Every finding on record at Memorial Manor Nursing Home

18750 Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Dignity, the facility failed to ensure residents ate in a dignified manor in that the facility supplied plastic utensils during meal service affecting three of 34 sampled Residents (R) (R3, R21, and R35). The plastic utensils were difficult for some of the residents to grip and carry food to their mouth for residents with certain disease processes. Findings include: Review of the facility's undated policy titled Dignity revealed, All Residents are to be treated with dignity, respect, consideration, and in a manner that recognizes their individuality. 1. During an interview on 4/28/2025 at 12:57 pm, R21 stated that she ate all meals in her room. When asked why she had plastic utensils, R21 said that was what always came with the trays. Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) revealed R21 was admitted on [DATE]. Review of the Quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 2/13/2025 for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15 which indicated R21 was cognitively intact; Section GG (Functional Abilities and Goals) revealed, R21 was independent with eating. 2. During an observation and interview on 4/28/2025 at 12:03 pm, R3 was served lunch in her room. The tray had a sealed packet containing plastic utensils. R3 described an injury to her right arm which made eating difficult. When asked how the resident used the plastic utensils to cut the chicken and large broccoli spears, R3 said Oh, I just get through it, this [plastic utensils] is what we always have. Review of the Admission Record located under the Profile tab in the EMR revealed R3 was admitted on [DATE]. Review of the Admission MDS with an ARD of 3/28/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 12 out of 15 which indicated R3 was cognitively intact. 3. During an observation on 4/28/2025 at 12:30 pm, room trays were passed to residents with plastic utensils. During an interview on 4/28/2025 at 12:35 pm, R35 was observed with plastic utensils and was eating with his hands. R35 was asked if he could use the utensils. R35 stated, I hate using these things. R35 was asked why plastic utensils were provided. R35 stated, I do not know. These are all I ever get to use. Review of the Resident Council meeting minutes dated 8/27/2024 revealed a note where the residents wanted regular silverware. Review of R35's EMR revealed an undated Admission Record located under the Profile tab that revealed an admitted [DATE]. During an observation on 4/29/2025 at 12:36 pm and on 4/30/2025 at 12:40 pm, R35 received a meal tray with plastic utensils. During an interview on 4/30/2025 at 12:48 pm, Certified Nurse's Aide (CNA) 4 was asked if she knew why R35 received plastic utensils. CAN 4 stated, It is because of an upper respiratory infection. He drools. In a group meeting on 4/30/2025 at 10:30 am, five residents (R6, R19, R30, R38, and R51) selected by the facility as interviewable and attended monthly Resident Council Meetings on a regular basis stated that they had always received plastic utensils with each meal. R6 stated, I shake, and the plastic fork makes it hard to keep food on it. Review of the Admission MDS with an ARD of 2/17/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 15 out of 15 which indicated R6 was cognitively intact. Review of the Quarterly MDS with an ARD of 1/25/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 15 out of 15 which indicated R19 was cognitively intact. Review of the Quarterly MDS with an ARD of 2/1/2025 for Section C (Cognitive Patterns) revealed a BIMS score of nine out of 15 which indicated R30 was moderately cognitively impaired. Review of the Admission MDS with an ARD of 2/24/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 13 out of 15 which indicated R38 was cognitively intact. Review of the Annual MDS with an ARD of 2/5/2025 for Section C (Cognitive Patterns) revealed a BIMS score of 15 out of 15 which indicated R51 was cognitively intact. Interview on 5/1/2025 at 9:00 am, the Dietician stated that silverware had not been utilized because it always goes missing, it gets thrown away. The Dietician was asked if she had considered the difficulty in using plastic utensils to cut food or keep food on a fork or if plastic utensils were undignified. The Dietician's reply was that she would order more silverware. During an interview on 4/30/2025 at 3:08 pm, the Social Worker (SW) was asked if it had been brought to her attention that R35 has been given plastic utensils to eat with. The SW stated it has been an ongoing problem that the Administrator has been trying to work out with the dietician. The SW stated, They can't eat with those. During an interview on 5/1/2025 at 10:06 am, the Administrator was asked about the residents getting plastic utensils rather than silverware. The Administrator stated, It is a dignity issue that we have been trying to get resolved for some time. The most recent reason is the staff are throwing the utensils away. In the past it has been because the dish machine is not working.

Based on staff interviews, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to report an alleged staff to-resident verbal abuse to the State Agency (SA) within the required time frame for one of one resident reviewed for abuse. Specifically, an allegation of verbal abuse by Licensed Practical Nurse (LPN) 1 to a resident. The deficient practice had the potential for continued episodes of unreported abuse, which posed potential for intimidation or mental anguish for the victimized residents. Findings include: Review of the facility's policy titled, Abuse Prohibition Policies and Procedures, revised 4/1/2015, indicated The Director of Nursing and/or designee shall ensure that the Compliant Center is notified immediately, or as soon as practical, of all allegations which appear to a reasonable person to be related to patient abuse,. Review of the facility's staff abuse education packet titled, The Many Forms of Resident Abuse and Neglect, indicated There are multiple types of abuse, including: Physical Abuse, Mental Abuse, Verbal Abuse, Sexual Abuse, Deprivation of goods and services, Misappropriation of funds, and Exploitation. Review of the intake form received from the SA revealed the SA received the report of the allegation of employee-to-resident verbal abuse on 3/19/2025 from an anonymous source. During an interview on 4/29/2025 at 1:30 pm, the Administrator and Director of Nursing (DON) were notified of the allegation of alleged verbal abuse for a resident by License Practical Nurse (LPN) 1. During an interview on 4/30/2025 at 11:29 am, the Administrator stated, The allegation of verbal abuse was reported to the SA on 4/29/2025 at 4:57 pm. When asked about the required time frame for reporting verbal abuse to the SA, the Administrator stated, Allegations of physical abuse with harm are reported within two hours. If there is no physical harm, then we have longer to report but I'm not sure. Review of the email confirmation for the submission of the allegation to the SA, revealed the facility reported the allegation of verbal abuse to the SA on 4/29/2025 at 4:57 pm. During an interview on 4/30/2025 at 12:46 pm, the Administrator stated, I'm used to allegations coming from staff, residents, or family members. I'm not used to being notified of allegations coming from the survey team. When I have been notified of allegations from the state in the past, they have handled all of the investigations. I didn't have to do any of the investigation. The state investigated the allegation and reported the findings to me. I didn't know I needed to follow all of the process.

Based on observation, interview, record review, and review of the facility's policy titled Abuse Prohibition Policies and Procedures, the facility failed to protect residents during an active investigation of alleged staff to resident verbal abuse by Licensed Practical Nurse (LPN) 1, who was permitted to work while the facility's Administrator conducted an active investigation for one of one abuse investigation reviewed. The deficient practice had the potential for continued episodes of staff-to-resident verbal abuse and the potential for victimized residents to suffer from intimidation or mental anguish. Findings include: Review of the facility's policy titled Abuse Prohibition Policies and Procedures dated 4/11/2025 indicated, Protection of resident(s) during investigation: The safety of the resident(s) will be immediately secured by the first facility employee aware of the alleged abuse. Review of the intake form received from the State Agency (SA) revealed an allegation dated 3/19/2025 in which Licensed Practical Nurse (LPN) 1 verbally abused a resident from an anonymous source. During an interview on 4/29/2025 at 1:30 pm, the Administrator and Director of Nursing (DON) were notified of the allegation of staff-to-resident verbal abuse by LPN1 to a resident. LPN1 was not working on 4/29/2025 but was scheduled to work on 4/30/2025. On 4/30/2025 at 9:30 am, the facility provided a copy of the staffing sheet for 4/30/2025. LPN 1 was on the staffing sheet, scheduled to work 7:00-7:00 pm. Observation on 4/30/2025 at 9:45 am, LPN1 was at the medication cart outside residents' rooms. During an interview on 4/30/2025 at 9:45 am, the DON stated, We have talked with [LPN1]. The Administrator is in the process of talking with residents. The DON was asked, Are you still in an active investigation The DON replied, Yes. The DON stated, She can't be here. Observation on 4/30/2025 at 10:08 am, LPN1 exited the Administrator's office and left the building. During an interview on 4/30/2025 at 12:46 pm, the Administrator stated I was not sure that I needed to follow the same process of investigating an allegation of verbal abuse that came from a survey team instead of a resident, other employee, or family member. I did not know the staff member still needed to be suspended. The Administrator stated, normally, the employee is notified of the allegation and suspended pending the results of the investigation and not permitted to return to work until the investigation is completed. In the past, if notified of an allegation of abuse from the SA, the SA would investigate the complaint and notify us of the results. To protect residents during an investigation, we ensure no residents are harmed, the employee is not allowed in the building.

Based on observation, interview and record review, the facility failed to assist one out of 34 sampled Residents (R) (R44) with turning and repositioning. The deficient practice has the potential to cause the resident skin breakdown. Findings Include: Review of R44's Electronic Medical Record (EMR) revealed R44 admitted to the facility with diagnoses that include but not limited to of venous insufficiency, diabetes, and peripheral vascular disease. Review of R44's Admission Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 4/5/2025 in the EMR under the MDS tab for Section C (Cognitive Patterns) revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15 which indicated R44 was cognitively intact; Section GG (Functional Abilities and Goals) revealed, resident was dependent with rolling left to right, sit to lying, lying to sitting and sitting to standing position. Observation on 4/29/2025 at 10:21 am, R44 was in bed lying on her back with feet elevated in boots to off load heals. Observation on 4/29/2025 at 11:00 am, R44 remains lying on her back in bed. Interview at this time, when asked if she has been turned by staff, R44 stated, NO. Observation on 4/29/2025 at 11:27 am to 12:31 pm, R44 remains on lying on her back in bed. Observation on 4/29/2025 at 12:47 pm, R44 was served her lunch tray, and staff pulled her up in bed, to be able to eat her lunch. R44's legs remained flat. Observation on 4/29/2025 at 1:17 pm, Certified Nurse Aide (CNA) 5 came in and removed her tray. CNA5 did not turn or reposition R44 to her side. Interview on 4/29/2025 at 1:25 pm, the Director of Nursing (DON) stated that R44 refused to get out of bed. The DON stated R44 can move her upper body but does not want to be moved. Observation on 4/29/2025 at 2:31 PM, R44 remained in bed lying on her back Interview on 4/29/2025 at 2:35 pm, Licensed Practical Nurse (LPN) 2 stated that R44 refused care and does not want to be moved. She will not get out of bed into a wheelchair or even up to take a shower. Staff give her a bed bath. Interviewed on 4/29/2025 at 2:45 pm, CNA 5 stated that R44 does not like to be bothered. I don't go in unless she calls me. R44 is incontinent of urine and stool. I just check her when I get time. It should be every two to three hours.

