Every finding on record at Oak Manor Healthcare & Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to ensure resident walls and ceiling tiles were maintained in a clean, sanitary, and homelike environment for three resident rooms (224, 225, and 226) out of three rooms observed on the central wing. Findings included: An observation was conducted on 1/27/25 at 9:50 AM of room [ROOM NUMBER]. There was peeling paint behind both beds in the room and missing paint on the wall near the bathroom door. Behind bed A there was missing paint with exposed wood that was shredded. The air vent was observed to be against a ceiling tile and where the ceiling tile and the air vent meet there was a black and rust-like discoloration on the ceiling tile. (Photographic evidence obtained.) An observation was conducted on 1/27/25 at 9:52 AM in room [ROOM NUMBER]. The air vent was observed to be against the ceiling tile and where the air vent and the ceiling tile meet the ceiling tile had a black and rust-like discoloration. An observation was conducted on 1/27/25 at 9:53 AM in room [ROOM NUMBER]. The air vent was observed to be against the ceiling tile and where the air vent and the ceiling tile meet the ceiling tile had a black and rust-like discoloration. An interview was conducted on 1/27/25 at 10:27 AM with Staff A, Certified Nurse Assistant (CNA) she said she did not know how long the walls in room [ROOM NUMBER] had peeling paint and shredded wood. She said she did not notice the discoloration on the ceiling tile above the air vent. She said when there was a problem whoever saw the problem notified maintence or put it into the work order reporting system. An interview was conducted on 1/27/25 at 12:49 PM with the Maintence Director. He said he did not have a schedule to clean air vents. He reviewed the photographic evidence and said the black and [NAME]-like discoloration was from the moisture of the air vents blowing onto the ceiling tiles. He said he would get notified by the staff of those concerns through the work order reporting system. He said for about a year he had been going room to room and doing renovations including drywall, paint, fixtures, faucets, replacing anything that is out of date. He reviewed the photographic evidence of room [ROOM NUMBER] and said he had a list of the rooms that had been renovated. He provided a map of the facility and said the orange highlighted rooms were the ones that had been renovated. room [ROOM NUMBER] was highlighted orange. The Maintence Director said room [ROOM NUMBER] was renovated but he needed to go back and do it again. He said his problems were electric wheelchairs and staff moving the beds up and down and scraping the walls. An interview was conducted on 1/27/25 at 2:09 PM with the Nursing Home Administrator. She said the facility did angel rounds on the resident rooms and if they saw something in the room that needed repairs, they would report it in the work order reporting system. She said the facility was doing room repairs but she was not sure how long they had been doing the repairs. She said she knew there were damaged walls in the resident rooms and once the room renovation was done there would be FRP [fiber reinforced polymer] wall panels behind the beds. Review of the facility's Environment policy and procedure dated 1/5/24 revealed, Intent: It is the policy of the facility to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible, according to state and federal regulations. Procedure: .3. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. .7. The facility will provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior .

Based on interview and record review, the facility failed to implement a comprehensive person-centered care plan related to wound care orders for one (Resident #1) of three sampled residents. Findings included: Resident #1 was admitted on [DATE] and discharged on [DATE]. Admission record showed diagnoses included but not limited to spinal stenosis lumbar region, spondylolisthesis lumbar region, low back pain, abnormalities of gait and mobility, and peripheral vascular disease. Review of orders showed offload heels often in bed as tolerated and skin prep heels every shift and wound consult for evaluation and treatment for issues identified. Review showed the physician orders to perform left dorsal wound care was not on the physician orders. Review of the Treatment Administration Record of April 2024 showed no documentation that left foot wound care was performed. Review of wound care specialist provider note dated 04/04/2024, showed wound left dorsal foot is a full thickness mixed and has received a status of not healing. Initial wound encounter measurements are 6 centimeters (cm) x 4 cm x no depth, are of 24 square cm. Moderate amount of serous drainage noted. No odor noted. Pain level of 3/10. The peri-wound was moist. Weeping edema, surrounding petechia of left dorsal foot. Cleanse with normal saline, apply alginate, then super-absorbent pad, wrap with rolled gauze and secure with tape daily and prn. Offload heels. Review of the nursing progress notes dated 04/04/2024 showed Resident #1 was assessed by the wound care specialist Advanced Practice Registered Nurse (APRN). Left foot was assessed due to weeping edema. Left dorsal foot 6 cm x 4 cm x 0 area of weeping edema with surrounding petechia. Arterial Ultrasound was ordered. Resident reeducated on his high risk for further skin breakdown including pressure injury. Resident voices good understanding. Review of care plans showed Edema risk to extremities as of 03/19/2024. Interventions included but not limited to treatment as ordered. During an interview on 06/05/2024 at 11:11 a.m., the Assistant Director of Nursing (ADON)/ Wound Care nurse stated the wound care specialist came in on Thursdays. The resident had weeping edema in his lower extremities. They did arterial and venous ultrasounds that were negative and they ruled out Deep Vein Thrombosis. His heels were clear. His dorsal left foot was observed by the specialist and she wrote it up as a mixed venous arterial wound, 6 cm x 4 cm x 0 depth. The wound was to be treated with super absorbent dressing due to the weeping. She stated the left dorsal foot did not have an open area. The area was surrounded by petechia. During an interview on 06/05/2024 at 1:10 p.m., the Director of Nursing (DON) was unable to locate wound care orders for the left dorsal foot. The DON stated the wound care for the foot was not performed per review of the Treatment Administration Record (TAR). The DON spoke with the (ADON)/ Wound Care nurse and said she was the staff member who normally entered the wound care orders. The DON stated he was not sure why the ADON did not follow up. Review of the facility's policy, Documentation of Wound Treatments, implemented 12/01/2023 showed the facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition, and changes in treatment. 4. Additional documentation shall include, but is not limited to: a. date and time of wound management treatments b. modifications of treatments and interventions, e. notification of physician and / or responsible party regarding wound or treatment changes.

Based on observations, staff interviews and facility file review, the facility failed to ensure an effective pest control program to include one of one kitchen space, and during two of four days observed (1/22/2024 and 1/24/2024). Findings included: On 1/22/2024 at 10:34 a.m. during an initial kitchen tour there were seven to eight black in color small flying insects observed flying around the area. The flying insects were observed flying around the sink wall, around and near the parked meal tray carts, around and near the S plastic water drain pipe under the sink, as well as at, near and under the dish washing machine, specifically near the floor drain. Immediately following the observation an interview was conducted with the Dietary Aide Staff E, who confirmed the small flying insects at and under the dishwashing machine. She confirmed the insects have been in the area on and off for a few weeks but did not know when they first appeared. Further interview with the Certified Dietary Manager, who was in the area, also confirmed the small flying insects at and around the dish washing machine, surrounding parked meal tray carts as well as at and near the hand washing sink. She too was not able to remember when the small flying insects first appeared, but they have been noticing them on and off for the past few weeks. She added the facility does have a pest control company who comes out and they have treated the kitchen for pests to include the small flying insects. The Certified Dietary Manager confirmed she was not sure where the flying insects were coming from but it could be possible from a floor drain or two. On 1/22/2024 at 12:10 during a second tour of the kitchen, and with the Certified Dietary Manager and the Nursing Home Administrator, it was again observed many small flying objects surrounding the dish washing machine area, parked meal tray carts and at and near the hand washing sink. The Certified Dietary Manager again confirmed the small flying insects and she did point out as they were receiving dish washer maintenance, there were some flying insects near the floor drain under the machine. She was not sure if the small flying insects were coming from that area, but would speak to maintenance about de clogging the floor drain. On 1/24/2024 during a third kitchen tour at 10:50 a.m. and after walking up to the hand washing sink; the sink area was observed with over five small black in color flying insects. The insects were noted to fly around the meal tray carts, the hand washing sink, one to two feet from the meal service station, and at and near the dish washing machine. The Certified Dietary Manager, and the head Cook Staff G also confirmed the flying insects and again confirmed they have been around the kitchen for some time and that Pest Control services treat but it seems the insects keep coming back. On 1/25/2024 at 8:00 a.m. the Nursing Home Administrator provided the facility's Pest Control program service contract and policy and procedure for review. Review of the Pest Control Agreement revealed a beginning service date of 4/1/2021 and is still current. The contract revealed Roaches, Ants, Silverfish and Rodents were the pests to be routinely controlled. The contract revealed services will be conducted on a monthly basis. Further review of the monthly pest control log revealed routine service visits on 8, 9, 10, 11, 12/2023 as well as 1/2024. The log also revealed request visits during the same timespan reviewed. Months 10/2023 revealed flying ants in the Administration office. There was no other documentation to support treatment for other flying insects, and specifically in the kitchen. The Nursing Home Administrator provided evidence of the type of product that was used to treat the surfaces, walls and ceilings, in order to prevent further outbreaks of flying insects. The date of that treatment was noted on 1/25/2024. Review of the pest control policy and procedure with a revision date of 1/5/2024 revealed; It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. The definition explained; an Effective pest control program is defined as measures to eradicate and contain common household pest (e.g. bed bugs, lice, roaches, ants, mosquitos, flies, mice and rats). The policy continued; 1. Facility will maintained a written agreement with a qualified outside pest service to provide comprehensive pest control services on a regular and scheduled basis. 2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the building without compromising resident health. 3. Facility will maintain a report system of issues that may arise in between scheduled visits with the outside pests services and treat as indicated. 4. Facility will utilize a variety of methods in controlling certain seasonal pests i.e. flies. These will involve indoor and outdoor methods that are deemed appropriate by the outside pests service and state and federal regulations. 5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any outlying buildings or structures, i.e. dumpster area, etc.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment for three (#126, #127, and #128) of three records reviewed, related to discharge. Findings included: 1. Review of the clinical record for Resident #126 revealed admission to the facility on [DATE] and discharge on [DATE] as per the face sheet. Further review of the Progress notes dated [DATE] revealed the resident was in respiratory distress. Orders were received, the family was notified, and the resident was sent out of the facility to [name of hospital] for further assessment and treatment. Review of the MDS assessment dated [DATE] revealed: Section A, Part F: Death in Facility. Section A, Part A2000: discharge date - [DATE]. Section A, Part A2105: Discharge Status - deceased . 2. Review of the clinical record for Resident #127 revealed admission to the facility on [DATE] and discharge on [DATE] as per the face sheet. Further review of the Progress notes dated [DATE] showed the resident was discharged to [name of Assisted Living Facility (ALF)] with all belongings, medications, and discharge instructions. Review of the MDS assessment dated [DATE] revealed: Section A, Part F: Discharge, Return not Anticipated. Section A, Part A2000: discharge date - [DATE]. Section A, Part A2105: Discharge Status - Short-Term General Hospital (acute hospital). 3. Review of the clinical record for Resident #128 revealed admission to the facility on [DATE] and discharge on [DATE] as per the face sheet. Further review of the Progress notes dated [DATE] showed the resident was discharged to [name of hospital] related to radiology results and a potential deep venous thrombosis. Orders were received and the resident's family was on site and aware. Review of the MDS assessment dated [DATE] revealed: Section A, Part F: Discharge, Return not Anticipated. Section A, Part A2000: discharge date - [DATE]. Section A, Part A2105: Discharge Status - Home/Community. On [DATE] at 9:32am, an interview was conducted with Staff A, Licensed Practical Nurse (LPN), MDS Coordinator. The above MDS assessments were reviewed with Staff A, who confirmed: -Resident #127 was discharged to an ALF and the Discharge MDS assessment, which listed the discharge disposition to a hospital, was incorrect. -Resident #128 was discharged to a hospital and the Discharge MDS assessment, which listed the discharge disposition to Home/Community, was incorrect. Staff A reviewed the MDS assessment and clinical records for Resident #126. She confirmed the resident was discharged to the hospital and the discharge disposition on the MDS Discharge assessment was listed as 'death in facility.' Staff A stated the resident expired in the Emergency Department (ED) of the hospital and as the resident was not admitted to the hospital, the discharge disposition was listed as 'death in facility.' On [DATE] at 9:49am, an interview was conducted with Staff B, LPN, MDS Coordinator. Staff B stated she was taught to use 'death in facility' when a resident expired in the ED of the hospital. Review of the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual dated [DATE], Chapter 2, Assessments for the RAI, Page ,d+[DATE] revealed: Death in facility refers to when the resident dies in the facility or dies while on leave of absence (LOA) . On [DATE] at 10:14am, an interview was conducted with the Director of Nursing (DON). The DON confirmed he signs all MDS assessments. He confirmed he does that as the MDS coordinators are LPNs. The DON said he does not always check the MDS assessment, stating, I trust them. Review of a facility-provided policy titled MDS 3.0 Completion and dated [DATE] revealed: 2i. Death Tracking: i. Complete when a resident expires in the facility or when on LOA no later than discharge (death) date + 7 calendar days. 4b. Coding of Assessment: i. All disciplines shall follow the guidelines in Chapter 3 of the current RAI Manual for coding each assessment.

