Gallaway Health And Rehab

Based on personnel file review, facility document review and interview, Administration failed to ensure that nursing services were provided by qualified personnel when the facility hired an imposter nurse (Imposter Nurse A) to function as a Licensed Practical Nurse (LPN) using another LPN's (LPN C) Tennessee license. The findings include: Review of Imposter Nurse A's personnel file revealed a letter from a Tennessee Criminal History Record Request for Imposter Nurse A's first and last name revealed, .NO TENNESSEE CRIMINAL HISTORY RECORD HAS BEEN FOUND FOR THE PERSON LISTED BELOW. There was no national background check found in the personnel file. Review of the I-9 form (Employment Eligibility Verification) used to verify the identity and legal authorization of individuals hired for employment in the United States dated 04/11/2023, revealed Imposter Nurse A's legal first and last name, along with a birth certificate and a valid Driver's license from another state. The last name used on the I-9 form was the same as the Driver's license. Review of a license verification form revealed the nursing license was in the name of the LPN. LPN C had the same first name as Imposter Nurse A but a different last name. Review of two Tennessee Abuse Registry checks dated 04/05/2023 revealed one check was for LPN C's name and the second check was for Imposter Nurse A's name. Review of the Offer Letter to Imposter Nurse A dated and signed by the candidate on 04/11/2023 revealed, .We are pleased to offer you the Temporary/Contract LPN.Start Date: 4/11/23 - 6/6/23 . Review of the time sheet for Imposter Nurse A revealed she worked in the facility on 04/11/2023, 04/12/2023, 04/13/2023, 05/02/2023, 05/09/2023, 05/10/2023, 05/12/2023, 05/13/2023, and 05/14/2023. Review of two separation notices revealed the first notice dated 05/08/2023 with a last day worked date of 05/02/2023 showed Voluntary Separation without Notice.Resignation No Notice. The second separation notice dated 05/22/2023 with a last day worked date of 05/14/2023 showed Voluntary Separation without Notice.Resignation No Notice. No paperwork was provided related to the rehire of Imposter Nurse A after the first termination. During an interview on 10/1/2025 beginning at 9:15 AM, the Human Resource Director admitted there was no policy related to hiring. The Human Resource Director confirmed Imposter Nurse A did work onsite at the facility briefly and was terminated for failure to attend training. The Human Resource Director reiterated she was terminated again for failure to come in as needed. Imposter Nurse A was hired as a Licensed Practical Nurse to render nursing services, and she was only terminated for failure to complete her training. The facility employed an unqualified person. There was no information given to the surveyor as to any cross reference of inconsistencies with the different names listed on the employment application, I-9 form and the nursing license verification form submitted by the candidate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, and interview, the facility failed to develop and implement a person-centered care plan for 1 of 3 (Resident #3) sampled residents reviewed. The findings include: 1.Review of the undated facility policy titled, KARDEX revealed, .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, F 656, F 657, F 658 Comprehensive Care Plans, with an effective date of 3/2025 revealed, .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.The IDT [Interdisciplinary Team] will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of the facility policy titled, Safe Lifting and Movement of Residents, with an effective date of 10/2024 revealed, .to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.Manual lifting of residents shall be eliminated when feasible.Staff will document resident transferring and lifting needs in the care plan.assessment shall include.Resident's mobility.Weight-bearing ability.Cognitive status. 2.Review of the medical record revealed Resident #3 was admitted to the facility on [DATE], with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- group of lung diseases that make it difficult to breathe), Dementia, History of falling, Drug Induced Subacute Dyskinesia (disorder that causes involuntary movements), and Anxiety. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 5, which indicated severe cognitive impairment. Resident #3 was coded 1 dependent for all Functional Abilities which included eating, bathing, dressing, hygiene, and toileting. Resident #3 was dependent for all bed mobility and transfers. Review of the comprehensive care plan for Resident #3 dated 4/27/2025 revealed, .risk for falls r/t [related/to] confusion.Interventions.Anticipate and meet [Named Resident #3]'s needs.requires activities that minimize the potential for falls while providing diversion and distraction.Due to increased alertness staff to check resident at end of shift.Move all furniture out of room. Leave bed and mattress only.[Named Resident #3] has potential for respiratory complications r/t Emphysema [lung disease that damages the lungs and makes it difficult to breathe]/ COPD.Interventions.Head of bed to be elevated.or out of bed upright in a chair during episodes of difficulty breathing.Monitor/document for anxiety [worry, nervousness, restlessness, sleep disturbances].[Named Resident #3] has potential.impairment to skin integrity r/t fragile skin, constant movement while awake.Interventions.Use caution during transfers and bed mobility.[Named Resident #3] has potential for acute/chronic pain r/t impaired physical status.Interventions.Monitor for and report to charge nurse s/s of pain-facial grimacing, moaning, groaning, resistive to movement. Review of the Skin and Wound Evaluation for Resident #3 dated 5/5/2025 revealed, .Skin Condition.Redness.Sacrum blanchable redness sacral area.no other new skin issues noted. Review of the Incident Report for Resident #3 dated 5/6/2025 at 8:50 AM revealed, .Bruise.CNA [Certified Nursing Assistant-] entered the room to provide care.observed bruises on the resident.front left lateral [outside] medial [inside] leg.inner [inside] left lateral [outside] knee.front left lateral leg.front of left lateral knee.front of the left lower leg.front of the right knee.right shin.right outer elbow.right shoulder.right cheek.left chin.left side of neck.left shoulder.left upper arm.left inner elbow.resident sent to ED [Emergency Department] for evaluation.police presence.Predisposing Physiological [related to the mind] Factors.Impaired Memory.Incontinent.Agitated/Anxious.Confused.Decreased safety awareness.Delusions.Hallucinations.Impulsive.Involuntary Movements.Receives Antipsychotics [Seroquel-rare, very low probability meaning most people will not experience the side effect of increased bruising].Predisposing Situation Factors.A cna [CNA BB] new to [Named Facility] assigned to resident last night [5/5/2025 to 5/6/2025]. Review of a Progress Note for Resident #3 dated 5/6/2025 at 9:58 AM revealed, .Resident [Resident #3] noted to have discoloration to right side of her face.Nodule noted right side forehead with discoloration.Under left chin dark blackish looking discoloration quarter size.both shoulders notes to have purplish [purple] discoloration, both arms.several new areas of discoloration.both tops of hands with new areas of discoloration.legs with new areas of discoloration. Behind right ear small new area of discoloration.order to send resident to ER [Emergency Room]. Review of the Incident Report for Resident #3 dated 5/6/2025 at 12:00 PM revealed, .Fall: Known Cause.Incident Description. [CNA BB] assigned to resident last night 7pm 7am [5/5/2025 to 5/6/2025] reported.resident was on her floor mattress multiple times last night.resident was on the floor multiple times last night up against the night stand, with her legs under the bed, lying on her side with face on floor.Resident with multiple bruising to body.[CNA BB] said she placed resident on the mat and in the bed multiple times last night. Review of CNA BB's handwritten signed statement dated 5/6/2025 revealed, .The going [CNA] gave me a walk through.on who does what, Incontinent or not.showed me when [where] the linen and garbage was.I checked on her [Resident #3].changed her.left the room. Later I heard her Really loud so I went Back in the Room she was hanging on the side of the Bed So I sled [slid] her down on the mat BC [because] I couldn't continue to put her Back in the Bed.I know I went In there at least 7-8 time [times] due to her loudness I went I [in] there one time she was on her side by the dressers I place her Back on the mat.me lifting on her trying to get her Back on the mat all night long.All night she was hollering .constantly moving all over the room off the mat.she have a bruise by her foot Is due to her Being on the mat. During an interview on 8/25/2025 at 4:24 PM the Director of Nursing (DON) stated .[Named CNA] said she picked up [Named Resident #3] 6 or 7 times during the night [5/5/2025-5/6/2025].[CNA] said she picked [Resident #3] up by putting her arms under [Resident #3's] arms and put her back on the bed or mattress on the floor beside the bed.that is how she got the bruises to her shoulders. The rest of the bruising came from falling off the low bed and bumping into things in the room while crawling around. The DON was asked if there was furniture in Resident #3's room. The DON responded, Yes, a bed, a bedside table and an over the bed table. The DON was asked if Resident #3 required a two person assist with mechanical lift for transfers. The DON responded, Yes. The DON reviewed Resident #3's comprehensive care plan and confirmed Resident #3 was care planned for falls with interventions which included move all furniture out of room, leave mattress and bed only. The DON also confirmed Resident #3 should have been care planned for two-person with mechanical lift transfer assistance and was not. During a telephone interview on 8/27/2025 at 9:35 AM, CNA BB stated 5/5/2025 was her first shift on the Memory Care Unit and she had no orientation other than paperwork/computer lessons on the job since being hired. CNA BB stated she did not get report on the residents at shift change and she did not know how to access the resident's care plan on the computer. CNA BB stated Resident #3 had fallen off the bed on to a cushioned mat several times during the night and also crawled around in the floor. CNA BB was asked if Resident #3 required a two-person assisted mechanical lift for transfers. CNA BB replied, .I really don't know what she required, I was told it was normal to leave her on the mat all night. CNA BB confirmed she pulled Resident #3 up and put her back on the bed multiple times without assistance and without using a mechanical lift. CNA BB was asked if she had reported Resident #3's falls to Licensed Practical Nurse (LPN) Y. She replied, .No, I figured she knew because she was sitting in the hall outside of her [Resident #3's] room all night.I figured it was something she [Resident #3] do [does] all the time, since the nurse didn't say anything. During an interview on 8/27/2025 at 6:16 PM the MDS Coordinator stated per facility policy residents who cannot bear weight require a two person assist with a mechanical lift. The MDS Coordinator reviewed Resident #3's comprehensive care plan and confirmed a care plan was not developed and implemented for transfer assistance. The MDS Coordinator stated Resident #3 was unable to bear weight and should have had a care plan for transfers using 2 person assist with the use of a mechanical lift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, email correspondence review, observation, and interview, the facility failed to protect the residents' right to be free from neglect for 3 of 14 (Resident #6, Resident #1, and Resident #12) sampled residents reviewed for abuse and neglect. Resident #6, a vulnerable, cognitively impaired, totally dependent resident who required enteral feeding (method of delivering nutrition directly into the gastrointestinal tract) for nutrition was reviewed for neglect. On 3/20/2025, the nurse documented Resident #6 had a tear on the side of the feeding port of the percutaneous endoscopic gastrostomy (PEG) tube which caused leakage of the feeding onto the bed. Resident #6 did not receive a new PEG tube until 4/7/2025, 19 days after the tear was found, which allowed for leakage of the enteral nutrition for 19 days. Resident #6's weight was 137 pounds (lbs.) on 3/14/2025 and decreased to 117 lbs. on 4/3/2025. Resident #6 sustained a severe weight loss of 14.59 percent (%) in 20 days which delayed healing on her current Stage 3 pressure ulcer/injury (a deep wound that involves full-thickness tissue loss) on the Left Ischial Tuberosity (the bony prominence on the posterior bottom left part of the pelvis). Resident #6 was noted to have a new in-house acquired blister on 4/8/2025, on her right lower back. On 4/16/2025 a new Stage 2 pressure ulcer/injury (partial thickness skin loss involving the epidermis and or dermis) to her coccyx was identified. On 4/30/2025, a new Deep Tissue Injury (DTI) (a pressure-related injury to the soft tissue under the skin) on her left heel was identified. The Registered Dietician confirmed the tear in the feeding tube contributed to Resident #6's severe weight loss Resident #1, a vulnerable, cognitively impaired resident who required 2-person, mechanical lift assistance for transfers sustained a left, distal femur fracture (a break in the lower part of the left thigh bone, just above the knee joint) when staff transferred her without the use of the mechanical lift on 7/4/2025. Resident #1 had a prior improper transfer without the use of the mechanical lift which resulted in a toe fracture (broken bone). The Certified Nursing Assistant (CNA) found Resident #1 sitting in her wheelchair screaming with excruciating pain on 7/4/2025 and attempted to stand Resident #1 up to transfer her to the bed without notifying the nurse for evaluation of Resident #1's pain, which resulted in increased pain. The CNA then picked Resident #1 up and placed her in bed, without the use of the 2-person mechanical lift. The nurse's assessment completed after Resident #1 was placed in the bed revealed bruising and swelling of her left knee. An X-Ray was obtained which revealed Resident #1 had a left distal femur fracture. The facility's failures resulted in Immediate jeopardy for Resident #1 and Resident #6. The facility also neglected to maintain and provide the ordered enteral feeding as scheduled for Resident #12's continuous enteral feed on 8/20/2025. Immediate Jeopardy (IJ) (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified related to the facility's failure to provide necessary goods and services to Resident #1 and Resident #6. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) of F-600 on 8/14/2025 at 10:53 AM. An amended template for F-600 was given to the Administrator and the DON on 8/20/2025 at 11:53 AM, in the Conference Room. The facility was cited at F-600 at a scope and severity of J, which constitutes Substandard Quality of Care. A partial extended survey was conducted from 8/20/2025 through 8/22/2025. An acceptable Removal Plan, which removes the immediacy of the Jeopardy for F-600 was received on 8/22/2025. The Removal Plan was validated onsite by the surveyor on 8/22/2025 through audit review, medical record review, observation, review of education records, and staff interviews. The IJ began on 3/20/2025 and was removed on 8/23/2025. The facility's noncompliance at F-600 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1.Review of the facility policy titled, Abuse Prevention Program F600, dated 8/2024 revealed, .Residents have the right to be free from abuse, neglect.resulting physical harm, pain.Abuse also includes the deprivation by an individual, including a caretaker, of goods and services that are necessary to attain or maintain, physical, mental or psychological well-being.Neglect means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.The facility administration and employees are committed to protecting residents from abuse by anyone including, but not necessarily limited to.facility staff.Identification of occurrences and patterns of potential mistreatment/abuse.The reporting and filing of accurate documents relative to incidents of abuse.The implementation of changes to prevent future occurrences of abuse.The current .components of the CMS [Centers for Medicare and Medicaid Services] directed Abuse Condition of Participation .Reporting to the state is per state guidelines. Review of the undated policy titled, KARDEX, revealed .the KARDEX is a vital section that outlines each resident's individualized daily care plan. It provides detailed instructions on various aspects of care, including the resident's daily activities.includes information on the resident's mobility.specific safety needs.and transfer methods.It notes whether the resident can ambulate independently. Review of the facility policy titled, Assessing Falls and Their Causes Guidelines, dated 10/2024, revealed, .The purposes of this procedure are to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall.Residents must be assessed in a timely manner for potential causes of falls.Relevant environmental issues should be addressed promptly.If a resident has just fallen.nursing staff will record.and evaluate for possible injuries to the head, neck, spine, and extremities.nursing staff will provide appropriate first aid.Documentation will include any observed signs or symptoms of pain, swelling, bruising.An incident report must be completed for residents falls. The incident report form should be completed by the nursing supervisor on duty at the time.no later than 24 hours after the fall occurs. Review of the facility policy titled, .Abuse Prevention Program, Recognizing Signs and Symptoms of Abuse/Neglect (Identification), dated 10/2024, revealed .Neglect occurs when the facility is aware of, or should have been aware of goods and services that a resident (s) requires but the facility fails to provide them to the resident (s), resulting in, or may result in, physical harm, pain.Signs of / Actual Physical Neglect.unexplained weight loss.Possible signs/symptoms.Inconsistent injury explanation. Review of the facility policy titled, .Comprehensive Care Plans, dated 3/2025, revealed .An individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident's medical, nursing, mental cultural and psychological needs is developed for each resident.The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physicians [physician's] orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.Each resident's comprehensive care plan is designed to.Incorporate identified problem areas.The Care Planning/Interdisciplinary Team is responsible for the periodic review and updating of care plans.At least quarterly.The IDT [Interdisciplinary Team] will outline services in the comprehensive care plan that meet professional standards of quality or accepted standards of clinical practice. Review of the facility policy titled, Enteral Nutrition ., dated 5/2025, revealed .Adequate nutritional support through enteral feeding will be provided to residents as ordered.A dietitian will assess residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance tolerance and nutritional adequacy of enteral feedings and to prevent complications associated with enteral feedings and to prevent complications associated with enteral feedings.Enteral feeding orders will be written to ensure consistent volume infusion. The following information will be included to ensure that the full volume will be infused, regardless of any interruption of feeding.Rate of infusion.Total calories per day.Total daily volume to be infused (number of ml (milliliter) per day).Central supply or Food Service Manager will be responsible for ordering all tube feeding supplies. Review of the facility policy titled, Wound Care Guidelines, dated 6/2025, revealed .The purpose of this procedure is to provide guidelines for the care of wounds and to promote healing. Review of the facility policy titled, Exercise of Rights/Resident Rights ., dated 11/2024, revealed .Our residents have the right to a dignified existence.access to persons and services inside and outside the facility.Our residents have equal access to quality care.Treated with dignity means the resident will be assisted in maintaining and enhancing his or her self-esteem and self-worth.Staff shall treat cognitively impaired residents with dignity and sensitivity. Review of the facility policy titled, Change in a Resident's Condition or Status ., dated 10/2024, revealed .The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical.condition and/or status.The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-Call Physician.A need to alter the resident's medical treatment significantly.A need to transfer the resident to a hospital/treatment center.There is change in the resident's level of care status. Review of the facility policy titled, Pressure Injury/Skin Breakdown-Clinical Guidelines, dated 6/2025, revealed .The nursing staff will complete an evaluation of the skin.Based upon need and the results of the evaluations the staff will implement interventions for the prevention and care of skin issues.Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect.weight.and overall nutritional balance. Review of the facility policy titled, Quality of Life-Activities of Daily Living ., dated 4/2025, revealed .The community environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity and well-being.Residents whom are unable to carry out activities of daily living receive the necessary care and services to maintain good nutrition.Residents are provided with appropriate care.Utilize ADL [activities of daily living] reports, paper or electronic to assess ADL decline.Update care plan appropriately and interventions as needed. Review of the facility policy titled, Accidents and Incidents - Investigating and Reporting ., dated 10/2024, revealed .All accidents or incidents involving residents, employees.The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident.The following data, as applicable, shall be included.nature of the injury.circumstances surrounding the accident or incident.condition of the injured person.disposition of the injured.Any corrective action taken.The Director of Nursing.shall review and complete.The Administrator shall review. 2. Review of the medical record revealed Resident #6 was admitted on [DATE], with diagnoses which included Encephalopathy, Aphasia, Dysphagia, and Cognitive Communication Deficit. Review of the Medication Administration Record (MAR) dated 3/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity (calorically dense, fiber-fortified nutrition that provides balanced nutrition for long term tube feeding) 1.5 at 55 milliliter (ml)/Hour via (by way of) PEG tube. Resident #6's enteral feed order revealed to turn off the pump at 11:00 AM and turn the pump back on at 1:00 PM. Review of the Weights and Vitals Summary revealed Resident #6 weighed 137 lbs. on 3/14/2025. Review of the Progress Notes for Resident #6 dated 3/20/2025, revealed .Peg [PEG] tube.needs to be replaced due to tear on the side at the port. Tape use [used] to secure the spike [the end of the tubing connected to the residents PEG tube] into the port. Review of the Skin & (and) Wound Evaluation for Resident #6 dated 3/24/2025, revealed a Stage 2 pressure ulcer to the Resident's Left Ischial Tuberosity which measured 2.0 centimeter (cm) in Length (l) by 2.5 cm width (w) by 0 depth (d) which equaled a total area of 3.7 cm2 (centimeter squared a unit used in the measurement of area). Review of the Weights and Vitals Summary revealed Resident #6 weighed 117 lbs. on 4/3/2025. Review of the Progress Notes for Resident #6 dated 4/3/2025, revealed .NP [Nurse Practitioner] spoke with this residents' RP [Resident's Responsible Party] regarding weight loss and slow decline in status. Review of Hospital #3's After Visit Summary dated 4/7/2025 revealed Resident #3's Peg tube was replaced. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #6 had poor short term and long-term memory. Resident #6 was dependent on staff for all activities of daily living. Resident #6 had an unplanned weight loss during the assessment reference period. Resident #6 received all nutrition through her PEG tube. Resident #6's pressure ulcer declined from Stage 2 to a Stage 3. Review of the medical record revealed Resident #6 was diagnosed with Abnormal Weight loss and Protein-Calorie Malnutrition on 4/8/2025. Review of the MAR dated 4/2025, revealed Resident #6 had scheduled continuous enteral feed for Jevity 1.5 at 55 ml/hour via PEG tube from 4/1/2025 through 4/8/2025. Resident #6's enteral feed was changed on 4/8/2025 to Jevity 1.5 at 65 ml/hour via PEG tube. Resident #6's enteral feed order revealed to turn off pump at 11:00 AM and turn pump back on at 1:00 PM Review of the NP Progress Notes dated 4/8/2025, revealed .Follow up.Prior unintended weight loss of 20lbs [20 lbs] .Patient [Resident #6] was found to have a dysfunctional PEG tube and it has since been replaced. She has also been moved to a room closure [closer] to nursing station for closer monitoring.Abnormal weight loss: PEG tube replaced. Will continue to monitor intake and feeding schedule . Review of the Skin & Wound Evaluation for Resident #6 dated 4/8/2025, revealed a new in-house pressure ulcer on her right lower back measuring 1.0 cm (l) by 1.5 cm (w). Review of the Nutrition Note dated 4/8/2025, revealed .A nutritional assessment was completed on this date for [Named Resident #6]. Resident's current weight.117.2 - 4/4/2025.Resident has had a weight change over the last 30 days. weight down 20# [20 lbs.] in 30 days, 14.5 % loss significant. Resident's current diet order .NPO [nothing by mouth] .Resident has stage II [2] pressure injury [ulcer] .per most recent skin report.Resident has skin concern(s) per most recent skin report.Enteral regimen has been unchanged since January and weight had been stable with gradual gain noted. Prostate [liquid protein].was added in March. Multiple pressure wounds noted, new area noted today. Labs reviewed.Peg tube was replaced 4/7 [4/7/2025] d/t [due to] split in tube.Rec [recommendation] to increase enteral [feeding] to Jevity 1.5 @ [at] 65ml/hr [hour] x [times] 22 hours. Review of the Skin & Wound Evaluation for Resident #6 dated 4/9/2025, revealed the pressure ulcer to the Left Ischial Tuberosity had progressed to a Stage 3 area. The Stage 3 pressure area had increased in size to 2.9 cm (l) by 3.2 cm (w) by 1.3 cm (d) which equaled a total area of 7.1 cm2. Review of the Skin & Wound Evaluation for Resident #6 dated 4/16/2025, revealed a new in- house acquired Stage 2 pressure ulcer on the coccyx that measured 2.9 cm(l) by 6.3 cm (w) by 0.1 cm (d) which equaled a total area of 13.1 cm2. Review of the Order Summary Report for Resident #6 revealed, .May substitute feeding formula as needed. Jevity 1.2 for 1.5.active.4/26/2025. Review of the Skin & Wound Evaluation for Resident #6 dated 4/30/2025, revealed a new in-house acquired Deep Tissue Injury (intact skin that is purple or maroon in color, with a blood-filled blister or other evidence of damage) on the left heel that measured 3.8 cm (l) by 2.5 cm (w) by 0 cm (d) which equaled a total area of 7.1 cm2. Review of an email sent by the Director of Nursing to the Director of Food Hospitality and Nutrition dated 7/17/2025, revealed .I have had a third feeding pump to malfunction. I notified the manufacturer a few months ago. I sent two back. The issues I have found have been inaccurate history recordings and not infusing properly. A return email from [Named Supply Company Representative] dated 7/30/2025, revealed, .I'm doing a day trip.tomorrow. I can be at your facility between 10-10:30 to dive into the pump issue. During an interview on 8/15/2025 at 11:45 AM, CNA U stated, .[Named Resident #6 ] is total assist with everything.she doesn't eat by mouth she has a feeding tube.she has had weight loss.the tube would not stay connected and the feeding would be all over the bed.they [nursing staff] tried to say the resident was doing it but I don't think she is capable of doing that.the tube had a split in it so there was no suction to it.I had brought it to the nurses attention that it was going all over the bed.I know it went on for over a month. Call placed to Licensed Practical Nurse (LPN) V (nurse who noted the tear in the PEG on 3/20/2025) on 8/15/2025 at 11:54 AM, left message for a return call. LPN V did not return the call. During a telephone interview on 8/18/2025 at 12:09 PM, Wound Care Nurse #2 stated, .[Named Resident #6] had a stage one [pressure ulcer] on admission to her coccyx.she started losing weight because the feeding would not stay connected.feeding would be on the bed, I would have to find a CNA to help me clean her up when I went to do wound care.about a month before the facility sent her out to get the tube fixed.a PRN [as needed] nurse documented that the tube had a slit in it and the tube was being taped.the Unit Manager was made aware.losing weight developing more wounds.the family came up there [to the facility] often they were very unsatisfied with her care and talked to the DON. During a telephone interview on 8/18/2025 at 12:23 PM, the Registered Dietician (RD) stated, .she [Resident #6] had a significant weight loss on my 4/8/2025 [referring to her progress note] review.20 lbs. in 30 days.she had her PEG tube replaced.and her weight started going up.the PEG tube had a split in the tube.it is possible formula was leaking out.I seen the split noted in the nurse note for 3/20/2025, so the PEG tube needed replaced.PEG was replaced on 4/7/2025.I don't know why it took that long.since the tube was replaced, her weight has improved.I don't remember no [a] formal meeting about her weight loss .prior to the significant weight loss, her weight had been pretty stable without any significant loss.4/8 [4/8/2025] note I do note a pressure wound and on 3/14/2025, I added a protein supplement for her. During an interview on 8/18/2025 at 1:30 PM, LPN S stated, .[Named Resident #6] had a split in her peg tube .I don't recall why it wasn't changed sooner .I think once they found out they got it fixed . During a telephone interview on 8/18/2025 at 2:03 PM, CNA T stated, .she [Resident #6] had some weight loss, yes .we were out of Jevity 1.5 we were going all over the building trying to find some .they gave her Glucerna [nutritional supplement for diabetics] .the Unit Manager poured the Glucerna in the Jevity bottle .I don't know when her peg tube was taped up .her brother is the one that brought it to everyone's attention, he took pictures of it . During an interview on 8/18/2025 at 3:10 PM, the Unit Manager stated, .they [RD/NP] assumed the weight loss was from the feeding and they changed her [Resident #6] feeding .[Named LPN V] never told anybody about the tear in the PEG tube .she forgot to say anything .[Family Member (FM) W] found the hole in her tube and the tape wrapped around it .he showed me .we got her sent out to get it [tube] replaced that same day .the order is on 4/7/2025 to send her out, I thought we sent her out before then .the DON reviews the nurses notes .[Named LPN V] taped it [slit in tube] up .it was never reported to me .[FM W] said it was leaking and it did have tape on it .it did have a hole in it .the slit was actually in the tube .from what I saw .