Every finding on record at Southfork River Therapy and Living

Number of residents sampled:22Number of residents cited:2Based on record review and interviews the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for two (Resident #2 and Resident #29) of 22 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's pain medication regimen was accurately completed for Resident #2 and failed to ensure information regarding nutritional approaches was accurately completed for Resident #29. The findings include: Resident #2 Review of an admission Record indicated the facility admitted Resident #2 on 06/06/2024 with diagnoses that included chronic pain, fibromyalgia [widespread chronic pain and fatigue], fracture of the top section near the hip joint of the left upper leg and osteoarthritis. Review of a quarterly MDS, with an Assessment Reference Date (ARD) of 02/05/2026, revealed Resident #2 had a Staff Interview for Mental Status (SAMS) score of 3 which indicated the resident was severely impaired for daily decision making. The MDS also revealed Resident #2 was on opioids and had not received a scheduled pain medication regimen. Review of Resident #2's Care Plan initiated on 11/13/2025, revealed the resident had chronic pain related to fibromyalgia and fracture of the top section near the hip joint of the left upper leg. Care Plan interventions included to anticipate the resident's needs for pain relief, monitor/record/report to nurse [if] resident complains of pain, and to notify physician if interventions are unsuccessful. Review of an Order Summary revealed Resident #2 had a pain patch to be applied every 72 hours with an order start date of 11/12/2025. A review of a February Medication Administration Record (MAR) revealed Resident #2 had a pain patch applied on 02/01/2026 that was not reflected in the five-day look back period for the quarterly MDS completed on 02/05/2026. During an interview on 03/12/2026 at 9:49 AM, the MDS Coordinator indicated it was her responsibility to complete the MDS. She stated she reviewed resident orders to see what the orders were to code the MDS appropriately for each resident. The MDS coordinator stated that if a resident was on a pain patch, then medication regimen in the MDS should be marked yes. The MDS Coordinator stated that Resident #2's quarterly MDS medication regimen should be marked as Yes instead of No due to Resident #2 having an order for a pain patch that was to be changed every three days. During an interview on 03/12/2026 at 11:20AM, the Director of Nursing (DON) stated Resident #2 was on a pain patch that was changed every 72 hours. The DON stated that if the MDS was not coded correctly, the MDS would need to be modified. Resident #29 Review of an admission Record indicated the facility admitted Resident #29 on 07/27/1988 with diagnoses of muscle wasting and atrophy, severe intellectual disabilities, dementia, and schizoaffective disorder. Review of a quarterly MDS with an ARD of 12/24/2025, revealed Resident #29 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #29 had severe cognitive impairment. The MDS indicated that Resident #29 had received parenteral/IV feeding, had had a feeding tube, received a mechanically altered and therapeutic diet while a resident in the facility. The MDS also revealed in a separate section that Resident #29 had no swallowing disorders, had no proportion of total calories or average fluid intake through parenteral or tube feeding while a resident or during entire seven days listed. Review of Resident #29's Care Plan, revised on 10/22/2024, revealed Resident #29 had a nutritional problem or potential nutritional problem related to intellectual disabilities, schizoaffective disorder, muscle wasting and atrophy. Care Plan interventions included monitor/record/report to Medical Doctor signs and symptoms of malnutrition. Review of an Order Summary revealed Resident #29 had a regular diet with regular texture and regular consistency with an order start date of 10/30/2024. During an interview on 03/12/2026 at 9:49 AM, the MDS Coordinator revealed that she interviewed Certified Nursing Assistants, reviewed orders, Nurse's Progress Notes, tasks, and the resident's chart to see what the orders were to code the MDS appropriately for the resident. The MDS coordinator revealed a resident was coded according to what dietary order the resident was on. The MDS coordinator stated that after looking at Resident #29, Resident #29 had parenteral/IV therapeutic diet, feeding tube/parenteral and mechanically altered diet coded. The MDS Coordinator stated that the dietary portion of the MDS was completed by the Dietary Manager, who was new to the position and probably did not know how to code the MDS correctly. The MDS Coordinator stated that it was ultimately her responsibility to make sure the MDS was coded correctly. The MDS coordinator also stated that coding the MDS was very important and could make the facility lose money or have to pay money back to Medicare/Medicaid. During an interview on 03/12/2026 at 11:20 AM, the Director of Nursing (DON) stated that Resident #29 had not had a feeding tube since she had been employed at the facility for the past 6 years.

Based on observation, record review, and interview, the facility failed to ensure potentially hazardous chemicals and hygiene products were stored in a secure location on 1 (200 Hall) of 3 (200 Hall, 300 Hall, and 400 Hall) halls to prevent potential access of hazardous items by cognitively impaired residents who ambulate by any means. The findings are: 1. An observation was made on 09/05/23 at 1:27 PM, on a table in the restroom of Resident room [ROOM NUMBER] was an emesis basin with 3 triple blade razors with no covers. On an open shelf mounted on the restroom wall was one small container of mentholated topical ointment, 2 unopened packages and 1 opened package of denture cleanser tablets. 2. On 09/06/23 at 9:21 AM, On a table in the restroom of Resident room [ROOM NUMBER] was an emesis basin with 3 triple blade razors with no covers. On an open shelf mounted on the restroom wall was one small container of mentholated topical ointment, 2 unopened packages and 1 opened package of denture cleanser tablets. 3. On 09/07/23 at 8:15 AM, On a table in the restroom of Resident room [ROOM NUMBER] was an emesis basin with 3 triple blade razors with no covers. On an open shelf mounted on the restroom wall was one small container of mentholated topical ointment, 2 unopened packages and 1 opened package of denture cleanser tablets. 4. On 09/07/23 at 3:13 PM, the Surveyor asked Certified Nursing Assistant (CNA) #2 where razors should be stored when not in use. CNA #2 stated, In the shower room. The Surveyor asked where denture cleanser tablets should be stored when not in use. CNA #2 stated, In a Ziplock bag in a closet. 5. On 09/07/23 at 3:16 PM, the Surveyor asked Licensed Practical Nurse (LPN) #1 where razors should be stored when not in use. LPN #1 responded, In the supply room. The Surveyor asked where denture cleanser tablets and mentholated topical ointment should be stored when not in use. LPN #1 stated The same, in the storage room behind locked doors for safety The Surveyor asked who was responsible for ensuring that those items are put up safely. LPN #1 replied, CNAs. 6. On 09/07/23 at 3:21 PM, the Director of Nursing (DON) stated that razors and denture cleanser should be stored in the supply cabinet, behind locked door and that residents personal care items should be stored in a bag in a drawer with their name on it to keep residents out of harm. 7. On 09/08/23 at 10:36 AM, the Administrator stated that the facility did not have a policy regarding storage of personal care items.

Based on observation, interview, and record review, the facility failed to ensure a Physicians Order was obtained for CPAP (Continuous Positive Airway Pressure) usage for 1 (Resident #63) of 1 sampled resident who used a CPAP. The findings are: a. On 09/05/23 at 1:28 pm, observed a CPAP mask on Resident #63's nightside, not in a container/bag. b. On 09/06/23 at 9:53 am, observed a CPAP nose piece lying on Resident #63 ' s nightstand, not in a container/bag. c. On 09/07/23 at 2:14 pm, observed a CPAP mask stored in an undated plastic bag. d. On 09/07/23 at 2:43 pm, the Surveyor asked Licensed Practical Nurse (LPN) #2 if Resident #63 had an order for the CPAP. LPN #2 said, I do not see one. e. On 09/07/23 at 2:45 pm, the Surveyor asked the Nurse Consultant if she had an order for [Resident #63's] CPAP. She stated, I do not have an order for the CPAP. The Surveyor asked, Does [Resident #63] have a diagnosis, as to why she is using a CPAP? The Nurse Consultant stated, I haven't found one, but I will keep looking. f. As of 09/07/23 at 2:50 pm, Resident #63's Physician Orders and/or Care Plan did not address CPAP usage.

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals contained a pharmacy label, contained a date opened, and expired medications were removed from the medication cart for 1 or 1 medication room and 2 of 3 medication carts on 2 (100 Hall and 300 Hall). The findings are: 1. On 09/06/23 at 2:41 PM, the following observations were made in the Central Medication Room with Licensed Practical Nurse (LPN) #1: a. An opened box of Acetaminophen Suppositories 650 milligrams with the patient label torn off was in the refrigerator. b. An opened vial of Novolog Insulin with no opened date. c. An intravenous administration set with an expiration date of 09/05/22. d. In the cabinet above the sink was an opened bottle of Vitamin C 1000 milligrams with an expiration date of August 2023. e. An opened box of mucus expectorant containing 9 tablets with an expiration date of 8/2023. f. A package of four 0.9% Sodium Chloride 250 milliliters with an expiration date of 06/01/2022. g. A package of 0.9% Sodium Chloride 250 milliliters with an expiration date of 12/2022. h. An opened plastic container with 50 milliliters of 0.9 % Sodium Chloride in a plastic box containing primary tubing intravenous sets with no name or no label with an expiration date of 01/22. i. A packaged Intravenous administration set with an expiration date of 09/05/2022. j. On 09/06/2023 at 3:15 PM, the Surveyor asked LPN #1 who was responsible to ensure insulin has an opened date. LPN #1 stated, Whoever opens the bottle of insulin. The Surveyor asked where the expired medications were to be placed. LPN #1 stated, We have a place next door, a bucket with a lock on it. 2. On 09/06/23 at 3:20 PM, the following observations were made in the 300 Hall Medication Cart with LPN #3: a. An opened bottle of nitroglycerin tablets with no name and no opened date. LPN #3 stated, The nitroglycerin bottle was taken from the emergency box and was given to one of the residents and should no longer be in the cart. There is no name on it. b. A medication card of Ondansetron (nausea and vomiting medication) with an expiration date of 7/15/2023. c. An unidentifiable half of a tablet was loose in the bottom of the drawer. 3. On 09/06/23 at 3:56 PM, the following observations were made in the 100 Hall Medication Cart with LPN #4: a. A vial of Humalog Insulin with an opened date of 7/18/23. (Humalog Insulin should be discarded 28 days after opening.) b. A medication card of Memantine HCL (Hydrochloride) (Alzheimer's Disease medication) with an expiration date of 02/20/2023. c. A bottle of Fluticasone (Allergy Medication) with an opened date 05/18/2023. LPN #4 stated, That medication was discontinued and is not being used. 4. A facility policy titled, Storage of Medications, provided by the Administrator on 09/07/23 at 12:55 PM documented, Policy Statement The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Policy Interpretation and Implementation .2. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. 4. The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be destroyed .

