Every finding on record at Oak Hollow of Georgetown Rehabilitation Center LLC

Number of residents sampled: 1Number of residents cited: 1Based on observation, interview, record review, facility document and policy review, and review of Centers for Disease Control and Prevention (CDC) and Centers for Medicare & Medicaid Services (CMS) guidelines, the facility failed to follow enhanced barrier precautions (EBP) for 1 (Resident (R)6) of 1 resident observed during direct patient care. Specifically, Certified Nursing Assistant (CNA)7 did not don a gown while bathing R6, who had a feeding tube. Findings include: A facility policy titled, Enhanced Barrier Precautions, revised 07/31/2024, indicated, Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. The policy also indicated, Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions. The policy also indicated, 3. Implementation of Enhanced Barrier Precautions: a. Make gowns and gloves available immediately near or outside of the resident's room. Note: face protection may also be needed if performing activity with risk of splash or spray (i.e. [id est, that is], wound irrigation, tracheostomy care). b. PPE [personal protective equipment] for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. The policy also indicated, 4. High-contact resident care activities include: a Dressing b. Bathing. A CMS, Department of Health & Human Services (HHS) memorandum, QSO-24-08-NH, titled Enhanced Barrier Precautions in Nursing Homes, effective 04/01/2024, revealed, EBP recommendations now include the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of their multi-drug resistant organism status. The memorandum also indicated, Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. An undated facility sign, published by the CDC, titled, Enhanced Barrier Precautions indicated, Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. - Dressing - Bathing/Showering An admission Record revealed the facility admitted R6 on 08/08/2023. According to the admission Record, the resident had a medical history that included diagnoses of cerebral palsy and gastrostomy status (presence of a feeding tube). A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/15/2025, revealed R6 had a short- and long-term memory problem and severely impaired cognitive skills for daily decision-making per a Staff Assessment of Mental Status (SAMS). The MDS indicated the resident was dependent on staff for showering/bathing and had a feeding tube for nutrition. R6's Care Plan Report included an undated focus area that indicated the resident was at risk for infection and exposure to pathogenic agents. Interventions directed staff to practice good infection control procedures such as hand hygiene, including wearing masks and social distancing, until instructed otherwise and to follow enhanced barrier precautions related to the resident's percutaneous endoscopic gastrostomy (PEG) feeding tube. R6's Care Plan Report included an undated focus area that indicated the resident had a self-care deficit related to cerebral palsy and the presence of contractures in all limbs. The focus area indicated the resident required total assistance with all activities of daily living (ADLs). During a concurrent observation and interview on 08/25/2025 at 11:10 AM, CNA7 was observed bathing and dressing R6 while wearing a surgical mask and gloves but no gown. CNA7 stated R6 was on EBP because of their PEG feeding tube. CNA7 stated that she should have worn a gown along with gloves and a mask since she was providing direct patient care. CNA7 stated that she was sorry, she had failed, and she needed to be following EBP since R6 was at high risk of developing an infection. During an interview on 08/28/2025 at 1:15 PM, the Director of Nursing (DON) stated she expected staff to follow the EBP protocol while providing direct patient care, such as bathing, and to don appropriate PPE, which included a gown and gloves and a face shield, if there was a potential for splashing. During an interview on 08/28/2025 at 1:28 PM, the Administrator (ADM) stated she expected staff to follow all infection control protocols, including PPE protocols. The ADM confirmed CNA7 did not don the appropriate PPE while providing a bed bath to a resident who had a feeding tube.

Based on record reviews, review of personnel files, interviews, and policy review, the facility failed to ensure care and services were provided in accordance with professional standards for 1 (Resident (R)77) of 3 closed records reviewed. Specifically, the facility failed to ensure nursing staff followed a resident's code status and physician order. The nursing staff performed Cardiopulmonary Resuscitation (CPR) on R77, even though the resident had selected Do Not Resuscitate (DNR). (Cross reference F835 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.25 - Quality of Care. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F684 at a lower scope and severity of D. An extended survey was conducted in conjunction with the Recertification Survey for non-compliance at F684, constituting substandard quality of care. Findings include: Review of the facility's undated policy titled, Advanced Directives indicated, Advance directives will be respected in accordance with state law and facility policy. Review of the facility's undated policy titled, Do Not Resuscitate Order indicated, Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect. Review of R77's electronic medical record (EMR) revealed R77 was admitted to the facility on [DATE], with diagnoses including but not limited to: Parkinson's disease and chronic atrial fibrillation. Review of R77's Documents tab in the EMR titled Emergency Medical Services Do Not Resuscitate Order, revealed that the resident has a terminal condition and that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. The form was signed by R77 and the facility's Medical Director on [DATE]. Review of R77's Progress Notes in the EMR under the Progress Notes tab dated [DATE] at 1:30 AM, indicated, At 2226 [10:26 PM] Code Blue initiated. Resident observed cyanotic, weak pulse, no respirations by evidence of lack of diaphragmatic movement. CPR and EMS [Emergency Medical Services] initiated at that time. After 2 minutes Resident regained consciousness and respirations observed. Shortly thereafter EMS arrived. Review of employee files revealed Annual Employee In-Service which included a section on Advanced Directives, that indicated the information is easily accessible on paper medical records under the Advanced Directive Tab. The section also indicated, If a resident is found unresponsive (without pulse and respirations), call for help and follow CODE STATUS - located under Advanced Directives on chart. The section indicated that if a resident's code status is DNR Registered Nurse assess for s/s [signs and symptoms] of death and report to MD [Medical Doctor]. LPN6 was in-serviced on [DATE], LPN1 was in serviced on [DATE], and CNA2 was in-service on [DATE]. During an interview on [DATE] at 1:27 PM, R77's resident representative (RR) confirmed that the resident was transferred to the hospital on the evening of [DATE]. She stated that she was told by the hospital that CPR had been performed on the resident and she contacted the staff at the facility to let them know that R77's code status was DNR. During an interview with the Administrator and Director of Nursing (DON) on [DATE] at 2:28 PM, both stated that they were familiar with the situation. The Administrator confirmed that she was not aware of R77's code status until she arrived at the facility the morning of [DATE] at approximately 5:00 AM. She stated that upon her arrival, Certified Nursing Assistant (CNA)2 approached her. The Administrator was asked if it is the facility's policy for a CNA to initiate CPR. The Administrator stated that their policy states only nurses can initiate a code but added that after initiation any CPR qualified staff can assist. The DON confirmed that it is the policy of the facility that only nurses can initiate CPR. When asked what type of education is provided to the nursing staff to ensure all staff is aware, she stated, it is basic knowledge that nurses have to be the one to initiate CPR. During an interview with CNA2 on [DATE] at 2:55 PM, CNA2 stated that on the evening of [DATE], she was giving R77 a bed bath. CNA2 stated that she turned away to grab something, the resident had gone quiet and when she turned around, R77 was convulsing. CNA2 stated that she attempted to shake him and bring him back but after a few moments the resident fell unresponsive. CNA2 then stated that she ran to the hallway and called for help. She said that Licensed Practical Nurse (LPN)6 and LPN1 arrived at the resident's room. CNA2 stated that LPN6 stated she was going to get the crash cart. CNA2 stated that she felt no one was doing anything so she hopped on the bed and began CPR adding that she felt she was left to assist the resident alone. CNA2 confirmed that she was the only staff member to conduct CPR and she continued until a pulse could be found and the resident was responsive again. CNA2 was asked if she was aware of the R77's code status and she stated that she found out later from CNA3. In a subsequent interview with the DON on [DATE] at 3:51 PM, the DON provided documentation that an In-Service on the process for initiating a code and confirming a resident's code status was conducted on [DATE]. Per the documentation 14 staff members (seven nurses and seven CNAs) completed the in-service as of [DATE]. The Administrator was also present and was asked when she found out about the R77's code status. The Administrator stated that she found out later on [DATE], when R77's representative called to notify her that they had been advised by the hospital that CPR had been performed on the resident and wanted to clarify that R77's code status was DNR. The DON and Administrator were asked if they had done any other investigation or taken this concern to Quality Assurance and Performance Improvement (QAPI) and they both confirmed that they had not. During an interview via telephone on [DATE] at 6:32 PM, the Medical Director stated he was familiar with R77, who he recalled had diagnoses that included Parkinson's and atrial fibrillation. The Medical Director stated he was aware the resident was transferred to the hospital but was not aware that the resident coded or that CPR was performed. He added that he was aware of the resident having a DNR code status. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: The resident's Electronic Medical Records have been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or resident's representative, that have elected a code status, the orders were updated to reflect the signed medical intervention. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. The Administrator and DON will educate the licensed nurses and certified nursing assistants to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses and Certified Nursing Assistants by [DATE]. The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies to be completed [DATE]. They will be further instructed that a breach in a policy may result in a negative outcome, must have an investigation to include reporting to any state agency if warranted and reviewed with the monthly QAPI committee. The new licensed nurses and certified nursing assistants will be educated on the medical intervention status and location of the code status binder at each nurse's station during new hire orientation. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN, upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100% compliance is achieved. Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Director of Nursing will review their findings with the Administrator weekly for recommendations or follow up as indicated. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]

Based on record review, document review, job description review, staff interview and facility policy review, the facility Administrator failed to implement her job description to ensure the correct clinical operations related to resident's code status was followed. There is a potential for serious adverse outcomes because of the facility providing cardiopulmonary resuscitation (CPR) to a resident without confirming the code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes for 1 of 1 resident (Resident (R)77) reviewed. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.70 - Administration. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F835 at a lower scope and severity of D. Findings include: Review of the undated facility policy titled, Accidents and Incidents - Investigating and Reporting revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the Licensed Nursing Home Administrator job description dated [DATE], revealed the Administrator is responsible for the overall management of the facility. The Administrator . monitors and supports all operational, administrative, clinical, customer service . for the facility's programs and services. The Administrator . ensures the quality and appropriateness of resident/patient care meets or exceeds company and regulatory standards. Review of R77's Electronic Medical Record (EMR) revealed R77 was confirmed to have a Do Not Resuscitate (DNR) order. Review of the EMR Progress Notes tab revealed a Progress Note dated [DATE] at approximately 10:26 PM, R77 became unresponsive and received CPR by Certified Nurse Aide (CNA)2 with Licensed Practical Nurse (LPN)1 and LPN6 being aware. Neither the DON nor Administrator were aware of R77's code status until the resident's family member called to inform the facility. Review of Quality Assurance and Performance Improvement (QAPI) monthly meeting notes dated [DATE] through [DATE] revealed that Administration did not identify an adverse event which occurred on [DATE] in which R77's code status of DNR was not followed and CPR was performed by nursing staff. Administration failed to investigate this incident in order to correct the quality deficiency and ensure the incident does not recur. Administration implemented training of only 14 out of 47 nursing staff members and stated they meant to get to everyone but had not. The facility did not implement monitoring or other interventions. During an interview on [DATE] at 4:45 PM, the Administrator confirmed she was unaware of the resident's code status until she received a call from the resident's representative on [DATE]. She stated that she had not been contacted regarding the incident and only found out when she arrived around 5:00 AM on [DATE] the morning after the incident. The DON was also present during the interview and stated she was contacted the evening of the event. The DON added that she was working with the previous DON and was told to start inservice education. During an interview on [DATE] at 7:20 PM, the DON and Administrator in Training (AIT) both stated that this type of incident would normally be investigated and reviewed in QAPI and not addressing the incident was an oversight. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: Unable to correct for resident 77 as the resident is no longer at the facility. The residents Electronic Medical Records has been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents representative that have elected Do Not Resuscitate has been updated. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. To include initiating an investigation if warranted. The investigation outcome if a breach of policy and procedure has been identified will include the corrective actions, staff training and monitoring of the deficient practice. The Administrator and DON will educate the licensed nurses to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses by [DATE]. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100% compliance is achieved. The Director of Nursing or designee will review their findings with the Administrator weekly for recommendations or follow up as indicated. Any code called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]

