Every finding on record at Wesley Village

Based on observation, interview and record review, the facility failed to ensure hairnets were worn in the kitchen, failed to ensure all in-use dishwasher machines reached the required dish surface sanitation temperature during the rinse cycle, failed to ensure opened food items in the refrigerator and freezer were dated and labeled, failed to ensure food items were kept off of the floor in the kitchen, failed to complete and record cool down temperatures for food items that were prepared ahead and stored for future use, and failed to ensure the ceiling in the kitchen was kept clean and free of debris and dust. These failures have the potential to affect all 45 residents residing in the facility.Findings include: The facility's Hairnet Use policy, dated 2/15/24, documents To maintain the highest standards of sanitation and food safety in all dietary service operations at (the facility) and to comply with state and federal food service regulations. All employees, volunteers, students, and contractors working in the dietary services department must wear an approved hairnet or other approved hair restraints at all times while in food production, preparation, service or dishwashing areas. Hairnets must be worn before entering any food handling area.On 12/1/2025 at 10:18 AM, V9 (Dietary Manager) exited the facility's kitchen without a hairnet. V9 then stated before re-entering the kitchen Let me grab a hairnet. On 12/1/2025 at 10:35 AM, V9 confirmed she was in the kitchen without a hairnet earlier in the morning and stated all employees should be wearing a hairnet whenever they enter the kitchen.The facility's Open Food Labeling and Storage policy (undated), documents Purpose: To ensure all food items stored within the facility are safely labeled, dated, and organized to prevent foodborne illness, maintain quality, and comply with healthcare regulatory standards. All opened, prepared, or repackaged food items must be labeled immediately, including bulk items, leftovers, portioned items, drinks, and resident-specific prepared foods. Each label must include: Product name, date opened or prepared, use by/discard date, and staff initials. Foods must be sealed, covered, stored off the floor, and separated properly.The facility's Cooling Food policy (undated), documents To ensure all hot foods requiring cooling are cooled safely and rapidly to prevent bacterial growth and foodborne illness in compliance with healthcare and food safety regulations. This policy applies to all dietary staff who prepare, handle, cool, and store hot foods within the facility. All potentially hazardous foods must be cooled as follows: 135 degrees (Fahrenheit, F) to 70 degrees F within two hours, and 70 degrees F to 41 degrees F within an additional four hours. Total cooling time must not exceed six hours. Foods that require rapid cooling: Soups, stews, sauces, gravies, cooked meats, casseroles, pasta, rice, vegetables, large batches of hot foods, and leftovers intended for reheating. This policy also documents Record temperatures when cooling begins, at two hours, and at six hours or when the 41 degrees F is reached. Once the food reached 41 degrees F, cover it and label with product name, date prepared, discard date, and staff initials.On 12/1/25 at 10:20 AM the facility's kitchen walk in cooler contained open food items that did not contain a label or an open date/date expired. These unlabeled items included a package of chocolate chips, a bag of almonds, a carton of heavy whipping cream, a partial block of butter, and a carton of liquid scrambled eggs. At this time, V9 confirmed the food items were opened and were not labeled. V9 stated Staff should be applying a label when the items are opened and initially placed in the refrigerator.On 12/1/25 at 10:25 AM, the facility's dry storage room contained a large mesh bag of red onions that was resting on the floor at the storage rooms entryway. At this time, V9 picked up the bag of onions and stated These should not be placed here.On 12/1/25 at 10:28 AM, the facility's walk-in freezer contained a large zipper closed bag with a large portion of frozen meat and Turkey, 11/27 written on the bag. This same freezer contained a second large bag with frozen light brown contents and Turkey Gravy, 11/27 was written on the bag. At this time V9 confirmed the contents of the larger zippered bags were roasted turkey and turkey gravy from 11/27/25 and both items did not contain a label with expiration dates or employee initials.The facility's Cooling Log dated, 11/16/25-11/30/25 does not document any food items were monitored for cool down temperatures on 11/27/25 and does not document any cool down temperatures for roasted turkey or turkey gravy. This same cooling log also documents cool down temperatures were started for ham and bean soup, ground beef, cream of asparagus, pork loin, white chicken chili, cream of chicken soup, and French onion soup. Several of these food items document only an initial time and temperature that cooling was started. All of these recorded food items do not document any cool down temperatures below 90 degrees F.On 12/1/25 at 10:35 AM, V9 confirmed the cool down logs for November do not document temperature recordings for roasted turkey or turkey gravy and stated those items would have been from the recent holiday meal.The facility's Dishwasher Sanitizing policy (undated), documents Machine temperature requirements (High-Temperature Dishwashers). Wash cycle: Minimum 150 degrees (Fahrenheit, F). Final rinse/ sanitize cycle: Minimum 180 degrees F at the dish surface. This policy also documents Record daily wash and rinse temperatures.The facility's Kitchen Deep Cleaning List (undated), documents Dish Area: Clean wall behind dish machine floor to ceiling. Clean wall behind the three-compartment sink floor to ceiling.On 12/1/25 at 10:30 AM the facility's dishwasher machine was running a cycle. V9 stated the machine is a high temperature sanitation machine and that employees check the outside recording to ensure the water gets hot enough. V9 stated I am not sure how we know the external temperature reading is accurate. V9 confirmed that staff are not placing any test strips or thermometers inside of the machine to check the surface temperatures. At this same time the kitchen area that contained the dishwasher became filled with steam abundant to the ceiling. The ceiling directly above the dishwash machine and clean pans, contained ceiling tiles that were bubbled in parts, stained with light brown or gray outlined damage, and areas of grey debris and a grey, fuzzy, dangling, dust-like substance. At this time V9 stated that dishes are removed from dishwasher and then placed on cart racks to dry (below the debris filled ceiling). V9 stated The ceiling is lower in this area so there is a lot of moisture when the dish cycle runs which might be why the dust clings there. On 12/1/25 at 10:40 AM, V10 (Certified Nursing Assistant/Cook) stated she prepares food in the facility's [NAME] neighborhood kitchen with its own private high temperature dishwasher. V10 stated the dishwasher temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. On 12/1/25 at 11:00 AM, V11 (Cook) stated she prepares food in the facility's Pearson North and Pearson South neighborhood kitchens, and they have their own private high temperature dishwashers. V11 stated the dishwasher temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. On 12/1/25 at 11:10 AM, V7 (Cook) stated she prepares food in the facility's [NAME] neighborhood kitchen with its own private high temperature dishwasher. V7 stated the temperatures are monitored from the external reading and there is nothing placed inside to monitor the dish surface temperatures. The facility's CMS (Centers for Medicare and Medicaid Services) Long Term Care Facility Application for Medicare and Medicaid Form 671 dated 12/1/25 and signed by V1 (Administrator) documents 45 residents currently reside within the facility.

Based on record review and interview the facility failed to ensure a MDS (Minimum Data Set) Assessment was accurately completed for one of one resident (R26) reviewed for MDS accuracy in the sample of 21.Findings include:The facility's MDS (Minimum Data Set) Assessment and Submission Policy dated 2/1/25 documents, Purpose: To ensure accurate, timely, and comprehensive resident assessments in compliance with CMS (Centers for Medicare and Medicaid Services) Requirements of Participation and IDPH (Illinois Department of Public Health) Long-Term Care Regulations, and to guide facility staff in the completion, submission, correction, and maintenance of the MDS and Resident Assessment Instrument (RAI). Policy Statement: It is the policy of this facility to complete the MDS and all related RAI processes accurately and timely, ensuring assessment reflect each resident's current condition, needs, and care plan.R26's Physician's Orders dated 10/16/25 (R26's admission date) through the current date 12/2/25 do not include an order for an anticoagulant medication.R26's MDS assessment dated [DATE] documents R26 was receiving an anticoagulant.On 12/3/25 V12 (MDS Coordinator) verified R26 has not received an anticoagulant medication since admission and R26's MDS assessment dated [DATE] was coded inaccurately.

Based on observation, interview and record review, the facility failed to ensure safe and sanitary kitchens to prevent foodborne illnesses. This failure has the potential to affect 48 residents who reside in the facility. Findings include: The Facility Resident Census Roster and Facility Matrix/802, dated 2/18/25, were reviewed. The Census Roster documented 48 Residents residing in the Facility. The 1st Shift and 2nd Shift Dietary Aide Responsibilities handout, not dated, instructed the Dietary Aides to record equipment (dishwashers, freezers and refrigerators) temperatures at 7:00 AM, 11:00 AM and between 4:30 PM and 4:45 PM. On 02/18/25 at 9:30 AM through 10:00 AM, Kitchen 1, Kitchen 2, Kitchen 3 and Kitchen 4 were toured with V5 (Food Service Advisor). The following dishwasher temperature logs, freezer logs and refrigerator logs indicated temperatures were not monitored three times daily: Kitchen 1 - December 2024, 15 of 31 days and January 14 of 31 days were missing temperatures; Kitchen 2 - January 2025, 2 of 31 days were missing temperatures; Kitchen 3 - December 2024, 6 of 31 days, January 2025, 10 of 31 days and February 2025, 10 of 17 days were missing temperatures; and Kitchen 4 - December 2024, 5 of 31days and January 2025, 1 of 31 days were missing temperatures. V5 agreed the logs should have been competed three times daily and had not been. On 2/20/25 at 1:00 AM, V10 (Dietary Manager) reviewed the dishwasher, freezer and refrigerator temperature logs for Kitchen 1, Kitchen 2, Kitchen 3 and Kitchen 4 and stated temperatures had not been monitored as required and should have been monitored three times daily by the Dietary Aide at 7:00 AM, 11:00 AM and between 4:30 PM and 4:45 PM.

Based on observation, interview and record review the facility failed to ensure required Personal Protective Equipment was donned prior to entering a COVID Positive Resident (R33) Room. This failure has the potential to affect all 12 residents (R1, R7, R8, R11, R17, R22, R23, R28, R3, R36, R38, R43) who reside in R33's Household Unit. The facility also failed to follow Enhanced Barrier Precautions and ensure required Personal Protective Equipment was donned during cares for two residents (R14 and R29) of 12 residents reviewed for direct cares in a total sample of 31. Findings include: 1. Facility Policy/COVID-19 Outbreak Investigation and Management dated 1/10/25 documents: It is the policy of this facility to recognize and contain COVID-19 outbreaks and outbreak measures will be instituted whenever there is evidence of an outbreak as outlined below. The Centers for Medicare and Medicaid Services indicates An outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. To implement immediate response for resident confirmed COVID-19 positive: Isolation Full PPE (Personal Protective Equipment) to prevent spread of the COVID-19 outbreak: Gloves, Gown, Eye protection, N95 mask or higher respirator. Facility COVID-19 Response Plan dated 5/23/23 documents: If a resident is suspected or confirmed to have COVID-19, HCP must wear an N95 respirator, eye protection, gown, and gloves. Infection Control tracking line list dated 2/2025 indicates R33 was COVID-19 and Influenza A positive on 2/17/25. On 2/18/25 at 10:50 am V8, CNA (Certified Nurse Assistant) entered and exited R33's room with a surgical-style mask. Posted on the outside of R33's door were the following signs: Airborne Precautions - Everyone Must: Clean their hands, including before and when leaving room. Put on a fit-tested N95 or higher level respirator (mask) before room entry. Remove respirator after exiting room and closing door. Door to room must remain closed. Contact Precautions - Everyone Must: Clean their hands, including before and when leaving the room. Provider and Staff must also: Put on gloves before room entry. Discard gloves before room exit. Put on gown before room entry. Discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. On 2/18/25 at 12:45pm V8, CNA donned PPE to bring lunch food items into R33's room. V8 wore a surgical-style mask into and when exiting R33's room. PPE equipment hanging on the outside of R33's door did include a supply of N95 respirator masks for staff to utilize. After exiting R33's room V8 stated that all of the isolation rooms are positive for Influenza A except for R33 as she is both Influenza A and COVID-19 positive. V8 stated We do the same PPE for all of the isolation rooms. On 2/19/25 at 11:10am V7, RN (Registered Nurse) stated an N95 mask is required to enter R33's room because she has COVID. V7 stated the other residents in isolation have Influenza A and staff only need to wear a surgical mask. On 2/21/25 at 2:45pm V3, Infection Preventionist stated an N95 mask is required when entering R33's room. 33970 2. The Facility's undated Enhanced Barrier Precautions policy documents It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms. Enhanced Barrier Precautions refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves use during high contact resident care activities. Initiation of Enhanced Barrier Precautions: a. enhanced barrier precautions will be initiated for residents with any of the following: ii. Chronic wounds (pressure ulcer stage III & IV, diabetic foot ulcers and venous ulcers) >6 weeks old, even if resident is not known to be infected or colonized with a MDRO. iii. Indwelling medical devices (Central Lines, Urinary Catheters, Gastronomy Tubes, and Tracheotomy), even if resident is not known to be infected or colonized with a MDRO. The Facility's undated Enhanced Barrier Precautions documents Implementing Contact versus Enhanced Barrier Precautions has wound or indwelling medical device, without secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO: Contact Precautions: no; Enhanced Barrier Precautions: yes. High-contact resident care activities include: g. device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes h. Wound care: any skin opening requiring a dressing. Enhanced barrier precautions should be used for the duration of the affected resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling medical device that placed them at higher risk. The facility's Enhanced Barrier Precautions signage documents everyone must: clean their hands, including before and entering and when leaving the room. Providers and staff must also: wear gloves and a gown for the following high-contact resident care activities: dressing, bathing/showering, transferring, changing lines, providing hygiene, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing. R29's Physician Order Sheet dated February 2025 documents Indwelling catheter for neurogenic bladder. On 2/19/2025 at 11:30 AM V5 (Certified Nurse Aid) performed catheter care. V5 only used gloves as PPE (Personal Protective Equipment) during catheter care. On 2/19/2025 at 1:00 PM V5 (Certified Nurse Aid) confirmed that R29 is in Enhanced Barrier Precautions and that she should have worn a gown while performing catheter care. R14's Physician Order Sheet dated February 2025 documents Silver hydrogel ointment to wound and cover with (gauze dressing) daily and PRN (as needed). On 2/19/25 at 2:00 PM V7 (Registered Nurse) performed wound care as ordered. V7 only used gloves as PPE (Personal Protective Equipment). On 2/19/25 at 2:10 PM V7 (Registered Nurse) confirmed that R14 is in Enhanced Barrier Precautions and that she (V7) should have worn a gown while performing wound cares.

Based on interview and record review, the facility failed to ensure the Hospice's coordinated communication and required documents were available and accessible to the facility staff. This deficiency affects one of one resident (R34) reviewed for Hospice care management in a sample of 31 residents. Findings include: The Nursing Facility Contract with the Hospice provider, dated 4/20/22, documented Information/Documentation provided to Facility on admission and on-going: Most recent hospice plan of care; Hospice election form and any advance directive specific to each patient; Physician certification and recertification of the terminal illness specific to each patient; Hospice medication information specific to each patient; Hospice physician and attending physician orders specific to each patient; Copies of clinical notes after each visit; Instructions on how to access Hospice's 24-hour on-call system; Name and contact information for hospice personnel involved in care of each patient. R34's Care Plan documented R34 was admitted to Hospice services on 10/11/24 with a diagnosis of Atherosclerotic heart disease and lacks specific Hospice responsibilities/interventions. R34's medical record lacked a Hospice plan of care, Election forms, Physician certification of terminal illness and/or copies of clinical notes. On 2/19/25 at 2:05 PM, V14 (Registered Nurse/RN) stated she was the second shift nurse for R34. While looking through R34's record, V14 stated there should be a Hospice sticker on the front of the chart and a tab labeled Hospice that has all the Hospice's documentation. V14 confirmed there was no sticker and no Hospice documentation in R34's medical record and did not know which company provided Hospice care to R34. On 2/19/25 at 2:15 PM, V13 (Licensed Practical Nurse/LPN) stated We don't keep Hospice documentation. On 2/20/25 at 9:55 AM, V4 (Registered Nurse) stated We call the Hospice and verbally give updates and notify them if there is a change in condition. The Hospice Nurse and Hospice Aide come together twice a week to give (R34) a bath. On 2/20/25 at 2:30 PM, V2 (Director of Nursing) stated the Hospice residents should have a Hospice binder with all the required information in it on the unit and available for staff.

