Every finding on record at Mission Point Nursing & Physical Rehabilitation Ce

Based on interview and record review the facility failed to ensure the acting Infection Control Preventionist (ICP) had the proper training and certification to ensure infection control measures were in place and being followed per federal regulation and the facility's policy, resulting in the potential for all residents residing in the facility to be at risk for serious infections and complications from different types of infections. Findings include: During an interview on 7/25/25 at 1:45 PM., the Director of Nursing (DON) reported she was the Infection Control Preventionist (ICP) for the facility. The DON reported she does not have the required Infection Control Prevention certification that she should. The DON reported the facility has been short staffed and she has been trying to keep up. The DON reported the new Nursing Home Administrator (NHA) has the required ICP certification as well as another staff member. DON reported the NHA has only been at the facility for 2 days, and the other staff member who holds the ICP certificate has been assigned as the wound nurse. DON reported she has been unable to keep up with the actual duties that are required by the ICP, as she is also the DON. Review of the facility Infection prevention & control program Routine Duties with no dated revealed: Daily Duties: Monitor the (Name Brand Electronic Medical Record [EMR]) Dashboard for any new antimicrobial orders - ensure diagnosis meets McGeer Criteria, stop date present on order, dosed per CDC (as applicable), diagnosis/indication for use on the order itself, complete the Infection Report UDA, trigger care plan for infection/antimicrobial use, and implement proper IC precautions, as applicable. Add the new infection to the IC line listing/map for tracking. Review in AM meeting and educate dept heads so they can cascade the information to their teams. Identify any staff illness and add to tracking document when they return to work. Refer to employee illness policy for when they are eligible to return to work. Be sure to document return to work dates of employees. Monitor the (Name Brand EMR) dashboard - alerts and weights/vitals tab for any change in condition or s/sx (symptoms) of infection. Order labs/contact physician/initiate change in condition if needed. Implement IC (Infection Control) precautions immediately, as applicable. Review wound assessment documentation for indication of skin/wound infection. Work with admissions team to review any new referrals for infections, colonization, or MDRO (Multi Drug Resistant Organism) status. Choose room according to required precautions. Notify staff ahead of time of admission/precautions. Ensure transmission-based precautions (isolation) placed on room door and PPE (Personal Protective Equipment) available for room if applicable. Monitor residents on antimicrobial therapy for effectiveness and for medication side effects via antibiotic time-out. If they are not showing improvement after 48-72 hours (about 3 days), contact the physician for further directions. Document applicable findings and notification in EHR (Electronic Health Record). Monitor for outbreaks - three or more cases on a unit (except for COVID-19 where 1 new case equates an outbreak) - implement outbreak procedure; notify Health Department as required. Complete/delegate IC audits per risk assessment or other identified need (ex. outbreak); be sure to provide surveillance to all areas of the facility (i.e., kitchen, laundry, storage rooms, nurse's stations, resident rooms, resident rooms, etc.). Monitor immunizations for new admissions and ensure the immunization tab is updated/consents uploaded. Verify immunization status in MCIR (state based immunization registry). Alert Housekeeping team to high-risk rooms for increased cleaning: residents with infections, residents on IV therapy, isolation rooms.Monthly Duties: Complete a monthly summary (seek trends/patterns) and map for the facility for each type of infection and overall infection rate per 1,000 resident days (calculation: [total # of in-house acquired infections / # of resident days] xIOOO = monthly infection rate). Summarize employee illnesses (all depts) and identify any correlation to resident illness (or indicate if none). Evaluate any outbreaks - ensure a separate line list is completed and write a summary/timeline of all actions taken. Verify notification of Health Department, Medical Director, Residents, Staff, Responsible Parties, QAPI (Quality Assurance Process Improvement). Summarize audits completed for the month to identify any education needed for staff or change in frequency/type of audits. Add a copy of any education/sign in log to IC binder. Complete hand hygiene audits weekly with addition of PPE audits if isolation rooms present. After the above is completed, write out a report to bring to QAPI. The Pharmacist Consultant attends QAPI quarterly and should provide a report on antibiotic ordering trends and pharmacy recommendations; this report is to be reviewed by the Medical Director. Provide PRN education to residents on antibiotic stewardship/infection control (ex. handwashing, antibiotic use, transmission-based precautions, pandemic awareness)- May attend Resident Council, if committee approves, small group and/or educate 1:1. Review vaccination status of all residents and staff. Schedule immunizations, or boosters, as indicated.Annual Duties: TB (Tuberculosis) Risk assessment- determine low/medium/high-risk to see if change is needed for TB monitoring process. Infection Control Risk Assessment - develop action plan(s) and add to the Facility Assessment. Review the LTC (Long Term Care) Facility Self-Assessment Tool to see if there are any areas not yet being addressed. Update the Reportable Communicable Disease Report for the State of Michigan (Michigan.gov) for the current year. Obtain copy of antibiogram from lab and provide to the physician for review (obtain signature, add to binder). Complete annual review of IC policies (obtain physician signature, add to binder) - proof for QAPI. Summarize the facility's IC for the year and compare it to the action plan developed in last year's risk assessment. Obtain report of staff Relias Training education for infection control to ensure compliance.

This citation pertains to intake # 1234673Based on interviews and record review, the facility failed to develop and implement a person-centered plan of care for one Resident (#44) of 12 residents reviewed for comprehensive care plans, resulting in the potential for aspiration and impaired physical, mental, and psychosocial well-being.Findings include:Resident #44 (R44)Review of the admission Record Face Sheet revealed R44 was an [AGE] year-old male admitted to the facility on [DATE] and had diagnoses including unsteadiness on feet and dysphasia (difficulty swallowing). Review of the Minimum Data Set (MDS) dated [DATE] revealed R44 had a brief interview for mental status (BIMS) score of 00 out of 15 which indicated he was severely cognitively impaired. Review of R44's Care Plan revealed, there was no person-centered care plan put into place for the focus area of having a feeding tube. During an interview on 7/24/2025 at 8:38 AM, Licensed Practical Nurse (LPN) J reported they did not recall much of R44 because the resident had been discharged for quite some time. LPN J reported they did recall R44 had a few hospitalizations for aspiration pneumonia and did have a feeding tube because R44 would refuse to eat and drink, and had difficulty swallowing. During an interview on 7/24/25 at 12:30 P.M., the Director of Nursing (DON) reported R44 should have had a person centered care plan in place for his feeding tube as a focus area with measurable goals and proper interventions. The DON indicated any nurse can update the care plans, but typically she had been doing them. The DON reported the MDS nurse working at the facility at the time R44 was in the facility no longer worked there. The DON reported she was aware of resident care plans not being developed as they should, or implemented and revised as they should be. Review of a facility Policy with a revision date of 6/2024 revealed: Policy.The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The initial care conference will be held within 72 hours of admission and quarterly thereafter.Policy Explanation and Compliance Guidelines:1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i. Initial goals based on admission orders.ii. Physician orders, iii. Dietary orders.iv. Therapy services.V. Social services, vi. PASARR recommendation, if applicable.1. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.b. Interventions shall be initiated that address the resident's current needs including:i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk.ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.living.111. Any special needs such as IV therapy, dialysis, or wound care.3. A written summary of the baseline care plan shall be provided to the resident and representatives in a language that the resident/representative can understand. The summary shall include, at a minimum, the following:a. The initial goals of the resident.b. A summary of the resident's medications and dietary instructions.c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.3. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable.4. The comprehensive care plan is developed from the RAI scheduled and is reviewed and revised by the IDT as necessary.

Based on interview and record review, the facility failed to employ a certified dietary manager or certified food service manager to manage the food service department.Findings include:During an interview on 7/22/25 at 4:24 p.m., the Business office Manager/Human Resources Manager E reported the Dietary Manager was not certified.During a follow-up interview on 7/24/25 at 12:55 p.m., the Business Office Manager/Human Resources Manager E reported the Dietary Manager was promoted to Dietary Manager on 11/20/23 but did not become certified.Review of the facility Job description for the Dietary Manager revealed under education and training, the Dietary Manager was required to be certified.During an interview on 7/24/25 at 3:15 p.m., the Nursing Home Administrator (NHA) acknowledged the Dietary Manager did not meet the qualifications of the job.The FDA Food Code identifies an acceptable level of education for a person in charge of a food service operation as: 2-102.11 Demonstration.Based on the RISKS inherent to the FOOD operation, during inspections and upon request the PERSON IN CHARGE shall demonstrate to the REGULATORY AUTHORITY knowledge of foodborne disease prevention, application of the HAZARD Analysis and CRITICAL CONTROL POINT principles, and the requirements of this Code. The PERSON IN CHARGE shall demonstrate this knowledge by:(A) Complying with this Code by having no violations of PRIORITY ITEMS during the current inspection; Pf(B) Being a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM

Based on observation, interview, and record review, the facility failed to ensure staff had the appropriate competencies and skills to carry out functions of the food and nutrition services. This deficient practice had the potential to affect all 38 facility residents.Findings include:During an observation on 7/22/25 at 11:28 a.m., the resident refrigerator had two small containers of food with a resident's name on a label but no date as to when it was brought to the facility or a use by date. There were also four containers of apple sauce with a use by date of 7/21/25 located in the resident refrigerator.During an interview on 7/22/25 at 11:34 a.m., Dietary Staff D reported she had already looked in the resident refrigerator and all the dates and food in the resident refrigerator were checked and the items in the refrigerator were labeled.During an interview on 7/22/25 at 11:38 a.m., Dietary Staff B reported she was unsure what temperature the resident's food had to be prior to serving the residents. During an observation on 7/23/25 at 8:53 a.m., there were two opened packages of deli meat on a small tray in the resident refrigerator. The tray was wet from the deli meat. Directly under the tray of meat on the shelf was an opened box of apples. During an interview on 7/23/25 at 8:59 a.m., Dietary Staff C reported the apples shouldn't be under the deli meat because the apples could be contaminated. However, they were not going to throw them away because they stated, that is above my pay grade.During an interview on 7/23/25 at 12:30 p.m., when queried about when the dietary staff check the dates on the food items in the freezer, refrigerator, dry storage, and in the main kitchen. Dietary Staff B stated, We don't really look at the dates and shrugged their shoulders. During an interview on 7/24/25 at 3:15 p.m., the Nursing Home Administrator (NHA) acknowledged concerns about the dating of food items and the competency of the dietary staff.

Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in accordance with professional stands for food service safety as evidenced by:- Failing to ensure labeling of food- Failing to ensure expired food was discarded- Failing to prevent possible contamination of fresh produce- Failing to prevent possible cross contamination from kitchen appliances- Failing to ensure the ice machine drainage pipe has a two-inch air gap to the floor drainThis deficient practice had the potential to result in food borne illness among any or all 38 residents in the facility who receive meals.Findings include:During an observation on 7/22/25 at 11:10 a.m., the walk-in refrigerator contained two unsealed, undated packages of deli meat stored directly over an uncovered open box of fresh apples.During an interview on 7/22/25 at 11:10 a.m., Dietary Staff B acknowledged the fresh apples would be considered contaminated due to the deli meat possibly leaking on the apples and then stated, I didn't do it.During an observation on 7/23/25 at 8:53 a.m., the walk-in refrigerator contained packages of deli meat stored directly over an uncovered open box of fresh apples. During an interview on 7/23/25 at 8:59 a.m., Dietary [NAME] C reported the apples shouldn't be under the deli meat because the apples could be contaminated. However, he wasn't going to throw them away because he stated, that is above my pay grade.Review of facility policy titled Food Storage, date reviewed/revised 1/24, read in part .meats shall we stored on shelves below fruits.so that meat juices to not potentially drip onto these foods.According to the 2022 FDA Food Code section 3-302.11 Packaged and Unpackaged Food -Separation, Packaging, and Segregation. (A) FOOD shall be protected from cross contamination by: (1) Except as specified in (1)(d) below, separating raw animal FOODS during storage, preparation, holding, and display from: (a) Raw READY-TO-EAT FOOD including other raw animal FOOD such as FISH for sushi or MOLLUSCAN SHELLFISH, or other raw READY-TO-EAT FOOD such as fruits and vegetables,(b) Cooked READY-TO-EAT FOOD. During an observation on 7/22/25 at approximately 11:15 a.m., the log books revealed:1. Food temps were not completed for the evening meal on 7/21/25 or the breakfast meal on 7/22/25.2. Dishwasher temperatures were not completed in the evening of 7/21/25 or the morning of 7/22/25.During an observation on 7/22/25 at 11:18 a.m., the dry storage area contained:1. Noodles dated as opened on 5/19/25 and a use by date of 6/19/25.2. A second opened bag of noodles with no open or use by date. 3. A bag of instant pudding with an expiration date of 3/20/25.4. Fruit drink mix that was out of the original box and no label of a use by or expiration date on the drink mix.Review of facility policy titled Food Storage, last reviewed/revised 1/24, read in part .food items in dry storage not in the original delivery box will be dated upon receiving with month, day and year. During an observation on 7/22/25 at 11:28 a.m., the resident refrigerator had two small containers of food with a resident's name on a label but no date as to when it was brought to the facility or a use by date. There were also four containers of apple sauce with a use by date of 7/21/25 located in the resident refrigerator.During an interview on 7/22/25 at 11:34 a.m., Dietary Staff D reported she had already looked in the resident refrigerator and all the dates and food in the resident refrigerator were checked and the items in the refrigerator were labeled.Review of facility policy titled Use and Storage of Food Brought in by Family or Visitors, last reviewed/revised 1/21, read in part .All food items that are already prepared by the family or visitor.must be labeled with resident name and date.During an interview on 7/22/25 at 11:38 a.m., When taking temperatures of the food, Dietary Staff B reported she was unsure what temperature the resident's food had to be prior to serving the residents. During an observation on 7/22/25 at 11:47 a.m., the following was noted:1. A bin of flour with an open date of 6/7/25 and a use by date of 7/7/25.2. A bag of walnuts that was opened with an open date of 5/29/25 and a use by date of 6/29/25. 3. A bottle of vanilla that was opened with an open date of 3/23/25 and a use by date of 5/23/25.4. A large bag of potato chips that was opened with no open date or use by date.5. A bag of brown sugar that was opened with no open date or use by date.6. A bag of marshmallows that were opened with no open date or use by date.During an observation on 7/23/25 at 8:53 a.m., the following was noted:1. A tray with 9 containers filled with pureed cookies that were not labeled or dated in the refrigerator.2. A container of mozzarella cheese with an open date of 7/15/25 and a use by date of 7/21/25.During an observation on 7/23/25 at 12:24 a.m., the mounted can opener was observed to contain black and brown slimy debris that was attached to the underside of the can opener near the blade. The can opener post was sticky, slimy, and black. The can opener holder had black and brown debris that clung to the sides of the holder.During an interview on 7/23/24 at 12:28 p.m., Dietary Staff C reported that the can opener is wiped down every day. During an interview on 7/23/24 at 12:30 p.m., Dietary Staff B looked at the can opener holder and reported they never clean the can opener holder.During an interview on 7/23/25 at 12:30 p.m., when queried about when the dietary staff check the dates on the food items in the freezer, refrigerator, dry storage, and in the main kitchen. Dietary Staff B stated, We don't really look at the dates and shrugged her shoulders. During an observation on 7/23/24 at 12:32 p.m., clumps of black and dried debris were noted on the underside of the large mixer in the kitchen. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. During an observation on 7/24/25 at 6:50 a.m., this surveyor walked into the kitchen freezer and noted a bag of green beans out of its original box with no use by date, a small box of pork out of the original box with no use by date, a banana cream pie out of the original box with no use by date, a pound cake out of its original box with no use by date, and a metal bin with a large piece of frozen meat that was out of its original box and was unlabeled and undated.Review of facility policy titled Food Storage, last reviewed/revised 1/24, read in part .Food items that are opened shall be put into a sealable container or bag, labeled and dated with open and use by date.During an interview on 7/24/25 at 6:51 a.m., Dietary [NAME] C reported that he had no idea what the meat substance was and shrugged his shoulders.Review of facility policy titled Food Storage, last reviewed/revised 1/24, read in part .Food stored in a freezer will have a receive date, or a date when the item was placed in the freezer.During an observation on 7/24/25 at 2:59 p.m., this surveyor reviewed the ice machine and noted that the outgoing pipes from the ice machine go directly to the floor. There was not a gap between the outgoing pipes and the drain to prevent potential for a backflow of sewage that could travel into the ice machine. During an interview on 7/24/25 at 3:15 p.m., the Nursing Home Administrator (NHA) viewed the ice machine and acknowledged there should be a gap to prevent the potential for a backflow of sewage into the ice machine. The NHA acknowledged concerns regarding the labeling of food, dating of food, storage of food, and the competency of staff in the dietary department.

Based on observation, interview, and record review the governing body failed to hire a licensed Nursing Home Administrator (NHA) to oversee the day-to-day operations of the facility and ensure the federal regulations are being followed.Findings include:During an interview on 7/22/25 at 11:05 a.m., the Director of Nursing (DON) reported that there was not a Nursing Home Administrator in the building, and she was taking care of everything in the facility.During an interview on 7/22/25 at 12:46 a.m., the Business Office Manager/Human Resource Manger E reported that the Nursing Home Administrator has been out of the facility since May but there is a new one starting on 7/23/25.During an observation on 7/22/25 at approximately 12:48 p.m., this surveyor noted that the Business Office Manager/Human Resource Manager E removed a NHA license that was posted in the hallway from the previous administrator.During a phone interview on 7/22/25 at 2:57 p.m., the previous Nursing Home Administrator reported that she had not been in the facility since May and was surprised that her license would still be posted within the facility. Review of the Employee list provided by the facility revealed that the Current Nursing Home Administrator was hired on 7/22/25.Review of the Federal Nursing Home Reform Act of 1987 revealed that nursing homes are required to have a licensed nursing home administrator to oversee the facility's day-to-day operations and ensure resident care. This requirement is based on both federal and state regulations.

Based on interview and record review, the facility failed to develop, implement, and maintain an effective, and comprehensive Quality Assurance Performance Improvement (QAPI) program that addresses the full range of services the facility provides. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.Findings include:During an interview on 7/25/25 at 8:38 a.m., the Director of Nursing (DON) reported, during the May 2025 QAPI meeting the team members did not go over anything as they were waiting for the whole team to be present.the Nursing Home Administrator (NHA) was not present and the Infection Preventionist (IP) was not present.During an interview on 7/25/25 at 9:43 a.m., the NHA reported the DON supervised the QAPI program.During an interview on 7/25/25 at 9:49 a.m., the DON reported the facility is not working on any Performance Improvement Projects (PIPS).we are not doing any data collection to assess for any problems within the facility.there are no action plans or anything the facility has been working on for QAPI.there is no feedback, analysis or tracking for the QAPI program. The DON then stated, I really don't have anything. I don't understand what the QAPI program is supposed to do.Review of a policy titled Quality Assurance and Performance Improvement, last reviewed/revised 3/24, read in part .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

Based on interview and record review, the facility failed to establish priorities for its improvement activities, develop and implement action plans, and review or analyze data collected under the Quality Assurance Performance Improvement (QAPI) program. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.Findings include:During an interview on 7/25/25 at 9:49 a.m., the Director of Nursing (DON) reported the facility is not working on any Performance Improvement Projects (PIPS).we are not doing any data collection to assess for any problems within the facility.there are no action plans or anything the facility has been working on for QAPI.there is no feedback, analysis or tracking for the QAPI program. The DON then stated, I really don't have anything, I don't understand what the QAPI program is supposed to do.Review of Facility policy titled Quality Assurance and Performance Improvement, last reviewed/revised 3/24, read in part .It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life.

Based on interview and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members. This deficient practice resulted in the potential for quality-of-care concerns for all 38 residents in the facility.Findings include:A review of the facility QAPI sign-in sheets revealed the following:The QAPI meeting was held on 5/15/25: The Nursing Home Administrator (NHA) did not attend the meeting and the Infection Preventionist did not attend the meeting.The facility did not have a QAPI meeting in April of 2025 or June of 2025.During an interview on 7/25/25 at 8:38 a.m., the Director of Nursing (DON) reported that the NHA did not attend the meeting, and the facility did not have an Infection Preventionist.A review of the facility policy titled Quality Assurance and Performance Improvement last reviewed/revised 3/2024, read in part .The QA committee shall.consist.of the Director of Nursing, Medical Director or designee, three other members of the facility staff, at least one of which must be the administrator. and the infection control and prevention officer.and meet at least quarterly.

Based on interview and record review, the facility failed to implement and operationalize their policy for antibiotic stewardship program and failed to ensure accurate monitoring of antibiotic use resulting in the potential for inappropriate antibiotic utilization and worsening or non-improving infections for all 38 residents residing within the facility as well as the potential for antibiotic resistance.Review of the facility's Infection Prevention and Control binder revealed multiple residents who had taken antibiotics on different occasions over different months of the look back period for antibiotic tracking sheets had an N under the antibiotic tracking sheet area of was criteria followed. The criteria per facility protocol had McGeer's Criteria listed. During an interview on 7/25/25 at 1:45 PM., the Director of Nursing (DON) reported she was the Infection Control Preventionist for the facility. The DON reported that she and or the physicians do not always use McGeer's criteria or any other acceptable/accredited antibiotic criteria when prescribing antibiotics. The DON reported she will go by signs and symptoms of certain residents because of her experience in Long Term Care. The DON reported sometimes residents don't meet the criteria, but not all residents will have symptoms when they have a UTI, or another type of infection. The DON reported she did not have the required Infection Control Preventionist training certificate. Review of a facility Policy with a revision date of 1/2024 revealed: Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. Policy Explanation and Compliance Guidelines: 1. The Infection Preventionist, with oversight from the Director of Nursing, serves as the leader of the Antibiotic Stewardship Program: a. Infection Preventionist - coordinates all antibiotic stewardship activities, maintains documentation, and serves as a resource for all clinical staff. b. Director of Nursing - serves as back up coordinator for antibiotic stewardship activities, provides support and oversight and ensures adequate resources for carrying out the program. c. Administrator - provides adequate resources for carrying out the program and ensures review of antibiotic use and resistance data at QAPI meetings. 2. The Medical Director, Consultant Pharmacist, and Attending Physicians and/or Midlevel Providers support the program via active participation in developing, promoting, and implementing a facility wide system for monitoring the use of antibiotics. a. Medical Director - serves as the primary medical point of contact for the program and serves as a liaison between the facility and other medical staff members. b. Consultant Pharmacist - reviews antibiotics prescribed to residents during their medication regimen review and serves as a resource for questions related to antibiotics. c. Attending Physicians/Midlevel Providers - prescribe appropriate antibiotics in accordance with standards of practice and facility protocols. 3. Licensed nurses participate in the program through assessment of residents and following protocols as established by the program. 4. The program includes protocols and a system to monitor antibiotic use. a. Antibiotic use protocols: i. Nursing staff shall assess residents who are suspected to have an infection and notify the physician as applicable. ii. Laboratory testing shall be in accordance with current standards of practice. iii. The facility uses McGeer's Criteria to define infections. iv. All prescriptions for antibiotics shall specify the dose, duration, and indication for use. v. Whenever possible, narrow-spectrum antibiotics that are appropriate for the condition being treated shall be utilized. b. Monitoring antibiotic use: i. Antibiotic orders obtained upon admission, whether new admission or readmission, to the facility shall be reviewed for appropriateness. ii. Antibiotic orders obtained from consulting, specialty, or emergency providers shall be reviewed for appropriateness. iii. Antibiotic use shall be measured by monthly prevalence.iv. A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices. 5. At least annually, feedback shall be provided on the facility's antibiotic use data shared with the QAPI Committee. 6. At least annually, the Medical Director shall be provided feedback on prescriber antibiotic use data. 7. Education regarding antibiotic stewardship shall be provided at least annually to nursing staff. 8. The elements of the program and associated protocols are reviewed on an annual basis as part of the facility's review of the overall infection prevention and control program. 9. Data obtained from antibiotic stewardship monitoring activities is discussed in the facility's QAPI meetings.

Based on interview and record review, the facility failed to update and revise care plan interventions for 1 Resident (#7) of 12 residents reviewed for care plan revision, resulting in the potential for unmet resident care needs, increased falls, unsafe resident environment, and resident injury. Findings include:Resident #7 (R7)Review of the admission Record Face Sheet revealed R7 was admitted to the facility on [DATE] with diagnoses including repeated falls. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R7 had a brief interview for mental status (BIMS) score of 13 out of 15, indicating cognition was intact. In an interview on 7/24/2025 at 8:51 AM, R7 reported he had fallen out of bed quite a few times trying to reach for things, or self-transfer. R7 reported he has not been injured but does have pain in his right elbow from a car accident he was in many years ago. Review of R7's Care Plan revealed: Focus At risk for falls aeb (as evidence by) impaired gait and mobility r/t (related to) s/p (status post) CVA (cerebrovascular accident/stroke), muscle weakness, seizures, encephalopathy (disorder or disease of the brain), impaired safety awareness, fatigue, use of antipsychotic medications, and h/o falls. Recommended to have assist x1 for transfers but continues to get up without assistance or using the call light. Date Initiated: 11/05/2022 Revision on: 07/23/2024. further review of R7's care plan revealed interventions had not updated/revised to reflect his current status of recent falls. Nor did the care plan address any additional identification of possible preventative measures. During an interview on 7/24/25 at 12:30 P.M., the Director of Nursing (DON) reported R7 should have had updated/revised care plan interventions for R7's Falls care plan. The DON reported she was aware of resident care plan intervention not being revised as they should be. The DON reported there have been many changes with staff in the last few months, so it has been hard to keep on ensuring care plans reflect the resident's current status and are individualized to reflect changes. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, v1.16, Chapter 2: Assessments for the Resident Assessment Instrument (RAI), revealed .the resident's care plan must be reviewed after each assessment .and revised based on changing goals, preferences and needs of the resident and in response to current interventions .Residents' preferences and goals may change throughout their stay, so facilities should have ongoing discussions with the resident and resident representative, if applicable, so that changes can be reflected in the comprehensive care plan . Review of a facility Policy with a revision date of 6/2024 revealed: Policy.The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care. The initial care conference will be held within 72 hours of admission and quarterly thereafter.Policy Explanation and Compliance Guidelines:1. The baseline care plan will:a. Be developed within 48 hours of a resident's admission.b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to:i. Initial goals based on admission orders.ii. Physician orders, iii. Dietary orders.iv. Therapy services.V. Social services, vi. PASARR (Preadmission screening and annual resident review) recommendation, if applicable.1. The admitting nurse, or supervising nurse on duty, shall gather information from the admission physical assessment, hospital transfer information, physician orders, and discussion with the resident and resident representative, if applicable.a. Once gathered, initial goals shall be established that reflect the resident's stated goals and objectives.b. Interventions shall be initiated that address the resident's current needs including:i. Any health and safety concerns to prevent decline or injury, such as elopement, fall, or pressure injury risk.ii. Any identified needs for supervision, behavioral interventions, and assistance with activities of daily living.living.111. Any special needs such as IV therapy, dialysis, or wound care.3. A written summary of the baseline care plan shall be provided to the resident and representatives in a language that the resident/representative can understand. The summary shall include, at a minimum, the following:a. The initial goals of the resident.b. A summary of the resident's medications and dietary instructions.c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.3. If the comprehensive assessment and comprehensive care plan identified a change in the resident's goals, or physical, mental, or psychosocial functioning, which was otherwise not identified in the baseline care plan, those changes shall be incorporated into an updated summary provided to the resident and his or her representative, if applicable.4. The comprehensive care plan is developed from the RAI scheduled and is reviewed and revised by the IDT (Interdisciplinary Team) as necessary.

Based on observation, interview, and record review, the facility failed to provide Activities of Daily Living (ADL) care i.e. bathing and grooming services for one Resident (R5) of two residents reviewed for ADL care which resulted in unmet care needs.Findings include:Resident #5 (R5)Review of the Minimum Data Set (MDS) assessment for R5, dated 5/13/25, revealed admission to the facility on 2/13/25. R5 scored 13 of 15 on the Brief Interview for Mental Status (BIMS) assessment, reflective of intact cognition. Section GG revealed R5 requires partial to moderate assistance for showers/bathing and set up or clean-up assistance for shaving.During an observation and interview on 7/22/25 at 1:40 p.m., R5 was sitting in a recliner in his room. R5 had long facial whiskers and disheveled hair. R5 stated, I haven't had a shower in two weeks, and no one will help me.I can't do it myself and would like to be shaved.My facial hair itches me.I would like to have a haircut too.On 7/23/25 at 9:30 a.m., R5 was observed sitting in his recliner in his room, still unshaved.On 7/23/25 at 9:30 a.m., during a follow-up interview, R5 reported he was not offered a shower this morning.During an interview on 7/24/25 at 8:40 a.m., the Director of Nursing (DON) reported residents receive showers weekly.During an interview on 7/24/25 at 8:42 a.m., Certified Nurse Aide (CNA) F reported residents receive showers weekly and shaving is offered weekly which occurs on the day the resident receives a shower.Review of the CNA shower log revealed R5 had not received a shower since 7/9/25 and had not refused a shower.Review of R5's care plan revealed they required assistance of one person when receiving a shower.During an interview on 7/24/25 at 3:15 p.m., the Nursing Home Administrator (NHA) acknowledged the residents should receive a shower weekly and residents should be shaved weekly if the residents requested to be shaved.Review of facility policy titled Activities of Daily Living (ADL) date implemented 2/25/24, read in part .Care and services will be provided for the following activities of daily living bathing, dressing, grooming.

Based on observation, interview, and record review, the facility failed to provide oxygen services including humidification and routinely changing oxygen tubing for one Resident (#11) of two residents reviewed for oxygen services. This deficient practice resulted in discomfort and unmet care needs.Findings include:Resident #11 (R11)Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 2/23/22, with active diagnoses that included Chronic Obstructive Pulmonary Disease (COPD), chronic respiratory failure with hypoxia (absence of enough oxygen in the tissues to sustain bodily functions), and respiratory failure. R11 scored a 15 of 15 on the Brief Interview for Mental Status (BIMS) reflective of intact cognition.During an observation on 7/22/25 at 1:20 p.m., R11 received oxygen via nasal cannula with an empty bottle of humidification solution attached to the oxygen concentrator and the label on the oxygen tubing was dated 6/30/25. During an interview at the time of this observation, R11 reported that her nose was very sore and dry from the oxygen.During an observation on 7/23/25 at 10:12 a.m., the oxygen concentrator for R11 was noted to have an empty bottle of humification solution attached to the oxygen concentrator and the label on the oxygen tubing was dated 6/30/25.During an interview on 7/24/25 at 8:34 a.m., Licensed Practical Nurse (LPN) G reported the tubing is changed weekly on night shift and the bottle of solution on the oxygen concentrator lasts 3 days.During an interview on 7/24/25 at 8:37 a.m., the Director of Nursing (DON) reported the oxygen tubing is changed weekly on night shift and that the humidification solution is monitored every night.Review of Doctors' order revealed oxygen with a start date of 3/13/25 for R11 to receive oxygen 4 liters by nasal cannula to maintain sats (saturation) greater than or equal to 88%.Review of facility policy titled Oxygen Administration and Concentrator Policy, last reviewed/revised 6/23, read in part .nasal cannula.requires humidification for flow rates of.4 liters. Review of facility policy titled Oxygen Concentrator, date implemented 1/1/21, read in part .fill the humidifier container to the correct level with distilled water and attach to the concentrator.changed oxygen tubing and mask/cannula weekly or as needed.change humidifier bottle when empty.During an interview on 7/24/25 at 3:15 p.m., the Nursing Home Administrator (NHA) acknowledged the oxygen concentrator for R11 was always supposed to have humidification solution present and the oxygen tubing is supposed to be changed weekly.

