Every finding on record at Post Nursing & Rehab Center

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services, in that: From 10/1/25 to 10/3/25, the facility failed to properly cover and store resident cups and drinks, exposing the rims of the glasses to the underside of serving trays. From 10/1/25 to 10/2/25, the facility failed to ensure food items (resident drinks, bread, frozen bread and frozen broccoli) in the dry pantry and freezer were labeled with received or use-by dates. On 10/1/25, the facility failed to maintain hot food items (spaghetti) at the required serving temperature of 165 F. From 10/1/25 to 10/3/25, the facility failed to separate dented cans from undamaged cans. These failures could place residents at risk for food contamination and foodborne illness. The findings included: The following observations were made on 10/1/25 in Kitchen A: On 10/1/25 at 11:20 AM, 38 glasses of fluid prepared for resident consumption were stored unsanitary with a serving tray placed directly on top, exposing the rims of the glasses to the underside of the serving tray. On 10/1/25 at 11:25 AM, seven resident drinks in the kitchen refrigerator were uncovered and unlabeled. Staff member DA G was observed placing a serving tray on top of the glasses, exposing the rims of the glasses to the underside of the tray. On 10/1/25 at 11:27 AM, hot food (spaghetti including ground beef) was observed with the temperature of 141.0 F being served below the required temperature of 165 F. On 10/1/25 at 11:32 AM, three loaves of bread and one package of hamburger buns were unlabeled (Did not include a manufactured used by date). At the same time, two of five dented cans (Chicken of the Sea tuna cans, dated 9/19/25) were stored with undamaged canned goods. On 10/1/25 at 11:34 AM, multiple food items in the freezer were unlabeled (no manufactured used by date observed), including 24 loaves of bread, six packages of hot dog buns, five packages of hamburger buns, and three packages of frozen broccoli. The following observations were made on 10/2/25 in Kitchen A: On 10/2/25 at 9:16 AM, 29 glasses of fluid prepared for resident consumption were stored unsanitary with a serving tray placed directly on top, exposing the rims of the glasses to the underside of the serving tray. On 10/2/25 at 9:18 AM, a dented can (Chicken of the Sea tuna can, dated 9/19/25) was observed stored with undamaged canned goods. One of the dented cans identified on 10/1/25 was observed stored on the bottom of a wire rack in the same dry pantry. On 10/2/25 at 9:20 AM, multiple food items in the freezer remained unlabeled (no manufactured used by date observed), including 24 loaves of bread, six packages of hot dog buns, five packages of hamburger buns, and three packages of frozen broccoli. On 10/2/25 at 9:21 AM, three loaves of bread and one package of hamburger buns were again observed without labels (no manufactured used by date observed). The following observations were made on 10/3/25 in Kitchen A: On 10/3/25 at 9:20 AM, a dented can (Chicken of the Sea tuna can, dated 9/19/25) was observed stored with undamaged canned goods. One of the dented cans identified on 10/1/25 was observed stored on the bottom of a wire rack in the same dry pantry. On 10/3/25 at 9:20 AM, one loaf of bread and one package of hamburger buns were observed without labels (no manufactured used by date observed). On 10/3/25 at 9:22 AM, multiple food items in the freezer remained unlabeled (no manufactured used by date observed), including 24 loaves of bread, six packages of hot dog buns, and five packages of hamburger buns. (The 3 frozen packages of frozen broccoli were no longer in the freezer). On 10/3/25 at 9:23 AM, 20 empty glasses prepared for resident liquids were stored unsanitary with a serving tray placed directly on top, exposing the rims of the glasses to the underside of the serving tray. Observed the [NAME] preparing to pour liquid in the cups. During an interview on 10/03/25 at 10:25 AM, the [NAME] stated that resident drinks should have been individually covered with plastic wrap. She stated that dented cans should not have been stored with undamaged cans. The [NAME] stated that she and DA H were responsible for unloading the truck on Tuesday (09/30/25). She stated she would have been responsible for labeling the frozen items, while DA H was responsible for placing dented cans in the appropriate area. The [NAME] stated that regarding food temperature, she should have removed the spaghetti from the steam table and reheated it to 165 F, then returned it to the steam table once it reached the correct temperature. She stated she was familiar with food storage and labeling requirements and had been employed at the facility for 22 years. She stated the potential negative outcome for not properly covering drinks was exposure to germs, which was unsanitary. She stated that serving food below the required temperature of 165 F could cause residents to become ill. She stated she did not know the potential negative outcome of storing dented cans with undamaged ones. The [NAME] stated she was aware of the uncovered cups observed on 10/03/25 that were exposed to the underside of serving trays. She stated she had filled those cups with liquid for breakfast service. She stated that on 10/01/25, she observed drinks that had been filled and covered with the bottom of serving trays but did not intervene because that was the way it had been done for years, and she tried not to interfere with others' work. She stated she knew the spaghetti was not at the correct temperature but did not reheat it because she was unsure whether she was allowed to do so while the HHSC investigator was present. She stated she proceeded to serve the meal as it was. The [NAME] stated she believed she had labeled the bread when it was received but noted that frozen items were difficult to label. She stated that not labeling food could negatively affect residents because old or expired food could be served, possibly leading to illness or mold growth. She stated she became aware of the dented can on 10/01/25 when the DM asked her why she had not moved or used it. She initially stated she thought the DM had told her to use the dented can of tuna but later clarified she was unsure whether the DM meant she should use the can for salmon patties or move it elsewhere. She stated the system in place to prevent such issues included not stacking serving trays on resident cups, using plastic wrap to cover individual or grouped drinks, and labeling drinks stored in the refrigerator. She stated plastic wrap was available for staff use. She stated food items, such as bread and broccoli, were to be labeled as they were received. She stated dented cans were typically reported to the DM and not placed on shelves. The [NAME] stated the procedure for food temperatures was to check the temperature 10 minutes before serving and reheat if needed. She stated she had received training when first hired and participated in refresher training as required. She stated she expected kitchen tasks to be performed the correct way, including labeling all food items and maintaining proper food temperatures. She stated everyone was responsible for ensuring food was served safely and explained that the identified failures occurred because things just slipped through the cracks, but they did the best they could.During an interview on 10/03/25 at 10:46 AM, the DM stated that DA H was unavailable because she was on break, and DA G was unavailable because she had been terminated earlier that morning for reasons unrelated to dietary deficiencies. The DM stated that DA G had been scheduled to return to work on 10/02/25 but was excused due to scheduling issues. The DM stated spaghetti could remain at 140 F on the steam table but acknowledged that milk and bread had never been labeled because they were used quickly, and it had never been an issue. She stated that after 10/01/25, she moved one dented can of tuna and later noticed another dented can after the HHSC investigator's visit. She stated that on 10/03/25, while reviewing policy, she learned of a new system for monitoring dented cans, which required taking a picture, notifying the vendor, and discarding the dented item. She stated the kitchen policy provided to the HHSC investigator was the only policy addressing labeling and storage. The DM stated she had been trained to label food with a received date. She stated drinks should have been individually wrapped in plastic and dated. She stated that while practices had changed over the years, staff should never have covered cups with the bottom of a serving tray-it was only acceptable to use the tray upside down. The DM stated the potential negative outcome of using the underside of trays to cover drinks was contamination, which could make residents ill. She stated dented cans should not be stored with undamaged cans because of the risk of botulism (a rare and serious poisoning caused by neurotoxins). She stated she would never instruct staff to use dented cans and always directed them to remove damaged ones. She stated staff were expected to refer to posted cooking temperatures, noting that most food must reach 165 F. She stated she was unaware of the failures observed and did not know the [NAME] had served food at 141 F. She stated the [NAME] should have reheated the food until it reached 165 F. The DM stated she had monitored the kitchen in the past but had not recently, as she worked evenings and was rarely present during cooking hours. She stated she had never observed the identified issues or inaccuracies in the temperature logs and had believed that temperatures above 140 F were acceptable. She stated there was no written policy for food temperatures, but they used the log for reference. She stated she was unaware that uncovered, unlabeled drinks were stored in the refrigerator and that staff should have individually wrapped and dated them. She stated staff should have labeled food upon receipt and that dented cans should have been removed. She stated the DM was responsible for monitoring compliance, the [NAME] for food temperatures, and dietary aides for labeling and covering food properly.During an interview on 10/03/25 at 11:44 AM, the ADM also stated she was familiar with the kitchen policy, confirming it was the only policy related to the identified failures. She stated she had been unaware of uncovered and unlabeled drinks, improperly labeled food, incorrect food temperatures, or dented cans stored with undamaged ones. She stated potential negative outcomes included contamination of drinks, residents becoming ill, or food being served past its expiration. She stated dented cans could cause illness but believed staff would not use them once identified. She stated she expected the DM to monitor compliance and ensure policies were followed, including covering drinks with plastic, labeling food with the date received, and removing dented cans. She stated the DM was responsible for preventing the identified issues and did not have a reason why they occurred.Record review of the DM's food handler training revealed that she completed the food handler training program on 5/16/23.Record review of the DM's Dietary Manager credential revealed that she completed the credentialing examination and met the qualifications on 2/6/20.Record review of the Cook's food handler training revealed that she completed the food handler training program on 3/13/25.Record review of DA G's food handler training revealed that she completed the food handler training program on 11/05/24.Record review of DA H's food handler training revealed that she completed the food handler training program on 7/15/25.Record review of facility posting, Time and Temperature Control (Listed appropriate Food temperatures), undated, revealed:155 F: Ground MeatRecord review of facility posting, untitled, undated, revealed:Juice Poured should be labeled with the date dispensed and should be used within 7 days.Bread (Frozen) should be labeled with the date dispensed and should be used within 7 days.Record review of the facility's temperature log, dated 10/1/25, revealed:The alternative meal (Spaghetti) had a temperature of 141 F.Record review of the facility policy, Food Receiving and Storage, Revised July 2014, revealed:Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in- first out system.All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date).Other opened containers must be dated and sealed or covered during storage. Record review of 2022 Food Code U.S. Food and Drug Administration revealed:Preface: Foodborne illness in the United States is a major cause of personal distress, preventable illness and death, and avoidable economic burden. It is estimated that foodborne diseases cause approximately 48 million illnesses, 128,000 hospitalizations, and 3000 deaths in the United States each year.Epidemiological outbreak data identified major risk factors related to employee behaviors and preparation practices that contribute to foodborne illness: Improper holding temperatures and food from unsafe sources.Labeling- Use-by dateThe use-by date must be listed on the principal display panel in bold type on acontrasting background for any product sold to consumers.Any label on packages intended for consumer sale must contain a combination of a sell-by date and use-by instructions which makes it clear that the product must be consumed within the number of days determined to be safeFood (Condition) Safe, Unadulterated, and Honestly Presented:FDA considers food in hermetically (completely airtight) sealed containers that are swelled or leaking to be unadulterated and actionable under the Federal [NAME], Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard.Proper Cooking time and temperatures: The cooking temperatures of foods must be measured to determine compliance or noncompliance.Internal Cooking Temperature Specifications (165 F): MeatPreventing Contamination from the premises (Food Storage):Food shall be protected from contamination by storing food: Where it is not exposed to splash, dust, or other contamination.

Based on interviews and record review, the facility failed to ensure that each resident was treated with dignity and respect for 1 of 16 residents (Resident #30) reviewed for resident rights, in that: Resident #30's care plan, dated 09/18/25, which Resident #30 had access to, contained negative descriptive language (argumentative, picky and manipulative) to describe Resident #30. This failure could negatively affect residents psychologically, socially, emotionally and physically overall affecting their dignity and quality of life. The findings included:Record review of Resident #30's face sheet, dated 10/01/25, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include altered mental status (deviation from a person's normal level of alertness, awareness, and responsiveness to stimuli). Record review of Resident #30's Comprehensive Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score of 12, which indicated the resident's cognition was moderately impaired.Record review of Resident #30's care plan, dated 9/18/25, revealed the following:RN I initiated a care plan dated 3/13/23 and revised 1/29/25 that read I am very manipulative; I will complain to my doctor that I am scared to be left isolated and would like to get out of bed but refused to allow staff to get me out of bed. I am very argumentative and am known to belittle staff.RN J initiated a care plan dated 5/12/25 and revised 5/12/25 that read I am very picky and usually find something wrong with staff on a daily basis. I can be very manipulative and am known to not say the truth at times.Record review of Resident #30's progress notes, dated, revealed:The SW documented on 07/22/25 at 10:54 AM that Resident Representative K told Resident #30 that she could no longer be her MPOA because Resident #30 was being manipulative by accusing her of things she had never done.During an interview on 10/03/25 at 2:35 PM, Resident #30 stated she had participated in her care plan meetings, which were usually held in her room. She stated she could not remember the date of the last care plan meeting she attended or what all the meetings entailed. She stated she did not remember going over any goals because she was on hospice and believed people on hospice did not have goals, as no improvement was expected. Resident #30 stated she had never seen her care plan before and did not know what it entailed. She stated she would never describe herself as a picky eater or picky. She explained she required a gluten-free diet, which was not her being picky. She stated she liked the staff at the facility, describing them as very nice and providing great care. She stated the staff positioned her pillows and phone the way she liked them and that all the staff were polite to her, and she was polite to them. Resident #30 told the HHSC investigator that she did not like the terms picky or manipulative because the staff were nice to her and she did not agree with those descriptive words being used. She stated the staff were efficient and knew what she liked. Resident #30 stated she would describe herself as calm, peaceful, and honest. She stated she would not describe herself as manipulative, argumentative, or picky, adding that those were not nice words and would be untrue if used to describe her. She stated she could not say how those words made her feel because they were untrue.During an interview on 10/02/25 at 3:07 PM, the SW stated she had participated in care plan meetings for Resident #30 but was unsure of the exact date of the latest meeting. She stated the most recent meeting was held to address whether Resident #30 was able to make her own decisions about what she wanted in place. The SW stated Resident #30 sometimes exhibited behaviors in which she became fixated on one issue. She stated that even after an issue was resolved, Resident #30 might approach another staff member as if it had not been addressed. The SW described Resident #30 as manipulative, clarifying that she did not say this directly to her but used the term because Resident #30 would tell one staff member one thing and another staff member something different to achieve a desired outcome. The SW provided an example, stating that Resident #30 had said her resident representative (K, MPOA) was not legitimate and later denied making that statement. The SW stated she had never heard Resident #30 describe herself as picky or manipulative. During an interview on 10/03/25 at 9:34 AM, Resident Representative K stated she had participated in Resident #30's care plan meetings, most recently by telephone. She stated that during the meetings, medications and eating habits were discussed and the meetings were typically held in Resident #30's room. She stated she had never seen or received a copy of the care plan. Resident Representative K stated Resident #30 was particular about her food, which was discussed during meetings. She stated she would not use the words picky or manipulative because Resident #30 was quadriplegic and unable to manipulate much. She stated Resident #30 did not have a way of doing things for herself. Resident Representative K stated Resident #30 had sometimes blamed people for things they had not done, but she did not know the details. She stated she had heard the terms manipulative and picky used to describe Resident #30 but did not disclose by whom. She stated she disagreed with those terms, explaining that Resident #30 was simply doing what she needed to do to have her needs met. She stated she was unsure if Resident #30's recent untruthful behavior was due to staff interactions or a natural progression of her condition. She stated Resident #30 had recently become increasingly paranoid, which she attributed to her situation. She stated Resident #30 had never described herself using the words argumentative, picky, or manipulative and would not like those words being used to describe her. During an interview on 10/03/25 at 10:03 AM, CNA C stated he had provided care for Resident #30 and had worked at the facility for a year and a half. He described her as really respectful and stated he would not describe her as manipulative, picky, or argumentative. He stated Resident #30 knew what she wanted, and he assisted her even when she was specific. He stated he did not consider her manipulative and had never heard anyone describe her that way. He also stated he had never heard her describe herself that way. He stated those words ( manipulative, picky, and argumentative) sounded bad and that he would not want to be described in such a way.During an interview on 10/03/25 at 10:07 AM, CNA D stated she had worked at the facility for about two years and had provided care for Resident #30. She stated Resident #30 knew what she wanted and needed regarding her care and communicated well with the staff. She stated she would not describe Resident #30 as picky or manipulative because those words would paint [Resident #30] in a bad way. She stated those words would not make her feel good if used to describe her. She stated she had never heard Resident #30 describe herself as picky or argumentative.During an interview on 10/03/25 at 10:11 AM, CNA E stated she had worked at the facility for 17 years. She stated she would describe Resident #30 as picky and manipulative, but clarified she would not have chosen those words on her own and only used them because of the interview. She stated she would never call Resident #30 those words to her face because she had too much respect for her. She stated Resident #30 was particular about her food and would send it back if it was not up to her standards. She stated she had never heard staff or Resident #30 use the words picky or manipulative.During an interview on 10/03/25 at 10:15 AM, MA F stated she had worked at the facility for four years and had provided care for Resident #30. She described Resident #30 as sweet and very picky, explaining that she liked things a certain way and did not like change. She stated Resident #30 was very polite but could be passive-aggressive. She stated Resident #30 could be manipulative but that she would never say those things directly to her. She stated the word picky was not a nice term and that she preferred to say Resident #30 was misunderstood. She stated she had never heard anyone call Resident #30 those words directly or heard her describe herself that way.During an interview on 10/03/25 at 11:22 AM, the Activity Director stated she had attended care plan meetings for Resident #30 but was unsure of the date of the last one. She stated department heads and sometimes family members attended, and meetings were typically held in Resident #30's room. She stated the care plan was reviewed during meetings, which were led by the DON, who ensured completion and signatures. She stated residents' exact wording should be used, especially when quoted, and was unsure whether quotation marks were used consistently. She stated Resident #30 did not exhibit behaviors but did speak her mind and wanted to be heard, which she did not consider a behavior problem. She stated she had never heard Resident #30 use the terms manipulative or picky and would not use them herself. The Activity Director stated she believed staff should not express personal opinions about residents. She stated she hoped she had never made Resident #30 feel bothersome or described her negatively. She stated that if Resident #30 knew such words were used, it would make her feel bad, as no one wanted to be described that way. She stated she had not observed those words in the care plan or heard staff use them. She stated the DON and SW were responsible for care plans and that Resident #30 could request to view her care plan in its entirety.During an interview on 10/03/25 at 11:44 AM, the ADM stated she attended care plan meetings that included department heads such as the DM, Activity Director, DON, and sometimes family members via phone. She stated the DON reviewed the care plan for accuracy and that resident wording should be used, especially I statements. She stated residents and families could receive copies of the care plan upon request, identical to what the HHSC investigator reviewed. She stated she did not recall behaviors being discussed for Resident #30 and was unsure who had chosen the wording manipulative and picky. She stated she would not allow her staff to use such language and would not want to be described that way herself. The ADM stated that although Resident #30 could be difficult, she would have preferred constructive wording focused on solutions. She stated she believed Resident Representative K might have used those words, which RN I then included. She stated she was familiar with the facility's policies on Resident Rights, Dignity, and Care Planning and was unaware that those words had been placed in the care plan. She stated the DON was responsible for reviewing and ensuring person-centered care plans, as the facility did not have an MDS Coordinator.During an interview on 10/03/25 at 12:21 PM, the DON stated she attended care plan meetings that included department heads, such as the Activity Director and SW, along with the resident. She stated she reviewed the care plans herself and expected them to be personalized. She stated that I am statements indicated the resident's own words. She stated that residents and families typically did not receive copies unless requested, but if they did, they would receive the same version reviewed by the HHSC investigator. She stated Resident #30 sometimes exhibited behaviors involving Resident Representative K, including saying one thing and later denying it. She stated she had never heard Resident #30 use the words argumentative, picky, or manipulative. She stated Resident #30 was particular about how she wanted her phone and food arranged but stated that calling her those words would be disrespectful. The DON stated she was unaware that those words had been included in the care plan and that doing so could upset Resident #30. She stated care plans were reviewed quarterly and should reflect residents' needs in a dignified way. She stated she had received training on Resident Rights, Care Planning, and Dignity and that she was responsible for care plans.During an interview on 10/03/25 at 12:45 PM, the SW stated she had been unaware that the words picky, argumentative, and manipulative had been used in Resident #30's care plan. She stated she was familiar with the facility's Dignity, Resident Rights, and Care Plan policies. She stated Resident #30 could request a copy of her care plan if desired and would likely be upset if she saw those words. The SW stated she expected care plans to reflect the resident's needs in a dignified manner. She stated she sent care plan invitations, while the DON conducted the meetings. She stated she had not heard Resident #30 use those words but had heard Resident Representative K describe her that way, though she did not provide details.During an interview on 10/03/25 at 12:59 PM, RN I stated she had used the words manipulative, picky, and argumentative in the care plan because she believed they described Resident #30's behaviors and were meant to inform the care team. She stated it was her understanding that care plans were to be person-centered. She stated she believed Resident #30 and Resident Representative K had previously reviewed the care plan in its entirety when discharge was being discussed. She stated the Ombudsman was also aware, as she assisted with an appeal at that time. RN I stated she believed the wording had never been an issue before and was unsure how it might make Resident #30 feel, though she might not like it. She stated she used the words so staff would know how to approach Resident #30, as she sometimes changed details when speaking with different staff members.During an interview on 10/07/25 at 9:26 AM, the Ombudsman stated she had attended care plan meetings for Resident #30 in the past. She stated recent meetings were more informal and included the DON, ADM, and Resident #30, sometimes with Resident Representative K present. The Ombudsman stated she had never seen the care plan and was unaware that it contained the words picky, manipulative, and argumentative. She stated Resident #30 did not describe herself that way and would be highly upset if she knew those words were used. She stated that even if the words were true or accurate, Resident #30 would deny them because she saw herself as kind and loving. The Ombudsman stated she only reviewed care plans if an issue arose and the residents gave permission to view the care plan.Record review of the facility policy, Quality of Life-Dignity, Revised February 2020, revealed: Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of wellbeing, level of satisfaction with life, feeling of self-worth and self-esteem.Policy Interpretation and ImplementationResidents are treated with dignity and respect at all times.The facility culture is one that supports and encourages humanization and the individuation of residents, and honors resident choices, preferences, values and beliefs. This begins with the initial admission and continues throughout the resident's facility stay.Staff speak respectfully to residents at all times, including addressing the resident by his or her name choice and not labeling or referring to the resident by his or her room number, diagnosis, or care needs.Demeaning practices and standards of care compromise dignity are prohibited. Staff are expected to promote dignity and assist residents.Staff are expected to treat cognitively impaired residents with dignity and sensitivity; for example: Not challenging or contradicting the resident's beliefs or statements.Record review of the facility policy, Resident Rights, Revised December 2016, revealed: Policy Statement: Employees shall treat all residents with kindness, respect and dignity.Policy Interpretation and Implementation:Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:A dignified existence.Be treated with respect, kindness, and dignity

