Every finding on record at Woodland Manor Nursing and Rehabilitation

Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident#1) out of 7 residents reviewed for reporting. -The facility failed to report to the State Survey Agency (SSA) Immediately, but not later than 24 hours when Resident#1 reported on 05/14/2026 that $107 was missing from his room. This failure could place residents at risk of not having complaints and concerns reported and investigated for abuse, neglect, and exploitation. Findings included: Record review of Resident#1's Face Sheet (undated) revealed, a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses to include vascular dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (memory and thinking problems caused by poor blood flow in the brain, where the exact stage is unrecorded, and experiences no major mental or emotional disruptions). Record review of Resident#1's quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 14 indicating he was cognitively intact. Record review of Resident #1's undated Care Plan with last review/revised date 06/03/2026 that read in part. Problem: Category: Cognitive Loss / Dementia, I have cognitive loss r/t dx: vascular dementia. Goal: Resident 1 will have symptoms of vascular dementia managed. Interventions: Resident 1 will have psych referral. Resident#1 will see psych services.' Record review of nursing progress note entered by LVN A on 05/15/2026 1:05pm read in part, Nurse call daughter to inform her about resident stating he had money in his room during fumigation of his room and that money is now missing, daughter possible knowns when and how much money resident has at all times and were he gets it from. Record review of nursing progress note entered by LVN A on 05/15/2026 6:10 pm read in part, Daughter called writer back and stated that resident does go to the bank and will withdraw money and keep it in his bible and wallet she does not know if he had any, but she will call him and visit this weekend to see what's going with his allegations. Record review of Grievance filed by the Housekeeping/Laundry Director dated 05/14/2026 and signed by the Administrator read in part. Resident#1 says he has money missing from his bible after his items were packed away for pest control. Resident#1 says he is missing $107 from his bible pages. Grievance Follow Up: Funds will be replaced upon receipt of check from our corporate office . Record review of TULIP did not reflect an incident reported to the SSA with regards to Resident #1 missing funds on 05/14/2026. In an interview on 06/16/2026 at 10:15am, LVN A said on 05/15/2026 Resident#1 reported to her that he was missing over $100 from a bible he kept in his room that he had gotten from a family member. She said she called the Resident#1's daughter and left a message, and reported it to the DON and Administrator B. She said she was told that the incident had been reported and they were awaiting contact from the Residents#1's daughter to confirm that he had access to the funds. She said that Residents #1's daughter called her back and reported that Resident#1 had access to the money from his bank. She said that she given the information to the Administrator and DON. In an interview on 06/16/2026 at 11:02am, Resident#1 said he had $107 in his bible in his room in May of 2026. He said that his daughter gives him the money each month to tithes for church. He said that in May of 2026 housekeeping packed his belongings in boxes for pest control, and afterwards he noticed the money was no longer in the bible. He said he reported the information to the Housekeeping/Laundry Director because she packed his belongings. He said Administrator A and the Social Worker came to speak with him and said they would investigate. He said he also told a nurse that the money was missing the next day. He said Administrator B told him that there was an investigation in May 2026 and that he would get the money back, but he still had not received the money. In an interview on 06/16/2026 at 11:18am, the Housekeeping/Laundry Director said on 05/13/2026 a deep cleaning was completed in Resident #1's room. She said she, along with another housekeeper did the deep cleaning. She said Resident#1's belongings were packed up to protect his personal items for pest control service after the deep clean. She said on 05/14/2026 Resident#1 reported to her that $107 was missing from his bible, and the funds had been there prior to the deep clean. She said she reported the information to Administrator A and the Social Worker, and it was documented in a grievance. She said that neither she nor the housekeeper were alone in the room to have taken the money. In an interview on 06/16/2026 at 12:36pm, Administrator B said that he started at the facility on 05/15/2026. He said Resident #1 alleged that funds were missing from the Bible in his room on 05/13/2026 and it had been documented on a grievance dated 05/14/2026 and initiated by the previous Administrator A. He said it was brought to his attention on 05/15/2026, the day he started. He said that the incident was investigated through a grievance and was inconclusive. He said that he submitted a request to reimburse the funds to Resident#1 in the amount of $107, the check was pending, and once received will be given to Resident#1's daughter. He said that all allegations of misappropriation should be investigated and reported to CII, but he was not sure of the timeframe. He said that he would use the timeframe according to the facilities policy. He said that the facility uses the HHSC PL for reporting guidelines and timeframes. He said that the Administrator was the abuse coordinator, and the abuse coordinator should report allegations of abuse, neglect, and exploitation to CII. He said that a self report was not made by Administrator A or himself to CII in regard to Resident#1's missing funds and it was an oversight. He said that when allegations of abuse, neglect, and exploitation are not reported to CII the risk to residents was the abuse, neglect, or exploitation could continue. In an interview on 06/16/2026 at 1:34pm, the ADON said that all allegations of allegations of abuse, neglect, and exploitation to SSA by the Administrator who is the abuse coordinator. She said that the facilities policy is to report to the Administrator all allegations of abuse, neglect, and exploitation immediately, and the Administrator should report to the SSA no later than the next day. She said when allegations of abuse, neglect, and exploitation are not reported to the SSA the risk to residents was the abuse, neglect, or exploitation could continue. She said that if Resident #1 reported that money was missing from his room on 05/14/2026, the SSA should have been notified on 05/14/2026 but no later than 05/15/2026. An attempt was made to contact Administrator A by telephone on 06/16/2026 at 1:50 pm, a message was left. In a phone interview on 06/16/2026 at 1:53pm, the Family Member of Resident#1 said that she was contacted sometime in May of 2026 to inform that Resident #1 report that he was missing over $100 from his room. She said that prior to the incident she would take Resident #1 to the bank to withdraw the funds and would store it in his bible in his room. She said that money was used for tithes monthly at church. She said that she had taken Resident#1 to withdraw the funds from his bank in the beginning of May of 2026. She said that she had spoken to Administrator A about the incident, who told her that the incident would be investigated. She said that she had spoken to Administrator B about the incident who confirmed that the funds would be refunded. An attempt was made to contact Administrator A on 06/16/2026 at 2:45pm by telephone, a message was left. Record review of facility policy titled Abuse, Neglect and Exploitation dated 08/05/2025 read in part, 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:.Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Record review of Long-Term Care Regulatory Provider Letter (PL) 2024-14 dated 08/29/2024 titled Title: Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission read in part .2.0 Policy Details & Provider Responsibilities, 2.1 Incidents that a NF(Nursing Facility) Must Report to HHSC(Health and Human Services Commission) A NF must report to CII( Complaint and Incident Intake ) the following types of incidents, in accordance with applicable state and federal requirements:. Misappropriation. 2.4 Reportable Incidents and Timeframes, This table describes required reporting timeframes for each incident type. It also describes events a NF is not required to report: . Do Report: an incident that does not result in serious bodily injury but that involves any of the following: neglect, exploitation, a missing resident, misappropriation of resident property. Immediately, but not later than 24 hours after the incident occurs or is suspected. Misappropriation: HHSC rules define misappropriation as, the taking, secretion, misapplication, deprivation, transfer, or attempted transfer to any person not entitled to receive any property, real, or personal, or anything of value belonging to or under the legal control of a resident without the effective consent of the resident or other appropriate legal authority, or the taking of any action contrary to any duty imposed by federal or state law prescribing conduct relating to the custody or disposition of property of a resident. CMS (Centers for Medicare and Medicaid Services) defines misappropriation of resident property as, the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent.

Based on observation, interview, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 3 (Resident #1, #2, and #3) of 6 residents reviewed for food services. 1. Resident #1, Resident #2, and Resident #3 received a piece of undercooked bacon on 04/12/26 on a BLT sandwich served during dinner service. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included: Record review of Resident #1' s face sheet, dated 04/22/26, revealed a [AGE] year-old female, admitted [DATE]. Her admitting diagnoses were Hemiplegia and hemiparesis (loss of strength and weakness to a side of the body), dysphagia (difficulty swallowing), a tooth infection, and morbidly obese due to excess calories. Record review of Resident #2' s face sheet, dated 04/22/26, revealed a [AGE] year-old male, admitted [DATE]. His admitting diagnoses were diabetes mellitus with a foot ulcer (an open sore, often caused by neuropathy (lack of feeling), poor circulation, and foot deformities), depression, and inappropriate diet and eating habits. Record review of Resident's #3's face sheet, dated 04/22/26, revealed a [AGE] year-old female, admitted [DATE]. Her admitting diagnoses were Stage 2 chronic kidney disease, dementia, (loss of cognitive functioning that interferes with daily life and activities), and unsteadiness on feet. During an observation on 04/22/26 at 1:30 p.m. in the Kitchen, the food handler's certifications for kitchen staff were displayed on a wall near the kitchen entrance. The certifications revealed the DM, DA, and DC had current certifications (dates not captured). During an attempted interview on 04/23/26 at 1:36 p.m., the DC was unable to be located in the facility. During an interview on 04/23/26 at 1:36 p.m., DA stated he was not sure where the DC went. DA stated that he had worked at the facility for 5-6 years and he worked 12 hours shift. He stated he recalled the incident where residents complained of being served raw bacon. He stated that the DC did not cook the bacon crispy because some of the residents were on special diets and it made it hard for them to chew. DA stated he tried a piece of the bacon and he did not think it was raw, but felt it was not cooked as crispy as normal. DA stated the residents who complained about the bacon were given the option of a ham sandwich. DA stated the incident occurred over the weekend, on either 4/11/26 or 4/12/26, during the dinner shift. DA stated the bacon was served on a BLT sandwich. During an observation and interview on 04/22/26 at 1:47 p.m., Resident #1 stated that on 04/12/26, she was served a piece of raw bacon on a BLT sandwich that was accompanied with a soup. She stated that when she received her dinner tray that day, she examined the bacon and immediately noticed how fatty it was and immediately informed the DC about the raw meat. She stated she asked the DC what would consuming raw pork do to her health and he did not know. Resident #1 stated she told the DM she needed to get those boys (DA and DC) educated and that the DM was a fantastic cook. She stated that as a substitution for the bacon, she was provided a turkey sandwich. Record review of a photo captured on Resident #1's cellphone, dated 04/12/26 at 6:01 p.m. revealed the only piece of bacon was covered in more than half of fat that looked translucent clear and tan in coloron her BLT sandwich. In an interview on 04/22/26 at 12:54 p.m. the DM stated that she had been working at the facility for 2 years. She stated she was not scheduled on the date of the incident regarding the bacon but she was made aware. She stated was shown the picture that was taken by Resident #1 and stated that bacon should have been cooked a little longer. The DM stated she talked to the DC and he told her that piece in the picture was the only piece of bacon cooked that way. The DM told the DC that he could not cook bacon like that, and he needed to make sure it was cooked all the way through by using the thermometer instead of going off of how it looked. She stated since that incident, the DC had not cooked bacon in that manner and had done better since then. The DM stated that she followed up with Resident #1 and she let her know that it was unacceptable and she could not recall receiving other complaints regarding the bacon served on 04/12/26. The DM stated that the harm in eating under cooked bacon was that you could get sick or food poisoning. In an interview on 4/23/26 at 12:59 p.m. with the DON, she stated that she had worked at the facility for 2 weeks, with a start date of 04/13/26. She stated that she viewed the picture of the bacon that was taken by Resident #1 on 04/12/26 and stated that bacon looked raw, terrible, and was unfit to eat. She received additional complaints regarding the bacon served on 04/12/26 from Resident #2 and Resident #3. She stated that the facility had very vocal residents there and they came to her often when they needed to voice concerns. In an interview on 4/23/26 at 1:13 p.m. with the ADM, she stated that she began working at the facility on 03/03/26. She was made aware of the situation of the bacon regarding Resident #1 after the day it happened. When she followed up with Resident #1, she was shown a photo and stated that she thought the bacon looked underdone but she was aware that some people preferred their bacon less crispy. She explained that she was not sure if it looked that way because it was more of a fatty piece of bacon but she did go to the kitchen and informed them that they were supposed to be checking the temperatures on all food. The ADM did not follow up with DC because that was something the DM would communicate. The ADM stated that her expectation of food was aligned with the policy as far as food looking good, smelling good, and tasting good. If there was a meal that a resident did not like, the facility would always have 3 substitution options available upon request. During an interview on 04/23/26 at 1:33 p.m., Resident #2 and Residdent #3 stated they were served raw bacon on 04/12/2026. Resident #2 stated that he only received one piece of bacon on his BLT sandwich and was upset because that was supposed to be their evening meal. He stated the DA and the DC did not care and would throw anything together. Resident #2 stated that on the day he was served the bacon, he asked the DC would he eat it, or pay for bacon prepared that way, and he stated that DC responded, well you don't pay for it either. Resident #2 stated that he found this disrespectful because he stated that he paid for everything at the facility and even contributed to the DC's salary. Resident #2 stated a photo of the bacon he received on 04/12/26. Resident #3 agreed with the statements made by Resident #2 and stated that the kitchen is horrible. Record review of a dietary photo received by Resident #2 of the bacon captured on 04/12/26 at 5:30 p.m., showed 1 piece of bacon on a piece of white bread and few pieces of lettuce were pushed to the side of the sandwich. Record review of the 2nd dietary photo received by Resident #2 of the bacon captured on 04/12/26 at 5:43 p.m., revealed a piece bacon that appeared to be completely translucent on the fatty parts of the meat. The lean parts of the bacon looked gray or a pale pink in color and looked limp, evidenced by how the end of the bacon curled over the edge of the plate. A follow up interview attempt was made on 04/23/26 at 11:30 a.m. with DC. He was not scheduled to work that day. Interview attempts via phone were made at 2:21 p.m. and 3:22 p.m. A voicemail and text messages were sent requesting a call back. On 04/24/26 at 10:30 a.m. and 04/30/26 at 10 a.m. additional calls were made to DC. DC did not answer calls, respond to messages, and was unavailable for interview during this investigation. Record review of the facility's policy titled Food Handling revised June 1, 2019, documented that the facility's policy was to ensure that all food served by the facility is of good quality and safe for consumption, all food will be handled according to the state and US Food Codes and HACCP guidelines.

Based on interview and record review the facility failed to consult with the resident's physician when there was An accident involving the resident that had the potential for requiring physician intervention for 1 of 4 residents (CR #1) reviewed for notification of changes. The DON failed to consult with CR #1's physician and hospice service on [DATE] between 4 pm to 5 pm. after an unwitnessed fall. CR #1 was prescribed a blood thinner (medication that prevents or slows down blood clotting). CR # 1 expired at the facility on [DATE]. An immediate Jeopardy (IJ) was identified on [DATE] at 1:40 p.m. While the IJ was removed on [DATE] at 1:00 p.m., the facility remained out of compliance at a severity level of Immediate Jeopardy to resident health or safety and a scope of isolation as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for bleeding, bruising, unwanted hospitalization and death. Findings include: Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE], with the following diagnoses: Hypertension (high blood pressure), relapsing fever, type 2 diabetes (high blood sugar) and vascular dementia (decreased blood flow to areas of the brain). Record Review of CR#1's care plan dated [DATE] revealed: At risk for falls r/t to impaired mobility. Psychotropic drugs. Incontinent of bladder and bowel. Impaired decision-making r/t to dementia. Requires oxygen therapy r/t to shortness of breath when lying supine or on exertion. Record review of MDS dated [DATE] revealed CR# 1 was dependent on staff for all ADL care and utilized a wheelchair, received PRN pain medication. CR # 1's BIMS was scored as :00, indicating severe cognitive impairment. Record Review of the facility's record revealed no documentation that the Physician and Hospice service were notified. Record Review of facility's progress notes between [DATE] to [DATE] revealed, there were no documentations related to the unwitnessed fall.In an interview with CNA A, on [DATE] at 12:58 p.m., she said the DON found CR #1 on the floor on [DATE], and the DON asked her for assistance to move CR#1 from the floor to bed. CNA A said CR # 1 denied falling and she did not see CR#1 with visible injuries. She said, CR#1's bed was always in its lowest position. In an interview with the DON on [DATE] at 1:26 p.m., she said she worked as a nurse on the floor from 6am to 6 pm on [DATE]. She said that CR# 1 was a fall risk with a history of falls. The DON said that sometime between 4pm to 5pm on [DATE] she found CR#1 on the floor in her bedroom on a fall mat. She said she assessed the resident for pain because she was found on the floor and because it was a shift protocol. She said that she did not document that she completed a pain assessment. She said that she did not compete a head-to-toe assessment, post fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs after CR#1's unwitnessed fall. She said that she did not notify the primary physician, hospice nurse, or RP after CR#'s unwitnessed fall. She said she did not complete the task because she did not consider CR#1 being found on the floor as an unwitnessed fall, because CR#1 was known to get out of bed, and crawl on to the floor mat. In an interview with LVN D, on [DATE] at 12:47 p.m., she said she administered Tramadol (pain medication) to CR #1 on [DATE] and [DATE] because she was in pain. LVN D said, she could tell CR # 1 was in pain because the family had told the facility if CR # 1 made any facial grimaces, that would signify pain. She said after each pain medication administration, CR # 1 would be calm and relaxed. LVN D said on [DATE] she noticed CR# 1 was declining, CR # 1 ate breakfast out of bed, but after that she did not get out of the bed. LVN D said on 03/23/ 2026, the hospice wound care nurse gave orders for the facility to start comfort care because CR # 1 had fluid-filled lungs and elevated temperature. LVN D said, she administered Tylenol suppository because CR # 1 could no longer swallow. In an interview with the DON, on [DATE] at 1:26 p.m., she said she was not aware CR #1 was on a blood thinner because the medication aide administered the regular medications and the DON did administer PRN, G-tubes, injections and inhalers. The DON said the protocol for unwitnessed fall for a resident on anticoagulant was-call doctor, Hospice, if the resident was on hospice care, monitor for bleeding, complete neuro checks. The DON said the risk of CR # 1 who was on anticoagulant and fell, could be internal bleeding, and bruises that would show up within hours. She said the risk for failure to notify the doctor, and hospice could be hospitalization and possible death In an interview on [DATE] at 2:43 p.m., with LVN B she said, any fall be it witnessed or unwitnessed should be reported to the doctor, family, ADON, DON, Administrator and the Weekend Supervisor if it happened on a weekend. For all hospice residents the facility should notify the hospice service. In an interview with the DON, on [DATE] at 1:26 pm, she said she did not notify the medical Personnel, POA, the Administrator, and hospice because she did not consider the fact that CR # 1 being on the mat was a fall. She said if a fall was not reported other staff would not know how to follow up. She said, if it was an unwitnessed fall, the Physician would order neuro checks. She said, it was the responsibility of the DON and ADON to ensure nurses report incidents correctly.In an interview with the NP, on [DATE] at 11:31 a.m., she said she was not notified CR#1 had an unwitnessed fall on [DATE]. She said that she expected the facility to follow their policy and procedure to notify her office with any change in condition such as falls. The NP said if she was notified, she would have ensured that CR #1 was properly assessed. She said the notification failure risk to the resident was that, CR#1 could have had fractures or head injury. In an interview with the MD [DATE] at 2:45 p.m., he said he was not notified CR#1 had an unwitnessed fall on [DATE]. He said that he expected the facility to follow their policy and procedure for fall notification. He said he did not see any communication about the fall. The MD said if he was notified, he would have followed the right procedure after a fall. In an interview with the RN A, she said that she assessed CR#1 in the morning of [DATE], and CR#1 was at her baseline. RN A said when she assessed CR#1 on [DATE], CR#1 was no longer at her baseline. RN A said there was a rapid decline in her neurological and respiratory status. RN A said she was not notified CR#1 had a fall on [DATE]. She said that if she was made aware of CR#1's fall, she would have come to facility to complete an assessment, which would have included a change in neurological status. She would have assessed injuries, and she would have notified the hospice physician. In an interview with the Administrator, on [DATE] at 5:28 p.m., she said the facility failed to notify the doctor, family, ADON, and the hospice service because, the DON did not consider CR # 1 being on the floor as a fall. She said if a fall was not reported staff would not assess and treat any potential symptoms. She said if she was notified, she would ensure the resident was safe. The Administrator said she expected the nursing staff to call her, the DON, Physician, family and hospice for any hospice resident. The Administrator said the risk of not notifying the physician and hospice lies was that they would not be aware of penitential injuries, assessment to be completed and updates. In an interview with the Administrator, on [DATE] at 5:28 p.m., she said the facility failed to notify the doctor, family, ADON, and the hospice service because, the DON did not consider CR # 1 being on the floor as a fall. She said if a fall was not reported staff would not assess and treat any potential symptoms. She said if she was notified, she would ensure the resident was safe. The Administrator said she expected the nursing staff to call her, the DON, Physician, family and hospice for any hospice resident. The Administrator said the risk of not notifying the physician and hospice lies was that they would not be aware of penitential injuries, assessment to be completed and updates.In an interview with the CCM/MDS Coordinator on [DATE] at 09:23 a.am., she said she was not notified of CR # 1's unwitnessed fall on [DATE]. CCM said if she was notified, she would have discussed that during the morning standup meeting and then review the nurses' notes to see what happened. In an interview with S T, on [DATE] at 11:16 a.m., she said she had told the nurse who worked with CR # 1 on the day she completed her evaluation. S T later said she did not notify the nurses of her 1:1 supervision recommendation because everyone knew CR # 1 was a fall risk. The S T , accepted responsibility for failure to notify the nursing staff. The ST said, if the nurses knew to keep CR # 1 at the nursing station because she was a fall risk, they should have known to make sure she is safe in her room as well. Record review of hospice agreement contract dated [DATE] and signed by the facility revealed: The facility shall immediately inform hospice of any change in the condition of a residential hospice patient that suggests a need to alter the plan of care. Facility shall make all reasonable efforts to protect hospice residents from accidents and injuries. Facility must report all alleged neglect within 24 hours of when the facility became aware of the alleged violation. On [DATE] at 06:49 p.m., an Immediate Jeopardy was identified. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template, and Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on [DATE] at 03:20 p.m. Immediate Jeopardy plan of removal by facility on [DATE] at 06;21 p.m. N3010; Notification of Change. The facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 (CR#1) resident reviewed for notification of change.The DON failed to consult with CR #1's physician and hospice service on [DATE] between 4 pm to 5 pm. after an unwitnessed fall. DON will be in serviced by administrator on change of condition and notification of appropriate persons - physician/physician extender, resident representative. Licensed staff will be in serviced on change of condition regarding notification of appropriate persons including physician/physician extender, hospice if applicable, family. No licensed staff will be allowed to work until training is received. Therapy, including speech therapist will be in serviced that any orders or recommendations regarding resident care will be immediately discussed with the DON or ADON who will initiate the order for the same. No therapy staff will be allowed to work until training is received. An audit of current residents will be completed to determine if a change of condition occurred and if so, were notifications made per policy. An ad hoc QAPI meeting will be conducted to discuss IJs and to determine root cause analysis. Change of condition policy will be reviewed to determine if it meets regulatory requirements and any revisions need to be made. Meeting is scheduled for 3:30 p.m. on [DATE]. Monitoring of resident changes in condition and notification of physician and resident representative will take place in clinical morning meeting each business day to include review of progress notes, incidents, medication changes, new orders. Staff will notify the DON/Designee during off business hours of any changes in condition by phone. Person Responsible: DON/Designee. Timeline for completion: ongoing Following acceptance of the facility's plan of removal, the facility was monitored from [DATE] at 6:21 p.m. through [DATE] at 1:00 p.m. The Investigator confirmed the facility implemented their plan of removal sufficiently from [DATE] to [DATE] Based on interview, with the Administrator in serviced the DON on change of condition and notification of appropriate persons - physician/physician extender, resident representative. In an interview with the Administrator and other staff, the DON was suspended pending investigation. Interviews and confirmed signed in service sheets revealed Licensed staff were in serviced prior to the start of their shifts on change of condition regarding notification of appropriate persons including physician/physician extender, hospice if applicable, family ([DATE]). Record reviews of in-service completed by the Director of Rehabilitation on [DATE] and [DATE], revealed all Physical Therapists including speech therapists on site were in serviced on orders or recommendations regarding resident care will be immediately discussed with the DON or ADON who will initiate the order with the nursing department. Record review of audits dated [DATE] done by the VP of clinical operations, were completed on current and CR # 1's previous fall on [DATE]. Review of CR # 1's progress note dated [DATE] revealed the Dr, hospice, [NAME] and family were notified. Record review of an ad hoc QAPI meeting dated [DATE] at 3;30 p.m., revealed the following were present: The Medical Director, the Administrator, the ADON and the CCM/MDS. In an interview with the CCM/MDS Coordinator on [DATE] at 11:06 a.m., she said she was in serviced on [DATE] about CR # 1's fall and care plan update for all residents after a fall. Interview with staff on [DATE] at 09:00 am , staff verbalized they will notify the DON/Designee during and off business hours of any changes in condition by phone and notify the physician and resident representative. The facility's fall policy dated [DATE] stated: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level. The event may be witnessed, reported or presumed when a resident is found on the floor or ground and can occur anywhere. After a fall, if found on the floor without a witness, evaluate for possible injuries to the head, neck, spine and extremities. The resident is not moved until after evaluation by a nurse. Obtain and record vital signs and initiate neuro checks for any unwitnessed fall. Reporting: The fall policy stated the following should be notified after a fall: Resident family, attending Physician, DON, Nursing Supervisor on duty and other team members as appropriate . Help shape the future of iQIES. 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Based on interview and record review: facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 1 (CR#1) resident reviewed for quality of care. The facility failed to complete neurological checks for CR #1 from [DATE]-[DATE] after an unwitnessed fall on [DATE]. CR # 1 was on an anticoagulant and experienced pain in the following days.The DON failed to complete a head-to-toe assessment, pain assessment, post fall assessment, progress note, SBAR, incident report, initiated neurological checks, or obtain vital signs after CR#1 had an unwitnessed fall on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 1:40 p.m. While the IJ was removed on [DATE] at 1:00 p.m., the facility remained out of compliance as the facility continued to monitor the implementation and effectiveness of their plan of removal. This failure could place residents at risk for bleeding, bruising, unwanted hospitalization and death. Findings include: Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE], with the following diagnoses: Hypertension (high blood pressure), relapsing fever, type 2 diabetes (high blood sugar) and vascular dementia (decreased blood floor to areas of the brain). Record Review of CR#1's care plan dated [DATE] revealed: At risk for falls r/t to impaired mobility. Psychotropic drugs. Incontinent of bladder and bowel. Impaired decision-making r/t to dementia. Requires oxygen therapy r/t to shortness of breath when lying supine or on exertion. CR # 1's anticoagulant was not care planned. Record review of MDS dated [DATE] revealed CR# 1 was dependent on staff for all ADL care, utilized a wheelchair, with a BIMS of 0, and history of 1 fall since admission. Record review of CR#1's electronic medical records revealed no head-to-toe assessment, pain assessment, post fall assessment, progress note, SBAR, neurological checks, or post fall vitals completed after CR#1 had an unwitnessed fall on [DATE]. Record review of incidents and accidents for [DATE] did not reflect that CR#1 had an unwitnessed fall on [DATE]. Record review of CR#1's Physician's order revealed, Eliquis (apixaban) tablet 2.5 mg to be administered twice a day by mouth. The order started on [DATE] and was discontinued on [DATE]. Record review of facility's progress note date [DATE] revealed, CR # 1 expired at the facility on [DATE]. In an interview with CNA A, on [DATE] at 12:58 p.m., she said the DON found CR #1 on the floor on [DATE], and the DON asked her for assistance to move CR#1 from the floor to bed. CNA A said CR # 1 denied falling and she did not see CR#1 with visible injuries. She said, CR#1's bed was always in its lowest position.In an interview with the DON on [DATE] at 1:26 p.m., she said she worked as a nurse on the floor from 6am to 6 pm on [DATE]. She said that CR# 1 was a fall risk with a history of falls. The DON said that sometime between 4pm to 5pm on [DATE] she found CR#1 on the floor in her bedroom on a fall mat. She said she assessed the resident for pain because she was found on the floor and because it was a shift protocol. She said that she did not document that she completed a pain assessment. She said that she did not compete a head-to-toe assessment, post fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs after CR#1's unwitnessed fall. She said that she did not notify the primary physician, hospice nurse, or RP after CR#'s unwitnessed fall. She said she did not complete the task because she did not consider CR#1 being found on the floor as an unwitnessed fall, because CR#1 was known to get out of bed, and crawl on to the floor mat. In an interview with LVN D, on [DATE] at 12:47 p.m., she said she administered Tramadol (pain medication) to CR #1 on [DATE] and [DATE] because she was in pain. LVN D said, she could tell CR # 1 was in pain because the family had told the facility if CR # 1 made any facial grimaces, that would signify pain. She said after each pain medication administration, CR # 1 would be calm and relaxed. LVN D said on [DATE] she noticed CR# 1 was declining, CR # 1 ate breakfast out of bed, but after that she did not get out of the bed. LVN D said on 03/23/ 2026, the hospice wound care nurse gave orders for the facility to start comfort care because CR # 1 had fluid-filled lungs and elevated temperature. LVN D said, she administered Tylenol suppository because CR # 1 could no longer swallow. In an interview with the DON, on [DATE] at 1:26 p.m., she said she was not aware CR #1 was on a blood thinner because the medication aide administered the regular medications and the DON did administer PRN, G-tubes, injections and inhalers. The DON said the protocol for unwitnessed fall for a resident on anticoagulant was-call doctor, Hospice, if the resident was on hospice care, monitor for bleeding, complete neuro checks. The DON said the risk of CR # 1 who was on anticoagulant and fell, could be internal bleeding, and bruises that would show up within hours. She said the risk for failure to notify the doctor, and hospice could be hospitalization and possible death In an interview with the Administrator, on [DATE] at 3:25 p.m., she said on [DATE] the DON found CR # 1 on the floor. She was notified on [DATE] at nighttime by the DON. The DON was working on the floor that day. She said the DON called CNA A who assisted in the care and assisted CR # 1 back to bed. The Administrator said CR # 1 had the tendency to crawl out of bed, and she did not considered CR#1 being found on the floor a fall. In an interview with LVN C on [DATE] at 5:49 p.m., she said, when she started her shift on [DATE], she was told to keep CR # 1 comfortable. CR #1 was responsive at the beginning of the shift. LVN C said she knew CR # 1 was transitioning because she was not at her baseline. She said normally, CR # 1 would be more responsive. In an interview with CNA B on [DATE] at 08:15 a.m., she said when she started her shift on [DATE], CR # 1 was still breathing but coming to end of life. CNA B said, the POA was at the facility and told them he came because CR # 1 was not going to make it. CNA B said, a family member who was in the room that night called the nurse to let her know that CR # 1 was unresponsive. In an interview with the Administrator, on 03/ 31/2026 at 5:28 p.m., she said she was not aware CR #1 was on an anticoagulant because she did not typically review MARs. She said she was not familiar with the protocol for residents on anticoagulants. She said anticoagulants are medications used to prevent blood clots. The risk of a resident on a blood thinner who had a fall is bleeding which could be external or internal bleeding. She said internal bleeding could lead to stroke and possible death. In an interview with RN A, on [DATE] at 1:30 p.m., she said, she assessed CR#1 pre-fall the morning off [DATE], and CR#1 was at her baseline. RN A saw CR#1 on [DATE], she assessed CR#1 to no longer be at her baseline with a rapid decline in her neurological and respiratory status. In an interview with LVN B, on [DATE] at 09:00 a.m., she said anticoagulants were like Aspirin. She said the most used anticoagulant at the facility was Aspirin, but they had few residents on Eliquis. LVN B said, if a resident was on Eliquis and had an unwitnessed fall, the facility should send the Resident out to ER for further evaluation, especially if they hit their head. LVN B said internal bleeding was a high a possible risk if a resident is on any blood thinner. She said if you found someone on the floor, it was an unwitnessed fall. LVN B said she would assess the Resident on the same position, take a set of vitals and complete a neurological assessment. Record review of the Hospice contract signed by the facility on [DATE] stated: -Facility shall make reasonable efforts to keep hospice patients protected from accidents and injury. The facility's fall policy dated [DATE] stated: A fall is an event in which an individual unintentionally comes to rest on the ground, floor or other level. The event may be witnessed, reported or presumed when a resident is found on the floor or ground and can occur anywhere. After a fall, if found on the floor without a witness, evaluate for possible injuries to the head, neck, spine and extremities. The resident is not moved until after evaluation by a nurse. Obtain and record vital signs and initiate neuro checks for any unwitnessed fall. On [DATE] at 06:49 p.m., an Immediate Jeopardy was identified. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template, and Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on [DATE] at 06:21 p.m. On [DATE] at 06:49 p.m., an Immediate Jeopardy was identified. The Administrator and DON were notified. The Administrator and DON were provided with the IJ template, and Plan of Removal (POR) was requested at that time. N3937; Quality of careThe facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice for CR#1 who had an unwitnessed fall on 3/20 /2026 who was on an anticoagulant and experienced pain on the following days. The facility failed to complete neurological checks from [DATE]-[DATE] when CR#1 had an unwitnessed fall on [DATE]. DON failed to complete a head-to-toe assessment, pain assessment, post fall assessment, progress note, SBAR, incident report, initiated neurological checks, or obtain vital signs after CR#1 had an unwitnessed fall on [DATE]. -The perpetrator -DON will be in serviced and suspended by administrator.-The [NAME] President of Clinical operations will audit residents' orders to determine those on anticoagulant and if side effects monitoring was in place. Care Plans will revise as needed. Medications will placed in the correct category as needed. -Licensed staff were in-serviced ADON, on the following: anticoagulant medication and monitoring for side effects, neuro checks post fall if unwitnessed or witnessed fall for residents who hit their head, completing a head to toe assessment, documentation to include completion of an SBAR, an incident report, and progress note. -All Licensed staff will be in serviced at the beginning of their shifts. No staff will be allowed to work without in-service.-Care Plans will be reviewed to determine if high risk medications, fall risk are care planned with approaches appropriate to the resident's cognitive status and physical ability. DON/ADON or CCM will communicate care plan changes/updates to the charge nurses in clinical morning meetings.- Falls will be reviewed and discussed in clinical standup each business day-reviewing incident reports, neuro checks if applicable, a head to toe assessment and SBAR completed. Care plan will be updated and post fall progress note entered. The event report for falls will be reviewed by the DON/designee to determine the assessment was completed and notifications made. An audit of falls that occurred from the period of February 28th, 2026, through [DATE]st, 2026, will be completed by the [NAME] President of Clinical Operations to ensure that the residents were assessed and notification of physician/reside representative occurred. - An Ad Hoc QAPI meeting will be held [DATE] at 3:30 p.m., by the Administrator and the ADON to determine the root cause analysis for the Immediate Jeopardy.-The fall prevention, change of condition policy, documentation policy will be reviewed by the [NAME] President of Clinical Operations to determine if they met regulatory requirements and revised. Monitoring of the Plan of Removal included:Following acceptance of the facility's plan of removal, the facility was monitored from [DATE] at 6:21 p.m. through [DATE] at 1:00 p.m. The Investigator confirmed the facility implemented their plan of removal sufficiently from [DATE] to [DATE]. -The perpetrator- the DON was serviced by administrator on [DATE] on change of condition, charting, documentation, fall assessments, fall prevention program. The DON was suspended pending investigation.-Record review revealed the Medical Director was notified of Immediate Jeopardy.-Record review revealed, licensed staff were in-serviced ADON, on the following: anticoagulant medication and monitoring for side effects, neuro checks post fall if unwitnessed or witnessed fall for residents who hit their head, completing a head to toe assessment, documentation to include completion of an SBAR, an incident report, and progress note. - Record review revealed, an Ad Hoc QAPI meeting was held on [DATE] at 3:30 p.m., by the Administrator by the ADON to determine the root cause analysis for the Immediate Treat.-The fall prevention, change of condition policy, documentation policy was reviewed by the [NAME] President of Clinical Operations to determine if they met regulatory requirements and revised.The medical director was notified of the immediate jeopardy on [DATE] by the administrator.- An audit of falls dated [DATE] that occurred from the period of February 28th, 2026, through [DATE]st, 2026, were completed by the [NAME] President of Clinical Operations to ensure that the residents were assessed and notification of physician/reside representative occurred. -Care Plans were reviewed to determine if residents were on high-risk medications, fall risk were care planned with approaches appropriate to the resident's cognitive status and physical ability. DON/ADON or CCM will continue to communicate care plan changes/updates to the charge nurses in clinical morning meetings.-The [NAME] President of Clinical operations determined those on anticoagulant and if side effects monitoring was in place. Care Plans were revised as needed. Medications were placed in the correct category as needed. -Interview with nurses on duty revealed they were in service prior to starting work. In an interview with the Administrator, on [DATE] at 12:20 pm, she said the DON was suspended. The Administrator, [NAME] President of Clinical Operations, ADON and the Medical Director, were informed. The Immediate Jeopardy was removed on [DATE] at 1:00 p.m. The facility remained out of compliance and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interviews and record review, the facility failed to ensure all alleged violations involving abuse, neglect, and misappropriation were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency (SSA) for 3 of 19 residents (CR #1, Resident #2, and Resident #3) reviewed for reporting.The facility failed to report neglect regarding the lack of intervention and assessment after the resident's fall to the SSA and then CR #1 subsequently passed away.The facility failed to report an allegation of misappropriation to the SSA when Resident #2 informed the ADM she had lost her debit card on 3/24/26.The facility failed to report an allegation of sexual abuse to the SSA when Resident #3 informed staff she was sexually assaulted on 2/8/26 by her roommate. These failures could place residents at risk for having abuse, physical harm, mental anguish, and emotional distress complaints from being investigated. Findings Included: 1. Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE], with the following diagnoses: hypertension (high blood pressure), relapsing fever, type 2 diabetes (high blood sugar) and vascular dementia (decreased blood flow to areas of the brain). Record Review of CR#1's care plan dated 3/16/2026 revealed the following care areas:*At risk for falls r/t to impaired mobility. Intervention: Increase staff supervision with intensity based on resident's needs. Keep bed in lowest position when resident is in bed. Implement exercise program that targets strength, gait and baalance.*Psychotropic drugs. Intervention: Monitor target behavior per psychotropic flowsheet.*Incontinent of bladder and bowel. Intervention: Keep call light in easy reach. Check for incontinence every 2 hours.*Impaired decision-making r/t to dementia. Intervention: Respect resident's rights to make decisions.*Requires oxygen therapy r/t to shortness of breath when lying supine or on exertion. Record review of MDS dated [DATE] revealed CR #1 was dependent on staff for all ADL care and utilized a wheelchair. Received PRN pain medication. CR # 1's BIMS was scored as :00, which means the resident's cognition could not be obtained due to her medical condition. In an interview on 3/28/2026 at 1:26pm, the DON said she worked as a nurse on the floor from 6am to 6pm on 3/20/2026. She said CR #1 was a fall risk and had a history of falls. The DON said sometime between 4pm to 5pm on 3/20/2026 she found CR #1 on the floor in her bedroom, on a fall mat. She said she did not compete a head-to-toe assessment, post fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs after CR #1's unwitnessed fall. The DON said she did not notify the primary physician, hospice nurse, RP, or ADM because she did not consider CR #1 being found on the floor, as an unwitnessed fall. In an interview on 3/31/2026 at 1:30pm RN A said she assessed CR #1 before her fall, on the morning of 3/20/2026 and CR #1 was at her baseline. RN A said she saw CR #1 again on 3/23/2026, after her fall, and she was no longer at her baseline, and had a rapid decline in her neurological and respiratory status. In an interview on 3/31/2026 at 5:28 pm, the ADM said if she was notified, she would have ensured the resident was safe and would have followed the Provider Letter PL 2024-14. 2.Record review of Resident #2's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of Dementia with anxiety (progressive or persistent loss of intellectual functioning), unspecified fall, age related cognitive decline (decrease in mental functioning), ADHD (trouble paying attention and being hyperactive), hemiplegia and hemiparesis affecting left side following CVA (paralysis and weakness after a stroke), and history of falls. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The resident used a wheelchair for mobility and was moderate assistance (helper does less than half the effort) with ADLs. Record review of Resident #2's Care Plan dated 12/22/25 revealed a Focus: Cognitive Loss r/t dementia. The goal was for the resident to be alert and oriented as possible. The interventions included approaching in a calm manner, explaining what is being done during care, introducing one self, and orienting to person, place, and time. Record review of Resident #2's Progress Notes revealed a note from 3/24/26 at 10:55am from the ADON that said, The resident and her friend.reported to this nurse that the resident's debit card is missing. This nurse immediately notified the administrator and the DON of the missing item for further follow-up. In an interview on 4/2/26 at 9:50am, the ADON said Resident #2 reported a missing debit card to her and said her old roommate may have taken it. The ADON said she spoke to the old roommate and she said she did not have it. The ADON said she did not know what the resolution was. She said she reported it as a grievance and reported it to the ADM and to the DON. In an interview on 4/2/26 at 12:12pm, the ADM said Resident #2's debit card was never found. She said she told Resident #2 to cancel the debit card and order another one. She said she did not report it and did not know why. The ADM said she did not think to report it. The ADM said there was not an investigation done because she never reported it. She said she was the Abuse Coordinator and staff reported abuse, neglect, and exploitation to her. The ADM said she followed the Provider Letter PL 2024-14, for reportable incidents. 3. Record review of Resident #3's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of cognitive communication deficit (difficulty communicating caused by memory loss), bipolar disorder (extreme mood swings from elation to depression), and other symptoms and signs involving cognitive functions and awareness. Resident #3's MDS assessment was corrupted and the file would not open. Record review of Resident #3's Care Plan dated 3/11/26 revealed the following:*Focus: Resident takes mood stabilizer for bipolar disorder. The goal was for the resident to not exhibit any signs of isolation by the next review date. The interventions included encouraging the resident to verbalize feelings and fears and involving the resident with others of shared interests.*Focus: The resident needs to participate in her decisions regarding tasks of daily life. The goal was for the resident to be fully informed in advance about care and treatment and any changes in care or treatment by the next review date. Interventions included allowing the resident to be independent to the safest degree possible and encouraging the resident to participate in meeting care plan goals. Record review of Resident #3's Progress Notes revealed a note from 2/8/26 at 4:21am completed by LVN L that read, Staff heard screaming come from down the hall. Staff went in the direction of room and found both resident coming up the hall was visibly upset. Patient stated that roommate continues to open the door while she is toileting. Patient then alleges that she was being sexual[[NAME]] assaulted by room mate. Staff immediately separated patients and asked in detail what happened. Patient alleges that while she's toileting, room mate comes into the bathroom. Writer asked if room mate had touched her ; she stated no. Writer then asked patient will she allow writer to perform a head to toe skin assessment and patient stated that she didn't see where that would be necessary since room mate did not touch her. Writer went down and consoled room mate and she kept apologizing not realizing what she had done. Writer then assist room mate back in her bed and patient went up front to the nurses stations where patient was sitting while we place her into another room. During this discussion with peers, patient came into the lobby and called the police without staff knowing. Police came in and informed writer that patient had called them. Police stated that the patient alleged that she was assaulted sexually and needed more details. Writer explained to the police what had happened and he then questioned her. Police came out and spoke with me and stated that patient stated that she was not touched but was upset because room mate comes to the bathroom when she's in there. Police voiced understanding and did not feel the need to do a report nor did he speak to the other patient. Patient is now in another room resting quietly. DON has been notified and family will be notified. Attempted to call family member but patient states that family is resting and to call later on in the morning. Record review of Resident #3's Room Change Notification from 2/8/26 at 4:30am by the SW revealed she was moved from room [ROOM NUMBER] to room [ROOM NUMBER] due to not getting along with her roommate. Record review of Resident #3's Progress Notes revealed a note from 2/9/26 at 12:56am from LVN L that read, Writer just made rounds and found patient resting quietly. Voiced no complaints at this time and is adjusting to room change well. Record review of Resident #3's Progress Notes revealed a note from 2/9/26 at 10:57am by the SW that said, MSW spoke with facility therapist to inform of behaviors this weekend and other room changes. Therapy reports she does not see her, but will add her on caseload. Record review of Resident #3's Progress Notes revealed a note from 2/9/26 at 11:48am from the SW that said, MSW had a note to call [family member] at [phone number]. [Family member] reports she is upset due to the event that happened this weekend and wants to make sure [Resident #3] is okay. [Family member] wants to know what plan is in place. MSW informed [family member] of speaking with psych NP, therapist, and [company] PASSR case manager last week. MSW reports the residents were seperated (sic). MSW reports she will follow up with resident today to see how she is feeling. MSW reports she will speak with DON and Admin to see about room change being permanent or temporary. MSW reports she will keep [family member] updated as well. Record review of Resident #3's Progress Notes revealed a note from 2/9/26 at an unknown time from the SW that read, .Resident reports she is glad that she was able to talk to her PASSR coordinator on Friday. Resident reports she gave her other facility options if needed, but she knows that there is a waiting list and waiting to get approved. MSW reports she can help resident transfer if she needed. Resident reports she does not want to at this time.Resident reports she is doing fine and is still getting adjusted to everything. MSW informed resident of talking with facility therapist for extra support as well. In an interview on 3/31/26 at 12:55am, Resident #3 said the facility had an issue with putting unstable residents with other residents. She said she had one roommate who was aggressive and one roommate who tried to sexually assault her. She said her roommate would watch her go to the bathroom, every time she went. Resident #3 said the roommate did have Dementia, but every time she went to the bathroom she would follow her. Resident #3 said it happened multiple times. She said the last time she barricaded the door with her wheelchair and her roommate still pushed it out of the way. Resident #3 said her roommate never touched her but she had her hand stretched out like she wanted to touch her. In an interview on 4/1/26 at 2:32pm, the SW said Resident #3's roommate would open the door to the bathroom every time she was in there because the roommate had dementia and would forget someone was in there. The SW said the roommate had her own room prior to being placed with Resident #3, so she would forget that she had a roommate. The SW said Resident #3 told her she was exposed and her roommate just stood there looking at her. The SW said Resident #3 told her that she should not have used the words sexual assault but did say she felt like she was raped by her eyes or something to that affect. The SW said Resident #3 had never complained about the incidents before this and this was the first time she had complained about the roommate. In an interview on 4/1/26 at 3:29pm, LVN L said both Resident #3 and the roommate were screaming and crying. She said Resident #3 was screaming that her roommate watched me. LVN L said Resident #3 did call the police and she explained to the police officer that the roommate had really bad dementia. She said the police officer spoke to Resident #3 but decided not to write a report and left. LVN L said she separated the residents immediately and put them in separate rooms. In an interview on 4/2/26 at 9:50am, the ADON said she received a call from the DON who informed her that Resident #3 had called the police and they were there because her roommate was watching her urinate and she felt uncomfortable and uneasy. The ADON said the police came, assessed the situation, and left. She said the nurses separated the residents and that was about it. In an interview on 4/2/26 at 12:12pm, the ADM said the incident with Resident #3 and the allegation of sexual assault was before she was hired on 3/3/26. She said she was not sure why it was not reported. She said she followed the Provider Letter PL 2024-14, for reportable incidents. She said some of the reportable events included: suspicious incidents, ANE, retaliation, suspicious injuries, death, missing resident, drug diversion, fire, and misappropriation. Record review of the facility's policy and procedure on Abuse, Neglect and Exploitation (revised 8/5/25) read in part: 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. Mental Abuse includes, but is not limited to, humiliation, harassment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Mistreatment means inappropriate treatment or exploitation of a resident.Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriate of resident property, reporting procedures, and dementia management and resident abuse prevention; .2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse -mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations.VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. B. The Administrator will report the results of the investigation when final within 5 working days of the incident.

