Every finding on record at Westbury Center of Mcdonough for Nursing & Healing

Based on observation, staff and resident interviews, record review, and a review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to protect the Resident's (R) (R1) right to be free from sexual assault by Environmental Service (EVS) Housekeeper EE. The sample size was eight.On January 20, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations, and Regional Director of Operations (RDOP) were informed of the Immediate Jeopardy (IJ) on January 20, 2026, at 5:10 pm. The noncompliance related to the IJ was identified to have existed on January 6, 2026.An Acceptable IJ removal Plan was received on January 23, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on January 8, 2026.Findings include:Review of the policy titled Abuse, Neglect and Exploitation, with a reviewed/revised date of 12/2025, revealed, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: Sexual abuse is non-consensual sexual contact of any type with a resident.Review of the admission Record for R1 revealed she was admitted to the facility on [DATE]. Diagnoses included, but were not limited to, anxiety, major depressive disorder, and vascular dementia.Review of the resident's most recent comprehensive Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 12, which indicated moderately cognitive impairment. Section D: none. Section E: No behavior exhibited. Cognitive Loss/Dementia triggered as an area of concern on the Care Area Assessment Summary (CAAS).Review of the resident's most recent quarterly MDS dated [DATE] revealed a BIMS was assessed as ten, which indicated moderately cognitive impairment. Section D: revealed a mood of feeling down, depressed, hopeless. Section E: no behavior exhibited.Review of the care plan revised on 1/13/2026 revealed that R1 had poor decision-making skills, required cueing and reminders for daily tasks. Interventions to be implemented included staff to monitor and give redirections as needed.Review of the Facility Incident Report Form dated 1/6/2026 revealed: a staff walked into R1's room and observed staff member with his pants down and it appears that the resident was engaged in oral sex with female resident {sic}.Review of the facility camera footage located in the human resource office with the Regional Director of Maintenance and the Human Resource Director (HRD). The camera footage was dated 1/6/2026 and started at 7:00 am military time. At 7:37 am, R1 came out of her room, turned to the right, exited the frame, and went outside the field of view (FOV). R1 reentered the FOV at 7:38 am and returned to her room, closing the door behind her. There was no other observation of R1 leaving the room. At 3:23 pm, a male staff member identified as EVS Housekeeper EE entered the FOV from the back door at the end of __ Hall, walked down the hall, and entered an additional resident's room __ (did not knock). At 3:24 pm, the EVS Housekeeper EE reentered the FOV coming out of room __, walking down the hall, and remained in the FOV. At 3:24:13 pm, the EVS Housekeeper EE knocked on R1's door and closed the door behind him. At 3:36:38 pm, a female staff member identified as Certified Nursing Assistant (CNA) DD entered the FOV, opened the door to R1's room, and walked in. The female CNA DD exited the room at 3:36:57 pm, turned right, exiting the frame. At 3:37:11 pm, the EVS Housekeeper EE reentered the frame, standing at the door of R1's room. The EVS Housekeeper EE looked in both directions and walked out of the room to the end of __ Hall. It took the EVS Housekeeper 22 seconds to enter the code and exit the back door of __ Hall. At 3:43:55 pm, two staff members, identified as two nurses, reentered the FOV and entered R1's room and exited the room at 3:44:15 pm.A review of the local police department body camera footage dated 1/6/2026, interview at time stamp 3:22 -5:18 with R1. During the interview, the resident verbalized, My mind is gone. The resident also verbalized to the Administrator and a police officer, I am not saying I enjoyed it. He enjoyed it. R1 additionally verbalized, It ain't about me, it is about him.An interview on 1/13/2026 at 12:23 pm with the Director of Nursing (DON) was conducted; the Administrator was present. The DON stated that on 1/6/2026, she received a call from the Assistant Director of Nursing (ADON) and was informed that CNA DD was passing ice water, and when entering R1's room, she observed the EVS Housekeeper EE with his penis in R1's mouth. The DON asked the ADON whether R1 was okay and whether the resident had been assessed. The ADON informed her that R1 had been assessed and was in no pain or distress. ADON informed her that the EVS Housekeeper EE had left the facility, and the police had been called. She informed the ADON to have someone stay with the resident at all times. The DON stated she called the Administrator, the Regional Director of Clinical Operations, the Regional Director of Operations, and the Medical Director. The DON revealed that the Medical Director instructed her to ensure someone was with the resident and to call him back once she had assessed the resident. The Medical Director also instructed her to send R1 out to the hospital for evaluation. The DON stated she arrived at the facility at 4:41 pm and went directly to the resident's room. The DON stated she assessed R1. She offered to send the resident to the hospital, and R1 refused. She revealed that she called the Medical Director, who ordered a complete head-to-toe skin check, and to ensure her psychosocial needs were met by consulting with psychiatric services, and to encourage the resident to engage in activities outside of the room, and placed R1 on every 15-minute checks. She stated R1's family was notified.A phone interview on 1/19/2026 at 4:10 pm with CNA DD stated that on 1/6/2026, she was pulled from her unit to __ Hall. CNA DD stated was passing ice water and entered R1's room. She stated the EVS Housekeeper EE was standing with his pants down, and R1 was lying in the bed. She stated the EVS Housekeeper EE penis was in the resident's mouth. CNA EE revealed that she gasp and the EVS Housekeeper EE looked at her and said, Oh shit, and ran into the bathroom. She stated that the EVS Housekeeper EE had a scary look in his eyes. She stated she left the room to get the nurse. CNA DD revealed she was in the room when the cameras were reviewed, and that man (EVS Housekeeper EE) was in the room for fifteen minutes with a resident who has dementia.

Based on interviews, record review, review of the Administrator's Job Description, and review of the facility policy titled, Abuse, Neglect and Exploitation, the Administration failed to provide protective oversight of the facility resident's to prevent the sexual assault against Resident (R) (R1) by the male Environmental Service (EVS) Housekeeper EE and failed to identify the EVS entering and remaining in resident rooms (R6) at unusual times, with no cleaning supplies, or housekeeping carts making them feel uncomfortable and afraid. Specifically, the facility Administrator failed to conduct an unbiased investigation and utilized leading questions towards the resident, implying the resident consented to sexual contact with the EVS Housekeeper EE. This failure compromised the integrity of the abuse investigation and minimized the seriousness of staff - to - resident sexual abuse. The sample size was eight.On January 20, 2026, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents.The facility's Administrator, Director of Nursing (DON), Regional Director of Clinical Operations, and Regional Director of Operations (RDOP) were informed of the Immediate Jeopardy (IJ) on January 20, 2026, at 5:10 pm. The noncompliance related to the IJ was identified to have existed on January 6, 2026.An Acceptable IJ removal Plan was received on January 23, 2026. Based on observation, record reviews, and review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on January 8, 2026.Findings include:Review of the undated document titled, Administrator-Job Description revealed position purpose is leads, guides, and directs the operations of the healthcare facility in accordance with local, state, and federal regulations, standards and established facility policies and procedures to provide appropriate care and services to residents. Plans, develops, organizes, implements, evaluates, and directs the facility's programs and activities in accordance with state and federal laws and regulations. Performs rounds to observe residents and ensure overall needs are being met. Knows residents by name and sight. Practices management by walking around. Makes himself/herself available to employees at all levels by practicing an open-door policy. Ensures resident incidents and concerns that rise to a reportable event such as alleged abuse, neglect, mistreatment, misappropriation, etc. are reported to the correct entity within the stated regulatory requirement. Protects residents from abuse and cooperates with all investigations. Promotes and encourages an environment of trust among all employees related to the overarching goal of resident safety and abuse prevention.Review of the policy titled, Abuse, Neglect and Exploitation with a reviewed/revised date of 12/2025, III. Prevention of Abuse, Neglect, and Exploitation. The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors.Review of the police body-worn camera video/audio dated 1/6/2026 revealed an interview with the Administrator and R1, with the police officer present. During the interview, the Administrator stated, You know I had to make sure you're alright, and nobody just doing something in here; so, you told me it has been happening for a while, right? R1, Yeah. Administrator, You say y'all kind of talk. I asked her how it happened. (Speaking to the police officer), (Administrator speaking to R1) He just come in and y'all just talk then it goes to that. R1, [NAME]. (while shaking her head yes). Administrator, Is he forcing himself on you. R1 Mhm, (while shaking her head no). Administrator, This something you consent, and you like for that to happen? R1, It ain't no big deal, Administrator, Ok, R1 I am [AGE] years old, I can put anything in my mouth that I want to. Administrator, And he does not, let me ask you this again, does he release himself in your mouth? R1 No. Administrator, And you said it has been happening for like months or has it been? R1 My mind is gone. Administrator, You don't know how long, but it has been several times? R1 Don't ask me how long it has been going on, I couldn't tell you. Administrator, You said has he, have yall had any kind of., R1 No. Administrator, None of that has happened, just him putting his penis in your mouth? R1 Yeah Administrator, And you enjoyed? R1 I didn't say I enjoyed it; he enjoyed it. It is not about me, it is about him. {sic}Review of the five- day follow-up submitted on 1/13/2026 conclusion staff to resident sexual contact was substantiated. Accordingly, while the resident's right to sexual expression is acknowledged and respected, __ Environmental Services (EVS) Housekeeper EE should have informed the facility's Administration of resident's desire for sexual encounter. The resident was assessed as alert and oriented and demonstrated the ability to express personal preferences and desires. The facility is engaged in protecting her dignity and confidentiality for her sexual desires.In an interview on 1/16/2026 at 10:39 am, R6 (BIMS 15) stated that on two occasions, the EVS/Housekeeper EE entered her room early in the morning while she was dressing. She stated she does not recall if the EVS/Housekeeper staff knocked. She stated she found it odd that he entered her room at those times. The resident stated it did make her feel uncomfortable. The resident stated she reported the incident to the Social Worker.An interview on 1/20/2026 at 10:11 am with the Social Service Director (SSD) stated that on 1/7/2026 around 9:30 am, she went to R6's room and spoke with the resident. She stated that R6 told her it was odd that EVS Housekeeper EE had been in her room twice. The SSD stated she asked the resident had the EVS Housekeeper EE touched her and the resident responded with no. The SSD stated that she did not file it as a grievance, and that no further investigation was conducted at the time of the resident's interview.In a phone interview on 1/19/2026 at 4:10 pm, Certified Nursing Assistant (CNA) DD stated on 1/6/2026 she was pulled from her unit to Hall. She stated she was passing ice water and entered R1's room. She stated the EVS Housekeeper EE was standing with his pants down, and R1 was lying in the bed. She stated the EVS Housekeeper's penis was in the resident's mouth. She stated she gasped, and the EVS Housekeeper looked at her and said, Oh shit, and ran into the bathroom. The CNA stated she was in the room when the cameras were reviewed and that man (EVS Housekeeper) was in the room for fifteen minutes with a resident who has dementia.In an interview on 1/20/2026 at 3:08 pm, the Regional Director of Operations stated R1 initiated the contact and that she had a BIMS score of 10-15. She further stated the incident was consensual. When asked if an employee was receiving fellatio from a resident, would that be a violation of the abuse policy? The RDOP stated, Yes.In a post-survey phone interview on 2/5/2026 at 4:20 pm, the Administrator revealed that she engaged in the line of questioning with the resident (R1) through her training and master's degree in social services. The Administrator stated that this was more of a style for questioning to gauge what was going on with the resident (R1), and it comes from professional training. She stated that the resident was alert, oriented, and communicated clearly during the interview.R1 and R6 both reside in the locked behavioral unit at the facility.

Based on interviews and record review, and a review of the facility's policy titled Resident and Family Grievances, the facility failed to ensure that a resident's verbal complaint was treated as a grievance, documented, and investigated in accordance with federal requirements. Specifically, when one Resident (R6) reported to the Social Service Director (SSD) that a staff member (Environmental Services Housekeeper (EVS) EE) entered her room on two occasions, making her feel uncomfortable. The sample size was 8.Findings include:Review of the facility policy titled Resident and Family Grievances revision date September 2025, revealed Policy: It is policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. Policy Explanation and Compliance Guidelines: 1. The Director of Social Services and the Administrator have been designated as the Grievance Officials for this center. The Grievance Official is responsible for overseeing the grievance process; receiving and tracking grievances through to their conclusion; leading any necessary investigations by the facility; maintaining the confidentiality of all information associated with grievances; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary considering specific allegations. 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. 10. Procedure: b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form or assist the resident or family member to complete the form. i. Take any immediate actions needed to prevent further potential violations of any resident right. e.The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievances.Review of the admission Record for R6 revealed she was admitted to the facility on [DATE] and a diagnosis of anxiety but not limited to anxiety.Review of the resident's most recent Prospective Payment System (PPS) Part A MDS dated 12/312025 revealed that a BIMS was assessed as 15, which indicated cognitively intact. Section D not assessed. Section E not assessed.An interview on 1/16/2026 at 10:39 am with R6 stated that on two occasions, the EVS Housekeeper EE entered her room early in the morning while she was dressing. R6 revealed that she does not recall if the EVS Housekeeper EE staff knocked. She stated she found it odd that he entered her room at those times. R6 stated that it made her feel uncomfortable. The resident stated she reported the incident to the Social Worker.An interview on 1/20/2026 at 10:11 am with the Social Service Director (SSD) stated that on 1/7/2026, around 9:30 am, she went to R6's room and spoke with the resident. She stated that R6 told her it was odd that EVS Housekeeper EE had been in her room twice. The SSD stated she asked the resident whether the EVS Housekeeper EE had touched her, and the resident responded no. The SSD stated she did not file it as a grievance, and no further investigation was conducted at the time of the resident's interview.