Based on record review, document review, staff interview, and facility policy review, the facility failed to take an adverse event to Quality Assurance and Performance Improvement (QAPI) for corrective action, specifically, on [DATE], facility nursing staff administered cardiopulmonary resuscitation (CPR) to 1 of 1 resident (Resident (R)77) who had a Do Not Resuscitate (DNR) order in the electronic medical record (EMR). There is a potential for serious adverse outcomes because of the facility providing CPR to a resident without confirming code status, leading to possible injury. This also presents a risk for psychosocial harm related to end of life wishes not being honored. (Cross reference F684 and F867) On [DATE] at 8:45 PM, the facility's Administrator and Director of Nursing (DON) were informed that Immediate Jeopardy (IJ) existed related to the failure to provide sufficient administration to implement and monitor the facility system for communicating each residents' code status. The IJ began on [DATE], the date the Administrator failed to ensure the correct clinical operations related to code status. The IJ is related to 42 CFR 483.75 - Quality Assurance and Performance Improvement. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan that was accepted. The survey team validated implementation of the removal plan through observations, staff interviews, and review of resident records and facility training records and the IJ was removed on [DATE] at 5:30 PM. The facility remained out of compliance at F867 at a lower scope and severity of D. Findings include: Review of the undated facility policy titled Accidents and Incidents - Investigating and Reporting revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of the undated facility policy titled Quality Assurance and Performance Improvement (QAPI) Plan revealed, This facility shall develop, implement, and maintain an ongoing, facility-wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care quality, and resolve identified problems . objective of the QAPI plan . provide a means to identify and resolve present and potential negative outcomes related to resident care and services. Review of R77's Documents tab in the EMR titled Emergency Medical Services Do Not Resuscitate Order, revealed that the resident has a terminal condition and that no resuscitative efforts including artificial stimulation of the cardiopulmonary system by electrical, mechanical, or manual means be made in the event of cardiopulmonary arrest. The form was signed by R77 and the facility's Medical Director on [DATE]. Review of R77's Progress Notes in the EMR under the Progress Notes tab dated [DATE] at 1:30 AM, indicated, At 2226 [10:26 PM] Code Blue initiated. Resident observed cyanotic, weak pulse, no respirations by evidence of lack of diaphragmatic movement. CPR and EMS [Emergency Medical Services] initiated at that time. After 2 minutes Resident regained consciousness and respirations observed. Shortly thereafter EMS arrived. Review of QAPI records dated [DATE] through [DATE], revealed the Quality Assessment and Assurance (QAA) committee was not aware of this high-risk, systemic issue, and was not monitoring facility practices related to accurate and consistent communication of residents' code status is being followed. During an interview on [DATE] at 7:20 PM, the Administrator stated the facility meets for QAPI monthly in which each department identifies issues and brings a Performance Improvement Project (PIP) to QAPI for compliance evaluation or additional recommendations. The Administrator stated QAPI reviews reportable incidents. The Administrator stated QAPI uses quality measures, survey results, and accidents/incidents. The Administrator stated the incident with R77 was not brought to the attention of QAPI. The DON and Administrator in Training (AIT) both stated that this type of incident would normally be investigated and reviewed in QAPI and not addressing the incident was an oversight. On [DATE] at 3:45 PM, the facility provided an IJ Removal Plan which included the following: Unable to correct for resident 77 as the resident is no longer at the facility. The residents Electronic Medical Records has been audited by the RN Nursing Home Administrator and Director of Nursing-RN to ensure all residents or residents representative that have elected Do Not Resuscitate has been updated. The necessary documentation has also been copied and placed in a 3-ring binder labeled Code Status Binder for ease of access for nurses to identify residents that are FULL CODE or DO NOT RESUSCITATE on [DATE] and placed at each nurse's station. The Administrator and DON will educate the licensed nurses and certified nursing assistant to ensure the wishes of the residents in relation to their DNR or Full Code Status are followed. The education will be completed for all licensed nurses and certified nursing assistants by [DATE]. The Administrator and Director of Nursing were educated by the CEO who is also a Social Worker, LNHA and Nurse on ensuring the resident is provided advanced directives upon admission, revised PRN and at a minimum of quarterly for any updates and changes they may elect. They were further instructed that a breach in a policy may result in a negative outcome must have an investigation to include reporting to any state agency if warranted reviewing serious concerns with the monthly QAPI committee. The licensed nurses and certified nursing assistants were educated on the facility's CPR/DNR policies to be completed [DATE]. The nurse Unit Managers will ensure the Code Status Binders and EMR are updated to reflect the residents, or RR wishes for advanced directives, PRN upon admission and at a minimum of quarterly. The Director of Nursing or designee will audit the Code Status Binders weekly for 4 weeks, monthly for 5 months or until 100%compliance is achieved. The Director of Nursing or designee will review their findings with the Administrator weekly for recommendations or follow up as indicated. Any code status called will be reviewed by the Director of Nursing or Administrator to determine the action provided by staff. Any identified areas of concern will result in further education or disciplinary action. The Administrator and/or Director of Nursing will report the finding of the weekly and monthly audit to the Monthly Quality Assessment Performance Improvement Committee for further recommendation as indicated. All areas will be completed by [DATE]

Based on document review and interview, the facility failed to ensure the Addendum One-Arbitration Agreement located in the facility's admission packet contained all the fundamental requirements particularly indicating admission to the facility was not predicated on the resident signing the agreement and that the resident had thirty days to rescind the decision to sign the agreement. This failure has the potential to cause negative legal ramifications for all residents that signed the agreement due to the agreement not containing the regulated information. Findings include: Review of the undated facility Addendum One- Arbitration Agreement revealed the agreement did not contain information stating the resident did not have to sign the agreement for them to be admitted to the facility. In addition, instead of indicating the resident or representative has thirty days to rescind the agreement, the facility agreement stated, this Arbitration Agreement may be rescinded by written notice to the Facility from the Resident or Authorized Representative within three (3) business days of signing the Agreement. During an interview on 08/14/24 at 10:55 AM, the Administrator verified the Arbitration Agreement signed in the admission packet did not specifically state the resident did not have to sign the Arbitration Agreement as a condition of admission. The Administrator also verified the agreement indicated the resident had three business days to rescind the signed decision and not thirty days.

Based on observations, interviews, record review, document review, and facility policy review, the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) while providing direct care for 2 of 3 residents (Resident (R)6 and R39) reviewed for Enhanced Barrier Precautions (EBP) of 21 sample residents. This failure could promote the spread of multi drug resistant organisms throughout the facility. In addition, the facility failed to ensure that the glucometer was cleaned according to manufacturer instructions for 1 of 2 residents (R58) of 21 sample residents. This failure has the potential to promote cross contamination between residents. Findings include: Review of facility's policy titled, ''Enhanced Barrier Precautions,'' revised 07/31/24, revealed, ''It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms . Policy Explanation and Compliance Guidelines . 2. Initiation of Enhanced Barrier Precautions . for residents with any of the following: i. Wounds (e.g., chronic wounds such as pressure ulcers . and/or indwelling medical devices (e.g., urinary catheters) .3. Implementation of Enhanced Barrier Precautions: a. makes gowns and gloves available immediately near or outside of the resident's room . b. Personal protective equipment (PPE) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. C. Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room) . 4. High-contact resident care activities include . f. changing briefs or assisting with toileting. g. device care or use . urinary catheters. 1. During initial tour observation of the facility on 08/12/24 at 5:30 AM, there were no EBP signs posted or PPE outside the doors of residents with catheters and residents receiving tube feedings. Review of R6's ''Admission Record'' located under the ''Profile'' tab in the electronic medical record (EMR) indicated that R6 was admitted to the facility on [DATE], with diagnoses including but not limited to: neuromuscular dysfunction of the bladder. Review of R6's ''Order Summary Report'' dated 08/14/24, located under ''Orders'' tab in the EMR indicated no evidence of enhanced barrier precautions. During a suprapubic catheter care observation with Licensed Practical Nurse (LPN)2 on 08/13/24 at 12:57 PM, LPN2 went into R6's bedroom, washed her hands and donned gloves. R6 did not have a sign outside the room indicating EBP and there was no PPE outside of the resident's room. LPN2 provided R6's catheter care, doffed her gloves and washed her hands prior to exiting the room. LPN2 did not wear any other PPE while providing catheter care. During observations on 08/13/24 at 8:30 AM, and 10:30 AM, no EBP sign and/or PPE outside R6's room door. In addition, an observation on 08/14/24 at 8:30 AM, no EBP sign and/or PPE outside R6's room door. 2. Review of R39's ''Admission Record'' located under the ''Profile'' tab in the EMR indicated that R39 was admitted to the facility on [DATE], with diagnoses including but not limited to: Alzheimer's. Review of R39's ''Order Summary Report'' located under the ''Orders'' tab in the EMR, dated 08/14/24, indicated that R39 has a stage three pressure ulcer to his left buttocks. There was no evidence of an EBP order. During observations on 08/13/24 at 8:30 AM, and 2:00 PM, revealed that there were no PPE and/or EBP sign outside of R39's room. In addition, at 10:45 AM, the surveyor knocked on R39's bedroom door, a Certified Nurse Aide (CNA) answered, who was observed providing care to R39 without wearing any PPE. Further observation on 08/14/24 at 8:30 AM, revealed there was no EBP sign and/or PPE outside of R39's room door. During an interview on 08/13/24 at 11:30 AM, the Director of Nursing (DON) indicated that the facility did not have any residents on EBP in the building at the time of survey. During an interview with Licensed Practical Nurse (LPN)2 on 08/13/24 at 3:20 PM, LPN2 stated that there were no resident on EBP in the building at the time of survey. During an interview with LPN4 on 08/13/24 at 4:05 PM, she indicated that she had no knowledge of EBP. During an interview with the DON and Administrator on 08/13/24 at 4:20 PM, both indicated that they have been waiting to get a policy from corporate about EBP and that there were no residents requiring EBP in the facility at this time. The Administrator indicated that after receiving the policy it goes through quality assurance (QA) and then the nurses are educated on the precautions. 3. Review of the facility's undated policy titled ''Obtaining a Fingerstick Glucose Level'' revealed, ''The purpose of this procedure is to obtain a blood sample to determine the resident's blood glucose level . Steps in the Procedure . 3. Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses. Review of a facility provided document titled, ''Bleach Wipe'' revealed, '' .One step cleaner and disinfectant. Kills .Hepatitis B virus, Hepatitis C virus, and Human Immunodeficiency Virus (HIV) type 1 .Contact time: Allow surface to remain visibly wet for 30 seconds to kill bacteria and viruses on the label except a one-minute contact time is required to kill Candida albicans and Trichophyton interdigital, and a three-minute contact time is required to kill Clostridium difficile spores.'' Review of a facility provided document titled ''Proper Storage of Diabetic Supplies'' revealed, '' .Glucometers should be properly cleaned following manufacturer's guidelines.'' Review of the facility provided In-Service Attendance Record titled, Proper Storage of Diabetic Supplies dated 01/25/24, revealed no evidence that LPN1, LPN3, or LPN4 attended the inservice. Review of R58's Admission Record'' located under the ''Profile'' tab in the EMR indicated that R58 was admitted to the facility on [DATE], with diagnoses including but not limited to: type 2 diabetes mellitus. During observation on 08/12/24 at 5:50 AM, LPN1 removed the glucometer from the medication cart, and without cleaning it, took it into R58's room, placing the glucometer on R58's overbed table without a barrier. LPN1 donned gloves and obtained R58's blood sugar. LPN1 exited R58's bedroom, placed the glucometer on top of the medication cart, without a barrier, then wiped it with an alcohol wipe. LPN1 then placed the glucometer back inside the medication cart. During observation on 08/13/24 at 10:46 AM, LPN3 obtained the glucometer from a clear cup on top of the medication cart, and without cleaning it, entered R58's bedroom. LPN3 placed the glucometer directly onto R58's overbed table without a barrier. After obtaining R58's blood sugar, she exited R58's bedroom. LPN3 placed the glucometer directly on top of the medication cart while she added R58's blood sugar results into the EMR. LPN3 picked up the glucometer and placed it back into a clear cup on top of the medication cart without cleaning the glucometer. During an interview on 08/13/24 at 4:05 PM, LPN4 indicated that there are two glucometers on each medication cart, so that when one is drying, the other one can be used. LPN4 stated that the glucometers should be cleaned with bleach wipes which are kept on the medication carts. During an interview on 08/13/24 at 4:20 PM, the DON indicated that each glucometer should start off clean at the beginning of the shift and that each medication cart has two glucometers so that they can be rotated for usage. The DON indicated after using the glucometer, nurses should clean the glucometer with a bleach wipe, which is kept in each medication cart. Also, the DON indicated that the nurses have been instructed to read the bleach wipe information because of the different contact times, ranging from one to three minutes. The DON confirmed there should be a barrier down when placing the glucometer on a resident's overbed table or directly on the medication cart.

Based on observations, record review, staff interview, and facility policy review, the facility failed to ensure 1 (Resident (R)26) of 3 residents reviewed for falls conducted a root cause analysis of each fall and appropriate interventions to help prevent further falls. These failures resulted in repeated falls after R26 returned to the facility from the hospital from a previous fall on 07/21/24. Findings include: Review of the undated facility policy titled, Falls and Fall Risk, Managing revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling . Resident-Centered Approaches to Managing Falls and Fall Risk . if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant . Monitoring Subsequent Falls and Fall Risk . The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 2. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 3. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the undated facility policy titled, Accidents and Incidents - Investigating and Reporting revealed, The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident . Review of the undated facility policy titled, Assessing Falls and Their Causes revealed, the purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . Documentation . documentation should be included in the resident's chart that includes, appropriate interventions taken to prevent future falls. Review of R26's Census tab located in the electronic medical record (EMR) revealed R26 was admitted to the facility on [DATE], and readmitted after her hospital stay on 07/26/24. Review of the Med Diag [Medial Diagnosis] tab located in the EMR revealed R26 was admitted with a fracture of the neck of her right femur, abnormal gait, lack of coordination, unsteadiness on feet, difficulty walking, and repeated falls. Review of the Orders tab located in the EMR revealed orders for bilateral Hipsters [hip padding] to always be on as tolerated and for a floor mat to be used on the side of R26's bed. Review of the Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/15/24 and located in the EMR revealed R26 had a Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating moderate cognitive impairment. The Care Assessment Area - CAA indicated triggers for functional abilities, urinary incontinence, and falls. Review of Fall Risk Evaluations under the Assessments tab located in the EMR and dated 07/29/24, 08/05/24, 08/06/24, and 08/09/24 revealed R26 was at risk for falls in each evaluation. Review of a Fall Investigation Report dated 07/29/24 provided by the Director of Nursing (DON) revealed R26 had fallen due to non-compliance and the intervention was to educate R26 with return demonstration. Review of a Fall Investigation Report dated 08/05/24 revealed R26 had fallen due to the resident does not use call bell for assistance and will frequently get up on her own. The intervention for 08/05/24 was education on the use of the call bell with verbal understanding. Review of a Fall Investigation Report dated 08/06/24 revealed R26 had fallen due to the resident is non-compliant with asking for assistance while ambulating. The 08/06/24 intervention was to reeducate R26 and to use non-skid socks. Review of a Fall Investigation Report dated 08/09/24 revealed that R26 had fallen due to the resident refuses to use call bell for assistance, still feels she can do it on her own. There was no intervention recorded on the 08/09/24 investigation. Review of the Care Plan (CP) located in the EMR under the Care Plan tab revealed a history of fall concerns/interventions beginning in February 2021. After returning to the facility on [DATE] from a hospital stay for a fractured leg, an intervention was initiated to have a floor mat to the side of the bed. The CP indicated, Fall 07/29/24 while unassisted transfer- re-educated on fall prevention and return demonstration. Interventions initiated on 07/29/24 for the 07/29 fall was to have the bed against the wall per resident preference, physical and occupational therapy to evaluate. The CP indicated a fall on 08/05/24, 08/06/24, and 08/09/24 the only intervention beginning on 08/06/24 was reeducating R26 on the use of the call bell with R26 giving a return demonstration. Observation on 08/12/24 at 1:18 PM, revealed R26 to be in her low bed with a floor mat next to the bed. R26 was not wearing hipsters. Observation on 08/13/24 at 3:00 PM, R26 was in her bed with no fall mat on the floor. R26 was not wearing hipsters. Interview on 08/14/24 at 9:20 AM, Licensed Practical Nurse (LPN)5 stated once a resident is found after an unwitnessed fall, the nurse will evaluate the resident and implement an intervention to prevent further falls and investigate the current fall to find out what happened. During the next interdisciplinary team meeting, the fall is discussed, and the care plan is updated. LPN5 stated interventions are tried and if they don't work then new ones are initiated. LPN5 verified the same intervention was tried after the 08/05, 08/06, and 08/09 falls without effect. She stated she had mentioned other interventions to the interdisciplinary team such as pressure alarms on the bed, but she was told the alarm is seen as a restraint. LPN5 stated the hipsters are used when R26 is out of the bed, and she has seen therapy use the device every time they work with R26. Interview on 08/14/24 at 12:05 PM, the DON stated many interventions have been attempted with R26. The DON continued to share that R26 understands what is asked of her [R26] but chooses to do as she wants in the moment and that she [R26] should not get out of bed without calling out for assistance. The DON stated the facility addresses each of R26's falls as an individual occurrence and determines interventions from the investigation of the fall. The DON verified R26 needed supervision and suggested the facility could try frequent checks on her, however, she could not explain how added supervision was accomplished. When it comes to supervision, the DON stated the resident's room is made as safe as possible and that supervision could be increased, if necessary, but she couldn't state what form the supervision has taken or would take. The DON was not sure if a toileting study had been done even though the resident's reason for falling was listed on the investigations as coming or going to the restroom.

