Every finding on record at Park Place Nursing Facility

Based on staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to implement the care plan for one of 58 sampled residents (R) (R14). Actual harm was identified to have occurred on 05/07/2026, when R14 sustained a laceration to the right side of the forehead, right ankle sprain, and abdominal wall contusion from a fall from his bed that occurred when staff provided ADL care with one-person assistance when the resident required two-person assistance.Findings include:Review of the facility's policy titled Comprehensive Care Plan, dated October 2025, revealed the Policy section included, 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The Policy Explanation and Compliance Guidelines section included . 8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made.Review of the admission Record for R14 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, multiple sclerosis, muscle wasting and atrophy, and acute and chronic respiratory failure with hypoxia. Review of the Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/05/2026, revealed that section GG (Functional Abilities and Goals) documented that the resident had bilateral upper and lower extremity impairment and was dependent for toileting hygiene, personal hygiene, and rolling left and right on the bed. The MDS stated that dependent meant that the assistance of two or more helpers was required to complete the activity. Review of the care plan for R14 revealed a Focus, dated 03/31/2023 and revised 03/28/2024, of the resident had an ADL self-care performance deficit secondary to a diagnosis of multiple sclerosis. Interventions/Tasks included, but were not limited to, the resident requires assistance by two staff to turn and reposition in bed, date initiated 03/31/2023 and revised on 02/11/2026. Review of the Progress Notes for R14 revealed an entry dated 05/07/2026 at 11:00 PM and titled Incident Note that documented the nurse was called to the patient's room via a CNA. The resident was lying on the floor next to his bed on his back with CNA BB standing over him and applying pressure to his bleeding forehead. The CNA reported that as she was changing the resident's linen after an incontinent episode, he rolled off the bed and hit his head on the side of the bed. A head-to-toe assessment was completed, vital signs were taken, the Nurse Practitioner was notified, and the resident was sent to the emergency room (ER) for evaluation. Review of the ER record for R14, dated 05/07/2026, revealed the reason for the visit was a fall. The diagnoses were: fall from bed, laceration of the skin of the forehead, sprain and strain of the right ankle, contusion of the abdominal wall, and injury of the head. The record documented that a laceration repair was completed. In an interview on 06/10/2026 at 10:05 AM, Licensed Practical Nurse (LPN) stated that R14's care plan indicated the resident required two persons for bed mobility. She stated the resident had a fall from the bed on 05/07/2026, when CNA BB was changing him unassisted, and sustained a laceration on his forehead. She stated R14 was transported to the emergency room and received sutures for the head laceration. In an interview on 06/10/2026 at 10:05 AM, CNA BB stated that on 05/07/2026, she provided care and changed R14's bed linen by herself. She further stated R14 fell from the bed and sustained a forehead laceration during the care. She stated she was unaware that the resident required two-person assistance with bed mobility. She stated she had received training on following the resident care plans. In an interview on 06/10/2026 at 11:50 AM, the Director of Nursing (DON) stated CNA BB provided care to R14 unassisted and did not follow the care plan for a two-person assist. She further stated that care was not provided according to the assessed needs of the resident and the care plan, and her expectation was for the care plan to be followed. Cross-Reference F689

Based on staff interviews and record review, the facility failed to ensure that Activities of Daily Living (ADL) care was provided by the appropriate number of staff, to prevent accidents, for one of four residents (R) (R14) sampled for ADL care. Actual harm was identified to have occurred on 05/07/2026, when R14 sustained a laceration to the right side of the forehead, right ankle sprain, and abdominal wall contusion from a fall from his bed that occurred when staff provided ADL care with one-person assistance when the resident required two-person assistance. Findings include: Review of the admission Record for R14 revealed the resident was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, multiple sclerosis, muscle wasting and atrophy, and acute and chronic respiratory failure with hypoxia. Review of the Significant Change Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 02/05/2026, revealed that section GG (Functional Abilities and Goals) documented that the resident had bilateral upper and lower extremity impairment and was dependent for toileting hygiene, personal hygiene, and rolling left and right on the bed. The MDS stated that dependent meant that the assistance of two or more helpers was required to complete the activity. Section H (Bladder and Bowel) documented that the resident was always incontinent of bladder and bowel. Review of the Progress Notes for R14 revealed an entry dated 05/06/2026 at 11:34 PM and titled N Adv-Left/Transfer Evaluation that included, Resident is not able to assist with repositioning in bed. Continued review of the Progress Notes for R14 revealed an entry dated 05/07/2026 at 11:00 PM and titled Incident Note that documented the nurse was called to the patient's room by a Certified Nurse Aide (CNA). The resident was lying on the floor next to his bed on his back with CNA BB standing over him and applying pressure to his bleeding forehead. The CNA reported that as she was changing the resident's linen after an incontinent episode, he rolled off the bed and hit his head on the side of the bed. A head-to-toe assessment was completed, vital signs were taken, the Nurse Practitioner was notified, and the resident was sent to the emergency room (ER) for evaluation. Further review of the Progress Notes for R14 revealed an entry dated 05/08/2026 at 4:04 AM and titled Health Status Note that documented the resident returned for the ER with right ankle sprain, abdominal wall contusion, and laceration repair to mid-dissolvable sutures to the forehead. Review of the ER record for R14, dated 05/07/2026, revealed the reason for the visit was a fall. The diagnoses were: fall from bed, laceration of the skin of the forehead, sprain and strain of the right ankle, contusion of the abdominal wall, and injury of the head. The record documented that a laceration repair was completed. In an interview on 06/09/2026 at 3:40 PM, Licensed Practical Nurse (LPN) CC stated that when she entered R14's room just after the fall on 05/07/2026, only one CNA was present, attempting to change his bed linens. She stated that a second staff member should have been present to assist.In a telephone interview on 06/09/2026 at 3:50 PM, CNA BB reported that at the time of R14's fall, she was changing him by herself and did not have another staff member present. She stated she was unable to keep him on the bed, and he fell to the ground. She stated she was unaware that the resident required a two-person assist. In an interview on 06/10/2026 at 10:05 AM, LPN CC stated R14 required two persons for assistance. She stated the resident had a fall from the bed when CNA BB was changing him unassisted and sustained a laceration on his forehead. She further stated that R14 was transported to the ER after the fall and received sutures to his forehead for a laceration. In an interview on 06/10/2026 at 11:50 AM, the Director of Nursing (DON) stated CNA BB was providing care for R14 unassisted when he fell from the bed. She stated the CNA did not provide care according to the resident's assessed needs. She further stated that education was provided to CNA BB after the incident. In an interview on 06/10/2026 at 12:30 PM, the Administrator explained that when CNA BB was changing R14, a sheet got tangled up, the CNA attempted to grab the resident, but was unable to keep him from falling to the floor. The Administrator further stated that if R14 was assessed as needing two persons' assistance, her expectation was for two persons to provide assistance for R14 when changing his bed.

Based on observations, staff interviews, and review of the facility policies titled Infection Prevention and Control Program and Laundry, the facility failed to follow infection control practices related to proper handling and transporting of soiled items throughout the facility and in the laundry room. The deficient practices had the potential to place the residents at risk of infections due to cross-contamination. The facility census was 158. Findings include:Review of the facility policy titled Infection Prevention and Control Program, revised on 02/20/2026, documented, . 12. Linens a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent spread of infection. b. Clean linen shall be separated from soiled linen at all times.Review of the facility policy titled Laundry, with a revised date of 10/2025, documented, Policy Explanation and Compliance Guidelines: . 3. Soiled laundry shall be kept separate from clean laundry at all times.Observation and joint interview on 06/10/2026 at 12:38 pm revealed that the Laundry Aide and Laundry Supervisor in the laundry room were removing clean towels from the washing machine and placing them in a wheeled wire bin to put in the dryer. During the process of putting the towels in the dryer, three clean towels fell from the pile, missing the wire bin, and landed on the floor. Both the Laundry Aide and the Laundry Supervisor were observed picking the towels up off the floor and placing them in the dryer. The Laundry Aide started the dryer. When asked about the towels that were picked up off the floor and placed in the dryer, the Laundry Supervisor revealed they should not have been placed in the dryer but should have been returned to the washing machine after landing on the floor. Joint Observation and interview on 06/11/2026 at 10:38 AM of Laundry Aide DD pushing a bin labeled soiled linens through C Hall with the top flap open and exposing the soiled items in the bin. When asked whether the bin lid should be closed, she stated, I got it, and closed it.Interview on 06/11/2026 at 11:47 AM with the Director of Nursing (DON) revealed it was best practice for staff to not push the bins labeled soiled linens throughout the hallways with the top off. Interview on 06/11/2026 12:04 PM with the Administrator revealed that it was not normal practice for soiled laundry bins to be pushed through the facility with the lids open, and it should not be done. She further revealed that the lid should be closed when going through the hall. The Administrator revealed that the laundry should not hit the floor and be put in the dryer, but should be re-washed.

Based on staff interviews and record review, the facility failed to ensure that one of 58 sampled residents (R208) received an accurate Minimum Data Set (MDS) assessment reflective of the resident's status at the time of the assessment. This deficient practice had the potential to place R208 at risk of inadequate care planning and interventions.Findings include:Review of the electronic medical record (EMR) for R208 revealed admission to the facility on [DATE] with diagnoses including, but not limited to, unspecified dementia, unspecified severity, with agitation, unspecified dementia, unspecified severity, with mood disturbance, and Parkinson's disease without dyskinesia, with fluctuations Further review of the EMR for R208 revealed the resident was discharged from the facility on 01/10/2026 with a 1013 Form (a legal document that authorizes a psychiatric hold and examination of someone experiencing a mental health crisis) related to behaviors. Review of the Discharge MDS assessment for R208, dated 01/10/2026, revealed section A (Identification Information) documented the resident had an unplanned discharge on [DATE] to a short-term general hospital. Section C (Cognitive Patterns) documented a staff assessment of mental status, which noted that the resident's short-term memory was okay and that he was independent in making decisions regarding daily tasks. No signs of delirium, disorganized thinking, or inattention. Section E (Behaviors) documented no hallucinations or delusions, no physical behavioral symptoms directed towards others, no verbal behavioral symptoms directed towards others, and no other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds).Review of the facility-provided document titled Form 1013-Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation (Mental Health), for R208, dated 01/10/2026, documented that the resident appeared to be mentally ill and had expressed recent threats/acts toward others, and the resident had threatened others. Review of the progress notes for R208 revealed an entry dated 01/10/2026 at 7:04 AM of At approximately 0645, resident exhibited aggressive and violent behavior. Resident grabbed staff by the neck and attempted to strike staff with a glass cup. Resident is COVID-19 positive; education was provided regarding the need to remain in his room for isolation precautions. Resident refused redirection and became increasingly agitated. Resident barricaded the door, preventing staff from exiting the room. Staff member called out for assistance, and additional staff responded to de-escalate the situation and assist with staff safety. {sic}Further review revealed an entry dated 01/10/2026 at 7:08 AM of Patient was discharged from facility and sent to the hospital for physical and verbal aggression on multiple and towards other residents. Unable to console or redirect. Officered snacks and incontinent care, morning medications given, offered reading materials. All confutable sets were not successful. Resident started the aggression with the CNA then transfer to the nurse then other resident around him. Other resident encouraged to remain safe from aggressive behavior to avoid any injury. After writer grabbed by neck and nearly lifting me off my feet, police called and report given. Inhouse supervisor alerte4d of the situation and assist with situation keeping all other resident safe along with resident initiating violence. NP [Nurse Practitioner] called, order given to 1013 resident immediately charge nurse with [hospital name] given full report. 911 in the building residemt became voilence with male Ems [emergency medical services]. Resident deescalated with stand by deputy officer. Resident eventually calmed down to get in the stretcher and been rolled out of the building to get medical help needed to ensure the safety of itself and others. {sic}Continued review revealed an entry dated 01/10/2026 at 9:59 AM of Resident was transferred out of the facility due to escalating violent and aggressive behavior posing an immediate risk to staff safety. Within the past 24 hours, resident demonstrated severe behavioral disturbances. On the prior day, resident barricaded a CNA [Certified Nurse Aide] inside a room. Overnight, resident physically assaulted the nurse by grabbing her around the neck and choking her, forcefully bending her hand backward, and attempting to strike her with the other hand while holding a cup; the incident ended only after the nurse screamed for help. These actions constitute an immediate safety threat that exceeds the facility's capacity for safe behavioral management. The facility is unable to safely meet the resident's needs at this time. Resident requires transfer to a higher level of care with specialized psychiatric and behavioral services to ensure safety of the resident and others. {sic}In an interview on 06/11/2026 at 11:33 AM, the Social Service Director (SSD) confirmed that the MDS Section E was coded incorrectly. She stated that the section was completed by the Social Service Assistant. In an interview on 06/11/2026 at 11:40 AM, the Social Service Assistant (SSA) AA stated that she reviewed the progress notes and care plan to code the sections on the MDS. She states that it was important to complete the MDS correctly. The SSA AA also stated that the MDS should reflect the current resident condition. The SSA AA confirmed that section E of R208's Discharge MDS was not coded correctly. In an interview on 06/11/2026 at 12:07 PM, the Director of Nursing (DON) revealed she expected the MDS to be coded accurately. The DON stated that it was important for the MDS to accurately reflect the resident's condition and care. In an interview on 06/11/2026 at 12:34 PM, the Administrator stated she expected staff to code the MDS assessment accurately and follow the regulatory guidelines.

