Every finding on record at Avir at Temple East

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foodservice safety in 1 of 1 kitchen. The facility failed to ensure food safety on 02/04/2026 by failing to consistently monitor and discard expired food, failing to label and/or date food items, and failing to keep bins, where serving utensils and dishes were stored, clean. These failures could place residents who received meals from the main kitchen at risk for foodborne illnesses.Findings included:Observation on 2/04/2026 at 8:40 AM of the walk-in refrigerator reflected the following:- Corn tortillas with a manufacture date of 10-25-2025 and no expiration date.- A bell pepper in a cardboard box with no date was written on the box. Observation on 2/04/2026 at 8:50 AM of the walk-in freezer reflected the following:- Waffles in a plastic tub with no open or expiration date on the package. - Pie shells that were not sealed and exposed to air - Icing in a piping bag with no open or expiration date on the package. Observation on 8/05/2025 at 9:00 am of the kitchen reflected the following:- Serving utensils stored in a plastic container had food debris at the bottom of the container. - Serving pans stored in a plastic container had food debris at the bottom of the container.- Corn tortillas on a shelf with a manufacture date of 10-25-2025 and no expiration date.- Two boxes that contained 6 1 gallons of Ozarka water stored on the floor.- The juice dispenser had old juice built up on the nozzle. An interview on 2/06/2026 at 12:35 pm with DM. DM stated thatthe kitchen was cleaned weekly. The DM stated that whoever did the dishes was responsible for cleaning the bins with the pans and utensils. The DM stated that the bins should be cleaned weekly. The DM stated that the dietary aides were responsible for cleaning them after every shift. The DM stated that there was a kitchen cleaning schedule for staff to follow. The DM stated that everybody, but the cook was responsible for labeling food items in the kitchen. The DM stated that they used a first-in, first-out system, with new items going in the back and old items going in the front. The DM stated that regularly checking dates would help ensure items did not expire. The DM stated that all ready-to-eat foods must be labeled with a use-by date or another expiration date. If a resident was served expired food, they could get sick. The DM stated that all staff had received food safety training. An interview on 2/06/2026 at 12:45 pm with DA. The DA stated that the kitchen and bins are cleaned after every service. The DA stated the dishwashers are responsible for cleaning the bins with the utensils and pans. The DA stated that the bins containing pans and utensils are cleaned daily. The DA stated that the night shift is responsible for cleaning the juice machine before they leave each day. The DA said staff have a cleaning schedule for the kitchen, and everyone knows their responsibilities. The DA stated that it is everyone's responsibility for checking dates on food items in the kitchen. The DA stated that old and expired food should be thrown out. The DA stated that to prevent using expired food, she uses older items first. The DA said all ready-to-eat foods must be labelled with a use-by date or another expiration date. If a resident were served expired food, they could get sick. The DA stated that she has had food safety training. An interview on 2/06/2026 at 12:54 pm with the CK. The CL stated the kitchen, and bins are cleaned once a week. The CK stated everyone in the kitchen goes by the cleaning schedule. The CK stated that the dishwasher is responsible for cleaning the bins with the utensils and pans. The CK stated that the bins with the pans and utensils are cleaned weekly. The CK stated that the juice dispenser should be cleaned every night and soaked in the solution. The CK stated that there everyone has a cleaning schedule for the kitchen. The CK stated that everyone is responsible for checking the dates on kitchen food items to ensure nothing has expired. The CK stated that he uses a first-in, first-out method, placing the old at the front and the new at the back. The CK stated that all ready-to-eat foods must be labelled with a use-by date or another expiration date. The CK stated that if a resident were to be served expired food, they could get sick. The CK stated that he has training on out-of-date food, labeling, and cleaning. Record review of the Manual Cleaning and Sanitizing of Utensils and Portable Equipment Policy that was not dated revealed:Record review of the Food Safety Policy that was not dated:Use the first-in, first-out (FIFO) rotation method. Date packages and place new items behind existing supplies, so that the older items are used first. Store all items at least 6 above the floor with adequate clearance between goods and ceiling to protect from overhead pipes and other contamination.

