Every finding on record at Macon Rehabilitation and Healthcare

Based on staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA), specifically an alleged head injury, within the required time frame for one of three sampled residents (R) (R1).Findings include:Review of the facility's policy titled Abuse Prevention Policy, with a reviewed date of [DATE], revealed all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but no later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in seriously bodily injury, to the Administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long term facilities in accordance with State Law).Review of the Facility Incident Report Form revealed the SSA was notified on [DATE] and indicated an off-campus injury at dialysis. The alleged incident was reported to have taken place on [DATE] at 3:00 pm. The details of the incident noted that the facility received notification that R1 was sent to the emergency room and arrived at the emergency room at 7:45 am. Per dialysis, he was sent due to a hematoma to the head that was bleeding profusely. R1 received care in the emergency room until he was pronounced deceased sometime after noon. Per the Coroner, a computed tomography scan (CT) was completed during his course of care at the emergency room that showed a subarachnoid hemorrhage. The Administrator reported to the Coroner that R1 was picked up from the facility, and transport started at 5:20 am, and per the transport team, arrived at the dialysis center at 5:25 am. Per transport crew interview and written statements, the resident was picked up from the facility with no apparent signs of injury or bleeding to his head or face. They deny any incident during transport and stated the resident arrived to dialysis with no injury and was placed in care of his assigned dialysis nurse. The resident was in the care of the dialysis center for over two hours prior to his transfer to the hospital.Review of the facility's final investigative summary, dated [DATE], revealed that it was sent to the SSA and noted that, in conclusion, the facility did not substantiate that R1 was injured or involved in any incident at the facility that would have caused the head injury. The facility had remained in contact with the local County Investigator in order to assist with any additional information they may need.During an interview with the Administrator on [DATE] at 2:30 pm, she stated she was notified on the evening of [DATE] by the Coroner that the resident was deceased . She stated she talked to the Coroner again later that evening, and he reported to her that the resident had a hematoma and a subarachnoid hemorrhage. She confirmed that she submitted the initial report on [DATE] because she wasn't sure what happened.

Based on staff interview, record review, and review of the facility's policy titled Abuse Prevention Policy, the facility failed to thoroughly investigate an allegation of injury of unknown origin for one of three sampled residents (R) (R1).Findings include:Review of the facility policy titled Abuse Prevention Policy, with a reviewed date of [DATE], revealed Injury of unknown source means source of injury was not observed by another person or injury could not be explained by the resident. Injury is suspicious because of the extent of the injury, location of injury (e.g. injury is located in an area not generally vulnerable to trauma such as facial injuries, bruising of inner thighs, wrap around bruises of arms, legs or torso, skin tears on sites other than arms/legs) or the number of injuries observed at one point in time or the incidence of injuries over time.Review of the Facility Incident Report Form revealed the State Survey Agency (SSA) was notified on [DATE] and indicated an off-campus injury at dialysis. The alleged incident was reported to have taken place on [DATE] at 3:00 pm. The details of the incident noted that the facility received notification that R1 was sent to the emergency room and arrived at the emergency room at 7:45 am. Per dialysis, he was sent due to a hematoma to the head that was bleeding profusely. R1 received care in the emergency room until he was pronounced deceased sometime after noon. Per the Coroner, a computed tomography scan (CT) was completed during his course of care at the emergency room that showed a subarachnoid hemorrhage. The Administrator reported to the Coroner that R1 was picked up from the facility, and transport started at 5:20 am, and the transport team arrived at the dialysis center at 5:25 am. Per transport crew interview and written statements, the resident was picked up from the facility with no apparent signs of injury or bleeding to his head or face. They deny any incident during transport and stated the resident arrived to dialysis with no injury and was placed in care of his assigned dialysis nurse. The resident was in the care of the dialysis center for over two hours prior to his transfer to the hospital.Review of the facility's final investigative summary, dated [DATE], that was submitted to the SSA, noted that, in conclusion, the facility did not substantiate that R1 was injured or involved in any incident at the facility that would have caused the head injury. The facility had remained in contact with the County Investigator in order to assist with any additional information they may need.There was no evidence that a complete investigation was conducted regarding the alleged head injury for R1. There was no evidence that the facility obtained the emergency room medical record, the County Sheriff's report, the Supplemental Report from the Sheriff's Department Investigator, and there was no evidence that the facility obtained information from the dialysis clinic to be able to complete a thorough investigation.Review of the [DATE] Emergency Department Provider Notes noted that the resident presented from dialysis for bleeding. At dialysis, he was given intravenous heparin and began bleeding from the back of his head. He was noted to have a 3-centimeter occipital scalp laceration, which was repaired at the bedside with three staples. The physician noted the resident had a large subarachnoid hemorrhage and subdural hemorrhage. Neurosurgery suspected an aneurysm rupture as the initial insult. The physician further noted this was a terminal non-cardiac event and medically futile to code.Review of the County Sheriff's Office Supplemental Report Narrative, dated [DATE], noted the Investigator made contact with the dialysis clinic manager along with her two nurses who were present during the appointment with R1. The clinic manager stated that the transport team lifts the patient and places them in the chair, and that her employees only touch the dialysis portion of the visit and do not move patients. There was no injury sustained during R1's visit. Dialysis staff AA stated he was giving R1 his treatment when he noticed that there was blood on his head. He wiped the blood and realized it was coming from the back of his head after blood thinners were administered. Dialysis staff AA stated the wound appeared to be a straight line, like a scrape on the back of R1's head that had reopened. He immediately applied pressure, and an ambulance was called to transport R1 to the emergency room. The clinic manager stated she would speak to her legal team about providing statements from the nurses and patients that were there during the incident.Review of the [DATE] Coroner's Death Investigation Report noted the resident came into the emergency room from dialysis on [DATE] at 7:45 am. CT showed subarachnoid hemorrhage. The Coroner noted the cause of death on discharge as renal failure. The date and time of death were [DATE] at 12:25 pm.The Georgia Death Certificate noted the resident was pronounced deceased on [DATE] at 12:25 pm. The immediate cause of death was cardiac arrest due to respiratory failure and renal failure.During an interview with the Administrator on [DATE] at 2:30 pm, she stated she was notified of the resident's death on the evening of [DATE] by the Coroner, who also told her that the resident had a hematoma and a subarachnoid hemorrhage. She stated that when she attempted to call the dialysis clinic, the phone would just ring and ring, forcing her to leave a voicemail message. However, she never received a returned call from the dialysis clinic and she did not go to the clinic to discuss the incident with management at the dialysis clinic. She further stated that when she spoke to the investigator, the investigator told her she would talk to the dialysis clinic staff, so she just turned the investigation over to her. She stated the investigator never got back with her. She stated she called the Sheriff's Office on [DATE] to obtain a copy of the investigator's report, and was told she would have to come to the office to obtain a copy.

Based on observations, staff interviews, and review of the facility policy titled Food Storage: Cold Foods, the facility failed to ensure food items were covered/wrapped, labeled, and dated when opened. In addition, the facility failed to ensure sanitary conditions for two of two ice machines used by the kitchen. Additionally, the facility failed to ensure sanitary conditions in the kitchen. These deficient practices had the potential to place the 89 residents receiving food and hydration from the kitchen at risk of foodborne illness. Findings include:Review of the facility policy titled Food Storage: Cold Food, revised 2/2023, revealed the Procedures section included, . 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross-contamination.1. Observations on 8/18/2025 at 10:02 am, during the initial kitchen tour with the Dietary Manager (DM), revealed the cooler contained:One unwrapped piece of ham. One unwrapped half of a tomato. One 5-pound (lb.) bag of shredded cheddar cheese that was unlabeled and undated. Five hamburger buns, unlabeled and undated.One 5-lb. bag of blueberries, unlabeled and undated. One unwrapped, opened bag containing three boiled eggs. Observation revealed the three-door reach-in refrigerator contained:One 6-quart (qt.) container containing a brown-like food substance, undated and unlabeled. One 6-qt. container with a yellow pudding-like substance, undated and unlabeled.One 6-qt. container labeled as pineapples, with an expiration date of 8/16/2025. The DM confirmed all findings and stated that if a package lacks an expiration date, it is not considered valid. The Dietary Manager stated that he, along with the cooks, was responsible for proper labeling and dating of food items.2. Continued observations on 8/18/2025, beginning at 10:02 am, during the initial kitchen tour, with the DM, of the ice machines revealed an ice scoop inside the machines, along with a black-like substance present on the inside near the ice dispenser in both the north and kitchen hall. The DM stated that the Maintenance Department was responsible for cleaning the ice machines. 3. Observation on 8/19/2025, at 12:26 pm, of the kitchen ceiling revealed a black and gray substance on the ventilation unit next to the meat/produce sink. Continued observation revealed a fan installed on the wall near the steam table, alongside the three-door refrigerator, with a black substance on both the blades and the ceiling. The DM confirmed the findings and stated that he had reported these concerns via the facility's computerized reporting system.In a concurrent interview and observation tour on 8/20/2025 at 12:02 pm, the Administrator and Maintenance Director confirmed that the ceiling ventilation unit and fan had black substances on them and confirmed they needed to be cleaned. The Maintenance Director further stated he was unable to clean the ice machine on a normal schedule.

Based on observations, staff interviews, record review, and review of facility policy titled Infection Prevention and Control Program, the facility failed to follow infection control procedures for one resident (R) R68 on Enhanced Barrier Precautions (EBP). This deficient practice had the potential to increase the risk of the spread of infection in the facility. The census was 94. Findings include:Review of the facility policy titled Infection Prevention and Control Program, dated June 2025, revealed the Policy Statement section included, To have a comprehensive program that addresses detection, prevention, and control of infections among residents and staff. This facility's infection prevention and control policies/practices are intended to facilitate in maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections. The Precaution Guidelines section included, All staff should wear appropriate personal protective equipment (PPE) as necessary to prevent exposure to spills or splashes of blood or body fluids or other potentially infectious materials. Review of the electronic medical record (EMR) for R68 revealed diagnoses including, but not limited to, pressure ulcer of sacral region, stage 3, encounter for orthopedic aftercare following surgical amputation, and acquired absence of left leg above the knee.Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/20/2025, for R68 revealed that Section GG (Physical Abilities and Goals) documented the resident required substantial to maximal assistance with toileting hygiene. Section H (Bowel and Bladder) documented the resident was always incontinent of bowel and bladder. Section M (Skin Condition) documented the resident had one unhealed stage 3 pressure ulcer. Review of the Order Summary Report for R68 revealed an order dated 7/2/2025 for Enhanced Barrier Precautions related to a wound. In a concurrent observation and interview on 8/20/2025 at 11:20 am, Certified Nursing Aide (CNA) FF was observed providing incontinent care to R68. Observation revealed CNA FF did not have a protective gown on while providing incontinent care. Interview with CNA FF confirmed she did not wear a protective gown while providing incontinent care to R68. CNA FF stated she should have worn a gown during the care. In an interview on 8/21/2025 at 12:30 pm, the Director of Nursing (DON) revealed her expectation was for staff to wear gowns and gloves while providing incontinent care to residents who were on EBP.

Based on staff interviews, record review, and review of the facility policy titled Behavioral Management Program, the facility failed to refer one of two residents (R) (R5) reviewed for Preadmission Screening and Resident Review (PASRR), from a total sample of 46, for evaluation by the appropriate State-designated authority. This deficient practice has the potential to place R5 at risk of not receiving necessary care and services.Findings Include:Review of the facility policy titled Behavioral Management Program, revised June 2024, revealed the Policy Statement stated, It is the policy of the facility that each resident must receive, and the facility must provide the necessary behavioral health care and services and medically related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment (483.20) and plan of care. The interdisciplinary team will utilize information from the PASARR process as well as to complete a comprehensive assessment of resident needs, strengths, goals, life history and preference using the resident assessment instrument (RAI) specified by CMS [Centers for Medicare and Medicaid Services].Review of the electronic medical record (EMR) for R5 revealed an admission date of 9/20/2024. Diagnoses included, but were not limited to, anxiety disorder and post-traumatic stress disorder (PTSD). Review of the admission Minimum Data Set (MDS) assessment for R5, dated 9/20/2024, revealed Section A (Identification Information) documented the resident was not considered by the State Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. Section I (Active Diagnoses) documents diagnoses, including, but not limited to, anxiety disorder and PTSD. Section O (Special Treatments, Procedures, and Programs) documents that the resident did not receive psychological therapy.Review of the Quarterly MDS assessment for R5, dated 6/25/2025, revealed Section D (Mood) documented the resident had little interest or pleasure in doing things 12-14 days. Section I (Active Diagnoses) documents diagnoses, including, but not limited to, anxiety disorder and PTSD. Section O (Special Treatments, Procedures, and Programs) documents that the resident did not receive psychological therapy. Review of the Physician's Orders for R5 revealed an order dated 7/2/2025 for buspirone HCL 5 milligram (mg), give 1 tablet via G-tube [gastrostomy tube] every 12 hours for anxiety. Further review revealed an order dated 7/2/2025 for psychiatric/psychological evaluation and treatment as needed. Review of the PASRR Level I application for R5, dated 9/20/2024, revealed that the resident did not have a primary diagnosis of dementia, anxiety, or PTSD.In an interview on 8/21/2025 at 8:50 am, the Social Services Worker (SSW) confirmed there were no diagnoses of dementia, anxiety, or PTSD on the PASRR Level I application for R5. In an interview on 8/21/2025 at 11:04 am, Admissions Staff GG confirmed a new PASRR submission should have been conducted due to the diagnoses of anxiety and PTSD.

