Every finding on record at Simpson Memorial Home

Based on clinical record review, facility policy review and staff interviews, the facility failed to notify the physician or their designee of significant weight loss for 1 of 1 residents reviewed for nutrition (Resident #17). The facility reported a census of 32. Findings include: The Minimum Data Set (MDS) Assessment completed 9/5/25 revealed Resident #17 with a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Diagnoses include chronic respiratory failure with hypoxia (low oxygen), chronic obstructive pulmonary disease, and heart failure. The Care Plan with a target date of 12/12/25 identified Resident #17 with an altered nutritional status related to poor appetite and progressive weight decline. Interventions initiated on 9/12/23 include referral to the medical doctor or Registered Dietitian (RD) as necessary. The Weight Change Progress Notes, completed by the RD revealed, in part: 1.On 1/7/25 at 3:50 PM .a significant weight loss was identified at 30 days .2.On 7/5/25 at 10:19 AM .a significant weight loss was identified at 90 days .3.On 10/6/25 at 7:14 PM . a significant weight loss was identified at 180 days .4.On 11/4/25 at 9:20 AM .a significant weight loss was identified at 180 days .Review of the electronic health record (EHR) lacked documentation of physician notification of the above significant weight changes. Review of the Physician Long-term Care Facility/Home Visit Notes dated 1/16/25 and 7/10/25 did not address the identified significant weight loss. During an interview on 12/3/25 at 2:00 PM, the Director of Nursing (DON) stated there is no formal process for physician notification related to significant weight changes. These are typically addressed during a resident's regulatory 60-day physician visit. If or when the physician is notified, this should be documented in the EHR. During an interview on 12/3/25 at 2:15 PM, the RD explained resident weights are reviewed during scheduled weekly facility visits. Identified significant weight changes are forwarded to the administrative nursing staff. The RD noted they do not notify the physician of these changes. The policy Weight Assessment and Intervention, revised March 2022 noted the following: 1.Resident weights are monitored for undesirable or unintended weight loss or gain2.The physician and the multidisciplinary team identify conditions and medication that may be causing anorexia, weight loss or increasing risk of weight loss

Based on clinical record review, the Resident Assessment Interview Manual, and staff interviews, the facility failed to accurately complete a Minimum Data Set assessment for 3 of 12resident's reviewed in the sample (Residents #6, #9 and #20). The facility reported a census of 32 residents.Findings include:1. The annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 had diagnoses of Non-Alzheimer's Dementia, bipolar disorder and anxiety disorder. The MDS (under section A1500) documented the resident not currently considered by the state level II PASRR (Preadmission Screening and Record Review, a review to prevent inappropriate placement and ensure people with mental illness or an intellectual disability receive the most suitable care) process to have a serious mental illness and/or intellectual disability or a related condition. The Care Plan initiated 3/15/22 and revised 6/18/25 revealed the resident had diagnoses of bipolar disorder, depression, and anxiety disorder. The resident took bupropion (anti-anxiety medication) and Seroquel (an antipsychotic medication) for management of her symptoms. The PASRR dated 5/17/17 revealed the resident's diagnoses of bipolar disorder and depression. The PASRR also indicated a Level II evaluation not required due to the primary diagnosis of dementia. 2. The admission MDS assessment dated [DATE] revealed Resident #20 had diagnoses of Non-Alzheimer's dementia, bipolar disorder, and anxiety disorder. The MDS documented the resident not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition. The Care Plan initiated 7/21/25 revealed the resident had a diagnosis of bipolar disorder. The Care Plan indicated the resident had received a PASRR Level II determination. The PASRR dated 7/18/25 revealed the resident had diagnoses of bipolar disorder, major depressive disorder, anxiety disorder and dementia. In an interview on 12/3/25 at 3:40 PM, the MDS Coordinator reported she completed the Resident #6 and Resident #20's MDS assessments. She obtained information to complete the assessments by talking with the resident and she performed the assessment. She entered the resident's diagnoses under section I of the MDS assessment as applicable. She also checked with the Social Services Director if she had a question about how to respond to the PASRR questions on the MDS. She manually filled out the questions under the PASRR section A of the MDS. She coded yes in the section under A1500 if a resident had a diagnosis of a serious mental illness. At the time, the MDS Coordinator checked Resident #6 and Resident #20's admission MDS assessment and confirmed the question under A1500 should have been marked yes. The MDS Coordinator reported she had only worked as the MDS Coordinator since 10/2025 and the MDS assessment had been done prior to her taking on the MDS Coordinator role. In an interview on 12/3/25 at 3:50 PM, the Social Services Director confirmed a diagnosis of bipolar disorder, or major depressive, or anxiety disorder would be classified as serious mental illness, according to the PASRR. 3. The MDS completed 8/28/25 revealed Resident #9 with a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. Diagnoses include cerebrovascular accident (CVA) and non-Alzheimer dementia. A wander/elopement alarm was coded as not used. The Care Plan identified Resident #9 at risk for elopement related to impaired safety awareness and dementia. Interventions initiated on 9/21/23 include the use of a wander guard placed on the right ankle. Physician Order Summary obtained on 12/2/25 noted wander guard placement on right ankle and to test its function nightly. This was initiated on 8/25/23. During an observation on 12/3/25 at 12:20 PM, a wander guard alarm was seen on Resident #9's right ankle. During an interview on 12/2/25 at 3:35 PM, Staff A, Certified Nursing Assistant (CNA) acknowledged the use of wander guard alarms in the facility and listed residents who currently wear them. Resident #9 was listed. During an interview on 12/3/25 at 3:15 PM, the MDS Coordinator noted the MDS should reflect the use of a wander guard alarm. Upon further review, the MDS Coordinator acknowledged the wander guard use should be coded on the Resident #9's MDS. During an interview on 12/3/25 at 3:50 pm, the Director of Nursing acknowledged MDS coding discrepancies from the facility's previous MDS Coordinator. Review of the Resident Assessment Interview Manual (RAI) coding instructions for the MDS directed the following for section A1500: PASRR: a. Review the Level I PASRR form to determine whether a Level II PASRR required b. Review the PASRR report provided by the state if [NAME] II screening was required c. Code 1, yes: If PASRR Level II screening determined that the resident has a serious mental illness and/or intellectual disability and continue to A1510, Level II PASRR conditions d. Check all conditions that apply, which include serious mental illness (question A1510) The RAI Manual coding instructions documented the following after determining whether or not an item listed in P0200 (alarms) was used during the 7-day look-back period, code the frequency of use: a. Code 0, not used, if the device was not used during the 7-day look-back period.b. Code 1, used less than daily, if the device was used less than daily.c. Code 2, used daily, if the device was used on a daily basis during the look-back period. Per the RAI the definition of a wander/elopement alarm described as: Wander/elopement alarm includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn by/attached to the resident that activate an alarm and/or alert the staff when the resident nears or exits a specific area or the building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings.

Based on observation, staff interview and policy review, the facility failed to ensure proper infection control practices to reduce the risk of contamination and food-borne illness during meal service. The facility reported a census of 32 residents. Findings include: Per the facility menu, the lunch on 10/16/24 for regular/NAS (no salt added) consisted of Sloppy [NAME] sliders, garden vegetable soup, American fries, seasonal vegetables blend, peas and mushrooms, spiced peach salad, and angel food cake During an observation of the lunch service on 10/16/24 starting at 11:39 AM, Staff B, Cook, wearing gloves reached into a bun bag to get a slider bun. Staff B, wearing the same gloves touched plates, utensils, ketchup bottles, resident menu orders and continued to obtain buns from the bag and plate meals. Staff B observed changing his gloves two times during the meal service. Each time after a glove change Staff B touched plates, condiment bottles, resident menu's and pull buns out of the bun bag and plate meals without a glove change between tasks. During an interview on 10/17/24 at 10:08 AM, the Dietary Supervisor stated it was the expectation staff use tongs instead of a gloved hand to serve items that are to be served on bread or buns to prevent cross contaminations. Staff are not to use gloves during food service. An undated facility policy, titled Bare Hand Contact with Food and Use of Plastic Gloves, Procedure section directed staff, in part: 3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. \ 8. Remember, gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed. Examples listed in part: a. After handling anything soiled. b. Anytime you touch any contaminated surface c. During food preparations, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks.

Based on clinical record review, interviews, and the facility policy, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a resident receiving hospice services and a resident that did not take an anticoagulant for 2 of 14 residents reviewed for MDS assessments (Resident #15 and Resident #24). The facility reported a census of 32 residents. Findings include: 1. The MDS assessment dated [DATE] revealed Resident #24 scored a 15 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition intact. The MDS listed diagnoses included: cerebral infarction (stroke) due to thrombus (blood clot) of unspecified precerebral artery, respiratory failure, and heart failure. The MDS High-Risk Drug Classes section indicated Resident #24 took an Anticoagulant during the seven days. A review of Physician Orders revealed an order, dated 4/22/23, for clopidogrel bisulfate oral tablet 75 mg (milligram)- give 75 mg by mouth one time a day. The Federal Drug and Food Administration website (www.accessdata.fda.gov) Highlights of Prescribing Information for Plavix (brand name of clopidogrel bisulfate) Indication and Use listed the medication as a plate inhibitor (reduce platelet aggregation and prevent thrombus formation). During an interview on 10/17/24 at 10:45 AM, Staff A, MDS Coordinator queried if Resident #24 MDS coded for an anticoagulant and he stated he must of miss clicked it because Resident #24 didn't take an anticoagulant. Staff A stated the resident took an antiplatelet (platelet inhibitor). During an interview on 10/17/24 at 11:22 AM, the Director of Nursing (DON) queried on Resident #24 MDS and she stated the resident didn't take an anticoagulant. The DON stated she expected the MDS to have the correct listing of anticoagulant versus antiplatelet. 2. The MDS assessment dated [DATE] revealed the BIMS exam not conducted due to Resident #15 rarely or never understood. The MDS listed diagnoses for acute respiratory failure with hypercapnia and Alzheimer's disease. The MDS indicated the resident not on hospice while a resident. The Care Plan revealed a focus area for resident being on hospice with [name redacted] initiated on 4/22/24. The interventions dated 4/22/24 revealed working cooperatively with hospice team to ensure spiritual, emotional, intellectual, physical and social needs were met. A review of Physician Orders revealed an order, dated 8/30/23, Hospice referral with [name redacted]. During an interview on 10/17/24 at 10:48 AM, Staff A confirmed Resident #15 currently receiving hospice services and he didn't click it on the MDS assessment. During an interview on 10/17/24 at 11:21 AM, the DON stated Resident #15 had been on hospice services for a long time and it should absolutely be on the MDS assessment. The review of the policy, dated March 2022, titled Resident Assessment, Policy Interpretation and Implementation section directed: 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments.

Based on clinical record review, observation, staff and resident interview, and policy review, the facility failed to revise the care plan to include the use of warfarin for 1 of 14 residents (Resident #19), and personalized interventions to prevent falls for 1 of 14 residents (Resident #21 reviewed. The facility reported a census of 32 residents. Findings include: 1. The admission Minimum Data Set (MDS) assessment, dated 7/7/24, indicated Resident #19 admitted the facility on 7/1/24. The MDS listed a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed diagnoses included: atrial fibrillation, pneumonia, chronic obstructive pulmonary disease (COPD), and presence of a cardiac pacemaker. A review of the clinical record revealed the following Physician Orders: a. Warfarin ((blood thinner, brand name Coumadin) 5 mg by mouth in the afternoon every Thursday. Start date 9/16/24, with hold date of 10/14/24, and start of 10/17/24. b. Warfarin 2.5 mg by mouth in the afternoon every Tuesday, Wednesday, Friday, Saturday and Sunday. Start date 9/17/24, with hold date 10/14/24, and start date of 10/15/24. c. Check INR (International Normalized Ratio, a blood test used to measure how long it takes for blood to clot) one time on 10/21/24 for Warfarin therapy. d. Zithromax (antibiotic) 250 mg by mouth 1 time a day every Monday, Wednesday, Friday for shortness of breath related to pneumonia. Start date 8/28/24. A review of a Progress Note from Resident #19's pulmonary provider, dated 8/15/24, indicated a recommendation for Zithromax (antibiotic) 250 mg daily 3 times a week on Monday, Wednesday, and Friday. Also recommended continued use of a spirometer (device used to helps improve lung function by training patients to breathe slowly and deeply) and increase in Wixela inhaler from 250-50 to 500-50 mcg/act (micrograms/asthma control test). The Care Plan, dated 7/7/24, included a Focus area to address The resident has shortness of breath (SOB) r/t (related to) Anxiety, Hx (history) of pneumonia and COPD. The Care Plan did not include updated Interventions for the use of Zithromax as prophylactic antibiotic and use of an inhaler. The Care Plan, dated 2/3/23, included a Focus area to address I have an altered cardiovascular status r/t arrythmia (irregular heart rate), Hypertension, Pacemaker. The Care Plan did not include updated Interventions for the use of warfarin, and INR testing related to the 7/7/24 admission. During an interview on 10/17/24 at 10:10 AM, the Director of Nursing (DON) stated it was the expectation that an anticoagulant and prophylactic antibiotic be addressed on the appropriate resident's Care Plan as it related to the resident's plan of care. The DON further stated all new orders were to be reviewed by the Minimum Data Set (MDS) nurse and placed on the Care Plans as appropriate. 47336 2. The Annual MDS assessment, dated 8/1/24, revealed Resident #21 BIMS score of 10 out of 15 indicating a moderate cognitive impairment. The MDS indicated the resident experienced two or more falls with no injury since the previous assessment period. The MDS assessed the resident independent with sit to stand; chair/bed to bed transfer and walking over 10 feet. The MDS listed diagnoses included unspecified dementia, unspecified severity, without behavior/psych/mood/anxiety, functional urinary incontinence, and an active related to vision (cataracts, glaucoma or macular degeneration.) The MDS indicated in the last seven days the resident took antidepressant, and opioid as listed in the High-Drug Risk Drug classes section. The Care Plan, dated 2/4/22, included a Focus area to address I am a High risk for falls. The Incident Note dated 9/24/24 at 6:25 PM, revealed staff was showering resident [Resident #21] when he became combative and was hitting at staff, resident lost his balance and staff was able to lower him to the floor, no injuries noted. Assisted up to shower chair with gait belt and 3 assist. Able to [NAME] (move all extremities) with difficulty. VS (vital signs) 97.6, 16, 76, 160/88. Son [name redacted] and Dr.aware of incident. The Incident Note dated 9/25/24 at 7:25 PM, revealed the resident [Resident #21] was last seen sitting in recliner at 7:23 PM, staff then heard resident yelling any body out there, was about to enter resident's room, when they heard a crash and found resident laying on the floor on his left side in front of his recliner with his walker at his feet. Able to [NAME] with difficulty. assisted resident up to wheelchair with 3 assist and gait belt. Noted a skin tear 6 x 5 cm (centimeter) to left elbow. skin approximated, 5-6 [NAME]- strips applied to area. Voiced no ac/O (complaints) pain. Dr. [name redacted] and son aware of incident. VS (vitals signs) 97.9, 69, 145/68. The Incident Note 10/2/24 at 9:45 AM, revealed this nurse was called down to residents [Resident #21] room by CNA (Certified Nurse Aide) because he was on the floor. Walked into his room and he was sitting on the bathroom floor on his buttocks with his pants around his knees. His back was up against the corner of both walls and he was using the wall to rest up against. His legs were straight out in front of him and his arms were at his sides. The toilet was directly in front of him. He had proper shoes on. His pants, brief, and socks were wet. His bathroom door alarm and call light were both off. His wheelchair was in his room and his walker was with him in the bathroom. Asked him what had happened and he stated that I decided to sit on the floor to hangout, now would you help me up. VS BP (blood pressure)-106/51 P (pulse)-68 R (respirations)-18 T (temperature)-97.8 O2 (oxygen)-99% RA (room air). Alert to himself per his baseline. PERRLA (Pupils are round, and reactive to light and accommodation). Hand grips were equal. He was able to move all extremities. No shortening or rotation noted. CNA's helped get him changed and cleaned up. Gait belt used to help him into a standing position and then he was transferred into his wheelchair. It was noted that had had a red area on his right upper back measuring 7 in (inches) X 5 in skin remains intact. No other injuries noted. Offered ice for his right upper back he denied the need. Initiated neuros and vital checks. Educated him on the importance of asking for help and using his call light. POA (Power of Attorney) and MD (Medical Doctor) notified. The Incident Note dated 10/6/24 at 11:15 AM, revealed this nurse hear resident [Resident #21] yelling help from bathroom. Walked into bathroom and he was sitting on the bathroom floor on his buttocks with his pants around his knees. His back was up against the wall by the doorway and he was using the wall to rest up against. His legs were straight out in front of him and his arms were at his sides. He had shoes on. His pants, brief, and socks were wet. His bathroom door alarm was off however both CNA's said they had turned it on when they brought him out for breakfast. His wheelchair was next to him. He had a bowel movement. There was feces in and on the toilet. Alert to himself per his baseline. PERRLA. Hand grips were equal. He was able to move all extremities. No shortening or rotation noted. CNA's helped get him changed and cleaned up. Gait belt used to help him into a standing position and then he was transferred into his wheelchair. Initiated neuros and vital checks. Educated him on the importance of asking for help and using his call light. POA and MD notified. The Care Plan, dated 2/4/22, did not include personalized interventions for the falls that occurred on 9/24/24, 9/25/24, 10/2/24; and 10/6/24. During an interview on 10/17/24 at 10:51 AM, Staff A stated interventions needed placed on the Care Plan as they were done with reviewing the fall and if possible they should be done right away. During an interview on 10/17/24 at 11:27 AM, the DON stated they reviewed the falls and looked for a root cause analysis, and for the fall on 9/24 the intervention was to get therapy started. The DON stated the intervention for the fall on 9/25 was to get a urine culture and for the fall on 10/2 she thought they had an intervention but didn't. The DON stated the intervention for the fall on 10/6 was to put a sign on the door written in Spanish as well as English to inform staff to turn the bathroom door alarm on. The DON stated the interventions were identified for the resident, and should have been entered on the Care Plan immediately. The DON stated nurses are not comfortable adding the interventions to the Care Plan and this is something they are working on. A review of the policy, dated March 2022, titled Care Plans, Comprehensive Person-Centered Policy, Policy Interpretation and Implementation directed staff to, in part: 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 9. The care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 11. Assessments of residents are ongoing and care plans revised as information about the residents and the resident's conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition b. when the desired outcome is not met