Based on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 2 of 16 residents (Resident #2 and Resident #3) reviewed for PASRR screening, in that: 1. Resident #2 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. 2. Resident #3 did not have an accurate and updated PASRR Level 1 assessment reflecting a diagnosis of mental illness. These failures could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk of not receiving care and services to meet their needs.The findings included:Resident #2 Record review of Resident #2's electronic face sheet dated 10/01/2025 revealed an [AGE] year-old male initially admitted to the facility on [DATE]. The face sheet included the following diagnoses: Parkinsonism (A group of movement symptoms found in several conditions, including Parkinson's disease. These symptoms include slow movements, stiffness, tremors, and problems with walking and balance.), Primary, with an onset date of 05/20/2025. Anxiety Disorder (excessive, ongoing worry that is hard to control), Admission, with an onset date of 05/21/2025. Major Depressive Disorder Single Episode, Severe without Psychotic Features (a mood disorder that causes a persistent feeling of sadness and loss of interest), no classification, with an onset date of 09/29/2025. Vascular Dementia, Moderate, with mood disturbance (loss of mental functions severe enough to affect daily life and activities) Secondary, with an onset date of 09/29/2025.The document did not indicate Resident #2 had a primary diagnosis of dementia. Record review of Resident #2's admission MDS dated [DATE], revealed under Section C Cognitive Patterns, Resident #2's MDS revealed a BIMS of 03, indicating the resident was significantly, cognitively impaired. There was not an option chosen on Resident #2's MDS, under section I Psychiatric/Mood Disorder, related to a Mood Disorder. Record review of Resident #2's care plan with a last Care Plan review date of 09/27/2025, under Diagnoses, indicated Resident #2 had a diagnosis of Major Depressive Disorder. Record review of Resident #2's Preadmission Screening and Resident Review (PASRR) Level One (PL1) form dated 05/19/2025 revealed under section C0090 Primary Diagnosis of Dementia an answer of YES, indicating the resident had a primary diagnosis of dementia. Additionally, under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #2. There were no additional documents provided to suggest Resident #2 had a completed PASRR Level 2 Evaluation. Resident #3 Record review of Resident #3's electronic face sheet dated 10/03/2025 revealed a [AGE] year-old male initially admitted to the facility on [DATE]. The face sheet included the following diagnoses: Atherosclerotic heart disease (progressive narrowing and hardening of coronary arteries due to the deposition of atheroma (fatty deposits).) Primary, with an onset date of 01/31/2025. Cognitive Communication Deficit, Unspecified Classification, with an onset date 01/31/2025. Major Depressive Disorder Single Episode, Severe without Psychotic Features (a mood disorder that causes a persistent feeling of sadness and loss of interest), no classification, with an onset date of 02/12/2025.The document did not indicate Resident #3 had a primary diagnosis of dementia. Record review of Resident #3's Quarterly MDS dated [DATE], revealed under Section C Cognitive Patterns, Resident #3's MDS revealed a BIMS of 13, indicating the resident was cognitively intact. There was not an option chosen on Resident #3's MDS, under section I Psychiatric/Mood Disorder, related to Mood Disorder. Record review of Resident #3's care plan with a last Care Plan review date of 02/26/2025, under Diagnoses, indicated Resident #3 had a diagnosis of Major Depressive Disorder. Additionally, the care plan included a focus area that began on 02/26/2025 which stated, I require antidepressant medication (Specify Lexapro) for diagnosis of (Major) Depression, with a goal that stated, I will verbalize/communicate and understanding of the discharge plan and describe the desired outcome by the review date., with the Interventions/Tasks that included the following: Encourage the resident to discuss feelings and concerns with impending discharge. Monitor for and address episodes of anxiety, fear, distress; Evaluate and discuss with the resident/family/caregivers the prognosis for independent or assisted living. Identify, discuss and address limitations, risks, benefits, and needs for maximum independence. Record review of Resident #3's Preadmission Screening and Resident Review (PASRR) Level One (PL1) form dated 01/31/2025 revealed under section C0100 Mental Illness an answer of NO, indicating the resident does not have a mental illness. There were no additional PL1 screenings provided by the facility for Resident #3. There were no additional documents provided to suggest Resident #3 had a completed PASRR Level 2 Evaluation. During an interview on 10/03/2025 at 11:25 AM the DON stated she was currently responsible for entering a Resident's PASRR, upon admission. The DON stated she was also responsible for reviewing the PASRR to ensure accuracy. The DON stated the PASRR was usually completed prior to the resident admitting to the facility, and she assumed they were completed correctly. The DON verified Resident #2 and Resident #3 both had an active diagnosis of Major Depressive Disorder. The DON stated, to her knowledge, major depressive disorder should have qualified a Resident for a positive PASRR Level 1 screening. The DON stated Resident #2 and Resident #3 did not have a primary diagnosis of dementia. The DON stated if a resident received a new diagnosis of mental illness, the facility notified their Local intellectual and developmental disability authorities (LIDDAs) representative to have a new PASRR screening completed for the resident. The DON stated she was not aware Resident #2 and Resident #3 received a new diagnosis of a mental illness, Major Depressive Disorder, after admitting to the facility. The DON stated she would ensure both residents were referred for new PASRR Level 1 screening. The DON stated she did not recall receiving training pertaining to PASRR. The DON stated it was important for a Resident to have an accurate PASRR to ensure the Resident was receiving services related to their mental illness. During an interview on 10/03/2025 at 12:08 PM the ADM stated the DON was currently the person responsible for entering PASRR screenings when a resident was admitted to the facility. The ADM stated the DON was responsible for checking the PASRR screening to ensure it was accurate. The ADM stated if a new diagnosis of mental illness was received for a resident a referral was made to their Local intellectual and developmental disability authorities (LIDDAs) representative to have a new PASRR screening completed for a resident. The ADM stated she was not aware Resident #2 or Resident #3 received a new diagnosis of Major Depressive Disorder since being admitted to the facility. The ADM stated a resident could potentially miss out on services available to them if their PASRR Level 1 screening was not accurate. Record review of the facility's policy titled, Pre-admission Screening & Resident Review (PASRR),, undated, revealed the following: GuidelineIt is the intent of Post Nursing and Rehab Center to meet and abide by all State and Federal regulations that pertain to resident Preadmission and Screening Resident Review (PASRR) Rules.PurposeThe intent of this guideline is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD. P ASRR Level 1 Screen (PL1) The community Admissions Coordinator or designee will ensure the referring entity provides a copy of the PL1 upon admission. In the event the facility is considering admission from the community (home, homeless shelter, jail, group home, off the street etc.) and if the facility Interdisciplinary Team (IDT) suspects any MI, ID or DD the community Admissions Coordinator prior to admission will contact the LIDDA and follow the preadmission process: 1. When it is determined that an individual's diagnosis was changed and/or a state surveyor determines the PL1 was incorrect, the social worker or designee will complete and submit a form 1012 (MI) or new PLl (ID/DD). A subsequent positive PLl will be entered according to 1012 findings.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 (Resident #17 and Resident #4) residents reviewed for infection control. 1. CNA A failed to utilize hand hygiene between glove changes during foley catheter care for Resident #4.2. CNA B failed to utilize hand hygiene between glove changes during incontinence care for Resident #17. These failures could place residents at risk for cross contamination and infection.The findings include:Record review of Resident #4's undated face sheet revealed a [AGE] year-old male originally admitted to the facility on [DATE]. Resident #4 had a medical history of paraplegia (a condition characterized by paralysis or loss of movement in both legs), neuromuscular dysfunction (a group of disorders that affect the nerves and muscles, impairing their communication and function), and tubulointerstitial nephritis (a condition that affects the kidneys). Record review of Resident #4's quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 11 which indicated Resident #4 had moderate cognitive impairment. Section H- Bladder and Bowel revealed Resident #4 had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine continuously) and was incontinent of bowel. Record review of Resident #4's physician orders revealed an order for Cath care every shift and PRN with a start date of 1/16/2023. Record review of Resident #4's care plan revealed a risk for catheter associated urinary tract infection or trauma with interventions for Cath care as needed, with a start date of 1/13/2022. During an observation of Resident #4's foley care on 10/1/2025 at 2:15pm, CNA A cleaned Resident #4's foley catheter and doffed (removed) contaminated gloves. CNA A failed to utilize hand hygiene between the glove change and donned (put on) clean gloves. CNA A turned Resident #4 onto his right side and cleaned Resident #4's bottom. CNA doffed contaminated gloves and donned clean gloves and placed a clean brief on Resident #4. CNA A did not utilize hand hygiene between the glove change. Record review of Resident #17's undated face sheet revealed am [AGE] year-old female originally admitted to the facility on [DATE]. Resident #17 had a medical history of dementia, chronic obstructive pulmonary disease (a group of lung diseases that cause persistent airflow obstruction and breathlessness), hypertension (high blood pressure), and muscle weakness. Record review of Resident #17's quarterly MDS dated [DATE], Section C- Cognitive Patterns revealed a BIMS score of 04 which indicated Resident #17 had severe cognitive impairment. Section H- Bladder and Bowel revealed Resident #17 was always incontinent of bowel and bladder. During an observation of Resident #17's incontinence care on 10/1/2025 at 3:07pm, CNA B cleaned Resident #17's front, doffed contaminated gloves and donned clean gloves. CNA B did not utilize hand hygiene between the glove change. CNA B turned Resident #17 onto her right left side and cleaned her bottom. CNA B doffed contaminated gloves and donned clean gloves. CNA B did not utilize hand hygiene between the glove change. During an interview on 10/02/2025 at 1:00pm with CNA A, she stated the DON was the infection preventionist. She stated she had been trained on infection control and the last training was approximately two months ago. She stated she was trained to utilize hand hygiene between glove changes. CNA A stated she did not use hand hygiene between glove changes because she forgot her hand sanitizer and she was nervous being observed. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be a chance of infection or spreading infection. During an interview on 10/02/2025 at 1:04pm with CNA B, she stated the DON was their infection preventionist. She stated she had been trained on infection control and hand hygiene last week. CNA B stated the training did cover utilizing hand hygiene between glove changes. She stated she did not utilize hand hygiene between glove changes because she was nervous and forgot. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection or causing sepsis (condition that occurs when the body's immune system overreacts to an infection). During an interview with the DON on 10/03/2025 at 10:15AM, she stated she is the infection preventionist. She stated she had been at this facility for a few months and had been training staff on infection control and catheter care. The DON stated there was an in-service in September 2025 on infection control. She stated she was not aware of staff not utilizing hand hygiene between glove changes. She stated compliance with infection control practices and hand hygiene are monitored through competencies, and those are done quarterly. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection. During an interview with the ADM on 10/03/2025 at 11:15AM, she stated the DON was the infection preventionist. She stated in-services on infection control and hand hygiene are done quarterly and as needed. She stated she was not aware of staff not utilizing hand hygiene between glove changes. The ADM stated hand hygiene is covered during infection prevention training. She stated the potential negative outcome of not utilizing hand hygiene between glove changes could be spreading infection and cross contamination. She stated compliance with infection control practices is monitored through competencies where staff are visually monitored during incontinence care and are corrected as needed. Record review of facility policy titled Handwashing/ Hand Hygiene last revised 8/2015 revealed; 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations. m. After removing gloves. 8. Hand hygiene is the final step after removing and disposing of personal protective equipment.

Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 12 of 12 confidential residents. The facility failed to ensure 12 of 12 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, were provided access to the Grievance form, were provided information who the facility grievance official was, their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life. Findings include: Interviews and Record Review during Resident Council on, 9/19/2024 at 1:00pm, attendees 12 of 12 confidential residents, stated they did not know the grievance process, they did not know where to obtain or submit a grievance form, they did know they could file a Grievance anonymously, the Grievance procedure had never been discussed in Resident Council, and they had not observed a posting of the Grievance procedure in prominent locations. Residents attending the group meeting did not know how to file a grievance. Residents did not know where to acquire a grievance form, who to turn the form into, and what happens once a grievance was filed. The Residents did not know they had the right to receive a written decision once their grievance was resolved. 12 Residents attended the meeting, the 12 Residents in attendance had all been Residents of the facility for 6 plus months. Record Review of the facility Grievance policy on 9/20/2024 at 12:05pm; according to the facilities' Grievance policy a copy of the Grievance/complaint procedure should be posted on the resident bulletin board. Observed prominent postings on 9/20/2024 at 12:30pm; the facility did not include instructions regarding the Grievance procedure with any of the prominent postings. Grievance forms were not available to Residents and there was no access to submit a Grievance anonymously. Interview with the ADM on 9/20/2024 at 1:18pm; the ADM stated she was the Grievance Officer for the facility. The ADM stated the Grievance form was kept in her office. The ADM stated the Residents do not have access to the Grievance form. The ADM stated she completes all Grievances. The Grievances were completed when a Resident comes to her with a complaint, complaints were shared in Resident Council, and when staff report complaints to her. The ADM stated the Grievance Procedure was not posted for Residents. The ADM stated the Residents cannot file a Grievance anonymously due to the Residents not having access to the Grievance form and having no means of submitting a Grievance form anonymously. The ADM stated she was responsible for assigning a Grievance to a staff member to address, she stated her expectation is Grievances be resolved in 24 hours. The ADM stated Residents who voice a complaint were interviewed by the staff member assigned to resolve the Grievance; she stated this was the first step in resolving the Grievance. These interviews were documented on the Grievance form. The ADM stated the resolution to the Grievance were documented on the Grievance form. The ADM stated the resolution was not presented to the complainant in writing as her policy directs. The ADM stated the resolution was discussed with the complainant one on one. The ADM stated she monitors the Grievance process for success by following up with the staff member assigned to resolve the Grievance, the ADM stated she will also meet with the complainant to ensure they were satisfied with the resolution. The ADM stated she was responsible for ensuring staff were trained on the Grievance process. The ADM stated she was not aware the Grievance procedure was not being discussed in Resident Council. Grievance Policy Record Review of the Grievance Policy last updated in 2017. Policy Statement: Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The Administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or their representative. has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. Policy Interpretation and Implementation: 1. Any resident, family member, or representative may file a grievance or complaint. 2. Residents, family, and representatives have the right to voice or file grievances without discrimination or reprisal in any form, and without fear of discrimination or reprisal. 3. All grievances from resident or family concerning issues of residents' care in the facility will be considered. Actions will be responded to in writing. 4. Upon admission residents are provided with written information on how to file a grievance. 5. Grievances may be submitted orally or in writing and may be filed anonymously. 6. The contact information for the individual with whom a grievance may be filed is provided to the resident or representative upon admission. 7. The ADM has delegated the responsibility of grievance investigation to the grievance officer who is [NAME]. 8. The grievance officer will review and investigate the allegations and submit the written report of such findings to the ADM with five working days of receiving the grievance. 9. The grievance officer will coordinate actions with the appropriate state and federal agencies depending on the nature of the allegations. 10. The ADM and staff will take immediate action to prevent further potential violations of resident rights while the alleged violation is being investigated. 11. The ADM will review the findings with grievance officer to determine what corrective actions need to be taken. 12. The resident or person filing the grievance on behalf of the resident, will be informed (verbally or in writing) of the findings of the investigation and actions will be taken to correct any identified problems. A written summary of the investigation will be provided to the resident and a copy will be filed in the business office. 13. If the grievance is filed anonymously the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance and report the findings. 14. The results of all grievances files investigated and reported will be maintained on file for a minimum of three years from the issuance of the grievance decision. 15. This policy will be provided to the resident or the resident's representative upon request.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 13 residents (Residents #10, #12, #14, #19, #23) and 1 of 5 staff (MA A) reviewed for infection control. 1. MA A failed to properly clean multi-use medical devices between each resident during medication administration for Resident #10, #12 and #23. 2. MA A failed to sanitize hands between residents during medication administration for Resident #10, #14, #19 and #23. These failures could place residents at risk for spread of infection and cross contamination. Findings included: 1. During a medication pass observation on 09/18/24 at 04:53 PM, MA A took an arm blood pressure device to the room of Resident #10 and took his blood pressure on the left upper arm. She then took the arm blood pressure device and placed it on top of the medication cart. MA A did not sanitize the arm blood pressure device before or after use. During a medication pass observation on 09/18/24 at 05:10 PM, MA A picked up the arm blood pressure device from the top of the medication cart and took it to Resident #12, who was seated in the dining room, and took his blood pressure on the left upper arm. She then took the arm blood pressure device and placed it on top of medication cart. MA A did not sanitize the wrist blood pressure device before or after use. During a medication pass observation on 09/18/24 at 05:11 PM, MA A picked up a wrist blood pressure device from the top of medication cart and took it to Resident #23, who was seated in the dining room, and took her blood pressure on the right wrist. She then took the wrist blood pressure device and placed in on top of the medication cart. MA A did not sanitize the wrist blood pressure device before or after use. 2. During a medication pass observation on 09/18/24 at 04:55 PM, MA A took the blood pressure of Resident #10 on the left upper arm. MA A did not sanitize her hands after taking Resident #10's blood pressure. MA A prepared a PRN medication for Resident #19 and administered the medication. MA A then returned to Resident #10's room and administered his medications. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/18/24 at 05:11 PM, MA A took the blood pressure of Resident #23 on the right wrist. MA A did not sanitize her hands after taking Resident #23's blood pressure. MA A then prepared and administered medications for Resident #14. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/18/24 at 05:19 PM, MA A prepared and administered medications to Resident #12, who was seated in the dining room. MA A did not sanitize her hands before or after medication administration. During an observation of medication pass on 09/18/24 at 05:24 PM, MA A prepared and administered medications to Resident #23, who was seated in the dining room. MA A did not sanitize her hands before or after medication administration. During an interview on 09/19/24 at 04:12 PM with MA A, she stated she did not sanitize her hands between each resident during medication pass. MA A stated she did not sanitize the wrist blood pressure device or the arm blood pressure device before or after use on each resident. She stated she was nervous while being observed and forgot to sanitize her hands and the blood pressure devices. MA A stated she should have sanitized her hands and the blood pressure devices between each resident during medication administration. MA A stated she had been trained on proper hand hygiene and proper sanitation of multi-use medical devices through in-services conducted by nursing administration approximately monthly. MA A stated a potential negative outcome for failure to properly sanitize her hands and multi-use medical devices was the spread of germs. During an interview on 09/20/24 at 11:21 AM with the ADM, she stated the DON was responsible for assuring staff were trained on proper hand hygiene and proper sanitizing of multi-use medical devices. She stated hand hygiene should be performed before and after each resident during medication administration. She stated multi-use medical devices should be sanitized after use on each resident. The ADM stated her expectation of staff for proper hand hygiene and sanitizing of multi-use medical devices was that it was done correctly because it was the most important thing. The ADM stated a potential negative outcome for failure to properly sanitize hands and multi-use medical devices was that germs could be passed from resident to resident. During an interview on 09/20/24 at 11:25 AM with the DON, she stated hand hygiene should be performed prior to handling medications and after administering medications. She stated multi-use medical devices should be sanitized after each use and between every resident. The DON stated staff were trained on proper hand hygiene and sanitizing multi-use medical devices through quarterly in-services and yearly skills checks conducted by nursing administration. She stated her expectation of staff for proper hand hygiene and sanitizing of multi-use medical devices was to always follow policy. The DON stated a potential negative outcome for failure to properly sanitize hands and multi-use medical equipment was the spread of infection. Record review of facility-provided staff education records titled Hand Hygiene and Alcohol-Based Hand Rub, dated 07/19/24, revealed MA A performed and met the skills check. Record review of facility-provided in-service training titled Infection Control Report dated 06/21/24, was signed by MA A and eleven other staff members. Record review of facility-provided in-service training titled Infection Control-How to Handwash, dated 02/22/24, was signed by MA A and seventeen other staff members. Record review of the facility-supplied policy titled, Handwashing/Hand Hygiene, revised August 2019, revealed: Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; 1. After contact with a resident's intact skin; Record review of the facility-supplied policy titled, Administering Medications, revised 2010, revealed: Purpose The purpose of this procedure is to provide guidelines for the safe administration of oral medications. Steps in the Procedure 1. Wash your hands. 21. Remain with the resident until all medications have been taken. 23. Perform hand antisepsis.

Based on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 1 of 14 residents (Residents #34) reviewed for care plans as follows: Resident #34 did not have a care plan for PASRR positive or PASRR services. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings include: Record review of Resident #34's face sheet, dated 09/19/24, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include schizoaffective disorder (mental health condition that is marked by a mix of schizophrenia symptoms, such as hallucinations and delusions, and mood disorder symptoms, such as depression and mania), bipolar disorder (a mental illness that causes extreme mood swings, affecting a person's energy, activity levels, and concentration), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), anxiety (feeling of fear and worry), and hypertension (high blood pressure). Record review of Resident #34's Comprehensive Minimum Data Set, dated dated [DATE], revealed Resident #34 had a BIMS score of 15 which indicated Resident #34's cognition was intact. Section A reflected PASRR screening with serious mental illness. Record review of Resident #34's care plan, dated 08/01/24, revealed no care plan for PASRR or PASRR services. During an interview on 09/19/24 at 10:00 AM with Resident #34, she stated she did receive mental health services and had a case worker. During an interview on 09/20/24 at 11:03 AM with the LVN A, she stated a care plan was a tool used to try to find solutions to resident problems. She stated it contained things like a resident's fall risk, what types of behaviors a resident had and how a resident should be positioned. She stated, I don't look at care plans that often, but I do one on one resident care and most information I need to care for a resident was given to me during morning team meetings. She stated the DON was responsible for updating the care plans. During an interview on 09/20/24 at 11:57 AM with the DON, she stated she was responsible for resident care plans. She stated Resident #34 was PASRR positive and does receive services. She stated Resident #34's PASRR positive and services should have been care planned. She stated PASRR positive, and services were not on the comprehensive care plan but was on the 48-hour baseline care plan. She stated if a resident was PASRR positive it must be care planned. She stated it may have gotten missed due to resident being a new admit. She stated it was included in the 48-hour baseline but did not pull over to the comprehensive care plan and she was not sure why. She stated the care plan was used to explain each resident's individual plan of care. She stated nurses, cna's, nursing administration and social worker use the care plan. She stated the care plan was part of the electronic health record and was available to all staff. She stated the potential negative outcome could be the resident's plan of care cannot be properly carried out. She stated her expectations were for all the information that was needed to care for the resident should be included in the care plan. She stated she had been trained on how to do care plans. She stated the initial care plane was done then periodic audits were conducted by administration staff in order to assure accuracy of the care plan. During an interview on 09/20/24 at 12:51 PM with the admin, she stated Resident #34 was PASRR positive and was receiving services. She stated there was no reason PASRR should not be care planned. She stated the care plan was used to make sure we have patient centered care that was appropriate for the resident. She stated the potential negative outcome could be failing to meet all the residents care needs. She stated the facility does have a system were administration staff audit the care plans. She stated her expectations were for the care plan to be accurate, so the residents achieve proper care and assure nothing was missed. Record review of the provided facility's policy titled Care Plans, Comprehensive Person-Centered, revised [DATE], reflected: Policy Statement - A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation . 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practical physical mental and psychosocial well-being. c. Describe services that would otherwise be provided for the above but are not provided due to the resident exercising his or her rights including the right to refuse treatment. d. Describe any specialized services to be provided as a result of PASARR recommendations . 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) .

Based on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 2 of 6 residents (Resident #1 and Resident #2) reviewed for notice of bed hold up on transfers. The facility failed to provide Resident #1, and Resident #2 or their resident representatives with a written bed-hold policy when the residents were transferred out to the hospital or were on therapeutic leave. This failure could place residents at risk for of being improperly discharged and placed in unsafe conditions. The findings were: 1. Record review of Resident #'1s face sheet, dated 03/22/24, reflected a [AGE] year-old female with an admitted [DATE]. Resident #1 had diagnoses which included: Alzheimer's (dementia/ memory loss) and psychotic disorder (symptoms that affect the mind) with hallucinations. Record review of Resident #1's comprehensive MDS assessment, dated 02/21/24, reflected Resident #1 BIMS was a 06, which indicated her cognitive state was severely impaired. Record review of Resident #1's care plan, dated 02/12/24 , reflected Resident #1 had an ADL self-care performance deficit due to confusion, disease process (lupus [Autoimmune disease], osteoporosis (bone disease), psychotic disorder, cognitive loss, pain and muscle weakness. Record review of Resident #1's Clinical Census report, dated 03/22/24, reflected she was transferred to a local hospital on 02/06/24 and on 02/23/24. The report was signed and confirmed by the DON. Record review of Resident #1 progress notes, dated from 02/06/24-03/22/24, reflected the following: LVN A documented on 02/06/24 at 11:46 AM, Resident #1 fell and 911 was called. LVN A documented on 02/26/24 at 12:07 AM, Resident #1 left with the local ambulance company and transported to the local hospital. Record review of Resident #1's admission packet did not reflect a bed hold policy was given upon admission. During an interview on 03/22/24 at 9:46 AM, Resident #1's Family Member stated Resident #1 had fallen twice since she was at the facility. He said he didn't have the specific dates but believed the first fall happened around 02/07/24 around lunchtime. He said the second fall happened on 02/21/24 around lunchtime. He said he became displeased when Resident #1 fell the second time. He said because of the second fall, he wanted her to complete therapy somewhere else but was not opposed to Resident #1 returning to the facility at the time of the fall. He said he intended for the resident to return to the facility after therapy and only to take a few items from the nursing facility. He wanted things she would need immediately, such as shampoos, soaps and a few personal items while she completed therapy at another facility. He said he picked a place of therapy closer to him so he could visit the resident more, possibly during his lunch break. He said when he explained this to the ADM and the staff at the facility, he was made to feel like Resident #1 was just a number. He said the ADM told him she needed the bed in case another resident needed it. He said he knew he saw in the past where other family members who were related to him had a room held for them. He said he was never given a written notice or anything concerning the bed hold policy . During an interview on 03/22/24 at 12:08 PM, the ADM stated Resident #1 went to the hospital each time she fell in the facility. She said when the second fall occurred, she had a conversation with the Family member that included Resident #1's therapy could be provided at the facility. She said they did not have a bed hold policy and the Family member discharged Resident #1 from the facility/hospital himself . She said they anticipated her returning to the facility each time Resident #1 went to the hospital. She said the Family member expressed he felt like Resident #1 was just a number, but she did not know why because all the staff loved and cared for Resident #1. She stated all of the resident's items were packed up and sent because the Family member requested all of the items, and if Resident #1 was discharged , all of her items needed to go with her. During an interview on 03/22/24 at 1:11 PM, Resident #1 said she remembered falling and went to the hospital but didn't know anything about the bed hold policy. 2. Record review of Resident #2's face sheet, dated 03/22/24, reflected a [AGE] year-old female with an admitted [DATE]. Resident #2 had diagnoses which included: lack of coordination and cognitive communication deficit. Record review of the EMR, under the MDS tab, reflected the following: On 12/01/23 a MDS was completed under the description of discharge return anticipated. On 12/18/23 a MDS was completed under the description of discharge return anticipated. On 01/02/24 a MDS was completed under the description of discharge return anticipated. On 01/27/24 a MDS was completed under the description of discharge return anticipated. Record review of Resident #2's Comprehensive MDS assessment, dated 12/30/23, reflected Resident #2 BIMs was a 07, which indicated her cognitive state was severely impaired. Record review of Resident #2's care plan, dated 02/2/24, reflected Resident #2 had an ADL self-care performance deficit due to confusion, hemiplegia (paralysis of one side) and impaired balance. Record review of Resident #2's Clinical Census report, dated 03/22/24, reflected she was transferred to a local hospital on 04/26/23, 12/01/23, 12/18/23, 01/02/24 and 01/27/24. The report was signed and confirmed by the DON. Record review of Resident #2 progress notes reflected the following on the specified dates: LVN A documented on 12/01/23 at 10:54 AM, Resident #2 requested to go to the hospital, she was very weak and hallucinating. The ambulance was called and she left the faciity on a gurney. LVN B documented on 12/18/23 at 2:27 PM the local ambulance was notified for transport and change in condition. LVN B documented on 1/02/24 at 2:03 PM, received a call from dialysis center stating they are sending resident out due to doctor's orders for tremors and increase. LVN A documented on 01/27/24 at 06:41 PM, the dialysis center called and left message which stated Resident #2 was sent to hospital. Record review of Resident #2 physician order's, dated 04/26/24, reflected the following: Send to the emergency room to evaluate and treat hardware displacement with fracture to the left knee. Record review of Resident #2's admission packet reflected it included bed hold Information and Practice guidelines/ Bed Hold policy signed by Resident #2 as of 02/17/23. During an interview on 03/22/24 at 1:48 PM, Resident #2 stated she had never received written notice about the facility's bed hold policy. She said she had never worried about it because she knew her bed would always be available but no one had ever told her this. During an interview on 03/22/24 at 2:24 PM AM, the DON stated she did not give a written notice of when residents went to the hospital. She stated she did not personally give Resident #1 or Resident #2 a notice when they transferred to the hospital. She said for each resident, she did anticipate each resident returning to the facility. She said she was unaware giving a written notice at the time of transfer was a requirement. She said she was actively reading her policy on this date . She said the potential negative outcome to the resident could be their room could be given to another resident or the resident's property could be lost or moved. She said she was unaware the notice had not been given. She said their facility did not have a system for issuing written notices for bed holds. She said she was unsure, but she believed the bed hold may be in the admission packet . She said she had not received any training regarding issuing a written notice. She said she expected they as the facility staff should communicate with families about the facility's bed hold policy. She said she didn't think they had an actual policy with specifics. She said she remembered there were some families who were confused with the bed hold policy in the past, so they did away with it . She said this was why she believed they never had an issue with it before. She said as a general rule, if they knew the resident was coming back, they did not give the residents bed up. She said she believed most facilities had to get rid of the resident items within 24-48 hours, but if they knew the resident was returning, they kept it as long as possible. She said regarding Resident #1, the family member was up in the air about whether or not Resident #1 was coming back. She said written notices were not given because this was something they had never practiced before with anyone. During an interview on 03/22/24 at 2:38 PM AM, the ADM stated their facility was not the ones that always sent residents to the hospital, for example, regarding Resident #2 the dialysis center would send her out. She said upon admission, the residents were told about the bed hold policy. She stated the residents, which included the family members, should have received the bed hold policy upon admission. She said it was her facility policy expectation they gave out the written notice of the bed hold twice. She said they gave it out upon admission and if the policy changed. She said nothing had changed regarding the policy. She said she knew the policy was not changed because she pulled it off the company website. She said she believed the policy had not changed in the last 2 years. She said the policy may have been changed in 2019. No indication was provided in tracking changes if the policy did not have a date. She said regarding Residents #1 and #2, they always anticipated both residents would return to the facility. She said she was aware of the regulation, but her written policy stated every resident was made aware upon admission into the facility. She said they had the residents sign and keep a copy of the bed hold policy. She said she did not see a potential negative outcome for residents because they explained there was no charge. She said whoever completed the admission was responsible for explaining the bed hold policy. She said she had not received any formal training. The ADM stated she did not have anything to support her system of providing the old bed policy only upon admission. During an interview on 03/22/24 at 3:05 PM, the Activity Director stated she had multiple roles in the facility. She said she did human resources work on top of her CNA and transportation duties. She stated Resident #2 received the bed hold policy upon admission. She said she never issued a written notice to Resident #1 or Resident #2 before their hospital transfer. The Activity Director said she was not sure who was responsible for issuing the bed hold notices. She said she was unaware of a system for issuing the written notice of the bed hold. She said she was not trained to issue the written notice before transfers. She said she did not personally issue any written notices and did not know why it was not completed. She stated they anticipated Resident #1 coming back to the facility. She stated they anticipated Resident #2 coming back to the facility. She stated she was aware of the regulation that written notice must be given before transfer. She said she did not know the potential negative outcome of not giving residents notice of the facility bed hold policy. She said she was unaware of who was responsible. She said she was unaware of a system to monitor the written bed holds for residents and their representatives. She said she was unaware of a system for residents who was in emergent situations. She said she was trained to issue the written bed holds prior to transfers but only went over them at admission. She said she had just read and signed them and was unaware of any changes. Record review of the facility's, undated, bed-hold and information and practice guidelines reflected the following: The facility's leadership will provide a written bed hold notice at the time of transfer of a resident for hospitalization or therapeutic leave. The facility's leadership will readmit a resident according to applicable state and federal guidelines if the residents hospitalization exceed the bed hold policy. Practice guidelines: 2 written notices are provided to resident or legal representative regarding the bed hold policy in the event of hospitalization or therapeutic leave. The first notice is given at admission and re-issued in the event that the policy was to change. The second notice is provided at the time of transfer for hospitalization or therapeutic leave and specifies the duration of the bed hold period. In the event of an emergency transfer the family or representative are provided written notice within 24 hours of the transfer, which can include sending a notice with other documents accompanying the resident. Record review of the facility's, undated, policy titled, Bed Hold Policy and Initiation reflected, after placement in the nursing facility, it sometimes becomes necessary for the resident to go out of the facility for brief periods of hospitalization or home visits. It is the policy of this facility to hold beds and readmit residents as follows: Private pay residents can go and come from the facility as often and for as many days as desired. Medicaid residents: When admitted to the hospital for a period excess of 24 hours, the resident's applied income will be used as authorized by the resident and/or his/her responsible party has the right to reserve their bed. Medicaid/Medicare/ Insurance reimbursed resident is admitted to the hospital in excess of 24 hours, the resident's applied income will be used, as authorized by the resident and/or her/his/ responsible party to reserve his/her bed. Medicare insurance does not pay to hold a resident's bed when the resident is admitted to the hospital. A bed will be reserved for the resident as long as the bed hold charges are paid when he/she is out of the facility. Bed hold charges may be discontinued at any time if the resident and or responsible party notifies the business office and removes all personal belongings within 24 hours and all claim to the resident's bed is released.