Based on observation, interview, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect four of 19 residents (R) (R200, R60, R66, and R73) right to be free from physical abuse by R154 and R160. Specifically, the facility failed to ensure R60 was free from physical abuse by R160 resulting in scratches on the face and R154's abuse towards R66 that resulted in actual harm when she sustained a sprained ankle and required an emergency room (ER) visit where an ankle immobilizer was initiated. R154's abuse towards R73 resulted in psychosocial harm using the reasonable person concept when dragged and pinned to the floor by R154. Findings include: Review of the facility's Abuse, Neglect, and Exploitation, policy dated 4/2024 revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish . 1. Review of the undated admission Record in the electronic medical record (EMR) under the Profile tab revealed R154 was admitted to the facility on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies and dementia. R154 was discharged on 4/1/2025; his closed record was reviewed. Review of the annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/2024 in the EMR under the MDS tab revealed R154 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) of four out of 15 indicating severe cognitive impairment. R154 required supervision or partial/moderate assistance with most activities of daily living (ADLS). R154 exhibited physical behaviors toward others and verbal behaviors towards others one to three days during the assessment period. Review of the EMR 2024 Progress Notes revealed the first incident involving R154, occurred on 1/18/2024 in when R154 grabbed R200 by the back of the neck and pushed her. Review of the undated admission Record in the EMR under the Profile tab revealed R200 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease. R200 was discharged on 2/9/2024. R200's closed record was reviewed. Review of R200's Care Plan dated 12/31/2021 revealed R200 was confused and required redirection. In addition, R200 was documented with behavior problems including spending most of her day wandering throughout the unit and into other residents' rooms. R200 had an ADL self-care deficit and required assistance with some ADLs. Review of the facility's Five Day Investigation, dated 1/24/2024 and provided by the facility, revealed R200 had diagnoses including Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. R200 was impaired in short- and long-term memory, and decision-making. R200 wandered on the secure unit without the use of assistive devices. The investigation revealed, On 1/18/2025 [name] charge nurse [Licensed Practical Nurse (LPN)16], who oversees the care of [R200] states that she observed [R154] get up from his wheelchair and grab [R200] by the shoulder at the base of her neck and push her. She did not fall. The residents were separated, and [R200] was moved to safety with no apparent injuries. The Responsible Party for both [R154] and [R200] were notified of incident. The MD [physician's name] was notified . A 1013 [psychiatric hold detaining someone experiencing a mental health crisis for an involuntary psych evaluation and treatment within 48 hours] was received from the MD and [R154] was sent to [hospital name] ER [emergency room] for a psych evaluation. The family [sic] were notified. Social Service Director spoke to [name] [ER charge nurse] due to resident's behavior. Law enforcement was notified for transportation. NP, MD, Psych NP, and Ombudsman were also notified of the incident. Both resident's care plans were updated. Upon [R154's] return to the facility, a 30-day discharge notice will be immediately presented due to concerns of safety for himself and the other residents . Review of the staff Witness Statement dated 1/18/2024 from LPN16 revealed, Resident [R154] observed grabbing another resident [R200] by the neck and shoving her, resident [R200] did not fall. LPN16 was not employed at the facility at the time of the survey and was not available for interview. Review of the behavior Care Plan dated 3/1/2023 in the EMR under the Care Plan tab revealed, Per behavior monitoring and nurse notes, resident struggles with yelling, wandering, rejection of care, verbal aggression, and physical aggression. The goal was, [R154] will have less refusal during the next review period. The behavior Care Plan was updated on 1/23/2024 with, On 1/18/2024 Resident grabbed fellow female wandering resident by her shoulders pushing her out of his room. [On] 12/30/2024 Aggressive outburst towards female staff grabbing her neck. The goal was, Resident will not injure self or others when agitated thru [sic] review date. Interventions included, [R154] was sent to [name] hospital for a psych eval. MD, Psych NP, and NP was notified dated 1/23/2024 . b. The second incident involving R154 occurred on 12/26/2024, when R154 pushed R66 down to the floor and R66 sustained a sprained ankle as follows: Review of the undated admission Record in the EMR under the Profile tab revealed R66 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease. Review of the annual MDS with an ARD of 2/18/2025 in the EMR under the MDS tab revealed R66 was rarely or never understood. The BIMS test was not conducted. R66 exhibited wandering behavior for four to six days during the assessment period. R66 was dependent on most ADLs. Review of the facility's Five Day Investigation dated 1/2/2025 revealed that on 12/26/2024, [R66] is a . female . Her diagnosis includes Alzheimer's disease and dementia with short- and long-term memory impairment. [R66] ambulates on the unit and often wanders into other residents' rooms. Her BIMS is 99. [R154] is a . male . His diagnosis includes neurocognitive disorder with Lewy bodies, dementia . severe with other behavioral disturbance . His BIMS is a 4. Investigation: [R66] wanders aimlessly with an unsteady gait about the unit. She is not aware of other's personal space or their personal items. At 1520 [3:20 PM] during shift change, .NA [nurse aide] observed [R154] sitting in his wheelchair outside his room when [R66] approached him. She [NA] was unable to intervene due to the distance between her and the two residents. She witnessed [R154] grab [R66] by her right arm, turn her around and push her in an attempt to redirect her . When she [R66] was attempting to ambulate, it was noted that she was unable to bear weight on her right leg and was placed into a wheelchair . NP [nurse practitioner] was notified and gave orders for [R66] to be transferred to the hospital for x-rays. RP [responsible party] notified . 911 was called . The Resident was transferred via stretcher to [name] hospital at 1614 [4:14 PM]. The . Police Department was notified with officer [name] responding to the facility . [R66] returned from the hospital at 2225 [10:25 PM] via stretcher. She was noted to have an immobilizer to her right ankle with a diagnosis of sprained ankle . She received a new order for cephalexin [antibiotic] . and trazadone [antidepressant] . A trauma assessment was completed for both residents. Both are followed by psychiatric services. Both of their care plans were updated. Actions put in place: The staff on Heritage Hall have been educated on close monitoring of the resident and to engage [R66] in activities during periods where she wanders into the space of others [R154] received a new order for Divalproex Sodium [anticonvulsant medication] . for impulse control. Review of a staff Witness Statement by Certified Nurse Aide (CNA)5 dated 12/26/2024 revealed, Yes I see [sic] [R154] turned around and push [R66] down to the floor. Other witness statements corroborated this statement. CNA5 was not available for interview during the survey. Review of R154's Behavior Care Plan dated 3/1/2023 in the EMR under the Care Plan tab revealed new interventions of 12/26/2024 - Consult psychiatric to eval and treat. 12/26/2024 - medication review and adjustment. 12/26/2024 - Staff to redirect resident behavior when observed aggression towards peers. c. The third incident involving R154 occurred on 4/1/2025, when R154 dragged R73 by her arm/sweater out of his room and pinned her down on the floor in the hallway and would not let her go until staff came and intervened. Review of the undated, admission Record in the EMR under the Profile tab revealed R73 was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder and aphasia (language disorder affecting the ability to communicate). Review of the admission MDS with an ARD of 2/24/2025 in the EMR under the MDS tab revealed R73 was rarely/never understood, was severely impaired in decision making, and was impaired in memory. The BIMS test was not attempted. R73 exhibited wandering behavior one to three days during the assessment period. R73 was 5'2 tall and weighed 145 pounds. Review of the facility's Five Day Investigation dated 4/8/2025 and provided by the facility revealed, [R73] was observed by staff being dragged by a male resident out of his room with him holding onto her arm/sweater. Both parties were separated to different locations. Upon skin assessment, half of dollar discoloration noted to [R73's] left upper arm, and some redness was noted on her back with no open area. Range of motion was done with no limitation to all extremities and no pain or discomfort. The resident was assisted into her wheelchair with assist x2. Neuro check initiated per facility protocol with no changes in mental status. Administration, [psychiatrist], and RP notified . A trauma assessment was completed for [R73] There were no negative findings . Both of their care plans were updated. Actions put in place: Staff remained with [R154] until he left. [R154] was 1013'd and left facility on 4/1/2025 accompanied by officers x4 to [name] hospital with paperwork and bed hold policy. Upon departure, the resident was alert and oriented x3 with some forgetfulness. No bruise or open areas noted. He has not returned. Review of the Witness Statement dated 4/1/2025 for CNA4 provided by the facility read, I was standing at the nurses station I heard commotion down the hall. I saw resident [R154] dragging [R73] out the room and he had her pinned on the floor by her arms and shirt and did not let her go until me [sic] and other staff approached him and then he got verbally abusive after that. During an interview on 6/25/2025 at 8:37 AM, the Psychiatrist stated R154 was agitated and aggressive and had continued behavior during his stay. The Psychiatrist stated R154 was a veteran and exhibited symptoms of post-traumatic stress disorder (PTSD), stating R154 had been violent at home prior to admission. The Psychiatrist stated R154 got agitated when residents came into his room unannounced. The Psychiatrist stated R154 came in on Seroquel (antipsychotic medication) but had no history of mental illness warranting the medication, so it was discontinued, and Depakote was initiated for impulse control. The Psychiatrist stated non-pharmacological interventions were initiated including videos of his family and military service that were played on this TV. The Psychiatrist stated R154 abused residents, was an imminent threat and that was why he was sent on the 1013 holds. During an interview on 6/25/2025 at 9:12 AM, Certified Medication Aide (CMA), who also worked as a CNA, stated R154 did not want anyone in his room. CMA stated R154 yelled and screamed and was both verbally and physically aggressive with staff. CMA stated the main intervention was to redirect other residents if they were going towards his room which worked some of the time. CMA stated she witnessed the incident between R154 and R200. CMA stated R154 grabbed R200 by the back of her neck and pushed her out of his room. CMA stated R200 screamed and cried when the incident occurred. CMA stated R200 was significantly cognitively impaired and did not know she should avoid R154. CMA stated she did not remember R154 having increased supervision or being put on one-to-one supervision after this incident or the other ones. During an interview on 6/25/2025 at 12:11 PM, LPN6 stated she worked in the Heritage unit during R154's entire stay in the facility. LPN6 stated R154 was originally admitted to the Heritage unit and was later transferred to [NAME] hall but started exit seeking and he was brought back to Heritage unit. LPN6 stated R154 was capable of doing ADLs with supervision and he could walk. LPN6 stated R154 was alert and could express his needs; however, expressed some confusion about events and needs. LPN6 described R154 as being irritable and confrontational and he did not like wanderers. LPN6 stated if residents tried to wander in his room, R154 would try to get them out by whatever force. LPN6 stated there were quite a few residents on the Heritage unit that wandered. LPN6 stated these residents were redirected out of R154's space and offered diversional activities. LPN6 stated she was working when the incident on 12/26/2024 with R66 occurred. LPN6 stated when she came to the scene, R66 was lying on the floor and R154 was in the area. LPN6 stated R66 was startled and was later diagnosed with an ankle sprain after having difficulty walking. LPN6 stated staff were cautious around R154 and stated R154 had the potential to be a threat to residents. LPN6 stated R154's room was at the very end of the hallway. During an interview on 6/25/2025 at 1:08 PM, the Social Service Director (SSD) and Social Service Assistant (SSA) who were interviewed together stated R154 could be verbally and physically aggressive and spent most of his time in his room or in his doorway. The SSD stated R154 did not like people in his space and most of the incidents with other residents were a result of other residents coming into his room. The SSD stated her role in investigations of abuse was to complete trauma assessments after the incident and to check on the residents. The SSD stated all three of the residents (R66, R200, and R73) were severely cognitively impaired and would not remember the incidents after they occurred, indicating they were negative on the trauma screens. During an interview on 6/25/2025 at 3:01 PM, CNA4 stated R154 did not want other residents in his room and cursed at them if they tried to come in or tell them to get out. CNA4 stated it was normal to have wandering residents on the Heritage unit. CNA4 stated she witnessed the final incident on 4/1/2025 between R154 and R73. CNA4 stated she observed R154 in a standing position dragging R73 out of his room and then holding her down on the floor in the hallway. CNA4 stated R154 sat down in the hallway with his leg pinning R73 down on the floor. CNA4 stated several staff ran down there to make R154 let go of R73 and R154 cursed at the staff and let go of R73. CNA4 stated R73 does not talk but she was crying and upset when the incident occurred. CNA4 stated staff took R73 to her room and staff stayed with R154 until he was taken by the police to the hospital. CNA4 stated staff were to redirect R154 or walk away when became aggressive towards them and were to redirect residents who wandered near or into R154's room. CNA4 stated she was physically assaulted by R154 once when she was in R154's room and tried to leave the room. CNA4 stated R154 stood up from his wheelchair, blocked her from leaving his room and grabbed her neck, popping her necklace. CNA4 stated she yelled for help and was able to pry R154's hands from her neck when two other staff entered the room to assist. CNA4 stated R154 was strong, had been in the military, and stated he tried to choke her. During an interview on 6/25/2025 at 4:16 PM, the Administrator verified she was the abuse coordinator. The Administrator stated she had spoken with the Medical Director about discharging R154 and the 30-day notice for discharge was issued on 1/29/2024. The Administrator stated R154 had incidents of aggressive behaviors and posed a safety concern. The Administrator stated the normal process was for the unit manager and the SSD to talk with the family and see what area specific facilities a referral would be sent to. The Administrator stated she would not have handled referrals and placement. There should have been documentation about efforts to find placement after 30-day notice was issued. The Administrator stated R154's behavior had improved after the 30-day notice was issued. The Administrator stated the final incident on 4/1/2025 resulted in the daughter of R73 being afraid for R73 to remain in the facility on the unit with R154. A decision was made to issue the immediate discharge notice on 4/1/2025 due to the fear that R154 was going to hurt someone. The discharge notice was issued on 4/2/2025 after speaking with the Medical Director. During an interview on 6/25/2025 at 6:24 PM, Family Member (F)1 stated he and one other family member were next of kin for R154. F1 stated he was aware of R154's aggressive incidents towards other residents and did not condone this behavior. F1 stated that residents roamed freely on the Heritage unit and family had observed many instances of other residents entering or trying to enter R154's room. F1 stated R154 kept his door shut to keep people from coming into his room. F1 stated, From our perspective they do not have control of roaming patients. This does not seem right. 2.Review of the Census tab in the EMR revealed R60 was admitted on [DATE]. Review of the Med Diag tab in the EMR revealed R60 had diagnoses including paraplegia and complete lesion of the C5, C6, and C7 level of cervical spinal cord Review of the Care Plan under the Care Plan tab in the EMR revealed R60 had a focus with interventions related to C5-C7 lesion of the spinal cord initiated on 2/24/2022. A focus with interventions related to restorative nursing for passive range of motion as tolerated was initiated on 1/24/2025. A focus with interventions related to paraplegia with complaints of pain/spasm to bilateral extremities initiated on 2/24/2022. Review of a quarterly MDS with an ARD of 12/1/2024 under the MDS tab in the EMR revealed R60 had a BIMS score of 15 out of 15 indicating no cognitive decline. R60 was impaired on both arms and both legs. In an interview on 6/24/2025 at 5:10 PM, R60 stated he remembered R160 well. R60 stated R160 was a good roommate for the longest time and then changed one day. He stated they were talking about stuff one day and then R160 said to him, Shut up or I will kick your ass. R60 stated he immediately became and remained silent because he was a little freaked out by the statement. R60 stated R160 came over and punched him on his ear, cheek, and across his nose. Observation of R60 indicated he was unable to move his arms. Review of a communication note dated 1/3/2025 under the Prog Note tab in the EMR revealed, resident alert and verbal . Being monitored for altercation with roommate. He was hit in the face by his roommate. No active bleeding noted at this time, no swelling, or c/o voiced. Call light in reach. Review of a communication note dated 1/3/2025 under the Prog Note tab in the EMR revealed, spoke with resident RP .[granddaughter] via phone whom [sic] called back concerning 1/2/2025 physical incident with resident and resident roommate. Resident RP made aware of full details of incident and well as resident current status. Plan of care ongoing safety maintained. Review of a communication note dated 1/7/2025 under the Prog Note tab in the EMR revealed, attempt made to call resident RP .[granddaughter] via phone. No answer. Voicemail full. Call was concerning resident request to press charges on former roommate for incident on January 2nd, 2025. The local police dept. contacted and resident made aware an officer will be in to receive his statement. will attempt to contact RP again. Review of a nurse note dated 1/2/2025 under the Prog Note tab in the EMR revealed, it was reported that resident [R160] verbally assaulted his roommate [R60], resident was immediately removed from room, Resident denied incident and took no accountability for alleged incident. Nursing supervisor made aware. 911 was contacted, resident RP contacted, and Tele med notified. Resident removed from room with belonging to room [room number] until further investigation. Plan of care on going, and safety maintained. A nurse note dated 1/2/2025 revealed, Resident [R160] left his room, sat next to the ice cooler in the hallway for a long time before we found out that he assaulted the roommate [R60], when asked what happened he denied ever touching the roommate, when asked to move out of the room, he refused, the police was called in, we all wrote down our statements and gave them, Meanwhile he [R160] has been transferred to room [room number]. His sister came to the facility to talk with him. Review of the facility self-report to the State Agency revealed that on 1/2/2025 the charge nurse was passing meds when staff asked her to look at R160's roommate. The nurse noted scratches on the roommate's face and the tip of his nose. The roommate stated R160 had hit him. The two residents were kept separated as R160 was sitting in the hall when the nurse assessed the roommate. The police were called to the scene. R160 denied striking his roommate but did admit to them arguing about some food that was brought in for R160. A trauma assessment was completed for the roommate, R160 was referred to psychiatric services, staff were re-educated on Managing Aggression and Behaviors which included de-escalation techniques, and both care plans were updated. Other residents were interviewed during the investigation. All timeframes for reporting were per requirement. The facility could confirm a verbal altercation but did not substantiate physical abuse. In an interview on 6/26/2025 at 12:00 PM Unit Manager (UM) stated she remembered the incident between R60 and R160. She stated she was informed there was an altercation, so she went to investigate. When she arrived at the room, R160 was sitting outside the door and the privacy curtain was pulled between the beds in the room. UM stated R160 would not look up at her when she asked what was going on. When she questioned R60, he stated R160 had hit him and that his face hurt. UM assessed scratches to his face and nose. UM cleaned R60's wounds and administered his pain medication. UM stated she then took R160 to another room to keep them separated and made the calls to the representatives, physician, and 911. UM stated she believed by what she saw and heard that R160 meant to hit R60 and the interaction was abuse. In an interview on 6/25/2025 at 1:45 PM the Administrator confirmed that R60 had requested a police officer so he could press charges against R160.

Based on observation, interview, record review, and review of the facility policy titled, Safe and Homelike Environment, the facility failed to ensure the environment was homelike, i.e. clean and comfortable, for five residents (R) (R42, R79, R80, R84, R122) attending the resident council interview, for 14 residents residing on the [NAME] Unit in rooms R32, R33, R34, R40, R45, R47, and R48 and for all 44 residents residing on the Heritage Unit and for one resident (R400) residing on the Memory Care Unit out of a total census of 143 residents. Findings include: Review of the facility's Safe and Homelike Environment policy dated 4/2025 and provided by the facility revealed, In accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike environment . A homelike environment is one that de-emphasizes the institutional character of the setting . Orderly is defined as an uncluttered physical environment that is neat and well-kept . Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable environment . During an observation on 6/23/2025 at 12:02 PM, R36's room was observed. There were crumbs strewn across the floor on both sides of the room. R36 stated his bathroom was unclean and in a state of disrepair. R36 stated the toilet was very difficult to flush and this had been reported multiple times, the toilet seat was loose, and the toilet cover was cracked. The bathroom was observed at this time and the flooring around the toilet was soiled with accumulated black residue and the top of the commode seat had two large brown streaks on it. The surveyor pushed the handle down to flush the toilet and it was very difficult to push the handle down. R36 stated he told staff on a daily basis about the toilet being difficult to flush but it had not been fixed. The toilet seat was observed to be loose and rocked back and forth when tested. There was a rust-colored substance on the toilet seat several inches long and a couple inches wide on both sides of the seat. During the resident council interview on 6/24/2025 at 2:33 PM, R80 and R84 stated housekeeping was inconsistent and their rooms did not always get cleaned. They stated housekeeping had a lot of staff turnover and there were less housekeepers on the weekends. R80, R84, and R122 stated when this occurred, their garbage cans overflowed, their rooms were not cleaned, and they ran out of toilet paper and paper towels. In addition, R79 stated repairs were not always made timely by maintenance. R79 stated his toilet clogged up recently and he had complained about it for three weeks before it was repaired. R42 stated her toilet was also stopped up and not working at the same time. R79 stated one of the shower heads had minimal pressure and dribbled. R84 stated the shower room was unpleasant as it was cluttered with lots of equipment stored there. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 3/28/2025 revealed R80's Brief Interview for Mental Status (BIMS) score was 15 out of 15, indicating R80's cognition was intact. Review of the Annual MDS with an ARD of 6/10/2025 revealed R84's BIMS score was 15, indicating R84's cognition was intact. Review of the Quarterly MDS with an ARD of 5/01/2025 revealed R122's BIMS score was 15, indicating R122's cognition was intact. Review of the Quarterly MDS with an ARD of 6/12/2025 revealed R42's BIMS score was 14, indicating R42's cognition was intact. Review of the Quarterly MDS with an ARD of 3/27/2025 revealed R42's BIMS score was 14, indicating R79's cognition was intact. Review of the Quarterly MDS with an ARD 4/22/2025 revealed R36's BIMS score was 12, indicating R36's cognition was moderately impaired (score of 8 - 12). Resident Council Minutes documented concerns with the environment as follows: a. Review of Resident Council Minutes dated 11/26/2025 revealed, Housekeeping is not sweeping the floor. b. Review of Resident Council Minutes dated 12/19/2024 revealed, Outside windows need cleaning . Resident stated they need more trash bags and can in rooms. c. Review of Resident Council Minutes date 1/29/2025 revealed, Need floor mopped d. Review of Resident Council Minutes dated 2/20/2025 revealed, wants room stripped (floor) . light above bed keeps going out. e. Review of Resident Council Minutes dated 3/27/2025 revealed, bathroom toilet keeps stopping up. f. Review of Resident Council Minutes dated 4/29/2025 revealed, We need more tissue in rooms . Shower head maintenance issue . Tissue we only have two rolls in rooms . Only getting room cleaned three times a week . Shower head is broke [sic] on [NAME]/[NAME]. During an observation on 6/25/2025 at 9:05 AM in room [ROOM NUMBER]B the ceiling tiles directly above the bed had an accumulation of dust. Several ceiling tiles were askew creating a gap where a thick layer of dust had accumulated. The ceiling in the bathroom had areas of discoloration/leaks. Observations in the bathroom revealed an area four inches in diameter with a black fuzzy substance on the ceiling tile. In addition, there was a second area the same size on a different ceiling tile that was discolored with a brown colored area. During an observation on 6/25/2025 at 3:12 PM, the MD and ES2 verified the difficulty flushing the toilet (the MD adjusted the handle and fixed it), the presence of brown streaks on the toilet seat, the cracked plastic, and black substance on the floor. The MD and ES2 stated they had not been aware of the issues in the bathroom. Observations revealed concerns in residents' rooms: During an observation on 6/26/2025 at 8:52 AM room [ROOM NUMBER]A was observed with water on the floor with base board peeling away from the wall underneath the window where bed B was located. There was a small puddle of water observed on the floor in the area where the base board was peeling away from the wall. During an observation on 6/26/2025 at 8:57 AM, the linoleum floor in room [ROOM NUMBER] was soiled with a black substance around and on the floor tiles for two feet at the entry to the room, where the hallway flooring and the room flooring met. Additional rooms on this hallway revealed the same discolored, blackened areas in rooms 32, 33, 34, 45, 47 and 48. Observation, on 6/26/2025 at 11:50 AM of the hallway and area near the locked door to the MCU, revealed the vinyl base boards looked soiled. Part of a vinyl baseboard was missing on one side of the door and a piece of wood (painted white) that did not match the other baseboards was in place. The brick wall just above the baseboards had a gray discoloration that looked like dust buildup. There were several floor tiles with missing pieces, and other tiles were stained with a yellow/brown discoloration. On 6/26/2025 at 2:30 PM, the [NAME] shower room was observed with missing tiles in the shower, 15 small tiles and several larger tiles. There was an area of several inches on the grout that was black and the MD stated scraping it would not remove the substance. There was a section of base board that was missing. On 6/26/2025 at 2:36 PM, the [NAME] shower room was observed. There were multiple pieces of equipment stored in the room, taking up 50% of the space including two Geri chairs, four mechanical lifts, and a wheelchair. The space was cluttered. The MD and ES2 verified these observations and that the shower was being used as a regular storage area for equipment. On 6/26/2025 at 2:40 PM, [NAME] shower room revealed one of the three shower heads was broken. There were three mechanical lifts stored in the bathroom presenting a cluttered appearance. There were two of three light bulbs that were burned out in the light fixture. On 6/26/2025 at 2:44 PM, the Heritage shower room revealed several large, tiled areas on the floor and walls that were missing tiles. There was a black substance along the entire baseboard trim and flooring in both of the two shower stalls and the MD stated it was mildew. The ceiling tiles and light fixtures above the tub were discolored brown and none of the fluorescent lights in this area worked. There was a section of baseboard trim approximately two feet in length that was peeling away from the wall; it was affixed to the wall with tape. The MD stated this bathroom needed the most attention. During an observation on 6/26/2025 at 2:50 PM with the Maintenance Director (MD) and regional manager, Environmental Services (ES)2, the MD stated the water that accumulated on the floor in the room was due to the resident in Bed B who routinely spilled water from a jug on the floor and that was why it was wet. During an observation on 6/26/2025 at 2:50 PM with the MD and ES2, the MD and ES2 walked down the hallway with the surveyor and verified that rooms 32, 33, 34, 40, 45, 47, and 48 had black substance on the floors in residents' rooms where the entry and hallway met. The MD and ES2 verified the accumulated black substance on the floors in residents' rooms on the [NAME] hall. ES2 stated the floors had not been cleaned properly previously and there was accumulated grime that was not easily removed. ES2 stated the floors would have to be completely stripped and then waxed. During an observation on 6/26/2025 at 3:07 PM in room [ROOM NUMBER], the MD verified the presence of the dust in ceiling panels above the bed and stated it needed to be cleaned. The MD entered the bathroom and observed the two areas on the ceiling (black fuzzy substance and brown area) and stated the facility had an issue with the roof and had recently done some repairs; however, there were still some areas of concern. During an interview on 6/26/2025 at 3:36 PM, MD and ES2 stated the Geri chairs and mechanical lifts were stored in the shower rooms because there was no place else to store them. Review of the face sheet for Resident(R) 400, revealed the facility admitted the resident on 6/20/2025 with diagnoses of coronary artery disease (CAD), Chronic Obstructive Pulmonary Disease (COPD), End Stage Renal Disease (ESRD) with need for Hemodialysis, Diabetes, and Dementia. During an interview on 6/27/2025 at 10:27 AM, Housekeeper (HK)1 and HK3 were interviewed together. HK1 stated she had been employed for three weeks and HK3 for five days. They stated their routine included cleaning some of the common areas when the first came on shift at 8:00 AM and then started cleaning residents' rooms around 10:20 AM. They stated the remainder of their shift was spent cleaning each resident's room in their respective areas. HK1 stated she was responsible for 24 - 26 resident rooms and HK3 stated she had 30 - 35 rooms. Cleaning rooms consisted of dusting, sweeping, mopping, emptying garbage, filling toilet paper and paper towel dispensers, and sanitizing surfaces. They stated the mechanical lifts and Geri chairs were routinely stored in the shower rooms. They stated the black gunk of the floors on the [NAME] unit was permanent; mopping it did not remove the black soiled areas. During an interview on 6/27/2025 at 2:59 PM, the Administrator stated the floors in residents' rooms on [NAME] where the linoleum met the hallway looked terrible. The Administrator stated improvement was needed.