Based on staff and resident interviews, record review, and review of the facility policy titled Activities of Daily Living, the facility failed to ensure two of 46 sampled residents (R) (R53 and R72) received assistance with Activities of Daily Living (ADL) care. This deficient practice had the potential to place R53 and R72 at risk of unmet care needs and a diminished quality of life. Findings include: Review of the facility policy titled Activities of Daily Living, revised June 2025, revealed the Policy Statement included, To ensure that all residents receive appropriate assistance with Activities of Daily Living (ADLs) in a manner that promotes dignity, independence, and quality of life. The Definition section included, Activities of Daily Living (ADLs) are basic self-care tasks essential for maintaining health and well-being. These include: Bathing Dressing Grooming and personal hygiene . 1. Review of the electronic medical record (EMR) for R53 revealed the most recent admission date of 4/22/2025 with diagnoses including, but not limited to, displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing, spinal stenosis, lack of coordination, and muscle weakness. Review of the Annual Minimum Data Set (MDS) assessment for R53, dated 7/22/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 15 (indicating little to no cognitive impairment). Section GG (Physical Abilities and Goals) documented that R53 required partial to moderate assistance with showering and bathing self. Review of the August 2025 Bathing/Shower system revealed R53 was scheduled for showers on Tuesday and Friday on the 7:00 am to 3:00 pm shift. Review revealed that from 8/1/2025 to 8/21/2025, R53 received five showers. In an interview on 8/18/2025 at 2:47 pm, R53 stated that her last shower was a month ago. R53 stated that she often performed a self-wash in her bathroom to avoid any unpleasant odors. In an interview on 8/19/2025 at 5:00 pm, R53 stated that she did not take a shower today. She stated that staff had informed her that she would receive one tomorrow. In an interview on 8/20/2025 at 5:00 pm, R53 stated that she had not received a shower all week. She stated that staff had told her she would receive one today, but later told her that it would be tomorrow. R53 also stated that she had never refused a shower. In an interview on 8/20/202, at 5:14 pm, Licensed Practical Nurse (LPN) EE stated there were no additional locations for shower sheets. In an interview on 8/20/2025 at 5:45 pm, the Director of Nursing (DON) stated that the facility had ceased enforcing the use of shower sheets and was attempting to transition away from paper usage. The DON affirmed that each resident has been entered into the electronic system for documenting ADL care for several months. In an interview on 8/21/2025 at 12:21 pm, the DON stated that she had confirmed with the Certified Nursing Assistant (CNA) responsible for providing a shower to R53 that he failed to provide a shower to the resident on 8/12/2025 and 8/19/2025. The DON further stated that she expected all staff members to review the shower log, inquire about residents' preferences, and if a resident refuses, to inform the nurse. The DON stated that she believed the oversight was a result of the responsibilities associated with the eight-hour and twelve-hour shift schedules. 2. Review of the EMR for R72 revealed an admission date of 7/12/2023 with diagnoses including, but not limited to, schizoaffective disorder, bipolar type, type 2 diabetes mellitus with hyperglycemia, and a history of falling. Review of the Quarterly Minimum Data Set (MDS) assessment for R72, dated 7/26/2025, revealed Section C (Cognitive Patterns) documented a BIMS of 15 (indicating little to no cognitive impairment). Section GG (Functional Abilities and Goals) documented R72 had lower extremity impairment on both sides, used a wheelchair, and required assistance for ADLs with two or more persons assistance. Review of the care plan for R72, dated 8/1/2023, indicated R72 had an ADL self-care performance deficit related to limited mobility. Interventions included, but were not limited to, assisting the resident with bathing and personal hygiene. Review of the clinical record revealed no documentation of R72 having her hair washed. In an interview on 8/18/2025 at 1:41 pm, R72 stated her hair needed to be washed. She stated it had been a long time since someone had washed her hair and her scalp itched. In an interview on 8/19/2025 at 12:40 pm, Certified Nursing Assistant (CNA) JJ stated R72 should ask to have her hair washed and that someone came on Wednesdays to wash and style residents' hair who had requested the service. CNA JJ informed R72 to ask someone for her hair to be washed, and R72 asked who she needed to ask, stating her scalp was itching, and it had been a long time since her hair had been washed. In an interview on 8/20/2025 at 1:07 pm, CNA JJ stated that all grooming was documented on the resident's shower sheet. In an interview on 8/20/2025 at 1:07 pm, R72 stated she still needed her hair washed. In an interview on 8/20/2025 at 1:40 pm, Hairdresser HH stated she worked at the facility once a week. She stated she could not provide services to all residents, made a list of the residents to see a week ahead of time, and was paid through the family. She stated the hair care service was for residents who want something extra for their hair. In an interview on 8/21/2025 at 11:44 am, the DON confirmed that hair washing, nail trimming, and personal grooming were part of ADL care that should be provided by staff.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled Care Plan Policy, the facility failed to ensure a care plan was developed or implemented for six of 37 residents (R) (R46, R51, R61, R4, R54, R67). Specifically, the facility failed to ensure the care plan was implemented for R46 and R51 for Activities of Daily Living (ADL), R61 for providing a privacy bag for a urinary catheter, R4 for oxygen use, and R54 for tube feeding. In addition, the facility failed to develop a care plan for R67 for the use of antipsychotic and anticoagulant medications. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. Findings include: Review of the facility's policy titled Care Plan Policy, revised April 10, 2024, revealed the Policy Statement of Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 1. Review of R46's care plan revealed a Focus area of the resident had an ADL self-care performance deficit related to a cerebral vascular accident (CVA), hemiplegia and requires assistance with ADL care. The goal was for the resident to have a clean, neat, and odor-free appearance through the review date. Interventions included the resident preferred to keep their beard trimmed as needed/desired and assist with daily grooming of oral, skin, hair, and nails. Observations on 4/19/2024 at 10:21 am and 4/20/2024 at 7:45 am revealed that R46 had a full beard with food scattered throughout it. Further observation revealed R46's fingernails on the left hand were long, with a brown substance noted under the nails. 2. Review of R51 Quarterly Minimum Data Set (MDS) Assessment date 2/27/2024 section C (Cognition): A Brief Interview for Mental Status (BIMS) score of 11 (indicating moderate cognitive impairment). However, the resident was able to articulate that she was in a nursing facility and her preferences for nail care. Review of the care plan revealed a Focus area of R51 was at risk for skin tear/injury secondary to skin fragility with aging. Resident has a personal preference of long fingernails. The goal included that R51's personal preferences will be met through the review period. Interventions included to encourage resident nail care as allowed. Observation on 4/19/2024 at 9:31 am revealed R51's fingernails were long with a thick brown substance underneath her nails. An interview on 4/19/2024 at 9:45 am with R51 revealed that she does not want her nails cut but would like for them to be cleaned. 3. Review of R61's care plan revealed a Focus of R61 has an indwelling catheter due to obstructive and reflux uropathy, bladder neck obstruction, chronic obstructive pyelonephritis, and chronic kidney disease. Interventions included, but were not limited to, emptying the catheter, ensuring emptying when the bag is under 3/4 full, and ensuring the catheter bag remains below the level of the bladder so that gravity works to bring urine down and does not backflow into the bladder. Provide privacy device per resident preference. Observation on 4/19/2024 at 8:55 am revealed the catheter drainage bag was uncovered and facing the door with 2000 cubic centimeters (cc) of urine (filled to the top). Observation on 4/20/2024 at 8:11 am revealed the catheter drainage bag was visible from the door. No privacy bag was noted during the observation. The catheter drainage bag had 1600 cc of urine noted. An interview on 4/20/24 at 8:28 am with Licensed Practical Nurse (LPN) BB confirmed R61's urinary catheter drainage bag was not in a privacy bag, and the catheter drainage bag contained 1600 cc of urine and should be emptied. LPN BB confirmed that R61 had a care plan for a urinary catheter, and the care plan should be followed. An interview on 4/20/2024 at 8:43 am with the Director of Nursing (DON) revealed her expectation was for staff to provide care for the residents according to their care plan and the care needs of each resident. An interview on 4/20/2024 at 9:49 am with the MDS Director revealed that each resident had a care plan centered around their care needs. The MDS Director stated CNAs were notified of changes in residents' care needs through their charting system, which is used daily for resident care. She further stated that the nurses have access to the resident care plans, with their care needs documented, and were expected to follow the residents' care plan when providing care. 45813 4. Review of R4's care plan, initiated on 10/7/2021, revealed that the resident was at risk for impaired air exchange due to COPD and allergic rhinitis. Interventions included, but were not limited to, administering oxygen as needed. Observation on 4/19/2024 at 9:37 am revealed R4 receiving oxygen via a nasal cannula at 3 liters per minute (LPM). Observations on 4/20/2024 at 8:27 am and 12:20 pm revealed R4 receiving oxygen via a nasal cannula at 2 LPM. Review of R4's Physician Orders dated April 2024 revealed orders for oxygen at 2 LPM via a mask or nasal cannula as needed for oxygen saturation (SP02) less than 92 percent. If ineffective, notify physician as needed for shortness of breath (SOB), add humidification water bottle to oxygen concentrator for humidification, fill with distilled water, and check SP02 every shift, notify physician if less than 92 percent every shift related to chronic obstructive pulmonary disease. Review of the oxygen saturation section in the EMR under the Vital Signs tab and on the April 2024 Medication Administration Record (MAR) revealed no documented oxygen saturations less than 92 percent. An interview on 4/20/2024 at 1:04 pm with the DON verified R4 did not have documented oxygen saturations of 92 percent or below to indicate the use of the oxygen according to the physician's order, and she verified that R4's care plan was not being followed. 33548 5. Review of R54's care plan, dated 4/3/2024, revealed the resident has nutritional problems or potential nutritional problems due to an NPO (nothing by mouth) diet and experiences weight fluctuations. The resident receives continuous tube feeding with hourly water flushes. Interventions included, but were not limited to, providing and serving diet and supplements as ordered. R54 also had a care plan developed for potential fluid deficit due to NPO status. Interventions included, but were not limited to, administering medications and nutrition/flushes as ordered. Review of R54's Physicians Orders revealed an order dated 4/1/2024 for enteral tube feeding for continuous formula Nepro (a nutritional product administered for nutritional support) at 65 cubic centimeters (cc) per hour for 22 hours. Observation on 4/19/2024 at 9:00 am of R54 revealed that Glucerna (a nutritional product administered for nutritional support) tube feeding was being administered via a pump at 65cc per hour. During an interview and observation on 4/19/2024 at 3:15 pm, the DON confirmed that R54 was receiving Glucerna tube feeding and not the Nepro tube feeding that was ordered by the physician. An interview on 4/21/2024 at 9:52 am with Registered Nurse (RN) HH/MDS Director revealed that each resident had a care plan centered around their care needs and physician's orders. She further stated staff was expected to follow the care plan for each resident. Continued interview revealed care plan meetings were attended by the administrative staff, and if anything needs to be relayed back to the staff, we put it on the care plan and communicate it with the floor staff. 39786 6. Record review revealed R67's diagnoses included, but were not limited to, paraplegia complete, neuromuscular dysfunction of the bladder, and chronic pain syndrome. Review of the Quarterly MDS assessment dated [DATE] revealed Section N (Medications) documented that R67 had received antipsychotic, antidepressant, anticoagulant medications, and antipsychotics were received on a routine basis during the assessment period. Review of the Physician Orders revealed orders of: 4/11/2024: quetiapine fumarate 25 milligrams (mg) (a medication used to treat mental and mood disorders) 1 tablet by mouth (PO) twice a day related to unspecified mood (affective) disorder. 4/11/2024: venlafaxine hydrochloride ER (extended-release) (a medication used to treat depression and anxiety) 75mg tablet Q24h (every 24 hours) give 1 tablet PO one time a day for depression. 4/11/2024: Eliquis 5 mg (a medication used to treat and prevent blood clots) give 1 tablet PO twice a day for blood clot prevention. Review of R67's care plan revealed there were no care plan areas or interventions for the use of antipsychotic, antidepressant, and anticoagulant medications. An interview on 4/21/2024 at 9:20 am with RN HH/MDS Director revealed care plans were updated quarterly, annually, and as needed when something was going on with the resident. She stated she received information through interviews with residents and staff and a clinical record review. The interview further revealed she was behind on care plan revisions. She confirmed that R67's care plan had not been updated since he was readmitted from a hospitalization . An interview on 4/21/24 at 11:17 am with the DON revealed that R67 was recently readmitted to the facility from a hospitalization . She confirmed the care plan was not updated or revised to include care plan areas and interventions for the use of antipsychotic, antidepressant, and anticoagulant medications before 4/21/2024. She stated her expectation was for resident care plans to be revised and updated in a timely manner and when changes in conditions warrant revisions or additions to the care plan. Cross-reference F550, F677, F695, F693