Based on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 4 of 14 residents (Residents #12, #15, #16, and #30) reviewed for advanced directives, in that: Residents #12, #15, #16 and #30 was listed as a DNR (Do Not Resuscitate) but had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records. Findings included: Resident #12 Record review of Resident #12's face sheet, dated 08/16/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include hypertension (high blood pressure), anxiety (feeling of fear and worry), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities) and insomnia (sleep disorder). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #12's physician order summary dated 08/16/23 revealed the following order: DNR-Do Not Resuscitate dated 06/20/23. Record review of Resident #12's care plan, dated 07/03/23, revealed care plan for DNR. Record review of Resident #12's Out of Hospital Do Not Resuscitate form dated 06/19/23 revealed under the declaration of the adult person no selection of male or female. Resident #15 Record review of Resident #15's face sheet, dated 08/16/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (cognitive loss), muscle weakness, major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), and anxiety (fell ing of fear and worry). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #15's physician order summary dated 08/16/23 revealed the following order: DNR dated 02/14/22. Record review of Resident #15's care plan, dated 07/20/23, revealed care plan for DNR. Record review of Resident #15's Out of Hospital Do Not Resuscitate form dated 02/14/22 revealed no witness 2 signature. Resident #16 Record review of Resident #16's face sheet, dated 08/16/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), hypertension (high blood pressure), major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), and anxiety (fell ing of fear and worry). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #16's physician order summary dated 08/16/23 revealed the following order: DNR dated 11/20/22. Record review of Resident #16's care plan, dated 07/27/23, revealed care plan for DNR. Record review of Resident #16's Out of Hospital Do Not Resuscitate form dated 11/29/22 revealed under the declaration by a qualified relative section no selection of qualified relative. Resident #30 Record review of Resident #30's face sheet, dated 08/15/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include major depressive disorder (mental health condition that causes a persistently low or depressed mood and loss of interest in activities), hypertension (high blood pressure) and hemiplegia and hemiparesis (mild or partial loss of strength to one side of the body). The face sheet also revealed under the advance directive section - DNR-Do Not Resuscitate. Record review of Resident #30's physician order summary dated 08/15/23 revealed the following order: DNR-Do Not Resuscitate dated 10/03/22. Record review of Resident #30's care plan, dated 07/27/23, revealed care plan for DNR. Record review of Resident #30's Out of Hospital Do Not Resuscitate form dated 03/24/22 revealed missing guardian/agent/proxy/relative signature. During an interview on 08/17/23 11:40 AM with the DON, she stated OOH DNR was not valid if it's not filled out correctly. She stated the social worker was usually the one who obtained the OOH DNR and then she reviews them. She verified missing information on OOH DNR for Resident #12, #15, #16 and #30. She stated there was no system for monitoring OOH DNR for accuracy. She stated, she will just review them as they are signed. She stated the reason the DNR's were not complete was human error. She stated the potential negative outcome could be somebody sent out to emergency room without a valid OOH DNR and could be worked as a full code. She stated she had been trained on how to complete OOH DNR and her expectations were for them to be filled out completely and right. During an interview on 08/17/23 11:57 AM with the ADM, she stated the OOH DNR was not valid if not filled out correctly. She stated nursing was responsible for making sure the OOH DNR was completed accurately. She stated they do not have a system in place to monitor OOH DNR for accuracy. She stated the DON reviews them once they are completed. She verified missing information on OOH DNR for Resident #12, #15, #16 and #30. She stated she does not know why they information is missing. She stated the potential negative outcome could be not doing the request of our residents. She stated her expectations were that the OOH DNR was done correctly to make sure they are valid. Record Review of the Instructions for Issuing An OOH-DNR Order (Revised July 1, 2009) revealed the following: INSTRUCTIONS FOR ISSUING AN OOH-DNR ORDER PURPOSE Section A - If an adult person is competent and at least [AGE] years of age, he/she will sign and date the Order in Section A. Section B - If an adult person is incompetent or otherwise mentally or physically incapable of communication and has either a legal guardian, agent in a medical power of attorney, or proxy in a directive to physicians, the guardian, agent, or proxy may execute the OOH-DNR Order by signing and dating it in Section B. In addition, the OOH-DNR Order must be signed and dated by two competent adult witnesses, who have witnessed either the competent adult person making his/her signature in section A, or authorized declarant making his/her signature in either sections B, C, or E, and if applicable, have witnessed a competent adult person making an OOH-DNR Order by nonwritten communication to the attending physician, who must sign in Section D and also the physician's statement section. Optionally, a competent adult person or authorized declarant may sign the OOH-DNR Order in the presence of a notary public. However, a notary cannot acknowledge witnessing the issuance of an OOH-DNR in a nonwritten manner, which must be observed and only can be acknowledged by two qualified witnesses. Witness or notary signatures are not required when two physicians execute the OOH-DNR Order in section F. The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Record review of the facility's policy titled Advance Directives, undated revealed no information regarding the OOH DNR. 46425

Based on observation, interview and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, facility-sponsored group, designed to meet the interest of and support the physical, mental, and psychosocial well-being of 3 of 14 residents (Residents #4, #12 and #24) reviewed for activities. The facility: 1. Failed to engage in activities at scheduled times. 2. Failed to offer engaging activity replacement for scheduled activities that were cancelled or not completed. This failure could affect Residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings include: Observation of the dining room and the commons area (television room) on 8/15/23 beginning at 3:15pm, revealed the scheduled activity at 3:00pm was Wahoo, there were 3 residents sitting in the commons area and three residents sitting in the dining area, the AD was not present. The residents in the commons area informed surveyor they were waiting for Wahoo to start. The residents in the dining room also stated they were waiting for Wahoo to start; all 6 residents informed surveyor they had not seen the AD. Continued observation of the dining room and commons area at 3:23pm revealed the residents in the dining room left; the three residents in the common area remained in the commons area and stated they assumed the activity was not going to happen, they had not seen the AD. Observation of the dining room and the commons area (television room) on 8/16/23 at 1:10pm, revealed the scheduled activity was Papacures, there were two male residents in the dining room who informed this surveyor they were waiting for the activity. The residents informed the surveyor they had not seen the AD. Continued observation of the dining room at 1:25pm revealed the same three male residents waiting for the activity; the residents informed this surveyor they had not seen the AD and nothing was set up for the activity. Observation of the dining room on 8/16/23 at 2:03pm, revealed the scheduled activity was painting, there was nothing set up for the activity and no residents were in the dining room. Continued observation of the dining room at 2:10pm revealed Resident #24 was in the dining room, Resident #24 stated she was looking for the Painting activity scheduled for 2:00pm. Resident #24 stated she guessed the activity was not going to happen. Surveyor informed Resident #24 she would attempt to find the AD and find out if the activity was going to happen. 8/16/2023 at 2:17pm ADM asked Surveyor if she was looking for something; Surveyor stated she and Resident #24 were looking for the scheduled painting activity. The ADM had Surveyor walked with her down the hall to an office with 5 staff members in the office. The ADM asked the AD if she was going to have the Painting activity, AD stated, No, I am going to stay in here. The ADM looked at Surveyor and shrugged her shoulders, then ADM walked the in the office with the 5 staff members. Observation of the dining room and the commons area on 8/17/23 at 10:10am revealed there were 3 residents in the dining room and 3 residents in the commons area; the AD was not in the area. Surveyor asked Resident #4 and Resident #24 if the 10:00am scheduled activity of walking around the block was going to happened as scheduled; both residents informed Surveyor they were waiting for the walk; however, they had not seen the AD since the 9:00am activity ended. Continued observation of the dining room and commons area at 10:25am revealed the same 3 residents in the dining room and the same 3 residents in the commons areas. Residents #4 and #24 both told Surveyor the activity did not happen as scheduled and the residents had not seen the AD. Resident #4 Record review of Resident #4's electronic face sheet revealed a [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnoses Information, anxiety disorder, major depressive disorder, panic disorder, and bipolar disorder. Record review of Resident #4's Quarterly MDS dated [DATE], revealed under Section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #4's most recent care plan, undated, revealed a focus area including activities; the care plan stated Resident #4 enjoys participating in activities, at times Resident may enjoy observing activities, the AD will encourage and remind Resident to attend scheduled activities, and the AD will praise the Resident for attending activities of her choice. Interview with Resident #4 on 8/17/2023 revealed activities often did not occur as scheduled; there are no alternative activities offered, there was often no activity offered at the scheduled time, and the AD was not present in the dining room or the commons area during the scheduled activity time. Resident #4 stated she had been told the AD was pulled away from activities to perform other duties. Resident #4 stated the AD cannot perform the scheduled activities because she was asked to perform many other duties. Resident #4 stated she attempted to attend the Wahoo activity at 3:00pm on 8/15/23, but the activity did not occur. Resident #4 stated she attempted to attend the Painting activity on 8/16/23 at 2:00pm, that activity did not occur. Resident #4 stated she waited in the commons area for the walk around the block activity at 10:00am on 8/17/23, the activity did not occur. Resident #4 stated it makes her feel forgotten and not important when activities did not happen as scheduled. Resident #4 stated she needed to interact with other residents to help with her depression and when the activities did not occur, she missed the interaction with her peers. Resident #24: Record review of Resident #24's electronic face sheet revealed an [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under Diagnosis Information a diagnosis of Age-related Cognitive Decline, Cognitive Communication Deficit, and Muscle Weakness. Record review of Resident #24's Quarterly MDS dated [DATE], revealed under Section C Cognitive Patterns, the MDS revealed a BIMS of 7 indicating the resident was slightly cognitively impaired. Record review of Resident #24's most recent care plan, undated, revealed a focus area with problem onset date of 07/30/21 which read in part that Resident #24 was prescribed antidepressant medication for a history of depression. In addition, Resident #24 was also prescribed anti-anxiety medication for a history of anxiety, this area of concern had an onset date of 11/15/2022. Surveyor interviewed Resident #24 on 8/17/2023 at 2:33pm, Resident #24 stated she had noticed more often activities did not occur as scheduled on the activities calendar and the AD was not present during the scheduled activities. Resident #24 stated she was unsure why the AD was not around, and she was not hosting scheduled activities. Resident #24 stated she felt disappointed when the activities did not occur as scheduled. Resident #24 stated she looked forward to the scheduled activities, especially any art activity, Resident #24 felt down when the painting activity did not occur today as she had been looking forward to it all day. Resident #24 stated the art activities helped with her muscle loss in her hands and she felt the activities help her to be motivated to get out of her room. Resident #12: Record review of Resident #12's electronic face sheet dated 8/17/23 revealed an [AGE] year-old female most recently admitted to the facility on [DATE]. The face sheet listed under diagnosis indicated diagnoses of MDD, Anxiety Disorder, and Age-related Cognitive Decline. Record review of Resident #12's Quarterly MDS dated [DATE], revealed under section C Cognitive Patterns, the MDS revealed a BIMS of 15 indicating the resident was cognitively intact. Record review of Resident #12's most recent care plan, undated, revealed a focus area involving activities; Resident #12 will be invited and encouraged to attend activities, especially activities involving exercise and being outdoors. Resident #12 will be provided with an activities calendar, and she will be informed of any changes to the activities. Surveyor interviewed Resident #12 on 8/17/23 at 10:45am, Resident #12 stated she attended the 9:00am Sittercise activity and then remained in the commons area to attend the Walk Around the Block activity. Resident #12 stated the AD held the 9:00am activity; however, she never returned to the commons area to host the Walk Around the Block Activity. Resident #12 stated she looked forward to the activities involving exercise, especially activities that involved going outside. Resident #12 stated she had noticed several activities had not been held as scheduled over the past two weeks. Resident #12 stated there were no alternative activities offered when the scheduled activity did not occur. Resident #12 stated she felt disappointed when activities on the schedule did not occur as planned. Resident #12 stated she planned her day based on attending the activity she enjoyed; therefore, it was a let down when the scheduled activity did not occur. Interview on 8/17/2023 at 12:35pm with the ADM, ADM stated her expectation was for the AD to follow the scheduled activities calendar when there are no circumstances that interfered with the activity. The ADM stated her Human Resources staff quit last week, so she had pulled the AD from performing activities. The ADM stated she needed the AD to perform other duties. The ADM said no other staff have been assigned to hold the activity when the AD was taken away from her normal duties. The ADM stated she expected her AD to go to the rooms to personally invite Residents to the scheduled activity if no residents showed up to the activity. The ADM stated she expected the AD to change the activity if there was no interested in the scheduled activity. The ADM stated there was no potential negative outcome to the residents if the scheduled activity was cancelled. The ADM stated the Residents can entertain themselves with the access they have to books, art supplies, and magazines. Interview on 8/17/2023 at 1:15PM, AD said she has been employed at the facility for [AGE] years, the AD stated she had been pulled by her ADM several times in order to perform alternate duties, especially Human Resources duties. The AD stated she did not announce or leave announcements for the Residents when an activity was cancelled. The AD stated she did not ask other staff to cover the activity for her when she could not attend the activity. The AD stated she walked around and invited residents to activities when there was no resident in attendance for an activity. The AD stated she will change a scheduled activity if there was no interest in the scheduled activity. The AD was asked why the calendar was not followed on 8/15/23 at 3:00pm, 8/16/23 at 1pm and 2pm, and 8/17/23 at 10:00am; the AD stated she assisted with other duties as requested by the ADM. The AD stated she added activities to the calendar that are requested by Residents. The AD stated she thinks Residents feel disappointed when activities did not happen as scheduled. The AD stated the potential negative outcome for residents when activities did not occur as planned was a loss in quality of like and the Residents will be bored which can potentially increase behaviors. Record Review indicated the AD completed an online training and was a licensed AD. Record Review of facility activity calendar policy dated 2020 reflected the following: Both large and small group activities are part of the activity program. The calendar will state all activities available for the entire month, which may also include scheduled in-room activities. The activity calendar will be displayed in high-visibility ad high traffic areas. Activities will be scheduled 7 days a week including holidays. The AD will be properly trained and be licensed to perform activity duties. Individual activities and room visit policy program will be provided for those residents whose situation or condition prevents participation in other types of activities, and for those residents who did not wish to attend group activities.

Based on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 2 of 14 residents ( Resident #11 and #19) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available from for Residents #11 and #19 prior to administering melatonin (sleep aide). These failures could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the risk of the medications prescribed. Findings included: Resident #11 Record review of Resident #11's face sheet, dated 08/15/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include paraplegia (paralysis in the legs), hypertension (high blood pressure), insomnia (sleep disorder) and anxiety (feel constant fear and worry, difficulty concentrating). Record review of Resident #11's order summary report dated 08/15/23 revealed the following orders: Melatonin 5mg at bedtime related to insomnia dated 12/08/22. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #11 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #11 had a BIMS of 06 which indicated the resident's cognition was severely impaired. Record review of a care plan for Resident #11 dated 04/26/23 revealed a focus for use of sleep aid related to insomnia, with an intervention to administer Melatonin. Record review of Resident #11's medication administration record undated for the month of August 2023 revealed resident received Melatonin 5 mg orally at bedtime August 1st through August 17th. Record review of Resident #11 electronic medical record revealed no consent for melatonin. During an interview on 08/17/23 at 11:40 AM, the DON stated Resident #11 did not have a consent for melatonin. Resident #19 Record review of Resident #19's face sheet, dated 08/15/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include paraplegia (paralysis in the legs), schizoaffective disorder (mental disease), major depressive disorder (mental health condition that causes a persistently low or depressed mood and a loss of interest in activities), and insomnia (sleep disorder). Record review of Resident #19's order summary report dated 08/15/23 revealed the following orders: Melatonin 10mg at bedtime related to insomnia dated 07/17/23. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #19 was understood (clear comprehension). The MDS revealed Resident #19 had a BIMS of 09 which indicated the resident's cognition was moderately impaired. Record review of a care plan for Resident #19 dated 08/10/23 revealed a focus for use of sleep aid related to insomnia, with an intervention to administer Melatonin. Record review of Resident #19's medication administration record undated for the month of August 2023 revealed resident received Melatonin 10 mg orally at bedtime August 1st through August 17th. Record review of Resident #19 electronic medical record revealed no consent for melatonin. During an interview on 08/17/23 at 11:40 AM, the DON stated Resident #19 did not have a consent for melatonin. During an interview on 08/17/23 11:40 AM with the DON, she stated that melatonin was used for sleep at night. She stated she was responsible for obtaining psychotropic medication consents. She stated medication consents where to be obtained when medication was ordered. She verified there was no consents for melatonin in the EMR for Resident #11 and #19. She stated she was not aware melatonin needed a consent but that it was used for sleep. She stated the potential negative outcome could be family members not made aware of side effects it could cause and if family is not aware medication could be administered without consent. She stated that she has had training on obtaining psychotropic consents. During an interview on 08/17/23 11:52 AM with the ADM, she stated the DON was responsible for obtaining medication consents. She stated consents should be obtained at the time of the medication order. She stated she does not know why the consents were not obtained. She stated melatonin was given to residents having trouble falling asleep or request by the doctor. She stated the potential negative outcome could be it might mix with other medications, not being aware sleeping was a behavior or sleeping too much. Record review of the facility's policy titled Informed Consent, undated revealed: 1. The facility will protect and promote the resident's right to informed consent regarding all medications, treatments, and care and right to refuse medications, treatments, and care . 4. The Unit Nurse will: a. Inform The resident and designated family member of any new or changed order for medication, treatment, or care when the order is received .

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one of one kitchen in that: A. One of two kitchen oven doors (right side) did not completely close and was being propped closed with a kitchen towel. B. One of two kitchen ovens (left side) were not working. These failures had the potential to place residents at risk of oven foods being under-cooked which could result in food-borne illnesses. The findings included: During an observation on 07/05/22 at 09:00 AM in the kitchen, the gas Vulcan Oven had one of two oven doors (right side) that did not close completely, and a white dish towel was wedged in the left side of the door with part of the towel in the heated portion of the oven. The oven was set at 425 degrees and was cooking turkey. During an interview with the Dietary Manager (DM) on 07/05/22 at 9:00 AM, she stated the left side of the Vulcan Oven had recently gone out. She said it had been out for about a couple of weeks. She said because the left side had stopped working, she and her staff started using the right side. She stated that the right side's door does not shut properly and that she had to put the towel in the door so that it can secure and hold the heat. She reported this door had been broken for at least three years. She stated that previous administrators told her they could no longer find the door for the oven. She stated that they are using the towel to shut the door only because the left side of the door is not working. She did not state that anyone instructed them to do this. During an interview with Kitchen Staff A on 07/06/22 at 8:27 AM, revealed that she has worked at the facility on and off for ten to [AGE] years. She stated the left side of the Vulcan Oven had been out two or three months. She said she preferred to use the Vulcan Oven's left side because she felt it cooks better. She stated if she wanted to use the left side, she laid on her back, crawled as far as he could, and pressed a red button under the oven (to release the gas). She stated that she has another staff to assist her by lighting the oven, but this does not always work. She said you must know the oven well enough to turn the knob so the fire would not go out. When asked if she were concerned about fire and her safety, she stated that if the oven were to catch on fire, she would have difficulty moving because she has a bad back and hip. She said she has no concern about the towel catching on fire because she ensures that she does not have any of the towel in the oven when she places the towel. She stated that the right side of the door had been an ongoing issue on and off for the entire time that she had been at the facility. She said that when she started at the facility in 1987, the same Vulcan Oven had been at the facility. She stated that she has not personally told anyone about the oven having issues but that the previous administration was aware the oven not always properly working. She stated that the kitchen staff had to cook food longer because the oven was not working properly. During an interview with the DM on 07/07/22 at 08:28 AM, she stated that on the first day when the towel was observed in the oven, the oven was set at 425 and was cooking turkey. She stated that an adverse outcome could be the potential for fire, but she does not believe this was an issue because she checks her food at least every 30 minutes, but if a person does not check the oven, a fire could start. She stated she was not concerned with undercooked food because she cooks longer and at a higher temperature than it does not happen. She said residents could have had to wait longer for their food because it takes longer to cook. She stated she had been trained to report maintenance issues. She stated the maintenance director was responsible for repairing broken equipment in the kitchen, and the kitchen staff were responsible for cleaning. She said they at one time had a log but that she had not seen this in a while. She stated that since there was no log, she would have told the staff in the office. She said she knew the thermo coupler (sensor to measure temperature) needed to be replaced based on experience. She stated that this oven part had to be replaced a couple of times. She stated that the local plumbing company came out and relit the left side but never addressed the thermal coupler. She said she had not notified the interim administrator but had notified the previous administrator of the issue with the left side. She stated that she had not told anyone about the right-side door not working properly because this has been an issue for a while. She said she had asked previous administrators about replacing the stove but was told they would repair the oven by purchasing parts. During an interview with the Human Resource Worker on 07/07/22 at 08:45 AM revealed that she was not aware that the kitchen staff was using a towel to prop the Vulcan Oven door closed. She stated that she knew the oven needed a part but was notified of this from the DM. She said the DM contacted the local plumbing company. She said she was unsure if the local plumbing company diagnosed the problem with the oven or if the DM called the local plumbing company and asked for the parts. She stated that she knew the local plumbing company had come out and that a part was needed. However, she said she was unsure if the local plumbing company diagnosed the problem or if the DM told the local plumbing what was needed. She stated the previous administrator was aware of the issue but not sure if the interim was aware that the Vulcan Oven needed to be repaired. During an interview with the Maintenance Director on 07/07/22 at 09:06 AM, he stated he had been the maintenance director since January 2022. He said he was never notified of the issues with the Vulcan Oven outside the stovetop, which he addressed. He said maintenance requests were by the written maintenance log, or he would be notified by phone if it were an emergency. He reported that the one sheet of maintenance request was the only maintenance record he has seen at the facility. He said no request for the oven was on that sheet. He stated he was unaware that the staff were using a towel to prop the oven closed. He stated that putting a towel in the oven door could risk the towel catching fire. He said outside of his prior knowledge of being a maintenance director, he has not had any additional training on the facility's policies and procedures related to maintenance at the facility. He stated the one sheet of maintenance requests located in the binder at the nursing station was the only maintenance log he has seen and reviewed. He reported no additional maintenance logs in the facility to his knowledge. During an interview with the Director of Nurses (DON) on 07/07/22 at 9:33 AM revealed that she was not aware that the oven in the dining area needed repair. She stated that the maintenance director was responsible for the repairs in the facility, including the kitchen. In addition, she reported that she was unaware that the kitchen staff were placing a towel in the oven to keep it closed. She stated that by staff doing this, there is a risk of the towel catching on fire. She said she had been the DON since 06/13/22. She stated that since the Interim Administrator was on vacation, she was in charge. During an interview with the Vice President on 07/07/22 at 10:33 AM, he stated that he was unaware that the kitchen oven needed to be repaired. He said he had not been notified. He stated that he thought a repair to the oven had occurred a year and a half ago. He reported the maintenance director was responsible for all repairs. He stated he believes that the process at the facility was for the repairs to be kept on a log, and the administrator was responsible for reviewing them. When asked about the potential negative outcome of the oven not working, he questioned where the conversation was going and asked if he could call the surveyor back. He returned the call on the same day at 10:31 AM. He stated without him being in the facility, he could not say anything about the repair of the oven and what the negative outcome would be for the left side not working and the use of the towel to keep the door closed on the right side. During an interview with the Plumbing Secretary on 07/07/22 at 10:20 AM, she reported that on 06/22/22, they received a call from the facility and stated the oven was not working. She said that when the technician went out, the technician did not diagnose the oven, but the staff told the technician what was needed. She stated that the technician took the staff's word and ordered the requested part (thermal couplings) and that they had not come in. She said the local plumbing company had not received any other calls concerning the oven within the past year. Record review of the local plumbing invoice dated 06/22/22 revealed a plumbing call was made because the oven turns off. No specification of which side was being addressed. The invoice indicated thermal couplings need to be replaced. Record review of the Maintenance Work Log (undated) revealed entries from 03/07/22-07/06/22 and there were no entries related to the kitchen ovens. Record review of policy on Maintenance Service (Revised December 2009): Policy Statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: (a) Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. (b) Maintaining the building in good repair and free from hazards. (i) Providing routinely scheduled maintenance service to all areas. 3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.

