Every finding on record at The Blossoms at Stamps Rehab & Nursing Center

Number of residents sampled: 1Number of residents cited: 1Based on observation, record review, interview, and facility policy review, the facility failed to ensure appropriate hand hygiene was performed during wound care to reduce the risk of cross contamination and infection for one (Resident #3) of one resident reviewed. Specifically, the facility failed to ensure an effective infection control program was implemented by staff to prevent the potential spread of infections. The findings include: Review of Resident #3's annual Minimum Data Set with an Assessment Reference Date of 03/02/2026 revealed Resident #3 had a Brief Interview for Mental Status score of 13, which indicated the resident was cognitively intact. The MDS revealed Resident #3 had diagnoses which included Parkinson's disease, psychotic disorder and pressure ulcers. The MDS also revealed Resident #3 needed substantial/maximal assistance with functional abilities including lower body dressing and personal hygiene Review of Resident #3's Order Summary dated 02/25/2026 revealed staff were to clean and dry wounds on the resident's right lateral heel and left ankle, apply antiseptic, wrap with gauze and elastic wrap, one time a day for pressure injury. Review of Resident #3's Care Plan Report dated 04/02/2026 revealed Resident #3 had unstageable pressure ulcers to the right lateral heel and left ankle. Care Plan interventions included administer treatments as ordered. On 04/16/2026 at 12:34 PM, this surveyor observed Licensed Practical Nurse (LPN) #1 perform wound care to Resident #3's pressure ulcers. LPN #1 performed hand hygiene prior to wound care and glove application only. Gloves were changed per protocol with no hand hygiene performed between glove changes during wound care. LPN #1 stated she was, not aware hand hygiene was to be performed with each glove change. During an interview on 04/16/2026 at 10:50 AM, the acting Director of Nursing (DON) stated hand hygiene should be performed when changing gloves and when you remove a dressing. During an interview on 04/16/2026 at 12:50 PM, the Administrator stated hand hygiene should be performed with each glove change. Review of a facility policy titled Infection Control general standards: Standard Precautions, with effective date 04/2021, revealed to Wash hands after removing gloves and Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces, and before going to another resident and wash hands immediately to avoid transfer of microorganisms to other residents or environments. Standard precautions of hand hygiene for infection control included to perform hand hygiene after touching a patient and after body fluid exposure risk.

Based on observation, record review, interview, and facility policy review it was determined the facility failed to ensure the rear casters or wheels of the mechanical lift were left unlocked when lifting and lowering residents affecting 1 sampled (Resident #211) resident, and to ensure medications were not left unattended in a resident's room to prevent misappropriation, accidents, or injuries for 1 sampled (Resident #51) of 2 sampled reviewed for accidents and injuries. Findings include: 1. A review of Medical Diagnosis, revealed Resident #211 with a diagnosis of dementia, heart attack, and anemia. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/04/2024, with a Brief Interview for Mental Status (BIMS) score of 00 (0-6 indicates cognitively impaired). Section GG0130 indicated Resident #211 is dependent on total care. a. On 10/15/2024 at 2:15 PM, a review of an in-service for Certified Nursing Assistants (CNA)s and nursing staff including a policy titled Mechanical Lift Procedure, revised, 09/29/2023 revealed the purpose is to establish a safe mechanical lift policy. The policy does not address locking the rear casters or wheels. b. Review of a Care Plan for Resident #211, revised 09/13/2024, revealed Resident #211 requires 1-2 staff members to use a mechanical lift for transfers. c. On 10/15/2024 at 6:53 AM, CNA #1 and #2 were observed using the mechanical lift with rear casters in the locked position when raising Resident #211 from the bed, and when lowering Resident #211 to a specialty chair. When asked the purpose of locking the rear casters or wheels when lifting and lowering residents, CNA #2 stated locking the rear wheels keeps the lift from moving, and the lift stays stationary. CNA #1 agreed and revealed it was a safety issue. d. During an interview with Director of Nursing (DON) on 10/15/2024 at 1:00 PM, the DON was asked the procedure staff were expected to follow when lifting and lowering residents with a mechanical lift. DON stated the legs of the left should be kept straight, and the wheels locked so that the lift stays in place. We want the wheels locked to make sure that the lift is stable. The DON was asked to provide mechanical lift policy, procedures, and any in-service documentation. e. On 10/15/2024 at 07:25 AM, A review of the Battery Operated Patient Lift Manual, stated to maintain mechanical lift legs spread open to the widest position, and ensure the casters are unlocked with lifting or lowering a resident except when lifting a resident from the floor. 2. A review of Medical Diagnosis, revealed Resident #51 with diagnosis of schizophrenia, bipolar, and Parkinson's. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/31/2024, with a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact). a. A review of Physician orders dated 07/31/2024 revealed: Antidepressant 60 milligrams 1 capsule in the morning by mouth for chronic pain. A blood pressure medication, 2.5 MG give 1 tablet by mouth in the morning for high blood pressure. Stool softener 8.6 MG, give 1 tablet by mouth every morning and at bedtime for stool softener Vitamin D3 Oral Tablet 25 micrograms 1 tablet by mouth in the morning for supplement A Physicians Order, dated 09/12/2024 revealed, Antipsychotic 2 MG, give 1 tablet by mouth every morning and at bedtime related to suicidal ideation. b. A review of an In-service titled Medication Administration Skills, dated 10/10/2024 given to nursing staff along with a policy titled Medication Administration, revised 11/25/2022, revealed medications must be given in a safe manner, and the medication cart must be clearly visible to the nurse administering medications, and the outward sides of the medication cart should be inaccessible to residents or other people passing by c. On 10/15/2024 at 8:00 AM, Resident #51 asked to take medications with applesauce and the Surveyor observed Licensed Practical Nurse (LPN) #3 set down a medication cup containing an antidepressant, antihypertensive, stool softener, antipsychotic, and a vitamin down in front of Resident #51 and walk out of the Resident's room and out of sight to a medication cart resting against the wall in the hallway. d. On 10/15/2024 at 8:04 AM, LPN #3 was asked if medications should have been left at Resident #51's bedside when retrieving applesauce from the medication cart, and LPN #3 stated the medications should not have been left at the bedside because another resident could have wandered in, or Resident #51 could have done something with the pills and she would not have known. e. During an interview on 10/15/2024 at 1:00 PM, the DON was asked the process nursing is expected to follow if they return to the medication cart before administering medications. The DON stated the nurse should take the medications with them when they return to the cart because another resident could get the medicine, or they could be knocked to the floor.

Based on observation, record review, interview, and facility policy review, the facility failed to ensure gloves were removed after touching a trash can, and appropriate hand hygiene was performed during medication pass to prevent cross contamination, and the risk of infection for 1 (Resident #51) sampled resident reviewed for infection control risk. Findings include: 1. A review of Medical Diagnosis, revealed Resident #51 had diagnoses of schizophrenia, bipolar, and type II diabetes. a. The quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/31/2024 revealed Resident #51 had a Brief Interview for Mental Status (BIMS) score of 13 (13-15 indicates cognitively intact). b. A review of a policy titled Hand Hygiene, dated 03/2020, revealed hand hygiene prevents the spread of infection, and all staff are expected to follow hand hygiene procedures to prevent the spread of infection to others. Gloves do not replace handwashing or hand hygiene. c. Review of a policy titled Medication Administration, revised 11/25/22, reveal staff should follow infection control procedures including handwashing and gloves for administering medications. d. A review of Physician Order, dated 07/31/2024 revealed, Lantus 30 units subcutaneously every morning and at bedtime for diabetes. (Lantus is a long acting insulin.) e. On 10/15/24 at 7:45 AM, Licensed Practical Nurse (LPN) #3 was observed putting on gloves, and holding a syringe in the left hand while wiping the top of a bottle of insulin with an alcohol pad. LPN #3 reached down with the right hand and opened the lid of the garbage can on the medication cart, then drew up insulin for Resident #51 in the syringe without sanitizing hands. e. On 10/15/24 at 7:59 AM, the Surveyor asked LPN #3 what process should be followed when administering medications after touching the trash can on the medication cart. LPN #3 stated she probably should have sanitized her hands because there are germs on the lid of the trash can. f. During an interview with Director of Nursing (DON) on 10/15/24 at 1:05 PM, the DON confirmed nursing should remove gloves after touching a trash can and sanitize hands because there could be a hole in the gloves, and it is an infection control issue.

Based on observation, record review, and interview the facility failed to ensure meal set up assistance was provided for (Resident #3) of 1 sampled resident and nail care was provided to promote good hygiene and reduce the risk for infection for 2 (Residents #8 and, #14) of 7 (Residents #3, #8, #14, #15, #24, #30 and #44) sampled residents who required nailcare on the East Hall. The findings are: 1. Resident #3 had diagnoses of dementia, anxiety disorder, and chronic atrial fibrillation. The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/13/2023 documented a Brief Interview for Mental Status (BIMS) of 6 (a score of 0-7 indicates severe cognitive impairment) and required set up assistance with meals. a. A Care Plan with a revision date of 11/24/2023 documented, .resident at risk for nutritional weight gain/loss related to therapeutic diet, BMI .Staff to assist me with tray set-up and observe for needed assistance during meal prn or as needed . b. On 11/29/23 at 7:20 AM, while observing the Activity/Dining Room area the Surveyor observed Resident #3 successfully pull apart the opening tab on a carton of milk but was unable to fully open the container. Resident #3 was holding the milk carton with his left hand and making a continuous jabbing motion with a fork held his right hand. The Surveyor observed 5 different staff members pass by Resident #3. c. On 11/29/23 at 7:23 AM, the Surveyor observed Resident #3 place his fork on the table, set the carton of milk off to the left side, and unwrap a muffin. d. On 11/29/23 at 07:27 AM, the Surveyor asked Certified Nursing Assistant (CNA) #1 if she was familiar with Resident #3, and if Resident #3 is care planned for set up assistance. CNA #1 said, Opening milk is part of serving meals to residents. I do not know if [Resident #3] is care planned for assistance. e. On 11/29/23 at 08:29 AM, during an interview the Surveyor asked the Director of Nursing (DON) what the process was for serving meals, and if opening milk is part of meal service. The DON said, Whether care planned or not, everyone should offer to open the residents milk. 2. Resident #8 had diagnoses of type 2 diabetes mellitus, dementia, and Alzheimer's disease. The Quarterly MDS with an of 10/27/23 documented a BIMS of 6 (a score of 0-7 indicates severe cognitive impairment) and required moderate assistance for transfers, maximal assistance for eating and dressing, and total assistance for personal hygiene. a. A Care Plan with a revision date of 08/25/2017 documented, .The resident is unable to provide her own ADL [activities of daily living] .Assist to bathe, dress, and groom daily per staff . b. On 11/27/23 at 10:31 AM, observed a brown substance under the left thumbnail, and the right pointer finger, and right thumbnail of Resident #8's fingernails. Resident #8's fingernails appeared to be 1/8 inch beyond the tip of the fingers and fingernail polish, and some nails had a filed rough edge. Resident #8 told the surveyor the fingernails are longer than she would like and did not know who cares for her fingernails. c. On 11/28/23 at 10:02 AM, observed Resident #8 in the dining area touching her hair braids. Resident #8's nails were 1/8 inch long beyond the tip of the fingers with chipped nail polish. d. On 11/28/23 at 2:06 PM, CNA #2 told the Surveyor that Resident #8 is a diabetic and nursing is responsible for trimming nails and can remove nail polish. The Surveyor asked CNA #2 how she would describe Resident #8's fingernails and she said, The nail polish has chipped most the way off. 3. Resident #14 had diagnoses of Alzheimer's disease, anxiety disorder, and psychosis. The Quarterly MDS with an ARD of 10/27/2023 documented BIMS of 01 (0-7 indicates severe cognitive impairment) and was dependent for eating, dressing, toileting, transfers, and personal hygiene. a. A Care Plan with a revision date of 10/10/2023 documented, .The resident has an ADL [activities of daily living] selfcare deficit related to Alzheimer's . She requires one-person dependent physical assistance with all personal care . b. On 11/27/23 at 10:33 AM, the Surveyor visualized a long fingernail on Resident #14's pointer finger, with a brown substance under the tip of the nail. c. On 11/28/23 at 8:24 AM, Resident #14's left hand had abnormally longs fingernails with a brown substance under all 5 fingernails. d. On 11/28/23 at 2:03 PM, the Surveyor asked CNA #2 what is the process for cleaning Resident #14's fingernails. CNA #2 told the Surveyor Resident #14 is bathed every other day on the 3-11 (3:00 PM to 11:00 PM) shift, and nailcare should be done then. CNA #2 was asked to describe Resident #14's fingernails. CNA #2 said, [Resident #14's] fingernails are long, there is dirt up under her nails, and her hands are dry. e. On 11/28/23 at 02:20 PM, the DON came to Resident #8's and Resident #14's and the Surveyor asked who was responsible for nail care for Resident #8, and Resident #14. The DON told the Surveyor the CNAs are responsible for nailcare. The Surveyor asked if CNAs cared for Resident #8's nails since she is a diabetic. The DON said, The nurses are responsible for [Resident #8's] nailcare, and the CNAs can do [Resident #14's] nailcare. The Surveyor asked the DON to describe Residents #8's fingernails. The DON said that she does not wear nail polish, so she cannot tell how long it has been since they were painted, and when nurses file fingernails it can chip the paint off like this. f. On 11/29/2023 at 2:00 PM, the Surveyor asked the Administrator for a policy on ADLs. g. On 11/29/2023 at 3:17 PM, the Administrator told the Surveyor there was not a policy on the serving of food, or ADLs.

