Every finding on record at Washington Center

Based on interviews and record reviews, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1). Despite being a known elopement and fall risk, Resident 1 left the facility lobby unnoticed by staff. This failure in care caused Resident 1 to suffer a fall during an episode of elopement. A review of Resident 1's Face sheet indicated that the resident was admitted to the facility on [DATE] with diagnoses which included history of falling and muscle weakness. During a review of Resident 1's MDS (an assessment tool) Section C (assesses a nursing home resident's cognitive patterns, including attention, orientation, short and long term memory, recall, and the presence of delirium) dated 5/15/26, Section C indicated Resident 1's cognition was moderately impaired. The MDS Section GG (measures a resident's functional abilities and goals, focusing on self-care and mobility) titled Functional Abilities indicated that Resident 1 used a manual wheelchair and needed partial/moderate assistance when wheeling to at least 150 feet. A review of Resident 1's Interdisciplinary Team (IDT) care conference notes dated 4/20/26 revealed Resident 1 fell outside the facility's lobby on 4/20/26 at 9:00 a.m. The IDT care conference notes indicated that Resident 1 was in the wheelchair and went out of the facility and stood up. Resident 1 sustained scrapes on right knee and left shoulder and had swelling of right leg and right ankle. The IDT notes also indicated that Resident 1 had unsteady gait and impaired balance (IDT, a group of individuals representing different departments of the facility). During a review of Resident 1's Leave of Absence Without Notice (LAWN or facility's elopement risk assessment) dated 2/18/26, it indicated that Resident 1 was at risk for Leave of Absence Without Notice or elopement. During an interview on 6/23/26 at 9:08 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated that on 4/20/26 at 9:00 a.m., CNA 1 was busy attending to another resident and did not notice Resident 1 leave the facility through the front lobby door. CNA 1 was unaware of the incident and did not know that Resident 1 had already fallen at that time. During an interview on 6/22/26 at 1:44 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated that on 4/20/26 at 9:00 a.m., the facility staff were busy and did not notice Resident 1 go out of the lobby door and fell. Also stated Resident 1 was a high fall risk and should not have gotten out of the lobby unsupervised. During an interview on 6/22/26 at 3:26 p.m., with the Director of Nursing (DON), the DON stated Resident 1 is a known fall and elopement risk and should have been supervised more closely. During a review of the facility's policy and procedure (P&P) titled Fall Management dated 5/26/21, the P&P indicated, Patients will be assessed for fall risk as part of the nursing assessment process. Those determined to be at risk will receive appropriate interventions to reduce risk and minimize injury. During a review of the facility's P&P titled, Leave of Absence Without Notice(LAWN), dated 1/16/26, the P&P indicated, Policy: The interdisciplinary team members (IDT) are recommended to evaluate if a resident is deemed at risk of leaving the facility without notice and identify resident-specific measures in a least restrictive environment.Procedural Guidelines: 1. Residents will be evaluated by the interdisciplinary team members (IDT) for possible leave of absence without notice/authorization upon admission, quarterly and when there is a significant change condition.

Based on observation, interview, and facility policy review, the facility failed to ensure the nursing staff locked two of four medication carts when it was not in their eyesight view. This failure had the potential for unauthorized users to access medications. Findings included: During a concurrent interview and observation of medication administration on 11/05/2024 at 7:02 AM and 7:09 AM, Registered Nurse (RN) 1 left medication cart labeled Lower 200 unlocked and out of her view in the hallway and entered a resident's room to administer medication. RN 1 stated the medication cart should be locked and that she forgot. The unlocked, unsecured medication cart contained several medications, not limited to Lasix to treat high blood pressure and fluid retention, Eliquis to prevent blood clot formation, and nitroglycerin to treat acute chest pain. During an interview on 11/05/2024 at 11:22 AM, RN 5 stated nurses must lock the medication cart and computer screen when they step away from the medication cart. During an interview on 11/05/2024 at 11:46 AM, Licensed Vocational Nurse (LVN) stated medication carts must be locked when nurses did not have an eye on the cart. LVN 6 said medication carts were kept in the facility hallways and were not safe when left unlocked. During an interview on 11/05/2024 at 11:48 AM, LVN 3 stated it was the nurse's responsibility to keep the medication cart secured to prevent accidents. During a concurrent interview and observation on 11/06/2024 at 8:57 AM, an unattended and unlocked medication cart was observed in the 100 hall in the hallway. At 9:02 AM, LVN 6 came from facility's entrance door and stated she was the nurse assigned to the cart. LVN 6 stated the medication cart should be locked because of the medications it contained. Per LVN 6, the medication cart contained Eliquis to treat atrial fibrillation, Lisinopril and Lasix used to treat hypertension. During a concurrent interview and observation on 11/06/2024 at 11:50 AM, the medication art labeled Lower 200 was observed unlocked in the hallway. When LVN #7 exited a resident's room, she stated the medication cart was not visible and she should not have left the medication cart opened. During an interview on 11/06/2024 at 2:08 PM, the Director of Nursing (DON) stated the medication carts must be locked when left unsupervised. The DON said it was important to keep it locked due to safety and privacy. The DON stated she expected nursing staff to make sure the medication carts were locked from unauthorized access. During an interview on 11/06/2024 at 2:33 PM, the Administrator stated the nurses must lock the medication when it was not in their eyesight. A facility policy titled, Medication Storage in the Facility with an effective date of 04/2028, indicated, Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized.

Based on interview, record review, and facility policy review, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) for three (Residents 12, 28, and 78) of 21 sampled residents. This failure had the potential to result in inaccurate care plans and inadequate care provisions. Findings included: 1. An Admission Record indicated the facility admitted Resident 78 on 06/25/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of encounter for other orthopedic aftercare. A quarterly MDS, with an Assessment Reference Data (ARD) of 09/30/2024, indicated Resident 78 was administered an anticoagulant medication in the last seven days. Resident 78's Order Summary Report for the timeframe 06/25/2024 to 11/30/2024, revealed no evidence to indicate the resident was ordered an anticoagulant medication. During an interview on 11/06/2024 at 9:37 AM, the MDS Coordinator stated she was responsible for section of the MDS that involved what kind of medication residents took during the look-back period. The MDS Coordinator stated it was important to have medication coded correctly to make sure it did not interfere with other medications and side effects from medications. The MDS Coordinator reviewed Resident 78's quarterly MDS with an ARD of 09/30/2024 and it indicated the resident received an anticoagulant medication; however, it was coded incorrectly and was a mistake. During an interview on 11/06/2024 at 2:01 PM, the Director of Nursing stated her expectations would be that MDS assessments were coded accurately. During an interview on 11/06/2024 at 2:32 PM, the Administrator stated she expected MDS to be coded accurately.During an interview on 11/06/2024 at 2:32 PM, the Administrator stated she expected MDS to be coded accurately. 45645 2. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/02/2024, revealed the facility admitted Resident 12 on 05/24/2018. Per the MDS, the resident had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no behaviors or hallucinations during the 7-day look-back period. The MDS indicated the resident had active diagnoses to include anemia, heart failure, hypertension, cerebrovascular accident, anxiety disorder, depression, and bipolar disorder. Resident 12's Medication Administration Record for the timeframe 07/01/2024 to 07/31/2024, indicated the resident displayed hallucinations and behaviors of crying/yelling out. Resident 12's Medication Administration Record for the timeframe 08/01/2024 to 08/31/2024, indicated the resident displayed hallucinations and behaviors of crying/yelling out. During an interview on 11/06/2024 at 8:18 AM, the Social Service Designee stated Resident 12 had episodes of hallucinations and behaviors and they were not accurately reflected on the resident's MDS. 3. An Admission Record indicated the facility admitted Resident 28 on 12/04/2021. According to the Admission Record, the resident had a medical history to include diagnoses of essential hypertension, dysarthria and anarthria, encounter for palliative care. A significant change in status Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/31/2024, revealed Resident 28 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had no behaviors during the 7-day look-back period. Resident 28's Medication Administration Record for the timeframe 08/01/2024 to 08/31/2024, indicated the resident displayed episodes of restlessness and yelling at staff. During an interview on 11/06/2024 at 8:18 AM, the Social Service Designee stated Resident 28 had behaviors and they were not accurately reflected on the resident's MDS. During an interview on 11/06/2024 at 2:01 PM, the Director of Nursing stated her expectations would be that MDS assessments were coded accurately. During an interview on 11/06/2024 at 2:32 PM, the Administrator stated she expected MDS to be coded accurately. A facility policy titled, Resident Assessments, revised 10/2023, indicated, 6. The resident assessment coordinator is responsible for ensuring that the interdisciplinary team conducts timely and appropriate resident assessments. The policy specified, 12. Information in the MDS assessments will consistently reflect information in the progress notes, plans of care and resident observations/interviews.