Based on a clinical record review, interviews, and the facility policy, the facility failed to complete a significant change in status on Minimum Data Set (MDS) assessment after a resident discharged from hospice services for 1 of 2 residents reviewed (Resident #22). The facility reported a census of 32 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 scored a 6 out of 15 on the Brief Interview for Mental Status (BIMS) exam, which indicated cognition severely impaired. The MDS revealed the diagnosis of senile degeneration of brain, not elsewhere classified. The MDS revealed the resident received hospice care while a resident. The Care Plan, dated 5/21/24, included a Focus area to address I have altered nutritional status related to malnutrition, worsening dementia, hospice services due to my end stage health status. A Physician Order, dated 5/17/24, revealed an order for [name redacted] Hospice Care. The Discharge Summary from [name redacted] Hospice Services revealed the resident discharged from services on 9/18/24. During an interview on 10/17/24 at 10:50 AM, Staff A, MDS Coordinator queried if a significant change is completed on MDS due to Resident #22 no discontinued hospice services. The MDS Coordinator stated yes, a significant change should be completed because of the resident improvements. During an interview on 10/17/24 at 11:18 AM, the DON (Director of Nursing) queried if Resident #22 needed a significant change after she discharged from hospice services and she stated yes, a significant should of been done. The DON stated anytime a resident moved to a different level, showed a decline, or improvement, they would need a significant change. A review of the facility policy, dated March 2022, titled Resident Assessment, Policy Interpretation and Implementation section directed staff, in part: 1. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments and reviews according to the following requirements: a. OBRA (Omnibus Budget Reconciliation Act) required assessments - conducted for all residents in the facility: (4) Significant change in status assessment (SCSA) Comprehensive

Based on clinical record review, staff interview, and facility policy review the facility failed to ensure adequate series of pneumococcal vaccinations were offered and administered or declined for four of five residents reviewed for immunizations (Resident #1, Resident #9, Resident #10, Resident #12). The facility reported a census of 30 residents. Findings include: Review of the Immunization tab in the electronic health record (EHR) revealed the following pertaining to dates pneumovax dose 1 was given, without documentation of administration of additional pneumococcal vaccination: a. The clinical record for Resident #1 lacked documentation of administration of pneumococcal vaccinations. b. The clinical record for Resident #9 revealed pneumovax dose 1 was administered 6/25/12, with no additional pneumococcal vaccination documented. c. The clinical record for Resident #10 revealed pneumovax dose 1 was administered 5/22/15. d. The clinical record for Resident #12 revealed pneumovax dose 1 was administered 12/30/15. On 8/17/23 at 12:26 PM, additional information for pneumococcal vaccinations for the above residents was requested via email from the facility's Administrator. On 8/17/23 at 2:01 PM, the Director of Nursing (DON) acknowledged the facility definitely had residents that needed updates for pneumococcal vaccine. The DON explained they would need to go though and audit everyone's file. When queried about more information as to documented pneumovax dose 1, the DON explained they would need to talk to the pharmacy. During the interview, the DON explained one resident (Resident #12) would have been up to date, and this year would have been year six. Review of additional documentation provided revealed administration of PCV-13 for Resident #12 on 2/20/17. The Facility Policy titled Pneumococcal Vaccine revised August 2016 documented, 7. Administration of the pneumococcal vaccines or revaccinations will be made in accordance with current Centers for Disease Control and Prevention (CDC) recommendations at the time of the vaccination.

Based on observation, interviews, and record review the facility failed to follow physician's order for hold parameters set on the cardiac medication Digoxin, as pulse rates had not been monitored or recorded for 1 of 6 residents (Resident #11) medication administrations observed. The facility reported a census of 30 residents. Findings include: The current Care Plan indicated Resident #11 on Digoxin therapy related to atrial fibrillation with a goal to be free from discomfort or adverse reactions related to Digoxin use. Interventions include: Record baseline peripheral pulses and report to physician if pulse falls below 60 or rises above 110, or if changes in heart rhythm are detected. Order Summary report, active as of 7/1/23, revealed physician order for Digoxin 125mcg by mouth one time a day related to Heart Failure; Hold if pulse less than 60 beats per minute. On 8/17/23 at 8:21 AM, Observed Staff A, LPN, administer one tablet of Digoxin 0.125mcg to Resident #11 without first performing pulse check to determine whether the pulse rate allows for medication administration in accordance with physician order parameters. On 8/17/23 at 10:37 AM , Interviewed Staff A about Resident #11 Digoxin order. Staff A confirmed Resident #11 has pulse check requirement for her Digoxin medication directed on the Medication Administration Record (MAR), the resident's orders, and the medication card all which indicate this medication is to be held if pulse is less than 60. Staff A confirmed that she had not checked pulse according to the directions indicated for this medication. When asked what she would do now, Staff A reported she would follow up by checking resident's pulse, notifying physician, and documenting results in Electronic Health Record. On 8/17/23 at 11:06 AM, Interviewed Director of Nursing (D.O.N.) who confirmed Resident #11 Digoxin order required pulse monitoring prior to administration. D.O.N. stated when orders are transcribed Nurses should include prompt for any hold parameters and confirmed this was missed for Resident #11 Digoxin order. D.O.N. stated the normal process is to check pulse prior to administration of this medication, hold if pulse is outside of parameters, notify the physician, document, and monitor the resident. D.O.N reported she is unaware if Digoxin medication has ever been held for Resident #11. When asked what harm may result from giving this medication when pulse is below 60 beats per minute, D.O.N. reported harm or death could occur. D.O.N. notified that she followed up by updating the order with a pulse check prompt and provided education to Nursing staff. Review of facility policy titled Medication Management Policy, revised on 1/22/23, instructed that medications are administered in accordance with written orders of the attending physician or physician extender.

Based on facility record review, and staff interviews the facility failed to submit accurate payroll data 5 of 90 days during the second quarter of 2023. Findings include: During an interview on 8/15/23 at 12:44 PM, the Business Office Manager (BOM) stated the facility contracted a payroll service, and the service submitted all required Payroll Based Journal (PBJ) information to the Center for Medicare and Medicaid Services (CMS) quarterly. The BOM stated she and the Administrator receive a copy of the PBJ information submitted, and it has always seemed to be correct. The BOM states she is unsure if the report is received before or after the payroll service submits the data to CMS. The BOM received a list of the days triggered on the PBJ report due to a lack of 24 hour nursing data. On 8/16/23, the Administrator provided an undated document titled Registered Nurse Hours Analysis by Day for the quarter 1/1/23 to 3/31/23 received from the payroll service. The report revealed the facility reported the following nursing hours: a. 1/2/23 - 12 hours reported b. 1/3/23 - 17.25 hours reported c. 1/7/23 - 17.88 hours reported d. 2/5/23 - 15.72 hours reported e. 2/12/23 - 14.77 hours reported During an interview on 8/17/23 at 11:30 AM, the BOM and Administrator stated the information submitted during the 2nd Quarter of 2023 had inaccuracies The BOM provided documentation of payroll information which revealed the following: a. 1/2/23 - 24 hours paid for nursing b. 1/3/23 - 27 hours paid for nursing c. 1/7/23 - 28 hours paid for nursing d. 2/5/23 - 24 hours paid for nursing e. 2/12/23 -24 hours paid for nursing On 8/17/23, when queried about a policy for PBJ reporting, the Administrator stated the facilty uses the CMS PBJ Manual. The CMS PBJ Manual, dated June 2022, 1.1 Introduction (u) (2) Submission requirements. The facility must electronically submit to CMS complete and accurate direct care staffing information, including the following: (iii) Information on direct care staff turnover and tenure, and on the hours of care provided by each category of staff per resident per day and hours worked for each individual.