Based on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 1 resident (Resident #1) reviewed for personal hygiene. The facility failed to provide Resident #1 with 2 scheduled showers between 01/24/2026 and 02/04/2026. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.The findings included :Record review of Resident #1's Face Sheet, dated 02/04/2026, reflected a [AGE] year-old resident with an initial admission date of 12/08/2025. Resident #1 had diagnoses that included other Osteomyelitis (inflammation or swelling of bone tissue, typically caused by a bacterial or fungal infection); Amputation of right leg below the knee, weakness, and heart failure. Record review of Resident #1's Quarterly MDS Assessment, signed and completed on 02/04/2026, reflected Resident #1 had a BIMS score of 15, indicating the resident was cognitively impaired. Resident #1's MDS assessment indicated that Resident #1 was Dependent (helper assist with the effort for showering). Record review of Resident #1's Comprehensive Person-Centered Care Plan, undated, reflected, [Resident #1] has an ADL self-care performance deficit with interventions, [Resident #1] requires (assistance by (1) staff with showering and as necessary. Record review of Resident #1's shower log revealed Resident #1 did not receive 2 of the 4 showers scheduled on 01/24/2026 and 02/04/2026, Resident #1 received showers on the following dates: 01/28/2026 and 01/31/2026. There were no other showers documented on the resident's electronic health record. During an interview on 02/04/2026 at 12:47 PM, Resident #1's stated that he had not had a shower in a week. Resident #1 stated that there were times that he asked for a shower, and they didn't come. Resident #1 stated that he was supposed to get a shower three times a week . Resident #1 did not appear to be unkempt and there was no odor coming from Resident #1.An Interview on 02/06/2026 at 12:30 pm, the DON stated that if a resident took showers, it should be documented in PCC. The DON stated that staff only marked yes or no when a resident takes or does not take a shower. The DON stated that they didn't give a reason why the residents did not shower. The DON stated that if a resident was refusing showers, then it should be in the care plan. DON stated that Resident #1 would refuse a shower when his brother came to visit and that is why there is a no on checked on the form. An Interview on 02/06/2026 at 12:38 pm, the MDS Coordinator stated that if a resident does not taking showers, then it needs to be logged into PCC . The MDS Coordinator stated that they need to find out the reason why a resident is not getting showers. The MDS Coordinator said that she goes by the progress notes and if a resident is refusing showers, it should be in the progress notes. The MDS Coordinator said that she would then add that to the resident's care plan. If the residents do not take showers they can have odors, build up on the skin, depression, and withdrawals.An Interview on 02/06/2026 at 12:45 pm, RN C stated that missed showers should be in the shower log and in PCC. RN C stated it is important for residents to get showers, because that is when they find issues with the skin. The RN C stated if a resident refuse there is a 24 hour report they use to notify staff on the next shift. The RN C stated that the MDS Coordinator needed to be informed so they can update the care plan so that the residents refuses to shower. The RN C stated that a resident could get a skin infection if they do not get showers. [NAME] interview on 02/06/2026 at 12:55 pm, CNA D stated that showers should be logged in PCC even if a resident refuses a shower. CNA D stated that it is important to log the showers so that other staff know if there is a pattern. The CNA D stated that it is important for residents to get showers because that is when they check residents' skin to see if there are any concerns. The CNA D stated that if a resident does not get showers they can smell and have skin break down. An Interview on 02/06/2026 at 12:55 pm, LVN H stated that when residents are given showers that is when skin and nails are checked. When there are any new issues, it should be reported and documented in PCC. Shower refusals should be documented as the reason why the shower is reused. If a resident refuses it should be in the care plan. LVN H stated that residents could be not get proper care if they are not getting showers. LVN H stated that residents could have skin breakdowns.Record review of facility policy, not dated. titled, Activities of Daily Living (ADL), Supporting, reflected, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 3 (Resident #135, #79 and 72) 8 residents reviewed for comprehensive care plans. The facility failed to ensure Residents #135, #79, and #72's comprehensive care plans reflected the residents were at a high risk for wandering and them residing in the memory care unit. This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans. Findings included: 1. Review of Resident # 135's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with a readmission on 10/4/2024. Her diagnosis included Dementia in other Diseases classified elsewhere, moderate, with other behavioral disturbance (long-term brain disorder causing personality changes and impaired memory, reasoning, and social function), Arteriosclerotic heart disease (abnormal called lesions in the walls of arteries), and anxiety disorder (a group for mental disorders characterized by significant and uncontrollable feelings of anxiety). Review of Resident # 135's Admission MDS assessment dated [DATE] revealed a BIMS score of 10 which can indicate she had moderate cognitive impairment. Section E - Behavior revealed the resident had verbal behavior occurred 1 to 3 days, and other behavioral symptoms not directed at others occurred 1 to 3 days, these behavioral symptoms did not put the resident or others are risk. The resident had wandering behavior that occurred 1 to 3 days with no impact of risk to resident or the privacy of others during the seven day look back period. Review of Resident # 135's Care plan dated 10/4/2024 revealed no indication of wandering behavior or interventions present. No indication in care plan for need for memory care unit or any interventions. Review of Resident #135's physician orders dated 10/08/2024 revealed admit to memory care unit. Review of Resident # 135's Memory Care Unit admission screening for placement dated 10/08/2024 revealed the resident has Alzheimer's of related dementia diagnosis; a habit of wandering, and was able to ambulate independently, and less restrictive alternative have been unsuccessful and will benefit from a structured environment with specialized activities therefore met criteria. Review of Resident # 135's Wandering assessment dated [DATE] revealed a wandering score of 11 (Above high risk to wander) Review of Resident # 135's Consent for Memory care unit dated 10/7/2024 revealed it was signed by resident's responsible party. 2. Review of Resident # 79's Face sheet dated 11/19/2024 revealed a [AGE] year-old male admitted on [DATE] with diagnosis that include Congestive Heart Failure (a long-term condition that happens when your heart can't pump blood well enough to meet your body's needs), and bipolar disorder (a mental disorder characterized by period of depression and periods of abnormally elevated mood that each last from days to weeks.) Review of Resident # 79's review of Admission MDS dated [DATE] revealed a BIMS score of 15 (cognitively intact). Behavior section revealed Physical behavioral symptoms towards others occurred 1-3 days during the look back period, verbal behavioral symptoms towards others occurred 1-3 days 1 to 3 days during the 7-day look back period and other behavioral symptoms not directed toward others occurred 1 to 3 days during the same look back period. Behaviors did not have an impact on the resident or others. Wandering occurred 1 to 3 days during the 7-day look back period with no impact on the resident or invasion of others privacy. Behavior symptoms remained the same. Review of Resident # 79's care plan dated 10/8/2024 revealed no problem or interventions for wandering behavior and no problem of interventions for need to be in the memory care unit. Review of Resident # 79's physician order dated 9/19/2024 revealed admit to Memory care unit. Review of Resident # 79's memory care unit admission screening dated 9/18/2024 revealed the resident had a habit of wandering and less restrictive alternatives had been unsuccessful. The resident was able to ambulate independently and would benefit from a structured environment with specialized activities. Review of Resident # 79's wandering risk scale dated 9/18/2024 revealed a score of 11 which placed the resident at high risk to wander. Review of Resident # 79's memory care unit consent for placement dated 9/18/2024 revealed it was signed by Resident # 79. 3. Review of Resident #72's face sheet dated 11/19/2024 revealed an [AGE] year-old female admitted on [DATE] with diagnoses that include Alzheimer's disease (a biological process that begins with the appearance of buildup of proteins in the brain), and schizoaffective disorder (a mental disorder characterized by symptoms of schizophrenia (a mental disorder characterized by hallucinations, delusions, disorganized thought process, a flat or inappropriate affect, and a mood disorder.) Review of Resident # 72's Quarterly MDS dated [DATE] revealed the resident has a BIMS score of 4 (severe cognitive impairment). Behavioral symptoms include verbal behavioral symptoms directed toward others and other behavioral symptoms not directed at others occurred 1 to 3 days during the 7-day look back period. Wandering behavior occurred 4-6 days but less than daily during the 7-day look back period. Review of Resident # 72's care plan dated 10/8/2024 revealed no problem or interventions for wandering or placement on the memory care unit. Review of Resident # 72's order listing report dated 11/19/2024 revealed an order to admit to memory care unit dated 3/14/2024. Review of Resident # 72's Memory care unit admission for screening for placement dated 9/17/2024 revealed the resident had a diagnosis of Alzheimer's, habitually wandered, less restrictive measures had been unsuccessful, resident was able to ambulate independently, and would benefit from a structured environment with specialized activities. Review of Resident # 72's Wandering risk scale dated 10/17/2024 revealed a score of 11 which indicated the resident was high risk for wandering. Review of Resident # 72's Memory care unit consent for placement dated 10/17/2024 revealed the consent was signed by resident's responsible party. Observation 11-19-24 at 11:30 am . Resident # 135 was sitting at a table drinking some water ready for lunch clean dry and odor free. Resident # 79 was sitting in the common room in her wheelchair Resident # 72 was roaming around the unit interacting with other resident and staff clean dry and odor free. Interview with SW on 11/20/2024 at 10:00 am stated that the IDT were responsible for updating the care plan. She stated she does the assessment to determine if a resident needs memory care and get with the nurse to get the order. She stated she was not aware of care planning behaviors and the need to be on the locked unit. Interview with the Corporate MDS nurse,11/20/2024 at 11:00 am revealed she came to the facility about once a week, and the remote MDS coder is responsible for updating the care plan for the care items that triggered on the MDS, nursing and the social worker could have updated the care plan for behaviors and the need for memory care. Interview with the DON on 11/20/2024 at 12:30 PM revealed that her expectation was the care plans are up to date and show an accurate picture of the resident's actual needs. She stated, I currently do not have a MDS nurse and that the IDT team were trying to fill in and make sure care plans are accurate. She stated they have a stand-up meeting daily to discuss current issues and a pre-admission meeting for new residents. She stated she is not sure how the behaviors and the need for the memory care unit did not get placed on the care plans. She stated if a care plan is not current it can place the resident at risk to get inappropriate care. She stated, at the least, her expectation is that the care plan is accurate when the quarterly assessment is completed. Interview on 11/202/2024 at 2:30 PM with the ADM revealed his expectation are that care plans are updated at least 24 hours after a need is identified. He stated the team has a daily meeting Monday through Friday, and any issues raised in this meeting, should be addressed on the care plan if needed. An undated care plan is essential for the resident to receive the care they need and deserve. Review of the facility's policy titled Care Plan; Comprehensive Person-Centered revised December 2016 reflected the following: .13. Assessments of residents are ongoing and care plans are revised as information about the resident and the residents' conditions change. 14. The Interdisciplinary team must review and update the care plan: a. when there has been a significant change in the resident condition, B. when the desired outcome is not met, d. At least quarterly, in conjunction with the required quarterly MDS Assessment .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and nutrition services. The facility failed to ensure food items in both refrigerators, in the kitchen, were dated and labeled. The facility failed to ensure personnel items were not stored in facility refrigerator with resident food. This failure could place the residents at risk for food borne illness and cross contamination. Findings included: Observation of the kitchen on 11/18/2024 at 7:25 am of refrigerator #1 revealed two opaque plastic pitchers with covers of unknown substance with no label as to contents or use by date. Observation of the kitchen on 11/18/2024 at 7:28 am of refrigerator # 2 revealed a personnel water bottle, A Ziploc bag containing a bag of yellow slivers not identified or labeled with a use by date. A Ziploc bag containing large brown and white objects, not labeled with an identifier or a use by date. A Ziploc bag containing oval shaped pink with brown on the outside objects with no identifier or use by date noted. Interview with the DC on 11/18/2024 at 11:30 am revealed that all foods placed in the refrigerators ere to be labeled with the identification of the product, the date it was opened, and the use by date. She stated that she would not use any food not labeled as it may pose a risk to the residents for food borne illnesses. She stated it was the responsibility of the staff member to have labeled correctly and food items placed in the refrigerators. Interview on 11/18/202 at 12:30 PM with the RD revealed that all opened items should be labeled with what they are, when they were opened, and when the use by date is; no matter where they are stored. The risk of using undated and unlabeled food products, is a food borne illness for the residents. Interview on 11/20/2024 at 8:30 am with the DM revealed his expectation was any product opened and placed in another container should be labeled with its name, date of when open and when used by placed on the outside of the new container. He had instructed his staff not to use items not labeled correctly. He said the use of food items not labeled correctly could put the residents at risk for foodborne illnesses. Interview on 11/20/2024 at 2:30 PM with the ADM who stated all food in the kitchen should be safely stored which includes labeling and dating. The ADM stated his expectation is that any food not labeled correctly, not be served to the residents due to the risk of foodborne illnesses. Record review on 11/20/2024 of the facility's policy entitled Food Storage updated 2018 reflected: .2. Refrigerators d. Date, label and tightly seal all refrigerated food using clean, nonabsorbent covered containers that are approved for food storage.