Based on record review, staff and resident interviews, and review of the facility policy titled Transactions Involving Resident Funds the facility failed to provide quarterly resident trust fund statements to 82 of 82 residents who have a resident account in the facility. Findings include: Review of the facility policy titled Transactions Involving Resident Funds revised 1/11/2023 revealed: 8. Quarterly statements will be provided in writing to the resident, or the resident's representative within 30 days after the end of the quarter and upon request. Interview on 12/19/2023 at 12:26 pm during the Resident Council meeting with R26 revealed nobody here knows how much money they have. R26 stated they were supposed to have $330.00 but had not received a quarterly statement so she was unsure of the exact amount available to her. Interview on 12/19/2023 at 2:30 pm with R96 revealed because they are not getting quarterly statements. They did not know exactly how much was in their accounts. Interview on 12/20/2023 at 8:30 am with the Business Office Manager (BOM) revealed she provided monthly billing statements and not quarterly resident trust statements as requested for review. She stated that she and the corporate office send out the billing statements. She revealed she thought she was meeting the requirements by sending out the monthly billing statements. Interview on 12/20/2023 at 9:16 am with the Administrator revealed the facility had not sent out quarterly resident trust fund statements since the new BOM started in March of 2023.

Based on observations, staff interviews, record review, and review of the facility policies titled, Dialysis: Hemodialysis (HD) - Communication and Documentation and Hemodialysis (HD) Provided by a Certified Dialysis Facility, the facility failed to maintain consistent communication with the dialysis center for three of eight residents (R) (R109, R2, and R381) receiving dialysis. Specifically, the facility failed to review the communication forms upon residents' return to the facility from the dialysis center and to notify the dialysis center when their portion was not completed. Findings include: Review of the undated facility policy titled Dialysis: Hemodialysis (HD) - Communication and Documentation revealed the policy of the facility is to communicate with the certified dialysis facility prior to sending a patient for hemodialysis (HD) by completing the Hemodialysis Communication Record and sending the document with the resident. The form will also be completed upon the return of the patient from the certified dialysis facility. Under the section titled Practice Standards revealed, 2. Following completion of the HD the dialysis facility nurse should complete the form and return it or other communication to the center with the patient. 3. Upon return of the patient to the center, a licensed nurse will: 4. Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the center. 4.1 Document notification of the certified dialysis facility regarding return of the form or other communication. Review of the undated facility policy titled Dialysis: Hemodialysis (HD) Provided by a Certified Dialysis Facility revealed under the section titled Professional Standards Subheading 1. Responsibilities for the Provision of HD Care/Services revealed 2. Shared Communication between the Center and the Certified Dialysis Facility: 2.1 the care of the patient receiving HD must reflect ongoing communication, coordination, and collaboration between the Center and dialysis staff. 2.2.4 communication topics: 2.2.4.1 timely medication administration (initiated, administered, held, or discontinued); physician orders, laboratory values, and vital signs; 2.2.4.5 dialysis adverse reactions/complications, and/or recommendations for follow up observations and monitoring and/or concern related to the vascular access site; 2.2.4.6 changes and/or decline in conditions unrelated to HD. 1. Observation and interview on 12/19/2023 at 4:45 pm with R109 revealed she was sitting up in bed. R109 revealed she receives dialysis outside of the facility at a dialysis clinic on Monday, Wednesday, and Friday. She stated she has no concerns with her dialysis care or transportation to and from dialysis. She stated that as far as she knows the dialysis center and the nursing facility communicate. Review of the Electronic Medical Record (EMR) for R109 revealed she was admitted to the facility with diagnoses listed but not limited to end stage renal disease (ESRD) and dependence on renal dialysis. Review of R109's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicates R109 was cognitively intact. Section O: Special Services revealed R109 received dialysis services, speech language and pathology services. Review of R109's care plan dated 9/3/2023 indicated a focus of care on requiring hemodialysis related to chronic kidney disease (CKD) at a local dialysis center, date initiated: 9/5/2023, created on: 9/5/2023. Goals included but not limited to the resident will have immediate intervention should any s/sx [signs and/or symptoms] of complications from dialysis occur through the review date. Date Initiated: 9/5/2023. Interventions included but not limited to encourage resident to go for the scheduled dialysis appointments, date Initiated: 9/5/2023, hemodialysis port location to R chest - monitor for bruit and thrill every shift date initiated: 9/5/2023; monitor for dry skin and apply lotion as needed, date Initiated: 9/5/2023; monitor labs and report to doctor as needed, date initiated: 9/5/2023; monitor vital signs as ordered, notify MD of significant abnormalities, date initiated: 9/5/2023; monitor/document/report as needed any signs/symptoms of infection to access site (Redness, Swelling, warmth or drainage), date initiated: 9/5/2023; monitor/document/report as needed signs/symptoms of renal insufficiency (changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds), date initiated: 9/5/2023. Review of physician orders dated 9/6/2023 included: dialysis days Monday, Wednesday, Friday, pick up time at 5:30 am for chair time of 6:00 am. Review of R109's EMR revealed Dialysis Communication Record dated 9/4/2023, 9/6/2023, 9/8/2023, 9/11/2023, 9/20/2023, 9/22/2023, 9/29/2023, 10/9/2023, 10/18/2023, 10/27/2023 and 11/3/2023 revealed that the dialysis center did not document the section indicated to be completed by the dialysis center following dialysis treatment. Review of R109's EMR revealed the nurses notes did not indicate the dialysis center was contacted for the information missing from the Dialysis Communication Record. Interview on 12/20/2023 at 11:23 am with Licensed Practical Nurse (LPN) AA and LPN BB revealed each resident who is a dialysis recipient has a binder at the nurse's desk with dialysis communication forms inside, which the top portion is filled out by the resident's nurse prior to leaving the facility. They stated that the nurse at the dialysis center completes the bottom portion of the form and sends the completed form back to the facility with the resident. They revealed that when the resident returns from the dialysis center, the nurse reviews the communication form and if it is not completed, they call the dialysis center to obtain the information. They are not always able to reach a clinician to verify the resident's condition prior to the resident leaving dialysis. They revealed when this occurs, they document the resident's condition upon return to the facility. Interview on 12/20/2023 at 2:11 pm with LPN AA revealed R109 dialysis frequency was decreased from three times a week to once a week last week. She stated she was not sure if there was an order in the EMR for this change in frequency. She verified and confirmed there were Dialysis Communication Records with missing documentation from the dialysis unit. She stated it is the nurse's responsibility to contact the dialysis clinic for this information that should be documented. Interview on 12/20/2023 at 4:22 pm with the Director of Nursing, she confirmed and verified the Dialysis Communication Record for R109 dated 9/4/2023, 9/6/2023, 9/8/2023, 9/11/2023, 9/20/2023, 9/22/2023, 9/29/2023, 10/6/2023, 10/18/2023, 10/27/2023, and 11/3/2023 were not completed by the dialysis center. She stated she expects staff to review the communication sheets and if they are not completed, she expects the nurse to call the dialysis center to receive the report or fax the document back to them so they can complete and return the document to the facility. 2. Review of R2's EMR revealed that she was admitted to the facility with pertinent diagnoses of but not limited to (ESRD) and dependence on renal dialysis. Review of R2's EMR revealed physician orders to complete post dialysis acceptance every Tuesday, Thursday, and Saturday (dated 4/15/2023), dialysis days Tuesdays, Thursdays and Saturdays, chair time 6:00 am (dated 4/1/2022), and document return from dialysis (dated 10/12/2021). Review of R2's quarterly MDS assessment dated [DATE] revealed a BIMS score of 15, which indicates R2 was cognitively intact. Section O: Special Treatments revealed she received dialysis treatments, speech language and pathology therapy. Review of R#2's care plan dated 12/24/2015 indicated a focus on diagnosis of ESRD, on hemodialysis, history of refusal to go to dialysis related to delusional events (initiated 3/7/2018). Goals included but not limited to resident will have minimal complications related to hemodialysis (initiated 3/7/2018). Interventions included but not limited to ergocalciferol 50,000 units as ordered (initiated 9/23/2020), medications as ordered, monitor for increased confusion (initiated 2/24/2020), monitor dialysis cath [catheter] site for bleeding, swelling, redness, etc. (initiated: 2/24/2020), fluid restriction as ordered (initiated: 3/20/2018), communicate with dialysis center regarding medication, lab results, etc. Coordinate resident care in collaboration with dialysis (initiated: 3/7/2018), dialysis days on Tuesdays, Thursdays, and Saturdays (initiated 3/7/2018). Review of the EMR for R2 revealed Dialysis Communication Record dated 10/17/2023, 11/14/2023, and 12/12/2023 had only the residents pre weight documented under the dialysis center's area to document after dialysis treatment. The Dialysis Communication Record dated 10/24/2023, 10/26/2023, and 12/9/2023 lacked documentation from the dialysis center after dialysis treatment. Review of the nurses' notes revealed that there was no documentation of contact with the dialysis center for the information that was not documented. 3. Review of the EMR for R381 revealed she was admitted to the facility with pertinent diagnoses of but not limited to ESRD and dependence on dialysis. Review of EMR for R381 revealed physician order dated 9/6/2023 for dialysis on Tuesday, Thursday, and Saturday at 6:00 am. Review of R381's admission MDS dated [DATE] revealed a BIMS score of 11 indicating moderate cognitive impairment. Section O: Special Procedures revealed R381 received dialysis, occupational therapy, and physical therapy. Review of R381's care plan dated 12/5/2023 revealed a focus on diagnosis of ESRD on dialysis (initiated on 12/5/2023). Goal established but not limited to resident will have no signs/symptoms of complications from dialysis (initiated on 12/5/2023). Interventions included but not limited to communicate with dialysis center regarding medication, lab results, etc. coordinate resident care in collaboration with dialysis (initiated 12/5/2023), dialysis days Monday, Wednesday, Friday (initiated 12/5/2023), make transportation arrangement for dialysis (initiated 12/5/2023), medications as ordered (initiated 12/5/2023), monitor and report to doctor as needed (initiated 12/5/2023), observe and report to MD [medical doctor] complications related to renal failure, edema/fluid overload, respiratory difficulty/SOB [shortness of breath], increased weakness, changes in mental status, changes in vital signs as needed, nausea/vomiting (initiated 12/5/2023), and obtain vital signs and weight per protocol (initiated 12/5/2023). Interview on 12/21/2023 at 10:00 am with the Regional Nurse revealed that they did an audit of all residents who receive dialysis and found more Dialysis Communication Record forms not completed by the dialysis center.

Based on observations, staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Safety, the facility failed to ensure O2 administered by nasal cannula (NC) was set at the rate prescribed by the physician for one of 25 residents (R) (R1) receiving O2 therapy. The deficient practice had the potential to cause R1 respiratory distress. Findings include: Review of the facility policy titled Oxygen Safety date reviewed/revised June 2023, revealed under the section titled Policy: 1. It is the policy of this facility to provide a safe environment for residents, staff, and the public. Under Policy Explanation and Compliance Guidelines: 1. Safety is the responsibility of all staff, residents, visitors, and the public. Review of the electronic medical record EMR) the quarterly Minimum Data Set (MDS) dated [DATE] revealed the Brief Interview for Mental Status (BIMS) score of 3, which is indicative of severe cognitive impairment. The pertinent diagnoses included heart failure and cerebral infarction (stroke). The care plan revealed R1 has O2 therapy related to decreased O2 saturations, the Resident has a history of congestive heart failure (CHF) exacerbation episode, history of chest congestion with a diagnosis of sinus bradycardia, and the Resident has a history of diagnosis of acute respiratory failure with hypoxia and hypercapnia. Review of R1's physician orders revealed orders from 3/26/2023 for ipratropium-albuterol inhalation solution 0.5-2.5 (3) MG (milligram) /3ML (milliliter) (ipratropium-albuterol) 1 application inhale orally every 4 hours as needed (PRN) for chest congestion, wheezing, and SOB [shortness of breath], and 3/31/2023 for furosemide oral tablet 20 mg give 1 tablet by mouth one time a day for CHF (congestive heart failure), and 5/1/2023 to obtain oxygen saturation and pulse every shift, and 3/26/2023 for oxygen at 2 L (liters) via nasal cannula continuous every shift for SOB/wheezing. Observation on 12/18/2023 at 1:30 pm, R1 was sitting up in the chair with their lunch tray at the bedside. O2 was on R1 at 4 LPM (liters per minute) via NC. Observation on 12/19/2023 at 9:00 am, R1 was sitting up in bed eating breakfast with no distress noted. R1 was wearing O2 at 4 LPM via NC. Observation on 12/20/2023 at 9:30 am, R1 was sleeping in the bed with no distress noted. She was wearing O2 by nasal cannula at 4 LPM. Interview on 12/20/2023 at 10:00 am with Licensed Practical Nurse (LPN) CC verified R1's O2 order was for 2 LPM via NC. The orders and care plan were reviewed with LPN CC, and it was revealed the O2 rate was written for 2 LPM via NC. Went to the R1's room with LPN CC and she verified the O2 was on R1 at 4 LPM via NC. LPN CC turned the O2 flowmeter down to 2 LPM. She stated one of the residents who walks in the hall and goes in other resident's rooms may have turned the meter up. She did not see the other resident do this, but she did see her earlier in the day in R1's room near her bed. LPN CC stated she was in the R1's room about 7:15 am this morning and the O2 rate was at 2 LPM via NC. Interview on 12/20/2023 at 10:15 am with Unit Manager DD confirmed that O2 at 2 LPM via NC was ordered but the O2 was set at 4 LPM via NC. Went to R1's room with Unit Manager DD and she confirmed the excess O2 with the O2 tubing on the floor. Interview on 12/21/2023 at 9:29 am with the Director of Nursing (DON) revealed the staff in the facility had access to a Respiratory Therapist (RT). The RT could be called and would come to the facility. When the RT is not in the building, the nurses would take care of monitoring O2 therapy.