Based on observation, interviews, and record review, the facility failed to ensure one resident (41) out of thirty-five sampled was care planned for behaviors. Findings included: On 01/22/24 at 2:30 p.m., an observation was made of two residents arguing in their room. Resident #41 was sitting on the edge of her bed with pieces of her landline phone in her hand. Resident #379 seated in a wheelchair, stated her roommate, Resident #41, was coming on her side and taking her stuff from her nightstand. Resident #41 stated her son was coming to pick up her phone and to repair it. Resident #41 then placed the phone down on the bed and reached over to Resident #379's nightstand and grabbed an item. Resident #379 yelled out, that's my bible, leave it alone, put it back, she keeps taking my things. Resident #379 stated not only does she keep taking her things but Resident #41 has struck her twice since Resident #379 has been newly admitted to this room stating, she's hit me twice since I've been with her but I don't strike back. Resident #379 stated she returned from the hospital recently and was placed in this room with her roommate. Immediate assistance from staff members was sought with a speech therapist outside hallway arrived to intervene. The Director of Nursing (DON) was sought out and updated immediately on events. On 01/23/24 at 10:45 a.m., an observation was made of Resident #379 in a new location with a new roommate. Resident #379 stated she was fine with the new move and her roommate stated, I heard what happened to her and I will protect her, she is safe with me. A review of Resident #41 admission has an admitted [DATE] with a primary diagnosis of Urinary Tract Infection (UTI) as well as dementia, anxiety, depression. A review of the Admission Minimum Date Set (MDS) dated [DATE] Section C-Cognitive Patterns has Resident #41 with a Brief Interview for Mental Status (BIMS) of 05 suggesting severe cognitive impairment. A review of the progress notes dated 12/27/23 at 12:09 p.m. for Behavior describes resident as, continuing to have periodic episodes of increased anxiety and aggression and is not easily directed. Resident in wheelchair, calling out for her son, grabbing at personal items belonging to other residents. Resident was scheduled to have diagnostic testing; however, refused. Non-pharmacological interventions were noted as soothing conversation, redirection from unsafe areas/situation, therapeutic activity of interest, offering of snack/hydration. A review of the progress note dated 1/10/24 at 7:01 a.m. for Behavior describes resident following CNA [certified nursing assistant] as they were trying to complete rounds during evening shift. Several attempts were made to try and enter other resident's room. She was redirected each time, becoming verbally aggressive towards staff each time. Compliant with HS [evening] meds after 3 attempts. Resident noted to be sleeping between 11pm and 4:30 am. At 04:50, resident started coming down the hall, attempting to go into resident's room. When attempts were made to redirect, resident became verbally and physically aggressive with nurse. Refused to take medications several times then when she agreed, she spit them out. Resident then remained in her room, refusing to allow nurse and CNA to enter the room. A review of Resident #41's Care Plan with a completion date of 12/31/23 showed no Behavior focused care plan. On 1/25/24 at 10:45 a.m. an interview was conducted with Staff J, Registered Nurse (RN). Staff J, RN stated resident #41 is confused sometimes but easily directed. Resident is no longer a 1:1 and had a visit from [a family member] yesterday that may have triggered resident in becoming slightly agitated by stating she wanted to go home but that she was able to calm resident down by offering a book to read. Staff J stated the Interdisciplinary Team (IDT) meets daily to discuss the facility's residents. When asked if Resident #41 should have been care planned for behavior Staff J stated, she should be. A review of the policy entitled, Comprehensive Care Plans revised 01/05/24, revealed, it is the policy of this facility to develop and implement a comprehensive person- centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 1. The care planning process will include an assessment of the resident's strengths and needs and will incorporate the resident's personal and cultural preferences in developing goals of care. Services provided or arranged by the facility, as outlined by the comprehensive care plan, shall be culturally- competent and trauma -informed. 2. The comprehensive care plan will describe, at a minimum, the following: a) the services that are to be furnished to attain or maintain the residence highest practicable physical, mental and psychosocial well-being. b) Any services that would otherwise be furnished but are not provided due to the resident's exercise of his or her rights to refuse treatment. c) Any specialized services or specialized rehabilitation services the nursing facility will provide as a result of PASARR recommendations. d) The resident's goal for admission, desired outcomes, and preferences for future discharge. e) Discharge plans as appropriate. 6. The comprehensive care plan will include measurable objectives and time frames to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed.

Based on observation, interview, and record review, the facility failed to maintain a system of records to accurately account for all controlled medications in one of three medication carts inspected for six (Resident #2, #5, #6, #7, #8, and #9) of 15 sampled residents. Findings included: An inspection of a medication cart was conducted on 9/18/2023 at 1:00 PM on the Central Wing of the facility with Staff A, Registered Nurse (RN). Staff A was observed at the unit nurse's station with the medication cart's controlled medication log. Staff A stated she was in the process of signing out the controlled medications she administered to residents during the morning medication pass. Staff A stated she would normally sign the controlled medications out at the point of the medication being administered to the resident, but she was having trouble keeping up with her assignment and stated it was hard to stop and go during the medication pass. Staff A addressed several of the resident's controlled medication count sheets would be incorrect as a result of her not signing them out at the time they were administered. The following was revealed during the inspection of the medication cart: - 28 prefilled syringes of Ativan/Benadryl/Haldol (ABH) 0.5 milligrams (mg)/12.5 mg/1 mg cream prescribed to Resident #6. The medication monitoring/control record documented 29 doses remaining. Staff A stated Resident #6 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 11 tablets of Ativan 0.5 mg prescribed to Resident #2. The medication monitoring/control record documented 12 doses remaining. Staff A stated Resident #2 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 10 tablets of Clonazepam 0.5 mg prescribed to Resident #7. The medication monitoring/control record documented 11 doses remaining. Staff A stated Resident #7 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 6 tablets of morphine sulfate 15 mg prescribed to Resident #8. The medication monitoring/control record documented 7 doses remaining. Staff A stated Resident #8 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 9 tablets of Oxycodone/acetaminophen 5 mg/325 mg prescribed to Resident #8. The medication monitoring/control record documented 10 doses remaining. Staff A stated Resident #8 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 16 tablets of Oxycodone/acetaminophen 10 mg/325 mg prescribed to Resident #5. The medication monitoring/control record documented 18 doses remaining. Staff A stated Resident #5 was administered two doses of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 13 tablets of morphine sulfate 15 mg prescribed to Resident #9. The medication monitoring/control record documented 14 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 13 tablets of Oxycodone/acetaminophen 7.5 mg/325 mg prescribed to Resident #9. The medication monitoring/control record documented 14 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. - A blister pack containing 4 tablets of Clonazepam 0.5 mg prescribed to Resident #9. The medication monitoring/control record documented 5 doses remaining. Staff A stated Resident #9 was administered a dose of the medication during the morning medication pass but she did not sign the medication out. An interview was conducted on 9/18/2023 at 2:56 PM with the facility's Director of Nursing (DON). The DON stated he would expect nursing staff to complete documentation on the medication monitoring/control record when administering controlled medication as well as in the electronic medical record at the time the medication was administered. The DON stated he would not expect nursing staff to wait until the completion of their medication pass to document on the medication monitoring/control record because it was not best practice and would assume the medication was not administered if it was not documented on either the medication administration record of the medication monitoring/control record. A review of the facility policy titled Control Substance Administration and Accountability, implemented 10/24/2022, revealed under the section titled Policy it is the policy of the facility to promote safe, high quality patient care, compliant with state and federal regulations regarding the use of controlled substances. The facility will have safeguards in place in order to prevent loss, diversion, or accidental exposure. The policy also revealed the following under the section titled Policy Explanation and Compliance Guidelines: F. All controlled substances are accounted for in one of the following ways: I. All controlled substances obtained from an automated dispensing system are accessed through the Remove function on the menu. II. All controlled substances obtained from a non-automated medication cart or cabinet are recorded on the designated usage form. Written documentation must be clearly legible with all applicable information provided. III. All specifically compounded or non-stock Schedule II controlled substances dispensed from the pharmacy for a specific patient are recorded on the Controlled Drug Record supplied with the medication or other designated form as per facility policy. G. In all cases, the dose noted on the usage form or entered into the automated dispensing system must match the dose recorded on the Medication Administration Record (MAR). H. The Controlled Drug Record (or other specified form) serves the dual purpose of recording both narcotic disposition and patient administration. Photographic evidence obtained.

Based on observation, interview, record review, the facility failed to store respiratory equipment in a sanitary manner for one (#376), out of thirteen residents receiving respiratory treatments. Findings Included: On 10/20/21 at 11:29 a.m., an interview was conducted with Resident #376. He confirmed that he received medication via a nebulizer. The nebulizer machine was observed in the first, open drawer of the nightstand. The mask was uncovered, sitting on top of the nebulizer machine (photographic evidence obtained). On 10/21/21 at 12:18 p.m., an interview was conducted with Resident #376. He stated that he used the nebulizer every four hours or as needed. He confirmed that he had used the nebulizer that day. The nebulizer machine was observed in the first, open drawer of the nightstand. The mask was uncovered, sitting on top of the nebulizer machine. (photographic evidence obtained). On 10/21/21 at 12:51 p.m., an interview was conducted with Staff K, Registered Nurse (RN). She confirmed that Resident #376 was currently receiving nebulizer treatments. She provided documentation of the order from the resident's medical record. The physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section O: Special treatments, procedures and programs; Respiratory Treatments, oxygen therapy. Review of the care plan, dated 09/30/21, revealed a focus area for oxygen therapy, related to [CONDITION(S)] ([CONDITION(S)]). Goal: the resident will have no sign and symptoms of poor oxygen absorption through the review date. Intervention: Nebs (Nebulizer treatments) as ordered-proper PPE (personal protective equipment) during treatment as indicated. On 10/21/21 at 3:45 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J came into resident #376's room and observed the nebulizer mask sitting in resident #376's drawer. She confirmed that the mask should be stored in a plastic bag and the nurse was responsible for putting it into the bag. Staff J stated that she did not know who placed the mask inside the drawer, she just started her shift, but said Resident #376 moved things around. She said when she had given Resident #376 his medication, she parked her cart in front of the door, and remained at the door until he was finished. Staff J retrieved gloves, put one glove on, and placed the mask into a plastic bag that was attached to the handle of the first drawer of the nightstand. Staff J walked down the hall to her medication cart to confirm Resident #376's order for the nebulizer treatment. Staff J stated that the resident received the nebulizer treatment four times a day. She said the resident's next scheduled time to receive the nebulizer treatment was at 8:00 p.m. On 10/21/21 at 4:12 p.m., an interview was conducted with Staff H, Licensed Practical Nurse (LPN), Unit Manager. Staff H confirmed that the nebulizer mask should be stored in a plastic bag after the medication was administered by the nurse. She said the nurse must don (put on) full PPE and remain in the room until the resident finished the medication. She was going to Resident #376's room to remove the mask, tubing, and plastic bag to replace them with new ones. On 10/22/21 at 10:45 a.m., an interview was conducted with the Director of Nursing (DON). He confirmed that all residents that use respiratory equipment should have a bag with their name and date on it. He said the nebulizer mask for Resident #376 should have been in the plastic bag. He said that respiratory services came into the facility on ce a week and changed it out. He said it was the nurses' responsibility to make sure this was completed and to follow up with respiratory services as needed. Review of the facility's policy titled, Nebulizer Therapy, revised October 2021, revealed that it was the policy of the facility for nebulizer treatments, once ordered, to be administered by nursing staff as directed using proper technique and standard precautions. The policy revealed under Care of the Equipment, 3. Disassemble parts after every treatment, 4. Rinse the nebulizer cup and mouthpiece with sterile or distilled water. 6. Air dry on an absorbent towel 7. Once completely dry, store the nebulizer cup and the mouthpiece in a zip lock bag.

Based on observation, interview, and record review, the facility failed to have posted staffing information for all shifts readily accessible to residents and visitors at the main entrance. Findings included: An observation was conducted on 10/19/2021 at 9:00 a.m. of the main entrance and exit in the facility. Daily staff posting was not observed to be posted anywhere in the main entrance and/or exit area. During a subsequent observation, staffing was not displayed to be posted and visible to residents and visitors at the facility's main entrance and/or exit. Staff A, Receptionist/Screener was asked where the day's staffing was located. She presented a clipboard that was near her at the reception desk which had a white sheet of paper on it that read, Daily Staffing Sheets. The clip board contained the staffing for all units. The posted staffing was not visibly seen, and would not have been known to a visitor or resident to be located on the clipboard that was covered with a piece of paper. An interview was conducted with Staff A, who stated, Someone must ask to see the staff posted numbers for the day. (Photographic Evidence Obtained.) On 10/19/2021 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON) related to posting of the daily staffing and accessibility to residents and visitors. The DON stated, Yes I agree it is not accessible, and I do know what you mean, I will get it corrected immediately. A facility provided policy titled, Nurse Staffing Posting Information,dated April 29, 2021, Page 01 of 01 reads under Policy It is the Policy of this facility to have sufficient staff to provide nursing services to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident and to make staffing information readily available Policy Explanation and Compliance Guidance: 4. The information posted will be b. In a prominent place readily accessible to residents and visitors.