Based on observations, record review, staff interviews, and facility policy review, it was determined the facility failed to maintain an infection prevention and control program to prevent the transmission of novel Coronavirus Disease 2019 (COVID-19). Specifically, 1. The facility failed to implement and monitor an effective screening process for staff to prevent a COVID-19 outbreak for 10 (Residents #21, #17, #31, #19, #13; #2, #6, #12, #10, and #3) of 34 residents. The lack of effective screening resulted in a staff member being able to work while exhibiting symptoms of COVID-19. Ten of the facility residents tested positive for COVID-19, as well as six other staff members. 2. The facility failed to implement a respiratory protection program compliant with Occupational Safety and Health Administration (OSHA) respiratory protections standards, which included medical evaluations, training, and fit testing for the use of N95 respirators. Two COVID-19 positive staff, one of whom wore an N95 respirator incorrectly, were allowed to work with COVID-19 negative residents. The facility reported a census of 34 residents. Ten residents had tested positive for COVID-19. The facility identified the first COVID-19 positive resident in the facility on 5/15/22. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.80 (Infection Control) at a scope and severity of K. The IJ began on 5/11/22 at 2:00 PM, when Staff A, Registered Nurse (RN), started her shift without self-screening and worked while having COVID-19 symptoms. The Administrator received notification of the IJ on 5/19/22 at 12:08 PM. At that time a Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 5/19/22 at 7:00 PM. The IJ was removed on 5/20/22 at 1:10 PM after the survey team performed onsite verification of implementation the Removal Plan. Noncompliance for F880 remained at the lower scope and severity of a pattern of an E, with no actual harm, and a potential for more than minimal harm that was not immediate jeopardy. Findings Included: A review of the facility policy titled, Staff Screening & [and] Return to Work Protocols, revised on 1/10/22, indicated, 1. All employees will enter and exit through a specific entrance door, as designated to them by their supervisor, that is setup with equipment and a log book to allow for screening of an employee prior to having access to any other areas in the facility. 2. Screening is to be done by a nurse, a department head, or an employee trained to properly screen by a nurse or department head. If an employee has been trained to screen for Covid-19 [sic], a note shall be placed in that employee's education file indicating the date of training and what was covered in the training. At the discretion of a community's Administrator based on vaccination rates of staff, tenants, and residents as well as a review of positivity rates and community transmission, self-screening by asymptomatic employees may be allowed. Employees with signs or symptoms will still get a nurse, department head, or other trained employee to conduct the screening . 6. If an employee has any symptoms consistent with Covid-19 and/or a fever of one hundred (100.0) degrees or greater, the employee will not be allowed to enter the facility and will be tested for COVID-19 . A review of a list of staff that were confirmed positive for COVID-19 and titled, Staff COVID 19 Positive or Suspected, indicated the first positive staff member was Staff A, Registered Nurse (RN), who tested positive on 5/12/22. The form further noted that Staff A had signs and symptoms of COVID-19 and got sent home prior to working her shift. A review of a list titled, Covid Suspected or Confirmed, revealed the resident list included five COVID-19 positive residents on 100 Hall (Resident #21, Resident #17, Resident #31, Resident #19, and Resident #13) and five COVID-19 positive residents on the 200 Hall (Resident #2, Resident #6, Resident #12, Resident #10, and Resident #3). The document indicated that within the last four weeks, the dates of the ten residents who tested positive started on 5/12/22 and ended on 5/15/22. A review of the Evening Shift Assignment indicated Staff A's schedule indicated she worked from 2:00 PM to 10:00 PM on 5/11/22 and worked the 100 Hall, providing direct care to 18 residents. A review of the Attendance Application indicated Staff A worked for 6.25 hours on 5/11/22. A review of the Daily Temps and Screening for COVID-19 on 5/11/22 revealed Staff A, did not self-screen before starting her shift. A review of POC Tracking List, the facility's COVID-19 test tracking form, for May 2022, indicated that Staff A tested positive for COVID-19 on 5/12/22. The list lacked documentation of Staff A having a test on 5/11/22. A review of an untitled time clock report indicated that on 5/17/22, Staff J worked from 2:00 PM to 10:00 PM, and Staff K worked from 6:00 AM to 2:00 PM. A review of the Daily Temps and Screening for COVID-19 on 5/17/22 revealed Staff J, Certified Nursing Assistant (CNA), and Staff K, CNA, did not fill out the screening form. During an interview on 5/17/22 at 3:47 PM, Staff A stated she tested positive for COVID-19 on 5/12/22. Staff A stated that she worked the previous day, 5/11/22, from 2:00 PM to 8:00 PM. Staff A said that she woke up on 5/11/22 feeling like she had allergies due to mowing the grass the day before. However, Staff A reported that she didn't have allergies but thought allergies may have been the issue. Staff A stated her symptoms were that she felt really stuffy and full and she had ear pain. She stated she sneezed and, my throat was scratchy. No upset stomach or headache. Staff A stated she was feeling ill, so tested herself for COVID-19 at work, and got a negative result. Staff A stated that throughout her shift, the symptoms got worse and included severe gastrointestinal (GI) symptoms, vomiting, dry heaving, fever, weakness, fatigue, sinus pressure, very stuffy, sore ears, and headache. She stated she told the other nurse on shift, name not provided, that she was not feeling well. Staff A added that she called Staff B, Licensed Practical Nurse (LPN)/MDS Coordinator, to tell her that she was not feeling good, but got no further instructions. Staff A reported that she did not think it was going to be COVID. Staff A stated that the they self-screened by taking their temperature and documenting if they had any signs and symptoms of COVID-19 for the screening process when they came to work. Staff A stated she usually filled out the screening form but did not remember what she documented on 5/11/22. She stated, I do believe that I filled it out and put 'sinus,' but I don't remember. Staff A stated she was scheduled to work a 16-hour shift on 5/12/22 but called out sick. The facility asked her to come in to take a COVID-19 test, which she did, and it was positive. Staff A stated she came back to work on 5/16/22 at 4:30 PM. The facility advised her that she could return to work due to being in a crisis mode for staffing and that positive staff were allowed to come back to work after five days from testing positive, as long as the staff member was fever-free. Staff A stated her fever ended on Friday night, 5/13/22. Staff A stated she tested positive still on Sunday night, 5/15/22, when she tested herself. Staff A reported that she still had symptoms of nasal congestion and pressure. Staff A acknowledged that she completed the self-screening form that day and put down the symptoms she experienced. Staff A stated that she was the first direct care staff that tested positive for COVID-19. During an interview on 5/17/22 at 4:39 PM, Staff C, Infection Preventionist (IP)/Registered Nurse (RN), stated that the screening process for staff included them taking their temperature and documenting if they were having any symptoms of COVID-19. Staff C stated that staff self-screened upon entry to the facility and staff had to notify her, the Director of Nursing (DON), or the nurse on duty if they were having any symptoms or a temperature. Staff C stated that both the DON and she reviewed the daily screening forms for any discrepancies. Staff C stated that currently, the facility was in crisis mode and was allowing COVID-19 positive staff members to work. Staff A stated that three out of seven nurses tested positive for COVID-19, as well as numerous Certified Nursing Assistants (CNAs). Staff C stated that they used contract staff but had trouble with staff picking up shifts due to the current COVID-19 outbreak in the facility. Regarding Staff A, Staff C confirmed that Staff A worked on 5/11/22 but Staff C didn't get notified that of the symptoms Staff A experienced. Staff C stated Staff A was scheduled to work on 5/12/22 but became symptomatic and come in to be tested . Staff C was shown the self-screen form for 5/11/22, which indicated Staff A did not self-screen, and Staff C stated she did not know why Staff A did not self-screen and that all staff were to self-screen. On 5/17/22 at 6:00 PM, observed no signage at the Director of Nursing's office, medication room, or staff screening room notifying staff of any changes related to the screening process. On 5/18/22 at 7:30 AM, the surveyor noted that the facility front door was locked, which previously had been open in the morning. Upon entry, the facility had numerous colored signs posted, which indicated, 5/17/22, Effective Immediately. Two procedures are now in place: 1. General screening at the start of your shift will require ALL staff to ring the outside doorbell to be let into the facility. Once in you will be screened for the following: a. Do you have fever or chills? b. Do you have a sore throat? c. Do you have a cough? d. Do you have congestion or runny nose? e. Do you have shortness of breath or difficulty breathing? f. Do you have fatigue? g. Do you have muscle or body aches? h. Do you have a headache? i. Do you have a new loss of taste or smell? j. Do you have nausea or vomiting? k. Do you have diarrhea? l. Do you have a temperature of 100.4 or more? m. Have you had an exposure or higher risk exposure to someone who has Covid-19? Charge nurse or designated/trained staff member will temp employee and fill out check in sheet and initial next to the temperature . During an interview on 5/18/22 at 8:28 AM, Staff L, Licensed Practical Nurse (LPN), stated the screening process for staff was that staff entered through the back door of the facility and self-screened by taking their own temperature, filling out a paper, and noting if they had any signs or symptoms. Staff L stated there was a list of symptoms located on the wall for staff to read. During an interview on 5/18/22 at 8:43 AM, Staff E, RN, stated that as of that day, 5/18/22, staff had to ring the bell at the back door of the facility to be let in by a nurse, who would screen the staff member. Prior to that day, staff were self-screening at the back door. During an interview on 5/18/22 at 9:00 AM, Staff B stated that starting that day, 5/18/22, the facility locked the back door, and they had to have a staff nurse open the door to screen the employee entering the building. Prior to 5/18/22, staff were self-screening. However, a nurse was supposed to be screening the staff. Staff B stated that Staff A called her on 5/11/22 after Staff A had already left their shift early, at 8:00 PM, but was scheduled to work until 10:00 PM. Staff B stated that Staff A complained of a sore throat and left work early. Staff B stated that Staff A was scheduled to work the following day and told Staff A to complete a COVID-19 test before starting her shift. However, Staff A did not show up for her shift. Staff B stated that Staff A called Staff E, RN, the morning of Staff A's shift and stated she would be late but never showed. Staff B stated that they finally were able to reach Staff A and stated she needed to come in to test for COVID-19, which she did and was positive. Staff B stated that she did not notify anyone that Staff A called her on 5/11/22 notifying Staff B that Staff A left work early and had symptoms of COVID-19. During an interview on 5/18/22 at 10:57 AM, the Director of Nursing (DON) stated that prior to the evening of 5/17/2021, staff were self-screening at the back door of the facility. As of the evening of 5/17/22, the DON sent out a mass text message to nursing staff notifying them of the change in the screening process, that staff had to be let in the back door and screened by another staff member. The DON stated that this process changed after the surveyor requested copies of the daily screening forms and the DON noticed missing employee screening information. The DON stated they felt it best to get started immediately on the new screening process. The DON stated that Staff A should have screened in before her shift on 5/11/22. During an interview on 5/18/22 at 12:46 PM, the Administrator (ADM) stated that prior to the evening of 5/17/22, staff were self-screening at the back door of the facility. The ADM stated that this process changed after the surveyor requested copies of the daily screening forms and he noticed the form had missing screening information. The ADM stated it was pointed out that there were missing entries for staff who had worked and did not screen and, it wasn't working the way it was supposed to. The ADM stated he didn't know that Staff A had any symptoms of COVID-19 on 5/11/22. During an interview on 5/18/22 at 2:55 PM, Staff J, Certified Nursing Assistant (CNA), stated that currently, the facility had the back door locked, staff had to ring the doorbell, a nurse would take their temperature, and screen them for signs and symptoms. Staff J stated prior to 5/17/22, the staff would self-screen. During an interview on 5/19/22 at 9:16 AM, Staff O, Laundry Aide, stated that the staff self-screened before starting their shift until 5/18/22, and a nurse now had to screen the staff. 2. A review of the CDC's, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/22, indicated, Source control options for HCP [healthcare personnel] include: A NIOSH [National Institute for Occupational Safety and Health] approved N95 or equivalent or higher-level respirator OR A respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering face piece respirators. (Note: These should not be used instead of a NIOSH-approved respirator when respiratory protection is indicated). A review of OSHA's Occupational Safety and Health Standard 1910.134, titled, Respiratory Protection, indicated the following: - 1910.134(c)(1) - In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures. The program shall be updated as necessary to reflect those changes in workplace conditions that affect respirator use. The employer shall include in the program the following provisions of this section, as applicable: Procedures for selecting respirators in the workplace; Medical evaluations of employees required to use respirators; Fit testing procedures for tight-fitting respirators; Training of employees in the proper use of respirators, including putting on and removing them, any limitations on their use, and their maintenance. - 1910.134(f) - Fit testing. This paragraph requires that, before an employee may be required to use any respirator with negative or positive pressure tight-fitting face piece, the employee must be fit tested with the same make, model, style, and size of respirator that will be used. - 1910.134(f)(2) - The employer shall ensure that an employee using a tight-fitting face piece respirator is fit tested prior to initial use of the respirator, whenever a different respirator face piece (size, style, model or make) is used, and at least annually thereafter. A review of the Makrite 9500-N95 instruction sheet provided with the masks utilized by facility staff indicated, the respirator should be fit checked for each wearing. Place both hands completely over the respirator and exhale. If air leaks around the nose or the edges, adjust the nosepiece and/or headbands until a good fit is achieved. During an interview on 5/17/22 at 3:47 PM, Staff A, Registered Nurse (RN), was wearing a 3M brand N95 respirator mask. Staff A stated she had not been fit tested for the N95 mask and didn't know what fit testing meant. Staff A tested positive for COVID-19 on 5/12/22, but worked due to the facility being in crisis mode for staffing. During an interview on 5/17/22 at 4:39 PM, Staff C, Infection Preventionist (IP)/Registered Nurse (RN) stated the facility did not have a respiratory protection program, nor had the facility completed fit testing for the use of N95 respirators, which were currently in use at the facility. During an interview on 5/18/22 at 8:28 AM, Staff L, Licensed Practical Nurse (LPN), was wearing a surgical mask underneath an N95 mask. Staff E stated they had not been fit tested for the N95 mask they were wearing and did not know what fit testing was. Staff L stated they were wearing the surgical mask underneath the N95 mask because, I want to be extra safe. During an interview on 5/18/22 at 8:43 AM, Staff E, RN, was wearing a surgical mask underneath an N95 mask. Staff E tested positive for COVID-19 on 5/15/22. Staff E stated they didn't get fit tested for the N95 mask they wore and did not know what fit testing was. Staff E stated that they were wearing the surgical mask underneath the N95 mask as an extra precaution, since I'm positive. Prior to the interview, Staff E was witnessed wearing the N95 respirator incorrectly and donning personal protective equipment (PPE), and then entered a resident's room to provide medication to the resident. During an interview on 5/18/22 at 9:00 AM, Staff B was wearing a KN95 mask and stated staff were to wear KN95 masks during the current outbreak and didn't know if the facility had any N95 masks. Staff B stated they didn't get fit tested for an N95 mask, nor received any training regarding how to properly wear a KN95 or an N95 mask. During an interview on 5/18/22 at 10:57 AM, the Director of Nursing (DON) stated she didn't know if the facility had a respiratory protection program, but it was going to be reviewed. The DON stated that staff were to wear N95 masks during the outbreak. The DON was wearing a KN95 with a face shield, she reported that she had asthma and could not wear an N95. The DON stated that depending on the size of the N95, fit testing should be completed, but she would have to look at the manufacturer's guidelines and go off their recommendations. The DON stated that staff should not wear regular masks underneath an N95 mask because it, defeats the purpose of the N95. During an interview on 5/18/22 at 12:46 PM, the Administrator (ADM) stated the facility did not have a respiratory protection program and didn't know what the program would consist of. The ADM stated the facility did utilize N95 masks but did not fit test the masks because they couldn't find a service provider to provide the facility with the training. The ADM stated that regular masks should not be worn underneath an N95 mask because it would defeat the purpose of the N95 fitting more snug. During an interview on 5/18/22 at 2:55 PM, Staff J, Certified Nursing Assistant (CNA), wore a 3M N95 mask. Staff J stated they didn't get fit tested for the mask and had not received any formal training on how to properly wear the mask, except for signs posted on the wall. During an interview on 5/18/22 at 4:30 PM, the DON stated the facility did not have a policy regarding the use and/or training of N95 masks. Removal Plan: As of the afternoon of 5/19/22, the following procedures were put into place to correct the F880 deficiency: On the evening of 5/17/22 item #1 [below] was posted at the employee entrance, time clock, Director of Nursing's office, Medication Room, Breakroom, Nurses' charting room, and the staff screening station. This was put into place for all employees to review and comply with. 1. General screening at the start of your shift will require ALL staff to ring the outside doorbell to be let into the facility. Once in your [sic] will be screened for the following: a. Do you have fever or chills? b. Do you have a sore throat? c. Do you have a cough? d. Do you have congestion or runny nose? e. Do you have shortness of breath or difficulty breathing? f. Do you have fatigue? g. Do you have muscle or body aches? h. Do you have a headache? i. Do you have a new loss of taste or smell? j. Do you have nausea or vomiting? k. Do you have diarrhea? l. Do you have a temperature of 100.4 or more? m. Have you had an exposure or higher risk exposure to someone who has Covid-19? The Charge Nurse or designated staff member will temp the employee and go over the above questions and fill out check in sheet and initial next to the temperature or symptom column. Further testing may be necessary depending on results of the questions above including but not limited to high temperature. The Administrator, Director of Nursing, or Infection Control/Preventionist will need to be contacted immediately for any question marked yes or temperature above 100.4. The document used for training on screening is our Staff Screening & Return to Work Protocols. The infection Preventionist or designee will administer the training and each team member trained will sign a copy that will be retained in the personnel file. Furthermore, the charge nurse or designee will compare the daily assignment sheet/schedules to the screening sheets no later than 30 minutes after the shift has started to verify all employees on duty were properly screened during their shift. Any discrepancies will be rectified with proper screening and the Administrator, Director of Nursing, or Infection Preventionist notified. 2. Signage was posted on the evening of 5/17/22 at eh [sic] employee entrance, time clock, Director of Nursing office, Medication Room, Breakroom, Nurses [sic] charting room, and the staff screening station to alert all staff members to the Protocols and the importance of reporting symptoms. In addition, starting on the afternoon of 5/19/22, all staff will be required to review the Covid-19 Signs and Symptoms sheet (included) and verify their competency and understanding by signing the education sheet. This will be done to all staff currently working (on duty) and as they come on duty prior to working the floor. This will be verified by the Administrator or designee. 3. Staff that are Covid positive and working the floor during crisis staffing, and staff that are taking care of Covid positive residents will be educated on how to properly wear an N95 based on the manufacturer's instructions. They will need to demonstrate the procedure based on those instructions and sign that they understand and completed the process. This will be done to affected staff currently working (on duty) and as they come on shift prior to working the floor. This sheet will be kept in the employee file or a file designated for contract staff. Training began the afternoon of 5/18/22 by the Administrator, Director of Nursing, MDS Coordinator, Human Resources Director, Social Services Designee. 4. Corrective action for staff currently on duty will be completed by 10pm [10:00 PM] today 5/19/22. Shifts that follow will be completed as they come on duty having all scheduled staff completed by 2pm [2:00 PM] the following day 5/20/22. Unscheduled staff will be contacted via telephone and conversation documented. The IJ will be removed by 5/20/22. Onsite Verification: The IJ was removed on 5/20/22 at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Onsite verification of the Removal Plan began at 8:10 AM on 5/20/22, when signage was verified at the employee entrance, time clock, Director of Nursing's office, medication room, breakroom, nurses' charting room, and the staff screening station. Verification completed at 8:40 AM of the employee screening sheet and audit. All staff got screened appropriately. A total of 17 staff interviews were conducted with staff from all three shifts to verify training got completed. The staff interviewed included Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Housekeeping, Environmental Services, Kitchen Staff, and the Activity Director. The staff interviewed verified they got trained on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, and the proper fit and use of N95 respirators. A review of the in-service sheets provided indicated that all 67 staff members had been provided training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, and the proper fit and use of N95 respirators. Those staff that were not physically present to receive the in-services were messaged via telephone, with the in-service information provided, the employee acknowledged the receipt, and voiced understanding.