Based on observations, interviews and record review, the facility failed to ensure controlled medication for stock medication lockbox was stored in a permanently affixed container to prevent the potential of misappropriation of resident property The findings are: a. On 11/28/23 at 2:00 PM, the Surveyor entered the medication room with Licensed Practical Nurse (LPN) #1 for an audit of medication storage. The Surveyor asked LPN #1 to unlock the refrigerator. The Surveyor observed a clear shelf with a clear locked box attached that housed one medication. The Surveyor pulled the clear shelf to see if it was removable. The Surveyor was able to remove the clear shelf with the clear locked box attached from the refrigerator with ease. b. On 11/28/23 at 02:05 PM, LPN #1 stated, while holding the clear shelf with the clear locked box attached in hand stated, is that a problem. The Surveyor asked LPN #1 if that was a narcotic in the locked box. LPN #1 stated yes. The Surveyor asked what the medication was. LPN #1 stated I think lorazepam. The Surveyor asked is it for a resident or is it stock medication? LPN #1 unlocked locked box and removed the medication and stated, Yes, it is lorazepam, and it is a stock a med [medication]. c. On 11/28/23 at 2:10 PM, the Surveyor asked the Assistant Director of Nursing (ADON) who had access to the med room. The ADON stated, Only nurses. The Surveyor, the ADON, and LPN #1 re-entered the medication storage room. After entrance, LPN #1 unlocked the locked refrigerator and pulled out the clear shelf with locked box attached and held it in her hand. The Surveyor asked the ADON if the locked box was permanently affixed to the refrigerator. The ADON stated, No. d. On 11/29/23 at 2:20 PM, the Surveyor requested a medication storage policy from the Administrator. e. On 11/29/23 at 3:17pm, a policy titled, Medication Storage in the Facility (2022 edition), provided by the Administrator documented, .Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .

Based on observation, record review, and interview the facility failed to ensure dental products were stored in a sanitary manner to prevent infection for 1 (Resident #44) of 2 (Residents #24 and #44) sampled residents who required denture care; and soiled laundry from isolation rooms was transported in a sealed container from the secure unit to the laundry room. The findings are: 1. Resident #44 had diagnoses of unspecified dementia, anxiety disorder and type 2 diabetes mellitus. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 09/21/2023 indicated the resident scored 4 (a score of 0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS) and required supervised set up assistance for eating and bed mobility, supervised one person assistance for transfers, and limited one person assistance for dressing, toileting, and personal hygiene. a. The Care Plan with a revised date of 03/25/2023 documented, . is dependent on staff to activities for emotional, intellectual, physical, and social stimulation . The resident needs assistance with ADLs as required during the activity . and I require .limited assist x1 staff with .personal hygiene . Observe for my hygiene needs and render as needed each shift and prn [as needed] . b. On 11/27/2023 at 10:07 AM, observed an uncovered, blue denture cup with Resident #44's name on the side, resting on the left-hand side of the sink, to the left of the toilet. The denture cup contained both upper and lower dentures resting in just enough clear fluid to cover the bottom of the denture cup. The upper dentures appear dry, with white patches on the upper sides. c. On 11/28/2023 at 8:54 AM, observed Resident #44's blue denture cup resting on the left-hand side of the sink with lower and upper dentures stored uncovered. The dentures were covered with clear fluid this morning. d. On 11/28/2023 at 2:41 PM, the Surveyor asked Certified Nursing Assistant (CNA) #1 to look in Resident #44's restroom. She pointed out there was not a lid on the blue denture cup resting on the left side of the sink, to the left of the toilet. CNA #1 said it is important to keep the dentures covered to keep out germs and bugs and staff would be responsible for noticing the lid was missing and replacing it. e. On 11/29/2023 at 8:25 AM, the Surveyor asked the Director of Nursing (DON) what process they use to provide hygienic dental care for residents with dentures. The DON said that staff and residents wash and brush dentures and place them in a labeled denture cup. The Surveyor asked if denture cups should be covered with a lid. The DON said, Yes, denture cups should be covered with a lid for residents. f. On 11/29/2023 at 3:17 PM, the Administrator said there is not an ADL policy. 2. On 11/30/2023 at 10:21 AM, the Surveyor entered the laundry room and Laundry Worker #2 was asked to show where PPE (Personnel Protective Equipment) is kept and how contaminated linen is transported. Laundry Worker #2 pointed out a red can with a lid broken on both sides with what appeared to be a 5 inch x 1.5 inch area preventing the container from sealing correctly. On one side the crack was extending in towards the middle of the container approximately 4 inches in length. Laundry Worker #2 told the Surveyor that the red can is placed outside of the isolation rooms, PPE is donned, and bagged soiled linens are tied in a knot and placed in the red can outside the resident's door. a. On 11/30/2023 at 10:25 AM, the Surveyor checked the inner red bag in the red rolling trash can and observed an open clear bag of soiled laundry. b. On 11/30/2023 at 10:54 AM, during an interview Laundry Worker #2 the red can needs a good seal for infection control. c. On 11/30/2023 at 1:53 PM, the Surveyor asked the DON what the process was for taking soiled linens from the isolation rooms and transporting them to the laundry room. The DON said that linens are placed in a disintegrating bag, that goes into a red barrel with a red liner. The contaminated laundry is taken to the laundry room, and it is not washed with other laundry. The disintegrating bag with linens is placed in the washer. The Surveyor asked if the red barrel should have a lid that seals tightly when transporting laundry. The DON said, Yes, the red barrel should have a lid. d. On 11/30/2023 at 2:18 PM, the Administrator was asked if the facility had an infection control policy addressing laundry. e. On 11/30/2023 at 02:37 PM, the Administrator provided a policy titled, Laundry and Bedding, Soiled, which documented, Policy Interpretation and Implementation .2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use. 3. Place and transport contaminated laundry in bags or containers in accordance with established policies governing the handling and disposal of contaminated items. 6. Environmental services and nursing staff will place and transport contaminated laundry that is wet enough to potentially leak or soak through the bag or container in double bags, or leak-proof bags or containers .

Based on record review and interview, the facility failed to ensure the resident and/or representative was notified in writing of the facility's bed hold policy and any potential bed hold charges for 1 (Resident #30) of 6 (Residents #4, #30, #39, #50, #51 and #52) sampled residents who were discharged or transferred over the last 90 days. The findings are: 1. Resident #30 had diagnoses of diabetes mellitus, (congestive) heart failure, and transient cerebral ischemic attack (a stroke that lasts only a few minutes). The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/29/2023 documented a Brief Interview for Mental Status (BIMS) of 11 (08-12 indicates moderately impaired). a. Resident #30 was discharged to the hospital on 02/20/2023. ER (emergency room ) records indicate resident was admitted with an altered mental status, and suspected seizure. Resident #30 was admitted for IV (intravenous) anti-seizure medication and neuro checks. b. On 11/29/2023 at 11:00 AM, review of the electronic record showed no bed hold policy was provided to the resident or the family for the hospitalization from [DATE]-[DATE]. c. On 11/29/2023 at 11:30 AM, the Surveyor asked the Administrator for a copy of the bed hold policy from Resident #30's hospitalization on [DATE]. d. On 11/29/2023 at 03:17 PM, the Administrator said they did not have a bed hold for Resident #30 for the 02/20/2023 discharge to the hospital. e. On 11/20/2023 at 03:17 PM, the Administrator provided the facility policy titled, Bed Holds and Returns (03/11/2022 Revision), documenting, .Policy Statement: Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy, unless the transfer is an emergency transfer to an acute care hospital. In those instances, the resident representative will be notified as soon as practical .

Based on observation, record review, and interview, the facility failed to ensure pureed food items were blended to a smooth, lump-free consistency to minimize the risk of choking or other complications for 1 (Resident #14) of 3 (Residents #9, #14 and #44) sampled residents who required pureed diets for 1 of 2 meals observed. This failed practice had the potential to affect 5 residents who received pureed diets. The findings are: 1. Resident #14 had diagnoses of Alzheimer's disease, psychosis, and anxiety disorder. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/27/2023 documented a score of 01 (0-7 indicates severe cognitive impairment) on a Brief Interview for Mental Status (BIMS) and was dependent for eating, dressing, toileting, transfers, and personal hygiene. a. A Physicians Order dated 12/22/2022 documented, .Pureed Texture, thin liquids consistency, add fortified cereal to breakfast, mighty shake with lunch and dinner . b. On 11/29/23 at 12:19 PM, Residents #14's meal slip showed Resident #14 was on a regular pureed diet. Resident #14's plate contained pureed beans, a pureed roll with a pudding consistency, and spaghetti that had a thick, chunky looking texture. c. On 11/29/23 at 12:20 PM, the Surveyor asked Certified Nursing Assistant (CNA) #3 to describe the texture of the spaghetti she was feeding Resident #14. CNA #3 said, Its soft . like a mechanical soft texture. It should look more like a smoothie. d. On 11/30/2023 at 0800 AM, during an interview the Surveyor asked the Dietary Manager (DM) to DM to describe the texture of the pureed food. The DM stated, Puree is a pudding consistency, and it is important to serve the food prepared as ordered to prevent choking.

Based on observation, record review, and interview the facility failed to ensure that oral care was provided for 1 (Resident #9) of 10 sampled residents (#4, #8, #9, #12, #13, #19, #22, #23, #24, #141), who were dependent for oral care according to the list given by the Administrator on 09/08/22 at 1:35 PM. The findings are: 1. Resident #9 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set [MDS] with an Assessment Reference Date [ARD] of 06/18/22 documented a Brief Interview Mental Status [BIMS} of 02 (indicated cognition severely impaired). required limited assist with activities of daily living self-performance skills with one-person physical assist. a. On 09/06/22 at 12:20 PM, The resident was ambulating in the hallway on unit. The Resident's pants were wet in the seat. The Surveyor asked the Resident, how are you? He stated, Fine, and then rambles when speaking. The Resident's teeth needed brushing. There was a milky cheesy film over them. b. On 09/08/22 at 10:48 AM, The Surveyor showed the Resident's teeth to the Licensed Practical Nurse (LPN) #1. The teeth were still in need of brushing. c. On 09/08/22 at 11:54 AM, The Surveyor asked the Minimum Data Set (MDS) Coordinator if the Resident's Plan of Care documented, that he resisted oral care. She read the Plan of Care and stated, No, it is not on the Plan of Care, but I will add it. d. On 09/08/22 at 2:58 PM, The Surveyor asked the Certified Nursing Assistant (CNA) #1, When should you perform oral care on residents? She stated, In the morning and after every meal. e. On 09/08/22 at 3:02 PM, The Surveyor asked CNA #2, When should you perform oral care on residents? She stated, After every meal. f. On 09/08/22 at 3:05 PM, The Surveyor asked Licensed Practical Nurse (LPN)#3, When should oral care be performed on residents? She stated, In the morning and after every meal and at night before they go to bed. Also, if a resident has any inhaled medication, it should be done after that. g. The Plan of Care dated 06/18/22 documented, PERSONAL HYGIENE: Resident requires limited-extensive assistance with cueing with short, simple instructions such as hold your brush, wash your hands; with personal hygiene care at times.

Based on record review and interview the facility failed to ensure that a Pre-Admission Screening and Resident Review [PASARR] Level II was in place in the medical record, and in the facility for 1 (Resident #13) of 12 sampled Residents (#1, #4, #6, #9, #13, #19, #22, #23, #24, #33, #39, #141) that required PASARR's according to the list given by the Administrator on 09/08/2022 at 4:56 PM. The findings are: 1. Resident #13 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set with an Assessment Reference Date [ARD] of 07/01/2022 documented a Brief Interview Mental Status of 14 (indicated cognition intact), required limited assistance with activities of daily living self-performance skills with one-person physical assist. a. On 09/07/2022 at 11:54 am, The Surveyor asked Licensed Practical Nurse (LPN) #1 if the Resident had a PASARR? She gave a letter from the screening entity which documented, Has been approved for nursing placement by OLTC (Office of Long-Term Care) and my enter nursing home of his/her choice. b. On 09/08/2022 at 11:45 am, The Surveyor notified the Screening entity for PASARR's and asked, Does this Resident have a Level II PASARR? The Resident does have a Level II PASARR, on March 11, 2022, the resident was not Psych stable, and was informed also that the facility needed to send in a new application within 30 days. In order to receive PASARR now there is a fee for it.