Based on interview and record review the facility failed to thoroughly investigate and to prevent further potential abuse, neglect, exploitation or mistreatment while the investigation is in process, and failed to ensure corrective action must be taken for 3 of 19 residents (CR #1, Resident #2 and Resident #3) reviewed for abuse. The facility failed to investigate neglect regarding the lack of intervention and assessment after the resident's unwitnessed fall, and then CR #1 subsequently passed away.The facility failed to investigate an allegation of misappropriation after Resident #2 informed the ADM she had lost her debit card on 3/24/26.The facility failed to investigate sexual abuse allegation after Resident #3 informed staff she was sexually assaulted on 2/8/26 by her roommate. These failures could place residents at risk of ongoing abuse, neglect, exploitation, and mistreatment.Findings included: 1. [TT1] Record review of CR#1's face sheet revealed she was a [AGE] year-old female admitted on [DATE], with the following diagnoses: hypertension (high blood pressure), relapsing fever, type 2 diabetes (high blood sugar) and vascular dementia (decreased blood flow to areas of the brain). Record Review of CR#1's care plan dated 3/16/2026 revealed: At risk for falls r/t to impaired mobility. Psychotropic drugs. Incontinent of bladder and bowel. Impaired decision-making r/t to dementia. Requires oxygen therapy r/t to shortness of breath when lying supine or on exertion. Record review of MDS dated [DATE] revealed CR #1 was dependent on staff for all ADL care and utilized a wheelchair. Receives PRN pain medication. CR # 1's BIMS was scored as :00. In an interview on 3/28/2026 at 1:26pm, the DON said she worked as a nurse on the floor from 6am to 6 pm on 3/20/2026. She said CR #1 was a fall risk and had a history of falls. The DON said sometime between 4pm to 5pm on 3/20/2026 she found CR #1 on the floor in her bedroom, on a fall mat. She said she did not complete a head-to-toe assessment, post fall assessment, progress note, SBAR, incident report, neurological checks, or obtain vital signs after CR #1's unwitnessed fall. The DON said she did not notify the primary physician, hospice nurse, RP, or ADM because she did not consider CR #1 being found on the floor, as an unwitnessed fall. The DON said an investigation was not performed because she did not think the resident had fallen, she thought the resident crawled out of bed. In an interview on 3/31/2026 at 1:30pm RN A said she assessed CR #1 before her fall, on the morning of 3/20/2026 and CR #1 was at her baseline. RN A said she saw CR #1 again on 3/23/2026, after her fall, and she was no longer at her baseline, and had a rapid decline in her neurological and respiratory status. In an interview on 3/31/2026 at 5:28 pm, the ADM said the facility failed to notify the doctor, family, ADON, and the hospice company of the resident's fall, because the DON did not consider the event as a fall. The ADM said if she was notified, she would have ensured the resident was safe and would have followed the Provider Letter PL 2024-14. 2. Record review of Resident #2's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of Dementia with anxiety (progressive or persistent loss of intellectual functioning), unspecified fall, age related cognitive decline (decrease in mental functioning), ADHD (trouble paying attention and being hyperactive), hemiplegia and hemiparesis affecting left side following CVA (paralysis and weakness after a stroke), and history of falls. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The resident used a wheelchair for mobility and was moderate assistance (helper does less than half the effort) with ADLs. Record review of Resident #2's Care Plan dated 12/22/25 revealed a Focus: Cognitive Loss r/t dementia. The goal was for the resident to be alert and oriented as possible. The interventions included approaching in a calm manner, explaining what is being done during care, introducing one self, and orienting to person, place, and time. Record review of Resident #2's Progress Notes revealed a note from 3/24/26 at 10:55am from the ADON that said, The resident and her friend.reported to this nurse that the resident's debit card is missing. This nurse immediately notified the administrator and the DON of the missing item for further follow-up. In an interview on 4/2/26 at 9:50am, the ADON said Resident #2 reported a missing debit card to her and said her old roommate may have taken it. The ADON said she spoke to the old roommate and she said she did not have it. The ADON said she did not know what the resolution was. The ADON said she reported it as a grievance and reported it to the ADM and to the DON. In an interview on 4/2/26 at 12:12pm, the ADM said Resident #2's debit card was never found. She said she told Resident #2 to cancel the debit card and order another one. She said she did not report it and did not perform an investigation. The ADM said she did not think to investigate it since the resident thought her roommate took it. The ADM said she was the Abuse Coordinator and staff reported abuse, neglect, and exploitation to her. The ADM said she followed the Provider Letter PL 2024-14, for reportable incidents. 3. Record review of Resident #3's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of cognitive communication deficit (difficulty communicating caused by memory loss), bipolar disorder (extreme mood swings from elation to depression), and other symptoms and signs involving cognitive functions and awareness. Record review of Resident #3's Care Plan dated 3/11/26 revealed a Focus: Resident takes mood stabilizer for bipolar disorder. The goal was for the resident to not exhibit any signs of isolation by the next review date. The interventions included encouraging the resident to verbalize feelings and fears and involving the resident with others of shared interests. Focus: The resident needs to participate in her decisions regarding tasks of daily life. The goal was for the resident to be fully informed in advance about care and treatment and any changes in care or treatment by the next review date. Interventions included allowing the resident to be independent to the safest degree possible and encouraging the resident to participate in meeting care plan goals. Record review of Resident #3's Progress Notes revealed a note from 2/8/26 at 4:21am from LVN L that read, Staff heard screaming come from down the hall. Staff went in the direction of room and found both resident coming up the hall was visibly upset. Patient stated that room mate continues to open the door while she is toileting. Patient then alleges that she was being sexual[[NAME]] assaulted by room mate. Staff immediately separated patients and asked in detail what happened. Patient alleges that while she's toileting, room mate comes into the bathroom. Writer asked if room mate had touched her ; she stated no. Writer then asked patient will she allow writer to perform a head to toe skin assessment and patient stated that she didn't see where that would be necessary since room mate did not touch her. Writer went down and consoled room mate and she kept apologizing not realizing what she had done. Writer then assist room mate back in her bed and patient went up front to the nurses stations where patient was sitting while we place her into another room. During this discussion with peers, patient came into the lobby and called the police without staff knowing. Police came in and informed writer that patient had called them. Police stated that the patient alleged that she was assaulted sexually and needed more details. Writer explained to the police what had happened and he then questioned her. Police came out and spoke with me and stated that patient stated that she was not touched but was upset because room mate comes to the bathroom when she's in there. Police voiced understanding and did not feel the need to do a report nor did he speak to the other patient. Patient is now in another room resting quietly. DON has been notified and family will be notified. Attempted to call family member but patient states that family is resting and to call later on in the morning. In an interview on 3/31/26 at 12:55am, Resident #3 said the facility had an issue with putting unstable residents with other residents. She said she had one roommate who was aggressive and one roommate who tried to sexually assault her. She said her roommate would watch her go to the bathroom, every time she went. Resident #3 said the roommate did have Dementia, but every time she went to the bathroom she would follow her. Resident #3 said it happened multiple times. She said the last time she barricaded the door with her wheelchair and her roommate still pushed it out of the way. Resident #3 said her roommate never touched her but she had her hand stretched out like she wanted to touch her. Resident #3 said she felt very violated, and gross. She said she called the police and told them she was sexually assaulted. She said the police told her it was called voyeurism and it was illegal. In an interview on 4/1/26 at 2:32pm, the SW said Resident #3's roommate would open the door to the bathroom every time she was in there because the roommate had dementia and would forget someone was in there. The SW said the roommate had her own room prior to being placed with Resident #3, so she would forget that she had a roommate. The SW said Resident #3 told her she was exposed and her roommate just stood there looking at her. The SW said Resident #3 told her that she should not have used the words sexual assault but did say she felt like she was raped by her eyes or something to that affect. The SW said Resident #3 had never complained about the incidents before this and this was the first time she had complained about the roommate. The SW said she did not know about the roommate reaching out to touch her, or about her barricading herself in the restroom with her wheelchair. In an interview on 4/1/26 at 3:29pm, LVN L said both Resident #3 and the roommate were screaming and crying. She said Resident #3 was screaming that her roommate watched me. LVN L said Resident #3 called the police and told them she was sexually assaulted even though she was not touched. LVN L said she explained to the police officer that the roommate had bad dementia, so the police officer spoke to Resident #3 but decided not to write a report and left. LVN L said she separated the residents immediately and put them in separate rooms. In an interview on 4/2/26 at 9:50am, the ADON said she received a call from the DON who informed her that Resident #3 had called the police and they were there because her roommate was watching her urinate and she felt uncomfortable and uneasy. The ADON said the police came, assessed the situation, and left. She said the nurses separated the residents and that was about it. In an interview on 4/2/26 at 12:12pm, the ADM said the incident with Resident #3 and the allegation of sexual assault was before she was hired on 3/3/26. She said she was not sure why it was not investigated. She said she followed the Provider Letter PL 2024-14, for reportable incidents. She said some of the reportable events included: suspicious incidents, ANE, retaliation, suspicious injuries, death, missing resident, drug diversion, fire, and misappropriation. Record review of the facility's policy and procedure on Abuse, Neglect and Exploitation (revised 8/5/25) read in part: 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. Mental Abuse includes, but is not limited to, humiliation, harassment. Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent. Mistreatment means inappropriate treatment or exploitation of a resident.Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations.The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law.Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. B. Written procedures for investigations include:1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents, as needed; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse.Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will report the results of the investigation when final within 5 working days of the incident.

Based on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 3 of 6 residents (Resident #5, Resident #6, and Resident #7) for nutritive value, flavor, and appearance. The facility served overcooked fried fish that was not palatable and attractive to Resident #5 and Resident #6 for the lunch meal on 03/06/2026. This failure could place residents at risk for poor food intake and/or dissatisfaction with the meals served. Findings included: 1.Record review of Resident #5's face sheet revealed an admission date 11/24/2023 with a primary diagnosis of diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (nerve damage caused by secondary diabetes). Record review of Resident #5's Quarterly MDS dated [DATE] revealed BIMS 14, indicating a cognitively intact status in section C.In section K revealed that Resident #5 was on a Therapeutic diet (e.g., low salt, diabetic , low cholesterol), and Resident #5 did not have a significant weight loss/gain or swallowing disorder. Record review of Resident #5's care plan edited 03/11/2026 by CCM/MDS coordinator was as follows:Problem Start Date: 12/04/2023Category: Nutritional StatusNutritional Status/Diet - Resident #5 is on a regular diet and does not eat pork products. Resident family brings outside food.Long Term Goal Target Date: 06/10/2026: Maintain Stable Weight.Approach: Determine likes/dislikes, Diet as ordered, encourage oral intake of food and fluids, Fluid consistency, Monitor meal %'s, Report problems to charge nurse, ie: choking,difficulty chewing, Weigh per MD. Record review of Resident#5's physician order dated 02/11/2025 with an order description, Diet: low concentrated sweets. Texture: regular texture, Fluid Consistency: regular thin. * 2.Record review of Resident #6's face sheet revealed an admission date 01/16/2025 with a primary diagnosis of cerebral infarction (stroke caused by a blockage in an artery, cutting off blood flow and oxygen to brain tissue). Record review of Resident #6's Quarterly MDS dated [DATE] revealed BIMS 13, indicating a cognitively intact status in section C. In section K it revealed that Resident #6 did not have a specialized diet, significant weight loss/gain or swallowing disorder. Record review of Resident #6's care plan edited 03/18/2026 by CCM/MDS coordinator was as follows:Problem Start Date: 01/16/2026Category: Nutritional Status - Resident #6 Nutritional Status Diet. Short Term Goal Target Date: 06/24/2026: Maintain Stable Weight.Approach: house supplement per order - TID, Wife may request house supplement to giveresident, Determine likes/dislikes, Diet as ordered: Regular/ Thin liquids, Monitor meal percentages, Report problems to charge nurse (IE: choking,difficulty chewing, etc), and Weigh weekly. Record review of Resident#6's physician order dated 08/01/2025 with an order description, Regular diet Texture: RegularFluid Consistency: Thin Liquids. 3.Record review of Resident #7's face sheet revealed an admission date 01/16/2025 with a primary diagnosis of cerebral infarction (stroke caused by a blockage in an artery, cutting off blood flow and oxygen to brain tissue). Record review of Resident #7's Quarterly MDS dated [DATE] revealed BIMS 13, indicating a cognitively intact status in section C. In section K revealed that Resident #7 was on a Therapeutic diet (e.g., low salt, diabetic , low cholesterol), and Resident #7 did not have a significant weight loss/gain or swallowing disorder. Record review of Resident #7's care plan edited 03/03/04/2026 by CCM/MDS coordinator was as follows:Problem Start Date: 05/02/2025Category: Nutritional Status - Resident #7 Nutritional Status Diet. LCS/Regular/ThinnedShort Term Goal Target Date: 06/03/2026: Maintain Stable Weight.Approach: Resident is non-compliant with diet and brings in outside food, Diet as ordered: LCS Regular , Fluid consistency: Thinned, and Weigh monthly. * In an interview and observation on 03/06/2026 at 11:40am Resident #7 was in his room eating lunch prepared from a restaurant with a meal tray at the beside. Resident#7 said that he declined his lunch meal tray because on Friday's the kitchen prepared fried fish that was always overcooked and the fish was inedible. Resident #7 said that if he told staff that the fish was overcooked, the staff would prepare another piece of fish for him, but he felt the fish should be cooked correctly the first time. In an interview and observation on 03/06/2026 at 12:05pm with Resident #6. Resident #6 was observed in the dining hall during the lunch meal service, and Resident #6 had only consumed half of the fried fish on his meal tray. Resident #6 said that he had not consumed all the fish because it was overcooked and inedible. He said that the kitchen served fried fish every Friday and it was always overcooked. Resident #6 said that if he told staff that the fish was overcooked, the staff would prepare another piece of fish for him, but he felt the fish should be cooked correctly the first time. Resident #6 was observed to pick up the half-eaten piece of fish, and he tapped the fish on the dining room table multiple times making a sound to show how over cooked the fish was. Resident#6 said that he told CNA M that the fish was overcooked, and she had a new piece of fish prepared for him. In an interview and observation on 03/06/2026 at 12:07pm Resident #5 was observed in the dining hall during the lunch meal service, and Resident #5 had not consumed his meal tray. Resident #5 said that he was waiting for CNA M to bring him a new tray because his fish was overcooked and inedible. Resident #5 was observed to pick up the piece of fish, and he tapped the fish on the dining room table multiple times making a sound to show how over cooked the fish was. He said that the kitchen served fried fish every Friday and it was always overcooked. Resident #5 said that if he told staff that the fish was overcooked, the staff would prepare another piece of fish for him, but he felt the fish should be cooked correctly the first time. In an interview on 03/06/2026 at 12:09 pm with CNA M, who said that Resident #5 and Resident#6 asked for a new piece of fried fish because it was overcooked, she told the Dietary Manager, and the Dietary Manager was preparing new trays for the resident with freshly cooked fish. She said that the residents should not be served food that was overcooked and the food should be prepared properly when it was initially served to the residents. In an interview and observation on 03/06/2026 at 12:11pm with the Administrator and DON. Both were observed to see Resident#5 to pick up the piece of uneaten fish from his tray as he tapped the fish on the dining room table multiple times making a sound to show how over cooked the fish was. Both said that they would ensure that the dietary staff prepared a new tray of any resident that felt they had received overcooked fish. Both said that the kitchen staff should ensure that overcooked food was not served to the residents. Both said that the fish that they had observed on the tray of Resident#5 was not palatable. Both said that the risk of serving residents food that was not palatable is that the residents may not want to eat their meals. In an interview and observation on 03/06/2026 at 12:15 pm with the Dietary Manager. She was observed to served Resident#5 and Resident #6 with new meal trays with freshly cooked fish, and she was observed to stay with both residents while they tasted the fish and it was cooked to their liking. She said that CNA M came to her with concerns that Resident#5 and #6 were served fish that was overcooked and both residents were requesting a new tray. She said that she would speak to the cook that prepared the fish and complete additional training. She said that the fish should have been served correctly initially and the fish served to Resident#5 and Resident #6 was not palatable. She said that the risk to residents is they may not want to consume their meals. In an interview with [NAME] L on 03/06/2026 at 12:52pm he said that he prepared the fish for the lunch meal serves. He said that he started frying the fish at 10:00am, and it was placed on the steam table. He said that he went to check the temperatures of the fish at 11:45am and the temperature had dropped. He said that he reheated the fish so that it would be served at the appropriate temperature, and he believed some of the fish could have been overcooked. He said that the food served from the kitchen should come to the residents fresh, hot, pleasing to eye, and palatable. He said that the fish served to Resident#5 and Resident#6 was not palatable. He said that that the risk to residents is they may not want to eat their meals. Record review of the facility policy titled, Food Preparation Guidelines, with a revised date 07/23/2025 read in part, Policy: It is the policy of this facility to prepare foods in a manner to preserve a resident's nutrition and hydration status. Definitions: Food palatability refers to the taste and/or flavor of the food.Policy Explanation and Compliance Guidelines: . 3. Food and drinks shall be palatable, attractive, and at a safe and appetizing temperature.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 2 out of 19 residents (Resident #2 and Resident #4) reviewed for ADLs. The facility failed to provide scheduled showers, three times a week to Resident #2 for the week of 3/29/26-4/4/26.The facility failed to provide scheduled showers, three times a week to Resident #4 for the week of 3/29/26-4/4/26. This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth. Findings included: 1.Record review of Resident #2's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE] with diagnoses of Dementia with anxiety (progressive or persistent loss of intellectual functioning), local infection of the skin and subcutaneous (fatty) tissue, urinary tract infection, unspecified fall, age related cognitive decline (decrease in mental functioning), ADHD (trouble paying attention and being hyperactive), hemiplegia and hemiparesis affecting left side following CVA (paralysis and weakness after a stroke), and history of falls. Record review of Resident #2's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15, which indicated moderately impaired cognition. The resident used a wheelchair for mobility and was dependent (helper does all of the effort, resident does none of the effort to complete the activity) for showers/baths. The resident was occasionally incontinent of bowel and bladder. Further review of the MDS revealed the resident was at risk of developing pressure ulcers. Record review of Resident #2's Care Plan dated 12/22/25 revealed a Focus: General- The following tasks will be documented in the POC. The goal was for the resident to perform the following tasks at their highest practicable level. Interventions included staff performing her bath on Tue/Thu/Sat from 6am to 6pm. There were no refusals of care planned. In an interview and observation on 4/2/26 at 11:00am, Resident #2 was sitting in her wheelchair watching television, in the living room. The resident's hair appeared to be oily looking and sticking to her scalp. The resident had thick, white build up on her bottom teeth, that was noticeable when she spoke. The resident said she wanted to get a bath/shower because her hair was so oily. She said she did not remember when her last bath/shower was. Resident #2 said CNA A told her in the morning that she was going to give her a bath/shower but now it was already lunch time so she did not think she was going to get one. Record review on 4/2/26 of Resident #2's Shower Sheets revealed they could not be located. 2.Record review of Resident #4's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE] with diagnoses of chronic kidney disease (kidneys are not filtering well), muscle spasms (muscles shake uncontrollably), afib (irregular heart beat), congestive heart failure (heart does not pump effectively), hypertension (high blood pressure), acute respiratory failure with hypoxia (not enough oxygen in the blood), MRSA (antibiotic resistant bacteria), and spinal stenosis in the lumbar region (narrowing of spinal canal in lower back). Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. He had impairment on both sides of his lower extremities and was dependent for showers/baths. The resident had an indwelling catheter (tube into bladder to drain urine) and was always incontinent of bowel. Resident #4 was at risk for developing pressure ulcers. Record review of Resident #4's Care Plan dated 1/21/26 revealed a Focus: General-The following tasks will be documented in the POC. The goal was for the resident to perform the following tasks at their highest practicable level. Interventions included having his bath/shower on Tue/Thu/Sat from 6am to 6pm. There were no refusals care planned. In an interview on 3/31/26 at 12:00pm, Resident #4 said he only got a shower/bath once a week and he would like to have one more often but was told there was not enough staff. Record review on 4/2/26 of Resident #4's Shower Sheets revealed the last Shower Sheet was dated 3/17/26. In an interview on 4/2/26 at 11:50am, CNA A said the facility closed the 100 and 300 halls for renovations and moved those residents to the 200, 400, and 500 halls. She said with the switch, some residents shower/bath days changed as well. CNA A said the 400/500 halls got their showers/baths on Tue/Thu/Sat and the 200 hall got theirs on Mon/Wed/Fri. She said both the A and B beds were done during the day and no showers/baths were given during the night shift. She was unsure why the night shift did not help and give showers/baths so it would lessen the burden during the day shift. CNA A said there was not enough time for them to shower/bathe all the residents, feed them, change them, and keep their eye on the fall risk residents. In an interview on 4/2/26 at 11:55am, CNA E said there were only two CNAs during the 6am to 6pm and there was not enough time to shower/bathe all the residents plus perform their other duties. She said she would try and give about five showers as soon as she got on shift as the resident's are getting up for breakfast. She said there were supposed to be four CNAs during the day so that one of the CNAs could be dedicated to giving showers/baths, but they had not had four CNAs in a long time. CNA E said they have talked to the DON about it before but nothing gets done. She said it was not that she did not want to give the residents their showers/baths, it was just they did not have time to do it along with their other duties. CNA E said she frequently left her shift without residents getting their showers/baths. In an interview on 4/2/26 at 12:11pm, CNA F said the facility had a CNA that worked on Tue/Wed and only gave baths/showers. She said on the days that CNA was not working, the regular CNAs had to give the showers/baths and it was hard to get all the residents done. She said there were times when all the residents did not get their bath/shower because there was not enough staff. CNA F said the night shift did not give showers/baths and she was not sure why they did not. In an interview on 4/2/26 at 12:16pm, the ADM said the facility was supposed to have 3-4 CNAs working so one of them could be a shower technician. She said it was too much work for only two CNAs, and said she had four CNA positions posted. The ADM said if the resident refused a shower/bath it had to be documented and the resident had to be educated because not having showers/baths could cause infection control issues and sanitary problems. She said the DON oversaw the showers to ensure they were being done. In an interview on 4/2/26 at 12:23pm, the ADON said when there were four CNAs one was a shower technician. She said all showers/baths were given during the day and she did not know why, it had been that way since she started. She said with only three CNAs it was heavy, but she felt it was still doable for them to give all the showers/baths and perform other CNA duties. The ADON said the facility always had at least three CNAs scheduled for the 6am-6pm shift. She said if the residents did not get showers/baths it could cause skin infections, or skin break down. She said the nurses oversaw the resident's showers/baths to ensure they were being done by collecting the shower sheets from the CNAs and then signing off on them. In an interview on 4/2/26 at 12:36pm, LVN B said she did oversee the CNAs to ensure residents got showers/baths or refused. She said the CNAs gave her the shower sheets and she looked at them to ensure they got their shower/bath, refused, and to see if they had any skin issues. The nurse said Resident #4 frequently refused showers/baths. LVN B said refusals were documented on the shower sheet and then the nurse talked to the resident to see if they could convince the resident to take a shower/bath or see why they refused. She said if the resident refused often it was care planned. She said they did not always have three CNAs at the facility. She said they had two CNAs scheduled and the third was PRN, so the CNA scheduled PRN did not always come in. The nurse said she felt like three CNAs should be able to get all of the baths/showers done, plus their other duties, because she was the type of nurse to help out when she could. LVN B said sometimes they were stretched thin even with three CNAs. She said having to do all the baths/showers during the day, feeding the residents, changing all the residents, and watching the at risk residents was a lot for only 2-3 CNAs. In an interview on 4/2/26 at 1:45pm, Resident #4 said he still had not had a shower/bath this week and his last shower/bath was 3/26/26. He said someone was supposed to give him a shower today (4/2/26) but it was already almost 2pm so he did not think he was going to get one today. Record review of the facility's policy and procedure on Resident Showers (revised 9/2025) read in part: It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice.Residents will be provided showers as per request or as per facility schedule protocols and based upon resident safety. Partial baths may be given between regular shower schedules as per facility policy. Record review of the facility's policy and procedure on Bed Baths (revised: no date) read in part: It is the practice of this facility to assist residents with bed bathing to maintain proper hygiene and help prevent skin issues.

Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #5) reviewed for comprehensive care plans. The facility failed to provide Resident #5 with comprehensive per-centered care plan to address his diet. This failure could place residents at risk of not having personalized plans developed to address their specific care needs. Findings included: Record review of Resident #5's face sheet revealed an admission date 11/24/2023 with a primary diagnosis of diabetes mellitus due to underlying condition with diabetic neuropathy, unspecified (nerve damage caused by secondary diabetes). Record review of Resident #5's Quarterly MDS dated [DATE] revealed BIMS 14, indicating a cognitively intact status in section C. In section K revealed that Resident #5 was triggered for a therapeutic diet (e.g., low salt, diabetic, low cholesterol). Record review of Resident #5's care plan edited 03/11/2026 by CCM/MDS coordinator revealed the following:Problem Start Date: 12/04/2023Category: Nutritional StatusNutritional Status/Diet - Resident #5 is on a regular diet and does not eat pork products. Resident family brings outside food.Long Term Goal Target Date: 06/10/2026: Maintain Stable Weight. Approach: Determine likes/dislikes, Diet as ordered, encourage oral intake of food and fluids, Fluid consistency, Monitor meal %'s, Report problems to charge nurse, ie: choking,difficulty chewing, Weigh per MD. Record review of Resident#5's physician order dated 02/11/2025 with an order description, Diet: low concentrated sweets. Texture: regular texture, Fluid Consistency: regular thin. In an interview on 04/02/2025 at 1:00pm with the ADON said that all residents should have a comprehensive person centered care plan. She said that without a comprehensive person centered care plan residents may not receive the appropriate care needed. She said that Resident#5 had a low concentrated sweets diet, and his care plan was not updated to reflect his diet orders. She said that she was under the impression that care plans were updated by either the DON or CCM/MDS Coordinator. She said that any clinical staff that reviewed the care plan could have caught the error and it was an oversight. In an interview on 04/02/2025 at 1:29pm the CCM/MDS Coordinator, said residents should have a comprehensive person centered care plan . She said that without a comprehensive person centered care plan care needs could be missed. She said that Resident#5 was diabetic with a therapeutic diet for low concentrated sweets. She said that she updated Resident#5, and it did not reflect his current diet orders. She said that the dietary section of the care plan can be updated by either the DON, ADON, or CCM/MDS Coordinator. She said that there was a QAPI and PIP to address comprehensive person centered care plans, with a plan for her to ensure that all residents had an updated care plan that was comprehensive and person centered from February 2026-April 2026. She said that the PIP was not effective if Resident#5's care plan was not updated to reflect his diet, it was an oversight, and any clinical staff could have caught the error and ensured it was corrected. In an interview on 04/02/2025 at 1:45pm with the Administrator, she said that that all residents should have a comprehensive person centered care plan. She said that without a comprehensive person centered care plan care could be missed. She said that the dietary section of the care plan can be updated by either the DON, ADON, or CCM/MDS Coordinator. She said that there was a QAPI and PIP to address comprehensive person centered care plans, with a plan for the CCM/MDS Coordinator to ensure that all residents had an updated care plan that was comprehensive and person centered from February 2026-April 2026. She said that the DON was suspended pending an investigation on 03/31/2026. She said that the PIP was not effective if Resident#5's care plan was not updated to reflect his diet, it was an oversight, and any nursing clinical staff could have caught the error and ensured it was corrected. Record review of facility document titled, Performance Improvement Plan (PIP), signed by the CCM/MDS Coordinator on 02/05/2026 read in part, Issue of Non-Compliance, updating and revisions of care plans: (Care plans not being resolved when problem has resolved need. Need to be person centered with measurable goals, approaches, to reflect the need of the resident) Care plans to be reviewed and updated to reflect current resident status on 5 residents weekly for the next 12 weeks. Start date 02/09/2026. Target Completion date 04/24/2026. Record review of the facility policy titled, Care Plans, Comprehensive Person-Centered, with a revised date December 2020 read in part, 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. The services provided or arranged by the facility, as outlined by the comprehensive care plan, are provided by qualified persons, are culturally- competent and trauma-informed. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings.- The facility failed to update the facility Daily Staff Posting on 02/10/26. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner.Findings Include:An observation on 02/10/26 at 10:39 AM revealed the facility did not have a posting with the nurse staffing posting information. The placard on the wall facing the lobby, across from the nursing station, was empty.In an interview on 02/12/26 at 08:01 AM, the DON said she was responsible for updating the staffing posting. She said the posting served to provide anyone in the building with the staffing to resident ratio. The DON said the posting was typically updated at the beginning of the shift, and her shift started at 08:00 AM and direct care staff had 2 shifts, 6AM- 6PM and 6 PM to 6 AM. She said the posting was not updated timely on 02/10/26 because she was in a morning meeting. The DON said failure to update the posting could place visitors at risk of not knowing what the current census or staffing was.In an interview on 02/12/26 at 08:09 AM, the Administrator said he just started working in the facility on 02/09/26. He said the nursing posting served to notify everyone who walked into the building what the census, staff hours and staff type were in the building. He said the DON and ADON were responsible for the posting and it should be posted as early as when the first shift started at 6:00 AM, and he didn't know it was not posted timely on 02/10/26. The Administrator said failure to update the facility posting would leave visitors unaware of the census and staffing information.An observation on 02/12/26 at 08:21 AM revealed, the facility Daily Staff Posting posted on the wall facing the lobby reflected 02/12/26. The posting indicated that the facility had 2 shifts (6AM- 6 PM & 6 PM to 6AM) for RNs, LVNs, CNAs and MAs. The posting indicated the facility census, number of staff types (RN, LVN, CNA, and MA) and total hours worked for all shifts.In an interview on 02/12/26 at 09:09 AM, the ADON said she and the DON were responsible for the nursing posting located at the front of the building. She said the posting provided the facility name, date, census, staff types and the number and hours of staff that worked on each shift and it served to let people know the type and number of staff as well as number of residents in the building. The ADON said the posting should be updated every day at the start of her shift, which was usually from 08:00 AM to 05:00 PM and direct care staff worked 12 hour shifts from 6AM- 6PM and 6PM- 6 AM. The ADON said on 02/10/26, she arrived for her shift at 09:00 AM, and was busy with patient related situations which resulted in a delay in updating the facility posting. The ADON said failure to update the daily posting could leave visitors unaware of the facility census as well as the staff type and hours available on a certain day.Record review of the facility policy titled Nurse Staffing Posting Information implemented 03/2025 revealed, Policy Explanation and Compliance Guidelines: I. The Nurse Staffing Sheet will be posted on a daily basis and will contain the following information: a. Facility name b. The current date c. Facility's current resident census. d. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: i. Registered Nurses. ii. Licensed Practical Nurses/Licensed Vocational Nurses. iii. Certified Nurse Aides. 2. The facility will post the Nurse Staffing Sheet at the beginning of each shift. 3. The inforn1ation posted will be: a. Presented in a clear and readable format. b. In a prominent place readily accessible to residents, staff, and visitors.