Based on interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 5 residents reviewed for supervision. (Resident #1) The facility did not develop and implement interventions to prevent Resident #1, a resident who was cognitively impaired with exit seeking behaviors, from eloping from the facility. Resident #1 was found in his wheelchair approximately 2 city blocks from the facility. Resident #1 was in the road traveling against traffic at approximately 7 p.m. when oncoming LVN A found Resident #1 and brought him back to the facility. This failure could place the residents with exit seeking behaviors at risk for injury or death. This failure resulted in an identification of an Immediate Jeopardy (IJ) situation on 03/23/22. While the IJ was removed on 03/24/22, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm, and a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Record review of Resident #1's face sheet indicated he was admitted on [DATE], was [AGE] years old, and had diagnoses of [CONDITION(S)] with delusions (i.e. [CONDITION(S)]-in which a person cannot tell what is real from what is imagined), Generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), Unspecified dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions and solve problems), Major Depressive Disorder (persistent feeling of sadness and loss of interest that interferes with daily living), [CONDITION(S)] (high cholesterol), and [CONDITION(S)] (buildup of cholesterol plaque in walls of arteries causing obstruction of blood flow). Record review of Resident #1's Care plan created on 11/4/2021 (revised 1/6/22) indicated Resident #1 had a BIMS of 1, meaning Severe Cognitive impairment, Behaviors of being known to wander, related to cognitive impairment and diagnosis of Dementia. Interventions included if the resident is exit seeking, stay with the resident and notify charge nurse by calling out, sending another staff member, call system. Record review of Resident #1's Elopement Risk Assessment completed on 3/18/22 indicated that Resident #1 was Moderately impaired-(decisions poor; cues/supervision required); unable to recognize stop lights and signs, does not know precautions when crossing streets, does not know current residence and is unable to recognize physical needs. Resident elopement score is 14 (high risk). Record review of Resident #1's progress notes dated 3/11/22 at 7:17 p.m.; completed by LVN B, indicated that family was notified of resident's elopement attempt. Record review of Resident #1's progress notes dated 3/12/22 at 11:08 a.m.; completed by LVN B, indicated that oncoming nurse noticed resident outside of facility 2 blocks away as she was coming to facility and brought resident back. Coming into facility resident was wearing long sleeve sweater with matching sweatpants. Observation log documentation started. Family and physician noted. Record review of Resident #1's progress notes dated 3/18/22 at 5:46 p.m., completed by unknown agency nurse (not listed on entry) indicated Resident #1 attempted X2 to leave facility. Resident did not get off facility grounds or out back gate. This writer encouraged resident back inside and resident called daughter and spoke with her and then had dinner. Administrator aware. Daughter aware. Record Review of Resident #1's progress notes dated 12/18/22 at 10:35 a.m.; completed by RN A indicated that Resident #1 wandering exit seeking, unable to redirected, dx of dementia. Resident noted to have exited through the west side door, door does not lock, alarm sounded for 5-10 seconds when door handle touched then alarm turns off, resident wheeled approx. 10 ft on sidewalk, did not leave premises, daughter notified, frequent monitoring per staff Record review of weather in the city on 3/11/22 indicated that there was a high of 40 degrees and low of 21 degrees and at approximately 7 p.m. it was dusk (getting dark) outside. During an interview on 3/23/22 at 9:50 a.m., ADON stated that Resident #1 was found by LVN A on her way to facility for her shift on 3/11/22 at approximately 7 p.m. She stated Resident #1 was found 2-3 blocks away near the High School football field, he was in his wheelchair and it was dark outside. ADON stated that the door alarm did not sound long enough for staff to hear. ADON stated that Resident #1 resides on hall B but exited hall A via the exit door. Resident #1 has a history of exit seeking and prior to this staff were advised to redirect him or try and talk to him about his former career in mechanics. She stated Resident #1 had attempted to elope facility in the past and made it down the sidewalk before staff found him. She stated the alarm system failed that day as well. During an interview and observation on 3/23/22 at 10:24 a.m. with Resident #1; Observed sitting in the dayroom in his wheelchair next to a female resident (non-family member) who was wearing purple. Observed Resident #1 use his feet to pull himself along in his wheelchair to another area in the dayroom to speak to Investigator. Resident #1 stated he was [AGE] years old and pointed to a woman across the room wearing purple and stated that was his wife. Stated he currently lives in New Mexico and he grew up here. Stated he helped his Dad build the building he is currently in. Stated that he has lived here [AGE] years. Stated he does not remember leaving the facility in his wheelchair or being found by staff outside of the facility. During an interview and observation on 3/23/22 at 10:51 a.m. with Administrator; stated on 3/11/22 when Resident #1 eloped, the A hall red box failed and prevented the alarm from sounding to notify staff the door was opened. Resident #1 exit seeks between 4-7 p.m. and staff are directed to keep Resident #1 busy. Stated Resident #1 is not orientated to time and place. Administrator stated, there are no records on the door alarms to say when or if they had been checked prior to this. Administrator stated that after the first elopement on 12/18/22, he hired a contractor to fix the alarms on the door but that after that repair he did not perform any type of checks to verify the alarm systems continued to work. On 3/11/22, there were two CNA's and a nurse working at the time Resident #1 eloped and it was around shift change at 7 p.m. Administrator stated that Resident #1 exit seeks between 4 p.m. and 7 p.m. I am not saying we are documenting anything because we are not. Maybe we need to do a 15 min check during that time. We did the 15 min checks that weekend until Monday, he left on a Friday. Resident #1 came from a previous facility where he (Administrator worked and Resident #1 had a history of eloping there also). Administrator stated that the facility does not use wander guards on the residents. Administrator stated that the alarm system and red box that failed have been repaired by the contracted maintenance man. Administrator provided a tour of facility exit doors to Investigator and it was observed that all door push bars sounded and alarms sounded when push bars were pushed for a continuous 15 seconds before door locked released. During an interview on 3/23/22 at 11:15 a.m.; with LVN A, stated that around 7 p.m. on 3/11/22 I was heading to work and found Resident #1 on side of road going against traffic. It was cold outside and dusk. LVN A stated, Resident #1 was about 2 blocks away from the facility in his wheelchair and he was wearing a grey t-shirt material shirt and sweatpants and shoes. LVN A stated Resident #1 was put in her personal vehicle and driven to the facility. She stated she was unable to take Resident #1's wheelchair due to lack of room. She stated that upon arrival to the facility she notified the ADON. She unloaded Resident #1 herself but Resident #1 did not want to get out of the vehicle because he stated he did not live there, and it was not his home. When she found Resident #1, he was in a hurry but did not tell her where he was going. Stated when she found him, she was driving in his direction and he was traveling down the wrong side of the street. LVN A stated that Resident #1 was cold to the touch and it was a colder day. Resident #1 has a history of trying to exit seek and is confused where he is. Stated that prior to this incident there were no checks in place to verify where Resident #1 was. LVN A stated that CNA's took Resident #1 to his room and he was assessed by the ADON when she arrived. LVN A stated Resident #1 had no injuries. LVN A stated that the CNA's on shift and the RN on shift did not know that Resident #1 was missing and when he was returned to the building they stated that they never heard a door alarm sound off alerting them that a resident had opened the door or exited the facility. During an interview on 3/23/22 at 1:40 p.m. the Administrator stated there is the code to the front door written on the door frame. Administrator stated that it is possible that another resident could provide the code or open the door for another resident and not be observed by staff. Administrator stated that If I was honest, this is not the best facility for Resident #1 because I cannot ensure the safety of Resident #1 or that he will not get out again, especially if there is an alarm door issue in future. Administrator admits that resident has a history of elopements and exit seeking. Administrator stated that on 12/18/22 Resident #1 exited west door (Hall A) and was found 10 feet outside the facility on the sidewalk. Administrator stated that the alarm system failed to alert staff and the door was unlocked. During an interview on 3/23/22 at 4:54 p.m. with the Administrator, ADON and Business Office Manager(BOM) the Administrator said, they were going to have to find another place for (Resident #1) he could not purchase a wander-guard system and could not hire someone to be with Resident #1 24 hours 7 days a week to make sure he does not elope. The Administrator said he could not keep Resident #1 safe, and he needed to be in another facility. The Administrator said even with the alarms on the doors he could not guarantee Resident #1 would not get out and leave the facility. During an interview and observation on 3/24/22 at 9:12 a.m. with ADON, stated that the doors off the living areas that lead to the smoking areas are not locked and the alarms are not set. Observed the alarms not set as the ADON escorted the Investigator to the smoking areas. Observed the two separate smoking areas have separate interior doors that are not armed or locked. Observed in both smoking areas of a chain-link fence with a metal bar inserted into the gate latch that is not a regulation approved method of securing the gate. Stated that Resident #1's spouse does not live at the facility. During an interview on 3/24/22 at 9:54 a.m. with CNA A; stated that she just started working at the facility a week ago and is PRN. Stated that when she started working at the facility, she was told that Resident #1 likes to exit seek and that he was the only resident that exit seeks. Stated that on 3/11/22 she and CNA B had finished supper service and were pushing all residents into the lobby area. Stated that a resident had vomited in their room and she went to go and change the resident. Stated she and CNA B were working together to clean the resident up that had vomited. Stated that the last time she saw Resident #1 was when he was in dining room around 6:30 p.m. Stated that she didn't see Resident #1 again until she saw LVN A with Resident #1. Stated that Resident #1 was wearing blue jogging pants, blue long sleeve t-shirt and no coat. Stated that it was dark and cold outside when LVN A was with Resident #1 near the nurses' station. Stated that LVN A stated that Resident #1 was found almost near the football field which is a few blocks away from the facility. Stated that she never heard the facility door alarm go off. Stated that she assisted CNA B get Resident #1 into his room and changed for bed. Stated that she observed dried grass on Resident #1's pants and his nose was red and cold. Stated that this was before the 7 p.m. shift change, when LVN A brought Resident #1 into the facility. Stated that there were no checks on Resident #1 prior to this incident to document where he was. Stated that the ADON arrived at the facility and performed an assessment on Resident #1 and found no injuries. During an Interview on 3/24/22 at 10:52 a.m. with ADON, States there is nothing that advises staff of which residents are at risk of elopement risks. Stated that they started a book at the nurses' station on 3/23/22 to inform staff of the residents at risk of eloping but prior to that entry, the last time it was updated was on 12/19/21 after an in-service on 12/14/21. Stated that staff that started employment after 12/14/21 would not know which residents were at risk of was an elopement because they were not in-serviced on it. During an interview on 3/24/22 at 11:28 a.m. with MDS/RN Coordinator, stated that Resident #1 has a history of exit seeking and wanders aimlessly. Stated that his care plan has not been updated to identify why Resident #1 exit seeks but she will update it. Stated it also does not list any precursors to the behaviors and will update the plan and how staff can redirect him and what activities can be offered such as taking him for a walk outside the facility. During an interview on 3/24/22 at 1:22 p.m. with CNA B; Stated she has worked here about 3 years and was working on 3/11/22. Stated that on 3/11/22, after dinner there was a resident who was sick, and she was assisting CNA in the room with the resident. Stated the last time she saw Resident #1 was in hall A at approximately 6:30 p.m. Stated she was in the resident room with CNA A for 20 minutes. Stated that about 7 p.m., she observed LVN A with Resident #1 come in the front door and was told by LVN A that Resident #1 was found 2 blocks from the facility. Stated that Resident #1 was wearing sweatpants and a long sleeve t-shirt but had no coat on. Stated that Resident #1 was cold when he arrived back to the facility and she assisted CNA A with bringing Resident #1 to his room and getting him changed. Stated that she noticed grass clippings on Resident #1's sweatpants. Stated that Resident #1 was really tired when he returned. Stated she never heard the alarm door go off to notify her or the other staff that a door had been opened. Stated that when Resident #1 returned to the facility she was not aware he had eloped, and it was cold and dark outside when he returned. Record Review on 3/24/22; document entitled: Purchase Order to Direct Supply on 3/15/22 at 10:26 a.m. documents a purchase order for 4(quantity) Exit Stopper, Single Door for amount of $463.27 Record Review on 3/24/22; document entitled; Johnny [NAME] Construction date: 12/22/2021 documents that the following was repaired: (8) Fixed door magnets, door handles, door hardware; (1) installed door locks and knobs; (1) Header was coming off with the magnet, rebuilt head and magnet is working properly. (8) Red alarm boxes above each exit had to be reprogrammed to alarm until staff turns it off due to elopement concerns. (1) Change doorknob in kitchen. Existing knob was barely opening. (2) Repaired exterior gates due to elopement concerns. (1) Change alarm codes for multiple doors During an interview on 3/24/22 at 5:02 p.m. with LVN B; stated that she works for an agency and was working on 3/11/22 from 7 a.m. to 7 p.m. Stated that she was not in-serviced on who was at risk for elopements or exit seeking. Stated that she was not aware that Resident #1 had a history of elopement from the facility or attempting to leave. Stated that on 3/11/22 the last time she saw Resident #1 was when she saw the CNA's talking to Resident #1. Stated that it was about 6:30 p.m. when she last saw Resident #1. Stated that she did not know Resident #1 had left the building until LVN A walked into the building with Resident #1 and stated she found him in his wheelchair a few blocks from the facility. Stated she never heard the door alarm sound or go off to notify her or the other staff that the door had been opened. Stated that Resident #1's family was notified when he returned and the ADON came and assessed him. The Administrator, DON and Business Office Manager were notified 3/23/22 at 4:54 p.m. an IJ situation was identified due to the above failures. Administrator was provided with a copy of the Immediate Jeopardy Template. The POR was accepted on 03/24/22 at 3:33 p.m. and reflected the following: Plan of Removal 1. a. Administrator is currently calling facilities to locate a more appropriate location for his needs. b. Until a facility is found, and Resident #1 is discharged from [facility name], he will be under Q20 min checks. c. An Elopement Assessment audit was conducted to determine what other residents are an elopement risk. Resident #2 was determined to be the only other resident who is potentially at risk for elopement. He eloped in December but shows no additional signs of exit seeking. He will be supervised while smoking on the back patio. We have specific smoking times for residents. Therefore, the staff will be able to supervise him during those times. Resident #2 has never shown any other signs of being an exit seeker. Resident #2 will be supervised while smoking until such time as he is deemed to be not at risk of elopement. d. Going forward an Elopement Assessment will be conducted quarterly and as needed and placed in the resident chart. e. Going forward an elopement assessment will be conducted upon admission of any new residents and recorded in the resident's chart. f. Any new elopement risk residents will be identified, and a specific care plan will be generated, and the resident will be placed under the facility specific elopement risk protocol including and consideration of discharge when required. 2. a. The care plans for these two individuals have been updated to include: i.When Resident #1 begins to sundown, he will be taken outside by a staff member and assisted in ambulating on the sidewalk for a short period of time. ii.Resident #2 will be supervised while smoking on the patio at all times b. All door alarms (panic bar and red alarm box) will be inspected by Administrator/DON/Designee and the results of the inspections will be logged each time in a logbook that will be kept at the nurse's station. The inspections will be performed sequential as follows: c. 7 days a week for 7 days d. 5 days a week for 1 week e. 3 times a week for 2 weeks 3. 3/23/2022 a. After 4 weeks on 4/21/2022 the administrator/DON/Designee will check them once a week going forward with no end date. This will be documented on a log which will be kept at nurses' station Staff will be in-serviced on the following: i. How to properly redirect exit seeking residents ii. How to properly arm the door alarms to ensure they are always working correctly. iii. When to take the resident for a walk when he is showing signs of sundowning. iv. We will train the staff on what specific signs that resident #1 shows when he begins to sundown v. Education will also be provided on our elopement policy and procedure The above logs, checkups, and observations will be monitored 5 days a week by the ADON, ADMIN, and the DON/Designee. Any issues will be reporting to the QAPI committee for review and discussion. Monitoring: Observation on 3/24/22 at 3:06 p.m. of Daily Door Log in 3 ring binder located at Nurses station with entry for 3/24/22 documenting that the Administrator verified doors at the kitchen (2), gate 1 and 2. Interview on 3/24/22 at 3:15 p.m. with Administrator, stated that Daily Door Log is located at the Nurses station and if there are any issues found with the alarm system that the contracted maintenance man will be contacted immediately to fix the system. Interviews and observation on 3/24/22 at 3:25 p.m. with the administrator, ADON, and 10 employees including CNAs, housekeeping, and administrative staff on shift indicated they were aware of the residents who were elopement risks. Investigator witnessed Administrator present training on elopement risk and completing elopement assessments. Staff were observed receiving training on how to redirect exit seekers, how to properly arm door alarms, Resident #1's sundowning and to take Resident #1 on walks if showing signs of sundowning, When resident #1 begins to sundown, he will be taken outside by a staff member and assisted in ambulating on the sidewalk for a short period of time. Staff were presented the elopement policy and procedures on elopement. Staff were in-serviced that until another facility is located for Resident #1, he will remain on 20-minute checks. Record Review of Wandering and Elopement Policy dated: 2001; Revised March 2019; documents that the facility will identify residents who are at risk of wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Record Review of QAPI Committee Follow up policy documented that the following individuals will be assisting the administrator from time to time to ensure that the elopement, door alarm logs are checked and up to date. If they are not please report to the administrator immediately. List of employees included Business Office Manager, Human Resources, ADON, DON, Activities, Dietary Manager and Administrator. Record Review of Door monitoring policy, effective 3/23/22 documents that all door alarms (panic bar and red alarm box) will be inspected by Administrator/DON/Designee: 7 days a week for 7 days; 5 days a week for 1 week; 3 times a week for 2 weeks. Documents that after 4 weeks the administrator/DON/Designee will check them once a week with no end date. The Administrator was informed the IJ was removed on 03/24/22 at 3:33 p.m. however, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to establish and maintain an Infection Control designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of disease and infection for all residents, staff, volunteers and visitors as evidenced by: The facility failed to ensure 15 out of 27 staff, including CNA C, Activity Director J, Laundry Aide #D, Dietician E, Hairdresser B, Cook F, Registered Nurse G, Dietary Aide I, LVN K, Dietician C, Laundry Aide L, Nurse Assistant M, Administrator A, CNA N, Business office manager H were screened for temperature and COVID-19 symptoms prior to starting their shift at the facility and placing residents, staff, and visitors at risk for exposure to COVID-19. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 9/29/2021. While the IJ was removed on 09/30/2021, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm with a scope identified as widespread. This failure could affect residents and staff members by placing them at risk for the transmission of communicable diseases, infections, including COVID-19, which could result in fatigue, cough, pneumonia, [CONDITION(S)] and death. Findings include: Interview on 9/29/21 8:52 a.m. Administrator A stated that one staff member Housekeeper W tested positive off-site for COVID-19 on 9/20/21. Administrator A stated all staff were tested for COVID-19 on 9/20/21 with no other positive results. Administrator A stated that residents were tested the morning on 9/21/21 and one resident, Resident #1 tested positive for COVID-19 and was immediately transferred to another nursing facility that had a COVID isolation wing. Administrator A stated that Housekeeper W only worked at the facility for two days prior to testing positive for COVID-19. Administrator A stated, Resident #1 was fully vaccinated and has had COVID-19 two times previously and it is unknown how Resident #1 contracted COVID-19. Administrator A stated that all staff should be wearing medical grade masks unless they enter a quarantined room or a room with a resident who is positive for COVID-19. Administrator A stated that he screens visitors, or the charge nurse will screen visitors for COVID-19. Administrator A stated that staff can self-screen themselves for COVID-19 symptoms and temperature. Observation on 9/29/21 at 10:30 a.m. the screening area was located right inside the front entrance of the facility. Time clock was located on the wall past the screening table to the right of the nurse's station. Interview on 9/29/21 at 11:23 a.m. Hairdresser B was observed in the beauty salon with an unidentified female resident who was coughing and was not wearing a mask. The Hairdresser was observed with surgical mask below chin. Hairdresser B stated that she arrived at the facility today at 9:30 a.m. and was not screened and did not screen herself by taking her temperature or answering screening questions. Hairdresser B stated that she works at the facility once per week and has two residents receiving hair services today. Hairdresser B stated she was not sure if she was supposed to be screened upon entrance into the facility. Hairdresser B stated that she entered the facility, no one stopped her to screen, and she grabbed a mask and went to the beauty salon. Hairdresser B stated that she was documenting and pulled her mask below her chin and stated that she knows and has been trained to wear a mask properly. Interview on 9/29/21 at 11:53 a.m. CNA #C stated that she screened herself and clocked in but did not log the screening in the COVID-19 Screening log at the front door. CNA C stated that she was trained on her first day to screen upon entrance into the facility for temperature and signs/symptoms of COVID-19. Interview on 9/29/21 at 12:16 a.m. with Laundry Aide D stated no one screened me. I didn't do it either. I should have been, but I ran in. I know the importance of screening to make sure I don't have a temperature and I do not have COVID-19 symptoms. I have been trained to be screened when I enter the facility. Interview on 9/29/21 at 12:20 p.m. with Administrator A stated that staff are required to screen for signs and symptoms of COVID-19 including temperature upon arrival to the facility. Administrator stated that he observed the dietician walk into the facility today and walk past the screening station and was not screened. Administrator stated that his staff knows better. Administrator stated that staff usually screen themselves and if a visitor comes a nurse or himself will screen for COVID-19 temperature and symptoms. Administrator provided Surveyor screening log for 9/29/21 and time clock entries for 9/29/21. Record Review of time clock entries and COVID-19 screening log documents that 12 staff were clocked in at the facility; 5 staff including CNA C, Activity Director A, Laundry Aide #D, Dietician E and Hairdresser B did not screen upon entrance into facility on 9/29/21. Record reviewed facility policies: Post Nursing and Rehab Covid-19 Response Plan revised: 7/26/21 -The facilities goal is to protect our residents and staff from infectious diseases and to maintain the highest level of care practicable by means of assessment and screen of resident's, employees and all types of visitors. By these screening and infection control practices the risk of transmission of COVID-19 will be reduced. (page 1) -Employee screening, page 5: All employees will complete CMS/CDC guided screening prior to entering the facility at the designated area prior to clocking in for their scheduled shift. Screening/assessment to be documented on the Tracking Log which includes; 1: Signs or symptoms: fever great or equal to 100.0, runny nose, nausea vomiting, cough, muscle aches/pain, confusion, shortness of breath or difficulty breathing, chest pain, loss of smell, sore throat, diarrhea, loss of taste, chills and headache. 2: In the last 14 days have had contact with someone with a confirmed diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . -Employee Education, page 6: Staff educated and kept up to date on new information pertaining to COVID-19 virus Education to staff, residents and resident representatives of the following measures they can do to prevent the spread of infection. -In-services to all staff with competencies and return demonstrations completed when necessary: Standard precautions/universal precautions; Social distancing; Hand washing; Donning and Doffing PPE; Reuse/reprocess of PPE; N95 test/seal check; Proper cleaning of equipment and surfaces. Facility copy of: COVID-19 Response for Nursing Facilities; Version 4.0, 7/20/21 6. To do's for nursing facilities: -Page 18: Actively screen, monitor, and surveil everyone who comes into the NF. -Page 19: Require staff self-monitoring on days they work and on days they don't work. 7. S.P.I.C.E: Surveillance; Protection/PPE; Isolate; Communicate; Evaluate -Page 21: S.P.I.C.E; S: Surveillance-Monitor for symptoms-fever, cough, shortness of breath, or difficulty breathing and other known COVID-19 symptoms. 9. NF Activities Required for LTC COVID-19 Response: -Page 24-25 -Immediate (0-24 hours) -Screen staff for signs and symptoms at least at the beginning of their shift. -Extended (24-72 hours) -Screen staff for signs and symptoms at least at the beginning of their shift. -Long Term (72 hours plus) -Screen staff for signs and symptoms at least at the beginning of their shift. 12. Interim Guidance for Prevention, Management, and Reporting of COVID-19 Outbreaks in LTC Facilities -Page 33: Active Screening- The CDC and CMS recommend, and the NF COVID-19 Response rules require, NFs screen all staff prior to entering the NF at the beginning of their shift for fever and symptoms consistent with COVID-19, Actively take their temperature and document the absence of or shortness of breath, new or change in cough, sore throat and other symptoms of COVID-19. If they are ill, have them put on a facemask per CDC guidance, immediately leave the NF, and self-isolate at home. Facilities should also screen any essential visitors who are permitted to enter the building, including visiting health care providers. Maintain a log of all visitors who enter the building that at a minimum includes name, current contact information, and fever and presence/absence of symptoms. Salon Services Agreement; dated October 7, 2020 and signed between nursing facility and salon service visitor: Duties and Obligations of Salon Services Visitor 1: Salon Services Visitor agrees to submit to the facility's initial screening before entering the facility. 7: Salon Services Visitor acknowledges and agrees that Salon Services Visitor has been trained on the proper Personal Protective Equipment (PPE) usage and infection control measures, hand hygiene, and cough and sneeze etiquette. Interview on 09/29/21 at 4:01 PM, Administrator A, was notified by surveyor that at 4:01 PM an immediate jeopardy was identified due to the above failures. Administrator A was provided a copy of the IJ template by the surveyor via email Record review of time clock entries and COVID-19 screening log reviewed for timeframe 9/1/21-9/29/21 and revealed: Housekeeper W did screen for shifts on 9/16/21 and 9/17/21. Cook F did not screen for COVID-19 for shift on 9/14/21. Registered Nurse G did not screen for COVID-19 for shift on 9/20/21. Dietary Aide I did not screen for COVID-19 for shift on 9/28/21. Activity Director J did not screen for COVID-19 for shifts on 9/20/21, 9/29/21. LVN K did not screen for COVID-19 for shifts on 9/8/21, 9/9/21, 9/18/21, 9/19/21, 9/22/21, 9/25/21, 9/29/21. Laundry Aide D did not screen for COVID-19 for shifts on 9/1/21, 9/2/21, 9/6/21, 9/7/21, 9/8/21, 9/9/21, 9/11/21, 9/19/21, 9/20/21, 9/21/21, 9/22/21, 9/25/21, 9/29/21. Dietician E did not screen for COVID-19 for shift on 9/29/21. Laundry Aide L did not screen for COVID-19 for shift on 9/14/21. Nurse Aide M did not screen for COVID-19 for shift on 9/8/21, 9/9/21, 9/18/21, 9/23/21, 9/27/21, 9/28/21. Administrator A did not screen for COVID-19 for shifts on 9/1/21, 9/2/21, 9/10/21, 9/18/21. CNA C did not screen for COVID-19 for shifts on 9/20/21, 9/21/21, 9/24/21, 9/25/21, 9/26/21, 9/29/21. CNA N did not screen for COVID-19 for shift on 9/2/21. Business Office Manager H did not screen for COVID-19 for shifts on 9/2/21, 9/6/21, 9/17/21, 9/24/21, 9/27/21, 9/29/21. Record review of time clock entries and COVID-19 screening log reviewed for timeframe 9/1/21-9/29/21 revealed the following staff bypassed the screening table and clocked into the timeclock before screening for COVID-19: Registered Nurse G bypassed screening for COVID-19 to clock in for the day on: 9/8/21. Business Office Manager bypassed screening for COVID-19 to clock in for the days of: 9/2/21, 9/6/21, 9/11/21, 9/24/21, 9/25/21. LVN O bypassed screening for COVID-19 to clock in for the day on: 9/1/21, 9/9/21, 9/14/21, 9/15/21, 9/16/21, 9/22/21, 9/28/21, 9/29/21. LVN V bypassed screening for COVID-19 to clock in for the day on: 9/2/21, 9/6/21, 9/11/21, 9/24/21, 9/26/21. CNA P bypassed screening for COVID-19 to clock in for the day on: 9/7/21, 9/11/21. Dietary Aide I bypassed screening for COVID-19 to clock in for the day on: 9/2/21, 9/3/21, 9/13/21, 9/14/21, 9/19/21, 9/20/21, 9/21/21, 9/25/21. Activity Director J bypassed screening for COVID-19 to clock in for the day on: 9/10/21, 9/21/21, 9/23/21. LVN K bypassed screening for COVID-19 to clock in for the day on: 9/4/21, 9/5/21, 9/22/21. Kitchen Aide Q bypassed screening for COVID-19 to clock in for the day on: 9/6/21, 9/10/21, 9/11/21, 9/12/21, 9/16/21, 9/18/21, 9/23/21. Cook R bypassed screening for COVID-19 to clock in for the day on: 9/2/21, 9/4/21, 9/17/21, 9/28/21, 9/28/21. Nurse Assistant S bypassed screening for COVID-19 to clock in for the day on: 9/1/21, 9/21/21. Laundry Aide L bypassed screening for COVID-19 to clock in for the day on: 9/3/21, 9/9/21. Nurse Aide M bypassed screening for COVID-19 to clock in for the day on: 9/5/21, 9/22/21. Administrator A bypassed screening for COVID-19 to clock in for the day on: 9/3/21, 9/14/21, 9/20/21, 9/21/21, 9/22/21. CNA C bypassed screening for COVID-19 to clock in for the day on: 9/6/21, 9/12/21. CNA N bypassed screening for COVID-19 to clock in for the day on: 9/15/21, 9/17/21, 9/23/21. Administrative Assistant T bypassed screening for COVID-19 to clock in for the day on: 9/29/21. Business Office Manager H bypassed screening for COVID-19 to clock in for the day on: 9/8/21, 9/15/21. Housekeeper U bypassed screening for COVID-19 to clock in for the day on: 9/20/21, 9/21/21, 9/23/21. Interview on 9/30/21 at 9:22 a.m. Physical Therapist stated she works for an outside agency and that she has not always been screened when arriving to the facility. Stated she was informed today that only the Administrator or Nurse can screen her for COVID-19 symptoms. Interview on 9/30/21 at 9:37 a.m. with Laundry Aide D stated that she was in-serviced on the new policy that only the Administrator, Nurse and Business office Manager can screen staff when they enter the facility; continued to state that on 9/29/21 she only had contact with one resident. Interview on 9/30/21 at 9:57 a.m. Activity Director J stated that she thought she screened on 9/29/21 when she entered the facility; stated that she was in-serviced today that only the Administrator, nurse and business office manager can screen staff when they enter. Stated that on 9/29/21 she had contact with all residents during her shift. Interview on 9/30/21 at 10:00 a.m. CNA C stated that on 9/29/21 when she did not screen for her shift, she had contact with approximately 21 residents. CNA C stated that she has been in-serviced on the new screening requirements that only the Administrator, Business Office Manager and Nurse can screen staff, residents or visitors when they arrive to the facility. On 09/30/21 at 11:31 AM the administrator was informed of the IJ was removed but facility remained out of compliance at a level of more than minimal harm with a scope identified as widespread. The facility was continuing to monitor their infection control procedures. The administrator was notified on 09/30/21 at 11:31 AM of the acceptance of plan of removal and the Immediate Jeopardy was lowered. The facility provided a plan of removal and was accepted by HHSC to include: The Facility Administrator secured entrances to the facility to restrict access to staff and visitors entering only through the front door. The Facility Administrator prominently placed written notices on each facility entry point stating the facility has one restricted entrance and that all individuals entering the facility must be screened. The Facility Administrator restricted employees with authority to open the front door and grant entry to individuals to the following individuals: Facility Administrator, Business Office Manager, and Charge Nurse. No other individuals are authorized to grant entry to individuals. These individuals are the only individuals who are authorized to complete and record the COVID screen. The Facility Administrator prominently placed written notices at the following location regarding the restricted authority of staff to grant entrance: time clock, nurse station, COVID screening station, and staff break room. The Facility Administrator developed a Memorandum of Understanding for individuals who are authorized to grant entry to the facility. He provided education and executed the Memorandum of Understanding with the charge nurse on duty. The Facility Administrator developed a written plan for completion of education and execution of the Memorandum of Understanding for all employees who are authorized to grant facility entry. The Facility Administrator developed a written plan to verify the completeness of the COVID-19 screening record and ensure only authorized individuals have completed the screening record. The Facility Administrator developed and began execution of an all-staff in¿ service for staff currently on duty. The Facility Administrator developed a written plan to verify completion of the all-staff in-service for staff members before beginning their next regularly scheduled shift. The in-service topics include the expectations of the screening process and are supplemental to the education provided to individuals authorized to grant entry to the facility and to the posted signage/education to all staff regarding the screening process. Record reviewed documentation of training and in-services of competency of handwashing and DON & DOFF PPE and infection control education. All was completed for all staff. Observations, interviews, and record reviews were made on 9/30/21 with the following: Observation of COVID screening station on 9/30/21 at 10:30 a.m., new screening log has been placed on screening table. Observed that new screening log contains space for screener to write their initials to confirm visitor/staff were screened by delegated screener. Reviewed written plan to verify the completeness of the COVID-19 screening record and ensure only authorized individuals have completed the screening record. Interview on 9/30/21 at 10:30 a.m. with Administrator A; Administrator A states that he has updated the screening log sheet to include space for delegated screener to sign their initials once screening of visitor or staff have been completed. Administrator A stated that by having the screener initial the form, it will be easier to ensure that the new policy regarding having delegated screeners is being followed. Record Review on 9/30/21 at 11:35 a.m. of document entitled, Memorandum of Understanding for staff members authorized to grant access to Post Nursing and Rehab. Signed by: Business Office Manager H, LVN O and LVN Von 9/29/21. Observation on 9/30/21 at 11:40 a.m., signage on all facility exits/entrances that states Entry to the facility is restricted to the front entrance only and all other access is restricted. Observation of COVID screening station, time clock, nurse station and break room on 9/30/21 at 11:43 a.m. Posted notice stating: Entrance to the facility is restricted to only the front entrance. All individuals entering the building must be screened for fever and for signs and symptoms of COVID-19. The only individuals who are authorized to grant entry to the facility and complete the COVID-19 screening are: Facility Administrator, Business Office Manager and RN or LVN. If individuals approach the front door, notify one of the individuals listed above. Please notify the individual seeking entrance they will need to wait outside until one of the authorized individuals responds to the front door and they successfully completed screening. If you have any questions, please let me know. Signed by Facility Administrator A. Record Review of Training Entry to the facility and screening completed on 9/30/21 at 11:45 a.m. In-service directs staff that No one is to enter the facility by any other door than the main entrance located on 7th street. This includes staff, visitors, or contractors ie.: hairdresser, plumber, HVAC technician or delivery drivers. The only staff authorized to let anyone into the facility is the Administrator, Business Office Manager and the charge nurse or any other nurse on duty. The person granting entry to the facility then must screen the individual(s) at that time. Surveyor observed 17 staff signatures on training sheet. Interview on 9/30/21 at 11:48 a.m. with LVN O; stated that she was in-serviced on the new policy regarding Entry to the Facility and screening. LVN O stated that she confirms that she is one of the staff delegated to open the facility door to completed visitor/staff screenings for COVID-19. LVN O stated she likes the policy change and that now it can be confirmed by that staff/visitors have been screened because the screener must initial the screening log. Interview on 9/30/21 at 11:51 a.m. with Business Office Manager, stated that she was in-serviced on the new policy regarding Entry to the Facility and screening. Business Office Manager confirms that she is delegated to perform screenings and has signed the Memorandum of Understanding. Interview on 9/30/21 at 12:03 p.m. with Registered Nurse G, stated that she was in-serviced on the new policy regarding Entry to the Facility and screening. Registered Nurse G stated that she confirms that she is also a charge nurse at the facility and is one of the staff delated to open the facility front door to complete visitor/staff screenings for COVID-19. On 09/30/21 at 11:31 AM, the administrator was informed of the IJ was removed but facility remained out of compliance at a level of more than minimal harm with a scope identified as widespread. The facility was continuing to monitor their infection control procedures.