Based on observations, resident and staff interviews, and a review of the facility's policies titled, Glucometer Disinfection, and Infection Prevention and Control Program, the facility failed to ensure the infection control process was followed by one of two Certified Medication Aides (CMA) and one of three Licensed Practical Nurse (LPN) on cleaning and disinfecting a glucometer (a device used to measure blood glucose) after using it on one resident (R) (#21) out twenty-five residents with a physician order for a glucometer reading. Also, using a barrier before placing the glucometer on any surface. In addition, the facility failed to maintain infection control standard precautions by not properly donning Personal Protective Equipment (PPE). Not doffing gloves and performing hand hygiene after handling trash. Mixing linen from the floor with the clean linen. Thirty-four out of forty-two automatic and manual dispensers located throughout the facility did not dispense sanitizer. The resident rooms were not stocked with soap, paper towels, or toilet tissue. Findings include: Review of the policy titled Glucometer Disinfection review date 9/12/2022 indicated: Policy- The purpose of this procedure is to provide guidelines for the disinfection of capillary-blood glucose sampling devices to prevent transmission of blood borne diseases to residents and employees. Policy Explanation and Compliance Guidelines 1. The facility will ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions for multi-resident use. 4. Glucometers will be cleaned and disinfected after each use and according to manufacturer's instructions regardless of whether they are intended for single resident or multiple resident use. 5. j. Using the first wipe, clean first to remove heavy soil, blood and/or other contaminants left on the surface of the glucometer. k. After cleaning, use a second wipe to disinfect the glucometer thoroughly with the disinfectant wipe, following the manufacturer's instructions. Allow the glucometer to air dry. Review of the policy titled Infection Prevention and Control Program dated 9/12/2022 indicated: Policy- This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 9. Equipment Protocol: a. All reusable items and equipment requiring special cleaning, disinfection, or sterilization shall be cleaned in accordance with our current procedures governing the cleaning and sterilization of soiled or contaminated equipment. 11. Linens: a. Laundry and direct care staff shall handle, store, process, and transport linens to prevent the spread of infection. b. Clean linen shall be separated from soiled linen at all times. 1. Observation on 3/30/2023 at 4:30 p.m. of CMA JJ performing a glucometer reading on R#21. The CMA removed the glucometer from the medication cart. The glucometer was placed on top of the medication cart without a barrier. The CMA collected the supplies and don clean gloves. The glucometer was not cleaned prior to entering R#12's room. During the observation, the CMA reached into his pockets several times. The CMA returned to the medication cart and laid the glucometer machine on the cart without a barrier. The CMA did not clean the glucometer machine. After the CMA doff the gloves, the machine was placed back inside the medication cart. The CMA arrived at R#38's room and performed hand hygiene, gathering supplies, the glucometer, and donning gloves. The CMA knocked on R#38's door and announced himself. At this point, the surveyor asked him to please return to the medication cart. Interview on 3/30/2023 at 4:45 p.m. with CMA KK and the Unit Manager (UM). The CMA confirmed that he did not clean the glucometer machine before or after checking R#21's blood glucose. The CMA stated he has never been educated on cleaning the glucometer machine and did not know he should have cleaned the machine between resident use. The UM stated it is the facility policy to clean the glucometer machine between resident's use. She stated she will immediately educate the CMA. 2. Observation on 4/2/2023 at 4:11 p.m. of LPN LL performing a glucometer reading on R#21. The glucometer machine was placed on the bedside table without a barrier. After obtaining the blood glucose on R#21, the glucometer machine was placed on a barrier on top of the medication cart. The machine was cleaned per policy. After cleaning the machine, the LPN placed the Glucometer machine on the dirty barrier. The LPN confirmed that she had laid the machine on the resident's bedside table, and after cleaning the glucometer machine, she placed the machine on the dirty barrier. The LPN stated she realized that it is an infection control issue, but she was nervous during the observation. 3. Observation during the entire complaint survey of the hand hygiene stations not dispensing sanitizer. Observation on 3/30/2023 at 4:11 p.m., the surveyor observed LPN LL go to three hand hygiene stations that did not dispense sanitizer. Observation on 5/5/2023 at 9:45 a.m. of the hand hygiene stations on Hall One, including the resident rooms, had three types of hand hygiene stations fifteen of seventeen do not dispense hand sanitizer. The automatic dispensers total of six located in the hallway that did not dispense sanitizer. Eleven manual dispensers (two types) are in ten resident rooms and the main dining room. Ten dispensers located in the resident's room were empty. Observation on 5/5/2023 at 10:45 a.m. of the hand hygiene stations on three hallways. In Hall One, five out of five automatic dispensers did not dispense sanitizer. In Hall Two, three out of seven automatic dispensers did not dispense sanitizer. Hall Three has two types of hand hygiene stations. Seven out of nine manual dispensers were empty. Four out of four automatic dispensers did not dispense sanitizer. Interview on 4/6/2023 at 11:22 a.m. Account Manager (AM) MM stated he knows that several hand hygiene stations are not dispensing the sanitizer. The AM stated that the company switched over to a touchless dispenser that are battery operated. The touchless dispenser batteries must be replaced almost every other day. The AM stated that when he identified that the hand hygiene stations were not working properly, he brought this to the attention of the corporation. He stated he could not remember the dates that the issue was identified and when he notified someone from the corporation. He stated he would call the individual who orders and oversees supplies so that the surveyor could speak with him. Interview on 4/6/2023 at 11:40 a.m. with the Regional Director of Clinical Operations (RDCO) JJ stated that the person over supplies for the corporation was unavailable. She stated that the facility is aware of the issues with the hand hygiene stations. She stated that the facility is in the process of getting new hand sanitizer dispensers. Interview on 5/4/2023 at 10:59 a.m. with the Account Manager MM and the Director of Nursing (DON) stated he is aware that the hand sanitizer dispenser is not working. He stated that the hand sanitizer dispensers are being replaced in all facilities. He stated he is not aware of a time that the new hand sanitizer dispenser will be available. The DON stated that there is hand sanitizer located at each nursing station, and all staff have been provided with pocket-size hand sanitizer. She stated that the cabinets at the nursing station have extra pocket-size hand sanitizer. Interview on 5/5/2023 at 10:50 a.m. with Certified Nursing Assistant (CNA) NN stated she did not have hand sanitizer in her pocket. 4. Interview on 4/4/2023 at 3:33 p.m. with R#17 stated the staff will enter the room with gloves on. The resident stated she has concerns if the staff are washing their hands and using clean gloves. R#17 stated that the response is rude if you ask the staff to perform hand hygiene and put on clean gloves. Observation and interview on 4/6/2023 at 2:11 p.m. during an interview with R#17, the CNA entered the room coughing, and PPE was not donned correctly. The CNAs surgical mask was positioned below her mouth. The CNA provided care to the other resident in the room. The CNA donned in blue disposable gloves, picked up the plastic bag, tied the bag, and placed it in the trash. The CNA picked up the open pack of wipes off the resident's bed. The CNA walked over to R#17 and asked the resident if she was ready to get changed. The surveyor asked the CNA if she had any education on infection control. The CNA did not answer the surveyor. The surveyor asked the CNA did she place the dirty items from bed A incontinence care in the plastic bag and threw it in the trash with the gloves that she has on. The CNA stated, Yes, why. The surveyor asked the CNA would that not make your gloves dirty? The CNA stated that these gloves are clean. The CNA walked away huffing and puffing, removed the gloves, and went into the bathroom. The CNA walked out to the hallway, loudly asking, Do anybody have gloves. 5. Observation and interview on 4/20/2023 at 3:05 p.m. of the Laundry Aide SS removing clean linen from the dryer. A washcloth fell on the floor. The Laundry Aide retrieved the washcloth off the floor and placed it with clean linen. The Laundry Aide confirmed that the washcloth fell on the floor, and she placed it with the clean items. She stated that the washcloth should have gone into the dirty bin. She said I will take it out and place it where it belongs. The Laundry Aide proceeded to fold the linen that was removed from the drier were the contaminated washcloth was. Interview on 5/4/2023 at 10:59 a.m. with the Account Manager MM stated the laundry aide did inform him of the incident. He stated that any linen that falls on the floor is considered contaminated and should be washed. The AM stated he has conducted an in-service with the staff on the proper way of handling linen. The surveyor requested a copy of the in-service; the AM stated that his computer was not working, and he was unable to provide a copy. 6. Observation on 3/17/2023 during the initial tour of the following rooms [ROOM NUMBER] with no soap or paper towel. Observation on 3/22/2023 at 3:45 p.m. of R#26 bathroom showed the resident had no paper towel or toilet tissue. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting, which had 12-14 residents in attendance. The residents complained about not having supplies, including access to clean linen, hand soap, paper towel, and toilet tissue in their bathroom. Interview on 3/24/2023 at 12:03 p.m. with District Manager (DM) and the Regional [NAME] President of Operations (RVPO) for the environmental services for the facility (Laundry and Housekeeping). The DM stated she expects the staff to check each resident's room for supplies, including soap, paper towels, toilet tissue, and stock if needed. The DM and VP stated they have been cleaning the facility and resident rooms and have identified several environmental issues, including the resident rooms not being fully stocked. The DM stated that more manpower is needed to correct and fix the issues that have been identified. The DM stated that the environmental services are short of three staff. She stated the Account Manager has been terminated and the staff are being retrained. The RVPO stated that linen is ordered twice a month, and there should be no linen issues.

Based on observations, resident and staff interviews, record review, and review of the facility's policy titled, Resident Rights, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity, respect, and individuality for nine of 46 sampled residents (R) (R#32, R#17, R#23, R#9, R#24, R#45, and R#46, R#32, and R Z). Findings include: Review of the policy titled, Resident Rights dated 9/12/2022 indicated: Policy- The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 4. Respect and dignity: The resident has a right to be treated with respect and dignity. Review of the Resident Council Minutes dated 9/21/2022, 10/27/2022, 11/30/2022, 1/18/2023, and 3/23/2023 revealed that seven to 14 residents attended the meetings. The resident voiced concerns repeatedly of staff being unsympathetic or with negative attitudes, staff not knocking on doors, and staff entering resident rooms without permission. Observation on 3/17/2023 at 10:00 a.m. revealed Certified Nurse's Aide (CNA) BB pulling R#45 in a geri-chair backwards from resident's room down the hall to the main dayroom. Observation on 3/22/2023 at 10:30 a.m. revealed CNA BB pulling R#46 in a shower chair backward from the shower room and heading to resident's room. Observation on 3/22/2023 at 2:30 p.m. revealed several dietary staff and the Speech Therapist walking in during the resident council meeting. The staff continued to enter even after the activities staff asked them not to disrupt the meeting. Observation on 3/28/2023 at 11:15 a.m. revealed the Director of Therapy staff entering a resident's room without knocking. Observation on 4/4/2023 at 3:20 p.m. revealed that while interviewing R#32 in their room, a CNA entered the room without knocking and left the room immediately before they were identified. Observation on 4/6/2023 at 2:11 p.m. revealed that while interviewing R#17 in their room, three CNA's at various times, entered the room without knocking or introducing themselves. They left the room before being identified. Observation on 4/20/2023 at 2:30 p.m. revealed several dietary staff walked in during the resident council meeting. The dietary staff continued to enter the room even after the activities staff asked the dietary staff not to disrupt the meeting. Observation on 5/4/2023 at 12:50 p.m. revealed that while interviewing R#23 in their room, a CNA entered the room without knocking or identifying themselves and left immediately. Interview on 3/17/2023 at 10:01 a.m. with CNA BB revealed she was trained to pull residents backwards in a chair and that it was the safest way to transport a resident. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting with R#9, they revealed that the nursing staff would enter their room without knocking. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting with R#24, they revealed that the staff would enter the room without knocking. Interview on 3/23/2023 at 10:25 a.m. with the Registered Nurse (RN) CC revealed the CNAs are not trained to transport residents by pulling them backward down the hall. Interview on 4/4/2023 with R#17 revealed that her roommate's call light was on the floor, Saturday, 4/1/2023. The resident stated that when she expressed her concern about the roommate's call light not being within reach and the roommate needing to be provided incontinent care, the nurse responded to her in a rude, nasty tone. Interview on 4/11/2023 at 10:00 a.m. with Resident Z revealed they have never seen so many mean people in one place. The resident stated the way the staff talked to their roommate, that fell on the floor was cruel. R Z stated the staff was standing over the roommate calling the resident heavy and saying, I cannot pick you up; get up. Interview on 4/25/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed her expectations of the staff are to treat the residents with dignity and respect. The DON stated that the staff are educated to knock on the resident's doors, ask permission to enter, and introduce themselves. The DON stated that all staff are responsible for answering call lights.

Based on observation and resident and staff interviews, and a review of the facility's policy titled, Preventative Maintenance Program, the facility failed to ensure that it was maintained in a safe, clean, and comfortable, homelike environment in 12 of 31 resident rooms with dirty air filters and dirty vents on the Packaged Terminal Air Conditioner (PTAC) units. In addition to the gaps between the wall and PTAC units, missing ceiling tiles, ceiling tiles with large holes, and dirty exhaust fans in the resident's bathrooms. Findings include: Review of the undated policy titled Preventative Maintenance Program revealed: Policy- A Preventative Maintenance Program shall be developed and implemented to ensure the provision of a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Policy Explanation and Compliance Guidelines: 1. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance services to ensure that the buildings, grounds, and equipment are maintained in a safe and operable manner. 2. The Maintenance Director shall assess all aspects of the physical plant to determine if Preventative Maintenance (PM) is required. Required PM may be determined from the manufacturer's recommendations, maintenance requests, grand rounds, life safety requirements, or experience. Review of the PTAC Installation & Operation Guide on page 22. Section J Routine Maintenance revealed: Clean the unit air intake filter at least every 300 to 350 hours (2.5 weeks) of operation. Clean the filters with a mild detergent in warm water and allow them to dry thoroughly before reinstalling. Clean the front cover when needed. Use a mild detergent. Wash and rinse with warm water. Allow them to dry thoroughly. Review of manufacture preventative maintenance instructions for PTAC: Clean air filters. 1. Remove or open the access cover. 2. Remove the air filter and inspect for cleanliness. If the filter is dirty, either wash or replace depending on the type of filter. If clean, reinstall the filter. 3. Re-install the access cover. 4. Clean the grill with the cover. Review of manufacture preventative maintenance instructions for Exhaust Fans: Inspect exhaust fans for proper operation and clean them if necessary. Check exhaust fans for proper operation: 1. Check all exhaust fans in bathrooms, shower rooms, and oxygen rooms. Clean vents using a vacuum and air compressor to remove all dust when needed. 1. An observation on 3/17/2023 at 9:28 a.m. of the PTAC unit in room [ROOM NUMBER], the outside cover was off. The PTAC unit has two filters located in the front that are clogged with a thick amount of dust and debris. The PTAC unit that is connected to the wall had a spoon and remnants of trash in the unit. The outside of the unit revealed that the discharge air grille and return air grille (vent) were covered with black dirt and debris. The PTAC unit was plugged into a wall socket but would not power on. 2. room [ROOM NUMBER] is occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. White pieces of paper (trash) are located inside the vent. 3. room [ROOM NUMBER] is occupied by one resident. A 1.5-inch gap between the PTAC unit and the wall. 4. room [ROOM NUMBER] is occupied by two residents. A 2-inch gap between the PTAC unit and the wall. 5. room [ROOM NUMBER] is occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. 6. room [ROOM NUMBER] is occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. 7. room [ROOM NUMBER] is occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. 8. room [ROOM NUMBER] is occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. 9. An observation on 3/21/2023 at 11:12 a.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. Inside the vent were needle caps and paper trash. 10. An observation on 3/21/2023 at 11:19 a.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has two air filters in the front that are clogged with thick dust and debris. The outside of the unit revealed that the vents were covered with dirt and debris. The ceiling in the bathroom had a 2.5-inch hole with thick black debris in the ceiling. 11. An observation on 3/21/2023 at 3:50 p.m. of room [ROOM NUMBER] occupied by two residents. Missing ceiling tile in the bathroom and dirty exhaust fan. 12. An observation on 3/22/2023 at 8:54 a.m. of room [ROOM NUMBER] occupied by one resident. The PTAC unit has one broken air filter located in the front. A 1-inch gap between the PTAC unit and the wall. 13. An observation and interview on 4/5/2023 at 7:16 a.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has an air filter that cannot be removed. The top of the unit is rusted and appears to be wet. Inside the unit is clogged with a bulky amount of dust and remnants of trash. The bathroom exhaust fan was also covered with dust. The Resident (R#23) stated there has not been anyone from maintenance or housekeeping to check or clean the PTAC unit. The resident also confirmed that the unit leaks on occasion. Review of R#23 quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as twelve which indicated moderately impaired. An observation on 4/6/2023 at 1:50 p.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has an air filter that cannot be removed. The top of the unit is rusted and appears to be wet. Inside the unit is clogged with a bulky amount of dust and remnants of trash. The bathroom exhaust fan was also covered with dust. An observation on 4/11/2023 at 9:20 a.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has an air filter that cannot be removed. The top of the unit is rusted and appears to be wet. Inside the unit is clogged with a bulky amount of dust and remnants of trash. The bathroom exhaust fan was also covered with dust. An observation on 5/4/2023 at 12:52 p.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has an air filter that cannot be removed. The top of the unit is rusted and appears to be wet. Inside the unit is clogged with a bulky amount of dust and remnants of trash. The bathroom exhaust fan was also covered with dust. Observations on 5/5/2023 at 9:40 a.m. of room [ROOM NUMBER] occupied by two residents. The PTAC unit has an air filter that cannot be removed. The top of the unit is rusted and appears to be wet. Inside the unit is clogged with a bulky amount of dust and remnants of trash. The bathroom exhaust fan was also covered with dust. Interview and observation on 3/17/2023 at 10:00 a.m. with the Maintenance Director (MD) confirmed that the front panel was off on the PTAC unit in room [ROOM NUMBER] and would not power on. After the MD obtained a laser thermometer, the temperature in room [ROOM NUMBER] was 69 degrees Fahrenheit. An interview and observation on 3/22/2023 at 11:20 a.m. with the Administrator and MD of the PTAC units, and bathroom ceilings. The Administrator and MD confirm that the filters and vents are dirty and that the filter in room [ROOM NUMBER] was ripped. The Administrator and MD also confirm the trash in the PTAC units, holes in the ceiling tile in room [ROOM NUMBER] and room [ROOM NUMBER], the broken vents in room [ROOM NUMBER], and the gap between the wall and the PTAC unit in rooms [ROOM NUMBER]. Interview on 4/6/2023 at 11:22 a.m. Account Manager (AM) and Maintenance Director (MD) stated that the PTAC units in the resident's room have been added to the daily cleaning routine. Cleaning the outside of vents in the bathroom and PTAC units is the responsibility of the housekeeper. Cleaning the filters and inside of the PTAC units is the responsibility of the maintenance department. The MD stated that all the PTAC units in the facility have been checked and cleaned and will be on a monthly cleaning schedule.