Based on observation, interview, and record review, the facility failed to provide timely and complete incontinent care for two out of 34 Residents (R) (R44 and R45) reviewed for incontinent care. This failure placed the residents at risk for skin breakdown and/or risk for transmission of infection to the urinary tract. Findings include: Review of the facility's Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 11/7/2024 for CNA5, dated 11/11/2024 for CNA7, and dated 11/12/2024 for CNA 3 indicated, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. Review of the Nursing Procedure Guide for Long-Term Care on Perineal Care provided by the Clinical Care Coordinator (CCC), documented, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. 1.Review of R44's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/5/2025 for Section C (Cognitive Patterns) revealed, a Brief Interview for Mental Status (BIMS) score of 15 which indicated R44 was cognitively intact; Section GG (Functional Abilities and Goals) revealed, R44 was dependent on staff for toileting; Section H (Bowel and Bladder) revealed, R44 was always incontinent of both bowel and bladder. During an interview on 4/28/2025 at 2:45 pm R44 was asked if anyone had been in the room and had provided incontinent care. She stated, not since this morning before breakfast. Observation on 4/30/2025 at 2:45 pm revealed, Certified Nurse Aide (CNA) 5 entered R44's room to perform peri care. CNA 5 donned gloves and unfastened R44's incontinent brief. Using one wet, wash cloth with no soap, CNA 5 made several wipes up and down across R44's vaginal area. There was no washing the meatus, moving in only one direction, away from the meatus and not using a clean area of the washcloth for each stroke. The area was not dried. R44 was having a bowel movement at this time. CNA5 wiped R44 rectal area with a wet wash cloth with no soap several times. CNA 5 took the second washcloth and used it in the same manner to wipe the stool from R44's rectum. Folding the washcloth over she then washed the buttocks on both sides and did not dry any of the buttocks. R44 continued to have more stool coming from the rectum. CAN 5 placed a clean incontinent protector on R44, pulling the soiled incontinent protector out from under R44. Then CNA5 went over to R44's bedside table, touched it and the nightstand looking for barrier cream to place on R44 buttocks while wearing the same soiled gloves. CNA 5 adjusted R44's nasal cannula on her face and then collected up the trash and solid incontinent protector, washcloths and other trash and tied the bag wearing the same soiled gloves. CNA 5 pulled the privacy curtain back while wearing the same soiled gloves, touched the doorknob and door and exited the room. CNA 5 went down the hallway wearing the same soiled gloves opening the soiled utility room door and disposing the trash. CNA 5 went to the nurses' desk and walked over to hand sanitizer and sanitized her hands. 2. Review of R45's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/7/2025 for Section C (Cognitive Patterns) revealed, R45 was rarely/never understood; Section GG (Functional Abilities and Goals) revealed, R45 required substantial/maximal assistance with toileting hygiene; Section H (Bowel and Bladder) revealed, R45 was always incontinent of both bowel and bladder. Observation on 5/1/2025 at 10:20 am revealed, CNA 3 and CNA 7 donned gloves and were going to provided R45's peri care. R45 was in the bathroom and his incontinent brief was wet. CNA 3 removed his incontinent brief while he was standing in front of the toilet. After voiding in the toilet R45 stood up and peri care was performed. CNA 3 was in bathroom with R45 and washed his penis and scrotum and groin area. The penis foreskin was not retracted and cleaned. During an interview on 5/1/2025 at 10:40 am, CNA 3 confirmed that she did not pull R45's foreskin back and clean the area. CNA 3 and CNA 7 both stated the foreskin should have been pulled back and area cleaned. Interview on 5/1/2025 at 9:25 am, the CCC stated, I would expect all staff to follow the Nursing Assistant Clinical Skilled Check list and Competency Evaluation. Staff should be washing their hands, not touching items around the room and going down the hallway wearing soiled gloves.

Based on interviews and record review, the facility failed to have a system in place to ensure ongoing assessments of the resident's condition and monitoring for complications before and after dialysis treatments for one of one Resident (R) (R47) receiving dialysis treatments. The failure created the potential for the resident's quality of care to be compromised. Findings include: Review of the Admission Record located under the Profile tab in the Electronic Medical Record (EMR) noted R47 was readmitted on [DATE] with diagnoses that included end stage renal disease and dependence on renal dialysis. Review of Physician's Orders dated April 2025 located in the EMR under the Orders tab, revealed, R47 received dialysis on Monday, Wednesday, and Friday each week. Review of R47's Progress Notes located in the EMR under the Progress Notes tab revealed, there was no documented communication between the facility and dialysis center pre and post treatments to include an assessment of the residents' health status. Interview on 4/29/2025 at 3:05 pm, with the Unit Clerk revealed there was no specific Dialysis Communication Book. The communication was documented in the Hard Chart located at the nurses' station. Review of R47's Hard Chart failed to reveal communication between the facility and dialysis center pre and post treatments. Interview on 4/29/2025 at 3:10 pm, with the Infection Preventionist (IP) revealed, the information was in the Hard Chart. Upon inspection of the Hard Chart, the IP was unable to locate information between the facility and the dialysis center. Interview on 4/29/2025 at 3:15 pm, with the Director of Nurses (DON) revealed, We document in the Progress Notes when there is a concern noted. When asked where that information was located, the DON was unable to locate the information. A policy and procedure for communication between the facility and dialysis center was requested of the DON. A Dialysis Communication procedure was provided on 5/1/2025 at 11:08 am from the DON. The form was dated 5/1/2025. Interview on 5/1/2025 at 11:08 am, with the Administrator revealed, We have a procedure now.

Based on observation, interview, and record review, the facility failed to adhere to infection control practices during peri care related to the staff failing to change gloves and perform hand hygiene for three out 34 sampled residents (R44, R45, R308). Findings include: Review of the facility's Nursing Assistant Clinical Skills Checklist and Competency Evaluation dated 11/7/2024 for CNA5, dated 11/11/2024 for CNA7, and dated 11/12/2024 for CNA 3 indicated, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. Review of the Nursing Procedure Guide for Long-Term Care on Perineal Care provided by the Clinical Care Coordinator (CCC), documented, .11. If heavy soiling is present, wear gloves and use tissues or wipes to remove soiling prior to perineal care. If necessary, use additional clean washcloths, towels, Iinen, basins, water, and gloves. Remove and discard gloves and wash hands. 1. Observation on 4/30/2025 at 2:45 pm revealed, Certified Nurse Aide (CNA) 5 entered R44's room to perform peri care. CNA 5 donned gloves and unfastened R44's incontinent brief. Using one wet, wash cloth with no soap, CNA 5 made several wipes up and down across R44's vaginal area. There was no washing the meatus, moving in only one direction, away from the meatus and not using a clean area of the washcloth for each stroke. The area was not dried. R44 was having a bowel movement at this time. CNA5 wiped R44 rectal area with a wet wash cloth with no soap several times. CNA 5 took the second washcloth and used it in the same manner to wipe the stool from R44's rectum. Folding the washcloth over she then washed the buttocks on both sides and did not dry any of the buttocks. R44 continued to have more stool coming from the rectum. CAN 5 placed a clean incontinent protector on R44, pulling the soiled incontinent protector out from under R44. Then CNA5 went over to R44's bedside table, touched it and the nightstand looking for barrier cream to place on R44 buttocks while wearing the same soiled gloves. CNA 5 adjusted R44's nasal cannula on her face and then collected up the trash and solid incontinent protector, washcloths and other trash and tied the bag wearing the same soiled gloves. CNA 5 pulled the privacy curtain back while wearing the same soiled gloves, touched the doorknob and door and exited the room. CNA 5 went down the hallway wearing the same soiled gloves opening the soiled utility room door and disposing the trash. CNA 5 went to the nurses' desk and walked over to hand sanitizer and sanitized her hands. 2. Observation on 5/1/2025 at 9:25 am revealed, CNA3 and CNA7 entered R308's room to provide peri care. CNA3 and CNA7 donned gloves and performed R308's peri care. While wearing the same soiled gloves, CNA3 and CNA7 pulled R308's shorts up. Then CNA7 proceeded to pull R308's blanket up around his neck while wearing the same gloves. CNA3 took the trash that was collected from the room and then touched the bathroom doorknob, the room knob and exited the room in the hallway. CNA3 removed her left glove, keeping the soiled right glove on. She then went to the soiled utility room and disposed of the trash. 3. Observation on 5/1/2025 at 10:20 am revealed, CNA 3 and CNA7 provided R45 peri care. CNA3 then placed a clean incontinence brief on R45 while wearing the same soiled gloves. CNA3 assisted R45 with his pants and then straightened his shirt. CNA3 moved R45's walker over near the resident wearing the same soiled gloves. CNA3 took dirty linens in bag and exited the bathroom touching the doorknob. CNA3 removed the right glove and did not perform hand hygiene to the right hand, exited the room, and preceded to the soiled utility room by the nurses' desk. CNA3 doffed the right glove and performed hand hygiene. Interview on 5/1/2025 at 10:40 am with CNA3 and CNA7 both stated that they realized that they had touched both R308 and R45's clothes without removing their soiled gloves. CNA3 voiced that she should not have touched items with gloved hand that were soiled and should not have gone up the hallway wearing soiled gloves to the soiled utility room touching the doorknobs and spreading germs. Interview on 5/1/2025 at 9:25 am, the CCC stated, I would expect all staff to follow the Nursing Assistant Clinical Skilled Check list and Competency Evaluation. Staff should be washing their hands, not touching items around the room and going down the hallway wearing soiled gloves.