Based on observation, interviews, and record review, the facility did not ensure that medications were stored according to current accepted professional principles as evidenced by 1. Failure to secure medications in six of six medication carts and 2. Failure to appropriately store respiratory medication for one (Resident #376) of thirteen residents that received respiratory treatments. Findings included: 1. On 10/21/2021 at 3:15 p.m., an observation of medication cart #2 located on Central Hall included ¼ piece of a white tablet, and three medications punch cards, which were seen to be in the back of the fourth drawer from the top of the medication cart, when the drawer was pulled all the way out. Staff B, Licensed Practical Nurse (LPN) confirmed the presence of the unsecured piece of tablet and three medication punch cards behind the fourth drawer. The Director of Nursing (DON) retrieved the three punch cards out from the back of the medication cart. The three medication punch cards were unseen by the DON and Staff B,LPN until the surveyor informed them both that they were unsecured. On 10/21/2021 at 3:30 p.m., an observation of medication cart #1 on Central Hall included three loose pills. Staff C, LPN confirmed the presence in the second drawer from the top of the medication cart of one round white tablet, one pink oval tablet, and in the 3rd drawer, one clear capsule. (Photographic Evidence Obtained.) An observation was made of the medication cart #1 on West Hall which included ¼ piece of white tablet loose in the second drawer. Staff D, LPN confirmed the presence of the unsecured piece of tablet. An observation was made on 10/21/2021 at 4:00 p.m. of medication cart #1 on the East Hall. During the observation a clear plastic bag was observed containing a resident's [MEDICATION(S)] medication, located behind the fourth drawer from the top of the medication cart when pulled out. Staff L, LPN confirmed the presence of the unsecured medication. On 10/21/2021 at 4 :15 p.m., an observation of medication cart #2 located on East Hall included one loose tablet. Staff E, (Agency LPN) confirmed the presence of the unsecured white tablet in the second drawer from the top of the medication cart. On 10/21/2021 at 4:40 p.m., an observation of medication cart #3 on the East Hall included one loose yellow tablet, behind the fourth drawer from the top of the medication cart when pulled out. The DON confirmed the presence of the unsecured tablet. On 10/22/2021 at 9:16 a.m., an interview was conducted with the DON. During the interview, the DON was informed of all observations made and stated, I did not realize pills can fall behind drawers. There should never be loose pills in the medication carts. A review of the facility's Polaris Pharmacy Policy and Procedure titled, Medication Storage in the Facility, dated April 2018, Pages 47, read under Policy, Medications and Biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: A. The provider pharmacy dispenses medications in containers that regularly meet requirements, including standards set forth by the United States Pharmacopeia (USP). Medications are kept in these containers. C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. 2. On 10/21/21 at 3:45 p.m., an interview was conducted with Staff J, Licensed Practical Nurse (LPN). Staff J was called to Resident #376's room to observe an inhaler that sat in a cart filled with Resident #376's personal belongings, next to his bed. She stated that she was not sure whether the resident was supposed to have the inhaler in his possession. Staff J immediately removed the inhaler from the cart with a napkin. When Resident #376 was asked where the inhaler came from, he stated that a nurse gave it to him to use while waiting to receive his nebulizer treatment, but he could not recall who. Staff J stated that the inhaler may have been brought in by a family member. She said the resident had a lot of visitors and received care from hospice services. Staff J walked down the hall to her medication cart to review Resident #376's current orders. She confirmed that he did not have an order to self-administer any medication. Staff J retrieved Resident #376's inhaler from inside the medication cart and confirmed that the inhaler removed from the residents' room was not the facility provided inhaler, that was given to him by the nurses. Staff J placed the two inhalers side by side on her cart (photographic evidence obtained). She checked the inhaler and stated that it was a new inhaler because it had a remainder of 70 out of 80 puffs left in it, indicating it may have been used about five times. Staff J stated that the activities department is responsible for completing the residents initial inventory list, she would check with them to see if the resident came into the facility with the inhaler. Staff J stated that she had never given the resident his PRN (as needed) inhaler that was kept inside the medication cart. Staff J stated that she would find out if the resident would like to self-administer his inhaler. She said she would try to get a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/21/21 at 4:12 p.m., an interview was conducted with Staff H, LPN, Unit Manager. Staff H stated that Resident #376 did not have the inhaler yesterday. She said she checked his room Monday and Tuesday; it was not there. She said the resident had a visit from his stepson yesterday and he could have given it to him. She said hospice also came to see the resident twice a week and last saw him Monday. She said effective immediately, she would place the resident's inhaler in a locked box. She said she informed the Nurse Practitioner (NP) about the inhaler found in his possession and asked for an order to allow the resident to self-administer his inhaler. She said the NP said that it was ok and provided a verbal telephone order. The activities department provided a copy of Resident #376's inventory sheet and the inhaler had not been recorded. Review of Resident #376's medical record revealed an initial admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . [MEDICATION(S)] Sulfate Aerosol Powder Breath Activated 108 (90 Base) Mcg/Act, two inhalations, inhale orally every four hours as needed for shortness of breath. Administer oxygen at 3 liters via nasal cannula, every shift for respiratory management. Review of the Minimum Data Set (MDS) assessment dated [DATE], Section C: Cognitive Patterns, revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. Section O: Special treatments, procedures and programs; Respiratory Treatments, oxygen therapy. Review of the care plan, dated 09/30/21, revealed a focus area for oxygen therapy, related to [CONDITION(S)]. Goal: the resident will have no sign and symptoms of poor oxygen absorption through the review date. Intervention: Nebs (Nebulizer treatment) as ordered-proper PPE during treatment as indicated. The Care plan revised on 10/21/21, revealed a focus area for Strength: Resident can self-administer handheld inhaler and self-administer per Dr. orders. Teaching and training given by Unit Manager. Goal: Resident will safely administer inhaler treatment through next review date. Interventions: Instructions and education by nurse given to the resident and signed by resident of understanding on proper procedure. Inhaler must be kept in a locked box with key and instructions, that after use return inhaler to the locked box. On 10/22/21 at 10:20 a.m., an interview was conducted with Resident #376. He was observed in bed, wearing a bracelet with a key on his wrist. The locked box was observed on the second shelf of the resident's cart, that held personal items, next to his bed. Resident #376 stated that he knew how to access the inhaler by putting the key in. He said he felt better now that it had been contained so no one else could get into his box besides himself. Resident stated that he was happy. On 10/22/21 at 10:31 a.m., a follow up interview was conducted with Staff H, LPN, Unit Manager. She stated that Resident #376 told her that he received the inhaler from hospice. She said she had reinforced teaching with the resident and placed the lock box in his room. She explained that Resident #376 had a copy of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . She said she had provided him with instructions on how to use it. On 10/22/21 at 10:45 a.m., an interview was conducted with The Director of Nursing (DON). The DON stated that he was notified by Staff H, that Resident #376 got the inhaler from Hospice. He said the resident was educated about self-administration of the inhaler and returned demonstration on how to self-administer. He said the resident was given a lock box with a key. Review of Resident #376's progress notes, dated 10/21/21 revealed, Resident found with inhaler at bedside. Resident made this writer aware that he was given this inhaler on the other side meaning Hospice. This writer asked the resident if he desires to self-administer his prn [MEDICATION(S)] inhaler. Resident verbalizes to self-administer prn inhaler but not nebulizer treatments. This writer made resident aware that nebulizer treatments must remain in bag if not in use. Resident verbalizes understanding, Nurse Practitioner (NP) notified. Order received for resident to self-administer prn inhaler. Medication to remain at bedside in locked box. Lock box obtained. Review of Resident #376's progress notes, dated 10/21/21 revealed, Medication Self Administration: Re-enforced teaching done with resident regarding inhaler use. Resident able to read instructions on medication box. Resident able to make this writer aware that medication is every 4 hours as needed. Resident instructed to rinse and spit after use. This writer made resident aware that medication must be kept in lock box in room. Resident verbalizes understanding. Review of Resident #376's progress notes, dated 10/21/21 revealed, Nursing spoke with son regarding inhaler at bedside. He denies bringing any kind of meds in house. Understands rules and regulations. Review of Resident #376's medical record revealed, a Self-administer assessment was completed 10/21/21 and will be reevaluated on 11/07/21. Review of Resident #376's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #376's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication must be kept in locked box at bedside. Review of the facility's policy, titled Bedside Medication Storage, dated April 2018, revealed that Bedside medication storage is permitted for resident's who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. Procedures: A) A written order for the bedside storage of the medication is present in the resident's medical record. B) Bedside storage of medications is indicated on the resident Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . C) For residents who self-administer medications, the following conditions are met for bedside storage to occur. 1) The manner of storage prevents access by other residents. Lockable drawers or cabinets are required only if unlocked storage is deemed inappropriate. Facility management should have a copy of the key in addition to the resident. 2) The medications provided to the resident for bedside storage are kept in the containers dispensed by the provider pharmacy or in the original container if a non-prescription medication. 3) The bedside medication record is reviewed on each nursing shift, and the administration information is transferred to the MAR kept at the nurse's station. Notation of each self-administered dose is made by placing a check mark in the appropriate space and noting in the nursing comments the initials of the nurse who obtained the information from the resident.

