Every finding on record at Vivo Healthcare Meadows

Based on record review, resident representative and staff interviews, the facility failed to ensure resident's refunds were refunded within 30 days after discharge for 1 (Resident #1) of 1 sampled resident due a refund.The findings included:Review of the clinical record revealed Resident #1 had an admission date of 12/9/25 and discharge date of 12/16/25. On 2/10/26 at 9:56 a.m., in a telephone interview the resident's life companion said Resident #1 had been discharged since 12/16/25 and a refund was due to her. He said they spoke with the Administrator the previous week but were still waiting on the money to be refunded.On 2/10/26 at 10:51 a.m., in an interview the Business Office Manager (BOM) said Resident #1 came to the facility as Medicaid pending. She stayed for a few days and decided she didn't want to stay there. The BOM said Resident #1 did not want to provide her information for the Medicaid application and she was advised that they would need to flip her over to private pay. The BOM said Resident #1spent seven days at the facility. She was admitted on [DATE] and was discharged on 12/16/25. He gave the facility a check for $2660.00. The rate is $380.00 per day. The BOM said when Resident #1 discharged she called and asked about the refund. The BOM said that when Resident #1 was admitted , she was Medicaid pending and paid a patient responsibility of $891.00. She said the facility owed Resident # a refund for the patient liability she paid. She told the resident the check had already been processed and they would have to issue her a refund. I told her we would have to issue her a refund as the check had already processed. BOM said the checks were not issued directly by the facility.The BOM provided documentation showing Resident #1 was active 12/9/25 and stop billing on 12/16/25. She also provided an invoice for December 9, 2025, through December 15, 2025, for a private Room and Board at $380.00/day. The invoice noted a charge of $2660.00 for 7 units. On 2/10/26 at 1:18 p.m., the Administrator provided admission documentation from the transferring facility indicating Resident #1 needed a Medicaid pending bed and help with Medicaid application. In an interview, the Administrator said Resident #1 came in Medicaid pending then decided not to give the needed information to complete the Medicaid application. They switched her over to private pay. The Administrator verified he spoke with Resident #1 and her life partner. The Administrator said they owed a refund to Resident #1 but the checks were not cut at the facility, but at the corporate level.Review of the facility's Resident Refund Policy with a date implemented of 05/2025 and a date reviewed of 1/2026 revealed that the timeframe refund for private pay, Issued within 30-45 days after the resident account is fully reconciled.On 2/10/26 at 1:14 p.m., in an interview the Regional Business Office Manager said Resident #1 was discharged on 12/16/25 and there had been confusion on the refund amount. The Regional BOM said they had the check, but as of today 2/10/26, Resident #1 does not have her refund yet. Regional BOM said their facility policy is private pay refunds were issued within 30-45 days after the resident is fully reconciled. She said she believed that everyone came together to reconcile on the amount that was supposed to be refunded on January 6, 2026. She verified their policy did not specify that refunds must be provided 30 days from the date of discharge. She verified that Resident #1 was discharged on 12/16/25 and was still waiting on her refund.

Based on interviews, records reviewed and facility policy the facility failed to properly exercise the rights of 3, (Resident #5, Resident #3 and Resident #4), of 3 residents with dementia that had designated representatives by disenrolling the residents from their Medicare Advantage coverage without proper authorization and documentation.The findings included:Review of Facility Policy titled Resident Rights implemented 9/1/23 documented the resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1) Exercise of Rights: The resident has the right to exercise his or her rights of the facility as a citizen of the United States.b) In the case of a resident who has not been adjudged incompetent by the State court, the resident has a right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by State law.Review of Facility Enrollment/Disenrollment Rights for Medicare Beneficiaries not dated documented skilled nursing facility residents have the right to choose their own healthcare insurance coverage. Residents have a right to understand the differences. Only a Medicare beneficiary, the beneficiaries authorized or designated representative, or the party authorized to act on behalf of the beneficiary under state law can request enrollment in or voluntary disenrollment from a Medicare health or drug plan. If you desire, the facility may act as your designated representative to make the process easier . With written authorization, the facility can help you switch at any permissible time.Review of the clinical record revealed Resident #5 was admitted to the facility 8/27/24 with diagnosis fracture of T7-T8 vertebra, cognitive communication deficit, and unspecified dementia.Review of the admission Minimum Data Set (MDS) with a reference date of 9/3/24 documented Resident #5 required partial/moderate assistance with Activities of Daily Living (ADLs). The MDS noted the residents' cognitive status was moderately impaired.Review of Hospital Patient Transfer Form 8/27/24 documented Resident #5 was unable to make healthcare decisions and required a surrogate.Review of admission Record documented Resident #5 designated his spouse as Responsible Party, Power of Attorney/Financial and Power of Attorney/Care.Review of Care Plan initiated 8/27/24 documented Resident #5 had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions 8/27/24 included communicate with the resident/family/caregivers regarding resident capabilities and needs. Cue, reorient and supervise as needed.Review of census documentation revealed Resident #5 was admitted under Blue Cross Blue Shield Medicare Advantage A. 9/1/24 census documentation revealed resident's primary payor was changed to Medicare A.Review of the clinical record revealed Resident #3 was admitted to the facility 7/8/25 with diagnosis displaced fracture of left lower leg and unspecified dementia.Review of the admission Minimum Data Set (MDS) with a reference date of 7/14/25 documented resident required partial/moderate assistance to substantial/maximal assistance with Activities of Daily Living (ADLs). The MDS noted the resident's cognitive status was moderately impaired.Review of Hospital Patient Transfer Form 7/8/25 documented Resident #3 was unable to make healthcare decisions and required a surrogate.Review of admission Record documented Resident #3 designated her daughter as Responsible Party and Power of Attorney/Care.Review of Care Plan initiated 7/16/25 documented Resident #3 had impaired cognitive function/dementia or impaired thought processes related to short term memory loss. Interventions 7/16/25 included communicate with the resident/family/caregivers regarding resident capabilities and needs. Cue, reorient and supervise as needed.Review of census documentation revealed Resident #3 was admitted under United Healthcare Medicare Advantage A. 8/1/25 census documentation revealed resident's primary payor was changed to Medicare A.Review of the clinical record revealed Resident #4 was admitted to the facility 7/25/25 with diagnosis complication of internal fixation device of right femur and unspecified dementia with other behavioral disturbance.Review of the admission Minimum Data Set (MDS) with a reference date of 8/7/25 documented resident required dependent on staff for Activities of Daily Living (ADLs). The MDS noted the residents' cognitive status was severely impaired.Review of the Hospital Patient Transfer Form 7/25/25 documented Resident #4 mental/cognitive status at transfer was alert, disoriented, but can follow simple instructions.Review of admission Record documented Resident #4 had an appointed Guardian as Responsible Party, Legal Guardian and Care Conference Person.Review of Care Plan initiated 7/28/25 documented Resident #4 had impaired cognitive function/dementia or impaired thought processes related to dementia. Interventions 7/28/25 included communicate with the resident/family/caregivers regarding resident capabilities and needs. Cue, reorient and supervise as needed.Review of census documentation revealed Resident #4 was admitted under United Healthcare Medicare Advantage A. 8/1/25 census documentation revealed resident's primary payor was changed to Medicare A.On 12/23/25 at 8:50 a.m., in an interview with the Power of Attorney (Spouse) of Resident #5. She said her husband has dementia and they changed his insurance without ever contacting her. The spouse said she was on his insurance and lost it with the change without notification. She was getting bills and the facility told them no problem but they have not taken care of it. She has since changed it back to the previous insurance for both her and Resident #5.On 12/23/25 at 12:20 p.m., in an interview the Business Office Manager (BOM) said if a resident wanted to disenroll from their insurance a form would be completed and uploaded to the electronic medical record. She said she thinks Resident #5 chose to disenroll. She said she believes the former admissions/marketer staff member spoke to the family for Resident #3 and Resident #4 in the hospital prior to admission about disenrolling. The BOM said she could not find any documentation regarding conversations with the families. She said if a resident had any cognition impairment the Power of Attorney, Responsible Party or Guardian should always be notified. The Business Office Manager said she could not locate Disenrollment Request Forms for Resident #5, Resident #3 or Resident #4.

Based on observation, review of facility policy and resident and staff interviews, the facility failed to maintain an effective pest control program to eradicate and contain common household pests. The findings included: The facility's Pest Control Program policy revised 8/24 documented It is the policy of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents. On 9/30/24 at 10:43 a.m., in an interview Resident #45 said she had seen bugs, black and medium sized crawling on the walls at night. The resident said, The man comes in and sprays, but it does not do the job. I have told the nurses several times. He sprays on the floor, but the bugs climb the walls, so it does not stop them. On 9/30/24 at 11:00 a.m., in the back hall of the lobby a medium brown bug was observed on it's back. Photographic evidence obtained. On 10/1/24 at 10:24 a.m., in an interview Resident #63 said she had seen large bugs in her room. She said, They come in from under the air-conditioning unit over there. They climb on the walls and the floor. They spray but that doesn't stop them. Sometimes they are the little brown ones walking around. On 10/1/24 at 3:41 p.m., in an interview Resident #90 said he has seen bugs in his room on the floors, on the walls and in his belongings. He said, It was really bad for a month or so, but it has gotten better. It is Florida, what can you do? I tell the nurse, the guy comes and sprays. When they spray it is good for a couple of days, but they come right back. They come in from under the air-conditioner, and the outside doors, they just walk right in. On 10/2/24 at 10:00 a.m., in an interview the Maintenance Director said he has been at facility one year. He said, There are pest logs at each nursing station. The company comes every Wednesday in the early morning, and he fumigates the outside of the building first, then he goes to the kitchen to spray before they begin cooking. He checks the logs on each unit and then does where it is reported and sprays the resident rooms. On 10/2/24 at 11:53 a.m., and 4:00 p.m., two dead brown insects were observed on their back in the hallway next to the conference room. Photographic evidence obtained. On 10/2/24 at 4:01 p.m., a large dead brown insect was observed on the floor of the 500 hallway. Photographic evidence obtained. On 10//24 at 3:31 p.m., a review of the pest sighting log located at the [NAME] Wing Nurses Station showed documentation of bugs in resident rooms, offices and common areas: On 6/13/24, 6/23/24, 6/27/24 and 6/30/24. On 6/28/24 there were five entries documenting bugs in residents' rooms and the nutrition room. On 7/30/24 there were five documented concerns of bugs in the nourishment room, storage room and resident' rooms. On 7/31/24 the entry for a resident's room documented at 2:20 a.m., bugs all over the room. On 8/6/24 and 8/28/24 documented bugs in resident' rooms. On 9/11/24, 9/17/24, 9/18/24, 9/21/24, 9/25/24, 9/27/24, and 9/30/24 documented bugs in resident' rooms. On 9/24/24 two entries documented bugs in all rooms on the 400 hall and the nourishment room. On 9/30/24 the log documented bugs in the classroom. On 10/2/24 the log documented bugs in all rooms on the 500 hall and in the nourishment room. Review of the Pest Log for the East Wing documented: On 4/8/24 and 4/25/24 documented large bugs running around in rooms. On 4/25/24 documented three bugs in residents room. On 4/26/24 documented bugs near bathroom, doors and bed. On 5/28/24 bugs in bathroom and on walls in residents' room. On 5/29/24 large bugs in resident dresser and in closet. Bugs were noted on 6/2/24, 6/15/24, 6/16/24, 6/25/24, 6/30/24, 7/24/24, 7/28/24, 8/30/34 and 9/4/24. On 10/2/24 at 10:23 a.m., in an interview Licensed Practical Nurse Staff B said the problem with the roaches is getting better but the residents drop food, they have food in the rooms, and some get food in their wheelchair. The facility is surrounded by trees and woods, and I think that is where they come from. I do see them, and I put it in the pest binder. Review of the Pest Control Summary of Service Recommendations dated 8/21/24, 9/11/24, 9/20/24, 9/25/24 and 10/2/24 revealed No activity and documented the following repairs required to prevent pest entry: All of hall 500 rooms baseboard on the bottom of air-conditioner on both sides need to be sealed to prevent pest entry. Trim trees/vegetation touching the building to prevent any pest entry to structure. Common areas all doors gap/damage noted that allows pest access. Please repair to prevent pests. Kitchen cracks or damage to floors allowing pest access. Cracks or damage to drains allowing pest access. On 10/3/24 at 8:33 a.m., in an interview the Maintenance Director said he was not aware the pest control service was documenting no activity noted when visiting the facility. He said the dead bugs observed on the floor were a good thing but confirmed they should have been removed. The Maintenance Director said he was aware of the repairs listed on the pest control reports every month to prevent pests from accessing the facility. He said, We have been working on the repairs, I had a hole in the wall repaired on the 500 hall. He confirmed he had not made the necessary repairs to the access doors, air-conditioning units or in the kitchen as recommended to prevent pests from entering the facility and said, We are working on them.

Based on observation, review of facility policy, resident and staff interviews the facility failed to make timely necessary repairs to maintain a safe, functional environment for residents, staff and the public. The findings included: Review of the facility Quality Assurance and Improvement Plan specified, We provide a comprehensive maintenance program that maintains building safety, conducts repairs when needed and performs safety inspections in accordance with State and Federal regulations to ensure the safety and well-being of all residents, visitors and staff. On 10/1/24 at 11:10 a.m., in a telephone interview Resident #103's family member said the facility is located down a dark road near the woods. The family member said the parking lot was dark at night, it was creepy and I didn't feel safe going to my car at night. On 10/2/24 at 8:26 a.m., in an interview the Administrator said several lights were out in the parking area and facility grounds. He said the lightbulbs were scheduled to be replaced last week but it was canceled due to the pending hurricane. The Administrator said they needed to order a lift crane to replace the burnt-out bulbs. The Administrator provided copies of the order forms for the lights dated 9/5/24. He said the lightbulbs replacement were scheduled for the next week. On 10/2/24 at 10:29 a.m., in an interview Registered Nurse Staff D said the parking lot was dark at night and could use more lighting. On 10/2/24 at 10:23 a.m., Licensed Practical Nurse Staff B said the parking lot was dark at night and could use more lighting. Staff B said some of the parking lot lights have been out for a while. Staff B said, I don't know how long they have been out, but it's been like that for a while. On 10/3/24 at 8:40 a.m., the Maintenance Director said two lights in the parking lot had been out for a month or so and were scheduled to be repaired on 10/10/24.

Based on observation, record review, review of facility's policy and procedure and staff interviews the facility failed to provide or obtain dental services to meet the needs of 1 (Resident #78) of 1 resident observed with multiple broken, carious teeth. The findings included: The facility's policy for Dental Services reviewed/revised January 2024 noted it was the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. Routine dental services means an annual inspection of the oral cavity for signs of disease, diagnosis of dental disease, dental radiographs as needed, dental cleaning, fillings (new and repairs) . smoothing of broken teeth . The dental needs of each resident are identified through the physical assessment and MDS (Minimum Data Set) assessment process and are addressed in each resident's plan of care. Oral/dental status shall be documented according to assessment findings. Referrals to . dental provider shall be made as appropriate. The facility will if necessary or requested, assist the resident with making dental appointments and arranging transportation to and from the dental services location . All actions and information regarding dental services, including any delays related to obtaining dental services, will be documented in the resident's medical record. On 9/30/24 at 1:15 p.m., Resident #78 was observed dressed and lying in bed. She was smiling and kept repeating I love you and you are beautiful. Resident #78 did not answer any interview questions. She was picking at her upper teeth with a plastic drinking straw. All visible top teeth were observed jagged and decayed to the gum line. Clinical record review revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included Dementia. The Nursing Comprehensive assessment dated [DATE] noted Resident #78 had her own/natural teeth. No dental concern were noted on the assessment. The Admission Minimum Data Set (MDS) assessment with a target date of 3/27/23 noted Resident #78 was rarely/never understood. Her cognition was severely impaired. She never/rarely made decisions. The assessment noted Resident #78 had no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth. The care plan initiated on 4/12/23, revised on 6/11/24, and 7/6/24 noted the resident was at risk for having oral discomfort and/or intolerance to current diet texture due to obvious dental caries/broken teeth related to poor oral hygiene. The goal was for Resident #78 to be free of infection, pain or bleeding in the oral cavity. The interventions as of 4/12/23 included: Monitor/document/report as needed any signs and symptoms of oral/dental problems needing attention, pain (gums, toothache, palate), abscess, debris in mouth, teeth missing, loose, broken, eroded, decayed, ulcers in mouth, lesions. Coordinate arrangements for dental care, transportation as needed/ordered. On 8/25/2023 a Social Service progress note documented the Social Services department had reached out to (specific dental office), the dental company to get Resident #78 signed up to receive dental services. No other documentation related to dental status and services was noted in Resident #78's clinical record. On 10/2/24 at 2:45 p.m. in an interview the Director of Nursing (DON) said she reviewed Resident #78's clinical record and verified the lack of documentation the facility coordinated arrangements for dental care to address the resident's dental issues. On 10/3/24 at 11:00 a.m., in an interview with the DON said she observed Resident #78's teeth and they were in bad shape. On 10/3/24 at 11:55 a.m., in an interview the Administrator said, The dental issues should have been identified and addressed upon admission.

Based on observation, review of the clinical record, review of facility policy and resident and staff interviews, the facility failed to provide the necessary care and services to maintain personal hygiene for 1 (Resident #11) of 5 residents reviewed for activities of daily living (ADL's). The findings included: The facility policy Activities of Daily Living (revised 1/24) documented The facility will, based on the resident's comprehensive assessment and consistent with the resident's abilities in ADL's do not deteriorate unless deterioration in unavoidable. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Review of the clinical record revealed Resident #11's diagnoses included major depressive disorder, type 2 diabetes mellitus, dementia, and mood disorder. The care plan initiated 6/7/21 documented Resident #11 had an ADL selfcare performance deficit as evidenced by need for assist with self-care. The interventions instructed The resident requires assist x 1 staff with bathing. The resident requires assist x 1 staff to dress. The resident requires assist x 1 (assistance of 1) staff with personal hygiene and oral care. Further review of the care plan specified the resident was resistive to hygiene care related to anxiety. The goal specified the resident will cooperate with care through next review date and instructed staff to : Allow the resident to make decisions about treatment regime, to provide sense of control. Educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. Give clear explanation of all care activities prior to an as they occur during each contact. On 9/30/24 at 2:20 p.m., Resident #11 was observed in her room in bed. The room had a strong, pungent and foul odor. Resident #11 was noted to have a strong and unpleasant body odor. Her fingernails were long extending approximately half an inch past the fingertip, with the right fifth fingernail extending over one inch past the fingertip. A brown substance was observed under the residents' nails. Resident #11 had facial hair extending approximately one inch. Resident #11 said, I need a shave.Resident #11 said staff sometimes clean her nails but no one cuts her nails. Observation of the resident's feet showed a thick, yellow buildup on the heels and between the toes. On 10/1/24 at 9:46 a.m., Resident #11 was observed in bed wearing the same shirt as the previous day. She had a strong body odor, was disheveled and unkempt. In an interview Resident #11 said, I need someone to cut my nails, this little finger is really long. She still had the facial hair to her chin. Her pillow was ripped with the stuffing coming out. Review of the Certified Nursing Assistant (CNA) documentation showed the resident received assistance with person hygiene daily on the 7:00 a.m., to 3:00 p.m., and 3:00 p.m. to 11:00 p.m., shifts. On 10/1/24 at 2:38 p.m., in a interview CNA Staff C said Resident #11 did not like to come out of bed, was incontinent, refused care but had not refused care for her in a while now. CNA Staff C said the CNAs shower and shave residents. She said, I don't know who does the nail care. On 10/1/24 at 3:18 p.m., in a joint observation, CNA Staff C looked at the resident's fingernails and said, Wow, they are really long. Resident #11 said she wanted her nails cut. CNA Staff C said, I can cut them for you. The resident told CNA Staff C she asks other staff to cut her nails all the time, but they don't cut them. On 10/2/24 at 10:29 a.m., in an interview Registered Nurse Staff D said the expectation was for nails and shaving to be done every day, including women but was not always realistic. On 10/3/24 at 9:40 a.m., in an interview CNA Staff A said nail care and shaving are done daily or with showers. Staff A said if she had a resident who continued to refuse care after she had tried, she would report it to the nurse. On 10/3/24 at 9:56 a.m., Resident #11 was observed in her bed, her nails had been trimmed and she had a new pillow. The resident's feet remained with a dry, yellow thick buildup between her toes and covering the bottom of both feet. On 10/3/24 at 11:06 a.m., in an interview the Director of Nursing (DON) said she was not aware of the concerns with Resident #11's fingernails, torn pillow, lack of hygiene and the condition of the resident's feet. On 10/3/24 at 12:10 p.m., in an interview Unit Manager Licensed Practical Nurse staff E, said she was informed of the concerns with Resident #11's hygiene and said the resident had a care plan for refusal of care. Staff E said she never saw the resident's facial hair, long fingernails with brown substance underneath the nails, tattered pillow, and resident #11 wearing the same shirt on 9/30/24 and 10/1/24. Staff E repeated the resident had a care plan in place for refusal of care. Staff E said Resident #11 changed her shirt daily. Review of the clinical record showed no documentation Resident #11 had refused personal hygiene or care.

Based on observation, record review, facility policy and procedure review, and staff interviews, the facility failed to ensure the comprehensive assessment accurately reflected the status for 2 (Resident #78 and Resident #105) of 32 residents reviewed for accuracy of assessments. The Findings Included: The Resident Assessment - RAI Policy provided by the facility with an October 2024 Revised date stated, This facility makes a comprehensive assessment of each resident's needs, strengths, goals, life history and preferences using the resident assessment instrument (RAI) specified by CMS . The current version of the RAI (MDS 3.0) will be utilized when conducting a comprehensive assessment of each resident in accordance with the instructions found in the RAI Manual . The assessment process will include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts . On 9/30/24 at 1:15 p.m., Resident #78 was observed dressed and lying in bed. She was smiling and kept repeating I love you and you are beautiful. Resident #78 did not answer any interview questions. She was picking at her upper teeth with a plastic drinking straw. All visible top teeth were observed jagged and decayed to the gum line. Clinical record review revealed Resident #78 was admitted to the facility on [DATE]. Diagnoses included Dementia. The Nursing Comprehensive assessment dated [DATE] noted Resident #78 had her own/natural teeth. No dental concern were noted on the assessment. The Admission Minimum Data Set (MDS) assessment with a target date of 3/27/23 noted Resident #78 was rarely/never understood. Her cognition was severely impaired. She never/rarely made decisions. The assessment noted Resident #78 had no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth. The care plan initiated on 4/12/23, revised on 6/11/24, and 7/6/24 noted the resident was at risk for having oral discomfort and/or intolerance to current diet texture due to obvious dental caries/broken teeth related to poor oral hygiene. The goal was for Resident #78 to be free of infection, pain or bleeding in the oral cavity. The interventions as of 4/12/23 included: Monitor/document/report as needed any signs and symptoms of oral/dental problems needing attention, pain (gums, toothache, palate), abscess, debris in mouth, teeth missing, loose, broken, eroded, decayed, ulcers in mouth, lesions. Coordinate arrangements for dental care, transportation as needed/ordered. On 8/25/2023 a Social Service progress note documented the Social Services department had reached out to (specific office), the dental company to get Resident #78 signed up to receive dental services. No other documentation related to dental status and services was noted in Resident #78's clinical record. The Annual MDS Assessment with a target date of 3/25/24 noted No was checked off, indicating Resident #78 had no obvious or likely cavity or broken natural teeth. On 10/2/24 at 2:45 p.m. in an interview the Director of Nursing (DON) said she reviewed Resident #78's clinical record and verified the MDS assessments did not accurately reflect the resident's dental status. She also verified the lack of documentation the facility coordinated arrangements for dental care to address the resident's dental issues. On 10/2/24 at 3:00 p.m., in an interview the MDS Coordinator verified she completed the section addressing the oral/dental status of Resident #78's on the Annual MDS assessment dated [DATE]. She verified No was checked off indicating Resident #78 had no obvious or likely cavity or broken natural teeth. The MDS coordinator said she completed the MDS assessment based on the information entered on the Nursing Comprehensive assessment which noted the resident did not have any dental issues. She said she did not see the care plan related to Resident #78's dental issues initiated on 4/12/23. On 10/3/24 at 11:00 a.m., in an interview with the DON said she observed Resident #78's teeth and they were in bad shape. On 10/3/24 at 11:20 a.m., in an interview the MDS Coordinator said the Resident Assessment Instrument manual did not require the person completing the assessment to lay eyes on the resident to complete the assessment. The MDS coordinator said she looked at Resident #78's mouth and will not make that mistake again. On 10/3/24 at 11:55 a.m., in an interview the Administrator said, The dental issues should have been identified and addressed upon admission. 41905 Review of the clinical record for Resident #105 revealed an admitted [DATE]. The care plan initiated 11/28/22 revealed Resident #105 was at risk for developing pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 5/12/23 revealed a score of 15, at risk for developing pressure sores. Review of the Quarterly Minimum Data Set (MDS) Assessment with a target date of 7/28/23 noted Resident #105's cognition was severely impaired. Resident #105 was incontinent of urine and feces, was wheelchair bound and totally dependent on staff for turning and repositioning. The MDS noted Resident #105 was not at risk of developing pressure ulcers. Review of the change in skin condition form dated 9/11/23 revealed Resident #105 developed a pressure ulcer. The care plan initiated on 9/26/23 noted Resident #105 had a deep tissue injury (Pressure injury with intact skin) to the left heel. Review of the Treatment Administration Records (TAR) for September and October 2023 revealed ongoing treatment for the deep tissue injury to the left heel from 9/12/23 through 10/7/23. The left heel deep tissue injury was not documented on the Discharge Return Anticipated MDS assessment dated [DATE]. On 10/2/24 at 10:26 a.m., the MDS coordinator verified the Discharge MDS dated [DATE] was innacurate and did not document the deep tissue injury. On 10/3/24 at 9:38 a.m., in an interview the MDS coordinator said the Quarterly MDS assessment dated [DATE] should have noted Resident #105 was at risk for developing pressure ulcers.

Based on observation, record review, resident and staff interviews, the facility failed to update the care plan and implement physician ordered interventions to prevent the development of pressure ulcers for 1 (Resident #42) of 2 residents reviewed with limited mobility. The findings included: Review of the clinical record revealed Resident #42 was admitted to the facility on [DATE]. Diagnoses included difficulty walking, muscle weakness, reduced mobility and compression fracture of the vertebra. The Admission Minimum Data Set (MDS) Assessment with a target date of 4/25/24 noted Resident #42 was dependent (Helper does all of the effort, Resident does none of the effort) to roll left and right, sit to lying, and lying to sitting on the side of the bed. Resident #42 had no pressure ulcer but was at risk of developing pressure ulcers. The Quarterly MDS assessment with a target date of 7/26/24 noted Resident #42's cognition was intact with a Brief Interview for Mental Status score of 14. Review of the physician's orders revealed an order dated 9/10/24 to apply bilateral offloading boots (relieve pressure from specific areas of the foot or ankle) as tolerated on every shift while in bed. On 9/30/24 at 9:45 a.m., and on 9/30/24 at 1:30 p.m., Resident #42 was observed in bed and appeared to be sleeping. Resident #42 was not wearing the offloading boots as ordered. Offloading boots were not observed in the resident's room. On 10/01/24 at 10:38 a.m., Resident #42 was observed in bed, sleeping. Resident #42 was not wearing the offloading boots as ordered. Offloading boots were not observed in the resident's room. On 10/01/24 at 1:40 p.m., Resident #42 was observed in bed, awake. She was not wearing the offloading boots as ordered. On 10/02/24 at 8:40 a.m., Resident #42 was observed in bed, awake. She was not wearing the offloading boots as ordered. In an interview Resident #42 said she did not know she was supposed to wear offloading boots to her feet and did not know where the boots would be. Review of the care plan initiated and revised on 4/20/24 noted Resident #42 has potential for pressure ulcer development related to immobility. The goal was for the resident to have intact skin, free of redness, blisters or discoloration. The interventions included to administer treatments as ordered and monitor for effectiveness. The care plan was not updated to include the physician's order of 9/10/24 to apply the offloading boots as tolerated every shift while in bed. The Certified Nursing Assistant (CNA) Kardex (Provides instructions for care) did not include to apply the offloading boots as tolerated every shift while in bed. On 10/3/24 at 8:30 a.m., in an interview CNA Staff C said she was assigned to provide care to Resident #42 on 10/2/24, and 10/3/24 but was not aware Resident #42 had an order for offloading boots while in bed. CNA Staff C reviewed the information in the Kardex and verified the Kardex did not include the application of offloading boots for Resident #42. On 10/3/24 at 8:55 a.m., in an interview the MDS Coordinator said MDS staff were responsible to update the care plan and CNA Kardex with new orders. She verified the Care plan and Kardex were not updated to reflect the physician's order dated 9/10/24 for the offloading boots.