Based on resident, family/resident representative (RP), and staff interviews, record review, and a review of the facility's policies titled, Care Plans, Comprehensive Person-Centered, Transfer or Discharge Preparing a Resident For, and Transfer and Discharge (including AMA), the facility failed to develop a discharge care plan for five of seven residents (R) (R#6, R#10, R#14, R#29, and R#30) that were reviewed for discharged from the facility. Findings include: Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered updated November 2022 indicated: Policy Statement- 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. 8. The comprehensive, person-centered care plan will: f. Include the resident's stated preference and potential for future discharge, including his or her desire to return to the community. 12. The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required comprehensive assessment (MDS) [Minimum Data Set]. Review of the facility's policy titled, Transfer or Discharge Preparing a Resident for dated December 2022 indicated: Policy Statement - Residents will be prepared in advance for discharge. Policy Interpretation and Implementation: 2. A post-discharge plan is developed for each resident prior to his or her transfer or discharge. 3. Nursing services is responsible for: Obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment. Review of the facility's policy titled, Transfer and Discharge (including AMA) review date October 2022 indicated: Policy- It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. 14. Anticipated Transfers or Discharges e. The comprehensive, person-centered care plan shall contain the resident's goals for admission and desired outcomes and shall be in alignment with the discharge. 1. Review of the Admission Record for R#6 revealed they were discharged home on 12/9/2022. Review of R#6's quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as thirteen which indicated R#6 was cognitively intact. Section Q revealed R#6 participated in the discharge planning to be discharged to the community. Review of the care plan initiated 6/15/2022 revealed no documentation of a care plan for discharge planning or desires. Review of the Nursing Note dated 12/9/2022 revealed: Resident discharged today at 11:18{sic} with family member via wheelchair. Resident has all medications, scripts {sic}[prescriptions], and personal belongings when he departed. A phone interview on 3/17/2023 at 2:57 p.m. with R#6's family revealed R#6 was discharged from the facility on 12/9/2022. The family stated that R#6 did not go home. The family stated they found alternate placement with the assistance of the social service department. The family stated R#6 was transported by car to the alternate nursing and rehabilitation center on 12/9/2022 where R#6 was admitted and remains. 2. Review of the Admission Record for R#10 revealed they were discharged to the hospital on 1/4/2023. Review of R#10's admission MDS dated [DATE] revealed a BIMS was assessed as fourteen which indicated R#10 was cognitively intact. Section Q revealed R#10 and the family participated in the discharge planning to be discharged to the community. Review of the care plan for R#10 initiated 10/15/2022 revealed no documentation of a care plan for discharge planning or desires. Review of the Social Service Note dated 11/14/2022 for R#10 revealed: Social Services (SS) spoke to R#10's family who requested that a referral be sent to an alternate facility. SS contacted the alternate facility's admission department, and the referral was faxed to the family's requested facility. There was no documentation that any other follow up was conducted. Review of the Social Service Note dated 1/4/2023 for R#10 revealed: SS spoke to R#10's family again regarding sending the alternate facility referral information. No documentation was found that the referral information was sent or of any other follow-up with the requested facility. An interview on 4/13/2023 at 5:09 p.m. with the family of R#10 revealed the family made a request that R#10 be discharged to an alternate facility. The family stated the Administrator ensured the family that their request for discharge would be honored and a referral would be sent to the facility that the family requested. 3. Review of the Admission Record for R#14 revealed they were discharged on [DATE]. Review of R#14's admission MDS dated [DATE] revealed a BIMS was assessed as thirteen which indicated R#14 was cognitively intact. Section Q revealed R#14 and the family participated in the discharge plan to remain in the facility. Review of the care plan initiated 1/31/2023 revealed no documentation of a care plan for discharge planning or desires. Review of the Nursing Note dated 2/28/2023 revealed R#14 was sent out to the emergency room . The Nurse Practitioner and RP were notified. A phone interview on 3/28/2023 at 6:14 p.m. with the RP revealed on 2/28/2023, R#14 was sent out to the emergency room and was admitted . The RP was informed by the business office manager that the facility would not be readmitting R#14. The family stated that there was never a discussion of R#14 being discharged prior to R#14 being sent out to the hospital. The RP stated the business office manager informed them that R#14 was discharged and would not be allowed to return to the facility after the hospital stay. 4. Review of the Admission Record for R#29 revealed they were discharged home 8/25/2022. Review of R#29's admission MDS dated [DATE] revealed a BIMS was assessed as thirteen which indicated R#29 was cognitively intact. Section Q revealed R#29 participated in the discharge planning to be discharged to the community. Review of the care plan initiated 8/10/2022 revealed no documentation of a care plan for discharge planning or desires. Review of the Nursing Note dated 8/25/2022 revealed R#29 was discharged home with personal belongings and scrips{sic}in a private van. A phone interview on 3/17/2023 at 2:10 p.m. with R#29 revealed the discharge was planned on admission. R#29 stated she was discharged back home on 8/25/2023. 5. Review of the Admission Record for R#30 revealed they were discharged home 2/17/2023. R#30 had no documented comprehensive or quarterly MDS completed. Review of the care plan initiated 2/14/2023 revealed no documentation of a care plan for discharge planning or desires. Review of Communication with Resident Note dated 2/17/2023 at 3:19 p.m. revealed: The resident (R#30) was transported via wheelchair to the front of the facility by staff, resident waited outside for his transportation. R#30 discharged without medication and home health. A phone interview on 4/20/2023 at 4:13 p.m. with R#30 revealed they had multiple sclerosis exacerbation and were unable to walk. R#30 stated the hospital physician recommended for R#30 to go to the facility for rehabilitation to get their strength back. R#30 stated during a care plan conference that they would be discharged to home with assistance from home health services. R#30 stated that the facility discharged them without any services. An interview on 5/5/2023 at 1:00 p.m. with the MDS-Coordinator FF revealed they were responsible for R#30's comprehensive and quarterly MDS. The MDS-Coordinator stated it is not the responsibility of the MDS Coordinators to initiate the residents discharge care plan, as part of the comprehensive care planning process. An interview on 5/5/2023 at 1:15 p.m. with the Social Services Director (SSD) stated a Post Admission Patient/Family Conference is conducted within 72-hours of the resident's admission to the facility. The SSD stated during the conference discharge plans are discussed during and documented with the Resident/Responsible Party/Family. The SSD stated the facility does not create an individualized discharge care plan as part of the residents comprehensive care plan.

Based on resident, family, and staff interviews, record review, and review of the facility's policy titled, Activities of Daily Living, the facility failed to ensure Activities of Daily Living needs were meat for nine of 46 sampled residents (R) (R#6, R#14, R#19, D, E, K,F, J, and K) related to receiving showers as scheduled and related to oral care. Findings include: Review of the facility's undated policy titled, Activities of Daily Living revealed: Policy- 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 diminish. Activities of daily living (ADLs) include Hygiene - bathing, dressing, grooming, and oral care. ADL care is documented every shift by the nursing assistant on an ADL flow record. The ADL flow record will be reviewed at morning meetings. Purpose- To attain or maintain the patient's highest practicable physical, mental, and psychosocial wellbeing. Review of the Grievance/Concern Log Form revealed from 1/1/2023 to 3/17/2023 five residents filed a concern regarding not receiving their scheduled showers/baths. 1. A phone interview on 3/17/2023 at 2:57 p.m. with the family of R#6 revealed the family decided to discharge R#6 on 12/9/2022 due to a lack of care. The family of R#6 stated the facility was not providing R#6 with their scheduled showers/baths. The family stated when they would question why R#6 was not receiving their scheduled showers/baths, the staff would accuse R#6 of refusing. R#6's family stated that R#6 would tell the family the staff was so rough and that was why R#6 refused. R#6's family's concerns were communicated to the facility during a care plan meeting. Review of the Admission Record for R#6 revealed multiple diagnoses of, but not limited to acute osteomyelitis right ankle and foot, diabetes Type II, and peripheral vascular disease. Review of R#6's quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was assessed as 13 which indicated R#6 was cognitively intact. Section G revealed R#6 required one person assist and physical help in part of the bathing. Review of the care plan initiated 6/13/2022 revealed that R#6 had an ADL self-care performance deficit. Intervention to be implemented included shower twice a week and as needed. Review of the Shower Sheet for R#6 revealed shower and skin assessment was completed and signed off by a nurse on 9/5/2022, 11/14/2022, and 11/15/2022. 2. An interview on 3/22/2023 at 2:30 p.m. during a resident council meeting with R D stated the facility was not providing showers/baths on the scheduled days. Review of R Ds quarterly MDS dated [DATE] revealed a BIMS was assessed as 15 which indicated R D was cognitively intact. Section G revealed R D required one person assist and physical help in part of the bathing. Review of the care plan initiated 9/28/2022 revealed that R D had an ADL self-care performance deficit. Intervention to be implemented included shampoo/shower twice a week and as needed. Review of the Shower Sheet for R D from 1/1/2023 to 3/31/2023 revealed shower and skin assessment was completed and signed off by a nurse on 1/6/2023, 1/17/2023, 1/24/2023, 1/31/2023, 2/3/2023, 2/10/23, 2/24/2023, 2/28/2023, 3/10/2023, 3/21/2023, and 3/31/2023. 3. A phone interview on 3/28/2023 at 6:14 p.m. with R#14's responsible party (RP) revealed R#14 was not receiving scheduled showers/baths and hair shampoo. The RP stated these concerns were voiced to the Administrator and the Unit Manager. R#14's RP stated on the day that the complaint was made, R#14 would get a shower/bath and would not receive one again until another complaint was made. R#14's RP stated her loved one, R#14, was also not getting their hair shampooed. Review of the Admission Record for R#14 revealed multiple diagnoses of, but not limited to chronic kidney disease, pulmonary hypertension, and type 2 diabetes mellitus. Review of R#14's admission MDS dated [DATE] revealed a BIMS was assessed as 13 which indicated R#14 was cognitively intact. Section G revealed R#14 required one person assist and physical help in part of the bathing. Review of the care plan initiated 1/31/2023 revealed that R#14 had an ADL self-care performance deficit. Interventions to be implemented included shampoo weekly and as needed. Assist with bathing. Mouth care daily and as needed. Review of the Shower Sheet for R#14 revealed shower and skin assessment was completed and signed off by a nurse on 12/12/2022, 12/14/2022, 12/16/2022, 1/22/2023, and 1/23/2023. 4. An observation and interview on 3/21/2023 at 4:49 p.m. of R K in a wheelchair coming out of the shower room with a family member. The family member stated someone from the family comes 2-3 times a week to give R K a bath/shower. The family stated this has been an ongoing problem with R K not receiving a bath/shower. The family stated they have spoken with the facility regarding the issue, but it continues to be ongoing. Review of R Ks quarterly MDS dated [DATE] revealed a BIMS was assessed as 12 which indicated R K had moderately impaired cognition. Section G revealed R K required one person assist and physical help in part of the bathing. Review of the care plan initiated 3/20/2023 revealed that R K had an ADL self-care performance deficit. Intervention to be implemented included shampoo and shower as scheduled and as needed. Review of the Shower Sheet for R K from 1/1/2023 to 3/31/2023 revealed shower and skin assessment was completed and signed off by a nurse on 1/7/2023, 1/11/2023, 1/18/2023, 1/25/2023, 1/28/2023, 2/1/2023, 2/9/2023, 2/11/2023, 2/16/2023, 2/25/2023, and 3/25/2023. 5. Review of a Grievance/Concern Form dated 3/22/2023 filed by the family of R#19 revealed the family had concerns regarding R#19 not receiving basic care. The family expressed the grievance that R#19 was not receiving the scheduled shower on shower days and that R#19's hair appeared greasy. The facility responded that was the responsibility of the hospice staff to shower and wash R#19's hair. Review of the Admission Record for R#19 revealed multiple diagnoses of, but not limited to heart failure, atrial fibrillation, and type 2 diabetes mellitus. Review of R#19's admission MDS dated [DATE] revealed a BIMS was assessed as 11 which indicated R#19 had moderately impaired cognition. Section G revealed R#19 required one person assist and physical help in part of the bathing. Review of the care plan initiated 2/27/2023 revealed that R#19 has an ADL self-care performance deficit. Intervention to be implemented included shampoo weekly and as needed. Shower as scheduled. Review of the Shower Sheet for R#19 revealed shower and skin assessment was completed and signed off by a nurse on 3/3/2023 and 3/6/2023. No documentation that hospice staff provided a Shower Sheet for bath/shower days. 6. An interview on 3/22/2023 at 2:30 p.m. with R E revealed they were not receiving a bath/shower and was getting worse. R E stated they were being told that there is not enough staff to get baths/showers. R E stated some days the staff would wait until the end of the shift and by that time of the day the residents are tired and didn't want to take one so late and be rushed. Review of R Es quarterly MDS dated [DATE] revealed a BIMS was assessed as 15 which indicated R E was cognitively intact. Section G revealed R E required one person assist and physical help in part of the bathing. Review of the care plan revised 10/24/2022 revealed that R E has an ADL self-care performance deficit. Intervention to be implemented included shampoo and shower as scheduled and as needed. Review of the Shower Sheet for R E from 1/1/2023 to 3/31/2023 revealed shower and skin assessment was completed and signed off by a nurse on 1/16/2023, 1/23/2023, 1/26/2023,1/30/2023, 2/6/2023, 2/9/2023, 2/20/2023, 2/23/2023, 3/13/2023, 3/16/2023, 3/23/2023, and 3/30/2023. 7. An interview on 3/21/2023 at 11:30 a.m. with R F revealed it was a battle to receive a bath/shower on the scheduled day. R F stated baths/showers averaged once a week. R F stated no one gets a bath/shower on the weekend because only one Certified Nurse's Aide (CNA) is assigned to work the entire hall. R F stated some days the shower room was too cold to take a shower. R F stated that if you were lucky to get a bath/shower, there was no clean linen to change your bed. Review of R Fs quarterly MDS dated [DATE] revealed a BIMS was assessed as 15 which indicated R F was cognitively intact. Section G revealed R F required one person assist and physical help in part of the bathing. Review of the care plan revised 1/28/2022 revealed that R F had an ADL self-care performance deficit. Intervention to be implemented included shampoo and shower as scheduled and as needed. Review of the Shower Sheet for R F from 1/1/2023 to 3/31/2023 revealed shower and skin assessment was completed and signed off by a nurse on 1/25/2023, 2/16/2023 2/22/2023, 3/15/2023, and 3/22/2023. 8. A phone interview on 4/5/2023 at 3:43 p.m. with the family of R J revealed they noticed that the facility was short staffed. R Js family stated that the hall that R J lived on had only one CNA. They stated they came to the facility often and provided R J with a bath/shower and mouthcare. They stated they do not believe anyone in the facility ever removed R Js dentures and provided mouth care. The family of R J arrived at the facility on Sunday, 4/2/2023 around 2:00 or 3:00 p.m. and found R J soaked with urine that was dripping from the cushion in the wheelchair. The family stated it was so much urine that R Js clothes and shoes were thrown away. They stated they asked the nurse pill tech for a towel and wash cloth so that they could take R J to the shower. They stated the nurse pill tech could not find the CNA to assist with the shower. R Js family stated the nurse pill tech did not help but stated Please do not do that, the surveyor is in the facility and if the surveyor sees you giving R J a shower we would be in trouble. They stated they gave R J a shower and after finishing they asked to speak to the state surveyor and was told the surveyor was not available. They stated they did come back on Monday and spoke with the Administrator about the gnats in the room from a pile of R Js dirty clothes. They stated they went down to visit R J, walked in the room, and the whole floor was soaked with urine dripping through her wheelchair onto her shoes again. R Js family member stated the roommate told her no one had been in the room all day. They stated they looked at their watch and it was 2:00 o'clock. They stated they asked the staff to get R J cleaned up. They stated because R J had no clean clothes, they left to go buy R J an outfit. When they returned around 6:00 p.m., R J was still sitting in the same spot and had not been cleaned up. R Js family member stated a female came in the room, told them she was from the agency, and pulled to take care of the residents on this hall. They stated the female told her this was her first and last day. R Js family member stated their family wants them to stop complaining about the baths/showers and mouth care because it will be taken out on R J. Review of R Js quarterly MDS dated [DATE] revealed a BIMS was assessed as 15 which indicated R J was cognitively intact. Section G revealed R J required one person assist and physical help in part of the bathing. Review of the care plan revised 1/28/2022 revealed that R J had an ADL self-care performance deficit. Intervention to be implemented included a shower as scheduled and as needed. Mouth care daily. Review of the Shower Sheet for R J from 1/1/2023 to 3/31/2023 revealed shower and skin assessment was completed and signed off by a nurse on 1/4/2023, 1/14/2023, 1/18/2023, 1/28/2023, 2/22/2023, 3/8/2023, 3/11/2023, 3/22/2023, and 3/29/2023. Review of the list of residents with dentures provided did not list R J as having dentures. An interview on 5/4/2023 at 12:54 p.m. with CNA VV revealed R J required help with all ADLs. CNA VV stated they were assigned to R J and did provide a.m. care for today. CNA VV stated R J could brush their own teeth with set up. CNA VV stated they set R J up today and R J brushed her teeth. An interview on 5/4/2023 at 1:00 p.m. with R J revealed they had top dentures only. Their bottom dentures were misplaced a long time ago. R J stated the staff had never provided them with a cup or denture cleaning tablets. R J showed the surveyor their top denture that had food particles and it did not look to be clean. R J gave the surveyor permission to look in their nightstand drawer and a denture cup was found in the back of a three-drawer plastic bin next to the nightstand. An interview on 5/5/2023 at 9:40 a.m. with R J revealed they had not had mouthcare today. R J stated we talked about this the other day. R J stated the staff do not help me with taking my dentures out and cleaning them. R J stated I do not have a cup, mouthwash, or denture cleaning tablets. An interview on 4/25/2023 at 11:00 a.m. with the Director of Nursing (DON) revealed they except the residents to receive their baths/showers as scheduled. All shower sheets are to be filled out completely including any skin changes. Shower sheets are to be completed and given to the Charge Nurse or the Unit Manager before the end of the shift. The Charge Nurses or Unit Manager are to sign off on bath sheets daily to ensure residents are receiving their baths/showers. The resident's linen are changed on bath/shower days. All residents should receive oral care daily. An interview on 5/5/2023 at 11:11 a.m. with MDS-Coordinator LL revealed the comprehensive care plan or the CNA care Kardex does not specifically state if the resident has dentures. They stated the care plan states mouth care daily. They stated it is the responsibility of the staff to assist or conduct mouthcare on all residents. They stated staff should be able to identify if a resident has dentures that need to be removed and cleaned by looking in the residents mouth. They stated the staff can also look for a denture cup to alert when assisting with mouth care.

