Every finding on record at Seasons Nursing and Rehab

Based on record review, resident interview, staff interview, and review of facility policy, the facility failed to provide a prompt rehabilitative (therapy) evaluation and failed to arrange needed therapy services. This effected one (#01) of three residents reviewed for specialized rehabilitative services. The facility census was 49.Findings include:Review of medical record revealed Resident #01 was admitted to the facility on [DATE]. Diagnoses included schizoaffective disorder, borderline personality disorder, psychosis, anxiety, major depression, hallucinations, post-traumatic stress disorder, type two diabetes, anemia, hypothyroid, lack of coordination, chronic kidney disease, parastomal hernia without obstruction or gangrene (ostomy hernia), encounter for surgical aftercare following surgery on the digestive system, muscle weakness, need for assistance with personal care, colostomy, rheumatoid arthritis.Review of Minimum Data Set (MDS) 3.0 Discharge Return Anticipated assessment dated , 05/29/26, revealed Resident #01's short term memory was adequate, the resident had moderately impaired cognitive skills. Resident #01 displayed physical and verbal behaviors but did not reject care. Supervision was needed for eating, oral hygiene. Resident #01 was dependent on staff for toilet hygiene, bathing and lower body dressing. Supervision was needed for personal hygiene. Supervision was needed to roll in bed, sit on the side of the bed, lie back in bed, stand from the bed, chair to bed transfer, toilet transfers. Resident #01 had an ostomy. Resident #01 did not receive speech therapy, occupational therapy or physical therapy minutes.Review of Plan of Care with a revision date of 05/28/26, revealed Resident #01 needed activities of daily living assistance related to weakness, chronic pain and cognitive status. Interventions included supervision for eating meals, oral hygiene, dressing, personal hygiene, bed mobility, wheelchair mobility, mechanical lift of two person transfers, and therapy as ordered for improvement in activities of daily living (ADLs).Review of facility document titled Occupational Therapy (OT) Discharge Summary with a date of service of 05/02/26 revealed Resident #01 needed Occupational Therapy for muscle weakness and for assistance with personal care. Resident #01 was discharged from OT care on 05/05/26 because Resident #01 was discharged to the hospital.Review of Transfer assessment dated [DATE] and timed 12:58 P.M., revealed Resident #01 had an unplanned transfer to the hospital on [DATE] due to abdominal pain. Resident #01 needed assistance with bathing, dressing, transfers, and toileting but was independent with eating. Resident #01 was not receiving rehabilitation therapy.Review of facility document titled Select Specialty Hospital Discharge Summary, dated 05/29/26 and timed 9:44 A.M. revealed Resident #01was hospitalized for a perforated posterior gastric ulcer (hole in the wall of the stomach) and incarcerated parastomal hernia (hernia around the ostomy). Resident #01 had an exploratory laparotomy with partial gastrectomy resection of gastric ulcer and relocation of stoma with partial colectomy and primary repair of parastomal hernia (an open abdominal surgery to treat a stomach ulcer, fix a hernia around your existing stoma, and remove part of the intestine), total parenteral nutrition ( nutrition that bypasses the gut) , acute kidney injury on chronic kidney disease, sepsis, intra-abdominal infection with vancomycin-resistant enterococci (VRE) (stomach or belly infection caused by antibiotic-resistant bacteria), debility and deconditioning. Resident #01 was admitted to the facility and received a physical and occupational therapy for the management of the chronic conditions.Review of facility document titled After Visit Summary, dated 05/29/26 for the dates of service between 05/16/26 to 05/29/26 revealed Resident #01 was discharged back to nursing home with instructions to continue Physical therapy (PT) to assist with transfers and wheelchair mobility and Occupational Therapy for the assistance with oral care, dressing, bathing and toileting was needed.Review of Re-entry MDS assessment dated [DATE] at 11:52 P.M. revealed Resident #01 was admitted from a hospital. Resident #01 had a surgical incision in the abdomen. A wheelchair was needed mobility.Review of Nursing to Therapy Referral assessment dated [DATE] at 11:03 P.M. revealed Resident #01 was post-operative with a healing abdominal incision. Pharmacological pain intervention was attempted and not effective. Reason for the referral included post operative weakness, decline in mobility and need for strengthen and functional rebab. Mobility included difficulty standing or walking, decreased wheelchair mobility, decreased bed mobility, increased weakness and increased assistance for transfers. Resident #01 had a decreased appetite and needed more assistance for grooming, dressing, toileting and bathing. After survey intervention a lock date of 06/10/26 at 12:40 P.M. was made by the Regional Director of Therapy #700, and the section to be completed by therapy was blank, a date stamp of 06/04/26 revealed the referral was received but no time stamp was made.Review of medical record Social Services assessment dated [DATE] at 3:00 P.M. revealed Resident #01 was readmitted to the facility on [DATE] and due to Resident #01's long hospitalization Resident #01 had a decline in physical abilities.Interview on 06/08/26 at 12:27 P.M. with Resident #01 revealed she was concerned that she had not seen therapy since she returned from her surgery and she was ordered and wanted to receive therapy.Interview on 06/09/26 at 4:31 P.M. with the Director of Nursing (DON) revealed a nurse could fill out a therapy referral form in the electronic medical record to alert the Director of Therapy for a need. The DON stated once the Director or Therapy received the referral they would assign a therapist to screen the resident. The DON verified under the Nurse to Therapy Referral Assessment, dated 05/30/26, the section to be completed by therapy had been dated 06/04/24 but there no documentation regarding the referral. The DON also verified Resident #01 had not been evaluated by therapy and therefore had not received any therapy services since returning to the facility on [DATE]. Interview on 06/10/26 at 9:27 A.M. with the Regional Director of Therapy (RDT) #700 stated the facility was without a Director of Therapy for the past two weeks. The RDT #700 stated she would come to the facility if there was a need. RDT #700 verified the Director of Therapy is the one to receive referrals from the nurse through the electronic medical record and after receiving would assign a therapist to screen the resident with three to five days of receiving the referral, adding if there was an identified need for therapy the order for therapy would be written. RDT #700 verified if a resident was in the hospital for twenty-three days a therapy screen would be appropriate. The RDT #700 verified Resident #01 was not screened and therefore had not received therapy services. Review of facility policy titled Therapy Evaluation, revised 06/25/26, revealed a licensed therapist would perform an initial evaluation upon referral and any re-evaluation where indicated.Review of facility policy titled admission and readmission of a Resident, dated 02/01/26, revealed within the first week of admission, the interdisciplinary team would meet with the resident and or resident representative to discuss goals of care.

Based on observation, record review, resident interview, staff interview, and review of facility policy the facility failed to ensure the oxygen tubing was changed and dated. This affected three (#20, #42 and #49) of three residents reviewed for oxygen therapy. The facility census was 49.Findings include:1. Review of Resident #20's medical record revealed an admission date of 09/10/12. Diagnoses included bipolar disorder, schizoaffective disorder, dementia, paranoid schizophrenia, lymphedema, morbid obesity, acute kidney failure, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, and hypertension.Review of Resident #20's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required set up to substantial assistance with activities of daily living (ADLs) and was on oxygen therapy.Review of the current physician orders for June 2026 revealed Resident #20 had an order for oxygen at one liter per minute per nasal cannula as needed to keep oxygenation saturation (SPO2) level above 93 percent.Observation on 06/08/26 at 8:02 P.M. revealed the resident was receiving oxygen therapy at 0.5 liters per minute via nasal cannula. The oxygen tubing was undated. Interview and observation on 06/08/26 at 10:27 A.M. with the Director of Nursing (DON) confirmed the oxygen tubing was to be dated and changed weekly. The DON confirmed Resident #20's oxygen tubing was not dated, and oxygen was being administered at 0.5 liters per min.2. Review of Resident #42's medical record revealed an admission date of 12/23/13. Diagnoses included COPD, emphysema, chronic respiratory failure with hypoxia, and hypercapnia, delusional disorders, anxiety, Alzheimer's dementia, rheumatoid arthritis.Review of Resident #42's quarterly MDS assessment dated [DATE] revealed intact cognition and required supervision with all ADLs and received oxygen therapy.Review of Resident #42's care plan dated 05/25/26 revealed the resident has complications related to COPD and requires oxygen therapy to maintain SPO2. Interventions include to keep the head of the bed elevated to promote optimal air exchange, administer oxygen as orders, give aerosols and bronchodilators as ordered and monitor for side effects, monitor for shortness of breath, document and report any shortness of breath, assist resident with in recharging concentrator and verify oxygen liter flow.Review of Resident #42's current physician orders for June 2026 revealed the resident was to receive oxygen via a concentrator at three liters per nasal cannula oxygen, with the ability to increase the oxygen to five liters per minute to keep SPO2 above 90 percent. Change oxygen tubing to concentrator and e-tank machine weekly on Sundays.Observation on 06/08/2026 10:13 A.M. revealed Resident #42 was receiving oxygen therapy using a concentrator at 3 liters per minute via nasal cannula. The oxygen tubing was not dated. Interview on 06/08/26 at 10:14 A.M. with Resident #42 revealed the resident was unable to remember when the oxygen tubing had been changed last, if ever.Interview on 06/08/25 at 10:25 with the DON confirmed Resident #42 had oxygen being administered at 3 liters per minute via nasal cannula and that the oxygen tubing was not dated. 3. Review of Resident #49's medical record revealed an admission date of 07/14/20. Diagnoses included dementia, major depressive disorder, anxiety, adjustment disorder, borderline personality disorder, atrial fibrillation, schizoaffective disorder Parkinson's disease, COPD, traumatic brain injury, history of COVID-19, chronic respiratory failure with hypoxia.Review of Resident #49's annual MDS assessment dated [DATE] revealed the resident had intact cognition and required set up to supervision for all ADLs and received oxygen therapy.Review of Resident #49's current physician orders dated June 2026 revealed an order to change oxygen tubing weekly on Sunday nights and for oxygen to be administered at three liters per minute via nasal cannula for shortness of breath.Interview on 06/08/26 at 10:20 A.M. with Resident #49 revealed she was unsure when the last time her oxygen tubing had been changed.Interview on 06/08/26 at 10:27 A.M. with the DON confirmed the oxygen tubing for Resident #49 was undated.Review of the facility policy titled Oxygen Administration, last revised 01/04/23 revealed oxygen is administered to residents who need it, consistent with professional standards of practice, comprehensive person-centered care plans, and the residents' goals and preferences. Staff were to change oxygen tubing weekly and as needed.

