Every finding on record at Riverview Post Acute

Based on policy review, employee list review, and interview, the facility failed to offer COVID-19 vaccinations to employees after February 2025, which had the potential to affect 76 of 76 residents that were residing in the facility. The findings include: Review of the facility policy titled, Employee Immunization and Vaccination Status, dated January 2024, revealed .Employees are offered or provided with immunization/vaccinations per state or local agency policies/regulations. Review of the employee list dated 1/14/2026 revealed 45 employees were hired from 2/2025 to 1/14/2026. The facility was unable to provide documentation that employees hired from 2/2025 to 1/14/2026 were offered the COVID vaccine. During an interview on 1/14/2026 at 8:30 AM, the Infection Control Preventionist (ICP) was asked if the COVID vaccine was offered to staff. The ICP stated, We do not offer the COVID vaccine to employees. We only educate them if a new vaccine is available .the vaccine was no longer offered to staff beginning in February 2025 .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) B and LPN C) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 25 opportunities, resulting in a medication error rate of 8%. The findings include: 1. Review of facility policy titled, Medication Administration, .Residents shall receive medications according to safe standards of practice.Medications are prepared and administered according to the following: right medication, right dose, right time, right person, right route, right position, right texture and right documentation.Prior to administration, the medication and dosage schedule on the resident's MAR (medication administration record) is compared with the medication label. If the label and MAR are different, stop and compare to physician's orders. Seek further clarification as needed. 2. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE], with diagnoses including Heart Failure and Enterococcus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed that the MDS had not been exported. Review of the Physician's Orders dated 1/2/2026, revealed .cefTRIAXone Sodium [an antibiotic used to treat bacterial infections] Intravenous [by way of a vein] Solution Reconstituted 2 GM [Gram].Use 2 gram intravenously two times a day for ENTEROCOCCUS AS THE CAUSE OF DISEASES CLASSIFIED ELSEWHERE (until 2/5/2026). Review of the medication label dated 1/8/2026, revealed .[Resident #26].CEFTRIAXONE INJ [injection] 2GM.INFUSE 1 BAG (2GM/100ML [milliliter]) INTRAVENOUSLY OVER 30 MINUTES TWICE A DAY UNTIL 2/5/2026. Observation in Resident #26 room on 1/13/2026 at 1:50 PM, revealed Licensed Practical Nurse (LPN) C prepared ceftriaxone sodium intravenous solution in 100ml sodium chloride [salt based additive solution used with IV medications] 0.9% (percent), set infusion pump to infuse at 100ml/hr (hour) for a total volume to infuse of 100 ml. LPN C administered the medication to Resident #26 resulting in the medication to be infused over 1 hour. During an interview on 1/13/2026 at 2:48 PM, LPN C was asked what the order or directions were for the ceftriaxone sodium intravenous solution to infuse at. LPN C stated .He only gets Rocephin (Ceftriaxone) once a day, the ampicillin [antibiotic medication used for infections] has a rate of 100ml/hr so we are running them both at 100ml/hr. LPN C was asked if the Physician Order should have a rate to infuse the medication. LPN C stated, Rocephin don't. LPN C then went to clarify with the Assistant Director of Nursing (ADON). LPN C returned with the medication label for Resident #26's ceftriaxone sodium intravenous solution and stated it should have been infused over 30 minutes per the medication label. Review of the Progress Note dated 1/13/2026 at 15:33 PM, revealed pt [patient] have 2 different antibiotic ( cefTRIAXone Sodium Intravenous Solution Reconstituted 2 GM and Ampicillin Sodium Intravenous Solution Reconstituted 2 GM ). Ampicillin is to be run over an hour according to the MAR and ceftriaxone did not have the rate on the MAR but it was on the bag to be run over 30 min. Both meds [medications] were run at the rate of an hour; med error was reported to NP [Nurse Practitioner] and was told there is nothing to monitor. Supervisor made aware. No adverse effect noted or reported. 3. Review of the medical record revealed Resident #59 was admitted to the facility on [DATE], with diagnoses including Heart Failure, Diabetes, and Peripheral Vascular Disease. Review of the quarterly MDS assessment dated [DATE], revealed Resident #59 scored a 13 on the BIMS assessment, which indicated she was cognitively intact. Resident #59 was assessed for the use of an antiplatelet [medication used to prevent blood clots or prevent heart attaches]. Review of the Physician's Orders dated 10/31/2025, revealed .Aspirin [medication used to thin the blood to prevent clots or heart attach] Tablet Chewable 81 MG [milligram] Give 1 tablet by mouth one time a day. Observation in Resident #59's room on 1/13/2025 at 8:34 AM, LPN B administered Aspirin 81 mg EC (Enteric Coated). During an interview on 1/14/2026 at 11:41 AM, the Director of Nursing (DON) was asked if staff should administer medications at the prescribed rate and in the correct form prescribed by the physician. The DON stated, Yes.

Based on facility policy review, medical record review, and interview, the facility failed to provide Advance Beneficiary Notice of Medicare Non-Coverage for 3 of 3 (Resident #20, #82, and #83) sampled residents reviewed for Advanced Beneficiary Notice. The findings include: 1. Review of the facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 9/2024, revealed .A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely.Written notices of the likelihood of Medicare payment denial are provided to the resident/beneficiary.as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made and before the item of service is furnished.far enough in advance of an event.so that the beneficiary can make a rational, informed decision without undue pressure. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with diagnoses including Pneumonia, Chronic Obstructive Pulmonary Disease (COPD), Hypertension, and Diabetes. Review of the facility's Notice of Medicare Non-Coverage, form revealed that Resident #20's last covered day was 12/23/2025. The form was signed on 12/23/2025. The facility failed to provide Resident #20 advanced notification of Medicare coverage ending far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. 3. Review of the medical record revealed Resident #82 was admitted to the facility on [DATE], with diagnoses including Amputation of Lower Limb, Abscess of Lower Limb, Gout, and Hypertension. Review of the facility's Notice of Medicare Non-Coverage, form revealed that Resident #82's last covered day was 11/5/2025. The from was signed on 11/5/2025. The facility failed to provide Resident #82's representative advanced notification of Medicare coverage ending far enough in advance that the beneficiary or representative has time to consider the options and make an informed choice. 4. Review of the medical record revealed Resident #83 was admitted to the facility on [DATE] with diagnoses including Pneumonia, Hypertension, and COPD. Review of the facility's Notice of Medicare Non-Coverage, form revealed that Resident #83's last covered day was 9/6/2025. The form was signed on 9/5/2026. The facility failed to provide Resident #83's representative with notification of Medicare coverage ending far enough in advance that the beneficiary or representative had time to consider the options and make an informed choice. During an interview on 1/14/2026 at 9:16 AM, the Social Services Director (SSD) was asked when notices at end of Medicare services should be given. The SSD stated, We usually give them 72-hour notice. The SSD was asked if the notice of end of Medicare services was given 72 hours before coverage ended. SSD stated, No.

Based on facility policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (Licensed Practical Nurse (LPN) B left a medication cart unsecured and unattended. The findings include: Review of the facility policy titled, Storage of Medications, dated 11/2020, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Drugs and biologicals used in the facility are stored in locked compartments.Only persons authorized to prepare and administer medications have access to locked medications.Compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Review of the facility policy titled, Medication Administration, dated 7/1/2025, revealed .The medication cart should always be locked when not attended by nurse. During an observation and interview on the 600 Hall on 1/13/2026 at 1:18 PM, LPN B walked away from the 600 Hall F/Bottom Medication Cart and walked into a resident's room out of sight of the surveyor and unsecured medication cart while the Surveyor was performing a medication cart inspection. LPN B was asked if they should have left the Surveyor alone with the medication cart unsecured and unsupervised. LPN B stated No, I should not have, but you are State. During an interview on 1/14/2026 at 11:41 AM, the Director of Nursing (DON) was asked if medication carts should be locked and secured at all times when unattended. The DON stated Yes. The DON was asked if a nurse should leave a medication cart unsecure and unattended while a Surveyor performed a medication cart inspection. The DON stated No, not if they were out of sight of the cart.

