Every finding on record at Terrace of Hialeah, The

Based on observations, interviews and record review, the facility failed to ensure oxygen therapy was delivered as prescribed for five residents (#9, #90, #214, #240, and #258) out of 37 residents on oxygen therapy. As evidenced by oxygen observed being administered at incorrect rates via nasal cannula from concentrators. There were 235 residents residing in the facility at the time of the survey. The findings include.During observations on 12/02/25 at 10:13 AM, 12/03/25 at 08:46 AM Resident # 9 was in bed with oxygen (02) running via nasal canula (NC) at 3.5 liters per minute (lpm).On 12/04/25 at 11:57 AM Resident # 9 was in bed with oxygen running via nasal canula at 3 liters per minute (lpm).Review of the medical records for Resident #9 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident # 9 had orders that included but not limited to: 07/13/25-oxygen (O2) at three (3) Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is receiving hospice careReview of Resident # 9's Care Plan Reference Date 11/23/25 revealed: Resident has potential for ineffective breathing pattern related to: Shortness of Breath, COVID+(resolved), (COPD), depends on continuous oxygen. Resident will have normal breathing pattern as evidenced by good skin color, and regular respiratory rate/pattern by next review date. Interventions include- Administer oxygen as ordered .During observation on 12/02/2025 at 9:35 AM Resident # 90 in bed, 02 running at 3 lpm via NCOn 12/03/2025 at 9:04 AM Resident # 90 observed in bed asleep 02 running at 2 lpm, no distress noted.On 12/04/2025 at 11:46 AM Resident # 90 observed in bed asleep 02 running at 2lpm via NC. Review of the medical records for Resident # 90 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD). Respiratory disorders in diseases classified elsewhere, Acute and Chronic Respiratory failure with hypoxia, severe persistent Asthma with (acute) exacerbation.Review of the Physician's Orders Sheet for December 2025 revealed Resident # 90 had orders that included but not limited to: oxygen (O2) at two Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 90's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is receiving oxygen therapy.Review of Resident # 90's Care Plan Reference Date 10/14/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing r/t asthma, COPD, episodes of shortness of breath, pneumonia, Acute and chronic respiratory failure with Hypoxia. On oxygen continuously. The resident will maintain normal breathing pattern as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include- Administer oxygen as ordered. During observation on 12/02/2025 at 10:16 AM Resident # 214 in bed oxygen (02) running at 2.5 lpm via NCOn 12/03/2025 at 8:48 AM Registered Nurse (Staff B) revealed Resident #214 went to the hospital last night for diagnosis of Pneumonia after review of lab results by the physician.Review of the medical records for Resident #214 revealed the resident was admitted to the facility on [DATE] and readmitted [DATE]. Clinical diagnoses included but not limited to: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Morbid (severe) obesity with alveolar hypoventilation. Chronic Obstructive Pulmonary Disease, unspecifiedReview of the Physician's Orders Sheet for December 2025 revealed Resident #214 had orders that included but not limited to: oxygen (O2) at three Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 214's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score (BIMS) 3, indicating the resident is cognitively impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented Shortness of breath or trouble breathing when lying flat. Section O for Special Treatments documented the resident is on oxygen therapy.Review of Resident # 214's Care Plan Reference Date 11/03/25 revealed: Resident have potential for alteration in respiratory functioning related to Chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, continuous 02, history of respiratory failure. Resident will be free from respiratory distress through next review date. Interventions include-Administer oxygen as ordered, During Observation on 12/02/2025 at 9:38 AM Resident #240 in bed asleep 02 running at 3 lpm via NC.During observation on 12/03/2025 at 9:03 AM Resident #240 was out of the facility for dialysis, and at 10:46 AM the resident was back from dialysis and in bed asleep with 02 at running at 2 lpm via NC.On 12/04/2025 at 11:45 AM Resident#240 in bed asleep, 02 running at 2 lpm via NC.Review of the medical records for Resident #240 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Other Sequelae of Cerebral Infarction.Review of the Physician's Orders Sheet for December 2025 revealed Resident #240 had orders that included but not limited to: oxygen (O2) at two Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 240's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental status score (BIMS) 10, indicating the resident is cognitively moderately impaired. Section GG for Functional Abilities documented dependent for care. Section J for Health Conditions documented no shortness of breath. Section O for Special Treatments documented the resident is receiving oxygen therapy and Dialysis.Review of Resident #240's Care Plan Reference Date 11/06/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing related to Congestive Heart Failure, episodes of shortness of breath. 02 continuous. The resident will maintain normal breathing patterns as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include- Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/as needed Encourage adequate rest periods in between tasks/activities.During observation on 12/02/2025 at 9:55 AM Resident #258 in bed asleep, 02 running at 2.5 lpm via NC.On 12/03/2025 at 8:58 AM Resident # 258 in bed, receiving care 02 running at 2 lpm via NC.On 12/04/2025 at 11:51 AM Resident # 258 moved to another room, 02 running at 2lpm via NC.Review of the medical records for Resident # 258 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident #258 had orders that included but not limited to: oxygen (O2) at two (2) Liters per minute (lpm) via nasal canula (NC) continuously every shift.Record review of Resident # 258's admission Minimum Data Set (MDS) dated [DATE] revealed: MDS in progress.Review of Resident # 258's Care Plan Reference Date 12/01/25 revealed: Resident is at risk for altered respiratory status/difficulty breathing related to Anxiety, COPD, episodes of shortness of breath, pneumonia. The resident will maintain normal breathing patterns as evidenced by normal respirations, normal skin color, and regular respiratory rate/pattern through the review date. Interventions include- Administer medication/inhalers/nebulizers as ordered. Administer oxygen as ordered. Monitor 02 saturations as ordered/as needed. Encourage and assist resident to elevate head of bed to facilitate breathing as toleratedInterview on 12/05/2025 at 12:52 PM Registered Nurse (RN), (Staff C) 7:00 AM to n3:00 PM shift, [NAME] House Unit stated: At the beginning of my shift, I make my rounds for all my assigned residents, for my residents on oxygen therapy, I check the orders in the system and make sure they match the rate on the concentrator, ensure the head of the bed is elevated, check their oxygen saturation and take vital signs. After my initial rounds at the beginning of my shift. I check on all my assigned residents at least every two hours and as needed.Interview on 12/05/2025 at 01:00 PM, Staff D, RN 7:00 AM to 3:00 PM shift, [NAME] House Unit stated: I have on my assignment right now five (5) residents with continuous oxygen, I know what their orders are, I am the regular nurse on the unit. for those residents when I start my shift, I check the concentrators to make sure they are running at the correct rate, ensure the head of the bed is elevated, check the oxygen saturation and take vital signs. After my initial rounds at the beginning of my shift. I check on all my assigned residents at least every two hours and as needed. I know that sometimes other staff that go into the residents' room may bump or hit the concentrators by accident and may cause the flow rate to go up or down, I am also aware that it is my responsibility as the assigned nurse to make sure the residents' oxygen is running at the correct rate at all times, that is why I make sure to check on the residents on oxygen therapy at least every two hours.Review of the facility policy and procedure Titled Oxygen Concentrator revision date 05/04/23 states: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Staff responsible for the use and care of oxygen concentrators receive training on oxygen safety and the functionality of the device.Oxygen is administered under orders of the attending physician, except in the case of an emergency.

Based on observation, interviews, and record review, the facility failed to develop and implement an effective Quality Assurance and Performance Improvement (QAPI) program. As evidenced by repeat citations related to F0584 - Housekeeping and Maintenance, F0645 - Pre-admission Screening and Resident Review (PASARR, F0695 - Respiratory Care and F0867- QAPI/Quality Assessment and Assurance (QAA) Improvement Activities). There were 235 residents residing in the facility at the time of the survey. The findings include. Review of the facility's survey history revealed during the recertification survey with an exit date of 06/26/2024, the facility was cited: F0584: Safe/Clean/Comfortable/Homelike Environment; F0645-PASARR (Preadmission Screening and Resident Review), for incomplete PASARR documentation, and F0695-Respiratory/Tracheostomy Care and Suctioning for failure to ensure prescribed respiratory care and F0867- QAPI/Quality Assessment and Assurance (QAA) Improvement Activities).During the current survey with an exit date of 12/05/2025, the surveyors identified repeated deficient practices for: F0584: Safe/Clean/Comfortable/Homelike Environment; F0645- PASARR (Preadmission Screening and Resident Review), and F0695: Respiratory/Tracheostomy Care and Suctioning. Interview with the Administrator on 12/05/2025 at 7:18 PM, revealed the QAA committee meets on the first Friday of each month and the last meeting was held on November 7, 2025 the committee includes the Medical Director, Administrator, Director of Nursing, Assistant Director of Nursing, Admissions, Social Services, MDS, Activities, Dietary, Wound Care, Restorative Nurse, Infection Preventionist, Therapy, Central Supply, Housekeeping, Maintenance, Committee Physician, and Pharmacy. the QAA committee is meant to improve the quality of care and services by reviewing practices, identifying problems or opportunities for improvement, and putting corrective actions in place. It's a team effort, and everyone's input is used to find solutions and make improvements. When asked how the committee knows when an issue comes up, staff said concerns are raised during daily morning meetings, through audits, or staff reporting processes and issues are reviewed by department heads during rounds, prioritized based on risk and resident impact, and addressed immediately if they are high risk. The QAA committee revisits interventions to make sure they are working, provides re-education if needed, and incorporates staff feedback to ensure corrective actions stay effective with setting a timeframe, usually about three months, and then review progress. Monitoring is ongoing through rounds, audits, teachable moments, monthly town halls, and safety committee activities. The committee tracks improvement using audits, observations, and comparing reports to previous data to make sure interventions are working. Review of the policy titled Quality Assurance and Performance Improvement (QAPI) and dated 11/28/2012 revealed that nursing home QAPI is the coordinated application of two mutually reinforcing aspects of a quality management system: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving residents and families, and all nursing home caregivers in practical and creative problem solving. Quality Assurance (QA): QA is the specification of standards for quality of care, service and outcomes, and systems throughout the facility for assuring that care is maintained at acceptable levels in relation to those standards

Based on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to ensure a sanitary, clean and homelike environment as evidenced by soiled stains on toilet seats in residents' bathroom, trash on floor in residents' bathroom, dirty hallway walls, and ripped bedside chair cushions in a resident's' room. There were 235 residents residing in the facility at the time of the survey. The findings include.Observation on 12/02/25 starting at 09:48 AM during the initial resident and room screenings on the facility's [NAME] Unit revealed:Rooms 124 red and green colored stains on toilet seat in resident's bathroom.Rooms 122, 126-soiled trash on floor in resident's bathroom.room [ROOM NUMBER]-Ripped bedside chair cushion.Rooms 101-116 hallway walls with scruff marks, black spots, stains, scrapes, dents and dings on the walls.Interview on 12/05/2025 at 5:43 AM, the Director of Housekeeping revealed reported there are seven housekeeping staff that work 5:00 AM to 1:30 PM daily on the floor. Additionally, there is one person in the mornings and one person in the afternoon that work 1:00 PM to 9:30 PM whose job it is to remove the garbage from the soiled utility rooms in the facility. The morning housekeeping staff are responsible for cleaning the entire residents' rooms, bathrooms and hallways. After the surveyor showed the pictures of the dirty walls in the hallways on [NAME] unit, residents' bathrooms and the ripped chair, the Director of Housekeeping stated: We were in the process of waxing the walls when the survey began and we stopped for now, we will continue waxing and cleaning the walls starting next week Monday. After the residents' rooms are initially cleaned by housekeeping in the morning, the Certified Nursing Assistant (CNAs) are responsible for maintaining the cleanliness of the room.Interview on 12/05/2025 at 8:56 AM, the Director of Maintenance revealed the administrator is aware of the chairs in the facility that are old and in disrepair and have been replacing them.Interview on 12/05/2025 at 8:58 AM, the Administrator stated: We have been replacing the old chairs a few at a time, we are going to be starting construction in the facility in a few months and eventually all the old chairs will be replaced.Review of the facility policy and procedures titled Infection Control-environmental Services revision date 03/01/2007 states: The purpose is to control the spread of infection within the facility by maintaining a thoroughly clean and safe environment.