Based on observations, resident and staff interviews, record review, and review of the facility's policies titled Activity of Daily Living, Quality of Life, Special Rehabilitative Services, and Nail Care (Finger and Toe), the facility failed to ensure five residents (R) (R51, R29, R21, R56, and R46) were provided care and services in accordance with their personal needs. Specifically, the facility failed to ensure R51 and R29's nails were clean and trimmed, R46's beard was trimmed and clean without food particles present, and R21 and R56 received baths and removal of facial hair. These failures placed R51, R29, R21, R56, and R46 at risk for unmet needs and a diminished quality of life. The sample size was 37 residents. Findings include: Review of the facility's policy titled Activity of Daily Living, Quality of Life, Special Rehabilitative Services, dated November 2022, revealed the Policy Statement included Each resident shall receive, and this facility will provide necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident comprehensive assessment and care plan. The Scope section stated, Residents will be given the appropriate treatment and services to maintain or improve their ability to carry out the activities of daily living including hygiene bathing, grooming and oral care mobility, transfer, ambulation, elimination/ toileting, dining, eating, and communication functions. Review of the facility's policy titled Nail Care (Finger and Toe), dated April 1, 2024, revealed the Standard of Practice section included 1. Nails can be partially cleaned during bathing. 3. Nail care includes daily cleaning and regular trimming. 1. Record review revealed R51's diagnoses included, but were not limited to, the need for assistance with personal care, major depressive disorder, and adjustment disorder mixed with anxiety and depression. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 11 (indicating moderate cognitive impairment). However, the resident was able to articulate that she was in a nursing facility and her preferences for nail care. A continued review revealed that section GG (Functional Abilities and Goals) documented that R51 had functional limitations with impairment on both sides of the upper and lower extremities. Observation on 4/19/2024 at 9:31 am revealed R51's fingernails were long with a thick brown substance underneath her nails. An interview on 4/19/2024 at 9:45 am with R51 revealed that she does not want her nails cut but would like for them to be cleaned. Further interview also revealed that resident could not recall the last time her nails were cleaned by staff. 2. Record review revealed R46's diagnoses included, but were not limited to, generalized muscle weakness, lack of coordination, and need for assistance with personal care. Review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 7 (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented that R46 had functional limitations with impairment on one side of the upper extremities. Observation on 4/19/2024 at 10:21 am revealed R46 had a full beard with food scattered throughout it. R46 stated he did not want to shave his beard but would like it trimmed and shaped. Further observation revealed R46's fingernails on the left hand were long, with a brown substance noted under the nails. Observation on 4/20/2024 at 7:45 am revealed R46 lying in bed wearing the same clothes as the previous day. His beard continued to have food particles scattered throughout it, and the fingernails on his left hand had a brown substance noted underneath. An interview on 4/20/2024 at 8:47 a.m. with the Director of Nursing (DON) revealed her expectation was that residents have their nails cleaned and trimmed as needed. She stated that Certified Nursing Assistants (CNAs) should trim the residents' nails as part of their daily care. Further interview revealed the DON stated that R51 prefers to have her nails long, but there should be an attempt to clean the residents' nails as needed. The DON confirmed previous observations for R46 and R51. 39786 3. Record review revealed R21's diagnoses included, but were not limited to, Alzheimer's disease and muscle weakness. Review of the most recent Comprehensive Annual MDS assessment dated [DATE] revealed section G (Functional Abilities and Goals) documented R21 required extensive assistance for personal hygiene and was dependent for bathing. Review of the care plan revealed R21 required physical assistance with activities of daily living (ADL) care related to decreased mobility and Alzheimer's disease. Interventions included bathing assistance and skin assessment with shower. Review of the Task list included skin assessment with showers two times per week and as needed (PRN). Review of the Task Schedule revealed bath two times per week on Tuesday, Friday and PRN, every week on 7 am-3 pm shift for bathing/skin assessment with shower. Review of the Kardex revealed R21 required assistance with ADLs, including bathing, skin assessment with shower, and personal hygiene/oral. Review of the Bath Schedule revealed R21's scheduled bath days were every Monday and Friday on the 11 pm -7 am shift. No bath sheets were found in the nurses' station notebook for R21 for April 2024. The DON provided four bath sheets dated 4/2/2024, 4/5/2024, 4/9/2024, and 4/16/2024. Record review revealed that R21 only received four bed baths in 20 days, and staff did not document that R21's face was shaved on any day. Observation on 4/19/2024 at 8:58 am revealed R21 had long facial hair on her chin, and her hair was stringy and greasy. An interview on 4/20/2024 at 10:35 am with CNA JJ revealed they did not have a bath team, and the CNAs were responsible for bathing all residents according to the bath schedule. She stated the CNAs check the schedule to know who was scheduled each day and the resident's bath preference. CNA JJ revealed the bath should be documented in the electronic medical record (EMR) and a bath sheet completed and signed by the CNA and the nurse. She verified that if the bath was not documented, it was not done. An interview on 4/20/2024 at 10:50 am with Licensed Practical Nurse (LPN) BB revealed the residents have a scheduled day for their shower/bath and have a choice of the day. LPN BB stated the schedule and bath sheets were kept in a notebook at the nurse's station. She further stated the CNAs fill out the bath sheet every time they provide a shower or bath, and the nurse signs off on it. She confirmed the bath was not provided if the sheet was not filled out. 4. Review of the clinical record revealed R56's diagnoses included, but were not limited to, bilateral primary osteoarthritis of knee, morbid obesity, pain in left and right knee, muscle weakness. Review of R56's Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 15 (indicating little to no cognitive impairment) Section GG (Functional Abilities and Goals) documented R56 required substantial/maximal assistance (which meant staff did more than half the effort) with bathing or showering and shower transfer. Review of the care plan revealed an ADL self-care performance deficit, and a risk for impaired skin integrity and wounds, related to morbid obesity, decreased mobility, and pain to bilateral knees. Interventions included assisting with bathing and daily grooming as needed. Review of the Task list included skin assessment with shower three times per week and PRN. The task care record for April 2024 had no documentation under bathing/skin assessment with shower. Review of the Task Schedule revealed bath two times per week on Monday and Thursday on the 3 pm-11 pm shift and PRN on the 11 pm -7 am shift. Review of the Kardex revealed R56 required assistance with bathing, daily grooming as needed, and skin care. Review of the Bath Schedule revealed R56's shower days were every Wednesday and Saturday on the 7 am - 3 pm shift and documented that R56 preferred showers. Review of the Bath/Shower Notebook revealed it contained the bath schedule, blank, and completed bath forms titled Daily Bath Sheet. Staff revealed these sheets were used to track when baths were given and should be completed every time a bath or shower was given. The sheet had the option of either a shower or bed bath and a checklist of care provided. Review of the bath sheets revealed R56 received one bath in the past 20 days. One sheet was dated 4/17/2024 and documented shower, showers self, use shower chair, apply clean clothing, change sheets, return to bed, return to chair, and was signed by the CNA and the Unit Manager. The other sheet was dated 4/6/2024 and documented refused, attempted three times, and was signed by the CNA and the Unit Manager. The DON provided three additional sheets dated 3/7/2024, 3/16/2024, and 3/21/2024 that revealed R56 received three showers in 31 days in March. Interview on 4/19/2024 at 11:32 am with R56 revealed he didn't get a shower like he should. He stated he was scheduled twice a week on Wednesday and Saturday but often got the runaround when he asked staff about his shower. He further stated that staff would tell him a specific day he was scheduled for a shower and, on the scheduled day, would tell him it was a different day. He also stated staff would tell him they were too busy or didn't have enough help to provide a shower. He revealed he gets frustrated because he never knew when he would receive a shower. Interview on 4/20/2024 at 8:28 am with R56 revealed he hadn't had a bath yet, and today was his shower day. Interview on 4/20/2024 at 11:03 am with CNA KK confirmed they did not have a bath team and the CNAs were responsible for doing all their resident's baths/showers. CNA KK revealed staff knew who was supposed to get a bath each day because they followed a bath schedule at the nurse station that was by room number and included the day of the week and shift. She revealed they documented in the EMR and on a bath sheet. She explained the CNA filled out the sheet, reported to the nurse, gave her the bath sheet, and both signed the form. CNA KK revealed they must do a bath sheet every time to show proof they did the bath, and if there was no bath sheet completed, the bath was not done. Interview on 4/21/2024 at 10:58 am with the DON revealed they do the bath schedule by starting with each resident's preference for bed bath or shower and time of day. She stated her expectation was for residents to get bathed on their shower day as desired. 33548 5. Review of the medical record revealed R29's diagnoses included, but were not limited to, Alzheimer's disease, depression, and weakness. Review of R29's Admission MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS score of 9 (indicating moderately compromised cognition). However, R29 was oriented and able to make her needs known. Section GG (Functional Abilities and Goals) documented R29 was dependent on staff to perform all ADLs. Review of R29's bath/shower sheet revealed a bed bath was completed on 4/5/2024. Nail care was listed as an item for nursing staff to check as completed. The box for the nail care task was not marked, indicating the task was not done. The bath/shower sheet dated 4/12/2024 stated that R29 had a shower with therapy, and there were no boxes for care items marked as completed. During observation and interview on 4/19/2024 at 10:10 am, R29 stated that she would like her fingernails cut and polished, but she did not have any money for nail service. Observation of R29 fingernails revealed they were about 1 to 1.5 inches long, and the left-hand index finger and middle finger had broken nails. An interview on 4/21/2024 at 10:00 am with the Activities Director (AD) and the Activities Assistant (AA) revealed that they scheduled an activity called Pretty Nails every two weeks on the resident activity schedule. The AD revealed that the Pretty Nails activity was held in the main dining room or solarium, and residents could get their nails trimmed and polished at the activity. The AD stated that they do go to the rooms of residents who do not come out of their rooms for activities and ask if they would like their nails trimmed and polished. The AA confirmed that R29 had not been approached and asked about nail care, but they will visit and ask if she would like her nails done. An interview on 4/21/2024 at 10:05 am with R29 revealed that she would really like her nails shortened and stated it had been difficult for her to do things when they were this long. An observation and interview on 4/21/2024 at 10:05 am with LPN II confirmed that R29 had long fingernails. LPN II stated that the CNAs were responsible for addressing resident fingernails during bathing. Cross-reference F656

Based on observations, staff interviews, record review, and review of the facility's policy titled Urinary Catheter Care, Anchoring and Changing, the facility failed to ensure a urinary catheter privacy bag was provided for one of four residents (R) (R61) with a urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility's policy titled Urinary Catheter Care, Anchoring and Changing, revised April 2, 2024, revealed the Policy Statement was Each resident who is incontinent of bladder and has an indwelling catheter receives appropriate treatment of services to prevent urinary tract infections and to restore as much bladder function as possible. In order to avoid mucosal damage, catheter tubing will be anchored to prevent tension on the {name of catheter} insertion site. The Standards of Practice section stated, 16. Catheter drainage bags will be covered when residents are in a public area. 1. Record review revealed R61's diagnoses included, but were not limited to, bladder-neck obstruction, chronic obstructive pyelonephritis, interstitial cystitis with hematuria, and chronic kidney disease. Review of the Annual Minimum Data Set (MDS) dated [DATE] revealed Section H (Appliances) documented R61 had an indwelling urinary catheter. Observations on 4/19/2024 at 8:55 am and 4/20/2024 at 8:11 am revealed R61's urinary catheter drainage bag was uncovered and facing the door, allowing R61's urine to be visible to other residents, staff, and visitors from the hallway. An interview on 4/20/2024 at 8:15 am with Certified Nursing Assistant (CNA) AA confirmed that R61's catheter drainage bag contents were visible from the hallway and the bag should be in a privacy bag. An interview on 4/20/2024 at 8:28 am with Licensed Practical Nurse (LPN) BB confirmed R61's urinary catheter drainage bag was not in a privacy bag, and the contents were visible from the hallway. An interview on 4/20/2024 at 8:43 am with the Director of Nursing (DON) revealed that there were four residents in the facility with a urinary catheter. Further interview revealed that R61 often removes the privacy bag and places it in the top drawer. She stated there should be attempts by staff to ensure that the bag is covered, and privacy is provided for the resident. Cross-reference F656