Based on interviews, record review, and facility policy review, the facility failed to develop and implement appropriate plans of action to correct identified quality deficiencies. In September of 20, the facility was cited for failure to implement and monitor an effective screening process for staff to prevent a novel Coronavirus Disease (COVID-19) outbreak. The facility implemented a screening policy that indicated nurses, or any department head, could screen employees upon entrance to the facility. In March of 21, the facility revised the policy and established that any staff could witness another employee screening prior to working. The facility lacked evidence of monitoring the new policy and, on [DATE], a facility staff member failed to screen themselves for symptoms of COVID-19 prior to working her shift and knowingly worked while having symptoms of COVID-19. As a result, ten facility residents and six additional staff members tested positive for COVID-19. The lack of screening by facility staff placed all residents and staff at risk of contracting COVID-19. It was determined the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.75(g) - Quality Assurance and Performance Improvement (QAPI) at a scope and severity of K. The IJ began on [DATE] at 2:00 PM, when Staff A, Registered Nurse, started her shift without self-screening and worked while having COVID-19 symptoms. The Administrator was notified of the IJ on [DATE] at 12:08 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on [DATE] at 7:00 PM. The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F867 remained at the lower scope and severity of a pattern of an E, with no actual harm and potential for more than minimal harm that was not immediate jeopardy. Findings Included: A review of the facility's, QAPI Written Plan, with no revision date, revealed, .The purpose of QAPI for [the facility] is to take a proactive approach to continually improving the way we care for and engage with our residents, caregivers, and other partners so that we may realize our vision to provide home like levels of care where residents feel loved, valued, safe and content . The outcome of QAPI in our organization is the quality of care and quality of life of our residents . 3. How the QAPI Plan will address key issues: .We will track, investigate, and try to prevent recurrent of adverse events . A review of the Statement of Deficiencies and Plan of Correction, Centers for Medicare and Medicaid Services (CMS) Form 2567, dated [DATE], revealed, .The facility failed to implement and monitor an effective screening process for staff to prevent a Coronavirus Disease (COVID-19) outbreak for 20 of 33 residents . Twenty of the facility residents tested positive for COVID-19 including one resident who passed away by the end of survey [DATE] . Further review of the Plan of Correction revealed a Staff Screening for the Pandemic procedure that stated, any department head or nurse can screen employees. A review of the facility's Risk Assessment on Change in Policy for Staff Screening, dated [DATE], revealed the Infection Control/QAPI Committee met to analyze the facility screening process. The risk assessment revealed the committee reviewed the current process that indicated, since September of 20, when a staff member arrives at work, a nurse or manager would screen the incoming staff member, asking the standard Covid-19 screening questions, witnessing the temperature reading from the wall mounted machine, or using the handheld temperature thermometer. The staff member or supervisor would record the findings on the daily log sheet . Anything outside of normal parameters would be immediately reported to the Charge Nurse or the Director of Nursing Services for further screening. Further review revealed a modification that stated staff may now screen in at the beginning of their shift using any staff member as witness. The witness is no longer required to put down their initial. It is of utmost importance that the witness must report any signs or symptoms, including temperature over 100 degrees, to the Charge Nurse immediately. The justification for the change in policy revealed the infection control/QAPI committee has studied the overall screening process . The committee feels that any coworker should be competent to witness another employee screen in. The assessment did not include how the facility would monitor or track the progress of this change. During an interview on [DATE] at 3:47 PM, Staff A, Registered Nurse (RN), stated she tested positive for COVID-19 on [DATE]. Staff A stated that she had worked the previous day, [DATE], from 2:00 PM to 8:00 PM. Staff A stated that she woke up on [DATE] feeling like she had allergies due to mowing the grass the day before. Staff A stated that throughout her shift, the symptoms got worse and included severe gastrointestinal (GI) symptoms, vomiting, dry heaving, fever, weakness, fatigue, sinus pressure, very stuffy, sore ears, and headache. Staff A stated she usually filled out the COVID screening form but did not remember what she documented on [DATE]. Staff A stated she was scheduled to work a 16-hour shift on [DATE] but called out sick. The facility asked her to come in to take a COVID-19 test, which she did, and it was positive. A review of the Daily Temps and Screening for COVID-19 on [DATE] revealed Staff A, did not self-screen before starting her shift. A review of the Evening Shift Assignment indicated Staff A was scheduled to work from 2:00 PM to 10:00 PM on [DATE] and worked the 100 Hall, providing direct care to 18 residents. A review of a list titled, Covid Suspected or Confirmed, revealed the resident list included five COVID-19 positive residents on 100 Hall (Resident #21, Resident #17, Resident #31, Resident #19, and Resident #13) and five COVID-19 positive residents on 200 Hall (Resident #2, Resident #6, Resident #12, Resident #10, and Resident #3). The document indicated that within the last four weeks, the ten residents who tested positive started on [DATE] and ended on [DATE]. During an interview on [DATE] at 11:51 AM, the Administrator (ADM) reviewed the facility's Quality Assurance Program with the surveyor. He explained the team met quarterly unless an issue were to arise. The ADM stated that issues were monitored as long as they need to be and further stated that once improvement was seen they would downgrade the monitoring. The ADM couldn't provide any information regarding the previous F880 IJ cited in [DATE], only stating that the committee addressed the IJ and stated it was related to the previous administrator. Removal Plan As of the afternoon of [DATE], the following procedures were put into place to correct the F865 [F867] deficiency: 1. [Facility] QAPI Committee will be called to order on the afternoon of [DATE] to review the F880 IJ tag, examine where the process failed and study the corrective actions currently put into place to immediately correct the deficiencies stated and make any further recommendations to improve the process. 2. Added to the QAPI committee is the newly hired Infection Preventionist that will bring a a higher level of professionalism to our process and help ensure compliance. Going forward, the QAPI committee will review past compliance issues at each meeting (agenda item) and document the discussion in the minutes. 3. A nurse consultant will be brought in on [DATE] to review our overall QAPI process and make recommendations for any needed changes in order to prevent further issues. 4. Staff will be educated on the facility's screening process for signs and symptoms of Covid-19 and the importance of reporting said signs and symptoms of Covid-19 to their supervisor. They will sign off acknowledging their understanding/competence of the issue. 5. This will be implemented today ([DATE]) by the Administrator. The IJ will be removed on [DATE]. Onsite Verification: The IJ was removed on [DATE] at 1:10 PM after the survey team performed onsite verification that the Removal Plan had been implemented. A review of the Special Session of QAPI Committee Re [regarding]: F865 [F867] IJ Tag revealed the facility conducted a QAPI meeting on [DATE]. A total of 17 staff interviews were conducted on [DATE] with staff from all three shifts to verify training had been completed. The staff interviewed included Certified Nursing Assistants (CNAs), Registered Nurses (RNs), Housekeeping, Environmental Services, Kitchen Staff, and the Activity Director. The staff interviewed verified that they received training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, the proper fit, and use of N95 respirators. A review of the in-service sheets provided indicated that all 67 staff members had been provided training on reporting signs and symptoms of COVID-19, the screening process before entry into the facility, the proper fit, and use of N95 respirators. Those staff who were not physically present to provide the in-services were messaged via telephone with the in-service information provided and the employee acknowledging receipt and voicing understanding. During verification of the Removal Plan, the Administrator introduced the nurse consultant to the surveyor and provided a document indicating that the nurse consultant arrived at 9:45 AM on [DATE], to assist the Administration staff with auditing their Infection Control compliance as well as assisting them in their plan of correction, education, audit tools, and ongoing QAPI PIP's [performance improvement plans].