Based on observation, interview, and record review the facility failed to have documented rationale or appropriate diagnosis for the use of an antipsychotic for one (R101) of five residents reviewed for unnecessary medications in the sample of 31. Findings include: The Diagnosis Report for R101, documents the following diagnoses as: Dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety and Major depressive disorder, single episode. R101's medical record does not include any other mental health diagnoses. The Medication Review Report for R101, dated 2/20/25, documents a physician order as of 2/14/25 for Quetiapine 25 mg (milligrams) one tablet by mouth at bedtime for depression. The current Care Plan for R101 documents (R101) is at risk for side effects to psychotropic medications. R101 was admitted with order for Quetiapine 25mg for depression. Interventions include to monitor for side effects, effectiveness and to notify physician of any pharmacy recommendations. Pharmacy to review medication at least monthly and give recommendations. On 2/18/25 through 2/20/25 between 9:30 am through 3:00 pm R101 exhibited no behaviors to support the use of an antipsychotic. R101 was pleasant, cooperative, and denied having any psychological issues. On 2/20/25 at 2:25 pm, V2 DON (Director of Nursing) confirmed R101 is receiving the antipsychotic medication Quetiapine (Seroquel) for Depression and the diagnosis of Depression is not a clinical rationale for the use of this medication. V2 DON stated R101 will be discharging tomorrow or (V2) would have called R101's physician for clarification of the medication. V2 DON stated the facility pharmacist has not yet reviewed R101's medications.

Based on interview and record review, the facility failed to notify the state mental health authority to reevaluate a resident with a significant change in mental status for one of two residents (R20) with a significant change in mental status in a sample of 31 residents. Findings include: The Preadmission Screening and Resident Review (PASRR) policy, no date, documented the policy was reviewed and updated annually to ensure compliance with CMS regulations and referenced the State Operations Manual, Appendix PP Guidance to Surveyors for Long Term Care Facilities and State-Specific PASRR regulations and guidelines. The policy documented the Level 1 screening was conducted by the nursing facility and did not include guidance for a reevaluation when a resident had a significant change in condition. R20's OBRA (PASRR) Initial Screen form dated 5/17/19 documented R20 was not suspected as having a mental illness and did not require a level 2 screening. R20's Medical Diagnosis record documented R20 was admitted from another Skilled Nursing Facility on 10/22/2019 with Unspecified Dementia, unspecified severity, without behavioral disturbance, psychotic disturbances, mood disturbances and anxiety, on 9/8/20 Unspecified Psychosis and on 10/27/21 Anxiety Disorder. R20's Minimum Data Set (MDS) section E-Behaviors dated 7/9/20 documented R20 developed physical and verbal behavior symptoms toward others; 8/20/21 documented R20 had delusions; 12/19/22 had physical symptoms such as hitting, scratching self, pacing, rummaging, public sexual acts, disrobing, throwing or smearing food or bodily waste or verbal symptoms like screaming or disruptive sounds and overall behaviors were worsening. R20's Care Plan documented on 5/10/23 R20 will be started on tracking for paranoid delusions noted by believing the facility is holding her hostage and family is trying to get rid of her. R20's medical record did not include documentation a new referral to the state mental health authority was made or a reevaluation was conducted by the state mental health authority for a significant change in mental status. On 2/20/25 at 2:27 PM, V2 (Director of Nursing) stated R20 was not referred or reevaluated by the state mental health and should have been revaluated with the change in R20's behavior.

Based on record review and interview the facility failed to effectively monitor all infections in the facility. This failure has the potential to affect all 54 residents who currently reside in the facility. Finding Include: The Facility's Infection Control Policy dated 01/11/2024 documents The Infection Prevention and Control Program includes a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to the regulatory requirements and follow accepted national standard. Surveillance: A system of surveillance designed to identify possible communicable disease or infections before they can spread to other persons in the facility. The Facility's October 2023, November 2023, December 2023, January 2024 and February 2024 Monthly infection control logs listed all infections for each respective month. None of these logs included information about whether or not the infection was community acquired or a house acquired infection. These logs also did not include when and if any of the listed infections were resolved. On 3/19/24 at 2:30 PM V4 (Registered Nurse/Infection Preventionist) confirmed that the infection surveillance logs do not indicate if the infections were community acquired or house acquired infections. V4 also confirmed that there were no resolution dates for the infections. V4 stated I know that there is a spot on the form that we should fill out if the infections are community based or house acquired, but I have never filled that part out. If there are no dates on the infection control logs for when those infections were resolved, I would have to go back through the charts of every resident who had an infection to get that information. I should put that on the form and start tracking it. The Resident Room Roster dated 3/17/24 lists 54 residents who currently reside in the facility.

Based on observation, interview and record review, the facility failed to report, track and perform COVID-19 testing of an employee that displayed COVID-19 like symptoms prior to providing services to 11 residents (R4 through R14) of 17 residents reviewed for COVID-19 in a sample of 14. Findings include: The facility's Infection Surveillance - Employee policy dated 4/2023 documents Infection prevention begins with ongoing surveillance to identify infections that are causing, or have the potential to cause, an outbreak. The facility closely monitors all employees who exhibit signs/symptoms of infection through ongoing surveillance and has a systematic method for collecting, consolidating, and analyzing data concerning the frequency and cause of a given disease or event, followed by dissemination of that information to those who can improve the outcomes. The intent of surveillance is to identify possible communicable diseases or infections before they can spread to other persons in the facility. In addition, surveillance is crucial in the identification of possible clusters, changes in prevalent organisms, or increases in the rate of infection promptly. The results should be used to plan infection control activities, direct in? service education, and identify individual resident problems in need of intervention The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections. The Infection Preventionist, department supervisor or other designated staff record reports of symptoms on the Employee Infection List/Log and/or other diagnostic test results consistent with potential infections to detect clusters and trends and to be able to identify and report evidence of a suspected or confirmed HAI (Healthcare-Associated Infection) or communicable disease. Sources of relevant data that can be used for outcome surveillance for infections and susceptibility may include: Reporting of fever or signs that may indicate an infection. Reporting of illness; including symptoms. Reporting of diagnostic test results consistent with potential infections to detect clusters, trends, or susceptibility patterns. R5's medical record dated 8/26/23 documents Resident's daughter called back, and requested a COVID test, reporting that her mother generally does not run fevers with UTIs (Urinary Tract Infection). (V2, Director of Nursing (DON)) was on the unit and a rapid swab was obtained. COVID swab was positive. R4, and R6's medical record documents they tested positive for COVID-19 on 8/26/23. R7 through R14's medical record documents they all tested positive for COVID-19 on 8/28/23. The facility's employee COVID-19 tracking sheet documents V7, Cook, tested positive for COVID-19 on 8/25/23. The facility's August 2023 employee infection surveillance tracking log does not document V7's, Cook, symptoms of COVID-19 prior to 8/25/23. The facility's dietary schedule dated 8/24/23 documents V7, Cook, worked on the memory care unit. On 9/14/23 at 10:05 AM, V3, Certified Nursing Assistant (CNA) stated I can't speak to what other employees do, but if we have symptoms of COVID, were supposed to notify the nurse prior to coming into the building and they come out, test us for COVID and take our temperature. If we're cleared, we can work, but we have to test every day if symptomatic. Like right now I have stuffiness, but I test every day prior to coming in and have to have my temp checked. On 9/14/23 at 10:17 AM, V6, Registered Nurse (RN) stated The employees are supposed to notify us before coming into the building if they have symptoms. If they do come in, we immediately send them out to their car. We go out to their car, perform a COVID test, take their temperature and then document their symptoms. If they're negative, we contact the on call, DON (Director of Nursing) or the administrator to find out if they're cleared to come in to work. If they're positive, they have to go home, and we still have to contact the DON and administrator to let them know there's a positive employee. On 9/10/23 at 10:50 AM, V7, Cook, observed in the kitchen on the memory care unit preparing resident meals. V7, Cook stated I came to work on Tuesday (8/22) with a sore throat. I didn't think much of it because that happens. I'll have a sore throat in the morning, but then it goes away. When I got home, I tested for COVID, and it was negative. The next day (8/23) I was still sick, so I went to clinic and tested , and it was negative. On Friday (8/24) I came to work with a stuffy nose, sore throat and my ears were popping. I didn't test before coming into work. No, I didn't report my symptoms to anyone, but they kind of knew. I sounded like a frog. The next day (8/25/23) I tested at home and was positive and notified my supervisor. I did not report my symptoms on 8/22 or 8/24 to the facility. On 9/14/23 at 10:57 AM, V2, DON, stated Anytime an employee is sick, they have to call from the parking lot and inform the nurse they're symptomatic and the nurse will go out, take their temperature and give them a COVID test. They are not to be in the building working with symptoms unless cleared by one of the nursing supervisors. They are required to report symptoms prior to working. I was not aware that (V7, Cook) came to work sick without testing, she should have tested prior to working. On 9/14/23 at 12:38 PM, V2, DON stated (R5) was the first one to test positive on 8/26. We then tested everyone on the unit and her roommate (R6) and (R4) tested positive, but no one at that point. We do days one, three and five for testing and on day three of the testing the rest of the unit tested positive.

Based on observation, interview, and record review the facility failed document a diagnosis and clinical indication to warrant the initiation of an antipsychotic for R14; and failed to comprehensively evaluate and assess R34 for underlying conditions or stressors, non-pharmacological behavioral interventions, and psychotropic drug use prior to starting an anti-psychotic medication. These failures have the potential to affect two of six residents (R14, R34) reviewed for anti-psychotic medication use in the sample of 25. Findings include: The facility's Psychotropic Medication Policy undated documents, Procedure: Prior to the administration of a psychotropic medication, the following includes a process for the IDT (Inter-Disciplinary Team) and resident/resident representative to participate in the care process: b.) Antipsychotic Medication: Diagnoses alone do not necessarily warrant the use of an antipsychotic medication. Antipsychotic medications may be indicated if: Behavioral symptoms present a danger to the resident or others. Expression or indications of distress that are significant distress to the resident. If not clinically contraindicated multiple non-pharmacological approaches have been attempted but did not relieve the symptoms which present a danger or significant distress. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. 2. A psychotropic drug assessment will be completed on admission, quarterly, and significant change in condition. The assessment will be reviewed by the IDT to help identify resident's needs, goals, comorbid conditions, and prognosis to determine factors that are affecting signs, symptoms, and test results. This evaluation process is important when selecting initial medications and/or non-pharmacological approaches and when deciding whether to modify or discontinue a current medication. Attempt to identify underlying cause for behavioral symptoms. This will include an evaluation of a resident's physical, behavioral, mental, and psychosocial signs and symptoms, to identify the underlying causes, including adverse consequences of medications. The evaluation will also consider each resident's goals and preferences, allergies to medications and foods, a history of prior and current medications and non-pharmacological interventions, recognition of the need for end-of-life or palliative care and the basis for declining care, medication, and treatment and the identification of pertinent alternative as well as documented indications of distress, delirium, or other changes in functional status. 3. Psychotropic medications may be used to treat an enduring condition. Before initiating or increasing a psychotropic medication for enduring conditions, the resident's symptoms and therapeutic goals must be clearly and specifically identified and documented. Not due to a medical condition or problem (example: pain, fluid or electrolyte imbalance, infection, constipation, medication side effect or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication are discontinued. Not due to environmental stressors alone that can be addressed to improve the symptoms or maintain safety. Not due to psychological stressors alone that can be expected or improve or resolve as the situation is addressed. 1. On 03/06/23 at 11:41 AM, R14 was alert sitting up in her wheelchair in her room. R14 was pleasant and not displaying any behaviors. On 03/08/23 at 12:24 PM, R14 was alert sitting in dining room at the table for lunch. R14 was pleasant conversing with her table mates and not displaying any behaviors. R14's Order history, dated 3/8/23, documents that R14 was started on Abilify (aripiprazole) 2 mg (milligrams) by mouth daily every morning for Depression on 8/3/22. It also documents that R14's current dosage of Abilify continues to be 2 mg daily. R14's Medicare/Skilled Progress Note, dated 7/16/2022 at 11:27 a.m., documents, Alert and oriented with confusion and forgetfulness. R14 yells aloud often, every time she sees a person walking down the hall in front of her door, she screams help. She voices understanding on how to use call light but does not use it. Resident refuses to go to dining area for meals. Resident cries often and when asked to do something she screams at staff. R14's Nurses Note, dated 7/19/2022 at 9:38 p.m., documents, R14 very anxious about going home and not being able to take care of self. Tried reassuring her about being in the facility for staff to take care of her. Another staff member was able to redirect and get R14 ready for bed. R14's Medication Administration Note, dated 7/20/2022 at 03:27 a.m., documents, R14 was very confused earlier this shift. She was looking for her husband and wanted to go to the doctors because she was feeling dizzy. This nurse gave R14 as needed Meclizine for dizziness and as needed Ativan for anxiety. This nurse sat by R14 and talked with her a little while to help her calm down. This nurse also let R14 know that it was only 2 AM and the doctor's office was closed at this time. R14 thought it was daytime and once she knew what time it was, R14 wanted to go back to sleep. R14 is sleeping soundly at this time. R14's Behavior Note, dated 7/20/2022 at 11:59 a.m., documents, R14 is alert and oriented times 2-3 with confusion and forgetfulness noted at times. She is able to let her needs be known and she understands others. She is pleasant with staff. She was admitted for long term care as she can no longer care for herself. She was admitted with orders for Lexapro 20 mg daily, and Ativan 0.5 mg daily and PRN (as needed). She will be started on tracking for signs/symptoms/ of anxiety noted by anxiousness, restlessness and worrying. Interventions will be 1) Encourage her to participate in activities. 2)Encourage her to socialize with her peers. 3)Try a distracting conversation. Her goal is to have 30 or less episodes per month. According to tracking so far, she has had 71 episodes for the month of July. She will also be started on tracking for signs/symptoms of depression noted by down/depressed mood, making negative statements, lack of interest and tearfulness. Interventions will be 1) Assess for pain and report to nurse. 2)Encourage her to talk to her family. 3)Sit and talk about what is bothering her. Her goal will be to have 30 or less episodes of depression per month. According to tracking she has had 51 episodes so far in July. R14's Behavior tracking, dated 7/22, documents that R14 was being monitored for the following behaviors prior to the initiation of R14's Abilify: anxiousness, restlessness, worrying, down/depressed mood, making negative statements, lack of interest, and tearfulness. R14's Physician progress note, dated 7/22/22, documents, Plan: Major Depression: Start aripiprazole 2 mg daily. Due to notably worsening symptoms, we will augment with low-dose of aripiprazole 2 mg at night. I feel she would greatly benefit from individual counseling. I suspect of lot of her low mood is related to situational changes now being a resident in the nursing home. Subjective: There have been concerns about patient's mood. Nursing staff notes that she is quite upset and crying a fair amount of the time. R14 notes that she is 'ready to die.' Has no direct suicidal intentions, but notes that she is not sure why she is still here. Nursing staff notes that she is actually sleeping through most of the nights. Objective: Psych: Mood again is a bit labile, sometimes tearful. Affect is a bit flattened. There is some decreased psychomotor function, but no restlessness or tremor. Thought process is mostly linear. There is no psychoses. R14's Physician progress note, dated 9/18/22, documents, Subjective: Anxiety and Major depression. She is still having a fair amount of breakthrough anxiety, particularly midday. Nursing staff does feel that her lorazepam is being well-tolerated as well as giving her relief. Objective: Psych: Mood is a little anxious but overall pleasant. Thought process is not linear. She does confabulate a little bit in regards to things that she thinks have happened recently but there is no way that she could have attended. Does not have any active suicidal ideation but knows that she is ready to die whenever. Insight and judgement are impaired. R14's Psychiatric Encounter Summary, dated 12/19/22, documents, R14 has reported significant symptoms related to depression and anxiety. R14 is being treated for these associated signs and symptoms. R14 was previously at assisted living facility but due to a decline in R14's ability to care for herself, she was transferred to this facility. R14 was referred due to crying, anxiety, restlessness, agitation and exit seeking behaviors. R14 presented fatigued. Long pauses for responses. R14 stated that she was 'all right.' She shared of a 'good' mood. Denies any sadness. Staff reported ongoing confusion and noted increased incontinent and urgency/frequency. R14 had a recent UTI (Urinary Tract Infection). Currently receiving treatment. R14 has had noted tearful episodes. Review of symptoms: R14 reports weight loss. R14 reports change in appetite. She reports urinary loss of control. She reports depression, sleep disturbances, anxiety, memory loss, and agitation but reports no hallucinations. Psychiatric exam: Appears fatigued. Behavior: cooperative. Mood: euthymic. Affect: blunted. Thought process: attention wandered throughout interview, concentration impaired and shows circumferentially. R14's Psychotropic Assessment, dated 1/6/23, documents that R14 is receiving Abilify 2 mg daily for Major Depressive Disorder. It also documents that the target behaviors are tearfulness/crying and sad/down/depressed mood. R14's current electronic medical record has no documentation of any psychotropic assessments addressing R14's Abilify including prior to initiating the Abilify. R14's MDS (Minimum Data Set), dated 1/6/23, documents in Section E Behaviors that R14 does not have any behaviors nor any behaviors that put herself or others at risk for injury. On 03/08/23 at 12:12 PM, V2 (Director of Nursing) stated, We were surprised when (R14) got started on the Abilify by her doctor. We weren't expecting an antipsychotic. She has major depression and that's what it is treating. Her behaviors do not put her or other residents at risk for injury. V2 also confirmed that there was no assessment for R14's use of the Abilify prior to 1/6/23. 31682 2. R34's Physician's Orders dated 5-12-22 document, Olanzapine (Zyprexa) 2.5 mg (milligrams) every day for diagnoses of Dementia with Behavioral Disturbance. R34's Physician's Orders dated 9-22-22 document, Discontinue Monday dose of Zyprexa 2.5 mg. R34's Physician's Orders dated 9-22-22 through 3-6-23 document R34 has received Zyprexa 2.5 mg every evening on Tuesdays, Wednesday, Thursdays, Fridays, Saturdays, and Sundays for the diagnosis of Dementia with Behavioral Disturbance. R34's Electronic Health Record does not include an evaluation by the IDT (Inter-Disciplinary Team) or Psychotropic Drug Assessment being completed prior to initiating the start of R34's Zyprexa. On 03/08/23 at 01:40 PM V2 (Director of Nursing) stated, There is no documentation of an evaluation by the IDT (Inter-Disciplinary Team) or Psychotropic Drug Assessment being completed prior to initiating the start of (R34's) Zyprexa