Based on interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's Hydrocodone-Acetaminophen (Norco) 10-325mg, 30 tablets (a narcotic pain reliever) received from the pharmacy on 12/19/23 and reported missing on 12/20/23. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity. Findings included: Review of Resident #1's face sheet printed 02/22/24 reflected a [AGE] year-old female originally admitted to the facility 10/02/22 and readmitted [DATE]. Her diagnoses included type 1 diabetes mellitus (a condition that affects the way the body processes blood sugar), end stage renal disease (loss of function of the kidneys), dependence on renal dialysis (a treatment that assists the body in removing extra fluid and waste from the blood), anemia (lack of red blood cells in the blood), hypertension (high blood pressure), legal blindness, and chronic pain syndrome. Review of Resident #1's quarterly MDS assessment dated [DATE], Section C (Cognitive Patterns) reflected a BIMS score of 15 indicating intact cognition. Section GG (Functional Abilities) reflected she required moderate assistance with hygiene and bathing and only supervision with most other ADLs. Section J (Health Conditions) the resident had pain occasionally during the assessment period. Review of Resident #1's comprehensive care plan, revised 03/06/23, reflected risk for acute and chronic pain related to a history of rib fractures and chronic pain syndrome. Interventions included administer analgesic (pain medicine), anticipate the need for pain relief, evaluate the effectiveness of pain interventions, monitor for side effects, and the resident prefers to have pain controlled by Hydrocodone-Acetaminophen. Review of Resident #1's physician order dated 11/17/23 reflected Norco oral tablet 10-325mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 4 hours as needed for pain. Review of Resident #1's medication administration record for December 2023, reflected eleven doses of Norco (Hydrocodone-Acetaminophen) were administered during the month. Review of the Provider Investigation Report dated 12/28/23 reflected, on 12/20/23 at 9:00 PM, drug diversion was reported. The alleged perpetrator was unknown. Four staff members were named as witnesses. The allegation reflected, Blister pack of 30 Norco (a narcotic pain reliever) along with all documentation missing from medication cart for a single resident (Resident #1). The charge nurse that had been on duty when Norco was received noticed that the blister pack of Norco and documentation was missing when she came back for her shift next day. The report reflected on injury or harm to the resident. The facility notified the police, the medical director, their family, and regional corporate nurse. The resident had no knowledge of the drug diversion. The statements were obtained, and staff were drug tested . The investigation findings confirmed the drug diversion. Review of the pharmacy packing slip dated 12/19/23 reflected 30 hydrocodone/APAP tablets 10-235mg, were delivered to the facility. Review of the business card left by the responding police officer reflected, CASE NO: P23100075 DATE: 12/21/23. During an interview on 2/22/24 at 1:00 PM, the DON stated they did not identify a perpetrator or find the missing medications. She stated, Maybe the medication had been accidently discarded, but that would not have accounted for the missing paperwork. During a phone interview on 2/22/24 at 3:35 with the local police department, the officer stated the case number he provided was not a case number. The call was transferred to the narcotics division, but the call went unanswered. During an interview on 2/22/24 at 3:58 PM, the DON stated after the medication was noticed to be missing, the narcotic drawer was recounted by two staff. The other medication cart was counted, then the nurse's switched carts, and recounted again. She stated they looked at each bubble-pack in both medication carts incase the medication was accidently put in the cart and not the locked drawer. She stated they notified the regional nurse, called the police, and notified family. She stated the pharmacist came to check the facility. She stated the resident had not missed any doses of the medication, there was no adverse effect for the resident. She stated that neither the medications nor the count sheet was ever located. She stated the nurses and medication aides were drug tested and all the results were negative . During an interview on 2/22/24 at 4:12 PM with ADON A, she stated she received 30 Norco tablets from the pharmacy on the night of 12/19/23. She matched the paper to the bubble pack confirming the number of pills delivered. She placed the medication in the narcotics drawer on the medication cart and locked the medication cart. She stated she counted the narcotics drawer at the end of her shift. The next day when she returned to work, she stated she was counting the narcotics with the off going nurse when she noticed the Norco, she received the night before was not in the narcotic drawer. She stated they looked in the other medication cart but could not locate the medication. She stated they notified the DON at that time. She stated she was drug-tested . During an interview on 2/22/24 at 4:23 PM, the ADM stated he was notified when the medication went missing. He stated they investigated and looked for the medication. He stated the police were notified and came to the facility, but they were there for less than five minutes. He stated the staff who had access to the medication all wrote statements and were drug tested . He stated they were not able to identify a perpetrator . Review of the facility policy Identifying Exploitation, Theft, and Misappropriation of Resident Property dated April 2021 reflected in part, 1. Exploitation, theft, and misappropriation of resident property are strictly prohibited. 4. Misappropriation of resident property means the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. 5. Examples of misappropriation of resident property include: f. drug diversion (taking the resident's medication).

Based on observation, interview, and record review the facility failed to ensure storage and/ or label of medications used in the facility in accordance with currently accepted professional principles and include the appropriate expiration dates for 2 of 4( unit 300, and unit 500) medication carts reviewed for medication storage. -The facility failed to date Insulin Injections ( unit 100/200, ) when the product was first opened according to manufacture and professional standards. -The facility failed to ensure expired medications were removed from the medication carts ( unit 300, and unit 500). These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or a contaminated medication. Findings Included: Observation on 09/26/2023 at 08:45 AM revealed the Unit 100 Medication cart with an Insulin Aspart 100 U/ ml injection with no open date. Observation on 09/26/2023 at 08:41 AM revealed the Unit 200 Medication cart with an Insulin Glargine 100 U/ ml injection with no open date. Observation on 09/26/2023 at 08:30 AM revealed the Unit 300 Medication cart with an Insulin Glargine 100 U/ ml injection with an open date of 08/17/2023. Observation on 09/26/2023 at 09:02 AM revealed the Unit 500 Medication cart with an Insulin Humalog 100 U/ ml injection with an open date of 08/05/2023. Observation on 09/26/2023 at 09:10 AM revealed the Unit 500 Medication cart with an Insulin Aspart 100 U/ ml injection with an open date of 08/17/23. In an interview on 09/26/2023 at 8:50 PM, LVN A stated insulin is supposed to be dated after opening to ensure medication does not expire. LVN A stated that insulin medication given after 28 days can impact the efficacy of the medication affecting treatment. In an interview on 09/26/2023 at 9:15 PM, LVN B stated the Nurse does not know how the insulin was overlooked. They should have been dated and the insulin that is passed 28 days should not be on the med cart. LVN B stated that insulin used passed the 28 days can lead to ineffective therapy. In an interview on 09/28/2023 at 2:00 PM, the DON stated Insulins should be dated as soon as they are removed from the refrigerator, staff are required to put the open date on them and keep them in the med cart for up to 28 days after opening them. The DON further stated Insulins have an expiration date and when given outside of the time allotted the potency can diminish and cause issues effecting residents' diabetes. In an interview on 09/28/2023 at 2:15 PM, the ADMIN stated his expectations are that Insulins should be dated as soon as they are removed from the refrigerator, staff are required to put the open date on them and keep them in the med cart for up to 28 days after opening them to sustain the efficacy. Review of the facility's Policy Storage of Medications dated April 2022 reflected The facility should ensure the medications requiring refrigeration are stored appropriately.

Based on observation, interview, and record review the facility failed to post nurse staffing information to include the facility name, current date, total number, and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides per shift and the resident census on a daily basis for one of two days (09/26/23) reviewed for nurse staffing information. The facility did not post the required current nurse staffing information on 09/26/2023. This failure could place residents at risk of not having access to information regarding staffing data and the facility census. Findings include: Observation on 09/26/23 at 9:00AM., revealed the nurse staffing information form on the wall next to the facility's nursing station was not filled out. During an interview on 09/26/23 at 9:30 AM, the DON stated she would fill out the form immediately. Observation on 09/26/23 at 10:00AM revealed the nurse staffing information was posted however it did not have the component of the total number and actual hours worked by Registered Nurses. During an interview on 09/27/23 at 11:00AM, the corporate nurse stated the everyday nurse staffing information form used by the facility was incomplete and she would direct the facility to use the correct form that reflects the total number and actual hours worked by Registered Nurses (RNs), Licensed Vocational Nurses (LVNs) and Certified Nurse Aides (CNAs) Observation on 09/28/23 at 2:00PM revealed the nurse staffing information was posted however the Registered Nurse component was absent. During an interview on 09/28/23 at 3:00PM the DON stated she was responsible for making sure the posting of the nurse staffing and census data daily. She stated posting needed to be done by 6:00AM immediately after the shift change over meeting finished. When investigator asked about the relevance of the staffing posting, the DON said posting the daily census and nurse staffing information was important for the residents and facility visitors, to determine if the facility had adequate staffing. On 09/26/23 there was no policy available at the facility reflecting the requirement of posting daily, the nurse staffing information at a prominent place readily accessible and available to residents, employees, and visitors. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 09/28/2023 reflected: 42 CFR Section 483.35(g) and 26 TAC Section 554.1001(b)(1)-(2) and Section 554.1921(e)(13) - An NF must conspicuously and prominently post the following information, in a clear and readable format and a prominent place readily accessible and available to residents, employees, and visitors, in accordance with Section 554.1921(e): On a daily basis: o Facility name o Current date o Resident census o Specific shifts for the day At the beginning of each shift, the total number of hours and actual time of day to be worked by the following licensed and unlicensed nursing staff, including relief personnel directly responsible for resident care: o Registered nurses (RNs) o Licensed vocational nurses (LVNs) o Certified nurse aides (CNAs) In addition, the licensed NF must make the information required to be posted available to the public upon request.