Based on observation, interview, and record review, the facility failed to maintain a medication administration error rate less than 5% in two Residents (#2 & #7) of three residents reviewed for medication administration, resulting in 2 medication errors in 26 opportunities for error and a 7.69% medication error rate.Findings include:Resident #2 (R2)On 7/24/25 at 9:01 a.m., Registered Nurse (RN) J was observed preparing an insulin pen for R2. RN J primed the pen holding it horizontally, with he needle cover on the pen. RN J did not observe the pen to ensure that insulin was primed into the pen needle, nor did he reprime to ensure it was done correctly. Review of the INSTRUCTIONS FOR USE, Insulin Lispro KwikPen, copyright 2023, retrieved from pi.[NAME].com/insulin-lispro-kwikpen-us-ifu-pdf on 7/24/25 at 9:51 a.m. revealed the following, in part: . Step 6: To prime your Pen, turn the Dose Knob to select 2 units. Step 7: Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top. Step 8: Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose Window. Hold the Dose Knob in and count to 5 slowly. You should see insulin at the tip of the Needle. If you do not see insulin, repeat priming steps 6 to 8, no more than 4 times. If you still do not see insulin, change the Needle and repeat priming steps 6 to 8 .Resident #25 (R25)On 7/24/25 at 8:46 a.m., RN J was observed leaving a prepared dose of miralax on R25's over bed table and left the room. When asked if R25 was able to self-administer medications, RN J said he could not tell this surveyor and reported that he could go back and watch her take the miralax.During an interview on 7/24/25 at 8:48 a.m., the Director of Nursing (DON) stated if the resident is in their room alone, the nurse should stay with the resident until the resident consumes the medication. Review of facility policy titled Preparation and General Guidelines IIA2: Medication Administration-General Guidelines, last revised 1/18, read in part .Medications are administered at the time they are prepared.the resident is always observed after medication administration to ensure that the dose was completely ingested.

Based on interview and record review, the facility failed to ensure the resident representative understood the purpose of binding arbitration agreements (an out of court alternate form of dispute resolution) for two Residents (Resident #8 and Resident #31) of three residents reviewed for arbitration.Findings include:Resident #8 (R8)Review of R8's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 5/12/22, with active diagnoses that included: Alzheimer's Disease, Non-Alzheimer's dementia, and anxiety disorder.During an interview on 7/25/25 at 9:10 a.m., Social Worker A reported R8 signed the arbitration agreement on 1/9/25. Social Worker A reported R8 had a responsible party (an individual designated to oversee various aspects of a resident's care and well-being) put in place which began on 1/17/25. Social Worker A acknowledged she did not review the arbitration agreement with the responsible party.Resident #31 (R31)Review of R31's MDS assessment dated [DATE], revealed admission to the facility on 9/13/23, with active diagnoses that included: non-Alzheimer's dementia, cerebrovascular accident (when blood flow to a part of your brain is stopped) and seizure disorder or epilepsy.During an interview on 7/25/25 at 9:10 a.m., Social Worker A reported R31 signed the arbitration agreement on 3/26/25. Social Worker A reported R31 had a responsible party which began on 4/22/25. Social Worker A acknowledged she did not review the arbitration agreement with the responsible party.Review of facility policy titled Binding Arbitration Agreements last reviewed/revised 11/1/22 read in part, .the facility shall explicitly inform the resident or his or her representative of his or her right not to sign the agreement.explain to the resident and his or her representative in a form and manner that he or she understands.ensure the resident or his or her representative acknowledges that he or she understands the agreement.explicitly grant the resident or his or her representative the right to rescind the agreement within 30 calendar days of signing it.

Based on observation, interview, and record review, the facility failed to ensure the call light communication system was fully operational for 6 Residents (#1, #2, #6, #9, #10, & #11), out of the total population of 46 residents residing in the facility. This deficient practice resulted in residents' inability to utilize the call light system for emergency care needs, delayed provision of care and resident dissatisfaction. Findings include: This deficiency pertains to Intakes MI00146426 & MI00147954 which both alleged the facility call lights were not operational. Resident #2 (R2) Review of Intake MI00147954 revealed; Complainant (F) states the resident call light also wasn't working (on 10/1/24) . between 10/7/24 and 10/11/24 the resident's (R2's) call light still wasn't working . during a visit with the resident [Complainant F] pressed [R2's] call button because they needed to have a bowel movement and needed help getting to the bathroom. The complainant states no one was responding so [Complainant F] went into the hallway and found the light wasn't coming on. The complainant states the resident ended up having their bowel movement in their brief . During an interview on 12/2/24 at 4:19 p.m., Complainant F stated, The call light was not operational [for Resident #2 (R2)] the same night the DON (Director of Nursing) came into the building. [The DON] went and got another cable (that plugged into the wall/call light)and plugged it in and (then) it was working. Later . that week the call light was not working again . During an interview on 12/3/24 at approximately 2:30 p.m., when asked if R2's call light had been found not working on 10/1/24 the DON acknowledged they had been in the building and tested the call light and found that it was not working. The DON stated, I pushed the call light (for R2), and it did not go on. I got a replacement cord and then verified that it worked before I left. Resident #1 (R1) During an interview on 12/3/24 at 1:35 p.m., when asked about call lights, R1 stated, At one time if the call light in the bathroom was on, then the main call light in the room (by the bed) wouldn't work. One time the call light itself burnt out . During an interview on 12/3/24 at 1:52 p.m., Certified Nurse Aide (CNA) E stated there were, .Occasionally problems with call light functionality (working properly). During an interview on 12/5/24 at 11:10 a.m., Registered Nurse (RN) H was asked about functionality of the call light system. RN H stated, Resident's complain, and I am aware that there have been times that call lights don't work. I tried them (call lights), and they don't work and then they have to be changed. The cords get frayed, or the [NAME] are messed up or the bulbs on the outside of the door are messed up. Resident #6 (R6), Resident #9 (R9), Resident #10 R10), Resident #11 (R11) During observations of call lights on 12/5/24 between 12:05 p.m. and 1:28 p.m., revealed the following call lights for four beds were not functioning for the following Residents: R6, Bed B, not working. R9, Bed A, not working. R10, Bed B, not working. R11, Bed A, not working. During an interview on 12/5/24 at approximately 1:05 p.m., when in the process of room observation of call light functionality, the Nursing Home Administrator (NHA) stated, It is almost like the whole system needs to be replaced. [Resident R9] did have his call light replaced not long ago . The NHA said they completed call light audits, and everything seems to be working, or they will replace the non-functional call light cords, and then randomly the call lights will continue to be non-functional with no apparent pattern.

Based on interview and record review, the facility failed to provide information regarding facility rules and regulations, including denture loss, prior to or upon admission to the facility for one Resident (R2) of three residents reviewed for notice of rights and rules. Findings include: This deficiency pertains to Intake MI00147954. Review of the Complaint Intake MI00147954 on 12/3/24 revealed the following, in part: .During the late afternoon on 9/29/2024 [Complainant F] cleaned the residents top and bottom dentures per his request and put them back in their case on his bedside table. The complainant states on 9/30/24 [they] received a call from the facility staff asking if [they] took the residents (R2's) dentures home . because they were missing. The complainant states [they] went to the facility at 5:00 p.m., and an aide [Certified Nurse Aide E] told [Complainant F] that [CNA E] saw the dentures on the nightstand the following evening and when he went into the room in the morning, they were missing . the residents' dentures still haven't been found . During a telephone interview on 12/2/24 at 4:19 p.m., when asked about R2's denture loss, Complainant F stated, [R2] entered the facility on September 27th . the CNA said they (dentures) were there on 9/29/24, on the night stand. When [CNA E] went in the room on 9/30/24 they (dentures) were gone . They never reimbursed me for the missing dentures. They should have taken my father to be fitted for new dentures . Upon [R2's] admission I should have been given a packet, and there would have been a pamphlet with her (Ombudsman) information on it. Complainant F said R2 did not receive any documentation of facility rules upon admission, and neither did the Resident Representative when it was determined [R2] was not able to make their own medical decisions. During an interview on 12/3/24 at 11:37 a.m., when asked about R2's missing dentures, the Nursing Home Administrator (NHA) stated, [R2] was admitted with upper and lower dentures on September 27th. [R2's Family Member (FM I)] took them out of [R2's] mouth and cleaned them and put them in a denture case after his lunch on the 29th . Then before supper [CNA E] said they took them out of the case and put them back in the resident's mouth for supper, and after supper [CNA E] removed them, cleaned them and put them back in the denture case and put them on top of the residents' dresser. Then the next morning the dentures were missing. The were discovered missing on September 30th. What I said to [FM I] was, 'This is our Dental Policy, and these are the steps we need to take before we can even get to that point (of replacing or reimbursing for the lost dentures) .So the first thing is several of us will search, and I gave her a copy of the Dental Policy . The Dental Policy is not in the admission packet .but the admission packet does have verbiage (wording) on dentures . On 12/3/24 at 11:49 a.m., a copy of the Admission Packet, and the Dental Policy were reviewed by the NHA and this Surveyor. During an interview on 12/3/24 at 1:52 p.m., when asked about R2's dentures, CNA E stated, I took them (dentures) out and brushed them and put them in a clear bowl on the bedside table on Sunday Night (12/29/24). The next morning, I came to work at 2:00 p.m. They asked me if I knew what happened to the teeth (R2's Dentures). I said 'Yes, I had put them in a clear bowl. There was no top on the bowl. There were not really close to the edge of the bedside table. They (facility staff) said they were not present at 7:00 a.m. that morning. CNA E said he had no idea what had happened to R2's dentures after that. During an interview on 12/5/24 at 3:03 p.m., the NHA provided R2's Receipt Acknowledgement of Admission Documents that was observed to be a list of items reviewed and/or provided to R2 following admission to the facility. The Receipt Acknowledgement of Admission Documents including all facility rights, rules, and responsibilities was dated 10/2/24. This was two days following the loss of R2's dentures. The NHA confirmed all Admission paperwork, including the admission contract, were completed by the facility for R2, dated 10/2/24. Review of the Admission Packet, Page 9 provided by the facility on 12/4/24 at 10:03 a.m., revealed the following, in part: Missing Items: The facility trains the staff to safeguard resident's personal property. Please report any lost or missing item to the charge nurse. All efforts will be made to investigate and locate the item. Review of the facility policy entitled Lost of Damage of Personal Property, dated 3/2024, revealed the following, in part: Policy: Loss or damage of personal property belonging to a resident will be promptly investigated and reported . 1. It is the responsibility of the facility to offer safeguard options for resident property to the extent possible to assure there is no misappropriation of resident property. 2. When an item is reported as missing a proper investigation is completed, regardless of the item's value. 3. Immediately search the facility to attempt to locate the missing item(s). 4. Talk with residents and staff to determine if anyone had seen or heard any unusual happenings. 5. Search the resident's room and other locations visited by the resident within the last 24 hours to determine if the item was misplaced. 6. If the item is not recovered after the initial search complete a Resident Assistance Form and notify the Administrator. 7. Notify law enforcement and complete state reportable 24-hour report and 5-day investigation for any suspicion of a crime. 8. Facility will investigate all complaints within 15 days following receipt of the complaint by the facility and within 30 days shall offer to the complainant a written report of the results of the investigation or a written status report indicating when the report may be expected. 9. Residents are offered the trust account to deposit money for safe keeping upon admissions. 10. Residents are encouraged to send home valuable items if able/desired. 11. The facility will not be responsible for lost or broken items unless it is determined that it was fault of facility. 12. Missing items should be reviewed by the QAPI for trends and patterns. No evidence was presented during the survey to show this policy was provided to Resident R2 prior to 10/2/24. Review of the Dental Policy, updated 6/2023, revealed the following, in part: . 4. The facility will not be responsible for lost or broken dentures unless it is determined that it was the fault of the facility. a. The facility shall determine responsibility for the loss or damage of dentures on a case-by-case basis, considering the circumstances surrounding the loss/damage, resident characteristics, and the residents' plan of care. 5. For residents with lost or damaged dentures, the facility will refer the resident for dental services within three days . No evidence was presented to show this policy was provided to R2 before or upon admission. During an interview on 12/6/24 at 11:28 a.m., the NHA acknowledged that upon review of R2's Admission Contract and Receipt Acknowledgement of Admission Documents there was no additional information to show why the documentation was not completed until five days following admission, and two days after R2's dentures had been lost in the facility. An attempt was made to contact form Admission Director D via telephone by the NHA on 12/6/24 at 11:36 a.m. No answer was obtained, and no return phone call was received prior to the end of the survey. The NHA did not provide any additional information from Admission Director D following the survey Exit on 12/6/24 at approximately 2:00 p.m. Review of the Admission Process for Contracts and Agreements facility procedure revealed the following, in part: 1. Day of Admission: Admission Director is responsible with BOM (Business Office Manager)/HIC (Health Information Coordinator/other as a back-up. a. Update Profile tab to ensure that all contacts are updated and the Primary Contact-Financial is correct. b. Generate Packet (if weekend-Generate Monday) (Wound have been September 30th). c. Complete Signatures within 24 hrs. (hours) for packet within Document Manager. i. Create Administrative Progress note if packet is unable to be signed with the 24-hour period from within the Residents Chart. Progress notes cannot be deleted or updated - make notes simple. 1. Example: Resident unable to sign packet due to being incapacitated. 2. Example: DPOA is refusing to sign. 3. Example: Working with DPOA to schedule time to complete packet in person. 4. Example: Patient left AMA or prior to being able to complete contract and reason why. Review of the Resident Rights policy, reviewed/revised 2/2024, revealed the following, in part: Policy: The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility . Receipt of any such information must be acknowledged in writing. Policy Explanation and Compliance Guidelines: 1. Prior to or upon admission, the social service designee, or another designated staff member, will inform the resident and/or the resident's representative of the resident's right and responsibilities .

Based on interview and record review, the facility failed to respond timely to a change in condition for one Resident (R2) of three Residents reviewed for a change in condition. This deficient practice resulted in delayed transfer and treatment of an identified changed in condition. Findings include: This deficiency pertains to Intake MI00147954. Review of the Complaint Intake MI00147954 revealed the following, in part: .Complainant (F) . on 10/11/24 visited the resident (R2) and noticed his eyes were closed, but [R2] was flailing their arms and legs and appeared to be in pain . [Complainant F] alerted nursing staff and was told it was part of [R2's] decline and nothing to worry about . [Complainant F] visited the resident again on 10/12/24 and [R2] was in worse condition . [Complainant F] found [Registered Nurse (RN) B] and told [RN B] that they wanted the resident sent to the hospital. The Complainant states [RN B] said they needed to finish what they was doing and then they'd call the doctor. The complainant states . hours later the resident was sent to the [Hospital] . was told [R2] was extremely dehydrated, had a collapsed lung, and [R2's] bladder was extremely full which was causing [their] pain . During a telephone interview on 12/2/24 at 4:19 p.m., when asked about R2's change in condition and transfer to the emergency room (ER), FM I stated, .When [R2] went to the ER, October 12th, I am ringing the bell (call light) and [R2] was worse than . the night before. I said you get [R2] to the hospital right now. The nurse said I have to finish morning medications (medication pass), and [RN B] probably waited two more hours. ER doctor said R2 was severely dehydrated, collapsed lung, bladder so full he would have been in so much pain . Review of R2's Minimum Data Set (MDS) assessment, dated 10/3/24, revealed R2 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: cancer, heart failure, urinary tract infection, acute pyelonephritis, and metabolic encephalopathy. R2 scored 4 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of R2's Admission Record, dated 9/27/24, revealed the Resident was identified as being responsible for themselves, with a family member (FM I) noted as Emergency Contact #1. Review of a Medical Determination detailing that R2 was no longer capable of participating in the medical treatment decision making process affecting his/her own health was signed by two physicians, completed on 10/9/24, when FM I was identified as R2's Responsible Party. Review of the following Secure Conversations found in R2's Progress Notes detailed the decline in R2's condition: Effective Date: 10/13/24 11:36 Type: Secure Conversations: Message: Subject: not able to swallow. [10/10/24 0034 AM (12:34 a.m.) ](from RN J): Hello, [R2] needs to be seen by speech therapy. [R2] has been unable to swallow any crushed pulls or pudding. Take any sips of liquids. No yogurts. It goes to the back of [their] throat and comes right back up. Thank you. [10/10/24 09:08 AM] [R2's] on ST (speech therapy). [R2] was unable to be seen yesterday evening due to being too lethargic . [10/10/2024 09:15 AM] Physician K: Noted. [10/12/2024 08:14 AM] RN B: Resident still having issues this morning. Was [R2] ever seen? [10/12/24 09:57 AM] RN B: [R2] has been doing some confused reaching and grasping with his hands too, [R2's FM I] is concerned and here. I know [FM I] would like an update when possible. [10/12/24 11:08 AM]: RN B; [R2] had a UA (urinary analysis) on 10/9 . [10/12/24 11:12 AM]: Physician K: Oh ok. Do you think [R2] is ill? Or do you think [R2] is just declining? [10/12/24 11:14 AM] RN B: I think [R2] is dehydrated and declining. [R2] is having a hard time keeping anything down, trouble swallowing still. [10/12/24 11:16 AM] RN B: I will talk to [FM I] after noon med pass. His vitals are okay, but I feel [FM I] probably will want him sent (to the hospital) . [10/12/24 12:28 PM] RN B; I just spoke with [FM I] . okay with [R2] being sent to [Hospital] for Eval [evaluation] and hopefully some fluids. Order to send okay? [10/12/24 12:19 PM] Physician K: Yes. [10/12/24 13:45 PM] RN B; [Ambulance Service] left with resident to bring to [Hospital] at 1340 (1:40 p.m.) for eval (evaluation) per dr (doctor). instruction. Review of R2's Change of condition Evaluation - 5.1, dated Effective Date of 10/12/24 at 12:48 p.m., revealed R2 was identified with altered mental status, food and/or fluid intake (decrease or unable to eat and/or drink adequate amounts), other change in condition (the resident has been not keeping his trunk control as much. Head bobbing and reaching with hands more. Communicating less . not been eating or drinking well for the last couple of days. 2. This started on 10/10/24 (two days previous) . 6. Most Recent Weight: Weight 108.6, Date: 10/4/24 11:08 AM, Standing .8. [FM I] would like [R2] evaluated. [They] are concerned. Unsure if . presentation is being sick, or if it is decline we are seeing . Summarize your observations, evaluation and recommendations: The resident should be evaluated by ER (emergency room ) for extra fluids and labs . Date and time of family/resident representative notification: 10/12/24 13:09 (1:09 p.m.) .signed by RN B . Review of R2's Skilled Documentation assessment completed 10/12/24 at 13:22 (1:22 p.m.) by RN B revealed the following documentation: . LOC (level of consciousness) Alert, Orientation: boxes for Person, Place, Time, and Situation were all checked, with Impaired Decision Making identified. Notable changes in LOC/Orientation/Cognition None, Changes to mood or behavior? No', Lung sounds WNL (within normal limits) remained unchecked for yes or not. Nutrition: Appetite poor, Resident is being sent to ED for Eval. An attempt was made to contact RN B on 12/6/24 at 10:25 a.m., with the number provided by the facility staff listing. The number was unable to be called. On 12/6/24 at 10:45 a.m., a new number was provided by the facility. There was no answer to the call at that time, but a voicemail was left to return the call to this Surveyor. No return call was received from RN B. Review of R2's 10/12/24 ER visit and subsequent inpatient treatment documentation revealed the following, in part: [R2] does show (urinary) retention and given his symptoms have been worsened since his Foley catheter was removed, Foley was placed. Given significant pleural effusions previously and shortage of IV fluids, patient was given 500 cc bolus of normal saline . Patient is much improved in terms of agitation after Foley catheter was placed . patient to inpatient service . Resident did not return to the facility. R2 was discharged to home on 10/16/24. Review of the Residents at Risk Meeting policy, revised 5/2024, revealed the following, in part: Policy: A weekly focused Residents at Risk meeting is held to monitor progress residents with acute conditions or situations posing a risk to their health or well being as part of the facility's systemic approach to risk prevention and management. Policy Explanation and Compliance Guidelines: 1. Clinical leaders from the interdisciplinary team and the Medical Director/designee meet weekly to discuss the care, and response to care, of residents identified as at risk. Residents deemed at risk may have one or more of the following conditions or situations: pressure injury or significant risk for pressure injury, existing wounds of other etiology, significant change in condition, nutritionally at risk, behavioral concerns/behavior management, pain control issues, end of life, elopement/wandering, risk for contractures, fall with significant injury, or multiple falls . 6. The facility will utilize the Residents at Risk Meeting Log to track resident to be monitored by the interdisciplinary team and discussed at the Residents at Risk Meeting. 7. The facility will utilize the Weekly At-Risk Meeting Attendance Sheet to track meeting attendance and policy adherence. Review of the At-Risk Meeting Logs for September and October 2024 revealed there were no Logs completed prior to R2's discharge/transfer from the facility on 10/12/24, showing R2 was being tracked by the IDT committee. During an interview on 12/3/24 at 2:01 p.m., when asked about the delay in transfer to the ER for an identified change in condition for R2, the DON stated, I did tell [RN B] that we don't have to wait for a physician order to send a resident out to the ER, and from the sounds of the Secure Communication (between RN B and Physician K) it sounded like [RN B] thought [R2] needed to be sent out (to the ER). The DON was asked to review R2's Change of Condition and Skilled Documentation both completed on 10/12/24 by RN B. The DON agreed that the Skilled Documentation dated 10/12/24 should match the Change of Condition dated 10/12/24; not contradicted each other. The DON acknowledged the Change of Condition assessment said the change in R2's condition started on 10/10/24. The DON also stated, No, it is not acceptable to delay from 9:57 a.m. (when FM I was present and concerned in the building) to 1:40 p.m. (the actual time of transfer to the ED). The noon med pass does not take priority over transfer to the hospital . During a telephone interview on 12/5/24 at 10:10 a.m., when asked about the timing of emergency transfers to the ER and any additional Change of Condition policy, Regional Clinical Director L stated, We just have the Change of Condition policy (already provided to this Surveyor). If the nurse feels there is a decline in and the DPOA wants them sent I would send them to the hospital. We don't have a policy for that .I would expect that the nurse would have sent the resident to the hospital right away, if they were failing .A daily Skilled Assessment should be done daily for this resident (R2). Regional Clinical Director L agreed the daily Skilled Assessment should match the Change in Condition form.

Based on interview and record review, the facility failed to appropriately assess weights to assist in identification and prevention of significant weight loss for three Residents (R2 , R4, & R8), of six residents reviewed for weight management. This deficient practice resulted in inadequate weight documentation/tracking and the development of a significant weight loss for R2. Findings include: This deficiency pertains to Intake MI00147954. Review of R2's Minimum Data Set (MDS) assessment, dated 10/3/24, revealed R2 was admitted to the facility on [DATE] with active diagnoses that included the following, in part: heart failure, urinary tract infection, acute pyelonephritis, and metabolic encephalopathy. R2 scored 4 of 15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of the 10/13/24 Hospital Progress Note , revealed the following, in part: . Assessment/Plan: Malnutrition/Cachexia (wasting away appearance): Documented 30-pound weight loss (significant weight loss) from when patient was here 3 weeks ago until admission (10/12/24). BMI (Body Mass Index) 13.3. Likely multifactorial in the setting of progressive chronic illness and decreased oral intake as patient (in facility) as dentures have been lost . Review of R2's Electronic Medical Record (EMR) on 12/3/24 at 10:22 a.m., revealed R2 was 67 inches in height (5'7), with an IBW (ideal body weight) range of 153-185 pounds, and the following documented weight measurements: 9/30/24 10:26 (a.m.) ,115 lbs. (pounds) in wheelchair. 10/1/24 17:10 (p.m.) ,117 lbs. in Wheelchair. 10/4/24 11:08 (a.m.), 108.6 lbs. Standing. During an interview on 12/3/24 at 11:37 a.m., the Nursing Home Administrator (NHA) was asked about R2's weight assessments while in the facility. The NHA stated, We failed to get an admission weight on this Resident . The NHA acknowledged no other weight measurements, other than the above listed, were found in R2's EMR. Review of the Weight Monitoring policy, reviewed 1/2024, revealed the following, in part: .A comprehensive nutritional assessment will be completed upon admission on residents to identify those at risk for unplanned weight loss/gain or compromised nutritional status. Assessments should include the following information: a. General appearance, b. Height, c. Weight .5. Weight will be obtained upon admission, readmission, and weekly for the first four weeks after admission and at least monthly unless ordered by the physician. If a resident declines to be weighed this should be noted in the resident's record . Resident R4 Review of R4's Admission/Readmission Assessment upon admission on 11/12/24, revealed R4 was admitted at 1608 (4:08 p.m.) on 11/12/24 with a Most Recent Weight of 262.8 lbs. (measured) on 8/13/2020 at 9:18 a.m. (weight from prior to admission). Review of R4's Weights and Vitals Summary, retrieved 12/5/24 at 17:27 (5:27 p.m.) revealed and admission weight for the 11/12/24 admission to the facility was not assessed upon admission, but first documented on 11/15/24 at 13:59 (1:59 p.m.) with a weight of 226.6 lbs. Resident R8 Review of R8's Weight and Vitals Summary retrieved 12/5/24 at 17:27 p.m. (5:27 p.m.) revealed weekly weights were documented as follows: 11/8/2024 - 152 lbs. (Standing) 11/8/2024 - 152.4 lbs. (Wheelchair) 11/8/2024 - 152.4 lbs. (Wheelchair) 11/29/2024 - 151.2 lbs. (Standing) Weekly weights were not performed and/or not documented in R8's Electronic Medical Record (EMR) for the weeks of 11/15/2024 and 11/22/2024. During an interview on 12/6/24 at 10:47 p.m., the Director of Nursing (DON) acknowledged R4 did not have an admission weight performed, R8 had two weeks following admission that their weight was not measured/documented, and R2 had a significant weight loss while in the facility. During an interview on 12/6/2 at 11:44 a.m., when asked about documentation of new admission resident weight monitoring, including R2, R4, and R8, the Nursing Home Administrator stated, More than one person was missing weights (either admission weight or weekly weights).