Based on observations, staff interviews and review of the facility's policy titled, Care of the Resident with a urinary catheter, the facility failed to ensure that four of six residents (R) (R2, R3, R9, R10) with indwelling catheters were secured and stored properly. Specifically, the facility failed to ensure that R2, R3, and R10's catheter tubing was secured with catheter straps, and R9's catheter drainage bag was not stored on the floor. Findings included: Review of the facility's policy Care of the Resident with a Urinary Catheter with revised date of 10/2014, revealed under Procedure: 5. Maintain tension free catheter by taping securely but still allowing movement. Never allow bag to touch the floor. 1. Review of the Admission record revealed R2 was admitted to the facility with diagnoses that included but not limited to hemiplegia and hemiparesis, vascular dementia, urogenital implants, hypertension, neuromuscular dysfunction of bladder, and dysphagia. Review of the Order Summary Report as of 10/22/2024 revealed an order for, catheter to bedside drainage bag. Review of Documentation Survey Report v2 dated Oct-2024 revealed no evidence of catheter care as indicated by blank boxes for 10/3/2024 dayshift, 10/7/2024 night shift, 10/12/2024 day and night shift, 10/15/2024 night shift, 10/18/2024 night shift, and 10/21/2024 night shift. Observation on 10/22/2024 at 10:31 am revealed R2 was lying in bed. Certified Nursing Assistant (CNA) CC, being assisted by CNA AA, were providing catheter care to R2. There was no evidence of a catheter strap or device to secure the catheter tubing. During catheter care, CNA CC turned R2 toward CNA AA, and the catheter tubing was caught on the bed frame pulling on the catheter tubing. R2 was rolled onto his back and CNA CC loosened the catheter tubing from the bed frame. CNA CC took the catheter drainage bag, with a dignity covering, and placed it on the bed next to the resident. R2 was again rolled facing the window. The catheter drainage bag with the dignity cover remained on the bed through the last phase of the perineal/catheter care. R2 was then turned on his back, the catheter drainage bag with the dignity cover was placed on the right side of the bed. During an interview on 10/23/2023 at 11:58 am, CNA AA confirmed that R2 did not have a catheter strap to secure the catheter tubing. After an observation and interview with the surveyor, CNA AA and CNA CC placed a strap and secured the catheter tubing on R2. 2. Review of the admission record revealed R3 was admitted to the facility with diagnoses that included but not limited to systolic congestive heart failure, retention of urine, chronic kidney disease, ileostomy, atrial fibrillation, hypertensive heart disease, type 2 diabetes mellitus and dysphagia. Observation on 10/22/2024 at 10:20 am, CNA DD and Licensed Practical Nurse (LPN) BB were in R3's room. R3 was observed without a catheter strap to secure his catheter tubing. The dignity bag was on the left side of bed. R3 was lying in bed. LPN BB stated that she does not assist and left the room. CNA DD informed the resident that he was going to perform perineal/catheter care. Review of documentation survey report v2 dated Oct-24 revealed no evidence of catheter care as indicated by the absence of task on the form. Interview on 10/23/2024 at 12:16 pm, Licensed Practical Nurse (LPN) BB confirmed that R3 didn't have a catheter strap when she pulled back R3's cover and saw him. She then went back and put catheter straps on all residents that had a catheter, because no one had a catheter tubing secure strap. 3. Review of the Admission Record revealed R9 was admitted to the facility with diagnoses that included but not limited to epilepsy, hypertension, atrial fibrillation, heart failure, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, alcoholic hepatitis with ascites and chronic kidney disease. Observation on 10/23/2024 at 10:09 am revealed R9's catheter drainage bag lying under the bed on the floor. There was no dignity bag. Interview on 10/23/2024 at 11:20 am, CNA HH revealed that she saw the catheter drainage bag on the floor and placed the drainage bag on the bed frame. CNA HH also revealed if a resident does not have a catheter strap, she will put on a catheter strap. She continued to state that she could not remember the last time she had an inservice on catheter care. 4. Review of the Admission Record R10 was admitted to the facility with diagnoses that included but not limited to retention of urine, hypertension and transient ischemic attack. Observation on 10/22/2024 at 10:46 am revealed R10 was lying in his bed. R10 had an indwelling catheter, and a StatLock to secure his catheter tubing was not securely fastened and was peeling away from R10's left thigh. Observation on 10/23/2024 at 10:44 am R10 revealed in the presence of the Director of Nursing (DON) that the StatLock was peeling off and not securely attached to his thigh Interview on 10/23/2024 at 11:58 am, CNA AA revealed that she reported to the nurse that R10's catheter secure strap was coming off. Interview on 10/24/2024 at 10:13 am, the DON revealed that if a resident was missing a catheter secure strap, the CNAs should report it to the nurse. The nurses are to place the catheter strap on the resident.

Based on observations, interviews, record reviews, and review of the facility policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities the facility failed to provide ADL Care for three of three Residents (R) (R# 6, R#29, and R#49). Specificall, the facility failed to ensure nail care was provided for R#6 and R#49. The facility also failed to ensure that R#29 received foot care from podiatrist ( Physician that specialises in foot care)on a regular basis. Findings include : Review of the facility undated policy titled, Activities of Daily Living (ADLs)/ Maintain Abilities Procedure: #1 revealed the following information: 1.Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility will provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. 1.Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that R# 29 was a diabetic patient therefore required care to be guided by a podiatrist. Review of the care plan for R#29, revealed no evidence of documentation that addressed the resident's podiatric needs. An observation on 2/7/2023 at 01:52 p.m. revealed R # 29's toenails appear to be thick with a yellowish color and they are jagged in appearance. An observation conducted on 2/8/2023 at 9:46 a.m. revealed R # 29's toenails were still jagged and with a yellowish appearance. An interview conducted on 2/9/2023 11:24 a.m. with certified Nurse Aide (CNA)AA revealed she was familiar with the R#29's care. As it relates to R # 29's toenails, they are cut when I receive instructions to cut them from the nurse, but she would not be the one to cut them because he is a diabetic resident therefore the podiatrist would have to cut his toenails. An interview conducted on 2/9/2023 11:24 a.m. with Licensed Practical Nurse (LPN) BB revealed she is familiar with the resident's care. As it relates to R # 29's toenails, the nurse revealed when she receives instructions from the podiatrist, she will cut them. At this time, the podiatrist has not seen R# 29. An interview conducted on 2/9/2023 11:37 a.m. with the Director of Nursing (DON) revealed she was aware of Resident # 29's toenails and was in the process of requesting a consult from the podiatrist. The DON also revealed that she noticed R# 29's toenails on yesterday but did not call the podiatrist until the Administrator brought it to her attention on today. An interview conducted on 2/9/2023 11:50 a.m. with the Administrator revealed she is aware of R# 29's toenails, but she is awaiting a consult from the podiatrist before any action is taken. At this time, no consult has been scheduled with the podiatrist. It is her expectation that all necessary consults and ADLs be conducted on all residents in a timely manner. An interview conducted on 2/9/2023 at 2:06 p.m. with the MDS LPN revealed that it was their responsibility to create the podiatric care plan once triggered on the MDS. 2. A record review of the clinical record for R#49 revealed a 70-year-male admitted to the facility with principal admitting diagnoses (Dx) chronic obstructive pulmonary disease (COPD) unspecified, Parkinson's disease, essential (primary) hypertension, paroxysmal atrial fibrillation, type 2 diabetes mellitus, personal history of transient ischemic attack, cerebral infarction, and cervical degeneration. Review of the most recent Minimum Data Set (MDS) quarterly assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score 10, which indicated mild cognitive impairment. Section G (Functional Status) revealed resident required oversight, encouragement, or cueing for personal hygiene, that included oral care, limited assistance with toileting and dressing, and one-person physical assist for full body bath/shower which included nail monitoring and care. Review of the comprehensive care plan included but not limited to, recent return/readmit and requires assist with activities of daily living (ADL); has unsteady balance and gait related to (r\t) Parkinson's, right hand is lobster claw, alert and forgetful but able to make needs known- Dx. dementia, history of CVA, COPD\emphysema, Chronic Pain; impaired cognition/ communication deficit-Dx. dementia, Parkinson's disease, schizoaffective bipolar type, history of cerebrovascular accident (CVA). Review of the CNA Tasks included ADL's-bathing on Tuesday and Friday; personal hygiene days and evenings; and skin observation every shift. Review of task list report revealed bathing, personal hygiene, and skin observations were initiated on 1/21/2021 at reentry. The task list care record revealed bathing was done twice a week, personal hygiene daily, and skin assessments twice a day each shift. Observation on 2/7/2023 at 10:09 a.m., 2/8/2023 at 8:54 a.m., and on 2/9/2023 at 12:30 p.m. revealed R#49 had long fingernails on both hands. Interview on 2/9/2023 at 12:30 p.m. with R # 49 confirmed his fingernails were long on both hands. He revealed toenails are trimmed regularly, when a young girl from the podiatrist office comes in and checks toenails, she comes about every three months. He revealed he takes a shower instead of bed bath, his scheduled bath/shower days were Tuesday and Friday, nails should be checked and cleaned when he showers but was not being done. 3. A record review of the clinical record for R#6 revealed resident was admitted to the facility with principal admitting diagnosis chronic obstructive pulmonary disease, tremor unspecified, transient cerebral ischemic (TIA) attack, diabetes mellitus due to underlying condition with diabetic neuropathy and chronic kidney disease, peripheral vascular disease, essential primary hypertension, hyperlipidemia. Review of the most recent Minimum Data Set (MDS) annual assessment dated [DATE], revealed a BIMS score 15 indicating intact cognition. Section G revealed resident required supervision for hygiene, and one-person physical help in part for bathing activity. Review of the comprehensive care plan revealed R#6 has an ADL self-care performance deficit related to TIA, is alert and able to make needs known. Interventions included, encourage resident to participate in his care, staff to provide assist with bathing, toileting, dressing, personal hygiene, and transfers as needed, date initiated: 12/15/2020. Review of the CNA Tasks included ADL's-bathing on Wednesday and Saturday night; personal hygiene days and evenings; and skin observation every shift. Review of task list report revealed bathing, personal hygiene, skin observation, and dressing were initiated on 12/21/2020. The task list care record documented bathing was done twice a week on Wednesday and Saturday night, personal hygiene every shift and prn, skin assessments every shift, and dressing every shift and prn. Observation on 2/9/2023 at 12:09 p.m., and interview at that time with R#6, confirmed his fingernails were long, staff had trimmed his nails before but do not very often, and he would like them to be trimmed regularly. Interview also revealed his shower days were Wednesday and Saturday, staff did not regularly help him with his shower or getting dressed and did not clean or trim his fingernails or toenails. He revealed CNA staff are supposed to assist him to the shower, should always be in the shower with him, but sometimes he goes to the shower alone and does the best he can. Staff told him they could not trim his nails because he was diabetic but had asked before and they had trimmed them. He could not recall who the person was. He confirmed he was diabetic, and the facility had not offered to send him to anyone who could provide nail care. 41429

Based on staff interview, family interview, and review of the facility policy titled, Change in Condition Notification, the facility failed to notify the designated resident representative or family member of significant changes for one of five Residents (R) R#22. Specifically, the facility failed to notify the responsible party (R/P) for R#22 of the transfer to the Acute hospital from the dialysis clinic on January 11, 2023. Findings: Review of the facility undated policy titled, Change in Condition Notification under Procedure: revealed the facility must inform the resident, consult with the resident's physician and/ or notify the resident's family member or legal representative when there is a change requiring such notification. (Situations Requiring Notification include:) 2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. 4. A decision to transfer or discharge the resident from the facility. A review of the progress notes revealed R#22 was transported from the dialysis clinic to the hospital on January 11, 2023. Progress notes revealed the Dialysis nurse called to inform the facility that residents' blood was low and was sending them to the hospital for blood infusion per Medical Doctor (Md). Progress notes do not indicate that the facility contacted the responsible party for R#22 on the day of hospitalization . A review of the Physician's Orders revealed R#22 was to receive dialysis treatment three days per week. Review of the Care plan revealed R#22 was on dialysis Related to (r/t) End Stage Renal Disease (ESRD) and is at risk for fluid overload\dehydration. An interview conducted on 2/9/2023 at 10:27 a.m. with family member of R#22 revealed she was not notified of residents transfer from the dialysis clinic to the hospital on 1/11/2023. An interview with the DON on 2/9/2023 at 12:15 p.m. revealed she was aware of R# 22 being transported to the hospital on 1/11/2023 from the dialysis clinic, but she was not aware the responsible party of R# 22 was not notified by the facility staff. The DON revealed this is not the common practice of this facility and the responsible party of R# 22 should have been notified and the notification should have been documented in the progress notes. It is her expectation that all staff members document the notification of responsible parties and all other necessary information as it relates to changes in a resident's status. An interview on 2/9/2023 at 12:30 p.m. with the Administrator revealed she was not aware of the responsible party for R# 22 not being notified of a change in the status or transport of resident to the hospital from the dialysis clinic on January 11, 2023. The Administrator agrees this event should have been documented and the responsible party of R# 22 should have been notified by this facility staff.

