Every finding on record at Vivo Healthcare Normandy

Based on kitchen food service observations, staff interviews, and a review of facility policies and procedures, the facility failed to follow proper food safety sanitation standards and food handling practices to prevent potential injury and the potential outbreak of foodborne illness to residents by failing to serve meals using dinnerware in clean and good condition. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure that can compromise residents' well-being. This failure had the potential to affect all residents who consumed food from the facility's kitchen. The findings include: A follow-up tour of the kitchen was conducted on 12/16/2025 at 11:00 a.m. Cracked plates and plates with food debris stuck on them were observed and pulled from the tray line. (Photographic Evidence Obtained) On 12/18/2025 at 9:00 a.m., an interview was conducted with [NAME] V. She was asked who was responsible for ensuring dinnerware and utensils were clean and in good condition. She replied, The Dietary Aides. On 12/18/2025 at 9:14 a.m., an interview was conducted with Dietary Aide U. When she was asked who was responsible for ensuring dinnerware and utensils were clean and in good condition, she replied, The Dietary Aides when they are washing the dishes. An interview was conducted on 12/18/2025 at 9:27 a.m. with the Certified Dietary Manager (CDM). He confirmed that Dietary Aides were responsible for ensuring dinnerware and utensils were clean and in good condition. A review of the facility's policy and procedure titled Food Safety Requirements (reviewed/revised: 1/2025), revealed:It is the policy of this facility to procure food from sources approved or considered satisfactory by federal, state and local authorities. Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety.Policy Explanation and Compliance Guidelines: 1. Food safety practices shall be followed throughout the facility's entire food handling process. This process begins when food is received from the vendor and ends with delivery of the food to the resident. Elements of the process include the following: .e. Equipment used in the handling of food, including dishes, utensils, mixers, grinders, and other equipment that comes in contact with food. (Copy obtained) Reference: FDA Food Code 2022 at https://www.fda.gov/media/164194/download, (Accessed on 11/25/2025) Chapter 4. Equipment, Utensils, and Linens 4-6 Cleaning of Equipment and Utensils, 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, Equipment Food-Contact Surfaces and Utensils. (A) Equipment Food Contact Surfaces and Utensils shall be clean to sight and touch. Cleanability; 4-202.11 Food-Contact Surfaces. (A) Multiuse Food-contact surfaces shall be: (1) Smooth; (2) Free of breaks, open seams, cracks, chips, inclusions, pits, and similar imperfections; and (3) Free of sharp internal angles, corners, and crevices.

Based on interviews, record review, and a review of facility policies and procedures, the facility failed to ensure food served was prepared by methods that conserved nutritive value and appearance by failing to follow standardized recipes to provide appetizing and appealing food in accordance with professional standards for food service. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. The findings include: During a follow-up tour of the kitchen on 12/16/2025 at 11:00 a.m., Employee V was observed as the cook on the tray line. During an observation of the tray line at this time, pureed meal components of savory based chicken, fluffy rice, seasoned spinach, and a white roll were observed smeared on the plate with no shape or consistent form. (Photographic Evidence Obtained) On 12/18/2025 at 9:00 a.m., an interview was conducted with [NAME] V. She was asked who was responsible for preparing pureed food. She replied, The Cook. When asked what was used to show cooks how to prepare pureed foods, she replied, When I first started cooking, they told me it had to be smooth; now they say it should be thick like mashed potatoes. I look at the consistency of it. If I overpour the liquid, then I add thickener to bring it back to the consistency it should be. On 12/18/2025 at 9:14 a.m., an interview was conducted with Dietary Aide U. When she was asked who was responsible for preparing pureed food, she replied, The Cook; Diet Aides only prepare pureed dessert. When asked what was used to show Cooks how to prepare pureed foods, she replied, The recipe. On 12/18/2025 at 9:27 a.m., an interview was conducted with the Certified Dietary Manager (CDM). He confirmed that the [NAME] was responsible for preparing pureed food. When he was asked what was used to show Cooks how to prepare pureed foods, he replied, Use of the recipe. A review of the facility's policy and procedure titled Menus and Adequate Nutrition (reviewed/revised: 1/2025), revealed:The purpose of this policy is to ensure menus are developed and prepared to meet resident choices including their nutritional, religious, cultural, and ethnic needs, while using established guidelines. Policy Explanation and Compliance Guidelines: The facility will provide residents with nourishing, palatable, well-balanced diets that meet his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident and established menus based upon this guidance. (Copy obtained)

Based on observations, interviews and record review, the facility failed to update comprehensive care plans to accurately reflect residents' current status related to intravenous access (Resident #30), skin condition (Resident #60), and Life Vest (Resident #139) for three of 22 residents reviewed for care plan development, implementation and revision. The findings include:1. During an observation on 12/16/2025 at 10:15 a.m., Resident #30 was observed with a Peripherally Inserted Central Catheter (PICC) line to his right upper inner arm. The area was observed to be clean and dry with a dressing dated 12/16/2025. During an interview on 12/16/2025 at 10:15 a.m., Resident #30 stated, They just changed the dressing this morning. I think I've got until 12/24/2025 for my last dose [of intravenous antibiotics]. During an observation on 12/18/2025 at 8:00 a.m., Resident #30 was observed with a PICC line to his right upper inner arm. During an interview on 12/18/2025 at 9:30 a.m., Licensed Practical Nurse (LPN) E stated, His [Resident #30] PICC line is in his right arm. A review of Resident #30's medical record revealed that he was admitted to the facility on [DATE] with the following diagnoses: Hereditary and Idiopathic Neuropathy, Other Specified Persistent Mood Disorders, Cutaneous Abscess of Chest Wall, Elevated [NAME] Blood Cell Count, Anemia, Anxiety Disorder, Depression, Pain and Essential (Primary) Hypertension. Resident #30 was admitted with the following physician's orders: PICC/Midline: Right Arm - Change dressing q 7 Days (every seven days) and as needed. A review of Resident #30's Care Plan revealed no care plan documentation for a Peripherally Inserted Central Catheter (PICC) line. During an interview on 12/18/2025 at 1:00 p.m., Minimum Data Set (MDS) Coordinator A stated, It should have been in there; I'm not sure why I would care plan the antibiotic but not the actual PICC line. 2. During an observation on 12/16/2025 on 11:00 a.m., Resident #60 was observed with a dressing on her right heel. During an interview on 12/18/2025 at 12:49 p.m., Wound Care Nurse D stated, We did a bilateral duplex lower extremities ultrasound on 9/25/2025 on her [Resident #60). MDS Staff does the wound care plans. A review of Resident #60's record revealed that she was admitted to the facility on [DATE] with the following diagnoses: Cerebral Infarction due to Unspecified Occlusion or Stenosis of Left Posterior Cerebral Artery, Aphasia, Hemiplegia and Hemiparesis following Cerebral Infarction affecting Right Dominant Side, Unspecified Protein-Calorie Malnutrition, Atrial Fibrillation, Hypothyroidism, Gout, Dysphagia, Essential (Primary) Hypertension, Personal History of Malignant Neoplasm of Ovary, Age-related Osteoporosis, Gastrostomy Status, Depression and Gastro-Esophageal Reflux Disease. Resident #60 had orders for the following: Wound care to right heel - cleanse with wound cleanser, pat dry, apply collagen cover with bordered gauze three times weekly on Monday, Wednesday, and Friday. A review of Resident #60's Care Plan revealed no care plan addressing the arterial ulcer on her right heel. During an interview on 12/18/2025 at 1:10 p.m., Minimum Data Set (MDS) Coordinator A stated, We go over new wounds in morning meeting; that's how I am notified. I don't know how that got missed. 3. During an interview on 12/16/2025 at 2:20 p.m., Resident #139 stated he got his Life Vest in the hospital and staff helped him change the battery. He added that he had not taken the Life Vest off and had not gotten a shower since he was admitted . He said he wiped off with a washcloth. A review of Resident #139's medical record revealed that he was admitted on [DATE] with diagnoses including Pulmonary Embolism without Acute Cor Pulmonale, Chronic Systolic Congestive Heart Failure, Acute Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease. He was admitted with a Life Vest. Per a Social Services note dated 12/12/2025 at 2:45 p.m., the resident had a Brief Interview for Mental Status (BIMS) score of 14 out of 15 possible points, indicating intact cognition. A review of the hospital transfer form dated 12/10/2025 revealed that a Life Vest from [Provider] with a phone number for contact was listed. A review of the resident's care plan revealed no care plan present for the Life Vest or orders. On 12/16/2025 at 6:03 p.m., an order for a battery change once daily for the Life Vest was entered by staff into Resident #139's electronic health record. During an interview on 12/18/2025 at 12:45 p.m., MDS Coordinator A stated, Yes, it needs to be care planned. In the mornings we have clinical meetings and we go over new admissions and the list of diagnoses. Also, during their stay, as orders come in, we adjust the care plans. When Employee A was asked if he was able to identify Resident #139's Life Vest in the current care plan now, he replied, No I do not. During an interview on 12/18/2025 at 2:30 p.m., the Administrator stated, I expect everything pertinent and relevant to a resident's care plan be included in their care plan.

Based on observations, interviews, record reviews and a review of facility policies and procedures, the facility failed to ensure adequate grooming for one resident (#116) who was unable to carry out activities of daily living (ADLs) independently, out of four residents reviewed for ADLs, from a total survey sample of 39 residents. Failure to provide assistance with ADLs can result in resident discomfort and negatively impact a resident's feelings of self-worth. The findings include: A review of the medical record revealed that Resident #116 was admitted to the facility on [DATE] with diagnoses including a need for assistance with personal care, Myasthenia Gravis without (acute) exacerbation, Encephalopathy and Seizures. On 12/15/2025 at 11:10 a.m., Resident #116 was observed in bed with excessively long hair on his face. He was asked if he was able to shave himself or if the staff shaved him. He stated, The staff shaves me. He was asked when the last time was that he recalled being shaved. He replied, a couple of weeks ago. The resident had greasy hair with a lot of white/gray flakes in it. (Photographic Evidence Obtained). The resident stated he could not remember the last time the staff washed his hair. On 12/17/2025 at 12:41 p.m., Resident #116 was observed lying in bed with excessively long hair on his chin and hair on his upper lip that partially covered his lip. The hair on his head was greasy with many white/gray flakes. (Photographic Evidence Obtained) The resident was asked if he desired a shampoo and shave. He stated, Yes. A review of the resident's Annual MDS (minimum date set) assessment, dated 9/30/2025, revealed that the resident had a BIMS (brief interview for mental status) score of 10 out of 15 possible points, indicating moderate cognitive impairment. He required set-up or clean-up assistance from staff with eating, and substantial/maximal staff assistance with toileting, bed mobility, and personal hygiene. Resident #116 required total staff assistance with transfers. He received antidepressant and opioid medications. A review of the resident's active physician's orders revealed the following orders:Oxygen continuous at 3 Liters via Nasal Cannula every shift for shortness of breath (8/14/2025)Sertraline Oral Tablet 50 mg (milligrams), give 3 tablets via G-Tube (feeding tube) one time a day for depression (11/7/2025)Hydrocodone-Acetaminophen Oral Tablet 7.5-325 mg, give 1 tablet via G-Tube every 6 hours as needed for pain moderate to severe (8-10) (6/26/2025)Gabapentin Oral Tablet 100 mg tablet via G-Tube three times a day for neuropathy (6/26/2025)Topamax Oral Tablet 25 mg via G-Tube at bedtime for breakthrough seizure (6/26/2025)Regular diet, Pureed texture, Thin consistency (7/3/2025). A review of Resident #116's active care plan revealed he had care plans for the following focus areas:FOCUS: The resident has an ADL/Self-Care Performance Deficit r/t impaired balance, limited mobility, and weakness. Date Initiated: 03/05/2024FOCUS: The resident has Impaired Cognitive Function/Dementia or Impaired Thought Processes. Date Initiated: 12/15/2025 Revision on: 12/15/2025 On 12/17/2025 at 1:21 p.m., Certified Nursing Assistant (CNA) Q was observed coming out of room [ROOM NUMBER] with a bag of soiled briefs in her hand. She was asked by the surveyor which resident she had been working with. She confirmed that she had just provided incontinent care for Resident #116, and that she was finished with his care. An interview was conducted. She was asked if the facility provided in-service education for abuse/neglect prevention and reporting. She stated, Yes. She was asked to identify three types of neglect. She stated, Not feeding a resident that needs to be fed, not answering call bells, and ignoring a patient when they try to talk to you. She was asked what her room assignment was today. She replied, I have rooms 107-111. She confirmed that she had provided care throughout the shift (7am-7pm) for Resident #116. She was asked how many residents she usually had on her assignment. She stated, Anywhere from 8 to 12 depending on if there are 4 or 5 aides. She was asked if she believed there was enough staff to provide the care the residents needed. She stated, Usually yes, but there are times when I feel we should get more help, like we used to have a shower team and that really helped. She was asked how she knew what the residents' shower schedules were. She stated, We have a printed shower schedule by the nurses' desk; they update it periodically according to the residents' preference, so we must check the shower schedule and the therapy schedule every morning. She was asked how she determined what the residents' preference was for showers. She replied, I ask the resident themselves. If they can't tell me, I ask the nurse or see if the resident will allow me to do another form of shower like a bed bath and observe their reaction. If they refuse, I leave them be and go back and try again later. First, we try, then we take another CAN, and then we take the nurse who will document the refusal. She was asked how often showers were offered. She stated, Two to three times weekly. She was asked to describe what grooming consisted of. She stated, Brushing teeth, brushing hair, making sure nails aren't too long or too sharp. She was asked how often grooming should be provided. She stated, Teeth and hair every day, nail care 2-3 times weekly. She was asked how showers were documented. She explained the facility's process for documenting showers on shower sheets. She further explained that the CNA filled it out after the resident's shower or bath, then it was given to the nurse to review and sign. The nurse passed it on to the unit manager or gave it back to the CNA to pass on to the unit manager. She stated she did not know what the unit manager did with it. She was asked if she provided care to Resident #116 today. She confirmed she had provided incontinent care, assisted him with eating, and straightened up his bed. She was accompanied to Resident #116's bedside. There she confirmed that the resident's hair was greasy with white flakes. She confirmed that his facial hair was excessive and long. At that time, the resident was asked if he wanted his hair washed and a shave. He confirmed that he did. On 12/17/2025 at 2:41 p.m., an interview was conducted with Licensed Practical Nurse (LPN)/Unit Manager W. She was asked if the facility provided in-service education for abuse/neglect prevention and reporting. She stated Yes. She was asked to name three types of resident neglect. She stated, Not giving a resident a shower, not providing care and not giving medication. She was asked what the facility shower schedule was. She stated, The residents get showers three times weekly, but there are some who get showered daily per their preference. She was asked how she knew if the resident preferred a bed bath or a shower. She stated, I ask them. She was asked what other services were provided for the residents along with their showers. She stated, They also get their hair washed, if they ask; they get feet/nail care; they get their linen changed. She was asked what her role was regarding the shower sheets. She stated, Primarily just to keep them organized. I place them in a binder so we can keep up with them. She was asked who was responsible for reviewing the shower sheets once they were completed by the CNAs. She stated, The floor nurse is responsible for making sure the shower is documented. She was asked to name three grooming tasks. She stated, Nailcare, facial hair, brushing teeth, and washing their face. She was asked how often grooming should be provided to the residents. She stated, Daily and as needed. LPN W was accompanied to Resident #116's bedside. Upon observation of the resident, LPN W confirmed that his hair was greasy with numerous white flakes. She confirmed that his facial hair was excessive and long. The surveyor asked the resident if he wanted his hair washed and his face shaved. The resident stated, Yes.On 12/18/2025 at 3:02 p.m., an interview was conducted with the Director of Nursing (DON). She was asked what the facility's expectation was for residents receiving showers and baths. She stated, The residents are to get showers or baths on assigned days, as requested and per their preference, day or night. She was asked what the facility's expectation was for residents receiving proper grooming. She replied, The same thing, that should be done on a daily basis, hair combed, washed when needed, facial hair removed, just like they would want to be cared for. She was asked if the facility provided the nursing staff in-service training related to ADL (activities of daily living) care and proper grooming. She stated, Yes. A review of the facility's policy and procedure titled Activities of Daily Living (ADLs) (Effective: 9/1/23, Reviewed/Revised: 1/1/25 by Clinical Services) revealed:The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure abilities in ADLs do not deteriorate unless deterioration is unavoidable. Care and services will be provided for the following activities of daily living:Bathing, dressing, grooming, and oral care.Policy Explanation and Compliance Guidelines:3. 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.