Based on observation, resident and staff interview, taste of a test tray, and review of the facility policy, the facility failed to ensure meals were served at a palatable temperature. This affected nine residents (#3, #6, #12, #13, #23, #27, #33, #40, and #45) and had the potential to affect all 47 residents residing at the facility who receive food from the kitchen. Findings include: Interviews on 03/03/25 between 10:07 A.M. and 11:00 A.M. with Resident #3, #6, #12, #23, #40 and #45 revealed their food was not warm enough when served. Observation and interview on 03/03/25 at 12:11 P.M. of the food/tray service in the dining room revealed the steam table sat in the dining room in front of the kitchen entrance door. Dietary Manager #221 and Dietary Assistant #232 were plating the residents food from the steam table. The meal included meatball subs with mozzarella cheese, French fries and strawberries and bananas mixed with cottage cheese. There was no steam coming from the steam table and the plug to the steam table was lying on the floor and not plugged in. Dietary Manager #221 stated there was no outlet within reach that supported the cord. The steam table was purchased approximately six months ago, and was used to serve all the residents meals since purchased but was never plugged in. Dietary Assistant #232 stated she poured hot water in the pans to keep the food warm prior to putting the food on the table. Observation revealed Dietary Assistant #232 lifted the pan the french fries were in and confirmed the water in the pan below it was chilled to touch. Interview in the dining room on 03/03/25 between 12:16 P.M. and 12:24 P.M. with Residents #45, #23, #13, and #27 stated their food was cold and was often served cold. Observation on 03/03/25 at 12:35 P.M. revealed six resident trays were served to resident rooms on a food cart. The last tray was a test tray. Observation on 03/03/25 at 12:40 P.M. with Dietary Manager #221 confirmed all residents trays were passed. Dietary Manager #221 observed, obtained food temperatures and tasted the food on the test tray with the surveyor. The cheese on the meatball sub appeared stiff and translucent. It was not appealing to the eye. The temperature of the french fries were 79 degrees Fahrenheit (F), the meatballs were 82 degrees F and the cottage cheese with strawberries and bananas were 59 degrees F. The meatballs tasted nearly room temperature; the french fries tasted cold/chilled inside. Dietary Manager #221 also tasted the food and confirmed the french fries tasted cold and the meatballs were not warm enough to taste palatable. Dietary Manager #221 stated the temperatures of the food were obtained after cooking it on the stove. Dietary Manager #221 confirmed the food temperatures were never obtained after placing it on the steam table and before serving it. Interview on 03/03/25 at 2:45 P.M. with Resident #33 stated his food was not hot enough when served. Review of the facility's undated policy titled Food Temperature Logs revealed to maintain a high level of quality assurance and to monitor potentially hazardous food temperatures as per state and federal health regulations thus ensuring that foods are provided in a safe, palatable manner. Food temperatures must be recorded on hot and cold foods prior to service. All employees are responsible for notifying their supervisor of any food items that are not in the regulated safe acceptable service ranges (below 41 degrees F or above 135 F). This deficiency represents non-compliance investigated under Complaint Number OH00161296.

Based on observation and resident and staff interview, the facility failed to ensure equipment used for storing and serving residents hot foods from was in good, working condition. This affected nine residents (#3, #6, #12, #13, #23, #27, #33, #40, and #45) and had the potential to affect all 47 residents residing at the facility who receive food from the kitchen. Findings include: Interview on 03/03/25 between 10:07 A.M. and 11:00 A.M. with Residents #3, #6, #12, #23, #40 and #45 stated their food was not warm enough when served. Observation and interview on 03/03/25 at 12:11 P.M. of the food/tray service in the dining room revealed the steam table sat in the dining room in front of the kitchen entrance door. Dietary Manager #221 and Dietary Assistant #232 were plating the residents' food from the steam table. There was no steam coming from the steam table and the plug to the steam table was lying on the floor and not plugged in. Dietary Manager #221 stated there was no outlet within reach that supported the cord. The steam table was purchased approximately six months ago, and was used to serve all the residents since purchased but was never plugged in. Dietary Assistant #232 revealed she poured hot water in the pans to keep the food warm prior to putting the food on the table. Observation revealed Dietary Assistant #232 lifted the pan the french fries were in and confirmed the water in the pan below it was chilled to touch. Additional interviews in the dining room on 03/03/25 between 12:16 P.M. and 12:24 P.M. with Residents #45, #23, #13, and #27 stated their food was cold and was often served cold. Interview on 03/03/25 at 2:45 P.M. with Resident #33 stated his food was not hot enough when served. This was an incidental finding during the complaint survey.

Based on observation, resident and staff interview, record review and review of the facility policy, the facility failed to ensure the resident's environment was maintained in a safe, sanitary. and comfortable environment. This affected one resident (#40) and had the potential to affect all 47 residents residing at the facility. Findings include: Record review for Resident #40 revealed an admitted [DATE]. Diagnoses included bipolar disorder, seizures, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #40 was cognitively intact. Observation on 03/03/25 at 10:24 A.M. of Resident #40's room revealed the walls had several deep gouges (make (a groove, hole, or indentation) with or as with a sharp tool or blade), in all of the walls. The walls were also dirty. There was a vent on the floor next to Resident #40's bed that was not secured to the floor and was approximately two to three inches shorter than the hole made for a floor vent. The bottom cove base was torn and partially removed from the walls. There was embedded dirt in all corners and base of the floor. Resident #40 stated it was always like that and he doesn't like it. Observation and interview on 03/03/25 at 10:35 A.M. with the Director of Nursing (DON) of Resident #40's room confirmed the walls with several long deep gouges, the missing and broken cove bases, the corroded dirt on the floors, and the unsecured vent on the floor that did not cover the entire hole. The DON confirmed the walls in the hallways of the facility had multiple chips, gouges and dirt on the walls, the cove bases had multiple areas throughout the facility that was beveled out and or missing pieces. The doorways leading to the shower room and entrances to additional hallways had multiple chips throughout the facility, large areas of missing and scraped paint and large gouges and indentations on both sides of the doorway frames. A vent located on the floor in the hall in front of room eight was indented in, not secured, beveled up on both sides and when stepped on, it lifted from the floor revealing the hole underneath. The DON confirmed all the above. Review of the facility policy titled Resident Environmental Quality dated 11/29/22 revealed it is the policy of this facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment for residents, staff and public. This was an incidental finding discovered during the complaint survey.

Based on record review, policy review, and interview, the facility failed to ensure all staff were checked against the Nurse Aide Registry (NAR) prior to employment to ensure the employee did not have a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. This had the potential to affect all 50 residents in the facility. Findings include: Review of the Employee Changes form revealed the facility hired fifteen new employees from 05/23/22 to 05/23/23. Of those fifteen new employees, the facility did not check seven new employees against the nurse aide registry (NAR) for indications of abuse including Registered Nurse (RN) #820 hired 10/13/22; Licensed Practical Nurse (LPN) #822 hired 10/19/22; Dietary Aide #831 hired 11/01/22; RN #815 hired 12/05/22; RN #809 hired 02/03/23; RN #837 hired 03/08/23; and Cook #830 hired 04/05/23. Interview on 05/23/23 at 10:55 A.M. with Business Office Manager(BOM)/Human Resources (HR) #805 confirmed all new hires were not checked against the nurse aide registry and she only checked the State tested Nursing Assistants (STNA's). Review of the facility policy titled, Abuse, Neglect and Exploitation, dated 10/01/22, revealed potential employees will be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property.

Based on observations, interview and record review, the facility failed to ensure that leftovers and food out of its original container were labeled and dated properly. This had the potential to affect all 50 residents receiving food from the kitchen. Findings include: A tour of the kitchen on 05/21/23 from 8:00 A.M. through 8:20 A.M. with Cook #828 revealed the following was not labeled or dated in the walk-in refrigerator: one half wrapped watermelon, a pan of cooked cheeseburgers, an opened bag with wilted salad mix, and a pan of fruited gelatin. In the freezer there was chicken and corn wrapped with no label or date on the bags. Cook #828 verified the findings and stated that everything that was opened must be labeled and dated. Interview on 05/22/23 at 2:30 P.M. with Registered Dietitian (RD) #901 revealed she audits the kitchen monthly and her concerns that have been addressed was labeling and dating of food. Review of the updated facility policy titled; Date Marking revealed an established procedure for date marking shall be utilized by the facility. Two options for date marking systems include: Use by date and Date of preparation/opening.

Based on interviews and record review, the facility failed to ensure resident assessments were timely completed and transmitted to the Centers for Medicare and Medicaid Services (CMS) System. This affected four (Residents #18, #30, #37 and #42) of 24 residents reviewed for resident assessments. The facility had a census of 50 residents. Findings include: 1. Review of the medical record for Resident #18 revealed an admitted [DATE] with diagnoses including schizoaffective disorder (a mental disorder that has symptoms of both schizophrenia and bipolar) and personal history of traumatic brain injury. Review of the Minimum Data Set (MDS) 3.0 Assessments for Resident #18 revealed he had a quarterly assessment dated for 04/12/23. The assessment was completed on 04/26/23 and stated export ready, however, had not been transmitted to the CMS system within 14 days. Interview on 05/21/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #807 verified Resident #18's quarterly MDS assessment dated [DATE] was not transmitted to the CMS system within the 14 days after completion. She stated it should have been submitted by 05/10/23. 2. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the Minimum Data Set (MDS) 3.0 Assessments for Resident #30 revealed he had a quarterly assessment dated for 04/14/23. The assessment was completed on 04/28/23 and stated export ready, however, had not been transmitted to the CMS system within 14 days. Interview on 05/21/23 at 3:24 P.M. with LPN #807 verified Resident #30's quarterly MDS assessment dated [DATE] was not transmitted to the CMS system within the 14 days after completion. She stated it should have been submitted by 05/12/23. 3. Review of the medical record revealed Resident #37 was admitted on [DATE] with diagnoses including diabetes mellitus and bipolar disorder. Review of the Minimum Data Set (MDS) 3.0 Assessments for Resident #37 revealed she had a quarterly assessment dated for 04/14/23. The assessment was completed on 04/28/23 and stated export ready, however, had not been transmitted to the CMS system within 14 days. Interview on 05/21/23 at 3:24 P.M. with LPN #807 verified Resident #37's quarterly MDS assessment dated [DATE] was not transmitted to the CMS system within the 14 days after completion. She stated it should have been submitted by 05/12/23. 4. Review of the medical record revealed Resident #42 was admitted on [DATE] with diagnoses including diabetes mellitus and anxiety. Review of the Minimum Data Set (MDS) 3.0 Assessments for Resident #42 revealed he had a quarterly assessment dated for 04/12/23. The assessment was completed on 04/26/23 and stated export ready, however, had not been transmitted to the CMS system within 14 days. Interview on 05/21/23 at 3:24 P.M. with LPN #807 verified Resident #42's quarterly MDS assessment dated [DATE] was not transmitted to the CMS system within the 14 days after completion. She stated it should have been submitted by 05/10/23.

