Every finding on record at New Martinsville Health & Rehab

Based on medical record review, observation, and staff interview, the facility failed to ensure Resident's received treatment and care in accordance with professional standards of practice. Specifically, physician's orders were not followed. Resident #87. Facility census: 94.a) Resident #87A review of Resident #87's medical record revealed, a Physicians order for: --Check residual prior to each tube feed. If >200ml hold feed and re-check in 1 hour. If >500ml notify MD. every shift with order date 4/24/2024.--Check placement before med administration or feedingevery shift with order date 4/24/2024.An observation on 10/15/25 at 930 AM of Resident #87s tube feeding revealed Licensed Practical Nurse #1 (LPN) failed to check residual prior to this tube feed. During an interview 10/15/25 at 930 AM, LPN #1 stated that there was not an order to check residual prior to feeding. She continued to state that she tries to wait a little longer after breakfast so Resident #87 doesn't get to full. On 10/15/25 at 10:02 AM, the findings were discussed with the Administrator. She verified the physician orders should have been followed.

Based on observation, policy review, and staff interview the facility failed to properly contain kitchen waste in garbage dumpsters in a safe and sanitary manner. Facility Census: 93.Findings Included:On 08/20/25 at 10:15 AM, facility dumpsters were observed overflowing, lids would not close on any dumpster, soiled gloves, bags and miscellaneous trash were around all sides of the dumpster. On 08/20/25 at 10:21 AM, the Administrator was notified and confirmed the dumpsters were overflowing, lids would not close and miscellaneous trash was around dumpsters. The Administrator stated, I'll call them they will make a special trip .they usually come on Tuesdays, Thursdays and Saturdays.Document titled Food-Related Garbage and Refuse Disposal was reviewed and revealed the following: Policy: Food-related garbage and refuse are disposed of in accordance with current state laws. Specific Procedures/Guidance under #7 stated Outside dumpsters provided by garbage pickup services will be kept closed and free of surrounding litter.

Based on resident interview, staff interview and observation the facility failed to provide a safe, clean, comfortable, homelike environment for residents. This is true for residents #58, #79, #87, and #40. Facility Census 93.Findings Included:a) Resident #58 Interview with Resident # 58 on 08/20/2025 at 2:38 PM who reported a black area on the tile on and around the base of the wall behind resident’s toilet. Observed area around resident's toilet at 2:41 PM and Nurse Aide (NA) #35 acknowledged the area and agreed to notify housekeeping/maintenance. b) Resident #79 On 08/20/2025 at 10:47 AM during an interview with Resident #79, he stated pieces of dry wall had been removed from the bathroom wall around the pipes to the toilet for approximately one month. The toilet is now working but he did not have access to his toilet for two weeks, he had to use the toilet at the nurse’s station. c) Resident #87 Observed on 08/20/2025 10:53 AM a large hole in ceiling exposing unfinished wood underneath. d) Resident #40 On 08/20/25 at 1:20 PM observed Resident's toilet lid sitting on the floor beside the toilet. On 08/20/25 at 1:24 PM interview with Nurse Aide #72 who reported as far as she knew, the toilet was broken. On 08/20/25 at approximately 1:30 PM during an interview with Regional Director of facilities for Maintenance #116, he acknowledged the hole in ceiling to Resident #87 room, Resident #79 dry wall in bathroom, the toilet lid and dirty bathroom to Resident #40 room and acknowledged the black substance on tile and rubber base board of the wall in bathroom of Resident #58 bathroom. He began working to correct these issues immediately.

Based on observation and staff interview the kitchen failed to store food in accordance to professional standards for food safety. Facility census: 93.Findings Included: a) During initial kitchen walk through on 08/20/25 the following items we found in the walk-in refrigerator: six (6) quarts of cranberry juice with a use by date of 08/08/25 five (5) Fruit Punch pitcher use by date of 08/18/25 three (3) grape drinks use by 08/15/25 four (4) sugar free drink use by 08/18/25 Unsweet tea use by 08/18/25 Interview with Kitchen Manager at 7:50 AM who acknowledged the drinks found in the walk-in refrigerator. Review of document titled, Receiving and Storage of Food, Policy: Foods shall be received and stored in a manner that complies with safe food handling practices. Specific Procedures/Guidance, Number eight (8) states the following: All foods stored in the refrigerator or freezer will be covered, labeled and dated (used by date). Dry food storage during initial walk through: - 6.63 lb. Sysco Classic Spaghetti Sauce dented During an interview with Kitchen Manager (KM) at 7:50 AM the KM acknowledged the dented can. Nourishment Rooms were observed on 08/21/25 and the following were found: Pantry near first hall had 70 [NAME] crackers individually wrapped, undated and in an unmarked drawer with other foods and snacks such as peanut butter. Pantry near second hall had 25 [NAME] Crackers individually wrapped, undated and in an unmarked container. On 08/21/25 at 11:10 AM during an interview with the Regional Kitchen Manager (RKM) RKM reported that when lunch snacks were taken to the nourishment rooms, the boxes were labeled and dated as far as the lunch cakes were concerned. RKM was not aware as to why the graham crackers were not labeled and continually placed in the drawer but would do an in-service. A review of a document titled Receiving and Storage of Food revealed Foods shall be received and stored in a manner that complies with safe food handling practices. Guidance #7 Dry foods that are stored in bins will be removed from original packaging, labeled and dated use by date.

Based on record review, policy review, resident representative interview, and staff interview, the facility failed to notify Resident #97's legal representative when he passed away in the facility and notify the resident representative of a new medication. This was a random opportunity for discovery. Resident identifiers: #97 and #76. Facility census: 93.Findings included: a) Resident #97 On [DATE] at 8:55 AM, an electronic record review revealed: Resident #97’s legal representative’s home telephone number Resident #97’s legal representative’s mobile phone number A Physician Orders for Scope of Treatment (POST) form dated [DATE] The POST form listed the legal representative’s mobile phone number A Care Conference note, dated [DATE] at 10:00 AM, indicated Resident #97’s legal representative participated in the meeting A Nursing Note, dated [DATE] 2:40 PM, which indicated the nurse had made Resident #97’s legal representative aware of a new skin issue A Nursing Note, dated [DATE] at 8:57 PM, indicated the legal representative was made aware of a new physician order for occupational therapy to evaluate and treat resident A Nutrition/Dietary note, dated [DATE] at 3:42 PM, indicated Resident #97’s legal representative was made aware of a new dietary supplemental order for resident A Nursing Note, dated [DATE] at 4:13 Am, indicated that the legal representative had visited the building the day prior and was aware of a new dietary order A Nursing Note, dated [DATE] at 11:52 AM, indicated that the resident’s family had taken resident out of the building to attend a family reunion A Nursing Note, dated [DATE] at 3:54 PM, indicated the resident had returned to the facility with two (2) skin tears to the top of left hand. A Nursing Note, dated [DATE] at 4:46 PM, indicated the nurse spoke to Resident #97’s legal representative about the new skin tears. A Nursing Note, dated [DATE] at 1:13 PM, indicated the resident’s legal representative had visited the facility on this date. Palliative care services, a specialized form of medical care that focuses on improving the quality of life for people with serious or life-limiting illnesses, were discussed. A Nursing Note, dated [DATE] at 8:53 PM, indicated the nurse had attempted to call resident’s legal representative to let the individual know the resident was not doing well. The note indicated the nurse was unable to reach the legal representative at either number listed. A Nursing Note, dated [DATE] at 12:59 AM, indicated a Nurse Aide (NA) called the nurse to Resident #97’s room. Upon assessment, the resident was not breathing, no breath sounds were heard, and the resident had no pulse. A Nursing Note, dated [DATE] at 1:56 AM, indicated the nurse attempted both numbers for resident’s legal representative but was unable to reach the representative. The nursing note also documented that the funeral home was notified of resident’s death at 1:09 AM. Additionally the note indicated resident’s watch and silver bracelet were sent to the funeral home with resident. Review of the facility’s policy, entitled “Death of a Resident – Documenting”, outlined the appropriate documentation that should be make in the clinical record concerning the death of a resident. The guidance listed: 1. A resident may be declared dead by a licensed physician or registered nurse with he physician authorization in accordance with state law. 2. All information pertaining to a resident’s death (i.e., date, time of death, the name and title of the individual pronouncing the resident death etc.) will be recorded on the nurses’ notes. 3. The attending physician will record the cause of death in the medical record and will complete and file a death certificate with the appropriate agency in accordance with state law. 4. The licensed nurse or designee will inform the resident’s family and/or resident representative of the resident’s death. 5. Nursing services will be responsible for preparing the deceased resident for discharge. 6. A physician’s order to release the body will be obtained and documented in the medical record. 7. The licensed nurse / designee must notify the mortician, as identified in the resident’s medical record, to pick up the deceased resident. During a telephone interview on [DATE] at 9:30 AM, Resident #97’s legal representative reported that she had never received a telephone call from the nursing home regarding her loved one’s death. The legal representative reported she had caller ID and voicemail and that she never showed a missed call from the facility nor did she have a voicemail message from the facility. She reported she had been home all evening and all night. The legal representative reported she received a call from the funeral home at approximately 9:30 AM stating they had her loved one’s body and wanting to discuss funeral arrangements. This was reportedly the first time she learned that her loved one had passed away at the nursing home. The legal representative reported she was devastated to get the news in that manner. She went on to report that she waited the entire day to receive a call from the facility but never did. In an interview on [DATE] AM at 11:40 AM, the Administrator acknowledged Resident #97’s legal representative had been actively involved in the resident’s care both via telephone calls and visits to the facility. Additionally, The Administrator acknowledged the nursing staff was unable to produce evidence that they had successfully notified Resident #97’s legal representative of his death. The Administrator stated it was a terrible oversight and had been addressed with the staff involved. b) Resident #76 On [DATE] at approximately 3:30 PM, a record review was completed for Resident #76. The review found the resident had seen MindCare Psychiatric Evaluation via video on [DATE]. The progress note dated [DATE] at 8:50 AM, stated, Vistaril 25mg (milligram) by mouth every eight (8) hours as needed for 14 days for anxiety. However, upon further review, the resident's Medical Power of Attorney (MPOA) was not notified. There was no change in condition completed. An interview was held with the resident's representative on [DATE] at approximately 4:15 PM. The MPOA was asked, do you feel the (Name of Resident) is anxious or having problems with anxiety? The MPOA replied, no, I don't. On [DATE] at approximately 4:30 PM, the Administrator was interviewed regarding the change of condition for the resident and the adding of a new medication. The Administrator stated, there should be a change in condition and a note stating the MPOA was notified.

Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: Based on record review and staff interview, the facility failed to provide a Pre-admission Screening (PAS) which included all psychiatric diagnoses for Resident #10. This was true for one (1) of three (3) residents reviewed during the survey process. Resident Identifier: #10. Facility Census: 93. Findings Include: a) Resident #10 On 08/25/25 at 2:00 PM, a record review was completed for Resident #10. The review found the PAS dated 07/01/24 did not include the diagnosis of generalized anxiety disorder (GAD). The diagnosis of generalized anxiety disorder was added during the stay at the facility on 06/16/23. On 08/25/25 at 2:58 PM, the Social Service Worker #22 confirmed the diagnosis of generalized anxiety disorder was not on the PAS dated 07/01/24. The Social Services Worker #22 stated, I'll get this corrected.

Based on record review and staff interview, the facility failed to provide an accurate and complete medical record for Resident #5. This was true for one (1) of five (5) residents reviewed under the care area of unnecessary medications. Resident Identifier: #5. Facility Census: 93.On 08/25/25 at 2:30 PM, a record review was completed for Resident #5. The review found a physician's order for Lamictal 200mg (milligram) one (1) tablet by mouth at bedtime for seizures. A review of the resident's diagnoses did not find the diagnosis of seizures.On 08/25/25 at 3:30 PM, the Minimum Data Set (MDS) Licensed Practical Nurse (LPN) #13 confirmed the resident did not have seizures and the correct diagnosis should be mood disorder. On 08/25/25 at 3:45 PM, the MDS LPN #13 stated, We will get this corrected.