Based on observation, interview and record review, the facility failed to store and prepare food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. 2. The facility failed to discard food stored in the refrigerator that should no longer be consumed. These failures could affect the residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness and food contamination. Findings included: An observation of the facility's kitchen walk-in refrigerator, on 09/26/23 at 7:18 a.m., revealed the following: 1 10-pound roll of thawed hamburger meat, un-dated. 1 30-pound box of thawed slab bacon unsealed with date on outside of box 09/15/23. Record review of the Facility Storage and Retention Guide, undated, posted on the outside of walk-in refrigerator reflected that bacon, that is thawed, was to be retained up to 7 days . 1 5-pound clear bag of lettuce, turning brown, expiration dated 09/20/23. 1 of 2 boxes containing 7 cucumbers with 5 cucumbers spotted white mold. 2 of 2 boxes containing 4 cucumbers all spotted with white mold and black spots. Plastic bin with lid containing approximately 30 green bell peppers with 1 bell pepper turning a deep green color with white mold covering the fruit located in the center of remaining peppers. 1 box containing 16 tomatoes. One tomato with 4 black spots and a soft to the touch. 9 additional tomatoes soft to touch, dark red, and wrinkled and one with 3 spots of white mold on the top. 1 box of thawed breakfast sausage, unsealed. Interview on 09/28/23 with the ADA at 9:43 am, revealed that if residents consume food that is spoiled or gone bad, residents could become sick or might have to go to the hospital. Interview on 09/28/23 with the ADMIN at 3:38 p.m., revealed, after he was shown the photographs of the rotten tomatoes and cucumbers, revealed that if residents consumed food that is spoiled or gone bad, they could become sick or might go to the hospital. Review of facility policy title Food Storage dated 2018 revealed: Policy: to ensure that all food served by the facility is of good quality and safe consumption. Refrigerators: Date, label and tightly seal all refrigerated foods.

Based on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that: CNA A failed to wash or sanitize her hands or change gloves before touching the package of wipes and after cleaning Resident #44's buttock area. This deficient practice could place residents at-risk for infection due to improper care practices. Findings include: Record review Resident #44's face sheet, dated 09/28/2023, revealed an admitted [DATE] and, a readmitted [DATE] with diagnoses including: Fracture right pubis, Dementia (decline in cognitive abilities), Hypertension (High blood pressure), Osteoarthritis, Muscle weakness, and a need for assistance with personal care. Record review of Resident #44's Quarterly MDS, dated [DATE], revealed the resident had a BIMS score of 2 indicating severe cognitive impairment. Resident #44 required extensive assistance, was always incontinent of bladder and bowel. Observation conducted on 9/27/2023 at 9:47 AM, revealed CNA A and CNA B conducted peri-care for Resident #44. CNA A cleansed Resident #44's bottom with multiple wipes and was pulling them directly out of the package. CNA A then removed more wipes from the package to cleanse Resident #44's peri area without changing gloves or conducting hand hygiene. In an interview on 09/28/23 at 09:10 AM, CNA A revealed she did not set up her station all the way during peri-care for Resident #44 by not removing the wipes from their package prior to providing peri-care. CNA A also stated the package of wipes became contaminated when she pulled more wipes while still wearing contaminated gloves. CNA A revealed she had received training on peri-care during CNA training at a nursing school, and in-servicing conducted in the facility. CNA A also revealed she felt remorseful about making the mistake and had become anxious with so many eyes watching the care. In an interview on 9/28/2023 at 2:30 PM, the DON stated a breach in infection control while providing resident care could cause an infection to develop. The DON's expectation for staff following Infection Control protocols during resident care included monthly training, and an expectation to conduct peri-care correctly. The DON further stated she would re-educate her staff on peri-care and hand hygiene during resident care. In an interview on 9/28/2023 at 2:45 PM, the ADMIN stated a breach in infection control could cause excoriation in the peri area, which could then lead to skin breakdown. The ADMIN's expectation was for staff to follow infection control protocol and proper handwashing techniques while providing resident care. Review of Policy and Procedures for Perineal Care dated October 2018 reflected, Always perform hand hygiene before and after glove use. Review of Policy and Procedures for Infection Control dated October 2018 reflected, To maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public and To prevent, detect, investigate, and control infections in the facility.

Based on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for one of one facility. The facility failed to ensure the survey result from the previous recertification surveys were readily available to the residents and family. This failure could place residents and visitors at risk of not being aware of the facility's past deficiencies. Findings included: Record review of ASPEN Central Office reflected the most recent annual recertification and re-licensure survey took place on 06/09/2022. Observation on 09/26/23 at 12:30 PM revealed that there was no state survey result available at the facility in a place readily accessible to residents and family members. During an interview on 09/26/23 at 1:00PM, the ADMIN stated he was not aware that the survey result should be posted at the facility for residents and family. He stated he never heard of this regulation and asked the investigator, since when this rule came into effect. When the investigator showed and explained the relevant portion of the regulation to ADMIN, he stated, he would make it available at the earliest. Observation on 09/26/23 at 3:00PM revealed the availability of the previous state survey results in a folder placed on a table towards the wall opposite to the reception counter however it was difficult to locate as there was no notice posted, indicating the availability of the state survey result. On 09/26/23, there was no policy available at the facility reflecting residents' right to readily access the results of the most recent survey conducted at the facility. Review of https://www.hhs.texas.gov/providers/long-term-care-providers/long-term-care-provider-resources/regulatory-services-facility-surveyors-liaisons/required-postings accessed on 09/28/2023 reflected: F577 - Most Recent Survey/Inspection Results and Notice of Availability of Survey/Inspection Results 42 CFR Section 483.10(g)(11) - An NF must: Post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility. Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the three preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request. Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility did not label and date all food items stored in the refrigerators and freezer. The facility failed to ensure a cleaning schedule was followed. The facility did not keep the kitchen neat and orderly. The facility failed to ensure kitchen staff used infection control prevention in the kitchen. The facility failed to discard pots and pans with carbon build up. The facility failed to ensure the drink dispenser and holder did not have slimy, brown build up. These failures placed residents at risk of food-borne illness. Findings included: During an observation on [DATE] at 9:20 a.m., Cook A was at the sink in the main kitchen area with her mask on her chin. During an observation on [DATE] at 9:25 a.m., the Assistant Dietary Manager was in the dishwasher area with no mask or beard guard on his face. During an observation in the dry storeroom on [DATE] starting at 9:26 a.m., revealed 1 opened puree rice mix with no date; 1 unopened puree rice mix with no date; 1 large tub of what appeared to be grits, with no label; 1 opened box of mashed potato granules with no date; 13 unopened boxes of drink concentrate with no date. During an observation in the kitchen hallway on [DATE] at 9:29 a.m., revealed a laminated daily cleaning schedule. The laminated cleaning schedule with no months or dates noted, had the items listed to be cleaned, when to clean, position responsible, days of the week, initials, and date. The schedule had no initials or dates marked for any of the 17 items list. During an observation in the dry storeroom on [DATE] at 9:35 a.m., revealed a white blanket with brown edges was noted next to a large metal equipment which was the air conditioner. Underneath the air conditioner, a medium size opening was visualized with debris and dust. During an observation in the main kitchen area on [DATE] at 9:40 a.m., revealed 3 skillets with carbon build up on the bottom was hanging from a rack; drink dispenser nozzle and holder with slimy, brown film was noted; 5 opened and in use boxes of drink concentrate, with no date; greasy film noted under and around the deep fryer. During an observation in the back area of the kitchen on [DATE] at 9:45 a.m., revealed 12 large metal pans with carbon buildup around the edges and sides. During an observation and interview in refrigerator 1 in the main kitchen area on [DATE] at 9:48 a.m., revealed 20 chocolate house shakes in a large clear container with no dates and 42 minis nondairy creamers in a large box with no date. The dietary manager said those were probably received on [DATE] and no one placed the date on the boxes. During an observation in the freezer on [DATE] at 3:05 p.m., revealed two partially frozen brown bags with no label or date and 1 opened box of 15 biscuits with freezer burn. During an observation on [DATE] at 10:28 a.m., cook B was frying chicken with no mask on her face. During an observation on [DATE] at 12:00 p.m., dietary aide D was checking meals cards and placing plated food on the transport cart with his mask on his chin and three flies noted flying around the kitchen. During an interview on [DATE] at 2:41 p.m., dietary aide E said it was everyone's responsibility for food items to be labeled and dated. He said it was the assistant dietary manager and the dietary manager responsibility to ensure items were labeled and dated by staff. He said it was important for food items to be labeled and dated to know when things are opened and to make sure residents do not receive expired food items. He said he had only worked at the facility for three weeks and did not believe they had a cleaning schedule. He said keeping the kitchen clean was a team effort. He said the dry storeroom was cleaning and organized, and he did not notice the area underneath the air conditioner. He said he did not notice the drink dispenser spout and holder being dirty. He said it was not his responsibility and did not know whose responsibility it was but knew it should be cleaned every day. He said he was responsible for making the resident's drinks. He said the drink dispense spout and holder should be cleaned to prevent germs from affecting the resident's respiratory and immune system. He said all staff should always wear their mask in the kitchen. He said it was important to wear masks to prevent spreading of germs or COVID-19. He said he only noticed staff pull down their masks when people could not hear them. During an interview on [DATE] at 3:00 p.m., cook C said she had worked at the facility for 7 years and worked the 11 a.m.-8 p.m. shift. She said her duties included preparing food, cleaning, and sanitation, washing dishes, and taking out the trash. She said dietary staff should label and date all food items. She said the cook was responsible for everything except desserts, which dietary aides handled. She said it was important to label and date food to not feed residents expired foods. She said about 20% of the pots and pans had carbon build up. She said pots and pans should not have carbon buildup because it could get in the resident's food and make them sick. She said the dietary manager did pot and pan inventory every ,d+[DATE] months, but the cooks should be notified also of carbon build up on pans. She said occasionally the air conditioner in the dry storeroom leaked water on the floor. She said staff place a blanket down to absorb the water leaking. She said the leaking should be fixed to prevent mold and falls. She said there was an established cleaning schedule, and it was posted on the wall near the dietary manager's office. She said basic cleaning was done after each shift, but weekly detailed cleaning was assigned to staff. She said the dietary aides were responsible for the drink dispenser. She said the drink dispenser and holder should be cleaned every night. She said the drink dispenser being cleaned was important to prevent mold and bacteria which could cause residents gastrointestinal issues. She said mask should be always worn. She said some staff do forget to keep them on. She said masks and beard guards were important for covid-19 precaution and help keep hair out of food which was contamination. During an interview on [DATE] at 3:20 p.m., the dietary manager said he had worked at the facility for a year. He said the kitchen had an assigned cleaning schedule by shift and position. He said the staff followed the cleaning schedule. He said he expected all dietary staff to label and date food items. He said it was the assistant dietary manager and dietary manager responsibility to ensure it was happening. He said he and the assistant DM did sanitation audits to make sure the kitchen was clean and organized. He said the staff normally get a 90% or better for the audits. He said the day I arrived, the kitchen was not clean and organized. He said the area underneath the air conditioner in the dry storeroom did have debris and needed to be cleaned and covered. He said he verbally told the maintenance worker about the issue and it would take approximately 2 weeks to cover it. He said it was the dietary aide's responsibility to clean the drink dispenser and holder. He said it was to be cleaned on the pm shift. He said it was important for it to be cleaned to prevent bacteria, mold, and gnats. He said those things could cause foodborne illnesses. He said the air conditioner leaked in the hot months and maintenance knew about the issue but did not have an estimated time it would get fixed. He said water leakage could cause slips, dry goods to get wet causing cross contamination and mold issues. He said it could cause residents to get sick. He said carbon build up on pots and pan could cause a fire. He said he or the cooks should be checking every day to ensure pots and pans did not have carbon build up. He said mask and beard guards should be always worn in the kitchen to prevent hair in the food and contamination. He said occasionally he did have to remind staff to keep masks on. He said cook B did not have a mask on when she was frying chicken yesterday. He said contamination of food could cause residents to get sick. At the end of the interview, the dietary manager brought the posted cleaning schedule. He said it was blank and should not be. During an interview on [DATE] at 2:54 p.m., the DON said she expected all kitchen staff to always wear a mask and beard guard. She said not wearing these items was an infection control issue causing illness. She said she expected all food items to be labeled and dated to prevent resident getting served expired or spoiled food making them sick. She said the kitchen should follow the cleaning schedule to prevent infection control issues. During an interview on [DATE] at 3:30 p.m., the administrator said staff wearing masks and beard guard was important due to COVID-19 and infection control. He said the kitchen should have a set cleaning schedule and clean after each meal and shift. He said kitchen staff should label and date food items was critical. He said the dietary manager should ensure it was happening. Record review of a facility food storage policy dated [DATE] revealed .to ensure that all food served by the facility is of good quality and safe for consumption .all food will be stored according to the state, federal and US food codes and HACCP guidelines .all containers must be labeled and dated .leave items in the original cartons placed with date visible .date, label, and tightly seal all refrigerated foods . Record review of a facility employee sanitation policy dated [DATE] revealed .employees of the facility will practice good sanitation practice .minimize the risk of infection and food borne illness .beard covering, or effect hair restraints must be worn to keep hair from food and food contact surfaces . Record review of a facility general kitchen sanitation policy dated [DATE] revealed .employees will maintain clean, sanitary kitchen facilities .in order to minimize the risk of infection and food borne illness .all cooking equipment free of encrusted grease deposits . Record review of a cleaning schedule facility policy dated [DATE] revealed .the facility will maintain a cleaning schedule .followed by employees as assigned in order to ensure that the kitchen is clean and free of hazards .the cleaning list will be posted weekly and initialed off and dated by each employee upon completion if the task .the Nutrition and Food service manager or designee will verify that the tasks were completed as assigned . FACILITY Dining Observation

Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the status for 5 of 19 residents reviewed for assessments. (Resident #13, Resident #17, Resident #19, Resident #48, Resident #60). The facility failed to accurately code Resident #13's preferred language as Spanish and needed or wanted interpreter for communication on following MDS after the admission MDS. The facility failed to accurately code Resident #17 as having contractures to upper and lower extremities on the MDS. The facility inaccurately coded Resident #19's [MEDICATION(S)] (antiplatelet) as an anticoagulant on the MDS. The facility failed to accurately code Resident #48 as PASRR (Pre-Admission Screening and Resident Review) positive and qualified due to intellectual and developmental disability on the MDS. The facility failed to accurately coded Resident #60's preferred language of Spanish and wish or need for interpreter to communicate with doctor or healthcare staff on the MDS. The facility failed to complete Resident 60's annually MDS assessment for Sections B, C, D, E, F, part of J, and Q dated 5/18/22. These failures could place residents at risk of having inaccurate assessments, not having individual needs met and a decreased quality of life. Findings included: 1. Record review of Resident #13's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's admission MDS dated [DATE] performed by LVN EE and LCSW FF, revealed the resident was Hispanic; resident needed or wanted an interpreter to communicate with a doctor or health care staff and her preferred language was Spanish; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. Record review of Resident #13's Resident Assessment and Care Screening MDS dated [DATE], completed by LVN AA, revealed the resident was Hispanic and did not want or need an interpreter to communicate with a doctor or health care staff; had a BIMS of 3 indicating she was cognitively severely impaired. The MDS indicated the resident required limited to extensive assistance of one person to physically assist with ADLs. 2. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the MDS dated [DATE], completed by RN DD and LCSW BB revealed Resident #17 was rarely/never understood and rarely/never understood others. The MDS revealed since Resident #17 was rarely/never understood, the BIMS (Brief Interview for Mental Status) could not be completed. The MDS revealed Resident #17 required extensive assistance for dressing and personal hygiene. The MDS revealed Resident #17 required total dependence for transfer with two persons assist, eating, toilet use and bathing. The MDS revealed Resident #17 had no impairment to upper or lower extremities. Record review of the undated care plan revealed Resident #17 had ADL self-care performance deficit related to impaired cognition/declined manifested with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan revealed Resident #17 had palliative care due to disease process. The care plan revealed Resident #17 had alternation in muscle skeletal status related to contracture of neck and bilateral foot drop. Intervention included anticipate and meet needs, monitor for fatigue, and PT/OT services/interventions in place. The care plan revealed Resident #17 was at risk for falls due to poor safety awareness, impaired cognition, and unsteady gait/balance. Interventions included required supervision-limited assistance for ambulation and assist to activities. During an observation on 6/6/22 at 10:30 a.m. Resident #17 was in a wheelchair. Resident #17 had contractures to her neck and upper extremities. During an observation on 6/7/22 at 9:20 a.m., Resident #17 was in bed and was getting prepped for mechanical lift transfer by CNA D and CNA P. Resident #17's blanket was removed, and contractures noted to left arm and leg. During an interview on 6/6/22 at 2:46 p.m., the family member of Resident #17 said she had been on hospice since March of this year. The family member said Resident #17 was wheelchair bound and occasionally would squeeze his hand when prompted. The family member said Resident #17 disease process had rapidly changed her and she no longer hung out at the nurse's station or listened to music. 3. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . It is an antiplatelet drug) for peripheral vascular disease. Record review an MDS dated [DATE], completed by LVN AA and LCSW BB, revealed Resident #19 usually understood and was usually understood by others. The BIMS assessment (Brief interview for Mental Status)-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #19 required supervision to limited assistance with ADLs. The MDS revealed Resident #19 received an anticoagulant (medications that decrease your blood's ability to clot; help stop your blood from thickening or clotting.) in last 7 days. Record review of undated care plan received from the facility on 6/9/22 revealed Resident #19 received an anticoagulant medication and was at risk for increase bleeding, bruising, etc. Interventions included attempt to avoid any injury causing bruising, cuts, or abrasions, give meds per MD order, and monitor for increased bruising, bleeding, dark brown or blood-tinged body secretions, abnormal pain or swelling, back pain, severe headache or increased joint pain. 4. Record review of the consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), intellectual disability (Below average intelligence and set of life skills present before age 18), stage 2 chronic kidney disease (damage to your kidneys is still mild), [CONDITION(S)] disorder (is a mental health condition that causes extreme mood swings), and difficulty walking. The consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #48 was not considered by the state level to have serious mental illness and/or intellectual disability or a related condition on the PASRR II. The MDS revealed Resident #48 did not have dyspnea (shortness of breath). The MDS revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #48 required supervision for ADLs except extensive assistance for bathing. The MDS did not address Resident #48's PASRR positive status or short of breath (dyspnea) which she has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of the undated care plan revealed Resident #48 had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited range of motion, and chronic pain. Intervention included supervision for ADLs and assist with sponge bath when shower cannot be tolerated. The care plan revealed Resident #48 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .), [CONDITION(S)] (weight is more than 80 to 100 pounds above their ideal body weight), and chronic allergies. Intervention included pain management and position resident with proper alignment as needed for optimal breathing pattern. The care plan revealed Resident #48 was PASRR positive related to intellectual disability. Record review of PASRR Comprehensive Service Plan Form dated 4/22/21 revealed Resident #48 was PASRR positive for intellectual disability. During an observation and interview on 6/6/22 at 11:20 a.m., Resident #48 was lying in bed with a nasal cannula on her face. Resident #48 struggled to sit up in bed and became slightly short of breath. 4. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE], completed by LVN CC revealed Resident #60 was Hispanic or Latino. The MDS revealed Resident #60 did not have preferred language and did not need or want an interpreter to communicate with a doctor or health care staff. The MDS revealed Resident #60 required extensive assistance for dressing, toilet use, and personal hygiene but total assistance for bathing. The MDS revealed Sections B, C, D, E, F, part of J, and Q were not answered for Resident #60's assessment. Record review of the undated care plan received from the facility on 6/9/22 revealed Resident #60 had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #60 had a BIMS score of 10 which indicated moderately impaired cognition. Goal of Resident #60 will be able to communicate basic needs on a daily basis. The care plan revealed Resident #60 had potential for communication problems related to Spanish being primary language but speak and understood some English. Interventions included allow time to respond, request clarification, and provide translator as needed. During an interview by phone on 6/8/22 at 1:37 p.m., the corporate MDS nurse stated she did not complete MDS assessments at the facility. She only comes on Monday and completes the assessments required to complete the MDS. The facility employees 3 prn nurses that come in when they can and work on MDSs to keep them up to date. The MDS nurses were responsible for completing and updating the care plans as they completed the MDS. Baseline care plans were the responsibility of the charge nurse. She stated MDS accuracy was important because the plan of care is created by the information coded on the MDS. The plan of care was how the employees knew what kind of care each resident needs. The corporate MDS nurse stated inaccurate assessments and care plans that are not complete or revised could negatively affect the care of the residents because the resident might not receive appropriate care, decreasing their quality of life. During an interview on 6/9/22 at 1:10 p.m., LVN H said she had been at the facility for [AGE] years and was a charge nurse. She said Resident #17 used to walk and is currently wheelchair bound. She said she did not know if Resident #17 was on Hospice or if she was on palliative care. She said it was important to know if Resident #17 was hospice to ensure she received the care according to family wishes. She said it should be on her MDS and care plan. LVN H said she believed Resident #48 was PASSR positive. LVN H said nursing staff should document accurately to ensure correct information is transferred to the care plan and MDS. She said Resident #60's primarily language was probably Spanish, but she can speak some broken English. She said the facility should have a process in place to communicate with non-English speaking residents. She said it was important be able to communicate with non-English speaking residents in case anything changes with them. She said if the MDS or care plan said Spanish speaking only or wanted and needed interpreter, then it is important to do that. LVN H said [MEDICATION(S)] was an anticoagulant or antiplatelet. She said coding the wrong medication class could cause staff to be looking for the wrong side effects. She said currently the facility was using a corporate MDS coordinator and they were responsible for the care plan and MDSs. During an interview on 6/9/22 at 2:02 p.m., LVN L said she had been at the facility for [AGE] years and was a charge nurse. She said when a resident has a change of condition, staff should verbally notify the MDS coordinator and write a progress note. She said it was important for accurate information to be documented no significant change was not missed. She said Resident #17 was on hospice and it should be documented in her chart and on her MDS and care plan. She said Resident #17 hospice status should be known to provide what the hospice company request. LVN L said Resident #48 was PASRR positive and was documented under the medical diagnosis. She said it should be on the MDS then placed on the care plan. She said it was important to monitor for behaviors, address them correctly, and receive appropriate services. She said there should be procedures in place to communicate with non-English speaking residents. She said accurate communication would be nice for resident. LVN L said she thought [MEDICATION(S)] was an anticoagulant or maybe it was an antiplatelet which can be confusing. She said on the physician orders, the medication class is noted. She said if [MEDICATION(S)] was coded wrong, it may be mixed with another drug or wrong labs could me ordered. LVN L said resident's needs and wants could not be addressed and overall care could be poor. During an interview on 6/9/22 at 2:54 p.m., the DON said she had been at the facility for [AGE] years. The DON said MDSs, and care plans should be accurate to show who the residents are. She said the facility did not have a MDS nurse or social worker. She the corporate MDS was handling assessments. She said inaccurate assessments can affect the resident's care and cause wrong coding on the MDS. She said Resident #48 was PASRR positive and should code on her MDS. She said all the information should be documented so everyone knowns and the social worker should have documented it. She said Resident #17 was on hospice and it should be on her MDS and care plan. She said it was important to follow the hospice plan of care. She said Resident #13 and Resident #60's primary language was Spanish. She said it was important to communicate in the Resident's preferred language to meet there needs. During an interview on 6/9/22 at 3:30 p.m., the administrator said the facility did not have a MDS coordinator or social works for the last 30 days, so care plan and MDS may be inaccurate. He said if staff could not communicate with residents through staff then they should use the phone system. He said it was important to provide information in the resident native language to accurately communicate. On 6/8/22 at 3:35 p.m., a policy regarding accuracy of assessment on the MDS was requested from the DON. The DON said the facility did not have one but followed CMS guidelines.