Based on record review and interviews, the facility failed to provide written notification to the resident, resident representative, and the Ombudsman, when the facility initiated a transfer/discharge for 2 of 3 residents (Resident (R)24 and R31) reviewed for hospitalization . Findings include: 1. Review of R24's Face Sheet found under the Profile Tab in the electronic medical record (EMR) revealed the resident was originally admitted to the facility on [DATE]. Review of R24's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/12/24, in the EMR under the MDS tab revealed the resident has a Brief Interview for Mental Status (BIMS) score of 3 out of 15, which indicated the resident's cognition was severely impaired. Review of R24's EMR revealed a Progress Note dated 07/01/24 at 8:32 AM, under the Progress notes tab indicated R24 was transferred to the hospital via EMS [Emergency Medical Services], due to nausea and vomiting. A subsequent note on 07/01/24 at 8:32 PM, indicated R24 was admitted to the hospital. 2. Review of R31's Face Sheet found under the Profile tab in the EMR revealed an admitted d 03/13/18, with primary diagnoses of aphasia and dysphagia. Review of R31's Quarterly MDS with an ARD of 04/29/24, in the EMR under the MDS tab, revealed the resident is severely cognitively impaired and was unable to complete the BIMS interview. Review of R31's Progress note in the EMR dated 04/14/24 at 8:43 AM, under the Progress notes tab, indicated R31 was transferred to the hospital on 04/13/24, due to difficulty breathing. Emergency Services was contacted on 04/14/24 at 9:01 PM. During an interview with the Director of Nursing (DON) on 08/14/24 at 12:20 PM, she was asked how the facility notifies the resident or resident representative of hospital transfers, and the DON stated that they are contacted via telephone. She was asked if they provide any written documentation to the resident or resident representative, and she confirmed that they only provide the Bed Hold physically to the resident or resident representative or via certified mail. In a subsequent interview on 08/15/24 at 3:30 PM, the DON confirmed that the facility does not have a policy related to hospital transfers. During a phone interview with the Ombudsman on 08/15/24 at 1:15 PM, she revealed that she recently received an email from the Administrator with all the transfer notifications from 01/01/24 through 08/13/24.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure that 1 of 1 resident (Resident (R)27) reviewed for side rail usage had required documentation completed prior to the use of the side rails and quarterly thereafter as long as the side rails were used. Findings include: Review of facility's undated policy titled ''Proper Use of Side Rails,'' revealed, ''The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms . General Guidelines . 3. An assessment will be made to determine the resident's symptoms, risk of entrapment and reason for using side rails. When used for mobility or transfer, an assessment will include a review of the resident's: a. bed mobility; b. ability to change positions, transfer to and from bed or chair, and to stand and toilet; c. risk of entrapment from the use of side rails; and that the bed's dimensions are appropriate for the resident's size and weight . 5. Consent for using restrictive devices will be obtained from the resident or legal representative per facility protocol. 6. Less restrictive interventions that will be incorporated in care planning 8. The risks and benefits of side rails will be considered for each resident. 9. Consent for side rail use will be obtained from the resident or legal representative, after presenting potential benefits and risks.'' Review of ''Admission Record,'' located under the ''Profile'' tab in the electronic medical record (EMR), indicated that R27 was readmitted to the facility on [DATE], with diagnoses including but not limited to: quadriplegia and muscle weakness. During an observation on 08/12/24 at 6:02 AM, R27 was in bed with the left side quarter side rail observed in the up position. Further observations on 08/13/24 at 8:30 AM, 08/14/24 at 8:30 AM, and 08/14/24 at 12:30 PM, revealed R27 was in bed with the left side quarter side rail observed in the up position. Review of R27's ''Enabler Bar Assessment,'' located under the Assessments'' tab in the EMR, dated 03/23/23, indicated ''Bilateral quarter side rails.'' However, there was no evidence of further side rail assessments and/or evidence of alternatives tried prior to side rails usage. Review of ''Bedrail-Side rails Consent Form'' dated 01/17/24, located in the ''Misc'' tab in the EMR indicated no evidence of alternatives tried prior to side rails. During an interview with the Director of Nursing (DON) on 08/14/24 at 12:30 PM, the DON stated that side rails are being assessed quarterly with the care plan meetings, which includes going over alternatives and risk/benefits at that time. During an interview with R27's family member on 08/14/24 at 2:04 PM, she indicated that she gave consent for the side rails to be on his bed, but the facility did not go over any alternatives, just was told that was what the facility does. During an interview with the Administrator on 08/14/24 at 4:25 PM, indicated that side rail assessments are completed yearly. The Administrator confirmed that R27 has not had a side rail assessment since 03/23/23.

Based on review of the facility policy, record review, and interviews, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency (SSA) within two hours as required for 1 (Resident (R)226) of 5 sampled residents reviewed for abuse. Specifically, on 04/04/22, R226 made an allegation of abuse; however, the facility did not report the allegation of the abuse to the SSA until 04/25/22. Findings include: Review of an undated facility policy titled, Abuse Prevention Program revealed that, as a part of the resident abuse prevention efforts, the facility's administration would, Investigate and report any allegations of abuse within timeframes as required by federal requirements. Review of an Admission Record revealed R226 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/14/22, revealed R226 had a Brief Interview for Mental Status (BIMS) score of 10, indicating the resident had moderate cognitive impairment. Review of an Initial 2/24-Hour Report revealed on 04/25/22, the facility notified the State Agency of an allegation of abuse regarding R226. The report indicated the alleged incident occurred on 04/04/22. According to the report, on 04/04/22, the Director of Nursing (DON) received a telephone call from an employee at the [CONDITION(S)] clinic, who stated that R226 reported facility Certified Nursing Assistant (CNA)1 kneed the resident in the back while getting the resident ready for [CONDITION(S)]. The report further indicated CNA1 was not working in the facility on 04/04/22 but that an investigation would be completed. During an interview on 08/31/22 at 12:21 PM, when asked why the allegation regarding R226 was not reported timely to the SSA, the Administrator stated the DON thought, since the staff member named in the allegation was not working in the facility during the time the allegation was made, that it was just a concern. After re-evaluation, the allegation was later determined to be a reportable incident. During an interview on 08/31/22 at 3:04 PM, the DON stated she received a call on 04/04/22 from a staff member of the [CONDITION(S)] clinic, who stated R226 alleged that CNA1 had kneed him/her in the back. Per the DON, she notified the [CONDITION(S)] clinic staff that the facility would investigate but knew nothing had occurred between CNA1 and the resident, because CNA1 was not working in the facility at the time of the allegation. The DON stated when there was an allegation of abuse, all parties involved were interviewed and a report was made to the SSA. In a follow-up interview on 09/01/22 at 11:29 AM, the Administrator stated her expectation was that all allegations of abuse be reported to the DON or Administrator immediately. The Administrator stated the facility should start an investigation and report the allegation to the SSA within two hours. The Administrator stated she was not in the facility on 04/04/22 when the DON was informed of R226's allegation. The Administrator stated the DON was under the impression that the [CONDITION(S)] center was going to report the allegation. The Administrator asserted the facility continued with the investigation but, given that CNA1 was not working in the facility on 04/04/22, the facility did not feel it was a reportable incident. According to the Administrator, the allegation of abuse was not reported until the ombudsman later called the facility and suggested the facility report the allegation of abuse.

Based on review of the facility's written procedure for [CONDITION(S)] care, record review, and interview, the facility failed to ensure a drain sponge (dressing) was in place around Resident (R)68's [CONDITION(S)] insertion site as ordered by the physician. This deficient practice affected R68, 1 of 2 sampled residents reviewed for respiratory care. Findings include: Review of an undated facility procedure titled, [CONDITION(S)] Care revealed staff were to apply a fenestrated gauze pad (a gauze pad with a split or opening) around the insertion site. Review of an Admission Record revealed R68 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan, dated as revised 02/07/22, revealed R68 had a [CONDITION(S)] related to a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/22 revealed R68 was severely impaired in cognitive skills for daily decision making per a staff assessment of mental status. According to the MDS, R68 required extensive assistance with personal hygiene and required suctioning and [CONDITION(S)] care during the assessment period. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 08/29/22 at 3:37 PM, 08/30/22 at 11:37 AM, 08/31/22 at 9:17 AM, and 09/01/22 at 11:01 AM, R68 was observed in bed in his/her room. The resident's [CONDITION(S)] was clean and free of secretions but there was no drain sponge in place around the insertion site, as ordered by the physician. During an interview on 08/31/22 at 9:20 AM, Registered Nurse (RN)1 stated R68 received [CONDITION(S)] care in the evening and a gauze pad was placed at that time, but the gauze pad was soiled and, since the resident did not have any secretions, the gauze pad was removed to avoid any irritation. RN1 acknowledged R68 did not have any irritated areas around the opening of the [CONDITION(S)]. During an interview on 08/31/22 at 11:02 AM, the Director of Nursing (DON) stated it was expected for the resident to have a gauze placed after [CONDITION(S)] care and replaced when needed. During an interview on 09/01/22 at 11:01 AM, Licensed Practical Nurse (LPN)1 stated R68 had a [CONDITION(S)] care on the previous shift, and she had not noticed the gauze pad was missing. According to LPN1, the resident pulled the gauze pad out at times, but she would replace it. Per LPN1, the gauze pad needed to stay in place to prevent any irritation from the resident's secretions and [CONDITION(S)].