Based on observation, interview and record review the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #1) reviewed for accident hazards in that: -The facility failed to ensure Resident #1 had interventions in place after she fell on 8/10/2025, 8/11/2025, or 8/14/2025 when she sustained a hematoma to her forehead and on 8/16/2025 when she fell again and suffered a laceration over the right eye requiring 7 sutures.-The facility failed to adequately supervise Resident #1 after she experienced the first fall on 8/10/2025. -The facility failed to determine the causative factors of the falls and address those factors timely. Resident #1 was admitted on [DATE]. An Immediate Jeopardy (IJ) was identified on 8/22/2025 at 3:40pm. The IJ template was provided to the facility on 8/22/2025 at 3:40pm. While the IJ was removed on 8/24/2025, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm as the facility continued to monitor the implementation and effectiveness of their plan of removal.This failure could place residents at risk of serious injuries requiring hospitalization or surgical intervention, and/or death.Findings Included:Record review of Resident #1's face sheet dated 8/7/2025 revealed that she was a [AGE] year-old female that was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of hypertension (high blood pressure), other muscle spasms(involuntary contractions of muscles), long-term aromatase inhibitors(used to treat hormone-receptor-positive breast cancer in women), and cervical myelopathy (a nervous system disorder that affects the spinal cord) and a history of falls.Record review Resident #1's care plan dated 8/8/2025 revealed that a 48-hour baseline had been completed. Problem: Baseline care plan will identify my care needs, risks, strengths and goals for the first 48-hoursGoal: Initial goal is to have access of services to promote adjustment to my new living environment. Approach: Safety falls: Fall risk evaluation will be completed to identify and minimize initial risk factors for falls/injury. Record review of Resident #1's initial MDS assessment dated [DATE] revealed:Section C500- Brief Interview for Mental Status was unscored.Section GG01300- Functional Abilities revealed C. toileting hygiene was coded as 04- representing supervision or touching assistance was needed by helper. E. Shower/bathe self was coded as 01- Dependent -helper does all of the work. F. Upper body dressing, lower body dressing, personal hygiene and putting on/taking off footwear were all coded as 3. Representing partial/moderate assistance needed by a helper.Section GG0170- Mobility revealed sit to stand, chair/bed-to-chair-transfer, and toilet transfer were coded as (2)- which represented substantial/maximum assistance-helper does more than half the effort. Helper lifts or holds trunk or limbs and does more than half the effort. Section J1700-Fall History A. Did the resident have a fall any time in the last month prior to entry/entry or reentry was coded 1. YesJ1800- Any falls since admission was coded as 1. Yes Record review of Resident #1's Morse Fall scale dated 8/7/2025 revealed Resident #1 had a history of falls, ambulated with a walker, had weakness, Gait: Normal. There was a score of 40 and she was deemed a low risk for falls.Record review of the morse scoring data revealed five factors for scoring:1. History of Falls (25 points)- Resident #1 has fallen prior to admission2. Secondary Diagnosis (15 points)- Resident #1 has more than one medical diagnosis3. IV Therapy- (0) - Resident #1 does not have an IV4. Gait- (20) points- Resident #1 had impaired gait, difficulty rising or poor balance5. Mental Status- (15 points) - Resident #1 overestimates her ability and is forgetful of their limitations. Low Risk if (Score of 0-24 points)Medium Risk- (Score of 25-44)High Risk (Score of 44 or higher than 50) Record review of Resident #1's admitting hospital record dated 6/25/2025 revealed the resident was admitted to the hospital and assessed due to recent falls, hemiplegia and hemiparesis following cerebral infarction. Record review of the Resident #1's clinical record from a local hospital ER visit dated 8/4/2025 revealed her chief complaint was a fall. She now presents with multiple falls due to myelopathy. CT head was negative however x-ray showed right shoulder mid shaft clavicle fracture comminuted proximal phalanx. Neurology was consulted to decompress her spinal cord as she underwent C3-C4, C4-C5, C5-C6 ACDF on 8/24/2022. She was not wearing her soft collar. Record review of Resident #1's clinical record from ER visit dated 8/14/2025 revealed she was admitted due to a fall at the facility and sustained a head injury and possible lumbar transverse process fracture. Activity instructions were for Resident #1 were to get up using only her walker, take her time standing and ask for assistance when needed. Continue wearing the cervical collar and sling. Record review of Resident #1's ER record dated 8/16/2025 revealed she was admitted to the hospital following a fall with a laceration over her right eyebrow. She received 7 sutures. Record review of Resident #1's nursing progress notes revealed: 8/10/2025 at 7:09pm- LVN D observed call light and upon arrival Resident #1 was observed on the floor. Resident #1 stated she was going to the restroom. No injuries observed, denied pain, neuro checks started every 30 minutes for 2 hours. 8/11/2025 at 2:57pm- LVN D stated she was notified by PT personnel that Resident #1 was observed on the floor. Observed to be in sitting position on the floor. Resident stated she was getting up to go to the restroom. RP, physician notified.8/14/2025 at 1:58am- LVN A wrote Resident #1 was lying on the floor, assessed and had hematoma to right forehead. She is alert with confusion, physician said send to ER via 911. No complaint of pain.8/16/2025 at 9:15am- LVN H wrote she was called to room to assess resident due to rt eye bleeding. Area cleansed with normal saline and dressing. Physician, RP, DON notified. Physician said send Resident #1 to ER. Record review of incidents of falls report dated 7/18/2025-8/18/2025 revealed:08/10/2025 06:53PM Resident #1-Fall 08/10/2025 06:51PM Resident #1- Fall08/11/2025 02:26PM Fall Resident#1's Room door was OPENED08/14/2025 02:11AM Resident#1's Room door was OPENED08/16/2025 09:14AM Resident #1's Room door was OPENED resident fell while attempting to transfer to restroomhematoma to right forehead.An observation and interview with Resident #1 on 8/18/2025 at 11:19am she had a bandage over her right eyebrow, hematoma on her forehead and a blackened right eye. She said she had been at the facility for a couple of weeks and fell twice when she was going to the restroom. She seemed confused when she was told that she had 5 falls at the facility. She said she kept falling because she lost her balance and was dizzy. She said her friend (RP) took care of her when she resided in her RV. She said she was confused sometimes and forgot to get help and that her falls were when she was going to the restroom. She said staff would not come to help her to the restroom. She admitted she would not use the call light although call light string was pinned to her fitted sheet.An interview with Resident #1's RP on 8/18/2025 at 11:21am said Resident #1 had experienced multiple falls at the facility due to staff not helping her to get to the restroom. She said Resident #1 had only been at the facility for about 2 weeks and had multiple falls. She admitted that Resident #1 had falls prior to being admitted to the facility due to her having a stroke. She said Resident #1 broke her collar bone and had surgery to remove two lipomas off her spine. She said the facility staff should be able to help her to the restroom as they were aware of her falls before coming to the facility. She said she had spoken to the DON about staff helping Resident #1 as they said they would. She said adequate supervision was needed because Resident #1 was confused. An interview with Resident #1's Psychiatrist NP on 8/18/2025 at 12:03pm she revealed she had visited with Resident #1 only once for an evaluation and said she was confused and had early signs of dementia. She said her dementia perhaps caused her to believe she was still capable of ambulating unassisted. She stated that they would be evaluating her medications to figure out if they could be causing her falls. She said this was her 2nd visit and she wanted to quickly find out if there was something she could do to help with the falls.An interview with PT Director on 8/18/2025 at 12:14pm he stated Resident #1 had received 5 days (8/11-8/15/2025) of PT to address falls, balance, and gait. He said Resident #1 participated in bilateral lower extremities (BLE) strengthening program to improve physical performance, dynamic standing balance to improve safety and prevent falls. He said Resident #1 would improve her ability to complete toilet/commode transfers with supervised or touching assistance with better balance. He said Resident #1 had been granted another 5 days of physical therapy and she started again today (8/18/2025). He said her left shoulder was also weak from a shoulder injury prior to coming to the facility. He said they would also concentrate on generalized weakness. He said the management team had discussed her falls and put therapy in place. He was not aware of any other interventions.Attempted interviews were made on 8/18, 8/19 and 8/23/2025 to contact LVN C and LVN D, which were the nurses on the night shift when Resident #1 fell on 8/10, 8/11 and 8/14/2025. These attempted phone calls were unanswered and not returned.An interview with the MDS Nurse on 8/18/2025 at 3:35pm she said she had been employed for 1 year. She said as the MDS Coordinator she completed the MDS assessment upon admission, quarterly, and upon significant change. She said she was working on Resident #1's initial MDS today (8/18/2025). She stated she had been at a work conference last week and knew coming back today (8/18/2025), that she would have to complete it. She said falls were discussed in morning meetings and there had already been discussions about Resident #1's falls. She said once there is a fall, another fall risk assessment should be completed, documentation should be done on an incident report and interventions added to the care plan. She said she looked at the care plan because she noticed there were no interventions it came up when she started the MDS. She said she discussed it with the DON today. She said they were still within their window for completing the comprehensive care plan because it was due within 7 days after completing the MDS or by day 21 of the resident' stay.An interview with the DON on 8/18/2025 at 4:25pm revealed she had been employed by the facility since April 2025. She said her duties were to oversee clinical for the residents and work closely with medical director in caring for the residents. She stated Resident #1 had about 5 falls. She said they had already provided physical therapy for her for one week. She said she was ambulatory with her walker, but she does not wait or call for assistance from staff. She said she believed that the resident was experiencing vertigo (a medical condition that causes a person to feel like they are spinning or moving). She said they did not use fall mats because they posed more of a risk for ambulatory residents. She said she had educated the resident on locking her overbed table to gain her footing first then to grab her walker. She said her bed was in its lowest position, however she had access to the remote control for the bed and would often lower and raise it as she wanted. She said Resident #1 had a C-collar when she was admitted and sling on her right arm. She said she used the affected arm which was another issue. Rehab was altering a wheelchair for her to be able to use it. She said they were in discussions with regional and had QAPI concerning the resident since it was difficult for her to determine the next steps for her. She said it was her expectation for nursing staff to make timely rounds to check on the residents. She said she felt facility staff supervised her, but Resident #1 did not wait for them to come to help. She said Resident #1 could have re-injured her shoulder or even worst she could have had a spinal injury from the falls. An interview with the VPO on 8/18/2025 at 4:27pm, he said he had been in the facility on Mondays, Thursday and Fridays since the facility did not have an Administrator. He stated that he wished he could argue their non-compliance, but he could not. He said Resident #1 had multiple falls and although PT was started to help with strengthening it was not enough especially since she continued to fall. He said there were not completed progress notes about the incidents. He said his expectation was for the nursing staff to document falls, brainstorm interventions and immediate act on those to prevent further falls.An interview with PCP-NP on 8/19/2025 at 1:13pm she stated she just started going to the facility. She said she saw Resident #1 for the first time today (8/19/2025). She said nursing staff briefed her and said she was a fall risk and had a cervical fracture prior to being admitted . She said she thought this fracture was from a few months ago, this is why she was admitted . She said Resident #1 would be having her sutures removed in the next few days. She said Resident #1 was confused and cognition seemed to be off. She said she would review any labs that were done or order labs just to check to see if there was some other underlying reason for her falls. An interview with Resident #1's PCP on 8/19/2025 at 1:28pm he said he saw her the day after she was admitted (8/8/25). He said he was not on his laptop to give specifics, but he had been notified she have had quite a few falls. He said she can slightly communicate and was very confused at times. He said what he did recall was that she wanted to do things on her own. He said Resident #1 fell this past weekend because she wanted to go to the restroom on her own. She needed help. She was not able to control her balance. He stated he was at the facility 2 times a week and his NP was there 3 times per week. He said the call light was in reach at his last visit. He said he did not think she fully understood that she could really hurt herself. He said he educated her on using the call light and the importance of her waiting for help. He said he believed the staff tried to supervise her to prevent her from falling. He said she could have injured herself badly. He agreed that a laceration requiring sutures was considered a serious injury. He said his NP was at the facility (today)and would be looking into some possible causes of her falls by looking at her labs.A subsequent interview with the VPO on 8/22/2025 at 3:34pm he stated that they discussed Resident #1's falls with the medical director because he was aware that they had no interventions in place and honesty he was upset to find there were no progress notes about the falls prior to 8/15/2025.An interview with LVN A on 8/23/2025 at 6:48pm, he said he had been employed since 2008. He worked the 6pm-6am Hall D and E (Hall 400 and 500). He stated he completed the Morse scale assessment for Resident #1 upon her admission. He input yes or no to the questions about gait, diagnosis and the system gave him a score of 40. He said he was not sure about the range for determining high or low risk. He said he entered her history of falls and answered all the questions, and the system tabulated and said she was a low risk for falls. He stated he was not the nurse on duty for none of the falls. He documented post fall observations as nurse observe 3 days after a fall. He stated that he reviewed the notes, and she fell on the day shift on 8/11 and 8/16, and he was not the night nurse on 8/10, 8/14 or 8/16/2025. He said they were oriented on the fall risk assessments being updated after a fall. He said Resident #1 could have re-injured herself and got more or worst injures from the falls. Accident and hazards policy was not received prior to exit. An IJ was identified on 8/22/2025 at 3:40 pm. The IJ template was provided to the facility on 8/22/2025 at 3:40 p.m. The Facility's plan of removal was accepted on 8/23/2025 at 11:44 a.m. and included the following: Immediate Action:Date: 08/23/2025-The facility failed to ensure Resident #1 had interventions in place after she fell on 8/10/2025, 8/11/2025, sustained a hematoma to right forehead on 8/14/2025 and a laceration over the right eye requiring 7 sutures on 8/16/2025.-The facility failed to provide an emergency plan to adequately supervise Resident #1 after she experienced the first fall on 8/10/2025. -The facility failed to determine the causative factors of the falls and address those factors timely. Resident #1 had been admitted since 8/7/2025Resident #1 was sent to the hospital for further evaluation. Resident has since returned to the facility, has sutures to right eyebrow, hematoma on her forehead, and a discoloration to right eye and is behaving per norm, no further concerns noted. Immediate action: Action: Resident #1 will have a medication review by the Medical Director. Resident #1 was care planned for the following interventions: education on safety, cont. encourage ask for assist and ask for assist to go to bathroom, monitor for orthostatic hypotension per order, frequent checks and see if needs assistance, continue with neck brace and sling per order, keep bed in low position. Notify nurse if resident removes neck brace or sling. Continue follow with Ortho.Resident #1 will be evaluated for appropriate assistive devices and will use wheelchair Resident #1 will be evaluated by PT servicesResident #1 will have medication review by Medical Director; (MD has discontinued Cycobenzapine and has initiated orthostatic blood pressure checks every shift which occurred on 8/22/2025).Resident #1 will have orthostatic b/p checks every shift-Resident will be monitored every shift, for 3 days, and daily thereafter for 7 days, on follow up charting related to the changes, including changes with medications. This will be located in the resident's progress notes and/or observations in the electronic medical record. Any concerns with medication changes and/or resident status will be communicated to the physician for further direction.Person(s) Responsible: Charge Nurse, Regional Nurse Consultant, and/or DesigneeDate: 8/22/2025Action: Review all residents fall risk assessments to ensure they are updated and accurately reflect the resident. Based on resident assessment and chart review, 25 residents were changed to from low fall risk to high fall risk. Their care plans will reflect their assessments. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: A 30-day audit will be completed for all falls in the facility, 12 falls were identified, 7 total residents affected. The facility will review all care planned interventions for the fall(s) to ensure they are present and person-centered. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Initiate a review of all admissions, prior to admitting into the nursing home, to identify if a resident is at risk for falls and to create a person-centered care plan/baseline care plan with person centered interventions in an attempt to reduce the risk of falling upon admission. Administrator and/or designee will monitor for compliance. Person(s) Responsible: Nursing Administration, Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025Facility's Plan to ensure compliance quickly:Action: Educate Charge Nurses and CNAs over resident person-centered interventions for falls. Education to include implementing interventions, notifying on call nursing administration, consulting the physician, getting therapy involved, increased rounding, etc. Test will be distributed to evaluate the effectiveness of the education. All Charge Nurses and CNAs will be educated prior to working their next shift. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Educate CNAs and Nurses on resident profile that will alert staff of a resident that is a fall risk, interventions will also be located in the resident profile located in the electronic medical record. CNAs and Charge Nurses will complete a return demonstration on pulling the resident profile and where to view interventions. All CNAs and Charge Nurses will be educated prior to working their next shift. Person(s) Responsible: Clinical Case Manager, Wound Care Nurse, and/or Designee Date of Completion: 8/22/2025 Action: Falls will be reviewed/monitored during clinical meetings, daily x5 days weekly, to review the event report, attempt to root cause, and update the care plan with person centered interventions. Administrator and/or designee will monitor for compliance.Person(s) Responsible: Clinical Administration, Assistant Director of Nursing, Clinical Case Manager, and/or Designee.Date of Completion: 8/23/2025 Action: Ad hoc QAPI to inform Medical Director of the IJ template for 689 and the facility's plan to remove the immediacy. Person(s) Responsible: Regional [NAME] President, Clinical Case Manager, Wound Care Nurse, and/or DesigneeDate of Completion: 8/22/2025 Monitoring: Observation of Resident #1 on 8/22/2025 and 8/23/2025 at various times revealed her to have her neck brace and sling on her right arm. Record review of Resident #1's care plan included the following interventions: Education of safety, continue to encourage ask for assist to go to the bathroom, monitor her orthostatic hypertension. Frequent checks will be provided, and staff would inform the nurse if she removed her neck brace and sling per order. Continue to follow with Orthopedic physician. Resident #1 would be evaluated for appropriate assistive devices and will use wheelchair. Resident #1 will be evaluated for PT. Resident #1's record also included a PT evaluation conducted on 8/22/2025. She was placed on services for five days.Record review of Resident #1's MAR was updated to reflect orthostatic blood pressure every shift. Further review revealed MD discontinued Cyclobenzaprine. Record review of Resident #1's progress note dated 8/23/2025 revealed she had been reporting that she was well without taking the muscle relaxer Cyclobenzaprine.Record review of the list of 25 residents listed were changed from low to high risk for falls.Record review of 5 out of 25 sampled residents from the list of 25 residents had updated care plans related to falls (Residents #1, 2, 3, 4 and 5).Record review of Resident #1's and Resident #3's resident profile revealed that it alerted staff that they are a fall risk. Record review of test given to the clinical staff asked questions concerning fall interventions, when and who should notify RP, Physician, DON, Administrator. Interviews with CNA's A, B, C, and D were conducted between 8/22-8/25/2025 on the 6am-6pm shift were able to communicate the recent in-services in which they were told where they could find resident interventions in their EMAR, notifying on-call administration after an incident event, and notifying their nurse of any incidents. Interviews with the night shift (6p-6a) staff were CNA's E, F, H, and J were conducted on 8/24/2025. They were able to communicate their in-services on interventions, resident profiles, increased rounding and notifying the Charge Nurse when there are Resident incidents. Interviews with LVN's A, B and G were conducted between 8/24 and 8/25/2025 of night shift staff revealed they had been in-serviced on completion of a fall risk assessment, adding additional or different interventions to the care plans, notifying the RP, Physician, DON and Administrator, checking Resident profile for their person-centered assessments, providing full body skin assessments.Interview with MDS Coordinator and Wound care nurse on 8/23/2025 revealed them to state they had been in-serviced on resident interventions, accurate and timely documentation, fall risk assessments, notifying Administration, RP, and Physicians. They were given a test for understanding the updated protocols. The VPO was informed the Immediate Jeopardy was removed on 8/25/2025 at 3:40pm. The facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. [NAME] A placed a 10lb pack of ground beef in the sink underneath running hot water to defrost for lunch service. 2. Intern A failed to secure her waist length hair in a hair net. 3. [NAME] A failed to use gloves when handling the ground beef for lunch service. 4. During a food temperature check, [NAME] A placed the thermometer in each item of food without properly sanitizing the thermometer between checks. 5. [NAME] A failed to wash hands before utilizing gloves. 6. [NAME] A touched the top of the trashcan with his gloved hands and proceeded to prepare a test tray for the investigator. 7. For lunch service, Resident #1 received food that fell below safe temperatures for hot foods during his lunch service on 07/02/25. The temperatures of the hashbrowns were 128 degrees F and string beans were 118 degrees F. These failures could place residents at risk of foodborne illnesses. The findings included:Record review of Resident #1' s face sheet revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were Hemiplegia and hemiparesis (loss of strength and weakness to a side of the body) and vascular dementia. In an observation on 07/02/25 at 9:45 am in the kitchen, a pack of ground beef sat in the sink and while hot water ran over the meat and a gulf of steam came off of the water. [NAME] A came over and turned the water off and took the meat out of the sink with his bare hands and placed it on a silver tray. There was a handwashing sink a few feet away from where the meat was being thawed, however, [NAME] A did not wash his hands prior to grabbing the meat. Intern A had long orange hair that hung to her waist that was not covered with a hair net. [NAME] A could be observed minutes later mixing the ground beef with his bare hands in a silver pan. The menu for 07/02/25 displayed that lunch for that day would consist of smothered chopped steak, hash brown casserole, green beans, garlic cheese biscuit, banana pudding desert, and a beverage. On a bulletin board, DA A and [NAME] A displayed up to date food service certifications. In an interview on 07/02/25 at 9:59 am, Intern A stated she had been interning in the kitchen as a dietary aide for 4.5 weeks and her last day would be July 11th. Some of her job duties included wrapping silverware for meal services, filling tea cups, clean up, and occasionally serving food in the dining room. In an interview on 07/02/25 at 10:03 am, [NAME] A stated that he had worked as a cook in the kitchen for almost 2 months and his schedule was 6am-6pm daily. He explained that when he took the meat out of the sink, he seasoned it and spread it flat in the silver pan. He stated that since they were serving smothered steak, the DM told him it would be better to cook that way. [NAME] A stated that he didn't normally unthaw meat using hot water but it was taking a long time to thaw out. He stated his normal practice was to place it in a pan of room temp water. When asked what the health concerns were of running partially frozen ground beef under hot water to unthaw and he explained that it depended on the time frame, and [NAME] A had only ran the hot water of the ground beef for 10 minutes. He explained that he worked yesterday (07/01/25), but he forgot to take meat out of the freezer. In an interview on 07/02/25 at 11:14 am, LPN A stated that when the trays came out to the halls for meal services, she tried to push them out immediately. In the past she had gotten complaints of the food being cold, one of the resident's being Resident #1. She explained that when the food was cold, she would take the plate and reheat it in the microwave. In an interview on 07/02/25 at 11:28 am, the AD stated that in a recent Resident Council meeting, he received complaints that the trays being served on the halls were cold. The AD said he explained to the residents that the residents who sat in the dining room were severed first and then trays were pushed out to the halls. He gave them the suggestion to eat their meals in the dining room and the residents understood but they refused to budge, which they have the right to. The AD stated that he also told residents to let the aides know their food was cold and document while he informed the nurses and management. In an observation on 07/02/25 at 11:43 am in the kitchen, the investigator requested temperature checks for the lunch service. [NAME] A grabbed the thermometer out of a basket and walked to the steam table. The temperatures were 200.7 degrees F for the chopped steak, 196.3 degrees F for the hashbrowns, and 174.4 degrees F for the green beans (range should be over 165 degrees F for hot food). During the temperature checks, [NAME] A took the thermometer from the chopped steak, to green beans, to hashbrowns and did not wipe or sanitize the thermometer between food items. Back in the kitchen, [NAME] A wiped the thermometer off with a paper towel and placed it back into the basket. The investigator requested a test tray to sample and [NAME] A grabbed the plate with his hands, but the investigator stopped him and requested he put gloves on prior to serving and told him that she noticed that he had not been wearing gloves. [NAME] A stated that he was supposed to wear gloves while cooking and he normally did. He grabbed a pair of gloves from a corner on the counter and mumbled that they were too small when his left hand burst through the plastic. With the right glove still on his hand, he walked to the trash can, opened the trash can lid with his right gloved hand, tossed the ripped glove inside with his left hand, returned the trash can's top with his right gloved hands, walked back to the box of gloves, and grabbed another glove to put back on his left hand. [NAME] A then returned to the plate to begin serving, however the investigator stopped him. The investigator explained that how he touched the trash can and plate with his gloves was a method of cross contamination. [NAME] A explained that his hands burst through the glove because they were a size medium and he normally wore a size large. When he wore gloves, his hands would burst through the gloves so it was almost like no point. He stated that the kitchen was required to keep the trashcan covered, but he understood how touching the lid with his glove and beginning to plate would be hazardous. When asked why he did not wear gloves when he handled the ground beef form earlier, he stated that he did not know they had gloves so he didn't put any on. On the counter wear the thermometer was held was a box of size large gloves. When asked about his training, he stated that he had completed his food handler's certification course and showed the investigator where it was placed on a bulletin board. In an observation and interview on 07/02/25 at 12pm, the DM entered the kitchen to oversee the lunch service. Intern A hair was still pulled back in a ponytail and no hair net was present. Intern A grabbed a pair of the large gloves, put them on, and began to rub her gloved hands on her mouth and face. The DM noticed that Intern A did not have a hair net on, and in structed her to get a hair net 3 times. After each request. Interne A replied what, huh, WHAT?, I don't know how. The DM grabbed a hair net and took her to the side to help place the net on her head. The DM told her to remove her gloves and walked her over to the kitchen and showed her how to properly wash her hands and gave her new gloves to place on her hands. When intern A was asked why she did not wear a hair net earlier, she explained that she did not normally wear a hair net and although she saw others doing it, no one had ever let her know it needed to be done. In an interview on 07/02/25 at 12:34 pm, Resident #1 stated that his food was cold. The investigator checked the food on his lunch tray using a thermometer. The temperatures were 128 degrees F for the hashbrown casserole, 146 degrees F for the chopped steak, and 118 degrees F for the string beans. In an interview on 07/02/25 at 3 pm with the DM, she stated that Intern A was not employed with the facility, but was a high school student with a work force staffing agency. She said Intern A had worked with the kitchen for less than a month and did not realize that she was not easy to direct. When informed that [NAME] A ran hot water to thaw the meat from today's lunch, she stated that she had gotten on him about that in the past and he was supposed to use cold water because hot water could cook the meat. She expressed that he should have known that from his food handler's certification course, but he would always say that he didn't remember. [NAME] A had also been written up recently regarding wearing improper footwear in the kitchen. She explained that the proper technique was to wear gloves when handling meat and she had often told him that if he was not sure, then he should ask her but she felt that he did not follow instructions. She explained that she trained all staff verbally and he trained with her for 4 days but she could not locate any training information when asked. The DM stated she had been working with [NAME] A for two months and felt that he did well initially, but he slacked off. With all the information presented, DM said that kitchen practices preformed by her staff could put residents at risk for cross contamination, especially using hot water to unthaw the meat and not wearing gloves. The DM also informed the investigator that she had recently hired a new cook and she was going to shorten [NAME] A's hours until she was able to remove him from her kitchen. She explained that since she had been getting complaints, she had started to pop up on weekends to monitor the kitchen staff and she also would assist at meal servings to monitor portion sizes and presentation. She wanted kitchen staff who were able to work without supervision and could train others when she was not there so that she could complete her duties. In an interview on 07/02/25 at 4:22 pm with the ADM, he was informed of the errors identified during the lunch meal service. He shook his head with a grimace and stated that he spoke with corporate and that the facility was in the process of ordering covers for the tray cart that would help keep the food warmer for the residents who chose to eat meals outside of the dining room. Record review of the facility's policy titled Employee Sanitation dated 2018, documented that:1. Employee Cleanliness Requirementsa. All employees must wear clean outer clothing.b. Hairnets, headbands, caps, beard coverings or other effective hair restraints mustbe worn to keep hair from food and food-contact surfaces2. Hand washinga. Employees must wash their hands and exposed portions of their arms atdesignated hand washing facilities at the following times:i. After touching bare human body parts other than clean hands andclean, exposed portions of armsii. After using the toilet roomiii. After coughing, sneezing, using a handkerchief or disposable tissue,using tobacco, eating, or drinkingiv. Immediately before engaging in food preparation including workingwith exposed food, clean equipment and utensils, and unwrappedsingle-service and single-use articlesv. During food preparation, as often as necessary to remove soil andcontamination and prevent cross contamination when changing tasksvi. When switching between working with raw foods and working withready-to-eat foodsvii. After engaging in other activities that contaminate the hands.3. Use of Glovesa. Gloves are not a substitute for thorough and frequent hand washing. Whenusing gloves, always wash hands before touching or putting on new gloves.b. Do not use latex or corn starch powder, which can transfer protein allergensfrom latex to person consuming foodc. Use single use gloves for one task.d. Change gloves:i. Between each food preparation task.ii. After touching items, utensils or equipment not related to task.iii. After touching hair, face or any other source of contaminationiv. When leaving food preparation area for any reason.v. When damaged, soiled or when interrupted.vi. Every hour for all tasks taking longer than one hour.e. Do not store gloves in pockets or aprons. Record review of the facility's policy titled Food Handling revised June 1, 2019, documented that:1. Thawing Foodsa. Thaw meat, poultry and fish in a refrigerator at 41 F or less.b. Foods may also be thawed using the following procedures:i. Completely submerged under running water at a temperature of 70 F or below with sufficient water velocity to agitate and float off loosened food particles into the overflow:1. For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 F; or2. For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41 F for more than four hours including the time the food is exposed to the running water and the time needed for preparation for cookingii. In a microwave oven using the defrost mode and immediately transferred to conventional cooking equipment with no interruption in the processiii. As part of the cooking process3. Hot Food Temperaturesa. Do not remove meats and other raw foods from refrigerator until ready to cook.b. [NAME] comminuted meat (such as hamburger) products thoroughly to heat all parts of the meat to a minimum temperature of 155 F for at least 15 seconds.c. [NAME] raw animal products such as eggs, fish, lamb, pork or beef, except roast beef, and foods containing these raw ingredients to an internal temperature of 145 F or above for at least 15 seconds.d. [NAME] poultry, stuffed fish or meat, stuffed pasta or stuffing containing fish, meat or poultry to 165 F or above for 15 seconds.e. When cooking raw animal foods in a microwave oven:i. Rotate or stir throughout or midway during cooking to compensate for uneven distribution of heatii. Cover to retain surface moistureiii. Heat to a temperature of at least 165 F throughout all parts of the foodiv. Allow to stand covered for two minutes after cooking to obtain temperature equilibrium.

Based on observations, interviews, and record review, the facility failed to serve foods that were palatable and attractive and prepare food by methods that conserve nutritive value, flavor, and appearance for 4 (Resident #1, #2, #3, and #4) of 7 residents reviewed. 1. Resident #3 revealed pictures of meals on 06/26/25, 06/23/25, and 06/22/25 that showed small meal portions with unpalatable and unrecognizable food items. 2. A test tray was provided for the lunch meal service that contained a chopped steak that resembled a slab of meat covered in gravy and a hashbrown casserole that was bland and gummy. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life. Findings included:Record review of Resident #1' s face sheet revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were Hemiplegia and hemiparesis (loss of strength and weakness to a side of the body) and vascular dementia. Record review of Resident #2' s face sheet revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were diabetes mellitus due to underlying condition with diabetic neuropathy (pain, tingling, or numbness in the hands or feet related to diabetes), Benign neoplasm of meninges (tumors that develop from the membranes surrounding brain and spinal cord), and lack of coordination. Record review of Resident #3' s face sheet revealed a [AGE] year-old man who was admitted to the facility on [DATE]. His admitting diagnoses were hypertension (high blood pressure), Stage 3 Chronic Kidney disease, and Type 2 Diabetes. Record review of Resident's #4's face sheet revealed a [AGE] year-old woman who was admitted to the facility on [DATE]. Her admitting diagnoses were cerebral edema (brain swelling), anoxic brain damage (brain injury where the brain loses oxygen), and unsteadiness on feet. In an observation and interview on 06/27/25 at 2:28 pm, Resident #1, #2, and #3 were sitting in a room enjoying a game. Resident #1, #2, and #3 stated unanimously that they have a strong aversion to the food and often have to order food from outside of the facility to feel satisfied. Resident #1 expressed that he always received his food cold and stated that although the aides could warm it up, he wanted to receive his food like it was when it was first cooked. When asked if he would go to the dining room during meal services, Resident #1 refused and stated his preference was to enjoy his meals in his room. Resident #1 added that he recently (date unknown) received a biscuit that was overcooked on top and raw on the inside, expressing that he felt the dietary requirements were not right at the facility and he inquired where his payments were going. Resident #1 explained that sometimes he would refuse medication because some of the meds he took required food and he would not take them on an empty stomach. Resident #3 explained that all three of the men were diabetics and it was important that they not only ate, but received enough food with access to snacks. Resident #2 agreed that he did not get large enough portions and explained that for dinner on 06/26/25 he received a piece of turkey, lettuce and a tortilla, and that was not enough to hold them overnight. Resident #2 stated that the two men who worked in the kitchen were lazy and recalled how he received grits for breakfast that were as hard as a baseball. During this conversation, Resident #3 interjected and stated that he had been taking pictures of the food they had been receiving during meals. Record review of the pictures shared by Resident #3 detailed the following:1. For dinner on 06/26/25 at 5:40pm, residents received a roll, creamed peas, a white tortilla with a small piece of lettuce, a possible piece of meat, and a heavy serving of a white sauce drenched across that tortilla. The food was hard to identify and did not look attractive. 2. For breakfast on 06/23/25 at 7:43 am, he received oatmeal that was shaped in a dome as if it was scooped out with an ice cream scooper and a Cinnabon with frosting. 3. For dinner on 06/22/25 at 5:51pm, he received one piece of what appeared to be a fried chicken strip, a roll, a very small scoop of peas, and a scoop of a red vegetable that could not be identified by Resident #3 or the investigator. In an interview on 06/27/25 at 2:36 pm, the DM stated that she had been working at the facility for 2 years and she started off as a cook. She explained that food was served first in the dining room and came to the halls after all the residents had received a plate. She admitted that she had received complaints regarding the food being cold and portion sizes from Resident #1, Resident #2, and Resident #3. She stated that when the trays came, the staff would let them sit on the hall and delayed passing them out immediately. The DM explained that she had spoken to the DON and nurses about the hall trays and suggested to get additional help from other staff to get trays out faster and to get more residents into the dining room for a hot plate. The interview was cut short due to the DM having prior engagements. In an observation on 07/02/25 at 9:45 am in the kitchen, a pack of ground beef sat in the sink while hot water ran over the meat and a gulf of hot steam came off of the meat. [NAME] A came over and turned the water off and took the meat out of the sink with his bare hands and placed it on a silver tray. The menu for 07/02/25 displayed that lunch for that day would consist of smothered chopped steak, hash brown casserole, green beans, garlic cheese biscuit, banana pudding desert, and a beverage. On a bulletin board, DA A and [NAME] A displayed up to date food service certifications. In an interview on 07/02/25 at 10:03 am, [NAME] A stated that he had worked as a cook in the kitchen for almost 2 months and his schedule was 6am-6pm daily. He explained that when he took the meat out of the sink, he seasoned it and spread it flat the silver pan. He stated that since they were serving smothered steak, the DM told him it would be better to cook that way. He stated that he had a received a few complaints regarding the food and said the criticism was centered around the way the food looked and was presented. He explained that the resident's wanted it a little neater on the plate. He stated that he had tried some of the meals that were prepared by him but he did not like them, but the things he did like he would eat. In an interview on 07/02/25 at 10:24 am, Resident #4 stated she would sometimes try food from the kitchen but it was not her favorite. She stated that the oatmeal came unsweetened and she would have to ask for extra sugar to put on it just so she would be able to eat it. She explained that the food tasted flat, lacked flavor, and was not served hot during meals. Resident #4 explained she stopped asking staff to do things for her because she felt that would put her down. She recalled that one staff (unknown) told her before you know it, you will be a diabetic and she responded before I know it, I will be malnourished because the food has no taste whatsoever. In an interview on 07/02/25 at 11:28 am, the AD stated that in a recent Resident Council meeting, he received complaints that the trays being served on the halls were cold and the food was not good. The AD said he explained to the residents that the DM had no control over the menu and they were pushed out by corporate. He stated that the biggest concern with the resident's was the food not being appealing to. The AD stated that he also told residents to let the aides know any issues with their food and document while he informed the nurses and management. In an observation on 07/02/25 at 11:43 am in the kitchen, three grilled cheese sandwiches were sitting on the counter. Of the 3, the top slice of bread on one the sandwiches was almost completely brunt. In an interview on 07/02/25 at 12:34 pm, Resident #1 was in his room and had just received his tray from one of the aides off the hall. He stated that his food was cold and the investigator checked the food on his lunch tray using a thermometer. The temperatures were 128 degrees F for the hashbrown casserole, 146 degrees F for the chopped steak, and 118 degrees F for the string beans. The suggested holding temperature should be heated to at least 135 degrees F. On 07/02/25 at 1:30 pm, the investigator began to taste the test tray provided by [NAME] A. The string beans were fine and had been seasoned and cooked properly. The chopped steak was unappealing to the eye and looked like a slab of mashed ground beef covered in gravy. The hashbrown casserole was bland and gummy. In an interview on 07/02/25 at 3pm with the DM, she explained that she trained all staff verbally and [NAME] A trained with her for 4 days but she could not locate any training information when asked. The DM stated she had been working with [NAME] A for two months and felt that he did well initially but had slacked off. She expressed that he had also completed his food handler's certification course when hired, but he would always say that he didn't remember what was covered. She explained that she would often have to redirect [NAME] A on kitchen protocols involving portion sizes, puree's, and using salt, but she felt that he did not follow instructions. Another issue she had with [NAME] A was that he would cook the biscuits too fast and not allow them to brown. Lastly, she expressed that her biggest issues were found the days he worked in the kitchen. The DM was showed the picture of the grilled cheese sandwich from the lunch service and she responded that she had told [NAME] A several times not to serve burnt food. With all of the information presented, the DM said that the kitchen practices performed by her staff could put residents at risk for cross contamination. The DM also informed the investigator that she had recently hired a new cook and she was going to shorten [NAME] A's hours until she was able to remove him from her kitchen because she needed someone who followed direction and was consistent with meal quality. On 07/02/25 at 3:15 pm, a request was made to the DM to attain any training and in-services completed by the DM to [NAME] A. The DM stated she could not remember where she put them and none could be located before the investigator exited the facility. In an interview on 07/02/25 at 4:22 pm with the ADM, he was informed of the errors identified during the lunch meal service. He shook his head and stated that he spoke with corporate and the facility was in the process of ordering new covers for the tray cart that would help keep the food warmer for the residents who chose to eat meals outside of the dining room. Record review of the facility's grievance logs from April 2025-July 2025 displayed no grievances regarding food had been documented. Record review of the facility's policy titled Food Handling revised June 1, 2019, documented that the facility's policy was to ensure that all food served by the facility is of good quality and safe for consumption, all food will be handled according to the state and US Food Codes and HACCP guidelines.

Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #31) reviewed for infection control. -CNA A failed to change gloves and perform hand hygiene during incontinent care on Resident #31. This failure could place residents who required incontinent care at risk for cross contamination and infection. Findings included: Record review of Resident #31's face sheet dated 3/20/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] and initially admitted on [DATE]. His diagnoses included: traumatic brain injury (a serious condition that occurs when an external force causes damage to the brain),stage 4 pressure ulcer of the sacrum (a deep wound that exposes underlying muscle, tendon, cartilage or bone to the tailbone),adult failure to thrive (a gradual decline in health and functional abilities), neuromuscular dysfunction of bladder (nerves to the bladder are damaged) vitamin deficiency, blindness to the left eye, elevated blood pressure and depression. Record review of Resident #31's significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had a BIMS score of 13 indicating he was cognitively intact. Resident #31 had impairment to one side of the upper and lower body. Resident #31 was dependent on staff for all ADLs. He was always incontinent of bowel and bladder. Record review of Resident #31's undated care plan, last reviewed/revised on 03/12/25, revealed in part; -Focus: Resident #31 had a stage 4 pressure ulcer to his sacrum. Interventions included: Resident #31 will be repositioned off his sacrum every 2 hours. He will have wound care daily by nursing. -Focus: Resident #31 required enhanced barrier precautions due to wounds. He was at increased risk of a MDRO (multidrug resistant organism) acquisition due to having a wound. Interventions included: Staff will wear PPE (personal protective equipment) during high-contact activities such as dressing bathing/showering, transferring, providing hygiene, changing linens, incontinent care, wound care of any type requiring a dressing. -Focus: Resident #31 is at risk for pressure ulcers d/t failure to thrive, vitamin deficiency, abnormal weight loss, low calcium, GERD, dysphagia (difficulty swallowing) and decreased oral intake. Interventions included: Follow facility skin care protocol. Observation and interview on 3/21/2025 at 7:15 AM, CNA A performed incontinent care on Resident #31. The resident was on EBP (enhanced barrier precautions) as evidenced by the signage on the door to the resident's room. CNA A gathered supplies, performed hand hygiene, donned PPE prior to entering resident room, then closed the door and drew the privacy curtain. CNA A unfastened Resident #31's brief. She then used disposable wipes to cleanse the front of the resident's peri areas. She then rolled the resident to his left side. The resident had a (BM) bowel movement. Using clean wipes, she cleansed Resident #31 from front to back using a fresh wipe for each pass until skin was clear. The resident had a large white dressing adhered to his skin just above the sacrum. The sacrum had an open wound that was clean and dry. The dressing was no longer covering the wound. The BM did not extend up to the sacral area. CNA A then touched the clean brief and positioned it under the resident then secured. CNA A touched the bedding to cover the resident. CNA A removed gloves, placed in trash bag, reached underneath her gown and into the pocket of her scrubs for hand sanitizer, then sanitized hands. She then removed a pair of gloves from her pocket, donned the gloves, gathered the trash, removed PPE and secured the trash bag. CNA A then performed hand washing at the sink. CNA A then opened door, picked up trash bag, deposited trash bag into dirty utility closet. CNA A hand sanitized her hands. CNA A said she was nervous and should have removed the dirty gloves, hand sanitized then put on clean gloves. She said the risk is cross contamination and risk of transferring dirt to the resident's wound area. CNA A stated she would notify the nurse about the loose dressing. In an interview on 3/21/2025 at 7:45 AM, the DON stated that she expected the staff to hand wash before going into the room and put clean gloves on. She stated she expected soiled gloves to be removed before touching anything clean to prevent cross-contamination. She stated she had been working hard on inservicing the staff on infection control. Record review of CNA A Nurse Aide Proficiency Audit signed and dated on 12/07/24 by CNA A and observed and signed by RN Supervision on 12/07/24, indicated CNA A's Hand Hygiene Competency, Perineal Care Return Demonstration, Personal Protective Equipment (PPE) Competency was validated. Record review of the facility policy for Handwashing/Hand Hygiene, revised on 1/20/23 read in part: Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation: 1. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors .5. Hand hygiene must be performed prior to donn (putting on) and after doffing (removing) gloves . Record review of the facility policy for Perineal Care, revised on 1/20/23 read in part: Policy Statement - Perineal Care is providing cleanliness and comfort to the resident, to prevent infections, skin irritation, and to observe the resident's skin condition 11. Discard disposable items into designated containers. 12. Remove gloves and discard into designated containers. 13. Perform Hand Hygiene. 14. Reposition the bedcovers .

Based on observation, interview and record review, the facility failed to ensure the residents' right to personal privacy and confidentiality of his or her personal medical records for 2 (Resident #34 and Resident #18) of 8 residents reviewed for personal privacy. The facility failed to ensure LVN C protected resident's right to privacy by verbalizing that Resident #34 was going to receive Insulin within earshot of Resident #18. This failure could place residents' protected HIPPA information at risk of being overheard resulting in low self-esteem and a diminished quality of life. Findings included: Record review of Resident #34's face sheet dated 03/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included orthopedic aftercare following surgical amputation, stroke, diabetes, and cognitive communication deficit. Record review of Resident #34's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4 out of 15 indicating severe cognitive impairment. Resident #34 was dependent on staff for ADLs. Record review of Resident #34's Continuity of Care Document dated 03/20/2025 revealed a physician order with start date of 03/05/2025 for Lantus insulin 20 units subcutaneous once a day for diabetes. Record review of Resident #18's face sheet dated 3/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included diabetes, schizophrenia (a serious mental disorder, characterized by symptoms such as hallucinations, delusions and disorganized thinking) and depression. Record review of Resident #18's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15 indicating intact cognition. He required a wheelchair for mobility. Record review of Resident #18's physician orders revealed an order for Lispro Insulin 5 units subcutaneous with meals at 7:00 AM, 12:00 PM and 5:00 PM, with a start date of 02/24/2025. Observation on 03/20/2025 at 6:50 AM, LVN C brought Resident #18 from the dining room to the medication cart in the 200 hall across from Resident #34's room. The room door was open, and Resident #34 was in the bed. LVN C asked Resident #18 if he was OK with checking his blood glucose level in the hallway. Resident #18 said yes. LVN C told Resident #18 she would first give Resident #34 his insulin. Resident #18 was sitting in his wheelchair next to LVN C. LVN C verbalized that she would administer 20 units of insulin to Resident #34. In an interview on 03/20/2025 at 7:03 AM after Resident #18 left the medication cart, LVN C stated she did not know if Resident #34 was OK with other residents hearing about his insulin. She stated she was nervous and should not have done so in front of another resident. In an interview on 3/20/2025 at 9:50 AM, Resident #18 stated he did hear LVN C say that she would give Resident #34 his insulin shot before she checks his blood sugar. Resident #18 stated she should have kept that information to herself. He stated a similar situation happened to him in the past and said it made him feel terrible knowing that other resident's had knowledge of his medical status. Record review of the facility's policy for Resident Rights, revised in February 2021 read in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity .1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .e. self-determination .h. be supported by the facility in exercising his or her rights .t. privacy and confidentiality .3. The unauthorized release, access, or disclosure of resident information is prohibited. All release, access, or disclosure of resident information must be in accordance with current laws governing privacy of information issues . Record review of the facility's example of a staff checklist for trainings and topics included HIPPA.