Based on policy review, observation and interview, 2 of 8 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to distribute and serve food in a sanitary manner during dining when they did not perform hand hygiene between serving residents and after touching contaminated surfaces. The findings include: Review of the facility's policy titled, Hand Hygiene Policy, revised 4/14/2020, revealed .Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .If hands are not visibly soiled, use an alcohol-based hand rub . Review of the facility's policy titled, Infection Prevention and Control Program, revised 4/10/2021, revealed .Hand Hygiene Protocol .All staff shall perform hand hygien [hygiene] when coming on duty, between resident contacts, after handling contaminated objects, after PPE [Personal Protective Equipment: isolation gowns, gloves, masks, shields] removal .Staff shall perform hand hygiene before and after performing resident care procedures . Observation outside of the resident's isolation room on 6/14/2021 at 7:39 AM, revealed CNA #1 donned gloves, gown, and a face shield and entered Resident #200's isolation room. CNA #1 delivered a breakfast tray, and removed the PPE in the room. CNA #1 did not perform hand hygiene after removing the PPE. Observation in the resident's room on 6/14/2021 at 8:00 AM, revealed CNA #1 placed a breakfast meal tray on the overbed table, removed the lid from the plate, touched the curtain to move it, raised the head of the bed, moved the overbed table, turned on the light, and touched Resident #11's pillow. CNA #1 proceeded to open the milk, touch the straw, opened the sugar packet and poured it in the oatmeal, opened the jelly, stirred the oatmeal and handed the fork and spoon to Resident #11. CNA #1 did not perform hand hygiene between touching contaminated objects in the room and assisting Resident #11 with her breakfast. Observation in the resident's room on 6/14/2021 at 8:05 AM, revealed CNA #2 entered Resident #32's room with a breakfast tray and placed it on the overbed table. CNA #2 touched the bed, the bed linens, and used the bed control to adjust the head of the bed. CNA #2 then proceeded to set up the breakfast tray for Resident #32, opening cartons and handling the silverware and other items on the tray. CNA #2 failed to perform hand hygiene between touching the contaminated surfaces in the room and setting up the breakfast tray. CNA #2 left Resident #32's room, did not perform hand hygiene, obtained another tray, entered Resident #13's room and set up the breakfast tray, opening cartons and handling the silverware and other items on the tray. CNA #2 did not perform hand hygiene between serving Resident #32 and Resident #13. Observation in the resident's room on 6/15/2021 at 12:25 PM, revealed CNA #2 set up a lunch tray for Resident #8. CNA #2 left the room, passed 2 wall mounted alcohol based hand rub dispensers and did not perform hand hygiene. CNA #2 walked to the kitchen, stood inside an alcove outside the kitchen door, handled her personal phone and touched the screen, went into the kitchen and came out with a lunch tray. She carried the tray to Resident #22's room and placed it on the overbed table. CNA #2 touched the foot of the bed, raised the head of the bed with the controller, placed a towel on Resident #22, walked out of the room, passed 2 alcohol based hand rub dispensers, obtained a cup from a medication cart, walked back to the room passing 2 alcohol based hand rub dispensers, without performing hand hygiene at any time. CNA #2 went back into Resident #22's room, touched a chair and positioned it beside Resident #22, pulled up the overbed table and began to touch all the items on the lunch tray as she assisted Resident #22 to eat lunch. CNA #2 failed to perform hand hygiene between Resident #8 and Resident #22, and failed to perform hand hygiene between touching contaminated objects and assisting Resident #22 to eat lunch. During an interview on 6/16/2021 at 5:17 PM, the Infection Control Preventionist (ICP) was asked about the process for delivering a meal tray to an isolation room. She stated staff should put on the PPE outside the room, take the tray in the room, remove the PPE and discard in the trash in the room, and then perform hand hygiene. She confirmed that staff should perform hand hygiene between every resident encounter, after they have touched contaminated objects, and before they assist a resident with a meal or set up a meal.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when staff failed to ensure 1 of 1 newly admitted residents (Resident #202) was placed in isolation on admission, when 1 of 8 staff members (Certified Nursing Assistant #1) failed to properly dispose of disposable Personal Protective Equipment, and when 2 of 2 isolation rooms (Isolation room [ROOM NUMBER] and Isolation room [ROOM NUMBER]) had trash overflowing and was spilling onto the floor. The findings include: Review of the facility's undated policy titled, New Admissions/LOA [Leave of Absence] Instructions, revealed .New admissions .will be placed in yellow zone [isolation] for at least 14 days to continue to monitor for s/s [signs and symptoms] of COVID-19. However if a resident has been fully vaccinated for COVID-19 .they do not have to be placed in isolation on the yellow zone . Review of the medical record, revealed Resident #202 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an Immediate 48 hour Care Plan dated 6/11/2021, revealed Contact/Droplet isolation precautions for Resident #202 . Observation of Resident #202's room on 6/14/2021 at 5:40 AM, 7:30 AM, and 12:30 PM showed no contact/droplet isolation sign on the door, no isolation cart outside of the room, and no red isolation trash containers inside the room. During an interview on 6/14/2021 at 3:30 PM, Licensed Practical Nurse (LPN) #1 confirmed Resident #202 was admitted [DATE], was a new admission, was not fully vaccinated, and should have been put in contact/droplet isolation when she was admitted . During an interview on 6/16/2021 at 5:25 PM, the Infection Control Preventionist (ICP) was asked if new admissions were placed in isolation. She stated, .Those with no vaccine get put in isolation . The ICP was asked if it was acceptable for a resident to be admitted to the facility on [DATE] and not be placed in isolation until 6/14/2021. The ICP stated, .I know who you are talking about .the Unit Manager discovered it on Monday afternoon [6/14/2021]. That's obviously not acceptable. She was not vaccinated . Review of the facility's policy titled, Infection Prevention and Control Program, revised 4/10/2021, revealed .All contaminated disposable items shall be discarded in a waste receptacle lined with a RED plastic bag .Hand Hygiene Protocol .All staff shall perform hand hygien [hygiene] when coming on duty, between resident contacts, after handling contaminated objects, after PPE [Personal Protective Equipment: isolation gowns, gloves, masks, shields] removal .Staff shall perform hand hygiene before and after performing resident care procedures . Observation outside of the resident's room on 6/14/2021 at 7:39 AM, revealed CNA #1 put on gloves, gown, and a face shield and entered Resident #200's room. CNA #1 removed the face shield, opened the drawer of the isolation cart outside of the room, and placed the used, disposable face shield in the top drawer on top of the clean surgical masks. During an interview on 6/16/2021 at 5:25 PM, the ICP was asked what staff should do with a used face shield when they are ready to leave a resident's isolation room. She stated, .Put them in the trash in the room, they are disposable. She confirmed they should not be put it back in the clean isolation cart. Observation in Resident #200's isolation room on 6/14/2021 at 10:30 AM, 1:25 PM, and 3:00 PM, and on 6/15/2021 at 9:10 AM, 12:55 PM, and 4:15 PM, revealed a red trash container full of dirty PPE gowns and gloves, overflowing and touching the floor, and not covered by the container lid. Observation in Resident 202's isolation room on 6/14/2021 at 10:33 AM, 1:30 PM, and 3:05 PM, and on 6/15/2021 at 9:15 AM, 12:59 PM, and 4:19 PM, revealed a red trash container full of dirty PPE gowns and gloves, overflowing and touching the floor, and not covered by the container lid. During an interview on 6/16/2021 at 5:30 PM, the ICP was asked if it was acceptable for the trash in the isolation rooms to be overflowing onto the floor. She confirmed the lid should be shut and stated that housekeeping and the CNAs should be making sure the trash is taken out.

Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 6 medication storage areas (A Hall Medication Cart) when a medication cart was unlocked and unattended and unattended medications were on top of the cart. The finding's include: Review of the facility's policy titled, Medication Storage, updated 6/2012, revealed .It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use .Medications .CANNOT be stored on top of the medication cart. All safety measures must be taken to protect the residents from accessing medications and other objects that could potentially harm the resident or others . Observation of the A Hall Medication Cart outside of room [ROOM NUMBER] on 6/15/2021 at 8:55 AM, revealed an unlocked and unattended medication cart. Observation of the A Hall Medication Cart outside of room [ROOM NUMBER] on 6/15/2021 at 9:03 AM, revealed umeclidinium-vilanterol aerosol inhaler (a medicated respiratory inhaler) and [MEDICATION(S)] nasal spray (a medicated nasal spray) were opened, unattended, and on top of the cart. During an interview on 6/16/2021 at 6:15 PM, the Director of Nursing (DON) confirmed that the medication cart should not be left unlocked and unattended. The DON also confirmed that medications should not be left opened and unattended on top of the medication cart.

Based on policy review, observation and interview, the facility failed to maintain or enhance resident dignity and respect when 1 of 7 staff members (Certified Nurse Assistant (CNA) #3) was standing over a resident (Resident #14) to assist with their meal. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, with an effective date of 6/16/2021, revealed that staff will be seated to assist with meals. Observation in the resident's room on 6/15/2021 at 8:12 AM, revealed CNA #3 was standing to assist Resident #14 with their meal. During an interview on 6/16/2021 at 5:48 PM, the Director of Nursing (DON) confirmed staff should be seated to assist residents with their meals.

Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 (Certified Nursing Assistant (CNA) #1) staff member failed to perform hand hygiene during indwelling catheter care. The findings include: The facility's undated Standard and Precaution Policy documented, .Hand Hygiene .before applying and after removing personal protective equipment, including gloves .before and after handling clean or soiled .linens . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician's orders [REDACTED].Foley cath (catheter) care q (every) shift .as needed . Observations in Resident #22's room on 5/21/19 at 9:01 AM, revealed CNA #1 gathered supplies, donned gloves, and completed indwelling catheter care. CNA #1 did not remove her gloves or wash her hands. CNA #1 completed incontinence care, and the wash cloth was noted with a moderate amount of dark brown substance. CNA #1 did not remove her gloves or wash her hands. CNA #1 applied barrier cream to Resident #22's buttock and assisted Resident #22 back to her wheelchair using the same gloved hands. CNA #1 then removed her gloves. Interview with CNA #1 on 5/21/19 at 9:20 AM, at the Nurses' Station, CNA #1 was asked if she should have removed her gloves and washed her hands between indwelling catheter care and incontinence care. CNA #1 stated, Yes. CNA #1 was asked if she should have removed her gloves and washed her hands between incontinence care and before applying barrier cream. CNA #1 stated, Yes, I should have put on new gloves. CNA #1 was asked if she should have removed gloves and washed her hands before assisting the resident back to her wheelchair. CNA #1 stated, Yes, I should .it's contamination. Interview with the Director of Nursing (DON) on 5/21/19 at 11:42 AM, at the Nurses' Station, the DON was asked when should staff wash their hands during indwelling catheter care and incontinence care. The DON stated, Before and after catheter care and incontinence care. The DON was asked if the staff should remove gloves and wash hands before applying barrier cream and performing incontinence care. The DON stated, Yes. The DON was asked if the staff should remove gloves and wash hands before assisting the resident back to a wheelchair. The DON stated, Yes.

Based on policy review, medical record review, and interview the facility failed to administer treatment to restore normal bowel function for 1 of 1 (Resident #53) sampled residents reviewed for bowel function. The findings include: The facility's Bowel Policy . dated 12/30/11 documented, .beginning of the 3rd day of no B.M (bowel movement) Administer [MEDICATION NAME] 17 gram, mix with prune juice or beverage of choice, wait 4 hours, if no bowel movement repeat one time, wait 2 hours. Apply one ducalox ([MEDICATION NAME]) sup (suppository) rectally, wait 2 hours. Administer fleets enema one rectally, wait 2 hours . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 1/29/19 documented, .Problem .I have the potential for constipation r/t (related to) Decreased mobility, Pain med (medication) use .Interventions .receive laxatives and stool softeners as needed/ordered nurse will monitor the effectiveness of laxatives that I receive .staff will monitor my BM record daily, report to charge nurse and if no BM >(greater than) 3 days initiate BM protocol . The progress note dated 2/22/19 documented, .Resident has not had a bowel movement in 10 days . Review of the (MONTH) 2019 Treatment Administration Record revealed there was no documentation that the [MEDICATION NAME] or Fleets Enema had been given per the bowel protocol. Interview with the Director of Nursing (DON) on 5/21/19 at 12:21 PM, in the Staff Development Room, the DON confirmed there was no documentation that [MEDICATION NAME] and Fleets Enema had been given per the bowel movement protocol.