Based on observations, record review, staff interview, and review of the facility policy titled, Nursing Care Plan the facility failed to develop a care plan which addressed the podiatric and diabetic care needs for one Resident (R) #29. The deficient practice had the potential to affect the residents' care regimen by not ensure all care needs were addressed in the person-centered Plan of Care for R#29. Findings: Review of the facility policy titled, Nursing Care Plan dated 10/2014 under purpose, revealed the following information: The plan shows what the nurse should know about the resident and includes: 1. Name, date of admission, diagnosis, and age. 2. Basic needs: A. Nutrition D. Safety G. ADL's B. Fluids E. Activity C. Vital signs F. Emotional status Information concerning basic needs is obtained from coordinated effort of all personnel caring for the resident, through observation, interviewing, inspection and MDS CAA's. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that R#29 was a diabetic patient therefore requiring podiatric care to be conducted or guided by a podiatrist (Physician specializing in foot care). Review of the care plan for R#29 revealed that there was no evidence of the care plan addressing the resident's podiatric or diabetic needs. An interview conducted on 2/9/2023 at 11:37 a.m. with the Director of Nursing (DON) revealed that all residents care needs should be addressed in the residents plan of care. Further interview also revealed that she was not aware that R#29 did not have a plan of care that addressed his diabetic and podiatric care needs. During interview it was also revealed that the MDS Coordinator is responsible for ensuring that all the residents' care needs are addressed on the residents' plan of care and that it was her expectation that the needs of the residents are met and that the plan of care reflected each residents' care needs. DON also confirmed that R#29 care plan did not address his diabetic or podiatric needs. An interview conducted on 2/9/2023 at 11:50 a.m. with the Administrator revealed that the residents care plan should reflect the care provided and or the care the resident requires. Further interview also revealed that it is the responsibility of the MDS Coordinator to ensure that the residents' Plan of care is completed and reflects the residents' care regimen, and the DON is responsible for ensuring that the residents' plan of care is updated and have all information that is needed to provide care the resident. Interview on 2/9/2023 at 2:06 p.m. with the MDS Coordinator revealed that it is her responsibility to update the residents plan of care. Further interview also revealed that she was not aware that R#29 did not have a plan of care that addressed his diabetic and podiatric care needs. Continued interview also confirmed that plan of care for R#29 did not address residents diabetic and podiatric needs and were not available for review.

Based on observation, interviews, record review, review of the facility's job descriptions for the Administrator and Director of Nursing (DON), the facility failed to ensure administration was consistent with oversight and monitoring of the Infection Control program, failed to ensure that one of 22 residents was free from neglect, and failed to ensure that the Infection Control program fully implemented the CMS and CDC recommended practices. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 12:50 p.m. The immediate jeopardy concerns are outlined as follows: 1. On [DATE], R#4 tested positive for COVID-19 and was placed on the COVID unit. On [DATE], physician orders [REDACTED].#4's vital signs to be obtained every four hours and as needed. R#4 remained asymptomatic on the COVID unit until day nine, [DATE]. On [DATE], R#4 developed a cough and her oxygen saturation (02 sat) kept dropping to ,[DATE]% (normal 95% - 100%) on room air. R#4 was started on continuous oxygen with an order to keep O2 sats at 92%. On [DATE], one day after R#4 became symptomatic, R#4 was prematurely discontinued from Transmission Based Precautions and was moved from the COVID unit back to her previous room. Although R#4 had been started on continuous oxygen for 02 saturation level dropping to 79% - 89%, had orders for vital signs to be monitored every four hours, and had an order for [REDACTED].#4's vital signs every four hours and failed to ensure that R#4's 02 sat was maintained at 92%. On [DATE], R#4 began showing signs of respiratory distress and was found to have an 02 saturation of 35%. R#4 was sent to the hospital and died two days later. [DIAGNOSES REDACTED]. 2. In addition, the facility failed to quarantine three of three newly admitted residents (R#6, R#17, R#18) who were admitted from an acute care facility. Specifically, R#6 was admitted from an acute care facility on [DATE], and without being admitted to an observation unit, and without being placed on Transmission Based Precautions, R#6 was placed in a semi-private room with another resident (a COVID negative resident). Six days later, R#6 tested positive for COVID 19. R#17 was admitted on [DATE] and R#18, was admitted on [DATE], both residents were admitted directly to the regular unit, in semi-private rooms with roommates. R#17 & R#18 were not placed on observation, or Transmission Based Precautions, and staff were observed not to wear appropriate Personal Protective Equipment (PPE) when providing care. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F600 - 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, Scope & Severity: J; F-835 - 42 CFR §483.70 Administration, Scope & Severity: K; F-880 - 42 CFR §483.80 (a)(1), (2) Infection Control, Scope & Severity: K. Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation F600 (J). The noncompliance related to the immediate jeopardy was identified to have existed since [DATE]. The immediate jeopardy remains ongoing and the State Survey Agency (SSA) was unable to remove the IJ prior to exit on [DATE]. Findings include: Review of the undated job description titled, Nursing Home Administrator documents that the nursing home administrator job description is a specialized field of medical and health services management. Nursing Home Administrator duties and responsibilities, in pertinent part, include: 1. Managing and monitoring daily operations of the nursing home. 2. Ensuring that the healthcare services are provided according to state's health and safety codes in order to minimize complaints, state license violations, and possible legal issues. Review of the undated job description titled, RN - Director of Nursing documents that the Director of Nursing (DON) is responsible for monitoring and evaluating the quality and appropriateness of care for adults, particularly geriatric residents requiring long term care. Section titled, Major Tasks, Duties, and Responsibilities, in pertinent part, documents: 1. The DON manages and coordinates the clinical and other units' activities of the Nursing Home in order to provide quality resident care. Supervises resident care to the adult residents, particularly geriatric residents requiring long term care. 5. Ensure that staff adheres to all policies. 9. Directs the evaluation of residents to ensure the proper level of care at admission. 10. Ensures proper treatment of [REDACTED]. 19. Coordinates information for regulatory agency reviews. Ensures meeting requirements for Federal/State Licensure and Medical Care Foundation. 25. Demonstrates knowledge of Infection Control Practices and Universal Precautions and enforces use of Personal Protective Equipment. 1. Administration failed to protect one of 24 sampled residents (R#4) from neglect. Specifically, the facility failed to ensure R#4, who was COVID positive, received needed care and services, including monitoring per physician orders [REDACTED]. After prematurely releasing R#4, who was newly symptomatic, from the COVID unit, the facility failed to monitor R#4 in accordance with physician orders [REDACTED]. Cross refer F600 2. Administration failed to ensure that R#4 was not prematurely discharged from the COVID-unit one day after the resident first presented with COVID-associated symptoms, Administration failed to ensure that R#4 was maintained on the isolation when she was placed on a non-COVID unit, Administration failed to ensure that transmission-based precautions were not discontinued prematurely for R#4. Administration failed ensure that three newly admitted residents (R#6, R#17, and R#18) whose COVID status was unknown were placed on Transmission Based Precautions. The new admissions were not kept under quarantine, were placed in rooms on the non-COVID unit which they shared with other residents (R#21, R#22, and R#23), and were not placed on transmission-based precautions. Administration failed to ensure that staff providing care for residents who were placed on a regular unit while symptomatic for COVID or whose COVID status was unknown (R#4, R#6, R#17, R#18) wore all required PPE designed to prevent the spread of the COVID-19 virus. Cross refer F880 During an interview on [DATE] at 11:00 a.m., the Infection Control Preventionist (ICP) stated that the facility did not have a COVID quarantine policy, adding, We follow Centers for Medicare Services (CMS) and Centers for Disease Control and Prevention(CDC) guidelines for quarantine. An interview with the Administrator on [DATE] at 4:22 p.m. confirmed that the facility's policy for continued isolation of COVID positive residents until at least seven days since the onset of symptoms was not followed. An interview with the ICP on [DATE] at 1:56 p.m. When questioned about the failure to follow the facility's policy to quarantine new admissions for 14 days, the ICP stated, We do not have enough private rooms to accommodate for new admissions to be on 14-day quarantine. An interview with the Administrator on [DATE] at 4:22 p.m. The Administrator was aware that the facility policy called for residents to be quarantined when newly admitted . When questioned about the failure to follow the facility's policy to quarantine new admissions for 14 days, the Administrator agreed with the ICP and stated that there were not enough rooms to put everyone on isolation. A telephone interview with the DON on [DATE] at 4:39 p.m. revealed the DON was aware that the facility policy called for residents to be quarantined when newly admitted . When questioned about the failure to follow the facility's policy and quarantine new admissions for 14 days, the DON agreed with the Administrator and ICP that there were not enough rooms to place residents in quarantine. The DON added, We get a negative test prior to admission, so the resident isn't contagious. Further interview with the DON revealed the DON confirmed that the facility's policy for continued isolation of COVID positive residents until at least seven days since the onset of symptoms was not followed. Review of the facility census for [DATE], [DATE] and [DATE], provided by the facility, indicated the facility had the capacity/empty beds to quarantine R#6, R#17, and R#18 when they were newly admitted residents. An additional interview was conducted with the Administrator on [DATE] at 1:45 p.m. Upon reviewing the census reports, the Administrator confirmed that during the dates R#6, R#17, and R#18 were newly admitted , there were several empty beds available. The Administrator stated, I have no explanation why they were not placed on quarantine. During a telephone interview with the Medical Director on [DATE] at 3:30 p.m., the Medical Director stated he was unaware the facility was admitting residents from an acute care facility and not placing them in quarantine. According to CDC guidance, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown dated [DATE], Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (healthcare professionals) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the CDC website https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html article titled, Options to reduce quarantine for contacts of persons with [DIAGNOSES REDACTED]-CoV2 infection using symptom monitoring and diagnostic testing retrieved [DATE], revealed, Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring . Quarantine is intended to reduce the risk that infected persons might unknowingly transmit infection to others. It also ensures that persons who become symptomatic or are otherwise diagnosed during quarantine can be rapidly brought to care and evaluated .Persons can discontinue quarantine at these time points only if the following criteria are also met: No clinical evidence of COVID-19 has been elicited by daily symptoms monitoring during the entirety of quarantine up to the time at which quarantine is discontinued .