Based on observation, interview, and record review, the facility failed to implement their Abuse, Neglect and Exploitation policy in the areas of identification, investigation, prevention, protection, reporting/responding, and training for two (#1, #4) of nine sampled residents. Findings included: 1. On 06/02/21 at 11:30 a.m., an interview was conducted with Resident #1. Resident #1 was observed in his room, sitting in a wheelchair at bedside. He had non-skid socks on his feet, dressed in seasonally appropriate clothing, appeared clean, observed to have a black eye (left side). He agreed to an interview. He explained that he had fallen earlier that day and that was how he got the black eye. During the interview he stated, That night, referring to 05/15/2021, a nurse [Staff C's first name] gave me a hard time for being out of bed. At the time, I was talking to a lady, [Staff D Agency Certified Nursing Assistant (CNA)]. Resident #1 stated that he had been in the facility about one week prior to the event. He stated, The nurse had helped me shower days before and he was a nice guy. But, that night, I was walking, he came around the bed, grabbed me, pushed me on the bed, straddled me, he had my arms pinned, and he slapped me. [Staff D] was scared. She started yelling, 'Nurse, Nurse', it was about 2:30 in the morning. I do not recall what happened after that. [Staff C] stopped at that point, he continued to reprimand me. I'm not sure who interviewed me from the management. The people are great here. I was in the medical field. I had never seen behavior like that. He must have been having a bad day. A review of Resident #1's clinical chart revealed that the resident was admitted on [DATE]. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #1's New Admission Data Collection and Observation form, dated 05/13/21, documented that the resident could verbalize his preferences, such as choosing clothing, preference of facial hair, and dining preferences. The functional status assessed the resident as being assisted by staff; his sensory/communication assessed as alert and oriented to person; alert and oriented to place; alert and oriented to time with no sensory impairment. For Fall Risk Observation, the resident needed, Assistance with transfers and mobility (requires guidance or minimal assistance.) A review of Resident #1's Plan of Care, revealed that resident's discharge plan was to transfer to an ALF (Assisted Living Facility), effective 05/14/21. The resident was a fall risk and staff, will encourage me to utilize my call light for assistance, effective 05/13/21. The resident used a Sara (mechanical) lift for all transfers, effective 05/20/21. He had impaired cognitive function or impaired thought processes related to [CONDITION(S)] medication use, short term memory loss, confusion increases when not wearing oxygen and the resident is frequently non-complaint with oxygen use., effective 5/23/2021. A review of the facility Abuse Log documented the following: Resident #1, Day 1=05/15/21; Day 5= 05/20/21; substantiated or not substantiated= No. On 06/02/21 at 1:18 p.m., an interview was conducted with the Staffing Coordinator. He identified the staff on the schedule for the event date of 05/15/21, which included Staff C, Licensed Practical Nurse (LPN) and Staff D, CNA. He also reported that Staff E, LPN was in the building but, not on the floor. On 06/02/21 at 1:28 p.m., Staff E, LPN was interviewed. She confirmed that she was in the building on Friday, 05/14/21 and that she had worked until 8:30 p.m. She also confirmed that she was in the building into the next shift that carried over into Saturday, 05/15/21. She reported that she interacted with Resident #1 earlier in the evening (05/14/21) which included assisting Staff C, LPN to shower the resident. Staff E, LPN reported that she was in the unit manager's office on the 100 hall and that around 2:30 a.m. on 05/15/21, Staff C, LPN came into the office and said that Staff D, CNA was mad at him because Staff D said he was rough with the resident. Staff E, LPN stated, I asked him if he was, and he said no he was trying to prevent [Resident #1] from falling during the transfer. I said, maybe you should have lowered him to the ground. He walked out of the office. I saw [Staff D CNA] and she walked down the hall to her assignment; she walked by the office several times and did not say anything. And then, she asked to go home. She said she was sick; she did not feel well. I said, ok, you can leave. That was it, she left. I cannot remember the exact time. Staff E, LPN, confirmed that she did not go down and talk to the resident or Staff D, CNA, after Staff C made his statement to her about being rough with Resident #1. She stated, Staff C, was the 3-11 supervisor. I think that if he had a supervisor, that it would have been the DON [Director of Nursing]. I was just there cleaning out my office. I was not in charge of the building at that time, I was just cleaning out my office. Staff E, LPN confirmed that she did not call the DON about what Staff C, LPN had said to her. She stated, [Staff C, LPN], and I had transferred the resident earlier, if I thought that he had abused him, I would have called. On 06/02/21 at 2:30 p.m. an interview was conducted with the Human Resource Director (HRD). She stated Staff C, LPN was terminated on 05/17/21. The employee record will show that he was removed from the facility's background screening roster at 3:30 p.m. on May 17th. I was not instructed to do anything further with Staff C. I removed him from the roster and removed him from the pay system so he could not work. She confirmed that she would be involved when there was an allegation of abuse and neglect to suspend an employee, document the suspension, communicate with the employee; and assist with the investigation depending on what it entailed. She stated, In this case, I was not involved with interviewing the employee. She confirmed that if there was an allegation of abuse or neglect, there should be an immediate suspension. She stated, I do not know what happened that night, he [Staff C] left the facility grounds, and he was arrested after he left. It was my understanding that he was arrested at his home. I found it out on Monday morning [05/17/21]. I knew that there was something that had occurred. I was surprised that it took so long to get to me. I, myself did not suspend him at that time; we knew that it would be either a suspension or termination. The work history of Staff C for 05/15, 05/16, 05/17 was requested but was not provided by the facility during the survey. An interview was conducted on 06/02/21 at 2:46 p.m. with the NHA and the DON regarding Resident #1. The NHA stated, The date of the event was Saturday morning, 05/15/21 at 12:30 a.m.; the event was an allegation that Staff C, LPN was involved in a transfer of Resident #1 from the chair to the bed and that Staff D, CNA, was a witness. The NHA stated that he found out about the allegation on 05/15/21 when the Social Worker notified him that the [state protective services agency] was coming out to the facility to investigate. He said, [Staff D, CNA] provided a statement through the staffing agency Monday morning, the 17th. During this interview, the DON confirmed that if the nurse had received information that a person was rough with a resident, then that resident should have been assessed right away. On 06/02/21 at 5:16 p.m., the NHA confirmed that the 5-day Federal Report that he had submitted on 05/20/21 reflected that the allegation of abuse for Resident #1 was not substantiated. He further stated that he was continuing to track down information regarding the event. He had tried to solicit more information from the police, and he was still working on the outcome of the investigation (06/02/21 was 12 business days after the incident on 05/15/21). He stated that regarding a neglectful transfer, we would say substantiated for a potential rough transfer. Regarding slapping, we were unable to reach a final determination. We have conflicting information. He said Abuse and Neglect training was conducted, starting on 05/15/21, definitions of reporting process, hotline location/familiarity of where the hotline postings were, and transfer training was conducted. 2. A review of the training that was provided by the facility after the incident occurred on 05/15/21 reflected the following: On 05/15/21, 20 staff members (10 dietary staff, 7 CNAs, 1 SW, 1 RN, 1 Receptionist) signed that they received training on Definitions and the Reporting process. On 05/21/21, 3 staff members (1=RN, 1=CNA, 1=LPN) signed that they received training on Pivot Transfer. On 05/22/21, 8 CNAs signed as attending training on Transfer Training. No other training was provided by the facility during the survey. A review of the facility employee listing reflected approximately 183 employees. 3. Continued investigation and review of the facility Abuse Log documented the following: Resident #4, Day 1=05/30/21, 5 day=blank; substantiated or not substantiated not designated. A review of a concern form dated 05/29/21, 9:10 a.m.-10:40 a.m., submitted by the daughter of Resident #4 documented the following, Mom still in bed. Bedspread covering crispy with dried up food upper half inside, green shirt and navy-blue tank top missing. Day old socks on with one rolled down to ankle, severe circulation marks on ankle. Bandage not attached firmly from day before. Injury on left forearm due to the arm fell off the armrest and down into wheelchair [between the wheelchair seat and armrest]. Body not cleaned up before bed, crusty eyes. Strong urine odor. Leave laundry for family. A phone interview was conducted on 06/15/21 at 2:20 p.m. with Resident #4's daughter. She stated that she was currently with Resident #1, that the resident had been recently moved from the short term to long term hallway. She confirmed that she had written the grievance on 05/29/21. She confirmed the contents of the grievance. She stated that she believed that the day that she wrote the grievance, the nursing manager was not there. She believed that she had given it to another staff member to provide to the nursing manager. The daughter stated that she recalled her mother having a strong urine odor the morning that she had seen her, like she had not been changed in some time. No one should smell like that. For the injury, she stated that her mom was new to the facility and the staff did not support her with the pillows in the wheelchair, and that her arm fell from the armrest, and she got a skin tear. She stated that a lot of the staff were agency. She stated she had to retrain staff daily about her mother. A review of Resident #4's clinical chart revealed an admission of 05/26/21. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #4's new Admission Data Collection and Observation form, dated 05/26/21, documented that the resident used a [reclining] chair and was depended on staff for mobility; transfers were performed by staff and the resident was non-ambulatory. For bathing, oral hygiene, and grooming, the staff performed the service. Skin observations documented blanchable redness to sacrum; incontinent of urine; incontinent of bowel; non-interviewable; and the discharge plan was to remain long term care. During an interview conducted on 06/02/21 at approximately 3:12 p.m., the NHA reported that the grievance form was submitted to Staff E, LPN, on 05/30/21, between 3:30 p.m. and 4:00 p.m. The allegation was still under investigation and had not been reported to the [state protective services agency] yet. The NHA stated that the event occurred on 05/29/21, between 9:10 a.m. and 10:40 a.m., the allegation was reported by the resident's daughter. Staff E, LPN was interviewed on 06/02/2021 at 2:46 p.m. She reported that she notified the DON and the administrator of the concerns related to Resident #4 on the grievance. She said she did not assess the resident at the time that the concern was given to her. An interview conducted on 06/02/21 at approximately 9:40 a.m. with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed the DON was the designated Abuse Coordinator. On 06/02/21 at 11:23 a.m., an interview was conducted with Staff B, Certified Nursing Assistant (CNA). She reported that she had been employed by the facility for 2 months. She stated that she did not remember who the abuse coordinator was, but she had abuse and neglect training in the orientation. She said she had recent training about abuse, food /diet, transfers, and reporting to the nurse or DON. 4. A review of the facility Abuse, Neglect and Exploitation policy / procedure, effective date September 22, 2012, last reviewed January 13, 2021, documented the purpose: The facility has developed and operationalized policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property; to include the use of physical and/or chemical restraints. The Administrator, Director of Nursing and Risk Manager in the facility are responsible for ensuring the implementation and ongoing monitoring of these requirements. Definitions: Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, physical pain, mental anguish. Verbal/Written Abuse is defined as the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to threats of harm; saying things to frighten a resident, such as telling a resident that he/she will never be able to see his /her family again . Physical Abuse includes hitting, slapping, pinching, pulling, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation . Neglect is the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Neglect occurs when facility staff fails to monitor and/or supervise the delivery of care and services to assure care is provided as required. The facility's abuse prevention officer is the Director of Nursing or designee. The Risk Manager is the Assistant Director of Nursing or designee. Residents of this facility shall be protected from occurrences of abuse, neglect, exploitation, misappropriation of property, mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Staff another relevant parties as determined by management shall be trained at least annually on abuse, neglect and exploitation, procedures for reporting incidents of this nature, dementia management and abuse prevention. Procedure: I. Screening . II. Training: Train employees, through orientation and on-going sessions on issues related to abuse prohibition practices such as: 1) Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; 2) How staff should report their knowledge related to allegations without fear of reprisal; 3) How to recognize signs of burnout, frustration and stress that may lead to abuse; 4) What constitutes abuse, neglect and misappropriation of resident property; 5) In addition to the freedom from abuse, neglect, and exploitation, requirements in $483.12, facilities must also provide training to their staff that at a minimum educates all staff on: . III. Prevention: .Identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. This includes an analysis of: 1)Features of the physical environment that may make abuse and/or neglect more likely to occur, . 2)The deployment of staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual resident's care needs; 3)The supervision of staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring residents while giving care, directing residents who need toileting assistance to urinate or defecate in their beds; and 4) The assessment, care planning, and monitoring of residents with needs and behaviors which might lead to conflict or neglect, . IV. Identification: Identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. V. Investigation: Investigate different types of incidents; and identify the staff member responsible for initial reporting, investigation of alleged violations and reporting of results to the proper authorities. VI. Protection: Protect residents from harm during an investigation. VII. Reporting/Response: Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required and take all necessary corrective actions depending on the results of the investigation. Report to the State Nurse Aid Registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate that employee is unfit for service; and analyze the occurrences to determine what changes are needed, if any to facility policies and procedures to prevent further occurrences. The Facility must develop and implement written policies and procedures that: 1) Ensure reporting of crimes occurring in federally-funded long-term care facilities are done in accordance with section 1150B of the Social Security Act. In response to allegation of abuse, neglect, exploitation, or mistreatment, the facility will: 1) Ensure that all alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the event that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the state survey agency and adult protective services where state law provides for jurisdiction in long term care facilities) in accordance with State law through established procedures. 2) Have evidence that all alleged violations are thoroughly investigated. 3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. 4) Report the results of all investigations to the administrator or his/her designated representative and to other officials in accordance with State law, including to the state survey agency, within 5 working days of the incident, and if the alleged violation is verified as substantiated, appropriate corrective action must be taken.

Based on observations, record reviews, and interviews the facility failed to appropriately implement the care plan related to falls for two residents (#3 and #4) out of three residents sampled for supervision. Findings included: 1. A review of the Admission Record revealed that Resident #3 was admitted on [DATE]. The Admission Record identified diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS), dated [DATE], indicated a Brief Interview of Mental Status (BIMS) score of 15 out of 15, indicative of an intact cognition. An observation at 10:16 a.m. on 5/17/21, revealed Resident #3 lying in a bariatric bed with audible rhythmic breathing, the resident's feet were against the footboard and his head was bent onto his shoulder A review of Resident #3's medical record indicated a fall had occurred at 4:30 a.m. on 2/20/21. The progress note, dated 2/20/21 at 5:02 a.m., identified that the resident was seen halfway out of his bed. The note identified that the bed was broken and was up in the air. After the resident was slid to the floor by the nursing staff the resident was put on a [mechanical lift] pad and lifted to another bed. The note identified that the resident had suffered three skin tears. A progress note at 2:56 p.m. on 2/20/21, indicated Resident #3 was transferred to an acute care facility due to a large open laceration noted to left big toe. The note identified that the resident's big toe was bleeding and causing resident a lot of pain and that the resident insisted on going to the hospital. On 2/20/21 at 10:00 p.m., the resident returned from the acute facility with three sutures to the left great toe and was made comfortable. The note indicated that the patient (pt) appears to only be in pain when touching the toe or moving it. A Post-Fall Huddle report, dated 2/20/21 at 5:12 a.m., indicated that Resident #3 had suffered a fall at 4:30 a.m. on 2/20/21. The Huddle did not identify that the fall was witnessed or what the resident had reported. The report indicated that the resident post-fall Range of Motion (ROM) was without limitations post fall, had sustained a skin tear as a result of the fall, and had a pain level of zero (0). The interventions in place were that the bed was in the low position and had enablers/side rails. Resident #3's care plan identified that he was at risk for falls related to (r/t) weakness, impaired mobility, morbid obesity, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The goal, with a target date of 6/9/21, and indicated that the resident would be free from major injury from falls through the next review, initiated 4/1/21, revised 4/22/21. The interventions related to the resident's risk for falls did not indicate the facility further developed the care plan following the resident's fall on 2/20/21. On 5/17/21 at 6:02 p.m., the Director of Nursing (DON) reviewed Resident #3's care plan. He stated that the facility had gotten the resident a big boy recliner and that it was no longer in the resident's room, he acknowledged that something (an intervention) should have been in place besides a recliner. 2. A review of the Admission Record revealed that Resident #4 was admitted on [DATE]. The Admission Record included diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS, dated [DATE], indicated the resident's BIMS score was 0 out of 15. A review of the quarterly MDS, dated [DATE], indicated that the resident had two falls without evidence of any injury since admission or prior assessment. Resident #4 was observed on 5/17/21 at 1:37 p.m., sitting in the hallway outside of his room in a low specialized wheelchair. The resident was observed with one shoe off, wearing no socks, and leaning forward in the chair. The chair seat appeared to be sloped backward. Staff A, Certified Nursing Assistant (CNA) stated that the resident does not get out of the chair and she was unaware of how long he had the specialized wheelchair. An observation at 4:09 p.m. on 5/17/21, was conducted with Staff B, CNA, of Resident #4's room. The staff member confirmed that the resident did not have a scoop mattress Staff B stated the resident had not fallen during his shift. A review of the facility Fall logs for January 2021 - April 2021 indicated that Resident #4 had suffered falls on 1/4/21 (in the hallway without injury) and 2/5/21 (in resident room with no injury). Review of Resident #4's Evaluations and Progress notes, indicated the following: - Post-Fall Huddle, dated 1/4/21 at 12:00, identified that the resident had an unwitnessed fall and was found on the floor following his legs gave out, and the resident was unable to verbalize what had happened The huddle indicated the resident's Range of Motion (ROM) had limitations but had not sustained an injury resulting from the fall. Staff had noted that the patient attempts to get up from wheelchair. Patient tries to stand and walk often and did not indicate if the care plan had been updated. - Post-Fall Safety Risk Evaluation, dated 1/4/21, indicated the resident had a fall in the last month preceding admission, had three or more falls since admission resulting in a minor injury. - Progress note, 1/6/21 at 7:55 a.m., Late Entry - status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Provider will be informed. - Progress note, 1/6/21 at 11:50 a.m., noted to have worsening bruising. ARNP (advanced registered nurse practioner) notified bruising, new complaint of (c/o) pain, order for x-ray (XR). - Progress note, 1/6/21 at 3:35 p.m., resident has distal left clavicle fracture. Sling applied. - Post-Fall Huddle, dated 1/18/21 at 8:16 p.m., identified Resident #4 had sustained an unwitnessed fall on 1/18/21 at 7:57 p.m., and had been found on the floor by staff. The huddle indicated that the resident had no injury resulting from the fall. The resident was unable to explain the happenings due to decreased safety awareness secondary to Traumatic Brain Injury (TBI) secondary to fall. The report indicated that the bed was in low position and staff did not indicate that the care plan was updated at the time of the fall. A review of the care plan for Resident #4 identified that the resident was at risk for falls r/t [CONDITION(S)], confusion, gait/balance problems, incontinence, psychoactive drug use; s/p fall 10/17/20, 10/21/20 - fall with skin tears to right upper extremity and forehead, s/p fall 11/1- rolled out of bed (OOB) with bed in lowest position fall, 1/4/21 s/p found on floor, s/p fall 11/4, s/p fall 11/7, s/p 12/7/20, s/p 12/17/20, s/p fall 1/4/21, s/p 2/5/21, and s/p fall 3/2/21, initiated on 10/14/20 and revised on 3/23/21. The interventions included: scoop mattress on bed - resident unaware of bed boundaries and has poor safety/impulsive behaviors, initiated on 2/5/21. An interview at 4:52 p.m. on 5/17/21 was conducted with the Director of Nursing. He stated the resident had either a scoop mattress or floor mats. He reported that the Interdisciplinary Team (IDT) met in the morning, goes over the care plan, and that management tells the staff to implement or to revise the care plan. An observation at 5:27 p.m., was conducted with the DON of the resident's room. He confirmed that the mattress on the resident's bed was not a scoop mattress. Additionally, at 5:59 p.m., Staff C and D, MDS Coordinators stated they do not do the interventions after a fall, the Risk Manager does them after a fall. The policy titled, Care Plans, dated May 1, 2017, indicated that it was the intent of the policy to create care plans in accordance to State and Federal regulations. The policy identified that the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment and the care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical mental, and social well-being.