This citation has two deficient practice statements: Based on observation, interview, and record review, the facility failed to implement a comprehensive infection control program, as evidenced by the failure to complete the following during a COVID-19 outbreak: 1. Implement measures to contain the outbreak. 2. Complete infection surveillance, tracking, trending, and monthly summaries, 3. Implement effective Transmission Based Precautions (TBP) and ensure appropriate donning and doffing of personal protective equipment (PPE). This deficient practice resulted in immediate jeopardy when 40 Residents out of a total facility census of 45 residents contacted COVID-19, including one death (R102), 4 Resident (R102, R14, R11 and R45) hospitalization s, and sustained outbreak transmission. Findings include: The Immediate Jeopardy began on [DATE] when R102 had symptoms of COVID and was not tested until [DATE]. R102 was positive on [DATE] and sent to hospital on [DATE]. R102 died on [DATE]. Facility did not monitor or perform any surveillance which led to a further outbreak of COVID. The Nursing home Administrator (NHA) was notified of the Immediate Jeopardy on [DATE] at 2:52 p.m. At that time, a written plan of correction for removal was requested from the facility. The removal plan was accepted on [DATE]. The Surveyors confirmed by observation, interview and record review, the Immediate Jeopardy was removed on [DATE], but noncompliance remained at a potential for more than minimal harm due to sustained compliance that has not been verified by the State Agency. Resident #102 (R102) Review of R102's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: coronary artery disease, renal insufficiency, diabetes mellitus, depression, cirrhosis, and osteoporosis. R102 scored a 9 of 13 on the Brief Interview for Mental Status (BIMS) reflective of moderate cognitive impairment. Review of Nursing Progress Notes on the following dates: [DATE] revealed that R102 had increased issues with secretions, coughing, and sats (oxygen saturation) decreasing. [DATE] revealed R102 over the last two days complained of sore throat and has dry mouth, noted more difficulty swallowing. [DATE] revealed R102 had positive covid test. During an interview on [DATE] at 12:58 p.m., the Director of Nursing/Infection Preventionist (DON/IP) stated, R102 passed as a COVID death .she had symptoms of COVID on [DATE] but was not tested and I don't know why she wasn't tested . Review of transfer form from [Facility to Hospital] dated [DATE] revealed, R102 had covid Review of Nursing Progress Notes dated [DATE] revealed, R102 on droplet precautions, R102 lungs diminished with Rhonchi (coarse loud lung sounds). R102's arms flaccid mottling on lower extremities. R102's oxygen increased to 5 liters per nasal cannula. Review of Physician Progress note dated [DATE] revealed, R102 returned from hospital with COVID. R102 was not making eye contact . R102 is on comfort care. Review of Nursing Progress Note dated [DATE] revealed, R102 was absent of respiration and pulse. Review of Death Certificate date filed [DATE] revealed, R102 died of COVID exacerbating end stage condition and end stage cirrhosis with ascites. R102 resided on the South hall of the facility. Resident #11 (R11) Review of R11's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: anemia, coronary artery disease, heart failure, hypertension, diabetes mellitus, and cerebral vascular accident (CVA). R11 scored a 10 of 15 on the BIMS assessment reflective of moderate cognitive impairment. Review of Nursing Progress Note dated [DATE] revealed, R11 complained not feeling good this morning .when asked if [Resident] was short of breath (SOB) R11 stated yeah, audible expiratory wheezing. Left lung diminished throughout .congested cough .resident transferred to Emergency Department (ED) Review of discharge Summary from [name of hospital] dated [DATE] revealed that R11's chief complaint was shortness of breath .R11 tested positive for COVID. R11 resided on the South hall of the facility. Resident #14 (R14) Review of R14's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: anemia, coronary artery disease, heart failure, hypertension, diabetes mellitus, and respiratory failure. R14 scored a 11 of 15 on the BIMS assessment reflective of moderate cognitive impairment. Review of Nursing Progress Note dated [DATE] revealed, R14 hollered out from his bedroom . is having trouble breathing, call 911. Review of Progress Note dated [DATE] revealed, R14 was sent to [Hospital] Emergency Department (ED) via ambulance. Called the ED at 0125 for an update- resident is COVID positive. R14 resided on the North hall of the facility. R14 died at hospital. Resident #45 (R45) Review of R45's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with active diagnoses that included: anemia, pneumonia, orthostatic hypotension, diabetes mellitus, manic depression, and respiratory failure. R45 scored a 14 of 15 on the BIMS assessment reflective of intact cognition. Review of Nursing Progress Notes at the following dates and times: dated [DATE] at 3:33 p.m., revealed, R45 complained of feeling sick to his stomach had several large projectile emesis .R45 stated he still doesn't feel good. dated [DATE] at 4:49 p.m., R45 stated not feeling well, stomach is upset. No vomiting but .gagging occurring at times .R45 having nausea.dated [DATE] at 5:17 p.m., revealed, R45 vomited.dated [DATE] at 6:18 p.m., revealed, R45 continues to have emesis and moaning out in pain stating R45 does not feel good. Review of Situation, Background, Assessment, and Recommendation (SBAR) Summary for Providers [DATE] 6:37 p.m., revealed, R45 sent to emergency room (ER). Review of Nursing Progress Notes dated [DATE] at 2:09 a.m., revealed R45 returned to facility with diagnosis of COVID. R45 resided on the South hall of the facility. Observations by this Surveyor on the following dates and times revealed: [DATE] at 12:53 p.m., room [ROOM NUMBER] did not have signage regarding COVID for COVID positive resident. [DATE] at 9:05 a.m., room [ROOM NUMBER] door opened with resident on airborne contact precautions (COVID). Fan in hallway outside of room blowing air down the hallway. [DATE] at 9:39 a.m., Certified Nurse Aide (CNA) I observed in hallway with surgical mask under her nose. [DATE] at 10:53 a.m., Resident on airborne precautions due to COVID with door open. A box fan blowing air down the hall was in hallway just outside of residents open door. Signage on resident room door indicated to keep door closed. [DATE] at 10:55 a.m., Resident on airborne contact precautions due to COVID with room door wide open. [DATE] at 12:16 p.m., Dietary aide J pushing meal cart down hallway with surgical mask below her nose. [DATE] at 12:17 p.m., CNA Ientered room of Resident on droplet precautions without cleaning hands before entering room. CNA I did not wear eye protection or remove face protection before CNA I left the room as indicated by signage on door of room. [DATE] at 1:48 p.m., CNA F charting in hallway with surgical mask pulled down below her mouth. During an interview on [DATE] at 8:46 a.m., the Director of Nursing (DON)/Infection Preventionist (IP) stated, I have not done any monitoring or surveillance for infection control .I have nothing done for the entire month of July .I have typed up a cheat sheet so you can see the staff and residents who have had COVID. A follow-up interview with the DON on [DATE] at 12:58 p.m., revealed, the outbreak started on [DATE] .we had a CNA with symptoms an [DATE] but there are no indications that she was tested .the CNA did test positive on [DATE] .that CNA worked all over the building . all the CNA's do, they are not scheduled on any particular wing, not during the outbreak, and not now .I believe this started our outbreak . I have not done any tracking or tracing of the COVID outbreak, so there is no line listing .I have not tracked employees or residents that have gotten COVID. On [DATE] at approximately 1:15 p.m., during a follow-up interview, the DON/IP acknowledged the Residents were still going out to smoke in groups throughout the outbreak, meals were offered in the dining room, and group activities were still occurring. The DON stated, we stopped activities and shut down the dining room on [DATE], but when dining started again, we had 15 residents that were positive for covid .we have had 40 residents out of 45 test positive for COVID .our last positive was on [DATE]. Review of the typed documentation for [DATE] COVID Outbreak provided by DON/IP revealed that between [DATE] and [DATE] a total of 12 residents were positive with COVID on one wing before facility closed the doors to the wing. On [DATE] residents on another wing were positive with COVID. The document did not indicate dining service in the dining room or activities were stopped. Review of facility policy titled COVID-19 Prevention, Response and Reporting date revised ,d+[DATE] . read in part, it is the policy of this facility to ensure that appropriate interventions are implemented to prevent the spread of COVID-19 and promptly respond to any suspected or confirmed COVID-19 infections .the infection preventionist will assess facility risk associated with COVID-19 through surveillance activities of COVID-19 infection .present in the facility . signs of COVID .fever or chills, cough, shortness of breath, fatigue, muscles or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, and diarrhea .the facility will establish a process to identify and manage individuals with suspected or confirmed COVID .residents with suspected or confirmed COVID infection should be placed in a single person room with the door closed .residents should remain in their current location. The facility may consider designating entire units within the facility, with dedicated health care personnel to care for residents with COVID infections when the number of residents with COVID infection is high, limit transport and movement of the resident outside the room to medically essential purposes . The Infection Preventionist .will monitor and track COVID-19 related information to include . the number of residents and staff who exhibit signs and symptoms of COVID-19, the number of residents and staff who have suspected or confirmed COVID 19 and the date of confirmation .employee compliance with hand hygiene, employee compliance with standard and transmission-based precautions, and employee compliance with cleaning and disinfection policies and procedures. Review of facility policy titled COVID-19 Antigen Testing date revised ,d+[DATE] . read in part, it is the policy of this facility to conduct antigen testing on symptomatic residents and staff, asymptomatic residents and staff as part of a COVID-19 outbreak response or testing of asymptomatic residents or staff who are known close contacts of persons with COVID-19 .antigen tests perform best when the person is tested within the first days of symptom onset when the viral load is generally highest. If an antigen test is positive .residents should be placed in Transmission Based Precautions .if the resident or staff is the first positive test for COVID-19 within the facility, an outbreak response should be initiated immediately. Review of facility policy titled Infection Outbreak Response and Investigation date revised ,d+[DATE] . read in part, the facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections .outbreak generally refers to the occurrence of more cases of a communicable disease than expected in a given area or among a specific group of people over a particular period of time. if a condition is rare or has serious health implications, an outbreak may involve only one case .the following triggers shall prompt an investigation as to whether an outbreak exists: a sudden cluster of infections on a unit .a single case of a rare or serious infection i.e COVID .symptomatic residents will be considered potentially infected .surveillance activities will increase to daily for the duration of the outbreak . Outbreak investigation: when the existence of an outbreak has been established an investigation will begin. The infection preventionist will be responsible for coordinating all investigation activities .A line list about each person affected by the outbreak will be maintained .a summary of the investigation will be documented and reported. Review of facility policy titled Personal Protective Equipment last revised ,d+[DATE] .read in part, this facility promotes appropriate use of personal protective equipment to prevent the transmission of pathogens to resident, visitors, and other staff .Personal protective equipment .refers to .gloves, gowns, face protection .wear gowns to protects arms, exposed body areas, and clothing from contamination .wear a mask to protect the face from contamination with .body fluids. Review of facility policy titled Infection Prevention and Control Program revised ,d+[DATE] .read in part, this facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections .the designated infection preventionist is responsible for oversight of the program and serves as a consultant to .implement isolation precautions .surveillance, and epidemiological investigations of exposures of infectious diseases .a system of surveillance is utilized for prevention, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents .the infection preventionist serves a the leader in surveillance activities, maintains documentation of incidents, findings, and any corrective actions made by the facility. Review of facility policy titled Infection Surveillance last revised ,d+[DATE] .read in part, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections .The DON .services as the leader in surveillance activities, maintains documentation of incidents, findings, and any correction actions made by the facility .surveillance activities will be monitored facility-wide and may be broken down by department or unit .monthly time periods will be used to capturing and reporting data, all residents infections will be tracked. Outbreaks will be investigated. Employee infections will be tracked. Data to be used in the surveillance activities include .documentation of signs and symptoms in the clinical record. The Immediate Jeopardy which began on [DATE] and was removed on [DATE] when the facility took the following actions to remove the immediacy. The Facility Removal Plan read: Issue Cited: The facility failed to investigate, perform surveillance, and implement preventative measures to mitigate an outbreak of Covid-19 resulting in 1 death multiple hospitalization s and sustained transmission in 40 of 45 residents. 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. o On [DATE], the DON reviewed the 24-hour report to ensure there were no unidentified residents exhibiting signs and symptoms to ensure all symptomatic residents were identified. o No previously unidentified symptomatic residents were found, so no additional residents need droplet precautions at this time. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. o On [DATE], all applicable facility COVID-19 policies and procedures were reviewed and deemed appropriate according to CDC recommendations. o On [DATE], the Regional Director of Clinical Operations reeducated the facility DON on the procedure for outbreak investigation, tracking, surveillance and the company COVID-19 policies. o Beginning on [DATE], the DON or designee provided education to all employees regarding the COVID 19 Prevention, Response and Reporting Policy, including the identification of COVID-19 illness, transmission-based precautions, source control and mitigating the spread of the virus. o Any staff who did not receive the education on [DATE] will not be permitted to work until the education has been received. o Beginning on [DATE], the Administrator or designee provided education to all housekeeping staff on cleaning high-touch areas such as light switches, call lights, doorknobs, and toilets/sinks to ensure sanitary conditions. o Any housekeeping staff who did not receive the education on [DATE] will not be permitted to work until the education has been received. o The employee call-off log includes surveillance for respiratory illness. Beginning [DATE], any staff call offs secondary to illness will be reported to the Infection Preventionist to ensure appropriate tracking. o The Infection Preventionist or designee is monitoring the 24-hour report to ensure that any resident with signs and symptoms of respiratory illness is immediately placed on transmission-based precautions (droplet precautions suspected or confirmed COVID-19). o Beginning on [DATE] the facility will limit transport and movement within the facility as much as able by: o Encouraging residents who have not tested positive with this outbreak to dine and/or smoke separately from those who are COVID positive and who recently recovered from COVID-19 (to clarify, avoid residents who tested positive within the last 30 days), o Utilizing closed hallway doors as physical barriers to reduce air flow and deter avoidable resident movement. o The facility will ensure passive screening of facility visitors with signage per the CDC's recommendation. o The facility Medical Director was notified by the facility of this Immediate Jeopardy on [DATE]. o On [DATE] the Director of Nursing notified all clinical staff of the immediate education required prior to the employee's next scheduled shift. No employee will work until they are able to demonstrate proper use of PPE and handwashing, as well as re-education on the COVID-19 Prevention, Response and Reporting. o On [DATE] the Director of Nursing called nine certified nursing assistants and seven nurses to the facility for re-education on the COVID-19 Prevention, Response and Reporting Policy. Clinical employees pending education on COVID-19 Prevention, Response and Reporting will not work until educated by the Director of Nursing or Unit Manager. o On [DATE] the Administrator observed the Director of Nursing and Unit Manager demonstrating donning and doffing protocol and handwashing with a total of 16 out of 31 clinical employees who were called back to the facility for immediate education. The Director of Nursing utilized the teach back method to educate employees on donning and doffing and handwashing. Immediate Jeopardy Removal Plan F-880 - Infection Prevention and Control o On [DATE] the EVS (Environmental Services) Director educated all employees in the housekeeping and laundry departments on the policy and procedure required for deep cleaning high-touch areas, call lights, doorknobs, toilets/sinks and all cleaning requirements to control and prevent the spread of COVID-19. o On [DATE] the EVS Director completed a deep cleaning of the laundry department and all utility cleaning carts. o On [DATE] the Dietary Manager completed a full deep clean of the kitchen, utility room, all sinks, and touch point areas. o On [DATE] the Dietary Manager educated dietary staff on handwashing, by demonstration and deep cleaning requirements. Any staff who did not receive the training on [DATE] will not be permitted to work until the training has been received. o On [DATE], 1:1 observation of clinical staff performing cares has been initiated with no discrepancies found during random observations by clinical management. o On [DATE] the Administrator held an ad hoc QAPI meeting to address this plan. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: [DATE] 35103 On [DATE] at 12:30 p.m., Registered Nurse P was observed donning personal protective equipment (PPE) to enter Resident R17's COVID-19 isolation room. An airborne transmission-based precaution sign was posted on the door of R17's room, and a PPE bin was located outside of his room. A small, black fan was plugged in and operational under the wall monitor where staff electronically documented their task completions. A black, plastic garbage can was also positioned outside of the R17's room door, lined with a red, hazard plastic garbage bag liner. An interview subsequent to the observation was conducted. When asked why the garbage can was outside of R17's room, in the hallway, RN P stated, We were removing our PPE out in the hall, after we came out of the room. The garbage can was observed to contain N95 face masks, surgical masks, gloves and yellow gowns. No face shields were observed in the red, hazard plastic liner. On [DATE] at 2:45 p.m., Registered Nurse (RN) P was observed providing wound care and donned personal protective equipment (PPE) (gown, gloves, N95 face mask) and was ready to enter the room, reaching for the door handle. RN P did not don eye protection. The COVID-19/Airborne precaution sign and PPE instructions clearly stated eye protection was to be worn. When this Surveyor pulled the face shields from the tall PPE bin outside of R47's room, RN P asked, Do we have to wear eye protection when we are wearing glasses? This Surveyor said, Yes, due to the access of air on all sides of the glasses. This Surveyor donned a face shield, and RN P then grabbed a face shield to put on. RN P wore an N95 mask over his long protruding beard, which was not able to be covered by the N95 mask. Water management Based on observation, interview and record review the facility failed to implement measures to prevent the spread of infectious organisms in the facility by failing to: 1. Develop and implement a water management program. 2. Properly transport and sort linens to prevent cross contamination. Findings Include: During an interview on [DATE] at 8:24 a.m., the Maintenance Director C was asked to provide monitoring systems for the water management program, water temperature monitoring, and records of flushing unused pipes. Maintenance Director C stated, Oh God! I don't have any records .I have not kept any records for any of that .I have not written anything down. The Water Management Program the Maintenance Director C provided was a toolkit on how to develop a Water Management Plan. During an interview on [DATE] at 8:46 a.m., the Nursing Home Administrator (NHA) was queried about the Water Management Program and water temperature monitoring. The NHA stated, the [Maintenance Director] C has done none of that.During a follow-up interview on [DATE] at 10:15 a.m., the NHA stated, Temperature logs don't exist .the water management program will need some work. Review of the facility policy titled Legionella Surveillance last revised ,d+[DATE] . read in part, it is the policy of this facility to establish primary and secondary strategies for the prevention and control of Legionella infections .Legionella surveillance is one component of the facility's water management plan for reducing the risk of Legionella .in the facility's water systems . primary prevention strategies: diagnostic testing .investigation for a facility source of Legionella, which may include culturing of facility water .physical controls .temperature controls. Review of facility policy titled Infection Prevention and Control Program last revised ,d+[DATE] .read in part, Water Management: A water management program has been established as part of the overall infection and prevention and control program. Control measures and testing protocols are in place to address potential hazards associated with the facility's water systems. Linen During an observation on [DATE] at 7:51 a.m., Laundry Aide K transported uncovered laundry in a cart on a wing with Residents that have confirmed COVID. Review of facility policy titled Infection Prevention and Control Program last revised ,d+[DATE] .read in part, laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection .clean linen shall be delivered to resident care units on covered linen carts with covers down. During an interview on [DATE] at 8:58 a.m., Laundry Aide K stated, I do not wear a gown when sorting clothing, but I do wear gloves . I have never worn a gown to sort clothes and I have worked in the laundry for [AGE] years. Review of facility policy titled Handling Soiled Linen Origination date [DATE] .read in part, Proper personal protective equipment should always be worn when sorting soiled linens. Review of second facility policy titled Handling Soiled Linen last revised ,d+[DATE] .read in part, it is the policy of this facility to handle, store, process, and transport linen in a safe and sanitary method to prevent the spread of infection .linen can become contaminated with pathogens from contact with intact skin, boy substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linens .generated from sorting and handling contaminated linen .linen that may require special handling include .visibly soiled with blood or large amounts of body fluids, residents with contagious conditions .residents with infectious drainage, residents with infections transmitted by contact. Review of facility policy titled Personal Protective Equipment last revised ,d+[DATE] .read in part, wear gowns to protect arms, exposed body area, and clothing from contamination with blood, body fluids, and other potentially infectious material.

Based on interview and record review, the facility failed to provide and document a safe and orderly involuntary discharge for one Resident (R1) of three residents reviewed for facility discharge. This deficient practice resulted in harm, based on a reasonable person standard, when R1 was discharged to home without notice to family members living in the home, no provision of home health services upon discharge from the facility, emotional distress due to lack of care, and return to the hospital resulting from unaddressed care needs. Findings include: This deficiency pertains to Complaint Intake #MI00143858 which alleged the facility failed to complete a thorough discharge plan for R1. The complaint was received from an advocacy agency and included the following information, in part: . The facility transported [R1] back to his residence without notifying [Wife H] and refused to provide an answer why he was returning to the residence . On 4/9/24, [R1] was observed at his resident to be lying in bed with his catheter bag bulging from not being changed. [Wife H] reported that she is on oxygen and is in no position to provide primary care to [R1] .There is concern that [Nursing Home Name] performed an unsafe and unprepared discharge that has now placed [R1] at risk of harm due to having no services and no proper caretaker. Review of R1's Minimum Data Set (MDS) Annual assessment, dated (in process) 4/6/24, revealed R1 was admitted to the facility on [DATE] with active diagnoses that included: stroke, heart failure, end-stage renal disease, neurogenic bladder (with surgical placement of a suprapubic catheter), diabetes mellitus, Non-Alzheimer's dementia, depression, antisocial personality disorder, chronic obstructive pulmonary disease, hemiplegia (paralysis of one side of the body), morbid obesity, and dependence on wheelchair. R1 scored 15 of 15 on the Brief Interview for Mental Status (BIMS) indicative of intact cognition. R1 required maximal assistance (more than half the effort) for shower/bathing, upper body dressing, lower body dressing, lying to sitting on the side of bed, and chair/bed-to-chair transfer. R1 was totally dependent upon staff for toilet transfers, toilet hygiene and putting on/taking off footwear. R1 used a wheelchair for mobility and was documented as Not attempted due to medical condition or safety concerns for being able to Walk 10 feet in the last seven days. Review of R1's Discharge Instructions and Recap of Stay, effective date 4/8/24 at 8:16 a.m., revealed the following, in part: Reason for Admission: Hemiplegia post CVA [cerebrovascular accident (stroke)]. 3. discharge date : 04/08/2024. 4. discharged to: His Home. 5. With (Who?) Facility Driver and (blank) . 7. Reason for discharge: . 5. Behavior status as resident endangers the safety of individuals in the facility . Social work-Recap of Stay . 3. Barriers (emotional, cognitive, financial, literacy concerns, transportation-appointments/items for daily living, safety, psychological to discharge and steps taken for discharge: [R1] will require daily assistance for his ADL's (activities of daily living), [Home Health Agency] will be admitting him on 4/9/24 (day after discharge). [R1] and family would benefit from behavioral therapy and counseling services to help with their family dynamics . 3. Nursing Services-Recap of Stay 1. Brief summary of medical stay: admitted with hemiplegia s/p (status post) CVA . Now being discharged r/t (related to) behavioral issues despite education and counseling. 2. Physical functioning status-check all that apply: . Non-ambulatory, Assist with ADLs . 5. Any problems/non-adherence encountered during the stay and treatment/education provided: behavioral issues of violent and sexual nature. This section signed by Registered Nurse (RN) E . In-Home Care or Services 1. Referrals made to (choose all that apply): 1. HHC (Home Health Care) Agency. [Name of HHC] documented. Medical Equipment Arrangements: 3. N/A (not applicable) Signatures: R1's activated DPOA signed that I understand the discharge plan on 4/8/24. Physician Summary: [R1] was admitted with hemiplegia s/p CVA. He received therapy and has achieved the ability to perform his ADLs with assistance from home health and a home aid. On multiple occasions he has been counseled and educated after being sexually inappropriate with staff and patients. He was evaluated by [Behavioral Health Agency] who reported these behaviors were not a part of dementia and are due to his antisocial-personality disorder. He continued with physical and sexual aggression towards fell ow patients and is now being discharged because of that. Signed by Physician on 4/8/24. Review of the [Behavioral Health Agency] psychological report completed by Psychologist F on 2/20/24 revealed the following, in part: .The facility social services director and the administrator requested that this resident be seen for an Initial Psychological Evaluation and assessment of capacity as the resident has shown ongoing aggression and inappropriate behaviors and no appreciation for the gravity of these despite being discussed many times with him .This was an initial psychological evaluation and capacity assessment of this resident who had been involved in a resident-resident occurrence . The history of this resident did involve numerous other incidents of varying types of aggression as well as verbal aggression to the staff and an ongoing history of inappropriate sexual behaviors toward female staff . Although the resident did not show significant cognitive deficits, his ongoing history and inability and seemingly unwillingness to learn boundaries supported the working view that I have espoused and shared with the facility professionals . Both the administrator, a professional with a history in research and having attained advanced degrees in areas that led to a full understanding of the psychological aspects displayed by the resident, and the social services director concurred that the behavior and ongoing dysfunctional interactions with the staff and others did support a lack of capacity. I signed the form to that effect and sent it back to the facility .Assessment and Plan: Antisocial personality disorder [F60.2] (new) Plan: For the 2/20/24 note. The given problem is a tentative diagnosis and may be supported or supplanted by future information .as the resident did not demonstrate signs of cognitive deficits on the basic assessments I gave, if there is some concern that that lack of capacity based on behavioral and personality factors is not robust, the facility may want to consider a more extensive cognitive assessment in the future . Review of R1's [Behavioral Health Agency] previous psychological report, dated 1/26/24, revealed the following observations/determinations of R1, who at that time also scored a BIMS of 15 out of 15, reflective of intact cognition. No diagnosis of antisocial personality disorder was present at that time: Demeanor: Cooperative Judgement: Intact Insight: Intact Impulse Control: Intact Thought Process: Organized Homicidal Ideation: Denied Memory: Grossly intact Fund of Knowledge: demonstrates good fund of knowledge Abstract Thinking: Intact Review of R1's care plans with revisions, revealed the following Focus: I have the potential for mood difficulties r/t impaired ability to go home, history of stroke, vascular dementia with mood disturbance, mood disorder, depression and anxiety . Interventions . [R1] Would like to discharge home however his wife would like him to remain in LTC (long term care) unless he is able to transfer independently. Date Initiated: 1/6/23. During an interview on 4/30/24 at 2:59 p.m., Social Services Director (Staff) B confirmed R1 had a Durable Power of Attorney activated 2/21/24 when signed by two medical professionals who determined he was not capable of participating in medical decisions. Staff B acknowledged R1 had a BIMS of 15, which was reflective of intact cognition, but stated, He lacked the capacity to understand his actions and the consequences of them, so he (Psychologist F) felt it was appropriate to activate his DPOA. Staff B said she was not qualified or able to determine a residents' capacity to participate in their own healthcare decisions. When asked for behavior tracking for R1, Social Services Director (Staff) B said that following an alleged incident of inappropriately touching a female resident, [R1] was placed on 1:1 supervision. When asked for copies of the documentation involving 1:1 supervision of R1 following that incident, Staff B said the facility did not have the staff to monitor R1's behaviors on a 1 to 1 basis. When asked for documentation that showed R1 was consistently engaging in inappropriate behaviors, Staff B said there was no documentation to show that - other than progress notes. No 1 to 1 supervision documentation, nor any consistent documentation of his behaviors that showed he was a consistent and imminent threat to facility residents was available, nor was it provided to this surveyor by Staff B or by any other facility staff member. Although R1 had been deemed incapable of participating in his own medical decision making, he was allowed to smoke unsupervised outside with other facility staff between 2/21/24 and the alleged inappropriate touching of a female resident while outside smoking on 3/12/24. Review of R1's discharged Resident Medication Transfer Record, dated 4/8/24, revealed the Resident Medication Acceptance Attestation which read, in part: As the resident or responsible party for the above-named resident . I confirm that the resident/responsibility party has been notified, understands, and accepts responsibility of this medication regimen and has taken possession of the applicable medications . was not signed by R1's responsible party. Although R1 was deemed unable to participate in healthcare decisions on 2/21/24, his signature was noted on the bottom of the medication transfer record. The DPOA was not present in the facility at the time of discharge. No physician order for oxygen was present on the discharged Resident Medication Transfer Record, and no referral to any medical equipment supply vendor was made for R1's oxygen. During the interview on 4/30/24 at 2:59 p.m., Staff B confirmed R1's DPOA was not present at the time of discharge. Staff B stated, We went over the medications with her on the phone, and it was a mistake on my part that I didn't have her sign at the time of discharge. Staff B acknowledged there was no documentation on the form that reflected review of the medications with R1's DPOA. Staff B said R1's DPOA did not live in the home that he returned to on 4/8/24. When asked who lived in the home, Staff B said R1's wife lived in the home. When asked if the wife was informed R1 was returning to the home on 4/8/24, Staff B stated, I don't have it documented that the wife was informed. I talked to who I felt needed to be talked to - the DPOA. The Nursing Home Administrator (NHA), present during the interview, asked if Staff B had directly spoken to R1's Wife H prior to discharging the Resident to the home, Staff B said she had never had a personal conversation with Wife H. When asked why R1 was discharged from the facility, Staff B stated, His behaviors no longer permitted him to continue to reside here. There are certain rules . they should abide by in how they are treating their fell ow residents. He was told he was being discharged because of his behaviors. I told [R1's DPOA] on multiple occasions that because of his behavior he was going to have to be discharged . Staff B said no other facility would take R1, so the only place he could go was home. When asked about the level of care in hours that were anticipated being necessary for R1 to successfully transfer to home, Staff B said she was not aware of what level of care R1 needed. Referrals to Home Health Care Agencies (HHAs) had been made, but no services were in place at the time of discharge to home. The HHA I was scheduled to assess R1 in the home on 4/9/24. When asked about medical equipment such as oxygen which R1 required, Staff B said they had taken one of the facilities oxygen concentrators and left it at R1's home but acknowledged she had not obtained additional nasal cannula's or tubing for the oxygen concentrator. Staff B stated, I didn't have an equipment provider, so he (R1) borrowed one of ours. There wasn't an order for it in the home. A physician order was not found for supplemental oxygen in the home on 4/8/24. When asked if supplies for R1's suprapubic catheter were provided to the Resident upon discharge, until HHA services could be initiated, Staff B said she had not delivered any to the home. Review of R1's Physician Order Recap Report revealed Physician G gave a verbal order on 4/7/24 to discontinue (d/c) R1's oxygen therapy order effective 4/8/24, the day of discharge. During an interview on 4/30/24 at 3:31 p.m., Staff B was asked about the scheduling of home health care aides. Staff B stated, [HHA] J said they would be able to take him (provide home care services) when their staffing allowed. When asked when HHA J reached out to Staff B to let her know staff were available to care for R1, Staff B stated, (They) didn't by the time he discharged . He (R1) did not have [HHA] I. They [HHA I], but when they came to admit him, they denied services. Staff B said she did not hear from the family or [HHC I] until the next week. Staff B stated, I don't have the exact date in front of me . The week of the 15th. I reached out to HHA K (that week) and asked if they still had his referral . He did not have HHC K services upon discharge. Staff B said a home assessment prior to discharge was not completed before R1 was discharged to home on 4/8/24. A previous home assessment had been completed, prior to a July 2023 failed home discharge attempt, and Staff B used that information. When asked about HHA services on April 8th, 9th, and 10th, Staff B stated, I do not know what services were provided to [R1]. Staff B said she went into R1's home to bring in R1's belongings, and tensions were high. They (family members) all started yelling at each other . During an interview on 4/30/24 at approximately 4:30 p.m., when asked about R1's behavior monitoring and documentation, the NHA said there were progress notes and stated, It is very sporadic documentation of his behaviors. During a telephone interview with R1's DPOA on 4/30/24 at 4:53 p.m., the DPOA was asked if they (she, the family, or R1) had been given a choice on R1's discharge from the facility. DPOA L stated, No, they were forcing them out of there. He needs 24/7 care, and we can't do that at home. [Staff B] told us that he is getting evicted out of there (the facility) because he has been touching girl's breasts . I feel like he was set up. There was him and another lady, and he said she asked him to touch her breast and he did it and then they were dropping him off at the home (discharging him home) . They sent him home with no help. They said the Doctor determined he could not make his own decisions because he has no remorse for anything he did there. During a continued telephone interview on 4/30/24 at 4:53 p.m., DPOA L said HHA I completed an in-home assessment of R1's care needs and they did not accept him for services. DPOA said the nurse who completed the initial assessment on 4/9/24, which was declined, said they would send a nurse into the home to show them how to care for R1's suprapubic catheter the next day (4/10/24). DPOA L said she waited for the nurse the next day, but no nurse ever came to show them how to care for the suprapubic catheter. DPOA L said R1 then had to go to the emergency room several days after his discharge from the facility for a urinary tract infection. HHA I said [Nursing Home Name] told them R1 wanted to come home. DPOA L stated, When they dropped him off (at home without notice to his wife) they brought his clothes and his meds, but they didn't tell me how to give the meds. We didn't even know he was diabetic. He has [an injectable blood glucose lowering medication] and he takes metformin [blood glucose lowering oral medication] as well and he gets a B12 shot every 14 days. We didn't know which ones he got in the morning; when to give them as far as the timing .[R1] said he used to be able to go on the toilet when he wanted in the nursing home. I told him he was 24/7 care. We do the best we can. They (Nursing Home) said they were kicking him out . When they dropped him off April 8th, until yesterday (4/29/24), we had no care (home health care aides) . DPOA L said finding R1 another nursing home to live in would be next to impossible because of the things the facility said about R1 in the request for transfer to the other facilities that were all declined. During a telephone interview on 5/1/24 at 10:58 a.m., Executive Director M, of HHA I, confirmed they had received a home health care referral from the nursing home where R1 resided prior to discharge. A nurse went out and completed an assessment on 4/9/24 and declined enrolling R1 in services with HHA I. Executive Director M said R1 was not enrolled in HHA I's home health care services because they did not feel he was safe in the home following completion of the in-home assessment. During a telephone interview on 5/1/24 at 10:08, Intake Department Team Lead N confirmed HHA K had received a referral from the nursing home for home health care for R1 on 4/11/24 after the first HHA I had declined R1's provision of services. R1 was processed and admitted to HHA K's in-home services on 4/17/24. Intake Team Lead K reviewed R1's current service plan and said R1 would receive a home health aide one time a week. During a telephone interview on 5/1/24 at 10:29 a.m., HHA O's Representative P said R1 had a higher acuity of care and . we could not accept him . based on the assessments that were provided upon his discharge from the nursing home. During a telephone interview on 5/1/24 at 10:35 a.m., Regional Case Manager Q said their agency was not notified until 4/10/24 of R1's discharge to home from the facility on 4/8/24. Manager Q stated, We prefer to be involved .in the discharge planning process so those things can be started while they (residents) are still in the facility . We considered him an imminent risk to return to a nursing home. [An assessment/referral agency] went out on the 18th (of April) and determined [R1] qualified for 142 hours a month because he has complex care needs . I have not heard what changed and why he decided to come home . it was a shock to all of them (family members) that he went (home). They (family) were upset that he came home . During an interview on 5/1/24 at 11:22 a.m., the Nursing Home Administrator (NHA) stated, How could [Social Services Advocate] say she didn't discharge him because of behaviors? The NHA reviewed R1's Discharge Recap assessment and confirmed it clearly said all over in the document that he (R1) was being discharged because of his behaviors and yet a 30-day notice was not provided . During a telephone interview on 5/1/24 at 11:56 a.m., R1 was asked how the discharge to home had gone. R1 stated, If we had help (home health) it would be all right. They more or less kicked me out. They packed my stuff and they said they would have help (home health) when I got home, and I got home and there was no help . I did have to go back to the ER (emergency room ) for a UTI (urinary tract infection) (following discharge). They (family members) are pretty stressed out . I know it wasn't right how they discharged me . During an interview on 5/1/24 at 1:39 p.m., Staff R said they were present when R1 was discharged to home on 4/8/24. Staff R stated, I didn't have him (R1) off the (vehicle) ramp, and they (family members) were screaming, I have to quit my f king (expletive) job because of you! The tension was so bad, that if someone was not with me, I would have brought him back (to the facility). I thought this does not feel right . This was insane . I was doing what was not right . Review of the facility Admission Packet Resource Guide, dated 5/2017, revealed the following, in part: An involuntary transfer or discharge of a resident is permitted under the following circumstances: - The Resident's needs cannot be met in the facility. - The Resident's health has improved significantly to no longer need the facility service; - The safety of the individuals in the facility is endangered. - Non-payment or; - The facility ceases to operate . No documentation was provided by the facility to show R1 was endangering the safety of other residents. Review of R1's Admission and Financial Agreement, signed 4/21/17, revealed the following, in part: . The Facility may terminate this Agreement and transfer or discharge the Resident in accordance with applicable State and Federal laws and regulations. The Facility shall give the Resident or Responsible Party advance notice of any reason for transfer or discharge as required by applicable State or Federal laws and regulations .

