Every finding on record at Westbury Center of Conyers for Nursing and Healing

Based on observation, staff interviews, record review, and review of the facility's policies titled Infection Prevention and Control Program Description and Hand Hygiene, the facility failed to practice hand hygiene between glove changes for one of four residents (R) (R4), sampled for incontinence care. This deficient practice had the potential to place R4 at risk of infections due to cross-contamination. Findings include:Review of the facility's undated policy titled Infection Prevention and Control Program Description revealed The major activities of the program are: 3. Implementation of Control Measures and Precautions, which includes basics such as hand hygiene. and measures to protect persons. from communicable diseases or infections.Review of the facility's policy titled Hand Hygiene, revised June 2023, revealed Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Policy Explanation and Compliance Guidelines: Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice.Review of the facility's electronic medical records (EMR) revealed R4 was admitted to the facility on [DATE] with diagnoses including, but not limited to, contracture of the left and right hands, urinary tract infection (UTI), and muscle weakness. Review of the quarterly Minimum Data Set (MDS) assessment for R4, dated 01/9/2026, revealed that Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 10, which indicated R4 had moderately impaired cognition. Section GG (Functional Abilities) revealed that R4 was dependent on staff for toileting hygiene.Review of the care plan for R4, dated 01/14/2026, included, but was not limited to, The resident has bowel and bladder incontinence r/t [related to] history of UTI, impaired mobility. The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Clean peri-area [perineal area]with each incontinence episode. Incontinent: Check and change as required for incontinence. Wash, rinse, and dry the perineum. Change clothing PRN [as needed] after incontinence episodes.Observation on 02/03/2026 at 02:26 PM of incontinence care for R4 revealed that Certified Nursing Assistant (CNA) AA did not perform hand sanitizing between glove changes.In an interview on 02/03/2026 at 2:26 PM, CNA AA confirmed she did not hand sanitize between glove changes. She stated that she should have sanitized her hands after removing the used gloves and before putting on a new pair. She further stated that when she did not sanitize her hands between glove changes, the resident could develop infections.In an interview on 02/04/2026 at 2:52 PM, the Staff Development Coordinator (SDC) stated that hands should be washed or hand sanitized between glove changes. She further stated that if hands were not washed or sanitized between glove changes, there could be the spread of germs, cross-contamination, or infection to the residents.In an interview on 02/04/2026 at 3:55 PM, the Director of Nursing (DON) stated that she expected staff to wash or sanitize their hands between glove changes. The DON further stated that if staff did not wash or sanitize their hands after removing gloves and before putting on gloves, it could cause transmission of pathogens and infection to the residents.

Based on observations, resident and staff interviews, and record review, the facility failed to ensure one of 75 sampled residents (R) (R7) was provided with a call device suitable for the resident's use. This deficient practice had the potential to place R7 at risk of unmet needs and a diminished quality of life. Findings include:Review of R7's admission Record revealed she was admitted [DATE] with diagnoses that included, but were not limited to, unspecified injury at unspecified level of cervical, unspecified injury at unspecified level of cervical spinal cord, and schizophrenia, unspecified.Review of the Comprehensive Minimum Data Set (MDS) assessment for R7, dated 7/15/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of eight (indicating moderate cognitive impairment). Section GG (Functional Abilities and Goals) documented R7 had upper extremity impairment on both sides, was dependent on eating, oral hygiene, toileting, bathing, dressing, personal hygiene, mobility, and transfers. Review of the Care Plan for R7, dated 8/22/2025, revealed no documentation regarding R7's inability to use upper extremities or to use the call button to activate the emergency call light.Observation and interview on 8/25/2025 at 1:20 pm with R7 revealed she was lying in a slightly elevated bed, with a call light approximately six inches from her right hand. Further observation revealed her right hand was immobilized in an inflatable brace. When the call device was placed in her hand, she was unable to press the button to activate the emergency call light. R7 stated she had to wait for someone to check on her for assistance. Observations on 8/26/2025 at 8:48 am and 3:00 pm of R7 revealed that the call button was within reach; however, R7 was unable to activate the call button.Observation on 8/27/2025 of R7 revealed a flat call light device within R7's reach; however, R7 was unable to activate the flat call device. In an interview on 8/25/2025 at 1:22 pm, Certified Nursing Assistant (CNA) confirmed R7 was physically unable to activate the call button and stated the resident needed a push call light.In an interview on 8/26/2025 at 3:04 pm, Licensed Practical Nurse (LPN) ZZ confirmed she was aware R7 was unable to use the call button to call for help and stated the resident should have a call device she could use. LPN ZZ stated that a replacement call light for R7 had been discussed in the clinical management meeting about a week ago, and it was agreed upon by all that a replacement call light would be ordered. In an interview on 8/26/2025 at 3:12 pm, the Administrator confirmed that an assessment should have been completed on R7 on admission, and a call light that the resident could activate should have been provided to the resident. The Administrator further stated that if the facility did not have a call device that the resident could use, one would be ordered. In an interview on 8/26/2025 at 3:14 pm, the Director of Nursing (DON) stated the nurses were expected to assess and identify resident needs for call lights. In a concurrent observation and interview on 8/28/2025 at 10:05 am, at R7's bedside, the DON confirmed that R7 could not activate the push pad call light and stated that a breath-activated call device was needed and would be ordered. The DON stated a 24-hour log of staff checks on R7 would be instituted immediately, with every 15-minute checks during R7 nighttime tube feeding infusion, and every 30-minute staff checks during the day, until a suitable call device was obtained for R7 to use.

Based on resident representative and staff interviews, record review, and review of the facility's policy titled Bed Hold Prior to Transfer, the facility failed to ensure one of two residents (R) (R4) reviewed for hospitalization was provided with a written bed hold notice or reason for transfer at the time of transfer. This deficient practice had the potential to place R4 or the resident representatives at risk of being uninformed about their rights related to hospital transfer and subsequent return to the facility. The sample size was 75. Findings include:Review of the facility policy titled Bed Hold Prior to Transfer, reviewed/revised 3/2025, revealed the Policy section stated, It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of, a transfer for hospitalization or therapeutic leave. The Policy Explanation and Compliance Guidelines section included, 1. As part of the admission packet and at the time of a transfer to the hospital or therapeutic leave, the facility will provide the resident and/or the resident representative written information that specifies a. the duration of the State bed hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility; b. the reserve bed payment policy in the state plan policy if any. c. The facility policies regarding bed hold periods to include allowing a resident to return to the next available bed. 3. The facility will keep a signed and dated copy of the bed hold notice information given to the resident and resident representative in the resident's file and or medical record. 4. The facility will provide this written information to all facility residents, regardless of their payment source.Review of the Discharge Minimum Data Set (MDS) assessment for R4, dated 6/21/2025, revealed Section A (Identification Information) documented the resident was discharged to a short-term general hospital on 6/12/2025, with return anticipated. Review of the Discharge Minimum Data Set (MDS) assessment for R4, dated 7/13/2025, revealed Section A (Identification Information) documented the resident was discharged to a short-term general hospital on 6/30/2025, with return anticipated.Review of the Quarterly MDS assessment for R4, dated 8/8/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BMS) score of 00 (indicating the resident was not cognitively intact to complete the assessment). Review of the Clinical Census for R4 revealed a hospital paid leave on 6/12/2025 and 6/30/2025.Review of the clinical record for R4 revealed no evidence of the provision of a notice of a bed hold or reason for transfer provided to R4 or the resident representative for the transfers dated 6/12/2025 and 6/30/2025.In an interview on 8/27/2025 at 3:23 pm, the resident representative for R4 stated that a written bed hold notice was not provided when R4 was transferred to the hospital on 6/5/2025 or 6/30/2025. He stated that this was the first time he had heard the term bed hold. In an interview on 8/27/2025 at 5:00 pm, Licensed Practical Nurse (LPN) PP stated that when a resident was transferred from the facility to a hospital, the nurse was responsible for calling the family or responsible party, calling the physician, and writing the orders being sent with the resident. She stated that she was not responsible for bed holds, and the business office or admissions was. In an interview on 8/28/2025 at 1:06 pm, the Business Office manager (BOM) revealed that all new admissions were asked at the initial 72-hour meeting if they wanted to pay for the bed hold if they were transferred to the hospital, or if they wanted to be discharged and readmitted upon return. She also stated that it was the nursing staff's responsibility to provide the residents or their representatives with a copy of the bed hold policy before they leave the facility. She stated that copies of the bed hold policy were located at the nurses' station. In an interview on 8/28/2025 at 1:15 pm, the Unit Manager (UM)/LPN XX revealed that part of the process when a resident was transferred to the hospital was to provide the residents with a bed hold policy. She stated that it is not documented anywhere, but it was just known to be provided. In an interview on 8/28/2025 at 2:40 pm, the Administrator revealed that the nurse was responsible for providing the residents with the bed hold policy upon transfer to the hospital, and the business office documented a bed hold in the billing. The Administrator was unable to locate proof that a written bed hold notice was provided to R4 or the resident representative for the hospital transfers dated 6/5/2025 and 6/30/2025. She stated that her expectation was for the nursing staff to provide the bed-hold policy to residents upon transfer to the hospital, and for it to be documented in the resident's record.

Based on observations, staff and resident interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure the medication error rate was less than 5 percent. The medication error rate was 7.69 percent, with two errors from 26 opportunities for two of four residents (R) (R89 and R77) observed for medication administration. This deficient practice had the potential to place R89 and R77 at risk of adverse effects or a lack of desired effects from the medications. Findings include:Review of the facility's policy titled Medication Administration, revised 4/2025, revealed the Policy section stated, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. The Policy Explanation and Compliance Guidelines section included, . 10. Ensure that the six rights of medication administration are followed: a. right resident, b. right drug, c. right dosage, d. right route, e. right time, f. right documentation. 17. Administer medications as ordered in accordance with manufacturer specifications. 1. Review of the electronic medical record (EMR) revealed R89 was admitted to the facility on [DATE] and diagnoses included, but were not limited to, hyperkalemia, acute kidney failure, and encephalopathy.Review of the Quarterly Minimum Data Set (MDS) assessment for R89, dated 6/5/2025, revealed Section K (Swallowing/Nutritional Status) revealed no swallowing disorder.Review of the Physician's Orders for R89 included an order dated 10/28/2023 for atorvastatin calcium oral tablet (a medication used to lower cholesterol) 40 milligrams (mg) daily. Further review revealed an order dated 12/5/2023 of May alter medication by crushing, opening capsules, and administering with food/liquid unless contraindicated.Observation of medication administration on 8/27/2025 at 8:12 am with Licensed Practical Nurse (LPN) PP revealed LPN prepared, crushed, and administered atorvastatin calcium oral tablet 40 mg to R89.In an interview on 8/27/2025 at 8:12 am, LPN PP confirmed she crushed the atorvastatin oral tablet and administered it to R89. She further confirmed the medication should not be crushed. In an interview on 8/27/2025 at 2:54 pm, the Registered Pharmacist (RPh) stated that atorvastatin calcium tablets should not be crushed.In an interview on 8/28/2025 at 9:10 am, the Director of Nursing (DON) confirmed that medications were to be crushed according to policy, and nurses should follow the list on each medication cart for reference. 2. Review of the EMR revealed R77 was admitted to the facility on [DATE] and diagnoses included, but were not limited to, hemiplegia and hemiparesis following cerebral vascular accident, dysarthria, anarthria, and muscle weakness.Review of the Physician's Orders for R77 revealed an order dated 11/18/2022 for MiraLax powder 17 grams per scoop, one scoop per day for constipation.Observation of medication administration on 8/27/2025 at 8:48 am with LPN AA revealed LPN AA reviewed the physician's orders and prepared and administered the two scoops of polyethylene glycol [generic medication for MiraLax] to R77.In an interview on 8/27/2025 at 9:00 am, LPN AA confirmed R77 should have received one scoop of polyethylene glycol, and he administered two scoops of polyethylene glycol powder because the resident asked for a second scoop. The LPN confirmed he should have given R77 one polyethylene glycol scoop of powder as ordered. In an interview on 8/28/2025 at 9:00 am, the Director of Nursing (DON) stated that there was no exception for not following the doctor's order. The DON stated that expectations for medication change require contacting the provider and obtaining approval prior to administering the medication.