Based on observation, resident and staff interviews, and a review of the facility's policy titled Care Plan Policy, the facility failed to update the care plan for one resident (R) (R56) related to an indwelling urinary catheter that had been removed and discontinued. The sample size was 37 residents. This failure placed R56 at risk for unmet needs and a diminished quality of life. Findings include: A review of the facility's policy titled Care Plan Policy, revised April 10, 2024, revealed a Policy Statement of Each resident will have a person-centered plan of care to identify problems, needs, and strengths that will identify how the facility will provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The Standards of Practice section stated, 12. The plan of care is to be reviewed and updated as necessary at the completion of every assessment by the interdisciplinary team and resident representative party if so desired. A review of R56's Quarterly Minimum Data Set (MDS) assessment, dated 3/6/2024, revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating no cognitive impairment), Section H documented no indwelling urinary catheter. A review of the care plan revealed a Focus area of [resident name] has an indwelling catheter. Goal and interventions were in place for an indwelling urinary catheter, and the last revision date was 9/20/2023. A review of the active Physician Orders revealed there was no order for an indwelling urinary catheter. An interview on 4/21/2024 at 9:20 am with Registered Nurse (RN) HH/MDS Director revealed she and the MDS Coordinator gathered information to update care plans by interviewing residents, reviewing their medication list, reviewing the clinical record, if the resident was not cognitive and could not be interviewed, they talked with staff for residents' functional mobility and behaviors, and discussed residents in the morning meetings. She stated care plans were updated quarterly, annually, with a change in condition, and as needed. She confirmed care plan revisions were behind. A continued interview revealed RN HH/MDS Director stated she was unaware of R56's urinary catheter being removed. During an observation on 4/21/2024 at 9:45 am, inside R56's room, RN HH/MDS Director confirmed R56 no longer had a urinary catheter. She stated the catheter must have been removed recently. R56 stated that staff took his catheter out five months ago in November 2023. An interview on 4/21/2024 at 10:58 am with the Director of Nursing (DON) revealed care plans must be completed and revised in a timely manner. She stated care plans were reviewed and updated quarterly and annually, with changes in condition and as needed. She confirmed that R56's urinary catheter was discontinued and removed on 11/1/2023. The DON stated her expectation was that care plans be revised and updated as indicated when changes in condition warrants.

Based on observation, resident and staff interviews, record review, and review of the facility's policy titled Nail Care (Finger and Toe), the facility failed to obtain a podiatry appointment for one resident (R) (R39) of 37 sampled residents. This deficient practice had the potential to cause R39 unnecessary discomfort and decreased quality of life. Findings include: Review of the facility's policy titled Nail Care (Finger and Toe), last reviewed April 1, 2024, revealed the section titled Standard of Practice stated, 4. Stop and report any evidence of ingrown toenails, infection, pain, or if nails are too hard or thick to cut with ease. The Step and Action section stated, 24. Report the condition of the resident's nails: . Complaints or problems with hands or feet. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) score of 15 (indicating intact cognition), and Section GG (Functional Abilities and Goals) revealed R39 was dependent on staff for all Activities of Daily Living (ADL). In an interview on 4/19/2024 at 8:57 am, R39 asked about seeing the Podiatrist to get her nails clipped and stated she had asked staff, but no one had made her an appointment. Observation of R39's left foot revealed the left great toe had a thick, long toenail with jagged edges. In an interview on 4/20/2024 at 9:30 am, R39 revealed she spoke with the Social Worker the previous day, and the Social Worker was supposed to make an appointment for her to see the Doctor to get her toenails on her left foot taken care of. In an interview on 4/20/2024 at 10:00 am, the Social Services Director (SSD) revealed that R39 spoke with her on 4/19/2024, asking to be put on the list to see the Podiatrist to have her toenails trimmed. The SSD stated the staff who assisted R39 with bathing had not told her the resident needed to see the Podiatrist nor had R39 asked to see the Podiatrist until 4/19/2024. The SSD stated she relies on staff, residents, and family members to let her know when someone needs to see the Podiatrist and that R39 fell through the cracks. In an interview on 4/20/2024 at 10:25 am, R39 revealed she had told a Certified Nursing Assistant (CNA) that she needed her toenails trimmed, but no one had spoken with her about the need before 4/19/2024. In an interview on 4/20/2024 at 10:35 am, CNA DD revealed she informs the nurse when she identifies a need for a resident to see a Podiatrist. She revealed she informed a nurse a few weeks ago that R39 needed to see a Podiatrist and further stated she had also informed the SSD that R39 asked to see her about making a podiatry appointment.

Based on observations, staff interviews, record review, and review of the facility's policies titled Tracheostomy Policy, Emergency Management, Tracheostomy Care and Services, and Oxygen Therapy Policy, the facility failed to ensure two residents (R) (R71 and R14) had a written physicians order for the tracheostomy tube sizes in use. In addition, the failed to ensure respiratory supplies for R71 were available at the bedside. Additionally, the facility failed to ensure two residents (R24 and R4) receiving oxygen (O2) therapy had written physician orders for oxygen use, ensure oxygen was administered as ordered by the physician, and failed to ensure oxygen concentrator filters were free of dust and debris. The deficient practices had the potential to place the residents at risk for medical complications, unmet needs, and a diminished quality of life. The sample size was 37 residents. Findings include: Review of the facility's policy titled Tracheostomy Policy, Emergency Management, dated March 2024, revealed the Policy Statement Purpose stated, The main purposes of this clinical practice guideline is to ensure the care of residents with a tracheostomy is consistent with the residents' goals of care along with the prevention and identification of complications, such as accidental decannulation and occluded tracheostomies. Continued policy review revealed the Policy Interpretation and Implementation section stated, In case of emergency tracheostomy tube dislodgement (decannulation) appropriate supplies and equipment to be kept at the bedside and/ or immediately accessible; the this includes times when the resident is being transported from unit to unit or any time the resident leaves the facility. Review of the facility's policy titled Tracheostomy Care and Services, dated April 1, 2024, revealed the Policy Statement stated, The facility must provide consistent implementation of all aspects of care related to provision of tracheostomy care and services, in accordance with accepted professional standards of practice, including emergency interventions as appropriate. A care plan must be developed and implemented to include appropriate interventions for respiratory care. The facility must develop an individualized care plan based on the resident's assessment. Review of the facility's policy titled Oxygen Therapy Policy, dated April 2024, revealed the Standard of Practice section stated, 1. Oxygen therapy is to be used with a written order by a physician. A physician's order for O2 therapy is to contain liter flow per minute via mask or cannula. On an emergency basis, O2 may be used at 2 liters per minute until physician is notified. 1. Review of R71's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Section O (Special Treatments, Procedures, and Programs) documented that R71 received oxygen therapy, required suctioning, required tracheostomy care, and had an invasive mechanical ventilator. Review of the medical record for R71 revealed the resident's diagnoses included, but were not limited to, anoxic brain damage, chronic respiratory failure, chronic obstructive pulmonary disease, and encounter for attention to tracheostomy. Review of R71's Physician Orders revealed there was no order for the tracheostomy tube size. Review of the care plan revealed a Focus area of the resident has a tracheostomy related to chronic respiratory failure and anoxic brain damage. The Goal indicated that the resident would have no signs and symptoms of infection through the review date. Interventions included ensuring that trach ties are secured at all times, giving humidified oxygen as prescribed, providing good oral care daily and as needed, and suctioning as necessary. Observation on 4/19/2024 at 9:43 am of R71's room revealed no tracheostomy supplies were visible at the bedside. An interview on 4/19/2024 at 10:56 am with Licensed Practical Nurse (LPN) CC revealed sterile water, a tracheostomy cleaning kit, and suctioning supplies were usually kept at the bedside. LPN CC also revealed that the resident's replacement tracheostomy tube was kept in the supply or medication room. An interview on 4/19/2024 at 11:30 am with the Director of Nursing (DON) revealed that a Respiratory Therapist (RT) comes to the facility weekly on Wednesday to see residents who have a tracheostomy. During the interview, it was determined that the supplies that should be stored at the residents' bedside were a resuscitator, oxygen, suction machine, and a replacement tracheostomy tube, specifically one of the size that was inserted and one of the next smaller size. During the interview, the DON revealed that Central Supply staff was responsible for ensuring the supplies were at the resident's bedside and were replenished weekly. Further interview with the DON revealed R71's tracheostomy tube was downsized by the RT on 4/17/2024 from a 7.5 millimeter (mm) to a 6.5 mm size. During the interview, the DON confirmed that there was no written physician's order for R71 documenting the resident's tracheostomy tube size of 6.5 mm or that the resident had a written order for the previous tracheostomy size of 7.5 mm. She stated the RT does not write the orders for tracheostomy residents and further stated the RT would notify the charge nurse of the changes made, and the charge nurse was responsible for ensuring the order was written and placed in the residents' medical records. Observation on 4/19/2024 at 11:35 am with the DON of R71's tracheostomy supplies revealed a resuscitator was observed in the second drawer of the resident's dresser. There were no suction kits or gauze. However, a replacement tracheostomy tube one size below was visible in the room. The DON confirmed the observations. An interview on 4/19/2024 at 11:45 am with the Central Supply Clerk (CSC) revealed that she was responsible for ensuring supplies for tracheostomy residents were stocked at their bedside. The CSC stated the supplies were replenished once a week on Wednesday when the RT informed her what was needed for each resident. During the interview, she revealed that there was no documentation to indicate what size tracheostomy tube each of the tracheostomy residents needed. Further interview revealed that R71's respiratory supplies were not restocked this week due to the CSC being off on Wednesday, and there was no other staff member in the facility who restocked the respiratory supplies. An interview on 4/19/2024 at 1:00 pm with the RT revealed that she visits the facility weekly on Wednesday to see residents who have tracheostomies. She also stated that R71's tracheostomy was downgraded to a smaller size of 6.5 mm on 4/17/2024. During the interview, it was revealed that the RT does not write physician orders for the residents, and when changes are made for the tracheostomy residents, the charge nurse is notified so they can write the orders. 38991 2. Review of R14's Quarterly MDS assessment dated [DATE] revealed Section I (Active Diagnoses) documented diagnoses including, but not limited to, respiratory failure, and Section O (Special Treatments and Programs) documented the resident received oxygen, suctioning, and tracheostomy care. Review of the electronic medical record (EMR) revealed a physician order dated 10/2/2023 for an 8 mm tracheostomy tube. Observations on 4/19/2024 at 10:03 am and 4/20/2024 at 7:45 am revealed tracheostomy supplies were in R14s room, including a 7.5 mm tracheostomy kit, 6.0 mm inner cannulas, gauze, tape, a resuscitator, sterile water, gloves, suction catheters, and tracheostomy cleaning kits. An interview on 4/20/2024 at 8:00 am with LPN EE revealed that R14's tracheostomy tube size was 7.5 mm, and the inner cannula size was 6 mm. She reviewed the physician's orders in the EMR and confirmed that the orders for tracheostomy sizes were dated 4/19/2024. LPN EE reviewed R14's discontinued physician's orders in the EMR and confirmed there were no previous orders for the tracheostomy tube size of 7.5 mm. An interview on 4/21/2024 at 8:40 am with the DON revealed that the RT changed R14's tracheostomy tube and inner cannula sizes on 4/17/2024. She stated the process for documenting orders for changes in tracheostomy tube and inner cannula sizes was for the RT to inform the nurse of the changes, and the nurse was responsible for putting the orders in the EMR. She further stated the change on 4/17/2024 was not put in as a physician's order and that she had put the order in on 4/19/2024. 45813 3. Review of the medical record revealed R4 had diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and obesity. Review of the quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Review of R4's Physician Orders dated April 2024 revealed orders for oxygen at 2 liters per minute via a mask or nasal cannula as needed for oxygen saturation (SPO2) less than 92 percent. If ineffective, notify physician as needed for shortness of breath (SOB), add humidification water bottle to oxygen concentrator for humidification, fill with distilled water, and check SP02 every shift, notify physician if less than 92 percent every shift related to chronic obstructive pulmonary disease. Review of the oxygen saturations in the EMR under the Vital Signs tab revealed no documented oxygen saturations less than 92 percent. Review of the April 2024 Medication Administration Record (MAR) revealed there was no documentation of R4 receiving oxygen. Further review of the MAR revealed all oxygen saturations documented were greater than 92 percent. Observation on 4/19/2024 at 9:37 am revealed R4 with oxygen on via a nasal cannula at 3 liters per minute (LPM) via an oxygen concentrator. There was no humidification bottle attached to the concentrator. Observation revealed the oxygen concentrator filter had a white/light grey fuzzy substance on the vent covering the filter, and the concentrator had an accumulation of a light grey fuzzy substance and a white substance along both sides and the front. Observations on 4/20/2024 at 8:27 am and 12:20 pm revealed R4 with oxygen on via a nasal cannula at 2 LPM via an oxygen concentrator. Further observations revealed the concentrator still did not have a humidification container. The concentrator continued to be dirty, and the vent covering the concentrator's filter continued to have a white/light grey fuzzy substance. An interview on 4/20/2024 at 8:27 am with R4 revealed that she wears oxygen most of the time and only removes it during mealtimes. An interview on 4/20/2024 at 12:28 pm with Certified Nurse Aide (CNA) FF revealed that she ensures R4 is wearing the oxygen. CNA FF further stated R4 wears oxygen at all times and can't go without it. Interview and observation on 4/20/2024 at 12:48 pm with LPN GG verified that R4's oxygen concentrator did not have a humidification bottle and should have one since there was an order for one. LPN GG verified the dirty filters and the unclean concentrator. She further stated that R4 wears oxygen at all times, and she checks her oxygen saturation daily. LPN GG verified the current physician's order for oxygen was for it to be given as needed at 2 LPM if oxygen saturations were 92 percent or less. LPN GG stated that R4's oxygen saturation was 97 percent today when it was checked, and according to the current order, the resident should not be wearing the oxygen. LPN GG further stated she was unsure who was responsible for cleaning the concentrator and the filters. During an interview and walking rounds on 4/20/2024 at 1:04 pm with the DON, she verified the oxygen concentrator to be dirty, the filters were not clean, and the oxygen was not humidified. The DON further stated she was not sure who was responsible for cleaning the filters but thought maybe it was the Maintenance Director. The DON verified the current oxygen order was not being followed. She verified there were no documented oxygen saturations of 92 percent or below to indicate the use of the oxygen according to the current order. The DON stated that the nurses should check the orders to ensure they were correct and being followed. An interview on 4/20/2024 at 1:36 pm with the Maintenance Director revealed the oxygen concentrator filters were not cleaned on a routine basis and stated he only changes and cleans them if there is a work order for it. A follow-up interview on 4/21/2024 at 9:30 am with LPN GG revealed she was aware that as-needed (PRN) oxygen should be documented on the MAR. She further stated that she did not notice that it was not being documented because the oxygen saturations were being documented daily. A follow-up interview on 4/21/2024 at 9:34 am with the DON revealed the nurses are required to sign off oxygen use on the MAR for continuous and PRN use of the oxygen. 4. Review of the medical record revealed R24 had diagnoses including, but not limited to, chronic combined systolic (congestive) and diastolic heart failure, cardiomyopathy, COPD, and presence of automatic (implantable) cardiac defibrillator. Review of the Quarterly MDS assessment dated [DATE] revealed Section C (Cognition) documented a BIMS of 15 (indicating little to no cognitive impairment). Review of R24's care plan, initiated on 2/1/2024, revealed that the resident had an altered respiratory status/difficulty breathing due to COPD with congestive heart failure (CHF). Interventions included checking oxygen saturations as ordered and providing oxygen as indicated. Review of the active Physician Orders dated 4/20/2024 revealed no order for oxygen therapy. Observations on 4/19/2024 at 8:52 am and on 4/20/2024 at 8:12 am and 12:56 pm revealed the filter vent on R24s oxygen concentrator had a large accumulation of light grey fuzzy substance and the concentrator was dirty. Further observation revealed the concentrator was turned on with oxygen flowing, and the nasal cannula was lying on the bedside table. An interview on 4/20/2024 at 1:12 pm with R24 revealed that he uses oxygen as needed due to having COPD and a pacemaker. R24 further stated he takes the oxygen off and on whenever he needs it. He stated that he had used the oxygen since admission to the facility. During walking rounds and interview on 4/20/2024 at 1:20 pm, the DON verified R24 had used oxygen in the last year. The DON verified the nasal cannula on the table, the dirty filter, and the dirty concentrator. She verified that R24 did not have a current physician's order for oxygen and stated there should be a physician's order if the resident is receiving oxygen. The DON further stated that R24 was recently sent to the hospital, and the oxygen order was not added back upon readmission to the facility. An interview on 4/20/2024 at 1:33 pm with CNA DD revealed she had observed R24 wearing oxygen. An interview on 4/20/2024 at 1:37 pm with LPN CC revealed that R24 uses oxygen as needed for shortness of breath. LPN CC further stated she was not sure who was responsible for cleaning the filters on the concentrators. She verified R24's oxygen order was discontinued on 4/10/2024 and there was no current physician's order for oxygen administration. Cross- reference F656