Based on observations, interviews and record review, the facility failed to provide residents treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #11) of two residents reviewed for wound care and for one (Resident #129) of one resident reviewed for positioning/mobility, from a total survey sample of 39 residents.The findings include: 1.On 12/16/2025 at 11:00 a.m., Resident #11 was observed with a dressing to his right lower leg dated 12/10/2025. (Photographic Evidence Obtained) On 12/17/2025 at 12:20 p.m., Resident #11 was observed with a dressing to his right lower leg dated 12/10/2025. (Photographic Evidence Obtained) On 12/18/2025 at 8:10 a.m., Resident #11 was observed with a dressing to his right lower leg dated 12/10/2025. (Photographic Evidence Obtained) During an interview on 12/18/2025 at 8:10 a.m., Resident #11 stated, I banged my leg in therapy. I can't remember when they changed it (the dressing). During an interview on 12/18/2025 at 12:10 p.m., Licensed Practical Nurse (LPN) E stated, The floor nurses do the skin tears (dressing changes), but I haven't had him in several days. A review of Resident #11's electronic medical record (EMR) revealed that the resident was admitted on [DATE] with the following diagnoses: Hereditary and Idiopathic Neuropathy, Unspecified Protein-Calorie Malnutrition, Sepsis, Type 2 Diabetes Mellitus, Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Muscle Wasting and Atrophy, Resistance to Multiple Antibiotics, Extended Spectrum Beta Lactamase (ESBL) Resistance and Bacteremia. Further review of the record revealed that the following change in condition documentation was noted on 12/10/2025: Skin Status Evaluation: Skin tear with the following recommendations: Skin tear addressed by wound care. The following physician's orders were noted: Skin care to right lower leg, cleanse with wound cleanser, pat dry apply xeroform and cover with border gauze three times weekly on Monday, Wednesday, Friday until resolved, with a start date of 12/11/2025. A review of the resident's December 2025 Treatment Administration Record (TAR) revealed that the dressing change was documented as having been completed on the following dates: 12/12/2025, 12/15/2025 and 12/17/2025 . During an interview on 12/18/2025 at 12:49 p.m., Registered Nurse (RN) D/Wound Care Nurse stated, There was a Change in Condition completed on 12/10/2025 regarding a skin tear with the documentation that the wound care nurse did the treatment. It just says addressed by wound care nurse. I do not follow their skin tears. I cannot explain why she did what she did. During an interview on 12/18/2025 at 1:51 p.m., the Director of Nursing (DON) stated, Dressing changes-skin tears, once the nurses identify the skin tear, they notify the wound care nurse, the family and the physician for orders. That is the procedure; there should have been an order put in right then. 2. On 12/15/2025 at 12:53 p.m., Resident #129 was observed sitting in his wheelchair watching TV. He stated he had no concerns with his care. When asked if he had limited range of motion, he replied yes, in his left hand. When asked if he wore a brace or splint on this hand, he replied that he had a brace in his drawer but did not wear it. On 12/16/2025 at 8:41 a.m., Resident #129 was observed lying in bed with covers pulled to his chest. He stated he had no concerns. A review of the resident's medical record revealed active physician's orders for: Skilled Occupational Therapy (OT) for left hand splint placement, splint to be worn daily when out of bed, off at night and hygiene care (6/2/2025). Physical Therapy (PT): Continue to evaluate and treat as recommended (10/3/2025). Skilled Maintenance PT Evaluation and Treatment for 3 times/week for 90 days for Therapeutic Exercise; Therapeutic Activities; Manual Therapy; Diathermy (10/3/2025) A review of the medical record revealed that Resident #129 was admitted to the facility on [DATE]. Primary diagnoses included: Hemiplegia and Hemiparesis following cerebral infarction affecting left non-dominant side; contracture of muscle, unspecified site; muscle wasting and atrophy, not elsewhere classified, multiple sites; and need for assistance with personal care. A review of the Quarterly minimum data set (MDS) assessment dated [DATE] revealed that Resident #129 had a Brief Interview for Mental Status (BIMS) score of 10 out of 15 possible points indicating moderate cognitive impairment. Behaviors and/or rejection of care were not exhibited. The resident had impairment on both sides of his upper and lower extremities and required set-up or clean up assistance for eating. Toilet transfers were not attempted due to his medical condition or safety concerns per documentation. A review of the Care Plan focus and goals included Activities of Daily Living (ADL)/Self-care performance deficit related to Activity Intolerance, Hemiplegia, Impaired balance, Limited Mobility, Musculoskeletal impairment, and weakness. Interventions included PT/OT evaluation and treatment as per medical doctor orders. (Copy Obtained) A review of the resident's December 2025 Medication Administration Record (MAR) revealed no documentation for the left hand splint placement order dated 6/2/2025, Skilled Occupational Therapy (OT) for left hand splint placement, splint to be worn daily when out of bed, off at night and hygiene care. (Copy Obtained) A review of a Nursing Comprehensive Assessment, dated 6/13/2024 on admission, revealed that Resident #129 was alert and cognitively intact with verbal communication. He required Therapy and Social Services with functional goals to improve functional status. A review of a Range of Motion: Functional Limitation Screen, dated 6/14/2024, revealed that Resident #129 was a new admission and a PT (physical therapy) evaluation was completed. Upper Extremity Functional Range of Motion (ROM) for wrist: Left Hand: Severe Limitation in ROM. On 12/18/2025 at 2:18 p.m., CNA K was asked how she was made aware of residents' daily care needs or any changes to them. She replied, Through morning reports from the previous CNA or resident charts. When asked whether she was aware that Resident #129 was to wear a splint, she replied, I don't normally get that section; I have the first four rooms on 100 and the first three rooms on 200. When asked if she had received training on abuse, neglect, and exploitation, she replied, Yes, at the facility three months ago. On 12/18/2025 at 2:25 p.m., CNA J was asked how she was made aware of residents' daily care needs or any changes to them. She replied, through the nurse. When asked whether she was aware that Resident #129 was to wear a splint, she replied, No, I have not worked with the resident; I normally work rooms 105-110. When asked if she had received training on abuse, neglect, and exploitation, she replied, Yes, on-line at the facility two weeks ago. On 12/18/2025 at 2:45 p.m., LPN I was accompanied to Resident #129's room. He was observed lying in bed not wearing his splint. The resident stated he was aware that he was to wear a splint during the day. When asked where his splint was, he stated it was in his drawer. When he was asked if he had been wearing the splint, LPN I responded no. When LPN I was asked if she was aware that the resident was to wear a splint, she replied No, I was on 200 and just returned from emergency leave on 12/3/2025. When asked how she was made aware of residents' daily care needs or any changes to them, she replied, Through the treatment administration record, if I see something wrong, I ask someone. She also reported that the nurse was responsible for putting on and taking off the resident's splint. When she was asked what the current treatment plan was for Resident #129's splint, she replied, I did not find an order unless I did not see it. She stated Resident #129 was not wearing the splint because his hand was opening a little and she thought he did not need it. A review of the facility's policy and procedure titled Prevention of Decline in Range of Motion (date reviewed/revised: 1/2025), revealed: Residents who enter the facility without limited range of motion will not experience a reduction in range of motion unless the resident's clinical condition demonstrated that a reduction in range of motion is unavoidable. Policy Explanation and Compliance Guidelines: .3. b. The facility will provide treatment and care in accordance with professional standards of practice. This includes, but is not limited to, . i. Appropriate services (specialized rehabilitation, restorative, functional maintenance). ii. Appropriate equipment (braces or splints). (Copy Obtained)

Based on observation, interviews and record review, the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (Resident #99) of one resident reviewed for pressure ulcer care and treatment.The findings include:During an observation on 12/18/2025 at 9:30 a.m., Registered Nurse (RN) D/Wound Care Nurse, prepared to change the ordered dressing to Resident #99's sacral pressure wound. Resident #99 positioned herself on her left side in preparation for the dressing change. Upon positioning with the sacral and gluteal area exposed, it was observed that there was a dark brown substance present, beginning at the top of the gluteal cleft and extending down to the bottom of the cleft. There was a fecal odor present. RN D cleaned the wound using wound cleanser, placed a new treatment and dressing over the sacral wound, refastened the resident's brief, and instructed her to position herself on her back. RN D did not clean the fecal matter from Resident #99's gluteal cleft prior to redressing the pressure ulcer and refastening the brief.A review of Resident #99's medical record revealed that the resident was admitted on [DATE] with the following diagnoses: Cerebral Infarction, Unspecified Fracture of the Upper End of the Right Humerus, Anemia, Hemiplegia, unspecified affecting Right Dominant Side, Unspecified Protein-Calorie Malnutrition, Muscle Wasting and Atrophy, Paralytic Gait, Other Fracture of Shaft of Right Tibia, Displaced Fracture of Shaft of Right Clavicle, Other Low Back Pain, Hereditary and Idiopathic Neuropathy, Other Specified Arthritis, Polyneuropathy, Personal History of Transient Ischemic Attack and Cerebral Infarction without Residual Deficits, Homelessness, and Depression. Further review of the record revealed the following physician's orders:Wound care: Cleanse sacrum with normal saline, pat dry. Apply Medihoney, collagen, and cover with border gauze dressing every day shift for Stage 3 PU (Pressure Ulcer) and as needed for soilage/dislodgement. During an interview on 12/18/2025 at 12:49 p.m., RN D/Wound Care Nurse, was asked if it was considered a professional standard of practice to change a sacral pressure dressing to an open wound and leave visible feces present in the gluteal cleft. RN D replied, I can't leave it open, but we should have cleaned her better. When asked to describe normal procedure if a resident was soiled when she approached them for a dressing change, RN D replied, We will let the CNAs know and then we will come back. When asked if this was an acceptable standard of practice, RN D replied, No Ma'am, we should change it if the CNAs are busy.During an interview on 12/18/2025 at 1:51 p.m., the DON stated the wound care assistant was a CNA as well and they could provide incontinent care. They don't have to wait on anyone. No ma'am. Tell me that didn't happen.

Based on interviews and record review, the facility failed to appropriately document the correct location of the Peripherally Inserted Central Catheter (PICC) line in five of 14 daily chart notes for one (Resident #30) of eight residents reviewed for required resident record components, from a total survey sample of 39 residents.The findings include:During an observation on 12/16/2025 at 10:15 a.m., Resident #30 was observed with a Peripherally Inserted Central Catheter (PICC) line to his upper inner right arm. The area was observed to be clean and dry with a dressing dated 12/16/2025.During an interview on 12/16/2025 at 10:15 a.m., Resident #30 stated, They just changed the dressing this morning. I think I've got until 12/24/2025 for my last dose [of intravenous antibiotics].During an observation on 12/18/2025 at 8:00 a.m., Resident #30 was observed with a PICC line to his right upper inner arm. During an interview on 12/18/2025 at 9:30 a.m., Licensed Practical Nurse (LPN) E stated, His [Resident #30] PICC line is in his right arm.A review of Resident #30's medical record revealed that Resident #30 was admitted to the facility on [DATE] with the following diagnoses: Hereditary and Idiopathic Neuropathy, Other Specified Persistent Mood Disorders, Cutaneous Abscess of Chest Wall, Elevated [NAME] Blood Cell Count, Anemia, Anxiety Disorder, Depression, Pain and Essential (Primary) Hypertension. Resident #30 was admitted with the following physician's orders: PICC/Midline: Right Arm - Change dressing q 7 Days (every 7 days) and as needed. A review of Resident #30's Daily Skilled Notes for 12/2/2025, 12/4/2025, 12/8/2025, 12/10/2025 and 12/11/2025, revealed that the PICC placement was in the resident's Left arm.During an interview on 12/18/2025 at 2:00 p.m., the Director of Nursing stated, I expect them (nursing staff) to document accurately.

Based on facility observations, interviews, and a review of facility policies and procedures, the facility failed to provide a safe, sanitary, and comfortable homelike environment for residents, by failing to ensure separate rooms for resident showers and equipment storage for the 32 residents residing on the 100 hallways, from a total facility census of 110 residents. This had the potential to put residents at risk for infection, compromised dignity and privacy, and physical harm. The findings include: On 12/16/2025 at 9:44 a.m., a storage sign was observed on the 100 hallways' resident shower room door. When the door was opened, mechanical lifts were observed stored in the room. (Photographic Evidence Obtained) On 12/17/2025 at 10:34 a.m., Certified Nursing Assistant (CNA) S was asked why the storage sign was posted on the 100 hallways' shower room door. She stated she did not know why it was on the door, as this was a shower room. On 12/17/2025 at 10:35 a.m., the same storage sign was posted on the 100 hallways' resident shower room door, the shower room that was being used for the 100 hallways' residents. (Photographic Evidence Obtained) On 12/17/2025 at 10:40 a.m., Licensed Practical Nurse (LPN) R was asked why the storage sign was posted on the 100 hallways' shower room door. She stated the room was a shower room and she did not know why the storage sign was on the door. On 12/18/2025 at 9:41 a.m., Housekeeper P reported she worked on the 100 hallways. When asked to explain the storage sign on the 100 hallways' shower room door, she replied, It was not told to me. On 12/18/2025 at 9:49 a.m., Environmental Services Director O reported that he completed AM and PM rounds checking for cleanliness and whether or not toilet paper and paper towels had been refilled. Showers were checked during his AM tour. He was asked to explain the storage sign on the 100 hallways' shower room door. He replied, They were putting equipment in the room; they started using it for storage. I thought residents were just using the shower on the 200 hallways. During the interview with Employee O at 9:56 a.m., Resident #77 was observed exiting the 100 hallways' shower/storage room after completing his shower. On 12/18/2025 at 10:12 a.m., Maintenance Assistant N reported he did not know the shower room was used for both showers and storage. On 12/18/2025 at 10:21 a.m., the same storage sign was observed on the 100 hallways' resident shower room door that was being used as the 100 hallways' residents' shower room. (Photographic Evidence Obtained) On 12/18/2025 at 10:12 a.m., Maintenance Director M reported he checked the shower rooms once monthly and the 100 hallways' shower room was being used for storage. He stated the storage sign had been on the door for about one year. There were too many lifts and no room to store them. That room became the storage room for the lifts. We are not supposed to provide showers to residents when the room is used as a storage. A review of the facility's policy and procedure titled Resident Rights (reviewed/revised: 1/2025), revealed:The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. The facility will also provide the resident with prompt notice (if any) of changes in any State or Federal laws relating to resident rights or facility rules during the resident's stay in the facility. Receipt of any such information must be acknowledged in writing.8. Safe environment: The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safety. (Copy Obtained)

Based on the kitchen food service observations, nourishment room observations, staff interviews, facility document review and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness with the potential to affect all of the residents in the facility when the walk-in cooler, a reach-in cooler, juice dispensing equipment and nourishment rooms were not regularly cleaned, and the floors were not maintained. Dietary staff also failed to implement the proper procedures for hand hygiene, disposable glove use and proper sanitation practices by failing to change contaminated gloves and wash their hands between glove changes during the lunch meal service. Hand hygiene, food handling and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure. The findings include: During the initial tour of the kitchen on 01/31/2022 at 10:30 AM, the walk-in cooler was observed. The storage racks were not clean. A build-up of black grime was observed on all of the shelving. (Photographic evidence obtained) Food debris and a build-up of black debris was observed on the floor in the corner of the cooler and on the fan cover. (Photographic evidence obtained) The underside of the juice dispenser was splattered with stuck-on juice. The tray had dried-on juice stuck to it. (Photographic evidence obtained) The reach-in juice cooler had dried-on juice stuck to the bottom of the cooler. (Photographic evidence obtained) The grout between the tiles in the dish room was missing in several places and some tiles were cracked/broken. (Photographic evidence obtained) During a tour of the kitchen on 02/01/2022 at 9:30 AM, the shelving, floors and fan cover of the walk-in cooler had not been cleaned. The grout in the tile was still missing. The bottom of the reach-in cooler had not been cleaned. The juice dispenser had not been cleaned. (Photographic evidence obtained) During a tour of the kitchen on 02/02/2022 at 8:55 AM, the walk-in cooler was observed. The floor and shelving had not been cleaned. The fan grate cover had not been cleaned. (Photographic evidence obtained) The bottom of the reach-in cooler had not been cleaned. The underside of the juice dispenser was splattered with stuck-on juice. During observations of the lunch meal service on 02/02/2022 from 11:55 AM to 1:00 PM, the walk-in cooler was observed. The floor and shelving had not been cleaned. The fan grate cover had not been cleaned. The bottom of the reac- in cooler had not been cleaned. The underside of the juice dispenser was splattered with stuck-on juice. Cook S was observed donning a pair of disposable gloves and then putting pans of food into the steam table using large heat resistant oven mitts that were stained and had food debris stuck on them. She then put the food scoops/ladles into the pans and prepared the tray line for service. She touched the steam table cutting board with the disposable gloves. She did not change her gloves. She started to plate the food at 12:03 PM. At 12:06 PM, the cook scraped mashed potatoes off of one plate back into the pan of mashed potatoes in the steam table with her gloved hand. At 12:19 PM, Dietary Aide R donned disposable gloves without washing her hands first. At 12:32 PM, the cook changed gloves without washing her hands in between. At 12:35 PM, Dietary Aide Q changed gloves without washing his hands while cutting up cucumbers at the prep table. At 12:55 PM, Dietary Aide Q opened a box of cucumbers, removed the tape on the box and put it into the large gray garbage can next to the prep table. He touched the side of the garbage can in an effort to get the sticky tape to release from his gloves. He did not doff the disposable gloves after touching the garbage/garbage can. He then picked up the cucumbers from the box and took them to the prep sink, rinsed them under running water and took them back to the prep table and proceeded to cut them with a chopping knife. He did not remove his contaminated gloves, wash his hands, and don new gloves prior to cutting up the cucumbers. Observations of the East Wing nutrition room on 02/02/2022 at 1:48 PM, revealed the cabinets under the sink were in disrepair, and there was food and debris on the bottom of the cabinets. The ice machine tray had plastic debris and a rubber band in it. The microwave appeared to be damaged and unclean on the top of the oven inside with open holes and stuck on food debris. (Photographic evidence obtained) Observations of the West Wing nutrition room on 02/02/2022 at 2:01 PM, revealed graham cracker crumbs in the corner of a drawer. (Photographic evidence obtained) During an interview with Certified Nursing Assistant (CNA) P at 2:08 PM on 02/02/2022, she stated she had only worked at this facility a few times, but her understanding was that the equipment in the nutrition rooms was all used for the residents. She got ice for the residents from the ice machine, and she heated food for the residents in the microwave. She was not sure who was responsible for cleaning the nourishment rooms. During an interview with CNA O at 2:15 PM on 02/02/2022, she stated she had worked at this facility for several months now. She confirmed that the equipment in the nutrition rooms was used for the residents. She thought the dietary staff were responsible for cleaning the nourishment rooms. During an interview with the Food Service Manager, the Food Services Consultant, and the Registered Dietician on 02/03/2022 at 1:40 PM, they were informed that the walk-in cooler, reach-in cooler, juice dispensing equipment, tile floors and nourishment rooms had not been cleaned and equipment maintained. The Food Service Manager was shown the inside of the walk-in cooler. She confirmed the build-up of food debris on the shelving and the floors. They were informed that the staff had not practiced appropriate glove use and hand hygiene during the lunch meal service on 02/02/2022. The Food Service Manager stated the staff had been trained to change gloves when they became contaminated, and wash their hands in between glove changes. She stated she would in-service the staff immediately and have the equipment cleaned. She would let the Administrator know about the grout missing in the tile floors of the dish room. A review of the Cleaning Schedule for the Dietary Department revealed the AM Aide #1 is to clean the juice machine, remove the white spouts and wash on Mondays. The aide is to conduct a detailed cleaning inside the juice cooler and throw outdated juice away. Make sure everything is dated on Thursdays. The AM Aide #2 is to wipe down juice cooler inside and out on Tuesdays. The cleaning schedule did not have a day and time for cleaning the walk-in cooler or nourishment rooms. (Copy obtained) A review of the Dietary Orientation Skills Checklist for new employees revealed the dietary staff received training on proper hand washing, glove usage, general kitchen sanitation, cleaning schedule and documentation, foodborne illness and prevention, cleaning equipment, refrigerator monitoring, and proper food storage. The checklist did not include cleaning of the nourishment rooms. The facility's policy and procedure entitled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices (No effective or revision dates) revealed: Food Service employees shall follow appropriate hygiene and sanitary procedures to prevent the spread of foodborne illness. Employees must wash their hands during food preparation, as often as necessary to remove soiled and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of disposable gloves does not substitute for proper handwashing. .