[LPN V] was only one reported .I don't know how long it had been that way .the DON was told she [Resident #6] does have a slit in it [tube] and it had been leaking . During a telephone interview on 8/18/2025 at 3:50 PM, NP #1 stated, .the PEG tube, the fluid wasn't running through it .wasn't getting her [Resident #6] nutrition .I do recall that .she had a couple of issues with her tubing .I don't remember exactly .that was contributing to the weight loss .the machine [feeding pump] was beeping a lot .I don't know how long that went on .I don't recall the nurse that told me about it .there were a lot of wounds .the enteral feed was noted on the bed . During an interview on 8/18/2025 on 4:08 PM, FM W stated, .in October 2024 she [Resident #6] had one bed sore on her bottom, the wound nurse then healed it up .she kept getting bed sores .I walked in and found the tube leaking, feeding all over the bed .the cover was brown .I found it [slit in tube] in April it was taped up all around .they moved her closer to the desk .the [Named DON & Administrator] put her on 1 on 1 for a month .during that time she didn't have a bed sore or anything .they were switching her feedings around and I could tell because the feeding would be a different color when I came in . During the interview FM W showed this surveyor a picture dated 4/7/2025 at 10:32 AM of Resident #6's PEG tube which revealed a hole in the connection at the end of her tube. During an interview on 8/18/2025, at 5:15 PM, the MDS Coordinator was asked why Resident #6 had a significant change assessment completed on 4/8/2025. The MDS Coordinator stated, .due to weight loss .the reason was unknown until they [facility] done [did] an investigation .monitored the [Named feeding pump] pumps and ordered new ones .we had faulty pumps .labs [laboratory values checked] were done to look for an underlying cause .sent her out to get a new [feeding] tube it was leaking .I am not sure when the leaking started .they were unsure about the weight loss but thought that may have had something to do with it .she had a stage 2 pressure ulcer that declined to a stage 3 pressure ulcer . During an interview on 8/18/2025, at 5:24 PM, the DON was asked if the damaged feeding tube contributed to Resident #6's weight loss. The DON stated, .4/3 [2025] the Restorative CNA weighed her and it [Resident #6's weight] was 117 lbs .she did look thinner, we reweighed her again the weight was the same .I had been auditing the pumps .Friday we have PAR [Patient at Risk] days .I would audit the pump .the first time I saw the split was on 4/3/2025 .the nurses never notified me the PEG was leaking .she is a nurse why didn't she notify the physician, no need to call me .new PEG tube on 4/7 [2025] . The DON was asked if she observed the split on 4/3/2025, why did it take until 4/7/2025 for Resident #6 to get a new PEG tube. The DON stated, .we got her out as soon as we could . The DON was asked if a resident's PEG tube should have a hole/tear in it. The DON stated, .Absolutely not, it was so minute .one CNA had said it was leaking .where you connect the tubing .nothing about it not flushing that I recall .I missed it in the notes .4/3 [2025] was when I first knew .I did not think it contributed to her weight loss .it could leak some of her nutrition out but it was so minute . The DON was asked if a different enteral formula was ever used for Resident #6. The DON stated, .the Unit Manager was on the floor late one afternoon and she poured Jevity 1.2 in it .I got on to her about it .I think we got a doctor order to substitute with the other Jevity .I done [did] an investigation about this .because it was a large weight loss .the nurse put in the notes about the slit in the tubing 3/20/2025 . The DON was asked if the family had ever called her about the feeding color looking different. The DON stated, .he called me at midnight .the feeding came in late that night .4/25 [2025] we replaced the pumps, 4 times I had voiced a complaint to the company about them .[Named LPN V] did not report it [slit in the tube] to the oncoming nurse [on 3/20/2025] .4/3/2025 is when we knew .I will have to look at that on why she didn't go out right then .we got right on it . Observation in Resident #6's room on 8/19/2025 at 8:20 AM, revealed the Resident's enteral feed bottle of Jevity 1.5 was completely empty and the enteral tubing line was clear without any feeding in the line. During an interview on 8/19/2025 at 8:30 AM, RN F stated, .I normally catch it [referring to the enteral feed for Resident #6] in time . During an interview on 8/21/2025 at 10:30 AM, CNA U stated, .her wounds were smaller, but they became larger when she was losing weight . During an interview on 8/21/2025 at 4:50 PM, Regional Director of Clinical Services #1 was asked if the facility had an Intake and Output (I & O) for Resident #6. She stated, I will look. Regional Director of Clinical Services #1 came back to the surveyor and stated, .We didn't have an I & O for [Named Resident #6] . During an interview on 8/27/2025 at 11:12 AM, the Unit Manager reviewed the picture FM W had provided. The Unit Manager stated, .that is not the area where I seen [saw] the tape .I seen the tape around the tubing, around another hole in the tubing below that area . During a telephone interview on 8/27/2025 at 2:22 PM, the Medical Director (MD) was asked what a nurse should do if a resident has a tear in their feeding tube. The MD stated, .report it to us, send [the resident] to the ER [Emergency Room] . The MD was asked if Resident #6's weight loss was discussed in the Quality Assurance Performance Improvement (QAPI) meeting. The MD stated, .Yes, yes, right and we changed the tube to solve the problem . 3. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnosis which included Major Depressive Disorder, Hypertension, Dysphagia, Abnormalities of gait and mobility, Psychosis, and other lack of coordination. Review of the Physical Therapy evaluation and Plan of Treatment for Resident #1 dated 5/1/2025 revealed impaired physical mobility and total dependence with transfers. Review of the Annual MDS dated [DATE], revealed Resident #1 had a BIMS score of 6, which indicated severe cognitive impairment. Resident #1 was dependent on staff for toileting, bathing, lower body dressing, sit to stand, chair/bed-to chair transfer, and walking 10 feet was not attempted. Resident #1's MDS did not reflect the use of a mechanical lift. Resident #1 had impairment to one side of her lower extremity. Resident #1 had no falls since the prior assessment. Review of the care plan revealed, .Focus.[Named Resident #1] has an ADL Self Care Performance Deficit r/t [related to] Stroke and Hemiplegia.Revision on: 05/05/2025.Interventions.TRANSFER: [Named Resident #1] requires times 2-person total Mechanical.lift with medium sling for transfers. Date Initiated: 05/08/2014 Revision on: 05/13/2025. Review of the Incident Description for Resident #1 dated 7/4/2025, revealed .10:00 [AM].Nursing Description.bruise noted on l [left] knee, pt [patient] reported pain when positioned to perform peri [perineal] care.Injury Type.Abrasion.Injury Location.Left Knee (front). Review of the facility investigation revealed a written statement completed by RN F dated 7/4/2025, which stated, .CNAs asked me to look at patient [Named Resident #1]. I walked to her room and she was yelling Ow it hurts. Swelling of left knee, light bruise noted on assessment. Pt repositioned w/[with] pillows under knee. Call [Named on call company].Hospice, DON, Manager. Review of the Radiology Results Report for Resident #1 dated7/5/2025, revealed .KNEE 1 OR 2 VIEWS.Reason for Study.PAIN IN LEFT KNEE.FINDINGS: There is a moderately displaced fracture of the distal femoral metaphysis [portion of the thigh bone located just below the knee joint] with adjacent soft tissue swelling.There are moderate degenerative changes. Bones are osteopenic. CONCLUSION: Fracture of the distal femur. Review of the MAR for Resident #1 dated 7/2025, revealed Morphine Sulfate Oral Solution 10 milligram (mg)/ 5 ml (milliliter) with a start date of 7/5/2025. The nurse noted a pain level of 10 on 7/5/2025 (pain scale 1-10 with 10 being the highest level of pain). Review of the care plan revealed, .Focus.Potential for pain R/T fx [fracture] left femur.Place overbed table away from resident's leg. Put water on bed side table with in reach.Date Initiated: 07/05/2025. Review of the facility investigation completed by the Administrator dated 7/5/2025, revealed, .DESCRIPTION OF INCIDENT.[Named Resident #1] responds to name. Disoriented to time, place, and situation. Long and short term memory are impaired. Communicates with simple words.Does not speak much. Requires assistance of one person to shower, dress, and have personal hygiene needs met.Requires assistance of two people to transfer by mechanical lift now. She did transfer with one person assist as she was able to stand and pivot.12 falls since her admission in 2014.On 7/4/25 [2025] at 10:01 AM, resident c/o [complained of pain] when staff was changing brief. [Named RN F] was summoned to the room to assess resident.observed edema to left knee.called the NP to report findings. New orders given for ice and pain medication.notified [Hospice #1].Hospice nurse enroute to the facility to assess resident at 10:20 [AM] on 7/5/24 [2024]. The x-ray results were received and it indicated a fracture of the left distal femur.She has had several fractures in the past. Left femur fracture with repair, exact date unknown.Upon observation of [Resident #1] in the bed as she was positioned the day the pain began, I, [Named DON], observed the over bed table next to her bed. The left knee was on the side of the bed next to the over bed table. The corner of the table lined up with the bruise and abrasion on her left knee. If a staff member pushed the table over her unaware that they hit her knee, it would hit her knee and possible [possibly] cause a fracture of the left femu

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 nurses (Licensed Practical Nurse (LPN) #7) followed policies and procedures for the administration of medication through a Percutaneous Endoscopic Gastrostomy (PEG) tube for 1 of 2 sampled residents (Resident #65) observed and the facility failed to ensure Physician Orders for lab were followed for 1 of 5 sampled residents (Resident #9) reviewed for lab services.
The findings include:
Review of the facility's policy titled, Administering Medication Through an Enteral Tube, revised 2/2018, revealed .The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube .Dilute powdered, crushed, or split (capsule) medications at the bedside .
Review of the medical record, revealed Resident #65 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease, Schizophrenia, Gastrostomy, and Depression.
Review of the Physician's Orders dated 6/7/2022, revealed .Cephalexin Capsule 500 MG [milligrams] Give 1 capsule via [by way of] PEG-Tube four times a day .for 10 Days .
Review of the Physician's Orders dated 5/31/2022, revealed .Zyprexa Tablet 5 MG .Give 1 tablet .two times a day .
Observation at the 300 Hall Medication Cart on 6/8/2022 at 9:30 AM, revealed LPN #7 sanitized her hands, crushed the Zyprexa tablet, placed it in a plastic medication cup, then opened the Cephalexin capsule and put the granular in a medication cup. LPN #7 entered Resident #65's room, washed her hands, donned clean gloves and began to administer the medication via PEG tube. LPN #7 flushed the PEG tube with 30 milliliters (ml) of water, poured the crushed Zyprexa into the peg tube, then flushed the PEG tube with 30 ml of water. LPN #7 poured the Cephalexin into the PEG tube, then flushed the PEG tube with 30 ml of water, reconnected the enteral feeding, disposed of the trash, sanitized her hands, and exited the room. LPN #7 did not to dilute each medication with 5-10 ml of water prior to administering the medications through the PEG tube.
During an interview on 6/9/2022 at 10:04 AM, the Interim Director of Nursing (DON) was asked if medications should be diluted before they are administered through a PEG tube. The DON stated, Of course .supposed to be with 10 milliliters of water or it will clog the tube .
During an interview on 6/9/2022 at 11:04 AM, LPN #7 confirmed she should have diluted both medications before administering them through the PEG tube.
Review of the medical record, revealed Resident #9 was admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease, Dysphagia, Protein-Calorie Malnutrition, and Diabetes.
Review of the Registered Dietician note dated 4/21/2022, revealed .weight is down 1.4 pounds x [times] 1 week .Last week added magic cup to lunch trays daily. Today recommending MD [Medical Doctor] review for weight loss .requesting full lab work-up to include CMP [Complete Metabolic Panel] .for continued weight decline .
Review of the Physician's Orders dated 4/22/2022, revealed .CBC [Complete Blood Count] [is a set of medical laboratory test that provide information about the cells in a person's blood] .CMP [is a blood sample that measures 14 different substances in your blood] .
Review of the medical record, revealed a CBC and CMP were not collected until 5/22/2022.
During an interview on 6/9/2022 at 9:24 AM, the Interim Director of Nursing (DON) confirmed the CBC and CMP were not performed until 5/22/2022, and stated, .no excuse lab was not done in April .no excuse .

Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, review of Employee Screening logs and employee time sheets, observation, and interview, the facility failed to ensure practices to maintain the spread of infection were maintained when 14 of 47 staff (Certified Nursing Assistant (CNA) #1, #2, #3, and #4, Licensed Practical Nurse (LPN) #1, #2, and #3, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2, #3 and #4) failed to complete screening for the prevention and detection of COVID-19 prior to working on 2 of 2 days (5/25/2022 and 5/28/2022) reviewed and when 1 of 4 nurses (LPN #7) failed to properly clean and store enteral feeding syringes after use for 2 of 2 sampled residents (Resident #65 and #75) observed. This had the potential to affect the 90 residents residing in the facility.
The findings include:
Review of the CDC document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 2/2/2022, revealed .Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic .Establish a process to identify anyone entering the facility, regardless of their vaccination status .options could include (but are not limited to) : individual screening on arrival at the facility .
Review of the facility's policy titled, E-007 Emergency Plan: COVID -19 Screening, Staff and Visitors, revised 1/2022, revealed .Staff will be screened at the point of entry into the community .Employees and visitors will be screened for signs and symptoms of COVID-19 and denied entry if they exhibit any signs and symptoms .
Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 7/2020, revealed .Reusable Items are cleaned and disinfected or sterilized between residents .
Review of the Employee Screening logs and employee time sheets revealed the following employees worked on the following days and failed to screen for signs and symptoms of COVID-19:
a. 5/25/2022-CNA #1, #2, #3 and #4, LPN #1 and #2, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2 and #3.
b. 5/28/2022-CNA #4, LPN #3, and Dietary Aide #4.
During an interview on 6/9/2022 at 10:13 AM, the Interim Director of Nursing (DON) confirmed staff should screen on arrival to work. The Interim DON stated, .Staff and Visitors .everyone who comes in the door should be screened .
During an interview on 6/9/2022 at 12:23 PM, the Staff Development Coordinator/Infection Preventionist Nurse confirmed she was unable to locate COVID -19 screenings for CNA #1, #2, #3 and #4, LPN #1 and #2, Housekeeper #1, #2, and #3 and Dietary Aide #1, #2 and #3 on 5/25/2022 and for CNA #4, LPN #3, and Dietary Aide #4 on 5/28/2022.