Based on observation, interview and record review, the facility failed to ensure that seven residents were not given a Notice of Involuntary Discharge due to facility downsizing and ensure residents were allowed to remain in the facility. This affected seven of seven (R1- R7) residents reviewed for Involuntary Discharge in a sample of nine. Findings: The Facility Admission Policy dated 10/27/17, states, Admission to the facility is based upon criteria in advance of the referral to determine that the facility is capable of providing the care and services to manage the potential admissions illness, physical status, clinical status, psychosocial status and plan of care. Potential admissions into the facility will be: over the age of [AGE] years of age; free from communicable diseases that cannot be managed within the facility; active drug addiction; and [CONDITION(S)]. Procedure: A. Conduct a preadmission assessment/screen with the resident, resident representative and referral entity to determine that the facility is capable of providing the care and services to manage the potential admissions illness, physical status, clinical status, psychosocial status and plan of care. The facility will complete the PASARR (Pre-Admission Screening and Resident Review) Resident process in accordance to regulatory requirements and facility policy. Additionally, the facility will complete a preadmission financial review to determine payer source and will coordinate with resident, resident representative, referral entity and payer contact for prior authorization for admission into a skilled nursing facility. The Facility Assessment, dated 7/21/22, states, (Admission) Acceptance Procedure: Face to face interview is conducted to assess the needs of the individual and to reveal their medical records. The contact or Power of Attorney fills out an application for the individual. The facility Care Plan Team reviews and decides whether the needs of the individual can be met. The family is contacted, and the plan is laid out to transfer the individual to the facility. The document, Transfer and Discharge Policy, no date, (V1, Administrator states 2017), documents, It is the policy (of this facility) that each resident has the right to remain in the facility and not transfer or discharge a resident unless a transfer or discharge from the facility is: A. Necessary for the resident's welfare and the resident's needs cannot be met in the facility; B. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met by the facility; C. The resident requires immediate transfer or discharge based on the resident's urgent medical need; D. The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; E. The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; F. The health of individuals in the facility is endangered due to the clinical or behavioral status of the resident; G. The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. H. Nonpayment applies if the resident does not submit the necessary paperwork for third party payment or after the third part, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or I. The facility ceases to operate. The rights of residents who voluntarily or involuntarily are discharged from the facility will be upheld and that a resident will not be involuntarily discharged unless the circumstances meet specific criteria defined by regulations and laws. The facility will make every effort to provide care and service to the residents it serves. On 8/08/22, V1's correspondence through email (electronic mail), notification was sent to V22, Regional Ombudsman, which stated, The facility Board of Directors made the decision at the July Board meeting to reduce the size of our nursing home. We are showing significant losses every month with the increase in wages for nursing staff and use of agency staffing. In order to survive, we think that downsizing to 50-52 will allow us to cut some staffing costs and eliminate the need for agency staffing. We plan to begin calling families today (8/08/22) with a 30 day notice. This change will impact the last 7 residents that were admitted for long term services at (the facility). We have a list of nursing homes in the area that have indicated that they have available beds. Our target size is 51 residents - we are currently at 58. Please let me know if you have any questions. On 8/08/22, R1, R2, R3, R4, R5 and R6 were given a verbal 30-day involuntary discharge notice by phone due to the facility being down sized. R7 was given the notice on 8/17/22 as R7 was in an acute hospital at the time. A letter, written on 8/08/22 and mailed to Family Members on 8/11/22 states, This letter is a follow-up to our phone conversation Monday. The facility Board of Directors made the difficult decision to downsize the nursing home portion of the campus at the July Board meeting. The operating environment for nursing homes across the country has been extremely challenging the past two and one half years since the start of the COVID-19 pandemic. The combination of increases in the minimum wage, significant increase in certified nurse aide and nurse wages, use of agency staffing and lack of candidates seeking employment have been unprecedented. This facility has suffered significant financial losses and are currently working on a plan to sustain operations. The board's decision requires us to find placement for seven residents. In order to be fair, we looked at each resident's admitted to determine which residents would need to be placed in another nursing home. Unfortunately, you or your loved one fell into this group. We plan to assist you in finding placement. Attached you will find a list of eight nursing facilities in the area that have beds available. After you have had a chance to review this list, we would ask that you select your first choice and one to two other homes that you would consider, and we will begin working with those facilities. Enclosed is the required 30 day- 'Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents.' The notice explains the process to follow if you wish to contest the proposed involuntary transfer. We hope to work with families starting this week to find each resident an alternative care facility. The document, Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents, date of notice to the resident 8/08/22, states, Federal Proceedings. This facility admits private pay and Medicare or Medicaid residents and is federally-certified and state licensed. This facility seeks to transfer or discharge you pursuant to the regulations of the Health Care Financing Administration for states and long-term care facilities, 42 CFR 483.15 ('federal regulations'). As recorded in your clinical record in accordance with Section 483.15 (c) of the federal regulations, the reason for this proposed transfer or discharge is: this facility ceases to operate, 483.15(c)(1)(i)(F). (handwritten on the form states:) facility is reducing (the number) of patients for financial reasons. On the date of transfer or discharge you will be relocated to: Facility/Person - not determined. The effective date of the proposed transfer or discharge is September 8, 2022. The person who will supervise your transfer or discharge is: (V1, Administrator). (R1's) Facesheet states that (R1's) original admitted was 2/28/22; Primary Payer source was Medicaid; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R1's) Care Plan, Date Initiated 3/01/22, and Revision on 3/01/22, states, Discharge potential: (R1) was admitted because (she) was not able to complete (R1's) ADLs (Activities of Daily Living) independently. (R1) is no longer able to safely live in and independent living environment. (R1) has no plans for discharge. (R1's) electronic medical record Progress Note states that on 8/08/22, (V13, R1's Family Member), was given (verbally on the phone) (R1's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to V13 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/22/22 at 2:05 PM, an attempt was made to interview R1 but was unsuccessful due to (R1's) cognition is poor. Attempts to contact (V13, R1's Family Member), have been unsuccessful. (R2's) Facesheet states that (R2's) original admitted was 3/21/22; Primary Payer source was Medicaid; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R2's Care Plan, Date Initiated 3/21/22, states, Discharge Potential: (R2) was admitted from another nursing home for long term care. (She) is not able to care for herself independently. (R2) has no plans for discharge. (R2's) electronic medical record Progress Note states that on 8/08/22, (V10, R2's Family Member), was given (verbally on the phone) (R2's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to V10 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/22/22 at 2:10 PM, (R2) was in (R2's) room, resting in bed. (R2) was alert. (R2) stated that she was staying in the facility. I don't know why you would think I should be leaving. This is my home. On 8/25/22 at 11:21 AM, (V10, R2's Family Member), stated, I found out that (R2) would need to leave the facility on 8/08/22. I received a document on 8/13/22 which included a list of possible places that (R2) could move to. I question the Involuntary Discharge document as it doesn't fit the reason that the facility hand wrote on the form, downsizing. I think it's dishonest. (R2) was on a waiting list to come here since October of 2021 and moved here in March (2022). I don't live close, but I come up frequently to see (R2). We would like for (R2) to stay in this town so (she) can visit with family who live in the area, but there just aren't many nice places that she could live in here. We don't want (R2) to go back to the place (R2) was in before (she) came to this facility as (R2) received poor care there. (R2) has been through a lot since May 2022. (R2) had to have an emergency surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] . The trauma of the surgery and aftermath was hard for (R2) to handle and (she) is just now starting to act more like (herself), although (R2) doesn't remember a lot of things. I'm afraid that if (R2) is taken out of this environment into another facility that (R2) will have a set back and never be the same again, maybe decline more. R2's Medical record documents that (R2) is now in the process of an appeal to the involuntary transfer. (R3's) Facesheet states that (R3's) original admitted was 11/22/21; Primary Payer source was Medicaid; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R3's Care Plan, Date Initiated 11/22/21; Revision on 12/20/21, Discharge Potential: (R3) was admitted from another long term care facility. (He) is not able to care for himself in an independent living setting. (R3) has no plans for discharge. (R3's) electronic medical record Progress Note states that on 8/08/22, (R3) and (V12, R3's Family Member), were given (verbally and on the phone) (R3's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to R3 and V12 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/23/22 at 10:30 AM, (R3) was sitting in the Dining Room in another Household. Once secluded in the room, (R3) stated, I do not want to leave. It will be a hardship for me and (V12, R3's Family Member). (V12) just sold our house and moved to this town and lives across the street. We can finally be close to visit with each other. (V12) can drive, but she's not getting around as well as (she) used to and I worry about (V12). Also, we are able to go to church together now on Sundays and I run a Bible study here at the nursing home every week. Those things are important to me. I'm going to have a surgery soon, if I do move, maybe, I won't get to have the surgery. I just don't know what I'm going to do. I don't think there's a nursing home that I can go to here in this town. If I move to another town what about (V12)? I want to be close to (her). On 8/26/22 at 10:33 AM, V12 (R3's Family), stated, We found out that (R3) was going to have to leave on 8/08/22. We are upset. I sold our house and moved to this town so I could be close to (R3). I live in an Assisted Living place right across the street from where (R3) is now. The facility said another facility will take (R3), but it's in another town. I'm having physical/health difficulties and worry that I won't be able to see (R3) very often if he goes to the other facility. I've never been to this new home and that's another worry as these nursing homes aren't all very good. I'm supposed to be the one that is informed about things, but the facility has been giving everything to (R3), which is okay, I guess. I don't know, this whole situation has me worried. R3's Medical record documents that (R3) is now in the process of an appeal to the involuntary transfer. (R4's) Facesheet states that (R4's) original admitted was 11/24/21; Primary Payer source was Medicaid; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] (R4's) Care Plan, Date Initiated 11/29/21, Revision on 12/17/21. Discharge Potential: (R4) was admitted from another long term care facility. (She) is not able to care for herself in an independent living environment. (R4) has no plans for discharge. (R4's) electronic medical record Progress Note states that on 8/08/22, (R4) and (V11, R4's Family Member), were given (verbally and on the phone) (R4's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to V11 and R4 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/11/22 at 1:35 PM, (R4's) Progress Notes, charted by V1, Administrator, stated, Talked to (R4) today about (her) move to the (new facility) on Tuesday, August 16th. Informed (R4) that I would also call (V11, R4's Family Member). Plan to get (her) things ready to move on Monday. On 8/25/22 at 11:40 AM, (V11, R4's Family), stated, I first heard about (R4) having to leave a week before (R4) left. (V1), Administrator, called and explained that the facility had to downsize, or they would have to close. I asked if anyone else had to leave and (she) told me there were seven residents altogether that had to leave. (V1) told me of the other places in town that (R4) may want to move to. I told (V1) that I would need help finding a place for (R4). Then I was told that another facility in town had accepted (R4) but that they did not know when that facility would be able to actually move (R4) into the facility. I was familiar with the new facility as another family member had been there in 2010. It all happened so fast. (R4) and I did not go on a tour of the new facility before (R4) moved there. I went to visit (R4) on Wednesday 8/17/22. You have to use this kiosk in the facility lobby to sign in. It asks who you are going to visit and when I put (R4's) name in the kiosk, it wouldn't check me in. I asked the girl who sits there why, and she looked (R4) up and she told me that (R4) wasn't there, that (R4) had moved out of the facility the day before. I was shocked. I had told the facility when we talked about (R4) leaving that I wanted to know when so I could be there on the day she moved out. You know, to help her pack. I can't lift but I was going to check and make sure that she got everything. I don't know if all of her things came with (R4). (R4) is still unpacking. I'm not sure how the transfer went, if there were any problems that day. I don't think so as (R4) never mentioned any. No one called me to tell me when (R4) was going to move to the new facility on Tuesday (8/16/22). When I was at the facility on Wednesday (8/17/22) I asked the office girls about the billing as I had already paid, and they told me how that would work. A nurse, I think (V6, Registered Nurse), called me this week and asked how (R4) was doing but that's it. No one called and explained or apologized for not letting me know when (R4) was going to leave. I didn't even sign the papers at the new facility until Thursday, (8/18/22). I was surprised they took (R4) before I signed them. (R4) has a lot of food allergies and I wanted to be sure that wherever she went they would be able to feed (R4) what (she) can eat. Thankfully, the new facility told me that they had already discussed (R4's) diet with (her) and everything worked out okay. That was a big relief. (R4) probably could have lived in an Assisted Living place, but eventually (R4) would have needed to move to a nursing home so I thought this would be easier on (R4), to make only one more move. I think (R4) likes it at the new place. When I visited with (R4), it was still all new to (her). (R5's) Facesheet states that (R5's) original admitted was 3/25/22; Primary Payer source was Private Pay; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R5's) Care Plan, Date Initiated 3/28/22, Discharge Potential: (R5) was admitted for rehabilitation services and plans to return home. (He) will likely need home services set up. On 5/23/22 (R5's) family decided he could not go home and care for himself safely. R5's electronic medical record Progress Note states that on 8/08/22, (R5) and (V14, R5's Family Member), were given (verbally and on the phone) (R5's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to R5 and V14 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/22/22 at 2:20 PM, (R5) was sitting in his room. (R5) was alert and oriented to the conversation. (R5) stated, I guess I don't care where I live - as long as I'm taken care of. I'm not sure why I was chosen to leave, but it doesn't really bother me. They're all the same. V14 was unable to be contacted for interview. (R6's) Facesheet states that (R6's) original admitted was 10/14/19; Primary Payer source was Medicaid; diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . R6's Care Plan, Date Initiated 6/20/22, Revision on 6/20/22, Discharge Potential: (R6) was admitted from another long term care facility. (R6) is not able to care for himself in an independent living setting. (R6) has no plans for discharge. (R6's) electronic medical record Progress Note states that on 8/08/22, (R6) and (V15, R6's Family Member), were given (verbally and on the phone) (R6's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to V15 and R6 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/22/22 at 2:25 PM, (R6) was lying in bed in his room. (R6) was alert and oriented to the conversation. (R6) stated, It's fine if I leave. What difference will it make? They need to save money and I'm going to be in another home. This place isn't perfect, either. V15 was unable to be contacted for interview. (R6) discharged to another nursing home on 8/26/22. (R7's) Facesheet states that (R7's) original admitted was 5/11/22; Primary Payer source was Medicaid; (R7) was readmitted to the facility from an acute care hospital on 8/12/22 and current payer source is Medicare A. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . (R7's) Care Plan, Date Initiated 5/12/22, Revision on 5/18/22, Discharge Potential: (R7) was admitted from another long term care facility. (R7) was admitted for rehab services and plans to return home when (he) is able. He may need home services when he discharges. (R7's) electronic medical record Progress Note states that on 8/08/22, (R7) and (V16, R7's Family Member), were given (verbally and on the phone) (R7's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to V16 and R7 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/22/22 at 2:30 PM, (R7) was sitting in his room. (R7) was alert and oriented to the conversation. R7 stated, I want to stay close to my home. I will be okay with moving if I can stay close to my home. V16 was unable to be contacted for interview. R7's Medical record documents that (R7) is now in the process of an appeal to the involuntary transfer. On 8/22/22 at 11:15 AM, V1, Administrator, stated, Inflation, the increase in staff salaries, lack of available staff which means using agency staff (who make twice the amount of our own staff) has caused our facility to be in financial difficulties. If we continue as we are now, I am not sure that we will still be open in a year from now. Our current census averages 55 to 60 residents. We had a board meeting in July and came to the decision that if we would downsize to a resident census of no more than 51 residents we could continue to operate. We chose residents who were the most recent admissions minus the two exceptions, the Life Care Commitment to those residents living in our independent living areas and a hospice resident. It was not an easy decision. I have researched and have reached out to (State agency) for guidance but there is none on how to discharge residents when you want to downsize a facility. We are doing our best to find places for those residents who have been given the involuntary discharge notice. One resident has left and one is leaving this Friday (8/26/22), Our goal is to relocate the other five residents by 9/08/22, but of course we would continue to help find a new home for any of these residents who have not discharged by that date They would have a home with us until they did. On 8/23/22 at 3:14 PM, V2, Director of Nursing, stated, (V15, R6's Family Member), came in to talk to me. (V15) told me that (R6) liked the new facility and was happy that there is a garden that (R6) can sit in by himself. He was not able to do so here. (V15) mentioned that (R6) told her that (he) was looking forward to moving to the new facility. On 8/23/22 at 3:10 PM, V2, Director of Nursing, stated that she is checking on possible transfers to other nursing homes for the five remaining residents who have not secured a new home. It's been a difficult task as we hate to see the residents leave. Finding homes that are acceptable to the resident and their families is our goal. We have reached out to those homes close to our facility. I'll continue to do what I can to help in this process. On 8/30/22, V21, Medicaid Billing, stated, We do things a little differently at this facility. Medicare and Medicaid are paid directly to the residents or to the Resident's Power of Attorney. The theory is to keep the family involved in the residents stay. The resident/families in turn pay the facility monthly. (R2, R4-R7) are paid up. (R1 and R3) still need to pay for August and we are working with them. On 8/29/22 at 3:05 PM, V8, Licensed Practical Nurse, stated, It's been hard for the staff to see our residents leave because even though some have been here a short amount of time, we are very fond of them. Even though some did have behaviors, we were able to determine what triggered the behaviors. Once we knew what caused the behaviors, we were better able to prevent or minimize them. I don't see that any of the seven residents (R1-R7) have had behaviors recently. On 8/29/22 at 3:30 PM, V19, Registered Nurse, stated I take care of (R2, R3 and R6). I have not noticed any issues with the residents since they found out they were leaving. I don't think it would matter to (R2) where (she) lives as long as (R2) gets to see (her) family. (R2) likes to stay alone in (her) room even for meals. (R2) watches television or listens to the radio. (R2) forgets things that happen from one day to the next and doubt that (R2) even remembers that (she) is going to leave. (R6) mentioned to me that (he) was leaving and was looking forward to it. (R6) wasn't one to say much so was surprised that (he) even mentioned it. On 8/29/22 at 3:40 PM, V18, Certified Nursing Assistant, stated, (R2) has changed a lot since (she) had cancer last spring. (R2) never wanted to leave (her) room much but now (R2) hardly ever will go out of (her) room. (R2) doesn't seem to be upset about leaving. (R6) stayed in (his) room most of the time also. I saw (R6) packing the day before (he) left and (R6) seemed in a good mood, even kidded around with me a bit. (R6) said there is a garden that (he) can go out and sit in at the new facility. The admitted s of two other residents living in the facility that were among the residents last admitted to the facility but were not given the Involuntary Discharge Notice. R8 (Admit 4/22/22) Brief Interview for Mental Status (BIMS) score of 6 (Severe Cognition Status), with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The patients in our Memory care are mostly late stage so we felt it would not be a good environment for the patients with higher levels of cognition. (R1) (admitted [DATE]) has a Brief Interview for Mental Status (BIMS) of 4 (Severe Cognition Impairment) and has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER]