Based on observations, record review, interviews, and facility policy review, it was determined the facility failed to conduct thorough investigations into falls and provide adequate supervision to prevent falls with major injuries for one resident (Resident #32) out of three sampled residents whose clinical records were reviewed for accidents. This deficient practice resulted in Resident #32 sustaining a left [CONDITION(S)] on 8/31/21, and again on 9/8/21. Resident #32's [CONDITION(S)] went unnoticed by the facility until identified on 9/16/21. The facility reported a census of 34 residents. Findings Included: A review of the facility's policy titled, Accidents and Incidents - Investigating and Reporting, revised August 2019, revealed, Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc [and so forth] occurring on our premises must be investigated and reported to the Administrator or Director of Nursing . 4. Investigative Action: a. The nurse supervisor/charge nurse and/or the department director or supervisor must conduct an immediate investigation of the accident or incident. b. The following data, as it may apply, may be included on the Accident Investigation Report Form . 3. The circumstances surrounding the accident or incident . 11. Any corrective action taken. A review of the Admission Record revealed the facility admitted Resident #32 with diagnoses which included dementia, [CONDITION(S)], and a history of falling. The resident's quarterly Minimum Data Set (MDS), dated [DATE], indicated the resident's cognitive skills for daily decision-making were moderately impaired, according to the Staff Assessment for Mental Status. The MDS indicated the resident was independent with transfers, walking, locomotion, and toilet use. The resident used a walker for ambulation. The resident was continent of bladder and bowel. The resident's discharge MDS, dated [DATE], indicated the resident's cognitive skills for daily decision making were moderately impaired, according to the Staff Assessment for Mental Status. The resident required extensive assistance with all other activities of daily living except eating. Walking did not occur during the seven-day lookback period. A review of Resident #32's Morse Fall Scale revealed assessments that determined Resident #32 as a high fall risk for falls on 3/2/21, 9/4/21, and 9/20/21. A review of Resident #32's facility incident reports revealed the resident fell on the following dates and times: - On 3/19/21 at 3:31 AM, in their room. - On 4/22/21 at 12:15 AM, in front of their bathroom door. - On 5/12/21 at 3:49 AM, in the resident's bathroom. - On 8/31/21 at 6:30 AM, the resident fell in their room and sustained a [CONDITION(S)] that required surgical intervention. - On 9/8/21 at 7:00 PM, the resident fell in their bathroom and received a new [CONDITION(S)] (discovered on 9/16/21). The fracture didn't require surgical intervention. - On 9/23/21 at 3:10 PM, in the resident's room. - On 11/8/21 at 8:00 AM, in the resident's room. - On 3/5/22 at 10:45 AM, in the resident's room. - On 3/18/22 at 7:00 PM, in the shower room, as staff left Resident #32 alone in the shower room. A facility incident report, dated 8/31/21 at 7:00 PM, indicated staff found the resident on the floor in their room. The resident complained of excruciating left hip pain and couldn't straighten their left leg. The staff notified the physician and family. Resident #32 got transferred to a local hospital for evaluation and treatment. The incident report indicated the predisposing physiological factors were gait imbalance and impaired memory. The predisposing situational factors were improper footwear and ambulating without assistance. A review of Resident #32's care plan, initiated 2/26/19, revealed the resident as a high risk for falls and had a self-care deficit. The Care Plan included the following interventions in place prior to the resident's fall with [CONDITION(S)] on 8/31/21: a. Encourage to use call bell for assistance (dated 2/26/21). b. Gripper socks at bedtime (dated 3/19/21). c. Remind to always use a four-wheeled walker (dated 3/27/21) d. Cue the resident to toilet first thing in the morning, before meals, after meals, at bedtime, and PRN (whenever necessary) (dated 5/12/21) e. Reminded Resident #32 to keep the walker close by (dated 5/27/20) f. Keep a tray table close by (dated 6/23/20) g. Assistance of one staff for 24 hours (dated 7/12/20) h. Ensure Resident #32 wore nonskid shoes (dated 7/24/20) i. Monitor transfers when in dining room for 48 hours (dated 7/24/20) j. Gripper strips by bed (dated 7/31/20) k. Cue to ensure adequate toileting (no date). l. Transfers independently. Verbally cue as needed to have the resident use a four wheeled walker (no date). A review of Progress Notes, dated 9/4/21 at 3:50 PM, indicated the resident arrived via ambulance on a stretcher from a local hospital. A [MEDICATION(S)] dressing covered Resident #32's incision to their left hip. Resident #32 required the assistance of two staff and a front-wheeled walker for transfers. The clinical record lacked documentation of an investigation conducted to determine the root cause of the fall with fracture on 8/31/21. A facility incident report, dated 9/8/21 at 7:00 PM, indicated the staff found Resident #32 sitting on the floor of the bathroom, in front of their wheelchair. The report indicated Resident #32 stated they had to pee. No injuries were observed at the time of the fall. The report further indicated no predisposing factors related to the fall. The facility document titled Staff Education, effective 9/9/21, indicated Resident #32's Care Plan got updated upon their return to the facility on [DATE]. The staff were not to leave the resident unattended in their room while in the wheelchair. Staff were to toilet the resident every morning, before and after each meal, at night, and as needed. The staff were to ensure that when Resident #32's laid in bed, their bed went in the lowest position with the floor mat down, and they could reach their call light before leaving the room. The Care Plan included the following new interventions put in place upon return to the facility after the resident's fall with a [CONDITION(S)] on 8/31/21: a. Stand pivot transfer and toilet use with an assist with two for all transfers. b Assist of one staff with dressing, personal/oral hygiene, and bathing. c. Low bed and in lowest position when the resident is in bed. d. Floor mat on the floor beside the bed when the resident laid in bed. e. Call light within reach at all times when the resident is in bed. f. Mobility: Assist with one staff while in their wheelchair. The clinical record contained no indication that the staff provided frequent toileting for the resident, as indicated in the updated care plan. The Care Plan included an intervention that directed staff to toilet the resident every morning, before each meal, after each meal, at night, and as needed. This was not a new intervention on 9/4/21, as the invention got added to the care plan initially on 5/12/21. Their clinical record lacked evidence of the implementation of the intervention. A review of Progress Notes, dated 9/10/21 at 11:56 AM, documented that therapy asked the nursing staff to assess the resident's lower legs. The assessment indicated the resident had two-plus [CONDITION(S)] (swelling) on the left leg (the side of the [CONDITION(S)]). The nurse notified the physician. The resident was comfortable. A review of Progress Notes, dated 9/10/21 at 1:18 PM, revealed the physician issued a new order for staff to monitor pedal pulses and put compression socks on the resident's legs every morning and remove at night. A review of Progress Notes, dated 9/16/21 at 10:25 AM, indicated the resident's left calf had purple/yellow bruising with a hard lump and four-plus pitting [CONDITION(S)]. The resident complained of tenderness with movement due to surgery. The nurse notified the physician and family. A note at 12:49 PM indicated the physician issued orders to send the resident to the emergency room . The resident transferred to the local hospital by ambulance. The hospital record, dated 9/16/21, indicated the radiology results revealed an acute minimally displaced fracture of the greater trochanter (broken hip). The record indicated the fracture was discussed with orthopedics who determined Resident #32's fracture as non-operable. A review of Progress Notes, dated 9/20/21 at 2:17 PM, indicated the resident returned to the facility. The clinical record lacked indication that an investigation got conducted to determine the root cause of the fall with fracture on 9/8/21. The facility incident reports revealed the resident had four additional falls after the fall with fracture on 9/8/21, they occurred on 9/23/21, 11/8/21, 3/5/22, and 3/18/22 During an interview on 5/17/22 at 2:10 PM, Staff J, Certified Nursing Assistant (CNA), stated that at the beginning of each shift, the staff get provided a Care Plan driven cheat sheet that informed them which residents were a fall risk. Staff J indicated the nurses also told them. The CNAs had CNA meetings every two months to discuss issues. She did not know if she went to an in-service about accidents and hazards. She stated she did not remember what interventions were in place during the time Resident #32 had the two falls with fractures. She stated she personally would check to see if the resident had on gripper socks and/or shoes and would make sure the wheelchair was locked during transfers. She said she would get another person to assist if a she needed to use a lift to transfer a resident. Staff J reported that she did not know of other interventions that would prevent falls. She was asked if the cheat sheet identified interventions in place for each resident. She replied when asked if the cheat sheet identified interventions in place for each resident, that it identified the necessary type of care but not a list of interventions. She did not remember if Resident #32 had a toileting schedule or frequent visual checks at that time. She did not know if there was a specific schedule to check on the resident; she thought staff were to take the resident to be toileted after meals. She stated the resident would self-transfer without assistance. Staff J responded to the question about if the resident could remember to use the call and said the resident would probably not be able to use the call light. On 5/17/22 at 2:15 PM, observed Resident #32 getting out of bed without assistance and ambulating to the wheelchair. The resident self-propelled the wheelchair into the hall. The Activities Director (AD)/CNA returned the resident to their room and asked the resident to put their shoes on, due to the resident not wearing any. The resident stated they were hungry, so the AD got a sandwich for the resident from the kitchen. During an interview on 5/17/22 at 2:25 PM, the AD reported that the facility fall protocol related to reporting falls, but not about preventing falls. The AD explained that some interventions used for residents at risk of falling were gripper socks, shoes, keeping their room clutter-free, and checking their call light placement. The AD denied remembering what interventions were in place for the resident when the resident had the two falls with fractures. She did remember that the resident continued to self-transfer and tried to be independent. She said whenever possible, if she (the AD) walked down the hallway she would look in the resident's room to see what the resident was doing. She did not know if there was a specific schedule to check on the resident. She stated the resident would not have been able to activate the call light. During an interview on 5/17/22 at 2:35 PM, Staff Q, CNA, stated the CNAs got a cheat sheet and report at the start of their shift. Staff Q explained that some possible interventions for preventing falls were fall mats and low beds. Staff Q recalled that they placed a squeeze call light in bed with the resident next to the resident's hip: so, if the resident rolled over it would activate the call light. Staff Q reported that when they had time, they checked on Resident #32 and the staff would ask if they needed to use the toilet. Staff Q explained that the resident was supposed to be toileted before and after meals. She denied remembering if everybody had time to do that. Staff Q couldn't recall when they had an in-service on accidents. She did not know if there was a specific schedule to do visual checks, just if they had time. She stated the resident would self-transfer and did not use a call light. During an interview on 5/17/22 at 4:20 PM, the Director of Nursing (DON) stated when interventions were put in place for falls, they would be determined by the circumstances of the fall. The interventions could be a toileting program, if the resident fell while attempting to self-toilet. The DON replied when asked how she would determine what the unusual circumstances of a fall were without an investigation to determine the root cause of the falls, that she depended on her staff to determine what was going on when the resident fell . She responded to the question about if an investigation would be required to determine the root cause of the fall or a pattern if there were multiple falls, it would be necessary to investigate to determine a root cause for a pattern for multiple falls. She was asked to provide documentation of an investigation conducted to determine the root cause of Resident #32's falls. She stated she did not think anything other than the incident reports had been prepared. The DON replied no when asked if interventions had been developed for offering the resident snacks, frequent toileting, or frequent visual checks while the resident was alone in the resident's room. The DON explained that she noticed that some of the falls were due to the resident wanting a snack or to use the toilet; but she did not think the resident would have cooperated with a toileting schedule. The DON was asked if there was documentation of a toileting schedule having been tried and failed. She stated she would look, but she did not think so. She added that she did not work at the facility when the resident [NAME] sustaining their fractures. The DON added the Care Plans did not contain an intervention to have the staff provide supervision for Resident #32. The DON stated the resident was an elevated risk for falls and was known to self-transfer. The DON stated that the resident probably would not remember to use a call light. During an interview on 5/18/22 at 2:51 PM, Staff R, Restorative Aide, stated she did not remember the resident's interventions. She stated she remembered the resident but not anything about the interventions to prevent falls. What she did remember was that after the second fall with a fracture, no one thought the resident had a fracture because the resident's pain level and resistance did not worsen, and the resident was medicated prior to therapy. She stated she was not sure if the resident was able to use a call light. During an interview on 5/19/22 at 11:48 AM, Staff A, Registered Nurse (RN), stated she remembered sometime after Resident #32 fell , they weren't supposed to be left alone in their room. She did not know if there was documentation of that happening. She did remember she would see the resident out in the lobby, but she couldn't remember if staff were with the resident. She thought they were to keep water at their bedside, look in their room when they walked down the hall, use gripper socks, and shoes. Staff A explained that she didn't remember anything else. Staff A replied that she didn't know when asked if there was a time frame the resident was supposed to be visually checked and/or toileted. She stated she did not know, but they were supposed to toilet the resident when needed. She added the resident would not have been able to remember to use the call light and would self-transfer. During an interview on 5/19/22 at 11:55 AM, Staff S, CNA, stated that staff were supposed to remind Resident #32 to use their call light and ask for assistance. The resident would try to self-transfer and would try to get dressed unassisted. She did not remember if they were supposed to do visual checks or toilet checks on the resident or ask the resident if she/he needed anything. Staff S reported that the resident couldn't remember anything and would not have remembered to use the call light.

Based on record review, interviews, and facility policy review, the facility failed to ensure a resident's medication regimen was free of unnecessary [CONDITION(S)] medication for one (Resident #32) of five sampled residents reviewed for [CONDITION(S)] medications. Specifically, Resident #32 was prescribed [MEDICATION(S)], an antipsychotic medication, in the absence of a documented diagnosis to support the use of the medication and without consistent behavioral monitoring. The facility reported a census of 34 residents. Findings Included: A review of the facility's undated policy titled, [CONDITION(S)] Medication Review, revealed, The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the long-term facility to include regular review for continued need, appropriate dosage, side effects, risks, and/or benefits. A review of the Admission Record revealed Resident #32 had diagnoses that included dementia with behavioral disturbance and depressive episodes. A review of the care plan dated 11/12/21 revealed Resident #32 took [CONDITION(S)] medications related to dementia and depression. The interventions included to administer the medication as ordered, to discuss the ongoing need for the use of the medication, to monitor for any adverse reactions, and to review behaviors/interventions and alternate therapies attempted and their effectiveness. A review of the physician's orders revealed an order dated 6/26/21 for the resident to receive [MEDICATION(S)] (an antipsychotic medication) 12.5 milligrams (mg) two times a day related to dementia with behavioral disturbance. During an interview on 5/18/22 at 9:53 AM, the surveyor asked the Director of Nursing (DON) for documentation of the diagnosis to support the use of [MEDICATION(S)], as well as documentation of monitoring for side effects and behaviors. During an interview on 5/18/22 at 1:10 PM, the DON stated she knew dementia was not an appropriate diagnosis for the use of [MEDICATION(S)] and that Resident #32 had no other appropriate diagnosis for the use of the medication. She stated she was trying to contact the physician to see about a diagnosis change. She also stated they did not conduct behavioral monitoring. During a follow-up interview on 5/19/22 at 12:23 PM, the DON revealed she spoke to the physician about changing the diagnosis from dementia to something else. She stated the physician refused to change the diagnosis but stated [MEDICATION(S)] could be changed from a routine medication to be given as needed. She acknowledged the need for an appropriate diagnosis to justify the use of [MEDICATION(S)]. During an interview on 5/19/22 at 1:17 PM, the Administrator stated the use of [CONDITION(S)] medications was a nursing issue and did not provide any information regarding the use of the medications without an appropriate diagnosis.

Based on observation, interviews, and policy review, it was determined the facility failed to ensure medication carts were locked when unattended for one medication cart (200 Hall) of two medication carts that were observed. The facility reported a census of 34 residents. Findings Included: A review of the facility's undated policy titled, Security of Medication Cart, revealed, The medication cart shall be secured during medication passes. Policy Interpretation and Implementation . 4. Medication carts must be securely locked at all times when out of nurse's view. 5. When the medication cart is not being used, it must be locked. On 5/17/22 at 3:45 PM, observed the medication cart on the 200 Hall unattended and unlocked. The 200 Hall observed to have no staff, and no nurse within eyesight. At 3:55 PM, Staff I, Licensed Practical Nurse (LPN), returned to the cart. She confirmed, when asked about the cart being unlocked, that she had left the cart unlocked and unattended. Staff I confirmed that leaving the cart unlocked unlocked violated the facility policy, when asked if an unlocked cart was against the facility policy. During an interview on 5/17/22 at 4:40 PM, the Director of Nursing (DON) stated that according to the facility policy medication carts must be locked if the nurse was not in proximity of the cart.

Based on interviews, record review, observations, and facility policy review, the facility failed to ensure indwelling urinary catheter drainage bags were not visible to fell ow residents and/or visitors, to maintain dignity for two (Residents #7 and #13) of three residents observed with urinary catheters. The facility reported a census of 34 residents. Findings Included: A review of the undated facility policy titled, Resident Rights, indicated, [Facility Name] will treat you with dignity and respect in full recognition of your individuality. 1. A review of the Admission Record revealed Resident #7 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. The MDS indicated the resident had an indwelling urinary catheter, which was managed totally by the facility staff. A review of the care plan, dated as initiated on 03/11/2022, revealed Resident #7 had an indwelling urinary catheter due to obstructive and reflux [CONDITION(S)] and [CONDITION(S)]. An intervention indicated a leg bag was to be used when the resident was out of bed. A review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 05/16/2022 at 10:00 AM, Resident #7 was in his/her recliner with a regular catheter drainage bag instead of a leg bag. The drainage bag was exposed, not in a privacy bag. During an observation on 05/16/2022 at 11:40 AM, Resident #7 remained in the recliner with no privacy bag covering the catheter drainage bag. During an observation on 05/16/2022 at 2:27 PM, Resident #7 was sitting in the recliner with no privacy bag covering the catheter drainage bag. During an interview on 05/17/2022 at 2:50 PM, Staff A, Registered Nurse (RN) revealed Resident #7's catheter-drainage bag should be covered with a dignity bag if a leg bag was not used. During an observation on 05/18/2022 at 8:29 AM, Resident #7 was in bed. The urinary catheter drainage bag was exposed, not in a privacy bag. During an observation on 05/18/2022 at 10:34 AM, Resident #7 was in bed with no privacy bag covering the catheter drainage bag. During an interview 05/18/2022 at 10:38 AM, Staff N, Certified Nursing Assistant (CNA), revealed Resident #7 usually used a leg bag. Staff N stated when a leg bag was not used, there should be a dignity/privacy bag over the catheter bag. 2. A review of the Admission Record revealed Resident #13 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the admission MDS, dated [DATE], indicated the resident had a BIMS score of 4, indicating severe cognitive impairment. The MDS revealed the resident had an indwelling urinary catheter. Review of the care plan, dated 03/11/2022, revealed Resident #13 had an indwelling catheter due to terminal illness. The goal related to the catheter indicated that the resident will be/remain free from catheter-related trauma through the review date. The care plan did not address the type of drainage bag to be used or provision of privacy related to the urinary catheter. During an observation on 05/17/2022 at 5:12 PM, Resident #13 was in bed. The urinary catheter drainage bag had been hung on the bedframe in a manner that caused the privacy bag to gape open, which exposed the drainage bag. During an observation on 05/18/2022 at 8:29 AM, Resident #13 was sitting in a recliner, with no privacy bag covering the catheter drainage bag. During an observation on 05/18/2022 at 10:28 AM, Resident #13 was sitting in his/her room with no privacy bag covering the catheter drainage bag. During an interview on 05/18/2022 at 10:34 AM, Staff F, the Housekeeping Supervisor, who was also a CNA, revealed that dignity bags should be used when the catheter bags were hanging from the bed and when a leg bag was not in use. During an interview on 05/18/2022 at 1:47 PM, the Director of Nursing revealed that every resident using a catheter bag should always be using a dignity bag. During an interview on 05/18/2022 at 3:15 PM, the Administrator indicated all residents with catheters should have privacy bags over their drainage bags.