Based on observation and interview, the facility failed to ensure staff followed the appropriate use of gloves during medication administration to prevent potential cross contamination for 1 (Resident #5) of 1 sampled resident. This failed practice had the potential to affect 27 residents who resided on the 200 Hall and shared staff with Resident #5. These findings are: a. On 09/07/23 at 8:44 am, Licensed Practical Nurse (LPN) #1 donned gloves before administrating medication via Percutaneous Endoscopic Gastrostomy (PEG) tube. After administrating the medications, she doffed and disposed of the gloves. She went to bathroom and rinsed out the syringe and put the syringe in a package and placed it in the nightstand drawer. Without washing her hands, LPN #1 then donned gloves to give an updraft treatment via nebulizer. She placed the face mask on Resident #5 and then placed a pulse oximetry on the resident's finger. During the treatment, LPN #1 touched the resident's doll and other items on the resident's bed, contaminating the gloves. After the treatment, she removed the nebulizer mask and placed it in a ziplock bag on the nightstand while wearing the contaminated gloves. b. A Physicians Orders dated 03/30/18 noted Resident #5's nebulizer mask was to be cleaned with soap and water after each use, air dry, and was to be kept in a ziplock bag when not in use. c. On 09/07/23 at 9:15 am, the Surveyor asked LPN #1, Should you have changed your gloves after touching multiple items on the resident's bed before placing the mask in the ziplock bag for storage? She stated, Yes. d. On 09/07/23 at 2:56 pm, the Surveyor asked the Director of Nursing (DON) When a nurse is giving medications via PEG tube, should gloves be changed between tasks or after touching multiple things? She stated, Yes, hand hygiene should be done, then change gloves. e. A facility policy titled, Personal Protective Equipment - Gloves, provided by the Administrator on 09/08/23 at 10:03 am documented, .3. The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: a. When it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure . d. When handling . items that may be contaminated . 8. Wash your hands after removing gloves .

Based on observation, record review and interview, the facility failed to ensure food items stored in the freezer were covered or sealed and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen according to the list provided by the Dietary Supervisor dated 6/14/2022 at 9:45 AM. The findings are: 1. On 6/13/2022 at 10:26 AM., the following observations were made in the kitchen: a. An opened box of beef patties was stored on a shelf in the freezer. The box was not covered or sealed. b. An opened box of pancakes was stored on a shelf in the freezer. The box was not covered or sealed. c. An opened box of cinnamon roll was stored on a shelf in the freezer. The box was not covered or sealed. d. An opened box of hamburger patties was stored on a shelf in the freezer. The box was not covered or sealed. 2. On 6/13/2022 at 10:43 AM., Dietary Employee #1 took out a pan of baked chicken from the oven and placed it on the counter. Without washing her hands, she picked up a clean blade an attached it to the base of the blender to be used in pureeing food items to be served to the resident who required pureed diets for lunch. 3. On 6/13/2022 at 10:48 AM., Dietary Employee #2 took out a bag of Cheetos and placed it on the counter. He picked up gloves from the glove box and placed them on his hands, contaminating the gloves. He picked a bag of bread from the bread rack and placed it on the counter. He opened the refrigerator door, took out a container of sliced cheese and a container of sliced ham and placed them on the counter. He picked up plates from a bag and placed them on the counter. He untied the bread bag and without changing gloves and washing his hands, he removed slices of bread from the bag and placed them on the plates, removed slices of cheeses from the container and slices of ham and placed them on the bread to be served to the residents who requested ham and cheese sandwich with their lunch meal. 4. On 6/13/2022 at 11:58 AM., Dietary Employee #2 pushed a rack into the dish washing machine to wash. Without washing his hands, he picked up a clean blade from the clean rack and attached it to the base of the blender to be used in pureeing food items to be served to the resident who received pureed diets for supper. 5. The facility's policy on hand washing under Dietary Department employees are required to wash their hands on the occasions listed below .after picking up anything from the floor .any other time deemed necessary.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meal observed. The failed practice had the potential to affect 6 residents who received pureed diets as documented on the Diet List provided by the Food Service Supervisor on 6/14/2022. The findings are: 1. On 6/13/2022 at 10:46 AM., Dietary Employee #1 placed 5 servings of chicken breast into a blender, added chicken broth and pureed them. She poured the pureed chicken in a pan. She covered the pan with foil and placed it in the oven. The consistency of the pureed chicken had pieces of chicken visible in the mixture and not smooth. 2. On 6/13/2022 at 4:14 PM., Dietary Employee #3 used a 4 oz [ounce] spoon and placed 5 servings of beef tips into a blender, added beef broth and pureed them. At 4:17 PM, She poured the pureed beef tips in a pan, covered the pan with foil and placed it on the steam table. The consistency of the pureed beef tips was not smooth. There were pieces of meat still visible in the mixture. 3. On 6/13/2022 at 4:26 PM., Dietary Employee #3 used a 4 oz to spoon 4 servings of parsley noodles into a blender, added both and thickener and pureed them. At 4:31 PM, she pureed the noodles in a pan. The consistency of the pureed noodles was lumpy and not smooth. There were pieces of noodles visible in the mixture. On 6/13/2022 at 4:33 PM, she added 2 more servings of noodles into a blender, added thickener, broth and pureed. At 4:36 PM, she poured the pureed noodles in the same pan. She placed the pureed noodles on the steamtable. The consistency of the last pureed noodles was lumpy and not smooth. There were pieces of noodles visible in the mixture. 4. On 6/13/2022 at 4:55 PM., Dietary Employee used a 4 oz spoon and placed 4 servings of broccoli with more of stocks into a blender, added thickener and pureed them. At 4:48 PM, she used #8 scoop and placed the pureed broccoli into a pan. She placed the pan of pureed broccoli on the steam table to be served to the residents on pureed diets for supper. The consistency of the pureed broccoli had pieces of broccoli in the mixture and was not smooth. 5. On 6/13/2022 at AM., Dietary Supervisor was asked to describe the consistency of the pureed food items prepared and served to the residents for supper. She stated, Pureed meat was gritty. It was not smooth and was not pureed longer than it should have. Pureed noodles should be pureed longer. Agreed there were pieces of noodles visible in the mixture.

Based on observation, record review, and interview, the facility failed to ensure Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Resident #58) of 1 (Resident #58) sample mix residents who had an indwelling catheter and for 1 (Resident #38) of 1 (Resident #38) sample mix residents who had a [CONDITION(S)]. The findings are: 1. Resident #58 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The Initial Care Plan dated 8/31/18 documented, [Resident #58] has Suprapubic Catheter . CATHETER: The resident has suprapubic catheter. b. The June Physicians Orders dated 9/16/18 documented, Change supra pubic catheter if not patent #16 with 30cc [cubic centimeters] bulb . c. On 6/13/22 at 12:19 PM, the resident was resting in bed. A foley catheter bag was hanging from the window side of the bed frame in a privacy bag. d. On 6/16/22 at 9:58 AM, the MDS Coordinator was asked, Who is responsible for completing Section H [of the MDS]? She replied, Me. The MDS Coordinator was asked, How long has the resident had an indwelling catheter? She replied, Since admission, The MDS Coordinator was asked, Is Section H0100 coded correctly? She replied, No, it is not, I will correct that. 2. Resident #38 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/22 documented the resident was severely impaired in cognitive skills for daily decision and did not require [CONDITION(S)] care. a. The Initial care plan dated 9/16/19 documented, [Resident #38] has a [CONDITION(S)] r/t [related to] Impaired breathing mechanics . b. The Physicians order dated 10/24/20 documented, [CONDITION(S)] 4DCT [Disposable Cannula Cuffed [CONDITION(S)] Tube] . [NAME] 4 cuff . c. On 6/13/22 at 11:21 AM, the resident was resting in bed, the head of bed was up, [CONDITION(S)] secured in-place with a c collar. d. On 6/16/22 at 9:58 AM, MDS Coordinator was asked, Who is responsible for completing Section O [on the MDS]? She replied, Me. The MDS Coordinator was asked, How long has the resident had a [CONDITION(S)]? She replied, Since admission, The MDS Coordinator was asked, Is Section O coded correctly? She replied, No, it is not, I will correct that.

Based on record review and interview, the facility failed to ensure the comprehensive care plan addressed functional limitation in range of motion (ROM) to ensure appropriate interventions were developed and implemented to prevent further decline for 1 (Residents #38) of 2 (Residents #8, and #38) sampled mix residents with contractures. The findings are: Resident #38 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/22 documented the resident was severely impaired in cognitive skills for daily decision, required total assistance with two-person assist for bathing, extensive assistance of two person assist for bed mobility, transfer, toilet use, and personal hygiene and had impairment to the upper and lower extremities on both sides. a. The Admission MDS with an ARD of 9/3/19 documented the resident had impairment to the upper and lower extremities on both sides. b. On 6/13/22 at 11:22 AM and on 6/14/22 at 2:23 PM, the resident was lying in bed, her left hand contracted, in a fist position with no device in place. c. On 6/14/22 at 2:41 AM, LPN [Licensed Practical Nurse] #1, was interviewed and asked, is the resident able to open her left hand? She replied, No, we tried to put a washcloth in her hand and if she starts to cry, we stop. She was asked, Is she supposed to have a device in her hand? She replied, I don't know. d. On 6/15/22 at 8:30 AM, RN [Register Nurse] #1 was performing Peg tube site care, the resident was resting in bed, a washcloth was in her left hand with no distress noted. e. The revised Care Plan dated, 6/15/22 documented, [Resident's Name] has limited physical mobility r/t [related to] TBI . washcloth placed in hand to maintain extension of fingers of left hand after ROM [Range of Motion] has been performed by CNA [Certified Nursing Assistant]. f. On 6/16/22 at 9:58 AM, the MDS Coordinator was interviewed and asked, Who is responsible for implementing and revising the care plans? She replied, Me. She was asked, Does the resident have a contracture to her left hand? She replied, Yes. The MDS Coordinator was asked, Should her contracture be care planned? She replied, Yes. The MDS Coordinator was asked, Was her contracture care planned prior to 6/15/22? She replied, No. g. On 6/16/22 at 10:08 AM, the DON [Director of Nursing] was interviewed and asked, does the resident have a contracture to her left hand? She replied, Yes. The DON was asked, Should she have a device in place to prevent further decline in range of motion? The DON replied, Yes. The DON was asked, should the resident be care planned for a hand roll or a device? She replied, Yes. h. On 6/16/22, the Policy on Resident Mobility and Range of Motion was received from the Administrator documented, Residents will not experience an avoidable reduction in Range of Motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The Care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercise, and/or improve and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of intervention, as well as measurable goals and objectives.