Based on record review and interview, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 3 resident reviewed who returned to facility from the hospital. The findings included: On 4/1/24 at 9:53 a.m., Resident #1's son said his mother had been at the hospital and when she returned to the facility in January, he did not believe she was getting all her medications. He said his mother passed away on January 13, 2024. Review of Resident #1's chart revealed she was a long term care resident who had been sent out to the hospital and returned to the facility on [DATE]. Physician progress note dated 1/9/24 indicated discuss case with nursing staff and continue with meds: Gabapentin (anticonvulsant and nerve pain medication), Nitroglycerin sublingual (treats chest pain), Breo Elipta and Ipratropium-Albuterol (inhaler), Protonix (treats reflux), Tegretol (treats seizures and nerve pain), Carbidopa-Levadopa (treats tremors), Pramipexole Dihydrochloride (treats tremors), Amantadine (anti viral), Trazadone (antidepressant), Tramadol (pain), Paxil (antidepressant), Lasix (water pill), and Ativan (anxiety). Review of Resident #1's Medication Administration Record for January showed these routine medications had not been restarted upon return from the hospital on 1/9/24. On 4/1/24 at 12:31 p.m., the Director of Nursing (DON) said she had not been employed at the facility during Resident #1's stay. She did review the file and agreed it looked as if staff overlooked and the medications had not been re-instated or given to this patient upon return to facility from the hospital. On 4/2/24 at 10:30 a.m., the DON again agreed the routine medications were missed. She said she had spoke to the doctor who said Resident #1 was going to be transitioning to Hospice but had passed before the hospice consult occurred.

Based on record review and interview the facility failed to ensure that within 30 days of discharge, eviction or death, residents personal funds and a final accounting is provided to the individual or probate jurisdiction administering the estate for 1 (Resident #1) of 3 residents reviewed discharged mid month. The findings included: On 4/1/24 at 9:53 a.m., Resident #1's son said his mother passed away on January 13, 2024. He said he had still not received a refund from the facility. Resident #1's son said he spoke with someone he believed to be corporate in New Jersey approximately 5 weeks earlier who told him the refund was approved but they were waiting for the check to be cut. Resident #'1's son said he had not yet received a check and had heard nothing since. On 4/1/24 at 1:33 p.m., the Administrator said if a Resident is discharged or passed away, the business office has to issue a refund from that date to the end of the month. He explained the request for refund is handled at the facility but the disbursement is by a third party company. On 4/1/24 at 2:17 p.m., the Administrator said he reviewed Resident #1's account. He said the account was actually closed on 2/21/24 by account rep who works for the third party company. The Administrator said in looking through the account it did look like the refund check was never mailed out. The Administrator said he cannot answer why they did not cut the check and mail it. The Administrator said they are going to go back and audit to make sure there are no other outstanding accounts like that. He said it was an oversight and does not know why it wasn't done.

Based on observation, record review, staff and resident interviews, the facility failed to implement processes to ensure accurate assessment and supervision of residents who smoke tobacco products to protect each resident's individual's safety and the safety of other residents. The facility failed to comprehensively assess and implement adequate interventions to minimize falls for 1(Resident #71) of 1 resident reviewed for falls. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. The smoking area was observed with an overfilled pole cigarette receptacle and the surrounding area littered with cigarette butts. The floor of a clearly marked nonsmoking area had scattered cigarette butts. Residents observed smoking unsupervised in the nonsmoking area with no ashtray. The facility failure to ensure safe smoking practices created a likelihood of serious injury, impairment or death from thermal burn and fire, and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of pattern (K) starting on 6/4/23. On 6/23/23 at 11:50 a.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ templates. The findings included: Cross Reference to F835. The facility policy Resident Smoking (revised 9/12/22) documented It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking and non-smoking residents. Policy Explanation and Compliance Guidelines: 1. Smoking is prohibited in all areas except the designated smoking area. A Designated Smoking Area sign will be prominently posted. 2. Safety measures for the designated smoking area will include, but not limited to: a. Protection from weather conditions (i.e. covered). b. Provision of ashtrays made of noncombustible material and safe design. c. Accessible metal containers with self-closing covers into which ashtrays can be emptied. d. Accessible fire extinguisher. e. Prohibition of oxygen use in the smoking area. f. Located outdoors from main entrances and exits, and common space utilized by other residents in order to protect non-smoking residents from second hand smoke. 4. All residents and family members will be notified of this policy during the admission process and as needed. 5. All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) assessment process. 6. Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all. 8. Any resident who is deemed safe to smoke will be allowed to smoke in designated areas (weather permitting) at designated times, and in accordance with his/her care plan. 12. Smoking materials of residents will be maintained by the centers designated associate. 1. Review of the clinical record revealed Resident #65 had an admitted [DATE] with diagnoses including major depressive disorder, anxiety, schizophrenia, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident #65's cognitive skills for daily decision making were intact. Resident #65 frequently experienced moderate pain which limited his day-to-day activities. The assessment noted the resident was receiving oxygen therapy. The care plan initiated 4/20/22 and revised on 1/19/23 noted Resident #65 was a current smoker. The care plan documented, supervised smoker; chooses at time to not follow facility policy regarding smoking and may require more encouragement. The goal was, The resident will not put other residents/staff at risk secondary to smoking. The interventions included, A smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits and care smoking care plan will be initiated. Encourage/ educate resident to use safety while smoking; assessed found to be at risk. Resident refuses- - A fire retardant smoking apron must be worn while smoking. Initiated: 01/20/2023 Resident will smoke only in authorized areas while supervised. Smoking education has been provided to resident including not smoking in facility; designated smoking areas; locking up cigarettes/lighters; cigarettes brought in by family/friends must be locked up; only facility ashtrays may be used. Violation of smoking rules or disregard for safety rules my result in revocation of smoking privileges. Smoking rules will be reviewed with the resident upon admission. Date Initiated: 01/20/2023. The care plan initiated on 8/12/22 and revised on 2/2/23 noted the resident had the behavior of picking up cigarettes from the floor and out of the garbage. The interventions included monitoring the resident's behavior and for staff to notify maintenance to ensure there were no remaining cigarette on the floor in the smoking area. The Smoking Evaluation completed by the Unit Manager and dated 5/19/23 noted, Independent smoking is allowed. The Unit Manager entered No to the questions Does the resident use oxygen?, and Does the resident have unsafe smoking habits? Review of the nurse's progress note dated 6/4/23 documented Resident #65 was found to be smoking in his room by certified nursing assistant (CNA). She ensured that he put it out and he put it out on restroom door ledge. This nurse immediately notified, room smells like smoke and resident's oxygen concentrator is on at bedside but not in use while resident was by the restroom. Resident denies that he was smoking educated by nurse and ADON (Assistant Director of Nursing). Cigarettes confiscated and placed in smoker box, resident denies having a lighter. Monitored frequently via 15-minute checks. Will continue to monitor. The smoking evaluation and care plan were not revised to reflect Resident #65's unsafe smoking incident. On 6/20/23 at 9:25 a.m., CNA Staff C said Resident #65 was a smoker and propelled himself to the smoking area several times a day. Staff C said the smoking area was always monitored, and no resident was allowed to smoke independently. On 6/20/23 at 12:08 p.m., Resident #65 was observed in bed with a lighter and cigarettes. An oxygen concentrator was observed in the room. Resident #65 said he smoked daily. He said he had been feeling drained with no energy in the last few weeks but was able to transfer himself and go outside to smoke on his own. On 6/20/23, the facility provided a new smoking evaluation completed on 6/20/23 at 3:42 p.m., which noted Resident #65 used oxygen, had unsafe smoking habits, and a history of sharing/selling cigarettes or smoking materials. The evaluation noted the resident had a decline in functionality and determined Resident #65 required supervised smoking. On 6/20/23 at 3:48 p.m., the Director of Nursing (DON) said the nurse had planned to complete another smoking assessment for Resident # 65 due to significant change in his status and physical decline. On 6/20/23 at 4:20 p.m., Resident #65 was observed propelling himself to the smoking area with cigarettes and a lighter. The resident was observed smoking unsupervised. On 6/20/23 at 4:20 p.m., the designated smoking area was observed with an overfilled pole cigarette receptacle with multiple cigarette butts littering the surrounding area. Photographic evidence obtained. Cigarette butts were observed on the floor of the smoking area of the wooden gazebo. Photographic evidence obtained. On 6/21/23 at 9:41 a.m., Licensed Practical Nurse Unit Manager Staff E said the smoking materials were kept at the nursing station in a box behind the desk. Staff E said the process was independent smokers can go out when they choose, there were no scheduled smoking times. She said the independent smokers did not require supervision and they come to the desk to get their cigarettes and lighter. Staff E said all staff were responsible to ensure the cigarettes and lighter were returned to the nursing station. Staff E said Resident #65 now required supervision with smoking. Staff E said the CNA was told to go out with the resident when he wants to smoke. Staff E said there was no set time or CNA assigned to assist Resident #65 with smoking. On 6/22/23 at 1:05 p.m., the DON verified a new evaluation was not completed on 6/4/23 after Resident #65 was found smoking in his room with the oxygen concentrator on. She said from that point on, he was put on supervised smoking which meant all his smoking materials needed to be kept at the nurses' station. She said the information was passed on verbally between staff members. 2. Review of the clinical record for Resident #70 revealed an admitted [DATE]. The Admission MDS assessment with an assessment reference date of 12/13/22 noted the resident's diagnoses included Dementia. The most recent smoking evaluation signed on 1/20/23 with an effective date of 12/6/22 noted the DON answered No to the question, Does the resident have dementia?. The facility determined Supervised smoking is required for Resident #70. No other smoking evaluation was completed after 1/20/23. The care plan initiated on 12/19/22 and revised on 6/19/23 noted, Resident will smoke only in authorized areas while supervised. On 6/20/23 at 10:25 a.m., and 12:46 p.m., Resident #70 was observed smoking unsupervised in the designated smoking area. On 6/21/23 at 4:45 p.m., Resident #70 said smoking was not allowed in the nonsmoking patio but, we do it all the time. 3. Resident #30 was a smoker with an initial admitted [DATE]. The resident was transferred to an acute care hospital on 6/15/23 and returned to the facility on [DATE]. The care plan initiated on 12/7/23 and revised on 1/19/23 noted the resident was a smoker and, Resident chooses to not follow facility protocol regarding smoking at times. The interventions included as of 12/7/21, The resident can smoke unsupervised. Review of the clinical record on 6/20/23 showed the last smoking evaluation completed on 1/19/23 noted due to past behavior of choosing to not follow facility policy regarding smoking, supervised smoking was required. No other evaluation was found in the clinical record after 1/19/23. The care plan was not updated to reflect the resident required supervised smoking. On 6/21/23 at 5:40 p.m., Assistant Maintenance Director Staff B said, I have picked up cigarette butts daily for the last year, they are always on the ground. The management team educates the residents on safe disposal of cigarettes, but I have seen the residents' throwing butts on the ground. Every morning I am picking up butts off the ground. Staff B said I have observed Resident #70, #10 and #30 throwing cigarette butts onto the ground and I tell them over and over to put them in the ashtray. I have spoken to management about the concerns. I have not seen residents smoking on the non-smoking patio but every morning I pick up the cigarette butts. I check every morning at the gazebo area, and I use a reacher and a broom to pick up all the butts from the ground. Staff B said, what you have seen out there was two days' worth of cigarette butts because I did not get to it today. I am responsible to empty the ashtrays and last Friday the 16th was the last time I emptied it. There was no certain time the residents are able to smoke, they smoke all day long. There is a red metal bucket outside by the fence for cigarettes and I empty it daily. I have never emptied the [NAME] bottle ashtray (pole cigarette receptacle). There are butts around the [NAME] ashtray in the rocks and I pick them up every day. I sweep the grass with a broom to try and get them up. Staff B said she had spoken to administration about the cigarette butts being put out on the ground and they spoke to the residents about using the ashtrays and not throwing them on the ground. Staff B said, I have not seen any changes since the Administrator said she educated the residents, they still throw them (cigarette butts) on the ground. On 6/22/23 at 1:05 p.m., the Administrator (AD) and Director of Nursing (DON) said the department heads conduct weekly rounds and fill out a form which covers multiple areas. The Administrator and Director of Nursing both said since they have been employed at the facility, respectively in February and March of 2023, no one had voiced concerns related to unsafe smoking practices. The Administrator said she was not aware residents were smoking in nonsmoking areas. The DON said as of 6/4/23 Resident #65 was the only resident who required supervision. She said a smoking evaluation is completed upon admission, on a quarterly basis and as needed. The DON verified staff did not consistently complete the smoking evaluation to address any change in condition placing residents at risk of thermal burns or fire due to unsafe smoking practices. 46824 4. On 6/20/23, review of the clinical record for Resident #43 revealed an initial admitted [DATE]. The Annual MDS assessment with an assessment reference date of 8/23/22 noted the resident had current tobacco use. Diagnoses included Dementia. The most recent smoking evaluation was dated 1/20/23 and was completed by the DON. The DON answered No to the question Does the resident have dementia?. The evaluation noted, Supervised smoking is required. No other smoking evaluation was noted in the clinical record. The care plan initiated on 8/20/21 and revised on 2/23/23 noted the resident was a current smoker with a goal to remain safe from injury. The interventions included, A smoking history and safe smoking assessment will be completed upon admission/readmission, quarterly, annually, and/or with a change in smoking habits. Resident must have cigarettes/lighters locked up at all times other than smoking time. Resident will smoke only in authorized areas while being supervised. On 6/20/23 at 10:52 a.m., Resident #43 was observed smoking unsupervised in the designated smoking Gazebo. Resident #43 had cigarettes and a lighter. He said he keeps his cigarettes and lighter in his room and smokes when he feels like it. The smoking patio was observed with a large plastic garbage container within proximity of an ashtray mounted to the pole of the gazebo of the smoking area. The garbage container was approximately filled 75% with items including paper items and Styrofoam cups. Multiple cigarette butts were observed on the wooden floor of the gazebo, on the grass surrounding the smoking area and around a pole cigarette receptacle which was overfilled with cigarette butts. Photographic evidence obtained. The wall mounted metal box containing the fire blanket had sharp rusted pieces. Photographic evidence obtained. There were cigarette butts next to the wooden walkway leading to the gazebo. Photographic evidence obtained. On 6/20/23 at 1:11 p.m., and 6/21/23 at 9:43 a.m., on the 400-hall patio, there was a nonsmoking sign on the door leading to the outside covered patio. The nonsmoking area did not have an ashtray and multiple cigarette butts were observed on the floor. On 6/21/23 at 12:30 p.m., an unidentified resident was observed smoking in the covered patio clearly marked with a large nonsmoking sign. 5. On 6/20/23, review of the clinical record for Resident #10 revealed an admitted [DATE] and a readmitted [DATE]. The care plan initiated on 5/17/21 and revised on 6/19/23 noted the resident was a smoker and non-compliant with smoking protocol. The goal was for the resident to not suffer injury from unsafe smoking practices. The interventions included instructing resident about the facility policy on smoking, locations, times, safety concerns and wait for assistance from staff. Resident #10's care plan also noted the resident had poor impulse control, had the potential to be physically aggressive, hitting out at staff/residents related to anger, altering oxygen orders per physician's order at bedside. The most recent smoking evaluation was dated 1/19/23 and noted the resident required supervised smoking, due to the safety of other and past behavior. No other smoking evaluation was completed after 1/19/23. On 6/20/23 at 9:13 a.m., Resident #10 was observed lying in bed. He said he usually kept his cigarettes and lighter with him. He said he dropped them on the floor and could not find them. 30599 5. Resident #71 was admitted to the facility on [DATE] with a history of hypertension, Cognitive communication deficit, Being unsteady on her feet, muscle weakness, Dementia, and Schizophrenia. On 1/23/23 the quarterly Minimum Data Set (MDS) showed Resident #71 had severe cognitive deterioration with a Brief Interview for Mental Status score of 2. On 6/19/23 at 10:55 a.m., Resident #71 was observed lying in the bed sleeping. There was a single floor mat noted on the side of the bed of window and wall. On 6/20/23 at 2:00 p.m. Resident #71 was observed lying in the bed sleeping. The same single floor mat was noted on the floor. On 6/21/23 at 11:10 a.m. Resident #71 was observed lying in the bed sleeping. The same single floor mat was noted on the side of the bed. On 6/22/23 at 1:20 P.M. Resident #71's daughter said she was concerned about her mother falling. She stated her mother had fallen two times at the facility where she had to be sent to the hospital due to her injuries. Resident #71's daughter said she was concerned because she did not think the facility had interventions in place to prevent her mother from continuing to fall. An incident report shows on 2/24/23 at 9:30 p.m. Resident #71 fell in her room and hit her head causing her to go to the hospital for treatment. According to the incident report the fall was witnessed by a certified nursing assistant whose statement is recorded as, room [ROOM NUMBER] was sitting up on the bed. I asked is she was ok, and she said OK. When she got up from the bed I asked her where are you going? She told me stop as she was getting up she lost her balance and stumbled and fell down and hit her head on the wall. I was sitting in the room with 301. On 2/24/23 at 10:13 p.m. documentation on the Fall Risk Assessment V2.0 shows Resident #71 was assessed to be a low risk for falls with a score of 9. The form reads a score greater than 10 is considered a risk for falls. On 4/14/23 at 5:45 p.m. an incident report shows Resident #71 had a fall after being put in her bed. The nurse who reported the incident wrote, At the beginning of the shift, resident was sitting in her wheelchair, and became increasingly agitated and combative. Assisted patient back to bed for safety. Bilateral fall matts in place. Bed in low position. Non skid socks in place. At about [5:45 p.m.] got called by staff to resident's room. Resident observed laying on the floor, face down in a moderate to large amount of bright blood. Resident responded to name calling by moaning, attempting to lift self from the floor. [vital signs] stable. Resident lifted off the floor by paramedics. The resident was transported to the hospital on 4/14/23. Resident #71 was diagnosed with a fractured nasal bone on 4/15/23. Resident #71's Had a fall care plan initiated on 1/26/22/ and it was last revised on 4/26/23. Interventions included in the care plan were ensure secure bilateral footwear for safety, Encourage and assist resident to lay down for naps, Review information on past falls and attempt to determine cause of falls. There was no intervention listed on the care plan for a floor mat or bilateral floor mats while the resident is in the bed. On 6/23/23 at approximately 1:30 p.m. the Administrator said if there was one fall mat it should be on the side of the bed toward the door where the resident gets out of bed. The Administrator was referred to the incident report on 4/14/23 where the resident had bilateral floor mats prior to her fall. On 6/23/23 at approximately 2:30 p.m. The administrator said they were removing the floor mat because the resident did not have a physician's order to have them. The Administrator was asked about the potential injury to the resident if she fell from her bed again. The Administrator stated she would have to get back with me. On 6/23/23 at 5:30 p.m. The administrator had not followed up as to whether the facility would continue with floor mats for Resident #71. The Immediate Jeopardy was removed on 6/23/23 after surveyor verification of an approved removal plan which included: A comprehensive skin assessment was completed by nurse manager/ charge nurse on Resident #65 on 6/5/23; 6/6/23; 6/7/23 and 6/23/2023, no new or old areas of skin impairment noted. The survey team verified through record review. The nurse manager examined Resident #65 clothes for signs of burn, none noted on same dates as skin assessment. The survey team verified through record review. On 6/21/2023 Nurse Manager searched Resident #65 room for smoking paraphernalia, cigarettes and lighter confiscated and placed in a lock box at the west wing nursing station. The survey team verified through observation of the locked box at the west nursing station. The Nurse Manager completed a smoking re-assessment on Resident #65 on 6/23/2023 and revised plan of care to include supervised smoking during assigned smoking times in designated smoking area and to wear an apron while smoking. The survey team verified through record review. Resident #65 was placed on supervised smoking on 6/23/2023. Supervised smoking consists of direct staff observation during designated smoking times in designated smoking area with smoking apron. The survey team verified through record review. The Social Service Director re-educated Resident #65 on smoking policy and procedure on 6/20/2023. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking only in designated smoke areas only, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to staff after smoking. Resident #65 signed the policy and procedure contract as good faith to adhere to the policy. The survey team verified through record review. The Administrator hosted an Ad Hoc Quality Assurance Performance Improvement meeting with Medical Director engagement on 6/21/2023 to discuss Smoking Policy and specific emphasis on Implementation of smoking times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. The survey team verified through record review. Administrator and/or designee conducted a room search of residents that smoke to search for and confiscate cigarette paraphernalia. Cigarettes and lighters were retrieved and placed in lock boxes at the west wing nurse's station. Only Nursing and/or Ancillary staff will have access to the storage boxes. The survey team verified through observation of the locked box at the nurse's station. Nurse Manager and/or designee completed a smoking assessment on all residents that smoke on 6/21/2023. All residents that were identified as needing supervised smoking plan of care was updated to reflect smoking supervision. The survey team verified through record review. All residents who smoke plan of care was revised on 6/23/2023 to include smoking allowed only during designated times in designated smoking location. The survey team verified through record review. Social Service Director and/or designee re-educated all residents that smoke on the Smoking Policy and Procedure on 6/21/2023. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking in designated smoke areas, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. The survey team verified through record review. A Smoking Contract on the policy and procedure was initiated with all residents who smoke to acknowledge and obtain written agreement to smoke only in designated smoke areas, dispose of cigarette butts in fire receptacles, adhering to smoke times, and wearing smoking aprons if needed 6/21/2023. The survey team verified through record review. Interdisciplinary Team thoroughly checked clothing for all resident identified as smokers to ensure no holes or burns were observed on 6/22/2023. No concerns were identified. Center staff on 6/21/2023 did grounds search and picked up cigarettes' butts and emptied ashtrays. Maintenance assistance will be responsible to make sure ash trays are frequently emptied, cigarette butts or evidence of smoking are not discarded in undedicated areas but in fire receptacles and re-educated to report noncompliance on 6/22/2023. The survey team verified through observation, record review and interview with the maintenance assistant and the Administrator. Maintenance assistance completed an audit of the smoking area on 6/22/2023 to validate availability of smoking blanket, fire receptacles, fire extinguishers and aprons. Effective 6/23/2023, smoking aprons will be in the designated smoking area. The survey team verified through observation. Maintenance assistance and/or designee validated no smoking signage is posted in non-smoking areas on 6/22/2023. The survey team verified through observation. Social Service Director and/or designee re-educated all residents that smoke on the Smoking Policy and Procedure on 6/22/2023. Education included adherence to the smoking times, smoking allowed only with staff supervision, smoking in designated smoke areas, smoking aprons, discarding of cigarette butts, and turning in cigarette paraphernalia to Nursing. The SDC or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning 6/22/2023 with emphasis on designated smoke times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. The survey team verified through record review and interview of random staff, including licensed Nurses and CNAs. Any employee on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. Staff re-education: Nursing staff 39/44 (89%); Non nursing staff 15/15 (100%); Therapy 13/13 (100%); Dietary 9/10 (90%); Housekeeping/Laundry 11/11 (100%). Agency staff not currently educated will be educated on this plan prior to working their scheduled assignment. The survey team verified through record review. Effective 6/22/2023, designated smoking times will be implemented for all residents who smoke. Cigarette paraphernalia and smoking aprons will be stored in a secure designated smoking storage cart. Additionally, documentation outlining individualized safety measures will be based on the smoking assessment and located on or inside the smoking storage boxes. Designated smoking aide will be added to daily staffing assignment. The survey team verified through record review. Effective 6/22/2023, Director of Nursing and/or designee will review new admissions during the Clinical Meeting to identify smokers and validate a smoking assessment has been completed and a plan of care is in place to maintain resident safety. If a resident is observed as being non-compliant with smoking, a care plan meeting will be scheduled with resident and/or legal representative. Smoking privileges may be revoked. Any further non-compliance may result in the issuance of an immediate discharge notice and/or a 30-day notice for discharge. The survey team verified through record review. Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on 6/23/2023 with Department Managers and reviewed with the Medical Director on the center's Smoking Policy and the performance improvement measures outlined in this document. The survey team verified through record review.

Based on observation, record review and staff interview the facility Administration failed to utilize its resources effectively to ensure safe smoking practices, including assessment and supervision of residents who smoke tobacco products to protect residents from serious injury, impairment, or death. On 6/4/23 staff observed Resident #65 smoking in his room with the oxygen concentrator on. The facility failed to reassess Resident #65's ability to adhere to safe smoking precautions and allowed the resident to keep, and store smoking materials. Resident #65 and other residents who required supervision to smoke were observed smoking unsupervised. The smoking area was observed with an overfilled pole cigarette receptacle and the surrounding area littered with cigarette butts. The floor of a clearly marked nonsmoking area had scattered cigarette butts. Residents observed smoking unsupervised in the nonsmoking area with no ashtray. The facility administration's failure to ensure safe smoking practices created a likelihood of serious injury, impairment, or death from thermal burns and fire and resulted in the determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on 6/4/23. On 6/23/23 at 11:58 a.m., the Administrator was notified of the Immediate Jeopardy and provided the IJ templates. The facility census was 105 and included 11 residents who smoke tobacco products. The findings included: Cross reference F689. The Administrator's job description signed on 3/13/23 noted in the position purpose, Leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents . Major duties and responsibilities . Performs rounds to observe residents and ensure overall needs are being met. Practices management by walking around . Manages and minimizes facility risk through a team approach to achieve desired outcome in customer service . other areas as identified. Additional tasks . Follows appropriate safety . measures at all times to protect residents and themselves . The Director of Nursing's job description signed on 2/3/23 included, Plans, develops, organizes, implements, evaluates, and directs the overall operations of the Nursing Services department, as well as its programs and activities, in accordance with current state and federal laws and regulations. Performs rounds to observe residents and ensure nursing needs are being met . Review of the facility's Resident Smoking policy implemented on 10/01/22 state the facility will provide a safe and health environment for residents, visitors, and employees, including safety related to smoking and safety protections apply to smoking and non-smoking residents. The policy further noted, All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS (Medical Data Set) assessment process . Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if resident is safe to smoke at all . All safe smoking measures will be documented on each resident's care plan and communicated to all staff, visitors, and volunteers who will be responsible for supervising residents while smoking. Supervision will be provided as indicated on each resident's care plan. Review of the clinical record for Resident #65 revealed an admitted [DATE] and a readmitted [DATE]. Diagnoses included Congestive Obstructive Pulmonary Disease (COPD) requiring the use of oxygen. Resident #65 smoked tobacco products. On 5/19/23, a smoking evaluation documented the resident was able to smoke independently. The evaluation noted the resident was able to safely hold a cigarette, and the resident was able to properly dispose of ashes or cigarette butts. Review of the progress notes revealed on 6/4/23 staff observed Resident #65 smoking in his room. The oxygen concentrator was on at the bedside but not in use. The staff confiscated the cigarettes. Resident #65 denied having a lighter. The clinical record lacked documentation the resident's ability to adhere to safe smoking practices was reassessed. On 6/20/23 at 12:08 p.m., Resident #65 was observed in bed. The resident had cigarettes and a lighter with him. He said he smoked independently. The oxygen concentrator was in the room but not turned on at the time of the observation. The facility provided a new smoking evaluation completed on 6/20/23 at 3:42 p.m., which noted Resident #65 had unsafe smoking habits and a history of sharing/selling cigarettes or smoking materials. The evaluation noted the resident had a decline in functionality and determined Resident #65 required supervised smoking. On 6/20/23 at 4:20 p.m., Resident #65 was observed smoking unsupervised in the designated smoking area. On 6/22/23 at 1:05 p.m., the Director of Nursing (DON) verified a new evaluation was not completed on 6/4/23 after Resident #65 was found smoking in his room with the oxygen concentrator on. She said from that point on, he was put on supervised smoking which meant all his smoking materials needed to be kept at the nurses' station. She said the information was passed on verbally between staff members. On 6/21/23 at 5:40 p.m., the Assistant Maintenance said since she's been employed at the facility a year ago, she has picked up cigarette butts from the floor every day. She said she observed Resident #70, #10 and #30 throwing cigarette butts on the floor. She has told them over and over to discard the cigarette butts in the ashtray to no avail. She said she reported the unsafe smoking practices to the Administrator who said she educated the residents. She said she has not seen any changes. The facility provided the survey team with a list of 11 current smokers. Review of the clinical records for a sample of smokers revealed the following: Resident #70 was a smoker admitted to the facility on [DATE]. Review of the clinical record showed a smoking evaluation with an effective date of 12/6/22 and signed by the DON on 1/20/23 noted the resident required supervised smoking. The resident's care plan dated 12/19/22 noted the resident was a smoker and the resident would smoke only in authorized areas while supervised. No other smoking evaluation was noted in the clinical record after 12/6/22. On 6/20 /23 at 10:25 a.m., and 12:46 p.m., Resident #70 was observed smoking unsupervised in the designated smoking area. The designated smoking area had an overfilled ashtray, and the floor of the wooden gazebo was littered with multiple cigarette butts. On 6/21/23 at 12:30 p.m., an unidentified resident was observed smoking in a covered patio clearly marked with a large nonsmoking sign. The patio did not have an ashtray. Several cigarette butts were observed littering the floor of the nonsmoking patio area. Photographic evidence obtained On 6/21/23 at 4:45 p.m., Resident #70 said he was aware smoking was not allowed in the nonsmoking patio but, we do it all the time. Resident #10 was a smoker admitted to the facility on [DATE] and a readmitted [DATE]. Review of Resident #10's clinical record revealed the most recent smoking evaluation completed on 1/19/23 noted the resident used oxygen and required supervised smoking due to safety of others and past behavior. No other smoking evaluation was completed after 1/19/23. Resident #30 was a smoker with an initial admitted [DATE]. The resident was discharged with return anticipated and on 6/15/23. The most recent admission was 6/20/23. Review of the clinical record on 6/20/23 showed the last smoking evaluation completed on 1/19/23 noted due to past behavior of choosing to not follow facility policy regarding smoking, supervised smoking was required. Resident #43 was a smoker admitted to the facility on [DATE]. Review of the clinical record showed the last smoking evaluation was completed on 1/20/23. The evaluation noted Resident #43 required supervised smoking. There was no other evaluation completed after 1/20/23. On 6/20 /23 at 10:25 a.m., and 12:46 p.m., Resident #43 was observed smoking unsupervised in the designated smoking area. On 6/22/23 at 1:05 p.m., the Administrator (AD) and Director of Nursing (DON) said the department heads conduct weekly rounds and fill out a form which covers multiple areas. The Administrator and Director of Nursing both said since they have been employed at the facility, respectively in February and March of 2023, no one had voiced concerns related to unsafe smoking practices. The Administrator said she was not aware residents were smoking in nonsmoking areas. The DON said as of 6/4/23 Resident #65 was the only resident who required supervision. She said a smoking evaluation is completed upon admission, on a quarterly basis and as needed. The DON verified staff did not consistently complete the smoking evaluation to address any change in condition placing residents at risk of thermal burns or fire due to unsafe smoking practices. The Immediate Jeopardy was removed on 6/23/23 after surveyor verification of an approved removal plan which included: On 6/21/2023 a Root Cause Analysis (RCA) on the smoking practices in the center to ensure safe smoking practices are in place to protect residents from serious injury, impairment or death was completed by the [NAME] President of Clinical Operations (VPCO), Administrator, Director of Nursing and Medical Director. Documentation of the RCA was put on the RCA Tool and will be included in the next Quality Assurance Performance Improvement (QAPI) meeting. The survey team verified through record review. On 6/23/2023, the VPCO educated the Administrator on ensuring the Center has a system in place to ensure safe smoking habits and practices are in place. Education included making sure staff in knowledgeable about habits that violate safe smoking practices and report them to administration when they occur. The survey team verified through record review. On 6/23/2023, the VPCO educated the Director of Nursing on conducting smoking assessments on residents that smoke on admission, quarterly and when they experience a change in condition that will affect smoking habits and competency. Education also included updating and individualizing plan of care of residents that smoke to reflect current assessment. The survey team verified through record review. On 6/23/23 all 11 smokers had an updated smoking evaluation. On 6/23/2023, the VPCO reviewed job descriptions for Administrator and Director of Nursing to ensure that they understand their duties and responsibilities. Review shows that Administrator and DON are capable of carrying out the job duties. The survey team verified through record review and interview of the Director of Nursing and Administrator. On 6/23/2023, the Administrator hosted an AD HOC Quality Assurance Performance Improvement (QAPI) meeting on 6/23/2023 with DON, VPCO and Medical Director to review the Root Cause Analysis of Res #65 smoking risk event, center smoking practices & Performance Improvement Plan put in place to address areas of opportunities. The survey team verified through record review. Administrator implemented after review of RCA a (PIP) on residents smoking assessments and plan of care, designated smoke times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance on 6/23/2023. The survey team verified through record review of smoking schedules and observation of supervised smoking in the designated smoking area. The SDC or designee re-educated Nursing, Social Services, Housekeeping, Dietary, Therapy, and Maintenance employees on the Smoking Policy and Procedure beginning 6/22/2023 with emphasis on designated smoke times, supervision of residents during smoking times, application of smoking aprons, adherence to smoking areas, discarding cigarette butts in fire receptacles, and reporting observations of non-compliance. Any employee on leave of absence (FMLA), vacation, or PRN will be re-educated prior to returning to duty. Staff re-education: Nursing staff 39/44 (89%); Non nursing staff 15/15 (100%); Therapy 13/13 (100%); Dietary 9/10 (90%); Housekeeping/Laundry 11/11 (100%). Agency staff not currently educated will be educated on this plan prior to working their scheduled assignment. The survey team verified through record review, and interview of three nurses, and two Certified Nursing Assistants. Effective 6/22/2023, designated smoking times will be implemented for all residents who smoke. Cigarette paraphernalia and smoking aprons will be stored in a secure designated smoking storage cart. Additionally, documentation outlining individualized safety measures will be based on the smoking assessment and located on or inside the smoking storage boxes. Designated smoking aide will be added to daily staffing assignment. The survey team verified through record review and observation of supervised smoking at the designated smoking times. Effective 6/22/2023, Director of Nursing and/or designee will review new admissions during the Clinical Meeting to identify smokers and validate a smoking assessment has been completed and a plan of care is in place to maintain resident safety. The survey team verified through record review. If a resident is observed as being non-compliant with smoking, a care plan meeting will be scheduled with resident and/or legal representative. Smoking privileges may be revoked. Any further non-compliance may result in the issuance of an immediate discharge notice and/or a 30-day notice for discharge. The survey team verified through record review.