Based on record review and staff interview, the facility failed to implement and monitor an effective screening process for staff to prevent a Coronavirus Disease 2019(COVID-19) outbreak for 20 of 33 residents. The lack of effective screening resulted in a staff member being able to work while knowingly ill. Twenty of the facility residents tested positive for COVID-19 including one resident who passed away by end of survey 9/21/20. The facility reported a census of 31 residents. Findings: Review of the untitled, undated list of staff COVID-19 tests revealed Staff A, Certified Nursing Assistant (CNA) had a fever, cough, headache, sore throat, and fatigue starting on 9/4/20 and was last in contact with the facility on 9/5/20. The facility schedule stated Staff A worked 10:00 p.m. to 6:00 a.m. on 9/4/20. Review of the facility-screening sheet for 9/4/20 revealed Staff A had a headache, sore throat, and a dry cough. Review of the untitled, undated list of resident COVID-19 tests revealed 13 residents tested positive for COVID-19 on 9/8/20, 1 resident tested positive on 9/9/20, 1 resident tested positive on 9/10/20, and 5 tested positive on 9/11/20. The list stated 2 of the positive residents discharged to the hospital/Intensive Care Unit(ICU) and 1 resident passed away. An undated facility policy entitled Staff Screening for the Pandemic, provided to the surveyor by the Director of Nursing (DON) on 9/14/20, stated if staff had symptoms but no fever and are feeling ok, they were allowed to enter. An Employee Counseling Form, dated 9/6/20, stated Staff B, Registered Nurse (RN) allowed a staff member to work with potential COVID-19 symptoms. The form stated Staff B's statement was that the staff member did not have a fever and told her she had a dry cough so Staff B didn't think much of it. A 9/8/20 policy Staff Screening Form inquired as to whether staff had the following symptoms: sore throat, cough, shortness of breath, chills, shaking, headache, loss of taste and smell, malaise, nausea, or a temperature greater than 100.0 F(Fahrenheit). The form stated if staff had a fever, they could not enter the building and if they had the above symptoms, a nurse must screen them. The policy Staff Screening for the Pandemic, revised 9/16/20 and provided to the survey team on 9/17/20 by the DON, stated the facility would not allow staff to enter the building if they had a cough, fever, chills, shortness of breath, runny nose, sore throat, headache, nausea, vomiting, or diarrhea. During an interview on 9/15/20 at 11:12 a.m., Staff A, CNA stated on Friday 9/4/20 she woke up with a dry cough and a sore throat. She went to work at 10:00 p.m. for the night shift. She stated she wrote on the screening sheet that she had a cough and a sore throat and also informed the nurse (Staff B, RN). Staff A stated Staff B told her no one would be in until Monday. Staff A stated Staff B brushed it off. She stated she worked the whole shift until the next morning and coughed during the shift. She stated her condition worsened throughout the day on 9/5/20 and she developed a temperature. She stated she called in for her scheduled 10:00 p.m.-6:00 a.m. shift on 9/5/20. Staff A stated she came to the facility on Sunday morning, 9/6/20 and received a COVID-19 test and she was positive. During a subsequent interview on 9/15/20 at 1:55 p.m., Staff A stated she screened herself in and took her own temperature when she arrived for work on 9/4/20. During an interview on 9/15/20 at 1:31 p.m., Staff B, RN stated on 9/4/20 Staff A informed her she had a headache and another CNA gave Staff A Tylenol. Staff B stated she did not remember screening Staff A in and stated Staff A did not inform her she had a cough. She stated Staff A did not have a temperature but stated she should have called her supervisor to report the headache. During an interview on 9/16/20 at 7:00 a.m., Staff D, CNA stated on 9/4/20 she worked with Staff A and Staff A said she had a headache. She stated Staff A did not inform her she had a cough but she observed Staff A coughing during the shift. During an interview on 9/16/20 at 6:53 a.m., Staff C, CNA stated when the facility was in Phase 3, staff screened themselves in at the beginning of their shifts. During an interview on 9/16/20 at 7:54 a.m., the DON stated she heard after the fact that Staff A worked the floor while she had symptoms. She stated she spoke with Staff B and Staff B admitted Staff A informed her she had a dry cough. The DON stated a cough was a big symptom and Staff B should have sent Staff A home. She stated she conducted counseling with Staff B. The DON stated during the time period Staff A worked with symptoms, the facility was in Phase 3 so staff were allowed to screen themselves in and had been from 7/27/20 till 9/8/20, when the first COVID positive residents discovered. Once residents noted to test positive for COVID, the facility pulled back to Phase 1 protocol with no self-screening of staff occurring. The facility Administrator was notified on 9/16/20 that the deficient practice detailed above resulted in an Immediate Jeopardy situation for the facility beginning on 9/4/20 when Staff A allowed to work with symptoms. The facility abated the above non-compliance on 9/16/20 by completing the following actions: a. The facility revised their policy Staff Screening for the Pandemic to reflect current CDC guidelines. b. The facility educated staff on proper screening protocol in order to keep COVID-19 from entering the building. Based on the results of the corrective measures taken by the facility lowered the scope and severity of the deficiency from an L level to an F level.

Based on record review and staff interviews the facility failed to accurately complete a Minimum Data Set for one of 12 residents. (Resident #31) The facility reported a census of 45. The Minimum Data Set ((MDS) dated [DATE], documented Resident #31 with [DIAGNOSES REDACTED]. The MDS also documented the resident not able to complete the Brief Interview for Mental Status indicating severe cognitive impairment. Record review of the MDS dated [DATE] revealed Resident #31 received an anticoagulant (blood thinner) for zero days out of the seven day observation period. Record review of Resident #31's Medication Administration Record [REDACTED]. During an interview on 01/08/20 at 8:43 a.m., the Director of Nursing stated the MDS should have identified the resident received the anticoagulant during the seven days of the MDS observation period.

Based on clinical record review, observations and staff interviews, the facility failed to update Care Plans when needed for 2 of 12 sampled residents (#29 and #31). The facility reported a census of 45 residents. Findings include; 1. The Minimum Data Set (MDS) assessment for Resident #29 dated 11/10/19 recorded [DIAGNOSES REDACTED]. The resident required the assistance of two staff for bed mobility, transfers, dressing, toilet use and personal hygiene. The MDS further indicated Resident #29 with an indwelling catheter. Resident #29's Care Plan with a target date of 2/27/20 revealed no indication Resident #29 with an indwelling catheter. The facility failed to revise the Care Plan for Resident #29 in regards to the indwelling catheter. During an interview on 1/7/20 at 3:05 p.m., the Director of Nursing (DON) indicated she expected the Care Plan be updated identifying Resident #29 with an indwelling catheter. During an interview on 1/9/20 at 9:10 a.m., the DON, reported Resident #29 required an indwelling catheter since 5/3/19 after returning from the hospital. Record review indicates Resident #29 received an order for [REDACTED]. 2. The Minimum Data Set ((MDS) dated [DATE], documented Resident #31 with [DIAGNOSES REDACTED]. The MDS also documented the resident not able to complete the Brief Interview for Mental Status indicating severe cognitive impairment. Record review of Resident #31 Minimum (MDS) data set [DATE] revealed that resident received an anticoagulant (blood thinner) for zero days out of the seven day observation period. Record review of Resident #31's Medication Administration Records for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2020 revealed the resident received an anticoagulant every evening. Record review of Resident #31's Car Plan failed to address Resident #31 received an anticoagulant. During an interview on 1/08/20 at 1:42 p.m., the Director of Nursing verified the anticoagulant not on the resident's Care Plan and she expected it to be addressed on the Care Plan.

Based on record review and staff interview, the facility failed to provide an adequate [DIAGNOSES REDACTED]. (Residents #31 and #44.) The facility reported a census of 45 residents. Findings Include: 1. The Minimum Data Set (MDS) assessment for Resident #31 dated 11/16/19, included [DIAGNOSES REDACTED]. The MDS documented the resident required staff supervision from for toileting, personal hygiene and dressing. Review of the Medication Administration Record [REDACTED]. Record Review of the Order Summary Report for Resident #31 revealed [MEDICATION NAME] to be given at bedtime related to unspecified dementia without behavioral disturbance. During an interview on 01/08/20 at 9:00 a.m., the Director of Nursing stated that the [DIAGNOSES REDACTED]. 2. The Minimum Data Set (MDS) assessment for Resident #44 dated 12/9/19 included [DIAGNOSES REDACTED]. The MDS documented the resident required extensive to total assist from staff for toileting, personal hygiene and dressing. The MDS for Resident #44 dated 12/9/19 revealed resident received an antipsychotic for 7 days during an observation period. Record review of Medication Administration Record [REDACTED]. Review of the Order Summary Report signed 12/30/19 revealed [MEDICATION NAME] to be given in the evening related to unspecified dementia without behavioral disturbance. During an interview with the DON on 01/08/20 regarding Resident # 44 antipsychotic medication [DIAGNOSES REDACTED].

Based on record review and staff interview the facility failed to ensure code status kept in the Electronic Health Record and the residents' hard chart was identified for 1 of 16 Resident charts reviewed. (Resident #23) The facility reported a census of 45 residents. Findings include: A record review on [DATE], for resident #23 revealed a Do Not Resuscitate (DNR) on the Cardiopulmonary Resuscitation (CPR)/DNR Form signed on [DATE]. The Electronic Health information lacked information on the Face Page and the Physician order [REDACTED].#23. During an interview on [DATE] at 9:11 a.m., the Director of Nursing (DON) stated to check the advance directive status of a resident she would utilize the Electronic Health Record or access the Iowa Physician order [REDACTED]. During an interview on [DATE] at 1:58 p.m., the DON looked at Resident #23's Electronic Health Record and verified that his advance directive status got missed and should be identified on the Electronic Health Record. During an interview on [DATE] at 11:15 a.m., Staff A, Nurse, stated the Electronic Health Record is utilized as an identifier for the residents' advance directive status.