Based on record review and interview, the facility failed to ensure a written discharge summary was completed that included a recapitulation of the resident's stay that consisted of a concise summary of the stay, course of treatment for 1 of 9 discharged residents (Resident #41) of 1 sampled resident who was discharged in the past 120 days. 1. Resident #41 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an assessment reference date of 06/29/22 documented a Brief Interview for Mental Status of 15 (13-15 indicates cognitively intact.) 2. The Discharge Return Not Anticipated MDS with an Assessment Reference Date (ARD) of 06/29/22 documented discharge planned to another nursing home or swing bed. 3. The Discharge Instructions and Summary dated 6/29/22 at 1:15 p.m., documentation under the section titled Recapitulation of Residents Stay on 6/29/22 was left blank. 4. On 09/08/22 at 2:10 p.m., The Surveyor asked the MDS Coordinator, Who's responsibility is it to complete the Discharge Summary Recapitulation of Stay? MDS Coordinator stated, The charge nurse at the time of discharge. She was asked, What is a recapitulation of stay supposed to identify? She stated, The overall care while a resident at the facility. She was asked is a recapitulation of stay be blank? She stated, No, it should not. 5. The Discharge Transfer Policy provided by the MDS Coordinator on 9/8/22 at 2:40 p.m., states the discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of the discharge in accordance with established regulations

Based on observation, and interview, the facility failed to ensure kitchen carts, storage racks, floors, and work tables were maintained in clean condition, foods were stored per manufacturer's guidelines, outdated foods were and promptly discarded before the expiration dates, fruit was discarded before it spoiled, and the can opener and vent hoods were cleaned to minimize the risk of food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 39 residents who received meals and ice from the kitchen (total census: 40), as documented on a list provided by the Dietary Manager on [DATE]. The findings are: 1. On [DATE] at 11:31 AM, during the initial rounds of the kitchen, the following observations were made: a. In the dry storage area, there was a box containing 40 1.5-ounce packages of 1000 Island dressing with a use by date of [DATE] on it. Dietary Employee #1 was asked if the expired product should be discarded and she said, Yes. They are expired by a few days. b. In the walk-in refrigerator there was a partial case of ,d+[DATE] ounce of nutritional milk shakes with a date of [DATE] written on the box. On the side of the box was documented Keep frozen. Per Dietary Employee #2 the date of [DATE] represented the date the product was delivered to the facility. Dietary Employee #2 was asked how long the shakes had been out of the freezer. Dietary Employee #2 stated, Whenever they come in, we put them on the shelf. I put some of them on this tray. On the other side of the refrigerator on a shelf there was a tray of ,d+[DATE]-ounce milk shakes. The manufacture's guidelines on the milk shakes document, HANDLING INSTRUCTIONS: Store frozen. Thaw under refrigeration (40F or below). After thawing, keep refrigerated. Use within 14 days after thawing. c. In the walk-in refrigerator there was two containers of fresh strawberries dated for [DATE]. There was one strawberry in each container with a gray, velvety substance on them. Dietary Employee #1 was asked to describe what she saw. She stated, They are bad. 2. On [DATE] at 9:19 AM, during follow-up rounds the following observations were made in the kitchen: a. The bottom shelf of the serving line was covered with a grayish fine substance. Dietary Employee #1 was asked to describe what she saw. She stated, An old steam table. It won't come off. The employee wiped the area with a napkin and gritty brownish substance transferred to the napkin. b. Near the serving line there was a kitchen cart with clean bowls store on it. On the third shelf there were three sticky yellowish spots on it. Dietary Employee #1 was asked what the substance was. She stated, Looks like food. It's probably from this morning. c. A can opener on the middle worktable was had blackish debris around the blade and the base attached to the worktable. Dietary Employee #3 said, It probably just hasn't been cleaned yet today. Dietary Employee #3, the cook, was asked if he had used the can opener this morning and he said, No ma'am. So far everything has been frozen products. d. The hood vents had shiny, smooth, blackish substance on them. Dietary Employee #1 was asked the last time the vents were cleaned. She replied, ,d+[DATE], but because of COVID they haven't been out. The Maintenance Director who was standing nearby was asked who is responsible for cleaning the vents and he stated, [Company] cleans it. They were supposed to have come at the end of June. I don't have all the paperwork yet. I will call them. When asked if the vents looked clean to him, he stated, Not as clean as it should be. e. There was a storage rack located behind the ovens with clean pots and pans on it. Stringy brownish substance was on the rack. Dietary Employee #1 was asked to describe what she saw, and she stated, It's built up dust. f. Throughout the kitchen under storage racks and other dietary equipment there were brownish and blackish spots on the floor. Dietary Employee #1 was asked how often the floor are swept and mopped, and she stated, After breakfast, lunch and dinner.

Based on record review and interview, the facility failed to ensure personal funds were available upon request or within 3 working days for 1 (Resident #14) of 14 (Residents #4, 5, 7, 10, 14, 16, 20, 21, 23, 25, 27, 29, 34, and 40) sampled residents who had personal funds in the facility. This failed practice had the potential to affect 28 residents whose personal funds were managed by the facility, per a list provided by the Business Office Manager (BOM) on 7/9/2021 at 8:28 AM. The findings are: 1. Resident (R) #14 was admitted [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/2021 documented a Brief Interview for Mental Status (BIMS) score of 15 (13-15 indicates cognitively intact) and has the ability to make self-understood and has the ability to understand others. a. On 07/10/2021 at 10:00 AM, during an interview with Resident #14, she informed the surveyor and the Ombudsman that she had requested $1400.00 but never had received it. They tried giving me the money in a check, but I wanted cash. They told me they couldn't do that because I'd need to go to the bank to get it cashed and would have to show them my ID. I told them that they had my ID, but they told me they didn't. I told them I didn't want the money if I had to go out to the bank. The Business Office Manager (BOM) told her that she could take her ID and go to the bank to cash her check or not. She also said that on the 6th of this month she requested her money plus interest: $1849 plus interest. They told me that they had attempted to give her the money she requested back in May but said she didn't want the check. She said she told them that she didn't want the money in a check; she wanted cash. (She showed the surveyor what she gave them on the 6th requesting her money). b. At 11:00 AM, the BOM was asked, Why [R#14] had not received her money she requested back in May of this year? She said, I tried to give her the money, but she told me she did not want the check. She was then asked, Did you ask her if she wanted it in another form like cash? She said, No. She was then asked, Did [R#14] ask for $1849 plus interest on the 6th? She said, Yes. She was asked, Have you given her that money yet? She said, No, I have to send the $1400 check for them to deposit back into her account then send in another check request for the $1849 she just requested. She was asked, Can you not give her money in cash since she still doesn't want a check? She said, No and then said, I guess I could have the Administrator sign a check to get her the cash. She was asked, Can you get her the cash today? She said, No, but I can send my request Fed Ex [Federal Express] and can possibly get it in a few days. She was asked, Is there no possible way for her to get the cash today? She said, Yes, I'll make that happen. 2. The Personal Fund Request Policy and Procedure provided by the Administrator on 7/9/2021 at 2:47 PM documented, Best Practice Guidelines: Residents have the rights to access funds on an ongoing basis. The facility must have accessibility that accommodates the residents this would also include weekends. Resident must have access to $100.00 ($50.00 for Medicaid Residents) in cash within a reasonable period, when requested. Requests for less than $100 (50.00 for Medicaid Residents) should be provided within the same day. Request for more than $100 (50.00 for Medicaid Residents) or more should be provided within three banking days. Resident request for access to their funds should be provided by facility staff as soon as possible.

Based on record review and interview, the facility failed to ensure the advance directive form in the record was complete and signed to assure the resident's wishes were known for 1 (Resident #14) of 1 sampled resident whose medical record was reviewed for Advance Directives. This failed practice had the potential to affect all residents who resided in the facility, according to the Resident Census and Condition of Resident form dated 7/6/2021 at 4:00 pm. The findings are: Resident #14 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/18/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS). a. On 07/07/21 at 11:03 AM, the Advance Directive form located in the chart was incomplete with no choice marked. b. On 7/09/21 at 3:15 PM, the Administrator was asked, Who gets the Advance Directive information signed? She stated, The Social worker. She was asked, Are you aware Resident #14 does not have an Advance Directive? She stated, No, I didn't, we will take care of that.

Based on observation and interviews, the facility failed to ensure that both Bath/Shower rooms were clean and disinfected and the walk in Tub/Shower on the Secured Unit was in good working order. These failed practices had the potential to affect 5 (Residents #7, 16, 21, 23, and 27) of 5 sampled residents who used the East Hall Bath/Shower room and 6 (Residents #3, 4, 5, 13, 25 and 26) of 6 sampled residents who used the walk in Tub/Shower on the Secured Unit. The findings are: 1. On 07/08/2021 at 04:00 PM, the water temperatures of both bath/shower rooms were checked with the Maintenance Supervisor in attendance. The temperatures were checked because of residents' complaint that the water was too cold when given a bath/shower. The water temperatures were in acceptable ranges but both bathrooms had sticky substance on the floors, soiled shower stall and soiled/dingy walk in tub/shower inside and outside, piles of hair in the floor, trash cans with overflow of trash. The walk-in tub/shower on the Secure unit had a handle and hinges broken, not allowing a complete closure; therefore, unable to take a bath; only a shower in the Secure unit area. After making observations of both rooms the Maintenance Supervisor was asked, Who is responsible for cleaning the shower stall, shower bench and walk in tub/shower between residents? He said, I think the aides do it between Residents and Housekeeping does it after all baths/showers have been given. He was asked, Are you also the Supervisor of Housekeeping? He said, No, they have their own Supervisor. He was asked, Are they able to shut the door on the walk in Tub/Shower so it seals and fills up to take a bath if they want? He said (as he was trying to shut the door), I had this fixed but now it is broken again. He was asked, With this broken can they take a bath? He said, No, they sure can't. 2. On 07/08/2021 at 04:30 PM, the Housekeeping Supervisor was asked to accompany the surveyor to both Bath/Shower rooms and was asked, When is Housekeeping staff supposed to clean and disinfect both Bath/Shower rooms? She said, They leave at 2:00 pm each day and they are supposed to clean/disinfect them and of course empty all trash receptacles. She was shown both Bath/Shower rooms and was asked, In your opinion have either of these rooms been cleaned/disinfected and/or trash taken out today before they left? She said, It sure doesn't look like it; I'll take care of this. 3. On 07/09/2021 at 12:20 PM, the Administrator was asked, How long the walk in Tub/Shower had been broken not allowing them to take baths? She said, It had been broken before I came here because when I came the owner told me that it was broken, and they were only able to take Showers. She was asked, How long has it been since you started here as Administrator? She said, I've been here since March of this year.

Based on observation, record review and interview the facility failed to ensure fingernails were trimmed to promote grooming and hygiene for 1 (Resident #34) of 11 (Residents #3, #5, #10, #11, #13, #16, #21, #26, #29, #30, and #31) sampled residents who required assistance with nail care. Also failed to ensure residents were getting their baths as scheduled to promote good hygiene and well-being for 3 (Residents #20, #33 and # 40) of 13 (Residents #34, #4, #13, #25, #5, #31,#3, #33, #29, #10, #21, #36, #40 and #20) who was required staff for assistance with bathing. These failed practices had the potential to affect 29 residents in the facility according to a list provided by the Administrator on 7/9/21. The findings are: 1. Resident #34 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 06/11/21 documented the resident scored 11 (8-12 indicates moderately impaired cognition) on a Brief Interview for Mental Status (BIMS) required limited assistance with activities of daily living with one person physical assist. a. The Plan of Care dated 6/11/21 documented, Please check my fingernail and toenail length and trim as needed unless I am diabetic. Please notify my nurse if I need my toenails trimmed. b. On 07/06/21 at 12:17 PM, the resident was self-propelling in hallway on unit and into the room. The fingernails on the left hand were long, thick with dark pigmentation, overgrown cuticles and extended approximately ¼ inch over the fingers. The thumb and the index finger have a dark thick unknown substance under the fingernails. c. On 07/08/21 at 04:22 PM, the resident's fingernails were observed with the assistance of Licensed Practical Nurse (LPN) #5 was shown the fingernails on the left hand. She agreed they needed trimming. d. On 7/09/21 at 10:40 AM, Certified Nursing assistant (CNA) #2 was asked, When should you cut a resident's fingernails? Toenails? She stated, Both when needed but if they are diabetic the nurse has to cut them. e. The Facility's Nail Care Policy provided by the Administrator on 07/09/2021 at 9:15 AM documented, It is the policy of the facility to provide personal hygiene .this includes clean, smooth nails at a well-groomed length . 2. Resident #20 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 5/3/21 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status (BIMS) and required extensive assistance of two person for bed mobility, transfer, toileting, dressing and required physical help with bathing activity. a. On 07/06/21 at 12:40 PM, the resident was asked how her care was. She stated, Well I'm not getting my baths, on a good week I get 2 and I am supposed to get 3. b. On 07/08/21 at 3:30 PM, the task sheets were reviewed for bathing, there was no bathing task on the resident's sheets. on further review it was noted that the resident did not have a bathing task at all. The progress notes were reviewed and there is no documentation of resident refusing a bath. c. On 07/09/21 at 8:30 AM, the Administrator reported that there was no bathing task on R#20's task sheets because she had been out of the facility and the task had not been reactivated. Resident was out of the facility from 2/4/21-2/23/21. d. On 07/09/21 at 08:40 AM, the resident was asked, Have you ever refused a bath or shower? She stated, No, never. I would rather get a shower. I have asked for baths in the morning. There have been times I asked them to come back a little later . I would like to have a little advance notice so I can prepare due to my responsibilities. I have been told by CNAs that they will come back after their break or after lunch and they never return, and I am not one to ride the light. 3. Resident #33 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . a. On 07/06/21 at 01:20 PM, the resident was asked how his care was. He stated, Well I'm not getting my baths, they don't want to help you, most times I have to wash myself. They keep the shower room cool because those girls say they are hot. b. On 07/08/21 at 03:30 PM, the task sheets were reviewed for bathing, there are many blank spaces on the task sheet, with no explanation. The progress notes were reviewed and the was no documentation of resident refusing a bath. c. On 07/09/21 at 08:40 AM, the resident, Have you ever refused a bath or shower? He stated, No, never. I would like to get showers, but those girls keep the shower room cool, and they don't offer me a shower. 4. Resident #40 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/19/21 documented the resident scored 6 (0-7 indicates severely impaired) on a BIMS and required supervision to limited assistance for bed mobility, transfer, toileting, dressing and required physical help limited to transfer with bathing activity. a. On 07/06/21 at 02:30 PM, the resident was asked how his care was. He stated, Well, I'm not getting my baths, I have to wash off with wipes. b. On 07/08/21 at 03:30 PM, the task sheets were reviewed for bathing, there are many blank spaces on the task sheet, with no explanation. The progress notes were reviewed and there was no documentation of resident refusing a bath. c. On 07/09/21 at 08:40 AM, the resident was asked, Have you ever refused a bath or shower? He stated, No ma'am, and I like a good bath. 5. On 07/09/21 at 10:25 AM, CNA #1 was asked, Are residents getting their baths as scheduled? She stated, No. She was asked, Are they refusing their baths? She stated, Only a few will refuse, but not all the time, you have to encourage them sometimes. She was asked, As far as you know have R#20, R#33 or R#40 refused baths? She stated, R#20 and R#40 no they want their bath, R#33 might if the shower room is cool, some CNA's keep it cold in there because they get hot and R#33 wants the heater on because he is cold natured. They have never refused when I went to get them for their bath. She was asked, Why has R#20 not been taken to get a shower? She stated, Well they took her wheelchair. 6. On 07/09/21 at 10:25 AM, Licensed Practical Nurse (LPN) #1 was asked, Are residents getting their baths as scheduled? She stated, I don't think so. She was asked, Are they refusing their baths? She stated, Usually no, the aides don't tell me if they do. She was asked, As far as you know have [R#20, R#33 or R#40] refused baths? She stated, I don't believe any of them are refusing.

