Every finding on record at Peterson Park Health Care CTR

Based on interview and record review the facility failed to prevent resident to resident physical abuse for two (R1, R2) of seven residents reviewed for abuse. This failure resulted in R2 sustaining an injury near the right eye and being sent to the hospital for evaluation. It can be determined that the reasonable person would have experienced psychosocial harm as a result of the physical abuse, since a reasonable person would not expect to be injured in this manner in his/her own home or a health care facility. Findings Include:R1 has diagnosis not limited to Nicotine Dependence, Cigarettes, Peripheral Vascular Disease, Type 2 Diabetes Mellitus with Diabetic Neuropathy, Acquired Absence of Right Foot, Mononeuropathy of Right Lower Limb, Complete Traumatic Amputation at Level Between Knee and Ankle, Right Lower Leg, Type 2 Diabetes Mellitus with Foot Ulcer, Morbid (Severe) Obesity due to Excess Calories and Major Depressive Disorder. R1's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response.R1's Care plan document in part: Focus: R1 is a long-time smoker and expresses the desire to smoke at this facility. Focus: R1 has/have a Right Below-the-Knee (BKA) Amputation.R1's Progress note dated 12/05/25 document in part: Visit Type: Follow-up Details: Chief complaint: Follow-up visit for evaluation of physical altercation with another resident. Patient seen and examined today 12/05/25. Per nursing, patient had a physical altercation earlier today with another resident. Per patient, he (R1) was hit on the Left side of his (R1) face, no bruising or redness or swelling noted on the affected area. Patient is aware and agrees that he (R1) will be sent out to Hospital for psych evaluation under petition. Social History: smoker, Nicotine Dependence Tobacco Abuse Counseling - patient is a current everyday smoker. Progress note dated 12/05/25 document in part Change of Condition Situation: 1. The change in condition, symptoms, or signs observed and evaluated is/are: Resident (R1) hit another resident 2. This started on: 12/05/25. 7. Other relevant information: Resident (R1) hit another resident 1. Summarize your observations and evaluation: resident hit another resident 2a. Recommendations of Primary Clinicians (if any): send to ER (Emergency Room) for psych evaluation. R1's Progress note dated 12/05/25 17:26 document in part: General Progress Note Text: Called Hospital, resident is admitted dx (diagnosis) Psyche evaluation (Under Petition). Progress note dated 12/8/25 15:03 document in part: admission Summary Note Text: patient from Hospital readmitted in the facility with the diagnosis of major depression with single episode w/o (without) psychosis. Abuse Reportable Initial Form dated 12/05/25 document in part: Allegation Type: Physical. On 12/05/25 at approximately 09:40 AM it was reported to this writer that during a dispute that occurred on the way out to the smoking patio between R1 and R2. R2 alleged that R1 hit him in the face. R2 was observed with redness on his upper cheek. Summary of Investigator's findings: Police were called they stated that it is unclear if there was an aggressor, and each individual thought they needed to defend themselves. R2 was sent to the hospital for evaluation. R2 had redness. On 01/29/26 at 02:28 PM R1 stated There is a smoke ramp that is between 2 doors. R2 was coming through the dining room and went through the first door. R2 was just standing on the ramp to the smoking patio about half the way down lighting a cigarette and knew I was behind him (R2). R2 knew it would be difficult for me to go down and I said let me get by. R2 stepped to a little to the left and I went to the right to go around R2. I brushed R2's jacket then I felt a blow to the left side of my face near the temple. I then reach up to R2, grabbed his jacket collar, pulled him down and gave R2 a couple of punches to the face with my fist. R4 stood over R2, said that was enough and helped R2 up. They called a code; staff came but we were already separated because it was quick within seconds. I said I did not appreciate R2 hitting me in the walk-up ramp to the smoke patio. R2 has diagnosis not limited to Essential (Primary) Hypertension, Type 2 Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Alcohol Abuse with Intoxication, Nicotine Dependence, Cigarettes, Ocular Hypertension, Unspecified Eye, Ischemic Optic Neuropathy, Right Eye and Hypotension. R2's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. R2's Progress note dated 12/05/25 17:39 document in part: General Progress Note Text: R2 is admitted with dx (diagnosis) of Hypotension, Facial contusion, Dehydration and Lactic Acidosis. Progress note dated 12/06/25 23:55 document in part: admission Summary Note Text: readmitted resident to the facility from Hospital. On 01/29/28 at 12:57 PM R2 stated there was a battery. This facility has a failure to protect the residents. I was attacked and I am still having problems to my right eye. I was hit on or about the right temple. R1 threatened to beat me into a coma. R1 was beating me in the temple, and he rammed me from behind with his wheelchair. I don't feel safe in my home. This happened in the vestibule on the way to the smoking tent. I was in the hospital overnight. The facility has a legal obligation to protect you.On 01/29/26 at 04:30 PM V1 (Administrator) stated at around 09:40 AM we had a code grey, and all the staff went there. On the way out to the smoking patio R2 was standing blocking the path lighting his cigarette making everyone wait. R1 tried to maneuver pass R2 and R2 attack R1 and pushed R1 out his (R2) way. We petition R1 out to the hospital based on the allegation and R2 went to hospital. After the residents are going down the smoking ramp a little there is a blind spot. V6 (Activity Aide) didn't see R1 push R2, but she saw R2 kind of push R1. R1 said he was trying to protect himself after R2 pushed him (R1) away and R1 hit back, it was defensive. R1 was being attacked and was trying to protect himself.On 01/29/26 at 04:21 PM V2 (Assistant Administrator) stated I was not here that day but the incident between R1 and R2 happened during smoke break. R2 stopped at the threshold to enter the smoking tent to light his cigarette. R1 asked could he proceed as he was trying to get through. R2 was reluctant and R1 tried to move around R2. R1 may have bump R2 unintentionally and there was a misinterpretation of each one's intentions. V6 (Activity Aide) went out to the smoking patio ramp to break up what was happening. R2 did have discoloration, bruising on his face.On 01/29/26 at 04:13 PM V3 (Director of Nursing) stated There was a bruise on the right side of R2's face that started turning dark like a dark spot (black eye).On 01/29/26 at 01:32 PM V5 (Licensed Practical Nurse) stated On 12/06/25 I readmitted R2 into the facility. R2 had a bruise, and his right eye was black. R2 said he got punched by another resident.On 01/29/26 at 01:58 PM V6 (Activity Aide) stated I was sitting here at the table near the smoking patio door. R2 went out the first door to the smoking patio and was standing in the middle of the walkway to light his cigarette. R2 went to the second door and R1 went out and said excuse me. R2 put his hand in R1 face and before I could get up R1 had struck R2 with his fist. I don't know where R1 hit R2 but about time I went out there R2 was on the ground. R4 stopped R1 from hitting R2 when R2 was knocked to the ground.On 01/29/26 at 02:50 PM V7 (Licensed Practical Nurse) stated On 12/05/25 when they went for smoking break around 09:30 AM R1 and R2 wanted to get out the door. R2 hit R1 first and R1 hit him *(R2) back. We separated the residents for safety and went to the administrator to report the abuse. R1 and R2 were sent to separate hospitals for evaluation.On 01/29/26 at 03:26 PM V9 (Wound Care/Licensed Practical Nurse) stated R2 came back from the hospital with discoloration on the upper right cheek. The area was a maroon color.On 01/29/26 at 02:15 PM R3 stated I witnessed the incident between R1 and R2. In the process of R1 rolling backwards down the smoking patio ramp R2 was coming through there. R1 and R2 had an altercation, and their voices elevated. R2 tried to act like he was going to hit R1 and R1 knocked R2 down. R4 helped R2 up from the ground. In a reaction, R1 hit R2 back in his face.On 01/29/26 at 01:20 PM R4 stated I was sitting on the southeast end of the smoking patio in a chair. I heard a disturbance and looked over to the side and say R2 was on the ground. They were coming down the ramp and R2 bumped into R1.On 01/29/26 at 01:49 PM R5 stated I was out there when R1 and R2 were arguing. R1 grabbed R2 threw him to the ground and start hitting R2 in the face. R2's eye was messed up for about 3 weeks.Policy:Titled Abuse and Neglect revised 01/09/26 document in part: It is the policy of the facility to provide professional care and service in an environment that is free from any type of abuse. Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention.

Based on observation, interview, and record review, the facility failed to provide and maintain an effective pest control program. These failures have the potential to affect 174 resident's residing in the facility. Findings Include: On 11/25/2025 at 9:53 AM, surveyor observed R159 laying on his bed free of pain. R159 is alert and oriented to person, place or time. R159 stated he has seen roaches today in the bathroom. Surveyors open the bathroom door and observe one small roach on the ground. R159 stated he has not seen an exterminator from the pest control company come in to spray medication to get rid of the roaches. On 11/25/2025 at 10:04 AM, Surveyor observed R70 sitting on the edge of the bed. R70 appears to be comfortable and free of pain. R70 is alert and oriented to person, place and time. R70 stated he has seen roaches in his bathroom, dresser, and nightstand. R70 opened his dresser, and there was live activity present of three different size roaches: small, medium and large. The roaches scattered away when the dresser door was opened. R70 stated this is nothing, I see them all the time everywhere. R70 stated he has not seen an exterminator from the pest control company come in to spray medication. On 11/25/2025 at 10:32 AM, surveyor observed R19 sitting on the edge of the bed while reading a magazine. R19 is alert to person, place and time, with occasional forgetfulness. R19 stated she has seen roaches in her bathroom. R19 stated when I saw the roach in my bathroom I stepped on it, then I called the nurse. R19 continued by stating the nurse then called the housekeeper, and she cleaned up the dead roach from the floor. R19 stated I don't recall seeing an exterminator come in to get rid of the roaches. On 11/25/2025 at 12:00 PM, surveyor observed activity of a small roach in the conference room table while it landed on the table. On 11/25/2025 at 9:48 AM, V17 (Maintenance Director) stated he has seen roaches in the past typically in the hallways but has seen improvement since the facility hired an exterminator. V17 stated the exterminator comes to the facility two times per month, and during that time he will let the exterminator know where he last seen any activity of roaches. Policy titled Pest Control documents in part it is the facility's policy to ensure that there is an effective pest control process in the building. If there is a suspicion or actual problem with pests, the facility will contact a pest control company to inspect presence of a pest control problem. If a pest problem or infestation is identified, the pest control company will treat the problem. It is the discretion of the pest control company if follow-up treatment or inspection is needed.

Based on observations, interviews, and record reviews the facility failed to follow the Resident Assessment Instrument (RAI) manual to reflect an accurate assessment for one (R109) out of six residents' Minimum Data Set (MDS) assessment reviewed in a total sample of thirty-seven. Findings Include:R109's face sheet shows he is [AGE] years old, admitted to the facility on [DATE] with diagnoses not limited to personal history of transient ischemic attack (TIA) and cerebral infarction, Gastrostomy status, adult failure to thrive, essential hypertension, type 2 diabetes mellitus, developmental disorder of scholastic skills, and unspecified asthma. On 11/25/25 at 1:18 PM, R109 is seated in his wheelchair with limitations to his left hand.On 11/26/25 at 12:41 PM, V22 (Certified Occupational Therapist Assistant/COTA) stated that she has been in the facility since March 2019, and she provided exercises for R109's arms/legs due to weaknesses upon initial admission from 6/6/24 to 6/18/24. He was referred to therapy again on 6/27/24 to 7/23/24 due to diagnosis of adult failure to thrive, he was not working, with limitation to bilateral upper, lower extremities, and with more limitation to left arm/hand. On 11/26/25 at 12:59 PM, V12 (Restorative Nurse) stated that he completed R109's functional limitation in range of motion assessment (section GG0115) of the MDS on 6/30/24. R109 was readmitted with diagnosis of adult failure to thrive on 6/26/24, he was weak and unable to perform activity of daily living (ADL). Surveyor and V12 reviewed R109's hospital discharge records dated 6/26/24 which shows limitation to all his four extremities. V12 stated that he coded no limitation to bilateral upper and lower extremities because he did not notice the limitation during R109's physical assessment.On 11/26/25 at 1:36 PM, V31 (Clinical Care Coordinator/CCC) stated that she has been in the facility since 2015, and it is her expectation that all sections of the MDS are coded accurately. R109's hospital physician's notes of 6/20/24 document in part: admitted from nursing home due to failure to thrive, is barely able to move his right arm. He is not able to move his left hand or lower extremities.Restorative Nurse job description, document in part completes assigned MDS portions accurately and on time.Centers for Medicare and Medicaid Services (CMS) RAI Version 3.0 Manual, 2025. page GG-5 document read in part: definition of functional limitation in range of motion, limited ability to move a joint that interferes with daily functioning (particularly with activities of daily living).

Based on observation, interview and record review, the facility failed to date/label and maintain proper storage of nebulizer tubing and mask when not in use for one (R3) out of one resident reviewed for respiratory care in a final sample of 37.Findings Include:On 11/25/25 at 10:01 AM, R3's resting comfortably in bed. R3's nebulizer machine was not being used, not inside a clear bag, was sitting on top of R3's nightstand. R3's nebulizer tubing mask was sitting on top of the nebulizer machine and was not inside a clear bag. R3's nebulizer tubing and mask had dates labeled 10/22/25. R3 stated he gets nebulizer treatment as needed for COPD (Chronic Obstructive Pulmonary Disease).On 11/25/25 at 10:10 AM, V6 (Assistant Director of Nursing) stated that nebulizer tubing and mask are changed weekly and as needed. V6 said the tubing and the mask should be dated when it was last changed. V6 stated that it's important to change it weekly to prevent infection and prevent fluid accumulation in the tubing. V6 said it should be stored inside a clear plastic bag and labeled with the date also to prevent infection and contamination. On 11/25/25 at 10:14 AM, Surveyor and V6 entered R3's room. V6 confirmed R3's nebulizer tubing and mask were dated 10/22/25 and should be inside the clear bag because it's not being used, and the bag should also be dated. R3's clinical records show an admission date of 1/4/23 with included diagnoses but not limited to Chronic Obstructive Pulmonary Disease, End Staged Renal Disease, and Hypertensive Heart Disease with Heart Failure. R3's order summary report with active orders as of 11/25/25 reads in part: Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol) 1 vial inhale orally every 6 hours as needed for shortness of breath/congestion (ordered 10/22/25). The facility's Respiratory Therapy Equipment Use policy dated 7/3/25 documents in part: All oxygen equipment including nasal cannula, humidifier, and nebulizer mask will not be reused. Once opened, this equipment will be dated and discarded after 7 days of use, whether used continuously or on a prn (as needed) basis.

Based on observation, interview and record review, the facility failed to provide honey thickened liquids as ordered by the physician for one resident (R138) during an activity function in a total sample of 37.Findings Include: On 11/25/25 at 12:30 PM, observed R138 sitting at table next to V23 (Activity Aide). R138 had mechanical soft items on her lunch plate, a closed container of honey thickened milk, an opened container of honey thickened juice and an opened can of soda next to her plate of food. R138's meal ticket read mechanical altered/ground, honey thick milk. On 11/25/25 at 12:32 PM, V23 stated R138 can only drink honey thickened liquids. V23 stated the soda can is in front of R138 because R138 requested it, but R138 is not drinking it. V23 stated the soda is not thickened. On 11/25/25 at 12:35 PM, observed R138 pick up the can of soda, bring it to her mouth and take several sips of soda. Surveyor pointed this out to the V23 and V26 (Social Worker) who also observed R138 drinking the soda from the soda can. V23 and V26 stated R138 should only be drinking honey thickened liquids. On 11/25/25 at 12:45 PM, V26 stated that a family member had donated pizza and soda for the residents to eat after the mass which ended around 12:00 PM which was right before the lunch trays were delivered. V26 stated that R138 asked for one of the cans of soda and one of the staff must have gotten it for R138 and then opened it up for her because R138 could not have opened the soda can up on her own. V26 stated that is how she was able to drink the soda. On 11/25/25 at 12:47 PM - R138 stated her liquids need to be thickened so that she does not cough. R138 said, all my liquids have to be thickened even water. R138 stated someone gave her the soda and a staff member opened it for her. She does not remember which staff member opened it for her. R138 said, I only coughed a few times while drinking the soda. R138 stated no one offered to thicken the soda for her and that she would have accepted the soda mixed with thickener. R138 said, the staff must have forgot to thicken it. On 11/25/25 at 12:53 PM, V27 (Registered Nurse) viewed R138's electronic health record (EHR) and stated that R138 is on a mechanical soft with honey thickened liquids diet order due to swallowing difficulties. V27 stated all R138's liquids must be thickened to honey consistency because otherwise she will cough. V27 stated R138 is at high risk for aspiration. V27 showed surveyor a large container of commercial thickener stored in the nurse's medication cart. V27 stated that he did not know R138 wanted or was given soda during activities/lunch and that no one asked him to provide thickener. V27 stated the staff should have asked him to put thickener in the soda to get the soda to a honey consistency so that it could be safely consumed by R138. On 11/26/25 at 11:10 AM, V23 stated she knows which residents require thickened liquids. V23 stated R138 is not allowed to drink any thin liquid and all her liquids always have to be thickened to honey consistency. V23 stated if R138 requests water or coffee or some other type of liquid that is being served at an activity function, then she would tell the nurse because the nurse has the thickener in their medication cart, and they are the ones who thicken the liquid to the right consistency for R138. V23 stated yesterday, there was a lot going on in the dining room and that after religious services a family brought in pizza and soda to share with everyone. V23 stated she did put the soda in front of R138, but she did not open it for her. V23 stated she told R138 that she had to wait and V23 was planning on letting the nurse on duty know that the soda needed to be thickened. V23 said, it was too busy, there was a lot going on. I don't know who opened the soda for her. It was busy. V23 stated the can of soda should not have been opened for R138 and R138 should not have been allowed to drink the soda. V23 said, I know this because all her liquids need to be thickened by the nurse.On 11/26/25 at 1:05 PM, V24 (Speech Language Pathologist) stated R138 requires mechanical soft solids with honey thickened liquids due to a history of a stroke, and dysphagia. V24 stated all the liquids R138 drinks must be thickened to honey consistency. V24 stated if R138 is given non-honey thick liquids this would place her at risk for increased coughing, choking and aspiration pneumonia. V24 stated thin liquids could slip down quickly without giving R138 time to react and go directly into her lung. V24 stated it is important for the staff to act on the resident's behalf and ensure R138's diet modifications are being met even when food/liquid is being served at activity functions. V24 stated the nursing units have thickener so they can manually thicken any liquid the resident would like, and any liquid can be thickened including soda. V24 stated if R138 wanted to drink soda the staff should have added thickener to make it the correct honey thickened consistency. V24 stated R138 does not mind having to use the thickener or complain about it, and she does not refuse liquids that have been thickened with thickener. R138's Order Summary Sheet dated 11/25/25 documents in part, diet order as mechanical soft texture, honey thick liquids consistency order date 04/23/25. R138's Speech Therapy Evaluation and Plan of Treatment certification period 10/21/25 - 11/19/25 documents in part with recommendations for honey thick liquids. Facility provided document titled, Census List dated 11/25/25, 11:52 AM which list R138's diet order as mechanical altered/ground - honey. Facility provided copy of R138's meal ticket dated 11/25/25 listing mechanical altered/ground, honey at the top of each meal for breakfast, lunch, and dinner. Facility provided kitchen policy titled, Thickened Liquids dated 10/01/25 which documents in part, thickened liquids will be made available to meet the nutritional and fluid needs of residents with dysphagia as ordered, to ensure residents receive thickened liquids meeting swallowing and fluid requirements and Dining Services will provide a powder or gel thickening agent to nursing to thicken thin liquids as needed. Facility provided kitchen policy titled, Therapeutic Diets dated October 2019 which documents in part, it is the center policy to insure (ensure) that all residents have a diet order, including regular, therapeutic, and texture modified, prescribed by the attending physician, physician extender or credentialed practitioner in accordance with applicable regulatory guidelines.

Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident. This failure affected 1 (R2) resident who vocalized that he felt that his life was in terrible danger when a resident (R5) slapped him on his face. Findings include: On 03/17/2025 at 12:24pm, R2 stated couple of weeks ago, we (R2 and R8) were talking about car insurance, when he (R5) slapped me with his open right hand above my temple. I did not know what to do. When his hand landed on my face, I felt I was in a terrible danger. On 03/17/2025 at 12:16pm, R8 stated I did observed (R5) hitting (R2) a couple of weeks ago. He (R5) hit him (R2) on the face. I was talking to him (R2), and he (R5) hit him on his face with open hand on the left side of his (R2) face. He (R5) said he was upset because he (R2) was talking to me. The intent was to physically harm him, and he said I told you I don't want you in my room. On 03/19/2025 at 2:21pm, V22 (Licensed Practice Nurse) stated I was working that weekend on 03/01/2025. I was by my cart outside of the room preparing (R8)'s medications, while doing that, I heard a strange sound. I went in the room to see what is going on. I saw (R5) and (R2) standing up. (R2) was panting. He was upset based on his body language. There was a frown on their faces. I went in the middle. I sat him (R2) on his wheelchair and propelled him to his room. I asked him what happened, and he (R2) said R5 hit me on my face. I went to (R5)'s room and asked him what happened, and he (R5) said I told him not to come to my room while I am sleeping; he just kept on coming and so I just let him know how serious I am about not coming to my room while I am resting. I did assess him (R2). He has redness on the side of his face, I don't remember which side. It was tender because when I touched it, he moved his face away not wanting to be touched. He did a reaction of pulling his face away when I touched that side of his face. On 03/19/2025 at 9:49am, V18 (Family Nurse Practitioner) stated I was called to assess him (R2). From what I was told, there was an altercation between (R2) and (R5) that he (R2) got punched on his left side of face. I assessed him and there was tenderness on that side of his face. There was no discoloration, but it was tender. On 03/17/2025 at 3:28pm, V11 (Social Service Director) stated (R5) slapping (R2) is considered physical abuse. It is not expected of resident to be slapped by another resident. Our environment should be a home like environment and safe for all the residents. On 03/17/2025 at 2:30pm, V1 (Administrator) stated I asked him (R5) about the incident. He (R5) said R2 kept coming into their (R5 and R8) room. He (R5) said that he was just sleep deprived and frustrated because he could not sleep, and he said he slapped him on the face. Of course, a resident is not expected to be slapped by another resident. He (R5) said he was just not himself and he made a poor decision. He really could not think because he was sleep deprive. R2's Admission Record documented that R2's diagnoses (include but not limited to) neoplasm of rectosigmoid junction, atherosclerotic heart disease, and hypotension. R2's (02/06/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 99. Unable to complete the interview. C1000. Cognitive Skills for daily decision making: 1 - modified independence - some difficulty in new situations only. R2's (Active Order as Of: 03/17/2025) Order Summary Report documented, in part send to hospital ER for head and hip protocol, due to physical altercation. Active 03/01/2025. R2's (3/6/2025) After Visit summary documented, in part Today's visit. Reason for visit: Battery. R2's (03/07/2025) final reportable documented, in part 2. Allegation type. Type of Abuse. Cross mark on 'Physical'. Summary of interview with individual name in the allegation: (R5) stated that he lost control over himself due to a lack of sleep and due to (R2)'s laughing at his request to keep it down. (R5) stated he never intended to just get his attention. Summary of Interview with residents on the unit: (R8) stated that he saw (R5) slap (R2)'s face as a means to get him to leave. Summary of investigator's findings: (R5) said he slapped (R2) as a way of telling him to leave the room. (R5) explained that he was extremely tired and 'lost himself a bit', believing it was the only way to achieve peace and quiet. Based on resident and staff interviews, the allegation of abuse cannot be substantiated. (R5) believed that slapping (R2) was the only way to create a quiet atmosphere and remove (R2) from his room. He stated that he 'lost himself' momentarily. R5's Admission Record documented that R5's diagnoses (include but not limited to) hypertension, osteoarthritis and Type 2 Diabetes Mellitus. Date of Discharge: 03/01/2025. discharged to: Acute Care Hospital. R5's (01/23/2025) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 15. Indicating R5's mental status as cognitively intact. R5's (09/05/2024) care plan documented, in part Focus: Identified Offender - history of criminal behavior. Aggravated battery. Goal: will behave in a safe manner consistent with resident conduct policies. R8's Admission Record documented that R8's diagnoses (include but not limited to) essential hypertension, alcohol abuse and dependence and anxiety disorder. R8's (12/16/2024) Minimum Data Set documented, in part Section C. Cognitive Patterns. C0500. BIMS (Brief Interview for Mental Status) Summary Score: 10. Indicating R8's mental status as moderately impaired. The (undated) Residents' Rights for People in Long-Term Care Facilities documented, in part As a long-term care resident in the State, you are guaranteed certain rights, protections and privileges according to State and Federal laws. Your rights to safety. You must not be abused physically. Your facility must be safe. The (7/12/24) Abuse and Neglect documented, in part Policy Statement: It is the policy of the facility to provide professional care and service in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect or mistreatment. The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. Abuse is a willful infliction of mistreatment and injury. Types of abuse: 1. Physical abuse. Includes but not limited to infliction of injury. Examples: slapping. Potential aggressors include but not limited to other residents.

Based on observation, interview, and record review the facility failed to ensure kitchen tongs and measurement pitchers were properly cleaned and sanitized and food was removed and discarded from the prep refrigerator by the use by date This failure has the potential to affect all the residents in the facility. Findings Include: On 09/17/24 at 09:34 the surveyor entered the kitchen for the initial tour with V14 (Dietary Manager). Red rice/chicken was observed in the prep refrigerator dated 07/12/24 - 07/16/24. V14 stated the wrong month was written on there but today is 09/17/24. On 09/18/24 at 09:35 AM the surveyor entered the kitchen. The Menu dated Wednesday 09/18/24 consisted of Beef Ravioli, Italian Parmesan, Medley Mixed Vegetables, French Garlic Bread and Pineapple Up-side Down Cake. On 09/18/24 at 09:47 AM V18 (Cook) place Steak burgers in a pan using tongs on top of stove. On 09/18/24 at 10:14 AM V18 (Cook) removed a green bucket from under the prep table near the sink, used a sponge that was in the green bucket and washed the tongs. On 09/18/24 at 10:16 AM V18 (Cook) used the tongs to remove the steak burgers from the pan and placed them on the hamburger buns. On 09/18/24 at 10:35 AM V18 (Cook) washed the strainer, small and large measurement pitcher using the sponge that was in the green bucket, then placed them to the right side of the sink. On 09/18/24 at 10:39 AM V18 (Cook) obtained the small measurement pitcher then dipped it into the pot Italian parmesan sauce then poured it into two pans before placing them on the steam table. On 09/18/24 at 10:45 AM V18 (Cook) washed the tongs and the pitcher with the sponge that was in the green bucket. On 09/18/24 at 10:49 AM Surveyor asked V14 (Dietary Manager) the contents of the red and green bucket. V18 stated the red bucket has the sanitizer; the green bucket has soap and water. On 09/18/24 at 11:03 AM V18 (Cook) used the small pitcher that she washed with the sponge from the green bucket to dip and remove excess water from the ravioli that was on the stove top. On 09/19/24 at 09:21 AM V14 (Dietary Manager) stated The green bucket had soap and water and it is used for towels after the counters are sanitized. The soiled towels are placed in the bucket then we have a large bucket that the towels are put in so they can be washed. The tongs and measurement pitchers should be taken to the three-compartment sink to be washed. V14 should have grabbed a clean pitcher each time she uses a dish. V14 should put the dishes in the three-compartment sink and get a new measurement pitcher, we have plenty of measurement pitchers. There is a potentially using the measurement pitcher and tongs could contaminate the food. The dishes should be washed, sanitized and air dry before using again. Document titled In-Service Sign in Sheet dated 09/17/24 document in part: In-service topic: Sanitation buckets concentration. Document titled In-Service Sign in Sheet dated 09/17/24 document in part: In-service topic: Label and dating. Temperature Control for Safety foods can grow harmful bacteria if stored or labeled incorrectly. Labeling Temperature Control for Safety foods we prepare helps us know when they were made and when they might spoil. We must label and us Temperature Control for Safety foods within 7 days from preparation or opening to stay safe. Proper labeling ensures the food we serve is fresh and safe to eat. If we use food labels incorrectly it could lead to us serving unsafe food. Labeling errors that can lead to unsafe food: incomplete labels or inaccurate information, incorrect use-by-dates. Document titled In-Service Sign in Sheet dated 09/19/24 document in part: In-service topic: Cleaning and Sanitizing, Preventing Cross Contamination. Cleaning removes dirt and soil, while sanitizing reduces bacteria and viruses on surfaces. Cleaning and sanitizing does not eliminate the need for disinfection. Both activities prevent contamination and keep our employees, locations, food, and customers safe. Cross contamination occurs when harmful bacteria move or transfer from one person, place, or surface to another. Preventing cross-contamination is an important step to preventing foodborne illness - protecting our employees, customers, and company's reputation. Conditions that can cause cross-contamination: Improper cleaning and sanitizing, Improper storing food. Behaviors that can contribute to cross contamination: Preparing food on or serving with unclean items. Policy: Titled Kitchen revised 08/16/24 document in part: The facility will comply with state and federal regulations in operating facility's kitchen. 1. Food Storage: h. Open containers or potentially hazardous food or leftovers should be dated and used within 3-5 days in the refrigerator. 5. 3 Compartment Sink (Wash, Rinse, Sanitize). a. The 1st compartment is water and soap for washing. b. The 2nd compartment is water for rinsing. c. The 3rd sink used for sanitizing pots and pans. d. The 3rd compartment for sanitizing has to comply with the sanitizer's manufacturer's recommendation. 8. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate. 11. Miscellaneous Areas: b. Food brought by the resident's family will be labeled to identify the date the food from the outside was brought in by the representative. c. Perishable food items brought in by the resident's representative will be discarded within 3-5 days after brought in and refrigerated in the resident's room.

Based on observations, interviews, and record reviews, the facility failed to ensure contracted staff wore appropriate Personal Protective Equipment (PPE) while caring for a resident (R34) on Enhance Barrier Precautions (EBP) and failed to ensure proper linen storage/handling. These failures have the potential to affect all 171 residents that reside in the facility. Findings include: R34's Admission Record documents in part medical diagnoses of gastrostomy status and encounter for attention to gastrostomy. R34's care plan documents in part that R34 is on Enhanced Barrier Precautions (initiated 7/13/2023). Interventions include Ensure that gown and gloves are used during high-contact resident are activities (like dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, Device care or use for those with central line, urinary catheter, feeding tube, tracheostomy/ventilator, and Wound care for any skin opening requiring a dressing) that provide opportunities for transfer of MDROs [multi-drug resistant organisms] to staff hands and clothing (initiated 7/13/2023). On 9/17/2024 at 11:08 AM, there was an Enhanced Barrier Precautions (EBP) sign posted outside of R34's bedroom door. It documents in part to wear gloves and a gown for High-Contact Resident Care Activities including dressing, bathing/showering, changing linens, providing hygiene, and changing briefs or assisting with toileting. Inside R34's room, V11 (Hospice Certified Nurse Aide - CNA) was bagging dirty linen. V11 wore gloves but no gown. V11 stated finishing R34's bed bath. V11 stated [V11] comes five times a week to care for R34. V11 stated facility did not inform V11 of any precautions for R34. Showed V11 the EBP sign outside of R34's door. V11 stated doesn't know what the sign is for and wasn't told to gown up while doing care for R34. V11 flagged down V12 (CNA) who was walking down the hall and asked what the EBP meant. At 11:13 AM, V12 stated EBP was for residents who were at risk. V11 stated they kind of are like easier for them to catch stuff. V11 stated staff are supposed to wear gloves and gown when doing contact stuff with the skin. On 9/18/2024 at 2:03 PM, V8 (Infection Preventionist) stated EBP is usually for residents with central lines, catheters, tracheostomy's, gastrostomy tubes (R34), and wounds. V8 stated staff are to don gloves and a gown for contact care including personal hygiene, changing linen, and bathing. Facility's Infection Prevention and Control policy, last revised 7/31/2024, documents in part that Enhanced Barrier Precautions (EBP) is an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs). The goal is to prevent transmission of MDROs to others. It involves the use of gloves and gowns during high contact resident care activities for residents infected or colonized with MDROs as well as residents with wounds and/or indwelling medical devices. On 9/18/2024 at 10:33 AM, surveyor conducted laundry observations in the basement. Outside the laundry room there were blue bins lined up against the wall. One blue bin had bundles of flat sheet. The bin was uncovered. Another bin contained white/blue incontinence pads. The bin was also uncovered. V9 (Laundry Aide) stated linens were clean and delivered that morning. V9 stated linen bins should remain covered. Laundry room door was propped open. There were two bins of dirty resident clothing on the right side waiting to be washed. To the left there was a metal rack of clean linen. On one of the metal racks there was a portable fan blowing directly on the clean linen. Fan intake was towards the door and dirty linen and fan output was to the clean linen (wind current going from dirty to clean). At 10:39 AM, V9 opened the laundry chute room. The bin inside was overflowing and there were multiple bags of linen/resident clothing backed up the chute. At 2:03 PM, V8 (Infection Preventionist) and V10 (Assistant Director of Nursing) stated linens are supposed to be covered to keep them protected from potential contamination. Linens in the blue carts should be covered with plastic. On 9/19/2024 at 11:01 AM, V23 (Housekeeping/Laundry/Central Supplies) stated an outside company delivers clean linen in blue bins. The blue bins need to be covered in plastic until time for use. V23 stated that laundry chute should be checked every two hours or as needed. V23 stated the laundry chute should not be overflowing. Facility's Linen Handling by Laundry Staff policy, last revised 8/16/2024) documents in part: Clean linen may be placed in a clean linen room or left in the cart that is protected from the environment. Facility did not have a policy pertaining to laundry chute.

Based on observations, interviews, and record reviews, the facility failed to provide supervision of residents during a smoking break and demonstrate competency and knowledge related to safety measures and equipment for the smoking patio and failed to secure first and second floor soiled utility rooms that contained sharps and infectious waste containers. These deficient practices have the potential to affect all residents who are identified as smokers (R15, R26, R40, R59, R75, R87, R93, R95, R111, R112, R117, R125, R128, R129, R137, R149, R151, R154, R159, R160, R163, R170, R171) and all ambulatory residents that reside on the first and second floors, in the sample of 35. Findings include: On 9/19/2024 at 9:35 AM, approximately 10 residents observed on the Smoking Patio. V26 (Activity Aide) observed helping wheelchair bound residents on to and off the smoking patio; no staff observed stationed on the patio to monitor residents during smoking break. On 9/19/2024 at 9:42 AM, V24 (Activity Aide) said we don't stay on the patio the whole time, we go out there periodically. V24 said I can find out where the smoking blanket is, I don't know what it is. I have not received any training related to what to do if resident's clothing catches on fire, I would call for help immediately. On 9/19/2024 at 9:52 AM V25 (Activity Director) said there is no training related to what to do if resident's clothing catches on fire. V25 said, we don't stay on the patio (duration of smoke break), we go out there periodically. On 9/19/2024 at 09:58 AM, V28 (Activity Aide) said staff do not stay on smoking patio for duration of smoking break; periodically go out and monitor. On 9/19/2024 at 10:08 AM, V1 (Administrator) said Activity Staff sit at door (first floor dining room) during smoking breaks. They periodically go out on the patio and check residents for paraphernalia when returning from smoking patio. V1 said, I would expect staff to call for help if resident's clothing catches on fire. V1 acknowledged Surveyor's concern that staff may not be able to see entire smoking patio if they are sitting inside the building.) V1 said Activity Staff would be provided with fire safety training for smoking patio. Fire Drill Evaluation Worksheets dated 5/28/2024, 6/11/024, 7/31/2024, and 8/27/2024, do not document any drills/training specific to the facility's smoking patio/smoke breaks. Employee Inservice Sign-In Sheets document Activity Staff received the following training: Location and how to use fire blanket. Safety of residents during smoke breaks. Monitor residents that are smoking at all times. Follow the facility('s) smoking policy. How to use the fire blanket safely. Where it is located. All sign-in sheets are dated 9.19.2024. Smoking Policy (revised 8.19.2024) documents: It is the facility's policy to monitor and assess residents that smoke to promote smoking in a safe manner. Smoking Policy (undated) does not document safety measures to be implemented if a resident's clothing catches on fire or monitoring of smoking patio. 45001 On 9/17/24 approximately 12:15 PM, observed R11 sitting in the day/dining room coloring. R11 was alert and oriented and had no concerns with the facility. R11 endorsed quitting smoking. On 9/17/24 at 12:42 PM, During review on the 2nd floor, surveyor/writer observed R11 come out of a room carrying a new trash bag. On the wall next to the room there was a sign that read Utility Room. On the door of the room there was a sign that read CAUTION Infectious Waste Storage Area Unauthorized Persons Keep Out and an entry code keypad. Writer asked R11 what was R11 doing in the room. R11 said R11 went to throw out trash and get a trash bag. Writer asked R11 how did R11 get inside of the room. R11 proceeded to press a series of buttons on the entry code keypad, turned a knob and opened the door. Multiple times, writer attempted to open the door without even pressing buttons on the entry keypad and the door opened each time. Inside of the room were two garbage cans with bags of trash inside, one red biohazard can with bags of trash inside, two red sharps containers that contained sharps, a hopper with standing water, a utility sink, a broom, and the room had a foul stench. On 9/17/24 at 12:55 PM, Writer reviewed the Utility Room with V28 (MDS/Clinical Care Coordinator). Writer opened the door of the room without entering a code. V28 verified the room was not locked and stated the room is supposed to be locked and entry is with a code. V28 stated residents should not be in the room. V28 picked-up and shook the sharps containers to verify they were full of sharps. V28 stated the sharps containers located in the room should not be accessible to residents. V28 stated the hopper is used to pour urine into. On 9/17/24 at 1:05 PM, V23 (Housekeeping Manager/Laundry/Central Supplies) stated red isolation bags, trash from resident rooms, full sharps containers are kept in the Utility Room. Housekeeping throws the trash in dumpsters at the end of shift. Maintenance takes the red isolation bags and sharps containers to a special area outside of the building. V23 stated the door to the Utility Room should be locked at all times. Residents should not be in the room and should not have the code to the door to the room. Residents should not be in the room because of the risk of infection from the garbage and sharps that are kept in there. On 9/18/24 at 2:54 PM, During review on the 1st floor, two surveyors, including writer, discovered an unlocked room. On the wall next to the room there was a sign that read Utility Room. On the door of the room there was a sign that read CAUTION Infectious Waste Storage Area Unauthorized Persons Keep Out and an entry code keypad. Writer opened the door to the room without entering a code into the entry code keypad. Inside of the Utility Room was a hopper, a biohazard box with at least one red isolation bag inside, a cube refrigerator, empty, with a sign on the door stating the Refrigerator is for Specimens, and two garbage cans. On 9/18/24 at 3:05 PM, V2 (Director of Nursing) stated urine and stool specimens are kept in the refrigerator in the Utility Room on the 1st floor. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated residents should not be in the Utility Room. That room is where we put the sharps containers when they are full, biohazard/isolation waste, garbage including used diapers, garbage from medication administration, garbage from resident rooms. The specimen refrigerator in the room is for urine, stool samples, Covid tests. The lab picks up samples daily. The door to the room should be locked. Its dirty in the room and don't want residents in there. The residents can hurt themselves with the sharps, they can mess with the samples. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated residents should not be in the Utility Room. It can be a safety hazard. They can be exposed to harmful bacteria. Without proper hand hygiene when they come out of the room, that can lead to cross contamination with staff and other residents. There can be biohazard waste, full sharps containers, dirty diapers, waste from resident rooms, waste from the medication carts in the room. The door to the room should be locked. The refrigerator is for urine, and stool specimens. The access to the refrigerator is for nurses and lab personnel. Facility policy Hazards, 7/30/24, documents in part: Policy Statement: It is the facility's policy to ensure the safety of each resident in the building and remove hazardous items and correct situations to prevent accidents. Procedures: 1. Ensure that residents have no access to medications, sharps, and chemicals that would be hazardous to them.