Based on observations, staff interviews, record review, and review of the facility's policy titled Comprehensive Care Plans, the facility failed to develop a comprehensive care plan that included the use of oxygen and nebulizer treatments for one out of 24 Residents (R) (R33) receiving oxygen therapy. Findings include: Review of the facility's policy titled Comprehensive Care Plans, revised 2/22/2024 under the Policy section revealed, It is the policy of the facility to develop and implement a comprehensive person-centered care plan for each resident, .to meet a resident's medical, nursing, .needs that are identified in the resident's comprehensive assessment .3. The comprehensive care plan will describe, at a minimum, the following: a. The services are to be furnished to attain or maintain the resident's highest practicable physical .well-being .5. The comprehensive care plan will be reviewed and revised by the interdisciplinary care team after each comprehensive and quarterly MDS assessment . Review of the medical records revealed that R33 was admitted to the facility on [DATE] with diagnoses that included but not limited to pneumonitis, acute respiratory failure with hypoxia and hypercapnia, and pleural effusion. Review of R33's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) revealed, a Brief Mental Interview of Mental Status (BIMS) score of six indicating severe cognitive impairment. Section O (Special Treatments and Programs) revealed that the resident received oxygen therapy while being a resident. Review of R33's care plan revealed, there was no mention of oxygen therapy, other respiratory problems the resident was admitted with, or nebulizer treatments in the care plan. However, during the survey the care plan was updated that included a Focus: I was admitted with pneumonia on admission and will remain on ABT (antibiotic) therapy for the next three days, with the goal of being free from complications of infection, dated 4/8/2025; The care plan also included another Focus that revealed, I have pneumonia date initiated on 11/8/2024 and revision date of 4/8/2024, with the same goal of being free from complications of infection. Interventions included but are not limited to: elevating the head of the bed, administering medications as ordered, and monitoring for and reporting signs and symptoms of pneumonia to the physician. Review of R33's physician orders revealed, albuterol sulfate inhalation nebulization solution (2.5 MG [(milligrams) /3ML (milliliters)]0.083% - 3 mL to inhale orally in the morning for shortness of breath with start date of 11/9/2024 and ipratropium-albuterol inhalation solution 0.5-2.5 (3) MG/3ML - 3 mL to inhale orally three times a day for wheezing, for 7 days with start date of 4/7/2025 however there was no active physician orders for oxygen. Further review of medical records revealed a discontinued order for oxygen that was started on 11/8/2024 and discontinued on 11/11/2024. Observation on 4/8/2025 at 11:21 am revealed, R33 in bed with oxygen (O2) at 2LPM (liters per minute) via nasal canula (NC). Observations on 4/8/2025 at 3:00 pm and 5:53 pm revealed, R33 O2 at 2LPM via NC. Observation on 4/9/2024 at 2:00 pm revealed, R33 O2 at 2LPM via NC. Observation on 4/10/2025 at 9:20 am revealed R33 in the room receiving O2 at 2LPM via NC. During an interview on 4/9/2025 at 9:00 am, the Director of Nursing (DON) revealed that if a resident was on oxygen therapy, it should be addressed on the care plan. She further revealed she conducted an audit of all residents on oxygen and held an in-service training with her staff on the evening of 4/8/2025 regarding residents on oxygen. In an interview on 4/10/2025 at 2:45 pm with Licensed Practical Nurse MDS, BB revealed, when a resident is admitted to the facility, a baseline care plan is initiated, followed by a comprehensive care plan completed. She noted that the entire interdisciplinary team was involved in this process. She explained that they interview the resident and review the resident's records, physician's orders, hospital records, and diagnoses. She revealed that the comprehensive care plan was developed based on all this information. She further confirmed that if a resident had respiratory problems, received oxygen and respiratory treatments, then this information should be included in the care plan.

Based on staff interviews, record review, and review of the facility policy titled, Comprehensive Care Plans the facility failed to make sure the care plan for one out of 59 sampled Residents (R) R154 was revised to specifically address the updated advance directives. The deficient practice had the potential not to receive treatment and care according to their needs and/or preference. Findings include: A review of the facility policy titled, Comprehensive Care Plans dated [DATE], under the Policy section 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 include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. Under the Policy Explanation and Compliance Guidelines revealed, 3. The comprehensive care plan will describe at a minimum, the following: d. The residents goals for admission, desired outcomes, and preferences for future discharge . 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment .8. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. A review of the Annual Minimum Data Set (MDS) for R154 for Sections C (Cognitive Patterns) revealed a Brief Interview of Mental Status (BIMS) of 12 which indicated moderate cognitive impairment. A review of R154's Physician Order for Life-Sustaining Treatment (POLST) dated for [DATE] revealed the resident wished to have a natural death and do not attempt resuscitation. A review of R154's care plan with date initiated on [DATE] revealed, a Focus: My Code status is DNR (Do Not Resuscitate). Goal My wishes will be honored and carried out as indicated through next review. Interventions included: Code Status will be on record, honor wishes as indicated, notify MD/Family of change in condition promptly. A review of R154's Order Summary Report revealed, a Full Code order with start date of [DATE] (discontinued), a DNR order with start date of [DATE] (discontinued), and a Full Code order with start date of [DATE]. A review of R154's health progress note dated [DATE] 14:29 documented, Resident [154] noted unresponsive 12;20 pm, CPR started, 911 called, Resident transfer to ER at 12:45 pm, R/P both notified, supervisor notified NP. Phone interview on [DATE] at 10:00 am with Licensed Practical Nurse (LPN) FF revealed she went in the room and R154 was unresponsive when she called his name. They called 911 and the Emergency Medical Technicians (EMT's) came and started cardiopulmonary resuscitation (CPR) on R154. She said she does not recall but it was around noon on [DATE]. She further revealed the EMT's stated he had no pulse, and his oxygen (O2) sat was low, she went out and called a code blue and CPR was started right away and then when the EMT's arrived, they took over. An interview conducted on [DATE] at 2:00 pm with the Director of Nursing (DON) revealed that due to the facility's high volume of admissions and discharges, they utilize an Admissions Nurse to help manage transitions. The DON explained that during internal audits, it was discovered that when residents returned from hospital stays, some medication orders were being reactivated based on previous orders without proper verification or a new physician order. A staff member was reconciling discharge orders from the hospital but was not independently placing new orders; instead, he was matching the orders to the physician's recommendations. However, the DON acknowledged that reconciliation should involve contacting the physician to confirm appropriateness, not simply reactivating past orders. According to the DON, the facility policy requires that upon a resident's readmission, staff complete a comprehensive review of discharge orders, verify the resident's code status, and perform a complete reassessment within 48 hours. The DON confirmed that residents' code statuses, such as Full Code or DNR, are expected to be verified upon admission or readmission. The DON confirmed R154, who was hospitalized on [DATE], had a change in code status at the hospital to Full Code. A phone interview was conducted on [DATE] at 2:14 pm with the physician regarding R154's code status upon return from the hospital on [DATE]. During the interview, the physician reviewed R154's chart and indicated the readmission was likely done by nurse practitioner. He revealed for every admission a discussion of life sustaining care is discussed. The progress note documented discussion patient/POA/family wishes to discuss advanced care planning. An additional 17 minutes spent with patient /POA/family addressing Advanced Care Planning, including current diagnoses, goals of care and meaning of Full Code, DNR, Hospice and other life sustaining measures such as PEG tube for nutrition, CPR, ventilator and IV fluids. Understanding voiced, all questions and concerns addressed. There is no acute change in resident status at this time. Wishes to maintain FULL CODE status. 45 minutes total time spent on this encounter.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Administration, the facility failed to provide specialized respiratory care in accordance with professional standards of practice by administering oxygen (O2) without a physician's order for one out of 24 Residents (R) (R33) receiving oxygen therapy. Findings include: Review of the facility's policy titled Oxygen Administration revised 2/22/2024 under the Policy section revealed, 1. Oxygen is administered under orders of a physician except in the case of an emergency .4. The resident's care plan shall identify the interventions for oxygen therapy, based upon the resident's assessment and orders, such as, but not limited to: a. They type of oxygen delivery system. b. When to administer, such as continuous or intermittent and /or when to discontinue. Review of the medical records revealed that R33 was admitted to the facility on [DATE] with diagnoses that included but not limited to pneumonitis, acute respiratory failure with hypoxia and hypercapnia, and pleural effusion. Review of R33's Quarterly Minimum Data Set (MDS) dated [DATE] for Section C (Cognitive Patterns) a Brief Mental Interview of Mental Status (BIMS) score of six indicating severe cognitive impairment. Section O (Special Treatments and Programs) revealed that the resident received oxygen therapy while being a resident. Review of R33's physician orders revealed there was no active physician orders for oxygen. Further review of physician orders revealed a discontinued order for oxygen that was started on 11/8/2024 and discontinued on 11/11/2024. Review of R33's electronic Medication Administration Record (eMAR) from November 2024-March 2025 revealed a standing order to change oxygen tubing and clean oxygen concentrator filter every Wednesday during the day shift with start date of 11/13/2024. Further review of eMAR revealed that this task was checked off as completed. Observation on 4/8/2025 at 11:21 am revealed, R33 in bed with oxygen (O2) at 2LPM (liters per minute) via nasal canula (NC). Observations on 4/8/2025 at 3:00 pm and 5:53 pm revealed, R33 O2 at 2LPM via NC. Observation on 4/9/2024 at 2:00 pm revealed, R33 O2 at 2LPM via NC. Observation on 4/10/2025 at 9:20 am revealed R33 in the room receiving O2 at 2LPM via NC. Interview on 4/10/2025 at 9:22 am with Licensed Practical Nurse (LPN) AA revealed that R33 was currently being treated for pneumonia with antibiotics and nebulizer treatments. She revealed vitals, including pulse oximeter were completed daily, and he was also on oxygen. When asked how she would determine how much oxygen R33 needed, she replied that she would look at the doctor's order. During this time LPN AA verified that she was unable to find a doctor's order for oxygen for R33. She confirmed that all residents must have a doctor's order for oxygen and stated she would call the Nurse Practitioner right away to correct it. Interview on 4/10/2025 at 9:27 am with the Director of Nursing (DON) confirmed that residents must have a doctor's order for oxygen because it's considered a drug. The DON verified that she also was unable to find an order for oxygen for R33.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Medication Storage, the facility failed to secure medication that was left unattended on top of medication cart for one out of eight medication carts (Hall D medication cart). In addition, the facility failed to ensure sterile resident care items in one out of two medication storage rooms (Hall D medication storage room) were not expired. The deficient practices created the potential for residents, unauthorized staff, and visitors to have access to medications stored on the medication cart and the potential for the use of expired resident care supplies. Findings include: Review of the facility's policy titled Medication Storage, revised 2/22/2024 under the Policy section revealed, It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security. Under the Policy Explanation and Compliance Guidelines section revealed, 1. General Guidelines: (c.) During medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart . 8. Unused Medications The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels . Observation on 4/9/2025 at 8:28 am with Licensed Practical Nurse (LPN) CC during medication administration, revealed two medication cards with apixaban and buspirone were left unattended on Hall D medication cart while LPN CC went into resident room to administer medications with medication cart not in view. Observation and interview on 4/10/2025 at 2:48 pm with the Director of Nursing (DON) in Hall D medication storage room revealed four expired sterile, urethral catheter trays with expiration date of March 2025. The DON confirmed the expiration date during this time. Interview on 4/9/2025 at 8:35 am with LPN CC confirmed that when she leaves the cart, it must be locked with no medications on top. LPN CC referenced and confirmed that the medications were expired, left unattended during her medication administration. LPN CC confirmed that she should not have left the medications unattended. At this time, she removed the medication cards from the medication cart and disposed of them. Interview on 4/9/2025 at 9:40 am with the Assistant Director of Nursing revealed her expectations regarding medication storage was that expired medications found on the medication cart were to be destroyed immediately, not stored on top of medication cart. Interview on 4/10/2025 at 2:48 pm with the DON revealed her expectations for management of storage of medications includes, if expired meds were found in the medication cart during administration, the nurse was expected to place it away from the active pile inside of the medication cart until administration was done and then disposed of it. DON also revealed, her expectations that no medications, expired or active, were to be stored unattended on top of the medication cart. DON also confirmed expectations of medication storage room was that all expired items, including expired urethral catheterization trays should be removed weekly. DON confirmed that she has overall responsibility for removal of expired items.