Based on medical record review, observation, and interview, the facility failed to follow interventions for the prevention of accidents for 1 of 2 (Resident #7) sampled residents reviewed for accidents. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] revealed a Brief Interview for Mental Status score of 13, which indicated no cognitive impairment, no behaviors, and was totally dependent on staff for transfers. The Care Plan dated 11/13/17, and last reviewed 4/28/19, documented, .risk for weakness, fatigue, malaise, lethargy r/t (related to) [MEDICAL CONDITION] .Interventions .If I experience any .bruising, or excessive bleeding alert my CN (Charge Nurse)/MD (Medical Doctor) .have impaired visual function .severely limited acuity .ADL (Activities of Daily Living) Self Care Performance Deficit r/t Debility, Stroke, [MEDICAL CONDITION] .have a right above the knee amputation .Transfers: 2 (staff) with hoyer . The incident report dated 5/8/19 and revised 5/10/19 documented, .CNA (Certified Nursing Assistant) approached this nurse and said that when they got (Resident #7) in lift, res (resident) bent forward and hit head on lift. After looking at res head, this nurse noted a half dime sized bruise on (L) (left) side of forehead .Immediate Action Taken .Have therapy review transfer practice . Observations in Resident #7's room on 5/19/19 at 12:12 PM, 5/20/19 at 9:11 AM, and 5/21/19 at 11:57 AM, revealed Resident #7 seated in her wheelchair with a lift pad underneath her, right leg amputation above the knee, and a large purplish bruise to the left side of her forehead that was approximately 3 centimeters in diameter. Interview with Occupational Therapist (OT) #1 on 5/20/19 at 4:04 PM, in the Staff Development Room, OT #1 was asked if she had reviewed the transfer practice for Resident #7. OT #1 stated, They had mentioned it to me .I haven't received a formal request for an eval (evaluation) or anything .I haven't seen staff do the transfer with her . OT #1 was asked in what timeframe the evaluation should have been completed. OT #1 stated, Ideally within a few days . Interview with the Director of Nursing (DON) on 5/21/19 at 12:20 PM, in the Staff Development Room, the DON was asked if the therapy referral should have been done after the accident. The DON stated, Yes . The facility was unable to provide documentation that the intervention for therapy to review the transfer practice for Resident #7 had been implemented.

Based on policy review, medical record review, observation, and interview, the facility failed to identify and assess 1 of 3 (Resident #22) sampled residents reviewed for pressure ulcers. The findings include: The facility's Wound Care policy dated 12/1/05 documented, .Document site, size, description of site, condition of skin around site, treatment started and who the pressure ulcer was reported to . The Facility's Standing Orders policy dated 5/30/18 documented, .Barrier Cream or [MEDICATION NAME] for reddened or excoriated skin .follow skin protocol for stg (stage) 1-4 pressure ulcers . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders [REDACTED].Barrier cream to BIL (bilateral) buttocks r/t (related to) pressure injury every shift for pressure injury .Order Date .4/30/2019 . There was no documentation for wound description, wound measurements, or wound staging. Observations in Resident #22's room on 5/19/19 at 10:39 AM, revealed a half dollar size open area to Resident #22's right buttock. The facility was unable to provide documentation that weekly assessments or measurements of Resident #22's wound had been done. Interview with the Unit Manager on 5/21/19 at 9:29 AM, in the in Staff Development Room, the Unit Manager was asked if the nursing staff should complete an assessment and measurement on wounds when they are identified. The Unit Manager stated, Yes. Interview with the Director of Nursing (DON) on 5/21/19 at 11:51 AM, at the Nurses' Station, the DON was asked what the nursing staff should do when they identified a wound. The DON stated, They should notify the Unit Manager .complete the assessment with the description .what they found .follow-up with the protocol .call the Nurse Practitioner or Wound Care Doctor .start an order .then make sure the Wound Care Doctor follows up on his next visit to make sure appropriate treatment is in place . Telephone interview with the Wound Care Physician on 5/21/19 at 3:28 PM, the Wound Care Physician was asked if the staff should complete measurements and staging of an identified pressure ulcer. The Wound Care Doctor stated, Absolutely. The Wound Care Physician was asked if he expected the nursing staff to contact him about any identified pressure ulcers. The Wound Care Physician stated, Absolutely. The Wound Care Physician was asked if he had seen Resident #22's wound on her buttock. The Wound Care Physician stated, .I have not seen the pressure ulcer on her buttock .I did not know about it .

Based on policy review, medical record review, observation, and interview, the facility failed to notify the physician for 2 of 2 (Resident #22 and #53) sampled residents reviewed for pressure ulcers and bowel function. The findings include: 1. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders [REDACTED].Barrier cream to BIL (bilateral) buttocks r/t (related to) pressure injury every shift for pressure injury .Order Date .4/30/2019 . Observations in Resident #22's room on 5/19/19 at 10:39 AM, revealed a half dollar size open area to her right buttock. Thyere was no documentation in the medical record th physician had been notified of this wound. Telephone interview with the Wound Care Doctor on 5/21/19 at 3:28 PM, the Wound Care Doctor was asked if he expected the nursing staff to contact him about any identified pressure ulcers. The Wound Care Doctor stated, Absolutely. The Wound Care Doctor was asked if he had seen Resident #22's buttock wound. The Wound Care Doctor stated, .I did not know about it . 2. The facility's Bowel Policy . dated 12/30/11 documented, .if there is not a bowel movement past completion of bowel protocol, notify the physician . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Care Plan dated 1/29/19 documented, .Problem .I have the potential for constipation r/t (related to) Decreased mobility, Pain med (medication) use .Interventions .will receive laxatives and stool softeners as needed/ordered .alert MD (Medical Doctor) if not effective . Review of the (MONTH) 2019 Treatment Administration Record revealed Resident #53 had not had a bowel movement from 2/13/19 through 2/22/19. Interview with the Nurse Practitioner (NP) on 5/21/19 at 12:30 PM, in the Staff Development Room, the NP was asked if she had been notified that Resident #53 did not have a bowel movement in 10 days. The NP stated, .not that I can recall . The NP was asked if she should have been notified. The NP stated, .would have liked to have been notified if no bowel movement in 3 days . Interview with the Director of Nursing (DON) on 5/21/19 at 3:15 PM, in the Staff Development Room, the DON was asked if the NP or physician should have been notified per the facility's policy when a resident did not have a bowel movement after the completion of the bowel protocol. The DON stated, .yes .

