Every finding on record at Northern Mahaska Specialty Care

Based on observation, diet spreadsheet/menu review, resident diet type report, staff interviews, policy review, and the Simplified Diet Manual the facility failed to serve the appropriate portions for 3 of 3 residents who received pureed diets (Resident #19, #33 and #49) and 1 of 1 resident served only pureed meat (Resident #29). The facility staff also failed to serve the appropriate portion size of meat for 10 of 11 residents on a mechanical soft diet (Resident #7, #8, #27, #30, #37, #38, #42, #55, #58, #67 and #68). The facility reported a census of 78 residents. Findings include:1. The facility's Cycle Day 4 Diet Spreadsheet identified one (1) serving of a deviled pork chop, 1 serving of squash, and 1 serving of a wheat roll to be served as part of the planned pureed textured diet for the lunch meal served on 9/24/25.The facility's Cycle Day 4 Diet Spreadsheet identified a 3 ounce (oz.) of deviled pork chop to be served as part of the planned mechanical soft textured diet for the lunch meal served on 9/24/25.The facility's Diet Type Report revealed three (3) residents on a pureed texture diet, 1 resident on pureed meat, eleven (11) residents on a mechanical soft textured diet plus two (2) residents on a regular diet with ground meat. During observations on 9/24/25 at 11:31 AM, Staff B, Dietary Cook, placed six pork chop patties and some broth into a Robot Coupe container and blended the contents together. Staff B added more broth and continued to blend the contents together. At 11:35 AM, Staff B poured the pureed contents into a metal pan, covered the pan with foil, and placed the pan into a steam oven. On 9/24/25 at 12:03 PM, Staff B placed six 4 oz. scoops of squash into a Robot Coupe container, added broth and blended the contents together. Staff B poured the pureed squash into a measuring cup and reported there was a total of 4 cups. Staff B checked the pureed serving chart located on the wall. Staff B reported since she made six servings and with the total amount of pureed contents pureed, she would use a #6 scoop (the equivalent of 5 1/3 oz.) when she served the pureed entree to the residents on a pureed diet. Observation of the lunch meal service on 9/24/25 starting at 12:11 PM revealed 10 of 11 residents on a mechanical soft diet received the ground pork chop and 3 of 3 residents received the pureed pork chop and pureed squash. The residents on a pureed diet did not receive a wheat roll (or bread) as indicated on the Diet Spreadsheet. On 9/24/25 at 1:24 PM, Staff B reported food plated for the last resident. Staff B checked the scoop handles and reported the scoop size used for each entree served: a. One green (#12) scoop of pureed squash, the equivalent of 2 1/2 to 3 oz. b. One gray (#8) scoop of pureed pork, the equivalent of 4 to 5 oz. c. One blue (#16) scoop of ground pork, the equivalent of 2 oz. In an interview on 9/24/25 at 1:31 PM, Staff B, Cook, reported she looked at the Diet Spreadsheet and checked the entrees and scoop sizes to determine what size scoop to serve the residents. Staff B reported she looked at the pureed serving chart posted on the wall (in the kitchen) to determine the scoop size to serve for the pureed entrees. Staff B reported she also checked the ounces listed on the scoop handle. In an interview 09/24/25 at 4:30 PM, the Dietary Manager (DM) reported staff used the Therapeutic Diet Spreadsheet to know what serving size to serve to the residents. If the serving size showed 1/2 cup, then she looked at the bottom of the therapeutic spreadsheet to look for 1/2 cup and determined the proper scoop size to use. For example, 1/2 cup would be a 4 oz ladle or scoop. The DM looked at the Diet Spreadsheet for Cycle Day 4 for the Lunch meal and reported a pureed pork serving equaled one serving. The DM reported staff needed to check the pureed portion serving chart posted in the kitchen to know the scoop size to serve for pureed entrees. The DM explained the process for determining the scoop size for pureed entrees. Staff pureed the entree, poured the contents into a measuring cup, then matched the amount in the measuring cup and the number of portions to determine the scoop size to use and serve for that entree. The DM reported three residents on a pureed diet and one resident got only the pureed meat. The DM reported she expected bread added to the meat whenever the entree was pureed. The DM reported there were about 13 residents on a mechanical soft diet but she added 2 extra portions so they had enough. The mechanical soft serving size was the same as the residents on a regular diet. The facility's undated Pureed Food Preparation Policy and Procedure revealed a resident on a pureed diet will receive the same items as the regular diet. All residents on a pureed diet shall receive the correct portions of pureed meat, starch, fat and vegetable. The policy revealed the following steps: a. The correct number of portions (plus 1-2 extra servings) are added into the Robot-Coupe. b. Liquids of nutritive value such as broth are added when pureeing.c. Bread and butter as planned on the menu may be added to the mixture. 1/2 of the bread and butter in the meat and 1/2 in the vegetable is suggested if the bread is not pureed separately. d. Scrape the pureed mixture from the Robot-Coupe into a measuring device to determine the total volume. e. Determine the scoop size. 2. The Electronic Health Record (EHR) Medical Diagnoses list revealed Resident #84 had diagnoses of Gastroesophageal Reflux Disease (GERD), diabetes, and postprocedural complications and disorders of the digestive system. The Care Plan revised 6/12/25 revealed the resident was at risk of altered nutritional status related to GERD and diabetes. The care plan directed staff to provide meals that are within his diet. The EHR under the Orders section revealed a clear liquid diet for abdominal distention. An order for clear liquid diet until x-ray results were received and evaluated started on 9/24/25 at 8:00 AM and had an end date of 9/26/25. The Progress Notes revealed the following: a. On 9/23/25 at 11:30 PM, resident said he wanted to go to the hospital because he believed his bowels are shutting down like the last time he was here (at the facility). Abdomen (ABD) slightly firm. He had a small emesis after supper. Spoke with ARNP (nurse practitioner). New order received for a mobile ABD x-ray in the morning. b. On 9/24/25 at 9:05 AM, new order for a two-view abdominal x-ray for constipation. Clear liquid diet ordered until the results were received and evaluated. During observation on 9/24/25 at 12:27 PM, Staff B, Cook, began to plate food for the 100 Hall room trays. Staff B reported Resident #84 was on a clear liquid diet. This was a new order that started today and it was not listed on the diet report yet. At the time, Staff C, dietary aide, asked Staff B if it was ok to give applesauce to the resident on a clear liquid diet. Staff B said yes. Staff C placed the container of applesauce on the tray for Resident #84. During observation on 9/24/25 at 12:45 PM, a surveyor observed a tray that contained beverages and a container of applesauce on Resident #84's bedside table. The resident's meal ticket indicated he was on a clear liquid diet. At 12:46 PM, Staff L, certified nursing assistant, stated Resident #84 was on a clear liquid diet. The surveyor inquired if applesauce was on a clear liquid diet. Staff L stated she was not sure if applesauce was ok to give to a resident on a clear liquid diet. The surveyor requested Staff L to double check whether applesauce could be given to someone on a clear liquid diet. In an interview on 9/24/25 at 1:31 PM, Staff B, Cook, reported the nurse brought a sheet with items that could be given to a resident on a liquid diet so dietary staff knew what to serve. Staff B relayed she knew what could be given to a resident on a liquid diet and didn't need to look at the list because she had worked as a cook for a couple of years. In an interview 9/24/25 at 4:30 PM, the DM reported they had received an order for a clear liquid diet for a resident today (9/24/25). The nurses provided dietary staff a list of items of what could be provided for a resident on a clear liquid diet. She had a list of things that could be given but couldn't find it. The DM confirmed that applesauce would not be considered a clear liquid. The DM reported she referred to the Simplified Diet Manual on page 69-70 for a list of clear liquid items that could be provided to someone on a clear liquid diet. The Daily Menu for a Clear Liquid Diet revealed beef or chicken broth, apple juice, gelatin, popsickles, and hot or iced tea. The clear liquid diet did not list applesauce. The Simplified Diet Manual 13th Edition used by healthcare facilities to assist in planning meals modified to meet current science-based diet recommendations for individuals with special health needs. The manual revealed recommendations for a clear liquid diet. A clear liquid diet focused on see-through liquids like water, clear fruit juices (apple, white grape), clear broths, sports drinks, and gelatin. The clear liquid diet prohibited pulp such as all juices and beverages with pulp.

Based on record review, observation, staff interview, policy review, and guidance from the Centers for Disease Control and Prevention (CDC), the facility failed to implement infection control practices consistent with CDC guidelines pertaining to COVID precautions and Enhanced Barrier Precautions to prevent cross contamination by staff failing to wear proper Personal Protective Equipment (PPE) during routine cares for 2 out of 4 halls (Residents #16, #23, #29 and #44). The facility also failed to perform hand hygiene after catheter care for 1 of 2 residents with catheters (Resident #44). The facility reported a census of 78 residents.Findings include:1. The Care Plan initiated 09/8/25 for Resident #16 indicated she was in isolation for COVID-19 infection. The Care Plan lacked information on the type of isolation. The Care Plan also indicated to follow CDC guidelines and recommendations. The Care Plan initiated 07/30/25 for Resident #29 indicated he was in isolation for COVID-19 infection that resolved on 09/23/25. The Care Plan lacked information on the type of isolation. The Care Plan initiated on 02/14/25 for Resident #23 indicated she was in isolation for COVID-19 infection. The Care Plan lacked information on the type of isolation. The Care Plan also indicated to follow CDC guidelines and recommendations. The Electronic Health Record (EHR) revealed that Resident #16 had an order dated 09/21/25 for droplet isolation precautions 09/21/25-10/1/25. The Electronic Health Record (EHR) revealed that Resident #29 had an order dated 09/15/25 for contact isolation precautions 09/23/25. The Electronic Health Record (EHR) revealed that Resident #23 had an order dated 09/18/25 for droplet isolation precautions 09/18/25-09/28/25. During an observation on 09/22/2025 at 12:21 PM a room tray delivery to room [ROOM NUMBER] showed Certified Nursing assistant (CNA) dons gown, gloves, and surgical mask and receives a room tray from nursing students. She then knocks and enters resident's room and closed the door behind her. At 09/22/2025 12:26 PM the CNA exits room and had removed her PPE removed. During observation on 09/22/25 at 2:20 PM, a Droplet Precautions and an EBP sign was posted on the wall outside Resident #16's room. A plastic bin with drawers had gowns, surgical masks, and gloves inside. At 2:24 PM, the lid of the red trash bin in Resident #16's room was propped open and the red trash bin was overflowing with used PPE (gowns, gloves and masks). One gown and mask were lying on the floor by the trash bin. At 2:30 PM, a male CNA reported Resident #16 had COVID. During an observation on 09/22/2025 at 3:15 PM room [ROOM NUMBER] was noted to have an EBP sign and a Droplet precaution sign outside of the door. A plastic 3 drawer container was also outside the room containing CaviWipes 2.0, surgical masks, gowns, face shields and gloves. No N95 masks were noted in the container. The Droplet precaution sign indicated that everyone must: Clean their hands, including before and entering and when leaving the room. Additionally, make sure their eyes, nose and mouth are fully covered before room entry and remove face protection before exiting the room. During an observation on 09/22/2025 at 3:18 PM Staff K, CNA entered room [ROOM NUMBER] wearing surgical mask, face shield, gown and gloves. An EBP sign and a Droplet precaution sign were noted outside of the door. The Droplet precaution sign indicated that everyone must: Clean their hands, including before and entering and when leaving the room. Additionally, make sure their eyes, nose and mouth are fully covered before room entry and remove face protection before exiting the room. There was also a plastic container outside the door containing gloves, gowns, face shields and surgical masks. No N95 masks were noted to be in container. During on observation on 09/22/2025 at 3:52 PM room [ROOM NUMBER] had a droplet precautions sign outside of the door. The Droplet precaution sign indicated that everyone must: Clean their hands, including before and entering and when leaving the room. Additionally, make sure their eyes, nose and mouth are fully covered before room entry and remove face protection before exiting the room. There was also a plastic container outside door containing gloves, gowns, face shields and surgical masks. No N95 mask were noted to be in container. During observation on 09/23/25 at 12:47 PM, Staff D, certified medication aide (CMA) wore a white hair covering and carried a beverage cup down the hall to Resident #16's room. Staff D sat the cup down and donned a gown, a face shield, and gloves and entered the room. At 1:05 PM, Staff D left Resident #16's room. Staff D no longer wore the gown, face shield or gloves but continued to wear the white hair cover. Staff D walked down the hall toward the dining room. At 1:08 PM, Staff D stood by the medication cart and looked at the computer and continued to wear the white hair covering. At 1:10 PM, Staff D removed white hair covering and threw it in the trash. During an observation on 09/23/25 at 12:54 PM the surveyor noted no signage on the front door indicating the facility was in outbreak status for COVID-19. During observation on 9/23/25 at 1:47 PM, a Droplet Precautions and an EBP sign were posted on the wall outside Resident #16's room. A plastic bin with drawers had gowns, surgical masks, and gloves inside. Staff E, Licensed Practical Nurse donned a gown, surgical mask, and gloves and entered the resident's room. Staff E did not wear an N95 mask or faceshield. At 1:56 PM, Staff E opened the door to the resident's room, removed the gown and gloves, then walked to the treatment cart and removed her surgical mask. During an observation on 09/25/25 at 7:43 AM room [ROOM NUMBER] and 215 had a new sign on the door indicating that it is a hot room and before entering the room to wear N95 mask, face shield or goggles, gloves and gown. During an observation on 09/25/25 at 8:16 AM the surveyor noted signage on the front door indicating COVID-19 outbreak. In an interview on 09/23/25 at 4:10 PM Staff F, CNA stated they found out Resident #16 had tested positive for COVID-19 on 09/22/25. Stated she was exposed as she took care of her. Added that she had not been asked about exposure, being tested or wearing source control. In an interview on 09/24/2025 at 7:32 AM Staff G, CNA stated she was not sure why the EBP sign on room [ROOM NUMBER] today but stated [NAME] tested positive for COVID on 09/18/25. Stated her roommate tested negative and is still testing negative. Added that she has not tested positive in the last 3 months. When questioned if she took care of Resident #23 without a mask for more than 15 minutes, Staff G, CNA stated she helped transfer at least twice and believed it was 15 minutes. Stated she was talked to about exposure and told to be wary of any symptoms. She was not advised to wear a mask for 10 days or to get tested. In an interview on 09/24/2025 at 12:01 PM Staff H, CNA stated resident in room [ROOM NUMBER] is COVID positive. Stated with COVID PPE needed would be glove, gown and surgical mask. Asked about eye protection and she stated they do not have face shields or goggles. Added that she has not been in that room or this hall before. When looking at signage outside of door, she stated she just knows to wear a gown but admitted it should probably be on the sign. In an interview on 09/24/2025 at 2:45 PM the Assistant Director of Nursing (ADON) stated that residents who have symptoms of COVID-19 should be placed in isolation, notify the physician and tested for COVID-19. She added that if a resident is positive for COVID, the doctor and family will be notified. The kitchen will also be notified. The ADON then stated they would be placed in isolation. Stated not sure what isolation sign is on the doors of the 3 positive residents as she did not put them up. When informed that droplet isolation signs were on the doors she stated they have a COVID sign that should have been used. Added that N95 masks should be worn in those rooms. Informed that no N95 masks are in the plastic containers. Stated they might have run out but should be using. Will restock with N95 masks as they are in the storage room. When questioned about contact tracing, the ADON stated she did not contact trace this time as Staff J, Corporate Nurse said to only test symptomatic staff and residents. Staff can wear masks if they want and are encouraged to wear face masks if they are negative. Stated not sure how long to wear and they cannot make the staff wear them. No contact tracing for residents or staff completed. In an interview on 09/25/25 at 11:11 AM with the ADON and Staff I, PA, the ADON stated they no longer follow the CDC guidelines on testing and masking as the CDC recommends and they do not have to adhere to recommendations. Also stated that this was a change in November of 2023. The surveyor reviewed that their policy dated November of 2023 indicated they should do testing and masking. The policy actually is almost verbatim to the CDC guidance. The surveyor pointed out that Quality Safety and Oversight (QSO)-20-39-Nursing Home (NH) revised 5/8/23 indicated that the CDC guidance on the core principles of COVID-19 should be adhered to at all times. Staff, I, PA stated that if Centers for Medicare & Medicaid Services (CMS) stated that they should then the need to follow the CDC guidance. In an interview on 09/25/25 at 12:35 PM with Staff J, Corporate Nurse and the Administrator, the Surveyor indicated the QSO-20-39-NH revised on 5/8/23 indicated that the CDC guidance on the core principles of COVID-19 should be adhered to at all times. The Administrator stated she wished it was easier to find then with all the links. Staff J, Corporate Nurse stated that she had no questions and that they would be looking at it. 2. The admission MDS assessment dated [DATE] revealed Resident #44 had diagnoses of renal insufficiency and diabetes. The MDS revealed the resident had an indwelling catheter. The Care Plan initiated on 8/20/25 revealed the resident had a urinary catheter and at risk for infection related to the catheter. The Care Plan directed staff to use Enhanced Barrier Precautions (EBP) whenever high-contact care activities were performed. The Electronic Health Record (EHR) under the Orders revealed an order created 9/11/25 for EBP's due to the catheter. During observation on 9/23/25 at 1:12 PM, Staff A, certified nursing assistant (CNA), entered Resident #44's room and donned a pair of gloves. Staff A obtained a graduate container and placed the graduate on a paper towel on the floor. Staff A unclamped the catheter and emptied the contents into the graduate. Staff A clamped the catheter, cleansed the catheter port with alcohol swabs, then placed the catheter port into the holder on the catheter bag. Staff A took the graduate and emptied the urine contents into the toilet. Staff A removed the glove on her left hand, turned the faucet on, and filled a small cup with water. Staff A poured the water into the graduate, then rinsed the graduate with water. Staff A sat the graduate on the back of the toilet, removed the glove on her right hand, then applied hand sanitizer to her hands and left the room. Staff A did not wear a gown while she emptied and handled the catheter. The Director of Nursing (DON) stood in the room and observed while the surveyor stood in the room and observed Staff A. An EBP policy dated 3/28/24 revealed EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms. A gown and gloves used during high contact resident care activities. High-contact resident care activities include device care or use including urinary catheters. A Handwashing / Hand Hygiene policy revised 8/2019 revealed hand hygiene is the primary means to prevent the spread of infections. Hands washed with soap and water when hands are visibly soiled and is the final step after removing and disposing of personal protective equipment. The use of gloves does not replace hand washing. The Center for Disease Control (CDC) website https://www.cdc.gov/clean-hands/hcp/clinical-safety/ updated 2/27/24 revealed hands cleaned immediately after glove removal and after contact with body fluids or contaminated surfaces. Many diseases and conditions are spread by not washing hands with soap and water. In a document titled Care Initiatives COVID-19 Policy updated May 8th 2023 indicated the same guidelines as the CDC guidance for testing and contact tracing. It also indicated using source control for close contact with SARS-CoV-2 for 10 after the exposure and that PPE for a Health Care Provider (HCP) that enters the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). On page 3 of the QSO-20-39-NH revised on 05/8/23 contained a section titled Core Principles of COVID-19 Infection Prevention and Control (IPC) with several bullet points containing multiple links to other websites in the CDC. The paragraph following the bullet points stated that the core principles of COVID-19 are consistent with the CDC guidance for nursing homes and should be adhered to at all times. This information can be reviewed at https://www.cms.gov/files/document/qso-20-39-nh-revised.pdf on the CMS website. On page 6 of the QSO-25-23-ALL dated 07/30/2025 stated, under the requirements for COVID-19 testing section, that throughout the Public Health Emergency (PHE), CDC and CMS have updated the testing guidance, including most recently, removing the recommendation for surveillance testing of staff. However, COVID-19 testing is still an important action and is a nationally recognized standard to help identify and prevent the spread of COVID-19. Therefore, while this specific regulatory requirement will end with the PHE, CMS still expects facilities to conduct COVID-19 testing in accordance with accepted national standards, such as CDC recommendations. Noncompliance with this expectation will be cited at F-880 for failure to implement an effective Infection Prevention and Control Program in accordance with accepted national standards. This information can be reviewed at the following link https://www.cms.gov/files/document/qso-25-23-all.pdf on the CMS website. In a document titled Appendix A: Type and Duration of Precautions Recommended for Selected Infections and Conditions on the CDC's website, it indicated that the proper isolation for Corona virus associated with Severe Acute Respiratory Syndrome (SARS) would be Airborne + Droplet + Contact + Standard for the duration of the illness plus 10 days after resolution of fever, provided respiratory symptoms are absent or improving. This information can be reviewed at the following link https://www.cdc.gov/infection-control/hcp/isolation-precautions/appendix-a-type-duration.html#sars on the CDC's website. In a document titled Infection Control Guidance: SARS-CoV-2 on the CDC's website, it indicated that routine infection prevention and control practices should provide guidance for patients and visitors such as posting signs or posters at entrances and in strategic places with instructions about when to use source control and perform hand hygiene. The document also indicated that source control she be used for staff and patients who had close contact with someone who had close contact with someone with SARS-CoV-2 infection for 10 days after their exposure. It also indicated that with a single new case of SARS-CoV-2 infected resident or HCP, an outbreak investigation could involve either contact tracing of a broad-based approach. Testing of all residents and health care providers with close contact should be tested immediately but not earlier than 24 hours after exposure and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. Furthermore, the document indicated that PPE for HCPs that enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to Standard Precautions and use a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (i.e., goggles or a face shield that covers the front and sides of the face). This information can be found at https://www.cdc.gov/covid/hcp/infection-control/index.html on the CDC's website.

Based on record review, observation, staff interview, and policy review, the facility failed to develop a comprehensive person-centered care plan to include pain for one of three residents reviewed (Resident #44). The facility reported a census of 78 residents. Findings include: The admission Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #44 admitted to the facility on [DATE]. The MDS revealed the resident had diagnoses of spinal stenosis, neuropathy and diabetes. The MDS recorded the resident took pain medication but had no pain in the past 5 days during the look-back period. The Care Area Assessment (CAA's) revealed pain not triggered. The MDS assessment was completed on 8/28/25. The Care Plan initiated 8/20/25 lacked information regarding the resident's pain and staff directives for pain management interventions. The admission Evaluation dated 8/20/25 revealed under Section F /Conclusion was marked no to the statement about the resident had new acute and/or chronic pain, used medication and/or non-pharmacological interventions for pain management. The Electronic Health Record (EHR) under the Orders section revealed the following: a. Check pain level every shift started on 8/20/25.b. Gabapentin 100 milligrams (mg) by mouth (PO) three times a day for pain started on 8/20/25. c. Lidocaine External Patch 5 % to bilateral lower extremities every shift for muscle spasms started on 8/20/25.d. Biofreeze Cool (topical analgesic)) to the back, abdomen, and thighs every 6 hours as needed (PRN) for muscle spasms. e. Orphenadrine Citrate Extended Release 100 mg PO two times a day for muscle spasms started on 9/3/25. f. Oxycodone 5 mg PO two times a day for spinal stenosis and give one tablet PO every 6 hours PRN for spinal stenosis started on 9/15/25. g. Diazepam 5 mg every 6 hours PRN for spasms started on 9/22/25.The Progress Notes revealed the following: a. On 8/28/25 at 3:52 AM, resident complained of muscle spasms in bilateral legs and abdomen. Diazepam given for muscle spasms. b. On 9/1/25 at 8:15 PM, resident rates pain to low back at 5. PRN APAP (Tylenol) given. c. On 9/9/25 at 1:16 AM, resident complained of intense sharp pain in lower back that traveled down her left leg. Pain medication requested at this time. d. On 9/13/25 at 9:03 PM, resident stated pain 10 out of 10. e. On 9/13/25 at 10:19 PM, follow up pain level was 7.f. On 9/15/25 at 12:00 AM, the resident had neuropathy, spinal stenosis and muscle spasms. She experienced severe spinal stenosis (back) pain that was particularly intense first thing in the morning. She also reported bilateral knee pain. The resident now used an electric wheelchair due to pain with ambulation. The resident expressed a desire to start on a pain pill. g. On 9/16/25 at 5:53 AM, resident complained of muscle spasms in her lower back. Diazepam PRN given h. On 9/17/25 at 8:29 PM, resident reported pain at 7. Scheduled oxy (oxycodone) given for pain. In an interview 09/24/25 at 5:10 PM, the MDS Coordinator reported she completed the residents' MDS assessments and care plans. She did an assessment, asking residents questions, and then developed the resident's care plan based on the assessment. She also looked at the orders to obtain additional information to determine things that were applicable to put on the care plan such as medications. The MDS Coordinator confirmed a focus area for pain should be included on the care plan. The facility's Comprehensive Person-Centered Care Plan policy revised 12/2016 revealed a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's needs is developed and implemented for each resident. The care plan will incorporate identified problem areas and describe the services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The care plan is developed within seven days of completion of the comprehensive MDS assessment.