Based on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice to including but not limited to the residents right to make choices about aspects of his or her life in the facility that are significant to the resident, healthcare and providers of healthcare services consistent with his or her interest, assessments, and plan of care and other applicable provisions of this part for 1 (Resident #4) of 8 residents reviewed for resident rights. The facility failed to honor Resident #4's request to be assisted to shower on Saturdays. This failure could place residents at risk for lack of choices/decision making resulting in depression, and diminished quality of life. Findings included: Record review of Resident #4's face sheet dated 03/20/2025 revealed a [AGE] year-old admitted to the facility on [DATE] and latest re-admitted [DATE]. His diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory and eventually the ability to carry out simple tasks)Parkinson's disease (a nervous system disorder), diabetes, Metabolic encephalopathy (a change in how the brain works due to an underlying condition), dementia, polyneuropathy (peripheral nerve disease) and history of fungal infection of the skin and nails. Record review of Resident #4's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 out of 15 indicating moderate cognitive impairment. He had no rejection of care. He was feeling down, depressed, or hopeless for several days over a two-week period. He had functional limitations in range of motion to one side of lower extremity. He used a wheelchair for mobility. He required partial/moderate assistance from staff with showering self. He required supervision for personal hygiene and upper body dressing and substantial assistance with lower body dressing. He was always incontinent of bowel and bladder. Record review of Resident #4's undated care plan included Problem: the following tasks will be documented in POC (Point of Care) assist. Problem start date was 01/15/2025. -Goal: the resident will perform the following tasks at their highest practicable level. Target date was 05/28/2025. - Approach included: I prefer to take my bath/shower on Tuesday, Thursday, and Saturday. Last reviewed/revised on 3/04/2025. Problem: Resident #4 had refusals of ADL incontinent care, baths/showers, changing clothes and taking medications. Problem start date was 07/03/2023. Goal: maintain skin integrity issue. Target date was 05/28/2025. Approach included: educate as needed, explain benefits, explain risk, update MD as needed and skin checks per schedule. Last reviewed/revised on 3/04/2025. Record review of Resident #4's POC History for dates 3/1/2025 to 3/20/2/2025 revealed CNA A documented a shower was done on Saturday 03/15/2025 at 6:06 AM. Record review of the facility's Shower Logbook revealed Resident #4 received a shower on 3/20/25 by CNA A and on 3/18/2025 by Shower Tech. There was no shower sheet for 3/15/2025. Record review of Resident #4's progress notes dated 03/06/2025 to 03/20/2025 revealed no refusals of showers. There was no documentation that resident did not shower on 03/15/2025. In an interview on 03/20/2025 at 10:23 AM, Resident #4 stated he was not getting showers three times a week like he is scheduled to on Tuesdays, Thursdays, and Saturdays. He stated he preferred showers after the afternoon smoke break. He stated he did not receive a shower on Saturday 3/15/2025. He stated they don't care, and it made him mad that he had to beg for showers. He stated that he did not refuse showers. He stated he reported the missed shower to the Administrator on Tuesday. He stated he did get a shower on Tuesday 3/18/2025. In an interview on 3/21/2025 at 10:40 AM, CNA A denied showering Resident #4 on Saturday 3/15/2025. CNA A stated there were no clean slings for the mechanical lift so she did not provide a shower for Resident #4. CNA A stated she did not offer him a bed bath but did wipe him down. CNA A stated sometimes she clicks on everything really quickly on the POC and did not intend to document that a shower was completed on 3/15/2025. In an interview on 3/21/2025 at 10:45 AM, the Shower Tech stated she worked Monday to Friday and had no issues getting all her assigned showers completed. In an interview on 3/21/2025 at 10:40 AM, LVN B stated that she worked on Saturday 3/15/2025 and did not recall if anyone told her Resident #4 missed a shower. LVN B stated the CNAs were responsible to provide the showers when there are no shower techs and that there was no shower tech available that day. She stated she worked from 6:00 AM to 6:00 PM shift. In an interview on 3/21/2025 at 10:50 AM, Resident #4 denied getting washed down on Saturday 3/15/2025. In an interview on 3/21/2025 at 11:00 AM, the RN Supervisor stated he was the weekend supervisor and stated sometimes the showers would be split between the CNAs and himself. He stated no one notified him that Resident #4 did not receive a shower on 3/15/2025. He stated he escorted Resident #4 to smoke breaks on 3/15/2025 and Resident #4 had the opportunity to tell him of any issues but did not. RN Supervisor stated the risk of not getting showers as scheduled would be health issues such as skin infection. He stated that he himself would feel uncomfortable if he did not shower. RN Supervisor stated there was a shower logbook the CNAs would record showers. He stated the CNAs would inform the nurse and then the nurse would notify him of any issues. He stated the residents deserve the right to shower anytime. He stated it was his job to ensure Saturday showers schedules were completed even if he had to be the one to do it. He stated moving forward he would ensure Resident #4 and other residents receive their showers on Saturdays. In an interview on 3/21/2025 at 12:00 PM, the Director of Housekeeping/Laundry stated he worked on Saturday 3/15/2025 during the day and did not receive any notifications from staff regarding unavailability of clean slings. He stated he keeps 20 slings for the mechanical lift. In an interview on 3/21/2025 at 11:15 AM, the Administrator stated Resident #4 notified him last week to complain about not getting showers as scheduled. The Administrator stated he expected the staff to call him on the weekend if there was a supply issue such as no clean slings. He stated he was unaware of any issues over the weekend of 3/15/2025. He stated a possible risk to Resident #4 would be skin breakdown and agitation if he did not receive showers. He stated there were times the staff could not find Resident #4 after a shower time was agreed upon or if he refused. The Administrator stated moving forward he would conduct staff Inservice on shower schedules. In an interview on 3/21/2025 at 1:15 PM, the DON stated the weekend supervisor was responsible to ensure showers were done on Saturdays and the charge nurse oversees it as well. She stated the CNAs assigned to the resident were responsible for showers when no shower techs were available. She stated she did not know why Resident #4 did not receive a shower on 3/15/2025. The DON stated the risks of not getting showers as expected would be a decreased feeling of well-being. Record review of the facility's policy for Resident Rights, revised in February 2021 read in part: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity . 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence .e. self-determination .

Based on interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for (1)of 4 residents reviewed. The facility failed to conduct a head-to-toe assessment to determine if Resident # 1 had sustained any injuries from his apparent fall. This failure could place residents at risk of not having necessary care and services to address the resident's individual needs. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral , urinary tract infection, Unspecified Dementia, Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, and Type 2 diabetes Mellitus without complications. Review of Resident #1's Quarterly MDS assessment dated [DATE], section C revealed a BIMS score of 4, indicating severe cognitive impairment. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and two persons assisting with bed mobility, transferring and toilet use. It also revealed resident required, two-person assistance with dressing, and personal hygiene. Record review of Resident #1's care plan dated 10/24/2024 revealed Resident #1 was care planned for falls. ADL Self Care Performance Deficit: Goal-Resident will remain free from falls. Approach- Resident's bed will be placed in its lowest position and a fall mat will be placed next to the resident's bed. Record review of video dated 12/14/24 revealed that Resident #1 was on the floor in his room in a prone position (lying on his stomach with his head on a pillow. The video showed that before he was lifted off the floor LVN A failed to perform and assessment on Resident #1 for possible injuries. The video did not reflect a time stamp. Record review of Resident #1's vital signs report dated 12/14/24 reflected there was no record of resident vital signs being taken during the time he was lifted off the floor The vitals report reflected that Resident #1's vitals were checked early in the day of 12/14/24 at 8:10am by LVN A. Interview with LVN-A on 12/24/24 at 12:22pm, she said that when a resident is found on the floor and it is unknown how the resident ended up on the floor, then a head-to-toe assessment should be performed. She said that the reason for the head-to-toe assessment is to rule out any serious injuries before the resident is moved. She said that she did not perform a head-to-toe assessment on Resident #1 when he was found on the floor in his room on 12/14/24. She said that she did a quick visual assessment because Resident #1's family was belligerent and that she just wanted to get Resident #1 off the floor and into his bed. She said that a head-to-toe assessment should include the vitals being taken and the resident's range of motion being checked to ensure no dislocations or broken bones before the resident is removed from the floor. And the risk of not performing a head-to-toe assessment could lead to injury. Interview with CNA-A on 12/24/24 at 12:36pm, she said that if a resident is found on the floor and the fall is unwitnessed then a nurse must perform a head-to-toe assessment before the resident is removed from the floor. She said that the reason for the assessment is to make sure that the resident does not have any serious injuries that would prevent the resident from being removed from the floor. She said that the head-to-toe assessment includes vitals, range of motion check and a check for a fracture. Interview with DON on 12/24/24 at 3:30pm, she said that if a resident is found on the floor and it is not clear how the resident ended up on the floor then a head-to-toe assessment should be performed to ensure that the resident does not have any serious injuries before they are removed from the floor. She said that if the assessment is not performed by a nurse, then it could lead to serious injury when removing the resident from the floor. She said that a head-to-toe assessment should include vital signs, range of motion and check for any fractures. Interview with Administrator on 12/24/24 at 3:50pm, he said that if a resident has a fall, then the resident should be assessed before they are removed from the floor because it's not sure if the resident is injured or the extent of their injuries if there are any. He said that each nurse should know to perform an assessment on a resident that has a fall or suspected fall. Record review of the facility's fall prevention policy dated 11/2024 revealed that: 1. If a resident has just fallen or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine, and extremities. The resident is not moved until after evaluation by a nurse. 2. Obtain and record vital signs as soon as it is safe to do so. 3. If an assessment rules out significant injury or complaints of pain, help the resident to a comfortable sitting, lying position, and then document relevant details. 4. Notify the resident's attending physician and family in an appropriate time frame.

Based on interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for (1) of (4) residents reviewed. The facility failed to use proper lifting technique or lifting device to remove resident#1 off the floor. This failure could place residents at risk of accidents and injuries. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included cerebral urinary tract infection, Unspecified Dementia, Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, and Type 2 diabetes Mellitus without complications. Review of Resident #1's Quarterly MDS assessment dated [DATE], section C revealed a BIMS score of 4, indicating severe cognitive impairment. Section G regarding resident's Activities of Daily Living (ADL) Assistance revealed resident needs supervision and two persons assisting with bed mobility, transferring and toilet use. It also revealed resident required, two-person assistance with dressing, and personal hygiene. Record review of Resident#1's care plan dated 10/24/2024 revealed Resident #1 was care planned for falls. ADL Self Care Performance Deficit: Goal-Resident will remain free from falls. Approach- Resident's bed will be placed in its lowest position and a fall mat will be placed next to the resident's bed. Record review of video dated 12/14/24 revealed that Resident #1 was on the floor in his room in a prone position (lying on his stomach) with his head on a pillow. The video showed LVN A grabbed Resident #1 by his left arm while CNA A grabbed Resident #1's right arm and together they lifted Resident #1 off the floor by his arms. The video did not reflect a time stamp. Interview with LVN-A on 12/24/24 at 12:22pm she said that she along with CNA-A lifted rResident #1 off the floor and placed him in his bed. She said that they grabbed Resident #1 by his upper extremities. She said that they were just trying to get the resident off the floor as soon as possible because the family was belligerent. Interview with CNA- A on 12/24/24 at 1:01pm she said that she and LVN-A rolled Resident#1 over on his back and picked him up in a cradle position and put him in his bed. Interview with CNA-B on 12/24/24 at 12:36pm she said that the correct and safest way to lift a resident off the floor is to get a mechanical lift and lift the resident off the floor. She said that at no time should a resident be lifted off the floor by their extremities because a dislocation may occur. Interview with LVN-B on 12/24/24 at 1:26pm she said that when a resident is on the floor in a prone position that the resident should be rolled over to their back and a mechanical lift should be used to lift the resident off the floor. And at no time should a resident be lifted off the floor by their extremities because of possible dislocation. Interview with DON on 12/24/24 at 3:30pm, she said that if a resident is found on the floor and after the resident has been assessed. Then the resident should be rolled over onto their back and a mechanical lift should be used to lift the resident off the floor. But at no time should the resident be lifted off the floor by their extremities are if the resident is on their stomach.

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 4 of 6 residents (Resident #1, #2, #3, #4) reviewed for ADLs. The facility failed to provide Resident #1 with scheduled showers and personal grooming (shaving of beard and nasal hairs). The facility failed to provide Resident #2 with scheduled showers. The facility failed to provide Resident #3 with scheduled showers. The facility failed to provide Resident #4 with scheduled showers and personal grooming (shaving of beard). This failure could place residents at risk for discomfort, and dignity issues. Findings included: Record review of Resident #1's face sheet dated 5/14/2024 revealed a [AGE] year-old male admitted on [DATE] (originally on 5/22/2023) with the following diagnoses included: heart disease, lack of coordination, reduced mobility, muscle weakness and dementia. The picture on Resident #1's face sheet revealed he had a goatee (short facial hair style that grows from the chin and not on the cheeks) Record review of Resident #1's care plan dated 5/14/2024 revealed the following: Problem: ADLs Functional status/rehabilitation potential. Goal: Resident will achieve maximum functional mobility. Approach: Bathing/Hygiene, Dressing/Grooming, Resident care as per facility protocol. Problem: General the following Task will be documented in POC . Goal: Resident will perform the following task at their highest practicable level. Approach: I prefer to take my Bath/Shower on Tuesday, Thursday, Saturday. My preferred time to Bath/Shower is 6a-6p. Flowsheet: ADL Once a Day on Tues, Thursday, Saturday 6am - 6pm. Record review of Resident #1's MDS (optional payment) assessment dated [DATE] revealed he had a BIMS of 7 which indicated severe cognitive impairment. Record review of Resident #1's progress notes dated 3/10/2024 - 5/8/2024 revealed Resident #1's last documented shower was 4/24/2024. Record review of Resident #1's shower sheets documentation over a 4-day look-back period reflected the last documented shower was 5/10/2024 (Friday). Resident #2 Record review of Resident #2's face sheet dated 5/14/2024 revealed a [AGE] year-old female admitted on [DATE] (originally 11/9/2023) with the following diagnoses included: candidiasis of vulva and vagina (itching/irritation in the vagina), need assistance with personal care, obesity, diabetes, depression, muscle weakness and lack of coordination. Record review of Resident #2's care plan dated 4/5/2024 revealed the following: Problem: General the following Task will be documented in POC . Goal: Resident will perform the following task at their highest practicable level. Approach: Start Date: 11/13/2023. I prefer to take my Bath/Shower on (Mon, Wed, Fri). My preferred time to Bath/Shower is (Day Shift). Flowsheet: ADL once a day on Mon, Wed, Fri: 6 AM- 6 PM. Record review of Resident #2's (other payment) MDS assessment dated [DATE] revealed she had a BIMS of 12 which indicated moderate cognitive impairment. Resident #2 required extensive assistance with 2 persons for bathing. Resident #3 Record review of Resident #3's face sheet dated 5/14/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses included: diarrhea, hypertension (high blood pressure), kidney failure and edema. Record review of Resident #3's care plan dated 5/7/2024 revealed the care plan did not include a problem, goal or an approach that addressed baths or showers. Record review of Resident #3's admission MDS assessment dated [DATE] reflected it was in progress and did not have the BIMS completed. Record review of Resident #3's point of care history dated 5/13/2024 revealed he did not receive a shower on 5/13/2024. Resident #4 Record review of Resident #4's face sheet dated 5/14/2024 revealed a [AGE] year-old male with the following diagnoses included: multiple sclerosis (disease that affects central nervous system) and major depressive disorder. Record review of Resident #4's care plan dated 2/12/2024 revealed the following: Problem: General the following Task will be documented in POC . Goal: (Resident #4) will perform the following task at their highest practicable level. Approach: Start Date: 11/13/2023. I prefer to take my Bath/Shower on (Mon, Wed, Fri). My preferred time to Bath/Shower is 6 AM- 6 PM. Flowsheet: ADL once a day on Mon, Wed, Fri: 6 AM- 6 PM. Record review of Resident #4's MDS (other payment) assessment dated [DATE] revealed he had a BIMS of 15 which indicated he was cognitively intact. Resident #4 required extensive assistance with 2 persons for bathing. Record review of Resident #4's point of care history with a 6-day look-back period, revealed Resident #4 did not receive a bath on his scheduled bath/shower days 5/10/2024 (Friday) and 5/13/2024 (Monday). Observation and interview on 5/14/2024 at 9:34 AM revealed Resident #1 laying in his bed. Resident #1 had a full overgrown beard and nose hairs that extended past his nostrils. Resident #1 said he had not had his showers consistent on his shower days and had not been shaven or asked if he wanted to be shaved. Resident #1 said his beard hair was too long and he usually wore a goatee and not a full beard. Interview on 5/14/2024 at 10:11 AM CNA A said she had to wait until after lunch for showers. She said residents are supposed to be groomed when showers were given. She said male residents should be shaven if they wanted along with other grooming task needed. She said they should document showers given on shower sheets. She said a resident's state of mind could be affected and they would not feel their best if they do not receive their showers. She is not sure why residents who should have received a shower did not. Interview on 5/14/2024 at 10:57 AM with the ADON said Resident #1 should have been offered or shaved and groomed when he had a shower. She said residents should receive their showers and been groomed as scheduled. She said she rounded daily but did not always fully look at a resident but would quickly peep in the room and say, How are you doing. She said she was not aware Resident #1's beard and nose hairs were as long as they were. She said it was the newly hired wound care nurse's responsibility to ensure the . She said the problem could have been that the facility had a dedicated shower tech and now the CNA's are responsible for showers. Interview on 5/14/2024 at 11:05 AM with the DON said when residents do not receive their showers as scheduled it is a dignity and rights issue. Interview on 5/14/2024 at 11:10 AM with Resident #2 said she did not receive her scheduled shower on yesterday (Monday). She said she felt nasty. She said she last had a shower on Friday. She said there used to be a shower tech who would help with the showers. She said today she was told by a CNA (unknown) she had to wait until after lunch for a shower. Interview and Record review on 5/14/2024 at 11:20 AM with Resident #3 revealed him in bed. Resident #3 said he had not had a shower or bed bath. He said he wanted a shower to feel refreshed. Interview and observation on 5/14/2024 at 11:30 AM Resident #4 said he did not have a shower on his scheduled shower day (Monday). He said he had not received his shower because staff had recently quit and there are not enough staff. He said he did not feel clean. Resident #4 was in bed, had on a hospital gown and his beard was overgrown and not groomed. Interview on 5/14/2024 at 12:52 PM with WC A said she looked at the shower sheets to check if showers had been completed. RN A did not have a specific protocol because she was new in the position. She said residents should receive their showers as scheduled. Interview on 5/14/2024 at 2:41 PM with the ADMIN, said the facility has had some challenges with staff when it came to ensuring showers were completed with residents. She said the facility had a dedicated shower technician, but that position was eliminated last week. She said two staff called in yesterday so there may have been resident who did not get a shower but should have received a bed bath. She said the newly hired wound care nurse was supposed to ensure residents received their showers. The ADMIN said the expectation was for residents to receive their showers on assigned days or as needed by CNA's. Record review of facility shower sheet binder cover revealed the following: Shower Schedule Monday/Wednesday/Friday - [rooms where Residents #1, #2, #3, and #4 resided] Record review of facility policy, Resident Rights (revised February 2021) revealed the following in part: Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. 2. These rights include the resident's right to : a. A dignified existence b. Be treated with respect, kindness and dignity . Record review of facility policy on Activities of Daily Living (ADLs), Supporting (Revised March 2018) revealed the following in part: Residents will be provided with care, . and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene. 2. Appropriate care and service will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene ( bathing, dressing, grooming, and oral care. 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Record review of facility CNA job description dated 10/25/2021 revealed the following in part: Under the supervision of the Charge Nurse and Director of Nursing, the Certified Nursing Assistant (CNA) performs direct resident care duties . Essential Functions/Primary Duties: Assist residents with activities of daily living including bathing, dressing, grooming .

Based on observation, interview and record review, the facility failed to treat the resident with respect and dignity and care for each resident in a manner that promotes enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Resident #1,#2,#3,#4) of 6 residents reviewed for resident rights. The facility failed to provide Resident #1 with scheduled showers and grooming. The facility failed to provide Resident #2 with scheduled showers. The facility failed to provide Resident #3 with scheduled showers. The facility failed to provide Resident #4 with scheduled showers and grooming. This failure could place residents at risk for loss of dignity. Findings included: Resident #1 Record review of Resident #1's face sheet dated 5/14/2024 revealed a [AGE] year-old male admitted on [DATE] (originally on 5/22/2023) with the following diagnosis included: heart disease, lack of coordination, reduced mobility, muscle weakness and dementia. Record review of Resident #1's care plan dated 5/14/2024 revealed the following: Problem: ADLs Functional status/rehabilitation potential. Goal: Resident will achieve maximum functional mobility. Approach: Bathing/Hygiene, Dressing/Grooming, Resident care as per facility protocol. Problem: General the following Task will be documented in POC . Goal: Resident will perform the following task at their highest practicable level. Approach: I prefer to take my Bath/Shower on Tuesday, Thursday, Saturday. My preferred time to Bath/Shower is 6a-6p. Flowsheet: ADL Once a Day on Tues, Thursday, Saturday 6a - 6p. Record review of Resident #1's MDS (optional payment ) assessment dated [DATE] revealed he had a BIMS of 7 which indicated severe cognitive impairment. Record review of Resident #1's progress notes dated 3/10/2024 - 5/8/2024 revealed Resident #1's last documented shower was 4/24/2024. Record review of Resident #1's shower sheets documentation over a 4-day look-back period reflected the last documented shower was 5/10/2024 (Friday). His shower day was Saturday and he has not had a shower in 3 days, Resident #2 Record review of Resident #2's face sheet dated 5/14/2024 revealed a [AGE] year-old female admitted on [DATE] (originally 11/9/2023) with the following diagnoses included: candidiasis of vulva and vagina (itching/irritation in the vagina), need assistance with personal care, obesity, diabetes, depression, muscle weakness and lack of coordination. Record review of Resident #2's care plan dated 4/5/2024 revealed the following: Problem: General the following Task will be documented in POC . Goal: Resident will perform the following task at their highest practicable level. Approach: Start Date: 11/13/2023. I prefer to take my Bath/Shower on (Mon, Wed, Fri). My preferred time to Bath/Shower is (Day Shift). Flowsheet: ADL once a day on Mon, Wed, Fri: 6 AM- 6 PM. Record review of Resident #2's (other payment ) MDS assessment dated [DATE] revealed she had a BIMS of 12 which indicated moderate cognitive impairment. Resident #2 required extensive assistance with 2 persons from wheelchair. Record review of Resident #2's shower sheets documentation over a 4-day look-back period reflected revealed a shower did not occur on 5/13/2024 (scheduled shower day). Resident #3 Record review of Resident #3's face sheet dated 5/14/2024 revealed a [AGE] year-old male admitted on [DATE] with the following diagnoses included: diarrhea, hypertension (high blood pressure), kidney failure and edema. Record review of Resident #3's care plan dated 5/7/2024 revealed the care plan did not include a problem, goal or an approach that addressed baths or showers. Record review of Resident #3's admission MDS assessment dated [DATE] reflected it was in progress and did not have the BIMS completed. Record review of Resident #3's point of care history dated 5/13/2024 revealed he did not receive a shower on 5/13/2024. Record review of facility shower sheet binder cover revealed the following: Shower Schedule Monday/Wednesday/Friday - [rooms where Residents #1, #2, #3, and #4 resided] Resident #4 Record review of Resident #4's face sheet dated 5/14/2024 revealed a [AGE] year-old male with the following diagnoses included: multiple sclerosis (disease that affects central nervous system) and major depressive disorder. Record review of Resident #4's care plan dated 2/12/2024: Problem: General the following Task will be documented in POC . Goal: (Resident #4) will perform the following task at their highest practicable level. Approach: Start Date: 11/13/2023. I prefer to take my Bath/Shower on (Mon, Wed, Fri). My preferred time to Bath/Shower is 6 AM- 6 PM. Flowsheet: ADL once a day on Mon, Wed, Fri: 6 AM- 6 PM. Record review of Resident #4's MDS (other payment ) assessment dated [DATE] revealed he had a BIMS of 15 which indicated he was cognitively intact. Record review of Resident #4's point of care history with a 6-day look-back period, revealed Resident #4 did not receive a bath on his scheduled bath/shower days 5/10/2024 (Friday) and 5/13/2024 (Monday). Observation and interview on 5/14/2024 at 9:34 AM revealed Resident #1 laying in his bed. Resident #1 had a full overgrown beard and nose hairs. Resident #1 said he had not had his showers consistent on his shower days and had not been shaven or asked if he wanted to be shaved. He said he did not feel respected Interview on 5/14/2024 at 10:57 AM with the ADON said Resident #1 should have been offered or shaved and groomed when he had a shower. She said a resident's dignity can be negatively affected by not being groomed. Interview on 5/14/2024 at 11:05 AM with the DON said when residents do not receive their showers as scheduled it is a dignity and rights issue. Interview on 5/14/2024 at 11:10 AM with Resident #2 said she did not receive her scheduled shower on yesterday (Monday). She said she felt nasty. She said she last had a shower on Friday. She said there used to be a shower tech who would help with the showers. She said today she was told by a CNA (unknown) she had to wait until after lunch for a shower. Observation and Interview on 5/14/2024 at 11:20 AM with Resident #3 revealed him in bed. Resident #3 said he had not had a shower or bed bath. He said he wanted a shower to feel refreshed. Interview on 5/14/2024 at 11:25 AM CNA A said she had to wait until after lunch for showers. Interview and observation on 5/14/2024 at 11:30 AM Resident #4 said he did not have a shower on his scheduled shower day (Monday). He said he had not received his shower because staff have recently quit and there are not enough staff. He said he did not feel clean. He said he would feel better about himself if he had his shower. Resident #4 was in bed, had on a hospital gown and his beard was overgrown and not groomed. Interview on 5/14/2024 at 12:15 PM with the ADMIN, said the facility has had some challenges with staff when it came to ensuring showers were completed with residents. She said the facility had a dedicated shower technician, but that position was eliminated last week. She said two staff called in yesterday so there may have been resident who did not get a shower but should have received a bed bath. She said the newly hired wound care nurse was supposed to ensure residents received their showers. The ADMIN said the CNA's should have filled out the shower sheets after showers were completed. The ADMIN said the expectation was for residents to receive their showers on assigned days or as needed. She said regular scheduled showers help to maintain the resident dignity. Interview on 5/14/2024 at 2:45 PM with the ADMIN facility shower policy was requested and the ADMIN said the facility did not have a shower policy. Record review of facility policy, Resident Rights (revised February 2021) revealed the following in part: Employees shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. 2. These rights include the resident's right to : a. A dignified existence b. Be treated with respect, kindness and dignity . Record review of facility policy on Activities of Daily Living (ADLs), Supporting (Revised March 2018) revealed the following in part: Residents will be provided with care, . and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADL). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good .grooming and personal and oral hygiene. 2. Appropriate care and service will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene ( bathing, dressing, grooming, and oral care). 6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Record review of facility CNA job description dated 10/25/2021 revealed the following in part: Under the supervision of the Charge Nurse and Director of Nursing, the Certified Nursing Assistant (CNA) performs direct resident care duties . Essential Functions/Primary Duties: Assist residents with activities of daily living including bathing, dressing, grooming .

Based on observation, interview, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] #5, and Resident #6) reviewed for sufficient staff. 1. The facility failed to assign dedicated staff for the COVID-19 unit and frequently left Resident #1, Resident #2, Resident #5, and Resident #6, who were all cognitively impaired with histories of falls, wandering, and exit seeking behaviors unattended for indeterminate amounts of time when designated staff provided care to residents in other parts of the building. 2. The facility failed to have staff available to supervise the COVID-19 unit when Resident #1 sustained a head injury and required five staples after a fall. 3. The facility designated temporary CNA's who were not adequately trained to care for cognitively impaired residents to work the COVID-19 unit. 4. The facility failed to have sufficient staff to ensure cognitively impaired residents who were COVID-19 positive and COVID-19 negative isolated separately. An Immediate Jeopardy (IJ) situation was identified on 07/14/2022 at 12:56 p.m. While the IJ was removed on 07/20/2022 at 10:00 a.m., the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place quarantined residents at risk of serious injury from falls, resident to resident incidents, and exposure to COVID-19 infection. Findings include: Resident #1 Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities) with behavioral disturbances, diabetes (too much sugar in the blood), muscle wasting and atrophy, reduced mobility, depression (a group of conditions associated with the elevation or lowering of a person's mood), [CONDITION(S)] (a sleep disorder in which you have trouble falling and/or staying asleep), generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), [CONDITION(S)] due to known abnormal physiological condition (serious disturbance in mental abilities that result in confused thinking and reduced awareness of surroundings), repeated falls, altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain), and cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness). Record review of Resident #1's MDS dated [DATE] revealed she had a BIMS score of 8 (mild cognitive impairment); wandering behaviors were not exhibited; she required extensive physical assistance from at least two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene; she was totally dependent on staff for bathing and locomotion; she was wheelchair bound; she was always incontinent of bowel and bladder; and she experienced one fall with injury since admission. Record review of Resident #1's care plan, updated on 07/10/2022, revealed she resided in the facility's secured unit (Goal: Safety will be maintained, and resident will wander about unit without occurrence of any injury over review period. Approach/Intervention . Keep environment free of possible hazards, Monitor to assure resident's safety .); she was prescribed [CONDITION(S)] drugs; and she had actual falls on 06/25/2022 and 07/07/2022 (with injury to head) (Goal: Resident will remain free of injuries and falls. Approach/Intervention . Continue frequent redirection to reduce falls, fall mat in place . Instruct resident on safety measures .) Record Review of Resident #1's, Event Report, dated 07/10/2022 revealed LVN C wrote, . Event Date: 07/07/2022, 5:55 p.m . What was resident doing just prior to fall? In wheelchair self-propelling in the hallway. Was Fall Witnessed? No . Does resident exhibit or complain of pain related to the fall? Yes (location) Head . Location of Injury: Back of Head. Note any injury to the head, extremities, or trunk: Laceration . Immediate measures taken: First Aid, Direct Pressure to Wound . Laceration with uncontrolled bleeding . Notes: 07/07/2022, 5:48 p.m. I was at the nurses station and heard yelling coming from the quarantine hall. I approached the 100 Hall and opened the door find this resident on the floor with her wheelchair in front of her. Resident was in sitting position and bleeding from her head onto her shirt. I asked resident what happened, and she stated she stood up and did not remember what happened after that. I Immediately called the CNA and other nurse on the floor for help. Resident laid down and I placed a towel on her head to stop the bleeding coming from the back of her head. Resident was able to tell me her date of birth and was responding to questions I asked her . Nurse stayed with resident and applied pressure to bleeding spot until EMS arrived. Hospice notified of 911 call . Record review of Resident #1's, Morse Fall Scale dated 07/13/2022 revealed the Regional Nurse Consultant wrote, . Description: Fall Assessment . History of Falling: Yes . Gait: Impaired, Mental Status: Overestimates/Forgets Limitation . Level: High Risk for Falls . Observation and interview with Resident #1 and TCNA A on 07/08/2022 at 4:09 p.m. in the COVID-19 unit (warm zone) revealed Resident #1 was in her bed turned sideways with her feet hanging off the bed. TCNA A rushed to assist Resident #1 and placed her feet back into bed. Resident #1 was alert and oriented at that time. TCNA A said Resident #1 should be on one on one at this time because she moved constantly. TCNA A said she tried to rush whenever she had to provide other residents with incontinent care because of Resident #1's behaviors (wandering behaviors and standing from her wheelchair). TCNA A said Resident #1 had a fall on the previous day (07/07/2002) and had to get staples in the back of her head. Resident #1's five staples were observed at that time. TCNA A said she was the only staff member assigned to the warm and hot zones at that time (07/08/2022). TCNA A said she did not get any help and she had not been trained to provide ADL's, incontinent care, or care for cognitively impaired residents when she transferred from the dietary department to work the floor as a temporary CNA. TCNA A said Resident #1 resided in the secured memory care unit and had always been up and down (stood up from her wheelchair). TCNA A said Resident #1 needed to be monitored at all times. Record review of Resident #1's Progress Notes for July 2022 revealed: On 07/05/2022 at 5:21 p.m., LVN H wrote, Nurse called RP and let them know that there are new cases of COVID-19 and that resident that was positive is in COVID-19 unit and this resident will be moved to COVID-19 unit (Resident #1's roommate, Resident #6, tested positive for COVID-19, so Resident #1 was moved to the warm zone on the 100 Hall). On 07/06/2022 at 1:30 p.m., RN I wrote, Day 2/10 resident on Warm area of COVID-19 hall due to COVID-19 exposure. Asymptomatic. Resident continues to self-propel ad lib (as much and as often as desired) in hallway. Redirection for resident to remain in Warm area, unsuccessful. Resident continues to propel self up and down hallway. Resident has wandering behavior at all times. Nurse able to get resident to sit quietly in room to eat all meals successfully. DON and Administrator aware. Will continue to monitor for any changes of condition. On 07/07/2022 at 4:17 a.m., LVN E wrote, Day 2/3 quarantine due to COVID-19 exposure. Resident on warm unit with continual need for monitoring due to increased wandering behaviors at baseline. Resident remains asymptomatic. Fluids encouraged. On 07/07/2022 at 11:35 a.m., LVN D wrote, Resident arrived back at facility via stretcher with EMT x2 personnel. Head laceration to posterior part of head addressed with 5 staples in place intact. Resident has no complaints of pain or discomfort and shows no s/sx of pain during assessment. Medication reconciliation sent to NP . Laceration was 44cm in size when measured in ED . Staples to be removed in 7 days per D/C orders from hospital . On 07/08/2022 at 9:15 a.m., LVN C wrote, Day 1/3 return from ER from fall causing laceration to posterior head with 5 staples in place. Resident states she has pain in her head. Scheduled Tylenol given for pain relief. Resident does not understand to call for help before getting out of bed alone or to use the call bell. Resident became angry and started swatting her hand when trying to redirect back into bed. PRN medication administered at this time for agitation. Resident is in her bed with call bell within reach but also has CNA at bedside to help prevent falls/ assistance to bed/wheelchair. On 07/16/2022 at 5:10 a.m., LVN E wrote, Quarantine completed, rapid test negative. Resident moved back to her room. Observation of Resident #1 on 07/13/2022 at 2:30 p.m. revealed she was in her wheelchair at the end of the 100 Hall, which was designated as the facility's hot zone (for COVID-19 positive residents). After approximately two minutes, an unknown staff member was observed pushing Resident #1's wheelchair out of the hot zone, into the warm zone (the warm zone was located behind the fire doors towards the front of the 100 Hall. The hot zone was located at the end of the 100 Hall. The two zones were separated by blue tape on the floor). Resident #2 Record review of Resident #2's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), COVID-19 acute respiratory disease, generalized anxiety disorder (severe, ongoing anxiety that interferes with daily activities), [CONDITION(S)] due to known abnormal physiological condition (serious disturbance in mental abilities that result in confused thinking and reduced awareness of surroundings), major depressive disorder (a group of conditions associated with the elevation or lowering of a person's mood), anxiety disorder (severe, ongoing anxiety that interferes with daily activities), [CONDITION(S)] (chronic pain condition affecting the trigeminal nerve in the face), abnormalities of gait, lack of coordination, and abnormal posture. Record review of Resident #2's MDS dated [DATE] revealed she had a BIMS score of 2 (severe cognitive impairment); wandering behaviors did not exist; she required supervision for set-up only with bed mobility, transfers, walking in room and corridor, locomotion on and off the unit, eating, and toilet use; she required limited physical assistance from one staff for dressing, personal hygiene, and bathing; she ambulated with the assistance of a walker; she is occasionally incontinent of bladder and frequently incontinent of bowel; she did not have a history of falls Record review of Resident #2's care plan, updated on 07/13/2022, revealed she resided in the facility's secured unit due to elopement risk; she was at risk for falls/safety/elopement and was aggressive to peers. Record review of Resident #2's progress notes for June 2022 and July 2022 revealed: On 06/29/2022 at 4:30 p.m., RN I wrote, Called and notified RP that during COVID-19 testing this morning, patient tested positive and would be moving to the COVID-19 hall . On 07/04/2022 at 10:36 p.m., LVN D wrote, Day 6/10 COVID-19 + in quarantine . Resident having to constantly be redirected on staying on COVID-19 unit as per morning shift, residents were allowed out of the unit if they wore a mask. This resident was given several different masks and she continued to remove it while in common areas. Nurse informed resident if she does not wear a mask that she has to stay behind the closed doors of the COVID-19 unit. Resident got upset and yelled at this nurse stating, leave me alone! Nurse explained to resident that she is sick and does not need to get the rest of the residents sick, she was still upset. Nurse directed resident onto COVID-19 unit and to her room several times . On 07/06/2022 at 11:24 p.m., LVN E wrote, Day 8/10 COVID-19 + quarantine. Resident alert and oriented x 1-2 with memory impairment noted. Wander behaviors present throughout shift . Observation and interview with Resident #2 and TCNA A on 07/08/2022 at 4:00 p.m. revealed she was walking back and forth on the 100 Hall, from warm zone to hot zone. TCNA A said Resident #2 wandered back and forth from warm zone to hot zone all day. Resident #2 was not wearing a mask, but she did have one in her hand. Resident #2 said she was going to get into trouble because she was not wearing her shoes (she was only wearing socks). TCNA A said Resident #2 was from the secured unit and she was COVID-19 positive. TCNA A attempted to redirect Resident #2 back to the hot zone by interlocking their arms. TCNA A walked Resident #2 across the blue tape on the floor into the hot zone. Resident #5 Record review of Resident #5's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions), COVID-19 acute respiratory disease, dementia with behavioral disturbance (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), altered mental status (a change in mental function that stems from illnesses, disorders and injuries affecting your brain), muscle wasting and atrophy, cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), history of falls, psychotic disorder with delusions (A mental disorder characterized by a disconnection from reality), dementia with behavioral disturbances (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), anxiety disorder (severe, ongoing anxiety that interferes with daily activities), major depression (a group of conditions associated with the elevation or lowering of a person's mood), and [CONDITION(S)] (a sleep disorder in which you have trouble falling and/or staying asleep). Record review of Resident #5's MDS dated [DATE] revealed she had a BIMS score of 3 (severe cognitive impairment); wandering behaviors were not exhibited; she required extensive physical assistance from at least one staff member for bed mobility, dressing, and personal hygiene; she required limited physical assistance from at least one staff member for transfers, toilet use, and bathing; she was independently ambulatory; and she was occasionally incontinent of bowel and bladder. Record review of Resident #5's care plan updated 07/13/2022 revealed she was at risk for injury/elopement due to impaired cognition, impaired safety awareness, and tendency to wander (Goal: I will not wander into an unsafe environment over the next 90 days. Approach/Interventions: Provie escort/guidance when leaving secured unit, Redirect as needed, resident requires queuing and reminders for hygiene .); she resided in the facility's secured unit; she was prescribed [CONDITION(S)] medication; she was at risk for falls due to impaired safety awareness and impaired mobility and she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Approach/Interventions: Keep bed in low position with brakes locked, Give frequent education on how to use and encourage her to use before ambulating/transferring for safety .) Record review of Resident #5's progress notes for June 2022 and July 2022 revealed: On 06/29/2022 at 4:09 p.m., LVN C wrote, Resident moved to quarantine hall for exposure to a COVID-19 + resident (Resident #'s roommate, Resident #2 tested positive for COVID-19 on 09/29/2022). Resident is asymptomatic at this time. Resident will not stay in her room after multiple times trying to explain to her that it is necessary to prevent the spread of COVID-19. She states she does not want to stay in that room. I was able to redirect her to her room. She is in her room at this time with call bell within reach. On 07/02/2022 at 10:35 a.m., LVN C wrote, Other nurse informed me that resident was tested last night for COVID-19 and tested positive. Previous day shift nurse notified DON. Resident refuses to stay in room. She states this is not her room. She wanders and redirection is successful after multiple attempts . On 07/05/2022 at 5:20 p.m., RN I wrote, Day 5/10 of resident testing positive for COVID-19. Resident remains on COVID-19 hall/quarantine. Continued redirection needed to keep resident on Hot Side. Resident cursing at this nurse at various times, redirection successful x 3 attempts . Will continue to monitor resident for any respiratory changes and wandering out of quarantine/Hot location. On 07/06/2022 at 1:16 p.m., RN I wrote, Day 6/10 on COVID-19 positive test. Remains asymptomatic. Resident required to have continued redirection on staying in quarantine and remaining on designated hall. Successful with multiple attempts . Interview with Resident #5 on 07/20/2022 at 11:30 a.m. she said she recalled being on the COVID-19 hall. She said there was not always a staff member present on the hall Resident #6 Record review of Resident #6's face sheet revealed she was an [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with dementia without behavioral disturbances (the loss of cognitive functioning [thinking, remembering, and reasoning] to such an extent that it interferes with a person's daily life and activities), muscle wasting and atrophy, cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), anxiety disorder (severe, ongoing anxiety that interferes with daily activities), depression (a group of conditions associated with the elevation or lowering of a person's mood), COVID-19 acute respiratory disease, mood disorder, restlessness, and agitation. Record review of Resident #6's MDS dated [DATE] revealed she had a BIMS score of 4 (severe cognitive impairment); wandering behavior was not exhibited; she required limited assistance from at least one staff member for bed mobility, dressing, toilet use, and personal hygiene; she was totally dependent on staff for bathing; she was independently ambulatory with a cane; she was occasionally incontinent of bladder and frequently incontinent of bowel; and she was prescribed antipsychotic medication. Record review of Resident #6's care plan, updated on 07/07/2022 revealed she was at risk for falls, injury, and/or elopement due to impaired cognition with impaired safety awareness, impaired memories, impaired daily decision making, and a history of exit seeking (Goal: Resident will remain free of injuries and falls. Approach/Interventions: Keep bed in low position as resident will allow . Keep cane within reach . Resident will have guidance/escort when exiting the secured unit); and she resided in the facility's secured unit. Record review of Resident #6's progress notes for July 2022 revealed: On 0706/2022 at 1:27 p.m., RN I wrote, Day 2/10 of resident on COVID-19 hall due to positive COVID-19 test. Resident asymptomatic. Continued redirection required to keep resident quarantined to designated Hot area. Successful at times after multiple attempts . Observation and interview with Resident #6 on 07/20/2022 at 3:30 p.m. in the locked memory care unit revealed she was in bed. Resident #6 said she could not recall her birthdate, but she knew it was in the summer (her birthdate was in February). In an interview with LVN C on 07/08/2022 at 3:40 p.m., she said she worked the COVID-19 unit and there were 6 residents currently (as of 07/08/2022) on the unit. She said Resident #1, Resident #3 and Resident #4 were in the warm zone and Resident #2, Resident #5 and Resident #6 were in the hot zone. In a follow up interview with LVN C on 07/08/2022 at 4:32 p.m., she said there were times when there were no staff in the COVID-19 unit (warm zone or hot zone) because the staff designated to work the COVID-19 unit were also designated to work other halls in the facility. LVN C said it was always like that (when no staff were in the COVID-19 unit, but she could not say how often this happened). LVN C said this was the first time residents from the secured memory care unit were placed in the COVID-19 unit and so far, they had been on isolation 8 days. In an interview with LVN C on 07/13/2022 at 12:45 p.m., she stated Resident #1 wandered and went from wheelchair to walking all day. She said Resident #1 was the only wheelchair bound resident in the COVID-19 unit at that time (07/13/2022). She said the rest of the residents from the secured unit (Resident #2, Resident #5 and Resident #6) walked independently. She said there were also two other residents in the warm zone at that time (07/13/2022). LVN C said it was not ok to leave dementia (confused) residents alone for any period of time, but she was designated to work two halls. She said the hardest thing was to watch Resident #1 because she was a wanderer and she needed constant redirection from going down to the hot zone. She said on 07/07/2022, during shift change around 5:49 p.m., she was outside of the COVID-19 unit by the nurse's station when she heard someone yell. She looked through the windows of the fire doors outside the COVID-19 unit and saw Resident #1 sitting on her buttocks. LVN C said when she entered the COVID-19 unit, she saw blood dripping from the back of Resident #1's head. She said Resident #1's wheelchair and a food cart was near where she fell . She said there were no CNA's or nurses inside the COVID-19 unit when Resident #1 fell . She said two CNAs went home early and there was only one left for the other halls, excluding the memory care unit. She said she called 911 at 5:51 p.m. Resident #1 had a laceration in the back of her head and returned to the facility that same night (07/07/2022) with five staples. She said Resident #1 knew she fell and told LVN C she was trying to walk around. She said this was the first time a resident fell in the COVID-19 unit while no staff was in the unit. She said she did not know how long the residents were left alone on 07/07/2022. She said the only CNA they had that day, TCNA B, was busy doing something else. In a telephone interview with TCNA B on 07/13/2022 at 1:40 p.m., she stated she often worked the COVID-19 unit alone. She said she was present on 07/07/2022 when Resident #1 fell . She said her co-worker had to go home early, so she was the only CNA on the floor. She said she had to run between the COVID-19 unit and other halls (there were two other occupied halls, excluding the secured memory care unit, who had their own staff). She said Resident #1 was confused, but she could have a conversation and knew she needed to sit down because she would fall. She said Resident #1 stood up a lot and wandered. She said Resident #1 was placed in the warm zone but frequently wandered into the hot zone. She said if any staff was in the COVID-19 unit, they brought her back to the warm zone, but if not, Resident #1 went into the hot zone. She said sometimes, there was nobody (no staff) in there (the COVID-19 unit) at all. She stated she had not been trained to care for dementia residents. In a telephone interview with LVN E on 07/19/2022 at 7:42 p.m., she stated she usually worked the 6:00 p.m. - 6:00 a.m. shift. She said she had worked as the night shift designated COVID-19 unit nurse, but she was also designated to work the 200 Hall at the same time. LVN E said one CNA also had the same assignment on the night shift (COVID-19 unit and 200 Hall). She said things got tricky (difficult) when wanderers from the secured unit got placed in the COVID-19 unit. She said the residents from the secured unit required constant redirection to keep the COVID-19 positive residents in the hot zone and the quarantined residents in the warm zone. She said once the confused residents moved into the COVID-19 unit, she tried to navigate working that unit and the other hall to keep everyone safe. She said she had to leave the residents in the COVID-19 unit alone if she had an admission (new resident admission) or if other residents on the other hall had needs. In an interview with the Interim Administrator 07/13/2022 at 10:15 a.m., she stated there were no dedicated staff to work the COVID-19 unit (warm and hot zones). She said staff were designated to work the COVID-19 unit in addition to working their other assigned halls. She said there was not a continuous staff member in the hot/warm zone at all times. She said she was aware that some residents in the COVID-19 unit required redirection because they wandered. She stated TCNA A was out on vacation. An unsuccessful attempt was made to contact TCNA A by phone on 07/13/2022 at 11:41 a.m. The phone number was disconnected. Record review of TCNA A's employee record revealed she was hired on 04/08/2021 as a dietary aide. Further review indicated on 03/08/2022, TCNA A submitted a 2-week notice to transfer from the dietary department to work the floor as a CNA. Record review of TCNA A's employee training record revealed the following : 01/28/2022 - Temporary Nurse Aide 8 Hour Training 02/07/2022 - Sensory Changes and Communication 02/10/2022 - Fire Safety, Resident Abuse, Hand Washing, HIPAA and You 02/11/2022 - A Review of F-TAGs for Residents Right and Grievances, Texas House Bill 300: Understanding Patient Rights Under the Law, Bloodborne Pathogens 02/22/2022 - Workplace Violence 02/28/2022 - Sexual Harassment 05/03/2022 - COVID-19 Training for Frontline Nursing Home Staff Record review of the facility's policy, Staffing revised July 2021 revealed, Our center provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the center assessment. Policy Interpretation 1. Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. 2. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care . Record review of the facility's policy, Secure Unit, revised 05/13/14 revealed, The Secure Unit is designed to provide a holistic approach of care for the residents with dementia, those with exit-seeking behaviors, hoarders and those that require less stimulation that the General Population . Staffing on the Secure Unit: Staffing requirements on the Secure Unit are determined by the DON and Administrator. Regardless of census, if the community requires additional staff due to increases in incidents/accidents the unit will be staffed based on acuity to ensure resident safety . The Secure Unit should not be left unattended, a staff member is required to be present on the Unit at all times . This was determined to be an Immediate Jeopardy (IJ). The Interim DON/Regional Nurse Consultant was notified on 07/14/2022 at 12:56 p.m. an IJ situation was identified due to the above findings, and IJ template was provided. The facility's Plan of Removal was accepted on 07/18/2022 at 2:16 p.m. and indicated: Plan of Removal is for Sufficient staffing Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on July 14th, 2022. 1. Action: 2 CNA's for each shift will be assigned to the Covid Unit which consist of warm and hot zones and will be trained by Nursing Administration to properly monitor and re-direct wandering residents that are cognitively impaired with behaviors. Licensed staff members assigned to the Covid Unit will not leave the unit which consist of warm and hot zones unless relieved by another staff member. 2 wandering residents were transferred off the Covid unit 07/16/2022, allowing 1 CNA on warm zone and 1 CNA on hot zone to timely provide adl care. a. Temporary Nurse Aides are assigned to COVID unit which consist of warm and hot zones have been trained and have demonstrated competencies related to PPE and handwashing on 7/18/2022. b. Temporary Nurse Aide skills competency checklist has been sent to AHCA Temporary Nurse Aide Training program. Resident # 1 and Resident # 2 are being monitored. Staff will not be allowed to work until appropriate training has been received. This will include part-time and or agency personnel. Interim Director of Nursing or designee will continue effective of training and report any concerns to Interim Administrator. No additional residents residing on COVID unit which consist of warm and hot zones have any noted injuries. All shifts appropriately staffed. c. Center audit completed related to temporary nurse aides hired under CMS waiver related to COVID pandemic. Currently, 6 temporary nurse aides employed by center. Training completed after 80 work hours post hire. 1 has completed testing and 5 temporary nurse aides awaiting for authorization to test from AHCA temporary nurse aide training program. d. There will be 2 qualified, trained staff on the COVID unit which consist of a warm and hot zone to meet and provide ADL care and to redirect wandering residents Training Completion date: Beginning July 14th, 2022 and ending July 16th, 2022. Staff out on leave, PRN, or Agency staff will be trained prior to the beginning of next scheduled shift. Interim Director of Nursing or designee will continue effectiveness of training and report any concerns to Interim Administrator daily for the next 2 weeks. Responsible: RNM/ Interim Administrator Residents residing on COVID unit which consist of warm and hot zones assessed by regional nurse manager on July 15th, 2022. 2. Action: Nursing Administration to conduct education with nursing personnel and anyone accessing the COVID unit on the following: 1. Caring for residents that are cognitively impairment with behaviors 2. Falls Preventions and 3. COVID response related to wandering residents with behaviors that require quarantine in warm and isolation hot zones. Completion Timeline: Beginning July 14th, 2022 and ending July 16th, 2022. Responsible: RNM/ Interim Administrator 3. Action: Adhoc QAPI meeting with medical director/nurse practitioner and IDT at 3pm on July 15th. The purpose of the Ad hoc QPAI was to inform the Medical Director of the IJ Situation, latest version of Covid response plan review, Falls Prevention and Behaviors Policies and Plan of Removal. Responsible: Interim Administrator, Director of Nursing/ RNM Monitoring of the plan of removal: The surveyor confirmed the facility implemented their plan of removal sufficiently from 7/18/22-7/20/22 to remove the IJ by: Record Review of, In-Servic [TRUNCATED]