Based on observations, record review, interviews, and review of the facility policy titled Pain Management, the facility failed to ensure that pain management was provided to one of six residents (R) R117 who required such service and was reviewed for pain management. Actual Harm was identified on 5/6/2024 when R117 was exhibiting physical signs and symptoms of pain and distress. Facility staff failed to assess R117's condition and only provided her with Tylenol tablets for pain when she had an active order for a stronger pain medication available. The resident requested to be sent to the hospital and was admitted on [DATE] with a diagnosis of colitis. Findings include: Review of the facility policy titled Pain Management revised August 2023, the policy statement indicated the facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. During an observation on 5/6/2024 at 10:30 am, Licensed Practical Nurse (LPN) AA was observed in the hall preparing medications during medication pass. A male voice was heard reporting to LPN AA that R117 was requesting her assistance. LPN AA was heard responding, Is (R117) breathing? When the male voice stated that R117 was breathing, LPN AA stated that R117 needed to wait until she finished the medication pass. Review of the clinical record revealed R117 was admitted to the facility on [DATE] with diagnoses including gastroparesis, diabetes, anxiety, acute respiratory failure with hypoxia, and systemic inflammatory response syndrome (SIRS-a defense mechanism of the body to a noxious stressor, such as infection, trauma, surgery, acute inflammation, ischemia, to localize and eliminate the source of the insult). Review of the Admission Minimum Data Set (MDS) assessment for R117 dated 1/11/2024, revealed a Brief Interview for Mental status (BIMS) score of 15, indicating the resident was cognitively intact. Review of R117's care plan initiated on 1/5/2024 and revised on 4/16/2024 indicated resident has a potential for acute/chronic pain with complaints of back and leg pain related to weakness, cerebrovascular accident (CVA), and cancer. Interventions for care include administering pain management as ordered, evaluating the effectiveness of pain interventions, monitor/record pain characteristics (quality, severity, location, onset), and monitor/record/report to nurse resident complaint of pain or requests for pain treatment. Observation on 5/6/2024 at 11:15 am, revealed R117 in bed rocking, moaning, and groaning, leaning on the left side of the bed rail, appearing to be in pain and distress. When asked if she was okay, she murmured she had nausea and was in pain. LPN AA was notified of R117 condition, who was in distress. LPN AA went into the room, and when she came out of R117's room she stated, She told me to give her something for hemorrhoids. Review of the May 2024 Medication Administration Record (MAR) for R117 revealed an order for Tylenol Oral Tablet 325 milligrams (mg) two tablets every six hours as needed (PRN) for abdominal pain and Ondansetron HCl Oral Solution 4 mg/5 ml (milliliters): Give 5 ml orally every six hours PRN for nausea and vomiting, both administered on 5/6/2024 at 11:30 am. Review of the Progress Notes written on 5/6/2024 at 11:30 am, revealed the patient complained of nausea and received PRN Zofran 4 mg orally, which was ineffective. The patient reported experiencing some diarrhea the previous morning and had a regular bowel movement the night before. She continued to complain of abdominal pain. Interview on 5/6/2024 at 12:35 pm with LPN AA at the nurse's station to discuss R117's current condition, LPN AA revealed the Nurse Practitioner (NP) ordered medication for R117 and reported that R117 was fine. Observation and interview with R117 on 5/6/2024 at 1:09 pm, she was observed leaning over a bedpan vomiting and appeared to be in more pain. R117 was asked if she was okay, and if she had received anything to help her symptoms. She responded no and stated, her stomach was hurting her badly. Further review of the clinical records revealed an order for Tramadol HCl 50 mg tablet, give one tablet by mouth every six hours as needed for pain with start date of 1/10/2024. Tramadol is a more potent pain medication available to the patient, prescribed to be administered every six hours as needed for pain. The medical records indicate that Tramadol was given less frequently than required by the patient's condition, with only three doses administered in March 2024 and two doses administered in April 2024. Observation on 5/6/2024 at 1:22 pm, surveyor asked the Director of Nursing (DON) to accompany her to check on R117. The DON was informed of the incident the surveyor overheard this morning and the condition of the resident observed throughout the day. Upon entrance to the resident's room, her condition had worsened. The call light was observed to be on, but no staff were in the room. The resident was leaning over the bedpan with vomit hanging from her mouth, asking for somebody to help clean her up. The DON left the room to get the Nurse Supervisor, LPN NN and briefed her on resident status and instructed her to check and see what could be done for R117. Within a few minutes, staff returned to the room with bedpans and washcloths to clean up R117. Observation on 5/6/2024 at 2:39 pm, R117 call light was on. Upon entrance to the room, R117 was observed to be in extreme distress. She was constantly dry heaving, vomiting, and still in pain. Admissions Concierge (AC) DD was standing at the bedside, talking to R117. As the nurse was exiting the room, she revealed that R117 did not want to go to the hospital. The surveyor informed the nurse that R117 had shared that she was in pain and requested to go to the hospital. At no time did licensed staff assess R117 for further orders to ease her distress. She was sent to hospital on 5/6/2024 - the same day, but approximately four hours later. Review of the Situation, Background, Appearance, Review (SBAR) dated 5/6/2024 revealed that the NP was notified on 5/6/2024 at 1:20 pm and ordered a KUB (kidneys, ureter, bladder) exam and Promethazine IM (intramuscular) for R117. It was noted that the resident was notified of all new orders but requested to go to the hospital to be evaluated. The NP gave the order to send the resident to the local hospital to evaluate and treat as indicated. There was no evidence that Promethazine was administered. Interview on 5/8/2024 at 8:05 am with LPN OO, the wound care nurse discussed the protocol for managing a resident's pain during medication passes. LPN OO emphasized the priority of addressing severe pain immediately, despite other duties. She stated she could tell that R117 wasn't her usual self on Monday. She stated she used to be sitting in her wheelchair and having a much better day. Surveyor asked her what the proper procedure was for a resident crying out for help. LPN OO stated she would immediately lock her cart and go and see the resident and do a pain assessment. When asked if her decision would be based on whether the patient was breathing, she said no, that would be neglectful. Interview on 5/8/2024 at 2:26 pm, the Administrator was asked for a status update for R117, and she stated that R117 always had stomach issues. Further interview on 5/8/2024 at 4:15 pm, the Administrator revealed that R117 had been admitted to the hospital on 5/6/2024 with a diagnosis of colitis with no discharge update.

Based on observations, record review, staff interviews, and review of the policy titled Medication Administration, the facility failed to ensure that it was free of a medication error rate greater than five percent by not ensuring medications were administered as ordered by the physician. A total of 27 medication opportunities were observed, with three errors, for one of five residents (R) R124, for a medication error rate of 11.11%. Findings include: Review of the facility policy titled Medication Administration revised January 2023, Policy Explanation and Compliance Guidelines: Number 11 b. Administer within 60 minutes prior to or after the scheduled time unless otherwise ordered by the physician. Review of R124's electronic medical record (EMR) revealed diagnoses including, but not limited to hypertension (HTN) and cerebral infarction affecting bilateral sides of the body. Review of the physician's orders included orders dated 3/11/2024 for amlodipine besylate 10 milligrams (mg) tablet, one tablet orally, once a day at 9:00 am, which she held due to the blood pressure being low and she was going to check with the provider regarding giving the medication. apixaban 5 mg tablet one tablet orally, two times a day; baclofen 10 mg tablet, one tablet orally, three times a day; and carvedilol 3.125 mg tablet, one tablet orally, twice a day. During observation of medication administration on 5/8/2024 at 7:13 am, Licensed Practical Nurse (LPN) KK was observed to administer medications to R124, including carvedilol (medication given for high blood pressure and heart failure) 3.25 milligrams (mg) one tablet, baclofen (medication used to treat muscle spasm) 10 mg one tablet, and apixaban (medication used to treat and prevent blood clots and prevent strokes) 5 mg one tablet. These medications were ordered to be administered at 9:00 am. Interview on 5/8/2024 at 7:33 am, LPN KK confirmed she had given R124's medications too early, and stated she knew the protocol was one hour before and one hour after the scheduled administration time. She verified that the scheduled time was 9:00 am. She stated that she had customized the time for the residents as it was the skilled hall and some of the residents took a long time, and others needed their pain medications prior to therapy. Interview on 5/8/2024 at 10:27 am, Assistant Director of Nursing (ADON) confirmed the 7:13 am time was too early to administer medications scheduled for 9:00 am. She stated an exception to administration of medications outside of parameters would be if a resident were going out for an appointment, or if they needed pain medication prior to therapy services. During further interview, she stated if there needed to be altered times of administration, the physician would be notified and documented. She stated she would expect that the nurses know the parameters of medication administration and follow them.

Based on observations, record review, staff interviews, and review of the facility's policy titled Residents Rights Regarding Treatment and Advanced Directives, the facility failed to have the code status for one of 65 sampled residents (R) R111 available to staff who cared for this resident. This failure had the potential to affect all residents in this facility. Findings include: Review of the policy titled Residents Rights Regarding Treatment and Advanced Directives revised February 2024, indicated the policy is to support and facilitate a resident's right to request, refuse, and/or discontinue medical or surgical treatment and to formulate an advance directive. Policy Explanation and Compliance Guidelines: Number 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. The Electronic Medical Record (EMR) banner indicated R111 code status as Do Not Resuscitate (DNR). Review of the physician orders dated 4/29/2024 documented an order for a code status of DNR for R111. Review of the 2/15/2024 Care Plan documented R111 had a DNR code status. Review of the Physician Orders for Life Sustaining Treatment (POLST) dated 4/26/2024 documented R111's code status as Full Code and was signed by two physicians and the resident's responsible party. Interview on 5/8/2024 at 1:58 pm, Certified Nurse Aide (CNA) GG stated she would look in the EMR on the opening page banner for a resident's code status. Interview on 5/8/2024 at 2:06 pm, Licensed Practical Nurse (LPN) HH revealed the code status could be found in the EMR and on the orders. He confirmed that R111 had documented a DNR in those places, and further stated he would expect the physician orders, the POLST, and the EMR to match. Interview on 5/8/2024 at 1:47 pm, Hospice Registered Nurse (RN) JJ caring for R111 confirmed that the code status for R111 was a full code as documented on a POLST. Interview on 5/8/2024 at 2:07 pm, the Director of Nursing (DON) revealed that her expectation would be that the code status would be easily located in the EMR on the banner, in the orders, or under miscellaneous documents. She confirmed that it did not match.