Based on observation, staff interview, and policy review, the facility failed to maintain the kitchen in a sanitary manner and in good repair by failing to store cloths used for wiping surfaces in red sanitizing pails, failing to repair the leaking 3-compartment sink sprayer, failing to change the ice machine water filter according to manufacturer's specifications, storing measuring scoop for thickener inside of the bin in contact with the thickener, kitchen staff eating lunch while working and touching kitchen equipment, failing to wash hands between eating lunch, changing trash can bag, and placing lunch plates in the plate warmer. The findings included: Review of the facility policy Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices: . Employees must wash their hands: b. After using tobacco, eating, or drinking; d. Before coming in contact with any food surfaces; f. After handling soiled equipment or utensils; h. After engaging in other activities that contaminate the hands. 14. Personnel may not . eat or drink in the food preparation area. On 6/19/23 at 9:15 a.m., during initial kitchen tour, the following was observed: The kitchen air conditioner was not working. The 3-compartment sink sprayer had water leaking continuously while not in use. Wet wiping cloths used to sanitize the counters were laying on the counter next to the coffee maker and not submersed in sanitizing solution. There was no sanitizer bucket in the food preparation area for wiping cloths. Photographic evidence obtained. During a subsequent visit to the kitchen conducted on 6/23/23 at 11:29 a.m., the following concerns were identified: The 3-compartment sink sprayer continued to leak water in a heavy stream while not in use. Wet, wiping cloths were laying on the counter in two separate areas next to the coffee maker and drink machine. There was no sanitizer bucket in the area. Dietary Staff AA was observed putting a black trash can liner in a large trash can near the 3-compartment sink. Staff AA touched the trash can rim. Staff AA did not wash or sanitize his hands after touching the trash can then picked up a piece of his lunch with his hands and walked through the kitchen eating the food with bare hands. Staff AA continued to work in the kitchen without washing or sanitizing his hands after eating, he picked up a green tray containing desserts and placed it in the counter height reach-in refrigerator. Staff AA then used both hands to pick up a stack of white dish plates from the cart and placed them in the plate warmer for lunch service. Dietary Staff AA touched the edges of the plates with both hands as he held them. On 6/23/23 at 11:37 a.m., observed Staff AA pick up the wet cloth laying near the drink machine and wipe a puddle of brown liquid under the drink machine. He then placed the cloth in an empty bucket in an adjoining room. Photographic evidence obtained. On 6/23/23 at 11:48 a.m., observed a yellow cloth on the stove top. The Certified Dietary Manager (CDM) used the yellow cloth to wipe crumbs from the steam table across from the stove top. Photographic evidence obtained. On 6/23/23 at 11:50 a.m., the CDM said the air conditioner did not work for a few days and was recently repaired. The CDM was informed of the observation of Staff AA not washing hands, the wiping cloths not kept in a sanitizing solution, and the 3-compartments sink sprayer continuously leaking water when not in use. The CDM looked for a sanitizer bucket in the food preparation area but could not find one. The CDM said he told staff to change the sanitizer buckets every two hours, but they still did not do it. The CDM instructed the dietary staff to re-wash the plates before using them for lunch service. On 6/23/23 at 12:04 p.m., the CDM removed the ice machine water filter from the water line. He poured out brown water from the filter cylinder into the sink. The label on the filter was dated 1/23/19 with instructions that read, Replacement every 6-12 months. The CDM said the filter was installed on 1/23/19. The CDM said he cleaned the ice machine in April 2023, but had not changed the filter. He said he did not keep a log or document when the ice machine was cleaned be changed recently. Review of the manufacturer's specifications for the make and model of the facility ice machine water filter indicated to change the filter every 6-12 months. A handheld scoop was observed laying within a container of dry thickening powder. The CDM verified the scoop stored in the container of thickening powder created the potential to contaminate the thickener with bacteria and germs. The CDM said he created a work order in the computer system for repair of the 3-compartment faucet, but the maintenance director quit over a month ago and it has not been repaired. Photographic evidence obtained. On 6/23/23 at 1:50 p.m., the maintenance assistant said the maintenance director quit over a month ago and was responsible for the ice machine maintenance. She said she did not change the ice machine water filter and did not know anything about it. On 6/23/23 at 2:08 p.m., the administrator was made aware of the concerns observed in the kitchen. The ice machine manual, maintenance log, and filter logs were requested. On 6/23/23 2:50 p.m., the CDM agreed with the observations made in the kitchen and said there was room to improve. He said he created a work order for repair of the 3-compartment sprayer a month ago. Review of the Open Work Order #7172 created on 5/26 9:18 a.m., noted, Sprayer by 3 compartment sink leaking. The CDM provided the maintenance logbook for the ice machine. The Logbook Documentation for the Ice Machines noted to Check filters (if present), clean coils, sanitize interior, delime as necessary. The log was marked as done on 1/31/23 and 4/27/23 by the previous maintenance director.

Based on observation, review of facility policy and procedures, staff and resident interviews the facility failed to provide the necessary care and services to maintain personal hygiene for 3(Resident #33, #60 and #101) of 4 residents observed for activities of daily living (ADLs). The findings included: The facility policy Activities of Daily Living (revised 9/22) documented Based on the comprehensive assessment of a patient and consistent with the patients needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in ADL'S do not diminish unless circumstances of the individual clinical condition demonstrate that such diminution was unavoidable. A patient who is unable to carry out ADL's receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. 1. Review of the clinical record revealed Resident #33 had an admitted [DATE] with diagnoses including cognitive communication deficit, need for assistance with personal care, dementia and major depressive disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/3/23 documented Resident #33 was dependent on staff for personal hygiene and bathing. The MDS noted Resident #33's cognitive skills for daily decision making were severely impaired. The care plan initiated 12/15/21 identified Resident #33 had an ADL self-care performance deficit as evidence by the need for assistance with self-care. The care plan interventions instructed staff to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The resident requires up to and including total assist of staff with personal hygiene and oral care. On 6/19/23 at 9:45 a.m., Resident #33 was out of bed in a specialized wheelchair in the small sitting area next to the nurse's station. Resident #33 had not been shaved with approximately 2-3 days growth. His fingernails were long, approximately 1/4 inch in length with a brown substance under the nailbeds. His wheelchair had dried food and other grime on the arm rests and on the seat. Resident # 33 was nonverbal and did not make eye contact when greeted. On 6/20/23 at 9:10 a.m., Resident #33 was observed in the small sitting area, he was unshaven with several days of growth. 2. Review of the clinical record revealed Resident #60 had an admitted [DATE] with diagnoses including cerebral infarction (a stroke), type 2 diabetes, and major depressive disorder. The Annual MDS with an assessment reference date of 5/4/23 documented Resident #60 required extensive assistance with personal hygiene and was dependent for bathing. The MDS documented Resident #60's cognitive skills for daily decision making were intact. The care plan initiated 5/16/22 and revised 5/16/23, identified Resident #60 had an ADL self-care deficit. The interventions specified check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. The resident requires up to and including extensive assist of staff with bathing/showering on rounds and as necessary. Review of the CNA shower list showed Resident # 60 was scheduled for shower Mondays and Thursdays on the 7-3 shift. Review of the certified nursing assistant (CNA) shower sheets documented Resident #60 received a bed bath on 6/1/23, 6/6/23 and 6/16/23 and a shower on 6/4/23 and 6/12/23. On 6/19/23 at 10:03 a.m., Resident #60 was observed in bed, and dressed in a green T-shirt. The resident was unshaven approximately three days growth and his fingernails were long, approximately 1/2 inch with a brown substance under the nail beds. Resident #60 said he had not received showers because there was only one shower room down the hall and too many people going in and out of it. He said the staff don't provide bed baths most of the time. He said he had wipes and that is how he bathes. Resident #60 said the staff shave him, but it had not done in a few days. He said he did not remember when his nails were cleaned or cut. On 6/20/23 at 9:12 a.m., Resident #60 was observed in bed in the same green T-shirt as the previous day. He remained unshaven with several days of growth. Resident #60's fingernails had recently been trimmed. He said he did not get his shower and did not know when he received a shave but said he needed one. On 6/20/23 at 9:13 a.m., in an interview CNA Staff C said Resident #60 does not always like to get out of bed but he did go to therapy. The CNA said he was not assigned to the resident today but knows him very well. He said Resident #60 was able to transfer with assistance to a wheelchair and was able to make his needs known. CNA Staff C confirmed Resident #60 had a few days growth of stubble on his face. CNA Staff C said the resident did not refuse care when he is on his assignment and said, I have no trouble shaving him. 3. Review of the clinical record revealed Resident #101 had a readmitted [DATE] with diagnoses including protein calorie malnutrition, weakness, lack of coordination and anxiety. A significant change MDS with an assessment reference date of 6/15/23 documented Resident #101 required extensive assistance with personal hygiene and was dependent for bathing. The MDS documented Resident #60's cognitive skills for daily decision making were intact. The care plan initiated 6/3/23 identified Resident #101 had a self-care deficit requiring staff assistance with personal hygiene. Review of the CNA shower schedule revealed Resident #101 was scheduled for showers on the 3:00 p.m. to 11:00 p.m., shift every Monday and Thursday. On 6/19/23 at 9:59 a.m., Resident #101 was observed in bed, he was unshaven approximately three days growth. He said he did not receive showers because he was not able to tolerate sitting up for long periods and the staff use wipes to clean him. He said the staff have not offered to shave him and he did not know when he had his nails cleaned and cut. On 6/21/23 at 9:11 a.m., CNA Staff D said the staff follow the shower assignment in the CNA assignment binder. CNA Staff D said fingernails and shaving were provided during shower care, but men should be shaved daily or every other day. Staff D said, some of the male residents didn't want to be shaved every day and some refuse care and we tell the nurse. On 6/21/23 at 10:51 a.m., Registered Nurse Unit Manager Staff G, said the nurses were responsible to ensure the CNAs were providing ADL care, including showers, shave and nail care. I instruct them to look at the resident when they go in to administer medications or care, to make sure the residents look clean, and have they been shaved. Staff G said she was aware of the resident concerns regarding bathing and hygiene care.

Based on observations, review of the clinical records, review of facility policies and procedures, and staff interviews, the facility the facility failed to implement meaningful resident centered activities to meet the interest and wellbeing of 8 (Resident #22, #33, #34, #47, #71, #74, #88 and #209) of 8 residents reviewed for activities. The lack of an individualized activity program has the potential to cause social isolation, boredom, agitation, and frustration. The findings included: The facility policy Resident Self Determination and Participation (Activities) revised 9/22, specified, The facility's activity program is designed to promote and facilitate resident self-determination through support of resident choice and resident rights. Each resident has the opportunity to exercise his or her autonomy regarding those things that are important in his or her life. The Activity Director shall develop a plan of care for the resident based on the resident's assessment, goals, and preferences. 1. Review of the clinical record revealed Resident #33 had an admitted [DATE] with diagnoses including cognitive communication deficit, dementia, and major depressive disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 6/3/23 documented Resident #33's cognitive skills for daily decision making were severely impaired. The care plan initiated 12/13/21 and revised on 6/9/23 documented Resident #33 would actively participate in activities of choice. The interventions specified Resident #33 was to be encouraged to attend activities of choice and enjoyed watching TV, spending time with family and listening to music. Provide assistance to location of activities of choice. During random observations on 6/19/23 at 9:11 a.m., and 11:12 a.m., Resident #33 was sitting in his wheelchair in the small television (TV) room on the unit. The TV and the radio were off, and no staff were present. On 6/20/23 at 9:51 a.m., and 3:43 p.m., Resident #33 was observed in the TV room. The TV was on, and the resident was sleeping in his wheelchair. On 6/20/23 at 10:10 a.m., Activities Assistant Staff F, said the facility did not have an Activity Director, and she also assists in other departments. She said the previous Activity Director had left about a month ago. The Activity Assistant said there was no specified room in the facility for activities and she currently used the main dining room on the main unit. Staff F said she did not keep a record of the residents who attend the activity programs. On 6/21/23 at 10:54 a.m., Licensed Practical Nurse Unit Manager Staff E, said Resident #33 did not attend activities because there was nothing for the resident to do. She said the resident liked to go outside and was now on Hospice services. Staff E said the Hospice staff will try and take the resident outside when they visit. Staff E said Resident #33's wife visits and when she does, she will have the staff assist him outside and she sits with him. On 6/21/23 at 1:27 p.m., the Activity Assistant, said Resident #33 did not attend activities. I do not do any activities with him. I have not been trained. 30599 2. Resident #34 was admitted to the facility on [DATE] from an acute care hospital with diagnoses including failure to thrive. On 6/19/23 at 10:06 a.m., Resident #34 was observed lying in bed. The resident said the facility provided her with no activities, and she felt as though she was being kept in a jail. Resident #34 said she just wanted to go outside for fresh air. On 6/20/23 at 10:10 a.m. Resident #34 was observed in the bed. No activities. On 6/20/23 at 2:40 p.m. Resident was observed in the bed. No activities. Review of Resident #34's progress notes showed on 7/28/22 she was having behavioral issues with excessively calling for staff and not having any issues when staff answered her call light. Resident #34's progress notes show she was screaming for no reason. On 7/29/23 the progress note shows Resident was calling staff every 5 minutes. On 8/10/22 a change in condition progress note showed Resident #34 was having agitation and psychosis. A care plan initiated on 7/29/22 read, BEHAVIOR: The resident has behavior problem: resident calls 911 r/t [related to] mood disorder The care showed Resident #34 was delusional, resistant to care, and refused medications. The interventions initiated on 2/17/23 included to Provide a program of activities that is of interest and accommodates resident status. On 6/21/23 at 1:10 p.m., Activities assistant, Staff F said it had been over a month since she had observed Resident #34 out of the bed. She verified during that time Resident #34 had not attended any group activities. Staff F said she had not provided any one-to-one activities with the resident. Staff F said she was the only staff member who had been providing activities during the weekdays over the last month. 3. Resident #209 was a [AGE] year-old male admitted to the facility admitted to the facility on [DATE] with a history of Metabolic Encephalopathy, Type 2 diabetes, Cognitive communication deficit, Stage 4 chronic kidney disease, and Dysphagia. On 6/19/23 at 12:42 p.m., Resident #209 was observed in bed. Resident #209's sister was visiting and said the facility did not provide any activities for him. She said she visited daily and assisted with his needs. She had not seen any staff member providing any activities for her brother. The sister said Resident #209 liked to be outside. A care plan initiated on 6/1/23 showed Resident #209 will attend/participate in activities of choice . Ensure activities the resident is attending are: compatible with physical and mental capabilities . Establish and record the resident's prior level of activity involvement and interests by talking with the resident. Caregivers, and family on admission and as necessary . Invite the resident to scheduled activities . On 6/21/23 at 1:10 p.m., Activities assistant, Staff F said she was the only staff member who had been providing activities during the weekdays over the last month. Staff F said she had not provided any activities for the resident since he had been admitted to the facility. 4. Resident #47 was an [AGE] year-old female admitted to the facility on [DATE] with severe cognitive decline. On 6/19/23 at 9:00 a.m., and 10:51 a.m., Resident #47 was observed in the TV room on the memory care unit with several other residents. No staff were observed interacting with the residents. There was no activity in progress. On 6/20/23 at 11:20 a.m., several residents, including Resident #47 were observed in the TV room of the memory care unit. There were no activities being provided for the residents. On 6/21/23 at 1:10 p.m., Activities assistant, Staff F said since the Activities Director resigned about a month ago, she has been the only staff providing activities to the residents on weekdays. She said provides activities for residents without cognitive impairment and brings Resident #47 to activities two or three times weekly. She said the rest of the time Resident #47 spends her days in the TV room of the memory care unit. Staff F said she's never seen staff providing activities for the residents in the TV room of the memory care unit. 5. Resident #71 was admitted to the facility on [DATE] with a history of hypertension, Cognitive communication deficit, Being unsteady on her feet, Dementia, and Schizophrenia. On 1/23/23 the Quarterly Minimum Data Set (MDS) assessment showed Resident #71 had severe cognitive deterioration with a Brief Interview for Mental Status score of 2. On 6/19/23 at 10:55 a.m., 6/20/23 at 2:00 p.m., and 6/21/23 at 11:10 a.m., Resident #71 was observed lying in bed sleeping. On 6/21/23 at 1:20 p.m., Activities assistant, Staff F said she had not seen Resident #71 out of bed in over a month. Staff F said she had not provided any one-to-one activities to the resident during that time. 6. Resident #74 was an [AGE] year-old male admitted to the facility on [DATE] with a history of Anxiety, Major Depression, Mood disorder, and psychosis. The Admission MDS assessment dated [DATE] shows it was somewhat important to the resident to have activities. A care plan initiated on 4/18/23 showed Resident #74 had a lack of participation in activities. The care interventions included inviting the resident to attend group activities and offer him activities of interest. On 6/21/23 at 1:25 p.m., Activities assistant, Staff F said Resident #74 had outbursts during group activities. Staff F stated he can be combative and start fights with other residents. He gets mad and creates a scene. Staff F said she encouraged Resident #74 to attend coffee and cookies. Staff F said she did not know what activities Resident #74 liked. Staff F said she did not have documentation showing Resident #74's participation in activities of choice. Staff F said she had never been trained in activities since taking her job. She said she spent a short time with the prior Activities Director and the only thing he instructed her on was to complete the activities calendar each month. 25618 7. Review of the facility's Resident Self Determination and Participation (Activities) policy dated September 2022 revealed, the facility's activity program was designed to promote and facilitate resident self-determination through support of resident choice and resident rights. The Activity Director should assist the resident to maintain as normal a lifestyle as possible while in the facility through the provision of activities consistent with the resident's interests. On 6/19/23 at 11:29 a.m., Resident #88 was observed sitting on the side of her bed with her breakfast table in front of her. Resident #88's television (TV) or radio were noted not to be on during the observation. On 6/19/23 at 11:30 a.m., Resident #88 said in an interview, she was admitted to the facility several weeks ago and since being admitted to the facility she was very bored. She said there was nothing to do at the facility and no one had invited her to a facility activity. On 6/19/23 at 1:23 p.m. and 3:30 p.m., Resident #88 was observed sitting on the side of her bed with the lights off. Neither the TV nor the radio were on, nor was she engaged in an activity. On 6/20/23 at 9:25 a.m., Resident #88 was again observed sitting on the side of her bed. Resident #88's TV nor radio were on during the observation. On 6/20/23 at 9:28 a.m., Resident #88 said the only time she was involved in an activity was when her family visited her on the weekends. She said no one from the facility had talked to her about activities she would like to attend nor invited her to any of the facility activities. Review of Resident #88's medical record revealed she was admitted to the facility on [DATE]. A Recreation Comprehensive Evaluation was completed on 6/7/23. The section which asked the resident what kind of hobbies they like, what types of games they like, religious/spiritual background, religious services she likes and what other things she would like to do are all blank. The activity plan of care developed on 6/12/23 stated, the facility would meet Resident #88's emotional, intellectual, physical, and social needs. The facility would ensure that the activities Resident #88 attended were compatible with her physical and mental capabilities and known interests and preferences. The facility would invite Resident #88 to scheduled activities and provide Resident #88 with an activity calendar and the facility would provide 1:1 beside/in-room visits and activities if Resident #88 was unable to attend out of room events. 8. On 6/19/23 at 11:40 a.m., 1:30 p.m. and 4:00 p.m., Resident #22 was observed wearing a hospital gown in bed. Resident #22's TV or radio were not on during the observation. On 6/20/23 at 10:40 a.m., 1:00 p.m. and 3:30 p.m., Resident #22 was observed wearing a hospital gown in bed. Resident #22's TV nor radio were not on during the observation. Review of Resident #22's medical record revealed she was admitted to the facility on [DATE]. The activity plan of care stated Resident #22 had the potential for social isolation and the goal was to see Resident #22, 3 times a week. The activity plan of care interventions noted, an activity staff would visit Resident #22 throughout the week, would encourage Resident #22 to attend groups/activities and would encourage her to socialize with others in the TV room. On 6/21/23 at 10:44 a.m., during an interview with Staff Z, Certified Nursing Assistant (CNA), she said she normally worked the East Nursing Unit. She said she normally worked with Resident #22 and Resident #88 and they were easy to work with. She said she does not remember the last time she had seen Resident #22 out of her bed in a wheelchair involved in an in-room or out of room activity program. She further said she didn't remember the last time she had seen Resident #88 involved in a facility activity program. On 6/21/23 at 11:38 a.m., in an interview with the Activity Assistant, she said she started working as the activity assistant on 5/9/23. She said the old Activity Director left the faciity on [DATE] and he gave her about a day and a half of training related to how to run the activity program at the facility. She said she was never given instructions about documenting which residents attended the facility's activity programs and she did not have a list noting which residents required 1:1 room visit from the activity department. She said she was the only person in the activity department, and she did her best to conduct daily activities for the residents in the facility. She said since she did not track which resident attended the activity programs and which residents, she had conducted 1:1 in-room activities with she was unable to say if Resident #22 or Resident #88 had attended an activity program of their choice for the past 2 months.

Based on record review, and staff interviews, the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professional. This has the potential to affect all current residents residing in the facility. The findings included: On 6/21/23 at 1:10 p.m., Activities assistant, Staff F said the facility had not had an Activities Director since the previous Activities Director (AD) resigned over a month ago. She stated she spent a small amount of time with the activities Director prior to him leaving and he taught her how to put the monthly activities calendar out every month. Staff F said she provided activities to the residents on weekdays, and a Certified Nursing Assistant provided activities on the weekends. Staff F said she did not receive training in activities since starting at her position, and had had no previous experience in activities prior to accepting the activities assistant position. Review of the background screening clearinghouse showed the previous Activities Director's employment at the facility ended on 5/17/23. On 6/22/23 at approximately 9:10 a.m., the Administrator verified the facility did not currently have an Activities Director.

Based on observations, record review, staff interview and resident interviews, the facility failed to provide food that is palatable, attractive, and at an appropriate temperature for 3 (Resident #32, 48, and 59) of 3 residents reviewed for food at the facility. The findings included: Review of the facility grievance log from April 2023 through June 2023 revealed 6 dietary complaints from residents and one group complaint from the resident council. The grievances included complaints about hot foods being served cold to the residents. On 6/19/23 at 12:49 p.m., Resident #48 said the food was always cold because the kitchen plate warmer doesn't work, and the food sits in the hall too long when the cart arrives from the kitchen. On 6/19/23 at 3:50 p.m., Resident #32 said the meat cuts they get for lunch and dinner are seldom tender, there is hardly any gravy on the biscuits and gravy, and the coffee is frequently cold. On 6/19/23 at 3:51 p.m., Resident #59 said the breakfast is crap and is ice cold. She said the meals are always cold and they need more gravy on the biscuits. She agreed with Resident #32 and said the meats are seldom tender and they either under or overcook the meat. On 6/20/23 at 8:53 a.m., Resident #59 said the breakfast eggs were cold this morning and the bacon was raw. Photographic evidence obtained On 6/20/23 at 8:54 a.m., Resident #32 said the breakfast eggs were cold, hard, and served like a rubbery ball on her plate. Resident #32 poked at the eggs to indicate they were hard and rubber-ball like. Resident #32 said the bacon was extremely undercooked and raw. Photographic evidence obtained On 6/20/23 at 12:29 p.m., observed the dietary aide remove 10 dish plates from the plate warmer and set them on the counter before plating allowing the dishes to cool before food was applied to them. The cook used the plates one by one until the last one was used at 12:35 p.m. On 6/20/23 at 12:35 p.m., observed stainless steel food cart being transported to 600 Hall. On 6/20/23 at 12:40 p.m., the stainless-steel food cart arrived at 600 hall and two Certified Nursing Assistants (CNAs) distributed trays to residents. The CNAs opened the cart doors, poured beverages, and distributed the trays one by one to all the residents in the hall. The CNAs did not close the food cart door between residents. This had the potential to cool the ambient temperature of the food and decrease the temperature of hot food being served to residents. Photographic evidence obtained On 6/20/23 at 12:50 p.m., the Certified Dietary Manager (CDM) said when he started working at the facility in September 2022, they did not have a functioning plate warmer. He said the plate warmer presently at the facility was acquired 2-3 months ago. He said he was unaware of the cook removing the plates from the warmer and setting them on the counter before she used them. On 6/20/23 at 12:55 p.m., a test tray was sampled on the 600 Hall for the lunch meal. Menu consisted of roast beef, brown gravy, mashed potatoes, Prince [NAME] Veggie Blend, Choice of roll, Key Lime cake, margarine, coffee, and tea. The test tray did not include the brown gravy. The temperature of the roast beef was 114 degrees, pale in color, with a large piece of fat to one side. The gravy was missing and there was no seasoning or salt on the meat. The roast beef slice was difficult to cut, chewy, tough, and barely warm. There were no additional condiments served with the roast beef and the taste was very bland. The key lime cake did not have frosting, was dry and over-cooked. The mashed potatoes were 120.3 degrees and seasoned but there was not gravy on top. The vegetables were 121 degrees but there was no seasoning on the vegetables, and they tasted bland. The Certified Dietary Manager (CDM) who had taken the temperatures of the food at the time, verified the beef did not contain the brown gravy as listed on the menu, was difficult to cut, was tough and contained a large piece of fat on the side. The CDM said the facility baked the key lime cake at the facility and agreed had been overbaked and dry. Photographic evidence obtained On 6/20/23 at 1:05 p.m., the Registered Dietician (RD) confirmed the stainless-steel carts were insulated and doors should be closed between residents to help keep the hot food warm. She said most of the carts have a sign on them with directions to keep the doors closed. 6/23/23 at 12:59 p.m., Resident #48 said last night's dinner was a Mexican dish with beans and rice. She said she requested sour cream and salsa, but there was none. She said food served on the weekends is served on foam trays with plastic utensils, so the kitchen staff do not have to wash the dishes. The weekend food is often unappealing and does not taste good. On 6/23/23 at 1:31 p.m., Resident #32 said her fish was burnt, could not eat it, sent it back for a grilled cheese sandwich. Photographic evidence obtained On 6/23/23 at 2:50 p.m., the food concerns were shared with the CDM. He agreed food served to residents was not consistently attractive, palatable, served at appropriate temperatures, and there was room for improvement.