Based on observations, interviews, and record review, the facility failed to provide appropriate treatment and services to prevent complications from enteral feeding for 2 (R35, R132) of 6 residents reviewed for enteral feedings. The facility also failed to ensure expired enteral feeding products were removed and unavailable to be administered to residents. This failure has the potential to affect 2 (R29, R36) residents that receive enteral nutritional feedings. Findings Include: 1. R35 has diagnosis not limited to Essential (Primary) Hypertension, Hyperlipidemia, Adult Failure to Thrive, Type 2 Diabetes Mellitus with Hyperglycemia, Bilateral, Indeterminate Type 2 Diabetes Mellitus with Diabetic Neuropathy, Chronic Obstructive Pulmonary Disease, Restlessness and Agitation, Dysphagia, Dementia, unspecified Severity, with Agitation, Severe Protein-Calorie Malnutrition, Gastrostomy Status, Ulcer of Esophagus, Vitamin D Deficiency, Type 2 Diabetes Mellitus with Foot Ulcer, Pressure Ulcer of Sacral Region and Personal History of other Diseases of the Digestive System. R35's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) indicate resident is rarely/never understood. R35's Order Review Report dated 09/18/24 document in part: NPO (Nothing by mouth) diet NPO texture, NPO consistency, for PEG (percutaneous endoscopic gastrostomy) tube. Enteral Feed Order every shift Enteral feeding- Tube type: Peg tube, Glucerna 1.5 Rate: 60 ml/hr. (milliliter/hour), start at 6 am and infuse x20 hours or until 1200 ml formula is reached per day. Care plan document in part: R35 is NPO d/t (due/to) dysphagia. S/p (status/post) PEG tube placement on 2/7/24. R35 is on therapeutic enteral formula dt (due to) dx (diagnosis) DM (Diabetes Mellitus) Date Initiated: 09/14/20. R35 has the following conditions and risk factors that puts her at risk for dehydration: increased risk of confusion and delirium, cognitive impairment, Senile Degeneration of the Brain, on diuretic therapy, on NPO and on enteral feeding via gastrostomy tube (s/p GT placement (02/07/24), s/p Explore Lap, Partial Gastrectomy of greater curvature of body of stomach (02/12/24), Dx of Dysphagia, Adult Failure to Thrive, Malnutrition, Type 2 DM w/ Hyperglycemia, Diabetic Neuropathy. Interventions: Administer fluids per doctor's order via appropriate routes (Nothing by Mouth, G- (gastric) tube). R35's currently on NPO and on enteral feeding of Glucerna 1.5 via gastrostomy tube given as scheduled. Observe aspiration precaution. Monitor for tolerance and effectiveness. Date Initiated: 09/08/20. On 09/17/24 at 12:28 PM R35 was observed in bed on a low air loss mattress positioned in a low [NAME] position receiving an enteral feeding of Glucerna at 60 ml/hr. On 09/17/24 at 12:34 the surveyor entered R35 room with V15 (Licensed Practical Nurse) then asked the position of R35 head of the bed. V15 responded, it looks like R35 head of bed should be up a little more because she could aspirate. On 09/19/24 at 12:45 PM V2 (Director of Nursing) presented a care plan that documents in part: R35 is at risk for alteration in nutritional status related to her Dx (diagnosis) of Adult Failure to Thrive, Dysphagia, Type 2 Diabetes mellitus w/ Hyperglycemia, Diabetic Neuropathy and Foot Ulcers, Gastrostomy Status. Interventions: Elevate head of the bed during enteral feeding. Observe aspiration precaution. Monitor for tolerance and effectiveness. 2. R132 has diagnosis not limited to Type 2 Diabetes Mellitus, Altered Mental Status, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Gastrostomy Status, Hyperlipidemia, Chronic Obstructive Pulmonary Disease, Emphysema, Anxiety Disorder, Restlessness and Agitation, Personal History of other Diseases of the Respiratory System, Dysphagia. R132's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 06 indicating severe cognitive impairment. R132's Order Summary Report dated 09/18/24 document in part: NPO (Nothing by mouth) diet NPO texture, thin liquid consistency. Enteral Feed Order every shift Enteral feeding- Tube type: Peg tube, Glucerna 1.5 Rate: 80 ml/hr. (milliliter/hour), start at 6 am and run 20 hours or until 1600 ml formula is administered daily. Care plan document in part: R132 is NPO, on PEG tube feeding d/t dysphagia and the inability to meet his nutritional/fluid needs. Presence of PEG tube places him at risk of infections, fluid overload, dehydration, and aspiration. -R132 is at increased nutrition risk d/t recent NPO status requiring enteral feeding to support nutrition, on NPO and on enteral feeding via gastrostomy tube s/p placement (04/01/24), Interventions: Administer fluids per doctor's order via appropriate routes (PEG-tube). R132 currently on NPO and on enteral feeding via gastrostomy tube. Observe aspiration precaution. Monitor for tolerance and effectiveness. Date Initiated: 05/10/23. On 09/17/24 at 12:21 PM R132 was observed in bed in a low [NAME] position receiving an enteral feeding of Glucerna at 80 ml/hr. (milliliters/hour). On 09/17/24 at 12:33 the surveyor entered R132 room with V15 (Licensed Practical Nurse) then asked the position of R132 head of the bed. V15 responded, I'd say 30 degrees. However, R132 head of the bed was observed positioned in a low fowlers position. On 09/19/24 at 11:53 AM V2 (Director of Nursing) stated A resident with a Gastric tube should be position at 30-to-45-degree angle, slightly elevated as long as they are not flat in the bed. There is a potential for aspiration if the resident is not properly positioned. On 09/19/24 at 12:45 PM V2 (Director of Nursing) presented a care plan that documents in part: R132 has/have a Dx of COPD related to Nicotine Dependence (cigarettes) in remission. Interventions: Head of bed elevated (semi-Fowlers to fowlers) secondary to shortness of breath while lying flat and difficulty breathing as needed. Head of bed to be elevated (semi-Fowlers to fowlers) or out of bed upright in a chair during episodes of difficulty breathing (Dyspnea). Document titled Diet Type Report dated 09/19/24 document in part: Eleven residents with a diet type of NPO. Policy: Titled Enteral Tube Feeding Care revised 07/26/24 document in part: Enteral Tube is an avenue of feeding and hydration nutritional support via gastrostomy route. Procedure: 9. Residents on enteral feeding must be positioned in a [NAME]'s position at all times while the feeding is running. Titled General Care revised 07/30/24 document in part: It is the facility's policy to provide care for every resident to meet their needs. Procedures: 1. Upon admission or readmission, the facility will evaluate the resident for physical and psychosocial needs, etc. Psychosocial needs would include but are not limited to areas of mental and psychosocial well-being. The facility will assist the resident to meet these needs. 45001 3. 9/17/24 at 3:15 PM, reviewed 2 North medication room with V29 (Licensed Practical Nurse) and V30 (Registered Nurse) and observed: -Osmolite Complete Balanced Nutrition; 1.5 CAL; with use before date Nov (November) 1, 2023; 2 bottles -TwoCal HN 2.0 CAL Calorie and Protein Dense Nutrition; with expiration date Sep (September) 1, 2024; 2 cartons According to face sheet printed 9/19/24, R29 diagnoses include but are not limited to quadriplegia, encounter for attention to gastrostomy, gastrostomy status, cerebral infarction. R29 physician order summary printed 9/20/24 reads in part: enteral feed order every shift enteral feeding-tube type: G-tube, Osmolite 1.5, Rate: 70 ml/hr, start at 5am and infuse until 1400 ml formula is reached per day. According to face sheet printed 9/19/24, R36 diagnoses include but are not limited to acquired absence of other specified parts of digestive tract, encounter for attention to gastrostomy, gastrostomy status, chronic diastolic (congestive) heart failure. R36 physician order summary printed 9/20/24 reads in part: enteral feed order six times a day enteral feeding-tube type: PEG tube, Bolus: 1 carton of TwoCal (240 ml), 6x/day. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated there should not be expired medications in the medication carts or medication rooms. If a resident is given an expired medication, it can harm the resident. The G-tube feedings and bolus feedings and oral feedings should not be expired. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated there should not be expired medications in the medication carts or medication rooms. It can be dangerous to the residents to have expired products administered to them. On 9/19/24 at 1:54 PM, V2 (Director of Nursing) stated there should be no expired medications or enteral feedings in the medication carts or medication rooms. Residents could have an adverse reaction to expired medications or enteral feedings. Central supply should be checking the supply for expiration dates. When the supply comes upstairs then the nurses should be checking dates. List of Residents with G-tubes and are on Enteral Feedings provided by facility 9/19/24 documents in part: R29, Osmolite 1.5; R36, TwoCal 240 ml. Facility policy Enteral Tube Feeding Care, 7/26/24, documents in part: 2. Check for feeding formulas expiration date.

Based on observation, interview and record review, the facility failed to ensure expired medications were removed and unavailable to be administered to residents. This failure has the potential to affect all residents receiving medications from the 2 North Front medication cart. Findings include: On 9/17/24 at 3:07 PM, reviewed 2 North front medication cart with V2 (Director of Nursing) and observed: -Gas Relief Simethicone 80mg chewable tablets with expiration date 8/24. On 9/19/24 at 11:55 AM, V27 (Registered Nurse) stated there should not be expired medications in the medication carts or medication rooms. If a resident is given an expired medication, it can harm the resident. On 9/19/24 at 12:10 PM, V8 (Infection Control Nurse) stated there should not be expired medications in the medication carts or medication rooms. It can be dangerous to the residents to have expired products administered to them. On 9/19/24 at 1:54 PM, V2 (Director of Nursing) stated there should be no expired medications or enteral feedings in the medication carts or medication rooms. Residents could have an adverse reaction to expired medications or enteral feedings. Central supply should be checking the supply for expiration dates. When the supply comes upstairs then the nurses should be checking dates. Facility policy Medication Storage, Labeling, and Disposal, 8/16/24, documents in part: 2. House stocks designed for multiple administration will be labeled with the name of the medication, the strength, instruction, and expiration. The information from the manufacturer is enough to meet this requirement. The facility does not date this medication when opened. And the medication automatically expires based on the expiration date based on the manufacture's guidelines.

Based on observation, interview, and record review the facility failed to follow the menu for residents receiving a pureed diet. This failure has the potential to affect 19 residents receiving a pureed diet. Findings Include: On 09/18/24 at 11:29 AM the kitchen staff began plating from the steam table. Staff was observed plating pureed ravioli, pureed medley mixed vegetable and mash potatoes to be served for the residents that receive a pureed diet. There was no pureed bread served. On 09/19/24 at 03:25 PM V20 (Registered Dietician) stated If it says a pureed bread item on the meal ticket the resident should be receiving it. The residents on the pureed diet should have received ravioli, mixed vegetables, French garlic bread and pineapple upside down cake. The residents could receive mashed potatoes in place of the bread. That would not be following the menu. The mashed potatoes would be a substitution and be marked in the substitution binder. There is a binder in the kitchen if there is not enough of an item, I need to give this as a substitution and I would have to sign off on it. I was not notified that they were serving mashed potatoes. The bread would be the first option. On 09/19/24 at 09:21 AM V14 (Dietary Manager) stated on 09/18/24 Beef Ravioli, California blend vegetable medley, garlic bread and pineapple upside down cake was served for lunch. All of the residents should have received bread, even the residents that receive a pureed diet. The Register Dietician let me know mashed potatoes were served instead of the garlic bread. When I spoke to the V14 (Cook) she said that she forget the pureed bread. The menu was not followed for the residents that receive a pureed diet. The mashed potatoes being substituted for the pureed bread there is a potential the residents could not have received the same calories. That should not have happened unless the dietician is aware of the substitution. Document titled Diet Type Report dated 09/18/24 document in part: Nineteen residents that receive a Pureed Diet. Policy: Titled Kitchen revised 08/16/24 document in part: The facility will comply with state and federal regulations in operating facility's kitchen. 8. All food items in the menu and recipe will be followed. In the event that change is needed, the dietician may be consulted first to approve the change and ensure that the change is appropriate.

Based on observation, interview, and record review the facility failed to place a hand splint to the left hand for contracture management for 1 (R145) resident reviewed for range of motion in a sample of 35. Findings Include: R145 has diagnosis not limited to Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Cerebral Infarction due to Unspecified Occlusion or Stenosis of Right Middle Cerebral Artery, Aphasia Following Cerebral Infarction, Dysphagia Following Cerebral Infarction, Dysarthria Following Cerebral Infarction, Facial Weakness Following Cerebral Infarction, Occlusion and Stenosis of Unspecified Carotid Artery and Essential (Primary) Hypertension. R145's MDS (Minimum Data Set) BIMS (Brief Interview for Mental Status) score is 15 indicating intact cognitive response. Order Summary Report dated 09/18/24 document in part: Apply resting hand splint and elbow on left hand and PRAFO (pressure relief ankle foot orthosis) on BLE (Bilateral lower extremities) for 4 hours daily as tolerated. Care Plan document in part: Focus: R145 has an ADL (activities of daily living) self-care deficit related to limited mobility in left hand d/t (due/to) hemiplegia. Resident is on a splint and/or brace assistance program Date Initiated: 12/10/23. Interventions: I am on a Splint Program. Staff will provide Passive Range of Motion daily before application of R145 splint. Date Initiated: 12/10/23. I am on a Splint Program. I would like staff to check for skin integrity, circulation, and motion before and after removal of splint and note condition of the skin Date Initiated: 12/10/2023. Restorative Splint/Brace Program: Please provide/use left resting hand brace for 4-6 hours daily or as tolerated. Date Initiated: 12/10/23. On 09/17/24 at 11:14 AM R145 was observed lying in bed on a low air loss mattress. R145 left hand was observed contracted with the left arm bent up and laying on R145's chest. There was no splint observed to the left upper extremity. R145 stated I have been here about a year. They exercise my left arm, but they haven't come today yet. On 09/19/24 at 09:45 V21 (Restorative Nurse) stated R145 has a splint to the left upper extremity. R145 had a stroke, is alert and oriented x3. R145's splint should be applied daily at least 4 hours. They have the charting in Point Click Care for that. If R145 refuses the splints the restorative aide or certified nurse assistant should document. The purpose of the splint is to prevent the worsening of a contracture or stiffness. R145 has a contracture to the left upper extremity and the splint is for the prevention of further contracture. On 09/18/24 at 10:12 AM V21 (Restorative Nurse) presented the surveyor with Documentation Titled Follow Up Question Report dated 09/12/24 - 09/18/24 with V22 (Certified Nurse Assistant) entry that document in part: 09/17/24 09:18 AM Was brace/splint applied? Yes. However, on 09/17/24 at 11:14 AM R145 was observed lying in bed with no splint in place to the left upper extremity. On 09/19/24 at 10:13 V22 (Certified Nurse Assistant) stated I was assigned to R145 on Tuesday 09/17/24. I provide total care, change, wash her face and on days that R145 want to get up I get her up. On Tuesday it was a normal day, I checked, changed, would go in when R145 put on the call light and turn her. I document the brace/splint because I see them applied but restorative applies the splints. I do not apply the splints myself. On 09/17/24 I saw R145 legs I don't remember if the left arm splint was on there. R145 is alert and oriented x3. I know for sure that R145 had the brace on her legs, but she did not get a bath on Tuesday. On 09/18/24 at 09:18 AM surveyor entered R145 room and observed R145 lying in bed with the left-hand splint in place. When asked did the staff ever come and apply the left-hand splint on Tuesday 09/17/24. R145 responded, they did not put it on at all yesterday and they just put it on about forty minutes ago. It is used to stretch my fingers out and they leave it on until lunch time. On 09/19/24 at 10:40 AM V21 (Restorative Nurse) stated my restorative aides put the residents' splints on. If they had applied the splints they would have charted. There is no proof that R145's splints were applied other then V22 (Certified Nurse Assistant) documentation. On 09/17/24 we only had two restorative aides for that day, and it is generally four restorative aides, one on each unit. I only had two restorative aides to cover the whole building. Generally, all of the residents should have some type of restorative program. If there are two restorative aides, I can't expect for them to cover the whole building. That is why we implemented the group program for about 3 months. Policy: Titled Restorative Nursing Program revised 08/19/24 document in part: It is the policy of this facility to assess for comprehensive nursing and restorative needs upon admission. Procedure: 2. Appropriate nursing and restorative services consistent to the resident's functional needs must be provided. 3. Nursing and Restorative Services may include the following: c. Contracture Prevention and Management. ii. Splint/Orthotic Management. 6. Restorative Programs shall be reflected and indicated in the resident's electronic restorative log in order to document the provision of services and the frequency by the nurses, cnas (certified nurse assistants) and/or restorative aides.