Based on facility policy review, medical record review, observation, and interview, the facility failed to ensure adequate supervision to ensure the residents environment remained free from accident hazards for residents utilizing electrical power strips for 1 resident (#87); and failed to prevent physical hazards by failing to utilize approved electrical power strips for 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for Resident #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The facility's failure at F-323 represents Substandard Quality of Care. The findings included: Review of facility policy, Incident/Accident Reporting, dated 12/1/05 revealed, .It is the policy of this facility that all incidents or accidents occurring on our premises be investigated and reported to the Director of Nursing and/or Administrator . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 or more people for bed mobility, dressing, toileting, and personal hygiene, was dependent with assistance of 2 or more people for transfers and bathing and required supervision and set up help for eating. Continued review revealed the resident did not ambulate and was receiving Hospice services. Observation on 8/7/17 at 9:10 AM in the resident's room revealed Resident #87 was laying on the right side of the bed with the head of bed elevated. Continued observation revealed the left side of the bed had personal items in a plastic box and a white electrical power strip with a cell phone charger attached to a cell phone plugged into a electrical power strip lying in the bed to the left side of the resident. Further observation revealed the electrical power strip was plugged into the wall and was in the 'on' position. Continued observation revealed a cup with approximately 2 ounces of red fluid in it on the overbed table to the right side of the bed next to the resident, and a urinal with approximately 200 milliliters of urine in it hanging on the trash can to the right side of the bed next to the resident. Interview with Licensed Practical Nurse (LPN) #6 on 8/7/17 at 9:15 AM in the C hallway confirmed she was the nurse for the resident. The LPN denied knowledge of the electrical power strip in bed with the resident and stated she had not assessed the resident yet. Observation on 8/7/17 at 9:18 AM in the resident's room revealed LPN #6 attempted to remove the electrical power strip from the resident's bed and he became very agitated. The LPN asked Certified Nurse Aide (CNA) #2 to get the Administrator while she stayed in the room with the resident. Continued observation revealed the Administrator came to the resident's door and stated the Social Worker (SW) had good rapport with the resident and she would ask her to come to the resident's room. Continued observation revealed the SW came to the resident's room, and she asked him if she could place the electrical power strip on the floor. The resident agreed and the SW removed the electrical power strip from the bed and placed it on the floor to the left side of the bed. Interview with CNA #2 on 8/7/17 at 9:30 AM in C hall revealed she regularly cared for the resident. When asked when she had last seen the resident and if she had any knowledge of the electrical power strip in the bed with the resident the CNA stated she had observed him at 7:45 AM and brought the resident breakfast at 8:15 AM, and the electrical power strip was not in the bed. Further interview revealed the CNA stated the resident could roll independently and reach the electrical power strip from the floor with his right hand, and roll back independently, and stated, that was probably how the electrical power strip got into the bed. Interview with CNA #3 on 8/7/17 at 9:35 AM in C hall revealed she also cared for the resident and last saw him at 8:00 AM, but could not recall if the electrical power strip was in the bed with the resident. The CNA stated the resident was not able to roll independently, needed assistance with bed mobility, and could use his right arm independently. The CNA recalled seeing the electrical power strip in the past on a chair next to the resident's bed, but was unsure how it got into the bed today. Observation on 8/7/17 at 12:36 PM in the resident's room revealed the resident was in the same position in bed. Continued observation revealed CNA #2 placed a lunch tray on the overbed table and positioned it over the resident. Further observation revealed the same glass of red fluid and the urine in the urinal were in the same place as they were at 9:10 AM. The electrical power strip was laying on top of the green lid of a clear tote stored on the floor to the left side of the bed with the resident's phone charger plugged into it. Continued observation revealed the CNA lowered the head of the bed and pulled the resident up in bed unassisted. The resident's lower extremities did not move voluntarily. Further observation revealed the CNA raised the head of the bed, repositioned the over bed table in front of the resident and prepared the lunch tray for the resident. Further observation revealed two 8 ounce glasses of fluid were placed to the left upper portion of the over bed table. Continued observation revealed the resident was able to use his right arm and hand to feed himself. The resident's left arm and hand had no voluntary movement. Observation on 8/8/17 at 7:35 AM in the resident's room revealed the resident was awake, alert, and in bed. The electrical power strip was laying on top of the green lid of a clear tote stored on the floor to the left side of the bed with the resident's phone charger plugged into it. Multiple items were piled on top of the overbed table which was in front of the resident. Interview with the Director of Nursing (DON) on 8/8/17 at 8:15 AM in the DON's office confirmed Resident #87 could not stand and needed assistance with all activities of daily living (ADL's). The DON stated he was bed bound, became very angry with repositioning, and preferred to stay on the right side of the bed on his back. The DON did not know how the electrical power strip got into the resident's bed. Interview with the Social Worker (SW) on 8/8/17 at 8:30 AM in the SW's office revealed she had a fairly good rapport with Resident #87. The SW stated the resident was not friendly and has had difficult speech since arrival. The SW reported the resident talked on the phone to his daughter who lived out of state and his sister. Continued interview with the SW revealed, He is very territorial. He hides things in his bed behind his back, under the blue pad, and under the covers. The SW stated the resident was admitted with the phone and phone charger but she was not sure where the electrical power strip came from. Interview and observation with the Maintenance Director on 8/8/17 at 8:45 AM in Resident #87's room confirmed the electrical power strip belonged to the facility. The Maintenance Director stated the electrical power strip was not supposed to be on the floor, that's why it's on the tote. Further interview confirmed the resident used the electrical power strip for his phone charger and something else he used for music. Further observation with the Maintenance Director present confirmed the electrical power strip was 'on' and charging the phone. The resident was asked to pull the phone charger, stored on the green lid of a clear tote stored on the floor, toward him. Using his right hand, the resident pulled on the phone and the phone cord to lift the electrical power strip. The resident was not able to pull the electrical power strip in the bed with him. The electrical power strip got hung on the underside of the mattress. The resident was not able to move his left arm or hand. A telephone call to the Life Safety Supervisor (LSS) at the State Agency on 8/8/17 at 9:15 AM revealed there was 1 type of electrical power strip approved for resident use with personal items at the facility. The LSS stated it had to be a UL (Underwriter's Laboratory) 1363 type of electrical power strip. Observation on 8/8/17 at 9:20 AM in the resident's room with another surveyor present revealed the electrical power strip used by the resident was a SS-2B-F (Temporary Power Tap) UL. Listed 99K8 E897, not an approved electrical power strip per the Life Safety Code regulation. Further observation revealed the electrical power strip had Caution Use only in dry location engraved on the electrical power strip. Interview with the Maintenance Director on 8/8/17 at 11:47 AM in the D hall was asked to provide the manufacturer's recommendations for the electrical power strip used in Resident #87's room. Continued interview at 12:02 PM in the classroom revealed the Maintenance Director provided this surveyor with a manufacturer's printed sheet and an opened box of a GE black electrical power strip. It was not the same model used by Resident #87. Further interview at 12:50 PM in the D hall, the Maintenance Director was informed by the surveyor the information he provided was not the same model used by the resident, and he stated, well they're all the same, it's general information. The Maintenance Director was not able to provide any manufacturer's recommendations for the SS-2B-F UL electrical power strip used by Resident #87 and provided by the facility. Observation on 8/8/17 at 1:40 PM in the resident's room with the SW and Registered Nurse (RN) #2 present revealed the resident was asked if he would roll to the left side of the bed. He asked Why? and did not comply. The SW asked Resident #87 to pick up his phone charger that was plugged into the electrical power strip and see if he could put it in his bed. The resident was observed moving his right lower leg and turning a little toward his left side while using his right hand to pull the electrical power strip up and over the mattress while it was attached to the phone charger. The SW and RN #2 confirmed the resident could place the electrical power strip in bed unassisted. Interview and observation with the Maintenance Director on 8/8/17 at 2:30 PM in the classroom revealed he had an electrical power strip in his hand and stated he had removed it from Resident #87's room and he had no electrical power strip at all. Observations on 8/8/17 between 3:30 PM and 4:30 PM revealed the following resident rooms contained electrical power strips not in compliance with the Life Safety Code (LSC) regulation: B-200 Hall 208A/Resident #70-electrical power strip with phone, computer, fan, and foot care item plugged into it, C-300 Hall 306/Resident #22-electrical power strip with oxygen concentrator, fan, and lamp plugged into it, 307A/Resident #29-electrical power strip dangling from the plug in the wall with TV and cable plugged into it, E-500 Hall 501A/Resident #91-electrical power strip with clock, TV and cable plugged into it, F-600 Hall 601A/Resident #88-electrical power strip with TV and cable plugged into it, 602B/Resident #65-black electrical power strip attached to the wall with TV and cable plugged into it, 603A/Resident #49-electrical power strip with bed plugged into it, 605A/Resident #16-electrical power strip with phone charger, fan, and clock plugged into it, 606A/Resident #1-electrical power strip with TV, cable, and VCR plugged into it, 608B/Resident #12-black electrical power strip with refrigerator and cable plugged into it, 609B/Resident #15-electrical power strip with TV, cable, and DVD player plugged into it, 610A/Resident #24-white electrical power strip with TV, cable, and boom box plugged into it, 610B/Resident #47-electrical power strip with TV, cable, and DVD player plugged into it. Observations on 8/8/17 between 3:30 PM and 4:30 PM revealed Resident #87's room, 305A, did not have an electrical power strip. His phone charger was plugged into the wall and his phone was in bed with the resident. Interview with the Maintenance Director on 8/10/17 at 9:30 AM in D Hall confirmed none of the electrical power strips previously used in the facility were model 1363, and stated he was confused with all the updates and changes recently. The Immediate Jeopardy was effective from 8/7/17 through 8/10/17. An acceptable Allegation of Compliance dated 8/10/17, which removed the immediacy of the jeopardy, was received and corrective actions were validated through direct observation of the removal of all electrical power strips in the facility; direct care staff interviews regarding education; review of maintenance audits of rooms with electrical power strips and their removal; interview with the Maintenance Director to validate comprehension of the approved type of electrical power strips acceptable for use in the facility; and review of in-service training records dated 8/8/17-8/9/17. The Allegation of Compliance was verified by: 1. Observation validated the electrical power strip was removed from Resident #87's bed by the Social Worker on 8/7/17 at 9:30 AM, and the Maintenance Director had removed the electrical power strip from the resident's room, 305A, on 8/8/17 at 2:30 PM. 2. Review of the electrical power strip audit conducted on 8/8/17 and observation of resident rooms validated all the electrical power strips were removed from resident rooms on 8/9/17. Validation: by review of the letter sent to the resident's family regarding electrical power strip use; by interview with the Administrator on 8/9/17 at 12:22 PM in the classroom confirming the letter dated 8/9/17 was mailed to the families on electrical power strip use; by review of the list of family names the letter was mailed to; and by observation of the signage placed on bathroom doors in resident rooms that all electrical power strips must be approved by maintenance prior to use. Review of the email from the facility to the Life Safety Director at the State Agency validated the .Power strips providing power to non-patient-care-related equipment must be relocatable Power taps (RPT) listed as UL 1363 . Review of the admission packet verified the electrical power strips use had to be approved by the Maintenance Director prior to use. Interview with the Administrator on 8/9/17 at 12:22 PM in the classroom verified the Resident and Family Councils, scheduled for August 2017, included the approved power strip use information. 3. Interviews on 8/10/17 with 4 Housekeeping and Laundry staff, 3 Nurse Aides, 7 CNA's, 3 LPN's and 3 RN's between 8:55 AM and 9:30 AM validated they had been inserviced on no electrical power strips in the building unless approved by Maintenance and electrical power strips were to be mounted, not on the floor, and not in bed with residents. Review of the facility audit of staff in-servicing validated staff not on duty had been contacted to educate them on the electrical power strip use. Interview with the Maintenance Director on 8/10/17 at 9:30 AM on the D hall verified he had been educated by the Administrator on 8/9/17, on the approved type of electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. 4. Interview with the Administrator on 8/10/17 at 1:20 PM in her office validated she or her designee would monitor for continued compliance through weekly quality improvement audits. The findings will be reported immediately to the Administrator and in the subsequent morning QA (Quality Assurance) meeting. Audit findings will be discussed in facility QAPI (Quality Assurance and Performance Improvement) meetings. Noncompliance continues at a scope and severity of E for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA Committee. The facility is required to submit a plan of correction. Refer to F-224 K Substandard Quality of Care.

Based on interview, observation, and audit review, the Administrator failed to administer the facility to prevent a physical hazard when the unapproved electrical power strip was located in a resident's bed for Resident #87; failed to administer the facility in a manner to monitor for physical hazards, and failed to ensure the safety of 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility utilizing unapproved electrical power strips in their rooms. The failure of the Administrator to maintain the safety of residents resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for Resident #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The findings included: Interview with the Administrator on 8/10/17 at 3:26 PM in the Administrator's office confirmed the facility had not provided residents with the approved electrical power strips acceptable for use in the facility. Further interview revealed the Administrator had no prior knowledge of the requirement of the UL (Underwriter's Laboratory) 1363 electrical power strips for resident use of non-medical equipment until discussed with the facility's Chief Operating Officer on 8/8/17. Continued interview confirmed the monitoring and prevention of physical hazards regarding electrical power strips for residents had never been assessed as a concern by the Quality Assurance (QA) committee or followed up in Quality Assurance and Performance Improvement (QAPI) meetings. The Administrator confirmed maintenance staff and facility staff were not educated on the approved type of electrical power strips acceptable in the facility, and failed to educate all staff to ensure electrical power strips were monitored for safe use. The Administrator failed to ensure residents only used electric power strips approved by the Maintenance Director. Resident #87 had an unapproved electrical power strip in the bed with fluids accessible creating a physical hazard. The facility had a total of 14 residents ( #87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) utilizing unapproved electrical power strips in their room. The Administrator and Maintenance Director were not knowledgeable of the electrical power strip approved for use in resident rooms. The staff was not monitoring the residents environment to ensure the safe use of the electrical power strips. The Immediate Jeopardy was effective from 8/7/17 through 8/10/17. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through direct observation of the removal of all electrical power strips in the facility; direct care staff interviews regarding education; review of maintenance audits of rooms with electrical power strips and their removal; interview with the Maintenance Director to validate comprehension of the approved type of electrical power strips acceptable for use in the facility; review of inservice training records dated 8/8/17-8/9/17. The Allegation of Compliance was verified by: 1. Observation validated the electrical power strip was removed from Resident #87's bed by the Social Worker on 8/7/17 at 9:30 AM, and the Maintenance Director had removed the electrical power strip from the resident's room, 305A, on 8/8/17 at 2:30 PM. 2. Review of the electrical power strip audit conducted on 8/8/17 and observation of resident rooms validated all the electrical power strips were removed from resident rooms on 8/9/17. Validation: by review of the letter sent to the resident's family regarding electrical power strip use; by interview with the Administrator on 8/9/17 at 12:22 PM in the classroom confirming the letter dated 8/9/17 was mailed to the families on electrical power strip use; by review of the list of family names the letter was mailed to; and by observation of the signage placed on bathroom doors in resident rooms that all electrical power strips must be approved by maintenance prior to use. Review of the email from the facility to the Life Safety Director at the State Agency validated the .Power strips providing power to non-patient-care-related equipment must be relocatable Power taps (RPT) listed as UL 1363 . Review of the admission packet verified the electrical power strips use had to be approved by the Maintenance Director prior to use. Interview with the Administrator on 8/9/17 at 12:22 PM in the classroom verified the Resident and Family Councils, scheduled for August 2017, included the approved power strip use information. 3. Interviews on 8/10/17 with 4 Housekeeping and Laundry staff, 3 Nurse Aides, 7 CNA's, 3 LPN's and 3 RN's between 8:55 AM and 9:30 AM validated they had been inserviced on no electrical power strips in the building unless approved by Maintenance and electrical power strips were to be mounted, not on the floor, and not in bed with residents. Review of the facility audit of staff in-servicing validated staff not on duty had been contacted to educate them on the electrical power strip use. Interview with the Maintenance Director on 8/10/17 at 9:30 AM on the D hall verified he had been educated by the Administrator on 8/9/17, on the approved type of electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. 4. Interview with the Administrator on 8/10/17 at 1:20 PM in her office validated she or her designee would monitor for continued compliance through weekly quality improvement audits. The findings will be reported immediately to the Administrator and in the subsequent morning QA (Quality Assurance) meeting. Audit findings will be discussed in facility QAPI (Quality Assurance and Performance Improvement) meetings. Noncompliance continues at a scope and severity of E for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA Committee. The facility is required to submit a plan of correction. Refer to F-223 K Substandard Quality of Care. Refer to F 323 K Substandard Quality of Care.

