Every finding on record at Pinecrest Medical Care Facility

Based on interview and record review, the facility failed to provide the resident and resident representative comprehensive information of resident appeal rights prior to transfer out of the facility for three Residents (R5, R72, and R73) of three residents reviewed for transfer and/or discharge.Findings include:Resident #5 (R5) Review of R5's EMR revealed he was emergently transferred to the emergency department on 6/28/2025 for evaluation of an acute change in condition. Further review of the EMR revealed R5's, Notice of Resident Transfer or Discharge, signed by the ADON on 6/30/2025. The notice listed the date of transfer as 6/28/2025 and the reason for the transfer to be, low grade fever, emesis x 2, increased respirations . Further review of the notice revealed the section designated to include the contact information for the SA and the state long-term care ombudsman were blank and the notice did not include any information on who to contact regarding the Resident's right to appeal the transfer. It was noted in review, the Notice of Resident Transfer or Discharge, and the attached Bedhold Notice, did not include R5's or the Resident's representative signature verifying receipt of the notices or any indication the forms were mailed and pending receipt of signed documents. During an interview on 7/17/2025 at 11:55 AM, the ADON reported she was responsible for completing the, Notice of Resident Transfer and Discharge, forms and was unaware the SA and ombudsman information needed to be included for transfers to the emergency department. The ADON stated, we call ahead to the family and get permission to transfer, and people aren't going to appeal that. Review of the facility policy titled, Transfer and Discharge (including AMA), last reviewed 8/2024, revealed the following: The facility's transfer/discharge notice will be provided to the resident and the resident's representative in a language and manner in which they can understand. The notice will include all of the following at the time it is provided: . An explanation of the right to appeal the transfer or discharge to the State. The name, address (mailing and email), and telephone number of the State entity which receives such appeal hearing requests. The name, address (mailing and email) and phone number of the representative of the Office of the State Long-Term Care Ombudsman. All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #72 (R72) Review of R72's electronic medical record (EMR) revealed she was emergently transferred to an acute care hospital for evaluation on 5/9/25 for an acute change of condition. Review of a form located in R72's EMR titled, Notice of Resident Transfer or Discharge, signed by the Assistant Director of Nursing (ADON) on 5/9/25, revealed the reason for transfer to be, stroke like symptoms . Further review of the notice revealed the section designated to include contact information for the State Agency (SA) and the state long-term care ombudsman were blank and the notice did not include any information on who to contact regarding the Resident's right to appeal the transfer. It was noted in review, the Notice of Resident Transfer or Discharge, and the attached Bedhold Notice, did not include R72's or the Resident's representative signature verifying receipt of the notices or any indication the forms were mailed and pending receipt of signed documents. Resident #73 (R73) Review of R73's EMR revealed he was emergently transferred to an acute care hospital for evaluation of acute changes of condition on 4/11/25, 4/25/25, and 6/6/25. Review of three separate forms located in R73's EMR titled, Notice of Resident Transfer or Discharge, signed by the ADON on 4/11/25, 4/25/25, and 6/6/25, revealed the reason for transfers to be, resident had (L) [left] side facial droop., unresponsive episode., and episode of unresponsiveness., respectively. Further review of the notices revealed the sections designated to include contact information for the SA and the state long-term care ombudsman were blank and the notice did not include any information on who to contact regarding the Resident's right to appeal the transfer. It was noted in review, the Notice of Resident Transfer or Discharge, and the attached Bedhold Notice, did not include R73's or the Resident's representative signature verifying receipt of the notices or any indication the forms were mailed and pending receipt of signed documents.

Based on interview and record review, the facility failed to follow the Pre-admission Screening (PAS)/Annual Resident Review (ARR) (PASARR) determination for three Residents (#3, #48, and #57) out of three residents reviewed for PASARR, resulting in the potential for delayed mental health services and unmet psychosocial needs. Findings include: All time recorded in Easter Daylight Time (EDT), unless otherwise noted. Resident #48 (R48) Review of the medical record revealed R48 was initially admitted to the facility on [DATE] with medical diagnoses that included dementia with psychotic disturbances. According to R48's Minimum Data Set (MDS) dated [DATE], revealed R48 scored a 5 out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS – a cognitive screening tool) and had no behaviors. R48 required assistance with toileting, showering/bathing, getting dressed and personal hygiene. Record review revealed a PASARR (Level I - 3877), dated 6/19/25 indicated R48 had a current diagnosis of dementia, was not receiving treatment for dementia, and was not routinely receiving one or more prescribed antipsychotic or antidepressant medications within the last 14 days.with explanation noted to state, Unspecified dementia, moderate, with agitation. R48's PASSAR (Level I – 3877) was incorrectly filled out as R48 was receiving treatment for dementia and is taking an antipsychotics. Resident #57 (R57) Review of the medical record revealed R57 was initially admitted to the facility on [DATE] with medical diagnoses that included dementia with psychotic disturbances. According to R57's MDS dated [DATE], revealed R57 scored a10 out of 15 (moderately impaired) on the BIMS and had no behaviors. R57 required assistance with toileting, showering/bathing, getting dressed and personal hygiene. Record review revealed a PASARR (Level I - 3877), dated 9/30/24 indicated R57 had a current diagnosis of mental illness and dementia, was receiving treatment for mental illness, and was routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days.with explanation noted to state, .Has diagnosis of unspecified dementia with psychoses, MDD (Major depressive disorder), bipolar disorder, dementia with Lewy bodies. Takes (Brand name antipsychotic) olanzapine 15mg (milligrams). According to the PASARR (Level I – 3877), Distribution: If any answers to items 1 – 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. R48's and R57's PASARR (Level I – 3877) should have been sent to the Community Mental Health Services Program (CMHSP) for a PASARR (Level II – 3878) and an exemption kept on file in the electronic medical record of the facility. On 7/17/25 at 1:20 PM, an interview was conducted with the Director of Nursing (DON) who was asked why R48 and R57 didn't have a PASARR (Level II -3878) completed and replied, I was not aware they needed a Level II. I thought they were automatically exempt. The DON was asked if R48's PASARR (Level I -3877) was filled out correctly as they were receiving antipsychotic medication and replied, I must have marked it in error. Resident #3 (R3) A review of R3's medical record revealed an initial admission to the facility on 6/16/2021 with diagnoses including major depressive disorder, delusional disorders, unspecified mood affective disorder, anxiety disorder, and paranoid personality disorder. A review of R3's MDS assessment, dated 7/2/25, revealed a BIMS score of 13, indicative of intact cognition. A review of the active physician's orders included an antidepressant of duloxetine prescribed 11/1/2023 for major depressive disorder and unspecified mood affective disorder as well as a current order for Seroquel prescribed 1/14/2024 for paranoid personality disorder. The care plan for R3 included a focus which read in part, (R3) has potential to be verbally aggressive r/t (related to) Mental / Emotional illness, Poor impulse control, and history of exaggerating stories, delusions that at times are of inappropriate/inaccurate thoughts and/or hallucinations. The medical record contained a PASARR level 1 (DCH-3877) screening dated 6/19/2025 was filled out for R3 with a no for question 3, The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last 14 days. This PASARR form also indicated a no for question 4, There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgement. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others. According to the PASARR Level I (DCH – 3877) instructions, Distribution: If any answers to items 1 – 6 in SECTION II is Yes, send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form (PASARR 2) DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative. The medical record did not contain a PASARR level 2 (DCH-3878) screening. During an interview on 7/16/2025 at 4:16 PM, the DON reviewed the PASSAR level 1 (DCH-3877) screening for R3 dated 6/19/2025 and agreed it was incorrect as #3 and #4 should have been marked as yes. When asked about the level 2 (DCH-3878) screening for R3, the DON replied that this resident never has had a level 2. The facility policy titled, Resident Assessment – Coordination with PASARR Program dated as reviewed 8/2024 read in part: All applicants to this facility will be screened for serious mental disorders (MD) or intellectual disabilities (ID) and related conditions in accordance with the State's Medicaid rules for screening. a. PASARR Level 1 – initial prescreening that is completed prior to admission. b. PASARR Level 2 – a comprehensive evaluation by the appropriate state-designated authority (cannot be completed by the facility) that determines whether the individual has MD, ID, or related condition, determines the appropriate setting for the individual, and recommends any specialized services and/or rehabilitative services the individual needs. 5. If the resident.remains in the facility longer than 30 days: a. The facility must screen the individual using the State's Level 1 screening process and refer any resident who has or may have MD, ID, or a related condition to the appropriate state-designated authority for Level 2 PASARR evaluation and determination. b. The Level 2 resident review must be completed within 40 calendar days of admission.

Based on observation, interview and record review, the facility failed to ensure a thorough trauma assessment to identify triggers and follow-up on identified concerns related to suicidal ideation for one Resident (12) of one resident reviewed for Trauma-Informed Care, resulting in the potential for the Resident to experience re-traumatization, feelings of low self-worth, worsening depression and fear. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted.Resident #12 (R12)Review of the Minimum Data Set (MDS) assessment, dated 5/21/2025, revealed R12 was admitted to the facility on [DATE] and had diagnoses including spinal cord injury, quadriplegia (paralysis of all four limbs), autonomic dysreflexia (life-threatening, uncontrolled increase in blood pressure), and anxiety disorder. Further review of the MDS assessment revealed R12 was cognitively intact and dependent on staff for all care.An observation on 7/16/2025 at 9:30 AM, revealed R12 awake and lying in bed, listening to music. Further observation revealed a breath call light activation device (device to activate the call light by puffing air through a tube) positioned in front of the Resident. R12 was covered in a white sheet and a white towel was draped over the Resident's right arm and hand. During an interview at the time of the observation, R12 reported to be paralyzed from the neck down due to a spinal cord injury sustained in a motor vehicle accident in 2001. R12 recalled the event with vivid detail and was observed to be emotional, scrunching up his face and closing his eyes tightly while talking. R12 reported I think about that day all the time . R12 recalled the negative impact the accident had on his life and was again observed to be fighting back tears. R12 reported certain music often triggered vivid memories of his accident, stating, to this day if I hear it, I'm back to that day.A search of the electronic medical record (EMR) revealed no assessment of R12 related to his trauma or an assessment indicating what triggers had the potential for re-traumatization.Review of the consultation note from Behavioral Care Solutions (BCS) for Adults and Seniors, Inc., the area psychiatric service provider, dated 3/28/2025, revealed the following: . presents with anxiety and depression. He is experiencing passive suicidal ideation recently, predominantly due to ruminating on his lifelong circumstances and long-term stay in the facility. He often feels helpless but has expressed no intentions or plans to act on these thoughts, stating he could never act out on them despite having days where he feels hopeless . Assessment & Plan: Generalized Anxiety Disorder. Plan - Encourage participation in psychotherapy . encourage opening curtains to allow sunshine into the room . Adjust care schedule to facilitate participate in bingo and other activities.Review of R12's progress note, dated 4/16/2025 at 9:47 a.m., revealed, PA (physician assistant) reviewed BCS consultation report from 3/28/25 visit. No medication changes per recommendation.Further review of R12's EMR for the period of 3/01/2025 through 7/14/2025, including all physician documentation, revealed no focused trauma assessment completed by the facility in response to R12's expressions of suicidal ideation per the BCS note dated 3/28/2035.During an interview on 7/17/2025 at 9:42 AM the facility's Social Services Designee, Staff E, reported she was unaware of R12 expressing suicidal ideation as documented in the BCS visit note dated 3/28/2025. Staff E reported the charge nurses reviewed consultation notes and referred to her if follow-up is required and she did not receive a referral to follow-up with R12 after his visit with BCS on 3/28/25. Staff E reviewed R12's EMR at the time of the interview and reported R12 was visited by BCS on 7/08/2025 and no suicidal ideation was documented. When asked what the procedure was when a resident express thoughts of suicide, Staff E reported when residents are reported to be having increased behaviors or worsening signs and symptoms of depression or anxiety, as reported by nursing or BCS, she would follow-up with the resident to determine the triggers to the behavior or worsening of mood and involve the care team to determine appropriate interventions aimed at avoiding triggers. A review of the care plan with Staff E at the time of the interview revealed no focus area, goals or interventions related to R12's expression of suicidal ideation. Staff E was asked if a trauma assessment was completed for R12 to which she answered trauma assessments were completed on admission and since R12 was admitted in 2004, the assessment would be in the old EMR system. Staff E reported being unaware if a trauma assessment was conducted on R12 and if completed, what the assessment revealed. When asked what triggered the potential for re-traumatization for R12, Staff E stated, I don't know, maybe the time of the year, he often states he's just having one of those days. Asked what helps to alleviate the resident's [NAME], Staff E stated, he loves music, movies, to sit in the sun . he loves to sit outside. Staff E was unaware of the connection certain music played in triggering traumatic memories as reported by R12 to this Surveyor. Staff E reported she believed R12's anxiety and depression stemmed from his condition and the accident that caused it. When asked if follow-up should have been conducted in regard to the documentation found in the BCS visit note, dated 3/28/2025, Staff E reported she believed follow-up was warranted at that time, but R12 did have a PHQ-9 assessment (assessment for depression) completed with the MDS assessment, dated, 5/21/25, which was negative and not unusual for the Resident. On 7/17/2025 at 9:48 AM a request was made to MDS Coordinator, Registered Nurse (RN) B, for a search of the prior EMR archive for the trauma assessment conducted for R12.On 7/17/2025 at 9:56 AM, RN B reported there was no trauma assessment found in the previous EMR system for R12. When asked if there were paper charts for review, RN B reported the facility did not archive paper documents.Review of R12's care plan revealed the following: [R12] has the potential for depression [related to] the trauma of the accident that resulted in his quadriplegia and limited contact with his children. Date Initiated: 11/02/2023. Revision on: 12/06/2024 . will remain free of [signs and symptoms] of depression, anxiety or sad mood by/through review date. Revision on 5/30/2025 . Arrange for psych consult, follow-up as indication. Dated Initiated: 11/02/2023. Monitor/document/report [as needed, signs and symptoms] of depression including hopelessness, anxiety, sadness, insomnia, anorexia, verbalizing, negative statements, repetitive anxious or health-related complaints, tearfulness. Date Initiated: 11/02/2023.It was noted in review, R12's care plan contained no focus area for the Resident's history of trauma, including triggers, or specific, person-centered interventions to avoid triggers that had the potential for re-traumatization.Review of the facility policy titled, Trauma Informed Care, last reviewed 7/2024, revealed the following: Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individuals, functioning and [NAME], physical, social, emotional or spiritual well-being. Common sources of trauma may include . Accidents . A trauma-informed approached to care deliver . incorporates knowledge about trauma into care plans, policies, procedures and practices to avoid re-traumatization . The facility will identify triggers which may re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident, and will be added to the resident's care plan .

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program in accordance with facility policies to prevent the potential transmission of communicable diseases and infections as evidenced by failure to: 1. Document signs and symptoms of infections. 2. Conduct departmental surveillance for adherence to infection control practices. 3. Handle meal trays for residents in transmission-based precautions in accordance with facility policy. 4. Provide barriers for insulin pens during medication administration. 5. Ensure urinary catheter drainage bag and tubing remained off the floor. This deficient practice resulted in the potential for the transmission of pathogens between residents and the spread of infectious organisms to all 63 residents in the facility. Findings include: The facility's Infection Prevention and Control Program was reviewed with the Infection Preventionist (IP) on 7/24/24 at 10:47 a.m. The IP explained the facility used a line list as part of a monthly infection surveillance to identify infections and determine if residents' symptoms met McGeer Criteria (a surveillance tool used to define types of infections). The IP explained each resident's signs and symptoms of infection were documented on a monthly line list to identify, track, trend, and correlate infections. The infection surveillance line list for May 2024 was reviewed. The line list contained the names of 13 residents. The column labeled symptoms was blank and did not document the symptoms of infections for any of the 13 listed residents. The IP was asked the location of the documentation of symptoms. The IP said the signs and symptoms of infection would be documented on the line list and said, I don't know how I missed that when shown the blank symptom column on the May 2024 line list. The IP was asked the process for conducting infection surveillance activities throughout the facility. The IP said departmental surveillance was conducted monthly by respective department managers. When asked if departmental surveillance had been completed for May, June, and July of 2024, the IP responded, Probably not. The IP presented a departmental surveillance form dated 7/17/24 by the dietary department. The IP confirmed no other department had conducted infection control and prevention rounds in their department during the quarter requested. When asked if the IP ever conducted surveillance rounds in the departments, the IP responded, No, but I need to. The policy Infection Surveillance dated 12/15/23 read, in part: .updated McGeer criteria or other nationally-recognized surveillance criteria will be used to define infections .Surveillance activities will be monitored facility-wide, and may be broken down by department .The facility will collect data to properly identify possible communicable diseases or infections among residents and staff before they spread by identifying: .signs and symptoms .Line charts will be used . 45123 On 7/24/24 at 8:30 AM, an observation was made of LPN H preparing medication pass for a Resident #14 (R14) and LPN H dropped a tablet of carvedilol on top of the medication cart. LPN H picked it up and threw it in the medication cart trash. LPN H proceeded to dispense medications for R14 and dropped a doxycycline on top of the medication cart and again picked it up and threw it in the medication cart trash. LPN H continued to dispense medications for R14 and dropped twice in a row spironolactone on top of the medication cart and after the second time he dropped the medication on top of the medication cart, he picked the second spironolactone up with his bare hands and placed it in the medication cup he was preparing for R14. LPN H was without explanation of why he used his bare hands, did not perform hand hygiene, or why he used the second dropped spironolactone and placed it in the medication cup for R14. On 7/24/24 at 1:55 PM, medication administration was observed with LPN H for R30. LPN H proceeded to R30's room to administer his medications. LPN H gave R30 his insulin and then placed the insulin pen on his bedside table without a barrier and then handed him his medication cup. LPN H returned the insulin pen back to the medication cart without wiping it off before returning it to the medication cart. On 7/24/24 at 9:45 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked what the proper destruction of medications was and replied, Nurses are required to take them to the medication room and use the drug buster container. RN A was asked if a barrier should be used on top of bedside tables if nurses need to set medications down that will be returned to the medication cart and replied, Yes, barriers are required in resident rooms if medical items are placed on bedside tables per policy. 40383 Resident #22 (R22) During a room visit on 7/22/24 at 2:55 PM, R22 was sitting in her wheelchair and her catheter tubing was observed extending from her pant leg and resting on the floor. During a dining room observation on 7/23/24 at 1:17 PM, R22 was sitting in her wheelchair and her catheter tubing was observed extending from her pant leg and resting on the floor. During a room visit on 7/25/24 at 10:00 AM, R22 was in bed and her catheter drainage bag was observed to be resting on the floor and not contained in a privacy bag. Licensed Practical Nurse (LPN) H was asked to observe the catheter drainage bag and said the drainage bag should not be touching the ground and proceeded to make corrections to prevent infection. The Electronic Medical Record (EMR) for R22 revealed a physician order dated 7/19/19 for an ongoing indwelling urinary catheter and diagnoses which included dysuria (difficult or painful urination). The care plan for R22 included, The resident has Indwelling Catheter. During an interview on 7/25/24 at 10:06 AM, when asked about the urinary catheter bag and tubing resting on the floor, RN A agreed the catheter tubing and drainage bag should be kept off the floor. The facility policy Catheter Care dated as reviewed 5/10/24 read in part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use . Privacy bags will be available and catheter drainage bags will be covered at all times while in use .

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to revise or update care plans to reflect residents' status for five Residents (R50, R39, R20, R32, and R29) of seventeen residents reviewed for care plans. This deficient practice resulted in the potential for inadequate care and unmet care needs. Findings include: The infection surveillance line list for July 2024 documented eleven residents with signs and symptoms of infections. Ten of the eleven residents received antibiotic therapy for infections. During an interview with the facility Infection Preventionist (IP) on 7/24/24 at 10:47 a.m., the IP was asked if care plans were developed for residents with symptomatic infections or if current care plans were amended and updated to include interventions for infections. The IP responded, some of them. Four of the residents listed on July 2024 line-listing were reviewed with the IP for care plans. Resident #50 (R50) was diagnosed with a Urinary Tract Infection (UTI) and subsequently prescribed the antibiotics Keflex on 7/10/24 and Bactrim DS on 7/15/24. R50 was documented on the July 2024 infection line list as having symptoms of increased fatigue and hematuria (blood in the urine). R50's medical record did not contain a care plan for the infection to provide staff with interventions to address R50's symptoms of infection. Resident #39 (R39) was diagnosed with a UTI and prescribed Rocephin and Macrobid starting 7/10/24. R39 had the following symptoms documented on the July 2024 infection line list: urinary urgency, lethargy, painful urination, mental changes, and decreased appetite. R39's medical record did not contain a care plan for the infection to provide staff with interventions to address R39's symptoms of infection. Resident #20 (R20) was diagnosed with a UTI and prescribed Levaquin starting 7/22/24. The documented symptoms on the July 2024 infection line list reflected R20 had painful urination and mental status changes. R20's medical record did not contain a care plan for the infection to provide staff with interventions to address R20's symptoms of infection. Resident #32 (R32) was admitted to the facility 6/6/24. A Minimum Data Set (MDS) assessment dated [DATE] documented R32 was infected with a multi drug resistant organism. R32 required Vancomycin administered via peripherally inserted central catheter (PICC - a tube inserted into a vein in the arm that passes to a larger vein near the heart) for Osteomyelitis (bone infection) of the vertebra. R32 was additionally diagnosed with a UTI on 7/22/24 for which he was started on Levaquin in addition to the Vancomycin. R32's medical record did not contain a care plan for the infections or the PICC to provide staff with interventions to address R32's infection or to maintain R32's PICC. 40383 Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left sided paralysis. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 of 15 indicating moderate cognitive impairment and the ability to transfer from chair to bed or off toilet required Substantial/maximal assistance - Helper does MORE THAN HALF the effort. This MDS also revealed R29 had a functional limitation in range of motion with impairment on one side for both upper and lower extremities. During an interview on 7/23/24 at 9:06 AM, R29 stated she had hurt her leg during a transfer early in the morning about 5 days ago. There was a question if the lift was used properly or used at all. On 7/23/24 the Nursing Home Administrator (NHA) presented the facility investigation on this concern which had been reported to the State Agency (SA). The investigation revealed that on 7/4/23 R29 had been transferred with the sit-to-stand lift and the resident had reported pain. That same day, R29 was transferred to the hospital for x -rays and further investigation. Upon return to the facility on [DATE], the resident had a leg immobilizer and assessed to need transfers with a maxi lift. During a telephone interview on 7/25/24 at 10:38 AM, Certified Nurse Aide (CNA) F stated she recalled the incident on 7/4/24 when she got R29 up as usual. CNA F stated she used the stand-up (sit-to-stand) lift as I always do. During an interview on 7/25/24 at 8:32 AM, CNA G stated R29 was recently changed to a maxi lift after she got the leg immobilizer. CNA G confirmed R29 used to be transferred with a sit-to-stand lift prior to her immobilizer being applied. The care plan for R29 was reviewed and listed an intervention of TRANSFER: The resident requires (Substantial assistance) by staff to move between surfaces as necessary. Use maxi lift until seen by ortho (orthopedics specialty). (Initiated on) 7/22/2024. During an interview on 7/25/24 at 8:27 AM, the Assistant Director of Nursing (ADON)/Registered Nurse (RN) A noted the care plan showed the sit to stand lift was changed to a maxi lift after the hospitalization on [DATE]. RN A stated the change to non-weight bearing and use of the maxi lift occurred as soon as R29 returned on 7/4/24, but the care plan was not updated until 7/22/24. RN A said the care plan should have been updated with the change in care. The facility policy titled Care Plan Revisions Upon Status Change dated 2023 read in part: The comprehensive care plan will be reviewed, and revised as necessary, when a resident experiences a status change . The care plan will be updated with new or modified interventions.