Based on observations, record review, and interviews, and review of the policy titled Activities of Daily Living, the facility failed to provide activities of daily living (ADL) care for one resident (R) R4 with contracted hands, resulting in inadequate nail care and hand hygiene. Five residents were reviewed for ADL care. Findings include: Review of the undated policy titled Activities of Daily Living indicated the purpose was to attain or maintain the patients highest practicable physical, mental, and psychosocial well-being. Practice Standards: 1.2. A patient who is unable to carry out ADL's receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the clinical record revealed R4 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, chronic kidney disease, Alzheimer's disease, hypertension (HTN), chronic obstructive pulmonary disease (COPD), and psychotic disorder with hallucinations. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating that R4 was cognitively intact, and that R4 was dependent on staff for ADL care. Review of the care plan initiated on 2/6/2019 indicated a self-care deficit-requires assistance with ADL care related to physical limitations and multiple comorbidities. Interventions to care include bath as scheduled-resident prefers bed baths. Observation and Interview on 5/7/2024 at 7:34 am, R4 was observed in her room with contracted hands with dirty fingernails and they were digging into her skin. R4 reported that her nails were last cut approximately two weeks ago and expressed dissatisfaction with the frequency and quality of care. Observation on 5/7/2024 at 2:40 pm during mealtime, R4's hands had a white substance in palm and dirty. R4 confirmed nobody cleaned her hands prior to eating her meal. Additional observations on 5/8/2024 at 7:38 am and 2:26 pm, and on 5/9/2024 at 11:15 am, R4 was observed with unclean hands and nails and untrimmed fingernails contracted into her skin on the palms of her hands. Interview on 5/9/2024 at 11:20 am, Certified Nursing Assistant (CNA) PP, working in the same area but not assigned to R4, confirmed that ADL care should include hand and nail care and verified R4 hands and fingernails remained dirty. She stated that the observed condition was not the usual standard and hands and nails must be clean, and nails cut shorter. Interview on 5/9/2024 at 9:44 am, Licensed Practical Nurse (LPN) NN revealed that the facility's ADL protocols should encompass comprehensive hand cleaning, and only nurses are permitted to cut nails if the resident is diabetic. LPN NN confirmed that R4 prefers her nails short and clean.

Based on interview, review of facility documentation, and review of the policy titled Ostomy Care-Colostomy, Urostomy, and Ileostomy, the facility failed to ensure urostomy care was provided consistent with professional standards of practice for one of two sampled residents (R) R262. Specifically, the facility sent R262 to an outside appointment without a urostomy bag. The deficient practice had the potential to cause infection. Findings include: Review of the policy titled Ostomy Care-Colostomy, Urostomy, and Ileostomy reviewed/revised January 2024, indicated the policy of the facility is to ensure that residents who require colostomy, urostomy, or ileotomy services receive care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. A urostomy is defined as a stoma for the urinary system used in cases where long-term drainage of urine through the bladder and urethra is not possible. Policy Explanation and Compliance Guidelines: Number 3. Ostomy care will be provided by licensed nurses under the orders of the attending physician. Number 10. Interventions to prevent complications or promote dignity associated with the ostomy will be included in the person-centered care plan. These may include, but not limited to h). Physical management of pouches, tubing, and night collection of devices to prevent infection. Closed Record review revealed R262 was admitted to the facility on [DATE] with diagnoses including malignant neoplasm of the posterior wall of the bladder, surgical aftercare of the genitourinary system, attention to artificial openings of the urinary tract, and major depressive disorder. R262 was discharged to the community on 3/24/2023. Review of R262's care plan initiated on 11/11/2022 documented that the resident had a urostomy with ileal conduit related to bladder cancer. Interventions to care include educating the resident on the importance of keeping a urostomy bag, monitoring/recording/reporting to physician signs/symptoms of urinary tract infection (UTI), provide urostomy care as ordered. Review of the Progress Notes dated 1/30/2023 at 5:11 pm, documented a late entry for 1/24/2023. It was documented that the writer received a call from resident's case worker that the resident had been out to a physician's appointment and did not have his urostomy appliance on. The case worker stated APS (Adult Protective Services) was notified, and staff relayed to the caseworker that the resident had pulled off the appliance before leaving and there weren't more supplies to reapply. Review of the final investigation of State Reportable dated 1/31/2023 confirmed R262 arrived at his doctor appointment on 1/24/2023 without a urostomy bag, and indicated the stoma was covered with an adult brief and a disposable bed pad. Interview on 5/9/2024 1:21 pm, Licensed Practical Nurse (LPN) CC revealed that residents with an ostomy of any kind should have extra supplies on hand. She stated there is currently one resident in the facility with an ostomy (gastrostomy). She showed where extra gastrostomy supplies were on hand, which included multiple boxes of ostomy bags and wafer dressings. Interview on 5/9/2024 at 1:35 pm, Director of Nursing (DON) stated she was not employed at the facility at the time R262 was a resident at the facility. During further interview, she stated that residents should not be sent out of the facility without the appropriate ostomy bag. Interview on 5/10/2024 at 3:45 pm, Administrator stated R262 would pull off his urostomy bag. She stated his supplies were a special-order item that could not be ordered through the facility's usual supply resources. She stated his supplies were ordered through a community pharmacy. During further interview, she confirmed that staff sent R262 to a doctor's office without a urostomy bag because they ran out and had not received their shipment. She stated staff wrapped the urostomy site in an incontinence pad and brief to absorb the urine because they didn't want him to miss the appointment.

Based on observations, record review, resident and staff interviews, and review of policies entitled Oxygen Administration and Medication Administration, the facility failed to follow standard infection control practices to prevent the spread of infections by not ensuring respiratory equipment was bagged when not in use for one of two sampled residents; and during medication observations, one of five Licensed Practical Nurses (LPNs), LPN KK, handled medications with her bare hands during medication administration. The census was 148. The findings include: 1. Review of the policy titled Oxygen Administration revised December 2022, indicated it is the facility ' s policy that Oxygen is administered to residents who need it consistent with professional standards of practice, the comprehensive person-centered care plans, and the resident's goals and preferences. The policy further instructed to keep the delivery devices covered in a plastic bag when not in use. Observation on 5/6/2024 at 10:05 am, in R147's room, revealed a continuous positive airway pressure (C-PAP) mask was lying on a towel, unbagged on the residents bed. Resident revealed he cleans the machine himself daily. Interview on 5/6/2024 at 10:13 am, Licensed Practical Nurse (LPN) AA confirmed that R147's C-PAP mask was not bagged. She stated that the mask should be placed in a plastic bag when not in use. Interview on 5/9/2024 at 9:10 am, the Director of Nursing (DON) revealed her expectation is for all nurses to clean and bag all C-PAP masks when not being used. Interview on 5/9/2024 at 9:15 am, the Administrator revealed that it is the nurse's responsibility to monitor and ensure that all C-PAP masks are clean and bagged when not being used. 50624 2. Review of the policy titled Medication Administration documented the policy is that medications are administered in accordance with professional standards of practice, in a manner to prevent contamination or infection. staff were to take care not to touch medication with bare hands. Revised January 2023, Policy Explanation and Compliance Guidelines: Number 13. Remove medication from source, taking care not to touch medication with bare hands. On 5/8/2024 at 7:13 am during observation of medication administration with Licensed Practical Nurse (LPN) KK was observed taking medications out of a medicine cup with her bare hands to place them into a bag to crush them. Interview on 5/8/2024 at 7:33 am, LPN KK verified she had administered resident medications after touching them with her bare hands. She stated that her hands were too big, and she did not want to drop any of them. She revealed that it was against infection control protocol to handle medications with bare hands. Interview on 5/8/2024 at 10:27 am, the Assistant Director of Nursing (ADON) stated that she would expect nurses to touch medications with their bare fingers. She explained the process for crushing of medications with cups, bags, and crusher. She stated there should be no touching involved, and gloved hands if touching was needed. She further stated she expects the nurses to follow infection control practices during medication administration.

Based on observations, interviews, and review of the policy titled Storage of Medications, the facility failed to ensure that two of four medication carts were locked and secured when the carts were out of view of the nurse. The census was 151. Findings include: Review of the facility policy titled Storage of Medications dated August 2021 revealed policy interpretation and implementation number 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. Observation on 10/5/22 at 2:45 p.m., medication cart located next to conference room on Parkway B Hall was unlocked and unattended without a nurse or staff within eyesight. The Administrator walked down the hall and to the area and confirmed that the cart was unlocked. Observation on 10/6/22 at 10:28 a.m. medication cart located on Pinewood A Hall was unlocked and unattended. Certified Medication Aide (CMA) was at the nurse's station and stated she had just stepped away from the cart. She confirmed the cart should be locked and secured at all times when not in use. Interview on 10/5/22 at 3:00 p.m. with the Administrator verified the medicine cart on Parkway B Hall was left unlocked and unattended. She stated her expectations are for all medicine carts to be locked and secured at all times when left unattended and that it is in the facility's policy. Interview on 10/6/22 at 9:15 am. with the Director of Nursing (DON) stated her expectations are for all medicine carts to be locked and secured at all times when left unattended. Interview on 10/6/22 at 10:00 a.m. with Administrator revealed she in-serviced the nursing staff on 10/5/22 about keeping the medication cart secured when not in use. States she expects the cart to be locked when nursing staff are away from the carts.

Based on observations, staff interview, and review of the policies titled Food Receiving and Storage and Sanitation, the facility failed to ensure opened food items were properly dated and labeled in the dry food pantry. In addition, the facility failed to ensure the oven and the ventilation hood were cleaned, by due date of 9/22. The census on was 151 Residents. Findings Include: 1. Review of the undated policy titled Food Receiving and Storage revealed policy interpretation and implementation number 6. dry foods that are stored in bins will be removed from original packaging, labeled, and dated (use by) date. Such foods will be rotated using a first in - first out system. Number 7. All foods stored in the refrigerator or freezer will be covered, labeled, and dated (use by) date. Observation on 10/3/22 at 9:45 a.m. during initial kitchen tour with the Dietary Director, revealed one opened loaf of bread with no expiration date or use by date; Sunflower Kernels dated opened 2/25/21 with no expiration date or use by date; Dark Brown Sugar with no opened date, no expiration date and no use by date; opened Cellino Noodles with no opened date, no expiration date, and no use by date; Wheat noodles opened 7/5/20 with no expiration date or use by date; crispy fry mix opened 4/21/21 with no expiration date and no use by date. Interview on 10/3/22 at 9:45 a.m. with the Dietary Director, confirmed the items identified during the initial tour and discarded the undated items. During further interview, the Dietary Director stated opened items are kept for 30 days. 2. Review of the undated policy titled Sanitation revealed policy interpretation and implementation number 2. All utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be kept in good repair. Number 3. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Number 15. Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime. Observation and Interview on 10/4/22 at 12:15 p.m. with the Dietary Director, stated the exhaust hood is cleaned every six months. The Dietary Director verified the sticker on the equipment indicated that cleaning was completed in 6/22 and the next cleaning was due 9/22 but had not been completed. Further observation revealed the oven has white material on the inside door, and debris and old food noted on the door and inside the oven. The Dietary Director stated the white material is from when her apron got caught on the door.