Based on observation, record review and interview, the facility failed to ensure oxygen was administered per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #36) sampled residents who used oxygen. This failed practice had the potential to affect 7 residents who were receiving oxygen according to the list provided by the Administrator on 07/09/21 at 9:15 am. The findings are: 1. Resident #31 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set with an Assessment Reference Date of 06/05/2021 documented the resident scored 15 (13-15 indicates cognition intact) on a Brief Interview for Mental Status and received oxygen while a resident. a. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Plan of Care dated 06/08/2021 documented, The resident has oxygen therapy r/t [related to] Respiratory illness . OXYGEN SETTINGS: O2 via nasal cannula [at] 2 l/m as needed. c. On 07/06/21 at 02:02 PM, the resident was in bed with O2 on at 2.5 LPM/NC humidifier bottle dated 7/5/21. d. On 07/08/21 at 03:48 PM, the resident was in bed, with the head of the bed elevated. O2 was on at 2.5 LPM/NC. e. On 07/09/21, the following staff were asked, Who monitors oxygen rates to ensure it is at the correct rate? At 3:30 PM, Licensed Practical Nurse (LPN) #2 stated, The nurses. At 3:40 PM, LPN #3 stated, The nurse. At 3:45 PM, LPN #4 stated, The nurse. f. The Facility's Policy and Procedure for Oxygen Administration provided by the Administrator on 7/9/21 documented, The purpose of this procedure is to provide guidelines for safe oxygen administration. Verify there is a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, record review, and interview, the facility failed to ensure that a Pre Admission Screening and Resident Review (PASARR) Level II was in place in the medical record, and in the facility for 2 (Residents #4 and #26) of 12 sample residents (#3, #4, #6, #7, #15, #16, #17, #21, #23, #26, #27, and #31) who required Level II PASARR. This failed practice had the potential to affect 30 residents in the facility who required Level II PASARR's according to the list provided by the Assistant Director of Nursing (ADON) on 07/09/21 at 2:00 PM. The findings are. 1. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2021 documented the resident score 3 (0-7 indicates cognition severely impaired), on the Brief Interview for Mental Status (BIMS). a. On 07/07/21 at 11:51 AM, a record review was done and there was no Level II PASARR in the resident's record. b. On 07/09/21 at 12:30 PM, the entity that does the PASARR was contacted and asked if the resident had a Level II PASARR. The staff there stated, Yes, he has one, from 2013, it would probably be at the facility that he was discharged from, there is no other information in our records. There is no information that he moved to another facility. c. On 07/09/21 at 3:50 PM, the Administrator was asked, Who contacts the PASARR entity to let them know a resident had been admitted to the facility? She stated, Usually Admissions. d. At 03:55 PM, the Admissions Personnel was asked about the PASARR and stated, I usually submit a fax and within 30 days they will send it out to us. Resident #4 was here when I came. Resident #26 I submitted her admitted on 5/13/21 requesting a Level II. 2. Resident #26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS with an ARD of 05/19/21 documented a BIMS score of 15 (13-15 indicates cognition intact). a. On 07/07/21 at 12:18 PM, a record review was done and there was no Level II PASARR in the medical record. b. On 07/08/21 at 11:30 AM, the Administrator was asked if the resident had a Level II PASARR. She gave a copy of the entity's determination letter for the resident, but there was no Level II found. c. On 07/08/21 at 11:54 PM, the State Designated Professional Associates was contacted. The surveyor spoke with an employee there and asked if the resident had a Level II PASARR. She stated, Yes she does but, we have not received an admitted stating she has entered a facility, so it has not been sent.

Based on observation, record review and interview, the facility failed to ensure toenails were trimmed to promote grooming, and hygiene for 1 (Resident #4) of 12 (Residents #3, #4, #5, #10, #11, #13, #16, #21, #26, #29, #30, and #31) sample residents who were dependent on staff for nail care. This failed practice had the potential to affect 29 residents in the facility dependent and/or assisted for nail care according to a list provided by the Administrator on 07/09/21. The findings are: Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/28/2021 documented the resident score 3 (0-7 indicates cognition severely impaired), on the Brief Interview for Mental Status (BIMS), required supervision with personal hygiene with one-person physical assist. a. On 07/07/21 at 08:48 AM, the resident was lying in bed during medication pass. The resident had his shoes off, no socks on, his toenails extended greater than 1/4 inch over the end of the toes, some were jagged, and some were twisted. b. On 07/09/21 at 04:20 PM, the resident's feet were observed with the assistance of Licensed Practical Nurse (LPN) #5. LPN #5 was asked, Do you think the resident's toenails need cutting? She stated, Yes, he is Diabetic, so the nurses have to cut his nails. c. On 07/09/2021, Certified Nursing Assitant (CNA) #2 was asked, When should you trim a resident's fingernails? Toenails? CNA #2 stated, When needed for fingernails and toenails.

Based on observation, record review, and interview the facility failed to ensure staff stored Personal Protective Equipment (PPE) appropriately to prevent the possible spread of respiratory infection after their shift; and staff who worked in the isolation / COVID-19 zone wore appropriate Personal protective Equipment (PPE) when working in the area. These failed practices resulted in Immediate Jeopardy which caused or was likely to cause serious harm, injury or death to 45 residents due to due staff who entered the COVID19 unit, then left unit and went to non COVID unit were not wearing personal protective gear while on the COVID unit and staff left the building with the N95 mask they had been wearing while on duty. The Administrator was notified of the Immediate Jeopardy on 8/14/2020. The findings are: 1. On 8/14/2020 at 10:15 a.m., in the Common area (Side doors into common area that have RED ZONE signs) with the Director of Nursing, Licensed Practical Nurse (LPN) #2 exited through the doors without proper PPE and returned to work in Green zone. A photograph of the side doors was taken at this time. b. On 8/14/2020 at 11:35 a.m., Laundry employee #1 come in through the Common area (Side doors into common area that have RED ZONE signs and then left thru the same doors. The only PPE she was wearing was a mask. A photograph of Laundry Employee #1 was taken at this time. c. On 8/14/2020 at 11:40 a.m., Certified Nursing Assistant (CNA) #1 was asked, What do you do with your N95 mask at the end of your shift? CNA #1 stated, I carry it home. We have to keep them for 5 days. CNA #2 was asked Are these doors supposed to be used (Side doors into common area that have RED ZONE signs)? CNA #2 stated, No Everyone is supposed to go around. CNA #2 was asked, Should you have full PPE when on the COVID unit? CNA #2 stated, Yes. d. On 8/14/2020 at 11:50 a.m., Housekeeping employee #1 was asked, What do you do with your N95 mask at the end of your shift? Housekeeper employee #1 stated, I carry it home. We must keep them for 5 days. Housekeeper employee #1 was asked, Are these doors supposed to be used? Housekeeper employee #1 stated, No Everyone is supposed to go around, but some staff have been using those doors. Housekeeper employee #1 was asked, Should you have full PPE when on the COVID unit (Red Zone)? Housekeeper employee #1 stated, Yes, I try to change my gown 2 times during the shift. e. On 8/14/2020 at 12:06 a.m., Laundry employee #1 was asked, What do you do with your N95 mask at the end of your shift? Laundry employee #1 stated, I carry it home. We have to keep them for 5 days. Housekeeping employee #1 was asked, Are these doors supposed to be used? (Side doors into common area that have RED ZONE signs(picture) We were told it was a green zone this morning. 3. Who told you it was a Green zone?(NAME)the Housekeeping supervisor f. On 8/14/2020 at 11:45 a.m., CNA #2 was asked, What do you do with your N95 mask at the end of your shift? CNA #2 stated, I carry it home. We have to keep them for 5 days. CNA #2 was asked, Are these doors supposed to be used? CNA #2 stated, No. People are supposed to use the outside door, but people use those doors all the time. CNA #2 was asked, Should you have full PPE when on the COVID unit (Red Zone)? CNA #2 stated, Yes. g. On 8/14/2020 at 11:20 a.m., Licensed Practical Nurse (LPN #1) was asked, What do you do with your N95 mask at the end of your shift? LPN #1 stated, I carry it home. We have to keep them for 5 days, unless it is visibly dirty then I throw it away. LPN #1 was asked, Should you have full PPE when on the COVID unit (Red Zone)? LPN #1 stated, Yes. h. On 8/14/2020 at 2:55 p.m., LPN #2 was asked, What do you do with your N95 mask at the end of your shift? LPN #2 stated, Well, I keep it for the next day. We are supposed to use them for 5 days unless it is soiled. LPN #2 was asked, Are these doors supposed to be used (Side doors into common area that have RED ZONE signs)? LPN #2 stated, No. Everyone is supposed to go around. LPN #2 was asked, Should you have full PPE ? LPN #2 stated, Yes. i. On 8/14/2020 at 2:35 p.m., LPN #3 was asked, What do you do with your N95 mask at the end of your shift? LPN #3 stated, I spray it with purple spray and take my mask home. LPN #3 was asked, How long have you had your N95? LPN #3 stated, 4 days. LPN #3 was asked, Should you have full PPE? LPN #3 stated, Yes. j. A Policy and Procedure Guide form titled Covid-19 PPE Zone Guidelines documented, Page 38: Facility Covid-19 Policy and Procedure states, under sub section titled Covid-19 PPE Zones Guidelines. Red Zone Full PPE: N95 Mask, gown, gloves, eye protection, face shield, hair covering, shoe covering. If shoe coverings are unavailable, must spray shoes (including soles) with disinfectant prior to leaving Red Zone. This PPE can be worn throughout the unit from room to room. Should only be changed if soiled or ill-fitting. There must be a barrier at the entrance of red zone. Red Zone must be clearly marked RED ZONE at the entrance. Once staff are in this zone, they must stay entire shift and not enter into any other zone. Green Zone: There should be no staff entering this unit from the Red or Yellow Zones. A barrier should be in place and Green Zone should be clearly indicated. Page 29: Facility Covid-19 Policy and Procedure states, Remove mask/respirator (after exit room/closed door) grasp bottom, then top ties or elastics and remove. Discard in waste container. 2. The Immediate Jeopardy was removed and the scope and severity was reduced to an F when the following Plan of Removal was implemented on 8/14/2020. a. Upon notification of the deficient practice the Maintenance Director changed the codes to the entrance of the designated contaminated area to ensure the staff do not enter a contaminated area to prevent the spread of Covid-19. b. All staff were given new Ng5s and paper bags for proper storage. DON placed plastic containers located at each nurses station for proper storage of N95's on 0g-14-2020 to prevent the spread of Covid-19. c. All residents on the affected area identified by positive lab results for covid-19 were reassessed by DON on 08-14-2020 with no negative findings d. All staff will be in-serviced on 08-14-2020 by DON/Designee on entering/exiting contaminated areas and properly storing N95 PPE in a brown paper bags and placed in a plastic container located at each nurses station to prevent the possible spread of Covid-19 e. DON/Designee will monitor, through observations and interviews, proper entrance into contaminated areas and proper N95 storage five times for four weeks and then three times a week until compliance is met to prevent the possible spread of covid-l9 throughout the facility and upon discovery, any negative findings will be corrected immediately. DON/Designee will report findings to the monthly QA&A Committee for follow up and recommendations.

