffee from the kitchen, which he put in the side of his wheelchair. When he went outside, the coffee spilled on his leg and burned him. By the time R28 notified her, he had already been changed. She stated he must have told a Certified Nurse Aide (CNA) or cleaned himself up before notifying her. After being notified, she put R28 in bed and placed a cold towel on the burn while gathering wound supplies, including medihoney. During the same interview, LPN L reported she educated kitchen staff on temping of coffee. LPN L stated she knew for a fact if the coffee was temped, it would not have burned R28 the way that it did. She reported also educating R28 that it was not safe to be moving around with a hot cup of coffee (in his wheelchair). LPN L reported the burn initially appeared as the length of her cell phone, with a large blister. When she saw the burn the following week, the blister was no longer intact, and there was raw skin. According to Mayo Clinic, .2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring .3rd-degree burn. This burn reaches to the fat layer beneath the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, causing numbness . (https://www.mayoclinic.org/diseases-conditions/burns/symptoms-causes/syc-20370539) On 4/18/24, R28's burn measured 20 centimeters (cm) in length by (x) 7 cm in width. The wound photo revealed a red, raised area with intact blisters. R28's pain level was recorded as eight out of ten. On 4/22/24, R28's burn measured 20 cm in length x 7 cm in width. The burn was staged as partial thickness (affects the top two layers of the skin). The tissue type reflected, Necrotic [dead tissue] Soft, Adherent=50%, Necrotic Hard, Firm, Adherent=50%. R28's pain level was recorded as eight out of ten. The assessment reflected the burn was Very painful. R28's burn was evaluated by the Wound Provider on 4/25/24. The assessment reflected R28 had a second-degree burn, measuring approximately 18 cm in length x approximately 6 cm in width and 0.1 cm in depth. The tissue was 75% slough (non-viable tissue that can present as yellow, tan, gray, green or brown) and 25% granulation (pink/red tissue that fills a wound when it begins to heal). On 4/29/24, R28's burn measured 20 cm in length x 5 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=50%, Slough Loosely Adherent=50%. R28's pain level was recorded as eight out of 10. On 5/6/24, R28's burn measured 18 cm in length x 4 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as four out of ten. R28's burn was evaluated by the Wound Provider on 5/9/24. The assessment reflected the burn was second-degree and measured 13.5 cm in length x 3.2 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. On 5/14/24, R28's burn measured 12 cm in length x 4 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as three out of ten. On 5/20/24, R28's burn measured 10 cm in length x 2.5 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as three out of ten. R28's burn was evaluated by the Wound Provider on 5/23/24. The assessment reflected the burn was second-degree and measured 8.5 cm in length x 2.3 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. Blue/green drainage was noted, with notation that it could be pseudomonas (bacteria) infection. On 6/3/24, R28's burn measured 5 cm in length x 1.7 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. On 6/10/24, R28's burn measured 4 cm in length x 1.7 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. R28's burn was evaluated by the Wound Provider on 6/13/24. The assessment reflected the burn was second-degree and measured 1.5 cm in length x 1 cm in width x 0.1 cm in depth. The tissue was 50% slough and 50% granulation. On 6/17/24, R28's burn measured 1.5 cm in length x 1.0 cm in width x 0.1 cm in depth. The burn was staged as partial thickness. The tissue type reflected, Bright Pink or Red=100%. R28's pain level was recorded as zero. On 6/24/24, R28's burn was recorded as healed, with intact skin. The photo showed an area of pink/red discolored skin, measuring greater than 12 cm in length. The facility's Hot Liquid Safety policy with a revision date of 4/18/24 reflected, .2. The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature of under 135 degrees . Review of Coffee Temperature Logs for May, June and July 2024 reflected, Coffee temperature needs to be between 130-150 degrees prior to serving. Coffee that is 150 degrees or higher needs a few minutes to cool down to serve and could cause severe burns. Further review of the logs reflected numerous missed temperature recordings as well as temperatures that exceeded the facility's policy pertaining to temperature parameters, without a documented action taken. On 7/10/24, review of the July 2024 Coffee Temperature Log reflected dinner coffee temperatures had not been recorded at all for the month. During an interview on 07/10/24 at 4:30 PM, Dietary Manager (DM) D reported coffee was served at each meal. The coffee machine brewed coffee at a minimum temperature of 165 degrees Fahrenheit and a maximum temperature of 180 degrees Fahrenheit. Dietary staff were to take the coffee temperature and hold the coffee, as the serving temperature needed to be less than 140 degrees Fahrenheit. He reported they did not want the temperature above 140 degrees Fahrenheit because the residents could burn themselves, and it was a safety issue. DM D reported he was told R28 was given a cup of coffee and received third-degree burns on his leg. During the same interview, DM D reported the facility also had self-serve coffee stations that were placed at the unit desks. When asked how the temperature of the self-serve coffee was monitored, DM D reported dietary staff temped the coffee when it was placed in the coffee urn. They then let it sit for 15 to 20 minutes. He reported the temperature for the coffee urns should be at least 150 degrees Fahrenheit, but he preferred it to be between 130 to 135 degrees Fahrenheit. He reported the coffee urns were insulated and would hold a temperature for many hours. When asked how he could be certain that resident's were not receiving self-serve coffee that was 150 degrees Fahrenheit, DM D stated he could not be certain. DM D reported the hot liquid policy was revised after R28's burn, and he believed anything under 140 degrees Fahrenheit was ok. Upon review of the July 2024 Coffee Temperature Log, DM D reported most of the temperatures were out of range, and there was no documented action taken. He reported the staff should have listed that they held the coffee and taken another temperature. DM D agreed the dinner coffee temperatures were missing from the log and should have been documented. In an interview on 07/10/24 at 4:48 PM, DM D reported Coffee Temperature Logs reflected the temperatures of the coffee served on the tray line. He stated the facility did not log the temperatures for the coffee urns before they went to the units. The coffee in the urns came straight from the brew pot at 180 degrees Fahrenheit. It then sat for 15 to 20 minutes, but a temperature was not logged. The Immediate Jeopardy began on 4/18/24 when the facility failed to ensure R28 was provided coffee at a safe temperature, resulting in a second-degree thermal burn and increased pain. Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy on 7/11/24 at 1:58 PM. The Immediate Jeopardy that began on 4/18/24 was removed on 7/11/24 when the facility took the following actions to remove the immediacy: 1. The NHA called an Ad Hoc QAPI meeting, which included the DON, Medical Director (via phone), Assistant Director of Nursing, MDS Coordinator, Registered Dietitian, and Dietary Manager. A root cause analysis was completed for the above-mentioned burn to Resident #28. 2. Dietary Manager and Registered Dietitian educated dietary staff on proper temping and serving of hot beverages. Hot beverages must be temped and logged prior to and during meal service. The temperature of hot beverages must be taken prior to any request by residents between meals. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents. 3. The DON and Social Services Director educated all staff that only dietary staff is permitted to serve hot beverages, with the exception that after hours (8 PM to 6 AM) only a nurse on duty is permitted to serve hot beverages to residents. 4. The DON educated nurses on correct process for temping and serving hot beverages. Hot beverages must be temped and logged prior to serving to residents. Hot beverages must be below 135 degrees Fahrenheit prior to serving to residents. 5. Signs were placed at both kitchen doors by the Registered Dietitian, stating only nurses can serve hot beverages to residents after hours. The Activity Director was instructed to inform residents of this at the next Resident Council Meeting. 6. The DON assessed all current residents for safe handling of hot beverages using the Hot Liquid Evaluation. Occupational Therapy was then notified for safety screening per written order for those deemed necessary. The Dietary department was notified to use spill proof cups via Dietary Communication forms for those deemed necessary. Tray tickets and care plans were updated as needed by the Registered Dietitian. 7. The Dietary Manager/designee will observe dietary staff at all meals to ensure proper temping and logging of hot beverages until assured that all dietary staff know the proper process. 8. The Dietary Manager/designee will audit temperature logs daily to ensure the process is being followed and temperatures are at approved levels for hot beverages. 9. The NHA will audit hot beverage logs weekly x 2 to ensure compliance. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 7/11/24 but noncompliance remains at a scope of widespread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to sustained compliance that has not been verified by the State Agency. 30337 DPS B: Based on observation, interview and record review, the facility failed to perform safe smoking assessments in two of three residents reviewed for smoking hazards (Resident #29 and Resident #4), resulting in the likelihood for injuries. Findings include: Resident #29 (R29) On 7/09/24 at 10:09 AM, R29 was observed sitting in his room in his wheelchair with two disposable pod vaping devices placed on his over-the-bed table. R29 stated he used to smoke cigarettes, but now vapes. R29's Minimum Data Set (MDS), with assessment reference date (ARD) of 6/28/24, introduced a Brief Interview for Mental Status (BIMS, a brief cognitive screener) score of 15 (13-15 Cognitively Intact). The same MDS indicated he had the diagnoses of heart failure, diabetes, end stage renal disease requiring dialysis, lung disease, skin tears, and moisture associated skin damage. In review of R29's electronic medical record, the last smoking safety screen assessment was completed on 12/18/22. In review of R29's care plans, there were no care plans addressing vaping. Resident #4 (R4) R4's MDS with ARD of 6/19/24, revealed a BIMS score of 14 (13-15 Cognitively Intact) and had the diagnoses of traumatic brain injury, hemiplegia (complete or severe paralysis on one side of the body including face, arm and leg), seizure disorder, anxiety and depression. In review of R4's Kardex (nurse assistant care plan) dated 7/10/24, R4's smoking materials were to be kept with the nurse, and did not specify vaping materials. In review of R4's Smoking screen assessment dated [DATE], there was no mention of her vaping and indicated she was safe to smoke without supervision. The same assessment revealed continues to forget she cannot smoke indoors. Facility keeps lighter and cigarette. Certified Nurse Assistant (CNA) X was interviewed on 7/11/24 at 8:36 AM and stated R4 was not allowed to smoke except when her family was supervising due to bumming cigarettes from other residents and vaping. CNA X stated R4 had vaping materials in her possession. Director of Nursing (DON) B was interviewed on 7/11/24 at 8:48 AM and stated smoking privileges had recently changed for her. DON B stated she was not aware of R4 vaping. DON B stated smoking screen assessments were completed every six months or if there was a change. The facility provided a list of residents that smoke on 7/09/24, R29 and R4 were not included on the list. In review of the Smoking Progress policy dated 6/25/24, there was no guidance on vaping.

Based on observations, interviews, and record reviews, the facility failed to provide palatable food products effecting 66 residents, resulting in the increased likelihood for decreased resident food acceptance and nutritional decline. Findings include: On 07/09/24 at 11:45 A.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded: Roasted Vegetable Lasagna - 185.5 Capri Blend Vegetables - 147.8 Garlic Toast - 140.0 Cheesecake - Room Temperature Beverage (2% Milk) - 47.8* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. On 07/09/24 at 11:55 A.M., An interview was conducted with Dietary Manager D regarding the resident food tray delivery schedule. Dietary Manager D stated: We deliver food trays to the Main Dining Room, B-Hall and then A-Hall. On 07/09/24 at 12:08 P.M., Resident food trays (18) were observed leaving the food production kitchen within a stainless steel non-insulated transport cart. On 07/09/24 at 12:09 P.M., Resident food trays (18) were observed arriving to B-Hall within a stainless steel non-insulated transport cart. On 07/09/24 at 12:16 P.M., Resident food trays (10) were observed leaving the food production kitchen within a stainless steel non-insulated transport cart. On 07/09/24 at 12:17 P.M., Resident food trays (10) were observed arriving to A-Hall within a stainless steel non-insulated transport cart. On 07/09/24 at 12:23 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #62: Roasted Vegetable Lasagna - 148.1 Capri Blend Vegetables - 110.7* Garlic Toast - 105.1* Cottage Cheese & Mandarin Oranges - 56.1* Cheesecake - Room Temperature Beverage (Apple Juice) - 60.6* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. On 07/09/24 at 12:31 P.M., An interview was conducted with Resident #62 regarding dietary food products. Resident #62 stated: The mashed potatoes are like eating mush. Resident #62 also stated: The eggs are nasty for Breakfast. Resident #62 additionally stated: The French toast and pancakes are usually cold. Resident #62 further stated: The scrambled eggs are overcooked and taste like rubber. On 07/10/24 at 11:42 A.M., Resident food trays (20) were observed leaving the food production kitchen within an aluminum rolling open shelve rack system. On 07/10/24 at 11:43 A.M., Resident food trays (20) were observed arriving to the Main Dining Room within an aluminum rolling open shelve rack system. On 07/10/24 at 11:58 A.M., Resident food trays (17) were observed leaving the food production kitchen within a stainless steel non-insulated transport cart. On 07/10/24 at 11:59 A.M., Resident food trays (17) were observed arriving to B-Hall within a stainless steel non-insulated transport cart. On 07/10/24 at 12:10 P.M., Resident food trays (13) were observed leaving the food production kitchen within a stainless steel non-insulated transport cart. On 07/10/24 at 12:11 P.M., Resident food trays (13) were observed arriving to A-Hall (North) within a stainless steel non-insulated transport cart. On 07/10/24 at 12:19 P.M., Food product temperatures were monitored utilizing a ThermoWorks Super-Fast Thermapen model CR2032 digital thermometer. The following food product temperatures were recorded for Resident #38: Open Face Turkey Sandwich w/Gravy - 122.1* Mashed Potatoes - 130.0* Vegetable Blend - 120.1* Dinner Roll - Room Temperature Chilled Peaches - 56.7* Beverage (Apple Juice) - 59.1* (*) The 2017 FDA Model Food Code section 3-501.16 states: (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57oC (135oF) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54oC (130oF) or above; P or (2) At 5 C (41 F) or less. Note (Palatability Taste Test): The apple juice was concentrated and contained an aftertaste. The mashed potatoes were flavorful and tasteful. The open face turkey sandwich was flavorful and tender. The canned peaches were crisp and full of flavor. The dinner roll was soft and tender. On 07/10/24 at 02:20 P.M., An interview was conducted with Dietary Aide/Cook T regarding the hot beverage (coffee) dispensing and delivery procedure. Dietary Aide/Cook T stated: We temp the coffee after drawing from the machine. Dietary Aide/Cook T additionally stated: We also temp the coffee before sending out the tray. Dietary Aide/Cook T further stated: The coffee temperature is usually around 160 degrees Fahrenheit from the machine and about 145 degrees Fahrenheit when delivered. On 07/10/24 at 02:31 P.M., An interview was conducted with Resident #38 regarding dietary food products. Resident #38 stated: The chicken is always overcooked and looks like roadkill. Resident #38 further stated: Could they get rid of the sausage, gravy, and biscuits for breakfast? It's the most unappetizing meal I have ever had. On 07/11/24 at 12:30 P.M., Record review of the Policy/Procedure entitled: Maintaining a Sanitary Tray Line dated (no date) revealed under Policy: This facility prioritizes tray assembly to ensure foods are handled safely and held at proper temperatures in order to prevent the spread of bacteria that may cause foodborne illness. Record review of the Policy/Procedure entitled: Maintaining a Sanitary Tray Line dated (no date) further revealed under Compliance Guidelines: (3)(k) Periodically monitor food temperatures throughout the meal service to ensure proper hot (at or above 135 degrees Fahrenheit) or cold holding temperatures (at or below 41 degrees Fahrenheit) are maintained. On 07/11/24 at 12:45 P.M., Record review of the Policy/Procedure entitled: Hot Liquid Safety dated 4-18-24 revealed under Policy: Hot liquids are to be served at proper (safe and appetizing) temperatures using appropriate safety precautions. Record review of the Policy/Procedure entitled: Hot Liquid Safety dated 4-18-24 further revealed under Policy Explanation and Compliance Guidelines: (1) Hot liquids can cause scalding and burns. The degree of injury depends on the temperature, the amount of skin exposed, and the duration of exposure. Refer to the table attached to this policy for an illustration of the time required for a burn to occur at various temperatures. (2) The temperatures of hot liquids will be checked in the dietary department prior to distribution to the nursing units. If the temperature is greater than 140 degrees Fahrenheit, hold the liquid in the dietary department until it reaches an appropriate temperature of under 135 degrees. (3) All residents are assessed for their ability to handle containers and consume hot liquids. Residents with difficulties will receive appropriate supervision and use of assistive devices in order to consume hot liquids. Interventions will be individualized and noted on the resident's plan of care. Interventions include, but are not limited to: a. Wide based cups b. Cups with lids and handles c. Limit Styrofoam cups to residents with no difficulties d. Aprons e. Disallow hot liquids while lying in bed (4) Staff shall respond immediately to spills or other accidents with hot liquids to minimize the risk for burns. Follow procedures regarding incidents/accidents should anyone experience exposure to hot liquids.