Based on observations, interviews, record review, review of the facility policy's titled, Interim Long-Term Care Setting Guidance for Residents with Suspected Confirmed Coronavirus Disease 2019, and the facility policy titled, Considerations for new Admissions or Readmissions to the Facility review of facility documents, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement an infection control program designed to prevent the spread of infection, including the COVID-19 virus, which affected seven (Resident (R) #4, R#6, R#17, R#18, R#21, R#22, and R#23) of 24 sampled residents. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 12:50 p.m. The immediate jeopardy concerns are outlined as follows: 1. On [DATE], R#4 tested positive for COVID-19 and was placed on the COVID unit. On [DATE], physician orders were given for R#4's vital signs to be obtained every four hours and as needed. R#4 remained asymptomatic on the COVID unit until day nine, [DATE]. On [DATE], R#4 developed a cough and her oxygen saturation (02 sat) kept dropping to ,[DATE]% (normal 95% - 100%) on room air. R#4 was started on continuous oxygen with an order to keep O2 sats at 92%. On [DATE], one day after R#4 became symptomatic, R#4 was prematurely discontinued from Transmission Based Precautions and was moved from the COVID unit back to her previous room. Although R#4 had been started on continuous oxygen for 02 saturation level dropping to 79% - 89%, had orders for vital signs to be monitored every four hours, and had an order for [REDACTED].#4's vital signs every four hours and failed to ensure that R#4's 02 sat was maintained at 92%. On [DATE], R#4 began showing signs of respiratory distress and was found to have an 02 saturation of 35%. R#4 was sent to the hospital and died two days later. [DIAGNOSES REDACTED]. 2. In addition, the facility failed to quarantine three of three newly admitted residents (R#6, R#17, R#18) who were admitted from an acute care facility. Specifically, R#6 was admitted from an acute care facility on [DATE], and without being admitted to an observation unit, and without being placed on Transmission Based Precautions, R#6 was placed in a semi-private room with another resident (a COVID negative resident). Six days later, R#6 tested positive for COVID 19. R#17 was admitted on [DATE] and R#18, was admitted on [DATE], both residents were admitted directly to the regular unit, in semi-private rooms with roommates. R#17 & R#18 were not placed on observation, or Transmission Based Precautions, and staff were observed not to wear appropriate Personal Protective Equipment (PPE) when providing care. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F600 - 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, Scope & Severity: J; F-835 - 42 CFR §483.70 Administration, Scope & Severity: K; F-880 - 42 CFR §483.80 (a)(1), (2) Infection Control, Scope & Severity: K. Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation F600 (J). The noncompliance related to the immediate jeopardy was identified to have existed since [DATE]. The immediate jeopardy remains ongoing and the State Survey Agency (SSA) was unable to remove the IJ prior to exit on [DATE]. Findings include: Review of the facility's undated policy titled, Interim Long-Term Care Setting Guidance for Residents with Suspected Confirmed Coronavirus Disease 2019 (COVID-19) and their Caregivers page 4 of 6 instructed Patients with COVID-19 should remain isolated and on appropriate precautions until: at least 3 days (72 hours) have passed since recovery defined as resolution of fever without the use of fever-reducing medications and improvement in respiratory symptoms (e.g., cough, shortness of breath); and, at least 7 days have passed since symptoms first appeared. This policy also noted: Adhere to Infection Prevention Precautions. Infection Prevention Precautions for Residents with Respiratory Illness Consistent with 2019 Coronavirus Disease (COVID-19) A. Resident placement: b. Isolate resident in a private room with their own bathroom. c. Ensure that all staff entering the room adhere to Contact and Droplet Precautions (including eye protection), and use the following PPE: i. Gowns ii. Gloves d. Facemask or NIOSH-approved fit-tested N95 mask) e. eye protection (e.g., goggles or face shield) 1. Review of R#4's Admission Record located in the Electronic Medical Record (EMR) revealed the resident was a long-term resident who did not have respiratory [DIAGNOSES REDACTED]. Review of R#4's Progress Notes located in the EMR under the Progress Notes tab revealed R#4 tested positive for COVID-19 virus on [DATE] and was placed on the facility's COVID unit. Per Progress Notes and Vital Signs records from [DATE] through [DATE], R#4 was asymptomatic for COVID until [DATE] at 3:08 p.m. At that time, R#4's oxygen saturation dropped down between ,[DATE] percent (%) on room air and R#4 complained of a cough. Licensed Practical Nurse (LPN) EE notified R#4's physician, who assessed the resident at 6:07 p.m. and gave orders to apply oxygen to keep oxygen saturation level at 92 % and to obtain a portable chest x-ray. Per Progress Notes dated [DATE] at 6:31 a.m., R#4 was transferred off the COVID unit by LPN JJ at 4:30 a.m. R#4 was returned to her previous (non-COVID care) unit with no isolation precautions in place. There was no evidence that the resident's symptoms, which had begun one day earlier, had resolved prior to R#4 being released from the COVID unit. Per the [DATE] Progress Notes entry at 6:31 a.m., LPN JJ documented that the resident continues 2 L (liters) of O2 (oxygen), .resident does have cough. Review of a Progress Note dated [DATE] at 5:16 p.m., the facility received the results of the chest x-ray which indicated that R#4 had bilateral pneumonia, and the resident was started on an antibiotic. The resident remained in a semi-private room with a roommate on the non-COVID unit and was not placed on transmission-based precautions with staff wearing all required PPE for a COVID-symptomatic resident. Review of a Progress Notes dated [DATE] at 3:30 a.m. documented the resident began showing signs of respiratory distress and oxygen saturation was 35% and R#4 was transferred to the hospital. Review of a [DATE] hospital Discharge Summary, documented the resident (R#4) expired on [DATE] at 9:10 a.m. with [DIAGNOSES REDACTED]. During an interview on [DATE] at 6:30 p.m. with LPN JJ, revealed she was the nurse responsible for transferring R#4 off the COVID unit. When asked why the resident was moved from the COVID unit/isolation when the resident was still showing COVID-related symptoms. LPN JJ stated, I moved the resident because it had been 10 days since her positive COVID test, the resident was already awake, and her oxygen saturations were stable on the oxygen. An interview was conducted on [DATE] at 11:00 a.m., with the Infection Control Preventionist (ICP). The ICP was asked about R#4 being discharged from the COVID unit less than one day after new onset of symptoms that included complaining of a cough, experiencing shortness of breath, and having low oxygen saturation levels. The ICP stated, I would have preferred to have monitored her a couple more days but when I assessed her that morning, she seemed stable and had met her required 10 days. Further interview with the ICP revealed that the criteria for transferring residents off the COVID unit is the resident has to be afebrile, and with no diarrhea or productive cough. The ICP was asked about ending isolation by discharging R#4 from the COVID unit less than one day after onset of symptoms. The ICP confirmed that although R#4 began displaying symptoms while on the COVID unit, the resident was not placed on quarantine/isolation or transmission-based precautions when moved back to her original room. Interview with the ICP confirmed that the facility's policy for continued isolation of COVID positive residents until at least seven days since the onset of symptoms was not followed. An additional interview was conducted with the ICP on [DATE] at 1:56 p.m. When asked about what type of precautions should be used for COVID-positive residents, the ICP stated that the resident is quarantined in a negative pressure room and has a dedicated blood pressure cuff. An interview was conducted with the Administrator on [DATE] at 4:22 p.m. The Administrator was asked if R#4 should have been moved off the COVID-19 unit/taken out of isolation when she was still exhibiting symptoms. The Administrator stated, If she is stable and her vitals were stable than she is okay to move back to room. Further interview with the Administrator revealed that the Administrator stated that R#4 should have been monitored closer after being moved off of the COVID unit. A telephone interview with the Director of Nursing (DON) on [DATE] at 4:39 p.m. The DON was asked if R#4 should have been moved off the COVID unit while still symptomatic. The DON stated, It had been 10 days since she tested positive. Any one of these residents could be short of breath and I didn't feel she was contagious. I don't see any issues with moving her. 2. Review of the facility's policy titled, Interim Long-Term Care Setting Guidance for Residents with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) and their Caregivers dated [DATE], revealed Facilities may designate a unit or wing exclusive for residents admitted from the acute care hospitals. Resident should be placed in a private room, remain in this unit or wing for 14 days, and be monitored for symptoms . use transmission-based precautions according to the patient's needs. Review of the facility's policy titled, Considerations for New Admissions or Readmissions to the Facility dated [DATE] revealed A single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID 19 for 14 days after admission and cared for using all recommended COVID-19 PPE. a. Review of an undated Census Report located in R#6's EMR under the Census tab indicated the resident was admitted on [DATE] from an acute care facility to a semi-private room with another roommate (R#21). Review of a tracking/trending log with the ICP on [DATE] at 1:56 p.m. revealed that R#6 had a negative COVID test while in the hospital, prior to admission to the facility. Review of the Physician Orders and Progress Notes from [DATE] through [DATE] which were located in R#6's EMR revealed no orders for quarantine for this resident, whose COVID status was unknown at the time of admission. There was no evidence the resident was placed on quarantine due to being a new admission to the facility or that the resident was placed on transmission-based precautions. Review of the Immunization tab in the EMR revealed the resident had not received the COVID-19 vaccine. Review of a Progress Notes dated [DATE] at 2:45 p.m., six days after admission, R#6 tested positive for the COVID-19 virus. The resident and her roommate, R#21 were both placed in isolation on the COVID unit, and all parties were notified. Review of the facility census for [DATE], provided by the facility on [DATE], indicated the facility had the capacity to quarantine R#6 in a private room with transmission-based precautions. Excluding the COVID unit, on the day of R#6's admission, the facility had seven empty beds available. b. Review of R#17's Admission Record located in the EMR, revealed the resident was admitted to the facility on [DATE] from an acute care hospital. Review of the resident's census located in the EMR, revealed the resident was admitted to Manor 2, (a non-COVID unit) and placed in a shared room with a roommate, R#22. Review of a tracking/trending log with the ICP on [DATE] at 1:56 p.m. revealed that R#17 had a negative COVID test while in the hospital, prior to admission to the facility. Review of the Physician Orders and Progress Notes from [DATE] through [DATE] (14 days after admission) revealed no orders for quarantine for this resident, whose COVID status was unknown on the day of admission. There was no evidence the resident was placed on quarantine due to being a new admission to the facility or that the resident was placed on transmission-based precautions. Review of the Immunization tab in the EMR revealed the resident had not received the COVID-19 vaccine. Review of the facility census for [DATE], provided by the facility on [DATE], indicated the facility had the capacity to quarantine the resident in a private room with transmission-based precautions. Excluding the COVID unit, on the day of R#17's admission, the facility had six empty beds available. c. Review of R#18's Admission Record located in the EMR, revealed the resident was admitted to the facility on [DATE] from an acute care hospital. Review of the resident's census located in the EMR revealed the resident was admitted to Manor 2, (a non-COVID unit) and placed in a shared room with a roommate, R#23. Review of a tracking/trending log with the ICP on [DATE] at 1:56 p.m. revealed that R#18 had a negative COVID test while in the hospital, prior to admission to the facility. Review of the Physician Orders and Progress Notes from [DATE] through [DATE] (seven days after admission) revealed no orders for quarantine for this resident, whose COVID status was unknown at the time of admission. There was no evidence the resident was placed on quarantine due to being a new admission to the facility or that the resident was placed on transmission-based precautions. Review of the Immunization tab in the EMR revealed the resident had not received the COVID-19 vaccine. Review of the facility census for [DATE], provided by the facility, indicated the facility had the capacity to quarantine the resident in a private room with transmission-based precautions. Excluding the COVID unit, on the day of R#18's admission, the facility had five empty beds available. Interview on [DATE] at 1:56 p.m., the ICP was questioned about the criteria for admitting residents from acute care facilities. The ICP stated the resident is tested for COVID prior to being admitted , and the test has to be negative and within three days prior to admission. Per the ICP, the residents are admitted to regular semi-private rooms. When questioned concerning the failure to quarantine newly admitted residents for 14-days the ICP stated, We do not have enough private rooms to accommodate for new admissions to be on 14-day quarantine. An interview with the Administrator on [DATE] at 4:22 p.m. The Administrator agreed with the ICP there were not enough rooms to put everyone in quarantine. Continued interview with the DON on [DATE] at 4:39 p.m., the DON agreed with the IP and the Administrator, stating that there were not enough rooms to put newly admitted residents in quarantine for 14 days. An additional interview was conducted with the Administrator on [DATE] at 1:45 p.m. Upon reviewing the census reports, the Administrator confirmed that during the dates that R#6, R#17, and R#18 were admitted , there were empty beds in which the residents could have been quarantined. The Administrator stated, I have no explanation why they were not placed on quarantine. When asked if they should have been the Administrator stated, Yes, I guess they should have been. During a telephone interview with the Medical Director on [DATE] at 3:30 p.m., the Medical Director stated he was unaware the facility was admitting residents from an acute care facility and not placing them in quarantine. 3. a. Observation on [DATE] at 1:00 p.m. revealed Certified Nursing Assistant (CNA) HH entered the room of R#17, who was not placed on quarantine when admitted to the facility on [DATE], 14 days earlier. CNA HH assisted the resident with her meal and washed the resident's hands and face. Observation on [DATE] at 5:00 p.m. revealed CNA NN entered R#17's room and provided care, touching the resident as she adjusted her in bed. During both of these observations, the CNAs wore a surgical mask and used hand sanitizer while providing care to the resident. However, neither CNA wore an N-95 mask, a gown, eye protection (shields/goggles), or gloves. b. Observation on [DATE] at 1:10 p.m. revealed CNA MM entered the room of R#18, who was not placed on quarantine when admitted to the facility on [DATE], seven days earlier. CNA MM assisted the resident with her meal, touching the resident and the resident's meal tray on the bedside table. Observation on [DATE] at 5:00 p.m. revealed CNA MM reentered R#18's room in response to a call light. During both observations, CNA MM was wearing gloves, a surgical mask, and a hair covering, but was not wearing an N-95 mask, gown, or eye protection. Observation on [DATE] at 8:45 a.m. revealed CNA FF entered R#18's room and provided care by adjusting the resident in bed, straightening her bed linens, and setting up her meal tray. CNA FF was not wearing gloves, an N-95 mask, gown, or eye protection. During an interview on [DATE] at 11:00 a.m., the ICP was asked about the use of PPE. The ICP stated for a COVID-unit and quarantined residents, the staff are expected to wear full PPE, including an N95 mask, gloves, face shield/googles, shoe covers and gowns. The ICP stated that the only PPE required for other residents was a mask and gloves if staff were providing care. An interview with the Administrator on [DATE] at 4:22 p.m. When questioned about the use of PPE, the Administrator stated if the resident was in a regular (non-COVID) room, staff only needed to wear a mask and gloves when providing care. However, for COVID/presumptive COVID, staff was expected to wear full PPE. During a telephone interview with the DON on [DATE] at 4:39 p.m., the DON stated her belief that staff caring for new admissions, such as R#6, R#17, and R#18 did not need to wear full PPE when providing care, Because we get a negative test prior to admission, so the resident isn't contagious. Interview on [DATE] at approximately 9:00 a.m. with CNA MM, CNA NN, and CNA HH. The CNAs were questioned if R#17 and R#18 were on any transmission-based precautions, specifically COVID-related precautions. The CNAs each responded no, the residents were not on any precautions. The CNAs were questioned about the type of PPE they wore when providing care to these residents, and the CNAs all responded they wore a mask and gloves. Interviews were conducted with both LPN OO and LPN PP on [DATE] at approximately 9:20 a.m. The LPNs, who worked on R#17 and R#18's unit, were questioned about the type of precautions used for these residents. LPN OO responded, Just universal precautions. LPN PP stated the residents were not on precautions as they both tested negative for COVID-19 before being admitted to the facility. Review of the facility's weekly line list, received from the facility, revealed that from the week of [DATE] through the week of [DATE] the facility had 11 COVID positive Residents, 6 positive staff, and three Resident deaths related to COVID. From the week of [DATE] through the week of [DATE] the facility had 14 COVID positive Residents, 9 positive staff members, and four Resident deaths related to COVID. According to CDC guidance, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown dated [DATE], HCP (healthcare personnel) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html According to CDC guidance, Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown dated [DATE], Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19 Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected. https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Review of the CDC website https://www.cdc.gov/coronavirus/2019-ncov/more/scientific-brief-options-to-reduce-quarantine.html article titled, Options to reduce quarantine for contacts of persons with [DIAGNOSES REDACTED]-CoV2 infection using symptom monitoring and diagnostic testing retrieved [DATE], revealed, Quarantine can end after Day 10 without testing and if no symptoms have been reported during daily monitoring . Quarantine is intended to reduce the risk that infected persons might unknowingly transmit infection to others. It also ensures that persons who become symptomatic or are otherwise diagnosed during quarantine can be rapidly brought to care and evaluated .Persons can discontinue quarantine at these time points only if the following criteria are also met: No clinical evidence of COVID-19 has been elicited by daily symptoms monitoring during the entirety of quarantine up to the time at which quarantine is discontinued.