Based on interview and record review, the facility failed to ensure residents were made aware of the grievance process for 12 of 12 Residents (Resident #19 and 11 confidential resident) who were reviewed for grievances This deficient practice could place the residents at risk for decrease quality of life and feelings of hopelessness. Findings include: Record review of the face sheet dated 6/9/2022 revealed Resident #19 was a [AGE] year-old-male that admitted to the facility on [DATE]. Resident #19 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of an MDS dated [DATE] revealed Resident #19 usually understood and was usually understood by others. The BIMS assessment (Brief interview for Mental Status)-screening tool to assist with identifying a resident's current cognition status) was a 14 which indicated intact cognition. Resident #19 required supervision to limited assistance with ADLs. Record review of undated care plan revealed Resident #19, Activities revealed he would be invited to scheduled activities and be provided with an activities calendar. During a confidential resident group interview on 6/7/22 at 10:00 AM, 11 residents in attendance stated the facility does not have regular Resident Council meetings, but if they did, they would attend. Residents indicated there had been one or two meetings in the last year. Residents in the confidential group interview were aware that they had the right to have a monthly Resident Council meeting. All residents expressed they would attend if they were held. Residents in attendance said there was no Resident Council President or other officers. Residents said there had not been an Activity Director in over a year. Residents said they had not had a social worker for approximately a year. Residents said they did not know how to file a grievance. Residents said when they made complaints or had issues that no one resolved those issues for them. Residents said they felt like no one wanted to address their concerns. During an interview on 6/6/2022 at 10:15 AM Resident #19 said he had filed grievances. He said the grievance process was a joke here. He said nobody writes anything down, so there will be no trail of complaints. Resident #19 said he asked for the issues with his bathroom to be a grievance and the air conditioner vents needing to be cleaned. He said, As you can see both are still untouched. He said it was very frustrating and it made him feel discouraged. He said he was stuck there because of finances and he was miserable. During an interview on 6/9/22 at 2:02 PM, LVN M said grievances were handled by the Social Worker and are filled out on a paper form and the Social Worker then follows up with whatever department it falls under to address. During an interview on 6/7/2022 at 1:22 PM, the DON brought in grievance log for the past 12 months. Three grievances were noted in total in the book. The DON was tearful and stated we don't write grievances down. If a resident has a problem, we just fix it. When asked where they document what the problem was and how they fixed it, the DON stated we don't document it. If a resident is missing clothing, we just go buy them some more clothes, if they lost money, we replace the money. Grievances are a Social Worker job, and we don't have a social worker. I can only be responsible for so much. We are doing our best. During an interview on 6/9/22 at 2:54 PM the DON said grievances were known to them by the Social Worker and since they haven't had a social worker, she was not sure who was in charge that would be a question for the administrator. The DON said when residents had complaints, they handled them and did not document the complaint or the outcome. During an interview on 6/9/22 at 3:30 PM the Administrator said the Social Worker's job had not been done and the grievance process fell through. He said this could leave residents feeling neglected or ignored regarding their concern or complaint. The facility had been without a Social Worker for 2 months. Record review of Grievance log from 6/2021 to 6/2022 indicated 3 grievances were addressed during 2/2022. These were the only grievances noted for the last year. There were no grievances for Resident #19. Policy for Grievances/Complaints was requested, and Administrator said there were no policies the facility followed CMS guidelines.