Based on observation, interview, and record review, the facility failed to provide sufficient staffing to meet the needs of the residents. This deficient practice resulted in an inability to provide needed services as voiced by 10 of 10 residents in attendance at a confidential group meeting and in an inability to sufficiently supervise 4 of 4 residents (R3, R17, R41, and R23) residing on the dementia unit. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. On 7/23/24 at 11:30 AM, a confidential group meeting was held with ten residents of the facility. In this meeting Resident C1 stated there was a poor attitude among the Certified Nurse Aides (CNAs). C1 stated, the CNAs did not want to listen and would say, they have been doing this for [AGE] years an implied they knew it all. C2 stated the CNAs do not seem to come in my room. C1 explained when she turns on her call light for help, the staff turn off the light and I have had accidents and have sat in soil for an hour or more. The group said the facility does not have enough staff. C3 stated while there are some awesome aides, others turn off the call lights and never help you. C8 stated we have to wait a long time especially on the weekends. C5 and C10 stated they both had accidents because the light was on, and no one would help them use the bathroom. One resident (who did not even want a confidential identifier as she felt there could be retaliation) said she almost fell as she decided she could no longer wait for a staff member and tried to walk to the bathroom herself. When the question was posed: How many of you feel the facility does not have enough staff, every member of the confidential group meeting stated there were not enough staff to take care of their needs. The minutes from previous Resident Council monthly meetings were reviewed. On 7/23/24 at 7:44 AM, the Resident Council minutes were reviewed. The 4/23/24 minutes noted in new business under the section Nursing/Aides: an issue with timely response to call lights was reported. The following meeting on 5/21/24 there was no mention of resolution or action taken on the call light concern. The June meeting was rescheduled to 7/1/24 and minutes under the section Nursing/Aides: recorded . Don't like them saying they're understaffed; we feel they use it as an excuse. We've heard them in the hallway talking. Beds are not being made completely/Neatly. (Education at the next CNA Meeting will be given). At the following meeting on 7/18/24 the paragraph from the Nursing/Aides section was repeated word for word in the Old Business section of the minutes. There were no responses of resolution, actions taken, or dates when the promised CNA education had occurred or was scheduled to address the staffing issues. 41978 An observation upon entering the Special Care Unit (SCU), the facility's locked dementia/behavioral care unit, on 7/22/2024 at 1:18 p.m., revealed R17 ambulating using a front-wheeled walker, down the hall toward the entrance/exit of the SCU. There were no staff visible in the hallway at the time of the observation. R17 was looking into resident rooms as she walked down the hall and appeared lost. R17 was heard mumbling as she entered the doorway of room [ROOM NUMBER], maybe this is it, I don't know, I need help. R17 continued down the hall toward the nurses' station, found and entered her room then proceeded to lay down in her bed. R17 could be heard calling out from her room, ow, ow. At 1:26 p.m., an unidentified staff member entered the SCU and upon hearing R17 calling out, entered R17's room at which time R17 reported my knees are killing me. The unidentified staff member closed the door to R17's room to provide care for the resident. Further observation revealed nine residents sitting in the living room area outside the nurses' station and one Resident (R41) ambulating in the hallway toward the entrance/exit of the SCU. It was noted there were no staff present in the nurses' station, hallways or living room area at the time of the observation. On 7/22/2024 at 1:27 p.m., R41 was observed ambulating in the hallway of the SCU near the entrance/exit of the unit. R41 stopped in front of a locked utility room near the entrance/exit of the unit and proceeded to turn the doorknob in an attempt to enter the room. R41 then turned and walked back down the hallway toward the empty nurses' station, at which time R23 was observed self-propelling in her wheelchair from the dining room area toward her room across from the nurses' station. R41 followed R23 into her room and proceeded to push R23 in her wheelchair toward her bed and attempted to assist R23 to stand but was unsuccessful. R41 was heard stating we need to get closer [to the bed]. It was noted there were no footrests attached to R23's wheelchair at the time of the observation. R41 then proceeded to push R23 in her wheelchair toward her closet. At 1:33 p.m., the unidentified staff member exited R17's room and proceeded to walk toward the nurses' station at which time she saw R41 in R23's room. The unidentified staff member redirected R41 out of R23's room and toward the dining room area. At 1:37 p.m., R41 was observed ambulating aimlessly and unattended, up and down the hallway of the SCU. An observation on 7/22/2024 at 2:05 p.m., revealed R41 walking toward the entrance/exit of the SCU. No staff were present at the time of the observation. At 2:08 p.m., Certified Nurse Assistant (CNA) X and an unidentified staff member entered the hallway from behind a closed door. CNA X turned to R41 and told the Resident to, come here, waving her hand down the hall toward the nurses' station. CNA X and the unidentified staff member continued down the hall to the dining room area. R41 was observed to stop at the unattended nurses' station and was heard asking, will someone let me out, please while attempting to open the locked door leading to the nurses' station. R41 proceeded to walk down the hall and sat in a chair in the hallway between rooms [ROOM NUMBERS]. At 2:16 p.m., CNA X entered the hallway and approached R41 at which time R41 asked CNA X to, let me out, please. CNA X asked R41 where he wanted to go and R41 answered, home. An observation upon entering the SCU on 7/23/2024 at 9:27 a.m., revealed no staff present in the hallway. R3 was observed ambulating with a front-wheeled walker down the hallway toward the entrance/exit of the unit. R3 appeared lost and confused and was heard saying, there's never anyone to ask . now to find my room. R3 walked to the entrance/exit door, turned and walked back down the hall toward the living room area. R3 stopped and entered R17's room, with R17 sleeping in bed, and looked around before exiting and heading back toward the living room and past her room proceeded to attempt to open the locked door to the empty nurses' station. R3 then walked to the living room and sat down in a chair near the nurses' station window. At 9:32 a.m., CNA X emerged from the dining room area. Further observation revealed CNA Y seated in the dining room providing dining assistance to two unidentified residents. During an interview at the time of the observation, CNA X reported this day there were two CNAs scheduled to work the SCU, herself and CNA Y. When asked if there were always two staff members present on the SCU, CNA X reported some days there was only one CNA scheduled to work on the SCU. CNA X reported a nurse was also assigned to the SCU, but the nurse would be split between the SCU, located on the second floor, and another unit on the first floor of the building, therefore was only present on the unit during medication pass. CNA X reported there are many residents residing on the SCU which required constant supervision. During an interview outside the SCU medication storage room, on 7/24/2024 at 9:45 a.m., Registered Nurse (RN) E reported R41 was noted to be more anxious and difficult to redirect during the previous shift. During the interview, the SCU exit door alarm sounded and CNA X was observed running down the hall toward the exit door. Further observation revealed R41 pushing through the exit door and stepping off the unit as CNA X approached and redirected R41 back onto the unit. It was noted the exit door led to an unused portion of the building's second floor, the elevator and stairway. An observation on 7/24/2024 at 7:46 a.m., revealed nine residents seated in the living area of the SCU. R41 was observed sleeping in a reclining chair across from the nurses' station. CNA F was seated in a chair near the nurses' station window. During an interview at the time of the observation, CNA F reported she was seated in the living room to supervise R41. CNA F reported R41 was going in other resident's rooms and she consistently needed to redirect him throughout her shift. When asked if a nurse was assigned to the SCU, CNA F reported a nurse would come up for medication pass earlier in the evening but then would leave the unit to go downstairs and attend to residents on the first floor of the facility and would come back up to the SCU, if summoned. Review of the facility staff Daily Schedule(s), for June 2024 through 7/25/2024, provided by Unit Manager, RN E, revealed the following: 6/08/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. One charge nurse worked 11:00 p.m. - 7:00 a.m.; 300 Wing: One CNA worked 11:00 p.m. - 7:00 a.m. One charge nurse worked 11:00 a.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m.; 100 Wing and Rooms 201, 202, 301 and 302: One CNA worked 11:00 p.m. - 7:00 a.m. No charge nurse scheduled. 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. No charge nurse scheduled. Review of the Shift Staffing Summary, dated 6/08/2024 revealed a resident census of 61. Comparison of the Daily Schedule, and the Shift Staffing Summary, revealed the facility assessed the need of two licensed nursing staff and 6.5 unlicensed nursing staff for the 11:00 p.m. - 7:00 a.m. shift for a total need for direct care staff of 8.5. It was noted only four unlicensed nursing staff shifts were scheduled/worked and a total of two licensed nurse shifts worked for a total direct care staff of six. 6/22/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA worked entire shift. One CNA worked 3:00 a.m. - 7:00 a.m. One charge nurse worked entire shift; 300 Wing: Two CNAs worked entire shift. On charge nurse worked 11:00 p.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m.; 100 Wing and Rooms 201, 202, 301 and 302: No staff worked/scheduled; 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. Review of the Shift Staffing Summary, dated 6/22/2024 revealed a resident census of 62. Comparison of the Daily Schedule, and the Shift Staffing Summary, revealed the facility assessed the need of two licensed nursing staff and five on-duty unlicensed nursing staff for the 11:00 p.m. - 7:00 a.m. shift for a total need for direct care staff of seven. It was noted only four unlicensed nursing staff shifts and two licensed nursing staff shifts were worked for a total direct care staff of six. 6/23/2024: Shift 7:00 a.m. - 3:00 p.m. 200 Wing: Two CNAs worked entire shift. One charge nurse worked the entire shift; 300 Wing: Two CNAs and one charge nurse worked the entire shift; 100 Wing: no staff scheduled/worked; 400 Wing (SCU, Second Floor): One charge nurse worked 7:00 a.m. - 11:00 a.m. and one charge nurse worked 11:00 a.m. - 3:00 p.m. One CNA worked the entire shift. Review of the Shift Staffing Summary, revealed a resident census of 64. Comparison of the Daily Schedule, and the Shift Staffing summary, revealed the facility assessed the need of three licensed nursing staff and six scheduled/on-duty unlicensed nursing staff for the 7:00 a.m. - 3:00 p.m. shift for a total need for direct care staff of nine. It was noted only five unlicensed nursing staff, and three licensed nursing staff shifts were worked for a total direct care staff of eight. 7/06/2024: Shift 11:00 p.m. - 7:00 a.m. 200 Wing: One CNA and one charge nurse worked the entire shift. One CNA worked 11:00 p.m. - 3:00 a.m.; 300 Wing: One charge nurse worked 11:00 p.m. - 3:00 a.m. and one charge nurse worked 3:00 a.m. - 7:00 a.m. One CNA worked the entire shift and one CNA worked 11:00 p.m. - 3:00 a.m.; 100 Wing: no staff scheduled/worked. 400 Wing (SCU, Second Floor): One CNA worked 11:00 p.m. - 3:00 a.m. and one CNA worked 3:00 a.m. - 7:00 a.m. It was noted in review direct care staff scheduled/worked totaled four and one-half (4.5) for a total resident census of 62 per the Shift Staffing Summary, dated 7/06/2024. Further review of the Shift Staffing Summary, revealed an assessed need of six direct care staff for the 11:00 p.m. - 7:00 a.m. shift. Review of the resident population conditions provided by Human Resource Director, Staff Z revealed as of 7/25/2024 the resident population of 63 included the following: Eight residents requiring two-person assistance with transfers/care. Eight residents requiring the use of a sit-to stand lift for transfers. Nine residents requiring the use of a two-person assisted, total mechanical lift for transfers. 54 residents assessed as being at risk for falls. 12 residents assessed at risk for elopement. During an interview on 7/25/2024 at 11:05 a.m., the Director of Nursing (DON) reported staffing needs are based on resident acuity and total census. The DON reported the residents residing on the SCU had dementia or psychological conditions requiring increased safety needs and supervision. The DON stated she was new to the facility and was working on having the SCU fully staffed. The DON acknowledged a safety concern when only one staff member was working on the second-floor unit due to the constant need for supervision and the distance other staff would have to travel when called for assistance. Review of the Facility Assessment, dated 3/17/2024, revealed the following, in part: Our Resident Profile . 400 Wing is our Special Care Unit . accommodates 30 residents in total . To be a member of the Special Care Unit you must have cognitive impairment and/or behavioral issues and benefit from a more structured environment with less stimulation .

Based on observation, interview, and record review, the facility failed to 1.) safely securing narcotic medications in one of two medication rooms; 2.) not dating biologicals in one of three medication carts reviewed for medication storage. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On [DATE] at 8:45 AM, an observation was made of the 200-hall medication cart. The 200-medication cart was found to have the following: a. Two undated and opened insulin pens; An observation was made on [DATE] at 8:20 AM, of the first-floor medication storage room. The first-floor medication storage room was found to have the following: a. Two vials and one liquid dropper bottle of lorazepam (scheduled II controlled substance) in a small refrigerator with no secondary lock. LPN T confirmed the lorazepam, which is a controlled substance should be under two locks. On [DATE] at 8:30 AM, an observation was made of LPN H preparing medication pass for a Resident #14 (R14) and LPN H dropped a tablet of carvedilol on top of the medication cart. LPN H picked it up and threw it in the medication cart trash. LPN H proceeded to dispense medications for R14 and dropped a doxycycline on top of the medication cart and again picked it up and threw it in the medication cart trash. LPN H continued to dispense medications for R14 and dropped twice in a row spironolactone on top of the medication cart and after the second time he dropped the medication on top of the medication cart, he picked the second spironolactone up with his bare hands and placed it in the medication cup he was preparing for R14. LPN H was without explanation of why he used his bare hands, did not perform hand hygiene, or used the second dropped spironolactone and placed it in the medication cup for R14. On [DATE] at 9:45 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked what the regulation was for storing controlled substances. RN A replied, They need to be double locked. RN A asked what this Surveyor was referring to and was told about how lorazepam was stored in the first-floor medication room refrigerator. RN A stated I do remember asking about that a little while ago. I told the maintenance guy we needed a lock on that refrigerator months ago. Review of policy titled, Medication Storage, dated [DATE], read in part, Policy: It is the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .2. Narcotics and Controlled Substances: a. Scheduled II drugs and back-up stock of Scheduled III, IV, and V medications are stored under a double-lock and key. B. Scheduled II controlled medications are to be stored within a separately locked permanently affixed compartment when other medications are stored in the same area, such as in refrigerator . Review of policy titled, Destruction of Unused Drugs, undated, read in part, Policy: All unused, contaminated, or expired prescription drugs shall be disposed of in accordance with state laws and regulations .1. Drugs will be destroyed in a manner that renders the drugs unfit for human consumption and disposed of in compliance with all current and applicable state and federal requirements. 2. Unused, unwanted and non-returnable medications should be removed from their storage area and secured until destroyed .

All times are in Eastern Daylight Time (EDT) unless otherwise noted Based on interview and record review, the facility failed to honor the advanced directive for one Resident (R20) of four residents reviewed for advance directives. This deficient practice resulted in the potential for residents' decisions regarding end-of-life care and medical care to not be followed by the facility. Findings include: Resident #20 (R20) R20's medical record included an order for Do Not Resuscitate (DNR). R20 signed an Advanced Directive (AD) on July 2, 2014. The AD documented, in part: .I want my life to be prolonged by life-sustaining treatment unless I am in a coma or vegetative state which my doctor reasonably believes to be irreversible . A Minimum Data Set (MDS) assessment dated [DATE] documented R20 was not in a vegetative state or coma. The AD further read, in part: . Once my doctor has reasonably concluded that I will remain unconscious for the rest of my life, I do not want life-sustaining treatment to be provided or continued . A review of physician documentation in R20's record revealed documentation of R20 being alert and responding appropriately to the physician during examination. R20 appointed a Patient Advocate (PA) in the AD dated 7/2/2014. The designation of PA and directions for health care documented, in part: .To my family, doctors, and all concerned with my care: These instructions express my wishes about my health care. I want my family, doctors, and everyone else concerned with my care to act in accord with them . . c. A Patient Advocate may make a decision to withhold or withdraw treatment which would allow a Patient to die only if the patient has expressed in a clear and convincing manner that the Patient Advocate is authorized to make such a decision, and that the Patient acknowledges that such a decision could or would allow the Patient's death . No such clear and convincing power was granted to allow the PA to change the code status through this document. A medical determination form of competency was signed by two physicians on January 19, 2024, deeming R20 incapable of participating in medical treatment decisions. A Patient Advocate Consent form for DNR code status was signed and dated by R20's PA on 2/14/24. The form read, in part: .I authorize that in the event the declarant's heart and breathing should stop, no person shall attempt to resuscitate the declarant . The Social Services Coordinator (Staff B) was interviewed on 7/24/24 at 12:50 p.m. Staff B confirmed she oversaw advanced directives in the facility. Documentation including R20's AD, code status order, and physician determination of capacity was reviewed with Staff B. After reviewing the documents, Staff B said, (R20's name) was competent to make his own decisions at the time he signed his Advanced Directive. Staff B was asked why the PA was offered a DNR option if R20 declared his choice of code status when he was cognitively competent to make his own choices and decisions. Staff B responded, I don't think (the PA's name) can sign for (R20's name) to be a DNR. Staff B confirmed there were no court-issued or legal documents allowing the PA to amend R20's choice of code status. Staff B attested there were no additional documents indicating R20 amended or rescinded his choice of code status as outlined in the AD. An undated policy Residents' Rights Regarding Treatment and Advance Directives read, in part: .It is the policy of this facility to support and facilitate a resident's right to request . medical or surgical treatment and to formulate an advance directive . Advanced directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under state law relating to the provision of health care when the individual is incapacitated .

Based on observation, interview, and record review, the facility failed to report potential abuse to the State Agency as required for two Resident (R23 and R45) of three Residents reviewed for abuse reporting. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #45 (R45) According to the Minimum Data Set (MDS) assessment, dated 4/10/24, R45 had a Brief Interview for Mental Status (BIMS) assessment and scored 03/15 which indicated severe cognitive impairment, with diagnoses including dementia and anxiety. On 7/25/24 at 9:45 AM, an observation was made of R45 in her bathroom being toileted with Certified Nurse Aide (CNA) P and CNA Q. R45 was sitting on the toilet and was noted to have a quarter sized circular bruise on her right thigh. Both CNA P and CNA Q were asked how long the bruise had been on R45's right thigh and if it was reported to management and replied, We are not sure. Neither of us had worked in the last couple of days. Review of the facility incident and accident report, dated 4/25/24, read in part, .found a bruise during morning care .there are 2 small skin discolorations on right upper thigh. It looked like in different stages of healing. Approximately 2 cm (centimeters) in circumference bigger area and approximately 1 cm next to it. Resident unable to give description. Further review of the report revealed that it was also reported to the family, Director of Nursing, and physician. Review of the facility incident and accident report, dated 5/27/24, read in part, .observed red bruising on left arm .bruises measuring 2.6 x 1.1 cm, 2.1 x 1.8 cm, and 1.0 x 2.1 cm, with multiple pin point red area's. Resident unable to give description. On 7/25/24 at 10:22 AM, an interview was conducted with the ADON/RN A and the Nursing Home Administrator (NHA) regarding the 4/25/24 and the 5/27/24 incident and accident reports from R45. The ADON/RN A and the NHA were both asked if either incident involving R45 were reported to the State Agency and replied, We did not report these, and we should have but we were not made aware of this incident. The ADON/RN A stated that, We are not getting the calls from the incident and accident reports. Sometimes they are not filled out correctly. The floor nurses don't know what's reportable and don't always call and get clarification. Review of policy titled, Abuse, Neglect, and Exploitation, dated 5/2/23, read in part, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property .Identification of Abuse, Neglect and Exploitation .B. Possible indicators of abuse include, but are not limited to .2. Physical marks such as bruises or pattered appearances such as a hand print .Investigation of Alleged Abuse, Neglect and Exploitation .Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . 41978 Resident #23 (R23) R23 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, anxiety and depression. Review of R23's Minimum Data Set (MDS) assessment, dated 4/26/2024, revealed she required substantial/maximal assistance with toileting, bathing, dressing and personal hygiene. Further review of the MDS assessment revealed R23 scored three out of 15 (3/15) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. Review of R23's electronic medical record (EMR) revealed the following: 2/22/2024, 14:30 [2:30 p.m. Central Savings Time, CST]. Incident Note . CNA [Certified Nursing Assistant] noted a bruise to resident's left bicep during her bath this afternoon. [CNA] stated that resident did not bump her arm while getting into the tub . unaware of resident bumping her arm today. Resident was a partial this morning and therefore was dressed early this morning by night shift . DON . ADON notified. Review of R23's Injury report, dated 2/22/2024 at 2:22 p.m. CST, revealed the following written statements: CNA X, dated 2/22/2024: No known injuries while I was with [R23] today 2/22/24 or any days earlier. CNA CC, dated 2/22/2024: I was giving [R23] a bath when I noticed a red area on her upper left arm and a Band-Aid a little above the red area. CNA DD, dated 2/22/2024: I worked on 400 [Special Care Unit] from [7:00 a.m. - 3:00 p.m.] and became aware of [R23's] arm redness at 2:20 p.m. when I started for the day she was already dressed. CNA EE dated 2/22/2024: I partialed [sic] resident in her bed [at] approx. 5:30 a.m. she stayed in bed until 6:30ish [sic]. I did not see any red marks on her arm at any time during this period. Further review of R23's EMR revealed the following: 2/22/2024 at 2:18 p.m. Skin & Wound Evaluation V7.0 . Type: Bruise . Location: Upper left arm (inner) . New . Wound Measurements: Area 26.3 cm2 [cubic centimeters]. Length 5.7 cm. Width 5.5 cm .? During an interview on 7/24/2024 at 4:18 p.m., the ADON reported the facility had not determined the cause of R23's bruising and application of a Band-Aid on 2/22/2024. The ADON confirmed an abuse investigation was not initiated and the incident was not reported to the SA. The DON, present during the interview, reported someone had to know what happened to cause the injury because R23 did not have access to Band-Aids and did not have the cognitive ability to apply a Band-Aid to her left inner arm.

Based on observation, interview, and record review, the facility failed to investigate potential abuse to the State Agency as required for two Resident (R#23 and R#45) of three Residents reviewed for abuse investigating. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #45 (R45) According to the Minimum Data Set (MDS) assessment, dated 4/10/24, R45 had a Brief Interview for Mental Status (BIMS) assessment and scored 03/15 which indicates severe cognitive impairment, with diagnoses including dementia and anxiety. On 7/25/24 at 9:45 AM, an observation was made of R45 in her bathroom being toileted with Certified Nurse Aide (CNA) P and CNA Q. R45 was sitting on the toilet and was noted to have a quarter sized circular bruise on her right thigh. Both CNA P and CNA Q were asked how long the bruise had been on R45's right thigh and if it was reported to management and replied, We are not sure. Neither of us had worked in the last couple of days. Review of the facility incident and accident report, dated 4/25/24, read in part, .found a bruise during morning care .there are 2 small skin discolorations on right upper thigh. It looked like in different stages of healing. Approximately 2 cm (centimeters) in circumference bigger area and approximately 1 cm next to it. Resident unable to give description. Further review of the report revealed that it was also reported to the family, Director of Nursing, and physician. Review of witness statement, dated 4/25/24, from CNA V, read in part, I had not did cares on resident since Monday noc (night) 4/22/24 - I had not seen anything as of that date . Review of witness statement, dated 4/25/24, from CNA U, read in part, .I noted two bruises on (R45's) upper right thigh near vagina reported to (nurse) . Review of the facility incident and accident report, dated 5/27/24, read in part, .observed red bruising on left arm .bruises measuring 2.6 x 1.1 cm, 2.1 x 1.8 cm, and 1.0 x 2.1 cm, with multiple pin point red area's. Resident unable to give description. Review of witness statement, dated 5/27/24, from CNA W, read in part, .Left arm bruise .I did not notice bruise all day as she (R45) was wearing sweatshirt all day . Review of witness statement, dated 5/27/24, from CNA Q, read in part, .bruise left lower arm .daughter noticed the bruise she (R45) had a sweater on all day and didn't notice . Review of R45's two incident and accident reports, dated 4/25/24 and 5/27/24, revealed the lack of any other facility employees being interviewed for witness statements to include a full investigation was conducted per facility policy. Interviews were only done with immediate staff working R45's hallway and not all staff from that day on other halls worked, or the prior two days to rule out any type of abuse or neglect. On 7/25/24 at 10:22 AM, an interview was conducted with Assistant Director of Nursing (ADON)/Registered Nurse (RN) A and the Nursing Home Administrator (NHA) regarding the 4/25/24 and the 5/27/24 incident and accident reports for R45. RN A and the NHA were both asked if either incident involving R45 were fully investigated and replied, We did not fully investigate these, and we should have but we were not made aware of this incident. We would have interviewed all staff working the days the bruising had been discovered and the prior two days before those days. RN A stated that, We are not getting the calls from the incident and accident reports. Review of policy titled, Abuse, Neglect, and Exploitation, dated 5/2/23, read in part, .Investigation of Alleged Abuse, Neglect and Exploitation .Written procedures for investigations include .4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation . 41978 Resident #23 (R23) R23 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's dementia, anxiety and depression. Review of R23's MDS assessment, dated 4/26/2024, revealed she required substantial/maximal assistance with toileting, bathing, dressing and personal hygiene. Further review of the MDS assessment revealed R23 scored three out of 15 (3/15) on the BIMS, indicating severe cognitive impairment. An observation on 7/24/2024 at 9:58 a.m. revealed CNA X and CNA DD assisting R23 with toileting in the shower room on the Special Care Unit (SCU). R23 was observed to have a large, linear purple bruise on the inner aspect of the back of her right lower leg. CNA X and CNA DD reported they were unaware of the bruising. CNA DD reported R23 often bumped herself. When care was completed, R23 was transferred from the toilet to her wheelchair which was positioned facing her. Upon standing, R23 was assisted to pivot so her buttocks were facing the chair. CNA DD placed a gait belt around R23's midsection and stood on the right side of the wheelchair with CNA X standing on the left. After R23 was pivoted so her buttocks were positioned over the wheelchair seat, CNA X lowered R23 to the seat by using her left hand and holding tightly onto the R23's left upper arm and lowered R23 to a seated position. Review of R23's electronic medical record (EMR) revealed the following: 7/18/2024 [7:53 a.m. Central Daylight Time] Skin/Wound Note . Resident noted to have a dark purple bruise to the back of left lower leg. Fading noted Resident noted to have a dark purple bruise to the back of right lower leg. Fading noted . Review of the Injury report, dated 7/13/2024 at 6:00 a.m., revealed the following: [CNA FF] found 2 bruises on resident while giving her her [sic] weekly shower. One to left, lower inner leg that measures 3 cm [centimeters] by 4.5 cm and back of right lower leg that measures 3 cm by 3.5 cm. Resident unable to give description. Review of CNA FF's written statement, attached to the Injury report, revealed the following: 7/13/2024 . Bruises found on back of legs where foot pedals located. Noticed bruises on back of lower legs during her shower. Bruises located right where foot pedals of wheelchair hit. During review of R23's Injury reports on 7/24/2024 at 4:18 p.m., RN A reported no investigation was conducted to look into the cause of R23's bruises found on 7/13/2024. RN A stated CNA FF's written statement was not obtained until the current day, 7/24/2024. The ADON confirmed R23 had severe cognitive impairment and could not account for how the bruising occurred. The DON, present at the time of the interview, reported the injury should have been investigated to rule out abuse or mistreatment.

Based on interview and record review, the facility failed to provide written transfer notification to the resident and resident's representative including reason, effective dates, and the location to which the resident was being transferred for one Resident (R39), of two residents reviewed for transfers out of the facility. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #39 (R39) The medical record for R39 revealed a transfer to the hospital on 7/9/23. The medical record did not indicate a written notification of transfer was given to R39 or sent to her representative. During an interview on 7/25/24 at 10:58 AM, Administrative Staff C stated she did not send written notifications of hospitalization stays to any residents or their representatives. She was not aware this was required. Staff C stated the previous person in her position had retired. The facility policy titled Transfer and discharge date d 7/2024 was provided and read in part: 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident . g. Provide a notice of transfer and the facility's bed hold policy to the resident and representative as indicated.

