Every finding on record at Munson Healthcare Crawford Continuing Care Center

This deficient practice pertains to Intake 2985836.Based on interview and record review, the facility failed to prevent an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.Findings include:Resident #1 (R1):Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 8/1/25 with a diagnosis of dementia with behavioral disturbances. Review of R1's most recent Minimum Data Set (MDS) assessment, dated 2/6/26, revealed a Brief Interview for Mental Status (BIMS) score of 2, indicative of severe cognitive impairment.Review of R1's quarterly Elopement Evaluation, dated 3/21/26, revealed a score of 6.0, indicating the resident was, at risk of elopement.Review of the Facility Reported Incident (FRI) included an investigation report submitted to the State Agency (SA) on 4/10/26 at 2:03 PM, which read, in part: On the evening of 4-09-2026, the Director of Nursing (DON) was exiting the facility for the day at 1624 [4:24 PM] and noted [R1] attempting to cross the front parking lot. [R1] has known wandering activities and has a history of elopement from this facility. [R1's] elopement prevention interventions prior to this incident included wandergards (a wearable device which triggers an alarm when a resident nears a restricted area) one to each wrist, and fifteen-minute safety tracking. At 1537 [3:37 PM], 4-09-2026, [Facilities Employee/Staff A] responded to the facility as the wandergard at the facilities front door would not reset. [Staff A] unplugged the power to reset the system. After completing this task, [Staff A] noted that the wandergard was showing a green light indicating it was functional. [Staff A] left the facility at this time. [R1] was noted to have exited the facility at 4:24:38 PM . [The DON] was noted exiting the facility at 4:24:57 PM and pursued [R1]. [R1's] wandergards did not trigger the front door wandergard system to alarm when she exited the facility. At 1630 [4:30 PM], [Staff A] from Facilities returned to the facility to assess the wandergard. It was noted at this time that the wandergard was not functioning appropriately.On 4/29/26 at 10:30 AM, an interview was conducted with the DON who confirmed she first saw R1 in the parking lot approximately 75 feet from the entrance after exiting the facility on 4/9/26. The DON stated she immediately called Registered Nurse (RN) D to notify the facility of the elopement and to summon additional help.On 4/29/26 at 10:32 AM, an interview was conducted with RN D who confirmed she received a call from the DON on 4/9/26 at 4:26 PM asking for assistance as R1 was outside the facility in the hospital driveway and beginning to walk toward the road. RN D showed this Surveyor the approximate path she negotiated with R1, nearly a block and half from the facility, before she and a certified nursing assistant (CNA) were able to successfully redirect R1 back into the facility.On 4/29/26 at 10:40 AM, a telephone interview was conducted with Staff A who verified he was asked to fix the wanderguard system around 3:30 PM on 4/9/26. Staff A stated the alarm would not stop sounding, therefore he reset the system to rectify the malfunction. Staff A stated after a system reset, the alarm was silenced, and the green light was illuminated on the system which he assumed indicated the system was properly functioning. Staff A confirmed he left the facility at this point. At approximately 4:30 PM, Staff A stated he was called back to the facility after R1's elopement because the alarm was not sounding as designed when a wanderguard came into proximity of the system. Staff A confirmed this finding when he tested the system with a probe/sensor when he returned.On 4/29/26 at 10:55 AM, an interview was conducted with Maintenance Director (MD) B regarding the wanderguard system. MD B stated it is protocol to manually test the system with a probe or sensor after performing any type of maintenance on the unit rather than relying on the green system light to indicate proper functioning.On 4/29/26 at 11:17 AM, a phone interview was conducted with CNA C who verified she was working at the time of R1's elopement. CNA C confirmed R1 had been restless in the hours leading up to the elopement, attempting to exit out of the [NAME] facility door just 15 minutes prior to the successful elopement. CNA C confirmed the door alarm did not sound when R1 successfully eloped from the facility at 4:24 PM on 4/9/26.On 4/29/26 at 11:40 AM, an interview was conducted with the Nursing Home Administrator (NHA) who verified R1 eloped from the facility on 4/9/26 and was unattended in the facility parking lot for approximately 19 seconds. The NHA confirmed the root cause of the elopement was failing to manually test the wandergard system following service for proper functioning resulting in a faulty alarm.During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:A staff member was placed at the door to monitor for any residents attempting to exit the facility while the wandergard system was being serviced following the elopement. The system was determined to be appropriately functioning on 4/9/26 at 8:15 PM. Resident #1 was assessed with no injury following the event and was placed on 1:1 supervision until transferred to a secured dementia unit.Audits of the main entrance door and elevators were conducted for proper functioning. All residents wearing wanderguards were checked for proper functioning following the event and continued to be checked twice per day.The Facilities Department has been educated on manually testing the wandergard system following any repairs or services. The charge nurse is now responsible for testing the functioning of the exit door and elevator alarms every shift.The NHA or designee will review the main entrance door and elevator door weekly for four weeks then monthly at the discretion of the facility Quality Assurance Performance Improvement Committee to ensure wandergard units are functioning appropriately for continued compliance.The facility was able to demonstrate monitoring of the corrective action and maintained compliance as of 4/27/26.

Based on interview and record review, the facility failed to document collaboration among the interdisciplinary team (IDT) and to offer and provide inclusion of resident's or their representatives in the quarterly review of the comprehensive care plan for three Residents (#5, #7 and #13) of 12 residents reviewed and affecting all 19 residents receiving long-term care of a total of 27 residents residing in the facility.Findings include:Resident #5 (R5) During a telephone interview on 3/23/2026 at 12:10 PM, R5's Medical Durable Power of Attorney (MDPOA), Family Member (FM) D reported she was unable to visit R5 as often as she would like but she was able to visit a couple of time per year. When asked if she was able to attend R5's care conferences, FM D reported she was unaware of when R5's care conferences were held and had not been alerted or invited to review the plan of care with the IDT. When asked if she would like the opportunity to meet with the IDT for review of the plan of care, FM D stated, I like to know what is going on with her health and so on, so yes, I would like the opportunity to hear what everyone has to say. Review of the electronic medical record (EMR) revealed R5 was admitted to the facility on [DATE] and had diagnoses including diabetes, chronic kidney disease and dementia. Review of R5's comprehensive care plan revealed multiple care areas of focus including the risk for alteration in nutrition; risk for falls/injury; risk for alteration in activity participation; risk for alteration in skin integrity; risk for pain; and risk for alteration in ADL (Activities of Daily Living) completion. Further review of the care plan revealed, [R5] requires long-term care due to multiple health conditions and is no longer able to care for herself and needs significant assistance for completion of ADLs. Revision on: 3/25/2025. [R5's] goals will be met by staff while respecting her wishes and dignity to the extent possible. Revision on 3/19/2026. Admit/DC planner to review LTC planning with [MDPOA] during comprehensive assessments and PRN [as needed]. Revision on 3/21/2025. During an interview on 3/24/2026 at 12:20 PM the facility Social Services Designee, Staff C was queried regarding the facility procedure for holding care conferences. Staff C stated, We're behind on those. Staff C reported the facility MDS Coordinator, Registered Nurse (RN) A scheduled the resident's care conferences. Staff C reported she provided a quarterly review for social services but did not meet with other members of the IDT to review the care plan as a whole for long-term care residents. During an interview on 3/24/2026 at 12:30 PM, RN A was asked about the process for reviewing the plan of care with the IDT, residents and resident's representatives. RN A reported formal care conferences were not held for long-term care residents. RN A stated, We aren't doing them right now. My understanding is the care plan just needs to be adjusted as needed. When asked the process for review of the plan of care, RN A reported she reviewed the care plans following quarterly MDS (Minimum Data Set) assessments and determined the appropriateness of the plan based on data entered in assessment by the IDT. RN A reported there was no need to discuss the plan with IDT, resident or resident representatives for long-term care residents because, We are a very small facility. We see people all the time. Everyone knows. Further review of R5's EMR from 10/01/2025 through 3/24/2026 revealed no documentation to indicate collaboration among the IDT or review of the comprehensive plan of care with the Resident or her DPOA. Review of R5's comprehensive care plan revealed all entries to the care plan were completed by RN A and there was no notation or indication the IDT reviewed their respective care areas. Resident #7 (R7) A review of the EMR revealed R7 was admitted on [DATE]. R7's care plan indicated problems including Alzheimer's disease with other behavioral disturbances – agitation, variable communication skills, altered safety awareness, episodes of incontinence. R7 had many areas of focus and many interventions listed on the care plan. During an interview on 3/24/2026 at 2:58 PM, RN A was asked when the last care conference for R7 had been held. RN A checked the medical record and replied, She (R7) came in on 8/1/2025. We never had one. RN A stated the Durable Power of Attorney (DPOA) was at the facility quite often and the facility communicated with them frequently. When asked where the conversations on R7's plan of care were documented, RN A stated, That would be in the EMR under clinical assessments. This section of the EMR was reviewed by RN A and she stated there was no documentation of a discussion on the plan of care for R7. Resident #13 (R13) A review of the EMR revealed R13 was admitted on [DATE]. R13's care plan indicated problems including Alzheimer's disease along with dementia with agitation, easily anxious, high strung, episodes of agitation. significant decline in status due to fall resulting in. fx (fracture). R13 had many areas of focus and many interventions listed on the care plan. The goals were printed in red color and marked as (OVERDUE). During an interview on 3/24/2026 at 12:37 PM, RN A was asked why the care plan goals were in red and marked as overdue. RN A stated, I update the MDS assessments and then the care plan, and I must have missed the care plan update . RN A also said R13 was admitted in October and probably has not had a care conference since her (R13's) admission. RN A explained R13's son was the activated DPOA and we talk to him all the time.

Based on interview and record review, the facility failed to obtain informed consent for psychoactive medications for one Resident (R10) of five residents reviewed for psychoactive medications.Findings include:A review of R10's electronic medical records (EMR) indicated an admission into the facility on 2/21/2024 with a primary diagnosis of severe vascular dementia with behavioral disturbance (a cognitive decline caused by reduced blood flow to the brain, damaging brain tissue and affecting memory, thinking and behavior). A review of the most recent Minimum Data Set (MDS) assessment with a submission date of 3/16/26 revealed R10 had severely impaired cognition and Section C indicated resident is rarely/never understood. The medical record documented R10 had an appointed responsible party for health care and financial decision making.A review of R10's 'Physician Orders' for March 2026 indicated the antipsychotic medication quetiapine fumarate 25 mg (milligrams) was prescribed and initiated on 7/10/25 and the antidepressant medication sertraline HCl 25 mg was prescribed and initiated on 1/9/26.A review of R10's EMR revealed no evidence R10's responsible party had given written or verbal consent for the administration of an antipsychotic or antidepressant nor were they informed of the potential side effects/adverse reactions.On 3/25/2026 at approximately 9:00 AM, consents for Quetiapine Fumarate and Sertraline HCl were requested. During an interview on 3/25/2026 at 9:30 AM, the Director of Nursing (DON) stated, We do not have a consent for those meds.The facility policy titled Chemical Restraints-Psychoactive Medications dated as last approved 3/28/25 was reviewed. The policy read in part, .The resident or responsible party will be notified of the drug order and documentation will reflect this. The facility policy titled Informed Consent - Diagnostic or Therapeutic Procedures and Treatments and last reviewed 6/4/2025 was reviewed and read in part, The patient's right to informed consent for invasive procedures, high-risk therapies/drugs, and experimental treatments will be supported by the providers and staff. Consents for Treatment, must be signed by the patient for therapeutic and diagnostic procedures where disclosure of significant medical information, including major risks involved, would assist the patient in making an educated decision about whether or not to undergo the proposed procedure.

Based on interview and record review, the facility failed to provide written notification of transfer or discharge and the facility bed hold policy for three Residents (#3, #6 and #32) of three residents reviewed for hospitalization. Findings include: Resident #3 (R3 During a room visit on 3/23/2026 at12:06 PM, R3 stated she had been out to hospital when she had experienced chest pain. A review of R3's medical record revealed the resident was sent to the Emergency Department on 2/7/26. The medical record included a facility Transfer Notice dated 2/7/26 with a reason for transfer, transfer location, and signature of the RN completing the form. The space designated for acknowledgement of receipt was unsigned and undated. The medical record also did not contain documentation that an explanation of the facility bed hold policy had been given to R3 or R3's responsible party. Resident #6 (R6) A review of R6's electronic medical record EMR) revealed the resident was transferred to the Emergency Department on 1/05/26 for evaluation of an acute episode of shortness of breath. Further review of the EMR revealed a Transfer Notice, dated 1/05/2026, indicating the reason for the transfer as, Medically unstable and needs medical treatment at another facility. The Transfer Notice, was signed by a facility nurse and the signature line for acknowledging receipt of the notice was blank. A handwritten note at the bottom of the Transfer Notice, read, Voicemail left for [resident representative] 1/5/26 [at] 1935 PM [7:35 p.m.]. It was noted there was no language included in the Transfer Notice, of the facility policy on bed holds or any indication on the form of R6 or R6's representative's provision of the written notice. Resident #32 (R32) A review of R32's EMR revealed the resident was transferred to the Emergency Department on 1/18/2026 for evaluation. Further review of the EMR revealed a Transfer Notice, dated 1/18/2026 indicating the reason for the transfer as, other: resident requesting. The Transfer Notice was signed by facility staff on 1/18/2026 and the signature line acknowledging receipt of the notice was blank. It was noted there was no language included in the Transfer Notice, of the facility policy on bed holds or any indication on the form of R32 or R32's representative's provision of the written notice. During an interview on 3/25/2026 at 10:38 AM, Social Services Designee, Staff C, reported she kept a paper file of all Transfer Notices. During review of the paper copies of the facility's completed Transfer Notices(s), Staff C confirmed the forms completed for R3's transfer on 2/07/2026, R6's transfer on 1/05/2026 and R32's transfer on 1/18/2026 did not include a signature acknowledging receipt of the forms or any indication the written forms were provided the resident's or their representatives. Staff C reported she was unaware the notification of transfer needed to be provided in writing then stated, We're not doing that. Staff C reported information of the facility policy on bed holds was provided at the time of admission and was not provided again for transfers to the Emergency Department. Review of the facility policy titled, Notice of Transfer and/or Discharge, dated as last reviewed on 7/21/2025, revealed the following: The facility will provide the resident, and/or resident's representative with the appropriate notice of transfer/discharge according to state and federal requirements. The residents and/or representative will be notified of the transfer/discharge and provided with the following information: The reason for the transfer or discharge. The effective date of the transfer or discharge. The location to which the resident is being transferred or discharged . The name, address, and telephone number of the state long-term care ombudsman. The name, address and telephone number of individuals or agencies responsible for the protection and advocacy of mentally ill or developmentally disable individuals. The name, address and telephone number of the state health department agency that has been designated to handle appeals of transfers an

Based on observation, interview, and record review, the facility failed to assess, monitor and maintain nutritional status of one Resident (R7) of two residents reviewed for nutritional needs.Findings include:Resident #7 (R7)A review of the electronic medical record (EMR) revealed R7 was admitted on [DATE] with a primary diagnosis of Alzheimer's disease. The Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 2 of 15 indicating severe cognitive impairment.On 3/23/2026 at 12:17 PM, R7 was observed at lunch feeding herself with success.During a telephone interview on 3/23/2026 at 2:23 PM, the Durable Power of Attorney said R7 was a very active person in youth and walked several miles a day but was not active now and was gaining weight and might outgrow her clothes.The facility Registered Dietitian (RD) B reviewed R7's nutritional status quarterly. The last progress note from RD B on 2/7/26 read, Note Text: Quarterly dietary review. Resident is receiving a level 7 diet with thin liquids and is tolerating well. Resident sometimes eats meals in her room, in the lobby by the birds, and sometimes the dining room. Resident has a current weight of 126.7 pounds, weight one month ago was 130.4 pounds, weight 3 months ago was 123.3 pounds, and weight 6 months ago was 126 pounds. Resident weight has been overall stable at this time, and skin remains free from pressure related areas at this time. Will continue to follow weight trends and food acceptance records to see if further intervention is needed.On 3/23/26 the weights for R7 were reviewed in the medical record:9/1/2025 = 122.410/1/2025 = 123.311/1/2025 = 127.912/1/2025 = 130.41/1/2026 = 126.73/1/2026 = 135.3No weight was recorded for February 2026 and no reweigh of the 8.6 pound weight gain (a significant 6.7% change since the previous monthly weight) had been taken.R7's care plan included a focus of at risk for alteration in nutrition r/t Alzheimer disease, dementia classified elsewhere with other behavioral disturbances, variable communication skills, hypothryroidism. (sic) . The goal for this focus was (R7) will receive adequate nutrition and her weight will remain stable t/o (by) next review. The only interventions listed to reach this goal were listed as, Monitor and record (R7's) weight. And Provide 7/0 (regular) diet with set up assist as needed.No further RD notes had been recorded and no update to the care plan after the significant weight change had been made.During a telephone interview on 3/25/2026 at 12:00 PM, RD B stated she had not been aware of a weight change for R7 and agreed the facility had not followed the weight procedure.The facility provided the policy titled, Resident Weight Procedure dated as created 1/24/2024. This policy read in part, .Long term care residents will have their weight obtained by certified or licensed staff at monthly intervals unless more frequent monitoring is determined. A weight difference of 5 pounds +/- during a monthly weight will require a re-weight within 24 hours.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for three Residents (R28, R30 and R36) of four residents reviewed for dining assistive devices. Findings include: On 3/23/2026 at 12:34 PM, lunch service was observed in the dining room.R28 was observed feeding himself. His hand was shaking and the food on his spoon was not all going into his mouth. Spills were present down the front of the clothing protector R28 was wearing. The meal tray card for R28 included instructions typed in capital letters and red ink indicating LARGER SPOON. The spoon R28 was using was not larger but was a standard teaspoon size. When the dining room staff were asked about the spoon, Certified Nursing Assistant (CNA) E said he should have received a larger spoon.R30 was observed in the dining room with his lunch. The meal tray card for R30 included instructions for a SMALL DIAMETER STRAW which was typed in capital letters and red ink. R30 did not have a straw . CNA G stated R30 did not geta smaller straw and it had been missed. CNA G said R3 needed a smaller straw as he drinks too fast with the larger straw.During an interview on 3/24/2026 at 10:04 AM, Dietary Manager (DM) F agreed the staff should be following the instructions on the meal tray cards.On 3/24/2026 at approximately 1:00 PM, R36 was observed eating lunch in his room. The meal tray card for R36 included instructions for BUILT UP FOAM FOR UTENSILS which was typed in capital letters, in red ink, and was further highlighted in yellow. R36 had regular utensils without built up foam to facilitate his grip. R36 was struggling to feed himself. R36 was asked if he did better with the foam. He replied, Yes, I need that. I did not get it this morning at breakfast either.During an interview on 3/24/2026 at approximately 1:15 PM, DM F' stated the therapy department had been working with R36 and had supplied the built-up foam handled utensils. A facility policy Scope of Services for Rehabilitation Services dated as last revised 1/17/2024 read in part, Rehabilitation Services are provided in accordance with the facility's mission and plan for the provision of care. and will provide Equipment Training and Recommendations.Adaptive aids for activities of daily living.