Based on observation, resident, and staff interviews, the facility failed to promote a positive, dignified dining experience by failure to serve meals with appropriate, and matching silverware. The findings included: On 6/19/23 at 12:24 p.m., observation of the lunch meal in the main dining room revealed the following: Residents were using a mixture of mismatched plastic and metal forks, knives, and spoons. Resident #27 was using a plastic fork, metal knife, and metal spoon. She said they get plastic cutlery 90% of the time and it bothers her, this is not what she would use in her own home. Resident #99 was using a plastic fork, metal knife and spoon. She said the dining room was like a yak place because it was noisy and not nice for dining. By the time she's given the food it is cold. Resident #99 said they are given plastic utensils a third of the time and it is not what she used at home. Photographic evidence obtained. On 6/19/23 at 12:49 p.m., Resident #4 said they get served plastic utensils a lot. She was using a plastic fork, plastic knife, and metal spoon. She said she prefers to use real silverware. On 6/20/23 at 8:51 a.m., observed Resident #32 in her room eating breakfast with plastic utensils. She said she was given the plastic fork to eat with along with a metal knife and metal spoon. On 6/20/23 at 8:52 a.m., observed Resident #59 in her room eating breakfast. There was a plastic fork, a metal knife, and a metal spoon on her breakfast tray next to the plate. She said they get plastic utensils a lot and does not like the plastic utensils. Resident #59 said it is not what she used in her home, and she said her guess is they ran out of the metal silverware. On 6/21/23 1:12 p.m., Resident #59 said they get the plastic utensils a lot and it bothers her because holding the food with a plastic fork is difficult, and it is a lower quality plastic fork. On 6/23/23 at 1:24 p.m., observed Resident #59 using a plastic fork and spoon along with metal knife to eat lunch. On 6/20/23 at 9:04 a.m., observed Resident #84 with a plastic fork, metal knife, and metal spoon on the breakfast tray. Photographic evidence obtained. On 6/20/23 at 12:18 p.m., observed the kitchen staff preparing the lunch meal trays. Many trays had plastic spoons and forks. On 6/20/23 at 12:41 p.m., observed plastic utensils on the trays served to residents in the 600 Hall. On 6/23/23 at 12:59 p.m., Resident #48 said food served on the weekends is served on foam trays with plastic utensils, so the kitchen staff do not have to wash the dishes. The weekend food is often unappealing and does not taste good. On 6/23/23 at 1:03 p.m., observed plastic fork and spoon with metal knife on Resident #48's tray. On 6/23/23 at 2:50 p.m., the Certified Dietary Manager (CDM) said he orders new silverware twice a month, forks, knives, and spoons but mainly knives and spoons. He said he does not get them back and he thinks they may get dumped in the trash. Review of the requisitions revealed on 5/15/23 the CDM ordered 24 dinner forks, 24 dinner knives and 48 dessert spoons. On 6/5/23, the CDM ordered 24 dinner knives.

Based on observations, and resident and staff interviews, the facility failed to provide housekeeping and maintenance services to ensure a clean, sanitary and homelike environment in 2 (400 and 600) of 6 halls observed, failed to ensure the availability of bed and bath linen to meet the needs of the residents and failed to implement policies and procedures to prevent the loss of personal items for 2 (Resident #59 and #84) of 5 sampled residents. The findings included: The facility policy, Preventative Maintenance Program (revised 1/2023) documented, A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. On 6/19/23 at 9:30 a.m., during an initial tour of the facility, the following observations were made: 1. The toilet in room [ROOM NUMBER] was missing the cover for the tank, exposing the inner mechanisms of the toilet. The top of the toilet tank was stored on the bathroom counter. There were unlabeled personal hygiene items on the toilet tank in the shared bathroom. There was a wash basin on the bathroom counter containing a used urinal and a large plastic measuring container for liquids that did not have a resident name to identify who the items belonged to. Photographic evidence obtained. 2. In room [ROOM NUMBER] there was a nebulizer mask (a machine that turns liquid medication into a mist through a mask or mouthpiece) stored on the nightstand uncovered. The mask was dusty and grimy. Photographic evidence obtained. 3. In the shared bathroom for room [ROOM NUMBER] there was a large, brown, dead bug on the floor next to the toilet. The observation was confirmed by the Administrator. Photographic evidence obtained. 4. In room [ROOM NUMBER] the cover for the toilet tank was not in place, exposing the inner workings of the toilet. The top to the toilet tank was on the bathroom counter and had a wash basin and toilet tissue on top of the cover. The counter of the shared bathroom contained several personal hygiene products that were not labeled including a toothbrush and hairbrush. The toilet bowel was backed up with urine and feces. Photographic evidence obtained. On 6/19/23 at 4:31 p.m., in an interview, the Administrator, said the facility did not currently have a Maintenance Director. The Administrator said she was aware the toilet tank tops were not on the toilets in rooms [ROOM NUMBERS], and the improperly stored personal hygiene items. 30599 5. On 6/19/23 at 12:44 p.m. Resident #209's sister said the facility had run out of sheets one day and left her brother lying on the bed without sheets or blankets. The resident's sister had a photo of her brother lying on the facility bed with no sheets or blankets. Review of the Grievance Log shows 19 grievances regarding laundry services over the last 6 months. A grievance dated 6/7/23 shows Resident #209's sister complained when her brother was in the bed without bed linen. The documentation on the form shows certified nursing assistant assigned to the resident on 6/7/23 had a in-service to not put the resident in the bed without linen. To assist Resident to the wheelchair if necessary. The grievance form did not address the lack of bed linen to make the bed. The form documents the complaint as resolved on 6/13/23. On 6/21/23 at approximately 1:00 p.m., the Administrator said on 6/7/23 the laundry was backed up and did not provide enough linen, and verified Resident #209 was placed in bed without linen. She verified the grievance form did not address the lack of linen. The Administrator provided documentation the shortage of linen was brought up in the morning meeting on 6/8/23 and the laundry service was to do a linen review. 6. On 6/21/23 at 2:03 p.m., a resident council meeting was held with eight residents in attendance, including the Resident Council President. During the meeting all the residents complained there never was enough linen, towels, and washcloths when needed. The residents said they had brought up the lack of sufficient linen and towels during the resident council on several occasions and it remained an on-going problem. Resident #4 said she gets a shower twice weekly and the staff do not change her bed linen on shower days. She said she wanted to have clean bed linen on her shower days. The Resident Council President said they have reported the lack of linen and towels to the administration on several occasions. They will fix the problem for a month, then it goes right back to the way it was. Resident #59 said they have been short of linen, towels, and wash cloths for over a year. The grievance log showed on 4/11/23 the Resident Council complained regarding laundry services at the facility. The Administrator provided documentation of emails between administration staff on 6/8/23. One email dated 6/8/23 at 11:50 a.m. read, We ordered a large Hurricane stock, they should not be low. If they are the linen is still being misused. On 6/8/23 at 4:03 p.m., an email read, Please get me the current number of supplies and how much more is needed to get them up to par. On 6/9/23 at 2:20 a.m., an email read, From what I saw yes we are needing more. They are having an issue getting the linen back. I had them pull from the emergency per administrator request for higher PAR level. So, I am needed that to be replaced. On 6/21/23 at approximately 1:10 p.m. the Administrator said they had in-serviced the Certified Nursing Assistants not to hoard linen as this was an identified issue. On 6/23/at 5:45 p.m., after several requests, the administrator was not able to provide documentation of corrective actions, including in-services, and audits to ensure the availability of sufficient linen and towels to meet the needs of the residents. 41905 7. Review of the facility policy Resident Personal Belongings revised June 2023 showed: All resident personal items will be inventoried at the time of admission . and documentation shall be retained in the medical record. Additional possessions brought in during the duration of the individual's stay shall be added to the existing personal belongings inventory listing. The facility will exercise reasonable care for the protection of the resident's property from loss or theft. On 6/20/23 at 9:40 a.m., Resident #59 said she submitted a bag of clothes to the laundry department, and none were returned to her. She said the clothes were marked with her name. She said she told the Housekeeping (HSK) Supervisor who said she would look into it, but she has not heard anything about them. She said this occurred about one month ago. On 6/22/23 at 1:26 p.m., the Social Services Director (SSD) said when a laundry complaint is received, the complaint is transferred to the HSK Supervisor. She said the resident, or the Power of Attorney (POA) is always contacted when the complaint is resolved. On 6/22/23 at 1:32 p.m., the HSK Supervisor said when residents are admitted to the facility, personal clothing items are added to the resident's Inventory of Personal Effects. She said after it has been added to the Inventory Sheet, she receives the clothing to apply the resident's name to the clothing with the label maker. The HSK Supervisor said whenever family or friends bring in new clothing for the residents, the process is the same, clothing is added to the Inventory Sheet, and she receives the clothing to apply the label. She said Resident #59 did not come in with much, so when there are unclaimed clothing garments that would fit the resident, she gives them to Resident #59. Review of Resident #59's Inventory of Personal Effects dated 2/22/22 showed one cell phone charger and one pair of glasses written on the Inventory Sheet. No other items were listed on the sheet. The resident had not signed the paper, verifying the accuracy of the personal items listed on the Inventory Sheet. On 6/22/23 at 3:16 p.m., Resident #48 was observed folding clothing for Resident #59. Several of the pieces were observed to have Resident #59's name handwritten in black magic marker on the size tag. There were no white labels with the resident's name on the garments. Resident #59 said she did not know about an Inventory of Personal Effects, and she had not signed one. Resident #48 said if clothing is lost by the facility, they no longer reimburse residents, and you are just screwed. Resident #48 said the system of labeling personal clothing is so bad, some of the residents have resorted to obtaining their own black markers and name stamps to apply to their clothing. On 6/22/23 at 3:19 p.m., observed several garments belonging to Resident #59: Blue and [NAME] flowered nightgown, light pink pajama bottoms, navy blue pants, gray pajama bottoms. The items did not contain the white name label applied by the HSK Supervisor. Resident #59's clothing contained an orange shirt labeled with another resident's name. None of the garments were listed on the Inventory of Personal Effects. 8. Review of the Grievance/Concern Form for Resident #84 received by the facility on 5/15/23: Resident #84 is missing five blankets. The facility found one Christmas blanket with Santa [NAME] faces. The SSD notified resident's daughter that blankets were returned. The HSK Supervisor signed and dated the form on 5/19/23. On 6/23/23 at 5:34 p.m., the HSK Supervisor said she washes and delivers clothing garments to the residents. She said she does not give the clothing to the Certified Nursing Assistants or any other staff to add to the residents' Inventory of Personal Effects. She said she does not notify the Certified Nursing Assistants (CNAs) when the residents receive new clothing. She said it would be too much to handle. The HSK Supervisor said she notified Resident #84's daughter she could only locate one of the five blankets missing at the facility. The HSK Supervisor said the resident's daughter told her that was okay, so she resolved the grievance.

Based on record review, and staff interviews, the facility failed to ensure a Level II Preadmission Screening and Resident Review (PASRR) was completed for 2 (Resident #24, and #74) of 4 residents reviewed with mental illness. This failure prevented residents from further evaluation to determine whether the residents required special services exceeding those provided by the nursing facility. The findings included: Review of the Facility Policy Resident Assessment - Coordination with PASRR Program Revised December 2022: 1. All applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. a. ii. Positive Level I Screen - necessitates a PASRR Level II evaluation prior to admission. b. PASRR Level II - a comprehensive evaluation by the appropriate stare-designated authority (cannot be completed by the facility) that determines whether the individual has Mental Disorder (MD), Intellectual Disability (ID) or related condition, determines the appropriate setting for the individual, and recommends any specialized services and or rehabilitative services the individual needs. 2. The facility will only admit individuals with a mental disorder or intellectual disability who the State mental health or intellectual disability authority has determined as appropriate for admission. 6. The Social Services Director shall be responsible for keeping track of each resident's PASRR screening status and referring to the appropriate authority. Record review showed Resident #24 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type. The Level I PASRR dated 7/12/21 documented Resident #24 with a diagnosis of Anxiety and Schizoaffective Disorders. The record review showed a PASRR Level I Screen, dated 7/12/21, completed by the hospital's Registered Nurse (RN) Case Manager who documented Resident #24 with Anxiety and Schizoaffective Disorders. The RN concluded Resident #24 did not need a Level II PASRR evaluation. (A Level II PASRR evaluation must be completed if the individual had a suspicion or diagnoses of an SMI [Serious Mental Illness], ID [Intellectual Disability], or both.) On 6/19/23 at 10:53 a.m., observed Resident #24 in her room in bed dressed in facility gown. She said she wanted to be in bed and had nothing to discuss. On 6/20/23, during several observations in the morning and afternoon, Resident #24 was in her room in bed, sleeping. On 6/20/23 at 4:42 p.m. Certified Nursing Assistant Staff X said Resident 24 likes to stay in bed and as you can see is pretty zonked out. On 6/21/23 at 12:05 p.m. Resident #24 was awake in bed in hospital gown. Her hair was long and greasy. Resident #24 said she refused to get a shower and wash hair. On 6/21/23 at 12:44 p.m., Licensed Practical Nurse Staff J said Resident #24 likes to stay in bed and refuses to take showers. He said the psychiatrist sees her but was not sure of any other mental illness service. Review of Care Plan initiated on 2/27/23 for Resident #24 revealed a Care Plan for Behaviors of hitting, increase in complaints, cussing, aggression, refusing care, refusing wound care, refusing out of bed activities, and difficult to motivate. Interventions included administering medications and monitoring for side effects; Provide opportunities for positive interactions and attention; Explain all procedures and allow resident to adjust; If reasonable discuss resident's behavior; Intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention and remove from situation to alternate location; Praise improvement; Provide a program of activities of interest and accommodation of resident. The interventions were initiated on 2/27/23 and there were no updates. The interventions did not include PASRR Level II or additional mental illness services beyond what the facility was providing. On 6/22/23 at 11:05 a.m., the Social Services Director (SSD) said she was familiar with Resident #24 and the resident was admitted with mental illness. She verified Resident #24 had a PASRR Level I only and there was no Level II in Resident #24's medical record. The SSD said she just recently became aware the resident requires a Level II screening and she would initiate it. 30599 2. Resident #74 was transferred to the facility on [DATE] from another long-term care facility where he had been residing since 7/25/22. On 4/6/23 at the time of transfer he was receiving Medicaid benefits. The clinical record included a level I PASSR completed by a hospital on 7/25/22 at the time of discharge to the previous skilled nursing facility. The PASSR did not document a history of mental illness, intellectual Disability, or Dementia. Resident #74 had a history of alcohol abuse. Review of Resident #74's medical history shows at the time of his admission to the facility on [DATE], diagnoses included cognitive communication deficit, Psychosis, Major Depressive Disorder, Anxiety Disorder, and a Mood disorder. Review of Resident #74's physician's orders showed he was ordered the antipsychotic medication Haldol 0.25 milligrams (mg) two times daily for Schizophrenia disorder. On 6/13/23 Resident #74 was order Ativan 0.5 mg daily for anxiety and aggression. On 6/7/23 Resident #74 was ordered Paxil for depression. On 6/12/23 Resident #74 was ordered Tegretol 200 mg daily for mood disorder. Documentation on Resident #74's 6/2023 Medication Administration Record showed the resident had on going mental health behaviors. A progress note dated 6/23/23 at 10:33 reads, Psych ARNP [Advanced Registered Nurse Practitioner] was called r/t [related to] resident increased behaviors, yelling, increase agitation, start to scream, and flung arms at staff when trying to redirect. New recommendations to increase Ativan from 0.5 qd [daily] to TID [three times daily]. Resident #74's Brief Interview for Mental Status completed on 4/10/23 showed a score of 11 which showed mild cognitive impairment. The 5-Day Minimum Data Set (MDS) dated [DATE] showed Resident #74 suffered from anxiety disorder, Depression, and Psychotic Disorder. On 6/22/23 at 3:40 p.m., Registered Nurse Staff BB said she worked part time at the facility completing PASSAR's. She stated at this time she was the only person who was completing PASSAR's. She stated she was not aware Resident #74 needed a updated PASSAR at the time he was admitted on [DATE].

Based on record review and staff interviews, the facility failed to protect residents' rights to be free from neglect. The facility failed to provide the necessary services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress, in that they failed revise the care plan and closely supervise 1 (Resident #1) of 2 sampled cognitively impaired residents with dysphagia (Difficulty swallowing) on a pureed diet with multiple incidents of grabbing and eating solid food from other residents' plates. On [DATE] Resident #1 choked on solid food he grabbed from another resident's plate. Resident #1 became unresponsive; staff performed the Heimlich maneuver (First-aid procedure for dislodging an obstruction from a person's windpipe) and Cardiopulmonary resuscitation (CPR). Resident #1 suffered serious harm, was transferred to a local hospital, and later expired on [DATE]. The facility's failure to provide the necessary structures to closely supervise cognitively impaired residents on a mechanically altered diet with impulsive behaviors of grabbing and consuming other residents' food resulted in a determination of Immediate Jeopardy at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and provided the Immediate Jeopardy templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F689, F835 and F867. The facility's policy for Abuse, Neglect, and Exploitation with a revision date of [DATE] and a date implemented of [DATE] noted, The facility will implement policies and procedures to prevent and prohibit all types of . neglect . that achieves . Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict and neglect . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Diffused Traumatic Brain Injury, Epilepsy, speech and language deficits, Aphasia (Disorder that affects communication), Gastro-esophageal reflux disease, dysphagia oropharyngeal (Swallowing issues in the mouth and/or the throat) phase. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the Quarterly MDS assessment dated [DATE], revealed Resident #1 had poor decision making and moderately impaired cognition. The resident required supervision, and cues for redirecting. The assessment revealed the resident had no speech and was rarely or never understood. Resident #1 had loss of liquids/solids from mouth when eating and drinking, coughing or choking during meals or when swallowing medications. The physician's orders included a pureed diet. The resident had dysphagia and no teeth. The progress notes revealed an entry dated [DATE] at 3:03 p.m., that read, Resident tried to obtain someone elses [sic] tray this afternoon. Resident started to cough because the food was not his diet. Resident was assisted when coughing and is now ok. The facility completed an incident report dated [DATE] which noted, Resident seen eating other resident food which was not right diet. Nurse intervenes [sic] and help patient cough food out and clear. Resident brought to little day room with meal to have more supervision. Other staff was informed of incident. Intervention: Resident is to be brought out in day room to eat while supervised. Physician notified with no recommendation. Supervisor/Unit Manager present during intervention with resident. The care plan was not updated to include individualized interventions for close supervision of the resident while in the day room to prevent further incidents of Resident #1 eating other residents' food and choking. Resident #1's Kardex (Instructions to the Certified Nursing Assistants to provide safe care) was not updated to include close supervision to prevent Resident #1 from grabbing and eating solid food which could cause coughing and choking. Further review of the progress notes revealed an entry dated [DATE] at 10:47 p.m., that read, . One of the staff members came stated that Resident was on [sic] distress before leaving resident was alert and oriented. Staff member starting CPR. 911 arrived took over CPR. Resident was transferred to ER (emergency room ) with pulse and BP (blood pressure). Doctor was notified. Review of the hospital record revealed the chief complaint was, Pt (patient) arrived via EMS (Emergency Medical Service) after grabbing a chewed up hot dog of someone else and choked. The hospital course noted, Patient is a [AGE] year-old male with history of traumatic brain injury presented from Tarpon Point nursing home after choking on chewed up hot dog suffering a PEA (pulseless electrical activity) cardiac arrest and respiratory arrest . He was treated for possible aspiration pneumonia . He had evidence of brain death. He was maintained on the ventilator for several days with no meaningful recovery . Family decided to make him comfort care . He eventually passed away today ([DATE]) at 12:25 PM under comfort care measures . Review of the facility's investigation dated [DATE] for the incident of [DATE] noted Resident #1 was a [AGE] year-old male with diagnoses including dysphagia, aphasia, and weakness. He can self-propel in a wheelchair. He had a pureed texture diet order. He has a history of having impulsive behavior of reaching out and consuming different food items not pertaining to his diet. Resident #1 completed his meal with no noted incident by staff. Resident #2 said Resident #1 had grabbed food from her plate and ate it. Resident #1 had difficulty breathing. Heimlich maneuver done with no food dislodged and during CPR Resident #1 vomited a pureed consistency meal and one piece of solid food. This confirmed the resident's statement that he grabbed something from her table. At the time of the incident, four residents were in the day room with one staff member who was feeding a resident. Resident #2 alerted Certified Nursing Assistant (CNA) Staff G to enter the day room. Resident #2 pointed to Resident #1 who appeared to have difficulty breathing. CNA Staff G initiated the Heimlich maneuver. CNA staff G alerted Registered Nurse Staff H who in turn alerted the Director of Nursing. Staff performed CPR on Resident #1 who was unresponsive. During CPR Resident #1 vomited pureed consistency meal as well as solid food item. Review of the facility's menu for the dinner meal on [DATE] revealed the entrees included fish sandwich, Hot Dog with Chili, tater tots. On [DATE] at 2:45 p.m., Licensed Practical Nurse (LPN) staff I said, Resident #1 would eat all his food and at times he would try to eat other residents' food. We had to keep an eye on him. There was an incident prior to the one he was taken to the emergency room . LPN Staff C, had to do the Heimlich on him that time. He was in the Day Room, it occurred about two weeks before the incident of [DATE]. On [DATE] at 2:55 p.m., the Advanced Practice Registered Nurse said Resident #1 was very impulsive. She said there was a time Resident #1 pulled a food tray off the cart. She said she could not remember the date of the incident. On [DATE] at 10:29 a.m., LPN Staff J said Resident #1 would grab cups, and food from the counter. She would give him a cup of water or juice to detract him from grabbing things, particularly food. She said she was saddened about the incident, and added, We knew he grabbed food and put it in his mouth. On [DATE] at 10:45 a.m., the Unit Manager said Resident #1 could self-propel in the hallways. He was on a pureed diet. He would hurriedly eat his food and try to take other residents' food at mealtime. He was admitted with this behavior and needed to be supervised. On [DATE] at 12:45 p.m., in a telephone interview LPN Staff C said Resident #1 had a couple of incidents with food. She could not remember the exact dates but said it was a couple of months before his hospitalization . She said one time he was in a room, the CNA called and said he was coughing. He had finished his meal, wheeled himself over to his roommate's side and was getting food off his tray. He was coughing. she did not do the Heimlich maneuver that time. LPN Staff C said there was a second incident when she had to check Resident #1's mouth and had to perform the Heimlich maneuver. There was some meat present. The Unit Manager was there. We said he needed to be watched. LPN Staff C said she thought the Unit Manager took the incident to the higher ups. No one came to speak with her about the incident. No one asked her to give a statement. She did not know if the incident was investigated. On [DATE] at 1:20 p.m., the Unit Manager said she did not report the incidents of choking to the physician. She was not involved in any investigation regarding Resident #1 coughing and choking. On [DATE] at 1:39 p.m., the Administrator said she was aware of an incident involving Resident #1 on [DATE]. Resident #1 took solid food from another resident and started coughing. That is when they started bringing him to the day room with residents with a mechanically altered diet. The Administrator verified the resident's care plan for impulsive behavior of grabbing and eating solid food from other residents' plates was not individualized with interventions to prevent further incidents of grabbing, eating solid food, and choking.

Based on record review, review of facility's policies and procedures and staff interviews, the facility failed to implement processes to ensure adequate supervision of 1 (Resident #1) of 3 sampled cognitively impaired residents on modified textured diet with poor impulse control and known behavior of grabbing food and consuming them to prevent choking from ingestion of solid food. On [DATE] Resident #1 choked on solid food he grabbed from another resident's plate. Resident #1 became unresponsive; staff performed the Heimlich maneuver (First-aid procedure for dislodging an obstruction from a person's windpipe) and Cardiopulmonary resuscitation (CPR). Resident #1 suffered serious harm resulting in a transfer to the hospital where he expired. The facility's failure to provide the necessary structures to closely supervise cognitively impaired residents on a mechanically altered diet with impulsive behaviors of grabbing and consuming other residents' food resulted in a determination of Immediate Jeopardy (IJ) at a scope and severity of isolated (J) starting on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and provided the IJ templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F600, F835 and F867. Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Diffused Traumatic Brain Injury, speech and language deficits, Aphasia (Disorder that affects how you communicate), and dysphagia oropharyngeal (Swallowing problems occurring in the mouth and/or the throat) phase. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the Quarterly MDS assessment dated [DATE], revealed Resident #1 had poor decision making and moderately impaired cognition. The resident required supervision, and cues for redirecting. The assessment revealed the resident had no speech and was rarely or never understood. The Quarterly MDS assessment dated [DATE] noted the resident required supervision (oversight, encouragement, or cueing) for eating. Resident #1 had loss of liquids/solids from mouth when eating and drinking, coughing or choking during meals or when swallowing medications. The physician's orders included a pureed diet. The resident had a diagnosis of dysphagia and was edentulous (no teeth). The care plan initiated on [DATE] noted Resident #1 was totally dependent on staff for eating. The progress notes revealed an entry dated [DATE] at 3:03 p.m., Resident #1 was assisted when coughing after consuming food not on his diet he obtained from someone else's tray. On [DATE], the facility completed an incident report. The intervention was, Resident brought to little day room with meal to have more supervision. Other staff was informed of incident. Intervention: Resident is to be brought out in day room to eat while supervised. The incident noted the physician was notified with no recommendation. The care plan was not updated with the level of supervision needed to prevent Resident #1 from grabbing and consuming food from other residents' plates. Further review of the progress notes revealed an entry date [DATE] at 10:47 p.m., that read, . One of the staff members came stated that Resident was on [sic] distress before leaving resident was alert and oriented. Staff member starting CPR. 911 arrived took over CPR. Resident was transferred to ER (emergency room ) with pulse and BP (blood pressure). Doctor was notified. At the time of the incident, four residents were in the day room with one staff member who was feeding a resident. Resident #2 alerted Certified Nursing Assistant (CNA) Staff G to enter the day room. Resident #2 pointed to Resident #1 who appeared to have difficulty breathing. CNA Staff G initiated the Heimlich maneuver. On [DATE] at 4:00 p.m., reviewed the incident of [DATE] with the Director of Nursing (DON). She said Resident #1 received his meal, he self-propelled to a table where another resident was eating a mechanical diet which had hot dog pieces. He grabbed and ate the hot dog pieces. On [DATE] at 10:45 a.m., the Unit Manager said Resident #1 needed to be supervised. He could self-propel in the hallways. He would hurriedly eat his food and try to take other residents' food at mealtime. He was admitted with this behavior. On [DATE] at 2:00 p.m., the Speech Language Pathologist said Resident #1 was impulsive with food. He had Oropharyngeal dysphagia (difficulty swallowing) which involves the mouth and the pharynx (the back of the throat) and did not have teeth hence the purpose of the pureed diet. On [DATE] at 12:45 p.m., in a telephone interview LPN Staff C said Resident #1 had a couple of incidents with food. Once he grabbed and ate his roommate's food in the room, and was coughing. There was a second incident where she had to check his mouth. There was some meat present. She had to do the Heimlich maneuver that time. She said the Unit Manager was present and thought she would take the incident to the higher ups. She said she did not know if the incident was investigated. No one spoke to her about it, no one asked her to give a statement. On [DATE] at 1:39 p.m., the Administrator verified the lack of documentation Resident #1's behavior of grabbing and eating food not in his diet was assessed, and adequately care planned for appropriate supervision to prevent choking. She said she was aware of an incident involving Resident #1 on [DATE]. Resident #1 took solid food from another resident and started coughing. That is when they started bringing him to the day room with residents with a mechanically altered diet. On [DATE] at 3:36 p.m., the DON said she started employment at the facility on [DATE] and wasn't aware of the previous incidents involving Resident #1. She verified the lack of supervision on [DATE] when Resident #1 choked on solid food he grabbed from another resident's plate. There was one CNA in the dining area with four residents. The CNA was feeding another resident when Resident #1 grabbed and ate solid food from another resident's plate. Review of the hospital record revealed the chief complaint was, Pt (patient) arrived via EMS (Emergency Medical Service) after grabbing a chewed up hot dog of someone else and choked. The hospital course noted Resident #1 was treated for possible aspiration pneumonia, had evidence of brain death. Resident #1 was maintained on a ventilator for several days without meaningful recovery. The resident passed away on [DATE] under comfort care measures.