Based on interview and record review, the facility failed to ensure a registered nurse served as the Director of Nursing on a full-time basis for one of one facility reviewed for registered nurse coverage, in that: The facility failed to ensure they had a designated RN to serve as the DON in the facility. This failure could place residents at risk of not having their nursing and medical needs met. The findings are: During an interview on 08/09/21 at 3:00 PM with ADM, ADM stated they did not have a current DON at this time. ADM stated they were still looking for a DON and were having a hard time hiring someone. ADM stated they have RN coverage as required, but no acting DON at this time. During an interview on 08/09/21 at 3:05 PM with LVN A, when asked who the DON was, she said, We do not have a DON at this time. We have an RN supervisor but nobody with the title of DON. During an interview on 08/09/21 at 3:15 PM with RN A, when asked if they had a DON, she stated, We don't have a DON at this time. I am an RN supervisor and not the DON at this facility. During an interview on 08/09/21 at 3:23 PM with CNA A, when asked if they have a DON, she stated, We go to the RN supervisor for problems, but we do not have a DON at this time. During a confidential interview on 08/09/21 at 3:34 PM with a Resident, when asked if the facility has a DON, Resident stated, We don't have a DON. We go to the ADM if we have any concerns. During a confidential interview on 08/09/21 at 3:40 PM with a Resident, Resident stated they go to the ADM for problems since there is not a DON at the facility. Record review of the facility's policy on Director of Nursing Services, revised August 2006, revealed the following: Policy Statement The Nursing Services Department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation 1. The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2. The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy; b. Developing standards of nursing practice; c. Developing and maintaining nursing policy and procedure manuals; d. Developing and maintaining written job descriptions for each level of nursing personnel; e. Scheduling of daily rounds to visit residents; f. Developing methods for coordination of nursing services with other resident services; g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care of each resident; h. Developing staff training programs for nursing service personnel; i. Participating in the planning and budgeting for Nursing Services; j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care; k. Assess the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care; l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan; m. Establishing resident selection criteria for determining which residents may be fed by paid feeding assistants, and n. Assuring that nursing care personnel are administrating care and services in accordance with the resident's assessment and care plan.

Based on interview and record review, the facility failed to ensure a registered nurse served as the Director of Nursing on a full-time basis for one of one facility reviewed for registered nurse coverage, in that: The facility failed to ensure they had a designated RN serve as the DON in the facility. This failure placed residents at risk of not having their nursing and medical needs met. The findings are: During an interview on 04/18/2021 at 8:10 AM with LVN B, when asked who the DON was, she said, [Facility] does not have a DON at this time. During the entrance conference on 04/18/2021 at 9:45 AM the Administrator said the last date the facility had a DON was 01/29/2021 when the former DON was in the building. The Administrator stated they currently did not have a DON but they were advertising on-line and couldn't find one. Record review of the facility's policy on Director of Nursing Services, revised August 2006, revealed the following: Policy Statement The Nursing Services Department is under the direct supervision of a Registered Nurse. Policy Interpretation and Implementation 1. The Nursing Services department is managed by the Director of Nursing Services. The Director is a Registered Nurse (RN), licensed by this state, and has experience in nursing service administration, rehabilitative and geriatric nursing. 2. The director is employed full-time (40-hours per week) and is responsible for, but is not necessarily limited to: a. Developing and periodically updating the nursing service objectives and statements of philosophy; b. Developing standards of nursing practice; c. Developing and maintaining nursing policy and procedure manuals; d. Developing and maintaining written job descriptions for each level of nursing personnel; e. Scheduling of daily rounds to visit residents; f. Developing methods for coordination of nursing services with other resident services; g. Recruiting and retaining the number and levels of nursing personnel necessary to meet the nursing care of each resident; h. Developing staff training programs for nursing service personnel; i. Participating in the planning and budgeting for Nursing Services; j. Ensuring that all health services notes are informative and descriptive of the supervision and care rendered including the resident's response to his or her care; k. Assess the nursing requirements for each resident admitted and assisting the Attending Physician in planning for the resident's care; l. Participating in the development and implementation of the resident assessment (MDS) and comprehensive care plan; m. Establishing resident selection criteria for determining which residents may be fed by paid feeding assistants, and n. Assuring that nursing care personnel are administrating care and services in accordance with the resident's assessment and care plan. FACILITY Sufficient and Competent Nurse Staffing

Based on interview and record review, the facility failed to employ a person to serve as the director of food and nutrition services who, in States that have established standards for food service managers or dietary managers, meets State requirements for food service managers or dietary managers in that: The current Food Service Supervisor (FSS) failed to meet the State requirements for Food Service Managers or Dietary Managers. The FSS had not completed a course recognized by the State as a qualifying course for Dietary Manager/Director of Food Service in a nursing facility. This failure could result in the spread of foodborne illnesses in the facility. The findings include: During an interview on 04/18/21 at 9:12 AM the Food Services Supervisor (FSS) said, I do not have my FSS certification. I do not have a food handler certificate [Learn 2 Serve]. I was going to get started with the FSS certification, but the Administrator has not set up my training for either course. I have been the designated FSS for a month and a half and before that I was a dishwasher. I did have my Learn 2 Serve certificate prior to this employment, but I let it expire. I did not think I would use it again. During an interview on 04/18/21 at 9:30 AM with the Administrator, when asked who he considered to be, the facility's Dietary Manager (DM), Administrator said, FSS is, but she was vacillating if she wanted the responsibility. When asked if the facility has set up FSS with the mandated FSS course, Administrator said, No, I have not set her [FSS] with the mandated FSS course, nor have we gotten kitchen staff or FSS their Learn 2 Serve certifications. I knew I needed to do this but unfortunately the state survey happened before I could get the employees certified. During an interview on 04/18/21 at 11:30 AM with Kitchen Staff A, she said, I do not have my Learn 2 Serve certificate. Record review of the personnel file for the designated FSS revealed a date of hire of 07/02/20 and had no documented evidence that met the State qualifications for DM/Director of Food Service. Record review of the facility policy on Food Services Manager dated (Revised December 2008) documented the following: Policy Statement The daily functions of the Food Services Department are under the supervision of a qualified Food Services Manager. Policy Interpretation and Implementation 1. The Food Services Manager is a qualified supervisor licensed by this state and is knowledgeable and trained in food procurement storage, handling, preparation, and delivery. 2. The Food Services Manager is responsible for the daily functions of the Food Services Department in accordance with the facility's department policies and procedures. Additional responsibilities of the Food Services Manager include: a. Supervision, training, and scheduling of Kitchen Supervisors; and b. Assisting the Dietician and the Nursing Services Department in selecting residents who may be fed by Feeding Assistants.

Based on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for one of one kitchen in that: A. One of two kitchen oven doors did not completely close. B. One of one juice machine did not dispense correctly. These failures had the potential to place residents at risk of oven foods being under-cooked which could result in food-borne illnesses and juices to be watered down and lose nutritive value. The findings include: Observation and interview on 04/18/2021 at 11:45 AM in the kitchen with the FSS, revealed the Vulcan Oven had one of two oven doors that did not close completely. The FSS said, I have told the Administrator the left-hand side oven door does not completely close. They have tried to adjust the door, but it has not fixed the problem. If I have two items that need baking at the same time with different temperatures, like a meat and a dessert, I can only use one oven because the oven that has the problem with the door does not close completely will not heat the oven to the proper temperature. Observation and interview on 04/18/2021 at 11:49 AM in the kitchen with Kitchen Staff A revealed the juice machine did not dispense the correct mixture of juice. Observed Kitchen Staff A push the orange juice button and it dispensed clear water, which the surveyor tasted. Kitchen Staff A stated they had a vendor out to adjust the settings, but the juice machine remained broken. During an interview on 04/18/21 at 11:50 AM the FSS stated the juice machine was broken and the Administrator, who was the acting Maintenance Supervisor had a vendor come adjust the juice machine, but it did not fix the problem. When asked how the staff served juice, FSS said they poured out of gallon refrigerated juice jugs. During an interview on 04/18/2021 at 12:05 PM the Administrator stated he was aware the left-hand oven door would not close completely. He stated the facility would get a vendor to correctly repair the oven door and juice machine. When asked why he had not corrected the problems, he stated he did not have time before the survey team entered for annual survey. Record review on 04/20/2021 of the facility's undated policy on Maintenance Repairs - All Equipment revealed the following: Policy Statement The Maintenance Supervisor or designee will maintain all equipment for the safety of the residents, staff, and visitors. Policy Implementation All equipment in use will be kept in proper working order. If it is not in proper working order, timely repairs will be made. This will include all equipment. If the equipment is a potential hazard for residents, staff, or visitors it will be removed from services immediately. This will be done by the maintenance supervisor when they are trained or competent to perform those repairs. If the maintenance supervisor is unable or not available to repairs an outside source that is qualified to perform those repairs will be contacted. If equipment poses an injury risk to staff, residents, or visitors it must be taken out of services. This can be done by removing the piece of equipment or using the lock out tag system if it's not able to be removed from its area. All repairs will be made in a timely manner to not affect the residents, staff, or visitors. If a piece of equipment cannot be repaired, it will be removed from service and a replacement will be sought.

Based on interview and record review, the facility failed to develop a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial for nine of nine residents (Residents' #1, #2, #3, #4, #5, #6, #9, #10 and #12) reviewed for care plans. Resident # 1 did not have a care plan for communication. Resident #2 did not have care plans for visual function, dental care, or pressure ulcer. Resident #3 did not have care plans for communication, dental, and [CONDITION(S)] medications. Resident #4 did not have care plans for [CONDITION(S)], communication, activities, and pressure ulcer. Resident #5 did not have care plans for communication, falls, nutritional, dental care, pressure ulcer and DNR. Resident #6 did not have care plans for falls or dental care. Resident #9 did not have care plans for activities or falls. Resident #10 did not have care plans for activities of daily living, urinary and pressure ulcer. Resident #12 did not have care plans for cognitive loss, urinary incontinence, mood state, falls, or pressure ulcer. These failures placed residents at risk of not reaching their physical, mental, and psychosocial needs which could result a decline in their physical and mental health. The findings include: Record review of Resident #1's face sheet dated 04/18/21 reflected the resident was [AGE] years old and was admitted to the facility on [DATE] with a readmitted on 12/25/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss, incontinence/urinary, communication, psychosocial well-being, activities, falls, nutrition, and pressure ulcer. During an interview on 4/19/2021 at 12:00 PM the ADON stated she was responsible for maintaining care plans. She is the person that ensures the resident has the appropriate care plans in order to care for the residents. Confirmed that Resident #1 did not have a care plan for communication. Record review on 4/18/2021 at 11:20 AM of Resident #2's face sheet dated 04/18/2021 reflected resident was [AGE] years old and admitted to the facility on [DATE] with some of the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 4/18/2021 at 11:25 AM of Resident #2's most recent comprehensive MDS dated [DATE] reflected in section V that his assessment triggered for the following care plans: Cognitive Loss, Visual Function, ADLs, Mood, Falls, Nutrition, Dental Care, and Pressure Ulcer. During an interview on 4/19/2021at 12:00 PM with ADON, stated she is responsible for care plans. Confirmed that Resident #2 did not have a care plan for Visual Function, Dental Care, or Pressure Ulcer. Record review of Resident #3's face sheet dated 4/18/2021 reflected the resident was [AGE] years old and admitted to the facility on [DATE] with a readmitted on 08/13/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of #3's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss/dementia, communication, ADL function, urinary incontinence, nutritional status, dental care, pressure ulcer, and [CONDITION(S)] medications. In an interview on 4/19/2021 at 11:32 AM the ADON was asked who was responsible for ensuring required care plans were created, she stated, Right now, me only. The ADON stated she had not had care plan training. When asked for the missing care plans for Resident #3, the ADON stated he did not have care plans for dental and [CONDITION(S)] medications. During an interview on 4/19/2021at 12:00 PM with ADON, stated she is responsible for care plans. Confirmed that Resident #2 did not have a care plan for Visual Function, Dental Care, or Pressure Ulcer. Record review on 4/18/2021 at 11:20 AM of Resident #2's face sheet reflected resident was admitted to the facility on [DATE] with some of the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review on 4/18/2021 at 11:25 AM of Resident #2's most recent comprehensive MDS dated [DATE] reflected in section V that his assessment triggered for the following care plans: Cognitive Loss, Visual Function, ADLs, Mood, Falls, Nutrition, Dental Care, and Pressure Ulcer. Record review of Resident #3's face sheet dated 4/18/2021 reflected the resident was [AGE] years old and admitted to the facility on [DATE] with a readmitted on 08/13/2020 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of #3's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss/dementia, communication, ADL function, urinary incontinence, nutritional status, dental care, pressure ulcer, and [CONDITION(S)] medications. In an interview on 4/19/2021 at 11:32 AM the ADON was asked who was responsible for ensuring required care plans were created, she stated, Right now, me only. The ADON stated she had not had care plan training. When asked for the missing care plans for Resident #3, the ADON stated he did not have care plans for dental and [CONDITION(S)] medications. Record review of Resident #4's face sheet dated 04/18/2021 reflected resident was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's most recent comprehensive MDS, dated [DATE], reflected in Section V her assessment triggered for the following care areas: [CONDITION(S)], cognitive loss, visual, communication, ADL's, urinary, psychosocial well-being, activities, falls, nutritional, feeding tube, dehydration, and pressure ulcer. During an interview on 4/19/2021 at 12:15 PM the ADON confirmed the following triggered care area assessments had not been addressed in Resident #4's care plan: [CONDITION(S)], communication, activities, and pressure ulcer. She stated the care area assessments should have been included in the care plan. She stated she was responsible for updating the care plans since the DON stopped working at the facility in November 2020. She stated the reason some of the care areas were not addressed was because she was responsible for so much and there were times where the agency nurses were assisting with the care plans. She stated she took responsibility for the care plans and the lack of care areas addressed. During an interview on 4/20/2021 at 10:06 AM the ADON stated she had not received any training on creating and maintaining care plans. She stated when the electronic computer program was implemented in November 2020 and she took her position as ADON she was not trained on creating or maintaining care plans. She stated she was instructed to watch online videos. Record review of Resident #5's face sheet dated 04/18/2021 reflected resident was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's most recent comprehensive MDS, dated [DATE], reflected in Section V her assessment triggered for the following care areas: cognitive loss, communication, Activities of Daily Living, urinary, psychosocial well-being, activities, falls, nutritional, dental care, pressure ulcer, DNR, and hospice. During an interview on 4/19/2021 at 12:15 PM the ADON confirmed the following triggered care area assessments had not been addressed in Resident #5's care plan: communication, falls, nutritional, dental care, DNR, hospice and pressure ulcer. She stated the care area assessments should have been included in the care plan. She stated she was responsible for updating the care plans since the DON stopped working at the facility in November 2020. She stated the reason some of the care areas were not addressed was because she was responsible for so much and there were times where the agency nurses were assisting with the care plans. She stated she took responsibility for the care plans and the lack of care areas addressed. Record review of Resident #6's face sheet dated 04/18/2021 reflected the resident was [AGE] years old and admitted to the facility on [DATE] with a readmitted on 2/19/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss, communication, ADLs, incontinence/urinary, psychosocial well-being, activities, falls, nutrition, dental care, and pressure ulcer. During an interview on 4/19/2021 at 12:00 PM the ADON stated she was responsible for care plans. The ADON confirmed that Resident #6 did not have care plans for falls or dental care. Record review of Resident #9's face sheet dated 4/18/2021 reflected resident was [AGE] years old and admitted to the facility on [DATE] with a readmitted on 02/05/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #9's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss/dementia, visual function, communication, ADL function, psychosocial well-being, mood state, behavioral symptoms, activities, falls, nutritional status, and [CONDITION(S)] medications. In an interview on 4/19/21 at 11:32 AM the ADON was asked who was responsible for ensuring the care plans were in place, she stated, Right now, me only. She stated she had not had care plan training. When asked about missing care plans for Resident #9, she stated she did not have them and would fix the care plans. Record review of Resident #10's face sheet dated 04/18/2021 reflected the resident was [AGE] years old and admitted to the facility on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record of Resident #10's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: Activities of Daily Living, urinary, falls, nutritional, dehydration, dental care, pressure ulcer, and pain. During an interview on 4/19/2021 at 12:15 PM the ADON confirmed the following triggered care area assessments had not been addressed in Resident #10's care plan: Activities of daily living, urinary, and pressure ulcer. She reported the previously mentioned CAA should have been included in the care plan. She stated she was responsible for updating the care plans since the DON stopped working at the facility in November 2020. She stated the reason some of the care areas were not addressed was because she was responsible for so much and there were times where the agency nurses were assisting with the care plans. She stated she took responsibility for the care plans and the lack of care areas addressed. Record review of Resident #12's face sheet dated 4/18/2021 reflected the resident was [AGE] years old and admitted to the facility on [DATE] with a readmitted on 2/6/2021 with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of #12's most recent comprehensive MDS, dated [DATE], reflected in Section V his assessment triggered for the following care areas: cognitive loss/dementia, visual function, urinary incontinence, nutritional status, mood state, falls, and pressure ulcer. In an interview on 4/19/2021 at 11:12 AM the ADON was asked if she could provide the missing care plans for Resident #12.S she checked her computer then stated she did not have them. Record review of the facility's policy on Care Planning-Interdisciplinary Team, revised September 2013, revealed the following: Applicability: this policy sets forth the procedures relating to developing a comprehensive, person centered care plan. Policy Statement A comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: #8. The comprehensive, person centered care plan will: Include measurable objectives and timeframes; g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; o. Reflect currently recognized standards of practice for problem areas and conditions. #10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful to the resident, are the endpoint of an interdisciplinary process. Resident #12 Comm-Sensory 04/18/21 09:08 AM would like to see the eye doctor Resident #4 FTag Initiation Resident #5 FTag Initiation General 04/18/21 10:39 AM Observed during incontinent care shearing on the resident bottom. Orders checked. Preventative measures put in place. May apply [MEDICATION(S)] or laniseptic to affected area. Skin assessments completed: Shearing on right side of buttock red and slightly purple in color noted. Skin protectant applied. Hospice and End of Life 04/19/21 01:02 PM Resident is receiving Hospice of Lubbock. Contract reviewed. Effective January 2018. Resident #10 FTag Initiation Resident #1 FTag Initiation Resident #2 Dental 04/18/21 03:23 PM Teeth are hurting and fillings have fallen out. Has not told staff. 04/19/21 01:35 PM All residents are being seen on 4/26/21 for dental care. FTag Initiation Resident #6 Dental 04/18/21 08:40 AM Has told staff she needs to see dentist. Does not have pain, but has some teeth that need to be pulled. Is missing a few teeth. 04/19/21 01:38 PM All residents are being seen on 4/26/2021 for dental care. FTag Initiation

Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 46.15%, based on 18 errors out of 39 opportunities, which involved one of five residents (Resident #269) and one of two staff (LVN A) observed during medication administration. The facility's failure could affect residents who receive medications administered by the facility. Findings Include: Record review on 04/19/2021 at 11:55 AM of Resident #269's face sheet revealed Resident was admitted on [DATE] with a birthdate of 9/18/1944 with some of the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 04/19/21 at 10:28 AM of medication pass with LVN A revealed Resident #269 was administered the following mediations: Prosource 30mL, [MEDICATION(S)] 40mg 1 tab, [MEDICATION(S)] 40meq 2 tabs, [MEDICATION(S)] 10mg 1 tab, Amlopidine 10mg 1 tab, [MEDICATION(S)] 5mg 1 tab, [MEDICATION(S)] 10mg 1 tab, [MEDICATION(S)] 0.1mg 1 tab, [MEDICATION(S)] 100mg 1tab, [MEDICATION(S)] 25mg 3 tabs, [MEDICATION(S)] 300mg 1 tab, [MEDICATION(S)] 15mg 2 tabs, [MEDICATION(S)] 100mg 1 tab, [MEDICATION(S)] 0.12% 15mL, [MEDICATION(S)] 40mg 1 tab, Lactobacillus 1 tab, [MEDICATION(S)] 0.25mg 1 tab, and [MEDICATION(S)] 1000mcg 1 tab. Interview on 04/19/21 at 10:28 AM with LVN A stated she knew that she was late giving Resident #269's medications. She gave them late because the Resident was in the shower. Record review on0 4/19/21 at 10:45 AM of Resident #269's April 2021 physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 04/19/21 at 3:05 PM with ADON revealed she expected all medications to be given within the two-hour window of when the medication is due. For a medication due at 8:00 AM, it should be given between 7:00 AM and 9:00 AM. Interview on 04/20/21 at 10:00 AM with Administrator stated medications should be given an hour before or an hour after their due time. Stated medications being given at 10:28 AM were due at 8:00 AM is unacceptable. Record review on 04/19/21 at 3:30 PM of the facility's policy and procedure titled Administering Medications with last revision date April 2019, reflected in part: Policy Statement- Medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation- 4. Medications are administered in accordance with prescriber orders, including any required time frame. 7. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders). FACILITY Medication Administration