Based on record review, staff interviews, policy review, American Heart Association (AHA) and Automated External Defibrillator (AED) Manufacture's Guide, the facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing interventions, including the use of an AED and administering a shock on a conscious, breathing resident, for 1 of 3 residents (Resident #64) reviewed for a change of condition and hospitalizations. The facility reported a census of 78 residents. Findings include:Review of Minimum Data Set (MDS) dated [DATE] revealed Resident #64's Brief Interview for Status (BIMS) of 6, indicating severe cognitive impairment with diagnoses of Coronary Artery Disease, Heart Failure, Non-Alzheimer's Dementia, Chronic Obstructive Pulmonary Disease (COPD), Anxiety, Depression, Schizophrenia, and health conditions of shortness of breath or trouble breathing when lying flat. Resident #64's The MDS also documented Resident #64 receives antipsychotic, antidepressant, anticoagulant (blood thinner) medications. Review of Resident #64's Electronic Health Recorded (EHR), revealed a Nurses Note dated [DATE] at 10:41 PM, by Staff N, LPN, a new order was received to send Resident #64 to Emergency Department (ED) for altered mental status. Temperature 102.9, blood pressure 80/66, pulse 165, oxygen 84% on room air. Review of the Change in Condition Evaluation dated [DATE] at 11:52 PM completed by Staff M, LPN, revealed the following document evaluation for Resident #64:a. Signs and symptoms: abnormal vital signs, fever, and shortness of breath. Most recent vital signs, blood pressure 80/66, pulse 250 beats per minute, regular pulse type. Respirations 24, temperature 102.9 and oxygen saturation 73% on room air. b. Evaluation of systolic blood pressure (top number) below 100, heart rate above 100, temperature above 100, suggested possible sepsis. c. Pertinent diagnoses include CHF, COPD, Dementia, Resident #64 is not on an anticoagulant, and CPR code status. d. Mental Status Evaluation: altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) with sudden change in level of consciousness or responsiveness, no changes in functional status observed. e. Respiratory status: respiratory changes; shortness of breath, abrupt onset of shortness of breath with pain, fever, or respiratory distress. f. Cardiovascular status: new irregular pulse, resting pulse greater that 100 or less than 50. During assessment, attempted to auscultate (listen/hear) pulse and unable to hear. g. Review of findings and provider notification, since the change in condition occurred the signs and symptoms got worse. From first assessment, second assessment performed, pulse 250, Oxygen 73% on room air. h. Summarization of observations, evaluation and recommendations: Resident #64's pulse continued to jump from 173-250 beats per minute, Staff M, LPN was unable to auscultate apical pulse (chest) or palpate radial (wrist) pulse. Automated External Defibrillator (AED) was applied to detect rhythm, AED stated shock was advised and issued one shock to Resident #64. Staff M, LPN monitored Resident #64 during and post shock and noted tremors slowing, breathing returning to normal, pulse reading down to 135 and oxygen up 89% with 2 liter oxygen via nasal cannula. Resident #64 began to blink his eyes again and was more alert. i. Provider had been notified, with recommendations to send Resident #64 to the Emergency Department (ED). Review of ED Physician's note dated [DATE] at 11:13 PM stated, Resident #64 brought in by ambulance due to altered mental status and fever. Fever began today, he has had some cough. EMS (Emergency Medical Services) reports the staff at the nursing home connected an AED to resident #64 and it said to shock, so they did (he was reportedly not unconscious and had generalized shaking at the time.) On physical exam the Physician noted, Resident #64 has generalized intermittent course shaking and tremors, greatest in the arms bilaterally. Cardiovascular (heart) with regular rhythm, tachycardia (condition where heart beats abnormally fast, typically at a rate over 100 beats per minute) present. Neurological, Resident #64 is alert with intermittent, waxing and waning (coming and going), generalized course tremors that Resident #64 reports he always shakes. Resident #64 admitted to hospital for further observation. Review of Hospital records dated [DATE] at 9:56 AM, revealed Resident #64 reportedly febrile (fever) at facility and was found to be tremulous (shaking or quivering) with altered mental status by nursing home staff. Resident #64 was never reported to be pulseless or unresponsive, he was placed on an AED at the facility. AED advised shock and one shock was administered by nursing home staff. EMS was called, Resident #64 was noted to be awake and alert on scene. On exam Resident #64 is asleep but arousable to voice, noted to be oriented to his name, hospital and state. Resident #64 is not oriented to the city, year, or current president. Resident #64 also reports he has tremors at baseline. During an interview on [DATE] at 4:12 PM, Staff N, LPN, stated she had come on at shift change (10:00 PM) and she had heard other staff saying Resident #64 was declining, Staff M, LPN grabbed the crash cart, while Staff N, LPN got the equipment to do an assessment. As Staff N, LPN, entered Resident #64's room, Staff M, LPN was in the room with the AED hooked up to Resident #64 and had shocked him. Upon entering the room Staff N, LPN, Resident #64 was laying in bed and responsive. With in minutes EMS arrived and Resident #64 was transferred to their gurney and report was given to an EMT. The EMT told Staff N, LPN and Staff M, LPN not to shock when they're responsive. Staff N, LPN, was not able to recall the details as to why Staff M, LPN, had placed the AED on Resident #64, but stated it was something related to Resident #64's vitals and Staff M, LPN thought a shock would be the solution. During an interview on [DATE] at 9:47 AM, Staff M, LPN stated she was finishing her charting from her shift (2:00 PM- 10:00 PM) and overheard the CNAs (Certified Nursing Assistants) saying something was not right with Resident #64. Staff M, LPN stated Staff N, LPN, had taken Resident #64's vitals with the facility's equipment. Staff M, LPN, stated she had gotten inaccurate reading in the past using this equipment and had her own manual equipment. Staff M, LPN, with her equipment, went to Resident #64's room to check his vitals, his oxygen was in the low 70's, pulse was in the 200's, and he had a fever. Staff M, LPN, stated she was not able to obtain an apical pulse or blood pressure due to Resident #64's tremors. Staff M, LPN stated she then told Staff N, LPN about the vitals she had obtained for Resident #64 and told the CNAs to get the crash cart. Staff M, LPN stated she was not sure what the resident's pulse was but was told by another CNA that the ED uses an AED to detect patient's pulse. Staff M, LPN stated she then attached the AED to Resident #64, the AED detected a pulse and advised a shock. Staff M, LPN then pressed the button to administer a shock. Staff M, LPN continued by stating, Resident #64 was conscious, the AED was used to detect Resident #64's heart rhythm as she was not able to determine the rhythm herself due to Resident #64's tremors. Further in the interview, Staff M, LPN stated, prior to administering the shock with the AED, Resident #64 was responsive to verbal stimuli, once the AED pads were placed Resident #64 did not seem to be as responsive to verbal stimuli but she did not try to touch, shake, or do a sternal rub for a response. Staff M, LPN stated a couple minutes after the shock was give, EMS arrived, given report and updated on the situation. No further communication was received from EMS crew. Staff M, LPN also stated the reason why the AED had advised the shock was because normally when an AED is put on a conscious person it will detect and know (that the person is conscious) and will not advise a shock. Review of an undated, Facility provided Incident Report and Statement Document, revealed the following:1. Situation: [DATE] around 11pm, Resident #64 was having increased shaking and his vital signs were abnormal (pulse or bottom blood pressure in the 170's and oxygen down to 73). When the nurse, Staff M, LPN, was assessing she got the order from the on call to send to ER. While waiting for paramedics Resident #64's heart went out of rhythm and so due to him being full code, even though he didn't lose consciousness, she put the AED on him to advise her if he was having a heart attack, and if he needed a shock, since she knew it would say shock advised or not. The machine registered his heart out of rhythm and gave a shock. After shock was given his oxygen increased, his tremors calmed down and he seemed to be getting better. The paramedics then arrived and took Resident #64 to the hospital. 2. Staff N, LPN notified facility's Physician of Resident #64's vitals and received an order to send him to ER. 3. No chest compressions or breathing support (other than 2 liters oxygen via nasal cannula) was provided.4. Upon Paramedic's arrival, Resident #64 was immediately transferred to gurney, no vitals were taken, no medications were given, Resident #64 had improved and was taken out of the facility and into the ambulance. 5. Staff M, LPN called back on call Physician to notify and inform then of the AED involvement, Physician's response was I ordered him to be transferred out, I will note this.6.Interactions between nurse and paramedics: Paramedics entered room, received nurse report, one Paramedic looked at Staff M, LPN and asked if Resident #64 was pulseless or unconscious, Staff M, LPN, stated no, Paramedic then told her that was malpractice and could have sent him into cardia shock.7. (Staff M, LPN written statement) Floor staff alerted Staff M, LPN to change in condition on Resident #64, he was not acting as his baseline. Staff M, LPN took Resident #64's vitals and assessed resident. Resident was shaking profusely, non-seizure activity, respirations fast and shallow, pulse was up to 250 per pulse oximetry on both hands, and oxygen was 72% on room air. Apical pulse was difficult to auscultate, arrythmia auscultated when it could be heard. Staff M, LPN applied 2 liters oxygen via nasal cannula. Checked Resident #64's code status and verified as full-code. Brought crash cart down as precaution. Order received from on-call to send to ER, 911 was called at 10:38 PM. While unable to auscultate apical pulse or palpate radial pulse, AED was applied to detect rhythm, AED stated shock was advised and issued one shock to Resident #64. Staff M, LPN, monitored Resident #64 during and post shock and noted tremors slowing, breathing returning to normal, pulse read on pulse ox down to 135 and oxygen up to 89% with 2 liters oxygen. Resident #64 began to blink eyes again and was more alert. Within two minutes post shock, paramedics arrived in room as AED was removed. Staff M, LPN gave report and paramedics questioned if Resident #64 had lost consciousness or was pulseless. Review of Staff M, LPN's Facility provided Employee file revealed the following:1. American Heart Association, Basic Life Support (BLS) for CPR and AED Certification, issued: [DATE] renew by: 10/20252. National Safety Council, BLS Certification, issued: [DATE], expiration date: [DATE] Review of Staff M, LPN, AED PLUS, AED Competency Checklist dated [DATE] revealed signed off competency to the following procedure steps:1. States correct method of confirming that AED is appropriately charged. (green check in window)2. Verbalizes correctly when AED is to be used. (pulseless, unresponsive victim), and to call 911.3. Correctly places CPR-d pads on victim's chest. (verbalize that CPR continues during placement) Review of AED Plus Operator's Guide, AHA 2015, revealed the following:1. WARNING! Use the AED Plus unit only as described in this manual. Improper use of the device can cause death or injury. 2. Indications for use: Use the AED when a suspected cardiac arrest victim has an apparent LACK OF CIRCULATION indicated by:a. Unconsciousness andb. Absence of normal breathing andc. Absence of a pulse or signs of circulation. 3. Contraindications for use: DO NOT use when a patient:a. Is conscious; orb. Is breathing; orc. Has a detectable pulse or other signs of circulation. Review of American Heart Association, Answers by heart, What is Cardiac Arrest, copyright 2024, revealed the signs of cardiac arrest:1. The person collapses suddenly and passes out.2. The person doesn't respond, even if you tap them hard on the shoulders or ask loudly if they're OK. The person doesn't move, speak, blink or react.3. The person isn't breathing or is only gasping for air. 4. The person has no pulse. Review of Facility Provided Automatic External Defibrillator, Use and Care of Policy, revised [DATE] stated the following:Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation, for victims of sudden cardiac arrest. Policy Interpretation and Implementation1. During a sudden cardiac arrest event, follow guidelines outlined in the procedure for Cardiopulmonary Resuscitation and Basic Life Support.2. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR immediately unless:a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death (e.g., rigor mortis).3. The automatic external defibrillator (AED) will be used to try to restore normal cardiac rhythm when arrhythmia is strongly suspected. Recognizing the signs and symptoms of arrhythmia (and when to use the AED) is part of the CPR/BLS training.4. In general, SCA should be suspected if:a. The victim's symptoms appeared very suddenly;b. He or she is unresponsive; andc. His or her breathing has stopped.5. If an individual is found unconscious and SCA is suspected, begin the AED Protocol below. Initial Assessment and Safety Precautions1. Call (or direct someone to call) 911.2. Apply personal protective equipment.3. Assess the victim:a. Responsiveness - if unresponsive, retrieve (or direct someone to retrieve) the AED from its location and bring it to the victim.b. Breathing - open airway and look, listen, feel for breathing. If breathing is absent, deliver two rescue breaths.c. Circulation - if signs of circulation are absent, begin CPR until the AED is available.4. Remove any flammable gases (e.g., oxygen) from the immediate environment. Applying Pads to the Victim1. Remove clothing from the victim's chest.2. Wipe chest dry (do not use alcohol wipes).3. Remove any patches or adhesives from the chest.4. Shave hair from the chest if necessary.5. Check the adhesive on pads to make sure they are sticky. If not, replace the pads.6. Attach two AED pads to the victim's bare chest (one on the upper right, one on the left). Apply away from any metal that is already in contact with the victim. Avoid applying over an existing implanted pacemaker or defibrillator.7. Plug in the connector.Defibrillation1. After applying pads and during initial setup, keep the victim still and do not touch him or her. The AED will analyze the heart rhythm and indicate whether a shock is needed. Movement or noise may interfere with the analysis.2. If a shock is indicated, make sure no one is touching the victim when administering the shock.3. Administer additional shocks as prompted by the AED.4. After delivering shocks (if signs of circulation are still absent) administer CPR for approximately 2 minutes.5. Follow the AED prompts until the emergency medical service arrives. EMS Arrival1. Communicate the following information to EMS personnel:a. Name of the victim;b. Any known medical history, allergies or conditions;c. The condition in which the victim was found;d. Time the victim was found;e. Number of shocks delivered;f. and Approximate length of CPR administration.2. Assist EMS as requested.

Based on staff interviews, clinical record review, and review of facility provided documents, the facility failed to report an allegation of abuse timely, within the required two hours, of staff becoming aware that allegation existed for 1 of 3 residents (Resident #1) reviewed for resident's rights and dignity. Findings include: The Admission Minimum Data Set (MDS) assessment, dated 1/14/25, revealed Resident #1 admitted to facility on 1/08/25, and had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, which indicated intact cognition. Resident #1 diagnoses included Bipolar Disorder, End Stage Renal Disease (ESRD), and atrial fibrillation. The Care Plan Kardex, a document Direct Care Staff use to direct resident care needs, dated 2/25/25, revealed Resident #1 required the presence of 2 staff for when performing care related to accusations of abuse and resident behaviors during cares. On 2/26/25 at 12:18 PM, Staff A, Certified Nursing Assistant (CNA), confirmed working the day shift with Resident #1 on 1/16/25. Staff A reported on 1/16/25, sometime after lunch and before Resident #1 was to leave for an appointment, Staff A answered Resident #1's call light and Resident #1 was found sitting in recliner, crying, and stated to Staff A, she had never been treated so terribly. Resident #1 had informed Staff A, that she threw something onto Resident #1 and left. Staff A recalled that resident had sat in recliner with blanket on lap, socks in her hands, and cloth bag next to recliner. Staff A stated Staff C, facility's Van Driver, had also been present in Resident #1's room during accusation and Staff C went to tell Director of Nursing (DON) that Resident #1 had been upset and was refusing to go to appointment, while Staff A stayed with Resident #1. Staff A recalled that Staff B, CNA, had also worked with Resident #1 on 1/16/25 and was the last staff known to go into Resident #1's room before finding resident upset. On 2/26/25 at 9:50 AM, Staff C, facility Van Driver, recalled that Resident #1 had an afternoon appointment on 1/16/25 and when he went to Resident #1's room to see if she was ready, Resident #1 had been upset and crying. Staff C notified that Staff A had also been present in room when Resident #1 stated she had never been treated that way and commented that something was thrown at her. Staff C recalled Resident #1 had sat in recliner with blanket across lap at the time with socks in her hands. Staff C stated he went to go notify DON of situation as Resident #1 was upset and refusing to go to appointment. Staff C reported that Resident #1 did go to appointment via facility van, accompanied by a family member, and continued to be upset, reporting the allegation to family member. Staff C stated he texted the DON in response to resident and family member concern with situation. On 2/26/25 at 1:30 PM, Director of Nursing (DON) recalled on 1/16/25, Staff C, facility van driver had come to her to report Resident #1 upset, crying, and not wanting to go to appointment. DON stated she went to Resident #1's room to speak to her about why she was upset, thought everything was okay, and Resident #1 was going to go to her appointment. DON confirmed receiving a text notification from Staff C, while Resident #1 was out to appointment, that Resident #1 and a family member had concerns about the situation. DON stated when Resident #1 returned, she spoke with family member, and would start investigation into the concern. DON reported that Staff B had been suspended on 1/17/25 pending investigation, due to Resident #1's allegation, Staff B working with Resident #1, and Resident #1 denying that Staff A upset her. DON stated she did not report an allegation of abuse to the State Department of Inspections, Appeals, and Licensing (DIAL) on 1/16/25 or 1/17/25 due to initially thinking situation was more of a customer service concern until more information was collected. On 2/26/25 at 2:05 PM, Facility Administrator, stated on 1/18/25, she received an email related to Resident #1's allegation of abuse and in response, Administrator called the facility to collect staff statements, called and spoke to Resident #1 and Resident #1's family, present at facility, and submitted a self reported incident for Resident #1 allegation of abuse. Administrator recalled that Resident #1 said something was thrown at her but the item thrown kept changing and Resident #1 had not been able to name or describe the accused staff member. Administrator revealed Staff B had been suspended on 1/17/25, pending investigation into allegation, as it was determined that Staff B had been in Resident #1's room just before allegation was made. Facility Administrator stated facility policy directs for any allegation of abuse to be reported to the State Agency within 2 hours of knowledge of the allegation and confirmed that staff had knowledge of allegation of abuse on 1/16/25, which had not been reported until 1/18/25. The facility provided Staff B, Certified Nursing Assistant (CNA) statement which informed that on 1/16/25 Staff B took Resident #1 to her room, got her in recliner and walked out. Staff B claimed that Staff C informed her that Resident #1 had an appointment, so she went back to Resident #1's room but Staff A was already there so let Staff A get her ready. Staff B's statement claimed that Resident #1 had never complained about Staff B going too fast or Resident #1 not feeling good that day. The facility provided document titled, Self Reports, revealed a report was made to the State Agency for allegation of abuse involving Resident #1 on 1/18/25. The facility provided document titled, Past Noncompliance F609 and F610, dated 1/18/25, revealed that on 1/16/25, Resident #1 approached by staff in her room and noted to be visibly upset, staff had consoled her and assisted to van for transport to appointment, during transport Resident #1 reported to family, with Staff C present, that a staff member yelled at her, thrown a belonging at her, was rude, and scolded her. Document identified corrective action for the self identified lack of reporting, included completing a head to toe assessment, a trauma assessment, and a skin assessment on Resident #1, notification to Physician, family, and Police, and all staff education provided on timely abuse reporting for allegations of abuse.

Based on observations, record review, and staff, resident and resident responsible party interviews, the facility failed to ensure the environment remained free of hazards, and failed to ensure employees reported hazards that posed an immediate threat to the safety of all residents when at least 3 employees failed to report an employee had a loaded handgun in her purse that she brought into the facility stored at the Nurse's Station, unsecured, where a cognitively impaired resident gained access to the purse (Resident #1). The facility reported a census of 79 residents. The State Agency informed the facility of the Immediate Jeopardy (IJ) on 7/3/24 at 1:15 p.m. The IJ began on May 5, 2024. Facility staff removed the Immediate Jeopardy on 7/6/24 by implementing the following actions; a. All Nursing Staff educated between 6/26/24 and 7/6/24 on: 1.) Firearms and weapons are not allowed on the premises, this includes in a vehicle in the parking lot. 2.) If you see or hear of a firearm or weapon being on property. 3.) Keep your personal belongings in your vehicle or the breakroom, not in public areas accessible to residents. 4.) If the person being reported is your supervisor, please go to the next person in charge. 5.) If a person or staff member enters facility carrying a weapon, who is not required to carry a weapon (i.e., a law enforcement officer) they will be asked to remove the weapon from the premises. If they refuse to do so, police will be contacted. Staff will move residents and other staff away from situation. Staff will notify manager on duty. 6.) Education will be completed with new staff or contracted staff prior to the start of their next shift. Based on the corrective measures taken by the facility, the scope and severity was from a J level to a G level. Findings include: The Annual Minimum Data Set (MDS) for Resident#1 dated 4/18/24 documented the resident had diagnoses including non-Alzheimer's Dementia, altered mental status, right hip pain. The MDS revealed that the resident scored a 4 out 15 for Brief Interview of Mental Status (BIMS), which indicated severe cognitive loss. The MDS documented that the resident used a manual wheelchair for mobility. The Residents Care Plan identified a focus area as follows; the resident had impaired cognitive function or impaired thought processes related to dementia. Resident continues to fidget with things and seeks things out activities to occupy her time, and sometimes this causes her to get into others things an invade other peoples personal space. The facility's self-reported incident dated 6/27/24 stated: Management notified of potential staff member with concealed carry within facility. Employee suspended pending investigation. Police notified. Further Investigation to follow. The facility's investigative summary completed by the Administrator stated she received a phone call around 7 p.m. on 6/26/24 from an employee (Staff D, Licensed Practical Nurse, LPN) who informed her that Staff B, Registered Nurse (RN) had just told her that a while back, Staff A, LPN, told Staff B that she forgot to take her gun out of her purse, brought it into the facility, and Resident #1 got a hold of it, Staff A was able to get it away from the resident and there were no injuries. The facility's investigation estimated the alleged incident occurred on May 5, 2024. The facility's daily nursing schedule/assignments revealed Staff A, Licensed Practical Nurse (LPN) was assigned to the 200 and 300 halls on the day shift (6 a.m. to 2 p.m.), and the first half of the evening shift (2 p.m. to 6 p.m.) The facility's Violence in the Workplace policy, dated effective 3/2015, directed that guns were prohibited from the premises, anyone that had a gun that was not someone that required it for their job, such as a law enforcement officer, was to be asked to remove the gun from the premises, and if the gun was not removed, staff were directed to call the police. The policy also directed if staff believed someone had brought a gun to work they were to notify the Administrator or immediate supervisor immediately. Observation at the Nurse's Station on 7/3/24 at 9:40 a.m. revealed the desk surfaces at the Nurse's Station were 60 inches wide, with open area under them, and the medication/treatment carts were 33 inches wide at the widest portion that included a waste receptacle. Observation on 7/6/24 at 1:25 p.m. revealed Resident #1 seated in a wheelchair, inside the Nurse's Station, and held a blood pressure cuff that was in a portable upright cart that staff used to take resident vital signs. A CNA near the resident asked if she could have it and was able to return the blood pressure cuff to the cart. Staff interviews revealed: On 7/2/24 at 2:46 p.m. Staff C, Certified Nursing Assistant (CNA) stated she heard Staff A, LPN, talking out loud about she was happy the resident didn't get into her purse because she would have got a hold of her gun, it wasn't the first time she'd made the comments, she thought it had been discussed before based on how Staff A was talking about it at the time. Staff C didn't know who all might have heard Staff A as she talked about it, but others had to know, and thought she'd heard her talking about it a month or so ago. Staff A always kept her purse at the Nurse's Station, usually on top of the desk and not below it. The resident fidgets, she likes to hold on to things, she gets a hold of things and sometimes it's hard to get them away if she shouldn't have them or they belong to someone else, and is often in the Nurse's Station opening drawers and grabbing papers if she sees them. Staff A said she was glad she got Resident #1 before she got her gun. On 7/2/24 at 4:52 p.m., Staff B, Registered Nurse (RN), stated she was at work one day in May, Staff A said that she forgot her gun was in her purse when she came to work one day, Resident #1 got her purse, but she got to the resident before she got the gun. Staff B stated she told Staff A at that time that she needed to report it to management and she said she was going to. Some time had passed since then and she thought it had been dealt with. When she gave report to Staff D, LPN last week, they started talking about the resident going through purses, the subject of the gun came up and Staff D didn't know anything about it and said she was calling the Administrator, and did. The resident likes to be busy, she likes to rummage through things, will go through drawers at the Nurse's Station, she loves purses and is always looking for her purse. On 7/2/24 at 2:48 p.m. Staff D, LPN, stated on the evening shift on 6/26/24, Staff B told her about an incident where Resident #1 got a gun out of Staff A's purse and she had a gun in her purse. She called the Administrator on the phone and told her about it. Staff D knew staff could not bring a gun to work, and all staff have since been educated that if anyone brought a gun into the facility the were supposed to call the Administrator. There are lockers here for staff to use to store their belongings while they work. On 7/2/24 at 3:01 p.m. Staff A, LPN, stated she'd been out late the day before it happened and didn't think to take the gun out of her purse. She kept her purse under the Nurse's Station, and when she went to the office around 2 p.m. to talk about the scheduler, she blocked the area where her purse was with the treatment cart, she positioned it the long way in front of the desk and locked the wheels. She hadn't been gone even 5 minutes and realized she needed her calendar from her purse, went to the Nurse's Station to get the calendar and the resident had her purse sitting on top of the desk at the Nurse's Station, the resident had moved the treatment cart, with wheels still locked, out of the way and was able to get to her purse. The resident was seated in her wheel chair, she'd been going through the center part of her purse and said she was looking for her hairbrush, she hadn't taken anything out of her purse. She got to the resident as she started to unzip the side pocket, she'd unzipped it about 4 to 5 inches and Staff A was standing above her and could see the case for the gun and that was when she realized the gun was in her purse. She didn't think the resident saw it because she was seated and couldn't see into the purse like Staff A who stood above her. She got the purse away from the resident and normally didn't bring her gun to work. Staff A said nobody else saw or witnessed it, and the resident didn't get a hold of her gun. She didn't want to get in trouble so she didn't tell management. She said something about it to one of the aides around that time, and somebody turned it in quite a bit later. During another interview on 7/8/24 at 9:04 a.m., Staff A stated her gun was a 22 caliber [NAME]. On 7/2/24 at 2:10 p.m., the facility Administrator stated all staff have been educated to notify her if staff brought a gun to work, have completed education about work safety and resident safety, they continued to educate staff as they came to work before they started their shift, and guns were not permitted on the property, it was addressed in the facility's Violence in the Workplace policy, and the Gun with the Null sign (guns not permitted sign) is posted outside the facility. During an interview on 7/2/24 at 3:57 p.m., the resident's Power of Attorney (POA) stated the facility told them that they needed to find a Memory Care unit for her, that she wasn't appropriate for their facility, she was getting into the staff's purses, but never said anything about a gun in one of the purses.

Based on observation, resident, family and staff interview the facility failed to maintain comfortable building temperatures between 71 degrees F (Fahrenheit) and 81 degrees F in the resident's rooms for 4 residents reviewed (Residents #5, #6, #7, and #8). The facility identified a census of 71 residents. Findings include: 1. During an observation and interview on a facility tour 12/19/2023 at 1:45 p.m., the Director of Facilities Maintenance checked temperatures in random resident rooms and revealed the following temperatures as identified: a. The room of Resident #6 (401) measured 69.4 degrees F (Fahrenheit) in the room. The resident stated that the room had been cold for the last couple of weeks and was covered in a wool blanket and wearing long sleeve shirt. b. The room of Resident #7 (room [ROOM NUMBER]) measured 68.0 degrees F in the room. The resident stated that it was cold in their room and sat with arms folded across their chest, and wearing a long sleeve hoodie and sweat pants. A family member was present and said that room was very cold. c. The room of Resident #5 (room [ROOM NUMBER]) measured 69.4 degrees F in the room. The resident stated that it has been cold in his room for the last two weeks and was wearing a hooded sweat shirt with the hood pulled over his face and two wool blankets across his legs. d. room [ROOM NUMBER]- 69.4 degrees F. e. room [ROOM NUMBER]- 67.0 degrees F. f. The room of Resident #8 measured 66.2 degrees F. The resident stated the room had been cold for three weeks and that is why he wore a shirt & coat, and covered himself with a blanket. A family member was present and said the room was really cold. Interview on 12/19/23 at 3:00 p.m., Staff A, CNA (certified nursing assistant) confirmed and verified that the residents rooms are cold and that when Staff A gets residents up in the morning they have multiple blankets on them and she has to bundle them up to get them warm. The heat has not worked for a couple of weeks now. Interview on 12/19/23 at 3:30 p.m., the Maintenance Director, confirmed and verified that the temperatures in the resident rooms were not within the parameters that are required and that the rooms that were tested failed to be at the required temperature. Interview on 12/21/23 at 11:00 a.m., the Regional Director of Clinical Operations, confirmed and verified that the facility follows the guidelines for comfortable environment per regulations.

Based on staff interview, resident interview, record review and policy review the facility failed to ensure adequate staffing for 4 of 30 residents reviewed (Residents #55, #26, #29, and #59). The facility census is 68. Findings include: The Minimum Data Set (MDS) dated [DATE] documented Resident #55 had a Brief Interview for Mental Status (BIMS) of 15 indicating intact cognitive response. The MDS further documented the resident had diagnoses including medically complex conditions, heart disease, diabetes, severe obesity, difficulty in walking, unsteadiness on feet, muscle weakness. The MDS indicated under functional limitation needed extensive assist of two-person physical assist with bed mobility, transfer, locomotion off and on the unit. In addition, was coded Resident #55 needed extensive assistance of two-person physical assistance with toilet use and personal hygiene. The Care Plan for Resident #55 revised 1/7/23 revealed focus area Activities of Daily Living (ADL) documented the resident required assistance with ADL's included toileting, to and from wheelchair for toileting, bathing, dressing, personal hygiene, bed mobility. During interview on 8/28/23 at 3:13 PM Resident #55 reported waited an hour while sitting on the toilet for staff to assist. Relayed one staff helped me to the bathroom and her shift ended, believed the staff didn't tell the next shift. I did pull the cord in the bathroom and no one came. Relayed she uses a clock in her room to know how long it takes for response. During interview on 8/28/23 at 4:58 PM the Administrator relayed she felt the Payroll Based Journal (PBJ) report that noted excessively low weekend staff referenced only that there was less management staff in the building on the weekends since most department heads do not work on weekends. The Centers for Medicare and Medicaid (CMS) Payroll Based Journal (PBJ) documented for the quarter January 1 2023 to March 31, 2023 triggered excessively low weekend staffing, reflected by the facility reported data. The facility policy titled, Answering the Call Light, revised March 2021 documented the policy purpose to ensure timely response to resident requests and needs. Guidelines included to ensure returned demonstration, explanation and availability of the call light. Staff to identify self, indicate time it will take to respond, if resident request requires another staff, notify the individual, ask the nurse supervisor for assistance if needed, if assistance if needed when you enter the room summon help by using the call signal and to document any significant requests or complaints and how was addressed. 48452 2. The Minimum Data Set (MDS) for Resident #26 dated 7/10/23 revealed the resident scored 12 on a Brief Interview for Mental Status (BIMS), which indicated moderately impaired cognition. The MDS documented diagnoses of respiratory failure, pacemaker, and arthritis. The resident required extensive assist of two for bed mobility, transfers, dressing, toilet use, and personal hygiene. The Care Plan focus area revised on 6/3/23 documented a risk for falls. A focus area revised on 6/17/23 documented the need for assistance with ADL. A focus area revised on 7/4/23 documented impaired cognition. On 8/27/23 at 12:51 PM Resident #26 stated that call lights are answered from 20 minutes out. The resident's spouse agreed that call lights take a long time to be answered sometimes, and supported his time frame of over 20 minutes. 3. The Minimum Data Set (MDS) for Resident #29 dated 6/8/23 revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included non-Alzheimers dementia, respiratory failure, and orthostatic hypotension (sudden drop in blood pressure with position change). The resident required extensive assist of two for bed mobility and toileting and extensive assist of one for dressing and personal hygiene. A Care Plan focus area revised 7/4/23 documented a risk for skin impairment. A focus area revised on 6/15/23 documented the need for assistance with ADL. A focus area revised 7/17/23 documented chronic pain. On 8/27/23 at 2:01 PM Resident #29 stated her call light had been left out of reach and she had to lean forward in her wheelchair to get the cord. She stated she turned her call light on at 7:00 PM on 8/26/23. At 8:20 PM Staff D, CNA, came in. The resident stated she and her roommate wanted something from the vending machine and that her light had been on for over an hour. Staff D told the resident her light wasn't on that long and asked her if she was ready for bed. The resident repeated that her light had been on for over an hour and asked to get something from the vending machine. Staff D again said her light hadn't been on that long. The resident stated that she told aides one thing and got ready to tell them another thing but they were already gone. The aides didn't stick around to find out everything the resident needed. The resident indicated the facility was understaffed and stated this wing was full so it stressed the staff out. On 8/30/23 at 8:32 AM Resident #29's roommate, Resident #57, confirmed that Staff D entered the room on 8/26/23 after the call light had been on for an hour and twenty minutes. She stated that everything Resident #29 said was spot on, and that staff often took a long time to answer Resident #29's call light because she usually asked for more than one thing which took a lot of their time. 4. The MDS for Resident #59 dated 8/10/23 revealed the resident scored 15 on a BIMS exam, which indicated intact cognition. Diagnoses included hemiplegia (paralysis on one side of the body) or hemiparesis (weakness or inability to move one side of the body), muscle wasting, and adjustment disorder. The resident required extensive assist of two for bed mobility and toileting and extensive assist of one for dressing and personal hygiene. A Care Plan focus area revised 5/30/23 documented a risk for falls. A focus area revised on 8/14/23 documented that Resident #59 had a behavior problem expressed by hitting things when she felt overlooked or had to wait for requests. On 8/27/23 at 1:38 PM Resident #59 stated she had kidney and bladder issues so a bedpan was an important part of her care, and shared that sometimes antibiotics and increased fluids caused diarrhea. She reported she has had to wait more than 15 minutes for her call light to be answered and 45 or more minutes between when she got the bed pan and when they helped her off due to slow response to call lights. The resident stated her friends brought a bell and whistle to use after 15 minutes to get attention. The resident reported staff told her they would take them away but resident stated she got desperate. She indicated yesterday (8/26/23) was the last time she had to wait more than 15 minutes, and that every night between 8:00 PM and 9:00 PM was bad because they were short staffed. The resident stated that she felt helpless. On 8/29/23 at 9:20 AM the Director of Nursing (DON) stated that she expected call lights to be answered within 15 minutes and it would be better if the wait was less than that. On 8/29/23 at 11:23 AM Staff A, Registered Nurse (RN) stated one nurse overnight with no CMA (Certified Medication Aide) was a problem if anything happened. On 8/29/23 at 11:33 AM Staff B, CMA stated that they never had enough help and thought that 3 aides for 4 halls between 9:45 PM and 6:15 AM was not enough. She stated the residents ran them ragged because they were needy. On 8/29/23 at 4:45 PM Staff C, CMA stated they were short staffed overnight. On 8/29/23 at 5:36 PM an email from the Administrator indicated that call log records could not be accessed for review according to the IT department.

Based on clinical record review, policy review, and staff interview, the facility failed to ensure the safety of a resident by not accommodating a resident's need for a mechanical lift sling to ensure safe transfers while at dialysis for 1 of 3 residents reviewed receiving dialysis services (Resident #32). The facility reported a census of 68 residents. Findings: The 6/22/23 Minimum Data Set( MDS) assessment tool listed diagnoses for Resident #32 which included heart failure, kidney failure, and diabetes. The MDS stated the resident required extensive assistance of 2 staff for transfers and listed the resident's Brief Interview for Mental Status(BIMS) score as 13 out of 15, indicating intact cognition. The 7/25/23 MDS stated the resident required extensive assistance for transfers. The facility policy Accommodation of Needs, revised March of 2021, stated the facility would evaluate the resident's individual needs and preferences, including the need for adaptive devices and modifications to the physical environment. Dialysis Treatment Details Reports revealed the following: A 5/26/23 report stated the resident arrived at dialysis with only one pedal on the wheelchair and no hoyer sling. The resident transferred to the dialysis chair with a gait belt and assist of 2 staff. The resident was not helpful with the transfer. A 6/21/23 report stated the facility did not send a sling with the resident today and they would call the facility and make them aware. The report stated the resident was a difficult 2 person assist with a gait belt without his sling and was slower to respond to commands after his treatments which made the sling the safest option for him. A 7/17/23 report stated that the resident did not have a hoyer sling with him and would not bear weight on his legs and grabbed the dialysis chair when attempting to transfer. The report stated the resident was very difficult and heavy to transfer to a wheelchair with a gait belt and the assist of 2. A 7/28/23 report stated the resident arrived without a sling for the hoyer and was very difficult to transfer to the dialysis chair with 2 as he could not bear weight on his legs and yelled out in apparent fear of falling. A 7/31/23 report stated the resident was unable to assist with the transfer from the dialysis chair to the wheelchair due to not seeming to be able to plant his feet on the floor. He required a full lift of two. An undated entry on the Care Plan included special instructions to place the hoyer sling under the resident on dialysis days as he was too weak to transfer after his dialysis. On 8/30/23 at 10:03 a.m., Staff F Registered Nurse(RN) stated the dialysis clinic called and stated they did not have Resident #32's sling. On 8/30/23 at 10:22 a.m. the Director of Nursing(DON) stated the facility sent hoyer slings with the resident to dialysis and she had not heard of a time that it was not sent.