Based on observations, record reviews and interviews, the facility failed to assure that it was free of significant medication errors based on 1 of 6 residents observed during medication pass and 12 of 12 resident's medication administration records reviewed for medication not charted as administrated. Cross refer F755 for inaccurate controlled substance records. The findings include: On 6/15/21 at approximately 8:04 AM during medication pass observation, LPN (Licensed Practical Nurse) # 2 prepared one capsule of [MEDICATION(S)] Sprinkles DR (delayed release) 125 mg (milligram) for administration to Resident #26. The Surveyor stopped LPN # 2 prior to administration and asked him/her to review the package which was labeled to give 3 capsules. LPN # 2 read the drug package label, checked the MAR (medication administration record), verified that the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During medication reconciliation on 6/15/21 at approximately 8:35 AM, a review of the June 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, a random observation of the MAR for Resident # 26 revealed that [MEDICATION(S)] 0.5 mg 1/2 tablet (2.5 mg) had not been given on 6/4/21 and 6/14/21 at 2100 (9:00 PM) and that [MEDICATION(S)] 200 mg had not been given on 6/4/21 and 6/14/21 at 2100. A subsequent review of the CSR (controlled substance records) for [MEDICATION(S)] revealed that a [MEDICATION(S)] 2.5 mg dose had been signed out for Resident # 26 at 2000 (8:00 PM) by LPN # 3 which prompted further investigation of Resident # 26 and 11 additional residents (59, 70, 13, 73, 12, 44, 56, 47, 36, 24, 1) February - June 15, 2021, as follows: Resident 26 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 5 mg 0.5 tablet at bedtime on June 4, 14 at 2100 (9:00 AM); May 2, 11, 20, 21, 22, 23 29 at 2100; April 9, 22, 23, 28 at 2100; March 25, 26, 30, 31 at 2100; February 17, 22, 25, 28 at 2100 -[MEDICATION(S)] 200 mg two times a day on June 4, 14 at 2100; May 21, 22 at 0900 (9:00 AM) and May 2, 11, 20, 21, 22, 23, 29 at 2100; [DATE], 23, 28 at 2100; March 25, 26, 30, 31 17, 22, 25, 26 ,30, 31 at 2100; February 17, 22, 25, 26 at 2100 -[MEDICATION(S)] 125 mg 3 capsules one time a day on May 21, 22 at 0900 -Senna S 8.6-50 mg one time a day on May 21, 22 at 0900 Resident 59 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg one time a day on May 21, 22 at 0900 -[MEDICATION(S)] 1,000 U (units) 4 tablets one time a day on May 21, 22 at 0900 -[MEDICATION(S)] 40 mg one time a day on May 21, 22 at 0900 -[MEDICATION(S)] 2 mg at bedtime on June 4, 8, 14 at 2100 and May 20, 21, 22, 23, 29, 30 at 2100 -[MEDICATION(S)] 50 mg one time a day on May 21, 22 at 0900 -[MEDICATION(S)] DR Sprinkle 125 mg two capsules every morning and at bedtime on June 4, 9, 14 at 2100; May 21, 22 at 2100 and May 11, 20, 21, 22, 23, 29, 30 at 2100 -[MEDICATION(S)] 10 mg every morning and at bedtime on June 4, 9, 14 at 2100; May 21, 22 0900 and 11, 20, 21, 22, 23, 29, 30 at 2100 Resident 70 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 50 mcg (microgram) one a day on May 14, 17, 21, 22, 23, 24, 30, 31 at 0600 (6:00 AM) -Losartan 25 mg one a day on May 21, 22 at 0900 -[MEDICATION(S)] 100 mg three capsules in the afternoon on May 21, 22, 28 at 1600 (4:00 PM) -Polyethylene [MEDICATION(S)] Powder 17-gram one time a day on May 21, 22 at 0900 -Multiple Vitamin one a day on May 21, 22 at 0900 -[MEDICATION(S)] 20 mg one at bedtime on June 4, 15 at 2100; May 13, 20, 21, 22, 23, 29, 30 at 2100 -[MEDICATION(S)] 100 mg one every morning and at bedtime on June 4, 15 at 2100; May 13, 20, 21, 22, 23, 29, 30 at 2100 -[MEDICATION(S)] 500 mg one every morning and at bedtime on June 4, 15 at 2100; May 21, 22 at 0900 and May 20, 21, 22, 23 29, 20 at 2100 -Aspirin 81 mg one time a day on May 21, 22 at 0900 -[MEDICATION(S)] 12.5 mg one time a day on May 27, 22 at 0900 Resident 13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg at bedtime on June 4, 9, 15 at 2100; May 2, 11, 20, 21, 22, 23, 29, 30 at 2100; April 9, 22, 23, 28 at 2100; March 25, 26 at 2100 -Aspirin 81 mg one time a day on June 4, 9, 15 at 2100; May 2, 11, 20, 21, 22, 23, 29, 30 at 2100; April 9, 22, 23, 28 at 2100 -[MEDICATION(S)] 25 mg at bedtime on June 4, 9, 15 at 2100; May 2, 11, 20, 21, 22, 23, 29, 30 at 2100: April 9, 22, 23,28 at 2100: March 25, 26, 31 at 2100: [DATE] at 2100 -[MEDICATION(S)] 10 mg at bedtime on June 4, 9. 15 at 2100; May 2, 11, 20, 21, 22, 23, 29, 30 at 2100: March 25, 26 at 2100: April 25, 26 at 2100 -[MEDICATION(S)] 10 unit subcutaneously one time a day on June 1, 4, 5, 9, 10, 13, 15 at 0600; May 2, 3, 4, 7, 12, 17, 18, 21, 22, 23, 24, 30, 31 at 0600; April 1, 2, 6, 9, 10, 15, 23, 24, 27, 29 at 0600: March 4, 12, 22, 26, 27, 29 at 0600: February 17, 18, 26, 27 at 0600 -Stool Softener 100 mg one time a day on June 4, 9, 15 at 2100; May 2, 11, 20, 21, 22, 23, 29, 30 at 2100; April 9, 22, 23, 28 at 2100 -[MEDICATION(S)] 0.1 mg each morning and at bedtime on June 4, 9, 15 at 2100; May 21, 22 at 0900 and May 2, 20, 21, 22, 23, 29., 30 at 2100: April 9, 22, 23, 28 at 2100 -Novolog [MEDICATION(S)] 100 unit/ml (milliliter) Inject as per sliding scale: if 351-400 = 2 units < (less than) 60 call MD (physician); 401-450 units =4 units; 451-500 = 6 units > (greater than) call MD four times daily on June 1, 4, 5, 9, 10, 13, 15 at 0600 and June 4, 9, 15 at 2100; May 2, 3, 4, 7, 12, 17, 18, 21, 22, 23, 24, 30 31 at 0600 and May 21, 22 at 1100 and May 21, 22, 28 at 1600 and May 2, 11, 20, 21, 22, 23, 29, 30 at 2100; April 1, 2, 5, 6, 9, 10, 15, 23, 24, 27 29 at 0600 and April 9, 22, 23, 28 at 2100 -[MEDICATION(S)] 5 mg one time a day on May 21, 22 -Metoclopram 5 mg 0.5 tablet two times a day on May 21, 22 at 0900 and 2100; March 25, 26 at 2000 (8:00 PM): February 25, 26 at 2000 -Rena-Vite Rx one time a day on May 21, 22 at 0900 -Sevelamer 800 mg before meals on May 21, 22 at 0730 (7:30 AM), 1130 (11:30 AM), 1630 (4:30 PM): April 1, 2, 6 at 0600 Resident 73 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 500 mg two tablets two times a day on February 12 at 0600 -Novolog [MEDICATION(S)] U-100 Insulin/ Insulin Pen 100 unit/3 ml (milliliter), four times a day before meals and bedtime on June 15 at 0900: May 18 at 1600; and May 21 at 2100 and [NAME] 22 at 0600, 1100, 1600, 210 and May 23 at 0600 (6:00 AM); May 29 at 2100; May 30 at 0600: 4/22/21 9pm; April 23 at 0600, 2100; April 24 0600; March 29 1600; February 12 at 0600, February 2 at 0600. -[MEDICATION(S)] 10 mg at bedtime on May 21, 22, 30 at 2100: April 22, 23 at 2100 -Trazadone 50 mg one time a day on April 22, 23 at 0900 -[MEDICATION(S)] 40 mg one time a day on May 22 at 0900 -[MEDICATION(S)] 175 mcg one time a day on May 22, 23, 30 at 0600: April 15, 23, 24 at 0900 -[MEDICATION(S)] 20 mg at bedtime on May 21, 22, 29 at 2100 and April 22 at 2100 -[MEDICATION(S)] [MEDICATION(S)] 10 mg one time a day on May 22 at 0900 -[MEDICATION(S)] 20 mg one time a day on May 22 at 0900 -[MEDICATION(S)] (extended release) 24-hour 30 mg one time a day on May 22 at 0900 -Sennsoside-[MEDICATION(S)] Sodium 8.6-50 mg one time a day on May 22 at 0900 -[MEDICATION(S)] XL ( extended release) 12.5 mg one time a day on May 22 at 0900 Resident 12 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Aspirin 81 mg one time a day on June 4 at 0900 on May 2, 11, 20, 21, 22, 29 at 0900; April 1, 2, 6, 9, 22, 23, 28 at 0900; March 18, 22, 26, 27, 31 at 0900; February 17, 18, 23, 26, 27 at 0900 -[MEDICATION(S)] Tab 2.5 mg one time a day on May 21, 22 at 0900; April 1, 2, 6 at 0900; March 18, 22, 26, 27, 31 at 0900; February 17, 18, 23, 26, 27 at 0900 -Acetaminophen 325 mg two tablets two times a day on June 4 at 2100; May 2, 11, 20, 21, 22, 29 at 2100 and May 21, 22 at 0900; April 1,2 at 0600, April 9, 22,23, 28 ay 2100, March 7, 16 29 at 2100 and March 18, 22, 26, 27 at 2000: February 17, 18, 23, 26 27 at 0800 -[MEDICATION(S)] 10 mg 0.5 tablet two times a day on June 4, at 2100; May 2, 11,20 21, 22, 29 at 2100 and May 21, 22 at 0900; April 1, 2, 6, at 0600 and April 9, 22, 23, 28 at 2100; March 7, 16, 29 at 2000 and March 18, 22, 27, 30 at 0800; February 17, 18, 23, 26, 27 at 0800 -[MEDICATION(S)] 200 mg two times a day on June 4 at 2100; May 2, 11, 20, 21, 22, 20 at 2100 and May 21, 22 at 0900; April 1, 2, 6, at 0600 and April 9, 22, 23 28 at 2100; March 7, 16, 29 at 2000 and March 18, 22, 26, 27, 30 at 0800; February 17, 18, 23, 26, 27 at 0800 -[MEDICATION(S)] Solution 100 mg/ml (milliliter), 5 ml two times a day on June 4 at 2100; May 2, 11, 20, 21, 22, 29 at 2100 and May 21, 22 at 0900; April 9, 22, 23, 28 at 2100; March 7, 16, 29 at 2000 and March 18, 22, 26, 27 30 at 0800; February 17, 18, 23, 26, 27 at 0800 -[MEDICATION(S)] 40 mg one time a day on June 4 at 2100; May 2, 11, 20, 21, 22, 29 ay 2100; April 9, 22, 23, 29 at 2100; March 7, 16, 29 at 2100 Resident 44 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg at bedtime on June 4 at 2100; May 2, 11, 20, 21, 22, 29 at 2100; April 9, 22, 23, 28 at 2100; March 25, 26, 30 at 2100; February 17, 25, 26 at 2100 -[MEDICATION(S)] 30 mg one time a day on June 4 at 0900; May 2, 11, 20, 21, 22, 29 at 0900; April 9, 22, 232, 28 at 0900; March 25, 26, 30 at 0900; February 17, 25, 26 at 0900 -[MEDICATION(S)] 137 mcg one time a day on June 4, 13 at 0600; May 2, 11, 20, 21, 22, 29 at 0600; April 1, 2, 6, 9, 10, 23, 24, 29 at 0600; March 15, 22, 26, 27 at 0600; February 17, 18, 26, 27 at 0600 -[MEDICATION(S)]-Acetaminophen 5-325 mg three times a day on June 5, 15 at 0600; May 3, 7, 12, 21, 22, 23 at 0600; May 21, 22 at 12 noon; May 21, 22 at 1800; April 1, 2, 6, 9, 10, 23, 24, 29 at 0600 and April 3 at 1800: March 15, 22, 26, 27 at 0600 and March 16, 23, 26, 29 at 1800; February 17, 18, 26, 27 at 0600 - [MEDICATION(S)] 500 mg two times a day on May 2 at 2000 Resident 56 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg 25 mg 2 to 2.5 tablets three times a day on May 21, 22, 29 at 2100 and May 22 at 1500; March 28 at 1500 -[MEDICATION(S)] 3 mg at bedtime on May 22, 23, 29 at 2100; -[MEDICATION(S)] Gel 1% (percent) apply to face/neck three times a day on April 24 at 2100 -[MEDICATION(S)] Sulfate 325 mg one time a day, every 2 days on May 22 at 0900 -[MEDICATION(S)] 50 mg one time a day in the morning on May 22 at 0900 -Stool Softener 100 mg one time a day on May 21, 22, 29 at 0900 Resident 47 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 25 mcg one time a day on June 9 at 0600 Resident 36 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Tamsulosin 0.4 mg at bedtime on June 4, 9 at 2100 -[MEDICATION(S)] 25 mg two times a day on June 4, 9 at 2100 -[MEDICATION(S)] Sodium 8.6-50 mg two times a day on June 4, 9 at 2100 Resident 24 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 2.5 mg one time a day on May 22 at 0900 -Cranberry Cap(sule) 425 mg two a day on May 21, 22 at 2100 and May 22 at 0900 -[MEDICATION(S)] 30 mg one time a day on May 22 at 0900 -[MEDICATION(S)] 25 mg one time a day on May 22 at 0900 -[MEDICATION(S)] 5 mg two times a day on May 21, 22 at 2100 and May 22 at 0900 -Metoclopram 5 mg two times a day on May 22 at 0900 & 1700 -[MEDICATION(S)] 20 mEq (milliequivalents)ER on e time a day on May 22 at 0900 -[MEDICATION(S)] 20 mg at bedtime on May 21, 22 at 2100 -Senna Plus 8.6-50 mg give two tablets two times a day on May 21 at 2100 and May 22 at 0900 & 2100 Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 10 mg one time a day on May 22 at 0900 -[MEDICATION(S)] 250 mg ER at bedtime on May 21, 22 at 2100 -[MEDICATION(S)] FlexTouch Solution Pen injector 100 UNIT/ML (Insulin Detemir) Inject 15 unit subcutaneously in the morning on May 22 at 0900 -[MEDICATION(S)] 50 mg two tablets one time a day on May 22 at 0900 -Vitamin C (Ascorbic Acid) 500 mg 1000 mg by mouth one time a day on May 21, 22, 29 at 2100 -Novolog FlexPen100 unit/ml Solution pen-injector Inject as per sliding scale: if 201 - 250 = 2 units; 251 - 300 = 4 units; 301 - 350 = 6 units; 351 - 400 = 8 units, subcutaneously four times a day on May 21, 22, 29 at 2100, May 22, 23, 30 at 0600, May 22 at 1100 and 1600 These findings were acknowledged by the Director of Nursing and the Regional Nurse Consultant on June 16, 2021, at approximately 2:30 PM who were not aware of a proactive computer or manual monitoring process for tracking doses not administered.