This deficient practice pertains to intake 2588223.Based on interview and record review, the facility failed to prevent and readily detect an elopement for one Resident (#1) of three residents reviewed for accident hazards and supervision.Findings include:Resident #1 (R1):Review of R1's electronic medical record (EMR) revealed initial admission to the facility on 8/1/25 with a diagnosis of dementia with behavioral disturbances. Record review of R1's Nursing Clinical admission report, dated 8/1/25, revealed a level of cognitive impairment as, severe impairment (affecting all areas of judgement).Review of R1's Elopement Evaluation, dated 8/1/25, revealed a score of 6.0, indicating the resident was, at risk of elopement.Review of the FRI submitted to the State Agency (SA) on 8/7/25 at 5:15 PM, included an investigation report which read, in part: Resident [R1] was admitted to our department on 8/1/2025 at approximately 11:30 AM. Resident [R1] was noted by staff to be missing at 1600 [4:00 PM]. The resident was found at 1616 [4:16 PM]. Security camera footage was reviewed by security staff and administrator. Resident [R1] exited out of the west door at 1531 [3:31 PM] and moved quickly out of the sight line of the windows.1 CNA [certified nursing assistant] did not [sic] that while she and other staff were assisting the resident through the west door at admission the door was not alarming. She did not see anyone at the nurses' station. The door was open for a prolonged period due to assisting [the] resident into the building with her personal items. The CNA returned directly to work and did not notify any staff that the alarm was not going off. She stated she was very busy and did not realize there was an issue until after the report of the elopement. Resident [R1] was found close to the facility, at the next-door elementary school.On 8/19/25 at 9:10 AM, all documentation related to R1's elopement on 8/1/25 was requested from the Nursing Home Administrator (NHA).On 8/19/25 at 9:55 AM, the NHA presented this surveyor with two witness statements but confirmed the facility did not complete a Risk Watch report in accordance with facility policy following the elopement. The NHA stated, the process will be corrected.On 8/19/25 at 2:12 PM, security footage of the elopement event on 8/1/25 was reviewed with Security Officer (SO) J and the NHA which revealed the following events:At 3:22 PM, R1 was observed exiting the facility via the west hall emergency door and subsequently walked out of view from the outdoor camera.At 3:34 PM, R1 was observed walking in Parking Lot A near the emergency ambulance bay at the attached local acute care hospital.At 4:15 PM, Occupational Therapist (OT) H was observed locating R1 in an elementary school parking lock adjacent to the acute care hospital.At 4:18 PM, R1 is observed walking back toward facility entrance with OT H and an additional staff member. On 8/19/25 at 12:13 PM, an interview was conducted with CNA E who verified she was working the day of R1's elopement event. CNA E stated she assisted R1 off the bus at the west facility door after she arrived at the facility around 11:30 AM. CNA E explained the door was alarmed and will continue to sound if the door was open unless the reset button is continuously held at the nurse's station which will temporarily silence the alarm. CNA E recalled it took an extended amount of time to assist R1 and her belongings off the bus, but noticed the alarm was not sounding despite the open door. CNA E stated she did not observe anybody engaging the silence button as she walked by the nurses' station with R1. When asked if CNA E notified staff about the malfunctioning alarm, she stated she did not because her priority at the time was to ensure R1 was assisted with toileting needs and acclimated to her room and the facility. CNA E stated R1 became restless and somewhat agitated as the day progressed, wandering in and out of resident rooms and walking around the facility. CNA E recalled the nursing assistants started taking their afternoon breaks around 3:15 PM and stated she could not locate R1 upon her return around 3:45 PM - 4:00 PM. On 8/19/25 at 1:50 PM, an interview was conducted with Maintenance Worker (MW) I who confirmed the exit door alarm would continue to sound while open unless the reset button was continuously held. MW I further explained after the door is opened and shuts, the reset button must be pushed once to disengage the alarm.On 8/19/25 at 12:26 PM, a telephone interview was conducted with Registered Nurse (RN) C regarding the elopement event on 8/1/25. RN C recalled soon after R1 arrived at the facility, she appeared restless and began wandering in and out of other resident rooms. RN C stated she placed a WanderGuard (an electronic monitoring system used to prevent at-risk residents from leaving designated safe areas by triggering an automated alarm when the user nears a restricted exit). RN C stated she was notified by CNA E that R1 could not be located and began a facility search around 4:00 PM (38 minutes after R1 was observed exiting the facility via security footage). RN C stated, I am 100% positive I didn't hear a [door] alarm go off.On 8/19/25 at 1:12 PM, an interview was conducted with OT H who confirmed she had located R1 in an elementary school parking lot following the elopement incident on 8/1/25. OT H stated she was assigned to look for R1 in Parking Lot A which was in front of the attached hospitals' emergency department. OT H walked the elopement path with this surveyor and recalled she had looked across a side street and saw a person, eventually identified as R1, sitting on top of stairs leading to a stationed construction trailer in a parking lot. OT H confirmed R1 must have independently crossed the busy side street which served as the main entrance and exit for hospital employees as well as emergency vehicles. OT H stated she did not hear a door alarm prior to the elopement event.On 8/19/25 at 12:13 PM, an interview was conducted with CNA D who stated she was working at the time of the elopement and did not hear a door alarm prior to R1's exit.On 8/20/25 at approximately 9:20 AM, an interview was conducted with the NHA who stated the facility was unable to determine if R1's elopement occurred because of a door alarm malfunction or if a facility member silenced the alarm without conducting a visual search of the area. The NHA understood the concern regarding the extended period of time which elapsed prior to the initial elopement detection as well as the lack of post-incident documentation in accordance with facility standards.Review of the facility policy titled, Missing Resident/Elopement Policy, revised 9/12/24, read, in part: Purpose: Maintain the safety and security of our residents. All staff members within this facility are responsible for maintaining the safety of all residents. Documentation of the Wandering resident must include the following. A Risk Watch report must be filled out.

Based on observation, interview, and record review, the facility failed to implement infection prevention and control measures to ensure a safe and sanitary environment for five Residents (#5, #10, #23, #15, and #13) of eight residents reviewed for infection prevention and control. Findings include: Resident #5 (R5 On 2/11/25 at 1:43 PM, R5 was observed with a urinary catheter drainage bag dragging on the floor beneath her wheelchair. There was no barrier beneath the drainage bag. R5's catheter drainage tubing was observed dragging on the floor beneath the wheelchair on 2/12/25 at 8:12 AM and 2/12/25 at 10:33 AM. Resident #10 (R10) On 2/11/25 at 1:13 PM, R10 was observed in a reclining geriatric care in the hallway. A plastic drinking cup with a straw was on the floor without a barrier beneath it next to R10's chair. At approximately 1:30 PM, Registered Nurse (RN) B picked up the cup from the floor and placed it on a mobile overbed table next to R10's chair. RN B did not sanitize the cup or obtain a clean cup of fluid for R10. Resident #23 (R23) R23 was diagnosed with Influenza A on 2/11/25. A review of R23's medical record on 2/13/25 revealed R23 did not have an infection care plan providing staff with interventions and direction to prevent the spread of Influenza. On 2/11/25 at 2:17 PM, Certified Nurse Aide (CNA) J was observed exiting R23's room and placing two bags of soiled linen on the floor in the hallway outside of R23's room. CNA J was asked if bags of soiled linen were typically placed on the floor. CNA J said bags of soiled linen should be taken to the soiled utility room and placed in soiled linen barrels to be taken to laundry. Resident #13 (R13)/Resident #15 (R15) On 2/11/25 at 12:31 PM, CNA I was observed sitting at a table with R15 sitting on the right side of CNA I and R13 sitting on left side of CNA I. CNA I was wearing examination gloves while simultaneously feeding R13 and R15. After providing approximately five forkfuls of food to each resident, CNA I removed the gloves and put on another pair of examination gloves without washing or sanitizing her hands. A clear plastic refuse bag containing clean and folded cloth clothing protectors was observed on the floor in the middle of the dining room on 2/11/25 at 1:15 PM. CNA J was asked the typical location to place the bag of clothing protectors. CNA J picked up the bag of clothing protectors from the middle of the dining room and placed the bag on the floor against the wall in the dining room next to a housekeeping cart. The Director of Nursing (DON) was interviewed on 2/13/25 at 4:10 PM. The DON said staff is expected to sanitize their hands between glove changes, and bags of linen should not be placed on the floor. The DON said staff should never place a drinking cup on the floor. The DON said a cup on the floor should be taken to the kitchen for appropriate cleaning and R10 should have been provided with a clean cup of fluids. The DON said urinary catheter drainage bags and tubing should never sit on the floor without a barrier. The DON confirmed flu interventions and precautions are required to be included in a resident's care plan. The undated policy Indwelling Urinary Catheter Care read, in part: . Never place urine collection bag on an unclean surface, such as the floor. This minimizes the potential for contamination . The policy Infection Control Surveillance and Outbreak Policy dated as last revised 6/27/24 read, in part: . Environmental rounds are conducted to assess the overall environmental risks of infection .

Based on interview and record review, the facility failed to ensure one Resident (#185) of one resident reviewed for end-of-life care (EOLC) had a care plan and physician's order for terminal care, and appropriate activation of patient advocate/durable power of attorney prior to placing a resident on EOLC. Findings include: Resident #185 (R185) On 2/11/25 at approximately 10:45 AM, Resident R185 was observed in his room with his daughter present. R185's daughter said R185 was admitted to the facility on Thursday (2/6/25) and placed on EOLC on Sunday (2/9/25). R185's medical record was reviewed on 2/12/25 and revealed admission to the facility on [DATE] for skilled therapy services. Physician's orders dated 2/6/25 and 2/7/25 directed R185 receive occupational therapy and physical therapy five times per week. Nurses' progress notes dated 2/6/25 at 5:06 PM, 2/6/25 at 10:26 PM, 2/7/25 at 1:26 PM, and 2/7/25 at 9:58 PM documented R185 was alert and oriented times three (A/O X 3 - a normal level of consciousness and orientation). A progress note dated 2/9/25 at 9:30 AM documented, in part: .Family decided to make resident comfort care . No physician's order for EOLC was in R185's medical record. There was no care plan for EOLC. There were no documented physicians' assessments or statements indicating R185 was incapable of making medical treatment decisions to activate his patient advocate designation. A document Medical Treatment Decisions of Resident was completed and signed by R185 on 2/6/25. The area of the document to elect palliative care or comfort care was blank, indicating R185 did not choose to receive palliative or comfort care when the form was signed on 2/6/25. A Patient Advocate Designation/Durable Power of Attorney for Healthcare document, signed by R185 on 9/15/24 read, in part: .My patient advocate(s) may only act on my behalf if I am unable to participate in decisions regarding my medical or mental health treatment . The portion of the document for acceptance of patient advocate designation was signed by R185's daughter and read, in part: . This designation shall not become effective unless the individual is unable to participate in medical treatment decisions . The facility's social services director (SS D) was interviewed on 2/12/25 at 2:00 PM. SS D said two physicians were required to assess a resident and document if a resident was incapable of making his own decisions before a durable power of attorney (DPOA) could be activated. SS D confirmed there was no physician documentation of R185 being incapable of making medical treatment decisions. When asked why competency for medical decision-making wasn't completed before activating the POA (power of attorney), SS D said, I don't know how that happened. [R185] should have been assessed [for medical decision-making capability] by two doctors before the family was allowed to make that decision [EOLC]. The Director of Nursing (DON) was interviewed on 2/13/25 at 4:28 PM. The DON confirmed the DPOA for R185 should not have been activated until R185 was assessed by two physicians and declared incapable of making his own medical decisions. The DON said R185's daughter should not have been allowed to place R185 on EOLC until after R185's medical decision-making ability had been assessed by two physicians. The DON confirmed a physician's order and care plan were required for EOLC. The policy Advanced Directives dated as last revised 7/3/24 read, in part: . If a patient loses decision-making capacity and has executed a legally recognized Advance Directive that meets legal requirements: 1. The DPOAH [Durable Power of Attorney for Healthcare] must be activated . If the patient loses decision-making capacity or presents without decision-making capacity, the attending physician and one other physician will complete the activation of the patient advocacy form .

Based on observation, interview and record review, the facility failed to provide appropriate assessments and documentation warranting the use of a physical restraint for one Resident (#10) of one resident reviewed for restraints, resulting in the potential for feelings of helplessness, agitation, decreased physical functioning and injury. Findings include: Resident #10 (R10) Review of the Minimum Data Set (MDS) assessment, dated 11/26/2024, revealed R10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and Parkinson's Disease. Further review of the MDS assessment revealed R10 was unable to participate in the Brief Interview for Mental Status (BIMS) and was assessed by staff to have severely impaired cognition. On 2/11/25 at 12:10 p.m., R10 was observed at the nurse's station seated in a reclining wheelchair with the leg rest engaged in the up position. R10 was awake and alert, attempting to get out of the chair and had both legs hanging off the right side of the leg rest. R10 made no attempt to disengage the leg rest to allow their feet to touch the floor. Further observation revealed an unidentified staff member exit the nurse's station and reposition R10 back into a seated position with his legs positioned on the engaged leg rest. On 2/11/2025 at 4:00 p.m., R10 was observed to be seated in the reclining wheelchair with the leg rest engaged in the up position near the nurse's station. R10 was awake and alert, with his knees bent and feet flat on the leg rest of the chair. On 2/12/2025 at 10:49 a.m., R10 was observed in his room, awake and alert, seated in the reclining wheelchair with the leg rest engaged in the up position. R10 was sitting upright so their back was not in contact with the reclined backrest and had his right leg off the right side of the leg rest and right foot on the floor. R10 made no attempt to disengage and lower the leg rest. On 2/12/25 at 4:27 p.m., R10 was observed to be seated in the reclining wheelchair with the leg rest engaged and up, positioned in hall across from nurse's station. R10 was awake and interacted with this Surveyor by waving. R10 appeared fully awake and alert. During an interview on 2/13/25 at 2:22 p.m., Certified Nursing Assistant (CNA) G was queried as to whether R10 could lower the leg rest of the reclining wheelchair on his own accord. CNA G stated R10 was unable to disengage the leg rest of the chair independently. CNA G stated the mechanism was positioned under the leg rest, and staff had to lower the leg rest and bring the chair back to an upright position for R10. CNA G stated R10 is placed in the reclining wheelchair for safety and to prevent the Resident from falling forward when [R10] gets tired. During an interview on 2/13/2025 at 1:39 p.m., the Director of Nursing (DON) reported she was unsure if R10's reclining wheelchair should be considered a restraint. The DON confirmed R10 was unable to lower the leg rest and bring the back rest of the chair to an upright position independently. The DON reported R10 could self-propel in his standard wheelchair and was placed in the reclining wheelchair with the leg rest in the up position when they were exhibiting fidgety behavior. A review of R10's electronic medical record on 2/13/2025 at 1:45 p.m., revealed no documentation of behaviors or restlessness targeted by use of the reclining wheelchair for dates and times observed during the survey. Further review revealed no documentation of regular assessments of the resident while seated in the reclining wheelchair to ensure R10's safety and psychosocial well-being. On 2/13/2025 at 2:59 p.m., the DON reported an assessment was not completed prior to implementing the use of the reclining wheelchair or any time after, to ensure R10 was safe to use the reclining wheelchair or if the Resident could remove themselves from the chair independently. On 2/13/25 at 5:03 p.m., R10 was observed self-propelling in a standard wheelchair down the hall outside their room. R10 was bent forward fidgeting with the legs and wheels of the chair. Further observation revealed CNA G approach R10 and redirect the Resident to the upright position in the chair. R10 was then observed seated in the upright position in the chair. Review of R10's care plan revealed the following: [R10] is at risk for alteration in ADL [Activities of Daily Living] . May use geri chair [reclining wheelchair with leg rest] as needed for comfort/positioning when leaning significantly in w/c (wheelchair). Date initiated 8/25/2024 . is at risk for falls/injury [related to] Parkinson disease with noted tremors, Alzheimer disease with mood disorder/agitation . episodes of incontinence, impaired mobility, no safety awareness, bent/stooped over posture when in w/c and staff are unable to get [NAME] to sit upright as he fights it . will bend over and touch things such as his w/c wheels . [NAME] self-transfers ad lib, unable to understand safety concerns . Reviewed 11/10/24 [NAME] was observed lowering himself to the fall . Reviewed 1/8/25 observed sitting on the floor picking at stuff. Unwitnessed and [NAME] is unable to tell us if he lowered himself to the floor thus coded as fall. [NAME] will remain free from falls/injury [through] next review. Attempt to keep [NAME] upright in his w/c by offering him things to do fiddle with out of the busy box or therapy clips, etc. 10/29/2024. [R10] experiences episodes of exit seeking and attempting to open facility doors, Date Initiated: 9/03/2024 . Review of the undated facility policy titled Restraint Free Environment, revealed the following, in part: Physical Restraint: . Placing a resident in a chair that prevents the resident from rising independently . Behavioral interventions should be used and exhausted prior to the application of a physical restraint . Medical symptoms warranting the use of restraints should be documented in the resident's medical record. The resident's record needs to include documentation that less restrictive alternatives were attempted to treat the medical symptom but were ineffective, ongoing re-evaluation of the need for the restraint, and the effectiveness of the restraint in treating the medical symptom . Potential negative outcomes should also be explained including, but not limited to: Decline in physical functioning. Decreased muscle condition . Delirium. Agitation . Accidents such as falls, strangulation or entrapment. Loss of autonomy and dignity. Withdrawal or reduces social contact.