Based on observation, interview, record review, facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for one (Resident 2) of 21 sampled residents. This failure had the potential to result in the spread of infection. Findings included: An Admission Record revealed the facility admitted Resident 2 on 02/27/2024. According to the Admission Record, the resident had a medical history that included a diagnosis of encephalopathy, sepsis, enterococcus, methicillin resistant staphylococcus aureus infection and gastrostomy status. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 10/17/2024, revealed Resident 2 had a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had moderate cognitive impairment. The MDS indicated Resident 2 had a feeding tube. Resident 2's care plan included a focus area, initiated 05/17/2024, that indicated the resident required enhanced barrier precautions (EBP) related to gastrostomy tube (G-tube) placement. Interventions directed staff to use gown and gloves during high contact resident care activities. Resident 2's Order Summary Report, that contained active orders as of 11/06/2024, revealed an order dated 08/07/2024, for EBP due to tube feeding every shift. During a concurrent observation and interview on 11/05/2024 at 9:20 AM, Registered Nurse (RN) 1 entered Resident 2's room to administer medications to the resident by way of a feeding tube. RN 1 wore gloves and no other personal protective equipment. RN 1 stated a gown was necessary because Resident 2 was on EBP precautions. During an interview on 11/06/2024 at 2:08 PM, the Director of Nursing (DON) stated EBP was initiated for residents at high risk and gowns were required. The DON stated RN 1 must use a gown during medication administration by way of a feeding tube for Resident 2. The DON stated she expected for the nurses to follow the protocols adopted by the facility to deliver diligent care and protect the residents. During an interview on 11/06/2024 at 2:33 PM, the Administrator stated staff must wear a gown when required and expected the staff to comply with the instructions and reach out to the charge nurse when in doubt. An undated facility policy titled, Enhanced Standard/Barrier Precautions, indicated, It is the policy of this facility to implement enhanced standard/barrier precautions for the prevention of transmission of multidrug-resistant organisms [MDRO]. Definitions Enhanced Standard/Barrier Precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medication devices. Per the policy, c. Chacterisitics of Residents at High Risk for MDRO Colonization and Transmission Functional Disability: i. Presence of indwelling devices: urinary catheter, feeding tube, tracheostomy tube, vascular catheters Ventilator-dependence.

Based on observation, interview, and record review, the facility failed to supervise one of two residents (Resident 2) to prevent Resident 2 from hitting Resident 1 on the forehead. The failure to supervise Resident 2, who had increasing behaviors of physical aggression, and failure to protect residents from Resident 2's physical aggression, resulted in a small bump and bruise to Resident 1's forehead, and had the potential to result in more serious injury. Findings: A review of Resident 1's Minimum Data Set (MDS, a resident assessment tool used to guide care) dated 4/7/21, indicated Resident 1 had entered the facility in 2014. The MDS indicated Resident 1 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's MDS dated [DATE], indicated Resident 2 was admitted in November 2020, with a BIMS (The Brief Interview for Mental Status is a scoring system used to determine the resident's cognitive status in regard to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) score of five, an indication of severe cognitive impairment. A review of Resident 2's Psychiatry MD Inpatient SNF Consult Follow-up note dated 5/19/21 at 10 a.m., indicated Resident 2 had eloped from the facility, several times, but then comes back. She tends to sleep a lot during the day, then is up at night in her wheelchair, with a lot of behavioral acting out. During a review of Resident 2's Free Text Note, Psychiatry MD Urgent Telephone Contact, dated 5/21/21, the Note indicated Resident 2 had been, exhibiting more problematic, manic-like [frenzied, abnormally excited, or irritated mood] behavior .She has been attempting to leave the facility .Medication changes 2 days ago have so far not resulted in any improvement and behavior seems worse today. A review of Resident 2's IDT (Interdisciplinary Team) Notes dated 5/24/21 at 1:58 p.m., indicated Resident 2 had hit two staff members on 5/21/21, and was subsequently sent to acute care hospital for evaluation. The IDT Note indicated Resident 2 had returned to the facility from acute care hospital on 5/22/21. A review of Resident 2's nursing progress notes dated 5/24/21 at 5:45 a.m., indicated, patient was not sleeping, in and out of the room, very loud, verbally abusive and tried to hit staffs. A review of Resident 2's nursing progress notes dated 5/24/21 at 11:07 p.m., indicated, At 9 pm she was sleeping in her bed and at 10:15 she was found walking fast in the hallway talking to herself saying she is going out and told everyone to back off, she went out of the front door and she stopped when told that its dark and there might be people there that will harm her, staffs persuaded her to go back to her room after 10 minutes of coaxing, after 2-3 minutes in the room, she came out and found [Resident 1] wheeling around and according to the witness she just gave her a surprise punch in the forehead and she started going wild and screaming. During an interview on 6/2/21 at 11: 45 a.m., with Certified Nursing Assistant (CNA 1), CNA 1 stated on 5/24/21 at 11:20 p.m., he found Resident 2 just outside the facility entrance, but had been able to redirect her back inside the facility. CNA 1 stated Resident 2 became very agitated and was yelling and seemed angry. CNA 1 stated Resident 2 went into her room briefly, then walked out of her room and into the hallway across from her room, where Resident 1 sat in her wheelchair and hit Resident 1 in the head. CNA 1 stated he helped to separate the residents after the physical attack and called 9-1-1. During an interview on 6/2/21 at 11: 45 a.m., with the Director of Nursing (DON), the DON stated Resident 2 had a prior history of physical aggression toward staff members but this had been the first time Resident 2 had hit another resident. A review of Resident 1's SBAR (Situation, Background, Appearance, Review) note dated 5/24/21, indicated Resident 1 showed non-verbal signs of distress, sad/frightened/frown, after she was hit by Resident 2. The SBAR Appearance indicated, patient was hit in the head by another patient with the back of her hand and she sustained a bruise and a bump in her rt [right] forehead, patent became hysterical for awhile .ice packs applied and it helped eased the pain . During an observation on 6/2/21 at 12:40 p.m., with Director of Nursing (DON), Resident 1 was in her room, laying on her bed. Resident 1 had a bump the size of a dime on the right side of her forehead.

Based on interview and record review the facility failed to ensure one of three sampled residents (Resident 10) with a gastrostomy tube (GT, a tube inserted through the wall of the abdomen directly into the stomach) had documentation of provision of ordered nursing care related to the GT. This failure resulted in impaired communication across shifts and had the potential to result in inaccurate assessments of needed care, and unnecessary duplication of care. Findings: A review of Resident 10's face sheet indicated Resident 10 admitted to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 10 ' s Medication Administration Record (MAR) dated 9/2021, indicated the following physician orders were not signed/initialed to indicate task completion by the night shift (the shift starting at 11 p.m. and ending 7:30 a.m. the following morning) nurse on 9/17/21, 9/18/21, 9/24/21, 9/28/21: every shift, check stomach contents before beginning a tube feeding, and delay feeding for one hour if the contents were more than 100 milliliters; elevate the head of the bed 30-45 degrees during feedings; flush the GT with 30ml of water before and after each medication. During a review of Resident 10 ' s Treatment Administration Record (TAR) dated 9/21, indicated the following physician orders were not signed/initialed to indicated task completion by the night shift nurse on 9/17/21, 9/24/21, 9/28/21, and 9/30/21: change the syringe that contained the tube feeding every night shift; monitor GT site for any redness or discharge every shift. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/13/21 at 12:50 p.m., with Licensed Vocational Nurse 1 (LVN1), LVN 1 stated she had been the assigned nurse on the night shifts of 9/17/21, 9/24/21, 9/28/21, and 9/30/21. LVN 1 stated she had forgotten to document completion of the tasks on those dates. LVN 1 stated if the tasks were not documented, the assumption was the tasks were not performed. During an interview and concurrent review of Resident 10 ' s September 2021 MAR and TAR on 10/12/21, at 11:13 a.m., with the Director of Nursing (DON), the DON stated the ordered tasks without initials on the MAR and TAR indicated those tasks had not been completed. The DON stated nurses should document completion of all resident care tasks. A review of the facility policy and procedure, Center's Nursing Policies revised 6/1/21, indicated, Documentation includes information about the patient's status, nursing assessment and interventions . Timely entry of documentation must occur as soon as possible after the provision of care . All patient information will be documented .