Based on observations, interviews and record review, the facility failed to ensure staff assisted residents with grooming and provide showers per resident preference and schedule. This affected four (Residents #12, #24, #30 and #34) of four reviewed for activities of daily living. The facility had a census of 50 residents. Findings include: 1. Review of the medical record for Resident #12 revealed an admitted [DATE] with diagnoses including Schizophrenia, diabetes mellitus, depression and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #12 revealed he had impaired cognition. He needed extensive assistance of one staff member for toileting, limited assistance of one staff member for personal hygiene and physical help of one staff member during bathing. Review of the facility shower schedule, undated, revealed Resident #12 was to have showers on Mondays and Thursdays on dayshift. Review of the State tested Nurse Aide (STNA) Point of Care (POC) documentation and shower sheets dated from 04/24/23 through 05/18/23, revealed Resident #12 did not receive showers on 05/11/23 and 05/15/23. There were no refusals of showers noted. Interview on 05/21/23 at 9:04 A.M. with Resident #12 revealed he didn't get his showers as scheduled. Observations of Resident #12 on 05/21/23 through 05/23/23 revealed he was in the same clothing each day. Interview on 05/22/23 at 11:24 A.M. with Licensed Practical Nurse (LPN) #807 revealed there was no further documentation related to Resident #12's showers. She verified he did not receive his showers as scheduled. 2. Review of the medical record for Resident #24 revealed an admitted [DATE] with diagnoses including paraplegia and personal history of traumatic brain injury. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #24 revealed he had intact cognition. He needed extensive assistance of one staff member for transfers, dressing, toileting and personal hygiene. For bathing he was totally dependent on one staff member. Review of the facility shower schedule, undated, revealed Resident #24 was to have showers on Tuesday and Friday on dayshift. Review of the State tested Nurse Aide (STNA) Point of Care (POC) documentation and shower sheets dated from 04/24/23 through 05/22/23, revealed Resident #24 did not receive showers on 05/05/23, 05/09/23, 05/16/23 and 05/19/23. There were no refusals of showers noted. Interview on 05/21/23 at 8:50 A.M. with Resident #24 revealed he didn't get his showers as scheduled. He was observed to have food debris on his shirt during the interview on 05/21/23 at 8:50 A.M. and on 05/23/23 at 9:45 A.M. Interview on 05/22/23 at 11:24 A.M. with Licensed Practical Nurse (LPN) #807 revealed there was no further documentation related to Resident #24's showers. She verified he did not receive his showers as scheduled. 3. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #30 revealed he had intact cognition. He did have inattention that was continuous. He needed extensive assistance from one staff member for toileting and limited assistance of one staff member for personal hygiene. Review of Resident #30's care plan dated 11/24/21 and last updated on 04/18/23 revealed he needed assistance with activities of daily living related to cognitive impairment and hemiparesis. Gait was unstable at times. The care plan stated he would ask staff to assist him in tasks he was capable of doing for attention stating he could not do them. Interventions including for staff to assist as needed with daily hygiene. Review of the nursing progress note dated 04/13/23 at 1:53 A.M. revealed Resident #30 had put on his call light to have his bedding changed and asked for another pull-up (brief). The State tested Nurse Aide (STNA) provided him with the pull-up and assisted him with getting cleaned up. While the STNA was changing his bedding, he began screaming at her for her to put his pull-up on him. The nurse then approached him and he stated for the nurse to put his pull-up on him if the STNA would not. He was noted to be cursing during the interaction. The nurse was noted to instruct the resident to put his pull-up on so he could get back to bed. Resident #30 was noted to become increasingly agitated due to staff not assisting him with care. Interview on 05/21/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #807 verified staff should have assisted Resident #30 with pulling up his brief after an incontinent episode on 04/13/23. She stated he usually does not become aggressive during care and his behaviors potentially increased as the staff did not assist him with care. 4. Review of the medical record for Resident #34 revealed an admitted [DATE] with diagnoses including anti-social personality disorder, anxiety and dementia. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #34 revealed he had impaired cognition. He needed extensive assistance of one staff member for transfers, toileting and personal hygiene. For bathing he needed physical assistance of one staff member. Review of the facility shower schedule, undated, revealed Resident #34 was to have showers on Tuesday and Friday on nightshift. Review of the State tested Nurse Aide (STNA) Point of Care (POC) documentation and shower sheets dated from 04/24/23 through 05/19/23, revealed Resident #34 did not receive showers on 05/05/23, 05/08/23, 05/12/23, 05/15/23 and 05/19/23. There were no refusals of showers noted. Interview on 05/21/23 at 8:55 A.M. with Resident #34 revealed he didn't get his showers as scheduled. Interview on 05/22/23 at 11:24 A.M. with Licensed Practical Nurse (LPN) #807 revealed there was no further documentation related to Resident #34's showers. She verified he did not receive his showers as scheduled. Review of the facility policy titled, Personal Care Procedure, revised July 2018, revealed the facility would provide and assist resident care and hygiene to each resident based on their individual status and needs. Residents who needed assist would be assisted with as much help as needed. The staff may need to provide total resident care to residents when they are too ill, too confused or physically unable to do it themselves. Bath/shows may be given at any time the resident chooses. Staff were to document care given in STNA POC or nursing progress notes. Staff were to complete shower sheets for scheduled and as needed showers that were given or refused.

Based on observation and staff interview, the facility failed to ensure a clean and well-maintained environment. This affected six residents (Resident #3, #5, #12, #23, #27, and #45) with the potential to affect all 50 residents residing in the facility. Findings include: 1. Observation on 05/21/23 at 8:45 A. M. revealed Resident #3's wheelchair was dirty with dust and dried food on it. Observation verified by Registered Nurse (RN) #843 at time of observation was dirty. 2. Observation on 05/21/23 at 8:48 A.M. revealed Resident #5's chest harness restraint and wheelchair was dirty with dust and dried food on it. Interview at time of observation with State tested Nursing Assistant (STNA) #900 stated she was not sure how to clean the chest harness restraint. 3. An environmental tour was conducted on 05/22/23 from 09:40 AM to 10:05 AM with confirmation from Maintenance Director #808 and Housekeeping Supervisor #847 of the following concerns: a. liquid splatter on hallway walls in the dining room and outside of Resident #3's room. b. Resident #12's dresser had missing handles on two of the drawers and there was dried liquid splatter on the dresser. c. Resident #27 and Resident #45's privacy curtains were dirty. Interview on 05/22/23 at 9:50 A.M. with Maintenance Director #808 revealed he was in the process of painting the facility. Interview on 05/22/23 at 10:00 A.M. with Housekeeping#847 revealed the housekeeping department was short staffed. Review of the facility policy titled, Resident Environmental Quality, dated 11/29/22 revealed it was the policy of this facility to make every effort to design, construct, equip, and maintain areas to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. 34297 4. Review of Resident #23's medical record revealed he was readmitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease and schizophrenia. Review of Resident #23's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited moderate cognitive impairment and was always incontinent of bowel and bladder. Review of Resident #23's Skin Integrity Care Plan indicated he had multiple amputations and scarring areas from burns. He used a motorized wheelchair that he had in constant motion which caused him to bump his leg on things he was unaware of. Observation on 05/21/23 at 8:54 A.M. revealed Resident #23 was in his room in his motorized wheelchair. The motorized wheelchair appeared to have a soiled seat cushion and the chair smelled of urine. Observation on 05/22/23 at 8:20 A.M. with Rehab Director #844 of Resident #23's wheelchair revealed the chair was in the hall and the resident was in bed. The chair appeared to have a slit in the left lateral arm area approximately three inches long with the hard plastic sticking out of the hole. Rehab Director #844 confirmed the chair smelled of urine and was not maintained in a clean and sanitary manner. She also stated she was unaware Resident #23's motorized wheelchair had damage to the left lateral arm and she would have the damage repaired.