Based on interview, observation, and audit review, the Quality Assurance (QA) committee failed to identify a physical hazard when the unapproved electrical power strip was located in a resident's bed of 1 resident (#87) of 14 residents reviewed with electrical power strips; and failed to monitor for physical hazards to ensure resident safety for a total of 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility. The QA committee's failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for Resident #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The findings included: Interview with the Maintenance Director on 8/10/17 at 9:30 AM in the D Hall confirmed he was educated by the Administrator on 8/9/17 on approved electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. Further interview revealed he received the correct information from an email provided by the Life Safety State Agency. The Maintenance Director confirmed none of the electrical power strips previously used in the facility were model 1363, and stated he was confused with all the updates and changes recently. Interview with the Administrator, the QA chairperson, on 8/10/17 at 3:26 PM in the Administrator's office confirmed the facility had not provided residents with the approved electrical power strips acceptable for use in the facility. Further interview revealed the Administrator had no prior knowledge of the requirement of the UL (Underwriter's Laboratory) 1363 electrical power strips for resident use of non-medical equipment until discussed with the facility's Chief Operating Officer on 8/8/17. Continued interview confirmed the monitoring and prevention of physical hazards regarding electrical power strips for residents had never been assessed as a concern by the QA committee or followed up in Quality Assurance and Performance Improvement (QAPI) meetings. The Administrator confirmed the QA committee failed to educate the Maintenance Director and staff on the approved type of electrical power strips acceptable in the facility, and failed to educate all staff to ensure electrical power strips were monitored for safe use. The Administrator confirmed the QA committee failed to ensure residents only used electric power strips approved by the Maintenance Director. Resident #87 had an unapproved electrical power strip in the bed with fluids accessible creating a physical hazard. The facility had a total of 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) utilizing unapproved electrical power strips in their room. The Administrator and Maintenance Director were not knowledgeable of the electrical power strip approved for use in resident rooms. The staff was not monitoring the residents environment to ensure the safe use of the electrical power strips. The Immediate Jeopardy was effective from 8/7/17 through 8/10/17. An acceptable Allegation of Compliance, which removed the immediacy of the jeopardy, was received and corrective actions were validated through direct observation of the removal of all electrical power strips in the facility; direct care staff interviews regarding education; review of maintenance audits of rooms with electrical power strips and their removal; interview with the Maintenance Director to validate comprehension of the correct type of electrical power strips acceptable for use in the facility; review of inservice training records dated 8/8/17-8/9/17. The Allegation of Compliance was verified by: 1. Observation validated the electrical power strip was removed from Resident #87's bed by the Social Worker on 8/7/17 at 9:30 AM, and the Maintenance Director had removed the electrical power strip from the resident's room, 305A, on 8/8/17 at 2:30 PM. 2. Review of the electrical power strip audit conducted on 8/8/17 and observation of resident rooms validated all the electrical power strips were removed from resident rooms on 8/9/17. Validation: by review of the letter sent to the resident's family regarding electrical power strip use; by interview with the Administrator on 8/9/17 at 12:22 PM in the classroom confirming the letter dated 8/9/17 was mailed to the families on electrical power strip use; by review of the list of family names the letter was mailed to; and by observation of the signage placed on bathroom doors in resident rooms that all electrical power strips must be approved by maintenance prior to use. Review of the email from the facility to the Life Safety Director at the State Agency validated the .Power strips providing power to non-patient-care-related equipment must be relocatable Power taps (RPT) listed as UL 1363 . Review of the admission packet verified the electrical power strips use had to be approved by the Maintenance Director prior to use. Interview with the Administrator on 8/9/17 at 12:22 PM in the classroom verified the Resident and Family Councils, scheduled for August 2017, included the approved power strip use information. 3. Interviews on 8/10/17 with 4 Housekeeping and Laundry staff, 3 Nurse Aides, 7 CNA's, 3 LPN's and 3 RN's between 8:55 AM and 9:30 AM validated they had been inserviced on no electrical power strips in the building unless approved by Maintenance and electrical power strips were to be mounted, not on the floor, and not in bed with residents. Review of the facility audit of staff in-servicing validated staff not on duty had been contacted to educate them on the electrical power strip use. Interview with the Maintenance Director on 8/10/17 at 9:30 AM on the D hall verified he had been educated by the Administrator on 8/9/17, on the approved type of electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. 4. Interview with the Administrator on 8/10/17 at 1:20 PM in her office validated she or her designee would monitor for continued compliance through weekly quality improvement audits. The findings will be reported immediately to the Administrator and in the subsequent morning QA (Quality Assurance) meeting. Audit findings will be discussed in facility QAPI (Quality Assurance and Performance Improvement) meetings. Noncompliance continues at a scope and severity of E for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA Committee. The facility is required to submit a plan of correction. Refer to F-223 K Substandard Quality of Care. Refer to F-323 K Substandard Quality of Care. Refer to F-490 K