Complaint # (AR 005) was substantiated, all or in part, with these findings: Based on observation, record review, and interview, the facility failed to ensure cardiopulmonary resuscitation (CPR) was correctly provided for a resident who had a physician order [REDACTED]. The failed practice resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Resident #1, who had a documented Full Code status and received CPR, and had the potential to cause more than minimal harm for 33 residents who had physician orders [REDACTED]. 1. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set with an Assessment Reference Date of [DATE] documented the resident scored 9 (,[DATE] indicates moderately impaired) on a Brief Interview for Mental Status; was independent for bed mobility, transfers, and toilet use; required supervision with one person physical assistance with dressing and personal hygiene; was independent with setup help only for eating; was always continent of urine; and was occasionally incontinent of bowel. a. A physician's orders [REDACTED].Full Code . b. A Care Plan dated [DATE] documented, .(Resident) is a Full Code . (Resident's) wishes will be honored .Notify MD (Medical Doctor) and family with any change in status, and treat as indicated . c. A Nursing Note dated [DATE] at 01:44 (1:44 a.m.) documented, .Laying (sic) in bed, eyes closed . Resp (respirations) even and unlabored . No S/S (signs/symptoms) of pain or discomfort noted . N/O (new order) noted for [MEDICATION NAME] 17 grams Q-day (every day) /[MEDICATION NAME] 4 MG (milligrams) PO (by mouth) Q (every) 6 hours PRN (as needed) . Meds (medications) have been ordered and will begin upon arrival . NAD (No acute distress) noted . Checked often per staff . C/L (call light) remains in easy reach and working . d. A Nursing Note dated [DATE] at 10:55 (10:55 a.m.) documented, . Resident lying in bed resting at this time. Resp (respirations) even and unlabored. Skin w/d (warm and dry). No c/o (complaints of) pain noted. Resident had vomiting episode at 9:30 a.m. Give one prn (as needed) [MEDICATION NAME] 4 mg (milligrams) for nausea / vomiting. No more emesis noted at this time. Remains on 17 grams of [MEDICATION NAME] q (every) day. No adverse reactions noted. Able to make needs known. Call light in reach. Continue with current plan of care . e. A Nursing Note dated [DATE] at 13:52 (1:52 p.m.) documented, .Resident ate some lunch and shortly after had emesis. Resting quietly at this time. Resp (respirations) even and unlabored. Skin w/d (warm and dry). No c/o (complaints of) pain noted. Checked often. Continue to observe . f. A Nursing Note dated [DATE] at 21:01 (9:01 p.m.) documented, .3:30 (p.m.) Resident in the bed. Alert and able to speak with clear speech. Resident said was ok. Noticed the resident had some sweat on the forehead. He said he had been sick earlier in the day. Vital (Vital signs) taken: B/P (blood pressure) ,[DATE] . P (pulse) 108 . R (Respirations) 22 . T (Temperature) 98.1A (Axillary) . O2 (oxygen) sats (saturations) on room air 81% . Applied O2 (oxygen) (at) 2 lpm (liters per minute). He is in no distress (at) this time. BLLS (bilateral lower lobe sounds) noted wheezes. Abdomen distended. No c/o (complaints of) pain to the touch. Notified APN (Advanced Practice Nurse) and informed him of the condition of the resident. Vitals given. Tylenol given for the elevated temp. Orders have been given for a chest x-ray, Z-pack ([MEDICATION NAME] pack) as ordered, [MEDICATION NAME] dose pack as ordered, [MEDICATION NAME] 1g (gram) mixed with 2.1ml (milliliters) of [MEDICATION NAME] IM (intramuscular) injection. Resident has clear speech, no distress . [MEDICATION NAME] given IM (intramuscularly) in the right hip ID (initial dose) of [MEDICATION NAME] 250 mg (milligrams) tabs (tablets) 2 given. He did c/o (complain of) nausea (at) 4 .m. (4:00 p.m.). [MEDICATION NAME] given. Resident continues to want to put his leg in the chair. Given order for O2 (oxygen) via N/C (nasal cannula) (at) 2 LPM (liters per minute) for O2 sats (saturations) (less than) than 92%. Will continue to monitor . g. A Nursing Note dated [DATE] at 23:08 (11:08 p.m.) documented, .CNA (Certified Nursing Assistant) called the LPN (Licensed Practical Nurse). She said, 'I think the resident needs you.' Entering the room, the resident was throwing up, turned on the side, dark color vomiting. Very large amount. Resident was trying to talk. Continued to vomit. He stopped breathing (at) 10:45 (10:45 p.m.). Had CNA to call the ambulance (Name). Could feel pulse on the neck. Resident continued to have vomit coming from the mouth. 10:50 (10:50 p.m.) no pulse or breathing. CPR (Cardiac [MEDICAL CONDITION] Resuscitation) started and continued until the EMT's (Emergency Medical Technician) arrived in the room and took over in the room. 10:55 (10:55 p.m.), they said they were taking him to (Hospital Name). Called Dr. (Doctor) and informed him of the situation and that the resident was being transferred to the (Hospital Name). He said that was good and that was fine. All necessary parties notified, DON (Director of Nursing), Administrator .Resident in route to (Hospital Name . h. A Nursing Note dated [DATE] at 23:24 (11:24 p.m.) documented, .Initial start 10:35 (10:35 p.m.) called by CNA to room . i. A CPR Note dated [DATE] at 23:40 (11:40 p.m.) documented, .Code Status Verified . Yes .Unresponsive .Yes .Most Recent Pulse .100 .Date XXX[DATE] . 22:35 (10:35 p.m.) .Most Recent Respiration .24 (breaths per min) . Date . [DATE] .23:35 (10:35 p.m.) . Date and Time CPR initiated . [DATE] . 2250 (10:50 p.m.) .Date and Time 911 Contacted . [DATE] . 22:45 (10:45 p.m.) . Date and Time 911 Arrived . [DATE] .22:55 (10:55 p.m.) . Date and Time Family / Responsible Party Notified . [DATE] . 23:15 . j. A County Ambulance Service Report dated [DATE], and provided by Emergency Medical Technician (EMT) #1, documented, .Transported Lights / Siren . PSAP (Public Safety Access Point) call . 22:44:12 (10:44 p.m.) . D - Unit called to respond. Emergency to the nursing home in (Name of town) for an unconscious person . nausea / vomiting with aspiration . now [MEDICAL CONDITION]. H (History) . Our patient nursing staff report he was feeling sick all day and had refused food and liquids. Patient ate two bites of his food this evening and went to bed. Nursing staff did a bed check and found him vomiting. Staff then started CPR. Patient in full [MEDICAL CONDITION], no ventilations, BVM (Bag Valve Mask) wasn't assembled appropriately. Patient has a past history of [MEDICAL CONDITION], Hypertension and [MEDICAL CONDITION] with Minor Cardiac Potassium issues. A (Assessment) . Our patient a 79 y/o (year old) unconscious in bed with chest compressions in progress. HEENT (Head, Ears, Eyes, Nose, Throat) .found mouth full of vomit, positive BBS (Bilateral Breath Sounds) (times) 4 with BVM (Bag, Valve, Mask) rales .bilateral skin warm very dry. Abd (Abdomen) soft, non-distended . R (Respirations) .SAO2 (Oxygen saturation) 0% . EKG (Electrocardiogram) PEA (Pulseless Electrical Activity) . 45 .ALS (Advanced Life Support) assessment . V/S (vital signs) monitored . CPR continued . started an IV (Intravenous Line) 18 G (gauge) left AC (antecubital) first attempt . NS (Normal Saline) wide open. DXT ([MEDICATION NAME] / Blood Sugar) 89 MG/DL (milligrams per deciliter) give EPI ([MEDICATION NAME]) 1: 1 MG (milligram) IVP (Intravenous Push) . no change . suction airway . placed ET (Endotracheal) tube 7.5 (size) first attempt . marked 22 MM (millimeters) . suction ET tube. Give [MEDICATION NAME] 1 MG IVP . no change . give 50 MEQ's (mill-equivalents) of Sodium [MEDICATION NAME] ([MEDICATION NAME]) IVP . patient EKG now . Junctional 67 . no ectopic with a pulse restored for a few minutes place . [MEDICATION NAME] drip 5 MCG (micrograms) /KG (per kilogram) /Min (per minute) set 19 drops. Patient entered [MEDICAL CONDITION] . CPR restarted Give second EPI 1: . 1 MG .no change. Give second [MEDICATION NAME] . 1 MG IVP .no change. Give third EPI 1: . 1 MG IVP . pulse restored second time . EKG . Ventricular rhythm 56 . no ectopic . reentered [MEDICAL CONDITION] asystole third time . CPR restarted .give fourth EPI 1: IVP . no change, give third [MEDICATION NAME] 1 MG IVP .no change give fifth EPI 1: 1 MG IVP .CPR continued on arrival .EKG remained in a ventricular stand still .only P waves . T (Transport) . Patient code 3 transport via stretcher .supine . patient released to (Name) hospital staff without incident or further change . [DATE] . 10:16:49 (10:16 p.m.) (EMT #2) .Nursing home staff appeared to be doing CPR in the epigastric upper abdomen area causing a lot of gastric fluids to come up through the mouth . k. A Progress Note from (Hospital Name) Emergency Record Outpatient Record dated [DATE] at 23:16 (11:16 p.m.) documented, .EMS reports that when they intubated him, he suctioned 200 cc (cubic centimeters) of coffee ground emesis from ET (Endotracheal) tube / trachea. Prior to arrival he had multiple epi ([MEDICATION NAME]), had [MEDICATION NAME] ([MEDICATION NAME]), started [MEDICATION NAME]. We gave 2 mm (millimeters) epi, D50 ([MEDICATION NAME] 50) here in ER (emergency room ). BS (Blood Sugar) was 79 in ER. Never got pulse. Pt (patient) had been down for 45 min (minutes) before arriving in ER. (At) 1133 (11:33 p.m.) called code. Pt down for almost 1 hr (hour) . TOD (Time of death) 2333 (11:33 p.m.). Cause of death . Aspiration Pneumonitis . 2322 (11:22 p.m.) Pt arrived via (Ambulance Transport Name) in [MEDICAL CONDITION]. Paramedics report arriving at the nursing home and nursing staff was performing CPR. EMS (Emergency Medical Services) intubated Pt (patient) and coffee ground secretions came out of tube. EMS performed CPR from the nursing home to the hospital. They report getting a pulse back twice, but pt returned to asystole. EMS arrived doing active CPR. Pt intubated ETT (endotracheal tube) #7.5 at 24 cm (centimeters) at the teeth, on monitor showing asystole. [MEDICATION NAME] drip hanging, 1000 ml (milliliters) of NS (Normal Saline) given prior to arrival . 2325 (11:25 p.m.) . 0.1 MG (milligrams) [MEDICATION NAME] given IVP (Intravenous push) . continuous chest compressions . 2327 (11:27 p.m.) . 1 amp ([MEDICATION NAME]) of D50 ([MEDICATION NAME] 50) given IVP . 2329 (11:29 p.m.) . FSBS (Finger stick blood sugar) performed . result of 79 . 2330 (11:30 p.m.) .0.1 MG [MEDICATION NAME] given IVP . 2333 (11:33 p.m.) . CPR stopped . Dr. (Doctor) pronounced Pt (patient) deceased . Time of death . 2333 (11:33 p.m.) . l. On [DATE] at 9:00 a.m., Charge Nurse Licensed Practical Nurse (LPN) #1 was asked the location of the Crash Cart. LPN #1 walked to the Nursing Supply Room where the Crash Cart was kept. LPN #1 stated there was one Crash Cart for the facility. The Crash Cart contained a suction machine on top of the cart. Other items in the drawers of the Crash Cart were: an adult manual resuscitator with bag reservoir and mask; a defibrillator; a sharps container; an extension cord; syringes; needles; IV start kit; flashlight; saline; alcohol swabs; stethoscope; blood pressure cuff; suction catheters; airway; peroxide; and an adult mask. A check list that was signed daily was in a binder on top of the crash cart. LPN #1 stated the resuscitator mask always comes attached to the bag. m. On [DATE] at 10:20 a.m., EMT #1 at (Name) Ambulance Service was asked about the facility's performance of CPR for the resident. EMT #1 stated, The facility did not have the BVM (Bag Valve Mask) properly expanded. He left the room and came back with a BVM (the same type used by the facility, an adult manual resuscitator with bag reservoir and mask) and demonstrated how the bag should have been expanded to provide air flow. He stated, We used to provide CPR training for the facility, but we haven't in a long time. n. On [DATE] at 10:25 a.m., EMT #2 at (Name) Ambulance Service stated when he arrived to the facility on [DATE] responding to a call regarding a resident that had aspirated, .they (staff) did not look like they knew what they were doing. One nurse was performing CPR on the abdomen pushing vomit from the stomach. It was coming up like a volcano. The other nurse had a BVM compressing it with 2 fingers, but the bag was not expanded. With her other hand behind her back, the mask was just lying over his (the resident's) mouth and nose. The BVM was not expanded so the air was not going anywhere. He stated at that point, the EMT's took over the code. He stated when he, .pulled the bag out to expand it, the nurse said, 'Oh I didn't know it did that'. His (resident's) mouth was full of vomit. I rolled him to his side and let it run out. I suctioned 100 cc's (cubic centimeters) from the ET (endotracheal) tube once he was intubated. o. On [DATE] at 10:35 a.m., LPN #1 was asked to demonstrate how the resuscitator device should be used. LPN #1 put on a pair of gloves, and demonstrated the correct assembly of the device, including expansion of the bag. p. A Basic Life Support certificate for LPN #2 (one of the two nurses who provided CPR to Resident #1) provided by the Administrator on [DATE] at 10:40 a.m. documented, .BLS (Basic Life Support) Provider .- American Heart Association . (LPN #2's Name) . The above individual has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) program . Issue date XXX[DATE] . Recommended Renewal Date XXX,[DATE] .Training Center Name . (Name and Location of Credentialing Center . q. A Basic Life Support certificate for LPN #3 (the other nurse who provided CPR to Resident #1) provided by the Administrator on [DATE] at 10:40 a.m. documented, .BLS Provider . American Heart Association . (LPN #3' Name) .The above individual has successfully completed the cognitive and skills evaluations in accordance with the curriculum of the American Heart Association Basic Life Support (CPR and AED) program . Issue date XXX[DATE] . Recommended Renewal Date . ,[DATE] .Training Center Name . (Name and Location of Credentialing Center) . r. A Guideline for Cardiopulmonary Resuscitation provided by the Assistant Director of Nursing (ADON) on [DATE] at 9:37 a.m. documented, .6. Clear the resident's airway, check for respiration .7. Place the resident on firm surface (board) . 8. Initiate basic life support . 9. Use Ambu -bag and / or mouth to mouth resuscitation using Mouth Screen . 10. Maintain basic life support until ambulance arrives for transfer to hospital . s. On [DATE] at 1:06 p.m., LPN #1 was asked if she was familiar with (Resident #1). She stated, I am familiar with (Resident #1). I worked on [DATE]. The resident was fine. The resident started having problems on the evening shift, with nausea / vomiting. On [DATE] the Night Nurse told me of his condition. The resident was resting in bed. We offered him some breakfast. The resident refused. The resident stated that his stomach was upset. The resident then vomited. I called the Nurse Practitioner and he gave the order for [MEDICATION NAME] and said that he would see him on rounds that day. I gave the resident the [MEDICATION NAME]. I monitored the resident until the Nurse Practitioner arrived. Upon arrival, the Nurse Practitioner assessed the resident, and his abdomen was distended. An order was given for an enema which I administered with results of two large bowel movements. This all happened before lunch. The resident did have another episode of vomiting after the enema. We received an order for [REDACTED]. I assisted the resident to the bathroom after lunch and the resident had another smaller bowel movement. I was off for the next two days. I did assess the resident's bowel sounds. They were very sluggish. You could hardly hear bowel sounds. I did do a Change of Condition note in the computer. The resident was able to tell us if he was having problems having bowel movements and we would give him his prescribed medication. I am CPR certified. t. On [DATE] at 1:48 p.m., LPN #4 was asked if she was CPR certified. She stated, I am certified in CPR. When I came to work here, I had to present my CPR certification. They showed me where all the equipment was located for administering CPR. I was shown a list of things to be on the cart. She was asked to demonstrate the assembly the resuscitator device with bag. LPN #4 attempted to place the mask on the bag, but it did not fit. She stated she had, .not seen an Ambu (air mask bag unit) bag like this before. She stated, .usually it's a large bag and is hung on the side of the cart. LPN #4 did not fully expand the bag on the device. u. On [DATE] at 3:07 p.m., LPN #2 was asked if she was familiar with (Resident #1). She stated, I am familiar with (Resident #1). (Resident #1) had been complaining about nausea at the beginning of (MONTH) (2019). On the day that the resident coded, when I came on duty the resident was complaining of nausea and vomiting. I called the Nurse Practitioner. I received orders for an x-ray of the chest. That evening I kept going back to check on him, and he kept complaining of nausea. The resident liked to sit in his chair with his feet up on the bed. We helped him back into the bed. The resident had eaten a little soup for supper. At approximately 10:45 p.m., the CNA (Certified Nursing Assistant) came and told me that she thought the resident needed me. He was throwing up. I immediately went to the room. The resident was throwing up when I went to his room; vomit was coming out of his mouth. His eyes were rolled back into his head. I was checking and assessing resident. I told the CNA that we needed to roll him to his side, which we did. I continued the assessment and the resident did not have a pulse. When the vomiting ceased we rolled the resident back onto his back. There were no respirations, no pulse. The resident was unresponsive. Three CNAs were in the room with me and I designated them each something to do; to go get the nurse from the other unit to come and help. I designated one them to go and get the Crash Cart. I gave them my key to go and get the Crash Cart. I designated someone to get the paperwork and call 911 to get an ambulance. The nurse from the other side came, I did the chest compressions and she did the Ambu bag. I kept performing compressions and then checked for pulse and respirations. There was no pulse and no respirations. I restarted the chest compressions. When the ambulance arrived, they took over. The resident was taken to (Name) Hospital. I was doing the compressions in the chest area, below the rib area. During the chest compressions there was no vomitus coming from resident's mouth. I am certified in CPR. We have had in-services on how to use the Ambu bag. We had our last in-service shortly after the incident with (Resident #1), on the Crash cart. LPN #2 was asked to demonstrate the assembly of the resuscitation device with bag, which she was able to do correctly. LPN #2 stated, .the nurse from the other side connected the Ambu bag to the oxygen on the night of the code. v. On [DATE] at 3:30 p.m., LPN #3 was asked if she was familiar with Resident #1. She stated, I am familiar with (Resident #1). I worked a couple of times on this side with him. I was working on the unit on the evening when the resident coded. The Nurse (LPN #2) was grabbing the Crash Cart and called for my help through the back double doors. When I got to his room, the resident was vomiting. She turned him onto his side. When the resident was finished vomiting, she rolled him back over onto his back. The bed was flat. You could tell the resident was passing, taking his last breath. The resident gasped. (LPN #2) started doing the compressions. She asked me to bag him. I am CPR certified. The CNAs were also in the room. There were three CNAs in the room with us. We did CPR on the resident until the ambulance people came. One of the CNAs called the ambulance. LPN #3 was asked to demonstrate the assembly of the resuscitation device with bag. She placed the mask onto the device and pulled out the reservoir bag. She stated she had connected the tubing to oxygen on the evening of the code. LPN #3 stated, This is how I had the bag put together on the evening of the code. The bag was not expanded, and LPN #3 was compressing the bag in its collapsed state. w. On [DATE] at 3:48 p.m., CNA #1 was asked, are you familiar with (Resident #1)? She stated, Yes. She was asked, can you give details of the night (Resident #1) coded? She stated, I had changed him and his roommate. He was fine and talking. When I was leaving the room, the other CNA was calling (Resident #1's) name, and told me to go get the nurse. I went and told the nurse (Resident #1) needed her. The nurse told one of the CNAs to go get the Crash Cart. She told one of the CNAs to go get the other nurse, and she told me to call 911. So I called 911, and told them we needed a Paramedic because someone had coded. I went back into the room. They (the two LPNs) were performing CPR. Me and the other CNAs were trying to make sure he was cleaned up and assisting the other resident out of the room. I went and made copies of his paperwork. x. On [DATE] at 5:13 p.m., the Director of Nursing (DON) was asked to demonstrate the assembly of the resuscitation device with bag, and how she demonstrated this assembly to the nurses. The DON was able to assemble the device correctly. The DON stated a 'Mock Code' was in-serviced on [DATE]. She stated, We had the ambu bag out. I cannot remember if it was collapsed or if it was one that was undone. We went through what was on the Crash Cart, the process of initiating CPR, calling the ambulance, and having someone call for help. With a new employee, we make sure they are CPR certified and show them the Crash Cart and go through what is on it. I went to (Name) for my CPR certification. All nurses are CPR certified. They had their training in (MONTH) (YEAR). On hire we check to see if they are certified. I was unable to find any further training on CPR. I am familiar with (Resident #1). I do not know any details of the code performed on him. I do know that CPR was initiated, and that the ambulance was called. I would be very surprised to know that some of the nurses do not know how to put the ambu bag together. These are the ones that were on the shelf when I came. I have not trained the nurses on the ambu bag. y. A facility in- service form dated [DATE] and provided by the DON on [DATE] at 5:13 p.m. documented, .Information provided during in-service . see attached .[DIAGNOSES REDACTED] info handout . Skin . 1. Watch for repositioning and cleaning timely . 2. Lotion and hydration . Change of Condition . Mock Code . Crash Cart . Gamma log in . Cleaning cart . z. The manufacturer's instructions for an Adult Manual Resuscitator provided by the Director of Nursing (DON) on [DATE] at 9:39 a.m. documented, .Warnings . This device should only be used by personnel trained in Adult CPR procedures . Preparation for Use . 1. Test the resuscitator for proper functioning . With patient port completely occluded, squeeze bag body to assure resistance is present . 2. Before using the mask, inspect for adequate inflation . 3. The resuscitator may be used with a 19 mm (millimeter) ID PEEP (Positive End Expiratory Pressure) accessory . Attach PEEP accessory to the exhalation port. Be sure that the accessory fits properly and does not interfere with compression of the resuscitator . 4. Actual PEEP may vary with patient lung compliance and resistance . Verify PEEP with a certified manometer . 5. For correct performance . Unfold reservoir bag and assure that airflow is not restricted . Directions for Use . 1. Place the patient in a supine position . Establish and maintain an open airway . 2. Grasp bag body with one hand . 3. Hold the mask between the index finger and thumb of the other hand . Place mask over face firmly to form a tight seal around the patient's nose and mouth . 4. Ventilate the patient by compressing the bag body for inhalation and releasing the bag body for patient's passive exhalation and bag body re-expansion . Continue this cycle as directed by medical authority . 5. To remove vomitus . Disconnect resuscitator from patient . Tap the patient valve several times while squeezing the bag body . Retest the resuscitator for proper functioning . 6. If patient is intubated, remove mask from patient port . Connect port directly to the endotracheal tube adapter . Continue ventilation . 7. Using supplemental oxygen . Connect oxygen supply tubing to O2 (oxygen) source at appropriate flow rate . Oxygen flows > (greater than) 15 LPM (liters per minute) may be necessary . 2. The Immediate Jeopardy was removed and the scope / severity reduced to G on [DATE] at 7:55 p.m., when the facility implemented the following Plan of Removal: a. Upon notification on [DATE] that Proper Training to ensure staff is efficient with using equipment and performing CPR for basic life support while caring for residents was not completed by the facility. Floor nurses caring for residents currently, In-serviced on inflation of Ambu Bag, with demonstration and return demonstration performed by ADON (Assistant Director of Nursing). b. All Nursing staff who are currently not working will be in-serviced by DON or designee with demonstration and return demonstration prior to start of their shift. c. Resident orders for code status to identify other residents who are Full Code reviewed by CEO (Chief Executive Officer) / DON / designee. All residents have orders for either Full Code or DNR (Do Not Resuscitate). d. Repeat in-servicing of nursing staff for efficiency of using equipment and performing CPR for Basic Life Support conducted Quarterly by CEO / DON / designee. e. All code status will be reviewed by CEO / DON / designee upon admission and monthly. If any discrepancy noted it will be corrected immediately. Review of purchased / new equipment for use with CPR to be in-serviced with demonstration and return demonstration upon receipt, and with existing equipment monthly. f. Any negative findings will be submitted to the QA&A (Quality Assessment and Assurance) Committee for review.