Based on observations, interviews, and record reviews, the facility failed to: (1) effectively clean and maintain food service equipment, (2) effectively date mark all potentially hazardous ready-to-eat food products, and (3) maintain the food production kitchen flooring surface effecting 66 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and resident foodborne illness. Findings include: On 07/09/24 at 09:51 A.M., An initial tour of the food service was conducted with Dietary Manager D. The following items were noted: The flooring surface was observed missing, directly beneath the Mainstreet Equipment 2-door reach-in cooler. The missing [NAME] tile surface measured approximately 3-feet-wide by 5-feet-long. Dietary Manager D indicated he would have maintenance make necessary repairs as soon as possible. The 2017 FDA Model Food Code section 6-501.11 states: PHYSICAL FACILITIES shall be maintained in good repair. The Scotsman ice machine sliding entrance door was observed loose-to-mount. Dietary Manager D indicated he would have maintenance repair the faulty entrance door as soon as possible. The Walk-In Cooler automatic door closer assembly was observed broken and sporadically functioning. Dietary Manager D stated: Parts are on order for repairs. The 2017 FDA Model Food Code section 4-501.11 states: (A) EQUIPMENT shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. (C) Cutting or piercing parts of can openers shall be kept sharp to minimize the creation of metal fragments that can contaminate FOOD when the container is opened. Two opened five-pound containers of GFS ([NAME] Food Service) Sour Cream were observed without an effective open or out date. The manufacturer's use-by-date was also observed to read 7-29-24. One opened five-pound container of Country Fresh Cottage Cheese was also observed without an effective open or out date. The manufacturer's use-by-date was additionally observed to read 7-22-24. The 2017 FDA Model Food Code section 3-501.17 states: (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S 3-502.12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1. The two Cobra Head beverage dispensers were observed soiled with accumulated and encrusted food residue. The Employee Breakroom Whirlpool dietary refrigerator interior was observed soiled with accumulated and encrusted food residue. The 2017 FDA Model Food Code section 4-601.11 states: (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. On 07/10/24 at 03:13 P.M., Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) revealed under Policy: The facility adheres to a date marking system to ensure the safety of ready-to-eat, time/temperature control for safety food. Record review of the Policy/Procedure entitled: Date Marking for Food Safety dated (no date) further revealed under Policy Explanation and Compliance Guidelines for Staffing: (2) The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. (3) The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. (5) The discard day or date may not exceed the manufacturer's use-by-date, or four days, whichever is earliest. The date of opening or preparation counts as day 1. (For example, food prepared on Tuesday shall be discarded on or by Friday). On 07/10/24 at 04:04 P.M., Record review of the Policy/Procedure entitled: Dietary Department Guidelines dated (no date) revealed under The Facility: (1) The dietary department will be maintained in a clean and sanitary manner to prevent foodborne illness. Record review of the Policy/Procedure entitled: Dietary Department Guidelines dated (no date) further revealed under Equipment: (1) All food preparation equipment, dishes, and utensils must be maintained in a clean, sanitary, and safe manner and used and repaired according to manufacturer's recommendations.

Based on interview and record review, the facility failed to ensure 2 out of 5 Licensed Practical Nurses had the required initial competency evaluations and annual competency evaluation, including demonstration in skills and techniques necessary to care for residents resulting in the potential for staff to lack in the necessary training to adequately meet the needs of 66 residents that currently reside at the facility. Findings Include: Record review of the facility staff personnel records demonstrated Licensed Practical Nurse (LPN) L was currently employed by the facility. The personnel record of LPN L did not demonstrate that she had completed an annual competency evaluation. During an interview on 07/12/2024 at 12:31 p.m. Director of Nursing (DON) B explained that all nursing staff receives a competency evaluation after completion of orientation and annually. She explained that the competency evaluations are completed by observation of skilled performed. DON B confirmed that LPN L personnel file did not demonstrate completion of a new hire competency and did not include an annual skills competency. DON B explained that she would attempt to locate the documents that would demonstrate clinical skills competency. Review of the facility policy entitled Competency Evaluation (provided by the facility) was absent of a date implemented and did not demonstrate a date last reviewed or revised. The Policy Explanation and Compliance Guidelines (of the above list policy) revealed #4 - Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. This surveyor was provided Licensed Practical Nurse (LPN) L post orientation skills competency which was completed 8/11/22. The facility failed to provide Licensed Practical Nurse (LPN) Ls annual skills competency evaluation for 2024 by the time of exit. 45038 Record review of the facility staff personnel records demonstrated Licensed Practical Nurse (LPN) DD was hired by the facility 2/15/2023. The personnel record of LPN DD did not demonstrate that she had completed a competency evaluation upon completion of orientation and her personnel file did not demonstrate that she had completed an annual competency evaluation. During an interview on 07/12/2024 at 12:31 p.m. Director of Nursing (DON) B explained that all nursing staff receives a competency evaluation after completion of orientation and annually. She explained that the competency evaluations are completed by observation of skilled performed. DON B confirmed that LPN DD personnel file did not demonstrate completion of a new hire competency and did not include an annual skills competency. DON B explained that she would attempt to locate the documents that would demonstrate clinical skills competency. Review of the facility policy entitled Competency Evaluation (provided by the facility) was absent of a date implemented and did not demonstrate a date last reviewed or revised. The Policy Explanation and Compliance Guidelines (of the above list policy) revealed #4 - Subsequent and/or annual competency is evaluated at a frequency determined by the facility assessment, evaluation of the training program, and/or job performance evaluations. This surveyor was provided Licensed Practical Nurse (LPN) DD post orientation skills competency which was completed 02/16/23. The facility failed to provide Licensed Practical Nurse (LPN) DDs annual skills competency evaluation for 2024 by the time of exit.

Based on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 66 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased air quality. Findings include: On 07/09/24 at 02:00 P.M., A common area environmental tour was conducted with Director of Maintenance V and Director of Housekeeping and Laundry Services U. The following items were noted: Lobby: The drywall surface was observed (etched, scored, particulate), adjacent to the receptionist desk. The damaged wall surface measured approximately 4-feet-wide by 8-feet-long. B-Hall (North) Soiled Utility Room: The return-air-exhaust ventilation was observed non-functional. Main Dining Room: The two sets of exit door surfaces were observed (etched, scored, particulate). Director of Maintenance V indicated he would have staff repaint the door surfaces as soon as possible. Food Production Kitchen: The exterior surfaces of the two entrance doors were observed (etched, scored, particulate). Director of Maintenance V indicated he would have staff repaint the door surfaces as soon as possible. Sunroom: The two exit door surfaces were observed (etched, scored, particulate). Director of Maintenance V indicated he would have staff repaint the door surfaces as soon as possible. On 07/10/24 at 09:20 A.M., An environmental tour of sampled resident rooms was conducted with Director of Maintenance V and Director of Housekeeping and Laundry Services U. The following item was noted: 218: The restroom hand sink basin drain was observed draining very slow. Director of Maintenance V indicated he would have staff make necessary repairs as soon as possible. On 07/10/24 at 11:15 A.M., An interview was conducted with Director of Maintenance V regarding the facility maintenance work order system. Director of Maintenance V stated: We have written work order request forms for staff. Director of Maintenance V further stated: We keep the completed forms on computer for future review. On 07/11/24 at 01:00 P.M., Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Rooms dated 10-2013 revealed under Purpose: The purpose of this procedure is to provide guidelines for cleaning and disinfecting resident's rooms. Record review of the Policy/Procedure entitled: Cleaning and Disinfecting Resident's Rooms dated 10-2013 further revealed under General Guidelines: (1) Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. (2) Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. On 07/11/24 at 01:15 P.M., Record review of the Policy/Procedure entitled: Maintenance Service dated 12-2009 revealed under Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Record review of the Policy/Procedure entitled: Maintenance Service dated 12-2009 further revealed under Policy Interpretation and Implementation: (1) The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. On 07/11/24 at 01:30 P.M., Record review of the Building Services Work Order Request Forms for the last 60 days revealed no specific entries related to the aforementioned maintenance concerns.

Based on interview and record review the facility failed to provide timely financial statements to one Resident (#26)/responsible person of one Resident reviewed for Resident trust fund, resulting in the resident/responsible person being not informed about personal funds. Findings Included: Resident #26 (R26) Review of the medical record revealed R26 was admitted to the facility 05/25/2017 with diagnoses that included Liver cirrhosis (chronic liver damage resulting in liver failure), type 2 diabetes, osteoarthritis right elbow, hepatic failure (liver failure), protein-calorie malnutrition, pain of right shoulder, alcohol dependence, schizoaffective disorder, abnormal gait, muscle weakness, heart disease, heart failure, dementia, gastro-esophageal reflux, depression, hypotension, chronic respiratory failure, history of myocardial infarction (heart attack), hypertension, urinary retention, and chronic viral hepatitis C. The most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/05/2024, revealed a Brief Interview for Mental Status (BIMS) of 1 (severe cognitive impairment) out of 15. During a telephone interview on 07/09/2024 at 10:43 a.m. R26's Family Member E explained that he was the Durable Power of Attorney (DPOA) of R26. R26's Family Member E explained that the facility managed R26's financial matters. R26's Family Member E denied every receiving a quarterly financial statement from the facility. R26's Family Member E explained that R26 had a financial account at the facility but again denied receiving a quarterly statement of R26's account balance or activities. In an interview on 07/10/2024 at 02:52 p.m. Business Office Manager (BOM) H explained that residents were allowed to have a financial account that was to be held by the facility and that the money was placed in an interest-bearing account. BOM H explained that the facility used a third-party contractor for the management of resident accounts and statements were mailed to the facility. After the financial statements are received by the facility they are mailed to the resident/responsible persons. When asked for documentation demonstrating that R26's Family Member E had been mailed a quarterly statement, she was unable to provide documentation. BOM H then explained that the facility has not received quarterly statements from the third-party or mailed statements to the residents/responsible party for an undetermined amount time. BOM H could not explain when the last time financial statements were mailed to R26's Family Member E Review of R26's financial statement revealed R26 had a current balance of $672.67, demonstrating that R26/R26's Family Member E should have been receiving quarterly financial statements.

This citation pertains to intake MI00144424. Based on observation, interview and record review, the facility failed to notify the Physician of a change in tissue appearance for a hot liquid thermal burn for one (Resident #28) of one reviewed. Findings include: Review of the medical record reflected R28 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included multiple sclerosis and unspecified severe protein-calorie malnutrition. The significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/23/24, reflected R28 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS-a cognitive screening tool) and was coded for second or third degree burns. During an interview and observation on 07/09/24 at 2:17 PM, R28 reported about three to four months prior, hot coffee fell over and was super hot. He reported having a fourth-degree burn on his leg. He lifted the left leg of his shorts and showed a darkened area, several inches long, on the lateral (outside) aspect of his left leg. R28 reported there was a lid on his cup, which he had next to him, in his wheelchair. According to R28, the lid did not seal good enough, causing the hot coffee to leak out of the side of the cup. R28 reported when the coffee spilled on him, he told staff right away, and they put stuff on to make it heal. An incident report for 4/18/24 at 11:17 AM, reflected R28 came up to the nurse, stating he had spilled coffee on himself and the floor. His left thigh was assessed and noted to have blisters and a raised, red area. The immediate action taken reflected the burn was cleansed, then iced for 20 minutes. Once the ice was off, medihoney (wound and burn treatment) was applied to the wound, then covered with an ABD dressing. During an interview on 07/10/24 at 2:59 PM, Licensed Practical Nurse (LPN) L reported being R28's nurse at the time he sustained the coffee burn. R28 came to her and reported receiving coffee from the kitchen, which he put in the side of his wheelchair. When he went outside, the coffee spilled on his leg and burned him. LPN L reported the burn initially appeared as the length of her cell phone, with a large blister. When she saw the burn the following week, the blister was no longer intact, and there was raw skin. According to Mayo Clinic, .2nd-degree burn. This type of burn affects both the epidermis and the second layer of skin (dermis). It may cause swelling and red, white or splotchy skin. Blisters may develop, and pain can be severe. Deep second-degree burns can cause scarring .3rd-degree burn. This burn reaches to the fat layer beneath the skin. Burned areas may be black, brown or white. The skin may look leathery. Third-degree burns can destroy nerves, causing numbness . (https://www.mayoclinic.org/diseases-conditions/burns/symptoms-causes/syc-20370539). On 4/18/24, R28's burn measured 20 centimeters (cm) in length by (x) 7 cm in width. The wound photo revealed a red, raised area with intact blisters. R28's pain level was recorded as eight out of ten. On 4/22/24, R28's burn measured 20 cm in length x 7 cm in width. The burn was staged as partial thickness (affects the top two layers of the skin). The tissue type reflected, Necrotic [dead tissue] Soft, Adherent=50%, Necrotic Hard, Firm, Adherent=50%. R28's pain level was recorded as eight out of ten. The assessment reflected the burn was Very painful. R28's burn was evaluated by the Wound Provider on 4/25/24. The assessment reflected R28 had a second-degree burn, measuring approximately 18 cm in length x approximately 6 cm in width and 0.1 cm in depth. The tissue was 75% slough (non-viable tissue that can present as yellow, tan, gray, green or brown) and 25% granulation (pink/red tissue that fills a wound when it begins to heal). R28's treatment was changed to silvadene (cream used to prevent and treat infections for people with burns). During an interview on 07/11/24 at 10:01 AM, Assistant Director of Nursing (ADON) R reported seeing R28's burn the day it happened. She reported the burn extended into the fatty layer of skin and was classified as a second-degree burn. ADON R reported that R28's burn had more dead tissue and was appearing more like a third-degree burn when she assessed it on 4/22/24. ADON R acknowledged she did not see any documentation in R28's medical record pertaining to notifying the Physician about the change in R28's burn appearance on 4/22/24. She reported she thought medihoney was still the appropriate treatment as of her assessment on 4/22/24. When R28 was seen by the Wound Provider on 4/25/24, the treatment was changed to silvadene.