Based on observation, interview, and record review, the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change for 1 of 18 residents (Resident #7) reviewed for notification of changes. The facility failed to consult Resident #7's physician when she developed a blister/boil on her chest near her [CONDITION(S)] port. The facility failed to notify Resident #7's responsible party for three days when she was transferred to the hospital with symptoms of infection on 07/11/2022. These failures could place residents who experience a change in condition at risk of delay in treatment, responsible not being informed in care decisions, and further harm or injury. Findings include: Record review of Resident #7's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with stage 4 (severe) [CONDITION(S)], cognitive communication deficit (an impairment in organization/thought organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), and [CONDITION(S)] (a serious bacterial infection that destroys tissue under the skin). Record review of Resident #7's MDS dated [DATE] revealed she had a BIMS score of 15 (cognitively intact); she required extensive physical assistance from at least one staff member for bed mobility, locomotion, personal hygiene, and transfers (at least two staff); she was totally dependent on staff for dressing and toilet use; she was always incontinent of bowel and bladder; and she had moisture associated skin damage (incontinence-associated [CONDITION(S)], perspiration, drainage). Record review of Resident #7's care plan, updated on 07/05/2022 revealed, Skin (Goal: Prevent/heal pressure sores and skin breakdown, Approach: . Report to charge nurse any redness or skin breakdown immediately) ., Infection Alert (Goal: Resolve Infection, Approach . Monitor for s/sx of infection, Monitor wound/lesion status and progress) ., General . (Approach . I prefer to take my bath/shower on [MWF] My preferred time to bath/shower is [6a - 6p] . Oral care: Twice a day 6:00 a.m. - 2:00 p.m., 2:00 p.m. - 10:00 p.m .) . Record review of Resident #7's progress notes for July 2022 revealed: On 07/06/2022 at 1:41 p.m., LVN H wrote, Sent message to NP to see what we needed to do for blister on resident's chest. Waiting on a call back. Called resident's family member who states that he is going to [CONDITION(S)] with her Friday . On 07/11/2022 at 11:00 p.m., LVN E wrote, This nurse answered call light, resident with complaint of not feeling right, + body chills, body aches, temperature is 102.8, blood pressure 147/65, pulse 98, respirations 20, slight shortness of breath and nurse raised head of bed, O2 saturation 86%, O2 placed on resident 2L and O2 improved to 92%. Resident states that [CONDITION(S)] may have given her an antibiotic during [CONDITION(S)] today but was not 100% sure. No information returned from [CONDITION(S)] with patient concerning this matter. Resident stated that it had to do with her blister. Resident showed this nurse an area in the center of her chest 2 inches to the left of her port ([CONDITION(S)] port) that was enlarged approximately 3x2 cm with irregular reddened borders, discolored areas throughout with darkened brown and mild greenish, no drainage or smell noted at this time. A thin clear scab layer present. Fluid filled in several areas throughout. Resident with complaints of tenderness and discomfort to area with touch. PRN Tylenol given at this time, and NP notified. New orders received: [MEDICATION(S)] 1 gram IM now x1, stat chest x-ray 2 views, and labs, [MEDICATION(S)] 100mg by mouth twice per day for 7 days On 07/11/2022 at 11:20 a.m., LVN E wrote, Nurse at bedside with resident updating on plan of care, preparing antibiotic IM injection and resident explained that she is feeling very much off and she feels scared requesting to go ahead and go to hospital. NP was called back and informed of resident request. New order to send resident to ER to evaluate and treat was given. And transport was called at this time. On 07/12/2022 at 1:04 p.m., RN I wrote, Called hospital and spoke with RN. Resident remains in ER. Nursing waiting for a bed to come available. RN informed this nurse that they have completed a swab to test for virus. Resident currently has an Infectious Disease (infectious disease doctor) on her case to find out the location of infection and type. Noted that resident would remain in hospital for at least 48 hours for test results. Informed NP. On 07/13/2022 at 8:30 a.m., LVN J wrote, Resident's family called to see if patient was going to [CONDITION(S)]. He was unaware that she was in the hospital. Resident's family member was made aware of her situation and that she is at hospital receiving [CONDITION(S)] treatments and an antibiotic regimen. Observation and interview with Resident #7 on 07/08/2022 at 3:18 p.m. revealed she was alert, oriented, and could self-propel herself in a wheelchair. In an interview with a representative from Resident #7's [CONDITION(S)] center on 07/19/2022 at 12:45 p.m., she stated Resident #7 was currently in the hospital (as of 07/11/2022). She said on 07/06/2022, Resident #7 disconnected her [CONDITION(S)] line and started to bleed. She said the [CONDITION(S)] center's team stopped the bleeding, but while they were cleaning Resident #7 up, the team noticed a large boil in the center of her chest. She said one of the [CONDITION(S)] center staff called the facility and informed them (the facility staff notified was not identified) about the boil because if it burst, it could cause an infection. The representative said Resident #7 was in the hospital because the boil burst and was infected. In an interview with the Interim Administrator and Interim DON on 07/19/2022 at 2:45 p.m. the Interim Administrator and Interim DON stated neither of them were made aware of Resident #7's boil. In an interview with Resident #7's NP on 07/19/2022 at 3:15 p.m., she said she never received any text or other notification regarding Resident #7 on 07/06/2022. She said on 07/11/2022, she received a text message from facility staff at 10:23 p.m. The NP said she ordered an antibiotic injection for Resident #7 because she had symptoms of infection. She said she was only going to treat the infection in-house because she knew Resident #7 would have to pay out-of-pocket at the hospital. She said she called the nurse back and told her Resident #7 may need to go to the hospital because she was recently agitated at [CONDITION(S)]. The NP said previously, Resident #7 was agitated when she had an infection and went to hospital. The NP said Resident #7 tried to pull her lines out at [CONDITION(S)], so they had to get a family member to go sit with her. She said had the facility initially notified her about Resident #7's boil, she would have given an order based on what the boil looked like. She said at the very least, she would have ordered something topical for the boil. The NP said she called the [CONDITION(S)] center, and they said the boil burst on location. In a telephone interview with Resident #7's RP on 7/20/22 at 11:53 a.m., he said recently, someone had to go with Resident #7 to [CONDITION(S)] to babysit her because she started taking the [CONDITION(S)] lines out while the machine was pumping her blood and there was blood everywhere. He said Resident #7 did some crazy things and she did the same thing (pulled her lines out during [CONDITION(S)]) at the hospital last Wednesday (07/13/2022). He said he did not know if Resident #7 was still in the hospital. He said the facility did not call him to let him know Resident #7 was in the hospital. He said when he called the facility on 07/13/2022 to make sure he still had to go sit with Resident #7 for [CONDITION(S)], a facility staff member (unidentified) told him Resident # #7 had been in the hospital since Monday, 07/11/2022. He said Resident #7 was diagnosed with an infection that started in her chest. He said he looked at the sore Resident #7 had on her chest. He said if he had not called the facility, he would not have known Resident #7 was in the hospital. Record review of the facility's policy, Change in a Resident's Condition or Status revised 02/2021 revealed, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medial/mental condition and/or status . Policy Interpretation and Implementation. 1. The nurse will notify the resident's attending physician or physician on call when there has been a (an): . d. significant change in the resident's physical/emotional/mental condition; . g. need to transfer the resident to a hospital/treatment center . 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: . b. there is a significant change in the resident's physical, mental, or psychosocial status . e. it is necessary to transfer the resident to a hospital/treatment center . 5. Except in medical emergencies, notifications will be made within twenty-four hours of a change occurring in the resident's medical/mental condition or status .

Based on observation, interview and record review, the facility failed to ensure that staff who provided direct services to residents had the appropriate competencies and skills sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for 2 of 7 residents (Residents #3 and #4) whose care was reviewed for competent and sufficient staff. The facility failed to ensure there were competent and sufficient staff to supervise 15 residents in the memory care unit. As a result, Resident #3 was not protected from physical and emotional harm after Resident #4 physically assaulted Resident #3 on two different occasions causing her pain and being afraid to leave her room. An Immediate Jeopardy (IJ) situation was identified on 12/1/2021. While the IJ was removed on 12/6/21, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of physical and emotional harm. Findings included: 1. Record review of Resident #3's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's Comprehensive MDS, dated [DATE], revealed the resident had a BIMS of 2, which indicated a severe cognitive deficit. Resident #3 did not exhibit behavioral symptoms. Resident required supervision and set up or 1 person physical assist for ADLs. Record review of Resident #3's Incident Report for event, dated 10/1/21 at 11:30 p.m., revealed the report was completed on 11/12/21 at 12:43 p.m. by LVN A. The report revealed Resident #3 was hit in her mouth by another resident. This incident occurred in the dining area. Resident #3 was not injured. Record review of Resident #3's Incident Report for event, dated 11/4/21 at 1:50 p.m., revealed the report was completed on 11/5/21 at 11:39 a.m. by RN A. The report revealed Resident #3 was struck in the back of her head by another resident with his hand. Resident #3 stated her scalp was tender. Resident #3 did not have any injury noted around her hair follicles. The incident occurred in the living room. Record review of Resident #3's care plan, dated 10/22/21, revealed Resident #3 resided on the secure unit due to elopement risk. Resident #3 was to be monitored to ensure safety and unit should be kept free of possible hazards. In an interview on 11/5/21 at 3:00 p.m. with Resident #3, she said she did not know who it was, but someone came up behind her and hit her in the head. Resident #3 was visibly upset, she was crying. She said she was afraid from being hit. She said she didn't know how staff intervened; she was crying. She said it happened before. She rubbed the back of her head and said it hurt. She said she didn't want to come out of her room because she didn't want to get hit again. In an interview on 11/5/21 at 3:00 p.m. with Resident #3's representative party, she said the facility contacted her in October because Resident #3 was hit in the face. She said she was contacted yesterday (11/4/21) because Resident #3 was hit in the back of the head 4 times. She said the facility reported no injuries both times. She rubbed the back of Resident #3's head and said, there were no bumps. She said Resident #3 said she was hurting. She said she spoke with the administrator today (11/5/21) about the 11/4/21 incident. The administrator could not tell her who the resident was who hit Resident #3, but did tell her both incidents involved the same resident. She said it was reported one of the staff left the unit to get linens yesterday when Resident #4 went up behind Resident #3 and hit her 4 times. She said the one staff on duty had to get help. She said she didn't know what staff were present. She said it was reported to her by the administrator, at the time of the first incident, there was only one staff present in the memory care. She said the administrator told her the plan of action was to always have 2 staff present in the memory care unit. She said she was disappointed and concerned when she came onto the unit and only saw one staff for the day. She said she had been concerned about the staffing. Many times there was only 1 staff in the unit. When there were 2 staff, they just sit in a chair by the door. 2. Record review of Resident #4's face sheet revealed a [AGE] year-old male was readmitted to the facility on [DATE] from local psychiatric hospital. Resident #4 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's, undated, care plan revealed the resident had behavioral symptoms of wandering throughout the secure unit. Staff approach was to always ask for help if the resident became abusive/resistive, convey acceptance of resident during periods of inappropriate behavior, redirect as needed. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed the resident was discharged to the hospital on 10/2/21. Resident #4 had a BIMS of 0, which indicated severe cognitive deficit. The MDS reveal ed there were zero behavioral symptoms towards others. Resident #4 required supervision with set up only for ADLs. Record review of the facility investigation, for incident dated 10/1/21 at 11:30 a.m., revealed the Administrator completed the investigation. Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident was described as, the staff was sitting in the living room with the residents watching television when Resident #4 got up and left the room. Staff followed Resident #4. Staff was a few feet away when Resident #4 hit Resident #3 in the face. Staff immediately separated the residents and notified the nurse. No injury was noted. Resident #4 hit Resident #3 without provocation. Resident #4 appeared agitated at the time of the investigation. As a result of the investigation, the Administrator sent Resident #4 to psychiatric hospital for evaluation. No additional actions taken. Record review of the Facility Investigation report, for incident dated 11/4/12 at 11:40 a.m., revealed the Administrator completed the investigation. Resident #4 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The incident was described as, Resident #4 hit Resident #3 in the back of the head in the living room area. At the time of the incident, one of the two staff assigned to the unit had gone to get linens and the other staff was providing care to another resident. As a result of the investigation, the Administrator educated Resident #4 of the right other residents have not to be hit. Staff in-serviced on the need to communicate to ensure there was a staff with residents at the living room area at all times. Staff in-serviced on the policy of not leaving the secured unit unattended. Staff were not in-serviced on any interventions for Resident #4. The investigation report did not include any monitoring of Resident #3 for emotional or physical harm. Record review of Psychiatric Services, Initial Evaluation, dated 11/10/21, revealed Resident #4 was referred due to aggressive behaviors, anger, elopement, long-term and short term memory problems. Resident #4 was admitted to the nursing home from a local behavioral hospital. Resident #4 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #4's Comprehensive MDS, dated [DATE], revealed Resident #4 did not have any behavioral symptoms towards others. The MDS did not reflect the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS reflected antipsychotic medication use. Observation on 11/5/21 at 2:00 p.m. revealed one staff present (CNA E) sitting in the entry way of the living room area in the memory care unit. Staff were not with Resident #4. There was not any other staff on the unit. Observation on 11/5/21 at 2:30 p.m. revealed one staff (CNA E) present on the memory care unit. Observation on 11/5/21 at 3:00 p.m. revealed one staff (CAN E) present on the memory care unit. Observation on 11/9/21 at 10:00 a.m. revealed the Activities Director was one of the 2 staff in the memory care unit. CNA H was the other staff on duty in the unit. Observation on 11/30/21 at 5:25 p.m. revealed 2 staff present in the memory care unit, one staff (CNA J) was in the office on the unit. The second staff (CNA K) was exiting a room down the hall. Resident #4 and Resident #3 were observed in the TV room with 8 other residents, unsupervised. Residents were not visible to either CNA. In an interview on 11/5/2021 at 2:20 p.m. with CNA E, she said there were 15 residents in the memory care unit. She said she worked the 6 AM to 6 PM shift. She said she was the only aide in the memory care unit today (11/5/21). She said the assigned nurse comes and goes. She said most of the residents had some type of behaviors. She said she worked yesterday, 11/4/21, at the time of the incident between Resident #3 and Resident #4. She was at the linen closet off the unit when the incident occurred. There was an aide present who was in training, but she could not remember her name. The new aide reported Resident #3 was hit by Resident #4. She said Resident #4 had aggressive behaviors and fought during incontinent care. She said it took 2 people to change him. He was care planned for one person assist in toileting. She said she was able to change him by herself earlier because he didn't fight, but that was not always the case. She said there was not another staff to relieve her to take a lunch, she would go into the office on the memory care unit to eat something. She cannot see the residents in the office while she ate. She said she tried to keep Resident #4 away from Resident #3. She said she had not had any additional training for behavior management, nor had she been instructed with interventions for Resident #4's behavior. She said when she provided incontinent care to residents, there was no one watching the other residents when she was by herself. In an interview on 11/5/21 at 2:34 p.m. with Resident #4, he said people were at war repeatedly. He was not able to answer questions directly. When Resident #4 was asked a question, he repeated people were at war. Interview was in the hallway. Resident #4 was not in sight of CNA E. In an interview on 11/5/21 at 8:45 p.m. with CNA F, she said there were 15 residents in the memory care. She said she worked the 6 PM to 6 AM shift. She said all of the residents had some type of behaviors and that was why they were on the secured unit. She said Resident #4 had behaviors of aggression towards staff and residents. She said she had not been in-serviced on any specific interventions for Resident #4. She said she was not aware on any interventions to protect Resident #3 and Resident #4. She said she just tried to keep them separated. In an interview on 11/5/21 at 8:55 p.m. with CNA G, she said she worked the 6 PM to 6 AM shift. She said she was unaware of any interventions in place to protect Resident #3 from Resident #4. She said she tried to keep them separated. She said he was aware Resident #4 had aggressive behaviors, but was not sure how to handle the aggressive behaviors. In an interview on 11/9/21 at 9:55 a.m. with CNA H, she said she was a temporary employee, and this was her fifth day. She said she worked the day shift, 6 AM to 6 PM. She said there were 15 residents in the memory care unit. She said she was not aware of any resident with specialized supervision or interventions. She said she was informed Resident #4 had behaviors of physical aggression when he needed to be changed. She said she spoke Spanish to him and it generally calmed him down. She said she was not given any specific interventions for his aggression. On 11/4/21, she was changing another resident in the resident's room when she heard someone holler. She said she looked out of the resident's room and another resident said Resident #4 was hitting Resident #3. The incident was in the living room. She said no one had to separate the residents because Resident #4 walked away. She said she did not know the name of the other staff she worked with that day, but she left the unit to go get linens. She said the residents were left by unsupervised because the other staff left the unit, and she was in a resident's room providing incontinent care. In an interview on 11/9/21 at 10:00 a.m. with the Activities Director, she said she was a CNA and a certified medication technician. She was going through the training to be an activities director. She said the intervention was to remove the aggressor from the area the incident was taking place in and walk the aggressor down the hall to a different area to change the scene. She did not witness either incident between Resident #3 and Resident #4. In an interview on 11/30/21 at 5:25 p.m., CNA J said she was not able to see any residents while she was in the office. She did not know where the other staff were. She said she knew of the behaviors from Resident #4. She said Resident #4 had physical aggressive behaviors towards staff and other residents. She said she was not given any special instruction for Resident #4 and was not aware of special supervision for Resident #4. She said they watched the residents. In an interview on 11/30/21 at 5:30 p.m., CNA K said she knew of the physical aggressive behaviors of Resident #4. She said she could not see any residents while she was in a resident's room. She said she did not know if Resident #4 had any special supervision. She was not given any special instructions. In an interview on 11/30/21 at 1:17 p.m., the MDS Nurse said Resident #4's MDS, dated [DATE], should reflect the behavior on 10/1/21. She said the MDS, dated [DATE], should reflect the new diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said when a psychoactive medication was used for behaviors or diagnosis, the MDS should reflect the diagnosis, medication and behavior. She said the care plan and MDS should correlate. She said she was aware of Resident #4's behavior towards Resident #3. She said Resident #4 was at the psychiatric hospital for about 3 weeks starting 10/2/21. She said she did not change Resident #4's care plan to include any interventions or reflect his aggressive behavior. She said she did not know why she did not, but she should have updated the care plan. She said Resident #4's care plan and MDS needed a change in condition due to the added antipsychotic medication. She said she was the person responsible for implementing interventions. She said she was also responsible for completing the education and updating the staff on the interventions. She conducted in person in-services with the staff when a care plan is updated with new interventions. She said Resident #4's behaviors came on suddenly in October 2021. There were no indications these behaviors were going to start, and likewise, there were no indication the behaviors would stop. Resident #4 was not placed on special supervision. She said she did not update Resident #3's care plan after the incident because she said Resident #3 was not the aggressor. She confirmed that there was not any documentation or assessment completed for the emotional harm Resident #3 sustained or any monitoring of her condition after the incidents. She said to ensure the incidents did not occur again the facility used medications. She said she did not implement specific interventions. She did not complete any in-service with the staff. There were not specific staffing or supervision interventions implemented. In an interview on 11/12/21 at 10:20 a.m. with the Administrator, he said in the secured unit, memory care unit, there were 2 staff. He said the goal was for one of the staff to always keep an eye on Resident #4. He said at the time of the incident on 11/4, one of the staff left the unit to go get linen and only one staff was left on the unit. He said Resident #4 hit Resident #3. He said in October, the incident occurred, he believed there were 2 staff present. He said Resident #4 had a psychiatric evaluation and was not found to be a danger to himself or others. He said he remembered he had a conversation with Resident #3's representative party and she wanted to know what the facility did to prevent further incidents. He said the measures were to have 2 staff present. He said the intervention was one staff always kept an eye on Resident #4. He said on 11/5/21, he was aware there was only one staff present the entire day shift. He said there was a staffing issue for the facility. He said 2 staff were always scheduled for the unit, but sometimes there were call outs. He said he would go in the unit to supervise residents when there was a need. He said the unit was prioritized, but they did not have back up staff to call and fill the shift. He said they used agency staff when possible, but they do not always get what was needed for staffing. He said he wanted to believe the nurses would get on board as well to assist the unit. He said he completed an in-service on the existing policy. He said the policy did not specify 2 staff needed to be in the unit at all times, but he reminded staff during in-service to not leave the unit without a second staff present. He said the intervention was one staff always kept an eye on Resident #4. He said there was not any documentation of any in service with staff for this intervention. If Resident #4 hit another resident, staff were encouraged to talk to him and redirect the resident to follow the staff away from the resident he had targeted. He said Resident #4 started a psychiatric medication when he was re admitted on ,d+[DATE]. Resident #4 had another episode of aggressive behaviors shortly after on 11/4. There was not any specific intervention in place during the time of monitoring the effectiveness of the medication. Record review of the facility Staffing Requirements of the secured unit, dated 5/13/14, revealed the staffing requirements were determined by the DON. Regardless of the census, if the community required additional staff due to increase incidents/accidents the unit would be staffed to ensure resident safety. The secured unit should not be left unattended, a staff member was required to be present at all times. The policy did not specify the need for 2 staff to be present at all times. This was determined to be an Immediate Jeopardy (IJ) on 12/1/121 at 2:04 p.m. The Administrator and DON were notified. The Administrator was provided with the IJ template on 12/1/21 at 2:04 p.m. The following Plan of Removal was submitted by the Administrator and accepted on 12/2/2 at 5:52 p.m.: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on December 1, 2021, for failing to protect memory care residents by not providing adequate supervision or intervention to prevent abuse. The Director of nursing and Assistant Director of Nursing will audit all events for aggressive behaviors over 90 days that may have been harmed by December 2, 2021. Any residents identified with aggressive behavior will be offered additional services such as psychological services. The other resident involved in the aggressive incident will be assessed by the Social Worker for emotional distress and the need for additional services by December 2, 2021. 1. Action: To ensure awareness of other residents who may be exhibiting behaviors towards other residents all direct care staff, nursing management, IDT team, and administrator will be educated on POC documentation of behaviors, ensure CNA communication (To include walking rounds, and nurse to CNA instruction at the beginning of each shift to ensure expectations are met and to review implementation and follow through of care plans. This will be monitored through our daily clinical meeting and widgets identifiers. For any identified resident behavior(s) the interdisciplinary team will initiate an intervention care plan update, provide follow-up documentation to include the effectiveness of intervention change. Completion Timeline: December 1, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Training will be conducted by Regional Nurse Manager. Completed on 12/02/2021. Responsible: Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and IDT team. 2. Action: Administration conducted education with all direct care staff regarding: 1) Notification upon identification of resident behaviors; 2) One-to-one resident monitoring procedure in which a staff member will be assigned to a resident. (They are not to leave them and must be close enough to intercede in any instance where a behavior could cause harm to another resident, visitor, or staff member), and 3) Dealing with resident behavior to include behavior management and intervention and documenting resident behaviors in POC. Beginning December 1, 2021, direct care staff (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Director of Nursing will be responsible for conducting training. Completion Timeline: Beginning December 1, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Training will be completed 12/02/2021 Responsible: Administrator, Director of Nurses, ADON, CCM, Nurse Manager, Charge nurses 3. Action: Residents with aggressive behaviors will be placed on 1:1 monitoring until alternative placement is found or the resident is no longer a danger to other residents or staff as determined by the IDT team. Direct care staff will be educated on what 1:1 monitoring means. No staff will be assigned to provide 1:1 Monitoring until in-service regarding 1:1 monitoring has been done. As a reminder to the expectation 1:1 supervision tool will be placed in sign in book. Administrator will be responsible to ensure that adequate staffing numbers on the unit are always in place to provide adequate supervision including but not limited to when 1:1 monitoring is being provided. There will be at least two staff members on the secure unit at all times. In the event an employee needs to exit the unit, the employee must contact the charge nurse and wait for relief prior to leaving the unit for break and any other task. If a resident is placed on one on one, there will be three staff in the locked unit. Staff have been educated on communicating with each other when at the memory care unit. If one staff is providing care in a resident's room, the other staff will keep an eye on the residents who may be at the sitting room area. Staff are educated on communicating and taking turns with resident care. In other words, staff who is providing care with residents in their rooms can switch with the staff sitting with residents in the sitting room area. Staff have been in-serviced not to leave residents unattended to in the memory care unit. If a staff member were to leave the unit for break, fetch linens, or run any errands, they cannot leave the unit until they have been relieved. If a staff member were to leave the unit, they would have to reach out to the charge nurse to request for relief. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Completion date 12/02/21. Responsible: Administrator, DON, ADON, Charge nurses, Nurse manager 4. Action: Beginning on December 2, 2021, Residents identified of being affected by deficient practice will have a consult by social worker. If follow up is needed, with consent social services/nursing will request a referral to the psychological service provider. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). The social worker will be responsible for interviewing the resident after the occurrence of an aggressive behavior event. . Responsible: Administrator, DON, Social Worker 5. Action: Beginning on December 2, 2021, daily during morning clinical meeting, administrative staff will utilize the open events widget located in the resident electronic medical record to review incident reports for intervention care plan update and follow-up documentation to include effectiveness of intervention change. The IDT team will monitor changes to the care plan to ensure effectiveness and follow up. Event will remain open until intervention(s) are effective. Adhoc QAPI will be completed with Medical Director, Administrator and DON on December 1, 2021. The QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Next QAPI meeting will be held on December 3th, monthly thereafter, and PRN. Completion Timeline: Beginning December 2, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, Director of Nursing 6. Action: Unmanageable Residents will be managed according to policy. Woodland Manor will use the following management approach guidelines to support behavior issues in the facility. Psych evaluation: [The facility] will use psych support to provide help to residents identified with behavior issues. [The facility] will use 1:1 intervention as a means of providing support to residents identified with behavior issues. Music Therapy: [The facility] will adopt the use of calming music or a resident's favorite type of music as a tool to decrease agitation in a resident. Activities: Woodland Manor will use safe activities as a good way for the resident to get back in touch with their earlier life and find meaning throughout the disease process Socialization: [The facility] will promote more interaction with the residents as much as possible to help decrease agitation in residents with behavior issues. All staff and leadership educated on policies and procedures in identifying at risk residents. All staff in serviced on procedures on policy to promote safety of residents, staff, and visitors. Completion Timeline: December 2, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: RNM, Administrator, DON, and nurse manager 7. Action: Resident #1 Social Worker will begin working with family and resident for Alternate placement will be sought at one of our more appropriate sister facilities when and if behaviors are controlled and resident is no longer a danger to himself or others. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN.) Responsible: Administrator, DON, Social Worker Plan of Removal monitoring included the following: Record review was completed for Policies and Procedures which included Identifying Triggers, Identifying Behaviors, Communication between Staff, One to One Observation, Disruptive Behavior, and Not leaving Secure Unattended. Record review of Resident #4's chart included updated care plan and care plan meeting, dated 12/2/21, with RP to discuss behaviors of aggression and additional options for placement at sister facility closer to family. Record review of Resident #3's medical file included an assessment and observations of Resident #3's emotional status and well-being at 3 different times on 12/3/21. Resident #3 was not fearful. Observation and interview of the Resident #3 included resident was out of her room in the TV area. She was talkative to other residents. She stated she was good, happy, and fine. Observations of Resident #4 on different shift, 6 AM to 6 PM, and 6 PM to 6 AM, revealed the resident was on one to one supervision. Resident was not left unsupervised. The secured unit had 3 different staff available on the unit. Observation of 6 AM shift change and 6 PM shift change revealed staff could not enter the secured unit without seeing manager on duty, ADON, or DON to receive in-service training. Signs were posted on the front door, and the secure unit as well as at the screening station to notify all staff to see manager on duty before shift. Interviews with 10 CNA's included agency staff, and facility staff, and each shift, 6 AM to 6 PM and 6 PM to 6 AM, revealed each CNA was aware of Resident #4's aggressive behaviors. Each CNA was in-serviced on documenting any behavior in Resident #4's file. Each CNA was trained on Resident #4 receiving one to one supervision. The designated staff assigned to Resident #4 was not available to complete any other tasks related to the unit or other residents. Each CNA stated they were trained to wait for relief from another staff member before leaving the unit or leaving Resident #4's side. Interview on 12/3/21 at 12:53 pm., the Administrator said the facility reached out to the family of Resident #4 about a transfer to a facility closer to the family. The family agreed to the transfer. The facility reached out to a sister facility for transfer. The facilities will review Resident #4's file and determine which facility is a better fit for Resident #4. In the meantime, the facility would maintain one to one supervision for Resident #4. Interview on 12/4/21 at 6:13 p.m., DON B said the signs were placed at the entrance, screening station, and memory care door to ensure if a new agency staff came on board, they would receive the training of behaviors, staffing and one to one supervision before starting their shift. The Administrator and DON were informed the Immediate Jeopardy (IJ) was removed on 12/6/21 at 11:32 a.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 7 residents (Resident #3 and Resident #4) reviewed for accidents and supervision. The facility failed to provide adequate supervision to 15 residents in the memory care unit. As a result, Resident #3 was not protected from physical and emotional harm after Resident #4 physically assaulted Resident #3 on two different occasions causing her pain and being afraid to leave her room. An Immediate Jeopardy (IJ) situation was identified on 12/1/2021. While the IJ was removed on 12/6/21, the facility remained out of compliance at a scope of a pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of physical and emotional harm. Findings included: 1. Record review of Resident #3's face sheet revealed an [AGE] year-old female admitted to the facility on [DATE]. Resident #3 had diagnoses which included anxiety disorder (intense, excessive and persistent worry), Alzheimer's disease (memory loss), [CONDITION(S)] (brittle bones), and abnormalities of gait and mobility (unsteady balance while walking). Record review of Resident #3's Comprehensive MDS, dated [DATE], revealed the resident had a BIMS of 2, which indicated a severe cognitive deficit. Resident #3 did not exhibit behavioral symptoms. Resident required supervision and set up or 1 person physical assist for ADLs. Record review of Resident #3's Incident Report for event, dated 10/1/21 at 11:30 p.m., revealed the report was completed on 11/12/21 at 12:43 p.m. by LVN A. The report revealed Resident #3 was hit in her mouth by another resident. This incident occurred in the dining area. Resident #3 was not injured. Record review of Resident #3's Incident Report for event, dated 11/4/21 at 1:50 p.m., revealed the report was completed on 11/5/21 at 11:39 a.m. by RN A. The report revealed Resident #3 was struck in the back of her head by another resident with his hand. Resident #3 stated her scalp was tender. Resident #3 did not have any injury noted around her hair follicles. The incident occurred in the living room. Record review of Resident #3's care plan, dated 10/22/21, revealed Resident #3 resided on the secure unit due to elopement risk. Resident #3 was to be monitored to ensure safety and unit should be kept free of possible hazards. In an interview on 11/5/21 at 3:00 p.m. with Resident #3, she said she did not know who it was, but someone came up behind her and hit her in the head. Resident #3 was visibly upset, she was crying. She said she was afraid from being hit. She said she didn't know how staff intervened; she was crying. She said it happened before. She rubbed the back of her head and said it hurt. She said she didn't want to come out of her room because she didn't want to get hit again. In an interview on 11/5/21 at 3:00 p.m. with Resident #3's representative party, she said the facility contacted her in October because Resident #3 was hit in the face. She said she was contacted yesterday (11/4/21) because Resident #3 was hit in the back of the head 4 times. She said the facility reported no injuries both times. She rubbed the back of Resident #3's head and said, there were no bumps. She said Resident #3 said she was hurting. She said she spoke with the administrator today (11/5/21) about the 11/4/21 incident. The administrator could not tell her who the resident was who hit Resident #3, but did tell her both incidents involved the same resident. She said it was reported one of the staff left the unit to get linens yesterday when Resident #4 went up behind Resident #3 and hit her 4 times. She said the one staff on duty had to get help. She said she didn't know what staff were present. She said it was reported to her by the administrator, at the time of the first incident, there was only one staff present in the memory care. She said the administrator told her the plan of action was to always have 2 staff present in the memory care unit. She said she was disappointed and concerned when she came onto the unit and only saw one staff for the day. She said she had been concerned about the staffing. Many times there was only 1 staff in the unit. When there were 2 staff, they just sit in a chair by the door. 2. Record review of Resident #4's face sheet revealed a [AGE] year-old male was readmitted to the facility on [DATE] from local psychiatric hospital. Resident #4 had diagnoses which included dementia with behavioral disturbances (memory loss and symptoms of agitation, depression etc), restlessness and agitation (inner tension), peripheral vascular disease (poor circulation to extremities), [CONDITION(S)] and collapse ([CONDITION(S)]), and hypertension (high blood pressure). Record review of Resident #4's, undated, care plan revealed the resident had behavioral symptoms of wandering throughout the secure unit. Staff approach was to always ask for help if the resident became abusive/resistive, convey acceptance of resident during periods of inappropriate behavior, redirect as needed. Record review of Resident #4's Quarterly MDS, dated [DATE], revealed the resident was discharged to the hospital on 10/2/21. Resident #4 had a BIMS of 0, which indicated severe cognitive deficit. The MDS reveal ed there were zero behavioral symptoms towards others. Resident #4 required supervision with set up only for ADLs. Record review of the facility investigation, for incident dated 10/1/21 at 11:30 a.m., revealed the Administrator completed the investigation. Resident #4 had a history of physical aggression. There was one staff present at the time of the incident. The incident was described as, the staff was sitting in the living room with the residents watching television when Resident #4 got up and left the room. Staff followed Resident #4. Staff was a few feet away when Resident #4 hit Resident #3 in the face. Staff immediately separated the residents and notified the nurse. No injury was noted. Resident #4 hit Resident #3 without provocation. Resident #4 appeared agitated at the time of the investigation. As a result of the investigation, the Administrator sent Resident #4 to psychiatric hospital for evaluation. No additional actions taken. Record review of the Facility Investigation report, for incident dated 11/4/12 at 11:40 a.m., revealed the Administrator completed the investigation. Resident #4 had a history of aggression. There was one staff present at the time of the incident. The incident was described as, Resident #4 hit Resident #3 in the back of the head in the living room area. At the time of the incident, one of the two staff assigned to the unit had gone to get linens and the other staff was providing care to another resident. As a result of the investigation, the Administrator educated Resident #4 of the right other residents have not to be hit. Staff in-serviced on the need to communicate to ensure there was a staff with residents at the living room area at all times. Staff in-serviced on the policy of not leaving the secured unit unattended. Staff were not in-serviced on any interventions for Resident #4. The investigation report did not include any monitoring of Resident #3 for emotional or physical harm. Record review of Psychiatric Services, Initial Evaluation, dated 11/10/21, revealed Resident #4 was referred due to aggressive behaviors, anger, elopement, long-term and short term memory problems. Resident #4 was admitted to the nursing home from a local behavioral hospital. Resident #4 had a diagnosis of [CONDITION(S)]. Record review of Resident #4's Comprehensive MDS, dated [DATE], revealed Resident #4 did not have any behavioral symptoms towards others. The MDS did not reflect the new diagnosis of [CONDITION(S)]. The MDS reflected antipsychotic medication use. Observation on 11/5/21 at 2:00 p.m. revealed one staff present (CNA E) sitting in the entry way of the living room area in the memory care unit. Staff were not with Resident #4. There was not any other staff on the unit. Observation on 11/5/21 at 2:30 p.m. revealed one staff (CNA E) present on the memory care unit. Observation on 11/5/21 at 3:00 p.m. revealed one staff (CAN E) present on the memory care unit. Observation on 11/9/21 at 10:00 a.m. revealed the Activities Director was one of the 2 staff in the memory care unit. CNA H was the other staff on duty in the unit. Observation on 11/30/21 at 5:25 p.m. revealed 2 staff present in the memory care unit, one staff (CNA J) was in the office on the unit. The second staff (CNA K) was exiting a room down the hall. Resident #4 and Resident #3 were observed in the TV room with 8 other residents, unsupervised. Residents were not visible to either CNA. In an interview on 11/5/2021 at 2:20 p.m. with CNA E, she said there were 15 residents in the memory care unit. She said she worked the 6 AM to 6 PM shift. She said she was the only aide in the memory care unit today (11/5/21). She said the assigned nurse comes and goes. She said most of the residents had some type of behaviors. She said she worked yesterday, 11/4/21, at the time of the incident between Resident #3 and Resident #4. She was at the linen closet off the unit when the incident occurred. There was an aide present who was in training, but she could not remember her name. The new aide reported Resident #3 was hit by Resident #4. She said Resident #4 had aggressive behaviors and fought during incontinent care. She said it took 2 people to change him. He was care planned for one person assist in toileting. She said she was able to change him by herself earlier because he didn't fight, but that was not always the case. She said there was not another staff to relieve her to take a lunch, she would go into the office on the memory care unit to eat something. She cannot see the residents in the office while she ate. She said she tried to keep Resident #4 away from Resident #3. She said she had not had any additional training for behavior management, nor had she been instructed with interventions for Resident #4's behavior. She said when she provided incontinent care to residents, there was no one watching the other residents when she was by herself. In an interview on 11/5/21 at 2:34 p.m. with Resident #4, he said people were at war repeatedly. He was not able to answer questions directly. When Resident #4 was asked a question, he repeated people were at war. Interview was in the hallway. Resident #4 was not in sight of CNA E. In an interview on 11/5/21 at 8:45 p.m. with CNA F, she said there were 15 residents in the memory care. She said she worked the 6 PM to 6 AM shift. She said all of the residents had some type of behaviors and that was why they were on the secured unit. She said Resident #4 had behaviors of aggression towards staff and residents. She said she had not been in-serviced on any specific interventions for Resident #4. She said she was not aware on any interventions to protect Resident #3 and Resident #4. She said she just tried to keep them separated. In an interview on 11/5/21 at 8:55 p.m. with CNA G, she said she worked the 6 PM to 6 AM shift. She said she was unaware of any interventions in place to protect Resident #3 from Resident #4. She said she tried to keep them separated. She said he was aware Resident #4 had aggressive behaviors, but was not sure how to handle the aggressive behaviors. In an interview on 11/9/21 at 9:55 a.m. with CNA H, she said she was a temporary employee, and this was her fifth day. She said she worked the day shift, 6 AM to 6 PM. She said there were 15 residents in the memory care unit. She said she was not aware of any resident with specialized supervision or interventions. She said she was informed Resident #4 had behaviors of physical aggression when he needed to be changed. She said she spoke Spanish to him and it generally calmed him down. She said she was not given any specific interventions for his aggression. On 11/4/21, she was changing another resident in the resident's room when she heard someone holler. She said she looked out of the resident's room and another resident said Resident #4 was hitting Resident #3. The incident was in the living room. She said no one had to separate the residents because Resident #4 walked away. She said she did not know the name of the other staff she worked with that day, but she left the unit to go get linens. She said the residents were left by unsupervised because the other staff left the unit, and she was in a resident's room providing incontinent care. In an interview on 11/9/21 at 10:00 a.m. with the Activities Director, she said she was a CNA and a certified medication technician. She was going through the training to be an activities director. She said the intervention was to remove the aggressor from the area the incident was taking place in and walk the aggressor down the hall to a different area to change the scene. She did not witness either incident between Resident #3 and Resident #4. In an interview on 11/30/21 at 5:25 p.m., CNA J said she was not able to see any residents while she was in the office. She did not know where the other staff were. She said she knew of the behaviors from Resident #4. She said Resident #4 had physical aggressive behaviors towards staff and other residents. She said she was not given any special instruction for Resident #4 and was not aware of special supervision for Resident #4. She said they watched the residents. In an interview on 11/30/21 at 5:30 p.m., CNA K said she knew of the physical aggressive behaviors of Resident #4. She said she could not see any residents while she was in a resident's room. She said she did not know if Resident #4 had any special supervision. She was not given any special instructions. In an interview on 11/30/21 at 1:17 p.m., the MDS Nurse said Resident #4's MDS, dated [DATE], should reflect the behavior on 10/1/21. She said the MDS, dated [DATE], should reflect the new diagnosis of [CONDITION(S)] and the behaviors exhibited on the unit. She said when a psychoactive medication was used for behaviors or diagnosis, the MDS should reflect the diagnosis, medication and behavior. She said the care plan and MDS should correlate. She said she was aware of Resident #4's behavior towards Resident #3. She said Resident #4 was at the psychiatric hospital for about 3 weeks starting 10/2/21. She said she did not change Resident #4's care plan to include any interventions or reflect his aggressive behavior. She said she did not know why she did not, but she should have updated the care plan. She said Resident #4's care plan and MDS needed a change in condition due to the added antipsychotic medication. She said she was the person responsible for implementing interventions. She said she was also responsible for completing the education and updating the staff on the interventions. She conducted in person in-services with the staff when a care plan is updated with new interventions. She said Resident #4's behaviors came on suddenly in October 2021. There were no indications these behaviors were going to start, and likewise, there were no indication the behaviors would stop. Resident #4 was not placed on special supervision. She said she did not update Resident #3's care plan after the incident because she said Resident #3 was not the aggressor. She confirmed that there was not any documentation or assessment completed for the emotional harm Resident #3 sustained or any monitoring of her condition after the incidents. She said to ensure the incidents did not occur again the facility used medications. She said she did not implement specific interventions. She did not complete any in-service with the staff. There were not specific staffing or supervision interventions implemented. In an interview on 11/12/21 at 10:20 a.m. with the Administrator, he said in the secured unit, memory care unit, there were 2 staff. He said the goal was for one of the staff to always keep an eye on Resident #4. He said at the time of the incident on 11/4, one of the staff left the unit to go get linen and only one staff was left on the unit. He said Resident #4 hit Resident #3. He said in October, the incident occurred, he believed there were 2 staff present. He said Resident #4 had a psychiatric evaluation and was not found to be a danger to himself or others. He said he remembered he had a conversation with Resident #3's representative party and she wanted to know what the facility did to prevent further incidents. He said the measures were to have 2 staff present. He said the intervention was one staff always kept an eye on Resident #4. He said on 11/5/21, he was aware there was only one staff present the entire day shift. He said there was a staffing issue for the facility. He said 2 staff were always scheduled for the unit, but sometimes there were call outs. He said he would go in the unit to supervise residents when there was a need. He said the unit was prioritized, but they did not have back up staff to call and fill the shift. He said they used agency staff when possible, but they do not always get what was needed for staffing. He said he wanted to believe the nurses would get on board as well to assist the unit. He said he completed an in-service on the existing policy. He said the policy did not specify 2 staff needed to be in the unit at all times, but he reminded staff during in-service to not leave the unit without a second staff present. He said the intervention was one staff always kept an eye on Resident #4. He said there was not any documentation of any in service with staff for this intervention. If Resident #4 hit another resident, staff were encouraged to talk to him and redirect the resident to follow the staff away from the resident he had targeted. He said Resident #4 started a psychiatric medication when he was re admitted on ,d+[DATE]. Resident #4 had another episode of aggressive behaviors shortly after on 11/4. There was not any specific intervention in place during the time of monitoring the effectiveness of the medication. Record review of the facility Staffing Requirements of the secured unit, dated 5/13/14, revealed the staffing requirements were determined by the DON. Regardless of the census, if the community required additional staff due to increase incidents/accidents the unit would be staffed to ensure resident safety. The secured unit should not be left unattended, a staff member was required to be present at all times. The policy did not specify the need for 2 staff to be present at all times. This was determined to be an Immediate Jeopardy (IJ) on 12/1/121 at 2:04 p.m. The Administrator and DON were notified. The Administrator was provided with the IJ template on 12/1/21 at 2:04 p.m. The following Plan of Removal was submitted by the Administrator and accepted on 12/2/2 at 5:52 p.m.: Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on December 1, 2021, for failing to protect memory care residents by not providing adequate supervision or intervention to prevent abuse. The Director of nursing and Assistant Director of Nursing will audit all events for aggressive behaviors over 90 days that may have been harmed by December 2, 2021. Any residents identified with aggressive behavior will be offered additional services such as psychological services. The other resident involved in the aggressive incident will be assessed by the Social Worker for emotional distress and the need for additional services by December 2, 2021. 1. Action: To ensure awareness of other residents who may be exhibiting behaviors towards other residents all direct care staff, nursing management, IDT team, and administrator will be educated on POC documentation of behaviors, ensure CNA communication (To include walking rounds, and nurse to CNA instruction at the beginning of each shift to ensure expectations are met and to review implementation and follow through of care plans. This will be monitored through our daily clinical meeting and widgets identifiers. For any identified resident behavior(s) the interdisciplinary team will initiate an intervention care plan update, provide follow-up documentation to include the effectiveness of intervention change. Completion Timeline: December 1, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Training will be conducted by Regional Nurse Manager. Completed on 12/02/2021. Responsible: Administrator, Director of Nursing, Social Services, Assistant Director of Nursing, and IDT team. 2. Action: Administration conducted education with all direct care staff regarding: 1) Notification upon identification of resident behaviors; 2) One-to-one resident monitoring procedure in which a staff member will be assigned to a resident. (They are not to leave them and must be close enough to intercede in any instance where a behavior could cause harm to another resident, visitor, or staff member), and 3) Dealing with resident behavior to include behavior management and intervention and documenting resident behaviors in POC. Beginning December 1, 2021, direct care staff (agency, PRN, new hires) who have not received the above stated education will be educated by Nursing Administration prior to providing resident direct care. Director of Nursing will be responsible for conducting training. Completion Timeline: Beginning December 1, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Training will be completed 12/02/2021 Responsible: Administrator, Director of Nurses, ADON, CCM, Nurse Manager, Charge nurses 3. Action: Residents with aggressive behaviors will be placed on 1:1 monitoring until alternative placement is found or the resident is no longer a danger to other residents or staff as determined by the IDT team. Direct care staff will be educated on what 1:1 monitoring means. No staff will be assigned to provide 1:1 Monitoring until in-service regarding 1:1 monitoring has been done. As a reminder to the expectation 1:1 supervision tool will be placed in sign in book. Administrator will be responsible to ensure that adequate staffing numbers on the unit are always in place to provide adequate supervision including but not limited to when 1:1 monitoring is being provided. There will be at least two staff members on the secure unit at all times. In the event an employee needs to exit the unit, the employee must contact the charge nurse and wait for relief prior to leaving the unit for break and any other task. If a resident is placed on one on one, there will be three staff in the locked unit. Staff have been educated on communicating with each other when at the memory care unit. If one staff is providing care in a resident's room, the other staff will keep an eye on the residents who may be at the sitting room area. Staff are educated on communicating and taking turns with resident care. In other words, staff who is providing care with residents in their rooms can switch with the staff sitting with residents in the sitting room area. Staff have been in-serviced not to leave residents unattended to in the memory care unit. If a staff member were to leave the unit for break, fetch linens, or run any errands, they cannot leave the unit until they have been relieved. If a staff member were to leave the unit, they would have to reach out to the charge nurse to request for relief. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). Completion date 12/02/21. Responsible: Administrator, DON, ADON, Charge nurses, Nurse manager 4. Action: Beginning on December 2, 2021, Residents identified of being affected by deficient practice will have a consult by social worker. If follow up is needed, with consent social services/nursing will request a referral to the psychological service provider. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN). The social worker will be responsible for interviewing the resident after the occurrence of an aggressive behavior event. . Responsible: Administrator, DON, Social Worker 5. Action: Beginning on December 2, 2021, daily during morning clinical meeting, administrative staff will utilize the open events widget located in the resident electronic medical record to review incident reports for intervention care plan update and follow-up documentation to include effectiveness of intervention change. The IDT team will monitor changes to the care plan to ensure effectiveness and follow up. Event will remain open until intervention(s) are effective. Adhoc QAPI will be completed with Medical Director, Administrator and DON on December 1, 2021. The QAPI Committee will be notified of identified non-compliance. QAPI Committee will develop a Performance Improvement Plan to address identified non-compliance to include staff education and/or disciplinary action. Next QAPI meeting will be held on December 3th, monthly thereafter, and PRN. Completion Timeline: Beginning December 2, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: Administrator, Director of Nursing 6. Action: Unmanageable Residents will be managed according to policy. Woodland Manor will use the following management approach guidelines to support behavior issues in the facility. Psych evaluation: [The facility] will use psych support to provide help to residents identified with behavior issues. [The facility] will use 1:1 intervention as a means of providing support to residents identified with behavior issues. Music Therapy: [The facility] will adopt the use of calming music or a resident's favorite type of music as a tool to decrease agitation in a resident. Activities: Woodland Manor will use safe activities as a good way for the resident to get back in touch with their earlier life and find meaning throughout the disease process Socialization: [The facility] will promote more interaction with the residents as much as possible to help decrease agitation in residents with behavior issues. All staff and leadership educated on policies and procedures in identifying at risk residents. All staff in serviced on procedures on policy to promote safety of residents, staff, and visitors. Completion Timeline: December 2, 2021, and going forward to include staff not working at time of in-service (FT, PT, agency, PRN) Responsible: RNM, Administrator, DON, and nurse manager 7. Action: Resident #1 Social Worker will begin working with family and resident for Alternate placement will be sought at one of our more appropriate sister facilities when and if behaviors are controlled and resident is no longer a danger to himself or others. Completion Timeline: December 2, 2021 and going forward to include staff not working at time of in-service (FT, PT, agency, PRN.) Responsible: Administrator, DON, Social Worker Plan of Removal monitoring included the following: Record review was completed for Policies and Procedures which included Identifying Triggers, Identifying Behaviors, Communication between Staff, One to One Observation, Disruptive Behavior, and Not leaving Secure Unattended. Record review of Resident #4's chart included updated care plan and care plan meeting, dated 12/2/21, with RP to discuss behaviors of aggression and additional options for placement at sister facility closer to family. Record review of Resident #3's medical file included an assessment and observations of Resident #3's emotional status and well-being at 3 different times on 12/3/21. Resident #3 was not fearful. Observation and interview of the Resident #3 included resident was out of her room in the TV area. She was talkative to other residents. She stated she was good, happy, and fine. Observations of Resident #4 on different shift, 6 AM to 6 PM, and 6 PM to 6 AM, revealed the resident was on one to one supervision. Resident was not left unsupervised. The secured unit had 3 different staff available on the unit. Observation of 6 AM shift change and 6 PM shift change revealed staff could not enter the secured unit without seeing manager on duty, ADON, or DON to receive in-service training. Signs were posted on the front door, and the secure unit as well as at the screening station to notify all staff to see manager on duty before shift. Interviews with 10 CNA's included agency staff, and facility staff, and each shift, 6 AM to 6 PM and 6 PM to 6 AM, revealed each CNA was aware of Resident #4's aggressive behaviors. Each CNA was in-serviced on documenting any behavior in Resident #4's file. Each CNA was trained on Resident #4 receiving one to one supervision. The designated staff assigned to Resident #4 was not available to complete any other tasks related to the unit or other residents. Each CNA stated they were trained to wait for relief from another staff member before leaving the unit or leaving Resident #4's side. Interview on 12/3/21 at 12:53 pm., the Administrator said the facility reached out to the family of Resident #4 about a transfer to a facility closer to the family. The family agreed to the transfer. The facility reached out to a sister facility for transfer. The facilities will review Resident #4's file and determine which facility is a better fit for Resident #4. In the meantime, the facility would maintain one to one supervision for Resident #4. Interview on 12/4/21 at 6:13 p.m., DON B said the signs were placed at the entrance, screening station, and memory care door to ensure if a new agency staff came on board, they would receive the training of behaviors, staffing and one to one supervision before starting their shift. The Administrator and DON were informed the Immediate Jeopardy (IJ) was removed on 12/6/21 at 11:32 a.m. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to offere a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 of 5 residents reviewed for care plans (Resident #1). The facility failed to implement physician ordered diet instructions for Resident #1's after a modified [MEDICATION NAME] swallow study revealed she had weakness of the tongue and muscles of mastication (chewing). She chocked at the facility and was admitted to the intensive care unit with acute [MEDICAL CONDITION] with cardiopulmonary arrest. The failure could affect any residents who required special or therapeutic diets. Findings Include: Resident #1 Record review of Resident #1's medical record revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly (Minimum Data Set) MDS assessment dated [DATE] revealed her (Brief Interview of Mental Status) BI[CONDITION] scored 6 out of 15, indicating severe cognitive impairment. She required supervision with eating and set up of meals. She had the active [DIAGNOSES REDACTED]. She had signs and symptoms of possible swallowing disorder with the box checked for coughing or choking during meals or when swallowing medications. Record review of Resident #1's comprehensive care plan dated [DATE] revealed in part. Resident #1 was on a regular diet with the following approaches: 1) Serve diet as ordered and offer substitute if less than 50% is eaten, monitor intake. 2) Food Service Supervisor to monitor and discuss food preferences. 3) Offer snacks within diet. 4) Weigh (every month/as needed) every mo./as needed and reports 5% loss or gain to the doctor and Resident Representative 5) Encourage dietary/fluid intake within dietary limits. Further review of Resident #1's comprehensive care plan revealed it was not updated to reflect the physician's orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had the active [DIAGNOSES REDACTED]. This assessment did not indicate that Resident #1 was holding food in her mouth .; or coughing or choking during meals . She was not on a mechanically altered diet. Record review of Resident #1's physician progress notes [REDACTED]. MBSS (modified [MEDICATION NAME] swallow study) revealed weakness of the tongue and muscles of mastication (chewing). Pain (Gastrointestinal) GI specialist been no surgeries or medications can improve her muscle strength .The physician also recommended sips of water to help food bolus pass. Record review of Resident #1's nurses' notes dated [DATE] revealed Resident 31 was in the dining room when she stood up raising and waving her hands; and pointing to her throat. She was unable to speak. Three thrusts were given during the [MEDICATION NAME] maneuver and a small amount of chewed food was expelled. Resident #1 was breathing, but hyperventilating. She was assisted to Hall B and given oxygen. She was sitting on her walker seat when she fell forward. The nurse caught her and placed her on the floor. There were no respirations or pulse and facility staff initiated cardiopulmonary resuscitation. Emergency Medical Services (E[CONDITION]-911) was called at 1:02 p.m. After 2 minutes of chest compressions, Resident #1 was breathing and had a pulse at 1:05 p.m. The NP was at the facility and the family was notified. Resident #1 left the facility at 1:25 p.m. Record review of Resident #1's medical records from hospital revealed she was admitted to the hospital on [DATE] with the following notes in part . Presented to the (Emergency Department) ED with suspected foreign body in airway that occurred suddenly this afternoon. Per (Emergency Medical Service) E[CONDITION], (patient) pt was eating pork chops at home when she started choking. (Cardiopulmonary Resuscitation) CPR was initiated from bystanders for 7 minutes . Resident #1 was intubated in the ED and transferred to the (Intensive Care Unit) ICU. [MEDICAL CONDITION] placed on [DATE]. Imaging in the ER .did not show evidence of foreign body. The admitting [DIAGNOSES REDACTED]. In an observation and interview on [DATE] at 10:00 a.m., at the local hospital, revealed Resident #1 was in a hospital bed, awake, alert. She had a [MEDICAL CONDITION] and was receiving oxygen via mask positioned over the [MEDICAL CONDITION]. She was able to talk in whispers but mostly gestured using her head. She indicated not remembering what she choked on. She indicated she was aware of the [MEDICAL CONDITION]. She said she did not know how to call the nurse here. There was a call button/bed control laying next to her. In an interview on [DATE] at 10:00 a.m., the hospital nurse said she was told Resident #1 had choked on something at the nursing home where she coded. Resident #1 was brought to the hospital emergency room and was admitted to the intensive care unit. She was extubated on [DATE] and was left with a [MEDICAL CONDITION]. She said Resident #1 was being evaluated by cardiology to determine the reasons for the [MEDICAL CONDITION]. She said she was swallowing ice chips and would have a swallow test. The hospital nurse said she believed Resident #1 would most likely recover fully. In an interview on [DATE] at 10:00 a.m., LVN G said during meals in the dining room, there were usually two restorative aides, two other aides and herself. She said she did not remember what Resident #1 was eating. She said Resident #1 was already having respiratory issues that day and she had received nebulizer treatment. When presented with Resident #1's special diet instructions, LVN G said she did not know about the instructions. In a telephone interview on [DATE] at 10:30 a.m., NP said Resident #1 had some dysphasia and they did swallow study. Resident #1 saw a GI doctor who said there was a pocket or something like that. The plan was mechanical soft diet; the resident declined to follow the diet plan; and family member was made aware. She said this regular diet with thin liquids was the best we could offer. She said she expected the nurses to make sure Resident #1 swallowed with sips of fluid in between bites. They were also to cue Resident #1 and encourage her swallow so the food can go down well. She said she had a choking episode in 2017 or maybe 2016 and that she has a history of [MEDICAL CONDITION]. In a telephone interview on [DATE] at 12:15 p.m., the Regional Nurse said she was the MDS nurse before leaving the position in [DATE]. She said The last annual care plan was [DATE] and I have no excuse, I didn't tag it. The resident was in and out of the hospital and I didn't catch the order. I haven't seen that order before and it should have been in the care plan. In an interview on [DATE] at 4:00 p.m., the DON said she expected nurses to check and follow the physician orders.