Based on observations, record review, interviews, and policy review, the facility failed to follow the care plan related to weekly weights for two residents (R) (R#201 and R#21) and activities of daily living for one resident (R#79). The sample size was 51. Findings include: Review of the undated policy titled Care Plans, Comprehensive Person-Centered revealed policy statement is a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation number 8. The comprehensive, person-centered care plan will: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; m. aid in preventing or reducing decline in the resident's functional status and/or functional levels. 1. Review of the clinical record revealed R#201 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) of nine, indicating severe cognitive impairment. Review of the 10/5/22 Order Summary revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of care plan created on 6/22/22 and revised on 9/9/2022, revealed the resident has potential nutritional problem related to variable intake. Resident had weight loss on 8/19/22. Interventions to care include Registered Dietician (RD) to evaluate and make diet change recommendations as needed, and weigh at the same time of day and record per protocol. Review of the documented weights for R#201 revealed no admission weight recorded for 6/22/22. Weight recorded for 6/30/22 = 207.8 pounds (lbs); on 7/11/22 = 204.6 lbs; on 8/15/22 = 188.2 lbs. There was no admission weight documented for 6/22/22, week of 7/6/22, or week of 7/20/22, as ordered. Interview on 10/5/2022 at 1:00 p.m. with the Registered Dietician, revealed she was having an issue with the weights being obtained, as she recommends. She stated that it has improved since the new Director of Nursing (DON) started. 2. Review of the clinical record for R#21 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed that R#21 had a Brief Interview Mental Status (BIMS) score of 13, which indicates no cognitive impairment. Review of care plan revised 9/9/22 revealed resident has a potential for nutritional problem related to fluctuating intake and presence of vascular ulcers. Interventions to care include monitor/record/report to doctor as needed signs and symptoms of malnutrition including emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in one week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months, provide and serve supplements as ordered, RD to evaluate and make diet change recommendations as needed (PRN), and weekly weights time four weeks. Interview on 10/6/22 at 10:15 a.m. with the RD revealed she has trouble getting weights from the facility and stated that they are not always entered in the EMR. She stated she was told there is a written logbook for the weights, but she has not seen it. During further interview, she stated she would send multiple email reminders about the weights and inquire why aren't they following the recommendations for weekly weights. She stated the Director of Nursing, Unit Managers, Registered Dietician, Certified Dietary Manager, MDS Coordinator, and the Assistant Direct of Nursing are in the interdisciplinary meetings discussing resident weight loss and recommendations. She confirmed the last two weights in the electronic record are on 8/25/22 - 173.2lbs, and 9/8/22 - 168.2, and that there were no additional weights documented in the EMR. Interview on 10/6/22 at 11:50 a.m., the DON stated that the nurse who is responsible for the weight program had been placed on a Performance Management Plan for poor performance. She has been disciplined twice for not putting the weights in a timely manner and this week she has been a no call, no show all week. She verified there is an issue of the weights not being documented in the system and they are working on rectifying the problem. Observation and Interview on 10/5/22 at 12:18 p.m. revealed R#21 lying in bed, with call light in reach. He stated that he has lost weight since being in the facility, but that he is not aware of a plan to address his weight loss. He also stated that he is weighed once a month to check to see if he has lost weight. Interview on 10/6/22 at 1:22 p.m. the DON revealed weights were being recorded by one staff member, who is no longer at the facility. She stated that she will try to locate the weights for 9/21 - 9/30/22, but the documentation that she provided for 8/28 - 9/20 is all that she has access to. Cross refer F692 3. Review of the clinical record revealed that R#79 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Section G revealed resident was dependent for all personal hygiene. Review of care plan dated 8/6/22 revealed resident had self-care deficit-requires assistance with ADLs related to [CONDITION(S)]. Interventions to care include bath as scheduled, observe and report decline in ADL's, assist with daily ADLs as needed. Review of the task section of the electronic medical record (EMR) revealed that R#79 received ADL/personal hygiene care one to three times daily without documentation of refusal of care since his admission. Observation and interview on 10/3/22 at 9:26 a.m. and at 2:35 p.m. revealed R#79 with facial hair on his chin, upper lip, and cheeks. R#79 stated he has not had his face shaved in at least a week. During further interview, he stated his teeth had not been brushed in several days and that he has asked staff to shave his face and brush his teeth. Interview on 10/5/22 at 12:00 p.m. with the Director of Nursing (DON), stated it is her expectation that all residents receive care according to their care plans. Cross Refer F677

Based on record review, interviews and review of policy titled, Residents' Rights Regarding Treatment and Advanced Directives, the facility failed to ensure code status was consistently documented accurately throughout the clinical record for one of 35 sampled residents (R) (R#97) after a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the undated policy titled Residents' Rights Regarding Treatment and Advanced Directives revealed it is the policy of this facility to support and facilitate a resident's right to request, refuse and or discontinue medical or surgical treatment and to formulate an advance directive. The Policy Explanation and Compliance Guidelines: 9. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. Review of the clinical record for R#97 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as nine, which indicated moderate cognitive impairment. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#97 Advanced Directive dated 9/17/21 revealed under section 6 c. Allow my natural death. Review of the current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record banner revealed Full Code Status for R#97. Review of the care plan dated 5/20/22, revealed that R#97 has an established advanced directive: Full Code. Interview on 10/5/22 at 11:50 a.m. with Social Service Director FF stated that if the resident or family requests and signs a Do Not Resituate (DNR) form, the Social Services Department sends a POLST form to the physician for his signature. After the POLST form is signed, it is given to the Medical Records Department to scan into the residents' electronic medical records (EMR). During continued interview, she stated it is up to the nursing staff to update the code status on the resident MAR and the care plan is updated by the Social Services department or the Minimum Data Set (MDS) department or Social Services. Interview on 10/5/22 at 11:59 a.m. with Social Service Coordinator II stated when residents are admitted their code status is assessed. If they want a DNR, after signing the DNR and POLST, the form is sent to the physician for his signature and returned to Medical Records Department to have it scanned into the residents' medical records. During further interview, she revealed she was not sure who updates the EMR to reflect code status. Interview on 10/5/22 1:30 p.m. with Director of Nursing (DON) revealed when a resident is found with no signs of life, the code status is checked by reviewing the MAR. She stated the Certified Nursing Assistants (CNA)'s ask the Charge Nurse and they can assess the code status from their Point of Care system (POC). The DON revealed she was not sure whose responsibility it is to update the orders and change the code status in the system to reflect Full Code or DNR. Further revealed it is her expectation that a residents correct code status be on the EMR. Interview on 10/5/22 at 1:40 p.m. with Director of Medical Records revealed he scans the Advanced Directives or POLST into the Residents EMR. He stated he is unsure who updates the orders or changes code status in the EMR. During further interview, he stated he is unsure how the staff gets the information to change the code status. Interview on 10/5/22 at 3:15 p.m. with Regional Nurse Consultant (RNC) confirmed that R#97's EMR was listed as a full code but had an Advance directive and POLST indicating Do Not Resituate. She stated the residents code status should have been updated on 8/15/22 when his advanced directives were received. During further interview, she stated any nurse can change code status in the system when documentation is received regarding DNR.

Based on observations, record review and interviews, the facility failed to provide activities of daily living (ADL) care for one dependent resident (R) (R#79) related to oral care and shaving. The sample size was 35. Findings include: Review of the undated policy titled Activities of Daily Living revealed based on the comprehensive assessment of a patient and consistent with the patient's needs and choices, the Center must provide the necessary care and services to ensure that a patient's abilities in activities of daily living do not dimmish unless circumstances of the individuals clinical condition demonstrate that such diminution was unavoidable. Activities of daily living include: * Hygiene - bathing, dressing, grooming and oral care Practice Standards 1.2- a patient who is unable to carry out ADLs receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene. Review of the clinical record revealed that R#79 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15 indicating no cognitive impairment. Section G revealed resident was dependent for all personal hygiene. Review of care plan dated 8/6/22 revealed resident had self-care deficit-requires assistance with ADLs related to [CONDITION(S)]. Interventions to care include bath as scheduled, observe and report decline in ADL's, assist with daily ADLs as needed. Review of the task section of the electronic medical record (EMR) revealed that R#79 received ADL/personal hygiene care one to three times daily without documentation of refusal of care since his admission. Observation and interview on 10/3/22 at 9:26 a.m. and at 2:35 p.m. revealed R#79 with facial hair on his chin, upper lip, and cheeks. R#79 stated he has not had his face shaved in at least a week. During further interview, he stated his teeth had not been brushed in several days and that he has asked staff to shave his face and brush his teeth. Observation and interview on 10/4/22 at 1:50 p.m. revealed resident continue to have facial hair on his chin, upper lip, and cheeks. He revealed he has not had his teeth brushed in several days. Interview on 10/4/22 at 2:15 p.m. with Licensed Practical Nurse (LPN) BB, stated that ADL care consists of shaving facial hair and brushing teeth. She further stated oral care should be provided daily and resident should be shaved on their bath days and any other days the resident requests. During further interview, she stated Certified Nursing Assistants (CNA) are required to report all refusal of care to the charge nurse and are required to document ADL care and refusal of care in the electronic medical record (EMR). Interview on 10/4/22 at 3:25 p.m. with CNA CC, stated oral care is part of the daily ADL care and that male residents are to have their face shaved on their scheduled bath days and at their request. She stated she documents ADL care in the EMR and reports refusal of care to the charge nurse. Interview on 10/5/22 at 8:30 a.m. with CNA DD, stated that brushing the resident's teeth should be done daily and that residents are to be shaved on their scheduled bath days and at their request. She stated she reports all refusal of care to the charge nurse and documents ADL care in the EMR. Observation on 10/5/22 at 8:30 a.m. with CNA DD, verified R#79 had facial hair and was unshaven. Interview on 10/5/22 at 8:40 a.m. with LPN EE, stated CNAs are to provide ADL care to assigned residents and are required to report refusal of care to the charge nurse. During further interview, she stated CNAs are required to document ADL care and refusal of care in the EMR task section. She stated it is her expectation if ADL care was documented as being provided, care was provided. LPN EE verified R#79 face had facial hair. Interview on 10/5/22 at 12:00 p.m. with the Director of Nursing (DON), stated it is her expectation that all residents receive oral care at least one time a day and residents to be shaved on their assigned bath days and at their request. She stated ADL care should be documented in the EMR task section and all refusal of care should be documented in the EMR task section and reported to the charge nurse. She stated it is her expectation if ADL care is documented as being provided, it was provided.