Based on observations, interviews and record review, the facility failed to ensure residents were able to exercise their rights without coercion related to smoking. This affected four (Residents #12, #24, #30 and #34) of the 19 residents who smoked but had the potential to affect all residents (Residents #4, #6, #10, #11, #12, #19, #20, #21, #23, #24, #26, #28, #29, #30, #31, #34, #35, #38 and #43) who smoked. The facility census was 50. Findings include: 1. Review of the medical record revealed Resident #12 was admitted on [DATE] with diagnoses including schizophrenia (a mental disorder having delusions, hallucinations, disorganized thoughts, speech and behavior), dementia and anxiety. His mother was his legal guardian. Review of the admission packet and agreement dated 05/16/13 revealed Resident #12's legal guardian signed for resident rights including that the center must ensure the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the center. There was no mention of behavior modification use with taking away smoke breaks or the use of facility equipment, rooms, and activities being considered privileges that could be modified or revoked in order to dis-incentivize inappropriate behaviors. Review of the Nursing Smoking assessment dated [DATE] revealed Resident #12 smoked five to ten times per day, could not light his own cigarette and needed supervision. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #12 had impaired cognition and had inattention that fluctuated, had delusions and hallucinations. Review of the facility designated smoking times revealed residents could smoke at 8:30 A.M, 10:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., 8:30 P.M. and 10:30 P.M. The designated smoking location was in the covered area in the courtyard. Observations on 05/23/23 for designated smoking breaks revealed smoke breaks were late due to staff not providing smoking materials timely for the break at 10:30 A.M. (arrived at 10:39 A.M.). Interview on 05/21/23 at 9:23 A.M. with Resident #12 revealed staff would take away his smoke breaks if they felt he did something wrong. He stated he did not feel like staff were respecting his rights. Interview on 05/21/23 at 1:01 P.M. with the Director of Nursing (DON) stated the facility did behavior modification for smoking privileges. She stated everything at the facility was a privilege for the residents and if the residents did not shower, change their clothes, eat their meals, etcetera, then they withhold their smoke break times. She stated this was the standard of practice in the building and the facility did not have the residents or guardians sign anything related to this upon admission to the facility. Interview on 05/21/23 at 2:45 P.M. with the Administrator stated the staff adhere to the designated smoke times and if residents were not there exactly at the designated time, they did not get a cigarette. The Administrator stated residents were allowed to have one cigarette and the facility did not bend the rules for anyone on the designated smoke break times. Interview on 05/22/23 at 1:15 P.M. with Registered Nurse (RN) #809 verified he allowed residents to be up to seven minutes late for smoke break. He stated the staff do not update residents when smoke-breaks are during the day as residents know when their smoke breaks happened. Interview on 05/23/23 at 8:57 A.M. with Licensed Practical Nurse (LPN) #812 stated she provided smoking materials to residents at smoke breaks at times. She stated she would allow two extra minutes for residents to get to smoke breaks before she would not provide them cigarettes. She stated if a resident had behaviors they did not get to smoke. Interview on 05/24/23 at 7:10 A.M. with State tested Nurse Aide (STNA) #834 verified she was the STNA who assisted residents at their 10:30 A.M. smoke break on 05/23/23 and was nine minutes late. She stated each team member is assigned a specific smoke break for the residents. She stated the other STNA was late with the break so she went to the courtyard to assist with the residents smoking time. She stated she would provide cigarettes to residents up to ten minutes after the smoke break starts to ensure residents get to have a cigarette. She stated she does not alert residents it is time to smoke prior to the break starting. She stated the staff are late at times for the smoke breaks but if another staff member notices this, another staff member will do the smoke break. 2. Review of the medical record revealed Resident #24 was admitted on [DATE] with diagnoses including personal history of traumatic brain injury, dementia and schizoaffective disorder (a mental disorder that has symptoms of both schizophrenia and bipolar). Resident #24 did have a legal guardian. Review of the admission packet and agreement dated 09/14/20 revealed Resident #24's legal guardian signed for resident rights including that the center must ensure the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the center. There was no mention of behavior modification use with taking away smoke breaks or the use of facility equipment, rooms, and activities being considered privileges that could be modified or revoked in order to dis-incentivize inappropriate behaviors. Review of the nursing progress notes dated from 06/13/22 through 05/17/23 for Resident #24 revealed staff would withhold smoke breaks during the allotted smoke break times. Nursing progress note dated 10/29/22 at 6:34 P.M. stated Resident #24 had asked nursing about smoking. He was told nothing was to be decided until after he ate dinner. He began yelling and attempting to kick the nurse. Resident #24 refused to eat dinner related to not being able to smoke. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 had intact cognition and no behaviors. Review of the Nursing Smoking assessment dated [DATE] revealed Resident #24 smoked five to ten times per day, could not light his own cigarette and needed supervision. Review of the facility designated smoking times revealed residents could smoke at 8:30 A.M, 10:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., 8:30 P.M. and 10:30 P.M. The designated smoking location was in the covered area in the courtyard. Observations on 05/23/23 for designated smoking breaks revealed smoke breaks were late due to staff not providing smoking materials timely for the break at 10:30 A.M. (arrived at 10:39 A.M.). Interview on 05/21/23 at 1:01 P.M. with the DON stated the facility did behavior modification for smoking privileges. She stated everything at the facility was a privilege for the residents and if the residents did not shower, change their clothes, eat their meals, etcetera, then they withhold their smoke break times. She stated this was the standard of practice in the building and the facility did not have the residents or guardians sign anything related to this upon admission to the facility. Interview on 05/21/23 at 2:45 P.M. with the Administrator stated the staff adhere to the designated smoke times and if residents were not there exactly at the designated time, they did not get a cigarette. The Administrator stated residents were allowed to have one cigarette and the facility did not bend the rules for anyone on the designated smoke break times. Interview on 05/22/23 at 1:15 P.M. with RN #809 verified he allowed residents to be up to seven minutes late for smoke break. He stated the staff do not update residents when smoke-breaks are during the day as residents know when their smoke breaks happened. Interview on 05/23/23 at 8:57 A.M. with LPN #812 stated she provided smoking materials to residents at smoke breaks at times. She stated she would allow two extra minutes for residents to get to smoke breaks before she would not provide them cigarettes. She stated if a resident had behaviors they did not get to smoke. Interview on 05/24/23 at 7:10 A.M. with STNA #834 verified she was the STNA who assisted residents at their 10:30 A.M. smoke break on 05/23/23 and was nine minutes late. She stated each team member is assigned a specific smoke break for the residents. She stated the other STNA was late with the break so she went to the courtyard to assist with the residents smoking time. She stated she would provide cigarettes to residents up to ten minutes after the smoke break starts to ensure residents get to have a cigarette. She stated she does not alert residents it is time to smoke prior to the break starting. She stated the staff are late at times for the smoke breaks but if another staff member notices this, another staff member will do the smoke break. 3. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Resident #30 did have a legal guardian. Review of the admission packet and agreement dated 08/25/21 revealed Resident #30's legal guardian signed for resident rights including that the center must ensure the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the center. There was no mention of behavior modification use with taking away smoke breaks or the use of facility equipment, rooms, and activities being considered privileges that could be modified or revoked in order to dis-incentivize inappropriate behaviors. Review of the nursing progress notes dated from 05/20/22 through 05/17/23 for Resident #30 revealed staff would withhold smoke breaks during the allotted smoke break times. Nursing progress note dated 04/19/23 at 9:21 P.M. stated Resident #30 went to the nurse's station at 8:38 P.M. (eight minutes after designated smoke break) demanding to be given a cigarette. He was observed to be screaming and cursing at staff. Resident #30 was advised that he needed to step away from the nurse's station and go to a common area or his room. He was told by the nurse that he was not smoking as he was not listening and was screaming at other residents. Resident #30 was observed in the hallway for 35 minutes punching himself in his head with a closed fist. After the nurse's failed attempt to intervene a new physician order for Ativan (anti-anxiety medication) was provided by the physician to calm Resident #30. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #30 had intact cognition though did have inattention continuously. Review of Resident #30's care plan dated 01/20/23 revealed he had a potential for safety hazard or injury related to smoking. Intervention dated 03/31/23 related staff were to remind him when it was time for him to smoke. Review of the Nursing Smoking assessment dated [DATE] revealed Resident #30 smoked five to ten times per day, was an independent smoker, could light his own cigarette and needed supervision. Review of the facility designated smoking times revealed residents could smoke at 8:30 A.M, 10:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., 8:30 P.M. and 10:30 P.M. The designated smoking location was in the covered area in the courtyard. Observations on 05/23/23 for designated smoking breaks revealed smoke breaks were late due to staff not providing smoking materials timely for the break at 10:30 A.M. (arrived at 10:39 A.M.). Interview on 05/21/23 at 1:01 P.M. with the DON stated the facility did behavior modification for smoking privileges. She stated everything at the facility was a privilege for the residents and if the residents did not shower, change their clothes, eat their meals, etcetera, then they withhold their smoke break times. She stated this was the standard of practice in the building and the facility did not have the residents or guardians sign anything related to this upon admission to the facility. Interview on 05/21/23 at 1:18 P.M. with Resident #30 revealed if he was bad he would not get to smoke. He stated if he was late, he would also not be able to smoke. Interview on 05/21/23 at 2:45 P.M. with the Administrator stated the staff adhere to the designated smoke times and if residents were not there exactly at the designated time, they did not get a cigarette. The Administrator stated residents were allowed to have one cigarette and the facility did not bend the rules for anyone on the designated smoke break times. Interview on 05/22/23 at 1:15 P.M. with RN #809 verified he allowed residents to be up to seven minutes late for smoke break. He stated the staff do not update residents when smoke-breaks are during the day as residents know when their smoke breaks happened. Interview on 05/23/23 at 8:57 A.M. with LPN #812 stated she provided smoking materials to residents at smoke breaks at times. She stated she would allow two extra minutes for residents to get to smoke breaks before she would not provide them cigarettes. She stated if a resident had behaviors they did not get to smoke. Interview on 05/24/23 at 7:10 A.M. with STNA #834 verified she was the STNA who assisted residents at their 10:30 A.M. smoke break on 05/23/23 and was nine minutes late. She stated each team member is assigned a specific smoke break for the residents. She stated the other STNA was late with the break so she went to the courtyard to assist with the residents smoking time. She stated she would provide cigarettes to residents up to ten minutes after the smoke break starts to ensure residents get to have a cigarette. She stated she does not alert residents it is time to smoke prior to the break starting. She stated the staff are late at times for the smoke breaks but if another staff member notices this, another staff member will do the smoke break. 4. Review of the medical record revealed Resident #34 was admitted on [DATE] with diagnoses including anxiety, personality disorder, anti-social personality disorder and dementia. Resident #34 did have a legal guardian. Review of the admission packet and agreement dated 05/22/15 revealed Resident #34's legal guardian signed for resident rights including that the center must ensure the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the center. There was no mention of behavior modification use with taking away smoke breaks or the use of facility equipment, rooms, and activities being considered privileges that could be modified or revoked in order to dis-incentivize inappropriate behaviors. Review of the Nursing Smoking assessment dated [DATE] revealed Resident #34 smoked five to ten times per day, could light his own smoker and was an independent smoker. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #34 had intact cognition though did have inattention and disorganized thinking that fluctuates. Review of the facility designated smoking times revealed residents could smoke at 8:30 A.M, 10:30 A.M., 1:30 P.M., 3:30 P.M., 6:30 P.M., 8:30 P.M. and 10:30 P.M. The designated smoking location was in the covered area in the courtyard. Observations on 05/23/23 for designated smoking breaks revealed smoke breaks were late due to staff not providing smoking materials timely for the break at 10:30 A.M. (arrived at 10:39 A.M.). Interview on 05/21/23 at 8:57 A.M. with Resident #34 revealed he was told that he had to eat in order to smoke. He also stated if he said bad words the staff automatically took his smoke breaks away. Interview on 05/21/23 at 1:01 P.M. with the DON stated the facility did behavior modification for smoking privileges. She stated everything at the facility was a privilege for the residents and if the residents did not shower, change their clothes, eat their meals, etcetera, then they withhold their smoke break times. She stated this was the standard of practice in the building and the facility did not have the residents or guardians sign anything related to this upon admission to the facility. Interview on 05/21/23 at 2:45 P.M. with the Administrator stated the staff adhere to the designated smoke times and if residents were not there exactly at the designated time, they did not get a cigarette. The Administrator stated residents were allowed to have one cigarette and the facility did not bend the rules for anyone on the designated smoke break times. Interview on 05/22/23 at 1:15 P.M. with RN #809 verified he allowed residents to be up to seven minutes late for smoke break. He stated the staff do not update residents when smoke-breaks are during the day as residents know when their smoke breaks happened. Interview on 05/23/23 at 8:57 A.M. with LPN #812 stated she provided smoking materials to residents at smoke breaks at times. She stated she would allow two extra minutes for residents to get to smoke breaks before she would not provide them cigarettes. She stated if a resident had behaviors they did not get to smoke. Interview on 05/24/23 at 7:10 A.M. with STNA #834 verified she was the STNA who assisted residents at their 10:30 A.M. smoke break on 05/23/23 and was nine minutes late. She stated each team member is assigned a specific smoke break for the residents. She stated the other STNA was late with the break so she went to the courtyard to assist with the residents smoking time. She stated she would provide cigarettes to residents up to ten minutes after the smoke break starts to ensure residents get to have a cigarette. She stated she does not alert residents it is time to smoke prior to the break starting. She stated the staff are late at times for the smoke breaks but if another staff member notices this, another staff member will do the smoke break. Review of the facility list of smokers, revealed there were 19 residents (Residents #4, #6, #10, #11, #12, #19, #20, #21, #23, #24, #26, #28, #29, #30, #31, #34, #35, #38 and #43) who smoked. Review of the facility policy titled, Resident Smoking, revised 12/13/21, revealed that any resident who was deemed safe to smoke would be allowed to smoke in designated smoking areas at designated times with supervision. Review of the new facility policy provided by the Administrator titled, Behavior Modification Policy, dated May 2023, revealed that residents, guardians, and staff at Seasons were under the understanding that the use of the facility's equipment, rooms and activities were considered privileges for the purpose of behavior modification and may be modified or revoked in order to dis-incentivize inappropriate behavior. The examples listed were if a resident became disruptive in the dining room during meal times they may no longer be permitted to eat meals in the dining room as well as if a resident was inappropriate with peers or staff may lose his/her next smoking privilege.