Based on observation, interview and record review, the facility failed to develop and implement comprehensive care plans that included measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents reviewed for care plans (Resident #1). The facility failed to update Resident #1's care plan after a modified [MEDICATION NAME] swallow study revealed she had weakness of the tongue and muscles of mastication (chewing). She chocked at the facility and was admitted to the intensive care unit with acute [MEDICAL CONDITION] with cardiopulmonary arrest. The facility failed to update Resident #1's care plan with the physician ordered special diet instructions. The failure could affect any residents who required special or therapeutic diets. Findings Include: Resident #1 Record review of Resident #1's medical record revealed a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's quarterly (Minimum Data Set) MDS assessment dated [DATE] revealed her (Brief Interview of Mental Status) BI[CONDITION] scored 6 out of 15, indicating severe cognitive impairment. She required supervision with eating and set up of meals. She had the active [DIAGNOSES REDACTED]. She had signs and symptoms of possible swallowing disorder with the box checked for coughing or choking during meals or when swallowing medications. Record review of Resident #1's comprehensive care plan dated [DATE] revealed in part. Resident #1 was on a regular diet with the following approaches: 1) Serve diet as ordered and offer substitute if less than 50% is eaten, monitor intake. 2) Food Service Supervisor to monitor and discuss food preferences. 3) Offer snacks within diet. 4) Weigh (every month/as needed) every mo./as needed and reports 5% loss or gain to the doctor and Resident Representative 5) Encourage dietary/fluid intake within dietary limits. Further review of Resident #1's comprehensive care plan revealed it was not updated to reflect the physician's orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had the active [DIAGNOSES REDACTED]. This assessment did not indicate that Resident #1 was holding food in her mouth .; or coughing or choking during meals . She was not on a mechanically altered diet. Record review of Resident #1's physician progress notes [REDACTED]. MBSS (modified [MEDICATION NAME] swallow study) revealed weakness of the tongue and muscles of mastication (chewing). Pain (Gastrointestinal) GI specialist been no surgeries or medications can improve her muscle strength .The physician also recommended sips of water to help food bolus pass. Record review of Resident #1's nurses' notes dated [DATE] revealed Resident 31 was in the dining room when she stood up raising and waving her hands; and pointing to her throat. She was unable to speak. Three thrusts were given during the [MEDICATION NAME] maneuver and a small amount of chewed food was expelled. Resident #1 was breathing, but hyperventilating. She was assisted to Hall B and given oxygen. She was sitting on her walker seat when she fell forward. The nurse caught her and placed her on the floor. There were no respirations or pulse and facility staff initiated cardiopulmonary resuscitation. Emergency Medical Services (E[CONDITION]-911) was called at 1:02 p.m. After 2 minutes of chest compressions, Resident #1 was breathing and had a pulse at 1:05 p.m. The NP was at the facility and the family was notified. Resident #1 left the facility at 1:25 p.m. Record review of Resident #1's medical records from hospital revealed she was admitted to the hospital on [DATE] with the following notes in part . Presented to the (Emergency Department) ED with suspected foreign body in airway that occurred suddenly this afternoon. Per (Emergency Medical Service) E[CONDITION], (patient) pt was eating pork chops at home when she started choking. (Cardiopulmonary Resuscitation) CPR was initiated from bystanders for 7 minutes . Resident #1 was intubated in the ED and transferred to the (Intensive Care Unit) ICU. [MEDICAL CONDITION] placed on [DATE]. Imaging in the ER .did not show evidence of foreign body. The admitting [DIAGNOSES REDACTED]. In an observation and interview on [DATE] at 10:00 a.m., at the local hospital, revealed Resident #1 was in a hospital bed, awake, alert. She had a [MEDICAL CONDITION] and was receiving oxygen via mask positioned over the [MEDICAL CONDITION]. She was able to talk in whispers but mostly gestured using her head. She indicated not remembering what she choked on. She indicated she was aware of the [MEDICAL CONDITION]. She said she did not know how to call the nurse here. There was a call button/bed control laying next to her. In an interview on [DATE] at 10:00 a.m., the hospital nurse said she was told Resident #1 had choked on something at the nursing home where she coded. Resident #1 was brought to the hospital emergency room and was admitted to the intensive care unit. She was extubated on [DATE] and was left with a [MEDICAL CONDITION]. She said Resident #1 was being evaluated by cardiology to determine the reasons for the [MEDICAL CONDITION]. She said she was swallowing ice chips and would have a swallow test. The hospital nurse said she believed Resident #1 would most likely recover fully. In an interview on [DATE] at 10:00 a.m., LVN G said during meals in the dining room, there were usually two restorative aides, two other aides and herself. She said she did not remember what Resident #1 was eating. She said Resident #1 was already having respiratory issues that day and she had received nebulizer treatment. When presented with Resident #1's special diet instructions, LVN G said she did not know about the instructions. In a telephone interview on [DATE] at 10:30 a.m., NP said Resident #1 had some dysphasia and they did swallow study. Resident #1 saw a GI doctor who said there was a pocket or something like that. The plan was mechanical soft diet; the resident declined to follow the diet plan; and family member was made aware. She said this regular diet with thin liquids was the best we could offer. She said she expected the nurses to make sure Resident #1 swallowed with sips of fluid in between bites. They were also to cue Resident #1 and encourage her swallow so the food can go down well. She said she had a choking episode in 2017 or maybe 2016 and that she has a history of [MEDICAL CONDITION]. In a telephone interview on [DATE] at 12:15 p.m., the Regional Nurse said she was the MDS nurse before leaving the position in [DATE]. She said The last annual care plan was [DATE] and I have no excuse, I didn't tag it. The resident was in and out of the hospital and I didn't catch the order. I haven't seen that order before and it should have been in the care plan. In an interview on [DATE] at 4:00 p.m., the DON said she expected nurses to check and follow the physician orders.

Based on observation, interview, and record review, the facility failed to develop and implement their policy that prohibited neglect for 10 of 11 residents (Residents #7, #6, #9, #10, #1, #2, #3, #5, #8, and #11) reviewed for neglect. The facility neglected to monitor staff training, ensuring staff followed infection control procedures to protect residents from becoming exposed to norovirus. On 2/12/2016, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/16/2016, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 45 residents, one requiring hospitalization and six who suffered with symptoms of nausea, vomiting and diarrhea twice, and 17 staff members and placed the other 27 residents who resided at the facility at risk of developing norovirus with the potential for complications and hospitalization . Findings included: Incident # 9 Resident #7 Record review of Resident #7 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #7 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required extensive assistance of one person for dressing, toileting and bathing, and required total assistance of one person for personal hygiene. Record review of Resident #7 ' s Nurse Notes revealed the following: - 1/31/2016 at 6:00 am: Resident had an episode of diarrhea (sic) this AM very loose and watery . - 1/31/2016 at 1:30pm: Resident in dining room eating small (amount) of lunch and started having projectile vomiting while in dining room. Record review of a Patient Transfer Form dated 1/31/2016 revealed Resident #7 was transferred to the hospital for diarrhea frequent, projectile vomiting. Record review of an Admission/Readmission Data Summary dated 2/2/2016 revealed Resident #7 returned to the facility. Record review of Resident #7 ' s Hospital Records dated 2/1/2016 revealed she was admitted to the hospital for nausea, vomiting, diarrhea and fever. The patient developed fever after has been admitted and we have not seen any more bouts of vomiting at this moment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #7 had symptoms of infection including nausea and vomiting that started on 1/31/2016 and ended on 2/3/2016, and was sent to the hospital on [DATE]. It further revealed on 2/10/2016, she became symptomatic a second time with diarrhea. Record review of a physician's order [REDACTED].#7 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #6 Record review of Resident #6 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #6 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of one person for toileting and bathing, and required extensive assistance of one person for dressing and personal hygiene. Record review of a Nurse Note dated 2/11/2016 revealed that Resident #6 had two episodes of diarrhea. Record review of a physician's order [REDACTED].#6 was prescribed Gatorade 240mL by mouth four times for one day for dehydration related to nausea or vomiting. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #6 had symptoms of infection including diarrhea, nausea and vomiting that started on 1/30/2016 and ended on 2/2/2016. It further revealed on 2/11/2016, she became symptomatic a second time with diarrhea that lasted 24 hours. Record review of a physician's order [REDACTED].#6 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #9 Record review of Resident #9 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #9 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder, required total assistance of one person for dressing, toileting, personal hygiene and bathing and required supervision for eating. Record review of Resident #9 ' s Nurse Notes revealed the following: - 1/31/2016 at 2:10am: Noted (with) episode of loose stool and emesis x1 . - 1/31/2016 at 5:30pm: Reported that resident has had multiple episodes of loose stool this AM. [MEDICATION NAME] 2mg 1 x dose given around 11AM. No recent reports of loose stool . - 2/10/2016 at 12:00pm: Resident having s/sx Diarrhea noted to be ' like water. ' - 2/11/2016 at 11:30am: Diarrhea noted today . - (After IJ was called) 2/14/2016 (no time documented): Resident on isolation (due to) emesis . Resident non-complaint (sic) to room. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg for diarrhea. There was no order in his medical record for isolation precautions. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #9 had symptoms of infection including diarrhea, fever, nausea and vomiting that started on 1/31/2016 and ended on 2/1/2016. It further revealed on 2/10/2016, he became symptomatic a second time with diarrhea, nausea and vomiting. In an observation on 2/11/2016 at 12:30 pm in the secure unit (500 hall), Resident #9 was sitting in the dining room eating his meal across from a resident who did not have signs or symptoms of the norovirus. In an observation and interview on 2/15/2016 at 11:05 pm, Resident #9 had personal protective equipment outside of his room, and there was a sign on his door that read Please see nurse before entering. Resident #9 exited his room and began walking around the secure unit. CNA D said it was difficult to keep Resident #9 in his room because he liked to wander. CNA D adn the SW at that time were observed to see Resident #9 in the unit and no one tried to redirect him back to his room. In an observation on 2/15/2016 at 12:38 pm, Resident #9 was sitting at a dining room table with Residents #17 and 25, who were not on contact precautions. He was eating lunch when he began coughing and drooling. LVN E had a towel in his hand and was wiping Resident #9 ' s mouth then placing the towel on the uncovered table. LVN E was not wearing any type of personal protective equipment. There were noticeable marks of a clear mucous substance on the table where the towel was placed. The SLP arrived with a new bowl of food. When the food was placed in his mouth, he vomited a clear substance. The SLP caught the emesis in a meal tray cover and took it away from the room. No one cleaned or disinfected the dining room table, and Residents #17 and 25 continued to eat at the table. In an interview on 2/15/2016 at 12:40 pm, LVN E said he did not believe residents with norovirus should be placed on isolation precautions. He said he had never isolated a resident with norovirus before. He said because Resident #9 was on contact precautions, he should not have been in the dining room. In an interview on 2/15/2016 at 1:30 pm, ADON said Resident #9 had [MEDICAL CONDITION] issues and said he choked on his food in the dining room which caused him to have an emesis. She said his last norovirus symptoms occurred on 2/10/2016, but he was placed on contact precautions because he had an emesis on 2/13/2016. She further stated LVN E was inserviced on the norovirus and contact precautions at 11:30 am that morning. She said she would talk to him again. Resident #10 Record review of Resident #10 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #10 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required total assistance of one person for toileting, bathing, and personal hygiene. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #10 had symptoms of infection including diarrhea and nausea that started on 2/7/2016 that lasted 24 hours. It further revealed on 2/13/2016, he became symptomatic a second time with diarrhea, headache, nausea and vomiting. Record review of a physician's order [REDACTED].#10 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED]. Resident #1 Record review of Resident #1 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and frequently incontinent of bladder, and required limited assistance of one person for toileting, personal hygiene, bathing, and dressing. Record review of a nurse note dated 2/4/2016 revealed Resident #1 had two episodes of diarrhea and complained of nausea. Record review of a nurse note dated 2/9/2016 revealed Resident #1 no longer had symptoms of diarrhea or nausea. Record review of a physician's order [REDACTED].#1 ' s vital signs every shift, and to hydrate every two hours as tolerated. There was no order in her medical record for isolation precautions. In an observation on 2/11/2016 at 10:15 am, RA A was in room [ROOM NUMBER] talking with Resident #1, who was sitting in her bed. There was a sign Resident #1 ' s door that read Please see nurse before entering. RA A's hands were on her wheelchair handles, and his clothing was brushing up against the back of the chair. RA A was not wearing any personal protective equipment, including gloves or a gown. When he exited the room, he did not wash his hands. Resident #2 Record review of Resident #2 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2 ' s significant change MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of two people for toileting, and required total assistance of one person for personal hygiene, dressing, eating, and bathing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #2 had symptoms of infection including diarrhea that started on 2/10/2016. Record review of a physician's order [REDACTED].#2 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #3 Record review of Resident #3 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3 ' s annual MDS assessment dated [DATE] revealed she was occasionally incontinent of bowel and bladder and required limited assistance of one person for toileting, personal hygiene, and dressing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #3 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/4/2016 and ended on 2/5/2016. Record review of a physician's order [REDACTED].#3 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea, and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for nausea and vomiting. There was no order in her medical record for isolation precautions. Resident #5 Record review of Resident #5 ' s medical record revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #5 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required extensive assistance of one person for toileting, personal hygiene, dressing, and bathing. He had a BIMS score of 13, indicating no cognitive impairment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #5 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/11/2016 and lasted 24 hours. Record review of a physician's order [REDACTED].#5 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for vomiting. There was no order in his medical record for isolation precautions. In an observation and interview on 2/11/2016 at 2:50 pm, there was a foul odor coming from Resident #5 ' s room. There was no sign on his door to indicate he had an infection. CNA A said, That is [DIAGNOSES REDACTED]. (an infection that causes diarrhea) right there, stay away from that room. The resident was in bed and said it is all over! CNA A put on a gown, gloves and mask before entering room then shut the door. She exited the room about 30 seconds later with the gown on and went to ask another aide for assistance. In an observation and interview on 2/12/2016 at 3:20 pm, Resident #5 was in bed. He said there was a sickness going around. He said he had been in bed since yesterday, and said he could not recall anyone cleaning his mattress. Resident #8 Record review of Resident #8 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #8 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and occasionally incontinent of bladder and required extensive assistance of one person for toileting, personal hygiene, dressing and bathing. Record review of Resident #8 ' s Nurse Notes revealed the following: - 2/12/2016 at 6:30am: Resident (with) nausea and emesis x1. c/o abdominal pain prior to emesis . - 2/12/2016 at 10:00am: Res. continues to vomit . - 2/12/2016 at 1:00pm: Res. ' thumbs up ' when asked if she was feeling better. No further emesis. - 2/13/2016 at 12:00am: Resident had diarrhea x1. Record review of a physician's order [REDACTED].#8 was prescribed one dose of [MEDICATION NAME] 25mg intramuscularly for vomiting. A physician's order [REDACTED].#8 was placed on contact isolation for precautions. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/12/2016 revealed Resident #8 was experiencing diarrhea and vomiting. In an observation on 2/12/2016 at 3:30pm, Resident #8 ' s room did not have personal protective equipment outside of room or a sign on her door to indicate she had an infection. Resident #11 Record review of Resident #11 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #11 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required supervision for toileting and limited assistance of one person for personal hygiene and dressing. She had short term and long term memory problems and did not display wandering behaviors. Record review of Resident #11 ' s Nurse Notes revealed the following: - 2/5/2016 at 6:00pm: Resident had an episode of diarrhea on this shift . - 2/9/2016 at 6:00pm: Resident reported c/o abdominal discomfort and with signs and symptoms of nausea and vomiting . Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 12.5mg intramuscularly for nausea and vomiting, and one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. In an observation and interview on 2/12/2016 at 3:38pm, Resident #11 was observed ambulating with a walker and exiting Resident #8 ' s room (room [ROOM NUMBER]). She said I went into my room, but it was occupied . According to the resident census, Resident #11 resided in room [ROOM NUMBER]. There was no staff on hall 200 to redirect Resident #11. Hand washing, protective wear In an interview on 2/11/2016 at 10:30 am, CNA A said she did not know the name of the infection that was affecting the residents. She said she had the infection and went to the emergency roiagnom on Sunday, 2/7/2016. She said It ' s bad. She said when the infection first started, she was in-serviced on normal hand washing, hand sanitizing, and using gowns and gloves as needed. She said she had been using gowns and gloves with every resident by choice. In an observation and interview on 2/11/2016 at 10:45am, room [ROOM NUMBER] (Resident #14 ' s room) had their call light on. The room had a sign on the door to Please see nurse before entering. LVN A entered the room to respond to the call light. She did not have personal protective equipment on. She had a balled up pair of gloves and a disposable cup in her hand. She turned off the call light and exited the room without washing her hands. LVN A said she just entered the room to turn of the call light because a resident pushed it on accident. She said she did not touch anything in the room except for the switch on the wall. She said Resident #14 had the infection, but was no longer symptomatic. She said she had been preventing the spread of infection by washing her hands and sanitizing as much as possible. In an interview on 2/11/2016 at 10:55am, CNA C said she was washing her hands and the resident ' s hands to prevent the spread of infection. She said she used a gown when residents were messy and used a mask for the smell. She said they kept the personal protective equipment in the linen closet. She said she changed her clothing at the facility so that she would not take the infection home. In an observation on 2/11/2016 at 11:35 am, HK A exited Resident #12 ' s room wearing a mask and two gloves on each hand. She removed her gloves in the hallway and put on two new pairs of gloves. She then entered Resident #5 ' s room and started to clean. She did not wash her hands or change her mask. Resident #12 ' s room (room [ROOM NUMBER]) and Resident #5 ' s room (room [ROOM NUMBER]) did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 11:50 am, the ADON said there was a list of residents with symptoms of norovirus at the nurse ' s station. She said they have instructed staff to wash their hands when they enter and leave the room, and to wear gloves when handling the resident. She said masks and gloves were optional. In an interview on 2/11/2016 at 3:00 pm, RA A said staff were using universal precautions when caring for residents with the infection. He said that meant he was washing his hands often. He said residents were not isolated, but said they usually wanted to stay in their room because they were so sick. He said he was sick himself and still felt a little achy. When asked about personal protective equipment, he said he did not understand why the nursing staff were wearing masks. If it ' s not airborne, why are they wearing them? In an interview on 2/12/2016 at 3:50pm, LVN C said she had been washing her hands and using gloves to prevent the spread of infection. When asked how she protected her clothing, she said she did not lean against objects or walls. She said she came back to work yesterday after becoming ill. Laundry Services In an interview on 2/12/2016 at 3:25 pm, CNA B said all of the laundry in the facility was processed normally. He said when resident ' s had an infection, they put the linens in a clear bag that was brought to the dirty linen closet. He said the facility stressed that the red biohazard bags were for serious infections. In an interview on 2/12/16 at 3:40 pm with Housekeeper C, he stated he was responsible for doing the laundry. He stated the linens and towels are placed in one bag and personal items like clothing are placed in another bag. The plastic bags are placed in large bins. He retrieves the bins and places the items in the washing machine. All the resident clothing gathered that day was washed together and all the towels and linens gathered that day was washed together. He stated the facility installed a new washing machine that week. The washing instructions were posted on the wall. Bleach was used when washing the towels and linens but not used when washing the personal items like clothing and bed spreads. In observations from 2/11/2016 at 10:00 am to 2/12/2016 at 4:45 pm, there were no red biohazard bags observed in the facility. All laundry was processed using clear plastic bags and placed in the same bin. Observations on 2/12/16 at 3:40 pm of the washing instructions posted on the laundry wall read in part, Washer/Items: sheets, towels, pads, heavy soiled, sheet, rags and cotton mops - bleach. Microfiber mops, personal/spreads, color table and bibs - no bleach . Cleaning of resident's rooms In an observation and interview on 2/11/2016 at 10:40 am, HK A was mopping room [ROOM NUMBER] (there was no sign on the door). She was using a cotton string mop head. She said she had been changing the mop water after each room. She said for residents with signs on their doors, she used a flat microfiber mop head to clean the floors. She said she put the mop heads in a bag to give to laundry when she finished. She said when she was cleaning resident rooms she would put on two sets of gloves. She said she did not wear a gown. In an interview on 2/11/2016 at 1:50 pm, the Administrator said the housekeeping staff had been very thorough. She said they had been cleaning with a disinfectant with bleach in every room and were changing the mops between each room. She said there were two housekeepers and a floor tech daily. She said they were making sure residents and staff were washing their hands and using sanitizer. She said residents with the infection were not isolated. We don ' t want to isolate them . they don ' t want to stay in their rooms. She said they were trying to maintain resident rights. In an interview on 2/11/2016 at 4:45pm, the HK Supervisor said the housekeeping staff were disinfecting everything with a cleaner with bleach. She said they were cleaning every room the same to stop the infection. She said she was not sure how or if the staff were mopping differently in the rooms with a recent infection. She said the housekeepers were aware of who had norovirus because they were given a list of residents with symptoms. In an interview on 2/12/2016 at 3:10 pm, the HK Supervisor said they had 3 housekeepers on staff and one floor tech. She said two housekeepers were scheduled per day. When asked if there were enough housekeepers staffed to keep the facility clean, she said it only took one hour to complete a hall, and said the housekeeper was there for 7 hours. She said they had been disinfecting everything that residents or staff members touch, like windowsills, headboards, phones, televisions, and handrails twice daily. She said they clean mattresses, curtains weekly on their deep cleaning schedule. In an interview on 2/12/2016 at 3:40 pm, Resident #10 was sitting outside of his room in the hallway. He said they had a resident council meeting that day. He said he did not know the name of the infection, but said the facility told them to wash their hands all of the time to prevent the infection from spreading. He said they have encouraged the residents to stay in their rooms. He thought the shortage of housekeeping staff attributed to the spread of the infection. In an interview on 2/12/2016 at 3:50 pm, LVN C said she was using Sani-cloth wipes to wipe down surfaces. (The label on the box did not say it killed norovirus). Notification to residents, visitors and staff In an observation on 2/11/2016 at 11:10 am, there was a sign on the front door of the facility that read, Several residents have been experiencing signs and/or symptoms of a stomach virus. Please considering (sic) visiting at another time, or limiting your visit. Please wash hands upon entering and exiting the building. Wash hands after touching resident and resident items. Handwashing is the most important prevention in the spread of infection. Please see the nurse if you have any questions. Observations on 2/11/2016 between 12:00 pm and 12:30 pm revealed Residents # 2, 6, 7, 9, 16, and 18 did not have a sign on their door to indicate they had an infection. Residents #1, 19, 20, 21, 22 and 23 had a sign on their door stating Please see nurse before entering. In an observation on 2/11/2016 at 12:45 pm, Residents #5 and 12 did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 3:00 pm, RA A said he knew who had the infection if they had a sign on their door and by word of mouth from the CNAs. In an interview on 2/11/2016 at 12:40 pm, LVN B said the facility started putting the signs on the doors of the residents with symptoms of infection about two days prior. She said it was the responsibility of the floor nurses to put the signs on the doors. She said she was aware some residents with the infection did not have signs on their doors, and said they were busy and did not have a chance to put them up. She said residents were not on isolation precautions. She said they were using standard precautions like hand washing. In an interview on 2/11/2016 at 12:42 pm, LVN A said the floor nurses were responsible for putting the signs on the resident ' s doors. She said they were supposed to remove them 72 hours after the resident becomes asymptomatic. She said the signs were there to remind staff to use standard precautions when in the rooms. She said there were supposed to wash their hands like normal and said they were not required to wear gowns, masks, or other personal protective equipment. She said residents were not on isolation precautions. In an interview on 2/12/16 at 4:05 pm with LVN D stated the residents with the [MEDICAL CONDITION] are asked to stay in their rooms. A sign instructing visitors to see the nurse is placed on the door. Those residents are placed on a list at the nursing station. The meals are served in their rooms. The staff is instructed to wear gloves, wash their hands when entering and leaving the room and use the sanitizer in between. The laundry is gathered by the staff, placed in plastic bags and taken to the laundry room. She stated the resident in room [ROOM NUMBER] had an active case of [MEDICAL CONDITION]. Observation on 2/12/16 at 4:10 pm revealed no sign instructing visitors to see the nurse on room [ROOM NUMBER] ' s door. In an interview with LVN D at the same time she said, the sign should be on the door. I ' ll take care of it right away. Meal service In an observation and interview on 12/11/2016 at 12:37 pm, CNA B entered Resident #13 ' s room to deliver her meal tray. There was a sign Resident #13 ' s door that read Please see nurse before entering. He was not wearing personal protective equipment when he entered the room. He dropped off meal trays to Resident #13 and her roommate. CNA B then raised her roommate ' s bed using a crank lift at the base of the bed facing the door. He did not wash his hands when he left the room. He said he did not wash his hands while delivering meal trays. He said he washed his hands before and after providing care to the residents. In an interview on 2/11/2016 at 10:00 am, the DON said she was away from the facility for two weeks when a norovirus outbreak started. She said there was an interim DON at that time (RN A). She said she returned to the facility two days ago. People are still getting it . I think it just needs to run its course. Record review of the list of residents with symptoms of norovirus posted at the nurse ' s station and updated on 2/11/2016 at 11:50 am revealed the following: - Residents #1, 20, 21, 22, and 23 experienced diarrhea and Residents #19 and 20 experienced vomiting on 2/8/2016. - Residents #13 and 15 experienced vomiting and diarrhea and Residents #1 and 14 experienced diarrhea on 2/9/2016. - Residents #1, 2, 7, 9, 16, and 17 experienced diarrhea on 2/10/2016. - Residents #6 and 18 experienced diarrhea on 2/11/2016. Two residents were added to the list on 2/11/2016 at 12:40 pm. It revealed that Residents #3 and 12 experienced diarrhea on 2/11/2016. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed on 1/30/2016, 6 residents started experiencing symptoms of norovirus including diarrhea, nausea and vomiting. This document further revealed that from 1/30/2016 to 2/13/2016, 41 residents were affected, and 5 residents were affected with symptoms a second time. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/16/2016 revealed that 4 residents started experiencing symptoms of norovirus on 2/16/2016, including 1 resident that had been affected previously. Record review of In-service Training Reports revealed the following: - On 2/3/2016, non-nursing staff including dietary, housekeeping and laundry staff received training on cleaning, hand washing, isolation procedures for resident meals, and preventing the spread of infection. - On 2/3/2016, nursing staff on different shifts received training on the prevention of GI symptoms or infection. The summary of meeting read in part . Attached is a list of all residents who have had symptoms of nausea/vomiting and/or diarrhea . All residents with such symptoms should be monitored in follow up charting for 48 hours after symptoms have resolved. Residents should be encouraged to comply with isolation measures and non-compliance should be documented. Assist residents with frequent hand washing . - On 2/9/2016, housekeeping and laundry staff received training on room cleaning. - On 2/9/2016, nursing and therapy staff received training on hand washing, door signs, and providing an updated list of residents with symptoms to housekeeping and dietary staff. Record review of a Staff Gastrointestinal (GI) Illness Log revealed that between 1/31/2016 and 2/9/2016, there were 16 nursing staff and 1 administrative staff that developed symptoms of norovirus that included blood in stool, cramps, diarrhea, fever, headache, nausea and vomiting. It further revealed one staff member tested positive for norovirus and was hospitalized . In an interview on 2/11/2016 at 1:00 pm, RN A said she worked at the facility when they asked her to. She said when the DON went out o