This citation pertains to MI 033, MI 494, MI 583, MI 647 and MI 648. Based on observation, interview and record review, the facility failed to prevent abuse for seven (Resident #1, #2, #6, #7, #8, #10 and #12) of 10 reviewed for abuse, resulting in resident to resident abuse and Immediately Jeopardy when the facility failed to implement appropriate interventions to prevent Resident #1 from being sexually abused by Resident #2 on 1/31/21 and by Resident #8 on 3/14/21. This deficient practice resulted in the likelihood for further resident sexual abuse, thereby putting all 59 facility residents at risk for abuse. Findings include: Resident #1 (R1) Review of the medical record reflected that R1 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/17/21 reflected that R1 scored five out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS reflected R1 required supervision for transfers and ambulation (walking). R1's Care Plan, initiated 9/12/19 and revised 2/1/21, reflected, .At times I have shown to have a behavior problem r/t (related to) sexually inappropriate behaviors, lifting up her shirt exposing herself and sexually inappropriate with others (sic) I have periods of having increased wandering in and out of other resident rooms at times . An intervention with a date initiated of 2/1/21 and a revision date of 2/1/21 reflected, redirect resident from entering other's rooms and if inappropriate with others. R1's Care Plan, initiated 9/12/19 and revised 12/13/19 reflected, I have shown to have impaired cognitive function or impaired thought processes r/t Disease Process [MEDICAL CONDITIONS]. Resident #2 (R2) Review of the medical record reflected that R2 was originally admitted to the facility on [DATE] and was readmitted on [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/7/21 reflected R2 scored 15 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R2 was non-ambulatory (did not walk) and required extensive to total assistance for most Activities of Daily Living (ADL's). R2's Care Plan, initiated 1/19/20 and revised 2/1/21 reflected, I have shown to have a behavior problem such as I have been noted to be sexually inappropriate with staff and residents. Review of a facility investigation reflected that on 1/31/21 at 8:00 PM, a Certified Nurse Aide (CNA) caught R1 performing oral sex on R2, in R2's room. The investigation summary/actions taken reflected that R2 admitted to asking R1 to perform oral sex on them and that R1's ability to make decisions was severely impaired. The investigation reflected that R2 was moved to a separate unit after the incident. According to the investigation, R1's Guardian and the Police were notified. An Incident Report for R1, dated for 2/1/21 at 4:55 AM reflected the CNA walked into R2's room and observed R1 sitting on the bed with their head between R2's legs, while R2's brief was undone. R1 was performing oral sex on R2, according to the Incident Report. When asked what she was doing, R1 reported I was sucking his dick. When asked why, R1 reported, because he told me to. When asked if she wanted to, R1 said, no. The Incident Report reflected R2 was moved to another hallway. R1 was placed on routine 15 minute checks to ensure she stayed away from R2 until she went to bed. After R1 went to bed, 30 minute checks were then performed on R1 to ensure she was still in bed, according to the Incident Report. An Incident Report for R2 on 2/1/21 at 5:09 AM reflected the CNA approached the nurse with R1, stating R1 was sitting on R2's bed, with her head between R2's legs while R2's brief was undone. R1 was performing oral sex on R2, according to the Incident Report. When asked what happened, R2 stated, I'm not talking about it. R2 then stated, I told her to suck it and that's all I'm saying about any of it. R1's medical record reflected a Progress Note for 1/31/21 at 8:45 PM that the CNA approached the nurse's station with R1. The CNA stated they were across the hall from a male resident room, when his (male resident) call light came on. The CNA completed their task in five to 10 minutes of observing the light on. As the CNA entered the male resident room, she walked towards his bed and observed R1 leaning over the male resident (R2) while standing. The male resident's brief was unattached and open. R1 was immediately removed from male resident's (R2) room. When asked what happened, R1 stated I was sucking his D*%$. When asked why she would do that, R1 stated, because he told me to do it. The note reflected R2 was moved to a room on the back hallway. According to the note, R1 stated he told me to do that. A Progress Note in R1's medical record for 1/31/21 at 9:32 PM reflected the Police questioned R1, who stated she did not want to perform the act on R2. A Progress Note for 2/1/21 at 12:07 AM reflected the nurse and CNA on the hall were to complete 30 minute checks while R1 was in bed to maintain distance and safety. A Progress Note for R2 on 1/31/21 at 9:14 PM reflected that R2 acknowledged he knew what took place (with R1) was wrong and inappropriate. During a Survey Team interview on 3/10/21 at 9:57 AM, CNA F reported R1 was like a child, wandered a lot, and they had to constantly redirect her. CNA F reported R1 was independent with ambulation and wandered into other resident rooms all the time. According to CNA F, R1 wandered aimlessly, in all areas of the facility. CNA F reported R1 exposed herself the other day by taking off her pants and pull-up and was walking in the hallway with only a shirt on. R1 was redirected to her room before the male resident in the lobby saw her. CNA F reported they kept R1 away from male residents to keep her safe because you never know what is going to happen. During a Survey Team interview on 3/10/21 at 10:24 AM, Licensed Practical Nurse (LPN) G reported R1 was ambulatory independently and wandered. LPN G reported R1 was quick, and if they were helping other residents, someone from the back hall would bring R1 back to her hall. LPN G reported that happened four to five times during their shifts. LPN G reported there were a couple male residents, Resident #8 and Resident #9, that would invite R1 into their room. LPN G reported Resident #8 would sit in the hallway and try to get R1 to come. LPN G reported last observing that about six months prior. LPN G reported R1 mimics others and would lift her shirt if motioned to. LPN G reported Resident #8 motioned and encouraged that with R1. On 3/10/21 at 11:40 AM, R1 was observed to be in bed. On 3/10/21 at 11:47 AM, the Survey Team spoke to R2 in his room, while he was resting in bed. R2 reported every once in a while someone else would wander into his room, but they did not do it anymore. R2 stated it was R1, and she got him in trouble. R2 reported there was a time when R1 came in and whipped her boob out, which he reported freaked him out. He reported another time that R1 came in and pulled his brief off. He reported she could not find it because it was between his legs. R2 stated there was another time he had a report written against him from the Sheriff's Department. R2 stated R1 jumped him big time months ago. When reporting what R1 did, R2 stated you don't want to know. He then stated R1 was sucking on it. R2 then stated R1 gave him a blow job. According to R2, one of the nurse aide's came in and caught R1 in the act. R2 stated, Of course I knew better than that. R2 reported they had not seen R1 in about a week. On 3/10/21 at 1:09 PM, R1 was observed lying in bed with a face mask in place. The Survey Team spoke to R1 in her room. R1 reported she went all over the facility by herself. R1 reported she visited other residents and was allowed to do so. She then reported staff came in to ask her to leave those rooms. R1 reported going to people's rooms in the back hall of the facility. R1 reported she was friends with R2 and mentioned R2 by first and last name. R1 reported they went to R2's room often but could not recall the last time they had been there. R1 reported they just talked and denied having any sexual encounters with anyone else at the facility. On 3/10/21 at 2:03 PM, R1 was observed ambulating on A hall, carrying a book and calling out BINGO numbers. She was observed ambulating to the area near the A hall nurse's station, then back through the hallway, past her room and into the dining room. R1 was then observed to wander to the doorway of the room next to hers. A male resident was overheard telling R1 that was not her room. R1 then went to her room and sat on her bed. During a Survey Team interview on 3/10/21 at 2:15 PM, Social Worker (SW) I reported R1 wandered into other resident rooms at times. SW I reported R2 understood what happened between him and R1 and was embarrassed by it. SW I reported R2 was in his room, exposed, and asked R1 to come in. SW I reported R1 performed oral sex (on R2). When SW I followed up with R1, she did not recall much or did not verbalize she recalled much. SW I reported he did not think R1 understood that (encounter with R2) was wrong. Regarding interventions taken by the facility, SW I reported R1 was immediately removed from R2's room, and R2 was moved to a room on the back hall. SW I reported his understanding was that some 30 minute checks were done with R1, and activities were increased. During a phone interview on 3/11/21 at 11:30 AM, CNA M reported R1 was very prompt oriented. If someone was calling R1's name, she would follow that call. CNA M reported R1 wandered to B hall (the back hallway) frequently. During a Survey Team interview on 3/15/21 at 10:07 AM, CNA N reported they did not really know what happened between R1 and R2, except they were to be kept away from each other. CNA N reported R1 wandered to the back hall, and they saw her at least once or twice a shift on that hall. According to CNA N, R1 wandered into other resident rooms. During a Survey Team interview on 3/15/21 at 10:23 AM, LPN P reported during the hours of 7 PM to 11 PM, when they worked, R1 wandered to the back hall once or twice, depending on who was working back there. LPN P reported if R1 was not with them, and the CNA's did not know where R1 was, their first reaction was to check the back hallway. During a Survey Team phone interview on 3/16/21 at 6:58 AM, CNA H reported R1 was independent with ambulation and walked through the building if she could get away with it. CNA H reported they tried to keep R1 on A hall because it was safer due to some of the men, who they referred to as R2 and Resident #8. CNA H reported that a few months prior, she walked into the room, R2's penis was out, and R1's head was down. CNA H stated they removed R1 from the room. According to CNA H they had last seen R1 not long before that, maybe 15 minutes but stated it could have been more than that. CNA H reported they kept R1 in sight after that. CNA H reported that R1's interventions did not change after that incident. They just made sure to keep an eye on R1. During a Survey Team phone interview on 3/16/21 at 8:07 AM, LPN L reported R1 roamed around the facility a lot. If a resident told R1 to come to them, R1 would. LPN L reported CNA H came to the nurse's station frantically with R1. CNA H had reported R2's (call) light was on, and they went in to answer it. When CNA H went in the room, R1 was over R2, and R2's brief was undone. According to LPN L, CNA H said R1's head was in R2's groin area. LPN L reported taking R1 to a private area, and R1 reported, I sucked his dick and it was gross. R1 reported doing it because R2 told her to, according to LPN L. During a Survey Team interview on 3/17/21 at 1:57 PM, LPN J reported R1 had been standing at the nurse's station, eating cookies, while the nurses were doing shift report. Approximately 15 minutes later, as they were getting up, CNA H was walking towards them with R1. CNA H had reported R1's head was down, and R2's brief was undone. A Progress Note for R1 on 2/5/21 at 9:14 PM reflected R1 was observed wandering into other resident rooms and was redirected several times out of other resident rooms. A Progress Note for R1 on 2/25/21 at 1:39 PM reflected R1 .has shown to be sexually inappropriate i.e. Attempting to rub her Breast on male Nurses, lifting up her shirt at times, easily redirected . The note further reflected R1 had increased wandering in and out of other resident rooms at times. Resident #8 (R8) Review of the medical record reflected R8 was admitted to the facility 11/2/17 and was readmitted [DATE], with [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 1/11/21 reflected R8 scored 13 out of 15 (cognitively intact) on the BIMS. The same MDS reflected R8 was independent with bed mobility, transfers, ambulation in their room and locomotion. R8's Care Plan, initiated and revised on 3/15/21, reflected, (R8) has a behavior problem r/t wandering in to other residents rooms, inappropriate touching. R8's Progress Notes reflected documentation for 11/8/2020 at 7:34 PM that R8 was sitting in the hallway in his wheelchair when another resident was walking towards him. The nurse observed R8 using his hands in an upward motion for the other resident to raise her shirt up. The note reflected the nurse told the resident to stop and removed the other resident. During a Survey Team interview on 3/15/21 at 10:07 AM, CNA N reported there was an incident with R8 the night prior (3/14/21), and the Police were called. During a Survey Team interview on 3/15/21 at 10:23 AM, LPN P reported the previous night (3/14/21), R8 fondled R1's breasts in R1's room. LPN P reported R1 looked kind of frazzled after the incident. During a Survey Team phone interview on 3/15/21 at 1:18 PM, CNA S reported they were going around doing vitals. When they got to R1's room, they saw a part of a wheelchair next to her bed. R1's shirt was up, and R8's hands were up under R1's shirt. He was fondling her. CNA S reported they startled R8 and told him to get out of the room. CNA S then ran out to get the nurse, per their report. She reported R1 had a blank look, like something happened to her. CNA S reported R1 could not consent to that. An attempt to speak to R8 on 3/15/21 at 2:13 PM was unsuccessful. During a Survey Team phone interview on 3/16/21 at 6:58 AM, CNA H reported hearing that R8 went into R1's room and was touching her. Regarding the intervention put in place after that incident, CNA H reported they believed they just tried to keep R1 in her room that night. During a Survey Team phone interview on 3/16/21 at 8:07 AM, LPN L reported they were passing medications and saw R8 many times while they were going room to room. LPN L reported being in a room for approximately five minutes, and it happened that fast. LPN L reported the CNA brought R8 back and reported catching him in R1's room. According to LPN L, it had been reported that R1 was in her room, with a t-shirt and no bra. R1's shirt was pulled up by their neck. LPN L reported R8 was pretty much fondling R1's breasts in her room. According to LPN L, they tried to talk to R8 about the incident, but he is hard of hearing. LPN L reported also trying to write it down. They reported R8 made grunting noises, and it was difficult to talk to him. Review of a facility reported incident document reflected that on 3/14/21 at 8:30 PM, staff found R1 and R8 in the hallway, and R8 was touching R1's breasts. SW I's statement for an interview with R1 on 3/15/21 reflected that R1 acknowledged another resident touched her breasts. When asked what happened, R1 stated, nothing he touched my tits . R1 then laughed. When SW I asked her why she laughed, R1 stated it wasn't a big deal, he touched her tits. Review of SW I's statement for an interview with R8 on 3/15/21 reflected that R8 denied touching R1 and reported they were only visiting her. CNA S's witness statement for 3/14/21 reflected they walked into R1's room and observed R8 with R1. R8's hands and mouth were under R1's shirt, according to the statement. R1's incident report for 3/14/21 at 8:30 PM reflected a male resident (R8) was caught in R1's room with their hands on R1's breasts while R1's shirt was up. R1's breasts were red, consistent with being handled, according to the Incident Report. R8's incident report for 3/14/21 at 8:30 PM was reflective of R8 being found in another residents room (R1) with their hands on (R1's) breasts while (R1's) shirt was up. R8 stated he could not hear when asked about the situation. Staff attempted to write it on paper, and R8 refused to look at the paper. Review of R1's Progress Notes on 3/18/21 did not reflect any documentation pertaining to the incident with R2 on 3/14/21. Review of R8's Progress Notes on 3/18/21 did not reflect any documentation pertaining to the incident with R1 on 3/14/21. Review of R8's task charting for behaviors for 2/17/21 to 3/16/21 did not reflect documentation of any sexual behaviors. On 3/15/21 at 11:35 AM, Nursing Home Administrator (NHA) A was notified of the Immediate Jeopardy that was identified on 3/15/21 and began on 1/31/21, due to the facility's failure to prevent resident sexual abuse. A corrective action plan was requested from the facility to remove the Immediate Jeopardy. Immediate Jeopardy was removed on 3/16/21, when the facility had the following in place: -On 3/15/2021, every 15 minute checks/increased supervision has been initiated for (R1) and will continue until deemed no longer needed or upon discharge to alternate placement. Checks will be documented on check off sheet kept at nurse's station. -On 3/16/2021 at 3 PM, the above supervision was revised to 1:1 supervision for (R1) during the hours of 7 AM to 10 PM and will have 15 minute checks from 10 PM to 7 AM. These interventions will continue until deemed no longer needed or upon discharge to alternate placement. Staff supervision and 15 minute checks will be documented on sheet kept at nurse's station. -On 3/15/2021 facility will interview resident to determine more activities of choice and resident will have increased activities, interventions in place for later in day when activities dept (department) is not here. Activities will increase one on ones to 4x a day, other interventions suggested are movies, music, books or shows about dogs, coloring, she likes puzzles and she likes having her hair brushed. -On 3/15/2021 Care plan was updated and mesh stop sign was attached with Velcro to (R1's) doorway to deter others from entering. -On 3/15/2021 Care plan updated to reflect increased supervision, interventions and redirections as needed. -On 3/15/2021 at 3 PM (R1) had a televisit with mental health, Psychiatrist and a referral was made for a psychologist visit. -On 3/15/2021 floor plan is being reviewed to determine if there is a room (R1) can move into that is within line of sight of the nurses station. -Facility is investigating alternative placement in attempt to find a safe and appropriate location more suitable to meet (R1's) needs. A call has been placed on 3/15/2021 to her father (guardian) as well as (Agency). -3/15/2021 Staff will begin to be educated on resident plan of care, supervision requirements, activities of choice. Although the Immediate Jeopardy was removed on 03/16/21, the facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency. Resident #10 (R10) Review of the medical record revealed R10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of 2/4/21 revealed R10 scored 9 out of 15 (moderate cognitive impairment) on the BIMS. A witness statement from Certified Nursing Assistant (CNA) H on 3/16/21 reflected that CNA H was asked about the incident from 3/15/21. CNA H reported, (R1) hit (R10). CNA H was asked if they witnessed the incident and reported, No, I just heard about it. During a Survey Team phone interview on 3/16/21 at 6:58 AM, CNA H reported that R1 had gotten a little physical with other residents every once in a while, swinging at them and sometimes connecting. CNA H reported that had happened recently with another resident on the hall. CNA H reported that the previous night (3/15/21) around 8:00 PM, R10 was watching TV in the lobby and got hit for no reason. CNA H believed R1 hit R10's chest but stated they did not witness the incident occur, but the nurse caught the tail end of it. In a telephone interview on 3/16/21 at 7:24 AM with the entire survey team present, LPN R reported on 3/15/21, R1 and R10 were both in the lobby without staff present. LPN R reported she had just come out of another resident's room when she witnessed R1 hit R10's stomach. LPN R reported R10 told R1 to stop. Review of R1 and R10's Incident Reports for 3/15/21 at 8:15 PM, prepared by Nursing Home Administrator (NHA) A, reflected, Nurse called me to