Every finding on record at Magnolia Manor - Greenville

Based on review of the facility policy, review of an Ecolab Manual, observations and interviews, the facility failed to ensure foods that are stored in the freezer, coolers and dry food storage were appropriately sealed, labeled, dated with an open or use by date, and/or discarded by the use by day in 1 of 1 walk in freezer, 1 of 1 walk in cooler, 1 of 1 reach in cooler and 1 of 1 Dry Food storage, reviewed. In addition, the facility failed to ensure that the dietary staff properly monitored the dishwasher ensuring that it reached the required temperature for safe/proper sanitation of the dishes.Review of facility policy titled, Food Safety in Receiving and Storage, last revised 6/20/23, revealed General Food Storage Guidelines. 3) Place food that is repacked in a leak-proof, pest-proof, nonabsorbent, sanitary container with a tight fitting lid. Label both the container and its lid with the common name of the contents, the date, it was transferred to the new container, and the discard date. Dry storage Guidelines, 2) Tightly seal open packages to prevent contamination or place food in covered containers. Refrigerated Storage Guidelines: 12) Refrigerated, ready to eat Time/Temperature Control for Safety Foods (TCS) are properly covered, labeled, dated with use-by date, and refrigerated immediately. [NAME] them clearly to indicate the date by which the food shall be consumed or discarded. The day of preparation or day original container is opened shall be considered day 1. Follow USDA guidelines for food storage.; 14) Refrigerated condiments and salad dressings are properly covered, labeled, and clearly marked to indicate a use by date two months from the date opened.Review of facility policy, titled Warewashing using Dishwashing Machine, last revised last revised 6/20/23, revealed Utensils and dishes washed by a mechanical dishwasher will be clean and sanitized. Procedures: 1) .Check the temperature of the wash and rinse cycles, verifying that both meet the temperatures posted on the dishwashing machine. If using a low temp machine, check the sanitizer lever at contact times specified in accord with the product label. Record data on the Temperature and Sanitizer Log Form .Review of an Ecolab [NAME] Installation & Operation Manual dated March 9 2022 revealed, Section 1: Specification Information, ES-4000 Series Specifications: Temperatures: wash --- F (minimum) 120, wash --- F (recommended) 140, Rinse --- F 120, rinse --- F (recommended) 140; water requirements: inlet temperature (minimum) 120 F, inlet temperature (recommended) 140 F, minimum chlorine required (PPM) (parts per million) 50.Review of the dishwashing machine date plate revealed, Ecolab model ES-4000CDL Minimum wash temperature 120 F, minimum rinse temperature 120 F, recommended incoming water temperature, minimum chlorine 50 PPM (parts per million).During an initial kitchen tour on 07/27/25 at 10:38 AM, the dry food storage revealed: 1 - 5 pound (lb.) box of gold metal buttermilk biscuit mix open without a open or use by date and not properly sealed; 2 - 24 ounce (oz) peppered old fashioned biscuit gravy mix with no open or use by date; 2 bags of spiral pasta noodles open with no clear open or use by date; 2 bags of elbow pasta noodles open with no open or use by date; 1 - 10 lb. bag of penne pasta with no open or use by date; 1 bag of tortilla chips with no open or use by date; 1 - 18 quart (qt) storage container labeled cornmeal with a Styrofoam cup inside container; 1 - 22 qt storage container labeled panko with a Styrofoam cup inside; 1 - 16 qt storage container labeled sugar with a Styrofoam cup inside; 1 - 22 qt container labeled flour with a Styrofoam cup inside; 1 - 25 lb. box imperial instant food thickener open with no open or use by date; 1 - 5 lb. bag of devil's food cake mix open with no open or use by date; 1 - 5 lb. bag of white cake mix open with no open or use by date; 1 - 12 oz bag of Hersey's chocolate chips open with no open date or use by date. During the initial kitchen tour on 07/27/25 at 11:14 AM, the walk-in freezer revealed:1 unlabeled Ziploc bag of bread sticks, identified by Dietary Manager (DM) with an illegible label, unsure of open or use by date; 1 Ziploc bag of unlabeled mac cheese bites,1 Ziploc bag of cooked bacon; 1 Ziploc bag of frozen okra with no open date and marked with use by date 05/15/25.During the initial kitchen tour on 07/27/25 at 12:13 PM, the walk-in cooler revealed: 1 - 5 lb. packaged of sliced American cheese not dated with an open or use by date; 1 - 5 lb. package of Mozzarella cheese not labeled with an open or use by date; 1 box of slimy cucumbers, 1 Ziploc bag with 6 cucumbers in a white cloudy liquid; 1 - 1 qt apple juice open not labeled with an open or use by date.During the initial kitchen tour on 07/27/25 at 12:23 PM the reach in cooler revealed: 1- 2 qt container of ground turkey sausage unlabeled, identified by DM; 1 - 2 qt container marked cream of chicken with no prep/open or use by date; 1 - 2 qt container of pureed squash, identified by DM, not labeled with contents or prep/open or use by date; 1 - 1 gal container of dill pickle chips with no open date or use by date; 1 - 4 qt of egg salad marked with a prep date 07/21/25 and a use by date of 07/24/25; 1 - 4qt container prepared oatmeal not labeled with contents or prep/open or use by date; 1 - 2qt container of oatmeal not labeled with contents or prep/open or use by date; 4 boiled eggs loosely wrapped in plastic wrap with no prep/open date and no use by date; 2 - 1 - gal containers of mayonnaise open with no open date or use by date; 1- 1 gal container of prepared yellow salad mustard open, with no open date and no use by date; 1 - 1 gal of sweet pickle relish open with no open date no use by date;During a follow up tour of the kitchen on 07/28/25 at 9:10 AM the DM was observed testing the dishwashing machine. The DM had to run the machine four times for the chlorine to reach 50 ppm. During the observation the thermometer affixed to the top of the machine revealed that the temperature line started at 60 F and went to 120 F, showing no color below 60 F.During an interview on 07/27/25 at 10:56 AM the Dietary Manager (DM) revealed that she just finished her Certified Dietary Manager (CDM) courses about 3 weeks ago and that she just needs to take exams. The DM states that none of her dietary staff are Servsafe certified and that their dietitian is contacted in and comes once a month. The DM explains that her expectation is for food items in the dry food storage to be labeled with the date it's received, and once the item is opened it should be labeled with a 30 day use by date.During an interview on 07/28/25 at 9:21AM the DM revealed that it often takes the dishwashing machine several runs to get up to temperature and the proper sanitation. The DM confirmed that the reading on the thermometer at the back of the machine started at 60 F and went up to 120 F with there being no color indicator from zero to 60 F. The DM states that this thermometer is what is used to ensure that the dishwashing machine gets up to the proper temp. The DM further states that the thermometer is broken. The DM continues to reveal that Ecolab usually comes to check the machine once monthly and are usually accompanied by the facility's maintenance director however they did not come last month and that they had not been here for this month.During an interview on 07/28/25 at 9:40 AM the Maintenance Director (MD) revealed that he accompanies the Ecolab tech when they come to service the dishwashing machine, but he is not certified to work on the machine. The MD states that the thermometer attached to the top back of the machine is broken. The MD states he is unsure how the dietary staff can ensure that the dishwashing machine gets to the required temperature to properly sanitize the dishes.During a brief telephone interview on 07/28/25 at 10:10 AM the Ecolab Tech (ELT) revealed that the correct gauge to monitor the temperature of the dishwasher is a circular gauge located at the bottom of the machine near the drain rather than the top. The ELT explains that the gauge at the top is an original part of the machine, but it does not work. The ELT continues to explain that he usually comes to service the machine once a month, but he has not always been the rep. The ELT states that he was at the facility in either May or June, however, he could not confirm that he serviced the machine last month.During a follow up interview on 07/28/25 at approximately 10:15 AM the DM revealed that she normally refers to the thermometer at the top of the machine and is unaware of the gauge mentioned by the ELT at the bottom of the machine. The DM states that she uses the thermometer/gauge that the top of the machine and use to it reading 120 . The DM states that she knows that the machine is getting to temp due to the heat coming from the machine and seeing the steam as well as the sanitation strips showing 50 ppm.During an interview on 07/28/25 at 11:02 AM Dietary Aide (DA)3 revealed that when she is using the dishwashing machine, she uses the gauge at the bottom of the machine. DA3 states that she often must run the machine up to four times for it to get to temp. DA3 states that she monitors both the gauge at the bottom and the top to make sure they both are reading the same temperature.During an interview on 07/28/25 at 11:07 AM DA1 revealed that he has been employed with the facility for about a year and that he has performs various tasks in the kitchen, including washing the dishes. DA1 explains that his process for washing the dishes is the first spray them down and them send them through the dishwasher. DA1states that he often forgets what the temperature the water should be during the wash and rinse process and must ask the DM. DA1 also states that he often forgets to document the temperature and the sanitation on the log. DA1 further revealed that he was taught how to use and work the dishwashing machine by his supervisor in which he named the current DM. DA1 states that the DM has also instructed him that if the machine is not working properly to notify maintenance.During an interview on 07/28/25 at 11:53 AM, DA2 revealed that she has been working at the facility for 19 years and she often train other employees. DA2 states that when washing the dishes she refers the gauge at the bottom left of the machine. DA2 states that the gauge is hard to see and you would not know it was there if you weren't looking for it. DA2 explains that the machine broke down several years ago under another DM, and when it was replaced by Ecolab gauge was put at the bottom of the machine. DA2 states that the temperature of the water should be between 120-140 for washing and rinsing and that the chlorine should be 50-100 to sanitize the dishes. DA2 continues explains that the gauge never starts at zero, but it usually starts at 90, and it usually takes the machine running for three cycles before it reaches 120. DA2 further explains that after the machine is stated a rack is sent though and it the dishes are not clean, she sends them back through a second time, and she monitors the gauge to ensure the machine is keeping its temperature. DA2 states that she documents the temperature and the sanitation level on the log. DA2 further reveals that she cannot recall if the current DM was made aware that the gauge was moved to the bottom of the machine after it was replaced.During an interview on 07/28/25 at 12:10 PM DA4 revealed that she has been employed at the facility for two years and that she helps the morning shift when she comes on shift in the afternoon. DA4 stated yes when asked if she assisted with washing the dishes and if she checked the temperature of the dishwasher. DA4 repeatedly stated it be different prices, when asked what the wash and rinse temperature should be. When the question was repeated, DA4 states that the rinse temperature should be 50 and the wash temperature is 100 and something. DA4 states that parts per million (ppm) should be 60 but it's different. DA4 further revealed that she does document the temperature and sanitation on the thing on the wall, and stated she did not know the correct name for the documentation.During a follow up interview on 07/28/25 at 12:18 PM the ELT revealed that he became the service representative for the facility in January 2025. The ELT explains that the temperature gauge at the bottom of the machine will never start at zero because the gauge is reading at room temperature until the machine is started. The ELT continues to explain that the gauge that the top of the machine is not connected to the machine and does not provide any assistance with the recording the temperature. The ELT further explains that he usually comes once a month to service the machine, however he was unable to find the documentation to show that he was at the facility in June. The ELT states that he changes the tubes every six months because over time the tubing bends more and can cause the chemicals not to flow properly. The ELT points to the sticker on the front of the machine stating that he had not changed the tubes since 12/12/2024, therefore he would change them today.During a brief interview on 07/28/25 at 1:01 PM the Administrator revealed that the Registered Dietitian (RD)is part time and comes to the facility the recommended hours required, however she comes as much as needed. During follow up interview, the Administrator revealed her expectation is for the dietary staff to follow the facility's policy, procedures and guidelines that have been set forth related to food in the dry food storage, coolers and freezers. The Administrator states that the staff should make sure food items are labeled and discard any items that are beyond the use by or expiration date. The Administrator further revealed that her expectation is for staff to follow the policy, procedures and guidelines related to the sanitation of the dishes.During an interview on 07/28/25 at 2:21PM the RD revealed that her services to the facility are contracted. The RD explains that between her business partner and herself they contract approximately 25 hours to the facility a month. The RD continues to explain that her partner works remotely on the clinical side, and with she comes in and goes through the kitchen sanitation and meal service following a checklist with the DM, as well as assessing new admission and seeing other residents as needed. The RD further explains that in relation to the sanitation checklist she observes the dish room looking at how clean the area is, how the flatware is stored, look at the dishwasher, checking the ppm and the water temperature. The RD stated that the ppm is important to ensure that the dishes are sanitized. The RD was unable to explain or describe where the gauge is located that she observes to ensure that the water reaches the correct temperature. The RD states that in the dry food storage she checks the room for organization, where condiments are not mixed together, open items are sealed and dated with an open date and ensures that all expired items are discarded. The RD states that she checks the temperature of the outside thermometer for both the freezer and cooler, but she goes by the thermometer inside of them. The RD states that she is also looking for organization in freezer and cooker as well as making sure open items are date labeled.During a follow up interview on 07/28/25 at 2:51 PM the DM revealed that her Servsafe certification expired in 2023. The DM states that she just finished her CDM classes about a week ago and that she is waiting on that certificate of completion which may take 7-14 days. The DM states that once she receives her certificate, she can schedule her exam.

Based on review of the facility policy and procedures, observations and interviews, the facility failed to ensure proper handling and processing of resident laundry during observation of laundry services. Review of the facility policy titled, Maintenance/Housekeeping Policies and Procedures Subject: Laundry states: Policy: Laundry services will comply with appropriate guidelines to assure that measures are implemented to provide pro effective laundry service. Procedures: 5. Personnel in the laundry services are properly garbed at all times. When handling soiled linens, gowns, and gloves, at a minimum will be donned. These are removed as soon as possible after completing of duties involving soiled linens. Personal protective equipment is not necessary when handling clean linens through uniforms or personal clothing should be clean. All Linens: 1. Linens are to be handled in a safe manner to prevent contamination of the linen, the personnel and the environment. 2. All soiled laundry is to be considered contaminated and handled in the same safe manner. This precludes the use of isolation or different procedures for soiled linen handling. During an observation on 07/28/25 at 10:00AM, the Housekeeping Supervisor was observed donning goggles, latex gloves and rubber gloves. No gown was donned. The soiled linen was separated, and the clear bags were thrown away. The soiled linen cart was pushed to the washing machine and the soiled linen was loaded into the washing machine. The Housekeeping Supervisor failed to don a gown while handling the soiled linen.During an interview on 07/29/2025 at 3:12 PM, the Housekeeping Supervisor stated, I just got nervous. I know I should always wear a gown. I looked up and saw the gown after I got started, I just forgot. During an interview on 07/29/2025 at 5:10 PM, the Administrator revealed, my expectation is for the laundry staff to apply and wear the correct PPE the way they are supposed to when sorting laundry.