Based on observations, record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for one (Resident #9) out of 6 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS for Special Treatments, Procedures, and Programs related to Oxygen therapy for Resident #9. There were 235 residents residing in the facility at the time of this survey. The findings include. During several observations on 12/02/25, 12/03/25, 12/04/25 and 12/05/25 Resident#9 was in bed with oxygen running via nasal canula.Review of the medical records for Resident #9 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included but not limited to: Chronic Obstructive Pulmonary Disease (COPD)Review of the Physician's Orders Sheet for December 2025 revealed Resident #9 had orders that included but not limited to: 07/13/25-oxygen (O2) at three Liters per minute (LPM) via nasal canula (NC) continuously every shift.Record review of Resident # 9's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) unable to be determined. Section O for Special Treatments documented the resident is receiving hospice care. Oxygen therapy is not coded.Review of Resident #9's Care Plan Reference Date 11/23/25 revealed: Resident has potential for ineffective breathing pattern related to: Shortness of Breath, COVID+(resolved), (COPD), depends on continuous oxygen. Interventions include- Change Oxygen Tubing and Humidifier every night shift on Sunday. Administer oxygen as ordered.Interview on 12/05/2025 at 7:26 AM Minimum Date Set Coordinator (Staff A) stated: For assessments of the residents, we go to see the residents physically, read the residents' doctor orders, nurses' notes and medical documents of the residents to complete the assessment. The resident was not coded for oxygen therapy on the quarterly assessment dated [DATE]. The resident has an order in the system for continuous oxygen; a mistake was made in not coding the oxygen therapy in section O for Special treatments on the most recent quarterly assessment.Review of the facility policy and procedure titled MDS Assessment completion and Accuracy dated 09/2022 states: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services. This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacities and assist staff to identify health problems for care plan development.

Based on observation, interviews, and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) for one (Resident # 16) out of two sampled residents, as evidenced by not including Serious Mental Illness (SMI) diagnosis on the resident's PASARR form. There were 235 residents residing in the facility at the time of the survey. The findings include.Record review of a policy titled Preadmission Screening and Resident Review (PASARR) revealed it is the policy of the facility to ensure that all residents receive a PASARR in accordance with State and Federal requirements and that the PASARR is updated whenever mental health diagnoses or conditions change. Observations on 12/02/25 at 10:43 AM Resident #16 was awake in low bed, on 12/03/25 at 11:58 AM and on 12/04/25 at 12:26 PM Resident #16 was observed in room being fed by staff no concerns noted.Resident #16 was initially admitted on [DATE] and re-entered the facility on 12/11/24 with medical diagnoses that included Parkinson's Disease without Dyskinesia, Mood Disorder due to a Known Physiological Condition (Unspecified), Bipolar Disorder, Generalized Anxiety Disorder, and Major Depressive Disorder, Single Episode, Unspecified.Record review of a Significant Change - No PPS MDS dated [DATE] revealed Section A had no mention of the PASARR. Section C documented a BIMS score of 6, indicating moderate to severe cognitive impairment. Section I showed the resident had diagnoses of Anxiety, Depression, and bipolar disorder. Section N showed the resident did not receive any antipsychotic medications but did receive antidepressant and anti-anxiety medications. Record review of the care plan, with a review start date of 12/10/25 and target completion date of 03/08/26 included a focus on the use of anti-anxiety medication for an anxiety disorder, use of antidepressant medication for depression and insomnia, with goals for the resident to remain free from adverse reactions related to therapy. Interventions included monitoring and documenting reactions such as drowsiness, confusion, impaired judgment .hostility or hallucinations .prevention of over-sedation . or suicidal thoughts and obtaining psychological services when needed.Record review of a physician's orders dated 08/21/25 showed an active order for Clonazepam 1 milligram (mg) tablet, to be given twice daily for anxiety. Record review revealed the admission PASARR provided by the hospital and the PASARR completed by the facility did not document the resident's mental health diagnoses of depression, anxiety, and bipolar disorder after these diagnoses became effective and began receiving treatment for these mental health conditions.During an interview on 12/02/25 at 6:53 PM the Social Services Director stated: Upon review of the admission PASARR completed at the facility and the PASARR provided by the hospital at the time of admission, findings were compared and verified. Neither PASARR contained the diagnoses listed in the medical record. The diagnoses of depression and anxiety were identified after admission and therefore were not reflected on the admission PASARR. The resident was later diagnosed with bipolar disorder. Social Services acknowledges that the PASARR should have been updated when these diagnoses became effective.

Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in problem areas related to repeated deficient practices for F645 PASRR Screening for Mental Diagnosis (MD) and Intellectual Disability (ID), F755 Pharmacy Services and Procedures and F689 Free of Accidents and Hazards. The facility was cited for F645, F689 and F755 in 2023. These repeated deficient practices have the potential to affect any of the 231 residents residing in the facility at the time of the survey. The findings included: Record review of the facility policy and procedure title Quality Assurance Performance Improvement (QAPI) Program, implemented November 2012, revised November 2023 indicate: The purpose of the QAPI program is to ensure the organization has an organized quality assessment and improvement process program that includes performance measurement, performance assessment and performance improvement and addresses the care and unique services provided by the facility. Guidelines and Standards In accordance with the direction of the board of directors, the Quality assurance Committee will establish a planned, systemic organization wide approach to design processes, measurements, assessments, and improve, organization performance and assure that: Activities are collaborative and the interdisciplinary team, including input from direct care staff, other staff, residents and residents' representatives. Data is systematically collected. Appropriate statistical technique is maintained. Data about its processes or outcomes is maintained. Staff are provided with education concerning the approaches and methods of quality improvement, and are trained in reporting, assessing and improving processes that contribute to improving resident outcomes. Expectations for the committee I terms of functions, reporting methods and appropriateness of systems used to facilitate the collection, management, and analysis of date needed for quality improvement are established. Specific quality assurance measures will be identified to be measured on a continuing basis Committee procedures include analyzing and evaluating the effectiveness of the committee's contribution to improving quality Committee ensures collected of data on important process or outcomes related to resident care and organization functions. Adequate resources for assessing and improving the organization's governance, managerial, clinical and support processes are allocated. This includes assignment of personnel and adequate time to participate. In addition, information system and data management processes are provided to support ongoing performance improvement activities. Review of the Quality Assurance and Performance Improvement (QAPI) Committee Meeting Sign-in Sheets dated 03/29/24, 04/29/24, and 05/29/24 documented the facility had a QAA Committee meeting monthly. Attendees included: Administrator, Medical Director, Director of Nursing (DON), Assistant Director of Nursing (ADON), Infection Control Preventionist/Risk Manager, Dietary Manager, Clinical Dietician, Director of Housekeeping, Director of Maintenance, Director of therapy, Director of Human resources, Director of admissions, director of Business office, Director of Social Services, Director of Activities, MDS (Minimum Data Set) Coordinator, and Consultant Pharmacist. During an interview with the Director of Nursing/Quality Assurance (QA), Administrator/QA on 06/27/2024 at 3:24 PM. The Don revealed: The QAA Committee meets every month on the last Friday of the month. The committee consists of the Medical Director, Administrator, DON, Assistant Director of Nursing (ADON) and all interdisciplinary team members. The focus of QA committee is to identify problem issues in the facility, track and trend and identify any opportunities for correction in the systems, implement interventions to correct the issue and monitor the effectiveness of the interventions though audits, staff feedback, town hall meetings with staff, education and training and observations on return demonstrations of trainings.

Based on observation, record review and interview, the facility failed to ensure one (Resident #435) out of 35 sampled residents was free from the use of physical restraints. As evidenced by during an observation the resident's bed was positioned with the foot of the bed elevated and the head of the bed flat, the overbed table was positioned by the side of the bed in the middle, preventing the resident from getting out of the bed without assistance. There were 231 residents residing in the facility at the time of the survey. The findings included: During observation on 06/23/24 at 06:18 AM, Resident #435 was in bed asleep, the bed was in the lowest position, the foot of the bed was elevated, and the head of the bed flat, the overbed table was positioned by the side of the bed in the middle (photo available). Observation on 06/24/24 at 07:45 AM the resident was in bed asleep, the bed was in the lowest position, in flat position from head to toe and the overbed table at the side of bed. On 06/25/24 at 11:30 AM the resident was in bed asleep, the bed was flat and in the lowest position from head to toe with the overbed table at the side of bed, Review of the medical records for Resident #435 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Depression. Review of the Physician's Orders Sheet for June 2024 revealed Resident #435 had orders that included but not limited to: Turn and reposition every 2 hours as needed. Mirtazapine tablet 30 mg (milligrams) give 1 tablet by mouth at bedtime related to depression. Trazodone oral tablet 50 mg -give 1 tablet by mouth two times a day related to depression and Behavior Monitoring for use of Trazodone due to Depression. Record review of Resident #435 's Admission Minimum Data Set (MDS) dated [DATE]; Section C for Cognitive Patterns documented Brief Interview for Mental Status (BIMS) score of 8 on a 0-15 scale, indicating the resident is moderately cognitively impaired. Section GG for Functional Status documented resident is dependent for care. Section E for Mood and behavior documented no behaviors exhibited. Section J for Health Conditions documented no falls since admission, no scheduled or as needed medication administered in the last 5 days and Section P for Alarms and restraints documented no physical restraints or alarms used. Record review of Resident #435 's Care Plans Reference Date 06/07/24 revealed the resident uses antidepressant medication related to depression. Interventions include- Administer antidepressant medications as ordered by physician. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of medications as indicated. Monitor/document/report as needed adverse reactions to antidepressant therapy; change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts . During an interview on 06/25/24 at 08:09 AM, the Director of Nursing (DON) after seeing the photo of the resident's bed positioning stated: We will do a one-to-one teaching with the whole staff about restraints, educate all the staff about restraints, evaluate the residents for behaviors and investigate the resident's assigned staff on the day of the surveyor's observation to see the reason for the bed being positioned the way it was. Restraints is anything that does not allow the residents to independently move by themselves. On 06/26/24 at 12:59 PM an attempt using the number provided to conduct a telephone interview with the 11:00 PM to 7:00 AM Registered Nurse (Staff E), that was assigned to Resident #435 on 6/23/24 was unsuccessful. A message was left with the assistance of another surveyor on the team to translate from Spanish to English with the surveyor's name and phone number along with the survey information. On 06/26/24 at 01:22 PM. Certified Nursing Assistant (Staff D) from the 11:00 PM to 7:00 AM shift, assigned to Resident #435 on 6/23/24, attempted twice to contact Staff D via telephone with number provided by the facility with another surveyor on the team to help with translation from Spanish to English; a message was left with surveyor name and phone number and the survey information. Review of the facility policy and procedure titled Restraints revision date 10/06/24 states: The purpose is to ensure each resident is to attain and maintain his/her highest practicable wellbeing in an environment that prohibits the use of restraints for discipline or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints. To ensure residents are provided a safe environment and the use of restraints is carefully monitored to protect resident rights, personal comfort and safety, assuring the least restrictive means are used.