Based on interview and record review, the facility failed to sufficiently prepare a resident and resident representative for a discharge from the facility for one (R4) of seven residents reviewed for Involuntary Discharge in a sample of nine. Findings include: The Transfer and Discharge Policy, no date, states, The Facility informs the resident where he or she is going and takes steps under its control to assure safe transportation. The facility should actively involve, to the extent possible, the resident and the resident's family in selecting the new residence. The interdisciplinary team designee will meet with the resident and resident representative to review the effective date of the transfer/discharge. The facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. The orientation will be provided to the resident and resident representative in a form and manner that can be understood. The facility will work with the resident and family to ensure that valued possessions are not left behind. (R4's) Care Plan, Date Initiated 11/29/21, Revision on 12/17/21. Discharge Potential: (R4) was admitted from another long term care facility. (She) is not able to care for herself in an independent living environment. (R4) has no plans for discharge. (R4's) electronic medical record Progress Note states that on 8/08/22, (R4) and (V11, R4's Family Member), were given (verbally and on the phone) (R4's) 30 day Involuntary Discharge notice due to the facility downsizing for financial issues. A letter was provided to R4 and V11 restating the issue including the Notice of Involuntary Transfer or Discharge and Opportunity for Hearing for Nursing Home Residents form and a list of potential nursing homes in the area. On 8/11/22 at 1:35 PM, (R4's) Progress Notes, charted by V1, Administrator, states, Talked to (R4) today about (her) move to the (new facility) on Tuesday, August 16th. Informed (R4) that I would also call (V11, R4's Family Member). Plan to get (her) things ready to move on Monday. On 8/25/22 at 11:40 AM, (V11), stated, I first heard about (R4) having to leave a week before (R4) left. (V1), Administrator, called and explained that the facility had to downsize, or they would have to close. I asked if anyone else had to leave and (she) told me there were seven residents altogether that had to leave. (V1) told me of the other places in town that (R4) may want to move to. I told (V1) that I would need help finding a place for (R4). Then I was told that another facility in town had accepted (R4) but that they did not know when that facility would be able to actually move (R4) into the facility. I was familiar with the new facility as another family member had been there in 2010. It all happened so fast. (R4) and I did not go on a tour of the new facility before (she) moved there. I went to visit (R4) on Wednesday 8/17/22. You have to use this kiosk in the facility lobby to sign in. It asks who you are going to visit and when I put (R4's) name in the kiosk, it wouldn't check me in. I asked the girl who sits there why, and she looked (R4) up and she told me that (R4) wasn't there, that (R4) had moved out of the facility the day before. I was shocked. I had told the facility when we talked about (R4) leaving that I wanted to know when so I could be there on the day she moved out. You know, to help her pack. I can't lift but I was going to check and make sure that she got everything. I don't know if all of her things came with (R4). (R4) is still unpacking. I'm not sure how the transfer went, if there were any problems that day. I don't think so as (R4) never mentioned any. No one called me to tell me when (R4) was going to move to the new facility on Tuesday (8/16/22). When I was at the facility on Wednesday (8/17/22) I asked the office girls about the billing as I had already paid, and they told me how that would work. A nurse, I think (V6, Registered Nurse), called me this week and asked how (R4) was doing but that's it. No one called and explained or apologized for not letting me know when (R4) was going to leave. I didn't even sign the papers at the new facility until Thursday, (8/18/22). I was surprised they took (R4) before I signed them. (R4) has a lot of food allergies and I wanted to be sure that wherever she went they would be able to feed (R4) what (she) can eat. Thankfully, the new facility told me that they had already discussed (R4's) diet with (her) and everything worked out okay. That was a big relief. (R4) probably could have lived in an Assisted Living place, but eventually (R4) would have needed to move to a nursing home so I thought this would be easier on (R4), to make only one more move. I think (R4) likes it at the new place. When I visited with (R4), it was still all new to (her). On 8/30/22 at 3:05 PM, V8, Licensed Practical Nurse stated, R4 was a sweet resident. (R4) was not happy about leaving, but then she seemed to accept it and she packed her things. On 8/23/22 at 2:55 PM, V4, Chaplin, stated, I knew (R4) very well. (R4) came to me right after (she) was told about (her) move to another facility. (R4) was confused about what was happening. (R4) thought it was about money that (R4) hadn't paid. I explained it to (her). I talked to (R4) again after the church service we have at the facility and (R4) told me (she) was leaving and I told (R4) I was sorry and would miss (her) and hoped (she) would be fine. (R4) pointed to a bracelet (she) was wearing that I gave (her) and (R4) said (she) loved me and would never forget me. On 8/22/22 at 11:30 AM, V1, Administrator stated, I felt terrible about not notifying (V11, R4's Family Member) of (R4's) discharge date . (V11) asked if we would look for a place for (R4) so (V11) would not have to. I talked to (V11) three different times discussing possible placements that (V11) would approve of. The last time I talked to (V11) I told (her) which facility that (R4) would be moving to. (V11) was pleased with the choice as another Family Member had lived there so a tour of the facility wasn't mentioned. We had not been told when (R4) could actually move into the facility. (V11) asked us to let (her) know the date. When we did find out, I went to (R4) and wrote it all out on (R4's) communication board (since R4 is hard of hearing) and told (R4) that I would let (V11) know. And, then when I left (R4's) room I got involved in some other issues with other residents and by the time I got to my office I forgot to make the phone call. It was my mistake and I regretted it.

Based on observation, record review, and interview, the facility failed to provide a dedicated space and dedicated staff to provide cares for two COVID-19 positive residents (R1, R2) reviewed for COVID-19 isolation practices. This has the potential to affect eleven (R3, R5, R6-R13) residents residing on the unit. Findings include: Facility Policy, entitled COVID-19 Outbreak Investigation & Management, updated 1/10/2022, documents, Resident Confirmed COVID-19 Positive: Isolation on a dedicated COVID-19 wing/unit; and Implement dedicated, essential staffing on designated COVID-19 wing/unit. Facility document, entitled [Facility Name] Xxxxxxxx/Xxxxxxxx [Hall names] Daily Census dated 4/21/22 midnight, document R1/R2[COVID-19 positive], R3, R5, R6-R13, reside on the same hallway. On 4/22/22, upon entry, to the facility, the State Agency was advised, by V4/Director of Residential Services, that R1 and R2 are the only residents currently on isolation for being COVID-19 positive. On 4/22/22, at 11:30 a.m., a tour of the hall, which R1 and R2 resided, was conducted. R1 and R2's rooms were located on a hall with non-COVID positive residents (R3, R5, R6-R13). No barriers were provided to separate R1/R2's rooms from other residents/resident rooms. V5/Certified Nursing Assistant (CNA), V6/Certified Nursing Assistant, and V7/Licensed Practical Nurse (LPN) were observed providing cares to residents on R1 and R2's hall. On 4/22/22, from 11:36 a.m. to 11:45 a.m., V5 (CNA), V6 (CNA) and V7 (LPN) confirmed that no dedicated staff were used to care for the two COVID positive residents (R1 and R2); and no barrier wall, except closed door, was used to separate the positive residents from other residents on the same hallway; and they each provide cares to both COVID-19 positive residents and other residents residing on the same hall. During this time, R1's door was not latched closed. On 4/26/22, at 11:15 a.m. V2/Director of Nursing confirmed that the facility policy was not followed as the COVID positive residents (R1 and R2) were not in rooms sectioned off by a barrier nor did they have dedicated staff to provide cares strictly for the COVID-19 positive residents.