Based on observations, resident and staff interviews, record review, and a review of the facility's policy titled Activities of Daily Living, the facility failed to provide Activities of Daily Living for three of 46 sampled residents (R) (R#17, R#11, and R#28) dependant of staff for care related to: scheduled showers for R#17; oral care for R#11; and shaving facial hair for R#28. Findings include: Review of the undated policy titled Activities of Daily Living revealed: Policy- 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 diminish. Activities of daily living (ADLs) include Hygiene - bathing, dressing, grooming, and oral care. ADL care is documented every shift by the nursing assistant on an ADL flow record. The ADL flow record will be reviewed at morning meetings. Purpose- To attain or maintain the patient's highest practicable physical, mental, and psychosocial wellbeing. A review of the Grievance/Concern Log Form revealed that from 1/1/2023 to 3/17/2023, five residents filed a concern regarding not receiving the scheduled bath/shower. 2/28/2023 (2), 3/2/2023, and 3/3/2023. 1. An interview on 4/4/2023 at 3:33 p.m. with R#17 voiced several concerns during the interview. The resident stated the staff is not consistent with providing her bath/shower on Tuesdays and Fridays on the 7 a.m.- 3:00 p.m. shift. A review of a grievance filed by R#17 on 2/28/2023 revealed that the resident voiced concerns regarding the water being too cold. Per the grievance, two new water heaters were installed, and the water is not cold. Review of the resident's quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS was assessed as 15, which indicated cognitively intact. Section G revealed that R#17 required one person assistance and total dependence. Record review of the care plan for R#17 initiated on 8/31/2022 revealed that R#17 has an ADL self-care performance deficit. Interventions to be implemented included shampoo weekly and as needed. Assist with bathing. A review of the Shower Sheet for R#17 revealed that a nurse completed and signed off the shower and skin assessment on 2/7/2023, 2/21/2023, 2/23/2023, 3/17/2023, and 3/30/2023. 2. Observation on 3/17/2023 at 11:19 a.m. R#11, in bed responds to her name by looking at the writer. R#11 teeth are dirty with remnants of food in her mouth. Observation on 3/22/2023 at 8:44 a.m. R#11 is in bed, lying on her back. The resident's eyes were open, and R#11 would respond to her name by looking at the writer. An observation of R#11 holding food in her mouth. Observation on 3/22/2023 at 2:00 p.m. of R#11 teeth dirty with remnants of food remaining in her mouth. Interview on 3/22/2023 at 8:50 a.m. with Certified Nursing Assistant (CNA) WW confirmed that R#11 teeth were not clean. The CNA stated the resident was holding grits in her mouth from breakfast. The CNA stated she was going to provide oral care to R#11. Record review of the most recent quarterly MDS for R#11 dated 3/8/2023 revealed in section G revealed that R#11 required one person assistance and total dependence. Record review of the care plan R#11 initiated on 8/31/2022 revealed that R#11 has an ADL self-care deficit. Interventions to be implemented included Assisting with cleaning, removing, and reinsertion of upper and lower partial as needed. Record review of the Dental Progress note for R#11 dated 3/9/2021 revealed that the resident was seen for an exam and cleaning. R#11 has a partial and doesn't take dentures out. The patient states soreness. Initially, wouldn't allow removal, facility nurse help encourage removal. Redness and bleeding were present once the partial was removed. Explained the importance of removing partials at night. The next dental visit was on 2/20/2023 by the hygienist. 3. Observation on 4/5/2023 at 7:34 a.m. of R#28 in bed facial hair noted. Observation on 4/6/2023 at 2:36 p.m. of R#28 in bed facial hair noted. Observation on 4/25/2023 at 10:00 a.m. of R#28 in bed showed a large amount of facial hair. Observation and interview on 5/5/2023 at 10:52 a.m. of R#28 in bed CNA XX entering the room. The CNA stated she had just completed the resident ADLs and will be getting her up for the day. The CNA confirmed that R#28 has facial hair. The CNA stated she shaved R#28 two days ago, and the hair on R#28 face grows fast. The CNA continued to get R#28 up in the Geri chair for the day. Record review of the most recent quarterly MDS R#28 dated 2/23/2023 revealed in section G revealed that R#28 required one person assistance and total dependence. Record review of the care plan for R#28 initiated on 8/31/2022 revealed that R#28 has an ADL self-care performance deficit. Intervention to be implemented included dependent personal hygiene. Interview on 3/22/2023 at 10:00 a.m. with the Administrator and the Social Service Director DD. The Administrator revealed that the facility has not had any grievances regarding showers since 2/27/2023. The Administrator further revealed that the facility has seen a great improvement with the residents being provided with ADL care, including bath/shower.

Based on observation, resident, resident family, and staff interviews, record review, and a review of the facility's policy titled, Answering Call Light and review of the Facility's Assessment, the facility failed to provide sufficient staff on three of four Halls (H) ( H#1, H#2, and H#3), the receptionist area, and environmental service department (laundry and housekeeping), to achieve the highest practicable level of well-being for all residents. The facility continued to admit new residents without having adequate staff. Findings include: Review of the facility's undated policy titled, Answering the Call Light revealed: Purpose-The purpose of this procedure is to respond to the resident's requests and needs. 4. Be sure that the call light is plugged in at all times. 5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 6. Some residents may not be able to use their call light. Be sure you check these residents frequently. 7. Report all defective call lights to the nurse supervisor promptly. 8. Answer the resident's call as soon as possible. 9. Be courteous in answering the resident's call. Procedure- Identify yourself and call the resident by his/her name (e.g., This is Mrs. Smith. Mr. [NAME], how may I help you?). Review of the Facility Assessment with a review date of dated 10/31/2022 revealed: Facility Assessment: The Purpose and Importance of a Facility Assessment: Under 42 CFR S483.70(e), every facility is required to conduct, document, and annually review a facility-wide assessment designed to determine what resources are necessary to care for the facility's residents. The assessment reviews the facility's ability to meet the needs of its residents in both day-to-day operations and emergency situations. Specifically, the assessment will review the following areas: 3. Resources needed- based on the needs identified in the resident profile, what facilities, staffing, equipment, and supplies are needed to properly care for residents. E. Other Needs: Describe all other pertinent facts or descriptions of the resident population that must be considered when determining staffing and resource needs (e.g., residents' preferences with regard to daily schedules, waking, bathing, activities, naps, food, going to bed, etc.) 3. Staff training, education, and competencies- Attach or describe your facility's training program. Include information on what training/education is required, the frequency of training (e.g. before hire and/or ongoing), which individuals or departments are responsible for conducting and tracking training, and how the process is monitored or audited. All New hires attend mandatory on boarding, competencies are completed based on position and title. Training and competencies are maintained in the associates personnel file and updated periodically & annually as determined by center and recertification needs. Review of the Action Summary from 4/4/2023 to 5/2/2023 revealed the facility has had twenty-one new admissions. Review of the Grievance/Concern Form from 2/17/2022 to 4/2/2023 revealed repeated complaints regarding lack of resident care. Review of the PPD (Per Patient Day) Detail Report dated 3/18/2023 and 3/19/2023 revealed: 7 a.m. -3:00 p.m. there were only seven Certified Nursing Assistants (CNA) scheduled on 3/18/2023. 7 a.m. -3:00 p.m. there were only six CNA's scheduled on 3/19/2023. The facility had a census of 141. That would make an average of twenty to twenty-four residents for each CNA that directly affects resident care on four Halls (H#1, H#2, H#3, & H#4). Review of the resident council minutes from 6/30/2022 to 3/22/2023 revealed repeated complaints regarding not receiving baths/showers and linen not being changed due to lack of staffing. Call lights were not being answered. Medications were being left at the bedside. Observation on 3/17/2023 at 8:53 a.m. of the entry door leading to the inside of the facility was propped open with a trash can. Observation of staff and others going in and out the door. There was no receptionist/staff at the door. The door that was propped open with direct access to resident rooms, Rooms 30, and room [ROOM NUMBER]. Observation on 3/21/2023 at 4:55 p.m. of a family member on H#3 removing linen from room [ROOM NUMBER]B's bed, wiping the mattress down, and making the bed with clean linen. Observation and interview on 3/21/2023 at 4:49 p.m. revealed R K on H#3 in a wheelchair coming out of the shower room with a family member. The surveyor spoke with the family in the residents room. R Ks family member stated someone from the family had come 2-3 times a week to give R K a bath/shower. The family stated this had been an ongoing problem with R K not receiving a bath/shower due to not having adequate staff. The family stated they had spoken with the facility regarding the issue, but it continues to be ongoing. Observation on 3/30/2023 at 11:15 a.m. of the call light being on in room [ROOM NUMBER]. The surveyor knocked and R#36 gave permission for the surveyor to enter the room. R#36 stated they had put their call light on about 15 minutes prior to the surveyor entering the room. R#36 stated they had a bowel movement and needed to be changed. Shortly after, CNA ZZ entered the room without knocking or introducing herself. CNA ZZ turned off the call light and asked R#36 What do you need? R#36 told CNA ZZ they had a bowel movement and needed to be cleaned. CNA ZZ told R#36, Your CNA is busy with another resident and will be with you shortly to clean you up. R#36 did not get incontinent care provided until 12:00 p.m. A phone interview on 3/17/2023 at 2:57 p.m. with the family of R#6 revealed R#6 was discharged from the facility due to the lack of care the facility was providing. R#6's family stated they were not sure if the lack of care was a staffing issue or staff competency. R#6's family stated the facility did not have adequate staff to keep the room clean. R#6's family stated they had to come with supplies and clean R#6's room. A phone interview on 3/17/2023 at 11:50 a.m. with the family of R#4 on H#2 revealed the family visits in the late evenings. R#4's family came to visit one night around 9:00 p.m. and found R#4 asleep on the toilet. R#4's family member stated they had to search for staff to assist with getting R#4 off the toilet and into bed. A phone interview on 3/17/2023 at 2:10 p.m. with R#29 revealed they were a resident at the facility for two weeks. R#29 stated there was not enough staff to take care of the residents. R#29 stated there would be one CNA assigned to thirty-five residents. R#29 put their call light on and waited hours before anyone answered. R#29 stated they laid in a urine-soaked bed for more than 15 hours, from day shift to night shift. R#29 did not provide the date or day of the week. R#29 stated the above concerns were reported to the Administrator. Interview on 3/21/2023 at 9:15 a.m. with CNA YY revealed there are not enough staff to adequately supervise the residents on H#2. CNA YY stated the residents on H#2 have behaviors and are impulsive and required close supervision. CNA YY stated to take care of and supervise the residents there needs to be five to six CNA's assigned to H#2. Interview on 3/22/2023 at 9:00 a.m. with the Staffing Coordinator BBB revealed they started this job two weeks ago. Staffing Coordinator BBB stated the facility utilized two agencies to assist with staffing needs. They stated the staffing was a challenge and they would work shifts when needed. Staffing Coordinator BB stated they were aware of the short staffing on 3/18/2023 and 3/19/2023. They stated there were calls made but it was difficult to find people to cover the open shifts. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting revealed R#16 on H#3 stated the laundry turn around is slow and they have clothes that have not been returned. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting revealed R#2, R#5, R#23, and R#25, who all reside on H#3, stated that on the 3:00 p.m. to 11:00 p.m. shift their medications are not given on time. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting revealed R#15 on H#3 stated last night on the 11:00 p.m. to 7:00 a.m. shift they had to put themselves on the bed pan. R#15 had to lay in wet urine all night because there was no staff to assist with removing the bed pan from under them. Interview on 3/22/2023 at 2:30 p.m. during the resident council meeting revealed all residents that attended the meeting expressed concerns regarding not having available linen to complete their activities of daily living (ADL). The call lights are not being answered in a timely manner. The resident council said that the issues that are happening were due to the lack of staffing. The residents on H#3 stated they stayed in their room/bed this past weekend because there was only one CNA to take care of forty residents. The residents complained about not having enough staff to clean the wheelchairs. The residents stated the wheelchairs have not been cleaned in over a year. Interview on 3/23/2023 at 9:06 a.m. with the family member of a resident on H#3 revealed someone from the family visits daily. The family member stated there was not enough staff to do the simple things like bathing and feeding the residents. The family stated someone from the family will visit each day during mealtime to feed their family member. The family member stated the facility does not have sufficient staff to provide adequate resident care. The family stated these issues have been discussed several times over the past four months with the administrative staff. Interview on 3/23/2023 at 12:14 p.m. with R#15's family stated R#15 on H#3 was not ready for their follow up cataract surgery today. The family stated it was not a transportation issue, the van was waiting. There was no staff to get R#15 ready for the appointment. The family had to come to the facility and get R#15 ready and take them to the appointment. Interview on 3/24/2023 at 12:03 p.m. with the District Manager (DM) and Regional [NAME] President of Operations (RVPO) revealed both the DM and RVPO stated they have identified issues with resident rooms not being adequately cleaned and lack of supplies in resident rooms. The DM stated the issues needed to be fixed. Interview on 3/30/2023 at 11:17 a.m. with CNA ZZ revealed they were busy assisting another staff member with a resident in the shower and she did not have time to provide incontinent care to R#36. CNA ZZ stated when R#36's CNA was finished, they would come and provide the incontinent care. Interview on 3/30/2023 at 5:00 p.m. with Licensed Practical Nurse (LPN) AAA revealed they were the nurse responsible for the medication pass on H#1 and H#3. LPN AAA stated they had three Certified Medication Aides (CMA) working. LPN AAA stated because they were the only nurse, that makes them responsible for any medication that the CMA's cannot administer, calls that have to made to the physician, documentation, and any family concerns. The average census on H#I and H#3 was 84. Interview on 4/11/2023 at 9:35 a.m. with R#17 on H#1 revealed this past weekend, 4/8/2023 and 4/9/2023, R#17 and their roommate were not provided incontinent care for over 16 hours. R#17 stated they were provided incontinent care early on the 7:00 a.m. to 3:00 p.m. shift on 4/8/2023. R#17 stated late in the evening on Saturday night, 4/8/2023, they put their call light on, and no one ever answered. R#17 stated there was only one CNA scheduled for both days on the evening shift. R#17 stated that CNA CCC worked a double shift (3:00 p.m.-7:00 a.m.) on 4/8/2023. R#17 stated on Sunday morning that the person who does staffing came in and provided herself and the roommate with incontinent care. Interview on 5/4/2023 at 4:50 p.m. with the Administrator revealed they are aware that the facility has a problem with staff, and they are working diligently to hire staff.

Based on staff interviews, record review, and a review of the facility's policy titled Advance Beneficiary Notice, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Centers for Medicare & Medicaid Services (CMS) Form 10055 and the Notice of Medicare Non-Coverage (NOMNC) CMS Form 10123 for three of five Resident (R) (#30, #31, and #32) who were discharged from Medicare Part A services in the last six months. The facility failed to provide the NOMNC Form CMS-10123 to R#30, who was discharged from the facility. In addition, R#31 and R#32, who remained in the facility, did not receive the NOMNC Form CMS-10123 or the SNFABN Form CMS-10055. Findings include: A review of the policy titled Advance Beneficiary Notice revision date 3/2019 indicated: Policy- It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage. 5. The current CMS-approved version of the forms shall be used at the time of issuance to the beneficiary (resident or resident representative). The contents of the form shall comply with related instructions and regulations regarding the use of the form. For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN), Form CMS-10055. c. A Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) is ending, no matter if the resident is leaving the facility or remaining in the facility. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). i. This notice is used when all covered services end for coverage reasons. ii. An exhaustion of benefits is not considered a termination for coverage reasons. 1. R#30 was discharged from Medicare Part A services on 2/17/2023 and was discharged from the facility. There was no evidence that the facility had issued a NOMNC Form CMS-10123 to R#30 or his responsible party. 2. R#31was discharged from Medicare Part A services on 12/1/2022 and remained in the facility. There was no evidence that the facility had issued a NOMNC Form CMS-10123 or the SNFABN Form CMS-10055 to R#31 or her responsible party, providing the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 3. R#32 was discharged from Medicare Part A services on 2/8/2023 and remained in the facility. There was no evidence that the facility had issued a NOMNC Form CMS-10123 or the SNFABN Form CMS-10055 to R#32 or his responsible party, providing the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. An interview on 4/4/2023 at 4:20 p.m. with the Social Service Director (SSD) stated she is responsible for providing the beneficiary notice. She stated that the NOMNC Form CMS-10123 or the SNFABN Form CMS-10055 should be provided to the Resident/Responsible Party (RP)/Family within 48 hours of being discharged from Part A services. She stated that if a resident is discharged from the facility at the end of the Part A coverage, the Resident/ RP/Family should be provided with the NOMNC Form CMS-10123. The SSD further revealed that when a resident decides to remain in the facility, the Resident/RP/Family should be provided with both the NOMNC Form CMS-10123 and SNFABN Form CMS-1005. The SSD verified that an answer could not be given for why the previous SSD did not give R#30, R#31, or R#32 beneficiary notices. She stated that the problem with the residents' not receiving the beneficiary notices has been identified and brought to the attention of the Administrator. An interview on 4/5/2023 at 12:00 p.m. with the Administrator stated it was her responsibility to ensure that the residents discharged from Part A services received the beneficiary notices. She stated that the issue with the Resident/ RP/Family beneficiary notice has been identified and placed in Quality Assurance and Performance Improvement (QAPI).