Based on observation, interview, and record review, the facility failed to change an intravenous catheter dressing timely for 1 (R33) resident reviewed for intravenous catheter care in a sample of 35. Findings Include: R33 has diagnosis not limited to Essential (Primary) Hypertension, Personal History of Malignant Neoplasm of Thyroid, Personal History of Malignant Neoplasm of other Parts of Uterus, Type 2 Diabetes Mellitus, Morbid (Severe) Obesity due to Excess Calories, Hypothyroidism, Hyperlipidemia, Spinal Stenosis, Cervical Region, Osteophyte, Vertebrae, Disorder of Bone, Adult Failure to Thrive, Restlessness and Agitation, Personal History of Transient Ischemic Attack (TIA), and Cerebral Infarction, Intervertebral Disc Degeneration, Lumbar Region, Spinal Stenosis, Lumbar Region , Adjustment Disorder with Anxiety, Bilateral Primary Osteoarthritis of Knee, Primary Osteoarthritis, Left Hand, Arthropathy, Atherosclerotic Heart Disease of Native Coronary Artery, Ankylosing Spondylitis of Multiple Sites in Spine, Spondylosis, Polyarthritis, Major Depressive Disorder, Adjustment Disorder with Depressed Mood, Ventral Hernia, other and Unspecified Ventral Hernia With Obstruction, Personal History of Covid-19, Primary Osteoarthritis, Left Shoulder, Intervertebral Disc Degeneration, Thoracic Region, Vascular Dementia, Unspecified Severity, with Agitation, Diverticulosis of Large Intestine, Intestinal Obstruction, Gastro-Esophageal Reflux Disease, Slow Transit Constipation, Carrier of Carbapenem-Resistant Enterobacterales. BIMS (Brief Interview for Mental Status) 11. Care plan documents in part: R33 has potential for infection related to presence of midline catheter on right upper arm. Date Initiated: 09/05/24. Interventions: Initiate proper precaution per facility policy. R33 on Antibiotic Therapy related to elevated WBC (Leukocytosis) and ESBL in urine. R33 received Meropenem Intravenous Solution Reconstituted 1 GM (gram) intravenously every 8 hours for leukocytosis for 5 Days -Start Date- 09/05/24 2200. On 09/17/24 at 11:26 AM R33 was observed lying on a low air loss mattress. The Midline observed to R33's right arm was dated 09/05/24. On 09/17/24 at 11:50 AM V16 stated facility policy on PICC (Peripheral Inserted Central Catheter)/Midline dressing change was the PICC/Midline dressing is changed every 7 days, but wound care changes the dressing and take care of it. On 09/17/24 at 01:35 PM surveyor entered R33's room with V16 (Registered Nurse) then asked what date was on R33's Midline dressing. V16 looked at the PICC line dressing using the flashlight on her (V16) cell phone and stated, it's dated 09/05/24. On 09/19/24 at 11:53 AM V2 (Director of Nursing) stated The Midline dressing is changed every 7 days once a week and as needed. If the Midline dressing is not changed as ordered there is a potential for infection. We need to check the site when doing the dressing changes, look at the skin condition during dressing changes make sure there is not any redness. Policy: Titled Intravenous Therapy revised 08/16/24 document in part: it is the facility's policy to ensure that intravenous policy and procedure are compliant to federal standard of care. Procedures: b. All midline catheter dressing are to be done every 7 days while following the procedure for dressing change of central lines. vii. The outside of the dressing will then be labeled with dressing change date and time.

Based on observation, interview and record review the facility failed to ensure food items in a residents personal refrigerator was labeled and dated for one resident (R143) reviewed in a total sample of 35 residents. Findings include: R143 has diagnosis not limited to Essential (Primary) Hypertension, Spastic Hemiplegia Affecting Right Dominant Side, Hyperlipidemia, Type 2 Diabetes Mellitus with other Diabetic Neurological Complication and Aphasia Following Cerebral Infarction. R143's Care plan document in part: R143 has a diagnosis of Type 2 Diabetes Mellitus. Interventions: Monitor compliance with diet and document any problems. On [DATE] at 12:03 PM surveyor entered R143 room and asked it was okay to check his refrigerator. R143 responded, yes. Two undated sandwiches and 2 undated chocolate chip cookies wrapped in clear plastic wrap were observed in R143's refrigerator. On [DATE] at 12:07 PM surveyor asked V15 (Licensed Practical Nurse) who is responsible for checking the resident refrigerators and discarding undated and expired items. V15 responded, any nurse can check the resident's refrigerator. Things in the resident refrigerator should be dated and if it is not dated, we discard it. On [DATE] at 12:10 PM surveyor entered R143 room with V15 (Licensed Practical Nurse) and asked to check R143's refrigerator. V15 opened R143's refrigerator and when asked what she observe in the refrigerator V15 responded, two cheese and turkey sandwiches and 2 chocolate chip cookies, both do not have a date on them. On [DATE] at 11:53 AM V2 (Director of Nursing) stated the checking of the resident refrigerators is done by housekeeping. If there is something unlabeled in the resident's refrigerator the nurses are made aware and social service talk to the resident. The food items in the resident refrigerators should be dated. If there is a sandwich in the resident refrigerator that is unlabeled, we offer another sandwich and we need to educate the resident.

Based on observation, interview, and record review, the facility failed to ensure a functioning call light system for one (R14) resident in a total sample of 35 residents reviewed. Findings include: On 09/17/2024 at 11:50AM, surveyor located inside of R14's room. R14 asks surveyor to assist her with finding her television remote control referring to it as the clicker. R14 states she wants her remote control so that she can change the channel on her television. Surveyor informs R14 that she should press her call light for staff assistance with her remote control. R14 then picks up her call light pad and continuously press her call light pad while stating that she has been pressing it for a long time already and no one has come to her room to assist her. Surveyor observes that when R14 presses her call light several times, the call light does not illuminate above R14's room door and no audible sound is heard. Surveyor observes that R14's call light is plugged into the wall. On 09/17/2024 at 11:53AM, surveyor makes V3 (Licensed Practical Nurse/LPN) aware of R14's call light status. V3 states she is the nurse responsible for caring for R14 today. V3 now located inside of R14's room and return demonstrates the use of R14's call light. V3 is observed pressing R14's call light pad and states she does not see a light illuminated above R14's door and does not hear an audible call light sound. V3 observes R14's call light and confirms that R14's call light is plugged into the wall. V3 states R14's call light should illuminate above R14's room and a call light sound should be audible. V3 states staff would not be able to respond to R14's call light to assist with her needs because R14's call light is currently not working. V3 states she needs to call maintenance and make them aware that R14's call light is not working. On 09/17/2024 at 12:04PM, surveyor makes V4 (Certified Nursing Assistant/CNA) aware of R14's call light status. V4 states she is the CNA responsible for caring for R14 today. V4 located inside of R14's room and return demonstrates the use of R14's call light. V4 is observed pressing R14's call light pad and states she does not see a light illuminated above R14's door and does not hear an audible call light sound. V4 observes R14's call light and confirms that R14's call light is plugged into the wall. V4 states staff would not be able to respond to R14's call light to assist with her needs because R14's call light is currently not working. R14's call light assessment dated [DATE] documents that V32 (Restorative Nurse/LPN) documented that R14 is not able to cognitively use her call light. On 09/19/2024 at 10:59AM, V32 (Restorative Nurse/LPN) states she performs call light assessments by going into resident rooms and asking them to return demonstrate the use of their call light button by having them press their call light button. V32 states if a resident is not able to use the call light button, she assesses them for the call light touch pad instead. V32 states R14 uses the call light touch pad to call for staff assistance. Surveyor makes V32 aware of R14's call light assessment dated [DATE]. V32 observes R14's call light assessment and states she must have made a mistake when documenting R14's call light assessment because R14 is able to use her call light although R14 can be cognitively confused at times. R14's care plan dated 07/05/2024 documents that R14 has an ADL self-care performance deficit and documents CALL LIGHT Encourage R14 to use call light to call for assistance. May use touch pad. Facility policy dated 07/26/2024, titled The facility also ensures that the call system is in proper working order. 3. Nursing staff shall check all call lights daily and report any defective call lights to the administrator/maintenance immediately for repair. 6. Be sure that when the call light is triggered, it will either alert the staff visually or audibly or both.

Based on interview and record review, the facility failed to provide services in compliance with applicable federal, state, and local laws, regulations, and codes, and with accepted professional standards and principles by not scheduling service plan meetings for the [NAME] Consent Decree Program in an effort to transition residents back into the community. This failure has the potential to affect 28 residents residing in the facility. Finding include: On 05/18/2024 at 11:48AM, V7 (Social Services Director/SSD) states she has been the SSD at the facility since February 2023. V7 states she is one of the people responsible for helping with the [NAME] Program. V7 states upon admission, the facility provides the resident with the [NAME] Program fact sheet. V7 states it usually takes 60 days for a [NAME] representative to come to the facility and assess the resident to be transitioned back into the community. V7 states there has been a lot of issues getting case managers from the [NAME] Program assigned to the residents. V7 states she has reached out to representatives of the [NAME] Program to inquire about the status of residents being assessed to be transitioned back into the community. V7 states when she would make this inquiry, V7 would be informed by someone from the [NAME] Program that they are still waiting to assign residents to a case manager. V7 states the [NAME] Program was taking too long to assist residents with transitioning into the community. V7 states because of this, the facility has been contacting the case manager of the resident's insurance company to try and help assist residents with transitioning back into the community. V7 states the [NAME] program has recently reached out to the facility and visited the facility on 04/25/2024 to visit and have a service plan meeting with a resident and help them transition to the community. V7 states she communicates with the [NAME] Program via phone and email but may not be included on all email correspondences with [NAME] Program representatives. V7 states she never denied the [NAME] Program from seeing the residents and they were always able to visit the residents in the facility. V7 states she did explain to the [NAME] Program representatives that certain residents are not good candidates. All email correspondences to/from [NAME] representatives from 03/14/2024 to 05/18/2024 was requested from V7 (SSD). V7 states she will send the requested emails to V3 (Assistant Administrator). On 05/18/2024, V3 (Assistant Administrator) states the facility does not have a policy for the [NAME] Program and provides surveyor with a document undated, titled Department of Human Services, Help is Here. On 05/18/2024, email correspondences to/from [NAME] representatives from 03/14/2024 to 05/18/2024 was provided to surveyor by V3. Email written by V6 ([NAME] Representative) dated 03/15/2024 at 10:36PM, addressed to V7 (SSD) and V9 (Social Services) documents V6 addressing concerns pertaining to how residents at the facility are assessed by the [NAME] Program. Email written by V8 ([NAME] Care Manager) dated 04/16/2024 at 2:41PM, addressed to V7 (SSD) documents a request by V8 to schedule care plan meetings for Colber Class Members at the facility. There is no email correspondence/documentation to show that V7 (SSD) responded to V8's email and requests. Email written by V6 ([NAME] Representative) dated 05/05/2024 at 10:05PM, addressed to V7 (SSD) and V9 (Social Services) documents V6 addressing concerns with not receiving a response from the facility and difficulty with scheduling care plan meetings. Email written by V7 (SSD) dated 05/06/2024 at 11:34AM, addressed to V9 (Social Services) and V6 ([NAME] Representative) documents in part, Now with caseworkers assigned it appears that ([NAME] Program) is trying to rectify this by having care plan meetings arranged quickly. Again, we're unable to facilitate these meetings for ([NAME] Program). Email written by V6 ([NAME] Representative) dated 05/06/2024 at 6:46PM, addressed to V7 (SSD) and V9 (Social Services) documents in part, We are going to continue to need to move forward with care plan meetings for these individuals. Email written by V7 (SSD) dated 05/07/2024 at 7:01AM, addressed to V9 (Social Services) and V6 ([NAME] Representative) documents in part, Again, ([NAME] Program) requires those meetings for those who are not appropriate. We do not. We have our own requirements Facility document undated, titled Department of Human Services, Help is Here documents in part, a Care Manager makes a Service Plan to identify the Class Member's needs, wants, and goals, and the services and supports they will need. The Care Manager works with the facility staff and other providers to do the activities in the Service Plan and move the Class Member into the community. Facility document undated, titled, DHS Comprehensive Class Member Transition Program: Consent Decree Fact Sheet documents in part, Referrals: Each nursing home or SMHRF works with one [NAME]/[NAME] agency. Assessment: Assessments are done by specially trained staff in the [NAME]/[NAME] program. These staff know about people with special and complex needs and how to identify what that person might need to live in the community. They look at the person's needs, strengths, abilities and preferences, and whether the person can safely and successfully move to the community. Class Members who are not recommended to move to the community are told the reasons why. They are given goals to work on for 6 months. List provided by facility documents that a total of 28 residents currently participates in the [NAME] Program.

Based on interview and record review the facility failed assert the right of the resident by failing to ensure a resident's personal belongings were inventoried upon readmission to the facility. This failure affects one (R1) resident out of three residents reviewed for resident rights. Findings include: R1's Facesheet documents that R1 was admitted to the facility on [DATE] and readmitted to the facility from the hospital on [DATE]. R1 was discharged from the facility on [DATE], R1 expired on [DATE]. On [DATE] at 1:40PM, V12 (Activities Director) states she has been working at the facility since [DATE]. V12 states when a resident is admitted to the facility, their belongings are inventoried and documented in their electronic health record. V12 states all residents who are admitted to the facility should have a resident inventory form placed in their electronic health record. V12 states not one person is responsible for handling the resident's belongings when they are admitted . V12 states she has seen staff such as nurses, housekeepers, receptionists, social services, CNAs, and administration bring resident belongings to the activity department in the basement to be inventoried. V12 states she has never personally performed an inventory of resident's belongings and have three other staff members who are responsible for resident inventories. V12 states the activities department work in collaboration with social services to perform the inventories for resident belongings. V12 states the activities department does not usually inventory resident valuable belongings and mainly inventory items such as hearing aids, eyeglasses, clothing, and shoes. V12 states the activities department mainly focuses on labeling the resident clothing to help prevent lost clothing items. On [DATE] at 2:01PM, V13 (Social Services/Dementia Coordinator) states she has been working at the facility for 5 years. V13 states when a resident is admitted to the facility, the activities department goes to the resident's room to retrieve the resident belongings to be inventoried. V13 states resident belongings are also taken down to the activities department in the basement. V13 states the activities department is responsible for inventorying all resident belongings such as phones, wallets, and jewelry. V13 states if the activities department discovers an item that is considered valuable or if a resident chooses, the items are placed in the facility safe that is kept in the social services office located in the basement. V13 states when a resident is admitted to the facility, they should have their belongings inventoried and documented in their electronic health record; V13 states since she has been working at the facility, this has been the process. V13 states the social services department will then place the valuable item in the safe. V13 states the social services department, maintenance department, and V1 (administrator) all have the code to the safe where resident belongings are kept. V13 states all residents should have an inventory list even if they do not have any belongings. V13 states it should be documented in the resident's electronic medical record that the resident does not have any belongings. V13 states she is aware that R1 had some clothing items and a ring that was inventoried when R1 was admitted to the facility. V13 states she remembers seeing R1 wearing a gold ring on her left ring finger and believe it was R1's wedding ring. V13 states she was made aware of R1's missing ring when R1's daughter called the facility after R1 expired and inquired about the whereabouts of R1's ring. V13 states R1 was hospitalized prior to R1 expiring and V13 believes R1 went to the hospital with the ring on. V13 states the facility filled out a concern form and performed a search for R1's missing ring and did not find it. V13 states she also interviewed the nurse and CNA and asked if they recalled seeing R1's ring when R1 returned from the hospital and they said no. V13 describes R1's ring as a gold ring with diamonds. V13 states she has seen R1 with the ring on her finger before. V13 states she informed V1 (Administrator) and V1 stated he would call R1's daughter. V13 states if the facility receives a report of a resident missing their belongings and the item is not inventoried, then the facility performs a search for the item. V13 states she believes the item is reimbursed if it is not found. V13 states she believes V1 is the person responsible for reimbursing the residents for lost items. On [DATE] at 10:03AM, V1 (Administrator) states he was made aware six weeks ago about R1's missing ring.V1 states the facility called the hospital to see if R1's ring was located there but the hospital stated R1's ring was not inside the hospital. V1 states R1's ring is invaluable and irreplaceable and is not sure how to continue with handling the process regarding R1's lost ring as it relates to legal issues. V1 states he called R1's daughter and she informed V1 that she was getting a lawyer. V1 states R1 had a legal guardian who is not R1's daughter. Social Services progress note written by V13 on [DATE] at 11:32AM documents Writer emailed R1's Guardian and attorney on this date d/t R1 leaving behind a wallet in SS safe. Attorney responded Any belongings of R1's can be given to R1's daughter. Writer will call R1's daughter regarding belongings. Social Services progress note written by V13 on [DATE] at 3:27PM documents R1's daughter called writer regarding a gold ring and a necklace with a Jewish [NAME] pendant. Writer recalls R1 wearing a ring before recent hospitalization s. Writer checked inventory and only a gold ring w/6 diamonds was inventoried. R1's daughter called local hospital and no ring in the lost and found. Writer and housekeeper cleaned R1's room and did not find a ring. Spoke with NOD and said they may have removed ring in hospital d/t swelling. Concern form completed and will continue to look out for a gold ring/necklace. No other concerns; R1's daughter expressed appreciation. Guardian and attorney also informed of missing jewelry and expressed appreciation for the update. Concern logs reviewed; concern form dated [DATE] documents a concern related to R1's missing ring and necklace. R1's resident inventory lists during R1's entire time of residing in the facility were requested from V3 (Assistant Administrator). Two resident inventory lists were provided to surveyor by V3 and were dated [DATE] and [DATE]. R1's resident inventory dated [DATE] documents a gold ring with six diamonds was inventoried in the facility. There is no documentation to show that R1's belongings were inventoried upon R1 being readmitted from the hospital to the facility on [DATE]. Ombudsman Program Residents' Rights for People in Long Term Care Facilities dated ,d+[DATE] documents in part, Your facility must try to keep your property from being lost or stolen. Facility policy dated [DATE] titled Personal Belongings List documents in part, Policy statement- It is the policy of the facility to protect the resident's belongings from being misplaced and from theft. In order to prevent this, the facility will ensure that resident's belongings are tracked accurately. Procedures- 1. Upon admission or readmission , the CNA will list all of the resident's belongings in the Resident Inventory UDA. 4. When a resident or family reports that a personal item is missing, the Resident's Resident Inventory UDA will be checked to rule out false claims.