Observation in the resident's room on 6/8/2022 at 9:30 AM, revealed LPN #7 removed an enteral feeding syringe from a plastic bag, checked placement of an enteral feeding tube, and used the enteral feeding syringe to administer medications to Resident #65 through an enteral feeding tube. LPN #7 entered the bathroom, removed the enteral feeding syringe plunger from the barrel, rinsed the plunger and barrel with water, and used a paper towel to wipe off the plunger and the outside of the barrel. LPN #7 then returned the plunger into the barrel and placed the enteral feeding syringe in the plastic bag and placed the plastic bag on the enteral feeding pole at Resident #65's bedside. LPN #7 failed to completely dry the plunger and barrel before reconnecting them and storing the enteral feeding syringe in the plastic bag.
Observation in the resident's room on 6/8/2022 at 4:40 PM, revealed during medication administration LPN #7 removed an enteral feeding syringe from a plastic bag on the bedside table, checked placement of an enteral feeding tube, and used the enteral feeding syringe to administer medications to Resident #75. LPN #7 entered the bathroom, removed the enteral feeding syringe plunger from the barrel, rinsed the plunger and barrel, placed them back in the plastic bag, and returned the plastic bag to Resident #75's bedside table. LPN #7 failed to completely dry the plunger and barrel before reconnecting them and storing the enteral feeding syringe in the plastic bag.
During an interview on 6/9/2022 at 11:04 AM, LPN #7 was asked how she should have let the plunger dry before placing it back in the plastic bag. LPN #7 stated, .got to air dry .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to develop a comprehensive Care Plan for Dementia for 2 of 4 sampled residents (Resident #10 and #62) reviewed.
The findings include:
The facility's policy titled, Care Plans - Comprehensive, revised 11/2017, revealed .And individualized comprehensive person centered care plan that includes measurable objectives and time frames to meet the resident medical, nursing, mental and psychological needs is developed for each resident .
Review of the medical record, revealed Resident #10 was admitted to the facility on [DATE] with diagnoses of Dementia, Atrial Fibrillation, Dysphagia, and Major Depressive Disorder.
Review of the admission Minimum Data Set (MDS) dated [DATE], revealed Resident #10 had Non-Alzheimer's Dementia.
Review of the Care Plan dated 2/28/2022, revealed there was no comprehensive Care Plan for Dementia.
Review of the medical record, revealed Resident #62 was admitted to the facility on [DATE] with diagnoses of Peripheral Vascular Disease, Dementia, and Hypertension
Review of the admission MDS dated [DATE], revealed Resident #62 had a BIMS score of 2, indicating he was severely cognitively impaired and had Non-Alzheimer's Dementia.
Review of the Care Plan dated 5/1/2022, revealed there was no comprehensive Care Plan for Dementia.
During an interview on 6/8/2022 at 2:39 PM, the Social Services Director confirmed Resident #10 and Resident #62 did not have a comprehensive Care Plan for Dementia.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, facility investigation review, medical record review, and interview, the facility failed to timely and thoroughly investigate an incident of resident-to-resident abuse for 2 of 7 sampled residents (Resident #11 and #32) reviewed for abuse.
The findings include:
Review of the facility's policy titled, Abuse Investigations, revised 11/2017, revealed .Reports of resident abuse .shall be promptly and thoroughly investigated by facility management .The individual conducting the investigation will, as a minimum .Review the completed documented forms .Interview any witnesses to the incident .Interview staff members (on all shifts) who have had contact with the resident during the period of the alleged incident .Interview the resident's roommate .Witness reports will be obtained in writing .
Review of the medical record, revealed Resident #11 was admitted to the facility on [DATE] with diagnoses of Schizophrenia, Dementia, and Psychotic Disorder
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 10, indicating he was moderately impaired.
Review of the medical record, revealed Resident #32 was admitted on [DATE] with diagnoses of Parkinson Disease, Legal Blindness, Hypertension, and Hyperlipidemia.
Review of the annual MDS dated [DATE], revealed Resident #32 had BIMS of 11, indicating he was moderately impaired and had wandering behaviors.
Review of the Progress Note dated 5/25/2022, revealed .Resident [#32] heard yelling out random people names .When this nurse asked if resident needed anything or any help .resident [#32] began yelling and cursing .Resident [#32] continued to be agitated and began to argue with roommate [Resident #11] .yelling at roommate .Roommate immediately removed from room .DON [Director of Nursing] notified of situation .NP [Nurse Practitioner] to be notified .
The facility's investigation of the allegation of resident-to-resident abuse by Resident #32 did not include a completed Incident Report, interviews from residents, and interviews/statements from all staff members working on the morning of the incident. The Investigation did not include 1 on 1 monitoring of Resident #32 (the aggressor).
During a telephone interview on 6/8/2022 at 9:41 AM, Licensed Practical Nurse (LPN) #5 confirmed she did not complete an Incident Report, did not complete a witness statement, and did not have all staff members on that shift complete a witness statement.
During an interview on 6/8/2022 at 10:40 AM, the Interim Director of Nursing (DON) confirmed there was no documentation of 1 on 1 observation of Resident #32 and no written witness statements from staff members.
During an interview on 6/8/2022 at 11:03 AM, the Administrator confirmed the facility did not complete a thorough investigation of the resident-to-resident altercation. The Administrator confirmed there was no Incident Report completed, no witness statements completed, and no documentation of 1 on 1 monitoring for Resident #32.
During an interview on 6/8/2022 at 5:09 PM, the Unit Manager was asked what the process was for a resident-to-resident incident. The Unit manager stated .we complete an Incident Report .document what happened .what was done .and who you notified .if there is a witnesses .have all staff on the unit write a witness statement .separate the resident .the aggressor is placed on 1 on 1 observation .document the 1 on 1 observations on the safety check log .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to notify the Physician and patient representative for an allegation of abuse for 1 of 7 sampled residents (Resident #11) reviewed for abuse and the facility failed to notify patient representatives of changes in pressure ulcer status for 2 of 3 sampled residents (Resident #36 and Resident #388) reviewed for pressure ulcers/injuries.
The findings include:
Review of the facility's policy titled, Reporting of Abuse Allegations, revised 11/2017, revealed .All suspected violations and all substantiated incidents of abuse .Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse .) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons (verbally or written) of such incident .The State Licensing/recertification agency .The resident's Attending Physician .The facility Medical Director .
Review of the facility's policy titled, Change in a Resident's Condition or Status, revised 11/2017, revealed .The facility staff shall promptly notify the resident, his or her Attending Physician, and resident representative of changes in the resident's medical/mental condition and/or status .A representative of the community will notify the resident, and the resident representative when .There is a change in the resident's level of care status .
Review of the facility's policy titled, Guidelines for Notifying Physicians of Clinical Problems, revised 4/2007, revealed .medical care problems are communicated to the medical staff in a timely, efficient, and effective manner .
Review of the medical record, revealed Resident #11 was admitted on [DATE] with a diagnoses of Schizophrenia, Dementia, and Psychotics Disorder.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 had a Brief Interview for Mental Status (BIMS) score of 10, which indicated he was moderately cognitively impaired.
Review of the Progress Note dated 5/25/2022, revealed .Resident [#32] heard yelling out random people names .When this nurse asked if resident needed anything or any help .resident [#32] began yelling and cursing .Resident [#32] continued to be agitated and began to argue with roommate [Resident #11] .yelling at roommate .Roommate immediately removed from room .DON [Director of Nursing] notified of situation .NP [Nurse Practitioner] to be notified .
The facility's investigation of the allegation of resident-to-resident abuse did not include notification of Resident #11's family or Physician.
During an interview on 6/7/2022 at 10:02 AM, the Social Services Director confirmed that the Physician and the family should be notified where there is a resident-to-resident altercation. The Social Services Director confirmed she did not notify Resident #11's family or Physician of the resident-to-resident altercation.
During an interview on 6/8/2022 at 5:09 PM, the Unit Manager and Licensed Practical Nurse (LPN) #4 confirmed that Resident #11's Physician and family should have been notified.
During an interview on 6/9/2022 at 11:52 AM, the Nurse Practitioner (NP) confirmed the staff did not notify her of the resident-to-resident incident.
Review of the medical record, revealed Resident #36 was admitted to the facility on [DATE] with diagnoses of Protein-Calorie Malnutrition, Dementia, and Unstageable Pressure Ulcer Left Heel.
Review of the quarterly MDS dated [DATE] and the quarterly MDS dated [DATE], revealed Resident #36 had a BIMS score of 8, which indicated the resident was severely cognitively impaired and had 1 unstageable pressure ulcer.
Review of the facility's Weekly Pressure Injury sheet dated 4/21/2022, revealed .1.1x1.8x0.6 .unstageable .improving .
Review of the facility's Weekly Pressure Injury sheets dated 4/25/2022, revealed the pressure injury was now a Stage 4 and was improving. There was no documentation that the patient representative was notified of the wound status.
Review of the facility's Weekly Pressure Injury sheet dated 5/16/2022, revealed .5/16/2022 .0.3x0.4x0.3 .stage
4 .improving .Notified Family .3/28/2022 .
Review of the facility's Weekly Pressure Injury sheet dated 5/31/2022, revealed .5/31/2022 .0.4x0.7x0.7 .stage
4 .declined .Notified Family .3/28/2022 . There was no documentation that the patient representative was notified of the wound status.
Observation in the resident's room on 6/8/2022 at 3:12 PM, revealed the Treatment Nurse removed the dressing to the Resident #36's left heel and revealed an open wound.
During an interview on 6/8/2022 at 3:34 PM, the Treatment Nurse confirmed that patient representatives should be notified when there is a change in a resident's wound condition and when the Physician changes the treatment orders. The Treatment Nurse confirmed the family should have been notified when Resident #36's wound had a change in status on 4/25/2022 and 5/31/2022. The Treatment Nurse confirmed that she was behind on her documentation and that all families were notified and given wound updates on 5/25/2022.
Review of the medical record, revealed Resident #388 was admitted to the facility on [DATE] with diagnoses of Disruption of Wound, Amputation of Left Great Toe, Peripheral Vascular Disease, and Pressure Ulcer of Right Buttocks.
Review of the admission MDS dated [DATE], revealed Resident #388 had a BIMS of 14, indicating the resident was cognitively intact and had diagnoses of Amputation Left Great Toes, and a Stage 2 Pressure Ulcer Buttocks.
Review of the facility's Weekly Pressure Injury Sheet dated 1/24/2022, revealed the following:
a.L Heel .Previous Measure .4.0 x 3.0 x 0.1 .Current Measure 4.1 x 6.4 x 0.1 .100% Eschar .Declined .Notified Family .1/11/2022 .
b.R Heel .Previous Measure .3.9 x 3.6 x 0.1 .Current Measure .6.8 x 7.6 x 0.1 .100 % Eschar .Declined .Notified Family .1/11/2022 .
c.L Out (Outer) Mid Foot .Previous Measure .2.6 x 1.9 x 0.1 .Current Measure .6.8 x 2.0 x 0.1 .100% Eschar .Declined .Notified Family .1/11/2022 .
d. L Foot Great Toe .Previous Measure .4.4 x 2.4 x 1.3 .Current Measure .4.4 x 2.7 x 2.2 .80% Slough 20% Gra [Granulation] .Declined .Notified Family 1/11/2022 .
There was no documentation the family was notified of the decline in status of the pressure injuries on 1/24/2022.
During an interview on 6/8/2022 at 1:30 PM, the Interim Director of Nursing (DON) was asked when a patient representative should be informed of a resident's wound status. The Interim DON stated, .well what I expect them to do is let them [representative] know when they [pressure injuries] are found and when they heal .
During an interview on 6/8/2022 at 3:42 PM, the Treatment Nurse was asked should the patient representative be notified of any changes in the wound and/or treatments. The Treatment Nurse stated, Yes, they should .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure the completion of a discharge summary that included a recapitulation of the resident's stay, the disposition status of the resident at the time of discharge, and a post discharge plan of care for 1 of 1 sampled residents (Resident #388) reviewed for discharge.
The findings include:
Review of the facility's policy titled, Discharge Summary and Plan, revealed .When a resident's discharge is anticipated, a discharge summary and post-discharged plan will be developed .The discharge summary will include a recapitulation of the resident's stay at this facility and a final summary of the resident's status at the time of discharge .The recapitulation will include .diagnoses, Course of illness, treatment or therapy, Pertinent lab, radiology and consultation results, reconciliation of all pre-discharge medications with the resident's post discharge medications .a final summary paragraph .
Review of the medical record, revealed Resident #388 was admitted to the facility on [DATE] with diagnoses of Disruption of Wound, Amputation of Left Great Toe, Peripheral Vascular Disease, and Pressure Ulcer of Right Buttocks.
Review of a Physician's Order dated 1/21/2022, revealed .Discharge home .
Review of a Social Services Note dated 1/28/2022, revealed the patient representative was in the facility and informed staff she would be taking resident home on 1/29/2022 at 2:00 PM, transporting the resident in a private vehicle and the resident would be living with her and receiving Hospice and Home Health services.
Review of a Transfer Note dated 1/29/2022, revealed .residents family picked up resident at 4:50 PM .in suv (Sport Utility Vehicle) .
Review of the medical record, revealed the facility failed to complete a discharge summary to recapitulate the resident's stay at the facility, his disposition, and post discharge plan of care.
During an interview on 6/8/2022 at 11:30 AM, the Interim Director of Nursing (DON) was asked who should complete the discharge summary when a resident is discharged home. The Interim DON stated, .Well that is something we just discovered we will need to work on .

Based on policy review, observation, and interview the facility failed to ensure that waste was disposed of properly for 1 of 1 dumpster observed.
The findings include:
The facility's Food-Related Garbage and Rubbish Disposal policy dated November 2017, documented .Outside dumpsters .will be kept closed and free of surrounding litter .
Observations of the dumpster on 6/26/19 at 7:56 AM revealed trash on the ground completely surrounding the dumpster. The trash included old used disposable gloves.