Based on review of facility policy, record review, observations and interviews, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests. Review of the facility policy titled, Pest Control last revised on 09/19/24, documented, Policy: The hospital will maintain an effective pest control program to prevent or eliminate infestation of pests and rodents. Procedures: 6. Pest management decisions will be based on the results of regular inspections. If a pesticide is needed, the least hazardous pesticide is selected that will effectively control the pest problem. Pesticides used at this hospital will be applied by certified pesticide applicators or registered technicians that have working knowledge of IPM principles and practices. 8. Facility staff will: A. Note and report any evidence of pest activity (i.e. rodent droppings). All documentation/reports shall be as detailed as possible with reporting this information. B. Report sightings of live pests immediately to the Integrated Pest Management Coordinator to request emergency service to provide additional, unscheduled treatment as necessary. During an observation on 07/28/25 at approximately 10:30AM, of the conference room in the front of the building, a large amount of small, light brown antlike insects were observed on the walls, floor and in the personal belongings of the survey team. The maintenance man was notified. He treated the area with an over-the-counter insect spray called Home Defense. The survey team was relocated to the Activities room.During an observation on 07/28/25 at 12:00 PM, there were four brown bugs crawling in resident's bathroom. During an interview on 07/28/25 at 12:09 PM, the Unit Manager verified the presence of the bugs. She stated that she would get maintenance to spray for the bugs.During an interview on 07/28/25 at 12:18 PM, Certified Nursing Assistant (CNA)1 stated she has worked at this facility for 10 years. She stated, this is an old building in the summer. There are going to be roaches. During an interview on 07/29/25 at 5:00 PM, the Administrator stated Regarding the pest control program. Ecolab sprays monthly. My expectation when staff have a pest sighting is that staff will notify myself, the Director of Nursing or Maintenance of the pest sighting. Whoever staff notifies they will call Ecolab. Ecolab knows that they must come out either that same day or the next day.

Based on review of the facility policy, observations, and interviews, the facility failed to 4 of 4 insulin prefilled syringes were labeled with an open date and 3 of 3 unopened prefilled insulin syringes were refrigerated, 2 of 2 medication carts were reviewed.Review of the facility's policy titled Medication Management: 6.4 Medication Labeling last revised [DATE] revealed, Policy . 2. The Facility shall ensure that all medications are labeled appropriately. Procedures 1. Ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions.Review of the facility's policy titled, Staff Education/Orientation Policies and Procedures last revised [DATE] stated, [sic] preparing the pen inspect expiration date on pen. If opening a new pen, writes date opened on the body of the pen being careful not to cover the manufacturer's expiration date or resident name. If pen is already opened, inspects date opened to ensure pen use within established parameters. (Max days 28 days or less depending on product).During an observation on [DATE] at 3:41 PM, the following was noted on the [NAME] Hall Medication Cart A:1. A Glargine SoloStar pen (Lantus) in use with no open/expiration date documented.2. A Glargine SoloStar pen opened on [DATE] with 160 units remaining was expired as of [DATE].3. A NovoLog FlexPen opened on [DATE] was expired as of [DATE].4. A Lantus SoloStar pen with no open/expiration date with 80 units remaining.5. Two NovoLog FlexPen prefilled syringes and one Lantus SoloStar pen were found unopened and unrefrigerated.During an interview on [DATE] at 03:55 PM, Registered Nurse (RN)1 stated, When pharmacy comes and checks the cart they place medications in the refrigerator. Once we get the keys to the cart, we make sure it is labeled and dated. RN1 disposed expired insulin syringe in the needle box.During an observation on [DATE] at 4:08 PM, the following was noted on the East Hall Medication Cart B, one unopened Lantus SoloStar insulin pen not refrigerated.During an interview on [DATE] at 04:10 PM, Licensed Practical Nurse (LPN)1 stated, We will have to get rid of the new insulin syringe. If you pull it out and do not use it and due to me not knowing, I will have to get rid of it. I'll give it to the Director of Nursing (DON). He will dispose of it.During an interview on [DATE] at 04:40 PM, the DON stated, The Interventionist Nurse educates the nurses on insulin medications. Currently, she is out on leave. The unit manager also educates the nurses on the floor. It is the unit manager and the nurses on the medication cart responsibility to check the carts. The pharmacy comes every two months to refill and check the medication carts.

Based on review of the facility policy, record review and interviews, the facility failed to provide Resident (R)2 with appropriate behavioral/mental health services as requested by their physician in a timely manner for 1 of 5 reviewed for behavioral health services. Findings include: Review of the facility policy titled, Social Services Policies and Procedures Assessment and Analysis of Behavioral Health Needs last revised 06/09/23 revealed Staff will utilize a knowledge and understanding of mental illness, trauma, substance abuse, diseases process and cultural diversity to assess the potential needs of each resident. The staff will incorporate behavior management techniques and cultural knowledge to assist patients/residents in reaching and maintaining their highest practical physical, mental, and psychosocial wellbeing in accordance with the comprehensive assessment and care plan. The treatment of mental and substance abuse disorders. Social services or designated staff will facilitate community referrals to meet the needs of the resident related to mood, behavior, mental illness, or cultural identity. Procedures include evaluate for and identify potential issues related to mental illness, substance abuse, disease process, trauma, and cultural diversity to assist in completing a comprehensive assessment related to mood, behavior, quality of life and personal preferences. Social Services or designee will make referrals for further evaluation, treatment, or support in a timely manner. The assessment will be completed within seven days of admission to the facility and periodically, as needs are identified. Review of R2's medical record revealed R2 was admitted to the facility on [DATE] with diagnoses including but not limited to; restlessness and agitation, anxiety disorder, major depressive disorder, and dementia with mood disturbances. Review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/26/24 revealed R2 has the Brief Interview of Mental Status (BIMS) score of 10 out of 15, which indicates that she has mild cognitive impairment. Further review of the Quarterly MDS revealed R2 during the assessment period exhibited physical behavioral symptoms towards others 1-3 days, had other behavioral symptoms not directed towards others 1-3 days, and rejection of care 1-3 days during the lookback period. Record review of R2's Physician Orders revealed an order dated 07/01/24 and discharge date d 09/10/24, which read please consult psychiatric services for history of psychiatric impairment related to dementia, anxiety, depression. Record review of a Physician Progress Note dated 08/09/24 revealed Nurse paged me yesterday and reported that patient was attempting to exit the building and when staff attempted to redirect her she started to swing and hit staff. Nurse reported that they tried to call her daughter who speaks Spanish did not help calm her down but made it worse. Nurse asked to send patient to emergency room for psychiatric evaluation, advised to give one dose of Haldol and call back if it does not help her (R2). Patient has known dementia with behaviors, she is observed today and appears calm and cooperative. She is frequently ambulating in the hallways with steady gait using her walker. She speaks to other residents in Spanish and appears that she tries to engage with them but due to language barrier and dementia it is difficulty for other residents to communicate with her She is also followed by in-house psychiatric services, patient is examined today and appears to be at baseline, I used Google translate to talk to her and she kept saying she is wanting to go home. She is observed ambulating with walker. She tells me that she has a headache today, will schedule her Tylenol as twice a day as she may not be able to let nursing staff known that she needs medicine. Nurse tried to give her medicine but resident refused and stated she will take them [NAME] (tomorrow), will ask psychiatric services to see patient on next visit. Record review of a Physician Progress Note dated 08/14/24 revealed Nurse asked me evaluate patient for concern regarding altercation with another roommate/resident. Nurse reported that patient was standing over her roommate and scratched her left arm and struck her in the face with a shoe. Patient was given as needed Haldol injection due to behavioral disturbances. Patient is a Spanish-speaking only and difficult to redirect. Patient is evaluated today and appears to be stable in no altered distress. She is observed ambulationg with her walker around the hallways. Unable to obtain meaning hisotyr due to language barrier, she often stated she wants to go to casa (home). Patient does have history of dementia with history of agitation and restlessness. Other patient was removed from the incident to another unit, Director of Nursing (DON) was notified of the incident, will have psychiatric services evaluate patient on next visit. Record review of a Physician Progress Note dated 08/19/24 revealed Patient is a Spanish-speaking female long term care resident who is unable to provide any meaningful history due to dementia. Patient also has behaviors and recently had an aggressive behavior towards another resident was started on Haldol as needed. Per the Medication Administration Record (MAR), it appears that she received two (2) doses so far. Nursing has not reported any other incidents, patient needs frequent monitoring and redirecting as she is attempting to elope per nursing. Psychiatric referral has been placed and is pending, we will continue to monitor and follow up in one to two weeks. Record review of a Physician Progress Note dated 09/03/24 revealed Patient seen today for acute concern, cough and hostility. Nursing reports that patient becomes hostile when she is trying to be redirected. Patient tends to wander around the in the hallways, recently was attempting to leave the building and had all of her belonging and when nursing was trying to redirect her, she became hostile to staff. Patient does have a history of dementia with behaviors, she is closely followed by psychiatric services. Patient is clinically alert and oriented however is difficult to obtain history due to language barrier. She is Spanish speaking only, patient uses walker and ambulates through the hallway frequently and needs redirecting at times. Record review of R2 Nursing Note dated 10/12/24 at 2:00 PM revealed Resident continues to wander without purpose, enter other residents rooms, and attempting to push another resident off the unit in her [NAME] chair. Record review of R2 Nursing Note dated 10/12/24 at 3:49 PM revealed Resident brought from dayroom from nursing desk. R2 attempted to push another resident's [NAME] chair off of the unit. Numerous attempts to redirect the resident (R2) by nursing staffing and Certified Nursing Assistants (CNA)s to no available. Resident became angered, verbally hostile, and attempted to look for item to use to throw. R2 picked up a broom and fell ow charge nurse intervened. Director of Nursing (DON) updated on resident's current behaviors, Nurse Practitioner notified via log of current behaviors and possible interventions for acute episodes. Record review of R2 Nursing Note dated 10/12/24 at 4:12 PM Alerted to resident by staff on another unit in the facility, resident continuously setting off door alarm to exit facility, writer and male CNA on duty retrieved resident and redirected her to appropriate unit. Ambulatory with rolling walker with secure guard bracelet in place and operational, Assistant Director of Nursing (ADON) consulted by phone to aid in communication with resident. Record review of R2 Nursing Note dated 10/12/24 at 4:53 PM ADON and Resident Representative on scene and spoke with resident which seemed to help calmed her down for the moment. , ADON explained to R2 that other resident was a woman and not a [NAME] (boy child) and that her needs would be meet by nursing staff. Resident currently sitting in dayroom on couch awaiting meal. Record review of R2 Nursing Note dated 10/12/24 at 6:50 PM Alerted by another resident that R2 was attempting to change brief of another resident in the facility. Attempts to redirect the resident to no availability, resident is verbally hostile, resisting removal from room and argumentative in Spanish. An observation and attempted interview on 10/22/24 at 4:47 PM with R2 was unsuccessful. R2 did not have the attention span/cognitive ability to speak via Google translator app. R2 was observed wandering on unit, but not attempting exit seek at this time. A phone interview on 10/22/24 at 5:13 PM with Licensed Practical Nurse (LPN)1 revealed that R2 has had two situations with other residents at the facility. The first incident involved her first former roommate where R2 hit her with a shoe, and they had to be separated. The second and most recent incidents have been involved with another resident that R2 believes to be her [NAME]/son and she attempts to take care of the resident by trying to feed and at times trying to change the resident's briefs (R2 was not successful with attempts). LPN1 further stated that they communicate to R2 with the Google translator app but when that is not successful they use cards that have pictures to help determine what the resident is trying to communicate. LPN1 finally stated that they were unsure if R2 was being followed by psychiatric services at this time. An interview with the ADON on 10/23/24 at 11:39 AM revealed that the resident is not currently being followed by psychiatric services at this time and the referral is pending. ADON further stated that they are unsure of how long the referral has been pending and Social Services is responsible for contacting the company. An interview with the Social Services Director (SSD) on 10/24/24 at 11:52 AM revealed that the resident is not currently being followed by Psychiatric services at this time and that they were unsure of what date they made the referral for services. The SSD was unable to provide documentation related to when they made the referral to psychiatric services. An interview on 10/24/24 at 1:05 PM with the Nurse Practitioner (NP) revealed that they requested/ordered the resident be followed by psychiatric services in July 2024 and was unaware that the resident had not yet been evaluated by psych and was under the impression that R2 was being followed. During interview with the NP, they stated that this evaluation should have been completed in a timely manner.

Based on interview and record review, the facility failed to ensure the dialysis communication sheets were completed to ensure ongoing communication between the facility staff and the dialysis center for three (3) of four (4) sampled residents (R)13, R24, and R237). Portions of several of the Dialysis Communication Sheets were left blank including the section where staff should be checking the shunt for bruit post dialysis care. The findings include: Review of the facility's Dialysis - Hemodialysis Policy and Procedure revised 9/22/17 revealed .3. The facility staff will participate in ongoing communication with the dialysis center by using the Dialysis Communication Form which is filed in the resident's medical record. Review of the facility's Shunt Care - Arteriovenous (A.V.) Policy and Procedure revised 5/5/23 revealed .3. Post Dialysis Care: .C. Check for bruit upon return from dialysis and then once per shift. Review of R13's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included End-Stage Renal Disease, Chronic Kidney Disease, and Dependence on Renal Dialysis. Further review revealed the resident had a central venous catheter (CVC) to the right femoral artery. Review of R13's Dialysis Communication Sheets dated 5/20/24, 5/30/24, 6/3/24, 6/5/24, and 6/12/24 revealed documentation of the shunt site was not completed in the pre- and post-dialysis sections. The staff failed to document if they checked the CVC for thrills and bruits. Review of R13's Dialysis Communication Sheet dated 4/29/24 revealed documentation of the shunt site was not completed in the pre-dialysis section. The post-dialysis section was not completed due to the resident refusing dialysis. Review of R13's Dialysis Communication Sheet dated 4/24/24 revealed documentation of the shunt site was not completed in the pre-dialysis section. The post-dialysis section was completely blank. Review of R24's clinic record revealed the resident was admitted to the facility on [DATE] with diagnoses which included End-Stage Renal Disease, Type 2 Diabetes Mellitus and Hypertensive Chronic Kidney Disease (Stage 5). Further review revealed the resident had an Arteriovenous (AV) Fistula for Dialysis. Review of R24's Dialysis Communication Sheets dated 11/18/23, 3/2/24, 4/27/24, 5/28/24, 5/30/24, 6/8/24, and 6/14/24 revealed the Dialysis Center Section was not completed. Further review revealed the facility received the dialysis report from the dialysis center for all the dates but failed to complete the document. Review of R24's Dialysis Communication Sheet dated 6/11/24 revealed the post-dialysis section was not completed. Review of R24's Dialysis Communication Sheet dated 6/13/24 revealed the Dialysis Center Section and the post-dialysis documentation of the shunt site were not completed. Further review revealed the facility received the dialysis report from the dialysis center for this date but failed to complete the document. Review of R24's Dialysis Communication Sheets dated 11/18/23, 12/9/23, 1/16/14, 2/27/24, and 1/16/24 revealed in the pre-dialysis section staff failed to document regarding the shunt site. The staff failed to document on checking the thrill and bruit. Review of R237's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included End-Stage Kidney Disease, Dependence on Renal Dialysis, Malignant Neoplasm of Prostate, Diabetes Mellitus Type 2 and Chronic Kidney Disease. Review of R237's Dialysis Communication Sheets dated from 6/9/24 to present revealed the sheet was not completed by the dialysis center on 6/13/24, 6/15/24, 6/18/24, and 6/20/24. During an interview on 6/21/24 at 10:30 a.m., the Director of Nursing (DON) stated the facility was having a hard time getting the dialysis center to complete their section. He/she stated when the Dialysis Communication Sheet's dialysis center section was returned incomplete or blank, staff was to call and have the center send the dialysis report for that day. During an interview on 6/21/24 at 12:30 p.m., the DON verbalized that he/she understood that if the facility was going to use the Dialysis Communication Sheet for ongoing communication between the facility and dialysis center, the form had to be totally completed. He/she stated the facility will revisit how they communicated with the dialysis center and possibly change the policy. The Regional Clinical Nurse stated some of the nurses were writing Progress Notes regarding checking the shunt site, but it was not being documented on the Dialysis Communication Sheet. Once again, this Surveyor reiterated to the Administrative staff present that if the Dialysis Communication Sheets were being used for ongoing communication between the facility and the dialysis center, the forms had to be complete.