Complaint # (AR 845) was substantiated, all or in part, in these findings. Based on observation, record review, and interview the facility failed to ensure injuries of unknown origin were thoroughly investigated to rule out possible abuse / neglect for a resident with a history of combative and self-injurious behaviors, failed to ensure the injuries were reported to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law and failed to ensure protective measures were immediately and consistently implemented to prevent further potential injury for 1 of 1 (Resident #2) case mix resident who sustained multiple injuries of unknown origin and was cognitively impaired. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #2, who was discovered on multiple occasions with bruising, bleeding and / or swelling to the face / head / eye / jaw areas, and had the potential to affect 17 residents who were cognitively impaired, according to a list provided by the Administrator on 3/29/17. The facility was informed of the Immediate Jeopardy condition on 3/27/17 at 7:15 p.m. The findings are: 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/25/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; unable to speak; rejected care on 1 to 3 of the last 7 days; was totally dependent on one person for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing; and required extensive assistance of one person for bed mobility and transfers. a. The Care Plan dated 1/20/17 documented, .Behavioral Symptoms . Resident will throw himself in floor when in wheelchair, his means of ambulating is crawling . Falls/Safety Risk/Elopement Risk . Resident floor in room is covered with mattress at all times. b. Nurse's Notes dated 2/4/17 at 11:30 a.m. documented, R (resident) in room . (resident) yelling out et (and) trying to grab staff. (Resident) cont's (continues) to try to stand up and then slides to floor. Staff monitoring (resident) . Nurse's Notes dated 2/4/17 at 7:15 p.m. documented, (Resident) out in hallway yelling banging head on floor disrupting other (residents); [MEDICATION NAME] 1 mg (milligram) po (by mouth) given as ordered PRN (as needed) . Nurse's Notes dated 2/5/16 at 7:00 a.m. documented, (Resident) combative during breakfast, this nurse held hands while feeding, seemed to calm down . Nurse's Notes dated 2/7/17 at 9:10 a.m. by Licensed Practical Nurse (LPN) #3 documented, Summoned to (Resident) room per CNA (Certified Nursing Assistant). (Resident) sitting @ (at) doorway on floor (with) blood noted on floor behind him, on both hands, and laceration noted to (resident's) left eyebrow (with) blood noted around laceration. There was no documentation that an investigation was initiated to determine how the injury occurred and rule out possible abuse / neglect and no documentation as to how the resident would be protected from further potential injury while an investigation was ongoing. d. A Care Plan with a review date of 2/15/17 documented, (Resident #2) has extensive behavior problems r/t (related to) PKU ([DIAGNOSES REDACTED]) and inability to comprehend. He will resist staff, slide out of chair to floor, bang head on the floor, grab at staff's extremities. These behaviors put him at great risks for falls . Interventions . Monitor behavior episodes and attempt to determine underlying cause . e. Nurse's Notes dated 2/23/17 at 12:26 a.m. documented, Aide approach desk asking have I seen (Resident #2's) eye. I stated 'no' got up from desk went to (resident) room. Noted (right) eye very swollen with redness and dark redness . This note was signed by LPN #4. A Resident Incident Report dated 2/23/17 at 1:50 a.m. documented, Describe Injury: Blackened eye redness and black noted. Location of Occurrence: (Resident) room . Narrative of incident and description of injuries . Called into (resident) room by aide. Seen (resident) right eye swollen redness & (and) blackness noted . Attached to the report were 4 OLTC Witness Statement Forms completed on 2/23/17 by 4 CNAs who worked the 11:00 p.m. to 7:00 a.m. shift. There were no other witness statements or documentation of efforts to investigate the cause of the injury and rule out possible abuse / neglect, and no documentation as to how the resident would be protected from further potential injury while an investigation was ongoing. f. Nurse's Notes dated 2/23/17 at 5:30 p.m. documented, (Resident) in front dining room conts to climb & slide out from w/c (wheelchair) to floor . CNA & this nurse were returning (resident) to w/c . & noted a skin tear to (right) ear . N/o (new order) to TAO (triple antibiotic ointment) & cover . g. Nurse's Notes dated 2/24/17 at 4:00 p.m. documented, (Resident) eyes bilaterally noted to be red, bruised and swollen shut. Swelling noted to (right) ear (with) bandage in place). Lg (large) amount swelling noted to (L) (left) jaw area. Hollering out and crying with facial grimaces noted . There was no documentation of an investigation to determine how the injury occurred or of any protective measures that were put in place to prevent further potential injury. h. Nurses Notes dated 3/4/17 at 9:00 a.m. documented, (Resident) in rm (room) and hallway banging head on floor screaming out unable to redirect hitting at (and) scratching staff . Nurse's Notes dated 3/5/17 at 8:30 a.m. documented, (Resident) yelling out banging head on walls & floor . [MEDICATION NAME] 1 mg po given as ordered prn WCTM (will continue to monitor) for safety . i. On 3/24/17 at 11:00 a.m., Resident #2 was in his room lying on mats on the floor with his eyes closed. There were 3 concave mattresses with wings on the floor and several exercise-type mats on the floor with no covering. There were 3 walls near the entrance of the room that were padded with a full or queen size mats 4-5 inches thick. The rest of the length of the walls were padded with mats that were 1 inch thick and covered the walls 3 feet (ft) up from the floor. There was a 42 inch television (TV) hanging on the wall 1/2 inch from the floor. The walls were not completely covered with padding and the edges / corners of the TV were not covered with padding in order to prevent the resident from banging his head on these items. There was an air conditioning/heating unit located in the wall facing the outside that extended 3 inches from the wall into the room and was not padded in order to prevent the resident from injury. The Director of Nursing (DON) stated, He sits up and bangs his head on the walls. j. On 3/27/17 at 1:20 p.m., the resident was in his room scooting around on the mats and concave mattresses on the floor. The 1 inch padding was covering the walls 3 feet (ft) from the floor. The thick mattresses that were covering the walls on 3/24/17 at 11:00 p.m. were no longer on the walls and no other pad was in it place. The TV and air conditioning/heating unit were not padded. The resident was sitting up on the padding and his shoulders and head were leaning on the brick wall above the padding. k. On 3/27/17/ between 3:35 p.m. and 4:15 p.m., the following LPN's were interviewed and asked how the resident's injuries occurred on 2/7/17, 2/23/17, and 2/24/17, who they reported the injuries to, who investigated injuries of unknown origin, and what was done to prevent future injuries from occurring. At 3:35 p.m., LPN #2 stated she worked on 2/24/17 on the 3:00 -11:00 p.m. shift. She stated, About 2:45 p.m., during rounds, he was laying the floor with his back to me. He had a bandage wrap around his head and bandage on the right ear. In report, (LPN #1) stated he bumped his ear on something and had a bandage on the right ear and the wrap bandage around his head was to help keep the bandage on the ear in place. LPN #2 stated, When I walked into his room around 4:00 p.m., both eyes were bruised, red, swollen shut . and he was hollering and crying. It was only reported to me he had a right ear injury. I told the Administrator and called the doctor. The LPN was asked if she did an investigation into how the injuries occurred and stated, No, I didn't do an investigation. At 4:10 p.m., LPN #1 was interviewed via telephone. She stated, .I work 7 to 3 p.m. (7:00 a.m. - 3:00 p.m.). When I left from work on 2/24/17, he (resident) did have a bandage on his right ear with a wrap around his forehead to hold the ear bandage in place. He had slid out of the wheelchair. There were no other injuries observed on him. At 4:15 p.m., LPN #3 stated, (CNA #1) was the CNA that summoned me to the room on 2/7/17 at 9:10 a.m. I'm the treatment nurse and (LPN #1) was the charge nurse that day. (LPN #1) would have been the nurse that completed the I/A (Incident and Accident) and investigated it. At the time of this incident, the mats were on the floor. There were no mats on the walls. I'm not sure how the injuries occurred. I did the treatment to left eye laceration. l. On 3/27/17 4:35 p.m., the DON was asked how the injuries occurred on 2/7/17, 2/23/17, and 2/24/17, whether an investigation was conducted, how the facility ruled out abuse as the cause of the injuries, and how the facility protected the resident from further potential injuries of unknown origin. The DON stated, The floor nurses prepare the Incident Reports, and I review them . He was in his room (room #), he had two small mats on the floor, 5 feet by 2 1/2 feet. When I returned the next day, I wasn't pleased with how the mats covered the floor. I spoke with the sister home that he came from and asked that they send all the mattresses they had on the floor to our facility. We implemented the mats and mattresses to cover the entire floor in his room the next day after his admission (1/20/17). We padded the walls in his room when he moved to room (room #). I'm unsure of the date he was moved to room (room #) near the nurses station. I spoke with his parents prior to admit, and they told me he had a history of [REDACTED]. I'm not sure how those injuries occurred on those days. We didn't do an incident report or conduct an investigation for the injuries to determine the cause. I was thinking maybe he was hitting his head on the night stand in his room. I had the night stand removed when he moved to room (room #). Unsure of the dates . I thought about contacting APS (Adult Protective Services). We should have investigated how the injuries occurred, because I wasn't sure how they happened. m. On 3/27/17 at 6:00 p.m., the Administrator was asked how the resident's injuries of unknown origin were investigated and whether the staff had reported the injuries to her. She stated, It was care planned that he banged his head on his knees. No one reported the incidents were witnessed. I figured he was banging his head on his knees. The Administrator was asked, Were investigations conducted to rule out possible abuse, and was the resident protected from further injury? She stated, .The TV stand had been moved out of the room, entire floor padded, and mattresses on the floor. n. On 3/28/17 at 9:30 a.m., the resident was in his room, lying on the mattress padding on the floor. There was padding covering the walls 3 feet (ft) up from the floor. The thick mattresses that were covering the walls on 3/24/17 were not on the walls. There was a 4 ft x (by) 3.5 ft area in the resident's room, near the door, that was not padded. The 48 by 36-inch air/heating unit extended out of the wall approximately 6 inches. There was a 3-ft thin, black foam covering, 1 inch wide along the bottom of the unit. A gray bumper was between the floor and the unit and was 35 inches long. The foam and bumper did not cover the pointed edges on the unit or the surrounding outer surfaces of the unit. 2. The Immediate Jeopardy was removed and the scope and severity reduced to E on 3/28/17 at 8:25 a.m. when the facility implemented the following plan of removal: a. On 3/27/17 an investigation into an injury of unknown origin for (Resident #2) was started. The resident was assessed for any negative findings due to the past incident with no negative findings noted. b. The height of the television in (Resident #2's) room has been adjusted so that resident does not have the ability to harm himself on the TV. c. All I&As for the past 3 months were audited to ensure complete investigations were conducted for all. Any injury of unknown origin will be reported to OLTC immediately with investigation to begin immediately. If any form of abuse or neglect is suspected, protection for the resident will be initiated immediately. d. All resident rooms were observed to ensure TVs were at an acceptable height for safety of each resident. e. On 3/27/17 re-educated CEO (Chief Executive Officer) and DON regarding abuse and neglect reporting of any injury of unknown origin and if abuse and neglect is suspected protection of resident will initiated. f. Beginning 3/27/17 all staff will be in-serviced prior to coming to work regarding abuse and neglect reporting including reporting to direct supervisor any injury of unknown origin and if abuse or neglect is suspected protection of resident is initiated immediately. Also, in-serving staff on observation of items in resident rooms to ensure that all things are at a safe height for each resident. g. All I&As will be reviewed by CEO/DON/Designee daily to ensure all are investigated completely and injury of unknown origin is investigated and reported to OLTC immediately. If any abuse or neglect is suspected, resident protection will be initiated immediately. h. Any negative findings will be submitted to the QA & A (Quality Assurance and Assessment) Committee for review.