Based on record review and interview the facility failed to notify residents and their representatives or families of the COVID-19 status of the facility within 24 hours following the admission of the last COVID-19 positive resident (#6) for one of one COVID-19 admissions. Findings included: Resident #6 was admitted on [DATE]. The Admission Record of the resident identified the principal diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the lab results received from the facility indicated that Resident #6 tested positive for COVID-19 on 2/25/21 at an acute care facility. The Hospital to Post Acute Care Facility Transfer _COVID-19 Assessment indicated that the resident may be transferred to a COVID-19 positive facility and currently met all of the Center of Disease Control and Prevention (CDC) symptom-based strategy requirements following severe to critical illness in patients or for patients who are severely immunocompromised. A request was made for a copy of the call that the residents, representatives, and/or families received following the admission of Resident #6. The facility failed to produce documentation that the residents, representatives, or families were notified of Resident #6's admission on Tuesday, March 2, 2021. During an interview, at approximately 6:30 p.m., the Nursing Home Administrator (NHA) confirmed he was unable to locate documentation that the residents, representatives, and/or families were notified of Resident #6's admission and COVID-19 status and acknowledged that even if the patient was a resident of a sister facility that once this facility admitted the resident; they were the responsibility of the facility and parties should have been notified. A policy titled, COVID-19 Reporting, dated 5/11/20, identified, Residents, their representatives, and families are notified of the conditions inside the facility related to COVID-19: by 5:00 p.m. the next calendar day following the occurrence of a single confirmed infection of COVID-19.

Based on observation, interview, and record review, the facility failed to ensure weekly COVID-19 testing for one (Staff F) of six staff sampled and failed to have a system in place for ensuring weekly COVID-19 testing and results were documented for agency staff. Findings Included: On December 7, 2020 at 9 a.m., the facility Administrator (NHA) stated routine facility staff COVID-19 testing was conducted every week. The NHA stated all facility staff were tested at the frequency required, which was once a week, based on the county positivity rate. The NHA stated the most recent county positivity rate was 5.6%.(Community COVID-19 Activity Medium 5%-10%). On December 7, 2020 at 10:15 a.m., a tour of the Persons Under Investigation Unit (PUI-patients suspected of COVID-19) was conducted. The Nurse Manager (NM) stated there were 35 residents in the unit. The NM stated there were 4 Certified Nursing Assistants (CNAs) and 2 nurses assigned to the unit. The NM stated one of the nurses (Staff F, Registered Nurse) was from an agency. The NM stated Staff F worked regularly in the facility. On December 7, 2020 at 10:35 a.m., Staff F stated she had been regularly assigned to work in the facility for two years. Staff F further stated she worked in the facility the day before and last week. On December 7, 2020 at 3 p.m., the Human Resources Manager (HRM) stated she coordinated and tracked facility staff testing for COVID-19. HRM stated if facility staff do not show up for required testing, the staff were removed from the schedule until the staff had the test done and with a negative result. The HRM stated testing for agency staff was thru the agency. The HRM stated she called the agency and asked for Staff F's testing results. The HRM did not have documentation that the required testing was completed for Staff F. On December 2, 2020 at 4:25 p.m., the HRM stated the agency could not find Staff F's test results. The HRM stated she was unable to obtain documentation from the agency that required testing corresponding to the facility's testing frequency were completed for Staff F. On December 7, 2020 at 4:35 p.m., the Staffing Coordinator (SC) stated she was responsible for the staff schedule, accepted call offs, and called the agency for coverage. The SC stated there were four agency nurses in the facility. The SC stated she should be able to get into the agency database and check for the agency nurses testing and results. The SC stated the agency would call or send an email if an agency staff tested positive. The SC stated she did not know how frequently the agency nurses were being tested . The SC stated she was unable to tell if the agency staff were getting tested every week. On December 7, 2020 at 5 p.m., HRM confirmed again that the agency was unable to provide the facility documentation of Staff F's testing information. A copy of Staff F's schedule/completed shifts from November 15 through December 7, 2020 indicated Staff F worked on the following days: -11/15, 7 a.m.-7 p.m. -11/17, 12 p.m.-7 p.m. -11/19, 7 p.m. -7 a.m. -11/20, 7 p.m. -7 a.m. -11/23, 7 p.m. -7 a.m. -11/24, 3 p.m. -11 p.m. and 11 p.m. -7 a.m. -11/25, 3 p.m. -7 p.m. -11/28, 7 a.m.-7 p.m. -11/30, 7 a.m.-7 p.m. -12/1, 3 p.m. -7 p.m. -12/2, 7 a.m. -3 p.m. and 3 p.m. -11 p.m. -12/3, 7 a.m. -3 p.m. -12/4, 3 p.m. -11 p.m. -12/6, 7 a.m.-7 p.m. -12/7, 7 a.m. -3 p.m. and 3 p.m. -11 p.m. On December 7, 2020 at 5:32 p.m., the SC stated she asked each of the four agency staff presently working in the facility to obtain their testing information. The SC stated the facility should have had information on testing dates and results for the agency staff before they were allowed to work in the facility. The SC stated the testing expectation for agency staff was the same as the facility staff. Review of the Daily Facility Staffing from December 1 through 7, 2020 was conducted with the SC. The staffing document indicated: -[DATE] -out of 47 staff - 14 were from the agency -[DATE] - out of 45 staff - 6 were from the agency -[DATE] - out of 52 staff - 10 were from the agency -[DATE] - out of 50 staff - 15 were from the agency -[DATE] - out of 47 staff - 15 were from the agency -[DATE] - out of 48 staff - 14 were from the agency Review of the facility policy titled, Coronavirus Testing last revised 11/03/2020 indicated, Policy: The facility will implement testing of facility residents and staff, including individuals providing services under arrangement and volunteers, for COVID-19 .Facility Staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and the students in the facility's nurse aide training programs or from affiliated academic institutions .Routine Testing of Staff 1. The facility will utilize their county's COVID positivity rate in the prior week as a trigger for staff testing frequency. The facility will check for newly posted rates on weeks one and three .2. The facility will test staff per the routine testing intervals as follows: a. If the community COVID-19 activity is low and the county positivity rate in the past week is <5%, the minimum testing frequency of staff will be once a month. b. If the community COVID-19 activity is medium and the county positivity rate in the past week is 5% - 10%, the minimum testing frequency of staff will be once a week. c. If the community COVID-19 activity is high and the county positivity rate in the past week is >10%, the minimum testing frequency of staff will be twice a week .Documentation of Testing .f. The facility will document the conducting of tests .h. The facility will document staff, including individuals providing services under arrangement and volunteers, test results in a secure manner . According to the Centers for Medicare & Medicaid Services QSO-20-38-NH dated August 8, 2020, .To enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary Facility staff includes employees, consultants, contractors, volunteers, and caregivers who provide care and services to residents on behalf of the facility, and students in the facility ' s nurse aide training programs or from affiliated academic institutions. For the purpose of testing individuals providing services under arrangement and volunteers, facilities should prioritize those individuals who are regularly in the facility (e.g., weekly) and have contact with residents or staff. We note that the facility may have a provision under its arrangement with a vendor or volunteer that requires them to be tested from another source (e.g., their employer or on their own). However, the facility is still required to obtain documentation that the required testing was completed during the timeframe that corresponds to the facility ' s testing frequency, as described in Table 2 .

Based on observation, interview and record review the facility's Quality Assurance and Assessment committee failed to implement an effective plan of action related to infection control measures for performing proper disinfection of reusable resident care equipment according to manufacturer's instructions for the contact time required to kill a [MEDICAL CONDITION], and for not using the correct disinfectant products according to the facility's designation for use for reusable resident care equipment. Findings included: Review of the facility's plan of correction for F880 with a completion date of 6/20/2020 revealed the following measures had been taken to correct the deficient practice: 1. Nursing staff were in-serviced on cleaning and disinfecting sit to stand slings and equipment. 2. Nursing and housekeeping staff were in-serviced on current products and on their formulary and the need to use only approved products as well as their appropriate kill times. 3. Random audits were completed by the Director of Nursing (DON) or appropriate designee on the following: 1. Cleaning of sit to stand lifts and slings 2. Cleaning products on formulary and education to kill time. A review of the facility policy and procedure titled, Cleaning and Disinfection/Non-critical care and shared equipment, (not dated) revealed: It is the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. The policy and procedure included: Any equipment used in rooms while a resident is on transmission-based precautions is to be cleaned with a disinfectant wipe immediately after use/upon exit of room. Disinfectant wipes are an EPA-registered (Environmental Protection Agency) hospital disinfectant with tuberculocidal claim (i.e. intermediate level disinfectant). A review of the facility policy and procedure titled, Infection Control-Standard and Transmission-based Precautions updated with Enhanced Barrier Precautions, dated 3/6/20 revealed: All shared medical equipment used in (transmission-based precautions) resident room will be wiped down with disinfecting wipe upon exit of the room. On 7/14/2020 at 10:56 a.m. during the entrance conference the DON stated that she was not aware of what product was being used for re-used resident equipment. On 7/14/2020 at 12.20 p.m. Staff C, Licensed Practical Nurse (LPN) stated that for re-usable vital sign equipment, she used Brand Name A between resident uses. She stated that the contact time for killing viruses was two minutes. She also stated that the CNAs (certified nursing assistants) were responsible for sanitizing mechanical lifts between use. On 7/14/2020 at 12:30 p.m. an interview was conducted with the Rehabilitation Program Manager in the therapy gym. She stated that the therapy staff used the wipes from the wall unit in the therapy gym to wipe down equipment between use or alcohol wipes. A container labeled Brand Name B was mounted on the wall in the therapy gym. She stated that she didn't know what chemical the wipes were and did not know what the contact time for disinfection was. On 7/14/2020 at 1:00 p.m. Staff B, Certified Nursing Assistant (CNA) was interviewed about the Coronavirus Disease (COVID-19) Persons Under Investigation (PUI) unit. She reported she used the Brand Name A wipes to clean the vitals sign machine before and after resident use, stating, Dries quick. She was unable to confirm what disinfectant product was used or what the contact time was. She did confirm that she wiped down the mechanical lifts between resident use. On 7/14/2020 at 1:00 p.m. Staff A, LPN was interviewed on the PUI unit. She stated that she used either a wipe or alcohol swab to disinfect equipment between resident use. A thermometer and pulse oximeter were observed on top of her medication cart. Staff A was not able to say what kind of wipes she used stating, The ones they give us at the nurse's station. On 7/14/2020 at 4:35 p.m. an interview was conducted with the DON. When asked what product should be used for disinfecting the vital sign equipment, she said that she thought it was the one with the purple top (Brand A). When asked about the contact time for disinfection, she said that different ones have different contact times. On 7/14/2020 at 5:04 p.m. an interview was conducted with the Assistant Director of Nursing (ADON) she stated that Brand Name C was used for disinfecting the mechanical lifts, as well as any other equipment (except glucometers) that was shared between residents. She stated that the dry time was 10 minutes. She stated that the Brand Name A wipes were used for the glucometers with a three-minute contact time for disinfection. On 7/14 2020 at 7:00 p.m. the Administrator provided product manufacturer information sheets for Brand Name A wipes and Brand Name B wipes. He stated that the wipe dispensers mounted on the wall in the therapy gym and the wipes at the nurse's station contained Brand Name B wipes. The information sheet for those wipes revealed that the product was an alcohol-based hand sanitizing wipe and was effective for killing Human Coronavirus on hands with a 15 second exposure time. The information sheet for the other Brand Name A wipes revealed a three-[MEDICAL CONDITION]/kill time. On 7/14/2020 at 6:30 p.m. an interview was conducted with the DON regarding their QAPI initiatives for infection control related to disinfection of shared resident care equipment. She stated that all sit to stand equipment was audited for soilage and any issues identified were corrected immediately. She stated that audits were usually done five times a week. She stated that nursing and housekeeping staff had been in-serviced on cleaning and disinfection of noncritical equipment She stated that she had lost some key staff recently and was now also acting as the facility's Risk Manager. She acknowledged that there were some concerns regarding infection control within the facility.