Based on observations, interviews and review of the facility policies titled, Dry Food Storage, and Frozen Food Storage, the facility failed to ensure food was stored, prepared, distributed and served in a safe sanitary manner under sanitary conditions in the main kitchen and has the potential to effect all residents receiving meals that are prepared in the kitchen. The findings included: Initial tour of the kitchen on 6/14/2021 at approximately 10:15 AM revealed the following: 1. Sandwich meat opened with no opened date in 1 reach in cooler. 2. Walk in freezer had a white 5 gallon bucket of pickles and the lid was not secure and had debris and dry spillage on the lid. 3. The floor of the walk in freezer had debris, trash and a dried, dark reddish substance. 4. The chest type freezer had an opened bag of cookie dough with no open date. 5. The reach in cooler had debris, a dried brown substance on the bottom and dirty packages of food. The Certified Dietary Manager (CDM) stated that he/she had been in the process of cleaning it out. 6. The mixer had a plastic bag cover that had spillage and splatter. The mixer itself was greasy and dirty. 7. The main stove and the warmer on the side of the stove, had excessive splatter, dried debris, grease, crumbs and dust caked up around and under the burners and knobs. 8. The sink for hand washing beside the ice maker did not have a trash receptacle that was closed with easy access to dispose of used paper hand towels. 9. The ice scoop for the ice maker was on the wall in a blue plastic container with no drainage and a dark brown and reddish substance was noted in the bottom of the blue plastic container. On 6/14/2021 at approximately 10:20 AM the CDM confirmed the findings. During an interview on 6/15/2021 at approximately 12:50 PM with the Cook and the Administrator, it was brought to their attention that the stove and side warmer were dirty, dusty, and had a heavy build-up of debris, grease and crumbs. The Administrator stated that they were not able to clean it This Surveyor requested a cleaning schedule for the kitchen, and the Administrator was unable to find any documentation to ensure the kitchen was being cleaned regularly. Review on 6/15/2021 at approximately 2:00 PM of the facility policy titled, Dry Food Storage, and Frozen Food Storage, states, Reseal open products and label with an open date. A kitchen cleaning policy was not provided.

Based on record reviews and interviews, the facility failed to ensure the linens and the resident's clothes were being sanitized in 1 of 1 laundry rooms observed. The facility further failed to ensure proper hand washing/hand sanitizing during for Resident #43 for 1 of 1 residents reviewed for wound care. The findings included: Review on 6/16/2021 at approximately 11:45 AM of the log from Eco Lab revealed the following. A service call on 1/11/2021 from Eco Lab revealed a water temperature of 135 degrees and 140 parts per million of bleach. There was no service call for February 2021 to check the bleach content of the washer. A service call on 3/31/2021 revealed the sanitizer was not dispensing in the kitchen, but the laundry was not checked for water temperature and sanitizer for the washing machines. A service call on 4/1/2021 revealed the washing temperature of 130 degrees but the laundry sanitizer still was not checked. A service call on 6/16/2021, while the sanitization of the laundry was in question, Eco Lab checked the water temperature was not checked but the bleach content was 130 parts per million to ensure the linens and the resident's clothes were sanitized. Based on the reports and lack there of there was no way to ensure the linens and the resident's clothes were sanitized from January 2021 until 6/16/2021. During an interview with the Housekeeping Supervisor, and the Eco Lab Representative on 6/16/2021 at approximately 1:00 PM confirmed that the sanitizer in the wash had not been verified since January 2021, and that the kitchen had had problems with the sanitizing of the dishes, pots, pans and utensils in March 2021. The facility admitted Resident #43 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/15/2021 at approximately 8:24 AM of the medical record for Resident #43 revealed a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 6/15/2021 at approximately 9:50 AM during wound care with Licensed Practical Nurse (LPN) #1 cleaned the 2 wounds with Dakin's solution as ordered, but failed to rinse each one well with normal saline. The wound care on 6/15/2021 at approximately 9:50 AM was observed as follows: Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 walked into Resident #43's room and did not knock. This surveyor knocked on the resident's room door and asked for permission to enter. The resident stated yes, then I introduced myself and asked permission to observe the nurse doing the wound care and changing the dressing. Resident #43 agreed for this surveyor to observe wound care. Both nurses went into the restroom to wash their hands. While RN #2 cleaned the over bed table, LPN #1 went out to the cart and poured Dakin's Solution into a clear cup marked Dakin's and then poured the Normal Saline into a clear cup marked NS, he/she then poked 4x4s into the cups with the solution. LPN #1 applied gloves and pulled down the covers, removed the brief and helped the RN #2 position the resident on his/her right side. LPN #1 using the same gloved hands removed the soiled dressing from both wounds, then reached into the Dakin's solution and took out a soaked gauze and wiped the wound inside out, each wound at time using clean gauze. The wound was not rinsed well with NS as the order states. LPN #1 removed his/her gloves and then applied clean gloves and did not sanitize or wash his/her hands. LPN #1 opened packed each wound with the NS soaked gauze, then opened the cover dressing, took a pen from his/her pocket and wrote the date and initialed the cover dressing. Then LPN #1 removed his/her gloves and did not clean his/her hands and applied gloves. The packing had fallen out and he/she covered the wound with the signed and dated dressing, I called it to his/her attention that the packing was not in the wound and then he/she pulled the dated dressing off, took the saline gauze and repacked the wound then coved it again with a dated and initialed dressing. RN #2 then made the resident comfortable, LPN #1 emptied the cups of Dakin's Solution and Normal Saline, cleaned off the table, removed his/her gloves, and helped RN #2 pull Resident #43 up in the bed. LPN #1 then bagged the trash. He/she carried the trash to the soiled utility room, I thanked the resident for allowing me to observe. LPN #1 failed to cleanse his/her hands each time he/she changed gloves during wound care. He/she also failed to ensure the wound on the left buttock was packed before applying the outer dressing. Review on 6/15/2021 at approximately 1:37 PM of the facility policy titled, Dressings, Dry/Clean, states, under Steps in the Procedure, states, each time the gloves are removed, Wash and dry hands, thoroughly. LPN #1 failed to wash his/her hands during wound care. An interview on 6/15/2021 at approximately 1:45 PM with LPN #1, confirmed that he/she had not washed/cleansed his/her hands each time after changing his/her gloves during wound care for Resident #43.

Based on observations, record reviews and interviews the facility failed to assure accurate record keeping and proactive monitoring of controlled substances based on 1 of 4 medication cart CSR (controlled substance records) and MAR (Medication Administration Record) accuracy reviews for Residents 26 and 44 on Jones Wing, Medication Cart # 2. (Cross Refer F760) The findings include: Resident # 26 was admitted to the facility on [DATE] with diagnoses including, but not limited to Anxiety, Intellectual Disabilities, Depression, and [CONDITION(S)] The facility's Controlled Substance policy states: 9. Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. 10. The Director of Nursing Services shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such finding. During medication reconciliation for Resident # 26 on 6/15/21 at approximately 8:35 AM, a random observation of the MAR for Resident 26 revealed that [MEDICATION(S)] 0.5 mg 1/2 tablet (2.5 mg) had not been given on 6/4/21 and 6/14/21 at 2100 (9:00 PM), and numerous medications not charted on the MAR as administered (cross refer F760). On 6/15/21 at approximately 9:15 AM, a review of CSR Rx (prescription) # (number) 6610/001 Date Received 06/03/2021 for [MEDICATION(S)] TAB 5MG 1/2 TABLET (2.5MG) BY MOUTH AT BEDTIME revealed that one (1) [MEDICATION(S)] 2.5 mg dose had been signed out for Resident # 26 on 6/14/21 at 2000 (8:00 PM) with no corresponding record of administration on the MAR. A subsequent review of CSR Rx # 800/001 Date Received 05/06/2021 for [MEDICATION(S)] TAB 5MG 1/2 TABLET (2.5MG) BY MOUTH AT BEDTIME revealed that two (2) [MEDICATION(S)] 2.5 mg tablets had been signed out for Resident # 26 on 6/4/21 at 2000 (8:00 PM) with no corresponding record of administration on the MAR. The signature of the nurse signing out these doses was not decipherable, and the Director Of Nurisng (DON) and Regional Nurse Consultant (RNC) were able to determine through staffing records that the signature belonged to LPN (Licensed Practical Nurse) # 3. Further review of CSR Rx # 800/001, 857/001 received 3/24/2021, and 452 received 2/22/2021 received 3/24/21, Rx # 8857/001 received 3/24/21, 452/001 received 2/22/2021 and the MARs for May, [MEDICATION(S)],l [NAME],h and February 2021 revealed that doses had been signed out with undecipherable signatures on 5/29, 5/23, 5/22, 5/21, 5/20, 5/11,5/2, 4/28, 4/23, 4/9, 3/31, 3/26, and 3/25. There were no entries of CSR sign out on 3/30 and 3/29, however the MAR showed that a dose had not been documented as administered on 3/30/21. On 6/15/21 at approximately 3:40 PM a review of MAR and CDR records for Resident 44, who was admitted to the facility on [DATE] with diagnoses including, but not limited to Hypertension, Urinary Tract Infection, >[CONDITION(S)], [CONDITION(S)] and Pain, revealed on CDR Rx #s 699/001, 886/001, 886/002, 4683/001, 308/001, 308/02, 3712/002, 712/002, 874/001 and 097/001 that multiple doses of [MEDICATION(S)]-Acetaminophen 5-325 mg, which had been prescribed as scheduled doses, had been signed out and that those doses and times correspond to doses not charted as administered (Refer F760). In addition, there were multiple instances on these CDRs where the time signed out does not correspond to the physician order or is not signed out according to the dosing frequency prescribed by the physician. The WASTED DOSES section of CDR Rx# 699/001 showed 22 tablets wasted on 2/18/21, but this quantity does not correspond with the Balance Forward and there was no evidence that two nurses signed the CDR under WASTED DOSES as required by facility policy On 6/16/21 at approximately 1:45 PM the DON and RNC acknowledged that the CSR signed documents did not correspond to MAR administration of those doses, that dates, times and signatures are not always decipherable on the CDR, that no discrepancies had been reported by the nursing staff and that there was no routine monitoring of CSRs and MARs by the DON or Unit Mangers. The DON and RNC had reviewed staffing records to determine names of nurses involved and according to their analysis, the majority of these discrepancies were by LPN # 3 on the 7 PM- 7 AM shift.

Based on record review and interview, the facility failed to provide documentation of education, consents, and vaccinations given/declined for five ( #1, #13, #24, #56, #73) of five residents reviewed for influenza, pneumococcal, and COVID-19 immunizations. The findings include: Resident #1's medical record revealed a COVID-19 vaccination consent form signed and dated by resident #1 1/11/2021. Additionally, records for influenza vaccine was documented as declined on 11/6/2020 however, there was no signed consent. There was no documentation for education regarding any vaccinations. Resident #13's medical record revealed a COVID-19 vaccination consent form signed and dated by resident #13 1/20/2021. Additionally, records for influenza consent and education was dated 11/4/2020. There was no education materials, consents, or record of the immunization given/declined for pneumococcal vaccination. Resident #24's medical record revealed a COVID-19 vaccination consent formed signed and dated by resident #24 1/20/2020. Additionally, consents, education material, and record of vaccination given/declined for influenza or the pneumococcal vaccination was not found for 2020 or 2021. Resident #56's medical record revealed a COVID-19 vaccination consent form signed and dated by resident #56 1/20/2021. Additionally, consents, education material, and record of vaccination given/declined for influenza or the pneumococcal vaccination was not found for 2020 or 2021. Resident #73's medical record revealed a COVID-19 vaccination consent form signed and dated by resident #73 1/20/2021. Additionally, consents, education material, and record of vaccination given/declined for influenza or the pneumococcal vaccination was not found for 2020 or 2021. In an interview with the Director of Nursing (DON), he/she acknowledged the consents were not in the medical record. The DON added it was unknown where the documents were and knew they should be readily available in the chart. FACILITY Infection Control 06/16/21 02:23 PM Requested Flu and Pneumonia records and notice of education from DON, [NAME] [NAME], she was not able to find all of the documentation required for this. She admitted she was not able to find it.

Based on record reviews and interviews the facility failed to to assist Resident #19 with obtaining eye glasses. The facility further failed to notify Resident #19's responsible party of his/her need for eye glasses and the cost following an eye examination for 1 of 1 residents reviewed for Vision and Hearing. The findings included: The facility admitted Resident #19 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview on 6/14/2021 at approximately 11:57 AM with Resident #19, revealed he/she had an eye examination in February 2021. The eye examination indicated that he/she has a need for eye glasses, and the facility has not followed up on assisting him/her in obtaining eye glasses. Review of the medical record on 6/15/2021 at approximately 9:09 AM for Resident #19 did indicate an eye examination on 2/20/2021. The documents from the eye examination states,Glasses were prescribed for this patient. A nurses note dated, 4/28/2021 from the Director of Nursing (DON) states, Spoke to the care givers at the Optometrist office. Resident had eye examination in February, but because she does not have vision insurance, he/she will not be receiving glasses. Further review of the medical record on 6/15/2021 at approximately 9:10 AM for Resident #19, indicated that the responsible party for Resident #19 was not made aware of the eye examination and the results which was the need of eye glasses. An interview on 6/15/2021 at approximately 11:25 AM with the facility Administrator, confirmed that Resident #19's responsible party had not been notified of the need for eye glasses and the cost.

Based on observations and interview, the facility failed to ensure call lights were within resident's reach for 2 of 2 (#12, #56) residents reviewed during random observations. The findings include: Environment Resident #12 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During facility tour on 06/15/21 11:03 AM Resident #12's call light was observed hanging from his/her bulletin board directly above the bed. Resident #12 was unable to reach the call light. On 06/15/21 at 12:32 PM Resident #12 observed eating, using left hand, call light on the left side of bed, within reach. On 6/16/21 at 08:34 AM Resident #12 observed in bed, call light within reach of left hand. During an interview, Resident#12's roommate, Resident #44, confirmed Resident #12's inability to use the call light. Certified Nursing Assistant (CNA) #1 stated Resident #12 is able to use his call light. Resident #56 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a facility tour on 06/15/21 at 11:30 AM Resident #56's call light was observed at the foot of the bed. When asked if it was within reach, Resident #56 stated it was not. Resident #56 went on to say sometimes it will fall on the floor and when it is picked up it is put at the foot of the bed. During a random observation on 06/16/21 at 01:35 PM Resident #56 called out as Surveyor walked by. Surveyor knocked and asked permission to enter. Upon entrance Resident #56 stated help was needed with his/her headphones, and the call light was not accessible. A CNA came in, assisted with the headphones and lowered the call light. During observations on 06/17/21 at 09:09 AM, call light was too far up on his/her bed to reach, it needed to be lowered. CNA was called into room by resident to lower it.