Based on observation, record review, review of the facility policy titled Enteral Feeding-Administering Medications, and staff interviews, the facility failed to ensure that medications were given according to standards of practice via enteral feeding tube by one (1) Licensed Practical Nurse (LPN) for one (1) Resident (R)66. The findings include: Review of the Nursing Policy and Procedures titled Enteral Feeding-Administrating Medications dated 5/5/2023 revealed that The licensed nurse will administer medication prescribed by the physician to be given by enteral tube, using the appropriate method according to recognized standards of practice. Equipment: Prescribed medication, fluid-impermeable pad or towel, clean enteral syringe (20 milliliters (ml) or larger, water, medicine cup (s), gloves, gown and crushed medications. Implementation: Verify the practitioner's order, gather and prepare the necessary equipment, supplies, and prescribed medication, put on gloves and other personal protective equipment, flush the enteral tube with a least 15 ml of water, repeat the procedure wit the next medication, flush the enteral tube one (1) final time with at least 15 ml of water. Clamp the enteral tube and detach the syringe, re-attach the feeding if continuous. Special considerations: If the patient's gastrostomy tube becomes clogged, flush the tube with water. Notify the practitioner if flushing with water is unsuccessful. Review of R66's Physician Orders revealed an order to flush tube with 30 ml of warm water before and after medication administration. Check residual every shift and placement verification air bolus instillation with auscultation every shift. Review of R66's Physician orders revealed orders for Jevity at 80 cc (cubic centimeters which is equal to ml) from 4:00 a.m. to 6:00 p.m. via gastric tube with water flush of 55 ml per hour continuous. Special Instructions on at 4:00 a.m. and off at 7:00 p.m. Medications ordered, per gastric tube, were Lactulose solution 10 gram/15 ml-give 30 ml once daily, fluoxetine 20 milligram (mg) capsule once daily, lorazepam 1 mg one tablet every 12 hours, midodrine 10 mg one tablet, Nexium packet granules delayed release, 40 mg, dissolve one packet in 15 ml of water, allow to stand 2-3 minutes and thicken, and take per peg-tube within 30 minutes once daily. Observation of Licensed Practical Nurse (LPN)1 on 6/19/24 beginning at 9:26 a.m. the medications were pulled from the medication cart, placed in a separate medicine cup, the lorazepam was signed out from the narcotic box and signed off (the count was correct), then the fluoxetine 20 mg capsule was opened into a separate medication cup, the midodrine and lorazepam were crushed separately and place in separate medication cups. The Nexium packet was poured into a small cup with water added and stirred. At 9:40 a.m. LPN1 put the medication cups and solution cups onto the bottom of a tissue box and brought them into the resident's room. Additional water for flush was not brought into the room or additional medicine cups for measuring the water flush. The medication cups, with the medication in them were taken to the resident bathroom and water was added to the medications. The tube feeding pump was stopped and the tubing was disconnected from the gastric tube. A clean 60 ml syringe was connected to the gastric tube and the capsule with water was then poured into the syringe to drain via gravity, then the next medication was given, and repeated. The Nexium solution was then poured into the syringe which caused the tubing to become clogged. LPN1 massaged the tubing repeatedly until the clog finally dislodged and the final amount of Nexium was administered, followed by the lactulose solution. LPN1 then re-attached the tubing to the gastric tube, set the pump to flush for 2-3 minutes then restarted the Jevity. LPN1 did not flush the gastric tube prior to medication administration, or between the medications. LPN1 then changed gloves, rinsed the syringe in the resident's sink, and left the room. An interview with the Administrator and the Regional Clinical Manager, after reviewing the Enteral Feeding-Administrating medication policy, on 6/19/24 at 2:35 p.m. revealed that the policy does call for water flushes before, between medications and when medication administration is complete for gastric tube medication administration.

Based on observations, record reviews and interviews with staff and resident the facility failed to provide Activities of Daily Living (ADL) care for one (1) resident out of 20 sampled residents. The findings included: The facility's Nursing Policies and Procedures titled Activities of Daily Living, Optimal Function dated 5/5/23 stated The facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. Review of Resident (R)20's clinical record revealed the resident was admitted to the facility on [DATE] with diagnoses which included Hypertension, Cerebrovascular Accident (CVA), Contracture of Joint: Multiple, Chronic Pain Syndrome, Osteoarthritis, Age-Related Debility, and Left-sided Hemiparesis. Review of R20's Quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was dependent on staff to meet his/her personal hygiene needs. Review of R20's Progress Note dated 10/27/24 revealed R20 was seen for follow up for onychomycosis. R20 was sent out to dermatology to possibly assist with trimming down the resident's significantly thickened fingernail to the resident's right thumb and other fingernails that needed to be trimmed down R20's podiatrist reported that they were unable to trim the resident's fingernails. R20 was referred to the Dermatologist, who recommended topical ciclopirox and terbinafine cream for three (3) months and then referred the resident to an outpatient podiatry. R20 had been wanting his/her fingernails trimmed due to soreness. Review of R20's Progress Note dated 11/28/23 revealed .(R20) is telling me that he/she wants his/her fingernails cut down. The resident had significant onychomycosis to fingernails and was recently seen by dermatology who started him on ciclopirox polish and tropical terbinafine cream. We have sent the resident out to multiple specialists and requested to trim his/her fingernail, but they have declined. The resident reports that he/she has pain all over his/her lower extremities and to his/her fingernails, he/she currently on Tramadol for pain. Review of R20's Progress Note dated 1/11/24, revealed The resident is complaining of his/her right fungal fingernail, he/she is currently getting topical terbinafine polish, states that it does not seem to be helping him/her. Observation of R20 on 6/20/24 at 12:20 p.m. revealed the resident's fingernails, on his/her left hand revealed the following: the thumb and pinky nails were both about an inch long, his/her third finger had a nail that was approximately a quarter inch long; and on the right hand his/her fingernails were observed to be the following: the thumb was about two inches long, the index finger was about one inch long, and his/her fourth finger had approximately a one half inch nail. During an interview on 6/20/24 at 11:15 a.m., R20 stated I want my nails cut. It hurts. This has been going on since November. They brought me to the doctor, and they didn't do anything. During an interview on 6/20/24 at approximately 11:15 a.m., the Unit Nurse Manager (UNM) stated, the facility did not have the equipment to cut R20's left hand nails because of his/her hand being contracted. R20 will only let the wound nurse cut his/her nails and even then, the wound care nurse will not cut the resident's nails all the way down. The UNM further stated, normally nail care was done once a week when the Certified Nursing Assistants (CNAs) do a full body audit. During an interview on 6/20/24 at approximately 1:20 p.m., the Nurse Practitioner (NP) stated, I have tried sending the resident out. My supervising physician suggested removing the nail, but because of co-morbidities the resident is not a good candidate for surgery. Ciclopirox was prescribed but the supervising physician said that it was ineffective. Cutting the nails causes pain. During an interview on 6/20/24 at approximately 1:45 p.m. during an interview, the Wound Care Nurse (WCN) stated anyone can cut the resident's nails but sometimes R20 would let them cut their nails. The WCN stated that they cut the resident's nails because they felt bad for the resident.

Based on observation, record review, review of the facility policy titled Enteral Feeding-Administering Medications, and staff interviews, the facility failed to ensure that medications were given according to standards of practice via enteral feeding tube by one (1) Licensed Practical Nurse (LPN)1 for one (1) resident (R)66). LPN1 failed to flush the gastric tube prior to administering five (5) medications, after each medication and when the medication administration. There were 26 medication opportunities and five (5) errors resulting a medication error rate of 19%. The findings include: Review of the Nursing Policy and Procedures titled Enteral Feeding-Administrating Medications dated 5/5/2023 revealed that The licensed nurse will administer medication prescribed by the physician to be given by enteral tube, using the appropriate method according to recognized standards of practice. Equipment: Prescribed medication, fluid-impermeable pad or towel, clean enteral syringe (20 milliliters (ml) or larger, water, medicine cup (s), gloves, gown and crushed medications. Implementation: Verify the practitioner's order, gather and prepare the necessary equipment, supplies, and prescribed medication, put on gloves and other personal protective equipment, flush the enteral tube with a least 15 ml of water, repeat the procedure wit the next medication, flush the enteral tube one (1) final time with at least 15 ml of water. Clamp the enteral tube and detach the syringe, re-attach the feeding if continuous. Special considerations: If the patient's gastrostomy tube becomes clogged, flush the tube with water. Notify the practitioner if flushing with water is unsuccessful. Review of R66's Physician Orders revealed an order to flush tube with 30 ml of warm water before and after medication administration. Check residual every shift and placement verification air bolus instillation with auscultation every shift. Review of R66's Physician orders revealed orders for Jevity at 80 cc (cubic centimeters which is equal to ml) from 4:00 a.m. to 6:00 p.m. via gastric tube with water flush of 55 ml per hour continuous. Special Instructions on at 4:00 a.m. and off at 7:00 p.m. Medications ordered, per gastric tube, were Lactulose solution 10 gram/15 ml-give 30 ml once daily, fluoxetine 20 milligram (mg) capsule once daily, lorazepam 1 mg one tablet every 12 hours, midodrine 10 mg one tablet, Nexium packet granules delayed release, 40 mg, dissolve one packet in 15 ml of water, allow to stand 2-3 minutes and thicken, and take per peg-tube within 30 minutes once daily. Observation of Licensed Practical Nurse (LPN) #1 on 6/19/24 beginning at 9:26 a.m. the medications were pulled from the medication cart, placed in a separate medicine cup, the lorazepam was signed out from the narcotic box and signed off (the count was correct), then the fluoxetine 20 mg capsule was opened into a separate medication cup, the midodrine and lorazepam were crushed separately and place in separate medication cups. The Nexium packet was poured into a small cup with water added and stirred. At 9:40 a.m. LPN1 put the medication cups and solution cups onto the bottom of a tissue box and brought them into the resident's room. Additional water for flush was not brought into the room or additional medicine cups for measuring the water flush. The medication cups, with the medication in them were taken to the resident bathroom and water was added to the medications. The tube feeding pump was stopped and the tubing was disconnected from the gastric tube. A clean 60 ml syringe was connected to the gastric tube and the capsule with water was then poured into the syringe to drain via gravity, then the next medication was given, and repeated. The Nexium solution was then poured into the syringe which caused the tubing to become clogged. LPN1 massaged the tubing repeatedly until the clog finally dislodged and the final amount of Nexium was administered, followed by the lactulose solution. LPN1 then re-attached the tubing to the gastric tube, set the pump to flush for 2-3 minutes then restarted the Jevity. LPN1 did not flush the gastric tube prior to medication administration, or between the medications. LPN1 then changed gloves, rinsed the syringe in the resident's sink, and left the room. An interview with the Administrator and the Regional Clinical Manager, after reviewing the Enteral Feeding-Administrating medication policy, on 6/19/24 at 2:35 p.m. revealed that the policy does call for water flushes before, between medications and when medication administration is complete for gastric tube medication administration.

Based on observation, review of the facility policy titled Infection Prevention and Control Policy and Procedures for Enhanced Barrier Precaution, and staff interviews the facility failed to ensure that one (1) Licensed Practical Nurse (LPN) followed personal protective equipment (PPE) requirement while administering medication via a gastric tube to one (1) resident (R)66) to prevent the transfer of infectious organisms during high-contact procedures. The findings include: Review of the facility policy titled Infection prevention and control policies and procedures dated 5/15/23, revealed Procedures: Enhanced Barrier Precautions (EBP) 1. Enhanced Barrier Precautions expand the use of PPE (gowns and gloves) during high-contact resident care activities that provide opportunities for transfer of MDROs (Multidrug-resistant organism) to staff hands and clothing. A. 2) Wounds and/or indwelling medical devices (central lines, urinary catheter, feeding tubes, tracheostomy/ventilator) regardless of MDRO colonization. B. EBP will be implemented during the following high-contact resident care activities: 7. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy/ventilator. Observation of Licensed Practical Nurse (LPN)1 on 6/19/24 beginning at 9:26 a.m. revealed that he/she entered the room of R66, (with three beds in the room with all resident's having a gastric tube) with a sign on the door stating EBP precautions. LPN1 did not put a gown on prior to the administration of medication via a gastric tube or at any time during the medication administration. An interview with LPN1 on 6/19/24 at 10:21 a.m. revealed that he/she should have worn a gown and just forgot. An interview with the Administrator and the Regional Clinical Manager, after reviewing the Enteral Feeding-Administrating medication policy, on 6/19/24 at 2:35 p.m. revealed that EBP went into effect on 4/1/24 and that LPN1, who is on a prn (as needed) basis has received training regarding the requirements for EBP. The Administrator revealed it has been challenging for staff although the facility has provided frequent education to the staff.