Based on interview and record review the Administrator and the DON failed to ensure the facility was administered in a manner which enabled it to use its resources effectively and efficiently to maintain the highest practicable physical well-being of the residents for 10 of 11 residents (Residents #7, #6, #9, #10, #1, #2, #3, #5, #8, and #11) reviewed for effective administration. The Administrator failed to: - Supervise the implementation of the facility ' s infection control policy to prevent a norovirus outbreak throughout the facility. - Supervise the DON and/or designee's training and monitoring of the nursing staff to ensure effective procedures were implemented to prevent the spread of norovirus. - Monitor/supervise housekeeping, laundry, and dietary staff to ensure the training and procedures concerning infection control were effective in the prevention of the spread of norovirus. - Ensure all visitors, residents and staff were notified of precautions to be used to control the spread of norovirus. The DON and/or designee failed to: - Train and monitor staff on infection control measures to prevent the spread of norovirus. - Ensure contact isolation procedures, as recommended by CDC, were put into place when there was an outbreak of norovirus. - implement an effective infection control system to track and prevent the spread of norovirus. On 2/12/2016, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/16/2016, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 35 residents, one requiring hospitalization and six who suffered with symptoms of nausea, vomiting and diarrhea twice, and 16 staff members and placed the other 37 residents who resided at the facility at risk of developing norovirus with the potential for complications and hospitalization . Findings included: Incident # 9 Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed that on 1/30/2016, 6 residents started experiencing symptoms of norovirus including diarrhea, nausea and vomiting. This document further revealed that from 1/30/2016 to 2/13/2016, 41 residents were affected, and 5 residents were affected with symptoms a second time. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/16/2016 revealed that 4 residents started experiencing symptoms of norovirus on 2/16/2016, including 1 resident that had been affected previously. Record review of a Staff Gastrointestinal (GI) Illness Log revealed that between 1/31/2016 and 2/9/2016, there were 16 nursing staff and 1 administrative staff that developed symptoms of norovirus that included blood in stool, cramps, diarrhea, fever, headache, nausea and vomiting. It further revealed one staff member tested positive for norovirus and was hospitalized . Record review of In-service Training Reports revealed the following: - On 2/3/2016, non-nursing staff including dietary, housekeeping and laundry staff received training on cleaning, hand washing, isolation procedures for resident meals, and preventing the spread of infection. - On 2/3/2016, nursing staff on different shifts received training on the prevention of GI symptoms or infection. The summary of meeting read in part . Attached is a list of all residents who have had symptoms of nausea/vomiting and/or diarrhea . All residents with such symptoms should be monitored in follow up charting for 48 hours after symptoms have resolved. Residents should be encouraged to comply with isolation measures and non-compliance should be documented. Assist residents with frequent hand washing . - On 2/9/2016, housekeeping and laundry staff received training on room cleaning. - On 2/9/2016, nursing and therapy staff received training on hand washing, door signs, and providing an updated list of residents with symptoms to housekeeping and dietary staff. Hand washing, protective wear In an interview on 2/11/2016 at 10:30 am, CNA A said she did not know the name of the infection that was affecting the residents. She said she had the infection and went to the emergency roiagnom on Sunday, 2/7/2016. She said It ' s bad. She said when the infection first started, she was in-serviced on normal hand washing, hand sanitizing, and using gowns and gloves as needed. She said she had been using gowns and gloves with every resident by choice. In an observation and interview on 2/11/2016 at 10:45am, room [ROOM NUMBER] (Resident #14 ' s room) had their call light on. The room had a sign on the door to Please see nurse before entering. LVN A entered the room to respond to the call light. She did not have personal protective equipment on. She had a balled up pair of gloves and a disposable cup in her hand. She turned off the call light and exited the room without washing her hands. LVN A said she just entered the room to turn of the call light because a resident pushed it on accident. She said she did not touch anything in the room except for the switch on the wall. She said Resident #14 had the infection, but was no longer symptomatic. She said she had been preventing the spread of infection by washing her hands and sanitizing as much as possible. In an interview on 2/11/2016 at 10:55am, CNA C said she was washing her hands and the resident ' s hands to prevent the spread of infection. She said she used a gown when residents were messy and used a mask for the smell. She said they kept the personal protective equipment in the linen closet. She said she changed her clothing at the facility so that she would not take the infection home. In an observation on 2/11/2016 at 11:35 am, HK A exited Resident #12 ' s room wearing a mask and two gloves on each hand. She removed her gloves in the hallway and put on two new pairs of gloves. She then entered Resident #5 ' s room and started to clean. She did not wash her hands or change her mask. Resident #12 ' s room (room [ROOM NUMBER]) and Resident #5 ' s room (room [ROOM NUMBER]) did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 11:50 am, the ADON said there was a list of residents with symptoms of norovirus at the nurse ' s station. She said they have instructed staff to wash their hands when they enter and leave the room, and to wear gloves when handling the resident. She said masks and gloves were optional. In an interview on 2/11/2016 at 3:00 pm, RA A said staff were using universal precautions when caring for residents with the infection. He said that meant he was washing his hands often. He said residents were not isolated, but said they usually wanted to stay in their room because they were so sick. He said he was sick himself and still felt a little achy. When asked about personal protective equipment, he said he did not understand why the nursing staff were wearing masks. If it ' s not airborne, why are they wearing them? In an interview on 2/12/2016 at 3:50pm, LVN C said she had been washing her hands and using gloves to prevent the spread of infection. When asked how she protected her clothing, she said she did not lean against objects or walls. She said she came back to work yesterday after becoming ill. Laundry Services In an interview on 2/12/2016 at 3:25 pm, CNA B said all of the laundry in the facility was processed normally. He said when resident ' s had an infection, they put the linens in a clear bag that was brought to the dirty linen closet. He said the facility stressed that the red biohazard bags were for serious infections. In an interview on 2/12/16 at 3:40 pm with Housekeeper C, he stated he was responsible for doing the laundry. He stated the linens and towels are placed in one bag and personal items like clothing are placed in another bag. The plastic bags are placed in large bins. He retrieves the bins and places the items in the washing machine. All the resident clothing gathered that day was washed together and all the towels and linens gathered that day was washed together. He stated the facility installed a new washing machine that week. The washing instructions were posted on the wall. Bleach was used when washing the towels and linens but not used when washing the personal items like clothing and bed spreads. In observations from 2/11/2016 at 10:00 am to 2/12/2016 at 4:45 pm, there were no red biohazard bags observed in the facility. All laundry was processed using clear plastic bags and placed in the same bin. Observations on 2/12/16 at 3:40 pm of the washing instructions posted on the laundry wall read in part, Washer/Items: sheets, towels, pads, heavy soiled, sheet, rags and cotton mops - bleach. Microfiber mops, personal/spreads, color table and bibs - no bleach . Cleaning of resident's rooms In an observation and interview on 2/11/2016 at 10:40 am, HK A was mopping room [ROOM NUMBER] (there was no sign on the door). She was using a cotton string mop head. She said she had been changing the mop water after each room. She said for residents with signs on their doors, she used a flat microfiber mop head to clean the floors. She said she put the mop heads in a bag to give to laundry when she finished. She said when she was cleaning resident rooms she would put on two sets of gloves. She said she did not wear a gown. In an interview on 2/11/2016 at 1:50 pm, the Administrator said the housekeeping staff had been very thorough. She said they had been cleaning with a disinfectant with bleach in every room and were changing the mops between each room. She said there were two housekeepers and a floor tech daily. She said they were making sure residents and staff were washing their hands and using sanitizer. She said residents with the infection were not isolated. We don ' t want to isolate them . they don ' t want to stay in their rooms. She said they were trying to maintain resident rights. In an interview on 2/11/2016 at 4:45pm, the HK Supervisor said the housekeeping staff were disinfecting everything with a cleaner with bleach. She said they were cleaning every room the same to stop the infection. She said she was not sure how or if the staff were mopping differently in the rooms with a recent infection. She said the housekeepers were aware of who had norovirus because they were given a list of residents with symptoms. In an interview on 2/12/2016 at 3:10 pm, the HK Supervisor said they had 3 housekeepers on staff and one floor tech. She said two housekeepers were scheduled per day. When asked if there were enough housekeepers staffed to keep the facility clean, she said it only took one hour to complete a hall, and said the housekeeper was there for 7 hours. She said they had been disinfecting everything that residents or staff members touch, like windowsills, headboards, phones, televisions, and handrails twice daily. She said they clean mattresses, curtains weekly on their deep cleaning schedule. In an interview on 2/12/2016 at 3:40 pm, Resident #10 was sitting outside of his room in the hallway. He said they had a resident council meeting that day. He said he did not know the name of the infection, but said the facility told them to wash their hands all of the time to prevent the infection from spreading. He said they have encouraged the residents to stay in their rooms. He thought the shortage of housekeeping staff attributed to the spread of the infection. In an interview on 2/12/2016 at 3:50 pm, LVN C said she was using Sani-cloth wipes to wipe down surfaces. (The label on the box did not say it killed norovirus). Notification to residents, visitors and staff In an observation on 2/11/2016 at 11:10 am, there was a sign on the front door of the facility that read, Several residents have been experiencing signs and/or symptoms of a stomach virus. Please considering (sic) visiting at another time, or limiting your visit. Please wash hands upon entering and exiting the building. Wash hands after touching resident and resident items. Handwashing is the most important prevention in the spread of infection. Please see the nurse if you have any questions. Observations on 2/11/2016 between 12:00 pm and 12:30 pm revealed Residents # 2, 6, 7, 9, 16, and 18 did not have a sign on their door to indicate they had an infection. Residents #1, 19, 20, 21, 22 and 23 had a sign on their door stating Please see nurse before entering. In an observation on 2/11/2016 at 12:45 pm, Residents #5 and 12 did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 3:00 pm, RA A said he knew who had the infection if they had a sign on their door and by word of mouth from the CNAs. In an interview on 2/11/2016 at 12:40 pm, LVN B said the facility started putting the signs on the doors of the residents with symptoms of infection about two days prior. She said it was the responsibility of the floor nurses to put the signs on the doors. She said she was aware some residents with the infection did not have signs on their doors, and said they were busy and did not have a chance to put them up. She said residents were not on isolation precautions. She said they were using standard precautions like hand washing. In an interview on 2/11/2016 at 12:42 pm, LVN A said the floor nurses were responsible for putting the signs on the resident ' s doors. She said they were supposed to remove them 72 hours after the resident becomes asymptomatic. She said the signs were there to remind staff to use standard precautions when in the rooms. She said there were supposed to wash their hands like normal and said they were not required to wear gowns, masks, or other personal protective equipment. She said residents were not on isolation precautions. In an interview on 2/12/16 at 4:05 pm with LVN D stated the residents with the [MEDICAL CONDITION] are asked to stay in their rooms. A sign instructing visitors to see the nurse is placed on the door. Those residents are placed on a list at the nursing station. The meals are served in their rooms. The staff is instructed to wear gloves, wash their hands when entering and leaving the room and use the sanitizer in between. The laundry is gathered by the staff, placed in plastic bags and taken to the laundry room. She stated the resident in room [ROOM NUMBER] had an active case of [MEDICAL CONDITION]. Observation on 2/12/16 at 4:10 pm revealed no sign instructing visitors to see the nurse on room [ROOM NUMBER] ' s door. In an interview with LVN D at the same time she said, the sign should be on the door. I ' ll take care of it right away. Meal service In an observation and interview on 12/11/2016 at 12:37 pm, CNA B entered Resident #13 ' s room to deliver her meal tray. There was a sign Resident #13 ' s door that read Please see nurse before entering. He was not wearing personal protective equipment when he entered the room. He dropped off meal trays to Resident #13 and her roommate. CNA B then raised her roommate ' s bed using a crank lift at the base of the bed facing the door. He did not wash his hands when he left the room. He said he did not wash his hands while delivering meal trays. He said he washed his hands before and after providing care to the residents. In an interview on 2/11/2016 at 10:00 am, the DON said she was away from the facility for two weeks when a norovirus outbreak started. She said there was an interim DON at that time (RN A). She said she returned to the facility two days ago. People are still getting it . I think it just needs to run its course. Record review of the list of residents with symptoms of norovirus posted at the nurse ' s station and updated on 2/11/2016 at 11:50 am revealed the following: - Residents #1, 20, 21, 22, and 23 experienced diarrhea and Residents #19 and 20 experienced vomiting on 2/8/2016. - Residents #13 and 15 experienced vomiting and diarrhea and Residents #1 and 14 experienced diarrhea on 2/9/2016. - Residents #1, 2, 7, 9, 16, and 17 experienced diarrhea on 2/10/2016. - Residents #6 and 18 experienced diarrhea on 2/11/2016. Two residents were added to the list on 2/11/2016 at 12:40 pm. It revealed that Residents #3 and 12 experienced diarrhea on 2/11/2016. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed on 1/30/2016, 6 residents started experiencing symptoms of norovirus including diarrhea, nausea and vomiting. This document further revealed that from 1/30/2016 to 2/13/2016, 41 residents were affected, and 5 residents were affected with symptoms a second time. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/16/2016 revealed that 4 residents started experiencing symptoms of norovirus on 2/16/2016, including 1 resident that had been affected previously. Record review of In-service Training Reports revealed the following: - On 2/3/2016, non-nursing staff including dietary, housekeeping and laundry staff received training on cleaning, hand washing, isolation procedures for resident meals, and preventing the spread of infection. - On 2/3/2016, nursing staff on different shifts received training on the prevention of GI symptoms or infection. The summary of meeting read in part . Attached is a list of all residents who have had symptoms of nausea/vomiting and/or diarrhea . All residents with such symptoms should be monitored in follow up charting for 48 hours after symptoms have resolved. Residents should be encouraged to comply with isolation measures and non-compliance should be documented. Assist residents with frequent hand washing . - On 2/9/2016, housekeeping and laundry staff received training on room cleaning. - On 2/9/2016, nursing and therapy staff received training on hand washing, door signs, and providing an updated list of residents with symptoms to housekeeping and dietary staff. Record review of a Staff Gastrointestinal (GI) Illness Log revealed that between 1/31/2016 and 2/9/2016, there were 16 nursing staff and 1 administrative staff that developed symptoms of norovirus that included blood in stool, cramps, diarrhea, fever, headache, nausea and vomiting. It further revealed one staff member tested positive for norovirus and was hospitalized . In an interview on 2/11/2016 at 1:00 pm, RN A said she worked at the facility when they asked her to. She said when the DON went out of town, she was the interim DON. She said the first case of nausea, vomiting, and diarrhea occurred on the secure unit on 1/30/2016. She said a few days later on 2/1/2016, it had spread to the other halls. She said she notified MD A and he wrote orders for Gatorade and medications that treated the symptoms. In the same interview RN A said she in-serviced staff on hand washing and using gowns, masks, and gloves for residents with active diarrhea and vomiting. She said the biggest challenge was that residents did not want to stay in their rooms. She said they took the residents with an infection out to smoke at different times than the other smokers. She said the residents with the infection were grouped together in the dining room. She said they disinfected the dining room tables after each meal and were washing the resident ' s hands frequently. She said she thought the infection was going away the first week it was in the facility. She said it started picking up again and she notified the health department, DADS, and MD A on 2/8/2016. She said they had two stool samples that confirmed it was norovirus. She said they started putting the signs on the doors of those with symptoms on 2/8/2016. She said when the health department visited a few days later, he said everything looked good. In an interview with the DON and ADON on 2/11/2016 at 1:30 pm, the ADON said the signs and symptoms of norovirus are nausea, vomiting, diarrhea, and increased temperatures. She said they were monitoring residents by checking vital signs every shift and monitoring for new symptoms. She said the physician has ordered Gatorade for residents with symptoms so they stay hydrated. When asked about how they were tracking and trending the infection, she said it ' s all over the building. She said Resident #7 was hospitalized related to projectile vomiting, but said it was not a confirmed case of norovirus. She said they had 35 residents with symptoms of norovirus, and 16 staff with reported symptoms of norovirus. She said because of the staff shortage, all of the nurses have been working the floor as CNAs. They both acknowledged they were not sure what housekeeping was doing differently. When asked about how residents were identified as having the infection, the ADON said they started putting signs on their doors when the outbreak started. She said because they were working on the floor, they did not have a chance to put the signs on doors of the residents with new symptoms. In a telephone interview on 2/11/2016 at 1:55pm, the Epidemiologist said he recommended the facility get 2 to 3 stool samples to confirm the type of outbreak. He said when he visited the facility a few days prior they had confirmed that it was norovirus. He said to prevent the spread of infection, he recommended hand washing when facility staff came into contact with all residents, and said the housekeepers should keep a safe distance from the residents with the infection. He said when he was there he added hand washing signage on resident doors as a reminder for staff to wash their hands. He said there were only three cases when he was there and said it looked like it was declining. When asked about contact isolation precautions and personal protective equipment, he said for future outbreaks, yes . it would be recommended. In an interview on 2/12/2016 at 4:15 pm, the DON said she returned from vacation on Wednesday, 2/10/2016. She said they had been using standard precautions for residents with the norovirus, including hand washing, sanitizing, and extra cleaning. She said she started monitoring staff one on one to ensure they were washing their hands. She said they were identifying residents with the infection with the signs on their doors. She said the signs would stay on the doors until the resident was asymptotic for 48 hours. She said personal protective equipment was available for staff if they wanted to use it. When asked when she would isolate a resident, she said, until 48 hours after symptoms go away, probably . but we are not isolating the residents right now. In an interview on 2/12/2016 at 4:45pm, the Administrator said she looked at CDC guidelines and they advised to make sure staff were hand washing and cleaning with a diluted bleach solution. She said they have been cleaning highly used surfaces like handrails, door handles, and armrests, twice daily. She said they were encouraging residents to stay in their rooms and wash their hands often. When asked why the signs were on the doors of residents with symptoms, she said she was not sure because she was out sick when the signs were implemented (Monday 2/8/2016). She said they were monitoring staff for hand washing throughout the day. She said there were 2 housekeepers on the schedule daily. When asked if there were enough housekeeping staff to keep facility clean, she said no, but said other staff members were helping keep the facility clean. In an interview on 2/15/2016 at 1:45pm, the ADON said the outbreak first appeared on the secure unit. She said RN A told nursing staff to treat the residents for their symptoms and wash their hands if coming into contact with someone who was symptomatic. She said she knew it was a problem when there were 12 residents with symptoms at the same time. She said they notified the Regional RN and she recommended trying to keep residents in their rooms as much as possible. She said the types of precautions were put in place by the Administrator and the Regional RN. In a telephone interview on 2/15/2016 at 3:10 pm, The Medical Director said he was first notified of the outbreak when it first started. He said he first recommended staff to use universal precautions like hand washing to prevent the spread of infection. He said about a week ago, they talked about starting contact isolation precautions because it was spreading so fast. He said when it got worse, he discussed with the Regional RN about CDC guidelines and said if they were following the guidelines then that would be sufficient. He said he thought the facility was doing everything they could to prevent the infection, and said it was unfortunate it spread so quickly. He said currently, the residents with symptoms were placed on more strict contact isolation and would be taken off 72 hours after symptoms subsided. In a telephone interview on 2/15/2016 at 3:20 pm, the Regional RN said she was first notified of the outbreak on the Tuesday after it started (2/2/2016). She said she made sure they were following facility policy and procedure, and monitoring signs and symptoms of norovirus. She said she recommended staff follow contact precautions. When asked to describe contact precautions, she said they suspended activities, put signs on resident ' s doors that were symptomatic, in-serviced staff on hand washing, separating laundry, and making sure visitors were notified to wash their hands. She said when the Epidemiologist visited the facility he said they were going above and beyond what was required. She said, We were doing everything we thought to do. When asked about CDC guidelines, she said she could not recall what kinds of precautions were recommended. Record review of the facility policy for Abuse-Reportable Events dated 5/2014 read in part . It is the policy of this home to prohibit resident abuse or neglect in any form . neglect: the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Record review of the facility policy for Infection Control-Precautions- Categories and Notices dated 3/2012 read in part . It is the policy of this home to assure that appropriate precautions will be established to ensure that the necessary isolation techniques are implemented. Precaution notices will be posted when isolation precautions are implemented . In addition to Standard Precautions, Contact Precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surface . Examples of infections requiring Contact Precautions include . Gastrointestinal, respiratory, skin, or wound infections . During the course of caring for a resident, change gloves after having contact with infective material . Remove gloves before leaving the room and wash hands immediately with an antimicrobial agent . wear a gown when entering the room if you anticipate that your clothing will have substantial contact with the infectious material . signs will be used to alter staff of the implementation of precautions . Record review of the facility policy for Infection Control- Outbreak Investigation dated 3/2012 read in part . It is the policy of this home that outbreak measure will be instituted whenever there is an incidence of infection about what would normally be expected, considering seasonal variations . The Director of Nursing/designee will conduct an Outbreak Investigation . To prevent the transmission of infection from one resident to others . Staff will be educated upon hire and periodically there after on the Infection Control Practices of the home to include: Their role in outbreak prevention (i.e. hand washing; appropriate isolation measures) .outbreak control measures such as isolation and quarantine. Record review of a document titled Key Infection Control Recommendations for the Control of Norovirus Outbreaks in Healthcare Settings by the CDC dated 1/3/2012 read in part . Place patients with norovirus gastroenteritis on Contact Precautions for a minimum of 48 hours after the resolution of symptoms. When symptomatic patients cannot be accommodated in single occupancy rooms, efforts should be made to separate them from asymptomatic patients . Consider the following precautions: Minimize patient movements within a ward or unit during norovirus outbreaks; Restrict symptomatic and recovering patients from leaving the patient-care area unless it is for essential care or treatment . Actively promote adherence to hand hygiene among healthcare personnel, patients, and visitors in patient care areas affected by outbreaks of norovirus gastroenteritis; During outbreaks, use soap and water for hand hygiene after providing care or having contact with patients suspected or confirmed with norovirus gastroenteritis . If norovirus infection is suspected, adherence to PPE use according to Contact and Standard Precautions is recommended for individuals entering the patient care area (i.e., gowns and gloves upon entry) . Increase the frequency of cleaning and disinfection of patient care areas and frequently touched surfaces during outbreaks of norovirus gastroenteritis (e.g., increase ward/unit level cleaning twice daily to maintain cleanliness, with frequently touched surfaces cleaned and disinfected three times daily using EPA-approved products for healthcare settings) This document can be reviewed on the following website: <http://www.cdc.gov/hai/pdfs/norovirus/ 0A-NorovirusControlRecomm508A.pdf> Record review of a document titled Preventing Norovirus Infection by the CDC dated 12/10/2015 read in part . After throwing up or having diarrhea, immediately clean and disinfect contaminated surfaces. Use a chlorine bleach solution with a concentration of 1000-5000 ppm (5-25 tablespoons of household bleach (5.25%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA) . This document can be reviewed on the following website: <http://www.cdc.gov/norovirus/preventing-infection.html> The facility Administrator and the DON were notified on 2/12/2016 at 4:55pm that an IJ situation had been identified due to the above failures. A Plan of Removal was submitted by the Administrator on 2/12/2016. After several revisions, the final Plan of Removal was accepted on 2/14/ at 6:20pm. The plan of removal included the following: 1. Medical Director will be notified of Immediate Jeopardy alleged by DADS. Notification made by Administrator on 2/12/16. Started: 2/12/16 Completed: 2/12/16 2. An emergency QA meeting, via telephone, held with the Medical Director regarding IJ. This meeting discussed actions currently being taken to remove the immediate jeopardy allegation. Areas reviewed were: In-servicing facility staff on Proper Handwashing In-servicing facility staff on When Hand Washing Should Be Performed Posting signs on the door of residents currently showing symptoms Posting sign on the Entrance to alert the public/visitors to the Norovirus symptoms and to restrict visiting if showing signs and symptoms Housekeepers using correct products for disinfecting contact surfaces No staff will be allowed to work until they complete these in-services Also discussed the need to not have residents with symptoms eating in dining room unless cohorted at same table; discussed continued use of Standard Precautions; action to in-service Laundry staff on proper handling of the microfiber mops and the action taken to increase the housekeeping services . All this action has been taken. A second QA Meeting with the Medical Director will be held on 2/15/16 to update him and the team of all actions taken. Started: 2/12/16 Completed: 2/13/16 3. Facility staff will be in-serviced on proper Handwashing and When Hand Washing Should be Performed. Director of Nursing and nurse managers will be responsible