Based on interview and record review, the facility failed to develop comprehensive care plans for two Residents (R41 and R54) of 17 residents reviewed for care planning. This deficient practice resulted in the lack of care plan goals and interventions, with the potential for unmet needs. Findings include: All times are recorded in Eastern Daylight Time (EDT) unless otherwise noted. Resident #54 (R54) R54 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, congestive heart failure, diabetes, major depressive disorder, panic disorder, anxiety disorder, dementia and multiple fracture history. On 7/22/24 the facility presented a matrix with all residents listed which included conditions and concerns. R54 was listed as End of Life Care/Comfort Care/ Palliative Care. The Electronic Medical Record (EMR) reflected weights of: 7/22/24 187.0 pounds 6/24/24 199.0 pounds 4/22/24 220.0 pounds 1/22/24 232.0 pounds These weights indicated a 6% weight loss in one month, a 9% weight loss over three months, and a 19% weight loss over six months (all significant weight losses). On 7/22/24 at 1:28 PM, the lunch tray arrived in the room of R54, but he was sleeping and showed no interest in lunch. Certified Nurse Aide D stated, Right now he is not eating much at all. On 7/22/24 At 2:19 PM, R54's tray was observed as he was finished with lunch. R54 had eaten nothing. The lid remained on the beverage of milk and although the salisbury steak was cut up, nothing had been consumed. On 7/23/24 at 1:23 PM, family members were present and trying to encourage R54 to eat lunch. He was belligerent and non-compliant. R54's family member spoke to this surveyor in private and stated R54 was declining and the family wanted R54 comfortable on palliative care. The EMR for R54 was reviewed. No physician order or care plan for palliative care was found. On 7/25/24 at 11:25 AM, Registered Nurse (RN) E reviewed the EMR and stated, We don't have an order or a care plan for palliative care (for R54), but we probably should. On 7/25/24 at approximately 11:45 AM, Assistant Director of Nursing (ADON)/RN A stated R54 had a significant change assessment completed in March 2024 due to his decline. RN Aagreed a care plan for palliative care should have been written. The facility policy titled Providing End of Life Care dated 5/24/24 read in part, Recognition: Residents will be evaluated for end of life care concerns upon admission, during scheduled assessments, and upon change of condition or status . Preferences for palliative care, hospice care, and advance directives will be identified and documented in the medical record . The facility and resident/family will coordinate a plan of care, and will implement interventions in accordance with the comprehensive assessment, and the resident's needs, goals, and preferences. The plan of care will identify the care and services that each discipline will provide. 41978 Resident #41 (R41) R41 was admitted to the facility on [DATE] and had diagnoses including dementia and anxiety disorder. Review of R41's Minimum Data Set (MDS) assessment, dated 6/18/2024, revealed he was independent with mobility and walking. Further review of the MDS assessment revealed R41 scored five out of 10 (5/10) on the Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. An observation on 7/22/2024 at 2:05 p.m., revealed R41 walking up and down the hallway near the entrance/exit of the SCU. At 2:08 p.m., Certified Nurse Assistant (CNA) X and an unidentified staff member entered the hallway from behind a closed door. CNA X turned to R41 and told the Resident to, come here, waving her hand down the hall toward the nurses' station. CNA X and the unidentified staff member continued down the hall to the dining room area. R41 stopped at the unattended nurses' station and was heard asking, will someone let me out, please while attempting to open the locked door leading to the nurses' station. R41 proceeded to walk down the hall and sat in a chair in the hallway between rooms [ROOM NUMBERS]. At 2:16 p.m., CNA X entered the hallway and approached R41 at which time R41 asked CNA X to, let me out, please. CNA X asked R41 where he wanted to go and R41 answered, home. During an interview outside the SCU medication storage room, on 7/24/2024 at 9:45 a.m., RN E reported R41 was noted to be more anxious and difficult to redirect during the previous shift. RN E stated R41's wandering and exit-seeking behavior seemed to worsen with the current attempt to reduce his psychotropic medications. During the interview, the SCU exit door alarm sounded and CNA X was observed running down the hall toward the exit door. Further observation revealed R41 pushing through the exit door and stepping off the unit as CNA X approached and redirected R41 back onto the unit. It was noted the exit door led to an unused portion of the building's second floor, the elevator and stairway. An observation on 7/24/2024 at 7:46 a.m., revealed R41 sleeping in a reclining chair across from the nurses' station. CNA F was seated in a chair near the nurses' station window. During an interview at the time of the observation, CNA F reported she was seated in the living room to supervise R41. CNA F reported R41 was going in other resident's rooms and she consistently needed to redirect him throughout her shift. Review of R41's EMR revealed the following, in part: 6/15/2024, 23:00 [11:00 p.m.]. Progress Note. Patient was admitted to [acute care hospital] for advancing dementia with behavioral disturbance . now admitted to the facility for long-term care in the memory unit where he will be able to ambulate in a controlled environment . Review of R41's care plan revealed no focus area, goals or interventions related to his wandering, exit-seeking behavior, or elopement risk. During an interview on 7/24/2024 at 4:16 p.m., RN A confirmed R41's care plan did not include a focus area, goal or interventions related to his wandering, exit-seeking behavior, or elopement risk. The DON (Director of Nursing), who was present at the time of the interview, reported R41 was admitted to the facility for the primary reason of requiring increased supervision related to unsafe wandering. Review of the undated facility policy titled Comprehensive Care Plans, revealed the following, in part: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . that The comprehensive care plan will describe, at a minimum, the following: the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being .

Based on observation, interview, and record review, the facility failed to provide medication administration to meet professional standards 1.) administer antibiotics according to physician order and 2.) flush peripherally inserted central catheter (PICC) for one Resident #32 of four residents reviewed for medication administration. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. Resident #32 (R32) Review of R32's physician order, dated 6/27/24, revealed an order for vancomycin 750 mg (milligrams) / 150 ml (milliliters), intravenously one time a day for sepsis until 8/6/24. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R32. LPN R accessed R32's PICC line using a 10 ml (milliliter) syringe filled with normal saline solution. LPN R failed to check for a blood return prior to administering the saline solution into the PICC line. R32's PICC line dressing was observed dated 7/10/24 indicating when the last time the dressing was changed. On 7/23/24 at 8:10 AM, an interview was conducted with LPN R and was asked if she checked for placement on R32's PICC line by pulling back on the syringe to watch for a blood return and replied, No, no one ever taught me that. I did not know I had to do that. LPN R was asked if R32's dressing was over due to be changed and replied, Yes, it should have been changed on the 17th last Wednesday. LPN R was asked who was responsible for PICC line dressing changes and replied, The Registered Nurses' (RNs'). LPN R was asked what she would do if she had a physician order that she could not complete and replied, I would go let one of the RN's know I needed them to complete the dressing change. Review of R32's physician order, dated 6/20/24, revealed an order to change PICC line dressing weekly and PRN (as needed), every day shift, every Wednesday. R32's treatment administration record (TAR) lacked PICC line dressing changes on 7/3/24 and 7/17/24. On 7/24/24 at 10:15 AM, medication administration was observed with LPN H for R32. LPN H accessed R32's PICC line using a 10 ml syringe filled with normal saline solution and failed to check for a blood return prior to administering the saline solution into the PICC line. On 7/24/24 at 10:20 AM, an interview was conducted with LPN H and was asked if he pulled back on the saline syringe before administering the saline solution into R32's PICC line and replied, No, I guess I forgot to do that. On 7/24/24 at 11:30 AM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A and was asked if the LPNs are trained on medication pass for PICC lines and replied, Yes. It is part of their nursing competencies. Review of facility document titled, Licensed Practical Nurse Skills Checklist, for LPN H and LPN R, dated 5/20/24, revealed no current competencies for IV skills related to administration and maintenance. Review of policy titled, Peripherally Inserted Central Catheter Flushing, Locking, Removal, undated, read in part, Policy: It is the policy of this facility to ensure that peripherally inserted central catheters (PICC) are flushed, locked and removed consistent with current standards of practice .Compliance Guidelines .3. Peripherally inserted central catheters will be flushed and aspirated for blood return prior to each infusion to assess catheter functionality and prevent complications .Flushing .7. Slowly aspirate for a blood return to confirm device patency. 8. If blood return is not obtained, investigate for external causes of obstruction and notify physician if troubleshooting is ineffective .

Based on observation, interview, and record review, the facility failed to meet the nutritional needs and preferences for two Residents (R29 and R54) of 3 residents reviewed for nutrition. This deficient practice resulted in residents not receiving prescribed diet, food preferences, experiencing thirst, and potential risk for physical decline. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left side paralysis. The Electronic Medical Record (EMR) revealed the physician diet Order Summary: Start dated 11/1/23, Regular diet Pureed texture, Nectar/Mildly Thick consistency . texture varies per DPOA (Durable Power of Attorney) sm (small) portions, gravy w/pureed meat, extra gravy on side, super cereal at B(breakfast), super spuds L (lunch); magic cup thawed or yogurt as dessert, nectar water with all meals; pureed banana . On 7/23/24 at 9:31 AM, the breakfast meal for R29 was observed. The meal tray card indicated a diet order of Puree, nectar mild sm portions HF/HC and contained instructions to give a banana crushed up. This diet order did not match the physician order per the EMR. During an interview on 7/23/24 at 9:45 AM, Dietary Aide (Staff) L stated a banana is difficult to get to the right consistency, so I did not give (R29) one today. The banana was included in the physician's order and was indicated on the meal tray card to be given. Staff L could not explain why dietary staff did not use a mechanical kitchen device to puree the banana if there was really a concern for resident safety. On 7/24/24 at 9:37 AM, the breakfast meal for R29 was observed. No crushed banana was provided. The hand-written instructions on the meal card included yogurt. This surveyor requested CNA O obtain a yogurt for R29. CAN O asked R29 if she would like a yogurt and R29 responded she needed yogurt for her bowels. During an interview on 7/25/24 at 10:13 AM, Certified Dietary Manager (CDM) N discussed R29's preferences and said, She takes a long time to eat and takes small bites and should get it (crushed up banana). CDM N stated if the tray card said yogurt, it should have been on the tray. The EMR care plan read in part, (R29) has potential for unplanned/unexpected weight loss r/t (related to) Poor food/fluid intake with interventions including, Offer substitutes as requested or indicated. The resident prefers : pureed scrambled eggs at breakfast, mushed up banana at breakfast/dinner . Resident #54 (R54) R54 was admitted to the facility on [DATE] with diagnoses including acute and chronic respiratory failure, congestive heart failure, diabetes, major depressive disorder, panic disorder, anxiety disorder, dementia and multiple fracture history. The current physician diet order as written on 3/1/2024, was Controlled Carb diet, Easy to Chew Texture, Regular/Thin consistency, 5 CHO (Carbohydrates)/meal, Large portions of ground meat; sugar cereal at B (breakfast), Large portions of Regular mashed potatoes at L/D (lunch/dinner). Colored plates. The Electronic Medical Record (EMR) reflected weights of: 1/22/24 232.0 pounds 4/22/24 220.0 pounds 6/24/24 199.0 pounds 7/22/24 187.0 pounds These weights indicated a 6% weight loss in one month, a 9% weight loss over three months, and a 19% weight loss over six months (all significant weight losses). On 7/22/24 at 1:22 PM, R54's lunch tray was observed and contained a salisbury steak which was not ground to the consistency specified in the physician's order. The tray card for R54 indicated a diet of CC, HF/HC and instructions of Large Portions ground meat w/gravy. On 7/22/24 at 1:28 PM, the lunch tray arrived in the room of R54, but he was sleeping and showed no interest in lunch. Certified Nurse Aide (CNA) D stated, Right now he is not eating much at all. The tray card for R54 indicated a diet of CC, HF/HC. CNA D was asked what type of diet R54 was on and could not answer what a CC HF/HC diet was and stated, There is a cheat sheet in the kitchen. I do not know what the diet is. On 7/22/24 at 2:19 PM, R54's tray was observed as he was finished with lunch. He had eaten nothing. The lid remained on the beverage of milk and although the salisbury steak was cut up, nothing had been consumed. During an interview on 7/22/24 at 1:48 PM, Dietary Aide (Staff) I was observed serving the lunch meal and stated those residents with mechanical soft or ground meat diets should have gotten ground chicken or ground salisbury steak. Staff I was asked what the HC/HF part of the diet order was. She thought HC was high calorie but did not know what HF was. Staff I found a sheet in the service area and HC/HF was defined as high calorie but the sheet did not indicate what HF stood for. Staff I said she would ask the dietary manager. During an interview on 7/22/24 at 1:52 PM, Dietary Aide (Staff) K was asked what the HC/HF part of the diet order was. Staff K said she was not sure what it was but maybe HF meant High Fructose? During an interview on 7/25/24 at 10:13 AM, CDM N stated We do not have a defined diet called HF/HC. The facility diet manual did not contain a diet called HF/HC. On 7/22/24 at 1:24 PM, two disposable 8 ounce cups of water and one 8 ounce cup with orange juice were observed on R54's bedside table. The table was across the room approximately 8 feet from the bed and not accessible to R54 who was lying in bed with his eyes closed. On 7/22/24 at 3:21 PM, R54 was heard to be crying out in a loud voice, Water. Water. I need some G** D*** water. CNA D went into the room and assisted R54 with the water and then placed the water back on the bedside table out of reach of R54. One minute later R54 exclaimed, I can't reach it. What good is it. Everyone is walking around doing nothing. On 7/22/24 at 3:24 PM, CNA D returned to R54's room with ice cream and R54 turned it down and said, Give me the water. On 7/22/24 at 3:47 PM, a disposable cup of water with straw was observed on the bedside table. R54 was in his bed. The bed was in the low position and the water was approximately 3 feet away and out of reach. On 7/24/24 at 3:18 PM, housekeeping staff GG stated Did you hear him (R54)? R54 had been crying out for water as he could not get to it. Staff GG said the water was too far from his bed and even when the bedside table was moved toward him his hands could not really reach it. The EMR care plan includes: The resident has potential for dehydration r/t diuretic use. The interventions included, The resident will maintain adequate hydration. Assure beverages of choice are offered to Resident. The facility policy titled Hydration and dated 4/2024 read in part: The facility offers each resident sufficient fluid, including water and other liquids, consistent with resident needs and preferences to maintain proper hydration and health . The resident's goals and preferences regarding hydration will be reflected in the resident's plan of care . Provide assistance with drinking. Ensure beverages are available and within reach.

Based on interview and record review, the facility failed to ensure nurse aides completed required dementia training and demonstrated the skills and techniques necessary to care for residents for three contracted Certified Nurse Assistants (CNAs F, AA and BB) of three contract nursing staff reviewed for competency evaluation, resulting in the potential for unmet physical and psychosocial needs for all 63 residents residing in the facility. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. A review of CNA F's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 5/03/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA F indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA F's skills. Review of CNA F's education roster titled Core Mandatory Exam - Nursing, dated 4/18/2024, revealed no completion of dementia training prior to or after beginning care provision at the facility. A review of CNA AA's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 4/10/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA AA indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA AA's skills. Review of CNA AA's education roster titled Core Mandatory Exam - Nursing, dated 4/17/2024, revealed no completion of dementia training prior to or after beginning care provision at the facility. A review of CNA BB's competency evaluation as provided by Human Resources Director, Staff Z on 7/24/2024 at 3:36 p.m., revealed a Skills Checklist by [contract company], dated 7/09/2024. Further review of the Skills Checklist, revealed the checklist to be a self-evaluation completed by CNA BB indicating how frequently she performed tasks and how proficient she felt at the listed tasks. Further review of the documents provided by Staff Z revealed no further evaluation of CNA BB's skills. No education roster or Core Mandatory Exam - Nursing, was provided for CNA BB to show proof of completion of mandatory dementia training prior to beginning care provision at the facility. During an interview on 7/25/2024 at 11:35 a.m., Unit Manager, Registered Nurse (RN) E reported new hires were evaluated through utilization of a checklist during two days of orientation. RN E stated CNA staff assigned to new hire orientation were responsible for completing the checklists and determining competency and human resources monitors for completion. RN E confirmed CNAs F, AA and BB were no longer on orientation and provided care throughout the facility. When asked for the orientation/competency checklists for CNA F, CNA AA and CNA BB, RN E reported the staff person responsible for completion of the evaluations was no longer employed by the facility. RN E stated she was unable to determine if the CNAs were deemed competent prior to being allowed to perform resident care activities. Review of the personnel files for CNA F, CNA AA and CNA BB with Staff Z on 7/25/2024 at 12:07 p.m., revealed no further information related to skill evaluations or competency were available. Staff Z reported she accepted the documentation from the contract company and nursing administration would complete the evaluations, if necessary. On 7/25/2024 at 12:30 p.m., Staff Z presented [Facility] CNA Competency, forms for CNA F, AA and BB. Staff Z reported the forms were found in a box with other documents. Staff Z stated the forms were not complete. Review of CNA F's [Facility] CNA Competency, dated 5/15/2024, revealed the following sections were not evaluated: Assisting a resident at meals; catheter care; assisting a male resident with a urinal; assisting resident with a bedpan; cleaning and storage of dentures; assisting with oral care; shower or tub bath; peri-care male; and complete bed bath. Review of CNA AA's [Facility] CNA Competency, dated 5/15/2024, revealed the following sections were not evaluated: Assisting a resident at meals; catheter care; assisting a male resident with a urinal; assisting resident with a bedpan; cleaning and storage of dentures; assisting with oral care; shower or tub bath; peri-care male; and complete bed bath. Review of CNA BB's [Facility] CNA Competency, dated 4/23/2024, revealed the following sections were not evaluated: catheter care; shower or tub bath; and peri-care male. Review of the facility Job Description: Certified Nursing Assistant, revealed the following, in part: Functions and responsibilities of position. Functions related to direct care of the resident: personal hygiene and grooming (special attention or oral hygiene, care of nails . perineal care . offer nourishment and fluids, answering call signals . During an interview on 7/25/2024 at 12:19 p.m., the Assistant Director of Nursing (ADON) reported evaluations should be complete prior to CNA's providing care. The ADON stated it was the facility responsibility to ensure competency and the self-evaluations provided by the contract company did not demonstrate observed competency. Review of the Facility Assessment, dated 3/17/2024, revealed the following, in part: Services and care we offer based on our resident needs: Specific Care and Practices: Bathing, showers, oral/denture care . eating . incontinence prevention and care, intermittent or indwelling or other catheter . care of someone with cognitive impairment . We provide competency checks: Person-centered care . Activities of Daily Living Caring for resident with Alzheimer's and other dementia .

Based on observation, interview, and record review, the facility failed to ensure a medication administration error rate of less than five percent, with three errors identified out of 30 opportunities, affecting two Residents (R30 and R32) of four residents observed for medication administration, resulting in a medication error rate of 10.00 percent. Findings include: All times noted are Eastern Daylight Savings Time (EDST) unless otherwise specified. On 7/23/24 at 7:50 AM, medication administration was observed with Licensed Practical Nurse (LPN) R for R30. LPN R was observed dispensing one torsemide 20 mg tab. LPN R was asked how many she dispensed and replied, One. That is how many he gets. After medications were verified, LPN R was made aware R30 had a recent order change related to drug amount for torsemide dispensed by pharmacy. Prior orders for R30 were to dispense one 40 mg tab and current supply was 20 mg. Review of R30's physician order, dated 7/12/24, revealed the current order for torsemide 20 mg, was to give 2 tablets by mouth one time a day for edema. On 7/24/24 at 10:15 AM, medication administration was observed with LPN H for R32. LPN H was observed accessing R32's PICC line with a 10 ml (milliliter) syringe filled with normal saline solution and failed to check for a blood return prior to administering the saline solution into the PICC line. LPN H was over an hour late in the administration of the antibiotic medication for R32. Review of R32's physician order, dated 6/27/24, revealed an order for vancomycin 750 mg (milligrams) / 150 ml (milliliters), intravenously one time a day for sepsis until 8/6/24. *Note administration timeliness is important in antibiotic delivery to maintain serum concentration for drug levels/dosing/treatment. On 7/24/24 at 1:55 PM, medication administration was observed with LPN H for R30. LPN H had primed two units, then dialed up the insulin pen to 12 units for R30, and set it on top of his medication cart. This Surveyor asked how many units he drew up for R30 and replied, Did I forget to prime it? I think I still need to prime it. LPN H picked up the pen and looked at the dose and then dialed one more unit up to equal 13 units. LPN H was stopped and asked if he had the correct dose and replied, I think so. No, I only need 12 units and I have 13 units. LPN H then primed two units out of the pen to now equal 11 units (administered to R30). During this same medication administration, LPN H was observed dispensing a calcium carbonate with all the rest of R30's medications. LPN H handed R30 all his medications in one cup. LPN H was asked if R30 should take them all at the same time including the calcium carbonate and replied, Oh, no. He takes that one last because he must chew it up. Review of R30's physician order, dated 7/4/24, revealed an order for insulin glargine subcutaneous solution pen-injector, inject 12 unit subcutaneously one time a day. On 7/24/24 at 2:30 PM, an interview was conducted with the Assistant Director of Nursing/Registered Nurse (ADON/RN) A who was made aware of the medication errors during medication pass. RN A replied, We have the sticker that the nurses can use to put on the medication cards when doses or concentrations are different. There should be a sticker on it. Calcium is always placed in a cup by itself and not mixed with all the other meds. LPN H gets very nervous if anyone watches him. We never have him train anyone. I will follow up on the insulin dose administered with him. Review of policy titled, Medication Administration, dated 2/14/24, read in part, Policy: Medications are administered by licensed nurses .as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection .10. Review MAR [medication administration record] to identify medication to be administered. 11. Compare medication source (bubble pack, vial .) with MAR to verify resident name, medication name, form, dose, route, and time .b. Administer within 60 minutes prior to or after scheduled time unless otherwise ordered by physician .

Based on observation, interview, and record review, the facility failed to provide adaptive dining equipment for two Residents (R22 & R29) of three residents reviewed for adaptive dining equipment needs. This deficient practice resulted in increased difficulty with food consumption and independent eating with the potential for decreased food/fluid intake and risk for weight loss. Findings include: All times are in Eastern Daylight Time (EDT) unless otherwise noted. Resident #22 (R22) On 7/22/24 at approximately 1:20 PM, the lunch meal was observed for R22. The meal tray card indicated Colored Plates be provided. R22 had her meal served on a white plate. During an interview on 7/22/24 at 1:49 PM, when asked for the purpose of the colored plates, Dietary aide (Staff) J explained they were used for those residents who were visually challenged. During an interview on 7/22/24 at 3:07 PM, R22 stated, I need colored plates. I am legally blind. R22 said they did not get one today. The Electronic Medical Record (EMR) for R22 revealed admission to the facility on [DATE] and the care plan included, The resident has impaired visual function with interventions including, The resident will maintain optimal quality of life within limitation imposed by visual function. Monitor/document/report .acute eye problems: . Sudden visual loss, Pupils dilated, gray or milky, c/o (complaints of) halos around lights, double vision, tunnel vision, blurred or hazy vision. On 7/24/24 at approximately 1:30 PM, the lunch meal was observed for R22. The tray card indicated Styrofoam Cups - all beverages. The coffee provided on the tray for R22 was observed in a regular mug and not in a Styrofoam cup. The care plan for R22 included, The resident has potential nutritional problems . with interventions including Provide Styrofoam cups for all beverages. Provide small cups for beverages- has hard time holding onto regular cups. Resident #29 (R29) R29 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing) , spasms of the esophagus, dementia, heart failure and stroke with left side paralysis. The EMR revealed the physician diet order as follows: Order Summary: Start dated 11/1/23, Regular diet Pureed texture, Nectar/Mildly Thick consistency . texture varies per DPOA (Durable Power of Attorney) .nectar water with all meals; . On 7/23/24 at 9:31 AM, the breakfast meal for R29 was observed. The meal tray card indicated a diet order of Puree, nectar mild sm (small) portions HF/HC with instructions to give small plastic teaspoon and straw. The beverages on the meal tray did not have straws. However, there was a straw in the thickened water on R29's bedside table. CNA HH stated R29 should not have straws with thickened liquids and did not know how the bedside beverage had a straw. R29 stated sometimes she does not have enough wind to get the fluid up the straw- it is thick. CNA HH stated they felt straws should not be given because R29 had too much difficulty using straws with thickened liquids and did not give a straw when offering a beverage. Although the tray card instructed straws should be given and the care plan also indicated straws should be given. On 7/24/24 at 9:37 AM, the breakfast meal for R29 was observed and the bedside water had a straw inserted but straws were not in the other beverages. CNA O stated it was standard practice that thickened liquids do not get straws and remarked the straw in the water is an error. CNA O stated they felt straws should not be given because R29 had too much difficulty using straws with thickened liquids and did not give a straw when offering a beverage. Although the tray card instructed straws should be given and the care plan also indicated straws should be given. The EMR care plan read in part, (R29) has a swallowing problem r/t (related to) Complaints of difficulty or pain with swallowing, difficulty with thin liquids, Swallowing assessment results, h/o (history of) stroke which resulted in swallowing problems. The interventions on R29's care plan included, Alternate small bites and sips. Use a teaspoon for eating. Use a straw for beverages and also Provide nectar thick water with meals.