Based on interviews, record review, and review of the facility policy titled, Abuse Prohibition Policies and Procedures the facility failed to protect one of 24 sampled residents (R#4) from neglect. Specifically, the facility failed to ensure R#4, who was COVID positive, received needed care and services, including monitoring per physician orders after the resident experienced a change in condition requiring continuous oxygen. R#4 who was newly symptomatic was prematurely released R#4 from the COVID unit, licensed staff failed to monitor R#4 in accordance with physician orders from [DATE] through [DATE]. The resident was transferred to the hospital where she subsequently died with [DIAGNOSES REDACTED]. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on [DATE] at 12:50 p.m. The immediate jeopardy concerns are outlined as follows: 1. On [DATE], R#4 tested positive for COVID-19 and was placed on the COVID unit. On [DATE], physician orders were given for R#4's vital signs to be obtained every four hours and as needed. R#4 remained asymptomatic on the COVID unit until day nine, [DATE]. On [DATE], R#4 developed a cough and her oxygen saturation (02 sat) kept dropping to ,[DATE]% (normal 95% - 100%) on room air. R#4 was started on continuous oxygen with an order to keep O2 sats at 92%. On [DATE], one day after R#4 became symptomatic, R#4 was prematurely discontinued from Transmission Based Precautions and was moved from the COVID unit back to her previous room. Although R#4 had been started on continuous oxygen for 02 saturation level dropping to 79% - 89%, had orders for vital signs to be monitored every four hours, and had an order for [REDACTED].#4's vital signs every four hours and failed to ensure that R#4's 02 sat was maintained at 92%. On [DATE], R#4 began showing signs of respiratory distress and was found to have an 02 saturation of 35%. R#4 was sent to the hospital and died two days later. [DIAGNOSES REDACTED]. 2. In addition, the facility failed to quarantine three of three newly admitted residents (R#6, R#17, R#18) who were admitted from an acute care facility. Specifically, R#6 was admitted from an acute care facility on [DATE], and without being admitted to an observation unit, and without being placed on Transmission Based Precautions, R#6 was placed in a semi-private room with another resident (a COVID negative resident). Six days later, R#6 tested positive for COVID 19. R#17 was admitted on [DATE] and R#18, was admitted on [DATE], both residents were admitted directly to the regular unit, in semi-private rooms with roommates. R#17 & R#18 were not placed on observation, or Transmission Based Precautions, and staff were observed not to wear appropriate Personal Protective Equipment (PPE) when providing care. The immediate jeopardy was related to the facility's noncompliance with the program requirements at F600 - 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation, Scope & Severity: J; F-835 - 42 CFR §483.70 Administration, Scope & Severity: K; F-880 - 42 CFR §483.80 (a)(1), (2) Infection Control, Scope & Severity: K. Additionally, Substandard Quality of Care was identified with the requirements at 42 CFR §483.12 Freedom from Abuse, Neglect, and Exploitation F600 (J). The noncompliance related to the immediate jeopardy was identified to have existed since [DATE]. The immediate jeopardy remains ongoing and the State Survey Agency (SSA) was unable to remove the IJ prior to exit on [DATE]. Findings include: Review of the facility's policy titled, Abuse Prohibition Policies and Procedures revision date ,[DATE] documented .residents will be free from abuse, neglect, involuntary seclusion and misappropriation of property. Review of R#4's Admission Record located in the Electronic Medical Record (EMR), documented the resident was admitted to the facility in 2014 with [DIAGNOSES REDACTED]. Review of R#4's quarterly Minimum Data Set (MDS), located in the EMR with an Assessment Reference Date (ARD) of [DATE], revealed the resident did not have any respiratory illness and did not require oxygen therapy. Review of R#4's Progress Notes located in the EMR documented that on [DATE], R#4 tested positive for COVID-19, was moved to the facility's COVID unit, and placed in quarantine. Review of R#4's Progress Notes and Vital Signs from [DATE] until [DATE] documented the resident remained asymptomatic until the ninth day on the COVID unit. On [DATE] at 3:08 p.m., R#4's oxygen saturation dropped down between ,[DATE] percent (%) on room air and the resident complained of a cough. The physician was notified and gave orders to apply oxygen and to keep oxygen saturation level at 92% and to obtain a portable chest x-ray. Further review of the Progress Notes revealed R#4 was transferred off the COVID unit and returned to the resident's previous room on [DATE] at 4:30 a.m. There was no evidence the resident's symptoms, which first presented on [DATE], had resolved prior to R#4 being released from the COVID unit. Review of a nurses note dated [DATE] at 6:31 a.m., Licensed Practical Nurse (LPN) JJ documented that R#4 remained on continuous oxygen at 2 liters (L) and continued to complain of cough. On [DATE] at 5:16 p.m., the facility received R4's chest x-ray results that indicated R#4 had bilateral pneumonia. The physician was notified of the results and an order to start antibiotics was given. On [DATE] at 5:19 p.m., R#4's oxygen saturation dropped to 90% on continuous oxygen. There was no evidence of documentation that R#4 was reassessed after her oxygen level was found to be less than 90% on continuous oxygen. On [DATE] at 3:30 a.m., R#4 was found showing signs of respiratory distress with an oxygen saturation of 35%. An oxygen mask was applied to the resident and the resident was taken immediately to the hospital. Review of the hospital's Discharge Summary dated [DATE], documented R#4 was admitted to the hospital and subsequently expired on [DATE] at 9:10 a.m. The [DIAGNOSES REDACTED]. Review of the Order Entry located in the EMR under the Orders tab revealed that on [DATE], (while the resident was in the COVID unit) the physician gave an order for [REDACTED]. Review of R#4's Vital Signs located in the EMR under the Vital Sign tab, revealed that from [DATE] at 4:23 a.m., prior to R#4 being discharged from the COVID unit, until 6:11 p.m. there were no vital signs or oxygen saturation levels obtained, which was over 13 hours later. On [DATE] from 7:20 p.m. until [DATE] at 5:02 p.m. there were no vital signs or oxygen saturations obtained for over 21 hours. From [DATE] at 5:19 p.m. until [DATE] at 3:30 a.m., when R#4's oxygen saturation dropped to 35% on continuous oxygen, there had not been any vital signs or oxygen saturations obtained for over 10 hours. During an interview on [DATE] at 11:00 a.m. with the Infection Control Preventionist (ICP), the ICP stated, I was not aware that R#4 was moved off the COVID unit until I came into work that morning, on [DATE]. The ICP stated that she would have preferred to have monitored the resident more closely for the next 24 to 48 hours due to the resident's oxygen saturations. An interview with Licensed Practical Nurse (LPN) JJ on [DATE] at 4:48 p.m. revealed LPN JJ was the nurse who discharged R#4 from the COVID unit on the morning of [DATE]. LPN JJ stated that R#4 was discharged from the COVID unit, where the resident's vital signs were monitored every four hours, because R#4 had been on the COVID unit for 10 days and the resident's name was on the discharge list. LPN JJ stated that she was not informed during shift report on the evening of [DATE] that R#4's oxygen saturation had dropped earlier that day or that R#4 had been started on oxygen. LPN JJ added there were no red flags, and she wasn't told not to move R#4. LPN JJ stated that if she had known about R#4's change in condition the previous day, she would not have moved the resident to the non-COVID unit where residents were not monitored as frequently as the residents on the COVID unit. An interview with LPN SS on [DATE] at 4:58 p.m. LPN SS, who was the receiving nurse when R#4 was transferred to the non-COVID unit, stated, If I had known R#4's oxygen saturations had dropped the day before, I would not have accepted the resident. LPN SS added had she known she probably would have monitored the resident closer. LPN SS stated the COVID unit monitors residents closer than the regular units. Further interview with LPN SS revealed she was not aware that R#4 had orders for vital signs to be obtained every four hours. LPN SS stated that she just assumed that since the resident was moved to a regular unit, vital signs were to be obtained every shift. LPN SS stated she had not looked at the resident's orders. During a telephone interview on [DATE] at approximately 4:00 p.m., LPN EE revealed she was the nurse who gave report to LPN JJ on the evening of [DATE]. LPN EE stated, I don't recall if I passed on R#4's change of condition on to the on-coming nurse but more than likely I did. LPN EE also stated that she had taken care of the resident on [DATE] and [DATE] after the resident was moved to the non-COVID unit. LPN EE stated on Manor 2 Unit (the non-COVID unit to which R#4 was moved), vital signs and oxygen saturation were obtained every shift (every 12 hours), and she was unsure if there was a set time to obtain the vital signs and oxygen saturations. LPN EE stated that she was not aware that R#4 had a current physician order for [REDACTED]., and did not know there was an order to do this. Further interview revealed that LPN EE was the nurse who was present when R#4's oxygen saturation dropped to 90 percent on [DATE]. LPN EE stated that in response to the drop in oxygen saturation, I had the resident do deep breathing, which did bring R#4's oxygen saturations back up to 93 percent. An interview with the Administrator on [DATE] at 4:22 p.m. revealed that when asked about moving the symptomatic resident from the COVID unit, the Administrator stated, If she is stable and her vitals were stable than she is okay to move back to room. The Administrator revealed her expectation was that staff followed physician orders. The Administrator stated, R#4 should have been monitored closer, at least the oxygen saturation levels, after R#4 was moved from the COVID unit. During a telephone interview on [DATE] at 5:45 p.m. with the Medical Director, he stated, According to the described condition of the resident, I would have expected that nursing would have monitored the resident more closely. A request for facility policies and procedures on assessment/reassessment of a resident, oxygen/respiratory assessments, and vital signs assessment was made during a meeting with the Administrator on [DATE] at 9:30 a.m. Another request for these policies was made on [DATE] at 9:00 a.m. Interview with the Administrator on [DATE] at 11:45 a.m. revealed the facility did not have policies and procedures for these care areas. The Administrator did provide a policy on [DATE] at 11:25 a.m., titled, Charting Guidelines for Manor Residents. Review of this policy revealed that, Resident's vital signs are to be taken and recorded at a frequency based on resident status and physician order. Further review of the Charting Guidelines for manor Residents revealed that the document stated that this Procedure valid on printed date only: [DATE].