Based on observation, record review, and interview, the facility failed to ensure incontinent care was provided in a manner to promote good hygiene, maintain skin integrity, and prevent potential urinary tract infections and the privacy curtain was pulled for 1 (Resident #31) of 15 (Residents #35, #8, #40, #39, #6, #18, #55, #45, #47, #58,#41, #31, #43, #20 and #38) case mix residents who were incontinent and failed to ensure residents' fingernails were cleaned and trimmed to promote good personal hygiene and grooming for 2 (Residents #58 and #18) of 16 (Residents #35, #8, #7, #40, #39, #6, #18, #55, #45, #47, #58, #41, #31, #43, #20 and #38) sampled residents who were dependent for nail care. The findings are: 1. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/22/22 documented the resident scored 11 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status (BIMS), required extensive two-plus person assistance with transfers and toilet use, and was always incontinent of bladder and bowel. a. The Initial Care Plan dated 10/19/20 documented, [Resident #31] has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Stroke . TOILET USE: The resident requires extensive assist by (2) staff for toileting. [Resident #31] has mixed bladder incontinence r/t previous Stroke, Dysuria. INCONTINENT: Check q [every] 2 hours and as required for incontinence. Wash, rinse, and dry perineum. b. On 6/13/22 at 10:59 AM, Certified Nursing Assistant (CNA) #1 performed peri-care. The CNA un-taped the wet brief, wiped down the labia one time without separating, rolled the resident onto the left side. The CNA cleansed the rectal area with one wipe, from front to back without spreading the buttocks to cleanse the rectum. c. On 6/13/22 at 11:15 AM, CNA #1 was asked, When performing peri care should the curtain be pulled all around the resident for privacy? He replied, Yes. He was asked, When cleansing the perineal area, should you separate the labia to cleanse both sides? The CNA replied, Yes. The CNA was asked, When cleansing the rectal area should you, separate the buttocks to cleanse the rectum? He replied, Yes. d. On 6/16/22 at 9:58 AM, the Director of Nursing (DON) was asked, When the CNAs are providing peri-care should the curtain encircle the resident for privacy? She replied, Yes. She was asked, when cleaning the perineal area should the labia be separated and cleansed on both sides? The DON replied, Yes. She was asked, When cleansing the rectal area, should the buttocks be separated to cleanse the rectum? She replied, Yes. e. On 6/16/22, the Policy on Perineal Care was received by the Administrator documented, The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Wash perineal area, wiping front to back . Separate labia and wash area in downward from front to back . Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. 2. Resident #58 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 5/25/22 documented the resident scored 00 (0-7 indicates Severe impairment) on a Brief Interview for Mental Status; required extensive assistance of two person for toilet use, personal hygiene, and extensive assistance of one person for bathing. a. The Initial Care Plan dated 9/4/18 documented, [Resident's Name] has an ADL self-care performance deficit r/t [CONDITION(S)] . BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary . b. On 6/13/22 at 12:24 PM and on 6/14/22 at 2:17 PM, the resident was resting in his bed, his left fingernails were approximately 1/8 inch long and had a brown substance underneath his fingernail tips. c. On 6/14/22 at 3:30 PM, LPN #1 was accompanied to the Resident #58's room and asked, What is that brown substance under his nail tips? She replied, Probably food, he eats with his fingers. She was asked, Should his fingernails be cleaned? She replied, Yes, I will get that done right now. 3. Resident #18 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The revised Care Plan documented, [Resident #18] has potential to skin integrity r/t [related to] fragile skin . The resident will maintain or develop clean and intact skin by the review date . Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. [Resident's Name] has an ADL self-care performance deficit r/t Dementia . TOILET USE: The resident is able to toilet self . PERSONAL HYGIENE/ORAL CARE: The resident is able to: perform own personal hygiene . b. On 6/13/22 at 3:10 PM, the resident was in his room, sitting in his wheelchair, his fingernails on the right and left hands were approximately 1/8 inch long, jagged, and had a brown substance under the fingernail tips. c. On 6/14/22 at 2:15 PM, the resident was in the hallway in his wheelchair. The resident's fingernails were uneven and jagged with a brown substance under the fingernail tips. d. On 6/15/22 at 3:24 PM, LPN #1 was accompanied down the hall, Resident #18 was in his wheelchair in the hallway. The LPN was asked, What is that brown substance under his fingernail tips? She replied, I'm not sure, but he does take himself to the bathroom. She was asked, Should his fingernails be filed, trimmed and cleaned? She replied, Yes, they are a little long and jagged. 4. On 6/14/22 at 2:22 PM, CNA #2 was asked, Who performs the resident's nail care? The CNA replied, The nurses must file and trim if diabetic, the CNAs can clean everyone's nails. The CNA was asked, When is nail care performed? The CNA replied, Once a week, for filing and trimming, cleaning on shower days and as needed. The CNA was asked, How often are the residents showered? The CNA replied, Twice a week. 5. On 6/14/22 at 3:20 PM, Licensed Practical Nurse (LPN) #1 was asked, Who performs the resident's nail care? She replied, The CNAs, if diabetic the nurses have to file and trim. She was asked, When is nail care performed on the residents? She replied, On shower days and as needed. The LPN was asked, Who is responsible to ensure the resident's nail care is being completed as needed? The LPN replied, The Nurses. 6. On 6/16/22 at 9:58 AM, the DON was asked, Who performs nail care on the residents? She replied, The CNAs, nurses, and the treatment nurse. If diabetic the nurses and treatment nurse have to file and trim them. The DON was asked, When is nail care performed on the residents? She replied, On shower days and as needed. The DON was asked, Who is responsible to ensure nail care is being provided to the residents as needed? She replied, The floor nurse, I just did an in-service on nail care. 7. The Policy on Fingernails/Toenails, Care of documented, The purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleaning and regular trimming. Trimmed and smooth nails prevent the resident from accidentally scratching and injuring his or her skin.

Based on observation, record review, and interview, the facility failed to ensure a splint, hand roll, and other positioning device was consistently utilized to prevent further decline in range of motion (ROM) for 1 (Residents #38) of 2 (Resident #38 and #8) sample mix residents who had contractures. The findings are: Resident #38 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/28/22 documented the resident was severely impaired in cognitive skills for daily decision, required total assistance with two-person assist for bathing, extensive assistance of two person assist for bed mobility, transfer, toilet use, and personal hygiene and had impairment to the upper and lower extremities on both sides. a. The Care Plan with a revision date of 6/01/22 documented, [Resident #38] has limited physical mobility r/t [related to] TBI . NURSING REHAB/RESTORATIVE: PASSIVE ROM . PROM BUE [Passive Range of Motion Bilateral Upper Extremities] hands as tolerated, begin with therapeutic massage to prepare joints and calm pt [patient] . b. On 6/13/22 at 11:22 AM and on 6/14/22 at 2:23 PM, the resident was lying in bed, with her left hand contracted, in a fist position with no device in place. c. On 6/14/22 at 2:41 AM, Licensed Practical Nurse (LPN) #1, was asked, Is the resident able to open her left hand? She replied, No, we tried to put a washcloth in her hand and if she starts to cry, we stop. She was asked, Is she supposed to have a device in her hand? She replied, I don't know. d. On 6/15/22 at 8:30 AM, Register Nurse (RN) #1 was performing feeding tube site car. The resident was resting in bed, a washcloth was in her left hand, with no distress noted. e. On 6/16/22 at 9:58 AM, the MDS Coordinator was asked, Who is responsible for implementing and revising the care plans? She replied, Me. She was asked, Does the resident have a contracture to her left hand? She replied, Yes. The MDS Coordinator was asked, Should her contracture be care planned? She replied, Yes. The MDS Coordinator was asked, Was her contracture care planned prior to 6/15/22? She replied, No. f. On 6/16/22 at 10:08 AM, the Director of Nursing (DON) was asked, Does the resident have a contracture to her left hand? She replied, Yes. The DON was asked, Should she have a device in place to prevent further decline in range of motion? The DON replied, Yes. She was asked, Should the resident be care planned for a hand roll or a device? She replied, Yes. g. On 6/16/22, the Policy on Resident Mobility and Range of Motion was received from the Administrator documented, Residents will not experience an avoidable reduction in range of motion (ROM). Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM. The Care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercise, and/or improve and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. The care plan will include the type, frequency, and duration of intervention, as well as measurable goals and objectives.

Based on observation and interview, the facility failed to ensure food items stored in the refrigerator were sealed or covered; dietary staff washed their hands and changed gloves between dirty and clean tasks and before handling clean equipment or food items to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen and expired food items were promptly removed and discarded on or before the expiration or use by dates. These failed practices had the potential to affect 66 Residents who received meals from the kitchen (total census: 68) as documented on a list provided by the Dietary Supervisor on [DATE]. The findings are: On [DATE] at 11:18 a.m., an initial tour was conducted with the following observations: a. An open Ziplock bag that contained an open box of baking soda was on a shelf above the counter. The bag or the box were not covered or sealed. b. On [DATE] at 11:19 a.m., a container of leftover scrambled eggs was on a shelf in the refrigerator. The Dietary Supervisor was asked, What do you do with leftover scrambled eggs? She stated, We use it sometimes for the pureed egg the next day. c. On [DATE] at 11:32 a.m., Dietary Employee #1 with gloves on his hands, picked up a rag and wiped off spilled food particles on the counter. He then picked up a pan liner and placed it on the food preparation counter. He picked up a spray bottle and sprayed inside a saucepan and placed it on the stove and turned the burner on. Without changing gloves and washing his hands, he picked up the premade bread and cheese to be grilled and placed them in the pan on the stove to grill. At 9:57 a.m., Dietary Employee #1 was asked, What should you have done after touching dirty objects before handling clean equipment or food items? He stated, I should have changed gloves and washed my hands. d. On [DATE] at 11:36 a.m., Dietary Employee #2 opened the refrigerator, he picked up a pitcher of sweet tea and placed it on the counter. He picked up cartons of nectar thickened water from a shelf in the storage room and placed them on the counter. Dietary Employee #2 did not wash his hands. He used his contaminated hand to pick up drinking glasses by their rims and placed them on the counter. After filling the glasses, he then picked-up lids and covered the glasses that contained beverages to be served to the residents for the lunch meal. e. On [DATE] at 11:59 a.m., a box with 24 - 8 ounce cartons of nectar milk and a box with 12 cartons of nectar milk was on a shelf in the storage room with a best by date of [DATE]. The Dietary Supervisor was asked if nectar milk was served to the residents on nectar thickened liquids. She stated, No. We have not given it to the resident, not with that date. f. On [DATE] at 12:46 p.m., Dietary Employee #2 with gloves on his hands, took out a container of toss salad and placed it on the counter. Without changing gloves and washing his hands, he used his contaminated gloved hand to pick up toss salad, slices of bread and ham and placed them on the plates to be served to the residents who requested a sandwich for the supper meal. At 4:33 p.m. Dietary Employee #2 was asked, What should you have done after touching dirty objects before handling clean equipment or food items? He stated, I should have changed gloves and washed my hands. g. An Employee Cleanliness and Handwashing Technique list provided by the Dietary Supervisor on [DATE] at 11:25 a.m. documented, Employees are required to wash their hands before beginning shift. After breaks. After handling dirty dishes. After picking up anything from the floor and Any other time deemed necessary. h. A Safe Food Handling policy provided by the Dietary Supervisor on [DATE] at 12:41 p.m. documented, .#13. Discard all cracked and leftover cooked eggs.