Based on interview and record review the facility failed to maintain a complete infection control program, including an outbreak line listing and surveillance mapping during an RSV (contageous respiratory illness) outbreak in the facility that had the potential to affect all 65 vulnerable residents in the facility. This deficient practice resulted in the potential for sustained spread of RSV within the facility resident population. Findings include: During an interview on 1/16/24 at 1:23 p.m., Infection Preventionist (IP) F and Registered Nurse (RN) Supervisor G were asked for the outbreak line listing and surveillance tracking map for the RSV outbreak in the facility. (IP) F said a line listing for the RSV had not been completed, nor had there been any surveillance mapping to identify RSV illness as it occurred in affected individuals. IP F stated, We did have an outbreak of RSV . [Resident R1] on 12/22/23 was suspected of having RSV. When asked for the name of the Resident with the first case of RSV in the facility, IP F stated, Give me just a second, as she looked through her emails to determine who she had first contacted at the local Public Health Department regarding an RSV infection. IP F and RN G verbally compiled a list of eight Residents, in the presence of this Surveyor, that had contracted RSV, with one resident who just tested positive this week. As mistakes were made in the order of resident infections, IP F and RN G would verbally correct each other, until they were satisfied the order was as accurate as they could recall. IP F stated, I do not have an outbreak listing for RSV (outbreak residents). I do not have time to do everything. IP F also confirmed surveillance mapping was not performed, to identify the location of the RSV infections within the building. During an interview on 1/16/24 at 1:59 p.m., when asked about staff education to reduce the risk of transmission of RSV within the facility, IP F stated, No, we did not do any staff education on RSV. Review of the Infection Outbreak Response and Investigation, with a reviewed date of 10/31/23, revealed the following, in part: Policy: The facility promptly responds to outbreaks of infectious diseases within the facility to stop transmission of pathogens and prevent additional infections . e. Staff will be educated on the mode of transmission of the organism, symptoms of infection, and isolation or other special procedures. This includes special environmental infection control measures that are warranted based on the organism and current CDC (Centers for Disease Control) guidelines. f. Surveillance activities will increase to daily for the duration of the outbreak. 3. Outbreak investigation: a. When the existence of an outbreak has been established, an investigation will begin. b. The Infection Preventionist will be responsible for coordinating all investigation activities . c. A case definition will be developed in order to identify other staff and residents who may be affected. Criteria for developing a case definition include: i. Person - key characteristics the patients share in common. ii. Place - the location associated with the outbreak. iii. Time - period of time associated with illness onset for the cases under investigation. iv. Clinical features - objective signs and symptoms, such as sudden onset of fever and cough. d. A line list about each person affected by the outbreak will be maintained. e. The incubation period, period of contagiousness, and date of most recent case will be used in making the determination that the outbreak is resolved . During an interview on 1/16/24 at 4:32 p.m., the Nursing Home Administrator (NHA) confirmed an RSV outbreak line listing and surveillance mapping should have been completed to monitor the progression of infection within the building, and to attempt to prevent further RSV resident infections.

This deficiency pertains to Intakes: MI00132367 and MI135306. Based on observation, interview, and record review, the facility failed to provide treatment and services to promote healing of pressure ulcers, including one Stage 3 pressure injury which resulted in harm, for three Residents (R42, R17 and R68) of four residents reviewed for pressure ulcer care. This deficient practice resulted in delayed wound healing, worsening of condition, and increased risk of infection. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. R42 During a wound care observation on 7/26/23 at 8:17 a.m., Registered Nurse (RN) GG emptied the contents of a clear plastic bag on the prepared overbed table in R42's room. Small pieces of wound packing which were previous cut, were tossed into the bag filled with open gauze pads that had been saturated with normal saline. This contaminated the wound packing prior to application on the stage 3 pressure injury. RN GG did not bring any normal saline vials or bottles into the room with the dressing supplies. This Surveyor indicated she wanted to see the entire wound care process. RN GG said she thought the Surveyor only wanted to see the wound dressing change, not the process of preparing the supplies for wound care. RN Supervisor (RN) C was also present in the room. RN GG uncovered the coccyx wound, and no dressing was present at the time of observation. RN GG began by using a 4x4 gauze pad she had previously moistened in her office and wiped the surface of R42's coccyx wound. No internal cleansing or irrigation of the Stage 3 pressure injury was performed. RN GG was asked how she cleansed the interior of the Stage 3 pressure injury. RN GG used a previously moistened 4x4 gauze pad, bunched it up in the middle of the gauze pad and attempted to stick it inside the small diameter Stage 3 pressure injury. When asked about the same process being used to cleanse the wound over that last several weeks, RN GG confirmed that was .how I always do it . Review of the most recent Consultation Report, dated 7/7/23, revealed the following correspondence from the Specialty Wound Clinic for R42: Nursing Concerns (from wound clinic): Please do what current order say. Call w/ (with) any questions or concerns . Wound #1 Coccyx . Wound Cleansing: Cleanse wound with soap and water or normal saline or wound cleanser. - May shower with dressing off. Do not wearing (sic) dressing in the shower and do not soak wound or take tub bath. Gently pat wound dry prior to applying clean dressing. Dressings - Cover and secure with: Sacral or regular Bordered Mepilex (foam dressing). - Apply Primary dressing to wound: Moistened Promogran then Mesalt. OK to use dry Promogran if maceration occurs. PLEASE USE THE SUPPLIES SENT WITH PATIENT IF FACILITY IS NOT ABLE TO GET PROMOGRAN OR MESALT. CONTACT THE WOUND CLINIC WITH ANY QUESTIONS OR ISSUES AT [telephone number]. - Change Dressing Every: Other day. Off-Loading - Keep weight off affected area/limb at all times. Avoid having patient laying (sic) flat on back. Side to side turns only . - Turn every 2 hours. Avoid direct pressure over wound site while limited side lying position to 30-degree tilt and/or HOB (head of bed) elevation to 30 degrees in bed. Review of R42's Reposition documentation, between 4/8/23 and 7/27/23, revealed inadequate repositioning, with no documentation of R42 being repositioned on the following days: 4/29, 4/30, 5/13, 5/14, 5/23, 5/28, 6/3, 6/5, 6/10, 6/11, 6/24, 6/25, 6/30, 7/1, 7/2, 7/8, 7/9, 7/10, 7/11, and 7/22. Review of documented Weekly Skin Assessments for R42 revealed the absence of weekly skin documentation in the electronic medical record between the following dates: 8/8/22 - 8/23/22: Stage 3 to coccyx measures 1.5 x 1.2 x 0.3 (8/8/22) 8/23/22 - 9/9/22 9/11/22 - 9/21/22 9/21/22 - 11/1/22 1/19/23 - 2/7/23 2/13/23 - 3/3/23 3/9/23 - 3/21/23: Stage 3 to coccyx, 0.8 x 0.4 x 0.1 (3/9/23) (improved) 4/4/23 - 4/20/23 5/11/23 - 5/25/23: Stage 3 to coccyx,1 x 0.3 x 0.5 (5/25/23) (worsened) 6/1/23 - 6/13/23: Stage 3 to coccyx, 1.2 x 0.4 x 0.3 (6/13/23) (worsened) 6/29/23 - 7/20/23: Stage 3 to coccyx, 1.5 x 0.3 x 0.2 (7/20/23) (worsened ) Wound measurements in March were significantly improved, with consultation of the Specialty Wound Clinic. Lack of wound supplies, improper wound cleansing, failure to complete weekly skin assessments and measurements all contributed to a demonstrated worsening of R42's size and condition of the Stage 3 pressure injury. Review of R42's Care Plans revealed the following, in part: 6/16/23: I have pressure injury to coccyx, impaired skin integrity R/T (related to) DM (diabetes mellitus), HTN (hypertension), PVD (peripheral vascular disease), non-ambulatory, not able to reposition in bed independently, incontinent with both bowel and bladder and failure to thrive. AEB (as evidenced by) stage 3 pressure injury to coccyx, damp skin, poor skin turgor, have history of open area to right heel, corn to left medial heal, rash to peri wound and multiple times of infection to coccyx wound. Interventions/Approaches included the following: 7/18/23 (first day of recertification survey): I need my nurses to: - Monitory my skin daily - Provide wound care per wound clinic order. - Follow up with new orders or treatment plan with wound clinic every month. - Ensure my air mattress is plugged in and working in alternating setting with comfort level of 3 . - Turn and reposition me in bed with body pillows during rounds. - Ensure that I am not laying in (sic) my back. - Monitor wound and peri wound daily. Document wound measurement per order. - Notify my wound care physician with any s/s (signs or symptoms) of infection . - Ensure my coccyx dressing is dry and intact every shift and may change if soiled as needed. Review of the physician orders for R42's pressure injury dressing revealed the following: 12/23/2021 TREATMENT: Skin: Weekly skin check, one time per week, Tuesday AM. 05/05/2022 TREATMENT: Ensure resident has a dressing to coccyx. Re-apply if dressing is soiled, every shift, AM, PM, NOC. 5/23/2023 TREATMENT: Skin: Document coccyx wound measurement, drainage and peri wound conditions two times per week AM, Thursday and Monday. 6/16/2023 TREATMENT: Cleanse coccyx open area with NS (normal saline), pack with moistened [collagen-based wound packing material], [sodium chloride dressing that stimulate debridement of heavily discharging wounds] and apply [foam dressing]. OK to use dry [collagen-based wound packing] if maceration occurs, every other day AM FIRST DATE: 06/15/2023. During an interview on 7/26/23 at 2:32 p.m., when asked who was responsible for transcribing and entering the wound orders from the specialty wound clinic for R42, RN GG stated, That would be me. Review of previous physician treatment orders revealed the following, in part: 4/18/23, TREATMENT: Cleanse coccyx open area with NS, apply moistened promogran and maxorb on top. Cover with mepilex every 3 days AM. All physician treatment orders reviewed began with Cleanse coccyx open area with NS . During an interview on 7/27/23 at 2:00 p.m., when asked about the wound care clinic giving instructions when physician ordered wound care supplies were unavailable, Wound Care RN GG stated, We always had the supplies. It was quite a bit ago we could not find Mesalt . I told them (Specialty Wound Clinic staff) we did not have Mesalt, so can you tell us something else, and then they switched dressing changes not that long ago. But they (Wound Clinic staff) knew about it (absence of prescribed wound dressing supplies) quite a bit ago. When asked about adherence to the 5/23/23 physician order to Document coccyx wound measurement, drainage and peri wound conditions two times per week AM, Thursday and Monday, RN GG said she was not aware she was supposed to be measuring R42's coccyx wound twice weekly. When asked who would have transcribed that order into the EMR physician orders, RN GG said that was probably something she could have put in (into the EMR). RN GG was asked to review the documentation provided by the facility related to Weekly Skin Assessment completion. RN GG stated, Other staff should be doing the Weekly Skin Assessments other than me, because I cannot be here all the time. I forgot to chart that (multiple weeks without Weekly Skin Assessment documentation). I don't do the measuring on the shower days. I do them on Tuesdays and Thursdays - at least try to. You have to trust your staff to do measurements. When asked if, in the capacity of the facility Wound Care RN, she had consistently measured R42's Stage 3 pressure ulcer weekly, RN GG stated, No, I did not always measure the wound weekly. RN GG stated she was not always able to do her job because she was being pulled to the floor to work as a floor nurse (passing medications, etc.). When asked if the wound care provided to R42 had ever been observed by the physician, supervisory staff, or the DON, RN GG was unable to recall any wound care oversight for R42's Stage 3 pressure injury. When asked about the 6/16/23 physician order in the EMR, to Cleanse coccyx open area with NS (normal saline) ., RN GG said the physician order was unclear, and that is why she didn't know she was supposed to irrigate the interior of the Stage 3 pressure injury with normal saline to cleanse the wound. RN GG confirmed she had been cleansing R42's Stage 3 pressure ulcer by wiping over the wound or compressing a gauze 4 x 4 moistened with NS and attempting to insert and twist the gauze inside the wound. During an interview on 7/26/23 at 2:32 p.m., when asked who was responsible for transcribing, entering, and/or clarifying wound orders from the specialty wound clinic for R42, RN GG stated, That would be me. During a telephone interview on 7/26/23 at 3:13 p.m., the Director of Nursing (DON) was asked about the wound care procedure for R42's Stage 3 pressure ulcer. The DON stated, You bring your supplies into your room, and you cut what you need at the time, you don't cut it up and put it into a bag . we have the vials of NS . they should be using that to irrigate the interior of the wound . by opening the wound and cleaning it out after the measurements are done . I would take two of the little vials (of NS) in to make sure it is irrigated well. I would not put a 4x4 into the wound. I would agree that was not an appropriate cleansing of the wound. Review of the Facility Assessment, reviewed 3/15/23, revealed the following, in part: . We perform the following competency checks (this is not an inclusive list): . Specialized care . wound care/dressings. During a telephone interview on 7/26/23 at 9:11 a.m., the Specialty Wound Clinic Practice Manager/LPN BBB was asked about R42's continuity of care between the Wound Clinic and the facility. LPN BBB stated, They (facility) were not using the correct products . usually we irrigate those (Stage 3 pressure injuries) with normal saline (by squirting the normal saline directly into the wound with a vial or syringe) - especially given the area it is in (coccyx) . We have had to be pretty specific with our orders due to them not being followed. We have had to be specific because they were not doing what we said. LPN BBB agreed by using a NS moistened 4x4 inside the wound, mechanical abrasion of the wound could occur and result in delayed or absence of wound healing. 45123 Resident #17 (R17) Review of R17's face sheet, printed on 7/26/23, revealed an original admission to the facility on [DATE], with medical diagnoses including dementia, hypertension (elevated blood pressure), and diabetes mellitus. Review of R17's electronic medical record (EMR) census detail, date printed 7/26/23, revealed, R17 had returned to the facility on [DATE] at 3:12 PM from a short acute hospital stay that was four days in duration. Review of R17's skin condition note, dated 6/26/23 at 6:33 PM, read in part, Stage 2 pressure ulcer noted to coccyx. Bilateral buttocks and coccyx are red. Open area measures 1.3 x 0.3 cm (centimeters). Resident noted with two other non-blanchable area to bilateral buttocks. Left buttocks area measures 2.5 x 0.5. Right buttock area measure 4 x 5 cm . R17 had a prior skin assessment that was completed on 6/8/23 and lacked another until she returned to the facility on [DATE]. Further review of R17's skin condition note, date 6/29/23 at 7:38 AM, read in part, Stage 2 pressure ulcer to coccyx measures 1.2 x 0.2 cm. Left buttock non-blanchable area is resolved. Right buttock non blanchable area continues. Mepilex applied to the area for protection. [Brand name] ointment applied to coccyx open are. Will continue to monitor. R17's skin condition note lacked further measurements of other open areas and or communication to physician for wound care orders on 6/29/23. On 7/11/23 at 12:47 PM, skin condition note for R17, read in part, Unstageable pressure injury to coccyx noted. Area measures 2 x 3 cm. Wound bed has 100% black necrotic tissues . R17's skin condition note lacked further measurements of other open areas on 7/11/23. On 7/13/23 at 10:51 AM, skin condition note for R17, read in part, Resident has stage 2 open area to coccyx. Area measures 1.5 x 1 cm. Resident readmitted to facility from acute care hospital with stage 2 pressure injury to coccyx . R17's skin condition note lacked further measurements of other open areas on 7/13/23. On 7/20/23 at 11:10 AM, skin condition note for R17, read in part, Unstageable pressure injury to coccyx is healing. It measures: 2.2 x 2 cm. Wound bed has 50-75% red beefy granulation and 25-50% slough . R17's skin condition note lacked further measurements of other open areas on 7/20/23. Review of R17's physician order, dated 7/11/23, revealed an order for weekly skin checks every Saturday, and a treatment order for her wounds. R17's physician orders lacked any orders for wound care until 7/11/23. Review of R17's weekly skin assessments, dated 7/11/23 through 7/28/23, lacked a skin assessment which should have been completed on or around 7/22/23. R17's wound measurement assessments, dated 7/11/23 through 7/21/23, lacked wound measurements from 6/30/23 through 7/10/23 (10 days). Review of R17's care plan, printed on 7/26/23, read in part, . I have acute alteration in skin integrity . I need my nurses to . monitor my skin weekly . An observation was made on 7/21/23 at 1:30 PM of R17's wound care by Registered Nurse (RN) GG. R17's bilateral buttocks was pink and her coccyx area had some granulation tissue present in the center of the wound bed. The outer portion of the open area also had some red granulation tissue. Resident #68 (R68) Review of R68's face sheet, printed on 7/26/23, revealed an original admission to the facility on [DATE], with medical diagnoses including cardiac arrhythmia (irregular heartbeat), hypertension, and monoplegia of upper right limb following cerebral infraction affecting right dominate side (loss of limb movement following a stroke). On 7/19/23 at 3:00 PM, an interview and observation were conducted with R68 in his room. R68 was asked if he had any skin condition and replied, Yes, but it has been there since my admission. R68 proceeded to state that his dressing changes are not done regularly. Review of R68's skin problem, dated since admission on 5/3/22 through 7/21/23, revealed a new skin condition dated 8/15/22, which read in part, Small open area to coccyx, 0.2 cm in diameter, fresh bleeding noted. Cleansed with NS [normal saline] . On 8/16/22, R68's skin problem note, dated 8/16/22 at 2:00 PM, read in part, Open area to coccyx does not appear to be a pressure injury. Wound opening measures 0.2 cm in diameter round shape. Depth is 1.5 cm. Suspecting abscess or fistula . [physician and practitioner] notified . Awaiting orders. Review of R68's physician order, dated 4/14/22, read in part, Treatment: Skin: Weekly skin check one time per week Monday AM. Review of R68's weekly skin assessments, dated 8/15/22 through 7/17/23, revealed the lack of weekly skin assessments completed on dates as follows: 9/5/22, 9/12/22, 10/10/22, 10/17/22, 10/24/22, 11/7/22, 11/14/22, 11/21/22, 11/28/22, 12/5/22, 12/12/22, 12/19/22, 1/2/23, 1/9/23, 1/16/23, 1/23/23, 2/13/23, 2/20/23, 2/27/23, 3/6/23, 3/13/23, 4/3/23, 4/10/23, 4/17/23, 4/24/23, 5/1/23, and 6/26/23. Review of R68's weekly wound measurements, dated 8/16/23 through 7/20/23, revealed the lack of weekly skin measurements completed on dates as follows: 8/30/22, 9/13/22 through 5/24/23, 6/14/23 through 6/22/23, 6/30/23 though 7/8/23 and 7/12/23 through 7/19/23. Review of R68's Braden Scale Skin Assessment Tool, dated 4/1/23 through 7/15/23, revealed no Braden Scale Skin Assessment was completed on re-admission for date 5/25/23. On 7/21/23 at 10:00 AM, an interview was conducted with Assistant Director of Nursing (ADON) A. ADON A was asked how often weekly skin assessments were to be completed and replied, Weekly and documented at the time the assessment was completed. ADON A was asked why weekly wound documentation was not being charted weekly and replied, The wound care nurse gets pulled a lot to work the floor. ADON A confirmed weekly skin assessment were not being completed per physician orders and facility policy. On 7/21/23 at 11:00 AM, an observation was made of R68's coccyx wound in his room and performed by RN GG. There was a small open area on R68's coccyx during observation which RN GG confirmed was tunneled, but no measurement was taken during the observation. R68's dressing had been removed prior to the observation by RN GG. RN GG did state R68 had a good amount of drainage on the dressing when it was removed prior to the observation. On 7/21/23 at 2:30 PM, an interview was conducted with RN GG regarding R17 and R68's skin conditions. RN GG confirmed it was difficult to do weekly assessments during the time period between October 2022 through March 2023. RN GG confirmed they were frequently pulled and having to work as a floor nurse during that time period. RN GG acknowledged weekly skin assessments and wound measurements should be completed and documented weekly in the electronic medical record. Review of facility policy titled, Skin Assessments, dated 7/10/2023, read in part, Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, ect.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why . Review of facility policy titled, Wound Care Policy and Procedure, dated 4/18/22, read in part, Policy: It is the policy of this facility to provide a quality of wound care through assessment and intervention that is consistent with best practices and evidence-based guidelines .Procedure: 1. All residents will have a skin assessment performed on admission (immediately but no later than 4 hours) to identify any immediate problems and will be documented in the resident's medical record. 2. An assessment will be done by the nursing staff using the Braden Tool Assessment upon admission, monthly, quarterly, annually and with significant change in condition .5. Charge nurses will assess residents' skin weekly on bath day and chart assessment in the Electronic charting system at that time. Any irregularities will be reported and followed up by licensed nursing personnel at that time .19. Once a pressure injury has been identified, the wound nurse will: a. Stage the wound using the Pressure Injury Staging protocol .b. Once a pressure injury has been identified, staff will (continued): Document about the wound in the Electronic Medical Record, Wound Nurse will notify the physician . Review of facility policy titled, Arrival of Resident, dated 11/13/19, read in part, .Upon admission nursing staff .RN [registered nurse] will start MDS [minimum data set] and nursing assessment and begin care plan process within 24 hours .