Based on observation, interview and record review, the facility failed to follow cool down temperature requirements for potentially hazardous food. This failure has the potential to affect six of six residents (R23, R32, R48, R100, R101, R102) residing on the [NAME] hall reviewed for food safety in the sample of 26. Findings include: The facility's (undated) Food Cooling Policy documents Cooling time starts at 135 degrees. Cool from 135 degrees to 70 degrees in two hours, then from 70 to 41 degrees in four hours. Total cooling time cannot exceed six hours. The facility's (undated) Cooling Log instructions document The total cooling process may not exceed six hours. Potentially hazardous foods must be cooled from 135 degrees Fahrenheit to 70 degrees Fahrenheit (F) within two hours. These food items must then be chilled from 70 degrees F to 41 degrees F or below within four hours. Record temperatures every hour during the cooling cycle. Record corrective actions, if applicable. The food service manager will verify that food service employees are cooling food properly by visually monitoring food service during the shift and reviewing, initialing and dating this log each working day. Maintain this log for a minimum of one year. On 4/12/21 at 10:00 AM, during a kitchen tour, cooked ribs were stored in multiple metal pans and covered with aluminum foil in the refrigerator. On 4/12/21 at 10:15 AM, V4 (Dietary Manager) provided the kitchens cooling log dated July 2020 to present. This document was incomplete for several potentially high risk foods. This log documents on 9/29/20 the beef did not have any cool down temperatures recorded; 10/3/20, 1/5/21, 2/16/21, 3/15/21, and 4/10/21, the ribs did not have any cool down temperatures recorded; 4/10/21 and 4/11/21, the ham and stuffed peppers did not have any cool down temperatures recorded. V4 confirmed that the cooling log is incomplete. On 4/14/21 at 10:15 AM, V5 (Director of Dietary Services) confirmed that the facility's cool down logs were incomplete. V5 stated, Food on the cool down logs would be served in the [NAME] hall. The facility's resident roster dated 4/11/21 documents R23, R32, R48, R100, R101 and R102 reside in the [NAME] hall.

Based on interview and record review the facility failed to document adverse behaviors to warrant the use of an antipsychotic medication for residents with a [DIAGNOSES REDACTED]. Findings include: The Facility's [MEDICAL CONDITION] Medication (date unknown), states Antipsychotic Medication: [DIAGNOSES REDACTED]. Antipsychotic medications may be indicated if: i. Behavioral symptoms present a danger to the resident or others; ii. Expressions or indications of distress that are significant to the resident; iii. if not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the symptom which present a danger or significant distress; and/or iv. Gradual Dose Reduction attempted but clinical symptoms returned . C. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned, non-pharmacological approaches and ongoing evaluation of the effectiveness of these interventions. 1. R5's current computerized Physician Orders, document that R5 takes [MEDICATION NAME] (Antipsychotic medication) 50 milligrams twice a day for the following Diagnosis: [REDACTED]. R5's Minimum Data Set (MDS) assessment, dated 12/13/19, documents that R5 has severely impaired cognition and a [DIAGNOSES REDACTED]. have no identified impact on others. R5's Monthly Behavior Monitoring Flowsheets, dated 8/2019 through 12/2019, document R5 receives [MEDICATION NAME] (Antipsychotic) for the following behaviors: [MEDICAL CONDITION], verbal behaviors towards staff, sexual remarks or gestures towards others, and physical behaviors towards staff. R5's Mood/Behavior Care Plan, dated 10/11/19, documents R5's behaviors are making sexual remarks or gestures towards others and physical behaviors. R5's [MEDICAL CONDITION] Medications Care Plan dated 10/11/19, does not address any additional behaviors that R5 has to justify the use of an antipsychotic medications. On 1/9/20 at 9:00 a.m., V3 (Care Plan Coordinator) stated R5 does have a [DIAGNOSES REDACTED]. V3 stated R5's behavior tracking or care plan do not document any psychotic behaviors. 2. R38's current computerized Physician order [REDACTED]. R38's MDS assessment dated [DATE], documents R38 has severely impaired cognition with Non-Alzheimer's Dementia. R38's MDS assessment also documents R38 has no behaviors other than wandering. R38's MDS assessment documents that R38's behaviors have no impact on others. R38's Care Plan dated 12/11/19, documents R38 has physical behaviors towards staff, has episodes of exit seeking in her wheelchair, and will get inappropriately close to peer and touches peers when they do not welcome it. R38's Monthly Behavior Monitoring Flowsheet dated 8/2019 through 12/2019, documents R38 is being monitored for signs and symptoms of depression, exit seeking, physical behaviors towards staff and inappropriate closeness to peers. On 1/9/20 at 1:00 p.m., V3 (Care Plan Coordinator) stated R38 does have a [DIAGNOSES REDACTED]. V3 also stated R38 is not a risk to harm self or others and does not have behaviors to warrant the use of an antipsychotic medication at this time.

Based on record review and interview the facility failed to provide a notice of transfer in writing to the Ombudsman and resident/resident's representative for seven of seven residents (R6, R18, R19, R24, R33, R43, R107) reviewed for hospitalization in the sample 17. Findings include: R6's Census report documents R6 was transferred to the hospital on 11-6-18 and 12-10-18. R18's Census report documents R18 was transferred to the hospital on 11-8-18. R19's Census report documents R19 was transferred to the hospital on 10-19-18. R24's Census report documents R24 was transferred to the hospital on 10-19-18. R33's Census report documents R33 was transferred to the hospital on 9-17-18, 10-19-18, 12-26-18, and 12-28-18. R43's Census report documents R43 was transferred to the hospital on 12-2-18. R107's Census report documents R107 was transferred to the hospital on 1-2-19. R6, R18, R19, R24, R33, R43, and R107's medical records do not include documentation of a notice of transfer being sent to the Ombudsman or the resident representatives for these transfers. On 01/16/19 at 09:15 AM, V1 (Administrator) stated, The Ombudsman, resident representatives, and residents are not notified in writing of the reason for transfer.

Based on observation, interview, and record review, the facility failed to document alternatives attempted prior to using side rails and reduce entrapment risks documented on the Bed Assist Bar Assessment Tool for one of one resident (R33) reviewed for side rails in the sample of 17. Findings include: An undated facility policy Bed Assist Bar Policy documents: It is the policy of (the facility) to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach will be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed assist bars evaluations. On 1/14/19 at 9:33 a.m., R33's bed was up against the wall and a single enabler bar was attached to the bed frame on the left side towards the top of the bed. R33's Minimum Data Set (MDS) assessment brief interview for mental status (BIMS) dated (MONTH) 7, 2019, documents R33 has a BIMS score of 6. A Bed Assist Bar Assessment Tool for R33 dated 12/17/18 documents: R33 is not ambulatory, level of consciousness fluctuates, displays poor bed mobility and has difficulty moving to a sitting position, is not able to get in and out of bed safely without assistance, has an alteration in safety awareness due to a cognitive decline, has a history of falls and is visually challenged. R33's Bed Assist Bar Assessment Tool dated 12/17/18 does not document alternatives attempted prior to using side rails. R33's current care plan does not include interventions to address R33's entrapment risks. On 1/16/19 at 8:45 a.m., R33 stated, The bar thing is supposed to keep me from falling out of the bed, I think. On 1/16/19 at 11:00 a.m., V5 Assistant Director of Nursing stated, No other alternatives have been used for (R33) prior to installing a side rail and we have not addressed (R33's) entrapment risks.

Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan addressing oxygen use for two of two residents (R19, R356) reviewed for oxygen in the sample of 17. Findings include: 1. On 1/14/19 at 10:25 AM, R19 was in his room with two liters of oxygen on via nasal cannula. R19's current physician order [REDACTED]. R19's medical record does not contain a plan of care for oxygen administration. 2. On 1/14/19 at 11:30 AM, R356 was in her room with two liters of oxygen on via nasal cannula. On 1/15/19 at 12:15 PM, R356 was in her room resting in bed with two liters of oxygen on via nasal cannula. R356's current physician order [REDACTED]. R356's current medical record does not contain a plan of care for oxygen administration. On 1/16/19 at 11:00 AM, V7 Registered Nurse/ Nurse Leader confirmed R19 and R356 do not have care plans for oxygen administration and stated Someone who's on continuous oxygen, I don't always put it on the care plan.

Based on observation, interview, and record review the facility failed to ensure hand hygiene was performed following incontinence care for four of nine residents (R20, R35, R52, R53, ) reviewed for infection control practices during incontinence care in a sample of 24. Findings include: A Hand Hygiene policy (undated) states, Hand hygiene continues to be the primary means of preventing the transmission of infection. A (facility) Infection Control and Prevention Plan (undated) states that Standard Precautions are infection prevention practices which apply to all residents, regardless of suspected or confirmed [DIAGNOSES REDACTED]. The plan also states, Standard precautions is based on the principle that all blood, body fluids, secretions, excretions except sweat, regardless of whether they contain visible blood, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include but are not limited to hand hygiene; use of gloves. Also, all equipment or items in the patient environment likely to have been contaminated with infectious body fluids must be handled in a manner to prevent transmission of infectious agents. 1. On 12/11/17 at 11:00A.M. V3 (Certified Nurse Aide) was preparing to assist Resident # 35 with perineal cleansing. V3 applied gloves then cleansed Resident # 35's genitals and buttocks area using premoistened disposable cloths. Without removing the soiled gloves or performing hand hygiene, V3 applied Resident # 35's clean incontinence brief and pants, then assisted Resident # 35 to transfer to the wheelchair. On 12/11/17 at 11:10A.M. V3 verified V3 did not remove the soiled gloves after providing perineal care to Resident #35 and prior to applying Resident # 35's clean incontinence brief, pants, or before transfering Resident # 35 from the toilet to the wheelchair. V3 stated, I knew it was wrong as soon as I did it. 2. On 12/12/17 at 11:20 AM, V4 (CNA/Certified Nursing Assistant) and V5/CNA performed perineal care for R20. V4 used several wash clothes to clean feces from R20. After cleansing the area, V4 grabbed a clean adult brief with the same soiled gloves on and proceeded to place the brief on R20. On 12/12/17 at 11:30 AM, V5 stated she did not remove her soiled gloves before applying R20's clean adult brief and she should have changed her soiled gloves before touching the clean adult brief. 3. On 12/12/17 at 10:44 AM, V8 (Certified Nursing Assistant) and V9 (Certified Nursing Assistant) provided R53's urinary catheter care and incontinence care. V8 provided R53's perineal care and urinary catheter care. V8 then positioned R53's clean adult brief around R53's ankles with the same gloves that V8 used to perform R53's perineal and urinary catheter care. V8 then removed V8's contaminated gloves, performed hand hygiene and put on clean gloves. V9 repositioned R53 on R53's left side and V8 cleaned R53's incontinent stool. V8 then repositioned R53's clean adult brief and touched R53's shirt, pants and clean linen without removing R53's contaminated gloves, performing hand hygiene or putting on clean gloves. On 12/12/17 at 11:05 AM, V8 verified that V8 used the same contaminated gloves to touch R53's clean clothing and linens after performing R53's incontinence care. V8 stated that V8 should have removed V8's contaminated gloves and performed hand hygiene after cleaning R53's incontinent stool and prior to touching R53's clean clothing and clean linen. 4. 12/11/17 12:25 PM V6 (Certified Nursing Assistant, CNA) assisted R52 to the bathroom. V6 was not wearing gloves when V6 assisted R52 to unlatch R52's belt, pull down R52's jeans and adult briefs. R52 voided and V6 assisted R52 with peri-care with no gloves on. V6 then assisted R52 to pull up R52's adult briefs and jeans and latch R52's belt. V6 did not perform hand hygiene and escorted R52 out of the bathroom to the dining room for lunch. V6 did not offer R52 hand hygiene. On 12/11/17 at 12:35 p.m., V6 verified V6 did not wash hands following R52's peri-care and before touching R52's adult briefs, jeans and belt.

Based on interview and record review the facility failed to ensure antibiotics were prescribed appropriately for two of six residents (R10, R38) reviewed for antibiotic use in a sample of 24. Findings include: A Centers For Disease Control and Prevention (CDC) policy titled, The Core Elements of Antibiotic Stewardship for Nursing Homes, (undated) states, Infection and syndrome specific interventions to improve antibiotic use (:) Identify clinical situations which may be driving inappropriate courses of antibiotics such as asymptomatic bacteriuria or urinary tract infection [MEDICATION NAME] (prevention or suppressive therapy) and implement specific interventions to improve use. A Facility Antibiotic Stewardship Education policy (undated) states, Antibiotics will be prescribed for the correct indication, dose, and duration to appropriately treat the resident while attempting to reduce the development of antibiotic-resistant organisms or other adverse consequences or outcomes. The facility will monitor antibiotic use to identify appropriate use of antibiotics to improve resident outcomes and reduce antibiotic resistance. The facility practices the Core Elements of Antibiotic Stewardship, outlined by the Centers for Disease Control and Prevention to, optimize the treatment of [REDACTED]. 1. R10 physician's orders [REDACTED]. R10's list of current active [DIAGNOSES REDACTED]. R10's electronic medical record does not include R10 has had laboratory results which are positive for a UTI or that R10 has had symptoms of a urinary tract infection. On 12/11/17 at 1:49p.m. V7 (Licensed Practical Nurse) verified that R10 does not currently have a UTI. V7 stated that R10 was prescribed a continuous antibiotic for prevention of a UTI. 2. R38's POS dated 9/5/17 documents R38 was prescribed the antibiotic [MEDICATION NAME] 100mg daily with the indication for use, Suppressive therapy for recurrent [MEDICATION NAME] UTI. R38's list of current active [DIAGNOSES REDACTED]. R38's medical record does not include R38 has had laboratory results which are positive for a UTI or that R38 has had symptoms of a UTI. On 12/11/17 at 1:49p.m. V7 (Licensed Practical Nurse) verified that R38 does not currently have a UTI. V7 stated that R38 was prescribed a continuous antibiotic for the prevention of a UTI. On 12/12/17 at 11:00a.m. V2 (Director of Nurses) stated that V2 is the facility's Infection Control Preventionist and is responsible for monitoring for the appropriate use of antibiotics for residents. V2 stated that antibiotics should not be prescribed for the prevention of urinary tract infections only for active infections. V2 stated, We are just starting our antibiotic stewardship program, and have not addressed inappropriate prescribing of antibiotics for prevention of UTI's.