Based on observation, staff interview, review of facility documentation, and review of the policies titled, Food Storage and Food Contamination, the facility failed to monitor dishwasher temperature (temp) daily to ensure proper wash and rinse temps were in a safe range; failed to discard expired foods in the dry storage area; failed to ensure opened food items in the walk-in cooler were properly labeled and dated; failed to ensure opened food in the walk-in freezer were securely wrapped, labeled and dated; and failed to maintain sanitary conditions of the two-compartment sink. This had the potential to affect 88 of 95 residents receiving an oral diet. Findings include: Review of the facility policies titled, Food Storage, and Food Contamination dated [DATE] revealed: 1.) Food items should be stored, thawed, and prepared in accordance with good sanitary practice. 2.) All products should be dated upon receipt and when they are prepared, use by dates are put on products, leftovers should be dated according to policy. 3.) Food to be frozen should be stored in airtight containers or wrapped in heavy-duty aluminum foil or special laminated papers. Label and date all food items. 4.) Raw fruits and vegetables will be washed before serving. 5.) All opened containers must be properly marked and covered, dated, and rotated. 6.) Water temperatures for washing dishes must be ,[DATE] degrees Fahrenheit, the rinse water must be ,[DATE] degrees Fahrenheit, if temperatures fall outside of acceptable range, maintenance department must be notified. Initial tour and observation of the kitchen on [DATE] between 11:35 a.m. and 12:20 p.m., with the Dietary Manager (DM), revealed the following concerns: 1. Observation at 11:40 a.m., during review of the dishwasher (temp) log, revealed there were no temp checks documented for (MONTH) 2020, additionally, there were 33 missed checks during (MONTH) 2020, and 32 missed checks during (MONTH) 2019. 2. Observation at 11:50 a.m. of the dry food storage area revealed the following items were identified: a. One opened box containing six large tea bags with expiration (exp) date [DATE]. b. Thirteen individual packets of Italian dressing with exp date [DATE]. c. Four large containers of dry pasta removed from the original box and placed in large containers, no label to know the received, opened, use-by, or expiration date. 3. Observation at 12:01 p.m. in the walk-in cooler, with the DM, revealed a sign posted on the door of the walk-in cooler reminding staff that everything was supposed to be labeled and dated. The DM revealed the sign had been there a long time. The following items were identified and confirmed by the DM: a. One large opened bottle of garlic with no open or use-by date. b. One opened bag of whipped topping, not sealed, no open or use-by date. c. One large opened container of Caesar dressing, no open or use by date. 4. Observation at 12:07 p.m. in the walk-in freezer, with the DM, the following items were identified and confirmed by the DM: a. One opened box of chicken breast cutlet with no open or use by date, the plastic bag inside containing the cutlets was not properly closed, exposing contents to air. b. Another opened box of chicken breast cutlet with no open or use by date, the plastic bag inside containing the cutlets was tore, exposing contents to air. c. One opened box of cheese omelets with no open or use by date, the plastic bag inside containing the omelets was tore, exposing contents to air. During an interview on [DATE] at 12:10 a.m., the DM, confirmed food items should be labeled, dated and stored properly, and expired food should be discarded, to prevent food contamination. Interview further revealed, per their policy, once an item was opened, it should be discarded after three days. DM confirmed they had missed several temp checks for the dishwasher, and it should have been checked three times a day following each meal. During observation on [DATE] at 10:00 a.m., and an interview at that time with the kitchen supervisor BB, a dietary aide poured grease down the left side of the two-compartment sink that was specified only for cleaning vegetables/produce. Kitchen supervisor (BB) verified she saw the aide pour the grease down the sink, and that she should not have done it. During a later interview at 10:15 a.m., the DM revealed the left side of the two-compartment sink was supposed to be used only for cleaning produce, the right side for thawing meat, and grease should be discarded in the grease container outside. Interview with the Administrator on [DATE] at 1:45 p.m., revealed she was not aware of any concerns in the dietary department. Her expectation was that food items should be labeled and dated so they know the received, opened, expired or the past use date. Further, she expected expired food be discarded, food be properly stored, closed and dated, and all areas of the kitchen, and equipment, be monitored and kept in a clean and sanitary working condition.

Based on record review and staff interview the facility failed to provide a Notice of Medicare Non-coverage (NOMNC) to two of three residents (R) (#17 and #58) who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of records for R#17 indicated that services were initiated on 11/1/19 with services ending 11/27/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. Review of records for R#58 indicated that services were initiated on 9/19/19 with services ending 10/23/19. The resident remained in the facility. The was no evidence that the Notice of Medicare Non-coverage (NOMNC) was provided to the resident. During an interview on 2/6/2020 at 10:25 a.m. with Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF it was reported that she has never given the NOMNC to residents remaining in the facility unless the insurance company provided it. RN MDS Coordinator FF reported that she was not aware that the NOMNC was required and denied that the facility had a policy about sending out notices when residents are discharged from Medicare Part A services.

Based on staff interview and record review, the facility failed to develop a baseline care plan for three residents (R), (#53, #83, and #142) of 44 sampled residents. Findings include: 1. R#53 admitted to the facility with principal [DIAGNOSES REDACTED]. R#53 was initially admitted for short term rehabilitation for knee contracture. Review of the clinical electronic record, facility documentation, and Minimum Data Set (MDS) Assessment at entry, 5-day, 14-day, and 30-day, revealed R#54 was admitted to the facility on [DATE]. He had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. Review of the Interim Care Plan (ICP) dated 12/5/18 revealed there was no interventions or instructional care specific for his [DIAGNOSES REDACTED]. Further review revealed there was no place to write a narrative, signature, or documentation that indicated the resident or representative was provided a summary of the baseline care plan that included the minimal information required. Interview on 2/06/2020 at 12:42 p.m., with the MDS Registered Nurse (RN) FF, and the MDS Licensed Practical Nurse (LPN) EE, confirmed the interim care plan was their baseline care plan, and it was completed by the nurse when the resident arrived. The nurse answered questions with information provided by resident, transfer papers, friends, and family, at admission or readmission and anything acute that came up afterwards. The information was entered by MDS staff. Interview further revealed they do not have a Baseline Care Plan policy and they take their direction from the Resident Assessment Instrument (RAI) manual. 2. R#83 had a BIMS score of 11, indicating moderate cognitive impairment. She was admitted to the facility with principal [DIAGNOSES REDACTED]. Review of the clinical record, facility documentation, and MDS Assessment at entry revealed R#83 was admitted to the facility on [DATE]. Review of the Interim Care Plan dated 1/13/2020 in the electronic record for R#83 revealed the assessment was a questionnaire with yes, no, unable to determine (UTD), or check all that apply options for the answer. The nurse was instructed to answer questions with information provided by resident, transfer papers, friends, and family, at admission or readmission. There was no problem/focus, goals, interventions, or place to write a narrative. Further, there was no place for a signature, and no documentation, that indicated the resident or representative was provided a summary of the baseline care plan that included the minimal information required. 3. Record review revealed that R#142 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the medical record revealed a document titled ICP-Interim Care Plan. Upon review of the interim care plan the instructions suggested the following: navigate to the care plan, click view, then triggered items and add the triggers from this assessment to start building the interim care plan. There is no evidence that an interim care plan was completed based on the triggered areas. During an interview on 2/6/2020 at 10:41 a.m. with the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF it was reported that the initial care plan is completed within the first 48 hours by the nursing staff and MDS staff are responsible for completing comprehensive care plan within 21 days. During an interview with the Director of Nursing (DON) on 2/6/2020 at 1:27 p.m. she confirmed that that interim care plan is being used as the baseline care plan. She further confirmed that there are no goals listed nor does it address physician's orders [REDACTED].#142. During a follow up interview with the DON on 2/6/2020 at 2:02 p.m. she confirmed that none of the interim care plans will have the necessary requirements for the baseline care plan. Cross refer to F688.