Based on observation, interview, and record review, the facility failed to follow infection prevention and control policies and procedures to reduce the spread of novel Coronavirus disease, commonly known as COVID-19 (a mild to severe respiratory illness) when: 1. Certified Nursing Assistant (CNA 1) continued to provide direct care to 9 of 9 sampled residents (4, 5, 6, 7, 8, 9, 10, 11, 12) for more than three (3) hours after she reported feeling tired and unwell, which were symptoms of COVID-19. 2. Doors to eight of 29 rooms (C, D, E, F, G, H, I, J) designated for 22 residents (13, 14, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38) with active COVID-19 infection and residents who were under investigation (PUI) for possible COVID-19 infection were left open. 3. Direct care staff did not doff (remove) the contaminated gowns before leaving the Isolation rooms (rooms designated for residents known to have and/or suspected to have COVID-19 infection). Bins designated to collect contaminated gowns were kept out in the hallways. These failures to follow transmission-based precautions, resulted in cross contamination and led to a significant number of positive COVID-19 cases at the facility. Facility reported 80 of 90 residents tested , were positive for COVID-19 during the period of 11/17/20 till 12/20/20. In addition, the facility's failure to effectively screen CNA 1 for signs and symptoms of COVID-19 infection after CNA 1's first complaint of feeling tired and wanting to go home; and remove CNA 1 from working with the residents, including those who were negative for COVID-19 virus, placed the residents at higher risk for further exposure to COVID-19 virus, and to suffer from COVID-19 related complications, up to and including death. Based on these failures, the Administrator (ADM), Director of Nursing (DON) and Resource Specialist Consultant (RSC) were verbally notified during an on-site visit on 12/15/20 at 11:36 a.m., of an Immediate Jeopardy (IJ) situation. The facility presented an acceptable plan of action to correct the IJ situation during an onsite visit at 2:54 p.m., on 12/15/20, which included, educating the licensed nurses to screen the employees immediately for COVID-19, who presented or verbalized symptoms related to COVID-19. All ancillary departments were to be educated to notify the licensed nurse or the screener if their staff developed any new onset of signs or symptoms of COVID-19. The licensed nurse would use facility's current screening form to further screen the employee for other signs and symptoms of COVID-19. The licensed nurse was to immediately, notify the Director of Nursing (DON) and the sick employee would be sent home. The plan of action was accepted at 2:55 p.m. on 12/15/20. Findings: 1. During a phone interview with CNA 1 on 12/16/20 at 10:16 a.m., CNA 1 stated around 9 a.m. on 12/14/20, she informed Licensed Vocational Nurse (LVN 1) that she was feeling tired and wanted to go home. CNA 1 stated LVN 1 told her to inform Staffing Personnel (SP 1) about her symptoms and wanting to go home. During an observation and interview with LVN 1 and CNA 1, on 12/14/20, at 11:50 a.m., LVN 1 stated CNA 1 was feeling sick since that morning and they were not sending her home. LVN 1 then checked CNA 1's body temperature with a non-touch thermometer, and stated it was 98.7oF. CNA 1 stated she had body aches and had called the SP 1 to ask is she could go home. CNA 1 checked the call log on her cell phone and stated she called SP 1 at 9:14 a.m. on 12/14/20. During an interview with LVN 1, CNA 1 and SP 1, on 12/14/20, at 11:55 a.m., SP 1 stated CNA 1 called her in the morning stating she was feeling tired. SP 1 stated she told the ADM, and ADM told her to have CNA 1 stay in the facility until CNA 1 passed lunch trays to the residents. During an interview with CNA 1, on 12/14/20, at 12:00 p.m., CNA 1 stated she felt over fatigued and was catching breath. During an interview with CNA 1, on 12/14/20, at 12:08 p.m., CNA 1 stated she provided direct care to her assigned residents all morning. CNA 1 stated she assisted Resident 4, 5, 6, 7, 8, 9, 10, 11 and 12, with dressing, incontinent care, and changing their bed linens. During an observation on 12/14/20, at 12:22 p.m., CNA 1 exited a room shared by Resident 4, 5, and 6 (Room A). SP 1 handed a lunch tray to CNA 1 and CNA 1 took the lunch tray inside Room A. CNA 1 then came out of Room A and stated she served lunch to Resident 5 and 6 at that time. During an observation and interview on 12/14/20, at 12:25 p.m., LVN 1 was standing by the medication cart in the back hallway. When asked what measures were taken by LVN 1 about CNA 1's complaints of feeling tired, sick, body aches, and wanting to go home, LVN 1 stated, thank you for reminding me. LVN 1 stated she had not informed anyone about CNA 1's complaints. LVN 1 then spoke with ADM and afterwards told CNA 1 she would be tested for COVID 19. During an observation, on 12/14/20, at 12:32 p.m., in the conference room, Director of Staff Development (DSD) conducted the Veritor Rapid Test (a lab test for rapid detection of COVID-19 virus) on CNA 1. CNA 1 collected the nasal swab from both nostrils and handed the swab collection kit to the DSD. DSD instructed CNA 1 to wait for her COVID-19 test results in the employee's break room. During an observation, on 12/14/20, at 1:10 p.m., CNA 1 was sitting in the employee's break room and the door of the break room was open. During an interview and record review, on 12/14/20, at 1:25 p.m., with DSD, facility's document titled [DIAGNOSES REDACTED] [MEDICATION NAME] TESTING MACHINE LOG was reviewed. The log had columns to indicate the name of person tested for COVID-19, date of the specimen collection date, test results . The DSD stated CNA 1 test results were positive for COVID-19. During a phone interview, on 12/14/20, at 4:03 p.m., SP 1 stated she informed CNA 1's complaint of feeling tired to the ADM, within 20-30 minutes of receiving CNA 1's call that morning. During an interview with ADM, on 12/15/20, at 9:55 a.m., ADM confirmed SP 1 informed her on the morning of 12/14/20, that CNA 1 was tired and wanted to leave the facility at 11:00 a.m. on 12/14/20. During an interview, with DSD, on 12/15/20, at 10:00 a.m., DSD stated CNA 1 cared for Resident 7 and 8 who did not have active COVID-19 infection as of 12/14/20. A review of Resident 7's COVID-19 lab test result dated 12/12/20 indicated, Resident 7 did not have COVID-19 virus detected in the nasal swabs collected on 12/09/20. A review of Resident 8's COVID-19 lab test result dated 12/12/20 indicated Resident 8 did not have COVID-19 virus detected in the nasal swabs collected on 12/09/20. During a record review of facility's Line list for COVID-19 outbreak, dated 12/22/20, indicated Resident 7 was tested on [DATE] and was positive for COVID-19 infection; Resident 7 was hospitalized for [REDACTED]. During an interview with Infection Preventionist (IP), on 12/15/20, at 10:02 a.m., IP stated if an employee experienced signs and symptoms of COVID-19 infection during working hours, the IP, DSD and the DON should be informed. IP stated if the employee reported feeling tired that should prompt the screener to ask if employee was feeling tired because he/she was overworked or he/she was feeling sick. IP stated if employee was feeling sick, the screener was required to check the vital signs, ask the employee when and how the symptoms started, and send the sick employee home. IP stated facility was offering Rapid test for COVID-19 infection to symptomatic employees just for peace of mind. IP stated the symptomatic employee was required to wait in the car, and or parking lot if they did not have a car, while they wait for the COVID-19 test results. IP stated symptomatic employee could not stay inside the facility to prevent the spread of COVID-19 infection. During an interview with IP, on 12/15/20, at 2:21 p.m., IP stated she was not consulted about CNA 1's symptoms she experienced at work on 12/14/20. IP stated she was not made aware of CNA 1's symptoms and positive lab test for COVID-19, until the IP was about to leave for the day on 12/14/20. During an interview with the DON, on 12/15/20, at 2:07 p.m., the DON stated she was not informed or consulted when CNA 1 reported that she was feeling tired on 12/14/20. During a record review of CNA 1's timecard dated 12/14/20, timecard indicated CNA 1 left the facility at 2:30 p.m., on 12/14/20. During a review of facility's policy and procedures dated 11/15/20 titled Infection control policies and procedures IC405 COVID-19 indicated, Employees who develop signs and symptoms of respiratory infection while on duty will be excused from duty and instructed to self-isolate at home. Inform the Center's Infection Preventionist and include information on individuals, equipment, and locations the person came in contact with; and follow current guidelines about returning to work . Review of Suspected COVID-19 Facility Checklist from the facility's policy and procedure dated EC405 dated 11/15/20 indicated, 'For all suspected/confirmed employees: If employees are symptomatic upon entry screening, they must immediately be sent home and instructed to self-isolate. Do not allow sick employees to work .'. 2. During a review of facility's Line List for COVID-19 outbreak, dated 12/14/20, indicated Resident 13, 19, 20, 23, 24, 26, 27, 28, 29, 30, 31, 32 and 33 had active COVID-19 infection. During an observation with ADM, on 12/14/20, at 11:09 a.m., Room F (occupied by Resident 19, 20), G (occupied by Resident 21, 22, 23, 24), and H (occupied by Resident 25, 26, 27) had a yellow colored, laminated sign posted right above the resident's name plate outside the rooms. The sign indicated to follow Extended contact and airborne precautions for special respiratory circumstances. Further down, the sign said, Keep room door closed. During observation, the doors for rooms F, G and H were left open. During an observation of room J (occupied by Resident 36, 37, 38, 14) on 12/14/20, at 12:16 p.m., room J had a yellow Stop sign indicating to keep the door closed. Room J's door was open. During an observation and interview on 12/14/20, at 12:17 p.m., CNA 3 came out of room J and left the door open. CNA 3 stated closing the door was important for isolation, but she forgot to do so. During an observation of room G (occupied by Residents 21, 22, 23, 24) with CNA 2, on 12/14/20, at 12:20 p.m., the door to room G was open. CNA 2 stated, Maybe the med nurse left it open. During an observation with LVN 1, on 12/14/20, at 1:06 p.m., Room I (occupied by Resident 34, 35) was left open. Room I had the yellow stop sign posted on top of residents' name plate, indicating to follow extended contact and airborne precautions, and to keep the door closed. During an observation and interview, on 12/14/20, at 1:17 p.m., Door to Room C (occupied by Resident 13, 28) was left open. By further observation, the privacy curtain around the bed of Resident 13, was also left open while IP was inside the room standing next to Resident 13. A coughing sound was coming out of Room C. During subsequent observation, IP came out of Room C, and confirmed Resident 13 was coughing when she administered the medication to the resident. During an observation and interview on 12/14/20, at 1:23 p.m., with the IP, Rooms D (occupied by Resident 29, 30, 31) and E (occupied by Resident 32, 33) were left open. Rooms C (occupied by Resident 13, 28), D (occupied by Residents 29, 20, 31) and E (occupied by Resident 32, 33) had a red colored stop sign posted on top of the resident's name plates. The red stop sign indicated to see nurse before entering room. The IP stated staff were reminded frequently to close the room doors of residents' with COVID-19 infection. IP stated closing the door was essential for containment of the (COVID-19) virus. During an interview with the IP, on 12/14/20, at 2:36 p.m., the IP stated red stop signs were meant for the rooms with residents who had active COVID-19 infection. IP also stated all facility residents were either positive or suspected to have COVID-19 infection on that day. During a review of facility's policy and procedures titled Infection control policies and procedures IC405 COVID-19, revised on 11/15/20 indicated, In addition to Standard precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. For the purpose of this policy, Airborne precautions is defined as .keeping the door to the patient's room closed . 3. During an observation on 12/14/20, at 11:42 a.m., Licensed Vocational Nurse (LVN 2) came out of room designated to Resident 15, 16, 17 and 18. The room had a yellow stop sign posted for Contact and Airborne precautions for special respiratory circumstances on top of resident's name plate outside the room door. LVN 2 removed a yellow reusable cloth PPE gown outside the Resident's room and disposed of it in a bin. LVN 2 stated, she would wash her hands and went back inside the Residents' 15, 16, 17, and 18 room. By further observation with LVN 2, bins for contaminated gowns were kept outside the rooms in the hallway for 18 more rooms in facility's back hallway. LVN 2 stated bins for contaminated gowns should be kept inside the rooms, and direct care staff should remove the gowns inside before leaving resident's rooms. During an interview with IP, on 12/14/20, at 2:36 p.m., IP stated facility residents were either positive or suspected to have COVID-19 infection on that day. During a review of facility's policy and procedures titled Infection control policies and procedures IC405 COVID-19, revised on 11/15/20 indicated, In addition to Standard precautions, Contact and Airborne Precautions will be implemented for patients suspected or confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. During a review of facility's Infection Control Policies and Procedures (PNP's), dated 11/15/20, titled for Airborne infection Isolation precautions, Contact Precautions, and Droplet Precautions, indicated, Before exiting room, remove and bag PPE (personal protective equipment such as gown).