Based on record review and interview, the facility failed to ensure staff reported an allegation of verbal and physical abuse for one resident (R2) immediately to the Administrator and failed to remove the alleged perpetrator from the facility immediately, for one of three allegations of abuse reviewed. These failures resulted in R2 being abused a second time by the same staff person (E4/Certified Nursing Assistant) and has the potential to affect all 68 residents in the facility that E4 has access to. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/18/16, the facility remains out of compliance at a Severity Level II. While the immediacy was removed on 3/18/16, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of facility Abuse policy revision and staff re-education for the Abuse policy including post-testing all direct care staff regarding reporting abuse, immediate notification of the administrator, and resident protection from abuse by removing the perpetrator. Findings include: E1's (Administrator) Abuse/Neglect Investigation Report dated 3-3-16 regarding (R2) documents, Investigation: 3/3/16 3:45 p.m. (E5/Licensed Practical Nurse) reported to (E6/Social Services Director) that an incident was reported to (E5) last night around 10:00 p.m. by (E3/Certified Nursing Assistant). (E3) witnessed treatment of [REDACTED]. (E6) reported incident to (E1/Administrator) immediately and initiated investigation .Initial report by witness: (E3) reported the following to (E5) at 10:00 p.m. on 3/2/16. (R2) was given a whirlpool bath around 8:30 p.m. on 3/2/16 by (E4 Certified Nursing Assistant). (E3) said (E3) entered the whirlpool room as (E3) heard (R2) yelling. (R2) was sitting on the bath chair and (E4) was working on getting (R2's) clothes off to begin bath. (E3) witnessed (E4) pulling (R2's) arm up and forcing (R2's) hand to (R2's) mouth. (E3) heard (E4) say, 'Go ahead bite yourself.' (E4) saw (E3) enter the room and stopped immediately and said, 'Don't even start I'm having a bad day.' (E3) left the room and returned to care for another patient. A few minutes later as (E3) was walking by the room (E3) witnessed (E4) spraying water directly in (R2's) eyes .Resident Interview: 3/3/16 4:00 p.m. (E6) interviewed (R2) about the incident during bathing on 3/2/16. (R2) said the following, '(E4) slaps and hurts me when (E4) takes my clothes off. Then it was blurry cause (E4) was spraying me with water in my face. I don't want (E4) to do anything for me anymore. (E4) acts this way every time.' .Perpetrator Interview: Called (E4) into (E1's) office at 4:05 p.m. 3/3/16 and asked if (E4) if there were any issues last night during bath given to (R2). (E4) said no. Asked if (E4) had sprayed (R2) in eyes. (E4) said no (E4) had washed (R2's) hair but not sprayed directly in face or eyes. Told (E4) that (R2) said (E4) was rough and slaps and hurts (R2) when undressing (R2). (E4) said no (E4) was not rough with (R2) and that (R2) doesn't like to take a bath so (R2) is resistant. (E4) said all CNA's (Certified Nursing Assistants) have trouble with (R2) at bath time. (E1) informed (E4) that (E4) was terminated immediately and to leave the facility at 4:10 p.m. 3/3/16. On 3-16-16 at 10:00 a.m., R2 stated, A few weeks ago a staff got rough with me. (E4) jerked my arms in the shower and hurt my shoulder. I told (E4) that (E4) hurt my shoulder, and then (E4) jerked my arm harder. (E4) then sprayed me in the the eyes with water. (E4) slapped me. (E4) was having a bad night and was taking it out on me. My shoulder hurts really bad. On 3-16-16 at 10:00 a.m., E1 (Administrator) verified that on 3-2-16 around 8:00 a.m. to 8:30 a.m., (E3/Certified Nursing Assistant) witnessed E4 physically and verbally abusing R2. E1 verified that E3 reported the alleged abuse to E5 (Licensed Practical Nurse) that same night around 10:00, but (E5) did not report the incident until around 3:30 p.m. to 4:00 p.m. the next day (3-3-16.) E1 stated, We (facility staff) have trained and trained on reporting of abuse. (E3) should have reported to the nurse when (E3) saw (E4) shove (R2's) hand to (R2's) mouth. (E3) should have pulled (E4) out of the shower room, initially, and reported to the nurse immediately. (E4) should have been suspended immediately. The incident should have been reported on 3-2-16. On 3-16-16 at 11:15 a.m., E1 verified that (E4) worked the remainder of (E4's) shift on 3-2-16, and worked from around 2:06 p.m. to 4:00 p.m. on 3-3-16. On 3-16-16 at 2:20 p.m., E3 (Certified Nursing Assistant/CNA) stated, On 3-2-16 (R2) was getting a whirlpool bath. I heard (R2) screaming, so I went into the shower room. I saw (E4/CNA) taking (R2's) shirt off. (R2) has a bad shoulder and cannot lift (R2's) arm that high, so (R2) was yelling in pain. (E4) lifted (R2's) arm to (R2's) mouth and was telling (R2) 'Bite yourself. I am not dealing with this today.' I walked out of the shower room and went to help another resident. I then heard (R2) screaming again, so I went back into the shower room. (E4) was spraying (R2) in the eyes with the shower hose. At that time I helped (E4) transfer (R2) to the chair, and myself and (E4) took (R2) to bed. (R2's) shower was around 8:00 to 8:30 p.m. that night. I told the nurse (E5/Licensed Practical Nurse) around 9:20 p.m. to 9:30 p.m. of this incident with (E4) and (R2). The incident caught me off guard. I was in shock. I know I should have removed (E4) from the situation and reported immediately, but did not. On 3-16-16 at 11:00 a.m., E5 (Licensed Practical Nurse) stated, On 3-2-16 around 10:00 p.m., (E3) reported to me that (E3) witnessed (E4) spraying water into (R2's) eyes, and holding (R2's) arm up to (R2's) face telling (R2) to bite self. I should have reported this that night but did not report till the next day. (E4) worked the entire shift that night, and worked both hallways. I knew I should have reported immediately. On 3-17-16 at 9:20 a.m., E7 (Medical Director/R2's Physician) stated, I expect residents most definitely to be free of abuse. This incident (3-2-16 incident between R2 and E4) is definitely considered abuse. (R2) has degenerate joint disease of both shoulders, gout, and is diabetic. (R2's) range of motion is very limited. Telling (R2) to bite self and spraying (R2) in the face is horrible. I do not know of any other definition of abuse besides these acts. The CNA should not have lifted (R2's) arm up to (R2's) mouth with as much pain as (R2) has in the shoulders. The CNA should have been removed from the shower room when the other CNA witnessed (R2) in pain and (E4) telling (R2) to bite self. On 3-17-16 at 9:00 a.m., E2 (Director of Nursing) verified that E4 works all hallways in the facility. E4's Timecard Report dated 3-2-16 through 3-3-16, documents E4 worked on 3-2-16 from 4:12 p.m. to 9:07 p.m., and 3-3-16 from 2:06 p.m. to 4:12 p.m. On 3/17/16 at 10:15 a.m., E1 verified that on 6/11/15 E6 educated staff at the Residents Rights/Abuse & HIPAA (Health Insurance Portability and Accountability Act) in-service on the definitions of abuse and immediately reporting abuse to the Administrator. A facility In-service sheet, dated 6/11/15, documents that E5 was in attendance for the Residents Rights/Abuse and HIPAA training. The In-service sheet also documents that E3 and E4 were not in attendance for the training. This inservice documents, Elder abuse is any knowing, intended, or careless act that causes harm or serious risk of harm to an older person-physically, mentally, emotionally, or financially .Physical abuse: includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .Verbal abuse: defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with their hearing distance regardless of their age, ability to comprehend, or disability .What to do if you suspect neglect/abuse: Immediately notify the abuse coordinator; Care, treat, and protect the resident .Protection: The facility will protect residents from harm during the investigation of the allegations. E5's Residents Rights and Abuse quiz, given during the 6/11/15 in-service, documents that E5 is aware that E5 is to report alleged abuse, neglect, or mistreatment to E1 and E2 immediately. E4's Orientation check list, dated 1/29/14, documents that E4 received education on abuse from E8 (Licensed Practical Nurse) including video training, and E4 received copy of the facility's abuse policy. E3's Orientation check list, dated 10/13/14, documents that E3 received education on abuse from E8 (Licensed Practical Nurse) including video training, and E3 received copy of the facility's abuse policy. An unnamed document, dated 12/19/14 and signed by E5, documents that E5 received a copy of the facility Abuse policy, understands the guidelines of the policy, and will follow the policy. The Facility Data Sheet dated 3-16-16 and signed by E1 (Administrator) documents 68 residents currently reside in the facility. The Immediate Jeopardy was identified at 2:00 p.m. on 3-17-16 to have begun on 3-2-16 when R2 was abused by E4. E1 and E2 were notified of the Immediate Jeopardy on 3-17-16 at 2:15 p.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. E4 was terminated on 3/3/16. 2. The facility provided all staff training by E1 (Administrator) on the facility's abuse policy and procedures regarding reporting, immediate notification of E1, and immediate removal of the perpetrator. Training to be completed by Friday 3-18-16 at 4:00 p.m.

Based on record review and interview, the facility neglected to immediately remove a resident (R2) in order to provide protection and immediately report the incident when physical abuse to R2 was witnessed as required by the facility abuse policy. These failures resulted in R2 being abused a second time by the same staff person (E4). The failures occurred for one of three allegations of abuse reviewed and have the potential to affect all 68 residents cared for by E4. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 3/18/16, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of facility Abuse policy revision, staff re-education for the Abuse policy, care plan updating for residents with behaviors and weekly Certified Nursing Assistant shower auditing. Findings include: The facility's Abuse and Neglect Prevention Policy, dated 12/4/14, documents, It is the facility's policy to not tolerate verbal, sexual, physical, or mental abuse, involuntary seclusion or neglect of its residents by any individual .All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are to be reported immediately to the Administrator or his/her designated representative .The facility will protect residents from harm during the investigation of allegations with the following guidelines. The facility reserves the right to discipline, suspend or terminate any employee who the facility reasonably believes has abused, neglected, involuntarily secluded any resident or misappropriated any resident's property. R2's Minimum Data Set ((MDS) dated [DATE], documents R2 has [DIAGNOSES REDACTED]. An Electronic Communication dated 3-7-16 and signed by E1 (Administrator) documents, (E4) was intentionally spraying water in a resident's (R2) eyes during a bath, and holding (R2's) forearm towards (R4's) mouth, telling (R2) to bite self. (E4) was terminated 3-3-16. On 3-16-16 at 10:00 a.m., R2 stated, A few weeks ago a staff got rough with me. (E4) jerked my arms in the shower and hurt my shoulder. I told (E4) that (E4) hurt my shoulder, and then (E4) jerked my arm harder. (E4) then sprayed me in the the eyes with water. (E4) slapped me. (E4) was having a bad night and was taking it out on me. My shoulder hurts really bad. No one else has abused me here, besides (E4). On 3-16-16 at 10:00 a.m., E1 (Administrator) stated, On 3-2-16(E3/Certified Nursing Assistant) went into the shower room and saw (E4/CNA) having hold of (R2's) forearm, holding it up to (R2's) mouth, and telling (R2) to bite self. (E4) let go of (R2's) arm when (E4) was (E3). (E4) told (E3) 'Don't start with me. I am having a bad night.' (E3) left the shower room and later heard (R2) hollering again. (E3) saw (E4) spraying water directly into (R2's) eyes. (E3) then helped (E4) take (R2) to bed. (E3) did not report this to (E5/Licensed Practical Nurse) until around 10:00 p.m. This incident occurred around 8:00 p.m. to 8:30 p.m. (E5) did not report the incident until around 3:30 p.m. to 4:00 p.m. the next day (3-3-16.) We (facility staff) have trained and trained on reporting of abuse. (E3) should have reported to the nurse when (E3) saw (E4) shove (R2's) hand to (R2's) mouth. (E3) should have pulled (E4) out of the shower room, initially, and reported to the nurse immediately. (E4) should have been suspended immediately. (E4) was terminated for resident abuse, mostly physical, but verbal abuse also because (E4) told (R2) 'Go ahead and bite yourself'. The incident should have been reported on 3-2-16. On 3-16-16 at 11:15 a.m., E1 verified that (E4) worked the remainder of (E4's) shift on 3-2-16, and worked from around 2:06 p.m. to 4:00 p.m. on 3-3-16. On 3-16-16 at 2:20 p.m., E3 (Certified Nursing Assistant/CNA) stated, On 3-2-16 (R2) was getting a whirlpool bath. I heard (R2) screaming, so I went into the shower room. I saw (E4/CNA) taking (R2's) shirt off. (R2) has a bad shoulder and cannot lift (R2's) arm that high, so (R2) was yelling in pain. (E4) lifted (R2's) arm to (R2's) mouth and was telling (R2) 'Bite yourself. I am not dealing with this today.' I walked out of the shower room and went to help another resident. I then heard (R2) screaming again, so I went back into the shower room. (E4) was spraying (R2) in the eyes with the shower hose. At that time I helped (E4) transfer (R2) to the chair, and myself and (E4) took (R2) to bed. (R2's) shower was around 8:00 to 8:30 p.m. that night. I told the nurse (E5/Licensed Practical Nurse) around 9:20 p.m. to 9:30 p.m. of this incident with (E4) and (R2). The incident caught me off guard. I was in shock. I know I should have removed (E4) from the situation and reported immediately, but did not. On 3-16-16 at 11:00 a.m., E5 (Licensed Practical Nurse) stated, On 3-2-16 around 10:00 p.m., (E3) reported to me that (E3) witnessed (E4) spraying water into (R2's) eyes, and holding (R2's) arm up to (R2's) face telling (R2) to bite self. I should have reported this that night but did not report till the next day. (E4) worked the entire shift that night, and worked both hallways. I knew I should have reported immediately. On 3-16-16 at 12:00 p.m., E6 (Social Service Director) stated, (E5/Licensed Practical Nurse) reported to me on 3-3-16 around 3:30 p.m. that one of the certified nursing assistants told (E5) that (E4) was rough with (R2), spraying (R2) in the face, and holding (R2's) arms down the night before (3-2-16). I told (E1) immediately, and spoke with (R2). (R2) told me that (E4) hurt (R2's) shoulder and was rough during (R2's) bath. (R2) told me (E4) sprayed water in (R2's) face and slapped (R2). On 3-17-16 at 8:15 a.m., E6 (Social Service Director), who is also R2's Power Of Attorney, stated, I was informed of an incident on 3-2-16 that occurred in the shower room. I was notified that (R2) was sprayed in the face with water and (E4) was holding (R2's) hands while giving (R2) a bath. (R2) was really unhappy. (R2) did not want (E4) to take care of (R2) anymore. (R2) told me (E4) sprayed (R2) in the face with water, hurt (R2's) shoulder when taking off (R2's) clothes, and slapped (R2). I fell like that is physical abuse. You do not slap a resident. You must control yourself when taking care of a resident, and should never lash back at a resident. On 3-17-16 at 9:20 a.m., E7 (Medical Director/R2's Physician) stated, I expect residents most definitely to be free of abuse. This incident (3-2-16 incident between R2 and E4) is definitely considered abuse. (R2) has degenerate joint disease of both shoulders, gout, and is diabetic. (R2's) range of motion is very limited. Telling (R2) to bite self and spraying (R2) in the face is horrible. I do not know of any other definition of abuse besides these acts. The CNA should not have lifted (R2's) arm up to (R2's) mouth with as much pain as (R2) has in the shoulders. The CNA should have been removed from the shower room when the other CNA witnessed (R2) in pain and (E4) telling (R2) to bite self. During this same time E7 was questioned to what effect this would have on the resident, E7 stated, Well it must have had some effect on (R2) for (R2) to recall the event from (3-2-16). She does not normally have a good memory. On 3-17-16 at 9:00 a.m., E2 (Director of Nursing) verified that E4 works all hallways in the facility. E4's Timecard Report dated 3-2-16 through 3-3-16, documents E4 worked on 3-2-16 from 4:12 p.m. to 9:07 p.m., and 3-3-16 from 2:06 p.m. to 4:12 p.m. On 3/17/16 at 10:15 a.m., E1 verified that on 6/11/15 E6 educated staff at the Residents Rights/Abuse & HIPAA (Health Insurance Portability and Accountability Act) in-service on the definitions of abuse and immediately reporting abuse to the Administrator. A facility In-service sheet, dated 6/11/15, documents that E5 was in attendance for the Residents Rights/Abuse and HIPAA training. The In-service sheet also documents that E3 and E4 were not in attendance for the training. This inservice documents, Elder abuse is any knowing, intended, or careless act that causes harm or serious risk of harm to an older person-physically, mentally, emotionally, or financially .Physical abuse: includes hitting, slapping, pinching, kicking, and controlling behavior through corporal punishment .Verbal abuse: defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with their hearing distance regardless of their age, ability to comprehend, or disability .What to do if you suspect neglect/abuse: Immediately notify the abuse coordinator; Care, treat, and protect the resident .Protection: The facility will protect residents from harm during the investigation of the allegations. E5's Residents Rights and Abuse quiz, given during the 6/11/15 in-service, documents that E5 is aware that E5 is to report alleged abuse, neglect, or mistreatment to E1 and E2 immediately. E4's Orientation check list, dated 1/29/14, documents that E4 received education on abuse from E8 (Licensed Practical Nurse) including video training, and E4 received a copy of the facility's abuse policy. E3's Orientation check list, dated 10/13/14, documents that E3 received education on abuse from E8 (Licensed Practical Nurse) including video training, and E3 received a copy of the facility's abuse policy. An unnamed document, dated 12/19/14 and signed by E5, documents that E5 received a copy of the facility Abuse policy, understands the guidelines of the policy, and will follow the policy. The Facility Data Sheet dated 3-16-16 and signed by E1 (Administrator) documents 68 residents currently reside in the facility. The Immediate Jeopardy was identified at 2:00 p.m. on 3-17-16 to have begun on 3-2-16 when R2 was abused by E4. E1 and E2 were notified of the Immediate Jeopardy on 3-17-16 at 2:15 p.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. E4 was terminated on 3/3/16. 2. The facility provided all staff training by E1 (Administrator) on the facility's abuse policy and procedures regarding reporting, immediate notification of E1, immediate removal of the perpetrator, and signs of burnout or stress in care givers. Training to be completed by Friday 3-18-16 at 4:00 p.m. 3. E10 (Restorative nurse) reviewed bathing care plans with the CNAs for residents that have behaviors during bathing. Review of Care Plans will be completed by Friday 3-18-16 at 4:00 p.m. 4. Weekly audits will be completed by E1 with CNAs to get feedback on resident behaviors while bathing, and care plans will be updated by E11 (Care plan Coordinator) based on the input from bathing staff.