Based on observation, record review, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) was coded correctly for one resident (R) (#51) related to the use of restraints and for one resident (R#27) related to receiving [MEDICAL TREATMENT] services of 44 sampled residents. Findings include: 1. A review of the MDS indicator for R#51 revealed the use of a restraint. An observation on 2/4/2020 at 8:11 a.m. revealed the resident was in bed unrestrained. A review of the Quarterly MDS dated [DATE] documented that the resident utilized a chair that prevented rising. An observation on 2/5/2020 at 8:58 a.m. revealed the resident was sitting up in a wheelchair in the activity area with no sign of a seat belt, lap buddy or cushion that would restrain the resident. An observation on 2/5/2020 at 4:49 p.m., and on 2/6/2020 at 8:44 a.m. revealed the resident was in bed unrestrained. An interview on 2/6/2020 at 9:55 a.m. with the Registered Nurse (RN)/MDS Coordinator FF revealed she thought that staff had used the Geri-chair with the resident at times because of increased weakness in her trunk. Further interview on 2/6/2020 at 11:09 a.m. with the RN/MDS Coordinator FF revealed that she was unable to locate documentation to show that the resident used a Geri-chair at times. During an interview with Licensed Practical Nurse (LPN)/MDS Nurse EE at this time revealed that the Quarterly MDS dated [DATE] was coded wrong related to the resident using a chair that prevents rising. She confirmed that the resident does not use a restraint and that she coded it wrong. 2. Review of the Admission Record revealed R#27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#27 is to have [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. Review of MDS Quarterly assessment dated [DATE] indicated no [MEDICAL TREATMENT] while or while not a resident in the last 14 days. Review of Progress Note dated 11/15/19 revealed Resident #27 goes out to [MEDICAL TREATMENT] on Monday, Wednesday and Friday of every week. Interview on 2/5/2020 at 1:00 p.m. with Prospective Payment System (PPS) Coordinator revealed R#27 was on [MEDICAL TREATMENT] at the time of her last assessment of 11/17/19. She confirmed it was coded incorrectly and stated it was done in error. During an interview on 2/5/2020 at 1:26 p.m., the Administrator stated she expects both the MDS and PPS Coordinators to complete assessments and care plans accurately based on Resident Assessment Instrument (RAI) guidelines and once an error has been identified, corrections are to be made based on RAI guidelines manual.

Based on observation, record review, and staff interviews the facility failed to follow the care plan related to oxygen therapy for one of 44 residents (R) (#75) reviewed for care plans. Findings include: Review of the medical record for R#75 revealed a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Observations on 2/4/2020 at 1:23 p.m., 2/5/2020 at 7:56 a.m., and 2/6/2020 at 7:15 a.m. revealed R#75 receiving oxygen therapy via nasal cannula ranging from 3 and/or 3.5 LPM. During an interview and observation on 2/6/2020 at 9:32 a.m., the Director of Nursing (DON) confirmed that R#75 was receiving oxygen at 3 LPM. However, when the order was checked by Licensed Practical Nurse (LPN) II, it was revealed that R#75's oxygen should be at 2 LPM. The DON reported that it is the charge nurse's responsibility to assure that oxygen is given as ordered. Cross Refer F695.

Based on observation, interview, and record review it was determined that the facility failed to ensure appropriate services and assistance were provided to maintain or improve mobility when the residents demonstrated a limited mobility for one of 44 sampled residents (R) (#142). Findings include: Record review revealed that R#142 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During interview on 2/4/2020 at 1:20 p.m. R#142 was observed in bed leaning towards the left side. R#142 denied receiving any therapy services at this time. During an interview with the Physical Therapy (PT) Director on 2/5/2020 at 2:16 p.m. it was reported that a therapy referral is not automatic for new admissions. PT director went on to report that the therapy department does not screen everyone that is admitted into the facility. The PT Director reported that nursing has to refer residents to be seen by therapy. During an interview on 2/6/2020 at 10:33 a.m. Licensed Practical Nurse (LPN) II confirmed that R#142 has not received a therapy referral at this time. LPN II indicated that this had not been done due to R#142's payor source. LPN II reported that a referral for restorative services could be done but confirmed that a referral to restorative services has not been completed. During an interview on 2/6/2020 at 10:41 a.m., Registered Nurse (RN) Minimum Data Set (MDS) Coordinator FF revealed payment source is a factor related to R#142 being referred to therapy services but referrals are typically made within the first 21 days of a resident's admission into the facility. During an interview with the Director of Nursing (DON) on 2/6/2020 at 2:02 p.m. she confirmed that residents who are admitted with Range of Motion (ROM) limitations can be referred to therapy or to restorative services if therapy is not available. DON reviewed orders for R#142 and validated that there were no orders or referrals for restorative services. DON reported that R#142 should have been referred for restorative services and nursing staff was responsible for sending the referral. During a further interview on 2/6/2020 2:23 p.m. with the DON she again confirmed that there were no orders for therapy or restorative services. DON further reported that R#142 should have been referred to the therapy department even if they were not able to provide services and referral to restorative would have been done. DON reported that it should not have taken a week for the referral to be initiated.

Based on record review, and interviews with resident and staff, it was determined that the facility failed to implement care plan interventions to address pain for one resident ("B") and for the use of a bed alarm for one resident (#41), from a total sample of 32 residents. This failure resulted in actual harm for resident ("B"). Findings include: 1. According to his/her medical record, resident "B" had [DIAGNOSES REDACTED]. She/He had a 4/14/11 plan of care to address his/her alteration in comfort because of bladder spasms. Care plan interventions included administering medication as ordered, monitoring for the effectiveness of the medication, and notifying the physician as indicated. However, nursing staff failed to notify the physician in a timely manner about resident "B's" continued complaints of pain. See F309 for additional information regarding resident "B". 2. Resident #41 had [DIAGNOSES REDACTED]. There was a plan of care since 4/15/11 identifying the resident's risk for falls and history of falls. There was a 6/29/11 care plan intervention for staff to apply a bed/chair alarm. However, observations of the resident in bed on 7/20/11 and 7/21/11 revealed that staff had failed to attach the alarm. See F323 for additional information regarding resident #41.

Based on observations, interviews with resident and staff and record reviews, it was determined that the facility had failed to follow-up with the physician about one resident's ("B") continuous complaints of pain, and to identify the need for monitoring the [MEDICAL TREATMENT] for one resident ("A"), from a total sample of 32 residents. This failure resulted in actual harm for resident "B". Findings include: 1. Resident "B" had [DIAGNOSES REDACTED]. On the 7/07/11 Minimum Data Set (MDS) assessment, licensed nursing staff coded sections J0300 through J0600 indicating that resident "B" had constant pain within the prior 5 days; rated his/her pain level as a 7 out of 10 and; indicated that the pain made it difficult to sleep at night. On the 4/11/11 Pain Assessment, nursing staff documented that the resident reported having pain daily. He/She had a plan of care since 4/14/11 to address his alteration in comfort because of bladder spasms. Care plan interventions included nursing staff administering medication as ordered, monitoring the effectiveness of the (pain relief) medication, and notifying the physician as indicated. However, although licensed nursing staff administered pain relief medication for the resident's complaints of pain, they had failed to follow up with the physician about its ineffectiveness for relief of the resident's continued pain. The nurse's notes revealed that resident "B" had been given pain medication for pain in his right side at least daily from 6/02/11 through 6/10/11; two times on 6/02/11, 6/06/11 and 6/09/11 and; three times on 6/07/11. However, despite the resident's daily complaints of pain in his right side, staff failed to attempt to notify the physician about the resident's pain until 6/10/11. On 6/10/11, licensed nursing staff sent a fax to the physician's office to notify him about the resident's complaints of pain with urination and sharp pain in both sides. However, there was no evidence that the staff followed up to ensure that the physician had received the fax or was aware of the resident's pain until 6/25/11 (15 days later). Although, there was documentation that pain medications had been given to the resident, there was not any nursing staffs' descriptive documentation about the resident's pain from 6/10/11 until 6/25/11. At that time (6/25/11), the nurse's notes described the resident as having had a greenish colored discharge from his penis for which the physician ordered an antibiotic. Documentation in the nurse's notes revealed that the resident had continued to be given pain medication for complaints of pain at least daily from 6/25/11 through 7/20/11; including three times a day on 6/26/11, 6/27/11, 6/28/11, 6/29/11, 7/02/11, 7/11/11 and; two times a day on 7/03/11, 7/08/11 and 7/20/11. A licensed nursing staff had sent a fax to the physician's office on 7/2/11 to notify him about resident's continued complaints of pain which the resident thought was from his kidneys. However, there was no evidence that the staff followed up to insure that the physician had received that fax or was aware of the resident's continued complaints about being in pain until 7/20/11 (18 days later), after surveyor inquiry. During an observation of range of motion exercises on 7/20/11 at 9:35 a.m., the resident refused the services. The restorative certified nursing assistant (RCNA) stated that the resident had refused range of motion exercises for several days because of having been in pain. The RCNA said that the resident had thought that the pain was in his/her kidney area. There was no evidence that the physician had been notified about the resident refusing restorative nursing services for several days. In an interview on 7/20/11 at 3:05 p.m., licensed nurse "AA" said that he/she did not know that the resident had been refusing restorative nursing services. On 7/20/11 at 4:00 p.m., resident "B" described his/her level of pain as having been "about a 6 out of 10" which was better than yesterday when it was 7 out of 10. He/she said that the pain was worse on the right side than the left. However, on 7/21/11 at 10:30 a.m., licensed nurse "AA" confirmed that there was not any evidence that nursing staff had followed up with the physician regarding the resident's continuing pain or level of pain until 6/25/11 after sending the fax on 6/10/11 and until 7/20/11 after sending the 7/02/11 fax. When the physician was notified about the resident's continuing complaints of pain on 7/20/11, he changed the specific pain medication being given to the resident and increased dosage. In a subsequent interview on 7/21/11 at 9:55 a.m. after the change in his/her pain medication, resident "B" said that the new pain medication had helped to alleviate some of his pain. 2. Resident "A" had [DIAGNOSES REDACTED]. Resident "A" received [MEDICAL TREATMENT] three times each week. There was a physician's orders [REDACTED]. There was a care plan to address his/her risk for dehydration related to his/her poor intake, the PEG tube and fluid overload. The care plan interventions included that staff would assess the resident for dehydration, provide fluids the resident liked, keep fluids accessible, and avoid fluids with a diuretic effect. However, the resident's care plan did not include his/her need for [MEDICAL TREATMENT], monitoring and care of the access site and the ordered fluid restriction. The physician had ordered a 1200 cc fluid restriction. On 7/21/11 at 9:35 a.m., resident "A" stated that the nursing staff at the facility did not routinely check his/her shunt . Resident "A" stated that his/her shunt had been replaced on Monday but since then only one nurse had observed the site. He/She that it had been draining at that time. On 7/21/11 at 10:00 a.m., licensed nurse "BB" stated that no one was assigned the responsibility of routinely monitoring the resident's access site. "BB" said that that she had observed the resident's access site that morning but, she was not aware of the dried blood that staff had observed beneath his/her shunt dressing. See F327 for additional information about resident "A".