Complaint # (AR 845) was substantiated, all or in part, in these findings. Based on observation, record review, and interview, the facility failed to ensure their abuse policy and procedure was implemented, as evidenced by failure to ensure injuries of unknown origin were thoroughly investigated to rule out possible abuse / neglect for a resident with a history of combative and self-injurious behaviors, failure to ensure the injuries were reported to the Office of Long Term Care (OLTC) and other state agencies in accordance with state law, and failure to ensure protective measures were immediately and consistently implemented to prevent further potential injury for 1 of 1 (Resident #2) case mix resident who sustained multiple injuries of unknown origin and was cognitively impaired. These failed practices resulted in Immediate Jeopardy, which caused, or could have caused, serious harm, injury or death to Resident #2, who was discovered on multiple occasions with bruising, bleeding and / or swelling to the face / head / eye / jaw areas, and had the potential to cause more than minimal harm to 17 residents who were cognitively impaired, according to a list provided by the Administrator on 3/29/17. The facility was informed of the Immediate Jeopardy situation on 3/27/17 at 7:15 p.m. The findings are: 1. The facility's Abuse Prohibition Policy and Procedure documented , .Policy: It is the policy of this facility to take appropriate steps to prevent occurrence of abuse, neglect, injuries of unknown source . and to ensure that all alleged violations . are reported immediately to the Administrator of the facility. Such violations will also be reported to state agencies in accordance with state law. The Administrator or his/her designee will direct a thorough investigation of each alleged violation. The Administrator or his/her designee is responsible to report the results of all investigations to the state agencies as required by state and federal law . Investigation: .The investigation shall include interviews of employees who have knowledge of the alleged incident . Corrective Action: The facility shall make reasonable effort to determine the cause of the alleged violation and take corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. The DNS (Director of Nursing Services) or his/her designee shall initiate a care plan to reflect the resident's condition and measures to be taken to prevent recurrence, where appropriate. Appropriate steps will be taken to prevent recurrence of incidents. This may include in-services or other measures and should be documented. Documentation: In addition to the Verification of Investigation, all alleged violations shall be recorded on the required investigation form for reporting to government agencies . 1. Resident #2 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set with an Assessment Reference Date of 1/25/17 documented the resident was severely impaired in cognitive skills for daily decision making per a Staff Assessment for Mental Status; unable to speak; rejected care on 1 to 3 of the last 7 days; was totally dependent on one person for locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and bathing; and required extensive assistance of one person for bed mobility and transfers. a. The Care Plan dated 1/20/17 documented, .Behavioral Symptoms . Resident will throw himself in floor when in wheelchair, his means of ambulating is crawling . Falls/Safety Risk/Elopement Risk . Resident floor in room is covered with mattress at all times. b. Nurse's Notes dated 2/4/17 at 11:30 a.m. documented, R (resident) in room . (resident) yelling out et (and) trying to grab staff. (Resident) cont's (continues) to try to stand up and then slides to floor. Staff monitoring (resident) . Nurse's Notes dated 2/4/17 at 7:15 p.m. documented, (Resident) out in hallway yelling banging head on floor disrupting other (residents); [MEDICATION NAME] 1 mg (milligram) po (by mouth) given as ordered PRN (as needed) . Nurse's Notes dated 2/5/16 at 7:00 a.m. documented, (Resident) combative during breakfast, this nurse held hands while feeding, seemed to calm down . Nurse's Notes dated 2/7/17 at 9:10 a.m. by Licensed Practical Nurse (LPN) #3 documented, Summoned to (Resident) room per CNA (Certified Nursing Assistant). (Resident) sitting @ (at) doorway on floor (with) blood noted on floor behind him, on both hands, and laceration noted to (resident's) left eyebrow (with) blood noted around laceration. There was no documentation that an investigation was initiated to determine how the injury occurred and rule out possible abuse / neglect and no documentation as to how the resident would be protected from further potential injury while an investigation was ongoing. d. A Care Plan with a review date of 2/15/17 documented, (Resident #2) has extensive behavior problems r/t (related to) PKU ([DIAGNOSES REDACTED]) and inability to comprehend. He will resist staff, slide out of chair to floor, bang head on the floor, grab at staff's extremities. These behaviors put him at great risks for falls . Interventions . Monitor behavior episodes and attempt to determine underlying cause . e. Nurse's Notes dated 2/23/17 at 12:26 a.m. documented, Aide approach desk asking have I seen (Resident #2's) eye. I stated 'no' got up from desk went to (resident) room. Noted (right) eye very swollen with redness and dark redness . This note was signed by LPN #4. A Resident Incident Report dated 2/23/17 at 1:50 a.m. documented, Describe Injury: Blackened eye redness and black noted. Location of Occurrence: (Resident) room . Narrative of incident and description of injuries . Called into (resident) room by aide. Seen (resident) right eye swollen redness & (and) blackness noted . Attached to the report were 4 OLTC Witness Statement Forms completed on 2/23/17 by 4 CNAs who worked the 11:00 p.m. to 7:00 a.m. shift. There were no other witness statements or documentation of efforts to investigate the cause of the injury and rule out possible abuse / neglect, and no documentation as to how the resident would be protected from further potential injury while an investigation was ongoing. f. Nurse's Notes dated 2/23/17 at 5:30 p.m. documented, (Resident) in front dining room conts to climb & slide out from w/c (wheelchair) to floor . CNA & this nurse were returning (resident) to w/c . & noted a skin tear to (right) ear . N/o (new order) to TAO (triple antibiotic ointment) & cover . g. Nurse's Notes dated 2/24/17 at 4:00 p.m. documented, (Resident) eyes bilaterally noted to be red, bruised and swollen shut. Swelling noted to (right) ear (with) bandage in place). Lg (large) amount swelling noted to (L) (left) jaw area. Hollering out and crying with facial grimaces noted . There was no documentation of an investigation to determine how the injury occurred or of any protective measures that were put in place to prevent further potential injury. h. Nurses Notes dated 3/4/17 at 9:00 a.m. documented, (Resident) in rm (room) and hallway banging head on floor screaming out unable to redirect hitting at (and) scratching staff . Nurse's Notes dated 3/5/17 at 8:30 a.m. documented, (Resident) yelling out banging head on walls & floor . [MEDICATION NAME] 1 mg po given as ordered prn WCTM (will continue to monitor) for safety . i. On 3/24/17 at 11:00 a.m., Resident #2 was in his room lying on mats on the floor with his eyes closed. There were 3 concave mattresses with wings on the floor and several exercise-type mats on the floor with no covering. There were 3 walls near the entrance of the room that were padded with a full or queen size mats 4-5 inches thick. The rest of the length of the walls were padded with mats that were 1 inch thick and covered the walls 3 feet (ft) up from the floor. There was a 42 inch television (TV) hanging on the wall 1/2 inch from the floor. The walls were not completely covered with padding and the edges / corners of the TV were not covered with padding in order to prevent the resident from banging his head on these items. There was an air conditioning/heating unit located in the wall facing the outside that extended 3 inches from the wall into the room and was not padded in order to prevent the resident from injury. The Director of Nursing (DON) stated, He sits up and bangs his head on the walls. j. On 3/27/17 at 1:20 p.m., the resident was in his room scooting around on the mats and concave mattresses on the floor. The 1 inch padding was covering the walls 3 feet (ft) from the floor. The thick mattresses that were covering the walls on 3/24/17 at 11:00 p.m. were no longer on the walls and no other pad was in it place. The TV and air conditioning/heating unit were not padded. The resident was sitting up on the padding and his shoulders and head were leaning on the brick wall above the padding. k. On 3/27/17/ between 3:35 p.m. and 4:15 p.m., the following LPN's were interviewed and asked how the resident's injuries occurred on 2/7/17, 2/23/17, and 2/24/17, who they reported the injuries to, who investigated injuries of unknown origin, and what was done to prevent future injuries from occurring. At 3:35 p.m., LPN #2 stated she worked on 2/24/17 on the 3:00 -11:00 p.m. shift. She stated, About 2:45 p.m., during rounds, he was laying the floor with his back to me. He had a bandage wrap around his head and bandage on the right ear. In report, (LPN #1) stated he bumped his ear on something and had a bandage on the right ear and the wrap bandage around his head was to help keep the bandage on the ear in place. LPN #2 stated, When I walked into his room around 4:00 p.m., both eyes were bruised, red, swollen shut . and he was hollering and crying. It was only reported to me he had a right ear injury. I told the Administrator and called the doctor. The LPN was asked if she did an investigation into how the injuries occurred and stated, No, I didn't do an investigation. At 4:10 p.m., LPN #1 was interviewed via telephone. She stated, .I work 7 to 3 p.m. (7:00 a.m. - 3:00 p.m.). When I left from work on 2/24/17, he (resident) did have a bandage on his right ear with a wrap around his forehead to hold the ear bandage in place. He had slid out of the wheelchair. There were no other injuries observed on him. At 4:15 p.m., LPN #3 stated, (CNA #1) was the CNA that summoned me to the room on 2/7/17 at 9:10 a.m. I'm the treatment nurse and (LPN #1) was the charge nurse that day. (LPN #1) would have been the nurse that completed the I/A (Incident and Accident) and investigated it. At the time of this incident, the mats were on the floor. There were no mats on the walls. I'm not sure how the injuries occurred. I did the treatment to left eye laceration. l. On 3/27/17 4:35 p.m., the DON was asked how the injuries occurred on 2/7/17, 2/23/17, and 2/24/17, whether an investigation was conducted, how the facility ruled out abuse as the cause of the injuries, and how the facility protected the resident from further potential injuries of unknown origin. The DON stated, The floor nurses prepare the Incident Reports, and I review them . He was in his room (room #), he had two small mats on the floor, 5 feet by 2 1/2 feet. When I returned the next day, I wasn't pleased with how the mats covered the floor. I spoke with the sister home that he came from and asked that they send all the mattresses they had on the floor to our facility. We implemented the mats and mattresses to cover the entire floor in his room the next day after his admission (1/20/17). We padded the walls in his room when he moved to room (room #). I'm unsure of the date he was moved to room (room #) near the nurses station. I spoke with his parents prior to admit, and they told me he had a history of [REDACTED]. I'm not sure how those injuries occurred on those days. We didn't do an incident report or conduct an investigation for the injuries to determine the cause. I was thinking maybe he was hitting his head on the night stand in his room. I had the night stand removed when he moved to room (room #). Unsure of the dates . I thought about contacting APS (Adult Protective Services). We should have investigated how the injuries occurred, because I wasn't sure how they happened. m. On 3/27/17 at 6:00 p.m., the Administrator was asked how the resident's injuries of unknown origin were investigated and whether the staff had reported the injuries to her. She stated, It was care planned that he banged his head on his knees. No one reported the incidents were witnessed. I figured he was banging his head on his knees. The Administrator was asked, Were investigations conducted to rule out possible abuse, and was the resident protected from further injury? She stated, .The TV stand had been moved out of the room, entire floor padded, and mattresses on the floor. n. On 3/28/17 at 9:30 a.m., the resident was in his room, lying on the mattress padding on the floor. There was padding covering the walls 3 feet (ft) up from the floor. The thick mattresses that were covering the walls on 3/24/17 were not on the walls. There was a 4 ft x (by) 3.5 ft area in the resident's room, near the door, that was not padded. The 48 by 36-inch air/heating unit extended out of the wall approximately 6 inches. There was a 3-ft thin, black foam covering, 1 inch wide along the bottom of the unit. A gray bumper was between the floor and the unit and was 35 inches long. The foam and bumper did not cover the pointed edges on the unit or the surrounding outer surfaces of the unit. 2. The Immediate Jeopardy was removed and the scope and severity reduced to E on 3/28/17 at 8:25 a.m. when the facility implemented the following plan of removal: a. On 3/27/17 an investigation into an injury of unknown origin for (Resident #2) was started. The resident was assessed for any negative findings due to the past incident with no negative findings noted. b. The height of the television in (Resident #2's) room has been adjusted so that resident does not have the ability to harm himself on the TV. c. All I&As for the past 3 months were audited to ensure complete investigations were conducted for all. Any injury of unknown origin will be reported to OLTC immediately with investigation to begin immediately. If any form of abuse or neglect is suspected, protection for the resident will be initiated immediately. d. All resident rooms were observed to ensure TVs were at an acceptable height for safety of each resident. e. On 3/27/17 re-educated CEO (Chief Executive Officer) and DON regarding abuse and neglect reporting of any injury of unknown origin and if abuse and neglect is suspected protection of resident will initiated. f. Beginning 3/27/17 all staff will be in-serviced prior to coming to work regarding abuse and neglect reporting including reporting to direct supervisor any injury of unknown origin and if abuse or neglect is suspected protection of resident is initiated immediately. Also, in-serving staff on observation of items in resident rooms to ensure that all things are at a safe height for each resident. g. All I&As will be reviewed by CEO/DON/Designee daily to ensure all are investigated completely and injury of unknown origin is investigated and reported to OLTC immediately. If any abuse or neglect is suspected, resident protection will be initiated immediately. h. Any negative findings will be submitted to the QA & A (Quality Assurance and Assessment) Committee for review.