Based on observation, record review and interview, the facility failed to provide a clean and sanitary environment for residents as evidenced by during several observations, garbage was observed on the floor in several residents' rooms, bed linen was observed on resident's bed with multiple holes, hole in wall in resident's room, and dirty walls in resident's room. There were 231 residents residing in the facility at the time of the survey. The findings Included: During observation on 06/23/24 at 06:18 AM rooms [ROOM NUMBERS] were observed with garbage on the floor. On 06/23/24 at 06:35 AM room [ROOM NUMBER] was observed with garbage on the floor, on 06/23/24 at 06:39 AM room [ROOM NUMBER] was observed with garbage/papers on floor, on 06/24/24 at 07:41 AM room [ROOM NUMBER] bed A was observed with several holes on the bed linen. On 6/24/24 at 11:00 AM room [ROOM NUMBER] was observed with a huge hole in the wall close to the electrical outlet and several brown colored stains on the wall (Photos available). Interview on 06/25/24 at 08:24 AM. The Director of Nursing (DON) and Corporate Nurse were shown the photos of environmental concerns, the DON stated the hole in the wall in room [ROOM NUMBER] was fixed yesterday and the wall cleaned, and they will be addressing the housekeeping issues observed with the housekeeping staff. Regarding the torn bed linen observed by the surveyor, they will do an audit, and any linen that is not up to facility standards will be discarded immediately and replaced. Interview on 06/25/24 at 10:58 AM. The Director of Maintenance stated: I have been working here for one month, I noticed the hole in the wall in room [ROOM NUMBER] a few days ago, to fix the whole we put compound in the wall, cut the whole out, let it dry, sand and painted the area. This was completed on 6/24/24. There is a maintenance book in each nursing station, where staff write down any maintenance issues to be addressed. Maintenance staff check all the books for maintenance issues daily in the morning, once the issue is fixed, I personally do an inspection of the area and then the staff that fixes the issue signs off on the issue as completed with the date, time and signature. Interview on 06/25/24 at 11:04 AM. The Director of Housekeeping stated: I have been working at this facility for 8 years. My housekeeping staff schedule is-day shift 6:30 AM to 2:53 PM, seven (7) housekeepers, 5-1:30PM, three (3) persons for garbage removal, 1-9:30PM, one (1) person for disinfection, spills, cleanup, and garbage removal. The morning housekeeping staff- in the mornings when they come in, they start cleaning the offices and common areas and then move on to the resident's, they try not to be in the residents' room too early in the morning cleaning. Review of the facility's policies and procedures titled Physical Environment revision date 1/04/24 states: Floors shall be maintained in a clean, safe, and sanitary manner. Procedures: 1. All floors shall be mopped/cleaned/vacuumed daily in accordance with our established procedures.

Based on observation, interview and record review facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I PASRR was not completed for four (Resident # 60, Resident # 3, Resident #112 and Resident #127) out of four residents investigated. This deficiency had the potential to affect 231 residents residing in the facility at the time of the survey. The findings included: Resident # 60 During multiple observations starting on 06/23/24 to 06/26/24, Resident # 60 was in the room in bed and no distress noted. The resident never responded to questions asked. Record review of the clinical records for Resident # 60 revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Clinical diagnoses included, but not limited to, Other Secondary Parkinsonism; Anxiety Disorder, Unspecified; Unspecified Psychosis; Adult Failure to Thrive. Record review of the Admission Minimum Data Set (MDS) Section A Identification dated 05/12/24 revealed the section 1500 Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? NO. Record review of PASRR Level I dated 05/12/24 revealed no identification of serious mental diagnosis illness under 1A. Section 1B was not checked for Serious Mental Illness (SMI). Section 2,3 (A/B) and 4 (A/B) were checked No. Section II Part A & B were checked No. Section IV, V and VI were not completed. Record review of Admission MDS Section C Cognitive Patterns dated 05/12/24 revealed the resident Brief Intervention for Mental Status (BIMS) summary score was 03 out of 15. Review of Admission MDS Section I Active Diagnosis the resident's diagnosis were Anxiety and Psychotic Disorder. Review of Annual MDS section N Medications revealed the resident was receiving antipsychotic and antianxiety medication. Review of Psychiatrist Consultation dated 06/24/24. Psychosocial history: Dementia, resident had a lifelong of mental illness characterized as delusion, depression, anxiety mood change. Diagnosis: Bipolar Disorder, Anxiety, Psychosis. continue with the same medications. Interview with Staff F Registered Nurse (RN) on 06/26/24 at 11:43 AM. He revealed Resident # 60 gets agitated if not medicated early so he prioritized her medication due to anxiety and agitations. The resident gets agitated and does not cooperate with the nursing staffing and after medication she gets better. Interview with Social Services Director on 06/26/24 10:47 AM. revealed she has been working in the facility for one month. The protocol for Level I PASRR was as follows: Level I PASRR from the hospital goes to Admissions Department to accept or not to accept the resident. For Resident # 60 the Level I PASRR was not completed, and she did not realize that the form was incomplete. 45019 Resident #3 Observations on 06/23/24 at 06:25 AM, Resident #3 was in bed asleep. On 06/24/24 at 07:50 AM Resident #3 was in bed asleep. On 06/25/24 at 11:27 AM Resident #3 was in bed awake, no distress noted. Record Review of Resident #3's Level I PASRR (Preadmission Screening and Resident Review) documented Section I: PASRR Screen Decision Making: A: Mental Illness (MI) or suspected MI (check all that apply) - no diagnosis checked off. Findings based on documented history were-Section II Other indicators for PASRR screening Decision-Making: All checked-no. Does individual have validating documentation to support dementia or related Neurocognitive disorder - no. Section III Not a provisional admission. Section IV. No diagnosis or suspicion of Serious Mental Illness (SMI) or Intellectual Disability (ID) indicated. Level II PASRR evaluation not required. PASRR Level I completed by a Registered Nurse at the hospital on 08/10/2023. Record Review of Resident #3's most recent Psychological Consultation dated 3/8/24 documented: patient noted with advanced dementia, alert and oriented times one, depression, delusions, insomnia, responding to medications. Review of the medical records for Resident #3 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but were not limited to: 8/10/23-unspecified psychosis not due to a substance or known physiological condition. 8/10/23-depression. 8/10/23-dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety Review of the Physician's Orders Sheet for June 2024 revealed, Resident #3 had orders that included but not limited to: Seroquel oral tablet 25 mg (Quetiapine Fumarate)-give 12.5 mg by mouth in the evening related to unspecified psychosis not due to a substance or known physiological condition. Trazodone tablet 50 mg-give 25 mg by mouth at bedtime related to depression, unspecified - administer at bedtime. Temazepam capsule 15 mg-give 1 capsule by mouth at bedtime related to insomnia. Record review of Resident # 3's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section A 1500 resident is currently considered by the state level II PASRR process to have a SMI or ID or a related condition-Not available. Section C for Cognitive Patterns documented Brief interview for mental status score (BIMS), 3 on a 0-15 scale indicating the resident is cognitively impaired. Section I for Active diagnosis documented Psychotic disorder and Depression Disorder. Section N for Medications documented resident is taking antipsychotic, antidepressant, hypnotic, diuretic and antiplatelets medications. Section O for Special Treatments documented resident is on hospice care. Record review of Resident #3 's Care Plans Reference Date 05/14/24 revealed: resident is at risk for adverse reactions related to the use psychotropic meds On Anti-anxiety medication (DC), Antidepressant Medication, On Anti-Psychotic Medication, On Sedative-Hypnotic Medication. Interventions include-Will remain free of signs and symptoms of over sedation and side effects related to psychotropic medication. Involve the family and resident with the care planning process and psychotropic reduction program. Monitor behavior for effectiveness of medications. Monitor for signs and symptoms of over-sedation and/or changes in condition. Obtain laboratory tests and/or vital signs as ordered. 48906 Resident #112 Record review of Resident #112's Preadmission Screening and Resident Review (PASRR) dated 5/7/24 Section I: PASRR Screen Decision-Making: Depressive Disorder was checked, Section IV: PASRR Screen Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, signed on 5/7/24 by social worker of nearby hospital. Record review of demographic sheet for Resident#112 revealed an admitted [DATE] with diagnosis that included Anxiety Disorder and Depressive disorders. Record review of Admission Minimum Data Set (MDS) dated [DATE] for Resident #112, Section A for Identification revealed Preadmission Screening and Resident Review (PASRR) was completed and the resident was not currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Section I for Active diagnosis revealed a diagnosis of Depression. Section N revealed resident was taking an antidepressant and antipsychotics were received on a routine basis since admission, a gradual dose reduction (GDR) has been attempted, last attempt on 5/16/24, and the physician did not document GDR as clinically contraindicated. Section O for special treatments revealed no psychological therapy in last seven days. Record review of Care Plan date initiated on 5/10/24 and start date 5/16/24 revealed Resident #112 was at risk for adverse reactions related to the use psychotropic meds, on Anti-Depressant Medication, On Anti-Psychotic Medication. Interventions included monitoring behavior for effectiveness of medications and signs and symptoms of over-sedation and or changes in condition. Record review of physician orders revealed orders dated 5/16/24 for Amitriptyline HCl Tablet 100 mg give 1 tablet by mouth at bedtime for depression and 5/10/24 for psychiatry consult as needed, 6/4/24 to monitor for s/s of depression Resident is taking antidepressant medication, 6/17/24 for Ativan oral Tablet 0.5 MG (Lorazepam) *Controlled Drug* Give 0.5 mg by mouth every six hours as needed for anxiety disorder related to anxiety, 6/19/24 for Behavior monitoring for use of Ativan due to: Anxiety, evidenced by periods of calling out, and 6/24/24 for Clonazepam Oral Tablet 0.5 milligrams (MG) *Controlled Drug* Give 0.25 mg by mouth two times a day related to anxiety disorder. Record review of a Psychiatric Consult dated 5/16/24 revealed diagnosis of Depression and Anxiety. Record review of Preadmission Screening and Resident Review (PASRR) dated 5/30/24 revealed Section I: PASRR Screen Decision-Making: Anxiety and Depressive disorder checked, Schizoaffective disorder and Bipolar are not checked Section IV: PASRR Screen Completion: No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required, signed on 5/30/24 by DON. Resident #127 Record review of demographic sheet for Resident#127 revealed an admitted [DATE] and readmission of 3/17/24 and diagnosis that included anxiety disorder and bipolar disorder. Record review of Discharge Return Anticipated Minimum Data Set (MDS) dated [DATE]-Discharge Return Anticipated, Section I for Active diagnosis revealed diagnosis of anxiety disorder and bipolar disorder. Section N for medications revealed Resident #127 was taking Antianxiety medication in the last 7 days and Section O for special treatment revealed no therapies coded. Record review of Care Plan date initiated 2/2/22 and start date 4/3/24 revealed Resident #127 was at risk for adverse reactions related to the use psychotropic meds on Anti-Anxiety Medication and on Anti-Psychotic medication with interventions that included monitor behavior for effectiveness of medications, monitor for signs and symptoms of over-sedation and or changes in condition. Record review of Psychiatric Note dated 5/23/24 revealed Resident #127 had diagnosis of Schizoaffective disorder, bipolar type and Anxiety. Record review of physician orders revealed orders dated 6/6/24 for Clonazepam Oral Tablet 1 mg *Controlled Drug* Give one by mouth two times a day related to anxiety disorder. On 06/25/24 at 11:50 AM the Social Services Director stated: I started working in this facility 4 weeks ago and I am going thru all the PASRRs to make sure they are correct. There are a lot of outdated PASRRs that I am correcting. I don't have a physical audit form regarding correcting the PASRRs. The nurses are to inform me during the morning meeting whenever a new qualifying diagnosis is obtained for the resident the I complete a PASRR for that resident on 5/23/24. Record review of Policies and Procedures for Preadmission Screening and Annual Resident Review (PASARR) Effective date 11/28/2012 last review 10/17/2023. Guidelines: It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (Level I) for all new and readmission per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen, the facility will not admit and individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and the facility's ability to provide the specialized services determined in the Level II screen. If a provisional admission to the facility is approved via the Level II screen process, the facility will coordinate with the State PASRR representative related to the individual needs of the resident as indicated. Annually and with any significant change of status, the facility will complete the PASRR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly. Objective PASRR Policy. The objective of the PASRR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated annually and upon any significant change for those individuals identified. Procedure: 1-Admissions and Readmissions: a) The facility will participate in or complete the Level I screen for all potential admissions regardless of payer source to determine if the individual meets the criterion for mental disorder (SMI/SMD) intellectual disability (ID) or related condition.