Based on record review and interview, the facility failed to ensure Resident #6 received adequate supervision to prevent the resident from eloping from the secured facility and failed to complete neurological assessments for Residents #30 and #36 after a fall. This finding affected one (Resident #6) of one resident reviewed for elopement and two (Residents #30 and #36) of three residents reviewed for falls. Findings include: 1. Review of Resident #6's medical record revealed he was admitted on [DATE] with diagnoses including schizoaffective disorder bipolar type, anxiety disorder, paranoid schizophrenia, and suicidal ideations. Review of Resident #6's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition. Resident #6 had a guardian of person. Review of Resident #6's Police Report form dated 03/17/22 at 12:13 A.M. indicated a caller reported a male wearing all black was sitting on the curb near a main intersection. He was located walking southbound on the road and the male was identified as Resident #6. Resident #6 stated he was homeless and was out walking. He was returned to the facility. Review of Resident #6's Wander/Elopement Assessment form dated 03/20/23 indicated he was at risk for elopement. Review of Resident #6's Police Report form dated 04/29/23 at 5:36 P.M. indicated the police were dispatched to the facility after Registered Nurse (RN) #809 reported the resident was missing from the facility. He was located on another road and was transferred back to the facility with no further issues. Review of Resident #6's progress note dated 04/29/23 at 3:24 P.M. (documented as a late entry for 05/05/23) authored by Licensed Practical Nurse (LPN) #812 indicated the resident returned to the building at approximately 6:30 P.M. He remained anxious at the time and stated he left because the walls were closing in on him. He stated he hitchhiked to the gas station and the driver gave him $20.00 (twenty dollars) which he used to purchase cigarettes, a lighter and soda. No injuries were noted and the guardian was made aware. Interview on 05/22/23 at 11:31 A.M. with LPN #812 indicated she worked on 04/29/23 and she was told by RN #809 that the therapy door alarmed. She stated she did a head count and determined Resident #6 was missing. LPN #812 stated they immediately called the police and then did a sweep of the grounds looking for the resident. She confirmed the resident was not on the grounds. LPN #812 indicated he left around dinner time on 04/29/23 at approximately 5:30 P.M. and returned to the facility on [DATE] at approximately 6:30 P.M. She stated he had went to the road and then hitchhiked to the gas station with money he borrowed from the driver and purchased items from the store. LPN #812 stated she documented the late progress note dated 04/29/23 on 05/05/23 per the request of the administrative staff. Interview on 05/22/23 at 11:40 A.M. with RN #809 confirmed he had heard the 15 second alarm for the therapy door go off and he looked outside and did not see any residents on the lawn. He stated sometimes the wind would make the door alarm go off but he told LPN #812 just in case. He confirmed the facility was searched and they had identified Resident #6 was missing. RN #809 stated the staff searched the grounds and called the police. He confirmed Resident #6 returned to the facility approximately one hour later and no injuries were noted. Interview on 05/22/23 at 11:57 A.M. with the Director of Nursing (DON) indicated she received a call from the facility (she was at home) informing her that Resident #6 was missing. She stated by the time she had arrived in the facility, Resident #6 had been returned. The DON stated Resident #6 knew each exit and when the exits would be unsupervised. She stated Resident #6 went out the secured therapy exit door when he pushed the 15 second alarm and staff were either in the dining room or providing care to other residents and would not hear the alarm. The DON confirmed Resident #6 left the facility unsupervised and had the potential to be a danger to himself while out of the secured facility. Review of the Elopement policy revised 07/25/18 indicated the facility would identify residents with potential and/or actual risk factors for elopement and protect the resident through development and implementation of safety interventions. In the event of a resident elopement, the facility would implement its policies and procedures immediately to locate the resident in a timely manner. 43063 2. Review of the medical record revealed Resident #30 was admitted on [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the nursing progress note dated 05/21/23 at 5:48 P.M. revealed Resident #30 had an unwitnessed fall in the courtyard. Resident #30 was then started on neurological assessments (which include the residents blood pressure, pulse, respirations, temperature, how their pupils react and if the resident was alert and oriented). Review of the First 24 Hour Neurological Evaluation Flow Record dated 05/21/23 revealed staff were to assess Resident #30 at different time intervals listed on the form. The times listed by staff did not follow the correct intervals per the form's instructions as well as having three timed assessments not completed by staff. Interview on 05/23/23 at 8:57 A.M. with Licensed Practical Nurse (LPN) #812 verified the Neurological Evaluation Flow Sheet for Resident #30's fall on 05/21/23 was not correctly filled out as the times listed to assess the resident were incorrect and did not follow the directions as well as three neurological assessments at the every four hour checkpoints were not performed by nursing staff. 39333 3. Review of Resident #36's medical record revealed she was readmitted on [DATE] with diagnoses including Huntington's disease, major depressive disorder, and unspecified dementia. Review of Resident #36's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited a memory problem. Review of Resident #36's progress note dated 12/21/22 timed 2:34 A.M. revealed at 2:07 A.M. a loud noise was heard from the resident's room. Upon entering, she was found on the floor next to her bed and was bleeding from her head. She was found to have a laceration on her forehead. The resident was transported to the hospital. Review of Resident #36's progress note dated 12/21/22 indicated she returned from the hospital and her head and neck cat scan were negative. The wound on her head was glued with a small amount of drainage noted. Neurological checks began upon the resident's return. Review of Resident #36's medical record revealed neurological checks did not begin upon the resident's return from the hospital. Interview on 05/24/23 at 10:55 A.M. with the Director of Nursing (DON) indicated the facility did not complete neurological checks as required. Review of the facility policy titled, Fall Prevention Program, revised 08/01/22, revealed when any resident experiences a fall, the facility will start neuro checks for any unwitnessed fall or fall that involves the resident hitting their head.

Based on observation, interview and record review, the facility failed to ensure skin conditions were assessed and treated. This affected one (Resident #30) of one resident reviewed for skin conditions. Findings include: Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the care plan dated 08/25/21 and last revised on 04/18/23 for Resident #30 revealed he had the potential for alteration in skin integrity. There were no indications he had an open area to his left hand or that he picked at his skin. Review of the nursing progress notes dated from 05/20/22 through 05/17/23 for Resident #30 revealed staff had not documented on any open areas of skin to his left hand. Review of the weekly skin observations for 05/06/23, 05/13/23 and 05/19/22, revealed Resident #30's skin to be intact. Observation on 05/21/23 at 9:17 A.M. revealed Resident #30 had an open area of skin to the top of his left hand. His left hand was noted to have an outline of where a band-aid had been around an area that had a scabbed area and open area of skin which was not bleeding. Resident #30 stated he was unsure of how he had obtained the open area of skin. He stated he had picked part of the scab off of the area. Interview on 05/21/23 at 1:01 P.M. with the Director of Nursing (DON) revealed she was unaware of Resident #30 having an open area of skin on the top of his left hand. On 05/21/23 at 4:10 P.M. the DON stated staff stated Resident #30 was attempting to get past the therapy gate and his hand got scratched. She was unsure of the date that this had occurred. The DON verified it was not in Resident #30's medical record including assessment, notification to the physician or the resident's representative. Review of the facility policy titled, Wound Care, revised November 2018, revealed the facility would notify the physician upon discovery of a new skin area, obtain orders for treatment, notify the resident representative of the skin area as well as to document the assessment, care, treatment and notifications made.

Based on medical record review, observation, staff and resident interview and policy review, the facility failed to ensure residents were free from physical restraints. This affected one (#5) of one resident reviewed for physical restraints. Findings include: Review of the medical record for Resident #5 revealed an admitted [DATE] with diagnoses including but not limited to Huntington's disease, anxiety disorder, chronic pain syndrome, unspecified dementia, and peripheral vascular disease. Review of the restraint decision assessment dated [DATE] revealed Resident #5 had Huntington's Disease. She was constant motion and will twist in the chair or pitch forward. She enjoyed being up in wheelchair watching the comings and goings in the building. She can remove the chest harness restraint on demand. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/04/23, revealed Resident #5 had severely impaired cognition. The resident required extensive assistance of one staff for activities of daily living except for transfer which required extensive assistance with two staff for transfers. The MDS did not indicate the use of restraints. Review of the therapy notes dated from 03/26/23 through 04/04/23 revealed Resident #5 was evaluated for chest harness; resident was educated on chest harness restraint and staff was educated on chest harness regarding safety. Review of physician's orders for Resident #5 revealed an order dated 05/21/23 for a chest harness restraint to wheelchair for safety, tremors, check skin and tightness every shift. There was no previous order that was completed or discontinued for a chest harness. Observation and interview on 05/21/23 at 8:48 A.M. with State tested Nursing Assistant (STNA) #900 revealed Resident #5 was wearing a chest harness restraint. STNA #900 stated that Resident #5 was ordered a chest harness approximately two months. Interview on 05/21/23 at 3:33 P.M. with Assistant Director of Nursing (ADON) #807 revealed that therapy initiated a chest harness restraint. ADON #807 verified the chest harness restraint order was put in today. Interview on 05/22/23 at 8:08 A.M. with Director of Rehabilitation #844 revealed initially Resident # 5's body was [NAME] so much that they tried tilting her tilt-in space wheelchair back further and limiting the amount of time in the wheelchair. Director of Rehabilitation #844 stated that Resident # 5 would get her legs caught on the side of the wheelchair with or without her seatbelt on. The therapy department evaluated her for the chest harness restraint and talked with the Director of Nursing (DON). Director of Rehabilitation #844 stated that she did not notify the doctor or the family, just the DON. Director of Rehabilitation #844 stated that a larger zipper loop was put on the harness so that Resident # 5 could undo the harness. Observation and interview on 05/22/23 at 8:18 A.M. with Director of Rehabilitation #844 revealed Resident #5's harness did not have a large zipper loop on it. Director of Rehabilitation #844 stated that Resident # 5 would not be able to undo the chest harness restraint without the larger zipper loop. Review of the facility policy titled, Restraint Use, dated 07/2018 revealed restraints shall only be used for the safety and well-being of the resident and only after other alternatives have been tried unsuccessfully. Prior to placing a resident in restraints there shall be a pre-restraining assessment and review to determine the need for restraints. The assessment shall be used to determine possible underlying causes of the problematic medical symptoms and to determine if there are less restrictive interventions that may improve the symptoms.