Observations of the dumpster on 6/26/19 at 6:30 PM revealed the doors of the dumpster partially open with trash bags sticking out and trash, including more than 12 used disposable gloves, scattered on the ground surrounding the dumpster.
Observations of the dumpster on 6/27/19 at 7:36 AM revealed the doors of the dumpster partially open with trash bags sticking out and trash scattered around the dumpster.
Interview and observation with the Dietary Manager (DM) on 6/27/19 at 7:58 AM in the dumpster area, revealed trash bags sticking out of the dumpster and trash on the ground around the dumpster. The DM was asked if trash should be lying on the ground around the dumpster. The DM stated, No Ma'am. The DM was asked if trash bags should be sticking out of the dumpster. The DM stated, No Ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Service Agreement review, policy review, observation, and interview, the facility failed to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly, and comfortable environment as evidenced by missing ceiling tiles, missing grout in tiles, brown debris and brownish and black build-up on the floors and in corners of rooms, unpainted, exposed plaster, brownish build-up on window ledges, blinds, and air conditioners, air conditioners with missing pieces, discolored grout in bathrooms, worn linoleum floors exposing subflooring, gray areas on ceiling tiles, unclean, broken and rust colered resident equipment, unclean exhaust fans, brown substance and stains in sinks and on commodes, holes in walls, loose and broken tiles and base boards, bulging and crumbling dry wall, odors, gouged and scratched walls, peeling paint; corroded faucets, missing covers on lights, an improperly hanging door, and mismatched floor tiles in 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 121, 122, 123, 124, 125, 126, 128, 130, 219, 220, 221, 225, 226, 227, 228, 230, 231, 232, 233, 234, 235, 241, 244, 245, 246, and 247) resident rooms observed.
The facility's failure to provide effective housekeeping services and maintenance services to maintain a sanitary, orderly and comfortable environment resulted in Substandard Quality of Care.
The Extended Survey was conducted on 6/26/19.
The findings include:
1. The facility's HOUSEKEEPING/LAUNDRY SERVICE AGREEMENT dated January 1, 2011 and signed 1/6/11 and 1/10/11, documented, .[Named Corporation] will provide .Monthly unit inspections and regular District Manager visits .
The (Named Corporation) Housekeeping Procedures policy with a revision date of 6/2016, documented .BATHROOM CLEANING .Dust mop. Pick up trash .Sanitize sinks .Sanitize commode, tank, bowl and base. Use brush for inside of bowl .Spot clean - Walls .Damp mop .Clean vents .DAILY PATIENT ROOM CLEANING .With a cloth & [and] disinfectant wipe all horizontal (flat) surfaces .spot clean all vertical surfaces .Use dust mop and gather all trash and debris .Damp mop floor .Every room to be cleaned is that resident's home .COMPLETE ROOM CLEANING .Every room must be Deep Cleaned at least 1x [time]/[per] month .
2. Observations on the 100 Hall on 6/24/19 beginning at 4:42 PM, 6/25/19 beginning at 8:22 AM, 1:50 PM, and 3:20 PM revealed the following:
a. room [ROOM NUMBER] - A missing ceiling tile, missing grout around the edge of the floor tile in the bathroom, a black substance in the corners of the room, and unpainted, exposed plaster.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:22 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor confirmed the missing ceiling tile and the missing grout around the edge of the floor tile in the bathroom. The Maintenance Supervisor looked at the unpainted, exposed plaster and stated, Needs some paint. The Housekeeping District Manager was asked if the black substance should be present in the corners of the room. He stated, No, Ma'am .
b. room [ROOM NUMBER] - [NAME] debris on the floor in the corner behind the door, pictures in the floor behind the first bed, brown build-up in the air conditioner, plastic pieces of the air conditioner unit were missing, and the flooring was worn away exposing some of the subflooring next to the wall in the room, and a black substance in the grout in the bathroom.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:24 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor was not clean. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, Part of this is broken off .no. The Maintenance Supervisor was asked if the black substance in the grout and the exposed subflooring should be present. The Maintenance Supervisor stated, No.
c. room [ROOM NUMBER] - Areas in the linoleum were worn, exposing the subflooring, and a sticky film was covering the floor.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:26 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the floor was clean and in good repair. He stated, No, it's old and torn. The Administrator was asked if the linoleum should be worn exposing the subflooring. He stated, No.
d. room [ROOM NUMBER] - Worn areas in the linoleum that exposed a large amount of the subflooring, and brown build-up on the blinds and the air conditioner.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:29 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the blinds and the floor were clean and in good repair. The Housekeeping District Manager confirmed the blinds were not clean and stated, Those are holes in the linoleum. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No.
e. room [ROOM NUMBER] - [NAME] debris behind the door and in the corners of the room.
f. room [ROOM NUMBER] - [NAME] debris in the corners of the room.
g. room [ROOM NUMBER] - A brown build-up on the air conditioner, a gray discoloration on the ceiling tile in the bathroom, a broken armrest on a raised toilet seat in the bathroom, and a thick layer of blue masking tape covering the bathroom door handle.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:35 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor confirmed the air conditioner was not clean and confirmed the gray discoloration on the ceiling in the bathroom. The Maintenance Supervisor was asked if residents should use broken raised toilet seats. The Maintenance Supervisor stated, No. The Maintenance Supervisor removed the layers of blue masking tape and stated, .that shouldn't be there .
h. room [ROOM NUMBER] - A brown build-up on the air conditioner, and a rectangular piece of wood lying on the floor behind the resident's bed.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:37 PM, in room [ROOM NUMBER], revealed the Maintenance Supervisor confirmed the air conditioner was not clean. The Maintenance Supervisor was asked why a wooden board was lying on the floor behind the resident's bed. The Maintenance Supervisor stated, To keep them from knocking the bed into the wall.
i. room [ROOM NUMBER] - [NAME] debris on the window ledge, brown build-up on the air conditioner, a bracket missing from the air conditioner unit with wires exposed. The commode tank was covered with an incomparable lid that did not properly fit over the tank, exposing the tank, and debris on the exhaust fan in the bathroom
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:39 PM, in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor was not clean. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No .it needs to be bolted to the wall. The Maintenance Supervisor confirmed the commode tank lid was not the appropriate size, and confirmed the exhaust fan was not clean.
j. room [ROOM NUMBER] - [NAME] debris on the floor throughout the room.
k. room [ROOM NUMBER] - [NAME] debris along the baseboard throughout the room.
l. room [ROOM NUMBER] - Scattered brown debris on the floor and in the corners, a call light and call light cord were covered in a brown substance. The vinyl baseboard was missing and the dry wall was exposed and rough with pieces of dry wall in the floor.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:43 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor was not clean. The Housekeeping Manager was asked if the call light was clean. The Housekeeping District Manager stated, No. The Maintenance Supervisor was asked if there should be missing vinyl cove base molding and crumbling dry wall. The Maintenance Supervisor stated, No.
m. room [ROOM NUMBER] - Rust colored build-up on the overbed table, and scattered brown debris on the floor and in the corners of the room.
n. room [ROOM NUMBER] - Rust colored build-up on the overbed table, and scattered brown debris on the floor throughout the room.
o. room [ROOM NUMBER] - Scattered brown debris on the floor throughout the room.
p. room [ROOM NUMBER] - [NAME] debris scattered on the floor throughout the room, brown spots on the floor in front of the closet, a dead fly, and brown debris on the window ledge.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:46 PM in room [ROOM NUMBER], the Housekeeping District Manager was asked if the floor and window ledge were clean. The Housekeeping District Manager stated, No.
q. room [ROOM NUMBER] - The base of an overbed table had brown build-up, brown stains in the toilet, and a hole in the wall in the bathroom where a paper towel holder previously had been on the wall.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:48 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the overbed table base should be not be clean and if there should be brown stains in the toilet. The Housekeeping District Manager stated, No. The Administrator looked at the hole in the bathroom wall and stated, Who did that? Gees!
r. room [ROOM NUMBER] - Grayish-black areas on the floor throughout the room
s. room [ROOM NUMBER] - Grayish-black areas on the floor throughout the room near the bed, peeling paint and damaged exposed drywall on the wall behind the first bed, a large, round, gray area on the ceiling, brown stains in the toilet, a corroded sink faucet, and a black substance scattered on the bathroom floor.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:55 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floors in the room and bathroom were not clean and confirmed the brown stains in the toilet. The Maintenance Supervisor confirmed the large, round, gray area on the ceiling and looked at the sink faucet and stated, It is corroded. The Maintenance Supervisor was asked if the peeling paint and damaged exposed drywall were acceptable. The Maintenance Supervisor stated, No.
t. room [ROOM NUMBER] - [NAME] build-up on the air conditioner and the vented front of the air conditioner was loose. There were large, round, gray areas on 2 bulging ceiling tiles with in the bathroom, a musty smell in the bathroom, a large area of bulging dry wall behind the commode, and no cover on the bathroom light, exposing a bare light bulb.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:07 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No. The Housekeeping District Manager walked in the bathroom and stated, .smells musty. The Maintenance Supervisor confirmed the bulging ceiling tiles on the bathroom ceiling tiles and the bulging dry wall and stated, It has been wet at one time. The Maintenance Supervisor confirmed there should be a cover over the light bulb.
u. room [ROOM NUMBER] - The linoleum floor near the first bed was worn exposing a large area of subfloor. There were brown substances on the floor throughout the room, a brown build-up on the air conditioner, and a loose screw lying on the window ledge.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:05 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the floor was clean and in good repair. The Housekeeping District Manager stated, No. The Maintenance Supervisor confirmed the air conditioner was not clean and looked at the screw and stated, .doesn't need to be there.
v. room [ROOM NUMBER] - areas of a brownish substance on the floor throughout the room, an odor in the room, large, round, gray areas on the ceiling tile, and dry wall bulging up on the wall beside the commode.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:52 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor was not clean. The Maintenance Supervisor stated, It doesn't smell very clean. The Maintenance Supervisor confirmed the gray areas on the ceiling tile and the dry wall bulging up beside the toilet and stated, It's been wet. The Administrator touched the wall and confirmed it felt damp.
w. room [ROOM NUMBER] - Areas of a brown build-up on the floor throughout the room and a dried, red substance on the floor near the bed, a brown build-up on the blinds and on the air conditioner and plastic parts of the air conditioning unit missing. There was veneer missing down the front right side of the 3 drawer bedside chest, no cover on the bathroom light, exposing a bare light bulb, and a corroded sink faucet.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:02 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor and the blinds were not clean. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No. The Maintenance Supervisor was asked if the 3 drawer chest was in good repair. The Maintenance Supervisor said, No. The Maintenance Supervisor confirmed that a cover was needed over the bathroom light bulb and confirmed the sink faucet was corroded.
x. room [ROOM NUMBER] - Areas of brown build-up on the floor throughout the room and on the air conditioner and the air conditioning unit was not securely attached to the wall. The drywall was bulging on the wall to the right of the bathroom commode.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:57 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor was not clean. The Maintenance Supervisor confirmed the drywall was bulging and stated, [It was due to] a leaky roof. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No, and confirmed it should be securely attached to the wall.
y. room [ROOM NUMBER] - A metal office chair with the back rest of the chair missing, and the seat was torn with jagged edges of material, exposing the inner foam.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 3:59 PM in room [ROOM NUMBER], revealed the Administrator looked at the chair and stated, It should be thrown out.
z. room [ROOM NUMBER] - Areas of brown build-up on the floor mats in the room and brown build-up on the air conditioner. There were plastic pieces missing from the air conditioning unit, 2 holes in the wall above the bed, and the dry wall was bulging beside the air conditioner.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:09 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the floor mats were clean. The Housekeeping District Manager stated, I don't think so . The Maintenance Director was asked if the air conditioner was clean and in good repair. The Maintenance Director stated, No. The Maintenance Director was asked if the dry wall should be bulging next to the air conditioner and should there be holes in the wall. The Maintenance Director stated, No.
3. Observations on the 200 Hall on 6/24/19 beginning at 9:20 AM and 4:22 PM, and on 6/25/19 beginning at 8:02 AM and 4:43 PM revealed the following:
a. room [ROOM NUMBER] - Yellowish brown stains in the sink.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:45 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if there should be stains in the sink. The Housekeeping District Manager stated, No .
b. room [ROOM NUMBER] - Areas of brown build-up on the floor throughout the room.
c. room [ROOM NUMBER] - Areas of brown build-up on the floor throughout the room, a dried white substance on the mirror, and a brown substance smeared on the commode.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:50 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if the mirror and commode were clean. He stated, No. The Housekeeping District Manager was asked if the floor was clean. He stated, .wax build-up.
j. room [ROOM NUMBER] - [NAME] build-up on the blinds and the air conditioner. The commode seat was loose and falling off the commode in the bathroom.
k. room [ROOM NUMBER] - [NAME] build-up on the air conditioner. The entire front vented section of the air conditioning unit was missing exposing the inner contents of the air conditioner, and brown build-up on the blinds.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:15 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No. The Housekeeping District Manager confirmed the blinds were not clean.
l. room [ROOM NUMBER] -Areas of brown build-up on the floor throughout the room, brown build-up on the blinds, broken blinds, brown build-up on the window ledge and on the air conditioner.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:17 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor, blinds, and window ledge were not clean. The Housekeeping District Manager was asked if the blinds were in good repair. He stated, No, they are broken. The Maintenance Supervisor confirmed the air conditioner was not clean.
m. room [ROOM NUMBER] - An exposed pipe under the sink that was wrapped in bright orange foam and black duct tape, 2 broken tiles lying under the sink on the floor, brown build-up on the blinds, and broken blinds on the windows.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:21 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor was asked if there should be exposed pipe under the sink covered in bright orange foam and black duct tape. The Maintenance Supervisor stated, No. The Maintenance Supervisor was asked if tiles should be falling off the wall and lying on the floor. The Maintenance Supervisor stated, No. The Housekeeping District Manager was asked if the blinds were clean and in good repair. The Housekeeping District Manager stated, No.