Based on observation, interview, and policy review, the facility failed to ensure floors, walls, ceiling, cold storage, dry storage, furniture, and equipment were kept clean and/or in good repair. Findings include: Observation of the kitchen on 05/04/22 at 9:03 AM, and on 05/05/22 at 1:45 PM, with the Dietary Manager (DM) revealed the following: 1.The dry food storage room had floor made of vinyl-type tile, which was in poor condition due to scuff marks, stains, build-up of dark wax-like substance around the walls, broken and chipped tile pieces, and rust spots throughout the room. The wire shelves, which stored food products located in the back right side of the room were rusted. The lower shelf on the long metal table located against the wall on the right side of the room was noted to have a significant amount of worn finish and severely rusted. 2. The wire shelves in the reach-in refrigerator were stocked with a variety of perishable food products. The metal shelves were heavily rusted. 3. The walk-in refrigerator was stocked with a variety of perishable food products. The walk-in refrigerator was in disrepair and unable to be sanitized due to the interior conditions. The metal floor throughout the unit was heavily rusted. A section of the flooring, approximately four inches in length, in the center of the entrance way was missing. The edges around the missing section were jagged. Underneath the missing section was an accumulation of dark particles and debris. The outside entrance of the walk-in refrigerator also had a build-up of dark particles and debris in the crevice where there was a gap. The interior left and right lower walls of the walk-in refrigerator contained extensive rust and a heavy collection of black spots that had a fuzzy appearance which also extended onto the pipes. A stream of standing water was noted under the black spots on the right side along the wall. The interior of the door was rusted as were the shelves. 4. The front metal facing of the steamtable contained a collection of long dried drips and rusted spots. 5. The lower shelf and poles to the metal production table, which stored condiments and the metal production table adjacent the three-compartment sink contained a heavy amount of rust spots. 6. The hand sink was observed with peeled and worn paint on the wall and around the sink caulking. 7. The ceiling tiles against the wall adjacent the hand sink contained a half moon shaped stain about one foot long in length. 8. The ceiling tiles in and around the cooking station needed replacement due to cracks, holes, gaps, and stains. The ceiling area between the cooking station and the three- compartment sink was especially damaged with very dark stains, gaps, and sagging tiles. 9. The interior of the convection oven contained a heavy coating of baked-on residue, small pieces of foil, and chard food particles. 10. The two-compartment sink was noted to have a heavy stream of leaking water from the faucet. During an interview on 05/04/22 at 9:15 AM, the DM stated that she was aware of the conditions in the kitchen and had reported them through TELS (electronic maintenance system) which was where the work orders were posted. She stated she brought staff in after hours to clean. However, rust on the metal furniture was hard to clean and remove, and that moisture made the rust worse. During an interview on 05/05/22 at 2:00 PM, the DM stated the sagging ceiling tiles was a result of a past leak. She stated it leaked when it rained but repairs had been completed on the roof but not to the ceiling. The DM also stated she conducted weekly sanitation check list, which included items that needed to be addressed. The DM stated the oven was cleaned monthly. Observation of the kitchen was conducted on 05/06/22 at 10:20 AM with the maintenance assistant (MA) revealed the same concerns as identified on 5/4/22 and 5/5/22 with the DM. During an interview on 05/06/22 at 10:30 AM, the MA stated the black spots in the walk-in refrigerator appeared to be mold. He confirmed the ceiling tiles in and around in the kitchen were damaged and should be replaced. He stated the wire shelves in the reach-in refrigerator were not fixable and therefore, should be replaced. The rust on the metal preparation table and steamtable could be scrubbed off, but the metal preparation table in the food storage room was too extensive and would have to be replaced. During an interview on 05/06/22 at 10:45 AM, the Administrator observed the conditions of the walk-in refrigerator. At 11:43 AM, the Administrator stated her expectation for the walk-in refrigerator and kitchen sanitation would be to clean, sanitize and repair so food can be stored under sanitary conditions. Review of the TELS report revealed that the tile in the walk-in cooler coming up was listed as a high priority and was entered into the system on 11/23/21 and again on 12/13/21, tile in stockroom lifting and cracking, faucet still dripping was listed as a high priority and entered on 01/26/22. Review of the May 2022 cleaning schedule included preparation tables, shelves, steamtable, and walls, but not the convection oven. Review of the undated Sanitation Check List revealed Floors, walls, ceiling, tiles in place and not cracked, leak free pipes, faucets and hoses had a score of zero next to them. A comment was included that revealed .tile in stockroom lifting and cracking and walk in cooler. The DM stated on 05/05/22 at about 4:00 PM the zero indicated these items had not been addressed. Review of the nutrition policy titled, Nutrition Policies and Procedures dated 08/01/20, revealed Stationary equipment and work surfaces will be cleaned and sanitized appropriately after use .Ovens will be clean and free of build-up of grease or spills .Stainless steel surfaces will be maintained as clean, shiny surfaces without damaging the finish .The walls will be maintained in a clean condition and in good repair .Walk-in refrigerator will be maintained in a clean, sanitary condition free of odors The floors will be maintained in a clean and safe condition.

Based on record review and interview, the facility failed to offer COVID-19 vaccinations to 1 of 5 residents reviewed for immunizations. Resident #1's immunization record did not include information relating COVID-19. The facility was unable to produce documentation that indicated the resident had been offered the vaccine. The findings included: R1 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R1 immunizations on 10/11/2021 at approximately 5 PM revealed there was no information on the COVID-19 vaccination. Interview with the Director of Nursing (DON) on 10/11/2021 at approximately 5 PM revealed there are paper copies of consent forms for COVID-19 immunizations. However, as of exit from the facility at approximately 5:45 PM, the facility failed to produce consent forms for the COVID-19 vaccine. Review of R1 progress notes on 10/12/2021 at approximately 9 AM revealed the facility emailed a progress note that was entered 10/11/2021 at 10:25 PM indicating the resident's family had declined the COVID-19 vaccine. The facility was unable, however, to provide documentation of refusal prior to the 10/11/2021 infection control survey. Review of Immunization Recommendations for Patients, Residents, and Health Care Workers on 10/12/2021 at approximately 10:20 PM revealed The facility will provide education regarding COVID-19 vaccines to residents and staff. Furthermore, The facility will track all staff and resident vaccination status for the COVID-19 vaccine. Resident vaccination status will be documented in the medical record and include Education provided to the resident or resident representative regarding the benefits and potential risks associated with the COVID-19 vaccine (including date and name of representative). Review of facility infection control records on 10/12/2021 at approximately 12 PM revealed the facility tracked a list of Residents that have declined the COVID-19 vaccination. R1 was listed among the resident names. However, it was unclear what education the resident or resident representative received and who specifically declined the vaccine (resident or representative). Furthermore, R1's record itself gave no indication whether he received the vaccine or was offered / educated on the vaccine.

Based on interview and record review, the facility failed to protect 3 of 8 residents from abuse. Resident #1 was involved in three altercations on 5/22/21, 5/24/21, and 6/18/21 involving up to eight residents. The facility failed to evaluate the effectiveness of the interventions, did not provide immediate additional interventions to assure the safety of residents, and did not provide sufficient protection to prevent resident to resident abuse from reoccurring. The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility investigation of the 5/24/21 incident (Facility Reported Incident or FRI SC 331) on 7/19/21 revealed only a witness statement by the Director of Nursing (DON). It read as follows Today, we were called to the west wing related to Resident #1 hitting residents in the back of head as they were sitting in the dayroom. I was attempting to protect Resident #3's back head when Resident #1 hit Resident #3 multiple times also hitting this nurse. Interview with the DON on 7/19/21 at approximately 12 PM revealed the following, on 5/24/21, they were in a meeting when everyone was called to the floor due to the altercation in the dayroom. DON saw Resident #1 hitting other residents. Residents #2, #3, and #7 were among the victims. Review of facility investigation of 5/22/21 incident (FRI SC 465) on 7/19/21 at approximately 1 PM revealed that Resident #1 passed Resident #10 and grabbed the resident, causing dark, purple bruises. Interview with LPN #3 on 7/19/21 at approximately 1:25 PM confirmed that Resident #1 grabbed Resident #10 after passing them in the hallway. LPN #3 was unsure of other details. Interview with LPN #2, who was named as a potential witness in the Licensure report, on 7/19/21 at approximately 1:30 PM revealed the following, was present for the 5/24/21 incident ( ) and was among the staff present before the DON and Assistant Director of Nursing (ADON) were called from the meeting. The incident occurred in the dayroom and began when Resident #1 began striking Residents #2, #3, and #7. LPN #2 also witnessed the 5/22/21 incident ( ) where Resident #1 grabbed Resident #10 but could not recall the details. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment, on 7/19/21 at approximately 12:30 PM revealed the following: 1. Abuse is the willful infliction of injury . with resulting physical harm, pain or mental anguish Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. 2. Physical assault / abuse includes hitting, slapping, pinching, and kicking. Interview with Social Worker (SW) #1 on 7/19/21 at approximately 1:40 PM revealed she was present for the 5/24/21 incident, though she only witnessed the end of it where Resident #1 struck Resident #3. The SW could not recall any other details. Review of facility investigation of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:15 PM revealed that a CNA witnessed a resident struck in the head. Residents denied pain. The investigation revealed that 5 residents were struck - 1 with no injury and 1 with discoloration to the left eye. The aggressor was evaluated by the medical doctor who felt she would benefit from a different level of care. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed two witness statements from LPN #3 and CNA #2, respectively. They read as follows: 1. This nurse was notified by resident that he was struck in head by another resident. Also notified this nurse that resident had just came out of room [ROOM NUMBER]. This nurse went to check on resident and was notified by two residents that they had been struck. Third resident in bed C denies being struck. No injury noted. No complaints of pain voiced. 2. 6/17/21 I was doing 15-minute rounds with resident last check resident was sitting in chair. About 10 minutes later nurse told me that the resident was in another resident's room. I went to the room and witnessed resident hit another resident. I tried to get to the resident in time. I then assisted [them] out of the room, took [them] back to [their] room. Resident continued to be aggressive, so I stayed with [them] one on one the rest of the night. Any time I had to leave, another CNA stayed with the resident. I was also told by one other resident that a little man came in room and hit him. None of the residents appeared to be hurt. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed statements from 3 of 5 residents involved in the incident. Resident #14 stated someone came into their room and struck them in the face about 2 times. Interview with LPN #3 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:38 PM revealed no new details. The LPN deferred to their statement and nursing note, refusing to elaborate. It was unclear if LPN #3 witnessed anything, or if everything was simply relayed to the nurse who documented it. Interview with CNA #2 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 3 PM confirmed that Resident #1 was the aggressor, but the CNA could not immediately recall which resident was struck. CNA #3 deferred to their statement; however, their statement did not clarify either.

Based on interview and record review, the facility failed to implement its policy regarding a complete and thorough investigation of abuse allegations for 3 of 4 abuse facility reported incidents (FRI's). Resident #1 was involved in physical altercations with 8 other residents on 3 different occasions, and the facility failed to properly investigate / document each incident. The findings included: Review of facility investigation of 5/24/21 incident (Facility Reported Incident or FRI SC 331) on 7/19/21 revealed only 2 witness statements by Licensed Practicing Nurse (LPN) #1 and the Director of Nursing (DON), respectively. They read as follows: 1. Resident was struck by another resident in back of head. No apparent injury was noted at this time. Residents separated for safety. 2. Today, we were called to the west wing related to [Resident #1] hitting residents in the back of head as they were sitting in the dayroom. I was attempting to protect [Resident #3]'s back head when [Resident #1] hit [Resident #3] multiple times also hitting this nurse. No other details were provided. No other potential witnesses are named in the statements. No other residents are mentioned, despite later accounts naming Residents #2 and #7. The statements failed to give a clear picture of what happened, how it started, who was involved, or how it came to end. Interview with DON on 7/19/21 at approximately 12 PM revealed the following, the DON lead the investigation of this incident, as well as the others involving Resident #1. On 5/24/21, they were in a meeting when everyone was called to the floor due to the altercation in the dayroom, the DON saw Resident #1 hitting other residents. Residents #2, #3, and #7 were among the victims. The DON could not recall which staff members were present at the incident, and this was not documented anywhere. The DON confirmed she did not interview all witnesses to the incident. The DON confirmed she did not interview any resident involved in the incident, citing 'cognitive impairment.' Review of facility investigation of 5/22/21 incident (FRI SC 465) on 7/19/21 at approximately 1 PM revealed that Resident #1 passed Resident #10 and grabbed the resident, causing dark, purple bruises. LPN's #2 and #3 were mentioned as potential witnesses, however there were no written statements relating to the incident. Interview with LPN #3 on 7/19/21 at approximately 1:25 PM confirmed that Resident #1 grabbed Resident #10 after passing them in the hallway. She was unsure of other details Interview with LPN #2, who was named as a potential witness in the Licensure report, on 7/19/21 at approximately 1:30 PM revealed the following, The nurse was present for the 5/24/21 incident (FRI SC 331) and was among the staff present before the DON and Assistant Director of Nursing (ADON) were called from the meeting. The incident occurred in the dayroom and began when Resident #1 began striking Residents #2, #3, and #7. The LPN also witnessed the 5/22/21 incident (FRI SC 465) where Resident #1 grabbed Resident #10 but could not recall the details. LPN #2 was not asked to give witness statements to either incident. Review of Abuse, Neglect, Exploitation, or Mistreatment policies on 7/19/21 at approximately 12:30 PM revealed the following: 1. The facility is to Conduct prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. 2. The facility is to Thoroughly investigate all allegations of abuse, neglect, misappropriation of property and take appropriate action. Interview with Social Worker (SW) #1 on 7/19/21 at approximately 1:40 PM revealed the following, the SW was present for the 5/14/21 incident, though they only witnessed the end of it where Resident #1 struck Resident #3. They could not recall any other details. SW #1 was never asked to give a statement or interviewed as a witness. Review of witness statement from Certified Nursing Aide (CNA) #1 on 7/19/21 at approximately 3:30 PM revealed the following the statement was dated 5/24/21 and read :I [CNA #1] witnessed resident in room [ROOM NUMBER] become physically abusive with staff and myself. Resident tried to bite, punch, kick and scratch me. No other details were provided. Previous accounts placed the incident in the dayroom rather than room [ROOM NUMBER]. Follow-up interview with CNA #1 at approximately 3:35 PM provided no clarification. Review of facility investigation of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:15 PM revealed that a CNA witnessed a resident struck in the head. Residents denied pain. The investigation revealed that 5 residents were struck - 1 with no injury and 1 with discoloration to the left eye. The aggressor was evaluated by the medical doctor who felt they would benefit from a different level of care. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed two witness statements from LPN #3 and CNA #2, respectively. They read as follows: 1. This nurse was notified by resident that he was struck in head by another resident. Also notified this nurse that resident had just came out of room [ROOM NUMBER]. This nurse went to check on resident and was notified by two residents that they had been struck. Third resident in bed C denies being struck. No injury noted. No complaints of pain voiced. 2. 6/17/21 I was doing 15-minute rounds with resident last check resident was sitting in chair. About 10 minutes later nurse told me that the resident was in another resident's room. I went to the room and witnessed resident hit another resident. I tried to get to the resident in time. I then assisted [them] out of the room, took [them] back to [their] room. Resident continued to be aggressive so I stayed with [them] one on one the rest of the night. Any time I had to leave, another CNA stayed with the resident. I was also told by one other resident that a little man came in room and hit him. None of the residents appeared to be hurt. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed statements from 3 of 5 residents involved in the statement. 1. Resident #13 stated a resident came into their room a few days ago and struck them in the face. The statement was taken 6/21/21. 2. Resident #14 stated someone came into their room and struck them in the face about 2 times. The statement was taken 6/21/21. 3. Resident #11 stated a resident came into their room and hit them on the chest about 4 times. The statement was taken 6/21/21. 4. Residents #1, #2, and #12 had no written statements, despite also being named as involved in the incident per the licensure / certification report. Interview with LPN #3 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:38 PM revealed no new details. LPN #3 deferred to their statement and nursing note, refusing to elaborate. It was unclear if the LPN witnessed anything, or if everything was simply relayed to the nurse who documented it. Interview with CNA #2 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 3 PM confirmed that Resident #1 was the aggressor, but CAN #2 could not immediately recall which resident was struck. The CNA deferred to their statement, however their statement did not clarify either. Finally, the CNA decided that Resident #1 struck Resident #14 and no others.