Based on observation, interview, and record review, the facility failed to ensure call lights were placed within reach to enable residents to call for assistance when needed for 1 (Resident #33) of 1 sample mix resident. This failed practice had the potential to affect 68 residents based on the Resident Census and Conditions of Residents provided by the Administrator on 04/05/2021. The findings are: Resident #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set with and Assessment Reference Date of 02/16/2021 documented the resident scored 4 (0-7 indicates severely impaired) on a Brief Interview for Mental Status and required extensive assistance for bed mobility, transfer, dressing, toilet use, and personal hygiene, and was always incontinent of bowel and bladder. a. The Care Plan with a revision date of 06/17/2020 documented, .has an ADL [activity daily living] self-care performance deficit r/t [related to] weakness encourage the resident to use bell to call for assistance .has had an actual fall and is moderate risk for fall r/t [related to] weakness/decreased mobility .resident educated on the importance of using call light for staff to assist her to prevent injury . b. On 04/05/2021 at 11:42 A.M., Resident # 33 was lying in bed, the call light was in the nightstand drawer approximately 3 feet out of reach. (Photo taken.) c. On 04/05/2021 at 12:46 P.M., Resident # 33 was lying in bed, the call light was in the nightstand drawer approximately 3 feet out of reach. d. On 04/06/2021 at 9:07 A.M., Resident # 33 was lying in bed, the call light was in the nightstand drawer approximately 3 feet out of reach. e. On 04/07/2021 at 01:03 P.M., Human Resource Personnel #1 was asked, Can [Resident #33] use a call light? Human Resource Personnel #1 replied, Yes. Human Resource Personnel #1 was asked, Should the residents call lights be in reach for use? Human Resource Personnel #1 replied, Yes. Human Resource Personnel #1 was asked, What could happen if a resident couldn't reach their call light? Human Resource Personnel #1 replied, They would try and get out of bed, that's why they should have their call light. f. On 04/07/2021 at 1:06 P.M., Certified Nursing Assistant (CNA) #2 was asked, Can [Resident #33] use a call light? CNA #2 replied, Yes she can. CNA #2 was asked, Should the residents call lights be in reach for use? CNA #2 replied, Yes, they should be in reach. g. On 04/07/2021 at 1:07 P.M., Licensed Practical Nurse (LPN) #2 was asked, Can Resident #33 use a call light? LPN #2 replied, Yes she can, and has. LPN #2 was asked, Should residents call lights be in reach? LPN #2 replied, Yes. h. On 04/08/2021 at 2:11 P.M., LPN #3 was asked, Why should call lights be in reach for residents use? LPN #3 replied, In case they need something, and they can call for assistance. i. On 04/08/2021 at 2:14 P.M., LPN #4 was asked, Why should call lights be in reach for residents use? LPN #4 replied, In case they need to get a hold of us. j. On 04/08/2021 at 2:24 P.M., the Director of Nursing (DON) was asked, Why should call lights be in reach for residents use? The DON replied, So they can ask for assistance when needed. k. On 04/08/2021 at 3:10 P.M., the Administrator was asked, Why should call lights be in reach for residents use? The Administrator replied, So they can call us if they need help.

Based on observation, interview and record review, the facility failed to ensure physician's orders were followed on oxygen administration to prevent the potential of respiratory complications for 2 (Residents #6 and #10) of 5 (Residents #10, #6, #29, #48 and #50) sample mix residents who had orders for oxygen therapy. This failed practice had the potential to affect 12 residents who had physician orders for oxygen therapy according to a list provided by the Director of Nursing (DON) on 04/08/2021. The findings are: 1. Resident #10 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 01/06/2021 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and received oxygen therapy. a. The Care Plan documented, . has altered cardiovascular status Date Initiated: 10/13/2018 . OXYGEN SETTINGS: O2 via [by way of] nasal cannula @ [at] 2 liters Date Initiated: 02/01/2019 . b. The April 2021 Physician Orders documented, .OXYGEN 2 LITERS AS NEEDED FOR SOB [shortness of breath] OR TO KEEP O2 [oxygen] SATS [saturation] AT OR ABOVE 90% [percent] - MAY REMOVE SELF - MAY REMOVE FOR ADL'S every day and night shift for LUNG DISEASE MAY REMOVE PER SELF Start Date 03/13/2021 . c. On 04/05/2021 at 11:51 A.M., Resident #10 had oxygen on at 3 liters per minute via nasal cannula. Resident #10 was asked, Do you use your oxygen all the time? Resident #10 stated, Yes, it's supposed to be on 2 liters. (Photo taken.) d. On 04/06/2021 at 08:57 A.M., Resident # 10 had oxygen on at 2.5 liters per minute via nasal cannula. (Photo taken.) 2. Resident #6 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. The April 2021 Physician Orders documented, .Oxygen every shift for Dyspnea At 3 liters n/c [nasal cannula] resident may remove self and may be removed for adl's Start Date 01/15/2018 . b. The Care Plan documented, .has Congestive Heart Failure .O2 [oxygen] PER ORDERS . Date Initiated: 10/19/2020 . c. On 04/05/2021 at 11:42 A.M., Resident #6 had oxygen on at 2.5 liters per minute via nasal cannula. (Photo taken.) d. On 04/06/2021 at 9:07 A.M., Resident #6 had oxygen on at 2.5 liters per minute via nasal cannula. 3. On 04/08/2021 at 02:11 P.M., Licensed Practical Nurse (LPN) #3 was asked, Who is responsible for ensuring a resident's oxygen is on and running at the physician ordered rate? LPN #3 replied, The nurses. LPN #3 was asked, Why should physician orders be followed for oxygen therapy? LPN #3 replied, Because the resident needs the oxygen, or the doctors wouldn't have ordered it. 4. On 04/08/2021 at 2:14 P.M., LPN #4 was asked, Who is responsible for ensuring a resident's oxygen is on and running at the physician ordered rate? LPN #4 replied, The nurse. LPN #4 was asked, Why should physician orders be followed for oxygen therapy? LPN#4 replied, To make sure you don't over oxygenate them, make sure they get the proper rate. 5. On 04/08/2021 at 02:24 P.M., The DON was asked, Who is responsible for ensuring a resident's oxygen is on and running at the physician ordered rate? The DON replied, The nurse. The DON was asked, Why should physician orders be followed for oxygen therapy? The DON replied, That's what the physician ordered, and we have to follow the physician order. 6. On 04/08/2021 at 3:10 P.M., The Administrator was asked, Who is responsible for ensuring a resident's oxygen is on and running at the physician ordered rate? The Administrator replied, The nurse. The Administrator was asked, Why should the physician orders be followed for oxygen therapy? The Administrator replied, Because the doctor said so, must be what they need medically. 7. An Oxygen Administration policy documented, The purpose of this procedure is to provide guidelines for safe oxygen administration.1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 2. Review the resident's care plan to assess for any special needs of the resident.

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. This failed practice had the potential to affect 4 residents who received pureed diets as documented on the diet list provided by the Dietary Supervisor on 04/06/2021 at 11:25 a.m. The findings are: 1. On 03/05/2021 at 11:50 a.m., the following observations were made on the steamtable: a. A pan of pureed chicken was on the steam table. The consistency of the pureed chicken was not smooth. It was lumpy. There were pieces of chicken visible in the mixture. b. A pan of pureed bread was on the steam table. The consistency of the pureed bread was thick. c. A pan of pureed turkey with gravy was on the steam table. The consistency of pureed turkey was not smooth. Dietary Employee #3 stated, That's pureed turkey with gravy. It was not pureed; it was ground meat with gravy. At 12:41 p.m. Dietary Employee #3 who prepared lunch was asked to describe the appearance of the pureed food items prepared and served to the residents on pureed diets. He stated, Pureed bread was thick. Pureed chicken was not smooth. They could have been pureed longer. The Dietary Supervisor stated, Pureed bread and pureed chicken could have pureed a little longer with more liquid. Pieces of coated mix on chicken were visible in the mixture. Pureed turkey is not supposed to be mechanicalized. It could have been pureed a bit longer. d. On 03/05/2021 at 4:21p.m., Dietary Employee #4 placed 4 ham and cheese sandwiches into a blender, added [NAME] deluxe mayonnaise and pineapple juice. He pureed the mixture and poured it into a pan. At 4:14 p.m. Dietary Employee #4 placed 4 more servings of ham and cheese sandwiches into a blender, added [NAME] deluxe mayonnaise, pineapple juice and thickener. He pureed the mixture and poured it in the same pan. Covered with foil and placed it in the oven to be served to the residents on pureed diets. The consistency was not smooth. It was lumpy with pieces of thickener visible in the mixture. Dietary Employee #4 was asked to describe the consistency of the pureed sandwich. He stated, It has pieces of thickener in it. I should have pureed it some more.

Based on observation, record review and interview, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurate and complete to facilitate the ability to plan and provide necessary care and services for 1 (Residents #41) of 25 (Residents #42, #41, #62, #37, #115, #21, #215, #55, #50, #61, #22, #58, #48, #23, #57, #36, #33, #19, #5, #47, #17, #18, #10, #6, and #24) case mix residents selected for MDS accuracy review. This failed practice had the potential to affect all 68 residents who resided in the facility as documented on the Resident Census and Conditions of Residents provided by the Administrator on 04/05/2021. The findings are: 1. Resident #41 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . a. A Nsg (Nursing)-I&A (Incident and Accident) Follow Up dated 12/31/2020 21:42 [9:42 p.m.] documented, .Incident Description: CNA [Certified Nursing Assistant] was coming in the room as resident tripped over foot of the bed and sat on the floor before the CNA could get to the resident. Nurse assessed resident. No injuries noted . b. A Nsg-I&A Follow Up dated 01/07/2021 20:02 [8:02 p.m.] documented, .Incident Description: staff alerted this nurse saying that resident was sitting on the floor holding the back of her head. upon entry to resident's room resident was sitting straight up facing her bed. resident was holding her head and stated that she hit it on her table. resident's house shoes were halfway on her feet . c. A Nsg -I&A Follow Up dated 01/10/2021 16:21 [4:21 p.m.] Nsg-I&A Note documented, .Incident Description: CNA from the hall came to get me and said [Resident #41] fell . Went to the resident's room where another CNA was with the resident holding her hand. Resident was sitting on the floor holding her right side/rib area complaining of pain. d. A Nsg (Nursing)-I&A (Incident and Accident) Follow Up dated 01/11/2021 09:36 [9:36 a.m.] documented, . Description: Staff called nurse to resident's room, resident was sitting on the floor, resident is legally blind, resident was attempting to walk without assistance and resident bumped into night stand, lost footing, and fell to the floor, resident was noted to be holding her right side/rib area and complaining of pain, nurse assessed resident for further injuries, none noted, . staff assisted resident to bed, received order from APRN [Advance Practical Register Nurse] to obtain XR [x-ray] r/t [relate to] right side pain, XR showed acute fractures of the right fourth, fifth, sixth, and seventh ribs. e. On 04/09/2021 at 8:34 a.m., the MDS Coordinator was asked why the 12/31/20, 1/7/21 and the 1/10/21 falls were not coded on the MDS. The MDS Coordinator stated, I just missed it.