Based on observation, interview and record review, the facility failed to ensure the right to be free from abuse for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on [MEDICATION(S)] about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

Based on observation, interview, and record review, the facility failed to ensure that residents had a right to organize and participate in resident groups, in that: Eleven residents in a confidential resident group interview were aware that they had the right to organize and participate in a group meeting monthly, but said they weren't done. This failure placed residents at risk of not having the right to voice their concerns in a Resident meeting. Findings include: During observations on 6/6/22 at 9:30am, 11:30 am, 1:30 pm and 3:30pm, 6/7/22 at 9:30am, 11:30 am, 1:30 pm and 3:30pm and 6/8/22 at 9:30am, 11:30 am, 1:30 pm and 3:30 pm the following was noted: No facility organized activities occurred. During a confidential resident group interview on 6/7/22 at 10:00 AM, the 11 residents in attendance stated the facility does not have regular Resident Council meetings, but if they did, they would attend. Residents indicated there had been one or two meetings in the last year. Residents in the confidential group interview were aware that they had the right to have a monthly Resident Council meeting. All residents expressed they would attend if they were held. Residents in attendance said there was no Resident Council President or other officers. Residents said there had not been an Activity Director in over a year. During an interview on 6/9/22 at 1:10 p.m. LVN L said she had not seen any Resident Council meetings on the memory care unit. She knew they should provide a space and have them if residents wanted to attend. During an interview on 6/9/22 at 2:54 p.m. the DON said Resident council meetings happen monthly or were supposed to happen. She could not say how long it had been since the last resident council meeting. She said Resident council meeting notes were supposed to be taken but when they asked for the minutes, she did not have them. She said the Activity Director was not doing notes and the facility thought it was happening, but it was not. The DON said they had just been so busy and had mentioned about this in morning meeting, but she did not follow through on it. She said it was important for residents to have for their wellbeing. It was the responsibility of the Administrator to ensure the resident council meetings were happening. During an interview on 6/9/22 at 3:30 p.m. the Administrator said they had not had an Activity Director since July of last year. He acknowledged that Resident Council meetings had not been held as they should have been. The Administrator said these meetings not being held could make residents feel ignored or neglected if they can't get their issues addressed. He said he was the one responsible to ensure the resident council meetings were happening and grievances were being followed up on in absence of the social worker. The minutes of the Resident Council meetings for the past 12 months were reviewed and did not provide detailed information according to paperwork provided the last resident council was on 2/21/22. The papers provided were scraps of notebook paper with doodles of hearts and residents' names listed on it. Policy regarding Resident Council was requested, and the Administrator said there was no policy; they used the job description for the Activity Director.