Based on record review, interviews, and policy review, the facility failed to weigh two residents (R) (R#201 and R#21) weekly as ordered, after significant weight loss. The sample size is 51. Findings: Review of the undated policy titled Weight Policy, revealed the purpose of the policy is to obtain baseline weight and to identify significant weight changes. Patients are weighed upon admission and/or readmission, then weekly for four weeks then monthly, thereafter. Additional weights may be obtained at the discretion of the interdisciplinary care team. 1. Review of the clinical record revealed R#201 was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE], revealed resident had a Brief Interview for Mental Status (BIMS) of nine, indicating severe cognitive impairment. Section G revealed resident required two person-assist with bed mobility, transfer, dressing and personal hygiene. Review of the 10/5/22 Order Summary revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the electronic Medical Record (EMR) weekly weights included the following: 6/30/2022 weight 207.8 pounds (lbs.); 7/11/2022 weight 204.6 lbs. and on 8/15/2022 weight 188.2 lbs., which reflects a weight loss of 9.43% in two months. There is no recorded admission weight on 6/22/22, no recorded weight for the week of 7/6/22 and no recorded weight for the week of 7/20/22. Review of care plan created on 6/22/22 and revised on 9/9/2022, revealed the resident has potential nutritional problem related to variable intake. Interventions to care include Registered Dietician (RD) to evaluate and make diet change recommendations as needed, and weigh at the same time of day and record per protocol. Review of the dietary note dated 8/19/22, revealed R#201 triggered significant weight loss (SWL) of 5% in a month. Resident eats independently and/or receives assistance/totally dependent on occasions. Intake fluctuates between 0 to 100%. Interventions - will add order for 1.7 supplement 90 milliliters (ml) two times per day (BID), decubi-vite daily. Weekly weights x four weeks. Registered Dietician (RD) following and will adjust plan of care as needed. Interview on 10/5/22 at 1:00 p.m. with the RD, revealed that when R#201 significant weight loss was identified, she made recommendations for resident to start decubi-vite and Med Pass 1.7 supplement. She was questioned about why weekly weights were not obtained as ordered, and she stated that she was having an issue with the staff obtaining the weights. 2. Review of the clinical record for R#21 revealed resident was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Minimum Data Set (MDS) dated [DATE] revealed that R#21 had a Brief Interview Mental Status (BIMS) score of 13, which indicates no cognitive impairment. Review of the care plan revised 9/9/22 revealed that the resident triggered for weight loss on 1/19/21, 3/18/21 and 9/9/22. The resident has potential for Nutritional problem related to fluctuating oral intake, nutritionally compromised related to presence vascular ulcers. Interventions to care include: 3/23/21-ice cream with dinner; 6/2/22 Lipid panel in six weeks; explain and reinforce to the resident the importance of maintaining the diet ordered, encourage the resident to comply, explain consequences of refusal, malnutrition risk factors. Monitor/record/report to physician as needed (PRN) signs/symptoms of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months. Provide and serve supplements as ordered, RD to evaluate and make diet change recommendations PRN, sugar free mighty shake as ordered and weekly weights time four weeks. Review of the handwritten weekly weight log revealed weight recorded on 9/1 = 168.2 pounds (lbs.); on 9/5 = 169.4 lbs.; on 9/15 = 171.6 lbs. There were no weekly weights documented for the weeks of 9/16/22 - 9/20/22 and 9/23/22 -9/29/22 as recommended by the Registered Dietitian. Review of dietary note dated 8/27/22 by the Registered Dietitian (RD), revealed that the resident triggered significant weight loss (SWL) 7.5% in two months. Current weight is 173.2 pounds. BMI 26.3 acceptable. Noted on diuretic tx ([MEDICATION(S)] and [MEDICATION(S)]) which may also be contributing factors to lose. 1.7 supplement 90 milliliters (ml) twice daily (BID) x 60 days added as an intervention. Resident is tolerating regular diet with average intakes 50-100%. Mainly eats independently. Treatment in place for venous ulcer right lower leg improved. Other meds: vitamin C, multivitamin, vitamin D3(1000), potassium Chloride (KCL). 7/14 HDL 26. Monitor weights for four weeks. RD following and will adjust plan of care as needed. Observation and Interview on 10/5/22 at 12:18 p.m. revealed R#21 lying in bed, with call light in reach. He stated that he has lost weight since being in the facility, but that he is not aware of a plan to address his weight loss. He also stated that he is weighed once a month to check to see if he has lost weight. Interview on 10/6/22 at 10:15 a.m. with the RD revealed she has trouble getting weights from the facility and stated that they are not always entered in the EMR. She stated she was told there is a written logbook for the weights, but she has not seen it. During further interview, she stated she would send multiple email reminders about the weights and inquire why aren't they following the recommendations for weekly weights. She stated the Director of Nursing, Unit Managers, Registered Dietician, Certified Dietary Manager, MDS Coordinator, and the Assistant Direct of Nursing are in the interdisciplinary meetings discussing resident weight loss and recommendations. She confirmed the last two weights in the electronic record are on 8/25/22 - 173.2lbs, and 9/8/22 - 168.2, and that there were no additional weights documented in the EMR. Interview on 10/6/22 at 11:50 a.m., the DON stated that the nurse who is responsible for the weight program had been placed on a Performance Management Plan for poor performance. She has been disciplined twice for not putting the weights in a timely manner and this week she has been a no call, no show all week. She verified there is an issue of the weights not being documented in the system and they are working on rectifying the problem. Interview on 10/6/22 at 1:22 p.m. the DON revealed weights were being recorded by one staff member, who is no longer at the facility. She stated that she will try to locate the weights for 9/21 - 9/30/22, but the documentation that she provided for 8/28 - 9/20 is all that she has access to. Interview on 10/6/22 at 3:25 p.m. with Certified Nursing Assistant (CNA) MM revealed that restorative obtains the weights for the residents and is supposed to enter them in the EMR system. She stated that only when restorative is not available and there is a new admit that the CNA may fill in and take the weight, but that it is not routine practice.

Based on observations, record review, staff interviews, and review of the policy titled Oxygen Administration, the facility failed to follow the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of undated policy titled Oxygen Administration, revealed the purpose is to provide guidelines for safe oxygen administration. Review of the clinical record revealed R#51 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The residents most recent annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating intact cognition. Section G revealed resident requires extensive assist with all ADL's. Section O revealed resident was receiving oxygen. Review of the 10/5/22 Order Summary revealed an order to change humidifier bottle when empty or as needed, ordered 4/14/22 and oxygen at four liters per minute continuous via nasal cannula (N/C). Check flow rate and record every shift, ordered 5/19/22. Review of care plan created on 12/5/18 and revised on 8/1/2022, revealed that resident has diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions to care include oxygen at four liters per minute (LPM) continuous and administer medications, treatments and oxygen as ordered. Observation on 10/3/22 at 10:50 a.m. R#51 was receiving oxygen at four LPM via N/C. She complained that her nostrils are dry. There is no humidification bottle on oxygen concentrator. Observation on 10/4/22 at 2:53 p.m. R#51 sitting up in wheelchair watching TV. Oxygen in use via N/C at 4 LPM tubing dated. No humidification bottle on oxygen concentrator. Observation on 10/5/22 at 10:05 a.m. R#51 lying in bed watching TV. Oxygen in use via N/C at 4 LPM new tubing in place dated 10/7/22. No humidification bottle on oxygen concentrator. Interview on 10/5/22 at 10:10 a.m. with Medication Tech (MT) KK revealed she could not see the order for humidity bottle on med cart computer. Interview on 10/5/22 at 10:14 a.m. with Licensed Practical Nurse (LPN) OO revealed she did not know about the humidification for the oxygen and had to look up the order. She obtained humidification bottle and placed on concentrator immediately.

Based on observations, record review, staff interviews, and review of policy titled [CONDITION(S)]: Hemodialysis (HD)-Communication and Documentation, the facility failed to maintain consistent communication forms with the [CONDITION(S)] center to coordinate care for one resident (R) (#41) of eight residents receiving [CONDITION(S)]. Findings include: Review of the undated policy titled [CONDITION(S)]: Hemodialysis (HD)-Communication and Documentation revealed the policy is the center staff will communicate with the certified [CONDITION(S)] facility prior to sending a patient for hemodialysis (HD) by completing the Hemodialysis Communication Record or other state required form and sending it with the patient. The form will also be completed upon return of the patient from the certified [CONDITION(S)] facility. Practice Standards number 1. Prior to a patient leaving the center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record or the state required form and send with the patient to his/her HD facility visit. Number 2. Following completion of the HD, the [CONDITION(S)] facility nurse should complete the form and return it or other communication to the center with the patient. Number 3. Upon return of the patient to the center, a licensed nurse will: 3.1 Review the hemodialysis center communication; 3.2 Evaluate/observe the patient; 3.3 Complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form. Number 4. Notify the certified [CONDITION(S)] facility if the form is not returned with the patient and ask that it be faxed to the center. 4.1 Document notification of certified [CONDITION(S)] facility regarding return of form or other communication. Number 5. Maintain the Hemodialysis Communication Record or state required form in the patient's medical record. Review of the clinical record revealed R#41 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating cognitively intact. Section O-Special Treatment and Programs indicated R#41 was receiving [CONDITION(S)]. Review of R#41's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of [CONDITION(S)] Communication Forms revealed inconsistent communication between facility and [CONDITION(S)] center. For the months of July, August, and September 2022 there were 14 missing [CONDITION(S)] Communication Forms and 18 [CONDITION(S)] Communication Forms that were not completed by either the facility or the [CONDITION(S)] center. Interview on 10/5/22 at 12:19 p.m. Unit Manager (UM) LL, revealed the nurse on duty is responsible for making sure residents' weight and vital signs are obtained prior to departure for [CONDITION(S)]. During further interview UM LL revealed the nurse is responsible to ensure the form is filled out by [CONDITION(S)] clinic. She stated that if it is not, the nurse is supposed to call the [CONDITION(S)] center and obtain the information. Interview on 10/5/22 at 12:26 p.m. with the Administrator, revealed her expectation is for the nurses to ensure open communication with [CONDITION(S)] clinic. She stated the [CONDITION(S)] Communication Form should be filled out completely by both the facility staff and the [CONDITION(S)] clinic staff. The Administrator confirmed the forms are not being consistently filled out.