Based on observation, interview, record review and review of the Center for Disease Control and Prevention (CDC) guidelines the facility failed to implement and maintain an infection prevention and control program as evidenced by: 1) not clearly identifying the type of precautions and appropriate personal protective equipment (PPE) to use by not having signage for the transmission-based precautions placed in a conspicuous place outside of five resident rooms (#309, #325, #212, #209, and #207) of five resident rooms, 2) failing to prevent a potential infection (COVID-19) through indirect contact transmission by not cleaning/disinfecting two out of three sit-to-stand lifts used for multiple residents, and by not identifying the necessary contact time required to kill microorganisms for the disinfectant solution used by the facility to clean and disinfect high touch areas. Findings included: 1. An observation was made, on 5/21/20 at 9:51 a.m., of a caddy hanging from the door of Resident room [ROOM NUMBER]. There was no sign in the area of room that identified what type of transmission-based precautions or directions to see a nurse prior to entering for staff or visitors to observe when entering the room or caring for the resident. Staff A, Registered Nurse (RN) stated the resident in 309, bed B, was on contact isolation for extended spectrum beta-lactamases (ESBL). (Photographic evidence was obtained) An observation, on 5/21/20 at 10:06 a.m., revealed a yellow caddy hanging from the door of Resident room [ROOM NUMBER]. The observation of the 4 bed-resident room identified two residents lying in bed. The area surrounding the door, or the caddy failed to identify the type of transmission-based precautions to be observed or instructions to see the nurse prior to entering. A PVC frame held two green laundry-type bags at the end of second bed. (Photographic Evidence was obtained) On 5/21/20 at 10:46 a.m., an observation identified a yellow isolation caddy hanging from the door of Resident room [ROOM NUMBER]. A sign was not posted as to what type of isolation precaution was to be utilized or instructions to see the nurse prior to entering. Staff B, Certified Nursing Assistant (CNA), stated the resident that resided in the A-bed had a fever and staff were to use gloves and masks when entering the room. (Photographic evidence was obtained). At 10:49 a.m. on 5/21/20, an observation of Resident room [ROOM NUMBER] revealed a yellow isolation caddy hanging from the door. A sign was not posted as to what type of isolation precaution was to be utilized or instructions to see the nurse prior to entering. On 5/21/20 at 11:00 a.m., an observation of the door to Resident room [ROOM NUMBER] revealed an isolation caddy hanging from it. The area and door to Resident room [ROOM NUMBER] was observed not to have a sign that identified what type of transmission-based precautions or directions to see a nurse prior to entering for staff or visitors to observe when entering the room or caring for the resident. A review of the LTC (long term care) Respiratory Surveillance Line List dated 5/18/20 revealed that the resident in the B-bed had a fever and shortness of breath and yes was indicated in the hospitalized column. The Infection Control Preventionist (ICP) provided the facility's current list of rooms that documented the type of transmission-based precautions for each room. The list included resident rooms #309, #325, #212, #209 and #207, which were located outside of the admission quarantine hallway. At 1:48 p.m., the ICP stated the facility utilized stop signs that attach to the hanging caddies that instructed staff and/or visitors to see a nurse prior to entering. The ICP reviewed the photographic evidence and stated, Clearly they are not there. She stated the facility staff knew to see the nurse, but wanted signs posted to see the nurse for the agency staff. At 7:13 a.m., the Director of Nursing (DON) stated her expectation was to have signs on the door of the precaution rooms. The policy titled, Infection Control - Standard and Transmission-Based Precautions, dated November 28, 2016, showed it was the policy of the facility to ensure that appropriate infection prevention and control measures are taken to prevent the spread of communicable disease and infections in accordance with State and Federal Regulations, and national guidelines. Procedure #7 of the policy identified, To designate a room for transmission-based precautions, a sign will be placed ______ (facility note where it will be, what it looks like, if color coded, etc.). 2. On 5/21/20 at 9:50 a.m., an observation on the low 300-hall revealed a sit-to-stand lift in the hallway with a blue and red sling lying across the handles. The footrest of the lift was littered with white, brown, and black unknown debris. (Photographic evidence obtained) At 9:51 a.m., Staff A, RN stated she was not sure if the sit-to-stand was used for different residents, and that she imagined the lift was used for multiple residents since the facility had only so many (lifts). At 10:46 a.m., Staff B, CNA confirmed the sit-to-stand lift was used for multiple residents and cleans the lifts after each use. Staff C, CNA, stated, at 11:10 a.m., she never cleaned the lifts. She said, Thought housekeeping cleaned them,, and that she uses the same sling for sit-to-stand, for multiple residents. After answering a call light, Staff C returned to the interview and stated that she uses wipes to clean the sit-to-stand sling. An observation, at 11:19 a.m., was made of an area at the end of the high-300 hallway of multiple different types of lifts. Three sit-to-stand lifts were observed with slings lying across the handles. One of the sit-to-stand lifts was the lift observed previously on the low 300-hall. The footrest continued to be littered with white, brown, and black debris. The sling lying across the handles appeared to be the same previously observed sling and labeled East Wing. The sling was fabric-lined as evidence by the material piling. Another sit-to-stand stored in the same area had a black footrest littered with an unknown substance and dried liquid outline. (Photographic evidence obtained) At 11:28 a.m., the Maintenance/Housekeeping Director stated housekeeping does not clean the lifts daily, but deep cleans them weekly. At 3:38 p.m., the DON stated lifts are cleaned by CNAs and nurses in between residents. She stated she would like to have two Brand Name pads for each resident but would have to check on the slings for the sit-to-stand. The DON stated, I want to say sit-to-stand slings are patient specific. The DON described assisting staff with sit-to-stand transfers, and they got them from the resident room, and after use, the slings should be put in the laundry. An observation of the Restorative Dining Room with the DON revealed the slings that were lying across the sit-to-stands had been removed. When the previous observation was described to the DON, she stated, Oh no, no, no, they shouldn't be stored with the lift. She observed the two lifts with dirty footrest pads and confirmed the dirtiness and the debris was not from one resident. The DON stated the CNAs should have cleaned the lifts. The DON stated the slings could be wiped down. When asked if the fabric slings could be wiped down, the DON did not answer. The policy titled, Infection Control -Cleaning and Disinfection/Non-critical care and shared equipment, undated, identified it was the policy of the facility to ensure that appropriate infection prevention and control measures are taken to provide a safe, sanitary, and comfortable environment to prevent the spread of infection in accordance with State and Federal Regulations, and national guidelines. Procedure #5 revealed non-critical medical equipment (equipment that only comes in contact with intact skin) is to be wiped down with a disinfectant wipe once per shift and as needed when soiled. At 9:37 a.m. on 5/21/20, Staff E, Housekeeper was observed in the high-200 hallway. The observation revealed an open pail on top of the housekeeping cart with a roll of white wipes and a smaller roll on top of the larger roll. The staff member stated, Another guy cleans high-touch areas every day with bleach wipes. Staff E stated she had to pour bleach in the pail. An observation was made, at 11:13 a.m. on 5/21/20, of Staff D, Floor Tech, entering the low 300-hall from the double doors at the entrance of the hallway pulling a 4-wheeled utility cart, and atop of the utility cart was a green bucket. Staff D was observed wiping the top of the handrail, that ran entire length of the hallway, with one white cloth. Staff D was asked what was in the green bucket. He stated, bleach wipes. Staff D stated he does the whole facility once a day. The observation of the staff member did not reveal any cleaning of doorknobs on the hallway. At 11:28 a.m., an interview was conducted with the Maintenance/Housekeeping Director. He stated Staff D cleans high-touch areas daily. The Director described high-touch areas as handrails, and doorknobs (resident rooms and double doors). During an interview, at 2:26 p.m., Staff F, Housekeeping Supervisor Assistant (Floor Tech Supervisor), stated the Maintenance/Housekeeping Director was the manager. Staff F stated the Disinfectant Sanitizer liquid in the pails observed to be used by housekeeping and Staff D was a form of chlorine bleach. Staff F stated, Like what is used in pools. The staff member stated he mixes up a jug of Disinfectant Sanitizer every three (3) days. Staff F stated he and Staff D cleaned handrails daily. The staff member described high-touch areas as doorknobs, handles, handrails, and everything in the hallway. Staff F stated housekeeping cleaned lifts when they were in the hallway. He stated the wet time for cleaning with Disinfectant Sanitizer was like 3 minutes. Staff F provided a container of Disinfectant Sanitizer. The container directions instructed users to, Prepare the appropriate solution strength by referring to Usage table. Refer to Dilution Chart for solution preparation. Apply to pre-cleaned surface with mop, cloth, sponge, brush, wipe, or mechanical sprayer. Allow surface to remain wet for appropriate contact time as indicated on Usage Table. Allow to air dry for areas contaminated with [MEDICAL CONDITION]. The container of Disinfectant Sanitizer included instructions for healthcare disinfection without preclean performance. The instructions indicated Disinfectant Sanitizer was a healthcare disinfectant when used at the doses and contact times indicated in the Usage Table. The container did not include information regarding the contact time for disinfection. At 3:37 p.m., the Maintenance/Housekeeping Director stated the Disinfectant Sanitizer was not safe, as the facility, don't know the dilution rate. The Maintenance/Housekeeping Director stated, Sometimes its 3 or 5. The Director was unable to provide the Usage Table or product insert, which the container instructions referred to for healthcare disinfection. The Director stated he was unable to provide any further information regarding Disinfectant Sanitizer. During an interview, at 7:13 p.m. on 5/21/20, the NHA and DON stated neither of them knew of the contact time for disinfection of the Disinfectant Sanitizer. The NHA stated high-touch areas are cleaned daily. The NHA stated the facility switched to other cleansers on Tuesday, so the new cleaners have a definite kill time. The Administration and Housekeeping staff were unaware of the necessary contact time to kill microorganisms of the Disinfectant Sanitizer liquid used to clean the facility and the high-touch areas of the facility were cleaned daily instead of per shift during the pandemic as recommended by the CDC. The Centers of Disease Control guidelines titled, Key Strategies to Prepare of COVID-19 in Long-Term Care Facilities - Webinar: Sparkling Surfaces: Stop COVID-19's Spread, (https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html), revealed [MEDICAL CONDITION] that causes COVID-19 can be spread by indirect contact with contaminated surfaces, surfaces that are touched frequently increase the chance that germs could be spread to residents or staff, and while surfaces may look clean pathogens may be lurking. The Webinar educated viewers that environmental and equipment surfaces create an opportunity for viruses and bacteria to survive, the coronavirus causing COVID-19 has been shown to survive on surfaces for several hours to days. The guidance, Sparkling Surfaces, indicated high-touch areas included door handles and light switches and the long-term care facility should create a process for cleaning equipment and room surfaces, clean high-touch surfaces at least once during each shift, and build in time to wipe down/clean all equipment shared between residents. The guidance revealed the following for products and practices: - Know which products should be used for each surface being cleaned; - Know how to apply products: clean the surface first and then apply the disinfectant and many products need to remain on surfaces for several minutes to fully kill the germ (contact time). A review of the Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings updated on 5/18/20, located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed: 10. Implement Environmental Infection Control Dedicated medical equipment should be used when caring for patients with known or suspected COVID-19. o All non-dedicated, non-disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings, including those patient-care areas in which aerosol generating procedures are performed. o Refer to List Nexternal icon on the EPA website for EPA-registered disinfectants that have qualified under EPA's emerging [MEDICAL CONDITION] pathogens program for use against [DIAGNOSES REDACTED]-CoV-2. Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Additional information about recommended practices for terminal cleaning of rooms and PPE to be worn by environmental services personnel is available in the Healthcare Infection Prevention and Control FAQs for COVID-19.