Based on staff interviews, record review, and review of facility's policy titled Abuse, Neglect, and Exploitation the facility failed to report an allegation of sexual abuse against one Resident (R) (R5) to the State Survey Agency (SSA) within two hours of the allegation being made and to notify law enforcement. Specifically, the facility failed to notify the abuse coordinator and the local law enforcement that R5 reported that he had been molested and raped by Certified Nursing Assistant (CNA) BB. The sample size was five. Findings include: Review of the policy titled Abuse, Neglect, and Exploitation dated 2/24/2024 under the section titled, Policy revealed: It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Under the section titled, Definitions revealed: Law enforcement is the full range of potential responders to elder abuse, neglect, and exploitation including police, sheriffs, detectives, public safety officers; corrections personnel; prosecutors; medical examiners; investigators; and coroners. Under the section titled, VII. Reporting/Response revealed: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of the clinical record for R5 revealed he was readmitted to the facility on [DATE] with diagnoses of, but not limited anxiety, depression, and intracerebral hemorrhage. Review of R5's most recent quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognitive Patterns: a Brief Interview for Mental Status (BIMS) was assessed as zero, which indicated severe cognitive impairment. Section D-Mood: revealed the mood of feeling down, depressed, hopeless. Section E revealed verbal and other behavior exhibited. Review of R5's care plan initiated on 2/21/2024 revealed that R5 has potential to be verbally aggressive. Interventions included but not limited to assess the resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Review of the Behavior Note dated 2/17/2024 revealed: the CNA assisted R5 with incontinent care and placed R5 in the day area in his Geri-chair. She (CNA) then reported to the writer that resident was screaming while receiving incontinent care Ohhh {sic} she's molesting/raping me. Which made the CNA very uncomfortable about the fictitious accusation. The writer reported this matter to the Manager on Duty. He then reported it to the supervisor. Writer informed the CNA to write a statement per Manager on Duty. The nurse received the statement and given it to the Supervisor. Review of the Facility Incident Report Form dated 2/19/2024 revealed: I (Administrator in Training) was notified on 2/19/2024 regarding the allegation on 2/17/2024. Details of Incident: The resident (R5) stated that he was molested and raped. Alleged Perpetrator's CNB BB. An interview on 2/28/2024 at 10:59 am with CNA DD stated she has been in-service on abuse. She stated all abuse should be reported to the Administrator (Abuse Coordinator) immediately. An interview on 2/28/2024 at 11:09 am with CNA EE stated the facility conducts abuse in-service weekly on reporting abuse. She stated that all abuse should be reported immediately to the abuse coordinator (Administrator). An interview on 2/28/2024 at 11:23 am with Licensed Practical Nurse (LPN) CC stated she was on duty on 2/17/2024 when R5 accused the CNA BB of molestation and rape. The LPN stated the resident and CNA were in R5's room when she entered to give medications. She stated R5 was verbally abusive to her and the CNA. She stated R5 called her a __ and refused his medication. She stated she explained to the resident that his behavior was not nice. She stated after talking with him he agreed to take his medication. She stated she asked the resident, and the CNA were they okay. The resident and the CNA said they were okay, and she left the room. She stated a few minutes later the CNA came up to her and told her she needs another resident because he (R5) is accusing me of molesting and raping him (R5). She stated she went to R5 and asked what happened. She stated that R5 turned his head away and would not talk. She stated she reported the incident to the Manager On Duty (MOD). She stated she was instructed by the MOD to have the CNA to write a statement. LPN CC stated she did not notify anyone else of R5's allegation. An interview on 2/28/2024 at 2:30 pm with the Administrator stated the incident with R5 was reported to the SSA but not to the local law enforcement. She stated she spoke with R5, and he told her the allegation of molestation and rape was not true. She stated because the resident stated the allegation was not true, she did not report the incident to the local law enforcement. The Administrator stated going forward the allegations of abuse/neglect will be reported timely to SSA and law enforcement.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation the facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for one Certified Nursing Assistant (CNA) of ten employee files selected for review. The facility census was 155 residents. Findings include: Review of the policy titled Abuse, Neglect, and Exploitation dated 2/24/2024 indicated: Screening-A. Potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. 1. Background, reference, and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. 2. Screenings may be conducted by the facility itself, third-party agency, or academic institution. 3. The facility will maintain documentation of proof that the screening occurred. During a record review of the employee files there was no documentation that a fingerprint records check was conducted on CNA BB. An interview on 2/28/2024 at 10:50 am with the Human Resources Director (HRD) stated she is responsible for background checks, fingerprints check, reference check and maintaining the employee's files. The HRD confirmed CNA BB did not have a fingerprint check conducted. An interview on 2/28/2024 at 2:27 pm with the HRD stated the facility follows the State and Federal requirements for conducting fingerprint checks. An interview on 2/28/2024 at 3:30 pm with the Administrator stated she has spoken with the staff in the Human Resource Department and an audit will be completed to ensure that all employees have the required background check and/or GCHEXS completed.

Based on record review, staff interviews, and review of the facility policy titled, Abuse, Neglect and Exploitation, the facility failed to report allegations of abuse timely for one resident of four residents (R) (R#2), reviewed for abuse allegations. R#2 reported to the Administrator on 1/2/2023 that staff had been rough during care; however, the allegation was not reported to the state agency until 1/6/2023, four days later. Findings included: Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 2022, revealed, The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Review of an Admission Record revealed the facility admitted R#2 with a diagnosis which included acute respiratory failure. A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#2 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. R#2 required the assistance of one staff member with bed mobility. A review of R#2's care plan, dated 7/8/2022, indicated R#2 required extensive assistance from one staff with bed mobility. A Grievance Form, dated 1/2/2023, indicated R#2 reported a certified nursing assistant (CNA) was rushed when putting the resident to bed and turning the resident on their side on 1/1/2023. The grievance form further indicated the resident reported the CNA was rough and the resident provided a description of the CNA. The form indicated the Administrator took the grievance from the resident. A Facility Incident Report Form, dated 1/6/2023, indicated R#2 reported staff were rough while changing the resident's brief. The incident allegedly occurred on 1/1/2023 and 1/2/2023. The allegation of abuse was reported to the state agency on 1/6/2023. Interview on 1/16/2023 at 1:54 p.m., R#2 stated that on a Sunday and a Monday (date unknown), a staff member (name unknown) rolled R#2 over during care and gave the resident a shove. R#2 stated the incident was reported to the facility. Interview on 1/19/2023 at 2:59 p.m., the Director of Nursing (DON) stated if a resident reported a staff member was too rough, she would report the allegation and remove the staff member involved from resident care. Interview on 1/20/2023 at 9:10 a.m., the Administrator stated that when a resident says staff was too rough, We dig a little deeper. She revealed that allegations of abuse should be reported within two hours. She further stated that when the resident initially denied feeling they had been abused, the incident was not reported as abuse. The Administrator revealed that when the resident later stated they thought the incident was abuse, it was reported within two hours.

Based on record review, resident and staff interviews, and review of the facility policy titled, Medication Administration, the facility failed to provide pharmaceutical services that assured the accurate administration of medications for two residents of five residents ( R) (R#13 and R#17) reviewed for medication administration. Specifically, the facility failed to administer R#13's and R#17's medications within one hour of the scheduled time. Findings included: The facility's policy, titled, Medication Administration, dated 2022, indicated, Policy Explanation and Compliance Guidelines: with instructions to Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician. The policy also instructed to Sign MAR [Medication Administration Record] after administered. 1. Review of R#17's Admission Record revealed the facility admitted the resident with diagnoses that included hypertensive chronic kidney disease, acute respiratory failure with hypoxia, atrial fibrillation, type 2 diabetes mellitus with unspecified complications, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#17 had a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident was cognitively intact. The MDS indicated R#17 had active diagnoses that included diabetes mellitus, hypertension, hyperlipidemia, depression, and respiratory failure. The MDS revealed R#17 received insulin injections, an antidepressant, an anticoagulant, and a diuretic on seven of seven days during the assessment period. Review of R#17's care plan, revised on 9/27/2022, indicated R#17 had interventions in place, including to administer medications as ordered by the physician. Review of R#17's Medication Administration Record (MAR) for January 2023 revealed the following medications scheduled for 8:30 a.m. had been administered after 9:30 a.m. on 1/16/2023 and 1/17/2023: - Alphagan P Solution eye drops for glaucoma - apixaban tablet for atrial fibrillation - aspirin tablet for health maintenance - docusate Sodium capsule for constipation - dorzol/timolol eye drops for glaucoma - fluticasone nasal spray for allergies - metoprolol tartrate tablet for hypertension Review of R#17's MAR for January 2023 revealed the following medications scheduled for 8:30 p.m. were administered after 10:00 p.m. on 1/16/2023 and 1/17/2023: - Alphagan P Solution eye drops for glaucoma - apixaban tablet for atrial fibrillation - Celexa tablet for depression - fluticasone nasal spray for allergies - novolin R insulin per sliding scale for hyperglycemia Interview on 1/16/2023 at 12:20 p.m., R#17 stated the nurses were late administering medications. R#17 also stated it was usually 10:00 p.m. or later when they received their evening medications. 2. Review of R#13's Admission Record revealed the facility admitted the resident with diagnoses that included acute respiratory failure with hypoxia, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, type 2 diabetes mellitus, hypertension, and hyperlipidemia. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed R#13 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS indicated R#13 had active diagnoses that included coronary heart disease, hypertension, diabetes mellitus, hyperlipidemia, chronic obstructive pulmonary disease, and respiratory failure. Review of R#13 's care plan, revised on 8/20/2022, indicated R#13 had interventions in place, including to administer medications as ordered by the physician. Review of R#13's MAR for January 2023 revealed the following medications scheduled for 8:30 a.m. administration had been administered after 9:30 a.m. on 1/16/2023 and 1/17/2023: - Arnuity Ellipta inhaler for chronic obstructive pulmonary disease - aspirin delayed release for hypertension - diclofenac gel for arthritis pain - Eliquis tablet for atrial fibrillation - flecainide tablet for atrial fibrillation - Hiprex tablet for prophylaxis related to urinary tract infection - Ketotifen Fumarate drops for eye inflammation - Metoprolol Tart tablet for hypertension - Polyethylene Glycol for constipation - Potassium extended release for diuretic therapy - Spiriva inhaler for chronic obstructive pulmonary disease Review of R#13's MAR for January 2023 revealed the following medications scheduled for 8:30 p.m. were administered after 10:00 p.m. on 1/16/2023 and 1/17/2023: - Diclofenac gel for arthritis pain - Eliquis tablet for atrial fibrillation - Melatonin tablet for insomnia - Metoprolol Tart tablet for hypertension - Mirtazapine tablet for depression - Montelukast tablet for allergy symptoms Interview on 1/16/2023 at 2:25 p.m., R#13 stated that there was sometimes a problem with getting prescribed medications. Interview on 1/19/2023 at 9:58 a.m., Licensed Practical Nurse (LPN) GG stated that sometimes medication could be late due to emergencies or new admissions. LPN GG also stated that if residents did not get their medications on time, all kinds of things could happen, and whatever condition the medication was used to treat could get worse. Interview on 1/19/2023 at 10:43 a.m., LPN HH stated morning medications should be administered within an hour of the scheduled time. LPN HH also stated that if a nurse was running late, the supervisor could help them. Interview on 1/19/2023 at 11:16 a.m., LPN II stated the morning medication pass started at 7:00 a.m. and ended at 9:00 a.m LPN II also stated she frequently did not get medications passed on time at this facility. She stated there were a lot of residents and they received a lot of medications that took a long time to administer. LPN II further stated she marked the MAR as she was removing the medication from the package. LPN II stated that medications not being administered timely could cause problems for a resident. Interview on 1/20/2023 at 8:51 a.m., the Director of Nursing (DON) stated some nurses were waiting until the end of their shift to document medication administration. She further stated medications should be given within one hour of the scheduled time. The DON revealed that if a nurse was late giving medications, they should contact the physician. She further revealed that some medications were very important to give on time in order to provide the appropriate benefit to the resident. Interview on 1/20/2023 at 9:48 a.m., the Administrator in Training (AIT) stated she expected medications to be passed timely per doctor's orders and to be documented timely.