Based on clinical record review, policy review, and interviews the facility failed to treat residents with dignity and respect for 2 of 23 residents reviewed, (Resident #29 and #59). The facility reported a census of 68. Findings include: 1. The Minimum Data Set (MDS) for Resident #29 dated 6/8/23 revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included depression, non-Alzheimers dementia, and orthostatic hypotension (sudden drop in blood pressure with position change). The resident required extensive assist of two for bed mobility and toileting and extensive assist of one for dressing and personal hygiene. A Care Plan focus area initiated on 5/26/23 documented the need for hospice services. A focus area revised 7/17/23 documented chronic pain. A goal revised 6/16/23 indicated the resident did not want to experience an increase in depression. On 8/27/23 at 2:01 PM Resident #29 stated some aides have a nonchalant attitude. She stated she spilled lemonade at a meal and no one moved to help her clean the table or her. The resident stated blankets and clothes were lost and staff had no idea where they were. She said she complained about the items, and told staff the blankets were special to her, but staff did not listen because they were tired of her complaints. Resident #29 stated she has been left on a bedpan for hours and that 'he forgot her'. The resident revealed she felt alone and forgotten. The resident included that she used to yell when she was repositioned due to pain but staff got mad at her and didn't try to understand her pain from diabetic neuropathy. She stated it felt like bubble wrap under her skin, that her feet tingled and felt hot. She stated her call light had been left out of reach and she had to lean forward in her wheelchair to get the cord. She added that she turned her call light on at 7:00pm on 8/26/23. At 8:20 PM Staff D, CNA, came in. The resident stated she and her roommate wanted something from the vending machine and that her light had been on for over an hour. Staff D told the resident her light wasn't on that long and asked her if she was ready for bed. The resident repeated that her light had been on for over an hour and asked to get something from the vending machine. Staff D again said her light hadn't been on that long. The resident stated Staff D liked her roommate but didn't like her and treated her differently. The resident stated she told aides one thing and got ready to tell them another thing but they were already gone,. The aides did not stick around to find out everything needed. The resident indicated the facility was understaffed and stated this wing was full so it stressed the staff out. On 8/30/23 at 8:32 AM Resident #29's roommate, Resident #57, confirmed that Staff D entered the room on 8/26/23 after the call light had been on for an hour and twenty minutes. She stated that everything Resident #29 said was spot on, and that staff often took a long time to answer Resident #29's call light because she usually asked for more than one thing which took a lot of their time. 2. The Minimum Data Set (MDS) for Resident #59 dated 8/10/23 revealed the resident scored 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated intact cognition. Diagnoses included hemiplegia (paralysis on one side of the body) or hemiparesis (weakness or inability to move one side of the body), muscle wasting, and adjustment disorder. The resident required extensive assist of two for bed mobility and toileting and extensive assist of one for dressing and personal hygiene. A Care Plan focus area revised 5/16/23 documented chronic pain. A focus area revised on 8/14/23 documented that Resident #59 had a behavior problem expressed by hitting things when she felt overlooked or had to wait for requests. A goal revised 5/30/23 indicated the need for ongoing psychiatric services to process feelings of frustration, sadness, thoughts of self harm and other mental health symptoms, and adjustment to the nursing home setting. On 8/27/23 at 1:38 PM Resident #59 stated she had kidney and bladder issues so a bedpan was an important part of her care, and shared that sometimes antibiotics and increased fluids caused diarrhea. She reported she has had to wait more than 15 minutes for her call light to be answered and 45 or more minutes between when she got the bed pan and when they helped her off due to slow response to call lights. The resident stated her friends brought a bell and whistle to use after 15 minutes to get attention. The resident reported staff told her they would take them away but resident stated she got desperate. She indicated yesterday (8/26/23) was the last time she had to wait more than 15 minutes, and that every night between 8:00 PM and 9:00 PM was bad because they were short staffed. The resident stated that she felt helpless. On 8/29/23 at 9:20 AM the Director of Nursing (DON) stated she expected call lights to be answered within 15 minutes and it would be better if the wait was less than that. She stated residents with a grievance filled out a form alone or assisted by floor staff and it was discussed at the standard of care meeting. On 8/29/23 at 11:33 AM Staff B, CMA stated that they never had enough help and thought that 3 aides for 4 halls between 9:45 PM and 6:15 AM was not enough. She stated the residents ran them ragged because they were needy. On 8/29/23 at 4:45 PM Staff C, CMA stated they were short staffed overnight. A policy titled Resident Rights revised December 2016 documented that federal and state laws guaranteed certain basic rights to all residents of the facility. These rights included the resident ' s right to be treated with respect, kindness, and dignity; to exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility; and to have the facility respond to his or her grievances.

Based on observations, interviews and record review, the facility failed to ensure safety for 1 out of 3 residents reviewed (Resident #2). Resident #2 was transferred from her bed into her wheelchair without removing/moving the leg rests/foot pedals from Resident #2's wheelchair. This resulted in a large skin tear, which required the need to transfer Resident #2 out to the emergency room (ER). The facility reported a census of 68 residents. Findings include: A Minimum Data Set, dated dated dated [DATE], documented that diagnoses for Resident #2 included heart failure, diabetes, and malnutrition. This resident's Brief Interview for Mental Status revealed a score of 14 out of 15, which indicated intact cognition. This resident was an extensive assist of 2 for bed mobility, and transfers. A Medical Diagnoses list for this resident printed on 5/9/23, documented diagnoses of lymphedema (tissue swelling caused by an accumulation of protein-rich fluid that's usually drained through the body's lymphatic system. It most commonly affects the arms or legs). A Care Plan with a focus area initiated on 3/3/23 and revised on 5/7/23, documented that Resident #2 was at risk for skin breakdown due to diabetes, incontinence, and fragile skin due to lymphedema and [NAME] failure. It documented that resident had edema to her bilateral lower extremities. It documented that this resident was readmitted from the hospital with a left shin laceration. A resident Census page documented that this resident went to the emergency roiagnom on [DATE]. A Progress Note dated 3/29/23 at 3:25 p.m., documented that this nurse was called to the resident's room STAT (immediately). Resident was observed sitting up in her wheelchair with a large skin tear to her inner leg. Area was cleaned with wound wash and steri strips were applied. Moist dressing was also applied and wound was covered with gauze. The provider was notified and a new order was received to send this resident to the ER to evaluate and treat wound. Daughter was agreeable to hold this resident's bed while out of the facility. The DON (Director of Nursing) and ADON (Assistant Director of Nursing) were at bedside. The Certified Nurse Aides explained that resident was being assisted to her wheelchair with the Hoyer lift and while bringing the resident down into her wheelchair, her left leg slipped off the wheelchair pedal, so it was moved causing a skin tear. A Progress Note on 3/29/23 at 3:35 p.m., documented the skin tear measured Length 6.9 centimeters (cm), Width 4.6 cm, and the Depth was 1.5 cm. This resident was sent to the ER for bleeding and pain. A Progress Note dated 3/29/23 at 4:44 p.m., documented that in a phone call with Resident #2's daughter to let daughter know about the skin tear, the daughter stated she wasn't surprised as her mom's skin is very fragile. A Progress Note dated 3/29/23 at 8:00 p.m., documented that this resident returned from the ER. A new order was received to moisten gauze, cover (wound) with dry gauze, watch for signs of infection, and protect area from further trauma. A Skin and Wound Evaluation dated 3/31/23, documented that a skin tear on the left shin had complete tissue loss and the wound was acquired at the facility on 3/29/23. The length of the wound was 10.3 cm and the width was 10.6 cm with no depth. The edges of the wound were not attached and appeared as a cliff. The surrounding tissue was black and blue, intact and fragile. This resident had edema extending more than 4 centimeters around the wound. It documented that this resident had occasional labored breathing with a short period of hyperventilation, occasional moan or groan, facial grimacing and that this resident rated her pain at a 5 out of 10 (which indicated moderate pain). On 5/9/23 at 11:40 a.m., Staff A, CNA, stated on the day of this incident she was going over to talk to a staff member about something, when she walked into this resident's room they were transferring Resident #2 to her wheelchair. When Staff A walked into the room she noticed that Resident #2's leg was on the wrong side of her wheelchair pedal, which the leg rest should not have been on (the wheelchair) in the first place. The leg was on the left side of Resident #2's foot pedal, so Staff A believed it would have been her left leg. Staff A stated the middle of this resident's lower leg caught on the foot pedal, it was like the calf area. Staff A stated when that happened it opened up the skin and it started bleeding. Staff A stated they then went and got a nurse. Staff A did not remember which nurse. Staff A stated the Assistant Director of Nursing (ADON) was there, the Administrator and Director of Nursing (DON) came and one of the Certified Meication Aides also came to the room. Staff A stated that basically the whole team came. Staff A stated that they are supposed to transfer people without the foot pedals (and leg rests) on the wheelchair. Staff A stated she was trained that way. Staff A stated she was trained at the facility and through her CNA training to remove the foot pedals prior to transfer. It's been a few years. Staff A stated the CNAs that were transferring this resident were Staff B, CNA who was from an agency and Staff C, CNA. Staff A stated she did not ask why the foot pedals were on. Staff A stated she did not receive education afterwards regarding the foot pedals and she did not know if the facility did education with the other 2 CNAs. Staff A stated she had not transferred Resident #2 prior to this incident and it was the first time she had assisted with transferring Resident #2. Staff A stated she had tried to get her leg up and over the foot pedal but Resident #2's leg was probably too heavy. After the whole thing was done, the next day the DON and the Administrator said that the pedals should have been off of the wheelchair when they talked to me about the whole situation. On 5/9/23 at 11:52 a.m., Staff B stated that she was present with 2 other facility workers at the time of this incident. Staff B stated she was behind the wheelchair, and the other 2 were on either side of the wheelchair. Staff B stated Staff A and Staff B were both there at the beginning of the transfer. Staff B stated this resident's leg kind of slipped off to the side. Staff B stated she told Staff C that Staff C could push the red button and she could already be down. Staff B stated that Staff C then pulled the red button. Staff B stated the red button was on the Hoyer's pole at the bottom. Staff B repeated that she believed Staff A pulled the red button. Staff B stated that a lot of the facility's workers said it was okay to use the red button. Staff B stated it was iffy whether or not Resident #2's body was down in her wheelchair. Staff B stated the Hoyer arms weren't all the way down. Staff A stated this resident's bottom was in the wheelchair. Staff B stated this resident's skin had not broken open. Staff B stated they then were talking about lowering this resident the rest of the way, and then they were like, oh shoot, they saw that this leg had opened up. Staff B stated she immediately told Staff A and Staff C to call for a nurse. Staff B stated this resident's left leg was what had opened, and this resident's left leg was on the outside (of the leg rest), but it was nowhere near the pedal. Staff B stated that it wasn't the foot pedal that caused the injury as there were no sharp points on the foot pedal and there was cushions on the foot pedal. Staff B stated that the DON and the nurse couldn't figure it out. Staff B stated that nobody had said anything about moving the leg rests. With them (the facility) everything was backwards. Normally you would take the leg rests off prior to the transfer. Staff B learned this during CNA training. Staff B stated she had never seen a button like the one on the Hoyer, but she was told you could use the button for emergency purposes. Staff B stated she felt like this incident was an emergency. When asked why she felt it was an emergency, Staff B stated it was because this resident's leg was already to the side (of the leg rest/foot pedal). Staff B added she did not think they could have done anything differently at that point. On 5/9/23 at 12:05 p.m., Staff A stated that the red button was not used during this situation. Staff A stated it was the agency CNA who had mentioned using it. Staff A stated she pointed at the red button and asked Staff B if that was the button she was talking about and she said it was. Staff A stated she did not push it. Staff A stated that Staff C was running the Hoyer lift and he kept lowering the lift the regular way. Staff A stated she went into the room just when they had Resident #2 over her wheelchair. Staff A stated she had only been told that they can use the red button only in case of an emergency. On 5/9/23 at 12:50, the ADON stated she really was kind of a second set of hands at the point when she walked into Resident #2's room. The ADON stated she was hollered at and took off running. The ADON stated a Registered Nurse (RN), was the one who hollered for the ADON and they did grabbed the DON too. The ADON stated she went in to the room and noticed the significance of the wound, and stated this resident was bleeding. This ADON stated she then ran and got the treatment cart, sanitized her hands and grabbed 4X4 gauze, wound wash, normal saline and applied directly to the wound. This ADON stated she had put pressure on the wound and then had the other nurse sanitize and glove (her hands) and then sat an absorbent pad under this resident's leg. The ADON stated this resident did not complain of pain and verbalized she was okay. The ADON stated this resident would just say 'oh, oh,' and this resident was kind of scared. There were a lot of people in there just trying to take care of the wound. The ADON stated she applied slight pressure. The ADON stated this resident had thin skin. The ADON stated the ambulance came and transferred this resident out of the facility and they then cleaned everything up and sanitized the area. The ADON stated the ER sent Resident #2 right back and the ER staff said there was nothing they could do. The ADON stated she was not in the room for the transfer and the staff had her already Hoyered Resident #2 down into her wheel chair. The ADON stated the lift was still in this resident's room. The ADON stated she asked what happened and the staff said they were trying to adjust this resident's leg and that's when it happened. The ADON stated she did not see the transfer but the leg rests were already on the chair when the ADON went in with her leg kind of propped up on the foot rest. The ADON stated this resident had a tilt wheelchair, so the ADON had the staff tilt the resident back in her wheelchair so the ADON could assess the wound better. The ADPN stated the foot pedals should be removed from wheelchairs with transfers. The ADON stated they did a lot of education afterwards regarding the leg rest/pedals needing to be removed prior to transfers. The ADON stated this resident's wheelchair had calf rests too and this resident's leg rests attached to her wheelchair just below the seat. The ADON stated they are the hook and swing into place type of leg rests. The ADON stated they used a Hoyer lift for the transfer. 5/9/23 at 3:00 p.m., Staff D, CNA stated that prior to any transfers out of or into wheelchairs, she removes the leg rests off of the wheelchair. She stated that most wheelchairs have a bag on the back of them where the leg rests/wheelchair pedals can be placed. On 5/9/23 at 3:17 p.m., Staff C, CNA, stated they were getting Resident #2 up for dinner(supper), from her bed to her wheelchair. Staff C stated he was operating the Hoyer and Staff B was turning Resident #2 toward her wheelchair. Staff C stated they got Resident #2 above her wheelchair and then Staff A saw them and came in to Resident #2 to help. Staff C stated they were lowering Resident #2 down (into her wheelchair) and then they realized her left leg was on the outside of the wheelchair pedal. Staff C stated that Staff A then tried to lift this resident's left leg up and over the left wheelchair pedal and the pedal kind of sliced Resident #2's leg open. Staff C stated they saw what he would call fat glands and then blood. Staff C stated there was nothing sharp on the wheelchair pedal, it was like the cut was from the fabric itself. Staff C stated the fabric was like normal wheelchair fabric, kind of like a tarp material. When asked if the red button was used, Staff C stated the only thing with the red button was that Staff A started to reach for it and Staff C told Staff A not to touch it and Staff A didn't touch it. Staff C stated that Staff B had told Staff A to push the red button. Staff C stated he had never been told they could use the red button, unless it was an emergency. The red button immediately lowers the resident down. Staff C stated they were supposed to have the leg rests off the wheelchair prior to the transfer and he knew that, but Staff B told Staff C to leave the leg rests on the wheelchair, and that it would be okay. Staff C reiterated that they were not supposed to have pedals on the wheelchair when they are transferring residents whatsoever. Staff C stated he had been at the facility approximately 1 1/2 to 2 months. Staff C stated he was a fresh CNA. Staff C stated he thought Staff B knew what she was doing. Staff C stated he learned from this incident and he does not trust anybody anymore. Staff C stated they had training regarding all types of transfers after that. Staff C stated there were educational offerings for the next couple of weeks after this incident. On 5/9/23/ at 4:15 p.m., the Regional Director of Clinical Services acknowledged the concern regarding staff not removing leg rests/pedals prior to transferring Resident #2 to her wheelchair. This Corporate Nurse acknowledged that a wound resulted from not removing the leg rests. On 5/9/23 at 4:35 p.m., the Administrator acknowledged the concern of the leg rests on the wheelchair at the time of the transfer. The Administrator stated the facility provided education on transfers following this incident. The Administrator did not have questions regarding this concern. Resident #2 was in and out of the facility at the hospital when survey was taking place. A Wound Evaluation dated 5/5/23, documented the laceration on the left shin measured 12.73 cm in length and 6.37 cm in width. An In-Service Form dated 3/30/23, documented the education included that staff must be trained and be able to demonstrate competency using machines and devices to transfer a resident safely. It directed staff to remove pedals to wheelchair or move pedals to the side on wheelchair. A Lifting Machine, Using a Mechanical policy revised on July 2017, documented that at least 2 staff are needed to safely move a resident wit a mechanical lift. It documented that a mechanical lift may be used for tasks that require transferring a resident from bed to chair.

Based on observations, interviews, and record review, the facility failed to ensure that coordination of a resident's assessment and a resident's actual food needs was communicated among and between staff which resulted in dietary recommendations not being followed for 1 of 3 residents reviewed (Resident #3). The facility's dietitian recommended this resident have double entree portions for meals and this recommendation was not implemented by the dietary manager. The facility reported a census of 68 residents. Findings include: A Quarterly Minimum Data Set, dated dated dated [DATE], documented Resident #3's diagnoses included hip fracture, other fracture, and malnutrition. A Brief Interview for Mental Status (BIMS) documented a score of 15 out of 15, which indicated intact cognition. This resident was independent with set up help only for eating. A Weight Change Notification dated 2/16/23 at 10:03 a.m., the Registered Dietitian (RD) documented that there was 8.3% weight loss within 90 days and 13.3 % weight loss within 90-180 days. The RD documented that she suspected the weight loss was related to fluid shift with bilateral lower extremities on admission and more recent no edema or trace lower extremity edema was documented. The dietitian documented that there was possible scale variances/inaccuracies contributing and possible inadequate nutrient intakes with increased nutrient needs related to wound healing contributing. The RD recommendations was that she would change double protein to double entrees with meals per this resident's request. A provider signed this form on 2/21/23. On 5/4/23 at 2:28 p.m., the above recommendation for double entree was noted in Resident #3's chart. An observation at lunch earlier that day revealed this resident had one bowl of chili, the same as what most residents were served. When asked, this resident verified he had the one bowl of chili. Resident #3 stated he didn't know he was supposed to get double entrees. When asked if he would have eaten more chili, he stated yes, he would have liked to have had a second bowl of chili. He stated his daughter brings in food for him, so he gets extra food from her. When asked about him eating meals in his room, he stated he preferred it that way as he wanted to stay healthy so he could discharge home when he was able. On 5/4/23 at 2:45 p.m., the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were asked about the double entree/portions for this resident. They both stated they not know anything about this and said they would look into it. The DON went into the kitchen where the Dietary Manager (DM) was asked about this. The kitchen staff pulled this resident's card and it said regular diet on it. The DM and the cook stated it would have been written on the card after diet that he was to have double entrees with meals, if that would had been communicated. The DM and the Staff E, Cook both stated they were not aware that this was a recommendation. The DM stated the process for updating diets was that the DM would receive any updates from nursing through the PCC (the facility's electronic health record). Then the DM would update the diet and change the card. The DM stated each resident has a card. On 5/8/23 at 3:23, the RD stated in her personal opinion the MNA (Mini Nutritional Assessment) tool is hard to capture a residents' status correctly. The RD stated Resident #3 flagged for being malnourished because of weight loss, acute stress, and mobility. The RD stated that Resident #3 was on a NIP (Nutritional Interventions Program). She stated that Resident #3's specific interventions are double entree with meals. This RD stated she met with him in February and that is when the double entree with meals was put into place. This RD stated they send out RD recommendations to the team every week. She stated the recommendations go out to the DM and the DM is the one that is supposed to see the recommendations and initiate them. The RD stated Resident #3 was initially on double protein and then wanted to go to double entree instead. She stated that Resident #3 had an initial weight loss. He had edema when he initially came in and there could be variables with different scales to weigh. She stated that obviously isn't good and stated she knew the facility was looking at weighing each resident the same way. The RD stated Resident #3 was still triggering for a significant weight loss at 6 months. The DM stated that the nurses get the information if a dietitian's recommendation required a doctor's order. She stated in that case the nurses would then get those orders to the DM. The RD stated that the NIP was basically a food based approach. She stated they would try this prior to recommending protein drinks or supplements which require a doctor's order. On 5/8/23 at 4:00 p.m., the DON and the Regional Director of Clinical Services acknowledged the concern of the facility not following dietary recommendations of double entrees since it was communicated back in 2/20/23. They acknowledged this was a concern and that it could play a part in wound healing and increasing of strength to regain mobility. On 5/9/23 at 4:35 p.m., the Administrator acknowledged the concern regarding a recommendation for Resident #3 to have double entrees with meals was not put into place. A Therapeutic Diets policy revised October 2017, documented that diet will be determined in accordance with the resident's informed choices, preferences, treatment goals and wishes. It documented that the diet order should match the terminology used by the food and nutrition services department. It documented that the dietitian, nursing staff, and attending physician will regularly review the need for, and resident acceptance of, prescribed therapeutic diets. A NUTRITION INTERVENTION PROGRAM from the Dietary Services Policy & Procedure Manual February 2016 Edition, documented the following: POLICY: Residents identified with a decline in their nutritional status will be placed on a Nutritional Intervention Program (NIP). High risk residents may include: -Residents who have had a significant weight loss defined by 5% in one month, 7.5 % in 3 months, 10% in 6 months or gradual weight loss over a longer period of time. -Residents with open/pressure area(s). -Residents with poor nutritional status or inadequate oral intake. PROCEDURE: 1. Consulting Dietitian, Dietary Services Manager (DSM) and/or DON will initiate one and/or a combination of the products listed below to increase calories and/or protein for residents who are at nutritional risk. A doctor's order is not needed for the addition of the NIP. Any one and/or any combination of the following food items may be used to promote weight gain, wound healing and/or improved nutritional status. -Super Cereal -Two slices bacon or sausage in addition to regular menu -Extra egg daily -Whole milk -Peanut Butter (may whip butter into the peanut butter for even more calories and to promote easier swallowing) -Cream Cheese -Extra margarine on all hot foods or squeeze bottle at the table -Extra ounce meat at lunch and dinner -Ice Cream/sherbet -Sour Cream -Cottage Cheese -Slices of cheese -Puddings/custards -Yogurt -Half and Half -Other high calorie additions resident may desire For best results the resident should be involved in deciding what food items to incorporate into his/her NIP whenever possible. Commercial supplements are appropriate for residents with pressure areas, extreme weight loss and/or with abnormal lab values as deemed appropriate by the Consulting Dietitian. Commercial supplement require a doctor's order. 2. The Consulting Dietitian will routinely evaluate approximate extra calories and protein provided by the NIP. 3. Interventions will be documented on the resident's Care Plan, including NIP, commercial supplements, and fortified foods. 4. Residents receiving the NIP may be identified with a particular designation on their dietary card and/or by a particular color napkin/placement.