This deficient practice pertains to the following Intakes: #MI 890, #MI 578, #MI 567, #MI 451, #MI 427, #MI 213, #MI 738, #MI 110, AND #MI 016. This citation has two deficient practice statements (DPS's): DPS A and DPS B. Deficient Practice Statement A: Based on observation, interview, and record review the facility failed to provide necessary structures to provide goods and services to meet the needs of all residents as evidenced by: 1. Insufficient nursing staff to meet resident needs. 2. Failure to follow protocols related to turning and repositioning, checking and changing of briefs, showers, and basic supervision and care needs. 3. Failure to timely pay facility vendors to ensure supply chain fluidity. 4. Failure to maintain facility environmental safety, function, and order for all facility residents. This deficient practice resulted in wide-spread neglect of all 42 facility residents at a level of immediate jeopardy. Findings include: Due to the critical content of the interviews and evidence provided during this survey with repeated verbalization of resident and staff concerns related to potential retaliation by the facility, all staff will be identified as Staff unless the position title is critical to deficiency understanding. Insufficient Staff for Resident Needs During a telephone interview on [DATE] at 5:22 p.m., Complainant FF, a former resident of the facility who resided in the building for approximately five months said in June and July of 2022 the facility was very short of nursing staff, especially on the night shift. Complainant FF stated, Once in a while there was only one nurse and one aide (all night). Complainant FF said the concern was voiced to facility administration who said they were doing the best they could. Complainant FF said the Director of Nursing (DON) position was not filled promptly and stated, Apparently nobody was in charge of the nursing things. I often had to wait for a respiratory treatment, and that made me short of breath and more anxious. I am incontinent and with one aide you may get changed once a night, and on afternoons you (I) had to wait over a half hour for a brief change with stool in it . They had a couple of weeks where they had to cancel my appointment because the bus didn't work . They were forever running out of washcloths and face towels. With the showers, you never got the showers you were scheduled. I probably got a shower a month . Complainant FF reported to staff wanting showers, but staff said they did not have time, and one of the resident shower rooms had been closed for repairs. As far as I know the other bathroom (shower room) was still torn apart . With the food . I was supposed to be on a diabetic diet, and I would get half a plate of corn. They way over serve the starches and the mashed potatoes. They don't very often get fresh fruit and vegetables . During a telephone interview on [DATE] at 8:06 a.m., anonymous Complainant EE, an advocacy organization employee, reported having been in the building approximately three to four weeks previous. Anonymous Complainant EE stated, The day I was there many of the residents were fearful of the staffing situation (low staffing levels). One of the huge complaints I got was the (lack of) showering. Resident #59 Review of Resident #59's Minimum Data Set (MDS) assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, dressing, toilet use, personal hygiene, and was totally dependent upon staff for bathing. Resident #59 scored 13 of 15 on the Bried Interview for Mental Status (BIMS) reflective of intact cognition. Review of Resident #59's Shower Task documentation in the Electronic Medical Record (EMR) for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Monday & Thursday AM shift - use [MEDICATION(S)] 2% shampoo on Thursdays. Leave shampoo on for ,d+[DATE] minutes before rinsing. A shower was documented on [DATE] and [DATE], a bed bath on [DATE], with one Resident Not Available documented on [DATE]. During an interview on [DATE] at 10:00 a.m., Emergency Staff F said she was working due to an emergency staffing crisis in the facility. Staff F said she felt emergency staff now working in the facility were like the last resort for a facility that is in a staffing crisis. Staff F said a Resident (Resident #59) died very recently while the emergency staffing aides were working in the building and noted Resident #59 had a pressure injury on her coccyx. Staff F said the emergency staffing aides would make sure to turn and reposition her when they were working, and when they left each day they would put a piece of paper underneath her, that would show if Resident #59 had been repositioned. Staff F said she did not believe Resident #59 was repositioned appropriately because they (emergency staffing aides) would come in and find the paper in the exact same place as they had placed it. Staff F said it was incredibly sad. Staff N stated in an interview on [DATE] at 3:20 p.m., I was concerned Resident #59 was not getting the care she needed, and now she passed away. During a telephone interview on [DATE] at 2:00 p.m., Staff N confirmed the following concerns related to Resident #59, who was transferred out to the acute care hospital with emergency care needs: 1. Prior to discharge to the hospital Resident #59 was observed to be dehydrated, with extremely dry oral mucosa, and was not observed to be offered sufficient oral hydration. 2. Resident #59 was not being timely changed and repositioned at nights, which was observed, reported, and education provided to the involved CNA's (Certified Nurse Aides) related to checking and changing briefs and repositioning of the resident. 3. Resident #59 was found wet, when she should have been checked and changed by inexperienced CNA staff. Resident #62 Review of Resident #62's EMR revealed she scored 15 of 15 on the BIMS reflective of intact cognition. Resident #62 required extensive two-person assistance with bed mobility, dressing, toilet use, personal hygiene, and was totally dependent upon staff for bathing. Resident #62 was always incontinent of urine, and frequently incontinent of stool. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation/interview on [DATE] at 2:58 p.m., when asked about care received in the facility, Resident #62 said she was not routinely receiving showers from the facility and had been left in a cold, wet brief for two and a half hours one night. Resident #62 said she has a problem with recurrent urinary tract infections, so sitting in a wet brief was a concern to her. Resident #62 was observed in bed wearing a hospital gown. Resident #62 said she had to be relocated from a different room because the previous room roof was leaking directly onto her bed. The Resident reported half of her personal belongs were still back in the other room, and she had not been moved back to that room (room [ROOM NUMBER]). She was unsure if the roof had been repaired. Review of Resident #62's care plans revealed, in part: BRIEF USE: I use disposable incontinence products. Change daily, when soiled and PRN (as needed) . Revision on [DATE]. INCONTINENT: Check me every 2 hours and as needed for episodes of incontinence . Revision on: [DATE]. No shower interventions were documented in Resident #62's care plan. Review of the Master Bath List provided by the NHA of Record/Regional Director of Operations revealed Resident #62 was scheduled for twice-weekly showers on Tuesday PM and Saturday AM. Review of Resident #62's Shower Task documentation in the EMR revealed showers were performed three times in the last 30 days as of [DATE], on: ,d+[DATE] (Tuesday), ,d+[DATE] (Friday), and ,d+[DATE] (Monday). Review of Resident #62's Turning and Reposition Task Documentation in the EMR revealed not all shifts were documenting repositioning of this Resident, and on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE] documentation checked revealed Resident #62 was turned and repositioned two times during the shifts documented. Checks for not applicable were noted on ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident #51 Review of Resident #51's Shower/Bathing/Bed Bath Schedule revealed the following: I prefer to let staff know when I would like to shower. No alcohol gel for hand washing. Use only Dove/Ivory soap. POC Response History (staff documentation software) revealed Resident #51 only had one shower on [DATE]. The form was absent any other staff documentation. Resident #52 Review of Resident #52's complete EMR revealed a BIMS score of 15, reflective of intact cognition. Resident #52 MDS assessment documented extensive two-person assistance with bed mobility, transfers, dressing, toilet use, personal hygiene and Bathing was documented as Physical help in part of bathing activity with one-person assistance. Resident #52 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation and interview on [DATE] at 3:48 p.m., Resident #52 self-propelled up to this Surveyor in his wheelchair and stated, loudly, I really, really need a shower. I have been sick and had diarrhea, and I need to get cleaned up, but even the new aides say they don't have time to give me a shower. I get really mad when I have to ask and ask, and I need a shower and I don't get one. Resident #52 said several aides who had recently quit would get his showers done. Resident #52 stated, Now, they don't get done. Review of Resident #52's Shower Task documentation in the EMR revealed a Shower/Bathing Scheduled Wednesday & Saturday shift. During the previous 30 days, as of [DATE], Resident #52 received one shower on [DATE], one bed bath on ,d+[DATE], and was documented with three not applicable dates checked on ,d+[DATE], ,d+[DATE], and [DATE]. Resident #53 Review of Resident #53's complete EMR revealed a BIMS score of 15, reflective of intact cognition. Resident #53 MDS assessment documented extensive, two-person assistance with bed mobility, transfers, dressing, toilet use, and Bathing was documented as Activity itself did not occur. Resident #53 had active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #53's Shower Task documentation in the EMR revealed a Shower/Bathing Scheduled Monday & Friday AM shift. During the previous 30 days reviewed, Resident #53 received no showers, one bed bath on ,d+[DATE], and was documented as refusing on ,d+[DATE] and ,d+[DATE], with two not applicable dates checked on ,d+[DATE] and [DATE]. Resident #54 Review of Resident #54's complete EMR revealed a BIMS score of zero, indicative of severe cognitive impairment. Resident #54's MDS assessment, dated [DATE], revealed Resident #54 required extensive, two-person assistance with bed mobility, transfers, and toilet use. Bathing was documented as Activity itself did not occur. Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 8:44 a.m., Resident #54 was in bed yelling out, Help, help, help repeatedly. No facility staff came and after 20 minutes the Resident gave up. The Resident was unable to/did not use her call light. There was an office just down from the room with management staff who did not come out of the office. Review of Resident #54's Shower Task documentation in the EMR for the last 30 days revealed one shower was given on ,d+[DATE], three bed baths, on ,d+[DATE], ,d+[DATE], and ,d+[DATE]. Resident Refused was documented on ,d+[DATE], ,d+[DATE], ,d+[DATE], and ,d+[DATE]. The Task was identified as Shower/Bathing/Bed Bath as scheduled Sunday & Thursday AM Shift - I require physical help with part of bathing and sometimes total assistance. Resident #55 Review of Resident #55's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, transfers, toilet use, and one-person physical help in part of bathing. Resident #55 scored 15 of 15 on the BIMS assessment reflective of intact cognition. During an interview on [DATE] at 3:01 p.m., when asked about showers in the facility, Resident #55 stated, Sometimes I go two weeks without a shower. I (had) a shower day on Monday, and that was the first shower I had in 21 days. Resident #55 denied ever refusing a shower and said staff would tell him they did not have time to give him a shower. When asked about call light response times, Resident #55 said he would be on the toilet and press the call light for assistance. Someone would came and said they would find someone to help him right away. Nobody came, and he had to use the call light again. Resident #55 stated, It is sometimes horrible at night here. Sometimes it is just the nurse here, and there is no aide. When asked about food, Resident #55 said the facility ran out of eggs, both fresh and hard boiled, they hardly ever had cottage cheese, and they ran out of brown sugar packets and oatmeal. Resident #55 stated, The good aides quit now. They were getting sick of being mandated. They quit and went somewhere else. Resident #55 said the facility was still short staffed, and no one come for months to [NAME] the lawn. Resident #55 stated, The lawn was almost three feet long. It looked horrible. Review of Resident #55's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed a shower was provided on ,d+[DATE], ,d+[DATE], and [DATE], with Shower/Bathing/Bed Bath as Scheduled Monday & Thursday AM Shift noted on the POC Response History. Resident #56 Review of Resident #56's MDS assessment, dated [DATE], revealed the Resident required one person assistance with physical help in part of bathing activity, and scored 15 of 15 on the BIMS assessment reflective of intact cognition. Review of Resident #56's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed no showers or bed baths were provided by facility staff with the Task of Shower/Bathing/Bed Bath as Scheduled Monday AM & Thursday PM Shift noted on the POC Response History. Resident #57 Review of Resident #57's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, dressing, toilet use, personal hygiene. Bathing was documented as Activity itself did not occur. Resident #57 scored 11 of 15 on the BIMS assessment reflective of moderate cognitive impairment. During an observation and interview on [DATE] at 3:45 p.m., Resident #57 was observed sitting in her wheelchair in the hallway with long (approximately 1 inch in length) facial hairs on her chin. When asked how she felt about grooming in the facility, especially the long chin hairs, Resident #57 stated, I want them to shave that, but they only do that when I get a shower, and I am not getting showers like I am supposed to. Resident #57 said the nurse aides were not nice and said the nurse aides did not have time to give her a shower. When asked about bed repositioning, Resident #57 said she could do that independently, but stated, There are not enough staff, and you have to wait a long time for them to respond if you need them . I want to get my hair cut . but said there had not been a hairdresser in the building for a long time. Resident #57's hair was long and unkempt. Review of Resident #57's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Tuesday & Friday PM shift. A shower was documented on [DATE], and a bed bath on [DATE]. Refusals were noted on ,d+[DATE] and [DATE]. Resident #58 Review of Resident #58's MDS assessment, dated [DATE], revealed the Resident required extensive one-person assistance with bed mobility, dressing, toilet use, personal hygiene, and bathing. Resident #58 scored 14 of 15 on the BIMS reflective of intact cognition. During an interview on [DATE] at 12:30 p.m., when asked about facility staffing, Resident #58 stated, They do not have enough staff, and noted staffing was less at night. Resident #58 stated, On night shift I have to wait a long time for call light assistance and have had to wait wet and in BM (bowel movement/stool) for a long time. Resident #58 said showers were not received twice a week, as they were supposed to be given. Resident #58 stated, The main thing is they are short of help . Review of Resident #58's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Monday & Wednesday AM shift. A shower was documented on [DATE], and bed baths on [DATE] and [DATE], with one Refusal documented on [DATE]. Resident #60 Review of Resident #60's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, toilet use, and personal hygiene. Bathing was documented as Activity itself did not occur. Resident #60 scored 15 of 15 on the BIMS reflective of intact cognition. Review of Resident #60's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Tuesday & Friday PM shift. A shower was documented on [DATE] and [DATE], with Not Applicable documented on [DATE] and [DATE]. Resident #61 Review of Resident #61's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, transfers, dressing, toilet use, and was totally dependent upon staff for Bathing. Resident #61 scored zero on the BIMS reflective of severely impaired cognition. Review of Resident #61's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Sunday & Wednesday PM shift. A shower was documented on [DATE], bed baths on [DATE] and [DATE], with Not Applicable documented on [DATE]. Resident #63 Review of Resident #63's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, and dressing. Bathing was documented as Activity itself did not occur. Resident #63 scored zero (0) on the BIMS reflective of severely impaired cognition. During an observation and interview on [DATE] at 5:00 p.m., Resident #63 was observed crying out for help while lying in her bed, flat on her back. Resident #63 was dressed only in a hospital gown and incontinence brief. Resident #63 had tears in her eyes as she cried, I hardly have any help anymore. I am not able to get the help I need. I don't want to be here anymore, I want to go somewhere else. They don't hardly come and see me (staff). I am so lonely, with nobody to talk to. Resident #63 confirmed she had not been getting her showers/bathing consistently as scheduled, and that she was not repositioned every two hours like she should be. Observation of Resident #63's positioning, with Staff V, at this same time, found Resident #63's left heel positioned directly on the bed, with a pillow under her right knee only, to keep the right heel floating in bed. Review of Resident #63's care plan revealed the following, in part: Assist me to turn &/or reposition routinely during CNA rounds while in bed and frequently redistribute my weight . Date Initiated: [DATE] and Assist/encourage me to elevate my heels off the bed. Date Initiated: [DATE]. Review of Resident #63's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Sunday PM Shift & Tuesday AM shift. No showers were provided to this Resident, bed baths were given on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Not Applicable was documented on [DATE]. Resident #64 Review of Resident #64's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with transfers and bathing, and extensive one-person assistance with bed mobility, locomotion, dressing, toilet use, and personal hygiene. Resident #64 was always incontinent of urine, and frequently incontinent of bowel. Resident #64 was documented as Severely Impaired on the Cognitive Skills for Daily Decision Making Review of Resident #64's Shower Task documentation in the EMR for the last 30 days as of [DATE], revealed Shower/Bathing/Bed Bath as Scheduled Wednesday & Saturday PM shift. No showers were provided, one bed bath on [DATE], with Not Applicable documented on [DATE], [DATE], and [DATE]. Staff documentation on the Turning and Repositioning and Bed Mobility POC Response Histories in the previous 30 days were inconsistently completed by staff on various shifts, with not all shifts recording task completion on the above residents. Review of Resident Council Meeting Minute concerns, March through [DATE], revealed the following, in part: New Business: [DATE] 1. Too many residents yelling in hallway. 2. CNA's getting mouthy with residents . 3. Getting left on toilet because EZ stand dies . 4. Want haircuts . [DATE] 1. Nurses don't always know how to answer [NAME] (call lights) . 2. Someone to keep an eye on people by the nurses' station (staff education/behavior intervention) . [DATE] 1. CNA's ignoring people . 2. Changing shower assignments . [DATE] 1. Showers still not being offered . New Business 1. CNA's being mean . 2. Showers not being served . [DATE] Old Business 1. Not getting showers - unhappy with follow up . New Business 1. Not getting showers . 2. Never want the fish from today again . [DATE] New Business 1. Sidewalks by the patio very broken, do not want to do activities out there. 2. Residents want to use area behind activity room. Note: Down to one shower room. Residents still do not have resident council present. [DATE] New Business: 1. Residents want trust money. Stated they have been waiting for over a week and that they do not want to wait any longer . [DATE] 1. Old Business - shower repair - will be getting bids . During an interview on [DATE] at 12:02 p.m., Staff L stated, Corporate flies here on their private jet, and staffing has been absolutely horrible. When corporate comes, they don't fix anything, even though they know the condition of the facility. Staff L said they were terribly short on Certified Nurse Aides (CNA's), with three CNA's working day shift that day. Staff L said normally there would be five, and stated, .but we are short today. During an interview on [DATE] at 1:17 p.m., when asked about staffing levels, Staff E stated, Our Corporate (management) doesn't care. They say we have adequate staff, but we don't . We have been begging and pleading with corporate. Out of a five-day week, staff are working four 16 hours shifts (because of mandated overtime). During an interview on [DATE] at 3:25 p.m., Staff H confirmed the facility was very short of staff, particularly CNA's. Staff H stated, Staffing has been terrible. There are some days I leave here (at approximately 10:00 p.m.) and there is nobody to work for nights . There are always two nurses if there are no aides, but there may be no aides. I am sure they (residents) don't get changed as often as they should be on night shift. The nurse can't pass pills and do all the medical things, and make sure everyone is checked and changed. Showers do not get done often, unless we have a shower aide . It is hard enough to take care of 16 people and make sure they are clean, dry, and safe. The with-it (cognitively intact) residents say, 'I haven't had a shower in weeks', and you feel sorry for them (residents), but you just don't have the time. Half the time I get the BM's and food charted, but to get the rest, I don't have time. Staff H said there was only one shower room for resident use. Staff were told it was being renovated, but Staff H said she had not seen anyone working on it. When asked about residents being left for extended periods of time in wet and/or soiled briefs, Staff H said that was a possibility because staff were so short. During an interview on [DATE] at 3:35 p.m., when asked about staffing levels, Staff I stated, It has been terrible. Everyone is getting mandated (required overtime) over and over and over. Everyone is exhausted . Showers do not get done . I get mandated into nights, and one night it was one nurse and me . The residents are complaining about care not being provided . During an interview on [DATE] at 9:30 a.m., when asked about staffing, Staff J stated It is horrible. I think we only have five people that are full-time. We had two of our best employees quit because they were getting nailed for four 16-hour shifts when mandated. It is insane here - because we don't have enough staff. It is insane because we don't have the right management here. What does corporate do for you? Nothing. We tell them and tell them, and they don't do nothing . Showers are not getting done. There is no staff time to do them. They got used to saying, 'I don't have time to do it'. They got into that rut, and we were really short, and we didn't have time. They are not getting done. I think there are pressure ulcers because people are not getting turned. They are not getting out of bed, because there is no time to get them out of bed. Elders (residents) will be left in their bed because it is easier. They are not getting checked and changed as frequently as they should During an interview on [DATE] at 10:50 a.m., when asked about facility functioning, including staffing, Staff D stated, Staffing is terrible, they have been begging for help forever. Last time we had this meeting with corporate, (it was) all about how to build a tree from its roots. Staff D said it had nothing to do with the living conditions in the facility and the lack of staff for resident care needs. Staff D said two CNA's recently quit because they worked four 16 hour shifts in a row. The wound care nurse quit too, because she worried she was going to have to go (work) on the floor. We had several people quit. They were good workers too. They didn't want to do all those shifts. During an interview on [DATE] at 9:55 a.m., the new NHA confirmed Social Service Designee C resigned on Monday ([DATE]) morning via email, with no notice provided. During an interview on [DATE] at 10:24 a.m., Administrative Staff (Staff) A and Administrative Staff (Staff) B confirmed new admissions were being planned; one for that day, and one on [DATE]. When asked if the facility had adequate staff to provide for current resident care needs, Staff A stated, Absolutely not, I do not have enough staff to provide care for the residents we have without the emergency staff that we currently have. Staff B stated, Corporate is pushing for us to take admissions. Staff A agreed and stated, Personally my thoughts, and I have had communication with [the NHA of Record] regarding my concerns - I personally don't feel we should be admitting right now . Corporate has asked us and told us to take admissions . It is crazy here. I didn't know that coming in. During an interview on [DATE] at 12:09 p.m., Administrative Staff B requested to speak with this Surveyor because Corporate instructs us on what to say about admissions and I didn't want to say anything in front of [Administrative Staff A] . I agree that our residents are not being taken care of with the staff that we have, and it is irresponsible for us to take more new admissions. That is not in the best interest of the residents or our staff. During an interview on [DATE] at 10:39 a.m., Staff T was asked for Nursing Competency Evaluations for five CNA's and three nurses. Staff T stated, I don't have any competencies for any of the CNA's or the nurses. I presented the list of all the nurses and CNA's that needed to be done. They could be in the DON's office, but I know that she would have them, and she would have given them to me. During an interview on [DATE] at 8:30 a.m., CNA and Nursing Competency Evaluations were requested from the new NHA for five CNA's and three facility nurses. The new NHA said that Staff T would have copies of those competencies, which Staff T had previously said the competencies were not found. During an interview on [DATE] at 11:52 a.m., the new NHA, regarding nurse competency evaluations, stated, I do not have any nurse aide, or nursing competencies to provide to you. No policy, or job descriptions detailed the requirement for annual competencies, but blank competency checklist forms were provided by the facility to show what information should have been completed. During an interview on [DATE] at 3:20 p.m., Staff N said right before the Emergency CNA's started, a night shift was staffed with two nurses. Staff N stated, We also had a weekend and a few other night shifts where it was one nurse and one CNA. The CNA had just graduated high school. [A Resident] said 'Nobody came in and offered to change and turn me.' It happened a second time, and it was each time it was just the one CNA working at night. I don't think we can provide the care that the residents need. [Resident #59] was also a bed bound resident who was not turned and repositioned and her bottom developed a coccyx wound which was previously healed and then she wasn't turned, and she developed a Stage III pressure injury to her coccyx. Staff N said Resident #59's urine was thick. We had been leaving one nurse (LPN) who had just graduated from LPN school a month ago, and the one CNA in the building at night . I have lost all hope and heart in this place. Staff N said management would rarely show up on Fridays and that is when she would get all the collection calls: [Paint Store], [hospitals], [internet provider], Medical Director sent faxes that we had outstanding bills. They were hand-written faxes, and I saw them saying she had not been paid . The wheelchair van bill had not been paid so they would not transport. [The Hospital] paid the wheelchair van so we could get our Resident (#53) back. Staff N was present when bill collectors dropped of envelopes for collection at the facility door. Staff N said permission had been given to not have a manager on weekends. Staff N stated, We have had just an LPN and a CNA. Staff V became the interim DON two days ago. Two days ago, she was told she was that role. We did not even have Staff V's telephone number. Staff N said Staff V was not reachable over the weekends and was not reachable when she was not here. We had no group communication - some things got taped to the desk. Staff N said there was no Director of Nursing (DON) between the last DON and yesterday when the new DON started. We were never able to communicate with Staff V as the DON. If there was an incident - I called the Administrator . No residents can get their Resident Trust Fund money - it is incredibly difficult. It is embarrassing . Review of emails provided between facility staff and corporate officers revealed the following, in part: [DATE] 9:46 a.m. - FROM: NHA of Record/Regional Director of Operations: .With the annual survey cleared and behind us, it is time to get the word out to the hospitals and actively engage in new admissions. Thank you all for your efforts with the survey process so that we can now 'get back to normal' . [DATE] 10:28 a.m. - FROM: Facility Staff V to NHA of Record/Regional Director of Operations: I was not under the impression that we cleared our annual survey. During exit the surveyor stated that she cannot clear us in regard to the incident due to unvaccinated staff not following the policy/guidelines during the revisit . She did say our timeline will continue and we will still be in denial of payment. Along with our current critical CNA staffing shortage I do not believe it is ethical to begin taking admissions as our current residents are not receiving[TRUNCATED]

This deficient practice pertains to Intake #MI 016 and MI 451. Based on interview and record review, the facility failed to provide appropriate activities of daily living (ADLs) that included, turning and repositioning, checking and changing of incontinence briefs, hydration, and wound care management to prevent the development and worsening of a facility-acquired Stage 3 pressure injury resulting in harm to one Resident (#59) of two residents reviewed for pressure injuries. This deficient practice resulted in worsening of condition, an increased in size of the Stage 3 pressure injury, and potential coccyx wound infection that required emergent medical care. Findings include: A Facility Reported Incident of potential neglect was identified and reported to the State Agency on [DATE]. The investigation summary, completed by the Nursing Home Administrator as of that date ([DATE]) revealed Certified Nurse Aide (CNA) TTT was 'neglecting' the residents on [DATE] when incontinence checks were not done on the night shift. Five residents including Residents #57, #59, #63, #64, and #65 were incontinent (wet) when staff came on at 2:00 a.m. on [DATE]. The night nurse informed CNA TTT it was an expectation to perform incontinence checks. When CNA TTT was interviewed by the NHA, regarding this allegation, the Investigation Summary documented [CNA TTT] stated the staff on duty had told her not to worry about the incontinence checks, and the investigation concluded [CNA TTT] did not perform midnight incontinence checks on [NAME] 14, 2022 . Review of Resident #59's MDS assessment, dated [DATE], revealed the Resident required extensive two-person assistance with bed mobility, dressing, toilet use, personal hygiene, and was dependent upon staff for bathing. Resident #59 had functional limitations in range of motion (ROM) of bilateral upper extremities (arms) and used a wheelchair for mobility. Resident #59 did not ambulate and was documented as Activity occurred only once or twice for transfers, and (wheelchair) locomotion on or off the unit. Resident #59 was always incontinent of urine and bowel, and had active diagnoses that included: anxiety, depression, heart failure, need for assistance with personal care, and history of urinary (tract) infections (UTIs). Resident #59 was documented as at risk for development of pressure ulcers, with no unhealed pressure injuries as of the [DATE] MDS assessment. Resident #59 scored 13 of 15 on the BIMS reflective of intact cognition. Review of Resident #59's Admission Record, printed [DATE], found no diagnoses related to pressure ulcers as of that date. Review of Resident #59's functional bowel and bladder incontinence care plan revealed the following intervention, in part: INCONTINENT Check me every 2 hours and as needed for incontinence. Wash, rinse, and dry perineum. Apply barrier cream after each incontinent episode and PRN (as needed) . Date Initiated: [DATE]. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] .Any resident confined to bed should be repositioned at least every two (2) hours unless contraindicated . Review of Resident #59's Turned and Repositioned every 2 hours POC (point of care) Response History, revealed Certified Nurse Aide (CNA) staff documentation of turning and repositioning of Resident #59 during the past 30 days (from [DATE]) included the following, in part: 1. Eight days were documented for one shift only. 2. Ten days were documented on two shifts only. 3. No documentation of task completion was noted on [DATE] and [DATE]. During an interview on [DATE] at 3:20 p.m., Staff N said right before the Emergency CNAs started a night shift was staffed with two nurses. Staff N stated, We also had a weekend and a few other night shifts where it was one nurse and one CNA. The CNA had just graduated high school. [A Resident] said 'Nobody came in and offered to change and turn me.' It happened a second time, and it was each time it was just the one CNA working at night. I don't think we can provide the care that the residents need . During an interview on [DATE] at 3:20 p.m., Staff N stated, We had a weekend and a few other night shifts where it was one nurse and one CNA (working). The CNA had just graduated high school. [A Resident] said 'Nobody came in and offered to change and turn me.' It happened a second time, and it was each time it was just the one CNA working at night. I don't think we can provide the care that the residents need. [Resident #59] was also a bed bound resident who was not turned and repositioned and her bottom developed a coccyx wound which was previously healed and then she wasn't turned, and she developed a Stage III pressure injury to her coccyx. Staff N said Resident #59's urine had a strong odor and was a thick consistency. I was concerned Resident #59 was not getting the care she needed . I have lost all hope and heart in this place. During a telephone interview on [DATE] at 2:00 p.m., Staff N confirmed the following concerns related to Resident #59, who was transferred out to the acute care hospital with emergency care needs: 1. Prior to discharge to the hospital Resident #59 was observed to be dehydrated, with extremely dry oral mucosa, and was not observed offered sufficient oral hydration. 2. Resident #59 was not being timely changed and repositioned at nights, which was observed, reported, and education provided to the involved CNAs related to checking and changing briefs and repositioning of the resident. 3. Resident #59 was found wet, when she should have been checked and changed by inexperienced CNA staff. Resident interviews conducted on [DATE] at 12:30 p.m. and 3:01 p.m., [DATE] at 2:58 p.m., 3:45 p.m. and 3:48 p.m., and [DATE] at 9:00 a.m., with Residents #58, #55, #57, #62, #63, and Resident #55 respectively, all said the facility did not have adequate staff to meet their needs, showers were not being performed as scheduled, and call light response times were very slow, especially at night. Staff interviews conducted on [DATE] at 12:02 p.m., 1:17 p.m., 2:17 p.m., 3:25 p.m., and 3:35 p.m., [DATE] at 9:30 a.m., 10:24 a.m., 10:50 a.m., 12:09 p.m. and 3:20 p.m., [DATE] at 10:08 a.m., Staff L, Staff E, Staff T, Staff H, Staff I, Staff J, Administrative Staff A, Staff D, Administrative Staff B, Staff N, and Medical Provider NN, acknowledge a serious staffing shortage. Direct care staff, of the above identified Staff, confirmed showers were not being done as scheduled, call lights were not being timely addressed, and dependent residents were not being repositioned every two hours. Review of Resident #59's Progress Notes revealed the following, in part: [DATE] 12:04 p.m., Resident obtained stage 3 pressure injury to coccyx . Educated CNA staff on freq (frequent) repositioning and brief changing . [DATE] 11:46 a.m., Weekly wound assessment to stage 3 coccyx wound show (sic) area larger . Reminded staff to do more freq brief checks with peri cares and repositioning at least q (every) 2 hours . [DATE] 12:59 p.m., Weekly wound assessment to stage 3 show little improvement . [DATE] 11:58 a.m., Weekly Wound Note . unstageable pressure injury to coccyx. Wound Measurements: Length x Width x Depth: 2.5 x 2 x 0.2 cm (centimeters) . [DATE] 10:47 a.m., .Resident calling for nurse; this nurse found resident to be on a deflated mattress. Upon investigation, the CPR cord had been detached, therefore, not retaining air/allowing air to escape . [DATE] 11:05 a.m., New pressure injury right coccyx unstageable pressure injury r/t slough. Wound Measurements: Length x Width x Depth: 1.5 x 1 cm . New Wound . [DATE] 12:04 p.m., IDT team wound and weight; Resident continues with pressure injuries to coccyx, right buttock and left buttock areas noted to be open with slough to the wound beds. New open area right of previous coccyx wound measuring 1.5 x 1 cm with slough in the wound bed .Orders placed for weekly weights r/t pressure injuries . [DATE] 2:32 a.m., Coccyx pressure injury .Unable to get into treatment cart for supplies . [DATE] 11:15 a.m., Late Entry: Coccyx III (Stage 3 Pressure Injury) . Wound Measurements: Length x Width x Depth: 4 x 2.5 . [DATE] 8:44 a.m., Weekly weights on Mondays r/t pressure injuries .We are extremely short staffed and have not gotten a weight yet . [DATE] 12:27 p.m., Note sent to MD regarding deteriorating wound and request foley to aid in wound healing . [DATE] 23:20 (11:20 p.m.) and [DATE] 23:14 (11:14 p.m.) Weekly weights on Mondays r/t pressure injuries . Weight not obtained . [DATE] 13:48 (1:48 p.m.), Coccyx stage III pressure injury . 3.4 x 2 x 0.2 . [DATE] 17:15 (5:15 p.m.), Resident's catheter was leaking all night and this morning . not able to be flushed . catheter removed and replaced . Urine is amber. Frequent thick white matter noted in the catheter tubing. MD notified via fax. [DATE] 14:40 (2:40 p.m.), Coccyx pressure injury's (sic): Change 3 times a week and PRN if soiled or lifting every day shift every Mon, Wed, Sat for wound care. Pressure ulcer dressing not changed sleeping x 2 when I went in . [DATE] 14:54 (2:54 p.m.), Approximately at 1330 (1:30 p.m.) sent resident to the ER (emergency room ) . for changes in condition . she had low urine output and it did have blood in it. [DATE] 17:39 (5:39 p.m.), [ER] called report on Resident (#59), stated she has pneumonia, [CONDITION(S)], Septic .Nurse stated they cannot keep her blood pressure up despite all their interventions . [DATE] 11:23 a.m., Nurse received phone call from [acute care hospital], Resident (#59) passed away. Review of Resident #59's Wound Assessment forms included the following information, in part: [DATE] New skin condition, acquired in-house, coccyx, pressure, Stage III (3), 1 x .4 x .2 cm. [DATE], coccyx, Stage III pressure, 2 x 1 x .2 (increased in size). [DATE], coccyx, Stage III pressure, 2 x 1 x .2 cm. [DATE], coccyx, Stage III pressure 2 x 1 x .2 cm. [DATE], coccyx, Stage III pressure 1.8 x 1.0 x .2 cm. [DATE], coccyx, Unstageable, pressure 2.5 x 2 x 0.2 cm (increased in size). [DATE], coccyx, Unstageable, pressure 2.5 x 1.7 x 0.1cm. (This wound assessment signed on [DATE] by a sister facility Director of Nursing (DON).) [DATE], coccyx, Stage II Pressure, 3.5 x 3 x 0.1 cm. [DATE], coccyx, Unstageable pressure, 4.2 x 8 x 0.2 cm, Additional Information: Deteriorating: wounds (left and right coccyx pressure injuries combined to 1). Pain was associated with wound. Education provided related to frequent repositioning and the air mattress. [DATE], Stage III pressure, originally unstageable wound, 4 x 2 x 0.2 cm. Review of the [Physician Group] Wound Care Clinic documentation signed [DATE] at 12:34 p.m., The #7 Stage III (3) Coccyx pressure injury was not healed and measured 2.2 x 1.3 x 0.2. and the new #8 Stage 2 coccyx pressure injury which was not healed and measured 0.7 x 0.5 x 0.1. These wounds were both documented as the Initial wound encounter, and the Initial exam. The Multi Wound Chart Details, dated [DATE], included additional facility acquired pressure injuries that included: #4, Left, proximal, lateral sacral Stage III pressure injury that measured 0.6 x 1.5 x 0.1, #5, Left, proximal sacral Stage II pressure ulcer that measured 0.5 x 0.5 x 0, and a right, proximal sacral Stage III pressure ulcer that measured 1.5 x 1.7 x 0.2. Review of the acute care hospital Emergency Department Physician Documentation: History of Present Illness, dated [DATE], revealed the following, in part: .Patient (Resident #59) has known sacral (coccyx) ulcer. She had an indwelling Foley catheter as she is incontinent of urine, and this was to protect the sacral ulcer . Foley in place with urine that is thick, purulent, and discolored. Breathing is shallow . B/P (blood pressure) was ,d+[DATE], and pulse oximetry (percentage of oxygen in the blood) was 95% on room air . ED Summary: Initial evaluation patient appears septic . Review of the [Acute Care Hospital] Assessment/Plan, signed [DATE], and [DATE], revealed the following, in part: 1. Septic Shock: Patient with chronic indwelling Foley catheter and stage III (Stage 3) sacral ulcer. Both could be related to septic shock. Pressure improved with fluid resuscitation . patient is not making enough urine. Will wait for urine output with fluid resuscitation . ([DATE]) . Blood culture positive for enterobacteria family and Proteus . 8. Dehydration: Continue IV hydration . Review of the facility Skin and Pressure Injury Risk Assessment and Prevention, revised ,d+[DATE], revealed the following, in part: .Interventions for Prevention and to Promote Healing: a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions . b. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care intervention could include, but are not limited to: i. Redistribute pressure (such as repositioning, protecting, and/or offloading heels, etc.); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status . 11. Modifications of Interventions: a. Interventions on a resident's plan of care will be modified as needed. Considerations for needed modifications include: i. Changes in resident's degree of risk for developing a pressure injury. ii. New onset or recurrent pressure ulcer development. iii. Lack of progression towards healing .