Based on family interview, staff interviews, record reviews, and review of policies titled Practice Guideline Investigating Injury of Unknown Origin' (undated), Empire Abuse Prohibition (revised 8/19), Accidents Incidents-Investigating and Reporting (undated), and Notification of Changes (undated), the facility failed to thoroughly investigate three (3) residents of three (3) residents (RA), (R#2) and (R#3),with injuries of unknown origin. Findings include: Review of facility policies Practice Guideline Investigating Injury of Unknown Origin, Empire Abuse Prohibition, and Notification of Changes revealed: Investigation steps include specifying the type of allegation reported and interviewing all staff with contact with the resident within the last 72 hours. This includes housekeeping, activities, and maintenance, not just nursing staff. Interview and obtain signed statements from staff. The report must include sufficient investigation detail to document that the facility conducted a thorough investigation. The report consists of copies of any additional documents that the center believes necessary to demonstrate that a thorough investigation was conducted. Staff will identify events such as suspicious bruising of patients, occurrences, patterns, and trends that may constitute abuse-and determine the direction of the investigation. 1. Record review revealed that R A admitted to the facility on [DATE], from an acute care hospital, with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS), dated [DATE], revealed the resident's functional needs were assessed for extensive assist, by one person, for bed mobility and dressing, and extensive assist, by two persons, for transfers. The resident had a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment, without behaviors during the look back period. A discharge assessment dated [DATE] revealed the resident was discharged to another Skill Nursing Facility (SNF) . An interview with a family member of R A on 1/11/2022 at 11:06 a.m. revealed that the resident was admitted to the facility on [DATE] for rehabilitation. When he visited on 11/7/2021, he observed a bruise on the resident's face below the left eye. He asked the staff who brought the resident to him, what happened to cause the bruise and she did not know and referred him to the receptionist. He was told by the nurse to contact the Administrator the following day. No one could give him any explanation of what occurred or that they even saw the blackeye before his inquiry. When he reached the Administrator the next day, he was informed that she was unaware of the bruise on the resident's face and would begin an investigation that would take up to 10 days. The family member revealed that 10 days later, on 11/19/2021, he contacted the Administrator and was informed that the resident had behaviors in which she was combative toward the staff when they attempted to provide care and indicated this was the reason for his mother's black eye. She could not tell him when the injury occurred, why no one noticed the black eye, or why he was not notified. He believes that the facility did not investigate the cause of the resident's and that he was given an excuse. An interview conducted with the Administrator on 1/11/2022 at 12:15 p.m. revealed that she received the call from the family of R A on 11/8/2021 informing her that the resident had a black eye, No one contacted him of the injury or how the injury occurred. She revealed that during her investigation, it was determined that the Certified Nursing Assistant (CNA) BB who brought the resident to the visiting area was not the resident's routine caregiver. She thought the bruise on the resident's face had been reported by another staff. When the family asked questions regarding the bruise, she referred him to the receptionist at the front desk. During a followed-up interview with the Administrator conducted on 1/12/2022 at 9:00 a.m. revealed that she performed the investigation of the injury however was unable to provide the names of the CNAs assigned to the resident on 11/7/2021 or the staff member who took the resident to the day area for her visit with her family therefore they were not interviewed. She also revealed that the unit nurse on duty was an agency nurse and was also not interviewed regarding the resident's injury due to her inability to reach via telephone. No further interviews were conducted according to the investigation guideline. An interview with the Director of Nursing (DON) on 1/11/2022 at 12:15 p.m. revealed that the agency nurse was on duty on 11/8/2021 and documented a late entry into R As medical record regarding the resident injury. An additional interview on 1/12/2022 at 1:50 p.m. with the DON revealed that when she assessed R A on 11/8/2021 and that she noticed a healing bruise beneath the resident's left eye. The bruise appeared to be approximately 2-3 days old. An interview with Activity Assistant BB on 1/12/2022 at 10:18 a.m. revealed that on 11/7/2021, she took the resident to the day area to visit with her family. Activity Assistant BB noticed the bruise on the resident face but revealed she did not know how the bruise occurred. She revealed that the incident was reported to the charge nurse. Because she does not work with the resident regularly, she assumed that the bruise was already reported. The two CNAs that she assisted did not respond when they saw the bruise. She also stated that she was not interviewed regarding the incident. An interview with CNA CC on 1/12/2022 at 2:06 p.m. revealed that she was assigned to R A on 11/7/2021 and that she first noticed the bruise on the resident's face when they brought her back to the room after visiting with her family. She further stated that she was not interviewed during the investigation by the Administrator. A review of the resident's medical records revealed the Physician was not notified immediately according to the facility compliance guidelines following the injury. 2. Record review revealed that R#2 was admitted to the facility on [DATE], from another SNF with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of of the Admission MDS, dated [DATE], revealed the resident could not be assessed for BIMS due to severe cognitive impairment, the resident was assessed for wandering behavior for one to three days during the look back period, the resident was assessed for extenstive assist, by one person, for bed mobility, and supervision for transfer, walking, personal hygiene, dressing and eating by one person and limited assistance for toilet use. Review of the MDS revealed a discharge assessment dated [DATE], with re-entry on 7/7/21. Review of a Significant Change MDS assessment, dated 7/19/21 revealed a decline in function for all ADL needs. Review of the Quarterly MDS, dated [DATE], revealed an improvement in function for all ADL needs. A review of the facility's investigation report to the State Survey Agency (SSA) dated 7/12/21 revealed the resident complained of left hip pain on 7/5/21 while walking in the hallway. The resident stated I can't walk my leg hurt while holding her left hip. The resident was returned to bed with a head to toe assessment completed. The Physician was notified and gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Responsible Party (RP) was also notified. The x-ray results, on 7/5/21, revealed an Acute left subcapital (hip) fracture with Osteopenia. The resident was transferred to the hospital per the Physician Orders. The resident returned to the facility on [DATE]. Further review revealed that the investigation of the injury did not include staff interviews or a possible reason for the fracture. The injury was undetermined, and a plan was developed without proper investigation. An interview with the Administrator on 1/25/2022 at 10:15 a.m. revealed that she did not investigate the cause for the resident's hip fracture incident. The former DON and Social Worker were responsible for the investigation and are no longer working at the facility. The Administrator further stated that she submitted the report to the SSA within the time allotted. 3. Record review revealed that R#3 was admitted to the facility on [DATE] with the following accumulative diagnoses, including hypertensive heart and kidney disease, vascular Dementia, alcoholic [CONDITION(S)] without ascites, [CONDITION(S)], [CONDITION(S)], muscle weakness, unspecified [CONDITION(S)] not due to substance or known physiological condition, major depressive due to, anxiety and wandering disease. Review of the Admission MDS, dated [DATE], revealed a BIMS assessment of seven, indicating moderate to severe cognitive impairment, the resident was assessed for wandering behaviors, limited assistance needed by one person for bed mobility, transfer, walking, except for off the unit with extensive assistance needed for dressing by one person. The resident was not assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the final incident report to the SSA, dated 9/14/21, revealed that on 9/7/21, the resident was noted to have a swollen/reddened left eye. The resident was interview and revealed she had been hit although her roommate stated the resident fell . There were no witnesses to the incident. No evidence was produced by the facility to include interviews of staff who cared for the resident around this time. An interview with the Administrator on 1/25/2022 at 10:15 a.m. revealed that the former DON was responsible for the investigation and the Administrator was responsible for ensuring the report was sent to the SSA timely.