Complaint # (AR 571) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure residents were free of abuse by resident-to-resident altercations of verbal and / or physical abuse to Resident #4 by Resident #2 who allegedly repeatedly verbally and / or physically abused Resident #4 over a 47 day period from September 15, 2020 through November 2, 2020. This failed practice resulted in Past Non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury, or death for Resident #4 who was allegedly verbally and / or physically abused by Resident #2 for a period of 47 days, and had the potential to cause more than minimal harm to 72 residents who resided in the facility, as documented on a list provided by the Administrator on 11/6/2020. The Immediate Jeopardy was removed prior to the survey entrance date of 11/5/2020 when Resident #2 was discharged from the facility, however the underlying deficient practice was not addressed by the facility to ensure that the failed practice did not reoccur. The Administrator was notified of the Past Non-compliance at Immediate Jeopardy condition on 11/6/2020 at 10:37 a.m. The findings are: 1. Resident #4 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 10/30/2020 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); and was independent with bed mobility, transfer, dressing, eating, toilet use, personal hygiene, and walking in room and corridor. a. The facility Incident and Accident Reports provided by the Administrator on 11/6/2020 contained documentation of one incident regarding the verbal and / or physical abuse which occurred for Resident #4. b. A facility Incident and Accident Report dated 10/8/2020 at 3:56 a.m. documented, .Incident description . Was notified by CNA (Certified Nursing Assistant) that resident had been recipient of aggression by her roommate. That roommate had hit her in the head 3 times with roommate shoe . Immediate action . Assessed resident for injuries; none noted . Questioned resident as to what was going on. Aggressor claimed that her roommate walked into the bathroom on her. The CNA claimed that was not true. Aggressor has reported to have made threatening gestures before towards roommate. Resident was assisted to bed and aggressor was instructed that his behavior would not be tolerated. Situation was de-escalated and door to room was to be left open for close monitoring of residents. Family and Physician were notified . c. The Nursing Progress Note dated 10/8/2020 at 09:52 (9:52 a.m.) documented, .Incident Description . Resident was recipient of aggression received by her roommate. CNA (Certified Nursing Assistant) claimed that he heard commotion in their bathroom. Went to see what was going on and witnessed resident's roommate hitting her in the head 3 times with her shoe. Aggressor claimed that she had opened the bathroom door while she was in there. CNA claimed the accusations were 'not true'. Residents were assessed for injuries, none noted . Immediate Intervention . Situation was de-escalated. Resident was put to bed and aggressor was counselled that her behavior was inappropriate and would not be tolerated. Room door is to be kept open at all times for monitoring . d. The Nursing Progress Note dated 10/9/2020 at 09:51 (9:51 a.m.) documented, .Type . Physician Communication . Resident was recipient of aggression received by her roommate. Roommate was seen by CNA to have hit her in the head 3 times with her shoe. Starting HR status to monitor behaviors. Family notified . VS (vital signs) . (blood pressure) 125/65 . (temperature) 97.8 . (oxygen saturation) 95% . (Heart Rate) 81 . (Respirations) 20 . e. The Nursing Progress Note dated 10/15/2020 at 11:09 (11:09 a.m.) documented, . Type . Nsg (Nursing) General Note . Note Text . CNA reported that resident's roommate (Resident #2) was leaning over resident (Resident #4) and shaking her remote in her face while she was lying in her own bed. Resident (Resident #4) appears upset, shaken and tearful. CNA removed resident from room and continues to console and comfort resident. Will assess and monitor throughout shift . f. The Nursing Progress Note dated 11/2/2020 at 02:03 (2:03 a.m.) documented, .Type . Nsg (Nursing) I&A (Incident and Accident) Note . Physician Contact (Who/When) . (facility staff member's name) at 0213 (2:13 a.m.) . Family Contact (Who/When) . (daughter) . left message . Incident Description . Resident was witnessed by CNA being struck in her legs by roommate with shoehorn . Immediate Intervention . Shoehorn removed. Aggressor counselled that this behavior would not be tolerated. Bed checks every 30 minutes. Door to remain open . Vitals (vital signs) . (blood pressure) 123/64 . (Heart rate) 84 . (Respirations) 20 . (Temperature) 98.1 . (oxygen saturation) 96% . 2. Resident #2 had [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 9/29/2020 documented the resident scored 7 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); was independent with bed mobility, transfers, dressing, eating, toilet use, personal hygiene, and with waking in room and corridor; required extensive assistance with bathing; exhibited verbal behaviors directed towards others and other behavioral symptoms not directed toward others; and required a walker for mobility. a. A Nursing Progress Note dated 9/15/2020 at 12:46 p.m. documented, .Alert Note . Note Text . Yelling Screaming Monitored. Staff witnessed resident yelling at roommate while her roommate got up to go to the restroom . b. A Nursing Progress Note dated 9/15/2020 at 12:48 p.m. documented, .Alert Note . Note Text . Threatening Behavior Monitored. Staff witnessed resident raise her right hand and made a fist and was shaking her fist at her roommate, while yelling at her roommate. Spoke to Social Nurse and she will also talk with resident related to her behavior . c. A Nursing Progress Note dated 9/16/2020 at 18:29 (6:29 p.m.) documented, .Alert Note . Note Text . Threatening Behavior Monitored. Staff reported resident in room when roommate was attempting to get to the restroom. This resident held up her remote control and shook it at roommate and stated, 'Don't you touch any of my stuff' . d. A Nursing Progress Note dated 9/17/2020 at 13:50 (1:50 p.m.) documented, .Alert Note .Note Text . Abusive Language . Monitored Resident . Redirected times 4 this shift. Resident refusing to allow her roommate to use restroom in shared room . Resident educated that she has a roommate, and this is not a private room. Resident appeared to get agitated at this nurse. Resident now sitting in Day Room and observed name calling to other residents . e. A Nursing Progress Note dated 9/18/2020 at 19:03 (7:03 p.m.) documented, .Alert Note . Note Text . Threatening Behavior Monitored . This resident was talking about another resident and telling other residents that she is nothing but trouble and she needs to be gotten rid of. This nurse spoke with her and she went to her room and stated we were all crazy . f. A Nursing Progress Note dated 9/22/2020 at 18:04 (6:04 p.m.) documented, .Nsg (Nursing) General Note . Note Text . Resident came to Dining Room and started yelling at her roommate and stated, 'You are nasty and couldn't even flush the toilet.' Attempted to explain to this resident her roommate is legally blind, and she replied 'Oh no she isn't. She goes through my stuff and takes if for her own.' Resident then walked away . g. A Nursing Progress Note dated 9/28/2020 at 22:12 (10:12 p.m.) documented, .Alert Note . Note Text . Threatening Behavior Monitored . (Resident) was getting after roommate for getting into her stuff . Staff talked with (Resident #2) and she calmed down . h. A Nursing Progress Note dated 10/6/2020 at 12:03 p.m. documented, .Alert Note . Note Text . Threatening Behavior Monitored . Roommate was walking through room and this resident had a hanger in her hand and shaking it at roommate and stated, 'Stay out of my stuff.' CNA witnessed this episode and roommate didn't touch anything that belonged to her . i. A Nursing Progress Note dated 10/6/2020 at 19:02 (7:02 p.m.) documented, .Alert Note . Note Text . Threatening Behavior Monitored . Staff reported that resident had remote control in hand and telling roommate she was ugly and raised her hand with remote in it and swung at roommate as if to hit her. Staff separated residents and then this resident stated, 'I didn't do that' . j. A Nursing Progress Note dated 10/8/2020 at 09:45 (9:45 a.m.) documented, .Nsg (Nursing) I&A (Incident and Accident) Follow Up . Date and I&A Description . 10/8/2020 . was aggressive towards her roommate by hitting her with a shoe after roommate verbalized dislike of TV (television) being loud . Long Term Intervention . Will get resident head-phones for TV . Added to the Care Plan . Ensure MD (Medical Doctor) and Family Notification . k. A Nursing Progress Note dated 10/10/2020 at 21:36 (9:36 p.m.) documented, .Alert Note . Note Text . Kicking Hitting . Monitored . CNA reported that she threatened to hit but did not. Resident was upset that she couldn't find her bookmark and thinks someone is stealing her things. CNA found her bookmark and she calmed down . l. A Nursing Progress Note dated 10/15/2020 at 11:05 a.m. documented, .Nsg (Nursing) General Note . Note Text . CNA reported that resident was observed leaning over her roommate while roommate was lying in her own bed, with remote control for TV and shaking it in roommate's face. Roommate visibly shaken and crying at this time. This nurse questioned resident as to why she was shaking remote at resident while she was lying in her own bed. Resident reported that her roommate was seen going through her belongings on her side of bed. The CNA witnessed occurrence and I again asked resident why she was shaking remote over roommate, and resident reports she won't do it again. Will monitor and assess . m. A Nursing Progress Note dated 11/1/2020 at 22:35 (10:35 p.m.) documented, .Nsg (Nursing) I&A (Incident and Accident) Note . Late Entry . Physician Contact (Who/When) . APN (Advanced Practical Nurse) .11/1/2020 . Family Contact (Who/When) . (Name) . Daughter 11/1/2020 . Incident Description . Staff saw resident hitting roommate with shoehorn . Immediate Intervention . Residents immediately separated, shoe horn removed from resident's possession . Vitals (vital signs) .(blood pressure) 122/76 . (Heart Rate) 85 . (Respirations) 20 . (Temperature) 97.8 . (Oxygen saturation) 96% room air . n. A Nursing Progress Note dated 11/2/2020 at 10:20 a.m. documented, .Nsg (Nursing) General Note . Note Text . Informed (Residents Daughter), facility will be sending resident to (facility name) then will proceed with finding resident long term care elsewhere r/t (related to) this facility not being able to meet this resident's needs. Left message with Case Manager, (Hospital name) to call this nurse back regarding finding resident placement after treatment is complete at (Facility name) . 3. On 11/5/2020 at 2:45 p.m., the Social Services Director was asked, Who does the room assignments? The Social Services Director stated it was a team decision. The Social Services Director was asked, When there are incidents between residents that are roommates, what is the facility to do? The Social Services Director stated, They are generally moved. (Resident #2) has had a history of [REDACTED]. (Resident #2) had been roommates with almost every resident on the Secure Unit. She would accuse them of taking her belongings and become aggressive. She had been in a room by herself for a while before (Resident #4) had been moved in the room with (Resident #2) on September 9, 2020. She was asked, In reviewing the clinical records, the first documented incident was on 9/15/2020, the yelling by (Resident #2) and raising her fist to (Resident #4). These types of incident continued with physical abuse on October 8. 2020 and shaking the remote control in the resident's face and then hitting the resident again on 11/1/2020. Why was the resident left in the room with the resident for this extended period of time, from September 15, 2020 through November 2, 2020, for approximately 47 days, with repeated verbal and / or physical abuse? The Social Services Director didn't give an answer. The Social Services Director stated, (Resident #2) has refused medication in the past. The Social Services Director was asked, How long had (Resident #2) been in a room by herself before (Resident #4) was put in the room with her? The Social Services Director stated, For over a month. a. On 11/6/2020 at 9:27 a.m., the Administrator was asked if there were reports to the Office of Long Term Care (OLTC) regarding the incidents of resident-to-resident altercations. The Administrator stated. No, due to there were no injuries. b. On 11/6/2020 at 9:40 a.m., the Social Service Director stated that on 9/9/2020 Resident #2 and Resident #4 were moved into a room together. c. On 11/6/2020 at 2:45 p.m., the Administrator and the Director of Nursing (DON) were asked, When there are incidents between residents that are roommates, what is the facility to do? The Administrator stated they try to move them, depending on the situation. The Administrator stated when she started at the facility, (Resident #2) was in a room by herself and it had been reported that the resident had a history of [REDACTED]. (Resident #4) had been moved in the room with (Resident #2), not sure of the date. The Administrator was asked, In reviewing the clinical records, the first documented incident was on 9/15/2020; the yelling by (Resident #2) and raising her fist to (Resident #4). These types of incidents continued with physical abuse on October 8. 2020, and shaking the remote control in the resident's face and then hitting the resident again on 11/1/2020. Why was the resident left in the room with the aggressive resident for this extended period of time from September 15, 2020 when the incidents were first documented, until November 2, 2020; a time period of time approximately 47 days with repeated verbal and / or physical abuse? The Administrator nor the DON gave an answer. 4. The facility policy titled Abuse Investigation Protocol provided by the Administrator on 11/6/2020 documented, .All reports of resident abuse, neglect, injuries of an unknown source, resident-to-resident abuse and resident-to-staff are promptly and thoroughly investigated by facility management . Abuse is defined as the willful infliction of injury . unreasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish or deprivation by an individual including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being . Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or their families, or within their hearing distance, to describe resident regardless of their age , ability to comprehend, or disability . Physical abuse is defined as hitting, slapping, pinching, kicking, etc. (et cetera) . It also includes controlling behaviors through corporal punishment . Mental abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services . Protection of Residents during Abuse Investigation . Policy statement . Our facility will protect residents from harm during investigations of abuse allegations . d. Allegations involving residents will require assessment and appropriate interventions to protect the victim and other residents . Interventions may include temporary one-on-one supervision, transfer to another level of care, or discharge to family member / responsible party . 5. The Immediate Jeopardy was removed, and the scope / severity was reduced to E on 11/2/2020 when the facility discharged the resident and implemented the following Plan of Removal: a.Residents will be immediately separated and assessed for injury. The aggressor will be placed on 1:1 (one-on-one) until they can be removed from facility or physician deems not a threat to self or others . b.Dementia Unit residents will be assessed for roommate appropriateness and any negative findings will be addressed immediately . c.All staff present were in-serviced by Administrator or Designee on Abuse policy and procedure for protecting residents and will continue until 100% training has been achieved to include staff on vacation and out sick .