report that she thought she saw (R1) hit (R10). As she got closer to the 2 residents she saw that (R1) was just swinging her hands, tapping him on his chest as she is care planned for. Care plan states (R1) is/has potential to be physically aggressive spontaneously bumping into others, patting other (sic) with open hand to arms, chest, back or head r/t (related to) Poor impulse control, cognitive and expressive difficulty r/t anoxia [MEDICAL CONDITION]. (R10) was holding her arm and neither resident was aggressive or intending harm. This is typical mode of communication for (R1) when she interacts with others. The report reflected that MDS was notified to update R1's care plan to reflect that R1 also taps on the chest. In an interview on 3/16/21 at 8:47 AM with the entire survey team present, NHA A reported on 3/15/21, she was informed that Resident #1 (R1) went up to R10 and was talking to him with her hands. NHA A reported R10 was doing it back and R10 grabbed R1's hands. NHA A stated, It wasn't an incident. It was her (R1) normal behavior where she flaps her hands. NHA A reported she did not have a written report or any documentation of how the incident was initially reported to her. When asked again about the incident, NHA A stated From what I understood, they were both in the lobby. (R1) went to (R10) and as talking, her hands were flapping. Her hand bumped his chest. He did it back and then held her arm . On 3/16/21 at 2:08 PM with the entire survey team present, Vice President of Finance (VPF) V reported he was in the building on 3/15/21 when LPN R was running down the hall and said (R1) just hit (R10) .I was in the office and heard her say that. VPF V reported R10 was definitely irritated, definitely pushed her (R1's) hand away, was definitely not enjoying it. VPF V reported he was the one who decided it was not incident worthy. On 3/16/21 at 2:01 PM, R10 was observed lying in his bed watching television. When asked about what happened the previous night, R10 pointed towards the wall that was in the direction of the lobby. When asked what happened, R10 stated, She came at me and hit me .I was sitting there and all of a sudden I'll be darned, hit me right dead in the (R10 then began demonstrating punching himself in the chest) .she came right at me. Resident #6 (R6) Review of the medical record revealed R6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/30/21 revealed R6 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS) and had no delusions or hallucinations. Resident #7 (R7) Review of the medical record revealed R7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of 2/3/21 revealed R7 scored 15 out of 15 (cognitively intact) on the BIMS, had verbal behavior directed toward others 1 to 3 days, and other behavioral symptoms not directed toward others 1 to 3 days. Review of R7's behavior care plan initiated on 12/10/20 revealed I am socially inappropriate/yelling, screaming, using profanity, disruptive to other res. (residents); slamming doors; try to run into staff (with wheelchair). The care plan was last revised on 1/19/21. In an interview on 3/10/21 at 12:32 PM with the entire survey team present, Nursing Home Administrator (NHA) A, with Social Worker (SW) I present, reported yesterday (3/9/21), she received an emotional abuse allegation. NHA A reported R6 reported that R7 was in her doorway, yelling, and made some type of threat .something about beating her up, basically he threatened to harm her, so I need to report that. On 3/10/21 at 1:24 PM, R6 was observed up in her room with her walker. R6 reported one day last week at 3:00 AM, R7 was in her doorway, screaming, just cussing and carrying on .I woke up and he was in my room screaming. I asked what was wrong. That's when he said he was going to kill me. R6 stated the constant threatening has to stop. R6 became tearful stating, Can I defend myself? Can I push him out of my room? He does whatever he wants. R6 reported she has witnessed R7 yell at other residents in the facility also. R6 reported she is used to living in a Christian environment and stated, this was all horrendous for me .He (R7) hurts people every day with his actions .He is a danger to people. When asked if she felt safe in the facility, R6 stated No, not when he (R7) is around. I am frightened to death. I just start shaking. Review of the undated Witness Statement written by R6 revealed First week of March approximately 3AM in the morning my roommate and I (name redacted) were awoken to (R7's name) screaming at the top of his voice. I was frightened and angry because his out burst (sic) are becoming more frequent and [MEDICATION NAME] longer. I sat up because he was in our doorway. I told him to grow up and get out of our doorway which gave him an excuse to threaten to beat my (ass) and was calling me a whore [***] ed (sic). It continued for about 45 minutes .people here feel trapped by this man. And we just want to live the rest of our life in peace and happiness. Please help us feel safe. R7 refused interviews on 3/10/21 at 1:35 PM and 3/10/21 at 2:57 PM. In an interview on 3/11/21 at 1:50 PM with the entire survey team present, Staff Member O reported never seeing anything like R7's behaviors before. Staff Member O stated at the drop of a dime he (R7) will cuss everyone out, call them names, threaten them .other residents will tell him to stop talking like that and he just goes off on them .we try to close the doors and calm the other residents down .he (R7) verbally attacks staff and residents . Resident #12 (R12) Review of the medical record revealed R12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS with an ARD of 1/18/21 revealed R12 scored 3 out of 15 (severe cognitive impairment) on the BIMS. On 3/16/21 at 2:32 PM, R12 was observed sitting in a chair in her room. R12 reported she has heard people yelling in the hallway and there is one person who called her names and was very mean. R12 reported this happened yesterday and it made her cry. R12 stated People yelling and screaming. I just don't care for that. In a telephone interview on 3/16/21 at 8:08 AM, Licensed Practical Nurse (LPN) L reported that just about every day that I work, I have residents that tell me how fearful they are regarding (R7). LPN L reported the other day during bingo, R7 was banging, kicking, and opening doors. LPN L stated He (R7) was in her (R12's) doorway yelling and screaming at her, calling her a retard. LPN L stated R10 was crying. When asked if she was aware of the incident when R7 yelled at R6, LPN L stated It happens with so many residents so often that I wouldn't even know which time you are talking about .It's an every day occurrence. It's just normal now. LPN L reported other residents were fearful of R7 and stated, These little ladies don't need to be scared and hiding in their room. In an interview on 3/17/21 at 1:16 PM, NHA A reported she was not aware of the incident between R7 and R12.

Based on observation, interview and record review, the facility failed to develop and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections including Covid-19 for all 56 facility residents as evidenced by: Delays in identification of Covid-19 positive residents and placing them immediately into isolation; and Laundry room - lack of Personal Protective Equipment and hand hygiene methods in the soiled linen room, generating potentially infectious aerosols into the clean linen room while sorting soiled linens, and cross contamination of machines and clean linens during loading/unloading washing machines; and Housekeeping practices irregularities; and Safety glasses used in place of goggles/face shields; and Inadequate respiratory assessments; and Incomplete visitor screening for Covid-19; and not disinfecting eye protection when moving from COVID-19 unit to non-isolation areas: collectively resulting in immediate jeopardy. This deficient practice resulted in the facility widespread infection of COVID-19 and the likelihood for further cross contamination of COVID-19 to other residents and staff, thereby putting all 56 residents at risk for infection, hospitalization , and/or death. Findings include: Upon entry to the facility, on [DATE] at 9:30 AM, Receptionist I took both Surveyors temperatures but did not ask any Covid-19 symptom screening questions or ask them to fill out the form themselves. However, when the Visitor Symptom Log dated [DATE] was reviewed (on [DATE]), it revealed Receptionist I filled in the log for both Surveyors with 'No' for each symptom: chills, cough, shortness of breath or difficulty breathing, fatigue, body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea. In an interview, on [DATE] at 11:59, Receptionist I reported she had just been taking temperatures but not asking staff and visitors about symptoms. Receptionist I said, Yes, I do all the screenings . I was supposed to ask screening questions. According to the facility's Infection Control during Visitation Policy and Procedure, dated [DATE], .For all staff and approved vendors - After signing in at the front desk all staff and approved vendors will have their temperature taken, use hand sanitizer and don a mask prior to entering the resident floor area . There was no mention of screening for symptoms of Covid - 19 such as cough, shortness of breath, etc. According to the CDC, Management of Visitors to Healthcare Facilities in the Context of COVID-19: Non-US Healthcare Settings, dated [DATE], Facilities should designate an entrance that visitors can use to access the healthcare facility. Visitors who are noted by healthcare facility staff to have fever or other symptoms of acute respiratory illness (e.g., cough or shortness of breath) should be instructed to leave the facility and seek care if needed. Facilities should encourage visitors to be aware of signs and symptoms of acute respiratory illness consistent with COVID-19 and not enter the facility if they have such signs and symptoms. Visual alerts, such as signs and posters, should be placed at facility entrances and other strategic areas instructing visitors not to enter as a visitor if they have fever or respiratory symptoms. Signage should include signs and symptoms (including cough and/or shortness of breath) of COVID-19 and who to notify if visitors have symptoms . <https://www.cdc.gov/coronavirus/2019-ncov/hcp/non-us-settings/hcf-visitors.html> During an observation/interview on [DATE] at 9:45 AM, Housekeeping Staff E was observed wearing safety glasses that were not shielding the sides of her eyes completely. Housekeeping Staff E held a bottle of Spic & Span in one hand and a bottle of liquid Comet (with bleach) in the other hand and sprayed the sink and toilet of a three bed ward (one side or the sink was sprayed with Spic & Span and the other side was sprayed with Comet and one side of the toilet was sprayed with Spic & Span and the other side was sprayed with Comet), then she placed the bottles, one in the sink and the other on the sink. When returning to her cart, Housekeeping Staff E first placed one of the bottles on the handrail just outside the residents' room but did not disinfect the handrail after she placed it into the cart. During the cleaning of the room, Housekeeping Staff E touched and placed new paper towels in the dispenser and opened toilet paper and placed it on the roll while wearing gloves she had been wearing while cleaning. Housekeeping Staff E wiped the surfaces in all three residents' areas (bedside tables tops and legs, call lights, cabinets, bed controls (which were laying on the floor) with a cloth soaked with a bleach water solution and then proceeded to wipe the bathroom fixtures, sink and walls all with the same cloth. Housekeeping Staff said she made the solution with two or three capfuls of bleach and an unmeasured amount of water in the bucket. Housekeeping Staff E used one presoaked (she did not know what the cleaning solution was) mop head for the entire room, including the bathroom and said, It is supposed to dry fast . See how fast it dries? (The floor was dry in less than three minutes). Housekeeping Staff E said there were no written instructions to guide her on how to clean the room, how many cloths and mopheads to use, what products were to be used for which surfaces, how long to keep surfaces wet with each solution, or when to change gloves but commented, The boss says you are allowed to get a new cloth or mop head if it gets dirty. In an interview, on [DATE] at 10:49 AM, Housekeeping/Laundry Staff F was observed wearing a different style of safety glasses and they had less shielding on the sides than the safety glasses that Housekeeping Staff E was wearing. Housekeeping/Laundry Staff F reported, Comet (spray) is used on the toilet. Spic & Span is used only in the bathroom for the rest (sink, walls, fixtures, etc.) Housekeeping Staff F reported, Purple (Super Sani Wipes) wipes are used for dresser, handrail, etc. In the Laundry, Housekeeping/Laundry F stated the Laundry staff sorted the soiled linens into two tubs directly in front of the washers, not in the soiled linen room. It was observed, there were no PPE (Personal Protective Equipment), sink or ABHR (alcohol-based hand rub) in the soiled linen room. There was no door separating the washing machine area with the clean laundry folding and storing area. Housekeeping/Laundry Staff F said she shut the washer and turned it on wearing the same gloves she was wearing to sort the dirty linens and then reported she did not wipe the washer controls or door every time she loaded it. Housekeeping/Laundry F stated she never thought about whether she was cross contaminating the clean linens when she was removing them from the washers because the door and controls had been contaminated with her soiled gloves. Housekeeping/Laundry Staff F said there was not written procedure to prevent cross-contamination while sorting soiled linens, washing linens and processing the clean linens. It was observed, and Housekeeping Staff F and Laundry Staff L both reported there was no ABHR or Hand Hygiene posters anywhere in the Laundry and said they were not aware that sorting laundry in the soiled laundry area minimized the possibility of dispersing germs, including viruses such as Covid-19, through the air and onto clean linens. On [DATE] at 12:49 PM, Administrator A reported the facility the Housekeeping staff were supposed to be using: Mr. Clean: Pro line Disinfecting Floor and Surface Cleaner, not redi-mix, 1oz per gallon, 10 minute contact time. Comet: Cleaner Disinfecting with Bleach, pre-mixed, 10 minute contact time. Spic and Span: Disinfecting All-Purpose Spray and Glass Cleaner RTU, pre-mixed, 10 minute contact time. Super Santi Cloth Wipes: 2 minutes contact time. Review of a Hand Hygiene poster inside the employee bathroom revealed it did not reflect current Professional Standards related to Hand Hygiene practices in the Health Care setting. It read as follows: Hand Hygiene. Employees must wash their hands for at least 20 seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: When coming on duty .Before and after direct resident contact . before and after performing any invasive procedure (e.g., fingerstick blood sampling); before and after entering isolation precaution settings; Before and after eating or handling food; Before and after assisting a resident with meals; before and after assisting a resident with personal care (e.g.; oral care, bathing); Before and after handling peripheral vascular catheters and other invasive devices; Before and after inserting indwelling catheters; Before and after changing a dressing; Upon and after coming in contact with a resident's intact skin, (e.g., when taking a pulse or blood pressure, and lifting a resident) .; Before and after assisting a resident with toileting (hand washing with soap and water) . According to the Centers for Disease Control Clean Hands Count for Healthcare Providers, [DATE] (last reviewed [DATE]), Alcohol-based hand sanitizers are the most effective products for reducing the number of germs on the hands of healthcare providers. Alcohol-based hand sanitizers are the preferred method for cleaning your hands in most clinical situations . Wash your hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. During Routine Patient Care: Use an Alcohol-Based Hand Sanitizer Immediately before touching a patient; Before performing an aseptic task (e.g., 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 the patient's immediate environment; After contact with blood, body fluids or contaminated surfaces; Immediately after glove removal. Wash with Soap and Water When hands are visibly soiled; After caring for a person with known or suspected infectious diarrhea; After known or suspected exposure to spores (e.g., B. anthracis,[DIAGNOSES REDACTED]icile outbreaks). <https://www.cdc.gov/handhygiene/providers/index.html> Review of the facility's infection control Work Practices Policy and Procedure, dated revised [DATE], revealed it did not contain the most current Professional Standards related to Hand Hygiene practices: . Employees shall wash their hands as soon as possible after removing gloves or other personal protective equipment . Review of the facility's Pandemic Communications Plan, dated [DATE], revealed, The Pandemic Response Coordinator will maintain a current Pandemic Planning Committee Roster, including the names, titles, departments, and contact information of committee members. However, Review of the facility's Pandemic Planning Committee and Response Coordinator Policy and Procedure and revealed it was last revised [DATE] and was not updated to reflect accurately the current Members of the committee (Administrator, Staff Development coordinator and Maintenance Services). According to the Centers for Disease Control, [DATE], .Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infections .Consider increasing monitoring of asymptomatic residents from daily to every shift to more rapidly detect any residents with new symptoms . <Responding to Coronavirus (COVID-19) in Nursing Homes | CDC> Review of the facility's Caring for resident with Covid-19 Policy and Procedure, dated [DATE], revealed, . The following measures will be implemented for residents with known or suspected COVID-19 . Vital signs and 02 saturations will be taken twice per day and this will be aligned with medication administration and ADL care . There was no mention of a respiratory exam (which typically includes lung sounds) in the policy. Resident #3 (R3) According to Minimum Data Set, dated dated [DATE], R3's was admitted to the facility [DATE], was cognitively intact and had [DIAGNOSES REDACTED]. On [DATE] at 12:36 PM Director of Nursing (DON) reported that R3 tested positive for Covid-19 on [DATE]. Review of R3's [DATE] Medication Administration Record [REDACTED]. of [MEDICAL CONDITION] infection. -Order Date- [DATE] 1015 (10:15 AM) . However, the MAR indicated [REDACTED]. R3's MAR indicated [REDACTED]. Review of R3's Medical Record revealed the last recorded Respiratory Infection Screener Assessment was done on [DATE]. R3 was discharged to the hospital on [DATE] due to brown tinged nausea and vomiting. Resident #6 (R6) According to the MDS, dated [DATE], R6 was admitted to the facility on [DATE], was cognitively intact and had [DIAGNOSES REDACTED]. Review of R6's laboratory test collected [DATE], received [DATE] and reported to the facility on [DATE]at 8:31 PM, revealed R6 was positive for Covid-19. Review of a Nursing Note documented by Assistant Director of Nursing (ADON) J, dated [DATE] at 11:32 AM revealed R6 was not moved into isolation until the next day: Note Text: Resident was informed that his Covid-19 testing was positive and that he would be moved to the covid unit for 14 days. Resident currently asymptomatic . According to the facility's Newly Identified Covid-19 Infected HCP (Health Care Personnel) or Residents, dated [DATE], . RESIDENT WITH NEW-ONSET SUSPECTED OR CONFIRMED COVID-19 1. Resident will be immediately placed on Transmission Based Precautions . (On [DATE] at 11:35 AM, DON reported the policy was incorrect and should say Resident will be immediately placed on Droplet Precautions and immediately to her means when she reads the lab report.) In addition, the electronic medical record Immunization tab revealed R6 refused the pneumonia vaccine (not dated), and on [DATE] at 10:21 AM, DON B reported she did not have a signed refusal from R6. Resident #7 (R7) According to the MDS, dated [DATE], revealed R7 was cognitively intact and had [DIAGNOSES REDACTED]. Review of laboratory data revealed R7 was tested on [DATE] and results indicating she was positive for Covid-19 were reported on [DATE]. And, review of laboratory data revealed R7 was tested on [DATE] and results indicating she was positive for Covid-19 were reported on [DATE]. Review of R7's Respiratory Infection Screener Assessments revealed the last screening conducted was on [DATE] but the screening did not include an assessment of lung sounds. Review of R7's Nursing Progress Notes between [DATE] - [DATE] revealed no documentation of lung sounds ever being assessed. On [DATE] at 6:32 PM, DON B reported, (R7) had COVID twice and (R8) only had it once. They have always been roommates and when (R7) got COVID in [DATE], (R8) was exposed and placed in isolation and (R7) was placed in the COVID positive unit. They were still roommates until this recent exposure. Review of Nursing Progress Notes, dated [DATE] at 10:23 AM, revealed, Transfer to Hospital Summary. Note Text: VS: ,[DATE] 90 100.4A 22 88% 90 Resident was observed by nurse at 8am this morning w/ labored breathing, pale skin color, unable to articulate words in attempts to answer questions, LS (lung sounds) diminished at bases bilat., (both sides) skin clammy to touch, lethargic; unable to swallow medications, HR (heart rate) regular and bounding, made eye contact w/ (with) no verbalization, and physical restlessness observed; O2 placed via NC (nasally) at 3L/min.; contacted residents daughter regarding acute change in status after speaking with PCP (primary care physician) receiving order to transfer to ER (emergency) . Communicated residents recent positive testing COVID .transferred via ems to ER leaving facility at 9am. (sic) On [DATE] at 3:55 PM, Director of Nursing B reported (R7) died in the hospital after she was discharged on [DATE]. However, in an interview, on [DATE] at 10:20 AM, Registered Nurse P reported R7 actually died in the emergency room and had not been admitted to the hospital. Resident #8 (R8) According to the MDS, dated [DATE], R8 was severely cognitively impaired and had [DIAGNOSES REDACTED]. Review of laboratory data revealed R8 was tested on [DATE] and results indicating she was positive for Covid-19 were reported on [DATE]. Review of R8's Respiratory Infection Screener Assessments revealed she had a screening (that did not include lung sounds) on [DATE] but not again until [DATE] when she had one assessment per day [DATE] - [DATE]. Review of R8's a Nursing Progress note, dated [DATE] at 7:11 PM revealed, This writer entered resident's room this morning, residents apical pulse was unobtainable and respirations had ceased. Presumed time of death (10:00 PM), verified by second nurse on shift . Resident #5 (R5) Review of the medical record revealed R5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R5 scored 9 out of 15 (indicating moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R5's COVID-19 lab results collected on [DATE] revealed the results were reported as positive on [DATE] at 8:31 PM. R5's medical record failed to reveal any isolation precautions were put into place on [DATE]. Review of the physician's orders [REDACTED]. Review of the Nurses Note dated [DATE] at 12:13 PM revealed Spoke with resident's POA, (name) and informed her that (R5) is positive for Covid and will be moved to the covid unit for 14 days and will be in (room number). Informed her also that the resident is asymptomatic at this time. Review of R5's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. There was no area to document a respiratory exam or signs/symptoms of respiratory distress. Review of the Respiratory Infection Screener revealed the following areas were assessed: vitals, chronic illness, screening questions including temperature greater than 100.5, pulse greater than 100, respirations greater than 24, oxygen saturation (O2 sats) less than 89%, cough, more lethargic, more confused than normal, change in level of consciousness, chest pain, chills, generally not feeling well, loss of appetite, sore throat, increased weakness, body aches, shortness of breath or trouble breathing when lying flat, oxygen therapy, anticoagulant, antibiotic, IV medications, average fluid intake per day IV/tub, isolation or quarantine for active infectious disease. As of [DATE], the Respiratory Infection Screener was completed once on [DATE], once on [DATE], and once on [DATE]. The assessment did not include a respiratory exam with lung sounds. Review of R5's vitals revealed the following: oxygen saturation was checked once on [DATE] and was not assessed on [DATE]. temperature was not assessed on [DATE]. respirations were assessed once on [DATE] and not assessed on [DATE]. blood pressure was checked on [DATE], [DATE], and not again since. pulse was assessed once per day on [DATE], [DATE], and [DATE]. In a telephone interview on [DATE] at 3:21 PM, Assistant Director of Nursing (ADON) J reported she did not have access to check COVID-19 test results from the laboratory. ADON J reported while DON B was recently off work DON B would call ADON J and notify her of anyone who was positive for COVID-19. ADON J reported R5 was tested for COVID-19 on [DATE] and she was made aware of R5's positive results on [DATE]. ADON J reported R5 was moved to the COVID unit on [DATE]. In a telephone interview on [DATE] at 11:16 AM, DON B reported she logged in and checked for COVID-19 laboratory results every day at 6:00 AM. DON B reported when she was recently off work, she was checking the laboratory results from home at 6:00 AM each day. DON B reported she was the only one who had access to login and view the COVID-19 test results. DON B was not aware that R5's results were available on [DATE] at 8:31 PM. When asked if anything changed once a resident was diagnosed with [REDACTED]. DON B reported the assessments were documented under the Respiratory Infection Screener. When asked about the frequency of vital signs, DON B reported temperatures and oxygen saturation was assessed twice a day for all residents regardless of COVID-19 status. When asked how often a respiratory assessment was done on a resident who was positive for COVID-19, DON B stated once a day. When asked if the respiratory assessment included assessing lung sounds, DON B stated I would assume so, but I can't say for sure .I don't think there is anything in the respiratory assessment (Respiratory Infection Screener) for that. When asked if the assessment frequency changed for a resident who was symptomatic and positive for COVID-19, DON B reported it depended on how bad they are. DON B agreed that R5 was not assessed on [DATE]. DON B clarified the assessments should be documented under the Respiratory Infection Screener and she was unaware the assessments were not consistently performed. Eye Protection: On [DATE] at 9:49 AM, observations in the facility revealed all but two staff were wearing face shields. The remaining staff were wearing safety glasses instead of goggles or a face shield. On [DATE] at 9:59 AM a staff member was observed coming off the COVID-19 and onto the non-COVID area of the unit. The staff member did not disinfect her safety glasses. On [DATE] at 10:00 AM ADON J was observed coming off the COVID-19 unit on the opposite side of the hallway and onto the non-COVID area of the unit. ADON J did not disinfect her safety glasses. On [DATE] at 10:06 AM two staff members were observed coming off the COVID-19 unit and onto the non-COVID area of the unit. Neither staff member disinfected their safety glasses. On [DATE] at 10:22 AM, Licensed Practical Nurse (LPN) O was observed exiting the COVID-19 unit onto the non-COVID area of the unit. LPN O did not disinfect his safety glasses. On [DATE] at 10:32 AM a staff member was observed exiting the COVID-19 unit onto the non-COVID area of the unit. The staff member did not disinfect her safety glasses. On [DATE] at 11:17 AM, Speech Therapist (ST) Q was observed exiting the COVID-19 unit with her face shield hanging on her arm. ST Q did not disinfect the face shield and was then observed setting the face shield on top of a clipboard that was on an overbed table near the nurse's station. ST Q then obtained ice out of the cooker, donned her face shield, obtained applesauce, and then entered room [ROOM NUMBER] which was a COVID negative room. ST Q was observed at the bedside assisting the resident with eating. On [DATE] at 11:20 AM LPN G who was scheduled to work the non-COVID 19 area of the building (A hall), was observed exiting the COVID-19 unit on B hall and did not disinfect her safety glasses before going back to A hall. In an interview on [DATE] at 12:12 PM DON B reported the facility offered glasses, face shields, and goggles for staff PPE. DON B stated they can wear either as long as when they come out of the room, they take them off and use the sani wipes. DON B reported without the safety glasses, there were enough face shields for all staff. According to the Centers for Disease Control and Prevention (CDC) Safety glasses provide impact protection but do not provide the same level of splash or droplet protection as goggles and generally should not be used for infection control purposes. https://www.cdc.gov/niosh/topics/eye/eye-infectious.html According to CDC's Strategies for Optimizing the Supply of Eye Protection, Crisis Capacity Strategies include Consider using safety glasses (e.g., trauma glasses) that have extensions to cover the side of the eyes. However, protective eyewear (e.g., safety glasses, trauma glasses) with gaps between glasses and the face likely do not protect eyes from all splashes and sprays. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html) On [DATE] at 1:51 PM, Administrator A was notified of the Immediate Jeopardy, (identified on [DATE]), that began on [DATE] when an outbreak of Covid-19 began at the facility and the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19. On [DATE] it was verified that the facility implemented the following, on [DATE], to remove the Immediate Jeopardy: On [DATE] Centers for Disease Control Handwashing signage was removed and signage from Clean Hands Count for Healthcare Providers was hung in place throughout the facility. On [DATE] Safety glasses were removed, and all staff have been provided face shields. On [DATE] policy review and update were initiated of COVID policies. On [DATE] the Infection Surveillance line listing was updated and will be maintained by the Director of Nursing or Designee. On [DATE] facility-initiated cleaning of each diabetic residents' personal glucometer. On [DATE] a request to add adverse Lung sounds to the Respiratory assessment made to Point Click Care. In meantime, staff are being educated to conduct respiratory assessments to include lung sounds, and to document the findings in the comments section of the Respiratory screeners. Respiratory Assessments will be completed 3x daily for Covid-19 positive residents and every 12-hour shift for skilled residents. On [DATE] initiated a new contract with new Lab provider and this lab will call the Director of Nursing with all COVID-19 positive results. Point of Care tests will be completed twice a week until the contract is finalized. On [DATE] the process was initiated to place isolation carts with Personal Protective Equipment outside of soiled laundry room and hand sanitizing station placed in soiled laundry room. Staff were provided isolation gowns, N95 masks, face shields, and gloves to wear when sorting soiled laundry on [DATE]. On [DATE] Housekeeping product standardization for all housekeeping carts was initiated. On [DATE] Director of Nursing or Designee initiated education of all staff on the requirement to move a resident immediately upon receipt of positive lab test, and education is ongoing. Contract is being obtained with new Lab and lab will immediately notify the DON of any positive result. In the meantime, Point of Care test's will be obtained on all negative residents and staff twice a week or if symptomatic. Staff will not be allowed to work until this education is completed; 35% of staff education is complete at this time. On [DATE] Director of Nursing or Designee initiated education of all Laundry/Housekeeping staff on donning and doffing required PPE (mask, gown, gloves, and face shield) when sorting soiled laundry and performing hand hygiene when removing gloves and between dirty/clean areas. 75% of Housekeeping and Laundry staff have received education. Housekeeping and Laundry Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee initiated review of cleaning products, and initiated education of all Housekeeping staff on proper use of cleaning products, to include wet/dry time, and on the requirement to use different cleaning materials between residents and resident items/areas. 75% of Housekeeping staff have been educated at this time. Housekeeping Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee completed replacement all CDC Hand Hygiene signage with Handwashing signage form Clean Hands Count for Healthcare Workers 100% completed. On [DATE] Director of Nursing or Designee initiated education of all staff on disinfecting face shields when exiting the COVID unit, and all staff that have worked in the facility have been given a face shield and educated not to wear safety glasses. 35% of staff have been educated at this time. Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee initiated education of licensed staff on glucometer cleaning and disinfecting. 40% of licensed staff have been educated at this time. Licensed Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee initiated education of licensed staff on completing lung assessments and documenting lung sounds on the Respiratory Assessment in the comment box, notifying physician of adverse lung sounds, and completion of Respiratory Assessments 3 times a day for COVID positive residents and once per 12-hour shift for skilled residents. 40% of licensed staff have received education at this time. Licensed Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee initiated education of all staff on completing COVID entrance questionnaire for all visitors. 20% of staff have been educated at this time. Staff will not be allowed to work until this education is completed. On [DATE] Director of Nursing or Designee initiated updating COVID binder with current policies. Although the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a scope of wide spread and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

Based on observation, interview and record review, the facility failed to prevent pressure ulcers for one of one reviewed for pressure ulcers (Resident #36), resulting in facility acquired pressure ulcers. Findings include: According to the Minimum Data Set (MDS), dated [DATE], Resident #36 (R36) was admitted to the facility on [DATE], was severely cognitively impaired, needed assistance of two or more staff for bed mobility, did not walk, was totally dependent on staff for locomotion in a wheelchair, had one stage 1, one stage 2, and one unstageable pressure ulcer, and had [DIAGNOSES REDACTED]. R36's Admission MDS, dated [DATE] revealed she received [MEDICAL TREATMENT] treatments. According to R36's [DIAGNOSES REDACTED].>Pressure ulcer of right buttock, unstageable - 2 separate areas noted on admit 4/8/2020. Pressure ulcer of right heel, Stage 2, date 7/15/2020 - [DIAGNOSES REDACTED]. Pressure Ulcer of other site, unstageable, 7/15/2020 -During Stay. According to R36's vital signs records, on 8/7/2020 at 11:35, R36 weighed 131.1 pounds and (4/14/2020 at 2:54 PM) was 62.0 inches tall. On 08/25/20 at 2:51 PM, R36 was observed lying in bed on her left side and did not respond when spoken to even though her eyes were open. R36 had a blue pressure relieving (Prevalon) boot on her right lower extremity but none on her left lower extremity. On 8/27/20 (Thursday) at 10:17 AM, R36 was not in her room, but a pair of Prevalon boots were lying on her bed. In an interview, on 08/27/20 at 11:09 AM, CNA G said, (R36) is at [MEDICAL TREATMENT] today . She gets sores easily. Her boots should be on her. They got her up early this morning, the shift before me . (R36) doesn't talk. Very sweet lady. In an interview, on 08/27/20 at 12:07 PM, Wound Nurse LPN (Licensed Practical Nurse) D stated she was not sure why R36's pressure relieving boots were on her bed and not on R36's feet and said, (R36) leaves so early for [MEDICAL TREATMENT]. Review of R36's Care Plans revealed they included, turn/reposition at least every 2 hours - side to side, avoiding pressure to buttock/coccyx - Date Initiated: 04/08/2020 (on admission). Review of R36's Physician order [REDACTED].>- [MEDICAL TREATMENT] at ([MEDICAL TREATMENT] facility) (Tuesday, Thursday, Saturday) and time to be picked up (6:25 AM). - Reposition and offload buttocks from side to side while in bed every 2 hours. Active 4/12/2020 23:00 (11:00 PM). - Float heels on pillow to prevent breakdown every morning and at bedtime for preventative measures. Active 7/15/2020 21:00 (9:00 PM). - Renal diet . Needs to be sitting up in wheelchair for all meals. Active 7/15/2020 00:00 (midnight). - Resident to wear Prevalon boots AAT (at-all-times) excluding ADL's (activities of daily living) and shower. Active 8/18/2020 21:00 (9:00 PM). In an interview, on 08/28/20 at 10:19 AM, Wound Nurse D said, A physician saw (R36) on 4/10/20 (two days after her admission) and wrote she had chronic wounds. However, there was no documentation to clarify what chronic wounds meant. Wound Nurse D said she would look for any physician progress notes [REDACTED]. Wound Nurse D stated, (R36's) left buttocks and coccyx has gotten better and worse and continues to go back and forth. Wound Nurse D stated she thought R36 acquired the facility acquired pressure ulcers because she was on [MEDICAL TREATMENT], had diabetes, and the wounds present on admission makes her more susceptible for them reoccurring. Wound Nurse D said she asked the night shift nurse that morning and was told, They never put the boots on (R36) when she goes to [MEDICAL TREATMENT] . I will have to follow up on why they don't. Wound Nurse D had spread sheets for the pressure ulcers that she said she did not load into R36's medical record, stating they were her records. Wound Nurse D said the Pressure Ulcer Tracking Records were not supposed to be scanned into the medical record, but she didn't know why. The Pressure Ulcer Tracking records for R36 revealed: Three pressure ulcers present upon admission that were healed: 4/08/20 - left inner ankle Stage II 1 x 1 (no depth documented) resolved on 6/02/20. 4/08/20 - midline inner buttocks unstageable 4.5 x 2.0 (no depth documented) resolved (date unknown). 4/08/20 - right outer ankle unstageable 1 x 1.5 (no depth documented) wound bed intact. Resolved 5/26/20. One pressure ulcer present upon admission that was still present: 4/08/20 - left inner buttock unstageable 1 x 0.5 (no depth documented) wound bed eschar. On 8/25/20 - left buttock: Stage II (see below) 4.0 x 1.0 (no depth documented), wound bed moist. Because lost muscle and other structures aren't restored during healing, a Stage IV pressure ulcer can't become a Stage III, II, or I ulcer; it remains a Stage IV ulcer throughout healing. After healing is complete, it should be classified as a healed Stage IV ulcer, not a Stage 0 ulcer. <journals.lww.com/nursing/fulltext/2004/ /why_you_should_avoid_reverse_pressure ulcer_staging .> Four facility acquired pressure ulcers: 7/15/20 - right inner heel, Stage II pressure ulcer 3.0 x 4.0 (no depth documented), wound bed pink/moist. 7/15/20 - bottom right foot unstageable 2.5 x 1.5 (no depth documented), wound bed scab. 8/11/20 - right foot ball joint deep tissue injury 2 x 1.9 (no depth documented), wound bed intact. 8/25/20 - left out foot unstageable, 1.0 x 1.5 (no depth documented), wound bed intact. In a telephone interview, on 08/28/20 at 11:01 AM, the [MEDICAL TREATMENT] center's RN (Registered Nurse) E stated, We have a bed that we put (R36) in, on her side, and we switch sides midway, but we don't do anything else. She is her for a total 4 hours. I know she has wounds on her bottom. I think there are some on her feet. I don't get a report on them but I wish I would. I can't recall any boots. There has been nothing said about boots - not at all. There is no reason she can't wear them here. If she needs them, I prefer she has them on. No, I did not speak with Wound Care (D) nurse there. I would personally prefer to know where (R36) has wounds and how to position her and prevent any new wounds. In an interview, on 08/28/20 at 11:08 AM, Nurse Aide (CNA) F stated she worked full- time and said, I always work with (R36) every time I work. She has an air mattress and a regular cushion in her wheelchair . she is up (in her wheelchair) when she goes to [MEDICAL TREATMENT]. She is supposed to have the boots on all the time. This Surveyor went to R36's room with CNA F and it was observed R36 was lying in bed with an air mattress but the air mattress flow switch was in the off position. CNA turned it on and said, It's supposed to be on. There was a standard wheelchair cushion in R36's wheelchair and CNA F reported that was the only cushion R36 had for her wheelchair and it was just a regular cushion. In an interview, on 08/28/20 at 11:41 AM, DON (Director of Nursing) B said, I just heard (R36's) air mattress was not on - it should be on. And, she didn't have a Roho cushion. (Name of R36), should have a Roho cushion in her wheelchair so I just ordered one. DON B agreed that the facility should have worked with [MEDICAL TREATMENT] on coordinating a plan of care and that R36 that included R36 wearing her Prevalon boots on while attending [MEDICAL TREATMENT]. DON B said, I don't know if the doctor has seen her pressure ulcers. (Wound Nurse D) does the dressing changes. I'm not sure what the doctor's involvement has been with (R36's) pressure ulcers. DON B said she would look to see if there are any physician progress notes [REDACTED]. Roho cushions are adjustable air seat cushion which usually prevents a person from pressure injuries, sores or skin rashes and ensures long-term comfort and safety. <www.wheelchair-experts.in/types-of-roho-cushions/