Based on facility policy review, medical record review, observation, and interview, the facility failed to prevent neglect by failing to provide the services necessary to avoid physical harm for residents utilizing electrical power strips for 1 resident (#87); failed to prevent neglect by failing to ensure the facility utilized approved electrical power strips for 14 residents (#87, #70, #22, #29, #91, #88, #65, #49, #16, #1, #12, #15, #24, #47) of 70 residents in the facility; and failed to prevent neglect by failing to prevent exploitation of 5 residents (#22, #26, #30, #49, #91) of 14 residents reviewed for abuse. The facility's system failure resulted in Immediate Jeopardy (a situation in which the provider's non-compliance has caused or is likely to cause serious injury, harm, impairment or death) for Resident #87. The Administrator was notified of the Immediate Jeopardy on 8/10/17 at 1:00 PM in the Administrator's office. The facility's failure at F-224 represents Substandard Quality of Care. The findings included: Review of facility policy, Abuse, Neglect, and Exploitation/Dementia Management, revised 6/14/17 revealed .'Neglect' means failure of the facility .to provide goods and services to a resident that are necessary to avoid physical harm .The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including but not limited to the following possible indicators: Evidence of photographs or videos of a resident regardless of whether the resident provided consent and regardless of the resident's cognitive status . Medical record review revealed Resident #87 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed the resident was severely cognitively impaired, required extensive assistance of 2 or more people for bed mobility, dressing, toileting, and personal hygiene, was dependent with assistance of 2 or more people for transfers and bathing and required supervision and set up help for eating. Continued review revealed the resident did not ambulate and was receiving Hospice services. Observation on 8/7/17 at 9:10 AM in the resident's room revealed Resident #87 was laying on the right side of the bed with the head of bed elevated. Continued observation revealed to the left side of the resident was a white electrical power strip with a cell phone charger attached to a cell phone plugged into a electrical power strip lying in the bed. Further observation revealed the electrical power strip was plugged into the wall and was in the 'on' position. Continued observation revealed a cup with approximately 2 ounces of red fluid in it on the overbed table to the right side of the bed next to the resident, and a urinal with approximately 200 milliliters of urine in it hanging on the trash can to the right side of the bed next to the resident. Interview with Licensed Practical Nurse (LPN) #6, assigned to Resident #87, on 8/7/17 at 9:15 AM in the C hall denied knowledge of the electrical power strip in bed with the resident and stated she had not assessed the resident yet. Observation on 8/7/17 at 9:18 AM in the resident's room revealed LPN #6 attempted to remove the electrical power strip from the resident's bed and he became very agitated. Continued observation revealed the Social Worker (SW) came to the resident's room, and she asked him if she could place the electrical power strip on the floor. The resident agreed and the SW removed the electrical power strip from the bed and placed it on the floor to the left side of the bed. Interview with CNA #2 on 8/7/17 at 9:30 AM in C hall revealed she regularly cared for the resident. Further interview with the CNA revealed she had observed him at 7:45 AM and at 8:15 AM, and the electrical power strip was not in the bed. Further interview revealed the CNA stated the resident could roll independently and reach the electrical power strip from the floor with his right hand, and roll back independently, and stated, that was probably how the electrical power strip got into the bed. Interview with CNA #3 on 8/7/17 at 9:35 AM in C hall revealed she also cared for the resident and last saw him at 8:00 AM, but could not recall if the electrical power strip was in the bed with the resident. The CNA stated the resident was not able to roll independently, needed assistance with bed mobility, and could use his right arm independently. Observation on 8/7/17 at 12:36 PM in the resident's room revealed the resident was in the same position in bed when observed at 9:10 AM. Further observation revealed the same glass of red fluid and the urine in the urinal were in the same place as they were at 9:10 AM. The electrical power strip was laying on top of the green lid of a clear tote stored on the floor to the left side of the bed with the resident's phone charger plugged into it. Continued observation revealed CNA #2 placed a lunch tray on the overbed table and positioned the overbed table over the resident. Continued observation revealed the CNA lowered the head of the bed, pulled the resident up in bed unassisted, raised the head of the bed, repositioned the over bed table in front of the resident and prepared the lunch tray for the resident. Further observation revealed two 8 ounce glasses of fluid on the tray were relocated to the left upper portion of the over bed table. Observation revealed the resident's lower extremities did not move voluntarily during the repositioning. Continued observation revealed the resident was able to use his right arm and hand to feed himself. The resident's left arm and hand had no voluntary movement. Interview with the Director of Nursing (DON) on 8/8/17 at 8:15 AM in the DON's office confirmed Resident #87 could not stand and needed assistance with all activities of daily living (ADL's). The DON stated he was bed bound, became very angry with repositioning, and preferred to stay on the right side of the bed on his back. The DON did not know how the electrical power strip got into the resident's bed. Interview with the Social Worker (SW) on 8/8/17 at 8:30 AM in the SW's office revealed she had a fairly good rapport with Resident #87. Continued interview with the SW revealed, He is very territorial. He hides things in his bed behind his back, under the blue pad, and under the covers. The SW stated the resident was admitted with the phone and phone charger but she was not sure where the electrical power strip came from. Interview and observation with the Maintenance Director on 8/8/17 at 8:45 AM in Resident #87's room confirmed the electrical power strip belonged to the facility and it was 'on' and charging the phone. The Maintenance Director stated the electrical power strip was not supposed to be on the floor, that's why it's on the tote. The resident was asked to pull the phone charger, stored on the green lid of a clear tote stored on the floor, toward him. Using his right hand, the resident pulled on the phone and the phone cord to lift the electrical power strip. Further observation revealed the resident could not pull the electrical power strip onto the bed because the electrical power strip got hung on the underside of the mattress. The resident was not able to move his left arm or hand. A telephone call to the Life Safety Supervisor (LSS) at the State Agency on 8/8/17 at 9:15 AM revealed there was 1 type of electrical power strip approved for resident use with personal items at the facility. The LSS stated it had to be a UL (Underwriter's Laboratory) 1363 type of electrical power strip. Observation on 8/8/17 at 9:20 AM in Resident #87's room with another surveyor present revealed the electrical power strip used by the resident was a SS-2B-F (Temporary Power Tap) UL. Listed 99K8 E897, not an approved electrical power strip per the Life Safety Code regulation. Further observation revealed the electrical power strip had Caution Use only in dry location engraved on the electrical power strip. Interview with the Maintenance Director on 8/8/17 at 11:47 AM in the D hall was asked to provide the manufacturer's recommendations for the electrical power strip used in Resident #87's room. Continued interview at 12:02 PM in the classroom revealed the Maintenance Director provided this surveyor with a manufacturer's printed sheet and an opened box of a GE black electrical power strip. It was not the same model used by Resident #87. Further interview at 12:50 PM in the D hall, the Maintenance Director was informed by the surveyor the information he provided was not the same model used by the resident, and he stated, well they're all the same, it's general information. The Maintenance Director was not able to provide any manufacturer's recommendations for the SS-2B-F UL electrical power strip used by Resident #87 and provided by the facility. Observation on 8/8/17 at 1:40 PM in the resident's room with the SW and Registered Nurse (RN) #2 present revealed the SW asked Resident #87 to pick up his phone charger that was plugged into the electrical power strip and see if he could put it in his bed. The resident was observed moving his right lower leg and turning a little toward his left side while using his right hand to pull the electrical power strip up and over the mattress while it was attached to the phone charger. The SW and RN #2 confirmed the resident could place the electrical power strip in bed unassisted. Observations on 8/8/17 between 3:30 PM and 4:30 PM revealed the following resident rooms contained electrical power strips not in compliance with the Life Safety Code (LSC) regulation with devices plugged into the electrical power strip: B-200 Hall 208A/Resident #70; C-300 Hall 306/Resident #22, 307A/Resident #29; E-500 Hall 501A/Resident #91; F-600 Hall 601A/Resident #88, 602B/Resident #65, 603A/Resident #49, 605A/Resident #16 606A/Resident #1, 608B/Resident #12, 609B/Resident #15, 610A/Resident #24 and 610B/Resident #47. Interview with the Maintenance Director on 8/10/17 at 9:30 AM in D hall confirmed none of the electrical power strips previously used in the facility were model 1363, and stated he was confused with all the updates and changes recently. In summary, the facility failed to prevent neglect by failing to provide the services necessary to avoid physical harm for residents utilizing electrical power strips based on the observation of Resident #87 with an electrical power strip in his bed which he was physically able to pull onto his bed. Further observation revealed fluids were accessible to Resident #87 while the electrical power strip was in the bed and while stored on the clear tote box stored on the floor. Further observation revealed a total of 14 residents were utilizing unapproved electrical power strips. The facility Administration and Maintenance Director were unaware of which electrical power strips were approved to be used in the facility. Refer to F-323. The Immediate Jeopardy was effective from 8/7/17 through 8/10/17. An acceptable Allegation of Compliance on 8/10/17, which removed the immediacy of the jeopardy, was received and corrective actions were validated through direct observation of the removal of all electrical power strips in the facility; direct care staff interviews regarding education; review of maintenance audits of rooms with electrical power strips and their removal; interview with the Maintenance Director to validate comprehension of the approved type of electrical power strips acceptable for use in the facility; and review of in-service training records dated 8/8/17-8/9/17. The Allegation of Compliance was verified by: 1. Observation validated the electrical power strip was removed from Resident #87's bed by the Social Worker on 8/7/17 at 9:30 AM, and the Maintenance Director had removed the electrical power strip from the resident's room, 305A, on 8/8/17 at 2:30 PM. 2. Review of the electrical power strip audit conducted on 8/8/17 and observation of resident rooms validated all the electrical power strips were removed from resident rooms on 8/9/17. Validation: by review of the letter sent to the resident's family regarding electrical power strip use; by interview with the Administrator on 8/9/17 at 12:22 PM in the classroom confirming the letter dated 8/9/17 was mailed to the families on electrical power strip use; by review of the list of family names the letter was mailed to; and by observation of the signage placed on bathroom doors in resident rooms that all electrical power strips must be approved by maintenance prior to use. Review of the email from the facility to the Life Safety Director at the State Agency validated the .Power strips providing power to non-patient-care-related equipment must be relocatable Power taps (RPT) listed as UL 1363 . Review of the admission packet verified the electrical power strips use had to be approved by the Maintenance Director prior to use. Interview with the Administrator on 8/9/17 at 12:22 PM in the classroom verified the Resident and Family Councils, scheduled for August 2017, included the approved power strip use information. 3. Interviews on 8/10/17 with 4 Housekeeping and Laundry staff, 3 Nurse Aides, 7 CNA's, 3 LPN's and 3 RN's between 8:55 AM and 9:30 AM validated they had been inserviced on no electrical power strips in the building unless approved by Maintenance and electrical power strips were to be mounted, not on the floor, and not in bed with residents. Review of the facility audit of staff in-servicing validated staff not on duty had been contacted to educate them on the electrical power strip use. Interview with the Maintenance Director on 8/10/17 at 9:30 AM on the D hall verified he had been educated by the Administrator on 8/9/17, on the approved type of electrical power strips acceptable in the facility. The Maintenance Director stated, Model 1363 was for personal equipment, and 1363A was for medical equipment. 4. Interview with the Administrator on 8/10/17 at 1:20 PM in her office validated she or her designee would monitor for continued compliance through weekly quality improvement audits. The findings will be reported immediately to the Administrator and in the subsequent morning QA (Quality Assurance) meeting. Audit findings will be discussed in facility QAPI (Quality Assurance and Performance Improvement) meetings. Noncompliance continues at a scope and severity of E for monitoring the effectiveness of corrective actions and evaluation of monitoring by the QA Committee. The facility is required to submit a plan of correction. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change Minimum Data Set ((MDS) dated [DATE] revealed Resident #22 scored 2 on the Brief Interview for Mental Status (BIMS) indicating she was severely cognitively impaired. Continued review of the MDS revealed Resident #22 required extensive assistance of 2 people for transfers, dressing, and grooming; was totally dependent on 2 people for bathing; was frequently incontinent of bladder and always incontinent of bowel. Medical record review revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly MDS dated [DATE] revealed Resident #26 scored 13 on the BIMS indicating she was cognitively intact. Continued review of the MDS revealed Resident #26 required supervision with transfers and ambulation; limited assistance of 1 person with dressing; supervision with toileting and grooming; limited assistance of 1 person for bathing; and was always continent of bowel and bladder. Medical record review revealed Resident #30 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #30 scored 12 on the BIMS indicating moderate cognitive impairment. Continued review of the MDS revealed Resident #30 required extensive assistance of 1 person for transfers, dressing, and grooming; was totally dependent on 1 person for bathing; was occasionally incontinent of bladder and always incontinent of bowel. Medical record review revealed Resident #49 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Significant Change MDS dated [DATE] revealed Resident #49 scored 11 on the BIMS indicating she had moderate cognitive impairment. Continued review of the MDS revealed Resident #49 required supervision with transfers,eating, toileting; required limited assistance with dressing and grooming; required physical help of 1 person with bathing; and was always continent of bowel and bladder. Medical record review revealed Resident #91 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Annual MDS dated [DATE] revealed Resident #91 scored 6 on the BIMS indicating she was severely impaired cognitively. Continued review of the MDS revealed Resident #91 required supervision with transfers and grooming; limited assistance with dressing and toileting; physical assistance of 1 person for bathing; and was frequently incontinent of bowel and bladder. During 1/2017 the facility had a birthday party for Resident #26 and pictures were taken of the occasion. Included in the pictures were Residents #49, #30, #91, #22, and #26. These pictures were later posted on social media. Interview with the Director of Nursing on 8/10/17 at 10:10 AM in the nurse's station revealed she was unaware of any instance of a Certified Nurse Aide (CNA) taking pictures of residents and posting them on social media. Interview with the Administrator on 8/10/17 at 10:20 AM in her office, revealed she was unaware of any CNA taking pictures of residents and posting them on social media. She spoke with Social Services and the Activity Director and neither of them was aware of such a posting. Telephone interview with CNA #1 on 8/10/17 at 3:54 PM revealed she did not take any pictures of the birthday party. Further interview revealed Social Services took the pictures at the birthday party. Then CNA #1 stated the activities assistant took the pictures on her phone; sent them to CNA #1 who posted them on her social media page for the daughter of Resident #26. Interview with the Director of Activities, on 8/10/17 at 4:10 PM in the classroom, revealed she did not send any pictures to CNA #1. The Admissions Coordinator put the pictures on the facility's social media page. Interview with the Admissions Coordinator, on 8/10/17 at 4:20 PM in the classroom, revealed the Admissions Coordinator and the Administrator had access to the social media page which was on the facility's web site. Further interview with the Admissions Coordinator revealed she did not send any pictures to staff, but staff can take pictures from the social media page and send them where they want. Interview with the Administrator on 8/10/17 at 4:45 PM in the Administrator's office, confirmed staff were not permitted to take pictures of residents and post them on social media, and confirmed this was exploitation of residents. Refer to F-323 K.