Based on interview and record review, the facility failed to ensure that Medication Regimen Reviews (MRR) were reviewed, addressed by the Physician, and maintained in the clinical record for two Residents (#3, #23) of five residents reviewed for MRR, resulting in the potential for the administration of unnecessary medications and adverse medication side-effects. Findings include: Resident #3 (R3) Review of the Minimum Data Set (MDS) assessment, dated 12/28/2024, revealed R3 was admitted to the facility on [DATE] and had diagnoses including heart failure and dementia. Further review of the MDS assessment revealed R3 scored two out of 15 (2/15) on the Brief Interview for Mental Status (BIMS), indicating R3 had severe cognitive impairment. Review of R3's electronic medical record (EMR) for August 2024 through January 2025, revealed the following: 1/28/2025 Medication Regimen Review . See Report - Lab Request. It was noted there was no previous MRR documentation found in R3's EMR for the period of August 2024 through December 2024. Further review of R3's EMR revealed no pharmacy report or recommendation related to the MRR dated 1/28/2025. On 2/13/2025 at 11:44 a.m., the Director of Nursing (DON) reported she kept paper records for the MRRs prior to contracting with a new pharmacy in January 2025. Review of the monthly paper MRR documentation listing residents reviewed for MRR, provided by the DON, revealed R3's medication regimen was reviewed by the pharmacist for the period between 12/01/2024 and 12/14/2024. Further review of the MRR listing revealed no order for [R3] in handwriting at the bottom of the document. During an interview on 2/13/2025 at 12:14 p.m., the DON reported the no order for R3 written on the MRR documentation meant there were no pharmacy recommendations for R3 during the referenced time period. On 2/13/2025 at 12:36 p.m., a request was made of the DON to provide the pharmacy recommendation referenced in the MRR dated 1/28/2025. On 2/13/2025 at 3:05 p.m., the DON reported during her search for the missing recommendation, she found recommendations for the period between 12/1/2024 through 12/14/2024 and the period between 1/1/2025 through 1/29/2025, were not addressed by her or the physician. The DON stated the recommendations were sent to the attention of nursing staff instead of the provider and the system is not set up to send notifications to her or the providers when addressed to nursing. Review of the missing pharmacy recommendations, provided by the DON at the time of the interview, revealed the following: 12/1/2024 through 12/14/2024: Resident is taking digoxin [drug used to treat heart failure and heart rhythm problems] daily. A digoxin level [blood test to determine how much medication is in the system, to rule out toxicity or inadequate dosing] is due to be obtained to assess. 1/1/2025 through 1/29/2025: Resident is taking digoxin daily. A digoxin level is due to be obtained to assess. Further review of R3's EMR for laboratory results revealed R3's last test for digoxin level was dated 3/27/2024. 49310 Resident #23 (R23) R23 was admitted to the facility on [DATE]. Review of the MDS, dated [DATE], revealed diagnoses of fractures, atrial fibrillation, renal insufficiency, respiratory failure, and others. The MDS documented R23 scored 14/15 on the BIMS, indicating R23 was cognitively intact. The medical record of R23 did not contain MRR recommendations or physician responses to MRR for November 2024 and December 2024. On 2/13/25 at approximately 4:00 PM, the DON was asked for R23's MRR for November 2024 and December 2024. On 2/13/25 at 4:11 PM, the DON reported the MRR for December 2024 was a recommendation by the pharmacist to the physician requesting blood tests on R23. The DON said only one of the recommended blood tests were obtained. The DON said no documentation by the physician was found regarding the reason for declination of the additional blood testing recommendations. A copy of the MRR for December 2024 was requested but not provided by the end of survey. On 2/13/25 at 4:46 PM, The DON said she was unable to locate R23's admission MRR for November 2024. The DON provided a paper document containing a list of residents with MRR activity between 11/1/24 and 11/26/24. The DON said she did not know what recommendations were made by the pharmacist to the physician in November 2024 and the DON stated she was unable to locate any documentation from the physician regarding the MRR. The undated policy Medication Regimen Review read, in part: .The consultant pharmacist will review the drug regimen of all the residents at least monthly and report any observed irregularities in drug use and other drug therapy recommendations to the director of nursing and attending physician . the prescriber's response will be recorded on a copy of the MRR report that shall remain in the facility or in the individual resident's clinical record. Recommendations are acted upon and documented by the facility staff or prescriber . Nursing and physician responses to the consultant pharmacist's observations and recommendations should be recorded in the resident's clinical record or on the consultant's written report and filed in the facility for at least two (2) years .

Based on interview and record review, the facility failed to ensure documentation of target behaviors/symptoms with attempted use of non-pharmacological interventions prior to the administration of as needed (prn) anti-anxiety medication for two Residents (#3, #10) of five residents reviewed for unnecessary medications, resulting in the potential for adverse side effects and decreased quality of life. Findings include: Resident #3 (R3) Review of the Minimum Data Set (MDS) assessment, dated 12/28/2024, revealed R3 was admitted to the facility on [DATE] with diagnoses including dementia and depression. Further review of the MDS assessment revealed R3 scored two out of 15 (2/15) on the Brief Interview for Mental Status (BIMS), indicating R3 had severe cognitive impairment. Review of R3's February 2025 Medication Administration Record (MAR) revealed the following order: Lorazepam [controlled drug used to treat anxiety] Tablet 0.5 MG [milligram]. Give 1 tablet by mouth every 8 hours as needed for anxiety. Start Date: 01/20/2024. Further review of R3's February 2025 MAR revealed lorazepam 0.5 mg was administered on the following dates/times: 2/1/2025 at 7:39 p.m., no behavior or symptom documented. 2/2/2025 at 3:51 a.m., no behavior or symptom documented. 2/2/2025 at 6:36 p.m., restless/anxiety. 2/3/2025 at 7:59 a.m., no behavior or symptom documented. 2/5/2025 at 1:40 a.m., no behavior or symptom documented. 2/9/2025 at 7:35 p.m., no behavior or symptom documented. The electronic medical record (EMR), including progress notes, behavior notes, assessments, miscellaneous documents, February 2025 MAR and Treatment Administration Record (TAR), for R3 were reviewed. No specific resident behaviors targeted by the administration of as needed lorazepam 0.5 mg were documented. No documentation of non-pharmacological interventions to coincide with the administration of the lorazepam 0.5 mg were referenced. Review of R3's care plan revealed the following, in part: [R3] is at risk for alteration in mood and/or adverse responses [related to diagnosis] depression . continual yelling out help me, help me, feed me, feed me, and is becoming louder and angrier with his yelling/demands, swearing more, unable to redirect/calm . [R3] is more vocal, obstinate and difficult to redirect . Interventions: . Attempt to redirect [R3] with snack/coffee, short conversation, Date Initiated: 1/10/2025 . Provide therapeutic listening, calm reassurance and support, Date Initiated: 4/24/2024 . During an interview on 2/13/25 at 1:41 p.m., the Director of Nursing (DON) reported the symptoms of anxiety and behaviors were a new sign of cognitive decline for R3. The DON reported staff had been attempting new interventions, including the administration of the as needed lorazepam 0.5 mg to address R3's behaviors. When asked if the implementation of non-pharmacological interventions was expected prior to the administration of the as needed lorazepam, the DON stated the expectation was to have all target behaviors documented in the EMR, along with non-pharmacological interventions attempted and failed prior to administration of any as needed lorazepam to allow for changes to be made to the resident's care plan and medication regimen, when warranted. Resident #10 (R10) Review of the MDS assessment, dated 11/26/2024, revealed R10 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia and Parkinson's Disease. Further review of R10's MDS assessment revealed the Resident was unable to participate in the BIMS and was assessed by staff to have severely impaired cognition. Review of R10's February 2025 MAR revealed the following order: Lorazepam Tablet 1 MG. Give 1 mg by mouth every 12 hours as needed for anxiety related to dementia in other diseases classified elsewhere, unspecified severity, with agitation. Start Date: 1/14/2025 0600 [6:00 a.m.]. Further review of R10's February 2025 MAR revealed as needed doses of lorazepam 1 mg were administered as follows: 2/1/2025 at 10:59 p.m., Push at, attempting to swat at staff, yelling, trying to climb out of chair. 2/2/2025 at 7:29 p.m., anxiety. 2/3/2025 at 8:20 p.m., resident agitated. 2/5/2025 at 1:01 a.m., Was behavior observed? Yes. It was noted in review of the 2/5/2025 administration note, no specific behaviors were documented. The electronic medical record (EMR), including progress notes, behavior notes, assessments, miscellaneous documents, February 2025 MAR and Treatment Administration Record (TAR) for R10 were reviewed. No documentation of non-pharmacological interventions prior to the administration of the lorazepam 1 mg were referenced. Review of R10's care plan revealed the following, in part: [R10] has [diagnosis] of Alzheimer's disease with mood disorder and agitation . Episodes of [R10] grabbing onto staff's hands/ arms while trying to assist him and not letting go with a firm grip on staff . episodes of yelling out for [spouse] and yelling at staff . Interventions: . If refusing cares/uncooperative/aggressive with cares, stop/wait and reapproach, Date Initiated: 9/03/2024. Provide therapeutic listening and calm conversation to minimize stimulation and provide [R10] with a chance to relax/calm down, observe for alteration in mood and/or adverse responses and report/document accordingly, Date Initiated: 8/25/2024. Review of the undated facility policy titled Behavioral Health Services, revealed the following, in part: Non-Pharmacological Intervention refers to approaches to care that do not involve medications, generally directed toward stabilizing and/or improving a resident's mental, physical, and psychosocial well-being . Pharmacological interventions shall only be used when non-pharmacological interventions are ineffective or when clinically indicated. Review of the undated facility policy titled Behavior and Symptom Management, revealed the following, in part: Interventions will be monitored frequently to determine effectiveness. Nonpharmacological interventions must be tried and documented in the clinical record before administering medication and/or increases made to resident's psychotropic medication regime whenever possible .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among any and all 26 residents. Findings include: On 7/2/24 at approximately 8:00 AM the morning meal was observed being served in the dining room. Included was a large pan of fresh cut cantalope melon. The temperature of the melon was measured using a Super fast Thermapen digital thermometer and found to vary between 45 F and 48 F. At this time an interview was conducted with Dietary Aide (DA) E related to the preparation of the melon. DA E stated They use some special wash. On 7/2/24 at approximately 8:30 AM an interview was conducted with prep cook (PC) F related to the preparation of the melon. PC F stated the kitchen no longer used any cleaner for the exterior of the melons prior to slicing. An interview with the Certified Dietary Manager (CDM) A confirmed there was no process to ensure thorough cleaning of the exterior of the melon, that the facility had discontinued the use of a fruit and vegetable wash a year prior. CDM A stated a fruit and vegetable wash product would be ordered immediately. The 2017 FDA Food Code states: 3-302.15 Washing Fruits and Vegetables. (A) Except as specified in (B) of this section and except for whole, raw fruits and vegetables that are intended for washing by the CONSUMER before consumption, raw fruits and vegetables shall be thoroughly washed in water to remove soil and other contaminants before being cut, combined with other ingredients, cooked, served, or offered for human consumption in READY-TOEAT form. On 07/02/24 at approximately 12:02 PM observations of the noon meal were made including a pan identified as mechanical chicken by DA E. DA E stated the temperatures of the foods had been taken and were ready for service. The temperature of the mechanical chicken was measured using a Super Fast thermapen and found to be between 119-131 F. the FDA Food Code 2017 states: 3-501.16 Time/Temperature Control for Safety Food, Hot and Cold Holding. (A) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under S3-501.19, and except as specified under (B) and in (C ) of this section, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be maintained: (1) At 57 C (135 F) or above, except that roasts cooked to a temperature and for a time specified in 3-401.11(B) or reheated as specified in 3-403.11(E) may be held at a temperature of 54 C (130 F) or above

Based on interview and record review, the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid). This deficient practice resulted in inaccurate reporting of staffing levels with the potential to affect all 26 residents. Findings include: Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 2 2024 (January 1- March 31) revealed the metric Failed to have Licensed Nursing Coverage 24 Hours/Day and No RN Hours Triggered with daily infractions from 1/1/24 to 3/31/24. On 7/8/24 at 8:55 AM, an interview was conducted with the Business Office Manager (BOM) P who verified she was responsible for submitting PBJ information to CMS. BOM P was unable to produce confirmation emails from CMS from Quarter 2 2024 indicating the required information had been successfully submitted. Review of PBJ XML Submission Process found at https://www.cms.gov/medicare/quality/nursing-home-improvement/staffing-data-submission read, in part: .XML Submission Process: After your submitted PBJ data file is successfully received by the CASPER Reporting and PBJ systems, the PBJ system validates the file structure and data content. Within 24 hours of a successful submission, a system-generated Final Validation Report is created in the CASPER Reporting system. This report provides a detailed account of any errors found during the validation of the records in the PBJ submission file .

Based on interview, and record review, the facility failed to implement an effective Quality Assurance & Performance Improvement (QAPI) program that included development, monitoring, and evaluation of performance indicators, identification of quality issues, and the conducting of distinct performance improvement projects to correct quality deficiencies and maintain sustained compliance. This failure had the potential to affect all 26 residents in the facility. Findings include: On the 7/8/24 at 12:41 PM, an interview was conducted with the Director of Nursing (DON) who verified she was in charge of leading the QAPI process. When asked about a current Performance Improvement Project (PIP), the DON was unable to provide a formal record of a PIP and stated, That's not a concept I was aware of, I guess. The DON could not present evidence of regular review or data analysis collected under the QAPI program including tracking and measuring performance, establishing goals and thresholds for performance improvements, nor monitoring and evaluating the effectiveness of corrective actions. The DON stated, I've struggled with what I had and what I needed to have [in reference to the QAPI program]. I didn't have a lot of orientation for this job. Review of facility policy titled, Quality Assurance and Performance Improvement, revised 7/12/23 read, in part: .The QAPI plan will address the following elements: .Process addressing how the committee will conduct activities necessary to identify and correct quality deficiencies. Key components of this process include, but are not limited to, the following: a. Tracking and measuring performance. b. Establishing goals and thresholds for performance improvements. c. Identifying and prioritizing quality deficiencies. d. Systematically analyzing underlying causes of systemic quality deficiencies. e. Developing and implementing corrective action or performance improvement activities. f. Monitoring and evaluating the effectiveness of corrective action/ performance improvement activities and revising as needed . .The facility will maintain documentation and demonstrate evidence of its ongoing QAPI program. Documentation may include, but is not limited to: 1. The written QAPI plan. 2. Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events. 3. Data collection and analysis at regular intervals. 4. Documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities . .The plan and supporting documentation will be presented to the State Survey Agency or Federal surveyor at each annual recertification survey and upon request .