Based on interview and record review, the facility failed to follow the abuse policy and procedure for one of four sampled residents (Resident 1). The facility failed to suspend Registered Nurse (RN) 1 from working in the facility until after completion of an investigation of Resident 1's abuse allegation that RN 1 caused her pain when RN 1 hit her teeth with a mouthpiece (used for inhalation of medication). This failure had the potential to result in exposure of Resident 1 and other residents to abusive behavior. Findings: A review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of Resident 1's Minimum Data Set (a resident assessment tool used to guide care) dated 1/25/19, showed a Brief Interview for Mental Status score of 13. (The Brief Interview for Mental Status is a scoring system used to determine the resident's cognitive status in regards to attention, orientation, and ability to register and recall information. A BIMS score of thirteen to fifteen is an indication of intact cognitive status.) A review of Resident 1's Medication Administration Record [REDACTED]. A review of Resident 1's MAR for 2/3/19 showed RN 1 administered inhaled [MEDICATION NAME] at 12:20 a.m., 2:27 a.m., and 5:27 a.m. During an interview with Resident 1 on 4/26/19 at 10:59 a.m., Resident 1 stated RN 1 had entered her room one night to administer her [MEDICATION NAME] treatment. Resident 1 stated RN 1 asked her to open her mouth wide, and told her to inhale it, inhale it, and shoved the medication mouthpiece into her mouth, hitting her teeth in the process. During a telephone interview with Registered Nurse (RN) 2 on 5/1/19 at 3:02 p.m., RN 2 stated when she was working the afternoon shift on 2/3/19, Resident 1 told her RN 1 had shoved the medication mouthpiece into her mouth and hurt her teeth on the previous night shift (11 p.m. to 7:30 a.m.). RN 2 stated she reported the abuse allegation to the Nurse Supervisor (NS), and management. RN 2 stated she saw RN 1 report to work on the following night shift, which started on 2/3/19. A review of the facility form, Situation, Background, Appearance, Review, indicated a start date of 2/3/19 for an allegation by Resident 1 of, physical abuse by hurting her teeth while RN rendering breathing txt (treatment). A review of the facility's Nursing Staffing Assignment and Sign-In Sheet dated 2/3/19-2/4/19 (night shift) indicated RN 1 worked from 10:30 p.m. on 2/3/19 to 7 a.m. on 2/4/19. During a telephone interview with NS on 5/1/19 at 3:21 p.m., NS stated she was the night shift supervisor on the night shift starting on 2/3/19, and was aware of Resident 1's abuse allegation against RN 1 when the night shift started on 2/3/19. NS stated she permitted RN 1 to work that night because RN 1 did not drive and could not get a ride home. During an interview with Administrator (ADM) on 4/26/19 at 10:52 a.m., ADM 2 stated RN 1 should have been suspended immediately upon receipt of the abuse allegation, and the suspension should continue until completion of an investigation. A review of the facility policy and procedure titled, Abuse Prohibition, revised 7/1/18, indicated, The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation.

Based on interview and record review the facility failed to maintain an effective infection control program to ensure [MEDICAL CONDITION] (TB- an infectious lung disease) screening was completed for nine of 13 sampled employees. This failure created the potential to spread TB to the residents, for a current census of 88, staff, and visitors. Findings: During a review of the employee files the following staff members were noted with outdated TB test results over one year. 1. Certified Nursing Assistant (CNA) 2, was hired to work at the facility on 10/11/16. The review showed CNA 2 was not tested for TB before starting employment at the facility or annually before termination from facility on 12/19/18. 2. CNA 3, was hired to work at the facility on 8/27/18 and there was no evidence of TB testing in the employee file. 3. Registered Nurse (RN) 8 was hired to work at the facility on 9/14/18 and there was no evidence of TB testing. 4. RN 9 was hired to work at the facility on 6/13/17 the review did not show RN 9 was tested for TB initially upon hire or annually thereafter. 5. CNA 6 was hired at the facility on 2/6/07. Review of a form titled, Employee [MEDICAL CONDITION] Screening, and under the subtitled, Periodic Skin Tests, indicated the last TB test administered to the CNA 6 was on 12/18/15. 6. CNA 5 was hired to work at the facility on 11/5/02. The Employee [MEDICAL CONDITION] Screening form under Periodic Skin Tests showed CNA 5 was last tested for TB on 12/2/16. 7. Licensed Vocational Nurse (LVN) 10, was hired to work at facility on 12/6/16. The Employee [MEDICAL CONDITION] Screening form under Periodic Skin Tests showed LVN 10 was last tested for TB on 12/14/16. 8. C.N.A. 4 was hired to work at the facility on 12/22/06. The Employee [MEDICAL CONDITION] Screening form under Periodic Skin Tests showed CNA 4 was last tested for TB on 12/2/17. 9. [MI]V.N. 11 was hired to work at the facility on 2/27/18 as the assessment nurse. The Employee [MEDICAL CONDITION] Screening form under Periodic Skin Tests showed LVN 11 was last tested for TB on 2/28/18. During an interview with the director of staff development (DSD) on 3/21/ at 12:30 p.m. the DSD stated, she had not audited all the employee's files since beginning her job on 1/2/19. The DSD stated the only persons having TB testing as of 1/2/19, were the newly hired employees. The DSD stated she had not scheduled any of the employees hired before 1/2/19 for TB testing. Review of the facility policy and procedure, Policy and Procedure for Infection Prevention and Control Program, revised 3/11/19, indicated, .The infection Prevention and Control Program (IPCP) is a comprehensive process that address preventing, identifying, reporting, investigating and controlling of infections and communicable disease for patients, staff volunteers, visitors, and other individuals providing services under a contractual agreement. The facility policy, [MEDICAL CONDITION] Screening, reviewed 8/20/18, indicated, Facility Health Care services will provide [MEDICAL CONDITION] screening and diagnostic measures as needed for all existing and potential employees. Will comply with guidelines for TB screening per state guidelines .Purpose .To provide for managing [MEDICATION NAME] Skin Testing (TST) program to ensure early detection and management of employees and volunteers who may have been exposed to or develop TB. Review of the facility's Health Examination policy dated 6/1/14 read under purpose, To ensure that each employee is sufficiently free of disease to perform assigned duties and does not have any health condition that would create a hazard to self, fell ow employees, patients/residents or visitors.