Based on observations, record and document review, staff interviews, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to prevent the transmission of Coronavirus Disease 2019 (COVID-19). Specifically, 1. The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak. The failure to follow facility policy resulted in a staff member being able to work on 07/11/2022 while having signs and symptoms of COVID-19 after having direct exposure to a COVID-19 positive staff member. 2. The facility failed to ensure Resident #38, who tested positive for COVID-19 on 07/05/2022, maintained isolation precautions to ensure staff, residents, and visitors were not exposed to COVID-19. 3. The facility failed to ensure staff working during a COVID-19 outbreak wore N95 masks in accordance with the Centers for Disease Control and Prevention (CDC) guidelines. 4. The facility failed to ensure N95 masks were fit tested before use. The facility reported a census of 64 residents. The first COVID-19 positive resident in the facility had been identified on 07/05/2022. Ten residents had tested positive for COVID-19 from 07/05/2022 through 07/15/2022. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of K. The IJ began on 07/11/2022 at 5:30 AM, when Staff A, Dietary Aide, came on duty and worked while having COVID-19 symptoms. The Administrator was notified of the IJ on 07/11/2022 at 6:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 07/12/2022 at 4:52 PM. The IJ was removed on 07/15/2022 at 3:15 PM, after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F880 remained at the lower scope and severity of a pattern, with no actual harm and a potential for more than minimal harm that was not immediate jeopardy. Findings included: A review of the facility's policy titled, Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures, revised July 2020, revealed the screening process included, 2. Anyone entering the facility (including staff) is screened and triaged for signs and symptoms of and exposure to others with [CONDITION(S)]-CoV-2 [severe acute respiratory syndrome coronavirus 2] infection including: a. fever (measured temperature > [greater than] 100 degrees F [Fahrenheit] or subjective fever; b. cough; c. shortness of breath or difficulty breathing; d. fatigue; e. muscle or body aches; f. headache; g. new loss of taste or smell; h. sore throat; i. congestion or runny nose; j. nausea or vomiting; and/or k. diarrhea. 3. Anyone with a fever, signs/symptoms of illness, or who has been advised to self-quarantine due to exposure is not allowed to enter the facility. 4. Residents are screened daily for fever and symptoms of COVID-19. Residents with fever or symptoms of COVID-19 are provided a facemask, immediately isolated, and placed on appropriate transmission-based precautions. Further review of the policy revealed, For a resident with known or suspected COVID-19: b. Resident is placed in a private room with a dedicated bathroom (if available) and closed door; OR c. Resident is cohorted per national, state, or local public health authority recommendations. 4. If there is a moderate to substantial COVID-19 transmission in the surrounding community: a. Staff wear all recommended PPE [personal protective equipment] (ie. [such as], gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms (based on availability). b. Residents are restricted to their rooms except for medically necessary purposes. c. When residents have to leave their room, they wear a face mask, perform hand hygiene, limit their movement in the facility, and practice social distancing. A review of the facility's policy titled, Personal Protective Equipment Program, revised on 03/12/2004, revealed, The use of Health Care N95 Particulate Respirator and Surgical Masks will be required to control exposure to contaminated airborne pathogen. Any worker who is required to wear any personal protective equipment (PPE) shall receive training in the proper use and care of the personal protective equipment (PPE). The policy also indicated, The training shall include, but not necessarily be limited to, the following subjects: 1. When PPE is necessary to be worn. 2. What PPE is necessary. 3. How to properly put on, take off, adjust, and wear PPE. 1. During an interview on 07/11/2022 at 8:30 AM (the first day of the survey), the Administrator (ADM) stated the facility had three COVID-19 positive residents who were located at the end of 200 Hall. The ADM stated they had positive staff members but was unaware of the exact number. During an interview on 07/11/2022 at 9:36 AM, Staff A, Dietary Aide, stated he was having signs and symptoms of COVID-19, sore throat, cough, and fever and chills the day before. Staff A stated he checked with the facility the night before and was told if he had no fever and tested negative, even with symptoms, he had to come to work. During an interview and observation on 07/11/2022 at 9:47 AM, Staff A was walking down the 300 Hall, pushing a meal tray cart, and coughed into his right elbow. Staff A was wearing a KN95 mask and had facial hair that was approximately 1 inch long. Staff A stated, I'm dying, and that his significant other was at home due to testing positive for COVID-19. Staff A stated he had direct contact with the significant other due to living together and provided meals to them. Staff A stated he woke up on Sunday, 07/10/2022, with a sore throat, cough, and fever. Staff A stated he took Tylenol for the fever and did not currently have a high temperature. Staff A stated the last time they had COVID-19, they tested negative on a rapid test, but tested positive on the PCR test. Staff A stated when they screened in the morning of 07/11/2022 on the screening kiosk, he answered the questions honestly about having symptoms of COVID-19, and the kiosk flagged him for answering yes to some of the symptoms. He stated there had to be an override code in order for him to continue checking in but nobody in the facility knew the override code. He stated his current symptoms were a sore throat, coughing up green stuff, chills, and body aches. He stated that he was having the same symptoms as the first time he had COVID-19. He stated that he had tried to get the dietary assistant manager to come in to complete his shift. He stated he notified the Interim Administrator (IADM) of his symptoms, who told him he had to stay until there was a replacement. He stated that he called the facility the previous night, 07/10/2022, and spoke to the Minimum Data Set (MDS) Coordinator/Charge Nurse, advising her that he had symptoms of COVID-19. The MDS nurse told him that he had to come to work and wear a mask. During an interview on 07/11/2022 at 9:56 AM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility for one week. The IADM stated that all staff had to ring a doorbell at the front of the facility to enter the facility. Upon entrance, they had to go to the screening kiosk to answer the screening questions, and the staff member who opened the door for the staff member had to take their temperature. At that time, the ADM removed her N95 mask and coughed. The IADM stated that if a staff member had symptoms, the screening kiosk would not let them continue to check in, and the staff had to complete a COVID-19 rapid test. If they were negative, they contacted their regional representative to see if the staff member needed to go home or continue working. The IADM stated they did not know who screened in Staff A but were aware that the staff member was flagged for answering yes to one or more of the screening questions. The IADM stated nobody in the facility had the override code for the screening kiosk. The IADM stated Staff A notified the IADM that he was not feeling well that morning. The IADM stated he was unaware who Staff A's significant other was or that they were positive for COVID-19. The IADM stated Staff A was waiting for the kitchen assistant manager to call Staff A back, so Staff A could go home. The IADM stated that Staff A should be wearing an N95 mask, not a KN95 mask, and an N95 mask would not fit properly if the staff member had facial hair. The IADM stated Interim Director of Nursing (IDON) A worked the previous night, so the Assistant Director of Nursing (ADON) would answer any questions related to infection control. At 07/11/2022 at 10:34 AM, the facility sent Staff A home. During an interview on 07/11/2022 at 10:42 AM, Interim Director of Nursing (IDON) B, who at the time of the interview had not been assigned the title of IDON and was a floor charge nurse, stated that when staff screened in at the kiosk and answered yes to any of the questions, It will pop up that you can't complete it, so you have to have a nurse come look at it. IDON B stated the facility would probably test the staff member and send them home. During an interview on 07/11/2022 at 10:47 AM, Staff K, Certified Nursing Assistant, stated that when staff screened in at the kiosk and answered yes to any of the questions, they had to call one of the nurses or the Administrator. She thought they would be tested but had never been in that situation. During an interview on 07/11/2022 at 10:57 AM, Staff I, Occupational Therapist, stated if she had symptoms while working, she would notify her boss and go home if the symptoms were beyond her normal symptoms. Staff I stated when staff screened in at the kiosk and answered yes to any of the questions, it would flag them. There would be extra screening involved, but Staff I was unsure what type of additional screening would be completed. During an interview on 07/11/2022 at 11:04 AM, the IADM stated if a staff member tested positive on a rapid test, they would be sent home. The IADM stated if the staff member tested negative and was vaccinated but still had symptoms, he would have to look at the facility policy. The IADM was unable to answer what the facility policy was. The IADM stated if staff had signs and symptoms and tested negative on a rapid test, the facility would monitor them, and they were still allowed to work. The IADM stated the charge nurse monitored staff who screened in, but the IADM was unsure if there was a way to actually monitor the screening process. The IADM stated that staff could not enter the building unless another staff member let them in, and that staff member then assisted with the screening of the staff entering the building. The IADM stated if a staff member answered yes to one of the screening questions on the kiosk, it sent the IADM an email notification, and the kiosk would not allow the staff to continue with the screening process. The IADM stated again that nobody in the facility had the override code if a staff member answered yes to a screening question. During an interview on 07/11/2022 at 11:13 AM, the Assistant Director of Nursing (ADON) stated if a staff member had symptoms of COVID-19, they should be sent home, even if the rapid test was negative. The ADON stated when staff screened in at the kiosk and answered yes to any of the questions, it would send an email to management, and the staff member would be rapid tested . During an interview on 07/11/2022 at 11:29 AM, the MDS Coordinator stated when staff screened in at the kiosk and answered yes to any of the questions, a nurse had to evaluate them, and they were rapid tested . If the staff member tested negative, they were allowed to work, and if they were positive, they would be sent home. The MDS Coordinator stated she understood that if the staff member was negative with symptoms, they had to wear a mask and go to work. The MDS Coordinator stated that Staff A did not call her on 07/10/2022, but his significant other did, and she was aware the significant other was positive for COVID-19. The MDS Coordinator stated the significant other advised the MDS Coordinator that Staff A was having signs and symptoms of COVID-19, and the MDS Coordinator advised Staff A that he needed to be rapid tested and, if he was negative, he needed to work. If he was positive, he did not need to come into work. The MDS stated she did not notify anyone that Staff A had signs and symptoms of COVID-19. The MDS Coordinator stated if the staff member had obvious signs of COVID-19, then they should stay home. The MDS Coordinator stated she was not aware who was notified if a staff member answered yes to one of the screening questions on the kiosk. During an interview on 07/11/2022 at 11:40 AM, the ADM and IADM stated they had not received a notification that an employee had answered yes to one of the questions on the kiosk. The IADM stated that an email should be sent to the ADM and the DON. During an interview on 07/11/2022 at 11:45 AM, Staff A, who had been sent home, stated he screened in around 5:30 AM on 07/11/2022 and that Staff AA, housekeeper, had screened him in. He stated neither he, nor Staff AA, were aware of what to do when the kiosk would not let him continue screening in, so they both went to work. He stated he was not advised that a nurse had to screen him in. He stated that when the IADM came into work around 8:00 AM, he notified the IADM of his symptoms and that he had tested negative on a rapid test. During an interview on 07/11/2022 at 3:20 PM, the ADM and IADM stated they were not aware that Staff A was taking Tylenol to decrease his temperature. The IADM stated that after a staff member answered yes to one of the screening questions, the kiosk would still allow other staff members to screen in. The IADM stated that at approximately 2:00 PM, the system notified the IADM that a staff member answered yes to body aches due to working in the garden during the weekend and was sore. The staff member came to the IADM to let them know the system flagged the staff member. The IADM was asked to provide a copy of the screening report. However, the IADM stated they were not aware of how to access it. The IADM stated that the outbreak started when a newly admitted resident, who was vaccinated, was tested 72 hours after being admitted and tested positive. Two staff members then tested positive, and several days later, another resident tested positive. Subsequently, Resident #38 and his/her roommate tested positive for COVID-19. During an interview on 07/11/2022 at 3:30 PM, Staff D, Registered Nurse, stated that another staff member had to assist with the screening process by taking the staff's temperature. Staff D stated that if staff had COVID-19 symptoms at work and tested negative, it just depended on how severe the symptoms were if the facility sent the staff member home or not. During an interview on 07/11/2022 at 4:48 PM, Staff A stated that he had a polymerase chain reaction (PCR) COVID-19 test completed, and the clinic had notified him that he was positive for COVID-19. During an interview on 07/11/2022 at 5:04 PM, the IADM stated the facility was not in contingency or crisis mode staffing. During an interview and observation on 07/12/2022 at 8:29 AM, the Maintenance Director stated two more residents tested positive that morning. On 07/15/2022, a copy of the Accushield-Health-Screening-Log dated 07/11/2022 was received and reviewed. The log revealed Staff A screened at 5:36 AM on 07/11/2022 and answered yes to the following questions: - Do you have a cough? - New Shortness of Breath or Difficulty Breathing - Fever greater than or equal to 100.0 or Chills> - Muscle or Body Aches? - Sore Throat? - In the last 14 days, outside of work, have you closely interacted with someone for 15 minutes or more, who is now COVID-19 positive? - Do you live with someone who has NEW symptoms of COVID-19 or has had a NEW positive test? The Screening Question Status indicated Staff A was Not Cleared. Further review revealed a housekeeper documented Staff A's temperature. During an interview on 07/13/2022 at 8:41 AM, Interim Director of Nursing (IDON) A stated if a staff member was experiencing signs and symptoms of COVID-19, they should be sent home regardless of whether they tested negative. During an interview on 07/16/2022 at 10:05 AM, IDON B stated staff who were exhibiting signs and symptoms of COVID-19 were not allowed to work. During an interview on 07/16/2022 at 4:14 PM, the IADM and ADM stated staff who were exhibiting signs and symptoms of COVID-19 were not allowed to work. Review of an untitled list of COVID-19 positive residents revealed five residents tested positive for COVID-19 from 07/13/2022 through 07/15/2022. 2. A review of Resident #38's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #38's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident was moderately cognitively impaired. According to the MDS, the resident also had an active diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] A review of an untitled list of COVID-19 positive residents indicated Resident #38 tested positive for COVID-19 on 07/05/2022. A review of Resident #38's Progress Notes dated 07/05/2022 at 1:10 PM (late entry) revealed the resident tested positive for COVID-19. According to Progress Notes dated 07/05/2022 at 4:00 PM, Resident #38 was sitting at the entry way. Staff members attempted to get the resident to quarantine in the isolation hall and to wear a mask and face shield, and the resident stated he/she was not sick and would not wear a face shield/mask and would not go to a room. The note stated the resident became irritated and threw the face shield and mask in the trash. A review of Progress Notes dated 07/06/2022 at 7:30 AM, revealed when the nurse entered the facility, Resident #38 was sitting at the front door. The nurse attempted to direct the resident to the room and to wear a face mask and shield. Resident #38 yelled, No, I'm not sick and leave me alone. During an interview on 07/11/2022 at 8:30 AM, the Administrator (ADM) stated the facility had three COVID-19 positive residents who were located at the end of 200 Hall. Resident #38 was observed sitting in the front lobby and was not wearing a mask. The ADM did not identify the resident as being COVID-19 positive at that time. Further review of Progress Notes dated 07/11/2022 at 8:46 AM, revealed staff attempted to get Resident #38 to wear a mask and face shield, and the resident threw them away. Staff then tried to get the resident to go to his/her room, and the resident stated he/she could not leave and was waiting for military command and the police. During an interview on 07/11/2022 at 2:16 PM, Staff F, Certified Nursing Assistant (CNA), and Staff G, CNA, were asked where Resident #38 was located. Due to a room change, the surveyor was unable to locate the resident during the initial screening process. Both staff stated Resident #38's room was on 100 Hall and was moved to the COVID-19 unit on 200 Hall, but the resident refused to stay in the room. Both staff stated the resident tested positive for COVID-19. During an interview on 07/11/2022 at 2:40 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident #38 was supposed to be on the COVID-19 unit at the end of 200 Hall, but the resident refused to go behind the plastic barrier. Staff E stated the resident had told her, That's where sick people go, and I'm not sick. Staff E stated the resident tested positive for COVID-19 on 07/05/2022. Staff E stated the facility was not allowing other residents out of their rooms, because Resident #38 refused to stay on the COVID-19 unit. Staff E stated the resident was previously in the military and had post-traumatic stress disorder ([CONDITION(S)]), and the resident refused to stay on the unit. Staff E stated Resident #38 sat in the front lobby all day and all night, and the only time the resident moved was to go to use the bathroom in their bedroom on 100 Hall. Staff E stated Resident #38's roommate also tested positive. During an interview on 07/11/2022 at 3:01 PM, the ADON stated the COVID-19 outbreak started with a resident who left the facility three times a week for [CONDITION(S)]. The ADON stated Resident #8 then tested positive, followed by positive staff members. The ADON stated there were more positive staff than there were residents. The ADON stated they did not have any other residents test positive until a week later, which was Resident #38, followed by Resident #38's roommate. The ADON stated the facility currently had three residents who were COVID-19 positive. The ADON stated they moved Resident #38's belongings to the COVID-19 unit, but the resident refused to move, and the facility stopped communal dining due to Resident #38's refusal to isolate. The ADON stated that Resident #38 ambulated down the 100 Hall, where the resident's room was located, and staff could not direct the resident to the COVID-19 unit. The ADON stated she re-tested the resident to prove to the resident that he/she was positive for COVID-19, but the resident did not believe the results. The ADON stated she offered the resident a face shield and face mask when the resident would sit in the front lobby, but the resident refused to wear them. The ADON stated the resident yelled at her and threw the items in the trash. The ADON stated she had verbally told staff to keep an eye on the resident and to keep the resident away from other residents. The ADON stated the facility put the resident's roommate on warm isolation, which meant the resident was on isolation, just not on the COVID-19 unit, until the roommate tested positive and was moved. During an interview on 07/11/2022 at 3:20 PM, the IADM stated the COVID-19 outbreak started when a newly admitted resident, who was vaccinated, was tested 72 hours after being admitted and tested positive. Two staff members then tested positive; several days later, another resident tested positive, then Resident #38 and his/her roommate tested positive for COVID-19. The IADM stated that when a resident tested positive, they were moved to the COVID-19 unit, and the facility tried to keep them in a room by themselves. The IADM stated that Resident #38 would not stay in the room. They kept Resident #38 in an area where there was not a lot of resident contact and stopped communal dining. The IADM stated, The front area is the best we can do. They could not tell the resident he/she was not allowed to move about the building and could not tell the resident he/she had to stay in the room. The IADM stated that instead, they requested all other residents to stay in their rooms. The IADM stated Resident #38 had the potential to get violent, and there was no choice, other than to reduce the resident's exposure to other residents and staff. During an interview on 07/11/2022 at 3:30 PM, Staff D, Registered Nurse, stated Resident #38 was noncompliant with staying isolated in his/her room and could become aggressive. Staff D stated all other residents were made to stay in their rooms. Staff D stated he was not aware if Resident #38 was positive for COVID-19. During an interview on 07/11/2022 at 4:22 PM, Resident #38's family member stated he/she was unaware the resident was positive for COVID-19. The family member stated that within the past three months, the resident started sitting at the front entrance because the resident thought someone was coming to pick him/her up. The family member stated the resident occasionally became aggressive, and the facility had called before when the resident had a bad day. The family member stated the last time the facility contacted him/her regarding the resident's behavior was at the end of April 2022. The family member stated the facility had not contacted him/her regarding the resident's refusal to isolate. During an interview on 07/11/2022 at 5:04 PM, the IADM stated he tried to redirect Resident #38 to his/her room. The resident had threatened to kill the IADM and also attempted to hit the IADM over the head with a fire extinguisher. The IADM stated the facility had not reached out to their public health contact for guidance and had only contacted their corporate office. During an interview on 07/12/2022 at 11:09 AM, the IADM stated the facility had not had a Social Service Director (SSD) for a month and a half, and they had someone coming in from another building. The IADM stated that whatever the resident concerns were, the department heads worked on those issues. During an interview on 07/12/2022 at 11:26 AM, the Medical Director (MD) stated the facility reached out to her last Tuesday (07/05/2022) about the outbreak. The MD stated the facility tried to make a plan for Resident #38, but the resident refused to isolate. The MD stated it was not ideal to allow the resident to wander while COVID-19 positive. The MD stated the resident kept coming out of his/her room and would not wear a mask and became aggressive and tried to hit a nurse. The MD stated the lobby became the resident's room, and every activity, dining, or therapy session was one-on-one with residents. According to the MD, it was interesting, because they had not had a spread of COVID-19 and had stopped it from going everywhere. However, the MD stated she was not aware of the recent positive resident cases. She stated the facility should have notified her, but they may have notified the nurse practitioner instead. The MD stated the facility tried to move Resident #38 to another facility, and the MD felt like the resident needed a facility with a secure unit due to being an elopement risk. The MD stated the previous SSD was working on getting the resident to move to another facility; however, the facility no longer had an SSD and was utilizing one from another facility. The MD stated she did not think the resident had been assessed for psychiatric care but felt the resident should be on a secure dementia unit. The MD stated allowing the resident to sit in the front lobby could possibly affect the other residents, and the best option was to keep the other residents isolated. The MD further stated that keeping the other residents isolated could lead to depression. The MD stated she believed the facility was violating the residents' rights, but they were trying to keep the residents healthy. During an interview on 07/13/2022 at 2:37 PM, the Director of Clinical Operations for Nurse Practitioners (DCONP) stated she did not feel it was appropriate for Resident #38 to be able to ambulate freely throughout the facility while COVID-19 positive. She stated she called her Chief Medical Officer, who stated the facility should transfer the resident to a locked facility due to the resident's behaviors. The DCONP stated she notified the Regional Director of Clinical Services (RDCS) of the recommendation, but the two nearby facilities were full. She stated the facility could send the resident to a local psychiatric facility, but they probably would not take the resident when he/she was COVID-19 positive. She stated she had worked with three different SSDs, and the facility was trying to find the resident another facility. She stated two SSDs had quit because there were no resources around the area. Further review of an untitled list of COVID-19 positive residents revealed 10 additional residents tested positive for COVID-19 from 07/08/2022 through 07/15/2022. 3. An observation on 07/11/2022 at 9:47 AM, revealed Staff A was walking down the 300 Hall, pushing a meal tray cart, and coughed into his right elbow. Staff A was wearing a KN95 mask and had facial hair that was approximately 1 inch long. During an interview on 07/11/2022 at 9:56 AM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility a week. The IADM stated that Staff A should be wearing an N95 mask, not a KN95 mask, and an N95 mask would not fit properly if the staff member had facial hair. The IADM stated the loops on the N95 mask should fit around the back of the head. During an interview on 07/11/2022 at 10:51 AM, Staff G, Certified Nursing Assistant, was observed wearing an N95 mask with the top band over the front of the mask and not behind her head. Staff G stated she was, not sure how to exactly wear it. During an interview on 07/11/2022 at 10:55 AM, the Maintenance Supervisor (MS) was wearing an N95 mask with the bottom strap underneath his chin and not behind his head. The MS stated, I'm supposed to wear it over my head. Sometimes I wear it right. I'm used to the KN95, but we can't wear those. During an interview and observation on 07/11/2022 at 1:53 PM, Staff H, Certified Nursing Assistant, was in room [ROOM NUMBER] talking to a resident. Staff H was wearing a face shield and an N95 mask that was below her chin. Staff H placed the mask back on her face and stated the mask should be worn above the nose. During an interview and observation on 07/12/2022 at 8:29 AM, the MS was again wearing the bottom strap of the N95 mask underneath his chin. When asked why the strap was below the chin, the MS responded, Ugh. I'm working on it. 4. During an interview on 07/11/2022 at 10:42 AM, Interim Director of Nursing (IDON) B, who at the time of the interview had not been assigned the title of IDON and was a floor charge nurse, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:42 AM, Staff R, Registered Nurse, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:47 AM, Staff K, Certified Nursing Assistant, stated they had not been fit tested for the N95 mask they were wearing. During an interview on 07/11/2022 at 10:51 AM, Staff G, Certified Nursing Assistant, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 10:53 AM, Staff S, Housekeeper, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:55 AM, the Maintenance Supervisor (MS) stated he had not been fit tested for the N95 mask he was wearing. During an interview on 07/11/2022 at 10:57 AM, Staff I, Occupational Therapist, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 at 10:59 AM, Staff N, Physical Therapy Assistant, stated she had not been fit tested for the N95 mask she was wearing. During an interview on 07/11/2022 10:59 AM, Interim Director of Nursing (IDON) C stated he had not been fit tested for the N95 mask he was wearing. During an interview on 07/11/2022 at 11:04 AM, the IADM and ADM both stated they had not been fit tested for the N95 mask they were wearing. The IADM stated they had contacted the local health department to complete fit testing; however, the health department would not come to the facility, and the staff members would have to make an appointment and go to the health department to be fit tested for the N95 masks. During an interview on 07/11/2022 at 11:13 AM, the Assistant Director of Nursing (ADON) stated she had not been fit tested for the N95 mask she was wearing. The ADON stated approximately a year and a half ago, she was fit tested for a different mask. During an interview on 07/11/2022 at 11:29 AM, the MDS Coordinator stated he had not been fit tested for the N95 mask he was wearing. During an interview on 07/11/2022 at 3:30 PM, Staff D, Registered Nurse, stated he had not been

Based on interviews, record review, and facility policy review, the facility failed to provide dental services to meet the needs of 1 (Resident #61) of 1 sampled resident reviewed for dental needs. The facility admitted Resident #61 with missing and broken teeth and failed to accurately assess the resident's dental status and identify dental issues in need of attention, which resulted in a delay in treating the dental issues. The resident subsequently developed pain and an abscessed tooth requiring antibiotic treatment. Findings included: A review of the facility policy titled, Dental Examination/Assessment Policy, dated 2001, revealed, Resident shall be offered dental services as needed. The policy also indicated, Upon conducting a dental examination, a resident needing dental services will be promptly referred to a dentist. A review of an Admission Record revealed the facility admitted Resident #61 on 06/11/2022 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a, NSG [Nursing]: Admission/Readmission Evaluation, dated 06/12/2022, revealed Resident #61 was alert and oriented to person, place, time, and situation. The evaluation indicated the resident's upper and lower teeth were in good condition. Review of a Dietary Note, dated 06/13/2022, revealed the Registered Dietitian (RD) performed a remote nutritional assessment. The RD indicated that the resident's upper and lower teeth were in good condition and that the resident had no chewing or swallowing difficulties, based on the documented admission evaluation that had been completed by nursing. A review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #61 scored 14 on a Brief Interview for Mental Status (BIMS), which indicating the resident was cognitively intact. The MDS indicated the resident had no obvious or likely cavities or broken natural teeth. Review of a Progress Note, dated 06/27/2022 (approximately two weeks after admission), revealed the resident complained of difficulty chewing meat due to dentition. The physical exam revealed poor dentition. During an interview on 07/11/2022 at 12:23 PM, Resident #61 stated there were issues with his/her teeth. The resident stated the bottom teeth were mostly removed or broken, with only a couple of teeth still in place. Resident #61 further stated at least two of the teeth had broken and the roots were still in the gum. In a follow-up interview on 07/13/2022 at 1:01 PM, the resident revealed he/she had told staff about the condition of the teeth when he/she was admitted to the facility. The resident stated he/she was experiencing pain and was now on antibiotics. Review of a Progress Note, dated 07/11/2022, revealed the chief complaint/reason for visit was a swollen, painful, lower right gum. The resident's level of pain was described as five on a scale of zero to ten. The resident complained of achy, constant pain to the right gum/jaw/face area with associated swelling. The resident had pain with eating. The provider indicated the resident had a tooth broken off at the jawline. The physical exam indicated the resident had poor dentition and was mostly adentulous (without teeth). The remaining teeth were in poor condition/cracked. The right lower gum had inflammation and was tender to palpation. The provider indicated there was a possible abscess forming under the incisor area. The assessment and plan indicated a cracked tooth with early [CONDITION(S)] versus abscess. The provider ordered [MEDICATION(S)] 500 milligrams three times daily for ten days and a dental referral. During an interview on 07/16/2022 at 10:06 AM, the Interim Director of Nursing (DON) revealed the expectation for assessment of dental status at admission would be to look at the teeth, gums, under the tongue, count the teeth, check for dentures and odor, and make note of any broken or missing teeth. The Interim DON stated the resident would not be assessed to have good teeth if there were missing and broken teeth. The Interim DON stated Resident #61 should have been referred to a dentist. The Interim DON further stated the facility was without a Social Services Director currently, and in the absence of a Social Worker, she was not sure who would be responsible for dental referrals. During an interview on 07/16/2022 at 3:30 PM, Staff Y, Registered Nurse (RN), stated the resident had an abscess on the right gum and an order was received for antibiotic treatment a few days ago. She stated she put the order in the system for a dental referral and looked in the resident's mouth. She stated on the other side (left side) of the resident's mouth, there was a tooth with decay that was yellow at the base. She stated she did not agree with the admission assessment that indicated the resident's teeth were in good condition. She also stated the resident should have been referred to a dentist upon admission, based on the condition of the resident's teeth. On 07/16/2022 at 4:56 PM, the Administrator and Interim Administrator were interviewed. It was their expectation that the assessment would be done soon after arrival and they would expect that the resident would be asked if he/she wore dentures. The resident's mouth should be opened so the staff could see the teeth. They stated if an accurate assessment had been completed, Resident #61 should have been referred to a dentist.

Based on observations, record review, interviews, document review, and facility policy review, the facility failed to investigate to determine the causative factors of falls to facilitate development of effective interventions to prevent further falls and minimize the risk of fall-related injuries for 1 (Resident #23) of 2 sampled residents reviewed for accidents, which resulted in a laceration to the head, bilateral bruising to the eyes, a hematoma to the right lower eye and mid-forehead, and neck pain resulting from a fall for Resident #23. Findings included: A review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised December 2016, revealed, The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. Further review of the policy revealed, 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. The policy also indicated, 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. A review of the facility's policy titled, Falls - Clinical Protocol, revised March 2018, revealed, 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event, etc. [et cetera]. Further review of the policy revealed, Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall. Further review under, Treatment/Management revealed, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. 2. If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment and nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. Further review under Monitoring and Follow-Up revealed, 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. 2. The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling. Additionally, the policy indicated, 4. If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. Review of an Admission Record revealed the facility admitted Resident #23 with diagnoses that included encounter for other orthopedic aftercare, difficulty in walking, lack of coordination, muscle weakness, history of falling, displaced intertrochanteric fracture of left femur, muscle wasting, and dizziness. A review of a quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #23 had modified independence in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), indicating the resident had some difficulty with new situations. Further review of the MDS revealed the resident required limited assistance of one person for transfers. According to the MDS, the resident had experienced one fall with no injury and one fall with injury since admission or prior assessment. A review of Resident #23's care plan, dated as initiated on 03/23/2022, revealed the resident was at an increased risk for falls. The goal was for the resident to experience no injuries related to falls. The planned interventions included: - Encourage the resident to use the call light for assistance. - Provide a safe environment without clutter. - Ensure the resident wears appropriate footwear. - Monitor the resident for signs and symptoms that may warrant a change in condition. - Place non-skid strips in front of the recliner. Further review of the care plan revealed the resident had a fall with no injury on 06/02/2022 during a self-transfer and a fall with a laceration to the back of the head on 06/05/2022. The goal was for the resident to resume usual activities without further incident. The planned interventions included: - Assess the resident's neurological status. - Continue the resident's at-risk plan. - Monitor the laceration with staples on the back of the head. - Monitor/document/report as needed for 72 hours any signs and symptoms of bruising, changes in mental status, new onset of confusion, sleepiness, inability to maintain posture, and agitation. - Physical therapy to evaluate and treat as needed. - [NAME] within reach just in case the resident decides to self-transfer again and a sign on the walker to remind the resident to use it when transferring. A review of a NSG [Nursing]: Fall Risk Evaluation, dated 03/23/2022, indicated the resident's total fall risk score was 12, with a score of 10 or above indicating the resident was at high risk for falls. A review of a Nurse's Note, dated 04/15/2022 at 6:15 AM, revealed Resident #23 had raised the recliner up and had fallen out of the recliner. Review of the Un-witnessed incident report, dated 04/15/2022 at 6:15 AM, revealed Resident #23 was found sitting in front of his/her recliner, which was in the upright position. The resident had raised the recliner up and slid out onto the floor. The resident stated, I must have been playing with the remote. The intervention for this fall was to place non-skid strips in front of the recliner. A review of a NSG: Fall Risk Evaluation, dated 04/15/2022, indicated the resident's total fall risk score was 12, with a total score of 10 or above indicating the resident was at high risk for falls. A review of a Incident, Accident, Unusual Occurrence Note, dated 04/19/2022 at 1:00 AM, revealed the resident was found lying on the floor in front of his/her recliner. A review of an Un-witnessed incident report, dated 04/19/2022 at 1:00 AM, revealed Resident #23 was found lying in front of his/her recliner. There were no interventions listed for this fall. A review of a NSG: Fall Risk Evaluation, dated 04/19/2022, indicated the resident's total fall risk score was 15, with a total score of 10 or above indicating the resident was at high risk for falls. A review of an SPN [Special Needs Plan]-Skilled Evaluation, dated 04/20/2022 at 3:33 PM, revealed the resident was on skilled nursing services and was working with therapy for strength training and rehabilitation services. A review of a Incident, Accident, Unusual Occurrence Note, dated 04/23/2022 at 3:45 AM, revealed the resident was found approximately 4 feet from his/her recliner. The resident was assisted back to the recliner and reminded to use the call light for assistance. A review of an Un-witnessed incident report, dated 04/23/2022 at 3:45 AM, revealed Resident #23 had a fall in his/her bedroom and was found approximately 4 feet from the recliner. The resident stated, I was getting up and walked a few steps and fell . The resident was reminded to use his/her call light for assistance. A review of a NSG: Fall Risk Evaluation, dated 04/23/2022, indicated the resident's total fall risk score was 10, with a total score of 10 or above indicating the resident was at high risk for falls. A review of an Un-witnessed incident report, dated 06/02/2022 at 8:15 AM, revealed Resident #23 was found lying on his/her right side, facing the front door. The resident's walker was not in reach and the wheelchair was parked against the wall. The resident stated he/she hit his/her head, but there were no injuries noted. The resident was reminded to use the call light and to have his/her walker within reach. A review of an Incident, Accident, Unusual Occurrence Note, dated 06/02/2022 at 2:35 PM, revealed Resident #23 was found lying on his/her right side, facing the front door. The resident's walker was not in reach and the resident's wheelchair was parked against the wall. The resident stated he/she hit his/her head, but there were no injuries noted. The resident was reminded to use the call light and to have his/her walker within reach. A review of NSG: Fall Risk Evaluation, dated 06/02/2022, indicated the resident's total fall risk score was 10, with a total score of 10 or above indicating the resident was at high risk for falls. A review of Un-witnessed fall on 06/05/2022 at 4:30 AM revealed Resident #23 had a fall in his/her bedroom and was found lying on the floor beside his/her bed. The resident stated, I was just getting up to go to the bathroom and slipped. The resident sustained a laceration to the back of the head that measured approximately 1.5 inches long and was sent to the hospital. No interventions were listed for this fall. A review of NSG: Fall Risk Evaluation, dated 06/05/2022, indicated the resident's total fall risk score was 13, with a total score of 10 or above indicating the resident was at high risk for falls. A review of an Un-witnessed incident report, dated 06/05/2022 at 4:30 AM, revealed Resident #23 was found lying on the floor beside his/her bed. The resident stated, I was just getting up to go to the bathroom and slipped. The resident sustained a laceration to the back of the head that measured approximately 1.5 inches long and was sent to the emergency room . No interventions were listed for this fall. A review of an Incident, Accident, Unusual Occurrence report revealed that on 06/05/2022 at 7:30 AM, the resident returned to the facility with staples to the laceration on the back of the resident's head. A review of an Un-witnessed incident report, dated 07/04/2022 at 2:30 PM, revealed Resident #23 was found lying on the floor in front of his/her chair. The resident stated he/she accidentally kept pressing the up button on the chair and the chair raised, causing the resident to fall to the floor. The resident was educated on the safety risks associated with the chair controller. There was no NSG: Fall Risk Evaluation for 07/04/2022 in the resident's electronic medical record (EHR). There was no Nurses Note or Incident, Accident, Unusual Occurrence report related to the resident's fall on 07/04/2022. A review of an SPN-Focused Evaluation, dated 07/05/2022 at 10:45 AM, revealed the facility continued with neurological assessments of the resident after a fall. During an observation on 07/11/2022 at 9:26 AM, two staff members came out into the hall and yelled down the hall that Resident #23 had fallen and there was blood. A review of an Un-witnessed incident report, dated 07/11/2022 at 9:30 AM, revealed Resident #23 was found lying on his/her left side in front of the recliner, which was in the upright position. There was a large pool of blood on the floor under the resident's head. The resident sustained a laceration to his/her forehead. The resident stated he/she raised the recliner up and was dumped out of it. The resident stated that his/her nose hit the floor. The intervention listed on the form instructed the facility staff members to change the recliner from electric to manual. A review of an Incident, Accident, Unusual Occurrence Note indicated that on 07/11/2022 at 9:30 AM, the resident was found lying on his/her left side in front of his/her recliner and the recliner was in the upright position. There was a large pool of blood on the floor underneath the resident's head. The resident sustained a laceration to the forehead and had a bloody nose. The provider was notified via fax. A review of a NSG: Fall Risk Evaluation, dated 07/11/2022, indicated the resident's total fall risk score was 12, with a total score of 10 or above indicating the resident was at high risk for falls. During an interview and observation on 07/11/2022 at 2:05 PM, Resident #23 was sitting in a manual recliner in his/her room with gauze wrapped around the resident's head. There was a quarter-sized circle of blood on the resident's forehead that was visible through the gauze. Resident #23 stated he/she was in the recliner with the remote control and had messed up the setting on the controller and took a spill from the recliner. A review of a Nurse's Note revealed that on 07/12/2022 at 3:50 PM, the resident was sent to the hospital due to complaints of neck pain. Further review of the note revealed the resident had bilateral bruising to the eyes and a hematoma to the right lower eye and mid-forehead. A review on 07/13/2022 at 8:15 AM of an Incident by Incident Type report indicated the resident had experienced six falls since admission, which included 04/15/2022, 04/19/2022, 04/23/2022, 06/02/2022, 06/05/2022, and 07/11/2022. There fall that occurred on 07/04/2022 was not listed. During an interview on 07/13/2022 at 9:58 AM, Interim Director of Nursing (IDON) B, who at the time of the interview was a registered nurse working the floor and not the IDON, stated she was not aware of the resident having a fall on 07/04/2022. When asked about the neurological assessment she completed on 07/05/2022, which indicated the resident had a fall, she requested to review the resident's electronic medical record (EMR). After the review, IDON B stated that the resident had the neurological assessments that started on 07/04/2022 after the resident had a fall. She stated she could not recall anything about the fall, only that it was in the afternoon on 07/04/2022 around the start of second shift (2:00 PM to 10:00 PM). She stated Staff D, Registered Nurse, initiated the neurological assessments. IDON B stated that she was unable to locate any information about the fall in the EMR or in the risk management section of the EMR, where falls were documented. IDON B stated that previous interventions for the resident's fall were grip strips in front of the recliner. After the fall on 07/11/2022, she requested that staff switch out the resident's recliner to a manual recliner. She stated she notified the nurse practitioner via fax and did not call the doctor. She stated the resident was just bleeding from [their] forehead, no hematoma. I did not feel like it was an emergency issue. The IDON B stated she could only recall one other fall, which occurred in the middle of the night. The IDON B stated the facility should try to figure out how to prevent the resident from falling and put an intervention in place to prevent future falls. The IDON stated she was unaware if the facility completed a root cause analysis to identify why the resident was falling. IDON B stated that when a resident fell , the facility staff members were to complete an assessment, notify the family, notify the DON and/or management, and notify the physician. If the fall was unwitnessed, staff were to start neurological assessments and create an event in risk management in the EMR, which would include the assessment and what intervention was put into place. IDON B stated the Quality Assurance (QA) team was supposed to review the falls in risk management, and she was not part of the QA team. The IDON stated that was how the facility previously addressed falls but was unsure how the facility addressed them currently. During an interview on 07/13/2022 at 2:37 PM, the Director of Clinical Operations (DCO), who was a previous nurse practitioner for the facility, stated the resident had a weak gait when he/she was admitted . The DCO stated she was unaware of any interventions in place for the resident besides physical and occupational therapy, which the resident had started when he/she was admitted . The DCO stated that as a nurse practitioner, she reviewed the residents' medications and complete laboratory work if the resident had multiple falls but was unsure if this was completed for Resident #23. The DCO stated the Minimum Data Set (MDS) Coordinator should update the care plan to include interventions related to falls. The DCO stated the resident's physician should take part in the root cause analysis to identify the cause of the resident's falls. During an interview on 07/13/2022 at 3:54 PM, Interim Director of Nursing (IDON) A stated the DON was responsible for updating the resident's care plan after each fall to include interventions to prevent further falls. IDON A stated that when a resident fell , staff were to assess the resident, and if the fall was unwitnessed, start neurological assessments and complete a risk management form, which would include an intervention. If the resident fell and hit his/her head, staff should call 911. IDON A stated, It's very strange here because the staff faxed the doctor when a resident fell instead of calling them. IDON A stated she had been teaching staff to call instead of fax. IDON A stated she was present when the resident fell on [DATE] and that Staff B was the nurse working with the resident. IDON A stated that she started the risk management form, and Staff B was supposed to complete it. IDON A stated she finished the form today (07/13/2022). IDON A stated for the fall on 07/04/2022, the resident was in his/her recliner and did not let go of the remote controller and it sling shotted the resident to the floor. IDON A stated the resident had a BIMS of 15, which indicated the resident was cognitively intact, and she educated the resident on the safety of the chair. IDON A stated she was not aware the resident had previous falls from the recliner. During an interview on 07/13/2022 at 4:09 PM, Staff D, Agency Registered Nurse, stated the RN on shift or the management team were responsible for updating the resident's care plan. Staff D stated the resident had several falls as of 07/04/2022, and on that day, the resident had lifted the recliner up and slipped out onto the floor. Staff D stated he did not complete a risk management form, which would notify other staff of the incident, because IDON A was supposed to complete it. Staff D stated interventions for Resident #23 included to ensure the call light was in reach, keep the bed in low position, routine two-hour checks, and educate the resident on not pushing the remote on the recliner and not to transfer him/herself to the bed. During an interview on 07/16/2022 at 10:05 AM, IDON B stated she was just appointed the IDON as of 07/15/2022 due to not having any other registered nurses in the facility. The IDON stated the nurse on duty could make changes to the care plan, but the MDS Coordinator was responsible for updating the care plan. During an interview on 07/16/2022 at 1:29 PM, the MDS Coordinator stated that the corporate office had contracted MDS Coordinators who had been completing the MDS Coordinator's duties because she had to work as a floor nurse due to the facility being short-staffed. The MDS Coordinator stated that anyone on the nurse management team could update the resident's care plan, or the nurse who witnessed the incident could update it. She stated that if the incident happened while she was not at the facility, the nurse should update the care plan. She stated, In the end, it is the nurse management team that ensure it is updated, based on the risk management or anything that's happened. Those falls should have been the DON [Director of Nursing] updating the care plan based on the risk management reports. I don't know why it wasn't updated. During an interview on 07/16/2022 at 4:14 PM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility a week. The IADM stated the MDS Coordinator was responsible for updating the care plan, but the charge nurse had the ability to update it as well. The IADM stated the facility should complete a root cause analysis of the resident's falls but did not believe there were any for this resident; otherwise, the IADM would have looked at how the falls occurred. The IADM stated he would have to complete a root cause analysis before he could state what interventions should have been put into place. The IADM stated the root-cause was discussed during the morning meetings and the interdisciplinary team (IDT) would determine the root cause. The IADM stated the fall on 07/04/2022 should have been documented in risk management. Then the DON would review the risk management information to ensure all information was completed, which included the neurological assessment, notification, and interventions. The IADM stated the DON had to sign off on the risk management form, then the IADM had to review it and sign off on it, then it was locked in the system.