Based on observation, interview, and record review, the facility failed to ensure staff providing care and services to a resident who has a feeding tube is competent in and utilize facility protocols regarding feeding tube nutrition and care. This failure affects one (R2) resident receiving enteral nutrition feedings out of three residents reviewed. Findings include: On 03/16/2024 at 11:13AM, surveyor enters R2's room and observes V10 (Wound Care Technician) providing care for R2. R2's enteral feeding pump observed off while V10 is providing care to R2. V10 states R2 does not have any wounds but V10 is applying bandages and cushioning to R2's legs to prevent pressure ulcers. Surveyor observes R2's right leg contracted and folded over R2's left leg. V10 observed placing padding and bandages in between where R2's right leg comes in contact with R2's left leg. V10 observed completing applying bandages and is observed putting R2's head of bed at 90 degrees. V10 observed turning R2's enteral feeding pump on. V10 states he is not a nurse. V10 states he is the person who turned R2's enteral feeding pump off prior to providing care for R2. V10 states he also turned R2's enteral feeding pump back on because he knows that R2 has certain times when R2's enteral feeding should be turned off and on. V10 states he is not certain of the exact times when R2's feeding should be turned on or off and he would have to check with the nurse. Surveyor asks V10 if he is authorized to operate R2's enteral feeding pump. V10 states he does not think that he is authorized to operate R2's enteral feeding pump. Surveyor asks V10 why did he operate R2's enteral feeding pump if he is not certain of the correct times when R2's enteral feeding should be turned on or off. V10 states he is not sure why he operated R2's enteral feeding pump because usually V10 would call the nurse to turn R2's enteral feeding back on. On 03/16/2024 at 11:21AM, V11 (Wound Care Nurse/RN) enters R2's room. Surveyor makes V11 aware of V10 operating R2's enteral feeding pump. V11 states she does not think that V10 is authorized to operate R2's enteral feeding pump. V11 states the nurses are authorized to operate resident's enteral feeding pumps. On 03/16/2024 at 11:53AM, V2 (Director of Nursing/DON) states V10 is not authorized to operate resident's enteral feeding pumps and V10 should have asked the nurse to operate R2's enteral feeding pump instead. R2's Physician Order Sheet/POS dated 03/05/2024 documents in part the following order: Enteral feed: every shift Enteral feeding- Tube type: G-tube, Glucerna 1.5, Rate: 60ml/hr (milliliters/hour), start at 6am and infuse until 1200 ml is reached per day. Turn off for ADLs (activities of daily living) and PRN (as needed). May give Glucerna 1.2 @ 75 ml/hr x20 hrs (1500 ml formula total) if Glucerna 1.5 unavailable. AND one time a day every Tuesday, Thursday, Saturday Turn tube feeding OFF at 9am. AND one time a day every Tuesday, Thursday, Saturday Turn tube feeding ON at 11am. AND one time a day every Monday, Wednesday, Friday, Sunday Turn tube feeding OFF at 11am. AND one time a day every Monday, Wednesday, Friday, Sunday Turn tube feeding ON at 1pm. AND one time a day Turn tube feeding OFF at 4pm. AND one time a day Turn tube feeding ON at 6pm. AND every night shift Total Volume Infused within 24 hrs: 1200 ml (Tube feeding expected to end during 11pm-7am shift) Facility policy dated 01/14/2017 titled Enteral Nutrition Care documents in part, Procedures- 4. Nurse shall identify proper French size, balloon volume, monitor and check that feeding tubes is in the right location in order to verify proper placement; 5. Before beginning of a feeding and before administering medications. 10. Nurse shall perform proper calibration of enteral feeding pumps to ensure that pump settings accurately provide the rate and volume consistent with the physician's order and plan of care.

Based on observation, interview, and record review the facility staff failed to document on the individual residents controlled drug administration record for 5 residents (R124, R167, R75, R67 and R159). This failure has the potential to affect all 172 residents in the facility. Findings include: On 10/17/2023 at 2:27PM surveyor with V22(LPN/Licensed Practical Nurse) reviewed the two north medication cart Controlled Drug Administration Records for the following residents R159, R75 and R67(these forms are used by the facility for accountability of controlled substances after the controlled substance medication is administered to the individual resident). The controlled drug administration records were not signed after the administration of the controlled substance to the resident. On 10/17/2023 at 2:28PM R159's MAR(medication administration record) documents R159 was administered one tablet of Hydrocodone-Acetaminophen Oral tablet 5-325mg(milligrams)- Give 1 tablet by mouth every 6 hours as needed on 10/17/2023 at 12:14. Upon review of R159's controlled drug administration record the tablet had not been documented as administered to R159 on 10/17/2023 at 12:14, which made the amount of tablets remaining in the bingo card not match the number of tablets documented on the controlled drug administration record. R159's diagnosis include but are not limited to Metabolic Encephalopathy, Major Depressive Disorder, Recurrent, Moderate, Generalized Anxiety Disorder, Primary Insomnia, Unspecified Severe Protein-Calorie Malnutrition, Unspecified Abdominal Pain, Anemia, Unspecified, Thrombocytopenia, Unspecified, Elevation Of Levels Of Liver Transaminase Levels, Myalgia, Unspecified Site, Calculus Of Gallbladder Without Cholecystitis Without Obstruction, Alcoholic Liver Disease, Unspecified, Alcohol Abuse, Uncomplicated, Alcohol Use, Unspecified With Withdrawal Delirium, Other Pulmonary Embolism Without Acute Cor Pulmonale, Iron Deficiency Anemia, Unspecified, Alcohol Abuse, In Remission, Alcoholic Hepatitis Without Ascites, Cholecystitis, Unspecified, Localized Edema. R159's MDS section C dated 07/06/2023 documents a BIMS of 15, which indicates R159 is cognitively intact. On 10/17/2023 at 2:30PM R75's MAR (medication administration record) documents R75 was administered one tablet of Hydrocodone-Acetaminophen Oral tablet 5-325mg(milligrams)- Give 1 tablet by mouth every 8 hours on 10/17/2023 at 1400. Upon review of R75's-controlled drug administration records the tablet had not been documented as administered to R75 on 10/17/2023 at 1400, which made the number of tablets remaining in the bingo card does not match the number of tablets documented on the controlled drug administration record. R75's diagnosis include but are not limited to Spondylosis Without Myelopathy Or Radiculopathy, Cervical Region, Urinary Tract Infection, Site Not Specified , Unspecified Severe Protein-Calorie Malnutrition, Adult Failure To Thrive, Neuromuscular Dysfunction Of Bladder, Unspecified, Pressure Ulcer Of Sacral Region, Stage 4 , Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Alzheimer's Disease, Unspecified, Unspecified Fall, Subsequent Encounter, Spinal Stenosis, Cervical Region, Unspecified Atrial Fibrillation, Heart Failure, Unspecified, Anemia, Unspecified, Thrombocytosis, Unspecified, Age-Related Osteoporosis Without Current Pathological Fracture, Hypotension, Unspecified, Other Cervical Disc Degeneration, Unspecified Cervical Region. R75's MDS section C dated 7/20/2023 documents a BIMS score of 03, which indicates R75's cognition is severely impaired. On 10/17/2023 at 2:32PM R67's MAR (medication administration record) documents R67 was administered one capsule of Floricet Oral Capsule 50-300-40 mg(milligrams)- Give 1 tablet by mouth every 4 hours as needed on 10/17/2023 at 1302. Upon review of R67's-controlled drug administration records the capsule had not been documented as administered to R67 on 10/17/2023 at 1302, which made the number of capsules remaining in the bingo card not match the number of capsules documented on the controlled drug administration record. R67's diagnosis include but are not limited to Fibromyalgia, Muscle Wasting And Atrophy, Not Elsewhere Classified, Other Site, Difficulty In Walking, Not Elsewhere Classified, Other Lack Of Coordination, History Of Falling, Unspecified Asthma, Uncomplicated, Hypothyroidism, Unspecified, Other Specified Disorders Of Urethra, Hyperlipidemia, Unspecified, Gastro-Esophageal Reflux Disease Without Esophagitis, Obesity, Unspecified, Major Depressive Disorder, Recurrent, Unspecified, Anxiety Disorder, Unspecified, Insomnia, Unspecified, Calculus Of Kidney, Suicidal Ideations, Nonrheumatic Mitral (Valve) Prolapse, Vitamin D Deficiency, Unspecified, Chronic Migraine Without Aura, Not Intractable, Without Status Migrainosus, Interstitial Cystitis (Chronic) Without Hematuria, Irritable Bowel Syndrome Without Diarrhea, Personal History Of Other Diseases Of The Digestive System. R67's MDS section C dated 9/28/2023 documents R67 has a BIMS score of 15, which indicates R67 is cognitively intact. On 10/17/2023 at 2:27PM V22(LPN/Licensed Practical Nurse) stated I just gave the residents their medications. V22 stated I am supposed to sign out the medication on the individual residents-controlled drug administration record immediately after I administer the medication to the resident. On 10/18/2023 at 12:52 PM V29(ADON/Assistant Director of Nursing) stated the nurse on duty is responsible for completing the controlled drug administration record. V29 stated the purpose of the nurse completing the controlled drug administration record is to track the total number of each controlled substance remaining in the bingo card. V29 stated if the nurse discovers the count documented on the controlled drug administration record does not match the number of tablets or capsules in the bingo card, the nurse is to call the director of nursing or the assistant director of nursing so that we can investigate why the count is off. On 10/18/2023 reviewed the facility's policy (revision date of 07/27/2023) titled Controlled Medications Count which documents, in part, Policy Statement: It is the policy of the facility to maintain an accurate count of Scheduled II (2) controlled medications. Procedure 1. After removing the controlled medication from the bingo card or individual packet, the nurse will sign off the accompanying controlled medication sheet indicating the medication was taken. On 10/18/2023 reviewed the facility's job description for RN (Registered Nurse) Floor Nurse dated 12/01/2019 which documents, in part, underneath Essential Functions 5. Administer medications within the scope of practice of the RN (Registered Nurse) Licensure Maintain a current report of narcotics received and used. 6. Review daily the documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory. 43351 On 10/17/2023 at 11:39am, during the controlled medication storage task observation with V18 (Licensed Practice Nurse) of the medication cart labeled 1 South back, there was one pill left on R167's Oxycodone dispensing card and R167's Controlled Drug Administration Record Tablet for Oxycodone IR 10mg indicated 2 tablets left on the dispensing card; and there were 23 pills left on R124's Briviact 50mg dispensing card and R124's Controlled Drug Administration Record tablet for Briviact 50mg indicated there were 24 tablets left on the dispensing card. V18 stated I (V18) signed in the PCC (EHR -electronic health record) but I (V18) forgot to sign in their (R167 and R124) controlled sheets that I (V18) dispensed their (R167 and R124) medications. On 10/18/2023 at 9:53am, V3 (Director of Nursing) stated the expectation is to initial the resident's controlled sheet after the staff dispensed the controlled medication to ensure controlled medications are accounted for. R124's (Active Order As Of: 10/18/2023) Order Summary Report documented, in part Briviact Oral Tablet 50mg Active 07/06/2023. R124's (Schedule Date: 10/17/2023 - 10/17/2023) Medication Admin (Administration) Audit Report documented, in part Briviact Oral tablet 50MG. Administration time: 10/17/2023 08:17 (am). R167's (Active Order As Of: 10/18/2023) Order Summary Report documented, in part Oxycodone HCl Oral tablet 10MG Active 08/29/2023. R167's (Schedule Date: 10/17/2023 - 10/17/2023) Medication Admin (Administration) Audit Report documented, in part Oxycodone HCl oral tablet 10MG. Administration Time: 10/17/2023 09:19(am). The (undated) Controlled Substance Storage documented, in part Policy. The medications included in the drug enforcement administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and recordkeeping in the facility in accordance with federal, state, and other applicable laws and regulations. Procedures. 4. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance: e) quantity received. The (05/05/15) Registered Nurse Job Description documented, in part Summary/Objective. In keeping with our organization's goal of improving the lives of the Guests we serve, the Registered Nurse (R.N.) plays a critical role in providing superior customer service and nursing care to all Guests and guests. The R.N. provides supervision of staff and will safeguard the health, safety and welfare of all Guests/guests under their care by following applicable laws, regulations and established nursing policies and procedures. Essential Functions. Reasonable accommodations may be made to enable individual with disabilities to perform the essential functions. 5. Administer medications within the scope of practice of the R.N. Licensure. Maintain a current report of narcotics received and used. 6. Review daily documentation of the dispensing of the controlled substances and narcotics. Ensure that drugs covered by controlled substances laws are verified by inventory.

Based on observation, interview, and record review, the facility failed to remove a faulty power cord resulting in a series of orange-red sparks accompanied by puffs of smoke and a series popping noises. This deficient practice has the potential to affect one of two residents (R3) reviewed for faulty power cords and could affect all residents in the entire building, as well as an indeterminable number of staff and visitors. The Immediate Jeopardy began on 9.4.2023. V1 (Administrator) was notified on 9.19.2023 at 2:14 PM of the Immediate Jeopardy. The facility presented the removal plan on 9.19.2023 at 3:14 PM. The plan was accepted on 9.20.2023 at 8:29 AM. The surveyor conducted onsite observations, interviews, and record reviews to confirm the removal plan was implemented. V1 (Administrator) was informed on 9.20.2023 that the Immediate Jeopardy was removed. Although the immediacy was removed, the facility remains out of compliance at severity level II until the facility can evaluate the effectiveness of the removal plan and maintain substantial compliance with this regulation. Findings include: R3's Face Sheet documents R3 is a [AGE] year-old admitted to the facility on 5.11.2022 with diagnoses including but not limited to: Chronic Atrial Fibrillation, Type 2 Diabetes Mellitus, Dysphagia, and Pressure Ulcer of Sacral Region, Stage 4. R3's MDS (Minimum Data Set of 8.9.23) Section C (Cognitive Patterns) documents R3 is mildly cognitively impaired. Section G (Functional Status) documents R3 requires extensive assistance of two plus persons physical assist for bed mobility, is totally dependent with two plus persons physical assist for transfers and requires extensive assistance of one person for toilet use. Section M (Skin Conditions) documents R3 is at risk for developing pressure ulcers/injuries, was admitted with one unstageable pressure ulcer, and has a pressure relieving device for the bed. R3's Order Summary Report (Active Orders as of 9.21.2023) documents: Skin: Mattress: [Low Air Loss Mattress] due to very limited mobility and presence of pressure injury. On 9.14.2023 at 8:35 AM, V11 (Long Term Care Support Specialist) said R3's son (V5) provided her pictures, including one of a cord with exposed frayed wires. On 9.14.2023 at 11:00 AM, Surveyor and V3 (Maintenance Director) entered R3's room. Surveyor observed R3 awake, alert, and sitting up in on a low air loss mattress. The power cord to the mattress pump was plugged in electrical outlet on the wall behind R3's bed; the pump was in the on position. V3 crouched down, picked up the electrical cord and said to the Surveyor: look at this. The black power cord had a small slit (approximately 1/4 inch long) with frayed, exposed wires. As V3 was showing Surveyor the power a cord, several orangish-reddish sparks and puffs of white smoke were observed; several popping noises were heard. On 9.14.2023 at 11:15 AM, V1 (Administrator) and V2 (DON-Director of Nursing) were notified of the issue with power cord. On 9.14.2023 at 11:51 AM, V5 (R3's Family Member) said, regarding frayed, exposed wire of power cord, I took a picture on 9.4.23 at 11:44 AM. I reported it to her (R3's) nurse.'' On 9.14.2023 at 2:29 PM, V7 (LPN-Licensed Practical Nurse) said, after reviewing Daily Nursing Schedule for 9.4.2023, she was working 7:00 AM to 7:00PM on that day; was assigned to Team One and was the nurse responsible for R3's care on that day. I don't remember anything about the cord (frayed cord with exposed wires). It could be a problem, it's a short circuit, there could be a fire, it's hazardous. 9.14.2023 at 4:05 PM, V3 (Maintenance Director) said, I already changed the power cord. What we should have done, is inspect it (low air loss mattress power cord) when it was delivered (to the facility). So now we will inspect any equipment that we rent when it is delivered. We have a checklist now. On 9.15.2023 at 9:26 AM, V3 (Maintenance Director) said, I did not know about it (frayed cord with exposed wires) until you and I found it. If someone here knew about it, they should have reported it to me. V5 (Family Member) never told us about the exposed wires. It should be fixed because it's a hazard, you don't want anyone to die. V3 said, I do rounds in the morning. I ask the residents if everything is okay, then I check the logbook. Every day I go into every resident's rooms. Do I visually inspect every cord, no. I don't visually inspect every day, I ask the resident. I depend on the Nurses and CNAs to let me know if there is a problem. If I inspected every remote control, bed cord, it would take me six hours per day. V13 (Maintenance Assistant) changed the power cord around 11:15 AM yesterday. On 9.15.2023 at 8:14 AM, V5 (R3's Family Member) said, I showed her (V7-LPN) the cord; she was in the room with me and (R3). I informed V4 (Social Service Designee) on Tuesday September 12, 2023, at 10:55 AM when she called me. 9.15.2023 at 12:35 PM, V4 (Social Service Designee) said, I was not informed about the exposed wires. R5 did not mentioned any exposed wires when I spoke with him. I would have mentioned the exposed wires to the Administrator and Maintenance. On 9.19.2023 at 11:51 AM, V5 emailed pictures of cord for R3's low air loss mattress pump. The black outer sheath was frayed with exposed wires. On 9.19.2023 at 12:45 PM, V5 (R3's Family Member) said, I found the frayed power cord when I was looking for the bed control (R3's) bed. It always seems to be missing. So, that's the first thing I do when I come to visit her, I look for the bed control. I saw the exposed wires when I was looking for her bed control. Facility's Maintenance policy (Revised 7.28.2023) documents, It is the facility's policy to maintain equipment and the building environment. All resident care equipment and the building environment will be maintained by the maintenance department. Any staff who is made aware of a malfunctioning equipment or any part of the building that is in disrepair will report the issue to the maintenance department. The maintenance department will address the issue as soon as possible. Any equipment that cannot be fixed will be replaced accordingly. On 9.15.2023, V12 (Vice President of Marketing and Sales Durable Medical Equipment Company) emailed Surveyor LS900 True Low Air Loss Operating Instructions Manual (undated) which documents, Care should be taken such that the power cord of the control unit is not pinched or any objects placed on the power cord, and also ensure it is not located where it can be stepped on or tripped over. United States Department of Labor - (OSHA) Occupational Safety and Health Administration webpage discussing Electrical - Hazards/Flexible Cords, reads: A flexible cord may be damaged by door or window edges, by staples and fastenings, by abrasion from adjacent materials, or simply by aging. If the electrical conductors become exposed, there is a danger of shocks, burns, or fire. Abatement Plan Accepted on 9.20.2023. These are the steps that (Facility) took to remove the immediacy from the alleged deficient practice: -On 9/14/23, low air loss mattress pump identified by (V3 Maintenance Director) as being frayed with exposed wires was immediately removed from resident (R3). -On 9/19/23, Facility staff of (V3 Maintenance Director), (V1 Administrator), (V2 Director of Nursing), and (V17 Assistant Administrator) conducted facility wide search for air mattresses to ensure cords attached to the pump are intact with no deficiencies (ex. no cuts, frayed wires, exposed wires). No other issues were noted during this audit -On 9/17/23, Administrator in-serviced Maintenance staff Preventative Maintenance Policy. This was completed on 9/19/23. -On 9/14/23, Maintenance Director and Assistant Administrator initiated facility-wide in-service on recognizing damaged cords, reporting them and removing power source in order replace with a properly working unit. The facility will ensure that new hires, staff on leave, and agency staff will be in-serviced prior to their shift regarding this topic. Completion date 9/22/23. -QA tool titled F689 QA Tool was initiated on 9/19/23. This audit tool will be utilized to monitor air mattresses and ensure they are intact. This will be carried out by the Maintenance Director or Maintenance Assistant daily for 4 weeks until 10/17/23, followed by twice a week for 4 weeks until 10/30/23.