Based on record review, and staff interview, the facility administration failed to use its resources effectively to ensure staff were adequately trained to supervise 1 (Resident #1) of 3 cognitively impaired residents with dysphagia with poor impulse control of grabbing and consuming food not on their prescribed diet. On [DATE] Resident #1 choked on solid food he grabbed from another resident's plate. Resident #1 became unresponsive; staff performed the Heimlich maneuver (First-aid procedure for dislodging an obstruction from a person's windpipe) and Cardiopulmonary resuscitation (CPR). Resident #1 was transferred to a local hospital where he expired on [DATE]. Resident #1 had a previous documented choking incident on [DATE] after trying to grab food from another resident's meal tray. The failure of the facility's administration to prevent neglect and ensure adequate supervision of cognitively impaired residents with dysphagia and known behavior of grabbing and consuming solid food not in their prescribed diet resulted in the determination of Immediate Jeopardy (IJ) on [DATE]. The Administrator was notified of the Immediate Jeopardy on [DATE] and provided the IJ templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F600, F689 and F867. Review of the Administrator's job description revealed under position's purpose, Leads, guides and directs the operations of the healthcare facility in accordance with local, state and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents . Major Duties and Responsibilities . Identifies and collaborates with members of the interdisciplinary team, physicians, consultants . to identify opportunities for enhances services to the residents and/or resolve issues . Review of the Director of Nursing job description revealed under purpose of the position, Planning, organizing, developing and directing the overall operations of the Nursing Service Department in accordance with local, state and federal standards and regulations, established facility policies and procedures and as may be directed by the Administrator and the Medical Director, to provide appropriate care and services to the residents . Major Duties and Responsibilities . Participates in daily or weekly management team meetings to discuss . resident changes in status, complaints or concerns . Oversees nursing schedules to ensure resident needs . are met . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Diffused Traumatic Brain Injury, Epilepsy, speech and language deficits, Aphasia (Disorder that affects how you communicate), Gastro-esophageal reflux disease, dysphagia oropharyngeal (Swallowing problems occurring in the mouth and/or the throat) phase. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] and the Quarterly MDS assessment dated [DATE], revealed Resident #1 had poor decision making and moderately impaired cognition. The resident required supervision, and cues for redirecting. The assessment revealed the resident had no speech and was rarely or never understood. The Quarterly MDS assessment dated [DATE] noted the resident required supervision (oversight, encouragement or cueing) for eating. Resident #1 had loss of liquids/solids from mouth when eating and drinking, coughing or choking during meals or when swallowing medications. Resident #1 was edentulous and had dysphagia. Resident #1 was on a pureed diet. Review of the facility's incident investigations revealed on [DATE] at approximately 6:00 p.m., Resident #1 was in the dayroom where residents eat meals, visible from the nursing station. Resident #1 was sitting at a table with another resident who also had a pureed diet. Resident #1 finished his meal and moved away from the table. Resident #2 informed a staff member who was pushing a cart near the dayroom Resident #1 was in distress. Resident #1 became unresponsive. Staff initiated the Heimlich maneuver and CPR. During CPR Resident #1 began to vomit pureed and a solid food item. Resident #2 said Resident #1 grabbed food from her plate and ate it. Since Resident #1 vomited both pureed and solid food, it confirmed the other resident's statement that he [Resident #1] grabbed something off a plate from her table. Resident #1 was transferred to the local hospital where he later expired on [DATE]. At the time of the incident, four residents were in the day room with one Certified Nursing Assistant (CNA) who was feeding another resident. Review of the clinical record revealed on [DATE] Resident #1 was assisted with coughing when he tried to obtain someone else's tray. The facility completed an incident report dated [DATE] which noted, Resident #1, is to be brought out in day room to eat while supervised. On [DATE] at 10:29 a.m., LPN Staff J said Resident #1 would grab cups, and food from the counter. She said she was saddened about the incident, and added, We knew he grabbed food and put it in his mouth. On [DATE] at 2:45 p.m., Licensed Practical Nurse (LPN) staff I said there was an incident about two weeks prior to [DATE] when Resident #1 was in the Day Room. Registered Nurse C, had to do the Heimlich on him that time. On [DATE] at 2:55 p.m., the Advanced Practice Registered Nurse said Resident #1 was very impulsive. She said there was a time Resident #1 pulled a food tray off the cart. She said she could not remember the date of the incident. On [DATE] at 12:45 p.m., in a telephone interview LPN Staff C said Resident #1 had a couple of incidents with food. She said one time he was in a room, the CNA called and said he was coughing. LPN Staff C said there was a second incident when she had to check his mouth and had to perform the Heimlich maneuver. There was some meat present. The Unit Manager was there. She said she thought the Unit Manager took the incident to the higher ups. No one came to speak with her about the incident. No one asked her to give a statement. She did not know if the incident was investigated. On [DATE] at 1:39 p.m., the Administrator said she was aware of an incident involving Resident #1 on [DATE]. Resident #1 took solid food from another resident and started coughing. That is when they started bringing him to the day room with residents with a mechanically altered diet. The Administrator verified the resident's care plan for impulsive behavior of grabbing and eating solid food from other residents' plates was not care planned with interventions to prevent further incidents of grabbing, eating solid food and choking. The Administrator verified the lack of documentation, and investigation of the multiple instances of Resident #1 grabbing and consuming food not on his diet resulting in coughing or choking. On [DATE] at approximately 3:36 p.m., the Director of Nursing said she started employment at the facility on [DATE] and wasn't made aware of the previous choking incidents involving Resident #1. She verified there was no documentation Resident #1's impulsive behavior of grabbing and eating food from other residents' plates was assessed, or care planned. She verified the lack of documentation of staff training to adequately supervise Resident #1 to prevent the likelihood of further incidents of chocking.

Based on staff interviews and review of the facility's Quality Assurance and Performance Improvement (QAPI) program, the facility failed to identify and correct quality deficiencies related to neglect and supervision of 1 (Resident #1) of 3 cognitively impaired residents with dysphagia, poor impulse control and multiple incidents of grabbing and eating food and other items not on their prescribed diet. Resident #1 was a cognitively impaired resident admitted to the facility on [DATE]. Resident #1 had a diagnosis of dysphagia (Difficulty swallowing) and required a pureed diet. Resident #1 had no teeth and did not wear dentures. Resident #1 required supervision due to poor impulse control and multiple incidents of grabbing and eating solid food items from other residents' plates, causing episodes of coughing and choking. On [DATE] Resident #1 had a documented incident of choking after eating another resident's food which was not the right diet. The facility completed an incident report on [DATE] and noted Resident #1 was to be brought out in the day room to eat while supervised. On [DATE] Resident #1 was not adequately supervised and choked on solid food he grabbed from another resident's plate. Resident #1 became unresponsive; staff performed the Heimlich maneuver (First-aid procedure for dislodging an obstruction from a person's windpipe) and Cardiopulmonary resuscitation (CPR). Resident #1 was transferred to a local hospital where he expired on [DATE]. The facility failure to develop and maintain an effective QAPI process with appropriate plans of action to prevent residents from neglect and likelihood of serious illness and/or death resulted in noncompliance at the Immediate Jeopardy level starting on [DATE]. The Administrator was notified of the determination of Immediate Jeopardy on [DATE] and provided the Immediate Jeopardy templates. The Immediate Jeopardy was ongoing. The findings included: Cross reference F600, F689, and F835. Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy with a date reviewed of [DATE] noted, It is the policy of this facility to develop, implement, and maintain an effective, comprehensive, data driven QAPI program that focuses on indicators of the outcomes of care and quality of life and addresses all the care and unique services the facility provides . High risk areas refers to care or services areas associated with significant risk to the health or safety of residents. Errors in these care areas have the potential to cause adverse events resulting in pain, suffering, and/or death . Problem-Prone Areas refers to care or service areas that have historically had repeated problems . Develop and implement appropriate plans of action to correct identified quality deficiencies . Systems and reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events . Review of the clinical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Diffused Traumatic Brain Injury, Epilepsy, speech and language deficits, Aphasia (Disorder that affects how you communicate), Gastro-esophageal reflux disease, dysphagia oropharyngeal (Swallowing problems occurring in the mouth and/or the throat) phase. The physician's orders included a pureed diet. The resident was edentulous with a diagnosis of dysphagia. On [DATE] at 3:00 p.m., Resident #1 was seen eating other residents' food which was not on his prescribed pureed diet, resulting in coughing episode requiring staff intervention to help the resident cough out the food. On [DATE] the facility completed an incident report which noted, Brought to little day room with meal to have more supervision. Other staff was informed of incident. Intervention: Resident is to be brought out in day room to eat while supervised. Physician notified with no recommendation. Supervisor/Unit Manager present during intervention with resident. The facility failed to investigate and implement appropriate corrective actions to prevent Resident #1 from further incidents of choking from grabbing and consuming solid food. Review of the facility's investigation dated [DATE] for the incident of [DATE] noted Resident #1 was a [AGE] year old male with diagnoses including dysphagia, aphasia, and weakness. He can self-propel in a wheelchair. He had a pureed texture diet order. He has a history of having impulsive behavior of reaching out and consuming different food items not pertaining to his diet. Resident #1 completed his meal with no noted incident by staff. Resident #2 said Resident #1 had grabbed food from her plate and ate it. Resident #1 had difficulty breathing. Heimlich maneuver done with no food dislodged and during CPR Resident #1 vomited a pureed consistency meal and one piece of solid food. This confirmed the resident's statement that he grabbed something from her table. Review of the hospital course revealed documentation, Patient is a [AGE] year old male with history of traumatic brain injury presented from Tarpon Point nursing home after choking on chewed up hot dog suffering a PEA (pulseless electrical activity) cardiac arrest and respiratory arrest. He was treated for possible aspiration pneumonia . He had evidence of brain death. He was maintained on the ventilator for several days with no meaningful recovery . Family decided to make him comfort care . He eventually passed away today ([DATE]) at 12:25 PM under comfort care measures . On [DATE] at 2:55 p.m., the Advanced Practice Registered Nurse said Resident #1 was very impulsive. She said there was a time Resident #1 pulled a food tray off the cart. She said she could not remember the date of the incident. On [DATE] at 10:29 a.m., LPN Staff J said Resident #1 would grab cups, and food from the counter. She would give him a cup of water or juice to detract him from grabbing things, particularly food. She said she was saddened about the incident, and added, We knew he grabbed food and put it in his mouth. On [DATE] at 12:45 p.m., in a telephone interview LPN Staff C said Resident #1 had a couple of incidents with food. She could not remember the exact dates but said it was a couple of months before his hospitalization . She said one time he was in a room, the CNA called and said he was coughing. He had finished his meal, wheeled himself over to his roommate's side and was getting food off his tray. He was coughing. I did not do the Heimlich maneuver that time. LPN Staff C said there was a second incident when she had to check his mouth and had to perform the Heimlich maneuver. There was some meat present. The Unit Manager was there. We said he needed to be watched. She said she thought the Unit Manager took the incident to the higher ups. No one came to speak with her about the incident. No one asked her to give a statement. She did not know if the incident was investigated. On [DATE] at 1:20 p.m., the Unit Manager said she did not report the incidents of choking to the physician. She was not involved in any investigation regarding Resident #1 coughing and choking. On [DATE] at 1:39 p.m., the Administrator said she was aware of an incident involving Resident #1 on [DATE]. The Administrator verified the resident's care plan for impulsive behavior of grabbing and eating solid food from other residents' plates was not individualized with interventions to prevent further incidents of grabbing, eating solid food and choking. On [DATE] the facility conducted an Ad hoc (unplanned) QAPI meeting to discuss the choking incident involving Resident #1. The facility developed a plan of action with interventions for increase supervision of residents in the dining room. The facility provided documentation of education completed on [DATE]. The topic was an overview of verbal report and walking rounds, using the Kardex and care plan and diet book. On [DATE] the facility provided documentation of education of review of use of Kardex (Provides instruction, and important resident data) /POC (Point of Care), Care Plan, diet books. Verbal and walking rounds, supervision of residents, the dining experience, assisting residents with mechanically altered diets and impaired cognition, recognizing signs and symptoms of choking and how to respond. Twelve of twelve licensed nurses and 29 CNAs counted as attended the in-service. The facility uses the services of Agency staff to provide resident care, 15 of the 29 CNAs noted on the in-service list were Agency staff. On [DATE] at 3:36 p.m., the DON reviewed the Performance Improvement Plan and corrective actions implemented on [DATE]. She said on [DATE] the facility conducted an ad hoc (unplanned) QAPI meeting to discuss the corrective actions, and review the audits implemented on [DATE]. She provided a sign in sheet dated [DATE] of QAPI members who attended the meeting. The DON did not have documentation of an analysis of the results of the interventions implemented in order to determine the effectiveness of the corrective actions.

Based on record review, staff interview, review of the facility's abuse and neglect policy, the facility failed to ensure adequate supervision to prevent resident to resident abuse for 1 (Resident #2) of 1 resident with known physical aggressive behavior with a likelihood for negative interactions. On 1/8/21 Resident #2 pushed Resident #1 who wandered in her room resulting in a fall, causing physical harm, subdural hematoma and finally death of Resident #1. The failure to protect vulnerable residents from resident to resident altercation resulted in noncompliance at the Immediate Jeopardy level starting on 1/8/21. Noncompliance for F600 at the Immediate Jeopardy level was identified after the exit. On 4/7/21 at 12:10 p.m., the Administrator was informed of the determination of Immediate Jeopardy. The Immediate Jeopardy was removed on 2/18/21 at 5:00 p.m., before the exit. The Immediate Jeopardy scope and severity was reduced to D on 2/18/21. The findings included: The facility's policy titled Abuse and Neglect which was not dated read Purpose: To prohibit abuse of residents from any source. To promote the well-being of residents by providing a safe and supportive environment. To maintain the resident's right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. The policy defined abuse as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also included the deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The abuse and neglect policy included training of staff Employees must be trained through orientation and annually about the following: Appropriate intervention to deal with aggressive and/or catastrophic reactions of residents. What constitutes abuse, neglect, and misappropriation of resident property. The abuse and neglect policy included identification that read Abuse and neglect in nursing facilities is a high priority. Any type of abuse constitutes a violation of resident rights. The following incidents should by assessed for possible abuse: . Injury to head, scalp, or face . Fracture, falls. Since every resident in long term care is at risk for abuse due to their diminished capacity, care must be taken by every staff member to identify individuals at greatest risk for abuse and monitor them closely for potential physical, emotional, or spiritual harm . 1. Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The care plan with an initial date of 11/28/17 indicated Resident #2 exhibited alteration in mood and behavior as evidenced by wandering on unit and in rooms, hoarding items, and fearfulness. Resident #2 has been observed turning roommates bed alarm on and off. The attempts included to approach in a calm manner, do not attempt to bring back to reality when confused or experiencing psychotic disturbances; maintain low stimulus environment, soft music, close exterior blinds when agitated and document response to decrease in external stimulus; avoid confrontation when agitated; educate resident regarding acceptable alternatives to identified behaviors and document. Review of the departmental notes in the resident medical record revealed documentation dated 10/16/20 at 3:37 p.m., that read IDT (interdisciplinary team) met and discussed resident's psychoactive medications; resident is noted with failed GDR (gradual dose reduction) in the past and is easily triggered; resident appears stable at this time so no recommendations were made. On 11/12/20 at 10:44 a.m., the nurse documented the IDT held a meeting to discuss psych services. Recommendation made to begin [MEDICATION NAME] ER 250 mg (milligrams) daily at bedtime as resident becomes agitated easily and shouts out at staff related to mood disorder. 2. Review of the facility's incident reports revealed Resident #3 was Resident #2's roommate on 12/26/20. The Director of Nursing documented on 12/26/20 During the morning rounds on 12/26/20 the c.n.a (certified nursing assistant) found a purple discoloration under the resident's (Resident #3) left eye, along with an abrasion between her eyes mid-forehead area; resident has dementia and is unable to state how it occurred. Resident's roommate (Resident #2) admitted that this resident (Resident #3) aggravates her when she is making a lot of noise; when roommate (Resident #2) was asked if she hit her she would say yes she did, and then she would say no she didn't; Resident's roommate (Resident #2) was started on [MEDICATION NAME] at HS (bedtime) for a mood stabilizer since she would get easily agitated around the same time this resident was taken off her [MEDICATION NAME] at bedtime; upon assessment resident (Resident #3) was found rubbing her eyes and scratching at her face; the area is consistent with resident rubbing her eye with just enough pressure to cause the discoloration, room changes have been made for roommate incompatibility. Review of the witness statements revealed the CNA documented on 12/26/20 . At the beginning of the shift Saturday night I observed 2 scratches on the left side of the resident's (Resident #3) face along with the bruised eye. Occasionally the resident (Resident #3) does talk at night and I have heard the resident (Resident #2) telling her to shut up and using other vulgar language. Review of the hospice nurse's notes for Resident #3 revealed documentation on 12/30/20 . Pt (patient) has moved rooms. Pt sustained a L (left) black eye. Facility thinks roommate (Resident #2) may have hit her. Review of the psychiatrist note dated 12/28/20 revealed Resident #2 had a history of [REDACTED]. Resident #2 per staff admitted to scratching her roommate due to her talking at night and then denied it. She had increased stealing from other residents, too. The psychiatrist ordered to increase [MEDICATION NAME] to 250 milligrams daily and 250 milligrams by mouth at bedtime for mood disorder and monitor for behaviors. She documented Patient has been unstable, is not cooperative with care, patient does have behavioral disturbances, and has s/s (signs and symptoms) of anxiety, and agitation at times. The physician documented considering risks and protective factors, the patient appeared to be at low risk of harming self or others intentionally. She documented activities disturbances noted in the following: Agitation wandering verbal and/or physical aggressiveness. Staff counseled regarding safety concerns: Fall risk, risk of wandering, and physical aggression. The clinical record lacked documentation of additional interventions to monitor Resident #2's specific behavior with the potential for resident altercations. Review of the progress notes for Resident #2 revealed documentation on 1/8/21 at 11:20 a.m., Resident (Resident #2) observed pushing another resident (Resident #1) out of her room and slamming door, resulting in resident (Resident #1) falling with laceration to left temple and hematoma. MD (physician) notified, pysch (sic) MD notified. Ordered Baker Act (involuntary psychiatric admission) in place . Resident placed on one to one waiting Baker Act transport. 3. Review of the clinical record revealed Resident #1 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a wanderer and had a care plan for elopement prevention. Resident #1 had a wanderguard (monitoring device to alert staff of attempts to leave a safe area). The facility developed a care plan dated 12/8/20 for Resident #1 which included the resident will not elope the facility and will be monitored of whereabouts on an ongoing basis. The interventions included to use diversional activities when exit-seeking behaviors occurs and wanderguard for safety to the left lower extremity. Review of the departmental notes in the resident medical record revealed documentation on 12/31/20 at 10:56 a.m., that read Alert to self/confused. Wanders out of her room, gait slightly steady. Needs redirection and assistance back to room and using the wheelchair. Able to propel self with w/c (wheelchair) . On 1/1/2021 at 2:35 p.m., the nurse documented Alert to self. Independent with toileting. Ambulates with a steady gait on short distances. Can be wobbly at times. Needs to be reminded to sit on the w/c. Monitored for safety. On 1/5/21 at 3:02 p.m., the nurse documented Alert to self/confused. Wandering on the hallway. Need redirection and reminder to use the w/c . Monitored for safety. A nurse's note entry for 1/8/21 at 10:56 a.m., read Writer at med cart passing meds and heard loud scream. Observed resident being pushed out of room (room number) stumbling and falling onto floor of hallway resulting in laceration to left temple with hematoma . Resident transported via 911 to (hospital name) for eval (evaluation) and TX (treatment) . On 2/1/21 at 10:45 a.m., in an interview CNA Staff B said resident #2 would go into other residents' rooms and take their things. She said Resident #2 tried to hit her and was verbally abusive to her. She said Resident #2 hit a resident. She said Resident #2 was also verbally abusive and used racial derogatory slurs and other profanities. She said Resident #2 had a roommate, but the roommate did not get hit. She said Resident #2 went into Resident #1's room and hit her. On 2/1/21 at 1:18 p.m., in an interview CNA Staff C said Resident #2 had behaviors such as cussing, stealing, going into other residents' rooms. She said Resident #2 got physical with her in the past when she was agitated by pushing her. She said when this type of behaviors occurred, sometimes she reported it but sometimes she just dealt with it, calmed Resident #2 herself and went about her work. She said the administration was aware of Resident #2's behavior. On 2/16/21 at 3:38 p.m., in a second telephone interview CNA Staff C said she was not at the facility the day of the incident, but everybody knew Resident #2's behaviors. Resident #2 was a thief and would always cuss you out. CNA Staff C said she never saw Resident #2 getting physical with other residents, just staff. She said she did not tell the new administrator. The clinical record lacked a care plan with interventions to address Resident #2's behavior of pushing others. Review of the facility's investigation revealed on 1/8/21 at 10:56 a.m., Licensed Practical Nurse (LPN) Staff D documented in a witness statement she observed resident (Resident #2) pushing another resident (Resident #1) out of her room and slamming door, resulting in resident (Resident #1) fall with laceration to the left temple and hematoma . On 2/15/21 at 10:41 a.m., in an interview LPN Staff D said she was next to room [ROOM NUMBER] in the 200 hallway when she heard a scream. She looked down the hall. By the time she got to the door, Resident #1 was hitting the floor. At the same time Resident #2's door slammed shut. They were assessing Resident #1. She said the Administrator went into Resident #2's room and asked if she pushed Resident #1. Resident #2 used a derogatory term and said yes. The hospital physician's progress notes dated 1/8/21 read Patient is a [AGE] year-old female who presents today after being pushed down by another resident at her nursing facility. Patient's head CT (special x-ray procedure to look at the inside of the body) came back showing a subdural hematoma (pool of blood between the brain and the covering) . and facial fractures. This patient is critically ill. The hospital discharge summary dated 1/10/21 read The patient is a [AGE] year old female status [REDACTED]. She is not a surgical candidate . Patient continued to have declining mental status and family decided on comfort measures to ensure patient is not having any pain or discomfort as she was exhibiting these signs. Patient TOD (time of death) 1735 (5:35 p.m.). On 2/1/21 at 1:21 p.m., the Administrator said he was not looking at the incident from an abuse standpoint. He said he did not file a report the allegation of abuse because it was reported Resident #1 went into Resident #2's room. He said there was no willful abuse. The facility submitted an acceptable IJ removal plan and the Immediate action to remove the Jeopardy and the removal actions were verified by the survey team.

Based on record review and interview the facility failed to prevent resident to resident altercation for 1 (Resident #2) of 6 residents reviewed. On 1/8/21 Resident #2 pushed Resident #1 who wandered in her room resulting in a fall, causing physical harm, subdural hematoma and finally death of Resident #1. The facility staff failed to report resident #2's physical aggressive behavior of pushing staff prior to the incident on 1/8/21. The facility failed to recognize abuse and conduct a thorough investigation of the incident on 1/8/21. The isolated noncompliance resulted in Immediate Jeopardy that started on 1/8/21. On 2/17/21 at 9:02 a.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ template. The Immediate Jeopardy was removed on 2/18/21 at 5:00 p.m., after supervisory verification of the IJ removal plan which included education of all staff on recognizing and reporting abuse, behaviors that may lead to abuse, immediate interventions when behaviors are identified. The Immediate Jeopardy scope and severity was reduced to D. The findings included: The facility's policy titled Abuse and Neglect which was not dated read Purpose: To prohibit abuse of residents from any source. To promote the well-being of residents by providing a safe and supportive environment. To maintain the resident's right to be free from verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. The policy defined abuse as The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also included the deprivation by an individual, including a caretaker, of goods, or services that are necessary to attain or maintain physical, mental and psychosocial well-being. The abuse and neglect policy included training of staff Employees must be trained through orientation and annually about the following: Appropriate intervention to deal with aggressive and/or catastrophic reactions of residents. What constitutes abuse, neglect, and misappropriation of resident property. The abuse and neglect policy included identification that read Abuse and neglect in nursing facilities is a high priority. Any type of abuse constitutes a violation of resident rights. The following incidents should by assessed for possible abuse: . Injury to head, scalp, or face . Fracture, falls. Since every resident in long term care is at risk for abuse due to their diminished capacity, care must be taken by every staff member to identify individuals at greatest risk for abuse and monitor them closely for potential physical, emotional, or spiritual harm . Review of the clinical record revealed Resident #1 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a wanderer and had a care plan for elopement prevention. Resident #1 had a Wanderguard (monitoring device to alert staff when a resident attempts to leave a safe area ). The facility developed a care plan dated 12/8/20 for Resident #1 which included the resident will not elope the facility and will be monitored of their whereabouts on an ongoing basis. The interventions included to use diversional activities when exit-seeking behaviors occurs and wanderguard for safety to the left lower extremity. Review of the departmental notes in the resident medical record revealed documentation on 12/31/20 at 10:56 a.m., that read Alert to self/confused. Wanders out of her room, gait slightly steady. Needs redirection and assistance back to room and using the wheelchair. Able to propel self with w/c (wheelchair) . On 1/1/2021 at 2:35 p.m., the nurse documented Alert to self. Independent with toileting. Ambulates with a steady gait on short distances. Can be wobbly at times. Needs to be reminded to sit on the w/c. Monitored for safety. On 1/5/21 at 3:02 p.m., the nurse documented Alert to self/confused. Wandering on the hallway. Need redirection and reminder to use the w/c . Monitored for safety. A nurse's note entry for 1/8/21 at 10:56 a.m., read Writer at med cart passing meds and heard loud scream. Observed resident being pushed out of room (room number) stumbling and falling onto floor of hallway resulting in laceration to left temple with hematoma . Resident transported via 911 to (hospital name) for eval (evaluation) and TX (treatment) . Review of the facility's investigation revealed on 1/8/21 at 10:56 a.m., Licensed Practical Nurse (LPN) Staff D documented in a witness statement she observed resident (Resident #2) pushing another resident (Resident #1) out of her room and slamming door, resulting in resident (Resident #1) fall with laceration to the left temple and hematoma . On 2/15/21 at 10:41 a.m., in an interview LPN Staff D said she was next to room [ROOM NUMBER] in the 200 hallway when she heard a scream. She looked down the hall. By the time she got to the door, Resident #1 was hitting the floor. At the same time Resident #2's door slammed shut. They were assessing Resident #1. She said the Administrator went into Resident #2's room and asked if she pushed Resident #1. Resident #2 used a derogatory term and said yes. The hospital physician's progress notes dated 1/8/21 read Patient is a [AGE] year-old female who presents today after being pushed down by another resident at her nursing facility. Patient's head CT (special x-ray procedure to look at the inside of the body) came back showing a subdural hematoma (pool of blood between the brain and the covering) . and facial fractures. This patient is critically ill. The hospital discharge summary dated 1/10/21 read The patient is a [AGE] year old female status [REDACTED]. She is not a surgical candidate . Patient continued to have declining mental status and family decided on comfort measures to ensure patient is not having any pain or discomfort as she was exhibiting these signs. Patient TOD (time of death) 1735 (5:35 p.m.). Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The care plan with an initial date of 11/28/17 indicated Resident #2 exhibited alteration in mood and behavior as evidenced by wandering on unit and in rooms, hoarding items, and fearfulness. Resident #2 has been observed turning roommates bed alarm on and off. The attempts included to approach in a calm manner, do not attempt to bring back to reality when confused or experiencing psychotic disturbances; maintain low stimulus environment, soft music, close exterior blinds when agitated and document response to decrease in external stimulus; avoid confrontation when agitated; educate resident regarding acceptable alternatives to identified behaviors and document. Review of the departmental notes in the resident medical record revealed documentation dated 10/16/20 at 3:37 p.m., that read IDT (interdisciplinary team) met and discussed resident's psychoactive medications; resident is noted with failed GDR (gradual dose reduction) in the past and is easily triggered; resident appears stable at this time so no recommendations were made. On 11/12/20 at 10:44 a.m., the nurse documented the IDT held a meeting to discuss psych services. Recommendation made to begin [MEDICATION NAME] ER 250 mg (milligrams) daily at bedtime as resident becomes agitated easily and shouts out at staff related to mood disorder. Review of the incident reports revealed Resident #3 was Resident #2's roommate on 12/26/20. The Director of Nursing documented on 12/26/20 During the morning rounds on 12/26/20 the c.n.a (certified nursing assistant) found a purple discoloration under the resident's (Resident #3) left eye, along with an abrasion between her eyes mid-forehead area; resident has dementia and is unable to state how it occurred. Resident's roommate (Resident #2) admitted that this resident (Resident #3) aggravates her when she is making a lot of noise; when roommate (Resident #2) was asked if she hit her she would say yes she did, and then she would say no she didn't; Resident's roommate (Resident #2) was started on [MEDICATION NAME] at HS (bedtime) for a mood stabilizer since she would get easily agitated around the same time this resident was taken off her [MEDICATION NAME] at bedtime; upon assessment resident (Resident #3) was found rubbing her eyes and scratching at her face; the area is consistent with resident rubbing her eye with just enough pressure to cause the discoloration, room changes have been made for roommate incompatibility. Review of the hospice nurse's notes for Resident #3 revealed documentation on 12/30/20 . Pt (patient) has moved rooms. Pt sustained a L (left) black eye. Facility thinks roommate (Resident #2) may have hit her. Review of the witness statements revealed the CNA documented on 12/26/20 . At the beginning of the shift Saturday night I observed 2 scratches on the left side of the resident's (Resident #3) face along with the bruised eye. Occasionally the resident (Resident #3) does talk at night and I have heard the resident (Resident #2) telling her to shut up and using other vulgar language. Review of the psychiatrist note dated 12/28/20 revealed Resident #2 had a history of [REDACTED]. Resident #2 per staff admitted to scratching her roommate due to her talking at night and then denied it. She had increased stealing from other residents, too. The psychiatrist ordered to increase [MEDICATION NAME] to 250 milligrams daily and 250 milligrams by mouth at bedtime for mood disorder and monitor for behaviors. She documented Patient has been unstable, is not cooperative with care, patient does have behavioral disturbances, and has s/s (signs and symptoms) of anxiety, and agitation at times. The physician documented considering risks and protective factors, the patient appeared to be at low risk of harming self or others intentionally. She documented activities disturbances noted in the following: Agitation wandering verbal and/or physical aggressiveness. Staff counseled regarding safety concerns: Fall risk, risk of wandering, and physical aggression. The clinical record lacked documentation of additional interventions to monitor Resident #2's specific behavior with the potential for resident altercations. On 1/8/21 at 11:20 a.m., the nurse documented Resident (Resident #2) observed pushing another resident (Resident #1) out of her room and slamming door, resulting in resident (Resident #1) falling with laceration to left temple and hematoma. MD (physician) notified, pysch (sic) MD notified. Ordered Baker Act (involuntary psychiatric admission ) in place . Resident placed on one to one waiting Baker Act transport. On 2/1/21 at 10:45 a.m., in an interview CNA Staff B said resident #2 would go into other residents' rooms and take their things. She said Resident #2 tried to hit her and was verbally abusive to her. She said Resident #2 hit a resident. She said Resident #2 was also verbally abusive and used racial derogatory slurs and other profanities. She said Resident #2 had a roommate, but the roommate did not get hit. She said Resident #2 went into Resident #1's room and hit her. On 2/1/21 at 1:18 p.m., in an interview CNA Staff C said Resident #2 had behaviors such as cussing, stealing, going into other residents' rooms. She said Resident #2 got physical with her in the past when she was agitated by pushing her. She said when this type of behaviors occurred, sometimes she reported it but sometimes she just dealt with it, calmed Resident #2 herself and went about her work. She said the administration was aware of Resident #2's behavior. On 2/16/21 at 3:38 p.m., in a second telephone interview CNA Staff C said she was not at the facility the day of the incident, but everybody knew Resident #2's behaviors. Resident #2 was a thief and would always cuss you out. CNA Staff C said she never saw Resident #2 getting physical with other residents, just staff. She said she did not tell the new administrator. The clinical record lacked a care plan with interventions to address Resident #2's behavior of pushing others. On 2/1/21 at 1:21 p.m., the Administrator said he was not looking at it from an abuse standpoint. He said he did not file a report the allegation of abuse because it was reported Resident #1 went into Resident #2's room. He said there was no willful abuse. The Immediate Jeopardy was removed on 2/18/21 at 5:00 p.m., after supervisory verification of the IJ removal plan which included education of all staff on recognizing and reporting abuse, behaviors that may lead to abuse, immediate interventions when behaviors are identified. On 2/17/21 six CNAs, two LPNs and one RN were interviewed. They all said they had received an in-service on recognizing and reporting abuse including how to handle difficult behaviors. The facility implemented a new form to report behaviors. All staff are to report allegation of abuse to the supervisor and the Administrator.