Based on clinical record review, family, physician and staff interviews, the facility failed to ensure one (1) of four (4 ) residents received services to maintain the highest physical, mental and psychosocial wellbeing by not adequately assess the resident's complains of pain, and or notify the physician of the resident's complaints of pain and or his/her threat of suicide due to increased pain. The facility reported a census of 54 residents. Findings included: According to the Minimum Data Set (MDS) assessment with a reference date of 3/13/17 for Resident #1 identified had intact cognition according to the Brief Interview for Mental Status (BIMS) score of 13 out of 15. The MDS indicated Resident #1 independent for activities of daily living. The test for balance revealed Resident #1 did not have a steady balance but was able to stabilize him/her (self) with one staff assistance. The resident utilized a wheelchair for mobility around the facility. The Resident's [DIAGNOSES REDACTED]. According to the physician's list of active [DIAGNOSES REDACTED].#1 had anxiety disorder, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] with Cardiac pacemaker, depression, anxiety, and hypertension. The resident's care plan with a goal date of 06/24/17 indicated the resident at risk for self care deficits, high risk for falls and pain related to [MEDICAL CONDITIONS], syncopal episodes with pacemaker placement, depression, anxiety, history of [MEDICAL CONDITION] with impaired healing and complaints of hip/back pain. The intervention revealed the resident's complaints of pain will be assessed, managed and instructed the staff to administer scheduled [MEDICATION NAME], Administer [MEDICATION NAME] for breakthrough pain and inform provider of inadequate pain control. Review of the Progress Notes reveal the resident had complaints of back and right hip pain for several weeks that continued to increase in frequency and intensity as follows: On 05/11/17 at 1:22 p.m. Staff A, LPN (Licensed Practical Nurse) documented the resident had received as needed [MEDICATION NAME] for sharp pain in the left upper extremity. On 05/14/17 at 00:14 a.m. Staff C, RN (Registered Nurse) documented the resident requested as needed pain medication for pain. On 05/20 17 Staff D, RN documented the resident received [MEDICATION NAME] for increased rectal pain. On 05/23/17 at 11:12 p.m. Staff C documented the resident received as needed pain medication for complaints of back pain. On 05/25 17 at 11:14 p.m. Staff D documented the resident received [MEDICATION NAME] for complaints of left hip pain. On 05/29 /17 at 11:54 p.m. Staff C documented the resident received [MEDICATION NAME] for general discomfort. On 06/04/17 at 11:03 p.m. Staff C documented the resident received as needed pain medication for complaints of back discomfort. On 06/05/17 at 3:52 a.m. Staff C documented the resident received as needed pain medication for complaints of back discomfort. On 06/06/17 at 3:35 a.m. Staff C documented the resident requested as needed pain medication for back pain. At 1:40 p.m. Staff E, documented CNA reported the resident refused to shower due to hip pain. On 06/07/17 at 8:38 a.m. Staff E, RN documented the resident complained of right side hip pain and received as needed pain medication. On 06/08/17 at 3:30 a.m. Staff D documented [MEDICATION NAME] given for complaints of general discomfort. At 2:37 p.m. Staff C documented the resident received as needed [MEDICATION NAME] for complaints of back and right hip pain. On 06/09/17 at 6:13 a.m. Staff B, LPN documented the resident received as needed pain medication for right hip pain. At 11:57 a.m. the resident requested pain medication for complaints of right hip pain. The staff had documented the pain medication effective. (There had been no documentation of the staff notifying the physician of the increasing and more frequent complaints of pain.) On 06/10/17 at 10:05 a.m. Staff B documented the resident requested pain medication for right hip/buttock pain, rated pain at 10 on a scale of 0-10 and received scheduled Tylenol, not effective. At 11:01 Staff B documented the as needed medication effective and resident reported pain at 4 on a scale of 0-10. At 3:27 p.m. Staff E stated the resident complained of right hip pain and received as needed pain medication. At 4:08 p.m. Staff E documented the pain medication effective with pain level at 2/10. On 06/11/17 at 7:12 a.m. the resident complained of right hip/leg pain with a level of 10/10 and received as needed pain medication. At 8:30 a.m. Staff B documented the pain medication effective. At 12:05 p.m. Staff B documented the resident received as needed pain medication for complaints of right hip/leg pain and at 1:04 p.m. documented the pain medication effective. At 9:00 p.m. Staff D documented [MEDICATION NAME] given for complaints of right hip pain. At 2:48 a.m. Staff D documented pain medication effective. On 06/12/17 at 3:34 a.m. Staff D documented the resident given [MEDICATION NAME] for pain and at 4:36 a.m. Staff D documented the pain medication effective. At 7:39 a.m. Staff A documented the resident received [MEDICATION NAME] 100 mg for pain rated 10/10 and resident noted to be tearful with the pain. At 8:30 a.m. the resident refused to have weight done due to pain in the right lower extremity. At 8:31 a.m. Staff B documented resident resting quietly at this time, resident stated does not have pain at this time. On 06/12/17 at 10:22 a.m. Social service notes stated Resident #1's family member had telephoned earlier and shared that he/she had been visiting the prior day and when talking with the resident on the telephone had felt the resident had exhibited confusion due to pain medication. The Social Worker shared with the family member she would check on the resident. The Social worker noted when meeting with Resident #1, he/she had shared the pain had been better that morning and that he/she had been taking pain medication. The resident reported having a wonderful nurse who had been taking good care of him/her. The resident volunteered the pain had got so bad at times (three times in recent past) that he/she had taken a knife out of the drawer and had thoughts of suicide. The Social Worker indicated the resident disclosed that he/she did not attempt to harm self because he/she remembered a family member had told him/her about keeping in mind that the pain would get better. The Social Worker documented the resident denied suicidal ideation on that date and laughed when asked that question. The resident stated would never harm self rather just thought that it would be easier to pass away if the pain was always going to be present. he Social worker documented the resident began to reminisced about his/her teenage years and shared felt better because it distracted him/her from thinking about the pain. The Social Worker documented she told the resident she would keep the knife in her office because the resident had no need of it in the room. The Social Worker noted she had called the family member and notified of the above. There had been no documentation on notification of the physician or facility Administrator or Director of Nursing (DON). The Progress Note dated 6/12/17 at 11:24 a.m. Staff A, LPN identified she had received a call from the resident's family member/POA requesting a Physical Therapy evaluation and treatment. Staff A documented a call placed to the physician and message left regarding the increased pain and request for physical therapy. The Progress Notes dated 06/13/17 at 8:02 a.m. Staff G, Nurse documented the resident requested pain medication for pain at 5/10 pain scale. At 1:43 p.m. Staff G documented the pain medication effective, the resident reported pain improved. On 6/13/17 at 2:03 p.m. The Social Worker documented the resident stated he/she had still been experiencing pain and the nurse had given pain medication. The Social Worker noted the resident presented as relaxed and smiling. The resident stated had been talking with family members regarding the pain and would likely have physical therapy and see the doctor for evaluation. According to the Progress Notes dated 6/13/17 at 4:45 p.m. Staff H, LPN documented continued to report pain. The resident stated It started in my leg (grabbing thigh) it hurt so bad whenever I moved it I would scream and then went up to my right thigh and lower middle back. The nurse documented the resident moved all extremities per usual, cross legs and self transfer independently in room. Remains in night gown this afternoon. Scheduled Tylenol given at this time. At 5:48 p.m. the resident reported to the CNA unable to come to the main dining room for the supper meal and requested a room tray. The CNA agreed to bring a room table when able. The resident had been noted to self propel wheelchair with feet up to nurses medication cart and stated I need a pain pill. Nurse questioned if Tylenol had helped and the resident stated no The nurse documented she gave the resident [MEDICATION NAME] 50 mg per request and as ordered. At 9:25 p.m. Staff H documented the pain medication effective. The Progress Notes dated 06/14 /17 at 3:59 a.m. Staff C, documented the resident requested pain medication for pain to right hip, rated pain at 10 on scale of 0-10 unable to describe pain as sharp-dull-etc. just pain. At 4:45 a.m. Staff C documented the resident asleep and showed no signs/symptoms pain/discomfort and pain mediation effective. At 5:45 a.m. Resident woke up and stated asking for assistance for appointment said had at 7:00 a.m., but appointment actually at 10:45 a.m. The resident requested another pain pill for complaints of back pain, did transfer self to wheelchair without assistance. At 7:34 a.m. the resident complained of pain at 10/10 level and earlier pain medication ineffective. At 2:55 p.m. Staff I, RN documented the resident complained of lower back pain, working with physical therapy at this time. Pain medication given per request. At 3:59 p.m. Staff I, RN documented the resident verbalized relief at this time; resting quietly in recliner at this time. According to Progress Notes dated 06/15/17 at 8:09 a.m. Staff B, LPN documented she had assisted the resident to sit up on edge of bed and resident hollering out in pain. The resident requesting [MEDICATION NAME] with scheduled Tylenol at this time. The resident rated the pain at 10 on a 0-10 scale. At 9:15 Staff B documented the pain medication effective. At 1:09 p.m. the resident requesting more pain medication for right hip/leg pain. The resident verbalized pain is excruciating. Sitting in wheelchair with right leg over left leg at this time. Encouraged resident needed to try and move around a bit. Out to lunch with much encouragement. Pain medication administered. At 3:06 p.m. Staff H, LPN documented the resident self-propelled wheel chair to nursing station, sitting with right leg crossed over the left and firmly stated I need a shot for my pain. Staff H identified Resident #1 grabbing his/her right hip/thigh. The nurse informed resident they did not have an order for [REDACTED]. Nurse encouraged the resident to go to room and as needed Bio-Freeze applied at this time. Staff H identified resident moaning while standing and once in standing position, let go of wheelchair, flung self back into nurses arms and then to wheelchair. A second attempt to transfer to recliner successful and independent while moaning in pain. Once in recliner pants were removed and Bio Freeze applied. Resident working with physical therapy at this time. At 5:50 p.m. The resident requested to see nurse. Noted the resident resting in recliner with feet up and eyes closed. When the nurse knocked on door, immediately opened eyes and asked to know when able to have more pain medication. Informed still not due for another. Appeared to be resting comfortably. The resident stated therapy really helped with the pain. Rates pain 2/10 on numeric scale at this time. On 06/15/17 at 5:50 p.m. The Social Service Notes indicated the writer had checked in with the resident to learn how the resident had been feeling on that day. The resident stated had been still struggling with the pain and working with physical therapy. The resident noted the therapist had been wonderful and hoped the treatment would help. The resident had shared he/she had seen the physician and recommended the social worker read his notes because the resident could not remember what had been stated. The Social Worker documented the resident denied suicidal ideation and stated would never do that to my family, no family should have to go through that. When asked what the resident meant when he/she had told staff that he/she felt like killing self, the resident responded I am trying to tell them I need to go to the hospital for test so they can figure out what is causing the pain. The Social Worker documented when asked if the resident wanted to go to the hospital emergency room , the resident responded no, not any more but if the pain gets worse I may want to then the resident chuckled and stated I drove my nurse nuts today when I kept asking to go to the hospital. My nurse responded by saying please eat something and take your medication and then think about whether you want to go to the hospital so I did. The resident shared that he/she wanted to rest before supper and hoped would be fine the rest of the evening. Progress Notes documented the following: On 06/15/17 at 8:09 p.m. Staff H. LPN documented [MEDICATION NAME] as needed given per request for achy, sharp, makes me cry in pain Rates pain 9/10 on numeric scale. Resident #1 appears comfortable in recliner at this time. Noted to ask staff for assistance applying incontinence products in bathroom. Continues to self transfer independently. On 06/16/17 at 1:30 p.m. Staff A, LPN documented the resident given [MEDICATION NAME] 50 mg for pain. At 06/16/17 at 3:00 p.m. Staff J, LPN documented the resident's family member in to discuss the resident's continued sciatic hip pain. The family member requested staff to offer [MEDICATION NAME] 100 mg in morning with alternating 100mg and 50 mg. The family member requested nurse to contact the physician about the possibility of starting [MEDICATION NAME] (medication used for nerve pain). The nurse sent a fax. At 3:07 p.m. Staff E documented as needed pain medication ineffective. At 4:58 p.m. Staff E documented the resident received as needed pain medication for complaints of back pain. At 9:56 p.m. Staff H documented the pain medication effective. On 06/17/17 at 8:39 p.m. Staff G documented the resident requested pain medication and at 11:38 a.m. documented the resident stated pain had let up, but still there. The resident rated the pain at 4. At 2:26 p.m. Staff H, LPN documented the resident self-propelled wheelchair to nurses station and stated It's time for my pain pill. When prompted, the resident grabbed right hip and described pain as achy and rated 10/10 on numeric scale. As needed [MEDICATION NAME] 50 mg given per request and as ordered. Staff G documented the resident smiled, thanked nurse and propelled wheelchair back to room. At 6:41 p.m. Staff G documented as needed [MEDICATION NAME] given at this time per request for pain to right hip. Rated pain as achy and 8/10 on numeric scale. The resident self-propelled wheelchair to main dining room and through supper line then stated in too much pain and needed someone to carry supper tray down to room. At 8:41 p.m. Staff G documented the pain medication ineffective. At 11:02 p.m. Staff D documented pain medication effective. On 06/18/17 at 7:03 a.m. Staff B, LPN documented the resident requested pain medication at 8 on 0-10 scale, rated pain as sharp, lower back area on right side and down leg. Resident lying in bed with right leg crossed over left. At 8:01 a.m. Staff B documented pain medication effective. The resident out to main dining room for breakfast, took all scheduled medications without difficulty, appetite remains fair. Fluids encouraged, resident voiced some relief from as needed [MEDICATION NAME] given earlier prior to cares/transfers being completed. At 11:57 a.m. Staff B documented the resident sitting in recliner with right leg crossed over left, complaining of terrible pain to right hip/lower right back area. The resident requesting as needed [MEDICATION NAME] 100 mg at this time. At 1:30 p.m. The staff noted pain medication ineffective, resident voiced little relief, requested further interventions for pain to right hip area. Staff B documented the resident sitting in recliner socializing with visitors, smiling. At 1:51 p.m. Staff B documented the resident requested pain medication for right hip discomfort. At 5:25 p.m. Staff H, LPN documented as needed [MEDICATION NAME] given for pain to right hip area and at 9:20 p.m. pain medication effective. On 06/19/17 Staff B, LPN documented the resident requested pain medication for right hip/lower right side back pain, out to main dining room for breakfast. Assistance of one for ADL's this morning. The resident propelled self in wheelchair without difficulty. The resident rated pain at 10 on a 0-10 scale with transfers out of bed, voiced pain improved after up in wheelchair. At 9:30 a.m. Staff B documented pain mediation effective continued to complain of generalized discomfort. The resident sitting in recliner with right leg crossed over left leg at the time. Staff B documented the resident did not appear to be in pain, no facial grimacing noted, smiled at nurse. Review of the above nursing documenting had only one mention of physician being notified of the resident's complaints of more frequent and increased pain. The one notification came at the request of the resident's family members. On 06/19/17 at 10:50 a.m. Staff A, LPN documented in a Behavior Note: Called to resident's room by CNA who stated Resident #1 is cutting his/her neck with scissors The nurse documented the CNA had a pair of orange handled sewing scissors in her hand. When entering the room, the resident noted to have a smaller pair of sewing scissors on bedside table. The second pair of scissors removed from the room. The resident noted to have lacerations to bilateral sides of neck. Laceration on the right side of neck noted deeper than the left side. Bright red bleeding noted from the right side, minimal bleeding noted from the left side. Pressure applied to both sides of the neck with 4 by 4 gauze. Resident noted to state I am done. I just want to end it, I don't want to be in this world anymore. A family member had been in room five minutes prior to the incident and still in the facility speaking with the administration and called back to the resident's room. On 06/19/17 at 11:20 Staff B, LPN documented in Health Status Note call placed to ER of family's choice and spoke with nurse regarding resident being transferred to the emergency room , and report given on incident. The ER nurse instructed that the resident should be transferred to the larger hospital ER for psych evaluation as they did not have anyone available to do so at their ER. The family notified and wanted the resident to go to the smaller hospital. The emergency room notified the family preference and staff will be waiting for the resident to arrive. At 11:36 a.m. Staff B documented placed call to resident's physician's office, the receptionist voiced that the physician not in office until noon and had been asked to have physician call the facility. The History and Physical dated 6/19/17 from the hospital revealed : the [AGE] year old resident with a history of depression and anxiety and a cognitive disorder had been admitted after a suicide attempt in an impulsive act in the context of uncontrolled back pain. The resident's family member indicated over the past 4 weeks, increase back pain, sciatic type pain were treated with [MEDICATION NAME] as high as 200 milligrams (mg) total daily with minimal benefit. (pain) still 8 out of 10. Last week the resident talked about using a knife to end his/her life and the knife was removed. In plan of care revealed in reviewing the resident's MAR from the nursing home, it did not seem that he/she had steady daily dosing of 3 times a day, in fact, on average, on average he/she was only getting it twice a day. Perhaps scheduling (routine) this will give him/her better pain control. The report revealed now resident's pain under control, he/she was not suicidal; however he/she would need acute psychiatric hospitalization until a plan for pain and behaviors can be established formally with the nursing home. A review of the Medication Administration Record [REDACTED]. On 06/29/17 at 1:10 p.m. The resident's physician stated he had not been notified by the facility regarding the resident's complaints of more frequent and increased pain nor threats of suicide the resident had voiced to the Social Worker prior to the actual attempt. He stated he found out about the pain and threats after the incident on June 19th. He stated he knows the family member/POA had not taken the threat seriously, thought that the resident had just been voicing frustration because of the increased pain and the act had been impulsive. The physician stated when the resident had visited his office on June 14th, 2017 there had been no mention of either an increase and or more frequent pain or suicide threats. He stated the family member and he felt the pain had been sciatic pain that the resident had in September of 2016 and that had been treated conservatively and eventually subsided. He stated the resident did not appear to have much pain in the office. The physician stated he did not know if he would have changed the treatment or not had he known of the more frequent and or increased pain, but since he found out after the suicide attempt it would have been just second guessing what he would have done before hand. On 06/28/17 at 2:15 p.m. Resident #1's family member and POA that the resident had never shown any suicidal ideation prior to this incident. The family member stated in the past few weeks the resident had started to complain of more and more pain and discomfort with low back pain and sciatic nerve pain. She stated another family member had been visiting the resident prior to the incident and had just left the resident's room when the resident cut self with scissors. The family member stated that they had been talking about financial stuff and with the pain the resident had just made an impulsive decision to cut self. the family member stated the resident had a long standing issue with depression and anxiety but did not feel that contributed to the suicide attempt. The family member stated when hospital personnel questioned the resident on why the resident did this, the resident could not give them an answer. The family member stated he/she felt it had been an impulsive act as a result of increased pain. The family member stated the resident had been admitted to inpatient care and they were going to try to get the pain under control with some alternative pain control methods. When asked if the family member knew how the resident obtained the knife and scissors that were in the resident's room, the family member stated they had the scissors in the resident's room to open bags of candy the resident kept in the room for visitors and staff. The family member stated they thought the knife the resident had was a cake knife (verses a steak knife). When told what the Social Worker had described, the family member stated they had brought a steak knife into cut pizza on Mother's day and that evidently Resident #1 had taken the (steak) knife to his/her room. On 06/29/17 at 12:00 the Facility administrator stated she felt that the Social Worker did not think the resident had been suicidal when speaking with her/him after the resident had told the Social Worker on the 12th of June that he/she felt like killing self with the knife because the pain had been so bad. The Administrator stated the Social Worker felt the resident to be sincere when he/she stated would not kill self because of his/her family and that is why they did not take further steps other than taking the knife away from the resident. On 06/28/17 at 10:00 a.m. The facility Social Worker stated the resident had told her in the past due to the pain that he/she felt like pulling out his/she knife and cutting self if the pain did not go away but that he/she would not kill self because a family member had told the resident the pain would go away and he/she would get better. The Social Worker stated she took the steak knife away from the resident. She stated she did not know where the knife had come from and did not think about asking the resident where it came from. The Social worker described the knife as a serrated edged metal knife with a hard black plastic handle and the resident had kept it in a night stand drawer. The Social worker stated she had told the charge nurse Staff A, LPN and spoke with the resident's family member/ POA. She stated she did not know if the nurse had spoken with the physician or not and stated that she did not call the physician herself. The Social Worker stated the family member had been going to take the resident to the physician to talk about the pain. The Social Worker stated that she had not thought about checking the resident's room for other objects that could be dangerous. She stated after the second incident when the resident actually tried to harm self, the DON removed some other things from the resident's room. In a note provided to the Department of Inspections and Appeals, the facility DON noted that the facility social worker had visited with Resident #1 after the incident on 06/12/17 and then notified the charge nurse and reported the incident to her. The charge nurse felt the social worker had handled the situation appropriately as the resident had no intent on harming self nor did the resident have a plan. At this time the physician had not been notified. The Social Worker did talk with the resident's power of attorney who felt this was all due to sciatic pain the resident had been experiencing and the POA had been in contact with the physician about the resident's care. The DON noted that all staff had been trained on suicide tendencies as it was the facility protocol to educate staff when an issue arises. The DON noted this had never happened in the facility before and staff needed trained to continue to provide quality care for our residents.