Based on record review and interview the facility failed to ensure Advanced Directives were current in the medical record for 2 of 2 residents (#12 & #73) reviewed for Advance Directives. The findings include: Resident #12 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #12's Electronic Medical Record (EMR) revealed, Resident #12's status as a FULL CODE. Further review revealed a Do Not Resuscitate (DNR) was found dated 3/18/2018 by the resident's representative. No further documentation was found. Resident #73 was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of Resident #73's Electronic Medical Record revealed, Resident #73 was coded a Do Not Resuscitate (DNR). Upon further review a DNR dated 10/17/2016 signed by the resident was discovered; however, a FULL CODE was found dated 9/30/2020, also signed by the resident. During an interview with the facility's Administration, it was confirmed the EMR was incorrect for Residents' #12 and #73.

Based on observation, record review, interview, and review of the facility policy titled, Dressings, Dry/Clean, the facility failed to follow the physician's order for wound care for Resident #43. The facility further failed to provide proper wound care/dressing change for Resident #43 for 1 of 1 residents reviewed for Wound Care. The findings included: The facility admitted Resident #43 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 6/15/2021 at approximately 8:24 AM of the medical record for Resident #43 revealed a physician's order for wound care as follows: Provide wound care to wounds at left buttock and right buttock (x 2) every day and as needed when soiled; clean each wound with Dakin's solution, rinse well with normal saline, pack each wound with normal saline soaked gauze, apply dry dressing on top. An observation on 6/15/2021 at approximately 9:50 AM during wound care with Licensed Practical Nurse (LPN) #1 cleaned the 2 wounds with Dakin's solution as ordered, but failed to rinse each one well with normal saline. The wound care on 6/15/2021 at approximately 9:50 AM was observed as follows: Registered Nurse (RN) #2 and Licensed Practical Nurse (LPN) #1 walked into Resident #43's room and did not knock. This surveyor knocked on the resident's room door and asked for permission to enter. Resident #43 stated yes, then I introduced myself and asked permission to observe the nurse doing the wound care and changing the dressing. Resident #43 agreed for this surveyor to observe wound care. Both nurses, RN #2 and LPN #1, went into the restroom to wash their hands. While RN #2 cleaned the over bed table, LPN #1 went out to the cart and poured the Dakin's Solution into a clear cup marked Dakin's and then poured the Normal Saline into a clear cup marked NS, he/she then poked 4x4s into the cups with the solution. LPN #1 applied gloves and pulled down the covers, removed the brief and helped RN #2 to position the resident on her right side. LPN #1 using the same gloved hands removed the soiled dressing from both wounds, then reached into the Dakin's solution and took out a soaked gauze and wiped the wound inside out, each time using clean gauze. The wound was not rinsed well with NS as the order states. LPN #1 removed his/her gloves, then applied clean gloves and did not sanitize or wash his/her hands. LPN #1 opened packed each wound with the NS soaked gauze, then opened the cover dressing, and took a pen from his/her pocket and wrote the date and initialed the cover dressing. then removed his/her gloves and did not clean his/her hands and applied gloves. The packing had fallen out and he/she covered the wound with the signed and dated dressing, I called it to his/her attention that the packing was not in the wound and then he/she pulled the dated dressing off and took the saline gauze and repacked the wound then coved it again with a dated and initialed dressing. The RN then made the resident comfortable, the LPN emptied the cups of Dakin's and Saline and cleaned off the table and then removed his/her gloves and helped the RN pull Resident #43 up in the bed. The LPN then bagged the trash. He/she then carried the trash to the soiled utility room, I thanked the resident for allowing me to observe. LPN #1 failed to cleanse his/her hands each time he/she changed her gloves during wound care. He/she also failed to ensure the wound on the left buttock was packed before applying the outer dressing. Review on 6/15/2021 at approximately 1:37 PM of the facility policy titled, Dressings, Dry/Clean, states, under Steps in the Procedure, states, each time the gloves are removed, Wash and dry hands, thoroughly. LPN #1 failed to wash his/her hands during wound care. An interview on 6/15/2021 at approximately 1:45 PM with LPN #1, confirmed that the physician's order was not followed related to rinsing the wound well after cleansing with Dakin's Solution and he/she also confirmed that he/she had not washed/cleansed his/her hands each time after changing his/her gloves during wound care for Resident #43.