This deficiency pertains to Intakes MI00134358, MI00132367, and MI00131319. Based on observation, interview, and record review, the facility failed to ensure sufficient staff to provide nursing related services, assure resident safety, and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, based on resident acuity and diagnoses of the resident population. This deficient practice resulted in unmet resident care needs and inadequate supervision to prevent and respond to resident needs. Findings include: All times noted are Eastern Daylight Savings Times (EDST) unless otherwise noted. Observation during breakfast on [DATE] at 8:58 a.m., found 10 residents seated in the dining room without nursing supervision while the meal trays were consumed. Two Dietary Aides (Staff); U and V, were present in the kitchen who prepared and delivered the individual meal trays to each resident. During an interview on [DATE] at 9:00 a.m., Staff U and V were asked if any licensed nursing staff was present to provide dining supervision when residents were eating breakfast. Staff U and V both turned their heads from side-to-side, and stated, No. When asked if Staff U and V were CPR (cardiopulmonary resuscitation) or Emergency First Aide certified, both said they were not. When asked if there was any concern for resident safety in the first-floor dining room during breakfast, Staff V stated Every day. Staff V continued, Aides [Certified Nurse Aides (CNAs)] will come in to bring residents in, but they do not stay in the dining room on the first floor to assist the residents (with their breakfast meal) . There is one nurse on each wing, and one CNA on each wing . Staff V said there was often not enough staff to cover the halls and the dining room. Continued observation on [DATE] at 9:09 a.m., showed CNA W entered the dining room with Resident (R54), placed a clothing protector around the Residents neck and left the dining room. During an interview on [DATE] at 9:33 Staff V approached this Surveyor in the first- floor dining room and stated, Just so you know, that (staff offering any assistance, or wheeling residents back to room) does not happen. Five residents remained in the dining room, with breakfast trays in front of them and/or eating, with no staff present. All CNAs left the dining room, and both dietary staff left the kitchen area where the food was served. During the dining observation on [DATE] at 9:57 a.m., CNA B removed Resident (R29's) clothing protector and left the first-floor dining room. All CNAs left the dining room, and both dietary staff left the kitchen area where the food was served. Residents remained in the dining room with breakfast meal trays. During a telephone interview on [DATE] at 8:31 p.m., Confidential Staff CCC was asked about the adequacy of facility staffing to meet resident needs. Staff CCC stated, Because our facility is not on one floor, I would say the staffing is not good. Staffing is supposed to be 1 to 8 (1 staff member to 8 residents) in the (memory care) unit. During the day the there is one RN (Registered Nurse) on the med (medication) cart, and one CNA is left on the floor by themselves. That happens a lot . I would say that we are understaffed based on the acuity of the residents. When asked about resident supervision in the dining rooms, Staff CCC stated, For the second floor, none of the residents eat in the dining room. On the 600 wing there is an empty resident room that they turned into a dining room . There is no dining supervision in the room. During an interview on [DATE] at 2:47 p.m., when asked about staffing, Staff FFF burst into tears and said a lot of people had left (employment at the facility), and it was very difficult have a Director of Nursing (DON) who was not in the building. Staff FFF stated, We are tired, and the ones (employees) that have been here are getting tired and they are leaving. There needs to be more staff. During an interview on [DATE] at 3:13 p.m., when asked about staffing levels, Staff AA stated, I have never seen us work so short as I have in the past year. One aide to 15 residents (during day shift). For my first hour - hour and a half, I just do aide work. There is no way that one aid can do one wing alone. They (CNAs) should not have that many residents . we have one aide (CNA) and 1 LPN (licensed practical nurse) to each wing. During an interview on [DATE] at 9:25 a.m., when asked about staffing in the facility, Staff PP stated [CNA B] is my aide today . There is always just one aide on the wing. They do the Hoyers (mechanical full-body lifts) by themselves all the time. I have never seen them do the (full-body mechanical) lifts with anyone (assisting them) . They (CNAs) don't have the staff to do anything with two staff . During a second-floor dining observation on [DATE] at 1:31 p.m., three Residents, including R9, were seated in the dining room (former Resident room). Two square dining room tables with five chairs were provided for a group dining experience on the second floor. R9 was observed eating broccoli from her plate, with several large pieces on her plate and lap. R9 was able to eat all the broccoli small enough to fit on their spoon without drinking any liquids for swallowing safety. R9 stated, I can't eat this (additional food on plate including ground meat with gravy, tater tots, and orange creamsicle dessert). I can't get it on my spoon. R9 picked up the chocolate supplement beverage and consumed it all. R9 coughed after the chocolate beverage was finished. No staff were in the small resident room converted to a small dining room. R9 picked up, what appeared to be juice, and drank that with a straw. No dining assistance was offered to the resident between 1:31 p.m. and 1:42 p.m., and no licensed staff were present for dining supervision. On [DATE] at 1:42 p.m., this Surveyor found LPN L and CNA DD in the hallway and told them R9 could not eat anything additional because she could not get it on her spoon. CNA DD said, I know who it is, as she returned to the 600-hall congregate dining area. CNA DD chopped up the large pieces of broccoli R9 could not eat independently. Review of R9's progress notes revealed the following, in part: [DATE] . TRANSFERRED TO: emergency department .REASON FOR TRANSFER . Resident (R9) was lowered to the floor earlier in the day (fell ) and is now complaining of right arm pain. Had a fall at 5:15 pm which she slid from her wheelchair and has complained on and off about right hip and lower back pain. Resident then choked on a piece of hot dog and had to have the Heimlich performed to remove the hotdog . Review of R9's lunch meal tray card, dated [DATE], revealed the following, in part: .SUPERVISION: close supervision, use/prompt swallowing strategies for slow rate - prompt with 2 sips - Stop, liquid wash after several bites and second dry swallow prior to consuming more food. Encourage at meals to eat . During an interview on [DATE] at 1:49 p.m., when asked about valid CPR certification or First Aide, CNA DD said their CPR (cardiopulmonary resuscitation certification) was not up to date, and they had not completed a current First Aide course. CNA DD was the only CNA for both the 500 and 600 Wings at the time of these dining observations and interview and was the only staff member who entered the congregate dining room where R9 was eating lunch. During an interview on [DATE] at 1:55 p.m., when asked if there were still additional lunch trays to be passed, CNA DD stated, I still have two feeders (in their room). During an observation on [DATE] at 1:57 p.m., an unidentified Resident was heard yelling, Ow, Ow, Ow, Ow, Ow for approximately five minutes on the 500 Hall. No staff were visible or present on the 500 Hall. As this Surveyor walked down the 500 Hall, Resident (R42) was heard crying out, Ow, ow. When asked what hurt, R42 stated, My foot hurts. R42 was observed with his heels in direct contact with the mattress, without protection of blue protective boots to prevent pressure injuries as specified in his care plan. Observation on [DATE] at 2:00 p.m., found Resident R5's call light on. No staff were on the 500 Hall to respond to the resident at the far end of the hall. This Surveyor found R5 with visible difficulty breathing. R5 stated I need a breathing treatment. LPN L and CNA DD were notified of the resident concerns by this Surveyor. Review of payroll documentation for [DATE], to show the number of direct care staff and administrative staff revealed the following; - 11 CNAs were working the day shift between 6, 100 foot halls. Two CNAs were on the Memory Care Unit, leaving nine CNAs to handle all resident cares, and dining assistance for breakfast and lunch as well as take their own breaks and lunches. - Two LPNs were on the floor providing direct care. - Six Registered Nurses (RN's) were working, but only three were providing direct care to the residents observed during lunch. The MDS RN, Staff Development RN, and Wound Care RN were not observed providing direct care to facility residents. - Three Activity Aides were working, but were not providing direct care or dining assistance or supervision to the facility residents. - 14 Administrative/Managers, including two nurses and one licensed CNA, were not providing direct resident care, nor were they on the floor assisting staff where there was no staff on the Wing, or only one CNA on the Wing due to breaks, lunches, baths, etc. On [DATE] at approximately 2:05 p.m., CNA DD entered R42's room and placed the blue protective boots on both of R42's feet. CNA DD also found R42's incontinence brief appeared wet with urine. CNA DD opened R42's incontinence brief, and reached her gloved hand in, and slightly under his scrotum, and she pulled a secondary brief liner out of the incontinence brief and secured the same brief with the adhesive tabs. When asked where R42's call light was positioned, it was found between the sheets in the two bottom layers of covers and the two top layers of blankets. The call light was not accessible for R42 to call for staff assistance. During an interview on [DATE] at 2:11 p.m., when asked about staffing, Staff HHH stated, (The) day has been tough. I just came back from lunch. When asked about the incontinence brief liner found in R42's incontinence brief, Staff HHH stated, Most of the guys have extra pads for urine absorption in their brief . basically all my guys . I took his (R42's) boots off for a break from them. I took them off - the blue boots . I move him on my own with the maxi lift. I have to (use the lift alone) because there is not enough staff . I was in with my bath lady [R5] today for an hour . when I came out (of their room) I had two call lights on, and it was mainly because I had to basically clean up incontinent BM (bowel movement) twice. While I was doing the bed bath, I was not watching the residents. The other aide is assigned to the other hall. In all honesty something terrible could happen here and we would not even know because we don't have enough staff. During an interview on [DATE] at 8:45 a.m., the Nursing Home Administrator (NHA) was asked about staff using the mechanical lift (Hoyer) without a second staff member present for Resident safety. The NHA said the full body lift (Hoyer) required two staff members for use, and she has been preaching to the CNA's that they are to get a nurse to assist if they need to use the lift. When asked if nurses could use the lift independently with residents, the NHA said they could not, and appeared as if in disbelief with an open mouth, that a nurse would be using the full-body lift without a second support person. During a telephone interview on [DATE] at 2:36 p.m., when asked by the facility NHA to specify the length of all resident occupied Halls, Maintenance Director X said the Wings (Halls) were all 100 feet long from the fire door to the end of the Hall. This distance pertained to the first and second floor Wings; each with three halls. During an interview on [DATE] at 2:55 p.m., Family Member (FM) QQ said they were aware facility staff were double-briefing R49 and R50. During a telephone interview on [DATE] at 3:37 p.m., Confidential FM III of a facility Resident (identity not revealed to protect confidentiality of FM) stated, They (facility staff) double brief my mom all the time. I would prefer they just be a single brief on her and put her in the bathroom. On Saturday when I came (to the facility) she was wet through the diaper liner, the diaper, her pants - she was soaked . This is not helping her condition - she does not go to the bathroom, and I get the excuse We are doing the best we can. We have limited help. They double diaper her - I wouldn't want that in my crotch all day . She is not being changed often enough . this is (an) every weekend occurrence. During an interview on [DATE] at 4:17 PM Confidential FM JJJ stated, I have been calling the State of Michigan and it is all answering machines . The concern that I had and want you to know about so it can be documented . happened back in June (2023) . I had come to visit my mom who is (resides) on the 200 Hall. I got in the building at 4:10 p.m. I was trying to see where she was at - and she was still sitting there (in the first-floor dining room) from lunch. Her tray was gone - she had her silverware, and empty glass in front of her, and her placemat in front of her (on the dining room table). The staff didn't know where she was. Staff was busy and there is really nobody on the floors to ask in the first place. This place is so big that there is not enough staff . Review of Rights of Residents in Michigan Nursing Facilities, dated [DATE], revealed the following, in part: . You have the right to be informed of, and participate in, your treatment, including: . The right to receive the services and/or items included in the plan of care . You have a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely . You are entitled to receive adequate and appropriate care . 40383 During a lunch meal observation on [DATE] at 1:37 PM, the 1st floor dining room had no nursing personnel present to assist residents or assure safety. The residents were on their own and encouraging one another. One resident who wished to remain anonymous, stated, I help him (a resident at her table) as I am afraid he will eat his blanket. At another table, a resident was encouraging her tablemate to pick up the silverware and take a bite, remarking, She doesn't eat very well. Dietary Staff V and Dietary Staff U were present in the 1st floor kitchen which was separated from the dining room with a half wall. Staff V said a nurse should be present as they were busy making trays and were not watching the residents. On [DATE] at 1:45 PM, an interview with LPN (Staff JJ) was conducted near the 1st floor nursing station. Staff JJ was asked if she was the LPN who should be in the 1st floor dining room. Staff JJ replied, although she was an LPN, she had been pulled to work as a CNA and was not assigned to the dining room. Staff JJ stated, RN (KK) was assigned to the dining room. When asked where RN KK was, Staff JJ stated, She is on break. Fourteen Residents were observed to be in the 1st floor dining room at that time. During a breakfast meal observation on [DATE] at 9:21 AM, the 1st floor dining room contained 10 residents eating breakfast. No CNAs or licensed nurses were present. At 9:45 AM, the final tray was being prepared and CNA LL was circulating through the first-floor dining room. CNA LL stood over a seated resident (unidentified), gave this resident a bite of eggs, and then proceeded to move toward another resident. CNA LL stated she did this on a regular basis (stood and gave bites to residents). CNA LL said, There are not enough CNAs (to provide the needed care) . There is just too much to do. CNA LL explained, We are supposed to come to the dining room to assist, but we cannot always make it. This happens often and I do the best I can but . CNA LL then shook her head. In a confidential group meeting on [DATE] at approximately 11:00 AM, the six residents in attendance agreed they would like to speak anonymously. They stated the staffing levels did not meet their care needs. Resident C2 said the facility needed more help. Others in attendance gave examples of problems that arose due to low staffing levels. C4 stated she had to wait upwards a couple hours after using her call light at night. She stated after waiting so long she ended up peeing my bed. She went on to say, I try not to go and not to go. I hate to make a mess. It makes you feel like sh*t. C3 stated, They are so short you have to be patient. C4 then added the night is the worst explaining, I feel like I am going to explode at 1:00 AM and they (nursing staff) would not come (to assist) until 9:00 AM. C4 then said, They (nursing staff) peek in and say we will be with you but they do not come in and help. C6 added she must be assisted to get into bed. C6 said, They do come, but I have to wait a long time every night. The minutes from previous monthly Resident Council meetings were reviewed. - The minutes of [DATE] included a resident statement regarding the CNAs (Certified Nurse Aides) working short on the floors. Two other named residents also brought up concerns of having to ask to have their mouth and teeth care done and felt they should not have to ask. - The minutes of [DATE] listed concerns that one resident wished the CNAs would set up her tray and cut up her meat. Other concerns revealed call lights were on, but no one answered, and there was no assistance available on the halls during mealtimes. A specific complaint was recorded regarding long wait times while on the toilet. 45123 Resident #61 (R61) Review of R61's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview Mental Status (BIMS) of ,d+[DATE] which indicated she was cognitively intact. R61's MDS also revealed, an activities of daily living assistance functioning for toileting indicated she was total dependance of two-person physical assist. On [DATE] at 2:00 PM, and interview was conducted with R61 in her room. R61 voiced concerns with extended periods of time to wait for call light to be answered. R61 stated this occurred mostly in the morning upon rising and needing to use the bathroom. R61 was asked if she had any specific dates and time that this occurred and responded, Yes. Do you see that notebook over there. That is where I have been writing dated and times down. Go ahead and take a look at it if you want. Surveyor picked up the notebook and verified the entries made by R61 as follows: [DATE] - Call light on at 5:38 AM and not assisted until 9:07 AM and noted call-in (a staff member who was to work called in and did not work); [DATE] - Call light on at 6:14 AM and not assisted until 9:00 AM and documented no staff on hall (R61 stated no CNA was working to care for residents in her 600 hall); [DATE] - Call light on at 6:50 AM and not assisted until 7:30 AM and call light on at 9:30 AM and not assisted until 1:48 PM; [DATE] - Call light on at 8:10 AM and not assisted until 9:00 AM and CNA WW made a rude remark stating, Good luck with that one! (referring to the R61) and left her hanging in the lift in her room; [DATE] - Call light on at 3:10 AM and not assisted until 6:29 AM, call light on again at 8:30 AM and got told by staff [unknown] she had to wait and then staff [unknown] sat at the desk and turned her light off and never returned until change of shift; [DATE] - Call light on at 3:57 AM and not assisted until 6:17 AM; [DATE] - Call light on at 4:53 AM and not assisted until 8:27 AM; [DATE] - Call light on at 5:59 AM and not assisted until 11:25 AM and documented that only one CNA for the entire wing and nurse trying to get someone to come in; [DATE] - Call light on at 4:56 AM and not assisted until 7:23 AM; [DATE] - Call light on at 4:50 AM and not assisted until 7:48 AM; [DATE] - Call light on at 4:38 AM and not assisted until 6:29 AM; [DATE] - Call light on at 5:48 AM and not assisted until 6:28 AM and documented only one CNA; [DATE] - Call light on at 3:15 Am and not assisted until 4:08 AM, then CNA [unknown] told her she would have to wait as they were doing computer work and did not get assistance until 9:28 AM (R61 stated that during these times she needed to use the bathroom and had to wait an extended period of time for assistance and voiced frustration). On [DATE] at 9:00 AM, an interview was conducted with staff XX. Staff XX was asked if she could verify the day that R61 reported her light was turned off by CNA [unknown] and replied, Yes. I remember and that did happen. On [DATE] at 1:00 PM, a follow up interview was conducted with R61 in her room. R61 was upset and said that the current CNA (DD) had work all by herself this past Saturday for both the 500 and the 600 halls. R61 was asked when she experienced extended periods of time for call light response how that made her feel and replied, Like sh*t. I can't imagine what the other residents go through. You know the ones that can not speak up for themselves or advocate that something happened or went wrong or did not have their needs met. On [DATE] at 1:05 PM, an interview was conducted with CNA DD. CNA DD was asked about working over this past weekend and replied, I was the only CNA on the schedule for both 500 and 600 halls (The 500 hall had 12 residents and the 600 hall had 12 residents and most of them were dependent on staff for some type of activities of daily living and most were two person assist). The LPN [L] on shift told me to do the best I could. I worked from 7:00 AM until 3:00 PM and the night shift CNA [unknown] left at 7:00 AM. Most of these residents are a two person assist and the nurse has their own stuff to do and are usually busy passing meds. On [DATE] at 1:30 PM, an interview was conducted with staff YY. Staff YY was asked how staffing was for this past weekend and replied, I was off Thursday and Friday. I heard it was a bit messy. Staff YY was asked why staffing was a bit messy and replied, A CNA [AAA] calling in sick. There was a Registered Nurse (RN) [C] on call and I think she came in, but you would have to ask her. Review of posted staffing schedules, dated [DATE], for shifts days/afternoons/nights, confirmed that only one CNA [DD] was listed and worked the day shift on [DATE] during 7:00 AM - 3:00 PM. Review of posted staffing schedules, dated [DATE], for shifts days/afternoons/midnights, had markings where white out had been used to alter the schedule. Staff YY was asked why white out had been used and not a line drawn through and then a correction and replied, I am not sure. Staff YY was asked if it was appropriate to use white out of the original posted schedules and replied, I guess not. It may look like we are trying to hide or falsify something. On [DATE] at 2:40 PM, an interview was conducted with RN C (formerly an LPN). RN C was asked why she did not work as a CNA up on the second floor and help CNA DD out and replied, I had not worked as a CNA before, but I did offer to help her a couple of times. RN C was asked what the proper policy and procedure was if there was a call-in when she was the on-call nurse. RN C replied, I guess I should have bumped the lowest seniority LPN [JJ] to work as a CNA and taken over her cart. RN C was asked why she did not bump lowest seniority staff and responded, I guess I did not think about doing that.

Based on interview and record review, the facility failed to prevent a significant medication error for one Resident (#10) of four residents reviewed for medication errors. This deficient practice resulted in harm when Resident #10 developed severe respiratory distress, became unresponsive and required emergency transfer to the hospital. Finding include: All time recorded in Easter Standard Time (EST), unless otherwise noted. This citation pertains to Intakes MI 727 and MI 926. Resident #10 was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the most recent, completed Minimum Data Set (MDS) assessment, dated 1/27/21 revealed Resident #10 was cognitively intact. A review of Facility Incident Report, received by the State Agency (SA) on 3/20/21 at 5:48 p.m., revealed the following, in part: Incident Summary: (Resident #10) was sent out for suspected aspiration pneumonia. Hospital did a urine drug screen and found [MEDICATION(S)] (a narcotic medication used to treat moderate to severe pain) in (Resident #10's) system. (Resident #10) does not have [MEDICATION(S)] prescribed. [MEDICATION(S)] (medication used to reverse the effects of narcotic medications) was administered and (Resident #10) improved . A review of Resident #10's Electronic Health Record (EHR) revealed a progress note, dated 3/20/21 at 12:43 p.m. (Central Standard Time or CST). Further review of the note revealed the following: Incident Type: new or worsening behavior, possible med error . Mental State: unresponsive . Pupils: sluggish bilateral . Respiratory Rate: 8 then decreased to 2 . Cause: possible med error. A review of a progress note dated 3/20/21 at 6:30 p.m. (CST), revealed the following: Spoke with (RN O at ED. Stated (Resident #10) is improving. (Resident #10) was in respiratory depression when admitted into the ED. They gave (Resident #10) ([MEDICATION(S)]) and (Resident #10) started improving. They did a urine drug screen and found [MEDICATION(S)] in (Resident #10's) urine . On 4/6/21 at 12:30 p.m., a review of an Investigation Report, dated 3/26/21, provided by the Director of Nursing (DON), revealed the following, in part: (Resident #10) . Date of Event: 3/20/21. Note: All times are Central . Resident (#10) was sent out for suspected aspiration pneumonia. Hospital did a urine drug screen and found [MEDICATION(S)] in resident's (#10) system. Resident (#10) does not have [MEDICATION(S)] prescribed. [MEDICATION(S)] was administered and resident (#10) improved. Resident (#10) was admitted for aspiration pneumonia . Investigation: At approximately 10:45 a.m., the Activities Aide (Staff N) went into (Resident #10's) room . (Staff N) noted at that time (Resident #10) was not responding as he normally does, (Resident #10) appeared out of it, visible sweat to the forehead, blank stare, not making eye contact . (Resident #10) was slow to respond and not responding consistent with his baseline . Licensed Practical Nurse (LPN B) assessed (Resident #10) . respirations were 8 (per minute) and shallow . At approximately 11:15 a.m., Registered Nurse (RN C) then went in to assess (Resident #10). (RN C) noted that (Resident #10's) pupils were pinpoint, gaze was fixed and (Resident #10) was stiff and very tense. (RN C) attempted to talk to resident (#10) but he was unable to respond . Resident #10 was transferred to the emergency department by ambulance on 3/20/21 at 11:56 a.m. Further review of the incident Investigation Report, signed and by the DON on 3/29/21, revealed the following, in part: at 3:40 p.m., (RN D) received a call from (RN O) at (hospital). (RN O) stated resident (#10) had a urine drug screen and it was positive for [MEDICATION(S)] . A review of the MAR (medication administration record) . revealed that (Resident #10) was not prescribed [MEDICATION(S)] . Controlled narcotic sheets were pulled by the DON, and (Resident #10's) scheduled liquid ([MEDICATION(S)], a controlled medication used to treat nerve pain) had not been signed out on the controlled narcotic sheet but was signed out on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The [MEDICATION(S)] was measured by (RN C and RN D) and there was 53 ml in the bottle at that time. The quantity of [MEDICATION(S)] in the bottle was compared to the controlled narcotic record for the [MEDICATION(S)]. The amounts did not match . there was a difference of 10.4 ml (more listed on the record than what was present in bottle). The controlled narcotic record (for the [MEDICATION(S)]) reconciled with the MAR, no doses were missed . (RN C and RN D) then evaluated the ([MEDICATION(S)]) bottle (belonging to Resident #10) . (there was) a difference of 11.5 ml of extra ([MEDICATION(S)]). (Resident #10's) MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] #10) on 3/20/21. In an interview on 4/6/21 at 12:10 p.m., the DON reported the results of the investigation revealed LPN B had accidentally administered 3.75 ml of [MEDICATION(S)] to Resident #10 instead of the Resident's scheduled dose of [MEDICATION(S)] 3.75 ml. The DON calculated that the error resulted in Resident #10 receiving 187.5 mg of [MEDICATION(S)], which the Resident (#10) had not been prescribed. The DON reported the bottle containing Resident #10's [MEDICATION(S)] looked almost identical to Resident #12's [MEDICATION(S)]. In an interview on 4/6/21 at 1:50 p.m., RN C reported she remembered the incident involving Resident #10 on 3/20/21. RN C reported the morning of 3/20/21 she had assessed Resident #10 per LPN B's request. RN C reported Resident #10 was slightly less responsive than normal but worsened and became unresponsive. When asked if the statement she provided to the DON during the incident investigation was true and accurate, RN C confirmed the events as recorded in her statement. A review of RN C's statement, recorded and signed by the DON on 3/28/21, revealed the following, in part: (Resident #10's) pupils were pinpoint, gaze was fixed and he was stiff, very tense . attempted to talk to resident but (Resident #10) was unable to respond. At 11:30 (a.m.) respirations were very irregular and (Resident #10) had periods of apnea (pauses in respirations). A review of a statement provided to the DON by LPN B on 3/27/21, revealed the following: (LPN B) states that the [MEDICATION(S)] bottle was accurate as far as he could tell at the start of his shift. He does state that it is sometimes hard to see because of the face shield . (LPN B brought (Resident #10) breakfast tray with medications . at 8:54 a.m . (Resident #10) was appropriate (and) responsive . A review of a statement, written and signed by LPN B on 3/21/21, revealed the following: I felt is was an odd mistake (Resident #10 receiving [MEDICATION(S)] instead of [MEDICATION(S)]). I get in auto-pilot mode . In a telephone interview on 4/7/21 at 12:43 p.m., LPN B verified his statements, as provided by the DON with the incident Investigation Report, were true and accurate. LPN B reported he was unsure how he had mistakenly given Resident #10 [MEDICATION(S)] instead of [MEDICATION(S)] as prescribed. LPN B reported the bottles of medication were similar but not identical. LPN B reported he had not completed a reconciliation of the controlled medications with another nurse when coming on shift on 3/20/21 but that the amount of medication present in both the [MEDICATION(S)] and [MEDICATION(S)] bottles were true to the amounts listed on the respective medication's controlled drug logs. LPN B reported it was difficult to determine the amount of medication present during administration due the need to always wear a face shield when in the facility. A review of a Medication Error Report, provided by the DON and dated 3/20/21, revealed the following: (Resident #10), Date of Error: 3/20/21, Medication as Ordered: ([MEDICATION(S)]) 75 mg (3.75 ml), Description of Error: wrong med given, [MEDICATION(S)] 50 mg per one ml given, Outcome to Resident: sent to ED (emergency department) for eval. [MEDICATION(S)] given in Ed. Type of Error: Wrong medication. Reason for error: Failure to identify correct medication for correct resident. The report was signed by LPN B on 3/21/21. A review of the ED Provider Notes, signed and dated 3/20/21, revealed the following: (Resident #10), Chief Complaint: Patient presents with respiratory distress. Patient presents from nursing home unresponsive . Was found unresponsive and hypoxic today reading about 2 (breaths) per minute . 3:50 (p.m.) [MEDICATION(S)] dose given and patient immediately had an increased (respiratory rate) and increased responsiveness . (urine) Drug Screen UR [MEDICATION(S)]: non-negative . A review of the hospital History and Physical, dated 3/20/21, revealed the following: (Resident #10) given a dose of [MEDICATION(S)] today. The patient is not normally on [MEDICATION(S)] . the patient was given a dose of [MEDICATION(S)] for decreased respirations. (Resident #10) immediately woke up after administration of [MEDICATION(S)]. Several more doses were given and (Resident #10) was eventually placed on a continuous infusion . Assessment and Plan . accidental [MEDICATION(S)] overdose, continuous [MEDICATION(S)] infusion, attempt to wean the [MEDICATION(S)] approximately 12-15 hours after the time of overdose. A review of the facility policy, titled, General dose Preparation and Medication Administration, revised 1/1/13 and provided by the DON, revealed the following, in part: Facility staff should verify that the medication name and dose are correct and should inspect the medication . During medication administration, facility staff should take all measures required by facility policy and applicable law, including but not limited to: 4.1.1 Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct rate, at the correct time, for the correct resident . 5.1 Identify the resident per facility policy.