Based on observation, staff interview, record review, and review of the facility's policy titled Enteral Nutrition Policy, the facility failed to provide enteral (a method of supplying nutrients directly into the gastrointestinal tract) nutrition according to physician orders for one resident (R) (R54) of 10 residents receiving enteral feeding in the facility. This deficient practice placed R54 at risk for medical complications and a diminished quality of life. Findings include: Review of the facility's policy titled Enteral Nutrition Policy, last reviewed April 16, 2024, revealed the Policy Statement included Adequate nutritional support through enteral feeding will be provided to residents as ordered. Review of R54's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed section K (Swallowing and Nutrition) documented R54 received tube feeding while a resident in the facility. Review of the medical record revealed R54's diagnoses included, but were not limited to, cerebrovascular accident, dysphagia, type 2 diabetes, and mild protein-calorie malnutrition. Review of R54's Physician Orders revealed an order dated 4/1/2024 for enteral tube feeding for continuous formula Nepro (a nutritional product administered for nutritional support) at 65 cubic centimeters (cc) per hour for 22 hours. Review of R54's Medication Administration Record (MAR) for April 19, 2024, revealed that R54 was administered Nepro tube feeding daily. Observation on 4/19/2024 at 9:00 am of R54 revealed that Glucerna (a nutritional product administered for nutritional support) enteral tube feeding was being administered via a pump at 65cc per hour. Observation of R54 on 4/19/2024 at 3:15 pm with the Director of Nursing (DON) cothnfirmed that Glucerna tube feeding was being administered instead of the Nepro tube feeding formula that was ordered by the physician. She stated the nursing staff administered the wrong tube feeding product and that the resident should have been receiving Nepro. She further stated she would have the nursing staff administer the correct tube feeding. Cross-Reference F656

Based on staff and resident representative interviews, record review, and review of facility policies titled Resident Grievance Policy, and Resident Rights, the facility failed to appropriately resolve a resident's grievance related to lost personal items and keep the resident informed of the progress towards resolution for one resident (R) (R2) of 15 sampled residents. Findings include: A review of the facility policy titled Resident Grievance Policy, with the last review date of December 2021, revealed the policy statement: The intent of this policy is to support each resident's right to voice grievances of any nature with the assurance that the facility actively seeks a resolution and keeps the resident appropriately apprised of its progress towards resolution. The Procedure section, line number 1 stated: The facility must provide each resident with documentation of the grievance process. Line number 3. The grievance process must include: d. The grievance review period will be completed within 72 hours unless an explanation is provided to the individual as to why the review period requires an extension period; e. The resident has the right to receive a written decision regarding the grievance. 4. The facility will designate a grievance officer who will be responsible for: overseeing the grievance process, receiving, and tracking grievances through to their conclusions. A review of the facility policy titled Resident Rights, revised October 20, 2022, revealed the section titled Resident Rights line number 35 stated: The resident has the right to, and the facility must make prompt efforts to resolve resident grievances, including those with respect to the behaviors of other residents. A review of R2's Admission Minimum Data Set (MDS) dated [DATE], revealed section C (Cognition) documented a Basic Interview for Mental Status (BIMS) score of 2 (indicating severe cognitive impairment). A review of the facility's grievance logs for January 2023 through January 2024 did not show any grievances for R2. In an interview on 2/7/2024 at 4:22 pm, R2's resident representative, who was the complainant, revealed she had spoken to multiple persons at the facility about the concerns she had on behalf of R2. She stated his dentures and clothing were lost and were still not recovered. She stated that after no resolve, she began to take his clothing home to laundry it. A review of the EMR Progress Notes, revealed an entry dated 1/15/2023 at 9:06 am by Licensed Practical Nurse (LPN) LL, which documented that the resident's granddaughter asked about the resident's clothing and documented that a grievance form was completed. In an interview on 2/14/2024 at 1:00 pm, the Administrator verified there were no grievances documented for R2. The Administrator stated that if the resident or family had a grievance, the grievance process should be followed. The administrator confirmed and agreed that no grievance was processed for R2. In an interview on 2/14/2024 at 1:25 pm, LPN LL revealed that she did recall the resident and the granddaughter visiting the resident. She stated that if she entered a progress note about the grievance it would then be handled by the Social Worker or Administrator.

Based on staff and resident representative interviews, record review, and review of the facility policy titled Incident Report-Documentation, Investigating, and Reporting, the facility failed to ensure a reportable incident for one of 15 sampled residents (R) (R8) to the State Agency (SA) in a timely manner. Specifically, the facility failed to report an incident of a mechanical device failing to operate and hitting R8 in the face. Findings include: A review of the facility policy titled Incident Report-Documentation, Investigating, and Reporting, with a revision date of November 2022, revealed the Policy Statement stated: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Procedure section line numbered 4 stated: The Administrator or Director of Nursing will notify the appropriate Regulatory Agency in the event the incident is reportable. A review of R8's Quarterly Minimum Data Set (MDS) dated [DATE] revealed section G (Functional Status) documented that the resident was coded as total dependent for all transfers. A review of R8's care plan revealed the resident required total care assistance for all Activities of Daily Living (ADLs) and required the use of a mechanical lift for transfers. Diagnoses included but were not limited to, a stroke with hemiplegia, morbid obesity, and difficulty walking. A review of the resident's Lift Evaluation Form under the assessments tab in the electronic medical record (EMR) dated 1/14/2023 revealed the resident required a total body lift transfer. A review of the Progress Notes in the EMR revealed an entry made by Licensed Practical Nurse (LPN) NN on 2/22/2023 at 10:04 am documented the aide reported to her that the lift tilted over while placing the resident in the wheelchair and the mechanical lift handle hit the resident on the nose and mouth. The LPN documented an assessment of the resident as having no visible injuries, notified the medical doctor and the resident's daughter, and the resident was sent to the hospital. A review of the facility's internal investigation report, dated 2/22/2023 at 9:53 am, revealed that the injury did occur, that the resident was assessed as not having any visible injuries, that the resident did complain of having pain to her face, and was sent to the emergency room for evaluation. In an interview on 2/7/2024 at 2:00 pm, the complainant, who is the resident's daughter, revealed that her sister was contacted about the incident of her mother getting hit in the face by the mechanical lift. The complainant revealed that her mother was sent to the hospital and was injured by the lift incident, but she was unsure of the extent of the resident's injury. In an interview on 2/12/2024 at 2:40 pm, the Administrator revealed an investigation was conducted, but could not find documentation of self-reporting to the SA. In an interview on 2/12/2024 at 2:50 pm, LPN NN stated that the incident was reportable and was reported to the Administrator and the Director of Nursing (DON). She stated she was unsure if the Administrator reported the incident to the state, and stated she did recall the facility doing an investigation. In an interview on 2/12/2024 at 4:45 pm, Certified Nursing Assistant (CNA) SS stated she was one of the aides helping with the transfer of the resident when the mechanical lift handle snapped while transferring the resident, and she further stated the handle of the lift hit the resident in the face. She stated she immediately reported the incident to the charge nurse.