Based on observation, record review, and interview, the facility failed to ensure complete incontinent care was provided and clean technique (front-to-back cleaning direction) was followed after bowel movements to prevent potential or further complications from Urinary Tract Infection for 3 (Residents #1, #5, and #6) of 6 (Residents #1 thru #6) case mix residents who had incontinence of bowel or bladder and were dependent on care from staff. This failed practice resulted in actual harm to Resident #5, who had recurring Urinary Tract Infections. This failed practice was also likely to cause more than minimal harm to 6 residents who currently had Urinary Tract Infections and were dependent for incontinent care, according to lists provided by the Administrator on 3/30/12. The findings are: 1. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/12 documented the resident scored 2 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent on staff for personal hygiene, and was incontinent of bowel and bladder. a. A Urine Culture laboratory report dated 12/16/11 documented, "Final Urine Providencia stuartii > (greater than) 100,000 (colony count)...Bactrim DS (Double Strength) (one) p.o. (by mouth) BID (twice a day)...12/19/11 Bactrim DS (one) tab BID per tube (times) 10 days..." b. A Urine Culture laboratory report dated 1/4/12 documented, "Final Urine Providencia stuartii >100,000 colony count...1/5/12 Bactrim DS (one) p.o. BID (times) 14 days..." c. The Resident Care Plan dated 1/5/12 documented, "UTI Will be resolved by next review Approaches- 1. ABT (antibiotic treatment) as ordered... 2. Provide good pericare after each incontinent episode..." d. A Progress Note dated 1/25/12 documented, "...Recent Lab Work: 1/2/12 UA (urinalysis) (positive) UTI (Urinary Tract Infection)... Assessment/Problem Diagnosis: [REDACTED]. e. A Urine Culture laboratory report dated 1/26/12 documented, "Prelim (preliminary) urine Gram negative bacilli >100,000...Cipro 250mg (milligrams) BID (times) 4 days till (culture and sensitivity)..." f. A Urine Culture laboratory report dated 1/27/12 Final Urine Culture documented, "Providencia stuartii > 100,000...Bactrim DS (one) tab per tube BID (times) 14 days..." g. A Urine Culture laboratory report dated 2/24/12 documented, "Prelim (preliminary) Urine Culture Providencia stuartii...Bactrim DS (one) tab BID (times) 10 days..." h. A Progress Note dated 2/29/12 documented, "...Assessment/Problem Diagnosis: [REDACTED]. i. A Urine Culture laboratory report dated 3/10/12 documented, "...Final Urine Providencia stuartii >100,000 (colony count) [MEDICATION NAME] faecalis >100,000 (colony count) ...3/12/12 Spoke (with) (physician) 1. [MEDICATION NAME] 100mg BID (times) 10 days 2. Bactrim DS (one) per tube BID (times) 10 days 3. Acidophilus (with) [MEDICATION NAME] (times) 10 days..." j. A physician's orders [REDACTED]." During the initial rounds, the resident was transferred to an area hospital for evaluation and returned to the facility. k. A physician's orders [REDACTED]. l. On 3/27/12 at 3:45 p.m., Nursing Assistant (NA) #2 provided incontinent care after an episode of incontinence of bowel and urine. The NA removed the brief, turned the resident to the right side and wiped over the rectal area, from back to front to the scrotal area and penis repeatedly. The buttocks, hips, and sacral areas were not cleansed. NA #2 had not changed gloves and was assisted by NA #1 to position the resident onto the back. At 3:50 p.m., NA #2 then wiped down each groin, up the shaft of the penis, retracted the foreskin, wiped over the urinary meatus once, and replaced the foreskin without changing gloves. The NAs then placed a clean brief on the resident. m. A Nurses Notes dated 3/28/12 at 1:00 a.m., documented, "...ABT (antibiotic) for UTI..." n. A Nurses Notes dated 3/28/12 at 7:15 a.m., documented, " ...New order noted to send to (Hospital) as Direct Admit to (physician) ..." o. A Resident Transfer Record dated 3/28/12 documented, "...UTI (Urinary Tract Infection)..." 2. Resident #6 (roommate to Resident #5) had [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) with an Assessment Reference Date of 1/10/12 documented the resident scored 0 (0-7 indicates severely impaired) on the Brief Interview for Mental Status (BIMS), was totally dependent on staff for toileting and personal hygiene, and was incontinent of bowel and bladder. a. The Resident's Care Plan dated 1/15/12 documented, "Incontinent of bowel and bladder... will be clean... pericare provided after each incontinent episode..." b. On 3/27/12 from 3:15 p.m. to 3:31 p.m., Certified Nursing Assistant (CNA) #1 provided incontinent care and cleansed the rectal area first. The CNA wiped back to front with disposable wipes, across the rectal area, to the scrotum to cleanse the bowel movement. Without changing gloves, the resident was turned and CNA #1 took a disposable wipe and wiped back to front, up the left groin twice, then up the scrotum back to front, up the penis shaft, retracted the foreskin and wiped across the urinary meatus before a clean brief was applied. CNA #1 did not change gloves. 3. Resident #1 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an assessment reference date of 3/14/12 documented the resident scored 9 (8-12 indicates moderate impairment) on a Brief Interview for Mental Status (BIMS), and was totally dependent for personal hygiene and bathing, had an ostomy and was frequently incontinent of urine. a. The Resident Plan of Care with a review date of 3/13/12 documented, "Problem-Continence... Provide peri-care after each incontinent episode..." b. A Nurses Note dated 1/28/12 documented, "[MEDICATION NAME] 100mg ... PO (by mouth) TID (three times a day) for ten days... (diagnosis) of UTI (Urinary tract infection)..." c. A Laboratory Report dated 3/12/12 documented, "Urinalysis- ...Bacteria 3+ ...." Urine culture results dated 3/14/12 from the urine specimen obtained on 3/12/12 documented, "Escherichia Coli > 100,000 ...Bactrim DS (one) PO BID x 14 days ..." d. On 3/27/12 at 3:52 p.m., the resident was assisted to bed for incontinent care. CNA #1 gathered supplies, explained the procedure and began care. CNA #1 removed a pre-moistened wipe and wiped from back to front over the urinary meatus two times with the same wipe. e. On 3/27/12 at 4:05 p.m., CNA #1 was asked, "Was the resident's brief saturated?" CNA #1 stated, "Yes." CNA #1 was asked, "Do you always wipe from back to front when you take care of an incontinent resident?" CNA #1 stated, "No, I don't, but she doesn't use the bathroom like everyone else so I didn't think it mattered how I wiped." CNA #1 was asked, "With the brief being so wet and oozing out onto her clothes, why didn't you wipe her legs and buttocks to get the urine off?" CNA#1 stated, "I don't know." CNA #1 was asked, "Would you consider the incontinent care that you provided for this resident complete?" CNA #1 stated, "No." 4. On 3/30/12 at 12:55 p.m., the Director of Nursing (DON) was asked if the skin should be wiped from back to front when a resident is given care for incontinence of bowel and the DON stated, "No." The DON was asked, "If gloves are not removed when pericare is given for an incontinent bowel movement, could that cause a Urinary Tract Infection from contamination to the urinary meatus?" The DON stated, "It could." 5. The facility's policy and procedure titled, "Incontinence Care", received from the Administrator on 3/30/12 at 8:40 a.m., documented, "Purpose 1. To keep skin clean, free of irritation, and odor...4. To prevent infection. ...Procedure...3. Wash all soiled skin areas, especially between skin folds with soap and water and/or periwash. 4. Wipe front to back with clean area of cloth at each stroke, then dry well..." 6. An Incontinent and Catheter Care Observation Checklist received from the Administrator on 3/30/12 at 9:20 a.m., documented, "...12. Male: Cleanse pubic area across - Retract foreskin of an uncircumcised male and wipe urinary meatus in a circular motion, wipe in a circular motion around the head of penis, if drying, change gloves and dry in same fashion, return foreskin over the head of penis, wiping down shaft of penis and scrotum. Cleanse skin folds front to back, thighs in a downward motion, and cleanse abdomen from hip to hip, changing area on cloth for each wiping stroke....15. Wipe the rectal area and buttocks thoroughly, ...extending over the buttocks. Changing area of wipe with each stroke, Wipe across sacrum. 16. Wiping downward on thighs (including all areas), Changing area of cloth for each wiping stroke,..."