Based on observations, record review, interviews, and facility policy review, it was determined: 1. The facility failed to ensure a resident was safely transferred using the appropriate assistive devices identified in the facility's policy and/or residents' care plans. Resident #1 had a care plan to be transferred with a Hoyer (mechanical lift). Resident #1 was transferred using stand and pivot, which resulted in the resident sustaining a [MEDICAL CONDITION] tibia. This deficient practice affected one of three residents (Resident #1). 2. The facility failed to ensure nursing staff had access to gait belts to ensure residents got the required support needed during transfers. Staff were observed transferring residents by grabbing their clothing, instead of safely transferring residents with the proper assistive devices according to the facility's policy and/or the residents' care plan. Staff were unaware of what assistive devices were to be used to transfer each resident. This affected 16 of 16 residents reviewed for transfers (Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19). 3. The facility failed to ensure two staff members were used to transfer residents when using the Hoyer. The facility's policy and the residents' care plans indicated two staff members should be utilized for Hoyer transfers. This affected two of three residents (Residents #2 and #3) observed for Hoyer transfers. The facility identified 15 residents were transferred by stand and pivot, and 32 residents were transferred using a Hoyer. The census was 62. It was determined the provider'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 was related to State Operations Manual, Appendix PP, 483.25 (Free of Accident Hazards/Supervision/Devices) at a scope and severity of K - pattern of deficient practice at Level 4. On 01/16/2021 at 8:30 AM, the Nursing Home Administrator (NHA) and Director of Nursing (DON) were informed and provided the template of the Immediate Jeopardy. Findings included: 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The resident required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. The resident was totally dependent on staff for toilet use. The resident was independent with eating and required only set-up assistance. Resident #1's plan of care, initiated on 02/24/2016 and revised on 01/15/2021, indicated under the activities of daily living (ADL) functional/rehabilitation potential portion of the plan of care that Resident #1 would maintain current transfer status: Total (2 person) assist using mechanical lift. A progress note, dated 12/06/2020 at 6:02 PM, revealed that Resident #1 had been complaining of (c/o) right hip pain, leg pain all the way to the feet for two days with no relief. It was reported that a telephone order for x-ray right leg, knee, hip, and foot was done. The progress note did not document the intensity of the resident's pain for the prior two days 12/04/2020 and 12/05/2020. There was no report in the progress note that indicated the resident's physician was notified of the resident's complaint about unrelieved pain. The x-ray report dated 12/06/2020 at 9:15 PM, noted there was a [MEDICATION NAME] fracture involving the proximal tibia with mild displacement from the radiographic imaging taken of Resident #1's right leg. A review of Resident #1's Medication Administration Record [REDACTED]. The MAR further revealed that the medication regimen captioned above was normal for Resident #1. There was no evidence that the resident got an increase in pain medication. On 01/15/2021 at 8:48 AM, Certified Nurse Aide (CNA) #3 was interviewed. The CNA said s/he recalled his/her encounter with Resident #1 before the resident was noted to be complaining of pain in the leg. The CNA said Resident #1 was in his/her wheelchair all day on 12/04/2020 (the day the resident was wrongly transferred). S/he said the shift was scheduled to end at 7:00 PM on the said day and Resident #1 requested to be put back to bed prior to shift change. The CNA described the transfer process that was carried out with Resident #1 on the evening of 12/04/2020. Specifically, CNA #3 said s/he did two persons assist with CNA #2. S/he said they took Resident #1 in his/her room while the resident sat in a wheelchair. CNA #3 said they parked the resident in front of the bed. S/he said Resident #1 was able to help with the transfer by putting some weight on his/her good side. CNA #3 said she positioned herself on one side of the resident while CNA #2 on the other side relative to Resident #1's body. S/he said, We put our hands, one under (his/her) arm and the other at the back of (his/her) pant and we then pivoted the resident to the bed. CNA #3 said the resident was fine before she closed on her shift. CNA #3 expressed that s/he was not familiar with Resident #1 or how he/she was to be transferred. S/he said they were not issued a gait belt to transfer residents. The CNA said there was no way she was able to tell what transfer technique to use with residents. S/he said nurse aides typically relied on their personal judgement about how to safely transfer a resident. She said following the discovery that Resident #1 potentially fractured a bone in (his/her) leg, they (CNA #2 and CNA #3) were questioned by the Nursing Home Administrator (NHA). The details about how Resident #1 was transferred on the evening of 12/04/2020 was relayed to the NHA. S/he said there was no follow-up education or any action taking against herself or with CNA #2 that she was aware of. On 01/15/2021 at 9:15 AM, CNA #2 was interviewed. CNA #2 said s/he recalled that s/he washed up Resident #1 the morning of 12/04/2020. S/he said s/he typically pivoted residents when they needed to be transferred because it was faster. S/he said she got the help of CNA #3 to get Resident #1 in bed on the day the resident was suspected to have a fractured leg. CNA #2 said s/he held on to Resident #1 using the back of the resident's pant and under arm on one side while CNA #3 did the same on the other side. S/he said she recalled that the transfer was carried out with Resident #1 close to shift change on the day. The CNA said after the resident was transferred to bed, she checked the resident to determine if his/her brief needed to be changed and it did not. S/he said the resident did not complaint of pain when they were done providing care. S/he said she was assigned the same resident when she came back to work on (did not recall the date). S/he said s/he sat the resident up in bed and washed his/her front area. S/he said when s/he tried to get the resident to roll, the resident yelled out in pain. S/he asked Registered Nurse (RN) #2 if anyone had reported that Resident #1 was in pain and the RN responded that the facility was aware of the resident's complaint of pain and had an x-ray was done a day before which came back positive for a fracture. CNA #2 reported that RN #2 said s/he had no idea why Resident #1 had not been sent to the ER. CNA #2 said s/he determined how a resident would be transferred based on the resident's mood and what she thought was safe for the resident. S/he said she was not aware of any system within the facility that told nurse aides how they were to transfer residents. S/he said she was not provided a gait belt, hence, s/he relied on the resident's pants. S/he said when residents got showered or used the toilet and did not have pants on, she usually just pulled them by their hands. S/he said she was questioned by Human Resource (HR) staff about how and what happened with Resident #1 when she returned to work on (did not recall the date). S/he said s/he relayed the events as it pertained to how the resident was transferred to the HR personnel and that was the last s/he heard about the incident. S/he said no education or action was taken by the facility. S/he said s/he still used her discretion when she transferred residents. On 01/15/2020 at 9:37 PM, RN #2 was interviewed. S/he said s/he observed Resident #1 on Friday (12/04/2020) when the resident was up. S/he said the resident had no complaints of discomfort or pain at the time. S/he said when s/he came back to work on 12/07/2020. S/he found an x-ray report that was from the day prior. S/he said she read the x-ray report and it was clear that the resident had suffered a fracture to the right leg. She said she reviewed the medical record and found that the resident's attending physician had not been made aware of the situation with Resident #1. S/he said she called the resident's physician and responsible party. S/he said the attending physician immediately ordered the resident be sent out to the ER. The RN said the nurse aide had no way to tell how they were to transfer a resident. S/he said the information was contained in the resident's plan of care. S/he said the nurse aides do not have access to the residents' care plan. S/he said she had not had a nurse aide ask her about how to transfer a resident. On 01/15/2021 at 4:25 PM, the Director of Therapy (DOT) was interviewed. S/he said when a new resident got admitted at the facility, they were screened. S/he said, the facility evaluated a newly admitted resident for their therapy needs and/or evaluated them based on the skilled order the resident came in with. S/he added that with new residents, the facility had a therapist complete a comprehensive evaluation of the resident which included transfer, mobility, strength, and balance. S/he said the occupational therapist evaluated for resident's needs with activities of daily living (bathing, dressing, wheelchair positioning etc .). S/he said once the therapist knew what the residents' needs were, the therapist wrote up their plan of care and goals. S/he said the therapist addressed the residents' skill need when they are on therapy. S/he said the therapy department communicated the residents' transfer needs to the nursing staff and kept them up to date if there were any changes made (if the resident continued to be dependent or independent and what the evaluated transfer modality was recommended for the resident). S/he said the therapy department re-assessed a resident when a decline was noted and recommended something else if needs warranted. S/he said it was very essential for nursing staff to adhere to the recommendation of the therapist on issues related to the therapist evaluated transfer modality for any resident. She said following the therapist recommendation was essential to ensure the safety of both staff and residents. S/he said deviation from what transfer modality was assessed and recommended for a resident could result in fall, fracture, increased pain, and other serious harm to the resident. S/he added that there was the potential for staff or resident getting hurt. S/he verified that the therapy assessment of Residents #1 identified that the resident was to be transferred using a Hoyer lift with assistance of two staff members. On 01/15/2021 at 4:47 PM, Resident #1's responsible party (RP) was interviewed. The RP said the facility called to make him/her aware that the resident sustained [REDACTED]. S/he said Resident #1 had been bed ridden for approximately [AGE] years and was not able to stand or walk. S/he said when s/he questioned the NHA about what had transpired that led to the resident's fractured leg, the NHA told him/her that he investigated the incident with the resident and determined that Resident #1's fractured leg resulted from staff incorrectly transferring the resident. The RP said he/she questioned what happened with the staff who were implicated in causing Resident #1's fractured leg and he/she was told by the NHA that they were written up and educated. The RP said when he/she arrived at the hospital and spoke to the resident, the resident revealed to him/her that he/she had been in pain for three days without relief. The RP said he/she called the NHA back based on the information the resident relayed to him/her. The RP said the NHA verified that it was plausible that Resident #1 had been in pain for three days. On 01/15/2021 at 5:08 PM, the NHA was interviewed. The NHA said, when he was made aware of the incident with Resident #1, s/he immediately launched an investigation. The NHA stated two CNAs were noted to have been the last staff observed providing care for the resident before the resident started complaining of pain. The NHA said the staff were interviewed and the interview revealed that CNA #2 and CNA #3 used the wrong transfer technique with Resident #1. The investigation of the incident concluded that Resident #1's fractured leg resulted from CNA #2's and CNA #3's incorrect transfer of the resident. The NHA took corrective action against and wrote-up CNA #2 and CNA #3. The NHA stated the facility conducted a facility wide in-service which educated staff on how to safely transfer a resident and the level of support each resident needed. On 01/15/2021 at 5:27 PM, a follow-up interview was conducted with CNA #2 with the NHA present. CNA #2 said to the NHA that she did not receive a corrective action nor got any in-service training about the incident with Resident #1. The NHA was unable to provide a corroborating evidence that CNA #2 received a corrective action and was in-serviced as he earlier asserted. In addition, CNA #3 took the same position as CNA #2 without the NHA being able to provide any corroborating evidence of his assertions as earlier described. 2. On 01/15/2021 at approximately 8:36 AM, an initial tour of the facility revealed 16 residents (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) who were randomly observed across the facility when staff assisted them with transfers, were held with their clothing when nursing staff attempted to assist the residents. On 01/15/2021 at 10:15 AM, CNA #1 was interviewed. S/he said she did not have access to a gait belt if s/he needed to use one. S/he said she improvised for the gait belt by using the resident's clothing to hold them up. S/he said s/he does not know how to lookup or have access to information about the transfer status of a resident. S/he said she had not been in-serviced about it either. On 01/15/2021 at 11:32 PM, CNA #5 was interviewed. S/He said he was not assigned a gait belt and had not had to use one because he was able to make his way with the transfer of the residents. S/He denied having been in-serviced about transfers or the importance of using a gait belt when transferring a resident who required one. On 01/15/2021 at 4:25 PM, the Director of Therapy (DOT) was interviewed. She said the facility evaluated a newly admitted resident for their therapy needs and/or evaluated them based on the skilled order the resident came in with. S/he added that with new residents, the facility had a therapist complete a comprehensive evaluation of the resident which included transfer, mobility, strength, and balance. S/he said the therapy department communicated the residents' transfer needs to the nursing staff and kept them up to date if there were any changes made (if the resident continued to be dependent or independent and what the evaluated transfer modality was recommended for the resident). S/he said it was very essential for nursing staff to adhere to the recommendation of the therapist on issues related to the therapist evaluated transfer modality for any resident. S/he said following the therapist recommendation was essential to ensure the safety of both staff and residents. S/he said deviation from what transfer modality was assessed and recommended for a resident could result in fall, fracture, increased pain, and other serious harm to the resident. S/he added that there was the potential for staff or resident getting hurt. S/he said the gait belt was needed to be able to safely transfer and mobilize a resident. S/he said whenever staff had to be hands on with a resident, they needed to use a gait belt. S/he said the gait belt needed to be accessible. S/he said staff were not able to safely transfer a resident by relying on pulling against the resident's pants. S/he cited an example of how it was going to be difficult for staff to transfer a resident without a gait belt when the resident went to the bathroom. The DOT reviewed the therapy evaluation for 16 residents (Resident #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, and #19) who were randomly observed across the facility when staff assisted them with transfers while holding onto the resident's clothing to determine what the therapy evaluation identified and deemed appropriate for assisting the residents with transfers. The DOT verified that the randomly observed residents ought to have been transferred using a gait belt. On 01/15/2021 at approximately 5:35 PM, a tour of the facility was conducted with the facility's administration. The tour revealed nursing staff had no gait belt when they assisted residents with transfers. An interview was conducted with randomly selected nursing staff and it revealed the nursing staff did not know or have an idea where or how they knew what level of assistance or transfer technique to use with the residents. The randomly selected staff also expressed not having access to gait belts and relying on pulling on residents' clothing when they provided transfer assistance. A policy titled Lifting Machine, using a Mechanical, revised on 07/2017, was provided by the DOT. The gait belt portion of the policy read: Staff members are required to utilize a gait belt at all time when assisting patients during transfers and/or ambulation. Residents participating in transfers and/or ambulation will be assessed by nursing or rehab staff for potential use of gait belt during gait and/or transfer, taking into consideration, potential precautions, or contraindications. Gait belt use is generally indicated for all residents participating in transfers and/or gait. Prior to transfer or ambulation, the gait belt is secured around the resident waist level (umbilicus level) and snugly adjusted to allow staff member's hand to firmly hold belt. 3.a. Resident #2 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required extensive assistance for bed mobility, locomotion, dressing, toilet use, eating and personal hygiene. The plan of care created on 10/15/2019, and updated 01/15/2021, indicated Resident #2 required extensive to total assistance in most ADLs. The approach portion of the care plan documented Hoyer lift x 2 staff members for transfer. On 01/15/2021 at 9:48 AM, CNA #1 was observed as s/he went into the room of Resident #2 with a Hoyer lift (a mechanical lift). The CNA was not in company of any other staff when s/he went in the room. After arriving at the room door, CNA #1 pushed the lift into the room and closed the door after herself. S/he exited the room after approximately 22 minutes. CNA #1 exited the room alone. Observation of the room after the CNA exited the room revealed there was no other staff in the room. The resident was in the wheelchair instead of being in bed. On 01/15/2021 at 10:15 AM, CNA #1 was interviewed. CNA #1 said s/he knew the level of assistance that Resident #2 required. The CNA stated s/he was required to have another staff present when s/he used the mechanical lift with the resident. S/he acknowledged that she performed the transfer of Resident #2 alone. 3.b. Resident #3 was admitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. The resident required assistance of two staff person for transfer; required one-person physical assistant with bed mobility, locomotion, dressing, toilet use, and personal hygiene. The resident was independent with eating and required only set-up assistance. The plan of care created 02/14/2018, and updated on 01/15/2021, indicated the resident required assistance with ADLs related to right sided [MEDICAL CONDITION] and right-hand contracture. Transfers were to be using a Hoyer lift with assistance of two staff. On 01/15/2021 at 11:07 AM, CNA #5 was observed as s/he went into the room of Resident #3 with a mechanical lift. S/He was not accompanied by any other staff. After the CNA went in the room, s/he was there for approximately 25 minutes. When s/he exited the room, observation of the room revealed there was no other staff present. The resident was in bed instead of still in the wheelchair. On 01/15/2021 at 11:32 PM, CNA #5 was interviewed. S/He said he transferred residents assigned to him based on his assessment of the resident. S/He said he made the determination of how to transfer a resident based on the resident size. S/He said if a resident appeared to be light weight, s/he transferred them by himself. S/He said, however, if the resident appeared bigger, or was not able to assist with the transfer, s/he used the mechanical lift alone with the resident. S/He said s/he did not know where to look for information regarding how to transfer a resident or the required level of assistance a resident needed. On 01/15/2021 at 4:25 PM, the Director of Therapy (DOT) was interviewed. S/he said the facility evaluated a newly admitted resident for their therapy needs and/or evaluated them based on the skilled order the resident came in with. S/he added that with new residents, the facility had a therapist complete a comprehensive evaluation of the resident which included transfer, mobility, strength, and balance. S/he said the occupational therapist evaluated for resident's needs with activities of daily living (bathing, dressing, wheelchair positioning etc .). S/he said once the therapist knew what the residents' needs were, the therapist wrote up their plan of care and goals. S/he said the therapist addressed the residents' skill need when they are on therapy. S/he said the therapy department communicated the residents' transfer needs to the nursing staff and kept them up to date if there were any changes made (if the resident continued to be dependent or independent and what the evaluated transfer modality was recommended for the resident). S/he said the therapy department re-assessed a resident when a decline was noted and recommended something else if needs warranted. S/he said it was very essential for nursing staff to adhere to the recommendation of the therapist on issues related to the therapist evaluated transfer modality for any resident. S/he said following the therapist recommendation was essential to ensure the safety of both staff and residents. She said deviation from what transfer modality was assessed and recommended for a resident could result in fall, fracture, increased pain, and other serious harm to the resident. She added that there was the potential for staff or residents getting hurt. S/he verified that the therapy assessment of Residents #2 and #3 identified that the residents were to be transferred using a Hoyer lift with assistance of two staff members. A policy titled Lifting Machine, using a Mechanical, revised on 07/2017, was provided by the DOT. The policy read in part: At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift. On 01/16/2021 at 3:27 PM, a Plan of Removal for the IJ situation was submitted by the facility and accepted by the State Agency. It read as follows: Plan of Removal (POR): Residents' care plans were updated to include current and appropriate transfer status. This was completed as of 01/16/2021 with an updated S/S of F. The transfer status will be determined by nursing and/or the therapy department (physical therapy or occupational therapy). Residents #1-#19 had their care plans updated to include their transfer status and the number of staff required for transfers (whether no assistance, one person assistance, or two-person assistance). Completed as of 01/16/2021. Nursing staff (RN's, LPN's, and C.N.A's) have been educated on where to locate information regarding current transfer status, which is accessed via the resident's Point of Care kiosk under resident profile and the current care plan tab, appropriate use of gait belts, mechanical lifts, and transfers. Staff members who provided transfer of affected resident/s were educated on using the correct transfer status according to the information available in the Point of Care profile in the kiosks. Resident #1 was treated at the emergency room , returned, and a follow-up orthopedic appointment was scheduled. The appointment was for 01/18/2021. All nursing staff (RN, LPNs, and CNA's) were educated on appropriate use gait belts (all transfers except for mechanical lift and those who are deemed to be totally independent must use gait belt), appropriate use of mechanical lifts, the necessity of having two staff members when using a mechanical lift and where to locate the appropriate transfer status for each resident. Gait belt training included the appropriately sized gait belt to use on the resident, how to apply the gait belt, how to remove the gait belt, and all other elements covered in the policy and procedure for use of gait belts. Policy and procedures were utilized for the education of staff. The education was being completed by the Director of Nursing, Unit Manager, Director of Therapy, and/or Staff Development Coordinator. Gait belts were issued to staff and/or staff were aware gait belts were available at the nurses' stations. Education was completed for staff on duty as of 01/16/2021. Off duty staff were contacted via phone and in serviced as of 01/16/2021. Staff that have not been reached will receive the education prior to their next scheduled shift. All residents being transferred by staff had the potential to be affected. All residents' care plans were reviewed for appropriate transfer status and updated as necessary This was completed 01/16/2021. Nursing staff were educated on appropriate use of gait belts (all transfers except for mechanical lift and those who were deemed to be totally independent), appropriate use of mechanical lifts, the necessity of having two staff members when using a mechanical lift and where to locate the appropriate transfer for each resident. With the updating and/or creation of the care plans, the information was immediately available to the CNA's through the kiosks and in the resident's record. Newly admitted residents will have their transfer status determined by nursing/therapy and a care plan will reflect the current transfer status. The DON, Unit managers, and/or therapy department (physical therapy and/or occupational therapy) will review care plans of new admissions to ensure the current transfer status and the number of staff to assist in transfer was present in the care plan. This will be accomplished during daily morning clinical meetings. The observations will be completed by the DON, Staff Development Coordinator, Director of Therapy, Unit Manager or Manager on Duty. They will observe five transfers per day on different shifts to include mechanical lifts and the proper use of gait belt for four weeks. Observations will continue at three observations per day a week on different shifts for 4 weeks. Observations will continue at one daily observation per shift for four weeks. Observations of four CNA's knowledge of location of transfer status of residents will be completed for four weeks on different shifts. Observations of two CNA's knowledge of transfer status of residents will be completed daily for four weeks on different shifts. Random observations of at least one CNA per day will be completed for four weeks on different shifts. The results of all audits will be reviewed at the monthly QAPI meetings for further recommendations for a minimum of three months and substantial compliance had been achieved. The NHA will be responsible for the implementation of the Plan of Removal. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 01/18/2021 between the hours of 8:45 AM and 3:49 PM. Eleven interviews were conducted to verify in-service training had been completed with nursing staff on where to locate information regarding current transfer status for all residents. The interview also involved the surveyor and nursing staff review all residents' care plans to verify that they had been updated to include current and appropriate transfer status and the number of staff required for transfers (whether no assistance, one person assistance, or two-person assistance). Of those interviewed, were eight CNAs, two were LPNs and one RN. The staff interviewed demonstrated that the facility provided gait belts to all nursing staff. In addition, the nursing staff demonstrated that they were educated on where to locate information regarding current transfer status and that the information was accessed via the resident's Point of Care kiosk under resident profile and the current care plan tab. The staff correctly demonstrated appropriate use of gait belts and mechanical lifts during residents' transfers observations. Resident #1 made it to the follow up orthopedic appointment on 01/18/2021.

Based on record review and interview, the facility failed to be administer in a way to prevent abuse, follow abuse policies, investigate, and report allegations of abuse. The findings included: Cross refer to F600 Abuse/Neglect, F610-Investigate/Prevent/Correct alleged violation, F657 Care Plan Timing and Revision, and F865 QAPI. Review of the facility's Abuse Prevention Program revealed As part of the resident abuse prevention, the administration will: 3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Identify and assess all possible incidents of abuse; 7. Investigate and report any allegations of abuse within timeframes as required by federal requirements; 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse . Review of the facility's policy labeled Abuse Neglect - Clinical Protocol revealed The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

Based on record review and interviews, the facility failed to maintain a Quality Assurance Program that identified and addressed the facility's problems. The findings included: Cross refer to F600 for incident involving resident #8 and #14. On 7/11/18 Resident #8 and #14 had inappropriate sexual behaviors in a common area. Resident #14 had a history of [REDACTED]. The facility did not investigate the incident nor report the incident to the state agency. Resident #8 and #14's care plans were not revised to address the behaviors of the incident. The facility failed to put a plan into place to prevent incident reoccurrences.