Based on record review, staff interviews, and review of the facility policy titled, MDS 3.0 Completion, the facility failed to ensure discharge Minimum Data Set (MDS) assessments were completed and transmitted timely for three of three residents (R ) (R#32, R#129, and R#131) reviewed for resident assessments. Findings included: A review of a facility policy titled, MDS 3.0 Completion, dated 11/1/2022, specified, 'OBRA Assessment refers to an assessment mandated by the Omnibus Budget Reconciliation Act of 1987, which specifies a Minimum Data Set (MDS) of core elements for use in assessing nursing home residents. The policy indicated, Types of OBRA Assessments: Discharge Assessment- completed using the discharge date as the ARD [Assessment Reference Date]. Must be completed within 14 days of the discharge date /ARD. The policy continued, Transmission Requirements: all assessments shall be transmitted to the designated CMS system (QIES ASAP) within 14 days of completion. 1. A review of an Admission Record indicated the facility discharged R#32 on 9/30/2022. A review of the MDS tab in the electronic health record indicated the discharge assessment was 96 days overdue. 2. A review of an Admission Record indicated the facility discharged R#129 on 9/1/2022. A review of the Minimum Data Set (MDS 3.0) Summary for R#129 indicated the discharge assessment was completed on 1/6/2023 and had not been transmitted. 3. A review of an Admission Record indicated the facility discharged R#131 on 9/2/2022. A review of the MDS tab in the electronic health record indicated the discharge assessment was 124 days overdue. Interview, with a concurrent record review, on 1/20/2023 at 8:16 a.m., the MDS Coordinator reviewed R#129's MDS data and indicated the discharge assessment had been completed late. The MDS Coordinator indicated R#129's discharge assessment should have been completed and transmitted already. The MDS Coordinator reviewed R#131 and R#32's MDS data and confirmed that neither resident's discharge assessment had been completed. Interview on 1/20/2023 at 8:28 a.m., the Director of Nursing (DON) indicated the MDS needed to be done timely. The DON indicated her expectation was for the MDS assessments to be completed accurately and timely and then submitted timely. Interview on 1/20/2023 at 8:33 a.m., the Administrator in Training (AIT) indicated she expected the MDSs to be done timely.

Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure a resident's responsible party was notified timely of their death for one (1) of 42 sampled residents, Resident (R) #137. Findings include: Review of the facility policy, Change in Resident's Condition updated 9/15/21, indicated the facility will notify the attending Physician, and representative of changes in the resident's medical/mental condition and or status. The staff member noticing a change in the resident condition shall report to the Nursing Supervisor/Charge Nurse at the point the assessment process begins and will then ensure the resident's family or representative are notified. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#137 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated R#137 had a Brief Interview for Mental Status (BIMS) score of eight (8), indicating moderate to severe impairment in cognitive skills for daily decision making. Review of a Do Not Resuscitate Order for Resident Without Decision Making Capacity dated 2/17/20, indicated the form was signed by the resident's responsible party. Review of the Hospice Notes dated 10/20/20, indicated R#137 was admitted to Hospice on 10/19/20. Review of the R#137's recapitulation of the 8/2021, Physician Orders indicated an order for [MEDICAL RECORD OR PHYSICIAN ORDER] Review of R#137's Release of Body form dated 8/24/21, indicated the date of death was 8/23/21 at approximately 5:00 a.m. Review of the facility's timeline of events on 8/23/21, revealed the following: -At approximately 5:49 a.m., Licensed Practical Nurse (LPN) KK was notified by Certified Nursing Assistant (CNA) ZZ that R#137 appeared to not be breathing. -LPN KK responded and noted no pulse of heartbeat. -At approximately 6:00 a.m., Hospice was called by LPN KK. Message left with answering service. -At approximately 6:35 a.m., LPN YY (hospice nurse) returned call and stated she was on another call regarding a pronouncement and would be at facility as soon as possible. -At a 7:11 approximately 7:11 a.m., LPN YY called for an update. Message left with answering service. -At approximately 8:15 a.m., LPN JJ called the responsible party to notify them of R#137's death (approximately 3 hours later). During an interview on 9/15/21 at 2:45 p.m., LPN JJ indicated LPN KK did not notify the responsible party of R#137's death and indicated she had a conversation with her around 7:30 a.m., (at the start of day shift) and then got tied up with an emergency and did not contact the family until around 8:15 a.m. During a telephone interview on 9/16/21 at 12:50 p.m., LPN KK (nurse who assessed R#137) stated she had called Hospice several times and was waiting for them to come and pronounce R#137. I did not think to call the family as I assumed that it was Hospice's job to call them During an interview on 9/17/21 at 9:35 a.m. the Clinical Administrator (CA) indicated there had been several nurses on the day shift and as soon as the night nurse (LPN KK) informed them of R#137's death, one of them should have called the family immediately. During an interview on 9/17/21 at 10:45 a.m., the Administrator indicated that the family had a conversation with him expressing their concerns of not receiving notification timelier than three (3) hours after the death of R#137. The Administrator expressed his apology and stated the call should have been placed as soon as the resident had passed.

Based on interviews, record review, and facility policy review, Referrals to Physical, Occupational, and Speech Therapy, the facility failed to provide rehab services for one resident (R)(R#99) out of 42 residents reviewed. Resident#99 had Physician orders for Physical, Speech and Occupational Therapy services that were not completed. Findings include: Review of the facility policy Referrals to Physical, Occupational, and Speech Therapy, dated 4/22/21, documented, It is the policy of the facility for all resident to receive therapy services if warranted (medical need). Policy: 1. MD orders for therapy screen/eval will be obtained in the following situations: b. New Admissions/Hospital Readmissions .Goal: Therapy will screen resident and evaluation will be completed (if indicated) within 3-4 days. Resident #99 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) which coded the resident as having short- and long-term memory problems and severely impaired decision-making skills. The MDS also coded the resident as needing extensive assistance with one staff for bed mobility and eating. The resident was assessed as being totally dependent on staff for transfers, dressing, toileting and hygiene. The resident used a wheelchair for ambulation. The MDS also assessed the resident as having a decreased range of motion on one upper and one lower side. The MDS also assessed the resident as not having any therapy. Review of the care plan, dated 8/9/21, listed as a Need/Preference, (R#99) can't complete cares on their own because they have dementia, [CONDITION(S)], and right-side weakness. The goal listed was, (R #99) will improve in their ability to participate in their activities of daily living in the next three months. Approaches listed on the care plan included to assess functional level, establish activity of daily living program, reposition, transfer, feed, use the bathroom, dress, hygiene/grooming, oral care with the help of one to two people. Review of the Physicians Orders revealed an order, dated 7/30/21, for Speech Therapy, Physical Therapy, and Occupational Therapy to evaluate and treat the resident. On 8/3/21, Occupational Therapy had a clarification order, Occupational Therapy treatment five (5) times per week for twelve (12) weeks for skilled services, including self- care management. Review of the therapy notes revealed an Occupational Therapy assessment, dated 8/3/21, which documented the resident was being seen for orthotic management and training, self-care management training, manual therapy, therapeutic activities, neuromuscular reeducation, and Occupational therapy evaluation: high complexity. The certification period was dated as 8/3/21 through 9/1/21. Review of the Occupational Discharge Summary, dated 8/5/21, documented under Summary of Care, patient has an unexpected discharge, no progress but responded well to manual passive range of motion exercises. The medical record contained no Speech Therapy or Physical Therapy evaluations as ordered by the Physician. In an interview with the Director of Rehabilitation, on 9/16/21 at 10:37 a.m., revealed that the resident's services were stopped because R#99 didn't receive Medicare/Medicaid, and the family didn't want to take financial responsibility. She stated the department was ready to provide therapy, but they received a call from the business office and were told to stop treatment due to lack of payment. She stated that was the reason there were no assessments from Speech Therapy or Physical Therapy and only one day of Occupational Therapy. In an interview with the Director of Nursing (DON), 9/16/21 at 4:15 p.m. revealed that she wasn't aware of R#99 lack of payment for rehabilitation services and would look into it. In an interview with the Administrator on 9/16/21 at 4:23 p.m. revealed that the facility had an agreement with the therapy company that if a resident can't pay for the services, the facility will still provide the services. He stated that Physical Therapy and Speech Therapy did an evaluation on R#99 today and Occupational Therapy will complete an evaluation tomorrow. The Administrator explained that the business office called the Director of Rehabilitation to tell her that the resident didn't have part B services, and she took it upon herself to discontinue the services. The Administrator stated it was a mistake to discontinue the services and they were correcting this.