Based on observations, interviews and record review facility failed to provide a safe environment for one resident (Resident #188) out of ten residents sampled as evidenced by a bundle of shaving razors observed in the drawer next to the resident's bed. There were 231 residents residing in the facility at the time of survey. The findings included: On 06/23/24 at 11:27 AM Resident#188 was observed laying in bed with eyes closed, a bundle of shaving razors was observed in the drawer next to bed. (photo evidence) On 06/23/24 at 11:27 AM Staff G, Registered Nurse (RN) was notified by surveyor and entered room with surveyor. Staff G, RN retrieved the bundle of razors and stated; these razors should not be in here for safety reasons because [Resident #188] can reach into drawer. I think a staff member left the razors in drawer. Record review of demographic sheet for Resident #188 revealed an admitted [DATE] with diagnosis that included Alzheimer's disease with late onset. Record review of Annual Minimum Data Set (MDS) dated [DATE], Section C for cognitive patterns revealed a Brief Interview for Mental Status (BIMS) score of 3 out of a scale of 0-15 indicated severe cognitive impairment. Section E for behavior revealed no Potential Indicators of Psychosis. Section GG for functional status revealed R#188 was dependent for Activities of Daily Living (ADL). Record review of Care Plan date initiated 3/27/23 and start date 3/31/24 revealed Resident #188 was at risk for falls related to unawareness of safety needs with interventions that included: maintain an environment free of clutter. On 06/23/24 at 1:28 PM Staff L, Certified Nursing (CNA) (translated by the DON) stated: I have been employed for seven years in this facility; when I start my shift, I check all the residents, tell them what I am going to do and I check all their personal belongings to make sure there are no objects that can be used to harm themselves or others like knife or forks. Razors cannot be kept in resident's rooms, once used the razors need to be placed in the sharps container. On 06/26/24 at 10:03 AM, the DON stated: Residents are not allowed to keep razors in their rooms. staff check residents' drawers every day to ensure that there are no objects that harm anyone. Record review of policy for Hazardous Areas, Devices, and Equipment. Revised July 2017. Policy Statement: All hazardous areas, devices, and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible. Policy Interpretation and Implementation: 1. As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the Safety Committee. Identification of Hazards: 1. A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are no limited to : c. Sharp objects that are accessible to vulnerable residents.

Based on observations, record review and interviews, the facility failed to ensure oxygen therapy was being received as prescribed for one Resident (#123) out of 35 sampled residents. As evidenced by, during several observations of Resident #123 the Continuous Positive Airway Pressure (CPAP) machine was positioned on Resident #123's forehead. The findings included: During several observations on 06/23/24 starting at 06:31 AM, 07:15 AM and 08:03 AM Resident #123 was observed with the CPAP machine located on her forehead. The CPAP machine was turned on and running. 06/24/24 at 07:53 AM Resident #123 was in bed asleep, oxygen (02) was running via nasal cannula (NC) at two (2) liters per minute (LPM), the call light was on the bed. On 06/25/24 at 11:29 AM resident was in bed awake, 02 running at 2 LPM via NC, no distress noted. On 06/23/24 at 08:06 AM Registered Nurse (Staff C) assigned to the resident stated that the resident takes off her CPAP machine herself, but it is time for it to be removed for breakfast, the nurse preceded to check the resident's orders and then removed the CPAP machine. The surveyor asked Staff C how often she checks on the resident to see if the machine is on correctly and did she check the resident's oxygen (02) saturation level knowing that the resident takes the machine off sometimes. Staff C stated, I checked her at the beginning of my shift, and I replaced the machine on the resident, she must have taken it off again, I work here part time and I usually work in different areas every day. Review of the resident's 02 saturation levels on 6/23/24 and 6/24/24 documented an average oxygen saturation level of 96% on 2 LPM oxygen via nasal cannula. Review of the medical records for Resident # 123 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Chronic obstructive pulmonary disease with (acute) exacerbation. Acute respiratory failure with Hypercapnia and Acute respiratory failure with hypoxia. Review of the Physician's Orders Sheet for June 2024 revealed Resident #123 had orders that included but not limited to: CPAP machine at bedtime with continuous oxygen at 2 liters per minute when use. every 12 hours related to obstructive sleep apnea. Continuous oxygen at 2 liters per minute continuously two times a day related to chronic obstructive pulmonary disease, unspecified. Record review of Resident # 123's Quarterly Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status Score (BIMS) 3 on a 0-15 scale, indicating resident is cognitively impaired. Section GG for Functional Status documented resident is dependent for care. Section J for health conditions documented no shortness of breath. Section O for Special Procedures and Treatments documented the resident is receiving oxygen therapy and Non-invasive Mechanical Ventilator. Record review of Resident # 123's Care Plans Reference Date 05/12/24 revealed: The resident has a potential for alteration in respiratory functioning related to chronic Obstructive Pulmonary Disease (COPD), Obstructive Sleep Apnea, continuous oxygen (02). Interventions include- Administer oxygen as ordered, monitor oxygen saturation as ordered and as needed. Assess respiratory status, observe for shortness of breath, monitor lung sounds. Call physician for any changes in condition and as needed. change oxygen mask, tubing and humidifier as ordered, CPAP machine as ordered, provide treatments as ordered. Remind resident to deep breath and cough.; and wear ear protector for nasal cannula. On 06/25/24 at 08:05 AM, the Director of Nursing (DON), and Corporate Nurse Consultant were shown the photo of the CPAP machine positioned on the resident's forehead. Review of the facility's policy and procedure titled Oxygen Concentrator revision date 05/04/23 states: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators. Policy Explanation and Compliance Guidelines: 2. Oxygen is administered under orders of the attending physician, except in case of an emergency.

Based on observation, interview and record review the facility failed to ensure pharmaceutical procedures were followed during medication administration observation for two residents (Resident # 12 and Resident #201) out of six (6) residents sampled) as evidenced by the omission of two (2) medications for residents during medication administration observations with Registered Nurses. In addition, the facility failed to ensure the narcotic count was correct for two residents (Resident #145 and Resident #73). There were 231 residents residing at the facility at the time of the survey. The findings included: During medication administration observation on 6/23/24 at 8:21 AM with Registered Nurse (Staff A), the prescribed medication-Simethicone 125 milligram (mg) 1 capsule daily was not available on the medication cart in the capsule form as prescribed to be given to Resident #12. Staff A called central supply in the facility and the staff in central supply reported the medication was not available in capsule form, only tablets. Simethicone 125 milligram (mg) 1 capsule daily was not given during the medication administration observation with the surveyor. Review of medical records for Resident #12 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Encounter for surgical aftercare following surgery on the digestive system. Record Review of the Physician's Orders Sheet for June revealed Resident #12 had orders that included but not limited to: Simethicone Oral Capsule 125 mg (Simethicone)-Give 1 capsule by mouth every 6 hours related to encounter for surgical aftercare following surgery on the digestive system. Record review of Resident # 12's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 9 on a 0-15 scale, indicating the resident is moderately impaired cognitively During an interview Registered Nurse, Staff A, stated: I called central supply and they do not have the medication available in capsule form, I will call the resident's doctor (MD) for new orders and notify the surveyor on what the new orders will be. During medication administration observation on 6/23/24 at 9:00 AM with Registered Nurse (Staff B), the prescribed medication- Amlodipine Besylate oral tablet 10 mg- Give 10 mg orally one time a day was not given to Resident #201 during the medication administration observation. Before entering Resident #201's room to administer the medications, the surveyor asked Staff B how many pills he had in the medication cup, Staff B-stated he had five (5) medications in the medication cup, Staff B entered the resident's room, gave the medications to the resident, exited the room, and documented all the resident's medications as given in the electronic medication administration record (EMAR). The surveyor asked Staff B to check/count how many medications the resident was supposed to receive, Staff B, checked the resident's prescribed ordered medications and realized that he had not given the Amlodipine 10 mg as prescribed to Resident #201, Staff B asked the surveyor if he could give the resident the missing medication, the surveyor referred Staff B to the facility policy, Staff B stated that he is allowed to give the missing medication to the resident and proceeded to give the medication-(Amlodipine 10 mg) to, Resident #201. Review of medical records for Resident #201 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hypertensive heart disease with heart failure Review of the Physician's Orders Sheet for June revealed Resident #201 had orders that included but not limited to: Amlodipine Besylate oral tablet give 10 mg orally one time a day related to hypertensive heart disease with heart failure hold if systolic blood pressure is less than 110 mm hg (millimetre of mercury) or diastolic blood pressure less than 60 mm hg or pulse less than 60 beats per minute. Review of Resident # 201's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status (BIMS) score 13 on a 0-15 scale, indicating resident is cognitively intact. On 6/23/24 at 9:20 AM Registered Nurse, Staff B stated he is still allowed to give the resident the medication even though it was missed on the initial medication pass. On 06/25/24 at 08:20 AM, the Director of Nursing (DON) stated: I am aware of the issues identified during medication administration observation, we have already started education with the nurses, the residents' orders were reviewed, and the necessary changes were made. Review of the facility policy and procedures titled Medication Administration revision date 2/20/24 states: Medications are administered by license nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection. 48906 On 06/24/24 at 3:45 PM a controlled medication count was completed with Staff J, Registered Nurse (RN) in Nursing Unit Center Court on medication cart one, the Narcotic Drug Count Record sign in /out sheet for Unit C. Court Cart one Month/Year June 2024 no signature for 7:00 AM to 3:00 PM off going staff. (see photo evidence). Further review revealed the Medication Monitoring/ Control Record for Resident #145 Clonazepam 0.5 mg one tablet by mouth twice daily noted the last signature was Staff J, Registered Nurse (RN) on 6/23/24 at 4:18 PM, noted number of medications remained as 55. However, on the Bingo card for Resident #145 the Clonazepam 0.5 mg one tablet by mouth twice daily contained 54 tablets and the Medication Administration Record for 6/24/24 for Resident #145 revealed Clonazepam 0.5 mg was given at 9:01 AM by Staff G, RN. (see photo evidence). Further review revealed the Medication Monitoring/ Control Record for Resident #73's Tramadol 50 mg (Ultram) take 1 tablet (50 mg) by mouth twice daily for nonacute pain was last signed by Staff J, RN on 6/23/24 at 4:30 PM, bingo card contains 21 tablets, and the Medication Administration Record for June 2024 for Resident #73 Tramadol 50 mg was given at 8:32 AM by Staff G, RN. (see photo evidence). On 06/24/24 at 3:59 PM Staff J, RN stated: when I start my shift, I reconcile the controlled medications by counting with the previous nurse, then we both sign the sign in sheet to indicate the count is correct. Today I counted with the previous nurse, but that nurse did not sign out the medications he administered. Once I dispense any controlled medication pill into the medication cup I sign after resident takes it. On 06/26/24 at 10:03 AM, the DON stated, nurses should sign out the controlled medication at the time they remove the pill from the bingo card and when leaving the shift, they must count with off going and oncoming nurse to verify the correct count. On 06/26/24 at 12:49 PM Staff G, RN stated he counts controlled medications with the off going nurse and on coming nurse; and I sign in or out on the sign in to verify that we count is correct. I missed these two medications due to the paper being stuck together. I always sign once I administer any controlled medication. This was a mistake. Record review of the facility's Policy: Narcotic/ Controlled Substances- Counting. Effective Date: 11/28/12. Review/Revisions: 11/26/17, 12-/20/21, 11/6/21, 10/30/23. Purpose: 1. To count controlled substances with a partner and to verify the accuracy of the log sheets. General Guidelines: 1. Always participate in the counting of the controlled substances at the beginning and end of your shift. Never say, go ahead without me and I'll sign later. Never leave it to someone else's discretion when you are the one on duty. If you do not observe the medications that you sign as being present, you may be implicated if the medications are later missing. general Procedure for Counting Controlled Substances: 1. Follow your facilities specific guidelines and use their specific log sheet.