Based on record review and interview, the facility failed to investigate, prevent and/or correct allegations of alleged abuse for 2 of 10 residents sampled for abuse. Resident #8 and #14. The findings included: On 7/11/18 residents #8 and #14 were observed with inappropriate sexual behavior conducted in a resident common area. The residents were separated, and the incident was reported to the Director of Nursing (DON). There was no evidence the facility conducted an investigation or put interventions in place to prevent any further abuse from occurring. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The surveyor requested the facility investigation for the incident dated 7/11/18 involving Resident #8 and #14. The surveyor was informed by the DON that an investigation was not completed. Review of Resident #14's care plan dated 9/26/17 revealed that the resident had inappropriate sexual behaviors, such as exposing him/herself in common areas of the facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. Review of Resident #14's medical record revealed a Psychiatric evaluation dated 9/26/17. BIMS (Brief Interview for Mental Status) - 6 (6 of 15). Due to Dementia, s/he is unable to provide reliable review of systems. S/he has behavioral episodes of resistance to care and unwillingness to participate in PT (Physical Therapy) program. Patient also has been observed with sexually inappropriate behaviors and poor boundaries. Has exposed self inappropriately and touched resident's breast. S/He has poor insight and memory regarding behaviors. Review of the facility's policy labeled Abuse Investigation and Reporting reveled All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported.

Based on record review and interview, the facility failed to revise care plans for 2 of 10 residents sampled for abuse. Resident #8 and #14 with sexual behaviors, care plans were not revised following an incident on 7/11/18 of sexual behaviors. The findings included: On 7/11/18 staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. Resident #8 was observed to be holding resident #14's penis. Resident #14 had a history of [REDACTED]. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that Resident #8 initiated the incident on 7/11/18. The Unit Manager stated that Resident #8 likes to touch and rub on people. Review of Resident #8's Care Plan revealed that the Care Plan did not address the resident's need to touch/feel others or the sexual encounter between the Resident #8 and #14. The facility admitted resident #8 on 7/20/17 with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed a Significant Change assessment dated [DATE]. The Significant Change Assessment revealed Long and short-term memory impairment. Seldom understood or understands. Never rarely makes decisions. Wanders daily throughout facility. No sexual behaviors were listed for the Significant Change. Review of the Resident #8's Plan of Care revealed care was planned for [MEDICAL CONDITION] drug use: [MEDICATION NAME] for depression, [MEDICATION NAME] for mood disorder and depression, [MEDICATION NAME] for depression and prn [MEDICATION NAME] for anxiety. There was no plan of care for the sexually inappropriate behaviors. The facility admitted resident #14 on 9/11/17 with [DIAGNOSES REDACTED]. Review of Resident #14's Care Plan revealed that the Care Plan addressed sexually inappropriate behaviors; however, the care plan was not revised to speak to reoccurrences of the behaviors. Resident #14 had repeated behaviors of sexually inappropriate behaviors. Review of Resident #14's Plan of Care dated 9/26/17 revealed, Inappropriate sexual behaviors, such as exposing self in common areas of facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. The care plan was not revised until 11/3/18.

Based on interview and record review the facility failed to keep residents free from abuse and neglect. Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for approximately 30 minutes during an evacuation. 2 of 2 CNA's reviewed for assignments. The facility failed to protect residents from sexual abuse. Staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. The facility failed to protect residents from verbal abuse. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. 3 of 10 residents sampled for abuse. The findings included: Two certified nursing assistants (CNAs), CNA #2 and #3, left their assigned residents unsupervised for an hour during an evacuation. Review of the facility assignment sheet for 9/11/18 revealed CNA #2 was assigned 12 residents and CNA #3 was assigned 10 residents. Review of the facility investigation on 11/3/18 at approximately 9:50 AM revealed that CNA #2 and #3 left their assigned residents without permission on 9/11/18 at approximately 10 AM. During an interview with the Director of Nursing (DON) and Chief Operations Officer (COO) on 11/3/18 at approximately 11 AM. The DON and COO stated that CNA #2 and #3 left the facility without reporting to supervisors. Review of 9/11/18 time card reports on 11/3/18 at approximately 11:38 AM revealed CNA #2 clocked out at 10:05 AM and CNA #3 clocked out at 9:50 AM. During an interview with the DON on 11/16/18 at approximately 1:20 pm. The DON stated that the resident assignments were redone within 30 minutes of CNA #2 and #3 leaving. During an interview with the Human Resources Director on 11/3/18 at approximately 11:51 AM. The Human Resources Director confirmed interviews with the DON and COO and stated that resident care was affected because the facility was short-staffed during the evacuation. During an interview with CNA #2 on 11/3/18 at approximately 3:15 PM revealed both CNAs left the facility without arranging for care for residents. CNA #2 stated that s/he did not know who would look after the residents after s/he left. On 7/11/18 staff members observed sexually inappropriate behavior in a common area between residents #8 and #14. Resident #8 was observed to be holding resident #14's penis. Resident #14 had a history of [REDACTED]. The facility admitted resident #8 on 7/20/17 with [DIAGNOSES REDACTED]. Review of Resident #8's medical record revealed Nurse's Notes dated 7/11/18. The Nursed Note revealed Resident noted to be standing in front of resident (#14) holding resident's penis in her/his hand. Resident #14 was sitting in rollator walker. Floor nurse separated the two immediately. Resident's family and physician notified. Review of Resident #8's medical record revealed a Significant Change assessment dated [DATE]. The Significant Change Assessment revealed Long and short term memory impairment. Seldom understood or understands. Never rarely makes decisions. Wanders daily throughout facility. No sexual behaviors were listed for the Significant Change. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that Resident #8 initiated the incident on 7/11/18. The Unit Manager stated that Resident #8 likes to touch and rub on people. The facility admitted Resident #14 on 9/11/17 with [DIAGNOSES REDACTED]. Review of the Resident #14's medical record revealed in (MONTH) of (YEAR), the resident displayed inappropriate sexual behavior of touching a resident's breast. Resident #14's medical record revealed that throughout Resident #14's stay the resident demonstrated inappropriate sexual behaviors of exposing him/herself in public areas. Review of Resident #14's Nurses Notes from (MONTH) 1, (YEAR) through 11/16/18 revealed that Resident #14 noted to be alert and able to make needs known with some confusion noted. The Nurses Notes also revealed that Resident #14 continually takes pull ups off and refuses to wear pull ups or any underwear at times. Review of the Resident #14's Plan of Care dated 9/26/17 revealed, Inappropriate sexual behaviors, such as exposing self in common areas of facility, attempting inappropriate behaviors with female residents, inappropriate comments also noted and can be difficult to redirect. Review of Resident #14's medical record revealed a Psychiatric evaluation dated 9/26/17. BIMS (Brief Interview for Mental Status) - 6 (6 of 15). Due to Dementia, s/he is unable to provide reliable review of systems. S/he has behavioral episodes of resistance to care and unwillingness to participate in PT (Physical Therapy) program. Patient also has been observed with sexually inappropriate behaviors and poor boundaries. Has exposed self inappropriately and touched resident's breast. S/He has poor insight and memory regarding behaviors. During an interview with Licensed Practical Nurse (LPN) #2 on 11/16/18 at approximately 11:45 AM. LPN #2 stated that when Resident #14 first came to the facility the resident would make sexual remarks. LPN #2 also stated that Resident #14 liked for the CNAs to wash him/her. During an interview with the Unit Manager on 11/16/18 at 12:05PM. The Unit Manager stated that when Resident #14 first came to the facility s/he did not wear underwear, and his/her penis would fall out of his/her pants. Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Review of the facility investigation on 11/3/18 at approximately 3:10 PM revealed that on 4/4/18 Resident #1 alleged that CNA #4 told him/her if s/he didn't stop hollering s/he was going to put a bag over his/her head and strangle him/her. Resident #1's roommate confirmed the CNA stating this. The facility investigation revealed that the facility substantiated the allegation and CNA #4 was terminated. During an interview with Resident #1's roommate on 11/3/18 at approximately 4:11 PM. Resident #1's roommate confirmed his/her statement that CNA #4 said s/he would put a bag over Resident #1's head who then started cursing him/her out. During an interview with CNA #4 on 11/4/18 at approximately 11:20 AM. CNA #4 stated that after s/he changed Resident #1 the Resident began cursing at him/her so s/he left and had another CNA care for the resident. CNA #4 denied stating s/he would put a bag over the resident's head.

On the days of the Complaint Survey, based on record review, interviews, and review of the facility's policies "Use of Physical Restraints/Devices and Side rails" and "Positioning the Resident," the facility failed to implement interventions and/or assistive devices, failed to communicate the interventions to all relevant staff, and failed to provide training as needed to reduce the risk for falls for Resident #1, 1 of 3 residents reviewed for falls. The facility failed to provide side rails for Resident #1, failed communicate to the staff that 2 staff members were needed for turning a resident that requires total care in the absence of side rails, and failed to train the staff on facility policies related to bed mobility. The findings included: The facility admitted Resident #1 with [DIAGNOSES REDACTED]. Observation of Resident #1 on 9/12/12 at 5:49 PM revealed the resident was supine in bed with the head of the bed elevated approximately 30 degrees with 1/2 side rails up on both sides of the bed. On 9/12/12 at 6:00 PM, review of the Kardex, the CNA (Certified Nursing Assistant) care plan, revealed a Section headed Side Rails that was noted blank. In the Section headed Bed Mobility the Kardex indicated "Staff" and additional instructions were "Turn (and) reposition q (every) 2 (hours) (and) PRN (as needed)." The Kardex did not include information related to the number of staff required to turn the resident. At 11:10 AM on 9/13/12, record review of the Nurse's Notes revealed a note dated 7/18/12 at 10:30 PM by the LPN on duty that the resident had rolled out of bed and fell on the floor. The note further stated there was "bruising to upper back between shoulders 16.5 x 7 in(ches)." A note dated 7/19/12 at 12:00 AM stated, "Abrasion noted btw (between) shoulder blades 16.5 x 7 inches." Review of the Progress Notes revealed a note from the physician dated 7/18/12 and no bruises or abrasions were noted at that time. Further record review revealed a Fall Risk assessment dated [DATE] with a score of 10, representing "HIGH RISK." The assessment was completed again on 7/30/12 with a score of 10, high risk. Continued record review revealed a Siderail Assessment, which stated, "(no) order for S/R (side rails)" dated 6/17/12. On 9/13/12 at 9:48 AM, record review revealed a Physician's Telephone Orders dated 7/18/12 at 10:30 PM that stated "Apply A&D ointment Q (every) shift to abrasion bw (between) shoulder blades until healed." Another telephone order dated 7/19/12 for "SR (side rails) 1/2 X (times) 2 (up) for safety" was noted during review of the telephone orders. Review of the July monthly cumulative physician's orders [REDACTED]. Review of the resident's care plan revealed it was updated after the resident's fall to include side rails for safety. Review of the facility's policy for "Use of Physical Restraints/Devices and Side rails" revealed that the use of side rails requires "a written order that specifies the type... when it is to be used, and why/medical symptom it is to be used." The policy further states, "Staff applying the ...side rail should be appropriately trained their use and application." Review of the facility's policy "Positioning the Resident," under Procedure, " revealed the instructions "6. To turn Resident on Side: a. Put side rail up on far side of bed." and "D. Roll gently away." During an interview on 9/12/12 at 6:05 PM, the Director of Nursing (DON) confirmed the Kardex did not indicate how many Certified Nursing Assistants were required for bed mobility. She stated it was the facility's policy to have 2 CNAs turn and reposition residents who could not assist. The Unit Manager, also present during the interview, stated if something was on the opposite side of the bed, such as another staff member or side rails, then the resident could be turned away from the staff member. She further stated that if there was no support on the opposite side of the bed then the staff should always turn the resident toward themselves. During an interview on 9/13/12 at 10:52, the MDS (Minimal Data Set) Coordinator stated that padded side rails had been discontinued over a year ago since the resident had not had any seizure activity and was unable to move herself. He also confirmed the care plan had been updated after the resident's fall to include side rails for safety. The DON was interviewed on 9/13/12 at approximately 1:20 PM and confirmed there was not information in the orientation provided to new CNAs related to positioning residents. She stated that the staff was told what's expected but there was not documentation to support that the staff involved were provided that information. The DON also confirmed that a skills checklist was not available for CNA #1 in her personal file and said it was possible the CNA did not finish the skills checklist. In addition, the DON stated that the lift policy stated if a second CNA was not available to assist, then the CNA should wait until another staff member was available. She stated the same would apply to turning a resident in bed if there was nothing on the other side of the bed to keep the resident from falling but confirmed that information was not in the facility policy for positioning a resident in bed. The DON also confirmed that Resident #1 did not have side rails on her bed prior to her fall. The DON also stated that CNA #1 told her "I wanted to get someone to help me but no one would come down. Then (CNA #2) entered the room and then left."

On the days of the survey, based on interview and review of the Resident Informed Consent Agreement and Resident Trust Fund records, deductions were made from multiple resident personal accounts for routine personal laundry services which were covered by Medicare and Medicaid provider agreements. The findings included: On 7/11/12 at approximately 11:15 am during a record review and interview with the Business office manager, revealed a letter sent to the residents, family members and responsible parties that due to cuts in medicaid, the facility will charge for resident's personal laundry. "Effective October 1, 2011 should you wish the facility to continue washing your personal laundry a charge of $15 will be charged toward your account." Review of the Resident Informed Consent agreement revealed: "There is a $15 fee per month for laundry service." Review of the Resident Trust fund records 55 resident accounts were deducted $15 fee per month for laundry. There was no evidence to substantiate that individual residents, family members, or responsible parties requested/authorized the facility to deduct funds for laundry. In an interview with the Administrator, she confirmed that the facility was not suppose to deduct resident funds for laundry services, since personal laundry is a covered service under Medicare/Medicaid.