Based on facility policy review, observations, staff interviews, and review of facility documentation, the facility failed to ensure food was stored and prepared properly and safely, kitchen equipment was maintained in clean condition, and staff kept their hair covered when in the kitchen area. Specifically, the facility failed to label and date food and discard outdated food in order to reduce the risk of food-borne illness; failed to cool leftover food properly to reduce the risk of food-borne illness failed to maintain the ice machine in clean condition; failed to ensure all staff entering the kitchen wore hair restraints; and failed to ensure dirty utensils were not placed in the handwashing sink. The facility identified a census of 64 current residents. Findings include: 1. A review of the policy titled, Personnel Health Standards and Conduct from the Dietary Services Policy and Procedure Manual dated February 2016 revealed hair will be properly covered by a hair restraint. Observations on 07/11/2022 at 9:45 AM revealed the Administrator (ADM) walked into the kitchen with no hair restraint. She went to the dishwasher area to talk to staff. Further observations during the initial tour of the kitchen revealed Staff C, Maintenance Staff, was observed in the kitchen with no hair restraint. On 07/14/2022 at 6:16 AM, Staff L, Certified Nursing Assistant (CNA), was observed going into the kitchen to get ice with no hair restraint. On 07/14/2022 at 6:24 AM, Staff J was observed going into the kitchen with no hair restraint to get coffee for a resident. During an interview on 07/11/2022 at 3:15 PM, the Interim Dietary Manager (IDM) stated anyone entering the kitchen needed to have a hairnet on before entering. During an interview on 07/11/2022 at 3:10 PM, Staff C stated that when he went into the kitchen, he should have worn a hair net. During an interview, Staff L stated on 07/14/2022 at 6:16 AM that it was her first day and she did not notice a sign that only kitchen staff were allowed in the kitchen. Staff L had been sent to get ice and just went in the kitchen. During an interview on 07/14/2022, Staff J stated she went to get coffee for a resident with no hair net because it was in the kitchenette which did not require a hair net in this or any other facility she had worked at in the past. During an interview on 07/14/2022 at 8:40 AM, the Interim Administrator (IADM) stated that if anyone went into the kitchen, they should wear a hairnet. He further stated the front part of the kitchen where the coffee maker and ice machine were located as not considered a part of the kitchen, but he would verify this. On 07/16/2022 at 5:05 PM, the IADM stated stated hairnets were to be used in the kitchen, including the area where the coffee and ice were located. 2. A review of the policy titled, Leftovers, dated February 2016, revealed Leftovers must be cooled to 70 degrees within two hours, then down to 41 degrees within another four hours. During observations in the kitchen on 07/11/2022 at 2:45 PM, there were two large, deep containers of leftover chicken pot pie dated 07/11/2022, which each held approximately 2 gallons of food. The temperature of the contents was noted to be 145 degrees Fahrenheit. During an interview with the IDM and the Regional DM on 07/11/2022 at 3:02 PM, they indicated the chicken pot pie should have been cooled in a shallow pan so it would reach the correct temperature in the correct time frame. It needed to cool as quickly as possible. On 07/16/2022 at 5:05 PM, the IADM stated that leftovers must be handled appropriately. 3. A review of the policy titled, Food Storage-Refrigerated Foods, dated February 2016, revealed refrigerated foods will be covered, labeled, and dated (month, day, year). A review of the policy titled, Leftovers, dated February 2016, revealed Leftovers will be covered, labeled, and dated. During observations in the kitchen on 07/11/2022 at 2:45 PM, the following concerns were identified in the reach-in cooler: a. One container of gravy dated 07/02/2022. b. One container of potato salad dated 07/03/2022. c. One container of pears did not contain a date. d. One container of chili did not contain a date. e. One container of pork chops dated 07/03/2022. On 07/16/2022 at 5:05 PM, the IADM stated that foods were to be dated. 4. A review of the Dietary Services Policy and Procedure Manual, dated 02/2016, (Section 6-53) revealed the procedure for cleaning the ice machine. The manual did not specify a frequency for cleaning. Observation of the ice machine on 07/14/2022 at 11:55 AM revealed a black substance on the flap at the top of the inside of the machine. During an observation and interview on 07/14/2022 at 11:55 AM, the IDM and the Regional DM looked at the ice machine and the black substance on the flap. The Regional DM stated that it did not look very good. During an interview on 07/14/2022 at 11:57 AM, the Maintenance Director came into the kitchen and stated the ice machine was cleaned every six months, and it was due to be cleaned later this month. During an interview on 07/14/2022 at 1:00 PM, the ADM stated the ice machine needed to be on a regular schedule for cleaning; she was unsure of the exact schedule. During an observation and interview on 07/14/2022 at 1:36 PM, the IDM used a paper towel to remove some of the substance from the flap of the ice machine. She stated it was wet, had areas of red and brown, and there was some of the black substance still on the flap of the ice machine. The substance was thicker and more viscous than water. A review of the Physical Plant Preventative Maintenance Manual (Revised 04/25/2014) revealed monthly/quarterly/semi-annual preventative maintenance for ice machines. A log was provided by maintenance with the semi-annual cleanings documented. During interview on 07/16/2022 at 5:05 PM, the IADM stated the ice machine should be cleaned on a quarterly basis to de-lime and clean it thoroughly, and it was to be documented on a cleaning schedule. 5. During the initial tour of the kitchen on 07/11/2022 at 9:36 AM, observation revealed two spoons in the handwashing sink. One of the spoons had peanut butter on it and the other spoon had jelly on it. During an interview with the ADM on 07/14/2022 at 1:00 PM, she stated anyone going into the kitchen should know the protocol for the handwashing sink. The ADM stated that staff may have been in the kitchen to make a sandwich for a resident.

Based on facility document review and staff interviews, the facility failed to review and update the facility assessment at least annually and failed to ensure the facility assessment included pertinent information to assure the necessary care and resources were allocated to meet the needs of the residents. The facility identified a census of 64 current residents. Findings include: During the entrance conference on 07/11/2022, the Administrator and Interim Administrator were asked to provide a copy of the current facility assessment. Review of the facility assessment initially presented to the survey team revealed the assessment as dated 01/04/2021. When asked if the facility had a current assessment available, the Administrator and Interim Administrator later provided a copy dated 07/01/2022. A review of the facility assessment dated [DATE] revealed the top five diagnoses, as coded on the Minimum Data Set (MDS) assessments, history and physical, and Medication Administration Records (MARs), were all the same diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 2021 report contained the fourth quarter number of residents with the top five diagnoses. These numbers were not included in the 2022 report. Further review of the facility assessments revealed specialty diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the 2022 facility assessment revealed the personnel listed on the assessment did not include dietary staff. Also, the assessment did not include any physical space, equipment, assisted technology, or other material resources needed to provide care and services to the residents. The physical environment was not evaluated regarding meeting the needs of the residents (evaluation of building maintenance, capital improvements, vehicles, or equipment and supplies). Also, emergency preparedness was not addressed on the facility assessment. During an interview on 07/15/2022 at 10:22 AM, the Interim Administrator stated the current facility assessment had not been updated beyond what had already been provided to the survey team.

Based on facility policy review, clinical record review, and interviews, the facility failed to protect residents' right to formulate an advance directive for 8 (Resident #23, Resident #8, Resident #50, Resident #38, Resident #21, Resident #17, Resident #64, and Resident #18) of 8 residents reviewed for advance directives. Specifically, the facility failed to ensure all 8 residents reviewed were provided with information regarding their right to formulate an advance directive. The facility identified a census of 64 current residents. Findings include: A review of the facility's policy titled, Advance Directives, revised December 2016, revealed, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advanced directives and applicable state law. The policy also indicated, 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. 1. A review of an Admission Record revealed the facility admitted Resident #23 on 10/07/2021. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #23 had modified independence in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), indicating the resident had some difficulty with new situations. A review of a care plan, dated as initiated on 03/23/2022, revealed a focus related to the resident's advanced directive/code status. The goal was for the advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #23's electronic health record (EHR) on 07/12/2022 at 9:55 AM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/12/2022 at 10:20 AM, the Interim Administrator (IADM) stated the resident's advance directive should be in the resident's EHR under the miscellaneous tab. The IADM was advised there were no advance directives available for review in Resident #23's EHR and was asked for a copy of the resident's advance directive. During an interview on 07/13/2022 at 1:03 PM, the IADM provided a copy of the resident's code status. The IADM stated he did not know the difference between an advance directive and code status. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the Social Service Director (SSD) was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #23's admission agreement was requested but not received. A review of the facility's admission packet revealed an Admissions Agreement which included a list of resident rights. The right to formulate an advance directive was not included on the list. However, if the resident already had one formulated, the instructions on the form indicated it was to be attached to the admission agreement. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 2. A review of an Admission Record revealed the facility admitted Resident #8 on 03/17/2022. A review of the quarterly MDS assessment, dated 06/23/2022, revealed the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of Resident #8's care plan, dated as initiated on 3/18/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #8's EHR on 07/12/2022 at 10:48 AM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/12/2022 at 12:00 PM, the IADM was asked for a copy of the resident's advance directive. During an interview on 07/13/2022 at 1:03 PM, the IADM provided a copy of the resident's code status. The IADM stated he did not know the difference between an advance directive and code status. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the Social Service Director (SSD) was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #8's admission agreement was requested but not received. A review of the facility's admission packet revealed an Admissions Agreement which included a list of resident rights. The right to formulate an advance directive was not included on the list. However, if the resident already had one formulated, the instructions on the form indicated it was to be attached to the admission agreement. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 3. A review of an Admission Record revealed the facility admitted Resident #38 on 05/04/2019. A review of the quarterly MDS assessment, dated 05/12/2022, revealed the resident had a BIMS score of 9 out of 15, which indicated the resident was moderately cognitively impaired. A record review of Resident #38's care plan, dated as initiated on 3/18/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned interventions were to honor the resident's wishes, review the resident's choices quarterly and as needed, and to review the resident code status. A review of Resident #38's EHR on 07/12/2022 at 12:32 PM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 1:03 PM, the IADM provided a copy of the resident's code status. The IADM stated he did not know the difference between an advance directive and code status. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the Social Service Director (SSD) was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #38's admission agreement was requested but not received. A review of the facility's admission packet revealed an Admissions Agreement which included a list of resident rights. The right to formulate an advance directive was not included on the list. However, if the resident already had one formulated, the instructions on the form indicated it was to be attached to the admission agreement. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 4. A review of an Admission Record revealed the facility admitted Resident #18 on 05/11/2022. A review of the MDS assessment, dated 05/16/2022, revealed the resident had a BIMS score of 15. A record review of Resident #18's care plan, initiated on 5/11/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #18's EHR on 07/12/2022 at 12:33 PM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 1:03 PM, the IADM provided a copy of the resident's code status. The IADM stated he did not know the difference between an advance directive and code status. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the Social Service Director (SSD) was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #18's admission agreement was requested but not received. A review of the facility's admission packet revealed an Admissions Agreement which included a list of resident rights. The right to formulate an advance directive was not included on the list. However, if the resident already had one formulated, the instructions on the form indicated it was to be attached to the admission agreement. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 5. A review of the medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #64's admission MDS assessment, dated 06/11/2022, revealed the resident had a BIMS score of 10, indicating the resident was moderately cognitively impaired. A review of the care plan, dated 06/05/2022, revealed Resident #64 was care planned for advanced directives/code status. The goal was for the resident's advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #64's EHR revealed no documented evidence the resident had an advance directive, nor that the facility provided information regarding the resident's right to formulate one. During an interview on 07/12/2022 at 10:55 AM, the surveyor requested a copy of advanced directive information for Resident #64 from the IADM. No information was provided. During an interview on 07/13/2022 at 2:15 PM, the IADM revealed the SSD as responsible for assisting with advance directives on admission. He stated if the resident had an advance directive, it would be in the resident's medical record. During an interview on 07/16/2022 at 10:06 AM, Interim Director of Nursing (IDON) B stated advance directive information should be obtained on admission. She stated the SSD used to obtain advance directive information; however, the facility had been without a SSD for about five months. She stated the facility obtained information regarding residents' code status (full code or do not resuscitate [DNR]) and stated a physician had to sign a DNR order. IDON B stated she was unsure about the difference between advanced directives and a DNR. She further stated she was unsure who was currently obtaining the information from residents but indicated the documents should be scanned into the medical record. 6. A review of an Admission Record revealed Resident #50 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an annual MDS assessment dated [DATE] revealed no assessment of the resident's cognitive status. A review of a care plan dated 08/26/2021 revealed Resident #50 was care planned for advanced directives/code status. The goal was for the advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #50's EHR revealed no documented evidence the resident had an advance directive, nor evidence the facility had provided information to the resident/responsible party regarding the right to formulate an advance directive. 7. A review of Resident #21's Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of an admission MDS assessment, dated 05/11/2022, revealed Resident #21 had a BIMS score of 15. A review of a care plan, dated 04/15/2022, revealed Resident #21 was care planned for advanced directives/code status. The goal was for the advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. Review of Resident #21's EHR revealed no documented evidence the resident had an advance directive, nor evidence the facility had provided information to the resident on the right to formulate an advance directive. 8. Review of Resident #17's 'Admission Record revealed the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS assessment, dated 05/12/2022, revealed the resident had a BIMS score of 13, indicating intact cognition. A review of a care plan, dated 05/06/2022, revealed Resident #17 was care planned for advanced directives/code status. The goal was for advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #17's EHR revealed no documented evidence the facility had provided the resident with the opportunity to formulate an advance directive. During an interview on 07/15/2022 at 10:04 AM, the MDS Coordinator revealed the SSD was responsible for getting advance directive information on admission to the facility; however, the facility had not had a SSD for approximately five months. She stated a staff member from another building came to the facility twice a week to help with the SSD's duties. She stated the facility had hired social workers in the past, but they had not worked out. During an interview on 07/15/2022 at 10:10 AM, IDON B revealed the opportunity to formulate an advance directive should be offered by social services upon admission. She stated the facility had not had a SSD for a couple of months, and the IADM was doing admission paperwork. According to the IDON, advance directive information was offered with the admission paperwork. On 07/15/2022 at 10:46 AM, during an interview with the Administrator, he stated advance directives were offered upon admission. He stated whoever did the admission, the Social Worker or nurse, should offer assistance with formulating an advance directive. He stated the facility did not have a Social Worker and was unsure how long the facility had been without one. When asked for documentation regarding advanced directives for Residents #17, #50, and #21, he stated the corporate nurse was checking to see whether the information could be located. On 07/15/2022 at 11:51 AM, during an interview with IADM, he stated he could not provide documentation that advance directives had been offered to Residents #17, #50, and #21. He stated if a resident was not admitted with an advance directive, the staff person who admitted the resident should offer assistance with formulating one, and it should be scanned into the resident's medical record.

Based on facility policy/job description reviews, observations, interview, and document review, the facility failed to ensure a Registered Nurse (RN) served as the Director of Nursing (DON) on a full-time basis. The facility identified a census of 64 current residents. Findings included: A review of the facility's policy titled, Staffing revised October 2017, revealed, the Facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. A review of the facility's Care Initiatives Job Description for the Director of Nursing position, revised May 2011, revealed, Under general supervision of the Administrator, the Director of Nursing manages Nursing Department human and material resources, with responsibility and accountability for provision of quality nursing care and service to facility residents/families, compliance with applicable laws and regulations, and adherence to company policy/procedure and budgetary guidelines. Functions with extensive autonomy in daily nursing department operations; prior approval required for activities having significant budgetary or employee relations impact. Technical assistance, professional guidance and quality monitoring is provided by the Director of Nursing with added assistance from the assigned Nurse Consultant, Medical Director, Administrator, Vice President/Operations and other corporate staff also available as resources. Observation during the recertification and complaint survey on 07/11/2022 through 07/16/2022, revealed Interim DON B worked as a direct care staff nurse, providing direct resident care, administering medications, and performing other floor nurse duties. During an interview with Interim DON B on 07/16/2022 at 3:28 PM, she stated that since being appointed Interim DON, she still had to work as a staff nurse, providing resident care, passing medications, and other direct care tasks. She stated there was no time to do the things normally expected of a DON and it was the same for the last Interim DON. An interview with the Interim Administrator on 07/16/2022 at 5:20 PM revealed it was not the desire of management for the DON to work as a staff nurse. However, he stated until the permanent DON began working in August 2022, the Interim DON had to be on the floor providing resident care due to the facility being short-staffed.

Based on record review, interviews, document review, and facility policy review, the facility failed to employ a social worker to meet social services needs for 10 residents (#71, #8, #17, #18, #21, #23, #38, #50, #64, and #68) of 10 sampled residents reviewed for social services needs. Specifically, the facility failed to ensure discharge planning was provided for 1 (Resident #71) of 1 sampled resident reviewed for discharge planning; failed to ensure residents were informed of their right to formulate advance directives for 8 residents (#8, #17, #18, #21, #23, #38, #50, and #64) of 8 residents reviewed for advance directives; failed to ensure the Ombudsman was notified of facility-initiated transfers/discharges for 1 (Resident #21) of 3 residents reviewed for Ombudsman notification and failed to ensure advanced beneficiary notices (ABNs) were provided for 2 residents (#23 and #51) of 3 sampled residents reviewed for beneficiary notices. The facility identified a census of 64 current residents. Findings include: Review of a facility policy titled, Social Services, dated October 2010, revealed, Our facility provides medically related social services to assure that each resident can attain or maintain his/her highest practicable physical, mental, or psychosocial well-being. Policy Interpretation and Implementation. 1. The Director of Social Services is a qualified social worker and is responsible for: . b. Consultation to allied professional health personnel regarding provisions for the social and emotional needs to the resident and family; . d. An adequate record system for obtaining, recording and filing of social service data; 2. Medically related social services is provided to maintain or improve each resident's ability to control everyday physical needs (e.g. [for example] appropriate adaptive equipment for eating, ambulation, etc.) and mental and psychosocial needs (e.g., sense of identity, coping abilities, and sense of meaningfulness or purpose) . 4. The social department is responsible for: a. Obtaining pertinent social data about person and family problems related to the resident's illness and care; . c. Assisting in providing corrective action for the resident's needs by developing and maintaining individualized social services care plans; . k. Working with individuals and groups in developing supportive services for residents according to their individual needs and interests; . m. Participating in the planning of the resident's admission, return to home and community, or transfer to another facility by assessing the impact of these changes and making arrangements for social and emotional support. 1. A review of the facility's policy titled, Discharge Summary and Plan, revised December 2016, revealed, When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be developed to assist the resident to adjust to his/her new living environment. Further review revealed, 2. The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations governing release of resident information and as permitted by the resident. A review of the facility's policy titled, Discharging a Resident without a Physician's Approval, revised October 2012, revealed, 3. If the resident or representative (sponsor) insists upon being discharged without the approval of the Attending Physician, the resident and/or representative (sponsor) must sign a Release of Responsibility form. Should either party refuse to sign the release, such refusal must be documented in the resident's medical record and witnessed by two staff members. A review of the Admission Record revealed the facility admitted Resident #71 on 03/25/2022. A review of the admission Minimum Data Set (MDS) assessment, dated 03/31/2022, revealed Resident #71 scored 11 on a Brief Interview for Mental Status (BIMS), which indicated the resident was moderately cognitively impaired. A review of Resident #71's care plan, dated as initiated on 03/25/2022, revealed the resident had a transitional care plan with a goal to transition to the community. The planned intervention was that the resident would transition home with goals met and when clinically ready. Review of a discharge-return not anticipated MDS assessment, dated 04/22/2022, revealed an unplanned discharge to the community was completed on 04/22/2022. Review of a Social Services Note, dated 04/22/2022 revealed the facility requested a wellness check be performed by the police department since the resident left the facility against medical advice (AMA) the previous day. A review of Resident #71's electronic health record (EHR) on 07/14/2022 at 11:29 AM revealed no evidence a discharge summary was completed for the resident. During an interview on 07/14/2022 at 4:02 PM, the Regional Director of Clinical Services (RDCS) stated she was unable to locate a discharge summary, or any information related to the resident's discharge. At this time an Against Medical Advise (AMA) form for the resident was requested. During an interview on 07/15/2022 at 12:09 PM, Interim Director of Nursing (IDON) B stated the resident was supposed to come off skilled nursing, and the therapy department recommended the resident to transition to long-term care. However, the resident's family took the resident home AMA. She stated she spoke with therapy and, due to the resident's cognition, they recommended the resident be transferred to long-term care. IDON B stated the nurse on duty should have completed an AMA form, and the Social Service Director (SSD) would follow up with the resident after discharging from the facility. IDON B stated the nurse should have made a note about the resident's medications being returned to the pharmacy and that the resident's belongings went with the resident. IDON B stated the nurse should go over all current medications and other teaching as necessary. During a phone interview on 07/15/2022 at 1:10 PM, Resident #71 stated he/she was living at home by him/herself and had a nurse and two aides, which were provided by the Veterans Affairs (VA), who came in to assist him/her during the week. Resident #71 stated he/she could not afford the cost of the nursing home and did not want to sell his/her house because the resident wanted the house to go to family members. The resident stated the facility called after discharge and stated the resident was welcome to come back to the facility, but the resident could not afford it. During an interview on 07/15/2022 at 2:33 PM, the MDS Coordinator stated the resident plateaued in therapy and could not afford to stay for long-term care. The MDS Coordinator stated the resident's family member took the resident home. The MDS stated the SSD had a meeting with the family member and the resident and advised them on the facility's recommendation to transfer to long-term care. The family member stated he/she was taking the resident home and then just packed up and left. The MDS Coordinator stated they should have signed an AMA form, depending on cognition. The MDS stated the facility did not do a discharge summary, because they did not go over any information with the resident, such as medications or treatments. The resident's medications went back to the pharmacy and not with the resident. During an interview on 07/15/2022 at 10:05 AM, IDON B stated discharge planning should start upon admission, and the SSD was responsible for the discharge paperwork. However, the facility did not currently have an SSD. During an interview on 07/16/2022 at 4:14 PM, the Interim Administrator (IADM) and the Administrator (ADM) were interviewed together due to the ADM only being at the facility a week. The IADM stated the facility policy was to have the resident sign an AMA form. However, many times the resident refuses and just walks out the door. The IADM stated the nurse on duty should put documentation in the electronic health record (EHR) and include the reason for the discharge. If the nurse did not know what to do, they should contact the DON. The documentation should 'paint a picture of why they left AMA and do a DC summary as much as possible. The physician needs to be notified.' The IADM further stated that nursing or the SSD should meet with the resident to discuss concerns with the resident before leaving AMA to ensure a safer discharge. The facility did not currently have a Social Services Director, so an interview was not completed. As of 07/16/2022 at 5:33 PM, the survey team had not received an AMA form for Resident #71. 2. A review of the facility's policy titled, Advance Directives, revised December 2016, revealed, 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. 2. Written information will include a description of the facility's policies to implement advanced directives and applicable state law. The policy also indicated, 7. Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. 8. If the resident indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. b. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline assistance. Review of the facility's admission packet revealed an Admissions Agreement which included a list of resident rights. The right to formulate an advance directive was not included on the list. However, if the resident already had one formulated, the instructions on the form indicated it was to be attached to the admission agreement. 2a. A review of an Admission Record revealed the facility admitted Resident #23 on 10/07/2021. A review of the quarterly MDS assessment, dated 06/23/2022, revealed Resident #23 had modified independence in cognitive skills for daily decision making per a Staff Assessment for Mental Status (SAMS), indicating the resident had some difficulty with new situations. A review of a care plan, dated as initiated on 03/23/2022, revealed a focus related to the resident's advanced directive/code status. The goal was for the advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #23's EHR on 07/12/2022 at 9:55 AM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the SSD was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #23's admission agreement was requested but not received. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 2b. A review of an Admission Record revealed the facility admitted Resident #8 on 03/17/2022. The MDS assessment, dated 06/23/2022, recorded the resident had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. A review of Resident #8's care plan, dated as initiated on 3/18/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #8's EHR on 07/12/2022 at 10:48 AM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the SSD was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #8's admission agreement was requested but not received. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 2c. A review of an Admission Record revealed the facility admitted Resident #38 on 05/04/2019. A review of the quarterly MDS assessment, dated 05/12/2022, revealed the resident had a BIMS score of 9 out of 15, which indicated the resident was moderately cognitively impaired. A record review of Resident #38's care plan, dated as initiated on 3/18/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned interventions were to honor the resident's wishes, review the resident's choices quarterly and as needed, and to review the resident code status. A review of Resident #38's EHR on 07/12/2022 at 12:32 PM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 1:03 PM, the IADM provided a copy of the resident's code status. The IADM stated he did not know the difference between an advance directive and code status. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the SSD was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #38's admission agreement was requested but not received. During an interview on 07/16/2022 at 4:14 PM, the IADM and Administrator (ADM) stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 2d. A review of an Admission Record revealed the facility admitted Resident #18 on 05/11/2022. A review of an admission MDS assessment, dated 05/16/2022, revealed the resident had a BIMS score of 15. A record review of Resident #18's care plan, dated as initiated on 5/11/2022, revealed the resident had an advanced directive/code status care plan with a goal for advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #18's EHR on 07/12/2022 at 12:33 PM revealed no documented evidence the resident had an advance directive on file, nor evidence the facility provided the option to formulate one. During an interview on 07/13/2022 at 3:31 PM, the IADM stated the SSD was responsible for completing the advance directive upon admission. The IADM stated if a resident had an advance directive in place, a copy was placed in their medical record. If the resident did not have one, the SSD went over the option to formulate one, and that document was located in the admission packet. The IADM stated the facility did not currently have an SSD. A copy of Resident #18's admission agreement was requested but not received. During an interview on 07/16/2022 at 4:14 PM, the IADM and ADM stated that an advanced directive should be offered upon admission, and the SSD completing the admission packet should go over the option to formulate an advance directive. The ADM stated that due to not having an SSD, the facility was dispersing the duties among the department heads. 2e. A review of the medical diagnosis list in the electronic medical record revealed Resident #64 had diagnoses including [CONDITION(S)], [CONDITION(S)], heart disease, [CONDITION(S)], and gout. A review of Resident #64's admission MDS assessment, dated 06/11/2022, revealed the resident had a BIMS score of 10, indicating the resident was moderately cognitively impaired. A review of the care plan, dated 06/05/2022, revealed Resident #64 was care planned for advanced directives/code status. The goal was for the resident's advance directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #64's medical record revealed no documented evidence the resident had an advance directive, nor that the facility provided information regarding the resident's right to formulate one. During an interview on 07/12/2022 at 10:55 AM, the surveyor requested a copy of advanced directive information for Resident #64 from the IADM. No information was provided. During an interview on 07/13/2022 at 2:15 PM, the IADM stated the SSD was responsible for assisting with advance directives on admission. He stated if the resident had an advance directive, it would be in the resident's medical record. During an interview on 07/16/2022 at 10:06 AM, IDON B stated advance directive information should be obtained on admission. IDON B stated the SSD used to obtain advance directive information; however, the facility had been without a SSD for about five months and she was unsure who was currently obtaining the information from residents but indicated the documents should be scanned into the medical record. 2f. A review of an Admission Record revealed Resident #50 had diagnoses which included congestive heart failure, [CONDITION(S)] disorder, spinal fusion, and [CONDITION(S)] disorder. A review of an annual MDS assessment dated [DATE] revealed no assessment of the resident's cognitive status. A review of a care plan dated 08/26/2021 revealed Resident #50 was care planned for advanced directives/code status. The goal was for the advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #50's medical record revealed no documented evidence the resident had an advance directive, nor evidence the facility had provided information to the resident/responsible party regarding the right to formulate an advance directive. 2g. A review of Resident #21's Admission Record revealed the resident had diagnoses that included chronic respiratory failure, dysphagia, and chronic obstructive pulmonary disease. A review of an admission MDS assessment, dated 05/11/2022, revealed Resident #21 had a BIMS score of 15. A review of a care plan, dated 04/15/2022, revealed Resident #21 was care planned for advanced directives/code status. The goal was for the advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. Review of Resident #21's medical record revealed no documented evidence the resident had an advance directive, nor evidence the facility had provided information to the resident on the right to formulate an advance directive. 2h. Review of Resident #17's 'Admission Record revealed the resident had diagnoses that included [CONDITION(S)], [CONDITION(S)], end stage renal disease, and muscle wasting and atrophy. A review of an admission MDS assessment dated [DATE], revealed the resident had a BIMS score of 13, indicating intact cognition. A review of a care plan, dated 05/06/2022, revealed Resident #17 was care planned for advanced directives/code status. The goal was for advanced directives to be followed per resident/family request. The planned intervention was to honor the resident's wishes. A review of Resident #17's medical record revealed no documented evidence the facility had provided the resident with the opportunity to formulate an advance directive. During an interview on 07/15/2022 at 10:04 AM, the MDS Coordinator stated the SSD was responsible for getting advance directive information on admission to the facility; however, the facility had not had a SSD for approximately five months. She stated a staff member from another building came to the facility twice a week to help with the SSD's duties. She stated the facility had hired social workers in the past, but they had not worked out. During an interview on 07/15/2022 at 10:10 AM, IDON B stated the opportunity to formulate an advance directive should be offered by social services upon admission. She stated the facility had not had a SSD for a couple of months, and the IADM was doing admission paperwork. According to the IDON, advance directive information was offered with the admission paperwork. On 07/15/2022 at 10:46 AM, the ADM stated advance directives were offered upon admission. He stated whoever did the admission, the Social Worker or nurse, should offer assistance with formulating an advance directive. He stated the facility did not have a SSD and was unsure how long the facility had been without one. When asked for documentation regarding advanced directives for Residents #17, #50, and #21, he stated the corporate nurse was checking to see whether the information could be located. On 07/15/2022 at 11:51 AM, during an interview with IADM, he stated he could not provide documentation that advance directives had been offered to Residents #17, #50, and #21. He stated if a resident was not admitted with an advance directive, the staff person who admitted the resident should offer assistance with formulating one, and it should be scanned into the resident's medical record. 3. Resident #21 was admitted with diagnoses which included chronic obstructive pulmonary disease ([CONDITION(S)]) and chronic respiratory failure. A review of the 05/11/2022 admission MDS assessment for Resident #21 revealed the resident scored 15 on a BIMS test. Review of a Nurse's Note, dated 04/23/2022 at 4:35 PM, revealed the resident transferred to the hospital for respiratory concerns. Review of the medical record revealed no evidence the Ombudsman was notified of the transfer. During an interview on 07/15/2022 at 9:20 AM, the Ombudsman stated the facility had not been notifying the Ombudsman's office when residents were transferred or discharged . She stated the facility should be notifying the agency monthly. During an interview on 07/16/2022 at 10:47 AM, DON B stated if a resident was sent to the hospital, the physician, family, and DON should be notified. She stated the Ombudsman was notified by social services every thirty days. During an interview on 07/16/2022 at 4:22 PM, the IADM stated when a resident was sent to the hospital the responsible party, physician, DON, and ADM should be notified. He stated a report should be sent to the ombudsman at the end of each month. He stated when he came to the facility, the ombudsman was not notified for the month of May. He stated the SSD oversaw sending the statement of hospitalization /discharges to the Ombudsman, but these duties would be split up to other staff members since the facility did not currently have an SSD. He stated he sent May's report on 06/28/2022 and June's report on 07/13/2022. 4a. Review of an Admission Record revealed the facility admitted Resident #23 on 03/23/2022 and readmitted the resident on 05/04/2022 with diagnoses which included orthopedic aftercare and [CONDITION(S)]. A review of a quarterly MDS assessment dated [DATE] revealed Resident #23 had a Medicare stay with a start date of 05/04/2022 and an end date 05/20/2022. A review of the Beneficiary Notice - Resident discharged within the Last Six Months revealed Resident #23 discharged from Medicare Part A services with benefits remaining on 05/20/2022. 4b. Review of an Admission Record revealed the facility admitted Resident #51 on 06/24/2020 with diagnoses which included dementia without behavioral disturbance, muscle wasting and atrophy, and contractures of both hands. A review of a quarterly MDS assessment, dated 06/01/2022, revealed the resident required extensive assistance with bed mobility, transfers, and toileting. The MDS indicated the resident had a Medicare stay with a start date of 03/18/2022 and an end date 05/18/2022. A review of the Beneficiary Notice - Resident discharged Within the Last Six Months revealed Resident #51 discharged from Medicare Part A services with benefits remaining on 05/18/2022. During an interview on 07/14/2022 at 9:54 AM, the ADM stated the Beneficiary Notices were not located for two (Resident #23 and Resident #51) of the three residents selected for ABN review. She stated the MDS Coordinator and the Assistant Director of Nursing (ADON) had been asked about the ABNs, and that an attempt was made to contact the former Administrator to locate the forms, but the facility had been unable to locate them. On 07/15/2022 at 10:52 AM, during an interview with the ADM, she stated further efforts to locate the ABNs had been unsuccessful. On 07/16/2022 at 10:16 AM, during an interview with IDON B, she stated the purpose of the Beneficiary Notices was to notify the resident when they were coming off skilled therapy. She stated the resident must be notified at least 48 hours in advance, or sooner if the staff knew in advance. She stated Social Services and the MDS Coordinator were responsible for providing the Beneficiary Notices to the residents. On 07/16/2022 at 1:49 PM, during an interview with Resident #51's family member, he/she stated the facility had not provided written notice of Medicare Part A services being stopped. He/she stated Resident #51 was at the end of therapy when the facility gave them verbal notice. On 07/16/2022 at 4:22 PM, during an interview with the IADM, he stated generally, Social Services and the MDS Coordinator took care of the Beneficiary Notices. He stated he had no idea why the Beneficiary Notices were not provided. Once the documents were received back from the family, the documents should be scanned into the resident's medical record. The medical records of Resident #23 and Resident #51 were reviewed for Beneficiary Notices, and none were found.