Based on interview and record review, the facility failed to ensure the Infection Preventionist (IP) attended the Quality Assurance and Performance Improvement (QAPI) meetings on a quarterly basis. This deficient practice resulted in the potential for ineffective interdisciplinary communications regarding facility process with the potential to affect all 26 residents residing in the facility. Findings include: On the 7/8/24 at 12:41 PM, an interview was conducted with the Director of Nursing (DON) regarding the QAPI process. Attendance documents from the previous 3 quarterly meetings were reviewed with the DON which revealed the IP was not in attendance. The DON confirmed the IP does not attend the QAPI meetings and instead, acts as a resource and is stationed in the acute-care portion of the facility. Review of facility policy titled, Quality Assurance and Performance Improvement, revised 7/12/23 read, in part: .The QAA Committee shall be interdisciplinary and shall: 1. Consist at a minimum of: a. The Director of Nursing (DON) Services; b. The Medical Director or his/her designee; c. At least three other members of the facility's staff, at least one of which must be the administrator, owner, a board member, or other individual in a leadership role; and d. The Infection Preventionist .

This citation will have two deficient practice statements: A and B A. Based on interview and record review the facility failed to implement a system for recording and tracking communicable disease during an outbreak of respiratory illness (Covid-19), resulting in the potential for further spread of the virus to 23 un-infected residents. Findings include: During review of the facility's infection surveillance documents on 7/8/2024 at 10:31 a.m., the Director of Nursing (DON) reported the facility had an outbreak of Covid-19 in March 2024. The DON reported she was the acting facility Infection Preventionist. A request was made to review the outbreak investigation and surveillance. The DON stated she did not have a written summary of the outbreak but did have a record she used to present at the facility QAPI (Quality Assurance and Performance Improvement) meetings. Review of the Infection Control Monthly Report, dated 3/2024 and provided by the DON, revealed the following, in part: Covid positive, no hospitalization s, minor symptoms. No further positive after 3/5 [3/05/2024] . There were five resident names listed as being Covid-19 positive with the date 3/5/24 written next to each name. The DON reported 3/5/24 was the day testing was completed in the facility in response to a staff member becoming ill and subsequently testing positive for Covid-19. The DON could not provide information on the listed Covid-19 positive resident's symptoms, including what the symptoms were, when symptoms began or when the symptoms resolved. The DON stated all residents and staff were found to be negative through testing conducted on 3/06/24 and 3/08/24. The DON reported she did not systematically track infections which did not require antibiotic use. When asked if all communicable disease required antibiotic use, the DON stated no and that she understood the concern. The DON reported all residents with signs and symptoms of infectious disease were discussed with staff in a daily morning meeting, so staff were aware, but no official record of onset or resolution of illness was kept unless the resident was prescribed an antibiotic. Review of the facility policy titled Infection Control Surveillance and Outbreak Policy, last revised on 6/27/2024, revealed the following, in part: The purpose of the surveillance program is to determine the incidence and prevalence of nosocomial infections [facility-acquired infections] in order to implement strategies designed to prevent disease transmission . after the outbreak a Root Cause Analysis (RCA) will be done to identify and address performance improvement opportunities . On 7/8/2024 at 1:00 p.m., a request was made for all infection surveillance documents related to the March 2024 Covid-19 outbreak. A review of the documents revealed no RCA to identify what the facility did to mitigate the risk of spread of Covid-19, if the actions were effective, or if improvement was needed to mitigate the risk if another outbreak of respiratory illness should occur. 13791 Part B: Based on observation, interview and record review, the facility failed to develop and implement laundry policies and procedures for residents' personal laundry, to prevent the transmission of resistant and difficult to eliminate pathogen infection. This deficient practice had the potential to affect all 26 residents. Findings include: On 7/1/24 a review of the facility's infection control policy for performing laundry services for transmission based pathogen sourced (including residents with C. diff; MRSA and Covid) laundry was reviewed. The policy was titled: Laundry Policy with an origination date of 7/11/23; Last Approved Date of 6/27/2024; and a Last Revised Date of 7/11/2023. Components of the policy stated the following: D. Laundry equipment will be used and maintained according to manufacturer's instructions. E. Laundry may be processed with low-temperature processes: 1. Low-temperature cycles: Wash with chemicals suitable for low-temperature washing at the proper concentration. 2. A 125 part per million (PPM) chlorine bleach rinse will be used to destroy microorganisms whenever possible. The section titled: Potentially contaminated laundry with Clostridium Difficile (C. Diff) stated: A. Laundry considered contaminated by C. Diff will be bagged in a red bag. Only items in red bags will be washed in the same load. B. Staff will wash the clothing with the following procedure: 1. 1/2 cup of bleach will be added once washer is full of hot water. 2. 1/2 cup of detergent then let machine agitate briefly. 3. Dump red bag into washer and run through the normal cycle. C. Bleach water should be a 1:10 bleach dilution as recommended by CDC On 7/2/24 at approximately 10:00 AM an interview was conducted with the Director of Nursing (DON) regarding the handling of potentially contaminated resident's personal clothing. The DON acknowledged the above policy was used with staff were using washing machines located on the resident unit, but stated staff no longer conducted laundry services of personal items from TBP (Transmission Based Precaution) sourced rooms. The DON stated this potentially contaminated laundry was sent down stairs and done by hospital laundry staff. The DON also acknowledged the some of the policy statements did not make sense including the use of 1:10 bleach dilution for laundry, which is generally a housekeeping and cleaning of high touch surface criteria. On 7/2/24 at approximately 10:30 AM, an interview was conducted with the hospital laundry manager (LM) B; Laundry staff (LS) C and maintenance supervisor (MS) D. It was learned the laundry department used yellow bags for potentially contaminated TBP sourced laundry from the long term care unit, in difference to the stated red bags. Also learned was that no added bleach or high water temperature wash cycles were used when cleaning these laundries. Upon looking behind the one washing machine used for this purpose, MS D identified the chemicals being dispensed into the machine were not connected correctly, stating that two of the buckets of chemicals were the same. Both LM B and LS C stated they were unaware of the need to utilize a chlorine disinfectant or monitor the levels of the disinfectant when used. The facility policy did not address the need to ensure that proper levels of the disinfectant were met during the washing process of the TBP sourced residents' clothing.

Based on interview and record review, the facility failed to ensure a qualified Infection Preventionist worked at least part-time at the facility and was present to properly assess, implement, and manage the Infection Prevention and Control Program resulting in the lack of outbreak surveillance and investigation and tracking of communicable diseases. Findings include: During an interview on 7/8/2024 at 10:31 p.m., the Director of Nursing reported she conducted all infection prevention and control duties for the facility. The DON reported she was in the process of completing an approved Infection Preventionist course but was having trouble finding the time. The DON stated Registered Nurse (RN) L was also in the process of completing the Infection Preventionist training, but neither the DON nor RN L had completed the courses as of 7/8/2024. The DON stated the hospital affiliate Infection Preventionist, RN Q acted as a resource for the facility Infection Prevention and Control Program. When asked how involved RN Q was in conducting infection prevention and control surveillance for the facility, the DON reported RN Q was a resource only, did perform actual oversight of the program and was not in the facility at least part-time. Review of the facility Infection Control Program with the DON at the time of the interview, revealed no outbreak investigation or symptom tracking for an outbreak of Covid-19 in March 2024. In addition, the DON reported she did not systematically track infections which did not require antibiotic use. When asked if all communicable disease required antibiotic use, the DON stated no and that she understood the concern. The DON reported all residents with signs and symptoms of infectious disease were discussed with staff in a daily morning meeting, so staff were aware, but no official record of onset or resolution of illness was kept unless the resident was prescribed an antibiotic. Review of the facility policy titled Infection Control Surveillance and Outbreak Policy, last revised 6/27/2024, and presented on 7/1/2024 at 11:31 a.m. as the facility guideline for the Infection Prevention and Control Program, revealed the policy did not include information regarding the regulatory need for a qualified Infection Preventionist to work on-site at least part-time in the facility.

Based on interview and record review, the facility failed to notify the resident in writing with the reason for a transfer out of the facility for three Residents (R82, R186, R27) of three residents reviewed for transfers. Findings include: Resident #82 (R82) A review of the facility census revealed R82 was sent to an acute care hospital with primary diagnosis of acute anemia from 6/10/24-6/21/24. R82 was again sent to an acute care hospital with primary diagnosis of acute blood loss anemia from 6/24/24-6/28/24. A review of R82's progress notes revealed the following: 1. 6/10/24: Guest SpO2 (oxygen saturation) in mid to high 70's on 3 L (liters) while at rest .MD (Medical Director) updated via page .order received to send to ED (Emergency Department) for eval (evaluation) and treat . 2. 6/21/24 Admission Details: arrived by ambulance. 3. 6/24/24: .Guest requested pain medication for 7/10 pain, something for nausea and dizziness. Approx (Approximately) 15 min (minutes) later CNA (Certified Nurse Aide) approached nurse stating (R82) is reporting she can't breathe. SpO2 taken 82% on 4 L via high flow tubing .order received to transport to ED .CNA and (R82) left unit via gurney . 4. 6/28/24: Admission Details: Arrived by ambulance. Review of the EMR for R82 revealed no written transfer notice. 49302 Resident #186 (R186): A review of the facility census revealed R186 was sent to an acute care hospital with the primary diagnosis of acute respiratory failure with hypoxemia (low blood oxygen levels) from 6/15/23 - 6/23/24. A review of R186's progress notes revealed the following: 1. 6/18/24: CNA [certified nursing assistant] wheeled resident out of dining room, verbalizing that she sounds course. Upon assessment VS [vital signs] were Sp02 [oxygen saturation] 55% on RA [room air], 110 pulse, 98.3 T [temperature], BP [blood pressure] 106/73, lungs course, resident unable to verbalize if she had SOB [shortness of breath] due to dementia .paged hospitalist .arrived to floor, assessed and ordered to send to ED [emergency department] . 2. 6/24/24 [late entry]: Admission summary . Reported that Res [resident] arrived at the facility 1800 hrs [hours] . Review of the Electronic Medical Record (EMR) for R186 revealed no written transfer notice. Resident #27 (R27): A review of the facility census revealed R27 was sent to an acute care hospital with primary diagnosis of leukocytosis and severe hypokalemia from 5/19/24 - 6/6/24. A review of R27's progress notes revealed the following: 1. 5/19/24, Transfer to Hospital Summary: Notified on-call provider .of [R27]'s worsening decline with visual hallucinations .Her BMP [basic metabolic panel] resulted with a critically low potassium .received verbal orders to send to emergency room for evaluation and treatment 2. 6/6/24, Clinical Admission: .Arrive by ambulance .readmit from hospital . Review of the EMR for R27 revealed no written transfer notice. On 7/3/24 at 2:04 PM, an interview was conducted with Business Officer Manager (BOM) P who verified residents and/or resident's representatives were not issued a notification in writing upon transfer or discharge. BOM P stated, I've never completed a transfer agreement .I wasn't trained to do so. A facility-initiated transfer policy was not provided by the time of survey exit.

Based on observation, interview and record review the facility failed to safely provide assistance with wheelchair mobility for three Residents (R6, R14, R186) and failed to investigate the root cause of self-injurious behavior for one Resident (R3) of four residents reviewed for accidents and supervision. This deficient practice resulted in the potential for injury related to unsafe wheelchair mobility assistance and the potential for continued self-injurious behavior. Findings include: Resident #6 (R6) On 7/2/24 at approximately 12:30 p.m. during an observation of the lunch meal service in the main dining room, R6 was observed being provided assistance by Certified Nurse Aide (CNA) S to a table while sitting in his wheelchair. R6's wheelchair did not have foot pedals in place, and R6's feet were noted to be scraping on the ground as he was being pushed by CNA S. R6 was noted to be wearing socks with grippers on the bottom. Resident #14 (R14) On 7/2/24 at approximately 12:30 p.m. during an observation of the lunch meal service in the main dining room, R14 was observed to be assisted by CNA T to a table while sitting in her wheelchair. R14's wheelchair did not have foot pedals in place, and R14 was attempting to move her feet while being assisted to a table. R14 was noted to be wearing socks with grippers on the bottom. 41978 R186 An observation on 7/3/2024 at 8:10 a.m., revealed R186 in a wheelchair, self-propelling toward the nurses' station on the East Hall. R186 stopping at the nurses' station and spoke with RN G, who advised R186 to continue down to the dining room for breakfast. R186 asked where the dining room was located at which time RN G called down the hall to an unidentified staff member to assist R186 to the dining room. The unidentified staff member was observed pushing R186 down the hall in her wheelchair with R186 holding her feet up approximately two inches off the floor. It was noted there were no foot pedals attached to the wheelchair for R186 to place her feet on. During an interview immediately following the observation, RN G stated staff rarely used foot pedals for residents that could self-propel. When asked the reason why foot pedals were not utilized, RN G reported staff would have to travel back to the resident's rooms to obtain the foot pedals and time did not allow for that. When asked if there was concern not using foot pedals could cause injury or accidents, RN G stated she understood the concerns and there was a potential for resident's to not understand the need to hold their feet off the floor resulting in injury or falls. R3 Review of R3's Minimum Data Set (MDS) assessment, dated 5/29/2024, revealed R3 was admitted on [DATE] with a primary diagnosis of dementia. Further review of R3's MDS assessment revealed a Staff Assessment for Mental Status indicating R3 had short- and long-term memory problems and severely impaired cognitive skills for daily decision-making. An observation on 7/2/2024 at 8:41 a.m., revealed R3 in her room, seated in a reclining wheelchair. R3 appeared restless and was observed moving her legs side to side while seated in the chair. A pan-type motion detection device was positioned on the footrest of the chair, near R3's left knee. Review of R3's Electronic Medical Record (EMR) revealed the following clinical progress note: 2/27/2024 5:57 [a.m.]. At 0500 [5:00 a.m.] CNA [Certified Nurse Aide] staff alerted this nurse to [R3] wrapping the call light cord around her neck. [R3] fought with CNA staff as they were removing it. No marks or skin issues were observed. Call button was removed from reach and bell placed on her bedside table to use for calling for assistance. The note was entered by Licensed Practical Nurse (LPN) N. Review of R3's Occurrence History documentation provided by the Director of Nursing (DON) revealed no report related to the incident on 2/27/2024 when R3 was found wrapping the call light cord around her neck. On 7/3/2024 at 11:39 a.m., the DON reported she was unaware of an incident involving R3 being found wrapping a call light around her neck. The DON confirmed there was no investigation initiated by the facility related to the incident. The DON was shown by this Surveyor, the entry in the progress notes dated 2/27/2024 at 5:57 a.m. The DON stated the incident should have been taken more seriously and reported to administration to allow for investigation into the root cause of the behavior to determine if R3 had thoughts of self-harm or other behavior posing a threat to her safety. The DON stated she was concerned the incident was not reported to her. The DON reported she would follow-up on the incident. A call was place to LPN N on 7/3/2024 at 1:29 p.m. and a message was left for a return call to discuss the survey. No call back was received by the end of the survey. During an interview on 7/8/2024 at 12:22 p.m., RN M reported the DON asked her about the incident involving R3 being found wrapping the call light cord around her neck on 2/27/2024. RN M stated she was unaware of the incident prior to the DON's inquiry on 7/3/2024. RN M stated she spoke to LPN N after being alerted to the incident but had no further information to offer. RN M reported R3 could not purposely use a call light and no longer had a call light within her sight but used a motion detection device placed near her thigh to alert staff of her movements. During a telephone interview on 7/8/2024 at 1:03 p.m., CNA O confirmed she found R3 on 2/27/24 in bed with the call light cord around her neck. CNA O stated she worked with R3 often and R3 was impulsive at times and not aware of her own safety. CNA O stated R3 needed to be checked on frequently to ensure her safety and after the incident they placed the call light cord out of R3's reach. CNA O was unsure why R3 wrapped the cord around her neck. CNA O reported R3 was not observed exhibiting self-harmful behaviors since the incident and the incident seemed to be isolated. On 7/8/2024 at 12:27 p.m., the DON reported no investigation into the incident was initiated after alerting her to the incident on 7/3/2024 at 11:39 a.m. The DON stated she did not know more information was required by the survey team regarding the incident therefore did not feel the need to investigate at that time. A query was made as to whether the DON spoke with RN N or CNA O regarding the incident to which she answered she did not. The facility policy related to resident supervision and safety was requested from the DON on 7/3/2024 at 2:45 p.m. No policy was received by the end of the survey on 7/8/2024.