Based on interview and record review, for one of three sampled residents (Resident 1), the facility failed to implement a discharge planning process that focused on discharge goals and preparation for post-discharge care. The failure to inform Resident 1 of her discharge plans caused her to have emotional distress. Findings: A review of the Admission Record indicated Resident 1 admitted to the facility in (YEAR) with an included [DIAGNOSES REDACTED]. Resident 1's Minimum Data Set (MDS, an assessment tool used to direct resident care) dated 11/2/18, indicated Resident 1 had moderate impairment of thinking and remembering skills, with a Brief Interview for Mental Status score of 8. (The BIMS is an assessment tool for a resident's orientation to time, and capacity to remember. The BIMS range is from 0-15, with zero as the most impaired.) The MDS reflected there was no active discharge planning in progress. During an interview with Resident 1 on 2/1/19 at 12:07 p.m., Resident 1 stated a staff member told her she would need a caregiver 24 hours a day if she discharged to her home. Resident 1 stated she was worried about her discharge plans, as she could not afford a caregiver around the clock, and no one had given her any other information. During an interview with Social Services Director (SSD) on 2/1/19 at 12:43 p.m., SSD stated Resident 1 wanted to be discharged home, by herself. SSD stated she had spoken to potential caregivers for Resident 1, as her respiratory condition would not allow Resident 1 to live at home without assistance. SSD said there was currently no clear discharge plan for Resident 1. During an interview with Unit Manager (UM) on 2/1/19 at 1:47 p.m., UM stated Resident 1's clinical record did not include a discharge care plan. UM stated there should be a discharge care plan for every resident. During a concurrent record review and interview with SSD and Director of Nursing (DON) on 2/1/19 at 1:19 p.m., SSD confirmed she was unable to locate documentation of a discharge care plan for Resident 1. DON stated it was not the facility's policy to write a discharge care plan for residents. A review of the facility policy and procedure titled, Discharge Planning Process, revised 2/1/19, indicated, Discharge planning will begin upon admission and be completed as part of the Person-Centered Care Plan process The Interprofessional Care Team (group composed of individuals from different departments of the facility) will use the discharge planning process to identify discharge needs and develop discharge plan to meet those needs; include regular evaluation of patients to identify changes that require modification of the discharge plan; the discharge plan must be updated to reflect these changes .Involve the patient and resident representative to establish goals of care and treatment preferences.

Based on observation, interview, and record review, the facility failed to serve and store food under sanitary conditions by: 1. The tuna salad was held at an unsafe temperature in the refrigerator. 2. Dry food bin lids, utensils, and equipment were dusty. 3. A dented canned good was stored in a rack for use. These failures placed residents at risk of developing food-borne illnesses. Findings: 1. During the initial kitchen observation on 2/25/19 at 3:50 p.m., the refrigerator had a sealed container labeled tuna salad, start date 2/24/19. DM confirmed the current measured internal temperature of the tuna salad to be 48 degrees Fahrenheit (°F). DM stated refrigerated food should be stored at or below 41°F. (Tuna is a Time/Temperature Control for Safety Food, requiring control of time and temperature to limit the growth of harmful, disease producing organisms.) 2. The lids of five of five dry food storage bin lids were dusty. DM stated dietary aides, including herself, checked utensils and equipment for cleanliness and proper storage in clean areas. DM stated dry food bin lids are cleaned every day by dietary aides per facility procedure. 3. During an observation in the dietary department, and concurrent interview with DM on 2/26/19 at 11 a.m., DM confirmed the presence of one dented can of 104 ounces of beets on a shelf in the dry storage area. DM stated cans are inspected for dents upon arrival and should be placed in a dented can storage area per facility procedure. The facility's policy and procedure titled, Food Handling, revised 12/01/15, reflected, All Time/Temperature Control for Safety Food must maintain an internal temperature of 41°F or lower

Based on observation, interview, and record review, the facility failed to revise the comprehensive care plans for activities for two of three sampled residents (Resident 30 and Resident 39) after changes in physical conditions. These failures had the potential for Resident 30 and Resident 39 to receive inappropriate activities, or have unmet psychological and/or emotional needs from lack of appropriate activities. Findings: 1. A review of Resident 30's face sheet dated 1/24/19 indicated she originally admitted to the facility in (YEAR), and readmitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/27/18, indicated her [DIAGNOSES REDACTED]. The MDS reflected Resident 30 rarely/never understood others, or was understood; had severely impaired hearing; had no speech; and had severely impaired thinking and reasoning skills for daily decision making. A review of the activities care plan revised 12/19/18 reflected Resident 30's responsible party wanted Resident 30 to have the opportunity to engage in the activities of hearing religious services, and listening to music, especially religious music. The MDS dated [DATE] reflected the responsible party confirmed it was very important for Resident 30 to participate in religious services or practices. A review of the facility Participation Log, reflected no participation in the categories of religious activity, and listening to music from 1/1/19 through 2/26/19. 2. Review of Resident 39's face sheet dated 7/19/18 indicated she originally admitted to the facility in 2014, and readmitted on [DATE]. The MDS section F0500 indicated listening to music was very important to Resident 39. A review of the activities care plan, revised 1/28/19, included listening to radio and outings under goals. During random observations of Resident 39 from 2/25/19 to 2/28/19, there was no music playing in her room. Review of the facility Participation Log, for (MONTH) and (MONTH) 2019, showed Resident 39 listened to music on four days: 1/3/19, 1/5/19, 2/3/19, and 2/9/19. During an interview with the Activities Assistant (AA) on 2/27/19 at 12:10 p.m., AA stated Resident 39 previously listened to music, went out to eat, and went out on the patio, but was not able to do all those activities now. The AA stated Resident 39 is always sleeping now, and that the care plan should be updated. During an interview with the Regional Nursing Consultant (CON) on 2/28/19 at 10:17 a.m., CON stated the expectation was for the facility to review and update care plans, even if residents are on hospice and the hospice agency had its own care plans. Review of the facility policy and procedure, Hospice, revised 3/1/18, reflected the facility was responsible for, meeting the patient's personal and nursing care in coordination with the hospice representative, and ensuring that the level of care provided is appropriate based on the individual patient's needs.

Based on observation, interview, and record review, the facility failed to provide adequate grooming services for one of one sampled resident (Resident 39) to prevent or treat dandruff (a skin condition usually confined to the scalp, and resulting in accumulation of dry, itchy, flaky scales). This deficient practice resulted in physical discomfort for Resident 39, and had the potential to result in emotional distress from poor grooming negatively impacting her physical appearance. Findings: A review of Resident 39's face sheet dated 7/19/18 indicated she was originally admitted to the facility in 2014, and readmitted on [DATE]. According to the Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide patient care) dated 1/11/19, had generalized muscle weakness. Review of Resident 39's care plan titled, .it is important that she has the opportunity to engage in daily routines that are meaningful ., revised 1/28/19, reflected as an intervention, It is important for me to keep clean. During an observation with Certified Nursing Assistant (CNA) 1 on 2/27/19 at 12:38 p.m., Resident 39 had white flakes at the front of her scalp. Resident 39 scratched her scalp and stated her scalp itched, and she needed a good shampoo. In a concurrent interview, CNA 1 stated Resident 39 does not take showers. Review of Resident 39's Weekly Bath and Skin Report for (MONTH) 2019 contained no documentation except the date of (MONTH) 2019, and that Resident 39's weekly shower days were Wednesdays and Saturdays. There were no signatures under the columns for CNA signature or Charge Nurse Signature; there were no documented abnormal conditions. Review of the facility, ADL (Activities of Daily Living) Record, for (MONTH) 2019 reflected Resident 39 was completely dependent on staff for bathing, and received bed baths only. The Record specifically excluded hair washing in the bathing record; there was no documented hair washing. During an interview with the interim Director of Nursing (DON) on 2/27/19 at 12:51 p.m., the DON was unable to find any documentation about Resident 39 refusing showers. The DON observed Resident 39's scalp and agreed that she had dandruff. Review of the facility policy and procedure, Activities of Daily Living, revised 11/28/16, reflected, A patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observation, interview, and record review, the facility failed to provide pressure ulcer treatment and services (pressure ulcer, a wound from prolonged pressure, also known as a bed sore) for one of five sampled residents (Resident 47). For Resident 47 the development of a pressure sore on 2/19/19, and the facility failure to provide treatment and services for eight days, resulted in increased size and depth of the ulcer, and had the potential to result in severe tissue damage at the site. Findings: A review of Resident 47's comprehensive Admission Minimum Data Set (MDS, an assessment tool used to guide care) dated 1/18/19 showed Resident 47 was always incontinent of bladder and bowel, and required physical assistance from two people for turning and repositioning in bed. The MDS showed Resident 47 had clear speech, and was usually able to understand and be understood by others. The MDS indicated Resident 47 was at risk for pressure ulcers, but had no healed, or unhealed, pressure ulcers. A review of Resident 47's care plan, At Risk for Skin Breakdown, initiated on 11/5/14, indicated, Monitor skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decreased sensation, and skin that does not blanche easily. Weekly skin assessment by licensed nurse. The care plan's last revision was dated 2/2/19. A review of Resident 47's record showed a form titled, SBAR (Situation, Background, Appearance, Review) Communication Form and Progress Note, dated 2/19/19, by Licensed Vocational Nurse 2 (LVN 2). The SBAR indicated Resident 47 had a newly identified superficial open area on her left buttock, which measured one centimeter (0.37 inches) by one-half centimeter. The SBAR indicated LVN 2 notified the physician about the open area on 2/19/19 at 2 p.m. During an interview with LVN 2 on 2/27/19 at 12:18 p.m., LVN 2 stated she had not completed a skin integrity report, or initiated treatment for [REDACTED]. During an observation and interview with Licensed Vocational Nurse 1 (LVN 1) on 2/27/19 at 9:05 a.m., LVN 1 confirmed Resident 47's left buttock had an open area with minimum bleeding and a red wound bed. LVN 1 stated she had not known Resident 47 had an open area on her buttock. During an observation and interview with LVN 1 on 2/27/19 at 11:29 a.m., LVN 1 measured Resident 47's left buttock pressure ulcer at five centimeters (two inches) in length, one-half centimeter in width, and 0.2 centimeter in depth, with minimum bloody drainage. Calculation of the differences in measurements from 2/19/19 to 2/27/19 showed length increased four centimeters (1.6 inches), and depth increased by 0.2 centimeters. During an observation, and interview with Regional Nursing Consultant (CON), of Resident 47's left buttock on 2/27/19 at 11:03 a.m., CON confirmed Resident 47's pressure ulcer was a Stage II ulcer. In a concurrent record review, CON stated she was unable to find documentation of a skin integrity report, a physician ordered treatment plan, or a nursing care plan with interventions for the ulcer. CON stated Resident 47's pressure ulcer treatment should have been initiated when the nurse first identified the presence of the ulcer. During an interview and concurrent record review with the interim Director of Nursing (DON) on 2/27/19 at 10:03 a.m., DON stated the facility procedure for newly identified pressure ulcers was for licensed nurses to complete a SBAR, notify the doctor, notify the responsible party, initiate a skin integrity report, create a care plan, and report the wound to the next shift. During an interview with LVN 1 on 2/27/19 at 11:29 a.m., LVN 1 said she had notified the physician about Resident 47's pressure ulcer, and had received treatment orders this morning. A review of the physician orders [REDACTED]. Review of the facility's policy and procedure titled, Skin Integrity Management, revised 11/28/16, indicated nursing staff were to document newly identified skin impairments on the facility 24-hour Summary Report, complete observations and measurements on a Skin Integrity Report, and document daily monitoring of the wound. The policy further reflected nursing was required to, 4. Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated.