Based on record review and staff interview the facility failed to utilize its resources effectively and provide necessary services to ensure each resident maintained the highest practicable physical and mental well-being. The facility Administration failed to address staff reports of resident #2 physician aggression toward staff, recognize resident to resident abuse and conduct a thorough investigation. On 1/8/21 Resident #2 pushed Resident #1 who wandered in her room resulting in a fall, causing physical harm, subdural hematoma and finally death of Resident #1. The isolated noncompliance resulted in Immediate Jeopardy that started on 1/8/21. On 2/17/21 at 9:02 a.m., the Administrator was informed of the determination of Immediate Jeopardy and provided the IJ template. The Immediate Jeopardy was removed on 2/18/21 at 5:00 p.m., after supervisory verification of the IJ removal plan which included education of all staff, including administrative staff on recognizing and reporting abuse, behaviors that may lead to abuse, immediate interventions when behaviors are identified. The Immediate Jeopardy scope and severity was reduced to D. The findings included: Review of the Administrator's position description (no date) revealed the essential functions of the position included to Ensure excellent care for residents is maintained by overseeing and monitoring patient care service delivered. Review of the Director of Nursing position description (no date) revealed the position purpose is to Plan, organize, develop, and direct the overall operation of the facility's nursing department in accordance with current federal, state and local standards, guidelines, and regulations that govern our facility, as may be directed by the Administrator, to ensure that the highest degree of quality of care is maintained at all times. Review of the clinical record revealed Resident #2 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the departmental notes revealed on 11/12/20 a recommendation was made for Resident #2 to begin [MEDICATION NAME] 250 milligrams as she becomes easily agitated and shouts out at staff. Review of an incident report dated 12/26/20 revealed on 12/26/20 Resident #3 (Resident #2's roommate) had a purple discoloration under the left eye along with an abrasion between her eyes. Resident #3 had dementia and was not able to say how she obtained the areas. Resident #3 has thin frail skin and appears translucent and she takes vitamin D3 10,000 units, ASA (Aspirin) 81 mg. Resident #2 admitted Resident #3 aggravates her when she makes a lot of noise. When roommate (Resident #2) was asked if she hit her (Resident #1) she would say yes she did, and then she would say no she didn't. Resident's roommate (Resident #2) was started on [MEDICATION NAME] at bedtime for a mood stabilizer since she would get easily agitated around the same time this resident was taken off her [MEDICATION NAME] at bedtime. Review of the witness statements revealed the CNA (Certified Nursing Assistant) documented on 12/26/20 . At the beginning of the shift Saturday night I observed 2 scratches on the left side of the resident's (Resident #3) face along with the bruised eye. Occasionally the resident (Resident #3) does talk at night and I have heard the resident (Resident #2) telling her to shut up and using other vulgar language. On 12/28/20 the psychiatrist documented Resident #2 per staff admitted to scratching her roommate due to her talking at night and then denied it. She had increased stealing from other residents, too. The psychiatrist ordered to increase [MEDICATION NAME] to 250 milligrams daily and 250 milligrams by mouth at bedtime for mood disorder and monitor for behaviors. She documented Patient has been unstable, is not cooperative with care, patient does have behavioral disturbances, and has s/s (signs and symptoms) of anxiety, and agitation at times. The physician documented considering risks and protective factors, the patient appeared to be at low risk of harming self or others intentionally. She documented activities disturbances noted in the following: Agitation wandering verbal and/or physical aggressiveness. Staff counseled regarding safety concerns: Fall risk, risk of wandering, and physical aggression. The clinical record lacked documentation of additional interventions to monitor Resident #2's specific behavior with the potential for resident altercations. Review of the clinical record revealed Resident #1 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1 was a wanderer and had a care plan for elopement prevention. Resident #1 had a Wanderguard (monitoring device to alert staff when a resident attempts to leave a safe area). Review of the clinical record revealed Resident #1 had an admission date of [DATE] with [DIAGNOSES REDACTED]. Resident #1's care plan dated 12/8/20 indicated the resident had a Wanderguard to the left lower extremity. A nurse's note entry for 1/8/21 at 10:56 a.m., read Writer at med cart passing meds and heard loud scream. Observed resident being pushed out of room (Resident #2's room) stumbling and falling onto floor of hallway resulting in laceration to left temple with hematoma . Resident transported via 911 to (hospital name) for eval (evaluation) and TX (treatment) . The hospital discharge summary dated 1/10/21 read The patient is a [AGE] year old female status [REDACTED]. She is not a surgical candidate . Patient continued to have declining mental status and family decided on comfort measures to ensure patient is not having any pain or discomfort as she was exhibiting these signs. Patient TOD (time of death) 1735 (5:35 p.m.). On 2/15/21 at 10:35 a.m., in an interview the Director of Nursing said Resident #2 was very quiet. She would go outside, pick flowers, she kind of stayed to herself. She would walk around the unit and would pick stuff off the unit. Her door was always shut, lights always off, blinds always closed. That's what she wanted. On 2/1/21 at 10:45 a.m., in an interview CNA Staff B said resident #2 would go into other residents' rooms and take their things. She said Resident #2 tried to hit her and was verbally abusive to her. She said Resident #2 hit a resident. She said Resident #2 was also verbally abusive and used racial derogatory slurs and other profanities. She said Resident #2 had a roommate, but the roommate did not get hit. She said Resident #2 went into Resident #1's room and hit her. On 2/1/21 at 1:18 p.m., in an interview CNA Staff C said Resident #2 had behaviors such as cussing, stealing, going into other residents' rooms. She said Resident #2 got physical with her in the past when she was agitated by pushing her. She said when this type of behaviors occurred, sometimes she reported it but sometimes she just dealt with it, calmed Resident #2 herself and went about her work. She said the administration was aware of Resident #2's behavior. On 2/16/21 at 3:38 p.m., in a second telephone interview CNA Staff C said she was not at the facility the day of the incident, but everybody knew Resident #2's behaviors. Resident #2 was a thief and would always cuss you out. CNA Staff C said she never saw Resident #2 getting physical with other residents, just staff. She said she did not tell the new administrator. On 2/16/21 at 9:44 a.m., in an interview the Administrator said he has been employed at the facility since July 2020 and had not seen Resident #2 have physical behaviors. He said she had verbal outbursts, but nothing physical. He said, If Resident #1 had not gone into Resident #2's room, we wouldn't be talking about it. He said it would have been different if Resident #2 went out to attack Resident #1. He said Resident #2 wasn't seeking anyone out. She didn't want anyone in her room. On 2/16/21 at 5:01 p.m., the Administrator said he oversees the day to day operation of the facility to ensure all policies and procedures are followed to ensure state and federal regulations comply. He said they address any area that is not going the way it should. They bring it to QAPI (Quality Assurance and Performance Improvement) for follow up. The Immediate Jeopardy was removed on 2/18/21 at 5:00 p.m., after verification of the IJ removal plan which included education of all staff on recognizing and reporting abuse, behaviors that may lead to abuse, immediate interventions when behaviors are identified. On 2/17/21 six CNAs, two LPNs and one RN were interviewed. They all said they had received an in-service on recognizing and reporting abuse including how to handle difficult behaviors. The facility implemented a new form to report behaviors. All staff are to report allegation of abuse to the supervisor and the Administrator.

Based on observation, record review and interview, the facility failed to accurately assess, comprehensively plan for and consistently monitor 4 (Resident #13, #55, #99 and #117) of 5 of 8 sampled residents with pressure ulcers. This failure to ensure they received the necessary treatment and services to resulted in the worsening of the pressure ulcer for Resident #55 and potential for worsening of other pressure ulcers. The findings included: The facility's policy and procedure for Pressure Ulcers/Skin Breakdown directed the following; The nursing staff and attending physician will assess and document an individuals significant risk factors for developing pressure sores. In addition the nurse shall describe and document/report the following- full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue. The National Pressure Ulcer Advisory Panel 2014 Prevention and treatment of [REDACTED]. http://www.npuap.org/resources/educational-and-clinical-resources/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guideline/ ) includes pressure ulcer assessment: Assess the pressure ulcer initially and re-assess it at least weekly. Document the results of all wound assessments. Assess and document physical characteristics including; location, Category/Stage, size, tissue type, color, periwound condition, wound edges, sinus tracts, undermining, tunneling, exudate and odor. 1. Review of Resident #55's face sheet documented he was admitted to the facility on [DATE]. The Nursing Admission Set dated 1/15/16 documented his skin as warm and dry, no open areas. The pressure ulcer risk screen was documented as having no pressure ulcers, and a Braden Score (pressure ulcer risk assessment tool) of 9. A score of 7 or higher indicates the resident is at risk for pressure ulcers and a care plan is indicated. The Skin Committee Intervention and Recommendation Sheet dated 1/19/16, completed by Staff D, documented no skin injury. Facility physician's orders [REDACTED]. Staff D contacted the Advanced Registered Nurse Practitioner (ARNP) for wound care to see resident on 2/2/16. Facility physician's orders [REDACTED]. The wound assessment dated [DATE], completed by Wound Care Registered Nurse (RN) Staff D documented the resident as having a new pressure ulcer to the sacrum, unstageable due to deep tissue injury measuring in length 13.0 centimeters (cm) and width 14.0 cm with no depth measurement. The note documented, acquired pressure ulcer. The wound assessment dated [DATE], completed by Staff D, documents unstageable due to slough / eschar wound measured length 13.0 cm and the width 14.0 cm. The ARNP wound care assessment dated [DATE], documented the measurement as 11 cm length by 13 cm width and 0.1 cm depth. The assessment notes, This is a worrisome area of rapid deterioration. The wound originates in the sacrum and extends into both buttocks. The wound is consistent with a Kennedy ulcer. The treatment ordered by the wound care ARNP, dated 2/2/16, documented discontinue duoderm. Cleanse wound on sacrum / buttocks with normal saline, pat dry. Apply [MEDICATION NAME] and cover with ABD pad and tape daily. The wound assessment dated [DATE], completed by Staff D, documented unstageable due to slough / eschar wound measuring length as 11.0 cm and width 13.0 cm and depth as 0.1 cm. The treatment ordered by wound care ARNP, dated 2/9/16, included to discontinue previous order and start; cleanse sacral wound twice daily with normal saline, fill wound depth and undermining with Gentamyocin - [MEDICATION NAME]- [MEDICATION NAME] solution (GCP) soaked gauze. Apply [MEDICATION NAME] ointment to the superficial perimeter wounding, cover all with ABD pad. The assessment dated [DATE], completed by Staff D, documented unstageable due to slough/eschar wound measuring length as 8.0 and width 10.5 and depth as 2.0. The note documented after debridement. The Facility Acquired Pressure Ulcer Investigative Tool dated 1/26/15, documented his last full body assessment was completed on 1/15/16. Staff D documented she completed her last assessment on 1/19/16. The location of pressure ulcer is on the sacrum as deep tissue injury, unstageable. The family and physician were notified of pressure ulcer. Certified Nursing Assistant Staff J found the area and notified Licensed Practical Nurse Staff F on 1/18/16. The Director of Nursing accepted the assessment on 2/2/16. Requested the Treatment Administration Record (TAR) for January 2016; the facility was unable to locate it. The TAR for February 2016 documented cleanse wounds on sacrum/buttocks with normal saline, pat dry. Apply [MEDICATION NAME] and cover with ABD pad and tape daily. The a.m. to p.m. shift started on 2/9/16 (when ordered) and documented as completed every morning through 2/17/16. The 7 p.m. to 7 a.m. shift documented as the resident refusing the dressing change on 2/10/16, 2/13/16,2/14/16 and 2/15/16. The other spaces for initials have been left blank. The evening dressing change was never picked up by the Wound Care Registered Nurse, Staff D after being ordered on [DATE] to 2/17/16. On 2/18/16 at 12:15 p.m. the DON said she didn't know Resident #55 was diagnosed with [REDACTED]. On discovery it was a deep tissue injury (DTI), unstageable. The Braden scale for pressure ulcers was completed on 1/15/16 and the score was a 9. The family and physician was notified of the pressure ulcer. The DON said the root cause was diabetes mellitus, hypertension, cardiovascular accident and was unavoidable due to impaired mobility and incontinence. The DON said Staff D actions included reposition frequent, limit sitting position. Treatment included duoderm to the sacrum. She said Staff D documented there was no injury upon admission assessment dated [DATE]. She said she thought the wound care registered nurse, Staff D was thorough but she was wrong. She said the wound care nurse evidently wasn't doing her assessment when she said she was. On 2/17/16 at 10:20 a.m. Staff J, Certified Nursing Assistant (CNA), said the resident came on the 15th and she returned to work on the 18th. She said she saw the resident had 2 black spots on his sacrum and his buttocks were very red. She told Staff F, licensed practical nurse (LPN) and she was told to put the Baza cream (antifungal medication used to treat fungal or yeast infections of the skin) on him. She said on the 20th she saw the areas were not getting any better. There was a very foul odor coming from the areas and told Staff F who went and got Staff D. She said from then on Staff D was dressing the wound with duoderm. On 2/18/16 at 12:55 p.m., Resident #55's daughter said when her father was admitted , she did not see the staff turn him every 2 hours. She said now that the wound is huge, and the family has starting complaining, the staff began turning him more frequently. She said the family is very upset with the lack of care that the wound has gotten so bad. She said she visits him frequently so she would know how often they turn him. She said her mother is with him even more than she is and stays into the evening. On 2/18/16 at 2:45 p.m., Resident #55's wife said the staff did not turn him side to side. She said she is here until at least 7:00 p.m. and she has never seen any nurse do a dressing change on his buttock in the evening or ask him, where he refused. On 2/18/16 at 2:50 p.m., Resident #55 said he has not been asked about having a dressing change to his buttocks in the evening. He said he has never refused a dressing change. On 2/22/16 at 8:30 a.m., the Advanced Registered Nurse Practitioner (ARNP) for Resident #55 said he first saw him in February and the wound was quite extensive. He said he has debrided it. He said he has no idea why he would not have gotten the referral sooner, why he didn't see him in January. He said the pressure ulcer is now a stage IV wound. He said the wound care registered nurse, Staff D has heard him call the resident's pressure ulcer a stage IV wound. The ARNP said he did not authorize or give an order for [REDACTED]. He verified he was in the building on 1/19/16 and 1/26/16 and did not see Resident until 2/2/16. He said he was not made aware of need to see the resident until 2/2/16. Care plan identified an issue for impaired skin integrity dated 1/19/16; open area on buttocks with a goal of free from additional skin breakdown and the interventions included weekly skin checks; report symptoms of infection; adult briefs and barrier cream as indicated; notify physician / family of changes; pressure relief as needed turn and reposition every 2 hours and as needed and tx as ordered. 2. Review of physician order [REDACTED]. The Treatment Administration Record (TAR) for December 2015 documented left buttock, clean wound with normal saline, apply silver alginate, cover with duoderm every other day and prn. Handwritten across the TAR was resolved 12/11/15. The last time the dressing is initialed as having been completed was on 12/11/15. Review of January 2016 TAR documented left buttock, apply duoderm every 3 days and prn. Done is documented next to the treatment, left buttock, clean wound with normal saline, apply silver alginate, cover with duoderm every other day and prn. There are no initials on the TAR for the entire month. Review of physician orders [REDACTED]. Review of Resident #99's February 2016 TAR documented physician order [REDACTED]. The last date it was initialed as having been completed was 2/3/15. The documentation for left buttock apply duoderm every 3 days and prn has been documented as completed on 2/15/16. Staff E confirmed the professional staff initialed as having applied the dressing as ordered on [DATE], 2/3/16 and the duoderm on 2/15/16. On 2/16/16 at 11:45 a.m., wound care registered nurse Staff D said Resident #99 does not have a pressure ulcer anymore, it has resolved. She said the resident gets duoderm applied as a precaution every 3 days. She was unable to locate a physician order [REDACTED]. She checked with the MDS coordinator to see if it had been thinned out, and was informed it had not. She looked in the computer and said there is an order in the computer to discontinue the dressing with the silver alginate, but she does not see an order for [REDACTED]. Observation on 2/17/16 at 5:40 p.m., with the Director of Nursing, confirmed Resident #99's skin on buttocks was intact was no redness. There was no duoderm or any dressing applied. On 2/18/16 at 12:30 p.m., the DON said they received a progress note today from the Advanced Registered Nurse Practitioner (ARNP) saying he recalled the previous verbal order to discontinue the silver alginate and apply the duoderm [MEDICATION NAME] starting on 1/9/16. Staff D failed to write the verbal order for the ARNP to sign. 3. Resident #117's clinical record revealed a nursing note that on 2/8/16 Staff A, Licensed Practical Nurse (LPN), was notified by a Certified Nursing Assistant (CNA) the resident had a blackened area measuring 2.5 cm by 1.5 cm, and no drainage but red periwound. Staff A noted the wound nurse (Staff D) was alerted and the resident's responsible party was to be notified. Staff A documented she applied skin prep. A wound assessment note on 2/16/16 by Staff D, Registered Nurse (RN), indicated on the resident's lateral right heel there was a dark red area that measured 2.5 cm by 1.5 cm in size. Staff D noted heel protector boots were in the resident's room to use when he is in bed. There was no documentation of the resident's physician being notified. On 2/16/16, Staff D obtained a physician's orders [REDACTED]. On 2/17/16 at 12:54 p.m., Staff C, CNA, she said she routinely takes care of Resident #117 on the day shift. Staff C said the resident has no skin concerns and does not know the reason for the heel protector boots in the resident's room. On 2/17/16 at 1:07 p.m., the residents right heel was observed along with Staff B, LPN. A pressure ulcer was observed on the resident's right lateral heel that was 1.5 cm by 1.5 cm in size. The area was dark red/black in color with suspected deep tissue injury (SDTI is a category/stage for certain pressure ulcers by the National Pressure Ulcer Advisory Panel). Staff B said she first observed the resident's heel last week and the skin around it was softer, there was some fluid in the area, and presented more as a blister. Staff B said the area looked to be improved. Staff B said she also made sure the resident's wife had been notified. In an interview on 2/17/16 at 4:24 p.m., Staff D, wound care nurse, said she was not notified of the area on Resident#117's heel until 2/16/16. She said the resident has a little area on his lateral heel and was going to consult the wound physician when he made rounds next week. On 2/17/16 at 4:55 p.m., the lack of assessment, documentation, and care planning surrounding Resident #117's pressure ulcer was reviewed with the Director of Nursing (DON). The DON said she would expect Staff D as the facility's wound nurse to be able to do an initial assessment of a wound. The DON reviewed her wound reports and confirmed she had not been made aware of any skin issues for Resident #117. On 2/17/16 at 5:00 p.m., the resident's right heel was again observed, along with the DON. The DON confirmed the area was a pressure ulcer and should have been documented as such until a clinician diagnosed the area to be otherwise. In an interview with Staff D on 2/18/16 at 8:46 a.m., she confirmed she was the one who called the Advanced Registered Nurse Practitioner (ARNP) who works with the resident's physician, to get the order for skin prep and heel protectors on 2/16/16. Staff D said she notified the ARNP of the lesion on the residents right heel. Staff D said she did not document this notification. In an interview with the ARNP on 2/18/16 at 8:51 a.m., he said he was very familiar with Resident #117 and had not been told the resident had any area on his heel. The resident's careplan for skin integrity dated 4/8/15, under the problem of risk of impaired skin integrity, listed a goal for the resident's skin to remain intact. The residents careplan had not been updated to reflect the resident had a pressure ulcer on his right heel or the new interventions in place to promote healing. There was no initial assessment of the resident's wound to include category/stage of the pressure ulcer, no weekly assessment of the pressure ulcer, and all staff caring for the resident being made aware of the presence of a pressure ulcer. The resident's careplan had not been updated; the resident' physician was not notified so the resident could be assessed medically for the reason for the pressure ulcer and for any complications; and treatment plan be approved and coordinated with other professional staff; the interdisciplinary team was not informed so the residents careplan could be revised to include the new interventions. 4. Resident #13's clinical record contained a nurses note that on 2/3/16 at 7:46 a.m., the resident was noted to have a broken blister to his left heel. Staff A, LPN, noted the blister measured 4.0 cm by 2.5 cm. A wound assessment report dated 2/17/16 was completed by Staff D, Registered Nurse. The assessment indicated the resident had a pressure ulcer on his left heel that measured 3.0 cm by 2.0 cm by 0.2 cm in depth. Staff D noted the pressure ulcer was unstageable due to slough/eschar (dead tissue). There was no initial and/or weekly assessment of the resident's pressure ulcer until 2/17/16, after being noted by the LPN on 2/3/16. In an interview on 2/18/16 at 11:48 a.m., the DON said she receives a weekly wound report and confirmed she had not been notified that the resident had an unstageable pressure ulcer.

Based on record reviews, observations and interviews, the facility failed to provide adequate nursing care, supervision, and interventions to prevent accidents which resulted in a bleeding and bruised lip and repeated skin tears for 1 (Resident #12) of 4 sampled residents. Staff failed to provide the proper supervision and assistance during care which resulted in the resident hitting his face when in bed on a metal side rail. When in the wheelchair, staff failed to prevent repeated bumping of his legs on the leg rests. The findings included: 1. On 10/21/14 at 10:45 a.m., Resident #12 was observed sitting in a wheelchair with his feet resting on the metal leg supports, visiting with his family member. An area of purplish discoloration, 2.0 cm by 1.5 centimeter (cm) in size, was noted on the residents right lower face, from his bottom lip down to his chin. The resident was also noted to have a dressing on his right outer leg. The resident's family member said she had been told by staff that the "bruise" on the resident's face was where he had bumped into the side rail. She was not sure how that could have happened as he has pads on the rails and does not move in bed. The family member said she was notified of the incident on 10/15/14 at 6:45 a.m., and when she arrived at the facility around 8:30 a.m., his mouth was bleeding. She said in regards to the dressing on the resident's leg, he has a skin tear that she had not been notified of, and was told by staff may have occurred from hitting the bed frame during a transfer. The family member said she did not know how that could happen as he requires a mechanical sling lift. Review of the Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #12 with severely impaired cognitive skills; dependent on 2 staff members for bed mobility and transfers; and required the assistance of 1 staff member for locomotion on the unit. Record review documented a physician's orders [REDACTED]. A review of nursing notes showed on 10/15/14 at 6:46 a.m., the resident hit his lip on the side rail when being turned onto his right side. The nurse noted the resident "obtained a small area to right lower lip". A nursing note dated 10/16/14 documented "bruising and mild swelling remain on lower lip". Observation on 10/22/14 at 9:20 a.m., found blue pads hanging on the outside of the resident's bed rails. In an interview with the East Wing Unit manager at the time of the observation, she said she could not explain how the resident would have sustained an injury from the side rail if the pads were in place. She said the Director of Nurses (DON) would have been the one to investigate the injury. She admitted the resident has had blue pads on the side rails as long as she has been at the facility. In an interview on 10/21/14 at 2:49 p.m., Staff E said she takes care of Resident #12 on the day shift and he is dependent on staff for bed mobility. Staff E acknowledged the resident requires the assistance of (2) staff members to move him in bed as the resident is not able to help. Staff E stated the resident has padded side rails for 2 years. On 10/22/14 at 10:20 a.m., the DON reviewed the facility's investigative report for the 10/15/14 incident. The narrative written by Staff A documented while changing the resident, she "pulled him on his side and his face must have hit the side rail." Staff A noted there was an area on the resident's bottom lip and she showed this to the nurse. The report was signed as being reviewed by the DON on 10/20/14 (5 days after the injury). The DON stated she did not investigate further into the incident. She did not believe the resident had padded side rails at the time of the incident. She said (1) staff member can position Resident #12 in bed. The Assistant Director of Nursing who was also present at the time of the interview, said the padded side rails were a new intervention after the injury. (This conflicts with the earlier interview with the Unit Manger and Staff A.) In a second interview on 10/22/14 at 11:16 a.m., the DON said she did not discuss the injuries with staff involved as it was clear to her what happened. The DON admitted she did not consider the resident required assistance by 2 staff member. The DON said she did not question if the pad was in use at the time of the incident. During an interview on 10/23/14 at 1:02 p.m., Staff A said she routinely takes care of Resident #12 on night shift. She said on the morning of 10/15/14, she raised the bed up to her waist level and flipped the pad from the inside of the rail to the outside as it was in the way. Staff A said she grabbed Resident #12's shoulder and buttocks to pull him towards her and Resident #12 must have rolled into the bed rail. Staff A admitted Resident #12 must have rolled into the rail with some force to cause the injury. She said she saw a little bit of blood on his lower lip and a small skin tear so she notified the nurse. She stated she did not see the bruising on his lower lip until she came back on duty the next night. Staff A said she doesn't know if she should have asked for help instead of pulling him so hard, the resident is heavy and doesn't help at all. Staff A said she does get a second staff member if she needs to change his bed but not usually to change his brief. Review of the facility's incident log revealed Resident #12 had sustained skin tears on 10/9/14, 10/14/14, 10/15/14 and 10/17/14. The investigative report dated 10/9/14 documented Resident #12 had bumped his left leg on the leg rest when being pushed in the wheelchair by his wife and sustained a skin tear. The report was signed by the DON as being reviewed on 10/20/14, (11 days later). The record contained a physician's orders [REDACTED]. The investigative report for 10/14/14 at 5:46 p.m. documented Staff C was notified by a certified nursing assistant (CNA) that a skin tear, 1 1/2 inch by 1/2 inch, was found on the resident's right forearm; she was unaware of how it happened, and the resident was in bed when the skin tear was found. Staff C documented the protective arm sleeve was not on but the resident "frequently removes stuff". The investigative report for 10/17/14 at 11:00 a.m. documented a skin tear on the resident's lower extremity that was 2.5 cm by 2.0 cm in size. The report noted the reason for the injury was "bumped against (wheelchair) leg rest and caused a skin tear". In an interview on 10/22/14 at 12:41 p.m., the DON verified there were no interventions put in place to prevent the resident from continuing to injure his legs on the wheelchair leg rests. She admitted she did not investigate how the resident obtained a skin tear on 10/14/14 or why the protective sleeves were not on the resident's arms. Photographic evidence is on file. .