Based on record review, resident interview, and staff interview, the facility failed to prevent verbal abuse. The state agency determined the failure to address verbal threats from Resident #61 placed all residents in the facility in an immediate jeopardy situation. The residents making the threats could physically harm other residents. Psychological harm, such as fear and anxiety. could occur for other residents who were threatened by the residents or overheard the threats. Residents with post-traumatic stress disorder could be triggered. Resident identifier: #61. Facility census: 86. Findings included: 50552 a) Resident #61 On 06/05/24 at 09:15 AM during a review of Resident #61's medical record it was noted Resident #61 was admitted to the facility on [DATE] with the diagnosis of Paranoid Schizophrenia, Depression and Unspecified Dementia, Moderate with agitation. Resident #61 was admitted to the facility from an acute behavioral and mental health hospital. The hospital evaluation, dated 12/28/23, noted the following: -Resident #61 was admitted to the behavioral and mental health hospital on 12/02/22. Before the hospitalization , Resident #61 was placed at a state psychiatric nursing facility. -Resident #61's signs and symptoms demonstrated diagnostic criteria for Neurocognitive Disorder. -Resident #61's affect was noted to be agitated. -Diagnostic impression was Major Neurocognitive Disorder. -Resident #61 was noted to have delusional thinking. -Resident #61's risk factors for suicide included: history of impulsivity, lack of social support and chronic mental health condition. It was also noted that Resident #61 had a physician's order for Physiatrist (psychiatrist) consult as needed. During a review of Resident #61's progress notes, it was noted Resident #61 had been aggressive and had made threatening statements on the following dates: -02/17/24 at 7:54 PM, RN #49 documented in a Behavior Note, When Resident (#61) came to nurses station to make a phone call, this Resident (#61) noted to yell at another resident (unidentified) when the other resident (unidentified) accidentally touched his arm. Resident (#61) stated, Stop touching me or I'll blow your brains out. Resident (#61) encouraged/educated to not speak like that to the other resident (unidentified). Residents were not physical with each other and were separated without incident. No physician intervention required, no injury noted, staff to continue to be alert for verbal altercations with resident. -04/28/24 at 8:36 PM, Resident #61 stated to CNA (unidentified) that if he had a gun he would shoot everyone. A room check was completed, no guns or weapons of any kind were found. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified. Resident #61 was placed on 15 minute checks which were from 8:30 PM that evening through 06:00 AM the following morning. -05/13/24 at 11:12 AM, Resident #61 screamed and cursed at a CNA (unidentified) who was attempting to provide care to Resident #61. Resident #61 stated he was going to kill the CNA (unidentified) if she didn't leave him alone. It was noted that several repetitive statements related to killing CNA (unidentified) were made by Resident #61. On 06/05/24 at 09:52 AM, an interview was conducted with the facility Administrator related to the above documentation. At this time, this Surveyor requested a copy of notifications made to Physician, the Residents Representative (RP) related to the above and documentation of any follow up performed by Physician. This Surveyor also requested documentation of any psychiatric visits, any documentation that the above incidents had been reported to the appropriate state agencies and asked the Administrator who the other resident was in the incident that occurred on 02/18/24. On 06/05/24 at 10:59 AM, the Administrator states the incident from 2/18/24 was reported to the Ombudsman, however, it was not reported to Adult Protective Services or the Office of Licensure and Certification (OHFLAC). On 06/05/24 at 11:32 AM, the Administrator brought a copy of an email sent to NAME Ombudsman stating the following: We have had a few resident to resident incidents with no injury this week that I wanted to bring to your attention. All residents involved do not have capacity. They are as follow: Resident #61 - on Sunday night he was overheard by a CNA telling another resident Don't touch me or I'm gonna blow your head off The residents were separated and there was no other incident. At this time, the Administrator acknowledged there was no documentation related to Physician notification or RP notification of the above listed incidents. In addition, the Administrator acknowledged that there was no documentation of a follow up performed by the Physician on either Resident #61 or the unidentified Resident. On 6/5/24 at 02:54 PM, the facility Administrator who acknowledged that Resident #61 had not seen the psychiatrist, which was ordered on 02/17/24. 50795 The state agency notified the Nursing Home Administrator of the immediate jeopardy at 6:50 PM on 06/05/24. The facility submitted a plan of correction (POC) on 06/05/24 at 9:25 PM. On 06/05/24 at 9:30 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 11:28 AM on 06/06/24. The facility's approved abatement POC consisted of the following: 1. Incidents on 2-18-24, 4-28-24 and 5-13-24 involving verbal threats by resident #61 reported to APS, OHFLAC and ombudsman. Resident #61 placed on one-on-one observation until see and cleared by psychiatric services. Incident on 5-27-24 involving Resident #11 allegation of verbal abuse reported to APS, OHFLAC and Ombudsman. Psychosocial follow up provided for resident #86. Resident #11 continues to follow with psych services as ordered. 2. All residents residing in the facility have the potential to be affected. All capable residents will be interviewed to ensure no other allegations of abuse and all residents not able to be interviewed will have skin checks to ensure no sign or symptoms of abuse with corrective action immediately upon discovery. Whole house audit completed on residents having behaviors and ordered psychological services to ensure services provided with corrective action upon discovery. 4. Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by QIC. The state agency notified the Nursing Home Administrator of the immediate jeopardy at 6:50 PM on 06/05/24. The facility submitted a plan of correction (POC) on 06/05/24 at 9:25 PM. On 06/05/24 at 9:30 PM, the POC was accepted by the state agency. The state agency verified the POC was implemented by conducting staff interviews and the immediate jeopardy was abated at 11:28 AM on 06/06/24.

Based on observation, facility record review, and staff interview the facility failed to follow Manufacturer's instructions regarding dishwasher temperature. Overall, commercial dishwasher temperature requirements are important to maintaining a safe and sanitary food service environment. This failed practice had the potential to affect every resident that gets their nutrition from the kitchen. This created an immediate jeopardy situation. Facility Census: 86. Findings included: a) Dishwasher A review of facility records on 06/03/24, found the dish washer is washing at 110 degrees and the final rinse temperature is 110 degrees since April 21, 2024. Review of operating manual reveals the wash cycle requires minimum 120 Degrees recommended 140 degrees and the rinse cycle requires minimum 120 degrees and recommend 140. On 6/03/24 at 10:50 AM an Observation of Dishwasher wash and rinse cycle found the dishwasher temperature only registered at 100 degrees. The Maintenance director confirmed it was not running at the recommended temperature. He stated that he has been aware of the issues since April 2024. He continued to state that the facility does not own the dishwasher so the company that they lease it from would have to come and fix it. The facility was notified of the Immediate Jeopardy (IJ) at 1:08 PM on 06/03/24. The facility submitted their first abatement plan of correction (POC) at 2:57 PM on 06/03/24. The state agency requested changes and the second abatement POC was submitted at 3:28 PM on 06/03/24. The state agency requested changes and the third abatement POC was submitted at 4:30 PM on 06/03/24. The abatement POC was accepted by the state agency at 4:38 PM on 06/03/24. After observation of the implementation of the abatement POC, the IJ was abated at 3:27PM on 06/04/24. The IJ started on 06/03/24 and ended on 06/04/24. The facility's approved abatement POC consisted of the following: Correction action for area of concern- Immediately upon notification of the malfunctioning doorbell, facility maintenance staff replaced the batteries, and doorbell function was immediately restored. 1. Dishwasher was taken out of use 6-3-24 at 1:08p. Regional Maintenance Director contacted EcoLab on 6-3-24 for dishwasher service. 2. All residents in the facility have potential to be affected. Whole house audit completed by Director of Nursing/designee to ensure all plates, utensils and water pitchers were taken out of resident's rooms and not in use. 3. All staff will be educated on 06/03/24 to use paper products for any food or fluid services until the dishwasher is repaired and working at recommended temperatures. Meal service and fluid pass will be observed three time a day to ensure disposable paper products are being used for residents until dishwasher is serviced by Ecolab. Once dishwasher is serviced, staff will be re-educated on manual instructions and machine operations, who to report to when system are out of range and maintenance to escalate when needing service. Pots/pans and cooking utensils will continue to be cleaned and sanitized via three sink /compartment method. 4. Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by QIC. DISCLAIMER: The preliminary findings and subsequent abatement plan are not an admission of wrongdoing, but an acknowledgement of the surveyor's preliminary findings. 43340 b) Resident #64's Refrigerator Temperatures During an observation, on 06/03/24 at 7:43 AM, it was determined that Resident #64 had a persoanl refrigerator in her room. There was no evidence regrigerator temperatures had been obtained per protocol. On 06/03/24 at 10:15 AM, CNA #8 confirmed there was no temperature sheet for Resident #64's refrigerator. CNA #8 reported, I do not know what the procedure is for ensuring daily temps are taken. On 06/03/24 at 11:37 AM, a review of the medical record for Resident #64 identified a new order which was placed into the electronic medical record on 06/03/24 at 10:43 AM. The order directed, Check refrigerator temp (temperature) daily. The order start date was listed for 06/04/24 at 7:00 AM for every day shift.

Based on record review and staff interview, the facility failed to ensure that a resident who is diagnosed with a mental disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Failure to provide one (1) of one (1) residents with essential menal health services and treatemnt created an immediate jeopardy sitauiton. Resident #61 did not receive the appropriate treatment and services for diagnoses paranoid schizophrenia, depression and unspecified dementia with moderate agitation. Resident #61 had documented violent behaviors that placed more than an limited number of residents at risk for serious harm. Resident identifier: #61. Facility census: 86. Findings included: a) Resident #61 On 06/05/24 at 09:15 AM during a review of Resident #61's medical record it was noted Resident #61 was admitted to the facility on [DATE] with the diagnosis of Paranoid Schizophrenia, Depression and Unspecified Dementia, Moderate with agitation. Resident #61 was admitted to the facility from an acute behavioral and mental health hospital. The hospital evaluation, dated 12/28/23, noted the following. -Resident #61 was admitted to the behavioral and mental health hospital on 12/02/22. Before the hospitalization , Resident #61 was placed at a state psychiatric nursing facility. -Resident #61's signs and symptoms demonstrated diagnostic criteria for Neurocognitive Disorder. -Resident #61's affect was noted to be agitated. -Diagnostic impression was Major Neurocognitive Disorder. -Resident #61 was noted to have delusional thinking. -Resident #61's risk factors for suicide included: history of impulsivity, lack of social support and chronic mental health condition. It was also noted that Resident #61 had a physician's order for Physiatrist (psychiatrist) consult as needed. During a review of Resident #61's progress notes, it was noted Resident #61 had been aggressive and had made threatening statements on the following dates: -02/17/24 at 7:54 PM, RN #49 documented in a Behavior Note, When Resident (#61) came to nurses station to make a phone call, this Resident (#61) noted to yell at another resident (unidentified) when the other resident (unidentified) accidentally touched his arm. Resident (#61) stated, Stop touching me or I'll blow your brains out. Resident (#61) encouraged/educated to not speak like that to the other resident (unidentified). Residents were not physical with each other and were separated without incident. No physician intervention required, no injury noted, staff to continue to be alert for verbal altercations with resident. -04/28/24 at 8:36 PM, Resident #61 stated to CNA (unidentified) that if he had a gun, he would shoot everyone. A room check was completed, no guns or weapons of any kind were found. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) were notified. Resident #61 was placed on 15-minute checks which were from 8:30 PM that evening through 06:00 AM the following morning. -05/13/24 at 11:12 AM, Resident #61 screamed and cursed at a CNA (unidentified) who was attempting to provide care to Resident #61. Resident #61 stated he was going to kill the CNA (unidentified) if she didn't leave him alone. It was noted that several repetitive statements related to killing CNA (unidentified) were made by Resident #61. On 06/05/24 at 09:52 AM, an interview was conducted with the facility Administrator related to the above documentation. At this time, this Surveyor requested a copy of notifications made to the Physician, the Residents Representative (RP) related to the above and documentation of any follow up performed by Physician. This Surveyor also requested documentation of any psychiatric visits, any documentation that the above incidents had been reported to the appropriate state agencies and asked the Administrator who the other resident was in the incident that occurred on 02/18/24. On 06/05/24 at 10:59 AM, the Administrator states the incident from 2/18/24 was reported to the Ombudsman, however, it was not reported to Adult Protective Services or the Office of Licensure and Certification (OFLAC). On 06/05/24 at 11:32 AM, the Administrator brought a copy of an email sent to [NAME] Richmond Ombudsman stating the following: We have had a few resident-to-resident incidents with no injury this week that I wanted to bring to your attention. All residents involved do not have capacity. They are as follow: Resident #61 - on Sunday night he was overheard by a CNA telling another resident Don't touch me or I'm gonna blow your head off The residents were separated and there was no other incident. At this time, the Administrator acknowledged there was no documentation related to Physician notification or RP notification of the above listed incidents. In addition, the Administrator acknowledged that there was no documentation of a follow up performed by the Physician on either Resident #61 or the unidentified Resident. On 6/5/24 at 02:54 PM, the facility Administrator acknowledged that Resident #61 had not seen the psychiatrist, which was ordered on 02/17/24. The facility was notified of the Immediate Jeopardy (IJ) at 6:50 PM on 06/05/24. The facility submitted their first abatement plan of correction (POC) at 10:59 PM on 06/05/24. The abatement POC was accepted by the state agency at 11:04 PM on 06/05/24. After observation of the implementation of the abatement POC, the IJ was abated at 11:28 AM on 06/06/24. The IJ started on 06/05/24 and ended on 06/06/24. Facility Abatement Plan: 1. On 6-5-24, incidents on 2-18-24, 4-28-24 and 5-13-24 involving verbal threats by resident #61 reported to APS, OHFLAC and ombudsman. Resident #61 placed on one-on-one observation until see and cleared by psychiatric services. 2. All residents residing in the facility have the potential to be affected. All capable residents will be interviewed to ensure no other allegations of abuse and all residents not able to be interviewed will have skin checks to ensure no sign or symptoms of abuse with corrective action immediately upon discovery. Whole house audit completed on residents having behaviors and ordered psychological services to ensure services provided with corrective action upon discovery. 3. All staff will be re-educated on identifying, reporting, and preventing abuse and assessing residents for psychiatric needs on 6-5-24 or upon return to work. Daily rounding audits completed by department heads regarding abuse and neglect concerns. 4. Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by QIC.