Based upon observation, interview and record review the facility failed to follow the abuse/neglect policy and failed to ensure that two of four residents (R3, R4) reviewed for abuse remained free from abuse. These failures have the potential to affect 45 (2 South) residents. On (2/21/23) R3 pushed R2 into R4 causing both residents (R2, R4) to fall, R4 sustained dizziness and head/neck/right shoulder pain rated 3 out of 10. Findings include: The (3/14/23) census includes 45 (2 South) residents. The (2 South) memory care unit is locked to prevent elopement. R3's diagnoses include dementia with agitation and other conduct disorders. R3's (12/28/23) BIMS (Brief Interview Mental Status) affirms resident was unable to complete the interview. R3's cognitive skills for daily decision making: moderately impaired. R3's care plan includes (12/23/22) presence of abuse factors: resident presents with behavioral symptoms. Wandering: resident going into and out of other resident's rooms. Resident demonstrates cognitive impairment related to dementia with agitation. (3/8/23) Behaviors: resident has been noted with taking items off nursing cart and throwing at wall/staff. Resident will at times make verbal threats to harm staff when attempting to redirect/de-escalate. Intervention: Psychiatric consult as indicated. Progress notes affirm (R3) was sent to the hospital for aggressive behaviors on 2/21, 3/7, 3/9, 3/10, and 3/11 (2023). However R3's last psychiatric consult was documented 1/25/23. R3's (2/21/23) progress notes state resident being aggressive towards another resident and pushed resident to the floor. The (2/21/23) initial abuse report includes name of alleged victims (R2) and (R4). Alleged perpetrator (R3). Writer was informed (2/21/23) by Nurse that (R3) made contact with (R2) who lost her balance and bumped into (R4). (R4) was sent to hospital for evaluation due to fall. The (3/14/23) census affirms R2, R3 and R4 reside on 2 South. On 3/14/23 at 3:32pm, surveyor inquired about R3's behaviors. V13 (Certified Nursing Assistant) stated, She (R3)doesn't want anyone to come in her (R3) room but she (R3) go into other rooms and take everything. R3 was subsequently observed by surveyor entering (3) other resident rooms and closing the doors however no redirection was provided. Surveyor inquired if R3 is aggressive. V13 responded, She (R3) was fighting with another resident and throw them on the floor. Surveyor inquired which resident R3 was fighting with. V13 replied, (R2). Surveyor inquired why R3 was entering R2's room (which was adjacent to R3's room) at this time. V13 stated, That's a problem. [R2 was in the room when R3 entered]. On 3/14/23 at 3:55pm, R3 was observed entering R2's room again (uninvited). Surveyor stated, V13 just reported to surveyor that R3 was recently thrown on the floor by R2 and inquired why R2 and R3 reside next door to each other. V18 (Agency Nurse) responded, It shouldn't be happening obviously there needs to be a separation. R3 subsequently exited R2's room entered room [ROOM NUMBER] and then room [ROOM NUMBER] (uninvited). V18 stated, She's (R3) going back and forth, I'll try and keep her (R3) separated from the others. V18 verbally redirected R3 to go back to her room. Surveyor observed, R3 become verbally aggressive towards V18 entered her room then slammed the door shut. R3 immediately opened the door and entered the hallway. V18 stated, She's got agitation, so I'll talk to the doctor about it. On 3/20/23 at approximately 4:00pm, surveyor requested a recent psychiatric consult for R3 V2 (Director of Nursing) affirmed the last psychiatric consult was documented 1/23/23 (roughly 2 months ago). R2's (2/2/23) BIMS affirms resident is rarely/never understood. On 3/14/23, at approximately 3:37pm, R2 was unable to communicate with surveyor due to cognitive status and communication barrier (Speaks Bosnian). On 3/14/23 at approximately 4pm, surveyor relayed concerns regarding R3 currently residing next door to R2 (post 2/21/23 abuse) and R3 entering R2's room uninvited. V2 (Director of Nursing) affirmed, R2 would be moved to 2 South today [3 weeks after the incident]. R4's (3/7/23) BIMS determined a score of 15 (cognitively intact). On 3/16/23 at 2:30pm, surveyor inquired about the (2/21/23) incident V19 (Staffing Coordinator) translated the conversation in Spanish. R4 stated she was walking and the next thing she knew her face, head and shoulder hit the floor. When she (R4) turned around there were 2 other people on the floor with her (R4). She (R4) doesn't know if she was pushed or what happened. R4 went to the hospital due to head and shoulder pain. R4's (2/21/23) pain assessment affirms resident verbalized pain rated 3 out of 10 (pain location is excluded). R4's (2/21/23) history & physical affirms patient states that she was bumped by another resident causing her to fall onto the floor. Patient states she did hit her head denies loss of consciousness but was complaining of dizziness at the time. Complaining of mild neck pain. Patient also complaining of right shoulder pain. On 3/15/23 at 10:02am, V3 (Assistant Director of Nursing) affirmed R4 was also involved in the (2/21/23) incident. Surveyor inquired why R4 still resides on 2 South (where R3 resides). V3 stated, We can move her to 2 North [3 weeks after the incident]. On 3/15/23 at 11:45am, surveyor inquired about the regulatory requirements for abuse. V1 (Administrator/Abuse Coordinator) stated, If there's a resident-to-resident abuse, we separate the residents. __ R3's (3/11/23) progress notes state resident going into other resident's room stealing items. Resident hurt writer's (V14/Agency Nurse) finger while swinging. Resident could not be redirected. Administered PRN (as needed) Ativan. Several hours later resident continues to curse and be abusive to staff and other residents. Resident hit resident when she went into resident's room to steal her blankets. On 3/20/23 at 1:46pm, surveyor inquired about R3's (3/11/23) incident. V20 (Agency Certified Nursing Assistant) stated, I just know that R3 is very very aggressive. She flips out a lot, she wanders in other people's room and takes things like pillows and bedding and put it in her room. When we try to get it back, she'll (R3) fight. She'll (R3) swing at staff, scream, yell, curse you out. We (staff) were trying to calm her down, when we were trying to take the linen out her room, she (R3) ended up hitting the Nurse's finger or something like that. It can get a little tough at times because she's (R3) very strong. Surveyor inquired which resident was hit (per 3/11/23 progress note) V20 responded, I don't know which resident it was. On 3/16/23 at 10:00am, V1 affirmed he was unaware of R3's (3/11/23) abuse and unsure which residents were abused. On 3/16/23 at 10:54am, surveyor inquired about the requirements for staff that incur and/or witness abuse. V2 (DON/Director of Nursing) stated, If they see abuse of course they need to report it. They need to separate the resident and assess both of them. The aggressive one needs to be monitored 1 to 1. On 3/21/23 at 10:24am, surveyor inquired about potential harm to residents if R3 pushed them (R2, R4) to the floor. V22 (Physician) stated, If she (R3) is pushing somebody, they (R2, R4) could potentially be harmed. They (R2, R4) can sustain bruises and soft tissue injury, or contusion, they could break a bone its possible anything can happen. Surveyor inquired about potential harm to other residents if R3 had 5 recent episodes of aggressive behavior and is not monitored 1:1 and/or victims (R2, R4) reside with R3. V22 responded, There's potential harm to the residents. I was not aware about that, nobody brought it to my attention. The abuse and neglect policy (reviewed 10/24/22) states in part: it is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse. If abuse is suspected the facility will: take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care.

Based upon interview and record review, the facility failed to implement the fall prevention interventions plan of care according to resident's assessment. This failure affected one resident(R2) of three residents reviewed for falls. As a result, R2 fell from the bed to the floor and sustained a blunt force injury to the neck. R2 was later pronounced dead after the paramedics arrived at the scene of the accident. Findings include: On [DATE] during this investigation, V2(Director of Nursing) presented the facility's incident investigation of R2's fall event and the Police Report Case number, with the written statement from V13(Agency CNA/Certified Nurse Assistant). The report states that R2 was DNR (Do Not Resuscitate) and was pronounced dead at 7:18pm. V13's statement states in part: On [DATE] around 6XXX,d+[DATE]:45pm, I went into the room to feed (R2). I got inside the room with his food tray and discovered he was covered in a lot of loose bowel movement which was diarrhea. I left the tray and went to get supplies to clean him first before I feed him. I got the bowl of warm water, soap and wash cloths. I started with his hands first because he had it all over his hands, and then continued to give him a full bath down the perineal area. I did the front first, and then turned him to clean the back, as soon as I turned him, it happened so fast, he fell over on the floor on the other side of the bed with his head and face down. I rushed over and called but he did not talk but had a pulse and was breathing. I ran out called the nurse and other staff for help. The nurse took his vitals, he was still breathing and had a pulse. We called the ambulance, and they came and took over. R2's records reviewed include but are not limited to the following: Fall Risk Evaluation dated [DATE] shows a score of 21(high risk for falls). MDS (Minimum Data Set) section G with target date [DATE] shows that R2 needs extensive assistance with two persons for bed mobility, transfer, personal hygiene and toilet use. MDS section C does not record any BIMS (Basic Interview for Mental Status) score for R2 due to history of Traumatic Brain Injury and Dementia. Care Plan dated [DATE] states that R2 is at high risk for falls related to medical diagnoses; Intervention states to make more frequent rounds and ensure that resident is properly positioned in bed to prevent resident from sliding. Another intervention dated [DATE] states to use wedge cushion to provide for positioning in bed to prevent R2 from sliding from bed. Care plan dated [DATE] states that R2 has an ADL (Activities of Daily Living) self-care performance deficit related to medical diagnoses; Intervention states that R2 requires extensive two staff participation to reposition and turn in bed. POS (Physician Order Sheet) dated [DATE] states: admitted to Hospice with Late Effect CVA (Cerebrovascular Accident). Progress notes dated [DATE] at 6:45pm written by V3(RN/Registered Nurse) states: Writer was alerted by assigned CNA. Resident was observed on the floor inside the resident's room in left side lying position. Immediately assessed resident together with another nurse. Neuro-check initiated. Resident not responsive to verbal and tactile stimulation. Resident is DNR (Do Not Resuscitate). Observed with eyes and mouth open. Head to toe assessment done. No bump, no open skin alteration noted on the head. No skin discoloration observed. Vital signs taken and noted to be, BP ,d+[DATE] P 18 R 18 T 97.5. Unable to read Sp02(oxygen saturation) using a pulse oximeter. Writer asked what happened, per assigned CNA, she was giving the resident a bed bath when he slid off the bed. On [DATE] at 1:35pm, V2 was interviewed regarding the fall event. V2 stated It happened during dinner tray pass on a Friday evening, close to change of shift. The CNA was from the agency and was supposed to ask for assistance to care for (R2). V3(RN/Registered Nurse) was the nurse. The night nurse(V4/RN) that came in at 7pm no longer works here but I will give you the phone number for all of them. V2 added, This CNA has been here several times and she knows the rules about getting assistance before transfer or bed bath, for residents that require 2 persons assist. We orientate every agency CNA about each resident that they will care for. At this time, V2 proceeded to show the surveyor letter H that stands for mechanical lift transfer/2 persons assist, and the star sign that stands for fall risk, written by R2's name post that was at the door. On [DATE] at 12:35pm, V3(RN) was interviewed. V3 stated It was during dinner tray pass; I was called to the room, and I saw (R2) on the floor. We called 911 and assessed and took the vital signs. The paramedics came within about 5 minutes, and they took over. They did not get any pulse and no breathing. Inquired from V3 about R2's level of assistance needed for bed bath or incontinence care; V3 stated that R2 requires 2 persons for incontinence care or bed bath. V3 explained When we have an agency CNA who is not familiar with the resident, we go from room to room of all the residents assigned to her to give orientation and information about transfer, assistance, and feeding the resident. I gave the CNA all the information. Also, at the door by the name of the resident, the information is there to show that the resident needs 2 persons for assistance. This CNA did not ask for assistance. We do room rounds and a tour of the section that the CNA will have. On [DATE] at 10:29am, V12(Medical Director/R2's Physician) was interviewed regarding R2. V12 stated It's a sad case for everyone here. (R2) has been very sick for over fifteen years and he was on hospice, and DNR (Do Not Resuscitate). The nursing home took good care of him, and he bounced back, and we took him off hospice. But after the stroke, he became very sick and the plan was to put him back in hospice again, and then, this happened. The surveyor inquired from V12 if the fall could have been prevented if the CNA had asked for assistance. V12 responded, Well, that is the policy, that two persons should care for him, maybe the fall could have been prevented, but he could also have died an hour later because of his serious medical condition. We don't know if he was having another stroke during the care that could make him fall over. You know when someone driving has a heart attack or brain bleed and crashes and dies, we don't know if the heart attack or stroke happened and cause the accident or if the accident resulted in the heart attack or stroke. I'm not saying that was what happened, but we don't know. When a patient is on blood thinner, the brain can bleed also. Inquired from V12 about the possible injuries from a fall that could lead to death, V12 stated If a patient falls, the main concerns are head and neck injuries; major injury to the neck area or brain bleed could happen. R2's document POLST (Practitioner Order for Life-Sustaining Treatment) dated [DATE] signed by R2's Daughter/Surrogate Decision Maker states: Do Not Attempt Resuscitation (DNR). R2's Death Certificate signed by Medical Examiner/Coroner on [DATE] states in #24: Cause of Death (a) Blunt Force Injury of Neck; (b) Fall. #35 states that R2 broke his neck due to fall. Several unsuccessful attempts were made to contact V13 and V4 for more information. Facility's Fall Policy dated [DATE] with latest revision date [DATE] states in part: It is the policy of the facility to ensure that residents are assessed for risk for falls, that interventions are put in place, and interventions are reevaluated and revised as necessary. Those identified as high risk for falls will be provided fall interventions. An interim Falls Care Plan may be started but a Falls Care Plan is necessary and required after the State required MDS was done. Facility's CNA Job description dated [DATE] states in #7: Must be knowledgeable of individual care plans and support the care planning process by providing supervisors with specific information and observations of the guest's needs, preferences and report any behavioral changes.

Based upon observation, interview, and record review, the facility failed to provide feeding assistance to (R2), failed to obtain monthly weights for (R2, R12), failed to document R12's height (accurately) to determine caloric needs and failed to follow dietary recommendations to maintain weight for three of 16 residents (R1, R2, R12) in the sample. These failures resulted in R12's significant weight loss of 12.9% and low [MEDICATION NAME] level of 3.2, R2's significant weight loss of 14.1%, and R1's significant weight loss of 12.1%. Findings include; The weight monitoring monthly policy (revised 8/5/20) states it is the facility's policy to obtain residents monthly weight unless otherwise ordered differently by the physician. During the 1st week of the month, the restorative staff or designee will weigh each resident to fulfill the monthly weight requirement. The monthly weights will be reflected on the resident's individual chart. The significant weight changes will be assessed and addressed by the IDT (Interdepartmental Team) which includes but not limited to the Dietician, Physician, and Nurses. R12's care plan states (9/16/16) Resident requires extensive, one staff physical assistance to eat ([MEDICAL CONDITION]). (3/27/20) Nutritional problem related to overweight. On 10/5/20 at 12:16pm, R12 appeared somewhat thin (not overweight as documented). R12's weight summary includes height: 64 inches however he appeared much taller. On 10/7/20 at 9:30am, surveyor inquired about R12's actual height and overweight status V2 (Director of Nursing) stated He's not overweight and affirmed his actual height is 70 inches (not 64 inches as documented). R12's weights include but not limited to; (4/7/20) 170lbs. (7/1/20) 148lbs. (-12.94% within 3 months). (Weights are not documented in June 2020). R12's nutrition assessments include; (7/2/20) significant weight loss at 3 and 6 months. Secondary to resident's significant weight loss, writer recommends Med Pass 2.0 BID (twice daily). (7/13/20) labs: [MEDICATION NAME] 3.2 (low). R12's (7/2/20) POS (Physician order [REDACTED]. __ R2's (11/26/19) care plan states resident has an ADL self-care deficit related to dementia. Intervention: resident requires set up staff participation to eat. On 10/5/20 at 11:55am, R2 was lying in bed (head of bed flat) his lunch was on the over-bed table (adjacent his bed) and untouched. V12 (Registered Nurse) entered R2's room (as requested) however provided no assistance to him. R2's weights include but not limited to; (1/9/20) 160 lbs. (pounds). (7/2/20) 137.4lbs. (-14.1% within 6 months). (Weights were not documented in May and June 2020). R2's (7/24/20) nutrition assessment states significant weight loss at 3 and 6 month. Secondary to significant weight loss, writer recommends increasing Med Pass 1.7 to TID (three times daily) to promote weight gain. R2's (8/7/20) nutrition assessment states secondary to resident's continual weight loss, writer recommends increasing Med Pass 1.7 to TID. R2's (2/18/20) POS (Physician order [REDACTED]. On 10/7/20 at 11:56am, V2 (Director of Nursing) stated With the dietary recommendation we check it side by side with the Nurse Practitioner here so all the recommendations are being carried out. __ R1's weights are as follows; (2/15/20) 231.2lbs. (3/11/20) 203.2lbs. (-12.11% within 1 month). R1's (3/10/20) nutrition assessment includes significant weight loss at 1 month. Due to significant weight loss, writer recommends Med Pass 1.7 TID to promote additional kilocalories and protein and to prevent further weight loss. R1's (2020) POS does not include Med Pass 1.7 as recommended. On 10/8/20 at 1:06pm, surveyor inquired about potential harm to a patient with significant weight loss V19 (physician) stated The patient will not be able to ambulate, and might develop secondary infection, and generalized weakness. Surveyor inquired how a low [MEDICATION NAME] affects the resident V19 responded She might develop nutritional deficiency. She might develop sores or another type of infection.