Based on record review and interviews, the facility failed to safely transfer one (1) of four (4) residents. Record review revealed the staff failed to use a gait belt when assisting Resident #4. Staff interviews revealed the resident ' s arm got stuck in-between the grab bar and the resident sustained [REDACTED]. The facility reported a census of 51 residents. Findings include: The Admission Record dated 3/5/14 revealed Resident #4 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] documented the resident required one staff assistance for transfers and toilet use. The MDS identified staff needed to provide weight bearing support to the resident during transfers on/off the toilet. The assessment documented the resident ' s balance unsteady and only able to stabilized with staff assistance when transiting from seated to standing, or when moving on and off the toilet, or during surface to surface transfers. The Care Plan updated 9/3/14 directed the staff to transfer Resident #4 with the assistance on one to two staff and ensure a gait belt for all transfers. The care plan identified the resident at a high risk for falls and used a wheelchair for mobility. The care plan noted the resident did not speak English and had dementia, glaucoma, mild degenerative changes of the cervical spine. The updated care plan dated 12/1/14 identified two staff would assist with transfers and utilize a gait belt for all transfers. The Staff Communication Sheet dated 2/26/14 revealed therapy recommended the staff provide assistance of one staff with a front wheeled walker. The therapist identified the Resident #4 had buckling of the knees and weakness. The Incident/Accident Report dated 11/5/14 at 3:10 p.m. revealed Resident #4 caught his/her wrist and forearm in the grab bar during a staff assisted transfer off the toilet. The report revealed Resident #4's knees buckled and he/she fell to the floor. Resident #4 had bruising During the transfer Resident #4's right wrist and forearm became caught in the grab bar. Resident #4 had swelling and bruising to the right wrist. The staff applied ice and Resident #4 transferred to the emergency room for evaluation. The Radiology Report dated 11/5/14 revealed Resident #4 sustained acute fractures of the right distal ulna and radius with slight displacement. The conclusion documented he/she sustained acute distal forearm fractures. The Major Injury Determination Form dated 11/5/14 revealed the Medical Director determined Resident #4 did not sustain a major injury. The form revealed the resident ' s wrist became stuck in the (grab) bar. The Progress Note dated 11/5/14 at 3:30 p.m. documented the nurse heard the resident calling from the hallway and walked into the resident ' s room. The nurse found the resident in the bathroom with Staff C, with the resident ' s wrist/forearm stuck in the handicap (side) rail located beside the toilet on his/her knees. The nurse & Staff C helped get the resident up and to his/her wheelchair. The nurse documented Staff C did not use a gait belt when transferring Resident #4 and did not have a gait belt with her. The nurse told Staff C she needed to use a gait belt when transferring Resident #4. The Progress Note dated 1/6/14 revealed Resident #4 had an orthopedic consult. The note revealed Resident #4 had the right wrist casted in a long cast and ordered to keep the arm in a sling as needed, keep the cast clean and dry, non-weight bearing to the right arm, encourage to wiggle fingers and follow up in two weeks. A hand written statement signed by Staff C dated 11/5/14 documented the following: the resident had been on the toilet and staff had him/her stand up and (hold) the grab bar on the wall to steady him/her(self). Staff C had been standing behind the resident when he/she stood up, and used her knee under the resident to support him/her in case he/she fell . The resident held onto the grab bar as staff was putting on his/her brief. The resident put his/her arm in between the grab bar and the wall to hold him/her(self) up more. The resident could not get his/her hand/arm out and panicked and got more stuck and lost all his/her balance meanwhile Staff C was trying to hold him/her up from falling. The resident had his/her knees bent and Staff C could not pull Resident #4 up and pulled the (call light) cord trying not to let go of the resident. Two other staff came in to help and staff finally got Resident #4 up enough where they could stand her/him up and get his/her arm out of the grab bar. An interview on 1/14/15 at 5:36 p.m. Staff C reported he/she did not use a gait belt transfer Resident #4. Staff C did not recall why he/she did not use a gait belt for the transfer. Staff C reported Resident #4's hand got stuck between the grab bar and the wall. Resident #4 got scared and put all of his/her weight on Staff C. Staff C supported Resident #4's weight with his/her leg as long as she could. Staff C reported the facility went over the gait belt policy on hired. Staff C was hired in September of 2014. Staff C reported the Resident Care Sheet directs the staff how to transfer each resident. An interview on 1/14/15 at 12:02 p.m. Staff A reported that during orientation the facility reviewed the gait belt policy with Staff A. Staff A reported the gait belt is part of the nurse aide uniform. Staff A he/she uses the gait to the gait belt for any resident requiring assistance of one or two staff assistance with transfers. An interview on 1/14/15 at 10:35 a.m. the Director of Nurses (DON) reported Staff C failed to use a gait belt when transferring Resident #4. The DON reported Resident #4 primarily required assistance of one staff with transfers. The DON indicated Resident #4 had fatigue and pain at times and required two staff to complete transfers. The DON reported the nurse aides make the decision when to use one or two staff for transfers. The DON reported the staff knew the gait belt is a part of the uniform. The Director of Nurses updates the Resident Care Sheet with any changes and specifically puts on the sheet to use a gait belt when indicated. The Gait Belt Policy reviewed 11/21/13 revealed upon hire each nurse aide will be issued a gait belt as part of the uniform, the nurse aide will sign the Safety Devices/Equipment policy contract and nurse aides are required to wear their gait belt each shift they are scheduled. The policy revealed an expectation of the nurse aide to use a gait belt when residents need assistance with ambulation and transfers. The Safety Devices/Equipment Utilization Policy signed by Staff C dated 9/15/14 documented the safety committee is responsible for overseeing the daily practices of employees to ensure that they and the resident they serve have a safe environment. The safety policies and practices are designed to prevent accidents and injuries to residents.

Based on observation, record review, staff and physician interviews, and facility policy/procedures, the facility failed to assess and provide timely intervention. Resident #1 fell and was placed in a chair without an adequate assessment and ongoing observation. The resident remained in a chair for 7 hours until the next shift discovered the resident in pain. The resident sample included 15 residents. The facility reported a census of 61 residents Findings include: 1. Resident #5 had a 30 day MDS (Minimum Data Set) assessment with a reference date of 2/28/2013 which reflected a BIMS (Brief Interview of Mental Status) score of 11 which indicated moderate long and short term memory deficits. Facility staff provided limited assistance with bed mobility, transfers, ambulation, personal hygiene, and toilet use. The falls section of the MDS revealed no information of the resident experiencing any previous falls. The plan of care identified [DIAGNOSES REDACTED]. The plan of care identified self-care deficits (start date 02/10/2013) and directed facility staff to assist with A.M. and P.M. cares, transfer with the assistance of a staff member and a front wheeled walker, assist with toilet use (resident leaks urine), keep the call light within reach at all times, keep the bed in low position with the brakes on, and a pressure alarm in use at all times. A Fall Risk Evaluation completed on 01/22/2013 with a score of 13 placed Resident #5 at high risk for falls. (Over 10 =high risk). A physician History and Physical report dated 02/24/201, when Resident # 5 became admitted to the hospital after the fall, revealed 2 plus [MEDICAL CONDITION] and increased redness in both lower extremities. The left hip appeared shortened and externally rotated. Resident # 5 demonstrated pain with any attempt to touch or provide range of motion to the slightly swollen left hip. The nursing notes revealed an entry on 02/24/2013 at 1:00 A.M. documenting vital signs of temperature: 99.6 (normal 98.6), pulse of 66 (normal 72-80), respirations of 32 (normal 16-20), and a blood pressure of 227/63. The note indicated the resident could move all extremities without any pain and displayed no redness, tenderness, or bruising and signed by Staff I (Registered Nurse). No other assessment of the resident's condition from 1:00 A.M. until the 8:00 A.M. entry (7 hours later) could be found in the chart. The next nursing note at 10:00 A.M. (a late entry for 8:00 A.M.) documented follow up of a fall for Resident # 5. Staff D (Registered Nurse) found Resident # 5 seated in a recliner voicing pain of the left hip. Upon assessment of the resident, Staff D found the left leg to be shortened. Arrangements to transfer Resident # 5 to the hospital were made. Staff D documented the resident stated staff lifted him/her into the chair from the floor and since that time no one had moved him/her. The Incident/Accident Report dated 02/24/2013 documented a nursing aide found the resident on the floor perpendicular to the bed after the alarm sounded. The type of injury checked as none apparent. The report failed to include the time of the fall. The incident report documented physician notification as 10:50 A.M. and family as 9:20 A.M. The Neurological Assessment Flow Sheet for 02/24/2013 began at 1:00 (does not specify A.M. or P.M.) and stops at 6 to 2 indicating shift time. From 1:00 to 4:45, the observation section documented denies pain at 1:00 and then an arrow extends down through until 4:45 indicating the documentation must have been completed all at the 1:00 time. The Master schedule for 02/18/2013 through 03/03/2013 revealed the night shift (10:00 P.M. to 6:00 A.M.) coverage at the facility to be 1 nurse and 3 to 4 aides depending on the night. The night of 02/23 to the morning of 02/24/2013, 4 aides and a Registered Nurse covered the night shift. The facility policy: Assessing Falls and Their Causes dated September 2004 directed the nursing staff to assess the potential cause of the fall immediately and clarify the details of the fall (when occurred and what the resident was trying to do at the time of the fall). Identify factors such as whether with others or alone, transferring or reaching, the urge to void, poor lighting, slippery floor, or objects in the way. An assessment including factors such as vitals, evaluation of head, neck, spine, or extremity injuries, fractures, bleeding, pain, swelling, deformities or decreased mobility, and statements made by the resident need to be documented. During an interview on 03/05/2013 at 4:55 P.M., Resident #5 sat in a blue straight back Victorian recliner with feet elevated. Resident # 5 verbalized not being able to recall the events of 02/24/2013 after falling. On 03/10/2013 at 8:20 P.M., Staff I (Registered Nurse) verbalized being on duty the night Resident # 5 fell and fractured the left hip (02/24/2013). Staff I stated the fall occurred at 1:00 A.M. An assessment of the resident found no injuries. An aide assisted to place the resident in a chair and a neurological assessment was completed. Staff I verbalized that a blood pressure of 227/60 was normal for the resident. She could not recall what the other vitals were. Staff I verbalized whenever she did a neurological check, she checked the resident over. She could not recall if the resident asked to go to the bathroom in the 5 hours following the fall that she was on duty. Staff I stated the aides did not report anything about the resident to her from 1:00 A.M. to 6:00 A.M. The statement Staff I wrote for the facility documented an evaluation of the resident while still on the floor and then again when lifted into a chair. Findings negative for any injuries and the resident voiced no pain. Staff I claimed Resident # 5 took the morning pills at 5:00 A.M. and still denied pain. The chart held none of these assessments. A review of Staff I's employee file produced disciplinary actions for not completing her work in a timely fashion, not completing mandatory in-services, and removing health information records from the facility. A documented statement from the Director of Nursing revealed speaking with Staff I on 02/25/2013 about the resident's fall. Staff I admitted failing to document the resident's fall in the medical record, failing to complete the incident report for the fall, and not notifying the physician or family due to getting busy with other residents' needs. In an interview on 03/11/2013 at 9:50 A.M., Staff D (Registered Nurse) verbalized taking report from Staff I on the morning of 02/24/2013. Staff D verbalized the night nurse reported Resident # 5 had a fall and neurological checks should be completed, but did not elaborate further. Staff D stated after report, she found Resident # 5 leaning over the arm of the chair towards the right side (on right hip). Resident # 5 expressed having pain in the left hip and head. When asked what happened, Resident # 5 told the nurse he/she could not find the wheeled walker in the dark and slipped and fell while trying to go to the bathroom. A Nurse ' s Note dated 2/27/2013 and signed by Staff D, reflected the event of 2/24/2013 when she came on duty. The resident was sitting in the chair with head leaning against the right side of chair. The resident sat sideways in the chair. The resident voiced she/he had pain in left hip. The left leg tender to touch and shorter than right leg. The resident voiced she/he had been up in the chair since they picked her/him up off of the floor. The resident didn ' t stand by self. On 03/11/2013 at 8:27 A.M., Staff L (Certified Nursing Assistant) was interviewed and stated being the one to hear Resident # 5's alarm and found the resident on the floor. Staff L verbalized going to find the nurse who came to the room and took vitals and asked the resident about any pain. Staff I and Staff L picked the resident up off the floor and placed her/him in a straight backed chair with a small foot rest. Staff L stated the resident did not help at all and the nurse and he had to lift the resident into the chair. The resident could not move legs or feet. He described the resident as confused, but not verbally expressing any pain and the resident had a habit of not using the call light and getting up per self. Staff L stated he peeked in the resident's room a couple of times after the fall, but did not enter. To his knowledge, the resident never did go to the bathroom or move from the chair in the 5 hours left on his shift. Staff L described the chair as a blue straight back Victorian style with a small foot rest that pulled out from the chair. Staff L stated the resident had a history of [REDACTED]. Staff M and Staff O (both Certified Nursing Assistants), both denied having any contact with Resident # 5 on the night shift of 02/23/2013 to 02/24/2013. In an interview on 03/11/2013 at 8:39 A,M,, Staff N (Certified Nursing Assistant) verbalized Resident # 5 was actually in her section the night of 02/24/2013, but not having much contact with the resident. She went in to see the resident after the fall around 1:30 A.M. to do vitals for the nurse. Staff N stated the resident sat in a recliner with both feet on the floor and the resident told her she had fallen but never expressed pain. She stated Resident # 5 rarely ever expressed any pain or discomfort prior to the fall or after. Staff N verbalized checking on the resident but not moving her/him from the chair for the next 5 hours of her shift. On 3/12/2013 at 4:50 p.m., the resident ' s physician was interviewed. The physician stated with the resident sitting in a chair for 5-7 hours without treatment or position changes was a problem. The physician stated he was not happy about that and the resident would have been in a lot of pain. The physician thought the fall probably did cause the fracture.