Based on observation and staff interview the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, comfortable environment and to help prevent the development and transmission of communicable diseases and infections with regards to readily available PPE. This was a random opportunity for discovery. This had the potential to affect more than a limited number of residents. Facility census: 86. Findings included: a) On 06/03/24 at 6:55 AM, a tour of the facility was performed. During that tour, it was noted that 3 (three) of the 4 (four) resident hallways had multiple residents on Enhanced Barrier Precautions (EBP) and that no Personal Protective Equipment (PPE) was readily available to facility staff. The observations made were as follows: On 06/03/24 at 6:55 AM, a tour of A Hall was performed. No PPE was readily available on the hall and that multiple residents were in EBP. At this time, an interview was conducted with Licensed Practical Nurse (LPN) #16 who stated, I don't know where it is, it was on the hall last week. LPN #16 also acknowledged there was no readily available PPE present. On 06/03/24 at 07:10 AM, a tour of C Hall was performed. It was observed that no PPE was readily available on the hallway and that multiple residents were in EBP. At this time, an interview was conducted with LPN #57 who stated, PPE is usually stocked on the linen carts. LPN #57 then checked the linen cart, LPN #57 confirmed that no PPE was readily available on the hallway or in the linen cart. On 06/03/24 at 7:15 AM, a tour of D Hall was performed. No PPE was readily available on the hallway and that multiple residents were in EBP. At this time, an interview was conducted with Certified Nursing Assistant (CNA) #34 who stated, It is usually on the linen cart. At that time CNA #34 checked the linen cart, confirmed that PPE was not present. CNA #34 then confirmed no PPE was readily available on the hallway or in linen carts.

b) Resident #60 On 6/03/24 at 12:00 AM, an observation of the facility dining area was performed. During this observation, Resident #60 was noted to be seated at a table wearing a facility gown that was not tied at the neck or waist. The front of the gown was exposing Resident #60's upper chest, shoulders and the right side of Resident #60's back. It was noted that several facility staff walked by Resident #60 without offering to adjust or tie Resident #60's gown to cover Resident #60's exposed body areas. On 06/03/24 at 12:12 PM, a staff interview was conducted with Employee #96. During this interview, Employee #96 acknowledged that Resident #60's gown should be tied and that Resident #60's upper chest, shoulders and back of Resident #60's body should not be exposed. Employee #96 then went and tied Resident #60's gown. 50795 Based on observation and staff interview, the facility failed to provide residents with a dignified dining experience. The dining room staff failed to serve the residents in a respectful manner, by not placing the food in front of the residents and removing the trays. This failed practice was true for all twenty-three (23) residents in the dining room and had the potential to affect more than a limited number of residents who currently reside in the facility. Additionally, the facility failed to ensure that Resident #60 was treated with dignity and respect. This was a random opportunity for discovery. Resident identifier: #60. Facility census: 86. Findings included: a) Dining Observation Based on an observation on 06/03/24 at 12:08 PM, the dining room staff had failed to take the food off the trays and place it in front of the residents, rather, they had left the trays with the food in front of each resident. Serving the residents their food on trays creates the atmosphere of an institutional setting. An interview with Activity Assistant #102 on 06/03/24 at 12:11 PM, revealed that she was not aware that resident's plates were to be taken off the trays and placed in front of them. Further interviewing revealed that she was new to the dining area. She also stated that as far as she was aware, the trays were for the residents safety. She stated that it prevented the residents from knocking their food off the table. She also stated that keeping each resident's food on their tray prevented the residents from mistakenly reaching for each other's food or drink. An interview with the Dietary Manager #90 on 06/03/24 at 12:18 PM revealed that she too was unaware that food was to be served in a homelike setting. Upon being questioned, she too stated that the trays prevented residents from knocking their food off the table, and that it also prevented residents from reaching for another resident's food or drink. She further stated that this is how we have always served the meals! b) Resident #60 On 6/03/24 at 12:00 AM, an observation of the facility dining area was performed. During this observation, Resident #60 was noted to be seated at a table wearing a facility gown that was not tied at the neck or waist. The front of the gown was exposing Resident #60's upper chest, shoulders and the right side of Resident #60's back. It was noted that several facility staff walked by Resident #60 without offering to adjust or tie Resident #60's gown to cover Resident #60's exposed body areas. On 06/03/24 at 12:12 PM, a staff interview was conducted with Employee #96. During this interview, Employee #96 acknowledged that Resident #60's gown should be tied and that Resident #60's upper chest, shoulders and back of Resident #60's body should not be exposed. Employee #96

Based on interviews, and document review, the facility failed to ensure that residents' food preferences and choices were honored. This failed policy had the potential to affect more than a limited number of residents. Resident identifiers: #17, #14, and #9. Facility Census 86. Findings included: a) Resident #17 Based on an interview, on 06/03/24, with Resident #17 at 10:13 AM, it was revealed that she was unable to order an alternate item, if the food served to them was not to their liking. She mentioned this was due to the facility policy governing the ordering of alternate food items. The policy stated that orders for any alternate items were to be placed 2 (two) hours before mealtimes. This policy prevented residents from being able to exercise their right to a choice of food during mealtimes. Further, the resident stated that she was provided with a weekly menu which required her to review that day's menu, at least two (2) hours before mealtimes, to ensure that she could order an alternate if she needed to. The resident further stated that she was occupied during the morning hours with PT and other activities, which left her with very little time to review the lunch menu and place an order for an alternative. Resident stated that the facility had previously provided a printed daily menu to them in a timely manner, and they would check off their choices or order an alternate. She stated that the current system of posted weekly menus prevents them from exercising their choices. b) Resident #14 Based on an interview on 06/03/24 with Resident #14 at 10:28 AM, the resident revealed that he was unable to order an alternate item, if he did not like the food served to him at mealtimes. He stated the facility policy governing the ordering of alternate food items made it impossible to get an alternate item during mealtimes. He stated the policy required residents to place any orders for an alternate item 2 (two) hours before meals. This facility policy prevented residents from being able to exercise their right to a choice of food during mealtimes. Further, the resident stated that the weekly menu that was provided to him required him to review it well in advance of every meal. He stated that if he forgot to check it, he would have to eat what was provided, even if he did not like the food. He stated he tried to make sure he checked the menu every day, but sometimes he forgot. He stated an alternative could be ordered at mealtime, but he would have to wait till the kitchen staff had finished serving all the residents. The resident stated the previous system of a daily menu worked better. An interview with the Dietary Manager #90 on 06/03/24 at 12:18 PM revealed the facility policy for ordering alternate items required residents to place their orders at least 2 (two) hours before mealtimes. She stated that residents could order an alternate during mealtimes, but they would have to wait a while because the cooks would be busy with the meal service.

Based on record review, resident interview and staff interview, the facility failed to identify verbal complaints/concerns as a grievance. This was a random opportunity for discovery. Findings include: a) On 06/04/24 10:00 AM, review of Resident Council Minutes for the last six (6) months indicated that the resident council voiced concerns about call lights not being answered in a timely manner every month from 12/2023 to 5/2024. On 06/04/24 10:35 AM, During resident council meeting, Resident #31 reported that staff did not answer call lights in a timely manner and that the council has discussed these issues monthly during resident council meetings. On 06/05/24 12:38 PM, during an interview with the administrator regarding call light concerns, the administrator reported the facility was aware of complaints being made in resident council meeting about call lights being answered in a timely manner. She reported that as a result, random Call Light Audits were being performed by nursing staff since 01/21/24 and reported that no issues had been found at this time. She stated that no grievances had been filed on the concern. On 06/05/24 2:00 PM during review of Call Light Audit forms. No issues documented. 06/05/24 4:31 PM, Reviewed Hill Valley Healthcare Grievance/Complaints Policy and includes the following: #3 (three) All grievances, complaints or recommendations stemming from resident or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing. including a rationale for the response. #9 (nine) When possible and appropriate, the Grievance Officer will attempt to resolve the grievance/complaint as soon as reasonably possible. On 06/05/22 05:05 PM, during an interview with social worker (SW) #44 who acknowledged the facilities grievance policy. She acknowledged that the resident council had brought up the concern of call lights not being answered in a timely manner since at least the last 6 months. She acknowledged that although staff had reported that they are randomly auditing call light responses by having nursing completed handwritten audits, randomly every shift, there continued to be the same concern month after month for the last six (6) months. She also acknowledged that there was not a grievance filed for this issue because of the concerns brought up by resident council.

Based on resident interview, record review and staff interview, the facility failed to report allegations of verbal abuse, neglect, and possible crime to all required stated agencies. This deficient practice had the potential to affect three (3) of 11 residents reviewed for the care area of abuse. Resident identifiers: #79, #29, and #86. Facility census: 86. Findings included: a) Resident #79 On 05/24/24, the Office of Health Facility Licensure and Certification (OHFLAC) received a complaint from an employee from a state agency reporting that marijuana, a baggy of pills, and drug paraphernalia had been removed from a resident's room by a police officer. The facility provided a log of facility reported incidences (FRIs) that had been reported to OHFLAC. The log contained no record of a FRI regarding illegal substances found in a resident's room. On 06/10/24 at 11:45 AM, the Regional Director of Operations (RDO) was asked about illegal substances being found in a resident's room. He stated neither he nor the Director of Nursing (DON) had worked at the facility at that time. The RDO stated he would ask other staff members about illegal substances being found. The following focus was found in Resident #79's Comprehensive Care Plan: Potential for safety hazard, injury r/t [related to] smoking, marijuana found in her room, medication found in her room. The initiation date was 04/23/24. The revision date was 05/31/24. Resident #79's progress note contained no information regarding the matter. On 06/10/24 at 1:45 PM, the RDO stated he had called the police department and spoke to the police chief. The RDO stated the police did not file a report or any charges. The Administrator confirmed the facility did not report the incident to OHFLAC and other required state agencies. The surveyor attempted to confirm the information with the police officer. However, no contact was able to be made through the completion of the survey process. b) Resident #29 During an interview on 06/03/24 at 1:39 PM, Resident #29 stated she had been left outside alone in the courtyard four (4) times following smoke breaks. Resident #29 stated she is unable to propel her wheelchair independently due to tremors and was unable to reenter the facility on her own. Resident #29 further stated there was no way to notify staff that she was outside and wanted to come in. The resident stated she was left out in the hot sun for two (2) hours on one day. Resident #29 also stated she had a history of falling from her wheelchair. Review of facility grievance forms showed a grievance on 05/13/24 which stated, Resident went outside with staff assistance for 1 pm smoke break. At end of smoke break as everyone returned inside [Nursing Assistant (NA) #5] said to this patient, If you can't bring yourself outside or inside, you shouldn't be able to smoke. [NA #5] then entered the building leaving this resident out in the courtyard unattended. Another resident [Resident #79] noted this patient outside alone and alerted staff. [NA #9] assisted this patient with returning to bed after 2 PM. Review of Resident #29's medical records showed a nursing note written on 5/22/2024 at 5:30 PM stated, CNA [certified nursing assistant] came to this nurse reporting resident was left outside by herself from a smoke break, patient was on the phone with [state agency] while she was present. CNA said she wanted me to be aware of. I went to patients room, patient was very tearful, she reported to this nurse that [Licensed Practical Nurse LPN #55] took her out to smoke, left her and no one returned to bring her back, says she was outside in the heat for over an hour. Patient was very upset and crying . (Note typed as written.) Vital signs were obtained and were within normal limits. Another nursing note written on 5/24/2024 at 6:28 PM, stated, This resident and another female resident from A/B side, along with male resident from C hall was offered help to come back in from smoke break. This resident and others said they were not ready at this time to come back in. All other smokers already have come back in at this time. Two of these residents is able to take self in and out of the door and were instructed that when they were ready to come in to please come get a staff member to assist this resident inside. Verbalized understanding. (Note typed as written.) Further review of Resident #29's medical records showed on 04/28/24 at 8:40 PM, the resident was found on the floor of her room in front of her wheelchair. The resident reported she had slid out of her wheelchair onto the floor. The resident received no injuries from this fall. Review of Resident #29's comprehensive care plan showed the resident required assistance of one (1) for mobility in a wheelchair. On 06/04/24 at 4:26 PM, observation of the facility courtyard was made with the Maintenance Director in attendance. No call lights were present in the courtyard. There was no push button to open the door for residents in wheelchairs to use. During an interview on 06/05/24 at 4:15 PM, the Administrator stated she was aware of two (2) instances during which Resident #29 had requested to remain outside after the smoke break had ended, 05/13/24 and 05/22/24. The Administrator confirmed the resident was not able to reenter the facility on her own. The Administrator stated she had not considered leaving the resident outside unattended to be neglectful and therefore, the incident had not been reported to the required state agencies. No additional information was provided through the completion of the survey process. 50795 c) Resident #86 During an interview with Resident #86 on 06/03/24 at 11:56 AM, the resident mentioned that she was verbally abused, and threatened, by Resident #11. She also stated that based on her complaint, the only intervention facility staff offered her, was a room change. Resident stated that she refused, and questioned why she would be the one to have to move to another floor! Further record review, and interviews revealed: A nursing note on 05/27/24 at 03:30 PM by the Assistant Director of Nursing (ADON) #58 which stated: Coordinator #56 and myself went to residents' room after it was reported that she was crying and feeling very anxious. Upon entering the room, the resident was breathing quickly and stated she has a history of panic attacks. She stated she was very upset with recent interactions she has had with a resident further down the hall. She states she had previously come in her room; she did not touch her but shook her fist at her. She also stated, when she attacked me in the hall, I asked if she touched her in the hall and she again said oh no she just shook her fist at me and made a mean face. We assured resident that we were addressing the issue. She then said she was scared to go to the bathroom, we offered assistance and she denied. She said she was getting ahold of her brother to take her home today. We offered a room move which she denied. She stated again she was just deathly afraid of this resident and that she would go on a different hall in the facility to avoid her. Prior to this conversation I spoke with residents' daughter on the phone about these same concerns and also reassured her that we were addressing the issue. Resident states as the resident down the hall wheels by her room she looks at her and she does not like it. Prior to exiting the room, I pulled curtain to the edge of bed with resident approval to avoid visual contact if she happened to roll by. Another note on 5/27/2024 at 08:30 PM by LPN #60 states: Resident crying in her room. When this nurse asked resident what was wrong, resident talking in a loud tone stating, I'm over this place, all this stuff that happened earlier today and nobody does anything about it, they continue to allow the other resident to do as she wants, she's allowed to go up and down the halls as she pleases when she should be in her room. They try to make me feel like I'm in the wrong. Resident also stating she wasn't taking anymore medications while in this facility and that she would be leaving tomorrow one way or another. This resident stating she didn't want to be here any longer because of the way other residents act and stating they need to be placed into different facilities than this one. Resident also stating that she would be filing a lawsuit on this place and could file restraining orders against the other resident. This resident was very tearful during this encounter which lasted approximately 5-6 minutes. interventions attempted: This nurse offered this resident to move to a different room to not have to see the other resident that there was previous conflict with, this resident refused. Curtains on each side of this resident was pulled (per her request) to not have to see anyone. A progress note from Resident #11's chart on 05/27/24 at 08:52 PM by LPN #63 states that a CNA reported that she was standing outside room [ROOM NUMBER] (Resident #86's room), when she saw this resident wheel past the room and point to the other resident (Resident #86) and tell the resident in 314 (Resident #86) that she was going to kill her. Resident was redirected away from doorway. A nursing note on 05/28/24 at 06:13 AM states that resident was awake most of the night. She had stripped her bed and didn't want staff to assist in remaking the bed. A nursing note on 05/28/24 at 12:02 PM by the Director of Nursing (DON) #49, states: Spoke to resident regarding interaction between herself and another resident yesterday. This resident was explaining what happened, stating the other resident was yelling things at her and other residents. When I offered a room change, the resident stated no, I'm working on being transferred to another facility today. When this nurse asked if she wanted a stop sign to put on her doorway, she stated no. The resident was also noted to be sitting in her bed w/o bed sheets on the bed. Staff have reported she took her sheets off and is refusing to allow staff to put new linens on the bed. Call light is within reach. This nurse notified Administrator #48, and Social Worker (SW) #44 of residents wishes to discharge somewhere else. Further record review revealed a note on 05/30/24 at 15:30 by SW #44 which stated: This worker sent out a referral to Pineview Center per the residents' request. This worker spoke to the social worker at this facility, who stated she would look it over as well as have her admissions director look over it. Waiting for a response at this time. Investigation, and a review of submitted reports, revealed that the facility had submitted a report of the abuse to the Ombudsman, but not to the Office of Health Facility Licensure and Certification (OHFLAC). An interview with Administrator #48 on 06/05/24 02:42 PM revealed that the facility had not submitted a Facility Incident Report (FRI) to OHFLAC. She stated that the facility followed the reporting requirements laid out in 42 CFR 488.301, which listed actions to be taken. The copy of the guidance for reporting she provided as evidence, stated: Abuse: Resident-to-Resident - (No sexual abuse occurred, and no physician intervention was required) A report only to the Ombudsman was required, (unless the incident was caused by lack of staff or encouraged by staff). A review of the document provided to this surveyor revealed that the facility was not utilizing the current guidelines for reporting.