Based on observations, staff and resident interviews and clinical record review, the facility failed to provide supervision to ensure that 6 female residents of the facility were free from sexual advances from 2 male residents identified in the sample allowing opportunities for exploitation of female residents. Female residents, ( Resident #2, #13, #15, #17, #19 and #22) were identified as having been groped and/or propositioned by Resident #1 and/or Resident #18. The interventions put in to place after the incidents were either non-existent or ineffective and did not prevent Resident #1 from groping and or propositioning female residents. These interventions included 15 minute checks which were not done consistently; an alarm placed in Resident #1's doorway that quit sounding after a few seconds, did not alert staff that it had sounded after it quit sounding and could not be heard consistently by staff; and no interventions put into place after staff reported incidents of a sexual nature toward female residents. These situations constituted Immediate Jeopardy to residents' health and safety. The facility failed to ensure stand lifts were in proper functioning order or had the appropriate sling available resulting in falls that occurred during transfers for 2 of 3 residents reviewed, (Resident #6, #3). The facility identified a census of 77 residents. 53 of the 77 residents were women. Findings include: 1. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/21, documented Resident #1's diagnoses included non-Alzheimer's dementia, cerebral infarction, and [CONDITION(S)]. This resident's Brief Interview for Mental Status (BIMS) score was 7 indicating severe cognitive impairment. Resident #1 was independent with bed mobility, transfers, and walking in room. A Care Plan for Resident #1 included the following focus areas and directed staff to do the following interventions: a. A focus area with a revision date of 8/8/21, documented Resident #1 had an emotional and physical relationship with Peer Resident #8 and was comfortable with physical affection of hugging and kissing and was comfortable with saying no or being told no and stopping if any further progression makes them uncomfortable. The goals revised on 8/4/21, documented Resident #1 would be free from physical/emotional contact with Resident #9 that would make Resident #1 uncomfortable. Resident #1 would be able to tell Resident #9 no if he was uncomfortable with physical contact. Interventions with a date initiated on 7/5/19, directed staff to conduct an additional assessment of understanding of consent if changes in mental status or behavioral difficulties are demonstrated and to monitor Resident #1's ability to accurately identify and express type of emotional and physical consensual contact ongoing. An intervention revised on 8/18//21, directed staff to provide privacy for Resident #1 and Resident #8 as needed and to direct them to Resident #8s room as to not disrupt Resident #1's roommate. b. A focus area revised on 3/4/21, documented Resident #1 enjoyed visiting with peers and Resident #1 refused to social distance during activities. His goal was documented he would engage in self-directed leisure pursuits, watching TV and reading the newspaper. An intervention dated 3/4/21, directed staff to provide education to resident regarding social distancing. An intervention dated 11/12/18, directed staff to respect Resident #1's decisions for self-directed leisure pursuits. An intervention revised on 7/18/19, directed staff to support his self-determination in activities of choice which included that he sometimes liked to walk around the facility. c. A focus area revised on 11/20/18, documented Resident #1 was at risk for decline in ADL (Activities of Daily Living) function related to diagnoses which included dementia, [CONDITION(S)] (a comprehension and communication (reading, speaking, or writing disorder resulting from damage or injury to the specific area in the brain), and possible medication side effects. The goal revised on 10/27/21, was for Resident #1 to participate in part of his ADLs. Interventions dated 11/20/18, directed staff to give Resident #1 verbal cures to help prompt him and that Resident #1 was independent with transfers and ambulation in the facility without the need of assistive devices. d. A focus area revised on 9/20/21 documented Resident #1 had a history of acting out with physical and verbal comments and actions of a sexual nature towards residents and staff when he had an untreated infection. It documented as a reminder when he was in the community he had been a very affectionate person which included hand holding, arm pats, and kissing on the top of the head. This resident's goal was to have fewer episodes of inappropriate comments toward female staff. Interventions dated as initiated on 10/18/21 directed staff that resident was started on [MEDICATION(S)] on 5/28/21 to help control sexual urges, resident was started on [MEDICATION(S)] on 9/16/21 to help reduce sexual urges and directed staff that resident's [MEDICATION(S)] was increased on 9/18/21 to help with sexual urges. An intervention initiated on 9/20/21 directed staff on 9/18/21 this resident would sit with staff at the nurses station for all meals. A resolved intervention dated 9/18/21 had directed staff this resident had a sensor pad in his doorway to alert staff when he was out in the public area. An intervention revised on 10/18/21, directed staff the sensor pad had been removed and a doorway sensor had been added on 10/4/21. An intervention revised on 11/25/19 directed staff to assist this resident to develop more appropriate methods of coping and interacting, to provide him with one on one education on appropriate vs inappropriate comments towards staff. This intervention gave an example to staff of you look nice today versus you look sexy today. This intervention directed staff to encourage him to express his feelings appropriately. An intervention dated 8/4/21, directed staff this resident sees meditellie as needed to assist with his behaviors. An intervention dated 11/25/19, directed staff to remove this resident from public area when behavior is disruptive and unacceptable. An intervention dated 7/5/19, directed staff to notify PCP (primary care provider) for an infection workup if this resident displayed increasing sexual based actions towards staff. e. A focus area revised on 7/1/19, documented Resident #1 had impaired cognitive function/dementia or impaired thought processed related to diagnosis of dementia and history of [CONDITION(S)] ([CONDITION(S)]). This resident's goals revised on 8/4/21, were to remain oriented to person and town through the review date and to be able to communicate basic needs on a daily basis through review date. An intervention revised on 11/14/18, directed staff to use his preferred name, identify themselves at each interaction, face resident when speaking and make eye contact, reduce distractions, and that resident understood consistent, simple and directive sentences. Staff were to provide him with necessary cues and to stop and return if this resident was agitated. An intervention dated 11/8/18, directed staff to provide cues, re-orient and supervise as needed. f. A focus area revised on 11/13/18, documented resident had difficulty recalling recent events related to history of [CONDITION(S)] and diagnosis of dementia. This resident's goal revised on 8/4/21, was Resident #1 would be able to find his room. Interventions dated 11/6/18, directed staff to remind this resident what their name was when they cared for him and to validate his thoughts and feelings when he got confused or anxious. g. A focus area revised on 11/13/18 documented this resident was at risk of unsafe wandering related to history of elopement. This resident's goal was revised on 8/4/21 and was his safety would be maintained through the review date. Interventions dated 11/6/18, directed staff a monitoring device was placed on him that sounded alarms when he left the building and to identify patterns of wandering, if the wandering was purposeful, aimless or escapist, if he was looking for something, did he need more exercise and to intervene as appropriate. An intervention revised on 11/25/19 directed staff that he had a wanderguard. An undated list of Resident #1's current interventions was provided by the facility. The interventions were listed as follows: 7/1/19 Emotional/Physical relationship with Resident #8 was care planned and consents were obtained. 7/1/19 Emotional/physical relationship with Resident #9 was care planned and consents were obtained. 5/28/21 Resident started [MEDICATION(S)]. 9/6/21 Touched Resident #13's breast. Stop sign was placed on Resident #13's door to prevent other resident from entering room. The residents were separated. 9/16/21 Resident started on [MEDICATION(S)] 250 mg BID (twice a day). 9/18/21 Resident touched Resident #17. The behavior was not reciprocated. Resident was to stay at nurses station during waking hours. Alarm in doorway and [MEDICATION(S)] was increased to 500 mg BID. 10/4/21 A sensory pad was added to the doorway, door alarm removed. 10/17/21 Resident #1 was sitting in Resident #2's room with her in his lap. Residents were separated and 15 minute checks were initiated. Resident #1's Progress Notes documented the following: * On 2/9/21 at 1:16 p.m., Resident #1 was reported making inappropriate statements to the resident across the hall (Resident #15). Resident #15 requested room change per her preference and was moved to the 300 hall. * On 5/20/21 at 5:30 p.m., a visitor approached staff and stated Resident #1 had gone into his wife's (Resident #19) room and kissed her on her lips. The visitor stated he wanted to file a complaint. * On 5/21/21 at 3:01 a.m., the resident had been in his room resting in bed with eyes closed . He did not make any attempts to go into other residents rooms or make physical contact with other residents. * On 5/27/21 at 7:05 p.m., a clean catch UA (urinalysis) was collected and dropped off, the results were pending. * On 5/28/21 at 11:00 a.m., the Social Services staff documented she was informed Resident #19 had concerns Resident #1 and Resident #18 had been in her room at some point in the past but not on that day. The SS staff documented she spoke to Resident #18 and told him to knock before entering anyone's room and to not go into Resident #19's room. A stop sign was placed on Resident #19's door. * On 5/28/21 at 1:42 p.m., the wife was okay to resume [MEDICATION(S)] after a long discussion with the Nurse and Social Worker about resident's behavior. The doctor was in the building and was okay with resuming. * On 5/28/21 at 1:45 p.m., the UA was back from review by the doctor and was clean. No new orders were obtained. * On 6/3/21 at 3:58 p.m., the POA (Power of Attorney) was phoned in order to update on [MEDICATION(S)] . The family wanted a UA due to change in behavior. UA was obtained and the results were negative. * On 7/19/21 at 11:08 a.m., Resident #1 had a tele psychiatric visit with PhD therapist. They discussed the recent incident he had with a CNA (Certified Nurse Aide) and that is important for him to remain sexually appropriate at all times. * On 7/20/21 at 4:44 p.m., A CNA reported to the Nurse that Resident #1 attempted to kiss her. The CNA stepped away from the resident and did not welcome his advances. The CNA was instructed to take another staff person into the room with her. * On 9/6/21 at 3:00 p.m., it was reported to the Nurse that Resident #1 had gone up behind another resident (Resident #13) and touched her breasts. When this was reported Resident #1 had already ambulated back to his room. * On 9/7/21 at 10:35 a.m., the Social Service Coordinator met with Resident #1 about the incident that had occurred over the weekend. The Social Service Coordinator did the sexual consent willing and stated he did not recall touching a female's breast. * On 9/10/21 at 4:04 a.m., monitoring for sexual behaviors and there were no behaviors that shift. Resident was about the facility per his usual without incidents. * On 9/16/21 at 3:47 p.m., new order for [MEDICATION(S)] 250 mg BID mood stabilizer. * On 9/18/21 at 9:59 a.m., a female resident (Resident #17)was sitting in lounge when Resident #1 walked up to her and then began talking to her. He then went to the front of her wheelchair and then put his hand down her shirt and touched her breast. Resident immediately removed from the lounge and taken to the nurses station. * On 9/18/21 at 10:09 a.m., Doctor notified of incident. Obtained an order to increase the [MEDICATION(S)] to 500 mg BID. The Nurse discussed with Administrator and a 5 Minute Meeting out to staff for resident to stay at nurse's station while awake and alarm in doorway at night time. Spouse was called and notified of new orders, incident and alarm. * On 9/19/21 at 3:12 a.m., Resident #1 remained on increased [MEDICATION(S)]. Resident had no memory of incident with female resident. He was able to leave his room undetected due to being able to step over alarm pad in doorway. * On 9/20/21 at 2:17 a.m., Resident stepped on pad in doorway triggering the alarm at that time. The writer noted resident standing by his door only wearing underwear. When resident was approached it was noted he had the alarm in his hand attempting to turn it off. Writer requested the alarm, resident handed it over and the writer reset the alarm. * On 9/20/21 at 9:31 a.m., Resident monitored for new order to increase [MEDICATION(S)]. Resident to be at nurses station when awake and kept away from female residents, alarm on in doorway at night. No behaviors at that time. Resident was eating at nurses station. * On 9/20/21 at 11:27 a.m., the Social Service Coordinator met with Resident #1 and asked about him touching another woman. Resident #1 stated he had only touched his wife. Resident #1 was asked if he ever touched a woman there (at the facility) on her breast and he stated no. * On 10/3/21 at 3:55 p.m., the Nurse notified the Nurse Manager regarding alarm in the resident's doorway. The Nurse witnessed the resident sort of [NAME] over alarm without setting it off. It was also reported to the Nurse that Resident #2 was seen putting her walker over the mat and alarm and trying to step over it. Resident #2 made it into Resident #1's room before she was redirected. This is a fall hazard and intervention needs to be reevaluated as the intervention is ineffective for monitoring Resident #1's whereabouts as Resident #1 can easily navigate around it without setting it off. * On 10/5/21 at 5:35 a.m., Resident #1 continues to circumvent alarm at his doorway. Resident has been up to nurses station twice this shift and alarm did not sound. Alarm was on when checked. * On10/17/21 at 2:15 p.m., A CNA opened door to resident's (Resident #2) door to pass ice and Resident #1 was sitting in recliner with Resident #2 on his lap. Resident #1 had his hand up Resident #2's shirt. CNA told Resident #1 he was not supposed to be in there and told Resident #2 to get off of his lap. Resident #2 moved to her bed. Resident #1 said he would not leave. CNA told Nurse. The Nurse stated she was walking down the hall and CNA explained situation to her. Nurse entered the room and saw Resident #1 sitting in Resident #2's recliner and Resident #2 sitting on her bed. Nurse had Resident #1 get up and go back into his room and then notified the Nurse Manager. The Nurse Manager had Nurse bring Resident #1 up to nurses station to keep the residents apart and then notified the Administrator and their Nurse Consultant. 15 minute checks were initiated. Administrator reporting incident and Doctor was notified. Resident' #1's wife was called without answer. Spouse returned call and was notified at 7:30 a.m. on 10/18. * On 10/24/21 at 11:51 a.m., Resident #1 continues on 15 minute checks due to history of entering other residents' rooms, attempts to touch a woman inappropriately. Resident has had no behaviors of this sort in the last 3 days. Resident pleasant and cooperative. Ambulates with a front wheeled walker from his room to the lobby area. He has made no attempts of going any other places than these 2 areas. Continues to sit near nurse's station for meals. Resident denies any concerns with this. Affect continues flat. Speaks when spoken to. Denies any pain or any needs at that time. * On 11/7/21 at 9:02 a.m., Resident continues on one to one supervision and 15 minute checks. Resident noted to be more touchy and trying to get close to female staff. One to one CNA came to this Nurse to report this. Resident was reminded to stay away from female residents. A note for Incident # 2264 dated 10/17/21 at 2:15 p.m., documented Resident #1 was put on 15 minute checks. The following 15 Minute Checks sheets were provided by the facility: * 10/17/21 4 p.m. to 10/18/21 at 9:15 a.m.: showed 15 minute checks were initialed as done * 10/18(21) and 10/19(21)(overnight): showed initialed checks starting at 3:15 p.m. to 3:45 p.m. and at 11:50 p.m. on 10/18/21. It then showed initialed checks from 12:05 a.m. to 3:45 a.m. * 10/20/21 9:30 a.m. to 3:45 p.m., all spots initialed. * 10/20/21 from 4:00 p.m. to 10/21/21 9:15 a.m. all spots initialed. * 10/21/21 from 9:30 a.m. to 3:45 p.m. all spots initialed. * 10/21/21 from 4:00 p.m. to 12:00 a.m. on 10/22/21. * 10/22/21 from 12:15 a.m. to 11:30 a.m. showed checks were initialed. Then from 2 p.m. to 8:00 p.m. showed checks were initialed. On this sheet it shows checks were resumed at 8:30 p.m. to 11:45 p.m., however the date written next to the 8:30 p.m. slot documented 10/23 (21). On top of this page the date 10/23/21 is written however by the 12:15 a.m. slot 10/22(21) is written. * 10/23/21 from 12:15 a.m. to 6:00 a.m., from 2:00 p.m. to 5:30 p.m. and from 6:00 p.m. to 11:45 p.m. showed checks were initialed. * 10/24/21 from 12:15 a.m. to 12:00 p.m. showed checks were initialed. * 10/24/21 from 12:00 p.m. to 10/25(21) 5:45 a.m. showed checks were initialed. * 10/25/21 from 6:00 a.m. to 3:30 p.m., showed checks were initialed. No further sheets were provided to show checks were done during the missing times. The Clinical Census printed on 11/18/21 at 9:11 a.m., documented Resident #1 was admitted on [DATE] into room #210 and stayed in that room until he was moved into room #201 on 10/21/21 and moved again to room #217 on 10/28/21. 2. A MDS with an ARD of 7/28/21, documented Resident #2's diagnoses included unspecified dementia with behavioral disturbance, anxiety, and depression. This resident's Brief Interview for Mental Status (BIMS) score was 9 indicating moderate cognitive impairment. Resident #2 was independent with transfers, and walking in room and required supervision for bed mobility. A Care Plan for Resident #2 included the following focuses and directed staff to do the following interventions: a. A focus area with a revision date of 2/13/19 , documented Resident #2 had questionable recall related to dementia, depression, potential medication side effects. The goals revised on 2/10/21, documented Resident #2 would remain oriented to self/family during the review period. Interventions with a date initiated on 10/17/21, directed staff Resident #2 has allowed Resident #1 to fondle her, her family is aware and that Resident #2 often seeks out Resident #1 for sexual attention. Staff are to redirect her as needed. Interventions dated 8/12/17, directed staff to provide Resident #2 with diversional activities as allowed, to re-orient/re-direct her as she would allow and to validate her thoughts/feelings when she exhibited frustration related to impairment. b. A focus area revised on 9/26/21, documented Resident #2 used safety devices and she had a wander guard. The goal for Resident #2 dated 9/26/21, was resident would remain safe in her environment. An intervention dated 9/26/21, directed staff Resident #2 had a wander guard. c. A focus area revised on 11/25/19, documented Resident #2 displayed socially disruptive behavior and would on occasion take items that belong to her roommate. Resident #2's goal revised on 2/10/21, was Resident #2 would decrease her episodes of disruptive behaviors by 50%. Interventions dated 11/26/19, directed staff to visit with her and provide diversional activities, to monitor and document her behavior, and to talk with her in a calm voice when her behavior is disruptive. d. A focus area revised on 8/4/21, documented Resident #2 exhibited signs of disorganized thinking and irrelevant conversation. The goal for Resident #2 dated 8/4/21, was Resident #2's symptoms of [CONDITION(S)] would resolve without [MEDICATION(S)] effects. An intervention dated 8/4/21, directed staff to report any changes in her level of consciousness to the doctor. A Progress Note dated 10/17/21 at 2:15 p.m., documented a CNA opened Resident #2's door to her room to pass ice and Resident #1 was sitting in Resident #2's recliner with Resident #2 on his lap. Resident #1's hand was up Resident #2's shirt. CNA reported she told Resident #1 he was not supposed to be in there and told Resident #2 to she needed to get out of his lap. Resident #2 moved to the bed. The CNA told Resident #1 to leave and Resident #1 said he would not leave. The CNA then notified the Nurse. The Nurse stated she was walking down the hall and the CNA explained the situation to her. The Nurse stated she entered the room and saw Resident #1 sitting in Resident #2's recliner with Resident #2 walking to her bed. Nurse stated she had Resident #1 get up and go back to his room. The Nurse then went to the nurse's station and notified the Nurse Manager. The Nurse brought Resident to the nurse's station to keep the resident's apart. The Nurse Manager then notified the Administrator, and the Nurse Consultant. New BIMS assessment was completed with a BIMS of 5 (severe cognitive impairment). Fifteen minute checks were initiated. Administrator was reporting incident and the doctor was notified. Resident #2's son was called and notified of the incident. A note for Incident # 2264 dated 10/17/21 at 2:15 p.m., documented resident was put on 15 minute checks for 24 hours. The following 15 Minute Checks sheets were provided by the facility: * 10/17/21 4 p.m. to 10/18/21 at 9:15 a.m.: showed 15 minute checks were initialed as done. * 10/18/21 at 9:30 a.m. to 3:45 p.m., showed 15 minute checks were initialed as done. No further sheets were provided. The Clinical Census printed on 11/18/21 at 9:13 a.m., documented Resident #2 moved from a room #404 in the 400 hall to room #211 in the 200 hall on 11/16/18. 3. A MDS with an ARD of 9/29/21, documented Resident #15's diagnoses included non-Alzheimer's disease, acute [CONDITION(S)] with [CONDITION(S)], and heart failure. Resident #15's BIMS score was 15 indicating intact cognition. Resident #15 was independent with bed mobility, transfers and walking in room. A Care Plan for Resident #15 included the following focus area and directed staff to do the following interventions: a. A focus area dated11/23/20, documented Resident #15 used safety devices. The goal for Resident #15 revised 8/16/21, was Resident #15 would remain safe in her environment. Interventions dated 11/23/20, directed staff Resident #15 had an electric high low bed and used an assist bar. An intervention dated7/14/21 directed staff Resident #15 used a wheeled walker for long distance. A Progress Note dated 2/9/21 at 10:43 a.m., documented it was reported to the Nurse last night, that Resident #1 made inappropriate comments to Resident #15. Resident #15 stated Resident #1 walked into the doorway of Resident #15's room and asked if she (Resident #15) wanted his (Resident #1's) penis. Resident #15 replied no to which Resident #15 replied oh, I thought you did. They talked for a little while and then Resident #1 went back to his room. When the Social Service staff talked with Resident #15, Resident #15 stated Resident #1 did not make her feel unsafe and she was not offended by his comments but she would like to move rooms just so that she isn't directly across the hall from him. We are moving Resident #15 immediately (to a different hall). A Progress Note dated 10/26/21 at 3:33 p.m., documented Social Services met with Resident #15 regarding a past incident that had occurred. Staff asked if there was ever a time she felt uncomfortable with another resident. Resident #15 stated she was in her other room and Resident #1 walked into her room while she was watching TV and asked her if she wanted it. Resident #15 pointed at her private area. Staff asked what she meant by this and she shared his penis/dick. Resident #15 stated no and Resident #1 stood there and then left. Staff asked Resident #15 if his clothes were on and Resident #15 stated yes. She stated she was (wasn't) sure if his privates were out or not. Staff asked if she felt safe and Resident #15 stated she did. Resident #15 stated she would respond better. She stated she was shocked but now she is aware and won't let that happen. She stated she goes to activities where he is and is able to do so witout being scared. She stated she always knows where he is and never sits by him. She stated she would talk to Social Services if she had any concerns. She stated she felt bad it took her awhile to tell but she was encouraged to tell from her daughters and she is glad she did. Staff thanked resident for meeting. The Clinical Census printed on 11/18/21 at 9:14 a.m., documented Resident #15 moved from a room #209 in the 200 hall to a room in the 300 hall on 2/9/21. 4. A MDS with an ARD of 8/25/21, documented Resident #13's diagnoses included non-Alzheimer's disease, diabetes, and heart failure. Resident #13's BIMS score was 13 indicating intact cognition. Resident #13 required limited assist of 1 with bed mobility, transfers and walking in room. A Care Plan for Resident #13 included the following focuses and directed staff to do the following interventions: a. A focus area dated 1/28/21, documented Resident #13 used safety devices. The goal revised on 5/26/21, for Resident #13 was she would remain safe in her environment. Interventions dated 1/28/21, directed staff Resident #13 had a specialty call light had an electric high low bed. An intervention dated 9/8/21 directed staff that Resident #13 had a body alarm. b. A focus area revised on 8/30/21, documented Resident #13 was an elopement risk/wanderer related to disoriented to place, impaired safety awareness and wandering aimlessly. The goals for initiated 8/24/21 were Resident #13 would be maintained safely through the review date and she would not leave the facility unattended through the review date. Interventions dated 8/24/21 directed staff to approach Resident #13 positively in a calm, accepting manner, to provide diversional activities, and she wears a wander alert. An intervention dated 8/30/21, directed staff to distract her from wandering by offering pleasant diversions, structured activities, food, conversation, TV shows and books. c. A focus area dated 1/28/21, documented Resident #13 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal revised on 5/26/21, was Resident #13 would be able to communicate basic needs on a daily basis through the review date. Interventions dated 1/28/21, directed staff to communicate with Resident #13, her family and caregivers regarding her capabilities and needs, to use her preferred name, identify themselves at each interaction, face her when speaking and make eye contact, reduce an distractions, provide her with necessary clues, stop and return if she is agitated, and keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. An intervention dated 3/5/21, directed staff Resident #13 had a sign to help locate her room. A Progress Note dated 9/6/21 at 3:00 p.m., documented it was reported to the Nurse that another resident came up behind this resident and touched her breasts. At the time this was reported the other resident had gone back to his room and this resident (Resident #13) remained in the dining room visiting with other female residents. A Progress Note on 9/7/21 at 10:00 a.m., the Social Service Coordinator met with Resident #13 regarding the possible incident that occurred over the weekend. Resident #13 willingly went through the sexual consent. Resident #13 stated there was no one who touched her and if there was they would be on the ground. Sexual consent was filed in documents. The Clinical Census printed on 11/18/21 at 9:17 a.m., documented Resident #13 resided in the 100 hall. 5. A MDS with an ARD of 6/16/21, documented Resident #14's diagnoses included diabetes, [CONDITION(S)] disorder and Post Traumatic Stress Disorder ([CONDITION(S)]). Resident #14's BIMS score was 15 indicating intact cognition. Resident #14 required supervision of 1 with bed mobility, extensive assist of 2 for transfers, walking in room did not occur, and was independent with locomotion on and off the unit. A Care Plan for Resident #14 included the following focus and directed staff to do the following interventions: a. A focus area dated 9/10/21, documented Resident #14 had a history of physical or emotional trauma. The goal revised on 9/10/21, was she would not have a trauma triggered event. Interventions revised on 11/1/21, directed staff that Resident #14 de-escalation interventions were taking deep breaths, talking to someone about her needs and reminding herself that it was better now. The Clinical Census printed on 11/18/21 at 9:16 a.m., documented Resident #14 resided in room #209 in the 200 hall. 6. A MDS with an ARD of 8/11/21, documented Resident #16's diagnoses included cerebral infarction, anxiety disorder, and [CONDITION(S)] disorder. Resident #16's BIMS score was 15 indicating intact cognition. Resident #16 required extensive assist of 1 with bed mobility, extensive assist of 2 for transfers and locomotion on and off the unit, and walking in room did not occur. A Care Plan for Resident #16 included the following focus and directed staff to do the following interventions: a. A focus area dated 7/21/21, documented Resident #16 was at risk for impaired communication related to visual impairment and hearing difficulty. The goal revised on 6/2/21, was she would be able to interact with peers, family and staff. Interventions revised on 7/21/20, directed staff that Resident #16 can understand simple direct communication, and to speak to her in a low, clear voice to increase her chance of hearing. The Clinical Census printed on 11/18/21 at 9:16 a.m., documented Resident #16 resided in room #208 in the 200 hall. 7. A MDS with an ARD of 10/19/21, documented Resident #17's diagnoses included cerebral infarction, diabetes and non-Alzheimer's dementia. Resident #17's BIMS score was 15 indicating intact cognition. Resident #17 required limited assist of 1 with bed mobility, transfers and walking in room. A Care Plan for Resident #17 included the following focus and directed staff to do the following interventions: a. A focus area dated 9/24/21, documented Resident #17 experienced unwanted sexual advances from Resident #1 on 9/18/21. The goal dated on 9/24/21, was she would be free of sexual advances or unwanted interaction with Resident #1. Interventions revised on 9/24/21, directed staff that Resident #17 is able to say no and state when I don't want to interact with other residents, and she had a room change and will avoid hanging out in 200 hall sunroom. A Progress Note dated 9/18/21 at 10:00 a.m., documented an incident was discussed with resident and she stated that a male resident had kissed her head. She told him he shouldn't be doing that and he told her don't worry about it. Resident #17 stated he then put his hand down her shirt. Resident #17 stated she put her hand over his and told him not to do that and he responded ok. Staff intervened. D [TRUNCATED]