Based on observation, interview, and record review, the facility failed to maintain an infection control program to provide a safe, sanitary and comfortable environment to help prevent the transmission of disease and infection for 10 of 11 residents (Residents #7, #6, #9, #10, #1, #2, #3, #5, #8, and #11) reviewed for infection control. The facility failed to implement appropriate infection control procedures to protect residents from becoming exposed to norovirus as evidenced by: The facility failed to isolate/limit residents and staff contact between symptomatic and non-symptomatic residents to prevent the spread of norovirus. The facility failed to train and monitor staff on proper/timely handwashing, wearing protective wear, identifying symptomatic residents, and preventing cross contamination with resident's personal use items to decrease the risk of spreading norovirus. The facility failed to train/monitor the cleansing and transporting of symptomatic resident's clothing to prevent the spread of norovirus. The facility failed to provide adequate/effective cleaning of symptomatic resident's rooms to prevent cross contamination to non-symptomatic resident's rooms. The facility failed to have an effective notification system to alert residents, visitors and staff as to which residents were experiencing symptoms of norovirus. On 2/12/2016, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/16/2016, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 35 residents, one requiring hospitalization and six who suffered with symptoms of nausea, vomiting and diarrhea twice, and 16 staff members and placed the other 37 residents who resided at the facility at risk of developing norovirus with the potential for complications and hospitalization . Findings included: Incident # 9 Resident #7 Record review of Resident #7 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #7 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required extensive assistance of one person for dressing, toileting and bathing, and required total assistance of one person for personal hygiene. Record review of Resident #7 ' s Nurse Notes revealed the following: - 1/31/2016 at 6:00 am: Resident had an episode of diarrhea (sic) this AM very loose and watery . - 1/31/2016 at 1:30pm: Resident in dining room eating small (amount) of lunch and started having projectile vomiting while in dining room. Record review of a Patient Transfer Form dated 1/31/2016 revealed Resident #7 was transferred to the hospital for diarrhea frequent, projectile vomiting. Record review of an Admission/Readmission Data Summary dated 2/2/2016 revealed Resident #7 returned to the facility. Record review of Resident #7 ' s Hospital Records dated 2/1/2016 revealed she was admitted to the hospital for nausea, vomiting, diarrhea and fever. The patient developed fever after has been admitted and we have not seen any more bouts of vomiting at this moment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #7 had symptoms of infection including nausea and vomiting that started on 1/31/2016 and ended on 2/3/2016, and was sent to the hospital on [DATE]. It further revealed on 2/10/2016, she became symptomatic a second time with diarrhea. Record review of a physician's order [REDACTED].#7 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #6 Record review of Resident #6 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #6 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of one person for toileting and bathing, and required extensive assistance of one person for dressing and personal hygiene. Record review of a Nurse Note dated 2/11/2016 revealed that Resident #6 had two episodes of diarrhea. Record review of a physician's order [REDACTED].#6 was prescribed Gatorade 240mL by mouth four times for one day for dehydration related to nausea or vomiting. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #6 had symptoms of infection including diarrhea, nausea and vomiting that started on 1/30/2016 and ended on 2/2/2016. It further revealed on 2/11/2016, she became symptomatic a second time with diarrhea that lasted 24 hours. Record review of a physician's order [REDACTED].#6 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #9 Record review of Resident #9 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #9 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder, required total assistance of one person for dressing, toileting, personal hygiene and bathing and required supervision for eating. Record review of Resident #9 ' s Nurse Notes revealed the following: - 1/31/2016 at 2:10am: Noted (with) episode of loose stool and emesis x1 . - 1/31/2016 at 5:30pm: Reported that resident has had multiple episodes of loose stool this AM. [MEDICATION NAME] 2mg 1 x dose given around 11AM. No recent reports of loose stool . - 2/10/2016 at 12:00pm: Resident having s/sx Diarrhea noted to be ' like water. ' - 2/11/2016 at 11:30am: Diarrhea noted today . - (After IJ was called) 2/14/2016 (no time documented): Resident on isolation (due to) emesis . Resident non-complaint (sic) to room. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #9 had symptoms of infection including diarrhea, fever, nausea and vomiting that started on 1/31/2016 and ended on 2/1/2016. It further revealed on 2/10/2016, he became symptomatic a second time with diarrhea, nausea and vomiting. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg for diarrhea. There was no order in his medical record for isolation precautions. In an observation on 2/11/2016 at 12:30 pm in the secure unit (500 hall), Resident #9 was sitting in the dining room eating his meal across from a resident who did not have signs or symptoms of the norovirus. In an observation and interview on 2/15/2016 at 11:05 pm, Resident #9 had personal protective equipment outside of his room, and there was a sign on his door that read Please see nurse before entering. Resident #9 exited his room and began walking around the secure unit. CNA D said it was difficult to keep Resident #9 in his room because he liked to wander. CNA D adn the SW at that time were observed to see Resident #9 in the unit and no one tried to redirect him back to his room. In an observation on 2/15/2016 at 12:38 pm, Resident #9 was sitting at a dining room table with Residents #17 and 25, who were not on contact precautions. He was eating lunch when he began coughing and drooling. LVN E had a towel in his hand and was wiping Resident #9 ' s mouth then placing the towel on the uncovered table. LVN E was not wearing any type of personal protective equipment. There were noticeable marks of a clear mucous substance on the table where the towel was placed. The SLP arrived with a new bowl of food. When the food was placed in his mouth, he vomited a clear substance. The SLP caught the emesis in a meal tray cover and took it away from the room. No one cleaned or disinfected the dining room table, and Residents #17 and 25 continued to eat at the table. In an interview on 2/15/2016 at 12:40 pm, LVN E said he did not believe residents with norovirus should be placed on isolation precautions. He said he had never isolated a resident with norovirus before. He said because Resident #9 was on contact precautions, he should not have been in the dining room. In an interview on 2/15/2016 at 1:30 pm, ADON said Resident #9 had esophageal issues and said he choked on his food in the dining room which caused him to have an emesis. She said his last norovirus symptoms occurred on 2/10/2016, but he was placed on contact precautions because he had an emesis on 2/13/2016. She further stated LVN E was inserviced on the norovirus and contact precautions at 11:30 am that morning. She said she would talk to him again. Resident #10 Record review of Resident #10 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #10 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required total assistance of one person for toileting, bathing, and personal hygiene. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #10 had symptoms of infection including diarrhea and nausea that started on 2/7/2016 that lasted 24 hours. It further revealed on 2/13/2016, he became symptomatic a second time with diarrhea, headache, nausea and vomiting. Record review of a physician's order [REDACTED].#10 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED]. Resident #1 Record review of Resident #1 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and frequently incontinent of bladder, and required limited assistance of one person for toileting, personal hygiene, bathing, and dressing. Record review of a nurse note dated 2/4/2016 revealed Resident #1 had two episodes of diarrhea and complained of nausea. Record review of a nurse note dated 2/9/2016 revealed Resident #1 no longer had symptoms of diarrhea or nausea. Record review of a physician's order [REDACTED].#1 ' s vital signs every shift, and to hydrate every two hours as tolerated. There was no order in her medical record for isolation precautions. In an observation on 2/11/2016 at 10:15 am, RA A was in room [ROOM NUMBER] talking with Resident #1, who was sitting in her bed. There was a sign Resident #1 ' s door that read Please see nurse before entering. RA A's hands were on her wheelchair handles, and his clothing was brushing up against the back of the chair. RA A was not wearing any personal protective equipment, including gloves or a gown. When he exited the room, he did not wash his hands. Resident #2 Record review of Resident #2 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2 ' s significant change MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of two people for toileting, and required total assistance of one person for personal hygiene, dressing, eating, and bathing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #2 had symptoms of infection including diarrhea that started on 2/10/2016. Record review of a physician's order [REDACTED].#2 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #3 Record review of Resident #3 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3 ' s annual MDS assessment dated [DATE] revealed she was occasionally incontinent of bowel and bladder and required limited assistance of one person for toileting, personal hygiene, and dressing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #3 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/4/2016 and ended on 2/5/2016. Record review of a physician's order [REDACTED].#3 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea, and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for nausea and vomiting. There was no order in her medical record for isolation precautions. Resident #5 Record review of Resident #5 ' s medical record revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #5 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required extensive assistance of one person for toileting, personal hygiene, dressing, and bathing. He had a BIMS score of 13, indicating no cognitive impairment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #5 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/11/2016 and lasted 24 hours. Record review of a physician's order [REDACTED].#5 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for vomiting. There was no order in his medical record for isolation precautions. In an observation and interview on 2/11/2016 at 2:50 pm, there was a foul odor coming from Resident #5 ' s room. There was no sign on his door to indicate he had an infection. CNA A said, That is [DIAGNOSES REDACTED]. (an infection that causes diarrhea) right there, stay away from that room. The resident was in bed and said it is all over! CNA A put on a gown, gloves and mask before entering room then shut the door. She exited the room about 30 seconds later with the gown on and went to ask another aide for assistance. In an observation and interview on 2/12/2016 at 3:20 pm, Resident #5 was in bed. He said there was a sickness going around. He said he had been in bed since yesterday, and said he could not recall anyone cleaning his mattress. Resident #8 Record review of Resident #8 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #8 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and occasionally incontinent of bladder and required extensive assistance of one person for toileting, personal hygiene, dressing and bathing. Record review of Resident #8 ' s Nurse Notes revealed the following: - 2/12/2016 at 6:30am: Resident (with) nausea and emesis x1. c/o abdominal pain prior to emesis . - 2/12/2016 at 10:00am: Res. continues to vomit . - 2/12/2016 at 1:00pm: Res. ' thumbs up ' when asked if she was feeling better. No further emesis. - 2/13/2016 at 12:00am: Resident had diarrhea x1. Record review of a physician's order [REDACTED].#8 was prescribed one dose of [MEDICATION NAME] 25mg intramuscularly for vomiting. A physician's order [REDACTED].#8 was placed on contact isolation for precautions. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/12/2016 revealed Resident #8 was experiencing diarrhea and vomiting. In an observation on 2/12/2016 at 3:30pm, Resident #8 ' s room did not have personal protective equipment outside of room or a sign on her door to indicate she had an infection. Resident #11 Record review of Resident #11 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #11 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required supervision for toileting and limited assistance of one person for personal hygiene and dressing. She had short term and long term memory problems and did not display wandering behaviors. Record review of Resident #11 ' s Nurse Notes revealed the following: - 2/5/2016 at 6:00pm: Resident had an episode of diarrhea on this shift . - 2/9/2016 at 6:00pm: Resident reported c/o abdominal discomfort and with signs and symptoms of nausea and vomiting . Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 12.5mg intramuscularly for nausea and vomiting, and one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. In an observation and interview on 2/12/2016 at 3:38pm, Resident #11 was observed ambulating with a walker and exiting Resident #8 ' s room (room [ROOM NUMBER]). She said I went into my room, but it was occupied . According to the resident census, Resident #11 resided in room [ROOM NUMBER]. There was no staff on hall 200 to redirect Resident #11. Hand washing, protective wear In an interview on 2/11/2016 at 10:30 am, CNA A said she did not know the name of the infection that was affecting the residents. She said she had the infection and went to the emergency roiagnom on Sunday, 2/7/2016. She said It ' s bad. She said when the infection first started, she was in-serviced on normal hand washing, hand sanitizing, and using gowns and gloves as needed. She said she had been using gowns and gloves with every resident by choice. In an observation and interview on 2/11/2016 at 10:45am, room [ROOM NUMBER] (Resident #14 ' s room) had their call light on. The room had a sign on the door to Please see nurse before entering. LVN A entered the room to respond to the call light. She did not have personal protective equipment on. She had a balled up pair of gloves and a disposable cup in her hand. She turned off the call light and exited the room without washing her hands. LVN A said she just entered the room to turn of the call light because a resident pushed it on accident. She said she did not touch anything in the room except for the switch on the wall. She said Resident #14 had the infection, but was no longer symptomatic. She said she had been preventing the spread of infection by washing her hands and sanitizing as much as possible. In an interview on 2/11/2016 at 10:55am, CNA C said she was washing her hands and the resident ' s hands to prevent the spread of infection. She said she used a gown when residents were messy and used a mask for the smell. She said they kept the personal protective equipment in the linen closet. She said she changed her clothing at the facility so that she would not take the infection home. In an observation on 2/11/2016 at 11:35 am, HK A exited Resident #12 ' s room wearing a mask and two gloves on each hand. She removed her gloves in the hallway and put on two new pairs of gloves. She then entered Resident #5 ' s room and started to clean. She did not wash her hands or change her mask. Resident #12 ' s room (room [ROOM NUMBER]) and Resident #5 ' s room (room [ROOM NUMBER]) did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 11:50 am, the ADON said there was a list of residents with symptoms of norovirus at the nurse ' s station. She said they have instructed staff to wash their hands when they enter and leave the room, and to wear gloves when handling the resident. She said masks and gloves were optional. In an interview on 2/11/2016 at 3:00 pm, RA A said staff were using universal precautions when caring for residents with the infection. He said that meant he was washing his hands often. He said residents were not isolated, but said they usually wanted to stay in their room because they were so sick. He said he was sick himself and still felt a little achy. When asked about personal protective equipment, he said he did not understand why the nursing staff were wearing masks. If it ' s not airborne, why are they wearing them? In an interview on 2/12/2016 at 3:50pm, LVN C said she had been washing her hands and using gloves to prevent the spread of infection. When asked how she protected her clothing, she said she did not lean against objects or walls. She said she came back to work yesterday after becoming ill. Laundry Services In an interview on 2/12/2016 at 3:25 pm, CNA B said all of the laundry in the facility was processed normally. He said when resident ' s had an infection, they put the linens in a clear bag that was brought to the dirty linen closet. He said the facility stressed that the red biohazard bags were for serious infections. In an interview on 2/12/16 at 3:40 pm with Housekeeper C, he stated he was responsible for doing the laundry. He stated the linens and towels are placed in one bag and personal items like clothing are placed in another bag. The plastic bags are placed in large bins. He retrieves the bins and places the items in the washing machine. All the resident clothing gathered that day was washed together and all the towels and linens gathered that day was washed together. He stated the facility installed a new washing machine that week. The washing instructions were posted on the wall. Bleach was used when washing the towels and linens but not used when washing the personal items like clothing and bed spreads. In observations from 2/11/2016 at 10:00 am to 2/12/2016 at 4:45 pm, there were no red biohazard bags observed in the facility. All laundry was processed using clear plastic bags and placed in the same bin. Observations on 2/12/16 at 3:40 pm of the washing instructions posted on the laundry wall read in part, Washer/Items: sheets, towels, pads, heavy soiled, sheet, rags and cotton mops - bleach. Microfiber mops, personal/spreads, color table and bibs - no bleach . Cleaning of resident's rooms In an observation and interview on 2/11/2016 at 10:40 am, HK A was mopping room [ROOM NUMBER] (there was no sign on the door). She was using a cotton string mop head. She said she had been changing the mop water after each room. She said for residents with signs on their doors, she used a flat microfiber mop head to clean the floors. She said she put the mop heads in a bag to give to laundry when she finished. She said when she was cleaning resident rooms she would put on two sets of gloves. She said she did not wear a gown. In an interview on 2/11/2016 at 1:50 pm, the Administrator said the housekeeping staff had been very thorough. She said they had been cleaning with a disinfectant with bleach in every room and were changing the mops between each room. She said there were two housekeepers and a floor tech daily. She said they were making sure residents and staff were washing their hands and using sanitizer. She said residents with the infection were not isolated. We don ' t want to isolate them . they don ' t want to stay in their rooms. She said they were trying to maintain resident rights. In an interview on 2/11/2016 at 4:45pm, the HK Supervisor said the housekeeping staff were disinfecting everything with a cleaner with bleach. She said they were cleaning every room the same to stop the infection. She said she was not sure how or if the staff were mopping differently in the rooms with a recent infection. She said the housekeepers were aware of who had norovirus because they were given a list of residents with symptoms. In an interview on 2/12/2016 at 3:10 pm, the HK Supervisor said they had 3 housekeepers on staff and one floor tech. She said two housekeepers were scheduled per day. When asked if there were enough housekeepers staffed to keep the facility clean, she said it only took one hour to complete a hall, and said the housekeeper was there for 7 hours. She said they had been disinfecting everything that residents or staff members touch, like windowsills, headboards, phones, televisions, and handrails twice daily. She said they clean mattresses, curtains weekly on their deep cleaning schedule. In an interview on 2/12/2016 at 3:40 pm, Resident #10 was sitting outside of his room in the hallway. He said they had a resident council meeting that day. He said he did not know the name of the infection, but said the facility told them to wash their hands all of the time to prevent the infection from spreading. He said they have encouraged the residents to stay in their rooms. He thought the shortage of housekeeping staff attributed to the spread of the infection. In an interview on 2/12/2016 at 3:50 pm, LVN C said she was using Sani-cloth wipes to wipe down surfaces. (The label on the box did not say it killed norovirus). Notification to residents, visitors and staff In an observation on 2/11/2016 at 11:10 am, there was a sign on the front door of the facility that read, Several residents have been experiencing signs and/or symptoms of a stomach virus. Please considering (sic) visiting at another time, or limiting your visit. Please wash hands upon entering and exiting the building. Wash hands after touching resident and resident items. Handwashing is the most important prevention in the spread of infection. Please see the nurse if you have any questions. Observations on 2/11/2016 between 12:00 pm and 12:30 pm revealed Residents # 2, 6, 7, 9, 16, and 18 did not have a sign on their door to indicate they had an infection. Residents #1, 19, 20, 21, 22 and 23 had a sign on their door stating Please see nurse before entering. In an observation on 2/11/2016 at 12:45 pm, Residents #5 and 12 did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 3:00 pm, RA A said he knew who had the infection if they had a sign on their door and by word of mouth from the CNAs. In an interview on 2/11/2016 at 12:40 pm, LVN B said the facility started putting the signs on the doors of the residents with symptoms of infection about two days prior. She said it was the responsibility of the floor nurses to put the signs on the doors. She said she was aware some residents with the infection did not have signs on their doors, and said they were busy and did not have a chance to put them up. She said residents were not on isolation precautions. She said they were using standard precautions like hand washing. In an interview on 2/11/2016 at 12:42 pm, LVN A said the floor nurses were responsible for putting the signs on the resident ' s doors. She said they were supposed to remove them 72 hours after the resident becomes asymptomatic. She said the signs were there to remind staff to use standard precautions when in the rooms. She said there were supposed to wash their hands like normal and said they were not required to wear gowns, masks, or other personal protective equipment. She said residents were not on isolation precautions. In an interview on 2/12/16 at 4:05 pm with LVN D stated the residents with the active virus are asked to stay in their rooms. A sign instructing visitors to see the nurse is placed on the door. Those residents are placed on a list at the nursing station. The meals are served in their rooms. The staff is instructed to wear gloves, wash their hands when entering and leaving the room and use the sanitizer in between. The laundry is gathered by the staff, placed in plastic bags and taken to the laundry room. She stated the resident in room [ROOM NUMBER] had an active case of the virus. Observation on 2/12/16 at 4:10 pm revealed no sign instructing visitors to see the nurse on room [ROOM NUMBER] ' s door. In an interview with LVN D at the same time she said, the sign should be on the door. I ' ll take care of it right away. Meal service In an observation and interview on 12/11/2016 at 12:37 pm, CNA B entered Resident #13 ' s room to deliver her meal tray. There was a sign Resident #13 ' s door that read Please see nurse before entering. He was not wearing personal protective equipment when he entered the room. He dropped off meal trays to Resident #13 and her roommate. CNA B then raised her roommate ' s bed using a crank lift at the base of the bed facing the door. He did not wash his hands when he left the room. He said he did not wash his hands while delivering meal trays. He said he washed his hands before and after providing care to the residents. In an interview on 2/11/2016 at 10:00 am, the DON said she was away from the facility for two weeks when a norovirus outbreak started. She said there was an interim DON at that time (RN A). She said she returned to the facility two days ago. People are still getting it . I think it just needs to run its course. Record review of the list of residents with symptoms of norovirus posted at the nurse ' s station and updated on 2/11/2016 at 11:50 am revealed the following: - Residents #1, 20, 21, 22, and 23 experienced diarrhea and Residents #19 and 20 experienced vomiting on 2/8/2016. - Residents #13 and 15 experienced vomiting and diarrhea and Residents #1 and 14 experienced diarrhea on 2/9/2016. - Residents #1, 2, 7, 9, 16, and 17 experienced diarrhea on 2/10/2016. - Residents #6 and 18 experienced diarrhea on 2/11/2016. Two residents were added to the list on 2/11/2016 at 12:40 pm. It revealed that Residents #3 and 12 experienced diarrhea on 2/11/2016. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed on 1/30/2016, 6 residents started experiencing symptoms of norovirus including diarrhea, nausea and vomiting. This document further revealed that from 1/30/2016 to 2/13/2016, 41 residents were affected, and 5 residents were affected with symptoms a second time. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/16/2016 revealed that 4 residents started experiencing symptoms of norovirus on 2/16/2016, including 1 resident that had been affected previously. Record review of In-service Training Reports revealed the following: - On 2/3/2016, non-nursing staff including dietary, housekeeping and laundry staff received training on cleaning, hand washing, isolation procedures for resident meals, and preventing the spread of infection. - On 2/3/2016, nursing staff on different shifts received training on the prevention of GI symptoms or infection. The summary of meeting read in part . Attached is a list of all residents who have had symptoms of nausea/vomiting and/or diarrhea . All residents with such symptoms should be monitored in follow up charting for 48 ho

Based on observation, interview, and record review, the facility failed to ensure residents received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 10 of 11 residents (Residents #7, #6, #9, #10, #1, #2, #3, #5, #8, and #11) reviewed for quality of care in that: The facility failed to implement appropriate infection control procedures to protect residents from becoming exposed to norovirus as evidenced by: The facility failed to isolate/limit residents and staff contact between symptomatic and non-symptomatic residents to prevent the spread of norovirus. The facility failed to train and monitor staff on proper/timely handwashing, wearing protective wear, identifying symptomatic residents, and preventing cross contamination with resident's personal use items to decrease the risk of spreading norovirus. The facility failed to train/monitor the cleansing and transporting of symptomatic resident's clothing to prevent the spread of norovirus. The facility failed to provide adequate/effective cleaning of symptomatic resident's rooms to prevent cross contamination to non-symptomatic resident's rooms. The facility failed to have an effective notification system to alert residents, visitors and staff as to which residents were experiencing symptoms of norovirus. On 2/12/2016, an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 2/16/2016, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy, and a scope of pattern as the facility was continuing to monitor the implementation and effectiveness of their plan of removal. These failures affected 45 residents, one requiring hospitalization and six who suffered with symptoms of nausea, vomiting and diarrhea twice, and 17 staff members and placed the other 27 residents who resided at the facility at risk of developing norovirus with the potential for complications and hospitalization . Findings included: Incident # 9 Resident #7 Record review of Resident #7 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #7 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required extensive assistance of one person for dressing, toileting and bathing, and required total assistance of one person for personal hygiene. Record review of Resident #7 ' s Nurse Notes revealed the following: - 1/31/2016 at 6:00 am: Resident had an episode of diarrhea (sic) this AM very loose and watery . - 1/31/2016 at 1:30pm: Resident in dining room eating small (amount) of lunch and started having projectile vomiting while in dining room. Record review of a Patient Transfer Form dated 1/31/2016 revealed Resident #7 was transferred to the hospital for diarrhea frequent, projectile vomiting. Record review of an Admission/Readmission Data Summary dated 2/2/2016 revealed Resident #7 returned to the facility. Record review of Resident #7 ' s Hospital Records dated 2/1/2016 revealed she was admitted to the hospital for nausea, vomiting, diarrhea and fever. The patient developed fever after has been admitted and we have not seen any more bouts of vomiting at this moment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #7 had symptoms of infection including nausea and vomiting that started on 1/31/2016 and ended on 2/3/2016, and was sent to the hospital on [DATE]. It further revealed on 2/10/2016, she became symptomatic a second time with diarrhea. Record review of a physician's order [REDACTED].#7 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #6 Record review of Resident #6 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #6 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of one person for toileting and bathing, and required extensive assistance of one person for dressing and personal hygiene. Record review of a Nurse Note dated 2/11/2016 revealed that Resident #6 had two episodes of diarrhea. Record review of a physician's order [REDACTED].#6 was prescribed Gatorade 240mL by mouth four times for one day for dehydration related to nausea or vomiting. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #6 had symptoms of infection including diarrhea, nausea and vomiting that started on 1/30/2016 and ended on 2/2/2016. It further revealed on 2/11/2016, she became symptomatic a second time with diarrhea that lasted 24 hours. Record review of a physician's order [REDACTED].#6 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #9 Record review of Resident #9 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #9 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder, required total assistance of one person for dressing, toileting, personal hygiene and bathing and required supervision for eating. Record review of Resident #9 ' s Nurse Notes revealed the following: - 1/31/2016 at 2:10am: Noted (with) episode of loose stool and emesis x1 . - 1/31/2016 at 5:30pm: Reported that resident has had multiple episodes of loose stool this AM. [MEDICATION NAME] 2mg 1 x dose given around 11AM. No recent reports of loose stool . - 2/10/2016 at 12:00pm: Resident having s/sx Diarrhea noted to be ' like water. ' - 2/11/2016 at 11:30am: Diarrhea noted today . - (After IJ was called) 2/14/2016 (no time documented): Resident on isolation (due to) emesis . Resident non-complaint (sic) to room. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #9 had symptoms of infection including diarrhea, fever, nausea and vomiting that started on 1/31/2016 and ended on 2/1/2016. It further revealed on 2/10/2016, he became symptomatic a second time with diarrhea, nausea and vomiting. Record review of a physician's order [REDACTED].#9 was prescribed one dose of [MEDICATION NAME] 2mg for diarrhea. There was no order in his medical record for isolation precautions. In an observation on 2/11/2016 at 12:30 pm in the secure unit (500 hall), Resident #9 was sitting in the dining room eating his meal across from a resident who did not have signs or symptoms of the norovirus. In an observation and interview on 2/15/2016 at 11:05 pm, Resident #9 had personal protective equipment outside of his room, and there was a sign on his door that read Please see nurse before entering. Resident #9 exited his room and began walking around the secure unit. CNA D said it was difficult to keep Resident #9 in his room because he liked to wander. CNA D adn the SW at that time were observed to see Resident #9 in the unit and no one tried to redirect him back to his room. In an observation on 2/15/2016 at 12:38 pm, Resident #9 was sitting at a dining room table with Residents #17 and 25, who were not on contact precautions. He was eating lunch when he began coughing and drooling. LVN E had a towel in his hand and was wiping Resident #9 ' s mouth then placing the towel on the uncovered table. LVN E was not wearing any type of personal protective equipment. There were noticeable marks of a clear mucous substance on the table where the towel was placed. The SLP arrived with a new bowl of food. When the food was placed in his mouth, he vomited a clear substance. The SLP caught the emesis in a meal tray cover and took it away from the room. No one cleaned or disinfected the dining room table, and Residents #17 and 25 continued to eat at the table. In an interview on 2/15/2016 at 12:40 pm, LVN E said he did not believe residents with norovirus should be placed on isolation precautions. He said he had never isolated a resident with norovirus before. He said because Resident #9 was on contact precautions, he should not have been in the dining room. In an interview on 2/15/2016 at 1:30 pm, ADON said Resident #9 had [MEDICAL CONDITION] issues and said he choked on his food in the dining room which caused him to have an emesis. She said his last norovirus symptoms occurred on 2/10/2016, but he was placed on contact precautions because he had an emesis on 2/13/2016. She further stated LVN E was inserviced on the norovirus and contact precautions at 11:30 am that morning. She said she would talk to him again. Resident #10 Record review of Resident #10 ' s medical record revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #10 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required total assistance of one person for toileting, bathing, and personal hygiene. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #10 had symptoms of infection including diarrhea and nausea that started on 2/7/2016 that lasted 24 hours. It further revealed on 2/13/2016, he became symptomatic a second time with diarrhea, headache, nausea and vomiting. Record review of a physician's order [REDACTED].#10 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED]. Resident #1 Record review of Resident #1 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #1 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and frequently incontinent of bladder, and required limited assistance of one person for toileting, personal hygiene, bathing, and dressing. Record review of a nurse note dated 2/4/2016 revealed Resident #1 had two episodes of diarrhea and complained of nausea. Record review of a nurse note dated 2/9/2016 revealed Resident #1 no longer had symptoms of diarrhea or nausea. Record review of a physician's order [REDACTED].#1 ' s vital signs every shift, and to hydrate every two hours as tolerated. There was no order in her medical record for isolation precautions. In an observation on 2/11/2016 at 10:15 am, RA A was in room [ROOM NUMBER] talking with Resident #1, who was sitting in her bed. There was a sign Resident #1 ' s door that read Please see nurse before entering. RA A's hands were on her wheelchair handles, and his clothing was brushing up against the back of the chair. RA A was not wearing any personal protective equipment, including gloves or a gown. When he exited the room, he did not wash his hands. Resident #2 Record review of Resident #2 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #2 ' s significant change MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required total assistance of two people for toileting, and required total assistance of one person for personal hygiene, dressing, eating, and bathing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #2 had symptoms of infection including diarrhea that started on 2/10/2016. Record review of a physician's order [REDACTED].#2 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. There was no order in her medical record for isolation precautions. Resident #3 Record review of Resident #3 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #3 ' s annual MDS assessment dated [DATE] revealed she was occasionally incontinent of bowel and bladder and required limited assistance of one person for toileting, personal hygiene, and dressing. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #3 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/4/2016 and ended on 2/5/2016. Record review of a physician's order [REDACTED].#3 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea, and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for nausea and vomiting. There was no order in her medical record for isolation precautions. Resident #5 Record review of Resident #5 ' s medical record revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He was [AGE] years of age. Record review of Resident #5 ' s quarterly MDS assessment dated [DATE] revealed he was always incontinent of bowel and bladder and required extensive assistance of one person for toileting, personal hygiene, dressing, and bathing. He had a BIMS score of 13, indicating no cognitive impairment. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed Resident #5 had symptoms of infection including diarrhea, nausea and vomiting that started on 2/11/2016 and lasted 24 hours. Record review of a physician's order [REDACTED].#5 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea and one dose of [MEDICATION NAME] 12.5mg, one tablet by mouth for vomiting. There was no order in his medical record for isolation precautions. In an observation and interview on 2/11/2016 at 2:50 pm, there was a foul odor coming from Resident #5 ' s room. There was no sign on his door to indicate he had an infection. CNA A said, That is [DIAGNOSES REDACTED]. (an infection that causes diarrhea) right there, stay away from that room. The resident was in bed and said it is all over! CNA A put on a gown, gloves and mask before entering room then shut the door. She exited the room about 30 seconds later with the gown on and went to ask another aide for assistance. In an observation and interview on 2/12/2016 at 3:20 pm, Resident #5 was in bed. He said there was a sickness going around. He said he had been in bed since yesterday, and said he could not recall anyone cleaning his mattress. Resident #8 Record review of Resident #8 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #8 ' s quarterly MDS assessment dated [DATE] revealed she was continent of bowel and occasionally incontinent of bladder and required extensive assistance of one person for toileting, personal hygiene, dressing and bathing. Record review of Resident #8 ' s Nurse Notes revealed the following: - 2/12/2016 at 6:30am: Resident (with) nausea and emesis x1. c/o abdominal pain prior to emesis . - 2/12/2016 at 10:00am: Res. continues to vomit . - 2/12/2016 at 1:00pm: Res. ' thumbs up ' when asked if she was feeling better. No further emesis. - 2/13/2016 at 12:00am: Resident had diarrhea x1. Record review of a physician's order [REDACTED].#8 was prescribed one dose of [MEDICATION NAME] 25mg intramuscularly for vomiting. A physician's order [REDACTED].#8 was placed on contact isolation for precautions. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/12/2016 revealed Resident #8 was experiencing diarrhea and vomiting. In an observation on 2/12/2016 at 3:30pm, Resident #8 ' s room did not have personal protective equipment outside of room or a sign on her door to indicate she had an infection. Resident #11 Record review of Resident #11 ' s medical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was [AGE] years of age. Record review of Resident #11 ' s quarterly MDS assessment dated [DATE] revealed she was always incontinent of bowel and bladder, required supervision for toileting and limited assistance of one person for personal hygiene and dressing. She had short term and long term memory problems and did not display wandering behaviors. Record review of Resident #11 ' s Nurse Notes revealed the following: - 2/5/2016 at 6:00pm: Resident had an episode of diarrhea on this shift . - 2/9/2016 at 6:00pm: Resident reported c/o abdominal discomfort and with signs and symptoms of nausea and vomiting . Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. Record review of a physician's order [REDACTED].#11 was prescribed one dose of [MEDICATION NAME] 12.5mg intramuscularly for nausea and vomiting, and one dose of [MEDICATION NAME] 2mg, one tablet by mouth for diarrhea. In an observation and interview on 2/12/2016 at 3:38pm, Resident #11 was observed ambulating with a walker and exiting Resident #8 ' s room (room [ROOM NUMBER]). She said I went into my room, but it was occupied . According to the resident census, Resident #11 resided in room [ROOM NUMBER]. There was no staff on hall 200 to redirect Resident #11. Hand washing, protective wear In an interview on 2/11/2016 at 10:30 am, CNA A said she did not know the name of the infection that was affecting the residents. She said she had the infection and went to the emergency roiagnom on Sunday, 2/7/2016. She said It ' s bad. She said when the infection first started, she was in-serviced on normal hand washing, hand sanitizing, and using gowns and gloves as needed. She said she had been using gowns and gloves with every resident by choice. In an observation and interview on 2/11/2016 at 10:45am, room [ROOM NUMBER] (Resident #14 ' s room) had their call light on. The room had a sign on the door to Please see nurse before entering. LVN A entered the room to respond to the call light. She did not have personal protective equipment on. She had a balled up pair of gloves and a disposable cup in her hand. She turned off the call light and exited the room without washing her hands. LVN A said she just entered the room to turn of the call light because a resident pushed it on accident. She said she did not touch anything in the room except for the switch on the wall. She said Resident #14 had the infection, but was no longer symptomatic. She said she had been preventing the spread of infection by washing her hands and sanitizing as much as possible. In an interview on 2/11/2016 at 10:55am, CNA C said she was washing her hands and the resident ' s hands to prevent the spread of infection. She said she used a gown when residents were messy and used a mask for the smell. She said they kept the personal protective equipment in the linen closet. She said she changed her clothing at the facility so that she would not take the infection home. In an observation on 2/11/2016 at 11:35 am, HK A exited Resident #12 ' s room wearing a mask and two gloves on each hand. She removed her gloves in the hallway and put on two new pairs of gloves. She then entered Resident #5 ' s room and started to clean. She did not wash her hands or change her mask. Resident #12 ' s room (room [ROOM NUMBER]) and Resident #5 ' s room (room [ROOM NUMBER]) did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 11:50 am, the ADON said there was a list of residents with symptoms of norovirus at the nurse ' s station. She said they have instructed staff to wash their hands when they enter and leave the room, and to wear gloves when handling the resident. She said masks and gloves were optional. In an interview on 2/11/2016 at 3:00 pm, RA A said staff were using universal precautions when caring for residents with the infection. He said that meant he was washing his hands often. He said residents were not isolated, but said they usually wanted to stay in their room because they were so sick. He said he was sick himself and still felt a little achy. When asked about personal protective equipment, he said he did not understand why the nursing staff were wearing masks. If it ' s not airborne, why are they wearing them? In an interview on 2/12/2016 at 3:50pm, LVN C said she had been washing her hands and using gloves to prevent the spread of infection. When asked how she protected her clothing, she said she did not lean against objects or walls. She said she came back to work yesterday after becoming ill. Laundry Services In an interview on 2/12/2016 at 3:25 pm, CNA B said all of the laundry in the facility was processed normally. He said when resident ' s had an infection, they put the linens in a clear bag that was brought to the dirty linen closet. He said the facility stressed that the red biohazard bags were for serious infections. In an interview on 2/12/16 at 3:40 pm with Housekeeper C, he stated he was responsible for doing the laundry. He stated the linens and towels are placed in one bag and personal items like clothing are placed in another bag. The plastic bags are placed in large bins. He retrieves the bins and places the items in the washing machine. All the resident clothing gathered that day was washed together and all the towels and linens gathered that day was washed together. He stated the facility installed a new washing machine that week. The washing instructions were posted on the wall. Bleach was used when washing the towels and linens but not used when washing the personal items like clothing and bed spreads. In observations from 2/11/2016 at 10:00 am to 2/12/2016 at 4:45 pm, there were no red biohazard bags observed in the facility. All laundry was processed using clear plastic bags and placed in the same bin. Observations on 2/12/16 at 3:40 pm of the washing instructions posted on the laundry wall read in part, Washer/Items: sheets, towels, pads, heavy soiled, sheet, rags and cotton mops - bleach. Microfiber mops, personal/spreads, color table and bibs - no bleach . Cleaning of resident's rooms In an observation and interview on 2/11/2016 at 10:40 am, HK A was mopping room [ROOM NUMBER] (there was no sign on the door). She was using a cotton string mop head. She said she had been changing the mop water after each room. She said for residents with signs on their doors, she used a flat microfiber mop head to clean the floors. She said she put the mop heads in a bag to give to laundry when she finished. She said when she was cleaning resident rooms she would put on two sets of gloves. She said she did not wear a gown. In an interview on 2/11/2016 at 1:50 pm, the Administrator said the housekeeping staff had been very thorough. She said they had been cleaning with a disinfectant with bleach in every room and were changing the mops between each room. She said there were two housekeepers and a floor tech daily. She said they were making sure residents and staff were washing their hands and using sanitizer. She said residents with the infection were not isolated. We don ' t want to isolate them . they don ' t want to stay in their rooms. She said they were trying to maintain resident rights. In an interview on 2/11/2016 at 4:45pm, the HK Supervisor said the housekeeping staff were disinfecting everything with a cleaner with bleach. She said they were cleaning every room the same to stop the infection. She said she was not sure how or if the staff were mopping differently in the rooms with a recent infection. She said the housekeepers were aware of who had norovirus because they were given a list of residents with symptoms. In an interview on 2/12/2016 at 3:10 pm, the HK Supervisor said they had 3 housekeepers on staff and one floor tech. She said two housekeepers were scheduled per day. When asked if there were enough housekeepers staffed to keep the facility clean, she said it only took one hour to complete a hall, and said the housekeeper was there for 7 hours. She said they had been disinfecting everything that residents or staff members touch, like windowsills, headboards, phones, televisions, and handrails twice daily. She said they clean mattresses, curtains weekly on their deep cleaning schedule. In an interview on 2/12/2016 at 3:40 pm, Resident #10 was sitting outside of his room in the hallway. He said they had a resident council meeting that day. He said he did not know the name of the infection, but said the facility told them to wash their hands all of the time to prevent the infection from spreading. He said they have encouraged the residents to stay in their rooms. He thought the shortage of housekeeping staff attributed to the spread of the infection. In an interview on 2/12/2016 at 3:50 pm, LVN C said she was using Sani-cloth wipes to wipe down surfaces. (The label on the box did not say it killed norovirus). Notification to residents, visitors and staff In an observation on 2/11/2016 at 11:10 am, there was a sign on the front door of the facility that read, Several residents have been experiencing signs and/or symptoms of a stomach virus. Please considering (sic) visiting at another time, or limiting your visit. Please wash hands upon entering and exiting the building. Wash hands after touching resident and resident items. Handwashing is the most important prevention in the spread of infection. Please see the nurse if you have any questions. Observations on 2/11/2016 between 12:00 pm and 12:30 pm revealed Residents # 2, 6, 7, 9, 16, and 18 did not have a sign on their door to indicate they had an infection. Residents #1, 19, 20, 21, 22 and 23 had a sign on their door stating Please see nurse before entering. In an observation on 2/11/2016 at 12:45 pm, Residents #5 and 12 did not have a sign on their door to indicate they had an infection. In an interview on 2/11/2016 at 3:00 pm, RA A said he knew who had the infection if they had a sign on their door and by word of mouth from the CNAs. In an interview on 2/11/2016 at 12:40 pm, LVN B said the facility started putting the signs on the doors of the residents with symptoms of infection about two days prior. She said it was the responsibility of the floor nurses to put the signs on the doors. She said she was aware some residents with the infection did not have signs on their doors, and said they were busy and did not have a chance to put them up. She said residents were not on isolation precautions. She said they were using standard precautions like hand washing. In an interview on 2/11/2016 at 12:42 pm, LVN A said the floor nurses were responsible for putting the signs on the resident ' s doors. She said they were supposed to remove them 72 hours after the resident becomes asymptomatic. She said the signs were there to remind staff to use standard precautions when in the rooms. She said there were supposed to wash their hands like normal and said they were not required to wear gowns, masks, or other personal protective equipment. She said residents were not on isolation precautions. In an interview on 2/12/16 at 4:05 pm with LVN D stated the residents with the [MEDICAL CONDITION] are asked to stay in their rooms. A sign instructing visitors to see the nurse is placed on the door. Those residents are placed on a list at the nursing station. The meals are served in their rooms. The staff is instructed to wear gloves, wash their hands when entering and leaving the room and use the sanitizer in between. The laundry is gathered by the staff, placed in plastic bags and taken to the laundry room. She stated the resident in room [ROOM NUMBER] had an active case of [MEDICAL CONDITION]. Observation on 2/12/16 at 4:10 pm revealed no sign instructing visitors to see the nurse on room [ROOM NUMBER] ' s door. In an interview with LVN D at the same time she said, the sign should be on the door. I ' ll take care of it right away. Meal service In an observation and interview on 12/11/2016 at 12:37 pm, CNA B entered Resident #13 ' s room to deliver her meal tray. There was a sign Resident #13 ' s door that read Please see nurse before entering. He was not wearing personal protective equipment when he entered the room. He dropped off meal trays to Resident #13 and her roommate. CNA B then raised her roommate ' s bed using a crank lift at the base of the bed facing the door. He did not wash his hands when he left the room. He said he did not wash his hands while delivering meal trays. He said he washed his hands before and after providing care to the residents. In an interview on 2/11/2016 at 10:00 am, the DON said she was away from the facility for two weeks when a norovirus outbreak started. She said there was an interim DON at that time (RN A). She said she returned to the facility two days ago. People are still getting it . I think it just needs to run its course. Record review of the list of residents with symptoms of norovirus posted at the nurse ' s station and updated on 2/11/2016 at 11:50 am revealed the following: - Residents #1, 20, 21, 22, and 23 experienced diarrhea and Residents #19 and 20 experienced vomiting on 2/8/2016. - Residents #13 and 15 experienced vomiting and diarrhea and Residents #1 and 14 experienced diarrhea on 2/9/2016. - Residents #1, 2, 7, 9, 16, and 17 experienced diarrhea on 2/10/2016. - Residents #6 and 18 experienced diarrhea on 2/11/2016. Two residents were added to the list on 2/11/2016 at 12:40 pm. It revealed that Residents #3 and 12 experienced diarrhea on 2/11/2016. Record review of the undated Resident Gastrointestinal (GI) Illness Log revealed on 1/30/2016, 6 residents started experiencing symptoms of norovirus including diarrhea, nausea and vomiting. This document further revealed that from 1/30/2016 to 2/13/2016, 41 residents were affected, and 5 residents were affected with symptoms a second time. Record review of the list at the nurse ' s station of residents with symptoms of norovirus dated 2/16/2016 revealed that 4 residents started experiencing symptoms of norovirus on 2/16/2016, including 1 resident that had been affected previously. Record review of In-service Training Reports revealed the following: - On 2/3/2016, non-nursing staff including dietary, housekeeping and laundry staff received training on cleaning, hand washing, isolation procedures for resident meals, and preventing the spread of infection. - On 2/3/2016, nursing staff on different shifts received training on the prevention of GI symptoms or infection. The summary of meeting read in part . Attached is a list of all residents who have had symptoms of nausea/vomiting and/or diarrhea . All residents with such symptoms should be monitored in follow up charting for 48

Based on record review and interview, the facility failed to follow its written policies and procedures were implemented for 1 of 4 residents (Resident #1) reviewed for neglect, as evidenced by: --LVN A failed to respond in accordance with facility policy when a resident was discovered to be unresponsive with no signs of respiration or heartbeat. This failure affected 1 CR (closed record) and placed 75 other residents at risk of not receiving cardiopulmonary resuscitation according to their wishes. Incident #: 5 Findings include: Record review of facility Nursing Policy and Procedure on Cardiopulmonary Resuscitation revised 3 / 2012 revealed the following instructions: "1. Determine unresponsiveness by tapping or gently shaking resident and shouting, "Are you okay? " 2. Call out for help. 3. Delegate a specific individual to obtain the Emergency cart and check resident status for CPR or no CPR in the folder/notebook provided; have individual call paramedics, attending physician and administrative personnel per home guideline and report back to you as soon as possible. 4. Note: Do not start cardiopulmonary resuscitation (CPR) if resident is breathing and has a pulse. Start emergency oxygen; delegate a specific individual (must be a nurse) to stay with the resident and monitor vital signs". Record review of facility Nursing Policy and Procedure on Emergency Care - Emergency Transport - 911 Protocol revised 3 / 2012 revealed the following procedure: "7. 911 Emergency Transport will be called when a resident is found to have experienced a change of condition indicating life threatening event occurred or the resident shows signs that impending life threatening event is suspected. In life threatening situations 911 will be called prior to contacting the physician. 911 will be called and resident will be transported to the hospital. Resident Advance Directive regarding Code Status and hospitalization will be honored in all instances. Examples of changes of condition indicating life threatening event include, but not limited to: a. [MEDICAL CONDITION] B. Respiratory arrest c. Head injury d. Severe trauma e. Abnormal signs or symptoms with no prior history" Record review of the Clinical File for CR #1 revealed he was re-admitted to the facility on [DATE]. He was [AGE] years old. His [DIAGNOSES REDACTED]. Record review of Resident #1's face sheet dated [DATE] revealed his code status as Full Code. Record review of the Facility Incident/Accident Report dated [DATE] revealed Resident #1 was found unresponsive with no breath sounds and no pulse on [DATE] at 2:30 am. In an interview on [DATE] at 5:00 am with LVN A she stated she was the nurse who assessed Resident #1 as having no breath sounds or pulse. She stated at that time she went to check his Clinical File for a code status and was unable to find the documents to indicate if the resident was a DNR (do not resuscitate) or Full Code status. In continued interview at that time, LVN A stated she attempted to contact LVN E, the On- Call Supervisor via the telephone, but was unable to do so. She stated she then contacted and reached LVN G on the phone and was instructed to begin CPR. LVN A stated that she administered CPR and CNA B assisted using the Ambu (Artificial Manual Breathing Unit) bag, while CNA C called 911 at 2:30 am. She further stated, emergency medical services (EMS) arrived, at approximately 3:10 am and called the time of death for CR #1. In an interview on [DATE] at 5:05 am with CNA B she said she was the staff person who reported Resident #1's lack of responsiveness to LVN A. She further said it was less than five minutes duration between the time Resident #1 was assessed as having no breath sounds or pulse and the time she accompanied LVN A back to the resident's room and began CPR. Record review of the Clinical File for CR #1 revealed the face sheet, dated [DATE], listed his code status as Full Code but no other Code Status Documentation was in the file. In an interview on [DATE] at 5:20 am, LVN I stated no training had been provided on the provision of CPR to non-responsive residents (with no breath sounds or pulse) until two days ago, [DATE]. In an interview on [DATE] at 5:30 am, LVN J stated no training on the provision of CPR had been provided until until two days ago, [DATE]. LVN J said, in the case of a non-responsive resident with no breath sounds or pulse, their procedure would be to wait with the resident and send another staff person to ascertain the resident's Code Status before beginning CPR. In an interview on [DATE] at 9:30 am with the DON and RN H they said they could not find the necessary Code Status Documents in Resident # 1's Clinical File. They said the documents might be in the resident's business file. Record review of Resident #1's Advance Directives Policy and Record form dated [DATE] revealed a Durable Power of Attorney document had been received on [DATE]. The space to note an Advance Directive/Out of Hospital Advanced Directive received, and the space to record No Advance Directive were both blank. The Durable Power of Attorney document had no instructions on resuscitation. No Out of Hospital Advanced Directives form was found. In an interview on [DATE] at 9:50 am with the DON she said in the absence of knowledge of a resident's Code Status, she would begin CPR. In an interview on [DATE] at 9:55 am, RN H said if a resident was found who was without breath sounds or pulse, and the resident's Code Status was not known, CPR would be initiated. In an interview on [DATE] at 10:00 am , LVN K said they had not been given facility instruction on starting CPR on a resident in the absence of information about the resident's Code Status. In an interview on [DATE] at 10:10 am, LVN L, said if a resident of unknown Code Status was not breathing and had no pulse, they would call for help, stay with the resident, and start CPR. In an interview on [DATE] at 10:15 am, LVN M initially stated that she would not administer CPR until knowing a residents code status. In continued interview, she stated she would administer CPR even if she did not know the residents code status. Record reveiw of the nurses notes dated [DATE] revealed CR #1 had requested a nebulizer treatment at 1:30 am. Further review revealed EMS arrived at 3:10 am. Record review of the facility training sheets entitled "Emergency Response and Calling 911", dated [DATE], revealed the training was attended by LVN I and LVN K. Further review revealed the DON, LVN J and LVN M were not identified as attending the training. The training was conducted by RN H. Record review of Lippincott's Nursing Procedures/Fifth Edition published in 2009 revealed the following cardiopulmonary resuscitation standards: "...CPR alone doesn't improve their chances of survival. Therefore, you must assess the victim and then contact emergency medical services (EMS) or call a code before starting CPR. Timing is critical because early access to EMS, early CPR, and early defibrillation greatly improve a patient's chances of survival." The facility's Resident Census and Condition form 672 listed a census of 75.