Based on observation and interview, the facility dietary department failed to serve residents hot food at or greater than 135 degrees Fahrenheit (F) and cold food at or less than 40 degrees F; and failed to maintain a sanitary environment in the production and meal service area in 3 observations. The findings included: Observation on 8/7/17 beginning at 12:00 PM in the dietary department resident mid-day meal trayline service revealed 1 resident tray delivery cart had been delivered to the 100 hall. Further observation revealed the dietary staff member calibrated the thermometer and obtained the following food temperatures on the trayline: Pureed Salisbury Steak was 124 degrees F. Pureed Asparagus was 132 degrees F. Peas and Carrots were 124 degrees F. Cheesecake stored on top of the milk chest was 46 degrees F. Pureed cheesecake stored on top of the milk chest was 52 degrees F. Interview with the staff member obtaining the food temperatures on 8/7/17 beginning at 12:00 PM in the dietary department confirmed the hot food was less than 135 degrees F and the cold food was more than 40 degrees F. Observation on 8/7/17 at 9:16 AM and 12:00 PM, and on 8/8/17 at 8:52 AM, of the dietary department ceiling revealed 2 vents over the steam table, 2 vents over a food preparation table, and 2 vents over the range area, had a heavy accumulation of blackened debris and could contaminate the food. Further observation revealed 2 ceiling air intake vents with a heavy accumulation of blackened debris. Interview with the Certified Dietary Manager on 8/8/17 at 8:52 AM in the dietary department confirmed the 2 ceiling air intake vents and the 6 ceiling air vents were dirty.

Based on medical record review, review of facility investigations, and interview, the facility failed to thoroughly investigate an allegation of abuse for Resident #120 and failed to timely report allegations of abuse for 3 residents (#119, #120, #16), and for 1 resident (#24) injury of unknown origin of 14 residents reviewed for abuse or injury injury of unknown origin. The findings included: Medical record review revealed Resident #120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the following: On 8/27/16 Resident #120 slapped Resident #57 on the face. On 8/31/16 Resident # 120 slapped Resident #57 on the face. Continued review revealed a guest/visitor witness statement dated 8/27/16 revealed the incident happened in the dining room. There were no witness statements for the 8/31/16 incident. Interview with the Administrator on 8/8/17 at 9:44 AM in the Administrator's office confirmed there were 2 instances of Resident #120 slapping Resident #57. Continued interview revealed the first instance was on 8/27/16 and the second instance was on 8/31/16; both incidents were reported to the State Agency in the same report on 9/2/16. Further interview revealed there was one witness statement documented on 8/27/16 by a visitor and there were no witness statements documented on 8/31/16. Continued interview confirmed the facility failed to report the alleged abuse in the required 24 hour time period for 2016 to the State Agency and the facility failed to thoroughly investigate the incident on 8/31/16. Medical record review revealed Resident #119 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the facility investigation revealed the resident reported the allegation of staff to resident verbal abuse, to the facility staff on 8/21/16 at 11:30 PM and the allegation was reported to the Administrator on 8/22/16 at 9:00 AM. Further review revealed the facility staff failed to report the allegation to the administrative staff immediately. Interview with the Administrator on 8/9/17 at 3:04 PM in the Administrator's office confirmed the allegation of verbal abuse was reported to facility staff on 8/21/16 at 11:30 PM by Resident #119. Continued interview revealed the allegation was reported to the State Agency on 8/23/16. Further interview confirmed the facility failed to timely report an allegation of abuse for Resident #119 in the required time of 24 hours for 2016 to the State Agency and failed to report to the facility administration immediately. Medical record review revealed Resident #16 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a facility investigation report dated 8/2/17 for an allegation of staff to resident physical abuse for Resident #16 revealed the facility reported the allegation to the State Agency on 8/2/17 within the 2 hour required timeframe to the State Agency. Further review revealed the facility failed to complete the investigation within 5 days in 2017 as required by the State Agency. Interview with the Administrator on 8/10/17 at 3:38 PM at the nurse's station confirmed the allegation of abuse was reported on 8/2/17 to the State Agency for Resident #16. Continued interview confirmed the facility failed to timely complete the investigation. Medical record review revealed Resident #24 was readmitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a nurse's note dated 5/10/17 at 1:57 PM revealed a purple bruise was discovered on Resident #24 on 5/10/17. Continued medical record review revealed administration was notified. Review of the facility investigation revealed the following: On 5/10/17 Resident #24 was found to have a bruise measuring 1 x 3 inches with a scratch down the center of the bruise (an injury of unknown origin). The resident stated it probably happened during transfer, but was unable to tell definitively how it occurred. Continued review revealed the bruise was found on 5/10/17 with no definitive cause. Further review revealed the facility first reported the incident with Resident #24's injury of unknown origin to the state agency on 5/16/17. Interview with the Administrator on 8/8/17 at 8:14 AM in her office revealed when the Administrator was asked when the incident involving Resident #24 took place, she stated on May 10. Further interview revealed when asked when the incident was reported to the State Agency, she stated it looks like May 16th. When asked if the incident was reported to the State Agency within the required 2 hour period, the Administrator confirmed the facility failed to report Resident #24's injury of unknown origin to the state agency timely.

Based on observation and interview, the facility failed to maintain 1 central bath (E-F hall) for 1 of 2 central baths in a safe and sanitary manner and for 1 random resident bathroom (301) of 46 resident rooms in a safe and sanitary manner. The findings included: Observations on 8/7/17 at 9:30 AM and 8/8/17 at 3:41 PM in the E-F central bath revealed 3 missing baseboard tiles on the wall to the right side of the bathtub. The missing tiles exposed the wet and blackened wooden wall studs. Continued observation revealed a commode chair beside the bathtub with black debris under the commode seat. Continued observation revealed two broken baseboard tiles located on the left side of the sink, 1 missing baseboard tile located to the left of the shower, and 1 cracked baseboard tile located under the wall socket and to the right of the bathtub. Further observation revealed multiple areas of peeling paint on all the walls. Continued observation revealed the railings of the permanent commode had dirty, gray and black stains on the straps. Observation on 8/8/17 at 8:02 AM in the bathroom of room 301 revealed peeling paint on the wall between the toilet paper holder and the shower. Interview with the Maintenance Director on 8/8/17 at 2:20 PM at the nurse's station revealed he was unaware the central bath needed repair and the facility had no specific procedure for informing maintenance of items needing repair. Continued interview confirmed the facility failed to repair the missing baseboard tiles in the E-F central bath. Interview with the Administrator on 8/8/17 at 4:25 PM at the nurse's station revealed the condition of the central bath has not been reported to me and that she would observe the bath when it was not in use. Interview with the Administrator on 8/8/17 at 5:20 PM in the E-F central bath confirmed 5 missing baseboard tiles, peeling paint to all walls, missing dry wall, 1 cracked base board tile, a penetrated, blackened wall where baseboard tiles were missing, and the dirty commode straps. The Administrator confirmed the facility failed to maintain the E-F central bath and room 301 bathroom in a safe and sanitary manner.