Based on staff and resident interviews, record review, and a review of the facility's policy titled Abuse, Neglect and Exploitation, and Resident Rights, the facility failed to ensure three of six residents (R) (#7, #24, #34) were free from neglect related to: leaving R#7 on the floor after a fall for an hour; R#24 being made to stay in the bed for three days due to lack of staff for two weekends; and not providing incontinent care R#34. Findings include: Review of the policy titled Abuse, Neglect and Exploitation review date 11/11/2022 indicated: Policy- It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Ill. Prevention of Abuse, Neglect and Exploitation: The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: C. Assuring an assessment of the resources needed to provide care and services to all residents is included in the facility assessment. Review of the policy titled Resident Rights dated 9/12/2022 indicated: Policy- The facility will inform the resident both orally and in writing, in a language that the resident understands, of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 4. Respect and dignity: The resident has a right to be treated with respect and dignity. 1. Review of the admission Minimum Data Set (MDS) for R#34 dated 1/24/2023 revealed a Brief Interview for Mental Status (BIMS) was assessed as 3, which indicated severe cognitive impairment. Falls are triggered as an area of concern on the Care Area Assessment Summary (CAAS). Record review of the care plan for R#34 initiated on 12/30/2023 revealed that the resident is at risk for falls related to impaired mobility and syncope. Interventions to be implemented included the Resident will not have a significant injury requiring hospitalization . A review of the Fall Incident List dated 12/1/2022 to 4/12/2023 provided by the facility revealed R#34 had the following falls: 1/12/2023 (two falls), 3/30/2023, 4/1/2023, and 4/3/2023. Interview with R Z (BIMS 13) stated R#34 had fallen and was on the floor. He stated he alerted the staff, and it took over an hour for the staff to come and get the resident off the floor. Interview on 4/25/2023 at 11:25 a.m. with the Director of Nursing stated that R#34 also had a fall on 3/28/2023 that was not on the logged. 2. Record review of the most recent quarterly MDS for R#24 dated 2/13/2023 revealed a BIMS was assessed as 15, which indicated cognitively intact. Section G, the resident requires one-to-two-person physical assistance with Activities of Daily Living (ADL). Record review of the care plan for R#24 initiated on 2/10/2023 revealed that the resident has an ADL self-care deficit. Interventions to be implemented include toileting every two hours and at the resident's request. Allow the resident to attempt each task before helping. A review of the grievance log for 3/1/2023 through 4/4/2023 revealed one grievance filed on 4/2/2023 by R#24 concerning maintenance. No other grievances were documented on the log for R#24 or the family of R#24. Interview on 3/22/2023 at 2:30 p.m. with R#24 during the resident council meeting. R#24 stated that this past weekend (3/18/2023 & 3/19/2023), she had to stay in bed because there was no staff to get her up. The resident revealed that not allowing a resident to get out of bed when requested is resident neglect. She stated that most weekends, there is only one Certified Nursing Assistant (CNA), and the residents are suffering because of the lack of staffing. Interview on 3/28/2023 at 3:29 p.m. with R#24 stated she stayed in bed all weekend (3/25/2023 and 3/26/2023) again. She stated that the staff did not give a reason for not getting her up this weekend. The resident stated that today was her 1st day being up since Friday (3/24/2023). The resident was visibly upset about being made to stay in bed. The resident stated she spoke with her family, and the family called to report the lack of care to the Administrator. Interview on 4/2/2023 at 5:00 p.m. with the family of R#24 stated that the facility is leaving R#24 in bed for three to four days in a row. The family called the facility on Monday (3/27/2023) and complained to the Administrator regarding R#24 being left in bed for days in a row. The family stated that R#24 has visitors, and she likes to be up to visit with her friends and family. Interview on 4/2/2023 at 5:03 p.m. with Registered Nurse (RN) UU stated that most weekends, there is only one CNA for each hall. She stated that on the days there is one CNA, the resident does have to stay in bed. The RN stated we do the best that we can. 3. Record review of the Admission MDS for R#7 dated 10/31/2022 revealed a BIMS was assessed as 13, which indicated cognitively intact. Section G, the resident requires two-person physical assistance with Activities of Daily Living (ADL). ADL Functional / Rehabilitation Potential triggered as an area of concern on the CAAS. Record review of the care plan for R#7 initiated on 10/24/2022 revealed that the resident is at risk for ADL self-care performance deficit related to diagnosis and history of a cerebrovascular accident with right hemiplegia (limb weakness). Interventions to be implemented included incontinent care every two hours and as needed. Interview on 4/11/2023 at 8:15 a.m. with R#32 (BIMs 15) stated that on Saturday (4/8/2023), the Certified Nursing Assistant (CNA) purposely placed his roommate's (R#7) call light out of reach and did not provide incontinent care to his roommate (R#7) all day on 4/8/2023. The resident stated that his roommate stayed wet with urine for over 24 hours. R#32 stated he kept putting his light on for the roommate, asking that his call light be placed within his reach and providing incontinent care to R#7. He stated that the staff ignored his request. Interview on 4/11/2023 at 8:20 a.m. with R#7 (BIMs 14) stated he was not provided incontinent care once on Saturday, 4/8/2023. The resident stated he could not call for assistance because his call bell was out of reach. The resident stated he did not get any care until Sunday, 4/9/2023. The resident stated he did not report this to anyone in the facility because it would not change anything. Interview on 4/21/2023 at 8:48 a.m. with Restorative Nursing Aide (RNA) stated, R#7 stated the resident requires total assistance with all ADL. She stated that R#7 can verbalize his needs.

Based on staff and resident interviews, record review, and a review of the facility's policies titled, Discharge Against Medical Advice (AMA) and Transfer and Discharge (including AMA), the facility failed to ensure that the Ombudsman was notified about four of seven residents (R) (#30, #10, #14, and #29) reviewed for discharge. R#30 discharge was initiated by the facility and documented as leaving against medical advice (AMA). In addition, R#10 and R#14 were transferred to the hospital, and R#29 was discharged from the facility to home. Findings include: Review of the undated policy titled Discharge Against Medical Advice (AMA) indicated: AMA discharges will be processed in accordance with the patient's/resident representative's request to arrange for a safe discharge. A Discharge Transition Plan will be provided to the patient or resident representative. Efforts will be made to make referrals to community resources. and agencies to the extent time permits. Appropriate discharge documentation will be completed as applicable. Referral to Adult Protective Services will be made when appropriate. Contact the Ombudsman and Adult Protective Services (APS). Review of the policy titled Transfer and Discharge (including AMA) review date 10/1/2022 indicated: Policy- It is the policy of this facility to permit each resident to remain in the facility, and not initiate transfer or discharge for the resident from the facility, except in limited circumstances. 12. Emergency Transfers/Discharges - initiated by the facility for medical reasons to an acute care setting such as a hospital, for the immediate safety and welfare of a resident (nursing responsibilities unless otherwise specified). h. The Social Services Director, or designee, will provide copies of notices for emergency transfers to the Ombudsman, but they may be sent when practicable, such as in a List of residents on a monthly basis, as long as the List meets all requirements for content of such notices. In situations where the facility has decided to discharge the resident while the resident is still hospitalized , the facility will send a notice of discharge to the resident and resident representative before the discharge and must also send a copy of the discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. Notice to the Ombudsman will occur at the same time the notice of discharge is provided to the resident and resident representative, even though, at the time of initial emergency transfer, sending a copy of the transfer notice to the Ombudsman only needed to occur as soon as practicable. 13. Discharge Against Medical Advice (AMA). a. Under no circumstances will the facility force, pressure, or intimidate a resident into leaving AMA. b. The physician should be notified of the intended AMA discharge and be encouraged to speak with the resident to encourage them to stay at the facility. d. Notify Adult Protection Services, or other entity, as appropriate if self-neglect is suspected. 1. Review of the Admission Record for R#30 revealed he was admitted to the facility on [DATE] and discharged against medical advice (AMA) on 2/17/2023. The resident had no documented comprehensive or quarterly Minimum Data Set (MDS) completed. A review of the Communication Note for R#30 Note dated 2/17/2023 at 1:30 p.m. revealed: that Social Services, Nurse Practitioner, and the unit manager spoke to R#30 regarding concerns and the smoking policy. R#30 stated he had concerns he reported to the insurance company the day after admission because he was not receiving his pain medication. R#30 was concerned because he feels staff will falsely accuse him of smoking, and he will be involuntarily discharged from the facility. R#30 was assured that all situations are thoroughly investigated before any decisions are made. R#30 was informed that while in the care of the facility, it is the facility's responsibility to ensure all possible measures are exhausted and to ensure the safety and security of the residents. A review of the Communication Note for R#30 dated 2/17/2023 at 3:19 p.m. revealed: R#30 was transported via wheelchair to the front of the facility by staff; the resident waited outside for his transportation. R#30 was discharged without medication and home health. A phone interview on 4/20/2023 at 4:13 p.m. with R#30 stated he had multiple sclerosis exacerbation and was unable to walk. He stated that the hospital physician recommended that he (R#30) go to the facility for rehabilitation to get his strength back. The resident stated he did not leave the facility on 2/17/2023 against medical advice. The resident revealed he was put out by the social worker. The resident stated that the social worker and the unit manager were accusing him of smoking weed. The resident stated that no weed was in his possession, and he offered the social worker to search his bag. The resident stated that the social worker threatened to call the police if he did not leave on his own. The resident stated that when the social worker threatened to call the police, he was afraid. He stated that black males are killed at the hands of the police every day. He stated that being a __-year-old black male, he did not feel anything good would come out of the situation by him remaining in the facility after being threatened with the County Police Department. The resident stated that the staff took him outside via wheelchair because he could not walk. The resident stated he left the facility through a transportation company with no medication or home health assistance. The resident stated he was not offered a 30-day discharge notice, he was only offered to leave the facility on his own or with the assistance of the police. There was no documentation that a 30-Day Notice Involuntary Transfer or Discharge Form was provided to R#30 or the family of R#30. There was no documentation that the Ombudsman or APS was notified of R#30's discharge. 2. Review of the Admission Record for R#10 revealed he was admitted to the facility on [DATE] and discharged to the hospital on 1/4/2023. Record review of the Admission MDS R#10 dated 7/13/2022 revealed in section Q R#10, that the family participated in the discharge planning to be discharged to the community. A review of the Nursing Note dated 1/4/2023 revealed: At 3:30 p.m., paramedics arrived at the nurse's station and stated R#10's family called 911 and would like her father to go to the hospital. A phone interview on 4/13/2023 at 5:09 p.m. with the family of R#10 stated that on 1/4/2023 around 3:00 p.m., upon entering their dad's (R#10) room, they noticed he was not acting like himself. The family stated that R#10's oxygen tank was empty, and the nasal cannula was clogged with a thick glue-like substance. The Family stated they alerted the Certified Medication Aide (CMA) to come and assess their dad. The CMA told the family to call the ambulance and have him (R#10) transferred to the hospital. The family stated that 911 was called from R#10's room. When the Emergency Medical Service (EMS) arrived and assessed R#10, they also agreed that he needed to be transported to the hospital. The family stated that their father did not return to the facility. No documentation that the Ombudsman was notified of R#10 transfer to the hospital. 3. Record review of the Admission Record for R#14 revealed she was admitted to the facility on [DATE] and discharged on [DATE]. Record review Admission MDS for R#14 dated 12/13/2022 revealed a BIMS was assessed as thirteen, which indicated cognitively intact. Section Q revealed R#14 and the family participated in the discharge plan to remain in the facility. Record review of the Nursing Note for R#14 dated 2/28/2023 revealed: The resident (R#14) Requested to be sent out to the emergency room related to complaints of constipation and stomach pain. The Nurse Practitioner and RP were notified. A phone interview on 3/28/2023 at 6:14 p.m. with RP stated that on 2/28/2023 R#14 was sent out to a local emergency room and was admitted . The hospital informed the RP that R#14 was ready to be discharged , but the hospital was having trouble contacting the facility. The RP made a visit to the facility and was told by the business office manager that the facility was refusing to take R#14 back. The RP stated she was not given a reason. The RP stated that R#14 was not offered a seven-day bed hold or provided a 30-Day Notice Involuntary Transfer or Discharge letter. There was no documentation that the Ombudsman was notified that R#14 was transferred to the hospital and the facility would not allow R#14 to return. 4. Review of the Admission Record for R#29 revealed she was admitted to the facility on [DATE] and discharged home on 8/25/2022. Record review of the Admission MDS for R#29 dated 8/15/2022 revealed a BIMS was assessed as 13, which indicated cognitively intact. Section Q revealed that R#29 participated in the discharge planning to be discharged to the community. Record review of the Nursing Note for R#29 dated 8/25/2022 revealed resident was discharged home with personal belongings and scrips {sic} in a private van. A phone interview on 3/17/2023 at 2:10 p.m. R#29 stated the discharge was planned on admission. The resident stated she was discharged back home on 8/25/2023. There was no documentation that the Ombudsman was notified that R#29 was discharged home. Interview on 4/11/2023 at 1:46 p.m. with the Social Service Director (SSD) stated it is the facility's policy, to notify the Ombudsman of all transfers (home or hospital) and discharges initiated by the facility. She stated that a copy of a resident's 30-Day Notice Involuntary Transfer or Discharge letter is sent by certified mail with a follow-up phone call. The SSD revealed she will notify the Ombudsman of the transfer (home or hospital) with a call and/or email. The SSD stated she was not employed with the facility when R#10, R#14, and R#29 were transferred (home or hospital). She stated that R#30 should have been offered counsel; intervention to engage in an activity. She stated that the physician and adult protective services should have also been notified of R#30 leaving AMA. She stated that if R#30 discharge or leaving AMA was facility initiated, the Ombudsman should have been notified immediately of the resident leaving. A phone interview on 4/6/2023 at 8:56 a.m. with the Ombudsman for the facility. The Ombudsman stated she was not aware that R#10, R#13, and R#14, were transferred to the hospital, and R#29 was discharged home. She also stated that she was not aware that R#30 was asked to leave the facility. The Ombudsman revealed that she has not received any discharge or transfer notifications from the facility since September 2022. Interview on 5/5/2023 at 1:15 p.m. SSD stated that a Post Admission Patient/Family Conference is conducted within 72 hours of the resident's admission to the facility. She stated that discharge plans are discussed and documented during the conference with the Resident/Responsible Party/Family. The SSD revealed that the response is documented on the Post Admission Patient/Family Conference form. The SSD stated that the facility does not create an individualized discharge care plan, as part of the resident's comprehensive care plan.

Based on staff and family interviews, record review, and a review of the document titled Social Services Care Management, the facility failed to ensure social services, including referrals to other facilities, were provided for one of seven sampled residents (R) (R#10) reviewed for tranfer/discharge. Findings include: Review of the undated document titled Social Services Care Management indicated: Medically related social services refer to services provided by the facility's staff to assist residents in attaining or maintaining their mental and psychosocial health. Examples of medically related social services include but are not limited to referral management. Record review of the Admission Minimum Data Set (MDS) for R#10 dated 10/21/2022 in section Q revealed, Participation in Assessment Discharge Plan and Goal setting: R#10 and the family were a source of information. The noted question, Is there an active discharge plan in place for the resident to return to the community? The response is to be noted to be Yes. Has a referral been made to the local contact agency? The answer was entered as No determination has been made by the resident and the care planning team that contact is not required. Record review of the Social Service Note for R#10 dated 11/14/2022 revealed: The SS contacted the facility's admissions department, and the referral was faxed to the family's requested facility. No documentation that any other follow-up was conducted. An on Interview 4/13/2023 at 5:09 p.m. with the family of R#10 stated the Administrator was contacted about the family's concerns with the lack of care R#10 was receiving at the facility. The family stated they also spoke with the Social Worker at the facility and were told they were waiting for a transfer referral from the physician. The family stated that when they contacted the facility, they wanted their dad transferred to, they were informed that the referral was never sent. Interview on 4/12/2023 at 3:41 p.m. with Social Service Director (SSD) EE stated the facility never received a referral for R#10 to be considered for admission. Interview on 5/4/2023 at 10:30 a.m. with the Social Service Director, DD for the facility stated she is responsible for sending referral information upon a Resident/Responsible Party (RP)/Family request. She stated that the required referrals are sent within 24 hours of the request (business days). The SSD further revealed that the information is sent by fax with a follow-up call on the next business day. The follow-up call is to ensure the information faxed was received. She stated she will inquire if the resident is considered for admission. If the resident is accepted, she will notify the Resident/RP/Family and the Interdisciplinary Team (IDT). She stated that the discharge and transfer process would be initiated. She stated that if the facility declines to accept the resident for admission, she will communicate that information to the resident/RP/Family. The SSD continued to reveal that she was not employed when the family of R#10 requested the transfer. She stated that the prior SSD should have communicated with the family regarding a transfer in a timelier fashion.

Based on observation, resident and staff interviews, record review, and a review of the facility's policy titled Medication Administration, the facility failed to ensure two of nine sampled residents (R) (R#5 and R#17) was free from a medication error related to: a significant medication error which resulted in a decline in condition for R#5 requiring a hospital admission twice for a hypertensive crisis; and not administering medications according to the physician orders for R#7. Findings include: Review of the undated policy titled Medication Administration revealed: Policy-A licensed nurse, Med Tech, or medication aide, per state regulations, will administer medications to patients. Accepted standards of practice will be followed. Purpose-To provide a safe, effective medication administration process. Administer medication. Remain with the patient until the administration is complete. Do not leave medications at the patient's bedside. Review of the document titled Clinical Competency Validation Medication Administration dated 1/1/2017 3. Medication Administration: B. Verifies medication orders in Medication Administration Record (MAR) matches the medication label. Checks specific administration directions and is aware of patient allergies. C. Verifies medication(s) expiration date. 0. Remains with the patient until the administration is complete. Does not leave medications at the patient's bedside. p. Correct medication(s) administered to patient. q. Correct medication dose administered to the patient. r. Medications administered as ordered. A review of the requested Review of Medication Pass Observation Report dated 5/17/2022 revealed the three employees, two Licensed Practical Nurses (LPN), and one Certified Medication Aide (CMA). No other medication pass observations were provided to the survey team. 1. Interview (BIMS 13) on 3/21/2023 at 11:25 a.m. The resident stated that he is not receiving his evening medications. He stated he receives three medications in the evening: seizure medication, blood pressure (BP) medication, and cholesterol medication. The resident stated the evening of 3/20/2023, he only received BP and Cholesterol medication. R#5 revealed while showing the surveyor a copy of his medication list that he did not receive his Keppra for seizure. He stated that when he questioned the nurse, he was told that Keppra (Levetiracetam) was not on the list of medications to be given. The resident could not give a definitive date but stated that not receiving his medication as ordered by his physician has been happening for the past few weeks. R#5 further revealed that the person administering the medications is never the same, and each person administers the medication differently. Some staff will administer the medication as scheduled, and some nights he will get all three medications at one time. The resident stated that it is very important to him to receive all the medication the physician ordered. He is fearful of having a seizure and ending up in the hospital. The resident stated he has complained to several people about not getting his medication. He stated that the staff will check the computer and tell him it is documented that he had received the medication. Record review of the Electronic Medical Record (EMR) Admission Record for R#5 revealed he was admitted with multiple diagnoses of, but not limited to, atrial fibrillation, essential (primary) hypertension, hypertensive urgency, and unspecified convulsions. A review of the Order Summary Report for R#5 revealed the following medications to be administered but not limited to: Levetiracetam (medication to prevent seizures) 500 milligram (mg) one tablet by mouth twice a day, Coreg (medication for elevated blood pressure) 12.5 mg one tablet by mouth twice a day, Lisinopril (medication for elevated blood pressure) 10 mg one tablet by mouth once a day, Atorvastatin Calcium (medication for high cholesterol) 40 mg one tablet by mouth at bedtime, Lasix (medication for excessive fluid in the body) 20 mg one tablet by mouth once a day, and Levothyroxine Sodium (medication for deficiency of thyroid hormones) 75 micrograms (mcg) one tablet by mouth once a day. Record review of the Medication Administration Record (MAR) from 1/2023 through 3/1/2023 revealed: Levetiracetam 500 mg no documentation that the dose was administered at 4:00 p.m. on 2/12/2023. Coreg 12.5 mg no documentation that the dose was administered at 4:00 p.m. on 1/16/2023 and 2/12/2023. Atorvastatin Calcium 40mg no documentation that the dose was administered at 8:00 p.m. on 2/12/2023, 3/4/2023, 3/6/2023, 3/22/2023. Levothyroxine Sodium 75 mcg 6:00 a.m. no documentation that the dose was administered on 1/29/2023, 2/18/2023, and 3/18/2023. Record review of the Nursing Note dated 4/16/2023 revealed that R#5 complained of chest pain, and the resident's BP was 184/126, pulse 130. The physician and responsible party were notified. The resident was transferred to the hospital. Record review of the Nurse Practitioner note R#5 dated 4/24/2023 revealed: chest pain, and shortness of breath, the resident's BP 220/130, respirations 22. The Resident was transferred to the hospital. 2. Observation on 3/30/2023 at 5:00 p.m. of medication administration for R#17 with Certified Medication Aide (CMA) GG. The CMA verbally verified the number of pills in the cup as seven and one nose spray. The CMA administered R#17 Flonase spray one spray in both nostrils that was not ordered for 5:00 p.m. The CMA did not administer the scheduled Fluticasone-Salmeterol (Advair) 100-50 one puff per physician order. Interview on 3/30/2023 at 5:20 p.m. with CMA GG confirmed that a medication error was made. She stated that R#17 should have received Fluticasone-Salmeterol (Advair). The CMA stated she would notify the unit manager. Record review of the Physician orders for R#17 during the period of 3/1/2023 to 3/31/2023 revealed the following medications to be administered at 5:00 p.m.: Baclofen 5 mg 1 tablet, Gabapentin 600 mg 1 tablet, Creon 24000 1 tablet, Mycophenolate 500 mg 1 tablet, Methenamine 1 gram 1 tablet, Pantoprazole 40 mg 1 tablet, Acidophilus with pectin 200 mil 1 tablet, Fluticasone-Salmeterol (Advair) 100-50 1 puff. Interview on 3/22/2023 at 9:10 a.m. with Licensed Practical Nurse (LPN) AA stated she just started her medication pass, and three residents have complained they did not receive their night medication on 3/21/2023. The LPN opened the EMR for R#5, revealing that the 3-11 p.m. nurse documented that the Atorvastatin Calcium was not available to give. Interview on 4/13/2023 at 10:04 a.m. with [NAME] President Clinical Services II revealed that the facility is required to conduct medication pass observations. She stated it is the agency's responsibility to provide training to their employees, including medication pass, abuse/neglect, etc., before the employee can begin working at the facility. Interview on 5/2/2023 at 1:20 p.m. with LPN HH stated that the staff is aware of how to use the automated medication dispensing system. In a case that the pharmacy has not delivered the resident's medication, the automated medication dispensing system can be utilized.