Based on interview, observation and record review, the facility failed to ensure that residents were free from neglect for 1 of 8 residents (resident #1) reviewed for neglect: The facility failed to ensure resident #1 was provided with a safe and functioning sling for use during transfer on a hydraulic lift. The sling tore away from the hydraulic lift hook, during transfer, resulting in serious complex head trauma, possible brain bleed, two lacerations on head, one required 6 to 8 sutures on top of head, another laceration occurred on his left side of head, and multiple skin tears to both lower and upper extremities. This was determined to be an Immediate Jeopardy at Past Non-Compliance on (MONTH) 30, 2019, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents who use the hydraulic lift at risk of severe injury or death. The evidence is as follows: Record review of resident #1's Face Sheet, dated 7/11/19, documented that resident date of birth 9/12/1955, was admitted to the facility on [DATE] from hospital. He has the following Diagnoses: [REDACTED]. Record review of the MDS, dated [DATE], for resident #1, documented that his functional levels for activities of daily living, including transfers were extensive assistance of two persons. Record review of resident #1's Care Plan, dated 5/27/19, documented: resident (#1) will be transferred with the use of the Hydraulic lift during this review period. Intervention: Resident requires two person assist with hydraulic lift. Lift to be used for all transfers. Resident will sustain no injuries during transfers over the next 90 days to (8/25/19). Record review of Facility Provider Investigation Report, dated 7/30/19, documented that resident was being transferred by mechanical lift (from shower chair) to bed when sling broke causing resident to fall to floor. [MEDICAL CONDITION] x2, left eyebrow laceration, multiple skin tears, left hand, and hip pain. Sent out via ambulance. Record review of Accident/Incident Report, dated 7/30/19, indicated that approximately 12:00pm, resident was transferring from hydraulic lift back to bed, sling broke, resident fell face first onto floor. [MEDICAL CONDITION] times two, left eyebrow laceration, multiple skin tears to left to face left hand, left hip pain. Sent to Hospital #1 ER for assessment and Tx=all Hoyer slings have been removed, lift is being examined for any faults, will order additional new slings. (ADON) Record review of resident #1's Hospital Admission Notes, dated 7/30/19, revealed that resident #1 was seen at the emergency room in hospital #1 with Assessment Plan including Scalp Laceration S01.01XA, Trauma T14.90XA, Complex [MEDICAL CONDITION], multiple skin tears LUE (lower, upper extremities), acute blood loss to [MEDICAL CONDITION]. Possible scapula fracture. He was found to have a complex [MEDICAL CONDITION] with a pulsatile bleeding vessel from the cranium as well and multiple skin tears on his LUE. Dr placed approximately 6-8 interrupted and FOE sutures and was able to gain [MEDICATION NAME] control, At this time, he was hooked up to the monitor and noted to have systolic blood pressure in the 70s and upgraded to Level 1. Resident #1 is a [AGE] year-old man with multiple medical comorbidities who presented a complex [MEDICAL CONDITION] and subdural/subarachnoid bleed on CT scan. Also results of CT scan were negative but also documented a possible head fracture. CT shows old [MEDICAL CONDITION], small SDH and left cerebral subarachnoid, Repeat CT Head w/o unchanged, non-op per NSGY Nurse's Note, dated 7/30/19, (witness statement for CNA #1, indicated that she was being assisted by CNA #2 to transfer resident #1 with a hydraulic lift after a shower and when resident #1 was lifted, and she moved the lift towards the bed, the sling busted and resident #1 fell face down. CNA #2 ran and called the LVN Charge nurse #1 for help at 12:11pm. Nurse's Notes, dated 7/30/19, witness statement from CNA #2 was assisting CNA #1 with Hoyer (hydraulic) lift after resident #1's shower. She said CNA #1 moved the lift and the sling busted and resident #1 fell face down off the sling. She said she ran to call LVN Charge nurse #2 for help. The facility provided the sling used during the incident, which was kept for surveyor observation, on 8/01/19 at approximately 10:30am. The sling was discolored, and extremely torn, worn and frayed. Also, evident, one of the loops on the sling was completely torn all the way. Witness Statement by CNA #1 on 8/01/19, indicated that CNA #2 assisted her in transferring resident #1 from his bed to shower chair on 7/30/19, and she took him to get bathed. After she got done, she took him back to his room and CNA #2 assisted her in putting resident #1 back to his bed. They got him in the lift and placed the sling on him and when she was turning the lift toward the bed, the right-side bottom of the sling busted and resident #1 flipped out of it (the sling) on his face and CNA #2 called the charge nurse #2 and provided first aide. On 8/02/19, CNA also wrote another statement at 3:20pm and stated that the slings were in bad shape back to when former administrator was here in (MONTH) 2019 until she left. Some were torn, and string hanging off them. The sling was shown to me (CNA #1) that was used on resident #1, when he fell , and the hooks (loop)s on that sling, were not in good condition. Interview with CNA #1 on 8/01/19 at approximately 10:21am revealed that she had CNA #2 assisting her in transferring resident #1 to his bed from the shower chair. CNA #1 said they (CNA #1 & 2) got the sling on him and even lifted him to get him to his bed and as soon as she (CNA #1) lifted him (with hydraulic lift) to put him on the bed, the sling busted and resident #1 fell . After looking at the sling used on resident #1 when accident occurred, CNA #1 said, she would not have used the sling because it was torn and in bad condition. Interview with CNA #2 on 8/01/19 at 11:45am indicated that she had been trained on the slings and the hydraulic lift. She demonstrated, along with CNA #3 and CNA #4 how she had transferred resident #1 and how he fell . She was shown the sling that they (CNA #1) used on resident #1 on 7/30/19 and asked if she should have used that sling. She responded by, now that I see it, no I wouldn't. When asked why not, she said because it was in bad shape. She said that it was her understanding they (facility) threw about 6 slings away. Witness Statement by CNA #2, dated 8/01/19, indicated that she assisted CNA #1 in transferring resident #1 to his shower chair and she bathed him. She documented that resident #1 never made it to his bed because the sling busted, and he fell face forward first. Interview with LVN #2 on 8/01/19 at 11:40pm revealed that he provided medical attention to resident #1 when resident #1 fell . LVN #2 said one of the CNAs had yelled to him and by the tone of her voice, LVN #2 knew it was an emergency, he went to resident #1's room where he saw him in a prone position and injuries to his head, bleeding and multiple skin tears to his arm, hands and even knuckles. He was bleeding quite a bit. He said emergency services were called and initially, resident #1 refused to go to the hospital but the EMS staff encouraged him to go to the hospital, so he went. The surveyor showed the sling that was used on resident #1, the surveyor asked if LVN #2 would use the sling. LVN #2 responded by saying, . no, because it looks dangerous, its torn and frayed. LVN #2 pointed to an area on the sling where it was torn. LVN #2 showed surveyor another area on the sling that was also torn and again, said, it would not be safe. Interview with Administrator #2 on 8/01/19 at 9:55am revealed that when asked how the accident with resident #1 occurred she said that it was an old sling that was used in the hydraulic lift. She said all staff were educated immediately after the incident on 7/30/19 and 7/31/19, on the use of the mechanical lift and sling inspections prior to working direct care and if not, since some staff were out, as soon as they come back, they will be. Observation of resident #1 on 8/01/19 at 2:00pm revealed he was in his bed and he was leaning to the right side with head curled, (contracted). He had numerous skin tears on his lower and upper extremities and sutures on top of his head and left side laceration. When asked he how he was doing, he said okay. Interview with CNA #4 on 8/01/19 at 11:25am, said that she had told the previous Administrator #1 about the slings being in bad shape since about (MONTH) 2019 and she even took one to her. She said that she just took it and doesn't know if she (Administrator #1) ordered new slings, but she was made aware that the slings were in bad shape. She acknowledged being trained on 7/30/19 on identifying worn slings and use of mechanical lift. Witness Statement dated 8/01/19 at 3:30pm for CNA #4 documented that she had reported, to the previous Administrator #1, on approximately (MONTH) (2019), about some slings being in very bad condition. One sling that broke, I bagged up and took it to her. Another one, I also bagged up and took it to her that was in very bad condition. She (Administrator #1) said that she would take care of it. Interview with DON on 8/02/19 at 12:58pm revealed that after the incident, approximately six (6) slings were thrown away and new ones were ordered. She said the ADON had gone and checked for them throughout the building. The DON said none of them were too bad, some discoloration, the stitching was frayed in some areas and there were notable areas where the bleach had eaten through the material. She said that laundry had been washing and drying them when they should have been hung to dry. Interview with Administrator #2 on 8/02/19 at 1:09pm by telephone, when asked if she knew about the worn slings and she said, she was not told and did not know they were in that condition. She responded when asked if there were processes in place before the accident with resident #1, she said, she was not aware of any prior processes in place to check the slings for wear and tear. She further indicated, now, there is monthly audits in place, done by Laundry and Housekeeping supervisor on the 30th of every month. The slings are going to be replaced every 6 months. Staff were also in-serviced they are to check the slings prior to using for wear and tear, if they are any, they are to give them to Administrator #2. Competencies were also assessed for hydraulic lift as part of the action that was taken after the accident. Interview with Housekeeping and Laundry supervisor on 8/02/19 at 1:14pm stated, that prior to the hiring of current Administrator #2, that one of the laundry aides had come into the office of Administrator #1, with one of the slings and it was old, discolored and strings were coming off. LA said yes the slings looked worn. She said that the Administrator #1 didn't do anything, never gave me permission to order the new slings. Prior to the ones, we got in (MONTH) 2019, it was (MONTH) (YEAR) that we had received any new (slings) ones. After we looked at some, we threw any away that looked like they were discolored, fraying on the side. Before the incident the Laundry aides were told to keep an eye out for 'them' (slings that were worn or frayed). Administrator #1 did not order any, and she didn't look to see if there other torn or worn slings. She threw that one a way, just didn't order any. Interview with Laundry Aide (LA) #1 on 8/02/19 at 1:30pm when asked if she had been told to watch out for worn slings and she said that she was not told until after this accident with resident #1. LA #1 said that she took two (2) of the slings that were cracking, peeling, to former Administrator #1, and these were not the mesh ones. This was back in (MONTH) or (MONTH) (of this year) and Administrator #1 didn't order new ones at that time. Now, I am told to make sure after washing the slings that they need to be hung up to dry and not let them dry in the dryer. She was also trained on taking worn and frayed slings to Administrator #2. Record review of the facility's Training In-service form date 7/30/19 was as follows: Substantial Compliance Documentation, dated 7/30/19, revealed that the facility: 1. Mechanical Lift 2. Staff Competency Evaluation for use of Mechanical Lift 3. Staff education Completed and Date: The DON or designee is verifying competency on use of the mechanical lift for all nursing staff prior to use of mechanical lift effective 7/29/19. Education is being done with nursing staff on checking the sling for wear and tear. The Laundry supervisor has been assigned to check each sling monthly to verify they are in good repair. A system has been implemented on sling stock rotation. Slings will be removed for circulation on a schedule. Slings will be marked and dated when put into circulation to verify compliance. 4. Scheduled Safety Committee Meeting for 8/30/19. Plan QAPI In-service Training 1. How to use a mechanical lift, dated 2001 and revised (MONTH) (YEAR) Record Review of Lifting Machine, Using a Mechanical: Purpose of this procedure is to establish the general principals of safe lifting using a mechanical lifting device. Steps in Procedure 2. Check to make sure sling is appropriate for size and purpose. .7. Double check the sling and machine's weight limits against the resident's weight. 10. Attach sling straps to sling bar, according to manufacturer's instructions. c. Before resident is lifted, double check the security of the sling attachment. .d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. Facility Inservice dated 7/30/19 Topic: Resident slings that are old, torn or frayed must be turned in to the Administrator/DON. They are not to be used. Record review of previous order, dated 7/01/19, from Supply company #1 documented that 4 slings (2 different sizes) were ordered and expected delivery date was 7/02/19 to the facility. Record review of order, from Supply company #1, dated 7/30/19, from Supply company #1 documented that 6 slings (2 different sizes) were ordered for the facility. During the interviews completed on 8/01/19 and 8/02/19 between 11:30am to 1:30pm with DON, LVN #2, CNAs #1, #2 and #3 Laundry and Housekeeping Supervisor, and Laundry Aide, all stated they received the in-serviced about not using slings that were worn, frayed or torn and to be given immediately to the Administrator. They were asked what they would do with the torn slings, asked about checking the sling prior to use, asked about mechanical lift competency, in-service on how to use mechanical lift, and monthly auditing system for slings.

Based on interview, observation and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible for 1 of 8 residents (resident #1) reviewed for accident hazards The facility used a worn, torn and frayed sling resulting in the sling loop breaking and resident #1 falling from the hydraulic lift. This resulted in serious complex head trauma, laceration that required 6 to 8 sutures on top of head, another laceration to the left side of head, possible brain bleed and multiple skin tears to both lower and upper extremities. Multiple slings in similar conditions were used for other residents requiring use of hydraulic lift by multiple staff. This was determined to be an Immediate Jeopardy at Past Non-Compliance on (MONTH) 30, 2019, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Failure to ensure the resident environment remains as free of accident hazards as possible by continuing to use the worn, frayed and torn slings with the hydraulic lift placed residents at risk of severe injury or death. The evidence is as follows: Record review of resident #1's Face Sheet, dated 7/11/19, documented that resident date of birth 9/12/1955, was admitted to the facility on [DATE] from hospital. He has the following Diagnoses: [REDACTED]. Record review of the MDS, dated [DATE], for resident #1, documented that his functional levels for activities of daily living, including transfers were extensive assistance of two persons. Record review of resident #1's Care Plan, dated 5/27/19, documented: resident (#1) will be transferred with the use of the Hydraulic lift during this review period. Intervention: Resident requires two person assist with hydraulic lift. Lift to be used for all transfers. Resident will sustain no injuries during transfers over the next 90 days to (8/25/19). Record review of Facility Provider Investigation Report, dated 7/30/19, documented that resident was being transferred by mechanical lift (from shower chair) to bed when sling broke causing resident to fall to floor. [MEDICAL CONDITION] x2, left eyebrow laceration, multiple skin tears, left hand, and hip pain. Sent out via ambulance. Record review of Accident/Incident Report, dated 7/30/19, indicated that approximately 12:00pm, resident was transferring from hydraulic lift back to bed, sling broke, resident fell face first onto floor. [MEDICAL CONDITION] times two, left eyebrow laceration, multiple skin tears to left to face left hand, left hip pain. Sent to Hospital #1 ER for assessment and Tx=all Hoyer slings have been removed, lift is being examined for any faults, will order additional new slings. (ADON) Record review of resident #1's Hospital Admission Notes, dated 7/30/19, revealed that resident #1 was seen at the emergency room in hospital #1 with Assessment Plan including Scalp Laceration S01.01XA, Trauma T14.90XA, Complex [MEDICAL CONDITION], multiple skin tears LUE (lower, upper extremities), acute blood loss to [MEDICAL CONDITION]. Possible scapula fracture. He was found to have a complex [MEDICAL CONDITION] with a pulsatile bleeding vessel from the cranium as well and multiple skin tears on his LUE. Dr placed approximately 6-8 interrupted and FOE sutures and was able to gain [MEDICATION NAME] control, At this time, he was hooked up to the monitor and noted to have systolic blood pressure in the 70s and upgraded to Level 1. Resident #1 is a [AGE] year-old man with multiple medical comorbidities who presented a complex [MEDICAL CONDITION] and subdural/subarachnoid bleed on CT scan. Also results of CT scan were negative but also documented a possible head fracture. CT shows old [MEDICAL CONDITION], small SDH and left cerebral subarachnoid, Repeat CT Head w/o unchanged, non-op per NSGY Nurse's Note, dated 7/30/19, (witness statement for CNA #1, indicated that she was being assisted by CNA #2 to transfer resident #1 with a hydraulic lift after a shower and when resident #1 was lifted, and she moved the lift towards the bed, the sling busted and resident #1 fell face down. CNA #2 ran and called the LVN Charge nurse #1 for help at 12:11pm. Nurse's Notes, dated 7/30/19, witness statement from CNA #2 was assisting CNA #1 with Hoyer (hydraulic) lift after resident #1's shower. She said CNA #1 moved the lift and the sling busted and resident #1 fell face down off the sling. She said she ran to call LVN Charge nurse #2 for help. The facility provided the sling used during the incident, which was kept for surveyor observation, on 8/01/19 at approximately 10:30am. The sling was discolored, and extremely torn, worn and frayed. Also, evident, one of the loops on the sling was completely torn all the way. Witness Statement by CNA #1 on 8/01/19, indicated that CNA #2 assisted her in transferring resident #1 from his bed to shower chair on 7/30/19, and she took him to get bathed. After she got done, she took him back to his room and CNA #2 assisted her in putting resident #1 back to his bed. They got him in the lift and placed the sling on him and when she was turning the lift toward the bed, the right-side bottom of the sling busted and resident #1 flipped out of it (the sling) on his face and CNA #2 called the charge nurse #2 and provided first aide. On 8/02/19, CNA also wrote another statement at 3:20pm and stated that the slings were in bad shape back to when former administrator was here in (MONTH) 2019 until she left. Some were torn, and string hanging off them. The sling was shown to me (CNA #1) that was used on resident #1, when he fell , and the hooks (loop)s on that sling, were not in good condition. Interview with CNA #1 on 8/01/19 at approximately 10:21am revealed that she had CNA #2 assisting her in transferring resident #1 to his bed from the shower chair. CNA #1 said they (CNA #1 & 2) got the sling on him and even lifted him to get him to his bed and as soon as she (CNA #1) lifted him (with hydraulic lift) to put him on the bed, the sling busted and resident #1 fell . After looking at the sling used on resident #1 when accident occurred, CNA #1 said, she would not have used the sling because it was torn and in bad condition. Interview with CNA #2 on 8/01/19 at 11:45am indicated that she had been trained on the slings and the hydraulic lift. She demonstrated, along with CNA #3 and CNA #4 how she had transferred resident #1 and how he fell . She was shown the sling that they (CNA #1) used on resident #1 on 7/30/19 and asked if she should have used that sling. She responded by, now that I see it, no I wouldn't. When asked why not, she said because it was in bad shape. She said that it was her understanding they (facility) threw about 6 slings away. Witness Statement by CNA #2, dated 8/01/19, indicated that she assisted CNA #1 in transferring resident #1 to his shower chair and she bathed him. She documented that resident #1 never made it to his bed because the sling busted, and he fell face forward first. Interview with LVN #2 on 8/01/19 at 11:40pm revealed that he provided medical attention to resident #1 when resident #1 fell . LVN #2 said one of the CNAs had yelled to him and by the tone of her voice, LVN #2 knew it was an emergency, he went to resident #1's room where he saw him in a prone position and injuries to his head, bleeding and multiple skin tears to his arm, hands and even knuckles. He was bleeding quite a bit. He said emergency services were called and initially, resident #1 refused to go to the hospital but the EMS staff encouraged him to go to the hospital, so he went. The surveyor showed the sling that was used on resident #1, the surveyor asked if LVN #2 would use the sling. LVN #2 responded by saying, . no, because it looks dangerous, its torn and frayed. LVN #2 pointed to an area on the sling where it was torn. LVN #2 showed surveyor another area on the sling that was also torn and again, said, it would not be safe. Interview with Administrator #2 on 8/01/19 at 9:55am revealed that when asked how the accident with resident #1 occurred she said that it was an old sling that was used in the hydraulic lift. She said all staff were educated immediately after the incident on 7/30/19 and 7/31/19, on the use of the mechanical lift and sling inspections prior to working direct care and if not, since some staff were out, as soon as they come back, they will be. Observation of resident #1 on 8/01/19 at 2:00pm revealed he was in his bed and he was leaning to the right side with head curled, (contracted). He had numerous skin tears on his lower and upper extremities and sutures on top of his head and left side laceration. When asked he how he was doing, he said okay. Interview with CNA #4 on 8/01/19 at 11:25am, said that she had told the previous Administrator #1 about the slings being in bad shape since about (MONTH) 2019 and she even took one to her. She said that she just took it and doesn't know if she (Administrator #1) ordered new slings, but she was made aware that the slings were in bad shape. She acknowledged being trained on 7/30/19 on identifying worn slings and use of mechanical lift. Witness Statement dated 8/01/19 at 3:30pm for CNA #4 documented that she had reported, to the previous Administrator #1, on approximately (MONTH) (2019), about some slings being in very bad condition. One sling that broke, I bagged up and took it to her. Another one, I also bagged up and took it to her that was in very bad condition. She (Administrator #1) said that she would take care of it. Interview with DON on 8/02/19 at 12:58pm revealed that after the incident, approximately six (6) slings were thrown away and new ones were ordered. She said the ADON had gone and checked for them throughout the building. The DON said none of them were too bad, some discoloration, the stitching was frayed in some areas and there were notable areas where the bleach had eaten through the material. She said that laundry had been washing and drying them when they should have been hung to dry. Interview with Administrator #2 on 8/02/19 at 1:09pm by telephone, when asked if she knew about the worn slings and she said, she was not told and did not know they were in that condition. She responded when asked if there were processes in place before the accident with resident #1, she said, she was not aware of any prior processes in place to check the slings for wear and tear. She further indicated, now, there is monthly audits in place, done by Laundry and Housekeeping supervisor on the 30th of every month. The slings are going to be replaced every 6 months. Staff were also in-serviced they are to check the slings prior to using for wear and tear, if they are any, they are to give them to Administrator #2. Competencies were also assessed for hydraulic lift as part of the action that was taken after the accident. Interview with Housekeeping and Laundry supervisor on 8/02/19 at 1:14pm stated, that prior to the hiring of current Administrator #2, that one of the laundry aides had come into the office of Administrator #1, with one of the slings and it was old, discolored and strings were coming off. LA said yes the slings looked worn. She said that the Administrator #1 didn't do anything, never gave me permission to order the new slings. Prior to the ones, we got in (MONTH) 2019, it was (MONTH) (YEAR) that we had received any new (slings) ones. After we looked at some, we threw any away that looked like they were discolored, fraying on the side. Before the incident the Laundry aides were told to keep an eye out for 'them' (slings that were worn or frayed). Administrator #1 did not order any, and she didn't look to see if there other torn or worn slings. She threw that one a way, just didn't order any. Interview with Laundry Aide (LA) #1 on 8/02/19 at 1:30pm when asked if she had been told to watch out for worn slings and she said that she was not told until after this accident with resident #1. LA #1 said that she took two (2) of the slings that were cracking, peeling, to former Administrator #1, and these were not the mesh ones. This was back in (MONTH) or (MONTH) (of this year) and Administrator #1 didn't order new ones at that time. Now, I am told to make sure after washing the slings that they need to be hung up to dry and not let them dry in the dryer. She was also trained on taking worn and frayed slings to Administrator #2. Record review of the facility's Training In-service form date 7/30/19 was as follows: Substantial Compliance Documentation, dated 7/30/19, revealed that the facility: 1. Mechanical Lift 2. Staff Competency Evaluation for use of Mechanical Lift 3. Staff education Completed and Date: The DON or designee is verifying competency on use of the mechanical lift for all nursing staff prior to use of mechanical lift effective 7/29/19. Education is being done with nursing staff on checking the sling for wear and tear. The Laundry supervisor has been assigned to check each sling monthly to verify they are in good repair. A system has been implemented on sling stock rotation. Slings will be removed for circulation on a schedule. Slings will be marked and dated when put into circulation to verify compliance. 4. Scheduled Safety Committee Meeting for 8/30/19. Plan QAPI In-service Training 1. How to use a mechanical lift, dated 2001 and revised (MONTH) (YEAR) Record Review of Lifting Machine, Using a Mechanical: Purpose of this procedure is to establish the general principals of safe lifting using a mechanical lifting device. Steps in Procedure 2. Check to make sure sling is appropriate for size and purpose. .7. Double check the sling and machine's weight limits against the resident's weight. 10. Attach sling straps to sling bar, according to manufacturer's instructions. c. Before resident is lifted, double check the security of the sling attachment. .d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. Facility Inservice dated 7/30/19 Topic: Resident slings that are old, torn or frayed must be turned in to the Administrator/DON. They are not to be used. Record review of previous order, dated 7/01/19, from Supply company #1 documented that 4 slings (2 different sizes) were ordered and expected delivery date was 7/02/19 to the facility. Record review of order, from Supply company #1, dated 7/30/19, from Supply company #1 documented that 6 slings (2 different sizes) were ordered for the facility. During the interviews completed on 8/01/19 and 8/02/19 between 11:30am to 1:30pm with DON, LVN #2, CNAs #1, #2 and #3 Laundry and Housekeeping Supervisor, and Laundry Aide, all stated they received the in-serviced about not using slings that were worn, frayed or torn and to be given immediately to the Administrator. They were asked what they would do with the torn slings, asked about checking the sling prior to use, asked about mechanical lift competency, in-service on how to use mechanical lift, and monthly auditing system for slings.

Based on interview, observation and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 8 residents (resident #1). The facility failed to ensure resident #1 was provided with a safe and functioning sling for use on a hydraulic lift. The sling tore away from the hydraulic lift hook, during transfer, resulting in serious complex head trauma. This was determined to be an Immediate Jeopardy at Past Non-Compliance from (MONTH) 30, 2019, due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. Failure to ensure the resident was using a sling in good working order, placed residents at risk of severe injury or death. The evidence is as follows: Record review of resident #1's Face Sheet, dated 7/11/19, documented that resident date of birth 9/12/1955, was admitted to the facility on [DATE] from hospital. He has the following Diagnoses: [REDACTED]. Record review of the MDS, dated [DATE], for resident #1, documented that his functional levels for activities of daily living, including transfers were extensive assistance of two persons. Record review of resident #1's Care Plan, dated 5/27/19, documented: resident (#1) will be transferred with the use of the Hydraulic lift during this review period. Intervention: Resident requires two person assist with hydraulic lift. Lift to be used for all transfers. Resident will sustain no injuries during transfers over the next 90 days to (8/25/19). Record review of Facility Provider Investigation Report, dated 7/30/19, documented that resident was being transferred by mechanical lift (from shower chair) to bed when sling broke causing resident to fall to floor. [MEDICAL CONDITION] x2, left eyebrow laceration, right wrist deformity, multiple skin tears, left hand, and hip pain. Sent out via ambulance. Record review of Accident/Incident Report, dated 7/30/19, indicated that approximately 12:00pm, resident was transferring from hydraulic lift back to bed, sling broke, resident fell face first onto floor. [MEDICAL CONDITION] times two, left eyebrow laceration, multiple skin tears to left to face left hand, left hip pain. Sent to Hospital #1 ER for assessment and Tx=all Hoyer slings have been removed, lift is being examined for any faults, will order additional new slings. (ADON) Record review of resident #1's Hospital Admission Notes, dated 7/30/19, revealed that resident #1 was seen at the emergency room in hospital #1 with Assessment Plan including Scalp Laceration S01.01XA, Trauma T14.90XA, Complex [MEDICAL CONDITION], one laceration on top of head required 6 to 8 sutures, the other laceration was on the left side of head, multiple skin tears LUE (lower, upper extremities), acute blood loss to [MEDICAL CONDITION]. Possible scapula fracture and subcranial hemorrhage. Nurse's Note, dated 7/30/19, (witness statement for CNA #1, indicated that she was being assisted by CNA #2 to transfer resident #1 with a hydraulic lift after a shower and when resident #1 was lifted, and she moved the lift towards the bed, the sling busted and resident #1 fell face down. CNA #2 ran and called the LVN Charge nurse #1 for help at 12:11pm. Nurse's Notes, 7/30/19, witness statement from CNA #2 was assisting CNA #1 with Hoyer (hydraulic) lift after resident #1's shower. She said CNA #1 moved the lift and the sling busted and resident #1 fell face down off the sling. She said she ran to call LVN Charge nurse #2 for help. The facility provided the sling used during the incident, which was kept for surveyor observation, on 8/01/19 at approximately 10:30. The sling was discolored, and extremely torn, worn and frayed. Also, evident, one of the loops on the sling was completely torn all the way. Witness Statement by CNA #1 on 8/01/19, indicated that CNA #2 assisted her in transferring resident #1 from his bed to shower chair on 7/30/19, and she took him to get bathed. After she got done, she took him back to his room and CNA #2 assisted her in putting resident #1 back to his bed. They got him in the lift and placed the sling on him and when she was turning the lift toward the bed, the right-side bottom of the sling busted and resident #1 flipped out of it (the sling) on his face and CNA #2 called the charge nurse #2 and provided first aide. On 8/02/19, CNA also wrote another statement at 3:20pm and stated that the slings were in bad shape back to when former administrator was here in (MONTH) 2019 until she left. Some were torn, and string hanging off them. The sling was showed to me that I used on resident #1 and the hooks (loop)s on that sling, were not in good condition. Interview with CNA #1 on 8/01/19 at approximately 10:21am revealed that she had CNA #2 assisting her in transferring resident #1 to his bed from the shower chair. She said they got the sling on him and even lifted him to get him to his bed and as soon as she lifted him (with hydraulic lift) to put him on the bed the right has used the sling, she said she would not have used the sling because it was torn and in bad condition. Interview with CNA #2 on 8/01/19 at 11:45am indicated that she had been trained on the slings and the hydraulic lift. She demonstrated, along with CNA #3 and CNA #4 how she had transferred resident #1 and how he fell . She was shown the sling that they (CNA #1) used on resident #1 on 7/30/19 and asked if she should have used that sling. She responded by, now that I see it, no I wouldn't. When asked why not, she said because it was in bad shape. She said that it was her understanding they (facility) threw about 6 slings away. Witness Statement by CNA #2, dated 8/01/19, indicated that she assisted CNA #1 in transferring resident #1 to his shower chair and she bathed him. She documented that resident #1 never made it to his bed because the sling busted, and he fell face forward first. Interview with LVN #2 on 8/01/19 at 11:40pm revealed that he provided medical attention to resident #1 when he fell . When the surveyor showed LVN #2, the sling that was used on resident #1, the surveyor asked if LVN #2 would use it. He responded by saying, .no, because it looks dangerous, its torn and frayed. I would not use it. LVN #2 pointed to an area on the sling where it was torn. LVN #2 showed me another area on the sling that was also torn and said, it would not be safe. Interview with Administrator #2 on 8/01/19 at 9:55am revealed that when asked how the accident with resident #1 occurred she said that it was an old sling that was used in the hydraulic lift. She said all staff were educated immediately after the incident on 7/30/19 and 7/31/19, on the use of the mechanical lift and sling inspections prior to working direct care and if not, since some staff were out, as soon as they come back, they will be. Observation of resident #1 on 8/01/19 at 2:00pm revealed he was in his bed and he was leaning to the right side with head curled, (contracted). He had numerous skin tears on his lower and upper extremities and sutures on top of his head and left side laceration. When asked he how he was doing, he said okay. Interview with CNA #4 on 8/01/19 at 11:25am, said that she had told the previous Administrator #1 about the slings being in bad shape since about (MONTH) 2019 and she even took one to her. She said that she just took it and doesn't know if she (Administrator #1) ordered new slings, but she was made aware that the slings were in bad shape. She acknowledged being trained on 7/30/19 on identifying worn slings and use of mechanical lift. Witness Statement dated 8/01/19 at 3:30pm for CNA #4 documented that she had reported, to the previous Administrator #1, on approximately (MONTH) (2019), about some slings being in very bad condition. One sling that broke, I bagged up and took it to her. Another one, I also bagged up and took it to her that was in very bad condition. She (Administrator #1) said that she would take care of it. Interview with DON on 8/02/19 at 12:58pm revealed that after the incident, approximately six (6) slings were thrown away and new ones were ordered. She said the ADON had gone and checked for them throughout the building. The DON said none of them were too bad, some discoloration, the stitching was frayed in some areas and there were notable areas where the bleach had eaten through the material. She said that laundry had been washing and drying them when they should have been hung to dry. Interview with the Administrator #2, on 8/02/19 at 1:09pm by telephone, when asked if she knew about the worn slings and she said, she was not told and did not know they were in that condition. She responded when asked if there were processes in place before the accident with resident #1, she said, she was not aware of any prior processes in place to check the slings for wear and tear. Administrator #2 further indicated, now, there is monthly audits in place, done by Laundry and Housekeeping supervisor on the 30th of every month. The slings are going to be replaced every 6 months. Staff were also in-serviced they are to check the slings prior to using for wear and tear, if they are any, they are to give them to Administrator #2. Competencies were also assessed for hydraulic lift as part of the action that was taken after the accident. Interview with Housekeeping and Laundry supervisor on 8/02/19 at 1:14pm stated, that prior to the hiring of current Administrator #2, that one of the laundry aides had come into the office of Administrator #1, with one of the slings and it was old, discolored and strings were coming off. LA said yes the slings looked worn. She said that the Administrator #1 didn't do anything, never gave me permission to order the new slings. Prior to the ones, we got in (MONTH) 2019, it was (MONTH) (YEAR) that we had received any new (slings) ones. After we looked at some, we threw any away that looked like they were discolored, fraying on the side. Before the incident the Laundry aides were told to keep an eye out for 'them' (slings that were worn or frayed). Administrator #1 did not order any, and she didn't look to see if there other torn or worn slings. She threw that one a way, just didn't order any. Interview with Laundry Aide (LA) #1 on 8/02/19 at 1:30pm when asked if she had been told to watch out for worn slings and she said that she was not told until after this accident with resident #1. LA #1 said that she took two (2) of the slings that were cracking, peeling, to former Administrator #1, and these were not the mesh ones. This was back in (MONTH) or (MONTH) (of this year) and Administrator #1 didn't order new ones at that time. Now, I am told to make sure after washing the slings that they need to be hung up to dry and not let them dry in the dryer. She was also trained on taking worn and frayed slings to Administrator #2. Record review of the facility's Training In-service form date 7/30/19 was as follows: Substantial Compliance Documentation, dated 7/30/19, revealed that the facility 1. Mechanical Lift 2. Staff Competency Evaluation for use of Mechanical Lift 3. Staff education Completed and Date: The DON or designee is verifying competency on use of the mechanical lift for all nursing staff prior to use of mechanical lift effective 7/29/19. Education is being done with nursing staff on checking the sling for wear and tear. The Laundry supervisor has been assigned to check each sling monthly to verify they are in good repair. A system has been implemented on sling stock rotation. Slings will be removed for circulation on a schedule. Slings will be marked and dated when put into circulation to verify compliance. 4. Scheduled Safety Committee Meeting for 8/30/19. Plan QAPI In-service Training 1. How to use a mechanical lift, dated 2001 and revised (MONTH) (YEAR) Record Review of Lifting Machine, Using a Mechanical Purpose of this procedure is to establish the general principals of safe lifting using a mechanical lifting device. Steps in Procedure 2. Check to make sure sling is appropriate for size and purpose. .7. Double check the sling and machine's weight limits against the resident's weight. 10. Attach sling straps to sling bar, according to manufacturer's instructions. c. Before resident is lifted, double check the security of the sling attachment. .d. Examine all hooks, clips or fasteners. e. Check the stability of the straps. Facility Inservice dated 7/30/19 Topic: Resident slings that are old, torn or frayed must be turned in to the Administrator/DON. They are not to be used. Record review of previous order, dated 7/01/19, from Supply company #1 documented that 4 slings (2 different sizes) were ordered and expected delivery date was 7/02/19 to the facility. Record review of order, from Supply company #1, dated 7/30/19, from Supply company #1 documented that 6 slings (2 different sizes) were ordered for the facility. During the interviews completed on 8/01/19 and 8/02/19 between 11:30am to 1:30pm with DON, LVN #2, CNAs #1, #2 and #3 Laundry and Housekeeping Supervisor, and Laundry Aide, all stated they received the in-serviced about not using slings that were worn, frayed or torn and to be given immediately to the Administrator, check slings prior to use, in-service on how to use mechanical lift, monthly auditing system for slings.