Based on observations, resident, family and staff interviews and record review, the facility failed to ensure that residents had the right to be free from abuse, and exploitation for 6 of 8 residents reviewed, (Resident #2, #13, #15, #17, #19 and #22). The facility must not allow verbal, mental, physical or sexual abuse which resulted in an immediate jeopardy to residents' health and safety. The facility reported a census of 77 residents, 53 of the 77 residents were female. Findings include: 1. A Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/4/21, documented Resident #1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Brief Interview for Mental Status (BIMS) score was 7 which indicated severe cognitive impairment. Resident #1 was independent with bed mobility, transfers, and walking in room. A Care Plan for Resident #1 included the following focus areas and directed staff to do the following interventions: a. A focus area with a revision date of 8/8/21, documented Resident #1 had an emotional and physical relationship with Peer Resident #8 and was comfortable with physical affection of hugging and kissing and was comfortable with saying no or being told no and stopping if any further progression makes them uncomfortable. The goals revised on 8/4/21, documented Resident #1 would be free from physical/emotional contact with Resident #9 that would make Resident #1 uncomfortable. Resident #1 would be able to tell Resident #9 no if he was uncomfortable with physical contact. Interventions with a date initiated on 7/5/19, directed staff to conduct an additional assessment of understanding of consent if changes in mental status or behavioral difficulties are demonstrated and to monitor Resident #1's ability to accurately identify and express type of emotional and physical consensual contact ongoing. An intervention revised on 8/18//21, directed staff to provide privacy for Resident #1 and Resident #8 as needed and to direct them to Resident #8's room as to not disrupt Resident #1's roommate. b. A focus area revised on 3/4/21, documented Resident #1 enjoyed visiting with peers and Resident #1 refused to social distance during activities. His goal was documented he would engage in self-directed leisure pursuits, watching TV and reading the newspaper. An intervention dated 3/4/21, directed staff to provide education to resident regarding social distancing. An intervention dated 11/12/18, directed staff to respect Resident #1's decisions for self-directed leisure pursuits. An intervention revised on 7/18/19, directed staff to support his self-determination in activities of choice which included that he sometimes liked to walk around the facility. c. A focus area revised on 11/20/18, documented Resident #1 was at risk for decline in ADL (Activities of Daily Living) function related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal revised on 10/27/21, was for Resident #1 to participate in part of his ADLs. Interventions dated 11/20/18, directed staff to give Resident #1 verbal cues to help prompt him and that Resident #1 was independent with transfers and ambulation in the facility without the need of assistive devices. d. A focus area revised on 9/20/21 documented Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . It documented that as a reminder when he was in the community he had been a very affectionate person which included hand holding, arm pats, and kissing on the top of the head. The resident's goal was to have fewer episodes of inappropriate comments toward female staff. Interventions dated as initiated on 10/18/21 directed staff that: resident was started on [MEDICATION(S)] on 5/28/21 to help control sexual urges, resident was started on [MEDICATION(S)] on 9/16/21 to help reduce sexual urges. It directed staff that resident's [MEDICATION(S)] was increased on 9/18/21 to help with sexual urges. An intervention initiated on 9/20/21 directed staff that on 9/18/21 this resident would sit with staff at the nurses station for all meals. A resolved intervention dated 9/18/21 had directed staff that this resident had a sensor pad in his doorway to alert staff when he was out in the public area. An intervention revised on 10/18/21, directed staff the sensor pad had been removed and a doorway sensor had been added on 10/4/21. An intervention revised on 11/25/19 directed staff to assist resident to develop more appropriate methods of coping and interacting, to provide him with one on one education on appropriate vs inappropriate comments towards staff. This intervention gave an example to staff of you look nice today versus you look sexy today. This intervention directed staff to encourage him to express his feelings appropriately. An intervention dated 8/4/21, showed the resident sees Meditellie as needed to assist with his behaviors. An intervention dated 11/25/19, directed staff to remove the resident from public area when behavior is disruptive and unacceptable. An intervention dated 7/5/19, directed staff to notify PCP (primary care provider) for an infection workup if this resident displayed increasing sexual based actions towards staff. e. A focus area revised on 7/1/19, documented Resident #1 had impaired cognitive function/dementia or impaired thought processed related to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's goals revised on 8/4/21, were to remain oriented to person and town through the review date and to be able to communicate basic needs on a daily basis through review date. An intervention revised on 11/14/18, directed staff to use his preferred name, identify themselves at each interaction, face resident when speaking and make eye contact, reduce distractions, and that resident understood consistent, simple and directive sentences. Staff were to provide him with necessary cues and to stop and return if this resident was agitated. An intervention dated 11/8/18, directed staff to provide cues, re-orient and supervise as needed. f. A focus area revised on 11/13/18, documented the resident had difficulty recalling recent events related to history of [CONDITION(S)] and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions dated 11/6/18, directed staff to remind this resident what their name was when they cared for him and to validate his thoughts and feelings when he got confused or anxious. g. A focus area revised on 11/13/18 documented the resident was at risk of unsafe wandering related to history of elopement. This resident's goal was revised on 8/4/21 and was that his safety would be maintained through the review date. Interventions dated 11/6/18, directed staff that a monitoring device was placed on him that sounded alarms when he left the building and to identify patterns of wandering, if the wandering was purposeful, aimless or escapist, if he was looking for something, did he need more exercise and to intervene as appropriate. An intervention revised on 11/25/19 directed staf that he had a wanderguard. An undated list of Resident #1's current interventions was provided by the facility. The interventions were listed as follows: 7/1/19 Emotional/Physical relationship with Resident #8 was care planned and consents were obtained. 7/1/19 Emotional/physical relationship with Resident #9 was care planned and consents were obtained. 5/28/21 Resident started [MEDICATION(S)]. 9/6/21 Touched Resident #13's breast. Stop sign was placed on Resident #13's door to prevent other resident from entering room. The residents were separated. 9/16/21 Resident started on [MEDICATION(S)] 250 mg BID (twice a day). 9/18/21 Resident touched Resident #17. The behavior was not reciprocated. Resident was to stay at nurses station during waking hours. Alarm in doorway and [MEDICATION(S)] was increased to 500 mg BID. 10/4/21 A sensory pad was added to the doorway, door alarm removed. 10/17/21 Resident #1 was sitting in Resident #2's room with her in his lap. Residents were separated and 15 minute checks were initiated. Resident #1's Progress Notes documented the following: * On 2/9/21 at 1:16 p.m., Resident #1 was reported making inappropriate statements to the resident across the hall (Resident #15). Resident #15 requested room change per her preference and was moved to the 300 hall. * On 5/20/21 at 5:30 p.m., a visitor approached staff and stated Resident #1 had gone into his wife's (Resident #19) room and kissed her on her lips. The visitor stated he wanted to file a complaint. * On 5/21/21 at 3:01 a.m., the resident had been in his room resting in bed with eyes closed . He did not make any attempts to go into other residents rooms or make physical contact with other residents. * On 5/27/21 at 7:05 p.m., a clean catch UA (urinalysis) was collected and dropped off, the results were pending. * On 5/28/21 at 11:00 a.m., the Social Services staff documented she was informed Resident #19 had concerns that Resident #1 and Resident #18 had been in her room at some point in the past but not on that day. The SS staff documented she spoke to Resident #18 and told him to knock before entering anyone's room and to not go into Resident #19's room. A stop sign was placed on Resident #19's door. * On 5/28/21 at 1:42 p.m., the wife was okay to resume [MEDICATION(S)] after a long discussion with the Nurse and Social Services about resident's behavior. The doctor was in the building and was okay with resuming. * On 5/28/21 at 1:45 p.m., the UA was back from review by the doctor and was clean. No new orders were obtained. * On 6/3/21 at 3:58 p.m., the POA (Power of Attorney) was phoned in order to update on [MEDICATION(S)] . The family wanted a UA due to change in behavrior. UA was obtained and the results were negative. * On 7/19/21 at 11:08 a.m., Resident #1 had a tele psychiatric visit with PhD therapist. They discussed the recent incident he had with a CNA (Certified Nurse Aide) and that is important for him to remain sexually appropriate at all times. * On 7/20/21 at 4:44 p.m., A CNA reported to the Nurse that Resident #1 attempted to kiss her. The CNA stepped away from the resident and did not welcome his advances.The CNA was instructed to take another staff person into the room with her. * On 9/6/21 at 3:00 p.m., it was reported to the Nurse that Resident #1 had gone up behind another resident (Resident #13) and touched her breasts. When this was reported Resident #1 had already ambulated back to his room. * On 9/7/21 at 10:35 a.m., the Social Service Coordinator met with Resident #1 about the incident that had occurred over the weekend. The Social Service Coordinator did the sexual consent willing and stated he did not recall touching a female's breast. * On 9/10/21 at 4:04 a.m., monitoring for sexual behaviors and there were no behaviors that shift. Resident was about the facility per his usual without incidents. * On 9/16/21 at 3:47 p.m., new order for [MEDICATION(S)] 250 mg BID mood stabilizer. * On 9/18/21 at 9:59 a.m., a female resident (Resident #17)was sitting in lounge when Resident #1 walked up to her and then began talking to her. He then went to the front of her wheelchair and then put his hand down her shirt and touched her breast. Resident immediately removed from the lounge and taken to the nurses station. * On 9/18/21 at 10:09 a.m., Doctor notified of incident. Obtained an order to increase the [MEDICATION(S)] to 500 mg BID. The Nurse discussed with Administrator and a 5 minute meeting out to staff for resident to stay at nurses station while awake and alarm in doorway at night time. Spouse was called and notified of new orders, incident and alarm. * On 9/19/21 at 3:12 a.m., Resident #1 remained on increased [MEDICATION(S)]. Resident had no memory of incident with female resident. He was able to leave his room undetected due to being able to step over alarm pad in doorway. * On 9/20/21 at 2:17 a.m., Resident stepped on pad in doorway triggering the alarm at that time. The writer noted resident standing by his door only wearing underwear. When resident was approached it was noted he had the alarm in his hand attempting to turn it off. Writer requested the alarm, resident handed it over and the writer reset the alarm. * On 9/20/21 at 9:31 a.m., Resident monitored for new order to increase [MEDICATION(S)]. Resident to be at nurses station when awake and kept away from female residents, alarm on in doorway at night. No behaviors at that time. Resident was eating at nurses station. * On 9/20/21 at 11:27 a.m., the Social Service Coordinator met with Resident #1 and asked about him touching another woman. Resident #1 stated he had only touched his wife. Resident #1 was asked if he ever touched a woman there (at the facility) on her breast and he stated no. * On 10/3/21 at 3:55 p.m., the Nurse notified the Nurse Manager regarding alarm in the resident's doorway. The Nurse witnessed the resident sort of [NAME] over alarm without setting it off. It was also reported to the Nurse that Resident #2 was seen putting her walker over the mat and alarm and trying to step over it. Resident #2 made it into Resident #1's room before she was redirected. This is a fall hazard and intervention needs to be reevaluated as the intervention is ineffective for monitoring Resident #1's whereabouts as Resident #1 can easily navigate around it without setting it off. * On 10/5/21 at 5:35 a.m., Resident #1 continues to circumvent alarm at his doorway. Resident has been up to nurses station twice this shift and alarm did not sound. Alarm was on when checked. * On 10/17/21 at 2:15 p.m., a CNA opened door to resident's (Resident #2) door to pass ice and Resident #1 was sitting in recliner with Resident #2 on his lap. Resident #1 had his hand up Resident #2's shirt. CNA told Resident #1 he was not supposed to be in there and told Resident #2 to get off of his lap. Resident #2 moved to her bed. Resident #1 said he would not leave. CNA told the Nurse. The Nurse stated she was walking down the hall and CNA explained situation to her. Nurse entered the room and saw Resident #1 sitting in Resident #2's recliner and Resident #2 sitting on her bed. Nurse had Resident #1 get up and go back into his room and then notified the Nurse Manager. The Nurse Manager had Nurse bring Resident #1 up to nurses station to keep the residents apart and then notified the Administrator and their Nurse Consultant. 15 minute checks were initiated. Administrator reporting incident and Doctor was notified. Resident' #1's wife was called without answer. Spouse returned call and was notified at 7:30 a.m. on 10/18. * On 10/24/21 at 11:51 a.m., Resident #1 continues on 15 minute checks due to history of entering other residents' rooms, attempts to touch a woman inappropriately. Resident has had no behaviors of this sort in the last 3 days. Resident pleasant and cooperative. Ambulates with a front wheeled walker from his room to the lobby area. He has made no attempts of going any other places that these 2 areas. Continues to sit near nurse's station for meals. Resident denies any concerns with this. Affect continues flat. Speaks when spoken to. Denies any pain or any needs at that time. * On 11/7/21 at 9:02 a.m., Resident continues on one to one supervision and 15 minute checks. Resident noted to be more touchy and trying to get close to female staff. One to one CNA came to this nurse to report this. Resident was reminded to stay away from female residents. A note for Incident # 2264 dated 10/17/21 at 2:15 p.m., documented Resident #1 was put on 15 minute checks. The following 15 Minute Checks sheets were provided by the facility: * 10/17/21 4 p.m. to 10/18/21 at 9:15 a.m.: showed 15 minute checks were initialed as done. * 10/18(21) and 10/19(21)(overnight): showed initialed checks starting at 3:15 p.m. to 3:45 p.m. and at 11:50 p.m. on 10/18/21. It then showed initialed checks from 12:05 a.m. to 3:45 a.m * 10/20/21 9:30 a.m. to 3:45 p.m., all spots initialed. * 10/20/21 from 4:00 p.m. to 10/21/21 9:15 a.m. all spots initialed. * 10/21/21 from 9:30 a.m. to 3:45 p.m. all spots initialed. * 10/21/21 from 4:00 p.m. to 12:00 a.m. on 10/22/21. * 10/22/21 from 12:15 a.m. to 11:30 a.m. showed checks were initialed. Then from 2 p.m. to 8:00 p.m. showed checks were initialed. On this sheet it shows checks were resumed at 8:30 p.m. to 11:45 p.m., however the date written next to the 8:30 p.m. slot documented 10/23 (21). On top of this page the date 10/23/21 is written however by the 12:15 a.m. slot 10/22(21) is written. * 10/23/21 from 12:15 a.m. to 6:00 a.m., from 2:00 p.m. to 5:30 p.m. and from 6:00 p.m. to 11:45 p.m. showed checks were initialed. * 10/24/21 from 12:15 a.m. to 12:00 p.m. showed checks were initialed. * 10/24/21 from 12:00 p.m. to 10/25(21) 5:45 a.m. showed checks were initialed. * 10/25/21 from 6:00 a.m. to 3:30 p.m., showed checks were initialed. No further sheets were provided to show checks were done during the missing times. A Nursing Facility Verbal Informed Sexual Consent Assessment Tool dated 3/16 and dated 12/22/20 by staff who filled out the tool, gave the following scenario: Imagine you are in a private place with a person you have kissed, hugged and touched before. Now this person unzips their pants and asks you to put your hand inside. What do you think this person is asking you to do? Resident #1's documented response was: having sex. The next question was What would you do? Resident #1's documented response was: I don't know. One of 4 principles of sexual informed consent was: An awareness of the nature of sexual acts and the ability to choose to engage or abstain. Staff documented yes for Resident #1. Staff did not sign nor date on the signature line provided for them. There was no Progress Note on or around this date regarding any incident. A Nursing Facility Verbal Informed Sexual Consent Assessment Tool dated 3/16 and dated 3/15/21 by staff who filled out the tool, gave the following scenario: Imagine you are in a private place with a person you have kissed, hugged and touched before. Now this person unzips their pants and asks you to put your hand inside. What do you think this person is asking you to do? Resident #1's documented response was: touch their genitals. The next question was: What would you do? Resident #1's documented response was: touch them. Resident's BIMS score was documented at a 7 indicating severe cognitive impairment. There was no Progress Note on or around this date regarding any incident. A Nursing Facility Verbal Informed Sexual Consent Assessment Tool with development date of 3/16 was not dated by staff, gave the following question: Is there someone NOW that you can talk to about sex? If so, who is that person? Resident #1's documented response was yes, mother. To the question: Who do you think is in charge of making sexual decisions in your life?, Resident #1 answered: my wife. Resident #1 answered yes to the questions: is it okay to pay money to have sex. Staff did not sign nor date on the signature line provided for them. There was no Progress Note on or around this date regarding any incident. A Nursing Facility Verbal Informed Sexual Consent Assessment Tool dated 3/16 and dated 9/7/21 by staff who filled out the tool, gave the following question: Is there someone NOW that you can talk to about sex? If so, who is that person? Resident #1's documented response was yes, wife. To the question: Who do you think is in charge of making sexual decisions in your life?, Resident #1 answered: myself. This tool gave the following scenario: Imagine you are in a private place with a person you have kissed, hugged and touched before. Now this person unzips their pants and asks you to put your hand inside. What do you think this person is asking you to do? Resident #1's documented response was: to have sex. The next question was: What would you do? Resident #1's documented response was: wouldn't do anything. The 4 principles of sexual consent questions were left blank and staff did not sign or date on the provided signature line. There was a documented incident on 9/6/21 in this resident's Progress Notes. The Clinical Census printed on 11/18/21 at 9:11 a.m., documented Resident #1 was admitted on [DATE] into room [ROOM NUMBER] and stayed in that room until he was moved into room [ROOM NUMBER] on 10/21/21 and moved again to room [ROOM NUMBER] on 10/28/21. 2. A MDS with an ARD of 7/28/21, documented Resident #2's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's BIMS score was 9 which indicated moderate cognitive impairment. Resident #2 was independent with transfers, and walking in room and required supervision for bed mobility. A Care Plan for Resident #2 included the following focuses and directed staff to do the following interventions: a. A focus area with a revision date of 2/13/19 , documented Resident #2 had questionable recall related to dementia, depression, potential medication side effects. The goals revised on 2/10/21, documented Resident #2 would remain oriented to self/family during the review period. Interventions with a date initiated on 10/17/21, directed staff that Resident #2 has allowed Resident #1 to fondle her, her family is aware and Resident #2 often seeks out Resident #1 for sexual attention. Staff are to redirect her as needed. Interventions dated 8/12/17, directed staff to provide Resident #2 with diversional activities as allowed, to re-orient/re-direct her as she would allow and to validate her thoughts/feelings when she exhibited frustration related to impairment. b. A focus area revised on 9/26/21, documented Resident #2 used safety devices and that she had a wander guard. The goal for Resident #2 dated 9/26/21, was resident would remain safe in her environment. An intervention dated 9/26/21, directed staff that Resident #2 had a wander guard. c. A focus area revised on 11/25/19, documented Resident #2 displayed socially disruptive behavior and would on occasion take items that belong to her roommate. Resident #2's goal revised on 2/10/21, was Resident #2 would decrease her episodes of disruptive behaviors by 50%. Interventions dated 11/26/19, directed staff to visit with her and provide diversional activities, to monitor and document her behavior, and to talk with her in a calm voice when her behavior is disruptive. d. A focus area revised on 8/4/21, documented Resident #2 exhibited signs of disorganized thinking and irrelevant conversation. The goal for Resident #2 dated 8/4/21, was Resident #2's symptoms of [CONDITION(S)] would resolve without [MEDICATION(S)] effects. An intervention dated 8/4/21, directed staff to report any changes in her level of consciousness to the doctor. A Progress Note dated 10/17/21 at 2:15 p.m., documented a CNA opened Resident #2's door to her room to pass ice and Resident #1 was sitting in Resident #2's recliner with Resident #2 on his lap. Resident #1's hand was up Resident #2's shirt. CNA reported she told Resident #1 that he was not supposed to be in there and told Resident #2 to she needed to get out of his lap. Resident #2 moved to the bed. The CNA told Resident #1 to leave and Resident #1 said he would not leave. The CNA then notified the nurse. The Nurse stated she was walking down the hall and the CNA explained the situation to her. The Nurse stated she entered the room and saw Resident #1 sitting in Resident #2's recliner with Resident #2 walking to her bed. Nurse stated she had Resident #1 get up and go back to his room. The Nurse then went to the nurse's station and notified the Nurse Manager. The nurse brought Resident #1 to the nurse's station to keep the resident's apart. The Nurse Manager then notified the Administrator, and the Nurse Consultant. New BIMS assessment was completed with a BIMS of 5 (severe cognitive impairment). Fifteen minute checks were initiated. Administrator was reporting incident and the doctor was notified. Resident #2's son was called and notified of the incident. A note for Incident # 2264 dated 10/17/21 at 2:15 p.m., documented the resident was put on 15 minute checks for 24 hours. The following 15 Minute Checks sheets were provided by the facility: * 10/17/21 4 p.m. to 10/18/21 at 9:15 a.m.: showed 15 minute checks were initialed as done. * 10/18/21 at 9:30 a.m. to 3:45 p.m., showed 15 minute checks were initialed as done. No further sheets were provided. A Nursing Facility Verbal Informed Sexual Consent Assessment Tool dated 3/16 and dated 7/15/21 by staff who filled out the tool, gave the following question: Is there someone NOW that you can talk to about sex? If so, who is that person? Resident #2's documented response was: my son. To the question: Who do you think is in charge of making sexual decisions in your life?, Resident #2 answered: it would be me if I was healthy and young . This tool gave the following scenario: Imagine you are in a private place with a person you have kissed, hugged and touched before. Now this person unzips their pants and asks you to put your hand inside. What do you think this person is asking you to do? Resident #2's documented response was: nothing because I don't have a husband. The next question was: What would you do? Resident #2's documented response was: kill them if I didn't want it. Resident #2's documented response to the following 2 questions was: cut if off- 1. When a man and a woman have sexual intercourse, the woman can become pregnant. What can you do to prevent pregnancy? 2. Sometimes two people have sexual behaviors, such as oral, anal and vaginal sex and if one person has an infection the other person can get it. What can a couple do to prevent an infection? The 4 principles of sexual consent questions were left blank and staff did not sign or date on the provided signature line. There was no documented incident on or around this date in Resident #2's Progress Notes. The Clinical Census printed on 11/18/21 at 9:13 a.m., documented Resident #2 moved from room [ROOM NUMBER] in the 400 hall to room [ROOM NUMBER] in the 200 hall on 11/16/18. 3. A MDS with an ARD of 9/29/21, documented Resident #15's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #15's BIMS score was 15 indicating intact cognition. Resident #15 was independent with bed mobility, transfers and walking in room. A Care Plan for Resident #15 included the following focus area and directed staff to do the following interventions: a. A focus area dated 11/23/20, documented Resident #15 used safety devices. The goal for Resident #15 revised 8/16/21, was Resident #15 would remain safe in her environment. Interventions dated 11/23/20, directed staff that Resident #15 had an electric high low bed and used an assist bar. An intervention dated 7/14/21 directed staff that Resident #15 used a wheeled walker for long distance. A Progress Note dated 2/9/21 at 10:43 a.m., documented it was reported to the nurse last night, that Resident #1 made inappropriate comments to Resident #15. Resident #15 stated Resident #1 walked into the doorway of Resident #15's room and asked if she (Resident #15) wanted his (Resident #1's) penis. Resident #15 replied no to which Resident #15 replied oh, I thought you did. They talked for a little while and then Resident #1 went back to his room. When the Social Service staff talked with Resident #15, Resident #15 stated Resident #1 did not make her feel unsafe and she was not offended by his comments but she would like to move rooms just so she isn't directly across the hall from him. We are moving Resident #15 immediately (to a different hall). A Progress Note dated 10/26/21 at 3:33 p.m., documented Social Services met with Resident #15 regarding a past incident that had occurred. Staff asked if there was ever a time she felt uncomfortable with another resident. Resident #15 stated she was in her other room and Resident #1 walked into her room while she was watching TV and asked her if she wanted it. Resident #15 pointed at her private area. Staff asked what she meant by this and she shared his penis/dick. Resident #15 stated no and that Resident #1 stood there and then left. Staff asked Resident #15 if his clothes were on and Resident #15 stated yes. She stated she was (wasn't) sure if his privates were out or not. Staff asked if she felt safe and Resident #15 stated she did. Resident #15 stated she would respond better. She stated she was shocked but now she is aware and won't let that happen. She stated she goes to activities where he is and is able to do so without being scared. She stated she always knows where he is and never sits by him. She stated she would talk to Social Services if she had any concerns. She stated she felt bad it took her awhile to tell but she was encouraged to tell from her daughters and she is glad she did. Staff thanked resident for meeting. The Clinical Census printed on 11/18/21 at 9:14 a.m., documented Resident #15 moved from room [ROOM NUMBER] in the 200 hall to a room in the 300 hall on 2/9/21. 4. A MDS with an ARD 1/25/21, documented Resident #13's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #13's BIMS score was 13 which indicated intact cognition. Resident #13 required limited assist of 1 with bed mobility, transfers and walking in room. A Care Plan for Resident #13 included the following focuses and directed staff to do the following interventions: a. A focus area dated 1/28/21, documented Resident #13 used safety devices. The goal revised on 5/26/21, for Resident #13 was she would remain safe in her environment. Interventions dated 1/28/21, directed staff that Resident #13 had a specialty call light and had an electric high low bed. An intervention dated 9/8/21 directed staff Resident #13 had a body alarm. b. A focus area revised on 8/30/21, documented Resident #13 was an elopement risk/wanderer related to disoriented to place, impaired safety awareness and wandering aimlessly. The goals initiated 8/24/21 were Resident #13 would be maintained safely through the review date and she would not leave the facility unattended through the review date. Interventions dated 8/24/21 directed staff to approach Resident #13 positively in a calm, accepting manner, to provide diversional activities, and she wears a wander alert. An intervention dated 8/30/21, directed staff to distract her from wandering by offering pleasant diversions, structured activities, food, conversation, TV shows and books. c. A focus area dated 1/28/21, documented Resident #13 had impaired cognitive function/dementia or impaired thought process related to dementia. The goal revised on 5/26/21, was Resident #13 would be able to communicate basic needs on a daily basis through the review date. Interventions dated 1/28/21, directed staff to communicate with Resident #13, her family and caregivers regarding her capabilities and needs, to use her preferred name, identify themselves at each interaction, face her when speaking and make eye contact, reduce an distractions, provide her with necessary clues, stop and return if she is agitated, and keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. An intervention dated 3/5/21, directed staff that Resident #13 had a sign to help locate her room. A Progress Note dated 9/6/21 at 3:00 p.m., documented it was reported to the Nurse that another resident came up behind this resident and touched her breasts. At the time this was reported the other resident had gone back to his room and this resident (Resident #13) remained in the dining room visiting with other female residents. A Progress Note on 9/7/21 a [TRUNCATED]

Based on clinical record review, observations and interviews, the facility failed to follow interventions to prevent a fall for 1 of 1 sampled (Resident #31) which resulted in a [MEDICAL CONDITION]. The facility reported a census of 67. Findings include: According to the Minimum Data Set (MDS) assessment dated [DATE] Resident #31 had [DIAGNOSES REDACTED]. Resident #31 had severe cognitive impairments. The MDS assessment dated [DATE] documented Resident #31 required extensive assistance of one staff for bed mobility, transfer, dressing, toileting and personal hygiene. Resident #31 had unsteady balance but able to stabilize without staff assistance. The Care Plan revealed Resident #31 at risk for falls related to fall prior to admit with minor injury, incontinence, dementia, weakness and possible medication side effects. Resident #31 had a falls on 10/25/2018, 11/4/2018, 11/30/2018, 12/10/2018, 2/27/2019, 3/5/2019 and 3/14/2019. The Care Plan directed staff to limit background noise, call light reminder sign in room, family education, grip strips by bed, frequently used items in reach, sign on walker to remind to use, monitor activities in room and do not put footrest up on recliner. The Progress Notes dated 6/8/19 at 4:00 p.m. revealed the staff found Resident #31 on the floor on her right side with her head on the bed frame. Staff B (Agency Aide) reported a visitor notified her of Resident #31 on the floor. Resident #31 denied any discomfort and the staff assisted her off the floor. The staff notified the Nurse Practitioner of the fall and no new orders received. At 4:45 p.m., Resident #31 complained of pain in the right hip and unable to bear weight on the right leg. The staff notified the Nurse Practitioner who ordered to transfer Resident #31 to the hospital for evaluation. Review of the #1025 Un-witnessed form dated 6/8/19 at 9:15 p.m., revealed the nurse aide reported that she had just taken the Resident #31to the bathroom and assisted her back to recliner chair and elevated her lower extremities. Review of Fall Investigation for CNA's sheet dated 6/8/19 revealed Staff B (Agency Aide) notified by a visitor that Resident #31 on the floor. Factors that contributed to the fall included feet tangled in the footrest of the recliner. Staff observed Resident #31 5 minutes earlier when they assisted her to the toilet and then back to the recliner. The undated Details of Reporting Event sheet revealed Resident #31 returned to the recliner after using the toilet and the staff elevated her feet in the recliner. The sheet revealed the agency staff failed to follow the plan of care as the root cause for the fall. Observation on 6/11/19 at 12:00 p.m., revealed a sign on Resident #31's wall that read Please Do not Put my feet up When in recliner and had a picture of a recliner. The Radiology - Final report dated 6/8/19 at 5:30 p.m. revealed Resident #31 sustained a intertrochanteric [MEDICAL CONDITION] proximal femur and nondisplaced fractures of the left superior and inferior pubic rami. During an interview on 6/11/19 at 2:10 p.m., Staff B (Agency Nurse Aide) reported she worked at the facility part time the last couple of months. Staff B walked by Resident #31 room and saw her up. Staff B assisted Resident #31 to the bathroom and then to the recliner chair. Staff B reported she put Resident #31's feet up in the recliner chair. Staff B reported she did this out of habit. Staff B reported this was the first time she put the footrest up because Resident #31 was usually in bed. Staff B reported at the end of the shift she found out that the care plans were located on the IPod. Staff B stated that she was not aware of this. During an interview on 6/11/19 at 3:31 p.m., Staff C (Nurse Aide) reported she never saw Resident #31 in the recliner with the footrest up. Staff C reported the staff carry an IPod that directed them on the resident care needs. Staff C did not know if the agency staff carried an IPod. During an interview on 6/11/19 at 3:53 p.m., Staff [NAME] (Agency Aide) reported working at the facility three times a week since February. Staff [NAME] reported knowing not to put Resident #31's footrest up. Staff [NAME] reported Resident #31 had a sign above the recliner to remind the staff not to put the footrest up. Staff F reported he/she carried an IPod and had an IPod and used it to document cares. Staff [NAME] reported the IPod had each residents Kardex that directed the staff how to care for the residents. During an interview on 6/11/19 at 4:45 p.m., Staff I (Agency Aide) reported working at the facility for 3 weeks. Staff I reported she was issued an IPod her first day. Staff I reported the IPod directs the staff on the residents care needs. During an interview on 6/12/19 at 5:50 a.m., Staff J (Agency Licensed Practical Nurse) reported working at the facility for 3 months. Staff J reported the aides use the IPod Kardex for directions on how to care for the residents. During an interview on 6/12/19 at 7:10 a.m., Staff K (Registered Nurse) reported Resident #31 had a sign in her room to remind the staff not to put the footrest up. Staff K reported the aides carry an IPod and that is how they know how to take care of the residents. Staff K reported the aides also document on the IPod. During an interview on 6/12/19 at 8:40 a.m., the Director of Nurses reported an expectation of staff to use the Kardex on the IPod to know how to care for the residents. The Director of Nurses reported she enters new interventions in capital letters to get the staff's attention. The Director of Nurses reported the agency staff carry an IPod and received proper orientation.