Based on record review and staff interviews, the facility failed to ensure that the resident's Pre-Admission Screening (PAS) reflected a pre-admission mental health diagnosis for three (3) of six (6) residents reviewed for the category of PASARR (Pre-Admission Screening and Resident Review). The lack of pre-screening resulted in the residents' conditions not being evaluated through the Level II PASARR process. Resident identifier: #79, #61, and #58. Facility census: 86. Findings included: a) Resident #79 A record review, completed on 06/03/24 at 11:07 AM, found the following details: Resident #79 was admitted to the facility on [DATE] with a bipolar disorder diagnosis. There was a Pre-Admission Screen (PAS) dated 04/02/24 that was completed by the referring hospital. This PAS failed to include Resident #79's bipolar diagnosis under Section III, Question #30. During an interview on 06/05/24 at 11:17 AM, the Social Worker confirmed Resident #79 had a bipolar diagnosis upon admission, the admission PAS did not capture the diagnosis, and a new PAS had not been done. The Social Worker stated the facility had overlooked the resident's bipolar diagnosis had not been captured on the initial PAS and agreed the lack of pre-screening resulted in the resident's condition not being evaluated through the Level II PASARR (Pre-Admission Screening and Resident Review) process. 50551 b) Resident #58 06/04/24 3:10 PM, Review of resident #58's record revealed the resident's diagnoses include Paranoid Personality, Schizophrenia Disorder, Bipolar Disorder, Anxiety Disorder, Depression, and Schizoaffective Disorder Bipolar Type. 06/04/24 3:15 PM Review of Resident's Pre-Admission Screening (PASARR) dated for 02/28/22 under section III. MI/MR ASSESSMENT, Question #30. Current Diagnosis: is checked marked as answer (a. None.) Seizure Disorder, Schizoaffective Disorder, Affective Bipolar, Schizophrenic Disorder were not marked. 06/05/24 10:10 AM Review of Resident #58's Discharge Summary from a local medical center dated for 03/14/2022 revealed, resident had discharge diagnoses of the following: -left elbow fluid collection likely osteomyelitis, history of substance abuse, chronic hepatitis C, Seizure disorder, Diabetes mellitus type 2, history of cerebrovascular accident with left-sided weakness residual, Bipolar disorder. -The medical history on this discharge summary stated that resident had a history of drug use, bipolar disorder, schizophrenia, TBI status post motor vehicle collision and bilateral lower extremity amputation. On 06/05/24 11:02 AM, an interview with Social Worker (SW) #44 acknowledged that resident #58's mental health diagnoses were not up to date on resident's Pre-Admission Screening dated for 02/28/22. SW #44 reported that she was in the process of updating her PASARR's. b) Resident #53 On 06/04/24 at 10:38 AM, a review of Resident #53's medical record was performed including diagnoses and Resident's Pre-Admission Screening (PASARR). Resident #53 was noted to have received a diagnosis of other seizures on 02/14/20, which was prior to admission to the facility. Upon review of Resident #54's (PASARR), dated as submitted on 03/08/21, it was revealed Resident #53's Seizure disorder was not identified on the PASARR. On 06/10/24 at 01:09 PM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #53's diagnosis of Seizure disorder was present upon admission to the facility and that Resident #53's PASARR did not identify the diagnosis of Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #53's Seizure disorder had not been completed. c) Resident #61 On 06/03/24 at 01:58 PM, a review of Resident #61's medical record was performed including diagnoses and Resident's Pre-Admission Screening (PASARR). Resident #61 was noted to have received a diagnosis of Paranoid Schizophrenia on 10/12/17, Psychotic disorder on 10/31/17 and Seizure disorder on 06/20/23, which was prior to admission to the facility. Upon review of Resident #61's (PASARR), dated as submitted on 02/08/24, it was revealed Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was not identified on the PASARR. On 06/10/24 at 11:10 AM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #61's diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was present upon admission to the facility and that Resident #61's PASARR did not identify the diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder had not been completed. 50552 c) Resident #61 On 06/03/24 at 01:58 PM, a review of Resident #61's medical record was performed including diagnoses and Resident's Pre-Admission Screening (PASARR). Resident #61 was noted to have received a diagnosis of Paranoid Schizophrenia on 10/12/17, Psychotic disorder on 10/31/17 and Seizure disorder on 06/20/23, which was prior to admission to the facility. Upon review of Resident #61's (PASARR), dated as submitted on 02/08/24, it was revealed Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was not identified on the PASARR. On 06/10/24 at 11:10 AM, an interview was conducted with the facility Social Worker (SW), the SW acknowledged that Resident #61's diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder was present upon admission to the facility and that Resident #61's PASARR did not identify the diagnosis of Paranoid Schizophrenia, Psychotic disorder and Seizure disorder. The SW then acknowledged that a new PASSAR including Resident #61's Paranoid Schizophrenia, Psychotic disorder and Seizure disorder had not been completed.

Based on record review and staff interview, the facility failed to ensure each resident had a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This was true for five (5) of 26 residents reviewed in the Long-Term Care Survey Process. Resident identifiers: #82, #190, #191, #54, and #61. Facility census: 86. Findings included: a) Resident #82 A record review, completed on [DATE] at 3:00 PM, revealed Resident #82 was a male admitted to the facility on [DATE]. In Resident #82's care plan the activities department expressed the following goal, I will participate in independent leisure activities of choice daily including word search, cross words, music, tv, sports, going outside through the review date, An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of [DATE]. However, the intervention for resident's activities department goal was still, All staff to converse with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #82 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it was a mistake on her part to refer to Resident #82 as a her. b) Resident #190 A record review, completed on [DATE] at 03:05 PM, revealed Resident #190 was a male. In Resident #190's care plan the activities department expressed the following goal, I will attend activities of choice 3x per week and will pursue my favorite leisure activities daily through this review. An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of [DATE]. However, the intervention for resident's activities department goal was still, All staff to convers with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #190 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it was a mistake on her part to refer to Resident #190 as a her. c) Resident #191 A record review, completed on [DATE] 3:42 PM, revealed Resident #191 was a male resident who was admitted to the facility on [DATE]. In Resident #191's care plan the activities department expressed the following goal, I will participate in independent leisure activities of choice daily through the review date. An intervention listed for this goal was, All staff to converse with her while providing care. The date this intervention was initiated was [DATE]. The care plan had a revision date of date [DATE]. However, the intervention for resident's activities department goal was still, all staff to converse with her while providing care. On [DATE] at 11:21 AM, the Social Worker confirmed Resident #191 was a male and his preferred pronouns were He/Him. During an interview on [DATE] at 11:26 AM, the Activities Director acknowledged it a was a mistake on her part to refer to Resident #191as a her. 50552 d) Resident #54 On [DATE] at 10:41 AM, a review of Resident #54's medical record was performed. Resident #54 was noted as having an order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT). A review of the Physician's Order for Scope of Treatment (POST) for Resident #53 revealed, Cardiopulmonary Resuscitation (CPR), full code with selective treatments, no artificial means of nutrition desired. A review of Resident #54's care plan was also made at this time. Resident #54's care plan was noted to have a focus that states CPR, Full Interventions, IV fluids, NFT. On [DATE] at 12:32 PM, an interview was conducted with the facility Social Worker (SW). At this time, the SW acknowledged that the POST was the correct code status per Resident #54's Medical Power of Attorney's (MPOA) wishes, that the order for Full Code, Full Interventions, Intravenous Fluids (IV), No Feeding Tube (NFT) and care plan indicating CPR, Full Interventions, IV fluids, NFT were incorrect. e) Resident #61 On [DATE] at 01:58 PM, a review of Resident #61's medical record was performed. Resident #61 was noted to have diagnoses of Paranoid Schizophrenia, Neurocognitive Disorder, Dementia, Psychotic disorder, and Seizure disorder. It was also noted during a review of the physician's orders that Resident #61 had an order for psych consult entered on [DATE], which Resident #61's behavior care plan also reflected as an intervention. On [DATE] at 09:52 AM, an interview was conducted with the facility Administrator. At this time, the facility Administrator was unable to confirm if Resident #61 had been seen by psychiatric services as ordered and care planned. On [DATE] at 02:54 PM, the facility Administrator acknowledged that Resident #61 had not seen the psychiatrist and that the care plan had not been implemented.

Based on resident interview, record review, and staff interview, the facility failed to ensure activities of daily living (ADL) care was provided to dependent residents. This deficient practice had the potential to affect one (1) of three (3) residents reviewed for the care area of activities of daily living. Resident identifier: #29. Facility census: 86. Findings included: a) Resident #29 On 06/03/24 at 1:06 PM, Resident #29 stated she had not been receiving twice weekly showers. Review of Resident #29's comprehensive care plan showed the resident had an ADL self-care performance deficit and required assistance of one (1) for bathing. Review of the facility's shower schedule showed Resident #29 was scheduled to receive showers on Tuesday and Sundays. Review of Resident #29's shower documentation for the past 30 days showed the resident received showers on 05/21/24, 05/23/24, and 05/25/24. No shower refusals were documented. On 06/04/24 at 3:56 PM, Regional Director of Clinical Operations confirmed Resident #29 had not received twice weekly showers. No further information was provided through the completion of the survey.