Based on observation, interview and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment, and provide maintenance services as necessary for residents in five (Rooms 106, 202, 402, 407 and 204) of six rooms identified with environmental concerns from a total of 62 resident rooms. The findings include: On 01/31/22 at 12:40 PM, room 106 was observed with a clogged bathroom sink that was not draining. On 01/31/22 at 11:02 AM, while touring with the Maintenance Director, three roaches were observed in room 202's bathroom sink. The Maintenance Director removed them with a paper towel. He stated pest control was on-site once a month and any time pests were sighted in the facility. He added that pest control would be contacted again. He also confirmed that the sink was clogged and stated he would fix it. On 02/01/22 at 11:24 AM, Resident #391 in room 402 stated the phone at his bedside was broken and so was the phone for the adjacent bed. He stated his beside television didn;t work either, so he watched the television designated for the adjacent bed. He stated he had to call the staff to change the channel for him. He added that he could not get out of his room due to the facility's quarantine policy, and he was lonely in the room by himself with dysfunctional equipment. On 02/01/22 at 11:33 AM, Resident #83 in room 407 stated there was no hot water in her bathroom sink. She added that it was inconvenient for her to take baths as she was in quarantine and could not go to the regular shower room. She also mentioned that staff did not assist her, and she had not had hot water in the bathroom sink since she was admitted . (Photographic Evidence Obtained) A review of Resident #83's medical record revealed she was admitted on [DATE]. The Admission Minimum Data Set (MDS) assessment, dated 01/19/22, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of a possible 15 points, indicating moderately impaired cognition. She required extensive assistance for bed mobility, transfers and toilet use. On 02/02/22 at 10:52 AM, Resident #90 in room 204 stated she had not had a call light since she had been in the facility, almost two weeks. She stated she told the staff and they stated they would come back, but no one ever came back. The resident denied having an alternative means to summon staff to her room. In an interview on 02/02/22 at 10:54 AM, Certified Nursing Assistant (CNA) G stated she worked for the facility through an Agency and had been at the facility for the last two days. She confirmed that she had worked with Resident #90 on both days and the resident did not have a call light. CNA G confirmed that the resident did not have an alternative means of summoning staff. When asked to explain the process for ensuring resident safety after providing care, CNA G stated the resident's call light should be within reach. She confirmed that she did not notify anyone that Resident #90 had no call light. She reiterated that she was employed as an Agency CNA and was not familiar with the facility's protocol. In an interview on 02/02/22 at 10:56 AM, Registered Nurse (RN) A stated she was familiar with Resident #90. She added that the resident was transferred from the short-term unit on 01/21/22. She stated the resident was able to make her needs known and was able to use the call light. She confirmed that the resident did not have a call light or an alternate means of summoning staff since 01/21/22. An interview was conducted on 02/02/22 at 11:00 AM with the Housekeeping Manager. He stated the maintenance department was responsible for making rounds to ensure all of the call lights were working, however, the facility had not had a Maintenance Director since 01/01/22. The Housekeeping Manager stated he was assisting as needed and had not had a chance to conduct the audits. On 02/02/22 at 11:05 AM, an interview was conducted with the Director of Nursing (DON). She stated the staff were supposed to ensure that the residents had a call light within reach at all times. She confirmed that Resident #90 was alert and oriented and able to use a call light. She added that residents were also assigned Guardian Angel staff that rounded weekly, but nothing had been reported about Resident #90's missing call light. When asked whether the facility conducted audits to ensure all call lights were present and working, she stated the maintenance department was expected to conduct those audits, but the facility had not had a maintenance person since 01/01/22. A review of Resident #90's medical record indicated that the resident was admitted to the facility on [DATE] with a primary diagnosis of [CONDITION(S)]. Her secondary diagnoses included [CONDITION(S)] ([CONDITION(S)]), history of [CONDITION(S)], pulmonary emboli without acute cor pulmonale, type II diabetes mellitus, long-term use of insulin, and hypertension. Her Admission MDS assessment, dated 01/20/22, revealed a BIMS score of 13, indicating intact cognition. The resident was documented as totally dependent on staff for bed mobility, transfers, and toilet use. A review of Resident #90's care plan reveaeld she was at Risk for Falls related to impaired mobility. Interventions included ensuring her call light was within reach. Another tour of the facility was conducted on 02/02/22 at 2:39 PM with the Vice President of Maintenance. He stated the maintenance requests were added to the computer software system and all staff had access to the system and could enter a maintenance request. He stated the maintenance managers were notified of the work orders as soon as they were added in the system. These notifications were received on the maintenance managers' phones and could be accessed anytime. When asked if there were any requests for room 407, he produced maintenance requests dated 07/06/21 and 01/31/22 for no hot water and no light in the bathroom. For room 402, he produced multiple maintenance requests dated 06/22/21, 06/24/21, 12/20/21, 01/27/21 and 01/29/21 for the television not working. (Copies obtained) He confirmed that the requests were not followed up on. On 02/03/22 at 10:56 AM, the bathroom sink in room 106 was still clogged. On 02/03/22 at 11:57 AM, the Administrator confirmed that the sink was clogged and there was an odor in the room. He provided a maintenance request dated 01/08/22 which read, The water in the sink takes a long time to drain and smells very bad. A review of the facility's policy titled,Resident Environmental Quality (No implementation or revision date) revealed, It is the policy of the facility to be designed, constructed, equipped, and maintained to provide a safe, functional, sanitary and comfortable environment. Policy explanation and compliance guideline: The facility must provide each resident with a nurse call system in the resident's room and toilet/bathing facilities, which relays the calls directly to a staff member or to a centralized staff work area. Establish procedure to ensure that water is available to essential area when there is a loss of normal water supply. General Guideline: 11. Preventative maintenance schedules, for the maintenance of the building and equipment, should be followed to maintain a safe environment. 12. All facility staff are responsible for reporting broken, defective or malfunctioning equipment or furnishings immediately upon identification of the issue. A review of the policy and procedure titled Call Bell Policy and Procedure revealed, Respond to request. If item is not available, or request questionable, get assistance from the charge nurse. Return to the resident with prompt reply. (Try to obtain item - Do not tell resident We don't have it.) Be sure call bell is operable and within resident's each before leaving the room. .

Based on observation, resident interview, staff interview, clinical record review and facility policy and procedure review, the facility failed to 1) Implement the comprehensive person-centered care plan for one (Resident #145) when the physician-ordered, pressure-reducing foam boots for her heels were not applied, and 2) Implement the comprehensive person-centered care plan for two (Residents #26 and #29) when oxygen flow rates were not set at the physician-ordered liters per minute. Seven residents were being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Failure to implement the care plan puts the resident at risk of not receiving appropriate interventions and could potentiate medical or physical complications and/or injury. The findings include: 1. During an interview with Resident #145 on 01/31/2022 at 2:00 PM, she was observed lying in bed with her covers on. She was lying on her right side. She stated she had a pressure ulcer on her bottom. The staff used pillows to position her. She needed help to reposition. She stated she had sores on her feet too. The resident did not have her feet elevated or any pressure-educing devices in place for her feet at the time of this interview. No pressure-educing devices were observed in her room. During a second interview with Resident #145 on 02/01/2022 at 9:30 AM, she was observed lying in bed on her back. Her feet were not elevated and no pressure-reducing devices were in place. When asked whether staff put foam boots on her feet or pillows under them, and would she allow that, she replied, I would if they wanted to. They don't put anything under my feet. No boots were observed in her room. A review of the medical record for Resident #145 revealed the face sheet, which read: admitted [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) A review of the Minimum Data Set (MDS) assessment, dated 01/05/2022, revealed the resident was assessed as being at risk for pressure ulcer development; as having one Stage 4 pressure ulcer and one unstageable pressure ulcer. Pressure-reducing devices used for bed; receiving pressure ulcer/injury care. Her Brief Interview of Mental Status (BIMS) score was 14 out of a possible 15 points, indicating intact cognition. (Copy obtained) A review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Start date 01/20/2022. A review of the current Care Plan revealed a focus area for Pressure Ulcer to sacrum, left heel and right lateral heel. Interventions included: Bilateral Prevalon boots while in bed. (Copy obtained) During an interview with Certified Nursing Assistant (CNA) K on 02/01/2022 at 10:30 AM, she stated she was not aware that Resident #145 had Prevalon boots to apply to her feet. She had not seen them in her room. She stated she looked on the Kardex for tasks she must accomplish, and for this resident, there was no task for applying the Prevalon boots or floating her heels. CNA K stated she thought maybe the nurse was supposed to do that. She was asked to open the electronic Kardex for review. A review of the electronic Kardex revealed no task to apply Prevalon boots or to float Resident #145's heels. During an interview with Licensed Practical Nurse (LPN) J on 02/01/2022 at 10:45 AM, he was asked to look at Resident #145's feet. The resident's feet were not in the Prevalon boots. The nurse stated, They are supposed to be in the boots while she is in bed. He proceeded to look for the boots. He went to the closet and took down a plastic laundry bag that was tied in a knot. He opened the bag, took out the Prevalon boots and proceeded to apply them to the resident's feet. During a third interview with Resident #145 on 02/01/2022 at 2:20 PM, she was observed with a boot on her right foot and a pillow under her left foot. She stated she was comfortable and her feet did not hurt. She stated, There is a lot the staff don't do that they are supposed to do. During an interview on 02/03/2022 at 10:00 AM with the Advanced Practice Registered Nurse (APRN) who worked for the contracted wound care provider, she stated the facility Minimum Data Set (MDS) nurse rounded with her once a week on Thursday mornings. The floor nurses performed the actual dressing changes and wound vacuum applications. She stated, I think she (Resident #145) had the wound on her heels when she came in. She reviewed her notes then stated, I saw the heel wounds on 01/06/2022 when I first saw her, and I assumed she came in with them. She read her progress notes, On 01/06/2022 when I first saw her the wound was 4 centimeters (cm) by 3 cm on the left heel. It was a deep tissue injury (DTI). She clarified the DTI was not an open wound. The standard order is to float the heels. I put it in my notes on 01/06/2022. She read her note out loud: Continue with air mattress encourage/assist in frequent repositioning/float heels. She ordered the Prevalon boots on the 01/20/2022 because the left heel had opened and was unstageable at that point and had deteriorated. She stated she could not say whether the staff were floating the resident's heels or not. She thought the wound opened on or about 01/19/2022. She clarified that unstageable meant that she could not measure and determine the depth of the wound because the wound bed could not be seen. She measured the wound circumference to be 3 cm by 1 cm. The circumference had improved but it was open at that point. She considered the left heel as having deteriorated because it was now an open wound. She confirmed that when a DTI opened it became more susceptible to infection. She stated none of the resident's wounds were infected at this point. There was stable eschar on the left heel. She did not want to debride it. (Copy obtained) A review of the Treatment Administration Record (TAR), dated January 2022, revealed: Bilateral Prevalon boots while in bed every shift for prevention. Start date 01/20/2022 - DC date - 02/01/2022. The TAR was blank on 01/21/2022 during the night shift, on 01/23/2022 during the night shift, on 01/26/2022 during the night shift, on 01/27/2022 during the night shift, and on 01/30/2022 during the day shift, indicating that the staff did not apply the Prevalon boots during those shifts. (Copy obtained) A review of the facility's policy and procedure entitled Prevention of Pressure Ulcers/Injuries, revealed: The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Preparation: Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. e. Reposition resident as indicated on the care plan. Mobility/Repositioning: 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 5. Provide support devices and assistance as needed. (Copy obtained) A review of the facility's policy and procedure entitled Process of Following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. On 02/01/2022 at 11:08 AM, Resident #26 was observed sitting up in bed in her room. Her oxygen (O2) flow rate was set at 2.5 liters per minute (LPM). The resident was asked what the O2 flow rate should be set at, and she replied that she didn't know. On 02/02/2022 at 2:16 PM, Resident #26 was observed sitting up in a wheelchair in her room. Her O2 flow rate was set at 2 LPM. On 02/02/2022 at 2:44 PM, Licensed Practical Nurse (LPN) J confirmed the order for Resident #26's O2 flow rate was 3 LPM via nasal cannula. He stated the 11 PM - 7 AM shift nursing staff was responsible for changing the O2 tubing. He also reported that the facility nurses and CNAs were responsible for monitoring for any adverse reactions or changes in the resident's condition. LPN J entered Resident #26's room at 2:51 PM. Upon entrance, he greeted the resident and checked the placement and date on the tubing and nasal cannula. He stated he observed the O2 flow rate was set at 2 LPM and confirmed that it should have been set for 3 LPM. A medical record review revealed that Resident #26 was admitted to the facility on [DATE]. Her last readmission was on 12/3/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions in the current Care Plan listed interventions which included, Administer medication as ordered and oxygen therapy per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. On 02/01/2022 at 10:40 AM, Resident #29 was observed resting in bed. She had an oxygen concentrator, and her O2 flow rate was set at 2 LPM. She was receiving O2 via nasal cannula. On 02/02/2022 at 10:17 AM, Resident #29 was observed sitting up in bed in her room. She had an oxygen concentrator and her O2 flow rate was set at 2 LPM. She was receiving O2 via a nasal cannula. On 02/02/2022 at 10:22 AM, during an interview with LPN J, he stated he was familiar with Resident #29. He confirmed that Resident #29 had orders for O2 at a flow rate of 3 LPM via nasal cannula. LPN J entered Resident #29's room at 10:25 AM. He acknowledged the presence of the O2 concentrator and nasal cannula. He confirmed that the O2 flow rate was currently set at 1.9 LPM and that the order was 3 LPM. He reported that it was the responsibility of the facility nurses and CNAs to check theresidents' O2 flow rates. A record review revealed that Resident #29 was admitted to the facility on [DATE]. Her last readmission was on 11/18/2021. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions in the current Care Plan listed interventions which included, Give oxygen as ordered by the physician.

Based on observation, staff interviews and a review of the facility's Policy and Procedure for Nail Care, the facility failed to provide nail care for one (Resident #65) of 30 sampled residents who was dependent for activities of daily living. The findings include: An observation was conducted of Resident #65 on 02/01/22 at 10:02 a.m. She was lying in her bed and the thumb nail on her left hand was curling under with all nails approximately one and half inches or longer. The left hand was kept closed and the nails were close to digging into the palm of her hand. The resident could open her right hand, but her nails were one and half inches or longer. Resident #65 was confused but could answer simple questions. She replied yes when asked if she felt her nails needed to be cut. She also replied yes when asked if staff could cut them. Observations was conducted of Resident #65 on 02/02/22 at 10:11 a.m. and on 02/03/22 at 10:08 a.m. Her nails remained the same. A medical record review was conducted on 02/01/22, which noted an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Minimum Data Set (MDS) assessment, dated 12/24/21, revealed the resident had severely impaired cognition and required extensive assistance with personal hygiene. An interview was conducted with Registered Nurse (RN) A on 02/03/22 at 11:07 a.m. She reported that the facility's CNAs provided nail care, such as cutting, unless a resident was diabetic. In that instance, a nurse provided nail care. Activities staff also provided nail care. A podiatrist came to the facility monthly to cut residents' toe nails. RN/Unit Manager C, present at the time, reported a list of residents requiring toenail care was generated and was given to the Social Worker who provided it to the podiatrist. An interview was conducted with Certified Nursing Assistant (CNA) B on 02/03/22 at 11:45 a.m. in the shower room. Resident #65 was showered and dressed, and the CNA was combing her hair. The CNA reported the resident's nails were long, and CNA B had asked RN C/Unit Manager if she could cut them. She planned to cut the resident's nails after lunch. She confirmed the thumb nail on the left hand was curling under and the nails on the left and right hands could cut into the resident's palms when she was closing her hands, which she likes to do. The nails were approximately one and half inches long. The CNA was employed through an Agency and her assignments changed daily. She reported also asking Employee C to place this resident on the list for podiatrist. An interview was conducted with RN C/Unit Manger on 02/03/22 at 12:22 p.m. He reported seeing residents nails and talking to CNA B about cutting them. He reported Resident #65 was on hospice and hospice guided her care. The undated facility Policy and Procedure for Nail Care was reviewed and revealed: Routine cleaning and inspection of nails will be provided during Activity Daily Living (ADL) care on an ongoing basis. Routine nail care to include trimming and filing will be provided on a regular basis per individual preference.

Based on observations, interviews and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for three (Residents #26, #29 and #391) of 10 residents receiving respiratory therapy from a total of 30 sampled residents. The findings include: 1. On 02/01/2022 at 11:08 AM, Resident #26 was observed sitting up in bed in her room. Her oxygen (O2) flow rate was set at 2.5 liters per minute (LPM). The resident was asked what the O2 flow rate should be set at, and she replied that she didn't know. On 02/02/2022 at 2:16 PM, Resident #26 was observed sitting up in a wheelchair in her room. Her O2 flow rate was set at 2 LPM. On 02/02/2022 at 2:44 PM, Licensed Practical Nurse (LPN) J confirmed the order for Resident #26's O2 flow rate was 3 LPM via nasal cannula. He stated the 11 PM - 7 AM shift nursing staff was responsible for changing the O2 tubing. He also reported that the facility nurses and CNAs were responsible for monitoring for any adverse reactions or changes in the resident's condition. LPN J entered Resident #26's room at 2:51 PM. Upon entrance, he greeted the resident and checked the placement and date on the tubing and nasal cannula. He stated he observed the O2 flow rate was set at 2 LPM and confirmed that it should have been set for 3 LPM. A medical record review revealed that Resident #26 was admitted to the facility on [DATE]. Her last readmission was on 12/3/2021. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/21/2021, to be checked every shift. Interventions in the current Care Plan listed interventions which included, Administer medication as ordered and oxygen therapy per physician's orders. 2. On 02/01/2022 at 10:40 AM, Resident #29 was observed resting in bed. She had an oxygen concentrator, and her O2 flow rate was set at 2 LPM. She was receiving O2 via nasal cannula. On 02/02/2022 at 10:17 AM, Resident #29 was observed sitting up in bed in her room. She had an oxygen concentrator and her O2 flow rate was set at 2 LPM. She was receiving O2 via a nasal cannula. On 02/02/2022 at 10:22 AM, during an interview with LPN J, he stated he was familiar with Resident #29. He confirmed that Resident #29 had orders for O2 at a flow rate of 3 LPM via nasal cannula. LPN J entered Resident #29's room at 10:25 AM. He acknowledged the presence of the O2 concentrator and nasal cannula. He confirmed that the O2 flow rate was currently set at 1.9 LPM and that the order was 3 LPM. He reported that it was the responsibility of the facility nurses and CNAs to check theresidents' O2 flow rates. A record review revealed that Resident #29 was admitted to the facility on [DATE]. Her last readmission was on 11/18/2021. Resident #29 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the February 2022 Physician's Order Sheets revealed an active order for oxygen (O2) via nasal cannula at 3 LPM, effective 12/9/2021. Interventions in the current Care Plan listed interventions which included, Give oxygen as ordered by the physician. 3. A record review for Resident #391, admitted [DATE] and readmitted on [DATE], revealed the resident had medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the 01/25/22 Minimum data set (MDS) assessment revealed that Resident #391 had a Brief Interview for Mental Status (BIMS) score of 13 out of a possible 15 points, indicating intact cognition. The resident was also documented as receiving oxygen. Resident #391 was observed and interviewed on 01/31/22 at 4:48 PM. He was receiving oxygen via oxygen concentrator at at flow rate of 3 liters per minute via nasal cannula. (Photographic evidence obtained) The resident denied any respiratory discomfort. Resident #391 was observed on 02/01/22 at 4:29 PM. He was observed out of bed in his wheelchair receiving oxygen via nasal cannula at a flow rate of 3.5 liters per minute. (Photographic evidence obtained) The resident denied any shortness of breath but stated he needed oxygen to help him breath. Resident #391 was observed on 02/02/22 at 1:42 PM sitting in his room on the side of his bed with his oxygen in place, at a flow rate of 3 liters per minute. A review of the February 2022 Physician's Order Sheets revealed an active order dated 01/19/22 for oxygen via nasal cannula at 4 liters per minute every shift for [CONDITION(S)] (chronic obstructive pulmonary disease). A progress note, dated 01/20/22, indicated the resident was on oxygen at 3 liters per minute via nasal cannula. A progress note, dated 01/24/22, recorded the resident's oxygen saturation was 95% with oxygen at 3 liters per minute. A progress note, dated 01/26/22, documented the resident's oxygen saturation was 93% with oxygen at 3 liters per minute to maintain oxygen saturation above 92%. A progress note, dated 01/28/22, recorded oxygen at 3 liters per minute with an oxygen saturation of 97%. There were no changes made to the February 2022 Physician's Order Sheets regarding a change of oxygen flow rate to coincide with the progress notes reviewed. A review of the Treatment Administration Records (TARs) for January and February 2022, revealed the staff was signing for the administration of oxygen at 4 liters per minute every shift. A review of the resident's care plan documented the use of oxygen therapy related to Altered Respiratory Status. Interventions included: Administer oxygen via nasal cannula as per physician's order (dated 01/13/22). The care plan had not been updated since the resident's readmission on 01/19/22. During an interview on 2/3/2022 at 10:51AM with LPN D/Unit Manager regarding the facility's policy on Oxygen Administration, the monitoring of residents receiving oxygen and the facility's policy on changing of the oxygen tubing, she stated the process began when a physician's order was received and transcribed on the TAR. The resident's oxygen saturation levels were checked daily or every shift and recorded. Oxygen tubing was changed on the 11AM - 7PM shift every Sunday, and the day shift nurses would follow-up to ensure that the tubing was changed and dated. When not in use, oxygen tubing and nebulizer tubing would be stored in plastic bags. An interview with the Director of Nursing (DON) was conducted on 02/03/22 at 11:00 AM regarding the facility's oxygen administration policy. She reported that oxygen must be ordered by a physician and the nurses signed for it each shift. She added that she had an done an in-service this same morning with her staff regarding the responsibility of the nurses on all shifts to check the rate of oxygen flow. She stated they needed to check the flow rate every shift to ensure that the resident was receiving oxygen as ordered by the physician. The facility's policy on Oxygen Administration (No effective or revision dates) revealed under the heading of Preparation: #1 Verify that there is a physician's order for the procedure. Review the physician's orders or facility protocol for oxygen administration.