Based upon observation, interview, and record review, the facility failed to obtain monthly weights and failed to follow enteral feeding orders for one of 16 residents (R3) in the sample. These failures resulted in R3's significant weight loss of 15.01%. Findings include; The weight monitoring monthly policy (revised 8/5/20) states it is the facility's policy to obtain residents monthly weight unless otherwise ordered differently by the physician. R3's (10/2/20) POS includes Enteral Feed Order; [MEDICATION NAME] 1.5. Rate: 60milliter (duration 20 hours) hold from 10am to 12pm and from 3pm to 5pm. (Weight is not inclusive therefore should be documented monthly - per facility policy). R3's weights are as follows; (5/4/20) 176.5lbs (pounds). (9/25/20) 150lbs. -15.01%. (Weights were not documented in June, July, or August 2020 as warranted). On 10/5/20 at 11:16am, R3 was lying in bed her G (Gastrostomy) tube feeding was hung. However, it was disconnected and the [DEVICE] pump was off. On 10/5/20 at 11:21am, surveyor inquired about R3's tube feeding V16 (Registered Nurse) stated She gets [MEDICATION NAME] 1.2 at 60cc (cubic centimeter) per hour. She gets turned off around 10:00am. V16 accessed R3's EMR (Electronic Medical Records) as requested and affirmed [MEDICATION NAME] 1.5 is ordered (not 1.2 as stated). V16 reviewed R3's weights and affirmed she incurred a significant weight loss on 9/25/20. Surveyor inquired why R3 lost weight V16 responded I'm not sure where it is coming from. Surveyor subsequently inspected R3's [MEDICATION NAME] container (which appeared full) and inquired when it was hung V16 stated Looks like there's no time on there, it was hooked up when I came in at 7(am). Surveyor inquired about the amount of R3's [MEDICATION NAME] remaining in the container V16 responded Like above 1500cc. (The [MEDICATION NAME] container states it contains 50.7 fluid ounces (1499.38cc) therefore nothing was infused). On 10/8/20 at 1:06pm, surveyor inquired about potential harm to a patient with significant weight loss V19 (physician) stated The patient will not be able to ambulate and might develop secondary infection, and generalized weakness. The enteral tube feeding policy (revised 8/5/20) states check that feeding bag is properly labeled to include: date, and time feeding was started.

This resulted in two deficiency practice statements: 1. Based on the unprecedented coronavirus global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 3/13/20, The Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) Memo QSO-20-14-NH revised on 3/13/20, Nursing Home guidance from the Centers for Disease Control and Prevention (CDC), observation, interview and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to 1) follow appropriate personal protective equipment (PPE) use when cleaning the room of three (R1, R2, R3) residents who were Persons Under Investigation (PUI) for potential COVID infection and who were on contact and droplet precautions; 2) adhere to social distancing; and 3) disinfect high-touch surfaces in a COVID-19 dedicated unit. This failure had a high likelihood of causing serious harm or death to other residents given their congregate nature, age, and underlying medical conditions. This had the potential to affect all 171 residents who resided in the facility. At the time of the survey, the facility had 74 residents who were tested positive for COVID-19 and 33 residents who were exposed and considered as PUIs. There were also 49 staff who were positive for COVID-19. The facility was in a county which had sustained community transmission, especially in the nursing home setting. The Immediate Jeopardy began on 5/6/20 when: 1) an Employee1 (E1) was observed mopping the floor in room [ROOM NUMBER] (a dedicated PUI room) without wearing appropriate PPE, which included gloves and gown. R1, R2 and R3 were in room [ROOM NUMBER] and were on contact and droplet precautions. E1 was observed only wearing a face mask. Outside the room, a contact and droplet precaution signage was posted. 2) On the COVID-19 designated unit, R4 who was diagnosed with [REDACTED]. The Regional Director, Regional Consultant and the Assistant Director of Nursing (ADON) were informed of the Immediate Jeopardy on 5/6/20 at 4:21pm. The Immediacy was removed when the removal plan was accepted on May 8, 2020 and was verified as implemented on May 12, 200 at 1:35pm. Findings include: Review of a CDC article titled Coronavirus Disease 2019 (COVID-19) dated April 30, 2020 under Older Adults revealed, Older adults and people who have severe underlying medical conditions like heart or lung disease or diabetes seem to be at higher risk for developing more serious complications from COVID-19 illness. Under Older Adults are at Higher Risk revealed, 8 out of 10 deaths in the U.S. have been in adults [AGE] years old and older. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older adults.html? CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fspecific-groups%2Fhigh-risk-complications%2Folder-adults.html 1. On 5/6/20 at 11:22am, E1 was observed mopping the floor in room [ROOM NUMBER], a room dedicated for housing three residents under investigation of COVID-19. R1, R2, and R3 were in the room at this time. E1 was observed wearing only a mask and no gown or gloves. Outside the room, contact and droplet precaution signage was posted. This was confirmed by another housekeeping staff member (E3) who was standing outside of room [ROOM NUMBER]. Review of the facility's Isolation List of Persons Under Investigation (PUI) provided by the facility revealed that R1, R2 and R3 were included on the list. A. Review of R1's May 2020 Order Review Report revealed Contact/Droplet Precaution. Review of R1's progress note dated 5/1/20 at 7:10pm, under General Progress Note revealed, Notified (R1's son) regarding COVID test to be done to (R1) due to symptom - low grade fever noted. Review of R1's progress note dated 5/1/20 at 1:07pm, under Medical Professional Progress Note revealed .CXR (chest x-ray) done on 4/30/2020 due to desaturation (low blood oxygen concentration), results reviewed. Per NOD (nurse on duty) patient is desaturating 87-88% on RA (room air), no respiratory distress noted. O2 (oxygen) 2L per NC (two liters per nasal cannula) administered and saturations went up to 96% . B. Review of R2's May 2020 Order Review Report revealed Contact/Droplet Precaution. Review of R2's progress note dated 5/1/20 at 3:07pm under Health Status Note revealed (R2) noted with period of emesis (vomiting) and productive coughing, Nurse Practitioner (NP) made aware. Review of R2's progress note dated 5/1/20 at 3:20pm under Medical Professional Progress Note revealed, COVID negative - done a week ago, repeating COVID testing. Emesis and productive coughing, Labs ordered . C. Review of R3's Clinical Physician order [REDACTED]. Review of R3's progress note dated 5/2/20 at 10:38pm under Health Status Note revealed, BP (blood pressure) 138/79, HR (heart rate) 87, RR (respiratory rate)18, SPO2 (oxygen saturation - is the fraction of oxygen-saturated hemoglobin relative to total hemoglobin in the blood. The human body requires and regulates a very precise and specific balance of oxygen in the blood. Normal arterial blood oxygen saturation levels in humans are 95-100 percent) 95% on room air, Temp 99.5 F. PRN (as needed) Tylenol administered d/t elevated temperature, will continue to monitor resident and endorse accordingly. Review of R3's progress note dated 5/3/20 at 6:00am under Behavior Note revealed .BP: 122/60, HR: 89, RR: 18, T: 99.9, SPO2 95% at room air . Review of R3's Temperature Summary revealed 5/4/20 at 10:00pm 102.9 F. During interview with the Director of Nursing (DON) on 5/12/20 at 1:50pm, when asked about her expectation from staff when entering a PUI room, the DON stated that staff should wear their full PPE of gown, mask, gloves and face shield. Review of facility's policy titled Infection Prevention and Control dated July 31, 2019, under Precautions to Prevent Transmission of Infectious Agents and Transmission Based Precaution revealed 2. Contact Precaution - intended to prevent transmission of infectious agents spread by direct or indirect contact with patient or the environment .b. Use of Gown and gloves is necessary for all interactions. Under 3. Droplet Precautions, it revealed, intended to prevent transmission through close respiratory or mucous membrane contact with respiratory secretions .b. Gown, gloves and mask may be worn for close contact with the resident. Review of facility's policy titled COVID 19 Guidelines and Emergency Preparedness Plan dated 4/30/2020 revealed, COVID 19 Transmission .Evidence now of: human to human transmission. Incubation period: 2-14 days. Transmission dynamics: person to person and contact of surfaces with infectious organisms Under Clinical Guidance, it revealed, Isolation: Suspect Person under Investigation (PUIs) should be immediately placed in respiratory isolation. Under C) Isolation, it revealed, Suspect PUIs .Healthcare personnel entering the room should use standard precautions, contact precautions, droplet precautions, and use eye protection (e.g., goggles or a face shield). Under Control of Infection, it further revealed, In-service all staff on infection control procedures to prevent COVID 19 .use of PPE, Standard, Contact and Droplet Precautions, Proper Donning and Doffing of PPEs . In a CDC article titled Healthcare Infection Prevention and Control FAQs for COVID-19 dated May 11, 2020 revealed, What personal protective equipment (PPE) should be worn by environmental services (EVS) personnel who clean and disinfect rooms of hospitalized patients with COVID-19? In general, only essential personnel should enter the room of patients with COVID-19. Healthcare facilities should consider assigning daily cleaning and disinfection of high-touch surfaces to nursing personnel who will already be in the room providing care to the patient. If this responsibility is assigned to EVS personnel, they should wear all recommended PPE when in the room. PPE should be removed upon leaving the room, immediately followed by performance of hand hygiene. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-faq.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Finfection-prevention-control-faq.html 2. Observations on 5/6/20 at 12:56pm, on the designated COVID unit revealed as Activity staff (E2) standing next to R4 in front of the nurses' station. E2 was wearing full PPE of face mask, face shield, gown and gloves. R4, who was not wearing a mask, was observed on the nurses' desk phone talking to an unnamed family member. When R4 was finished, E2 talked on the phone with R4's family member. E2 hung up the phone without disinfecting it. Further, it was observed that Registered Nurse 1 (RN1) was about to use the same phone and the surveyor had to stop RN1 from using the telephone before it was disinfected. Review of R4's May 2020 Order Review report revealed, Contact/Droplet Precaution. Review of R4's Progress Noted dated 4/30/20 at 5:35pm under Notification (COVID) revealed 1. Notification of Resident's Positive COVID 19 Test Result a1. Was the resident/representative notified the resident was positive for COVID-19? Yes. a2. If YES, please specify name of the representative: (R4's nephew) Date & Time of Notification: 4/29/20 5:15 PM. Review of facility's Isolation List dated 5/7/20 revealed Asymptomatic but tested (+) full house testing. During interview with the Director of Nursing (DON) on 5/12/20 at 1:50pm, when asked about her expectation from staff on what to do immediately after a COVID-19 positive resident used the phone, the DON stated, Sanitize the high-touch areas. The DON further stated that they encourage family to call the phone inside the resident's room. Review of facility's policy titled COVID 19 Guidelines and Emergency Preparedness Plan dated 4/30/2020 revealed, Under Control of Infection, it revealed, If staff or resident has a close contact to a PUI or confirmed COVID 19 case .Disinfection of the general high touch surfaces of the facility using an EPA-approved disinfectant under List N. In a CDC article titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID--19) in Healthcare Settings dated April 13, 2020, under Recommendations #3. Patient Placement revealed, Limit transport and movement of the patient outside of the room to medically essential purposes .Patients should wear a facemask or cloth face covering to contain secretions during transport. If patients cannot tolerate a facemask or cloth face covering or one is not available, they should use tissues to cover their mouth and nose while out of the room . https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html In a CDC article titled Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs) dated April 15, 2020, under #3. Prevent spread of COVID-19 revealed, Actions to take now .Ensure all residents wear a cloth face mask covering for source control whenever they leave their room or are around others .If COVID-19 is identified in the facility, restrict all residents to their rooms . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care-strategies.html In a CDC article titled Social Distancing dated May 6, 2020 revealed, Limiting face-to-face contact with others is the best way to reduce the spread of coronavirus disease 2019 (COVID-19) .Social distancing, also called 'physical distancing,' means keeping space between yourself and other people outside of your home. To practice social distancing: Stay at least 6 feet (about 2 arms' length) from other people . https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/social-distancing.html The Immediacy was removed when the removal plan was accepted on May 8, 2020. On May 12, 2020 at 1:35pm, the surveyor verified (through observation and interview) implementation of an acceptable removal plan that included the following: 1. The facility re-educated all staff (including housekeepers) on general infection control procedures with emphasis on proper use of PPE, accurate donning and doffing procedure after leaving the contact and droplet isolation room, hand hygiene, proper disinfection of high touch surfaces and devices (such as phones), and social distancing of at least 6 feet apart. 2. The infection control policy had been reviewed by the Administrator, DON and the Medical Director. 3. The DON or designee had begun a system for monitoring staff for adherence to proper use of PPE, social distancing, and disinfection of devices. After removal of the Immediacy, the non-compliance remained at the level of no actual harm with the potential for more than minimal harm that is not Immediate Jeopardy until sustained compliance is verified. 2. Based on observation, interview and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure on: proper storage of face shields; proper use of face mask; observe isolation precautions; proper storage of used patient care equipment; proper handling and storage of clean linens; and proper handling of soiled linens. This had the potential to affect the 97 residents who had not tested positive for COVID-19 in the facility. Findings include: 1. A. On 5/6/20 at 10:40am, a face shield was observed laying on top of the laundry washer. There was no barrier or covering under the face shield. This was confirmed by the Plant Operations Manager (E4). When asked, E4 stated, It shouldn't be there. E4 stated that the face shields laundry staff use should be in the hanger stand when not in use. B. On 5/6/20 at 10:52am, Restorative Aide (E5) was observed on the second floor wearing a face mask but her nose was not covered. E4 was present during this observation. C. On 5/6/20 at 11:31am, a face shield was observed laying on top of a table in the second floor dining room. There was no barrier or covering under the face shield. This was verified by Licensed Practical Nurse1 (LPN1). During interview with the Director of Nursing (DON) on 5/12/20 at 2:00pm, when asked how staff should store their face shield when not in use, the DON stated, In a plastic bag. When asked if staff should wear the face mask covering both nose and mouth, the DON stated, Yes. Keep it at all times while in the unit. Review of facility's policy titled COVID 19 Guidelines and Emergency Preparedness Plan dated 4/30/20 under Control of Infection revealed, In service all staff on infection control procedures to prevent COVID 19 including risk of transmission, infection control practices .In the event of shortage of PPEs, staff will resort to conservation and reuse or extended use of mask, N95 respirators, face shield, goggles, and/or gown per CDC guidelines. However, the policy did not include how staff should store the face shield when not in use. In a CDC article titled Strategies for Optimizing the Supply of Eye Protection dated 3/17/20, under Implement extend use of eye protection revealed, Selected Options for Reprocessing Eye Protection .while wearing gloves, carefully wipe the inside, followed by the outside of the face shield or goggles using a clean cloth saturated with neutral detergent solution or cleaner wipe. Carefully wipe the outside of the face shield or goggles using a wipe or clean cloth saturated with EPA-registered hospital disinfectant solution. Wipe the outside of face shield or goggles with clean water or alcohol to remove residue. Fully dry (air dry or use clean absorbent towels) . https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html 2. On 5/6/20 at 9:13am, a used dark-blue colored special bed mattress was observed on the first floor near the reception desk. There was no barrier or covering. This was confirmed by the Assistant Director of Nursing (ADON). When asked, the ADON stated the mattress had been used and was scheduled for pick up by the rental company. The ADON further stated, It should be in a plastic bag. At 10:48am, while in the basement hallway, a dark-blue colored special bed mattress was observed on the floor, without a barrier or covering. E4 was present during this observation and confirmed that it was the same mattress sitting by the reception desk earlier that day. During interview with the DON on 5/12/20 at 2:00pm, when asked what staff should do before returning a rental equipment to the supplier, the DON stated that it should not be on the floor. The DON further stated, Maintenance and housekeeping disinfects the equipment before returning it to the supplier. Maintenance takes it out of the resident's room, place it in a cart with a lining. Review of the facility's policy titled Medical Care Equipment, Instruments and Health IT Devices Infection Control Plan Policy dated August 1, 2019, under Procedures revealed, #4. Equipment/devices that may be contaminated with blood or other potentially infectious materials shall be examined prior to servicing or shipping and shall be decontaminated, containerized and labeled as necessary .#13. After equipment is properly cleaned with facility approved disinfectant, it may be stored in a clean bag and labeled READY FOR USE and shall be moved to a clean storage location. In a CDC article titled Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings dated May 18, 2020, under 10. Implement Environmental Infection Control revealed, All non-dedicated non disposable medical equipment used for patient care should be cleaned and disinfected according to manufacturer's instructions and facility policies. Ensure that environmental cleaning and disinfection procedures are followed consistently and correctly. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#infection_control 3. A. On 5/6/20 at 10:58am, on the second floor, a clean linen cart was observed near the nurses' station. The front of the linen cart was completely open, exposing multiple clean gowns and blankets to air and dust. A fitted sheet was observed sitting on top of the linen cart. This was confirmed by E4. B. On 5/6/20 at 1:15pm, inside the COVID unit on first floor, a clean linen cart was observed near the nurses' station. The front of the linen cart was completely open containing towels, fitted sheets, two small bags of unidentified linen and a stuffed toy. Outside of room [ROOM NUMBER], a bedside table was observed with multiple folded clean gowns, cloth underpads and flat sheets exposed. There was no barrier or covering between the linen and the bedside table. This was confirmed by LPN3. C. On 5/6/20 at 11:25am, Hospice Certified Nursing Assistant (E6) was observed holding linens and gown close to her body and touching her apron and gown. This was confirmed by Licensed Practical Nurse1 (LPN1). During interview with the DON on 5/12/20 at 2:00pm, when asked on her expectation from staff when handling clean linens, the DON stated that the linen carts should be covered at all times. The DON stated, Nothing should be on top of the linen cart. When asked how staff should carry clean linens, the DON further stated, It should be inches away from the body. Review of facility's policy titled Linen Handling by Laundry Staff dated 8/1/20, revealed under Procedure, 7. Clean linen will be brought to the floor in a cart that prevents contamination from the environment. 8. Clean linens may be places in a clean linen room or left in the cart that is protected from the environment. In a CDC article titled Linen and Laundry Management dated March 27, 2020, under Best practices for management of clean linen revealed, Sort, package, transport, and store clean linen in a manner that prevents risk of contamination by dust, debris, soiled linens or other soiled items. Each floor/ward should have a designated room for sorting and storing clean linens. Transport clean linens to patient care areas on designated carts or within designated containers that are regularly (e.g., at least once daily) cleaned with a neutral detergent and warm water solution. https://www.cdc.gov/hai/prevent/resource-limited/laundry.html 4. A. On 5/6/20 at 11:04am, an isolation set-up was observed outside of R5's room. There was no signage posted on the door. This was confirmed by Licensed Practical Nurse2 (LPN2). LPN2 stated that R5 was a Person under Investigation (PUI - any person who is under investigation for having [MEDICAL CONDITION] that causes COVID-19, or who was under investigation but tested negative for [MEDICAL CONDITION]). LPN2 further stated that R5 was readmitted from the hospital on [DATE]. Review of R5's medical record revealed a re-admission date of [DATE]. [DIAGNOSES REDACTED]. Review of facility's 14-day Observation Re-Admission/New Admission List revealed R5 was included in the list. Review of R5's May 2020 Order Review Report revealed R5 had [DIAGNOSES REDACTED]. Review of R5's progress note dated 5/2/20 at 10:02pm, under general progress note revealed, Received resident from (name of hospital) around 1pm in stable condition vie stretcher, two person assist with admitting [DIAGNOSES REDACTED]. Review of R5's progress note dated 5/7/20 at 2:47pm, under behavior note revealed, Resident refused nasal swab. Review of R5's progress note dated 5/9/20 at 2:00pm, under health status note revealed, Staff reported (R5) not eating her breakfast and lunch, when NOD went to resident's room, she said she doesn't like the food, she was asking orange juice and a can of milk . B. On 5/6/20 at 11:10am, a contact and droplet precaution signage was observed posted on the door of R7's room but there was no isolation set-up outside of the room. This was confirmed by E4 and Registered Nurse2 (RN2). RN2 stated that R6 and R7 shared the room [ROOM NUMBER] and that R6 was sent to the hospital for high fever on 5/4/20 and tested positive for COVID-19. She further stated that R7 was being monitored. When asked how come there was no isolation set-up outside of R7's room, RN2 stated there was no set-up when she came to work at 7am and added, It should. Review of R6's progress note dated 5/4/20 at 10:30am, revealed under Change of Condition, During morning care (R6) noted with fever 103.7 and SPO2 (amount of oxygen-carrying hemoglobin in the blood) 85%. Placed on non-rebreather (device used to assist in delivery of oxygen therapy) at 10 L (liter). Blood pressure was 84/53 with pulse of 158 beats per minute. NP (nurse practitioner) made aware with instructions to send resident out via 911. POA (power of attorney) called and made aware . Review of R6's progress note dated 5/4/20 at 3:56pm, revealed under Change of Condition, Called (name of hospital) and spoke with (name of RN) who mentioned they are trying to admit (R6) under (name of hospice) resident will be admitted for [MEDICAL CONDITION] and positive for COVID-19. Review of R7's May 2020 order summary revealed, Contact/Droplet Precaution The order date was 5/7/2020. Review of R7's progress notes did not reveal any documentation that R7's was placed on contact and droplet precautions immediately after staff learned that R6 was positive of COVID on 5/4/20. There was no documentation that a repeat COVID test was done on R7 after 5/4/20. During interview with the ADON on 5/6/20 at 9:30am, the ADON stated the facility had the first batch of COVID-19 testing on 4/24/20 and the second batch was done on 5/1/20. Review of R7's progress note dated 5/6/20 at 4:43pm, revealed under General Progress Note, Resident is COVID-19 negative. (Daughter) notified about the result. Review of R7's progress note dated 5/11/20 at 2:53pm, revealed under Health Status Note, (R7) with SOB (shortness of breath) and SPO2 stats (sic) at 86% placed on 4 L nasal cannula. Rechecked with stats (sic) at 91%. A-febrile (sic) with vitals (sic) signs within normal limits. Noted with poor appetite. Encouraged fluids. MD made aware. During interview with the DON on 5/12/20 at 2pm, when asked what an isolation room should have outside of the room, the DON stated, Should have the set-up and signage. Review of facility's policy titled COVID 19 Guidelines and Emergency Preparedness Plan dated 4/30/2020 revealed under C) Isolation, Suspect PUIs .In LTC setting, the AIIR (Airborne Infection Isolation Room) is not applicable but the patient should be isolated in a room if the respiratory illness is undiagnosed and placed on Standard, Contact and Droplet Precaution. Healthcare personnel entering the room should use standard precautions, contact precautions, droplet precautions, and use eye protection (e.g. goggles or a face shield). Review of facility's policy on Infection Prevention and Control dated July 31, 2019 revealed under Procedure, .6. If the resident with infection needs transmission-based precaution, the facility will provide the Transmission-based precaution set required .7. A transmission-based precaution set-up will be provided outside the resident's room to provide Personal Protective Equipment (PPE) like gown and gloves to staff and visitors entering the resident's room .8. A sign will be provided outside the room for residents on transmission-based precaution indicating the type of precaution (Contact or Droplet). As long as the type of infection is not included in the signage, the Isolation sign is compliant with F583 in the SOM. In an undated article titled Follow all Posted Precaution Signs by the Association for Professionals in Infection Control and Epidemiology (APIC) revealed, Isolation precautions are used to help stop the spread of germs from one person to another. These precautions protect patients, families, visitors, and healthcare workers from the spread of germs .Generally, when patients are placed on isolation precautions, there will be sign at the door of their hospital rooms to remind visitors and healthcare workers which isolation precautions are needed. All healthcare workers and visitors need to follow these guidelines. http://professionals.site.apic.org/protect-your-patients/follow-the-rules-for-isolation-precautions/ In an undated CDC article titled Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long Term Care Settings under supplies and resources revealed, Signs are posted immediately outside of resident rooms indicating appropriate IPC precautions and require personal protective equipment (PPE) .Necessary PPE is available immediately outside of the resident room and in other areas where resident care is provided. https://www.cdc.gov/coronavirus/2019-ncov/downloads/novel-coronavirus-2019-Nursing-Homes-Preparedness-Checklist_3_13.pdf 6. A. On 5/6/20 at 11:08am, on the second floor, a soiled face towel was observed on top of the hallway railing next to room [ROOM NUMBER]. This was confirmed by LPN1. B. On 5/6/20 at 11:30am, in the second floor south dining room, an open green plastic bag containing soiled clothing protectors was observed on the floor. This was confirmed by LPN1. C. On 5/6/20 at 1:13pm, inside the COVID unit, an open green plastic bag containing a blanket was observed on the floor outside of room [ROOM NUMBER]. This was confirmed by LPN3. During interview with the DON on 5/12/20 at 2:00pm, when asked of her expectation from staff when collecting soiled linens like clothing protectors, blankets and face towels and placing them in bags, the DON stated, Put it directly in the chute. Review of the facility's policy on Linen Handling by Laundry Staff dated Aug. 1, 2019 did not show any documentation on proper handling of soiled linens while in the unit. In an article by the Agency for Healthcare Research and Quality (AHRQ) titled A Unit Guide to Infection Prevention for Long-Term Care Staff dated 3/2017 revealed, Soiled or improperly cleaned or disinfected linens can spread germs .Make sure the soiled linen is properly handled from the point of collection to the laundry. https://www.ahrq.gov/hai/quality/tools/cauti-ltc/modules/resources/guides/infection-prevent.html#section1 In a CDC article titled Background G. Laundry and Bedding dated Nov. 5, 2015 revealed, The laundry process starts with the removal of used or contaminated textiles, fabrics, and/or clothing from the areas where such contamination occurred, including but not limited to patient's rooms .Handling contaminated laundry with a minimum of agitation can help prevent the generation of potentially contaminated lint aerosols in patient-care areas .Contaminated textiles and fabrics are placed into bags or other appropriate containment in this location; these bags are then securely tied or otherwise closed to prevent leakage .Contaminated textiles and fabric in bags can be transported by cart or chute .Loose contaminated pieces of laundry should not be tossed into chutes, and laundry bags should be closed or otherwise secured to prevent the contents from falling out into the chute. https://www.cdc.gov/infectioncontrol/guidelines/environmental/background/laundry.html