Based on observation, interview, and record review, the facility failed to prevent, assess, treat, and avoid worsening of a pressure ulcer which resulted in the development of cellulitis within a stage 2 pressure ulcer. These deficiencies resulted in worsening of a stage 2 pressure ulcer into a stage 4 pressure ulcer, additional multiple stage 2 pressure ulcers to develop, required hospitalization , and provided for the increased likelihood of serious complications including sepsis, further hospitalization , and death for one Resident (Resident #10) of two residents reviewed for pressure ulcers. Findings include: Resident #10 was admitted on [DATE] to the facility without pressure ulcer on his left buttocks. Resident #10 developed multiple stage 2 pressure ulcers on 4/28/23 including both buttocks. Resident #10 subsequently developed cellulitis in one of the pressure ulcers, was sent to the hospital on 5/17/23. While at the hospital Resident #10 required surgical debridement, additional antibiotics, and a wound vac. On 9/28/23, the Director of Nursing (DON) and the Nursing Home Administrator (NHA) were notified of the Immediate Jeopardy that began on 5/10/23, when R10 developed a facility acquired pressure ulcer, that worsened to a stage 4 pressure ulcer, leading to hospitalization , antibiotics, and surgical intervention. The Surveyor confirmed by observation, interview, and record review, that the Immediate Jeopardy was removed on 9/29/23 at 2:15 PM, but noncompliance remained at the lower scope and severity of potential for harm that was not immediate jeopardy due to sustained compliance that has not been verified by the State Agency. Resident #10 (R10) Review of a Face Sheet revealed R10 was originally admitted on [DATE], with pertinent diagnoses of diabetes mellitus, muscle weakness, and open wounds to bilateral feet. Review of R10's Admission Minimum Data Set (MDS) assessment, dated 4/18/22 revealed a risk for developing pressure ulcers and R10 had an existing stage 2 pressure ulcer. A subsequent five-day MDS for R10, dated 6/8/22 revealed an existing stage 2 pressure ulcer and the development of two additional stage 2 pressure ulcers. R10 was cognitively intact, with a Brief Interview for Mental Status (BIMS) of 15/15. Review of R10's Admission Assessment, completed 4/13/22, reflected a clinical note .Patient's skin is with issues. Bilateral feet have dressings that were completed prior to patient's hospital discharge 4/13/22. Feet have erupted bolus (sic) related to edema . Review of R10's Clinical Note, dated 4/14/22, read in part, Resident admitted to the facility with a stage 2 pressure ulcer to coccyx measures 2 x 2 x 0.1 . (Note: Did not specify unit of measurement.) Review of R10's Clinical Note, dated 4/15/22, read in part, .notified of an open area just below patient's right buttock 2.6 x 1 cm (centimeter) sheered open area . Review of the Care Plan for R10, date printed 9/27/23, read in part, Problems: .is at risk for alteration in skin integrity .range of motion deficit .bowel incontinence, Foley catheter .non-ambulatory .Interventions: 2 assist with bed mobility/repositioning during care rounds and as needed .Observe skin integrity during cares, bathing/showers and weekly skin checks for signs and symptoms of alterations and report accordingly .treatment to right buttock pressure ulcer as ordered .Foley catheter to aid in wound healing . Review of R10's Braden Scale (a tool used to predict the likelihood of a resident to develop a pressure ulcer), dated 4/18/23, reflected R10 was at risk for developing a pressure ulcer. Review of R10's Physician Orders, dated 4/14/22 through 9/27/23, revealed orders for Clear Zinc Barrier Cream, to buttocks, start date 4/14/22 through 1/18/23. A second order for Magic Butt Cream, to buttocks, had a start date 1/19/23 through 5/18/23. On 9/27/23 at 8:30 AM, an interview was conducted with R10 who was lying in bed on his back. R10 was asked about any skin conditions on his backside and confirmed he did have a stage 4 pressure ulcer to his right buttock. R10 had an observed wound vac (a type of therapy for wounds) powered on at the bedside on the nightstand with the tubing from the wound vac leading to R10's buttock area. The wound vac, per R10 was making a lot of racket. An observation was made of the wound vac, which indicated an improper seal and was fluctuating pressure from 65 to 125 millimeters of mercury (mmHg) on the screen. The wound vac canister was a third full of serosanguinous drainage from R10's stage IV pressure ulcer. R10 stated he had additional sores on his left buttocks. On 9/27/23 at 8:45 AM, an interview was conducted with Licensed Practical Nurse (LPN) D, who was asked if R10's wound vac was working properly and replied, I need to take a look at the dressing, but it sounds like the dressing is not properly sealed. On 9/27/23 at 12:00 PM, an observation was made of R10 sitting up in his wheelchair in his room. On 9/27/23 at 2:15 PM, a second observation was made of R10 sitting up in his wheelchair in his room. (Note: Remained in the same position and was not offered repositioning or off loading during this time or reminded to make small positioning changes while up in his wheelchair.) On 9/27/23 at 2:30 PM, an observation was made of R10's pressure ulcers to his bilateral buttock with Registered Nurse (RN) A and LPN D. LPN D had already removed all R10's dressings and cleaned his wounds. R10 was lying in bed on his right-side with his back side exposed. RN A did measurements as follows: a.) Left upper buttock, stage 2, measured 4.9 x 3.8 cm, and appeared yellow base tissue, b.) Left lower buttock, stage 2, measured 2.5 x 1.3, and appeared yellow base tissue, c.) Sacral mid, stage 2, measured 1.5 x 0.8 cm, and appeared yellow base tissue, d.) Right mid buttock to the 7 to 11 o'clock side of the stage 4 pressure ulcer a C shaped stage 2 mostly pink and open in the middle portion with a yellow base tissue and measured 0.5 cm, e.) Right buttock gluteal cleft, stage 4 (with wound vac), measured 6.5 x 5 x 4.3 cm depth, on the boarder dark purple portions at 1 - 11 - and 9 through 7 o'clock, and in the wound bed slough was noted, f.) Right buttock distal to the stage 4 in the 12 to 2 o'clock area, measured 5.5 x 5.5 unstageable circular area covered in patched of dark purple, yellow, and red in various portions. Review of facility Wound Care Log, no date, page one revealed R10 had five facility acquired wounds as follows: a.) Stage 2 on to left lower buttock, started on 3/3/23, and measured 2 x 2, b.) Stage 2 on right lower buttock, started on 3/3/23, and measured 3 x 3, c.) Split in gluteal cleft right side, started on 3/3/23, and measured 4 x 0.5, d.) Stage 2 left center buttock, started on 3/10/23, and measured 2 x 2, e.) Stage 2 right center buttock, started on 3/10/23, and measured 2 x 2. Review of R10's Long Term Care Physician Progress Note, dated 3/8/23 lacked any documentation of facility acquired stage 2 pressure ulcers or any new orders related to treatment of the pressure ulcers. On 9/28/23 at 10:00 AM, an interview was conducted with RN A, who was asked about R10's pressure ulcers. RN A stated that she and the DON recently took over wound care monitoring and management in the last two weeks. RN A confirmed R10 had some facility acquired pressure ulcers on his buttocks. RN A confirmed R10 had two stage 2 pressure ulcers on his left buttock and one stage 2 and a stage 4 pressure ulcer that were all facility acquired that started the end of April 2023. Further interview with RN A confirmed she and the DON took over wound care and management related to inconsistencies related to wound care measurements (not having unit of measurement in documentation and not completed weekly), interventions, lack of physician oversight, and communication with the physician regarding pressure ulcer care. RN A also confirmed the prior wound care nurse was not certified. On 9/28/23 at 10:30 AM, a policy for pressure ulcer care was requested. This surveyor was notified that the facility did not have a policy specific to pressure ulcer care and the only policy the facility had was titled, Wound Treatment Management. Review of the Census tab for R10, revealed an admission to the hospital on 5/17/23 through 5/23/23. Review of R10's Weekly Skin Assessments, dated from 2/6/23 through 5/15/23, revealed a single question, Did you notice any new skin issues? All R10's weekly skin assessments were answered with a No. Review of facility Wound Care Log, no date, page two revealed R10 had three facility acquired wounds as follows: a.) Stage 2 left buttock, started on 4/15/23, and measured 1 x 1, b.) Stage 2 left buttock, started on 4/28/23, and measured 1.5 x 1.5, c.) Stage 2 right buttock, started on 4/28/23, and measured 2 x 2. Review of R10's Clinical Note, dated 4/16/23, read Resident has a new stage 2 pressure ulcer to left buttock which measures approximately 1 x 1 with wound bed having pink granulation present, no odor or drainage noted, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, will continue with .magic butt cream . Review of R10's Clinical Note, dated 4/19/23, from Certified Dietary Manager (CDM) B read in part .Left buttocks pink, sheared, small open area per nursing notes. Resident with level 7 diet with variable food average 50-100% with most meals 100% .multi-vitamin everyday ordered for resident to facilitate healing. Will monitor status ongoing. Review of R10's Clinical Note, dated 4/28/23, read in part Resident has a new stage 2 pressure ulcer to left buttock which measures approximately 1.5 x 1.5 with wound bed having pink granulation present, no odor or drainage noted, there is a new stage 2 pressure ulcer to right buttock that measures 2 x 2, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, also a lot of scar tissue present in gluteal cleft will continue .magic butt cream . Review of R10's Clinical Note, dated 5/4/23 at 6:38 AM, read in part Notified by Certified Nurse Aide (CNA) of change in wound status from pink to red .per communications from management, notified on-call provider of change in patient status. Wound was reddened, hot, firm to touch, and painful when pressed per resident .probable cellulitis (a bacterial infection of the skin), started on amoxicillin and doxycycline .Nurse Practitioner (NP) stated need for follow-up and further monitoring by wound care nurse and day providers . Review of R10's Long Term Care Progress Note, from NP F dated 5/4/23, read in part Encounter info: Cellulitis; called by nursing in regards to concerns for possible cellulitis on the right hip, patient has what appears to be a pressure sore on the right gluteal fold, redness noted above that wound appears to be cellulitis. Reddened area is warm to touch, no fluctuance felt .Plan: .started on amoxicillin twice daily and doxycycline twice daily for 5 days. Wound care to evaluate patient for open wound and provide interventions .Patient will need follow-up to ensure resolution. Review of R10's Clinical Note, dated 5/4/23 at 3:14 PM, read in part, .he continues oral antibiotics for cellulitis .redness noted to right hip .there is an area that is firm, warm to the touch more erythematous than the other areas .the DON observed the area .Magic butt cream applied to buttocks per order .will continue to monitor for changes. Probiotic order was processed . Review of R10's Clinical Note, dated 5/6/23, read in part .magic butt paste applied to buttocks, open area with shearing present .will continue to monitor. Review of R10's Clinical Note, dated 5/9/23, read in part .Magic butt cream applied to buttocks per order .there is an area that is firm, warm to the touch more erythematous (and blanchable) on his right hip/butt .doctor was in to assess cellulitis today and extended his antibiotics .and also ordered a foley catheter to help promote wound healing to his buttocks, as he is incontinent .will continue to monitor for changes. (Note: No physician documentation dictated regarding the visit.) Review of R10's Clinical Note, dated 5/12/23, read in part Resident continues with stage 2 pressure ulcer to left buttock which measures approximately 1.5 x 1.5 with wound bed having pink granulation present, no odor or drainage noted, continues with stage 2 pressure ulcer to right buttock that now measures 8 x 3, some serosanguinous drainage noted peri wound is reddened but blanchable, continues with area of reddened and hard tissue on right buttocks which is being treated for cellulitis, buttocks have large amounts of shearing on both sides, area is reddened but blanchable, also a lot of scar tissue present in gluteal cleft will continue with .magic butt cream . (Note: measurements on wound care log were dated 5/10/23 and lacked physician communication of increase in wound size). Review of R10's Hospital Summary, dated 5/17/23, read in part .Diagnoses this visit: Pressure injury of buttock, stage 4 .Hospital Course: .Patient was continued on vancomycin, taken to OR (operating room) on 5/18/23 for incision and drainage, he was found to have a stage 4 pressure ulcer, it was unroofed and debrided. Final measurements of the wound 12 cm x 7 cm in area, 2 cm in depth and I cm of undermining at the superior edge with 1 cm of underlying at the inferior lateral aspect .Wound care was consulted, patient continues with enzymatic debridement .plan is to transition to a wound VAC (negative-pressure wound therapy, also known as a vacuum assisted closure, is a therapeutic technique using a suction pump, tubing and dressing to remove excess exudate and promote healing) . Review of facility Wound Care Log, no date, page three revealed R10 had three facility acquired wounds as follows: a.) Stage 2 left buttock, started on 4/28/23, and measured 1.5 x 1.5, b.) Stage 2 right buttock, started 4/28/23, and measured 2 x 2 - Measured 8 x 3 on 5/10/23 - Measured 14 x 6 x 2 on 5/24/23 with tunneling at bottom and at right of wound approximately 2 - 2.5 and now a stage 4 pressure ulcer. Review of R10's Clinical Note, dated 5/24/23, read in part Resident admitted back to the facility yesterday after hospitalization .stage 4 pressure ulcer measures 14 x 6 x 2 and there is tunneling at the bottom of the wound and the left side of the wound that measures approximately 2-2.5. The left and bottom of the wound still has yellow slough present in the wound bed, the rest of the wound bed has red beefy tissue present, there was no odor from the wound itself but the old dressing did have odor, there was some serous drainage noted from the wound, treatment at this time consists of flushing the wound with normal saline, applying a chemical wound debriding agent to the wound base, then applying a wet to dry dressing . Review of R10's Surgical Progress Note, dated 5/30/23, read in part Patient was briefly evaluated on Friday, 5/26/23 prior to placement of wound VAC on right buttock. He had debridement of a necrotic pressure ulcer .Wound bed is approximately 80% healthy pink granulation tissue. Recommend starting wound VAC today. Reevaluate next week to see if any further debridement is needed. Review of R10's EMR progress notes and wound care log, from 6/7/23 through 6/18/23, revealed the lack of measurements of his stage 4 pressure ulcer (thirteen days). Review of R10's EMR progress notes and wound care log, from 8/17/23 through 8/25/23, revealed the lack of measurements of his stage 4 pressure ulcer (nine days). Review of R10's Clinical Notes, from 9/6/23 through 9/20/23, lacked any wound care measurement notes (fourteen days). On 9/28/23 at 11:30 AM, an interview was conducted with the DON. The DON was asked where the pressure ulcer measurements are documented and replied, The pressure ulcer wound care measurements are documented in the progress notes weekly in the EMR and no other place. The DON agreed that it is difficult to see any changes in pressure ulcer conditions if they are not documented in the EMR consistently. The DON had no explanation of why the pressure ulcer lacked consistent documentation weekly or why communication of the pressure ulcer worsening and increasing in size was not consistent. On 9/28/23 at 12:30 PM, an interview was conducted with the DON and RN A regarding R10's stage 4 pressure ulcer to his left buttocks, gluteal fold area. The DON stated that she was the primary care provider for R10 up until mid-April 2023 and another group of physicians took over and there was an unknown gap in supervision of wound care by a provider. The DON was asked if she observed R10's skin on his backside/buttocks area when she completed a visit on 3/8/23 and replied, I do not recall if I looked at his skin. The DON was asked if she was aware that R10, at the time of her visit on 3/8/23, had three open areas on his buttocks which were documented to start on 3/3/23. The DON was also asked about the two additional open areas which developed on 3/10/23 and replied, I do not recall. If I did not chart on them, then I most likely did not see them. What I do remember is [RN A] coming to me and we looked at it together at the same time and that was about two weeks ago. The DON and RN A were asked when they both took over wound care in the facility and both replied, Two weeks ago when we decided we needed to make changes because of what we were seeing. RN A was asked if she felt the wound care logs were correct and replied, I think they do not match and there are some incorrect entries. I was always taught to go by the nurses' notes when completing the MDS forms. The DON replied, I think you might be able to refer back to the sizes in some instances, but I would say rely on the nurses' notes. In review of the physician notes R10 was seen on 3/8/23 and then the next physician note is dated 5/4/23 is that correct? RN A replied, That is probably correct. I believe we printed all of them. The DON was asked if the wound was seen by a physician when it increased in size and replied, If there was a note. No. I do not think so. I do not see a note. I just see orders for cream and no dressing changes. RN A was asked about the wound care log and the dates of the resolved wounds on 5/18/23 when R10 was not even in the facility and replied, He was discharged , and it was poor wording. The wounds were not resolved. The DON was asked if there were any additional wound care measurements after 9/6/23 and replied, Not until we measured it on 9/20/23. RN A replied, I have not put measurements in yet from 9/27/23. On 9/29/23 at 11:40 AM, an interview was conducted with R10, who stated, I have been lying on my left side for three hours. On 9/29/23 at 2:45 PM, a second observation was made of R10's bilateral buttock. RN A, the DON, and LPN D were present. RN A measured the wounds, and the DON recorded the findings as follows: a.) Left buttocks, stage 2, and measured 2 x 1.5 cm. b.) Left gluteal fold, stage 2, and measured 0.3 X 1.6 cm, c.) Sacral mid, stage 2, and measured 4 x 3.7 cm, d.) Right buttocks C shaped, stage 2, measured 5.5 x 0.4 cm, e.) Right buttock lateral redness, measured 2.7 x 1.9 cm, f.) Right buttocks lower, stage 2, measured 1.6 x 1 cm, g.) Right buttock gluteal fold, stage 4, measured 5.2 x 5.5 x at 4 o'clock depth 2.6, at 12 o'clock depth 3.9 cm, and at the distal base measured 4.5 x 5.8 cm, circular area and at 7 and 8 o'clock dark purple around crest, with approximately 35% dark within the circular area along with other tissue colors of red, yellow and slough. Review of facility policy titled, Wound Treatment Management, dated 2/1/23, 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 .8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. B. Changes in the characteristics of the wound . Review of facility policy titled, Skin Risk Assessment and Prevention Protocol, dated 6/14/22, read in part, Purpose: Prevention of pressure injuries begins with the identification of persons at risk for developing pressure injury .G. Communication of pressure injury development, risk assessment, skin inspection results, and treatments will be consistent. Any change in skin condition is communicated to Wound Care Nurse and providers as soon as observed .Minimize Pressure: a. Assess for immobility .J. Encourage patients to make frequent, small position changes. K. Use pillows or wedge to reduce pressure on bony prominences. L. At a minimum nurses should turn patient every two hours .N. If the patient's condition limits repositioning, still attempt to off-load pressure .P. Patient's in a sitting position: 1. Encourage patients to shift weight every 15 minutes. Reposition every hour if patient is unable to reposition self . Review of facility policy titled, Physician Visits, dated 7/12/23, read in part, Purpose: It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents .3. The resident must be evaluated at a minimum once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law .B. The Director of Nursing or Designee should: 1. Conduct monthly audits for timeliness of physician visits. 2. Contact the physician regarding an overdue physician visit. Record the physician's response regarding the overdue visit in the nurse's notes. 3. Notify the Medical Director of the need to make a visit, for the attending physician, if he/she is unable to visit. The Immediate Jeopardy that began on 5/10/23 and was removed on 9/29/23 when the facility took the following actions to remove the immediacy. 9/28/2023 1. Developed new paper-based skin assessment for weekly nursing skin assessment. 2. Developed new paper-based skin assessment for Wound Team use. Used weekly and PRN as identified by Wound Team. 3. Wound Team formally identified as MDS coordinator and Director of Nursing. 4. All residents: skin assessment performed by nursing with any suspected deep tissue injury identified over the next 24 hours. 5. Staff notified at each change of shift of date and time of onset of citation and abatement plan. 6. Medical director notified of abatement plan, 1900. 7. Policy drafted for Pressure Injury Focus Meeting. Pressure Injury Focus Meeting will be added to the current weekly interdisciplinary team meeting each Thursday. 9/29/2023 1. Wound Team to re-assess variances identified in the skin assessments performed 9/28/2023 & 9/29/2023. Skin assessments were completed on all residents by 1000 9/29/2023. 2. Interdisciplinary team special meeting to review skin assessments, discuss changes to meetings, and review new policy regarding Pressure Injury Focus Meeting and draft policies, and to develop meeting schedule for ongoing changes regarding overall wound care process. Residents requiring physician/provider assessment to be identified and communicated to medical director. Scheduled for 1545. 3. Drafting pressure injury policy with specifics for pressure injury a. Twice weekly skin assessment by Wound Care Team b. Turning schedule reviewed with staff and placed in resident room c. Review of pressure injury every 10-14 days with medical director or designee 4. Hospital wound care nurse in-service at 1415 for CENAs, RNs, LPNs, recorded for staff not present today to review at next worked shift. 5. Drafting admission policy stating the initial skin assessment will be conducted with two nurses. Specifically for Resident #10: 9/29/2023 Assessment by Wound Team and Surgical Services provider 1300. Instituted new wound care orders and follow up scheduled for 10/4/2023 with surgical services for debridement. Current interventions: Magic Cup, air mattress, Roho cushion for wheelchair, Ensure once daily, Foley catheter, registered dietician review monthly. Interventions above instituted: Twice weekly skin assessment by Wound Care Team, turning schedule reviewed with staff and placed in resident room, review of pressure injury every 10-14 days with medical director or designee.