Based on observation, interview, and record review, the facility failed to prevent the development of multiple pressure ulcers for one Resident (# 6) of two residents reviewed for pressure ulcers. This deficient practice resulted in harm with the development of an unstageable coccyx wound and a Stage IV (four) right ankle wound which have the potential for delayed healing, infection, and deterioration of condition. Findings include: Review of Resident #6's Minimum Data Set (MDS) Assessment, dated 2/24/22, showed the following applicable Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) score was 14/15 which reflected intact cognition. Resident #6 required two staff assistance for bed mobility, transfers, and toileting for both urine and bowel incontinence. The same MDS assessment identified pressure ulcer risk without any unhealed pressure ulcers at Stage I (one) or higher. On 5/26/22 beginning at 9:29 a.m., Resident #6's wound care was observed performed by Wound Care Nurse/ Licensed Practical Nurse (LPN) U and initially assisted by Certified Nurse Aide (CNA) M. Both performed hand washing in the bathroom and applied gloves. Resident #6 was lying on their back with their bilateral heels elevated on a blue foam pad. Resident #6's air mattress setting was dialed to 120 which indicated the softest setting. LPN U placed a paper towel on Resident #6's overbed table without first removing personal care items and cleaning and disinfecting the surface before placing down wound care supplies. Resident #6 personal items encompassed half of the overbed table. After dressing supplies were opened and prepped, LPN U removed their gloves and put on a new pair without the performance of hand hygiene. Resident #6's right ankle wound dressing was removed. The circular shaped wound was open, with surrounding redness outside of the wound edges. LPN U changed gloves before redressing the right ankle wound without the performance of hand hygiene. A left heel dressing was observed but not removed and assessed by LPN U who then changed gloves without performance of hand hygiene. CNA M turned Resident #6 on their left side (facing the direction of the door). The air mattress was not adjusted to a firmer setting to assist with repositioning. LPN U lowered the brief and folded it over into itself when a large amount of soft to liquid stool was found. LPN U removed the coccyx wound dressing and left it uncovered throughout the incontinence care which increased the opportunity for cross-contamination of stool to the wound. CNA M stood on the left side of the bed and repeatedly reached over Resident #6's body to dispose of the soiled, disposable incontinence wipes in a small garbage can located directly under the overbed table which contained the opened wound care supplies. LPN U removed gloves and washed hands in the bathroom while CNA M and now CNA S continued incontinence care on Resident #6 who was repeatedly turned from their right side to their back, and to their left side to cleanse stool. Resident #6's lift sheet was replaced by a bath blanket which was thicker and less smooth. When LPN U said that a top sheet was needed because of the air mattress, CNA S said the facility was completely out of them. CNA S handed soiled disposable wipes to CNA M who then placed them in the same trash can located under the wound care supplies. CNA M changed gloves without the performance of hand hygiene. LPN U with a new pair of gloves, redressed the coccyx wound. LPN U throughout the wound care observation touched the front of their mask which was ill-fitting, at times positioned under the nose, and which contained an exhalation valve. Hand hygiene was never performed after touching the mask. The air mattress was never adjusted to provide additional support to Resident #6's repositioning during wound and incontinence care. Resident #6 lower extremities appeared stiff and completely dependent for movement from staff. During a follow-up interview on 5/31/22 at 11:02 a.m., the Director of Nursing (DON) confirmed the following: 1) Staff were expected to clean and disinfect an overbed table prior to setting up wound care supplies and to place a larger sized barrier in place such as a blue disposable pad. 2) Staff were trained to either wash their hands or to use hand sanitizer with all glove changes. 3) Staff should not remove a dressing from an area before incontinence care was performed and/or to properly cover the wound to avoid cross-contamination. 4) Staff could have used a second waste bag to properly dispose of soiled incontinence supplies in their immediate proximity rather than reach over a resident to dispose of soiled items. When asked about Resident #6's facility-acquired wounds, the DON said she now had concerns with why the wounds were not improving after this Surveyor identified breeches in aseptic technique during Resident #6's wound care observation. When asked about the air mattress not being adjusted during the wound care and incontinence care, the DON confirmed the mattress should have been adjusted to a firmer setting to avoid causing potential injury to Resident #6. When asked about Resident #6's incontinence care with staff repeatedly turning from their left to right side, the DON said if frog positioning (by bending the knees and separating the legs), was used, Resident #6 would not have had to endure the repeated turning. Review of a facility provided untitled document sent via electronic transmission on 6/1/22 at 1:31 p.m. from the Nursing Home Administrator (NHA) showed Resident #6's pressure ulcer histories: A. Right ankle (malleolus) facility acquired pressure ulcer identified on 4/7/22 with the following measurements on 5/26/22 were 0.7 cm (centimeter) L (length) by 0.7 cm W (width) by 0.4 cm D (depth). Stage IV. B. Right lateral foot-facility acquired pressure ulcer identified on 4/4/22 Wound measurements and stage were not provided. Wound resolved 5/17/22. C. Left lateral facility acquired pressure ulcer identified on 4/4/22. Wound measurements and stage were not provided. Wound resolved 5/17/22. D. Coccyx-facility acquired pressure ulcer identified on 5/13/22 with the following measurements on 5/26/22 were 1.1 cm (L) by 1.1 cm (W) by 0.1 cm (D). Unstageable. Review of Resident #6's right ankle wound culture (collected 5/12/22) showed a positive culture for staphylococcus aureus. (Bacterial infection most often spread by contaminated hands). Review of Resident #6's Braden Scale for Determining Pressure Ulcer Risk dated 5/26/22 placed them in a low-risk category for the development of pressure ulcers. As of the date this assessment was completed, Resident #6 had an unstageable pressure ulcer on the coccyx, a Stage IV pressure ulcer on the right ankle, and two previous facility aquired pressure ulcers to bilateral heels (healed as of 5/17/22) which would have caterorized them at a higher risk. Review of the facility's Wound Treatment Management and Documentation revised 7/21, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to provide emergency medical care, including CPR (cardiopulmonary resuscitation), for one Resident (#1) of three residents reviewed for emergency care consistent with physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Immediate Jeopardy began on [DATE] at approximately 6:55 a.m., when Full Code Resident #1 stopped breathing, was without a pulse (heartbeat), and CPR was not performed. The Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON A) were notified at 3:35 p.m. on [DATE] that the [DATE] incident was determined as IJ. The IJ deficient practice was corrected on [DATE], prior to the start of the abbreviated complaint survey, and the deficient practice was therefore deemed Past Non-Compliance. Findings include: This citation relates to Intake #MI 274. Review of the facility Investigative Summary, received from the NHA on [DATE], revealed Resident #1 was admitted to the facility on [DATE], alert and oriented, documented as responsible for self, and able to make his needs known. Resident #1 was short of breath with audible respiratory gurgling and an oxygen saturation of 79% (percent), at 6:00 a.m. on [DATE]. Resident #1 requested Sudafed medication, and at 6:52 a.m.secretions came out of his mouth, and he took his last breath. At 7:00 a.m., there were no vital signs and no cardiopulmonary resuscitation (CPR); however, he wanted to be resuscitated based on admission notes . (the) DON, reported to the Administrator that [Resident #1] had expired; however, he did not get resuscitated . [Registered Nurse (RN) D], .attending to [Resident #1] was interviewed to find out what transpired before his expiration. [RN D] responded that she did not start CPR as she was unaware of his advance directive . The facility substantiates that [Resident #1] did not have CPR performed on him when he stopped breathing on [DATE]. During an interview on [DATE] at 10:02 a.m., Staff C confirmed she provided care for Resident #1 the morning of [DATE]. Staff C stated she responded to Resident #1's call light at about 6:40 a.m., and Resident #1 said he could not breathe, needed his meds, and he requested Sudafed. Staff C stated she then ran and told RN D that Resident #1 could not breathe. RN D gave Staff C a pulse oximeter (to measure oxygen saturation in the blood). Staff C went back to Resident #1, measured his oxygen saturation at 79% (,d+[DATE]% considered normal range). RN D told Staff C to grab an oxygen concentrator from another resident's room. Staff C stated, We hooked him (Resident #1) up with the oxygen (from the oxygen concentrator). He wasn't getting any oxygen. He was very gurgly sounding, and [RN D] said to jack up the oxygen as far as it goes. I put it on five liters, and [RN D] kept saying she should get him a mask (oxygen delivery mask). He could not swallow (the) Sudafed - it was stuck on his tongue - and [RN D] said it would dissolve in his mouth. [RN D] did apply an oxygen delivery face mask . Staff C said Resident #1 was alert and oriented and could hear what was being said. Staff C stayed with Resident #1. Staff C stated, . [RN D] and Licensed Practical Nurse [(LPN) E] were both there. [LPN E] handed [RN D] the stethoscope and [Resident #1's] chest was moving up and down. [RN D] was listening to his lungs. [RN D] said 'he is gone'. He died at five minutes to seven . Staff C stated, You can see 'Full Code' [status on the electronic Medication Administration Record (eMAR)], it was right by the Resident's picture. Staff C confirmed no attempts were made to start CPR on Resident #1. Review of a written To Whom it May Concern letter authored by Staff C, dated [DATE], received from the NHA on [DATE], provided written statement corroborating the sequence of events as told in the above interview. The letter had been provided to the facility NHA following Resident #1's failure to receive CPR per his documented wishes. Review of Resident #1's [DATE] eMAR revealed Advance Directive: Full Code noted near the top left of each page. Review of Resident #1's Medical Treatment Decision Form (MTDF), signed and dated by Resident #1 and two required witnesses on [DATE] and signed by Resident #1's physician on [DATE] revealed the following emergency treatment decision made by Resident #1: CPR Full resuscitation, I request that in the event my heart and breathing should stop, I am given resuscitating measures. Review of Resident #1's Progress Notes revealed the following, in part: [DATE] 17:19 (5:19 p.m.) Resident arrived to facility at 1500 (3:00 p.m.) via medical transport on a stretcher. Resident is alert and oriented. Able to make needs known . [DATE] 17:27 (5:27 p.m.) Resident verbally expresses that he would like CPR should his heart stop. [DATE] [DATE] 11:47 a.m., CNA called this RN (RN D) to resident's room at 0600 (6:00 a.m.), was observed to be short of breath with gurgling, immediately applied oxygen, O2 sats (saturations) were 79% .at (sic) went back to resident's room and observed medium amount secretion come out and resident took his last breath, no vital signs at 066 (sic). Author RN D. [DATE] 4:11 a.m., Resident complained of secretions and pain throughout the night . [RN D] came out (of Resident #1's room) and said he was 'knocking on deaths door', and a CNA called to her. I (LPN E) followed her (RN D) with my stethoscope so that she could utilize it. When I walked in, he was still breathing, but she was holding his pulse attempting to take a radial pulse and saying he no longer had one. He was still visabaly (sic) engaging in agonal breathing . [RN D] came out saying he had passed . This is written and signed by [LPN E] with permission of [LPN G] due to issues with [Electronic Medical Record]. During an interview on [DATE] at 11:19 a.m., LPN E said she heard Resident #1 calling for assistance around 11 p.m. on [DATE]. Resident #1's call light had fallen to the floor, and he mentioned he was having a hard time breathing. He was in the high 80's (oxygen saturation level), so I elevated the head of the bed. LPN E traded halls with another nurse shortly before 4:00 a.m. on [DATE], and Resident #1 was no longer her patient. LPN E said RN D came out of Resident #1's room around 6:30 a.m. and said his 02 sats were low and he needed to be put on oxygen. About 10 minutes later RN D said he has passed (died ). LPN E stated, I was under the assumption that she knew what was happening (regarding Resident #1 being a full code) .About 9:30 a.m., [RN D] mentioned that he was a full-code and she had not initiated CPR. LPN E confirmed their policy: if facility staff were not aware of a resident's code status, CPR was to be initiated. LPN E said she was not asked to write a Witness Statement and would have called a code (to maintain respiration and circulation with CPR), but RN D was the charge nurse. During an interview on [DATE] at 12:14 p.m., LPN G confirmed she had provided care for Resident #1 during the early morning hours on [DATE], but had exited the facility prior to Resident #1's decline. When asked when CPR should be initiated, LPN G stated, With a full code (resident) you would call a code, call for help, get the crash cart and call 911 immediately. When asked about how she would identify a resident's code status, LPN G stated, It is in their chart, and it is in our MAR (Medication Administration Record), under their picture, whether DNR (do not resuscitate) or Full Code. Review of Employee Counseling Notice(s) for RN D on [DATE], and LPN E on [DATE] revealed the following, in part: 1. RN D received a Suspension/Final for Failure to follow facility policy CPR - Adult on [DATE] for [Resident #1] and was Suspended pending investigation. 2. LPN E received a Written Counseling Notice for As a nurse assigned earlier in the shift to the Resident (#1) who later expired/coded, you did not recognize change of condition or express code status (Full Code) to assigned nurse (to) initiate and call a CODE BLUE as required with Education - One on One with ADON (A). During an interview on [DATE] at 11:49 a.m., the NHA, DON, and ADON A all confirmed Resident #1 was a full code, and wanted CPR performed with absence of pulse and/or respiration. The NHA stated, I would have expected them to start CPR, someone starts the code and then another staff member makes the calls to EMS (Emergency Medical Services) and the Doctor . I don't feel that [RN D] did everything (she could have) because if he (Resident #1) asked for Sudafed, she [RN D] would have had to go to the MAR and she would have seen he was a full code. During a telephone interview on [DATE] at 2:34 p.m., when asked about the failure to perform CPR for Resident #1 on [DATE], RN D stated, I take full responsibility .I should have given the guy CPR, not knowing the code status he was. I don't have any idea why I didn't . I assumed he was a no code (because of his diagnoses) . Review of the Cardiopulmonary Resuscitation (CPR) - Adult policy, revised ,d+[DATE], revealed the following, in part: Policy: Appropriate cardiac and respiratory function will be maintained until a definitive treatment can be given. CPR will be initiated on all residents with an Advanced Directive stating CPR - Full Resuscitation: . It is the policy of this facility to respect each resident's individual, informed decision regarding advance directives and code statuses. Cardiopulmonary Resuscitation (CPR) will be initiated for residents with full code status and residents who have not declared a code status in the event of cardiopulmonary arrest. Policy Explanation and Compliance Guidelines: 1. In the event a resident is identified unresponsive and upon a thorough assessment determines that there is no pulse or respiratory activity, and the resident has declared a full-code status, a licensed staff member will: a. Simultaneously with the initiation of chest compressions direct a staff member to immediately retrieve the crash cart located on the nursing unit. b. Continue to administer chest compressions and rescue respirations per the [Name] recommendations. c. Direct a staff member to contact the Emergency Response Team (911) immediately to inform them of a full code requiring life support interventions and possible transportation to the emergency department . e. Identify a member of the response team to be responsible for documenting the time of each intervention and resulting response . g. Facility staff shall defer all resuscitation efforts to Emergency Response Personnel once they arrive at the location and declare that they will assume the responsibility of maintaining life support interventions. The immediate jeopardy was removed, and the deficient practice corrected on [DATE] after the facility implemented a systemic plan that included the following actions: Action taken for the employee involved: - [RN D] was suspended on [DATE]. - [RN D] personnel file was reviewed on [DATE] by the administrator. The employee had completed background check, reference checks, and abuse training/education on file as well as an up-to-date nursing license. Areas identified requiring quality improvement: - Code status was listed on PCC system (in documents and progress notes) - Incomplete Medical Treatment Decision form (MTDF) on file - Facility reviewed all residents MTDF for code status and updated orders on PCC on [DATE]. Quality Improvement measures or systemic changes made: - Interviews were completed with all necessary individuals starting on [DATE]. - Initiation of a QAA (Quality Assessment and Assurance) Investigation on [DATE] to identify details of the incident and to identify any potential deficient practice that may have occurred in relation to the incident. -The facilities Cardiopulmonary Resuscitation (CPR) - Adult Policy was reviewed on [DATE] and deemed appropriate by the Administrator and Assistant Director of Nursing. - Immediate in-servicing of all RN and LPN facility floor staff was initiated on [DATE]. Any staff member who has not received the education by [DATE] will receive the education prior to start of their next shift. All Licensed Nursing staff were educated on the Cardiopulmonary Resuscitation (CPR) - Adult Policy by [DATE]. A One-to-One in-service on [DATE] was provided by the Administrator to [RN D] via telephone, before working their next shift. Audits were developed for MTDF completion, correct code status in PCC (chart reviews on new admissions). How facility monitors the effectiveness of its quality improvement measures (sustained compliance): - Administrator/designee will conduct new admit chart reviews weekly x (times) 4 weeks and then monthly x 2 months to ensure correct code status, until substantial compliance maintained. Results of these audits will be submitted to the QAA Committee for review and further recommendations. All measures implemented by the facility following Resident #1's lack of emergency medical treatment (including CPR) on [DATE] were reviewed and verified, including quality assurance audits implemented to monitor and maintain continued compliance. The facility was found to be in substantial compliance at the time of this abbreviated survey.