Based on observation, staff interview, clinical record review, facility document review and facility policy and procedure review, the facility failed to ensure a member of the Interdisciplinary Team was designated to coordinate the hospice care and obtain a plan of care and physician's certification form from the hospice provider before hospice care was furnished to one (Resident #143) of two residents receiving hospice care, from a total of 30 residents in the sample. The findings include: Resident #143 was observed on 01/31/2022 at 1:32 PM lying in her bed. The hospice provider's Advanced Practice Registered Nurse (APRN) was in the room with her. She was calling out in pain, Too much pain, too much pain. Please take the pain away. It's too much, it's too much. During an interview with the hospice provider's APRN on 01/31/2022 at 1:45 PM, he stated he was in the facility seeing Resident #143 today for the first time. He did not know her well yet. He was aware that she was in a lot of pain and was adjusting her medications. He would see her again later in the week and the nurse would see her daily. He was not sure how long she had been a hospice recipient, but he thought it was a few days now. A review of the electronic medical record and the paper chart for Resident #143 on 02/01/2022 from 2:45 PM to 3:05 PM, revealed no certification for hospice services. A review of the face sheet for Resident #143 revealed she was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (Copy obtained) A review of the facility's care plan, dated 01/27/2022, revealed: Hospice: The resident and their family/caregivers have determined that the goal of care will be comfort care and hospice will be assisting in providing care along with facility staff. Care will be provided by [facility hospice provider]. Date Initiated: 01/27/2022. Goal: All care will be focused on the patient's comfort and will be collaborated with [facility hospice provider] through the remainder of their stay. Interventions: Hospice to provide a copy of current Plan of Care for collaboration of care. Date initiated: 01/27/2022. (Copy obtained) During an interview on 02/01/2022 at 3:10 PM with Medical Records Staff G, she stated she did not recall seeing a hospice certification or plan of care for Resident #143. She stated, It should be in her file. She confirmed that she had not scanned one into the electronic record. During an interview on 02/01/2022 at 3:13 PM with Unit Manager (UM) D, she stated she was not the facility coordinator of care for the hospice residents. She thought it was the Director of Nursing's (DON's) responsibility. She stated the Social Services Director coordinated the initial contact with the family, and the hospice provider and the Minimum Data Set (MDS) Coordinator wrote the care plan for the hospice services the facility provided. She was not aware of where the hospice certification and plan of care forms were. She did not recall seeing them. She did not know the hospice certification period for Resident #143. She did not know when it started. She asked, Monday [01/31/2022] was the first day they provided service to her, right? This surveyor stated the APRN from the hospice provider was interviewed on Monday 01/31/2022. She stated she did not have a care plan from the hospice provider. She stated, We have our [facility] care plan. She then asked, They have to meet with the family and certify her before providing services to her, right? Then she stated, I haven't seen one. Let me look. She did not produce the care plan or the certification form from the hospice provider. During an interview on 02/01/2022 at 3:22 PM with the Minimum Data Set (MDS) Coordinator, she stated Resident #143 was a new admission and they had not had a care plan meeting with the hospice provider yet. She had written an initial care plan for the resident to include hospice care, but she had not seen a plan of care from the hospice provider. She stated the medical records staff probably had not scanned it into the electronic medical record yet. She had not spoken to any of the hospice provider staff regarding the hospice care plan for Resident #143. During an interview on 02/01/2022 at 4:10 PM with the Regional Nurse Consultant and the Business Office Manager, the Hospice Certification and Plan of Care forms were requested. They stated they contacted the corporate office and the hospice provider to have them sent. No forms were produced by the end of the day on 02/01/2022. On 02/02/2022 at 9:45 AM, a faxed copy of the certification form and the plan of care were provided. The copy was faxed to the facility on [DATE] at 4:51 PM. (Copy obtained) A review of the Hospice Certification and Plan of Care form, dated 01/27/2022, revealed the Medical Director and the hospice physician signed the form that stated, I certify/recertify the patient is terminally ill with a life expectancy of six (6) month or less if the disease process runs its normal course. The certification period was documented as 01/27/2022 to 04/26/2022. (Copy obtained) During an interview on 02/02/2022 at 3:03 PM with the DON, she stated the Unit Managers coordinated the care and communicated with the hospice providers when they came into the building. She was informed that the Unit Manager thought it was her role as the DON to coordinate the care with the hospice providers. She stated she would have to talk with the UM. She stated there was no one person on the Interdisciplinary Team that was responsible for the coordination of the hospice care. They all have different parts of it. No one from the facility participated in care planning with the hospice provider. The facility wrote their own plan of care and hospice provided theirs. A review of the facility's policy and procedure entitled Hospice Services - Provided by External Provider (effective date 10/01/2018 revised 11/01/2019) read: It is the policy of the facility to provide Hospice Care to residents with a wide range of end stage diagnoses. Services Provided: Scheduled visits by RN Case Managers, Hospice aides who provide additional and individual comfort care, Emotional support the resident and the family, Spiritual counselors, Bereavement support, Pain and Symptom management. Criteria: A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician and family agree on a palliative course of care and no longer seek curative treatment. The attending physician must consent to Hospice care. The presence of an Advanced Directive, Has had a significant decline in functional status. General deterioration in physical condition to the extent that the benefits of available treatments are outweighed by the burden of such treatments and significant recover is likely. Referrals can be made by the request of the resident/Power of Attorney/family/Sponsor/Health Care Surrogate/Guardian to the attending physician and/or facility. Attending physician may suggest Hospice Care to the family. The Interdisciplinary Team may meet and suggest Hospice Care to the attending physician. The resident was a Hospice Care recipient prior to admission. (Copy obtained) A review of the Hospice Nursing Facility Agreement, dated 09/10/2021, revealed: Joint Responsibilities: 3.2 Communication and Access. Both parties will allow each other to 3.2.1 Access all records of Hospice Services rendered to Hospice Patients and 3.2.2 Attend and participate in the other party's Interdisciplinary Group Meetings held for the purpose of developing and evaluating the Plans of Care for Hospice Patients. 4.2 Designation of a Facility Interdisciplinary Group Member. Facility will designate a member of the Facility's Interdisciplinary group (IDG Member) who is responsible to work with Hospice personnel to coordinate care provided to the Hospice Patient. 4.2.1 Collaborating with Hospice representatives and coordinating Facility staff participation in the care planning process for those Hospice patients receiving Hospice Services. 4.2.4 Obtaining the following information from the Hospice: a. The most recent Hospice Plan of Care for each Hospice Patient. c. Physician certification of the terminal illness for each Hospice Patient.

Based on resident interviews and a review of residents fund account for the entire facility, the facility failed to notify 7 (#5,#7, #10, #22, #24, #35, # 76) of 32 residents that their account had reached $200 less than SSI resource limit for one person specified in Section1611(a)(3) (B) of the Act. These residents were at risk of losing their Medicaid or SSI. The findings include: Interviews with Resident #16 on [DATE] at 12:13pm and Resident #9 on [DATE] at 12:33pm revealed complaints regarding their personal funds. An interview with the Business Office Manager on [DATE] at 11:21AM revealed that Resident #16 issue was already resolved by the facility but Resident #9 did not receive his Resident allowance of $130 after his care cost payment and Dental Insurance was deducted from his Social Security check. Interview with the Business Office Manager on [DATE]20 at 11:21 AM revealed also that the facility became the Payee on Resident #9s Social Security account December 24, 2019. Social security letter noted that effective January 2020, his payments will no longer be sent to a financial institution. The Payee will be Heartland Health Care Center for Resident #9. He received $1,108.00 for January. Around February 3, 2020, $741,20 was his care cost payment to the facility; Dental was $106.[AGE]. The remaining $130 should have been paid into his resident funds account. However, the Office Manager failed to credit Resident #9's account with $130, but sent all the money into Heartland's account. During our interview, staff promised to do a reversal on the account and return the $130 into Resident #9's funds account by 2/20/2020 but it was not reversed until the Administrator was involved on 2/20/2020. The Business Office Manager was asked, Does the facility notify Medicaid residents when the amount in the resident's account reaches $200 of the eligibility limit? Staff stated Yes. She also said that she would involve the Social Worker in assisting the residents to spend down to prevent eligibility losses. On 2/20/2020 at 2:38PM, the Administrator was asked for a copy of the Trial Balance for all 32 residents with funds account in the facility. A review of this list revealed that 7 Residents #5,#7,#10,#22, #24, #35, and #76 were close to the limit or above the limit. An interview was conducted with the Social Service Director (Employee D) at 2:45PM on 2/20/2020 about her knowledge of the list of residents who needed to spend down their funds; she stated that the Office Manager gave her a list yesterday. She said both of them needed to work on the list. Prior to my interrogation and review, these residents could have lost their benefits.

Based on observations, record review and interview, the facility failed to provide respiratory care in accordance with physician's orders and care plan for 1 (#91) of 1 resident reviewed with ordered oxygen. The findings include: On 0[DATE] at 01:34 PM Resident #91 was observed in his room, sitting up in bed with lunch on overbed table and oxygen being administered through a nasal cannula @ 3 liters per minute using an oxygen concentrator with no date and time on the tubing. It was also observed his nebulizer mask was sitting on the bedside table, not in a labeled plastic bag. Photographic evidence was obtained. An interview was attempted with the resident but he was unable to remember what his oxygen flow rate should be. A review of his medical record revealed oxygen was ordered at 4 liters per minute via nasal cannula administered by an oxygen concentrator. On 02/18/20 at 11:23 AM, the resident was observed sitting in his wheelchair in his room with nasal cannula in place and oxygen being administered at 3 liters per minute via nasal cannula using an oxygen concentrator. (Photographic evidence obtained). On 02/18/20 at 02:46 PM, the resident was observed in his room, sitting in his wheelchair with nasal cannula on and oxygen being administered using a portable oxygen tank on the back of his wheelchair with the flow rate set on 2 liters per minute. On 0[DATE] at 09:58 AM, the resident was observed in his room, sitting in his wheelchair with oxygen being administered through a nasal canula using an oxygen concentrator and flow rate was set on 3 liters per minute. (Photographic evidence obtained). Also at this time, it was observed that the resident's nebulizer and mask were both on bedside table covered with a plastic bag which was not labeled or dated. (Photographic evidence obtained). On [DATE]20 at 11:43 AM, a clinical record review was performed on Resident #91 which documented the medical [DIAGNOSES REDACTED]. A review of the current physician's orders for Resident #91 documented the following: oxygen via nasal cannula at 4 liters per minute continuously. [MEDICATION NAME]-[MEDICATION NAME] solution 0.5-2.5 (3) MG/3 ML 3 ml inhale orally four times a day for [MEDICAL CONDITION]. [MEDICATION NAME]-Formoteril [MEDICATION NAME] aerosol 1[AGE]-4.5 MCG/ACT 2 puffs inhale orally two times a day for [MEDICAL CONDITION]; Rinse mouth after each use. Change oxygen tubing and humidifier bottle weekly on Sunday 7PM-7AM shift, change nebulizer set and tubing weekly on Sunday 7PM-7AM shift. A record review of minimum data set (MDS) documented a Brief Interview for Mental Status (BI[CONDITION]) score of 5 which indicated severely impaired cognition and documented the resident did have shortness of breath with exertion as well as shortness of breath while lying flat and had a past history of tobacco use. A review of care plan documented History of smoking in community, At risk for respiratory impairment related to asthma, [MEDICAL CONDITIONS] with interventions of evaluate lung sounds and vital signs as needed, report abnormalities to physician, obtain pulse oximetry and report abnormal findings, administer medications/treatments per physician orders, elevate the head of the bed, administer oxygen per physician order. A review of oxygen saturation levels was done and documented twice a day since admission. Levels range from a low of 95% on 2/18/2020 to a high of 99% on 2/12/2020 A review of the medication administration records for January and February 2020 all revealed documentation of oxygen at 4 liters per minute via nasal cannula. A review of the treatment administration records for February 2020 revealed the oxygen flow rate was checked on every shift, 7-1, 3-11 and 11-7. On 0[DATE] at 10:07 AM, an interview with Employee C, RN was conducted. Employee C was the nurse caring for Resident #91 on Monday, Tuesday and Wednesday on the 7-3 shift. She was asked how many residents she was caring for that received oxygen. She stated it changed weekly because she mainly worked on the rehabilitation unit but thought she had 3 resident's currently on oxygen. Employee C, RN was asked to verify on her Medication Administration Record [REDACTED]. Employee C, RN verified that on the current Medication Administration Record, [REDACTED]. She was then asked to check Resident #91 oxygen concentrator and verify the current flow rate. She went into Resident #91 room and visually checked the gauzge on the front of the concentrator and confirmed the oxygen flow rate was set on 3 liters per minute. She then adjusted the oxygen flow rate up to 4 liters per minute. On 02/20/20 at 10:24 AM, a review of facilities Policy and Procedure Oxygen Administration under the heading PREPARATION OF EQUIPMENT was performed. On #3 it states For oxygen concentrator, plug in power cord, turn unit on and set flow meter to correct flow rate-[MEDICATION NAME] oxygen from room air. Ensure that exhaust filters care clean and unblocked and under the heading of COMPLETION OF PROCEDURE #2 When oxygen not in use, store oxygen tubing and nasal cannula or mask in separate, labeled plastic bag. A review of the facility Policy and Procedure Respiratory: Nebulizer Mist Therapy was also performed and under the heading of Procedure #18 Store dried nebulizer, t-piece or mask in separate, labeled, plastic bag.

Based on observation, interview and record review, the facility failed to ensure that medications were not expired and/or stored within the right recommended conditions in three of five carts inspected for medication storage. The findings include: On [DATE] at 12:51 PM observed unopened [MED] with instruction to refrigerate until open in the Split Cart (,[DATE] hall). (Photographic evidence obtained). In an interview at [DATE] at 12:55 PM, Staff B stated that the medication was supposed to be in the fridge. An observation on [DATE] at 01:15 PM for East wing 200 hall cart and West wing 300 hall cart, revealed expired Milk of Magnesium with expiration date [DATE] and [DATE]. Further inspection of the East wing 200 hall cart revealed three bottles of opened [MEDICATION NAME] with no open date. In an Interview on [DATE] at 01:30 PM, Staff A, confirmed that the milk of magnesia was expired she added that she forgot to label the opened bottles of [MEDICATION NAME]. In an interview on [DATE] at 01:35 PM, the Director of Nursing (DON) stated that the nurses were supposed to check theirs every shift and ensure that medications were not expired and were labeled. she added that she checked the cart weekly. She stated that education has been done to the employees. Record review of the policy and procedure titled Storage and Expiration dating of Drugs, Biologicals, syringes and Needles Revision date ,[DATE]: 4. Once any medication or biological package is opened, the Nursing Center should follow manufacturer guidelines with respect to expiration dates for opened medications. Nursing Center staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. 16. Nursing Center personnel should inspect nursing storage areas for proper storage compliance on a regular scheduled basis.

Based on observations and interviews, the facility failed to provide a clean and sanitary environment for its residents. This could potentially impact all 99 residents residing in the facility. The findings include: A tour of the building was conducted on 2/3/20 starting at 10:23 AM and continuing until 11:10 AM. The following concerns were identified during the tour: room [ROOM NUMBER] - Soiled, unbagged plunger sitting next to the toilet with brown substance (resembling feces) observed room [ROOM NUMBER] - Enteral feeding pump, pole and floor were soiled with what appeared to be dried enteral feeding product. There was an unlabeled and unbagged [MEDICAL CONDITION] pan on the floor in the bathroom, as well as an unlabeled/unbagged basin on the sink, with two drinking cups stored in it. room [ROOM NUMBER] - The trash can was overflowing room [ROOM NUMBER] - Soiled, unbagged plunger sitting next to the toilet with brown substance (resembling feces) observed. There was a graduate unlabeled/unbagged on the counter, as well as a soiled, unlabeled toothbrush in a basin on the counter. room [ROOM NUMBER] - Bag of soiled linen sitting in the room on the floor. room [ROOM NUMBER] - Urine sample container lying next to the toilet on the floor, unlabeled and unbagged. room [ROOM NUMBER] - Enteral feeding pump, pole, bed rail and floor was soiled with what appeared to be dried enteral feeding. Soiled, unbagged plunger sitting next to toilet with brown substance (resembling feces) observed. room [ROOM NUMBER]- Enteral feeding pump, pole and floor was soiled with what appeared to be dried enteral feeding. room [ROOM NUMBER] - Bag of soiled linen sitting in the room on the floor. room [ROOM NUMBER] - [NAME] powder substance covered the floor throughout the room. Soiled, unbagged plunger sitting next to the toilet with brown substance (resembling feces) observed. room [ROOM NUMBER] - Soiled, unbagged plunger sitting next to the toilet with brown substance (resembling feces) observed. room [ROOM NUMBER] - Soiled, unbagged plunger sitting next to the toilet with brown substance (resembling feces) observed. room [ROOM NUMBER] - Two disposable razors obserevd on the sink. Photographic evidence was obtained of all the concerns identified above. An interview was conducted with Employee F, Housekeeper, on 2/3/2020 at 1:35 PM regarding cleaning the facility. She stated that this facility was not consistent with cleaning the rooms and other areas. We don't have enough staff to cover the facility on an all-day basis. Right now, there are two staff working the floor. I'm the second staff, and I just came in because they called me in. When we walk into a room, we check the bathrooms. We clean the toilets, the sinks, sweep and mop the entire room, and this is done daily. We are supposed to clean the bed rails, as well. When I'm off and I come back, you can tell the rooms haven't been cleaned, plus some residents tell me their rooms were never cleaned while I was off. I have expressed my concerns to all my bosses and their bosses, but nothing changes. We are to dust regularly, but as you can see, that's not being done. An interview was conducted with the Housekeeping Supervisor on 2/3/2020 at 1:45 PM regarding the staff and the procedure to ensure the facility was kept clean. He stated, I'm in the process of changing some things for the better. We currently have two staff on duty right now for the 7am-3pm shift and there should be three. The weekends have had two staff scheduled. I'm changing it to three. He was then asked about the housekeeping check-off list and he stated, I didn't know we had a housekeeping check-off cleaning list. I will be looking into that. I know the housekeeping in this facility needs improving. I have only been here for a couple of days, and I do notice changes need to be made in the housekeeping department. An interview was conducted with the Regional Consultant on 2/3/2020 at 3:17 PM regarding who was responsible for cleaning the feeding pumps, poles, etc. She stated that the nurse was responsible for cleaning up any feeding that was spilled, and that housekeeping was also supposed to ensure the poles and floors were clean.