Based on observation, interview and record review the facility failed to provide resident care consistent with professional standards of practice, to prevent pressure ulcers from developing, the development of treatment and services to promote healing and prevent development of new pressure sores for 2 of 5 Residents reviewed for pressure injuries (Residents #9 and #17). The facility failed to prevent the development of a right heel pressure ulcer for Resident #9 and failed to prevent the worsening of a left heel pressure ulcer from Stage 2 to Stage 3 for Resident #9. The facility failed to keep pressure off the developed pressure ulcer on left heel, allowing Resident #9's feet to drag on the floor during transfers. The facility failed to follow physician orders [REDACTED].#9. The facility failed to provide pressure ulcer care plans for Resident #9 and #17. The facility failed to complete weekly skin assessments for 2 residents, Resident #9 and #17. These failures could place other residents who had pressure injuries at risk for new development or worsening of existing pressure injuries. Findings included: Resident #9 Record review of Resident #9's face sheet dated 05/29/19 documented Resident #9 was a [AGE] year-old male who was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Observation on 5/29/2019 at 10:00 AM Resident #9 lying supine in bed 30- degree angle, air mattress in place, no Prevalon boot observed as per physician orders. Observation on 05/29/2019 at 3:03 PM Resident #9 is being transported rear- facing to shower by CNA #1 with bilateral feet dragging on the floor on a white towel. Left heel wound is undressed and bleeding onto towel as his feet are being dragged. In an interview on 05/29/2019 at 3:03 PM with LVN #1 confirmed CNA's always transport Resident #9 to the shower with his feet dragging on a towel because he is too tall for the chair. In an interview on 05/29/2019 at 3:05 PM with the ADON, confirmed the facility does not have an appropriate shower chair for Resident #9. ADON confirmed Resident #9 should be transported by 2 CNA's, front facing with one staff to carry his feet and not allow them to drag. In an interview with LVN #1 on 5/29/19 at 3:10 PM he confirmed Resident #9 the right lateral heel pressure sore was first found by himself on 5/26/19 and developed at the facility. Observation on 05/30/2019 at 9:14 AM Resident #9 observed reclined in TV room in Geri- chair, there is no pressure relieving device in Geri-chair, bilateral feet are dependent with feet/heels resting directly against surface of recliner and there is no pressure relieving intervention for feet/heels. In an interview on 5/30/2019 at 3:03 PM with Nurse Consultant she confirms she spoke with physical therapy about a recliner for Resident #9 because the Geri- chair does not fit him properly and he does not like the Geri- chair. In an interview on 5/30/2019 at 10:08 AM with Wound Care Consultant (WCC #1), confirmed Resident #9 did not have open wounds to bilateral heels during wound care rounds last month. In an interview on 5/30/2019 at 10:27 AM, the DON confirmed the Charge Nurse, LVN #1 does skin rounds. DON confirmed she does not have weekly skin documentation. DON reported changing offices and an inability to locate skin round book. In an interview on 5/30/2019 at 6:34 PM, the DON confirmed she has never seen documentation from the WCC #1. In an interview on 5/30/2019 at 6:35 PM, the Administrator confirmed the WCC #1 sends her wound evaluations to the facility via email. The last email the Administrator received from the WCC #1 is dated (MONTH) (YEAR) and is addressed to the current Administrator and former DON. Observation on 05/31/2019 at 9:05 AM Resident #9 observed reclined in TV room in Geri- chair, there is no pressure relieving device in Geri-chair, bilateral feet are dependent with feet/heels resting directly against surface of recliner and there is no pressure relieving intervention for feet/heels. Right foot is dangling off the side of the chair. In an interview on 5/31/2019 at 10:05 AM with LVN #3 confirmed no notification on 5/31/2019 of any new skin concerns with Resident #9 and LVN #3 is the nurse assigned to his hall. In an interview on 5/31/2019 at 10:05 AM with the ADON confirmed no notification of any skin changes on 5/31/2019 with Resident #9. She confirms the Skin Roster documentation should be completed daily by CNA's but at some point, they stopped completing the assessment. In an interview with CNA #4 on 5/31/2019 at 11:20 AM confirmed informing LVN #3 about Resident #9's foot. In an observation on 5/31/19 at 11: 21 AM Resident #9 observed resting supine in bed. He is not wearing Prevalon boots as per physician orders [REDACTED]. In a confidential interview on 5/31/19 at 11:25 AM a confidential staff confirms Resident #9 remains in bed because facility is out of wound care supplies and administration does not want survey team to observe soiled dressings. Record review of Resident #9's MDS assessment dated [DATE] documents Resident #9 triggered the following care areas in: Section V: Cognitive Loss/Dementia, Visual Function, Communication, ADL Function, Urinary Incontinence/Indwelling Catheter, Psychosocial Well Being, Behavioral Symptoms, Falls, Nutritional Status, Pressure Ulcer, [MEDICAL CONDITION] Drug Use, Pain Record review of Resident #9's Care Plan dated 4/5-16/2019 documents no care plan or interventions for pressure ulcers Record review of Order Summary Report dated 05/2019 revealed the following orders in part: 1. 3/30/19 - Apply padded Podous boots when in Geri-Chair. Discontinued on 5/26/19 2. 4/26/19- Cleanse right lateral ankle, with NS or WC, Pat dry and apply collagen dressing and secure with foam dressing daily and as needed. 3. 4/26/2019-Cleanse bilateral buttocks open areas with normal saline or wound cleanser, pat dry, apply and pack with calcium alginate with collagen powder and secure with foam dressing daily and as needed. 4. 5/26/19- Cleanse Left medial heel with wound cleanser or normal saline, pat dry and apply collagen powder and secure with foam dressing every other day and as needed. Report any signs and symptoms of infection to primary care physician. 5. 5/26/2019- Apply Prevalon boots while in bed to prevent skin break down every shift Record review of Wound Care Flow Sheet dated 5/15/2019 documented the following in part by LVN #1: 1. #3 Wound Type - Pressure. Wound Location- Right lateral heel. Measurements 3-3.5 cm. The wound has no undermining, a moderate amount of serosanguineous drainage with a musty odor. 2. #4 Wound Type-New Pressure. Wound Location-Left Medial Heel. Measurements 3x2.5cm. The wound has no undermining, a moderate amount of serosanguineous drainage with no odor. Record Review of Skin Roster dated 4/8/2019- 5/31/2019 documented the following in part: 1. CNA #5 documented No new skin concern on the following dates 4/20/2019, 4/22/2019, 5/4/2019, 5/5/2019, 5/14/2019,5/27/2019 2. CNA #4 documented No new skin concern on the following dates 5/13/2019 3. CNA #4 documented New skin concern- Nurse notified at 9:45 AM on the following date 5/31/2019 Record review of Nursing notes documents the following in part: 3/26/2019 at 1700 by LVN #1- Resident #9 arrived at facility .bilateral ankle unblanchable redness area . 3/30/2019 at 7:14 PM by LVN #1- Resident #9 noted to have a large amount of musky smell . 3/31/2019 at 6:22 PM by LVN #1-Noted this day that Resident (#9) non blanchable area to right lateral heal is open, measures 1.5cm x 1.5cm, red and healthy, cleansed with normal saline, pat dry and applied small layer of [MEDICATION NAME] gel and secured with foam dressing . 4/26/2019 at 6:06 PM by LVN#1- Wound Care Consultant also recommended to cleanse right lateral heel with normal saline, or wound cleanser and pat dry then apply collagen powder and secure with foam dressing and did receive this treatment this day as well. 5/26/2019 at 6:04 PM by LVN#1-New area noted to left lateral heel, 3x4cm, red, sanguineous drainage, weeping, order present, no signs and symptoms of infection, denies pain, area cleansed with normal saline, pat dry, applied collagen powder with foam dressing and secured with tape .updated wound assessment on wound care sheet DON notified. Record review of Skin Sheet Tracking Record dated 5/30/2019 documented the following in part by DON: 1. Resident #9 -Date found is coded A(Antibiotics). Stage type is documented 2. Location is Left lateral heel. Length/Width/Depth is documented 3.0x4.0x0 there is no unit of measurement documented. Treatment is documented as collagen powder, small amount of drainage, no odor. Progress is coded S (Same). Preventative measures used- air mattress. Dietary consult, Dietary supplement, Vitamin Supplement and Labs needed are coded Y (Yes) On 5/30/2019 at 12:51 PM by LVN#1- Wound Care Consultant (WCC #1) here to visit this day, assessed bilateral heels, WCC #1 recommended right heel to be cleansed with normal saline or wound cleanser, pat dry an apply mixed hydrogel with collagen powder and apply a foam and wrap with gauze and secure with tape every other day and as needed. WCC #1 then recommended for left heel to be cleansed with normal saline or wound cleanser, pat dry and apply collagen powder, then apply foam and wrap with gauze and secure with tape every other day and as needed. Record review of Wound Care Consultant Evaluation dated 5/30/2019 documents the following in part: Left heel, Stage 3 pressure ulcer, 3.00 length x 4.00 cm width. RESIDENT #17 Record reviewed of Resident #17's face sheet revealed [AGE] year old admitted [DATE] with the following Diagnoses: [REDACTED].; disorder of urinary system; vitamin deficiency; dementia without behavioral disturbance; [MEDICAL CONDITION] without current pathological fracture; restlessness and agitation; dementia with behavioral disturbance; unsp open wound of left cheek and TMJ area, subs; partial loss of teeth, unspecified cause, unspecified class; bacterial infection; and pain. During an interview on 05/30/19 at 9:45 AM with the ADON of nurses she stated the charge nurses do skin rounds, she only helps the nurses when she is asked to help. On 05/30/19 9:58 AM observation made of wound consultant entering the facility to see residents. During an interview on 05/30/19 at 10:27 AM with the DON she stated LVN #1 is the charge nurse who does the skin rounds. The DON went further to state that she had changed offices and could not find the wound care log book. Observation on 05/30/19 at 10:21 AM of the wound consultant observing the heel of Resident #17. The wound consultant stated the pressure sore to the left heel of resident #17 was unstagable. LVN #1 stated it was an in-house wound and that he called the Dr. with recommendations of the wound consultant and if they approved the recommendation he would write the order and put it into the computer system. During an interview on 05/30/19 at 6:11 PM LVN #1 stated he was the one who would measure the wounds and mostly do the wound care because the other nurses did not like to measure the wounds, LVN #1 continued to state that he would ask the DON to come with him to see the wounds when he saw changes and she would only come to see the wounds occasionally when he asked her. LVN #1 also stated he would call the doctors when he saw the wounds changed and called the wound consultant who would come if he asked her to. LVN #1 continued to state he felt comfortable with doing wound care, but he would like for the DON to see the wounds with them when she only did so occasionally. During an interview on 05/30/19 at 6:31 PM with the Nurse Consultant she stated the wound care consultant reports for the wounds could not be found. The nurse consultant continued to state the wound consultant used to fax reports to the previous DON but the reports could not be found and the wound tracking book could not be found either that possibly the business office manager may have put the files in a folder on the computer but they were going to look further for the reports.(No wound care consultant reports were provided). During an interview on 05/31/19 at 9:45 AM with LVN #3 she stated she was aware of the left heel wound on resident #17 but she had been working the medication cart and had not seen the wound but as far as she knew there was a wound on the left heel. Record review of Resident #17's progress notes under nursing documented: 04/12/19 4:44 PM PODIATRIST HERE TO TX RESIDENT THIS DAY. signed by LVN #1. 04/13/19 4:01 PM P[NAME]KET FILLED BLISTER NOTED TO LEFT MEDIAL HEEL, 3X2.5 CM, APPLIED FOAM DRESSING FOR PREVENTATIVE MEASURES, FNP AWARE AND FAMILY MEMBER NOTIFIED AND MADE AWARE VOICES NO CONCERNS. signed by LVN #. 04/14/19 6:58 PM MONITORED P[NAME]KET FILLED BLISTER TO LEFT MEDIAL HEEL, CONT WITH SAME APPEARNACE, HAS NOT BURST, CONT WITH FOAM DRESSING FOR PREVENTATIVE MEASURES. signed by LVN #. 04/17/19 5:58 PM RESIDENT CONT WITH P[NAME]KET FILLED BLISTER TO LEFT MEDIAL ANKLE, SEEMS TO BE ABSORBING WELL, HAS NOT RUPTERED, CUSHION PADDED SHOW (shoe) WEAR APPLIED. signed by LVN #1 05/23/19 6:32 PM MONITORED P[NAME]KET FILLED BLISTER TO LEFT ANKLE, AREA IS OPEN, MEASURED 2CMX2CM, CLEAN AND HEALTHY APPEARANCE, CLEANSE WITH WC, PAT DRY AND APPLIED TAO THEN CALLED FNP WITH NEW ORDER TO CLEAN AREA WITH NS OR WC, PAT DRY, APPLY COLLAGEN POWDER AND APPLY FOAM AND SECURE WITH GAUZE QOD. FAMILY MEMBER HERE IN HOUSE AND MADE AWAR OF NEW ORDER. sign by LVN #1. Record reviewed of Resident #17's Wound Care Flow Sheet documented: 04/30/19 Wound type: Stage 2. Wound Location- left medial heel. Measurements 3.3 cm x 3.0cm. The wound has no undermining, no drainage, the wound bed is not visible, and the margins are closed. Tissue: intact blood- filled blister Pain: mild Surrounding Tissue: boggy, pink, non-blanchable Current TX/TX Changes: Foam pad QD to protect Evaluation Needed (ET Nurse, Nutritional): consult AMT WC specialist Alternate Pressure Devices/ Wound Vac: 0 Visit Frequency: N/A Nurse Signature: LVN #3 Record review of Resident #17's Hospice Comprehensive Assessment and Plan of Care Updated Report revealed: Benefit Period of Dates: 04/26/19 - 07/24/19 The Meeting Date: 05/09/19 Client Orders since last meeting date: Order date 05/06/19 NEW ORDER FOR LEFT HEEL UNSTAGABLE PRESSURE ULCER. COVER WITH NON-ADHERENT DRESSING DAILY AND PRN. DX: LEFT HEEL UNSTAGABLE PRESSURE ULCER HOSPICE NURSE AND FACILITY WILL CHANGE DRESSING TO PHYSICIAN/RN. Record reviewed of Physician order [REDACTED]. Order date of 05/23/19 and Start Date of 05/24/19 Pressure ulcer of left heel, unstageable CLEANE LEFT MEDIAL OPEN AREA WITH NS OR WC, PAT DRY, APPLY COLLAGEN POWDER WITH FOAM AND WRAP WITH GAUZE QOD AND PRN, REPORT ANY CHANGES TO PCP. Record reviewed of Resident #17's Skin Roster dated 02/01/19 - 05/31/19 documented CNA(s) observed on 23 days (approximately every 2 weeks) No New Skin Concern documented by CNA #4 and CNA #5. Record reviewed of Resident #17's Weekly Skin Integrity Review dated (MONTH) 2019 documented the following: 05/07/19 SDT1 to Left Medial heel leather kind appearance signed by LVN #1; 05/14/19 heel Left signed by LVN #2; 05/21/19 No new Skin condition; Left heel SDII 3cm X 3cm Black 05/28/19 Left heel See TAR Left foot swollen Record reviewed of Resident #17's Skin Sheet Tracking Record dated 05/30/19 documented: Resident: #17 Date found: 05/28/19; Wound location- Left heel, Stage 2. Measurements are 1.0 cm length x/1.0 cm width/x 1.0 cm depth. The wound is New with no drainage, no odor. Dietary Consult, Dietary supplement, Vitamin Supplement and Labs needed are coded N (No). Treatment: Collagen Powder Drainage: NA Odor: N Progress: New Preventative Measures used: [MEDICATION NAME] and socks Record review of Resident #17's Quarterly MDS dated [DATE] documented: Section I Active Diagnoses No skin conditions noted Section M Skin Conditions M0100. Determination of Pressure Ulcer/Injury Risk indicated by a check mark are: B. Formal assessment instrument/tool (e.g. Braden, Norton, or other) C. Clinical assessment M0150. Risk of Pressure Ulcers/Injures 1 is coded for Yes M0210. Unhealed Pressure Ulcers/Injures 0 is enter as No M0300. Current Number of Unhealed Pressure Ulcers/Injury at Each Stage No skin issues noted M1030. Number of Venous and Arterial Ulcers 0 was enter M1040. Other Ulcers, Wounds and Skin Problems Foot Problems - no noted Other Problems: H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated [MEDICAL CONDITION] (IAD), perspiration, drainage) was indicated by a check mark M1200. Skin and Ulcer/Injury Treatments were indicated by a check mark are: A. Pressure reducing device for chair B. Pressure reducing device for bed H. Applications of ointments/medications other than feet was Record review of Resident #17's Significant MDS dated [DATE] documented: Section I Active Diagnoses No skin conditions noted Section M Skin Conditions M0100. Determination of Pressure Ulcer/Injury Risk indicated by a check mark are: B. Formal assessment instrument/tool (e.g. Braden, Norton, or other) C. Clinical assessment M0150. Risk of Pressure Ulcers/Injures 1 is coded for Yes M0210. Unhealed Pressure Ulcers/Injures 0 is enter as No M0300. Current Number of Unhealed Pressure Ulcers/Injury at Each Stage No skin issues noted M1030. Number of Venous and Arterial Ulcers 0 was enter M1040. Other Ulcers, Wounds and Skin Problems Foot Problems - no noted Other Problems: H. Moisture Associated Skin Damage (MASD) (e.g., incontinence-associated [MEDICAL CONDITION] (IAD), perspiration, drainage) was indicated by a check mark M1200. Skin and Ulcer/Injury Treatments were indicated by a check mark are: C. Pressure reducing device for chair D. Pressure reducing device for bed H. Applications of ointments/medications other than feet Record reviewed of Resident #17's Care Plan documented no care plan for the actual pressure sore, only preventive measures. Record review of facility policy titled Prevention of Pressure Ulcers (revised (MONTH) 2013) documents the following in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. Preparation: Review the residents care plan to assess any special needs of the resident Interventions and Preventative Measures: General 1. Identify risk factors for pressure ulcer development A. change position at least every 2 hours or more frequently if needed 4. When repositioning, reduce friction and shear by lifting rather than dragging 9. Routinely assess and document the condition of the resident's skin per Weekly Skin Report form for any breakdown. 10. Report any signs of a developing pressure ulcer to the physician 11. The care process should include efforts to stabilize, reduce or remove underlying risk factors, to monitor the impact of the interventions and to modify the i interventions as appropriate. Risk Factor: Lowered Mental Awareness a. Choose preventative actions appropriate to individual risk factors and adjust for cognitive impairment of the resident. For example, if the person is chair fast, refer to the specific interventions for that risk factor, adjusting for any limitations in resident's understanding of instructions or ability to participate in preventative actions. Additional Risk Factors that Indicate Resident at Risk: 1. Impaired/decreased mobility and decreased functional ability 5. Resident refusal of some aspects of care or treatment 6. Cognitive impairment 7. A healed ulcer. The history of a healed pressure ulcer and its stage if known is important, since areas of healed Stage 3 or 4 pressure ulcers are more likely to have recurrent breakdown Record review of facility policy titled Pressure Ulcer/Skin breakdown- Clinical Protocol (Revision date (MONTH) 2014) documents the following in part: Assessment and Recognition: 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores . 2. In addition, the nurse shall describe and document/ report the following a. Full assessment of pressure sore including location, stage, length, depth, width, presence of exudates and necrotic tissue b. Pain assessment c. Resident's mobility status d. Current treatments, including support surfaces and e. All active diagnoses 3. 4. The physician will assist the staff to determine etiology of skin alterations Record review of facility policy titled Pressure Ulcer Treatment (Revision date (MONTH) 2013) documents the following in part: Purpose: The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcers. Preparation: 1. Review of the resident's care plan to assess for any special needs of the resident. 2. Review current Braden Scale of facility risk assessment tool. Stage 1 Pressure Ulcer: Intact skin with non-blanchable redness of a localized area usually over a bony prominence . 1. Pressure a. Determine cause of pressure and relieve b. Redistribute pressure and interventions to off load if indicated c. Implement pressure relieving device in accordance with resident's assessed needs d. Evaluate until redness is no longer persistent e. Persistent redness is determined only after pressure has been relieved for at least ¾ of the time it was applied, and the redness remains f. Notify physician, family and appropriate facility personal g. Generate pressure form and complete 4. Immobility: a. Turn schedule b. Restorative Nursing (range of motion, walking, bed mobility) ~ Review of the facility submitted CMS form 672 (Resident Census and Conditions of Residents) dated 05/29/19 confirmed a census of 34.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 2 of 2 residents (R1 and R2) reviewed for neglect in that: R1, who was diagnosed with [REDACTED]. R1 had five falls between 12/01/16 to 04/19/17; however, these falls were not addressed in her care plan. The last fall on 04/15/17 resulted in R1 sustaining a [MEDICAL CONDITION]. R2 was diagnosed with [REDACTED]. R2 had 3 falls between 12/16/17, 02/09/17, and 04/17/17; however, these falls were not addressed in her care plan. This failure affected R1 and R2 and placed the remaining 33 residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . The evidence is as follows: Review of R1's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/01/15 and readmitted [DATE]. This report included R1's [DIAGNOSES REDACTED]. Review of R1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated she scored a 10 on her Brief Interview For Mental Status (BIMS), revealing she was moderately impaired. This report included her Functional Status as needing extensive assistance with one person, who would provide weight-bearing support for bed mobility and transfers; R1 required limited assistance with one staff, who would provide maneuvering of limbs or other non-weight-bearing assistance, when walking in her bedroom or corridor; and R1 required one staff to stabilize, when walking (with assistive device if used). This report indicated she had one fall since her admission (11/01/15). Review of Accident/Incident Report indicated R1 on 12/11/16 was found on the floor by Certified Nurse Aide (C.N.A.) conducting rounds, and R1 sustained a hematoma to forehead, bruise to her upper left arm, and a bruise to her foot. Afterwards R1 was sent to local hospital. Accident/Incident Report dated 12/24/16 indicated R1 sustained a fall and hit her head on concentrator, but no injuries were noted; however, an order for [REDACTED]. R1's hospital report dated 12/24/16 indicated R1 was discharged with order to use walker when getting up, and to follow fall precautions. Accident/Incident Report dated 01/14/17 indicated R1, whose bed alarm was sounding off, was found on the floor of her bedroom, and that's when R1 informed staff she had tripped on her oxygen tubing. This report indicted she was reminded to leave her oxygen tubing intact when going to bathroom. Afterwards R1 had an x-ray, this Radiology Interpretation report dated 01/14/17 indicated she had not sustained a fracture but had moderate joint space narrowing. Accident/Incident Report dated 01/24/17 indicated R1 was found on the floor, and she sustained a skin tear to her left wrist. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 01/24/17 indicated no evidence of fracture; however, she has old fixated [MEDICAL CONDITION] tibia and fibula in near anatomic alignment with arthritis. Accident/Incident Report dated 02/21/17 indicated R1 was found on the floor with blanket tangled up around her, and no injuries were noted. Accident/Incident Report dated 04/15/17 indicated Licensed Vocational Nurse (LVN 1) was walking in the hallway, when he heard a thump noise, and that's when he entered R1's bedroom and found her on the floor. This is when R1 informed LVN 1 she had tripped on her oxygen hose. This report indicated a bed alarm would be obtained, due to R1 being non-complaint with using her call light, and indicated family wanted her to use a long oxygen tube so she could transfer herself to bathroom. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 04/15/17 indicated she had sustained an acute [MEDICAL CONDITIONS] femur, and then sent to hospital where she remained as of 04/20/17. R1's hospital report indicated her [DIAGNOSES REDACTED]. Observation of R1 at the hospital on [DATE] at 6:05 PM indicted she was lying in her bed with her eyes closed, while family member 1, who sat near her, indicated R1 could not be interviewed due to being heavily sedated. Review of R1's Fall Risk Assessment and Interventions dated 12/02/16 indicated she scored a 22, revealing she was at higher risk. This assessment included instructions/recommendation to complete after each fall and according to policy; however, this report was not updated after R1's falls as noted on her Incident/Accident Reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). Review of R1's Physician order [REDACTED].> Review of R1's Care Plan indicated her history of falls was added on 10/03/16, and falls would be decreased within the next 60 day by approaching R1 with assistance when walking to activities, dining room, and so forth; teaching R1 to use call light for assistance; giving R1 verbal reminders not to ambulate or transfer without assistance; and posting signs when floors are wet. This plan indicated R1's muscle wasting and atrophy was added on 10/03/16, and indicated she would be able to ambulate with minimal assistance, and be able to self-propel her wheelchair by the next review date, which would be approached by providing extensive assistance with one person for ambulation and bed mobility, and providing ring of motion exercises and using a wheelchair for mobility. This plan was not updated after R1 sustained falls as documented on her Incident/Accident reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). R1's last fall was on 04/12/16, and as of 04/20/17 R1 was still at the hospital. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. During an interview with LVN 1 on 04/19/17 at 3:45 PM indicated he was working on 04/15/17, when at approximately 7:40 AM he heard a thump sound. LVN 1 indicated he opened R1's bedroom door and that's when he found her lying on the floor with her head against a cabinet. LVN 1 indicted R1 informed him she had tripped on her oxygen cord, and she had pain to her left hip. Afterwards LVN 1 assessed R1, obtained an x-ray order, and then had R1 sent to emergency room . During interviews on 04/19/17 with Certified Nurse Aide (C.N.A.1) and Restorative Aide) at 11:06 AM, Certified Medication Aide (CMA 1) at 11:15 AM, LVN 1 at 3:45 PM, and on 04/20/17 with C.N.A. 3 at 11:09 AM, C.N.A. 4(shower aide) at 11:28 AM, C.N.A. 5 at 11:52 AM, C.N.A. 6 (Activity Director) at 1:41 PM, C.N.A. 7 (Assistant Activity Director) at 2:13 PM, Nurse Aide (NA1) at 2:35 PM, Registered Nurse (RN 1) at 2:55 PM, Director of Nurses at 6:08 PM, and Administrator at 5:45 PM indicted they were aware that R1 had a history of [REDACTED]. Review of R2's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/07/15. This report included R2's [DIAGNOSES REDACTED]. Review of R2's Accident/Incident Report dated 12/16/16 indicated R2 fell out of her wheelchair while bending over to pick something off the floor, and she hit her head on the bed frame, and recommendations were not listed. Accident/Incident Report dated 02/09/17 indicated R2 was discovered by C.N.A. to have a skin tear to her left leg, which required steri strips, and recommendation was for steri strips. Accident Incident Report dated 04/17/17 indicated another resident alerted staff that R2 had fallen onto the floor, that's when R2 was found on her left side in front of her wheelchair. Recommendation on 04/17/17 report indicated to continue to remind R2 not to bend over to pick up objects off the floor, and monitor R2 during snack times so she does not drop her food. Review of R2's Care Plan indicated that on 08/02/16 she required one person with extensive assistance for all transfers, and active range of motion. This plan addressed on 08/02/16 her risk for falls, and should be referred for physical therapy evaluation, restorative nursing program, assist her with extensive assistance with transfers, keep call light within reach, and use a wheelchair for mobility. This plan was reviewed on 11/03/16, but not after R2's falls as noted on her Accident/Incident Reports dated 12/16/16, 02/09/17, and 04/17/17. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. Interview with DON on 04/20/17 at 6:08 PM indicated she has been the backup Minimum Data Set coordinator for Care Plans; however, she had not updated R1 or R2's Care Plans after they had noted documented falls on Incident/Accident reports to reevaluate possible interventions to prevent falls. Further interview with DON indicated she was aware that R1 was not compliant with using her call light and walker, and that R1 had tripped over her oxygen hose. Review of facility's Provider Letter No. 14-13 for abuse and neglect dated 08/19/14, defined neglect as The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. Review of facility's policy for Falls dated April 2013 indicated residents falls would be assessed, determine cause identification, provided treatment/management intervention to prevent subsequent fall and risk of serious injuries, and then monitor and follow-up as needed. Review of facility's policy for Fall and Fall Risk, Managing dated December 2007 indicated that based on previous evaluations and current data, staff would identify intervention related to resident's specific risks and causes to try to prevent the resident from falling, and to minimize complications of from falling. Review of facility's current Care Plan policy (not dated) indicated it should address any physical issues, and/or care needs of the residents. Review of facility's CMS-802 indicted a current census of 37, but two of these residents were at the hospital.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent neglect for 2 of 2 Residents (R1 and R2) reviewed for abuse/neglect. R1, who was diagnosed with [REDACTED]. R1 had five falls between 12/01/16 to 04/19/17; however, these falls were not addressed in her care plan. The last fall on 04/15/17 resulted in R1 sustaining a [MEDICAL CONDITION]. R2 was diagnosed with [REDACTED]. R2 had 3 falls between 12/16/17, 02/09/17, and 04/17/17; however, these falls were not addressed in her care plan. This failure affected R1 and R2 and placed the remaining 33 residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . The evidence is as follows: Review of R1's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/01/15 and readmitted [DATE]. This report included R1's [DIAGNOSES REDACTED]. Review of R1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated she scored a 10 on her Brief Interview For Mental Status (BIMS), revealing she was moderately impaired. This report included her Functional Status as needing extensive assistance with one person, who would provide weight-bearing support for bed mobility and transfers; R1 required limited assistance with one staff, who would provide maneuvering of limbs or other non-weight-bearing assistance, when walking in her bedroom or corridor; and R1 required one staff to stabilize, when walking (with assistive device if used). This report indicated she had one fall since her admission (11/01/15). Review of Accident/Incident Report indicated R1 on 12/11/16 was found on the floor by Certified Nurse Aide (C.N.A.) conducting rounds, and R1 sustained a hematoma to forehead, bruise to her upper left arm, and a bruise to her foot. Afterwards R1 was sent to local hospital. Accident/Incident Report dated 12/24/16 indicated R1 sustained a fall and hit her head on concentrator, but no injuries were noted; however, an order for [REDACTED]. R1's hospital report dated 12/24/16 indicated R1 was discharged with order to use walker when getting up, and to follow fall precautions. Accident/Incident Report dated 01/14/17 indicated R1, whose bed alarm was sounding off, was found on the floor of her bedroom, and that's when R1 informed staff she had tripped on her oxygen tubing. This report indicted she was reminded to leave her oxygen tubing intact when going to bathroom. Afterwards R1 had an x-ray, this Radiology Interpretation report dated 01/14/17 indicated she had not sustained a fracture but had moderate join space narrowing. Accident/Incident Report dated 01/24/17 indicated R1 was found on the floor, and she sustained a skin tear to her left wrist. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 01/24/17 indicated no evidence of fracture; however, she has old fixated [MEDICAL CONDITION] tibia and fibula in near anatomic alignment with arthritis. Accident/Incident Report dated 02/21/17 indicated R1 was found on the floor with blanket tangled up around her, and no injuries were noted. Accident/Incident Report dated 04/15/17 indicated Licensed Vocational Nurse (LVN 1) was walking in the hallway, when he heard a thump noise, and that's when he entered R1's bedroom and found her on the floor. This is when R1 informed LVN 1 she had tripped on her oxygen hose. This report indicated a bed alarm would be obtained, due to R1 being non-complaint with using her call light, and indicated family wanted her to use a long oxygen tube so she could transfer herself to bathroom. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 04/15/17 indicated she had sustained an acute [MEDICAL CONDITIONS] femur, and then sent to hospital where she remained as of 04/20/17. R1's hospital report indicated her [DIAGNOSES REDACTED]. Observation of R1 at the hospital on [DATE] at 6:05 PM indicted she was lying in her bed with her eyes closed, while family member 1, who sat near her, indicated R1 could not be interviewed due to being heavily sedated. Review of R1's Fall Risk Assessment and Interventions dated 12/02/16 indicated she scored a 22, revealing she was at higher risk. This assessment included instructions/recommendation to complete after each fall and according to policy; however, this report was not updated after R1's falls as noted on her Incident/Accident Reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). Review of R1's Physician order [REDACTED].> Review of R1's Care Plan indicated her history of falls was added on 10/03/16, and falls would be decreased within the next 60 day by approaching R1 with assistance when walking to activities, dining room, and so forth; teaching R1 to use call light for assistance; giving R1 verbal reminders not to ambulate or transfer without assistance; and posting signs when floors are wet. This plan indicated R1's muscle wasting and atrophy was added on 10/03/16, and indicated she would be able to ambulate with minimal assistance, and be able to self-propel her wheelchair by the next review date, which would be approached by providing extensive assistance with one person for ambulation and bed mobility, and providing ring of motion exercises and using a wheelchair for mobility. This plan was not updated after R1 sustained falls as documented on her Incident/Accident reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). R1's last fall was on 04/12/16, and as of 04/20/17 R1 was still at the hospital. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. During an interview with LVN 1 on 04/19/17 at 3:45 PM indicated he was working on 04/15/17, when at approximately 7:40 AM he heard a thump sound. LVN 1 indicated he opened R1's bedroom door and that's when he found her lying on the floor with her head against a cabinet. LVN 1 indicted R1 informed him she had tripped on her oxygen cord, and she had pain to her left hip. Afterwards LVN 1 assessed R1, obtained an x-ray order, and then had R1 sent to emergency room . During interviews on 04/19/17 with Certified Nurse Aide (C.N.A.1) and Restorative Aide) at 11:06 AM, Certified Medication Aide (CMA 1) at 11:15 AM, LVN 1 at 3:45 PM, and on 04/20/17 with C.N.A. 3 at 11:09 AM, C.N.A. 4(shower aide) at 11:28 AM, C.N.A. 5 at 11:52 AM, C.N.A. 6 (Activity Director) at 1:41 PM, C.N.A. 7 (Assistant Activity Director) at 2:13 PM, Nurse Aide (NA1) at 2:35 PM, Registered Nurse (RN 1) at 2:55 PM, Director of Nurses at 6:08 PM, and Administrator at 5:45 PM indicted they were aware that R1 had a history of [REDACTED]. Review of R2's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/07/15. This report included R2's [DIAGNOSES REDACTED]. Review of R2's Accident/Incident Report dated 12/16/16 indicated R2 fell out of her wheelchair while bending over to pick something off the floor, and she hit her head on the bed frame, and recommendations were not listed. Accident/Incident Report dated 02/09/17 indicated R2 was discovered by C.N.A. to have a skin tear to her left leg, which required steri strips, and recommendation was for steri strips. Accident Incident Report dated 04/17/17 indicated another resident alerted staff that R2 had fallen onto the floor, that's when R2 was found on her left side in front of her wheelchair. Recommendation on 04/17/17 report indicated to continue to remind R2 not to bend over to pick up objects off the floor, and monitor R2 during snack times so she does not drop her food. Review of R2's Care Plan indicated that on 08/02/16 she required one person with extensive assistance for all transfers, and active range of motion. This plan addressed on 08/02/16 her risk for falls, and should be referred for physical therapy evaluation, restorative nursing program, assist her with extensive assistance with transfers, keep call light within reach, and use a wheelchair for mobility. This plan was reviewed on 11/03/16, but not after R2's falls as noted on her Accident/Incident Reports dated 12/16/16, 02/09/17, and 04/17/17. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. Interview with DON on 04/20/17 at 6:08 PM indicated she has been the backup Minimum Data Set coordinator for Care Plans; however, she had not updated R1 or R2's Care Plans after they had noted documented falls on Incident/Accident reports to reevaluate possible interventions to prevent falls. Further interview with DON indicated she was aware that R1 was not compliant with using her call light and walker, and that R1 had tripped over her oxygen hose. Review of facility's policy for Falls dated April 2013 indicated residents falls would be assessed, determine cause identification, provided treatment/management intervention to prevent subsequent fall and risk of serious injuries, and then monitor and follow-up as needed. Review of facility's policy for Fall and Fall Risk, Managing dated December 2007 indicated that based on previous evaluations and current data, staff would identify intervention related to resident's specific risks and causes to try to prevent the resident from falling, and to minimize complications of from falling. Review of facility's current Care Plan policy (not dated) indicated it should address any physical issues, and/or care needs of the residents. Review of facility's CMS-802 indicted a current census of 37, but two of these residents were at the hospital.