Based on observation, interview, and record review, the facility failed to properly prevent a facility-wide outbreak of COVID-19. This deficient practice resulted in the transmission of COVID-19, which had the potential to affect all 47 facility residents. This deficient practice has eight noted deficiencies: 1. Failure to ensure staff used Personal Protective Equipment appropriately during and following a COVID-19 outbreak. 2. Failure to complete timely infection control surveillance, infection mapping and analysis. 3. Failure to complete a thorough Outbreak Investigation, outbreak timeline, accurate contact tracing, and staff education related to a COVID-19 outbreak. 4. Failure to accurately monitor employee illness to prevent COVID-19 transmission. 5. Failure to ensure social distancing to in prevention of COVID-19. 6. Failure to ensure compliance with visitor entrance screening protocol. 7. Failure to ensure housekeeping supplies were reconstituted and used effectively to kill the COVID-19 virus. 8. Failure to ensure unvaccinated residents received the COVID-19 upon their consent. The Immediate Jeopardy began on 11/18/21, when eight residents and three staff members tested positive for COVID-19 through rapid testing. Evidence obtained throughout the first two days of the survey (12/13/21 - 12/14/21) confirmed facility staff had not been using PPE appropriately and consistently while providing direct care for facility residents. The Nursing Home Administrator (NHA), Director of Nursing (DON), and Assistant Director of Nursing (ADON) A were informed of the Immediate Jeopardy concern on 12/14/21 at 3:30 p.m. The Immediate Jeopardy was removed on 12/15/21, with the initial implementation of the accepted Abatement Plan. Non-compliance remained at the lower scope and severity of widespread potential for more than minimal harm that is not immediate jeopardy, pending on-site verification of the Plan of Correction. Findings include: PPE On 12/13/21 between 3:45 p.m. and 3:52 p.m., Food and Nutrition Aide (Staff) K was observed with his face mask under his chin once, and under his nose two additional times. Immediately upon seeing this Surveyor, Staff K moved behind the food tray cart and pulled the mask up over his nose. Cook L was also observed, at this same time with mask below her nose during food preparation at the back table in the kitchen. Cook L also, upon seeing this Surveyor, immediately pulled her mask up to cover her nose. When interviewed, at this same time, both Staff K and Cook L, confirmed they were to be wearing their face masks covering their nose during food preparation in the kitchen. On 12/13/21 at 4:20 p.m., Registered Nurse (RN) H was observed standing at a medication cart directly in front of the main nurses' station. RN H quickly pulled down her face mask and sneezed into her bare hands, cupped in front of her face. RN H pulled her face mask back up with her right bare hand on the front of the mask. RN H performed hand hygiene with hand sanitizer but did not wash her hands with soap and water after gross contamination of her hands with the sneeze. On 12/14/21 at 7:50 a.m., Staff K was observed with face mask under his chin and Cook J with mask under her nose. When both Staff K and Cook J saw this Surveyor open the kitchen door (with glass window), they quickly pulled up their face masks to cover their noses. When asked what concern this Surveyor had, Staff K stated, My face mask (not covering face). Cook J stated, When I am done cooking, I pull down my mask sometimes. No hand sanitation was noted following touching of the front of their face masks. During an interview on 12/14/21 at 9:15 a.m., the DON/IP and ADON A were asked about staff not wearing face masks properly in the kitchen during food preparation. ADON A stated, The expectation is to cover their mouth and nose while preparing food in the kitchen. In the office, with their door open, they should have their mask up (covering their mouth and nose). When asked about sneezing, face masks and hand sanitation following a sneeze, ADON A said the face mask should be changed after it was sneezed into, and if the mask was removed and staff sneezed into their hands both the DON/IP and ADON A considered it gross contamination of the staff member's hands that would require hand washing. When asked if either the DON/IP or ADON A were aware of any complaints related to failure to wear proper PPE when the COVID-19 outbreak began, the DON/IP confirmed a staff member had contacted the corporate office and said that we were supposed to have full PPE on and we were told differently. The DON stated, I got an email from (a) call made to corporate that we were not compliant with PPE. [They] said you have to have N95 (face masks), face shields, so we got them on everybody. The DON/IP confirmed they were not wearing full PPE with their facility wide (both halls positive) outbreak of COVID-19 on 11/18/21. During an interview on 12/14/21 at 10:01 a.m., Staff B confirmed she had concerns with inadequate PPE usage at the beginning of the COVID-19 outbreak in November. Staff B said she told the DON/IP that staff needed to be switching to N95 masks. Staff B stated, I saw that people (staff) were still wearing surgical masks. Staff B stated, I think the 18th (of November) was a Thursday, and maybe people were switching over (to N95 face masks) on Friday . I got them (N95 masks) from the central supply and put the N95's out there . Staff B said she reached out to corporate to make sure they were following all the steps to provide guidance for PPE requirements during a COVID-19 outbreak. During an interview on 12/14/21 at 11:04 a.m., when asked what PPE was used at the beginning of the COVID-19 outbreak in November, Housekeeper N stated, I was wearing a surgical mask, and once we were told to go closer to the COVID unit we had to wear the N95 masks. I just wore my regular surgical mask. I had my personal glasses on - no face shield, no goggles - they didn't tell me to wear that, at that time. On 12/14/21 at 8:36 a.m., the DON/IP was observed in her office, next to the nurses' desk, with her surgical mask positioned under her chin in the presence of ADON A. The office door was found wide-open at the time of the observation. During an interview on 12/14/21 at 11:52 a.m., ADON A confirmed direct care staff cared for residents who were COVID-19 positive, who were negative, and/or under observation simultaneously during the same day and shift. The ADON A was asked to describe the PPE donning and doffing procedures as staff were moving between the Visqueen barrier (plastic sheeting used to create temporary wall) which was used to separate COVID-19 positive residents from other residents. The ADON A explained staff removed dirty PPE in the hallway on the side of the COVID-19 positive resident hall and would pass through the barrier without wearing any PPE to enter the other side of the hallway. When asked about possible COVID-19 exposure to both residents and staff since no face covering was worn during this time, ADON A did not respond to the question. During an interview on 12/14/21 at 11:14 a.m., CNA D confirmed she worked caring for residents who were COVID positive on the Quarantine Hall and at the same time cared for COVID negative residents who were on the other side of the Visqueen barrier. CNA D was asked to describe the donning/doffing of PPE when she worked on the Quarantine Unit and needed to enter the other side of the Visqueen barrier. CNA D said that dirty PPE was removed in the hallway of the Quarantine side and then clean PPE was applied before unzipping the Visqueen barrier. When asked about PPE cross-contamination of clean/dirty being in the same area, CNA D said, I realize now it was wrong. During a telephone interview on 12/16/21 at 9:16 a.m., CNA D confirmed she had moved residents to the South Hall the next day following testing for COVID-19 positive residents on 11/18/21. CNA D stated, The residents were still trying to congregate by the nurses' station, (and) staff were wearing surgical masks, and then later in the afternoon (on 11/19/21) the employees were wearing N95's (face masks). Surveillance During an Entrance Conference on 12/13/21 at 12:30 p.m., the NHA and DON/IP were asked to provide resident line-listing infections (to include COVID-19) for November and December 2021, staff COVID-19 testing for November and December 2021, and a list of staff who have confirmed or suspected cases of COVID-19. The DON/IP said the facility's outbreak began with positive residents on 11/18/21which later affected staff. Review of an untitled and undated document showed that staff were tested on [DATE], 11/8/21, 11/11/21, and on 11/16/21. The document had multiple dashes and blanks without either the DON/IP's or ADON A's initials which would indicate testing was performed. The document does not indicate vaccination status for each staff person to determine which staff were fully vaccinated. Also, the same document does not indicate the COVID-19 results for each staff person. The total number of staff listed on the same document was 40; however, the facility's staff list was 69. During an interview on 12/14/21at 9:15 a.m., the DON/IP was asked to provide individual, staff COVID-19 Rapid Test Result forms to identify which staff was tested , which staff performed the test, which type of test was used, the date and time the test was performed and the results of the test. The DON/IP said, the facility stopped using the form and was unable to provide the data in any other way. Review of November 2021 line-listing infections identified 13 residents with COVID-19. The first onset of a resident with COVID-19 was documented for 11/22/21. After four repeated requests beginning on 12/13/21 at 12:30 p.m., on 12/13/21 at 4:24 p.m., on 12/14/21 at 8:19 a.m., and on 12/14/21 at 8:36 a.m. a December 2021 line-listing was never provided. Review of the EMR, identified the first COVID-19 positive residents were on 11/18/21 during the facility's routine bi-weekly point of care (POC) testing and not on 11/22/21 as indicated on the line-listing surveillance. Outbreak Management Review of facility's Outbreak Investigation (undated) read in part, On 11/18/21 testing was completed on all residents d/t (due to) positive staff member. Positive staff member was a floor nurse that had direct contact with residents. During this routine outbreak testing 8 residents tested positive for Covid 19 with rapid tests . Additional residents tested positive: 1 on 11/19/21, 5 on 11/22/21, 1 on 11/23/21, 2 on 11/24/21, and 1 on 11/29/21 . (This indicates 18 residents tested positive in November 2021 and not 13 residents as documented on the November 2021 line-listing. During an interview on 12/13/21 at 3:57 p.m., the DON/IP was asked if the facility had identified the possible cause of outbreak. The DON/IP said, I would think they (Resident #2 and Resident #3) were 80% the cause of the outbreak since they both routinely left the faciity on LOAs (leave of absences) on Sundays. During follow-up interview on 12/14/21 at 8:43 a.m., both the DON/IP and the ADON A confirmed the Outbreak Investigation was completed by Regional Clinical Coordinator S and that neither of them had read the outbreak summary. The DON/IP said, I didn't analyze it. The ADON A said, I didn't review it. During an interview on 12/14/21 at 2:30 p.m., the NHA confirmed she had not read the facility's Outbreak Summary and was unaware who wrote the summary. During an interview on 12/14/21 at approximately 9:30 a.m., the DON/IP and the ADON A confirmed no staff surveillance nor audits were performed for infection control practices during the outbreak such as hand hygiene, smoking practices, PPE use, donning and doffing, and/or appropriate TBP. The DON/IP also confirmed no additional staff education was provided during the outbreak for staff and residents. Outbreak Timeline During an interview on 12/14/21 at 8:43 a.m., the DON/IP was asked to provide a timeline to show what actions were taken to manage the outbreak such as: 1. Date/time notifications were made to the NHA, Medical Director, and local health department 2. Date/time facility-wide testing began and ended 3. Education for all staff, residents, and visitors 3. Staff monitoring for infection control compliance 4. Date/time residents placed in TBP 5. Date/time the Visqueen barrier was set-up for COVID-19 hall 6. Contract tracing of ill staff and 7. Initiation of Monoclonal Antibody Therapy. The DON/IP confirmed a timeline was never completed on 12/14/21 at 8:43 a.m. Employee Illness Review of facility's COVID-19 Rapid Test Results showed that CNA C tested positive on 11/17/21 at 06:02 a.m. The following symptoms were listed as cough and runny nose. During a telephone interview on 12/14/21 at 10:24 a.m., CNA C said she was scheduled to work and came to the facility ill with the following symptoms: sore throat, cough, and runny nose. CNA C said LPN G performed a rapid test inside the facility's vestibule (where entrance screenings were performed) and was found positive. When asked what PPE LPN G wore to perform the test, CNA C said only a surgical mask and gloves. During an interview on 12/16/21 at 9:19 a.m., LPN G confirmed she had incorrectly recorded the wrong date on CNA C's rapid COVID test and indicated she had tested her on 11/18/21 and not on 11/17/21. LPN G said CNA C looked ill and told her she needed to be tested . LPN G confirmed she only wore a surgical mask and gloves and not an N95 (higher filtration mask), face shield or goggles, and a gown. When asked why CNA C would have attempted to come to work ill, LPN G responded, I don't know what she was thinking. Review of November 2021 Employee Infection Control Log showed CNA C on 11/18/21 had symptoms of cough and headache. And under the column Date of Symptoms Resolved read 11/18/21 (the same day she had symptoms of sore throat, cough, and runny nose). During an interview on 12/14/21 at 8:43 a.m., the DON/IP confirmed that no contract tracing was performed for any of the positive staff in November 2021. When asked which staff was identified as positive within one week prior to 11/18/21, the DON/IP did not answer the question. When asked why LPN F was not on the Employee Illness Log when she was positive for COVID-19 on 11/18/21, the DON/IP responded, Another (DON/IP) blunder . During an interview on 12/14/21 at approximately 10:30 a.m., Recreation Director (Staff) R said she sent Activity Aide (Staff) BB home due to the development of fever and feeling unwell around 1:00 p.m. on 11/18/21. Staff R confirmed Staff BB had taken residents in groups out to smoke that day. Review of an e-mail with Subject: Positive Employees sent by DON/IP on 12/1/21 identified Staff BB was tested and found positive on 11/22/21. Social Distancing -[NAME] we may need to add more residents to the sample list. See below. I wrote out their names and room numbers that will need identifiers. During an initial tour observation on 12/13/21 at 1:17 p.m., four Residents (#17, #18, #19, and #20) were seated across from the nurses' desk without adherence to social distancing. Licensed Practical Nurse (LPN) AA confirmed the identities of the four residents and confirmed they were not separated by at least six feet. All five residents were not wearing face coverings at the time of the observation. Smoking During an interview on 12/13/21 at 2:07 p.m., CNA D said residents had smoking privileges before, during, and after the facility's COVID-19 outbreak. CNA D said residents were taken outside in groups of three to four approximately five times per day and most residents did not wear a face covering while waiting together to go outside by the back door located by the Rehab Department. During an observation on 12/13/21 at 4:24 p.m., a group of unidentified residents were observed outside, under the pavilion, by the facility's Rehab Department. Residents were actively smoking, seated in close proximity to one another, without social distancing in place. During an interview on 12/14/21 at 10:39 a.m., Housekeeper (Staff) O confirmed she takes residents outside to smoke. Staff O confirmed that all but one resident was in wheelchairs and that the ground was not marked for social distancing. When asked if residents were encouraged to perform hand hygiene upon their return inside the building, Staff O said no but offered it should be done. When asked about residents' mask use, Staff O indicated it was poor. During an observation on 12/14/21 at approximately 1:30 p.m., Recreation Director (Staff) R confirmed seven residents were grouped together, who were waiting to go outside to smoke, located by the Rehab Department, were not socially distanced and were not wearing any facial coverings. Review of the eleven residents who smoked in November 2021 during the facility's outbreak, five residents contracted COVID-19 (Resident #1, #5, #6, #7, and #8). During an interview on 12/14/21 at approximately 9:30 a.m., the ADON A confirmed residents who smoked were still taken out in groups, and not individually, even though group activities were cancelled beginning on 11/18/21. Visitation Screenings During an interview on 12/14/21 at 1:14 p.m., Staff R confirmed responsibility for scheduling and screening visitors. Staff R confirmed that visitors were allowed to enter the building at two separate locations (one in the front and one in the back by Rehab Department). Staff R provided three visitation screening forms, undated, which were located from the back entrance. Review of the visitor screening forms showed many entries with missing dates, missing times, missing which resident was visited, missing temperatures, missing location of the visit, missing health questions screenings, and/or missing COVID-19 exposure. Staff R confirmed the incompleteness of the visitor screening forms were a concern for the transmission of COVID-19. Immediately after the interview with Staff R on 12/14/21 at 1:14 p.m., Staff R was asked to show the visitation screening location by the Rehab Department. Upon walking up to the table located in the vestibule, Staff R said, The hand sanitizer is missing. Housekeeping During an interview on 12/14/21 at 10:39 a.m., Housekeeper (Staff) O was asked to show each cleaning product used during the outbreak and to describe each product's intended use. When asked how long each product was to remain wet prior to wiping to ensure product kill-claim, Staff O said she did not know. When asked about PPE used for the (brand name toilet bowl cleaner), Staff O said she only wore gloves. When asked to read the instructions on the bottle, Staff O said, Am I supposed to have eye protection? I didn't know. I never read it. During an interview on 12/14/21 at approximately 9:30 a.m., the DON/IP and the ADON A were interviewed regarding housekeeping during the outbreak. The ADON A said that the facility's Housekeeping, Laundry, and Maintenance Director left the position on 11/3/21 and the position had not been filled. The ADON A said the facility had three staff persons for housekeeping and said they all worked the day shift. When asked about the outbreak time and need for terminal cleaning and increased high-touch cleaning for evenings and nights, the ADON A said the certified nurse aides were expected to perform those duties. When asked if additional CNAs were added to the schedule, the DON/IP said no. The DON/IP and the ADON A confirmed no staff surveillance was performed. During an interview on 12/14/21 at 11:04 a.m., Housekeeper (Staff) N was unable to identify each cleaning product's kill-claim nor understood that some products were only effective in cleaning and disinfecting specific viruses and bacteria. Staff N said the only time she left the surface wet (without immediately wiping the surface) was when a room was terminally cleaned. Staff N was asked about the reconstituted bleach spray bottle. Staff N said she guessed the amount of bleach and did not use any type of measuring device. The bottle was not marked to identify the proper amount of bleach was needed for a 1:10 dilution. When asked how often the bleach/water mix was made, Staff N said she waited until the bottle was empty before making a new bottle. (Bleach/water solution needs to be reconstituted every 24 hours to ensure proper dilution for kill-claim). COVID Missed Vaccination Review of Resident #6's MDS assessment, dated 9/14/21, showed the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12 BIMS score reflected intact cognition. Review of Resident #6's consent form, dated 9/21/21, showed consent was granted for COVID-19 vaccination but the EMR showed the vaccine had never been administered. Resident #6 contracted COVID-19 on 11/23/21 while residing in the facility. During a telephone conference on 12/15/21 at 3:13 p.m., the NHA was asked why (Resident #6) had not received the COVID-19 vaccine when she consented for it on 9/21/21. The NHA said she had reached out to the pharmacy to set-up a clinic, but it had not been scheduled. When asked if other arrangements had been made such as contacting the local health department, locating a community vaccination clinic, utilizing a walk-in clinic, or through her primary care physician, the NHA said, ok.' The EMR confirmed no other arrangements had been made to ensure Resident #6 received the COVID vaccination, with high community transmission rates, after her admission of approximately two months. References Review of the facility's policy Novel Coronavirus Prevention and Response revised 9/21, read in part: 1.b. Threat detected-the facility will respond promptly and implement emergency and/or outbreak procedures .5. F. Assess visitors and healthcare personnel, regardless of vaccination status, for symptoms of COVID-19, a positive [CONDITION(S)] test for COVID-19 or who meets criteria for quarantine or exclusion from work .6. b. Ensure proper social distancing, wearing of facemask, and hand hygiene are followed c. iv. Implement heightened surveillance activities . d. Monitor staff for fever or respiratory symptoms. Restrict from work .7. o. Restrict other residents to their rooms (to the extent possible) except for medically necessary purposes. If they leave their room, have them wear a facemask, perform hand hygiene, limit movement in the facility, and perform social distancing (efforts are made to keep them at least 6 feet away). On 12/15/21 the apporved facility abatement plan was initiated which included the following: 1. All residents were assessed for signs and symptoms of respiratory illness. The DON reviewed the 24-hour report to ensure there were no residents exhibiting signs and symptoms that were overlooked. 2. Line Listing was corrected and updated by the DON/designee and reviewed for accuracy by the Regional Clinical Consultant. 3. Staff contact tracing was completed by the DON/designee. 4. There are currently no active resident COVID-19 cases in the facility. 5. The Outbreak Timeline was completed by the DON/designee and reviewed for accuracy by the Regional Clinical Consultant. 6. The Outbreak Summary was corrected and updated by the DON/designee and reviewed for accuracy by the Regional Clinical Consultant. 7. Any current visitors in house have had a COVID-19 screening completed. 8. The Infection Preventionist has returned from leave and is on-site at the facility. 9. The screening log was reviewed by the DON/designee to ensure all staff currently working have been screened for COVID-19 and there are no acutely ill employees working . 11. Staff COVID-19 Testing log was corrected and updated by the DON/designee and reviewed for accuracy by the Regional Clinical Consultant. 12. The dates and source of the COVID-19 outbreak were corrected and updated by the DON/designee and reviewed for accuracy by the Regional Clinical Consultant.

Based on interview and record review, the facility failed to timely execute COVID-19 Standing Orders (physician orders) and failed to assess for individual resident qualification for treatment with and timely administration of physician ordered Monoclonal Antibodies for COVID-19 to four COVID-19 positive Residents (#1, #9, #10, #11) of 13 residents reviewed for quality of care. This deficient practice resulted in a delay in laboratory blood testing to assess resident condition, the potential for worsening of condition and/or prolonged duration of their COVID-19 illness. Findings include: Resident #1 Review of Resident #1's Electronic Medical Record (EMR) revealed Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 had a court appointment guardian who made health care decisions. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Progress Notes revealed the following, in part: 11/18/21 16:02 p.m. (4:02 p.m.), .Resident's guardian, updated on resident's + (positive) Covid test. He is agreeable to having resident receive the antibody (monoclonal antibody) tx (treatment), recommended by [Medical Director (MD) Z]. 11/19/21 10:40 a.m., Sats (oxygen) at 88% (percent) to 91% on room air. [Resident #1] was started on O2 at 2L (liters) . 11/20/21 16:45 (4:45 p.m.), .Resident continues to be in quarantine due to a positive covid test .O2 sat was 86 this morning without oxygen, currently on 2 liters of O2 via nasal cannula . Lungs are diminished with some wheezes, he has a dry cough with no sputum. He has been very tired and sleeping most of the day . 11/24/21 14:44 (2:44 p.m.), Late Entry (Created 11/26/21 at 9:45 a.m. by the Director of Nursing (DON) . Given 4 divided doses of Casirivimab and Imdevimab (Monoclonal Antibodies). No side effects noted. Review of Resident #1's Casirivimab/Imdevimab Consent Form, consent for the monoclonal antibodies was received via verbal consent by Licensed Practical Nurse (LPN)/Health Information Coordinator M on 11/18/21 at 16:02 (4:02 p.m.). During an interview on 12/13/21 at 3:58 p.m., when asked why monoclonal antibodies were not administered to Resident #1 until 11/24/21, when the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON stated, I can't give you an answer why it (monoclonal antibodies) wasn't given (earlier). It should have made a difference, and it did with a lot of our other residents. The sooner it is given the better the outcome. When asked if Physician Z knew the monoclonal antibody treatment had been delayed, the DON said she did not know if Physician Z was aware of the delay. Review of the Pharmacy Casirivimab/Imdevimab Intake/Prescriber Order, revealed Resident #1 was identified as COVID-19 positive on 11/18/21, with the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A photo of the same form was received from the Consultant Pharmacy on 12/15/21 at 2:55 p.m. via electronic transmission, showing the order for Resident #1's Monoclonal Antibodies was not submitted to the pharmacy until 11/22/21 at 11:11 a.m., and delivered the same night (11/22/21) to the facility. Review of the pharmacy Infection Disease Algorithm, Casirivimab/Imdevimab (Monoclonal Antibody) for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] ? Or if previously on oxygen, has patient required increase in flow rate? (if) 'YES', (Individual) Does not qualify. Follow facility COVID-19 treatment protocol . Review of Standing Orders for Residents Positive for COVID, dated 8/26/21, and signed by Medical Director (MD) /Physician Z revealed the following, in part: 1. D-dimer (blood test to measure D-dimer protein fragment made when a blood clot dissolves in the body) to be drawn day of diagnosis, and day 7 + (and) 14 +21 if upper respiratory symptoms . 2. [MEDICATION(S)] 250 mg (milligrams), 500 mg x (times) 1 day then 250 mg Daily x 4 days. 3. [MEDICATION(S)] 4 mg (milligrams), 1 tablet BID (twice daily) x 3 days then 1 tablet daily x (unidentifiable number) days. 4. Vitamin C ([MEDICATION(S)]), 500 mg 1 x day x 1 mo. (month). 5. Vitamin B complex, 1 tablet daily x 1 mo. 6. [MEDICATION(S)] 2 mg, one tablet nightly for 10 days. 7. [Anticoagulant] 5 mg twice daily x 5 weeks if D-dimer is elevated, D-dimer - High. Hand-written, [MEDICATION(S)] 80 mg 1x daily x 1 month. Hand-written, Vitamin D, 5000 IU daily x 1 month . During an interview on 12/14/21 at 11:40 a.m., the DON confirmed Resident #1 had been on oxygen prior to administration of the monoclonal antibodies. The DON said ADON A had administered the monoclonal antibodies to Resident #1 on 11/24/21 but did not have authorization to document in the Electronic Medical Record (EMR) because she was new to the facility. The DON also reviewed the Monoclonal Antibody algorithm, and when asked if Resident #1 would qualify for administration of the Monoclonal Antibodies, the DON stated, [Resident #1] does not qualify according to the algorithm. The DON also acknowledged the D-dimer testing should have begun on 11/18/21, the date Resident #1 tested positive. During an interview on 12/14/21 at 11:47, ADON A confirmed she had administered the Monoclonal Antibodies to Resident #1 on 11/24/21 but did not document administration on the Electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked why a late entry for administration of the medication had not been completed, the ADON A stated, I don't know why. Review of Resident #1's D-dimer laboratory report, dated 11/24/21, revealed a High Out of Range score of 5817, with a Reference Range (normal range) shown as 0-500. Review of a Physician Order, completed 11/24/21 by LPN M, revealed the following, D-dimer enclosed. We will proceed with [anticoagulant] 5 mg BID (twice daily) x 3 weeks (COVID-19 Standing Order) due to elevated labs. Review of Resident #1's Casirivimab/Imdevimab [Name Brand] Administration Flow Sheet, revealed Resident #1 received the monoclonal antibodies on 11/24/21 beginning at 1600 (4:00 p.m.), administered by ADON A. Review of Emergency Department (ED) Triage Vital Signs, dated 11/24/21 at 2334 (11:34 p.m.), revealed Resident #1 had a Pulse Ox (oximeter) reading of 98% on 10 Liters (L) of oxygen supplied by NRB (non-rebreather) mask. The ED Summary, Date of Service 11/24/21, revealed, in part: The patient has not been given [MEDICATION(S)] for [CONDITION(S)] with COVID-19, and this was started also . Review of Resident #1's eMAR for November 2021, revealed 10 of the 16 Standing Orders for Resident Positive for COVID were not initiated until on or after 11/24/21. When Resident #1 was admitted to the ED on 11/24/21, the only medication of the COVID Standing Orders administered was [MEDICATION(S)], with the other medications including [MEDICATION(S)], [MEDICATION(S)], Vitamin B complex, [MEDICATION(S)], and [MEDICATION(S)] being placed on Resident #1's eMAR following his return from the ED on 11/25/21. [MEDICATION(S)] and Vitamin D were not added to Resident #1's eMAR at all. During a telephone interview on 12/14/21 at 1:45 p.m., when asked when facility nursing staff were to complete blood draws for D-dimer analysis (related to potential increased blood clotting) for COVID-19 positive residents, Physician Z stated, The nurses draw the D-dimer on day one, day seven, and day 14 . If we are on top of making sure they are not having clotting problems we don't have the number of deaths that we normally do. Physician Z was unaware Resident #1 did not have a D-dimer drawn until day six following Covid-19 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . When advised Resident #1 did not receive the monoclonal antibodies until six days following diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .This is all fairly new to the nurses. During an interview on 12/14/21 at 1:57 pm., when asked if Resident #1 had a D-dimer drawn per Physician COVID-19 Standing Orders, Health Information Coordinator/Licensed Practical Nurse (LPN) M stated, [Resident #1] did not get a day one draw (for D-dimer). There were a bunch of them (residents) that turned positive. The whole building was in disarray .There was so much confusion at the time, and it was a lot of work with moving residents around. LPN M confirmed Resident #1's D-dimer was drawn on 11/24/21, six days following testing positive for COVID-19. Review of a faxed Physician Order, dated 11/25/21 (date of Resident #1's return from the ED), and signed by Physician Z on 12/7/21, (the date the form was faxed in return to the facility), revealed the following: Resident Status: Please sign below order for 'No Code Status' .for [Resident #1] . No Code Status, Comfort Care, 12/7/21. Review of Resident #1's 11/25/21 Nursing Progress Note at 17:30 (5:30 p.m.) revealed the following: Received call from [Name] ED that resident (#1) was ready to come back to facility on comfort care, Due to no beds available in ICU, he has been in the ED. MD notes state that the patient has [CONDITION(S)] flutter with rapid rate, worsening COVID-19 pneumonia and [CONDITION(S)] .he continues to worsen in the hospital and his prognosis is poor . Resident #9 Review of the facility listing of COVID-19 positive residents beginning 11/18/21 through 11/30/21 revealed Resident #9 tested positive for COVID-19 on 11/18/21. Review of Resident #9's Nursing Progress Notes, revealed Resident #1's responsible party was contacted by telephone on 11/18/21, and notes the responsible party wanted Resident #9 to have the Antibody treatment if she was eligible. Review of a Physician Order, signed 11/19/21 by Physician CC, authorized subcutaneous injections of Monoclonal Antibodies for Resident #9. Review of Resident #9's complete medical record found no documentation that Monoclonal Antibodies had been administered to Resident #9. During a telephone interview on 12/16/21 at approximately 11:00 a.m., the DON, ADON A , and Nursing Home Administrator (NHA) were all present. When asked about the absence of Monoclonal Antibody documentation in Resident #9's record, the DON stated, It (Casirivimab/Imdevimab Monoclonal Antibodies) had not come in from the pharmacy. It was not given by me, and it was not given. Upon review of Resident #9's EMR, the DON confirmed there was no documentation showing Monoclonal Antibodies had been administered to Resident #9, although verbal consent, and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 Review of the facility listing of COVID-19 positive residents beginning 11/18/21 through 11/30/21 revealed Resident #10 tested positive for COVID-19 on 11/22/21. Review of Resident #10's Nursing Progress Notes, revealed Resident #1's responsible party was contacted by telephone on 11/22/21, and wanted Resident #10 to have the Antibody treatment if she was eligible. Review of a Physician Order, signed 11/22/21 by Physician DD, authorized subcutaneous injections of Monoclonal Antibodies for Resident #10 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #10's complete medical record found no documentation that Monoclonal Antibodies had been administered to Resident #10. During a telephone interview on 12/16/21 at approximately 11:00 a.m., the DON, ADON A, and NHA were all present. When asked about the absence of Monoclonal Antibody documentation in Resident #10's record, the DON stated, It (Casirivimab/Imdevimab Monoclonal Antibodies) was not available on the 24th (of November) when we gave them. Pharmacy should have been notified that we needed it, and when it came it should have been given. Upon review of Resident #10's EMR, the DON confirmed there was no documentation showing Monoclonal Antibodies had been administered to Resident #10, although verbal consent, and a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #11 Review of the facility listing of COVID-19 positive residents beginning 11/18/21 through 11/30/21 revealed Resident #11 tested positive for COVID-19 on 11/22/21. Review of Resident #11's Nursing Progress Notes, revealed Resident #1's responsible party was contacted by telephone on 11/22/21, and wanted Resident #11 to have the Monoclonal Antibody treatment. Review of a Physician Order, signed 11/22/21 by Physician Z, authorized subcutaneous injections of Monoclonal Antibodies for Resident #11 for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #11's complete medical record found no Casirivimab/Imdevimab Administration Flow Sheet, which documented Monoclonal Antibodies had been administered to Resident #11, nor evidence of the vital sign assessment completed every 15 minutes for one hour. Review of Resident #11's Nursing Progress Notes, revealed a 11/26/21, 9:47 a.m., note that read: Note Text: Given 4 equal doses of Casirivimab and Imdevimab No side effects noted, created by the DON four days following the verbal authorization and signed physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #11's eMAR, revealed COVID-19 Standing Order medications were not administered until 11/25/21, except [MEDICATION(S)] administered on 11/24/21, and the D-dimer was not drawn until 11/27/21, when Resident #11 was identified as COVID-19 positive on 11/22/21. During a telephone interview on 12/16/21 at approximately 11:00 a.m., the DON, ADON A, and NHA were all present. When asked about the absence of the Monoclonal Antibody Flow Sheet in Resident #11's record, the DON confirmed a Monoclonal Antibody Flow sheet was not present in Resident #11's medical record, and administration of the Antibodies was not documented on Resident #11's eMAR.

Based on observation, interview, and record review, the facility failed to prevent abuse (non-consensual sexual contact) for one Resident (#52), of five residents reviewed for abuse. This deficient practice resulted in Immediate Jeopardy with the likelihood of serious physical and/or psychosocial harm for Resident #52, and the potential for serious harm for all residents within the facility. The immediate jeopardy began on 2/19/19 at approximately 1:30 a.m. when Resident #52 was observed by staff with incontinence brief off, and Resident #28's hand on Resident #52's exposed genitals. Immediate jeopardy was identified on 4/1/19 at 3:20 p.m. when the Nursing Home Administrator (NHA) was provided notification of the immediate jeopardy. The immediate jeopardy was removed on 4/1/19 at 4:47 p.m. when the facility received acceptance of, and began implementation of, an Abatement Plan for removal of the immediate jeopardy, that included: 1. All residents with a BIMS (Brief Interview for Mental Status) of 12 or higher will be assessed using the Abuse Investigation Interview Form. Any Yes answer will be thoroughly investigated and reported to the State Agency as indicated. Residents with a BIMS less than 12 will be observed for any changes in behavior or affect. 2. All residents with a history of sexual behavior will be re-evaluated and care plans updated as appropriate. 3. Staff will be immediately educated on the abuse policy. The education will continue for all staff and will be completed prior to next scheduled shift. Training to include competency evaluations. 4. All staff will be interviewed to determine if they have witnessed any abuse. Any potential allegations from these interviews will be thoroughly investigated. Noncompliance remained at a level of no actual harm with potential for more than minimal harm, until confirmation of abatement plan completion is verified. Findings include: Review of Resident #52's Minimum Data Set (MDS) assessment, dated 11/24/2018, revealed Resident #52 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #52 had severely impaired cognition and required extensive, one-person physical assistance with all activities of daily living. Following a 2/13/19 fall with pelvic fracture, Resident #52's MDS assessment, dated 2/21/19, documented extensive, two-person assistance with bed mobility, transfers, and toileting. Resident #52 was observed in a high-back wheelchair during dining on 3/25/19 at 12:03 p.m., and 3/28/19 from 12:09 p.m. to approximately 12:45 p.m. Resident #52's head was drooped forward, eyes closed, and appeared to be sleeping. She was unable to eat independently and did not engage with any other residents. Review of Resident #52's progress notes revealed the following entries: 2/19/19 01:30 (1:30 a.m.), by Registered Nurse (RN) L, The resident in room (number), (Resident Initials) was found in (Resident #52's) room trying to get into bed with her .Complete head to toe assessment was performed and was unremarkable 2/20/2019 10:51 (10:51 a.m.), by the Director of Nursing (DON), (Resident #52) has no exhibited distress from when (Resident 28) was in her room during the night on 2/19/2019 .Author: (Director of Nursing (DON)). On 4/1/19 at 12:20 a.m. RN C was interviewed, via telephone. RN C confirmed the resident getting into bed with Resident #52 was Resident #28. RN C stated, He liked to visit in different rooms .He liked the ladies . Review of Resident #28's 1/25/19 MDS assessment revealed (Resident #28) was readmitted to the facility on [DATE], had clear speech, was able to understand and be understood, and scored 13 out of 15 on the BIMS, reflective of intact cognition. Review of Resident #28's progress notes, written by RN L, included the following: 1/19/19 06:03 (6:03 a.m.), .CNA (Certified Nurse Aide)Z came out of the room upset telling this nurse that resident pulled his brief down exposing himself and offering money for sex . 2/4/19 04:50 (4:50 a.m.), This RN spoke with (Resident #28) regarding his inappropriate comments he has been making to the girl that works in laundry. She came to me tonight and told me that he said he wants her to come to his room after she is done with work and then close the door. (Resident 28) has made many inappropriate sexual comments to this staff member and many others . On 4/1/19 at 12:40 a.m. CNA A, interviewed via telephone, confirmed she found Resident #28 in Resident #52's room on 2/19/19 at approximately 1:30 a.m. CNA A stated, .(Resident #28) .had been going into different rooms . Per, CNA A, on the night of 2/19/19 facility staff were looking for (Resident #28), and CNA A assisted in checking every room in the facility. CNA A stated, I came to the last room, which was the closest one to the nurses' station. He (Resident #28) was in there with her (Resident #52's) brief off, and his hands on her private area (genitals) and he had his knee on the bed and he was about to climb onto the bed. She is unable to resist .I just walked in on that and I said Stop! The explanation that he gave was that She looked like she wanted it . I told the nurse. She had me make a report .which I did .No one (in administration) ever asked me any questions about this (incident). This was not the first time .He (Resident #28) had gone in another woman's (Resident #500's) room. He was next to her bed, with his hand on her blanket .He had been in (Resident #500's) room twice .the second time he was by the bed . On 4/1/19 at 9:40 a.m. Social Services Director/(Staff) J was asked about Social Service involvement in potential abuse, specifically involving non-consensual sexual contact with Resident #52. Staff J stated, I am aware of the one incident (on 2/19/19) .The resident was found near her bed. I believe both were clothed .I heard it from (the DON) who does the morning report. When asked if she assessed Resident #52 for psychosocial effects from the incident, Staff J stated, .I did not do an assessment with (Resident #52) because she does not make her needs known. She is unable to participate in the cognition assessment. I did see a note from the nurse (DON) saying she did not show signs of distress. I don't believe she would call out in fear (with non-consensual sexual advances). I know with the cognition assessment she may not answer at all, and may not respond appropriately, if she responds at all . When asked if other residents were interviewed for potential abuse, Staff J stated, I didn't specifically set out to interview residents that may have been affected by him (Resident #28) .He had (other) reported sexual advances toward staff .I don't know if it (non-consensual sexual contact of Resident #52) was reported to the police . When asked when non-consensual sexual contact would be reported to the police, Staff J stated, If the resident, victim, was in distress, was able to report that inappropriate contact was made, if they didn't feel safe, and especially if there was visible bodily harm. When asked if the resident had bare genitals and touching was involved, Staff J stated, I suppose that would warrant contacting the authorities . On 4/1/19 at 1:04 p.m. Staff J confirmed Resident #28 was having sexually explicit behaviors during his most recent stay at the facility beginning 1/18/2019. Staff J stated, He was having frequent sexually explicit behavior toward staff. When asked if social services was informed of any sexually inappropriate behavior by Resident #28, Staff J stated, I don't always know the specifics of each instance. When asked if she followed up on Resident #28 after incidents of inappropriate sexual behavior/contact, Staff J stated, I can't recall if I specifically met with him. His family was not notified (of the 2/19/19 incident). I did not notify them. I don't see any social services notes in here (about any sexually inappropriate behavior) . Staff J' confirmed there was documentation of inappropriate sexual behaiors during Resident #28's (YEAR) facility admission. Staff J stated, So, we are aware of it this time (at time of readmission 1/18/19). Regarding Resident #28's Care Plans, Staff J confirmed Resident 28's care plan provided to this Surveyor, was not his original care plan in, but a reconstructed version of interventions recalled by facility staff .The MDS coordinator accidentally deleted his whole care plan . On 4/1/19 at 10:35 a.m. the DON and Nursing Home Administrator (NHA) were interviewed regarding their knowledge of the non-consensual sexual contact between Resident #28 and Resident #52. The DON stated, I know that he (Resident #28) went into her (Resident #52's) room when he was confused that night (2/19/19) . When I came in the morning, it was in the 24 - hour report. Both the NHA and DON confirmed there was no report of potential abuse. The DON stated, I don't remember any incident report . When asked if the 2/19/19 incident was reported to the State Agency (SA), the DON stated, (It was) not reportable, because we did not suspect abuse. I didn't perform an investigation, because we did not suspect abuse . The DON confirmed the police were not notified. The NHA stated, I don't know anything about this (incident) .The whole protocol (abuse) should have been followed .You cannot investigate what you do not know .I would want to make sure that he hadn't touched her genitals. I would have sent her out for evaluation .We would not have touched her (completed an assessment) in house. On 4/1/19 at 1:31 p.m. an interview was conducted via telephone with RN L, who worked on Resident #28's hall on 2/19/19. RN L stated, They were moving him (Resident #28, between rooms) because they were having problems with that (inappropriate sexual behavior) .He would get up during the night. He was able to get in his wheelchair from the bed. He would go into other people's rooms, and he would creep by in his wheelchair and see if there was a woman. He had pulled his wheelchair up to her (Resident #52's) bed, and he was trying to get in bed with her . (Resident #52's) brief was down .I believe I texted (Administration) . RN L confirmed she did not notify Staff J, or the families of Resident #28 and Resident #52, regarding the incident of non-consensual sexual contact on 2/19/19. Review of several, text messages provided by RN L which were sent to the DON on Tuesday, (MONTH) 19th, at 12:50 a.m., included the following: RN L: Can u (you) call when u can. We found (Resident #28) in (Resident #52's) room with her clothes pulled down and shirt up, he was trying to get into bed with her. That's attempted sexual assault .He admitted to lifting her shirt and pulling her pants down. He said she was playing with herself so he thought she wanted him to do that and she never said not to do it .So I don't know if I need to call (the NHA) .I tried calling (the NHA) so I don't know what to do . Response texted from DON: Fill out safety check list to for (sic) documentation that you kept your eye on him all night please. RN L: Okay. On 4/1/19 at 2:50 p.m., the DON was interviewed with the NHA present. When asked again regarding notification of the non-consensual sexual contact incident on 2/19/19, the DON stated, Correct, I was not notified, by any manner, of the incident that occurred on 2/19/19. The DON was notified, by this Surveyor, that there was evidence of her being informed of the incident on 2/19/19. On 4/1/19 at 3:09 p.m., during a telephone interview, CNA T confirmed she was working the night shift on 2/19/19. CNA T stated, (CNA A) found him .with one knee on (Resident #52's) bed. He had her gown pulled up and her brief down. (CNA A) did write a report. We turned it into the charge nurse .He (Resident #28) did try to get into resident rooms all the time. We had to keep constantly watching him .He usually stayed away from the male rooms - just the female rooms. He would try to watch them (females) when they were going to the bathroom . Review of progress notes for Resident #28 following the 2/19/19 incident included: 2/20/19 08:44 (8:44 a.m.) This nurse (DON) spoke with (Resident #28) yesterday about entering (room number) . during the night this week. He said, the door was open and reports that he was confused since his room change . 2/20/19 15:00 (3:00 p.m.) Alerted by resident in room [ROOM NUMBER]A yelling Get out of that room! Observed (Resident #28) trying to enter room [ROOM NUMBER] . 2/22/19 09:25 (9:25 a.m.) (Resident #28) .entered room [ROOM NUMBER] last evening, which is inhabited by a female Review of Resident #28's Behavior Symptom Follow Up Question Report, which was initiated by Staff J on 2/18/19, included the following: 2/19/19 01:22 (1:22 a.m.) Sexually Inappropriate 2/20/19 01:08 (1:08 a.m.) Sexually Inappropriate 2/22/19 04:50 (4:50 a.m.) Sexually Inappropriate 2/23/19 01:53 (1:53 a.m.) Sexually Inappropriate 2/28/19 05:56 (5:56 a.m.) Sexually Inappropriate 3/02/19 01:32 (1:32 a.m.) Wandering Review of the facility Abuse Program policy, revised 8/2017, read, in part: The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents .Prevention: . This facility identifies, corrects, and intervenes in situations in which abuse, neglect .is more likely to occur .Identification: .Each resident has the right to be free from mistreatment .This includes the facility's identification of residents, whose personal histories render them at risk for abusing other residents, and development of interventions strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior and reassessment of the interventions on a regular basis .Protection of Residents and Staff: . Employees are required to immediately report any occurrences of potential mistreatment they observe, hear about or suspect .to a supervisor or the administrator or local police as soon as possible at the time of the occurrence .the facility shall ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment .are reported immediately but no later than 2 hours after the allegation is made if the events that caused the allegation involve abuse .The administrator or designee will report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, and take all necessary corrective actions depending on the results of the investigation .