Based on observations, record review, interviews, review of the facility policies, and review of Centers for Disease Control and Prevention (CDC) guidance, the facility failed to implement effective infection control program to prevent the spread of infections. Specifically, the facility failed to follow isolation procedures; facility failed to ensure signage was posted for use of personal protective equipment (PPE) and failed to ensure that PPE was worn appropriately on two of two Halls (North Hall and South Hall) to prevent the spread of [CONDITION(S)]-CoV-2 infection. Findings include: Review of CDC guidance, dated [DATE], indicated . HCP [Health Care Professional] caring for residents with suspected or confirmed [CONDITION(S)]-CoV-2 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html. Review of a policy provided by the facility titled Infection Prevention and Control Program Overview, revised date of [DATE], indicated . Prevention of spread of infections is accomplished by use of hand hygiene, standard precautions and other barriers . On [DATE] at 7:30 a.m. upon entry to the facility, surveyors were screened by Admissions Director. Admissions Director noted to be wearing a surgical mask and no eye protection. A tour of the North Hall was conducted on [DATE] at 7:52 a.m. An isolation cart was observed outside Room N17 (middle of the N Hall) but there was no signage on the door. During an interview with the Activities Director at that time, she stated that the two residents in Room N17 were positive for COVID-19. One resident was observed to open door and stand at the door with no mask on. The resident walked back into the room and the door remained open. Certified Medication Aide (CMA) YY was observed passing medications by Room N17 and did not close the door. She stated that this is not an isolation area; that it is a general area. She confirmed that the two residents in Room N17 were positive for COVID-19 and are isolated to that room. She stated that she worked Friday ([DATE]) and the residents were not on isolation but when she returned on Tuesday ([DATE]) the isolation cart was there. She and other staff in the area were observed not wearing face shields or eye protection. On [DATE] at 8:03 a.m. there was signage indicating Transmission Based Precautions (TBP) for the resident in Room P2 and the door was open. A tour of the South Hall on [DATE] at 8:05 a.m. revealed Room S3 and S19 with PPE outside the doors and no signage. On [DATE] at 8:06 a.m. the door to room P8 (Isolation room for COVID) was open and there was PPE outside of the door. Resident was observed in bed asleep. On [DATE] at 9:03 a.m. two Housekeeping (HSK) staff observed with N95 mask on but no face protection. On [DATE] at 9:15 a.m. revealed CMA YY, wearing an N95 mask but no eye protection. On [DATE] at 9:17 a.m. Admissions Director observed on North Hall with no eye protection. On [DATE] at 9:18 a.m. a laundry aide was noted with an N95 mask on just below her nose and no eye protection. On [DATE] at 9:19 a.m. Room S19 had the door cracked open and PPE was observed outside the door. There was no signage on the door. Staff CNA FFF was observed to enter Room S19 with only a face mask and close the door. She exited the room within a few minutes and proceeded down the hall. During an interview, at that time, she stated she knows she was supposed to put on PPE before going in the room but confirmed that she didn't. She said, I know that's what you got me for. On [DATE] at 9:25 a.m. a family member was observed to enter Room S19 without placing on any PPE. Staff was heard saying that they needed to leave the room because they were providing care. During an interview with the family member at that time, they were asked if they knew what that equipment on the door was for and they said that they guessed the staff puts that out for themselves periodically. Again, there was no signage on the door with instructions. On [DATE] at 1:13 p.m. CNA NN, observed on North Hall with N95 and no eye protection. On [DATE] at 7:46 a.m. CNA XX observed delivering breakfast tray to COVID positive resident in room P7. CNA noted to wear gown, gloves, N95, but did not wear any eye protection. The door remained open in the room until 7:48 a.m. On [DATE] at 7:52 a.m. CNA XX was observed going into (isolation room for COVID positive resident) Room P8 to deliver breakfast tray to resident. The door in this room remained opened until 8:01 a.m. At 7:55 a.m. CNA NN assisted CNA XX with pulling resident up in bed. Both CNAs wore N95 masks, gowns, and gloves. Neither CNA NN or CNA XX were observed wearing eye protectants. On [DATE] at 9:50 a.m. in Room N4 the door was noted to be open with a Stop sign across the door. There was no PPE on the door or indication that resident had been exposed. (Roommate tested COVID positive on [DATE] and moved to room N6). On [DATE] at 9:59 a.m. facility staff was observed placing signage and PPE on multiple doors throughout the facility. On [DATE] at 7:29 a.m. Dietary staff observed pushing food cart down hallway to North Unit with goggles on top of head. During interview on [DATE] at 2:40 p.m. with CNA XX it was reported that she was aware that she should have worn eye protection (goggles) this morning when passing meal trays but forgot to do so. CNA XX reported that when entering the COVID positive rooms she should wear goggles, gloves, gowns, and masks. She reported that the facility has more than enough PPE for usage, and she actually has two pairs of goggles in her car. CNA noted to be wearing goggles and N95 mask at this time. During an interview with the Infection Control Preventionist (ICP) (who is also the Staff Development Coordinator) on [DATE] at 8:41 a.m. she provided a list of residents in the building who were tested and confirmed positive for COVID-19. It was confirmed that residents in Rooms S3, S19, P2, P8 and N17 were positive for COVID-19. An interview was conducted with the ICP, the Regional Director of Clinical Operation (RDCO) and the Director of Nursing (DON) on [DATE] at 10:18 a.m. The ICP stated that residents positive for COVID-19 are isolated in place in their rooms. Those residents with exposure are placed in the Person Under Investigation (PUI) Room. The PPE and signage are supposed to be placed on the doors outside of those rooms. There is no designated area for persons under quarantine. The DON stated, The waiver has expired for the COVID units so we can quarantine in place. The IPC stated that on [DATE] they began resident and staff testing after a staff tested positive for COVID-19. On [DATE], six residents tested positive. No additional staff tested positive on that day. When asked if there was documentation of room changes and PUI rooms for the purposes of tracking and trending, the IPC stated that she does not keep track of the room changes or take documentation of the room changes. The ICN and the DON stated that that information is in each resident's individual clinical record. The IPC confirmed that as on [DATE], there were 13 residents positive for COVID-19 and seven residents PUI. III. Observations: 1. On [DATE] at 7:30 a.m. upon entry to the facility surveyors were screened by Admissions Director. Admissions Director noted to be wearing a surgical mask and no eye protection. 2. On [DATE] at 8:03 a.m. there was signage indicating TBP for the resident in room P2 and the door was open. 3. On [DATE] at 8:06 a.m. the door to room P8 (Isolation room for COVID) was open and there was PPE outside of the door. Resident was observed in bed asleep. 4. On [DATE] at 9:03 a.m. two housekeeping (HSK) staff observed with N95 mask on but no eye protection. 5. On [DATE] at 9:15 a.m. revealed Medication Aide YY, wearing an N95 mask but no eye protection. 6. On [DATE] at 9:17 a.m. Admissions Director observed on North Hall with no eye protection. 7. On [DATE] at 9:18 a.m. a laundry aide was noted with an N95 mask on just below her nose and no eye protection. 8. On [DATE] at 1:13 p.m. CAN NN was observed on North Hall with N95 mask on and no eye protection. 9. On [DATE] at 7:46 a.m. CNA XX observed delivering breakfast tray to COVID positive resident in room P7. CNA XX noted to wear gown, gloves, N95 mask, but did not wear any eye protection. The door remained open in the room until 7:48 a.m. 10. On [DATE] at 7:52 a.m. CNA XX was observed going into (isolation room for COVID positive resident) Room P8 to deliver breakfast tray to resident. The door in this room remained opened until 8:01 a.m. At 7:55 a.m. CNA NN assisted CNA XX with pulling resident up in bed. Both CNAs wore N95 masks, gowns, and gloves. Neither CNA NN or CNA XX were observed wearing eye protection. 11. On [DATE] at 9:50 a.m. in Room N4 the door was noted to be open with a Stop sign across the door. There was no PPE on the door or indication that resident had been exposed to COVID by roommate on [DATE]. 12. On [DATE] at 7:29 a.m. Dietary staff observed pushing food cart down hallway to North Unit with goggles on top of head. During interview on [DATE] at 2:40 p.m. with CNA XX it was reported that she was aware that she should have worn eye protection (goggles) this morning when passing meal trays but forgot to do so. CNA XX reported that when entering the COVID positive rooms she should wear goggles, gloves, gowns, and masks. She reported that the facility has more than enough PPE for usage, and she actually has two pairs of goggles in her car. CNA noted to be wearing goggles and N95 mask at this time.

Based on observation, interview and review of the facility's policy, the facility failed to ensure an expired medication was not available for use and that controlled substances (narcotics) were stored under double lock in one (1) of one (2) medication refrigerators. Findings include: Observation on 7/30/22 at 4:02 p.m. of the Medication Storage Room, located behind the nurse's station on South Wing, with Licensed Practical Nurse (LPN) BB, revealed that the medication refrigerator does not have a lock in place. The refrigerator contained narcotics to include four bottles of [MEDICATION(S)] oral concentrate solution and one blister/bubble pack containing 12 [MEDICATION(S)] 2.5 milligrams (mg) capsules. There is also one expired vial of [MEDICATION(S)] vaccine ([MEDICATION(S)] Purified Protein Derivative- Mantoux) with an open date of 6/26/22 in the refrigerator. The manufacture instructions on the box read Date the [MEDICATION(S)] vial when opening and discard it after 30 days. The expiration date calculated with LPN BB to be 7/26/22. There is a huge buildup of ice in the refrigerator. On 7/30/22 at 4:11 p.m. during an interview LPN, Unit manager (UM) CC stated that she has worked at the facility for three months and there has not been a lock on the medication refrigerator since she has been at the facility. LPN, UM CC stated that the medication refrigerator has not been defrosted in about three months as well. LPN UM DD further stated that the Director of Nursing (DON) is aware the medication refrigerator containing narcotics does not have a lock because she informed her that the narcotics should be under double locks. On 7/30/22 at 4:33 p.m. during an interview with DON, she stated that she is aware that that the narcotics should be under double locks. She stated that she had been aware that medications were not under double locks since May 2022, but she just had not gotten around to ensuring the lock was placed on the medication refrigerator. DON stated that the night nurses are responsible for checking the refrigerator for expired medications and defrosting the refrigerator. Review of facility policy titled Controlled Substances Date of issue November 2016, Reviewed October 1, 2021, reads; the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule ll and other controlled substances. Facility failed to provide surveyor with policy on expired medications as requested.

Based on record review and staff interview, the facility failed to attempt to obtain background checks for eight of 11 files reviewed and reference checks for nine of 11 employee files reviewed. Findings include: Review of the employee files with the Human Resources (HR) representative began on 7/31/22 at 11 a.m. It was determined that there were no background checks for staff who did not require completion of the GCHEXS (fingerprint background check). In addition, there were also no reference checks completed for nine of the 11 staff reviewed. 1. Director of Nursing (DON) started on 4/12/22 and no evidence of a background check and no references. 2. Certified Nursing Aide (CNA) BBB started on 3/3/22 and no evidence of a background check and no references. 3. Medication Aide YY started on 6/21/22 and no evidence of a background check and no references. 4. CNA CCC started on 6/18/22 and no evidence of a background check and no references. 5. Medication Aide DDD started on 7/25/22 and no evidence of a background check and no references. 6. CNA EEE started on 7/25/22 and no references. 7. Maintenance Director started on 7/25/22 and no evidence of a background check and no references. 8. Licensed Practical Nurse (LPN) ZZ started on 6/29/22 and no evidence of a background check and no references. 9. Occupational Therapist (AAA) started on 6/9/22 and no evidence of a background check and no references. During the interview with HR she reported that she was informed that a background check was not needed for anyone that was exempt from the fingerprint background check. She reported that if she is unable to get the GCHEXS back quickly that she will get the standard background check to have on file until the GCHEXS can be obtained. HR went on to report that whoever interviews the potential employee is responsible for checking the references, but she was not aware of or did not have evidence of reference checks being completed for anyone but the Administrator.