Based on interview and record review, the facility failed to properly investigate and prevent further potential abuse from occurring for 3 of 8 residents. Resident #1 was involved in physical altercations with 8 other residents on 3 different occasions, and the facility failed to properly investigate / document each incident and prevent from reoccurring. The findings included: Review of facility investigation of 5/24/21 incident (Facility Reported Incident or FRI SC 331) on 7/19/21 revealed only 2 witness statements by Licensed Practicing Nurse (LPN) #1 and the Director of Nursing (DON), respectively. They read as follows: 1. Resident was struck by another resident in back of head. No apparent injury was noted at this time. Residents separated for safety. 2. Today, we were called to the west wing related to [Resident #1] hitting residents in the back of head as they were sitting in the dayroom. I was attempting to protect [Resident #3]'s back head when [Resident #1] hit [Resident #3] multiple times also hitting this nurse. No other details were provided. No other potential witnesses are named in the statements. No other residents are mentioned, despite later accounts naming Residents #2 and #7. The statements failed to give a clear picture of what happened, how it started, who was involved, or how it came to end. Interview with DON on 7/19/21 at approximately 12 PM revealed the following, the DON lead the investigation of this incident, as well as the others involving Resident #1. On 5/24/21, they were in a meeting when everyone was called to the floor due to the altercation in the dayroom, the DON saw Resident #1 hitting other residents. Residents #2, #3, and #7 were among the victims. The DON could not recall which staff members were present at the incident, and this was not documented anywhere. The DON confirmed she did not interview all witnesses to the incident. The DON confirmed she did not interview any resident involved in the incident, citing 'cognitive impairment.' Review of facility investigation of 5/22/21 incident (FRI SC 465) on 7/19/21 at approximately 1 PM revealed that Resident #1 passed Resident #10 and grabbed the resident, causing dark, purple bruises. LPN's #2 and #3 were mentioned as potential witnesses, however there were no written statements relating to the incident. Interview with LPN #3 on 7/19/21 at approximately 1:25 PM confirmed that Resident #1 grabbed Resident #10 after passing them in the hallway. She was unsure of other details Interview with LPN #2, who was named as a potential witness in the Licensure report, on 7/19/21 at approximately 1:30 PM revealed the following, The nurse was present for the 5/24/21 incident (FRI SC 331) and was among the staff present before the DON and Assistant Director of Nursing (ADON) were called from the meeting. The incident occurred in the dayroom and began when Resident #1 began striking Residents #2, #3, and #7. The LPN also witnessed the 5/22/21 incident (FRI SC 465) where Resident #1 grabbed Resident #10 but could not recall the details. LPN #2 was not asked to give witness statements to either incident. Review of Abuse, Neglect, Exploitation, or Mistreatment policies on 7/19/21 at approximately 12:30 PM revealed the following: 1. The facility is to Conduct prompt investigation of any allegation of suspected abuse, neglect or exploitation or mistreatment and implement immediate action to safeguard resident. 2. The facility is to Thoroughly investigate all allegations of abuse, neglect, misappropriation of property and take appropriate action. Interview with Social Worker (SW) #1 on 7/19/21 at approximately 1:40 PM revealed the following, the SW was present for the 5/14/21 incident, though they only witnessed the end of it where Resident #1 struck Resident #3. They could not recall any other details. SW #1 was never asked to give a statement or interviewed as a witness. Review of witness statement from Certified Nursing Aide (CNA) #1 on 7/19/21 at approximately 3:30 PM revealed the following the statement was dated 5/24/21 and read :I [CNA #1] witnessed resident in room [ROOM NUMBER] become physically abusive with staff and myself. Resident tried to bite, punch, kick and scratch me. No other details were provided. Previous accounts placed the incident in the dayroom rather than room [ROOM NUMBER]. Follow-up interview with CNA #1 at approximately 3:35 PM provided no clarification. Review of facility investigation of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:15 PM revealed that a CNA witnessed a resident struck in the head. Residents denied pain. The investigation revealed that 5 residents were struck - 1 with no injury and 1 with discoloration to the left eye. The aggressor was evaluated by the medical doctor who felt they would benefit from a different level of care. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed two witness statements from LPN #3 and CNA #2, respectively. They read as follows: 1. This nurse was notified by resident that he was struck in head by another resident. Also notified this nurse that resident had just came out of room [ROOM NUMBER]. This nurse went to check on resident and was notified by two residents that they had been struck. Third resident in bed C denies being struck. No injury noted. No complaints of pain voiced. 2. 6/17/21 I was doing 15-minute rounds with resident last check resident was sitting in chair. About 10 minutes later nurse told me that the resident was in another resident's room. I went to the room and witnessed resident hit another resident. I tried to get to the resident in time. I then assisted [them] out of the room, took [them] back to [their] room. Resident continued to be aggressive so I stayed with [them] one on one the rest of the night. Any time I had to leave, another CNA stayed with the resident. I was also told by one other resident that a little man came in room and hit him. None of the residents appeared to be hurt. Review of witness statements of 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:30 PM revealed statements from 3 of 5 residents involved in the statement. 1. Resident #13 stated a resident came into their room a few days ago and struck them in the face. The statement was taken 6/21/21. 2. Resident #14 stated someone came into their room and struck them in the face about 2 times. The statement was taken 6/21/21. 3. Resident #11 stated a resident came into their room and hit them on the chest about 4 times. The statement was taken 6/21/21. 4. Residents #1, #2, and #12 had no written statements, despite also being named as involved in the incident per the licensure / certification report. Interview with LPN #3 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 2:38 PM revealed no new details. LPN #3 deferred to their statement and nursing note, refusing to elaborate. It was unclear if the LPN witnessed anything, or if everything was simply relayed to the nurse who documented it. Interview with CNA #2 regarding the 6/18/21 incident (FRI SC 544) on 7/19/21 at approximately 3 PM confirmed that Resident #1 was the aggressor, but CAN #2 could not immediately recall which resident was struck. The CNA deferred to their statement, however their statement did not clarify either. Finally, the CNA decided that Resident #1 struck Resident #14 and no others.

Based on record reviews, interview, and review of the facility's policy titled Abuse, Neglect, Exploitation, or Mistreatment, the facility failed to submit/provide results of the full investigation report within 5 working days. The findings include: An interview on 5/18/21 at 2:50 p.m. with RN #1, supervisor, revealed on 3/7/21 at 9:35. it happened right in the middle of a code. RN #1 heard a Licensed Practical Nurse (LPN) #1 yelling for him/her to come help. RN #1 states s/he ran from the incident s/he was helping with to see what was going on. Resident #1 was on the floor face down. Resident #1 was witnessed by LPN #1 falling face first on the floor in the day room while trying to get out of the wheelchair to walk. Resident #1 was assessed and was bleeding from the nose and a hematoma was noted to right forehead. Director of Nursing (DON), Administrator, Responsible Party (RP), and Nurse Practitioner (NP) notified. Resident #1 sent to emergency room (ER). A CT of the head was negative; however, Resident #1 received a nasal bone fracture related from the fall on 3/7/21. A 5-day follow-up investigation report was not completed or submitted to the State Agency, nor was it provided during this complaint survey. LPN #1 was not available for interview to give her statement after several attempts. Review of the facility's policy titled, Abuse, Neglect, Exploitation, or Mistreatment states, Conduct an internal investigation, at the direction of the FAS Legal Department if applicable and report the results to enforcement agencies within five (5) working days or as prescribed by state law. Enforcement agencies include but are not limited to the State's survey and certification agency.

Based on interview and record review, the facility failed to offer flu and pneumococcal immunizations for 3 of 5 residents reviewed. Residents #1, #4, and #5 were missing documentation for pneumococcal immunizations, and Resident #5 had no influenza immunization documentation. The findings included: Review of resident immunizations on 1/13/2021 at approximately 12:25 PM revealed the following: 1. Resident #1 received the PCV13 pneumococcal vaccination on 11/4/2019, but there was no documentation regarding the follow-up PPSV23. 2. Resident #4 had no documentation regarding either pneumococcal vaccination (PCV13 or PPSV23). 3. Resident #5 had no documentation regarding either pneumococcal vaccination (PCV13 or PPSV23) or the influenza vaccination for the 2020 - 2021 flu season. Interview with the administrator on 1/13/2021 at approximately 12:50 PM confirmed the missing documentation. Review of facility policy on 1/13/2021 at approximately 1 PM revealed the facility will follow CDC and ACIP recommendations for vaccines and recommend both the PCV and PPSV23 to be administered routinely in all adults 65 or older.

Based on observation and interview, the facility failed to properly store and label food items in 1 of 1 kitchen observed. The findings include: During initial tour of the kitchen on 09/28/2020 at approximately 11:00 am, observation of the walk-in cooler revealed an opened gallon of milk without an open date label. The tour also identified five (5) Imperial Thickened Diary Drinks, with an expiration date of 09/10/20 and three (3) with an expiration date of 07/01/20 in the dry storage room. The tour also identified a box on top of a pan of bacon covered with parchment paper with the edges of the bacon exposed on the bottom rack in the walk-in freezer. The Dietary Aide was informed there was a possibility of cross-contamination. Review of the facility's policy on Food Safety in Receiving and Storage stated, 1. Food packages shall be in good condition to protect the integrity of the contents so that the food is not exposed to adulteration or potential contaminants. 2. Check expiration dates and use-by dates to assure the dates are within acceptable parameters. 3. Place food that is repackaged in a leak-proof, pest-proof, non-absorbent, sanitary container with a tight-fitting lid. Label both the container and its lid with the common name of the contents, the date it was transferred to the new container, and the discard date. An interview and follow-up visit with the Certified Dietary Manager (CDM) on 09/29/20, at approximately 11:15 am revealed a box on top of a pan of bacon covered with parchment paper with the edges of the bacon exposed on the bottom rack in the walk-in freezer. The CDM was informed there was a possibility of cross-contamination. S/he confirmed.

Based on observations and interviews and record review, the facility failed to follow guidelines to decrease the possible spread of COVID-19 by allowing multiple residents to wander the hallways in 2 of 2 wings of the facility without masks or social distancing. The findings include: Upon entry to the facility on [DATE] at approximately 11 AM, six residents were observed in the West wing either in the sitting area in wheelchairs, or walking in the hallway, not socially distanced or wearing masks. Several residents in the West wing hallway had masks under their chin or covering just their mouth, not their nose and mouth. All facility staff, including clinical staff and housekeeping were wearing masks appropriately. During an interview on 9/28/2020 at approximately 11 AM with CNA #1, s/he stated, these residents are supposed to be wearing masks, but they won't keep them on, they don't understand enough to know it is important. We try to keep them separated and keep the masks on them, but they just won't do it. During the interview CNA #1 was asked if the facility used alternative approaches with these residents, s/he stated the facility could keep the residents in their rooms where they are not required to wear a mask. S/he stated that most of the residents on the West wings do not have the functional ability to understand keeping a mask on or the meaning of social distancing. Interview with the Assistant DON 0n 9/28/2020 at approximately 11:30 AM confirmed there were no current COVID 19 cases in the facility and no residents were currently on transmission precautions due to COVID signs or symptoms. The Assistant DON also confirmed the facility staff have been tested twice weekly for COVID 19 (which will continue), and there have been no COVID positive staff. Observation on 9/29/2020 at 9 AM of the facility West wing revealed residents in the hallways and common areas in wheelchairs, separated by more than 6 feet, and masks, covering the nose and mouth on all residents. During the observation a resident removed his/her mask and RN #1 walked over and replaced the mask to cover the resident's nose and mouth and verbally reminded resident to leave the mask in place. Residents wandering in the West wing common area were encouraged by staff to keep distance between themselves. All staff, including clinical and dietary were wearing appropriate PPE. Observation on 9/29/2020 at 2:30 PM on the facility East wing revealed residents in common area and walking in hallway with masks on, masks covering both nose and mouth. All facility staff, including clinical and housekeeping observed appropriately wearing masks. Interview with the DON on 9/29/2020 at 3:30 PM confirmed all residents in the hallways are to be reminded to keep masks over nose and mouth and stay socially distant. S/He stated it was difficult to have full compliance from the residents due to their low cognitive understanding of the need for masks and social distancing, but the staff continued to try and educate and re-direct the residents throughout the day. During an observation on 9/30/2020 at 11 AM in the facility East wing common area, there were 3 residents without masks, 1 resident with a mask under his/her chin, and several clinical staff in area who made no attempt to correct mask placement or offered masks to the residents. Later in the day on 9/30/2020 at 2 PM multiple residents were again observed in both the East and West hallways without mask covering nose and mouth. Staff did not intervene. When the observation was brought to the attention of the DON, the staff were immediately reminded to have the residents instructed to keep face coverings on. The doors to West wing were then closed to keep residents from wandering to the East wing without masks on. During another observation on 09/30/20 at 04:22 PM, CNA #4 was noted to have hisw/her masks down below his/her nose. In an interview at that time, he/she confirmed he/she was aware of PPE policy requiring the mask to cover the nose and mouth but stated, sometimes it just slips down. Record review on 10/01/20 at 09:09 AM revealed the most recent training on PPE donning and doffing occurred 9/18/2020. An observation of residents in East and West hallways and common areas on 10/1/2020 at 09:30 AM revealed 2 residents on the East wing, in the common area with masks around their necks and not socially distanced. All clinical and maintenance staff were wearing masks appropriately.