Based on observation, interview, and record review, the facility failed to provide sterile tracheal suctioning, competent [MEDICAL CONDITION] nursing care, ensure emergency equipment in the room, and provide oxygen to meet the Resident's needs, resulting in immediate jeopardy, with the potential for serious harm, and/or death, for one Resident (#155), from one resident reviewed for [MEDICAL CONDITION] care. The immediate jeopardy began on [DATE] at 5:50 p.m., when a nursing assessment was conducted at Resident #155's admission. The immediate jeopardy was identified on [DATE] at 4:55 p.m., with notification to the Administrator (NHA) on [DATE] at 5:50 p.m. The immediate jeopardy was removed on [DATE] at 7:08 p.m., when the facility received acceptance of, and began implementation of its Abatement Plan, that included: A spare trach, with obturator was taped to the wall above the bed in Resident #155's room. The Director of Nursing (DON) was trained on [MEDICAL CONDITION], licensed nurses were educated prior to their next shift, and competencies will be performed for all nurses. Noncompliance remained at a level of no actual harm with potential for more than minimal harm, until confirmation of completion of the abatement plan, and verification of the facility process to ensure care for residents with tracheostomies has been completed. Findings include: According to the hospital discharge summary, signed on [DATE], Resident #155 was admitted to the facility on [DATE], with paralysis of lower extremities, tube feeding, refeeding syndrome, history of [MEDICAL CONDITION], and severe hypoxic (lack of oxygen to the brain) event, with head injury. Resident #155 was newly admitted to the facility and did not yet have a Minimum Data Set (MDS) assessment completed. No diagnoses were listed in the electronic medical record (EMR). Resident #155's medical record revealed a nursing assessment, dated [DATE] at 5:50 p.m., upon admission including a [MEDICAL CONDITION], PEG (percutaneous endoscopic gastrostomy) tube (for nutritional support feedings), and a central line catheter to the right jugular vein. On [DATE] at 1:33 p.m., Resident #155 was observed in bed, unresponsive to this Surveyor's introduction. The Resident was observed unable to move any extremity, or verbally communicate. The Resident did turn his head toward this Surveyor upon conversation. Eye contact was not distinct. The Resident was observed with a [MEDICAL CONDITIONS] (oxygen delivery device) with oxygen running through a concentrator at full capacity, just over 5 liters per minute (LPM). Of note, there was no spare trach, obturator (a device to assist in maintaining the airway, in the event of a dislodged [MEDICAL CONDITION]), or ambu bag (a device used to manually provide artificial breaths, and oxygen, to a non breathing person) in the room. The room was cluttered with many products, on many surfaces, but not organized in any distinguishable way. On [DATE] at 2:22 p.m., Resident #155 was observed in the bed with oxygen running through [MEDICAL CONDITION] at maximum capacity of the concentrator; just above 5 LPM. [MEDICAL CONDITION] tubing was observed to be taped together, undated, at the hose/tube junction. There was no spare trach, obturator or ambu bag in the room. On [DATE] at 4:16 p.m., Resident #155's room was observed again, with no spare trach, obturator or ambu bag in the room. A review of Resident #155's physician orders revealed no specific order for oxygen. Standing Orders, dated [DATE], for Resident #155, revealed, .May use Oxygen to maintain an oxygen saturation of 90% or greater. Nurses may use suction as needed to keep airway clear. Contact Physician if either of these measures have been taken . No contact of physician was evident in the medical record regarding oxygen use or suctioning. On [DATE] at 7:21 a.m., Resident #155 was observed to have a second oxygen concentrator in the room running a Y tubing with the first concentrator. Both concentrators were running oxygen at 5 LPM, for a total of 10 LPM. No progress note was evident in the medical record for the increased oxygen. During an interview on [DATE] at 11:06 a.m., the Assistant Director of Nursing /Registered Nurse(RN) K was asked whether Resident #155 had specific physician orders for oxygen, and responded, O2 (oxygen) is by standing orders and (the Resident's oxygen rate) was at 6.5 (LPM) this morning when I was in the room. The standing order is for sats (oxygen saturations) above 90 (percent). RN K confirmed she added the second concentrator that morning. This Surveyor went to the room at this time, and observed Resident #155's oxygen concentrators to be running at 4.25 LPM and 4.5 LPM. During an interview on [DATE] at 6:54 p.m., when asked about the expectation during an emergent situation, and the DON confirmed the expectation was there should be an extra trach, with an obturator, immediately accessible at the head of the bed. During an interview on [DATE] at 2:19 p.m., Family Member (FM) DD stated she was in to visit on [DATE] to find Resident #155 was not suctioned, but was gurgling. FM DD said a different nurse, from another hall came to suction the Resident, while showing Registered Nurse (RN) H, who was the assigned nurse, how to suction the Resident. On [DATE] at 9:36 a.m., Certified Nurse Aide (CNA) Y was observed providing care for Resident #155, when the Resident became gurgly, and struggled with sputum in the trach. CNA Y went to get RN O, who was assigned to the Resident. RN O entered the room, performed hand hygiene, then donned clean, not sterile, gloves. The Resident choked on the sputum in the trachea, while RN O tried to assemble a sterile suctioning tube, after touching the bed control, equipment on night stand, the suction machine and the intravenous (IV) pole. RN O suctioned the Resident, while still donning the contaminated gloves, extending the catheter into the trachea, with her thumb and forefinger touching and extending the sterile catheter inch by inch. RN O did not obtain any vital signs (VS), or listen to the Resident's lung sounds, before or after suctioning. RN O did not hyper ventilate or oxygenate (provide manual extra oxygen and lung expansion to support suctioning) prior to or following suctioning. On [DATE] at 11:31 a.m., RN O was observed providing suctioning care for Resident #155. RN O performed hand hygiene, then donned sterile gloves. RN O advanced the suctioning catheter through [MEDICAL CONDITION] (oxygen delivery device) opening, touching the sterile catheter tip to the [MEDICAL CONDITION], and advancing the catheter into the trachea. The catheter touched the Resident's gown. The portable suction machine was observed to be on 5 centimeters of Hg (mercury). RN O did not obtain VS prior to or following suctioning and did not listen to the Resident's lung sounds. RN O did not hyperventilate or hyperoxygenate the Resident before or after suctioning. Resident #155's medical record was absent any specific assessment data for any suctioning of the Resident. During an interview on [DATE] at 10:25 a.m., RN O stated, I was on the night (Resident #155) got admitted , but I had to stay when (Licensed Practical Nurse (LPN) FF) was here alone and doesn't have experience with IVs, tube feeds and trachs. There's a little book out there they (management) made us sign it. We had [MEDICAL CONDITION] recently. During an interview on [DATE] at 11:27 a.m., RN O said the facility put out a notebook [MEDICAL CONDITION] and other care area policies, for nurses to read and sign. RN O confirmed the notebook obtained at the nursing desk was the training packet to read and sign, starting on [DATE]. RN O's name was not on the sign-in page. Only one nurse, RN M, signed the packet. During an interview on [DATE] at 4:25 p.m., RN O was asked if she knew what type [MEDICAL CONDITION] #155 had, and stated, I guess not exactly. When asked if there was an [MEDICAL CONDITION] the room, RN O stated, Are we supposed to have one? When asked if she could change [MEDICAL CONDITION] it dislodged, RN O responded, I don't know. When asked if there was an obturator in the room, RN O asked, What? When asked if she knew what an obturator was, RN O said she thought it was something for the oxygen concentrator. RN O stated, I don't know right this minute. I didn't really realize that an extra should be taped to the wall. During an interview on [DATE] at 4:52 p.m., LPN EE was asked about the care of someone with a trach, and responded, Yes, I know how to take care of trachs. When asked what kind [MEDICAL CONDITION] #155 had, LPN EE stated, I think he just has the normal one with inner cannula. When asked how [MEDICAL CONDITION] be cared for LPN EE stated, Depending on what the doctor ordered. When asked what should happen if the Resident'[MEDICAL CONDITION], LPN EE stated, Clean him up and stick a new one in. They should have at least one set of supplies in his room. When asked where the supplies would be found, LPN EE stated, Either in a dresser drawer or on the table. When asked what the obturator is used for, LPN EE stated, Well, your guess is as good as mine. I haven't heard that term before. When asked about how the inner cannula would be replaced, LPN EE stated, I know the angle is like this (LPN EE gestured a sideways hooking action, that would most likely scrape the trachea). Usually the people can take care of it themselves. When asked about the suctioning procedure, LPN EE stated the procedure is a Clean procedure, as opposed to sterile. LPN EE had not signed the training notebook. During an interview on [DATE] at 7:30 am., RN H was asked if she received any training on caring for a resident with a trach, and responded, I didn't have it initially, but I got it (training) today. On [DATE] at 7:36 a.m., this Surveyor entered Resident #155's room to find the room empty of equipment, bedding, and Resident #155 was not in the room. A progress note, dated [DATE] at 4:42 a.m., and authored by RN C, revealed, .observed resident to be in [MEDICAL CONDITION] with no vital signs, immediately began performing CPR (cardiopulmonary resuscitation) .time of death at (2:50 a.m.) . During an interview on [DATE] at 12:04 p.m., the DON was asked if a resident with a [MEDICAL CONDITION] should have specific orders for oxygen needs, rather than use standing orders, and responded, Yes, I would expect that. The DON, at this time, confirmed the ambu bag on the crash cart was replaced. An attempt was made to contact RN C on [DATE] at 7:31 a.m., without success. Resident #155's care plan revealed, .has a [MEDICAL CONDITION] (related to) head injury, recent resp(iratory)/[MEDICAL CONDITION] Date Initiated: [DATE] . Monitor/document for restlessness, agitation, confusion, increased heart rate XXX[DATE] . [MEDICAL CONDITION] per policy twice daily . date initiated: [DATE] .Suction as necessary. Date Initiated: [DATE] . The policy [MEDICAL CONDITION] Care, Revised (MONTH) 2013, revealed, .A replacement [MEDICAL CONDITION] must be available at the bedside at all times .A suction machine, supply of suction catheters, exam and sterile gloves, and flush solution, must be available at the bedside at all times . The following information should be recorded in the resident's medical record: The date and time that the procedure was performed . The type and size of catheter used Amount of negative pressure used to suction . Amount, color and characteristics of secretions . The resident's response to the procedure . The policy Suctioning the Lower Airway (Endotracheal ET) or [MEDICAL CONDITION]), Revised (MONTH) 2010, revealed, .The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract .Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for suctioning .Review the resident's care plan to assess for any special needs .Obtain baseline vital signs and oxygen saturation from the resident's medical record .Obtain information about the resident's medical history, including date of intubation .respiratory signs and symptoms, and risk factors .Test equipment before use .Portable suction devices should have negative pressure set at ,[DATE] mmHg (millimeters mercury)(equivalent to ,[DATE].5 centimeters mercury) .Complications of suctioning the lower airway include trauma to the airway, infection, [MEDICAL CONDITION] (lack of oxygen), hypoxemia (lack of oxygen in blood), (heart irregularities). To minimize the risk of complications, apply the following guidelines: .Suction only as needed, based on assessment of the resident's level of respiratory distress .Use sterile equipment to avoid widespread [MEDICAL CONDITION] and systemic infection )Note: Suctioning of the lower airway is a sterile procedure. All equipment that comes in contact with the lower airway must be sterile.) .Hyperinflate the resident with a manual resuscitation (Ambu) bag, before and after suctioning; and Hyperoxygenate the resident by increasing the oxygen flow (as ordered) before the procedure and between suctioning .Monitor pulse and oxygen saturation during suctioning .Identify the following risk factors for impaired airway clearance or aspiration: Impaired cough of gag reflex .Dysphagia .Weak respiratory muscles .Presence of feeding tube .decreased level of consciousness .Diminished breath sounds, Dyspnea, Gurgling, crackling or wheezing upon inspiration .Decreased oxygen saturation .Restlessness .Drooling, secretions .Procedure .Turn on suction unit an adjust to appropriate negative pressure .Remove gloves .apply sterile gloves .Remove oxygen deliver device (trach collar) using non-dominant hand .Hyperinflate and hyperoxygenate the resident using an Ambu bag connected to supplemental oxygen .Limit suction time to no more than 10 seconds .assess cardiopulmonary status .replace oxygen delivery device .Assess the resident .Documentation .date and time .type and size of catheter used .amount of negative pressure used .Amount, color and characteristics of secretions .resident's response .Cardio-pulmonary status, including lung sounds, during the procedure .

Based on interview and record review, the facility failed to provide diabetic care and management to maintain well-being for one Resident (#202) out of four residents reviewed for diabetic medication administration, out of a total sample of six residents. This deficient practice resulted in Resident #202 experiencing severe [DIAGNOSES REDACTED] (low blood glucose (BG)), loss of consciousness, and a fall resulting in a sprained wrist requiring medical attention and increased pain medication. Findings include: Review of the Minimum Data Set (MDS) assessment revealed Resident #202 is [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #202's Brief Interview of Mental Status (BIMS) revealed a scored of 12/15, indicating moderate cognitive impairment. Resident #202 was ambulatory, able to perform most activities of daily living with setup and supervision only. Resident #202's medical care was being overseen by Physician A, the facility Medical Director, and Family Nurse Practitioner (FNP) B. Record review of the 'SBAR (Situation, Background, Assessment, and Request) Communication Form' dated 8/14/15, revealed a med (medication) error. Nursing notes documented, Resident's (#202) Orders (basal insulin) 18 units, increase by 1 unit each dose daily until FBG (fasting blood glucose) less than or equal to 130 (milligrams/deciliter, mg/dl). Resident #202 received the following basal insulin doses: 8/11/15 19 units, 8/12/15 20 units, 8/13/15 21 units, 8/14/15 22 units. He (Resident #202) was under guideline (FBG less than or equal to 130 mg/dl) already on these dates. MAR (Medication Administration Record) orders not followed correctly. Assistant Director of Nursing notified at 0048 (12:48 a.m.) 8/15/15. Resident is being monitored and vital signs taken for 3 days . The 'SBAR Communication Form' revealed that Physician A was notified on 8/15/15 at 0700 (7:00 a.m.) of the medication error: continued increase of basal insulin despite FBG goal being met. Record review of the 'SBAR Communication Form' dated 8/24/15, revealed Resident #202 had a .fall caused by low blood sugar . Resident #202 was .found on floor in bathroom. Res (Resident #202) very sweaty, clammy appearing, unable to sit up without assistance. Shaky. (Blood Sugar) was 33 (mg/dl) at 0955 (9:55 a.m.), rechecked at 1010 (10:10 a.m.) was 57, then 61 at 1020 (10:20 a.m.). Res (#202) told CNA that R (right) wrist hurt. Nurse observed wrist, bruise appearing and res stated he twisted it. This 'SBAR Communication Form' revealed that Physician A was notified of the [DIAGNOSES REDACTED] and fall on 8/24/15 at 1055 (10:55 a.m.). Resident #202 was transferred to a hospital for x-rays which revealed a sprained wrist. A review of the Pain Flow Sheet dated 8/26/15 through 8/30/15, showed Resident #202 had vocal complaints of aching pain with pain intensity between 6 to 10 (on a scale of 1 to 10, with 10 being highest pain level) requiring administration of narcotic [MEDICATION NAME] (pain medication) three times on 8/26/15, once on 8/28/15 and once on 8/30/15. Review of the 'SBAR Communication Form' dated 8/27/15 (for time period 8/25/15 through 8/27/15), revealed a .med(ication) error . that caused .increased confusion, weakness or [MEDICAL CONDITION], and decreased mobility . for (Resident #202). 'SBAR Nursing Notes' explained the error: .8/27/15 1230 (12:30 p.m.) Res (#202) with low bg (blood glucose) at 1100 (11:00 a.m.). BG 40 up to 127 (mg/dl). Upon review of resident insulin orders: found that (fast acting insulin) should have been decreased to 3 units from 5 units with breakfast and lunch. Dinner dose should have been decreased to 5 units from 6 units. (Basal insulin) should have been changed to 15 units at 1700 (5:00 p.m.). (Basal insulin) 8 units in AM and 5 units in PM were not d/c'd (discontinued) . Review of a 'Medication Incident' completed by the Director of Nursing (DON) dated 8/26/15 for incidents between 8/25/15 and 8/27/15, revealed the following explanation: .(fast acting insulin) order did not get transcribed; (long acting insulin) order transcribed, old order was not dc' d (discontinued). Review of '(Facility Name) Health Care Employee Corrective Action Form' dated 9/1/15, revealed a 1st Written Warning for Licensed Practice Nurse (LPN) D with 'Description of Violation' as following: Four med errors/near misses within the last month and failure to follow proper procedure for new orders and red lining (double checking of physician orders). During an interview on 9/9/15 at 2:45 p.m., when asked about the diabetic management for Resident #202, Registered Dietitian (RD)/Certified Diabetes Educator (CDE) L stated, .I recommended to change (basal insulin) to once a day, (Physician A) went along with it, (and) now it is twice a day . my recommendations need to get to (Physician A) in an understandable fashion (I believe there is a) lack of understanding . that is not how you manage diabetics . A review of Physician order [REDACTED]. Recommendations/requests for insulin adjustments were made by RD/CDE L on 7/20/15 and by nursing staff on 8/10/15 and 8/14/15. Insulin medication orders were written by FNP B on 8/10/15 and 8/14/15. There was no evidence of communication between facility staff and FNP B/Physician A regarding the 18 units basal dose of insulin originally ordered for 1700 (5:00 p.m.), resulting in the continuation of the long-acting basal insulin dose from 8/11/15 - 8/25/15. In addition, on the following dates Resident #202 received injections of 8 units long-acting and 5 units fast-acting insulin, despite BG readings indicative of [DIAGNOSES REDACTED]: 8/13/15, 8/14/15, 8/15/15, 8/18/15, 8/23/15, and 8/27/15. During an interview and review of the August 2015 MAR indicated [REDACTED]. Specific to insulin administered to Resident #202 on 8/24/15 (day of fall), it was confirmed Resident #202 received: at 0600 (6:00 a.m.) - 8 unit dose of basal insulin, at 1700 (5:00 p.m.) - 18 unit dose of basal insulin, at bedtime (8:00 p.m.) - 5 unit dose of basal insulin, and scheduled fast acting insulin at each meal. During interviews on 9/9/15 at 4:10 p.m. with the Director of Nursing (DON), on 9/10/15 at 1:45 p.m. by telephone with Physician A, and 9/11/15 at 9:25 a.m. with FNP B, when asked if they were aware Resident #202 was being administered three doses of basal insulin for at least 11 days, including the day of Resident #202's fall on 8/24/15, the DON, Physician A and FNP B all responded that they .were not aware . of three daily basal insulin doses. When Physician A was asked if the increased basal insulin could have resulted in severe [DIAGNOSES REDACTED] leading to Resident #202's fall, Physician A replied, .It certainly could .giving him more insulin is more likely to lower it (blood glucose) and that could lead to a fall . When the same question was asked of FNP B, she replied, .Yes, it could have had an influence on it .insulin lowers blood sugar . The DON responded to the same question, .That is a substantial amount of extra insulin that could have contributed to his fall . ( ) --

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY SUPERVISE ONE (#1) COGNITIVELY IMPAIRED RESIDENT OF NINE RESIDENTS IDENTIFIED FOR ELOPEMENT RISKS FROM THE TOTAL FACILITY POPULATION OF FIFTY-SEVEN RESIDENTS. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 LEAVING THE FACILITY USING A WHEELED WALKER AND LEAVING THROUGH AN ALARMED FRONT DOOR, WITH STAFF NOT RESPONDING TO THE ALARMING DOOR FOR AT LEAST TWO MINUTES. RESIDENT #1 PROCEEDED TO CROSS WILLOW STREET AND WAS FOUND BY STAFF WALKING DOWN POPLAR STREET, A BUSY RESIDENTIAL STREET, PLACING HER IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 5/14/12 AT 3:01 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 5/10/12 AT APPROXIMATELY 5 P.M. WHEN RESIDENT #1, A COGNITIVELY IMPAIRED RESIDENT WHO HAD BEEN ASSESSED TO BE AT RISK FOR ELOPEMENT, EFFECTIVELY LEFT THE FACILITY THROUGH AN ALARMING FRONT DOOR, BUT THE ALARMING DOOR WAS NOT IMMEDIATELY ATTENDED TO DUE TO SOME STAFF ASSISTING OTHER RESIDENTS AND OTHER STAFF NOT HEARING THE ALARM. AT LEAST TWO MINUTES AFTER THE DOOR ALARM BEGAN SOUNDING, CERTIFIED NURSE AIDE (CNA) "A" WENT OUT THE FRONT DOOR AND SAW RESIDENT #1 AMBULATING DOWN THE ROAD, USING HER WHEELED WALKER. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 5/14/12 AT 4 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON 5/15/12 AT 10 A.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - A FRONT DOOR "SUPERVISOR PROGRAM" WAS PUT IN PLACE TO ENSURE THE FRONT DOOR AREA IS UNDER STAFF SUPERVISION TWENTY-FOUR HOURS EACH DAY, UNTIL THE FACILITY HAS IMPROVED THEIR "CODE ALERT" SYSTEM. OBSERVATIONS OF STAFF SEATED IN VIEW OF THE FRONT DOOR OCCURRED ON 5/14/12 AT 4:30 P.M. AND 5 P.M. AND AGAIN ON 5/15/12 AT 7 A.M., 9:30 A.M. AND 12:15 P.M. - THE NINE RESIDENTS IDENTIFIED AS ELOPEMENT RISKS WERE REASSESSED AND THEIR WANDERGUARD BRACELETS CHECKED TO ENSURE THEY WERE IN WORKING ORDER. THE NINE 5/14/12 RESIDENT ELOPEMENT ASSESSMENTS WERE REVIEWED ON 5/16/12. - RESIDENT #1 WAS REASSESSED REGARDING ACTIVITIES. IT WAS DETERMINED SHE WOULD BENEFIT FROM A MORE STRUCTURED ACTIVITY PLAN OF CARE. RESIDENT #1'S ACTIVITY PLAN OF CARE WAS UPDATED TO INCLUDE A DAILY CALENDAR SPECIFIC TO HER, GIVING HER DUTIES AND FUNCTIONAL TASKS SHE WOULD FIND ENJOYABLE. ACTIVITY STAFF WILL MEET WITH RESIDENT #1 DAILY TO REVIEW THE CALENDAR AND MAKE CHANGES BASED ON RESIDENT #1'S CHOICES. RESIDENT #1'S UPDATED ACTIVITY CARE PLAN WAS REVIEWED. RESIDENT #1 WAS OBSERVED IN THE ACTIVITY ROOM ON 5/14/12 AT 10 A.M., 10:59 A.M. AND 3:15 P.M. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM TO THE NINE ELOPEMENT RISK RESIDENTS (#1, #2, #3, #4, #5, #6, #7, #8 AND #9). THE DEFICIENT PRACTICE WILL CONTINUE, PENDING VERIFICATION BY THE STATE AGENCY OF THE FOLLOWING ACTIONS NEEDED TO BE MADE BY THE FACILITY: - IMPROVEMENT OF THE "CODE ALERT" SYSTEM TO INCREASE IT'S SENSITIVITY TO ALERT STAFF BY ALARMING EARLIER, WITH THE RESIDENT CODE ALERT TRANSPONDER (WANDERGUARD BRACELET) TRIGGERING THE DOOR ALARM SYSTEM WHEN THE RESIDENT COMES WITHIN FOUR FEET OF THE EXIT DOOR, INSTEAD OF ALARMING AS THE RESIDENT PASSES THROUGH THE DOOR. - IMPROVEMENT OF THE CODE ALERT SYSTEM BY ADDING ADDITIONAL SOUNDING DEVICES IN OTHER LOCATIONS OF THE FACILITY TO ALLOW ALL STAFF TO HEAR THE CODE ALERT SYSTEM EVEN WHEN THEY ARE IN THE DINING ROOM OR THE STAFF BREAK ROOM. - TO ASSESS ALL RESIDENTS TO DETERMINE IF THEY HAVE BEEN EVALUATED FOR POTENTIAL ELOPEMENT RISKS. - MONITOR THE FACILITY'S IMPROVED CODE ALERT SYSTEM AND ELOPEMENT PREVENTION PROCEDURE. - TRAIN ALL STAFF IN THE IMPROVED CODE ALERT SYSTEM AND ELOPEMENT PREVENTION PROCEDURE. FINDINGS INCLUDE: THE FACILITY'S 5/11/12 "INCIDENT & ACCIDENT REPORT" SHOWED ON 5/10/12 AT 5 P.M., RESIDENT #1 WAS FOUND BY CERTIFIED NURSE AIDE (CNA) "A" ON THE (STREET) CORNER AFTER HEARING THE DOOR ALARM AT THE FACILITY'S MAIN ENTRANCE. THE REPORT DOCUMENTED "RESIDENT ALREADY WITH CODE ALERT (WANDERGUARD) ON - SYSTEM WAS IN PLACE TO ALERT STAFF AND RESPONDED AND RETURNED HER BACK INSIDE THE FACILITY..." RESIDENT #1'S CLINICAL CHART FACE SHEET SHOWED SHE WAS admitted INto the facility on [DATE] AND IS [AGE] years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