Based on interviews and record reviews, the facility failed to ensure one of 18 sampled residents (Resident 30) had complete, accurate, and readily accessible records. 1. For Resident 30, the facility failed to ensure care plans accurately represented patient care issues by initiating a care plan for anticoagulant medication (medication used to prevent abnormal clotting of the blood) not ordered or administered. This failure had the potential to result in unnecessary care adjustments such as patient education and dietary changes to prevent adverse effects associated with anticoagulant medications. 2. The facility failed to ensure accurate documentation of treatment when Resident 30's treatment record reflected nursing provided wound care to a resolved left upper thigh blister, and failed to accurately reflect treatment of [REDACTED]. This failure had the potential to result in impairment of nursing ability to monitor, evaluate, and plan interventions on an ongoing basis. Please refer to tags F 656 and F 657. Findings: 1. Review of Resident 30's face sheet dated 1/24/19 indicated she was originally admitted to the facility on [DATE], and re-admitted on [DATE]. The Significant Change in Status Minimum Data Set (MDS, an assessment tool used to guide care) dated 6/27/18, indicated her [DIAGNOSES REDACTED]. The MDS reflected Resident 30 rarely/never understood others, or was understood; had severely impaired hearing; no speech; and had severely impaired thinking and reasoning skills for daily decision making. The Quarterly MDS dated [DATE] indicated Resident 30 had two pressure ulcers (damage to skin or underlying soft tissue from prolonged pressure). Review of Resident 30's medical record showed a care plan related to anticoagulant medication (medication used to prevent blood from forming clots), initiated 12/19/18, and revised 2/15/19. Review of Resident 30's Order Summary Report for (MONTH) 2019 showed no order for anticoagulant medication. During an interview with the MDS Coordinator (MDSC) on 2/28/19 at 11:15 a.m., MDSC stated the care plan for anticoagulant medication did not accurately reflect Resident 30's condition, as the resident had not received anticoagulant medication. 2. During an observation of Resident 30's pressure ulcer treatment with Licensed Vocational Nurse (LVN) 3 and Certified Nursing Assistant (CNA) 1 on 2/28/19 at 1:45 p.m., Resident 30 had a right posterior thigh wound, and a sacral (the bony structure located at the bottom of the spine and connected to the pelvis) wound. Review of Resident 30's Treatment Administration Record (TAR) for (MONTH) 2019 showed nursing provided daily treatments to a left upper thigh blister from 2/1/19 through 2/27/19, with only one day of missed treatment (2/10/19). The TAR also reflected nursing provided treatment to a left posterior thigh wound twice daily from 2/1/19 through 2/15/19, 2/26/19, and 2/27/19 (with the exception of only one treatment on 2/10/19). The record indicated LVN 3 provided a combined total of 19 of the documented treatments to the left upper thigh blister and left posterior thigh wound. During an interview with LVN 3 on 2/28/19 at 2:41 p.m., LVN 3 stated there had been no left posterior thigh wound. LVN 3 stated the order should have indicated treatment for [REDACTED].

Based on interview and record review for two of five sampled residents (Resident 30, Resident 39), the facility failed to notify the Long Term Care (LTC) Ombudsman (an advocate for nursing home Residents) of resident transfers to acute care hospital. This deficient practice had a potential for Residents to not receive advocate support. 1. Review of Resident 30's clinical record showed a hospital admission on 1/20/19, and an emergency room visit on 1/26/19. The record did not reflect ombudsman notification of the transfers to the hospital. 2. A review of Resident 39's clinical record showed an emergency room visit on 12/10/18. The record did not reflect any notification to the Ombudsman for the emergency room visit. During an interview with the Director of Social Services (DSS) on 2/28/19 at 10:13 a.m., DSS stated the facility had not notified the Ombudsman when residents were transferred to the hospital. A review of the facility policy and procedure, Discharge and Transfer, revised 2/1/19 indicated, Copies of notices for emergency transfers must also be sent to the Ombudsman for patients transferred to a hospital.

Based on interview and record review, the facility failed to document proceedings of the quality assessment and assurance committee during scheduled quarterly meetings. This failure had the potential to result in facility inability to monitor the ongoing, comprehensive evaluation of provision of facility care and services. Findings: During an interview and record review with Regional Executive Administrator (REA) on 2/28/19 at 3:02 p.m., REA confirmed the quality assurance and performance improvement meeting log had no documentation for the quarterly meetings.

Based on the interview and record review facility failed to conduct quarterly meeting on a regular basis and required members were not in attendance. this deficient practice failed to, monitor departmental performance data routinely in order to identify deviations in performance . Findings: During a review of QAPI log book on 2/28/19 at 2:55pm it was noted that there were no quarterly meeting documentation. the one quarterly meeting which was held on 11/18 there were no Medical Director or designee,no DON(Director of Nursing) and no administrator was in attendance. During an interview on 2/28/10 at 3:02pm, with regional executive Administrator stated: I don't see any documentation of quarterly meetings. not having quartely QA meeting FACILITY QAA and QAPI 02/28/19 03:02 PM no required members in the Q A meeting- no medical director, no DON, ( novembr (YEAR), ) april (YEAR) no DON, no administrator met with(NAME) [NAME] ski executive administrator November meeting held in December