Based on interview and record review, the facility failed to follow operational policies and procedures regarding immediately notifying the Abuse Coordinator, protecting the resident, and removing the suspected perpetrator for one resident (R2) in one of three abuse allegations of abuse reviewed. This had the potential to affect all 68 residents residing in the facility. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 3/18/16, the facility remains out of compliance at a Severity Level II as the facility revises operational policies and procedures on Abuse. Findings include: The facility's Abuse and Neglect Prevention Policy, dated 12/4/14, documents, It is the facility's policy to not tolerate verbal, sexual, physical, or mental abuse, involuntary seclusion or neglect of its residents by any individual .All alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are to be reported immediately to the Administrator or his/her designated representative .The facility will protect residents from hard during the investigation of allegations with the following guidelines. The facility reserves the right to discipline, suspend or terminate any employee who the facility reasonably believes has abused, neglected, involuntarily secluded any resident or misappropriated any resident's property. E1's (Administrator) Abuse/Neglect Investigation Report dated 3-3-16 regarding (R2) documents, Investigation: 3/3/16 3:45 p.m. (E5/Licensed Practical Nurse) reported to (E6/Social Services Director) that an incident was reported to (E5) last night (3-2-16) around 10:00 p.m. by (E3/Certified Nursing Assistant). (E3) witnessed treatment of [REDACTED].(E1) informed (E4/Certified Nursing Assistant) that (E4) was terminated immediately and to leave the facility at 4:10 p.m. 3/3/16. On 3-16-16 at 10:00 a.m., E1 (Administrator) stated, (E3) did not report this (3/2/16 incident involving R2) to (E5/Licensed Practical Nurse) until around 10:00 p.m. This incident occurred around 8:00 p.m. to 8:30 p.m. (E5) did not report the incident until around 3:30 p.m. to 4:00 p.m. the next day (3-3-16.) .(E3) should have reported to the nurse when (E3) saw (E4) shove (R2's) hand to (R2's) mouth. (E3) should have pulled (E4) out of the shower room, initially, and reported to the nurse immediately. (E4) should have been suspended immediately .The incident should have been reported on 3-2-16. On 3-16-16 at 11:15 a.m., E1 verified that (E4) worked the remainder of (E4's) shift on 3-2-16, and worked from around 2:06 p.m. to 4:00 p.m. on 3-3-16. On 3-16-16 at 2:20 p.m., E3 (Certified Nursing Assistant/CNA) stated, On 3-2-16 (R2) was getting a whirlpool bath. I heard (R2) screaming, so I went into the shower room. I saw (E4/CNA) taking (R2's) shirt off. (R2) has a bad shoulder and cannot lift (R2's) arm that high, so (R2) was yelling in pain. (E4) lifted (R2's) arm to (R2's) mouth and was telling (R2) 'Bite yourself. I am not dealing with this today.' I walked out of the shower room and went to help another resident. I then heard (R2) screaming again, so I went back into the shower room. (E4) was spraying (R2) in the eyes with the shower hose. At that time I helped (E4) transfer (R2) to the chair, and myself and (E4) took (R2) to bed. (R2's) shower was around 8:00 to 8:30 p.m. that night. I told the nurse (E5/Licensed Practical Nurse) around 9:20 p.m. to 9:30 p.m. of this incident with (E4) and (R2). The incident caught me off guard. I was in shock. I know I should have removed (E4) from the situation and reported immediately, but did not. On 3-16-16 at 11:00 a.m., E5 (Licensed Practical Nurse) stated, On 3-2-16 around 10:00 p.m., (E3) reported to me that (E3) witnessed (E4) spraying water into (R2's) eyes, and holding (R2's) arm up to (R2's) face telling (R2) to bite self. I should have reported this that night but did not report till the next day. (E4) worked the entire shift that night, and worked both hallways. I knew I should have reported immediately. On 3-17-16 at 9:00 a.m., E2 (Director of Nursing) verified that E4 works all hallways in the facility. The Facility Data Sheet dated 3-16-16 and signed by E1 (Administrator) documents 68 residents currently reside in the facility. The Immediate Jeopardy was identified at 2:00 p.m. on 3-17-16 to have begun on 3-2-16 when R2 was abused by E4. E1 and E2 were notified of the Immediate Jeopardy on 3-17-16 at 2:15 p.m. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. The facility revised their Abuse and Neglect policy to include types of abuse on 3/17/16 at 3:30 PM.

Based on record review and interview, the facility failed to protect a resident (R2) from repeated verbal and physical abuse by a staff member, for one of three abuse allegations reviewed. This failure resulted in R2 suffering severe shoulder pain causing R2 to scream as a result of the physical abuse by a staff member. Findings include: E1's (Administrator) Abuse/Neglect Investigation Report dated 3-3-16 regarding (R2) documents, Investigation: 3/3/16 3:45 p.m. (E5/Licensed Practical Nurse) reported to (E6/Social Services Director) that an incident was reported to (E5) last night around 10:00 p.m. by (E3/Certified Nursing Assistant). (E3) witnessed treatment of [REDACTED]. (E6) reported incident to (E1/Administrator) immediately and initiated investigation .Initial report by witness: (E3) reported the following to (E5) at 10:00 p.m. on 3/2/16. (R2) was given a whirlpool bath around 8:30 p.m. on 3/2/16 by (E4 Certified Nursing Assistant). (E3) said (E3) entered the whirlpool room as (E3) heard (R2) yelling. (R2) was sitting on the bath chair and (E4) was working on getting (R2's) clothes off to begin bath. (E3) witnessed (E4) pulling (R2's) arm up and forcing (R2's) hand into (R2's) mouth. (E3) heard (E4) say, 'Go ahead bite yourself.' (E4) saw (E3) enter the room and stopped immediately and said, 'Don't even start I'm having a bad day.' (E3) left the room and returned to care for another patient. A few minutes later as (E3) was walking by the room (E3) witnessed (E4) spraying water directly in (R2's) eyes .Resident Interview: 3/3/16 4:00 p.m. (E6) interviewed (R2) about the incident during bathing on 3/2/16. (R2) said the following, '(E4) slaps and hurts me when (E4) takes my clothes off. Then it was blurry cause (E4) was spraying me with water in my face. I don't want (E4) to do anything for me anymore. (E4) acts this way every time and I'm scared.' .Perpetrator Interview: Called (E4) into (E1's) office at 4:05 p.m. 3/3/16 and asked if (E4) if there were any issues last night during bath given to (R2). (E4) said no. Asked if (E4) had sprayed (R2) in eyes. (E4) said no (E4) had washed (R2's) hair but not sprayed directly in face or eyes. Told (E4) that (R2) said (E4) was rough and slaps and hurts (R2) when undressing (R2). (E4) said no (E4) was not rough with (R2) and that (R2) doesn't like to take a bath so (R2) is resistant. (E4) said all CNA's (Certified Nursing Assistants) have trouble with (R2) at bath time. (E1) informed (E4) that (E4) was terminated immediately and to leave the facility at 4:10 p.m. 3/3/16. On 3-16-16 at 10:00 a.m., R2 stated, A few weeks ago a staff got rough with me. (E4) jerked my arms in the shower and hurt my shoulder. I told (E4) that (E4) hurt my shoulder, and then (E4) jerked my arm harder. (E4) then sprayed me in the the eyes with water and slapped me. (E4) was having a bad night and was taking it out on me. My shoulder hurts really bad. On 3-16-16 at 10:00 a.m., E1 (Administrator) verified that on 3-2-16 around 8:00 p.m. to 8:30 p.m., (E3/Certified Nursing Assistant) witnessed E4 physically and verbally abusing R2. E1 verified that E3 reported the alleged abuse to E5 (Licensed Practical Nurse) that same night around 10:00 p.m, but (E5) did not report the incident until around 3:30 p.m. to 4:00 p.m. the next day (3-3-16.) E1 stated, We (facility staff) have trained and trained on reporting of abuse. (E3) should have reported to the nurse when (E3) saw (E4) shove (R2's) hand to (R2's) mouth. (E3) should have pulled (E4) out of the shower room, initially, and reported to the nurse immediately. (E4) should have been suspended immediately. The incident should have been reported on 3-2-16. On 3-16-16 at 2:20 p.m., E3 (Certified Nursing Assistant/CNA) stated, On 3-2-16 (R2) was getting a whirlpool bath. I heard (R2) screaming, so I went into the shower room. I saw (E4/CNA) taking (R2's) shirt off. (R2) has a bad shoulder and cannot lift (R2's) arm that high, so (R2) was yelling in pain. (E4) lifted (R2's) arm to (R2's) mouth and was telling (R2) 'Bite yourself. I am not dealing with this today.' I walked out of the shower room and went to help another resident. I then heard (R2) screaming again, so I went back into the shower room. (E4) was spraying (R2) in the eyes with the shower hose. At that time I helped (E4) transfer (R2) to the chair, and myself and (E4) took (R2) to bed. (R2's) shower was around 8:00 to 8:30 p.m. that night. I told the nurse (E5/Licensed Practical Nurse) around 9:20 p.m. to 9:30 p.m. of this incident with (E4) and (R2). The incident caught me off guard. I was in shock. I know I should have removed (E4) from the situation and reported immediately, but did not. On 3-17-16 at 9:20 a.m., E7 (Medical Director/R2's Physician) stated, I expect residents most definitely to be free of abuse. This incident (3-2-16 incident between R2 and E4) is definitely considered abuse. (R2) has degenerate joint disease of both shoulders, gout, and is diabetic. (R2's) range of motion is very limited. Telling (R2) to bite self and spraying (R2) in the face is horrible. I do not know of any other definition of abuse besides these acts. The CNA should not have lifted (R2's) arm up to (R2's) mouth with as much pain as (R2) has in the shoulders. The CNA should have been removed from the shower room when the other CNA witnessed (R2) in pain and (E4) telling (R2) to bite self. During this same time, E7 stated, Well it (incident 3-2-16) must have had some effect of (R2) to recall the event from 3-2-16. She does not normally have a good memory.