n. room [ROOM NUMBER] - Areas of a brown substance on the floor throughout the room, brown build-up on the blinds and on the air conditioner, and plastic parts of the air conditioning unit were missing.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:27 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor and blinds were not clean. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No.
o. room [ROOM NUMBER] - Areas of a brown substance on the floor throughout the room, brown build-up on the window ledge and on the air conditioner, and the floor tiles did not match.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:30 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor and window ledge were not clean. The Administrator confirmed the floor tiles did not match and stated, It's not homelike.
p. room [ROOM NUMBER] - A strong odor in the room, brown build-up on the air conditioner and plastic parts of the air conditioning unit were missing.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:30 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager stated, Smells like urine in here. The Maintenance Supervisor was asked if the air conditioner was clean and in good repair. The Maintenance Supervisor stated, No.
q. room [ROOM NUMBER] - Peeling paint and broken, bulging drywall between the bathroom and sink.
r. room [ROOM NUMBER] - The drywall in the bathroom was bulging. There was a brown stain on the wall next to the toilet. The tile was separating from the wall in the bathroom, and there were stains in the commode.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:00 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor was asked if there should be bulging dry wall, stained walls, and tiles separating from the wall. The Maintenance Supervisor stated, No. The Housekeeping District Manager confirmed the commode was not clean.
s. room [ROOM NUMBER] - There was a hole approximately the circumference of an empty toilet paper roll above the toilet in the bathroom that was covered with a toilet paper roll to hide the insulation.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:05 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor was asked if there should be a hole in the bathroom wall, exposing insulation, with a toilet paper roll covering it. The Maintenance Supervisor stated, No.
t. room [ROOM NUMBER] - Areas of a brown substance on the floor throughout the room, several tiles separating from the base of the bathroom wall near the floor, and dry wall bulging in the bathroom.
u. room [ROOM NUMBER] - The entry door was scraping the floor when opened or closed, making it difficult to open and close the door.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:10 PM in room [ROOM NUMBER], revealed the Administrator confirmed the door needed to be readjusted.
v. room [ROOM NUMBER] - [NAME] stains in the commode, brown build-up in the bathroom sink.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 4:55 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager was asked if there should be brown stains in the toilet and brown build-up in the bathroom sink. The Housekeeping District Manager stated, No.
w. room [ROOM NUMBER] - Areas of a brown substance on the floor throughout the room and in the corners of the room, brown build-up on the blinds, a brown stain in the sink, several loose tiles in the bathroom floor, and large brown stains on the ceiling tiles.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:30 PM in room [ROOM NUMBER], revealed the Housekeeping District Manager confirmed the floor and corners were not clean, and the sink was stained. The Maintenance Supervisor was asked if there should be large brown stains on the ceiling tiles. The Maintenance Supervisor stated, No.
x. room [ROOM NUMBER] - There was brown build-up on the air conditioner. The bathroom sink faucet was rusted, and there was a brown stain in the commode.
Interview with the Administrator, Housekeeping District Manager, and the Maintenance Supervisor on 6/25/19 at 5:32 PM in room [ROOM NUMBER], revealed the Maintenance Supervisor confirmed the air conditioner was not clean. The Maintenance Supervisor was asked if the faucet should be rusted. He stated, No. The Housekeeping District Manager was asked if the toilet should have brown stains. The Housekeeping District Manager stated, No.
3. Interview with the Housekeeping District Manager on 6/26/19 at 11:20 AM, in the Conference Room, revealed the Housekeeping District Manager stated he took over this facility in May. The Housekeeping District Manager was asked what problems he had identified in May. He stated, .build up on the floors .walls, dirt build up .cleaning schedules weren't being followed, no systems in place .the quality control inspection was not being followed .
Interview with the Administrator on 6/26/19 at 5:15 PM, in the Conference Room, revealed the Administrator stated that he had been in the administrative position since October 2018. The Administrator was asked what problems he had identified in October. He stated, Flooring, roof, rooms, it was dirty .problems were here for years .rooms were in bad shape .they still look bad, roof has to get fixed .flooring .don't even like to look at it, we know it's got to come out . The Administrator was asked why these problems have not been addressed. The Administrator stated, .corporate .approval process .
Interview with the Maintenance Supervisor on 6/27/19 at 9:41 AM, in the Conference Room, revealed the Maintenance Supervisor was asked what problems he had identified in the building. He stated, .we have a lot of issues with the roof, the ceiling, with them being wet .we've got pinholes everywhere [in the copper water lines in the ceiling] .the bathroom wall situation, that's from moisture .old floors .wall damage .
Telephone interview with the Corporate Director of Plant Operations on 6/27/19 at 11:02 AM, the Corporate Director of Plant Operations was asked what environmental problems he had identified in the building. The Corporate Director of Plant Operations said that he started his position in January and stated, .We came down to look at .copper lines .had multiple saddle repair [pipe repair] clamps .pipe over the nurse station had a number of saddle clamp repairs, we made the conclusion that the pipe was reaching its end and deteriorating. The Corporate Director of Plant Operations was asked when he was made aware of problems. He stated, .the Maintenance Director told me about it in February .it [referring to the leaking pipes] wasn't a dire issue in February . The Corporate Director of Plant Operations was asked who monitors the work provided by the contracted Housekeeping Services. The Corporate Director of Plant Operations stated, .What I understand was that the Administrator will walk around and grade them and make adjustments from there. The Corporate Director of Plant Operations was asked how Corporate ensures the Administrator is doing that. The Corporate Director of Plant Operations stated, I don't have an answer for that. The Corporate Director of Plant Operations stated, I've been there twice. The Corporate Director of Plant Operations was asked if he noticed problems with housekeeping on those visits. The Corporate Director of Plant Operations stated, .didn't notice .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure the safety of a resident during transfer for 1 of 6 (Resident #35) sampled residents reviewed for accidents.
The findings include:
1. The facility's Lifting Machine, Using a Portable policy with a revision date of October 2010 documented, .Preparation .Review the resident's care plan to assess for any special needs of the resident .General Guidelines .The portable lift can be used by one nursing assistant if the resident can participate in the lifting procedures. If not, two (2) nursing assistants will be required to perform the procedure .Documentation .The following information should be recorded in the resident's medical record .Any problems .related to the procedure .Report other information in accordance with facility policy and professional standards of practice .
The facility's Fall and Fall Risk, Managing policy with a revision date of November 2017 documented, .Fall Definition .Unintentionally coming to rest on the ground, floor, or other lower level .
2. Medical record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses of Contracture of Bilateral Knees, Generalized Muscle Weakness, Lack of Coordination, History of Falling, and Dementia.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognition impairment, walking did not occur, required extensive assistance using 2-plus persons for transfers, had functional limitation in range of motion to bilateral lower extremities, moving from seated to standing position did not occur, and was not steady with surface-to-surface transfers.
The care plan dated 10/12/18, and last reviewed 6/20/19, documented, .at risk for falls .d/t [due to] impaired mental [status], medications, and physical status Interventions .Provide a mechanical lift for all transfers with the support of 2 staff members. Date Initiated: 06/13/2019 .TRANSFER: Requires staff participation .requires extensive weight bearing assist for all transfers . The interventions that were in place on the care plan prior to the fall on 6/12/19 did not document 1 or 2 persons to assist with transfers.
The Progress Notes documented, .6/12/2019 .Nursing Note .Reported by staff that residents [resident's] legs gave out while being transferred using standup lift on the previous shift .swelling to upper left chest region with bruising to the left axilla .
The hospital emergency room history and physical dated 6/12/19 documented, .presents with .LEFT ARM, SHOULDER AND LEFT CHEST PAIN, SWELLING AND BRUISING .Musculoskeletal: Proximal upper extremity: Left, anterior, shoulder, arm, tenderness, swelling, erythema, ecchymosis .CT [Computed Tomography] Chest W/ [with] Contrast .10 cm [centimeter] hyperdense lesion along the left pectoralis musculature, with surrounding edema, most compatible with hematoma . The resident required no aggressive treatment and returned to the facility on 6/12/19.
The Progress Notes documented, .6/23/2019 .Nursing Note .chest on left side remains swollen and fluid filled .
Observations in Resident #35's room on 6/27/19 at 4:15 PM revealed bruising to Resident #35's chest area and the rib cage, and slight swelling to the left shoulder and axilla area.
Interview with Certified Nursing Assistant (CNA) #3 on 6/26/19 at 2:00 PM in the Conference Room, revealed CNA #3 was asked how many staff members should be used when transferring a resident with the stand-up lift. CNA #3 stated, Always a 2-person. They always tell us to never use the lift alone.
Interview with CNA #4 on 6/26/19 at 2:59 PM, in the Conference Room, revealed CNA #4 was asked what happened while she was transferring Resident #35 using a stand-up lift. CNA #4 stated, I used the stand-up lift to transfer him from the chair to the bed. He did not stand up completely .I put the stand up lift in front of him, hooked him up, and he held on .I raised the lift up, and when he came up in the air, his feet wasn't on the bottom of the lift .a pad goes around him and it hooks about his waist. The other part of the pad hooks around the lift. Part of the pad goes up under his arms .I yelled out in the hall for help, and [Named CNA #2] came to help .he [Resident #35] was hooked on the lift and sitting on the side of the bed I lowered the lift and unhooked him and he was on the side of the bed he never complained pain CNA #4 was asked if she reported the incident to anyone. CNA #4 stated, No .
Interview with CNA #2 on 6/26/19 at 3:13 PM in the Conference Room, revealed CNA #2 was asked about the incident with Resident #35 and the use of the lift. CNA #2 stated, When [CNA #4] called for me to come in there and help her, he was like down on the floor already, his legs were on the floor . CNA #2 was asked if Resident #35 could stand. CNA #2 stated, No. I been working with him a long time and I never use the stand up lift. We just transfer him .2-person transfer. CNA #2 was asked if anyone else was in the room helping CNA #4 with him when she attempted to use the stand up lift. CNA #2 stated, No, ma'am, just her.
Interview with CNA #2 on 6/26/19 at 3:23 PM across from the 100 Hall Nurses' Station, revealed CNA #2 pointed to the stand-up lift base, and stated, He was like down on the base of the lift .his knees. His arms were like coming through the pad. He was still trying to hold on .We were just trying to keep him from falling and get him on the bed .If they ain't weight bearing, we are not supposed to use it. If they don't have the strength in his legs, it's not safe .
Interview with Licensed Practical Nurse (LPN) #2 on 6/27/19 at 3:55 PM in the Conference Room, revealed LPN #2 was asked what happened during the incident with the lift with Resident #35. LPN #2 stated, I think they were transferring him from chair to bed . LPN #2 was asked how many staff members should be used to transfer a resident using the lift. LPN #2 stated, 2 persons with all lifts. LPN #2 was asked if only 1 CNA should transfer a resident using the lift alone. LPN #2 stated, No ma'am.

Based on policy review, observation and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions as evidenced by a dirty bowl stacked in clean bowls, chipped plates, a dirty ice machine, a mound of ice in the walk-in freezer, a dirty freezer floor, staff allowing dirty dishes to come in contact with clean dishes, wet nesting of dishes [stacking of wet items, such as pans and dishes], staff touched clean dishes with dirty gloves, and staff stored personal food in a resident nutrition refrigerator. The facility had a census of 93 with 91 of those residents receiving a meal tray from the kitchen.
The findings include:
1. The facility's Sanitization policy revised 2017, documented, .The food service area shall be maintained in a clean sanitary manner .Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair and shall be free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning .Plastic-ware, china and glassware that cannot be sanitized or are hazardous because of chips, cracks or loss of glaze shall be discarded .
The facility's undated AM Shift Cleaning Schedule documented, .Check dishes for wet nesting .Ice Machines .sanitize interior .
The facility's Refrigerators and Freezers policy dated 2017 documented, .This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation .Refrigerators and freezers will be kept clean, free of debris, and mopped with sanitizing solution on a scheduled basis and more often as necessary .
The facility's Dishwashing Machine Use policy revised 2017 documented, .Wash hands before and after running dishwashing machine .when leaving the dirty end of the machine going to the clean end of the machine .frequently during the process .After running items through entire cycle, allow to air-dry .
The facility's Handwashing/Hand Hygiene policy revised April 2010, documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands .s. after handling soiled equipment or utensils .u. After removing gloves or aprons .
2. Observations in the kitchen on 6/24/19 at 8:45 AM, revealed the following:
a. A bowl containing black specks and a dead insect and 5 saucers with black specks stored with the clean dishes
b. 2 broken, chipped dinner plates stored with other dinner plates
Interview with the Certified Dietary Manager (CDM) on 6/24/19 at 8:48 AM, in the kitchen, revealed the CDM was asked if dishes with black specks and a dead insect on them should be stored with the clean dishes. The CDM stated, No, Ma'am.
Interview with the CDM on 6/26/19 at 8:59 AM in the kitchen, revealed the CDM was asked if broken, chipped plates should be stored with clean plates. She stated, No .
3. Observations in the kitchen on 6/24/19 at 8:50 AM and 1:28 PM, on 6/25/19 at 11:59 AM, and on 6/26/19 at 8:00 AM, revealed the following:
a. The ice machine had a pink slimy substance across the bottom of the white plastic overhang dripping into the ice.
b. There was a mound of ice in the walk-in freezer and freezer floor had an orange and blue frozen substance.
Interview with the CDM on 6/26/19 at 8:02 AM, in the kitchen, revealed the CDM used a towel to confirm the pink slimy substance in the ice machine. The CDM was asked if the pink slimy substance should be present. The CDM stated, No. The CDM was asked if ice should be piled in the freezer floor. The CDM stated, No, Ma'am. The CDM was asked if the freezer floor should be kept clean at all times. She stated, Yes.
4. Observations in the kitchen on 6/24/19 at 10:00 AM, revealed Dishwasher Staff #1 used a rack of dirty dishes to push a rack of clean dishes out of the dishwasher. Dishwasher Staff #1 repeated this action 3 times and did not wash her hands.