Based on observation, interview and record review, the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of COVID-19 including, but not limited to, 1) the failure to ensure that certain residents were cohorted after testing negative for COVID-19, 2) the failure to immediately isolate and segregate residents who tested positive for the COVID-19 virus including door closure of Covid positive room and eliminating oscillating fan use in droplet isolation rooms, 3) the failure to clearly post isolation signage, 4) the failure to perform proper hand hygiene, 5) the failure to ensure appropriate Personal Protective Equipment (PPE) utilization, supply, and care including use of cloth masks, 6) the failure to place residents who leave for appointment on observation unit, and 8) the failure to develop and operationalize policies and procedures related to COVID-19. These deficient practices resulted in Immediate Jeopardy when on 8/6/20 two facility residents with reported positive COVID-19 test results (Resident #1 and #3), with the likelihood for further cross contamination of other residents residing in the facility, thereby putting all 69 facility residents at risk for infection, hospitalization and/or death. Findings Include: On March 9th, 2020 the Centers for Medicare and Medicaid Service and the Centers for Disease Control and Prevention released guidance for Long Term Care facilities related to prevention and management of COVID-19 to protect their residents and staff from being affected by the deadly virus. Since that release the CDC has made changes to their recommendations for management of COVID-19 as more has been learned and as the pandemic evolved. HCP (healthcare personnel) should wear a facemask at all times while they are in the facility. When available, facemasks are generally preferred over cloth face coverings for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Guidance on extended use and reuse of facemasks is available. Cloth face coverings should NOT be worn by HCP instead of a respirator or facemask if PPE is required. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Flong-term-care-strategies.html) Resident with new-onset suspected or confirmed COVID-19 Ensure the resident is isolated and cared for using all recommended COVID-19 PPE. Place the resident in a single room if possible pending results of [DIAGNOSES REDACTED]-CoV-2 testing. Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents (e.g., residents who have fever, for example, due to a non-COVID-19 illness could be put at risk if moved to a COVID-19 unit). If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html) When undertaking facility-wide [MEDICAL CONDITION] testing, facility leadership should expect to identify multiple asymptomatic and pre-symptomatic residents with [DIAGNOSES REDACTED]-CoV-2 infection and be prepared to cohort residents. See Public Health Response to COVID-19 in Nursing Homes for more details. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html) HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: ?Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters .If admitted , place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The patient should have a dedicated bathroom .Personnel entering the room should use PPE as described below. As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection. Dedicated means that HCP are assigned to care only for these patients during their shift .HCP who enter the room of a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection should adhere to Standard Precautions and use a NIOSH-approved N95 or equivalent or higher-level respirator (or facemask if a respirator is not available), gown, gloves, and eye protection .HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. (https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html) During an observation and interview on 8/6/20 at 9:15 a.m., upon entering the facility for an infection control survey, the Administrator (NHA) A and Director of Nursing (DON) B met surveyors at the facility front door and reported they had just been notified of two positive COVID-19 test results from 8/3/20 for residents that had been asymptomatic and were roommates. NHA A reported the weekly resident testing was performed because the facility had two staff who tested positive for COVID-19 over the past couple weeks. DON B reported she was concerned about false positive COVID-19 test results because residents had no symptoms. This surveyor was escorted down A South hall and noted a three drawer cart located in front of one room. The resident room had an open door with an oscillating fan noted functioning and on with three resident names (R1, R2, R3) noted on the name plate outside the door. No isolation signage was observed clearly posted. Staff were noted in halls with cloth masks. In an interview on 8/6/20 at 9:33 AM, Director of Nursing (DON) B reported the two COVID positive residents were Resident #1 (R1) and Resident #3 (R3). When asked if there was a third resident in the room, DON B reported Resident #2 (R2) was negative for COVID-19 and still remained in the room with R1 and R3. When asked why R2 was still in the room with COVID positive residents, DON B sated Because he (R2) is in isolation. Everyone is asymptomatic. When asked what PPE should be used in the room, DON B reported shield, mask, gown, and gloves. When asked what type of mask, DON B stated If we have N95 masks, we would use them, but right now we only have surgical masks. N95s are hard to come by. When asked what type of mask should be worn in the facility, DON B reported surgical masks. During an observation on 8/6/20 at 9:40 a.m. three residents were noted in a room that appeared to be a three bed ward with three drawer cart located outside open door with box of gloves noted in cart. The oscillating fan continued to be functioning and on inside the room. A large industrial floor fan was observed outside of the room. Review of the medical record revealed R1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] revealed R1 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS). Review of R1's laboratory results revealed R1 was tested for COVID-19 on 8/3/20 and positive results were reported on 8/6/20. Review of the medical record revealed R2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed R2 scored 15 out of 15 (cognitively intact) on the BIMS. Review of R2's laboratory results revealed R2 was tested for COVID-19 on 8/3/20 and negative results were reported on 8/6/20. Review of the medical record revealed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R3's laboratory results revealed R3 was tested for COVID-19 on 8/3/20 and positive results were reported on 8/6/20. According to observations and the medical records, R1, R2, and R3 shared a room. On 8/6/20 at 9:49 AM, R2 was observed in a room with R1 and R3. There was a PPE cart outside the room, but there was not any signage alerting staff to any precautions. R1 was not wearing a mask and was up, ambulating in the room. R3 was lying in bed. R2 was wearing a mask and was observed on the floor, waving and calling for help. The call light was on. The oscillating fan was located against the wall, across from the foot of R1's bed. The fan was oscillating and blowing towards all three residents in the room. A housekeeper on the hallway was observed wearing a cloth mask and a face shield. At 9:54 AM, Certified Nursing Assistant (CNA) H answered the call light wearing only a cloth face mask and a face shield. CNA H did not put on a gown or gloves before entering the room. CNA G then came out of the room, did not perform hand hygiene, touched the telephone on the hallway wall, and then exited the unit. At 9:55 AM, CNA H entered the unit, did not perform hand hygiene, again entered R1, R2, and R3's room without a gown or gloves and then exited the room and obtained a gown. At 9:56 AM, the nurse entered the room without a gown or gloves. The nurse touched the door handle, dropped her pen light on the floor twice, picked up the pen light, and set it on top of the PPE cart outside the room. The nurse was unable to find another gown in the PPE cart and then exited the hall. The nurse did not perform hand hygiene. CNA H then entered the room wearing a cloth face mask, face shield, gown, and gloves and approached R2. CNA H touched the privacy curtain, bedside table, and obtained a gait belt from inside the room. At 9:59 AM, falling star was paged overhead. Another staff member arrived, knocked on the door, and opened the door. The unidentified staff member was wearing a cloth face mask and a face shield. The nurse arrived back to the unit with more gowns, donned a gown, and entered the room with a cloth face mask, face shield, gown, and gloves. The nurse did not disinfect the pen light which had fallen on the floor twice previously nor perform hand hygiene. At 10:00 AM, a second nurse arrived to the unit with a sterile isolation gown kit. This nurse was wearing a surgical mask and a face shield. At 10:03 AM, NHA A arrived onto the unit and removed the large industrial fan from the hallway. NHA A reported the facility's air conditioning was not functioning properly and the fan was used, but a new unit was installed on 8/5/20 and the fan was no longer needed. At 10:08 AM, Central Supply staff K and Activities Manager L arrived to the unit with a cart of supplies to stock the PPE cart. When staff exited the residents' room, none of the staff were observed disinfecting their face shields. During an interview on 8/6/20 at 10:38 a.m. DON B reported she received positive COVID-19 test results that morning at approximately 6:30 or 7:00 AM and notified the local health department via email as well as the corporate office. DON B reported she placed room R1, R2, and R3's shared room in isolation, informed staff including environmental services and kitchen staff who plan to provide paper products for two of three residents in the room. DON B reported R1 and R3 that tested positive for COVID-19 that day were the first two asymptomatic residents and they placed residents on isolation for 14 days. DON B reported symptomatic residents would be sent to the hospital. DON B reported the facility had three residents that leave the facility for [MEDICAL TREATMENT] and wear masks when out of rooms and return to same rooms occupied by other residents that do not leave the facility for appointments. When asked how staff knew which mask to wear, DON B reported she was told by local Health Department that staff can use any type of mask and stated they never specified. DON B reported the facility had no access to N95 masks. When asked about the facility's plan for R1, R2, and R3, DON B stated if they remain aysymptomatic for 14 days and have two negative tests, then off isolation. When asked about the plan if the facility acquired additional positive COVID -19 test results with the next weekly testing, DON B stated Notify health department .If it's a resident, their room will be isolated just like this one (R1, R2, R3) here. If no symptoms, they can't go to the emergency room . During an observation on 8/6/20 at 12:08 p.m., staff were observed on COVID-19 observation unit wearing cloth masks and face shields. During an observation on 8/6/20 at 12:48 p.m., Certified Nurse Aid (CNA) entered the open door of R1, R2, and R3's room (isolation room) with Personal Protective Equipment (PPE) that included face shield, cloth mask, disposable gown, and gloves. CNA staff obtained food tray from inside isolation room that included hard plastic tray, Styrofoam food container, clear plastic cups and placed on top of the isolation cart located in the hall. After CNA staff removed PPE she then moved the meal tray located on top of the isolation cart and placed in meal cart located in the hall. The same CNA staff then entered isolation room immediately after with no PPE and exited with meal tray and placed in meal cart that included Styrofoam food container, plastic tray and cups. This surveyor noted at same time another staff member entered A South hall with another meal cart from the front lobby through A South hall toward the Main Dinning Room doors. During a telephone interview on 8/7/20 at 11:25 a.m. CNA G reported all staff enter through front door and complete screening process including temperature and log at start of shift and not at end of shift. CNA G reported he often worked on observation unit that included new admission residents that remained on isolation for 14 days. CNA G reported DON B informed staff 8/6/20 at about 7:00 AM about two positive COVID-19 residents in the building. CNA G reported he placed an isolation cart in front of R1, R2, and R3's shared room on the morning of 8/6/20 and did not verify if the cart was stocked and reported another staff member was responsible for stocking isolation carts. CNA G reported he received education on 8/6/20 related to use of N95 masks and shield at all times in the facility. CNA G reported education included to use N95 masks for 48 to 72 hours. CNA G reported staff had recently worked on several halls between 8/3/20 and 8/6/20. CNA G reported he had not received education related to ensuring COVID-19 room doors remained closed. CNA G reported meal trays were served with Styrofoam food containers but real plastic tray and stated, now that I think about that hmmm, should all be disposable. CNA G reported the observation unit used regular meal trays. CNA G reported he was given N95 mask 8/6/20 after lunch and observed large box of stock available for use. During a telephone interview on 8/7/20 at 2:39 p.m. Dietary Aid (DA) J, reported working at the facility for [AGE] years. DA J reported staff could wear cloth masks until 8/6/20 about lunch time then changed to N95 and face shields. DA J reported 8/6/20, the entire A South unit used Styrofoam, plastic silverware, Styrofoam cups and regular glasses because no small glasses for juice were available and reported the observation hall had been and continued to receive regular trays, plates and glasses. DA J reported she was unsure why the manager started Styrofoam for A south other than she was told to because of 2 COVID-19 cases. DA J reported she was unsure why they use Styrofoam other than in the past it was used for isolation rooms but unsure why. DA J reported Styrofoam food containers are returned in the meal carts and disposed of in the kitchen. Review of a chain of emails between the facility and the local Health Department, revealed the following: -On 5/16/20, the local health department sent the facility three CDC links regarding PPE, including eye protection and respirators and one link for FEMA - On 5/24/20, the local health department sent the facility an email with information regarding the National Guard performing COVID testing and stated While we fully support testing of all residents and staff, it is critical that you have a plan in place that addresses the following before you move forward with testing: A plan to isolate a resident who tests positive Do you have sufficient staff so that staff attending to any positive residents are also not attending to non-positive residents . - On 6/2/20, the local health department sent the facility information on PPE purchasing and N95 fit testing - On 8/6/20 at 9:54 AM, the local health department sent an email to DON B that read It was my undertanding from our phone conversation this morning that all HCP staff have been wearing surgical masks and face shields prior to today. If for some reason that has not been the standard for all HCP (see definition below (CDC definition) employees providing any resident care or who will be within 6 feet of any resident then it needs to be adopted immediately. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html which I emailed to you on 7/16/20. This is the part that speaks to the eye protection .Also, this morning you said that residents can go outside to smoke-I was not aware that this was allowed. Smoking would be a high-risk activity for the spread of COVID. - On 8/7/20 the local health department sent an email to NHA A which revealed .(DON B) said the two positive residents smoke outside-we had discussed and I also emailed my recommendations re: the smoking and (DON B) said it had been halted . On 8/6/20 at 12:05 PM, the Administrator was notified of the Immediate Jeopardy that began on 8/6/20 and was identified on 8/6/20, when the facility failed to follow and implement infection control practices per the Centers for Disease Control (CDC) guidelines to prevent the spread of Covid-19. On 8/7/20 it was verified that the facility implemented the following to remove the Immediate Jeopardy: 1. Resident # 2 with negative COVID test has been moved to private room on the observation unit, isolation signage placed on room door, with door closed due to possible exposure to COVID-19. Oscillating fan removed, door closed, isolation signage placed for room which houses resident # 1 and resident #3. Isolation carts with PPE placed outside of room [ROOM NUMBER] and room [ROOM NUMBER]. Staff provided isolation gowns, N95 masks, and face shields for use when caring for these residents. Isolation signage was posted on observation and isolation rooms and to remain at all times. Residents who leave for appointments will be placed on the observation unit upon return. [MEDICAL TREATMENT] residents have been cohorted with other [MEDICAL TREATMENT] residents and placed in isolation. Oscilating fan was disinfected and removed from (resident room #). 2. DON or Designee has educated staff on the use of PPE, to include gloves, gown, N95 mask, and face shield when caring for any COVID positive resident and for any resident in observation for COVID-19 on 8/6/20. DON or Designee has educated all staff on proper hand hygiene, face shield disinfecting, gloves and N95 masks donning and doffing of PPE on 8/6/20. DON or designee will educate remaining staff prior to assignment. DON or Designee has educated all staff on resident co hoarding per CDC guidelines on 8/6/20. DON or Designee has educated all staff that any resident that leaves the facility for a medical appointment must be placed in the observation area for 14 days on 8/6/20. DON or Designee will educate staff that there can not be any oscillating fans in COVID positive rooms due to potential spread of [MEDICAL CONDITION] on 8/6/20. 3. If a resident tests positive for COVID-19 and has signs and symptoms they will be sent to the ER for treatment. If they are asymptomatic, they will be put in isolation with themselves or another positive COVID 19 patient on A south hall. A south hall will be considered under investigation. Should we have more Covid positive residents they will be put in a separate area on A south separated from other A south residents. Although the Immediate Jeopardy was removed on 8/6/20, the facility remained out of compliance at a scope of isolated and a severity of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the fact that sustained compliance had not yet been verified by the State Agency.