Based on observations, record reviews and interviews, the facility failed to treat 2 (Resident #1 and #11) of 4 sampled residents with dignity and respect. The facility failed to recognize a staff member's ongoing behavior of speaking disrespectfully to Resident #1 which caused Resident #1 emotional distress and anxiety and fear of retaliation for reporting staff behavior. The facility failed to develop an effective care plan for Resident #11 which contributed to staff physically restraining the resident during care causing the resident increased stress, anxiety and combativeness during activities of daily living. The findings included: 1. Observation on 10/21/14 at 10:20 a.m., showed Resident #1 laying sideways across her bed. Oxygen was observed via nasal cannula through her nose. Licensed Practical Nurse (LPN), Staff D, was standing over Resident #1 holding a water bottle that was previously attached to an oxygen concentrator. While holding the water bottle in her left hand, the nurse stated in a condescending tone, "I told you I was going to take it out of here. I've told you before. We go through this with you all the time." Staff D walked away from the resident with a scowl on her face and her brows furled. In an interview as Staff D was exiting the room, Staff D stated in a loud voice, "I constantly go through this all the time with her...my patience gets thin. She wants a water bottle on her concentrator and she doesn't need it. She's getting oxygen 2 liters and doesn't need it. She thinks she does. We put the water bottle on for her convenience and she asks me to put the water bottle on and take it off constantly. I constantly go through this with her. I'm sorry but I don't know what else to do about her. I don't know what to do at this point. She was sick for the past 2 weeks but now she's feeling better. I know I lost my patience and I'm sorry about it...." Staff D acknowledged she was disrespectful toward the resident and walked into the medication room. During an interview on 10/21/14 at 10:28 a. m., Resident #1 stated, "...I thought she was yelling at me. If you ask the nurse (Staff D) she will tell you she is yelling at me because I am deaf as a reason she has to yell, but that is what she does when she is mad at me... My feelings were hurt but I'm used to it." Resident #1 said she felt Staff D was very disrespectful towards her but tolerates it because Staff D keeps coming back and apologizes to her each time she offends her. In an interview on 10/21/14 at 11:45 a.m. with the Director of Nursing (DON), she said she interviewed Resident #1 who confirmed Staff D hurt the resident's feelings. The DON said Resident #1 told her she and the nurse were friends, that when Staff D does this "stuff" to the resident, she usually comes back later and apologizes. The nurse has been suspended. The DON admitted Staff D should not have the ongoing type of relationship, where, the nurse offends the resident and then comes back later and apologizes to the resident. During an observation on 10/21/14 at 1:50 p.m., Resident #1 was in her room, resting in bed. The resident was teary eyed and stated, "Staff D asked me about a water bottle on my oxygen and I told her it helps me with my nose. We were going back and forth at one another like we usually do and she left the room... Yes, I'm upset... I'm used to her yelling at me and then she comes back and apologizes. This is how she is... I just accept it. I'm not doing anything the rest of the day. I can't, I'm too upset." The clinical documented Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) with an assessment reference date of 9/01/14 documented a brief interview for mental status (BIMS) of "14". The score ranges from "0 (resident unable to perform the test)" to "15 (high level of cognitive functioning)". The resident was assessed as having "minimal" difficulty hearing (e.g., when person speaks softly or setting is noisy), has adequate vision, clear comprehension and understanding. A care plan was developed on 6/2/14 for, Impaired communication as evidenced by: difficulty hearing at times in loud environments. There was no indication Resident #1 was deaf or hard of hearing to the point where a voice needed to be raised when speaking in a normal setting. During an interview on 10/22/14 at 11:00 a.m., Resident #1 said even though Staff D yells at her, this is something she's been used to for a long time. She stated, "What you didn't see was how she slammed down the water bottle on the table. Then I knew I was really getting her upset, but I didn't mean it. The night before, an oxygen bottle was attached and the one that morning was making noises. What happens is, the water from the bottle goes up through the tubing and I don't want it to go into my nose, I have to call her and tell her. So, I wanted (Staff D) to take a look at it. She started jiggling it around and then told me she didn't have time for this. Like I told you, I'm used to her yelling at me and then she comes back and apologizes...On Monday, I wanted to know when my heart doctor's appointment was and I went up to (Staff D) while she was at her cart. Well, like she always does, she scratched her head and kept looking forward. I wasn't sure if she heard my request or not, so, I asked her again. She looked at me, shook her head and yelled at me saying, "Yes, I heard you (Resident #1) but I can't help you right now, can't you see I'm in the middle of something? I know how she gets so I waited. Well, she never came back to me and I never did find out when my appointment was until yesterday when (the charge nurse) got it for me and let me know. (Staff D) gets frustrated and loses her patience with me. Maybe she has too many patients to take care of, I don't know." The resident said she feared retaliation. Staff D admitted her patience with Resident #1 was "thin". She was observed to speak to Resident #1 in a hostile, condescending tone of voice. Resident #1 said she is used to Staff D treating her this way and Resident #1 accepts this behavior. The failure of Staff D to maintain her composure and promote care in a respectful manner in honoring the resident's dignity caused the resident emotional distress and despair, hurt the resident's feelings, causing her to become teary-eyed and voiced fear of potential retaliation. 2. Observation on 10/23/14 at 10:30 a.m. in Resident #11's room revealed four (4) female Certified Nursing Assistants (CNA's). The resident was standing up beside his bed. The resident was confused and disoriented. Staff F was adjusting the bed linens. Staff H was standing next to the resident. Staff I was on the opposite side of the resident's bed; Staff J was at the foot of the bed. Staff F turned and stated, "Come on in and put your gloves on. You can help us too. He's a fighter." The other CNA's laughed as they all stood in front of the resident. Staff F and H then assisted the resident into bed. In an interview on 10/23/14 at 10:45 a.m. with Staff J, she said she is familiar with Resident #11. She said the resident hates women and will grab at their "private parts." She stated, "He will kick and punch at you. He does not always require (4 ) CNA's to take care of him, but, sometimes he does. Two will hold his arms down while the other two change him. He does not like women. They used to have male CNA's who spoke some Spanish who would be able to calm him down. They don't have them anymore. I have told my nurse." Staff J failed to acknowledge using (4) CNA's may cause Resident #11's stress and may escalate his behavior. In an interview with Staff I on 10/23/14 at 12:53 p.m., she said Resident #11 always fights and with women he always tries to grab "your (breasts), your private parts, he fights, kicks us, that is why we needed two to hold him by his arms and the other two changes the brief." She said she has been a CNA since 2000 and she knows that "you ' re supposed to only use two people but for this resident, sometimes they need to use 4". She stated they used to go over to the other unit and get the men who speak Spanish to help with Resident #11, who also speaks Spanish, which is what calms Resident #11 down. She stated, "But, they don ' don't really have any Spanish speaking men anymore to help". Staff I failed to acknowledge using (4) CNA's may cause Resident #11 stress and may escalate his behavior. In an interview on 10/23/14 at 1:13 p.m., Staff H said she is usually able to take care of Resident #11 by herself without any problems. A staff member from Hospice informed her Resident #11 works better with men. Staff H said Resident #11 had wet the bed and she went to get sheets. Resident #11 hit her, when they came down to his room he "turned into a wild man, when he swings he tries to grab your private areas. He doesn't require (4) people all the time, it's just when he gets bad...We have told our nurses it takes (4) people at times, then we just get the job done. We gotta move on to our next resident, do you know what I mean? We just know we can't leave them in their poop or pee cuz they will have skin breakdown. He does better with men. He is a fighter. Everyone knows he is". Record review on 10/23/14 documented Resident #11 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent MDS assessment with reference date of 10/8/14 documented the resident with a BIMS of "0" (resident unable to perform the test). The assessment documented the resident "needs or wants an interpreter" and his preferred language is "Spanish". The assessment documented Resident #11 with signs of [MEDICAL CONDITION] and inattention. Resident #11 was assessed to have physical behavioral symptoms toward others 4-6 days a week and verbal behavioral symptoms 1-3 days a week which interfere with resident care and social activities. Rejection of care occurred daily. His behavior has gotten worse. Review of the care plan dated 5/3/12 documented Resident #11, "Exhibits alteration in mood/behavior: combative with care, resistive to care, and sexually inappropriate with female staff 1:1 related to (r/t) increased combative behavior and falls frequently". Interventions include: "If resident refuses/rejects care/interventions, assure safety and leave immediate area. Reapproach in 5-10 minutes or provide alternate caregiver. Document response. Avoid confrontation when agitated ...Refer to psych services as needed with exacerbation or inability to effectively redirect behaviors". In an interview on 10/23/14 at 1:26 p.m. with the Unit Supervisor, she said she is aware the resident can be combative but was never aware that it would take (4) CNA's to try and provide care. She stated the resident does do better with men, but they don't always have men to take care of him. He has recently been put on 1:1 staffing due to increased fall risks. Facility staff are physically restraining Resident #11 in order to perform care. The facility failed to accommodate Resident #11 by not providing alternate (male, Spanish speaking) caregivers in an attempt to de-escalate the resident's anxiety and prevent combative behaviors. This failure contributes to the resident's increased stress and anxiety while staff are providing care which leads to increased physical aggression and combativeness by the resident which can result in harm or injury to the resident and/or staff. .

Based on interview, observation and record and policy and procedure review the facility failed to ensure 1 (Resident #1) of 3 residents reviewed received the care and services to meet the needs for bowel care. The facility had a systemic problem with incomplete and inaccurate documentation of bowel movements (BM) and on several occasions failed to provide ordered bowel care. Resident #1 was hospitalized found impacted with stool. The findings included: 1. Review of the physician orders [REDACTED]. a). Milk of Magnesia (MOM) 30 milliliters by mouth every day as needed for constipation. b). [MEDICATION NAME] 10 milligram suppository, insert one rectally after 12 hours if MOM ineffective. c). Fleet Enema insert one rectally if [MEDICATION NAME] suppository ineffective. Review of the Medication Administration Records found no documentation of the bowel protocol being used at any time during June, July, or August 2014. 2. Resident #1's BM report showed from 6/1/14 through 8/14/14, was reviewed. Documentation was incomplete and inconsistent; many days had BM documentation on only 1 or 2 of the 3 shifts each day. There was no documentation of BM consistency (that is hard, soft, or diarrhea) during months reviewed. There was no BM documentation on any shift on 6/8/14. There was no BM documentation from 6/7/14 at 6:40 a.m. through 6/10/14 at 2:59 p.m. There was no documentation the bowel protocol being started on the morning of 6/10/14. This would have been 3 full days (using the facility's 24-hour clock system of tracking BMs). Resident #1 had one "small" BM documented on 6/10/14 at 7:30 p.m. This was a total of 5 days without a significant BM. The facility had no documentation of starting the physician ordered bowel protocol after 3 days without a bowel movement for Resident #1. BM record of 7/16/14 through 7/24/14 showed a medium BM was documented on 7/16/14 at 12:45 p.m. There was no documentation of any BMs from 7/16/14 at 12:45 p.m. through 7/21/14 at 5:51 p.m. The bowel protocol should have started after 3 days without a BM which was 7/20/14 at approximately 12:45 p.m. (per the 24-hour clock). A "small" bowel movement was documented on 7/21/14 at 7:30 p.m. There was no documentation of a BM from 7/22/14 through 7/25/14 at 2:15 p.m. The bowel protocol should have started 7/24/14 at approximately 7:30 p.m. There was no documentation of a BM until a small BM on 7/25/14 at 7:30 p.m. Only one "small" BM was documented from 7/16/14 at 12:45 p.m. through 7/25/14 at 7:30 p.m. This is a total of 8 consecutive days with only one "small" BM. Three times during the months of June and July (6/1/14 through 7/25/14) the bowel protocol was not started as ordered. The BM records reflect regular bowel activity 8/1/14 through 8/14/14. Nursing note dated 8/14/14 at 3:30 p.m., documented vital signs as blood pressure 74/47 (low), pulse 78, respirations 26 (rapid). Resident's skin was cool and clammy. Documentation made of call to the physician. Three episodes of gold-brownish emesis were documented. No further vital signs documented. When the nurse received the telephone call back from the physician at 4:40 p.m., they received an order to send the resident to the emergency room for evaluation. At that time the resident was a "full code" (wanted all life saving measures). Sarasota County Fire Department documented their first assessment at 4:53 p.m. 3. Interviews were conducted on 9/4/14 with 3 certified nursing assistants (CNAs) who all said a small BM is about the size of a finger. During an interview 9/29/14 at 11:00 a.m., the Director of Nursing (DON) and Assistant Director of Nursing (ADON) said CNA's chart through a headset which records the CNA's work during their shift. Each CNA has their own headset which is programmed to record their voice commands. The CNAs are able to document a resident BM at the time it occurs. The DON stated, "Documentation follows a 24-hour clock to track bowel movements." The system is called Accu Nurse by American Health Technologies... The system can track if an aide does not document a BM during the shift. The aide has the ability to document a small, medium, or large BM, or none if none occurred during the shift. The aide can also document the consistency of the bowel movement... The system sends an alert to the nurse when the resident has not had a bowel movement in 3 days (using the 24-hour clock)." The nurse then starts the bowel protocol. The nurses cannot override the alert. The DON stated, "I am not sure if a small bowel movement would clear the alert, I will have to check with the company rep." During an interview 9/29/14 at 11:30 p.m., the DON stated "the system of documenting BMs was set up to count a small BM as a BM and it does restart the 24 hour clock. I talked to the rep, and our system has now been changed to count only medium and large BMs." During an interview 9/29/14 at 12:30 p.m., the DON said she does not know how so many shifts could miss seeing the alert to start the bowel protocol on Resident #1. 4. Review of hospital records for Resident #1 after transfer from the facility on 8/14/14, revealed the following: Nursing Home to Hospital Transfer Form signed 8/14/14 at 4:40 p.m., noting to the hospital emergency room with decreased blood pressure, decreased oxygen, and increased respirations. Physician Note 8/14/14 at 6:36 p.m., described patient had presented with [MEDICAL CONDITION] but "course duration of symptoms is resolved ... " Shortly thereafter she was admitted as the signs and symptoms returned. Physician Consultation 8/15/14 service time 1:48 a.m., included physical examination describing "Abdomen: Benign. Distended. Bowel sounds are absent." Assessment noted "The patient with what appears to be acute [MEDICAL CONDITION], most likely related to [MEDICAL CONDITION], aspiration, absent bowel sounds, bowel distention. She has acute oliguric (low urine output) [MEDICAL CONDITION] with lactic acidosis, at this [MEDICAL CONDITIONS], possible ischemic bowel, all reasons for re-constellation of signs and symptoms." Nursing note 8/15/14 at 4:30 a.m., documented transfer to intensive care unit (ICU). Nursing assessments & treatments 8/15/14 at 5:15 a.m. included: "Abdomen description - distended, rounded; abdomen palpitation - firm; emesis description - coffee ground (suggestive of [MEDICAL CONDITION])." It was noted at 8:00 a.m. "coffee ground aspirated from oral suction." Nursing Note 8/15/14 service time 8:00 a.m. documented "Enema performed per order, estimated 500g (a little over 1 pound) of brown stool output. P(atien)t tolerated. Physician Consultation 8/15/14 service time 10:51 a.m. included history of present illness included: She has developed worsening of respiratory distress earlier this morning, had one episode of emesis (vomiting), totally aspirated and was brought to the intensive care unit where she has been intubated ... " Physician Consultation 8/15/14 included: "KUB (an abdominal x-ray) showed that the N(asal) G(astric) tube is in the region of distal esophagus and the bowel was distended." The assessment included: " (patient) seen on 8/15/14 with multiple issues including most likely a stool impaction which was disimpacted ... " Treatment 8/15/14 at 5:11 p.m. noted tap water enema given with results of a large amount of brown stool. The Discharge Summary noted a [DIAGNOSES REDACTED]. While on the ventilator she had asystole (heart stopped). About 6 in the afternoon she passed away in the ICU. .

Based upon resident observation, record review and interview the facility failed to assess residents for the appropriate supervised use of a stand-up lift, failed to develop and implement an individualized care plan for use of the stand-up lift and failed to validate direct care staffs competency in using the stand-up lift. The facility failed to reevaluate the appropriateness of a stand-up lift for Resident #1. The use of 1 CNA for transferring Resident #1 with the stand-up lift and lack of demonstrated competency resulted in the resident sustaining a cut to her lip, a bruise to her back and a femur fracture requiring surgical intervention. The facility's noncompliance created a situation causing actual harm to 1 (Resident #1) of the 10 residents' records reviewed and potentially impacting 9 (Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 9 residents records reviewed who are transferred with a Stand-up Lift and other residents being transferred with a Hoyer Lift. The Immediate Jeopardy beginning on 07/12/201 was identified on 07/29/2013, due to the facility not identifying system failures that contributed to Resident #1's injury which occurred on 7/12/13. The Immediate Jeopardy was removed on 07/30/2013, based upon the implementation of corrective action. The findings include: 1. Record review for Resident #1 documents admission to the facility on [DATE]. History and physical, dated 12/22/11, documents Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. Observations of Resident #1 on 7/29/13, 7/30/13 and 7/31/13 during the day reveals she is in a reclining chair most of the day with a splint on her fractured right leg. Her husband is with her most of the afternoon into the evening. The resident was asked on 7/31/13 at 2:30 p.m. how she was doing and she said okay. Resident #1's hands were observed to be closed, confirming the resident's contractures in both hands. Review of the activity of daily living (ADL) monthly coding summary documented by the direct care staff documents the residents ability to transfer varied in the month of July from total dependence with 2 staff to total dependence with 1 staff. The staff continued to document the use of 1 staff to transfer (8 times from July 1- July 11) the resident after being instructed during inservices on 4/1/2013 and 4/3/2013 to use 2 people to transfer with lifts during an inservice in April. Review of the Fall Risk assessment dated [DATE], 9/22/12, 12/24/12 and 3/26/13 documents the resident to be full weight bearing and requires maximum assist with transfers. The resident is noted to have mild/moderate cognitive impairment. Review of Resident #1's care plan revised on 6/20/13 related to falls documents an intervention to include "Assist with transfers as needed." The care plan related to personal care and activities of daily living include an intervention to use a mechanical lift "as needed." The care plan does not specify what type of lift to use, how many people to assist or what the term "as needed" means. Review of the most recent discharge summary from physical therapy for Resident #1, dated 1/24/12, documents at that time the resident required maximum assist for transfers, had poor sitting balance, and standing at parallel bars required a max assist for 15-50 seconds. The comments document the resident was not cooperative with standing activities. Cognitively, resident is unable to understand the rationale for therapeutic intervention. The therapy notes do not reflect the use of a stand-up lift by direct care staff. Resident #1's lower extremity strength was 4/5 upon discharge. The staff were using a stand-up lift during dates of therapy service from 12/28/11-1/24/12. The therapist does not document the use of the stand-up lift by the staff for this resident. Review of the Occupational Therapy (OT) evaluation, dated 1/28/13 - 2/27/13, documents the resident is a moderate assist with self feeding, moderate assist with hygiene and grooming, maximum assist with bathing, moderate assist with toileting and moderate assist with upper body dressing. Review of the OT discharge summary, dated 2/6/13, documents the resident needed minimum care giver assist with hygiene and grooming and upper body dressing, set up only for self feeding, minimum assist with toileting and minimum assist with functional mobility during activities of daily living. The resident was noted to have a right hand splint in place. Review of the Minimum Data Set (MDS) Section G functional status, dated 3/14/13, on the quarterly MDS assessment documents Resident #1 requires extensive assist with one or 2 staff for activities of daily living. This would indicate a decline in upper extremity functional ability since discharge from therapy. Review of the MDS Section G functional status, dated 6/12/13, documents the resident requires extensive assist with one or 2 staff for activities of daily living. Nursing made a referral to therapy for reduced upper extremity functioning, contractures to both hands and tone in neck with wheelchair positioning on 6/19/13. The most recent OT evaluation for Resident #1, dated 6/21/13, documents the resident to have flexion contractures, fingers are fixed in a closed position, in both hands, right greater than left. During an interview on 7/30/13 at 10:34 a.m., with the therapist (B) who completed the evaluation, he said the resident cannot open up her hands. He said she would not be able to grab on and hold the handles of the stand-up lift and he did not feel she would be safe with the stand-up lift. The evaluation documents the resident required total dependence in feeding and was unable to hold regular utensils and feed self. The evaluation continues to document the resident was having difficulty holding up her head, therapy was applying a cervical collar to assist. The discharge summary, dated 7/12/13, documents Resident #1 to be total dependence in self- feeding, severe contractures in both hands unable to hold regular utensils and flexion contractures in both hands right greater than left. During an interview on 7/29/13 at 2:54 p.m., Staff (D), who is familiar with Resident #1 and has transferred her with the stand-up lift. She said the resident has been a stand-up lift transfer for several months. She said as long as you would tell her what you were doing she would hold on and stand-up. Staff D would ask the nurse how she transfers. The resident used to be able to stand and pivot and transfer with 2 people. She started declining and could no longer stand. When asked if she would be comfortable with just one person using the stand-up lift on Resident #1, Staff D said no she would not. During a second interview on 7/30/13 at 11:00 a.m. Staff D said the resident was not able to sit up on the side of the bed without assistance. During an interview on 7/29/13 at 3:08 p.m., CNA E, who took care of Resident #1 on 7/8/13 and 7/11/13, stated we have been taught to always use 2 people when using a lift. She said the resident could only hold the lift with one hand. She said her right hand was weak. Her other hand is very strong. CNA E said the resident could stand-up with the lift. She was able to follow directions. CNA E said she would never transfer the resident with the lift by herself. During an interview on 7/30/13 at 10:36 a.m., Staff F, who is familiar with Resident #1 stated the resident was not able to sit on the edge of the bed independently. "I assisted with her a couple of times for stand-up lift transfers and I would support her at the back." She said the therapy department will determine what type of a lift to use with the resident. If I do not feel the resident is safe for a stand-up lift then I would talk to therapy about it. She said the day Resident #1 fell she was called into the room. She said the resident was on her knees on the lift and the sling was under her arms. She was not holding onto the lift with her hands. During an interview on 7/29/13 around 5:00 p.m. and other times during the survey, Resident #1's husband said when he was at the facility he would assist the aide with using the standing lift. He said he would assist by holding the resident up so she would not fall back onto the bed. He said most of the time there was just one aide assisting his wife with the stand-up lift. He said frequently she would tell the aide she was about to fall. He said his wife did not look steady on her feet when using the lift. He said he feels like the staff need education in that he has observed inconsistencies in the care of his wife including use of the stand-up lift. He said the facility has used the stand-up lift on his wife since admission. He said there is new staff all of the time. Review of a nursing note, dated 7/12/13 at 11:15 a.m., documents nurse called to Room 504 W by CNA A. Upon entering room nurse observed patient sitting on floor with legs underneath bent. Sling was around her upper back. Nurse observed for injuries. Noted lip bleeding, lower lip, and bruise on right mid back. Patient stated was not in pain, resident was transferred from floor to wheelchair (w/c) using maximum assist times (x) 4 people. Patient noted weak, nurse left room, once Patient was up in w/c to get cleaned up and dressed for the day. 2 CNA's left room. Will monitor. There is no documentation of any additional assessment by the nurse. Review of nursing note, dated 7/12/13 at 11:30 a.m., documents nurse called to where patient was sitting in w/c at nurses station. Director of Nursing (DON) was with patient. Patient observed to be not as responsive with a different affect. Not speaking much as usual. Patient noted with altered mental status. Husband notified of change in status and also of what was observed in room. Nursing note dated 7/12/13 at 11:40 a.m. documents EMS arrived, patient transferred onto stretcher via 2 person assist. Review of the hospital record documents Resident #1 was diagnosed as having a right supracondylar femur fracture above her right total knee arthroplasty. Medscape reference, Drugs, Disease & Procedures documents "Supracondylar femur fractures usually occur as a result of low-energy trauma in osteoporotic bone in elderly persons. Elderly patients usually have a history of a fall." The physician note continues with the fracture is indeed displaced and will require surgical intervention. The resident was observed to have some mild swelling around her right knee. During an interview on 7/29/13 around 5:00 p.m., Resident #1's husband said the resident was on a medication for Osteoporosis before she came into the facility but he is not sure if she takes it now. He said after the injury the facility completed a bone density test that shows his wife to have Osteoporosis. 2. Resident #3 was readmitted to the facility on [DATE]. She is a [AGE] year old resident who recently began kidney dialysis and has a history to include Diabetes and multiple strokes with left sided weakness. The occupational therapy (OT) notes dated 6/5/13, document Resident #3 is a maximum assist with a Hoyer lift, a non-stand-up lift, for sitting on the edge of the bed. The Occupational therapist no longer works here and was not available for an interview. Physical therapy (PT) evaluation dated 5/30/13, documents the reason for the referral from nursing is that patient exhibits new onset of decrease in strength, decrease in functional mobility, decrease in transfers, reduced ability to safely ambulate, reduced balance, increased need for assistance from others, reduced balance. The discharge summary documents the resident is totally dependent on staff for transfers. Upon discharge the therapist documents no progress was made. During an interview on 7/30/13 at 11:38 a.m., Physical Therapist (Staff C) stated upon discharge from therapy on 6/11/13 the resident was maximum assist of 2 person with transfers. He said Resident #3 could not support her weight with her legs and after review of the occupational therapy evaluation he said she was unable to use her left hand due to a previous stroke. Review of the Summary of Physical Therapy skill documents, not dated, for Patient (Pt) and Caregiver training: Instructed patient and primary caregiver in positioning maneuvers, safe transfer techniques, safety precaution and positioning/pressure relieving techniques in order to increase safety and decrease need for assistance with variable carry over demonstrated by caregivers, facilitating the need for further instruction and analysis of caregiver implementation and patient response to instructions/techniques. During an interview on 7/31/13 at 5:10 p.m., Physical Therapist (Staff C) said he worked with the CNA staff on manual transfers with a maximum assist of 2. He said after the residents discharge it is up to nursing to decide if they need to use the lift. Review of the most recent Minimum Data Set (MDS) assessment for Resident #3, dated 6/25/13, 30 day assessment documents the resident is a 3/3 for transfers, extensive assist, with 2 people. Review of the nursing admission assessment, dated 5/30/13, documents the resident to score a 14 on the fall risk screen, moderate risk for falls. The risks documented include severe cognitive status, maximum assist with transfer ability, non-weight bearing. Review of the Activities of Daily Living (ADL) Monthly Coding Summary for July 1 through 29, 2013, documents the staff transferred the resident with 1 staff 16 transfers during the month. Review of the most recent care plan revised on 6/24/13 documents Resident #3 to have a history of Cerebrovascular accident (CVA / stoke) with left hemiparesis weakness. Interventions include mechanical lift as needed. The resident has a care plan in place related to falls to include "use mechanical lift as needed". The care plan does not specify what type of lift is to be used or how many people to assist. Resident #3 cannot bear weight, has a history of multiple strokes, has left sided weakness and is unable to use her left hand. The occupational therapist documented the use of a Hoyer, non-stand-up lift, baseline dated 5/30/13, is maximum times (x) 2. On June 5, 2013, previous is maximum times 2 with Hoyer Lift for sitting on the edge of the bed. Upon discharge on 6/11/13, the goal was not met for sitting on the edge of the bed with the assistance of 1 caregiver. There is no additional documentation regarding the use of the Hoyer Lift. Resident #3 was observed in the hallway in her wheelchair on 7/20/13 in the late afternoon. She declined an interview. She had blue booties, heel protectors, on both feet. 3. Resident #2 is an alert and oriented resident with a Neuromuscular disease affecting the lower extremities. During an interview on 7/29/13 at 1:32 p.m., Resident #2 when asked if the aides use a lift to transfer him he said he is able to transfer to his electric wheelchair independently with a sliding board, but he requires the stand-up lift for toileting. He said on the middle, the 3:00 p.m. to 11:00 p.m., shift there is not always enough people to use 2 people to transfer him using the lift. He said he has never been injured while using the stand-up lift and has good upper body strength. Review of Section G Functional status on the 60 day assessment dated [DATE], documents Resident #2 is a two person extensive assist with transfers. Review of the fall risk assessment dated [DATE] documents the resident is a maximum assist for transfers and is non-weight bearing. Review of the current care plan dated 7/3/12 documents the resident is at risk for falls. Interventions include: Assist with all transfers on a daily basis as needed, slide board used for transfers in and out of bed. Lift used for transferring to and from toilet. The care plan does not specify what type of lift or how many people to assist. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1 - July 31, 2013, documents the staff used a one person assist for transfers 16 times. 4. Review of the significant change assessment Section G - functional status dated 7/17/13, documents Resident #4 to be a two person extensive assist with transfers. Review of the fall risk assessment, dated 7/23/13, documents the resident is partial weight bearing and maximum assist with transfers. Review of the current care plan related to falls documents the resident requires the use of a Hoyer lift with assist of 2 for transfers then switched to a stand-up lift with assist of 2 person for transfers at some unknown date. Review of the Activities of Daily Living (ADL) Monthly Coding Summary for from July 1- July 31, 2013 documents 1 staff was used to transfer the resident 11 times. There is no documentation to support the change from a Hoyer Lift to a Standing Lift. 5. Review of the quarterly assessment, Section G - Functional status for Resident #5 dated 7/3/13, documents the resident is a two person extensive assist for transfers. Review of the residents fall risk assessment dated [DATE] documents the resident to be partial weight bearing with maximum assist and general health declining. Review of the current care plan related to falls due to left sided weakness, impaired cognition and poor safety awareness. The documented Approaches included mechanical lift with assist of 2 for transfers, later updated to specify the stand-up lift, date unknown. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1 - July 31, 2013, documents 1 staff transferred Resident #5 for 9 transfers. 6. Review of the quarterly assessment, Section G - Functional status for Resident #6, dated 7/15/13, documents the resident to be a two person extensive assist for transfers. Review of the fall risk assessment dated [DATE] documents the resident to be partial weight bearing with maximum assist for transfers. The residents general health is documented as Terminal/Failure to Thrive. Review of the current care plan dated 7/22/13, documents the resident at risk of falls related to impaired mobility, history of falls and poor safety awareness. Interventions include mechanical lift with assist of 2 for transfers, later updated to Sara (stand-up) lift with assist of 2 for transfers. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1 - July 31, 2013 documents 1 staff assisted with 12 transfers. 7. Review of the significant change assessment, Section G - Functional status for Resident #7 dated 6/20/13 documents the resident to be a two person extensive assist for transfers. Review of the fall risk assessment dated [DATE], documents the resident is full weight bearing with maximum assist for transfers. Review of the current care plan, dated 6/20/13, related to falls includes use of a mechanical lift with assist of 2 for transfer then changed to a stand-up lift with assist of 2. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1- July 31, 2013 documents 1 staff assisted with 38 transfers. 8. Review of the admission assessment, Section G - Functional status for Resident #8 documents the resident to be a two person extensive assist for transfers. Review of the fall risk assessment, dated 5/3/13, documents the resident to be maximum assist with transfers and partial weight bearing. Review of the current care plan, dated 5/15/13, for falls includes mechanical lift with assist of 2 for transfers later updated to use of the stand-up lift with assist of 2. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1 - July 31, 2013 documents only 1 staff assisted with 45 transfers. 9. Review of the significant change assessment, Section G - Functional status for Resident #9, dated 6/19/13, documents the resident to be an extensive assist with two person transfer. Review of fall risk assessment dated [DATE], documents the resident to be full weight bearing and maximum assist for transfers. Review of the current care plan, dated 6/30/13, related to to to falls includes intervention to assist with transfers as needed. The care plan was updated after surveyor intervention on 7/29/13 to stand-up lift with two person assist for all transfers. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1- July 31, 2013 documents 1 staff assisted the resident with 22 transfers. 10. Review of the significant change assessment Section G - Functional status for Resident #10 dated 6/10/13, documents the resident to need extensive assistance by two people for transfers. Review of the fall risk assessment dated [DATE] documents the resident to be full weight bearing requiring maximum assist for transfers. Review of the Activities of Daily Living (ADL) Monthly Coding Summary from July 1 - July 31,2013, documents 1 staff assisted the resident with 18 transfers. 11. Review of general manufacturer's instructions for use of the stand-up lift provided by the facility are as follows: - Professional assessment should be carried out before lifting patients who are non-weight bearing. This also applies to patients who have limited shoulder movement or cannot hold on with one or both hands. These instructions also direct two staff assist with the lift for those patients who have suffered stroke or who can only hold with one hand, or patients who cannot hold on at all. The administrator indicated the facility uses Invacare mechanical lifts. There is no policy and procedure or manufacturers guidelines in the facility based upon Invacare lifts. This was confirmed by the administrator on 7/31/13 at 12:01 p.m. Review of the Invacare product website under the topic patient lift basics documented the following: Things to Consider -Patient must have some upper body strength & head and neck control -Patients must be able to bend at hip, knee and ankle Review of current inservices related to lifts include the following: April 1, 2013 and April 3, 2013. The program content was focused on non-stand-up lifts and the following topics covered. -Mechanical lifts -Be careful with limbs during transfer - The Hoyer lifts with handout - Residents may need the lift (s) -If there is an order for [REDACTED]. - Take care in transferring your resident and caution so there are no skin tears -2 people to transfer with lifts June 21, 2013- Program content to include - Care with using Hoyer lifts (non-stand-up lifts) During an interview on 7/29/13 at 12:15 p.m., the physical therapist (PT) (C) stated the therapy staff will complete an evaluation to determine if a resident is appropriate for using a lift. He said for those residents who are not on therapy caseload, if a resident is declining and the staff feel they need assistance with transfers, nursing can do a referral to therapy then an evaluation will be completed to determine if a lift is necessary or if continued therapy will help staff with transfers. During an interview on 7/31/13 at 5:10 p.m., The physical therapist (C) sated therapy does not involve themselves with nursing on using the lifts. During an interview on 7/29/13 in the afternoon, the Director of Rehabilitation stated the therapy department does not get involved with the nursing staff in recommending lifts. She said nursing should be the ones to determine what lift would be appropriate for the resident. The system failures include: - The facility has no process in place for assessing the appropriate use of stand-up lifts for Residents who are difficult transfers. - The facility has no written criteria for use of the stand-up lift. - The facility has no policy or procedure in place for the use of the stand- up lift for staff reference and education. The policy referenced by the facility is from MED-PASS Inc. 2010 and is for use of a Lifting Machine, Using a manual lift. The policy does not refer to the stand- up lift. -The facility has hired 30 plus new direct care staff in 2013 and has not completed documented competency skills checklists for required skill including the use of the stand-up lift for transfers. The facility has not completed skills competency checklists for over a year according to the Director of Nursing. After Resident #1's incident on 7/12/13, the facility allowed direct care staff to use the stand-up lifts without demonstrated competency. Upon entrance to the facility on [DATE] according to the Director of Nursing (DON) approximately 60% of the staff had demonstrated competency in using the stand-up lift. During an interview on 7/31/13 around noon the DON stated upon hire aides are paired with an experienced CNA however skills demonstrated are not recorded. - The facility has no system in place identifying who is responsible for assessing residents for use of the stand-up lift. Interviews with nursing staff identified therapy staff to be responsible for determining the type of lift to be used for a resident. Interviews with therapy staff identified nursing staff as being responsible and stated they had nothing to do with recommending lifts. - Care plans for the use of a lift are not individualized to the type of lift and assistance needed. The Immediate Jeopardy (IJ) was removed upon exit on 7/30/13 based upon the following actions by the facility: 1. On 7/29/2013, at various times of the day, observed four Certified Nurse Assistants use the stand-up lift to transfer two residents from the wheelchair into the bed. The transfer were observed to be safe. When asked how they would know what type of lift to use for the residents they said they would ask the nurse or therapy staff. 2. The use of stand-up lifts was suspended until all staff have demonstrated competency. 3. All residents who use stand-up lifts will be assessed by the therapy department to determine the appropriateness of the stand-up lift. 4. Only staff that have demonstrated competency will be allowed to use mechanical lifts. 5. The facility is developing criteria for use of the stand-up lift and a policy and procedure for use of the stand-up lift. The Immediate Jeopardy has been removed and the Scope and Severity changed from a J to a D effective 07/30/13. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.