Based on observation, record review, interviews and review of the facility policies titled, Coronavirus Surveillance, Coronavirus Testing, and COVID-19 Reporting, the facility failed to cohort negative, but exposed residents, after an outbreak of COVID-19 began with negative, never exposed residents on two units (Pinewood A and the Memory Unit), failed to have a dedicated COVID-19 positive unit with dedicated staff, failed to properly utilized Personal Protective Equipment (PPE) between COVID-19 positive residents and negative resident all housed on the same unit, failed to contact the local Department of Public Health (DPH) after the outbreak occurred, and failed to prevent further spread to [MEDICAL CONDITION] to residents and staff. As a result, seven additional residents tested positive (R#4, R#10, R#11, R#16, R#25, R#26 and R#27) were hospitalized with COVID-19 and R#7 and R#25 expired after testing positive for COVID-19. On [DATE] a determination was made that the facility's noncompliance had resulted in Immediate Jeopardy. The facility's Administrator, Assistant Administrator, Director of Nursing (DON) and the facility owner were notified on [DATE] at 10:00 a.m. that the failure due to improper cohorting of negative, but exposed residents, with negative residents, maintaining both positive and negative residents on the same unit while utilizing the same staff to care for both positive and negative residents, improper use of Personal Protective Equipment (PPE), after a new outbreak of COVID-19, failed to notify the local Department of Health for guidance, failed to ensure that test results were received within 48 hours, for residents on two of eight units. The Immediate Jeopardy is outlined as follows: 1. The facility failed to ensure an effective Infection Prevention Control Program was implemented and maintained that would investigate and identify an infection outbreak to prevent or reduce the spread of COVID-19 to residents and staff. 2. The facility failed to ensure that staff were trained to properly utilized PPE for positive and negative residents to prevent or reduce the spread of COVID-19 to both residents and staff. As a result of these failures, between [DATE] and [DATE], 23 additional residents on Pinewood A tested positive for COVID-19 and 12 staff members tested positive. Seven residents were hospitalized during this timeframe (R#4, R#10, R#11, R#16, R#25, R#26 and R#27) and two residents expired (R#25 and R#7). The Immediate Jeopardy was identified on [DATE] and was determined to exist on [DATE] in the area of 42 CFR §483.80, Infection Control, F880 which was cited at a Scope and Severity (S/S) of K. An Acceptable Immediate Jeopardy Removal Plan was approved on [DATE] with an alleged removal date of [DATE]. The State Survey Agency (SSA) attempted to validate the Immediate Jeopardy removal plan although it was found the facility had not completed implementation of the removal plan. The Administrator, Assistant Administrator, DON and the owner were notified on [DATE] at 2:11 p.m. that the IJ could not be removed and remained ongoing. Findings include: Review of the facility policy titled Coronavirus Surveillance, revised [DATE], revealed: 9. Surveillance data will be used for reporting to local health departments (DPH), CDC (Centers for Disease Control and Prevention), staff, resident, and resident representatives. a. The local health department will be notified of resident or staff with suspected or confirmed COVID-19, resident with severe respiratory infection resulting in hospitalization or death, or greater than 3 residents or staff with new-onset respiratory symptoms with 72 hours of each other. 11. All new admissions and hospital returns will be placed on transmission-based precautions as per DPH, CDC guidance. Review of the facility policy titled COVID-19 Reporting, revised [DATE], revealed: Policy: It is the policy of this facility to share appropriate information regarding COVID-19 with staff, residents and their representatives and to report COVID-19 information to the local/state health department and the CDC. Policy Explanation and Compliance Guidance: 4. The local/state health department is notified of reportable events in accordance with local/state procedures. Review of the facility policy titled Coronavirus Testing, revised [DATE]. Testing of Staff and Residents in Response to an Outbreak 1. All staff and residents will be tested upon identification of a single new case of COVID-19 infection in any staff or residents. 3. Staff who test positive for COVID-19 will not repeat testing but will follow the symptom-based strategy guidelines for returning to work as outlined above. Routine Testing of Staff 3. Should the 48 hour turn-around time not be met due to community testing supply shortages, limited access or inability of laboratories to process test within 48 hours, the facility will document its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and it contact with the local and state health departments. During the initial tour on [DATE] at 11:30 a.m. revealed a plastic cover, from ceiling to floor, at the entrance to Pinewood A. Further observation revealed that the sides, of the plastic cover were not sealed. On the same day, at 12:00 p.m., the Memory Secured unit, revealed there was no PPE supplies outside the rooms on this unit. Observation on [DATE] at 12:35 p.m., during meal service on Pinewood A, revealed Certified Nursing Assistant (CNA) AA exiting a room, occupied by R#12 and R#13, (COVID-19 negative) with a lunch tray without wearing gloves then used hand sanitizer. CNA AA then donned two gowns and gloves to take a tray into another of COVID-19 room occupied by R#21, then exited room with only one gown on. Observation on [DATE] at 12:50 p.m. during meal service on Pinewood A, revealed CNA BB exiting a COVID-19 positive room, occupied by R#15 and R#16 who tested positive on [DATE], with the resident's lunch tray for disposal without wearing gloves and passing the tray to another CNA who also was not wearing gloves. Both CNAs used hand sanitizer after the transfer and disposable of the lunch tray. Review of the facility's line listing revealed that R#12 tested positive on [DATE] and R#13 tested positive on [DATE] and that R#21 tested positive on [DATE]. Observation on [DATE] at 3:05 p.m. revealed a laundry aide on Pinewood A with a gown and mask on although the laundry aide exited Pinewood A unit and continued to wear her gown off the COVID-19 unit. An observation and interview with CNA CC on [DATE] at 3:08 p.m. revealed the CNA donned a gown but did not sanitize his hands first. CNA CC confirmed that he should have sanitized his hands first. An observation and interview with CNA DD on [DATE] at 2:40 p.m. revealed the CNA exiting a room on Pinewood A with her mask below her nose then put on gloves without sanitizing her hands. An interview with CNA DD revealed that she uses two gowns prior to entering a resident's room, then removes one and places it on the hook on the door. CNA DD revealed that she will use that gown again when providing care for the resident. Observation on [DATE] at 2:45 p.m. of the ice cart/cooler on Pinewood A revealed the ice scoop was lying on the cart and was not covered. Observation on [DATE] at 2:46 p.m. of the plastic cover at the entrance to Pinewood A (ceiling to floor) revealed the sides of the plastic cover were not sealed. Observation on [DATE] at 11:15 a.m. on the Pinewood A unit, revealed that three COVID-19 positive rooms had three gowns hanging on the back of the door. Observation and interview with LPN EE on [DATE] at 11:15 a.m. on Pinewood A (COVID-19 Unit) revealed that Pinewood A had both positive and negative residents on the same hallway. LPN EE was observed exiting a COVID-19 resident's room, was not wearing a hair cover or shoe covers and walked directly to the medication cart. LPN EE confirmed that she should change PPE between positive residents' rooms. She then walked outside the plastic covering to change her PPE. Observation on [DATE] at 11:40 a.m. revealed LPN EE was working at the common nurses' station which was outside of Pinewood A. Observation on [DATE] at 11:30 a.m. revealed a doffing room just outside the designated unit. In the doffing room an uncovered barrel containing discarded PPE. Observation revealed that clean PPE was located outside the plastic barriers although no hand sanitizer or hand washing area was available in this area. Observation on [DATE] at 2:00 p.m. on the Pinewood A unit revealed that one COVID-19 positive room had one gown hung behind the door. Observation on [DATE] at 10:45 a.m. revealed that the barrier (plastic covering) on Pinewood A, had not been put into place to separate the positive and negative residents as recommended by DPH. An interview with the Administrator on [DATE] at 8:45 a.m. revealed that the facility had a COVID-19 outbreak in late [DATE] through [DATE], and they were able to contain it. She revealed that during the week of [DATE] they had three positive residents and this week they have five positive residents. She revealed that the facility has had four residents expire from COVID-19. The Administrator revealed that they have also had two staff members test positive, a CNA on [DATE] who worked on Pinewood A and one laundry aide on [DATE]. She revealed that the local DPH had not been contacted regarding the new outbreak other than sending the line listing daily. She revealed that if DPH needs to speak to the facility then they will call the facility. Record review of the facility Line Listing which is sent to the local DPH district daily (cumulative report), dated [DATE] revealed the first resident test positive on [DATE] with addition positive resident through [DATE]. On [DATE] a CNA tested positive for COVID-19, then the first new outbreak resident tested positive on [DATE], a second staff tested positive on [DATE], on [DATE], four additional residents, on the same unit, tested positive, with two residents (on the Memory Unit) tested on [DATE] although their test results were not received until [DATE]. Record review of the facility COVID-19 tracking map revealed that Pinewood A had 14 semi-private rooms with a total of 28 beds. As of [DATE], the facility had 14 COVID-19 positive residents located on Pinewood A and six residents also located on Pinewood A, in three semi-private rooms, who were negative for COVID-19. Review of a COVID-19 LTCF Response Checklist (DPH) dated [DATE] (first outbreak) revealed the following recommendation during this visit: Continued education during the pandemic, Recommend increasing the number of ABHR (hand sanitizer) dispensers (inside and outside of resident rooms) for convenience, recommended continued education regarding PPE donning and doffing and monitoring of staff for proper procedures, designated COVID positive and Observation units have been established. Supplies are available in a separate Anteroom for donning PPE. Full PPE is being worn on both isolation units. Best Practice: Only confirmed positive COVID residents should be housed on the COVID unit. Ideally, this area is separate for the COVID unit. Review of an email dated [DATE] at 8:47 a.m. from the local Department of Public Health (DPH) Epidemiology (Epi) nurse to the Administrator revealed that an Infection Control Assessment and Response Program (ICAR) assessment with DPH took place on [DATE] with the following concerns and recommendations to the facility: 1. Critical to separate the COVID positive residents from other residents and to have dedicated staff to care for the COVID positive residents. A COVID PUI unit should also have dedicated staff and be separated from other residents. If positive and negative resident must be housed on the same hall then a barrier should be placed between the positive and negative residents' rooms. Continuing to house COVID positive with COVID negative residents increases the risk of transmission to both residents and staff. 2. Establish a separate Nurses' Station and break area for COVID Unit staff. 3. The same PPE should never be used between positive and negative residents. 4. Critical that PPE be donned/doffed with each resident to limit potential spread. PPE supplies should be available at each room, PPE can only be used in multiple patient rooms in dedicated COVID positive areas. Hand hygiene and glove changes are still required with each resident. 5. PPE should be donned/doffed with each resident on the Memory Care Unit and enhanced cleaning and disinfection on this unit. Staff should be dedicated to care for COVID positive residents. A telephone conference call with the Administrator, Assistant Administrator, DON and Assistant DON, surveyor, Regional Director and the local DPH Epidemiology Nurse on [DATE] at 12:00 p.m. to clarify questions related to PPE use, cohorting of residents, need to directly notify the local DPH of an outbreak rather than depending on faxing line listing daily, establishing a COVID and PUI unit, education of staff, requirements for timeframes of laboratory results and how to ask for staffing if needed from WebEOC (State of Georgia (SOG)). The Administrator revealed that some staff do double gown, if they feel more comfortable, then leave the extra gown inside the door of the room for reuse. The DPH nurse reminded the Administrator that this was discussed during the last outbreak as not needed and may increase the opportunity for spread to residents and staff. The Administrator then revealed that in her opinion that DPH was notified by sending in the daily line listing and if DPH had a problem with the numbers then DPH should contact the facility. The Administrator revealed that since they had already gone through one outbreak that the facility knew how to handle an outbreak. The DPH nurse confirmed that if an outbreak occurs the facility should call the local DPH office as it may takes several days or more to review all the line list that are received daily by their office. The Administrator revealed that the facility has not been able to utilize the Point of Care testing due to only receiving 40 kits from the SOG about every two weeks and that the laboratory is taking sometimes five days to send reports of COVID-19 Polymerase chain reaction (PCR) test. The Administrator revealed she had tried to order some POC kits, but they were backorder in early [DATE] although she confirmed not contacting the laboratory about getting the test results earlier. The Administrator further stated that they felt by moving the resident's around they would spread [MEDICAL CONDITION] further even though the facility had 40 vacant beds through out the building. The Administrator and the DON confirmed that exposed negative residents were being housed with never exposed negative residents and that staff were caring for both positive and negative residents on the same hallway. The Administrator confirmed that a ICAR with DPH is scheduled for [DATE]. A telephone interview with the Medical Director on [DATE] at 1:15 p.m. revealed that he was aware of the outbreak and felt the facility was doing everything they could to protect the residents. He felt it best not to start moving residents all over the building and to do so would spread the infection. He was not aware that DPH should be notified if the facility has a new case and was not aware of some of the care concerns of the survey agency. An interview with the Administrator on [DATE] at 9:30 a.m. revealed they were no longer accepting new admissions. The Administrator revealed that the DON was out on medical leave (non-COVID related) but the on Monday, [DATE] the Assistant DON and the Treatment Nurse were out due to positive COVID test. The Administrator further revealed that since [DATE] that three new residents tested positive and one positive resident was sent to the hospital and expired on [DATE]. A telephone interview with family of R M, on [DATE] at 10:15 a.m. revealed that her mother was sent to hospital and tested positive for COVID-19 in mid-October. The family member became aware after the resident was sent to the hospital and was concerned to find the facility was knowingly keeping both positive and negative resident on the same unit. The family member was not aware that the resident's roommate had tested positive for COVID-19, exposing R M. The facility had contacted the family member regarding the need for supplemental oxygen for R M and the family insisted the resident be sent to the hospital. An interview with the Administrator on [DATE] at 2:30 p.m. revealed that the outbreak on Pinewood A is ongoing. A telephone interview with the local DPH Epi Nurse on [DATE] at 3:15 p.m. revealed that DPH had conducted an onsite visit to the facility and found a concern that staff conducting the POC test (recently acquired by the facility) were not following the manufactures instructions for the POC test for reagent drops used and the timeframe for reading the test results. As a result, DPH recommended to discard all improperly conducted test and start again testing correctly. An interview with the Administrator on [DATE] at 12:50 p.m. revealed that staff from a sister facility were coming to the facility to assist in getting baseline testing for all negative residents in the building. An interview with the sister facility Administrator on [DATE] at 10:24 a.m. revealed that due to the hiccup with the testing yesterday that they are retesting the negative resident via PCR testing today. An interview with Registered Nurse (RN) FF on [DATE] at 12:50 p.m. revealed that the rapid test kits were used yesterday but there were none remaining therefore the test today will be PCR test. She revealed that the facility was not using a timer, yesterday, to ensure the test were read between ,[DATE] minutes. The facility had also received new POC testing that had different instructions for use, but the staff was not aware, therefore some staff were processing them correctly and some were not. She revealed that those tests were discarded, and the residents are being retested today. RN FF revealed that the Assistant Director of Nursing (ADON) had completed the training on POC testing with the staff but she is out due to testing positive for COVID-19. An interview with the Administrator on [DATE] at 11:42 p.m. revealed that the facility discovered during the DPH onsite visit of [DATE] that staff were not conducted the POC testing correctly. An interview on [DATE] at 9:29 a.m. with the Administrator revealed that over the weekend, the facility had six new COVID-19 positive residents. An interview on [DATE] at 11:06 a.m. with the Administrator revealed that three residents tested positive along with six staff members. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On [DATE], at approximately 1:00 p.m., the facility infection preventionist and Staff Development Coordinator (SDC) began performing rapid COVID-19 [MEDICATION NAME] tests on all residents. During the testing, it was determined that the tests were not performed correctly. At that time, immediate in-service and competency evaluations were performed (Exhibit 1) with the infection preventionist and SDC. The tests were immediately repeated, and staff were re-educated they must perform the tests according to the manufacturer's recommendations for the various tests. Our facility is currently testing residents weekly based on our county's positivity rate. Asst. Administrator will review 2 tests per hall, observing different nurses on different units for a total of 16 observations until substantial compliance is achieved. This will be monitored using the Covid·l9 Rapid Test Monitoring Tool. (attached) All rapid tests results are uploaded via spreadsheet to DPH by the Administrator. 2. Once all results were received, the QAPI committee under the direction of the Medical Director and DPH met to discuss current policies and procedures related to COVID-19 infection control practices and leadership developed a plan to immediately implement distinct units for COVID-19 positive residents, Patients Under Investigation (PUI), Observation and Negative COVID-19 UNITS. See Facility Floor Plan Layout. (attached) a. Parkway A, Parkway B, and Terrace were designated as Negative Units. b. Pinewood A was designated as the COVID-19 Positive Unit c. Pinewood B, Pinewood C, and Patio were designated as PUI Units. d. Terrace C was designated as the Observation Unit. 3. Residents are monitored every shift and as needed for signs and symptoms of COVID·19. Any residents noted to have symptoms will be immediately reported to the MD for orders and treatment. Unit managers and shift supervisors will monitor the brand of Electronic Medical Record (EMR) dashboard every shift to ensure proper follow up for any abnormalities. 4. Per guidance of DPH staff, Patio (Memory Care) was made a PUI Unit due having three positive residents that were wandering and difficult to re-direct. Velcro STOP signs were placed on each door. 5. Immediate staff education began on [DATE] by the SDC, the SDC from a sister facility and the DON from a sister facility and continued through [DATE] regarding hand hygiene, meal service delivery, PPB Don and Doff, and proper PPB for each designated unit. Signage was placed on units to provide frequent reminders for staff. PPE containers were placed outside each resident door on the PUI Units. 6. The following comprehensive, full facility education and competency evaluations have been completed regarding PPE and Hand Hygiene. Skills Validation Checklists (attached) a. 42 of 48 C.N.A's (1 out with COVID-19; 3 are PRN, and 2 are on PTO)- 87.5% b. 19 of 22 LPN's (2 out with COVID-19; 1 is PRN)- 86.3% c. 8 of 13 RN's (4 are PRN; 1 on FMLA)- 61%- 4 will receive telephone education on [DATE] to total 92.3% d. 20 of 22 ENVS/Laundry (1 PTO; 1 FMLA)- 91% e. 16 of 18 Food and Nutrition Services (2 PRN)- 88.8% f. 2 of 3 Activity Staff (! out with COVID-19)- 66%- 1 will receive telephone education [DATE] to total 100% g. 4 of Maintenance/Plant Ops- 100% h. 11 of 11 Administrative Staff. 100% Staff not included in these numbers will be educated before returning to work and accepting an assignment. A\l staff receiving telephone education will have hands on education upon returning to work prior to accepting an assignment. New hires will continue to receive this education prior to being given an assignment. 7. At approximately 5:15 p.m. on [DATE], the facility began resident relocations under the direction of the medical director and DPH via QAPI meeting utilizing recommended precautions during transfer to accommodate each resident according to his/her COVID-19 status. 5 residents were moved to the COVID-19 unit. 3 residents were moved to the PUI Unit due to resident being symptomatic ore resident having a roommate test positive. 4 residents remained on the observation uni1t as a result of being a new admission. 6 residents were moved off the COVID- 19 unit to the PUI Unit. 8. On [DATE], all residents that had not had a positive test result in the last 90 days were re¿ tested utilizing the PCR test. All results were received within 48 hours and residents were co¿ horted according to DPH guidance and COVID-19 status. The Assistant Administrator will monitor test results as sent to contracted laboratory. See COVID-19 PCR Test Monitoring Tool (attached) 9. The facility has not admitted any new residents since [DATE] and will not admit until the outbreak has cleared. 10. Facility leadership has maintained continued ongoing communication with DPH staff epidemiologist I since [DATE]. 11. Administrator, Assistant Administrator, ICP, and SDC will assist in observations to monitor compliance with PPE adherence, proper hand hygiene, and meal delivery and service procedures every shift until substantial compliance is met. See Infection Control Observation Rounds (attached). 12. Applicable infection control policies and procedures were reviewed and revised to reflect CDC, DPH and current professional standards of practice, as applicable. 13. The facility will utilize the many monitoring tools as stated above to ensure the situation involving the immediate jeopardy does not occur again. These tools will be monitored daily by the Administrator and reviewed weekly at QAPI. Findings, if necessary, will be immediately addressed with staff member. The State Survey Agency (SSA) conducted a revisit on [DATE] through [DATE] to validate the facility's Immediate Jeopardy Removal Plan as follows: 1. An interview on [DATE] at 4:55 p.m. with the Administrator and the Assistant Administrator revealed that COVID testing is done weekly, on Friday. The Assistant Administrator confirmed that two test per hall will be observed weekly to ensure the procedures are being followed. The Administrator confirmed that a new type of testing was delivered last week with the nurses who perform the testing were trained on the new kit procedure. It was discovered on [DATE] that some of the nurses were using three drops of reagent for both types of test although new test required six drops of reagent. All tests results were discarded, and new testing was completed on [DATE] by the PCR laboratory test method. A blank COVID-19 Rapid Test Monitoring tool was provided which would be utilized starting [DATE]. Review of the Skills Validation Checklist for COVID-19 Rapid test dated [DATE] by RN JJ for RN FF, RN LL and LPN KK. Review of the Skills Validation Checklist for COVID-19 Rapid test dated [DATE] by RN FF for LPN MM and RN NN. Review of the uploaded COVID-19 test results, dated [DATE], and faxed sheet dated [DATE] at 7:36 a.m. which included one new resident and six staff members who were positive for COVID-19. An interview with Registered Nurse (RN) FF on [DATE] at 12:50 p.m. revealed that a new brand of Rapid Test had been received and utilized for testing on [DATE] when it was discovered that some testing staff were not following the correct procedure for processing the test. As a result, all rapid test conducted that day were discarded due to the error. 2. Review of the QAPI meeting dated [DATE] revealed that 17 staff members were present to discuss implementing distinct COVID-19 positive units, PUI units and negative unit although the Medical Director was not present. An interview with the Administrator on [DATE] at 9:37 a.m. revealed that the Medical Director was not present for the QAPI meeting although discussions were held with him after the meeting. 3. An interview with LPN OO on [DATE] at 2:05 p.m. revealed that she monitors residents on Parkway A for signs and symptoms of COVID-19 per shift and enters this information into the Electronic Medical Record (EMR). She was able to demonstrate her findings in the EMR. An interview with LPN PP (Unit Manager) on [DATE] at 3:04 p.m. revealed that she is unsure how the EMR dashboard is utilized to confirm that residents are being checked for signs and symptoms of COVID-19 although she is responsible for this task. 4. Observation on [DATE] at 10:40 a.m. of the Memory Unit revealed no Velcro Stop Signs located on the unit. An interview with the Administrator on [DATE] at 10:55 a.m. revealed that R#29, R#30 and R#31 (positive residents) were moved to the COVID positive unit therefore the Velcro Stop Signs are not being used at this time. An interview with LPN QQ on [DATE] at 4:20 p.m. revealed that after the positive residents were moved to the COVID positive unit there are no other wandering residents, therefore, the Stop Signs are not being used at this time. 5. Review of the Skills Validation Checklist for detection of [DIAGNOSES REDACTED]-CoV-2-COVID-19 by RN JJ on [DATE] for RN FF, LPN KK, and RN LL. Review of the Skills Validation Checklist for detection of [DIAGNOSES REDACTED]-CoV-2-COVID-19 by RN FF for LPN RR and on [DATE] for RN NN. Review of the confirmation skills validation for PPE and Hand Hygiene revealed all staff had completed this component although there was no documentation of education related to meal service delivery and proper PPE, or hand sanitization on each designated unit. An interview on [DATE] at 12:13 p.m. with RN LL revealed that staff had been in-serviced on the proper PPE and hand hygiene although since the in-service was done verbally, no documentation was necessary. Observation on [DATE] between 10:20 a.m. through 10:50 a.m. revealed signs were noted on each unit and that PPE containers were located outside the doors of residents on the PUI units. 6. Review of the PPE Competency Validation revealed that staff had been checked off on the use of PPE although on 6 of 12 Administrative Staff had Competency Validation. There we no specific in-service sign off sheets. 7. Review of the Resident Relocation log as of [DATE] revealed that on [DATE] that five residents (R#28, R#30, R#27, R#31 and R#29) were moved to the COVID positive unit. Three residents (R#35, R#36 and R#37) were moved to the PUI unit. Four residents (R#38, R#39, R#40, and R#41) remained on the PUI unit. Six residents (R#19, R#20, R#21, R#22, R#23, and R#24) were moved off the PUI unit. Review of the email communication between the facility and the local DPH representatives revealed direct communication continues. 8. Review of the (Lab Name) Testing Roster for Parkway A, Parkway B, Pinewood C, Terrace A, Terrace C, Patio and Pinewood A (positive unit) revealed that PCR testing was performed on [DATE] with results received on [DATE] for 84 residents, 18 residents were not tested on [DATE] due to having a negative test within the last 90 days. The facility currently had 21 positive residents in the facility. Of the 84 residents tested on [DATE], six residents had positive test results on [DATE] and were moved to the COVID-19 positive unit (Pinewood A). A post survey interview on [DATE] at 1:04 p.m. with the Assistant Administrator revealed that for this round of PCR testing the facility had used an alternative laboratory to ensure the results would be received with in the 48-hour requirement. The Assistant Administrator confirmed that the former laboratory was taking five days to get results. 9. Review of the facility log for New Admissions for [DATE] through [DATE] revealed the last new admission received was on [DATE] and one hospital return on [DATE]. An interview with the Admission Coordinator on [DATE] at 1:00 p.m. confirmed the facility is no longer taking new admissions since [DATE]. 10. Review of the COVID-19 Illness Log for ill residents and staff dated [DATE] which contains all positive residents and staff through [DATE] which was sent to the local DPH. This was confirmed, via email, with the local DPH District office on [DATE]. 11. Review of the Infection Control Observation Rounds audit sheet dated [DATE] revealed that seven observations were made on the 7:,[DATE]:00 p.m. shift, three observations were made on the 3:00 p.m.-11:00 p.m. sheet and no observations were conducted on the 11:00 p.m.-7:00 a.m. shift. An interview on [DATE] at 2:50 p.m. with RN NN revealed that she was responsible for the Infection Control Observation Round log on [DATE] although she was not give specifics as to what she should check or observe and was not aware this (TRUNCATED)