This citation pertains to MI 307. Based on observation, interview and record review the facility failed to ensure that 1 of 2 residents reviewed for elopement (#35) did not leave the facility unattended and sustain a minor injury of unknown origin and failed to supervise 2 of 6 residents reviewed for falls (#32 and #35) to prevent falls from a total sample of 11 residents resulting in Resident #35 being found outside the facility with abrasions over the right eye and a cut on the right thumb requiring hospital emergency room treatment and Resident #32 having multiple falls with minor injuries. Findings include: Resident #35 Based on the Minimum Data Set (MDS) assessment, dated 3/12/16, Resident #35 was a severely cognitively impaired [AGE] year old male whose [DIAGNOSES REDACTED]. Based on the above MDS Resident #35 required one staff assist for transfers, ambulation, toileting and bathing and his Brief Interview for Mental Status (BIMS) score was 3/15 indicating severe cognitive impairment. The MDS, dated [DATE], reflected improvement in Resident #35's physical status to supervision with ambulation and transfers but no change in his mental status. There was no assessment for elopement risk found in the clinical record. On 1/16/16 at 3:40 PM Director of Nursing (DON) B and Assistant Director of Nursing (ADON) M stated the facility did not complete an elopement risk assessment for residents but did do a wandering risk assessment. The facility policy Elopement Response, undated, reflected It is the intent of the facility to provide a safe and home-like environment for all residents and to provide adequate supervision and assistance to prevent the possibility of elopement or unsafe wandering. All residents are assessed for elopement risk on admission. The above policy defined elopement as when a confused resident leaves the facility property without authorization (e.g. an order for [REDACTED]. Elopement is usually unknown to staff. Generally, the resident at risk for unsafe wandering is also at risk for elopement and should be assessed using the tool. Under Specific procedures/Requirements: .15. Following the direction of the administrator or DON (Director of Nursing), initial notification will immediately be made to all required authorities, including the state survey agency is the resident got off the facility property unattended. 16. The Charge Nurse shall be responsible for documenting the incident of the resident's leaving the premises in Nursing Notes of the resident's clinical record. The documentation will be concise and include dates, times, persons contacted, behavior and condition of resident (upon leaving ad return), physician orders, treatment, and any other information deemed pertinent. The resident's plan of care shall be revised to include interventions to prevent further elopement or the potential for elopement and any treatment resulting from the incident. The Care Plan for Resident #35, dated 2/27/16, did not reflected the Resident was at risk for elopement but did address his risk for falls with the interventions of assisting with transfers, wearing appropriate footwear, call light availability and encouraging its use, encouraging participation in activities that promoted physical activity and following the facility fall protocol. An 8.5 inches by 11 inches orange sign was posted on the inside and outside of the exit door leading to the parking lot on the north side of the building with instructions and a code to put into the key pads on the walls next to the door which allowed anyone to exit the building without the door alarm sounding. The laundry entrance door was next to the exit door and there was a window facing the parking lot in the laundry room where the exit ramp and parking lot were clearly visible. The sign was on the doors on 11/9/16, 11/10/16, 11/15/16 and 11/16/16. The Quality Assurance Worksheet Fall Investigation, dated 4/5/16 at 8:10 PM, written by Licensed Practical Nurse (LPN) J reflected staff member came got this nurse to assist with man she saw outside Bleeding from head and right hand. Resident Poor historian. Alert but very confused. abrasion over right eye and laceration to right thumb. no witness as to if resident fell . Page two of the report reflected under the question what was the resident trying to do? Resident observed outside staff unable to determine what resident was trying to do. The report reflected staff observed Resident #35 sitting in his room within 30 minutes before the incident and the Resident was not wearing a wander guard (a device usually worn on the wrist or ankle that sounds an alarm to alert staff when a resident passes through a door equipped with a monitor). Under the question What did you do to prevent further falls? the entry was Placed wander guard on resident. The attached Witness Statement form and CNA (certified nursing aide) checklist containing information related to the resident's room/bathroom conditions, use of interventions such as walkers, gait belts and glasses and common area conditions were blank. An untitled page reflected the faces scale for pain assessment indicating hurts a little bit and that Resident #35 was alert, oriented to person and place and ambulatory without assistance. A hand written note on the same page reflected Resident #35 was .more confused in the evening. The Quality Assurance Worksheet Nurse Manager Investigation, dated 4/5/16 and completed by Assistant Director of Nursing (ADON) M, reflected under Was the resident able to give a statement? Y (yes) was circled and the written entry was said he fell on to sidewalk. The form documented independent under mobility and Forgets limitation and poor safety awareness under possible causative factors. The intervention identified was wanderguard (sic) placed on resident. The investigation did not address the elopement from the facility of Resident #35. The nursing progress note in the electronic medical record (EMR), dated 4/6/16 at 12:28 PM written by LPN J more than 16 hours after the incident, reflected Laundry Aide (first name and identified by the facility as Laundry Aide (LA) K) came and got this Nurse to assist her with a man who was bleeding from hand and forehead. This nurse assisted laundry aide to B wing nurses stations and identified resident as (Resident #35's name). Resident was alert but confused. Resident had an abrasion over right eye and was bleeding from the right thumb which he was holding with drsg (dressing). Upon assessment right thumb had a laceration that appeared significant enough to send to ER (emergency room ) for evaluation and treatment if necessary. On-call physician for (physician name) was notified. Family was Notified (male and female names) and was told resident was sent to ER. The nursing progress note, dated 4/6/16 at 12:41 PM by LPN J reflected Resident returned to Facility approximately 2230 (10:30 PM) on 4/5/26 from ER with 4 stiches to Right thumb. F/U with (physician name). A nursing progress note in the EMR, dated 4/6/16 at 10:47 by AM LPN L, reflected Wander guard placed on residents (sic) left ankle. Elder was sleeping peacefully at time. Edler was awoke and asked his permission to apply wander guard. Elder nodded consent. Tolerated well. On LPN J stated Resident #35 was found in the parking lot by LA K on 4/5/16 around 8:00 PM and brought to the B Hall nursing station where staff thought he was visitor or family member (Resident #35 resided on the A Hall). LPN J stated she had talked to the resident earlier in the shift about current events and he was sharp but after he was found in the parking lot he was very confused like night and day different, like sundowners. LPN J stated Resident #35 was not able to say what had happened, he was not oriented and was holding his hand like he had no clue. LPN J stated apparently he read the code on the (north B hall) exit door and let himself out. LPN J stated she had not completed and Incident/Accident report related to the elopement and not aware she was to do any kind of investigation or witness statements. On 11/15/16 at 5:20 PM LPN L stated the exit code instructions on the B Hall/parking lot exit door were removed on the inside after the 4/5/16 elopement and while Resident #35 resided in the building but the sign was replaced. LPN L stated there were no residents identified as elopement risk in the building currently who would be able to use the code. On 1/16/16 at 3:40 PM DON B stated she had removed the sign from the inside of the B Hall exit door after the 4/5/16 elopement of Resident #35 and was not aware the sign had been re-posted even though she went in and out of the door on a daily basis. The facility investigation of Resident #35's 4/5/16 elopement/injury of unknown origin was reviewed on 11/16/16. Based on the witness statements no staff saw Resident #35 exit the building. The Resident was seen in the parking lot when Laundry Aide K looked out the laundry room window and by the time LA K got outside Resident #35 was walking behind the building and went around the corner toward the front of the building walking in an alley used by cars and attempted to enter the south B Hall exit door by punching numbers on the key pad. LA K did not witness Resident #35 sustain his injuries. Resident #35 was brought into the building through the south B Hall door. The investigation did not include an analysis of the statements to identify the root cause of the elopement. On 11/16/16 at 3:40 PM DON B confirmed there was no root cause analysis of Resident #35's elopement and injury but stated she was .confident we did the right thing . for interventions. Resident #32 Based on the MDS assessments, dated 6/8/16 and 9/8/16, Resident #32 was a [AGE] year old male whose [DIAGNOSES REDACTED]. Based on the above MDS assessments Resident #32's BIMS score was 9/15 on 6/16 indicating moderate cognitive impairment and 5/15 on 9/8/16 indicating severe cognitive impairment. On the 6/8/16 MDS Resident #32 was coded as independent for transfers and ambulation. On the 9/8/16 MDS the Resident had declined and required one staff assist for transfers, ambulation and toileting. No alarms, low bed or floor mats were observed in use for Resident #32. Resident #32 was not interviewable during the survey. Review of Accident & Incident Forms for Resident #32 reflected 10 falls between 6/1/16 and 10/3/16. The falls occurred on the following dates and times; 1) On 6/1/16 12:30 PM found on the floor without injury in the B Hall hallway, the circumstances of the fall were not documented and no new interventions were identified, 2) The nursing progress note date 6/12/16 at 12:58 AM reflected a fall on 6/11/16 at 11:25 PM while transferring himself to the bathroom with his walker. The Resident stated the walker got too far ahead of him. Intervention of a bed sensor pad was instituted., 3) On 6/13/16 at 9:45 PM Resident #32 was found on the floor at the foot of his roommates bed. The bed sensor was not working. The intervention was to use both bed and chair alarms., 4) On 6/16/16 1:30 AM the Resident was witnessed ambulating with a wheeled over bed table and lost his balance incurring a laceration over his left eye. The Resident's laceration was treated in the hospital emergency room . The intervention was to place a falling star sign on his room door frame and educate him on the use of the call light. There was no intervention to address the inappropriate use of the wheeled over bed table. 