Based on record review and staff interview the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This was true for 3 (three) of 11 residents reviewed for the Long-Term Survey Process. Resident identifiers: #39, #41, #191. Facility census: 86. Findings included: a) Resident #39 On 06/04/24 at 09:57 AM a review of Resident #39's medical record was performed. At this time, it was revealed that Resident #39 had a history of frequent falls. Upon further review of Resident #39's medical record, it was noted that Resident #39 had fallen 6 (six) times since January 2024. On 06/10/24 at approximately 10:30 AM, a further review of Resident #39's medical record was performed. Review of Resident #39's care plan noted an intervention that stated, medication per orders for Parkinson's. At this time, it was noted that Resident #39 had a Pharmacist Consultation Report dated 06/30/23 that stated the following: A comprehensive review of the medical record was conducted, identifying the following medications which may contribute to falls: Nuplazid at 11:00 AM, Carbidopa-Levodopa. Recommendation: Please evaluate these medications as possibly causing or contributing to this fall and consider obtaining order: - Change Nuplazid dosing time to HS (bedtime) -Orthostatic blood pressure twice daily for 2 (two) days. If this therapy is to continue, it is recommended that a) the prescriber document an assessment of risk versus benefit, indicating that the medication is not believed to be contributing to falls in this individual; and b) the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. At this time a review of Resident #39's Medication Administration Record (MAR), progress notes, vital signs and physician's orders was conducted. Resident #39 was noted to be receiving Nuplazid at 09:00 AM and that no documentation was found related to orthostatic blood pressures having been obtained. On 06/10/24 at approximately 11:15 AM, an interview was conducted with the facility ADON who stated that the Nuplazid had in fact been changed to bedtime at per the recommendation. This Surveyor then asked the ADON to provide documentation from the physician related to the risks versus benefits as to why the medication had been changed back to 09:00 AM, as per the current order and for documentation that the orthostatic blood pressures had been obtained. On 06/11/24 at 12:09 PM, an interview was conducted with the facility Medical Director and ADON. The Medical Director stated, I have no idea why it was switched back, with the ADON stating, I can't find any documentation why it was switched back. The ADON then stated that she had found documentation that orthostatic blood pressures had been obtained, however, acknowledged that the orthostatic blood pressures had not been obtained according to the physician's order. b) Resident #41 On 06/04/24 at 01:00 PM, a review of Resident #41's medical record was performed. During the review of the physician's orders, it was noted that Resident #41 had orders as follows: * Novolog Injection Solution (Insulin Aspart) Inject as per sliding scale: if 201- 250 = 4; 251- 300 = 6; 301- 350 = 8; 351- 400 = 10; 401- 450 = 12; 451 + = 15. Notify Medical Doctor (MD) if blood sugar (BS) is less than 60 or above 450, subcutaneously before meals and at bedtime for Diabetes Mellitus (DM) II. Order date: 01/29/24 * Complete Blood Count (CBC)/Glycated hemoglobin (HgbA 1c) every 6 (six) months. Order date: 08/09/23. Upon further review of the medical record, Resident #41's Medication Administration Record (MAR) revealed multiple areas of missing documentation in reference to the above order. At this time Resident #41's diabetic care plan was reviewed which included the following intervention: *Labs as ordered and report results to MD (Medical Doctor). On 6/10/24 at12:30 PM, an interview was conducted with the DON (Director of Nursing) and ADON (Assistant Director of Nursing), this Surveyor then requested documentation related to missing blood sugar documentation and a copy of Resident #41's most recently obtained CBC and HgbA 1c. On 6/11/24 at 09:06 AM, the ADON acknowledged she was unable to locate labs, unable to confirm if the ordered labs had been obtained, or provide further information related to the missing documentation on the MAR related to Resident #41's blood sugar monitoring. 50552 c) RSV immunization Findings included: During an interview, and record review with the Infection Preventionist (IP) #56, on 06/04/24 at 2:20 PM, it was revealed that the facility had not offered the RSV vaccination to residents during the Fall immunization period of 2023. During a subsequent interview on 06/05/24 at 09:42 AM, the Infection Preventionist (IP) #56 stated that to her knowledge, the residents had not been provided with educational information about the risks and benefits of receiving Respiratory Syncytial Virus (RSV) vaccination. She further stated that the facility had not provided residents with information on locations where they could receive immunizations, had they decided to do so. Record review on 06/05/24 at 10:03 AM revealed that Residents #17, #31, #41 and #64 had not been offered information on the RSV vaccine, the RSV vaccine, or locations where residents could receive a vaccine, if they so desired. Guidance from The Centers for Disease Control and Prevention (CDC) states that: Respiratory syncytial virus, or RSV, is a common respiratory virus that usually causes mild, cold-like symptoms. Most people recover in a week or two, but RSV can be serious. Infants and older adults are more likely to develop severe RSV and need hospitalization . Vaccines are available to protect older adults from severe RSV. Monoclonal antibody products are available to protect infants and young children from severe RSV. CDC recommends RSV vaccines to protect adults ages 60 and older from severe RSV, using shared clinical decision-making. According to the CDC the RSV vaccine was made available in early August of 2023. In general, simultaneous administration of vaccines remains a best practice. Providers should continue to simultaneously administer the vaccines for which a patient is eligible, including COVID-19, influenza, and pneumococcal vaccines. Simultaneous administration of RSV vaccine with other vaccines for older adults is also acceptable. When deciding whether to simultaneously administer other vaccines with RSV vaccine on the same day, providers should consider whether the patient is up to date with recommendations for currently recommended vaccines, the feasibility of administering additional vaccine doses later, risk for acquiring vaccine-preventable disease, vaccine reactogenicity profiles, and patient preferences. d) Resident #191 A record review, completed on 06/10/24 at 9:58 PM, revealed the following details: Resident #191 was admitted to the facility on [DATE]. Physician order, on 04/05/24 at 12:03 PM, directed, Weekly weights every day shift every Tue (Tuesday) for 4 Weeks until finished. There was no weight listed for Tuesday, 04/09/24 There was no weight listed for Tuesday, 06/16/24 During an interview on 06/11/24 at 10:40 AM, Regional Director of Clinical Operations #116 reorted the facility was unable to produce weights for the weeks of 04/09/24 and 04/16/24. 50795

Based on record review and staff interview the facility failed to ensure that a resident received the treatment and care in accordance with professional standards of practice in regard to monitoring pain levels. This was true for two (2) of four (4) residents reviewed for pain during a revisit survey. Resident Identifier: #69 and #80. Facility census: 86. Findings included: a) Resident #69. Medical record review revealed Resident #69's Physician orders for pain management: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every four (4) hours as needed for pain use for pain scale 4-10. Order date 04/24/24 with a discontinue date 04/26/24. A continued review of Medication Administration Record (MAR) revealed: --04/26/24 at 9:42 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. Physician Order: Acetaminophen tablet, give 650mg every 6 hours as needed for general discomfort. Give for pain scale 1-3. Order date 04/23/24 with a discontinue date 04/26/24. No Acetaminophen tablet, administered. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every four (4) hours as needed for pain use for pain scale 4-10. Order date 04/26/24 with a discontinue date 05/07/24. A continued review of Medication Administration Record (MAR) revealed: --04/26/24 at 1:23 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --04/27/24 at 8:21 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --04/27/24 at 12:53 PM pain level 2 - Hydrocodone-Acetaminophen tablet given. --04/28/24 at 7:52 AM pain level 2 - Hydrocodone-Acetaminophen tablet given. --04/28/24 at 1:26 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/03/24 at 8:01 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/03/24 at 1:00 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/04/24 at 10:37 AM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/04/24 at 3:38 PM pain level 1 - Hydrocodone-Acetaminophen tablet given. --05/05/24 at 9:22 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/05/24 at 3:34 PM pain level 1- Hydrocodone-Acetaminophen tablet given. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every six (6) hours as needed for pain use for pain scale 4-10. Order date 05/07/24 with a discontinue date 05/14/24. A continued review of Medication Administration Record (MAR) revealed: --05/10/24 at 8:42 AM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/10/24 at 2:43 PM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/11/24 at 9:15 AM pain level 1- Hydrocodone-Acetaminophen tablet given. --05/11/24 at 4:33 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/12/24 at 1:05 PM pain level 2- Hydrocodone-Acetaminophen tablet given. Physician Order: Hydrocodone-Acetaminophen tablet 7.5-325 MG, give one (1) tablet every six (6) hours as needed for pain use for pain scale 4-10. Order date 05/14/24. --05/17/24 at 7:27 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/17/24 at 3:16 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/18/24 at 10:27 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/18/24 at 4:05 PM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/19/24 at 11:26 AM pain level 2- Hydrocodone-Acetaminophen tablet given. --05/25/24 at 9:39 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/26/24 at 5:00 AM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/28/24 at 4:35 AM pain level 3- Hydrocodone-Acetaminophen tablet given. --05/31/24 at 10:03 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --06/01/24 at 9:00 PM pain level 3- Hydrocodone-Acetaminophen tablet given. --06/02/24 at 9:17 PM pain level 3- Hydrocodone-Acetaminophen tablet given. Physician Order: Acetaminophen tablet, give 650mg every 6 hours as needed for general discomfort. Give for pain scale 1-3. Order date 04/26/24, No Acetaminophen tablet, administered. An interview on 06/05/24 at 5:18 PM with [NAME] Director #116, she confirmed Resident #69's Pain medication was not given per physician order. b) Resident #80 Medical record review revealed Resident #80's Physician orders for pain management: Physician Order: -Oxycodone HCl Oral Tablet 5 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain. Order date 05/01/24 with a discontinuation date 05/15/24. A continued review of Medication Administration Record (MAR) revealed: --05/03/24 at 10:20 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/12/24 at 9:38 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. Physician Order: Tylenol Oral tablet 325 mg give two (2) tablets by mouth every four (4) hours as needed for pain. Order date 05/01/24 with a discontinuation date 05/15/24. --05/03/24 at 3:34 AM pain level 8 - Tylenol Oral Tablet 325 MG tablet given. Physician Order: Pain assessment every shift (sale 0-10) 0=no pain 1-3=mild 4-6=moderate 7-10=severe Every shift, Start date 05/01/24. Physician Order: -Oxycodone HCl Oral Tablet 5 MG *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for moderate pain. Order date 05/15/24. A continued review of Medication Administration Record (MAR) revealed: --05/19/24 at 9:38 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/25/24 at 10:27 PM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --05/28/24 at 4:30 AM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. --06/08/24 at 6:40 AM pain level 3 - Oxycodone HCl Oral Tablet 5 MG tablet given. Physician Order: Tylenol Oral tablet 325 mg give two (2) tablets by mouth every four (4) hours as needed for pain. Order date 05/15/24. An interview on 06/11/24 at 12:12 PM with [NAME] Director #116, she confirmed Resident #80's Pain medication was not given per physician order. No further information was provided prior to the end of the survey on 06/11/24.