Based on observation, interview, and record review, the facility failed to follow infection control practices per their facility policy and the Center for Disease Control (CDC) current recommendations on infection control, infection isolation, and standard and transmission-based precautions for preventing and containing communicable disease outbreaks, including but not limited to: 1) the failure to implement appropriate infection control precautions for two confirmed Coronavirus (COVID-19) positive Residents (#1, #2) and seven Residents (#5, #6, #7, #8, #9, #10, #11) who exhibited symptoms of infection on the non-COVID-19 unit, and 2) the failure to implement appropriate transmission based precautions regarding the use of Personal Protective Equipment (PPE) per CDC guidelines for 14 COVID-19 positive Residents (#1, #2, #3, #4, #13, #14, #15, #16, #17, #18, #19, #20, and #21). These deficient practices had the increased likelihood to affect all residents (many of whom were at high risk due to age and co-morbidities) to be exposed to, or contract COVID-19 infection, increasing the risk of serious health complications of COVID-19, including death. The deficient pratice resulted in an Immediate Jeopardy (IJ) which began on 4/7/20, when the facility received notice of the first direct care staff testing positive for COVID-19, and the facility failed to implement their infection control policy to ensure prevention of COVID-19 transmission. The Administrator and Director of Nursing (DON) were notified of the IJ on 4/29/20 at 9:34 a.m. and a plan to remove the immediacy was requested. The IJ was removed on 4/29/20 at 3:00 p.m., based on the facility initiation of the plan of removal as verified by the Surveyors on-site. Although the IJ was removed on 4/29/20, the facility remained out of compliance at scope of widespread and a severity of potential for more than minimal harm that is not Immediate Jeopardy, until verification of adequate infection control procedures is completed. Findings include: On 4/28/20 at 10:30 a.m., an interview was conducted with the Administrator who reported there were 13 confimed positive cases of COVID-19 and two results (for Residents #1 and #2) had just come back positive this morning. When asked where Residents #1 and #2 were residing, the Administrator reported the two Residents would be moved to the COVID unit as soon as possible, but they were currently on the non-COVID unit. On 4/28/20 at 10:50 a.m., an interview was conducted with Registered Nurse (RN) E. RN E was asked about the two COVID-19 positive Residents (#1 and #2) on her hall. RN E stated Residents #1 and #2 would be moving to the COVID unit soon. When asked about the seven presumptive positive Residents (#5, #6, #7, #8, #9, #10, #11 as noted by RN E), RN E reported they were working on getting things in place for them. On 4/28/20 at 10:55 a.m., observations were made of the non-COVID unit. At 10:58 a.m., the door of the room for Resident #1 and Resident #2 was observed to be open. There was a sign on the door to alert staff that the Residents had an infection. There was a container with PPE in the hallway outside of this room. At 11:00 a.m., RN E was observed donning PPE to enter the room. RN E was wearing a surgical mask but no N95 respirator (particulate mask to prevent inhalation of [MEDICAL CONDITION] particles). On 4/28/20 at 11:01 a.m., Resident #6 was observed in her room with the door open, and was coughing. There was no signage on Resident #6's room door to indicate any infection control precautions were in place. On 4/28/20 at 11:06 a.m., Physical Therapist (PT) F was observed to enter the room of Resident #11 (presumptive positive) with only a surgical mask on. On 4/28/20 at 11:07 a.m., RN E was observed coming out of the room of Residents #1 and #2. She left the room wearing the same surgical mask that she wore into the room with the COVID-19 positive Residents. RN E was observed to go about her duties on the unit without changing the contaminated mask. RN E also left the door of Resident #1 and #2's room open to hallway. On 4/28/20 at 11:10 a.m., PT F was observed entering the room of Residents #5 and #6 (presumptive positive) with only a surgical mask on. On 4/28/20 at 11:14 a.m., a housekeeper/Staff G was observed going down the hallway with her cart. When asked which rooms she was supposed to clean she reported that she was supposed to stay in the 'healthy' Resident rooms and to stay out of rooms 161 (Residents #5 and #6), 162 (Residents #1 and #2), and 163 (Residents #7 and #8). Staff G then proceeded to enter the room of Residents #9 and #10 and clean their room while wearing a surgical mask and gloves. On 4/28/20 at 11:20 a.m., the DON was asked for a list of the presumptive positive Residents for clarification. Then DON asked RN E to write a list of Residents. The list of Residents revealed Residents #5, #6, #7, #8, #9, #10, and #11 were all presumptive positive for COVID-19 infection. When asked about the lack of signage and PPE for these rooms, the DON asked RN E how they were coming along with getting the PPE in place. RN E stated, We're getting it together. On 4/28/20 at 11:22 a.m., RN E was observed entering the room for Resident #11 with only a surgical mask on, no gown and no gloves. On 4/28/20 at 11:25 a.m., an interview was conducted with the DON and the Administrator regarding the facility documents required for Focused Infection Control survey review. When asked why the presumptive positive Residents still had no signs in place at room entrance or PPE in place for staff to use when caring for them, the DON stated, We're working on it. A review of Resident #1's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 started to exhibit symptoms of cough on 4/27/20, and was tested for COVID-19 which came back positive on 4/28/20. A review of Resident #2's medical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #2's medical record revealed she had complaints of nausea on 4/25/20 but had a history of [REDACTED]. On 4/28/20 at 1:12 p.m., the Administrator was asked what time the DON was notified of Resident #1 and and Resident #2's positive COVID-19 test results, and reported the DON was notified 4/28/20 at 6:31 a.m. A review of the facility Patient/Resident COVID-19 Tracking log revealed the 7 presumptive positive Residents were noted with symptoms as follows: Resident #5 on 4/28/20 of lethargy and congestion. Resident #6 on 4/28/20 of cough, nasal congestion, and weakness. Resident #7 on 4/28/20 of cough. Resident #8 on 4/28/20 of malaise. Resident #9 on 4/28/20 of malaise. Resident #10 on 4/28/20 of cough. Resident #11 on 4/28/20 of malaise. On 4/28/20 at 12:28 p.m. during a phone interview the DON was asked who was the facility's infection Control Coordinator. The DON stated, That would be me. When asked about the supply of N95 respirators, the DON stated, We can get them from the hospital (that is attached to the facility). When asked how many they had access to, the DON stated, A few dozen. The DON indicated that they felt they did not need to be using them yet. A review of the document titled, Patient/Resident COVID-19 Tracking revealed only Date of Onset, Date Resolved and whether or not the test was Negative or Positive. There was no indication on the log of when the residents were tested or when the test came back positive. Further review of this log revealed two staff were documented being tested Positive and one Presumed Positive prior to the first Resident case. This tracking log revealed a lack of consistent and collective monitoring of the staff and Resident illnesses. On 4/28/20 at 5:05 p.m., the Administrator was asked to provide what Health Department guidance the facility was following. The Administrator reported that they had been using the state guidance and provided a document titled, Guidance to Protect Residents of Long-Term Care Facilities (upon readmission or current stay) dated 4/9/20. This document revealed, .Certified Nursing Homes must comply with CMS (Centers for Medicare & Medicaid Services) and CDC guidance related to infection control . Identify Infection Early: Screen residents daily for fever and respiratory symptoms: immediately isolate if symptomatic . If COVID-19 is diagnosed in the healthcare worker, Residents should be cared for using recommended PPE until 14 days after last exposure and prioritized for testing if they develop symptoms . HCP (health care professionals) should use recommended PPE . for the care of Residents in the affected area (or facility) . On 4/28/20 at 5:25 p.m. the Administrator was asked to clarify the dates on the Patient/Resident COVID-19 Tracking log. The Administrator reported the date of onset was when the symptoms started, but that an occupational health nurse from the hospital (RN C) tracked the date of testing (and the date it came back as positive or negative). A review of the CDC document titled, Guidance to Protect Residents of Long-Term Care Facilities (Upon Return or Current Stay) dated 4/9/2020 revealed, Key Concepts: .Isolate symptomatic patients as soon as possible. Set up seperate, well ventilated triage areas, place patients with suspected or confirmed COVID in private rooms with the door closed . On 4/28/20 at 10:55 AM, on the COVID-19 designated unit housekeeper/ Staff L was observed performing a terminal cleaning of the first room (room [ROOM NUMBER]) directly on the left upon entering the unit. Staff L was wearing a medical grade facemask, and not an N95 mask or comparable respirator protection during this observation. On 4/28/20 at 11:00 AM, there were a total of five staff, Staff L, RN H, Certified Nurse Aide (CNA) I, CNA J, and CNA K present on the COVID-19 designated unit. All staff were wearing medical grade disposable facemasks, and not an N95 or comparable respirator. There were a total of 11 COVID-19 positive Residents (#3, #4, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21) on the hall at the time of this observation. On 4/28/20 at 11:05 AM, CNA I and CNA J were observed performing a two-person pivot transfer for Resident #4. The top gown ties for CNA J were not tied upon entry to the room of Resident #4. Resident #4 was observed with oxygen provided at two (2) liters per minute via nasal cannula (oxygen tubing inserted into the nose). During the tasks involved with caring for Resident #4, CNA J had to reach up and pull the isolation gown being worn back toward the neck to keep it protecting CNA J's clothes. During this process CNA J contaminated the clothing underneath during one of these occasions with a gloved hand which had already come into contact with Resident #4. CNA I and J proceeded to transfer Resident #4 with their faces within one foot of Resident #4's face. Resident #4 was not wearing any face mask during the procedure. Resident #4 produced a loose non-productive cough while in proximity to the CNAs during the process of the transfer. CNA J continued to have difficulty with keeping the isolation gown up around the neck area while in the process of stripping the bed, and incidentally contaminated self again when reaching to bring the gown back up to their neck area. A review of the Electronic Medical Record (EMR) for Resident #4 revealed the following: Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the line listing for residents who developed COVID-19 revealed Resident #4 developed symptom onset of fever on 4/11/20 and subsequently tested positive for COVID-19. Resident #4 was the first positive COVID-19 in the facility according to the line listing, which gave no date for when the test was done or when the positive result was received. A review of vital signs in the EMR revealed Resident #4 first developed a temperature of 101.8 Fahrenheit (F) on 4/11/20 at 08:49 AM. Two additional temperatures were recorded on 4/11/20. One at 8:49 AM of 102.3 F, and one at 10:50 AM of 100.6 F. A review of the Physician Note by Physician A related to a chief complaint of Fever on 4/8/20 at 16:48 (4:48 PM) revealed the following: . This am patient (Resident #4) noted with Temp 102.1. Staff also note he is much weaker and requiring assistance with transfers . Has chronic cough. States no different than normal . Low suspicion of COVID 19. Keep in isolation tonight. Re-eval (re-evaluation) coming out of isolation tomorrow. There was no record of Resident #4's temperature on 4/8/20 recorded in the progress note of Physician A in the vital sign section of the EMR (referenced above). A review of the progress notes for Resident #4 revealed the following: Progress Note 4/8/20 at 5:19 PM . Resident (#4) placed on droplet isolation . Progress Note 4/9/20 at 12:20 AM . (Resident #4) continues on droplet precautions at this time . Physician A Note 4/9/20 12:48 AM: .I do not feel patient has COVID-19. D/C (discontinue) isolation precautions . Progress Note 4/9/20 at 1:10 PM: . Currently on droplet contact precautions due to fever within last few days . Resident removed from isolation precautions per (Physician A). New orders received and processed. Progress Note 4/11/20 at 2:45 PM: . Resident (#4) placed on precaution due to temp (temperature) of 101.8 F and increased to 102.3 F. Cold compresses applied temp decreased to 99.2 F. At approximately (9:30 AM) temp elevated to 100.6 F. At 1050 (AM) temp decreased (temperature) 98.6 F. At (sic) temp 97.7 F. On call provider notified with elevated temps and placed on isolation precautions Progress Note 4/11/20 at 10:24 PM: . (Resident #4) remains on droplet precautions at this time . Progress Note 4/12/20 at 10:47 PM: . (Resident #4) continues on droplet precautions and has been sneezing this evening . I have no energy. I feel like I have run out of gas before going back to sleep. BP (Blood Pressure) 160/74, P (Pulse) 63, R (Respirations) 20, O2 (Oxygen) sat (Saturations) 90% RA (Room Air) . Physician ANote 4/13/20 at 3:46 PM: . (Resident #4) has had some intermittent fevers . despite appropriate ATB (antibiotic)based on urine cx (culture) results . Fevers 4-11: 102.3 (F), 100.6 (F), 4-12: 99.9 (F), 4-13: 99.4 (F) . Fever. (Resident#4) recently hospitalized and potentially exposed to COVID (-19). Will check swab . Continue to monitor and continue isolation. CBC (Complete Blood Count) does demonstrate leukopenia (low white blood cells) with lymphopenia (low lymph cells (infection fighters)) possibly associated with [MEDICAL CONDITION] infection . Progress Note: 4/14/20 at 10:31 PM: . He continues on droplet precautions and remains PUI (Person Under Investigation(Presumptive Positive)) for (COVID-19) . Physician M Note: 4/16/20 at 12:14 . (Resident #4) was swabbed for COVID-19 and tested positive. Resident (#4) complained of shortness of breath last night. Vital signs were stable at the time with oxygen 92% room air. Supplemental oxygen was placed and (Resident #4) symptoms improved . [DIAGNOSES REDACTED] (Sudden Acute Respiratory Syndrome) CoV2 (Coronavirus) RNA (Ribonucleic Acid (virus coding identifier)) detected (COVID-19). 4/13/20 . COVID-19 with cough and intermittent SOB (shortness of breath): VSS (vital signs stable). Tylenol for fever. Add [MEDICATION NAME] (mucous relief) ER (extended relief) 600 mg (milligram) BID (twice daily) x (times) 7 days. Remain in isolation . On 4/28/20 at 11:15 AM, CNA I was observed doffing (removing) PPE and used gloved hands to doff the gown touching clothing underneath and contaminating clothing. RN H after observing CNA I contaminate herself instructed CNA I how to properly doff PPE. On 4/28/ 20 at 11:15 AM, RN H was observed performing a glucometer check for Resident #3. While gathering supplies for the glucometer check, CNA K was observed squeezing between RN H and CNA J who had their backs to each other. CNA K had gloves and a gown on and came into contact with the exposed backs of RN H and CNAJ. CNA K also placed gloved hands on the exposed back of RN H while maneuvering between RN H and CNA J. RN H proceeded to the room of Resident #3 with the glucometer supplies and situated supplies on the bedside table of Resident #3. The glucometer was placed on papers already sitting on the bedside table of Resident #3 with no barrier provided. RN H then explained to this Surveyor the machine had timed out and had to retrieve another test strip. RN H then proceeded to the hallway and went to the medication cart to retrieve another test strip for the glucometer. RN H then brought the glucometer and supplies back into the room and again set the glucometer on the bedside table with no barrier provided. A review of the EMR for Resident #3 revealed the following: Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the resident line listing for COVID-19 revealed onset date was recorded as 4/26/20 with symptoms of changed lung exam, and unspecified pain and subsequently tested positive for COVID-19. A review of the progress notes in the EMR for Resident #3 revealed the following: Physician M Note: 4/24/20 12:44 PM: . [AGE] year-old male admitted [DATE] after a fall at home resulting in a left humeral head fracture, treated non-operatively. Resident (#3) was transferred to our facility for rehabilitation. The first 2 weeks he was making some progress with therapy. Approximately 2 weeks ago he began to exhibit some regression in his functional status. He is having increased difficulty with transfers. Requires much motivation to work with therapy. Remains moderate assistance x (times) 2 (staff)to stand. Newer behaviors include yelling and swearing at staff. Staff feel (Resident #3) may be giving up . Known exposure to COVID-19. Swab and send to (Hospital) lab .Generalized weakness and debility: Has regressed with therapy, possibly related to [MEDICAL CONDITION] infection . Physician M Note 4/24/20 16:59 COVID-19 swab is positive. On 4/28/20 at 11:30 AM, an interview with CNA K revealed the following: When asked about trying to move between other staff members with isolation PPE worn, CNA K stated, I shouldn't have touched either one of them. CNA K then tried to explain her actions and stated she needed to get to the light being responded to because the Resident (#16) was impulsive. On 4/28/20 at 11:35 AM, Housekeeper Staff L was observed doffing PPE following terminal cleaning of the same room as this Surveyor observed upon entry. Staff L took off the face shield and immediately placed it between his torso and right arm, contaminating their clothing while trying to continue doffing other PPE. On 4/28/20 at 12:15 PM, an interview with the DON revealed the following: When asked if a barrier should be provided for a glucometer prior to setting it down in a resident's environment, the DON stated, Yes, I'll talk to (RN H). On 4/29/19 at 2:00 PM, this Surveyor was entering the COVID-19 unit and observed Physician A exiting the COVID-19 unit. Physician A was wearing a medical grade facemask, not an N95 or comparable respirator. On 4/29/20 at 2:05 PM, CNA K was observed in the COVID-19 unit wearing only a medical grade facemask and not an N95 or comparable respirator. CNA K was assisting Resident #21 with fluid intake. A review of the EMR revealed Resident #21 had a [DIAGNOSES REDACTED]. On 4/29/20 at 2:10 PM, RN H was observed entering the COVID-19 unit, and donned PPE. RN H donned a medical grade facemask and not an N95 or comparable respirator. On 4/29/20 at 2:15 PM, upon exiting the COVID-19 unit a personal stainless steel drinking glass was observed sitting on a supply cart located on the COVID-19 unit. RN H was asked who the cup belonged to, and if it was supposed to be sitting out on a supply cart in an isolation unit. RN H stated the drinking glass belonged to CNA K and stated, Probably not, I will have it removed. On 4/29/20 at 2:30 PM, the DON was asked why staff were not wearing N95 or comparable respirators on the COVID-19 unit. The DON stated the facility was utilizing droplet and contact precautions. The DON stated an N95 was not required for those isolation types. The DON and Physician A confirmed they were not aware of the latest CDC guidance for long term care facilities to implement N95 or comparable respirators for the care of COVID-19 residents. Review of the facility policy Novel [MEDICAL CONDITION] Prevention and Response dated 3/3/20 revealed the following: . 5. Interventions to prevent the spread of respiratory germs within the facility: . b. Monitor residents and employees for fever and respiratory symptoms. ii. In general, for care of residents with undiagnosed respiratory infection use Standard, Contact, and Droplet Precautions with eye protection unless suspected [DIAGNOSES REDACTED].g., [MEDICAL CONDITION]) . . 6. Procedure when COVID-19 is suspected: . f. Implement standard, contact, and airborne precautions (droplet precautions if no airborne isolation room is available). Wear gloves, gown, goggles/face shields, and masks (respirators) upon entering the room and when caring for the resident . . 7. Environmental infection control: . b. Housekeeping staff shall adhere to transmission based precautions . A review of the CDC guidance for Long Term Care facilities https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html (accessed 4/13/20) revealed the following: In addition to the actions described above, these are things facilities should do when there are cases in their facility or sustained transmission in the community . Consider having HCP (Health Care Personnel) wear all recommended PPE (gown, gloves, eye protection, N-95 respirator, if not available, a facemask) for the care of all residents regardless of the presence of symptoms. Implement protocols for extended use of eye protection and facemasks. A review of the CDC guidance for Long Term Care facilities accessed on 4/28/19 revealed the following: . If COVID-19 is suspected, based on evaluation of the resident or prevalence of COVID-19 in the community, follow the Interim Infection Prevention and Control Recommendations for Patients with suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. This guidance includes detailed information regarding recommended PPE, which includes use of an N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e. goggles, or disposable face shield that covers the front and sides of the face), gloves, and gown . because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility wide depending on the situation) is recommended when even a single case among residents or HCP (Health Care Professional) is identified in the facility; this should also be considered when there is sustained transmission in the community . A review of a COVID-19 outbreak timeline provided by the facility revealed the following: 3/26/20 .1. First confirmed case of COVID-19 in (community) . 4/4/20 .1. Pandemic response level raised to level orange. 2. Universal masking begins system wide . 4/6/20 .1. Two confirmed cases of COVID-19 in (community) . 4/7/20 . 3. Employee (Staff N) notified of positive COVID-19 results. 5. Five confirmed cases in (community) . 4/9/20 . 4. COVID-19 widespread in the community at this time . 4/16/20 . (Resident #4) with positive result for COVID-19. First case noted within the facility . Two additional staff members tested positive for COVID-19. 4/18/19 Three additional residents positive for COVID-19. 4/21/20 four additional residents test positive for COVID-19. On 4/30/20 an interview with the DON revealed the following: We started fit testing (masks) yesterday. We did find it (N95 Use recommendations for COVID-19 in Long Term Care) in the CDC guidance. A review of the doffing procedure from the CDC revealed the following: 1. Gloves . Outside of gloves is contaminated! . 2. Goggles or face shield . 3. Gown .4. Mask or Respirator . A review of the facility's Standard Precautions and Transmission Based Precautions policy dated 3/1/19 revealed the following: . Refer to Centers for Disease Control and Prevention (CDC) for transmission based precaution guidelines and recommendations