Interview with the CDM on 6/26/19 8:05 AM, in the kitchen, revealed the CDM was asked if a rack of dirty dishes should be used to push a rack of clean dishes out of the dishwasher. The CDM stated, No, Ma'am.
5. Observations in the kitchen on 6/24/19 at 1:28 PM, revealed the following:
a. There were 14 wet plate covers stacked together on a counter in the kitchen.
b. There were 5 wet plate covers stacked together on the clean counter in the dishwashing area.
Observations in the kitchen on 6/25/19 at 12:01 PM, revealed 17 small bowls stacked together wet on the clean dish cart
Interview with the CDM on 6/25/19 at 12:03 PM, in the kitchen, revealed the CDM confirmed the 17 bowls should not be stacked together wet.
6. Observations in the kitchen on 6/26/19 at 9:09 AM, revealed Dishwasher Staff #1 was wearing gloves in the dishwashing area and handled her personal cell phone. Dishwasher Staff #1 stated, I spilled milk on my phone. Dishwasher Staff #1 had milk on her uniform and gloves. Dishwasher Staff #1 wiped her hands on her uniform and began to handle the clean dishes with the same gloves used to clean the personal cell phone.
Interview with the CDM on 6/27/19 at 8:07 AM in the hall outside the kitchen, revealed the CDM was asked if dishwasher staff should touch a personal cell phone, wipe her hands on her uniform while wearing the gloves, and then touch the clean dishes. The CDM stated, No .
7. Observations in the Secure Unit Nutrition Room on 6/26/19 at 9:36 AM, revealed an unlabeled jar containing an unknown beige creamy substance in the residents' nutrition refrigerator. Certified Nursing Assistant (CNA) #1 entered the Nutrition Room and stated, That's my food.
Interview with Licensed Practical Nurse (LPN) #1 on 6/26/19 at 9:38 AM, in the Secure Unit Nutrition Room, revealed LPN #1 was asked if an employee should store their personal food in the residents' nutrition refrigerator. LPN #1 stated, This is only for resident nutrition.
Interview with the Director of Nursing (DON) on 6/27/19 at 11:36 AM in the Conference Room, revealed the DON was asked if staff should store their food in the residents' nutrition refrigerator. The DON stated, No, Ma'am.

Based on observation and interview the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program, failed to recognize an ongoing environmental concern, and failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. The QAPI committee failed to identify the root cause of the concerns, develop appropriate plans of action, and ensure systems and processes were in place to address the concern. The failure of the QAPI Committee to ensure the facility implemented and provide effective housekeeping services and maintenance services to maintain a sanitary, orderly and comfortable environment for 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 121, 122, 123, 124, 125, 126, 128, 130, 219, 220, 221, 225, 226, 227, 228, 230, 231, 232, 233, 234, 235, 241, 244, 245, 246, and 247) resident rooms observed resulted in Substandard Quality of Care.
The Administrator and Director of Nursing (DON) were notified of the Substandard Quality of Care on 6/26/19 at 5:15 PM in the Conference Room.
The facility was cited F584-F at a scope and severity of Substandard Quality of Care.
An extended survey was conducted on 6/26/19.
The noncompliance continues at F584-F for monitoring of effectiveness of the corrective actions.
The findings include:
Interview with the Housekeeping District Manager on 6/26/19 at 11:20 AM, in the Conference Room, revealed the Housekeeping District Manager stated he took over this facility in May. The Housekeeping District Manager was asked what problems he had identified in May. He stated, .build up on the floors .walls, dirt build up .cleaning schedules weren't being followed, no systems in place .the quality control inspection was not being followed .
Interview with the Administrator on 6/26/19 at 5:15 PM in the Conference Room, revealed the Administrator had been in the administrative position since October 2018. The Administrator was asked what problems he had identified in October. He stated, Flooring, roof, rooms, it was dirty .problems were here for years .rooms were in bad shape .they still look bad, roof has to get fixed .flooring .don't even like to look at it, we know it's got to come out .
Interview with the Maintenance Supervisor on 6/27/19 at 9:41 AM, in the Conference Room, revealed the Maintenance Supervisor was asked what problems he had identified in the building. He stated, .we have a lot of issues with the roof, the ceiling, with them being wet .we've got pinholes everywhere [in the copper water lines in the ceiling] .the bathroom wall situation, that's from moisture .old floors .wall damage .
Telephone interview with the Corporate Director of Plant Operations on 6/27/19 at 11:02 AM, revealed the Corporate Director of Plant Operations was asked what environmental problems he had identified in the building. The Corporate Director of Plant Operations stated he assumed his position in January and further stated, .We came down to look at .copper lines .had multiple saddle repair [pipe] clamps .pipe over the nurse's station had a number of saddle clamp repairs. We made the conclusion that the pipe was reaching its end and deteriorating. The Corporate Director of Plant Operations was asked when he was made aware of the problems and he stated, .the Maintenance Director told me about it in February .it wasn't a dire issue in February . The Corporate Director of Plant Operations was asked who monitors the work provided by the contracted Housekeeping Services. The Corporate Director of Plant Operations stated, .What I understand was that the Administrator will walk around and grade them and make adjustments from there. The Corporate Director of Plant Operations was asked how Corporate ensures the Administrator was monitoring the housekeeping services. The Corporate Director of Plant Operations stated, I don't have an answer for that.
Interview with the Administrator on 6/27/19 at 1:51 PM, in the Administrator Office, revealed the Administrator was asked what he had identified as a concern in QA. The Administrator stated, .I had a plan in January for new floors but it got stopped .they have had a lot of turn over .lots of things didn't get done .
1. The QAPI Committee failed to identify and correct concerns to provide effective housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment for 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 121, 122, 123, 124, 125, 126, 128, 130, 219, 220, 221, 225, 226, 227, 228, 230, 231, 232, 233, 234, 235, 241, 244, 245, 246, and 247) resident rooms observed which resulted in Substandard Quality of Care.
Refer to F584.
2. The Facility's QAPI committee failed to develop and implement appropriate plans of action to ensure a sanitary and comfortable environment for 44 of 57 (101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 111, 112, 113, 114, 115, 117, 118, 119, 121, 122, 123, 124, 125, 126, 128, 130, 219, 220, 221, 225, 226, 227, 228, 230, 231, 232, 233, 234, 235, 241, 244, 245, 246, and 247) resident rooms observed which resulted in Substandard Quality of Care.
Refer to F584.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 (Wound Care Nurse, Certified Nursing Assistant (CNA) #5, Licensed Practical Nurse (LPN) #1) staff members failed to perform proper hand hygiene during 3 of 3 (Resident #7, #21, and #41) observations of provision of care and dirty linens were left on the bathroom floor in 1 of 3 (100 Hall Central Bath) shower rooms and 1 of 42 (room [ROOM NUMBER]) resident room bathrooms.
The findings include:
1. The facility's Handwashing/Hand Hygiene policy with a revision date of April 2010 documented, .This facility considers hand hygiene the primary means to prevent the spread of infections .Employees must wash their hands .Before and after direct contact with residents .After removing gloves .The use of gloves does not replace handwashing/hand hygiene .
2. Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Hypertension, Contractures, Dementia with Behavioral Disturbance, Anemia, Pressure Ulcer of Right Hip, Pressure Ulcer of Left Buttock, and Anxiety.
Observation in Resident #7's room on 6/20/19 at 11:05 AM revealed the Wound Care Nurse performing a dressing change on Resident #7 with the assistance of CNA #5. The Wound Care Nurse removed the dressing from the Stage 3 (full thickness skin loss) pressure ulcer on the left gluteal fold, cleaned the open wound with wound cleanser, patted the wound dry, applied skin prep and Calazime Skin Protectant around the wound using the same gloved hands. The Wound Care Nurse then removed her gloves and donned clean gloves without performing hand hygiene, and applied a clean dressing over the wound.
The Wound Care Nurse did not perform hand hygiene and change gloves between cleaning the wound and applying a clean treatment to the wound.
The Wound Care Nurse did not perform hand hygiene after removal of her gloves and before donning clean gloves.
Continued observation revealed CNA #5 pushed the edge of Resident #7's brief down, and revealed a small amount of feces oozing from the brief and onto CNA #5's glove. CNA #5 then pressed down the edges of the clean dressing with the same gloved hand without changing the soiled glove.
The Wound Care Nurse then removed a dressing from the Stage 3 pressure ulcer to the right hip, cleaned the wound with wound cleanser, patted the wound dry, applied skin prep and Calazime Skin Protectant around the wound edges using the same gloves.
The Wound Care Nurse did not perform hand hygiene and change gloves between cleaning the wound and applying a clean treatment to the wound.
3. Medical record review revealed Resident #41 was admitted on [DATE] with diagnoses of Osteomyelitis, Dysphagia, Adult Failure to Thrive, Parkinson's Disease, Protein Calorie Malnutrition, and Dysphagia.
Observation in Resident's #41's room on 6/20/19 at 1:00 PM revealed the Wound Care Nurse performing a dressing change on Resident #41. The Wound Care Nurse cleaned the sacral wound, removed her gloves, and donned new gloves without performing hand hygiene.
The Wound Care Nurse cleaned the left hip wound, washed her hands, donned a new pair of gloves, and placed Alginate into the wound bed using a cotton swab. The Wound Care Nurse then covered the left hip with a clean dressing and removed her gloves. The Wound Care Nurse did not perform hand hygiene.
The Wound Care Nurse covered Resident #41 with a blanket, picked up the bed remote, and raised the head of the bed without performing hand hygiene. The Wound Care Nurse used her bare hands to partially remove Resident #41's left sock, went to the medication cart, picked up a hand held mirror, looked at the bottom of Resident #41's heel, and then placed a new glove on her right hand, without performing hand hygiene. The Wound Care Nurse picked up the wound barrier and placed it into the biohazard bag, and removed her glove and donned clean gloves without performing hand hygiene after removal of the gloves.
The Wound Care Nurse then removed Resident's cover again, turned Resident #41 to her left side, removed the right hip dressing and applied a new cover dressing over the right hip wound. The Wound Care Nurse removed her gloves and covered the resident with a blanket using her bare hands without performing hand hygiene. The Wound Care Nurse failed to wash her hands between glove changes, between dirty and clean dressings, and before direct contact with the resident.
4. Medical record review revealed Resident #21 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Diabetes, Heart Failure, Alzheimer's, Dementia, Anxiety, Depression, Hypertension, Peripheral Vascular Disease, Osteoarthritis, and Chronic Obstructive Pulmonary Disease.
Observations in Resident #21's room on 6/25/19 at 2:04 PM revealed Licensed Practical Nurse (LPN) #1 cleaned Resident #21's buttock area with disposable wipes, changed gloves without performing hand hygiene, and then applied Calazime Skin Protectant cream to the coccyx/sacrum/buttocks areas.
LPN #1 then cleaned the scrotum and groin area with disposable wipes and applied Calazime Skin Protectant cream to these areas using the same gloved hands. LPN #1 assisted Resident #21 to reposition himself in bed, repositioned the 3 pillows behind his head, and used his bed remote to raise his head of bed, still wearing the same gloves. LPN #1 then removed her gloves and performed hand hygiene at the sink in Resident #21's room. LPN #1 turned off the faucet with the same paper towel she used to dry her hands.
Interview with the Director of Nursing (DON) on 6/27/19 at 11:34 AM in the conference room, revealed the DON was asked if a resident had a soiled brief on, should the staff change the brief before performing wound care. The DON stated, Yes ma'am. The DON was asked when the nurse should perform hand hygiene during wound care. The DON stated, Before beginning, before gloves, when changing gloves in between, and at the end of wound care. The DON was asked when staff should perform hand hygiene during perineal care. The DON stated, Before beginning, before putting gloves on, after removal of soiled items. They should wash hands and put on new gloves and wash again after they take them off.
5. Observations in room [ROOM NUMBER]'s bathroom on 6/24/19 at 9:41 AM revealed a dirty, crumpled towel and washcloth on the floor beside the toilet.
Observations in the 100 Hall Shower Room on 6/25/19 at 8:06 AM revealed dirty, wet towels on the floor.
Interview with CNA #6 on 6/24/19 at 9:42 AM in room [ROOM NUMBER]'s bathroom, revealed CNA #6 was asked if the dirty towel and washcloth should be on the bathroom floor. CNA #6 stated, No ma'am, they shouldn't .

Based on observation and interview, the facility failed to ensure 1 of 2 (100 Hall Dayroom) dayrooms, 2 of 2 (100 Hall and 200 Hall) halls, and 3 of 3 (100 hall Central Shower, Secure Unit Women's Shower, and Secure Unit Men's Shower) shower rooms were clean and sanitary.
The findings include:
1. Observations in the 100 Hall Dayroom on 6/24/19 at 9:12 AM, 11:39 AM, 2:49 PM, 6/25/19 at 8:04 AM, and 3:38 PM, and on 6/26/19 at 7:46 AM revealed black streaks on the floor, brown debris, stains and scattered debris on the floor. The windows were cloudy and smeared with a grayish white substance between the dayroom and the nurses' station.
Interview with the Housekeeping District Manager on 6/27/19 at 10:16 AM in the Conference Room, revealed the Housekeeping District Manager was asked if the common areas and dayrooms should be kept clean and sanitary. The Housekeeping District Manager stated, Yes.
2. Observations in the 100 Hall on 6/24/19 at 7:55 AM, 9:10 AM, 11:45 AM, 2:23 PM, 6/25/19 at 8:01 AM, 3:25 PM, and on 6/26/19 at 7:46 AM revealed brown debris, brownish-black stained areas, and scattered debris throughout the entire hall.
Interview with the Housekeeping District Manager on 6/25/19 at 3:33 PM in the 100 Hall, revealed the Housekeeping District Manager was asked if the 100 Hall was clean and sanitary. The Housekeeping District Manager confirmed the hall was not clean.