Based on interview and record review, the facility failed to ensure the quality assessment and assurance committee had regulatory required members in attendance at the (MONTH) (YEAR) quarterly meeting. This failure resulted in facility inability to routinely review and evaluate departmental performance data, and initiate necessary corrective actions. Findings: A review of the Quality Assurance Performance Improvement (QAPI) log on 2/28/19 at 2:55 p.m., reflected the 11/14/18 meeting was not attended by either the Medical Director (or a designee), Director of Nursing, or an admistrator/board member/owner/leadership staff member. During an interview with Regional Executive Administrator (REA) on 2/28/19 at 3:02 p.m., REA stated he was unable to find any documentation of the (MONTH) QAPI meeting.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) was safely transferred from the bed to the wheelchair, when: 1. Certified Nursing Assistant (CNA 1) used a mechanical lift (a specialized piece of equipment used to lift and transfer a resident from one area/surface to another, to reposition or to lift a resident) without a second staff member to assist as required per facility policy. 2. CNA 1 did not use the appropriate size sling (a flexible canvas strengthened/supported with strap or belt used in the form of a loop attached to a mechanical lift to support or raise a weight to assist resident with changing of position or transfer from/to different surfaces) and did not perform sling inspection per manufacturer ' s recommendation. 3. The facility did not provide CNA 1 training in the use of mechanical lift per facility policy. During Resident 1 ' s transfer, the straps of the sling attached to the mechanical lift snapped and broke. Resident 1 fell on to the floor and sustained multiple rib fractures (broken bone) on her left side. Findings: Review of Progress Notes dated 11/15/18 indicated, at 10 a.m., Resident 1 was on the floor on her back near her bed. CNA 1 reported Resident 1 was being transferred from bed to wheelchair using a mechanical lift. The sling suddenly snapped and Resident 1 fell on to the floor. The note indicated, Called 911 for immediate transfer to the hospital for further eval (evaluation) and management. Review of Resident 1's Emergency Department (ED) Physician Notes dated 11/15/18 indicated Resident 1 sustained multiple fractures of five of 12 ribs on the left side as a result of the fall. The Medical Decision Making section indicated The complexity of data and the risk of complications for this case is high. Review of the Minimum Data Set (MDS, an assessment tool used to guide care) dated 11/1/18, indicated Resident 1 was cognitively intact and had [DIAGNOSES REDACTED]. Further review indicated Resident 1 require extensive assist from two persons for bed mobility and transfer between surfaces. During an interview with CNA 1 on 11/27/18 at 10:20 a.m., CNA 1 stated, on 11/15/18, she transferred Resident 1 from the bed to the wheelchair using a Tollos (mechanical lift) using a white colored sling. CNA 1 stated she started to lift Resident 1 from the bed with the mechanical lift when the straps, which were attached to the lift, the sling snapped and broke on the left side then on the right side and Resident 1 fell on to the floor on her left side. CNA 1 stated she was not sure if the white sling used during the transfer was the right sized sling for Resident 1. CNA 1 stated she did not check the sling for integrity prior to use, as the same sling was used in the previous day for Resident 1. CNA 1 stated she did not receive training in the use of mechanical lift. Review of Resident 1's Lift Transfer Reposition (assessment) dated 11/9/18 indicated Resident 1 required two staff for repositioning and transfer using a mechanical lift. Further review indicated Resident 1 had a body weight of 179.5 pounds. The Care Plan Section indicated two persons extensive assist should be provided during transfers with mechanical lift to decrease the risk for falls. During an inspection of the Tollos sling tag with the Central Supply Staff (CSS 1) on 11/27/18 at 10:28 a.m., the Tollos sling tag indicated: the approximate weight guideline for white colored sling (designated as Extra Small) was between 49 to 74 lbs.; the approximate weight guideline for green colored sling (designated as Large) was between 175 to 249 lbs. During an interview with Director of Staff Development (DSD) on 2/11/19 at 3:15 p.m., DSD stated there were no staff in-service conducted from (YEAR) until 11/15/18. DSD acknowledged there was no record of in-service on the use of mechanical lift for CNA 1. During an interview with the Director of Nursing (DON) on 11/27/18 at 11:30 am, the DON stated CNA 1 had worked in the facility for 8 months. The DON was not able to produce CNA 1 ' s in service training record on the use of mechanical lift for transferring residents. Review of an undated Manufacturer Owner ' s Manual provided by the facility indicated, Warning: Visibly inspect sling prior to each use to ensure sling is the correct type, size and design to handle lifting. Ensure the sling is not damaged, torn worn, discolored or past its useful life; .that the sling ' s straps are correctly attached to the spreader bar, and that the sling is tested with resident in it at a few inches over bed or chair prior to actual transferring to proper operation .Warning: Untrained operators can cause injury or be injured. Permit only trained personnel to operate the lift. Improper operation can cause injury. Operate the lift only as described in this manual. Review of the facility's Policy and Procedure titled, Safe Resident Handling/Transfer Equipment dated 5/15/17, indicated, Patient will be assessed to determine the correct equipment to use. Staff will be trained in the use of each type of equipment .

Based on interview and record review, the facility failed to provide an anti-coagulant medication (a blood thinner, a medication used to prevent clot formation in the blood), as ordered for one of three residents (Resident 1). For Resident 1, this failure resulted in a [MEDICAL CONDITION] (a stroke) due to formation of a blood clot in the brain (an ischemic stroke). Findings: A review of the Admission Record of Resident 1 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].). The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated [DATE], reflected Resident 1 could feed herself, but needed assistance from one person for locomotion and other activities of daily living (hygiene, bathing, etc.). A review of Resident 1's hospital Discharge Summary dated [DATE], reflected Resident 1 had [DIAGNOSES REDACTED] (a condition where the heart rate suddenly increases, then subsides, in variable time intervals) and needed to continue use of the anticoagulant [MEDICATION NAME] (dabigatran etexilate, a blood thinner). The Summary indicated the discharge medications included: [MEDICATION NAME], 150 milligrams (mg), twice a day. During a telephone interview [DATE], at 3:30 p.m., the hospital physician (Phys 1) confirmed she had written the [DATE] hospital Discharge Summary with the discharge medication orders. Phys 1 said it was important for Resident 1 to have received the [MEDICATION NAME] 150 mg twice a day because she had [MEDICAL CONDITION]. During an interview on [DATE], at 2:35 p.m., registered nurse 1 (RN 1) said Resident 1 was admitted from acute care hospital with admission orders [REDACTED]. RN 1 said she did not notice she had missed transcribing the order for [MEDICATION NAME]. A review of the [DATE] transcribed Physician order [REDACTED]. The Medication Administration Record [REDACTED]. A review of Resident 1's care plan, Resident is at risk for cardiovascular symptoms or complications due to A-fib, dated [DATE], reflected, Administer meds (medications) as ordered and assess for effectiveness and side effects and report abnormalities to physician. A review of the pharmacy Shipment Summary for Resident 1 dated [DATE] indicated 30 capsules of [MEDICATION NAME] had been delivered and signed for by RN 2 at 11:12 p.m. A review of the facility's Summary of Investigation, dated [DATE], indicated the medication was confirmed to be in the medication cart, unopened. The Summary concluded because the nurse did not enter the [MEDICATION NAME] order into the computer system for Physician order [REDACTED]. During an interview [DATE] at 2 p.m., the Administrator (Admin) and Director of Nurses (DON) confirmed Resident 1 did not receive [MEDICATION NAME] during her admission in the facility, despite presence of a physician order [REDACTED]. Admin and DON said the order was missed during the transcription of the admission orders [REDACTED]. During an interview [DATE] at 3:20 p.m., LVN 1 said she assessed Resident 1 around 9 a.m. on [DATE] and noted increased confusion and facial drooping. LVN 1 said she alerted the DON, called the physician and family, and made arrangements for transfer to the hospital. A review of the Hospital Transfer Form Appendix completed by LVN 1 on [DATE] reflected Resident 1 was transferred for stroke treatment. A review of the emergency department Provider Notes dated [DATE], at 10:50 a.m., indicated Resident 1 arrived in the emergency roiagnom on [DATE], at 10:47 a.m., for evaluation of an altered mental state and facial droop. The hospital History and Physical (H & P) dated [DATE], indicated Resident 1 was admitted for treatment of [REDACTED]. A review of a hospital imaging test (Magnetic Resonance Angiogram) completed [DATE] indicated Resident 1 had significantly decreased blood flow to the right side of her brain from a blood clot. A review of the hospital Discharge Summary dated [DATE] indicated Resident 1 had significant brain abnormalities and physical deficits as a result of a massive right sided stroke from a blood clot. A review of Resident 1's Certificate of Death issued on [DATE] indicated she died on [DATE]. The immediate cause of death was stroke. A review of the Food and Drug Administration (FDA) boxed warning (a warning placed on a prescription drug ' s label and is designed to call attention to seri¿ous or life-threatening risks) indicated abrupt discontinuation of [MEDICATION NAME] increases the risk of clot formation. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------- Class B Citation No. [DATE] 483.25(m)(2) RESIDENTS FREE OF SIGNIFICANT MED ERRORS The facility must ensure that residents are free of any significant medication errors. A review of the Admission Record of Resident 1 indicated she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].). The Minimum Data Set (MDS, a resident assessment tool used to guide care) dated [DATE], reflected Resident 1 could feed herself, but needed assistance from one person for locomotion and other activities of daily living (hygiene, bathing, etc.). A review of Resident 1's hospital Discharge Summary dated [DATE], reflected Resident 1 had [DIAGNOSES REDACTED] (a condition where the heart rate suddenly increases, then subsides, in variable time intervals) and needed to continue use of the anticoagulant [MEDICATION NAME] (dabigatran etexilate, a blood thinner). The Summary indicated the discharge medications included: [MEDICATION NAME], 150 milligrams (mg), twice a day. During a telephone interview [DATE], at 3:30 p.m., the hospital physician (Phys 1) confirmed she had written the [DATE] hospital Discharge Summary with the discharge medication orders. Phys 1 said it was important for Resident 1 to have received the [MEDICATION NAME] 150 mg twice a day because she had [MEDICAL CONDITION]. During an interview on [DATE], at 2:35 p.m., registered nurse 1 (RN 1) said Resident 1 was admitted from acute care hospital with admission orders [REDACTED]. RN 1 said she did not notice she had missed transcribing the order for [MEDICATION NAME]. A review of the [DATE] transcribed Physician order [REDACTED]. The Medication Administration Record [REDACTED]. A review of Resident 1's care plan, Resident is at risk for cardiovascular symptoms or complications due to A-fib, dated [DATE], reflected, Administer meds (medications) as ordered and assess for effectiveness and side effects and report abnormalities to physician. A review of the pharmacy Shipment Summary for Resident 1 dated [DATE] indicated 30 capsules of [MEDICATION NAME] had been delivered and signed for by RN 2 at 11:12 p.m. A review of the facility's Summary of Investigation, dated [DATE], indicated the medication was confirmed to be in the medication cart, unopened. The Summary concluded because the nurse did not enter the [MEDICATION NAME] order into the computer system for Physician order [REDACTED]. During an interview [DATE] at 2 p.m., the Administrator (Admin) and Director of Nurses (DON) confirmed Resident 1 did not receive [MEDICATION NAME] during her admission in the facility, despite presence of a physician order [REDACTED]. Admin and DON said the order was missed during the transcription of the admission orders [REDACTED]. During an interview [DATE] at 3:20 p.m., LVN 1 said she assessed Resident 1 around 9 a.m. on [DATE] and noted increased confusion and facial drooping. LVN 1 said she alerted the DON, called the physician and family, and made arrangements for transfer to the hospital. A review of the Hospital Transfer Form Appendix completed by LVN 1 on [DATE] reflected Resident 1 was transferred for stroke treatment. A review of the emergency department Provider Notes dated [DATE], at 10:50 a.m., indicated Resident 1 arrived in the emergency roiagnom on [DATE], at 10:47 a.m., for evaluation of an altered mental state and facial droop. The hospital History and Physical (H & P) dated [DATE], indicated Resident 1 was admitted for treatment of [REDACTED]. A review of a hospital imaging test (Magnetic Resonance Angiogram) completed [DATE] indicated Resident 1 had significantly decreased blood flow to the right side of her brain from a blood clot. A review of the hospital Discharge Summary dated [DATE] indicated Resident 1 had significant brain abnormalities and physical deficits as a result of a massive right sided stroke from a blood clot. A review of Resident 1's Certificate of Death issued on [DATE] indicated she died on [DATE]. The immediate cause of death was stroke. A review of the Food and Drug Administration (FDA) boxed warning (a warning placed on a prescription drug label and is designed to call attention to serious or life-threatening risks) indicated abrupt discontinuation of [MEDICATION NAME] increases the risk of clot formation. Therefore the facility failed to provide an anti-coagulant medication (a blood thinner, a medication used to prevent clot formation in the blood), as ordered for one of three residents (Resident 1). For Resident 1, this failure resulted in a [MEDICAL CONDITION] (a stroke) due to formation of a blood clot in the brain (an ischemic stroke).