Based on observation, interview, and record review, the facility failed to prevent and contain COVID-19 by failure to: 1. Perform proper staff entrance screenings, including hand hygiene and cleaning and disinfection of reusable medical equipment. 2. Limit staff entrance screening locations. 3. Perform Resident Line-Listing COVID-19 infection surveillance. 4. Complete staff illness surveillance. 5. Report accurate and timely COVID-19 staff positivity data to the local Health Department. 6. Follow transmission-based precautions (TBP), Personal Protective Equipment (PPE), and signage. 7. Adequately monitor staff for infection control practices during a COVID-19 outbreak. 8. Ensure staff maintained six feet social distancing. 9. Prevent cross-contamination of COVID-19 with meal tray delivery. 10. Aseptically perform staff COVID-19 lab specimen collection. This deficient practice resulted in Immediate Jeopardy for the continued spread of COVID-19 potentially affecting all 97 residents. Review of the facility's COVID-19 data as of 1/7/2021 at 12:51 p.m., sent via electronic communication from the Nursing Home Administrator (NHA) reflected the following cumulative numbers: Residents infected with COVID-19 was 29. Staff infected with COVID-19 was 36. Deaths related to COVID-19 was three. Immediate Jeopardy was identified at F 880 on 12/30/2020 at 3 p.m., during an abbreviated COVID-19 Infection Control Survey. The NHA was notified of the Immediate Jeopardy while still on-site and an Abatement Plan was requested and approved the same day. The NHA was instructed to provide documentation of the initiation of the Abatement Plan by the Survey Team prior to exit on 12/30/20, and again requested via electronic communication sent on 12/30/20 at 4:46 p.m. by the Survey Manager. A third request for evidence of the initiation of the Abatement Plan was sent on 1/6/21 at 11:06 a.m. The Immediate Jeopardy was removed on 1/6/2021 at 12:20 p.m. but continued at a level of no actual harm with potential for more than minimal harm. The Immediate Jeopardy began on 12/9/2020 with the identification of a COVID-19 resident outbreak as identified by Registered Nurse/Infection Preventionist (IP) A. Findings include: All times noted are Eastern Standard Time (EST). 1. Staff Entrance Screening/Hand Hygiene/Reusable Medical Equipment/PPE Storage Review of the facility's undated staff entrance screening form, Start of Shift Daily Employee Screening Log included name, temperature, and the following screening questions: cough/sore throat, new SOB (shortness of breath), traveled internationally within the last 14 days, taken a fever reducer within the last 4 hours, and asked to go home. The screening log did not include all symptoms of COVID-19 per Centers for Disease Control and Prevention (CDC) current recommendations. Review of the CDC Preparing for COVID-19 in Nursing Homes updated November 20, 2020 read in part, Screen all HCP (healthcare personnel) at the beginning for fever and symptoms of COVID-19 . According to the CDC Symptoms of Coronavirus updated December 22, 2020, read in part, People with these symptoms may have COVID-19: fever or chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestions or runny nose, nausea or vomiting, and diarrhea. On 12/30/20 at 11:40 a.m., in the sub-basement entrance, Certified Nurse Aide (CNA) J completed Entrance Screening without performing hand hygiene and no screening monitor was present. On 12/30/20 at 11:45 a.m., in the sub-basement, Occupational Therapist (Staff) N completed Entrance Screening without performing hand hygiene, without cleaning and disinfecting the thermometer, and no screening monitor was present. On 12/30/20 at 11:46 a.m., in the sub-basement, Dietary Aide (Staff) CC completed Entrance Screening in the absence of a screener. On 12/30/20 at 11:47 a.m., in the sub-basement, Activity Aide (Staff) DD completed Entrance Screening without cleaning and disinfecting the thermometer after use, and no screening monitor was present. On 12/30/20 at 11:47 a.m., in the sub-basement, at the staff entrance screening table, the following signs were posted: YOU CANNOT CHECK YOURSELF IN WHEN YOU COME TO WORK IF NO ONE IS AVAILABLE CALL THE RN . and ATTENTION STEPS FOR CHECKING STAFF IN PRIOR TO SHIFT 1. SANITIZE HANDS 2. APPLY GLOVES 3. CHECK STAFF MEMBER'S TEMPERATURE 4. ASK ABOUT SYMPTOMS 5. DISCARD GLOVES 6. REPEAT FOR EACH PERSON During an interview on 12/30/20 at 1:20 p.m., the Director of Nursing (DON) stated a staff member was present to monitor employee Entrance Screenings for all three shifts. On 12/30/20 at approximately 4:00 p.m., CNAs A and B were observed inside the COVID-19 isolation unit (500 Wing) break/charting room. Licensed Practical Nurse (LPN) EE, also present in the 500 Wing break room, asked CNA A and CNA B if they had completed their entrance screening. Both acknowledged they had not screened (prior to entrance onto the COVID-19 isolation unit), and immediately exited the COVID-19 unit, into the stairwell. They did not remove potentially contaminated PPE prior to exiting the unit and no hand hygiene was performed. CNA A used a thermal thermometer, without cleaning and disinfection prior to, or following use. CNA A tossed the thermal thermometer, onto the entrance screening log sheet and re-entered the COVID-19 isolation unit. CNA B picked up the same thermometer previously used by CNA A and did not perform hand hygiene. CNA B did not clean or disinfect the thermometer before or after use. During an observation of the 500 Wing stairwell (used for entrance and exit from the COVID-19 isolation unit) on 12/30/20 at 4:13 p.m., discovered the employee screening log, two boxes of opened (lids lifted) N95 disposable respirators (40 count each), one cannister of cleaning and disinfecting wipes, a thermal thermometer, an opened box of surgical masks, one opened box of medium disposable gloves, and one spray can of disinfectant spray all placed directly on the top-vented heat register. Across from the same screening station, three coats (beige, black, and khaki in color) were hung over the stairwell railing. The black coat was touching a discarded surgical mask lying on the floor. The khaki coat was over an uncovered garbage can, half-filled with discarded PPE supplies. A white, fabric laundry bag contained clean, reusable cloth isolation gowns was found on the wet floor to the left of the same entrance screening station. On 12/30/20 at 11:03 a.m., when asked about staff entrance screening on the COVID-19 isolation unit, the DON stated, Inside the unit is where they are screening. room [ROOM NUMBER] is the breakroom - that is where they eat and are getting screened .They are self-screening themselves. During an interview on 12/30/20 at 4:12 p.m., CNA B confirmed she had not cleaned or disinfected the thermal thermometer when used after CNA A. During telephone interviews on 1/5/21 at 10:44 a.m., and 2:46 p.m., LPN D and CNA FF, respectively, confirmed their entrance screenings were routinely performed without a screening monitor present. During a telephone interview on 1/5/21 at 9:19 a.m., when asked where administrative staff were completing entrance screenings, Staff X stated, We are screening in the administrative secretary's office (past the entrance, inside the facility, up the stairs or ramp, into a multi-staff working area on the 1st floor) . Review of Centers for Medicare and Medicaid Services (CMS) COVID-19 Long-Term Care Facility Guidance, dated April 2, 2020, read in part: .Every individual regardless of reason entering a long-term care facility (including residents, staff, visitors, outside healthcare workers .) should be asked about COVID-19 symptoms and they must also have their temperature checked .Facilities should limit access points and ensure that all accessible entrances have a screening station . Review of the facility Handwashing/Hand Hygiene policy, revised August 2019, revealed the following: . Use an alcohol-based hand rub .for the following situations: . Before handling . contaminated equipment . Before and after entering isolation precaution settings . During a telephone interview on 1/6/21 at 4:19 p.m., when asked if it was acceptable to store clean isolation gowns on the wet stairwell floor, outside of the 500 Wing COVID-19 isolation unit, the DON stated, No . that was not acceptable. When asked if it was acceptable for staff to enter the COVID isolation unit without completion of Entrance Screening for COVID-19, the DON stated, No, it is not. 2. Staff Entrance Screening Locations On 12/30/20 during Initial Tour, four staff entrance screening locations were observed: sub-basement, basement, 500 COVID Isolation Unit, and 100 Wing ramp entrance. The staff screening location in the administrative hall was not observed. During an observation on 12/30/20 at 3:51 p.m., the 100 Wing ramp entrance screening station contained undated Start of Shift Daily Employee Screening Logs with repeated entries for multiple staff on unknown dates and times. The following screening supplies were observed: oral (no protective sheaths) and thermal thermometers, one container of cleaning and disinfecting wipes, one box of alcohol wipes, two boxes of gloves, three bottles of hand sanitizer, and one small garbage bag attached to the railing which contained blue gloves, face mask, and a paper towel. The exterior door was unlocked. During a telephone interview on 1/7/21 at 3:47 p.m., the NHA, DON, and Infection Preventionist (IP) A indicated the 100 Wing ramp entrance had not been used since 12/21/20 with the closure of the previously used 100 Wing COVID Isolation Unit. When asked why the screening logs were still present on 12/30/20, the DON stated, We never thought about grabbing the screening sheets .it was overlooked .They are not pulled daily. When asked if the results of the screening logs were time sensitive to identify staff with possible signs and symptoms of COVID-19, IP A said, Most of the time we do not pull them until a week later. The DON then said, They are not pulled daily because every department head reviews their own staff. Upon review of the Start of Shift Daily Employee Screening Logs for the same area, IP A said there were no dates (or times) on the logs, and LPN EE and CNA FF did not answer the (screening) questions. When asked who was responsible for review of the screening forms, IP A said, It was me. 3. Resident Infection Control Surveillance During the Entrance Conference interview on 12/30/20 at 10:37 a.m., when asked for infection control surveillance documentation for December 2020, including the COVID-19 line-listing (record of COVID-19 surveillance), IP A stated, I am working on it. I am not completely finished with it . The NHA estimated 27 positive COVID-19 residents, and provided a form entitled Positive Residents that listed 27 resident names. IP A identified 12/9/20 as the beginning of the resident COVID-19 outbreak within the facility. During the interview IP A and the NHA were unable to provide detailed information related to the COVID-19 positive residents. IP A was asked to provide all surveillance completed for December 2020. At approximately 10:55 a.m., IP A returned to the interview and provided the Resident COVID-19 line-listing which detailed nine Residents positive for COVID-19 in December 2020. When asked why the Line-Listing contained nine Resident names when the Positive Resident list included 27 residents identified as positive for COVID-19, IP A stated, I have been working on it (since) you arrived . I don't have it all done. Review of the December 2020 line-listing showed seven of nine residents positive for COVID-19 were missing any documentation of signs and symptoms. The same line-listing had no information on 18 known COVID-19 positive Residents. The line-listing identified the first COVID-19 positive Resident with a date of onset of 12/6/20. At the time of survey entrance (12/30/20) the line-listing placed the facility's COVID-19 outbreak into their fourth week. When asked if infection control mapping for COVID-19 was available for December 2020, IP A said no infection control mapping had been completed and was therefore unavailable for review (to visually show spread of COVID-19 throughout the facility). Review of the facility Surveillance for Infections policy, dated 4/2020, revealed the following, in part: The Infection Preventionist will conduct ongoing surveillance . Gathering Surveillance Data: 1. The Infection preventionist or designated infection control personnel is responsible for gathering and interpreting surveillance data . Data Collection and Recording: 1. For residents with infections that meet the criteria for infection for surveillance, collect the following data as appropriate: Identifying information (i.e., resident's name, age, room number, unit . [DIAGNOSES REDACTED]. Pathogens . additional relevant information, i.e., temperatures, other symptoms . and precautions . For targeted surveillance using facility-created tools, follow these guidelines: . DAILY (as indicated): Record detailed information about the resident and infection on line listing form . 4. Positive COVID-19 Staff Illness Surveillance During the Entrance Conference interview on 12/30/20 beginning at 10:25 a.m., the staff COVID-19 positive line-listing/surveillance was not completed. The COVID-19 Employee Illness Logs were requested during the Entrance Conference, and on 12/30/20 at 1:23 p.m. The Employee Absence Reports for November and December 2020, and Employee Illness Log (copied spiral notebook pages), were received at approximately 3:00 p.m. on 12/30/20. Review of the Employee Absence Report for November 2020 listed 13 entries for nine staff persons but failed to identify a single COVID-19 positive employee. The December 2020 Employee Absence Report listed 17 entries for 15 staff persons, with three employees identified as positive for COVID-19. Review of the Employee Illness Log (spiral notebook pages) identified 36 employee entries from November 2020, and 15 employee entries from December 2020 that were not listed on the November and December Employee Absence Reports, respectively. The facility was unable to provide a complete list of the Covid-19 positive staff names, and dates of positivity for employees prior to Surveyor departure from the on-site portion of the Focused Infection Control survey. On 1/7/21 at 12:51 p.m., eight days later, the NHA, via electronic transmission provided, the list of COVID-19 positive staff. The list identified a total of 36 COVID-19 positive staff; 2 for September, 2 for October, 19 for November, and 13 for December 2020. During a telephone interview with the NHA, DON, and IP A on 1/7/21 at 3:47 p.m., when asked for the date the facility had identified their COVID-19 outbreak within the facility, IP A stated, It was 11/5/20 for our staff. Review of the facility Outbreak of Communicable Diseases, policy, Revised August 2014, revealed the following, in part: An outbreak of most communicable diseases can be defined as one of the following: a. One case of an infection that is highly communicable . 6. Symptomatic residents and employees are to be considered potentially infected and will be assessed for appropriate actions .8. The Infection Preventionist and Director of Nursing Services will be responsible for: a. Receiving surveillance information and tabulating data; b. Maintain a line listing of identified cases on the appropriate Line Listing Report . 5. COVID-19 Health Department Reporting Review of a facility Facsimile Transmittal to the local Health Department, completed by IP A, dated 11/17/20, revealed the following: These are our POC (point of care) Test Logs for our staff and residents. All were negative except 2. Staff on 10-29-20 & 11-9-20 . Review of a Facsimile Transmittal to the local Health Department, completed by IP A, dated 11/21/20, revealed the following: 20 staff POC tested [DATE], 1 positive . Comparison of the Facsimile Transmittals to the local Health Department, dated 11/17/20 and 11/21/20, to the cumulative list of all COVID-19 positive staff showed the following: 1. November 2020 reporting to the Health Department reflected three positive staff. 2. Between 10/29/20 and 11/21/20 the cumulative staff COVID-19 positive list showed seven positive staff tested by the facility. Five staff members were not reported accurately and timely to the Health Department. 3. Four additional staff members tested positive for COVID-19 in November 2020 and were not reported to the Health Department in a timely manner. Review of December 2020 Facsimile Transmittals to the local Health Department, identified three COVID-19 positive staff between 12/2/20 and 12/28/20. Comparison to the cumulative COVID-19 positive staff listing showed seven staff were tested by the facility as positive for COVID-19 during the same time. An accurate and timely reporting to the Health Department was not performed. A telephone attempt was made to the local Health Department on 1/6/2020 at 1:48 p.m., with a voicemail message requesting a return call. On 1/7/2020 beginning at 2:13 p.m., six unsuccessful telephone attempts were made with the local Health Department. The Health Department voicemail indicated the mailbox was full. No return call was received from the Health Department to confirm the COVID-19 positive staff reporting data for the facility. During a telephone interview on 1/6/21 at 3:21 p.m., the NHA, DON, and IP A were asked if staff COVID-19 testing done by the facility and by other providers were both reported to the local Health Department. IP A said only COVID-19 tests performed by the facility were reported. The DON immediately said, Yes, we did include them (both testing done by the facility and outside providers) in our numbers. When asked for clarity in the number of staff COVID-19 positives reported to the local Health Department in November 2020, the NHA said, .we have not compared our numbers. Review of the facility Pandemic Event, Infection Control Measures During policy, revised 3/16/20, revealed the following: .If pandemic event is detected in the geographic region of the facility, the following measures will be taken to prevent or delay the introduction of [MEDICAL CONDITION] to the facility: . Increase resident surveillance for virus-like illness. Notify local or state health department if a case is suspected . Review of the facility Surveillance for Infections policy, last revised 4/2020, revealed the following: .The Infection Control Committee will determine how important surveillance data will be communicated to the Physicians and other providers, the Administrator, nursing units, and the local State Health Departments . Review of the CDC Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs), retrieved 5/13/20, revealed the following: Notify your state and or local health department immediately (less than 24 hours) if these occur: . For clusters (> or = 3 residents and/or HCP) of respiratory infections . Individuals with suspected or confirmed COVID-19 . 6. TBP/PPE/Signage During initial tour on 12/30/20 at 12:37 p.m., an observation of the 200 Wing COVID-19 quarantine unit found no TBP signage to indicate what PPE was required prior to entry. The doors to the following resident rooms were wide open on the 200 Wing: 203, 205, 206, 208, 209, 210, 211, 214, and 216. Observation of the 500 Wing COVID-19 isolation unit, on 12/30/20 at approximately 4:00 p.m., found all room doors wide open including room [ROOM NUMBER] (staff break room). CNA B was observed in room [ROOM NUMBER], wearing no eye protection, cleaning her face shield in the presence of CNA C and LPN EE. Signage found on the double doors outside the 500 Wing on 12/30/20 at 4:03 p.m., included the following: ATTENTION ALL STAFF: FULL PPE MUST BE PUT ON BEFORE ENTERING THE 500 WING. Review of the undated facility Resident with Known or Suspected COVID 19, policy, revealed the following: New Admissions and Readmissions Whose COVID-19 Status is Unknown: HCP will wear an N95 (high filter medical face mask) or higher-level respirator ., eye protection (i.e., goggles or a disposable face shield), gloves, and gown when caring for these residents . When a resident is suspected of having COVID-19: . They will be moved to a private room on the dedicated unit (100 wing) . Private room may be appropriate based on community spread - door will be closed, and resident isolated to room . 7. Infection Control Monitoring During an interview on 12/30/20 at 2:20 p.m., IP A was asked for evidence of infection control staff monitoring during the COVID-19 outbreak. IP A provided five Hand Hygiene Observation Records and five PPE Compliance Audits, dated between 12/2/20 and 12/23/20. None of the observations included weekends. The Hand Hygiene Observation Records did not indicate location within the facility, specific staff persons involved, or time of observation. When asked about non-compliance noted on the 12/2/20 Hand Hygiene Observation Record, IP A was unable to identify the staff person involved, location, circumstances, or Resident involved. IP A completed all five of the hand hygiene audits submitted for review. Review of the five PPE Compliance Audits completed by the DON and IP A, failed to identify the staff person, what TBPs were in place, the type of PPE required, room number, and time of observation. During the same interview on 12/30/20 at 2:20 p.m., when asked to explain the monitoring tools, IP A was unable to recall any of the staff observed, the time or location of the observation, other than the date and the hall specified on two of the 10 forms provided for review. When asked about other infection control monitoring opportunities, such as housekeeping, laundry, and dining, IP A stated, I don't have anything written down . When asked if IP A thought the PPE Compliance Audits and Hand Hygiene Audits were adequate during an outbreak, IP A stated, No, probably not. 8. Social Distancing On 12/30/20 at approximately 12:25 p.m., food and beverages were observed in the laundry sewing room. Food items identified, included: a jar of peanuts, rolls of (name brand) crackers, and cookies. Salt and pepper shakers were positioned on the same table directly in front of a microwave and refrigerator. The three tables in the room were measured by Laundry Aide (Staff) AA with the facility's measuring tape. Two chairs were located across from one another at each table. Five individual beverage containers were found on three tables located inside the sewing room and were noted to be close together (less than six feet). Each table's measurement, based on drink locations was as followed; table one was 35.5 inches (less than 3 feet), table two was 28.5 inches (less than 2.5 feet), and table three was 40 inches (less than 3.5 feet). During an interview on 12/30/20 at 12:30 p.m., Laundry Aide (Staff) Q was asked about seating at table one, and confirmed she was sitting at that same table, across from Staff AA. Staff Q confirmed that laundry staff did eat and drink with face masks and face shields removed while seated close together. Laundry staff confirmed they did not utilize the facility break room located just across the hall from the laundry, but used the laundry sewing room as their break room. During a telephone interview on 1/5/21 at 12:21 p.m., when asked if laundry staff were permitted to eat and drink in the laundry department, including the sewing room, Director of Housekeeping and Laundry (Staff) GG stated, No, not at all. During a telephone interview with the NHA, DON, and IP A on 1/6/2021 at approximately 4:40 p.m., when asked if eating and drinking in the clean laundry room was acceptable, IP A stated, No, it is not. The DON stated, The only place (to eat and drink) is in the multi-purpose room and the break room. 9. Ensure Sanitary Distribution of Meal Trays During an observation on 12/30/20 at 12:55 p.m., CNA U and CNA V entered the 200 Wing COVID-19 quarantine unit fully donned in PPE with the meal tray cart, and then began passing resident lunch trays. Neither CNA U or CNA V performed hand hygiene after delivery of each resident's lunch tray, prior to delivery of the next resident's meal tray. All PPE worn by CNA U and CNA V was the same PPE worn when they first entered the unit. Prior to exit from the COVID-19 quarantine unit CNA U removed both gloves and isolation gown at the far end of the hall and walked the entire length of the 200 Wing without gown or gloves. CNA U and CNA V exited the quarantine unit with the meal tray cart which had not been cleaned or disinfected prior to or following exit from the quarantine unit. They returned to the 1st floor dining area with the potentially contaminated meal tray cart where they continued to add additional partially prepared meal trays from the meal tray cart, for the 200 Wing. During an interview at this time, CNA U confirmed she had removed and disposed of her isolation gown and gloves at the far end of the 200 Wing. CNA U acknowledged she should have removed it near the entrance door, and stated, They should have more gowns down the hall. During an interview on 12/30/20 at 1:08 p.m., CNA II was asked why only six trays were delivered at one time to the 200 Wing quarantine unit, when there were 16 available tray slots in the cart. CNA II stated, To keep (the meal trays) hot. At the time of the observation there were 11 residents on the 200 Wing. Review of the facility Passing of Trays COVID 19 policy, dated 4/2020, revealed the following: Quarantine/Observation rooms/units: . Gloves will be worn when delivering and picking up food trays. Gloves need to be changed and hand hygiene must occur in between every resident's room when serving/picking up trays. Staff will be wearing PPE as indicated for the area. Carts need to be disinfected immediately before leaving the quarantine unit. During an interview on 12/30/20 at approximately 3:30 p.m., the NHA said she was unaware that all meal trays were not being delivered at the same time to the quarantine unit. The NHA confirmed meal tray carts leaving a quarantine unit should be cleaned and disinfected. 10. Staff COVID-19 Testing Observation of staff self-collection of COVID-19 lab specimens on 12/30/20 at 11:46 a.m., 11:55 a.m., 11:56 a.m., and 11:57 a.m., with CNA K, Staff N, CNA CC and Staff W, respectively, found the listed staff members all removed their face shields and face masks and placed them on the counter below the testing station. All face shields were placed with the potentially contaminated front surface of the face shield directly onto the counter. The counter was not cleaned nor disinfected prior to the next staff person moving into the testing station and placing their potentially contaminated mask on the same counter. The staff members all reapplied the same potentially contaminated face shields and face masks prior to exit from the testing area and returned to work. During an observation on 12/30/20 at 11:55 a.m., Staff N completed PCR (polymerase chain reaction laboratory test) and POC (point of care rapid test) COVID-19 specimen collection without performance of hand hygiene between each collection. The COVID-19 testing monitor, Staff M, did not provide guidance or direction to Staff N with the omittance of hand hygiene. During an interview at this same time, Staff N confirmed she had not performed hand hygiene between the PCR and POC testing. During an observation on 12/30/20 at 11:56 a.m., Staff CC rotated the COVID-19 specimen collection swab in each nostril while verbally counting to 20 rotations in each nostril. The COVID-19 testing monitor, CNA L, said (Staff CC) always does more (nostril rotations) than she needs to. Staff CC stated, Yep, this is how I do it. Staff L was asked if she had written guidelines to ensure proper steps were being taken for COVID-19 test staff self-collection. Staff L said no and pointed to the wall and indicated those were the instructions. Review of the POS [REDACTED]. Slowly twist the swab, rubbing it along the insides of your nostril for 15 seconds . During an observation on 12/30/20 at 11:57 a.m., Staff W completed 29 swab rotations for each nostril. When asked how many rotations she had completed, Staff W stated, 16. During an interview on 12/30/20 at 1:05 p.m., Staff W confirmed she had not cleaned or disinfected her face shield following her earlier COVID-19 testing and acknowledge she had donned the same potentially contaminated face shield and returned to work in the dietary department. During an interview on 12/30/20 at 2:20 p.m., IP A stated, They (staff) do remove their face shield and N95 mask (when COVID-19 testing), and they are placing it on a ledge below the mirror . It (testing) should actually be four to five good swipes with the anterior nares (nostrils) . The area (where potentially contaminated face shields were placed) is wiped down every hour . When asked if cleaning and disinfection of the counter where everyone was placing their potentially contaminated face shields, was adequate to prevent transmission of COVID-19, IP A stated, I had not thought of that until you just said that - about dirty contamination of face shields . IP A also confirmed no clock or timer was provided for testing monitors to ensure 15 second timing for nares COVID-19 specimen collection. Review of the facility Self-Collection for Employee COVID Testing policy, revised 12/3/20, revealed, .Firmly sample the nasal membrane by rotating the swab against the nasal membrane for 15 seconds. C. Sample the other nostril with the same swab . F. Surfaces within 6 feet of where specimen collection was performed should be cleaned and disinfected using an Environmental Protection agency - registered disinfectant if visibly soiled and at least hourly.