Based on record review, observation and interview, the facility failed to ensure the Minimum Data Set (MDS) was accurately coded for Resident # 52 related to the prognosis of less than 6 months. The findings included: The facility admitted resident #52 on 10/15/2015 with [DIAGNOSES REDACTED]. disturbance, Age-related [MEDICAL CONDITION] without current pathological fracture, [MEDICAL CONDITION], Essential (primary) Hypertension , [MEDICAL CONDITION], Unspecified [MEDICAL CONDITION] not due to a substance or known physiological condition, Anxiety disorders and [MEDICAL CONDITION]. Review of the residents record revealed Resident # 52 was admitted to Hospice on 02/13/2020 with a prognosis of less than six months. During review of the 08/13/2020 Quarterly Minimum Data Set (MDS) and the 05/15/2020 Quarterly Minimum Data Set (MDS) , section J1400 was coded 0= no for Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? During an interview on 09/29/2020 at 04:10 PM with the MDS Coordinator, she stated, 'I did not know that had to be coded as yes. I am new in this position and still learning.

Based on observations and interviews, and review of the facility policies titled Intake and Output and Catheter Urinary Cleaning & Maintenance, the facility failed to provide appropriate care and services to 2 of 2 sampled residents reviewed for urinary catheters. Resident #62's catheter drainage bag/tubing was observed on the floor. While providing catheter care to Residents #62 and #340, the nurse failed to anchor the tubing prior to cleansing it, causing discomfort to Resident #62. Output was not monitored for Residents #62 and #340. The findings included: The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During an observation on 03/05/19 at 09:20 AM Resident #62's catheter bag was on the floor, uncovered and visible from the hallway. Throughout the course of the survey (on 03/05/19 at 09:20 AM, 11:08 AM, and 04:16 PM; on 03/08/19 at 8:46 AM and 10:52 AM), Resident #62's catheter bag was observed uncovered and on the floor. During an interview and observation on 3/08/19 at 10:52 AM, Licensed Practical Nurse (LPN) #1 confirmed that Resident #62's catheter tubing was on the floor and that the catheter bag was uncovered and visible from the corridor. Record review of Resident #62's medical record on 03/05/19 at 04:09 PM revealed no evidence that the facility was routinely monitoring the resident's urinary output. Review of Resident #62's care plan for the indwelling catheter revealed that interventions included to Assess the drainage every shift. Record the amount, type, color, odor. The facility's policy titled Intake and Output provided by the Assistant Director of Nurses on 03/07/19 at 5:30 PM stated: Note: Conditions which can require monitoring as indicated: 1. Foley or intermittent catheter. During an interview on 03/08/19 at 03:03 PM, MDS (Minimum Data Set) Coordinator #1 reviewed Resident #62's medical record and verified that the urinary output was not being monitored. The facility admitted Resident #62 with [DIAGNOSES REDACTED]. During observation of catheter care for Resident #62 at 9:57 AM on 3/7/19, no leg band was noted to secure the catheter from pulling at the insertion site during activities of daily living. After preparing the work area, Registered Nurse (RN) #1 proceeded to cleanse Resident #62's perineal area. After cleansing around the head of the penis, the nurse proceeded to cleanse and rinse the Foley tubing without anchoring it to prevent pulling at the insertion site. The resident started moaning continuously at this point, but the nurse did not address it with the resident. The surveyor asked the resident, Does that hurt? He replied, Very much. During an interview at that time, RN #1 stated, For immobile people, we don't use something to secure the catheter from pulling. The facility admitted Resident #340 with [DIAGNOSES REDACTED]. During observation of catheter care for Resident #340 on 3/8/19 at 1:33 PM, RN #1 cleansed around the urethral meatus and held the penis while cleansing the catheter tubing. S/he did not anchor the tubing to prevent pulling on the insertion site. The facility policy titled Catheter Urinary Cleaning & Maintenance states: 13. Cleanse area at catheter insertion site, taking care not to pull . It did not address anchoring of the catheter while cleaning the tubing.

Based on observation, record review, and interview, the facility failed to transfer Resident #67 per the Care Plan, 1 of 6 sampled residents reviewed for accidents. Resident #67 was not transferred with a hoyer lift per the Care Plan but by a stand and pivot method used by one Certified Nursing Assistant. The resident was found the next morning to have a femur fracture. This action resulted in an Immediate Jeopardy at Past non-compliance. The facility put a corrective plan of action in place to address this incident and it was accepted by the survey agency. However non-compliance was identified at F282 when the facility failed to provide splints for Resident #76 and #101 per the care plan, 2 of 4 sampled residents reviewed for range of motion. The finding included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Record review of Resident #67's Resident Profile on 12/13/2016 at 3:09 PM, revealed that Resident #67 was to transfer with the assist of 2 persons with a hoyer lift. Record review of Resident #67's Care Plan on 12/13/2016 at 4:37 PM, revealed that staff were to use a hoyer lift to transfer the resident. Review of documentation of an interview conducted by the facility with CNA (Certified Nursing assistant) #1 on 12/12/2016 at 10:30 AM, revealed that on 6/10/2016 CNA #1 transferred Resident #67 inappropriately. Per the statement (dated 6/12/2016), CNA #1 stated that he/she transferred Resident #67 from the bed to the wheelchair without using a hoyer lift and assistance from other staff. In addition, CNA #1 later transferred the resident back to bed without using a hoyer lift and assistance from other staff. Per the statement, CNA #1 stated he/she did not know the resident was to be transferred with a hoyer lift. In addition, CNA #1 did not know where to look in the resident's record to know how the resident should be transferred. During an interview with CNA #3 on 12/13/2016 at 2:19 PM, CNA #3 was asked how CNAs know how to transfer residents. CNA #3 stated that CNAs look at the Resident Profile in the computer to find this information. In addition, CNA #3 stated that there are symbols above each residents bed that indicate certain types of care the resident should receive, including transfers. CNA #3 stated that she/he received training during orientation on using the Resident Profile in the computer, on the symbols above the bed and on the use of hoyer and other mechanical lifts for transferring residents. During an interview with CNA #1 on 12/13/2016 at 3:28 PM, CNA #1 confirmed his/her statement from 6/12/2016. CNA #1 stated he/she did not transfer the resident with a hoyer lift and assistance from other staff. CNA #1 stated he did not remember receiving any training on how to access the Resident Profile or training on what the symbols above the resident's bed meant. CNA #1 stated he/she asked other staff how to transfer the resident prior to caring for her/him. CNA #1 stated that he/she was told that Resident #67 was a one person transfer. CNA #1 could not remember who told him/her that the resident was a one person transfer. Immediate Jeopardy at Past Noncompliance existed in the facility on 6/10/16 related to Resident #67 found to have a fractured femur after an incorrect transfer by a Certified Nursing Assistant. The facility submitted a Plan of Correction ( POC ) which was reviewed by the survey team and approved on 12/14/16. The identified Immediate Jeopardy citation was corrected as of 7/16/2016. The POC included the following: All residents at the facility were reviewed to ensure they were not affected by the deficient practice. On July 13, 2016 education was initiated by Director of Nursing (DON) and Director of Education (DOE) for Nursing staff that included: Staff re-education by Director of Education on Resident Abuse/Neglect was initiated and completed on July 14, 2016; Inservice included icons to determine care plan of residents Following that date, education was completed as staff members arrived for their next scheduled shift. Administrator and Director completed an ad hoc Quality Assurance and Performance improvement meeting with the Medical Director on July 13, 2016. In addition inservice to all staff on resident transfer technique, resident profile and the icons posted in each resident's room to inform staff which type of transfer to use for the resident. Results of monitoring will be presented by the Quality Assurance Performance Improvement (QAPI) committee by the Director of Nursing and Administrator for period of 3 months to ensure compliance is maintained. Any areas of concern identified will be addressed at time of discovery. During the survey based on observation and interview of staff members and residents related to the items noted in the facility plan of correction the Immediate Jeopardy at Past non-Compliance was determined to be in place and corrected as of 7/16/2016. The facility admitted Resident #101 with [DIAGNOSES REDACTED]. Random observations on 12/12/16 and 12/13/16 between the hours of 8:30 AM and 4: 30 PM revealed Resident #101 had contractures in both hands with no splint devices in place. Review of the medical record on 12/13/16 at approximately 1:44 PM revealed a physician's orders [REDACTED]. Further review of the medical record revealed a care plan updated on 11/17/16 that indicated hand carrots as ordered. An interview on 12/13/16 at approximately 2 PM with Registered Nurse (RN) #1 stated Resident #101 needed hand splints and confirmed they were not in place as care planned. The facility admitted Resident #76 with [DIAGNOSES REDACTED]. Random observations on 12/12/16 and 12/13/16 between the hours of 8:30 AM to 4:30 PM revealed the resident was not wearing hand splints for contracture. Review of the medical record on 12/13/16 at approximately 2:52 PM reviewed a physician's orders [REDACTED]. Further review of the medical record revealed a care plan updated on 11/09/16 that indicated PROM and apply splints as ordered. An interview on 12/13/16 at approximately 3:11 PM with Registered Nurse (RN) #1 confirmed Resident #76 was care planned for wrist splint. RN #1 stated there was no documentation to indicate the wrist splint was being provided as care planned.