Based on interview and record review the facility failed to implement appropriate interventions during ADSL (Activities of Daily Living) for two of three residents (R4, R5) reviewed for injury. These failures resulted in R4 sustaining a head injury, cut on face and fractured clavicle (collar bone) and R5 sustaining tibia/fibula fractures (leg). Findings include: Review of the facility's incident report of 12.5.16 notes in part, (R4) continues to display impaired functional capacity, requiring total assistance x2 person in all ADLs/mobility. (R4) can be very resistive to care making it difficult for the staff to provide care for (R3). (R4) has behavior(s) by(of) kicking, pushing things near (R4), grabbing (and) not letting go. At the time of the incident during care resident grabbed the side rail and did not let it go, side rail went loose and resident fell out (of) bed. Resident was sent out (to the hospital) for further evaluation. Post incident diagnosis(es): head injury, cut on face and closed nondisplaced fracture of right clavicle. Review of facility's Post Incident Investigation notes in part: II. Analysis of Data and Cause of Incident: Resident (R4) needs 2 person assist for ADL transfer. Review of R4's medical record (Face Sheet) notes in part R3 has the following [DIAGNOSES REDACTED]. R4's most recent RAI (Resident Assessment Instrument) prior to incident of 12.5.16, dated 10.17.16) notes in part, R4 requires extensive assistance of two plus persons assist in the area of toilet use (including but not limited to how resident cleanses self after elimination). Care plans (bed mobility revised 12.1.15; ADL self care performance deficit initiated 10.21.16 and at risk for falls revised 9.7.16) note under interventions, R4 requires extensive two staff physical participation to reposition/turn in bed/use toilet and for falls, floor mat provided. E5 (CNA-Certified Nursing Assistant, 12.21.16 at 5:47 PM) said in part, while rendering incontinence care to R4 (on 12.5.16), E5 was moving from the left side of R4's bed to the right (after first positioning R4 on his right side) when R4 grabbed the left side rail with his right hand and began shaking the side rail. The side rail went loose and R4 fell to the floor. E5 said the bed was raised to a comfortable height for her to provide care to R4; she was alone in R4's room while performing incontinence care; floor mats were in place prior to but not during the time E5 rendered incontinence care to R4. E5 said she would only ask for help when transferring R4 from bed or when moving resident up in bed. E2 (DON-Director of Nursing, 12.22.16 at 12:19 PM) said in part, R4 is a two person assist with all ADLs. E5 did not seek the assistance of additional staff in order to safely render incontinence care to R4. Review of facility's incident report of 12.15.16 notes in part, (R5) claims she was asked by CNA to stand and pivot for transfer at the time of incident. At 8 am, R5 complained of pain to the right lower extremity. Due/scheduled Morphine sulfate was given. At 9 am R5 still with complaint of pain, PRN (as needed) medications given. R5 was referred to the Nurse Practitioner with order of right hip and lower extremity(ies) x-ray. X-ray report shows nondisplaced fracture involves the mid tibial (tibia) and fibula. Resident attending (physician) aware of x-ray result with order to sen to ER (emergency room ) for evaluation and treatment. Review of R5's medical record (Face Sheet) notes in part [DIAGNOSES REDACTED]. Progress Note of 12.19.16 notes in part, R5 was readmitted to the facility with the admitting [DIAGNOSES REDACTED]. (R5) requires extensive, two staff physical assistance during transfers. (R5) requires a (mechanical) lift during transfers. R5's most recent RAI (dated 11.3.16) prior to the incident of 12.15.16 indicates R5 requires extensive assistance of two plus persons assist during transfers. Care plan (ADL Self Care Performance Deficit, initiated 11.7.16) notes under interventions, (R5) requires extensive two staff physical assistance with transfers. R5 (12.23.16 at 4:25 PM regarding incident of 12.15.16) said in part, per translation assistance provided by E10, he (black male) came into my room around 5 am. It was the first time he took care of me. He stood me up. He told me to grab the side rail, then tried to stand me up. I didn't stand. Then he put me in the (recliner) chair. That's when I got hurt, when he tried to make me stand. Z1 (Former employee, 12.23.16 at 12:55 PM regarding incident of 12.15.16) said in part, he asked a colleague to assist to transfer R5 from bed to (recliner) chair. He said he waited for assistance for 10 minutes then transferred R5 from bed to (recliner) chair by sliding R5. Z1 also said this was the first time he took care of R5. E9 (CNA, 12.23.16 at 1:32 PM regarding incident of 12.15.16) said in part, R5 requires a (mechanical) lift with two person assist for transfers. E6 (Assistant Director of Nursing, 12.23.16 at 12:42 PM) said in part, Z1 transferred R5 from bed to (recliner) chair by himself; R5 is a two person assist for transfers. Z1 did not seek the assistance of additional staff in order to safely transfer R5 from bed to chair.

Based on interview and record review the facility failed to thoroughly assess, and obtain physician orders [REDACTED]. This failure resulted in a delay of treatment for [REDACTED]. Findings include: R1 per the facility's physician order [REDACTED]. R1's diet orders per the physician's orders [REDACTED]. On 5/22/13 at 11:37 am E5 (registered nurse) stated "I heard commotion in the resident's room. He was half naked and being clean by CNA's (certified nurses assistant). They said the patient spilled noodles on himself. They said the resident asked the roommate to heat the soup and he put it in the bed. It spilled on the resident. I assessed him and didn't see any redness on his groin or bottom. I paged the doctor. We have a standing order for [MEDICATION NAME] cream so I put the [MEDICATION NAME] cream on him. I forgot to write it down in the endorsement book that this patient had an incident. I should have written it in the endorsement book so that all the shifts would have known what happened. I should have told my supervisor." On 5/22/13 at 12:28 pm E9 (certified nurses assistant) stated the roommate was screaming "help, help", R1 was sitting on the bed and she called the CNA in charge and we went there and changed and cleaned everything. "They asked the roommate what happened. He said he asked the roommate to prepare noodles for him and he got burned." On 5/22/13 at 11:22 am E8 (certified nurses assistant) stated the "Roommate made the noodles hot. I don't know if the roommate put the noodles on the table or bed but the noodles spilled in the bed. R1 "was in the sitting position. His skin was red a little on the butt area. It wasn't real red, it was a light color." On 5/22/13 at 11:56 am E6 (registered nurse) stated "A CNA came to me and said his buttock was pinkish color. I went to check, his buttock was pinkish in color with a little skin peeling off. He's incontinent so I applied moisture barrier cream. I went to recheck his skin at 3:30 - 4:00 pm and it changed to a red color with more skin peeling in the genital area and buttock." She stated she informed the director of nurses and called the covering doctor since R1's primary doctor was on vacation. The doctor ordered to send the resident out to the hospital for evaluation. On 5/22/13 at 12:11 pm E7 (registered nurse supervisor) stated E5 "didn't tell me anything about it. I found out about it on 5/13/13 when I came back to work from 5 pm to 1 am. I supervise at night. I was in the building and usually they inform me. They would page me if they are on another floor. I didn't know, I could have assessed the resident or done something but I didn't know." On 5/11/13 at 10:38 am E11 (registered nurse) stated "I work the 11-7 shift. I know it happened on 3-11 shift. It was not endorsed in the book. It was documented in the chart that the resident got burned by the soup. I assessed the resident on my shift. It was slightly reddened. There was no reports of complaints of pain. The doctor was paged by the 3-11 nurse but the doctor didn't call during my shift. It was just slight redness. I didn't see any progress and the [MEDICATION NAME] was put on the resident." Per the local hospital Emergency Physician Evaluation dated 5/13/13 Present History initial comments: "This is a [AGE] year old male who is a resident of a nursing facility presents to the emergency room with a chief complaint of a burn to his buttocks penis and scrotum. Patient apparently spilled hot soup on his perineum yesterday however according to the nursing home records there was no discovery of the burn until this afternoon. The patient is unable to give any further history." Comments: There is a second-degree burn over both buttocks completely scrotum as well as penis. Disposition: Other acute inpatient hospital The facility policy for Management of Pain reads: 3. Nursing Involvement: A. Pain Screening Upon admission, readmission, each MDS assessment, change of condition or when new pain or an exacerbation of pain is suspected, the Pain Questionnaire will be filled out with input from the resident, family member, or responsible party. By receiving input from someone who knows the resident well, pain management can be more specific to the resident. If the resident scores 5 or above on the Pain Questionnaire, the Comprehensive Pain Assessment must be completed. The facility policy for Resident Condition Changes/Documentation dated 5/21/13 reads: 1. Accidents/Incidents with or without injuries Service given and key points for documentation. -Notification of physician and family member -Date/time physician notified. Results and follow-through of orders, if any The facility policy for Procedures to follow in cases requiring Physician attention: In case acute condition change/s not requiring NH facility to call 911, the followinf procedures are to be followed: 1. Call and/or page residents physician and landline and wait for MD to call back. 2. If MD does not call back within a prudent amount, nurse may call/page the physician again, if no response and condition of patient requires treatment, Medical DIrector will be followed. 3. If no reply in received from PCP, nurse mat send resident to the hospital depending on the residents medical condition, using her nursing judgement, then notify her supervisor or designee. Receiving Hospital will be advised to inform respective patient's attending physician. There is no documented evidence that the pain questionnaire was completed after the incident on 5/12/13. On 5/28/13 at 1:38 pm Z1 (doctor) stated he was covering for Z2 (doctor) at the time of the incident. Stated he doesn't remember when he was notified of the incident "I think it was the day after. Z1 stated when he was notified he ordered that R1 be sent to the local hospital. Z1 stated it was hard to say whether he would've sent the resident to the hospital had he been notified the day of the incident because "They didn't call me until the day after."