Based on record review and interview, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each fall for 1 of 2 residents (R1) whose comprehensive care plans and assessments were reviewed in that: R1 has a total of 5 falls between 12/11/16 and 02/21/17. Then on 04/15/17 R1 fell and sustained a [MEDICAL CONDITION], and as of 04/20/17 she was still at the hospital. R1's care plan was not updated to indicate she had falls after 10/06/16, and was not updated with appropriate interventions to prevent any further falls and serious injuries, or reflect the numerous falls and injuries sustained. R2 had 3 falls between 12/16/16, 02/09/17 and 04/17/17; however, these falls were not addressed in her care plan. This deficient practice could affect 33 residents at the facility who could result in a fall, serious injury, and declining health. The evidence is as follows: Review of R1's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/01/15 and readmitted [DATE]. This report included R1's [DIAGNOSES REDACTED]. Review of R1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated she scored a 10 on her Brief Interview For Mental Status (BIMS), revealing she was moderately impaired. This report included her Functional Status as needing extensive assistance with one person, who would provide weight-bearing support for bed mobility and transfers; R1 required limited assistance with one staff, who would provide maneuvering of limbs or other non-weight-bearing assistance, when walking in her bedroom or corridor; and R1 required one staff to stabilize, when walking (with assistive device if used). This report indicated she had one fall since her admission (11/01/15). Review of Accident/Incident Report indicated R1 on 12/11/16 was found on the floor by Certified Nurse Aide (C.N.A.) conducting rounds, and R1 sustained a hematoma to forehead, bruise to her upper left arm, and a bruise to her foot. Afterwards R1 was sent to local hospital. Accident/Incident Report dated 12/24/16 indicated R1 sustained a fall and hit her head on concentrator, but no injuries were noted; however, an order for [REDACTED]. R1's hospital report dated 12/24/16 indicated R1 was discharged with order to use walker when getting up, and to follow fall precautions. Accident/Incident Report dated 01/14/17 indicated R1, whose bed alarm was sounding off, was found on the floor of her bedroom, and that's when R1 informed staff she had tripped on her oxygen tubing. This report indicted she was reminded to leave her oxygen tubing intact when going to bathroom. Afterwards R1 had an x-ray, this Radiology Interpretation report dated 01/14/17 indicated she had not sustained a fracture but had moderate join space narrowing. Accident/Incident Report dated 01/24/17 indicated R1 was found on the floor, and she sustained a skin tear to her left wrist. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 01/24/17 indicated no evidence of fracture; however, she has old fixated [MEDICAL CONDITION] tibia and fibula in near anatomic alignment with arthritis. Accident/Incident Report dated 02/21/17 indicated R1 was found on the floor with blanket tangled up around her, and no injuries were noted. Accident/Incident Report dated 04/15/17 indicated Licensed Vocational Nurse (LVN 1) was walking in the hallway, when he heard a thump noise, and that's when he entered R1's bedroom and found her on the floor. This is when R1 informed LVN 1 she had tripped on her oxygen hose. This report indicated a bed alarm would be obtained, due to R1 being non-complaint with using her call light, and indicated family wanted her to use a long oxygen tube so she could transfer herself to bathroom. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 04/15/17 indicated she had sustained an acute [MEDICAL CONDITIONS] femur, and then sent to hospital where she remained as of 04/20/17. R1's hospital report indicated her [DIAGNOSES REDACTED]. Observation of R1 at the hospital on [DATE] at 6:05 PM indicted she was lying in her bed with her eyes closed, while family member 1 who sat near her, indicated could not be interviewed due to being heavily sedated. Review of R1's Fall Risk Assessment and Interventions dated 12/02/16 indicated she scored a 22, revealing she was at higher risk. This assessment included instructions/recommendation to complete after each fall and according to policy; however, this report was not updated after R1's falls as noted on her Incident/Accident Reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). Review of R1's Physician order [REDACTED].> Review of R1's Care Plan indicated her history of falls was added on 10/03/16, and falls would be decreased within the next 60 day by approaching R1 with assistance when walking to activities, dining room, and so forth; teaching R1 to use call light for assistance; giving R1 verbal reminders not to ambulate or transfer without assistance; and posting signs when floors are wet. This plan indicated R1's muscle wasting and atrophy was added on 10/03/16, and indicated she would be able to ambulate with minimal assistance, and be able to self-propel her wheelchair by the next review date, which would be approached by providing extensive assistance with one person for ambulation and bed mobility, and providing ring of motion exercises and using a wheelchair for mobility. This plan was not updated after R1 sustained falls as documented on her Incident/Accident reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). R1's last fall was on 04/12/16, and as of 04/20/17 R1 was still at the hospital. During an interview with LVN 1 on 04/19/17 at 3:45 PM indicated he was working on 04/15/17, when at approximately 7:40 AM he heard a thump sound. LVN 1 indicated he opened R1's bedroom door and that's when he found her lying on the floor with her head against a cabinet. LVN 1 indicted R1 informed him she had tripped on her oxygen cord, and she had pain to her left hip. Afterwards LVN 1 assessed R1, obtained an x-ray order, and then had R1 sent to emergency room . During interviews on 04/19/17 with Certified Nurse Aide (C.N.A.1) and Restorative Aide) at 11:06 AM, Certified Medication Aide (CMA 1) at 11:15 AM, LVN 1 at 3:45 PM, and on 04/20/17 with C.N.A. 3 at 11:09 AM, C.N.A. 4(shower aide) at 11:28 AM, C.N.A. 5 at 11:52 AM, C.N.A. 6 (Activity Director) at 1:41 PM, C.N.A. 7 (Assistant Activity Director) at 2:13 PM, Nurse Aide (NA1) at 2:35 PM, Registered Nurse (RN 1) at 2:55 PM, Director of Nurses at 6:08 PM, and Administrator at 5:45 PM indicted they were aware that R1 had a history of [REDACTED]. Review of R2's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/07/15. This report included R2's [DIAGNOSES REDACTED]. Review of R2's Accident/Incident Report dated 12/16/16 indicated R2 fell out of her wheelchair while bending over to pick something off the floor, and she hit her head on the bed frame, and recommendations were not listed. Accident/Incident Report dated 02/09/17 indicated R2 was discovered by C.N.A. to have a skin tear to her left leg, which required steri strips, and recommendation was for steri strips. Accident Incident Report dated 04/17/17 indicated another resident alerted staff that R2 had fallen onto the floor, that's when R2 was found on her left side in front of her wheelchair. Recommendation on 04/17/17 report indicated to continue to remind R2 not to bend over to pick up objects off the floor, and monitor R2 during snack times so she does not drop her food. Review of R2's Care Plan indicated that on 08/02/16 she required one person with extensive assistance for all transfers, and active range of motion. This plan addressed on 08/02/16 her risk for falls, and should be referred for physical therapy evaluation, restorative nursing program, assist her with extensive assistance with transfers, keep call light within reach, and use a wheelchair for mobility. This plan was reviewed on 11/03/16, but not after R2's falls as noted on her Accident/Incident Reports dated 12/16/16, 02/09/17, and 04/17/17. Interview with DON on 04/20/17 at 6:08 PM indicated she has been the backup Minimum Data Set coordinator for Care Plans; however, she had not updated R1 or R2's Care Plans after they had noted documented falls on Incident/Accident reports. Further interview with DON indicated she was aware that R1 was not compliant with using her call light and walker, and that R1 had tripped over her oxygen hose. Review of facility's policy for Falls dated April 2013 indicated residents falls would be assessed, determine cause identification, provided treatment/management intervention to prevent subsequent fall and risk of serious injuries, and then monitor and follow-up as needed. Review of facility's policy for Fall and Fall Risk, Managing dated December 2007 indicated that based on previous evaluations and current data, staff would identify intervention related to resident's specific risks and causes to try to prevent the resident from falling, and to minimize complications of from falling. Review of facility's Care Plan policy (undated) indicated it should address any physical issues, and/or care needs of the residents. Review of facility's CMS-802 indicted a current census of 37, but two of these residents were at the hospital.

Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 2 of 2 residents (R1 and R2) reviewed for accidents in that: R1, who was diagnosed with [REDACTED]. R1 had five falls between 12/01/16 to 04/19/17; however, these falls were not addressed in her care plan. The last fall on 04/15/17 resulted in R1 sustaining a hip fracture. R2 was diagnosed with [REDACTED]. R2 had 3 falls between 12/16/17, 02/09/17, and 04/17/17; however, these falls were not addressed in her care plan. This failure affected R1 and R2 and placed the remaining 33 residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization . The evidence is as follows: Review of R1's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/01/15 and readmitted [DATE]. This report included R1's [DIAGNOSES REDACTED]. Review of R1's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated she scored a 10 on her Brief Interview For Mental Status (BIMS), revealing she was moderately impaired. This report included her Functional Status as needing extensive assistance with one person, who would provide weight-bearing support for bed mobility and transfers; R1 required limited assistance with one staff, who would provide maneuvering of limbs or other non-weight-bearing assistance, when walking in her bedroom or corridor; and R1 required one staff to stabilize, when walking (with assistive device if used). This report indicated she had one fall since her admission (11/01/15). Review of Accident/Incident Report indicated R1 on 12/11/16 was found on the floor by Certified Nurse Aide (C.N.A.) conducting rounds, and R1 sustained a hematoma to forehead, bruise to her upper left arm, and a bruise to her foot. Afterwards R1 was sent to local hospital. Accident/Incident Report dated 12/24/16 indicated R1 sustained a fall and hit her head on concentrator, but no injuries were noted; however, an order for [REDACTED]. Afterwards R1 was sent to local hospital. R1's hospital report dated 12/24/16 indicated R1 was discharged with order to use walker when getting up, and to follow fall precautions. Accident/Incident Report dated 01/14/17 indicated R1, whose bed alarm was sounding off, was found on the floor of her bedroom, and that's when R1 informed staff she had tripped on her oxygen tubing. This report indicted she was reminded to leave her oxygen tubing intact when going to bathroom. Afterwards R1 had an x-ray, this Radiology Interpretation report dated 01/14/17 indicated she had not sustained a fracture but had moderate join space narrowing. Accident/Incident Report dated 01/24/17 indicated R1 was found on the floor, and she sustained a skin tear to her left wrist. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 01/24/17 indicated no evidence of fracture; however, she has old fixated fracture of the distal tibia and fibula in near anatomic alignment with arthritis. Accident/Incident Report dated 02/21/17 indicated R1 was found on the floor with blanket tangled up around her, and no injuries were noted. Accident/Incident Report dated 04/15/17 indicated Licensed Vocational Nurse (LVN 1) was walking in the hallway, when he heard a thump noise, and that's when he entered R1's bedroom and found her on the floor. This is when R1 informed LVN 1 she had tripped on her oxygen hose. This report indicated a bed alarm would be obtained, due to R1 being non-complaint with using her call light, and indicated family wanted her to use a long oxygen tube so she could transfer herself to bathroom. Afterwards R1 had an x-ray, and Radiology Interpretation report dated 04/15/17 indicated she had sustained an acute fracture of the intertrochanteric fracture of the left femur, and then sent to hospital where she remained as of 04/20/17. R1's hospital report indicated her [DIAGNOSES REDACTED]. Observation of R1 at the hospital on [DATE] at 6:05 PM indicted she was lying in her bed with her eyes closed, while family member 1, who sat near her, indicated R1 could not be interviewed due to being heavily sedated. Review of R1's Fall Risk Assessment and Interventions dated 12/02/16 indicated she scored a 22, revealing she was at higher risk. This assessment included instructions/recommendation to complete after each fall and according to policy; however, this report was not updated after R1's falls as noted on her Incident/Accident Reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). Review of R1's Physician order [REDACTED]. Review of R1's Care Plan indicated her history of falls was added on 10/03/16, and falls would be decreased within the next 60 day by approaching R1 with assistance when walking to activities, dining room, and so forth; teaching R1 to use call light for assistance; giving R1 verbal reminders not to ambulate or transfer without assistance; and posting signs when floors are wet. This plan indicated R1's muscle wasting and atrophy was added on 10/03/16, and indicated she would be able to ambulate with minimal assistance, and be able to self-propel her wheelchair by the next review date, which would be approached by providing extensive assistance with one person for ambulation and bed mobility, and providing ring of motion exercises and using a wheelchair for mobility. This plan was not updated after R1 sustained falls as documented on her Incident/Accident reports (dated 12/11/16, 12/24/16, 01/14/17, 01/24/17 and 02/21/17). R1's last fall was on 04/12/16, and as of 04/20/17 R1 was still at the hospital. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. During an interview with LVN 1 on 04/19/17 at 3:45 PM indicated he was working on 04/15/17, when at approximately 7:40 AM he heard a thump sound. LVN 1 indicated he opened R1's bedroom door and that's when he found her lying on the floor with her head against a cabinet. LVN 1 indicted R1 informed him she had tripped on her oxygen cord, and she had pain to her left hip. Afterwards LVN 1 assessed R1, obtained an x-ray order, and then had R1 sent to emergency room . During interviews on 04/19/17 with Certified Nurse Aide (C.N.A.1) and Restorative Aide) at 11:06 AM, Certified Medication Aide (CMA 1) at 11:15 AM, LVN 1 at 3:45 PM, and on 04/20/17 with C.N.A. 3 at 11:09 AM, C.N.A. 4(shower aide) at 11:28 AM, C.N.A. 5 at 11:52 AM, C.N.A. 6 (Activity Director) at 1:41 PM, C.N.A. 7 (Assistant Activity Director) at 2:13 PM, Nurse Aide (NA1) at 2:35 PM, Registered Nurse (RN 1) at 2:55 PM, Director of Nurses at 6:08 PM, and Administrator at 5:45 PM indicted they were aware that R1 had a history of [REDACTED]. Review of R2's current Face Sheet indicated she was an [AGE] year-old female, who was admitted into this facility on 11/07/15. This report included R2's [DIAGNOSES REDACTED]. Review of R2's Accident/Incident Report dated 12/16/16 indicated R2 fell out of her wheelchair while bending over to pick something off the floor, and she hit her head on the bed frame, and recommendations were not listed. Accident/Incident Report dated 02/09/17 indicated R2 was discovered by C.N.A. to have a skin tear to her left leg, which required steri strips, and recommendation was for steri strips. Accident Incident Report dated 04/17/17 indicated another resident alerted staff that R2 had fallen onto the floor, that's when R2 was found on her left side in front of her wheelchair. Recommendation on 04/17/17 report indicated to continue to remind R2 not to bend over to pick up objects off the floor, and monitor R2 during snack times so she does not drop her food. Review of R2's Care Plan indicated that on 08/02/16 she required one person with extensive assistance for all transfers, and active range of motion. This plan addressed on 08/02/16 her risk for falls, and should be referred for physical therapy evaluation, restorative nursing program, assist her with extensive assistance with transfers, keep call light within reach, and use a wheelchair for mobility. This plan was reviewed on 11/03/16, but not after R2's falls as noted on her Accident/Incident Reports dated 12/16/16, 02/09/17, and 04/17/17. Facility failed to show evidence that these incidents of falls were reevaluated to determine possible interventions to prevent further falls. Interview with DON on 04/20/17 at 6:08 PM indicated she has been the backup Minimum Data Set coordinator for Care Plans; however, she had not updated R1 or R2's Care Plans after they had noted documented falls on Incident/Accident reports to reevaluate possible interventions to prevent falls. Further interview with DON indicated she was aware that R1 was not compliant with using her call light and walker, and that R1 had tripped over her oxygen hose. Review of facility's policy for Falls dated April 2013 indicated residents falls would be assessed, determine cause identification, provided treatment/management intervention to prevent subsequent fall and risk of serious injuries, and then monitor and follow-up as needed. Review of facility's policy for Fall and Fall Risk, Managing dated December 2007 indicated that based on previous evaluations and current data, staff would identify intervention related to resident's specific risks and causes to try to prevent the resident from falling, and to minimize complications of from falling. Review of facility's current Care Plan policy (not dated) indicated it should address any physical issues, and/or care needs of the residents. Review of facility's CMS-802 indicted a current census of 37, but two of these residents were at the hospital.