Based on observation and staff interview, the facility failed to provide and maintain an infection prevention and control program designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases, including COVID-19, and infections in the facility. The facility failed to ensure that all staff utilized and adhered to current Centers of Disease Control (CDC) infection control guidelines to effectively control the spread of COVID-19 and other infections. Staff failed to properly don and doff personal protective equipment when required and follow infection/isolation guidelines prior to entering a resident's room and when handling, transporting soiled linens and when storing clean linens. This practice had the potential to affect all residents in the facility. Resident Census:78. Staff identifiers: Nurse Practice Educator (NPE), Nursing Assistant #1, Nursing Assistant #2, Laundry Aide #3, Licensed Practical Nurse #4, Dietary Aide #5, Housekeeping #6, Housekeeping #7, and Cook #8, Nursing Assistant #10, Licensed Practical Nurse #11 , Licensed Practical Nurse #12, Physical Therapist #13 and DA #20. The deficient practices identified had the potential for serious outcomes because of the facility's non-compliance requiring need for immediate action. The findings were observed in all resident care areas (units) and was determined to pose an immediate jeopardy to the health and safety of all 78 residents in the facility. As of 11/04/20, the facility reported 76 positive COVID-19 cases with 26 active COVID-19 cases currently in the facility. After consulting with the State Agency (SA), the facility administrator was notified of the Immediate Jeopardy on 11/06/20 at 8:35 AM. The time identified as to when the Immediate Jeopardy first began was on 11/04/20 at 2:05 PM. An acceptable Plan of Correction was received on 11/06/20 at 12:23 PM. The facility's removal plan consisted of the following measures to abate the immediate jeopardy: All residents of the facility have the potential to be affected. All nursing staff including agency staff on duty on 11/6/20 will be provided immediate reeducation by the Infection Preventionist (IP)/designee regarding appropriate way to remove trash from the floor, appropriate donning and doffing gowns, use of hand sanitizer/hand hygiene, wearing of face masks and face shields, donning and doffing gowns when entering a resident's room on halls B, C, and D and exiting A hall, passing of meal trays to residents on both the non COVID and COVID halls and storage/disposal of masks/face shield when taking a break, leaving the center and/or at end of shift. The Laundry Aide identified as LA #3 will be provided reeducation by IP/designee upon return to work before starting laundry job duties and the laundry staff on duty 11/6/20 will be reeducated regarding appropriate Personal Protective Equipment including gown and gloves to be worn when opening and shutting laundry bins, when transferring soiled linen from COVID Unit into laundry bin, to include appropriate hand hygiene when exiting the COVID unit, separation of laundry from the COVID unit with other halls B, C, and D, and appropriate procedure to sanitize soiled laundry bins, use of hand sanitizer and hand hygiene when going from soiled side of laundry to clean side. All dietary staff on duty on 11/6/20 will be reeducated by the IP/designee on infection control procedures to enter building, use of hand sanitizer, and handling of masks and face shields when exiting and entering the center for breaks to include storage/disposal of masks and face shields when taking a break, leaving the center and at end of shift. All housekeeping staff on duty on 11/6/20 will be provided reeducation by IP/designee regarding appropriate wearing/donning of gowns on the COVID units and hand hygiene/glove usage when taking trash out to the dumpster. All staff on duty 11/6/20 will be provided reeducation by IP/designee regarding not using the church pavilion when taking breaks. All staff including agency staff will be provided reeducation starting 11/6/20 regarding maintaining a safe sanitary environment to help prevent the development and transmission of communicable diseases including COVID-19 to ensure adherence to current Centers of Disease Control (CDC) infection control guidelines and facility policies to include appropriate use of PPE, standard verses transmission based precautions prior to entering a resident's room, handling and transporting soiled linens and storage of clean linens prior to beginning job duties by the IP/designee with a posttest to validate understanding. Staff including agency staff not available during this timeframe will be provided reeducation and complete posttest upon return to work by the IP/designee. New staff and agency staff will be provided education and complete posttest during orientation. The IP/designee will conduct observations across all shifts starting 11/6/20 daily x 2 weeks including weekends, then 3 x per week x 2 weeks, then randomly thereafter to ensure staff are using appropriate/wearing of PPE, storage/disposal of masks when taking a break, leaving the center, and at end of shift, use of hand hygiene, glove usage and hand sanitizer. Laundry Supervisor/designee will observe starting 11/6/20 Laundry staff using appropriate Personal Protective Equipment including gown and gloves to be worn when opening and shutting laundry bins when transferring soiled linen from COVID Unit into laundry bin, including appropriate hand hygiene when exiting the COVID unit, separation of laundry from the COVID unit with other halls B, C, and D, and appropriate procedure to sanitize soiled laundry bins, use of hand sanitizer and hand hygiene when going from soiled side of laundry to clean side daily across all laundry shifts x 2 weeks, then 3 x per week x weeks then randomly thereafter. Housekeeping Supervisor/designee will observe starting 11/6/20 housekeeping staff's appropriate wearing/donning of gowns on the COVID units and hand hygiene/glove usage when taking trash out to the dumpster. Results of audits will be reported by the IP/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or inservicing until the issue is resolved then randomly thereafter as determined by the QIC committee. Observations and interviews to determine abatement was conducted on site from 11/06/20 at 12:23 PM through 11/06/20 at 5:30 PM. On 11/06/20, at 5:30 PM, it was determined the facility had implemented their Plan of Correction removing the Immediacy of the deficient practices identified in the Immediate Jeopardy. The facility was notified the Immediate Jeopardy was abated on 11/06/20 at 5:30 PM. Findings Included: a) B-Hall During an observation on B-Hall (Covid-Unit), on 11/04/20 at 2:05PM, Nurse Assistant (NA) #1 was observed bending down picking up an item off the floor. NA #1 took the item and lifted the lid on the trash can and threw item away. NA #1 proceeded to walk down the hall with her hands in her pockets. NA #1 had not sanitized her hands prior to putting them in her pockets. NA #1 was observed five (5) minutes later, hand sanitizing at the other end of the hall. She had passed closer hand sanitizing stations with hands in her pockets. An observation on B-Hall (Covid-Unit), on 11/04/20 at 2:10 PM, revealed an active call light. NA #2 unzipped barrier and entered B-Hall. NA #2 was observed inappropriately donning gown. NA #2 tied the top part of the gown around her neck and proceed into room. NA #2 failed to tie the portion of the gown around her waist. NA was observed entering a Resident room with the back area of clothing not appropriately covered. An interview with the Director of Nursing (DON) and the Administrator, on 11/04/20 at 2:50PM, confirmed identity of NA #1 and NA #2 and informed them of deficient practices observed. b) Laundry Pickup An observation of a Laundry Aide (LA) #3, on 11/04/20 at 2:20PM, revealed the gathering of linens from C/D Hall (Covid-Unit). LA #3 was observed wearing only one (1) glove on the right hand and no glove on the left hand. LA #3 was observed opening and shutting the laundry bins with left ungloved hand and picking up linens with her right gloved hand. LA #3 was not wearing a gown and transferring dirty linen from D-Hall (Covid Unit) into the laundry bin. LA #3 disposed of the right-hand glove into the trash but did not hand sanitize before exiting the C/D-Hall. The hand sanitizing station was located on the wall two (2) resident rooms in the opposite direction of the exit door. An interview with LA #3, on 11/04/20 at 2:30 PM, confirmed she did not have a gown on to collect the Covid-19-unit linen because no one ever told me that I needed to wear one. LA #3 stated, if someone would tell me I need to wear a gown to collect linen on the Covid Unit, I would do it. LA was asked about only having one (1) glove on while collecting linen. LA stated that she only touched the dirty linen with the gloved hand and only touched the lids of the containers with the non-gloved hand. When asked if she was concerned about Covid-19 in the building she responded, I already had Covid-19 so I am immune to it now, so I am good. LA #3 was asked how they separate laundry and if Hall A (Non-Covid Unit) with Halls B, C and D (Covid-19 Units) were laundered together. She stated when we get laundry, we just throw it in the washer to get it done. LA #3 stated, at this point the whole building has Covid so no sense in separating hallways anymore. Nurse Practice Educator (NPE) was present during observation and at the start of interview with LA #3. NPE did not respond to observation where deficient practice was identified and walked away from interview. Observed LA #3, on 11/04/20 at 2:35 PM, rolling the dirty laundry bin to the side door where she proceeded to spray the bin with hydrogen peroxide and wiped down the bin with non-gloved hands. LA #3 proceeded to leave the bin outside and walk back into the facility. LA did not utilize the hand sanitizer when entering the building after cleaning the laundry bin with non-gloved hands. LA #3 walked in the building touching two (2) doors and a keypad with dirty hands and walked into the clean side of the laundry room. An interview with the Administrator, on 11/09/20 at 3:03 PM, via email, stated, policy titled, Interdisciplinary Process for Long Term Reusable Washable Gown Use with updated date of 09/24/20 would be the only other thing I could find related to a specific policy that involved linen handling and transporting on and off the Covid units. There was no policy to address handling and transporting of soiled lines from Covid Units. A policy review titled, IC204 Linen Handling with Revision date 03/01/18, on 11/09/20 at 12:53 PM, revealed, all soiled linen will be handled using standard precautions. Standard precautions included wear gloves when collecting linen. A policy review titled, Interdisciplinary Process for Long Term Reusable Washable Gown Use with updated date of 09/24/20, on 11/09/20 at 3:04PM, revealed, laundry staff with pick up soiled gowns form designated location. To sort the gowns and prepare for laundering, the laundry employee should be fully gowned, masked, gloved, and using a face shield. c) Tray Passing (A-Hall) An observation on 11/05/20 at 12:15PM revealed two (2) staff LPN #4 and the NPE serving trays on A-Hall. The CDC Airborne/Contact precaution signs on all Resident doors during the outbreak stated, wear a N95 mask, gown, face shield and gloves upon entering this room. LPN #4 and NPE were observed passing lunch trays and entering rooms without gloves. An immediate interview with NPE, on 11/05/20 at 12:15PM, revealed all staff are to follow the CDC Airborne/Contact precaution signs attached to the A-Hall Resident rooms. Review of Education records, on 11/09/20 at 4:00PM, revealed Isolation Precautions and when/how to wash hands training on 09/22/20. Observations on 11/05/20 revealed inappropriate resident care related to rooms placed on Airborne/Contact precautions. d) Cross-Contamination An observation on 11/05/20 at 12:45PM revealed Dietary staff (DS) #5 wearing masks pulled down under their chin and face shield hanging off arms. Face shield observed against staff clothing while outside smoking. An interview with Dietary Staff (DS #5), on 11/05/20 at 12:50 PM, revealed staff were just told they were no longer able to smoke under the pavilion beside the facility. DS #5 stated that staff no longer have anywhere to go to take a break. DS #5 after interview proceeded to enter the facility through the side door at 1:00PM. DS #5 touched both doors and used the keypad not utilizing the hand sanitizer unit available. DS #5 was observed using dirty mask and shield not obtaining fresh or new Personal Protective Equipment (PPE) upon re-entry into the facility. e) Trash Disposal An observation, on 11/05/20 at 1:40PM, revealed a housekeeper (HK) #7 taking out the trash to the dumpster not wearing gloves. An observation, on 11/06/20 at 9:15AM, revealed a Dietary Aide (DA) #20 took trash to the dumpster with no gloves touching the tops of the dumpster and dirty trash barrel. DA #20 was observed using hand sanitizer, touched first door to enter building, utilized keypad and touched second door. DA #20 continued to transport dirty trash barrel back into the building. An interview with DA #20, on 11/06/20 at 9:20 AM, revealed, the normal practice of trash disposal is to not wear gloves. DA #20 stated, no one ever told me that I had to wear gloves when taking out the trash. An interview with the Administrator, on 11/06/20, at 9:55 AM, verified the facility expectation is for employees to wear gloves when handling or taking out trash to the dumpster area. A policy review titled, Trash Removal with a revision date of 11/01/07, on 11/10/20 at 8:46 AM, revealed, employees wear gloves when removing trash from containers. f) PPE An interview with the Administrator on 11/04/20 at 1:00 PM, revealed N95 masks and face shields were to be discarded if an employee went outside for breaks etc. and the employee would obtain new PPE before re-entering the facility. On 11/05/20, at 12:55 PM, three facility staff were observed to be at a covered area adjacent to the facility seated at picnic tables, eating or smoking. HK#7 was observed re-applying used PPE after eating and pulling the mask down and eating Cheez-its (crackers) holding the outside of the shield against personal clothing, then was observed at this time to smoke after being in contact with the used PPE. No hand-washing or sanitization of the hands was observed prior to re-entering the building. Additionally, HK #7 touched the code keypad and failed to sanitize hands prior to touching the keypad and opening the door to return inside the facility. g) Donning and Doffing On 11/04/20, at 1:40 PM, an interview with the NPE, during the initial tour, revealed the Personal Protective Equipment (PPE) is to be doffed in described locations inside the facility but also directed surveyor to two outside trash receptacles, one at the main walk and one at B Hall exit. However, when the receptacles were observed, there was no sanitizing stations available in these areas. An observation on 11/5/20 at 1:00 PM, revealed Cook #8 outside, re-donning the same used PPE (mask and face shield), she had inside the facility. Cook #8 proceeded to touch the keypad to re-enter the facility outside the dietary/laundry entrance area and did not use sanitizer prior to touching the keypad and opened the door and entered the facility. An observation on 11/6/20, at 10:30 AM, revealed PT #13 was donning a gown to enter room A10 Hall. It was observed at this time, the isolation gown was not drawn tight enough to close allowing the backside not to be covered with the PPE (gown). The employee was observed to enter the room. An interview, on 11/06/20 at 2:15 PM, the Administrator and Corporate Manager confirmed that all gowns used did fit all employees properly and needed to identify a correction to this. An observation on 11/06/20 at 4:05 PM, NA# 10 removed soiled PPE (gown) and donned a new gown. NA #10 failed to wash hands or sanitize the hands after removing the soiled gown and donning a clean gown. An interview with the NPE, who was present at the time, on 11/06/20 at 4:05 PM, confirmed NA #10 did not wash hands or sanitize between removing the soiled gown and donning a clean one and should have done so. An observation on 11/06/20, at 4:20 PM, revealed LPN #11 donning clean PPE (gown). LPN #11 opened gown to don and allowed the gown to drag on the floor as she donned the PPE (gown). An interview with the Administrator and Corporate Manager, on 11/06/20 at 4:30 PM, verified understanding of the deficient practice and stated they would re-educate the employees making the mistakes with donning and doffing of PPE. According to review of Education records on 11/9/20 at 3:00 PM, revealed staff had been trained on hand washing and donning and doffing of PPE on 10/10/20, and 10/20/20 and 11/06/20 but continued to perform these procedures incorrectly. An email interview with the Administrator, on 11/10/20 at 9:01 AM verified the facility is utilizing CDC guidelines for Donning and Doffing PPE and utilizing the Corporate Clinical Competency Evaluation to ensure competency of staff which notes, under Hand Hygiene, section 1, indicated staff were to perform hand hygiene using soap and water or alcohol based had rub (ABHR) immediately after removing all PPE. Review of putting on PPE (donning) under #5 notes that gown is not to be shook or allowed to touch the floor.