Based on observation, interview and record review the facility failed to ensure the medication error rate was not five (5) percent or greater. As evidenced by the omission of two (2) medications for residents during medication administration observations with Registered Nurses. There were 231 residents residing at the facility at the time of the survey. The findings included. During medication administration observation on 6/23/24 at 8:21 AM with Registered Nurse (Staff A), the prescribed medication-Simethicone 125 milligram (mg) 1 capsule daily was not available on the medication cart in the capsule form as prescribed to be given to Resident #12. Staff A called central supply in the facility and the staff in central supply reported the medication was not available in capsule form, only tablets. Simethicone 125 milligram (mg) 1 capsule daily was not given during the medication administration observation. Registered Nurse, Staff A, stated the resident's doctor (MD) will be called for new orders and notify the surveyor on what the new orders will be. Review of medical records for Resident #12 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Encounter for surgical aftercare following surgery on the digestive system. Record Review of the Physician's Orders Sheet for June revealed Resident #12 had orders that included but not limited to: Simethicone Oral Capsule 125 mg (Simethicone)-Give 1 capsule by mouth every 6 hours related to encounter for surgical aftercare following surgery on the digestive system. Record review of Resident # 12's Annual Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented a Brief Interview for Mental Status (BIMS) score of 9 on a 0-15 scale, indicating the resident is moderately impaired cognitively During medication administration observation on 6/23/24 at 9:00 AM with Registered Nurse (Staff B), the prescribed medication- Amlodipine Besylate oral tablet 10 mg- Give 10 mg orally one time a day was not given to Resident #201 during the medication administration observation. Before entering Resident #201's room to administer the medications, the surveyor asked Staff B how many pills he had in the medication cup, Staff B-stated he had five (5) medications in the medication cup, Staff B entered the resident's room, gave the medications to the resident, exited the room, and documented all the resident's medications as given in the electronic medication administration record (EMAR). The surveyor asked Staff B to check/count how many medications the resident was supposed to receive, Staff B, checked the resident's prescribed ordered medications and realized that he had not given the Amlodipine 10 mg as prescribed to Resident #201, Staff B asked the surveyor if he could give the resident the missing medication, the surveyor referred Staff B to the facility policy, Staff B stated that he is allowed to give the missing medication to the resident and proceeded to give the medication-(Amlodipine 10 mg) to, Resident #201. Review of medical records for Resident #201 revealed the resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Hypertensive heart disease with heart failure Review of the Physician's Orders Sheet for June revealed Resident #201 had orders that included but not limited to: Amlodipine Besylate oral tablet give 10 mg orally one time a day related to hypertensive heart disease with heart failure hold if systolic blood pressure is less than 110 mm hg (millimeter of mercury) or diastolic blood pressure less than 60 mm hg or pulse less than 60 beats per minute. Review of Resident # 201's Significant Change Minimum Data Set (MDS) dated [DATE] revealed: Section C for Cognitive Patterns documented Brief Interview for Mental Status (BIMS) score 13 on a 0-15 scale, indicating resident is cognitively intact. On 6/23/24 at 9:20 AM Registered Nurse, Staff B stated he is still allowed to give the resident the medication even though it was missed on the initial medication pass. On 06/25/24 at 08:20 AM, the Director of Nursing (DON) stated: I am aware of the issues identified during medication administration observation, we have already started education with the nurses, the residents' orders were reviewed, and the necessary changes were made. Review of the facility policy and procedures titled Medication Administration revision date 2/20/24 states: Medications are administered by license nurses, or other staff who are legally authorized to do so in the state, as ordered by the physician, and in accordance with professional standards of practice, in a manner to prevent contamination or infection.

Based on observations, interviews and record review facility failed to properly store medications for two residents (Resident #73, Resident #24) out of ten residents sampled as evidenced by observations of a bottle of vitamins on the side table next to Resident#73 and a nasal spray and rubbing alcohol on Resident #24's side table. There were 231 residents residing in the facility at the time of survey. The findings included: On 06/23/24 at 11:21 AM Resident #73 was observed in bed awake and alert. A bottle labeled {supplement} was observed on the resident's side table next to the bed. (photo evidence) On 06/23/24 at 11:22 AM Staff G, Registered Nurse (RN) was notified by surveyor and entered the room with the surveyor. Staff G, RN removed the bottle labeled [supplement] and explained to the resident that she is not allowed to keep any medications at bedside without first notifying the nurse. Resident #73 replied ok. On 06/23/24 at 11:22 AM Staff G, RN stated: I do rounds when I start my shift and check each resident. I did not observe this medication at the resident's bedside. I will notify the physician. On 06/23/24 at 11:17 AM Resident #24 was observed walking into room. A bottle labeled [ Brand} Nasal Decongestant was observed on overbed table and a bottle labeled [Brand} rubbing alcohol on the side table next to the bed (photo evidence). On 06/23/24 at 11:18 AM Staff H, RN was notified by surveyor and entered the room with the surveyor. Staff H, RN removed the bottle and explained to Resident #24 that medications are not allowed to be kept at bedside without first notifying the nurse. Resident #24 responded ok. On 06/23/24 at 11:20 AM Staff H, RN stated: I did not see this medication upon initial rounds, and I will notify the physician. On 06/26/24 at 10:03 AM The director of Nursing (DON) stated: Residents are not allowed to keep medications in rooms without an order from the doctor and assessed by the nursing. Record review of Policy: Medication Storage effective date: 10/1/15 Revisions: 2/5/18, 7/2/19, 5/5/22, 10-11-23. Purpose: To ensure proper storage, labeling and expiration dates of medications, biologicals, syringes and needles. Guidelines: 2. Facility should ensure that medications and biologicals are stored in an orderly manner in cabinets, drawers, carts, refrigerators/freezers of sufficient size to prevent crowding.

Based on observations, interviews, and record review the facility failed to ensure the dishwashing machine was operating properly. This has the potential to affect 218 who ate by mouth out of 237 residents who reside in the facility at the time of survey. The findings included: On 02/06/2023 at 1:09 PM during the first observation of the dishwashing in progress revealed the dishwashing machine was a [ brand] multi tank machine high temp sanitization. The three temperature gauges was noted with the following temperature readings - Wash was noted at 155 degrees Fahrenheit (F) instead of 150 F. Rinse was noted at 170 F (supposed to be 165 F) The final rinse was noted at 110 F (supposed to be 180 F). (Photographic evidence) On 02/06/2023 at 11:40 AM, the Dietary Manager stated that for a few months they were already providing the residents with disposables cups for cold and hot drinks. The Dietary Manager explain this was done because when the dish machine runs for extensive periods of time the power goes off, thus the reason the facility decides to wash only the plates, silver wear, and bowls for the soup and the facility was using disposable cups and glasses. They are working on the electrical systems. As soon as they fix it, we will start using the regular cups and glasses. On 02/06/2023 at 01:15 PM, the Dietary Manager stated, when the problem started the Administrator has been in charge of getting electricians to come and check, but up to now they had not fixed it. On 02/06/2023 at 01:18 PM, the Administrator stated, that the dish machine has been giving some problems a few days ago but the Director of Maintenance, would have more information about that. On 02/07/2023 at 09:35 AM during the second observation the Dishwashing was in progress. It was noted that the [ brand] multi tank machine high temp sanitization dishwashing machine temperature gauge for the wash temperature was 160 F (supposed to be 150 F), gauge for rinse was noted at 175 F (supposed to be 165 F) and the gauge for final rinse was noted at 190 F (supposed to be 180 F). On 02/07/2023 at 09:40 AM, the Dietary Manager stated that the day before the final rinse temperature was low because a switch, the Buster, was off and they did not check it before they started the cycle to wash the dishes. On 02/07/2023 at 09:54 AM the Maintenance Director, stated that he has been working in the facility for eleven months already. The problem with the dish washing machine is due to an overload in the buildings' electricity. There is a project going on with the electricity and the city. This issue with the dishwashing machine has been ongoing for around two months, since then the facility has been trying to fix it. Record review revealed the electrician invoice showed that the work was completed on 12/2022 but the problem still existed. Review of the Resident Council Meeting dated 11/30/2022 with start time 10:00 AM and adjourned time 11:30 AM revealed in attendance with residents were the Administrator, Social Director, and Activities Director. All members were informed the facility continues to use disposable utensils during mealtimes due to the dishwashing machine currently not working. The December Resident Council Meeting notes dated 12/30/2022 with start time 10:30 AM and adjourned time 11:30 AM revealed, residents were informed that the facility continues to use disposable utensils during mealtimes due to dishwasher currently not working. Residents understood and did not share any concerns with the information shared with them. Review of the facility's policies and procedures revealed: Guideline: The dining service staff shall maintain the operation of the dishwashing machine according to established procedure and manufacturer guidelines posted or contained in guideline to ensure effective cleaning and sanitizing of all tableware and equipment used in the preparation and service of food. Procedure: 1. All dishwashing machines should be operated according to manufacturer recommendations. Tableware, utensils, and pots and pans should be cleaned and sanitized in either a high-temperature dishwashing machine that uses hot water, or chemical-sanitizing dishwashing machine that uses a chemical sanitizing solution. 2. Check the dishwashing machine before first use. If the dishwashing machine has not been used several hours, it is generally recommended to allow the dishwashing machine to cycle for one or two cycles to allow dishwashing machine to come up to proper function. 3. If the machine is found to be out of the acceptable range for either final rinse temperature or proper chemical sanitizing concentration, do not proceed to wash dishes. Empty dishwashing machine, check nozzle and empty bottom screen and restart the dishwashing machine. 4. If the dishwashing machine cannot be repaired in timely manner, the facility will utilize the manual dishwashing procedure. Paper good may be used as a temporary measure until the dishwashing machine is repaired.

Based on observations, interview, and record review the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) Level I for individuals with a Serious Mental Illness (SMI) or Intellectual Disability (ID) or related conditions was completed at the time of admission for resident one (Resident # 54) out of one resident whose PASRR was reviewed. The findings included: On 02/07/2023 at 10:37 AM Resident # 54 was observed lying in bed, awake. No distress noted. Observation on 02/08/2023 at 11:25 AM. Resident #54 was observed lying in bed trying to take her gown off. The nurse was called to help the resident and a Certified Nursing Assistant came and assisted the resident to get dressed. Record review of Admission Record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Medical Diagnoses included, but were not limited to, Chronic Obstructive Pulmonary Disease, Unspecified, Unspecified Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic Disturbance, Anxiety, Other Bipolar Disorder and Other Depressive Episodes. Record review of Resident # 54's PASRR Level dated 05/08/2017 revealed no identification of any serious mental diagnosis under section 1A PASRR Screen Decision-Making. Review of orders dated 11/21/2022 revealed the resident was receiving Mirtazapine tablet 30 milligrams. 1 tablet by mouth at bedtime related to Other Specified Depressive Episodes. Record review of orders dated 11/21/2022 revealed the resident was receiving Clonazepam tablet 1 milligram. 1 tablet by mouth two (2) times a day related to Anxiety Disorder, Unspecified. Record review of orders dated 01/25/2023 revealed the resident was receiving Temazepam Capsules 15 milligrams orally at bedtime related to Insomnia. One capsule by mouth every night at bedtime. Record review of orders dated 01/25/2023 revealed ordered Morphine oral solution 20 milligrams/5 milliliters. Give 0.5 milliliters by mouth every two (2) hours as needed for pain related to Shortness of Breath. Record review of orders dated 02/02/2023 revealed ordered Lorazepam Oral Concentrated 2 milligrams/milliliters. Give 0.5 milligram/milliliters by mouth every 6 hours as needed for agitation, anxiety, acute seizures related to other specified Anxiety Disorders. Review of the Annual Minimum Data Set (MDS) Section A dated 06/22/2022 revealed the resident was not currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition. Review of the Quarterly MDS Section C for cognitive status dated 02/10/2022 revealed the resident's Brief Interview for Mental Status (BIMS) Summary Score was 02 out of 15 indicating the resident has severe cognitive impairment. Review of the Quarterly MDS Section I for active diagnoses dated 12/20/2022 revealed the resident's diagnoses of Anxiety disorder, Depression Disorder and Bipolar Disorder. Review of Quarterly MDS Section N for medication dated 12/20/2022 revealed the resident was receiving antianxiety and antidepressant medications. Review of Resident # 54's Medication Administration Record for January 2023 revealed the resident was receiving antianxiety and antidepressants medications as ordered. Review of Medication Administration Record for February 2023 revealed the resident was receiving antianxiety and antidepressants medications as ordered. Review of the Care Plan initiated on 03/30/2022 and revised on 12/28/2022. The resident was at risk for adverse reactions related to the use psychotropic meds on Anti-Anxiety Medication, on Antidepressant Medication and on Sedative Hypnotic Medication. Goal: Will remain free of signs and symptoms of over sedation and side effects related to psychotropic medication. Interventions: Involve the family and resident with the care planning process and psychotropic reduction program. Monitor behavior for effectiveness of medications. Monitor for signs and symptoms of over-sedation and/or changes in condition. Obtain laboratory tests and/or vital signs as ordered. During an interview on 02/08/2023 at 10:00 AM, Registered Nurse, (Staff J) revealed the resident is very anxious and sometimes aggressive with the Certified Nursing Assistants (CNAs) when care was provided. Staff J added that the resident behaved good with her regular CNA, but not with other CNAs. The resident would be anxious in the morning until the medication is working. Staff J reported that the resident received medications for anxiety, depression and morphine for pain as needed, and tolerated the medication well. The resident was not able to use the call light for assistance. During an interview on 02/08/2023 at 02:16 PM, the Social Services Director reported she started to work in the facility six (6) months ago. Resident # 54 was admitted in 2017. The resident did not have any significant change or any disturbing behavior. The Social Services Director revealed she reviewed the PASRR Level I with the Director of Nursing when the residents will be admitted . The Social Services Director reported that she will review the resident's ( Resident # 54) PASRR Level I with the Director of Nursing and acknowledged the PASRR Level I for this resident (Resident #54) was not completed and that she will submit it again. On 02/08/2023 at 3:02 PM the Social Services Director reported that the Level I PASRR for Resident # 54 was submitted with the resident's diagnosis. Record review of Policy and procedures for PASARR dated 01/01/2022 revealed Policy: It is the policy of the facility to assure that all residents admitted to the facility receive a Pre-Admission Screening and Resident Review, in accordance with Stated and Federal Regulations. 3-Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. The facility will not admit, on or after January 1, 1989, any new residents with a-Mental disorder, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission.