Based on facility record review and staff interviews, the facility Administrator failed to effectively attain and maintain the highest practicable physical and medical well-being regarding the facility processes impacting 1 (Resident #1) of the 10 residents' records reviewed and potentially impacting 9 (Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 9 residents records reviewed who are transferred with a Stand-up Lift and other residents being transferred with a Hoyer Lift. The review of these records revealed the facility administration failed to identify the potential for inappropriate facility process integrity related to failure to ensure staff received training and demonstrated competency in use of the Stand-up Lift to transfer residents. The Administrator failed to ensure the facility developed and implemented policy and procedures for assessment of residents for lift type, training and competency of staff using assistive lift devices and reassessment of residents for lift assistive devices adjustment due to change in conditions. This resulted in Resident #1 experiencing pain, discomfort, and requiring transfer to a higher level of care. The facility Administrator failed to provide effective nursing staff development with demonstrated competency to ensure the health well-being of all facility residents. The Administrator failed to provide administrative oversight to ensure a complete and through investigation was conducted resulting in the systems' failure regarding facility approaches for all nursing staff having demonstrated understanding of facility expectations in competency to assess and utilize Stand-up Lift. This failure created a situation that is likely to result in serious injury, harm, impairment, or death to residents and requires immediate corrective action on the part of the facility. The Immediate Jeopardy beginning on 07/12/201 was identified on 07/29/2013. The Immediate Jeopardy was removed on 07/30/2013 based upon the implementation of corrective action. The findings include: 1. During a review of the Administrator's Position Description the section titled "Position Purpose" documented: To direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing facilities to assure that the highest degrees of quality care can be provided residents at all times. "Essential Function of Position" included: ? Responsibilities will encompass facility management, compliance management, facility staffing and retention, business management, marketing and revenue management, and community relations. ? Ensure excellent care for residnets in maintained by overseeing and monitoring patient care services delivered. ? Develop, implement, monitor and evaluate programs to promote the recruitment, retention, career development and continuing education of staff. ? Works with and supervises personnel in facility by providing opportunities for instruction guidance and counseling as necessary to ensure completed understanding of responsibilities. The facility Administrator failed to ensure the provision of services based on residents assessed needs, the use of assistive Stand-up Lift by staff demonstrating competency with safe transfers, consistent implementation of care plans related to mechanical lift devices, and the formulation of policy and procedures to ensure appropriate and safe resident mechanical lift transfers. See F323 and F498 for additional information. 2. Review of general manufacturers instructions for use of the stand-up lift provided by the facility are as follows: - Professional assessment should be carried out before lifting patients who are non-weight bearing. This also applies to patients who have limited shoulder movement or cannot hold on with one or both hands. These instructions also direct two staff assist with the lift for those patients who have suffered stroke or who can only hold with one hand, or patients who cannot hold on at all. The Administrator indicated the facility uses Invacare mechanical lifts. There is no policy and procedure or manufacturers guidelines in the facility based upon Invacare lifts. This was confirmed by the Administrator on 7/31/13 at 12:01 p.m. Review of the Invacare product website under the topic patient lift basics documented the following: Things to Consider -Patient must have some upper body strength & head and neck control -Patients must be able to bend at hip, knee and ankle Review of current inservices related to lifts include the following: April 1, 2013 and April 3, 2013. The program content was focused on non-stand-up lifts and the following topics covered. -Mechanical lifts -Be careful with limbs during transfer - The Hoyer lifts with handout - Residents may need the lift (s) -If there is an order for [REDACTED]. - Take care in transferring your resident and caution so there are no skin tears -2 people to transfer with lifts June 21, 2013- Program content to include - Care with using Hoyer lifts (non-stand-up lifts) During an interview on 7/29/13 at 12:15 p.m., the physical therapist (PT) (C) stated the therapy staff will complete an evaluation to determine if a resident is appropriate for using a lift. He said for those residents who are not on therapy caseload, if a resident is declining and the staff feel they need assistance with transfers, nursing can do a referral to therapy then an evaluation will be completed to determine if a lift is necessary or if continued therapy will help staff with transfers. During an interview on 7/31/13 at 5:10 p.m., The physical therapist (C) sated therapy does not involve themselves with nursing on using the lifts. During an interview on 7/29/13 in the afternoon, the Director of Rehabilitation stated the therapy department does not get involved with the nursing staff in recommending lifts. She said nursing should be the ones to determine what lift would be appropriate for the resident. 3. Record review for Resident #1 documents admission to the facility on [DATE]. History and physical, dated 12/22/11, documents Resident #1 is a [AGE] year old female with [DIAGNOSES REDACTED]. Observations of Resident #1 on 7/29/13, 7/30/13 and 7/31/13 during the day reveals she is in a reclining chair most of the day with a splint on her fractured right leg. Her husband is with her most of the afternoon into the evening. The resident was asked on 7/31/13 at 2:30 p.m. how she was doing and she said okay. The residents hands were observed to be closed, confirming the residents contractures in both hands. Review of the activity of daily living (ADL) monthly coding summary documented by the direct care staff documents the residents ability to transfer varied in the month of July from total dependence with 2 staff to total dependence with 1 staff. The staff continued to document the use of 1 staff to transfer (8 times from July 1- July 11) the resident after being instructed during inservices on 4/1/2013 and 4/3/2013 to use 2 people to transfer with lifts during an inservice in April. Review of the Fall Risk assessment dated [DATE], 9/22/12, 12/24/12 and 3/26/13 documents the resident to be full weight bearing and requires maximum assist with transfers. The resident is noted to have mild/moderate cognitive impairment. Review of Resident #1's care plan revised on 6/20/13 related to falls documents an intervention to include "Assist with transfers as needed." The care plan related to personal care and activities of daily living include an intervention to use a mechanical lift "as needed". The care plan does not specify what type of lift to use, how many people to assist or what the term "as needed" means. Review of the most recent discharge summary from physical therapy for Resident #1, dated 1/24/12, documents at that time the resident required maximum assist for transfers, had poor sitting balance, and standing at parallel bars required a max assist for 15-50 seconds. The comments document the resident was not cooperative with standing activities. Cognitively, resident is unable to understand the rationale for therapeutic intervention. The therapy notes do not reflect the use of a stand-up lift by direct care staff. Resident #1's lower extremity strength was 4/5 upon discharge. The staff were using a stand-up lift during dates of therapy service from 12/28/11-1/24/12. The therapist does not document the use of the stand-up lift by the staff for this resident. Review of the Occupational Therapy (OT) evaluation, dated 1/28/13 - 2/27/13, documents the resident is a moderate assist with self feeding, moderate assist with hygiene and grooming, maximum assist with bathing, moderate assist with toileting and moderate assist with upper body dressing. Review of the OT discharge summary, dated 2/6/13, documents the resident needed minimum care giver assist with hygiene and grooming and upper body dressing, set up only for self feeding, minimum assist with toileting and minimum assist with functional mobility during activities of daily living. The resident was noted to have a right hand splint in place. Review of the Section G functional status, dated 3/14/13, on the quarterly assessment documents Resident #1 requires extensive assist with one or 2 staff for activities of daily living. This would indicate a decline in upper extremity functional ability since discharge from therapy. Review of Section G functional status, dated 6/12/13, documents the resident requires extensive assist with one or 2 staff for activities of daily living. Nursing made a referral to therapy for reduced upper extremity functioning, contractures to both hands and tone in neck with wheelchair positioning on 6/19/13. The most recent OT evaluation for Resident #1, dated 6/21/13, documents the resident to have flexion contractures, fingers are fixed in a closed position, in both hands, right greater than left. During an interview on 7/30/13 at 10:34 a.m., with the therapist (B) who completed the evaluation, he said the resident cannot open up her hands. He said she would not be able to grab on and hold the handles of the stand-up lift and he did not feel she would be safe with the stand-up lift. The evaluation documents the resident required total dependence in feeding and was unable to hold regular utensils and feed self. The evaluation continues to document the resident was having difficulty holding up her head, therapy was applying a cervical collar to assist. The discharge summary, dated 7/12/13, documents Resident #1 to be total dependence in self- feeding, severe contractures in both hands unable to hold regular utensils and flexion contractures in both hands right greater than left. During an interview on 7/29/13 at 2:54 p.m., Staff (D), who is familiar with Resident #1 and has transferred her with the stand-up lift. She said the resident has been a stand-up lift transfer for several months. She said as long as you would tell her what you were doing she would hold on and stand-up. Staff D would ask the nurse how she transfers. The resident used to be able to stand and pivot and transfer with 2 people. She started declining and could no longer stand. When asked if she would be comfortable with just one person using the stand-up lift on Resident #1, Staff D said no she would not. During a second interview on 7/30/13 at 11:00 a.m. Staff D said the resident was not able to sit up on the side of the bed without assistance. During an interview on 7/29/13 at 3:08 p.m., CNA E, who took care of Resident #1 on 7/8/13 and 7/11/13, stated we have been taught to always use 2 people when using a lift. She said the resident could only hold the lift with one hand. She said her right hand was weak. Her other hand is very strong. CNA E said the resident could stand-up with the lift. She was able to follow directions. CNA E said she would never transfer the resident with the lift by herself. During an interview on 7/30/13 at 10:36 a.m., Staff F, who is familiar with Resident #1 stated the resident was not able to sit on the edge of the bed independently. I assisted with her a couple of times for stand-up lift transfers and I would support her at the back. She said the therapy department will determine what type of a lift to use with the resident. If I do not feel the resident is safe for a stand-up lift then I would talk to therapy about it. She said the day Resident #1 fell she was called into the room. She said the resident was on her knees on the lift and the sling was under her arms. She was not holding onto the lift with her hands. During an interview on 7/29/13 around 5:00 p.m. and other times during the survey, Resident #1's family said when he was at the facility he would assist the aide with using the standing lift. He said he would assist by holding the resident up so she would not fall back onto the bed. He said most of the time there was just one aide assisting his wife with the stand-up lift. He said frequently she would tell the aide she was about to fall. He said his wife did not look steady on her feet when using the lift. He said he feels like the staff need education in that he has observed inconsistencies in the care of his wife including use of the stand-up lift. He said the facility has used the stand-up lift on his wife since admission. He said there is new staff all of the time. Review of a nursing note, dated 7/12/13 at 11:15 a.m., documents nurse called to room [ROOM NUMBER] W by CNA A. Upon entering room nurse observed patient sitting on floor with legs underneath bent. Sling was around her upper back. Nurse observed for injuries. Noted lip bleeding, lower lip, and bruise on right mid back. Patient stated was not in pain, resident was transferred from floor to wheelchair (w/c) using maximum assist times (x) 4 people. Patient noted weak, nurse left room, once Patient was up in w/c to get cleaned up and dressed for the day. 2 CNAs left room. Will monitor. There is no documentation of any additional assessment by the nurse. Review of nursing note, dated 7/12/13 at 11:30 a.m., documents nurse called to where patient was sitting in w/c at nurses station. Director of Nursing (DON) was with patient. Patient observed to be not as responsive with a different affect. Not speaking much as usual. Patient noted with altered mental status. Husband notified of change in status and also of what was observed in room. Nursing note dated 7/12/13 at 11:40 a.m. documents EMS arrived, patient transferred onto stretcher via 2 person assist. Review of the hospital record documents Resident #1 was diagnosed as having a right supracondylar femur fracture above her right total knee arthroplasty. Medscape reference, Drugs, Disease & Procedures documents "Supracondylar femur fractures usually occur as a result of low-energy trauma in osteoporotic bone in elderly persons. Elderly patients usually have a history of a fall." The physician note continues with the fracture is indeed displaced and will require surgical intervention. The resident was observed to have some mild swelling around her right knee. During an interview on 7/29/13 around 5:00 p.m., Resident #1's husband said the resident was on a medication for [MEDICAL CONDITION] before she came into the facility but he is not sure if she takes it now. He said after the injury the facility completed a bone density test that shows his wife to have [MEDICAL CONDITION]. 4. During an interview on 7/31/2103, at 4:30 p.m., the Director of Nursing (DON) stated there was a training person, Training Coordinator, until last week. There is a question if the Training Coordinator was doing competency, but the DON and other administrative staff are unable to find documentation of staff training or competency performance test for CNA A or other staff prior to 7/29/2013. The DON stated she does not have in her possession at this time any competencies completed on new hires or during the last year. The DON stated right now to my knowledge, I am starting to complete competency training as of today. The DON provided a blank copy of what she plans to start completing for Certified Nursing Assistants (CNAs) and Licensed Practical Nurse (LPN) competencies. During an interview and on 7/31/2103, at 4:30 p.m., the Administrator and the DON confirmed they were unable to find documentation of staff training or competency performance test for CNA A and other staff prior to 07/29/2013 for Standing Lift utilization. 5. Documentation of staff in-service training, competency with demonstration for transferring residents with a Stand-up Lift and required competency training was requested on 7/31/2013. The facility staff was unable to produce documentation that Certified Nurse Assistant (CNA) A or other CNA staff have received the in-service education for using a Standing Lift prior to 7/29/2013. During an interview on 7/31/2103, at 4:30 p.m., the Director of Nursing (DON) stated there was a training person, Training Coordinator, until last week. There is a question if the Training Coordinator was doing competency, but the DON and other administrative staff are unable to find documentation of staff training or competency performance test for CNA A or other staff prior to 7/29/2013. The DON stated she does not have in her possession at this time any competencies completed on new hires or during the last year. The DON stated right now to my knowledge, I am starting to compete competency training as of today. The DON provided a blank copy of what she plans to start completing for CNA and Licensed Practical Nurse (LPN) competencies. During an interview and on 7/31/2103, at 4:30 p.m., the Administrator and the DON confirmed they were unable to find documentation of staff training or competency performance test for CNA A and other staff prior to 07/29/2013 for Standing Lift utilization. The Immediate Jeopardy (IJ) was removed on 7/30/13 based upon the following actions by the facility: 1. On 7/29/2013, at various times of the day, observed four Certified Nurse Assistants use the stand-up lift to transfer two residents from the wheelchair into the bed. The transfer were observed to be safe. When asked how they would know what type of lift to use for the residents they said they would ask the nurse or therapy staff. 2. The use of stand-up lifts was suspended until all staff have demonstrated competency. 3. All residents who use stand-up lifts will be assessed by the therapy department to determine the appropriateness of the stand-up lift. 4. Only staff that have demonstrated competency will be allowed to use mechanical lifts. 5. The facility is developing criteria for use of the stand-up lift and a policy and procedure for use of the stand-up lift. The Immediate Jeopardy has been removed and the Scope and Severity changed from a J to a D effective 07/30/13. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.

Based upon interview and personnel record review the facility failed to ensure direct care staff are demonstrating competency in the use of a Stand-up lift. The facilities noncompliance created a situation causing actual harm to 1 (Resident #1) of the 10 residents' records reviewed and is likely to cause serious injury, harm, impairment, or death to 9 (Residents #2, #3, #4, #5, #6, #7, #8, #9 and #10) of 9 residents records reviewed who are transferred with a Stand-up Lift and other residents being transferred with a Hoyer Lift. The Immediate Jeopardy beginning on 07/12/201 was identified on 07/29/2013. The Immediate Jeopardy was removed on 07/30/2013 based upon the implementation of corrective action. The findings include: 1. During an interview on 7/30/13 at 10:36 a.m., Staff F, who is familiar with Resident #1 stated the resident was not able to sit on the edge of the bed independently. "I assisted with her a couple of times for stand-up lift transfers and I would support her at the back." She said the day Resident #1 fell she was called into the room. She said the resident was on her knees on the lift and the sling was under her arms. She was not holding onto the lift with her hands. During an interview on 7/29/13 around 5:00 p.m. and other times during the survey, Resident #1's husband said when he was at the facility he would assist the aide with using the standing lift. He said he would assist by holding the resident up so she would not fall back onto the bed. He said most of the time there was just one aide assisting his wife with the stand-up lift. He said frequently she would tell the aide she was about to fall. He said his wife did not look steady on her feet when using the lift. He said he feels like the staff need education in that he has observed inconsistencies in the care of his wife including use of the stand-up lift. He said the facility has used the stand-up lift on his wife since admission. He said there is new staff all of the time. Review of a nursing note, dated 7/12/13 at 11:15 a.m., documents nurse called to room [ROOM NUMBER] W by CNA A. Upon entering room nurse observed patient sitting on floor with legs underneath bent. Sling was around her upper back. Nurse observed for injuries. Noted lip bleeding, lower lip, and bruise on right mid back. Patient stated was not in pain, resident was transferred from floor to wheelchair (w/c) using maximum assist times (x) 4 people. Patient noted weak, nurse left room, once Patient was up in w/c to get cleaned up and dressed for the day. 2 CNA's left room. Will monitor. There is no documentation of any additional assessment by the nurse. Review of nursing note, dated 7/12/13 at 11:30 a.m., documents nurse called to where patient was sitting in w/c at nurses station. Director of Nursing (DON) was with patient. Patient observed to be not as responsive with a different affect. Not speaking much as usual. Patient noted with altered mental status. Husband notified of change in status and also of what was observed in room. Nursing note dated 7/12/13 at 11:40 a.m. documents EMS arrived, patient transferred onto stretcher via 2 person assist. Review of the hospital record documents Resident #1 was diagnosed as having a right supracondylar femur fracture above her right total knee arthroplasty. Medscape reference, Drugs, Disease & Procedures documents "Supracondylar femur fractures usually occur as a result of low-energy trauma in osteoporotic bone in elderly persons. Elderly patients usually have a history of a fall." The physician note continues with the fracture is indeed displaced and will require surgical intervention. The resident was observed to have some mild swelling around her right knee. 2. Documentation of staff in-service training, competency with demonstration for transferring residents with a Stand-up Lift and required competency training was requested on 7/31/2013. The facility staff was unable to produce documentation that Certified Nurse Assistant (CNA) A or other CNA staff have received the in-service education for using a Standing Lift prior to 7/29/2013. Review of the personnel list on 7/31/13 documents the facility employs 80 Certified Nursing Assistants (CNA). The facility has hired 30 new direct care staff in 2013, without completing a competency skills checklist to include the use of Stand-up lift for transfers. The facility has not completed skills competency checklists for over a year according to the Director of Nursing (DON). After an incident with injury on 7/12/13, involving use of a stand-up lift with Resident #1, the facility continued to allow direct care staff to use the stand-up lift for 9 other residents. Upon entrance to the facility on [DATE] the DON stated approximately 60% of staff has demonstrated competency in using the stand-up lift which leaves approximately 48 staff remaining. The demonstrated competency of using all mechanical lifts began after the incident with Resident #1 on 7/12/13. During an interview on 7/31/13 around 12:00 p.m., the DON said upon hire aides are paired with an experienced CNA, however skills performed are not documented. 3. During an interview with the Director of Nursing (DON) on 7/31/13, around 4:30 p.m. she was asked how she monitors the following: - Adequate staff to meet the needs of Residents; - Staff is knowledgeable about the needs of the Residents and is capable of delivering the care as planned; - Staff is appropriately deployed to meet the needs of the Residents; - Orientation for new or temporary staff regarding the Resident needs and the interventions to meet those needs; - Staff is advised of changes in the care plan. The DON stated she communicates with the unit managers and observes independent, alert, and oriented residents in the dining room. She said she did have a Staff Development Coordinator who did a lot training on the floors with direct care staff and completed in-services. Currently the facility does not have a staff member designated as the staff development coordinator. She said the facility staff is trained to meet and greet new residents and the certified nursing assistants are reminded to get report from the nurse. She was not sure at what point the competency skills checklists ceased to be completed. When asked how she would know if an aid could safely use the stand-up lift she said "I ask them." During an interview with the Administrator and the DON on the morning of 8/1/13 they said they had reviewed the regulations and could did not find this requirement. According to the administrator, the facility uses Invacare mechanical lifts. There is no policy, procedure, or manufacturer ' s guidelines in the facility based upon Invacare lifts. This was confirmed by the Administrator on 7/31/13 at 12:01 p.m. Review of the Invacare product website under the topic patient lift basics states the following: Things to Consider -Patient must have some upper body strength & head and neck control -Patients must be able to bend at hip, knee and ankle Review of current in-services related to lifts includes the following: April 1, 2013 and April 3, 2013. The program content was focused on non-stand up lifts and the following topics covered. -Mechanical lifts -Be careful with limbs during transfer- The Hoyer lifts with handout - Residents may need the lift (s) -If there is an order for [REDACTED]. - Take care in transferring your resident and caution so there are no skin tears -2 people to transfer with lifts June 21, 2013- Program content to include - Care with using Hoyer lifts (non-stand up lifts) 4. During an interview on 7/31/2103, at 4:30 p.m., the Director of Nursing (DON) stated there was a training person, Training Coordinator, until last week. There is a question if the Training Coordinator was doing competency, but the DON and other administrative staff are unable to find documentation of staff training or competency performance test for CNA A or other staff prior to 7/29/2013. The DON stated she does not have in her possession at this time any competencies completed on new hires or during the last year. The DON stated right now to my knowledge, I am starting to compete competency training as of today. The DON provided a blank copy of what she plans to start completing for CNA and Licensed Practical Nurse (LPN) competencies. During an interview and on 7/31/2103, at 4:30 p.m., the Administrator and the DON confirmed they were unable to find documentation of staff training or competency performance test for CNA A and other staff prior to 07/29/2013 for Standing Lift utilization. The Immediate Jeopardy (IJ) was removed on 7/30/13 based upon the following actions by the facility: 1. On 7/29/2013, at various times of the day, observed four Certified Nurse Assistants use the stand-up lift to transfer two residents from the wheelchair into the bed. The transfer were observed to be safe. When asked how they would know what type of lift to use for the residents they said they would ask the nurse or therapy staff. 2. The use of stand-up lifts was suspended until all staff have demonstrated competency. 3. All residents who use stand-up lifts will be assessed by the therapy department to determine the appropriateness of the stand-up lift. 4. Only staff that have demonstrated competency will be allowed to use mechanical lifts. 5. The facility is developing criteria for use of the stand-up lift and a policy and procedure for use of the stand-up lift. The Immediate Jeopardy has been removed and the Scope and Severity changed from a J to a D effective 07/30/13. Although the Immediate Jeopardy was removed, ongoing noncompliance continues until all corrective actions are completed to achieve substantial compliance.