Based on record review, observation, interview, review of diet cards and policy review, the facility failed to provide timely assessments and interventions for the presence of signficant weight loss causing actual harm to 3 of 14 (Residents #47, #22, and #21) residents of the sample. The findings included: 1. Resident #47's [DIAGNOSES REDACTED]. The significant change Minimum (MDS) data set [DATE] revealed the resident had short and long term memory problems and severely impaired decision making skills. The resident required total assistance with activities of daily living, weighed 143 pounds, and was on a prescribed weight loss regimen. The nutrition Care Area Assessment (CAA) dated 5/27/15 revealed the resident was at risk for nutritional deficits related to he/she received a mechanically altered diet, received a therapeutic diet, weight loss and diagnoses. The resident had experienced an 11 pound weight loss in 30 days and 12 pound weight loss in 90 days. The updated care plan dated 5/27/15 listed the interventions and start dates: a. 4/27/11 - weigh monthly and more often if significant weight loss or gain, if occurs alert the family and physician, registered dietician to consult and dietician to assess for likes and dislikes as needed, obtain and monitor lab/diagnostic work as ordered, and report results to physician and follow up as needed. b. 12/10/12 - independent with meals after set-up. c. 9/9/14 - currently on diuretics. d. 10/15/14 - med pass 2.0 (nutritional supplement), 60 milliliters four times a day. e. 1/8/15 - no grapefruit products secondary to [MEDICAL CONDITION]. f. 1/19/15 - currently on [MEDICAL TREATMENT]. g. 2/27/15 - juven (protein supplement) two times a day and mix with 4 ounces of water. h. 4/7/15 - pureed, no added salt diet with large protein portions, 1600 milliliter fluid restriction diet. Dietary to provide 480 milliliters and nursing to provide 1020 milliliters. The weight list revealed Resident #47's weights as followed: a. 3/4/15 - 154.4 pounds (#). b. 3/23/15 - 151.1#. c. 4/10/15 - 157#. d. 5/4/15 - 152#. e. 5/19/15 - 141.9#. f. 5/29/15 - 136.4#. g. 6/8/15 - 132.8#. Consisting of a 21.6# or 13.98 percent (%) significant weight loss in 3 months. The 2/26/15 dietary note revealed the facility would increase the resident's med pass from 60 milliliters four times a day to 120 milliliters four times a day. The 4/7/15 dietary note lacked interventions for weight loss. The 5/12/15 registered dietician note recommended to continue nutritional supplements and continue current nutrition plan of care. The 5/20/15 quarterly dietary note revealed the resident had an 11 pound weight loss in 30 days. The recommendations were for staff to continue nutritional supplements and continue current nutrition plan of care. The 5/27/15 dietary note revealed the resident was under hospice care. The 5/28/15 dietary note revealed the resident had a significant weight loss from 5/4/15 and no new recommendations were made. The 6/9/15 dietary note revealed the resident continued to have weight loss, was on palliative care, and interventions were in place but the resident's intakes did not support the nutritional needs. No new recommendations made. Review of the facility provided list of residents on Hospice Care or comfort care lacked evidence this resident received comfort or hospice care. Observation on 6/10/15 at 12:45 PM, revealed Resident #47 laid in bed on his/her left side. Observation at 1:00 PM, revealed the resident's position remained unchanged and the resident ate only 1 to 2 bites of the pureed diet. Observation on 6/10/15 at 5:06 PM, revealed Resident #47 laid in bed on his/her left side and staff fed the resident. Observation of the resident's tray after the staff finished feeding the resident revealed, the resident ate 100 percent of the turnip greens, 5 percent of the pureed ham and beans, and a small amount of the soda. The staff did not attempt to feed the resident the bread or the orange sherbet and the staff did not attempt a substitute for the uneaten food or provide additional turnip greens. Interview with Direct Care Staff #13 on 6/10/15 at 1:00 PM, revealed Resident #47 required total assistance with meals. Interview with Licensed Nurse #5 on 6/11/15 at 10:50 AM, revealed the resident was turned down by 3 hospice agencies and was not on hospice at this time. Licensed nurse #5 stated the facility increased the resident's med pass from 60 milliliters to 120 milliliters on 2/27/15. Licensed Nurse #5 stated the facility did not fortify the resident's food to increase the calorie content. Licensed Nurse #5 was unable to list additional interventions for weight loss from March to May of 2015. Interview with Licensed Nurse #2 on 6/11/15 at 12:30 PM, stated the dietary manager coded the resident was on a prescribed weight loss regimen because he/she felt they had tried everything for the weight loss and the resident continued to lose weight. The facility provided Weight/Weight Loss policy dated 3/19/15 included: offer foods of choice and/or increased high calorie foods, evaluate needs for other high calorie, high protein supplements, refer to speech therapy and/or restorative as needed, and care plan significant weight loss. The facility failed to accurately assess, care plan, and provide timely interventions for the presence of weight loss for this dependent resident, which resulted in actual harm. 2. Resident #22's [DIAGNOSES REDACTED]. The significant change Minimum (MDS) data set [DATE] revealed staff did not assess the cognition status, the resident required supervision and set-up with eating, weighed 118 pounds (#), had experience weight loss, and was not on a prescribed weight loss regimen. The nutrition Care Area Assessment (CAA) dated 4/14/15 revealed the resident had experienced a four pound weight loss in 30 days and a 16 pound weight loss in 90 days. The resident received [MEDICATION NAME] to boost his/her appetite and refused med pass. The resident ate his/her meals in his/her room and the resident's consumptions would vary depending on the meal. The updated care plan dated 5/6/15 listed the interventions and dates: a. 1/6/11 - mechanical soft diet with ground meat and obtain and monitor labs as ordered. b. 1/7/11 - weights as ordered and report significant loss/gain to the physician, family, and registered dietician and registered dietician to consult as needed. c. 1/18/11 - encourage adequate nutritional intake at meal times and as needed. d. 1/9/12 - offer foods of choice within diet parameters for increased consumption and to decrease food complaints and update food preferences as needed related to the resident's many complaints about the food. e. 3/13/12 - no sugar packs on tray. f. 8/8/12 - receives dinner at 3:00 PM per the resident's request. g. 12/13/12 - resident is independent with meals. h. 5/14/15 - juven (protein supplement) two times a day. The Weight list revealed Resident #22 weighed: a. 12/1/14 - 142#. b. 1/5/15 - 137.2#. c. 2/2/15 - 135.4#. d. 3/7/15 - 128.4#. e. 3/16/15 - 125.8#. Consisting of a 16.2# or 11.4 percent significant weight loss in 3 months. The 1/22/15 laboratory results revealed: a. [MEDICATION NAME] 3.0 grams/deciliter (g/dl) with the normal range of 3.5-5.7 g/dl b. Hemoglobin 10.7 g/dl with the normal range of 12-16 g/dl c. Hematocrit 31.2 percent with the normal range of 36-46 percent. The dietary note date 1/12/15 revealed the resident had lost 5# in 30 days and no new recommendations were made. Review of the clinical record lacked evidence the dietician saw the resident during the weight loss until 4/14/15. Observation and interview on 6/10/15 at 8:30 AM, revealed Resident #22 had eaten breakfast The resident ate 70 percent of the fried egg and none of the toast. Resident #22 revealed he/she was unable to eat the toast and the white part of the fried egg because they were too tough to chew. Observation on 6/10/15 at 12:05 PM, revealed Resident #22 ate the noon meal in his/her room and ate spaghetti, peaches, orange juice and water. The resident did not eat the bread. Interview with Licensed Nurse #5 on 6/11/15 at 10:40 AM, revealed the facility did not fortify this resident's food. He/she could not provide any new interventions the facility initiated during the resident's weight loss from 12/14 to 3/16/15. Review of the facility provided Weight/Weight Loss policy dated 3/19/15 interventions included: Any resident with a significant weight loss will be added to weekly weights until weight stabilizes, will care plan significant weight loss, and refer to speech therapy and/or restorative as needed. The facility failed to provide timely interventions for the significant weight loss from December, 2014 to March, 2015, which resulted in actual harm. 3. Resident #21 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The current electronic physician's orders [REDACTED]. The Admission MDS dated [DATE] documented the resident required extensive assistance of one staff for eating and consumed a mechanically altered diet. The resident was 62 inches tall and weighed 131 pounds. Staff did not document the resident's cognitive condition. The CAA for nutrition dated 10/13/14 documented the resident had the potential for nutritional deficits related to consuming a mechanically altered and therapeutic diet. The Quarterly MDS dated [DATE] documented the resident had short and long term memory problems and required extensive assistance of staff for eating. The resident had a weight loss of five percent (5%) or more in the last month or ten percent (10%) or more in the last six (6) months. The Care Plan for nutrition dated 10/14/14 and revised 5/8/15 documented the resident had a 12.01 percent weight loss in 180 days; 10.51 percent weight loss in 90 days and 5.70 percent weight loss in 30 days. On 4/9/15 staff were directed to begin weekly weights for four (4) weeks. On 5/8/15 staff were directed to continue the weekly weights for another two (2) weeks for a trending downward weight loss. Staff were to provide Med Pass 2.0 sixty cubic centimeters (60cc's) four (4) times daily and encourage the resident to consume seventy-five percent (75%) of the meal daily. The resident ate meals independently. Dietary and Nursing staff were to interview the resident and discuss likes and dislikes for food preferences and the resident had the right to refuse the diet and request what he/she wanted to eat. Review of the Nurse's Progress Notes from 6/10/15 at 7:00 AM through 6/10/15 at 5:53 PM revealed staff did not document food was offered to the resident after the noon meal was offered in the dining room on 6/10/15. Review of the current Electronic Weight Record revealed staff documented 12/8/14 the resident weighed 131.0 pounds, then on 6/8/15 staff documented the resident weighed 107.0 pounds which indicated the resident had a significant weight loss of twenty-four pounds, (18.3%) weight loss in six (6) months. Staff also documented on 4/8/15 the resident weighed 115.8 pounds (a weight loss of (11.6%) a significant weight loss before the facility initiated nutritional interventions for supplements to help with the residents problem of weight loss. Review of the current Diet Cards revealed the Dislikes portion of the diet card was blank which indicated staff did not assess for the resident's food dislikes for any of the three meals. Staff also failed to assess or document the resident's Meal Preferences for lunch or supper. The Nourishments area of the Diet Cards was also blank. The Dietary Progress Note dated 10/14/14 documented the resident weighed 131 pounds. On 1/12/15 the Dietary Quarterly Note indicated the resident remained at risk for weight loss, had no nutritional supplements and weighed 129.4 pounds and needed weighed weekly for four weeks. The next Dietary Progress Note was not until 4/9/15 (after the resident had a weight loss of 10.51% in 90 days and 5.70% in 30 days) at which time a nutritional supplement was started. Further review of the Electronic Weight Record revealed staff failed to weigh the resident weekly for four weeks as the Dietary Progress Note indicated was needed on 1/12/15 and did not weigh the resident until 2/2/15 (18 days later) and documented the resident weighed 127.6 pounds (a 1.8 pound weight loss). On 3/4/15 staff documented the resident weighed 122.8 pounds (a weight loss of 6.6 pounds and no dietary assessment was documented since 1/12/15). Review of the Scanned Electronic Laboratory results from 12/1/14 to 6/11/15 revealed the facility failed to assess the resident's total protein or [MEDICATION NAME] levels during the period of the significant weight loss. Observation on 6/10/15 at 12:27 PM, revealed Resident #21 wheeled out of dining room with a clothing protector on. The resident's tray on the table remained covered with the plate cover and not eaten. Staff did not attempt to feed Resident #21. Observation on 6/10/15 from 12:27 PM to (-) 1:10 PM, revealed Resident #21 sat in the wheelchair. Staff did not attempt to offer food to the resident. Interview on 6/10/15 at 12:30 PM, Licensed Nurse #5 reported Resident #21 would not stay in one place, was kicking and would not eat anything of the pureed diet. They laid the resident down and would attempt to feed the resident later and staff would document that in the progress notes since that would not be a meal consumption. Observation and interview on 6/10/15 at 5:11 PM, revealed Direct Care Staff #10 fed Resident #21 (who was slumped down in bed) Ensure, turnip greens with ham, bread and tea. The resident made a grimace face when staff spooned the turnip greens and the ham and beans into his/her mouth. Staff said to the resident, you don't like the greens or the beans do you and continued to spoon feed the greens and beans to the resident without offering any alternate foods the resident may have liked. Direct Care Staff #10 said, he/she didn't eat nothing. The resident consumed approximately ten percent (10%) of the meal before he/she fell asleep. Interview on 6/11/15 at 12:33 PM, Licensed Nurse #1 reported the dietician should identify the weight loss first, then it is discussed in the risk meetings. Staff should assess and document resident food likes and dislikes and they make sure the resident is fed. The staff should have fed the resident in a restorative dining setting and did not know why restorative was not working with the resident. In the dining room staff should have released the seat belt, transferred the resident into a different chair for the meal and restorative should have worked with the resident to eat. The staff should not have fed the resident slumped down in bed for the supper meal and should have attempted to feed the resident an alternate food based on the resident's food preferences. The dietician was not available for interview and visited the facility once a week. Licensed Nurse #1 acknowledged the resident had significant weight loss and staff failed to weigh the resident as directed and timely interventions were not initiated to prevent further weight loss for this dependent and cognitively impaired resident. The facility failed to timely assess and implement interventions for significant weight loss, failed to assess food likes and dislikes and honor recognized food dislikes and failed to provide appropriate feeding assistance for a dependent resident with significant weight loss, which resulted in actual harm.