Based on interview and record review, the facility failed to provide scheduled telephone and virtual video visitation during COVID-19 pandemic nursing home visitor restrictions for three Residents (#1, #2, & #8) out of five residents reviewed for resident rights. This deficient practice resulted in psychosocial harm, based upon a reasonable person standard, increased isolation, decreased family support, and feelings of sadness and loneliness for the Residents and families. Findings include: All times noted are Eastern Standard Time (EST). During an abbreviated survey, conducted 12/30/20 through 1/7/21, a complaint allegation of facility failure to facilitate virtual visits with family members was investigated. Review of Resident #1's Minimum Data Set (MDS) assessment, dated 12/22/20, revealed Resident #1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 required extensive, one-person assistance with transfers, dressing, toilet use, and personal hygiene. Resident #1 had severe cognitive impairment. Review of Resident #2's MDS assessment, dated 12/22/20, revealed Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #2 was independent or required supervision only for bed mobility, walking, and eating. Resident #2 had severe cognitive impairment. During a telephone interview on 1/5/21 at 11:41 a.m., Family Member (FM) G provided the following additional information: A scheduled virtual visit, via Facebook Messenger, was scheduled for Christmas day at 11:00 a.m., but was not completed because only one of the facility seven iPads was equipped with Facebook Messenger. That specific iPad was used on a wing that was COVID-19 positive, and therefore not available for other wings. The facility did not call FM G at the time of the virtual visit as scheduled. FM G called the facility after the scheduled time, because the family was all together on Christmas day. FM G stated, She (facility staff) told me I had to get Zoom. I told her I did not have an Apple phone, and the girl (staff) said I had to have an Apple phone. When I asked how I visit with my parents, she said, 'you don't - you have to come back'. All I wanted to do is watch them open their presents. I could not even find out if they got the Christmas presents that we sent. The family is all gone now, and they didn't even get to see my parents. For these kids to see them - we don't know if it is their last chance to see them. FM G's voice trembled, as she stated, It is very upsetting. FM G said Facebook Messenger should have been on all the iPads, so that people without an iPhone could communicate with their loved ones. FM G said she did not have an iPhone and could not use Facetime. FM G continued to explain, The facility policy is that they have to have 14 days with no (COVID-19) positive residents or staff before visitation can be allowed. That is what I have been told . During a telephone interview on 1/5/21 at 2:52 p.m., Staff Z was asked to explain the facility process for virtual visits. Staff Z said at Christmas there was one iPad that had Facebook Messenger installed on it, and the rest of the iPads had Zoom. Staff Z stated, It was kind of an error on our part. We only had two iPads for virtual visits . Resident #1 and Resident #2 were down (scheduled) for a virtual visit with Facetime (requires an iPhone) on the 25th (Christmas) . Additional iPads were here, but they were worried about them coming up missing. They were locked up in the (activity) office until we needed one for each wing . During a telephone interview on 1/5/21 at 3:15 p.m., Staff BB confirmed she had worked in the Special Care Unit (dementia unit) on Christmas day. Staff BB said she had the iPad with Zoom, not the iPad with Facebook Messenger, and that FM G would need to download Zoom on her phone. Staff BB stated, She (FM G) said 'I told you I have an Android (cell phone)'. Staff BB continued, She (FM G) was very upset, and I totally understand that. I kept reminding her about the Zoom thing. She said, 'I have everybody (family) here'. At Christmas that (Messenger) was not set up at all . we had more iPads, but none of them were set up yet. The black one was in the 600 wing, and the red one was in the (dementia) unit . The black one was used for everything - because it has everyone's contact (information) .(I) never did a virtual visit with (Resident #1 and Resident #2). I think this was their first (scheduled virtual) visit . Review of the facility activity calendar detailing virtual visits showed Resident #1 and Resident #2 scheduled for 12/25/20 at 11:00 a.m. Central Standard Time (CST). The telephone number was listed below the last name of the Residents. FT (Facetime)- was written, in what appears to be pencil, or a different color ink, even though FM G had an Android cell phone that was not able to used for Facetime visits. During a telephone interview on 1/5/21 at 1:14 p.m., FM H stated, I would not be able to do Zoom. There have been a few times when they (facility staff) weren't able to get it set up (virtual visit). The Christmas thing was the last straw .We had a time arranged for Christmas .it is almost like there is no communication between anybody there .They told us they did not have the equipment in the dementia unit .There should be no reason they should not have the equipment available. It has been so long since we even had a virtual visit (that) my parents can't even remember who we are . During a telephone interview on 1/7/21 at 10:54 a.m., Staff KK confirmed the facility had applied for a grant which provided funding for five new iPads. The iPads were received in July of 2020. Staff KK confirmed when the new iPads arrived, they all had Facetime (which required family members to have an iPhone) and they did not have Messenger or Zoom. When asked where the iPads were stored between July and December, Staff KK confirmed they were held in the Activity Department. Staff KK also acknowledged family members would have to use an iPhone to participate in a virtual visit prior to installation of Zoom on the iPads on 12/21/20. Staff KK stated, An Android or non-iPhone would not be able to be used with the new iPads without Messenger or Zoom. When asked why the iPads were not set up with the various formats to be accessible by all resident family members, Staff KK stated, It would have been a good idea, but IT (Information Technology) did not think Messenger was a very secure format, so they did not want to install it on the iPad . Staff KK confirmed Activity staff did load Messenger onto the iPads following Christmas after a family was unable to complete a virtual visit due to the lack of compatible equipment. Review of the facility invoice detailing the five new iPads revealed the following: Items will be invoiced once they have shipped or are ready for pickup .Invoice Date: July 16, 2020 . IPAD Air Wi-Fi 64 GB Space Grey . Quantity Ordered: 5, Quantity Fulfilled: 5. Review of Resident #1 and Resident #2's Activity Charting between 9/1/2020 and 1/7/2021, revealed there was only one virtual visit completed, on 12/6/2020, during that four-month period. No Activity Charting was completed for Christmas day, 12/25/20 for Resident #1 or Resident #2. During a telephone interview with Activity Director/Staff LL on 1/7/2021 at 10:03 a.m., when asked about virtual visits and the use of iPads, Staff LL stated, The girls (facility activity staff) had been using the two (older) iPads .I had five in my office, that our RNs (registered nurses) have a key to get to . The administrator (NHA) did not authorize Zoom on the iPads - she did not want Zoom on the iPads . Staff LL confirmed the new, grant acquired iPads (invoiced 7/2020) were not loaded with Zoom or Messenger, for use by families with Android or other non-iPhone cellphones until December 21st, and December 28th, respectively. Review of the facility iPad/Tablet Policy, dated 8/3/20, revealed the following: Purpose: To allow our residents to have access to technology that gives them the opportunity to communicate with family or friends .3. iPad/Tablets and stands will not be shared between COVID-19 positive or suspected residents and other residents. 4. iPad/Tablets and stands will be stored in the activity department. According to Resident #8's MDS assessment, 11/4/20, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Brief Interview for Mental Status (BIMS) revealed a score of 3/15, which indicated severe cognitive impairment. During a telephone interview on 1/6/21 at 2:37 p.m., FM MM of Resident #8 said a telephone visit was scheduled through the Activity's Department. FM MM requested staff's presence when the call was expected to be placed to the facility on [DATE] at 10 a.m. (CST)FM MM requested the phone be answered and then placed on speaker so that Resident #8 could better hear and not be confused with the facility's portable phone. FM MM said when she called at her appointed time (10 a.m.) on Christmas Eve, an unknown employee answered her incoming call and delivered the telephone to Resident #8 and simply left the room. FM MM said Resident #8 was repeatedly heard saying that she couldn't hear. FM MM sreamed into the phone for approximately 10 minutes without ever having Resident #8 hear anything she was trying to communicate. FM MM said after 10 minutes of trying to project her voice into the telephone without success, ended up disconnecting the call. FM MM said, It (the telephone call) wasn't good. It's heartbreaking. I have no way to communicate with her. She (Resident #8) may not remember (the telephone call) but I do. During the telephone interview, FM MM repeatedly indicated how upset she was with the experience because she had previously arranged for staff to assist Resident #8 with using the telephone. During a telephone interview on 1/7/21 at 10 a.m., Staff LL verified FM MM's telephone visit was scheduled on the Activity calendar on 12/24/20 at 10:00 a.m. and it was known to expect the call to be generated by FM MM. Staff LL verified Resident #8 did not have her own personal phone and would require assistance from staff since she resided on the Special Care Unit. Staff LL confirmed she had not assisted with FM MM's phone call to Resident #8 on 12/24/20 at 10:00 a.m. During a telephone interview on 1/7/21 at 10:58 a.m., Staff BB verifed working the day of FM MM's scheduled call to Resident #8 but confirmed she had not assisted with the call and suggested that perhaps a certified nurse aide in the Special Care Unit had answered FM MM's call and brought the phone to Resident #8. Review of Resident #8's Activity Charting, 9/1/20 through 1/7/20, showed no activty was documented for 12/24/20 at 10 a.m.

Based on observation, interview and record review, the facility failed to prevent physical abuse of one Resident (#200), from eight Residents reviewed for abuse. This deficient practice resulted in emotional distress and psychosocial harm, that, based on the reasonable person standard, would have [MEDICATION NAME] affects on daily function and movement about the living environment. Findings include: (All times are recorded in Central Standard Time.) According to a Facility Reported Incident (FRI) to the State Agency (SA), on 6/5/2020 at 6:25 p.m., Resident #100 walked up to Resident #200 and put his hands around her neck and squeezed, choking her. Two Certified Nurse Aides (CNAs) N and O were witnesses to the incident and intervened. During a phone interview on 7/22/20 at 1:34 p.m., CNA O confirmed her Witness/Interview Statement, dated 6/5/20, stating she observed Resident #100's hands around Resident #200's neck. During the interview, CNA O said she and CNA N rushed to intervene, as they were in the nursing station at the time of the incident. CNA O said she saw Resident #100 walk across the room outside the nursing station on the special care unit (SCU), and put his hands around Resident #200's neck and squeezed. CNA O stated, Something must have triggered (Resident #100) and he went after (Resident #200). When asked how Resident #200 appeared when approached by staff, CNA O said Resident #200's eyes were wide and she was scared. CNA O continued, Resident #200 was in distress and holding her neck and said, 'He tried to choke me.' When asked if Resident #100 ever bothered Resident #200 before, CNA O said Resident #100 would approach Resident #200 and point his finger at her. CNA O said a couple months prior she was walking with Resident #200, when Resident #100 was near. Resident #200 stated to her, He doesn't like me. (referring to Resident #100.) CNA O said staff were instructed to keep the two Residents apart, but it was not in the care plan. During a phone interview on 7/22/20 at 3:15 p.m., CNA N confirmed the incident. CNA N said she was in the nursing station when she saw Resident #100 walk across the room toward Resident #200 and put his hands around Resident #200's neck and squeezed. CNA N said she and CNA O came to assist and she had to pull Resident #100 off Resident #200, who was pinned against the wall. When asked to describe how Resident #200 appeared, CNA N said Resident #200's eyes were big and wide and she was scared. CNA N continued to say Resident #200 was trying to yell out but could only make gurgling noises. Then, when Resident #100 finally let go, Resident #200 said, He tried to choke me. CNA N said Resident #200 was shaken up for several minutes, but then did not remember the incident. When asked if there were other incidents between the two Residents, CNA N said there was another time when Resident #100 twisted Resident #200's thumb. CNA N said staff were aware that Resident #100 targeted Resident #200 and were told to keep the two apart. The Witness/Interview Statement, dated 6/5/20, by CNA N, revealed, .(Resident #100) was walking past and approached (Resident #200). He put his hand(s) on her throat and was squeezing. (Resident #200) was yelling and scared .(Resident #200) triggers (Resident #100) for some reason . Hand written follow up interview notes, with CNAs O and N, as part of the facility's investigation, undated and unsigned, confirmed the above interviews and statements, and revealed, .(Resident #200 was) really scared .shaken up . The facility Investigation Report, dated 6/10/20, revealed, .At 6:25pm .on 6/5/2020 .(Resident #100) walk(ed) up to (Resident #200) and put his hands around her throat and squeezed. (Resident #200) was able to yell out .appeared scared when the incident happened but could not recall the incident 10 minutes later .(Resident #100) has a history of approaching (Resident #200) in the past giving her dirty looks and telling her I don't like you .Conclusion: Substantiated resident to resident abuse .(Resident #200) was moved out of the SCU .appears (Resident #100) fixated on (Resident #200) . The facility Behavior Management Investigatory Tool, dated 6/5/2020, revealed, .Resident (#200) appeared upset & confused .Disrupted other residents. Resident who was victim to abuse (Resident #200) was scared . During an interview on 7/22/20 at 12:36 p.m., the Director of Nursing (DON) confirmed the facility was aware of Resident #100's targeting of Resident #200, stating, Yes, we knew he targeted her because there was another incident .where he twisted her thumb. The DON said Resident #100 was placed on 1 to 1 observation for a time, but came off of the close observation on 5/21/20. The Investigation Report, dated 3/17/20, revealed, .(Resident #100) grabbed (Resident #200) right thumb and squeezed and held onto it Resident #100's care plan was absent any specific interventions regarding Resident #200 prior to 6/5/20, but was updated on 6/8/20. According to the DON, Resident #200 was removed from the secure SCU following the incident, but returned to the unit after 7/14/20. On 7/21/20 at 11:00 a.m. Resident #200 was observed in the living area on the SCU sitting at a table with beverages. The Resident was unable to converse coherently and spoke in simple unrelated phrases only. She appeared happy and pleasant. Resident #100 passed away prior to the survey. According to the Minimum Data Set (MDS) assessment, dated 3/31/20, Resident #200 was severely cognitively impaired with [DIAGNOSES REDACTED]. According to the MDS assessment, dated 5/19/20, Resident #100 was severely cognitively impaired with [DIAGNOSES REDACTED]. Although Resident #200 appeared to have forgotten the incident ten minutes later, due to disease process, a reasonable person would suffer the ongoing psychosocial trauma of repeated targeted harm by Resident #100, likely affecting their daily movement about the living environment, and social functioning with others. The policy Abuse Prevention, dated 1/31/20, revealed, .It is the policy of .Facility to maintain an environment free of abuse .The resident has the right to be free from .abuse .Residents with not be subjected to abuse .by anyone .

All times are in Eastern Standard Time. Based on observation, interview, and record review, the facility failed to protect from sexual abuse, one Resident (#60) of seven residents reviewed for abuse. This deficient practice resulted in Immediate Jeopardy and psychosocial harm for Resident #60, with the likelihood of serious physical and/or psychosocial harm from abuse of any residents residing at the facility. The immediate jeopardy began on 5/6/19 at 8:50 p.m., when Staff B entered Resident #60's room and observed Resident #30 kneeling next to Resident #60's bed and observed Resident #30's left hand was on Resident #60's right breast which had been removed from her bra. Resident #30's left hand was seen up Resident #60's right pant leg to the thigh, and Resident #30's left hand was observed moving on the genital area of Resident #60. Resident #60 was crying out for help and using her left hand to try and push Resident #30 away from her. The immediate jeopardy was identified on 5/15/19 during the recertification survey and the Director of Nursing (DON) and Administrator were notified on 5/15/19 at 6:45 p.m. A copy of the immediate jeopardy notice was emailed to the DON on 5/15/19, and a plan for abatement was requested. The immediate jeopardy was removed on 5/15/19 at 8:46 p.m. after the Abatement Plan for removal of the immediate jeopardy was accepted, and the facility began implementing the Abatement Plan. This plan included the following: 1. 1:1 supervision was started on Resident #30 on 5/6/19 and will remain ongoing. 2. Resident interview in progress. All residents with a BIMS (Brief Interview for Mental Status) of 8 or higher will be questioned regarding abuse by 8 pm on 5/15/19. 3. All staff on pm shift tonight (5/15/19) will be questioned on resident abuse by 9pm on 5/15/19. All remaining staff (not working on 5/15/19) will be questioned by 5/17/19. 4. Administrators number will be posted at all nurses informing staff to notify her of any and all protentional allegations of abuse of residents. 5. Within 1 week all staff will have new name tags with Administrator's number on the back of it. 6. Abuse training is ongoing and was initiated on 5/7/19 and will be completed with all staff by 5/17/19. 7. QA (facility Quality Assurance) audits will be completed. Noncompliance remained at a widespread level of no actual harm with potential for more than minimal harm for all residents in the facility, until an acceptable plan of correction is completed and verified. Findings include: Review of Resident #60's Face Sheet revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #60 had a BIMS score of 3, indicative of severe impaired cognition, according to the Minimum data Set (MDS) assessment dated [DATE]. The same MDS assessment revealed Resident #60 ambulated with assistance of a wheelchair, and was a one-person assist for toileting, dressing and bed mobility. An observation of Resident #60 was made on 5/15/19 at 9:47 a.m. on the 2nd floor main dining room. Resident #60 was sitting with two other residents at a table, and was leaning her head in her right hand, appeared tired, eating toast with her left hand. Review of Resident #30's Face sheet revealed the Resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] revealed Resident #30 had a BIMS score of 10, which indicated he had moderately impaired cognition. The same MDS assessment revealed Resident #30 was independent and required no help or staff oversight for bed mobility, walking, and toileting and limited assistance for dressing and personal hygiene. On 5/14/19 at 11:50 a.m., Resident #30 was observed in his room, with a one-on-one staff member sitting outside his door to supervise. The staff member stated Resident #30 was in his room getting dressed, and that the Resident had been on one-on-one supervision since last Monday night (5/6/19). This Surveyor knocked and went in the room when Resident #30 said come in. The resident answered all questions appropriately, and had no complaints about the facility or his care at this time. The facility Investigation Summary, submitted to the State Agency on 5/13/19, read in part: (Staff A) stated that she had walked into the room and witnessed (Resident #30) on resident (#60)'s bed and he had a hand up her pant leg and one on her breast. (Registered Nurse (RN) I) states that (Resident #60) was laying in her bed covered up, her shirt was in place, and she was crying. (Resident #60) stated that someone had hurt her, why would someone want to hurt me? I have never hurt anyone. (Resident #60) stated a man had put his hands in her pants and had put another hand on her face and held her down. (RN I) then notified (the) DON. (The) DON instructed (RN I) to take (RN SS) with her and go in and interview (Resident #60) and assess her for injuries and that she (the DON) would be leaving to come to the facility immediately. She also instructed them to make both residents 1 to 1 immediately. When (RN SS) and (RN I) entered (Resident #60)'s room she was still laying in bed with her covers on. When (Resident #60) was asked what had happened, she stated he touched me, when asked where she pointed down there to her groin area . On 5/14/19 at 7:21 p.m., a phone interview was conducted with Staff A regarding her knowledge of interaction between Resident #30 and Resident #60. Staff A stated, Over the past few weeks, it (Resident #30's behaviors) escalated, at one point, he would try to take her into the bathroom or kiss her right before mealtimes when everybody is busy . he's very sneaky. One time I talked to a CNA (Certified Nurse Aide) in the dining room area and noticed those two (Resident #30 and #60) were sitting at a table together playing cards and he (Resident #30) stood up and grabbed (Resident #60's) face and started kissing her and I immediately yelled to the CNA and said, 'Look', she said 'Yup, we were all told it's none of our business and it's fine', and this is not fine! .The day after he'd (Resident #30) been caught (5/6/19 incident), I got called and was told we had an emergency meeting . they (Administration) were giving us abuse training, and we had to answer questions about what we thought abuse was. We flipped the paper they (Administration) gave us over and it said have you seen any interaction between (Resident #60) and (Resident #30) and what did you see, and at first we were all leery and wondered why we had to write this down . and numerous people in my department all wrote it down, handed it in . We were told we could not talk about it and couldn't discuss anything because it was gossip. He (Resident #30) would follow her (Resident #60) into the bathroom and we were all 'what they hell is going on' and nobody's doing anything about it and we were all reporting it, but nothing was happening to stop it (Resident #60) is such a wonderful lady and she's not the same now . She (Resident #60) was much more social, but she's different now. He's (Resident #30) very controlling over her. On 5/15/19 at 9:21 a.m., an interview was conducted with Staff H, who stated, I saw him (Resident #30) talking her out of activities that she has always gone to, like catholic mass and bingo. He'd say 'oh come on (Resident #60) you don't have to go to that' and she'd stay (not go to scheduled activity). I've worked here for [AGE] years and it was very unusual for her to not go to activities she's always gone to in the past. Yes, the change in her (Resident #60's) behavior started when (Resident #30) came here. I've seen a decline, like more tiredness, maybe she's staying up later at night playing cards or something. Regarding the investigation into the 5/6/19 incident, Staff H was asked about participation in the incident reenactment. Staff H stated, Yes, I played (Resident #60), they called (Staff B) in, and she said he was leaning over the bed, his hand was up her pant leg and his hand was moving around and (Resident #60) said later he was 'poking inside of me' and ' why would someone do that to me?'. An interview was conducted on 5/15/19 at 10:16 a.m. with Staff G, who stated, (Resident #30) is very controlling over her (Resident #60) to the point where he talks her out of going to activities, and I've seen him patting her on the rear, rubbing her shoulders, and back, kissing her and I've seen him take her into the bathroom . unfortunately she has short term memory and dementia, so she doesn't remember. We've talked with him about taking her into the bathroom and he'll leave, but if we miss it, I've seen him coming out of the bathroom with her. When asked if this issue was brought up to Administration, Staff G stated, They basically say they're both consenting adults or else they'll say we're taking care of it . After the last situation that occurred (the incident on 5/6/19), she (Resident #60) was just out of it for the next couple of days, almost a week she seemed so withdrawn, and would close her eyes and curl up like she was inside herself and didn't want to partake in any activities. It got more intimate and that's when things started to change, her not participating in activities as much as before. He's so controlling of her, and she shows no emotion. On 5/15/19 at 11:55 a.m., an interview was conducted with Staff F, who stated, . I don't know the date but it was still winter, the one thing that I reported to the nurse. It was before meal time and (Resident #60) was using her walker and they were getting to the bathroom door and he (Resident #30) said, '(Resident #60), look at me' and when she looked up, he kissed her right on the lips and said, ' I love ya', so I reported it to (Registered Nurse (RN) NN) and she said I needed to write an incident report and I did, but punched out a minute late and we can't have overtime and when I handed it to her (RNNN) said 'It's fine, I spoke to (DON) and we don't need it, we can throw it (Staff F's written incident report) away. The next day . I went in to (the DON)'s office and said I need to talk to you, and she said is this about last night and I said yes, and she said it's fine, I already know about it, and also told me my overtime was fine. I feel like something should have been done about it (Resident #30 kissing Resident #60) at that point in time. There was another incident where they were playing cards and he (Resident #30) said and continued to say '(Resident #60) doesn't feel good she needs to go to bed right now' . (Resident #30) says (to staff) 'Sometimes (Resident #60) doesn't know what's good for her'. Also, I've seen (Resident #30) where she (Resident #60) was in the bathroom and he (Resident #30) was coming out. I don't know how long he was in there, I didn't see them go in. To me, it's obsession, it's not just a friendly game of cards . I feel so bad this has happened. You know, the very next day (5/7/19) they gave us a pretest to see what our knowledge of abuse is and we turned the page over and it was very distinct, a question that said have you seen anything take place between (Resident #60) and (Resident #30) . the next question was who do you report it to, and I wrote down my experience of what I saw and who I reported it to . the next day I asked to have my paper back, and my boss (Activities Director/ Staff MM) texted me and said they (the reports of incidents between Residents #30 and #60) were all shredded. I have her text. And when I was in the meeting with my boss, she (Staff MM) was downplaying everything . He's (Resident #30) opportunistic because he refuses to let (Resident #60) go into the dining room [ROOM NUMBER] minutes early like everyone else does because she always goes into the bathroom first and that is his opportunity, when everyone is busy at mealtime. We reported (these incidents) and have done our job, but why aren't they doing anything? You know, they made every single employee do that abuse training and answer those questions regarding (Resident's #30 and #60), even those who didn't even know who they were. She (Resident #60) isn't interested in what she used to be interested in . she was our go-to girl for activities, whatever we had going on, she'd come to, always up for everything we did, but very recently, she's been awful, awful, awful. (Resident #30) is deciding everything for her because he wants her time and attention, 24/7. I know there were times (Staff O) has brought (Resident #60) to her room because she was tired and wanted to go to bed, then about a half hour or so later, (Resident #30) had gotten her up and playing cards again. He's controlling. And when I spoke to my boss again and she just dismisses it and doesn't seem to interested in it. We went to (RN RR) and she said if anything seems inappropriate to come to her and let her know. I do know the second meeting they (Administration) had with (Resident #30) he came out very angry and was disgruntled and he was threatening violence, but we calmed him down. They said if he wants to rub her leg or foot he can, but I don't think that's fine at all. They say they are two consenting adults but that's not true, she's not consenting. Review of Care Plan dated 2/20/18 for Resident #60 revealed, MY GOAL IS TO: feel secure in my surroundings. Review of Care Plan dated 3/28/19 revealed, MY GOAL IS TO: I want to go to social groups every week and I want to attend mass weekly. Review of Mood Note dated 5/10/19 for Resident #60 revealed, . little interest or pleasure in doing things, appears down, depressed, or hopeless, feels tired/little energy. On 5/15/19 at 1:43 p.m. this Surveyor asked the DON if she had any other incident reports for Resident #30, and she shook her head side to side and said, No. An interview was conducted on 5/15/19 at 2:29 p.m. with Staff E, who stated, I never saw any touching, but I got a bad vibe from him (Resident #30) and watched him like a vulture watches a dying animal. (Resident #30) followed her (Resident #60) all over, and I'd watch him when (Resident #60) would go into her room to make sure he didn't follow. During an interview on 5/15/19 at 2:48 p.m., StaffD stated, I saw him (Resident #30) at the St Patrick's Day party, rubbing her (Resident #60) upper thigh. I've seen him kiss her on the lips once, and he usually comes up behind her and kisses the top of her head or her hands. At first it seemed like fun and games, but then he'd get mad and anxious and rude if (Resident #60) didn't get the ball in ball toss often enough. I reported it (Resident #30's behavior) multiple times to the nurse. I never went further up, just reported it to the nurse, but they just told me to keep watching . Yes, we had abuse training last week, and yes, on the back page (of the form given by Administration) we had questions about (Resident #30) and (Resident #60)'s interactions. Social Worker (SW) C was interviewed on 5/15/19 at 3:02 p.m. SW C stated, I went to see (Resident #60) the very next morning (5/7/19) to interview her. She was confused. She didn't remember anything. This Surveyor asked SW C if (Resident #60) was capable of being a consenting adult. SW C stated, No. An interview was conducted on 5/15/19 at 3:20 p.m. via telephone with Staff B, who found Resident #30 in Resident #60's room on 5/6/19. Staff B stated, Honestly (Resident #30) was with her (Resident #60) all the time, I saw him kissing her on the cheek. It was a well- known fact that when you work on second floor, you keep an eye on (Resident #60) when she's around (Resident #30), everyone had observations of his sneaking into other rooms. On the night of the incident when I realized, he (Resident #30) wasn't in his room, I went running to (Resident #60's room) to see if he was in there. I saw him down on one knee between the bed and the wall, her (Resident #60)'s right breast was out of her bra and he (Resident #30) was fondling her and his right hand was up her pant leg which was pulled up to her thigh. When asked if she had seen inappropriate interaction between Resident #30 and Resident #60 before, Staff B stated, A couple of times. When asked if she was sure of what she saw in Resident #60's room on 5/6/19, Staff B responded, I know what I saw. On 5/15/19 at 5:47 p.m., an interview was conducted with Registered Nurse (RN) I, who was on duty on 2nd floor the evening of 5/6/19. RN I stated, I did write a statement. I was doing med (medication) pass, and I couldn't find (Resident #30) . No one was in the TV room, so (CNA B) walked down the hall and I remember one of the red lights going on and I didn't think anything of it other than when there's someone in the bathroom. The trainee called for me and said I need to come down here, so I walked in and (Resident #60) was crying, very upset, and the (CNA) told (Resident #30) to leave the room, and said he'd had his hands on her (Resident #60) inappropriately. (Resident #60) said somebody hurt me, why would anyone want to hurt me, and said there was a man in the room, she couldn't give me a name, had no idea who it was. I called (DON), and she told me to take (RN SS) as a witness, and we talked to (Resident #60). (Resident #60) pointed at her groin and said someone was poking at her. (Resident #60) said he had his hands on her face, (Resident #60) spread her fingers like they were over her nose and face . (Resident #30) was in his room, in the bathroom, and I asked him if he was in (Resident #60)'s room. He said, 'Yes, we were sitting together praying. On 5/16/19 at 8:49 a.m., the DON was asked if the RN who assessed Resident #60, after the incident, had done a head-to-toe assessment. The DON confirmed a head to toe assessment was not done on 5/6/19. Review of Physician Notes for Resident #30, dated 3/10/19, revealed, (Physician) aware of resident's increased behaviors of hoarding, stealing, and obsessions. Review of Progress nurses notes for Resident #30, dated 2/8/19 and written by Staff RR revealed, .monitor if my behavior changes and for Social Services to watch if I behave differently. Nurses notes dated 10/3/18 revealed I may: be confused or forgetful lay in other peoples beds. Review of a Progress Mood note dated 3/9/19 and written by Staff O revealed, Resident obsessive with other residents, constantly telling other resident what to do and worried about what they are doing. RN (NN) notified. Review of Behavior notes for Resident #30 dated 3/30/19 revealed, Resident was playing card(s) with other residents. Resident started swearing to the staff and said, Nobody here takes care of 'name of another resident in 500' I am the only one takes care of her. Staff noticed that resident has been spending a lot of time with the female resident playing cards. On 5/16/19 at 10:35 a.m. a phone interview was conducted with Staff O who stated, .about 4-6 weeks ago, I was walking behind them, and saw that (Resident #30's) hand was between (Resident #60's) legs . I tapped him on the shoulder and told him to remove his hand because it wasn't very appropriate. I went and told (RN QQ), . and I told (RN RR), who was there at the time .I'm not really sure what they (RN QQ and RN RR) did with it. Then there were a couple other times I caught him (Resident #30) trying to go into the bathroom with her (Resident #60) and I stopped that, also reporting it to the head RN. When asked if she thought anything had been done to prevent future inappropriate behavior, Honestly, not really, I've reported numerous things to them (nurses/Administration), and I've also been told that as long as they're just playing cards, they're fine, they're friends. I was told it was consensual, that they're two adults that are able to make their own decisions. Yes, I wrote it on that abuse sheet with the questions about (Resident #30) and (Resident #60). It really hurts me to know that stuff like this happened because this could have been prevented. If I could have done something I would have. The Abuse Prevention Policy And Procedure, revised on 3/20/19, revealed, The facility will identify and investigate all suspicions of allegations of abuse such as suspicious bruising of residents, unusual occurrences, patterns and trends that may constitute abuse .a. Any alleged violation involving mistreatment .abuse, exploitation .shall be reported to the Administrator immediately after the allegation is made. b.the Administrator will ensure that all alleged violations involving abuse .exploitation or mistreatment, including injuries of unknown source .are reported immediately .c. The Administrator .shall thoroughly investigate all allegations. When the immediate jeopardy notice was served to the Administrator and the DON on 05/15/19, the DON denied knowledge of any other incidents of unwanted touching (between Residents #30 and #60) other than 'holding hands', which she stated was consensual. On 5/16/19 at 11:11 a.m., in an interview with the DON and Administrator present, the DON stated she was unaware of any incidents prior to the reported incident on 5/6/19. She also stated all staff reports (from 5/8/19) regarding Residents #30 and #60 had been put into QAA, and the originals had been destroyed (the forms staff completed regarding observed interactions between Resident #30 and Resident #60).