Based on observation, interview and record review, the facility to failed to have a Registered Dietitian (RD) complete comprehensive nutrition assessments for six high risk Residents (Residents #7, #8, #10, #13, #27, #28) out of 13 reviewed for nutrition, resulting in an Immediate Jeopardy when the facility failed to ensure adequate nutritional care. This deficient practice resulted in inadequate nutritional interventions contributing to significant weight loss (Residents #7, #13, #28), unwanted weight gain (Resident #8) no renal diet modification or guidance (Resident #10), and inadequate nutrient intake via feeding tube (Resident #27) with the likelihood of worsened medical conditions. Immediate Jeopardy was identified at F692 during the recertification survey on 6/12/19 at 1:54 p.m. The Administrator was notified of the Immediate Jeopardy on 6/12/19 at 3:02 p.m., and a plan for Abatement was requested. The immediacy began on 5/11/19 when Resident #27, a high risk Resident dependent on tube feeding, was admitted to the facility. The immediacy was removed on 6/12/19 at approximately 4:00 pm when Physician Assistant I (former RD) began nutrition assessments on the identified high-risk residents. The deficient practice then carried on as a pattern level at harm, until confirmation of the plan of correction. Findings include: Resident #10 A review of Resident #10's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 4/2/19 MDS assessment revealed Resident #10 scored 13 out of 15 on the Brief Interview of Mental Status (BIMS) assessment, indicating intact cognition. A review of Resident #10's medical record revealed no nutritional assessments had been completed since 10/18/18, despite being a high nutritional risk resident due to her comorbidities. A review of Resident #10's 6/6/19 progress note revealed, This nurse was notified by CNA (Certified Nurse Aide) of a new open area. This nurse with (Registered Nurse (RN) L) in to assess area. Open area noted to L (left) buttock/thigh crease measuring 1.2 x 1.2. Area is blanchable with light bloody drainage . Per interview with the DON on 6/11/19 at 12:12 p.m., this open area was closed. On 6/11/19 at 12:12 p.m., an interview was conducted with the Director of Nursing (DON). When asked if Resident #10 had been assessment by an RD for a quarterly or comprehensive nutritional assessment since 10/18/18, the DON stated, No. When asked if Resident #10 was on a therapeutic diet, the DON stated, No. She is very resistant and noncompliant. We do a diet of choice for her. Her family brings in cases of bugles (a brand name high calorie and sodium snack chip). When asked about Resident #10's medical concerns, the DON stated, She did have a stage two pressure ulcer, but it is resolved now. She goes to [MEDICAL TREATMENT] three times a week. Resident #13 A review of Resident #13's medical record revealed he admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 4/9/19 MDS assessment revealed he scored 3 on the BIMS assessment, indicating severely impaired cognition. A review of Resident #13's weight record revealed the following: 4/9/19 183.4 pounds 5/6/19 168.0 pounds 6/5/19 172.0 pounds Between 4/9/19 and 5/6/19 (a one month lookback) Resident #13 lost 15.4 pounds (-8.3 %). On 6/11/19 at 12:12 p.m., an interview was conducted with the DON. When asked if any nutritional assessment had been completed for Resident #13, the DON stated, No. A review of a 6/13/19 physicians note for Resident #13 revealed, .admitted . 4-8-19 after prolonged hospitalization . Patient has moderate dementia and was found at home down for undetermined amount of time . His other comorbidities include: Severe protein calorie malnutrition, insulin-dependent diabetes, dementia . history of [MEDICAL CONDITION] with right upper lobe and right lower lobe lobectomy .On admission patient had wounds consisting of the following . 2. Left chest debridement (surgical removal of tissue) down to bone 9 by 7 cm (centimeters). 3. Left shoulder deep tissue injury 3×2 cm. 4. Left trochanter (hip) 9.5×6 cm deep tissue injury. 5. Left proximal tibia 2×3 cm open wound. 6. Coccyx deep tissue injury unstageable . Appetite has been fair . Usually accepting 50-100% of meals. Family also brings him other snacks and goodies . Despite Resident #13's poor medical and nutritional status, no nutritional assessment had been completed by an RD at the time of survey entry on 6/10/19. Resident #27 A review of Resident #27's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 5/18/19 MDS assessment revealed Resident #27 scored 13 out of 15 on the BIMS assessment, indicating intact cognition. Resident #27 was discharged home from the facility on 5/29/19. On 6/11/19 at 11:55 a.m., the Administrator was asked about the lack of nutritional assessment for Resident #27. The Administrator stated, We don't have a dietitian right now. We had one (RD) who left in (MONTH) (2019) . We are supposed to get one (RD) soon. A review of Resident #27's Hospital Summary from prior to admit to the facility revealed, . Diet after discharge: Patient may have full liquids. [MEDICATION NAME] 1.5 (tube feeding formula) - 1 can QID (four times per day) via G (Gastrostomy) Tube (feeding tube). All Medications via G Tube. A review of Resident #27's Treatment Administration Record (TAR) for (MONTH) 2019 revealed the following: [MEDICATION NAME] 1.5 QID 8 oz. D/c (discontinue) when Glucerna (special tube feeding formula for diabetes) arrives 5/24/19 This order was documented as given from 5/11/19 through 5/28/19. Another order on the TAR revealed, Glucerna 1.5 (one) 8oz can QID via PEG (Percutaneous Endoscopic Gastrostomy) tube. Flush (with) 200 mL H20 (after) tube feeding, Continue with [MEDICATION NAME] 1.5 until Glucerna arrives. There was no space for nor any documentation on the TAR for the 200 mL flushes, nor any flushes documented prior to this order. The Glucerna tube feeding was never documented as being given. Another order on the TAR revealed, INFO: Glucerna shake 8oz (with) breakfast/dinner. There was no documentation of whether the supplements were given nor the acceptance of the supplement. There was no documentation on the TAR that any of the flushes had been completed per the order. A review of progress notes for Resident #27 revealed, the following: 5/11/19 . He has a G tube (PEG tube) for feeding ([MEDICATION NAME] 1.5 8oz QID) and med(ication) consumption . 5/12/19 .accu check (blood sugar check) AC/HS (before meals/hour of sleep), his HS BG (blood glucose): 285 (mg/dl, milligrams per deciliter), res (resident) stated the [MEDICATION NAME] (tube feeding) makes it (blood glucose) high . 5/13/19 .PA (Physician Assistant) in to see res new orders noted, res BS (blood sugar/blood glucose) at dinnertime was 463 (mg/dl) new order for extra 5 units of Humalog (insulin) noted. 5/13/19 PA note .positive dysphagia (difficulty swallowing) tolerating full liquid diet and [MEDICATION NAME] 1.5 bolus feedings QID. Positive weight loss due to hospitalization . BG since admission ranging 191-485 (mg/dl) . Continue [MEDICATION NAME] 1.5 feedings . 5/20/19 PA note . Plan . IDDM (insulin dependent diabetes mellitus) type 2: BG remain elevated. Increase [MEDICATION NAME] (insulin) from 60 to 65 units at HS (bed time) . 5/23/19 . HS BS 455 (mg/dl) provider notified order for 10 units of [MEDICATION NAME] (insulin) received and given recheck 406(mg/dl) . 5/23/19 Physician C note, .Patient seen for PEG removal and replacement with gastric tube . Assessment/Plan: . 4. Insulin-dependent diabetes mellitus. Reviewed medications . discussed tube feedings. Will d/c [MEDICATION NAME] and convert to Glucerna which should help with [MEDICATION NAME] and better bs control . 5/24/19 Physician note . Dietary consult discussed with (DON), tube feedings to be adjusted according to recommendations, to ensure patient is receiving optimal nutrition . 3. Poor Nutrition: continue tube feedings to ensure adequate nutritional intake. Dietary consult reviewed with (DON). Feedings to be increase to QID and Glucerna shakes BID . 5/26/19 New order obtained for insulin this shift r/t (related to) blood sugar of 572 (mg/dl). 5/28/19 .HS BS 460 (mg/dl) provider notified 10 U (units) given as ordered recheck of BS 530 (mg/dl) provider notified 8 U (units) given . 5/29/19 Resident discharged with wife approx. 1540 hrs (3:40 p.m.) A review of an At Risk progress note dated 5/31/19 revealed, Retro (back dated to) to 5-23-2019. Pt (patient) reviewed with RD (RD J). Pt kcal (kilocalorie/energy) needs 1900-2400 kcal daily, 97-116 gm (grams) of protein daily, and 1930-2410 ml (milliliters) of fluid daily. Spoke with (Nurse Practitioner (NP) H) and new orders obtained as follows: 8oz (ounces) Glucerna 1.5 via Peg Tube (feeding tube) QID with 200 cc H20 (water) flush following feeding. 8oz Glucerna shake orally BID (twice per day) with breakfast and lunch, may use [MEDICATION NAME] 1.5 until Glucerna 1.5 arrives . A review of the fluid Intake and Output tracking for Resident #27 revealed data for only three days: 5/12/19 intake: 800 (mL), output 2100 (mL), 5/13/19 intake: 1140, output 2050, 5/14/19 intake: 2670, output 2000. A review of Resident #27's weight record revealed: 5/13/19 218.7 pounds 5/29/19 212.7 pounds This demonstrated a weight loss of 6 pounds in 16 days (2.7%). A review of Resident #27's Meal Percent document which showed food acceptance revealed the following: Over the 18 day stay Resident #27 consumed 100% at lunch on two days, and consumed an HS snack six times. No other food or fluid intake, nor the calories from the full liquid diet, were calculated, assessed or tracked to ensure that between the tube feeding and the full liquids the Resident #27 was being provided adequate calories. A review of Resident #27's 'Interdisciplinary Discharge Summary' revealed under dietary status: Weight admit: 218.7 (pounds), discharge 212.7. Nutrition via gravity feeding tube due to [MEDICAL CONDITION] obstruction. The sections for weight trends, diet order, and signature by the Dietary Professional was left blank. A review of the 'Discharge Plan of Care to Home' revealed, Tube feed --- Ensure sugar free COA. A review of 'Discharge Home Instructions and Orders' revealed, Diet Order: Tube feed (Ensure sugar free - COA) 8 oz QID flush (with) 200 cc H20 . A review of the 5/28/19 Discharge Summary written by Nurse Practitioner (NP) H revealed, .(Resident #27) Previously was able to take his pills orally eat and drink. He is now dependent on the PEG tube for nutrition and fluids, medications . Diet: Nutrition via gravity feeding tube due to [MEDICAL CONDITION] obstruction. Ensure sugar-free one can 4 times a day and flush with 200 cc of water after each feeding . On 6/12/19 9:35 a.m., an interview was conducted with Certified Dietary Manager (CDM) E. When asked who was in charge of ordering nutritional supplements and tube feeding stated, The kitchen (staff) is in charge of ordering and maintaining the supplements. When asked if the facility had the tube feeding supplement Glucerna, CDM E stated, No, but I can get it. On 6/12/19 at 11:34 a.m., an interview was conducted with the DON and NP H. When asked about Resident #27's nutritional concerns, NP H stated, His sugars (blood glucose levels) were very labile (continually changing). They (the family of Resident #27) couldn't afford the supplements he was on here ([MEDICATION NAME]) so I recommended the sugar free version. When told there was no 'sugar free ensure', NP H stated, Oh well, I don't know how they do that (change tube feeding) when they go home. When asked if there were orders for the tube feeding to be flushed (cleansed with water), the DON stated, Yes. When asked why the flush documentation was not on the TAR, the DON stated, I don't know. They (nursing) are following the policy. (The policy is) 50 cc (water) before and after the feeding. When asked if the Glucerna supplement that was ordered to be given twice per day had been documented on the TAR as given and the acceptance rate, the DON stated, It's on the TAR as 'info'. When asked if Resident #27 had ever received the Glucerna tube feeding per the order, the DON stated, No, because it didn't come in until after he left. On 6/12/19 at 11:50 a.m., an interview was conducted with the DON. When asked if the orders for the nutritional supplement were correctly written on the TAR, the DON stated, No, it should be written out with the documentation of when it was given and how much was consumed. When asked how the flushes should have been documented, the DON stated, They should have been on the TAR. When asked how the facility was able to determine that the flushes were all done appropriately, the DON stated, I know they did them. It's our policy. When asked if there was any documentation of the flushes being done, the DON stated, No. On 6/12/19 at 11:54 a.m., an interview was conducted with the family of Resident #27 (Family Member (FM) K). When asked about Resident #27's transition home with the tube feeding, FM K stated, Home health changed him over to Glucerna when we got home because he is diabetic and they had him on [MEDICATION NAME] . He is doing much better, his blood sugars are much less (lower) now. They are between 100-140 now instead of really high like they were there (at the facility). On 6/12/19 at 2:46 p.m., an interview was conducted via phone with RD J. When asked if she worked at the facility, RD J stated, No, I am not employed as their Dietitian. I was contacted about a Resident because the routine RD was not there. When asked if she had been onsite to observe and assess Resident #27, RD J stated, No. RD J reported she had only spoken on the phone with the DON about Resident #27, and had not actually assessed him. A review of the facilities Food Service policy reviewed 2/2018 revealed, . 3. A Registered Dietitian is available on a part time basis, with a Certified Dietary Manager responsible for communications with the residents and staff of (Facility Name). 4. Patient's nutritional needs are met in accordance with physician's orders [REDACTED]. 8. An initial nutritional assessment of each resident will be initiated by a Registered Dietitian/designee within the first three days of admission. The resident's food preferences will be recorded at this time. A nutrition care plan will be initiated within 48 hours of admission and will be updated based on State and Federal Regulation. 9. Dietetic progress notes are included in the resident's medical record under the Notes section . 13. The dietitian is available to instruct residents on modified diets to be followed after discharge. She/he should be notified as soon as possible of discharge so that proper care may be provided. On 6/12/19 at 11:55 a.m., the Administrator reported that the last Registered Dietitian employed by the facility actually left employment on 11/21/18. On 6/12/19 it was identified that 0 of 13 sampled Residents had received nutritional assessment and services by a facility Registered Dietitian since (MONTH) (YEAR). Resident #7 A review of the medical record face sheet for Resident #7 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment of 3/24/19 showed a score of 5 on the Brief Interview for Mental Status (BIMS) assessment indicating severely impaired cognition. Resident #7's weight record revealed the following: 12/25/18 115 pounds 03/24/19 117 pounds 03/25/19 108 pounds 04/22/19 108 pounds 05/06/19 105 pounds 06/10/19 104.9 pounds The weight history from 3/24/19 through 6/10/19 indicated a weight loss of ~10% over 3 months. The most recent nutritional assessment was dated 10/4/18. On 6/13/19 at 10:43 AM, the Director of Nursing (DON) confirmed that the last nutrition assessment for Resident #7 was completed on 10/4/18. He stated, There are no others completed. Resident #8 A review of the medical record face sheet for Resident #8 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The MDS assessment with a target date of 4/1/19, showed a score of 8 on the BIMS assessment indicating moderately impaired cognition. Resident #8's weight record revealed the following: 3/7/19 186.4 pounds 4/2/19 196.8 pounds 5/2/19 209.7 pounds 6/3/19 219.1 pounds The weight history from 3/7/19 through 6/3/19 indicated a weight gain of ~17.5% over 3 months. The electronic medical record did not have a nutrition assessment for Resident #8. On 6/10/19 at 1:30 PM, Resident #8 stated, I have gained over 30 pounds because all we do is eat They have generous portions .I do not want to gain more weight. On 6/12/19 at 11:19 PM, a nutritional assessment for Resident #8 was requested from the Nursing Home Administrator (NHA), who stated, It's probably not here as it is an area we are deficient in No, there is not one there. Resident #28 Review of the Admission History and Physical dated 5/16/2019 at 1:03 PM, and the medical facesheet, revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of the left heel, and protein calorie malnutrition (a condition of body wasting resulting from a diet deficient in both calories and proteins). Review of the Minimum Data Sets assessment dated [DATE], revealed Resident #28 was severely cognitively impaired (BIMS score 2/15) and required extensive assistance from 1 to 2 facility staff members with activities of daily living (ADLs). Review of his nutritional status documented a base weight of 158 pounds. Review of the care plan initiated 5/15/2019, revealed Resident #28 was identified with a nutritional issue, and the established goal was to . maintain adequate nutritional intake for incision and wound healing, and his weight will remain stable throughout his SNF (skilled nursing facility) stay. Review of the physician orders [REDACTED].#28 was to receive a general diet. This order was revised on 5/18/2019 to include ingestion of thin liquids. On 6/6/2019 at 1:20 PM, the Resident was ordered to receive 8 ounces of Ensure between meals, and a Magic Cup (high calorie supplement) on each meal tray (introduction of these supplements added additional calories and protein to the Resident's diet). On 06/11/19 at 12:54 PM, Resident #28 was observed during his lunch; he fed himself with utensils, and without difficulty. The Resident's son, FM D, acknowledged the family's awareness of the Resident's weight loss. He has no appetite. He gets ice cream and they offer him double entrees, and all sorts of things just to get him to gain weight. They offer him Ensure. We're leery of Ensure 'cause he only has one kidney, has [MEDICAL CONDITION], and ends up with elevated potassium levels. He just won't eat. Review of Resident #28's medical file revealed he experienced significant weight loss (calculated as approximately 13%) from the date of his admission to the facility on [DATE] to the date of review by Surveyors on 6/12/2019; documented weight on 5/16/2019 was 162.9 pounds and on 6/12/2019 was recorded as 141.7 pounds, a loss of 21 pounds in 28 days. Review of IDT (interdisciplinary team) meeting entries for the dates of 5/24/2019 at 8:36 AM, 5/30/2019 at 1:27 PM, and 6/6/2019 at 1:09 PM, revealed Resident #28's weight loss was identified, yet he received no nutritional evaluation/assessment by an RD. Review of the facility Food Services policy and procedure dated 2/27/2018, provided on 6/11/2019 at 3:52 PM by the DON as the current policy and procedure in use by the facility, revealed in entry #8: An initial nutritional assessment of each resident will be initiated by a Registered Dietitian/designee within the first three days of admission. Review of Resident #28's medical file revealed no nutritional assessment. On 6/11/2019 at 2:17 PM, the DON was asked for copies of the Resident's nutritional assessments/evaluations. On 6/11/2019 at 3:52 PM, copies of electronic records of the IDT meeting entries for the dates 5/24/2019, 5/30/2019, and 6/6/2019, not the requested nutritional assessments/evaluations, were provided. On 6/12/2019 at 12:50 PM, CDM E acknowledged, in the presence of the Nursing Home Administrator and the DON, that Resident #28 had received no nutritional assessment/evaluation by an RD since his admission on 5/15/2019. The Nursing Home Administrator and DON acknowledged the facility had not been able to fill a vacancy for the Registered Dietitian position for several months, and nutritional assessments were not completed.