Based on observations, resident interview, and staff interviews, the facility failed to ensure residents had a comfortable and dignified dining experience during four of four days observed (2/4/2020, 2/5/2020, 2/6/2020, and 2/7/2020), in one of four dining rooms (the café restorative room). It was observed that residents were 1. Cramped and in the room with staff constantly carrying items over their heads, 2. Residents positioned close to the wall with hand sanitizer stations right at or just above their heads and 3. Residents seated at tables in a manner not able to receive and take bites of food comfortably. Findings included: On 2/4/2020 at 12:10 p.m. the main dining room and back Café restorative room were observed during the lunch meal service. During this time Staff were observed assisting with hydration pass and awaiting the tray cart to pass out and set up meals. The back restorative room was observed with seven tables and with seventeen residents positioned at them. The tray cart arrived at 12:16 p.m. and staff started service immediately. Further observation revealed the tables were positioned in such a way, residents and staff were cramped in. Staff were observed to walk discarded trays and other items while they held them over the heads of residents, who were seated. Some tables were observed with approximately less than two feet of space between each other. Staff were observed at least eight times to pass or walk trays, while carrying them over resident's heads. Also, the room was observed with three hand sanitizer stations hanging on the wall on three of the four walls in the room. There was one resident (#49), who was seated directly next to a hand sanitizer station, which was no more than seven inches from the left side of his head. Various staff were observed to use this station at least twelve times while resident #49 was being assisted with his meal. Resident #49 could not be interviewed related to his dining service. There was also a table in the room that was directly next to another hand sanitizer station, and with two residents seated at it. Staff were observed at least ten times to go directly behind the resident to use the station, which was directly back and over the residents' heads. The lunch meal dining service lasted about one hour and ten minutes. On 2/5/2020 at 12:20 p.m. the small restorative dining room was again observed for the lunch meal service. There were eighteen residents in the room seated at the same seven tables. There were seven staff members observed in the room assisting and interacting with residents. At 12:32 p.m. the meal tray cart arrived for this dining room. The right side of the room and to the back wall was observed with a table used to place empty trays and other various used items. Upon placing/setting up meal trays, staff had to maneuver their way between three tables. Upon doing this, staff had to lift and carry empty trays and various other items directly over the heads of three residents. One resident was seated in a Geri chair. The Geri chair was reclined and positioned in a manner where staff had to squeeze their way by between that resident and another. It was observed that tables needed more spacing so staff would not have to squeeze between residents and carry items over their heads. Further, this was observed to happen over ten times. On 2/6/2020 at 8:10 a.m. the small restorative dining room was observed for the breakfast meal service. There were continued observations of the hand sanitizer stations on the walls, being utilized by staff, with residents seated directly next to and below them. It was observed that Resident #49 was again seated no more than seven inches with his head next to one of the stations. Staff were also observed to maneuver themselves at least ten times between resident #49's head and the wall sanitizer station. On 2/7/2020 at 8:30 a.m. the small restorative dining room was again observed during the breakfast meal service and with the same seven tables positioned tightly throughout the room. There were thirteen residents seated at these tables. Resident #44 still positioned at a table with the hand sanitizer station next to his head. Staff were observed to use the sanitizer station over twelve times as residents were being served meals. The station was seven to nine inches away from the resident's head. Further, while setting up and passing meal trays, staff were still observed to carry discarded/used trays and other items over the heads of several residents, who were in process of eating. The space and walk through area between two tables were tightly cramped. Observations during all four days in the small restorative dining room revealed residents were not interviewable and were not able communicate related to their dining experience. On 2/7/2020 at 1:00 p.m. an interview with both the Director of Nursing (DON), and the Nursing Home Administrator (NHA) confirmed the small restorative dining room is a bit cramped and that the meal service in that room needs to be expanded to two meal services, for both lunch and dinner, so there is more room for residents and staff to move throughout. The NHA further confirmed that the hand sanitizer stations were positioned on the walls directly close to residents and that they need to be addressed as well. Observation on 02/06/2020 Resident #68 at 12:15 p.m., revealed she was seated in her low wheelchair at a table in the small restorative dining room. The Resident's head was turned downward resting in her hand, resulting in the edge of the table being level with her forehead. When the Resident #68 would slightly lift their head upward, the edge of the table was still above the Resident's mouth. An Aide sat in a high-level swivel chair next to Resident #68 and began to assist her with eating. The Aide's shoulder was level with the Resident's top of head. The Aide brought the utensils with food down below the edge of the table to reach the resident's mouth. At 12:19 p.m., another Aide sat next to the Resident #68 in a lower level chair, resulting in the Aide's shoulder being level with the Resident's shoulder and began assisting with eating. The observation during the entire meal service from at least 12:15 p.m. through to 1:00 p.m. revealed resident #68's face and mouth were at or too close to the table's edge, making it very difficult for her to take bites of food comfortably. Interview with Aides in the room revealed resident #68 is seated in a low wheelchair and she does not use a seat booster. None of the Aides had reasoning as to why she was being assisted with her meals at such a low position. Resident #68 was not able to be interviewed related to her positioning and meal service.

Based on interviews, observations, and record review, the facility did not ensure that one of sixty-one sampled residents (#44,) received adequate treatment and care in accordance with recognized practice standards. Specifically, this was related to the facility did not have orders for Resident #44's thumb splint, hand splint and brace during three of four days. Findings include: An observation was conducted on 2/06/20 at 10:55 a.m. Resident #44 was observed in her room sitting in her wheelchair. She was observed wearing a left leg orthotic brace. A left thumb splint was not observed. The Resident stated the thumb brace had fallen off. She stated they will replace it in therapy when they come get her. On 2/07/20 at 12:36 p.m., Resident #44 was observed in her room, seated in her wheelchair watching TV. Her left hand thumb brace was in place. A blue finger loop hand splint was also observed on top of the side table. Resident stated, The aides put it on when I go to therapy. Review of Resident #44's medical record revealed that Resident #44's initial admission was 8/10/19. The Admission Record included medical [DIAGNOSES REDACTED]. A review of Resident #44's Comprehensive Care plans, most recently revised on 10/17/19 revealed there were no focus areas or interventions pertaining to splints or braces. Review of the physician Order summary Report dated 2/7/2020 revealed there were no orders for Adaptive devices such as splints or braces or a Restorative Program. The MDS (minimum data set) dated 11/17/19 revealed: Cognitive Patterns: BIMS (Brief Interview for Mental Status) score of 09, which indicated she had moderate cognitive impairment. Section F Functional Status: resident requires 1-2 person extensive to total dependence assistance with most activities of daily living (ADL's). Under Specialized Treatments/Services: OT (Occupational Therapy): certification period 11/15/19-12/13/2019: use of an adaptive device was checked. On 2/04/20 at 10:37 a.m., Resident #44 was observed in her room seated in her wheelchair. Resident #44 stated she was waiting for therapy. She had a soft splint on her left thumb. Resident #44 stated the splint on the thumb is to straighten the thumb. Review of the OT Recert, Progress Report and Update Therapy Plan (certification period 12/13/19 - 3/11/2020) revealed: continue Short Term Goal (STG) # 3: Patient will increase time out of bed/out of room in her wheelchair with the use of adaptive equipment/devices for 6 hours, in order to improve skin integrity and hygiene, and facilitate weight distribution. Long Term Goal (LTG) #5.0: Patient will safely wear resting hand splint and a hand roll on left hand for up to 8 hours, with minimal S/S (signs and symptoms) of redness, swelling, discomfort or pain. Review of the Restorative Nursing Referral form dated 01/07/2020, revealed that Resident #44 had a resting hand splint with finger loops and a soft thumb extending splint. It was signed by the referring therapist on 01/12/20. An interview on 02/06/20 at 08:42 AM with Staff A, Registered Nurse (RN).Staff A reviewed the 3008 admission form, admission note for 8-24-19, Hard Copy Medical record and did not find information on splints. Staff A stated the resident may have received the splints in therapy because the admission was through Physical therapy/Occupational therapy. Staff A confirmed there were no orders for the Restorative program nor splints in the electronic or hard copy record. Nurse A then stated I'm familiar with the maintenance restorative program usually the devices are taken off at night and placed back on in the morning and residents also have routine skin checks. Restorative nurses take care of the braces. Unless it is maintenance ROM there would be a Restorative program order and I don't see it. An interview on 02/06/20 at 09:06 AM with the Restorative Nurse stated she was new in the position and is also the risk manager. Nurse confirmed the Restorative program referral was dated 1/7/20 and she stated she did not place the order for the resident to begin the restorative program. The Director of Nursing present at the time of interview, confirmed the date of the referral and added that there had been a CNA trained by PT to perform the resident's treatment recommended. The director also stated the restorative CNAs receive a special training. After the duration of the program is completed the resident is reevaluated by physical therapy for further recommendations. The CNAs are trained by PT/OT in the treatment that is recommended. An interview on 02/06/20 at 09:29 AM with the Rehabilitation Director and Staff D PTA (Physical Therapy Assistant). The Director stated the resident has a AFO (ankle foot orthotics) because she was able to stand but was rolling her ankle. The resident consulted with orthotics and they made a custom cast mold. The AFO was made for the resident. Physical Therapy recommended and ordered a hand brace but it was not here yet. The department provided the resident with a temporary one. When the resident transitions to restorative from Physical therapy the department assistants follow the Restorative CNA for a couple of visits to ensure the resident is comfortable and the treatment is being performed correctly. OT (Occupational therapy) gave the resident a finger splint. The Resident is able to put it on and take it off. Rehabilitation director reviewed the Restorative nursing referral form and stated she had been referred to the restorative program (MONTH) 7, 2020 and that the CNA had been accompanied by Physical Therapy in three occasions to review treatment with the resident. An interview on 02/06/20 at 11:01 AM with staff B MDS RN. Staff B reviewed the care plan and confirmed there were no devices listed in the care plan. An orthotic device should be on the care plan under ADL's, if the resident was in the restorative program there would be a separate care plan for that. Staff B stated the other Restorative Nurse would write the restorative care plan. On 02/07/20 09:05 AM an interview with Rehabilitation Director, she stated an AFO is part of the resident's dressing it is placed in the morning before patient gets up from bed and taken off before going to bed, it is used for transfer. The AFO is one whole piece, shoe and brace with straps, there is really no wrong way to place an AFO, because it is a custom fit device, unless you place it on the wrong foot or the resident has recent [MEDICAL CONDITION] you might tighten the strap too much. Unlike a hand splint which we have to determine amount of time tolerated the AFO is a dressing piece.

Based on observation, clinical record review, and interview, the facility failed to ensure proper storage of respiratory equipment, of a facemask for two (Resident #102 and Resident #309) of two residents sampled. Findings included: A review of facility policy titled Equipment Storage-Respiratory (Disposable) (oxygen, tubing/cannula, nebulizer administration equipment) with effective date of (MONTH) 2014, under Procedure, reads as follows: 3. Place respiratory equipment (e.g. excess tubing, cannula, nebulizer mouthpiece/mask, medication chamber) in plastic storage bag labeled with resident's name and store at bedside until next use. On 02/04/20 at 9:38 a.m. Resident #102 was observed to be sitting in a wheelchair wearing oxygen Nasal Cannula (NC) of 2 Liters (L). Respiratory equipment of a nebulizer facemask was observed to be on top of a night-stand table, located next to the resident's bed, and not properly stored in a labeled plastic storage bag. (Photographic Evidence Obtained.) A repeat observation of Resident #102's room was conducted on 02/05/20 at 11:45 a.m. The facemask was noted to be again improperly stored, and in the same spot, on top of the night-stand table. (Photographic Evidence Obtained.) During a subsequent observation of Resident #102's room on 02/06/20 at 10:20 a.m., the nebulizer facemask was again observed not to be stored properly. The facemask was in the same spot located on top of the night-stand next to the bed. (Photographic Evidence Obtained.) Clinical record review for Resident #102 indicated that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Further clinical record review of Physician order [REDACTED].#102 revealed [MEDICATION NAME] Nebulization Solution 2.5 MG/3ML) 0.083% 1 vial inhale orally via nebulizer every 6 hours as needed for SOB/Wheezing. On 2/04/20 at 9:45 a.m., an observation of Resident # 309's room was conducted. The resident was not in her room at the time, and respiratory equipment of a facemask was observed to be on the night-stand next to the resident's bed. The facemask was next to a black nebulizer machine and was not be properly stored in a labeled plastic bag. On 2/05/20 at 9:54 a.m., a second observation was conducted of Resident #309's room. The resident's respiratory equipment of a facemask was observed to be on top of the night-stand next to the black respiratory nebulizer equipment. (Photographic Evidence Obtained.) An interview with Resident #309 was attempted, but she indicated she did not want to say anything to get the staff in trouble. Clinical record review for Resident #309 indicated that he was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Further clinical record review of Physician order [REDACTED].# 309 revealed [MEDICATION NAME]-[MEDICATION NAME] Solution 0.5-2.5 (3) MG/3ML 1 application inhale orally every 4 hours as needed for Wheezing. On 02/07/20 at 8:24 a.m., an interview was conducted with the Director of Nursing (DON). The Don was informed of numerous observations made of both Resident #102's and Resident # 309's nebulizer facemask, not being stored properly per facility policy by staff. The DON was shown Photographic Evidence of both resident's rooms and their respiratory equipment and facemask not being stored appropriately in a labeled plastic bag. The DON stated, The nebulizer mask should be cleaned, placed and stored in a bag.