Based on observation, interviews and record review, the facility failed to obtain physician's orders for one (Resident #3) of five sampled residents using oxygen at the time of the resident's admission. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: An observation made of the oxygen concentrator in Resident #3's room on 11/05/19 at 9:54 AM, revealed that the oxygen flow was set at 3.0 Liters Per Minute (LPM). An interview was conducted with Resident #3 on 11/05/19 at 9:54 AM concerning how much oxygen he was supposed to receive and whether he had any problems receiving his oxygen. He stated, No, I haven't had any problems with my oxygen, and I get 3.0 LPM of oxygen. An interview was conducted with Employee B, Licensed Practical Nurse (LPN), and Resident #3's assigned nurse on 11/05/19 at 9:58 AM. When asked whether she knew how much oxygen Resident #3 received, she replied, Yes, I do. He's on three LPM and he is on Hospice. When she was asked to review the resident's physician's orders on her computer, she said, I don't see any orders for oxygen, but I know he's on three LPM, because it says it on the daily report sheet that he gets three liters of oxygen. When she was asked to check whether the resident had any previous oxygen orders, she reviewed his discontinued orders on the computer and said, Yes, he had an order on 6/14/19 for oxygen at three liters per minute via nasal cannula every shift for shortness of breath (SOB), but it was discontinued on 9/23/19 due to him going to the hospital. She further stated, I'm not sure how it got missed when he was readmitted to the facility on [DATE], but I'm going to call the doctor right know to get an order. A review of Resident #3's medical record, which noted an admission date of [DATE] and a readmission date of [DATE], included a [DIAGNOSES REDACTED]. A review of the physician's orders written on 6/14/19 revealed, Oxygen (O2) at three liters per minute via nasal cannula every shift for SOB. A review of the physician's orders on 9/23/19 revealed, Discontinue O2 at three liters per minute via nasal cannula every shift for SOB. The reason was to hospital. A review of the resident's Medication Administration Record [REDACTED]. A review of the residents Hospice Care Plan revealed he had been on Hospice since 8/6/19, with the Hospice Nurse visiting weekly to observe and assess his respiratory status, including assessing lung sounds, respirations, and 02 saturation. His Hospice medications included O2 - oxygen - 3 LNC, O2 continuous, start date 8/6/19, reason: [MEDICAL CONDITION]. An interview was conducted with the Director of Nursing on 11/5/19 at 12:30 PM regarding Resident #3 not having any current oxygen orders. She confirmed that the resident did not have current oxygen orders and said, We should have picked up on it when he was readmitted to us from the hospital, but we contacted the doctor this morning and now have an oxygen order of three LPM in place for him. When asked what her expectations were for Resident #3's oxygen orders, she replied, We should have an order for [REDACTED]. A review of the Oxygen Administration policy and procedure revealed: Purpose: To describe method for delivering oxygen in order to improve tissue oxygenation, reduce risk for [MEDICAL CONDITION], decrease work of breathing and reduce shortness of breath with activity. During a respiratory emergency it is appropriate for nursing to administer oxygen immediately and obtain physician's order after patient is stabilized or transferred.

Based on observation, interview, record reviews and a review of the policy and procedure for oxygen administration, the facility failed to ensure that one (Resident #1) of five residents sampled, received the correct number of liters of oxygen ordered by the physician. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: An observation made of the portable oxygen tank hanging on the back of Resident #1's wheelchair on 11/05/19 at 9:19 AM, revealed that the oxygen flow was set at 2.5 liters per minute (LPM). An interview was conducted with Resident #1 on 11/05/19 at 9:19 AM concerning how much oxygen she was supposed to receive. She stated, I'm supposed to have 1.0 LPM of oxygen. An interview was conducted with Employee A, Licensed Practical Nurse (LPN), and Resident #1's assigned nurse on 11/05/19 at 9:23 AM. When asked to check the oxygen setting on Resident #1's portable tank, she reported the oxygen was set at 2.5 LPM. When she was asked how many LPM the resident was supposed to receive, she replied, I'll have to check her orders. An interview was conducted with Employee A on 11/5/2019 at 9:27 AM concerning the oxygen order for Resident #1. She confirmed that Resident #1 had an oxygen order for 1 LPM via nasal cannula continuously, and then returned to Resident #1's room and set her portable oxygen flow rate at 1 LPM. A review of Resident #1's medical record noted an admission date of [DATE] and a [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED].< 90. (blood oxygen saturation of less than 90) An interview was conducted with the Director of Nursing on 11/5/19 at 12:30 PM concerning the oxygen orders for Resident #1. She confirmed the oxygen order of 1 LPM via nasal cannula continuously, and stated it shouldn't have been set at 2.5 LPM. When asked what her expectations were for Resident #1's oxygen, she replied, I expect the nurses to follow the physician's orders [REDACTED]. A review of the Oxygen Administration policy and procedure, read: 1. Verify physician's orders [REDACTED].>

Based on observations, interviews, record reviews, a review of the Even Care G3 Blood Glucose Monitoring System QA/QC (quality assurance/quality control) reference guidelines, and a review of the Centers for Disease Control and Prevention guidelines, the facility failed to ensure blood glucose meters were cleaned and disinfected between residents to prevent the spread of bloodborne pathogens. During observations of Blood Glucose Monitoring (BGM) via finger stick testing, one (1) of one (1) Licensed Practical Nurses (Employee A), failed to clean and disinfect the glucometer (a device used to measure blood glucose levels) between each resident's use for two (Resident #53 and #19) of two residents observed, out of a total of 19 residents who required blood glucose monitoring. This failure placed the residents at risk for transmission of potentially infectious bloodborne pathogens such as [MEDICAL CONDITION] (HBV), [MEDICAL CONDITION] (HCV), and human immunodeficiency virus ,[MEDICAL CONDITION]. On 10/16/18 at 4:24 PM, Immediate Jeopardy (IJ) started. On 10/18/18 at 11:00 AM, the Administrator and Director of Nursing (DON) were notified of the Immediate Jeopardy determination. On 10/16/2018 at 1:45 PM, the facility provided an acceptable Credible Allegation of Compliance (A[NAME]). On 10/18/18 at 7:00 PM, the Immediate Jeopardy was removed after validation of the implementation of the A[NAME]. The findings include: 1. On 10/16/18 at 3:54 PM, an observation was made of Employee A, Licensed Practical Nurse (LPN), obtaining a blood glucose level for Resident #53. She removed a basket of lancets, a blood glucose meter (glucometer) and an alcohol wipe from the top drawer of her medication cart, and placed them on top of the cart. She removed the bottle of Accu-check test strips, took a strip from the bottle, and placed it in the glucometer. She obtained a lancet (small needle) from the basket, and placed the basket back inside of the cart. She entered the room, and obtained a paper towel from the bathroom. She wiped the resident's middle finger with the alcohol wipe, and pricked her finger with the lancet. The nurse wiped the drop of blood off with the paper towel, and squeezed the finger to obtain another drop of blood for the blood glucose reading (result 220). The nurse wiped the resident's finger off again with the brown paper towel obtained from the bathroom. She returned to the medication cart and threw the test strip and paper towel in the trash bag on the cart, then disposed of the lancet in the sharps container on the medication cart. She placed the glucometer on the towel next to the water pitcher on top of her medication cart. She did not clean the glucometer before or after obtaining the blood sugar level for Resident #53. 2. On 10/16/18 at 4:26 PM, an observation was made of Employee A, LPN, obtaining a blood glucose level for Resident #19. She removed a lancet from the basket in the top drawer of her cart along with an alcohol wipe. She removed a test strip from the bottle of strips in the top drawer. She placed the strip into the glucometer that was sitting on the towel beside the water pitcher on top of the medication cart. This was the same glucometer that she used previously with Resident #53 and did not clean. She entered Resident #19's room, cleansed the resident's middle finger with the alcohol wipe, and poked her finger with the lancet. She obtained a drop of blood on the test strip and got a blood sugar level of 222. She returned to the cart and placed the test strip and the alcohol wipe in the trash can on her medication cart, then placed the lancet in the sharps container (also on the cart). She placed the glucometer back on the towel next to the water pitcher. She did not clean the glucometer before or after performing the blood glucose testing for Resident #19. On 10/16/18 at 4:30 PM, an interview was conducted with Employee A, LPN, regarding her use of the glucometer for two residents without cleaning it before or after either resident. She confirmed that she did not clean the glucometer. I was supposed to wipe it with alcohol or something. She was asked whether she was sure she was supposed to use alcohol and she replied, I was supposed to use this. She removed a germicidal bleach wipe from the top drawer of the cart. On 10/16/18 at 4:40 PM, an interview was conducted with the Quality Assurance Consultant (QAC), Employee A, and the Assistant Director of Nursing (ADON). Employee A again confirmed that she failed to clean the glucometer between the two residents. 3. On 10/17/18 at 9:40 AM, an observation was made of the medication cart on Hall 200, and one of two glucometers on the cart was observed with a red substance at the test strip insertion site. (Photographic evidence obtained) 4. On 10/17/18 at 10:10 AM, an observation was made on Hall 400 with Employee C, Registered Nurse (RN), of two glucometers in the medication cart. A red substance was noted on one of the glucometers. (Photographic evidence obtained) The red substance on the glucometer was brought to Employee C's attention as it had been sitting in a basket along with other supplies. As she was taking the glucometer to look at it, she stated, It is okay, because I have not used it yet. She tossed it back in the basket with the other glucometer, alcohol wipes and lancets. On 10/17/18 at 12:37 PM, aother interview was conducted with Employee C, RN, regarding the red substance found earlier on the glucometer. She stated she had cleaned the device and had notified her supervisor about what had been found. She was asked about the other supplies that were in the basket with the glucometer (alcohol wipes and lancets), and she stated she had used some of those items. It hadn't occurred to her that they might be contaminated from their contact with the glucometer. A review of the facility's policy and procedure for cleaning and disinfecting the glucometers revealed the following: Glucose Blood Monitoring (Finger Stick Blood Sugar) Orig. Date 03/2110 (Updated 1/2010, 7/2010, 2/2011) Revised 2/2011 Nursing Procedures - G Page 2 of 2 18. Clean blood glucose meter utilizing an EPA (Environmental Protection Agency) approved bleach wipe or approved germicidal disinfectant per manufacturer's instructions. A review of the Even Care G3 Manufacturer's Instructions revealed the following: Medline.com Page 48 of 62 Cleaning and Disinfecting Procedures for the Meter The EVEN CARE G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning cycle of ten times per day for an average of three years. The following products have been approved for cleaning and disinfecting the EVEN CARE G3 Meter: Medline Micro-Kill Bleach Germicidal Bleach Wipes A review of the facility's Medline Micro-Kill Bleach Germicidal Bleach Wipes cleaning instructions revealed the following: Hospital Disinfectant: 1. Always use personal protective equipment. 2. Open Micro-Kill Bleach Wipe Germicidal Bleach Wipe packet. 3. Remove pre-saturated packet4. Apply pre-saturated towelette and wipe desired surface to be disinfected. 5. A 30-second contact time is required to kill all of the bacteria [MEDICAL CONDITION] on the label except a 1-minute contact time is required to kill [MEDICAL CONDITION][MEDICATION NAME] and [MEDICATION NAME] mentagrophytes, and a 3-minute contact time is required to kill [MEDICAL CONDITION] spores. Reapply as necessary to ensure that the surface remains wet for the entire contact time. 6. Allow surface to air dry and discard used wipe and empty packet. A review of the Centers for Disease Control and Prevention (CDC) guidelines for Infection Prevention during Blood Glucose Monitoring and Insulin Administration revealed the following, The Centers for Disease Control and Prevention (CDC) has become increasingly concerned about the risks for transmitting [MEDICAL CONDITION] virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. Whenever possible, blood glucose meters should not be shared. If they must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected, then it should not be shared. Outbreaks of [MEDICAL CONDITION] virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings, such as nursing homes and assisted living facilities, where residents often require assistance with monitoring of blood glucose levels and/or insulin administration. On 10/18/18 at 11:00 AM, the Administrator and the Director of Nursing were notified of the Immediate Jeopardy determination. Information was shared regarding Licensed Practical Nurse A using the Ever Care blood glucose monitoring device for two separate residents on 10/16/18 between 3:45 PM and 4:30 PM without ever cleaning the machine before or after either resident. Two Ever Care blood glucose meters were also identified with a red substance on them while they were being stored on two medication carts on either side of the facility during a review of the medication carts on 10/17/18 at 9:40 AM and 10:10 AM. The facility presented an acceptable Credible Allegation of Compliance (A[NAME]) on 10/18/18 at 1:45 PM that included the following immediate actions taken by the facility: 1. LPN A was provided one on one counseling/education related to cleaning/disinfecting of blood glucose meters before and after each resident use on 10/18/18. 2. The DON provided immediate one on one education (with return demonstration) to all nursing staff in the facility (on every shift) related to appropriate cleaning and disinfecting of blood glucose meters before and after each resident use. 3. The DON and ADON called all nurses that were not on duty to come into the facility by 3:00 PM on 10/18/18 for mandatory training on appropriate blood glucose meter cleaning/disinfecting. Any nurse not educated by 3:00 p.m. on 3/18/18 will not begin his/her next shift until education has been provided. 4. The DON and ADON immediately removed all of the glucometers that were currently in use, and replaced them with new glucometers on 10/18/18. 5. The DON and ADON completed an audit to ensure the facility had an adequate supply of bleach wipes for cleaning and disinfecting the glucometers before and after use for each diabetic resident currently in the facility. The team lifted the Immediate Jeopardy at 7:00 PM on 10/18/18, after validation of the implementation of the A[NAME]. Validation was made through facility record reviews, observations, and staff interviews including: 1. A 3/18/18 review of the education provided to LPN A, related to cleaning and disinfecting of the blood glucometers before and after each resident, verified that the nurse had been educated. 2. A review of the education that had been provided by the DON to 17 of 25 nurses so far, requiring that the nurses perform return demonstration on cleaning and disinfecting of the blood glucose meters, confirmed that the education had been provided as stated in the A[NAME]. The education is ongoing, and nurses will not begin a work shift without having received this training. Based on a review of facility documentation, 25 nurses in total are employed by the facility. 3. Observations were conducted on four of four carts, and new glucometers were observed. There were no concerns identified. All of the devices were clean when observed. An ample supply of bleach wipes was available on each cart for disinfecting of the devices. 4. Interviews were conducted on 10/18/18 between 4:00 PM and 4:45 PM with four nurses, and all of the nurses were able to verbalize the training that they received regarding the appropriate way to clean and disinfect the blood glucose meters. 5. Observations of blood glucose monitoring were conducted with four nurses on 10/18/18 between 4:00 PM and 5:00 PM. No non-compliance was identified. 6. An interview was conducted with the DON on 10/18/18 at 6:45 PM. She stated that the facility was currently working on implementing a policy and procedure specifically for cleaning and disinfecting of the blood glucose meters. A rough draft was reviewed, and no concerns were identified.

Based on medical record review and staff interviews, the facility failed to ensure that the services provided by the facility met professional standards of quality for 1 (Resident #1) of 4 sampled residents with a physician's orders [REDACTED]. Professional Standard of Care is defined in Chapter 766.102 as the prevailing professional standard of care for a given health care provider shall be that level of care, skill, and treatment which in light of all relevant surrounding circumstances is recognized as acceptable and appropriate by reasonably prudent similar health care providers. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not limited to: the administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured or infirmed and the promotion of wellness, maintenance or health, and the prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician or a licensed dentist. The findings include: A medical record review was conducted for Resident #1 which revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. A physician's orders [REDACTED]. A 7/2/17 nursing note written at 5:55 a.m. by Employee A, Registered Nurse (RN), reported that the family member arrived and stated Resident #1 was having difficulty breathing. Employee A obtained the resident's oxygen saturation level (79%), and proceeded to administer a breathing treatment ([MEDICATION NAME] 0.5-1 vial inhale orally every 4 hours as needed). Vital signs were not documented. Employee A increased the oxygen flow from 3.5 to 4 Liters. Resident #1's oxygen saturation increased to 81%. Employee A documented that after 40 minutes the oxygen saturation was checked again and it was still 81%. Therefore, at 6:45 a.m., Employee A placed the resident on a portable oxygen canister at 10 Liters, and his oxygen saturation level increased to 94%. There was no documentation that the physician was ever notified or permission to increase the resident's oxygen was given by the physician. Employee B, Licensed Practical Nurse (LPN), arrived for the following shift (morning shift), and was alerted by the certified nursing assistant (CNA), that Resident #1 was unable to breathe. Employee B observed the resident using accessory muscles to breathe, and oxygen saturations were fluctuating between 88 and 92% on 10 Liters of oxygen. Employee B notified the physician on call, and received an order to send the resident to the emergency room . The resident was documented as having left at 8:15 a.m. (Photographic evidence obtained) During a 7/12/17 conversation with the resident's family member at 10:20 a.m., she stated that Resident #1 was currently in the intensive care unit at the hospital with [DIAGNOSES REDACTED]. During a 7/13/17 interview with the Unit Manager (RN) on the West Wing at 12:40 p.m., it was confirmed that if a resident was short of breath, vital signs should be obtained along with oxygen saturation, and the physician should be notified. The unit manager stated, If a resident has an oxygen saturation of 79%, we should make sure the oxygen is working, and call the physician. During a 7/13/17 interview with the Director of Nursing (DON) at 1:05 p.m., she stated, If I had a resident complaining of shortness of breath, using accessory muscles, and had nasal flaring with low oxygen saturation, I would call the physician. An interview was conducted with the physician on 7/13/17 at 2:40 p.m. in the facility. The physician stated, If a patient is receiving oxygen, and his oxygen saturation is 79%, I would give an order to increase the oxygen, and send the patient to the emergency room . I would expect the nurse to go into emergency mode, apply a rebreather mask, and bump up the oxygen while calling the physician for orders. During a 7/13/17 interview via telephone with Employee A, RN, at 3:05 p.m., it was confirmed that Employee A was on duty and caring for Resident #1 when the resident was short of breath on 7/2/17. Employee A stated he took the vital signs but did not document them in the medical chart. He reported that the resident's oxygen saturation level was 79 %, and increased to 81% after a breathing treatment was administered. Employee A confirmed he did increase the resident's oxygen from 3.5 to 4.0 Liters, but he could not recall when or if he had increased the resident's oxygen from 2.0 Liters to 3.5 Liters. He confirmed that he never called the physician. This surveyor asked at what point would he call the physician for a resident with shortness of breath and low oxygen saturation levels. Employee A stated, If a resident's oxygen saturation level was below 94-95%, I would call the physician. If I had to do it over again, I would have called the physician immediately for Resident #1. During a 7/13/17 interview with the DON at 4:11 p.m., she stated, I expect the vital signs to be documented in the nursing notes or under vital signs. For residents with an oxygen saturation of 90% or below, the physician should be notified with an intervention to help the resident. The DON confirmed during this interview that Employee B (the day shift nurse) called her on the morning of 7/2/17 to inform her that Resident #1 was being sent to the emergency room , but that she did not know the circumstances of the event. She only knew that the resident was short of breath. She went on to say that she was notified by staff anytime a resident was sent to the hospital.

Based on medical record review and staff interviews, the facility failed to provide the necessary care and services to attain or maintain residents' highest practicable well-being for 1 (Resident #1) of 4 sampled residents with a physician's orders [REDACTED]. The findings include: A medical record review was conducted for Resident #1 which revealed an admission date of [DATE] with the following Diagnoses: [REDACTED]. A physician's orders [REDACTED]. A 7/2/17 nursing note written at 5:55 a.m. by Employee A, Registered Nurse (RN), reported that the family member arrived and stated Resident #1 was having difficulty breathing. Employee A obtained the resident's oxygen saturation level (79%), and proceeded to administer a breathing treatment ([MEDICATION NAME] 0.5-1 vial inhale orally every 4 hours as needed). Vital signs were not documented. Employee A increased the oxygen flow from 3.5 to 4 Liters. Resident #1's oxygen saturation increased to 81%. Employee A documented that after 40 minutes the oxygen saturation was checked again and it was still 81%. Therefore, at 6:45 a.m., Employee A placed the resident on a portable oxygen canister at 10 Liters, and his oxygen saturation level increased to 94%. There was no documentation that the physician was ever notified or permission to increase the resident's oxygen was given by the physician. Employee B, Licensed Practical Nurse (LPN), arrived for the following shift (morning shift), and was alerted by the certified nursing assistant (CNA), that Resident #1 was unable to breathe. Employee B observed the resident using accessory muscles to breathe, and oxygen saturations were fluctuating between 88 and 92% on 10 Liters of oxygen. Employee B notified the physician on call, and received an order to send the resident to the emergency room . The resident was documented as having left at 8:15 a.m. (Photographic evidence obtained) During a 7/12/17 conversation with the resident's family member at 10:20 a.m., she stated that Resident #1 was currently in the intensive care unit at the hospital with [DIAGNOSES REDACTED]. During a 7/13/17 interview with the Unit Manager (RN) on the West Wing at 12:40 p.m., it was confirmed that if a resident was short of breath, vital signs should be obtained along with oxygen saturation, and the physician should be notified. The unit manager stated, If a resident has an oxygen saturation of 79%, we should make sure the oxygen is working, and call the physician. During a 7/13/17 interview with the Director of Nursing (DON) at 1:05 p.m., she stated, If I had a resident complaining of shortness of breath, using accessory muscles, and had nasal flaring with low oxygen saturation, I would call the physician. An interview was conducted with the physician on 7/13/17 at 2:40 p.m. in the facility. The physician stated, If a patient is receiving oxygen, and his oxygen saturation is 79%, I would give an order to increase the oxygen, and send the patient to the emergency room . I would expect the nurse to go into emergency mode, apply a rebreather mask, and bump up the oxygen while calling the physician for orders. During a 7/13/17 interview via telephone with Employee A, RN, at 3:05 p.m., it was confirmed that Employee A was on duty and caring for Resident #1 when the resident was short of breath on 7/2/17. Employee A stated he took the vital signs but did not document them in the medical chart. He reported that the resident's oxygen saturation level was 79 %, and increased to 81% after a breathing treatment was administered. Employee A confirmed he did increase the resident's oxygen from 3.5 to 4.0 Liters, but he could not recall when or if he had increased the resident's oxygen from 2.0 Liters to 3.5 Liters. He confirmed that he never called the physician. This surveyor asked at what point would he call the physician for a resident with shortness of breath and low oxygen saturation levels. Employee A stated, If a resident's oxygen saturation level was below 94-95%, I would call the physician. If I had to do it over again, I would have called the physician immediately for Resident #1. During a 7/13/17 interview with the DON at 4:11 p.m., she stated, I expect the vital signs to be documented in the nursing notes or under vital signs. For residents with an oxygen saturation of 90% or below, the physician should be notified with an intervention to help the resident. The DON confirmed during this interview that Employee B (the day shift nurse) called her on the morning of 7/2/17 to inform her that Resident #1 was being sent to the emergency room , but that she did not know the circumstances of the event. She only knew that the resident was short of breath. She went on to say that she was notified by staff anytime a resident was sent to the hospital.