Based on observations, interviews, and record review the facility failed to (1) ensure the care plan was followed for one of 28 sampled residents (R#35) related receiving oxygen as ordered; (2) failed to develop an Activities of Daily Living (ADL) care plan for one of 28 sampled residents (R#1) related to grooming and dressing; (3) failed to implement an Activities of Daily Living (ADL) care plan for two of 28 sampled residents (R#2 and R#39) related to grooming and dressing; (4) failed to implement the activities care plan for three of three residents (R#1, R#16, R#39) reviewed for activities. Findings include: 1. There was an oxygen order with a start date of 1/31/2020 for: OXYGEN AT (2) LITERS PER (MASK OR NASAL CANNULA) CONTINUOUSLY. Every shift related to ACUTE [CONDITION(S)], UNSPECIFIED WHETHER WITH [CONDITION(S)] OR HYPERCAPNIA. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] R#35 received oxygen therapy. Review of the care plan revealed a focused area related to impaired air exchange related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An intervention of administer oxygen nasal canula as ordered. On 7/29/22 at 11:13 a.m. R# 35 was observed lying in bed with oxygen via nasal canula. The oxygen level was noted to be between on notch between 2 lpm and 4 lpm. On 7/29/22 at 5:14 p.m. R# 35's oxygen observed between 2 lpm and 4 lpm. On 7/30/21 at 5:50 p.m. R# 35 observed in bed wearing oxygen. The oxygen was noted to be between 2 and 4. During an interview on 7/30/22 at 6:35 p.m. with the Director of Nursing (DON) it was confirmed that that oxygen should be administered to residents as ordered and nursing should be checking the oxygen each shift. 2. Admission MDS 4/11/2022 noted R#1 was admitted on [DATE]; BIMS of five. Total assistance for total dependence for dressing and hygiene. On 7/29/22 at 9:00 a.m. R#1 was observed in bed with hospital gown on and was not shaved. On 7/29/22 at 2:32 p.m. R#1 was observed still in bed in hospital gown and was unshaved. A review of the undated Shower Schedule revealed that R#1 shower days was Monday, Wednesday, and Friday. On 7/29/22 at 5:13 p.m. R#1 was observed still in bed in hospital gown and was unshaved. On 07/30/22 from 12:30 p.m. to 4:00 p.m. R#1 was observed in bed in hospital gown and was unshaved. On 7/30/22 at 1:09 p.m. CNA OO stated that she did not shower R#1 but he was provided a bed bath because they need help getting him on a shower bed. She stated that he has a lot of hair on his face but the little razors they have won't get all that hair off his face. On 7/30/22 at 1:12 p.m. CNA MM stated that she has been at the facility for three weeks. She stated that she did not shave R#1 because they need an electric razor. She stated, He bites and that scares me. So no, I didn't shave him. On 7/30/22 at 1:23 p.m. CNA PP stated that she does shave the male residents assigned to her. She stated that she has taken care of R#1 before, and it is hard to shave him because he fights. She stated, We need an electric razor to shave him. When asked if they had an electric razor to shave him, she confirmed that they did not. On 7/31/22 at 8:37 a.m. R#1 was observed in his room, in bed, in hospital gown, being assisted by staff with eating breakfast. He was still not shaved. On 7/31/22 at 4:06 p.m. Interview with the resident's family member, they stated that when they have come to visit R#1, his nails have not been trimmed and that he has not been shaved. They stated that they have asked about this, but the staff stated that the resident fights with them, so they don't do it. They stated that prior to R#1 becoming ill, he did not have a beard and would always be shaved. They would like to see R#1 cleaner when they visit. Care Plan last revised date 4/5/22: No Care Plan for ADL, dressing and grooming. On 7/31/22 at 4:00 p.m. the MDS Coordinator confirmed that there was no ADL care plan for R#1, but she was creating one for him. 3. A review of the Quarterly MDS assessment dated [DATE] revealed that R#2 was admitted to the facility on [DATE]; has a BIMS of eight and requires extensive assistance with dressing and total assistance with grooming. A review of the Care Plan, last revised date of 11/14/19, revealed that R#2 requires assistance with personal hygiene and extensive one person assistance with dressing. On 7/29/22 at 8:50 a.m. R#2 was observed in bed, in hospital gown. On 7/29/22 at 3:08 p.m. R#2 was observed still in bed in hospital gown. On 7/29/22 at 5:13 p.m. R#2 was observed still in bed in hospital gown. On 7/31/22 10:14 a.m. Interview with CNA MM she stated that she was aware she is supposed to sign off on the shower sheets, but she forgot. She confirmed that she has been at the facility for three weeks, but she only works weekends. She stated that they don't have time to give showers, so they give bed baths. She has not given any showers since she has worked at the facility. On 7/31/22 at 3:48 p.m. interview with R#2's family member stated they have had concerns with the staff not providing care. When they visit, they see staff just sitting around on their phones and they aren't doing anything. They stated that R#2 is not getting baths. He has told the family that they just wipe him down, but he is not getting showers. The staff were not shaving him. They have to have family members come to shave him. 4. A review of the Quarterly MDS assessment dated [DATE] revealed that R#39 was admitted to the facility on [DATE]; has a BIMS of four and requires extensive one-person physical assistance with bathing and personal hygiene. A review of the Care Plan, last revised date of 11/29/21, revealed that R#39 requires assist with personal hygiene and bathing/showers three times per week. On 7/29/22 at 9:00 a.m. R#39 was observed in bed with hospital gown on and was not shaved. On 7/29/22 at 2:32 p.m. R#39 was observed still in bed in hospital gown and was unshaved. A review of the undated Shower Scheduled revealed that R#39 shower days was Monday, Wednesday, and Friday. On 7/29/22 at 5:13 p.m. R#39 was observed still in bed in hospital gown and was unshaved. On 7/30/22 from 12:30 p.m. to 4:00 p.m. R#39 was observed in bed in hospital gown and was unshaved. On 7/30/22 at 1:09 p.m. CNA OO stated that she did not shave or shower R#39 yesterday because he was not feeling well. She stated that she let the nurse know. On 7/30/22 at 1:12 p.m. CNA MM stated that she has been at the facility for three weeks. She stated that she gave R#39 a bed bath today when she got him up. When asked why he was not shaved, she said she was just trying to get him up and didn't have time, but she was going to go back and do it today. On 7/31/22 at 8:37 a.m. R#39 was observed in his room. He was still not shaved. 5. A review of the Admission MDS dated [DATE] noted R#1 was admitted on [DATE]; BIMS of five; Activities MDS completed with resident. It was noted that the resident indicated that it was very important for him to go outside when the weather is good and be around animals. A review of the Care Plan for R#1 with last revised date of 4/5/22 noted, When the resident chooses not to participate in organized activities, turn on TV, music in room to provide sensory stimulation. On 7/29/22 at 9:00 a.m. R#1 was observed in his room, in bed. There was no television on or music playing or any signs of activities in the room. On 7/29/22 at 2:32 p.m. R#1 was observed still in bed. There was still no television on or music playing or any signs of activities in the room. On 7/29/22 at 5:13 p.m. R#1 was observed still in bed. There was still no television on or music playing or any signs of activities in the room. On 7/30/22 from 12:30 p.m. to 4:00 p.m. R#1 was observed in his room lying in bed. There were no activities observed for this resident at any time during this observation. 6. Admission MDS 5/16/2022 noted R#16 was admitted on [DATE]; BIMS 15; activities MDS completed with resident. It was noted that the resident indicated that it was very important to do her favorite activities and to go outside when the weather is good. A review of the Care Plan for R#16 revealed resident is dependent on staff for activities cognitive stimulations and social interaction. when resident chooses not to participate in social activities, turn on tv or music or tv sensory simulation. On 7/29/22 from 12:40 p.m. to 1:40 p.m., R#16 was observed slowly self-propelling her wheelchair down the hall. She was alert with confusion. She was observed saying she was ready to get this party started. She kept repeating let's do something. At 1:00 p.m. A staff member wheeled the resident back into her room and left her there. At 1:40 resident was back at the nursing station calling out: Please help me. Please. Ma'am. Come here for a moment. Hand me one of those brooms . Please. Please. The multiple staff members were observed to pass by resident. On 7/29/22 at 1:48 PM South Hall Unit Manager stated that she believes the MDS Assessment completed in May 2022 noting that R#16 had a BIMS of 15 was inaccurate because the resident has always been confused. On 7/29/22 from 12:30 p.m. to 2:00 p.m., R#16 was observed to not have any activity. On 7/30/22 from 12:35 p.m. to 3:30 pm no activities observed for R#16. She was in her room all day. On 7/30/22 at 2:39 p.m. R#16 was observed in room in sitting in a Broda chair. She was hollering out, please help me. No television or music observed on for the resident. On 7/31/22 at 3:00 p.m. R#16 was observed sitting in a wheelchair outside of her room across from nursing station. Was mumbling and talking to herself and attempting to get staff attention as staff walked by. On 7/31/22 at 5:00 p.m. R#16 observed awake in bed staring blankly, with no television of music on. 7. A review of the Quarterly MDS dated [DATE] noted that R#39 was admitted on [DATE]; BIMS 4; activities MDS not completed. A review of the Care Plan for R#39 with last revised date of 9/20/19, documented participation in activities. On 7/29/22 at 9:00 a.m. R#39 was observed in bed with hospital gown. There was no television on or music playing or any signs of activities in the room. On 7/29/22 at 2:32 p.m. R#39 was observed still in bed with hospital gown. There was still no television on or music playing or any signs of activities in the room. On 7/29/22 at 5:13 p.m. R#39 was observed still in bed with hospital gown. There was still no television on or music playing or any signs of activities in the room. On 7/30/22 from 12:30 p.m. to 4:00 p.m. resident was observed in his room. There were no activities observed for this resident. On 7/30/22 at 4:25 p.m. interview with the two CNA QQ and CNA RR, they stated there are never any activities on the weekends. On 7/31/22 at 8:40 a.m. Activities Director she has been acting in that position since January 2022. She stated that she was not trained for this position and has no prior experience. She stated that she does not document any activities for each individual resident. Some residents she provides a copy of puzzle sheets but again that is not documented. She stated that for resident who stay in their beds and who are not alert she will go in and speak to them, but she can't go in all resident rooms every day. She does have a volunteer that comes in and helps but the volunteer has been out with COVID. She stated that with it just being her, she does not feel she can provide and effective activities program but if she had an assistant she could. On 7/31/22 at 2:03 p.m. the Regional Director of Clinical Operation (RDCO) that there was training for the Activities Director but she was not sure of her qualifications. She confirmed that each resident should have individualized activities program and there should be documentation of each residents' activities.

The facility failed to provide an individualized activities program to meet the needs of three of three residents (R#1, R#16, and R#39) reviewed for activities. Findings include: 1. A review of the Admission Minimum Data Set (MDS) dated [DATE] noted R#1 was admitted on [DATE]; BIMS of five; Activities MDS completed with resident. It was noted that the resident indicated that it was very important for him to go outside when the weather is good and be around animals. A review of the Care Plan for R#1 with last revised date of 4/5/22 noted, When the resident chooses not to participate in organized activities, turn on TV, music in room to provide sensory stimulation. On 7/29/22 at 9:00 a.m. R#1 was observed in his room, in bed. There was no television on or music playing or any signs of activities in the room. On 7/29/22 at 2:32 p.m. R#1 was observed still in bed. There was still no television on or music playing or any signs of activities in the room. On 7/29/22 at 5:13 p.m. R#1 was observed still in bed. There was still no television on or music playing or any signs of activities in the room. On 7/30/22 from 12:30 p.m. to 4:00 p.m. R#1 was observed in his room lying in bed. There were no activities observed for this resident at any time during this observation. 2. Admission MDS 5/16/22 noted R#16 was admitted on [DATE]; BIMS of 15; activities MDS completed with resident. It was noted that the resident indicated that it was very important to do her favorite activities and to go outside when the weather is good. A review of the Care Plan for R#16 revealed resident is dependent on staff for activities cognitive stimulations and social interaction. When resident chooses not to participate in social activities, turn on tv or music or tv sensory simulation. On 7/29/22 from 12:40 p.m. to 1:40 p.m., R#16 was observed slowly self-propelling her wheelchair down the hall. She was alert with confusion. She was observed saying she was ready to get this party started. She kept repeating let's do something. At 1:00 p.m., a staff member wheeled the resident back into her room and left her there. At 1:40 p.m. resident was back at the nursing station calling out: Please help me. Please. Ma'am. Come here for a moment. Hand me one of those brooms . Please. Please. The multiple staff members were observed to pass by resident. On 7/29/22 at 1:48 p.m. South Hall Unit Manager stated that she believes the MDS Assessment completed in May 2022 noting that R#16 had a BIMS of 15 was inaccurate because the resident has always been confused. On 7/29/22 from 12:30 p.m. to 2:00 p.m., R#16 was observed to not have any activity. On 7/30/22 from 12:35 p.m. to 3:30 pm no activities observed for R#16. She was in her room all day. On 7/30/22 at 2:39 p.m. R#16 was observed in room in sitting in a Broda chair. She was hollering out, please help me. No television or music observed on for the resident. On 7/31/22 at 3:00 p.m. R#16 was observed sitting in a wheelchair outside of her room across from nursing station. Was mumbling and talking to herself and attempting to get staff attention as staff walked by. On 7/31/22 at 5:00 p.m. R#16 observed awake in bed staring blankly, with no television of music on. 3. A review of the Quarterly MDS dated [DATE] noted that R#39 was admitted on [DATE]; BIMS of four; activities MDS not completed. A review of the Care Plan for R#39 with last revised date of 9/20/19, documented participation in activities. On 7/29/22 at 9:00 a.m. R#39 was observed in bed with hospital gown. There was no television on or music playing or any signs of activities in the room. On 7/29/22 at 2:32 p.m. R#39 was observed still in bed with hospital gown. There was still no television on or music playing or any signs of activities in the room. On 7/29/22 at 5:13 p.m. R#39 was observed still in bed with hospital gown. There was still no television on or music playing or any signs of activities in the room. On 7/30/22 from 12:30 p.m. to 4:00 p.m. resident was observed in his room. There were no activities observed for this resident. On 7/30/22 at 4:25 p.m. interview with the two CNA QQ and CNA RR, they stated there are never any activities on the weekends. On 7/31/22 at 8:40 a.m., Activities Director stated she has been acting in that position since January 2022. She stated that she was not trained for this position and has no prior experience. She stated that she does not document any activities for each individual resident. Some residents she provides a copy of puzzle sheets but again that is not documented. She stated that for resident who stay in their beds and who are not alert she will go in and speak to them, but she can't go in all resident rooms every day. She does have a volunteer that comes in and helps but the volunteer has been out. She stated that with it just being her, she does not feel she can provide an effective activities program but if she had an assistant she could. On 7/31/22 at 2:03 p.m. the Regional Director of Clinical Operation (RDCO) stated there was training for the Activities Director but she was not sure of her qualifications. She confirmed that each resident should have individualized activities program and there should be documentation of each residents' activities.