Based on observations, interviews and review of facility policies titled Education, Monitoring, & Screening of Healthcare Personnel During Covid-19, and Education, Monitoring, & Screening, and Cohorting of Residents during COVID-19 the facility failed to ensure healthcare personnel followed guidelines by ensuring that all staff were being screened appropriately at the beginning of their work shifts and failed to have a designated COVID-19 area to place residents who were positive for COVID-19, with dedicated staff and to have a designated unit for observation of new admissions. This had the potential to affect all residents. The census was 144. On [DATE], a determination was made that the facility's noncompliance had resulted in Immediate Jeopardy. The facility's Administrator, Clinical Administrator and the Director of Nursing (DON) were notified on [DATE] at 3:06 p.m. that the failure due to admitting new residents beginning in [DATE], along with two Covid-19 positive residents, without a dedicated Observation (Person Under Investigation-PUI) or dedicated Covid-19 unit, and not ensuring the staff were screened for symptoms of Covid-19, and failed to notify the Department of Public Health (DPH) that the facility did not implement a dedicated Observation or Covid-19 unit effected all residents. The Immediate Jeopardy is outlined as follows: 1. The facility had stopped conducting active screening of staff in [DATE] without a method for ensuring that all staff were screen before each shift. The facility screening form during the months of [DATE] and [DATE] revealed inconsistency of screening and the facility could not provide any evidence of staff screening between [DATE] and [DATE] while in an outbreak status. 2. The facility began admitting new residents on [DATE] through [DATE], which included two known Covid-19 positive residents (R#1 and R#2), without a dedicated PUI or COVID-19 unit and were located throughout the facility, without dedicated staff, to prevent or reduce the spread of COVID-19 to both residents and staff. As a result of these failures, between [DATE] and [DATE], by [DATE], 24 residents tested positive for COVID-19 and 27 staff members tested positive for COVID-19. Two residents had expired (R#1, and R#3) in the facility. The facility did not implement dedicated units until late [DATE] after the surveyor began making inquiries. The Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the area of 42 CFR §483.80, Infection Control, F880 which was cited at a Scope and Severity (S/S) of K. An Acceptable Immediate Jeopardy Removal Plan was received on [DATE] with an alleged removal date of [DATE]. Based on observations, record review, facility staff interviews and the facility policies and interventions as outlined in the Immediate Jeopardy Removal Plan, the State Survey Agency (SSA) validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. However, the facility remains out of compliance as the facility continues to implement systematic changes related to proper location of COVID-19 positive residents, new admissions and consistent and accurate screening of staff to prevent further spread of COVID-19 to residents and staff. The Scope and Severity (S/S) was lowered as follows: F880: S/S: E. Findings include: Review of the facility's, undated, policy titled Education, Monitoring and Screening of Healthcare Personnel (HCP) During Covid-19, revealed a policy statement: It is the policy of the facility to educate, monitor, and screen HCP, according to CDC (Center for Disease Control and Prevention) and CMS (Center for Medicare/Medicaid Services) recommended guidelines. Policy Implementation: Screening of Personnel-The facility policy is that staff will screen and record temperature, upon entering and leaving the building, and report any possible active COVID-19 symptoms, and/or any recent exposure to active COVID-19 individuals. Review of the facility's, undated, policy titled Education, Monitoring, and Screening, and Cohorting of Residents During COVID-19 revealed a Policy Statement: It is the policy of this Facility to educate, screen, and monitor residents, regarding the COVID-19 virus. The implementation of this policy will also address the protocols used regarding the chohorting of residents. Admissions/Re-admissions: Residents admitted to/readmitted to this facility are isolated for the first 14 days, regardless of COVID-19 status. Dedicated COVID-19 Resident Space/Unit: The facility has dedicated a space within the building to care for residents with confirmed COVID-19. All HCP are informed as to the location of the space used to cohort residents with COVID-19. In addition, the facility has a team of HCP staff which is dedicated to work only in this area of the building. This HCP staff wears complete PPE (Personal Protection Equipment )gear at all times. Tracking COVID-19 Residents: The Director of Admissions, with assistance from Nursing Staff, keeps a current hall list, showing all beds in the facility. This list is colored-coded to indicate positive residents, residents who have recovered, negative residents, and residents with test pending. Each resident is assessed for symptoms and any resident without symptoms for 3 consecutive days can be retested at the discretion of the Nursing Staff. An observation on [DATE] at 11:30 a.m. revealed the facility did not have a designated area or hallway located in the facility to quarantine COVID-19 positive residents or new resident admissions as a Person of Interest (PUI) unit. Further observation revealed several rooms throughout facility with warning signs and PPE door hangers on the outside of the door facing the hallway. Record review of New Admissions from [DATE] to [DATE] revealed that the facility had admitted a total of 18 residents which included two COVID-19 positive residents admitted to the facility on [DATE] and [DATE] and placed in the general area of the facility. The other 16 new admissions were placed throughout the facility under precautions. An observation on [DATE] at 2:30 p.m. of F hall nurses station located right inside the facility side door revealed a large binder placed on the counter of the nurse's station. Further observation revealed the binder contained a daily log dated for each day of the month with all staff names listed in alphabetical order. The title of the log stated Park Place Nursing Facility Staff Screening Attestation. Below the title the log stated by signing below, I attest that I have answered NO (written in bold font) to all questions in the screening questionnaire. If you answered yes to any of the questions in the questionnaire, see your supervisor. The binder did have not any document that listed any screening questions. Additional observation revealed there were no alcohol wipes or disinfectant located by the binder. Record review of staff screening logs and timecards for the months of [DATE] and [DATE] revealed staff were not regularly screening themselves after entering the facility and prior to beginning their shifts. Further review in the 30 calendar days for the month of [DATE] and [DATE] revealed that zero days out of thirty (30) were completed correctly and completely. Additional review revealed the month of November was missing screening logs for the days of [DATE] through [DATE] and the facility was unable to produce the staff screening logs for those four days. Record review of education roster revealed the in-service and/or education related to staff screening process was completed on [DATE], [DATE] and [DATE]. The facility was unable to produce any other documentation that any additional training or in-services were completed after the last date of [DATE]. 1. Review of the medical record for R#1 revealed an admission to the facility, from the hospital, on [DATE] with the [DIAGNOSES REDACTED]. R#1 was placed in a room on the F hall, which was not on a designated COVID-19 unit. Review of Routine Resident Testing - COVID-19 Rapid Test document revealed on [DATE] that R#1 tested positive for COVID-19. Further review revealed resident expired, in the facility, on [DATE]. Review the Death Certificate for R#1 revealed the cause of death on [DATE] was [MEDICAL CONDITION] and COVID signed by the Physician on [DATE]. 2. Review of R#2 medical record revealed an admitted , to the facility, of [DATE] to a room on the F hall with an admission [DIAGNOSES REDACTED]. Review of Routine Resident Testing - COVID-19 Rapid Test document revealed on [DATE] the resident tested positive for COVID-19. Further review revealed resident tested negative on [DATE] and was discharge home. 3. Review of R#3 medical record revealed an admission, to the facility, on [DATE] with [DIAGNOSES REDACTED]. The resident was located on the D hall and that the resident was moved to another room on the D Hall on [DATE]. Review of the Routine Resident Testing - COVID-19 Rapid Test document revealed that R#3 tested positive for COVID-19 on [DATE] and was moved to another room on the D hall which was not on a designated COVID-19 unit with dedicated staff. Record review revealed that on [DATE] the resident was moved to the newly created COVID-19 unit. Review of nurse's narrative notes, dated [DATE] at 2:45 a.m., revealed R#3 began having a change in condition which included lethargy and an increased need with assistance with Activities of Daily Living (ADL). Review of the Nurses Notes dated [DATE] at 11:31 a.m. revealed the resident was noted with shallow and more rapid breathing, not verbally responding when spoken to, and glassy eyes. Resident's family members at bedside. Review of the Nurses Notes dated [DATE] at 1:40 a.m. revealed the resident was unresponsive to painful stimuli, no palable pulse, no visible respirations, no breath sounds heard via stethoscope, no apical pulse via stethoscope, unable to attain blood pressure and O2 sat via pulse oximeter, eyes fixed and unresponsive to light. Hospice and on call nurse notified. Family and Physician were notified. Review of the Death Certificate for R#3 revealed the cause of death on [DATE] was [MEDICAL CONDITION] and Dementia signed by the Physician on [DATE]. 4. Record review of the Face Sheet for R#4 revealed an admission from the hospital, dated [DATE] with [DIAGNOSES REDACTED]. Review of Nurse Notes dated [DATE] at 11:00 a.m. revealed the resident had tested positive for COVID-19. The family and the Physician (MD) was notified. Record review of the Nurses Shift Narative dated [DATE] at 3:19 a.m. revealed that the resident had increased confusion today and was insisting that her grandson was in the facility and needed to return a blanket to him because she heard his baby crying. The resident walked out of her room and down the hall approximately 50 feet looking for her grandson. The resident was reassured and returned to her room. Review of the Nurses Shift Narrative dated [DATE] at 12:18 p.m. revealed the resident's oxygen (O2) saturation was low at ,[DATE]% on room air. O2 was administratered via nasal cannula which increased the O2 saturation to 94%. 5. Review of R#5 medical record revealed an admission date of [DATE] and had [DIAGNOSES REDACTED]. Review of the Routine Resident Testing - COVID-19 Rapid Test document revealed a positive test result on [DATE]. The resident was moved to a private room C hall. An interview was conducted on [DATE] at 2:30 p.m. with family member of R#5, who visits weekly for [MEDICATION NAME] care visits. The family member revealed that there is video showing that staff are not wearing masks when providing care to R#5, although the family would not release the video. It was further reported that there have been times, during visits, that staff have been observed in the front office not wearing a mask or staff walking throughout the facility with out masks on. An interview with the Infection Control Nurse (ICN) on [DATE] at 1:30 p.m. revealed in [DATE] the facility stopped having a designated person screening staff at the start of their work shifts upon entering the facility and started allowing staff to screen themselves. ICN further revealed that all ancillary staff enter through the side door of the building and stop at the nurse's station located immediately inside the facility, at F hall, to take their temperature and record it along with their signature in a staff screening binder. The ICN stated a no-touch forehead thermometer is placed beside the staff screening binder located at F hall nurse's station. ICN stated a list of screening questions is placed on the inside of the staff screening binder for staff to read and then sign their names stating they have answered no to all the questions. ICN stated there is disinfectant located by the thermometer to allow staff to disinfect before and after use. ICN stated that she audits the staff screening process but ICN was unable to say how often she audits the process or when the last time she completed an audit, because she does not document any information related to the audit. The ICN stated she did not complete an audit in [DATE]. The ICN further revealed that the facility does not currently have a COVID-19 unit set up in the facility to quarantine residents who are COVID-19 positive or a Person of Interest (PUI) unit for new admissions. The ICN stated the COVID-19 positive residents who are currently in the facility are located throughout the facility and are in private room under precautions. ICN stated the facility has recently admitted two COVID-19 positive residents into the facility and they have had two additional residents test positive for COVID-19 and were all placed under precautions. The ICN confirmed that the facility does not have dedicated staff to care for these residents. An interview with Certified Nursing Assistant (CNA) AA on [DATE] at 12:35 p.m. revealed she was aware of the facilities policy that requires that all staff be screened upon entering the facility at the beginning of their work shifts. CNA AA further revealed that the screening process includes staff taking their own temperature and recording it in the staff screening log. CNA AA revealed that there have been a lot of days that she did not screen herself after entering the facility for a work shift and has worked many shifts in the facility without having her temperature taken or answering any screening questions. CNA AA stated she was unsure of any screening questions and she has never been asked or told any questions related to COVID-19 screening. CNA AA stated she has received training related to COVID-19, but she does not remember when or how long ago she had training. CNA AA further revealed that the facility does not have a certain hall or area in the building designated for residents who are COVID-19 positive or the new admissions (PUI) and that she did not know what Transmission based Precautions was or what it meant. She further revealed that COVID-19 positive residents were in different areas of the facility and she recognized those rooms due to the signs on the door and door hanger with Personal Protective Equipment (PPE). An interview with Registered Nurse (RN) BB on [DATE] at 1:25 p.m. revealed she is aware of the facility's policy requiring that all staff be screened upon entering the facility at the beginning of their work shift. RN BB further revealed that as a nurse she understood the importance of the screening process to try and reduce the likelihood of spreading COVID-19. RN BB further revealed that staff enter at the side door of the facility and stop immediately at the nurse's station located right inside, to take their own temperature and log it along with their signature. RN BB stated that staff sign their name verifying the temperature logged is correct and they have no symptoms. RN BB revealed that she was unaware of what the screening questions were or if there was a list of questions in the staff screening binder for staff to read and answer. RN BB revealed that she does forget to screen herself upon entering the facility at the beginning of her shifts and does not always screen herself. RN BB stated she was unsure of when the last time she received training or education related to the screening process. Continued interview with RN BB, at this time, revealed that the facility does not currently have a COVID-19 unit designated for COVID-19 positive residents or an area for new admissions (PUI) although the residents who are COVID-19 positive are placed in a private room under precautions. RN BB confirmed that these resident's rooms are located throughout the facility and are next to rooms with COVID-19 negative residents. An interview with the Director of Nursing (DON) on [DATE] at 1:30 p.m. revealed the facility changed their staff screening process in [DATE] and stopped having a designated person screen all staff upon entering the facility. The DON stated to reduce time and paperwork they changed to process allowing staff to screen themselves and take and record their own temperatures upon entering the facility at the beginning of their shifts. The DON revealed that all staff were educated and aware of the facilities policy and requirement for staff screening although the was unsure the when the last education or in-service related to staff screening was completed. The DON stated she assumed that all staff were following policy and she was unaware that staff were not completing the screening log correctly or that it was not being completed on a regular basis. The DON revealed that she was not aware of any type of audit to ensuring the screening process was being completed regularly and accurately. Continued interview with the DON, at this time, revealed that the facility did not have a COVID-19 unit until today and that the facility had been admitting residents who were COVID-19 positive and placing them in general areas of the facility under precautions. The DON stated the facility did have an area in the building that was kept empty, until recently, to be used in the event they had a COVID-19 positive resident. The DON stated as of today [DATE] the facility was relocating their COVID-19 positive residents to a specific area that will be sectioned off for COVID-19 positive residents and an area for residents who may be suspected of being positive. During an interview with the Administrator on [DATE] at 2:46 p.m. he reported that the facility did not have any COVID-19 positive residents for a time. He went on to report that once the facility started admitting COVID-19 positive residents they were placed in private rooms at the end of F hall that had previously been the COVID-19 unit during the previous outbreak. The Administrator reported that he was not sure if there was designated staff for the residents who admitted COVID-19 positive or who later tested COVID-19 positive. He denied ever telling anyone that they were not to have a COVID-19 unit at the facility. He reported that the DON and the Clinical Administrator would have to answer any questions related to staffing for the residents. An interview on [DATE] at 2:55 p.m. with the Director of Nursing (DON) and the Clinical Administrator revealed that all new admissions that were COVID-19 positive were being placed on F hall. However, they acknowledged that this was not a designated isolation unit. The DON further revealed that when R#4 tested positive for COVID-19 on [DATE], the resident was not moved due to being in a private room. When R#3 tested COVID-19 positive on [DATE] resident was moved to a private room on D hall. The Clinical Administrator revealed that a COVID-19 unit was initiated in [DATE] when another group of surveyors brought it to their attention. The DON reported that she spoke with the epidemiologist daily but did not discuss where the COVID-19 positive residents were housed in the facility. The Clinical Administrator revealed that initially staff were signing off on an attestation sheet daily and a designated staff person was supposed to check daily to assure that staff were being screened each day. She denies that it was ever brought to her attention that there were problems with staff screening. It was further reported that the original COVID-19 unit was shut down in [DATE] and there was no observation unit (PUI) for new admissions. A telephone interview, during post survey Quality Assurance review, on [DATE] at 10:42 a.m. with the DON revealed that the facility has two Administrators, one overall and one who is the Clinical Administrator. She further revealed that the Administrator had informed her and the Clinical Administrator to close the COVID-19 unit and start admitting residents because they needed revenue. The DON further stated that when they began admitting new residents and the confirmed COVID-19 positive residents, that she wanted them assigned to a designated area but was overruled by the non-clinical Administrator. A telephone interview with the Medical Director on [DATE] at 1:31 p.m. revealed that he visits the facility at least twice a month, but he does not have many residents which he provides services. He revealed that the facility keeps him abreast of the COVID-19 positive residents during the Quarterly QAPI (Quality Assurance, Performance Improvement) meetings with the last meeting being in [DATE]. He denied being aware that the facility did not have a COVID-19, Observation/PUI unit. He stated he was aware that the facility was admitting residents that were positive, but he was not notified that the positive residents were not on a COVID-19 positive hall. He stated he is not sure if the facility has a policy regarding COVID-19 but the facility should follow the Centers for Disease Control (CDC) guidelines. The Medical Director expressed that when a resident is admitted to the facility his expectation is that the COVID-19 positive residents would be place on a COVID-19 unit, all admissions should place on an observation unit for 14-days or what the CDC recommends. An interview on [DATE] at 9:26 a.m. with the Administrator revealed that it was identified on [DATE] by another survey team that there were concerns regarding placement of COVID-19 positive residents in general population and not in a COVID-19 positive unit. The Administrator revealed that the decision for placement of residents was/is done by the Clinical Administrator. The Administrator acknowledged that he was aware the COVID-19 positive residents were being admitted . He revealed that residents were placed in a room at the end of F hall, as it was the last room on the hallway and there were several empty rooms before getting to that room. He reported that he did not have any discussions with anyone related to who would care for the residents who were COVID-19 positive. He further revealed that he was aware of new residents admitting to the facility and there were no conversations related to the need for an observation unit for these residents. The last QAPI meeting was in [DATE], although he was not present but that the previous DON and the Medical Director were present. The Administrator reported that if there are clinical issues to discuss with the Medical Director then the Clinical Administrator would do so. It was reported that an additional QAPI meeting was held on [DATE] with the Clinical Administrator, DON, and other Department Heads related to the need for a COVID-19 unit. However, he is unsure if the Medical Director or the other Physicians were involved in this meeting. An interview on [DATE] at 10:13 a.m. with the DON revealed that she does not remember what was discussed at the QAPI meeting in [DATE] and she would have to pull her notes. She went on to report that an additional QAPI meeting was held on [DATE] or [DATE], after identifying the issue of not having a COVID-19 unit. The DON reported that the Medical Director was not present for this meeting. It was also reported that the department heads were present, but she does not recall calling the Medical Director to inform of this meeting. As the result of the meeting she reported that their plan was to determine which rooms to use and they were to use a separate area on the same hall to use for isolation. The DON revealed that a weekly communication was done with the Physicians and their Nurse Practitioner (NP) and that the NP was not happy with not having an isolation unit and this information was brought back to the Administrator and the Clinical Administrator. However, the Administrator made the final decision about where the residents go. An interview on [DATE] at 2:44 p.m. with the DON revealed that the facility did not have a designated COVID-19, Observation, or Person Under Investigation unit (PUI) until [DATE]. She stated the units were closed in [DATE]. The DON stated the facility admitted residents that were COVID-19 positive without a designated COVID-19 or designated staff to care for the COVID-19 positive residents. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], it was found that the facility was not actively screening or consistently screening staff for COVID-19 symptoms. The facility was admitting residents without an observation unit. Two COVID- 19 residents were admitted without having a designated COVID-19 unit. Resident #1 and #2 have been discharged from the facility as of [DATE]. (R#1 expired in the facility on [DATE] and R#2 was discharged home on [DATE]). 2. On [DATE], a COVID Unit and Persons Under Investigation (PUI) Unit (split by fire doors) was established on D-Hall (partitions were placed at the entrance of the PUI area and at the entrance of the COVID area) and a criterion by which residents would be admitted to or discharged from these units. Signage was placed on the doors of the unit and on the resident doors. There were no new COVID positive residents identified on [DATE] when resident testing was completed.Two previously identified COVID positive residents were already residing on D-Hall prior to it being made a designated unit and they were not moved. One additional resident that was COVID positive was moved from C-Hall to D-Hall the COVID unit on [DATE]. One Covid positive resident returned from the hospital on [DATE] and was admitted directly to D-Hall the COVID unit. There were no additional positive residents identified that needed to be moved. On [DATE], Zip Walls were installed based on the recommendations from DPH's ICAR Zoom meeting on [DATE] to serve as a barrier and signage was placed on the Zip Walls for easy identification. From [DATE] to [DATE], 18 additional residents tested positive for COVID and were moved to D-Hall the COVID Unit, each on the day they tested positive.On [DATE] there was a need for expansion, so C-Hall was designated as the new PUI Unit and D-Hall was designated completely as the COVID Unit. Therefore,all residents residing in the PUI area on D-Hall were moved to C-Hall. Signage was added to C-Hall for easy identification along with a zippered wall to serve as a barrier and signs were posted there as well. From [DATE] to [DATE] nine residents were readmitted to the facility (negative for COVID) and seven newly admitted residents (negative for COVID) were placed on the PUI Unit. There have been no new admissions since [DATE]. On [DATE], all residents previously in the PUI area on D-Hall were moved to C-Hall, the newly expanded PUI Unit. 3. All residents of the facility have the potential to be affected. On [DATE] a complete 100% audit was conducted of all residents by the DON and Unit Managers to determine if any other resident's positive for COVID-19 were roomed outside of the COVID-19 unit. No other residents were found to be improperly roomed or cohorted. The results of this audit were documented on the Resident Room Roster Audit Tool. The facility implemented a process by which to ensure residents are isolated appropriately if they are COVID- 19 positive or a new admission. Nursing staff are monitoring resident for signs and symptoms of COVID-19 three times a day and if residents experience symptoms of COVID-19 they will be tested immediately. Unit Managers and the Weekend Supervisor are auditing signs and symptoms of residents daily to ensure timeliness of testing. If a resident currently residing in the facility is identified as COVID-19 positive they will be masked and moved to the COVID Unit immediately. Any resident that has been exposed to Covid-19, has tested positive for Covid-19, or has gone to the hospital and tested positive, or is a new admission that is positive will be placed on the COVID-19 Unit. COVID-19 positive residents are also reviewed in daily clinical meeting as a second check to ensure they are roomed appropriately. A resident line listing and facility map identifying resident room placement is utilized to track COVID-19 residents. Resident plans of care were updated on an ongoing basis to reflect the most recent test results. The plans of care will be updated as new test results are available by the Unit Managers. The roommate of the newly diagnosed COVID positive resident will be masked and moved to the PUI Unit immediately. 4. All new admissions, who are not positive, are roomed on the PUI Unit. Resident tracking on the PUI Unit is also done on the facility map. 5. On [DATE], staff were trained and assigned all shifts to monitor the entrance of the facility and conduct employee and visitor screening on an ongoing basis. The facility has implemented a process to ensure all staff or visitors entering the facility are screened actively and consistently. Training on [DATE] for the staff assigned to the entrance consisted of observation for signs and symptoms of COVID, screening questions, temperature checks, hand hygiene and PPE usage and who to notify if there is a positive response. Stickers are being provided to staff to wear on their clothing that evidences that they have been screened. Staff are not permitted to proceed past the entrance screening if there is a positive response/finding. The Unit Clerk services as a back-up for the screening station. The Orientation lnservice Coordinator and Infection Control Nurse are monitoring to ensure consistency in the process and documenting on the COVID Screening Attestation Compliance Rounds daily. Staff are tested twice per week. Staff experiencing symptoms of COVID-19 are tested immediately and CDC return to work guidelines are followed. 6. On [DATE], [DATE], [DATE], and [DATE], the Clinical ADM, DON, IP, EVS, RN Weekend Supervisor, and Unit Manager participated in the DPH ICAR Zoom/COVID-19 LTCF Response Checklist. The DON is to contact DPH on [DATE] to schedule the next ICAR. 7. From [DATE] to [DATE], education was provided by the DON and Unit Managers to the RNs, LPNs and certified nursing assistants consisting of: a) Proper screening procedures for entering the building at start of shift to include COVID-19 signs and symptoms, cough, congestion, fever, resp difficulty, low 02 sat, loss of sense of taste or smell, nausea, vomiting, diarrhea. b) Admitting new residents to the PUI Unit; any resident that is returning from the hospital will be admitted to (TRUNCATED)