Based on record review and interview Resident #67 was transferred incorrectly by a staff Certified Nursing Assistant (CNA). The CNA transferred the resident alone using a stand and pivot method instead of the hoyer lift with the assistance of two staff members. The resident was found to have a fracture of the left femur the next morning. Resident # 78 was left unsupervised in an enclosed courtyard for an extended period of time with staff not checking on him/her. This failure on the part of staff resulted in Resident #78 receiving burns to both shoulders. After review of corrective action put in place related to both incidents it was determined that Immediate Jeopardy at past non-compliance existed in the facility as of 6/10/2017 (with Resident 67's incorrect transfer) and continued with Resident #78's burns. The facility was in compliance with both as of 7/16/2017. ( 2 of 6 residents reviewed for accidents/hazards.) The findings included: The facility admitted Resident #67 with [DIAGNOSES REDACTED]. Review of the facility's Initial 24 - Hour Report regarding an injury of unknown source for Resident #67 on 12/12/16 at 10:30 AM, revealed that on 6/11/2016 at 7:00 AM the resident had a large discoloration to the left inner thigh. The resident was sent to the emergency room where x-rays revealed that the resident had suffered a fracture of the Left Femur. Record review of Resident #67's Resident Profile on 12/13/2016 at 3:09 PM, revealed that Resident #67 was to transfer with the assist of 2 persons with a hoyer lift. Record review of Resident #67's Care Plan on 12/13/2016 at 4:37 PM, revealed that staff were to use a hoyer lift to transfer the resident. In addition, the Care Plan revealed that the resident will kick, bite, cry, pull hair and scratch during care. Review of an Incident Report on 12/13/2016 at 1:45 PM, revealed that the injury was identified by the facility on 6/11/2016 at 7:00 AM. Record review of the Radiology Reports on 12/12/2016 at 10:30 AM revealed that Resident #67 had significant Osteopenia (reduced bone mass). The report indicated that the age of the fracture (when it occurred) could not be determined by x-ray due to the Osteopenia. Review of documentation of an interview conducted by the facility with CNA (Certified Nursing assistant) #1 on 12/12/2016 at 10:30 AM, revealed that on 6/10/2016 between 9:30 AM - 10:00 AM, CNA #1 transferred Resident #67 inappropriately. Per the statement (dated 6/12/2016), CNA #1 stated that he/she transferred Resident #67 from the bed to the wheelchair without using a hoyer lift and assistance from other staff. Per the statement CNA #1 used a stand and pivot transfer. In addition, at approximately 1:30 PM CNA #1 used a stand and pivot transfer to return the resident back to bed. Per the statement, CNA #1 stated he/she did not know the resident was to be transferred with a hoyer lift. In addition, CNA #1 did not know where to look in the resident's record to know how the resident should be transferred. CNA #1 denied that the resident had any pain or bruising at any time on his/her shift. CNA #1 cared for Resident #67 on the 1st shift. Review of documentation of an interview conducted by the facility with CNA #4 on 12/12/2016 at 10:30 AM, revealed that CNA #4 cared for Resident #67 on the 2nd shift. Per the statement (dated 6/13/2016), CNA #4 did not transfer the resident, but did reposition the resident in bed. CNA #4 denied seeing any bruising or discoloration to the resident's skin on his/her shift. Per the statement, while turning the resident to change her/his brief, Resident #67 did fight a little and was grabbing at me, but she always does this. Review of documentation of an interview conducted by the facility with CNA #2 on 12/12/2016 at 10:30 AM, revealed that CNA #2 cared for Resident #67 on the 3rs shift. Per the statement (dated 6/11/16), CNA #4 stated that while changing the resident's brief she/he noticed a large, dark discoloration to the resident's upper, left thigh. This was observed on CNA #4's final rounds. Review of documentation of an interview conducted by the facility with LPN (Licensed Practical Nurse) #2 on 12/12/2016 at 10:30 AM, revealed that LPN #2 cared for Resident #67 on the 1st shift on 6/10/2016. Per the statement (dated 6/13/2016), LPN #1 stated that she/he did not observe nor was it reported to her/him that Resident #67 had any complaints of pain or discoloration to the left thigh. Review of documentation of an interview conducted by the facility with LPN (Licensed Practical Nurse) #1 on 12/12/2016 at 10:30 AM, revealed that LPN #1 cared for Resident #67 on the 2nd shift on 6/10/2016. Per the statement (dated 6/13/2016), LPN #1 stated that she/he did not observe any discoloration to Resident #67's thigh. In addition, LPN #1 stated that CNA #4 did not report any skin changes or complaints of pain to her/him. The statement indicated that CNA #4 did report the combative behavior during care to LPN #1. Review of documentation of an interview conducted by the facility with the Orthopedic physician who treated Resident #67's fractured Femur on 12/12/2016 at 10:30 AM, revealed that the resident had brittle bones. Per the statement (dated 6/16/2016), the physician stated Resident #67 suffered an impact fracture to the Left Femur. The physician could not identify the cause of the fracture. He/she stated that it may have occurred during a transfer in which the resident's foot landed on the floor. The physician statement indicated that it would not have taken much to cause the fracture due to the resident's brittle bones and age. During an interview with CNA #3 on 12/13/2016 at 2:19 PM, CNA #3 was asked how CNAs know how to transfer residents. CNA #3 stated that CNAs look at the Resident Profile in the computer to find this information. In addition, CNA #3 stated that there are symbols above each residents bed that indicate certain types of care the resident should receive, including transfers. CNA #3 stated that she/he received training during orientation on using the Resident Profile in the computer, on the symbols above the bed and on the use of hoyer and other mechanical lifts for transferring residents. CNA #3 is Resident #67's current CNA. During an interview with CNA # 2 (3rd shift) on 12/13/2016 at 2:15 PM, CNA #2 confirmed her/his statement from 6/11/2016. CNA #2 denied transferring the resident, but did reposition the resident during rounds. CNA #2 stated the resident had no signs of pain during her/his shift. CNA #2 verbalized what type of care the resident required and where to look in the record for the type of care the resident required. During an interview with CNA # 1 on 12/13/2016 at 2:15 PM, CNA #1 confirmed her/his statement from 6/12/2016. CNA #1 stated he/she did not transfer the resident with a hoyer lift and assistance from other staff per the Care Plan and Resident Profile. CNA #1 stated he did not remember receiving any training on how to access the Resident Profile or training on what the symbols above the resident's bed meant. CNA #1 stated he/she asked other staff how to transfer the resident prior to caring for her/him. CNA #1 stated that he/she was told that Resident #67 was a one person transfer. CNA #1 could not remember who told him/her that the resident was a one person transfer. During an interview with the facility's Medical Director (MD) on 12/13/2016 at 2:26 PM, the MD stated he/she had read the Orthopedic physicians statement and office notes. The MD stated she concurred with the findings of the Orthopedic physician. The MD stated we can't be sure of how the fracture occurred. The MD stated it was a logical, educated guess that the fracture occurred during the one person transfer. The MD stated the resident had a history of [REDACTED]. In addition, the MD stated he/she had witnessed these behaviors and it was possible the fracture occurred as a result of kicking. LPNs #2 and #1 confirmed there statements during interviews on 12/13/2016 at 2:45 PM and 3:06 PM. Both LPNs stated that the resident seemed like her normal self on their shifts. LPN #1 and #2 stated they checked on Resident #67 at least every 2 hours. Both LPNs denied that the resident had any signs or symptoms of pain or that any injury had occurred. During an interview with the Nurse Practitioner (NP) on 12/14/2016 at 9:39 AM, the NP stated that it was unknown when exactly Resident #67's fracture occurred. The NP reviewed the Radiology Reports during the interview and stated that the x-rays could not determine if this was an acute fracture. When asked what this meant the NP stated that this meant the fracture could have occurred on the day of the incident or days before the incident. The NP stated that the resident had brittle bones from Osteopenia The facility admitted Resident # 78 with [DIAGNOSES REDACTED]. Hyperthermia, Blisters to both shoulders, and Dehydration were a result of the failure of the facility to bring the resident back in timely from the courtyard after being left outside by the Speech Therapist. On 7/12/16 at 4:30 PM Resident #78 was observed alone in the enclosed courtyard unattended. Staff described the resident as lethargic and unresponsive with blisters noted to both shoulders. The resident was brought into the Activity room and the Director of Nursing and nursing staff called to the room. The resident's temperature axillary was 106.6 degrees. Ice packs were applied and EMS called to transport resident to the hospital. The resident was given IV fluids( intravenous) and admitted for observation. Resident #78 also treated for [REDACTED]. Resident #78 was readmitted to facility on 7/14/6 with thermal burns to both shoulders and was treated with silvadene cream and xerofoam dressing twice a day. An interview with Resident #78 on 12/12/16 revealed that the resident remembered being taken to the courtyard by the speech therapist and being left out side for a long time. He had no way to call for help and he could not self propel his wheelchair. Also he could not open the door to exit the courtyard. The facility DON ( Director of Nursing) went with this surveyor to observe the resident's shoulders. Both shoulders near back of shoulders had scar tissue. The Resident did state that was where he got burned sitting out in sun. He said he did not have any T Shirts, CNA's (Certified Nursing Assistants) assigned stated they had never seen him have any T Shirts. DON checked residents closet and drawers. There were no T Shirts. Director of Social services stated also that resident did not own any T Shirts. He/she only wore button up shirts or short sleeved pull over shirts. Resident said it was really hot outside that day. DON checked weather app on her phone and stated on 7/12/16 It was between 68-95 degrees. The average temperature being 82 degrees. The staff interviews done by the Director of Nursing stated the Speech Therapist said she was taking the resident outside for a while and would bring him back to his room. Interview With LPN #1 ( Licensed Practical Nurse.) on 12/14/16 at 11:30 AM stated he/she was on duty the day of the incident and heard the therapist tell the floor nurse she/he was going to take the resident outside and would bring him back in side in a few minutes. Whenever Therapy takes a resident off the unit, they always return the resident to their unit. Staff thought the resident had been brought back into the facility. On 12/14/16 at 10:25 AM the Administrator, Director of Nursing , and Corporate Consultant were notified that Immediate Jeopardy and Substandard Quality of Care was identified at F 323 at a scope and severity of J. Immediate Jeopardy and Substandard Quality of Care at Past Noncompliance existed in the facility on 6/10/16 related to Resident #67 found to have a fractured femur after an incorrect transfer by a Certified Nursing Assistant and Resident # 78 being found unresponsive and lethargic in the courtyard after 3.0 hours unattended. The facility submitted a Plan of Correction ( POC ) which was reviewed by the survey team and approved on 12/14/16. The identified Immediate Jeopardy citations were corrected as of 7/16/2016. The POC included the following: All residents at the facility were reviewed to ensure they were not affected by the deficient practice. On July 13, 2016 education was initiated by Director of Nursing (DON) and Director of Education (DOE) for Nursing staff that included: the expectation that residents are hydrated especially during summer months water pitchers are full and within reach Residents are to be signed out in log book by a staff member when leaving the unit The log book is located at all nurse's stations Residents are not to be left in any area without a way or ability to communicate need for help; residents are not to be left in any area without supervision nurses and aides are to do hourly rounds on unit and record on log Nursing staff are to complete walking rounds at shift change and record on log. Education for Maintenance staff was done by Director of Nursing and Director of Education on completing outside walking rounds during daylight hours and recording on log. This was initiated and completed on July 13, 2016 Education by Director of Nursing for Department Heads on completing walking rounds to account for residents was initiated and completed on July 14, 2016. Staff re-education by Director of Education on Resident Abuse/Neglect was initiated and completed on July 14, 2016; Inservice included icons to determine care plan of residents Following that date, education was completed as staff members arrived for their next scheduled shift. Outside rounding conducted by Maintenance personnel was recorded on log sheets beginning July 14, 2016. Rounding on units was conducted by Nurses beginning July 14, 2016. Resident sign out books are located at all nursing stations. Administrator and Director completed an ad hoc Quality Assurance and Performance improvement meeting with the Medical Director on July 13, 2016. In addition inservice to all staff on resident transfer technique, resident profile and the icons posted in each resident's room to inform staff which type of transfer to use for the resident. Results of monitoring will be presented by the Quality Assurance Performance Improvement (QAPI) committee by the Director of Nursing and Administrator for period of 3 months to ensure compliance is maintained. Any areas of concern identified will be addressed at time of discovery. During the survey based on review of log books for both nursing and maintenance staff, interview of staff members and residents related to the items noted in the facility plan of correction and observation of residents leaving the unit supervised by staff per their plan of correction the Immediate Jeopardy at Past non-Compliance was determined to be in place and corrected as of 7/16/2016.

On the day of the survey, based on review of facility files and interview, the facility failed to ensure that each resident received adequate supervision and assistance to prevent accidents. Resident #1 was injured on during a transfer on 9/19/12 when the Certified Nurse Aide failed to use the appropriated transfer device. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes revealed an entry on 9/19/12 "resident with c/o (complaints of) pain to lt (left) ankle no swelling or discoloration." And an entry on 9/20/12 "CNA (Certified Nurse Aide) reported that resident had c/o pain to lt ankle check area slight swelling noted." Review of Resident #1's Radiology Report dated 9/20/12 revealed "fracture left os calcis." Review of the resident's Quarterly Minimum (MDS) data set [DATE] revealed resident required extensive assistance with transfers. Review of the residents care card revealed "stand up lift - AM, Hoyer lift - PM." Review of Resident #1's Treatment Flowsheet dated 9/1/12 - 9/30/12 revealed "May use hoyer lift to place resident back in bed at end of day." Review of the Resident Incident form dated 9/20/12 revealed "resident stated that CNA 2 days ago transferred her to bed her L (left) foot hit side of bed spoke with CNA did transfer resident to bed didn't realize that her foot hit the bed." During interview on 10/15/12 at approximately 3:45 PM CNA #1 stated that s/he did not know Resident #1 needed a lift for transfers. Resident #1 was not in CNA #1's resident group, but CNA #1 was helping another CNA with his/her residents. CNA #1 stated that there was no lift pad under the resident so s/he thought Resident #1 was a stand and pivot transfer. CNA #1 did not know about resident care cards or icons until the inservice the first part of October. Review of facility documentation revealed CNA #1 was hired 8/14/12. Review of facility documents revealed CNA #1 received competency training on transfer techniques and training on icons and care cards on 10/2/12. No documentation was provided showing that CNA #1 received competency training prior to 10/2/12. During interview on 10/15/12 at approximately 12:45 PM the Director of Education stated that s/he had been out on leave from 7/24/12 - 10/1/12. The Director of Nursing stated that different departments did inservice training while the Director of Education was out on leave. During interview on 10/15/12 at approximately 3:40 PM the Director of Nursing (DON) stated that after talking with CNA #1 after the incident on 9/20/12 s/he realized that new CNA's needed more training. The DON wanted to make sure new CNA's had the skills they needed and an inservice was completed the first part of October after the Director of Education returned.

On the day of the survey, based on review of facility files and interview, the facility failed to ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs. Nurse aides did not receive appropriate training related to transfers with lifts resulting in a fall with a fracture for 1 of 2 residents reviewed for lifts. The findings included: Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse's Notes revealed an entry on 9/19/12 "resident with c/o (complaints of) pain to lt (left) ankle no swelling or discoloration." And an entry on 9/20/12 "CNA (Certified Nurse Aide) reported that resident had c/o pain to lt ankle check area slight swelling noted." Review of Resident #1's Radiology Report dated 9/20/12 revealed "fracture left os calcis." Review of the resident's Quarterly Minimum (MDS) data set [DATE] revealed resident required extensive assistance with transfers. Review of the residents care card revealed "stand up lift - AM, Hoyer lift - PM." Review of Resident #1's Treatment Flowsheet dated 9/1/12 - 9/30/12 revealed "May use hoyer lift to place resident back in bed at end of day." Review of the Resident Incident form dated 9/20/12 revealed "resident stated that CNA 2 days ago transferred her to bed her L (left) foot hit side of bed spoke with CNA did transfer resident to bed didn't realize that her foot hit the bed." During interview on 10/15/12 at approximately 3:45 PM CNA #1 stated that s/he did not know Resident #1 needed a lift for transfers. Resident #1 was not in CNA #1's resident group, but CNA #1 was helping another CNA with his/her residents. CNA #1 stated that there was no lift pad under the resident so s/he thought Resident #1 was a stand and pivot transfer. CNA #1 did not know about resident care cards or icons until the inservice the first part of October. Review of facility documentation revealed CNA #1 was hired 8/14/12. Review of facility documents revealed CNA #1 received competency training on transfer techniques and training on icons and care cards on 10/2/12. No documentation was provided showing that CNA #1 received competency training prior to 10/2/12. During interview on 10/15/12 at approximately 3:20 PM CNA #2 stated that s/he had received one day of class training and shadowed another CNA for two days when hired. CNA #2 also stated that s/he had attended an inservice the first part of October and had learned things she did not know. Review of facility documentation revealed CNA #2 was hired on 8/20/12. During interview on 10/15/12 at approximately 12:45 PM the Director of Education stated that s/he had been out on leave from 7/24/12 - 10/1/12. The Director of Nursing stated that different departments did inservice training while the Director of Education was out on leave. During interview on 10/15/12 at approximately 3:40 PM the Director of Nursing (DON) stated that after talking with CNA #1 after the incident on 9/20/12 s/he realized that new CNA's needed more training. The DON wanted to make sure new CNA's had the skills they needed and an inservice was completed the first part of October after the Director of Education returned.