Based on record review and interview, the facility failed to ensure planned fall interventions were consistently implemented to prevent further falls with injury for 1 (Resident #7) of 1 Case Mix resident who had a history of [REDACTED]. This failed practice resulted in actual harm for Resident #7, who had a fall and sustained major injuries, resulting in hospitalization , and had the potential to cause more than minimal harm for 1 resident who had falls in the past 30 days, according to a list provided by the Administrator on 11/30/2020 at 11:52 a.m. The findings are: 1. Resident #7 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/2/2020 documented the resident scored 14 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS); was independent with no physical assistance for transfers; required limited assistance of one person for toilet use; and had no falls since last assessment. a. The Closet Care Plan dated 8/21/19 documented, .Falls . Non-skid socks when transferring . An undated entry documented, (Times) 2 (person) assist (assistance) with acutely ill with COVID . b. The Plan Of Care with a revised date of 1/2/2020 documented, .Transfer . The resident requires limited assist by (1) staff to move between surfaces and as necessary . Toilet Use . The resident requires extensive assist by (1) staff for toileting . c. The Incident and Accident Report dated 11/19/2020 at 5:57 a.m. documented, .(Resident #7) was being assisted by CNA (Certified Nursing Assistant) with gait belt in the BR (bathroom) when her knees gave out and CNA lowered her to the floor; sustained a ST (skin tear) to left elbow . Immediate Intervention . make her a two (person) assist with gait belt for all transfers during acute illness. (COVID Positive 11/17/2020 with symptoms) . d. The Plan of Care with a revised date of 11/19/2020 documented, .Staff to use 2 assist while resident acutely ill and has increased weakness . The revised Plan of Care was signed by Licensed Practical Nurse (LPN) #1. e. The Incident and Accident Report dated 11/20/2020 at 5:00 a.m. documented, .(Resident #7) was being assisted by CNA (Certified Nursing Assistant #1) with gait belt in the BR (Bathroom) when CNA #1 had (Resident #7) stand up so he could pull down pants before having her sit down onto toilet when she fell face forward hitting her face and head on the wall before sliding down to floor; sustained a laceration to nose, ST (skin tear) to left knee and shin; hematoma to center of forehead and small one to left side . Immediate Intervention . change from a 1-person assist (assistance) to a 2-person assist with all transfers during acute illness related to COVID-19 and to have MD (Medical Doctor) review medications; had recently increased [MEDICATION NAME] from 50 mg (milligrams) to 150 mg. APN (Advanced Practice Nurse) notified at 5:05 a.m. with orders to monitor and report any changes . f. The neurological checks implemented after fall on 11/20/20 documented the following: Neuro (Neurological) checks every 15 minutes (times) 4 and every 30 minutes (times) 1 were all within normal limits (WNL); however, with the second 30 minute neuro checks at 7:00 a.m., she (the resident) was oriented to person only and drowsy; and with the third neuro check at 7:30 a.m. she became unresponsive and the Advanced Practice Nurse (APN) gave orders to send the resident to (Name) hospital for evaluation and / or treatment. g. Hospital Progress Notes dated 11/20/2020 documented, .Assessment Impressions . [DIAGNOSES REDACTED]. 10:35 a.m. Discussed with patient's son (Name) is next of kin and making decisions for the patient. He agrees with making patient DNR (Do Not Resuscitate). He understands dire nature of resident's medical condition . 11:13 a.m.Son (Name) called back and after talking with family, they would like to make her Comfort Care . h. On 12/1/2020 at 10:14 a.m., information provided by the Emergency Medical Service (EMS) dispatch stated the call from the facility came in at 8:07 a.m.; EMS arrived at the facility at 8:37 a.m.; left the facility at 8:48 a.m.; and arrived at the hospital at 8:54 a.m. i. On 12/1/2020 at 11:19 a.m., Licensed Practical Nurse (LPN) #2 who was present at the time of the fall on 11/20/2020, was asked what her involvement was when (Resident #7) fell on [DATE]. She stated, The aide (Certified Nursing Assistant (CNA)) called me in there to help transfer her from the bed to the wheelchair so he could take her to the bathroom. She was asked if she (the resident) was able to bear weight. She stated, She required very little help from us, but she was groggy. She was asked if she helped the CNA transfer her from the wheelchair to the toilet in the bathroom. She stated, No. After we got her to her wheelchair, I left the room to get her medications. I did not go back in there until I was notified that she had fallen. When I got back in there, she was lying face down on the bathroom floor; had a laceration on her nose, hematoma to her forehead and side of her head, and a laceration on her lower left leg. We got her up by using a lift pad and put her back to bed. I called the APN (Advanced Practice Nurse) at approximately 5:05 a.m. and she gave orders to monitor her and initiate neuro (neurological) checks and call her with any changes. I went back down there with the on-coming nurse, (Name), to assess her prior to me leaving work that morning. At that time, she was stable. LPN #2 was asked if she was aware that she (the resident) had been changed to a two-person assist after her fall the previous morning. She stated, No, I wasn't, and (Certified Nursing Assistant #1) didn't know either. They told me in report that she was requiring more assistance, but that's all they said. I thought prior to that morning she was able to transfer herself without any assistance. j. On 12/1/2020 at 11:56 a.m., an email received from the Advanced Practical Nurse documented, .Resident (Name) had fall on 11/19/2020 early morning and I was notified and given rept (report). She (the resident) was evaluated by me that day and was stable to stay in the facility. (Resident) .Had another fall early hrs (hours) of 11/20/20. I was notified at 5:05 a.m. and given report. She was stable and placed on rounds that day. Before rounds were made, I was notified two more times at 7:54 (a.m.) .gave VO (verbal order) to transport to (Hospital) via ambulance when additional Changes of Condition, to include low O2 (oxygen) sats (saturations) and decreased responsiveness . Was given per verbal report . k. On 12/1/2020 at 1:02 p.m., Certified Nursing Assistant (CNA) #1 was asked what his involvement was with (Resident #7) the morning of 11/20/20 was. He stated he was the Float CNA that morning and when he went in to check on her a little before 5:00 a.m. that morning, she was needing to go to the bathroom. Her Oxygen saturations were in the low 60's, but she wasn't wearing oxygen that she usually wears, so I put her oxygen on, and it came up to the low 80's with oxygen. I don't remember what her oxygen was at, but I called for the Nurse to help me transfer her from the bed to her wheelchair since her oxygen level was running low. She came and helped me with the transfer but left right afterwards to go get her medications. CNA #1 was asked if he reported the resident's low oxygen saturations before they got her up to her wheelchair. He stated, Yes. He stated, I took her to the bathroom, had her stand up and hold onto the grab bar while I pulled her pants down, asked her to sit down on the toilet, and that's when she just fell forward hitting her head and face on the wall and floor. I then called for the Nurse to come and she did. We got her up using a lift pad and put her back into the bed and initiated frequent neuro (neurological) checks and monitoring. The rest of my shift she was stable. CNA #1 was asked if he was aware that she was a two-person assist with all transfers. He stated, No. I was not, and her Closet Care Plan still said one-person assist. CNA #1 was asked how they are made aware of changes in their transfer status. He stated, By the Closet Care Plan and through report. l. On 12/2/2020 at 11:10 a.m., Licensed Practical Nurse (LPN) #3, who worked with Resident #7 after the fall on 11/20/2020, was asked what her involvement was the morning the resident fell on [DATE]. She stated, I wasn't here during her falls. The fall on the 20th (11/20/2020), I came in at 7:00 a.m. During report, (LPN #2) told me she had fallen at 5:00 a.m. and that she had bruising on her face and new skin tears, I believe, on her left elbow and another one on her left lower leg. As soon as we finished report, I went down to assess (Resident #7). When I walked into the room, one of the other CNAs (male CNA) was getting her vital signs. At that time, her vital signs were stable, and her oxygen saturation was in the low 90's. She was wearing oxygen flow rate was set at 3 liters per minute. I did notice she was very drowsy or sedated. During report LPN #2 didn't tell me of any sedating medications she had given her. I had CNA stay in the room while I went to get LPN #2 and brought her into (Resident #7's) room to lay eyes on her to see if this was normal for her or different. That's when (LPN #2) told me she had given her an [MEDICATION NAME] after her fall. She also told me that during the night she was sedated as well. I don't know if she gave her any sedating medication during the night; I only know that she gave her [MEDICATION NAME] after her fall. At that time, approximately 7:15 a.m., her vital signs were stable. I went and told the DON (Director of Nursing) her condition. At the time, I felt like her condition was different. That's when (DON) told me the APN (Advanced Practice Nurse) was going to be here that morning so I didn't make any calls at that time. (LPN #2) didn't tell me what her neuro's (neurological checks) had been prior to my assessment, so that's when I told the staff to round on her every 15 minutes. They were to check her vital signs, oxygen saturation, and to make sure she was arousable, but I nor the CNAs documented any of this anywhere. The next time (approximately 7:30 a.m.) staff went to check on her and her oxygen saturation was approximately 74% on 3 Liters of oxygen. I went into the room to recheck her pulse oximetry on a different finger, and it was 76% on 3 Liters of oxygen, and had another staff to get the DON (Director of Nursing) and (Licensed Practical Nurse (LPN) #1). I let them know what was going on, and (LPN #1) called the APN (Advanced Practice Nurse) at approximately 7:40 to 7:50 a.m. During that time, I kept assessing (Resident #7). Her color was good; she was just not as arousable. LPN #3 was asked if she was aware that she (the resident) was changed from a one-person assist to a two-person assist with transfers. She stated, No, I wasn't aware of that either. I should have been told that in morning report. m. On 12/2/2020 at 12:16 p.m., LPN #1 was asked what her involvement was in ensuring that the immediate intervention after the 11/19/2020 fall to change the resident from a one-person assist to a two-person assist was relayed to all staff. She stated, My responsibility was to update the Care Plan and it should have been the Hall Manager's (who was out for COVID) responsibility to update the Closet Care Plan and make sure All staff knew of the change in her (the resident's) transfer status. Since the Hall Manager was off, it should have been the Nurse (Registered Nurse (RN) #1) who initiated the Incident and Accident immediate intervention; her responsibility to make sure All her staff knew of the change; the change was reported to the next shift; and their responsibility to report to the following shift. (RN #1 was not available for interview.) n. On 12/2/2020 at 3:04 p.m., Certified Nursing Assistant (CNA) #2, the resident's CNA the morning of 11/19/2020 and 11/20/2020, was notified via telephone and was asked if she was aware of either one of these falls. She stated, Yes, I was. On the 19th (11/19/2020), she (the resident) fell with me, and on the 20th (11/20/2020), she fell with the float aide helping her. She was asked if she was aware that she (the resident) had been changed from a one-person assist to a two-person assist after her fall on the 19th (11/19/2020). She stated, No, I wasn't. She was asked how she is made aware of these types of changes. She stated, Through report and the Closet Care Plan. She was asked what the Closet Care Plan documented about her (the resident's) transfer status. She stated, Actually, it still had her transferring independently. It didn't even document that she was a one-person assist before the 19th (11/19/2020) fall. o. The facility policy titled Falls provided by the Administrator on 12/3/2020 at 10:44 a.m. documented, .Falls . Critical Protocol Assessment and Recognition . 5. The staff will evaluate, and document falls that occur while the individual is in the facility . Treatment and Management . 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .

Complaint # (AR 815) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure infection control measures for Contact and Droplet Isolation were followed by staff not wearing gloves upon entering the residents' COVID-19 Positive Isolation room for 3 (Residents #1, #3, and #5) of 3 case mix residents who had tested Positive for COVID-19 and resided on the 300 Hall, Isolation Hall for COVID-19 Positive residents; and failed to follow proper handwashing techniques for 1 (Certified Nursing Assistant (CNA) #1) on the 300 Hall, Isolation Hall for COVID-19 Positive residents. These failed practices had the potential to affect 22 residents who resided on the 300 Hall, Isolation Hall for COVID-19 Positive residents, according to a list provided by the Administrator on 11/4/2020. The findings are: 1. On 11/4/2020 at 3:21 p.m., during the Entrance Conference, the Administrator stated the facility had 22 COVID-19 Positive residents who were placed on the 300 Hall for isolation. 2. Resident #1 had a [DIAGNOSES REDACTED]. a. A physician's orders [REDACTED].Droplet and contact isolation precautions . b. A Nursing Progress Note dated 11/3/2020 at 9:40 a.m. documented, .This nurse called and spoke with (Resident #1's) son regarding (Resident) testing Positive for COVID-19 .(signed by Licensed Practical Nurse (LPN) #2) . c. On 11/5/2020 at 7:58 a.m., Licensed Practical Nurse (LPN) #1 was administering medication to Resident #1. LPN #1 set the medications up at the Medication Cart and entered the resident's room to administer the medications. LPN #1 did not wear gloves and was touching the resident's objects on the over-the-bed table with her bare hands. d. On 11/5/2020 at 9:11 a.m., Certified Nursing Assistant (CNA) #1 entered Resident #1's room. The resident had called for assistance and stated she needed to be changed. CNA #1 entered the resident's room without wearing gloves. CNA #1 touched the resident, the resident's bed covers, the over-the-bed table, and objects on the over-the-bed table. CNA #1 got plastic bags and set them on the foot of the bed. She left the resident's room and came back with an alcohol-based hand rub (ABHR) bottle and set it on the plastic bag. The ABHR bottle was lying directly on the resident's bedspread. CNA #1 picked up the contaminated bottle and put the bottle in her pocket which resulted in cross contamination of the CNA's uniform. 3. Resident #3 had a [DIAGNOSES REDACTED]. a. A Nursing Progress Note dated 11/3/2020 at 8:57 a.m. documented, .Physician Communication Conversation . On 11/03/2020 (at) 2:27 (2:27 p.m.) Resident was Rapid tested for COVID-19 r/t (related to) her roommate testing Positive and COC (change of condition) of SOB (shortness of breath) . She tested Positive and was moved to Isolation . (Signed by Director of Nursing (DON)) . b. A physician's orders [REDACTED].Contact / Droplet Isolation . c. On 11/5/2020 at 8:13 a.m., Certified Nursing Assistant (CNA) #1 entered Resident's #3 room without gloves on. The resident was on the floor, with back against the bed, and legs straight out in front of the resident. The resident was coughing. CNA #1 did not put gloves on upon entering the resident's room. She touched the resident, turned the call light on, and went to the door and called out for help and the nurse. While CNA #1 was waiting for help, CNA #1 sat on the resident's bed with her uniform touching the resident's bed linen. CNA #2 entered the room without gloves on. CNA #2 picked up the gait belt from the chest area. CNA #1 and #2 put the gait on the resident with their bare, ungloved hands. At 8:20 a.m., Licensed Practical Nurse (LPN) #1 entered the room without gloves on. At 8:22 a.m., CNA #3 entered the resident's room with the vital sign equipment without gloves on. The resident was transferred to the bed by CNA #1 and #3. CNA #1 entered the bathroom, washed her hands 23 seconds, and turned the faucet off her with bare hands. 4. Resident #5 had a [DIAGNOSES REDACTED]. mobility; had no functional limitation in range of motion; and was always continent of bowel and of bladder. a. A physician's orders [REDACTED].Contact / Droplet Isolation . b. A Nursing Progress Note dated 10/30/2020 at 15:35 (3:35 p.m.) documented, .This nurse spoke with resident's daughter and explained that one COVID Test resulted as Inconclusive, a rapid COVID test resulted Positive, and another swab has been sent to Diagnostics. Daughter stated that 'she thought her mom had COVID the first of October, but she had taken her to (Hospital) twice and was told test results were negative'. This nurse explained that resident was not showing signs and symptoms of [MEDICAL CONDITION], but at this time we were taking Isolation Precautions. Daughter was understanding and thankful for the notification . (Signed by the Assistant Director of Nursing) . c. On 11/5/2020 at 8:03 a.m., CNA #1 entered room [ROOM NUMBER] on the Isolation Hall for COVID-19 residents without wearing gloves. She touched the resident and used hand sanitizer upon leaving the resident's room. d. On 11/5/2020 at 8:04 a.m., CNA #2 entered room [ROOM NUMBER] on the Isolation Hall for COVID-19 residents without gloves on, touching the resident. She asked the resident if they were hungry and set up the resident's breakfast meal tray. e. On 11/5/2020 at 8:05 a.m., CNA #1 room [ROOM NUMBER] on the Isolation Hall for COVID-19 residents without gloves on. CNA #1 touched the resident and objects in the room. CNA #1 entered the resident's bathroom, washed her hands in the bathroom for approximately 8 seconds, and turned the faucet off with her bare hands. f. On 11/5/2020 at 8:59 a.m., Licensed Practical Nurse (LPN) #2 set up the resident's medication at the Medication Cart. LPN #2 took the medications into Resident #5's room. LPN #2 was not wearing gloves and LPN #2 touched the resident and objects on the over-the-bed table with her bare, ungloved hands. g. On 11/5/2020 at 9:03 a.m., Certified Nursing Assistant (CNA) #1 walked into Resident #5's room without gloves on and touched the resident and the resident's bed covers. CNA #1 asked the resident if she was ready to eat. CNA #1 assisted the resident to sit up on the side of the bed. CNA #1 touched the resident, the resident's breakfast meal tray, and objects on the resident's over-the-bed table with her bare, ungloved hands. h. On 11/6/2020 at 10:30 a.m., the Administrator and the Director of Nursing (DON) were asked if the staff should be wearing gloves when they enter the resident's room on the 300 Hall with the residents on the hall all having tested Positive for COVID-19 Virus with a census of 22. The Administrator and Director of Nursing (DON) both stated, Yes. They should be wearing gloves when entering the residents' rooms. The Director of Nursing was asked if the staff had in-services and had training on the proper technique for handwashing. The DON stated, Yes. The DON was asked if the staff should be turning the faucet off with their bare hands. The DON stated, No. 5. The facility policy titled Coronavirus Disease (COVID-19) Infection Prevention and Control Measures provided by the Administrator on 11/4/2020 documented, .The facility follows recommended standard and transmission-based precautions, environmental cleaning and social distancing practices to prevent the transmission of COVID-19 within the facility . 1. The policy is based on current recommendations for standard preventions and transmission-based precautions, environmental cleaning and social distancing for COVID-19 . 2. While in the building, personnel are required to strictly adhere to established infection prevention and control policies including . a. Hand hygiene . c. Appropriate use of PPE (Personal Protective Equipment) .d. Transmission-based precautions where indicated . 14. If there are COVID-19 cases in the facility . a. Staff wear all recommended PPE (i.e. (such as) gloves, gown, eye protection and respirators or facemask) for the care of all residents on the Unit (or facility-wide based on the location of affected residents) regardless of symptoms (based on availability) . a. The facility policy titled Contact Precautions provided by the Administrator on 11/6/2020 documented, .Everyone must .Clean hands, including before entering and when leaving the room . Provider and staff must also . Put on gloves before room entry . Discard gloves before room exit . b. The facility policy titled Handwashing / Hand Hygiene provided by the Administrator on 11/6/2020 documented, .Policy Statement . The facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections . 2. All personnel shall follow the handwashing / hand hygiene procedures to help prevent the spread of infection to other personnel, residents, and visitors . Washing hands . 1. Wet hands first with water, then apply an amount of product recommended by the manufacturer to hands . 2. Rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers . 3. Rinse hands with water and dry thoroughly with disposable towel . 4. Use towel to turn off the faucet . c. The facility in-services titled COVID-19 dated 10/12/2020 and 10/26/2020 documented, .Contact precautions . Clean hands before entering and after leaving a residents room . Put gloves on before entry and discard gloves before room exit . d. The facility in-services titled COVID-19 dated 10/26/2020 documented, .Handwashing . Apply soap to hands . Lather all surfaces, fingers, hands and wrist for 20 seconds, . Rinse all surfaces of the hands and wrists . Dry hands thoroughly with paper towel . Use paper towel to turn the facet off .

Based on observation, record review, and interview, the facility failed to ensure all soiled areas of the skin that were in contact with urine were cleansed during incontinent care to maintain good hygiene and prevent potential odors, skin issues, and infection for 1 (Resident #3) of 2 (Residents #1 and #3) case mix residents who were dependent with incontinent care. This failed practice had the potential to affect 5 residents who resided on the 300 Hall and were dependent with incontinent care, according to a list provided by the Administrator on 11/6/2020. The Findings are: Resident #3 had [DIAGNOSES REDACTED]. The Modification of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/10/2020 documented the resident scored 3 (0-7 indicates severe impairment) on a Brief Interview for Mental Status (BIMS); required extensive two-person assistance for bed mobility, transfer, toilet use, and personal hygiene; and was frequently incontinent of bowel and of bladder. a. On 11/5/2020 at 8:29 a.m., Certified Nursing Assistants (CNAs) #1 and #3 assisted the resident to a standing position. CNA #1 removed the resident's incontinent brief which was soiled with urine. CNA #3 placed the soiled incontinent brief in the trash can. The resident was in a standing position with the assistance of CNA #1. CNA #3 cleansed the resident's rectal area. CNA #3 failed to clean the resident's outer buttocks and the resident's front peri-area skin surfaces which had been in contact with the resident's soiled incontinent brief. b. On 11/6/2020 at 10:30 a.m., the Director of Nursing (DON) was asked, During incontinent care, should all the surfaces of the skin be cleansed? The DON stated, Yes. c. The facility policy titled Perineal Care provided by the Administrator on 11/6/2020 documented, .Purpose . The purpose of this procedure is to provide cleanliness and comfort to the resident . To prevent skin infections and / or irritation . And to observe the resident's skin condition . For females . Wash perineal areas wiping from front to back . (1) Separate labia and wash areas downward from front to back .