Based on observation, record review and interview the facility failed to provide appropriate hand hygiene during incontinence care. This deficient practice affected one resident (Resident #5) out of one resident reviewed for incontinence care. The facility census was 50. Findings include: Review of Resident #5 medical record revealed resident was admitted to the facility on [DATE], with admission diagnoses including Huntington's Disease, anxiety disorder, seborrheic dermatitis, major depressive disorder, type 2 Diabetes Mellitus. Review of Resident #5 quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 required extensive assistance of one staff member for toileting, which included cleaning resident following incontinence episodes. Further review of the quarterly MDS revealed Resident #5 has a functional limitation in range of motion due to impairment on one side of her body. Review of Resident #5 Activities of Daily Living care plan revised date 04/26/23 revealed Resident #5 required assistance of staff for personal care tasks and personal cleaning following incontinence episodes. Review of Resident #5 Point of Care (POC) staff documentation for the past 30 days revealed Resident #5 was marked as being dependent on staff for personal care. Further review of POC staff documentation revealed Resident #5 was marked as being incontinent of bladder and bowel for the past 30 days of staff documentation. During observation of incontinence care on 05/23/23 at 10:37 A.M. State tested Nursing Assistant (STNA) #900 was observed washing hands and donning (putting on) gloves. STNA #900 removed Resident #5 soiled brief and then cleansed Resident #5 peri-area with Peri Cleanser and wet wash clothes. Further observation revealed STNA #900 then dried Resident #5 peri-area with a clean towel and placed a clean brief on Resident #5 without doffing (taking off) soiled gloves, washing hands, and donning clean gloves to complete the task. Continuing to wear soiled gloves, STNA #900 assisted Resident #5 with a transfer from her bed to the wheelchair. Once Resident #5 was positioned in the wheelchair and located in front of her television, STNA #900 removed the soiled gloves and used hand sanitizer to cleanse hands. Interview on 05/23/23 at 10:50 A.M. with State tested Nursing Assistant (STNA) #900 confirmed appropriate hand hygiene, including removal of soiled gloves, washing hands, and donning clean gloves, was not completed during Resident #5 incontinence care. Review of facility policy titled, Hand Washing Guidelines revised 01/2019, reveals hands should be washed with soap and water or an antiseptic agent before and after providing routine care, after contact with bodily fluids, if moving from a contaminated body site to a clean body site during care and when a procedure calls for changing gloves hands should be washed after removing the dirty gloves and before putting on the clean gloves.

Based on observation, record review and interview, the facility failed to notify Resident #2's guardian of a new reddened chapped area on her chin, failed to notify Resident #5's guardian and physician of a new restraint order and failed to notify Resident #30's guardian of an open area on the back of his left hand. This finding affected three (Residents #2, #5 and #30) of three residents reviewed for notification of changes. Findings include: 1. Review of Resident #2's medical record revealed she was readmitted on [DATE] with diagnoses including cerebral palsy, unspecified intellectual disabilities and bipolar disorder. Review of Resident #2's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed she exhibited moderate cognitive impairment. Review of Resident #2's medical record revealed she had a legal guardian who was her responsible party. Observation on 05/21/23 at 11:29 A.M. revealed Resident #2 had a rash under her chin area. Interview on 05/21/23 at 11:40 A.M. with Registered Nurse (RN) #809 confirmed the rash under her chin area was new and a treatment would be applied. Review of Resident #2's progress note dated 05/21/23 at 5:26 P.M. indicated she was noted to have a chapped area under her lower lip. A&D ointment was applied earlier in the morning. A chap stick was given for her to apply as she wants. The physician was aware and agreeable. The progress note did not have evidence the guardian was notified of the new skin area under her lip (on her chin area). Interview on 05/22/23 at 9:30 A.M. with the Administrator confirmed the staff did not notify Resident #2's guardian of the new chapped area (rash) on her chin area because they considered it a behavior instead of a new skin condition. He stated the guardian would be notified immediately. 39333 2. Review of medical record for Resident #5 revealed an admitted [DATE] with diagnoses including but not limited to Huntington's disease, anxiety disorder, chronic pain syndrome, unspecified dementia, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/04/23, revealed Resident #5 had severely impaired cognition. The resident required extensive assistance of one staff for activities of daily living except for transfer which required extensive assistance with two staff for transfers. The MDS did not indicate use of restraints. Review of physician's orders for Resident #5 revealed an order dated 05/21/23 for a chest harness restraint to wheelchair for safety, tremors, check skin and tightness every shift. There was no previous order that was completed or discontinued for a chest harness restraint. Interview on 05/21/23 at 3:33 P.M. with Assistant Director of Nursing (ADON) #807 revealed therapy initiated the chest harness restraint. ADON #807 verified the chest restraint order was put in on this date. Review of progress notes from 03/01/23 through 05/21/23 revealed no documentation the family or physician was notified about the chest harness. Observation and interview on 05/21/23 at 8:48 A.M. with State tested Nursing Assistant (STNA) #900 revealed Resident #5 was wearing chest harness restraint. STNA #900 stated that Resident #5 was ordered a chest harness approximately two months. Interview on 05/22/23 at 8:08 A.M. with Director of Rehabilitation #844 revealed that initially Resident # 5's body was [NAME] so much that they tried tilting her tilt-in space wheelchair back further and limiting the amount of time in the wheelchair. Director of Rehabilitation #844 stated that Resident # 5 would get her legs caught on the side of the wheelchair with or without her seatbelt on. The therapy department evaluated her for the chest harness restraint and talked with the Director of Nursing (DON). Director of Rehabilitation #844 stated that she did not notify the doctor or the family, just the DON. Director of Rehabilitation #844 stated that a larger zipper loop was put on the harness so that Resident # 5 could undo the harness. A phone interview on 05/22/23 at 3:58 P.M. with Physician #849 revealed he stated he gets updates on a daily basis. He stated he was aware of the chest harness restraint due to Huntington's. He stated last time he was in she jerked so hard she kicked the bottom of the table even with the chest harness restraint on, it is more of a safety thing with her. They notify him when things occur but could not state a date he was notified of the restraint. 43063 3. Review of the medical record for Resident #30 revealed an admitted [DATE] with diagnoses including personal history of traumatic brain injury and cerebral infarction (stroke). Review of the nursing progress notes dated from 05/20/22 through 05/17/23 for Resident #30 revealed staff had not documented on any open areas of skin to his left hand. Review of the weekly skin observations for 05/06/23, 05/13/23 and 05/19/22, revealed Resident #30's skin to be intact. Observation on 05/21/23 at 9:17 A.M. revealed Resident #30 had an open area of skin to the top of his left hand. His left hand was noted to have an outline of where a band-aid had been around an area that had a scabbed area and open area of skin which was not bleeding. Resident #30 stated he was unsure of how he had obtained the open area of skin. He stated he had picked part of the scab off of the area. Interview on 05/21/23 at 1:01 P.M. with the Director of Nursing (DON) revealed she was unaware of Resident #30 having an open area of skin on the top of his left hand. On 05/21/23 at 4:10 P.M. the DON stated staff had told her that Resident #30 was attempting to get past the therapy gate and his hand got scratched. She was unsure of the date that this had occurred. The DON verified it was not in Resident #30's medical record including assessment, notification to the physician or the resident's representative. Review of the facility policy titled, Wound Care, revised November 2018, revealed the facility would notify the physician upon discovery of a new skin area, obtain orders for treatment, notify the resident representative of the skin area as well as to document the assessment, care, treatment and notifications made. Review of the facility policy titled, Notification of Changes, revised 04/15/21, revealed the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring such a notification including accidents resulting in injury or a new treatment.

Based on record review and interview, the facility failed to ensure Resident #11's annual comprehensive assessment was completed timely. This finding affected one (Resident #11) of twenty-four residents reviewed for comprehensive assessments. Findings include: Review of Resident #11's medical record revealed he was admitted on [DATE] with diagnoses including antisocial personality disorder, major depressive disorder and chronic obstructive pulmonary disease. Review of Resident #11's annual Minimum Data Set (MDS) 3.0 comprehensive assessment dated [DATE] indicated the assessment was in progress. Interview on 05/21/23 with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #807 confirmed Resident #11's annual MDS 3.0 comprehensive assessment dated [DATE] was not completed as required and it should have been completed by 05/06/23.

Based on interview and record review, the facility failed to ensure resident assessments were completed timely. This affected one (Resident #10) of 24 residents reviewed for resident assessments. The facility had a census of 50 residents. Findings include: Review of the medical record revealed Resident #10 was admitted on [DATE] with diagnoses including depression, anxiety and borderline personality disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] was noted to be in progress and had not been completed. Resident #10's last MDS quarterly assessment was dated 01/30/23. Interview on 05/21/23 at 3:24 P.M. with Licensed Practical Nurse (LPN) #807 verified Resident #10's MDS was not completed timely and should have been completed by 05/02/23. LPN #807 stated she had not completed the MDS as she still had some information to enter into the assessment.

Based on observation, record review and interview, the facility failed to ensure Resident #45's catheter care was completed as ordered. This finding affected one (Resident #45) of one resident reviewed for catheter care. Findings include: Review of Resident #45's medical record revealed he was admitted on [DATE] with diagnoses including hereditary spastic paraplegia, adjustment disorder with mixed anxiety and depressed mood and neuromuscular dysfunction of the bladder. Review of Resident #45's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed he exhibited intact cognition and had an indwelling urinary catheter. Review of Resident #45's physician orders revealed an order dated 11/17/22 to flush the suprapubic catheter (a catheter inserted a couple of inches below the navel, or belly button, directly into the bladder, just above the pubic bone which allows urine to be drained without having a tube going through the genital area) with 30 cc (cubic centimeters) of 0.25% (percent) acetic acid solution every shift for suprapubic irrigation; an order dated 11/30/22 to use a 18 French five cc silicone catheter to the suprapubic for urinary retention; and an order dated 01/06/22 to cleanse the area around the suprapubic catheter site with normal saline solution or wound cleanser, pat dry, apply a cover using a split bordered dressing. The suprapubic catheter dressing was to be changed every nightshift and as needed. Review of Resident #45's medication administration records (MARS) and treatment administration records (TARS) from 04/01/23 to 05/22/23 revealed the suprapubic catheter dressing was to be changed once daily from 7:00 P.M. to 7:00 A.M. The MARS and TARS did not reveal evidence the dressing around the suprapubic catheter was completed as ordered on 04/02/23, 04/07/23, 04/14/23, 04/16/23, 04/29/23, 04/30/23 and 05/13/23. Review of Resident #45's MARS and TARS from 04/01/23 to 05/22/23 revealed the acetic acid solution was to be completed twice daily from 7:00 A.M. to 7:00 P.M. and 7:00 P.M. to 7:00 A.M. The MARS and TARS did not reveal evidence the suprapubic catheter was irrigated with acetic acid on 04/02/23 on the 7:00 A.M. to 7:00 P.M. shift; 04/06/23 on the 7:00 A.M. to 7:00 P.M. shift; 04/07/23 on the 7:00 P.M. to 7:00 A.M. shift; 04/14/23 on the 7:00 P.M. to 7:00 A.M. shift; 04/16/23 on the 7:00 P.M. to 7:00 A.M. shift; 04/20/23 on the 7:00 A.M. to 7:00 P.M. shift; 04/29/23 on the 7:00 A.M. to 7:00 P.M. shift; 04/30/23 on the 7:00 P.M. to 7:00 A.M. shift; 05/13/23 on the 7:00 P.M. to 7:00 A.M. shift; 05/17/23 on the 7:00 A.M. to 7:00 P.M. shift; and 05/18/23 on the 7:00 A.M. to 7:00 P.M. shift. Observation on 05/21/23 at 3:20 P.M. with Licensed Practical Nurse (LPN) #826 of Resident #45's suprapubic site revealed he was sitting up in his chair and he had an adult incontinence brief in place. His suprapubic catheter was located in the abdominal fold and it did not have a supra pubic dressing in place at the time of the observation. Interview on 05/21/23 at 3:30 P.M. with LPN #826 confirmed Resident #45's suprapubic dressing was not in place per the physician's order nor was the suprapubic dressings completed per the MARS and TARS from 04/10/23 to 05/22/23 for seven days per the physician orders. LPN #826 also confirmed Resident #45's MARS and TARS did not reveal evidence the acetic acid irrigation was not implemented for eleven treatments per the physician orders. Review of the undated Personal Care Procedure policy indicated the facility would provide/assist resident care and hygiene to each resident based on their individual status and needs. This includes such things as baths/showers, oral care, resident grooming and peri-care/catheter care.