Based on observations, record review, facility policy review and staff interview, the facility failed to ensure one of five residents who receive [MEDICAL TREATMENT] services, and out of sixty-one sampled total residents (#66), was evaluated for pre and post [MEDICAL TREATMENT] visits. It was determined that the facility's [MEDICAL TREATMENT] communication sheets were not documented with all the required information in order to closely evaluate the residents. Findings included: Review of resident #66's medical record revealed he was admitted to the facility for long term care on 2/12/2017 and again more recently from the hospital on [DATE]. Review of the advance directives revealed resident #66 was his own responsible party and medical decision maker. Review of the [DIAGNOSES REDACTED]. On 2/06/20 5:04 p.m. an interview with Resident #66 revealed when he goes to [MEDICAL TREATMENT] they give him a lunch but he doesn't remember what he ate. He feels safe when he is getting transported. When asked about why he was sent to the hospital from the [MEDICAL TREATMENT] center the resident said that blood pressure drops sometimes. It doesn't happen a lot but it generally does. He indicated that he doesn't feel pain around his stent. Review of the current POS (physician's orders [REDACTED].#66 was ordered for: [MEDICAL TREATMENT] schedule Tuesday's, Thursday's, and Saturdays; Diet order No Added Salt, regular consistency with thin liquids. Per review of the order sheet, observations during the survey from 2/4/2020 through to 2/7/2020, and interview with the resident and floor care staff, resident #66 is transported to a [MEDICAL TREATMENT] center three times a week to receive services. Review of the facility's [MEDICAL TREATMENT] Communication Forms, dated from 1/1/2020 through to 2/7/2020, it was determined that six communication sheets were not filled out entirely, to include: a. Form dated 1/11/2020 revealed the section filled out by nurse prior to leaving the facility, revealed lacked vital signs, lack of when the resident had his last meal, and was not signed or dated by the nurse. Further, the section where the [MEDICAL TREATMENT] center fills out, was not signed or dated by a nurse. Additionally, upon return from the [MEDICAL TREATMENT] center, the section for the facility nurse did not document admitting vital signs, nor was it signed and dated by a nurse. b. Form dated 1/14/2020 revealed no section completed with vitals signs, etc., prior to leaving the facility. Further, the section to be completed by facility nurse, upon returning from the [MEDICAL TREATMENT] center, lacked vitals signs and who and when that information was completed. c. Form dated 1/18/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs, lacked when the resident had his last meal, and was not signed or dated by nurse. Further, the section completed by the [MEDICAL TREATMENT] nurse, was not signed or dated. Additionally, the section to be completed by the facility nurse, upon resident returning from the [MEDICAL TREATMENT] center, it was totally blank and not signed or dated. d. Form dated 1/23/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs, lacked when the resident had his last meal, and was not signed and dated by the nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the [MEDICAL TREATMENT] center, it was totally blank and not signed or dated. e. Form dated 1/28/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs, lacked when the resident had his last meal, and was not signed and dated by the nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the [MEDICAL TREATMENT] center, it was totally blank and not signed or dated. f. Form dated 2/1/2020 revealed the section filled out by the nurse prior to leaving the facility, lacked vital signs and was not signed or dated by the facility nurse. Additionally, the section to be completed by the facility nurse, upon resident returning from the [MEDICAL TREATMENT] center, it was totally blank and not signed or dated. Interview with the Central Unit Manager on 2/7/2020 at 12:20 p.m. revealed that prior to leaving the facility, those who receive [MEDICAL TREATMENT] are to have their vitals taken and to include Blood Pressure signs. She further indicated that the form goes to the [MEDICAL TREATMENT] center with the resident and that center is responsible for filling out their section. She also indicated that upon return, the facility nurse is to take vitals and fill out the third section of the form to include vital signs. The Unit Manager confirmed that the above listed [MEDICAL TREATMENT] Communication forms were not completed entirely and that they should have. The Unit Manager was asked if the information was documented elsewhere in the chart and she revealed that it was not. On 2/7/2020 at 3:10 p.m. the DON (Director of Nursing) indicated that for residents who go to [MEDICAL TREATMENT] center, and to include resident #66, staff are to initiate every day and to do the following: Facility nurse is to fill out top portion of communication sheet with vitals, weights, med holds, and any other information prudent to [MEDICAL TREATMENT], and sign and date. The DON further indicated that the communication form goes to the [MEDICAL TREATMENT] center and that nursing staff there are responsible for filling out their section with the same documenting of vitals, weights, med holds, etc. and that a nurse there is to sign and date as well. The DON also explained that the communication form is returned from [MEDICAL TREATMENT] with the resident and upon arriving back, the nurse will again complete and document vitals, weights, med holds, etc. and then sign and date. She confirmed that out of sixteen communication sheets reviewed, six were not filled out completely with either weights not completed, and also staff not signing their section. She further confirmed that after checking the entire medical record and to include progress notes, none of the missing information on these communication sheets were documented and therefore nursing staff would not be able to make good assessment judgements from the lack of information. On 2/7/2020 at 2:45 p.m., review of the facility's Special Care - General Care of the Resident Receiving [MEDICAL TREATMENT] policy and procedure, dated 6/7/2014, under the Procedure section, (I), and #12, revealed, Monitor the resident's blood pressure after the [MEDICAL TREATMENT] treatment, or per physician's orders [REDACTED].

Based on interview and record review the facility failed to honor the resident's right to resolve grievances in a timely manner for 1 of 3 (#1) sampled residents, related to refunds. Findings included: Review of Resident #1's record revealed that this resident was readmitted to the facility from the hospital on [DATE], under hospice care. The record indicated that the resident expired in the facility on [DATE]. Review of the record revealed a Resident Trust Fund Permission Form which was signed and dated on [DATE]. Review of Resident #1's record revealed a Trust Transaction History for the period of [DATE] - (MONTH) 31, 2019 which indicated that on [DATE] the resident had a deposit of $1,400.00 from a government agency. On the same date the same amount ($1,400.00) was withdrawn from the account for patient liability, leaving a closing balance of resident funds in the amount of $0.00. Review of email correspondence between the facility and the resident's Power of attorney (POA) revealed that on [DATE] the Business Office Manager (BOM) informed the POA via email that their was a refund on the resident's account for $350.09. Review of the record revealed that there was no documentation that would indicate that the resident's account had been balanced and that the refund was sent to the appropriate parties. Interview on [DATE] at 12:07 PM with the BOM. revealed that Resident #1 opened a trust fund account on [DATE]. She reported that after the resident's death the POA contacted the BOM via phone to find out if there was a refund and how much the refund was. She reported that the POA requested a ledger of Resident #1's financing. The BOM reported that there is no documentation that would indicate that the information that was requested from the POA was provided. The BOM reported that she was going to send out the refund to the POA this Friday which would have been (MONTH) 6th, 2019. The BOM reported that she was not sure that anyone else was aware of the concern related to Residents #1's refund. She confirmed that the Nursing Home Administrator (NHA) is the Grievance Coordinator and handles all grievance, but did not report this concern to the Grievance Coordinator, as she did not think that this was a grievance as the concern was being worked on. Interview with the NHA on [DATE] at 1:08 PM revealed that she did received a phone call from Resident #1's POA on [DATE], asking for all of the resident's financial statements. She reported that she informed the POA that she would expedited the statements to her. She reported that the statements were scanned and emailed to the POA on [DATE]. She reported that at this point she is not sure as to why the refund has not been issued. Interview on [DATE] at 1:32 PM with the NHA/Grievance Coordinator, revealed that a grievance is anything that cannot be promptly or immediately resolved. She reported that if the family had a concern regarding inaccurate patient funds, that a grievance should have been developed to ensure resolution. Review of the facility undated policy titled Memorandum of Direction with a subject ofGrievance Program revealed that All facility grievance investigations will be initiated as soon as possible after the grievance is filed. Completed and timely follow up will be conducted by the department supervisor, the Grievance Officer and/or the Administrator.

Based on observation, interview and medical record review the facility failed to ensure that pain management was provided for one (#58) out of forty one sampled Residents by not addressing unrelieved pain after a fall at the facility that resulted in a pelvic fracture. Findings Included: On 10/15/18 10:34 a.m. Resident #58 was observed sitting up in her wheel chair in her bedroom and was receptive to an interview. When she was asked if she was having any pain she said yes. She rated her pain level at a 7. She said that the nurse had just provided her with the pain medication and that she gets, it's ordered every 6 hours. She then said that it has not been effective. She spoke of having a fall last month at the facility as she was attempting to go into her bathroom. She said that she always went to the bathroom by herself and pointed to her wheeled walker. She went on to say that someone was in the bathroom and when the door was opened it caused her to fall. She stated that was how she fractured her pelvis. Resident #58 said that she used to be able to walk before by herself but she no longer can because of the pain. And she said they don't want me going to the bathroom by myself anymore because I fell . So I just sit in this wheel chair now. Medical record review showed that the resident was originally admitted to the facility on [DATE] for short term rehabilitation. She was not ambulating when admitted . Prior to her discharge on 9/15/2018 to an assisted living facility she was walking up to four hundred feet. Resident #58 returned to the facility on [DATE] after a change in condition while residing at the Assisted Living Facility (ALF). Her Admission Record indicated she was in her middle eighties with a [DIAGNOSES REDACTED]. The medical record contained a document titled 72 HOUR FALL MONITOR time 10:15 am dated 9/21/2018. Pt. sustained a fall @ 10:15 AM after trying to lean over to knock on the bathroom door to notify another pt. she was coming in, that she was in the bathroom; the other pt. opened the door as pt. attempted to knock, pt. lost her balance and fell on to the floor on her Right (R) side. Pt. Complained Of (C/O) Right Lower Extremity (RLE) pain; x-rays ordered of R hip, pelvis, R femur, R knee with negative results. Medical record was reviewed that included a copy of the a Mobile x-ray report dated on 9/26/2018. Listed under significant findings; Lumbar Spine 2-3 View; Impression: Central compression of the superior endplate of L1. No further x-ray reports were located in her medical record. The Unit manager was asked and a copy was obtained titled Bone Scan dated on 10/8/2018. Impression: 1. Intense uptake along with the right SI joint compatible with a fracture. 2. Fractures of the inferior pubic rami. A Consultation Report was on the medical record dated on 10/08/2018. Patient s/p fall with sacral fracture (fx) and pubic rami. Medical record review revealed documents from a physician visit that was dated on 10/15/2018. Stated here today for a pelvic fx. fell while opening door bathroom while at Oak Manor approximately on 9/26. Pain is worse with any movement. Lumbar spine: pain with motion. Plan: Modified weight bearing as tolerated. No carrying over 10 pounds. She understands that these injuries will certainly take time to heal, no acute surgical intervention. Multiple pelvic fractures review of the resident's medical record revealed [REDACTED]. The goal was Resident #2 will experience relief from pain without verbal/non-verbal complaints/signs of pain through next review, revised 9/10/18, target date 11/20/18. Interventions included assess pain severity, location and precipitation factors, Contact MD if medication is not effective, encourage her to ask for pain medication before pain is severe, medicate as needed and document effectiveness, observe for signs of non-verbal discomfort such as wincing, grimacing, guarding, striking out or moaning, observe for verbal discomfort such as crying or yelling out, try nursing measures such as back rubs, repositioning, ambulation food/fluids to alleviate pain; all the interventions were initiated on 4/24/18 and revised on the same day 4/24/18. On 10/16/2018 at 1:00 p.m. Resident #58 was observed lying in bed with her eyes closed. She appeared comfortable and in no distress. On 10/17/18 at 10:56 a.m. Resident #58 was observed lying in her bed and when approached stated that she had just returned from her therapy session and said that she was in pain. She stated I wish I could get it just below a 6. She said her pain was currently at a 7 out of 10. She stated as long as I lie still and don't move I can just tolerate the pain. Medical record review was conducted that revealed Physician orders [REDACTED].>8/17/2018 for Tylenol Extra Strength tablet give 2 tablets by mouth three times a day for knee pain relief scheduled times to be given at 6:00 a.m. (0600), 2:00 p.m. (1400) and 9:00 p.m. (2100). 8/19/2018 for [MEDICATION NAME] HCI Tablet 50 mg one tablet by mouth every 6 hours as needed for right knee pain. 8/17/2018 read [MEDICATION NAME] HCI tablet 5 mg one by mouth every 4 hours as needed for pain. Review was conducted of the Medication Administration Record [REDACTED]. On 10/17/2018 at 11:00am the narcotic log was reviewed that did not contain a sign out sheet for the ordered [MEDICATION NAME]. At 11:00 05 a.m. Licensed Practical Nurse M was asked if the medication cart contained a card for Resident # 58's [MEDICATION NAME]. She stated that a card was not present but she had a card for the [MEDICATION NAME]. On 10/17/2018 at 11:45 a.m. an interview was conducted with Physical Therapy Assistant (PTA) N that confirmed he knew Resident # 58. He said that he worked with her today. He stated that she is on case load to be seen 3 times a week and that he had just returned her to her room after her session because she was having pain. PTA N confirmed at that time her pain was limiting ambulation. He also said that some days she can only walk up to two feet. An interview was conducted with Occupational Therapist P; she said she represented the therapy department in the daily meetings. She was asked about Resident #58's change in her pain level. She said that we have on going communication with her nurse about her pain. Physical Therapy notes were reviewed for date of service of 10/17/2018. Gait training with emphasis on increasing safety and performance within the facility and gait training to normalize pattern. Pt. ambulated for 10ft Contact Guard Assist (CGA), pt with slow cadence and sever pain secondary to pelvic fx. Physical Therapy notes were reviewed for date of service on 10/16/2018. Pt. ambulated 3 ft and 2 ft with CGA pt. complained of increased pain with weight bearing activities demonstrated decreased pace, decreased step length and decreased feet clearance. Set up and break down on omni cycle to facilitate continuous coordinated reciprocal movement to improve functional mobility. Performed 6 min only due to increased pain. Bilateral Lower Extremity (BLE) strengthening while seated in WC (wheelchair) completed 3 sets of 10 reps requiring increased toe for rest breaks due to pain. On 10/17/18 03:05 PM an interview was conducted with the Risk Manager that confirmed he knew Resident #58, he said that she was alert and oriented. He was asked about her statements that the current pain medication she was on was not being effective. The RM read from the nursing notes dated on 10/2 and said that the [MEDICATION NAME] she was taking was effective. The RM was asked if the resident fractured her pelvis could that indicate a change in condition. He stated no that it is not. It has to be more than just a pelvic fracture. At 3:10 p.m. the DON was present and stated that she was calling the floor nurse to get the resident's [MEDICATION NAME] reinstated from the physician. The DON stated I'm contacting, I'm contacting, and I'm texting. On 10/18/2018 at 1:00 p.m. an interview was conducted with Minimal Data Set nurse G (MDSG) he confirmed that Resident #58's MDS was currently in progress. The due date was 10/21 with the look back period starting on 10/15/2018. He stated that he had spoken with the resident just yesterday and he had asked her pain level. She told me a 7. He said that a 7 was too high. I went to look at orders and asked the staff why she was not getting her [MEDICATION NAME]. He said that no one could tell him why. He was asked if the resident would trigger a change in condition with the pelvis fracture, change in her ambulation and increased pain. He stated What? She has a pelvic fracture? He confirmed he was unaware of the bone scan that was conducted on 10/8/2018. MDS G confirmed that with the pelvic fracture and pain the system would trigger a change. He said all you need is two changes. The RM was asked if a new pain assessment had been performed after Resident #58 had fallen. He stated the only pain assessment he could find was the MDS assessment on 8/17/2018. At 3:30 p.m. the DON stated that she texted the Physician. The RM stated we will fix this. The DON stated that I can only go by nursing notes and it appears effective. Then said we chart on pain every shift. RM stated Why isn't therapy telling the nurse? The DON was asked if the facility premedicates residents prior to their scheduled therapy session she stated that that has always been our standard. She stated I'm going back to therapy after this. She stated we have a clinical board that addresses pain, falls, new admissions and grievances. If Resident #58 had a pain issue going on it would have been on my board. The DON then said this was a communication breakdown.