Based on observation, interview, and record review, the facility failed to ensure residents with complicated feeding problems were fed by a licensed staff, and to have a charge nurse assessment prior to allowing unlicensed staff feed residents for one of six residents (R8) reviewed for swallowing difficulties in the sample of fifteen. These failures resulted in unlicensed staff (E16) feeding R8 and R8 choking on 1/11/16. This failure result in an immediate jeopardy. While the Immediate Jeopardy was removed on 1/14/16 at 2:45 p.m., the facility remains out of compliance at a severity level two. Additional time is needed to monitor the effectiveness of facility policy changes regarding resident feeding, resident dietary risk assessments and investigation of resident choking incidents. Findings include: The facility's Resident Attendant policy, no date available, documents: The facility will use the resident attendant to assist certain residents as assigned in eating and taking fluids .Only those residents who have been evaluated by a nurse or dietitian as appropriate for feeding by resident attendants will be assigned to them; i.e. residents eating in the dining room under supervision and no residents that tend to aspirate or otherwise pose a risk during the feeding process . 1. R8's Electronic Record, documents that R8 has a [DIAGNOSES REDACTED]. R8's Minimum Data Set (MDS), dated [DATE], documents in Section K: Swallowing/Nutritional Status that R8 has coughing or choking during meals or while taking medication, and in Section G: Functional Status that R8 is totally dependent on one assist staff for eating. The facility's Resident's to be fed list, no date available, documents: Residents to be fed by Certified staff only-CNA's (Certified Nursing Assistant), LPN (Licensed Practical Nurse), RN (Registered Nurse): R8. R8's physician's orders [REDACTED]. R8' Care plan, dated 12/17/15, documents: R8 does need some assistance with eating as well due to R8's advanced [MEDICAL CONDITION]. R8 has had multiple choking episodes while being fed. R8 had a swallow study done that did show a deficit but the doctor and family still wanted food to be regular consistency. After R8's last choking episode on 9/1/15 doctor did change diet to pureed and family agreed .9/27/15 R8 was diagnosed with [REDACTED].Interventions: Diet as ordered: General pureed; do not feed R8 unless R8 is completely alert; Monitor for signs/symptoms of dysphagia. R8's Care plan has no documentation specifying which staff members are able to feed R8. On 1/14/16 at 11:30 a.m., E4 (MDS/Care plan Coordinator) confirmed this was not on the care plan. R8's Nutritional Assessment, dated 7/2/15, documents: Nutritional Risk Assessment Summary: Difficulty chewing and delayed pharyngeal swallowing phase. Speech therapy working with (R8). Nursing notes that resident coughs some when fed . R8's Speech therapy progress and discharge summary, dated 7/24/15, documents: Impact on burden of care/daily life: at risk for aspiration/pneumonia, malnutrition/dehydration. Precautions: aspiration . R8's Progress noted, dated 8/1/15 at 11:10 a.m., documents: Activity aide came to get (E8/LPN) stating (R8) was choking. Upon walking in (R8) had a half dollar size piece of food in the back of (R8's) mouth that (R8) was trying to cough out. (R8) taken out of activity and into bathroom and (R8) had dislodged it on her own and was spitting it out. The item was a partially chewed up piece of sausage from breakfast. R8's X-ray video fluoroscopy report, dated 8/5/15, documents the reason for the exam was choking and the results were stasis or pooling with various substances, and there was element of penetration with thin liquids and nectar. R8's Progress note, dated 8/7/15 at 8:36 a.m., documents: (R8) became choked at breakfast when (Z1 /R8's husband) was feeding (R8) a regular diet of pancakes and sausage. (R8) was finally able to swallow and clear (R8's) airway. (Z1) then gave (R8) pudding to which (R8) began coughing while swallowing. R8's Speech therapy progress and discharge summary, dated 8/17/15, documents: Summary of skilled services provided since start of care: Safe swallow guidelines developed and the staff inservicing completed. Impact on Burden of Care/daily life: at risk for aspiration/choking. Precautions: aspiration . R8's Progress note, dated 8/23/15 at 12:13 p.m., documents: (R8) became choked on prime rib at lunch. Was able to cough and expel food. R8's Progress note, dated 9/1/15 at 9:32 p.m., documents: At 5:50 p.m., (E14 LPN) called to dining room by (E17 RN/Paid feeding assistant instructor) and (R8) was noted with eyes open, mouth open unable to speak or expel air. (E14) and (E17) assisted (R8) to feet and (E14) began [MEDICATION NAME] maneuver. After three thrusts (R8) was able to expel air, small amount of food and water. (R8) able to breath at this time and lips noted blue but color returning to lips .Lung sounds noted to be clear and diminished bilateral anterior and posterior. (R8) noted with wet harsh non-productive cough . R8's physician progress notes [REDACTED]. R8's Nutritional Assessment, dated 9/24/15, documents: Nutritional Risk Assessment Summary: Difficulty chewing and delayed pharyngeal swallowing phase. Speech therapy working with (R8). Nursing notes that (R8) chokes some when fed prior to the pureed diet . R8's Progress note, dated 9/26/15 at 10:08 p.m., documents: (Z1) took (R8) at 10:00 a.m. this morning. (Z1) called at 4:00 p.m (Z1) stated that (R8) choked several times and (Z1) was scared it may be the last time .(R8) came back with family at 5:50 p.m .(R8) was unable to eat or drink .The doctor on call was called and (R8) was sent to emergency room for possible aspiration. R8's Phone order, dated 9/26/15 at 7:37 p.m., documents that R8 received an order to be sent to the emergency room for evaluation and treatment for [REDACTED]. R8's Progress note, dated 9/26/15 at 10:45 p.m., documents: Nurse from emergency room called to report that (R8) would be returning to the facility with the [DIAGNOSES REDACTED]. R8's emergency room physician documentation, dated 9/26/15, documents: (R8) presents to the emergency room via wheelchair with complaints of possible aspiration . R8's emergency room physician's orders [REDACTED]. R8's Progress note, dated 10/7/15 at 5:35 p.m., documents: (Z2/R8's daughter) feeding (R8) in dining room. CNA called nurse over stating that (R8) was choking on mashed potatoes. (R8) noted to have large bite of mashed potatoes in mouth. (R8) was able to clear own airway at this time. R8's Nutrition note, dated 10/8/15 at 4:22 p.m., documents: (R8) has continued to loose weight and presents with chewing/swallowing difficulty in the form of choking . R8's Progress note, dated 11/26/15 at 2:04 p.m., documents: (R8) was out with family and began choking. Once (R8's) throat was cleared (R8) was struggling with (R8's) breathing. Family brought (R8) back to the facility and (R8) is now breathing fine with no trouble. R8's Progress note, dated 12/5/15 at 11:55 a.m., documents: (R8) got choked up on (R8's) lunch, but was able to clear it herself by coughing and deep breathing. R8's Nutrition Note, dated 12/10/15 at 12:18 p.m., documents: Regular pureed diet .Continues with occasional choking episodes. Swallow evaluation competed with recommendations for pureed diet . On 1/11/16 at 11:50 a.m., R8 was being fed pureed broccoli, mashed potatoes, beef, and applesauce by E16 (Activity Director/feeding assistant). R8's Progress note, dated 1/11/16 at 1:02 p.m., documents: (E18 LPN/Licensed Practical Nurse) was called to the dining room at 12:15 p.m. due to (R8) choking on (R8's) lunch. Two nurses were present along with E16(Activity Director/Feeding Assistant). (R8) was taking breaths and working on clearing the material in (R8's) throat .(R8) did get food particles dislodged and is now breathing without difficulty. On 1/13/16 at 12:10 p.m., R8 was being fed a pureed diet of pudding, applesauce, mashed potatoes with gravy, peas, meatloaf, and gelatin cake by E16. During this feeding, R8 had occasional coughing. On 1/13/16 at 12:25 p.m., E16 stated, I am the Activity Director not a CNA. I just completed the feeding classes. Often when (R8) eats (R8) coughs. (R8) has swallowing issues. I was feeding (R8) on 1/11/16 when (R8) had a choking spell. After I fed (R8) a small bite of mashed potatoes (R8) started gagging, and it looked like (R8) might vomit. So I got the nurses and CNAs. I jump in and help residents who need assistance feeding. I can assist any of the residents .I completed the feeding program 12/29/15. On 1/13/16 at 1:55 p.m., E18 (LPN) stated, On 1/11/16 (E16) was feeding (R8) when (R8) choked. On 1/13/16 at 2:10 p.m., E17 (Paid Feeding Assistant Instructor) stated, The feeding assistants are allowed to feed almost anyone as long as they don't have a swallowing/choking issues or frequent aspirations At times (R8) can be fed by a paid feeding assistant on certain days but not all days .(E16) was feeding (R8) today. I don't think there was an actual written feeding assessment done. On 1/13/16 at 3:55 p.m., E21 (Paid Feeding Assistant) stated, I have a certificate for paid feeding assistance completed on 8/6/2014. I have fed (R8) who I've fed only one time on 1/8/15 . On 1/13/16 at 6:20 p.m., Z1 was assisting R8 with drinking a glass of chocolate milk with a straw when R8 began coughing trying to catch R8's breath. Z1 removed R8's drink and pushed R8 forward in R8's high back wheelchair. Z1 began rubbing R8's back and R8 was able to clear the liquids herself. On 1/13/16 at 6:25 p.m., E17 stated, I am over the paid feeding assistant program. I have taught two classes in the last year. The paid feeding assistants can feed anyone as long as the nurse taking care of the resident says it is ok. I am not aware of any assessment done by the nurses of which residents are able to be fed safely by a feeding assistant. I put (R8) on the only to be fed by CNA or nurses' list because (R8) has [MEDICAL CONDITION] swallowing issues. Paid feeding assistants usually are not allowed to feed (R8). (E16) fed (R8) at lunch 1/13/16 .(E16) has taken the feeding class, but is not a CNA. (E16) feeds any resident, including (R8) .The doctor ordered a pureed diet for (R8) due to (R8's) choking. Z3's (R8's Hospice Doctor) Progress note's, dated 1/14/16, documents: 9/29/15: (R8) has increased dysphagia and is on a pureed diet .10/6/15: (R8) coughs and chokes with bigger intake .12/29/15: (R8) choking and dysphagia .1/12/16: (R8) had single episode of choking . On 1/14/16, E18 (LPN) stated, It is sporadic with (R8) .We watch (R8) for coughing while (R8) is eating .I did not do a risk management 1/11/16 with the choking incident. It was reported to the family and hospice. Up until 1/13/16 the feeding assistants could feed anybody. No other interventions to prevent choking have been implemented for (R8) Paid feeding assistants can feed all other residents. There is no formalized assessment done to determine which residents the paid feeding assistants can feed. On 1/14/16 at 9:40 a.m., E2 (Director of Nursing) stated, The paid feeding assistants are not allowed to feed (R8). (R8) is the only resident the paid feed assistants can not feed. (E16) I know was feeding (R8) 1/13/16 and was not suppose to. (E16) should have known (E16) was not suppose to feed (R8). (E16) was told this in the paid feeding assistant class. (E16) was certified on 12/29/15 as a paid feeding assistant .There is no formal assessment done by the nurses, care plan coordinator, or myself of the residents to decide who the paid feeding assistants can feed. It is not on the resident's plan of care if the resident can be fed by the paid feeding assistants. The nurses notify me if the [MEDICATION NAME] was done if choking occurred. The nurses do not do risk management for that .I do not know if this was put on the care plan or new interventions implemented .We do not do actual investigations with the choking incidents, not on paper. When the [MEDICATION NAME] maneuver was performed on (R8) I'm not sure if it was reported to the state agency. I do not feel that is is safe for a paid feeding assistant to feed (R8) because of (R8's) choking episodes. On 1/14/16 at 9:55 a.m., Z4 (Speech Language Pathologist), stated, I've seen (R8) quite a bit. (R8) was discharged for speech therapy several months ago .Someone needs to feed (R8) who is trained and licensed because (R8) is a choking hazard. (R8) pockets food, inhales food, and (R8's) alertness level varies throughout the day. On 1/14/16 at 10:50 p.m., E 24 (Medical Director) stated, (R8) choked previously while (R8) was at home prior to admission .(R8) is a very difficult feed. (R8) is especially high risk for choking because of (R8's) [DIAGNOSES REDACTED]. It is Pseudobulbar or swallowing difficulty type of [MEDICAL CONDITION] .I think (R8) has a complicated swallowing problem that requires certified or licensed staff to feed (R8). On 1/14/16 at 1:00 p.m., an Immediate Jeopardy was identified to have begun on 1/11/16 when R8 was fed by an unlicensed staff member (E16) and R8 choked. E1 (Administrator) and E2 (Director of Nursing) were notified of the Immediate Jeopardy on 1/14/16 at 1:00 p.m. The surveyor confirmed through interview and record review the facility took the following actions to remove the immediate jeopardy. 1. The facility suspended the use of Paid feeding Assistants 1/14/16 at 1:30 p.m. by E1 (Administrator) for all residents. 2. Feeding assistants were notified of the suspension of the program immediately by E1 (Administrator). 3. Only CNA and Licensed or Registered Nurses will be permitted to feed residents. 4. Dietary risk assessments will be completed on all residents by E2 (Director of Nursing), E4 (Minimum Data Set Coordinator), and E7 (Restorative/Wound Nurse) to identify feeding problems, such as difficulty swallowing, recurrent lung aspiration, and tube or parental/intravenous feedings by 1/15/16 at 1:00 p.m. 5. Any dietary risk assessment that verifies a complicated feeding problem will be provided feeding assistance by a CNA or Licensed or Registered Nurse to be completed by 1/15/16 at 4:00 p.m. 6. Care plans for residents with a complicated feeding problem will be updated to reflect the dietary risk assessment to be completed by 1/15/16 at 4:00 p.m. by E2 (Director of Nursing), E4 (Minimum Data Set/Care plan Coordinator), and E7 (Restorative/Wound Nurse). 7. A risk management report will be completed by the nurse on duty for each choking incident. The report will include details regarding the incident, including resident name, time, staff present, cause, witness, notification of physician, Power of Attorney, Administrator, and Director of Nursing. A follow up investigation will be completed for each choking incident; which may include interventions, care plan changes, resident and staff education on alternate feeding techniques. Risk management reporting for choking incidents will be implemented immediately on 1/14/16 at 3:00 p.m.

Facility noncompliance resulted in three deficient practices. 1. Based on interview, observation and record review the facility failed to implement new fall interventions after each fall and failed to follow a fall prevention care plan for one of seven residents (R1) reviewed for falls in the sample of fifteen. This failure resulted in R1 falling and sustaining a hairline fracture of R1's nose, and requiring sutures to R1's forehead. Findings include: R1's Incident Report dated 1/17/14 documents R1 fell at the facility while using an enclosed walker on 1/17/14. This same report documents no new intervention was implemented and instructed facility staff, "Continue to monitor." R1's Incident Report dated 1/26/14 documents R1 fell at the facility while using an enclosed walker on 1/26/14. This same report documents the intervention, "Staff reminded to keep (R1) in direct supervision at all times," was implemented. R1's Incident Report dated 3/13/14 documents R1 fell while using an enclosed walker at the facility on 3/13/14. This same report documents no new intervention was implemented and the intervention, "Remind staff (R1) needs constant supervision while in (enclosed walker)," was continued. R1's Care Plan dated 4/14/14 documents the following interventions: "Continue to monitor...remind staff that (R1) needs supervision at all times while in the (enclosed walker)...remind staff to keep (R1) in direct supervision at all times when (R1) is in (enclosed walker). R1's Incident Report dated 5/6/14 documents R1 fell at the facility on 5/6/14. This same report documents, "Heard [DIAGNOSES REDACTED] sound down hallway. (R1) had tipped over (enclosed walker). Lying on side. Has a half inch size gash on right side of forehead. Has a quarter inch horseshoe shaped gash on nose. Forehead and nose both bleeding...took resident to (local emergency department) to be evaluated." R1's emergency room record dated 5/6/14 documents R1 had a three centimeter laceration to R1's forehead, and R1 received four sutures to repair the laceration. This same record documents R1 received a Computerized Tomography scan of the head, diagnosing a bilateral nasal fracture. On 12/04/14 at 10:05 a.m., E2, Director of Nursing, verified that R1's fall with injury on 5/6/14 was unwitnessed. On 12/4/14 at 11:00 a.m., E1, Administrator, stated that E1 expects a new intervention to be implemented after a resident falls to prevent further falls. E1 also verified no new interventions were implemented after R1's falls on 1/17/14 and 3/13/14. E1 then stated that E1 expects facility staff to follow R1's care plan, and verified the interventions on R1's fall prevention care plan dated 4/14/14 were not followed on 5/06/14. 2. Based on interview and record review the facility failed to investigate, analyze and educate staff for two incidents involving resident injury for R18 and R19 in the supplemental sample. Findings include: R19's incident report dated 12/15/13 documents unidentified CNA (Certified Nursing Assistant) asked "the nurse to check (R19) because another CNA, E12 "just made incident to (R19) while being positioned." When the unidentified nurse went to check R19, E12 explained that R19 hit R19's head with R19's right siderail when E12 was performing morning cares." The same form documents under section titled Description of action taken: "...checked the head area. noted right forehead is red and hematoma, also observed facial grimaces of pain while doing assessment." The same form documents under signatures: E1 Administrator notified 3/17/14 and E2 DON (Director of Nursing) notified 12/17/13. E12's CNA personnel file reviewed and did not contain education following the incident on 12/15/13. R18's incident form dated 1/22/14 documents R18 complained of discomfort and tells nurse R18's face "is hit by the lifting machine while...helped R18 transfer from the wheelchair to the recliner." The same form documents under Description of Action Taken: "noted redness on R18's left face. Applied ice pack on R18's left face." The same form documents the incident was witnessed by E9 (SSD/Social Service Director). On 12/3/14 at 2:15 p.m. E9 (SSD) stated during the incident on 1/22/14 the lifting machine did not hit R18. E9 verified E9 did not fill out a witness statement. On 12/3/14 E1 Administrator provided E11's CNA (Certified Nursing Assistant) personnel file which did not contain education following the incident on 1/22/14. E1 identified E11 as the CNA involved in the incident dated 1/22/14. On 12/3/14 at 2:15 p.m. E1 stated "I did not see concern for the incidents on 12/15/13 and 1/22/14. E1 stated "I know the staff and in life, things happen." E1 verified additional inservices were not held after the incidents on 12/15/13 and 1/22/14. 3. Based on interview and record review, the facility failed to ensure that one of three residents (R4) reviewed for oxygen administration in the sample of fifteen was kept safe while oxygen was in use. Findings include: On 12/02/14 at 10:35 a.m., R4 was sitting under an electric hair dryer in the facility's beauty shop. R4 was wearing a nasal cannula and was receiving oxygen from a portable oxygen tank attached to the back of R4's wheelchair. On 12/02/14 at 10:37 a.m., E13, Hairdresser verified that R4's oxygen was in use while R4 sat under a hot electric hair dryer. On 12/02/14 at 10:46 a.m., E1, Administrator, confirmed the presence of oxygen administration in the beauty shop during use of an electric dryer and stated, "It (oxygen use) shouldn't be in there. (E13) didn't know that it shouldn't be." On 12/04/14 at 8:30 a.m., E1, Administrator stated the facility does not have a policy in place for staff guidance specific to oxygen use in the beauty shop.