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO ADEQUATELY ASSESS AND MONITOR THE HYDRATION STATUS FOR ONE HIGH RISK RESIDENT (#1) OUT OF FIVE RESIDENTS REVIEWED FOR HYDRATION FROM A TOTAL POPULATION OF 52 RESIDENTS. RESIDENT #1 WAS DEPENDENT ON STAFF TO OBTAIN FLUIDS AND WAS KNOWN BY THE FACILITY TO HAVE DIFFICULTY SWALLOWING ALONG WITH AN ACTIVE GASTRO-INTESTINAL INFECTION AND DIARRHEA. THIS FAILURE RESULTED IN RESIDENT #1 DEVELOPING ACUTE DEHYDRATION AND LATER hospitalized for [REDACTED]. FINDINGS INCLUDE: THE IMMEDIATE JEOPARDY BEGAN ON 1/24/12 WHEN THE FACILITY FAILED TO ADEQUATELY MONITOR AND ENSURE RESIDENT #1 WAS RECEIVING THE ESTIMATED FLUID REQUIREMENTS AS DETERMINED BY THE DIETARY MANAGER AND SUBSEQUENTLY WAS diagnosed with [REDACTED]. THE FACILITY FAILED TO EFFECTIVELY MONITOR AND TAKE ACTION TO ENSURE ADEQUATE HYDRATION FOR RESIDENT #1 CONTINUED AFTER INTRAVENOUS THERAPY WAS DISCONTINUED ON 1/27/12, RESULTING IN A DETERIORATION OF RESIDENT #1'S LEVEL OF CONSCIOUSNESS AND SUBSEQUENT DISCHARGE TO emergency room SERVICES ON 2/01/12 WHERE SHE WAS diagnosed with [REDACTED]. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 3/07/12 AT 5:00 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/08/12 AT 9:00 A.M., AFTER THIS SURVEYOR CONFIRMED BY INTERVIEW AND RECORD REVIEW THAT THE FACILITY HAD IMPLEMENTED THE FOLLOWING ACTIONS: 1. ALL RESIDENTS WITHIN THE FACILITY WILL BE AUDITED (ASSESSED) FOR CLINICAL SIGNS AND SYMPTOMS OF NOT MEETING FLUID REQUIREMENTS. AN AUDIT OF LABORATORY RESULTS FOR RESIDENTS ON I & O (INTAKE AND OUTPUT) TO BE DONE WITH NOTIFICATION TO THE MD (MEDICAL DOCTOR) OF ANY ABNORMALITIES. CARE PLANS SHALL BE REVISED AS NEEDED TO ENSURE ADEQUATE FLUIDS ARE OFFERED/AVAILABLE FOR THOSE RESIDENTS WITH INADEQUATE FLUID INTAKE. 2. ALL NURSING STAFF TO BE EDUCATED REGARDING HOLES (BLANKS) IN THE INTAKE AND OUTPUT DOCUMENTATION. NURSING STAFF EDUCATED ON TOTALING I & O'S AND REVIEWING/EVALUATING THE VOLUME AGAINST THE RD (REGISTERED DIETICIAN) DAILY FLUID REQUIREMENTS. ALL NURSING STAFF TO BE EDUCATED ON POLICY TO FOLLOW WHEN VOLUME IS OUTSIDE THE REQUIRED PARAMETERS. ALL NURSING STAFF TO BE EDUCATED ON HYDRATION POLICY AND DEHYDRATION PREVENTION PROTOCOL AND THE CLINICAL SIGNS AND SYMPTOMS OF DEHYDRATION. EDUCATION TO BE COMPLETED PRIOR TO OR DURING THE NURSES NEXT SCHEDULED SHIFT. 3. AN AUDITING OF I & O DOCUMENTATION FORMS AND OF MD NOTIFICATION WHEN FAILURE TO MEET THE RESIDENTS' DAILY FLUID REQUIREMENTS IS NOTED WILL BE DONE DAILY BY THE CHARGE NURSE. DON (DIRECTOR OF NURSING) (OR DESIGNATED UNIT MANAGER IF UNAVAILABLE) WILL AUDIT THE CHARGE NURSE'S AUDITS MONDAY THROUGH FRIDAY FOR 3 WEEKS, THEN WEEKLY FOR 3 MONTHS TO ENSURE COMPLIANCE. THIS INFORMATION WILL BE BROUGHT TO MONTHLY RMQI (RISK MANAGEMENT QUALITY IMPROVEMENT) COMMITTEE FOR REVIEW. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED ON 3/8/12, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT AN ISOLATED LEVEL WITH POTENTIAL FOR MORE THAN MINIMAL HARM PENDING THE FACILITY'S ABILITY TO: 1. COMPLETION OF HYDRATION ASSESSMENTS OF ALL RESIDENTS IN THE FACILITY ACCORDING TO FACILITY'S HYDRATION STATUS IDENTIFICATION POLICY WITH IMPLEMENTATION OF THE FACILITY'S HYDRATION STATUS - MANAGEMENT/IMPROVEMENT PROTOCOL IF APPLICABLE. 2. DEMONSTRATE THAT ANY RESIDENT NEEDING ASSISTANCE WITH OBTAINING ADEQUATE HYDRATION WILL BE PROTECTED FROM DEHYDRATION. 3. SUSTAINED COMPLIANCE AS VERIFIED BY THE STATE AGENCY. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S CLINICAL RECORD OCCURRED DURING AN ABBREVIATED SURVEY AT THE FACILITY FROM 3/06/12 THROUGH 3/08/12. ACCORDING TO THE FACE SHEET, RESIDENT #1 IS AN [AGE] year-old WOMAN, admitted to the facility on [DATE] AND discharged TO THE emergency roiagnom on [DATE]. RESIDENT #1'S ADMITTING [DIAGNOSES REDACTED]. RESIDENT #1'S BASELINE VITAL SIGNS RECORDED WHILE AT HOSPITAL PRIOR TO ADMISSION TO THE FACILITY ARE BLOOD PRESSURE OF 108/50, HEART RATE OF 64, AND TEMPERATURE OF 98.5. ACCORDING TO THE ADMISSION MINIMUM DATA ASSESSMENT ((MDS) dated [DATE], RESIDENT #1 NEEDED EXTENSIVE ONE PERSON PHYSICAL ASSIST FOR TRANSFERS, DRESSING AND EATING. SHE WAS TOTALLY DEPENDENT UPON ONE STAFF MEMBER FOR HYGIENE NEEDS. RESIDENT #1 WAS discharged TO A HOSPITAL VIA EMERGENCY SERVICES ON 2/1/12 AND CURRENTLY RESIDES AT ANOTHER LONG TERM CARE FACILITY. A REVIEW OF A POLICY TITLED "HYDRATION - INTAKE AND OUTPUT MONITORING, 3G-13" LOCATED IN A "CLINICAL PROGRAMS MANUAL" WITH A REVISED DATE OF 08/10 READS; "FLUID INTAKE AND OUTPUT MONITORING MAY BE INITIATED BY THE INTERDISCIPLINARY TEAM AND/OR MD. INTAKE AND OUTPUT MAY BE MONITORED FOR RESIDENTS/PATIENTS AT RISK FOR FLUID DEFICIT. CONDITIONS THAT MAY PLACE RESIDENT/PATIENT AT RISK FOR FLUID DEFICIT INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: DIARRHEA, NON-FEBRILE INFECTION. CONDITIONS THAT MAY REQUIRE INTAKE MONITORING AND DOCUMENTATION EVERY SHIFT INCLUDE, BUT ARE NOT LIMITED TO, THE FOLLOWING: ...FLUID MANAGEMENT... AS INDICATED BY CLINICAL CONDITION..." THIS POLICY ALSO DOCUMENTS THE FOLLOWING PROCEDURE FOR THE CARE PROVIDERS TO FOLLOW; "...IDENTIFY THE RESIDENTS/PATIENTS AT RISK FOR FLUID DEFICIT... COMMUNICATE TO THE CAREGIVING TEAM AND PROVIDE EDUCATION AS NEEDED. INITIATE THE APPROPRIATE DOCUMENTATION. RECORD ALL FLUIDS CONSUMED DURING THE 24-HOUR PERIOD FOR THE IDENTIFIED RESIDENTS/PATIENTS... EVALUATE RESIDENT/PATIENT INTAKE/OUTPUT DURING THE CARE MANAGEMENT MEETING..." A REVIEW OF A DOCUMENT TITLED "NUTRITION DATA COLLECTION TOOL" DATED 12/05/11 REVEALED RESIDENT #1'S ESTIMATED DAILY FLUID NEEDS TO BE "2295 CC" (CUBIC CENTIMETERS). AN INTERVIEW WITH THE DIETARY MANAGER (STAFF "A") WAS CONDUCTED ON 3/06/12 AT APPROXIMATELY 1:10 P.M. STAFF "A" WAS ASKED IF SHE CALCULATED THE ESTIMATED FLUID NEEDS FOR RESIDENT #1 AND SHE REPLIED "YES." STAFF "A" WAS THEN ASKED IF THERE WAS ANY REASON WHY RESIDENT #1 COULD NOT HAVE THE 2295 CC/DAY OR IF THERE WERE ANY RESTRICTIONS. STAFF "A" REPLIED, "THE ONLY RESTRICTION IS THE FLUIDS NEED TO BE THICKENED AND STAFF NEEDED TO HELP HER." A REVIEW OF A DOCUMENT IN RESIDENT #1'S MEDICAL RECORD TITLED "PLAN OF CARE: NUTRITION/HYDRATION MANAGEMENT", DATED 12/06/11, READS; "GOAL: DECREASE THE RISK OF DEHYDRATION" THIS PLAN OF CARE DOES NOT IDENTIFY THE ESTIMATED DAILY FLUID NEED FOR RESIDENT #1 NOR DOES IT DIRECT CARE PROVIDERS TO RECORD THE FLUID INTAKE FOR RESIDENT #1. THE INTAKE AND OUTPUT RECORDS DATED 12/6/11 THROUGH 1/2/12 HAVE 82 SHIFTS/OPPORTUNITIES FOR FACILITY STAFF TO RECORD RESIDENT #1'S FLUID INTAKE. OF THESE 82 SHIFTS, 33 SHIFTS HAVE NO DOCUMENTATION OF ANY FLUID INTAKE. THE RECORD FOR THESE SHIFTS ARE BLANK. ONLY TWO OF THE ENTIRE 28 DAYS HAVE A TOTAL 24 HOUR FLUID INTAKE DOCUMENTED. OF WHAT IS RECORDED, THE TOTAL 24 HOUR INTAKE RANGES BETWEEN 100 CC AND 1590 CC OF FLUID INTAKE FOR RESIDENT #1. RESIDENT #1'S ESTIMATED DAILY FLUID NEED WAS CALCULATED BY THE FACILITY TO BE 2295 CC. THE FACILITY PROVIDED NO INTAKE AND OUTPUT RECORDS BETWEEN THE DATES OF 1/3/12 THROUGH 1/18/12 FOR RESIDENT #1. A REVIEW OF A FORM TITLED "CARE MANAGEMENT SUMMARY" DATED 1/19/12 INVOLVING RESIDENT #1 READS IN PART; "REASON FOR MEETING ...LETHARGY, [MEDICAL CONDITION], CARE PLAN FOCUS/ NUTRITION/ HYDRATION... MAINTAINING... CARE PLAN FOCUS/ INCONTINENCE PREVENTION/ MANAGEMENT... STILL HAVING LOOSE STOOL..." THIS SUMMARY DOES NOT REFLECT ANY INDICATION THAT RESIDENT #1'S LACK OF SUFFICIENT FLUID INTAKE WAS REVIEWED OR DISCUSSED AS DIRECTED IN THE FACILITY'S "HYDRATION - INTAKE AND OUTPUT MONITORING" POLICY. THIS DOCUMENT HAS THE SIGNATURE OF THE DIRECTOR OF NURSING AS THE PERSON COMPLETING THE SUMMARY. ADDITIONALLY, ON 1/19/12 AT 11:45 A.M., A "CHANGE IN CONDITION EVALUATION" FOR RESIDENT #1 WAS INITIATED. THIS FORM READS IN PART; "...LEVEL OF CONSCIOUSNESS - LETHARGIC... MUCUS MEMBRANES - ORAL ...TONGUE WITH DRYNESS... CHANGE IN ADLS (ACTIVITIES DAILY LIVING)... YES, INCREASED DIFFICULTY..." A REVIEW OF A DOCUMENT TITLED "PHYSICIAN FAX FORM" DATED 1/23/12 WITH RESIDENT #1'S NAME RECORDED ON IT READS, "...INCONTINENT OF LARGE LOOSE STOOL. BLOOD OBSERVED IN STOOL... B/P -120/59, PULSE -100... T-97.6..." THE PHYSICIAN ORDERS [REDACTED]. A REVIEW OF THE INTAKE-OUTPUT RECORD FOR RESIDENT #1 REVEALS THE FACILITY FAILED TO MONITOR URINE OUTPUT AS DIRECTED BY THE PHYSICIAN: 1/24/12 - 7-3 SHIFT; HNV (HAS NOT VOIDED) 3-11 SHIFT; INC X 1 (INCONTINENT ONE TIME) 11-7 SHIFT; INC X 2 (INCONTINENT TWICE) 1/25/12 - 7-3 SHIFT; HNV, 150 CC STRAIGHT CATH 3-11 SHIFT; INC X 1, 20 CC STRAIGHT CATH 11-7 SHIFT; INC X 2 1/26/12 - 7-3 SHIFT; FORM IS BLANK, THERE IS NO OUTPUT RECORDED 3-11 SHIFT; INC X 1 11-7 SHIFT; FORM IS BLANK, THERE IS NO OUTPUT RECORDED 1/27/12 - 7-3 SHIFT; FORM IS BLANK, THERE IS NO OUTPUT RECORDED 3-11 SHIFT; INC X 1 11-7 SHIFT; FORM IS BLANK, THERE IS NO OUTPUT RECORDED A "RESIDENT PROGRESS NOTE" DATED 1/24/12 AT 12:30 P.M. READS; "PT (PATIENT) WITH INCREASED WEAKNESS TODAY - INTOLERABLE DIARRHEA AFTER RECENT TX (TREATMENT) OF UTI (URINARY TRACT INFECTION) [MEDICATION NAME](ANTIBIOTIC) -- PT WITH HX (HISTORY) OF C.DIFF [MEDICAL CONDITION] (HOSPITAL NAME)... AWAKE BUT SLEEPY - C/O (COMPLAINED OF) BEING DRY... INCREASED FATIGUE-WEAKNESS LETHARGY... INCREASED (3 ARROWS DRAWN UPWARD) DIARRHEA - DEHYDRATION... C.DIFFICILE [MEDICAL CONDITIONS] REWRITE OF ALL ORDERS -START IV (INTRAVENOUS) FLUIDS... CLOSE MONITORING, SPOKE WITH HUSBAND ABOUT PATIENT..." THIS PROGRESS NOTE IS SIGNED BY PHYSICIAN #1. A REVIEW OF PHYSICIAN ORDERS [REDACTED].M., READS IN PART; "...DX (DIAGNOSIS) ACUTE DEHYDRATION & C.DIFF [MEDICAL CONDITION] IV D5LR ([MEDICATION NAME] 5% [MEDICATION NAME] RINGERS) AT 100 ML/HOUR (MILLILITERS/HOUR) - GIVE 500 ML [MEDICATION NAME]" RESIDENT #1 WAS AGAIN SEEN BY PHYSICIAN #1 ON 1/31/12. THE physician progress notes [REDACTED]. STILL APPEARS DRY & VERY SLEEPY... ANTIBIOTIC INDUCED DIARRHEA... LETHARGY... PLAN: OBSERVE... FORCE FLUIDS..." A REVIEW OF PHYSICIAN ORDERS [REDACTED].M., READ; "OFFER PO (ORAL) FLUIDS EVERY 2 HOURS... KEEP RUNNING FLOW SHEET IN ROOM..." THE INTAKE AND OUTPUT RECORDS DATED 1/19/12 THROUGH 2/1/12 HAS 40 SHIFTS/ OPPORTUNITIES FOR THE FACILITY STAFF TO RECORD RESIDENT #1'S ORAL FLUID INTAKE. OF THESE 40 SHIFTS, 7 SHIFTS HAVE NO DOCUMENTATION OF ANY FLUID INTAKE. THE RECORD FOR THESE SHIFTS ARE BLANK. FURTHERMORE, ONLY ONE OF THE ENTIRE 14 DAYS HAS A TOTAL 24 HOUR ORAL FLUID INTAKE DOCUMENTED. OF WHAT IS RECORDED, THE TOTAL 24 HOUR ORAL INTAKE RANGES BETWEEN 480 CC AND 1940 CC OF FLUID INTAKE FOR RESIDENT #1. BETWEEN THE DATES OF 1/24/12 AND 1/27/12, RESIDENT #1 RECEIVED INTRAVENOUS FLUIDS. DURING THIS TIME PERIOD, RESIDENT #1 DID RECEIVE THE ESTIMATED REQUIRED FLUID INTAKE. HOWEVER, AFTER THE INTRAVENOUS THERAPY WAS DISCONTINUED ON 1/27/12, THE FACILITY FAILED TO ADEQUATELY MONITOR RESIDENT #1'S ORAL FLUID INTAKE TO ENSURE HER ESTIMATED DAILY FLUID NEEDS WERE MET. THE FACILITY FAILED TO MONITOR RESIDENT #1'S TOTAL FLUID INTAKE EVEN AFTER SHE WAS diagnosed with [REDACTED]. A DOCUMENT TITLED "ADDITIONAL ADL INFORMATION" REFLECTING THE MONTH OF JANUARY 2012 REVEALS THE NUMBER OF INCONTINENT (BOWEL) EPISODES AND THE CONSISTENCY (SOFT, HARD, LOOSE) OF STOOLS RESIDENT #1 HAD FROM THE 1ST THROUGH 31ST DAY. DAY NUMBER 2, 10, 11 AND 24 SHOWED RESIDENT #1 HAD 8, 9, 8, 10 LOOSE STOOLS RESPECTIVELY. A TELEPHONE INTERVIEW WITH PHYSICIAN #1 WAS CONDUCTED ON 3/07/12 AT 9:50 A.M. PHYSICIAN #1 STATED RESIDENT #1 WAS TREATED AT (HOSPITAL NAME) WITH DIARRHEA. HE INDICATED HE KNEW ABOUT RESIDENT #1'S DIARRHEA BUT DID NOT REALIZE THE EXTENT/SEVERITY OF IT. WHEN PHYSICIAN #1 WAS ASKED HOW HE DETERMINED THE [DIAGNOSES REDACTED]." AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "C" ON 3/07/12 AT APPROXIMATELY 12:00 P.M. RN "C" WAS SHOWN THE HYDRATION POLICY AND WAS ASKED IF SHE WAS FAMILIAR WITH IT. RN "C" STATED "I KNOW WHERE IT'S LOCATED... NO I'VE NEVER LOOKED AT IT... I NEVER KNEW THERE WAS AN ESTIMATED FLUID INTAKE RECOMMENDATION FOR A RESIDENT'S HYDRATION NEEDS EITHER." WHEN RN "C" WAS ASKED ABOUT THE I & O RECORDS AND WHO IS RESPONSIBLE FOR TOTALING DAILY FLUID INTAKE, RN "C" REPLIED, "THE LAST SHIFT TO RECORD I & O SHOULD TOTAL THE RECORD." RN "C" DIDN'T KNOW WHAT TO DO WITH THE 24 HOUR FLUID TOTALS OR WHO IS RESPONSIBLE FOR ANALYZING THE FLUID INTAKE. NURSES NOTES DATED 2/01/12 AT 12:55 P.M., READ, "...RES (RESIDENT) LEANING TO THE R (RIGHT) SIDE ...HAVING DIFFICULTY HOLDING CUP & UTENSILS... RES. WITH INCREASED CONFUSION... 13:10 (1:10 P.M.) ORDER OBTAINED TO SEND RESIDENT TO THE ER (emergency room )..." emergency room RECORDS DATED 2/1/12 INVOLVING RESIDENT #1 READ; "...CHIEF COMPLAINT: LETHARGY... THE PATIENT TODAY WAS FOUND MORE LETHARGIC... APPETITE IS NOW POOR... WHEN ASKED OPEN ENDED QUESTION THE PATIENT HAS NONSENSE ANSWERS... MUCUS MEMBRANES DRY... PLAN: THE PATIENT WILL BE admitted TO THE HOSPITAL..." THE HOSPITAL DISCHARGE SUMMARY DATED 2/07/12 FOR RESIDENT #1 SHOWS A FINAL [DIAGNOSES REDACTED]. THIS SUMMARY WAS SIGNED BY PHYSICIAN #1. RESIDENT #1 WAS INTERVIEWED AT ANOTHER FACILITY ON 3/08/12 AT APPROXIMATELY 9:30 A.M. SHE WAS ALERT AND ANSWERED QUESTIONS APPROPRIATELY. RESIDENT #1 STATED "I'VE KNOWN (PHYSICIAN #1) FOR OVER [AGE] years. HE'S BEEN MY DOCTOR. HE WAS WORRIED ABOUT ME." RESIDENT #1 WAS SEEN RESTING IN HER BED, WELL GROOMED, LIPS WERE MOIST (NOT CHAPPED), A SIPPY CUP OF THICKENED LIQUIDS AND A CONTAINER OF YOGURT WERE VISUALIZED AT THE BEDSIDE (RIGHT HAND SIDE) AND A SPLINT WAS ON THE LEFT HAND. A TELEPHONE INTERVIEW WAS CONDUCTED WITH FAMILY MEMBER (FM) #1 ON 3/08/12 AT APPROXIMATELY 10:00 A.M. FM #1 STATED, "THEY FINALLY GOT HER STRAIGHTENED OUT... (PHYSICIAN #1) TOLD US SHE (RESIDENT #1) WAS DEHYDRATED... WHEN WE SAW HER AT THE HOSPITAL, HER LIPS WERE CHAPPED, HER MOUTH WAS DRY... SHE LOOKED LIKE A ZOMBIE..." FM #1 WAS ASKED TO DESCRIBE RESIDENT #1'S BEDROOM LAYOUT AT THE FACILITY. SHE STATED, "HER BED WAS AGAINST THE WALL AND HER LEFT SIDE WAS TOWARDS THE ROOM, SHE CAN'T USE HER LEFT SIDE... SHE COULDN'T GET HER WATER..." A TELEPHONE INTERVIEW WAS CONDUCTED WITH FM #2 ON 3/08/12 AT 4:00 P.M. FM #2 STATED HE VISITED RESIDENT #1 IN THE AFTERNOON AND EVENING BECAUSE OF HIS WORK SCHEDULE. FM #2 ALSO STATED THAT RESIDENT #1 ALWAYS SAID SHE DIDN'T FEEL GOOD AND THAT TOGETHER, FM #2 AND RESIDENT #1 TOLD THE NURSES, BUT THE NURSES WOULD REPLY, "IT'S ALL IN HER HEAD." ( ) --

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION OR ASSISTIVE DEVICES FOR ONE RESIDENT (#2) OF FOUR RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF 58 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN RESIDENT #2 SUSTAINING A PAINFUL SCALP LACERATION AND SUBDURAL HEMATOMA AFTER FALLING. FINDINGS INCLUDE: A REVIEW OF RESIDENT #2'S FACE SHEET SHOWED SHE WAS A [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. AN ADDITIONAL [DIAGNOSES REDACTED]. RESIDENT #2'S MOST RECENT MINIMUM DATA SET ((MDS) dated [DATE], REVEALED SHE WAS UNABLE TO COMPLETE THE BRIEF INTERVIEW FOR MENTAL STATUS. A STAFF ASSESSMENT OF MENTAL STATUS WAS DONE INSTEAD AND INDICATED THAT RESIDENT #2 HAD SHORT AND LONG TERM MEMORY PROBLEMS, AND WAS MODERATELY IMPAIRED FOR DAILY DECISION MAKING (DECISIONS WERE POOR REQUIRING CUES/SUPERVISION). THIS MDS REVEALED THAT RESIDENT #2 NEEDED LIMITED ASSISTANCE OF ONE PERSON FOR TRANSFERS AND TOILET USE. RESIDENT #2'S FALL CARE PLAN DATED 11/11/11, INCLUDED THE INTERVENTIONS OF PRESSURE PAD ALARM IN CHAIR. AFTER A FALL ON 12/10/11, A BED ALARM WAS ADDED TO RESIDENT #2'S CARE PLAN AND ON 12/14/11, THE CARE PLAN WAS UPDATED AGAIN TO INCLUDE HER IN THE FALLING STAR PROGRAM. ON 12/17/11, A FACSIMILE (FAX) WAS SENT TO RESIDENT #1'S PHYSICIAN. IT READ IN PART, "RES (RESIDENT) WITH INCREASED CONFUSION AND AGITATION AT HS (BEDTIME).....RES WANDERING WITHOUT WHEELCHAIR AND REFUSING ASSISTANCE PUSHING STAFF AWAY. PLEASE ADVISE." THE PHYSICIAN RESPONDED, "REASSURE HER GENTLY AND COMFORT HER." ON 12/18/11, A NURSING REFERRAL TO REHAB (REHABILITATION) WAS MADE REGARDING RESIDENT #2. THIS REFERRAL INDICATED A CHANGE IN RESIDENT #2'S AMBULATION AND/OR BALANCE, A CHANGE IN HER MOBILITY AND/OR TRANSFERS, AND A HANDWRITTEN NOTE THAT READ, "UNABLE TO AMB (AMBULATE) 2 PERSON TRANSFERS LETHARGIC." SKILLED REHAB WAS RECOMMENDED AND ANOTHER HANDWRITTEN NOTE READ, "WAITING FOR MD (PHYSICIAN) APPROVAL. HE WILL ASSESS PT. (PATIENT) PRIOR TO ANY TX (TREATMENT)." RESIDENT #2 WAS SEEN BY HER PHYSICIAN ON 12/21/11 WITH NO NEW ORDERS. NURSE PROGRESS NOTES SHOWED THAT ON 12/23/11 AT 3:30 A.M., RESIDENT #2 WAS FOUND ON THE FLOOR IN HER BATHROOM. DUE TO THIS FALL, SHE SUSTAINED A LACERATION TO THE BACK OF HER SCALP AND COMPLAINED OF PAIN. ORDERS WERE RECEIVED TO SEND RESIDENT #2 TO THE EMERGENCY DEPARTMENT. ALTHOUGH A COMPUTERIZED TOMOGRAPHY (CT) SCAN OF THE HEAD AT FIRST INDICATED A [DIAGNOSES REDACTED], THE EMERGENCY DEPARTMENT SUMMARY READ, "RADIOLOGIST DESCRIBED EXTRAAXIAL HEMORRHAGE VERSUS A SMALL [DIAGNOSES REDACTED]. OUR RADIOLOGIST....THIS AM (MORNING) COMPARED CT TO OLD STUDY. DEFINITE HEMORRHAGE." RESIDENT #2 WAS SEEN BY HER PHYSICIAN ON 12/23/11; HE WROTE, "S/P (status [REDACTED]. PREVIOUS TO HER FALL ON 12/23/11, RESIDENT #2'S DECEMBER MEDICATION ADMINISTRATION RECORD (MAR) SHOWED SHE HAD an order for [REDACTED]. RESIDENT #2'S "PAIN INTERVENTION FLOWSHEET" SHOWED SHE ONLY REQUESTED THIS MEDICATION FIVE TIMES IN THE TWO WEEK PERIOD BETWEEN 12/1/11-12/14/11. THE DECEMBER MAR SHOWED THAT STARTING 12/23/11, AFTER RESIDENT #2 fell , THE STRONGER PAIN MEDICATION WAS ORDERED: ANEXSIA 5/500 MG, ONE BY MOUTH EVERY FOUR HOURS AS NEEDED. THIS MEDICATION WAS INCREASED TO 7.5/500 MG ON 12/27/11, THEN TO 5/500 MG EVERY SIX HOURS ON 12/29/11, AND AGAIN INCREASED TO 5/500 MG EVERY FOUR HOURS ON 12/30/11. THE "PAIN INTERVENTION FLOWSHEETS FOR DECEMBER 2011 AND JANUARY 2012 SHOWED THAT RESIDENT #2 REQUESTED THIS STRONGER PAIN MEDICATION TWENTY NINE (29) TIMES IN THE TWO WEEK PERIOD BETWEEN 12/23/11-1/6/12 FOR COMPLAINTS OF BACK PAIN, LEFT HIP PAIN AND ABDOMINAL PAIN. IN ADDITION TO RESIDENT #2'S INCREASED LEVEL OF PAIN AFTER HER FALL, TWO FACSIMILES (FAXES) TO HER PHYSICIAN DATED 12/27/11, READ "RES. (RESIDENT) C/O (COMPLAINED OF) L (LEFT) HIP PAIN & HAS BEEN MORE DIFFICULT TO TRANSFER SINCE FALL. PLEASE ADVISE;" AND "RES DOUBLED OVER IN PAIN, C/O PAIN TO L HIP SECONDARY TO FALL." THE PHYSICIAN RESPONDED TO THE FAX WITH, "SEND TO ER (emergency room ) FOR EVAL." A CARE TRACK NOTE DATED 12/27/11 AT 11:35 PM, SHOWED THAT RESIDENT #2 HAD BEEN RETURNED TO THE FACILITY FOLLOWING EVALUATION IN THE emergency room ; NO FRACTURES FOUND. CARE TRACK NOTES DATED 12/24/11, 12/25/11, 12/27/11, 12/29/11, 12/30/11 AND 12/31/11, AND NURSE PROGRESS NOTES DATED 12/31/11 AND 1/4/12, REVEALED THAT RESIDENT #2 WAS EXPERIENCING A POOR APPETITE. NURSE PROGRESS NOTES DATED 1/4/12 AND 1/6/12, REVEALED THAT RESIDENT #2 WAS LETHARGIC. A FAX TO THE PHYSICIAN ON 1/6/12 READ, "RES. VERY LETHARGIC, UNABLE TO AWAKE TO EAT OR DRINK, AUDIBLE WHEEZES & CRACKLES...." THE PHYSICIAN ORDERED THE ANTIBIOTIC ROCEPHIN 1 GRAM INTRAMUSCULARLY ONCE DAILY FOR SEVEN DAYS. THE JANUARY MAR SHOWED THAT RESIDENT #2 RECEIVED THE FIRST DOSE ON 1/6/12. ACCORDING TO A NURSING PROGRESS NOTE DATED 1/7/12, RESIDENT #2 PASSED AWAY ON 1/7/12 AT 4:54 A.M. THE FACILITY'S INVESTIGATION OF RESIDENT #2'S FALL OCCURRING ON 12/23/11 AT APPROXIMATELY 3:00 A.M., REVEALS THAT CERTIFIED NURSE AIDE (CNA) 'A' RESPONDED TO RESIDENT #2'S BED ALARM SOUNDING. RESIDENT #2 STATED SHE NEEDED TO USE THE RESTROOM AND WAS ASSISTED THERE BY CNA 'A' AND CNA 'B'. CNA 'A' THEN HEARD ANOTHER BED ALARM SOUNDING AND WENT TO RESPOND, TELLING RESIDENT #2 TO RING FOR HELP WHEN SHE WAS DONE ON THE TOILET AND NOT TO GET UP ALONE. CNA 'B' THEN LEFT WITH CNA 'A' TO RESPOND TO OTHER ALARMS. THE FACILITY'S FALLING STAR PROGRAM IDENTIFIES RESIDENTS AT HIGH RISK FOR FALLS TO ALERT CNA 'A' AND CNA 'B' THAT RESIDENT #2 WAS NOT SAFE IF LEFT UNATTENDED. AT APPROXIMATELY 3:10 A.M., REGISTERED NURSE (RN) 'C' HEARD A BUMP AND THEN SOME MOANING COMING FROM RESIDENT #2'S BATHROOM. RN 'C' IMMEDIATELY RESPONDED AND UPON ENTERING HER BATHROOM, FOUND RESIDENT #2 ON THE BATHROOM FLOOR. THE FACILITY INVESTIGATION SURMISED THAT RESIDENT #2 HAD GOTTEN HERSELF OFF THE TOILET WITHOUT RINGING FOR HELP, IN AN ATTEMPT TO GET BACK INTO HER WHEELCHAIR, BUT LANDED ON THE FLOOR IN THE PROCESS. ATTEMPTS TO INTERVIEW CNA 'A', CNA 'B' AND RN 'C' BY TELEPHONE ON 1/12/12 AT 2:40 PM, 2:38 PM AND 2:47 PM RESPECTIVELY, WERE UNSUCCESSFUL AS NONE OF THEM ANSWERED THEIR PHONES. DURING AN INTERVIEW WITH THE ADMINISTRATOR AND THE DIRECTOR OF NURSING (DON) ON 1/12/12 AT 3:45 P.M., THEY WERE ASKED IF THEY THOUGHT THAT CNA 'A' AND CNA 'B' HAD FOLLOWED RESIDENT #2'S FALL PREVENTION PLAN OF CARE, BASED ON THE FACILITY'S FALLING STAR PROGRAM. THE ADMINISTRATOR STATED, "I THINK THEY DID THE BEST THEY COULD. OTHER ALARMS WERE GOING OFF TOO, SO THEY LEFT (RESIDENT #2) TO KEEP THOSE RESIDENTS FROM FALLING." THE DON STATED, "IT WAS A REALLY BUSY NIGHT. (CNA 'A') WAS AN ON-CALL CNA TRYING TO TRAIN IN A NEW CNA. OTHER CALL LIGHTS AND ALARMS WERE GOING OFF AT THE SAME TIME." DESPITE THE EXPLANATIONS GIVEN, NEITHER THE ADMINISTRATOR OR THE DON DIRECTLY ANSWERED THE QUESTION OR AFFIRMED RESIDENT #2'S FALL PREVENTION PLAN OF CARE WAS FOLLOWED. RESIDENT #2 HAD CLEARLY BEEN IDENTIFIED AS BEING AT RISK FOR FALLS WITH INTERVENTIONS THAT INCLUDED ALARMS AND HAD BEEN ON THE FALLING STAR PROGRAM, WHICH ALERTS STAFF TO RESIDENTS AT RISK FOR FALLS. THE FACILITY LEFT RESIDENT #2 ALONE IN HER BATHROOM WITHOUT SUPERVISION AND WITHOUT ALARMS ATTACHED; THEREFORE IT WAS DETERMINED THIS FALL MAY HAVE BEEN AVOIDED IF STAFF HAD STAYED WITH HER UNTIL SHE WAS ASSISTED BACK TO WHEELCHAIR OR BED WITH ALARMS IN PLACE. THIS FAILURE TO PROVIDE ADEQUATE SUPERVISION RESULTED IN RESIDENT #2 SUSTAINING A FALL RESULTING IN HARM. ( )