Based on record review and staff interview, the facility nurses failed to provide care that met professional standards of quality for Resident #1's biliary drainage tube (opening in the gallbladder, with a tube draining fluid out through the abdomen) and pain management, according to the Florida Nurse's Practice Act and Lippincott Manual of Nursing Practice 10th Edition. The nurses did not administer the following treatments as prescribed or authorized by a duly licensed practitioner, according to the Florida Nurse's Practice Act and Lippincott Manual of Nursing Practice 10th Edition: ? Not flushing the biliary drainage tube daily, according to physician's orders [REDACTED]. ? Not notifying the physician when Resident #1 complained about abdominal pain and bleeding from the biliary tube ? Not monitoring the biliary output from the drainage tube ? Not providing pain medication to treat the resident's moderate to severe abdominal pain as ordered. The resident did not receive any prescribed pain medication for 12 hours after he was assessed having moderate pain and at the time he received his pain medication, his pain level was severe. Resident #1 was 1 out of 3 residents reviewed for quality of care. The facility practices of not providing care, which did not meet professional standards of quality, resulted in actual harm to Resident #1. The facility's failure to provide care for Resident #1's biliary drainage tube resulted in complications of bleeding, pain, hospital readmission, and infection. The facility's failure to treat Resident 1's pain resulted in the resident experiencing significant episodic pain, which impacted his activities and existing anxiety. The facility's census was 99, with only one resident (Resident #1) requiring the special care need for a biliary drainage tube after a recent hospitalization . See also F309. The findings include: The Florida Nurse Practice Act, Chapter 464.003 defines the "practice of professional nursing" as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: 1. The observation, assessment, nursing diagnosis, and evaluation of care; health teaching and counseling of the ill, injured and infirm; and the promotion of wellness, maintenance of heath, and prevention of illness of others. 2. The administration of medications and treatments as prescribed or authorized by a duly licensed practitioner. Additionally, the Act states that the "practice of practical nursing" means "the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or infirm and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. The professional nurse and the practical nurse shall be responsible and accountable for making decisions that are based upon the individual's educational preparation and experience in nursing." Per Lippincott Manual of Nursing Practice 10th Edition, 2013, Hepatic, Biliary, and Pancreatic Disorders: "If a patient has a biliary drain, monitor catheter exit site for bleeding or bile drainage and monitor drainage in bile bag for color, amount, and consistency. The drainage initially may have some blood mixed with bile but should clear within a few hours. There should be adequate drainage. Report frank blood and blood clots that appear. Maintain patency and security of biliary catheter; perform routine care and dressing at catheter exit site. Perform routine flushing of biliary catheter per order. Do not aspirate from the catheter because this draws bacteria from the bowel and may cause cholangitis. Signs of complications include inability to flush the catheter, bleeding from the catheter, and leakage around the exit site of the catheter." 1) Record review for Resident #1 revealed a [AGE] year old male admitted to the facility on [DATE] at 9:00 p.m. with [DIAGNOSES REDACTED]. Resident #1's admission Brief Interview for Mental Status score was 15 out of 15 (no cognitive impairment). Review of the Advanced Registered Nurse Practitioner's (ARNP) progress note for Resident #1 dated 11/5/14 at 12:15 revealed that on 10/27/14 the resident had [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Biliary tube output every shift." an order written [REDACTED]. Clean site every evening shift with NS (normal saline). Apply DSD (dry sterile dressing)." Review of Resident #1's Treatment Administration Record (TAR) for October, 2014 revealed that on 10/29/2014 and 10/30/2014 there was no documentation to indicate that the resident's biliary tube care and biliary tube flushes were completed on the second shift as ordered. On 10/29/2014 and 10/30/2014, there was no documentation to indicate that biliary tube output was measured on either the second or third shifts as ordered. An 11/17/2014 interview with Employee H, Licensed Practical Nurse (LPN) and Supervisor, at 4:36 p.m. revealed the following: Employee H was presented with Resident #1's Treatment Administration Record (TAR) for October, 2014. When asked whether he could recall providing biliary tube care, or flushing the biliary tube, or recording biliary output during second shift on 10/29/14, he replied, " I'm not sure if that was the day that he went out and came back. I don't remember the care I gave. I don't recall why I didn't document on it." Review of the ARNP's progress note for Resident #1 dated 11/5/14 at 12:15 revealed that the resident's Cholecystostomy drain was replaced on 11/3/14, and was currently bleeding. Employee J, Registered Nurse, told the ARNP that the resident's shirt and sheets were covered in blood that morning. The nurse changed the dressing and the resident went to therapy. The resident came back from therapy with blood leaking from the dressing to the right abdomen. Vital signs were as follows: blood pressure 150/94 (elevated), temperature 98.9 degrees fahrenheit, pulse 67 beats per minute, respirations 18 breaths per minute. A large blood clot was noted in the 4x4 dressing at the puncture site on the abdomen. The blood clot was not removed (due to concern that it would lead to additional bleeding). The drain from the abdomen had sanguineous (bloody) fluid. The resident was noted to have a history of [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] (both involving blood clots), and the resident was receiving [MEDICATION NAME] 3mg (anticoagulant to prevent blood clots). The resident's wife stated she would contact the resident's hematologist regarding anticoagulation when the drains were removed, since the resident had multiple problems with clots in the drain and was now bleeding. The ARNP promptly sent the resident to the emergency room (ER). Record review of Resident #1's skilled nursing progress note by Employee J dated 11/5/2014 at 12:40 p.m. revealed the following: "This writer was called to patient room at 7:30 a.m. asking for a pain pill. Complained of 7 out of 10 pain in right abdomen. Gross amount of fresh bleeding from around biliary drain site. Changed dressing. By 11:00 a.m. dressing saturated with fresh bleeding (after resident went to therapy). ARNP assessed patient. New order to send to ER for evaluation. Vital signs stable. Still complaining of pain at an 8 out of 10 at this time. Report called to ER. ARNP notified patient's spouse on transfer." Review of Employee J's witness statement dated 11/19/14 revealed she assessed the resident's abdomen on the morning of 11/5/14 and noted the dressing on the right drain site from the biliary tube had bloody discharge on the bandage. There was no drainage in the bag. The nurse changed the bandage and the resident's shirt. She flushed the drain. The nurse returned to the room a few hours later (after the resident went to therapy) and noticed the bandage with bloody drainage again. She changed the dressing again and notified the ARNP. An interview on 11/20/2014 at 1:55 p.m. with Employee J revealed that she was called to Resident #1's room at approximately 7:30 a.m. on 11/5/14 because the resident wanted medication for pain. She stated that Resident #1 complained of abdominal pain, and she medicated him at that time. She stated that she also checked his biliary tube site, and saw that his dressing was saturated with blood, and there was some blood on his gown; "about a quarter-sized amount." Employee J stated that she cleansed the drainage site and applied a new dressing. She stated that Resident #1 then went to therapy at approximately 9:00 a.m. When the resident returned from therapy between 10:15 a.m. and 10:30 a.m., Employee J stated that the dressing at Resident #1's biliary tube site was again saturated with blood in "about the same amount" as it had been at 7:30 a.m. She stated that she removed the dressing, cleansed the site and re-dressed the area with a new dressing. When asked the size of the dressing, Employee J stated that it was a 4 inch x 4 inch [MEDICATION NAME] dressing pad ([MEDICATION NAME] Composite Island Dressing). She stated that when Resident #1 returned from therapy he had no complaints of pain. Employee J stated that at approximately 11:00 a.m., she called Resident #1's ARNP, who had just arrived at the facility, to come and assess Resident #1's biliary site. Review of Resident #1's Physical Therapy Service Log Matrix dated 11/5/14 revealed that the resident started therapy at 9:40 am. Stop time was 10:07 am. Review of the therapist's witness statement dated 11/18/14 revealed that she did not note any blood at the resident's biliary site. The therapist checked the biliary site each time she worked with the resident, to make sure the resident didn't pull on it during exercise. She did not note any blood on the resident at the end of the therapy session. Review of the Therapy Treatment Encounter for 11/5/14 revealed that during the therapy session the resident practiced transferring from bed to wheelchair, ambulating, standing, and using stairs. He performed bilateral lower extremity exercises in a seated position. He did therapeutic exercises for 17 minutes and therapeutic activities for 10 minutes. The session ended early because the resident was lethargic (drowsy), and fatigued easily. In an interview on 11/18/2014 at 10:38 a.m. with the ARNP assigned to Resident #1, she stated that when she assessed the drainage site she noted a large blood clot "around the base of the tube." The ARNP stated that she explained to Resident #1's spouse that she was afraid that if she removed the clot herself, she would not be able to stop the bleeding. When asked whether she felt at the time that Resident #1 urgently needed to be evaluated in the ER, she replied, "Yes." Review of Resident #1's hospital History and Physical dated 11/5/14 revealed that the resident presented to the ER with complaint of fever, chills, and generally not feeling well within the last 24 hours. The facility had already started intravenous [MEDICATION NAME] (antibiotic administered into a vein). The fever maximum was 101.9 degrees per the resident's wife. The resident developed increased swelling, pain, and oozing at the catheter site today. At the facility the resident's INR was 2.1 (test for blood clotting ability), and recheck at the hospital was 2.7 (the higher the number, the slower the blood clots). A large clot was at the catheter site with tenderness. The resident had an elevated heart rate of 100-110, and an elevated white blood count at 33.30 (both signs of infection). The resident's hemoglobin was low at 9.6 (sign of blood loss). Assessment in the ER revealed systemic [MEDICAL CONDITION] response syndrome, intraabdominal source such as [MEDICATION NAME] (inflammation of the gallbladder) versus pneumonia. Review of Resident #1's hospital records revealed that an abdominal CT scan dated 11/5/14 showed high density material within the gallbladder with surrounding [MEDICAL CONDITION] type stranding and fluid. Further review of hospital records revealed that the resident subsequently had his gallbladder removed on 11/14/14 due to gallstone pancreatitis. An 11/17/2014 interview at 1:15 p.m. with the Director of Nursing (DON) revealed that the facility had no policy and procedure related to the care of a biliary tube. An 11/17/2014 interview at 2:15 p.m. with the Director of Nursing (DON) revealed the following: When asked whether a nurse who finds frank bleeding at the biliary tube site should notify the physician, the DON stated that it depended upon how much blood was present. "She (the nurse) may have changed the dressing, and then monitored the site to see how it was doing. If it was a new tube, it might have bled. If the resident was on anticoagulants, it might have bled." 2) Review of Resident #1's Nursing Progress Note dated 10/27/2014 at 10:45 p.m. revealed that Resident #1 was admitted to the facility on [DATE] at 9:00 p.m. with admitting [DIAGNOSES REDACTED]. No complaint of pain was mentioned in this note. Review of Resident #1's physician's orders [REDACTED]. Another physician's orders [REDACTED]." This order was discontinued on 10/28, and a new order was written which stated, "Pain evaluation every shift for pain." Review of Resident #1's Medication Administration Records (MAR) for October, 2014 revealed that on 10/27/14, Resident #1 was admitted at 9:00 p.m., and on 10/28/14 during the first shift, his pain was documented at a 0 (using a numerical pain scale of 0-10, with 0 indicating no pain and 10 indicating the worst pain). Each shift documented a pain level in the pain evaluation section of the MAR indicated [REDACTED]. Review of Resident #1's Pain assessment dated [DATE] at 11:00 p.m. revealed the following: "Present pain" was documented at a 5 on a scale of 0-10, with 10 being the worst pain. The assessment indicated that Resident #1's pain was generalized, and that at best, his pain level was a 2, and at worst his pain was a 10. Resident #1's pain goal was noted as a 0. Medication was listed as the only "relieving factor," and Resident #1's pain was noted to impact his activities and anxiety. There was no indication on the assessment that Resident #1 had received any medication for pain at the time of the assessment. Review of a nurse's note dated 10/28/2014 at 11:47 a.m. revealed that Resident #1 complained of pain at a level of 8, with 10 being the worst pain. This was the first notation of pain since completion of Resident #1's Pain Assessment on 10/27/14 at 11:00 p.m. Resident #1 was medicated, and on 10/28/14 at 12:36 p.m., the nurse documented that the medication had been effective. Review of the Emergency Drug Kit (EDK) records from 10/27/14 to 11/5/2014 revealed that [MEDICATION NAME] - [MEDICATION NAME] ([MEDICATION NAME]) 10-325 mg tabs were contained in the kit. However, no medication was signed out for Resident #1. Review of Resident #1's clinical record revealed that there was no documentation to indicate that Resident #1 received any pain medication between 11:00 p.m. on 10/27/2014 when he stated that he had a pain level of 5, and 11:47 a.m. on 10/28/2014 when he stated that he had a pain level of 8 and received his prescribed pain medication. (12 hours and 47 minutes) During an 11/17/2014 interview at 4:05 p.m. with Employee E, Registered Nurse, she stated, "If a resident is admitted before 10:00 p.m., their medication is usually dropped off by the pharmacy at about 5:00 a.m. the next morning, but the medications we need are generally in the EDK. I can't recall whether he (Resident #1) came to the facility with a prescription for the pain medication. When asked about assessing a resident's pain, Employee E stated, " If a resident reports a level of pain at a 5 on a scale of 0-10, I would ask them what their pain goal was. If it was a 4 to a 5, I wouldn't ask them whether they needed anything more for pain. If it was lower, I would ask if they needed something for pain. That's why the pain assessment has a question about the resident's pain goal." .