Based on observations and interviews, the facility failed to ensure privacy of confidential information by leaving unlocked computer screen with resident's information visible. Observation on 02/05/2023 at 12: 57 PM, the computer for Center Court unit middle cart electronic medical records screen was left open with visible residents' information exposed. On 02/05/2023 at 12: 57 PM, during an interview Registered Nurse (Staff B) was asked about the computer screen that was left unlocked with residents' information exposed. Staff B acknowledged the concern and stated a resident called her and she went to see what the resident needed.

Based on record review and interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for two (Resident #237, and Resident #123) out of 38 residents reviewed for resident assessments. As evidenced by inaccurate coding of MDS section for Discharge Status for Resident #237 and inaccurate coding of the MDS sections for Active Diagnosis and Medications for Resident #123. The facility census was 237 residents at the time of the survey. The findings included: Record review of Resident #237's Discharge Return Not Anticipated Minimum Data Set (MDS) dated [DATE] Section for Identification Information in subsection A 2100 for Discharge Status documented that the resident was discharged to an Acute Hospital. Review of the Physician's Orders Sheet for November 2022 revealed Resident #237 had orders that included but not limited to: Discharge to home with her family, one time only until 11/14/2022. Review of the nurses' progress notes for Resident #237 documented on 11/14/2022 timestamped 12:28: Resident left the facility at this time. Discharge to home with her family. Resident in stable condition, no pain reported. No skin lesions. Her belongings and medicines were handed over to the family. Further review of the medical records for Resident #237 revealed resident was admitted to the facility on [DATE]. Clinical diagnoses included but not limited to: Gout, unspecified. Resident #237 was discharged on [DATE]. Record review of Resident #237 's Care Plans dated 8/3/2022 revealed: Resident's Short-term Discharge Plan: The plan for resident is to be discharge back to the community with family support. Interventions Included: The goal for the resident is to have all needs met related to discharge planning and staff to assist and coordinate with the resident as needed for a safe discharge. On 02/08/2023 at 08:21 AM, during an interview with Registered Nurse, Minimum Data Set Coordinator, (Staff C) the surveyor had Staff C check the nurses progress notes documented on 11/14/2022 that noted the resident was discharged to home with family and check the Discharge Minimum Date Set with reference dated 11/14/2022, Section A that documented that the resident was discharged to an acute hospital. Staff C acknowledged the discrepancy, Staff C stated, in this situation we would check the progress note, speak to the nurses, we would correct the discrepancy and create a modification request and submit the request to Center for Medicare and Medicaid Services (CMS). I will speak to the nurses to the floor to confirm the discharge status. Review of the facility's policy and procedures titled policy and Procedures: Residents Assessments dated 01/01/2022 states: Step 7-A Registered Nurse will sign and certify that the assessment is completed. Step 8-Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. 42532 2. On 02/08/2023 at 08:02 AM, Resident #123 was observed in the dining area seated in a reclining type chair being fed a pureed textured and honey consistency breakfast by a Certified Nursing Assistant (CNA). Review of Resident #123's clinical records revealed the resident was admitted on [DATE] and readmitted on [DATE]. Medical diagnoses included but were not limited to, Cerebral Atherosclerosis; Type 2 Diabetes Mellitus without complications; Hypertensive Heart Disease with Heart Failure. Review of Resident #123's active orders as of 02/08/2023 documented an order dated 08/24/2021 for Glimepiride tablets 2 milligrams orally two times a day related to Type 2 Diabetes Mellitus without complications. Orders for Metformin tablet 500 milligrams orally two times a day related to Type 2 Diabetes Mellitus without complications, dated 08/24/2021. Record review of Quarterly Minimum Data Set (MDS) Section I for Active Diagnosis dated 11/20/2022 revealed the resident's diagnosis of Type 2 Diabetes Mellitus (DM). Record review of Quarterly Minimum Data Set (MDS) Section N for medications dated 11/20/2022 revealed the resident were receiving insulin injections seven (7) days a week. Review Resident #123's Medication Administration Records and order sheets for January 2023 revealed the resident was not receiving insulin injections. Review of Medication Administration Records for February 2023 revealed the resident was not receiving insulin injections. Review of Care Plan initiated on 03/03/2022 and revised on 03/03/2022 documented the resident has potential for fluctuating blood glucose levels related to Diabetes Goal: Will maintain blood glucose levels within the parameters set forth by physician. Interventions: Administer medications as ordered. Hemoglobin A1C [blood glucose level test] every 3 Months. Monitor for signs and symptoms of hypoglycemia - shaky, rapid heartbeat, sweating, dizzy, anxious, hungry, blurry vision, weakness or fatigue, headache, irritable. Monitor for signs of hyperglycemia- extreme thirst; frequent urination; dry skin; hunger, blurred vision, drowsiness, decreased healing, numbness of fingers, toes, mouth. Provide diet as ordered. During an interview on 02/08/2023 at 08:33, Registered Nurse, MDS Coordinator (Staff C) stated the resident's diagnosis was Type 2 diabetes Mellitus and he will check the physician orders to make sure the resident was not receiving insulin injections. On 02/08/2023 at 08:45 AM, Staff C reported that the resident's diagnosis was Type 2 Diabetes Mellitus but the resident received pills for the Diabetes, not insulin injections. Record review of Policy and Procedures for Residents assessment dated [DATE] revealed: Policy: It is the policy of the facility to adhere to the following procedures related to the proper documentation and utilization of a resident's Minimum Data Set (MDS) to ensure a comprehensive and accurate assessment of residents will be completed in the format and in accordance with time frames stipulated by the Department of Health and Human Services Center for Medicare and Medicaid Services (CMS). This assessment system will provide a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capabilities and assist staff to identify health problem for care plan development. Procedure: 1-Resident Assessment Instrument. A facility will complete a comprehensive assessment of a resident's needs, functional and health status, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: J-Disease diagnosis and health conditions. N-Medications.

Based on observation, record review and interview, the facility failed to provide an ongoing activities program for one out of 38 sampled residents (Resident #112). There were 237 residents residing in the facility during the survey. The findings included: During observation of Resident #112 on 02/06/2023 at 10:37 AM, the resident was observed in bed asleep. The resident's bed was observed to be in a low position. The resident was awakened, and she was asked how she was feeling, the resident responded that she was okay. The resident was not observed to be involved in any meaningful activity. Observation of Resident #112 on 02/07/2023 at 9:37 AM while medications were being administered to one of the resident's other 3 r roommates revealed, the resident was in bed asleep. There was no radio or television (TV) on the side where Resident #112's bed was located. The only television in the room was on the opposite side of the room, in front of Resident #207. The television was being watched by Resident #207 and was on a Spanish program. The resident was not observed to be involved in any meaningful activity. Observation of Resident #112 on 02/07/2023 at 02:47 PM, the resident was observed in bed asleep, the resident was easily awakened, and reported she's okay and reported lunch was okay. There was no radio at the bedside or TV for Resident #112. The resident was not observed to be involved in any meaningful activity. Record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertensive Heart Disease without Heart Failure, Unspecified Dementia, Unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The residents Brief Interview for Mental Status (BIMS) score was a 03, indicating the resident had severe cognitive impairment. The resident's primary language was documented as English. Review of Resident #112's Minimum Data Set Comprehensive assessment dated [DATE], Section F, Preferences for Customary Routine and Activities revealed the residents preferences included, music was very important to the resident, it is very important to do things with groups of people, it was important to participate in a religious service or practice, it was somewhat important to have books, newspapers and magazines, it was somewhat important to keep up with the news, and it was somewhat important to go outside to get fresh air when the weather is good. Review of Resident #112's care plans included, [Resident] will have the opportunity to participate in recreational activities through next review. Include resident in relaxing activities. Include resident in special events. Invite resident to go outside to get fresh air when the weather is appropriate to enjoy from facility's patio. Keep communication with family members offering video calls. Offer 1-1 informal visits in room for socialization with activity staff. Another care plan for Resident #112 included, [Resident] is potential for cognitive problem related to Difficulty Making Decisions, Impaired Decision Making, [ .] has episodes of confusion at times and able to make little to no decisions of daily life. [Resident] will be able to communicate basic needs on a daily basis through the review date. [Resident] will maintain current level of cognitive function through the review date. Administer medications as ordered. Monitor/document for side effects and effectiveness. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Encourage activities of choice. Encourage small group discussion/participation as appropriate. Praise all efforts made. Provide opportunities for resident to give his/her name. Provide prompts and cues as needed. Provide safety measures at all times. Provide staff's name with each interaction and prompt resident to repeat and rephrase as needed. Staff to address resident by name daily at each interaction. Use simple terms, phrases, direct yes/no questions and allow time for resident to comprehend and respond. During the review of Resident #112's electronic medical record, it was noted there were no activities progress notes from 06/01/2022 to 02/08/2023. During interview and observation of Resident #112 on 02/08/2023 at 09:30 AM with Staff G, a Registered Nurse, Staff G reported the resident was getting a shower. It was noted, this was the first time the resident had been observed out of her room during the facility's survey. Interview on 02/08/2023 at 04:10 PM with Staff I, the Activities Director about the resident's activity notes. Staff I reported, she was new and had been at the facility for 1 week and was being trained. Staff I was asked to find the activities progress notes and was unable to find the activities notes for Resident #112. Observation of Resident #112 on 02/08/2023 at 04:20 PM revealed, the resident was in bed with her head covered with a blanket. There was no TV or radio at the side where the resident bed was located. During an interview on 02/08/2023 at 05:40 PM with Staff I, the following documents were presented, a copy of the facility's Activities Program Policy and Procedures. Resident #112's Quarterly Activity evaluation dated 01/03/2023 was presented. The residents' February 2023 list showing activities provided to Resident #112 was presented and reviewed. During the review of the February 2023 list of activities, it was documented the resident had been provided the following activities from 01/26/2023 to 02/08/2023-television group, television in room, music in group, social group/club, reminiscing memory stimulation, conversation with the resident and snack time. On 02/06/2023, the list documented at 2:45 PM, there was conversation with the resident. There was no other activity documented as being provided to the resident on 02/06/2023. On 02/07/2023, the list documented at 12:21 PM, there was conversation with the resident. On 02/07/2023, the list documented at 12:22 PM, there was a TV in the resident's room and the resident had snack time. There was no other activity documented as being provided to the resident on 02/07/2023. On 02/08/2023, the list documented at 12:13 PM, there was conversation with the resident and the resident was at a social group club. On 02/08/2023, the list documents at 12:14 PM, the resident was given snack time and reminiscing memory stimulation. Staff I was informed during this review that the resident does not have a TV at the bedside and that the TV in the resident's room is on the opposite side of the 4-resident bedroom and that the resident's primary language was English. There was no documentation from 01/26/2023 to 02/08/2023, that the resident had been involved in a religious service, that the resident had a reading activity, time outdoors and no phone activity with family and/or a friend as documented on the resident's activity preferences. During the review of the facility's policy and procedure for the Activities Program dated 01/01/2022, the policy documented the Purpose was to provide an ongoing program of activities designed to appeal to the resident's interests and to enhance his or her highest practicable level of physical, mental, and psychosocial well-being. The guidelines included, but was not limited to: 1. Identify and involve each resident in an ongoing program of activities designed to appeal to his or her interests and needs. 2. Enhance the residents highest practicable level of physical, mental, and psychosocial wellbeing by offering a program of activities that provides the following: A heightened sense of wellbeing. Promotion of feelings of self-esteem, pleasure, comfort, education, creativity, success, and independence. Produce something useful and provide purpose. Religious activities Activity Participation Records: The activity staff shall record residents' activity attendance and participation in the task in [ brand cloud-based healthcare software provider]. Make use of task information as data for summary within the resident activity assessments and/or progress notes.