Based on record review, staff interview, and family interview, the facility failed to provide care and services to maintain the highest practicable physical well-being in accordance with the comprehensive plan of care for two (2) of eighteen (18) Stage II sample residents. Resident #153 complained to her family of a sore mouth, tongue, and throat, which the resident's legal representative conveyed to the facility. The facility's licensed nursing staff failed to collect and record physical assessment data related to the condition of the resident's entire oral cavity and related to the attending physician only the presence of a slightly inflamed tongue, for which the physician ordered a medicated [MEDICATION NAME]. The resident's legal representative ultimately made an appointment for the resident to be evaluated and treated by a second physician outside the facility, who diagnosed glossitis, mouth ulcers, and possible candidiasis and ordered five (5) medications for treatment of [REDACTED]. A nurse failed to ensure Resident #73 received all medications ordered by the physician during a medication pass on the morning of 11/10/10. Resident identifiers: #153 and #73. Facility census: 98. Findings include: a) Resident #153 An interview with the Resident #153's daughter, on 11/11/10 at 8:50 a.m., revealed the resident had been in pain from sores in her mouth and the resident's tongue was irritated and swollen. The resident had told the her the inside of her mouth had sores, her tongue was very irritated, and that her throat was also sore. According to the daughter, her brother visited Resident #153 and reported back to her that he had observed sores in the mouth and that her tongue was red. The daughter further stated she called the facility and asked for the physician to look at her mother's mouth. According to the daughter, the facility's physician did not look at her mother's mouth, so she called her mother's previous attending physician (who was no longer affiliated with the facility) and made an appointment to have her evaluated. - Record review revealed a nursing note, dated 04/28/10 at 5:30 p.m., which stated, "... Resident C/O (complained of) sore tongue (sic) slightly red / inflamed. (Name of attending physician) notified (sic) new order [MEDICATION NAME] 10 mg x 2 weeks - resident notified." On 04/29/10 at 1:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont(inued) for mouth soreness. No complaints at this time." On 04/29/10 at 7:40 a.m., a nurse wrote, "... [MEDICATION NAME] to begin this AM (morning) for sore mouth, tongue slightly red and irritated. ..." On 04/29/10 at 4:00 p.m., a nurse wrote, "... [MEDICATION NAME] cont /s (without) adverse effects noted r/t (related to) sore touth (sic), tongue - slightly red / irritated - denies any further C/O (complaints). ..." On 04/30/10 at 8:00 a.m., a nurse wrote, "... [MEDICATION NAME] cont /c (with) no adverse effects noted for sore mouth, tongue slightly red, irritated. Denies any C/O this AM. ..." On 04/30/10 at 11:30 a.m., a nurse wrote, "Dtr (daughter) made appt (appointment) today /c (name of outside physician) at 1:30 p - follow-up (sic). Facility to take." On 04/30/10 at 3:00 p.m., a nurse wrote, "Returned back from (name of outside physician). Dx (diagnosis): glossitis, mouth ulcers, possible candidias (sic). New orders OK per (name of facility's physician): (1) [MEDICATION NAME] xylocane (sic) 1 tablespoon swish, gargle, and swallow QID (four times a day) x 10 days. (2) [MEDICATION NAME] 150 mg qday (sic) (every day) x 3 days. (3) 2 cc B12 IM (intramuscular injection) in AM. (4) 80 mg [MEDICATION NAME] IM x 1. (5) [MEDICATION NAME] oral susp(ension) 1 tsp QID PO (by mouth) swish, gargle, and swallow x 10 days. Dtr notified. Cont to monitor." This entry was followed by an addendum, dated 04/30/10, noting the discontinuation of the [MEDICATION NAME]. - The nursing entries from 04/28/10 until 04/30/10 only addressed the resident's irritated tongue and did not contain evidence of an assessment of the resident's oral cavity as a whole; there was no mention of the presence of mouth ulcers which had been identified by the outside physician on the afternoon of 04/30/10. - In an interview on 11/16/10 at 8:45 a.m., the director of nursing (DON - Employee #88) reported the nurses had assessed the resident's mouth and only found that the resident had an irritated tongue. A nurse called the facility's physician and told him about the irritated tongue, and he ordered [MEDICATION NAME]. The DON provided, as evidence of assessment of the resident's oral cavity, a nursing assessment form (which include an oral / nutritional assessment) dated 02/27/10. However, this nursing assessment was completed two (2) month before the resident was diagnosed by the outside physician as having a glossitis, mouth ulcers, and possible candidiasis, for which he ordered treatment with five (5) medications. The DON further stated the facility's physician was in and visited the resident on 04/26/10, and there was no evidence the resident had complained about a sore mouth at that time. - A review of the physician's progress notes found an entry, dated 04/26/10, which did not indicate the resident had complained of a sore mouth. This physician visit, however, occurred two (2) days prior to the resident's first complaint of a sore mouth on 04/28/10. - A review of the monthly summary completed, by a licensed nurse on 04/05/10, revealed a section titled "16. Oral Hygiene". Within this section was "Condition of Mouth" followed by a space where a description of findings could be recorded; this space was left blank. - Review of nursing notes entered in the medical record after the resident returned from her outpatient physician visit on the afternoon of 04/30/10 with orders to treat found references to the resident's complaints of mouth pain or discomfort in entries made at 4:00 p.m. on 05/01/10, at 6:20 a.m. on 05/02/10, at 9:50 a.m. on 05/02/10, and at 4:00 p.m. on 05/02/10. However, there were no entries describing the physical condition of the resident's oral cavity until 10:00 p.m. on 05/03/10, when a nurse wrote: "... Cont to have observable mouth ulcerations /c C/O discomfort..." - Resident #153's daughter, after hearing complaints of oral pain and soreness from the resident and after hearing a report by her brother of the presence of sores in her mother's mouth, reported having asked facility staff to have the attending physician evaluate her. The facility failed to provide a full assessment, either by a registered nurse or the physician, of the resident's oral cavity after the resident complained of pain and soreness to her mouth. The resident's daughter was required to intervene and schedule an appointment with an outside physician in order to obtain appropriate treatment for [REDACTED]. -- b) Resident #73 During the observation of the passing of medications at 9:00 a.m. on 11/10/10, the licensed practical nurse (LPN - Employee #13) failed to administer [MEDICATION NAME] 25 mg which was ordered to be given at that time to Resident #73. The nurse surveyor compared the list of medications verbally told to her by the LPN during the medication pass (and observed being given to the resident) with the physician's orders [REDACTED]. Employee #13 continued on with her medication pass to the remaining residents on the B hall. During an interview with Employee #13 at 9:50 a.m. on 11/10/10, after she had completed the pass, she acknowledged she had not administered the [MEDICATION NAME]. She reviewed the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A comparison of the medications in the medication cart labeled for use by Resident #73 with the resident's MAR indicated [REDACTED] .

Based on record review, staff interview, and family interview, the facility failed to provide care and services for one (1) resident of five (5) sampled residents with an indwelling Foley urinary catheter who was exhibiting signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and did not receive timely medical intervention. The resident was transferred to the hospital after becoming lethargic on [DATE], four (4) days after she was first symptomatic for a UTI on [DATE] (as evidenced by an elevated temperature and a finding of "very cloudy and dark" urine). The resident subsequently died at the hospital [MEDICAL CONDITION] on [DATE]. Resident identifier: #153. Facility census: 98. Findings include: a) Resident #153 Closed record review revealed Resident #153 was a [AGE] year old female who was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #153's comprehensive admission assessment with an assessment reference date (ARD) of [DATE], she had short-term memory problems but no long-term memory problems, she exhibited modified independence with her cognitive skills for daily decision making, she required the extensive physical assistance of two (2) or more persons with bed mobility and transfers, and she was totally dependent on two (2) or more persons with toilet use. She was also incontinent of bowel elimination, continent of bladder elimination with the presence of an indwelling Foley urinary catheter, and had been diagnosed with [REDACTED]. According to her comprehensive annual assessment with an ARD of [DATE], Resident #153's cognitive status remained the same, she required the extensive physical assistance of one (1) person with bed mobility, she was totally dependent on two (2) or more persons for transfers, and she required the extensive physical assistance of two (2) or more persons with toilet use. She was also now continent of bowel elimination and bladder elimination with the presence of an indwelling urinary catheter, and she had NOT been diagnosed with [REDACTED]. -- According to her care plan dated [DATE] through [DATE], the interdisciplinary team identified the following problem: "Risk for infection R/T (related to) indwelling foley (sic) cath (sic) and hx (history) of uti (sic)." The goal associated with this problem statement was: "Resident will exhibit no s/sx (signs / symptoms) of UTI thru next review aeb (as evidenced by) afebrile, no change in sedimentation of urine." The interventions intended to assistant the resident in achieving this goal included: "#16F foley (sic) with 30cc balloon per orders, Change Q (every) 4 weeks and prn (as needed). change (sic) urinary drainage bag Q 4 weeks and prn. Foley cath care Q shift. Provide incontinence cares (sic) frequently as able ensuring proper peri care due to increased risk of ecoli (sic) infection. Encourage and assist with fluids with and between meals for preventative measures. Monitor for s/sx of UTI such as hematuria (blood in urine), dysuria (painful urination), pyuria (pus in urine), abdominal pain, temp (sic), increasd (sic) confusion, etc. Notify MD as needed. hx (sic) of vre ([MEDICATION NAME]-resistant [MEDICATION NAME]). Monitor for s/s of uti (sic) during periods of increased blood sugars. Notify md (sic) of findings." -- A nursing note, dated [DATE] at 12:30 a.m., revealed, "Temp (temperature) 100.2 (symbol for 'oral') ... Urine very cloudy and dark. New order (sic) UA (urinalysis) & C&S (culture and sensitivity) this AM (morning) ...." A nursing note, dated [DATE] at 11:15 p.m., stated, "Labs returned. Abnormal UA - pH 9.0, Protein 75, Blood 250, Leukocyte Est 500 preliminary (sic) awaiting final." (The normal ranges for these labs are: pH = 4XXX,[DATE].0, Protein = negative (0), Blood = negative (0), and Leukocyte Est = negative (0).) The next consecutive entry in the nursing notes, dated [DATE] at 12:20 a.m., stated, "Temp 97.6 (Ax) (axillary). Foley catheter draining cloudy dark yellow." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, " ... yells / moans @ (at) times (sic) complaints generally nonspecific and cease /c (with) conversation. T (temperature) 99.0 (symbol for 'oral') awaiting final C&S of UA. foley (sic) cath patent (sic) draining tea colored urine. denies (sic) abd(ominal) pain upon palpation. C/O (complains of) bladder feeling full (sic) abd small & soft. ... fluids (sic) encouraged by staff as well as ice chips ... will continue to monitor." The next consecutive entry, dated [DATE] at 4:00 p.m., stated, "Temp 98.6 (Ax). ... Yells / moans out occas (occasionally) /c C/O mouth pain. ... ice chips & fluids encouraged. foley (sic) cath patent draining dark tea colored urine - slightly blood tinged. Awaiting C&S of UA. ..." The next three (3) consecutive entries in the nursing notes (dated [DATE] at 6:20 a.m., [DATE] at 9:50 a.m., and [DATE] at 4:00 p.m.) contained no mention of the status or characteristics of the resident's urinary output. The next entry, dated [DATE] at 2:10 a.m., stated, " ... Indwelling foley (sic) drng (draining) small - mod amts of dk sl amber urine. ..." The next consecutive entry in the nursing notes, dated [DATE] at 10:00 a.m., stated, "Temp 99.6 (Ax). Lethargic. C/O not feeling well (sic) not wanting to be bothered." An addendum following this entry stated, "10 am. Received napoxen (sic) ([MEDICATION NAME] - a non-steroidal anti-[MEDICAL CONDITION] drug) @ 7:45 a.m. Will cont to monitor for S/Sx fever; infection." The next consecutive entry, dated [DATE] at 11:00 a.m., stated, "Up to BSC (bedside commode) (sic) became very weak, pale. Put back to bed. BP (blood pressure) ,[DATE]. P (pulse) 84. Skin cool (sic) clammy. After stimulation BP ,[DATE] P 82. Had expelled hard BM (bowel movement) prior to episode." The next consecutive entry, dated [DATE] at 11:30 a.m., stated, "Yelling (sic) insisting to be back up on BSC. ..." This was followed by an entry by the same author with the same date and time, noting that a dose of [MEDICATION NAME] was withheld related to a possible adverse effect. The next consecutive entry, dated [DATE] at 10:00 p.m., stated, " ... also C/O feeling very weak - orders rec (received) for lab wk (work) in AM (morning). Res (resident) made aware." The next consecutive entry, dated [DATE] at 4:00 a.m., stated, "Resting quietly in bed - awakens easily (sic) appears sl (slightly) listless. ... Ate 0% of meals [DATE] /c only (approx) 300 ml of fluids /c meals ..." The next consecutive entry, dated [DATE] at 5:00 a.m., noted the arrival of the vendor laboratory service to collect specimens for blood work. The next consecutive entry, dated [DATE] at 10:00 a.m., stated, "Lethargic. BS (blood sugar) elevated. BP low. Consulted Dr. (name of attending physician) /c exam. New order. Novalog ,[DATE] 10 units bid (twice daily). IV (intravenous fluids) 0.45% NaCl @ 100 cc/hr x 2 hours then 80 cc/hr. Transfer to (name of hospital) ER for eval." The next four (4) entries in the nursing notes recorded the successful insertion of the IV, notification of the resident's change in condition and transfer to the resident's legal representative, transfer of the resident to the hospital, and mailing of the notice of transfer and bedhold policy to the resident's legal representative. -- The above nursing notes recorded evidence of the resident exhibiting signs and symptoms of a UTI beginning on [DATE] (e.g., dark, cloudy urine; blood in urine; low grade temperature; lethargy). These signs and symptoms continued without treatment or physician intervention from [DATE] until [DATE], when the resident was transferred to the hospital. -- Review of a lab specimen inquiry dated [DATE] with a run time of 1146 (11:46 a.m.) revealed the following abnormal results of the blood work collected in the early morning hours of [DATE]: - Glucose - 354 (normal range ,[DATE]) - Blood urea nitrogen (BUN) - 194 (normal range ,[DATE]) Below this lab value on the report was typed, "Tried to notify Sunbrige (sic) of results - could not get pick-up on floor. Notified (name) (front desk) that I would be faxing results to floor. ..." - Creatinine - 5.1 (normal range 0XXX,[DATE].3) - B/C (BUN / Creatinine) Ratio - 38 (normal range ,[DATE]) - Potassium - 5.1 (normal range 3XXX,[DATE].5) -- Lab results after Resident #153 arrived at the hospital revealed the following: - Urine specimen collected on [DATE] (with results dated [DATE]) - the appearance was noted to be "turbid (cloudy) specimen red" with "large" amount of blood, equal to or greater than 300 mg/dl of protein in the urine, with a quantity of red blood cells in the urine "too numerous to count" and "loaded" with bacteria. - Blood specimen collected on [DATE] (with results dated [DATE]) - cultured positive for [DIAGNOSES REDACTED] pneumoniae and Streptococcus mitis group. The resident was septic and subsequently expired at the hospital on [DATE]. -- An interview with the director of nursing (DON - Employee #88), on [DATE] at 8:45 a.m., revealed the resident's attending physician would always wait until the final lab report was received to determine what antibiotic to order. She further stated the physician would treat if a resident were symptomatic, but according to the DON, Resident #153 only had an elevated temperature on [DATE] and was not symptomatic of a UTI. -- Resident #153 was exhibiting signs and symptoms of a UTI beginning on [DATE] and continuing to [DATE], when the resident was transferred to the hospital. There was no evidence to reflect staff notified the attending physician of the resident's dark, cloudy urine, the presence of blood in the resident's urine, the resident's moaning and yelling, her lethargy, and/or of the overall change in the resident's condition prior to [DATE]. .