Based on record review, review of the facility policy titled Abuse Prevention Policy, and staff interviews, the facility failed to ensure one resident (R) (#1) was free from physical abuse from R#12, of five residents reviewed for abuse. Actual harm occurred on 12/30/21 when R#1 sustained a laceration to the right temporal scalp requiring sutures. Findings include: Review of the policy titled, Abuse Prevention Policy dated 9/5/16 indicated the resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment and involuntary seclusion. The policy included a definition of physical abuse as including hitting, slapping, pinching and kicking. R#1 was admitted to the facility on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 12/9/21 Admission Minimum Data Set revealed the resident had no behaviors and was dependent on staff for bed mobility, transfers and was non-ambulatory. Review of the Facility Incident Report Form dated 12/30/21 documented an allegation of resident-to-resident abuse that occurred on 12/30/21 at 2:00 a.m. and was reported by the facility at 3:22 a.m. The form included that the physical abuse involved R#12 sticking R#1 on the head with an assistive device which required R#1 to go to the emergency department. It was documented that the physician, responsible party, and the police were notified. A review of the accompanying investigation that included staff statements and the five-day summary conclusion which noted that on 12/30/21 it was reported to the Administrator that R#12 assaulted R#1 possibly with an oxygen tank. R#1 was found to have a laceration, and bleeding from the head. EMS (Emergency Medical Services) and the police were called, and R#12 was placed on one-to-one observation until he was sent to the hospital with a 1013 (physician order to initiate transport to an emergency receiving facility). R#1 was sent to the ER (emergency room ) and admitted to the ICU (Intensive Care Unit) due to complications related to his new COVID positive status. R#12 remained in the hospital Geri-psych unit and was not readmitted to the facility. Review of the Hospital Records for admitted [DATE] revealed R#1 had a laceration to the right temporal scalp that required sutures. Review of the Electronic Medical Record (EMR) for R#12 revealed the following entries: 11/12/21 Behavior Note documented the resident stated his roommate was plotting to kill him. This is his fourth roommate in the short time he has been here, and, in every case, he starts complaining that his roommates were plotting to kill him. Writer has contacted Social Worker with hospice to inform her of his paranoia. 11/19/21 Progress Note indicated the resident requested another room change. States all the roommates he's had (4) were making plans to kill him and he needs to move. 11/16/21 Hospice Nurse Practitioner Note documented (R#12) has required multiple room changes, some due to delusions that other residents were attempting to murder him. Facility caregivers note increased confusion and agitation, especially in evening/night hours. Medications have required adjustment to address these changes. 11/17/21 Hospice Social Worker (SW) Note documented Facility Social Worker informed Hospice SW earlier that resident will see a psych team member who comes into facility. SW reports resident always says someone is plotting to kill him. Resident has moved around to several rooms due to not being able to get along with other residents. 11/18/21 Hospice Registered Nurse (RN) Note documented patient reported roommate was shouting out all night and patient was not able to get any rest. RN contacted SW to see if there was a way we could get patient moved to another room. 11/27/21 Behavior Note documented resident was angry with roommate wandering in and out of room and refused to open the door. The other nurse on the hall opened the door to talk to resident. The resident was holding some sort of stick and yelled You come in here and I'll knock you out. Roommate was moved to another room. 11/30/21 Hospice Recertification Assessment documented patient behavior has been very labile this period. Patient was restarted on [MEDICATION(S)] 1mg bid (twice per day) for anxiety. However, patient paranoia has increased despite adding [MEDICATION(S)]. Patient has moved rooms several times due to telling staff roommates are trying to kill him. During an interview with Licensed Practical Nurse (LPN) DD on 3/17/22 at 1:18 p.m., she stated that on 11/27/21 R#12 was aggravated about his roommate going in and out of the room. She and another nurse went to his room, and he would not open the door. The other nurse opened the door to talk with the resident and he threatened to hit the nurse with a stick. She stated the stick looked like a homemade walking stick that she had seen before. She stated he was usually sweet and nice. During an interview with the Administrator and the Director of Nursing (DON) on 3/17/22 at 3:20 p.m., they stated they were not made aware of the resident having a walking stick and it was not reported to them on 11/27/21. They were also not aware of the resident saying his roommates wanting to kill him. Hospice and the facility staff did not report this to them. Review (name) Behavioral Service Consultations dated 11/16/21 and 12/7/21 noted there was no evidence of self-harm risk or a risk to others. During an interview with Certified Nursing Assistant (CNA) AA on 3/17/22 at 10:05 a.m., he stated that R#12 came out of his room saying his roommate was making a noise. He told R#12 as soon as he was finished helping a resident across the hall he would come and check on R#1. He stated five minutes later he went to check on R#1 and saw blood on his head and then ran to get the nurse. He further stated that R#12 was short of breath and was sweating like he was high on adrenaline. He stated that R#12 was a little weird and would talk to himself at times but never threatened anybody and he never saw the resident with a stick. During an interview with the Administrator on 3/16/22 at 3:15 p.m., she stated that R#12 never showed any violent behaviors or aggression. R#12 was very friendly, liked to come to the offices and talk with staff and would also sit in the front lobby talking with others. When she came to the facility the next morning there was blood on wall over the head of the bed of R#1 and on the wall at the foot of the bed. She stated that staff thought R#12 used an oxygen tank to hit R#1, but there was no blood on the tank. While she was in the room, she saw a dowel rod sticking out of R#12's laundry basket that was covered with blood on end. She noted it was the dowel rod that was in the resident's closet. During an interview with LPN BB on 3/16/22 at 4:00 p.m., she stated that she could not believe what happened or that R#12 would even do that because he was always so friendly and bubbly. She stated he had a lot of friends in the facility and liked everybody. She never saw him threaten anyone and was never aggressive and agitated. During an interview with LPN CC on 3/17/22 at 11:25 a.m., she stated that night all was quiet when CNA AA came to get her. She stated she called 911 and the police and kept R#12 at the nurse's station with her for one-to-one observation while another nurse helped R#1. She stated R#12 was usually quiet and would sleep through the night. She had never seen him threaten other people and never saw him with a stick.

Based on observation, interview, and record review, the facility failed to ensure two new admissions and readmitted residents (R#5 and R#6) of seven sampled residents were placed in fourteen day transmission based precautions (TBP) for Covid-19 and that staff used personal protective equipment (PPE) when entering a designated TBP room. This failure had the potential to spread communicable diseases throughout the facility's 74 residents. On June 18, 2020 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on June 18, 2020 at 6:45 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on June 12, 2020 and continued through June 18, 2020. An acceptable Immediate Jeopardy Removal Plan was validated on June 19, 2020. The immediate jeopardy is outlined as follows: The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. §483.80(a) Infection Prevention and Control Program (F880, Scope/Severity: J). The facility failed to ensure two of six new and/or readmitted residents (R#5 and R#6) had two negative Covid-19 tests prior to admission/re-admission and/or were placed in quarantine isolation for 14 days after admission/re-admission to the facility in the past two weeks; and that staff were utilizing the appropriate personal protective equipment (PPE) when entering a room with transmission based isolation precautions posted. This failure to quarantine isolation the new/re-admission residents and use appropriate PPE had the potential to negatively affect all 74 residents and constituted an immediate jeopardy at F880. An Immediate Jeopardy Removal Plan was received on June 19, 2020. Based on observations, record reviews, interviews and review of the facility's policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on June 19, 2020. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of resident admission/readmission procedures to ensure proper quarantine isolation and use of appropriate PPE. This oversight process included the analysis of facility staffs' conformance with the facility's Policies and Procedures governing the appropriate transmission-based precautions and staff compliance with isolation PPE. Observations verified that the new/readmitted residents were placed in private rooms, droplet/contact isolation signage was in place, and PPE supplies were at each room entrance. Review of revisions to the admission policy showed new and readmitted residents would be placed in quarantine isolation. Interview with facility staff revealed they had received education regarding the need for quarantine isolation for new/readmitted residents and were aware of the required droplet isolation PPE required. Findings include: In an entrance conference on 6/18/20 at 9:30 a.m., the Director of Nursing (DON) stated there were no current Covid-19 positive residents or residents under investigation for the Covid-19 virus. 1. Review of R#5's Admission Record showed an admission date of [DATE] with medical [DIAGNOSES REDACTED]. Upon initial tour of the facility on 6/18/20 at 10:00 a.m., R#5's door did not have any isolation signage or PPE available at doorway. Tour of the same hall on 6/18/20 at 11:55 a.m. showed R#5's door with a Contact Precautions sign and a PPE supply door hanger. Review of R#5's electronic health record (EHR) showed the facility admitted R#5 on Hospice respite on 6/17/20 without a negative COVID test. In an interview on 6/18/20 at 3:43 p.m., the Administrator confirmed R#5 had not had a negative Covid-19 test result prior to admission but was tested the morning of 6/18/20. 2. Review of R#6's Admission Record showed a re-admission date of [DATE] with medical [DIAGNOSES REDACTED]. The facility admitted R#6 on 6/12/20 with a negative COVID test that was five days prior to admission (6/7/20); it was the only negative test after a positive result on 5/31/20. Upon initial tour of the facility on 6/18/20 at 10:00 a.m., R#6's door did not have any isolation signage or PPE available at the room entrance. Tour of the same hall on 6/18/20 at 11:55 a.m. showed a Contact Precautions sign on the door and a PPE supply door hanger. In an interview on 6/18/20 at 11:58 a.m., Licensed Practical Nurse (LPN) CC stated, the PPE and the signs went up about an hour ago and confirmed the signs and PPE hangers had not been there previously. Observation on 6/18/20 at 1:10 p.m. showed Certified Nurse Aide (CNA) AA entering R#6's room (with sign on the door Contact Precautions Everyone must: -Clean hands when entering and leaving room and - Gown and glove at door.) without performing any hand hygiene or putting on gloves. CNA AA removed the lunch tray and placed it in the lunch cart in the hallway. Subsequent observations on 6/18/20 at 1:15 p.m. to 1:23 p.m. showed CNA AA entering four other rooms on the halls without performing hand hygiene between rooms (no other isolation rooms). In an interview on 6/18/20 at 1:10 p.m. regarding the precautions sign and not using PPE, CNA AA stated, I think she is going to come off isolation because I was going to move her today. In an interview on 6/18/20 at 1:33 p.m., the DON expressed an expectation that hand hygiene (clarified to mean hand washing or hand sanitizer) must be completed between patients. In regard to CNA AA not using PPE, the DON confirmed that she would expect staff to use PPE if the resident is in true isolation. Most of our residents are in social isolation and they just stay in their room. When asked about the TBP signage, the DON stated it was there because the surveyor was in the building. In an interview on 6/18/20 at 1:45 p.m., the Administrator verified the facility admission/re-admission directive from regional clinical management dated 4/8/20 You are able to admit residents and take hospital returns who have been screened. admitted residents and hospital returns should be placed in social isolation for 14 days. During the social isolation timeframe, you should continue with screening and observing the resident. You will follow standard universal precautions. All patients new to facility are treated as positive patients unless they have an accompanying negative lab test for COVID-19. Continued interview on 6/18/20 at 1:45 p.m., the Administrator verified the following facility Covid-19 information, updated 6/3/20, which stated, . 3. For hospital returns: a. Resident is to be placed in a room by themselves. Staff should then check their temperature every 4 hours x 14 days. b. Staff should utilize droplet precautions and practice heightened hand washing precautions. c. Resident will remain in infection precaution room for at least 14 days. On day 14 if resident has been free from further fever and has shown no other symptoms of respiratory illness then they can be moved to a regular room . 4. For new admissions: a. Resident to be placed in a room by themselves. Staff should then check their temperature every 4 hours x 14 days. b. Staff should utilize droplet precautions and practice heightened hand washing precautions. c. Resident will remain in infection precaution room for at least 14 days. On day 14 if resident has been free from further fever and has shown no other symptoms of respiratory illness then they can be moved to a regular room . ***Remember these patients are not on isolation, however we want them to remain in their room area so that contact with other patients is avoided .