Based on observation and interview, the facility failed to ensure accurate posted nurse staffing. This finding had the potential to affect all 50 residents currently residing in the facility. Findings include: Observation on 05/21/23 at 8:00 A.M. revealed the posted nurse staffing information was dated 03/15/23. Interview on 05/21/23 at 8:15 A.M. with Licensed Practical Nurse (LPN) Assistant Director of Nursing (ADON) #807 confirmed the facility did not appropriately display the accurate nursing staff information.

Based on the unprecedented global pandemic that resulted in the Presidential declaration of a State of National Emergency dated 03/13/20, review of the Department of Heath and Human Services, Center for Medicare and Medicaid Services (CMS) Memo QSO 20-14-NH (revised 3/13/20, the Centers for Disease Control and Prevention (CDC) guidelines, the facility's Coronavirus (Covid-19) policy, facility admissions, observations, and interviews, the facility failed to implement appropriate infection control practices related to quarantine and isolation precautions for new admissions. This resulted in Immediate Jeopardy on 06/22/20 when Resident #49 was admitted and not quarantined to identify possible Covid-19 infection and to prevent the spread of infection to other residents. Subsequently between 06/29/20 and 09/03/20, eight additional residents were admitted (Residents #2, #3, #4, #8, #29, #40, #42, and #50) and not placed in quarantine. The lack of effective infection control practices placed all residents at the facility at risk for serious life-threatening harm, complications and/or death related to the facility's failed practice of infection control. Facility census was 48. On 10/14/20 at 11:57 A.M. the Licensed Nursing Home Administrator (LNHA) and Regional Administrator (RA) were notified Immediate Jeopardy began on 06/22/20 when the facility began admitting residents without placing them in quarantine to prevent the potential spread of Covid-19 to all facility residents and staff. The facility admitted nine residents to semi-private rooms between 06/22/20 and 10/14/20 (Residents #2, #3, #4, #8, #29, #40, #42, #49, and #50) without placing them in quarantine per CDC guidelines. The Immediate Jeopardy was removed on 10/14/20 when the facility implemented the following actions: · On 10/14/20 from 3:00 P.M. through 5:00 P.M., all facility residents were re-assessed by the Minimum Data Set 3.0 (MDS) nurse for signs and symptoms of Covid-19 with negative results. · On 10/14/20 at 5:30 P.M., the facility developed a quarantine room for new admissions to be triaged in upon arrival to the facility. Once in the facility the new resident would be given a Covid-19 test using the facility's Point-of-Care (POC) machine by the Director of Nursing (DON). If the resident tests positive for the Covid-19 virus, the facility will work with the resident based on their specific needs; the resident will either stay in the triage room in isolation/quarantine precautions for fourteen days or will be transferred to a hospital or sister facility which can better care for individuals with the Covid-19 virus. · The Chief Clinical Operator updated the facility policy titled, Care for the Patient with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19), on 10/14/20 to promote rapid safe triage of patients upon admission and to assure at the time of arrival to the facility, all patients would be assessed for the presence of symptoms of a respiratory infection. The policy also addressed the need to follow isolation guidelines as per the CDC guidelines. · On 10/14/20 starting at 3:00 P.M. through 8:30 P.M. all staff were educated regarding the new infection control policy regarding the quarantine process for new admissions. This was completed by the Administrator, Director of Nursing, and Director of Therapy in person and by phone. The was confirmed by in-service sign in sheets and phone logs. · On 10/15/20 from 2:30 P.M. to 3:40 P.M., interviews with Registered Nurse (RN) #510, STNA #525, Human Resources #535, Social Service Director (SSD) #536, STNA #539, and Director of Environmental Services #547, reported they had been in-serviced on 10/14/20 regarding the quarantine process/ room and the new infection control policy. · On 10/15/20 at 4:20 P.M., the newly assigned triage room was observed with the Administrator. The triage room was the first room upon entrance to the resident care area and located directly next to the Director of Nursing's (DON) office. The triage room had a large sign across the door to stop other residents from entering and had a large supply of personal protective equipment located in plastic drawers next to the door. Inside the triage room was a bedside commode placed next to the bed. · The DON will perform an audit with each admission to monitor that quarantine is maintained upon admission for fourteen days on an on-going basis. Any unusual finding from these audits will be reported to the facility's Quality Assurance committee for prompt resolution. · The LNHA will monitor the quarantine area for compliance on an ongoing basis. Although the Immediate Jeopardy was removed, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Review of the Department of Health and Human Services, Centers for Medicare and Medicaid (CMS) Memo QSO 20-20-ALL dated 03/03/20 revealed CMS was committed to taking critical steps to ensure America's healthcare facilities were prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus (Covid-19). As part of CMS guidance, the Focused Infection Control Survey was made available to every provider in the country to make them aware of infection control priorities during this time of crisis, and providers could perform a voluntary self-assessment of their ability to meet the priorities. The Quality, Safety and Oversite Group (QSO) Memo included additional instructions to nursing homes. We are disseminating the Infection Control survey developed by CMS and Centers for Disease Control (CDC) so facilities can educate themselves on the latest practices and expectations. We expect facilities to use this new process, in conjunction with the latest guidance from CDC, to perform a voluntary self-assessment of their ability to prevent the transmission of Covid-19. We also encourage nursing homes to voluntarily share the results of this assessment with their state or local health department Healthcare-Associated Infections (HAI) Program. Furthermore, we remind facilities that they are required to have a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility, and when and whom possible incidents of communicable diseases or infections should be reported (42 CFR 483.80 (a) (2) (i) and (ii). During interview on 10/13/20 at 10:31 A.M. the DON and LNHA stated the facility did not have a Covid-19 or isolation unit established for new admission. The DON stated the facility had their last Covid-19 resident on 06/15/20 and started admitting new residents 06/22/20, however due to the type of population they served, they were unable to quarantine or isolate their residents. The DON stated the staff members had been tested twice weekly through 10/05/20 as per regulations with no positive Covid-19 and the facility felt they had no concerns, as residents and staff wore masks and socially distanced. The DON explained the facility residents consisted of individuals with psychiatric [DIAGNOSES REDACTED]. Observations of the facility on 10/13/20 from 10:55 A.M. through 11:50 A.M., 10/13/20 from 11:55 A.M. through 12:15 P.M., 10/13/20 from 2:30 P.M. through 3:30 P.M., and 10/14/20 from 2:05 P.M. through 2:45 P.M. revealed the facility did not have any rooms with isolation carts or any areas marked for possible isolation. Observation of resident rooms revealed the rooms were semi-private rooms (two individuals to each room) with one shared bathroom. On each of the three main halls were a common shower room and an additional bathroom which residents were observed using. Interview on 10/13/20 at 10:55 A.M. with Licensed Practical Nurse (LPN) #501 revealed all residents were evaluated twice a day, every shift, for signs and symptoms of Covid-19. LPN #501 said new admissions were not quarantined upon admission but screened for signs and symptoms upon arrival. Interview on 10/13/20 at 11:02 A.M. with LPN #507 revealed all residents were evaluated on every shift for signs and symptoms of Covid-19 but they were not quarantined upon admission. LPN #507 indicated new admissions were not placed in quarantine because of the type of residents served. Interview on 10/13/20 at 11:24 A.M. with LPN #524 revealed when the facility had active Covid-19 cases within the facility the residents were quarantined; however, since the facility no longer had active Covid-19 residents, it was harder to keep residents in their rooms. Instead of placing residents in quarantine they assessed the residents for signs and symptoms every shift. Interview with the DON on 10/14/20 at 8:45 A.M. revealed the facility required a negative Covid-19 test within 72 hours of an admission to the facility. Residents were not placed in quarantine upon admission to the facility. A review of admissions to the facility since 06/22/20 revealed a total of nine admissions, five from other facilities, three from hospitals, and one from home. Resident #49 was admitted on [DATE] from another facility, Resident #3 was admitted on [DATE] from another facility, Resident #8 was admitted on [DATE] from the hospital, Resident #42 was admitted on [DATE] from the hospital, Resident #50 was admitted on [DATE] from home, Resident #4 was admitted on ,[DATE] from the hospital, Resident #29 was admitted on [DATE] from another facility, Resident #40 was admitted on [DATE] from another facility and Resident #2 was admitted on [DATE] from another facility. Review of the facility policy titled, Triage and Quarantine Management, revised 06/01/20, revealed all new admissions would be placed in a designated Triage Room and assessed by a licensed nurse for signs and symptoms of Covid-19. If a resident did not have any signs or symptoms of Covid-19 but was coming from a hospital system that had confirmed Covid-19 positive patients, they would be transported to a private room/quarantine room with isolation precautions for monitoring for 14 days. If the resident did not have any signs or symptoms of Covid-19 and was not coming from a hospital system that had confirmed Covid-19 positive patients, they would be placed in a semi-private room without isolation precautions.