Based on closed medical record review, review of facility records, staff interview, resident interview, review of the manufacturer's instructions for operating a sit-to-stand lift, observation, and demonstration by staff of the proper use of a sit-to-stand mechanical lift, the facility failed to ensure one (1) of eighteen (18) sampled residents received adequate supervision and assistance devices to prevent avoidable accidents. Resident #54 fell during a transfer using a sit-to-stand lift, sustaining a fracture to the right femur which resulted in hospitalization and surgical repair of the fracture. The two (2) nursing assistants who were involved in the transfer did not use the equipment in accordance with the manufacturer's instructions to ensure a safe transfer, by failing to ensure the legs of the lift were in the maximum open position for stability during the transfer. The facility also failed to ensure the lift used for transferring Resident #54 was the most appropriate device in view of the fact that the resident was not always able to bear the majority of her own weight, and the legs of the lift could not be opened to the maximum open position for stability when placed under the resident's electric bed, both of which were required by the manufacturer's instructions. Resident identifier: #54. Facility census: 98. Findings include: a) Resident #54 Closed record review revealed Resident #54 was a [AGE] year old female who was originally admitted to the facility on [DATE] for aftercare of surgical repair to a fractured femur. According to her comprehensive admission assessment with an assessment reference date (ARD) of 08/24/09, she was alert, oriented, and independent with cognitive skills for daily decision-making, her [DIAGNOSES REDACTED]. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion with one (1) leg with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 296#. According to her most recent abbreviated quarterly assessment with an ARD of 05/12/10, in Section G, the assessor noted Resident #54 required the extensive physical assistance of two (2) or more staff for bed mobility, and she was totally dependent on two (2) or more staff for transfers. Under "Test for Balance" at Item G3a, the assessor encoded "3" for "Not able to attempt test". Under "Range of Motion" and "Voluntary Movement" at Items G4dA and G4dB, the assessor indicated the resident had limitations to range of motion in both legs with partial loss of voluntary movement. In Section K, the assessor noted she was 5' 1" tall and weighed 298#. Review of her care plan revealed the following problem statement with an initiation date of 05/18/10: "Resident at risk for falls r/t (related to) decreased mobility and weakness. (sic) hx (history) of falls and med usage." The goal associated with this problem statement, with a target date of 08/18/10, was: "Will have no injury r/t falls thru next review." Interventions to achieve this goal included: "up (sic) with sit to stand lift for all transfes (sic) wbat (weight bearing as tolerated) per orders." Review of her physician orders [REDACTED]." -- A nursing note, recorded by Employee #104 (a registered nurse) and dated 08/15/10 at 12:45 p.m. revealed, "Called to resident room. Resident was holding onto bar of sit to stand with hands. Left leg was stretched under bed and right leg was twisted with knee cap facing out and foot up by chin. Resident was lowered to floor. Unable to move by staff and squad called to assist resident. 4 squad members and 2 RN (sic), 1 LPN, (sic) 2 CNA (sic) assisted resident on back board and stretcher. Support provided to right leg. When getting resident out of bed with sit to stand lift (per orders). Resident stated, I am not in w/c (wheelchair) right. Staff lifted her up with lift and she said she was sliding. When attempting to get back in bed, bed was too high and unable to lower further down. She let go of lift with one hand. Staff instructed resident to hold on then she let go with the other hand and slid to the floor. Unable to obtain VS (vital signs) due to positioning. ..." -- A review of the facility's Fall Investigation / QA Report found Resident #54 fell from a sit-to-stand lift at 12:45 p.m. on 08/15/10. The resident was transported to local hospital where she was diagnosed with [REDACTED]. She was subsequently readmitted to the facility on [DATE], and she was discharged to another nursing facility at her request on 10/22/10. A hospital operation summary, dated 08/19/10, stated, "The patient is a [AGE] year-old female who is known to me. Approximately a year ago, she sustained an intertrochanteric hip fracture while getting out of bed. ... She was admitted to an outside hospital and found to have a subtrochanteric femur fracture as above. She is extremely and morbidly obese. She does not really ambulate and has not ambulated for some time because of this. ..." -- The facility's investigative report of the fall on 08/15/10 included statements from staff present during the fall and from staff summoned to the resident's room after the fall, as follows: In a statement dated 08/15/10 at 12:15 p.m., Employee #92 (a nursing assistant) wrote: "We were getting resident out of bed and had her hooked up on the sit to stand lift. We were trying to get her into wheel chair (sic) and we lowered her and she said she wasn't in chair (sic) right. We lifted her up and she said that she was sliding (sic) to get her onto the bed. We got her back to the side of the bed but (sic) bed was to (sic) high. We had no way of lowering the bed. (Electric) (sic) She let go of one hand and said she couldn't hold on. She then let go with other hand and slid down to the floor." In a statement dated 08/15/10 at 12:15 p.m., Employee #134 (a nursing assistant) wrote: "When getting resident out of bed with sit and stand lift, we put resident in chair and she said she wasn't in right (sic), we lifted he (sic) back up then she started sliding, When (sic) we tried to put her on her bed, bed (sic) wouldn't lower and she was sliding more (sic) so we had to lower her to floor. Resident let go of lift with one hand and (sic) made her slide more." In a statement dated 08/15/10 at "12:15 about" (per the author of the statement), Employee #22 (a nursing assistant) wrote: "I (name) was called to (initials) by another CNA (certified nursing assistant). When I entered (sic) resident was lying on floor face down with lift still attached to her. With help from 3 RNs & CNAs we lowered her to the floor completely to try to make resident as comfortable as possible until emergency squad arrived, then was (sic) asked to assist squad members to get resident on back board & out to emergency squad (sic)." In a statement dated 08/15/10 (no time noted), Employee #81 (a nursing assistant) wrote: "CNA yelled for help. I entered room and resident had slipped through the sit to stand sling. We lowered (sic) to floor. Ambulance arrived." In a statement signed on 08/18/10, Employee #135 (a registered nurse - LPN) wrote: "Called to resident's room by CNAs. Resident was in position of left leg stretched behind her & right leg twisted /c (with) foot by chin. When questioned what happened (sic) resident stated 'I slid in the lift, I let go of bar.' Denied pain @ (at) that time. Was sent to ER (sic) for eval." In a statement dated 08/16/10 at 12:30 p.m., Employee #109 (a licensed practical nurse - LPN) wrote: "On 8/15/10 ~ 12:45 p called to residents (sic) room by staff. Resident lying on abdomen in center of floor /c (R) (right) leg bent & extended out & upwards towards (R) side. Multiple staff members in room to assist. Squad notified, arrived & called for extra squad members to assist /c transport. ... Upon arrival of 2nd squad & instructions received from their Command Center, resident transferred onto backboard on abd (abdomen) /c leg supported by 8 staff & squad to cot. ..." There was no evidence to reflect the facility had interviewed the resident during their internal investigation of this fall, even though she was alert and oriented, she had been determined to possess the capacity to make her own informed medical decisions, and she returned to the facility after her hospital stay on 08/24/10. (See also citation at F225.) -- An interview with Employee #121 (a registered nurse), on 11/15/10 at 12:55 p.m., revealed the RN was called to the resident's room. She walked into the room and saw the resident lying on her abdomen with her right leg under her and her foot up under her chin. The other staff in the room told the nurse that the resident was being transferred from the bed and the resident changed her mind about getting up in the chair. She felt weak and let go of the bar on the sit to stand and slipped through the sling. She further stated, "The resident sustained [REDACTED]. -- An interview with the administrator, on 11/15/10 at 2:00 p.m., revealed the resident had been transferred to the wheelchair from her bed and slid out of the sit-to-stand lift when she requested to be put back to bed. He stated his belief that the two (2) nursing assistants did the transfer the resident properly, and the fall was an accident. -- An interview with the physical therapist, at 9:15 a.m. on 11/16/10, revealed he had discharged Resident #54 from therapy in June of 2010, and the therapy staff had utilized the sit-to-stand lift for transferring the resident. He further stated if a resident was feeling weak, the staff should use a Hoyer lift, because the resident needed to have the strength to hold onto the bars with the sit-to-stand lift. -- In a telephone interview on 11/16/10 at 9:55 a.m., Resident #54 (who now resides in another facility) reported that she looked down during the transfer while seated in the lift and noticed the back wheel bending under. The next thing she remembered was the bar on the lift moving at an angle and then she was on the floor. She stated that the sit-to-stand lift was broken and was placed out of service for repair and, somehow, the lift was used the day she was injured. She also stated, "I never said that I was weak and did not change my mind about sitting in the chair. The lift was not working properly and turned over with me still in the sling." -- An interview with the maintenance supervisor (Employee #70), on 11/16/10 at 10:00 a.m., revealed he thought that a sit-to-stand lift was taken out of service in August and there would be a work order for the repairs. He further stated the spring apparatus was not working properly and would not allow the legs to stay in the open position. He said he would go and look for the work order. At 3:00 p.m., the maintenance supervisor stated that a Hoyer lift was the equipment that needed to be repaired, not the sit-to-stand lift. -- An interview, on 11/16/10 at 10:35 a.m., with the two (2) nursing assistants involved in the transfer (Employees #92 and #134) revealed, "The resident was being transferred in the sit-to-stand lift from the resident's bed. The resident was in an electric bed, and when we had her get into the sit-to-stand lift, she said she was not in the seat right. We situated her in the seat again and moved the lift with the resident seated from under the bed. We had the legs of the lift in the straight position. The legs were not opened, and we attempted to move the resident. She let go of the bars on the lift and slid out onto the floor." -- A review of the "Owner's Operating and Maintenance" manual for the Invacare Stand Up Lift - Model RPS350-1(referred to by staff as the "sit-to-stand lift") revealed a "Safety Summary" on pages 4 and 5, which included the following in a box labeled "Warning": "DO NOT attempt any transfer without approval of the patient's physician, nurse or medical assistant. Thoroughly read the instructions in this Owner's Manual, observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. "Individuals that use the Standing Sling (Model R130) MUST be able to support the majority of their own weight, otherwise injury can occur. ..." In the section titled "Transferring From" on page 10, under the heading "Lifting the Patient (Figure 1)" were the following instruction to be performed before raising a resident above the surface being transferred from: "F. Make sure the legs (of the lift) are in the maximum open position and the shifter handle is locked in place." In the above noted interview, Employees #92 and #134 stated the legs of the lift were closed (not in the "maximum open position") during the transfer of Resident #54, contrary to the manufacturer's instructions. -- At 11:40 a.m. on 11/16/10, the director of nursing (DON - Employee #88) demonstrated the proper use of the sit-to-stand lift, stating the legs of the lift must be in the fully opened position when a resident is in the lift to provide stability for safe use. The DON stated, "When a resident is in the lift, the legs (of the lift) are to be opened to the maximum width. The staff knows that they never have the legs closed with a resident in the sit-to-stand." She further stated, "We have some electric beds, and the sit-to-stand lift will not fit under the bed with the legs in the maximum open position. The legs will not go under the bed or you can't remove the sit-to-stand (lift) from under the bed in the open position." Observation of an electric bed verified the bed frame would not permit the legs of the sit-to-stand lift to open when placed under the bed. .