3. Observations in the 200 Hall beginning on 6/24/19 at 7:54 AM, 2:23 PM, and on 6/25/19 at 2:15 PM and 4:15 PM revealed brown debris, clear red stained areas, a sticky clear brown substance, and scattered debris on the floor.
Interview with the Housekeeping District Manager on 6/25/19 at 4:36 PM in the 200 Hall, revealed the Housekeeping District Manager was asked if the 200 Hall was clean and sanitary. The Housekeeping District Manager confirmed the 200 Hall was not clean and sanitary and stated, We replaced the Housekeeping Supervisor and the Regional Supervisor within the last 3 to 4 weeks because of the condition of this building.
4. Observations in the 100 Hall Central Shower on 6/24/19 at 9:51 AM, 6/25/19 at 8:06 AM, 2:30 PM, and 4:33 PM revealed broken tile, missing shower curtains in the shower stalls, dark black substance in the corners of the shower stall to the right, a discolored nonskid strip and a spider web in the corner of the left shower stall, a dripping shower head in the back left shower stall. There was a large amount of dark greenish black build-up on the tiles and in the grout of the shower wall, extending down to a large area of dark greenish black substance on the floor of the shower, below the shower head, and the shower had rusty shower fixtures.
Interview with the Maintenance Supervisor, Housekeeping District Manager, and the Administrator on 6/25/19 at 4:35 PM in the 100 Hall Central Shower, revealed the Maintenance Supervisor was asked if broken tile should be present. He stated, No. The Housekeeping District Manager confirmed the showers were not clean. The Housekeeping District Manager was asked if a large amount of dark greenish black build-up on the tiles below the shower head and in the grout of the shower wall extending down to the floor of the shower should be present in the showers. The Housekeeping District Manager stated, No. The Housekeeping District Manager confirmed the nonskid strip was not clean and needed to be replaced. The Housekeeping District Manager confirmed the shower curtains were missing and needed to be replaced. The Maintenance Supervisor and the Administrator confirmed that the fixtures should be replaced.
Interview with Certified Nursing Assistant (CNA) #7 on 6/26/19 at 1:56 PM in the Conference Room, revealed CNA #7 was asked if the 100 Hall Central Shower Room was clean. She confirmed she had been concerned about the back left shower stall. She stated, .look like mold .all around the edges of the shower room floor. I have noticed some tiles missing. I think they know about it .
Interview with CNA #4 on 6/26/19 at 2:59 PM in the Conference Room, revealed CNA #4 was asked if the 100 Hall Central Shower was clean and sanitary. She confirmed it was not clean and stated, It's clean maybe once a week, then that shower stall [back left] has mildew or mold in the floor, and it's been there since I been here 2 years. It's like a dark green black color, it's like what it looks like in the ceiling where the mold is throughout the halls. Maintenance knows.
5. Observations in the Secure Unit Women's Shower Room on 6/25/19 at 5:52 PM, and on 6/26/19 at 11:10 AM revealed a brown round formed substance in the shower, a musty odor, and a non-functioning light.
6. Observations in the 200 Hall Men's Shower Room on 6/25/19 at 5:52 PM, and on 6/26/19 at 11:14 AM revealed broken tile, a black substance in the grout and in the corners of the shower stall, and the walls had broken and missing tile.
Interview with Housekeeper #1 on 6/27/19 at 8:19 AM in the Conference Room, revealed Housekeeper #1 was asked if the greenish black substance in the corners, on the tiles and on the floor of the showers should be present. Housekeeper #1 stated, No, Ma'am .it's been there a long time .
Telephone interview with the Director of Plant Operations on 6/27/19 at 11:20 AM, revealed the Director of Plant Operations was asked if residents have the right to shower in a shower room that is clean and in good repair. The Director of Plant Operations stated, Absolutely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to notify the physician of blood glucose (blood sugar) results for 1 of 5 (Resident #46) sampled residents.
The findings include:
1. The Obtaining a Fingerstick Glucose Level policy with a revision date of October 2010 documented, .The person performing this procedure should .Report results promptly to .the Attending Physician .
2. Medical record review revealed Resident #46 was admitted to the facility on [DATE] with diagnoses of Parkinson's Disease and Type 2 Diabetes Mellitus.
The Medication Administration Record (MAR) for the month July, August, and September 2018 documented, .Insulin Lispro Solution .Inject as per sliding scale .>[greater than] 349, give 6 units and call physician .
The MAR documented the following blood glucose results:
a. 390 on 7/26/18 at 4:00 PM
b. 496 on 7/28/18 at 4:00 PM
c. 356 on 7/30/18 at 4:00 PM
d. 350 on 8/28/18 at 7:30 AM
e. 350 on 8/29/18 at 11:00 AM
f. 352 on 8/30/18 at 7:30 AM and 350 at 4:00 PM
g. 508 on 8/31/18 at 7:30 AM
h. 370 on 9/1/18 at 4:00 PM and 9:00 PM
i. 370 on 9/2 /18 at 4:00 PM
k. 509 on 9/3/18 at 7:30 AM and 469 at 11:00 AM
Interview with the Director of Nursing (DON) on 9/6/18 at 4:45 PM, in the DON office, the DON was asked if the physician had been notified of the blood glucose results above 349, the DON confirmed the physician had not been notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to provide care and services to maintain an indwelling urinary catheter when nursing staff failed to keep the drainage bag off the floor for 1 of 2 (Resident #93) sampled residents reviewed for indwelling urinary catheters.
The findings include:
The facility's Indwelling Urinary Catheters . policy with a revision date of 11/17, documented, .Be sure the catheter tubing and drainage bag are kept off the floor .
Medical record review revealed Resident #93 was admitted to the facility on [DATE] with diagnoses of Neuromuscular Dysfunction of Bladder, Hypertension, and Hyperlipidemia.
The physician's orders dated 8/7/18 documented, .Indwelling (foley) catheter .16ff [french]/10cc [cubic centimeters] .
Observations in Resident #93's room on 9/4/18 at 9:05 AM, 2:23 PM, and 3:13 PM, revealed Resident #93 seated in a wheelchair with the indwelling catheter drainage bag hanging underneath the chair and touching the floor.
Observation in the dining room on 9/4/18 at 12:17 PM, revealed Resident #93 seated in a wheelchair with the indwelling catheter drainage bag hanging underneath the chair and touching the floor.
Observation in Resident #93's room on 9/5/18 5:01 PM, revealed Resident #93 lying in bed with the indwelling catheter drainage bag hanging on the bedside and touching the floor.
Interview with Licensed Practical Nurse (LPN) #1 on 9/5/18 at 5:03 PM in Resident #93's room, LPN #1 confirmed the urinary catheter drainage bag was touching the floor. LPN #1 was asked if the drainage bag should be touching the floor and LPN #1 stated, No ma'am.
Interview with the Director of Nursing (DON) on 9/6/18 at 4:07 PM, in the conference room, the DON was asked if it the indwelling urinary catheter drainage bag should be touching the floor. The DON stated, No ma'am .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to follow physician orders related to an enteral feeding for 1 of 1 (Resident #52) sampled resident reviewed for enteral feeding.
The findings include:
The facility's Enteral Nutrition . policy with a revision date of 11/16, documented, .Enteral feeding orders will be written to ensure consistent volume infusion .Fluids to be provided (beyond free fluid in product) will be calculated by the Dietician and referred to the Physician for an order .
Medical record review revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of Adult Failure to Thrive, Gastrostomy Status, Dementia, and Diabetes.
The significant change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment, required staff assistance for all activities of daily living, received tube feedings, and received 51 percent or more calories and 501 cubic centimeters (cc) or more fluid intake from tube feeding.
The physician's orders dated 8/13/18 documented, .H2O [Water] flush 60 cc/hr [hour] .
Observations in Resident #52's room on 9/4/18 at 9:13 AM, and 9/5/18 at 5:10 PM, revealed Resident #52 lying in bed with Glucerna 1.5 infusing per the percutaneous endoscopic gastrostomy (PEG) tube via pump at 65 cc/hr with the water flush rate set to 0 cc/hr.
Observations in Resident #52's room on 9/4/18 at 5:32 PM, revealed Resident #52 in bed with Glucerna 1.5 infusing per PEG via pump at 65 cc/hr with the water flush rate set to 55 cc/hr.
Observations in Resident #52's room on 9/5/18 at 9:12 AM, revealed Resident #52 seated in her wheelchair at the bedside with Glucerna 1.5 infusing per PEG via pump at 65 cc/hr with water flush rate set to 0 cc/hr.
Interview with Licensed Practical Nurse (LPN) #1, on 9/5/18 at 5:15 PM in Resident #52's room, LPN #1 was asked if the water flush rate was correct. LPN #1 confirmed the water flush rate should be set to 60 cc/hr.
Interview with the Registered Dietician (RD), on 9/6/18 at 12:58 PM in the conference room, the RD was asked what Resident #52's water flush rate should be. The RD stated, .I recommended her flush at 60 cc/hr. The RD was asked if she expected the nursing staff to follow her recommendations for water flushes. The RD stated, Yes ma'am.
Interview with the Director of Nursing (DON) on 9/6/18 at 4:07 PM in the conference room, the DON was asked if it was acceptable for the nursing staff not to follow the physician's orders for the water flush rate. The DON stated, No ma'am.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, observation, and interview, the facility failed to ensure 1 of 4 (Licensed Practical Nurse (LPN) #2) nurses properly disposed of a topical medication patch during medication administration, and failed to ensure medications were not stored past their expiration dates in 1 of 6 (100 Medication Room) medication storage areas.
The findings include:
1. The facility's Discarding and Destroying Medications . policy with a revision date of 6/12, documented, .Ointments, creams, and other like substances may be discarded into the trash receptacle in the medication room .Expired medications will be disposed of per state or contracted pharmacy guidelines .
2. Medical record review revealed Resident #199 was admitted to the facility on [DATE] with diagnoses of Dementia, Pneumonia, Seizures, and Chronic Obstructive Pulmonary Disease.
The physician's order dated 8/31/18 documented, .Rivastigmine Patch 24 Hour [medication patch used to treat dementia] 9.5 MG [milligrams]/24HR [hours] Apply 1 patch transdermally [to the skin] one time a day for dementia .
Observations in Resident #199's room on 9/5/18 at 11:39 AM, revealed Licensed Practical Nurse (LPN) #2 removed the old Rivastigmine patch from Resident #199's left upper arm, and disposed of it inside her gloves in the trash receptacle in Resident #199's room.
Interview with the Director of Nursing (DON) on 9/6/18 at 4:07 PM in the conference room, the DON was asked how nurses should dispose of used transdermal patches. The DON stated, Normally they put them in a sharps box . The DON was asked if nurses should dispose of used medication patches in the regular trash in a resident's room. The DON stated, No ma'am.
3. Observations in the 100 Medication Room on 9/5/18 at 12:10 PM, revealed the locked narcotic emergency box had an expiration date of 7/31/18. LPN #3 opened the emergency narcotics box, and revealed 2 zolpidem 5 mg tablets [sedation/hypnotic medication] with an expiration date of 7/31/18, and 1 lorazepam 0.5 mg tablet [anxiety medication] with an expiration date of 8/31/18.
Interview with LPN #3 on 9/5/18 at 12:12 PM, in the 100 Medication Room, LPN #3 confirmed the emergency narcotics box contained 2 expired zolpidem tablets and 1 expired lorazepam tablet.
Interview with the Director of Nursing (DON) on 9/6/18 at 4:07 PM in the conference room, the DON was asked if it was acceptable to have expired medications in the medication rooms. The DON stated, No ma'am.

Based on observations and interview, the facility failed to ensure personal care items were stored in a sanitary manner in 2 of 42 (shared bathroom of Resident #12, 15, and 87, and shared bathroom of Resident # 51 and 60) bathrooms.
The findings include:
The facility was unable to provide a policy for storage of personal care items.
Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/4/18 at 9:12 AM, revealed an uncovered, unlabeled bath basin on top of the toilet, an unlabeled bottle of shampoo/body wash on the sink, an unlabeled tube of toothpaste and an unlabeled toothbrush on top of the soap dispenser.
Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/4/18 at 3:01 PM, revealed an unlabeled bath basin in an unlabeled plastic bag with the unlabeled shampoo/body wash inside on the top of the toilet, an unlabeled tube of tooth paste and an unlabeled toothbrush remained on top of the soap dispenser.
Observations made in the shared bathroom of Residents #12, 15, and 87 on 9/5/18 at 9:08 AM, and on 9/6/18 at 7:57 AM, revealed the unlabeled bath basin in an unlabeled plastic bag, with the unlabeled shampoo/body wash inside, sitting on the top of the toilet.
Interview with Certified Nursing Assistant (CNA) #1 on 9/4/18 at 4:18 PM in the shared bathroom of Residents #12, 15, and 87, CNA #1 was unable to confirm which resident the personal care items belonged to. CNA #1 stated, .none of them [residents sharing the bathroom] do their own ADLs [Activities of Daily Living] .
Interview with Licensed Practical Nurse (LPN) #1 on 9/6/18 at 7:57 AM in the shared bathroom of Residents #12, 15, and 87, LPN #1 confirmed that personal care items should be placed in a labeled plastic bag and stored in the resident's bedside table when not in use. LPN #1 confirmed the bath basin and body wash were not stored correctly. LPN #1 stated, .It's an infection control issue .
2. Observations made in the bathroom of Residents #51 and 60 on 9/4/18 at 9:15 AM, and 3:03 PM, revealed 2 unlabeled bottles of shampoo/body wash on the sink, an unlabeled urine stained collection device on the back of the toilet, and 2 unlabeled graduated cylinders the floor behind the toilet.
Interview with CNA #1 on 9/4/18 at 4:20 PM, in Resident #51 and 60's bathroom, CNA #1 was unable to confirm to which resident the urine collection device or the graduated cylinders belonged. CNA #1 stated, .Those are used to catch urine if they have a lab test .the nurse would put them in the room then throw them away after they get the urine .I'm not sure why they are still there .