Complaint # (AR 965) was substantiated, all or in part, with these findings: Based on record review and interview, the facility failed to ensure treatment and care were provided in accordance with accepted standards of nursing practice, as evidenced by failure to promptly act upon the resident's repeated requests to be transferred to the hospital and failure to consult with Hospice, the resident's physician, and / or the resident representative regarding the resident's requests for 1 (Resident #1) of 2 (Residents #1 and #4) case mix residents who received hospice services. This failed practice resulted in actual harm to Resident #1, whose requests for hospitalization were not acted upon, after which the resident eloped from the facility and attempted to walk to the hospital, resulting the in the resident sustaining a laceration to the head and a fracture to the clavicle. The failed practice also had the potential to cause more than minimal harm to 2 residents who were receiving Hospice services, according to a list provided by the Director of Nursing (DON) on 12/11/19 at 1:32 p.m. The findings are: Resident #1 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/16/19 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview of Mental Status (BIMS); required extensive one person assistance for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing; and used a walker for mobility. a. A physician's orders [REDACTED]. b. A nursing progress note dated 12/8/19 at 6:34 a.m. documented, Late Entry: Note Text: assist patient to sit in walker and brought to room and full body and skin assessment done by this nurse. Complete neuro (neurological) exam patient at baseline lungs diminished and heart rate regular vs (vital signs) stable. c/o (complains of) pain to head and back. Full skin assessment as follows. Found open [MEDICAL CONDITION] dressed and cleaned wound. bruise to left shoulder and mid lower back bruise. patient was incontinent of bowel and urine. peri area and coccyx reddened applied [MEDICATION NAME]. cleaned and placed new brief. chronic wound to left lower leg remains unchanged, cleaned and redressed. small scratches to right lower leg cleaned no dressing needed. scratches to right and left hand cleaned no dressing needed. MD (medical doctor) called about [MEDICAL CONDITION] and gave orders to send to (hospital) for eval (evaluation) and treat. c. A nursing progress note dated 12/8/19 at 6:54 a.m. documented, .Incident Description: resident brought back to facility with police officer at 6:58 a.m. assess patient and found open [MEDICAL CONDITION] cleaned and dressed wound cleaned and placed clean brief incont (incontinent) of bowel and bladder and transport per facility van to (hospital) for eval (evaluation) and treat . d. Hospital Records dated 12/8/2019 at 7:12 a.m. documented, .Chief Complaint: [MEDICAL CONDITION] . HPI (History of present illness): Transport via (by way of) facility van to suture room with complaint of [MEDICAL CONDITION]. Patient coded himself out of the facility at an unknown time. Was documented in the facility at 4 am, per nursing staff I spoke to. Police called at 6 am with patient found at (Supermarket) with laceration on his head. Ambient temperature around 38F (Fahrenheit) overnight. He complains of pain in the right should and right hand / thumb . Radiology Notes: Right shoulder, 2-view: Nondisplaced distal clavicle fracture . Right hand, 3-view: No fractures appreciated . Diagnosis: [REDACTED]. e. Hospital records dated 12/8/2019 documented, I spoke with two hospice nurses, and patient's son (Son's name) (POA) (Power of Attorney) who does not want to revoke hospice for a transfusion. BP (Blood Pressure) has improved as well as it's probably going to without a transfusion. Is not likely to be compliant with a figure 8 splint. Will discharge back to (facility) with q (every) 2-hour pain assessment / VS (Vital Signs) for 48 hours . f. A nursing progress note dated 12/8/19 at 7:34 a.m. documented .Incident Description: This Nurse was notified at 0600 (6:00 a.m.) that the Resident was found wandering down the road. Resident escorted back to facility by (Police Officer). When Resident got back was checked out by RN (registered nurse) on the floor. Resident said that he fallen when he was gone. Resident has laceration to forehead and a skin tear to his Rt leg. Resident sent to (Hospital) for treatment. g. A nursing progress note dated 12/8/19 at 1:31 p.m. documented, Note Text: (emergency room ) called to report resident is being sent back to facility. New dx. (diagnosis) Right distal clavicle fx (fracture) States resident has had ([MEDICAL CONDITION]) during ER (emergency room ) visit. Received steri-strips for 4cm (centimeter) laceration to forehead. pain assessment to be done every 4 hours x (times) 48 hours along with neuro checks . h. An OLTC (Office of Long Term Care) Witness Statement Form dated 12/8/19 at 7:36 p.m. completed by the Director of Nursing documented, .What was witnessed: I went to speak with (Resident #1) about him leaving the facility this morning, he stated to me that the nurse didn't do what he wanted to do so he was walking to the hospital, I told him he could have been hurt and he stated 'at this point in my life I don't care.' He laughed as he said this. I educated him that he has to let staff know he was leaving, and he had to sign the book and he stated, 'I'm my own person and I can do what I want.' He did state he was in pain, but it was tolerable, and he would not leave again without letting someone know. I did BIMS Assessment he scored a 14. He is AAO (alert and oriented) x (times) 4. i. An OLTC Witness Statement Form dated 12/8/19 at 11:00 p.m. completed by the DON documented, What was witnessed: Per phone conversation with (Licensed Practical Nurse (LPN) #1) she stated she saw (Resident #1) around 11:30 (p.m.) and he asked for a glass of water. He did not c/o anything at that time. She then saw him at 2am when he stated his hemorrhoids were bothering him and he needed to go to the doctor - She said she offered his PRN (as needed) pain / hemorrhoid meds (medications) and he refused, she said she spoke with him and explained that the hospital wouldn't do anything more than what we could do for him here at our facility and that was the last she saw him until the police brought him back at 0612 (6:12 a.m.). j. A nursing progress note dated 12/9/19 at 10:08 a.m. documented, Date and I&A (incident and accident) Description: 12/8/19 Resident was brought back to facility by (Sheriff) at 0612 (6:12a.m.) - resident last seen on rounds at 0400 (4:00a.m.) by two staff members who assisted with toileting and dressing - BIMS 15 - Vital signs WNL (within normal limits) upon return to facility - sent to (emergency room ) for evaluation - Long Term Intervention: facility door codes changed - resident placed on secure unit pending investigation to send to facility with wander guard use . k. An OLTC Witness Statement Form dated 12/9/19 at 2:36 p.m completed by the DON via telephone with Certified Nursing Assistant (CNA) #1 documented, .What was witnessed: No I did not see him leave. I saw him at 0400. I checked his bed and changed his bed. He asked me to ask the nurse for something for his hemorrhoids - (LPN #1) explained he could have his PRN meds and he refused, stating he needed to go to the hospital, she told him the hospital couldn't help him with the hemorrhoids but I walked out and didn't hear anything else he said . l. The Care Plan dated 12/10/19 documented .Focus - The resident is an elopement risk/wanderer r/t (related to) impulse control 12/8/19 exited facility Date Initiated: 09/12/2019 . Interventions: admitted to secured neighborhood door codes reset. Assess for fall risk . Focus: Focus: Resident is receiving hospice care related to terminal [DIAGNOSES REDACTED]. Interventions: Facility staff will notify hospice of any identified need and/or significant change in the resident's status as indicated. Hospice nurse will visit (SPECIFY) times weekly for assessment of pain management, symptoms management and any physical or psychosocial needs. Hospice provider (Hospice) 24-hour contact number (SPECIFY) Hospice social worker, chaplain and volunteers will visit prn. Hospice staff will communicate any identified needs and/or changes in resident's condition to hospice coordinator / facility staff / other designee as appropriate. Work with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met . m. On 12/11/19 at 10:09 a.m., CNA #1 was asked if she was working when Resident #1 exited the facility and she stated I worked 10-6 (10 pm to 6 am). I was there that morning. She was asked when the last time she saw the resident that night and she stated It was a little bit before 4 that morning. He was lying in bed sleeping. I didn't see the nurse. I was doing my rounds and taking care of people. He asked to go to the hospital. He had asked when I started my shift at 10:00 p.m. It was several times that night that he wanted to go. He was on Hospice so they couldn't really do anything. She was asked why he wanted to go to the hospital, and she stated He said he wanted to go to the hospital because he thought he was bleeding worse than he was originally. I had to change his bed twice that night because he was bleeding. She was asked if she notified the nurse and she stated, No, well, it happened all the time. It's something that wasn't progressing. n. On 12/11/19 at 12:08 p.m., RN #1 with (Hospice) was asked if they were notified that the resident had requested to go to the hospital related to his rectal bleeding on the night of 12/7/19 until the morning of 12/8/19 and she stated, We have nothing. They did call on 12/8/19 after he was in the hospital. Hospice isn't going to send him to the hospital. Someone would have to revoke his hospice before sending him out. His son signed all of his consents. o. On 12/11/19 at 12:20 p.m., CNA #2 assisted with interviewing Resident #1. The resident was asked where he was trying to go when he exited the facility and he stated, I was going to the hospital. They wouldn't help me here. He was asked if he had his walker and he stated Yes. He was asked if he notified anyone that he was leaving or if he took it upon himself to leave and he stated, Took it upon myself. He was asked if he remembered what time he left and he stated, Around 3 o'clock. He was asked why he wanted to go to the hospital and he stated, Nursing home wouldn't help. p. On 12/11/19 at 1:54 p.m., LPN #1 was asked if, on 12/7/19, the resident requested to be sent to the hospital and she stated, He did and we went and talked to him about the reason why he was wanting to go was because he had hemorrhoids and his bleeding. For some reason he thinks that if he goes to the hospital, they can stop it. She was asked what time he made this complaint and she stated Probably around 10:30-11 p.m. She was asked how many times he made the request and she stated Only a couple. He's done this before. We'll go in there and talk to him and he'll calm down. He knows that if we send them to the hospital, they are going to send him right back. He always says he needs to go because he's dying. We try to talk to him and calm him down and that it's just his hemorrhoids. We told him there's not much the hospital can do than what we already have. She was asked if she notified anyone that he requested to go to the hospital, and she replied No. She was asked why she didn't notify anyone, and she stated, It has been his normal behavior that it's something he just does. Normally if we talk to him, he's fine. He came out and got a drink of water from me probably around 11:30 p.m. She was asked when she last saw the resident and she stated, That would be the last time I saw him was when he came out and got a drink of water from me. She was asked if she saw him at 2:00 a.m. and she stated No. She was notified that her witness statement over the phone with the DON stated that she did. She stated, I didn't do a witness statement. The witness statement was read to her and she stated, I think he may have been asking about it one more time that night. He seemed okay and he did tell me he did not want his suppository. He complains about everything and then he doesn't want his medicine. She was asked if the resident was assessed since there was no documentation available for review and she stated, Yes. He did have bleeding. It wasn't, he's had it a lot worse. He has [MEDICAL CONDITION] or something and it gets really bad. That night it wasn't that bad. I went and checked him out and looked. I tried to tell him it wasn't that bad. I told him it would just be a trip there (hospital) and back. She was asked if the resident had internal or external hemorrhoids to verify, she physically assessed him, and she stated, Both. They're' pretty bad. I can understand him getting frustrated with it but there's only so much you can do for that. q. As of 12/11/19 at 2:11 p.m., there was no documentation available for review in the clinical record regarding the resident having a history of wanting to go to the hospital or of the rectal bleeding.