5) On 7/25/16 at 7:00 PM the Resident was found on the floor at his bedside with the alarm turned off. The intervention was placement of the falling star sign on his room door frame which had already been instituted on 6/15/16, 6) On 9/14/16 at 5:00 PM the resident was found on the floor at his bedside with a bruise on his left forehead. At 7:30 PM Resident #32 did not response to stimuli and was transferred to the hospital returning at 9:30 PM fully awake. The interventions were frequent checks (already on the care plan 7/25/16) and education related to call light use., 7) On 10/3/16 at 12:30 PM Resident #32 was found on the floor. There were no details as to where or what happened. The intervention was to educate the Resident on safety awareness., 8) On 10/22/16 at 1:20 PM the Resident was found on the floor near his bathroom dressed only in his brief and carrying his clothes in his hands. The bathroom floor was wet with urine. The interventions were a bed sensor alarm and continued education related to safety., 9) 11/2/16 at 3:50 PM Resident #32 was found on the floor in the front lobby with his wheelchair tipped over. The Resident stated he was walking with his wheelchair and slipped. Anti tipper devices for the wheelchair was the identified intervention., and 10) On 11/8/16 at 4:30 PM the Resident was found on the floor at his bedside. The resident stated he was sleeping and woke up on the floor. The interventions were a low bed with mats on the floor. Resident #32 did not use the call light prior to any of the falls listed above. The nursing progress note dated 6/16/16 at 7:26 AM reflected Resident #32's response to being encouraged to use his call light for assistance. .Resident became angry and told me 'No he didn't have to use the call light or wait for help.' And tried to push me out of the way . As Resident #32's cognitive level declined he had less capacity to recall he needed to use the call light and wait for help and less safety awareness. Review of the care plan related to falls, dated 6/16/16 and last updated on 9/19/16, reflected the interventions; be sure the call light is in reach and encourage him to use it (6/16/16), ensure he is wearing appropriate footwear when ambulating (6/16/16), Fallen Star (6/15/16), follow facility fall protocol (6/16/16), encourage him to participate in activities that promote exercise, physical activity for strengthening and improved mobility (6/16/16), he has alarms to alert staff of unassisted attempts to transfer self (6/16/16) and discontinued on 10/11/16. The care plan for actual falls, dated 6/11/16 and revised on 11/4/16, reflected the interventions; anticipate and meet resident's needs (11/2/16), educated on safety awareness (6/11/16), Fallen star (6/11/16), frequent checks (7/25/16), and sensor (alarm) at all times (6/13/16) and discontinued on 9/19/16. The care plan did not specify a bed and/or chair sensor, only a sensor alarm. In addition, the sensor alarm intervention was not added to the care plan on 10/22/16 as identified on the Accident & Incident report and investigation. The intervention for anti tipper devices to the wheelchair identified on 11/2/16 was not found on the care plan. The interventions for a low bed and mats on the floor identified on 11/8/16 was not found on the care plan. On 11/10/16 at 3:50 PM Resident #32's care plan interventions related to falls were discussed with ADON M who stated she was the one responsible for updating resident care plans. ADON M stated she had not removed the wheeled over bed table from Resident #32 and had not thought of an over bed table without wheels. ADON M stated there was no alarm in use on 9/14/16 as it had been discontinued prior to the 10/11/16 date on the care plan related to Resident #32 removing the alarm, removing alarm wires and turning it off. ADON did not recall when the alarm had been discontinued. ADON M stated the sensor alarm use began after the 10/22/16 fall as Resident #32 continued to mess with the wires and turn it off. ADON M stated the low bed and mats were not the best for Resident #32 as he still wanted his independence and they were an increase fall risk for him. No root cause analysis was found to identify why Resident #32 continued to fall. ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW THE FACILITY FAILED TO ENSURE THAT 1 OF 15 SAMPLED RESIDENTS (#12) WAS PROTECTED FROM UNWANTED SEXUAL TOUCHING BY RESIDENT #7 RESULTING IN EMOTIONAL DISTRESS FOR RESIDENT #12. FINDINGS INCLUDE: RESIDENT #12 WAS AN [AGE] year OLD SEVERELY COGNITIVELY IMPAIRED FEMALE WHOSE [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENTS, DATED [DATE] AND [DATE], REFLECTED THE RESIDENT WAS DEPENDENT ON STAFF FOR ALL ACTIVITIES OF DAILY LIVING AND WANDERED IN HER WHEELCHAIR DAILY. THE RESIDENT WAS NON-VERBAL A MAJORITY OF THE TIME. THE RESIDENT ASSESSMENT PROTOCOLS FOR COGNITIVE LOSS/DEMENTIA AND COMMUNICATION, DATED [DATE], REFLECTED THE RESIDENT'S VERBAL STATEMENTS WERE RAMBLING AND OFTEN NOT APPROPRIATE TO THE TOPIC OF CONVERSATION. RESIDENT #12'S NURSING NOTES, DATED [DATE] ,[DATE] (AM), REFLECTED THAT AT "11:35 AM, CNA (COMPETENCY EVALUATED NURSE AIDE) WITNESSED MALE RESIDENT WITH HIS HAND IN HER L (LEFT) SLEEVE FONDLING HER L BREAST...THIS RESIDENT UNAWARE OF INCIDENT..." THE FACILITY "RESIDENT INCIDENT REPORT", DATED [DATE] AT 11:35 AM, REFLECTED THAT RESIDENT #7 WAS OBSERVED WITH HIS ARM IN THE LEFT SLEEVE OF RESIDENT #12'S SHIRT. RESIDENT #7 WAS FONDLING RESIDENT #12'S LEFT BREAST. THE INCIDENT REPORT FOR RESIDENT#7 STATED THE INCIDENT HAPPENED WHILE THEY WERE IN THE HALLWAY BY THE ACTIVITIES OFFICE AND THAT RESIDENT #12 WAS CONFUSED AND DISORIENTED. THE IMMEDIATE ACTION TAKEN WAS TO ESCORT RESIDENT #7 TO AND FROM THE DINING ROOM. RESIDENT #7 WAS PUT ON 1 TO 1 SUPERVISION FOR 2 DAYS THEN STAFF WAS TO KEEP THE RESIDENTS #7 AND #12 SEPARATED FROM EACH OTHER. THE SOCIAL WORK PROGRESS NOTES, DATED [DATE] AT 11:30 AM, REFLECTED "...IMMEDIATELY AFTER THE INCIDENT, RESIDENT (#12) WAS INTERVIEWED, PRESENTS AS SMILING, UNABLE TO VOICE INCIDENT OR ANY CONCERN, RAMBLING A PLEASANT CONVERSATION STATING 'THAT'S FINE'. NO HARM OR INJURY APPARENT..." RESIDENT #12'S CARE PLAN RELATED TO HER RISK FOR PSYCHOSOCIAL DECLINE, DATED [DATE], REFLECTED THE INCIDENT WAS ADDED TO THE CARE PLAN UNDER THE PROBLEM SECTION BUT NO INTERVENTIONS TO PROTECT THE RESIDENT WERE FOUND IN THE APPROACHES SECTION. THE FACT THAT THE RESIDENT WANDERED THROUGHOUT THE FACILITY WAS NOT ADDRESSED. ON [DATE] THE NURSING NOTES FOR THE 3:00 PM-11:00 PM SHIFT FOR RESIDENT #12 REFLECTED "RESIDENT (#12) IN SUNROOM AROUND 8 PM IN WC (WHEELCHAIR). NURSE NOTICED MALE RESIDENT (#7)NEXT TO HER WITH HIS HAND ON HER R (RIGHT) BREAST. RESIDENT (#12) WAS PUSHING HIS HANDS AWAY...RESIDENT (#12) VERY CONFUSED AND DISORIENTED." THE FACILITY IDENTIFIED THE MALE RESIDENT AS RESIDENT #7. THE "RESIDENT INCIDENT REPORT", DATED [DATE] AT 8:00 PM, FOR RESIDENT #7 REFLECTED "...RESIDENT IN SUNROOM AND KEPT LOOKING AROUND AT STAFF SEEING IF STAFF WERE PAYING ATTENTION. NURSE NOTICED THIS ODD BEHAVIOR SO KEPT EYE ON RESIDENT, NURSE TURNED AROUND TO GIVE MEDICATION TO ANOTHER RESIDENT AND WHEN TURNED BACK TO POSITION THIS RESIDENT HAD WENT ACROSS THE SUNROOM AND HAD HIS LEFT HAND ON A FEMALE RESIDENT'S (#12) RIGHT BREAST. FEMALE RESIDENT WAS PUSHING HIM AWAY..." THE NURSING NOTES FOR RESIDENT #7, DATED 8:00 PM ON [DATE], REFLECTED RESIDENT #7 STATED "...SHE'S FIGHTING ME..." WHEN THE NURSE SEPARATED THE TWO RESIDENTS. THE FACT THAT RESIDENT #12 WAS PUSHING RESIDENT #7'S HANDS AWAY FROM HER RIGHT BREAST COULD HAVE INDICATED RESIDENT #12 DID NOT WANT HER BREAST TOUCHED BY RESIDENT #7. THE "RESIDENT INCIDENT REPORT", DATED [DATE] AT 8:00 PM, FOR RESIDENT #12 REFLECTED THE IMMEDIATE ACTION WAS TO SEPARATE THE RESIDENTS AND RESIDENT #7 WAS SENT TO HIS ROOM. RESIDENT#12'S CARE PLAN RELATED TO RISK FOR PSYCHOSOCIAL DECLINE, DATED [DATE], AND NEED FOR SOCIALIZATION, DATED [DATE] REFLECTED NO ADDITION OF ANY INTERVENTIONS TO PROVIDE SAFETY FOR RESIDENT #12. A CARE PLAN RELATED TO BEHAVIOR MANAGEMENT WHICH ADDRESSED WANDERING WAS NOT DEVELOPED UNTIL [DATE]. THE INTERVENTIONS DID NOT INCLUDE ANY INFORMATION RELATED TO THE TWO INCIDENTS WITH RESIDENT #7 OR HOW RESIDENT #12 WAS TO AVOID CONTACT WITH RESIDENT #7. RESIDENT #12'S NURSING NOTES, DATED [DATE] 3:00 AM-3:00 PM, REFLECTED "11 AM-RESIDENT (#12) WAS SITTING IN SUNROOM AT TABLE WHEN A CENA (COMPETENCY EVALUATED NURSE AIDE), OBSERVED A MALE RESIDENT (#7) WITH HIS HAND DOWN HER PANTS...RESIDENTS WILL BE KEPT SEPARATED AND MONITORED FOR SAFETY." THE IMMEDIATE ACTION WAS TO SEPARATE THE RESIDENTS AND RESIDENT #7 WAS ESCORTED TO HIS ROOM. THE NURSING NOTES FOR THE SAME DATE ON THE 3:00 PM-11:00 PM SHIFT REFLECTED RESIDENT #12 WAS PLEASANT AND COOPERATIVE. THE SOCIAL WORK PROGRESS NOTES, DATED [DATE] AT 10:00 AM, REFLECTED "...SHE (RESIDENT #12) IS UNAWARE OF THE INCIDENT CALM, VERBALIZING NONSENSICAL PHRASES. SHE HAS BEEN OBSERVED SINCE THEN IN NORMAL ROUTINE..." STATEMENTS WRITTEN ON [DATE] BY THE NURSING AIDE "M" WHO WITNESSED THE INCIDENT AND THE MEDICAL RECORDS STAFF "N" WHO WAS AT THE COPY MACHINE IN VIEW OF THE SUNROOM REFLECTED THERE WAS NO STAFF MEMBER IN THE SUNROOM WHEN BOTH RESIDENT #7 AND #12 WERE IN THE ROOM. RESIDENT #12'S CARE PLAN RELATED TO RISK FOR PSYCHOSOCIAL DECLINE, DATED [DATE], REFLECTED THE FOLLOWING INTERVENTIONS HAD BEEN ADDED TO THE PLAN; 1) [DATE] DISCUSS ALTERNATE PLACEMENT OPTIONS WITH CLOSED UNIT FOR RESIDENT WITH FAMILY, 2) [DATE]-ESCORT TO ACTIVITIES. ENCOURAGE RESIDENT TO BE IN COMMON AREAS. MORE SUPERVISED, 3) [DATE]-INCREASE ATTENDANCE TO STRUCTURED ACTIVITIES, ENCOURAGE FAMILY VISITS AND INVOLVE IN STRUCTURED ACTIVITY PROGRAM AND 4) [DATE]-OFFER ROOM CHANGE TO ANOTHER HALLWAY. THE BEHAVIOR CARE PLAN, DATED [DATE] AND REVISED ON [DATE], REMAINED UNCHANGED. ON [DATE] AT 1:00 PM THE DIRECTOR OF NURSING "B" CONFIRMED THAT THE CARE PLAN FOR RESIDENT #12 DID NOT CONTAIN INTERVENTIONS TO PROTECT HER FROM RESIDENT #7 AND DID NOT IDENTIFY RESIDENT #7 AS A THREAT TO HER. RESIDENT #7 WAS AN ALERT AND ORIENTED MALE WHOSE [DIAGNOSES REDACTED]. THE MDS, dated [DATE], [DATE] AND [DATE], REFLECTED THE RESIDENT WAS MODERATELY COGNITIVELY IMPAIRED AND WAS ABLE TO MAKE DECISIONS FOR DAILY ACTIVITIES. THE CARE AREA ASSESSMENT FOR COGNITIVE LOSS/DEMENTIA IN THE MDS, dated [DATE] REFLECTED THE RESIDENT WAS IMPULSIVE AND ADAMANTLY DENIES ANY BEHAVIORS BUT STATES HE WILL NEVER BACK DOWN FROM CONFRONTATION. RESIDENT #7 WAS INDEPENDENTLY MOBILE IN HIS WHEELCHAIR THROUGHOUT THE FACILITY. AFTER THE THREE INCIDENTS ON [DATE], [DATE] AND [DATE], RESIDENT #7 DENIED HE HAD TOUCHED RESIDENT #12 ON THE BREASTS OR ABDOMEN. THE SOCIAL WORK PROGRESS NOTES, DATED [DATE], REFLECTED THAT RESIDENT #7 STATED HE WAS SITTING IN THE "PUZZLE ROOM" (SUNROOM) AND 'I (#7) FELT SORRY FOR HER, SHE WAS CRYING ASO I WENT OVER TO HER AND TOUCHED HER FACE'. ACCORDING TO THE SAME NOTE RESIDENT #7 STATED "THEY SAY I PUT MY HAND IN HER PANTS, WHY WOULD I DO THAT, THERE'S NOTHING IN THERE FOR ME". RESIDENT#7 FURTHER STATED RESIDENT #12 REMINDED HIM OF HIS WIFE. RESIDENT #7'S WIFE WAS deceased IN 2008 BUT HE HAD CARED FOR HER FOR MANY YEARS AT HOME BEFORE SHE WAS admitted TO A LONG TERM CARE FACILITY. THE RESIDENT HAD CONSISTENTLY DENIED SEXUAL CONTACT WITH RESIDENT #12 WHEN CAUGHT IN THE ACT AND WHEN INTERVIEWED BY FEMALE STAFF. HOWEVER, ON [DATE], THE COMMUNITY MENTAL HEALTH (CMH) MALE PSYCHIATRIST'S NOTES, REFLECTED THE RESIDENT admitted HE HAD EXHIBITED SEXUALLY INAPPROPRIATE BEHAVIOR. RESIDENT #7 STATED HE DID NOT KNOW WHY HE DID IT. RESIDENT #7 ALSO STATED HE HAD URGES TO TOUCH STAFF BUT HAD NOT DONE IT. RESIDENT #7 WENT ON TO SAY HE WAS BOTHERED BY THESE BEHAVIORS, KNEW THEY WERE INAPPROPRIATE AND IT WAS NOT LIKE HIM TO DO THESE THINGS. THE CARE PLAN FOR RESIDENT #7 RELATED TO AGGRESSIVE BEHAVIORS, DATED [DATE], REFLECTED THE INTERVENTION THAT THE RESIDENT WAS TO BE ESCORTED TO AND FROM MEALS WAS ADDED ON [DATE]. IN ADDITION, 1 TO 1 SUPERVISION WAS TO BE DONE THROUGH [DATE] THEN HE WAS TO BE "...KEPT IN LINE OF VISION/ESCORT WHEN OUT OF ROOM..." ON [DATE] THE INTERVENTION "FOLLOW CMH RECOMMENDATIONS" WAS ADDED. WHEN THE CARE PLAN WAS REWRITTEN ON [DATE] THE INTERVENTIONS WERE TO; 1) DIRECT THE RESIDENT AWAY FROM POTENTIAL CONFRONTATIONS, 2) SUPERVISE HIM WHEN HE WAS OUT OF HIS ROOM AND 3) RE-DIRECT FROM OTHER FEMALES WHO REMIND HIM OF HIS SPOUSE TO DECREASE INAPPROPRIATE TOUCH POTENTIAL. THE CARE PLAN DID NOT IDENTIFY WHO THE FEMALES MIGHT BE THAT LOOKED LIKE HIS SPOUSE. THE BEHAVIOR MANAGEMENT CARE PLAN, DATED [DATE], IDENTIFIED INAPPROPRIATE SEXUAL BEHAVIOR AS A PROBLEM AND THE BOX "TOUCHING OR EXPOSING BODY PARTS OR MASTURBATION IN PUBLIC" WAS CHECKED. THERE WAS NO INFORMATION RELATED TO HIS TOUCHING RESIDENT #12 OR WHAT INTERVENTIONS TO TAKE RELATED TO THAT BEHAVIOR. AFTER THE [DATE] INCIDENT THE INTERVENTION OF A MOTION SENSOR WAS ADDED TO THE DOORWAY OF HIS ROOM TO ALERT STAFF WHEN HE WAS LEAVING. THE "KARDEX" USED BY THE NURSING AIDES WHEN PROVIDING CARE CONTAINED ONLY THE INTERVENTION TO KEEP RESIDENT #7 IN LINE OF VISION WHEN OUT OF HIS ROOM, DATED [DATE], AND USE THE MOTION SENSOR ON THE DOOR. ON [DATE] AT 2:10 PM RESIDENT #7 WAS OBSERVED IN THE MAIN DINING ROOM SEATED NEXT TO A FEMALE RESIDENT AT A TABLE. AN ACTIVITY AIDE WAS SETTING UP BINGO AND IN AND OUT OF THE ROOM. NO OTHER STAFF OR RESIDENTS WERE IN THE ROOM. ON [DATE] BETWEEN 11:10 AM-12:30 PM RESIDENT #7 WAS IN THE SUNROOM WATCHING A MOVIE ON THE TELEVISION SITTING NEXT TO 2 DIFFERENT FEMALE RESIDENTS. AT 12:00 NOON THERE WERE 2 ADDITIONAL FEMALE RESIDENTS IN THE TELEVISION AREA. NO STAFF WERE PRESENT EXCEPT FOR THOSE THAT OCCASIONALLY WALKED THROUGH THE ROOM TO GET TO THE A OR B NURSING UNITS. ON [DATE] AT 4:00 PM THE SOCIAL WORKER "F" CONFIRMED THAT THE ABOVE MEASURES WERE THE ONLY INTERVENTIONS IN PLACE FOR RESIDENT #7 AND THE CARE PLAN DID NOT SPECIFICALLY IDENTIFY RESIDENT #12 AS THE TARGET FOR RESIDENT #7'S SEXUAL TOUCHING. RESIDENT #12 WAS INAPPROPRIATELY TOUCHED BY RESIDENT #7 ON THREE OCCASIONS THAT WERE KNOWN TO THE FACILITY. THE ONLY PLAN TO PROTECT RESIDENT #12 WAS TO KEEP RESIDENTS #7 AND #12 SEPARATED AND MAINTAIN VISUAL SUPERVISION OF RESIDENT #7 WHEN HE WAS OUT OF HIS ROOM. THE FACILITY FAILED TO ENSURE THAT RESIDENTS #7 AND #12 WERE KEPT SEPARATED AND/OR SUPERVISED WHILE THEY WERE IN THE SAME AREA. USING THE REASONABLE PERSON CONCEPT, RESIDENT #12 POTENTIALLY SUFFERED EMOTIONAL DISTRESS AT THE TIME OF THE UNWANTED SEXUAL TOUCHING BUT THIS COULD NOT BE DETERMINED RELATED TO HER DEMENTIA AND MENTAL ILLNESS. ( )