Based on observation, record review and interview, the facility failed to ensure 1 out of 9 sampled residents (Resident #112) reviewed for Accidents and environment remained free of accident hazards. Resident #112 had an electrical socket next to bed that had exposed electrical wires. There were 237 residents admitted to the facility during the survey. The findings included: During observation of Resident #112 on 02/06/2023 at 10:37 AM, the resident was observed in bed asleep. The resident's bed was observed to be in a low position. The bed was against the wall and there was an electrical socket on the wall where the cover of the electrical socket was detached from the socket. The electrical socket was above the resident's bed and electrical cords were observed to be exposed. The socket was observed to be connected to a cover for other wiring extending down the wall and was next to the resident. This tubing was within the reach of the resident. The resident was awakened and asked how she was feeling, and she said she was okay. (Photo obtained of the electrical socket) Observation of Resident #112 on 02/07/2023 at 9:37 AM while medications were being administered to one of the resident's 3 other roommates revealed the resident was in bed asleep and the electrical socket remained with the exposed wiring. Observation of Resident #112 on 02/07/2023 at 02:47 PM, the resident was observed in bed asleep, the resident was easily awakened, and reported she's okay and lunch was okay, two half siderails were up, the resident's bed was against the wall. The electrical socket remained with the exposed wiring. Record review revealed Resident #112 was admitted to the facility on [DATE] with diagnoses to include but not limited to Hypertensive Heart Disease without Heart Failure, Unspecified Dementia, Unspecified severity, without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance and Anxiety. The residents Brief Interview for Mental Status (BIMS) score was a 03, indicating the resident had severe cognitive impairment. During the Life Safety Code Survey tour of the facility at 3:02 PM on 02/07/2023 with the Maintenance Director, it was observed that there was a damaged electrical receptacle with exposed wiring in Resident #112's room. During an interview and observation on 02/08/2023 at 09:30 AM with Staff G, a Registered Nurse, about the electrical outlet in Resident #112's room, Staff G reported the resident was getting a shower. At this time, the electrical outlet had been repaired, but the metal tubing covering the other wiring was still present. Staff G reported, the resident pulls on the metal tubing on the wall. Staff G was shown the picture of the broken electrical outlet. Staff G was asked, what does she do when she finds something like the broken outlet, she reported, she reports it to the charge nurse. Interview on 02/08/2023 at 09:40 AM with Staff H, Charge Nurse, and Licensed Practical Nurse (LPN), about what they do when they identify broken things in the environment, she reported, they document it in the Maintenance Book. Staff H presented the maintenance repair logbook that was kept at the nurses' station on the Center Court Unit. The repair book was reviewed and the repair for the room outlet cover was documented as repaired on 02/07/2023. Staff H reported, maintenance staff checked the maintenance log daily and makes the repairs. Interview on 02/08/2023 at 09:42 AM with the Director of Nurses (DON), about the electrical outlet in Resident #112's room, he reported the Nurses and Certified Nursing Assistants must report these findings. The DON was shown a picture of the broken outlet. The DON was informed, Staff G reports, Resident #112 pulls on the metal tubing on the wall that is connected to the electrical outlet. The facility's accident hazards policy and procedure was requested. Review of the facility's policy and procedure for Reporting Accidents and Incidents dated 01/01/2022, documents The facility will ensure that: a. The resident environment remains as free from accident hazards as is possible. This section of the policy was not followed. Review of the facility's undated policy and procedure for Preventive Maintenance and Inspection documents, In order to provide a safe environment for residents, employees and visitors, a preventive maintenance program has been implemented to promote the maintenance of fixtures and equipment in a state of good repair and condition. The section for Work Orders and Service Requests documents, A system for work orders is established among all staff, elders, and . [Preventive Maintenance] employees that provides rapid communication regarding equipment problems. The work order system includes documentation of: the problem, Date the problem was identified, who was notified, correction action (servicing, repair or replacement), and completion date. This portion of the policy was not followed.

Based on observation, interview, and record review the facility failed to implement their written policies on abuse and visitor identification at their back door. By not following their policies and procedures, one of 5 sampled residents (sample resident #4) was potentially physically abused, and the rest of the residents in the facility were placed at risk for physical harm, pain or mental anguish. Immediate Jeopardy was identified because the abuse was not immediately reported to the appropriate facility staff on 2/24/2012, the potential abuser had access to the facility and its residents for five (5) days without staff intervention, until 2/29/2012. The Immediate Jeopardy was identified on 3/9/2012 at approximately 3:30 PM and was determined to have been removed on 3/9/12 at approximately 3:30 PM. The findings include: Review of facility's policy and procedure titled, "Reporting of Crimes Occurring in the Nursing Home," revealed that "Section V: Policy: In order to assure that the facility can take measures to protect a resident or patient from further abuse or criminal activity, a covered individual that suspects that a crime has been committed against a resident or patient of the facility is required to report the suspicion to: the facility abuse prevention program coordinator; and at least one law enforcement agency of jurisdiction; and the state agency. Section VI: Reporting Requirements: D) Timing of Report; 2-Hour Reporting: if the events that cause the suspicion result in serious bodily injury, the individual shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. 24-Hour Reporting: If the events that cause the suspicion do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion." Review of the facility's policy and procedure titled, "Abuse and Events," revealed the section titled, "Prevention and Reporting: Suspected Resident/Patient Abuse or Misappropriation of Property" contained item #4 which read, "Instruct staff that they are required to report concerns, incidents, and grievances." Review of the facility's policy and procedure titled, "Visiting Hours," revealed the following, "suggested visiting hours are from 11:00AM to 8:00PM. If for some reason, a family member or someone the resident wishes to see is unable to come during these hours, other arrangements can be made; a guest book is located inside the front door and visitors are encouraged to sign this book." Record review of the facility's "Federal Immediate/ 5-Day Report" dated 2/29/2012 revealed the following information from that day: On 2/29/2012, CNA#2 was told by CNA#1 that an unknown male visitor was observed touching resident #4 inappropriately. She indicated that, approximately two weeks ago, this same male visitor was observed touching the resident's chest. Today, 2-29-12, the same male visitor was seen by a housekeeping employee caressing sampled resident #4's legs and stomach. The visitor was then questioned as to why he was touching sampled resident #4 and the visitor allegedly replied that he was attempting to induce the resident to talk. Sampled resident #4 is alert with impaired speech and severely impaired cognitive skills for decision making. Sampled Resident #4 was unable to provide any information regarding the incident. A physical assessment of sampled resident #4 was done by staff, but no signs of injury were found. Interview on 3/7/2012 at 1:21PM with the facility's Director of Social Services revealed, she also serves as the facility's Abuse Prevention Coordinator. She stated that her investigation revealed the following timeline of events occurred at the facility: On 2/20/2012 through 2/23/2012- A Certified Nursing Aide (CNA #1) observed a male visitor on the facility's 2nd floor with sampled resident #4 during the lunch time hours; On 2/24/2012- CNA #1 observed the same male visitor touching the resident's leg. She indicated that when she asked the male visitor about his relationship to the resident he reported that he was her cousin and he was trying to get the resident to talk. She did not report this incident to anyone else in the facility; On 2/29/2012- Housekeeping Staff #1 saw the same male visitor in sampled resident #4's room touching her breasts over her shirt. She did not report this incident to anyone else in the facility; On 2/29/2012- CNA #1 saw the same male visitor in sampled resident #4's room touching the resident's leg. CNA #1 then reported this information to CNA #2 who was assigned to sampled resident #4 during that shift. CNA #2 asked CNA#1 if she had reported this to anyone else in the facility, to which she replied "no." CNA #2 then proceeded to report the incident she was told about to the nurse and risk manager later that day. Interview with the Abuse Prevention Coordinator on 3/7/2012 at 1:21PM revealed, the facility launched an investigation of this incident on 2/29/12, including confronting the male visitor on 2/29/2012 at approximately 5:20 PM. She explained, they informed the physician and sampled resident #4's family about the incident, performed a physical exam on the resident, contacted proper authorities, and they counseled and re-trained their staff on the facility's policy and procedure regarding reporting abuse. She confirmed, there was no record of when this male visitor entered the facility in the receptionists' record(s). Interview on 3/8/2012 at 11:47AM with CNA #1 revealed, on 2/24/2012, she observed a male visitor touching resident #4's leg. She confirmed, she did not report this incident to anyone in the facility for 5 days, at which point, she reported it to CNA #2 who was not the appropriate person to whom to report the incident. She confirmed, she should have reported the incident to the Abuse Prevention Coordinator, not another CNA. She confirmed that she was aware of the facility's policy and procedures regarding abuse reporting. Interview on 3/8/2012 at 12:02PM with CNA #2 revealed, on 2/29/2012, she was assigned to care for sampled resident #4. She confirmed, on that date, CNA #1 approached her and told her that she observed a male visitor inappropriately touching sampled resident #4, 5 days ago, on the resident's leg. She confirmed that she asked CNA #1 if she had reported the incident to anyone in the facility and she said, "no." CNA #2 confirmed that she then proceeded to report what she had been told to the resident's nurse and the facility's Risk Manager. Interview on 3/8/2012 at 12:10PM with Housekeeping Staff #1 revealed, she saw a male visitor in resident #4's room touching her breasts over her clothing. She confirmed, she did not report this incident to anyone else in the facility and that she should have reported the incident to the Abuse Prevention Coordinator. She confirmed that she is aware of the facility's policy and procedures regarding abuse reporting. Observation of the 1st floor Oliver House back door on 3/8/2012 at 3:15PM revealed a newly posted notification on the door (on yellow paper with black capital letters), which read, "All visitors must see nurse/secretary to sign in get a visitor ID; also please return visitor ID before leaving." Interview on 3/8/2012 at 3:17PM with the 1st floor Oliver House Charge Nurse revealed, there is a new procedure at the back door. She reported, there is a book at the nurse's station for visitors to sign in and that they must obtain a visitor's badge. She indicated that this new procedure is the responsibility of the unit secretary at the desk. She said, when a visitor rings to gain entry into the facility, they must appear at the nurse's station to sign in and be given a visitor's badge. She provided evidence of this newly implemented visitor's log, which revealed today's date and four (4) separate visitor entries. Observation of the back door on 3/8/2012 at 3:18PM revealed, the door had less usage than the prior observation. Staff was utilizing this door for exit and entry. During this observation, no visitors were observed using the back door. Based on the corrective measures implemented by the facility the Immediate Jeopardy was determined to be removed. The scope and severity was decreased to a "D." The corrective measures included: 1) The physical assessment of sampled resident #4 on 2/29/2012 with no noted injury; 2) One-to-one staff supervision for sampled resident #4 for three days starting on 2/29/2012; 3) Local law enforcement authorities were contacted on 2/29/12; 4) Resident #4's family and physician were both contacted on 2/29/2012; 5) Staff was re-trained on reporting abuse beginning on 2/29/12. By 3/9/2012, the facility had completed training for 54 out of 150 CNAs (36%). They had completed training for 4 of 17 Housekeeping staff (24%). This included reprimanding and re-training CNA #1, CNA #2, and Housekeeping Staff #1. 6) The facility implemented a new visitor sign-in procedure for the facility's front entrance on 2/29/12, and visitor education on the newly implemented sign-in procedures. All visitors are now required to sign in, pick up a visitor badge, sign out and return the visitors badge. The new procedure for the back entrance was implemented on 3/7/12 on the Oliver House unit and included placing a unit secretary at the Oliver House nurse's station with a sign in book and a badge to give to visitors. Signs were posted on the entrances to direct visitor to the front desk and the Oliver House nurse's station on 3/7/12. The signs were yellow with capital lettering and said, "All visitors must see nurse/secretary to sign in to get a visitor ID; also please return visitor ID before leaving."