Based on observation, record review, policy review and staff interview, the facility failed to ensure each resident received adequate supervision to protect against hazards in the environment for one (1) of 3 (three) residents reviewed. Resident #1 eloped from the facility without staff knowledge. A nurse aide turned off the alarm without fully investigating what caused the alarm to activate. Resident #1 was discovered in the driveway by the Director of Nursing as she arrived to work. The findings constitute an immediate jeopardy to residents health and safety. The facility identified a census of sixty two (62) residents, with two additional residents at risk for elopement (Residents #5 & Resident #6). Findings include: The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #1 had a moderately impaired cognition as evidenced by a Brief Interview for Mental Status (BIMS) score of 10 (the BIMS scale for cognitive impairment states a score of 0-7 indicates severe impairment, 8-12 indicates moderate impairment, and 13-15 indicates the resident is not cognitively impaired). The MDS revealed Resident #1 independent with a wheeled walker (WW) for ambulation and required staff assistance for toileting and hygiene cares. The MDS behavior assessment revealed the resident had episodes of disorganized thinking and hallucinations. The resident did not have wandering behaviors noted during the seven day observation period. The resident had no balance issues and some functional range of motion impairments were noted on both upper and lower extremities. The resident's [DIAGNOSES REDACTED]. The MDS revealed the resident received anti-psychotic and anti-depression medications. The MDS identified Resident #1 had experienced two falls (no injury noted) during that quarter. The plan of care for Resident #1, revised 6/30/16, identified the resident had questionable recall due to his/her [DIAGNOSES REDACTED]. The care plan revealed the resident had been ambulatory for bed mobility, transfers, and ambulation with a wheeled walker. On 7/15/16 the care plan noted the resident had experiencing multiple medication changes and staff was instructed to assist the resident with ambulation. Review of an Elopement Risk Assessment for Resident #1 dated 3/30/16 revealed the resident had a score of 1 (low risk) and on 6/21/16 the score was 2. A score of 10 or above indicated high risk of for elopement. Review of Nurse's Notes revealed the following entries regarding the resident's behaviors and interventions implemented: On 7/2/16 at 5:30 p.m. Resident #1 had been visibly upset in the dining room with all staff and the POA (Power of Attorney). On 7/5/16 at 4:00 p.m., the facility received orders to discontinue Celexa (anti-depressant medication), to increase Remeron (anti-psychotic medication), and initiate Nuplazid (a new anti- psychotic medication). On 7/7/16 at 10:45 a.m., the resident had been observed wandering and told staff he/she is aware that he/she is confused. On 7/14/15 at 10:30 p.m., Resident #1 had been found on the ground on his/her hands and knees. The resident told staff I'm disoriented . On 7/15/16 at 9:00 AM- the resident was reoriented multiple times. At 12:40 p.m., the resident displayed increase confusion and visual disturbances throughout the morning. At 3:00 p.m., the facility received orders to decrease the resident's Remeron dosage. On 7/16/16 at 12:30 p.m., the resident stated I'm confused, but I don't know why. At 3:30 p.m., the resident remained mildly confused. On 7/17/16 at 9:00 a.m., the resident appeared confused at times with multiple attempts to walk out the door. A Wanderguard device placed on the resident's wheeled walker. On 7/18/16 at 8:00 a.m. the resident had increased confusion and had been reoriented and redirected several times this morning. On 7/19/16 at 3:30 a.m., Resident #1 displayed some confusion this shift. Review of an Incident/Accident/Unusual Occurrences Form dated 7/19/16 noted Resident #1 had been found outside of the building at 5:25 a.m. on 7/19/16, ambulating without his/her wheeled-walker. The resident had been escorted back into the facility and assessed for injuries. The resident's vital signs were within normal limits. Review of an Internal Quality Assurance Investigation Form dated 7/19/16 revealed the resident was assist of one and Staff A, Certified Nurse's Aide (CNA) was responsible for the resident's care at the time of elopement. A possible contributing factor was the recent medication changes. During an interview with Staff A, CNA, on 8/24/16 at 6:00 a.m., she stated the night Resident #1 eloped had been a very busy shift because there were only two CNAs and one nurse caring for approximately 60 residents. She stated she was responsible for providing cares for 31-32 residents including Resident #1. At 5:00 a.m. she was on the 300 hall and assisted a resident in their bedroom. She heard Resident #1 snoring in his/her room (across the hall). She left the 300 hall when she was asked to help the other CNA and stated she returned to the 300 hall at 5:10 a.m. At approximately 5:15 a.m. she heard the door alarm sound and she went to the front door of the facility and did not see anyone. As she returned to the 300 hall she saw Staff B, CNA (day shift employee). Staff A saw the green light above the exit door at the end of the 300 hall when she returned to the 300 hall. She stated the green light signified the door had been opened. She stated she thought kitchen staff had come in the door so she went down to the door and punched in the code to silence the alarm. She then returned to her CNA duties in another resident's room. She was unaware the resident had left the building until the Director of Nursing (DON) came into the building with the resident shortly afterwards. The CNA stated she was aware of the protocol when a door alarm sounded. She stated she should have contacted the other staff present, checked the outside of the building, and completed a head count of residents. She stated at the time she thought kitchen staff had opened the door and caused the alarm to sound. She stated Resident #1 had been dressed in shorts, a tee-shirt, and slipper socks at the time. She stated Resident #1 had left the building without the wheeled-walker. If the resident had taken his/her wheeled-walker through the door, the Wander-guard alarm would have sounded as well. Staff A reported she took full responsibility for her failure to follow the facility policy to determine the reason for the door alarm and account for residents. During an interview with Staff B, CNA, on 8/24/16 at 5:30 a.m. she reported walking into the break room at about 5:25 AM (on 7/19/16) to clock in for day shift when she heard the door alarm sounding. She checked the dining room door and the front door the alarm was turned off, so she went back to the break room to clock in for the day. She stated she had not observed Resident #1 with exit seeking behaviors prior to this however, he/she did wander the building halls a lot. During an interview with Staff C, Licensed Practical Nurse (LPN), on 8/24/16 at 5:40 AM she stated the night shift on 7/19/16 was a normal shift with no unusual occurrences. Shortly before 5:00 a.m. she completed an early morning treatment for [REDACTED].#1 lying on his/her bed at that time. She then started medication pass and went into a resident room at the end of 400 hall and did not hear the alarm sounding. She stated staff are educated on the policy and procedure for the possible elopement of a resident at time of hire and during in-services. She stated if a door alarm sounded staff was to go to the door and push on the door to see if it opens (door is an egress door- when pushed the alarms sounds but the door will not open for 15 seconds). If staff cannot account for why the alarm sounded they are to go outside and check outside perimeter (of the building) and do a head count of all residents. If a resident is missing staff is to thoroughly check all closets and bathrooms in the building, notify the police, and continue searching outside. She stated she had not seen Resident #1 display exit seeking behaviors in the past. During an interview with Staff D, CNA, on 8/24/16 at 5:50 a.m., she stated she arrived in the building for day shift at 4:45-5:00 a.m She was asked to clock in early to assist a resident on the 100 hall. Staff D heard something while assisting the other resident and thought it could have been a generator. Staff D did not investigate the sound any further. She stated normal policy when a door alarm sounds is for staff to check the outside of the building and to do a head count of the residents. During an interview with Staff F, Dietary Aide, on 8/23/16 at 2:00 p.m. she reported she arrived to the building around 5:25 a.m., on the morning of 7/19/16. She stated it was 5-10 minutes later when she saw the DON come into the building with Resident #1. Prior to this, Staff F had seen Resident #1 in his/her room sitting in the recliner when she first arrived. She did not hear a door alarm sounding. During an interview with Staff E, LPN, on 8/24/16 at 3:05 PM she stated she did not work the night Resident #1 eloped. Resident #1 had a wanderguard but she never saw him/her try to exit the facility. She stated the resident always used the WW (wheeled-walker) when ambulating and this is why staff placed the Wanderguard device on the WW instead of the resident's wrist or ankle. She confirmed the policy for possible elopement was for the nurse to stand by the door that is alarming, send staff outside to check the perimeter of the building and to assign staff to count the residents. The nurse is to stay by the door until all residents are accounted for and the All clear is given. She stated door alarms can only be turned off by punching the code into the number pad by the door. During an interview and tour of the outside grounds with the Director of Nursing (DON) on 8/23/16 at 12:00 PM she stated the doors at the end of the each of the four halls are egress doors. The doors are alarmed with a door alarm which sounds when the door handle is pushed open and then will unlock and open the door 15 seconds later. The doors also have Wanderguard alarms and a buzzer alarm which sounds for 1-2 seconds after a staff member enters the code into the pad to enter/exit the door. The door alarm (where the code is not entered and the door is opened after 15 seconds) can only be silenced when the code is pushed while the alarm sounds. She stated she was coming to work on 7/19/16 when she saw Resident #1 outside the building in the driveway by the exit door of the 400 hall. She reported this occurred at 5:28 a.m. She stated the alarm record revealed the alarm for the door at the end of the 300 hall went off at 5:17 a.m. She stated the resident had been easily directed back into the building and had been assessed thoroughly. The physician and the resident's spouse were notified. She initiated an investigation that revealed Staff A had not followed facility policy when the CNA heard the door alarm sounding. She stated she would expect all staff members who hear the door alarm to investigate why the alarm went off and to follow the elopement protocol if the cause could not be determined. During the tour of the outside of the building (with the DON), the exit door at the end of the 300 hall opened onto a small fenced in patio with one exit gate. A locked laundry building was located across the patio. The fence was approximately 6 foot tall and the gate had a latch on it. The DON stated fire marshal regulations prohibited the facility from locking the gate. Residents were not allowed on the patio without a staff member present. The distance from the end of the 300 hall door to the driveway where the resident was found was approximately a short one-half block distance. The DON stated multiple interventions have been put into place since the resident's elopement. Staff A, CNA, was re-educated on 7/19/16, and suspended for three days. All staff was re-educated on 7/19/16 and missing resident drills were performed on each shift on 7/19/16, 7/20 and 7/21/16 to ensure staff were following the policy. The Wanderguard device was moved from the resident's wheeled-walker to his/her wrist. Staff implemented 15 minute checks on Resident #1 on 7/19/16 and these continue currently. The resident ' s Nuprazid medication was discontinued and the resident's confusion had improved significantly. A second latch (foot latch) had been added to the gate on the patio at the end of hall 300 exit door. The facility reported two additional residents (Residents #5 and #6) were at risk for elopement and used a Wanderguard device. On 7/17/16, the facility abated the Immediate Jeopardy when they re-educated all staff on the Elopement Prevention Policy. The Policy (January 2015 edition) revealed the purpose of the policy was to maintain resident safety and prevention of injury and provide guidelines for staff to follow. The policy directed staff to respond promptly to all door alarm(s) activation and if the immediate cause of activation was not determined, all residents must be accounted for at this time. The policy indicated elopement drills were performed and are completed to monitor that staff are initiating the search and implementing the policy. The QA (quality assurance) team will continue to monitor staff ' s response to door alarms/the policy via drills. The door alarms are checked daily to ensure they are working properly.

The following deficiency relates to incident -I Based on record review and staff interviews, the facility failed to provide adequate supervision and implement care plan interventions identified to prevent accidents for 1 of 4 residents reviewed (Resident #9). Record review identified Resident #9 used a walker for ambulation. Staff interviews and record review identified Resident #9 fell and fractured his/her left hip when staff failed to follow the resident's care plan interventions. The facility reported a census of 63 residents. Findings include: According to the Minimum Data Set (MDS) assessment with assessment reference date of 1/2/14, Resident #9's [DIAGNOSES REDACTED]. Resident #9 required the assistance of one staff when transferring from one surface to another, when ambulating, and to use the toilet. The resident had an unsteady balance during transitions and walking and required staff assistance to stabilize. Resident #9 used a wheelchair and walker for mobility. The Care Plan dated 12/20/13 identified he/she had been at risk for falls due to a recent fall with hip replacement, a history of self transferring in his/her room, [DIAGNOSES REDACTED]. The plan directed staff to implement the following interventions: 1. Provide stand by assist of one staff for all ambulation. 2. Keep walker, wheelchair and frequently used items within reach of resident. 3. Use Grip socks/tennis shoes with ambulation. 4. Use a wheelchair for longer distances. 5. Monitor for changes in his/her condition that may warrant an increase in supervision/assistance (and notify the physician. 6. Grip strips to floor at bedside.(1/2/14) 7. On 1/2/14, a sign had been placed on the resident's walker to remind him/her to ask for help. The care plan for pain management identified the resident did not always verbalize complains of discomfort. The Fall Risk Evaluation form dated 12/20/13, identified Resident #9 scored 16. A score above 10 represented he/she had been assessed as a high risk for falls. The Incident/Accident/Unusual Occurrences form dated 1/9/14, identified Resident #9 had been found sitting on the floor facing the north wall next to the wheelchair, with the wheelchair brakes locked. The resident's walker had been located in the corner by the wardrobe. The resident reported he/she turned and lost his/her balance and fell . The form identified the resident's walker had not been in reach. Resident #9 had been taken to the emergency roiagnom on [DATE]. The Fall Investigation for CNAs form completed and signed by Staff A on 1/9/14, identified potential factors which may have contributed to the fall as clutter on the floor, a chair by the recliner and the walker had not been within reach. Staff A did not elaborate what he meant by clutter on the floor. The hospital admission/discharge summary dated 1/9/14 to 1/13/14, identified Resident # 9's had been previously been treated for [REDACTED]. On the day of admission, the resident apparently got up and fell injuring his/her left hip. The radiology report identified Resident #9 had sustained an acute fracture involving the left femoral neck. No other fractures were seen, and no dislocation. After treatment options were discussed with Resident #9's family, he/she had been taken to the operating room for surgery of the left hip performed without complications. A facility document (untitled) noted Resident #9 had a fall on 1/9/14. The form identified at the time of the fall, Resident #9 had been receiving speech therapy when the resident needed to use the bathroom. The aide (Staff A) was called to assist the resident to the toilet. The speech therapist reported the resident had been very impulsive and wanted to go to the bathroom since he/she had loose stools. The therapist did not have a conversation with the aide about whether or not she had completed her treatment for [REDACTED]. Interviews: In an interview on 1/23/14 at 12:30 p.m. Staff A, Certified Nurse Aide (CNA), indicated he was worked the day shift (6:00 a.m. to 2:00 p.m.) on 1/9/14 and had been assigned to work with residents on the 400 hall which included Resident #9. Around 10:45 a.m. the speech therapist summoned Staff A to Resident #9's room. Staff A reported the speech therapist reported Resident #9 needed to use the bathroom. Staff A reported he assisted Resident #9 to the bathroom as the speech therapist left the room. Afterwards, Staff A reported he assisted Resident #9 back into his/her recliner. Staff A reported he reclined the chair and placed his/her walker next to the therapist's chair which was positioned to the left and in front of the recliner. Staff A indicated the walker was within reach of Resident #9. Staff A demonstrated where he positioned the walker. The demonstration showed the walker had not been within reach of Resident #9. Staff A reported he left the room and at approximately 11:00 a.m. he walked by Resident #9's room and noticed the resident sitting in the recliner. Staff A entered another resident's room (across the hall) and within a few minutes heard a loud noise. Staff A went to Resident #9's room and found him/her lying on the floor. The resident ' s head had been against the wall. Staff A indicated the walker had been moved towards the bed. In an interview on 1/23/14 at 12:20 p.m. the Director of Nursing (DON) reported on 1/9/14 at approximately 11:00 a.m. she had been called to Resident #9's room. The DON stated she found Resident #9 on the floor by north wall next to his/her wheelchair. The wheelchair brakes were locked. The DON also noted Resident #9's walker sitting at the end of the bed between the bed and wardrobe, facing the wall. The DON reported a straight back chair had been against Resident #9's bed where a speech therapist had been using earlier. When assessed by nursing, Resident initially showed no pain but when staff assisted Resident #9 to the wheelchair, he/she shifted weight off his/her left hip and complained of pain. The resident was transported to the hospital where x-rays confirmed an acute fracture involving the left femoral neck. The DON questioned Staff A regarding how the room had been left prior to the fall. Staff A informed the DON that he had toileted Resident #9, had been aware of the care plan interventions, but believed the speech therapist was returning to the resident ' s room. The DON questioned Resident #9 who indicated he/she had been over by the bed, then turned around and lost his/her balance. The DON indicated Staff A had been given a coaching form on 1/9/14 regarding his failure to have a call light in reach for a resident on 1/8/14; and an alarm had not been in place for another resident. The DON reported Staff A also received a three day suspension for failing to follow Resident #9's care plan. In an interview on 1/27/14 at 11:40 a.m. Staff B, Registered Nurse, indicated on 1/9/14 Staff A informed her Resident #9 had fallen to the floor. Upon entering the room, Staff B noted the DON sitting next to Resident #9 on the floor. Staff B recalled there had been a straight back chair against the bed and the walker was up against the wardrobe by the window. In an interview on 1/27/14 at 1:30 p.m. Staff C, Speech Pathologist, reported she had been providing therapy with Resident #9 from 9:45 a.m. until around 10:23 a.m. Staff C had pulled a straight back chair next to the bed and 90 degrees to the left of Resident #9's recliner. At 10:20 a.m. Staff C called Staff A and informed him Resident #9 had an urgent need to use the bathroom. Staff C reported she thought Staff A had used the walker to escort the resident to the bathroom, but she had left the room. Staff C returned to the room some 10-15 minutes later and asked some follow up questions, before leaving. Staff C did not recall where the walker had been located, but noted Resident #9 had been in the recliner with his/her feet elevated and call light within reach.

The following deficiency relates to Self Report # -I Based on observation, record review, and interviews, the facility failed to implement interventions, or direct services and provide adequate supervision to prevent falls for one of four residents (Resident #1). The facility reported a census of 63 residents. Findings include: According the MDS (Minimum data set) assessment with a reference date of 11/04/12, revealed Resident #1 was admitted to the facility on [DATE]. The MDS further identified Resident #1 had [DIAGNOSES REDACTED]. Review of the Facility Admission History dated 11/1/12 indicated [DIAGNOSES REDACTED]. The MDS indicated Resident #1 required the extensive assistance of one staff member for bed mobility, transfers, ambulation, eating, dressing, toilet use and personal hygiene. The MDS documented the resident had no prior fall history. The MDS indicated the resident not steady with balance during transitions and walking, turning around, moving on and off the toilet, and surface-to-surface transfer and had functional impairment in range of motion of the upper and both lower extremity that placed the resident at risk for injury. Review of the Facility's Fall Risk Evaluation dated 10/30/12, revealed Resident #1 to have a total score of 14, a total score of 10 or above represents High Risk. Review of the Care Plan with a Problem Onset Dated 11/9/12, listed problems for Resident #1 that included hard of hearing, require assist for all cares, at risk for falls related to [DIAGNOSES REDACTED]. The Care Plan included interventions that directed staff to: a) Staff to provide extensive assist of one for resident with bed mobility, transfers, dressing, toilet use, and personal hygiene. b) Staff to provide resident with front wheeled walker in room for short distance ambulation and use of wheel chair with staff propel for long distance. (This was discontinued on 11/14/12. c) Staff to provide extra time for cares due to resident's vision and hearing problems. d) Staff to keep walker within reach of resident at all times and remind resident to ask for assist for ambulation and transfers, Review of the Facility's Internal Quality Assurance Investigation Form, Fall Investigation Form, Injury Investigation Form, and Incident Occurrence Form dated with occurrence date of 11/18/12 of Resident #1 revealed Staff A (nurse) assisted the resident to the toilet at 9:00 am on 11/18/12 and placed call light in resident's hand and left walker in the bathroom for resident. Staff A then left the resident and continued to do cares in the hallway. Staff A documents that Staff B had been on break when Staff A assisted the resident to the toilet and when Staff B returned from break Staff A reported to Staff B that the resident is on the toilet and Staff A went to another hall way. Staff A was paged at 9:30 pm when Staff B found the resident on the floor of the bathroom. Staff A documented that the resident was confused and attempted to self-transfer. Further review of the documentation revealed the staff identified the risk factors of the resident's confusion and blindness contributed to the fall. Description of event documentation revealed resident hit head, multiple skin tears and bruises to extremities and forehead, resident found with blood on face, hands, night gown, walker and floor. Review of the Nurse's Notes dated 11/18/12 at 9:30 PM, revealed Staff B reported to nurse, Staff A, that Resident #1 is on the floor in the bathroom. Upon Staff A assessment of the resident revealed blood on the floor and the resident, appeared resident tried to self-transfer self to bed and fell hitting head. Pressure applied to left side of forehead above eye, noted left eye completely swollen and unable to assess left eye due to swelling. Staff A completed assessment and called the resident's physician of resident incident and condition status. The directed staff to continue with neurological checks and vitals signs and if call if abnormal. Staff continued to monitor resident and at 11:35 PM staff documented the resident having a nose bleed to left nostril and staff notified physician. Staff documented at 11:00 PM that staff noted resident to have bloody drainage from left eye. Staff notified the physician and received orders to transfer resident to the emergency room for further evaluation and treatment. Review of the History and Physical dated 11/19/12, revealed Resident #1 attempted to get off the toilet on the evening prior to admission and fell . resident sustained [REDACTED]. Resident's left knee is also bruised and swollen. The resident alert to name only upon arrival to the emergency room , which is usual for this resident. Resident had X-rays done that showed acute left fontal bone fracture involving the walls of the frontal sinus and probably left orbital roof. Acute hemorrhage in the left medial temporal region. The resident's family was conferred with and they wanted comfort care only and resident was admitted for comfort care. Interview on 12/21/12 at 2:58 PM, Staff A, nurse, reports he/she went into Resident's #1 room to administer the resident's night time medications sometime between 8-9:00 PM. Staff A states after she gave the resident the medications the resident ask to go to the bathroom. Staff A assisted the resident to the bathroom and onto the toilet, placed call light in resident's hand and left walker in bathroom. Staff A states this is normal routine for resident and she left the room to continue doing duties of assisting other resident in their room of the hallway. Staff A states she/he never checked on the resident after assisting her to the toilet and did not see the call light come on. Staff A states that Staff B came back to the hallway after taking a break of approximately 10 minutes and Staff A reported to Staff B that the Resident #1 is on the toilet. Staff A then left the hallway to do cares on another hallway. Staff A states he/she was paged around 9:30 to the resident's room and found the resident on the floor in the bathroom with Staff B. Interview on 12/18/12 at 3:07 p.m., Staff B indicated she was confused and really don't recall much prior to Resident's #1 fall. Staff B states he/she recalls walking down the resident's hall and noted the resident light to bathroom on and when Staff B looked into the room of the resident he/she seen blood on the bathroom floor. Staff B entered the resident's room and found the resident on the bathroom floor. Staff B went and got the nurse. Staff B's report of incident indicates she/he last seen the resident prior to fall when Staff B assisted resident to bed. Staff B reports it is the resident's normal routine to be assisted to toilet and call light placed in her hand and resident would use the call light when she needed assist from staff. Interview on 12/18/12 at 4:00 PM, Staff C indicated that she/he has taken care of Resident #1 before. Staff C states that he/she never leaves the resident alone on the toilet due to her blindness and attempts to self-transfer from toilet. Staff C further indicated that the resident will pull the call light when on the toilet and then immediately will attempt to self-transfer. Staff C states she is right there and reminds the resident not to get up on her own. Staff C further states she thought all staff stayed with the resident while the resident is on the toilet. Interview on 12/18/12 at 4:40 PM, Staff D indicated that he/she would not leave Resident #1 alone on the toilet nor should any staff leave the resident alone due to the resident ' s blindness. Interview on 12/19/12 at 9:49 am, Staff E indicated that he/she works full time on Resident's #1 hall and when the resident use the toilet he/she never stays on the toilet very long at all. Interview with the DON (Director of Nursing) on 12/19/12, revealed the resident returned to the facility on [DATE] and the facility further implemented safety interventions of staff to remain with the resident while resident is on the toilet. The DON reported the resident had not attempted to self-transfer prior to fall and no staff reported that resident would make attempts to self-transfer. The facility had knowledge the resident would attempt to self-transfer and failed to implement safety intervention or plan for and direct nursing services to prevent falls.

The following deficiency relates to incident -I Based on record review and staff interviews, the facility failed to provide Resident #1 adequate supervision to prevent falls and failed to supervise the implementation of the care plan or provide revision of the care plan to meet the resident ' s needs and behaviors. The sample consisted of 4 residents and the facility identified a census of 62 residents. Resident #1 required extensive assistance with transfers and ambulation due to poor balance and at a risk for falling. The facility staff interviews determined multiple staff members had been aware the resident would remove the personal alarm and self transfer and ambulate. On 12/5/2011 at 12:00 a.m., the staff heard the resident yelling. The staff found the resident lying on the bathroom floor with the personal alarm. The alarm had not sounded to alert the staff the resident attempted to self transfer. The Nurse ' s Note of 12/5/2011 indicated the resident had a fractured left hip and required surgical repair. The resident returned to the facility on [DATE] with less than 50 percent weight bearing ability. Findings include: 1. Resident #1 had a Minimum Data Set (MDS) assessment with reference date of 11/24/11 which identified the resident had a BIMS (Brief Interview for Mental Status) score of 2. This score indicated long and short term memory deficits and severely impaired cognitive skills for daily decision making. Resident #1 required extensive assistance with transfers and locomotion due to poor balance and at risk for falls. The resident required extensive assistance with dressing, toilet use, personal hygiene and bathing. Resident #1 [DIAGNOSES REDACTED]. The Care Plan dated 8/1/11 identified a problem of poor safety awareness related to dementia. The care plan goal reflected the resident would be free of falls and the approaches directed staff to do the following: 1. Assist with transfers. 2. Physical therapy to develop strengthening. 3. Utilize a wheel chair for longer distances. 4. Transfer into straight back chair at meals. 5. Keep in common areas when awake or restless to better supervise. 6. Positioning wedge in bed to help with boundaries. (8/17/11) 7. Bed/Chair alarm at all times. (8/17/11) Discontinued (8/22/11) 8. Personal alarm at all times. (8/22/11) The Nurse ' s Note dated 12/5/2011 at 12:15 a.m. indicated the nurse responded to Resident #1 yelling. The nurse found the resident on the bathroom floor. After the nurse performed an assessment, the nurse stood the resident and the resident could not bear weight onto the left leg. The note indicated the nurse notified the physician. The Nurse ' s Note dated 12/5/2011 at 10:45 a.m. revealed the resident ' s physician saw the resident at the facility and ordered the resident be sent to the hospital for an evaluation of the left hip and left knee pain. The Nurse ' s Note dated 12/5/2011 at 1:25 p.m. indicated the nurse spoke with the physician assistant and the resident did have a left hip fracture. The Radiology Report indicated on 12/6/2011, the left hip had been repaired surgically with an internal fixation of the fracture. The Nurse ' s Note dated 12/13/2011 at 11:20 a.m. indicated the resident returned to the facility. The resident had less than 50 percent weight bearing ability. On 12/19/11 at 11:25 p.m. Staff A was interviewed and stated she worked the overnight shift (11:00 p.m. to 7:00 a.m.). Staff A stated she had just finished rounds on 200 hall at 12:00 a.m. and was standing at the nurse's station when she heard someone yelling. Staff A responded to Resident #1's room where she found Resident #1 lying on the bathroom floor. Staff A stated Resident #1 had been in bed just 15 minutes earlier with all safety interventions (personal alarm, positioning wedge and gripper socks) in place. Staff A stated the resident ' s personal alarm was attached and the alarm box was with the resident in the bathroom, but the alarm did not sound. Staff A stated Resident #1 must have carried the personal alarm box to the bathroom. On 12/20/11 at 3:40 p.m. Staff B was interviewed and stated she worked the overnight shift (11:00 p.m. to 7:00 a.m.). Staff B stated they had just completed rounds and were standing at the nurse's station when they heard yelling. Staff A responded to the room and found Resident #1 lying on the bathroom floor. Staff B and Staff C then responded to the room. Staff B stated Resident #1 had previously been in bed with all safety interventions (personal alarm, positioning wedge and gripper socks) in place. Staff B indicated Resident #1's personal alarm was intact but did not sound as it was lying next to Resident #1. Staff B stated she believed Resident #1 must have carried the personal alarm box to the bathroom. On 12/20/11 at 3:15 p.m. Staff C was interviewed and stated she worked the overnight shift (6:00 p.m. to 6:00 a.m.) on 12/4/11-12/5/2011. Staff C stated she was called to Resident #1's room by Staff A and Staff B. Resident #1 had been found on the bathroom floor. Staff C stated Resident #1's appeared to have carried the personal alarm into the bathroom and the alarm had not sounded. Staff C stated she has previously witnessed Resident #1 sitting up in bed, holding the personal alarm box, but had not attempted to stand at that time. On 12/20/11 at 12:05 a.m., Staff D stated she worked on the overnight shift (11:00 p.m. to 7:00 a.m.). Staff D stated Resident #1 is often restless at night and she had seen Resident #1 remove the personal alarm. On 12/20/11 at 12:30 a.m., Staff E was interviewed and stated she worked on the overnight shift (11:00 p.m. to 7:00 a.m.). Staff E stated she had witnessed Resident #1 remove the personal alarm from his/her clothing or carry the alarm. On 12/20/11 at 5:10 p.m. Staff F was interviewed and stated she worked on the evening shift (3:00 p.m. to 11:00 p.m.). Staff F stated she had witnessed on one occasion Resident #1 carrying the personal alarm while trying to self transfer. On 12/20/11 at 5:15 p.m. Staff G was interviewed and stated she worked on the evening shift (4:00 p.m. to 8:00 p.m.). Staff G stated when Resident #1 first received the personal alarm, he/she would frequently take it off or carry it with him/her while attempting to self transfer. On 12/20/11 at 5:30 p.m. Staff H was interviewed and stated she worked on the evening shift (2:00 p.m. to 10:00 p.m.). Staff H stated on one occasion she witnessed Resident #1 transferring self from the couch to wheelchair while carrying the personal alarm box. On 12/21/11 at 12:20 p.m. Staff I was interviewed and stated she worked on the day shift (6:00 a.m. to 2:00 p.m.). Staff I stated she had witnessed Resident #1 attempt to remove or silence his/her personal alarm while trying to self transfer and carry the personal alarm with him/her so it wouldn't sound. On 12/21/11 at 12:00 p.m. Staff J was interviewed and stated she worked on the day shift (5:00 a.m. to 2:00 p.m.). Staff J indicated Resident #1 has frequently gotten him/herself out of bed with the personal alarm box in hand. In an interview on 12/21/11 at 2:40 p.m. Staff K indicated she worked on the day shift (6:00 a.m. to 2:00 p.m.). Staff K indicated she has witnessed Resident #1 self transfer while holding his/her personal alarm. In an interview on 12/21/11 at 2:55 p.m. Staff L (Director of Nursing) indicated she reviewed all falls, read charting and coordinated with the care plan coordinator to have safety interventions re-evaluated and changed as needed. Staff L stated she had not been aware Resident #1 attempted to self transfer while carrying the personal alarm box. In an interview on 12/21/11 at 2:50 p.m. Staff M (Care Plan Coordinator) indicated she is responsible for keeping the care plans updated. Staff M indicated she received a note from Staff E that Resident #1's alarm was changed from a chair and bed alarm to a personal alarm, but was not aware as to why the change was made. Staff M stated she was never notified of Resident #1 carrying the personal alarm.