Based on observation, interview and record review, the facility failed to identify, report, and investigate allegations of abuse for four Residents (#7, #30, #60, #83) of eight residents reviewed for abuse. This deficient practice led to failure to identify and prevent abuse of Resident #60, failure to follow the Facility's Abuse Policy, and had the potential for psychosocial harm and physical abuse of residents. Findings include: The facility failed to implement their abuse policy, by failing to investigate and report the concerns and allegations of nonconsensual touch and incidents (witnessed coming out of the bathroom together on more than one occasion, kissing on the lips)involving Resident #30 and Resident #60. Numerous staff had witnessed interactions and behaviors such as controlling behaviors and obsessions that Resident #30 exhibited towards #60 which should have been investigated. The lack of investigating and reporting of allegations and incidents proved to be a system failure when Resident #30 sexually assaulted Resident #60 on 5/6/19. The Abuse Prevention Policy And Procedure, revised on 3/20/19, revealed, The facility will identify and investigate all suspicions of allegations of abuse such as suspicious bruising of residents, unusual occurrences, patterns and trends that may constitute abuse .a. Any alleged violation involving mistreatment .abuse, exploitation .shall be reported to the Administrator immediately after the allegation is made. b.the Administrator will ensure that all alleged violations involving abuse .exploitation or mistreatment, including injuries of unknown source .are reported immediately .c. The Administrator .shall thoroughly investigate all allegations. On 5/15/19 at 11:55 a.m., an interview was conducted with Staff F, who stated, . I don't know the date but it was still winter, the one thing that I reported to the nurse, it was before meal time and (Resident #60) was using her walker and they were getting to the bathroom door and he (Resident #30) said, '(Resident #60), look at me' and when she looked up, he kissed her right on the lips and said, ' I love ya', so I reported it to (Registered Nurse (RN) NN) and she said I needed to write an incident report and I did, but punched out a minute late and we can't have overtime and when I handed it to her (RN NN) said it's fine, I spoke to (DON) and we don't need it, we can throw it (Staff F's written incident report) away. The next day . I went in to (DON)'s office and said I need to talk to you and she said is this about last night and I said yes, and she said it's fine, I already know about it, and also told me my overtime was fine. I feel like something should have been done about it (Resident #30 kissing Resident #60) at that point in time. On 5/15/19 at 1:43 p.m. this Surveyor asked the DON if she had any other incident reports for Resident #30, and she shook her head side to side then said no. On 5/15/19 at 2:48 p.m., Staff D was interviewed. D stated, I saw him (Resident #30) at the St Patrick's Day party, rubbing her (Resident #60) upper thigh. I've seen him kiss her on the lips once, and he usually comes up behind her and kisses the top of her head or her hands. At first it seemed like fun and games, but then he'd get mad and anxious & rude if (Resident #60) didn't get the ball in ball toss often enough. I reported it multiple times to the nurse. I never went further up, just reported it to the nurse, but they just told me to keep watching. I can't recall who exactly I reported it to, but it was several times. Yes, we had abuse training last week, and yes, on the back page we had questions about (Resident #30) and (Resident #60)'s interactions. On 5/16/19 at 10:15 a.m. a review of Physician Notes for Resident #30, dated 3/10/19 revealed, (physician) aware of resident's increased behaviors of hoarding, stealing, and obsessions. Review of nurses notes for Resident #30, dated 2/8/19 revealed, .monitor if my behavior changes and for Social Services to watch if I behave differently. Nurses notes dated 10/3/18 revealed I may: be confused or forgetful lay in other peoples beds. Review of a Mood note dated 3/9/19 revealed, Resident obsessive with other residents, constantly telling other resident what to do and worried about what they are doing. RN (NN) notified. On 5/16/19 at 10:35 a.m. a phone interview was conducted with Staff O who stated, .about 4-6 weeks ago, I was walking behind them, and saw that (Resident #30's) hand was between (Resident #60's) legs . I tapped him on the shoulder and told him to remove his hand because it wasn't very appropriate. I went and told (RN QQ), . and I told (RN RR), who was there at the time .I'm not really sure what they (RN QQ and RN RR) did with it. Then there were a couple other times I caught him (Resident #30) trying to go into the bathroom with her (Resident #60) and I stopped that, also reporting it to the head RN. When asked if she thought anything had been done to prevent future inappropriate behavior, Honestly, not really, I've reported numerous things to them (nurses/Administration), and I've also been told that as long as they're just playing cards, they're fine, they're friends. I was told it was consensual, that they're two adults that are able to make their own decisions On 5/16/19 at 11:11 a.m., in an interview with DON and ADMIN present, DON clarified that she was unaware of any incidents prior to the reported incident on 5/6/19. She also stated all staff reports (from 5/8/19) regarding Resident #30 & #60 have been put into QAA, and the originals have been destroyed (the forms staff filled out regarding the questions having to do with interactions between Resident #30 and Resident #60). During an interview on 5/13/19 at 4:00 p.m., Resident #83 stated,(Resident #7) comes in (my room) and rubs my leg, under the blanket. (It's) been in the last week. Everyone knows about it. I don't wanna (expletive), if (Resident #7) was getting a sexual charge I would (expletive). (Resident #7) doesn't know what (Resident #7) is doing. I tell (Resident #7) to leave. (Resident #7) is in a wheelchair. It's at night. Maybe 1:00 to 2:00 a.m .in the last week or two. I feel out of control. I'm glad it's me and not someone who doesn't know what they're doing. I am going in a depressive mood. During an interview on 5/13/19 at 5:20 p.m., the Director of Nursing, DON, was asked if this incident was reported and investigated. The DON responded, Yes, (Resident #83) said it happened awhile ago .(Registered nurse, RN GG) investigated the incident. It is my understanding it was not sexual touch. No, I would not say it was abuse because (Resident #7) didn't touch (Resident #83) in an inappropriate way, (Resident #7) does not know what (Resident #7) is doing. I don't think it was intentional .I would not consider it abuse, it was non-sexual. It was not reported as it was resident touch; we can't report every physical touch resident to resident . During an interview on 5/13/19 at 5:30 p.m., the assistant director of nursing, Registered Nurse, RN GG, was asked if this incident was reported and investigated. RN GG responded, (Resident #83) said that (Resident #83) felt another resident, (Resident #7), rubbing (Resident #83's) leg, thigh and down. (Resident #83) told me it was a couple months ago, and (Resident #83) yelled at (Resident #7) to stop and (Resident #7) didn't. (Resident #83) kicked at (Resident #7) and (Resident #7) left. I asked (Resident #83) if (Resident #83) felt scared and (Resident #83) said yes. I did not feel it needed to be reported. I did not feel it was abuse. On 5/13/19 at 5:35 p.m., this Surveyor requested any additional notes or documentation of this incident from the DON and RN GG. RN GG provided a handwritten document titled, (Resident #83), 5/10/19, 1:44 p.m., signed by RN GG. This document revealed, I was sleeping-woke up and (Resident #7) was rubbed (sig) my leg-I told (Resident #7) to get the (expletive) out. (Resident #83) kept rubbing my leg and I kicked at (Resident #7) and (Resident #7) wheeled .out of here. (Resident #7 was) rubbing upper left thigh; actually it was the whole leg, that's what woke me up . (Resident #7's) hand was under the blankets .(a) couple months ago .I did not tell anybody. 'Did you feel scared?' Yes, but I didn't think (Resident #7) could do anything to me anyway . On 5/13/19 At 5:40 p.m., the facility provided a second document, Resident Interview, dated 5/07/19, 12:15 (p.m.). This form revealed, 2. Has anyone ever come into your room and touched you inappropriately? (typed), with a handwritten response, Yes. (Resident #7). (A) couple months ago (Resident #7 was) Rubbing my leg. Made (Resident #83) feel uncomfortable. I kicked (Resident #7) and told (Resident #7) I was going to tell the nurse. I have not told anyone . The policy, Abuse Prevention Policy and Procedure, revised 3/20/19, revealed, 6. The facility will identify and investigate all suspicions of allegations of abuse. When an allegation is received the Administrator will ensure that all alleged violations involving abuse are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. c. The Administrator, or designee, shall thoroughly investigate all allegations. If the incident or allegation involves sexual abuse, the Administrator immediately notifies law enforcement in accordance with the Elder Justice Act Policy. There was no evidence provided to the survey team of how the facility followed their Abuse Prevention Policy and Procedure with regard to the incident involving Resident #7 by the time of exit from this survey.

Based on interview and record review, the facility failed to thoroughly investigate allegations of witnessed sexual exploitation and prevent alleged violations of verbal, physical and sexual abuse and mistreatment for [REDACTED].#7, #30, #60, and #83) of eight residents reviewed for abuse. This deficient practice led to helplessness for residents, delayed interventions to prevent continued abuse/ mistreatment, and the potential for abuse of all residents residing at the facility. Findings include: On 5/6/19 facility Staff B found Resident #30 sexually assaulting Resident #60. Registered Nurse (RN) I witnessed Resident #60 crying out, stop, and was observed to be visibly upset by the assault. Eight interviews with staff members, who had witnessed many interactions which were inappropriate for a resident (Resident #60) unable to give consent, reported it to their supervisors. However, no follow-up preventative measures were taken regarding the allegations reported by staff to prevent the inappropriate behaviors from escalating to the incident which took place on 5/6/19. On 5/16/19 at 11:11 a.m., in an interview with the DON and Administrator present, the DON stated she was unaware of any incidents involving Residents #30 and #60 prior to the reported incident on 5/6/19. She also stated all staff reports (from a meeting held on 5/8/19) regarding Residents #30 and #60 had been put into QAA (Quality Assurance Audits), and the originals had been destroyed (the forms staff filled out regarding observed interactions between Resident #30 and Resident #60). The Abuse Prevention Policy And Procedure, revised on 3/20/19, revealed, The facility will identify and investigate all suspicions of allegations of abuse such as suspicious bruising of residents, unusual occurrences, patterns and trends that may constitute abuse .a. Any alleged violation involving mistreatment .abuse, exploitation .shall be reported to the Administrator immediately after the allegation is made. b.the Administrator will ensure that all alleged violations involving abuse .exploitation or mistreatment, including injuries of unknown source .are reported immediately .c. The Administrator .shall thoroughly investigate all allegations. During an interview on 5/13/19 at 4:00 p.m., Resident #83 reported to this Surveyor,(Resident #7) comes in (my room) and rubs my leg, under the blanket. (It's) been in the last week. Everyone knows about it. I don't wanna (expletive), if (Resident #7) was getting a sexual charge I would (expletive). (Resident #7) doesn't know what (Resident #7) is doing. I tell (Resident #7) to leave. (Resident #7) is in a wheelchair. It's at night. Maybe 1:00 to 2:00 a.m .in the last week or two. I feel out of control. I'm glad it's me and not someone who doesn't know what they're doing. I am going in a depressive mood. During an interview on 5/13/19 at 5:20 p.m., the Director of Nursing, DON, was asked if this incident was reported and investigated. The DON responded, Yes, (Resident #83) said it happened awhile ago .(Registered nurse, RN GG) investigated the incident. It is my understanding it was not sexual touch. No, I would not say it was abuse because (Resident #7) didn't touch (Resident #83) in an inappropriate way, (Resident #7) does not know what (Resident #7) is doing. I don't think it was intentional .I would not consider it abuse, it was non-sexual. It was not reported as it was resident touch; we can't report every physical touch resident to resident . During an interview on 5/13/19 at 5:30 p.m., the assistant director of nursing, Registered Nurse, RN GG, was asked if this incident was reported and investigated. RN GG responded, (Resident #83) said that (Resident #83) felt another resident, (Resident #7), rubbing (Resident #83's) leg, thigh and down. (Resident #83) told me it was a couple months ago, and (Resident #83) yelled at (Resident #7) to stop and (Resident #7) didn't. (Resident #83) kicked at (Resident #7) and (Resident #7) left. I asked (Resident #83) if (Resident #83) felt scared and (Resident #83) said yes. I did not feel it needed to be reported. I did not feel it was abuse. At 5:35 p.m., this Surveyor requested any additional notes or documentation of this incident from the DON and RN GG. RN GG provided a handwritten document titled, (Resident #83), 5/10/19, 1:44 p.m., signed by RN GG. This document revealed, I was sleeping-woke up and (Resident #7) was rubbed (sig) my leg-I told (Resident #7) to get the (expletive) out. (Resident #83) kept rubbing my leg and I kicked at (Resident #7) and (Resident #7) wheeled .out of here. (Resident #7 was) rubbing upper left thigh; actually it was the whole leg, that's what woke me up . (Resident #7's) hand was under the blankets .(a) couple months ago .I did not tell anybody. 'Did you feel scared?' Yes, but I didn't think (Resident #7) could do anything to me anyway . At 5:40 p.m. the facility provided a second document, Resident Interview, dated 5/07/19, 12:15 (p.m.). This form revealed, 2. Has anyone ever come into your room and touched you inappropriately? (typed), with a handwritten response, Yes. (Resident #7). (A) couple months ago (Resident #7 was) Rubbing my leg. Made (Resident #83) feel uncomfortable. I kicked (Resident #7) and told (Resident #7) I was going to tell the nurse. I have not told anyone . There was no evidence of facility investigations into incidents involving Residents #7 and #83 supplied to the survey team by the time of exit from this survey. The policy, Abuse Prevention Policy and Procedure, revised 3/20/19, revealed, . The facility will identify and investigate all suspicions of allegations of abuse. When an allegation is received the Administrator will ensure that all alleged violations involving abuse are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. The Administrator, or designee, shall thoroughly investigate all allegations. If the incident or allegation involves sexual abuse, the Administrator immediately notifies law enforcement in accordance with the Elder Justice Act Policy.

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO PREVENT AN ELOPEMENT FOR ONE (#1) OF THREE COGNITIVELY IMPAIRED RESIDENTS WHO REGULARLY SAT ON THE CEDAR GROVE COTTAGE PORCH. THIS FAILURE LED TO THE ELOPEMENT OF RESIDENT #1 FOUND IN A WHEELCHAIR ONTO A BUSY SERVICE ROAD (USED BY STAFF, VISITORS AND DELIVERY PERSONNEL) WITHIN 1/10TH OF A MILE OF FEDERAL HIGHWAY (US-2) WHERE SEMI'S AND LOGGING TRUCKS TRAVEL DAILY. THIS FAILURE RESULTED IN IMMEDIATE JEOPARDY TO THE HEALTH AND SAFETY FOR RESIDENT #1. IMMEDIATE JEOPARDY BEGAN ON 9/19/11 AT APPROXIMATELY 4:35 P.M. THE FACILITY STAFF DID NOT KNOW RESIDENT #1 HAD LEFT THE CEDAR GROVE COTTAGE PORCH FOR AN APPROXIMATE TIME OF FIFTEEN MINUTES, WHEN AN OFF-DUTY EMPLOYEE CALLED CEDAR GROVE COTTAGE VIA CELL PHONE TO ALERT STAFF OF A PERSON IN A WHEELCHAIR OBSERVED TO BE APPROXIMATELY 200 YARDS FROM THE PORCH ALONG THE SERVICE ROAD. STAFF RETURNED RESIDENT #1 TO THE CEDAR GROVE COTTAGE IMMEDIATELY AFTER NOTIFICATION. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 9/22/11 AT 1:02 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON 9/22/11 AT 4:10 P.M. BY THE FOLLOWING FACILITY ACTIONS: 1. PHYSICAL ASSESSMENT PERFORMED BY A REGISTERED NURSE (RN) SUPERVISOR UPON RESIDENT #1'S RETURN TO THE FACILITY FOUND NO PHYSICAL INJURIES. RESIDENT #1 WAS PLACED ON EVERY (Q) 15 MINUTE CHECKS BY STAFF. 2. VERIFICATION OF THE DOOR ALARMS WHICH WERE CHECKED AND FUNCTIONING PROPERLY. 3. ALL NINE RESIDENTS OF CEDAR GROVE COTTAGE AND THE 10 RESIDENTS IN THE NEIGHBORING PINE GROVE COTTAGE WERE REASSESSED FOR ELOPEMENT POTENTIAL WITH CARE PLANS AND "CNA FLOW RECORDS" UPDATED ACCORDINGLY. 4. ALL STAFF OF CEDAR GROVE AND PINE GROVE COTTAGES WERE IMMEDIATELY EDUCATED THROUGH AN IN-SERVICE REGARDING ELOPEMENT POLICY AND PROCEDURE. 5. ALL RESIDENT OUTDOOR ACTIVITY WILL BE SUPERVISED BY STAFF FOR ONE HOUR IN THE MORNING AND ONE HOUR IN THE EVENING. 6. ALL DOOR ALARMS WILL BE CHECKED BY STAFF EVERY SHIFT IN THE HOMES AND ALL WINDOW LOCKS WILL BE CHECKED NIGHTLY BY STAFF. 7. ALL PINE GROVE OR CEDAR GROVE COTTAGE FAMILIES/DPOA'S/GUARDIANS WILL BE INFORMED OF NEW POLICY TO SIGN ELDERS IN/OUT FOR LEAVING THE COTTAGE. 8. RESIDENT #1 WAS MOVED FROM CEDAR GROVE COTTAGE TO THE MAIN FACILITY ON THE SECOND FLOOR. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM FOR THE REMAINING TWO RESIDENTS IDENTIFIED AS ELOPEMENT RISKS, PENDING THE FACILITY'S ABILITY TO: 1. DEMONSTRATE THEIR ABILITY TO PREVENT RESIDENTS WHO ARE AT RISK FOR ELOPEMENT FROM EXITING THE FACILITY WITHOUT ADEQUATE SUPERVISION. 2. DEMONSTRATE THEIR ABILITY TO PROVIDE ADEQUATE SUPERVISION TO MEET THE SPECIAL NEEDS OF THE RESIDENTS WHO ARE AT RISK FOR WANDERING AND ELOPEMENT. 3. DEMONSTRATE THEIR ABILITY TO MONITOR THE FACILITY'S EFFECTIVENESS WITH STAFFS' SUPERVISION OF RESIDENTS IDENTIFIED AS ELOPEMENT RISKS. 4. VERIFICATION OF THE INITIATION AND MONITORING OF THE FACILITY'S QUALITY ASSURANCE MEASURES BY THE STATE AGENCY. FINDINGS INCLUDE: A REVIEW OF RESIDENT #1'S FACE SHEET FROM HIS CLINICAL RECORD REVEALED HE IS A [AGE] year OLD MALE admitted to the facility on [DATE] WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET ASSESSMENT ((MDS) dated [DATE] REVEALED RESIDENT #1'S COGNITIVE FUNCTIONING AS SEVERELY IMPAIRED. HE IS WHEELCHAIR DEPENDENT, AND NEEDS EXTENSIVE ONE-PERSON ASSIST FOR ALL OTHER AREAS OF HIS ACTIVITIES OF DAILY LIVING (ADLS). AN INTERVIEW WAS CONDUCTED WITH CERTIFIED NURSE AIDE (CNA) "A" AND CNA "B" ON 9/21/11 AT 4:10 P.M. AND 4:20 P.M., RESPECTIVELY. CNA "A" STATED SHE WAS IN ROOM 116 AT APPROXIMATELY 4:30 P.M. ASSISTING ANOTHER RESIDENT IN THE BATHROOM; SHE HEARD A LOUD NOISE COME FROM THE OPPOSITE END OF THE COTTAGE; SHE WENT THROUGH THE LIVING ROOM TO CHECK ON HER CO-WORKER; SHE SAW RESIDENT #1 SITTING ON THE PORCH, "I COULD SEE HIS RED HAT WHEN I WENT TO ASSIST (CNA "B"). I WENT BACK TO ROOM 116 AND FINISHED WHAT I WAS DOING THERE. HE (RESIDENT #1) HAD BEEN SITTING ON THE PORCH WITH (RESIDENT #3 & RESIDENT #4). I HEARD THE PHONE RING AND I SAW (CNA "B") RUN OUT THE FRONT DOOR... SHE BROUGHT (RESIDENT #1) BACK UP THE DRIVEWAY AND INTO THE HOUSE." DURING THE INTERVIEW WITH CNA "B", SHE STATED WHEN SHE ARRIVED AT WORK AROUND 3 P.M., "(RESIDENT #1) WAS SITTING ON THE PORCH LIKE HE USUALLY DOES, I ASKED HIM TO MOVE BACK OUT OF THE BRIGHT SUNSHINE. THE BENCH WAS ACROSS THE RAMP" (PREVENTING EGRESS FROM THE PORCH). CNA "B" CONTINUED, "I WENT INTO THE HOUSE TO REPORT FOR WORK... I WAS WORKING WITH A RESIDENT IN THE BATHROOM AT APPROXIMATELY 4:30 P.M., I HEARD THE PHONE RING AND ANSWERED IT, I WAS ASKED BY (STAFF "F") TO CHECK ON MY RESIDENTS BECAUSE ONE HAD BEEN SEEN DOWN ON THE SERVICE ROAD... I CALLED PINE GROVE COTTAGE (NEXT DOOR) TO NOTIFY THE NURSE AND THE STAFF THERE AND RAN DOWN THE DRIVEWAY TO SEE WHO WAS OUT THERE... WHEN I REACHED HIM, I ASKED (RESIDENT #1) WHERE HE WAS GOING AND HE STATED 'TO SEE WHAT'S OVER HERE' AS HE POINTED DOWN THE ROAD TO US-2." CNA "B" WENT ON TO SAY, RESIDENT #1 BECAME UPSET WITH HER WHEN SHE TURNED HIM AROUND TO COME BACK TO THE COTTAGE. AN INTERVIEW WAS CONDUCTED WITH LICENSED PRACTICAL NURSE (LPN) "H" ON 9/22/11 AT 9:15 A.M. SHE STATED SHE HAD BEEN IN THE CEDAR GROVE COTTAGE AND WENT OVER TO THE PINE GROVE COTTAGE TO PASS SUPPER TIME MEDICATIONS. SHE STATED WHEN SHE LEFT CEDAR GROVE COTTAGE, RESIDENT #1 WAS SITTING ON THE PORCH WITH THE MARRIED COUPLE (RESIDENT #3 & RESIDENT #4) AND THE BENCH WAS ACROSS THE RAMP. LPN "H" STATED RESIDENT #1'S MOOD WAS 'GOOD' THAT AFTERNOON. LPN "H" CONFIRMED SHE RECEIVED A PHONE CALL FROM CNA "B" AT APPROXIMATELY 4:35 P.M. INFORMING HER A RESIDENT WAS SEEN ON THE SERVICE ROAD AND ASKING PINE GROVE COTTAGE STAFF TO CHECK THEIR RESIDENTS. INTERVIEWS WERE CONDUCTED WITH CNAS "A", "B", "C", "D", AND LPNS "E" AND "H" ON 09/21/11 AT 1:33 P.M., 4:10 P.M. AND 4:20 P.M., AND ON 09/22/11 AT 9:15 A.M. THE STAFF WERE ABLE TO DEFINE "CODE WHITE" (THE FACILITY'S ELOPEMENT CODE) AND IDENTIFIED THE PROCESS TO SEARCH THE AREA AFTER IT WAS DETERMINED A RESIDENT WAS MISSING AND THAT FAMILIES NEEDED TO SIGN THE RESIDENTS IN/OUT WHEN THEY LEFT THE BUILDING. STAFF ALSO STATED THEY ARE NOW TO BE OUTSIDE WHEN RESIDENTS ARE SITTING ON THE PORCH OR IN THE GARDENS. THIS SURVEYOR CONFIRMED ON 9/21/11-9/22/11, THROUGH REVIEW OF RESIDENT #1'S CLINICAL CHART AND STAFF INTERVIEWS, THAT RESIDENT #1 RECEIVED 15 MINUTE CHECKS UNTIL HE WAS TRANSFERRED TO THE MAIN FACILITY ON 9/20/11. THIS SURVEYOR OBSERVED DOOR ALARMS TESTS ON THE FRONT AND BACK DOORS OF CEDAR GROVE AND PINE GROVE COTTAGES ON 9/21/11. THIS SURVEYOR VERIFIED, THROUGH TRAINING SIGN-IN FORMS AND INTERVIEWS, THE FACILITY STAFF HAD RECEIVED THE ELOPEMENT PREVENTION TRAINING AND KNEW THE FACILITY'S "ELOPEMENT PREVENTION PROCEDURE." IN ADDITION, THE STAFF CONFIRMED ALL RESIDENT OUTDOOR ACTIVITIES WERE TO BE SUPERVISED. ( )