On the day of the Complaint Survey, based on record review and interview of the facility staff, the facility staff failed to provide care and services in accordance with professional standards of practice for one of two residents reviewed with tracheostomies. Resident #1 did not receive [MEDICAL CONDITION] care or humidified oxygen on 9/28/2011-9/29/2011,Resident #1 was not sent to the emergency room timely for respiratory distress on 10/27/11, and Resident #1 did not have an interim care plan or comprehensive care plan that reflected the resident's care needs. The findings included: The facility admitted Resident #1 on 09/05/2011 with [DIAGNOSES REDACTED]. The resident was admitted to the hospital for treatment several times after the 9/5/11 facility admission and then finally discharged from the facility to the hospital on [DATE] and readmitted to the facility on [DATE]. Resident #1 was again discharged to the hospital on [DATE] and remained in the hospital at the time of the survey. Review of the Interim Care Plan dated 09/09/2011 (4 days after the resident was originally admitted ) revealed, "Pulmonary Disease: suction PRN (as needed), O2 per 5 [MEDICAL CONDITION] 5 LPM (liters per minute), Humidified O2 at 28% [MEDICAL CONDITION]" The Interim Care Plan did not include any other interventions related to the care of the resident'[MEDICAL CONDITION] any hospitalization s, Central Line Access, [MEDICAL TREATMENT] access changes and infections. The Interim Care Plan did not address the resident's complexity of care or her unstable medical conditions. No Interim Care Plan was developed for the resident's second admission back to the facility on [DATE]. During an interview on 11/15/2011 at 10:55 AM, the Care Plan Coordinator confirmed the Interim Care Plan was dated 09/09/2011 and did not include the necessary care items for Resident #1. An Admission Minimum (MDS) data set [DATE] coded the resident as having moderately impaired decision making abilities. The resident was coded as requiring total two person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. The resident was noted to receive all nutrition via a [DEVICE]. The resident was coded as receiving [MEDICAL TREATMENT] and [MEDICAL CONDITION] Care. No Comprehensive Care Plan was developed. During an interview on 11/15/11 at 10:55 AM, the Care Plan Coordinator stated that Resident #1 did not have a comprehensive care plan developed. She stated that the Admission MDS had been completed but when the resident was scheduled to have her care plan developed she had been transferred to the hospital. Review of the physician's orders [REDACTED].@ 28% [MEDICAL CONDITION], check O2 saturation every shift and as needed to keep saturations greater than 92%, #6 [MEDICATION NAME]. Review of the Nurses Notes dated 09/29/2011 revealed, "Approximately 7:40 AM resident anxious and writer (Licensed Practical Nurse #1) pulled [MEDICATION NAME] to take in room c (with) other meds. Resident a little SOB (Short of Breath) p (after) being turned- wound care nurse going on started to suction while writer prepped for meds- when wound care nurse attempting to suction, very dry, writer aided and added a little saline out of pink [MEDICATION NAME] to provide moisture. Suctioned a little thick sputum appeared tight in trach- inner cannula removed - found to be completely filled c thick dry mucous- almost completely filled c very little area though for air- also when writer entered room, sterile water container on humidifier was empty- writer placed sterile water in to produce humidity p suctioning- inner cannula changed- med administered and respiratory treatment administered by writer... sat maintained at 95-96%... when coming out of room across hall from resident at approximately 10:15 AM, resident's roommate was standing in door way saying honey come here she needs you- writer in room noticed all electricity out, yelled for assistance, attempt to move plug to another outlet would not work- all plugs removed all equipment rolled to door and plugged in outside door into a red emergency outlet- (Maintenance) had already been paged in beginning- on scene immediately and out of room to check the breaker- during all this time wound care nurse had been giving resident air through Ambu Bag prior to electricity source being switched on... Sat 83%-84%. EMS had already been called, they arrived in approximately 8 minutes-incident started at 10:15 AM, EMS here at 10:30 AM... EMS to (Hospital)... " At 3:30 PM, "spoke with daughter, stated Pulmonologist at (Hospital) admitting her mom... " The resident returned on 10/7/2011. The resident returned with a Central Line for IV Antibiotics for Endocarditis. On 10/11/2011 during the 11-7 shift, Resident #1 had a "mod(erate) amount of white blood tinged secretions." On 10/22/2011 during the 3-11 shift, " suctioned x1 upon return- blood tinged thin secretions." On 10/23/2011 during the 7-3 shift, the resident "coughed up blood tinged secretions and noted when suctioned, notified MD via MD book." On 10/24/2011 during the 7-3 shift " resident in distress shortly after writer entered building... sent to ER." The resident returned at 2:55 PM the same day. On 10/25/2011 during the 7-3 shift, "bloody mucous inside dried to inner cannula." During the 11-7 shift the resident was noted to cough up a "small amount of blood tinged secretions. On 10/26/2011 during the 7-3 shift, "trach care completed inner cannula replaced- had small amount of dried blood on wall of cannula..." On 10/27/2011 at 12 AM, Resident #1 was "diaphoretic, skin cool and clammy, O2 sat= 54%... Resident repositioned, PRN [MEDICATION NAME] nebulizer tx (treatment) given. [MEDICAL CONDITION] cannula changed. Sats remained in the 50's. Lung sounds diminished. Resident alert and responding to staff. Abdominal breathing noted, MD and RT paged. " At 12:10 AM, The Respiratory Therapist returned the page and "advised to sent resident to ER." At 12:30 AM, "Telephone order rec'd (received) from (Provider on Call) to send to ER. Resident's daughter notified and she asked that her mom be sent to (Hospital). EMS called for transport." At 12:50 AM, "Resident transported to ER via stretcher. Report called..." Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1 did not [MEDICAL CONDITION] on the 11-7 shift on 09/29/2011. During an interview on 11/15/2011 at 2:30 PM, LPN #1 stated that she was assigned to the resident on 9/29/11 during the 7-3 shift. She stated that she noted the water bottle to the resident's humidifier was empty and the resident had a thick mucous plug that occluded the inner cannula. She stated that the nurses were to check the bottle frequently and refill as needed. Review of the Facility's 5 Day Report submitted to the State Agency on 10/7/2011 regarding the facility reported neglect related to [MEDICAL CONDITION] care revealed the facility substantiated neglect against Registered Nurse (RN #1). RN #1 was terminated due to her lack of care for Resident #1 on the 11-7 shirt on 09/28/2011. RN #1 failed to provide [MEDICAL CONDITION] care and failed to assure the humidifier was functioning appropriately. Review of the facility obtained statement dated 9/29 revealed "(RN #1) stated that she went in at 1 AM to give resident her [MEDICATION NAME] and [MEDICATION NAME]. Never really went in rest of night except to hang new tube feeding bag at 5 AM. Stated she would walk by and look in. (RN#1) stated she did not remember doing [MEDICAL CONDITION] on the resident and she did not realize that the suction machine was on all night or that the water bottle on humidified air compressor to the resident'[MEDICAL CONDITION] out of water. She stated that she never really did check on the resident. She stated that she knew the resident was up all night in the geri chair but she didn't think about it because she was told that the family requested it." Registered Nurse #1 (the nurse assigned to Resident #1 on 9/29) was not available for interview. Review of the Assignment Sheet revealed RN #1 was assigned to care for Resident #1 on the night shift of 9/28/2011-9/29/2011. Review of the Facility Corporate Training on [MEDICAL CONDITION] Care and Assessment revealed: "...Nursing Assessment: Humidity delivered to airway... [MEDICAL CONDITION] care is provided at least every 8 hours and more often if indicated." Review of the Respiratory Assessment Corporate Training dated 2011 revealed: "... Assessment of respiratory function is one of the MOST important assessments..."

On the day of the Complaint Survey, based on record review and interview, the facility failed to ensure one of two residents reviewed with tracheostomies received the necessary care and services to maintain the highest practicable wellbeing as possible. Resident #1 did not receive [MEDICAL CONDITION] care or humidified oxygen on [DATE]-[DATE]. The resident developed a mucous plug that occluded the inner cannula and was transferred to the hospital. Resident #1 also was not sent to the emergency room timely for respiratory distress on [DATE]. Resident #1's Attending Physician documented on ,[DATE] that the resident's complex care needs would be better served at an intermediate hospital. The facility admitted the resident back to the facility on [DATE] despite the physician's statement. Resident #1 coded on [DATE] and was readmitted to the hospital. The findings included: The facility admitted Resident #1 on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and readmitted on [DATE]. Resident #1 was again discharged to the hospital on [DATE] and remained in the hospital at the time of the survey. An Admission Minimum (MDS) data set [DATE] coded the resident as having moderately impaired decision making abilities. The resident was coded as requiring total two person assistance for transfers, bed mobility, dressing, toilet use, hygiene and bathing. The resident was noted to receive all nutrition via a [DEVICE]. The resident was coded as receiving [MEDICAL TREATMENT] and [MEDICAL CONDITION] Care. No Comprehensive Care Plan was developed. Review of the Interim Care Plan dated [DATE] (4 days after the resident was originally admitted ) revealed, "Pulmonary Disease: suction PRN (as needed), O2 per 5 [MEDICAL CONDITION] 5 LPM, Humidified O2 at 28% [MEDICAL CONDITION]. The Interim Care Plan did not include any other interventions related to the care of the resident'[MEDICAL CONDITION] any hospitalization s, Central Line Access, [MEDICAL TREATMENT] access changes and infections. The Interim Care Plan did not address the resident's complexity of care or her instability of medical conditions. No Interim Care Plan was developed for the resident's second admission on [DATE]. During an interview on [DATE] at 10:55 AM, the Care Plan Coordinator stated that Resident #1 did not have a comprehensive care plan developed. She stated that the Admission MDS had been completed but when the resident was scheduled to have her care plan developed she had been transferred to the hospital. The Care Plan Coordinator confirmed the Interim Care Plan was dated [DATE] and did not include the necessary care items for Resident #1. Review of the physician's orders [REDACTED].@ 28% [MEDICAL CONDITION], check O2 saturation every shift and as needed to keep saturations greater than 92%, #6 [MEDICATION NAME]. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Resident #1 also did not [MEDICAL CONDITION] on the ,[DATE] shift on [DATE]. Review of the Nurses Notes dated [DATE] revealed, "Approximately 7:40 AM resident anxious and writer (Licensed Practical Nurse #1) pulled [MEDICATION NAME] to take in room c (with) other meds. Resident a little SOB (Short of Breath) p (after) being turned- wound care nurse going on started to suction while writer prepped for meds- when wound care nurse attempting to suction, very dry, writer aided and added a little saline out of pink [MEDICATION NAME] to provide moisture. Suctioned a little thick sputum appeared tight in trach- inner cannula removed - found to be completely filled c thick dry mucous- almost completely filled c very little area though for air- also when writer entered room, sterile water container on humidifier was empty- writer placed sterile water in to produce humidity p suctioning- inner cannula changed- med administered and respiratory treatment administered by writer... sat maintained at ,[DATE]%... when coming out of room across hall from resident at approximately 10:15 AM, resident's roommate was standing in door way saying honey come here she needs you- writer in room noticed all electricity out, yelled for assistance, attempt to move plug to another outlet would not work- all plugs removed all equipment rolled to door and plugged in outside door into a red emergency outlet- (Maintenance) had already been paged in beginning- on scene immediately and out of room to check the breaker- during all this time would care nurse had been giving resident air through Ambu Bag prior to electricity source being switched on... Sat 83%-84%. EMS had already been called, they arrived in approximately 8 minutes-incident started at 10:15 AM, EMS here at 10:30 AM... EMS to (Hospital)... " At 3:30 PM, "spoke with daughter, stated Pulmonologist at (Hospital) admitting her mom... " The resident returned on [DATE]. The resident returned with a Central Line for IV Antibiotics for Endocarditis. On [DATE] during the ,[DATE] shift, Resident #1 had a "mod(erate) amount of white blood tinged secretions." On [DATE] during the ,[DATE] shift, " suctioned x1 upon return- blood tinged thin secretions." On [DATE] during the ,[DATE] shift, the resident "coughed up blood tinged secretions and noted when suctioned, notified MD via MD book." On [DATE] during the ,[DATE] shift " resident in distress shorted after writer entered building... sent to ER." The resident returned at 2:55 PM the same day. On [DATE] during the ,[DATE] shift, "bloody mucous inside dried to inner cannula." During the ,[DATE] shift the resident was noted to cough up a "small amount of blood tinged secretions. On [DATE] during the ,[DATE] shift, "trach care completed inner cannula replaced- had small amount of dried blood on wall of cannula..." On [DATE] at 12 AM, Resident #1 was "diaphoretic, skin cool and clammy, O2 sat= 54%... Resident repositioned, PRN [MEDICATION NAME] nebulizer tx (treatment) given. [MEDICAL CONDITION] cannula changed. Sats remained in the 50's. Lung sounds diminished. Resident alert and responding to staff. Abdominal breathing noted, MD and RT paged. " At 12:10 AM, The Respiratory Therapist returned the page and "advised to sent resident to ER." At 12:30 AM, "Telephone order rec'd (received) from (Provider on Call) to send to ER. Resident's daughter notified and she asked that her mom be sent to (Hospital). EMS called for transport." At 12:50 AM, "Resident transported to ER via stretcher. Report called..." Review of the Physician's Progress Notes revealed the resident was assessed on [DATE] due to the resident's daughter was concerned the resident was anxious "...AP 1) SOB- probably related to anxiety, however will obtain chest x-ray secondary to history of [MEDICAL CONDITIONS] " (CXR negative for [MEDICAL CONDITIONS]). On [DATE] the Attending Physician documented: "(Resident #1) has very high intensity resident needs c constant risk of decompensation or respiratory and cardiovascular status. She also requires very high intensity of care from the standpoint of her size. She has had repeated trips to the hospital with problems related to to her medical conditions. The level of her care requirements are likely beyond the capacity of a typical skilled care nursing facility and will be better provided in a long term intermediate level hospital facility. " The resident was readmitted to the facility on [DATE]. On [DATE] the resident decannulated and was sent to the emergency room . On [DATE] at 8:20 AM, Resident #1 coded and CPR was initiated. The resident was sent to the hospital and remained there during the survey. During an interview on [DATE] at 1:15 PM, the Attending Physician confirmed his note on [DATE] indicating the facility would not be able to meet the resident's care needs. He stated that the facility "probably shouldn't have admitted the resident " on [DATE]. He stated that the resident had multi-organ complex care needs including, [MEDICAL CONDITION], [MEDICAL TREATMENT], cardiovascular and obesity. He stated that the the resident's needs would be better served in intermediate care facility. He also stated that one LTACH denied the resident and the hospital was ready to discharge her. The Attending Physician stated that the facility would "try again" and she was readmitted on [DATE]. The Attending Physician stated that the time of the survey, the resident was on a ventilator in the Intensive Care Unit. The Physician once again stated that the resident's care needs could best be met in a different type of facility. The Physician stated that the resident was supposed to have humidified oxygen at all times. He stated that the resident did have problems with secretions. He stated that a lack of humidity could lead to dry mucous and mucous plugging that could lead to respiratory distress. The Attending Physician also stated that if a resident was in respiratory distress then the nursing staff should call 911 and send the resident to the emergency room . He stated that the provider should be notified but stated that he relied on nursing judgment to call 911 first if the situation was emergent. The Attending Physician stated that on [DATE] the resident should have been sent to the emergency room immediately. He stated that the nursing staff should not have waited 50 minutes before the resident was sent out. During an interview on [DATE] at 2:15 PM, the Director Of Nurses confirmed the resident had multiple care areas that exceeded the level of care abilities of the facility. She also confirmed that due to the complexities of the resident the facility wanted the resident to be admitted to a Long Term Acute Care Hospital. The DON stated that one LTACH denied the resident and the facility made the decision to accept the resident back. The DON confirmed the Attending Physician's statement stated that the facility would not be able to meet the care needs of the resident. The DON confirmed again that the resident was readmitted despite the physician's statement. During an interview on [DATE] at 2:30 PM, LPN #1 stated that she was assigned to the resident on [DATE] during the ,[DATE] shift. She stated that she noted the water bottle to the resident's humidifier was empty and the resident had a thick mucous plug that occluded the inner cannula. She stated that the nurses were to check the bottle frequently and refill as needed. Licensed Practical Nurse #2 (the nurse assigned to the resident on [DATE]) was not available for interview. Review of the 5 Day Report submitted on [DATE] revealed the facility substantiated Neglect against RN #1. RN #1 was terminated due to her lack of care for Resident #1. RN #1 failed to provide [MEDICAL CONDITION] care and failed to assure the humidifier was functioning appropriately. Review of the facility obtained statement dated ,[DATE] revealed " (RN #1) stated that she went in at 1 AM to give resident her [MEDICATION NAME] and [MEDICATION NAME]. Never really went in rest of night except to hang new tube feeding bag at 5 AM. Stated she would walk by and look in. (RN#1) stated she did not remember doing [MEDICAL CONDITION] on the resident and she did not realize that the suction machine was on all night or that the water bottle on humidified air compressor to the resident'[MEDICAL CONDITION] out of water. She stated that she never really did check on the resident. She stated that she knew the resident was up all night in the geri chair but she didn't think about it because she was told that the family requested it. " Registered Nurse #1 (the nurse assigned to Resident #1 on ,[DATE]) was not available for interview. Review of the Assignment Sheet revealed RN #1 was assigned to care for Resident #1 on the night shift of ,[DATE]-[DATE]. Review of the Time Care report revealed RN #1 clocked in at 10:19 PM on ,[DATE] and clocked out at 7:14 AM on [DATE]. Review of RN #1's Inservices revealed she received training with competencies on emergent [MEDICAL CONDITION] reinsertion and [MEDICAL CONDITION] care on [DATE]. Review of the Facility Corporate Training on [MEDICAL CONDITION] Care and Assessment revealed: Nursing Assessment: Humidity delivered to [MEDICAL CONDITION] care is provided at least every 8 hours and more often if indicated. " Review of the Respiratory Assessment Corporate Training dated 2011 revealed: " Assessment of respiratory function is one of the MOST important assessments. "