Based on observations, record review, interviews, and review of the facility policies titled Notification of Changes and Accidents/Incidents, the facility failed to promptly notify the Physician and responsible party (RP) timely for a change in condition including a fall and self-injurious behavior after a fall for one of three residents (R) R#119. Actual harm occurred when R#119 had a fall on 2/19/2022 and suffered a laceration to the residents' scalp that required 10 staples and the resident exhibited a change in behavior of banging his head on doorframe of bathroom. The Physician was not notified until the following day at 4:25 p.m., 37 hours after the residents fall. Findings include: Review of the facility policy titled, Notification of Changes dated November 2017 revealed the purpose is to ensure the facility promptly informs the resident, consults the resident's physician, and notifies, consistent with his or her authority, the resident's representative when there is a change requiring a notification. Circumstances requiring notification include but are not limited to: 1. Accidents resulting in injury or the potential to require physician intervention 2. Significant change in the resident's physical, mental or psychosocial condition such as a deterioration in health, mental or psychosocial status 3. Circumstances that require a need to alter treatment Review of the undated facility policy titled, Accidents/Incidents revealed accident is defined as any unexpected or unintentional incident which may result in injury or illness to a resident/patient. Assessment, Medical Assistance, Documentation 2.1.3 the Nurse will notify the Physician/Advanced Practice Provider (APP) of the accident, report the physical findings and extent of injuries, and obtain orders as indicated. 2.1.3.1 if the injury is of an emergent nature, the patient will be transported to the hospital. 2.1.5 the patient's responsible party/family will be notified of the accident and any follow-up treatment needed. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Admission Minimum Data Set (MDS) dated [DATE] was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of a document taped to the glass at the desk on the dementia unit, during the survey with the Director of Nursing (DON) name and cell phone number that states weekends and after hours please call for: falls, staff incident/staffing concerns, injury of unknown origin, change in condition, emergency room /hospital visits, unexpected deaths, State, and Police. Review of Progress Note dated 2/19/2022 at 3:50 a.m. written by Registered Nurse (RN) BB, revealed resident (R#119) in the bathroom washing his face. Resident stated he was sitting in chair, fell asleep and leaning forward. Upon assessment, abrasion noted in his head and bruise under right eye. Resident complains of pain and was medicated. Abrasion cleaned with normal saline, pat dry and apply triple antibiotic ointment (TAO), leave in air [sic]. Nurse Practitioner and responsible party will be notified in the a.m. Review of Progress Note dated 2/20/2022 at 6:50 a.m. written by LPN DD, revealed resident hit his head in the bathroom door three times and each time a new dressing was replaced. The Certified Nursing Assistant (CNA) and nurse observed resident taking dressing off and hit his head to the door corner and calling for help. At 7:00 a.m., he did it again. Review of the Progress Note dated 2/20/2022 at 4:25 p.m. written by Unit Manager (UM) EE, revealed Physician HH was notified of the fall that took place Friday. Physician HH gave order to send resident to the emergency room (ER) for eval [sic] related to head injury from the fall. Responsible party was notified of resident going to the ER. Review of the Interact Change in Condition Evaluation V 5.1 dated 2/20/2022 at 7:20 p.m. completed by UM EE, revealed the physician wasn't notified of the change in condition for R#119 until 2/20/2022 at 4:05 p.m. Review of the Progress Note dated 2/19/2022 at 1:56 p.m. written by Licensed Practical Nurse (LPN) CC revealed call was made to family member regarding fall. There is no documentation that the Physician was notified of R#119 fall with injury at this time. Interview on 2/20/2022 at 3:50 p.m. with the DON stated she was not aware R#119 had a fall or that he had a head injury but would have expected staff to call her and the MD immediately. Interview on 2/21/2022 at 10:00 a.m. with LPN AA stated R#119 had taken off his bandage 3 to 4 times the previous day. LPN AA stated she should have reported his head injury immediately when she changed his bandage after starting her shift yesterday morning, and saw what it looked like, but stated she did not tell anyone. Telephone interview on 2/21/2022 at 10:51 a.m. with Physician GG stated he has not known R#119 to physically harm himself, but if he were hitting his head against a door frame, he would expect staff to notify him immediately. He revealed the facility did not inform him R#119 was hitting his head against the door of the bathroom, when the DON called him on 2/20/2022, sometime after 2:00 p.m. During further interview, he stated that he would expect the facility to notify him right away for behaviors of self-harm or injury. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. She stated the morning of 2/20/2022 at approximately 6:30 a.m. she heard a CNA yelling for help. When she arrived at R#119's room, he was observed hitting his head on the bathroom door frame. During further interview, LPN DD stated she did not call the physician regarding the resident hitting his head because she did not feel it was bad enough to notify the Doctor. Interview on 2/22/2022 at 2:30 p.m. with the DON stated she had no prior knowledge of R#119 having behaviors of hitting his head against things. She revealed she had concerns that the Physician was not notified of resident hitting his head against the doorframe of the bathroom. During further interview, she stated her expectation is that staff should contact the Physician immediately for any accident or a change in condition. During a telephone interview on 2/22/2022 at 8:30 p.m. with RN BB revealed she was the nurse on duty 2/19/2022 when R#119 fell from his chair. She revealed she did not see him fall but found him at the sink in his bathroom washing blood from his face. She stated R#119 told her he fell out of his chair. RN BB stated the resident had an abrasion on his head and it was bleeding, so she held pressure and once it slowed down, she cleaned his head and put a bandage on it. She stated she did not call the MD because it was between 2:00 a.m. and 3:00 a.m. and it was too early to call him and stated she didn't believe it was serious enough to call the Doctor. Post survey telephone interview on 3/15/2022 at 2:30 p.m. with the DON revealed the nurses are expected to be charting in the electronic medical record (EMR) in real time, meaning that as soon as things happen, the staff should be documenting it. She further stated that she does believe that the staff are doing as they are required, with documentation. During further interview, she stated that staff are to call the Physician and responsible party for all incidents and changes in condition and stated it is not acceptable to postpone notification until later in the day, or the next day. Cross refer F600

Based on observations, record review, resident and staff interviews, and review of the facility policy titled Abuse Prohibition, the facility neglected to ensure that one of three residents (R) R#119 received timely treatment following a fall and change of condition. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. The facility neglected to send the resident to the emergency room (ER) for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled Abuse Prohibition dated 8/2019, revealed the policy is to prohibit abuse, mistreatment, neglect, involuntary seclusion, and misappropriation of property for all patients. Neglect is defined as the failure to provide goods and services necessary to avoid physical harm. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's most recent Admission Minimum Data Set (MDS) dated [DATE] was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of Progress Note dated 2/19/2022 at 3:50 a.m. written by Registered Nurse (RN) BB, revealed during rounds, writer noted resident in the bathroom washing his face. Resident stated he was sitting in chair, fell asleep and leaning forward. Upon assessment, abrasion noted on his head and bruise under right eye. Moderate amount of blood noted on his head. Neuro checks initiated. Resident complains of pain and was medicated. Abrasion cleaned with normal saline, pat dry and apply triple antibiotic ointment (TAO), leave in air [sic]. Review of Progress Note dated 2/20/2022 at 6:50 a.m. written by LPN DD, revealed resident (R#119) was observed to hit his head on the bathroom door three times and each time a new dressing was replaced. The Certified Nursing Assistant (CNA) and nurse observed resident taking dressing off and hitting his head to the door corner and calling for help. Review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review had no evidence that R#119 was medicated for pain. Observation on 2/20/2022 at 3:30 p.m. R#119 sitting in a wheelchair in the doorway of his room. He had a bandage on the top of his head, near his forehead, taped to his hair. There was blood noted on his shirt and pants. The dressing was removed by Licensed Practical Nurse (LPN) and noted to have large lump and gash that went down to the crown of his head. There was dried blood in his hair. He was also noted to have bruising under his right eye. Interview on 2/20/2022 at 3:30 p.m. with R#119 revealed he had a fall a day or two ago from his chair and stated his head hurts. Observation on 2/20/2022 at 3:35 p.m. with LPN AA removed the bandage from R#119 head to reveal a laceration with a large hematoma. Observation revealed a large amount of a reddish-brown substance in the top part of the resident's hair. Interview on 2/20/2022 at 3:35 p.m. with LPN AA stated she was informed that R#119 fell when she arrived to work today. She stated with a head injury, the resident should have been sent to the hospital for evaluation. During further interview she stated she changed the dressing to R#119's scalp earlier that morning and did not tell anyone about the laceration and large hematoma to his head. Interview and observation on 2/20/2022 at 3:50 p.m. with the Director of Nursing (DON) revealed she was not aware R#119 had a fall or that he had a head injury. She stated she would expect staff to call her and the Doctor immediately. The DON observed the resident's scalp wound, at this time, and confirmed the resident had a laceration to his head. Review of the Interact SNF/NF to Hospital Transfer Form dated 2/20/2022 at 4:50 p.m. completed by Unit Manager (UM) EE, revealed reason for transfer as trauma (fall related). The usual mental status/cognition function for R#119 before the acute change in condition was alert, oriented, follows instructions with behavioral issues of yelling with verbal reminders from staff to call for help. Further review revealed there was not any evidence of documentation of the observations of R#119 hitting his head and calling for help. Review of the Interact Change in Condition Evaluation V 5.1 dated 2/20/2022 at 7:20 p.m. completed by UM EE, revealed the change in condition was documented to be a laceration to top of the head related to injury to site which started on 2/19/2022 at night. Further review of the document revealed the physician wasn't notified of the change in condition until 2/20/2022 at 4:05 p.m. Review of the hospital ER record encounter date 2/20/2022 revealed chief complaint as fall. The patient (R#119) came from nursing home via EMS with a fall. Patient hit their head causing a laceration on the forehead. Patient is on blood thinners upon arrival bleeding is controlled. General appearance is disheveled, cachectic, altered, does not answer questions appropriately, laceration with dried blood to head, refuses to open eyes. Interview on 2/20/2022 at 10:30 p.m. with the ER Physician II, revealed R#119's head injury was a laceration with contusion and not an abrasion. He stated he was not aware that the resident's fall happened after midnight on 2/19/2022. The ER Physician II stated he thought R#119 fell and received the head injury the same day he came to theER on [DATE]. During further interview, ER Physician II revealed he would be using staples to close the laceration. Interview on 2/21/2022 at 10:00 a.m. with LPN AA revealed she had never known R#119 to have behaviors of physically harming himself or beating his head against anything. She stated that when she changed R#119's dressing on 2/20/2022 she should have reported it immediately. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. She stated yesterday morning, on 2/20/2022, she heard a CNA yelling for help. When she arrived at R#119's room, she observed R#119 hitting his head on the bathroom door frame. She stated his head was bleeding, so she applied pressure, put ice on his head, tried to stop the bleeding, and even tried cutting his hair to get to the laceration on his head, to be able to clean it. During further interview, LPN DD stated she did not call the physician because she did not feel it was bad enough to notify the Doctor. Telephone interview on 2/21/2022 at 10:39 p.m. with Medical Doctor (MD) HH revealed he received a call on 2/20/2022 around 3:00 p.m. to 4:00 p.m. related to R#119 head injury. He stated he was informed R#119 had a fall and had a hematoma on top of his head but was not made aware he was hitting his head against the bathroom door frame. During further interview, he stated he would have expected staff to notify him, or one of his partners, immediately about a fall with injury. Interview on 2/22/2022 at 2:30 p.m. with the DON revealed the facility is investigating what happened related with the fall and head injury to R#119. She stated she has no prior knowledge of R#119 having behaviors of hitting his head against things. She revealed she had concerns related to the fall with a head injury and the resident not being sent to the hospital. Telephone interview on 2/22/2022 at 8:30 p.m. with RN BB, revealed she was on duty when R#119 fell from his chair. She stated he told her he fell out of his chair. RN BB stated the resident had an abrasion on his head and it was bleeding, so she held pressure and once the bleeding slowed down, she cleaned his head and put a bandage on it. She stated she did not call the Doctor because it was 2:00 a.m. - 3:00 a.m. and it was too early to call him and stated she didn't believe it was serious enough to call the Doctor.

Based on observations, record review, staff interviews, and review of the facility policy titled Person Centered Care Plan, the facility failed to implement the person-centered care plan for one resident (R) R#119 care plans reviewed, related to notifying the Physician after a fall. Actual harm was identified to have occurred on 2/19/2022 when R#119 had a fall and suffered a laceration to the scalp which required 10 staples. In addition, the facility failed to follow the care plan for one resident (R#24) reviewed for active range of motion (AROM) to bilateral upper extremities. The sample size was 38. Findings include: Review of the undated facility policy titled, Person Centered Care Plan revealed the purpose is to structure and guide therapeutic interventions to meet patient needs and achieve expected outcomes. Practice standards include develop individualized plan of care based upon social history and initial assessments, Care Area Assessment (CAA) triggers, and observations. Review, evaluate, and update care plans as required. 1. Review of the clinical record for R#119 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's Admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section G revealed he required extensive assistance of one person for bed mobility, transfers, dressing, toilet use and personal hygiene. Section J revealed resident had falls prior to admission to facility. Review of the resident's care plan dated 1/31/2022 revealed he was at risk for repeated falls with a fall resulting in hip fracture. Interventions to care included assist with mobility as needed, be sure call light is within reach and encourage resident to use for assistance, prompt response to all requests, and notify Medical Doctor (MD) and family as needed. Observation on 2/20/2022 at 3:30 p.m. R#119 was observed to have large lump and gash that went down to the crown of his head. There was dried blood in his hair. He was also observed to have bruising under his right eye. Interview on 2/20/2022 at 3:30 p.m. with R#119, stated that he fell out of his chair yesterday. He stated he did not go to the hospital. Interview on 2/20/2022 at 3:35 p.m. with LPN AA stated she was informed of R#119 fall when she arrived to work today. She stated with a head injury, the resident should have been sent to the hospital for evaluation. During further interview she stated she changed the dressing to his scalp and did not tell anyone about the laceration and large hematoma to his head. Interview on 2/21/2022 at 7:05 p.m. with LPN DD revealed R#119 had a fall on 2/19/2022 during the 11:00 p.m. to 7:00 a.m. shift between 2:00 a.m. and 3:00 a.m. LPN DD stated she did not call the physician because she did not feel it was bad enough to notify the Doctor. Cross refer F600, F580 2. Review of the clinical record for R#24 revealed she 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 9, which indicated moderate cognitive impairment. Section G revealed she required extensive assistance of two persons for bed mobility, transfer, dressing, toilet use, and personal hygiene. Section O revealed resident received active range of motion four of seven days. Observation on 2/22/2022 at 11:04 a.m., R#24 lying in her bed, wearing a hospital gown, with therapeutic boots on bilateral lower extremities. Review of the care plan revised on 7/13/2021, revealed restorative nursing program for active range of motion (AROM) to bilateral upper extremities as indicated. Interventions to care include provide verbal cues, demonstration, and physical assistance for active range of motion (AROM) to bilateral upper extremities (BUE) 15 minutes/day for a minimum of five days per week. Review of the February 2022 Order Summary Report revealed a physician's order for Restorative Nursing PRN [as needed] per the P.O.C [plan of care], ordered 7/1/2021. Review of facility documentation related to R#24 restorative services/AROM to BUE revealed service was provided from 1/26/2022 through 2/23/2022. The facility could not provide any documentation of restorative activities from July 2021 through December of 2021. Interview on 2/22/2022 at 11:04 a.m. with R#24 stated her therapy was stopped because Medicare stopped paying for it. She stated she is not getting any kind of rehab at all. She stated she wanted to go home but she can't walk and without therapy, she can't go home. Interview on 2/23/2022 at 3:36 p.m. with the Director of Nursing (DON) stated she was not sure if R#24 was receiving restorative services but would investigate it and provide documentation, if applicable. Interview on 2/23/2022 at 4:15 p.m. with Vice President of Operations (VPO), Regional Nurse Consultant, and Administrator revealed, since the fall of 2021, the facility has experienced a massive turnover of leadership, including the Administrator, the DON, the Infection Preventionist, and several key nursing personnel. During further interview, the VPO stated a review of all facility processes was in progress and identified issues with documentation and record keeping. Interview on 2/23/2022 at 5:35 p.m. with Administrator stated she would continue to look for documentation related to restorative care/services for R#24 and would provide it to the State Survey Agency. Post survey interview on 3/15/2020 at 3:35 p.m. with Administrator, confirmed that the facility could not provide documentation of restorative services for AROM during the period of July 2021 through December 2021. Cross Refer 825