Based on interview and record review, the facility failed to ensure that qualified dietary staff, a Registered Dietitian (RD), was employed by the facility to provide nutritional care to six high risk Residents (#7, #8, #10, #13, #27, #28) out of 13 Residents reviewed for nutrition care. This deficient practice resulted in lack of assessment and interventions related to the increased nutritional needs from pressure ulcers, [MEDICAL TREATMENT], and significant weight loss with the potential to effect all facility residents. Findings include Resident #10 A review of Resident #10's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 4/2/19 Minimum Data Set (MDS) assessment revealed Resident #10 scored 13 out of 15 on the Brief Interview of Mental Status (BIMS) assessment, indicating intact cognition. A review of Resident #10's medical record revealed no nutritional assessments had been completed since 10/18/18, despite being a high nutritional risk Resident. A review of a 6/6/19 progress note revealed, This nurse was notified by CNA (Certified Nurse Aide) of a new open area. This nurse with (Registered Nurse (RN) L) in to assess area. Open area noted to L (left) buttock/thigh crease measuring 1.2 x 1.2. Area is blachable with light bloody drainage . This note indicates that Resident #10 had incurred facility acquired pressure ulcers which may increase nutritional needs and require supplemental or increased protein intake. On 6/11/19 at 12:12 p.m., an interview was conducted with the Director of Nursing (DON). When asked if Resident #10 had been assessment by a Registered dietitian for a quarterly or comprehensive nutritional assessment since 10/18/18, the DON stated, No. When asked about Resident #10's medical concerns, the DON stated, She did have a stage two pressure ulcer, but it is resolved now. She goes to [MEDICAL TREATMENT] three times a week. Resident #13 A review of Resident #13's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 4/9/19 MDS assessment revealed he scored 3 on the BIMS assessment indicating severely impaired cognition. A review of Resident #13's weight record revealed the following: 4/9/19 183.4 pounds 5/6/19 168.0 pounds 6/5/19 172.0 pounds Between 4/9/19 and 5/6/19 ( a one month lookback) Resident #13 lost 15.4 pounds (-8.3 %). On 6/11/19 at 12:12 p.m., an interview was conducted with the DON. When asked if any nutritional assessment had been completed for Resident #13, the DON stated, No. Resident #13 had increased nutritional needs due to his recent surgeries and multiple pressure ulcers requiring a wound vac (appliance applied to the wounds). The Resident had also had weight loss in facility which was not assessed by a Registered Dietitian. Resident #27 A review of Resident #27's medical record revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the 5/18/19 Minimum Data Set (MDS) assessment revealed Resident #27 scored 13 out of 15 on the BIMS assessment indicating intact cognition. Resident #27 was discharged home from the facility on 5/29/19. On 6/11/19 at 11:55 a.m., the Administrator was asked about the lack of nutritional assessment for Resident #27. The Administrator stated, We don't have a dietitian right now. We had one (Registered Dietitian) who left in (MONTH) (2019) . We are supposed to get one (RD) soon. A review of a 5/23/19 Physician note revealed, .Patient seen for PEG removal and replacement with gastric tube . Assessment/Plan: . 4. Insulin-dependent diabetes mellitus. Reviewed medications . discussed tube feedings. Will d/c [MEDICATION NAME] and convert to Glucerna which should help with [MEDICATION NAME] and better bs control . 5/24/19 Physician note . Dietary consult discussed with (DON), tube feedings to be adjusted according to recommendations, to ensure patient is receiving optimal nutrition . 3. Poor Nutrition: continue tube feedings to ensure adequate nutritional intake. Dietary consult reviewed with (DON). Feedings to be increase to QID and Glucerna shakes BID . On 6/12/19 at 11:34 a.m., an interview was conducted with the DON who, when asked if there was comprehensive nutrition assessment for Resident #27 conducted by a Registered Dietitian, stated, No. On 6/12/19 at 2:46 p.m., an interview was conducted via phone with RD J. When asked if she worked at the facility, RD J stated, No, I am not employed as their Dietitian. I was contacted about a Resident because the routine RD was not there. When asked if she had been onsite to observe and assess Resident #27, RD J stated, No. RD J reported she had only spoken on the phone with the DON about Resident #27, and had not actually assessed him. A review of the facilities Food Service policy reviewed 2/2018 revealed, . 3. A Registered Dietitian is available on a part time basis, with a Certified Dietary Manager responsible for communications with the residents and staff of Crawford Continuing Care. 4. Patient's nutritional needs are met in accordance with physician's orders [REDACTED]. 8. An initial nutritional assessment of each resident will be initiated by a Registered Dietitian/designee within the first three days of admission. The resident's food preferences will be recorded at this time. A nutrition care plan will be initiated within 48 hours of admission and will be updated based on State and Federal Regulation . On 6/12/19 at 11:55 a.m., the Administrator reported that the last Registered Dietitian employed by the facility left employment on 11/21/18. On 6/12/19 it was identified that all 13 Residents on sample for the recertification survey had not received nutrition assessment and services by a facility Registered Dietitian since (MONTH) (YEAR). Resident #5 On 6/11/19 at approximately 11:00 AM, a Resident Council meeting was held with 15 residents. Several issues came up regarding satisfaction with the meals. Resident #5 stated, We do not have a dietitian. We had one but she left all of the good people get transferred. Resident #7 A review of the medical record face sheet for Resident #7 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The weight history from 3/24/19 through 6/10/19 indicated a weight loss of ~10% over 3 months. The most recent nutritional assessment was dated 10/4/18. On 6/13/19 at 10:43 AM, the Director of Nursing (DON) confirmed that the last nutrition assessment for Resident #7 was completed on 10/4/18. He stated, There are no others completed. Resident #8 A review of the medical record face sheet for Resident #8 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. The weight history from 3/7/19 through 6/3/19 indicated a weight gain of ~17.5% over 3 months. The electronic medical record did not have a nutrition assessment for Resident #8. On 6/12/19 at 11:19 PM, a nutrition assessment for Resident #8 was requested from the NHA. She stated, It's probably not here as it is an area we are deficient in No, there is not one there. Resident #28 Review of the Admission History and Physical dated 5/16/2019 at 1:03 PM, and the medical facesheet, revealed Resident #28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. of the left heel, and protein calorie malnutrition (a condition of body wasting resulting from a diet deficient in both calories and proteins). Review of the Minimum Data Sets assessment dated [DATE], revealed Resident #28 was severely cognitively impaired (BIM score 2/15) and required extensive assistance from 1 to 2 facility staff members with activities of daily living (ADL's). Review of his nutritional status documented a base weight of 158 pounds. Review of the care plan initiated 5/15/2019, revealed Resident #28 was identified with a nutritional issue, and the established goal was to . maintain adequate nutritional intake for incision and wound healing, and his weight will remain stable throughout his SNF (skilled nursing facility) stay. Review of the physician orders [REDACTED].#28 was to receive a general diet. This order was revised on 5/18/2019 to include ingestion of thin liquids. On 6/6/2019 at 1:20 PM, the Resident was ordered to receive 8 ounces of Ensure between meals, and a Magic Cup on each meal tray (introduction of these supplements added additional calories and protein to the Resident's diet). On 06/11/19 at 12:54 PM, Resident #28 was observed during his lunch dining experience; he fed himself with utensils, and without difficulty. The Resident's son, witness D acknowledged the family's awareness of the Resident's weight loss. He has no appetite. He gets ice cream and they offer him double entrees, and all sorts of things just to get him to gain weight. They offer him Ensure. We're leery of Ensure 'cause he only has one kidney, has [MEDICAL CONDITION], and ends up with elevated potassium levels. He just won't eat. Review of Resident #28's medical file revealed he experienced significant weight loss (calculated as approximately 13%) from the date of his admission to the facility on [DATE] to the date of review by State Surveyors on 6/12/2019; documented weight on 5/16/2019 was 162.9 pounds and on 6/12/2019 was recorded as 141.7 pounds. Therefore, he was documented to have lost 21 pounds in 28 days. Review of IDT (interdisciplinary team) meeting entries for the dates of 5/24/2019 at 8:36 AM, 5/30/2019 at 1:27 PM, and 6/6/2019 at 1:09 PM revealed Resident #28's weight loss was identified, yet he received no nutritional evaluation/assessment by a Registered Dietitian (RD). Review of the facility Food Services policy and procedure dated 2/27/2018, provided to State Surveyors on 6/11/2019 at 3:52 PM by the Director of Nursing as the current policy and procedure in use by the facility, revealed in entry #8, An initial nutritional assessment of each resident will be initiated by a Registered Dietitian/designee within the first three days of admission. Review of Resident #28's medical file was conducted by this State Surveyor; after thorough review, no nutritional assessment was located. On 6/11/2019 at 2:17 PM, the Director of Nursing was asked for copies of the Resident's nutritional assessments/evaluations; the State Surveyor was provided on 6/11/2019 at 3:52 PM, copies of electronic records of the IDT meeting entries for the dates 5/24/2019, 5/30/2019, and 6/6/2019, not the requested nutritional assessments/evaluations. On 6/12/2019 at 12:50 PM, Certified Dietary Manager E acknowledged to the State Surveyor, in the presence of the Nursing Home Administrator and the Director of Nursing, that Resident #28 had received no nutritional assessment/evaluation by an RD since his admission on 5/15/2019. The Nursing Home Administrator and Director of Nursing acknowledged that the facility had not been able to fill a vacancy for the Registered Dietitian's position for several months, and that assessments were not completed.