Based on observation, interview, and record review, the facility failed to ensure one (1) out of five (5) sampled residents, sampled resident #4, was free from sexual abuse by 1) Failing to report an incident of witnessed inappropriate touching of the resident for 5 days and 2) Failing to ensure the safe control of visitor access to the facility. Immediate Jeopardy was identified because the abuse was not immediately reported to the appropriate facility staff on 2/24/2012, the potential abuser had access to the facility and its residents for five (5) days without staff intervention, until 2/29/2012. The Immediate Jeopardy was identified on 3/9/2012 at approximately 3:30 PM and was determined to have been removed on 3/9/12 at approximately 3:30 PM. The findings include: Observation of resident #4 on 3/7/2012 at 11:48AM revealed, she was in bed watching television, in no apparent distress, and was appropriately dressed. The resident was alert with impaired speech. When asked orienting questions, she was unable to answer. Her speech was unintelligible. The resident was unable to verbally provide any information to the surveyor. Clinical record review revealed, the resident was admitted to the facility on [DATE]. She resides on the 2nd floor of the facility. Her [DIAGNOSES REDACTED]. Record review of the facility's "Federal Immediate/ 5-Day Report" dated 2/29/2012 revealed the following information from that day: On 2/29/2012, CNA#2 was told by CNA#1 that an unknown male visitor was observed touching resident #4 inappropriately. She indicated that, approximately two weeks ago, this same male visitor was observed touching the resident's chest. Today, 2-29-12, the same male visitor was seen by a housekeeping employee caressing sampled resident #4's legs and stomach. The visitor was then questioned as to why he was touching sampled resident #4 and the visitor allegedly replied that he was attempting to induce the resident to talk. Resident #4 is alert with impaired speech and severely impaired cognitive skills for decision making. Sampled Resident #4 was unable to provide any information regarding the incident. A physical assessment of sampled resident #4 was done by staff, but no signs of injury were found. Interview on 3/7/2012 at 1:21PM with the facility's Director of Social Services revealed, she also serves as the facility's Abuse Prevention Coordinator. She stated that her investigation revealed the following timeline of events occurred at the facility: On 2/20/2012 through 2/23/2012- A Certified Nursing Aide (CNA #1) observed a male visitor on the facility's 2nd floor with sampled resident #4 during the lunch time hours; On 2/24/2012- CNA #1 observed the same male visitor touching the resident's leg. She indicated that when she asked the male visitor about his relationship to the resident he reported that he was her cousin and he was trying to get the resident to talk. She did not report this incident to anyone else in the facility; On 2/29/2012- Housekeeping Staff #1 saw the same male visitor in resident #4's room touching her breasts over her shirt. She did not report this incident to anyone else in the facility; On 2/29/2012- CNA #1 saw the same male visitor in resident #4's room touching the resident's leg. CNA #1 then reported this information to CNA #2 who was assigned to sampled resident #4 during that shift. CNA #2 asked CNA#1 if she had reported this to anyone else in the facility, to which she replied "no." CNA #2 then proceeded to report the incident she was told about to the nurse and risk manager later that day. Interview with the Abuse Prevention Coordinator on 3/7/2012 at 1:21PM revealed, the facility launched an investigation of this incident on 2/29/12, including confronting the male visitor on 2/29/2012 at approximately 5:20 PM. She explained, they informed the physician and sampled resident #4's family about the incident, performed a physical exam on the resident, contacted proper authorities, and they counseled and re-trained their staff on the facility's policy and procedure regarding reporting abuse. She confirmed, there was no record of when this male visitor entered the facility in the receptionists' record(s). Interview on 3/8/2012 at 11:47AM with CNA #1 revealed, on 2/24/2012, she observed a male visitor touching sampled resident #4's leg. She confirmed, she did not report this incident to anyone in the facility for 5 days, at which point, she reported it to CNA #2 who was not the appropriate person to whom to report the incident. She confirmed, she should have reported the incident to the Abuse Prevention Coordinator, not another CNA. She confirmed that she was aware of the facility's policy and procedures regarding abuse reporting. Interview on 3/8/2012 at 12:02PM with CNA #2 revealed, on 2/29/2012, she was assigned to care for sampled resident #4. She confirmed, on that date, CNA #1 approached her and told her that she observed a male visitor inappropriately touching sampled resident #4, 5 days ago, on the resident's leg. She confirmed that she asked CNA #1 if she had reported the incident to anyone in the facility and she said, "no." CNA #2 confirmed that she then proceeded to report what she had been told to the resident's nurse and the facility's Risk Manager. Interview on 3/8/2012 at 12:10PM with Housekeeping Staff #1 revealed, she saw a male visitor in sampled resident #4's room touching her breasts over her clothing. She confirmed, she did not report this incident to anyone else in the facility and that she should have reported the incident to the Abuse Prevention Coordinator. She confirmed that she is aware of the facility's policy and procedures regarding abuse reporting. Interview on 3/7/2012 1:39PM with the facility's receptionist revealed, she sits at the front desk, where the front door is located. She stated, when visitors come into the facility, she logs their name, the resident they are visiting, and the tag number of their car into a computerized checklist. She indicated, there is staff at the front desk performing these duties until 8:00PM. She said, the facility has a back door which is used by visitors and that she was not aware of the process for tracking visitors at this entrance. Interview on 3/7/2012 at 1:49PM with the Charge Nurse at the 1st floor's Oliver House nursing station revealed, the facility's visiting hours are relaxed, and that families can visit any time. She confirmed, the reception area in the front closes daily at 8:00PM. She stated, when the reception closes, the only way into the facility is through the back door on the nursing unit in the facility's Oliver House. She said, there is a bell that visitors can ring outside of the door and the bell is then heard at the nurse's station in Oliver House. When the bell is heard at the nurse's station, staff does not have to physically go to the door to open it, as the lock can be released by pressing a button at the nurse's station. She reported, at 8:00PM the door must be locked at all times. Interview on 3/7/2012 at 1:53PM Staff Nurse #1 on the 1st floor Oliver House nursing unit revealed, she works both day and night shift(s) and is familiar with the processes at the facility's back door. She reported, there was nobody assigned to answer the back door during the day or at night. She also indicated that there was no protocol in place for the staff to determine whether or not visitors are appropriate and can be in the facility. She confirmed that the back door is used throughout the day and night by staff as well as visitors. Observation on 3/7/2012 at 2:03PM of the facility's 1st floor Oliver House back door revealed that the door led directly onto the nursing unit. Once inside the back door, immediately to the left and right was a hallway with direct access to resident(s) rooms. Approximately 20 feet after entering through the back door, the nurse's station is located. A loud buzzer/ring sound was observed when the bell was rung outside and the door was opened. Neither staff nor residents reacted to the buzzer/ring sound, as it was occurring frequently. There was little staff interaction observed at this door regarding control and/or identification of who was coming into the facility. The following observations were made: 1) At 2:04PM on 3/7/12, a visitor was observed entering with no staff interaction; 2) At 2:07PM on 3/7/12, the surveyor exited and entered the back door. The lock did not engage upon re-entry. 3) At 2:09PM on 3/7/12, a visitor was observed coming in the door as a uniformed ambulance worker was leaving with no staff interaction. Review of facility's policy and procedure titled, "Reporting of Crimes Occurring in the Nursing Home," revealed that "Section V: Policy: In order to assure that the facility can take measures to protect a resident or patient from further abuse or criminal activity, a covered individual that suspects that a crime has been committed against a resident or patient of the facility is required to report the suspicion to: the facility abuse prevention program coordinator; and at least one law enforcement agency of jurisdiction; and the state agency. Section VI: Reporting Requirements: D) Timing of Report; 2-Hour Reporting: if the events that cause the suspicion result in serious bodily injury, the individual shall report the suspicion immediately, but no later than 2 hours after forming the suspicion. 24-Hour Reporting: If the events that cause the suspicion do not result in serious bodily injury, the individual shall report the suspicion not later than 24 hours after forming the suspicion." Review of the facility's policy and procedure titled, "Abuse and Events," revealed the section titled, "Prevention and Reporting: Suspected Resident/Patient Abuse or Misappropriation of Property" contained item #4 which read, "Instruct staff that they are required to report concerns, incidents, and grievances." Review of the facility's policy and procedure titled, "Visiting Hours," revealed the following, "suggested visiting hours are from 11:00AM to 8:00PM. If for some reason, a family member or someone the resident wishes to see is unable to come during these hours, other arrangements can be made; a guest book is located inside the front door and visitors are encouraged to sign this book." Observation of the 1st floor Oliver House back door on 3/8/2012 at 3:15PM revealed a newly posted notification on the door (on yellow paper with black capital letters), which read, "All visitors must see nurse/secretary to sign in get a visitor ID; also please return visitor ID before leaving." Interview on 3/8/2012 at 3:17PM with the 1st floor Oliver House Charge Nurse revealed, there is a new procedure at the back door. She reported, there is a book at the nurse's station for visitors to sign in and that they must obtain a visitor's badge. She indicated that this new procedure is the responsibility of the unit secretary at the desk. She said, when a visitor rings to gain entry into the facility, they must appear at the nurse's station to sign in and be given a visitor's badge. She provided evidence of this newly implemented visitor's log, which revealed today's date and four (4) separate visitor entries. Observation of the back door on 3/8/2012 at 3:18PM revealed, the door had less usage than the prior observation. Staff was utilizing this door for exit and entry. During this observation, no visitors were observed using the back door. Based on the corrective measures implemented by the facility the Immediate Jeopardy was determined to be removed. The scope and severity was decreased to a "D." The corrective measures included: 1) The physical assessment of sampled resident #4 on 2/29/2012 with no noted injury; 2) One-to-one staff supervision for sampled resident #4 for three days starting on 2/29/2012; 3) Local law enforcement authorities were contacted on 2/29/12; 4) Resident #4's family and physician were both contacted on 2/29/2012; 5) Staff was re-trained on reporting abuse beginning on 2/29/12. By 3/9/2012, the facility had completed training for 54 out of 150 CNAs (36%). They had completed training for 4 of 17 Housekeeping staff (24%). This included reprimanding and re-training CNA #1, CNA #2, and Housekeeping Staff #1. 6) The facility implemented a new visitor sign-in procedure for the facility's front entrance on 2/29/12, and visitor education on the newly implemented sign-in procedures. All visitors are now required to sign in, pick up a visitor badge, sign out and return the visitors badge. The new procedure for the back entrance was implemented on 3/7/12 on the Oliver House unit and included placing a unit secretary at the Oliver House nurse's station with a sign in book and a badge to give to visitors. Signs were posted on the entrances to direct visitor to the front desk and the Oliver House nurse's station on 3/7/12. The signs were yellow with capital lettering and said, "All visitors must see nurse/secretary to sign in to get a visitor ID; also please return visitor ID before leaving."