Based on review of the medical record, personnel files, a facility self-reported incident (SRI), the facility Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, Police Report, and interviews with staff, the facility failed to ensure one cognitively impaired resident (Resident #1) was free from physical abuse by facility staff resulting in Immediate Jeopardy and the potential for serious physical and psychosocial harm for Resident #1. On 09/29/20 State tested Nursing Assistant (STNA) #500 struck Resident #1 three times in the face with a closed fist between his eyes resulting in multiple scratches, an abrasion, bruising and need for facial x-rays. This affected one of three residents reviewed for abuse. The facility census was 48. On 10/14/20 at 11:57 A.M. the Licensed Nursing Home Administrator (LNHA) and Regional Administrator (RA) were notified Immediate Jeopardy began on 09/29/20 at approximately 5:45 P.M. when STNA #500 struck Resident #1 with a closed fist three times in the face between his eyes directly on the bridge of his nose while the resident was seated in his wheelchair. This resulted in scratches, abrasions, bruising and the need for facial x-rays to rule out fracture. The Immediate Jeopardy was removed on 10/16/20 when the facility implemented the following corrective actions: · On 09/29/20 at approximately 6:00 P.M., the Director of Nursing (DON) and LNHA received notification from Licensed Practical Nurse (LPN) #501 of the physical altercation between Resident #1 and STNA #500. · On 09/29/20 at 6:00 P.M., STNA #500 clocked out, left the facility, and was suspended pending investigation. · On 09/29/20 at 6:15 P.M., a twenty-four-hour neurological evaluation was initiated for Resident #1. · On 09/29/20 at 6:30 P.M., the DON and LNHA arrived at the facility and initiated an investigation including interviews with all residents for similar incidents. · On 09/29/20 at approximately 6:40 P.M., the LNHA interviewed STNAs #502, #503, and #504 who were working at the time of the altercation regarding the incident with Resident #1 and STNA #500. · On 09/29/20 at 7:33 P.M., the facility notified the local Police Department of the incident (Case Number OH 00) and LPN #501 completed a head to toe assessment on Resident #1 which revealed small multiple scratches and an abrasion to the top bridge of the nose. · On 09/29/20 at 7:48 P.M., Resident #1's psychiatrist was notified of the abuse and Resident #1's subsequent agitation and an order for [REDACTED]. · On 09/29/20 at 8:10 P.M., Resident #1's guardian, family member, was notified of the incident. · On 09/29/20 at 8:53 P.M., Resident #1's physician ordered facial x-rays due to the location of the punches. · On 09/29/20 at 9:40 P.M., Resident #1's facial x-rays showed no evidence of fracture or dislocation. · On 09/29/20, from 6:00 P.M. to 11:00 P.M. facility staff were educated on Abuse, Burn-Out, and De-Escalation of Behaviors by the DON. Twenty five of forty-three facility staff signed the staff in-service sign in sheet. · On 09/29/20, no time listed, the LNHA submitted notification in the form of an SRI to the State Agency. · On 09/30/20 (no time available), Resident #1 was seen by the facility psychologist to determine psychological state after physical altercation with staff member. The psychologist determined Resident #1 remembered the incident and suffered no ill effects. · On 09/30/30 from approximately 6:00 A.M. to 12:00 P.M., the remaining facility staff were educated on Abuse, Burn-Out, and De-Escalation of Behaviors by the DON. This included eight additional staff members who were trained in person and twelve individuals educated by phone totaling the forty-three staff members employed at the facility. Four employees contracted through an outside company for housekeeping needs were also educated by phone. · On 09/30/30 at approximately 4:15 P.M., the LNHA interviewed STNA #500 by phone to obtain her statement regarding the incident on 09/29/20. STNA #500 stated she struck Resident #1 once in the forehead. After striking Resident #1, STNA #500 stated she went to the breakroom and was then informed by LPN #501 she had to leave the floor and subsequently left the facility. · On 10/06/20 at 1:45 P.M., STNA #500's employment was terminated by telephone secondary to not adhering to abuse policy and admission of striking a resident. · On 10/15/20, the facility provided a revised Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy which indicated if the Administrator determined abuse occurred, the conclusion would be substantiated specifically in staff to resident occurrences. · On 10/15/20, the DON re-educated all 43 staff either in person or via phone regarding the new Abuse, Neglect, Exploitation, and Misappropriation of Resident Property policy. This was confirmed via staff sign in sheets and phone call logs. · On 10/15/20 from 2:30 P.M. to 3:40 P.M., interviews with Registered Nurse (RN) #510, STNA #525, Human Resources #535, Social Service Director (SSD) #536, STNA #539, and Director of Environmental Services #547, reported they had been in-serviced on 10/15/20 regarding abuse prevention. · The DON will complete weekly audits of three random residents to monitor for Abuse, Neglect, and Misappropriation and any unusual findings will be reported to the Quality Assurance Committee. · The LNHA will monitor for on-going compliance and report to the Quality Assurance Committee. Although the Immediate Jeopardy was removed on 10/16/20, the deficiency remained at a Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and were monitoring to ensure continued compliance. Findings include: Record review revealed Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's quarterly Minimum Data Set 3.0 (MDS) assessment, dated 07/01/20, revealed Resident #1 had severely impaired cognition having scored a three on the Brief Interview for Mental Status. The assessment indicated Resident #1 was exhibiting delusions during the assessment period. Review of Resident #1's care plans revealed most recently updated on 10/05/20, revealed Resident #1 had a history of [REDACTED]. Resident #1's care plan also stated he would often become upset when self-propelling in the hallway. Interventions listed included to encourage Resident #1 to be in front of nurse's station or with administration in the front of building, for staff to intervene when Resident #1 was in the hallway and attempt to redirect Resident #1. Review of Resident #1's progress notes revealed the following events occurred on 09/29/20: At 4:45 P.M., Resident #1 was exit seeking after a family visit stating he had to get to his truck, Resident #1 was redirected to the dining room with no further behaviors. At 7:48 P.M., Resident #1 was agitated with attempts to exit seek and was redirected by staff. Staff witnessed an altercation between Resident #1 and a staff member. Resident #1 was immediately assessed. The psychiatrist was notified and an order for [REDACTED]. At 7:51 P.M., Resident #1 was assessed to have a small abrasion to his forehead area with multiple scratches and no bleeding or bruising noted. A neurological assessment was completed. Resident #1's cognition was baseline at this time. At 8:54 P.M., The x-ray company was in the facility to obtain facial x-rays of Resident #1. Progress notes for Resident #1 on 09/30/20 revealed at 2:01 A.M., x-ray results received from company with no evidence of fracture or dislocation. At 5:06 P.M., social services documented Resident #1 was seen by the psychologist who noted Resident #1 recalled the altercation with the facility staff member but denied any difficulties following the incident. Review of SRI # 1 dated 09/29/20 revealed at approximately 6:00 P.M., the DON and LNHA received notification from Licensed Practical Nurse (LPN) #501 of the physical altercation between Resident #1 and STNA #500. The SRI indicated STNA #500 was suspended pending investigation of the incident and an investigation was initiated. The conclusion of the SRI revealed as a result of the investigation, the facility terminated the employment of STNA #500 on 10/06/20 and educated all facility staff. The conclusion also indicated they were unable to determine if the incident was with intent or if STNA #500's response was reactionary due to the reported aggressive behaviors she stated Resident #1 exhibited towards her. No staff witnesses or residents were present at the beginning of the interaction. The allegation of physical abuse was unsubstantiated. Review of the facility investigation revealed interviews were conducted with all residents in the facility by asking if they had concerns with any staff members and if they felt safe. Their responses were marked as either a yes or a no on a resident roster. The residents had no concerns and felt safe. Two written statements were obtained from the two LPNs who witnessed the incident (LPNs #501 and #507). The LNHA wrote a statement after interviewing the facility staff present during the altercation. The investigation indicated a police report was made and all staff education regarding abuse was initiated. The LNHA summarized the facility was unable to determine if the incident was with intent or if STNA #500's response was reactionary due to the reported aggressive behaviors she stated Resident #1 exhibited towards her. The statement also included no staff witnesses or residents were present at the beginning of the altercation to help provide more evidence. Review of a phone interview between LNHA and STNA #500 on 09/30/20 regarding the incident revealed Resident #1 had been in the hallway near a fire door to the lobby area which was closed to prevent Resident #1 from alarming the front entrance door. STNA #500 stated Resident #1 had been behaving belligerently with her, kicked her in the stomach, spit at her, and pulled her glasses from her face. STNA #500 said she struck Resident #1 in the face once. STNA #500 said LPN #501 took Resident #1 down the hall and she assumed it was to his room and she went to the breakroom. It was after this LPN #501 informed STNA #500 she had to leave the floor and STNA #500 left the facility. Review of the family notification interview by the DON dated 09/30/20 at 8:10 P.M. revealed the family member, also Resident #1's guardian, stated Resident #1 probably provoked the incident and deserved it. Observation of Resident #1 on 10/13/20 at 10:50 A.M. revealed he was seated in a wheelchair. An attempt to interview Resident #1, at the time of the observation was unsuccessful due to his quiet speech and perseveration on his current thoughts. Interview on 10/13/20 at 10:55 A.M. with LPN #501 revealed she was the first nurse to observe the altercation between Resident #1 and STNA #500. LPN #501 stated Resident #1 was in the main hallway by the administrative nurse's offices, Resident #1 was in his wheelchair and STNA #500 was observed punching Resident #1 on his nose. LPN #501 stated Resident #1 had been having a bad day, had been at the front door and had been combative and flailing his arms and liked to use racist words. LPN #501 stated STNA #500 was informed to leave Resident #1 and was observed to walk in the opposite direction towards the front door. LPN #501 stated all attention was focused on Resident #1 and his needs at the time. LPN #501 thought STNA #500 left the building as she was told but she did not. LPN #501 stated STNA #500 thought her actions were an appropriate response. LPN #501 stated STNA #500 should not have been that close to Resident #1 and she could have walked away. Interview on 10/13/20 at 11:02 A.M. with LPN #507 revealed she observed the altercation between Resident #1 and STNA #500. LPN #507 stated she was at the medication cart when she heard LPN #501 yell for assistance. LPN #507 stated when she entered the hallway, she saw STNA #500 punching Resident #1 between the eyes on the bridge of his nose three times. LPN #507 stated Resident #1 was in his wheelchair and STNA #500 was punching down onto Resident #1. LPN #507 stated LPN #501 informed STNA #500 she had to leave the building, and all attentions were placed onto Resident #1 who was taken back to his room. LPN #507 stated Resident #1 was very upset stating he was going to beat STNA #500's butt and it took some time to calm him including getting an injection of an antianxiety medication. Interview on 10/13/20 at 11:19 A.M. with STNA #503 revealed after the altercation between STNA #500 and Resident #1, STNA #500 went to the breakroom. STNA #503 saw STNA #500 in the breakroom when she went to pick something up. STNA #500 informed her that Resident #1 had punched her, so she punched him. STNA #503 stated STNA #500 did not leave the facility until told a second time. Interview with the LNHA on 10/13/20 at 2:06 P.M. revealed after discussion between the LNHA and corporate individuals, the decision was intent could not be established and the altercation was attributed to a snap reaction or burn-out. The altercation was deemed not to be a usual behavior and therefore the SRI was marked unsubstantiated. Review of the Police report, Number OH 00, revealed a known suspect allegedly struck listed victim, family of the victim did not wish to pursue charges, and the case was closed. Intermittent observations of Resident #1 on 10/14/20 revealed the resident self- propelling his wheelchair. Resident #1 took rest breaks in route to his destinations. He was observed at the nurse's desk and in the business office obtaining snacks. Attempts to hold a conversation with Resident #1 were unsuccessful. Review of the personnel file for STNA #500 revealed a hire date of 02/13/20. STNA #500 completed her Nurse Aide Training and Competency Evaluation Program on 02/09/20 and passed her licensure test on 06/06/20. Review of STNA #500's personnel file revealed STNA #500 signed acknowledgement of the facility abuse policy on 02/13/20 as well as received additional information and training on dealing with and caring for behavioral residents and resident with psychiatric/ mental health needs. STNA #500's personnel record showed a termination form of 10/06/20, including suspension since 09/29/20 for not adhering to facility abuse policy and having admitted to striking a resident. Review of the facility policy titled, Abuse, Neglect, Exploitation, and Misappropriation of Resident Property, dated 2016, stated all abuse, including staff to resident must be identified as willful. This deficiency substantiates Complaint Number OH 319.