Based on record review and staff interview, the facility failed to provide the following care for Resident #1's biliary drainage tube (opening in the gallbladder, with a tube draining fluid out through the abdomen): ? Not flushing the biliary drainage tube daily, which was ordered by the physician ? Not notifying the physician when Resident #1 complained about abdominal pain and bleeding from the biliary tube ? Not monitoring the biliary output from the drainage tube The facility also failed to provide care and treatment for [REDACTED]. The resident did not receive any prescribed pain medication for 12 hours after he was assessed having moderate pain, and at the time he received his pain medication, his pain level was severe. Resident #1 was 1 out of 3 residents reviewed for quality of care. The facility practices of not providing care for the resident's biliary tube and pain management resulted in actual harm to Resident #1. The facility's failure to provide care for Resident #1's biliary drainage tube resulted in complications of bleeding, pain, hospital readmission, and infection. The facility's failure to treat Resident 1's pain resulted in the resident experiencing significant episodic pain, which impacted his activities and existing anxiety. The facility's census was 99, with only one resident (Resident #1) requiring the special care need for a biliary drainage tube after a recent hospitalization . See also F281. The findings include: 1) Record review for Resident #1 revealed a [AGE] year old male admitted to the facility on [DATE] at 9:00 p.m. with [DIAGNOSES REDACTED]. Resident #1's admission Brief Interview for Mental Status score was 15 out of 15 (no cognitive impairment). Review of the Advanced Registered Nurse Practitioner's (ARNP) progress note for Resident #1 dated 11/5/14 at 12:15 revealed that on 10/27/14 the resident had [DIAGNOSES REDACTED]. Review of Resident #1's physician's orders [REDACTED]. Biliary tube output every shift." an order written [REDACTED]. Clean site every evening shift with NS (normal saline). Apply DSD (dry sterile dressing)." Review of Resident #1's Treatment Administration Record (TAR) for October, 2014 revealed that on 10/29/2014 and 10/30/2014 there was no documentation to indicate that the resident's biliary tube care and biliary tube flushes were completed on the second shift as ordered. On 10/29/2014 and 10/30/2014, there was no documentation to indicate that biliary tube output was measured on either the second or third shifts as ordered. An 11/17/2014 interview with Employee H, Licensed Practical Nurse (LPN) and Supervisor, at 4:36 p.m. revealed the following: Employee H was presented with Resident #1's Treatment Administration Record (TAR) for October, 2014. When asked whether he could recall providing biliary tube care, or flushing the biliary tube, or recording biliary output during second shift on 10/29/14, he replied, " I'm not sure if that was the day that he went out and came back. I don't remember the care I gave. I don't recall why I didn't document on it." A review of Resident #1's care plans revealed that there was no care plan related to care of Resident #1's cholecystostomy (other than related pain), or care of his biliary drainage tube. The following care plans were in place, and were initiated by Employee E on 10/28/2014 unless otherwise noted: Infection of blood related to increased WBC's (white blood cells) (Initiated on 11/5/14, by Employee I, RN, ADON) Anticoagulant therapy to treat [MEDICAL CONDITION] ([MEDICAL CONDITION], blood clot) Abdominal pain related to cholecystectomy (Resident had a cholecystostomy) Skin risk Review of the ARNP's progress note for Resident #1 dated 11/5/14 at 12:15 revealed that the resident's Cholecystostomy drain was replaced on 11/3/14, and was currently bleeding. Employee J, Registered Nurse, told the ARNP that the resident's shirt and sheets were covered in blood that morning. The nurse changed the dressing and the resident went to therapy. The resident came back from therapy with blood leaking from the dressing to the right abdomen. Vital signs were as follows: blood pressure 150/94 (elevated), temperature 98.9 degrees fahrenheit, pulse 67 beats per minute, respirations 18 breaths per minute. A large blood clot was noted in the 4x4 dressing at the puncture site on the abdomen. The blood clot was not removed (due to concern that it would lead to additional bleeding). The drain from the abdomen had sanguineous (bloody) fluid. The resident was noted to have a history of [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] (both involving blood clots), and the resident was receiving [MEDICATION NAME] 3mg (anticoagulant to prevent blood clots). The resident's wife stated she would contact the resident's hematologist regarding anticoagulation when the drains were removed, since the resident had multiple problems with clots in the drain and was now bleeding. The ARNP promptly sent the resident to the emergency room (ER). Record review of Resident #1's skilled nursing progress note by Employee J dated 11/5/2014 at 12:40 p.m. revealed the following: "This writer was called to patient room at 7:30 a.m. asking for a pain pill. Complained of 7 out of 10 pain in right abdomen. Gross amount of fresh bleeding from around biliary drain site. Changed dressing. By 11:00 a.m. dressing saturated with fresh bleeding (after resident went to therapy). ARNP assessed patient. New order to send to ER for evaluation. Vital signs stable. Still complaining of pain at an 8 out of 10 at this time. Report called to ER. ARNP notified patient's spouse on transfer." Review of Employee J's witness statement dated 11/19/14 revealed she assessed the resident's abdomen on the morning of 11/5/14 and noted the dressing on the right drain site from the biliary tube had bloody discharge on the bandage. There was no drainage in the bag. The nurse changed the bandage and the resident's shirt. She flushed the drain. The nurse returned to the room a few hours later (after the resident went to therapy) and noticed the bandage with bloody drainage again. She changed the dressing again and notified the ARNP. An interview on 11/20/2014 at 1:55 p.m. with Employee J revealed that she was called to Resident #1's room at approximately 7:30 a.m. on 11/5/14 because the resident wanted medication for pain. She stated that Resident #1 complained of abdominal pain, and she medicated him at that time. She stated that she also checked his biliary tube site, and saw that his dressing was saturated with blood, and there was some blood on his gown; "about a quarter-sized amount." Employee J stated that she cleansed the drainage site and applied a new dressing. She stated that Resident #1 then went to therapy at approximately 9:00 a.m. When the resident returned from therapy between 10:15 a.m. and 10:30 a.m., Employee J stated that the dressing at Resident #1's biliary tube site was again saturated with blood in "about the same amount" as it had been at 7:30 a.m. She stated that she removed the dressing, cleansed the site and re-dressed the area with a new dressing. When asked the size of the dressing, Employee J stated that it was a 4 inch x 4 inch [MEDICATION NAME] dressing pad ([MEDICATION NAME] Composite Island Dressing). She stated that when Resident #1 returned from therapy he had no complaints of pain. Employee J stated that at approximately 11:00 a.m., she called Resident #1's ARNP, who had just arrived at the facility, to come and assess Resident #1's biliary site. Review of Resident #1's Physical Therapy Service Log Matrix dated 11/5/14 revealed that the resident started therapy at 9:40 am. Stop time was 10:07 am. Review of the therapist's witness statement dated 11/18/14 revealed that she did not note any blood at the resident's biliary site. The therapist checked the biliary site each time she worked with the resident, to make sure the resident didn't pull on it during exercise. She did not note any blood on the resident at the end of the therapy session. Review of the Therapy Treatment Encounter for 11/5/14 revealed that during the therapy session the resident practiced transferring from bed to wheelchair, ambulating, standing, and using stairs. He performed bilateral lower extremity exercises in a seated position. He did therapeutic exercises for 17 minutes and therapeutic activities for 10 minutes. The session ended early because the resident was lethargic (drowsy), and fatigued easily. In an interview on 11/18/2014 at 10:38 a.m. with the ARNP assigned to Resident #1, she stated that when she assessed the drainage site she noted a large blood clot "around the base of the tube." The ARNP stated that she explained to Resident #1's spouse that she was afraid that if she removed the clot herself, she would not be able to stop the bleeding. When asked whether she felt at the time that Resident #1 urgently needed to be evaluated in the ER, she replied, "Yes." Review of Resident #1's hospital History and Physical dated 11/5/14 revealed that the resident presented to the ER with complaint of fever, chills, and generally not feeling well within the last 24 hours. The facility had already started intravenous [MEDICATION NAME] (antibiotic administered into a vein). The fever maximum was 101.9 degrees per the resident's wife. The resident developed increased swelling, pain, and oozing at the catheter site today. At the facility the resident's INR was 2.1 (test for blood clotting ability), and recheck at the hospital was 2.7 (the higher the number, the slower the blood clots). A large clot was at the catheter site with tenderness. The resident had an elevated heart rate of 100-110, and an elevated white blood count at 33.30 (both signs of infection). The resident's hemoglobin was low at 9.6 (sign of blood loss). Assessment in the ER revealed systemic [MEDICAL CONDITION] response syndrome, intraabdominal source such as [MEDICATION NAME] (inflammation of the gallbladder) versus pneumonia. Review of Resident #1's hospital records revealed that an abdominal CT scan dated 11/5/14 showed high density material within the gallbladder with surrounding [MEDICAL CONDITION] type stranding and fluid. Further review of hospital records revealed that the resident subsequently had his gallbladder removed on 11/14/14 due to gallstone pancreatitis. An 11/17/2014 interview at 1:15 p.m. with the Director of Nursing (DON) revealed that the facility had no policy and procedure related to the care of a biliary tube. An 11/17/2014 interview at 2:15 p.m. with the Director of Nursing (DON) revealed the following: When asked whether a nurse who finds frank bleeding at the biliary tube site should notify the physician, the DON stated that it depended upon how much blood was present. "She (the nurse) may have changed the dressing, and then monitored the site to see how it was doing. If it was a new tube, it might have bled. If the resident was on anticoagulants, it might have bled." 2) Review of Resident #1's Nursing Progress Note dated 10/27/2014 at 10:45 p.m. revealed that Resident #1 was admitted to the facility on [DATE] at 9:00 p.m. with admitting [DIAGNOSES REDACTED]. No complaint of pain was mentioned in this note. A care plan for abdominal pain related to cholecystectomy (opening in the gallbladder to drain fluid out through the abdomen) was initiated by Employee E, Registered Nurse, on 10/28/2014. Review of Resident #1's physician's orders [REDACTED]. Another physician's orders [REDACTED]." This order was discontinued on 10/28, and a new order was written which stated, "Pain evaluation every shift for pain." Review of Resident #1's Medication Administration Records (MAR) for October, 2014 revealed that on 10/27/14, Resident #1 was admitted at 9:00 p.m., and on 10/28/14 during the first shift, his pain was documented at a 0, (using a numerical pain scale of 0-10, with 0 indicating no pain and 10 indicating the worst pain). Each shift documented a pain level in the pain evaluation section of the MAR indicated [REDACTED]. Review of Resident #1's Pain assessment dated [DATE] at 11:00 p.m. revealed the following: "Present pain" was documented at a 5 on a scale of 0-10, with 10 being the worst pain. The assessment indicated that Resident #1's pain was generalized, and that at best, his pain level was a 2, and at worst his pain was a 10. Resident #1's pain goal was noted as a 0. Medication was listed as the only "relieving factor," and Resident #1's pain was noted to impact his activities and anxiety. There was no indication on the assessment that Resident #1 had received any medication for pain at the time of the assessment. Review of a nurse's note dated 10/28/2014 at 11:47 a.m. revealed that Resident #1 complained of pain at a level of 8, with 10 being the worst pain. This was the first notation of pain since completion of Resident #1's Pain Assessment on 10/27/14 at 11:00 p.m. Resident #1 was medicated, and on 10/28/14 at 12:36 p.m., the nurse documented that the medication had been effective. Review of the Emergency Drug Kit (EDK) records from 10/27/14 to 11/5/2014 revealed that [MEDICATION NAME] - [MEDICATION NAME] ([MEDICATION NAME]) 10-325 mg tabs were contained in the kit. However, no medication was signed out for Resident #1. Review of Resident #1's clinical record revealed that there was no documentation to indicate that Resident #1 received any pain medication between 11:00 p.m. on 10/27/2014 when he stated that he had a pain level of 5, and 11:47 a.m. on 10/28/2014 when he stated that he had a pain level of 8 and received his prescribed pain medication. (12 hours and 47 minutes) During an 11/17/2014 interview at 4:05 p.m. with Employee E she stated, "If a resident is admitted before 10:00 p.m., their medication is usually dropped off by the pharmacy at about 5:00 a.m. the next morning, but the medications we need are generally in the EDK. I can't recall whether he (Resident #1) came to the facility with a prescription for the pain medication. When asked about assessing a resident's pain, Employee E stated, " If a resident reports a level of pain at a 5 on a scale of 0-10, I would ask them what their pain goal was. If it was a 4 to a 5, I wouldn't ask them whether they needed anything more for pain. If it was lower, I would ask if they needed something for pain. That's why the pain assessment has a question about the resident's pain goal." .

Based on observations, resident and staff interviews, and record review, the facility failed to ensure an allegation of physical abuse was investigated and immediately reported for 1 resident (Resident #5) out of 7 sampled residents. The facility had knowledge that a resident reported an allegation of physical abuse on February 14, 2014, but failed to investigate and report the allegation of abuse to the Abuse Coordinator, Administrator, or State authorities until 2/17/14. In addition, the facility failed to assure Resident #5 was protected from the alleged perpetrator during the investigation. After the resident's allegation, the alleged abuser continued to work with the resident on 2/15-16/14, and 2/19/14. This resulted in Immediate Jeopardy beginning on 2/14/2014. The facility's failure to prevent, investigate, and report physical abuse placed all residents on the unit at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was removed on 2/21/14 when the facility provided evidence of a complete investigation, including 45 written statements from staff regarding the resident and any allegations of abuse, and submitted an acceptable corrective action plan including reporting of the incident, retraining of all staff on identification and reporting of abuse, retraining on how to access the abuse policy, on-going monitoring of the retraining, more frequent abuse training, resident interviews regarding abuse, resident council in-service on reporting of abuse, resident skin checks, suspension of the two CNAs on duty at the time of the allegation, suspension of the Abuse Coordinator, assignment of the Administrator as the Abuse Coordinator, monitoring of concern forms to ensure accuracy, retraining of all staff on falsification of records, implementation of QAA tracking tool for abuse, and amendment of the abuse policy to protect all residents from the alleged abuser. Substandard quality of care was identified at F-225 S/S J and F-226 S/S J, 42 CFR 483.15. The findings include: On 2/17/2014 at 10:20 am, Resident #5 was observed on isolation precautions in a private room. When asked if anyone treated her roughly, Resident #5 said that a Certified Nursing Assistant (CNA) did 3 or 4 days ago while providing care. Resident #5 stated, "I was pushed against the wall while I was in bed; she was changing me and I was too weak to turn." The resident described the CNA who treated her roughly as, "my age, black, fat, but not real fat". The resident complained that the CNA hurt her right arm and her stomach when she pushed her against the wall. She said her stomach still hurt because of the incident. The resident stated, "I think she meant to push me against the wall. She's mean." The resident said she told all the nurses about the incident. The resident said she was fearful that the CNA might hurt her if she found out that the resident reported the abuse. On 2/17/14 at 2:35 pm, the Director of Nursing (DON) revealed that Employee #4 (CNA) fit the description given by the resident. She said the other CNA on that shift was black, tall, skinny, and younger. On 2/17/14 at 4:09 pm, the DON stated that Employee #4 was on her way in to provide a statement, and she would be suspended pending an investigation. On 2/18/14 at 10:40 am, the DON confirmed that Employee #4 was assigned to work with Resident #5 on 2/14-16/14 on the 11-7 shift. The DON said she contacted the Administrator, who was in Ohio, on 2/17/14, to let him know about the allegation of abuse. The DON stated that the allegation was reported to State authorities on 2/17/14. The DON apologized that the abuse policy "had not worked". Record review of staff assignment sheets for February 14-16, 2014 and February 19, 2014 revealed that Employee #4 was assigned to Resident #5 on the 11:00 pm to 7:00 am shift on those dates. Medical record review for Resident #5 revealed that she was admitted to the facility on [DATE]. The resident was hospitalized with pneumonia on 2/4/14, and readmitted to the facility on [DATE]. The resident had a Peripheral Intravenous Central Catheter (a tube for intravenous access) in her right upper arm. She had a gastrostomy tube in her stomach (for feeding), and a healing wound on her stomach. The Minimum Data Set, dated dated [DATE], revealed a brief interview for mental status (BIM) score of 12, out of a possible score of 15. Resident #5 required extensive two person assistance with bed mobility. The resident was always incontinent of both bladder and bowel. Review of the resident's readmission assessment on 2/11/14 revealed a mental status code of 5: Independent, decisions consistent/reasonable; speech clear, makes self understood, vision adequate. Review of the resident's care plan revealed a problem identified for Activities of Daily Living self-care deficit, due to weakness from [MEDICAL CONDITION] (breathing problem), [MEDICAL CONDITION] (backflow of blood into the heart), and [DIAGNOSES REDACTED] infection (bacterium in the intestines). The resident was also care planned for a surgical site to the abdomen that had opened up. Physician orders [REDACTED]. An interview on 2/17/2014 at 12:04 pm with the Agency Nurse revealed that on 2/14/14 during the 11-7 shift, Resident #5 complained that a CNA handled her roughly. The Agency Nurse stated that two black female CNAs were on duty on 2/14/14 on the 11-7 shift, "one older and one younger". The nurse stated, "Resident #5 kept saying she was reporting this to everyone". The agency nurse said she reported the resident's allegation to the on-coming nurse, Employee #5, on 2/15/14 during shift change report. She said she informed the Long Term Care Unit Manager (UM) of the allegation on the morning of 2/17/14. An interview conducted with Employee #5 on 2/18/2014 at 9:33 am revealed that she received a report at shift change on the morning of 2/15/14from the Agency Nurse. Employee #5 said the agency nurse did not report that any resident made an allegation of abuse. On 2/18/2014 at 10:00 am, an interview with Employee #1 revealed that Resident #5 told her on 2/16/14 around 6:00 am that the woman who changes her wigs a lot slammed her against the wall. The resident said her stomach hit the wall. When Employee #1 asked the resident if she was hurt, the resident pointed to her stomach. Employee #1 stated that she gave the resident something for pain. Employee #1 said she asked Resident #5 when it happened, and the resident said it occurred yesterday morning (2/15/14). When Employee #1 asked the resident who she reported the incident to, the resident said she reported it to the nurse. Employee #1 said she called and left a voice mail with her Unit Manager (UM) on 2/16/14, but the UM did not answer or call her back. Employee #1 said she reported the resident's allegation to the UM on the morning of 2/17/14, and wrote out a concern form at that time. Employee #1 stated, "My only regret is that I did not call the abuse hotline myself." On 2/17/2014 at 1:16 pm, an interview with the UM revealed that she tells her staff to call her if anything happens. The UM stated that Employee #1 called her on the night of 2/16/14, but the UM did not know what she wanted. The UM stated that when she came in this morning (2/17/14), Employee #1 told her that on 2/16/14, Resident #5 said she was slammed against the wall by a CNA. The UM instructed Employee #1 to "write it up" on a concern form. The UM stated that Employee #1 handed her the concern form this morning (2/17/14), and the UM gave it to the Abuse Coordinator. When asked what was on the concern form, the UM stated, "That staff slammed her into the wall". The UM stated that Employee #1 should have called the abuse coordinator when she found out about the allegation. She added that Resident #5 was not a complainer. Telephone interview on 2/20/14 at 5:00 pm with Employee #4 (CNA), with the DON present, revealed that she was assigned to care for Resident #5 on 2/14-16/2014 on the 11-7 shift. Employee #4 denied that anything adverse happened during her shifts throughout the weekend. She said that on 2/17/14, she came into the facility wearing street clothes. The Regional Director escorted her to the resident's room "to see if the resident knew me, and she said she knew me". The Regional Director then asked the resident "if I took care of her". The resident said, "No". When asked during the same interview if Employee #4 was still suspended from duty, the DON stated, "Yes, both CNAs are still suspended". When asked if she had returned to work, Employee #4 stated, "Yes, I returned to work last night and had my same assignment as usual". When asked if she meant 2/19/14 on the 11-7 shift, Employee #4 stated, "Yes". After the interview with Employee #4, the DON was reminded that when asked earlier if the two CNAs from the night shift were still suspended, she answered that they were. The DON replied, "Well, I just found out 15 minutes before this interview that (Employee #4) returned to work". The DON said she did not make the decision for Employee #4 to return to work. Review of the facility Investigation Report dated 2/19/14 and signed by the DON revealed, "It has been concluded that the allegation of abuse is not substantiated. Identified employees will be removed from suspension and returned to work." Interview on 2/21/14 at 1:30 pm with the Manager on Duty (MOD) for 2/15/14 (Employee #11) revealed that he was in the facility from 10:00 am to 2:00 pm on 2/15/14. He stated that staff did not report any allegations of abuse, or any other concerns to him on 2/15/14. He stated that he did not find out about Resident #5's allegation of abuse until he came to work on 2/17/14. He stated that the procedure for staff to follow for an abuse allegation on the weekend is to notify the MOD, who in turn notifies the Administrator and the Abuse Coordinator. Interview on 2/21/14 at 3:25 pm with the MOD for 2/16/14 revealed that she was in the facility from 6:00 am to 2:30 pm on 2/16/14. She stated that staff did not report any allegations of abuse, or any other concerns to her on 2/16/14. She stated that she did not receive any calls from staff after hours on 2/16/14 to report any concerns. She stated that she did not find out about Resident #5's allegation of abuse until she came to work on 2/17/14. Interview with the Abuse Coordinator on 2/17/14 at 12:58 pm revealed that all complaints, including abuse, are written on the concern log. She stated that she had not received any allegations of abuse since 2/12/14, and there were no new concerns reported over the weekend. She stated that the facility policy is for staff to complete a concern form as soon as an allegation of abuse is made. "Weekend staff on the 11pm - 7am shift should notify the on-call MOD immediately." When specifically asked if an abuse allegation was made by a resident on 2/14/14, she stated this was the first time she had heard of it. A record review of the concern log dating back to November, 2013 revealed no entries of concerns for Resident #5. The February, 2014 concern log revealed that the last entry was dated 2/12/2014. Interview on 2/20/14 at 10:45 am with the Department of Children and Families investigator revealed that the facility's report of the incident did not inform her agency of the resident's statement that she was slammed against the wall. She also stated that the facility did not reveal that the incident went unreported for several days. She said the Regional Director stated that she took Employee #4 into the resident's room and asked her if "it was her". The resident said, "No". Review of the Immediate Federal report submitted by the facility Abuse Coordinator revealed, "Patient states that she was pushed against wall in room when aide was providing routine care." On 2/18/14 the report was updated with the following statement: "Patient has verbalize numerous different accounts of the incident. Patient has reported one that she was slammed into the wall while being cleaned up, patient reported that she was pushed into the wall while receiving care, patient reported that she rolled over and hit her arm while receiving care, patient reported that she hit her left side and has bruises on her leg from receiving care, patient reported that her abdomen was still hurting from receiving care." On 2/20/14 at 1:36 pm, the Regional Director was interviewed. She stated that it was undetermined whether Employee #4 was the person involved in the allegation. She said she escorted Employee #4 into the resident's room on 2/17/14. She said the resident saw the employee, and after the employee left the room, the resident was asked if that was the person that did something to you. The resident said, "No". On 2/21/2014 at 12:55 pm, an interview with the Administrator revealed that he was not aware of the resident's allegation of abuse until he was notified by the facility on the afternoon of 2/17/14. He explained that his expectation of the staff is for them to call him immediately when there is any allegation of abuse. The Administrator said there was not a specific facility policy that explained how to conduct an abuse investigation. He said that taking the alleged abuser into the victim's room with an escort is one way of confirming who did it, by observing the body language of the victim, as well as interaction. He said then they would go back and ask the victim if that was the person who was accused. He said the abuse policy that was copied for the agency was "just a guide"; not necessarily a policy. He did not provide any other policy. An interview on 2/20/2014 at 5:07 pm with the Medical Director revealed that his expectation is that facility staff will immediately inform the Unit Managers, Director of Nurses, and the Administrator when abuse is reported or witnessed. The Administrator will then inform the Medical Director directly. However, if the issues or complaints are clinical in nature, then the staff are expected to call the Medical Director or the ARNP. The Medical Director revealed that he was made aware of Resident #5's allegation on the afternoon of 2/17/14. Review of the facility's Quality Milestone Action Plan revealed the following: Interviews of all staff scheduled to work on the weekend of 2/14/14 were completed on 2/18/14 (confirmed by review of the staff statements). Interviews of all interviewable residents regarding possible abuse were completed on 2/18/14 (confirmed by census list annotated and signed by Department Heads). The Active Employee list revealed 182 employees. Review of the Staff Development Program Attendance Record sign-in sheet and Inservice Attendance Matrix for each department revealed that 165 staff were inserviced on 2/17-18/14 regarding abuse and neglect protection. Interview with the DON on 2/21/14 at 3:50 pm revealed the remaining staff were on leave of absence or as needed status, and will receive training if they return to work. Interview on 2/21/14 at 1:29 pm with Employee #6 (CNA) revealed She was given an in-service on 2/18/14 about abuse. The training included reporting abuse right away, who the abuse coordinator is, and the abuse hotline number. Interview on 2/21/14 at 1:39 pm with Employee #7 (CNA) revealed she received education about abuse on 2/18/14 when she came to work. The training included who to report abuse to, who the abuse coordinator is, and the abuse hotline number. The 11-7 shift from the night before was also receiving in-service when she came onto the unit. Interview on 2/21/14 at 1:48 pm with Employee #8 (CNA) revealed that she received education regarding abuse when she arrived to work on 2/20/14. The training included what is abuse, reporting immediately, who the abuse coordinator is, and the abuse hotline number. Interview on 2/21/14 at 2:11 pm with Employee #1 (Nurse) revealed she received education on abuse in the supervisor's office on 2/18/14. The training included what to do if abuse happened to a patient, calling the chain of command and the abuse hotline number, and who the abuse coordinator is. Interview on 2/21/14 at 2:55 pm with Employee #9 (Activity Assistant) revealed she received an in-service on abuse when she clocked in on 2/18/14. The training included what she would do if she saw abuse, or if a resident reported abuse, and who she would tell about it. Review of 45 written statements taken by the facility from staff revealed that all weekend staff were interviewed about the resident, and any indications of abuse. No concerns were found. Interview on 2/21/14 at 3:20 pm with the Human Resources Director revealed that an orientation checklist for Agency staff was now in use. The checklist was completed on 2 Agency nurses to date. Further interview at 4:00 pm revealed that previous to implementation of the checklist Agency nurses were required to have abuse training, but the facility did not provide it. She stated that she provided orientation today to an Agency nurse on duty (Employee # 10). Interview on 2/21/14 at 3:25 pm with the Administrator revealed that the orientation checklist was initiated on 2/18/14 or 2/19/14 for use with all Agency staff before they work in the facility. Interview on 2/21/14 at 3:50 pm with the DON revealed that previous to implementation of the orientation checklist, Agency staff were allowed to work based on the training provided by the Agency. She stated that there are 3 Agency nurses who the facility uses regularly. Interview with Employee #10 (Nurse)on 2/21/14 at 4:20 pm revealed that the Agency required her to keep her continuing education for abuse updated. The Agency provided a packet of written information to her, including abuse training. She confirmed that the facility oriented her today, including abuse training. Interview with Employee #11, (Maintenance) on 2/21/14 at 2:15 pm revealed that he received training on abuse on 2/17/14. The training included who to notify, and the types of abuse. He stated that he would notify the Administrator and the Abuse Coordinator if he knew of any abuse. Interview on 2/21/14 at 3:25 pm with the Dietary Manager revealed she was trained on abuse by the facility this week, and she in turn trained all of her staff on abuse. the training included what abuse is, who the abuse coordinator is, and what the chain of command is for reporting immediately. .