Based on observation, policy review and staff interviews, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary conditions in the kitchen by not stacking wet cookware and ensuring the cleanliness of kitchen equipment and not changing gloves during puree process. The facility also failed to maintain proper holding temperatures for cold food items at 41 degrees Fahrenheit (F) or below during meal service. There are 161 residents that receive an oral diet. Findings include: 1. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed in the dry storage area one opened/unsealed 12 ounce box of raisins with no open date; one 16 ounce opened/unsealed box of dry rice with no open date. In the walk in cooler, a large clear storage container with cooked chili with use by date of 11/3/19; one clear container with gravy with use by date of 11/5/19; one clear container of macaroni and cheese with use by date of 11/3/19; one clear storage container with red food substance, unlabeled with no use by date (identified by staff as stewed tomatoes); a large clear storage container of food substance, unlabeled with no use by date (identified by staff as green beans) and one stainless steel container of dinner rolls with use by date of 11/5/19. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated that the kitchen staff know that foods are to be dated and discarded after three days. She further stated that she has had many discussion with the dietary staff about not saving the leftover food, because they rarely use it. She verified the concerns identified during the initial tour. 2. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed food slicer on the back table with dried food debris on the blade and the slide tray; wet nesting of three stainless steel cake pans and two stainless steel medium sized holding pans, which were stacked with wet condensation between them; dust and crumbs/food particles on bottom shelving of stainless steel table with pots/pans and serving utensils stored on the shelf. Review of untitled and undated documentation provided by CFSM regarding cleaning and sanitizing stationary equipment, revealed to scrape or remove food from the equipment surfaces and to wash the equipment surfaces. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated staff have a cleaning list they are to do before leaving, and the shift supervisor checks the duties off before the staff leave for the day. During further interview, she stated there is not a scheduled list of cleaning tasks to be done. She stated she would talk with the supervisors about the dirtiness of the kitchen shelving and equipment and the wet nesting of the dishes. She verified the concerns identified during the initial tour. 3. During observation of steam table temperatures on 11/14/19 at 11:45 a.m., obtained by Dietary Cook DD with the facility's calibrated digital thermometer, observation of cold food item of jello, temperature was 47.9 degrees Farenheit (F) and milk temperature was 67 degrees F. Bowls of jello noted to be sitting on tray rack, with no ice bath. Milk cartons sitting in a shallow dish on the counter, with no ice bath. Review of untitled and undated documentation provided by CFSM regarding food temperatures, revealed cold foods should be held at 41 degrees or lower. Interview on 11/14/19 at 12:16 a.m. with Certified Food Service Manager (CFSM) stated that they check the temperature of the foods when they remove them from the oven, during mid service and post service. She stated that they don't obtain temperatures for the cold items, they just take them from the cooler when its time to serve. She verified the concerns identified during the initial tour. 4. During observation of puree food process on 11/15/19 at 10:29 a.m. with Dietary Cook DD, she measured out desired portion of fish filets and placed into food processor, along with bread slices and melted butter. During the blending process, she stopped the blender and placed her dirty gloved hand into the blender bowl to mix the partially blended food. Without changing her gloves, she continued the blending process, until food was blended smooth. She washed the blender bowl and lid in the three compartment sink, but did not allow the items to air dry before continuing the pureeing of squash. Interview on 11/15/19 at 10:55 a.m. with Dietary Cook DD, stated that she didn't think about changing her gloves before putting her hand into the food to mix the items in the blender to make it easier to puree. She further stated that she didn't know that she had to wait for the blender bowl and lid to air dry, before proceeding with the puree process. She stated she has always just rinsed them off and continued to puree until all items were pureed. Interview on 11/15/19 at 4:00 p.m. with CFSM, stated that they do not have policy and procedures for the kitchen, that she uses the servesafe manual for best practices. She stated that she did not have anything in reference to food storage and labeling/dating of opened food items or the process of pureeing foods.

Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer.

Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to make prompt effort to file a grievance for one resident (R) #25 who verbally reported to staff she was missing her lower denture. The sample size was fifty-seven residents. Findings include: Review of an undated policy titled Dental Policy revealed 3. Nursing staff to report missing dentures, notify social service, and fill out concern forms. Review of the policy titled Complaint (Grievance) Policy revised date of (MONTH) (YEAR) revealed Such complaints may include those related to his or her treatment, medical care, missing clothing or other complaints regarding their stay. Record review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed R#25 had a Brief Interview for Mental Status of nine indicating moderate cognitive impairment. An interview and observation was conducted on 11/12/19 at 11:50 a.m. with R#25 who responded to interview questions appropriately. The resident was asked about dentures. The resident revealed she is missing her bottom denture. Observation of only top dentures in the resident's mouth. The resident also revealed she reported to the staff and the dentist that she was missing her lower denture. The resident revealed the lower denture has been missing for a couple of months. An interview was conducted on 11/15/19 at 3:25 p.m. with the Certified Nursing Assistant (CNA) CC. The CNA revealed R#25 had reported to the staff during mealtime in the dining room a month ago that she was missing her bottom denture. Record review of R#25's dental notes dated 9/10/19 revealed Patient states her lower denture has been lost. An interview was conducted on 11/15/19 at 9:44 a.m. with the Social Service Director (SSD). The SSD was asked how the facility handles residents missing items. The SSD revealed when a person reports (verbally or in writing) a missing item a grievance form is completed by the staff and the completed form is turned in to the social service department. The social service department will start the investigation to locate/replace the missing item. The SSD revealed there was no grievance filed for R#25's missing lower denture.

Based on record review and staff interviews, the facility failed to provide documentation of a written agreement or contract with the company providing out patient [MEDICAL TREATMENT] services for one resident (R) (#44) of 3 residents receiving [MEDICAL TREATMENT] services. Findings include: A review of the clinical record revealed R#44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment. Section: O revealed the resident was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the physician's orders [REDACTED]. Review of the Facility Resident Census and Conditions of Residents Form dated 11/12/19 revealed the facility had three residents receiving [MEDICAL TREATMENT] at an outside certified end-stage [MEDICAL TREATMENT] facility. Interview on 11/13/19 at 4:56 p.m., with the Assistant Administrator revealed the facility had been trying for months to obtain a [MEDICAL TREATMENT] agreement from the [MEDICAL TREATMENT] center but has not had any luck. She stated she would call again to speak with someone who understood the importance of having this information on file. During an interview on 11/14/19 at 12:05 p.m., the Administrator stated the facility had made several attempts to get a contract from the [MEDICAL TREATMENT] center. He reported and confirmed that when R# 44 was admitted , he was not made aware that there was not a [MEDICAL TREATMENT] contract. He further stated that he had made several attempts to get an agreement with the [MEDICAL TREATMENT] provider but had not been successful until today.

Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. On 7/18/18 at 12:55 p.m. an interview was conducted with Licensed Practical Nurse (LPN) FF (who was assigned to the resident on 7/5/18) at the D hall nurse's station. LPN FF was asked how does staff know how to care for the residents they are assigned. LPN FF replied, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF was asked to review the ADL sheet and acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. When asked who completed the ADL sheet, LPN FF stated that nursing was responsible for completing at the time of admission, We write it up in pencil, so it can be updated (with information from the care plan). On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked to explain the incident and investigation when R#40 was transferred on 7/5/18 resulting in rib fractures. The DON stated, We had never seen the resident get out of the bed, we want her to get up, but she refuses, and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18 using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know what R#40's transfer status was the DON stated that it was on the ADL sheet (information from the resident's care plan). The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. When asked what the ADL sheet should have documented, the DON stated that it should have been updated to reflect the resident's actual transfer status at that time. The DON further stated that R#40 did not get out of bed and she was totally dependent, and the ADL sheet should have reflected that she needed, at minimum, a two person assist and / or a Hoyer lift for safe transfers. No further information was provided prior to the end of the survey process. Cross reference to F689

Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively moderately impaired with poor decision making requiring cues/supervision. R#40's functional status was coded as requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. Located in a book at the nurse's station on the unit where R#40 resided there was an undated document titled Nurse Aide's Information Sheet (also referred to by the facility staff as the ADL sheet (a communication tool used by the CNAs to determine a resident's ADL needs, including transfers). Review of the sheet revealed R#40 was documented as requiring assistance of one staff member to place in wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Further review of R#40's clinical record revealed that the resident was discharged from physical therapy on 4/18/18. The discharge summary documented the following; Patient progress and response to treatment: Per Medical Doctor, patient (pt.) is to discharge (D/C) from skilled physical therapy (PT) services. Transfers: Dependent. Review of the Nurse's Monthly Progress Note revealed the following: Dated: 4/24/18, Licensed Practical Nurse (LPN) AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. R#40's Activities of Daily Living are documented as deteriorated. Assistive Devices, Hoyer. Dated: 6/27/18, LPN AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. Assistive Devices, Hoyer. Review of R#40's Nursing notes revealed the following documentation: Dated: 7/5/18 at 3:12 p.m. notified by CNA that resident was complaint of (c/o) severe pain to left side, assessment done, noted resident c/o pain to left rib cage, [MEDICATION NAME] (a pain medication) 5/325 milligrams (mg) tablet (tab), 1 (one) given and Medical Director notified, X-ray of left rib cage and abdominal (ABD) area ordered, son notified. A review of R#40's Patient Report from the mobile imaging company revealed the following documentation: Dated: 7/5/18. Reason: Pain. In: 4:30 p.m. Examination: Left rib series. Findings: The visualized ribs demonstrate fractures of the left lateral 10th and 11th ribs. No underlying pneumothorax demonstrated. No overlying subcutaneous [MEDICAL CONDITION] noted. Patchy infiltrate in the left lung base. Impression: 1. Acute left lateral 10th and 11th rib fractures. 2. Left lower lobe pneumonia. Dated: 7/5/18 at 6:51 p.m. received x-ray report results of abdomen and left rib cage, revealed abdomen with nonobstructive bowel gas pattern and left lateral 10 and 11th rib fractures. Resident denies falling or bumping self into anything, c/o left rib pain [MEDICATION NAME] 5/325 mg by mouth (po) given for pain, spoke with son regarding resident c/o pain to left rib and abdomen area and of x-ray results. Will continue to monitor. Dated: 7/5/18 at 6:55 p.m. X- ray results for abdomen and chest showing fractured left 10th and 11th ribs and left lower lobe pneumonia. Called Medical Director and left message and also faxed results. Awaiting return call at this time. Dated: 7/5/18 at 8:56 p.m. No response from Medical Doctor. 911 called and hospital called and given report to nurse. Son notified that resident was going to be sent to emergency room (ER) for further evaluation. Awaiting transport at this time. A review of R#40's hospital admission record dated 7/5/18, revealed the following documentation: Disposition Summary: Preliminary [DIAGNOSES REDACTED]. Review of the facility investigative report conducted by the Director of Nursing (DON) regarding the incident with R#40 on 7/5/18, revealed the following written statements: Review of the written statement by CNA BB had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. Review of the written statement of dated 7/9/18 revealed a statement from an Occupational Therapist (OT) II who was in the room working with R#40's roommate at the time of R#40's transfer by CNA BB. The OT documented, in part, the following: I observed the CNA complete the transfer without a gait belt as she instructed R#40 to hold her neck as she proceeded to transfer her to the recliner as she held her by the side of her elastic waist pants. At the completion of the transfer I heard R#40 say, I don't want to do that again. The OT was not available for interview during the survey process. On 7/17/18 at 3:30 p.m., an interview was conducted with CNA CC at the D Hall nurse's station. CNA CC was asked what information she was provided regarding each resident's transfer status. CNA CC stated, I am familiar with the residents and know what they need. If I don't know then I will ask the nurse, or I can ask another aide. When asked if there was any type of communication tool, a care card or cheat sheet that directed the aides to the ADL needs of each resident, CNA CC stated I do not know of any. An interview on 7/17/18 at 4:00 p.m., with the Physical Therapy (PT) Supervisor in the therapy office. The PT Supervisor was asked if he was familiar with R#40 and he stated that he had worked with her in (MONTH) and (MONTH) of (YEAR) to get her back to her prior level of function. The PT Supervisor stated that at the request of her family and her physician her therapy was discontinued on 4/18/18. The PT Supervisor also stated at the time of discharge the resident was totally dependent, could not stand, walk or assist with her transfers. She needed a Hoyer lift for transfers. When asked how that information was communicated to nursing staff, the PT Supervisor stated that when therapy documented that someone was dependent nursing knew to initiate a Hoyer lift. An interveiw on 7/18/18 at 9:40 a.m., with CNA DD on the E hallway. CNA DD was asked how she knew the transfer status of each resident she worked with, especially if they were new to her. CNA DD stated, We have an ADL book that tells us what the resident care needs are. We can go to that book and see what to do. We also meet every day at three o'clock as a team to discuss the residents. On 7/18/18 at 12:55 p.m., an interview was conducted with LPN FF (who was assigned to the resident on 7/5/18 the day of the fall) at the D hall nurse's station. LPN FF was asked, how does staff know how to transfer a resident? LPN FF stated, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF when asked what she could remember about R#40's functional ability leading up to the 7/5/18 incident, LPN FF stated R#40 could not walk and generally stayed in the bed. She had a recliner and from time to time I would see her in it. When asked how she was normally transferred into the recliner from the bed. LPN FF stated, I would say by a Hoyer lift. The resident had a lot of [MEDICAL CONDITION] and skin issues. I would question her being a one-person transfer, I wouldn't move her by myself and would call for help. LPN FF was asked to review the ADL sheet and the LPN acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. LPN FF commented the sheet was not correct at the time R#40 fell . We write it up in pencil so it can be updated. When asked what should have happened when R#40 was identified as being totally dependent by PT, LPN FF stated that the ADL sheet should have been updated. When asked how an update would be communicated to the aides working with the residents, LPN FF stated, They have to read the ADL book. Further interview with LPN FF revealed that on 7/5/18 the day of the fall, she had administered medications to R#40 at about 9:30 a.m.she was not sure of the time but the aide went in the resident's room to provide ADL care. LPN FF further stated that R #40 was put back into her bed by lunchtime and that she was unaware that R#40 was in pain until she went in to check on her at about 2:30 p.m. at which time she assessed the resident, provided pain medication and contacted the physician. The aide should never have transferred the resident without assistance. LPN FF stated that R#40 was very alert that day, unusually so, and asked to be put in the recliner. She revealed the aide should have asked for help. Before this incident the aides who worked with R#40 had been using the Hoyer lift. On 7/18/18 at 2:30 p.m. an interview was conducted with LPN AA, the Unit Supervisor, at the D Hall nurse's station. When asked about R#40, LPN AA stated that she was very familiar with the resident and that she hadn't been transferred in about two months leading up to the incident as she did not get out of the bed. If she was to be transferred then she was assessed for use of a Hoyer lift as she was not able to turn herself. When asked what it meant when therapy stated someone was total dependent, LPN AA stated that if the therapy department stated someone was total dependent that meant they could not bear weight and would need a Hoyer lift for transfers. When asked about the incident on 7/5/18 when R#40 was transferred, LPN AA stated She wasn't getting out of bed. I don't know what happened, the aide should have used the Hoyer lift. The ADL sheet was reviewed with LPN AA at this time. LPN AA was asked if the information regarding R#40's transfer ability was correct. LPN AA stated the ADL sheet used by the CNAs was incorrect, it documented that R#40 was a one person assist. When asked if this was the document used by the aides to determine a resident's transfer status LPN AA stated that it was. On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked about the incident that occurred on 7/5/18, when an improper transfer occurred with R#40 that resulted in the residents rib fractures. The DON stated, We had never seen the resident get out of the bed. We wanted her to get up but she refuses and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18, using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know how to transfer a resident that was new to her. DON stated that it was on the ADL sheet. The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. The DON further stated that R#40 did not get out of bed and she was totally dependent and the ADL sheet should have reflected that she needed, at minimum, a two person assist and/or a Hoyer lift for safe transfers. . On 7/18/18 at 4:30 p.m. an interview with the Administrator and Clinical Services Administrator was conducted in the Clinical Service Administrator's office regarding improper transfer of R#40 on 7/5/18. The Clinical Services Administrator stated that R#40 was transferred improperly and that the ADL sheet should have correctly reflected the resident's transfer status as that was the communication tool used by the CNAs. Observation and interview on 7/19/18 at 12:10 p.m. with CNA GG revealed that R#40 in her bed. During the repositioning observation by CNA GG revealed that she had worked with R#40 for a long time. When asked what R#40 transfer status was between the end of her therapy on 4/18/18 and the date of the incident on 7/5/18, CNA GG stated, When she came out of therapy in (MONTH) she did pretty well, she would stand and pivot but then in (MONTH) she stopped being able to assist with transfers and started requiring a Hoyer lift. CNA GG further stated, Starting then I always used a Hoyer lift on her, she cannot stand. When asked about the ADL book CNA GG stated that she did not realize that the ADL sheet was incorrect and further stated that R#40 had never really been a one person assist, she required extensive assistance regardless of what it says in the ADL sheet. An interview on 7/19/18 at 12:10 p.m., outside of R#40's room , with LPN HH, a nurse who has worked with R#40 consistently since was admitted . When asked about R#40's transfer status and what happened on 7/5/18, the day R#40 fell . LPN HH replied, She has required a Hoyer lift since May. She cannot stand and she cannot walk. Everyone was aware, but the aide was new and had never worked with this resident prior to the date of the incident. The aide should have asked for help or instructions, regardless of what it said on the ADL sheet. CNA BB did not know her. On 7/19/18 at 3:15 p.m. a telephone interview was conducted with R#40's Medical Doctor (MD). The MD was asked to describe R#40's functional status between 4/18/18 and 7/5/18. The MD stated, Zero, she cannot do anything independently, she has to be moved, she cannot do anything. When asked if one person would be able to safely transfer the resident, the MD stated, Absolutely not. That would be unsafe and the resident could not be safely transferred in that manner. She cannot do anything, she has been totally dependent for a long time. A review of the facility undated policy titled Facility Assessment documents, in part, the following: Staff Training Topics: Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. Staff Competencies: Activities of daily living - transfers, using gait belt, using mechanic (sic) lifts. On 7/10/18 the facility submitted a follow up report to the incident that occurred on 7/5/18 with R#40 that documented, Based on written statements and verbal reports, we believe that the left rib fracture happened during resident transfer. No further information was provided prior to the end of the survey process. A post survey telephone interview on 8/1/18 at 1:53 p.m., during Quality Assurance review, with the DON revealed the facility does have a process for what to do if the resident's physician does not return their phone calls. She revealed that the nurse would contact the Medical Director for direction but that the resident was also complaining of shortness of breath and the nurses felt the resident needed to be transferred to the emergency room (ER) for further evaluation. A post survey QA telephone call on 8/2/18 at 10:47 a.m. with the Clinical Services Administrator revealed that the resident had been a resident at the facility off and on for many years and the staff were familiar with her. She stated that the resident had experienced many fractures over the years due to osteopenia. She further revealed that this resident had been refusing to get out of bed for the last two months but that on 7/5/18 had asked to get up. The CNA was a new PRN (as needed) who did not know the resident. She confirmed that the resident was transferred improperly to get out of bed and that the CNA had also transferred her back to bed around lunchtime. It was at this time that the resident began complaining of pain in the rib area which progressed to also having shortness of breath. The Clinical Services Administrator revealed that the nurse did not document the resident's shortness of breath in the nurses notes, although it is documented in the five day report submitted to the state agency. After receiving the x-ray results, the nurse contacted the resident's physician and was awaiting a return call but due to the resident's shortness of breath, the nurse felt the resident should be transferred to the ER for immediate evaluation. The Clinical Services Administrator revealed that neither CNA BB or OT II had reported to nursing the improper transfer on 7/5/18. Review of the, undated, policy titled Physician Notification 5. The license nurse to notified Medical Director if no response from the attending Physician within 4 hours for any medical emergency. Review of an undated policy titled Hoyer Lift Policy: This is the policy to (name of) Facility to use a Hoyer lift as needed to assure a resident is moved safely and as comfortably as possible. Procedure: The procedure for using Hoyer lift includes, but is not limited to the following: There must be at least 2 people to assist with transfer. Review of policy titled Gait Belt Policy and acceptance form revealed that every CNA that works here wears a gait belt. It is your responsibility to wear your Gait Belt daily. The facility provided signed documentation the CNA BB had signed as agreed on 5/8/18, to wear a gait belt.

Based on record review and staff interview the facility failed to follow the care plan for one (1) resident (# 21) on a sample of twenty one (21) residents related to skin assessments and reporting of skin conditions that contributed to an identified pressure sores that resulted in actual harm to the resident. Findings include: Review of the Resident Assessment Protocol dated 1/25/10 for resident #21 documented the resident was at risk for skin breakdown related to impaired bed mobility and incontinence of bowel and bladder and to proceed to the care plan. Review of the care plan dated 1/24/10 documented that visual skin assessments were to be done with the resident's bath and activities of daily living and to report any red or open areas. Review of the Weekly [MEDICAL CONDITION] Assessment sheets dated 7/12/10 documented the resident was found with two (2) stage IV pressure sores to her right foot and on 7/14/10 was found with one (1) stage IV pressure sore to her left buttock. During interview with the Director of Nurses (DON) on 8/11/10 at 9:35 am she revealed that the Certified Nursing Assistants (CNA) gave a shower to this resident twice weekly and they are responsible for documenting and reporting any skin problems/observations. She could not provide evidence that they were reporting or documenting any of these areas on resident #21. There were no routine skin assessments being conducted on any of the residents in the facility by licensed (LPN or RN) nurses. Weekly assessments are conducted for resident with identified pressure ulcers. Interview with one CNA "BB" on 8/12/10 at 9:45 am revealed she had provided care for this resident during the month of July 2010 and she had noticed a blood red area on the resident's "bottom". She was applied a "cream" to the area. She stated she had reported the area to a nurse but could not recall which nurse. Interview with CNA "CC" on 8/12/10 at 9:55 am who also cared for the resident during the time the pressure sores occurred revealed she had noticed a dark red open area on the residents buttocks around the first of July 2010 and reported it to a nurse but could not recall which nurse. She revealed the resident had had a raw open area on her buttocks for "awhile". Both CNA's stated they had not noticed a skin problems on the right foot. Review of skin notes written on shower days revealed that the last one was completed for resident #21 was dated 7/07/10 , documented no bruises on the body old or new and completed by CNA "CC".

Based on observation, record review and staff interview it was determined that the facility failed to ensure that residents who entered the facility without pressure sores did not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable. This failure to monitor resident's at risk for skin breakdown affected one (1) resident (#21) on a sample of twenty-one (21) residents and resulted in actual harm. Findings include: Record review for resident #21 revealed all MDS assessments since her admitted on 2/05/09 revealed the resident had never been assessed as having had a pressure sore before. Review of the record revealed the resident had a [DIAGNOSES REDACTED]. Review of the MDS dated 7/18/10 assessed this resident as having one (1) Stage I and three (3) Stage IV pressure sores. Review of the Weekly [MEDICAL CONDITION] assessment dated [DATE] documented resident #21 had two (2) new Stage IV pressure sores on the right outer foot. One pressure sore was measured as being 1.0 by 1.0 centimeters, black in color and necrotic. The other pressure sore to the right foot was measured as being 1.2 by 1.2 cm, brown in color and necrotic. Review of a Nurses Note dated 7/13/10 documented the resident had a new skin problem with a three (3) cm pressure sore to the left lower buttock. Further review of the Weekly Skin Lesion assessment dated [DATE] documented the new Stage IV pressure sore that was found to the resident's left buttock measured as 2.0 by 3.0 cm, grey in color and necrotic. After the pressure sores were identified (7/13/10) a [MEDICATION NAME] level was done with a low result of 16.1 (normal range of 20-40). A [DIAGNOSES REDACTED]. Observation on 8/11/10 at 9:15 a.m. of the wound treatment to the resident's right foot revealed there were two (2) Stage IV pressure sores to the right foot one near the 5th digit and the other of the mid area of the outer foot. There was also a Stage IV pressure sore to the left buttocks. All the areas were treated individually using aseptic technique by cleaning the areas with normal saline then santyl ointment was applied to areas and covered with a dry dressing. The most current measurements on these Stage IV pressure sores were done on 8/04/10 with the 1st area to right outer foot measuring 0.8 cm by 1.0 cm by 0.3 cm. The 2nd area to the right outer foot measured 1.2 cm by 1.5 cm by 0.3 cm. The left buttock measured 1.8 cm by 2.8 cm x 0.3 cm. Interview with the Director of Nurses (DON) on 8/11/10 at 9:35 a.m. revealed that these Stage IV pressure sores were acquired at the facility on 7/12/10 and 7/13/10. She revealed that the Certified Nursing Assistants (CNA) who gave showers to this resident twice weekly and are to document and report any skin problems they see, however, she could find no evidence that they were reporting or documenting any of these pressure areas for this resident. She stated at the current time no routine skin assessments were being conducted by the nursing staff. She revealed that a nurse found the two (2) stage IV pressure sores on the resident's right outer foot on 7/12/10 and called the physician for treatment orders. She further stated the nurse did not do a head to toe skin assessment on the resident on 7/12/10. She stated that the staff discussed the pressure sores on the resident's right foot in the Patient at Risk (PAR) meeting on 7/13/10 and a policy was developed regarding skin assessments. When a head to toe assessment was conducted for resident #21 on 7/13/10 another Stage IV pressure sore to the resident's left buttock was discovered. Review of the last skin note dated 7/07/10 completed by a CNA, who bathed the resident, documented there were no bruises on the body old or new. However, interview with two (2) CNAs, "BB" and "CC" on 8/12/10 at 9:45 a.m. and 9:55 a.m. revealed they had both noticed a red open area to the resident's buttock and stated they had reported it to a nurse. In addition, a wound culture was collected on 7/14/10 that revealed there was a heavy growth of proteus mirabilis in the wound and the resident was started of antibiotic therapy to treat the infection. An arterial duplex doppler study conducted of both lower extremities on 7/26/10 documented no significant arterial occlusive disease.