Based on observation, interview and record review of two of 18 sampled residents (Resident 8, 17), the facility failed to provide personal care with supervision and safe transfers and failed to provide identified assistive devices to protect residents from fall injuries. Resident 8 sustained a fall injury as a result of the lack of identified personal care assistance and supervision. Resident 17 fell from a tilt wheelchair and sustained a forehead laceration and abrasion to the bridge of her nose. These failures resulted in fall injuries to residents that could have been prevented. Findings: 1. Clinical record review indicated that Resident 8 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident 8's comprehensive assessment dated [DATE] indicated that the resident required one person assist for ambulation with a wheelchair assist for transfers. The nursing care plan for Resident 8 dated 3/28/11 identified the resident with episodes of weakness, unsteady with ambulation and at risk for falls. On 6/14/11 at 4:30 p.m., the Director of Nurses (DON) was interviewed and stated that after investigation of the fall incident, certified nursing assistant (CNA 1) was terminated for not following personal care protocol and for not following Resident 8's nursing care plan for safe transfer. The investigation found that on 5/5/11 at 9:25 p.m., CNA 1 ambulated Resident 8 to the bathroom without the use of a wheelchair. Upon returning from the bathroom, CNA 1 ambulated Resident 8 from the bathroom with her pants around her knees. CNA 1 had Resident 8 sit on the bed with her pants still around her knees. When CNA 1 turned away to pull back the bed covers, Resident 8 attempted to get up, lost her balance, fell and sustained an injury to her left wrist. On 6/14/11 at 4:35 p.m., licensed vocational nurse (LVN 1), the unit charge nurse, was interviewed, and stated that Resident 8 was unstable to ambulate and needed assistance to stand. On 5/5/11 LVN 1 stated she observed CNA 1 transfer Resident 8 in a wheelchair from the dining area back to her room so the resident could use the bathroom. LVN 1 said she heard her name called and went to Resident 8's room where she saw Resident 8 lying on the floor on her left side with her pants below her knees. Resident 8's wheelchair was away from the resident next to her roommate's bed. LVN 1 stated she asked CNA 1 what happened. CNA 1 told LVN 1 that after Resident 8 had used the bathroom, she ambulated her back to her bed and made Resident 8 sit at the edge of the bed. CNA 1 told LVN 1 that she turned away to pull back the bed covers, when Resident 8 stood up, lost her balance and fell . After the fall, Resident 8 complained of pain of her left leg and left hand. An X-ray of the left arm and left hip was ordered by the physician. The x-ray findings indicated, soft tissue swelling, fracture of distal radial metaphysis (wrist joint) with impaction (a bone break in which the adjacent fragmented ends of the fractured bone are wedged together). Resident 8 was transferred to the local emergency department for treatment where a cast was placed on Resident 8's left arm and wrist. An interview with CNA 1 was attempted twice by phone during and after the survey without success. 2. Resident 17 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The comprehensive assessment dated [DATE] and 2/24/11 indicated Resident 17 was totally dependent for all care and her primary mode of locomotion and transfer was a wheelchair. An occupational therapy (OT) evaluation and assessment done 2/8/11 identified Resident 17 with poor upper body positioning secondary to her lack of upper body control which resulted in a continuous leaning forward and sliding down when up in the wheelchair. OT assessed that this condition placed Resident 17 at in increased fall risk from the wheelchair. As a result of OT's assessment and evaluation, a tilt wheelchair with bilateral elevating leg rest was ordered and provided. The application of a seat belt was recommended by OT and ordered by the physician on 3/8/11. The seat belt was to be used to assist with positioning when Resident 17 was up in the wheelchair. After instruction to the nursing staff on use of the wheelchair and application of the seat beat, OT discharged Resident 17 from their service on 3/8/11. (Tilt wheelchair wheelchair: Wheelchair with seat and back angle that remain constant up to 45 degrees; angle tilt feature. When a person is put in a tilt chair and tilted back, their natural head position is upright instead of tilted forward. When positioned upright, many users require a combination of straps, pads and braces to restrain them from falling over in or out of the wheelchair. The seat to floor height of the wheelchair is higher when in tilt recline position and which result in the feet elevated and not dangling). The nursing care plan dated 3/7/11 was reviewed on 6/27/11. There was no care interventions specific to the use of the tilt in space wheelchair and the need for the application of a safety belt for the positioning and safety of Resident 17. On 5/9/11 at 3:00 p.m., Resident 17 was found lying face down on the floor next to her wheelchair bleeding from her forehead. Resident 17 had sustained a 2 centimeter laceration in her forehead, and abrasion at the bridge of her nose. 911 was called and Resident 17 was transported to the emergency department for evaluation and treatment. Certified nursing assistant (CNA 2) was interviewed on 6/16/11 at 4:00 p.m., and stated that on 5/9/11 at 2:00 p.m., the Administrator requested her to transport Resident 17 back to her room because her clothing was soiled with food and needed to be change. CNA 2 stated that Resident 17's soiled clothing did not look too bad to her, so she left Resident 17 alone in her room. CNA 2 stated that she remembered she left Resident 17 seated in her wheelchair which was in a reclined position and that Resident 17 did not have on seat belt. CNA 2 stated she told CNA 3, who was assigned that day to care for Resident 17 that she had left Resident 17 in her room. CNA 2 stated she did not check back Resident 17 after she spoke with CNA 3. In an interview with registered nurse (RN 1) on 6/16/11 at 4:15 p.m., who was the unit charge nurse on the day Resident 17 fell , RN 1 stated that it was reported to the all the CNAs that Resident 17's wheelchair should be tilted because of the safety risk and the problem of the Resident 17's tendency of leaning forward. On 5/9/11 at 3:00 p.m., RN 1 stated that on 5/9/11 at 3:00 p.m., she was as called to the room and found Resident 17 lying face down on the floor next to her wheelchair bleeding from her forehead. Resident 17 had sustained 2 centimeter laceration in her forehead, and abrasion at the bridge of her nose. 911 was called and the paramedics applied a neck collar on Resident 17 and placed her on a stability board for transport to the ED for evaluation and treatment. Resident 17 was admitted to the hospital for observation and assessment. The laceration on her forehead was surgically sutured, a CT (computer tomography) scan was done to rule out intracranial bleeding, possible skull fracture and neck injury. Chest X-ray was also done to rule out rib fractures and pneumothorax ( air in the lungs).