Based on observations, resident and staff interviews, and policy and record reviews, the facility failed to implement their abuse policy to identify, investigate, protect and report/respond to an allegation of abuse for 1 resident (Resident #5) out of 7 sampled residents, which resulted in Immediate Jeopardy on 2/14/14. The facility had knowledge on 2/14/14 that Resident #5 voiced an allegation of physical abuse. The allegation was not investigated or reported to the Administration or the Abuse Coordinator until 2/17/14. After the resident's allegation, the alleged abuser continued to work with the resident on 2/15-16/14, and 2/19/14. The facility's failure to implement thier policy to prevent, investigate and report abuse, and protect the the alleged victim of physical abuse placed all residents on the unit at risk for serious injury, harm, impairment, or death. Immediate Jeopardy was removed on 2/21/14, when the facility provided evidence of a complete investigation, including 45 written statements from staff regarding the resident and any allegations of abuse, and submitted an acceptable corrective action plan including reporting of the incident, retraining of all staff on identification and reporting of abuse, retraining on how to access the abuse policy, on-going monitoring of the retraining, more frequent abuse training, resident interviews regarding abuse, resident council in-service on reporting of abuse, resident skin checks, suspension of the two CNAs on duty at the time of the allegation, suspension of the Abuse Coordinator, assignment of the Administrator as the Abuse Coordinator, monitoring of concern forms to ensure accuracy, retraining of all staff on falsification of records, implementation of QAA tracking tool for abuse, and amendment of the abuse policy to protect all residents from the alleged abuser. Substandard quality of care was identified at F-225 S/S J and F-226 S/S J, 42 CFR 483.15. The findings include: On 2/17/2014 at 10:20 am, Resident #5 was observed on isolation precautions in a private room. When asked if anyone treated her roughly, Resident #5 said that a Certified Nursing Assistant (CNA) did 3 or 4 days ago. Resident #5 stated, "I was pushed against the wall while I was in bed; she was changing me and I was too weak to turn." The resident described the CNA who treated her roughly as "my age, black, fat, but not real fat". The resident complained that the CNA hurt her right arm and her stomach when she pushed her against the wall. She said her stomach still hurt because of the incident. The resident stated, "I think she meant to push me against the wall. She's mean." The resident said she told all the nurses about it. The resident said she was fearful that the CNA might hurt her if she found out that the resident reported the abuse. On 2/17/14 at 2:35 pm, the Director of Nursing (DON) revealed that Employee #4 (CNA) fit the description given by the resident. She said the other CNA on that shift is black, tall, skinny, and younger. On 2/17/14 at 4:09 pm, the DON stated that Employee #4 was on her way to the facility to provide a statement, and she would be suspended pending an investigation. On 2/18/14 at 10:40 am, the DON confirmed that Employee #4 was assigned to work with Resident #5 on 2/14-16/14 on the 11-7 shift. The DON said she contacted the Administrator, who was in Ohio, on 2/17/14 to let him know about the allegation of abuse. The DON stated that the allegation was reported to State authorities on 2/17/14. The DON apologized that the abuse policy "had not worked". Medical record review for Resident #5 revealed that she was admitted to the facility on [DATE]. The resident was hospitalized with pneumonia on 2/4/14, and re-admitted to the facility on [DATE]. Observations on 2/17/14 at 9:30 am revealed that the resident had a Peripheral Intravenous Central Catheter (a tube for intravenous access) in her right upper arm. She had a gastrostomy tube in her stomach (for feeding), and a healing wound on her stomach. The Minimum Data Set, dated dated [DATE], revealed a brief interview for mental status (BIM) score of 12, out of a possible score of 15. Resident #5 required extensive two-person assistance with bed mobility. The resident was always incontinent of both bladder and bowel. Review of the resident's readmission assessment on 2/11/14 revealed a mental status code of 5: Independent, decisions consistent/reasonable; speech clear, makes self understood, vision adequate. Review of the resident's care plan revealed a problem identified for Activities of Daily Living self-care deficit, related to weakness from [MEDICAL CONDITION] (breathing problem), [MEDICAL CONDITION] (backflow of blood into the heart), and [DIAGNOSES REDACTED] infection (bacterium in the intestines). The resident was also care planned for a surgical site to the abdomen that had opened up. Physician orders, dated 2/11/14, also revealed treatment for [REDACTED]. An interview on 2/17/2014 at 12:04 pm with the Agency Nurse revealed that on 2/14/14 during the 11-7 shift, Resident #5 complained that a CNA handled her roughly. The Agency Nurse stated that two black female CNAs were on duty on 2/14/14 on the 11-7 shift; "one older and one younger". She stated, "Resident #5 kept saying she was reporting this to everyone". The agency nurse said she reported the resident's allegation to the on-coming nurse, Employee #5, on 2/15/14 during the shift change report. She said she informed the Long Term Care Unit Manager (UM) of the allegation on the morning of 2/17/14. An interview conducted with Employee #5 on 2/18/2014 at 9:33 am revealed that she received a change of shift report from the agency nurse on the morning of 2/15/14. Employee #5 said the agency nurse did not report that any resident made an allegation of abuse. On 2/18/2014 at 10:00 am, an interview with Employee #1 revealed that Resident #5 told her on 2/16/14 around 6:00 am that the woman who changes her wigs a lot slammed her against the wall. The resident said her stomach hit the wall. When Employee #1 asked the resident if she hurt, the resident pointed to her stomach. Employee #1 stated that she gave the resident something for pain. Employee #1 said she asked Resident #5 when it happened, and the resident said it occurred yesterday morning (2/15/14). When Employee #1 asked the resident who she reported the incident to, the resident said she reported it to the nurse. Employee #1 said she called and left a voice mail with her Unit Manager (UM) on 2/16/14, but the UM did not answer or call her back. Employee #1 said she reported the resident's allegation to the UM on the morning of 2/17/14, and wrote out a concern form at that time. Employee #1 stated, "My only regret is that I did not call the abuse hotline myself". On 2/17/2014 at 1:16 pm, an interview with UM revealed that she tells her staff to call her if anything happens. The UM stated that Employee #1 called her on the night of 2/16/14, but the UM did not know what she wanted. The UM stated that when she came in this morning (2/17/14), Employee #1 told her that Resident #5 said on 2/16/14 that she was slammed against the wall by a CNA. The UM instructed Employee #1 to "write it up" on a concern form. She said Employee #1 handed her the concern form this morning (2/17/14), and the UM gave it to the Abuse Coordinator. When asked what was on the concern form, the UM stated, "That staff slammed her into the wall." The UM stated that Employee #1 should have called the Abuse Coordinator when she found out about the allegation. She added that Resident #5 was not a complainer. When asked for the facility abuse policy, the UM stated that she did not know how to access it. Interview with the Abuse Coordinator on 2/17/14 at 12:58 pm revealed that all complaints, including abuse, are written on the concern log. She stated that she had not received any allegations of abuse since 2/12/14, and there were no new concerns reported over the weekend. She stated that the facility policy is for staff to complete a concern form as soon as an allegation of abuse is made. "Weekend staff on the 11pm - 7am shift should notify the on-call MOD immediately." When specifically asked if an abuse allegation was made on 2/14/14, she stated this was the first time she had heard of it. Record review of staff assignment sheets for February 14-16, 2014 and February 19, 2014 revealed that Employee #4 was assigned to Resident #5 on the 11:00 pm to 7:00 am shift on those dates. Telephone interview on 2/20/14 at 5:00 pm with Employee #4, with the DON present, revealed that she was assigned to care for Resident #5 on the 11-7 shift on 2/14-16/2014. Employee #4 denied that anything adverse happened during her shifts throughout the weekend. She said that on 2/17/14, she came into the facility wearing street clothes. The Regional Director escorted her to the resident's room "to see if the resident knew me, and she said she knew me". The Regional Director then asked the resident "if I took care of her". The resident said, "No". When asked during the same interview if Employee #4 was still suspended from duty, the DON stated, "Yes, both CNAs are still suspended". When asked if she had returned to work, Employee #4 stated, "Yes, I returned to work last night and had my same assignment as usual". When asked if she meant 2/19/14 on the 11-7 shift, Employee #4 stated, "Yes". After the interview with Employee #4, the DON was reminded that when asked earlier if the two CNAs were still suspended, she answered that they were. The DON replied, "Well, I just found out 15 minutes before this interview that (Employee #4) returned to work." The DON said she did not make that decision. Review of the facility Investigation Report dated 2/19/14 and signed by the DON revealed, "It has been concluded that the allegation of abuse is not substantiated. Identified employees will be removed from suspension and returned to work." Review of Employee #4's personnel record revealed that she received disciplinary action on December 13, 2013 regarding the facility policy on proper turning and repositioning of residents. Interview with Employee #1 revealed that Employee #4 was not turning the residents every two hours as needed. Interview on 2/21/14 at 1:30 pm with the Manager on Duty (MOD) for 2/15/14 (Employee #11) revealed that he was in the facility from 10:00 am to 2:00 pm on 2/15/14. He stated that staff did not report any allegations of abuse, or any other concerns to him on 2/15/14. He stated that he did not find out about Resident #5's allegation of abuse until he came to work on 2/17/14. He stated that the procedure for staff to follow for an abuse allegation on the weekend is to notify the MOD, who in turn notifies the Administrator and the Abuse Coordinator. Interview on 2/21/14 at 3:25 pm with the MOD for 2/16/14 revealed that she was in the facility from 6:00 am to 2:30 pm on 2/16/14. She stated that staff did not report any allegations of abuse, or any other concerns to her on 2/16/14. She stated that she did not receive any calls from staff after hours on 2/16/14 to report any concerns. She stated that she did not find out about Resident #5's allegation of abuse until she came to work on 2/17/14. On 2/18/2014 at 8:33 am, an interview with the DON revealed that agency nurses receive an hour of abuse training prior to working in the facility. The surveyor asked the DON for the Agency Nurse's education and training record. The DON was not able to produce this record. Interview on 2/20/14 at 10:45 am with the Department of Children and Families' investigator revealed that the facility's abuse report did not inform her agency of the resident's statement that she was slammed against the wall. She also stated that the facility did not reveal that the incident went unreported for several days. She said the Regional Director stated that she took Employee #4 into the resident's room and asked her if "it was her". The resident said, "No". Review of the Immediate Federal report submitted by the facility Abuse Coordinator revealed, "Patient states that she was pushed against wall in room when aide was providing routine care." On 2/18/14 the report was updated with the following statement: "Patient has verbalize numerous different accounts of the incident. Patient has reported one that she was slammed into the wall while being cleaned up, patient reported that she was pushed into the wall while receiving care, patient reported that she rolled over and hit her arm while receiving care, patient reported that she hit her left side and has bruises on her leg from receiving care, patient reported that her abdomen was still hurting from receiving care." On 2/20/14 at 1:36 pm, the Regional Director was interviewed. She stated that it was undetermined whether Employee #4 was the person involved in the allegation. She said she escorted Employee #4 into the resident's room on 2/17/14. She said the resident saw the employee, and after the employee left the room, the resident was asked if that was the person that did something to you. The resident said, "No". On 2/21/2014 at 12:55 pm, an interview with the Administrator revealed that he was not aware of the resident's allegation of abuse until he was notified by the facility on the afternoon of 2/17/14. He explained that his expectation of the staff is for them to call him immediately when there is any allegation of abuse. The Administrator said there was not a specific facility policy that explained how to conduct an abuse investigation. He said that taking the alleged abuser into the victim's room with an escort is one way of confirming who did it, by observing the body language of the victim, as well as interaction. He said then they would go back and ask the victim if that was the person who was accused. He said the abuse policy that was copied for the agency was "just a guide"; not necessarily a policy. An interview on 2/20/2014 at 5:07 pm with the Medical Director revealed that his expectation is that facility staff will immediately inform the Unit Managers, Director of Nurses, and the Administrator when abuse is reported or witnessed. The Administrator will then inform the Medical Director directly. However, if the issues or complaints are clinical in nature, then staff are expected to call the Medical Director or the ARNP. The Medical Director revealed that he was made aware of Resident #5's allegation on the afternoon of 2/17/14. A record review of the concern log, from November, 2013 to February, 2014 revealed no entries of concerns for Resident #5. The February, 2014 concern log revealed that the last entry was dated 2/12/2014. Review of the facility abuse policy, with a copyright date of 2011, revealed that abuse means "the willful infliction of injury, ...intimidation, or punishment with resulting physical harm, pain or mental anguish". Under the heading Procedures for Reporting, the policy states that employees are educated upon hire and annually for the abuse prevention program, including the immediate reporting of any suspicion of abuse. The policy states, "The key to investigating abuse allegations is an environment that facilitates the reporting of such allegations. Once reported, the center conducts timely, thorough, and objective investigation of any allegations of abuse." The facility must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. The policy states that the Center must establish an environment where staff and patients who report abuse "...are not fearful of reprisal and are protected from retaliation, both during and after any investigation into the event". Patient protection actions include immediately removing the patient from contact with the alleged abuser during the investigation. If the incident involves a Center employee, the employee is suspended pending completion of the investigation. Actions may include "...Patient daily schedule change". Under the heading Reporting, the Center must ensure that all alleged violations involving mistreatment, neglect or abuse "....are reported immediately to the administrator of the facility and other officials in accordance with state law". Review of the facility's Quality Milestone Action Plan revealed the following: Interviews of all staff scheduled to work on the weekend of 2/14/14 were completed on 2/18/14 (confirmed by review of the staff statements). Interviews of all interviewable residents regarding possible abuse were completed on 2/18/14 (confirmed by census list annotated and signed by Department Heads). The Active Employee list revealed 182 employees. Review of the Staff Development Program Attendance Record sign-in sheet and Inservice Attendance Matrix for each department revealed that 165 staff were inserviced on 2/17-18/14 regarding abuse and neglect protection. Interview with the DON on 2/21/14 at 3:50 pm revealed the remaining staff were on leave of absence or as needed status, and will receive training if they return to work. Interview on 2/21/14 at 1:29 pm with Employee #6 (CNA) revealed She was given an in-service on 2/18/14 about abuse. The training included reporting abuse right away, who the abuse coordinator is, and the abuse hotline number. Interview on 2/21/14 at 1:39 pm with Employee #7 (CNA) revealed she received education about abuse on 2/18/14 when she came to work. The training included who to report abuse to, who the abuse coordinator is, and the abuse hotline number. The 11-7 shift from the night before was also receiving in-service when she came onto the unit. Interview on 2/21/14 at 1:48 pm with Employee #8 (CNA) revealed that she received education regarding abuse when she arrived to work on 2/20/14. The training included what is abuse, reporting immediately, who the abuse coordinator is, and the abuse hotline number. Interview on 2/21/14 at 2:11 pm with Employee #1 (Nurse) revealed she received education on abuse in the supervisor's office on 2/18/14. The training included what to do if abuse happened to a patient, calling the chain of command and the abuse hotline number, and who the abuse coordinator is. Interview on 2/21/14 at 2:55 pm with Employee #9 (Activity Assistant) revealed she received an in-service on abuse when she clocked in on 2/18/14. The training included what she would do if she saw abuse, or if a resident reported abuse, and who she would tell about it. Review of 45 written statements taken by the facility from staff revealed that all weekend staff were interviewed about the resident, and any indications of abuse. No concerns were found. Interview on 2/21/14 at 3:20 pm with the Human Resources Director revealed that an orientation checklist for Agency staff was now in use. The checklist was completed on 2 Agency nurses to date. Further interview at 4:00 pm revealed that previous to implementation of the checklist Agency nurses were required to have abuse training, but the facility did not provide it. She stated that she provided orientation today to an Agency nurse on duty (Employee # 10). Interview on 2/21/14 at 3:25 pm with the Administrator revealed that the orientation checklist was initiated on 2/18/14 or 2/19/14 for use with all Agency staff before they work in the facility. Interview on 2/21/14 at 3:50 pm with the DON revealed that previous to implementation of the orientation checklist, Agency staff were allowed to work based on the training provided by the Agency. She stated that there are 3 Agency nurses who the facility uses regularly. Interview with Employee #10 (Nurse)on 2/21/14 at 4:20 pm revealed that the Agency required her to keep her continuing education for abuse updated. The Agency provided a packet of written information to her, including abuse training. She confirmed that the facility oriented her today, including abuse training. Interview with Employee #11, (Maintenance) on 2/21/14 at 2:15 pm revealed that he received training on abuse on 2/17/14. The training included who to notify, and the types of abuse. He stated that he would notify the Administrator and the Abuse Coordinator if he knew of any abuse. Interview on 2/21/14 at 3:25 pm with the Dietary Manager revealed she was trained on abuse by the facility this week, and she in turn trained all of her staff on abuse. the training included what abuse is, who the abuse coordinator is, and what the chain of command is for reporting immediately. . .