Based on observation, interview, and record review the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 9 of 24 residents reviewed for resident rights. (Resident #8, Resident #16, Resident #24, Resident #45, Resident #56, Resident #80, Resident # 83, Resident # 84, and Resident #193) The facility failed to treat Residents #8, #16, #24, #56, #83, #84, and #193 with respect and dignity when they had to wait extended lengths of time at their tables where other residents had already been served their meals. The facility failed to treat Resident #45 with respect and dignity when her meal tray card was marked with large black marker with the word FEEDER. The facility failed to treat each resident with respect and dignity when multiple staff members referred to residents who required assistance with feeding, as feeders. The facility failed to treat Resident #56 with respect and dignity when she was wheeled in a reclined wheelchair to the assisted dining room and parked facing the back wall away from the other residents who were watching a movie on the TV. The facility failed to treat Resident #80 with respect and dignity when his door was left open, and the curtain was not pulled to provide privacy when the nurse exposed his abdomen while she performed feeding tube flushes and medication administration. These failures could place residents at risk for diminished quality of life, loss of dignity and self-worth. Findings included: 1. Record review of resident #8's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #8's quarterly MDS dated [DATE] revealed the resident's BIMS was 3 indicating she was cognitively severely impaired. The MDS indicated the resident required supervision and set up while eating. 2. Record review of resident #16's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #16's quarterly MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance with 1 person assist while eating. 3. Record review of Resident #24's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #24's quarterly MDS dated [DATE] revealed the resident's BIMS was 8 indicating she was cognitively moderately impaired. The MDS indicated the resident required supervision and set up while eating. 4. Record review of Resident #45's face sheet dated 6/9/2022 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #45's MDS dated [DATE] revealed the resident's BIMS was 00 indicating she was severely cognitively impaired, she had disorganized thinking and she was sometimes understood and sometimes she understands. The MDS revealed resident required extensive assistance of one staff member for eating. The MDS also revealed resident was on a mechanically altered therapeutic diet. Record review of Resident #45's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 5. Record review of resident #56's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #56's annual MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance of 1-person physical assist while eating. 6. Record review of resident #80's face sheet dated 6/9/22 revealed a [AGE] year-old male who was admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #80's annual MDS dated [DATE] revealed the resident was unable to complete the BIMS. The MDS indicated the resident required total assistance of 1 to 2 persons for all ADLs. 7. Record review of resident #83's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #83's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. 8. Record review of resident #84's face sheet revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #84's annual MDS dated [DATE] revealed the resident's BIMS was 0 indicating she was cognitively severely impaired. The MDS indicated the resident required limited assistance with 1 person assist while eating. 9. Record review of resident #193's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of resident #193's admission MDS dated [DATE] revealed the resident's BIMS was 13 indicating she was cognitively intact. The MDS indicated the resident required extensive assistance of 1-person physical assist for ADLs. During an observation and interview on 6/6/22 at 11:50 AM, lunch service began in the main dining room B. Resident #193 shared a table with 2 other residents. At 11:54 AM the two residents' sharing the table with Resident #193 were served. Resident #193 was served lunch at 12:18 PM. Resident #193 said she was always the last served and she was tired of sitting and staring at the other residents eat. During an observation and interview on 6/6/22 at 11:50 AM, one other resident at the table with Resident #24 was served lunch. Resident #24 was served lunch at 12:15 PM. Resident #24 asked the other resident at her table multiple times if the food was good, and she said she hoped hers came out soon. During an interview on 6/06/22 at 11:55 PM with CNA K, when surveyor asked her where a certain resident was, she said the resident was on the feeder side then corrected herself and said the assisted dining side. During an observation on 6/06/22 at 12:04 PM, observed dining staff place the 1st plate of food served from the kitchenet in the assisted dining area of the memory care unit on the table in front of Resident #56, who was in a reclined wheelchair and unable to feed self. Observed the resident look over at food multiple times and starring at the food. At 12:19 PM after all the other residents had been served, a CNA sat down and served Resident #56 her first bite of food. During an observation on 6/06/22 at 12:04 PM, observed four residents sitting at a table in the assisted dining area of the memory care unit. Lunch service began and Resident #83 was served her lunch at 12:04 PM, then at 12:07 PM Resident #84 was served her lunch. At 12:09 PM, observed CNA K sit down to assist Resident #83 with feeding. At 12:11 PM observed Resident #16 receive her lunch meal and then at 12:13 PM Resident #8 received her lunch meal. Observed CNA K originally sit down to assist feeding Resident #83, then she stood and went from resident-to-resident walking around the table feeding each resident a bite and/or drink, then to the next resident and only sanitized her hands prior to sitting down to assist Resident #83. Observed CNA K standing over Resident #84 while feeding the resident during mealtime, then CNA K walked around the table and was standing over Resident #16 while assisting the resident at mealtime, then CNA K continued to walk around the table and stood over Resident #8 while assisting the resident during mealtime, then she walked around the table and stood over Resident #83 while assisting the resident during mealtime feeding each resident a bite. During an observation on 6/07/22 at 8:35 AM observed LVN N leave Resident #80's door open and did not close the curtain when the nurse exposed his abdomen while she performed feeding tube flushes and medication administration. During an interview on 6/07/22 at 8:45 AM with LVN N, after she performed the feeding tube flushes and medication administration, she said she could not think of anything that she should have done differently and asked surveyor for help with the question. Surveyor asked LVN N, if there was anything, she could have done to promote dignity while performing the feeding tube procedure and she stated, I should have closed the door. She said the resident could feel uncomfortable with the door left open during procedures. During an observation on 6/7/22 at 11:45 AM, Resident #45's tray card was marked in large black marker as a feeder. Resident #45 was seated in the assisted dining room. Resident #45 fed herself 50% of her lunch. Verbal cuing by staff was offered but no physical assistance with feeding was noted. During an observation and interview on 6/7/22 at 12:00 PM, lunch service began in the main dining room B. Resident #193 shared a table with 2 other residents. At 12:03 PM the two residents' sharing the table with Resident #193 were served. Resident #193 said she was going to wheel herself to a restaurant nearby for a burger if she had to continue to wait. Resident # 193 continued to make comments about how hungry she was until Resident #193 was served at 12:23pm. During an interview on 6/7/22 at 12:15 PM with CNA P, she said the kitchen staff wrote feeder on the bottom of Resident #45's tray card to help them know where the tray needed to be sent. She said no resident should be labeled as a feeder for dignity. She said labeling the resident as a feeder could make the resident feel less worthy and childlike. During an observation on 6/08/22 at 9:15 AM, observed CNA J push Resident #56 into the assisted dining room in the memory care unit with the wheelchair reclined back and she parked the wheelchair with the resident facing the back wall away from the other residents, who were watching a movie. CNA J then left the dining room area. At 9:20 AM observed Resident #56 sitting up in her wheelchair at the table with other residents facing the TV. During an observation on 6/8/22 at 12:00 PM. Resident #45's tray card was marked with large black maker the word FEEDER. Resident #45 was served lunch in the assisted dining room and consumed 25% of lunch. Resident #45 was not fed by staff at this meal. During an interview on 6/8/22 at 8:30 AM with CNA G, she said when you set up meal trays, and if the resident had a disability, you would tell them where the food was on the tray, cut up meat, open any containers that would need to be opened, and the feeders you would tell them what you are giving them and make sure they are sitting up with proper posture. She said staff should sit to keep eye contact when feeding residents. She said it is important to sit, because when standing up, they take that as standing over them or they are lower. She said we usually feed 2 residents and you just sit in between the residents, and she did not know how she would manage 4 residents. She said, I guess give each one of them a bite. She said if staff stood to feed a resident, that is not appropriate. She said if she was feeding multiple residents, she would just use my left hand for the resident on her left and my right hand for the resident on the right. She said we do not have many feeders right now. During an interview on 6/8/22 at 9:03 AM with CNA H, she said she had worked at the facility for 18 to [AGE] years. She said her CNA job duties included everything any everything all over the facility. She said when she assists a resident with feeding, you should encourage them to eat, tell them what she was putting in their mouth, and tell them to blow on the food if it is hot. She said we sit when feeding residents, we are trained to do that because it is a dignity/respect issue. She said standing over a resident while feeding them would make the resident feel awful and make them feel rushed. She said she would not be the only person to assist residents at a table with multiple residents. She said we try to not to put residents that need assistance with feeding all together. She said it would be an infection control issue with cross contamination to feed multiple persons. During an interview on 6/8/22 at 10:06 AM with CNA J, she said she has worked at the facility for 7 years. She said she usually worked the memory unit. She said her job duties included assisting residents with daily activities of life, meals, getting ready for bed, and doing activities. She said she assisted residents with eating. She said she would go to the feeder side to help. She said she would set up the resident's food, tell them hello, tell them what she was feeding the resident for their meal one item at a time. She said if the resident does not like the food, she would give them a nutritional shake. She said she would sit to feed residents. She said you should sit so you can make sure you are hitting their mouth. She said she has had multiple residents at a table. She said there would be two staff at a table and the staff would sit between two residents. She said she has not had to feed more than two residents at one time. She said she would put on gloves or wash hands and change gloves out between residents. She said she learned to do that in CNA school. She said, sometimes, she has had to help both residents without washing/sanitizing hands due to behavior issues. She said all residents at a table should get their meals timely. She said it would not happen often, because they tried to get the tickets lined up, so the food would come out together for the residents at the same table. She said it would be upsetting to the residents if they did not receive their meals at the same time, because they could be very hungry. During an interview on 6/9/22 at 1:10 PM with LVN L, she said she has worked at the facility for [AGE] years. She said her job duties included taking care of residents, supervising CNA's, blood sugars, passing medications, and toileting residents. She said staff should sit in a chair when feeding a resident. She said staff needed to be at eye level with the resident while feeding them, because the resident could feel fearful or inferior. She said staff have been in-serviced and trained on how to properly feed a resident. She said the appropriate term to use is they or they need assistance and the term feeder is not appropriate. She said calling a resident a feeder could be a dignity issue. She said she had never seen feeder on a meal ticket. She said they had an assisted dining room and an independent dining room. She said it was not okay for one resident to get their food and the other residents at the same table get their food fifteen minutes later. She said she would not want that to happen with my family if she was eating. She said it could make the ones eating feel bad and the ones not eating think they were not getting anything. She said they try to get the whole table their food at the same time, especially in the memory unit. She said they sometimes had to make abrupt changes to tables, based on how residents were getting along, and she would do the meal tickets to make sure we have it running smooth. She said it was not appropriate for one staff to feed four residents at a table at the same time. She said cross contamination would be a problem and by the time you get to the 4th person their food may be cold. She said she thought CNAs got ahead of themselves sometimes. During an interview on 6/9/22 at 2:02 PM with LVN M, she said she had worked at the facility for [AGE] years. She said her job duties included passing medications, treatments, head to toe assessments, and discharges. She said resident assistance eating staff should be seated and give small bite size pieces. She said staff should not stand over the resident so not to intimidate or rush resident. She said terminology feeder is not a term to use, it was degrading to the resident. She said residents at the same table should receive their food at the same time, so that one does not feel left out. She said the one without a meal tray may feel left out and the other may feel special for getting their meal tray before others at the table. She said when there was a table of four residents that needed assistance with feeding, you would just have to go to each resident and feed each. She said that was not the ideal way, because one resident could feel like they were not getting enough food or attention at that time. She said hand sanitizer should be used between residents for infection control. She said a nurse should introduce themself to the resident, wash hands, and it is important to close the door to while providing care with the resident's feeding tube. During an interview on 6/9/22 at 2:54 PM with the DON, she said she had worked at the facility for [AGE] years. She said we try to feed just one resident at a time. She said staff should be seated when feeding a resident. She said the resident could feel intimidated if staff were standing over them. She said when multiple residents were at the same table, they should all receive their meal trays at the same time, because residents would try to take food from another resident's plate sometimes. She said staff should not be feeding four residents at a table, that would not be best practice. She said staff not using hand sanitizer between residents when assisting with feeding multiple residents, would not be best practice. She said when staff are providing care to a resident, they should close the door or pull the curtain to preserve the resident's dignity. She said she was responsible to ensure staff were treating residents with respect and dignity and was responsible for providing training to the staff. During an interview on 6/9/22 at 3:30 PM with the Administrator, he said he has worked at the facility for 6 years. He said his job duty was to oversee the complete operation of the facility. He said he expected residents at the same table would have their meals delivered to the table at the same time. He said not receiving their meals at the same table at the same time was a dignity issue and the residents that had not received their meals might be afraid of not receiving their meal. He said when staff were assisting multiple residents at a table with feeding, staff should not be feeding all four residents at the same time. He said not using gloves or hand sanitizer between assisting each resident with feeding would be an infection control issue. He said he was not aware these things were happening and would address it with his staff. Record Review of In-service logbook revealed there were no in-services on Resident Rights performed. Record review of a facility Resident Rights policy titled Resident Rights dated 12/16 revealed . federal and state laws guarantee certain basic rights to all residents of this facility . resident's right to a dignified existence . be treated with respect, kindness, and dignity . orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights . Record review of a facility Meal Service policy titled Meal Service dated 2018 revealed . Residents will be properly positioned in chairs, wheelchairs or geri-chairs at an appropriate distance from the table . residents will be treated with respect and courtesy . all residents at one table will be served at the same time prior to serving residents at other tables . table service will be rotated so that the same table is not always served first or last . residents who require dining assistance will not have their trays delivered until a staff member is available to assist with dining .

Based on observation, interview and record review, the facility failed to ensure an allegation of sexually abuse was reported immediately for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on [MEDICATION(S)] about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

Based on observation, interview and record review, the facility failed to ensure an allegation of sexually abuse was thoroughly investigated for 3 of 19 residents reviewed for abuse. (Resident #21, Resident #25 and Resident #61) CNA G stated she reported sexually inappropriate behavior to the SW and DON in early March 2022 when Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated she felt the need to report the behaviors because none of the female residents were cognitive enough to understand what was going on and give consent for Resident #29's actions. CNA G stated nothing happened after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was comprised of male and female (28) residents. This failure could place residents at risk for abuse, physical or psychological harm or injury. Findings included: 1. A review of the face sheet dated 6/9/2022 revealed Resident #21 was an [AGE] year-old female with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS provided by the facility revealed an incomplete blank MDS. A review of care plans for Resident #21 with a target date of 4/07/2022 indicated Resident #21 had dementia and was a risk for increased confusion and had a BIMS of 5 which indicated some cognitive impairment. The care plan indicated Resident #21 was usually understood and usually understood others but may miss some part or intent of the message. The care plan indicated Resident #21 was dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 2. A review of the face sheet dated 6/9/2022 revealed Resident #61 was an [AGE] year-old female admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident # 61 was sometimes understood and sometimes understood others. Resident #61 had a BIMS of 00 which indicated severe cognitive deficits. Resident #61 required extensive assistance with ADLs and exhibited no behaviors according to the MDS. A review of the care plan dated 7/20/2021 indicated that Resident #61 had elected to distance herself from others, had trust issues, was confused and dependent on staff for emotional, leisure, cognitive, religious, physical, and social needs related to cognitive deficits. 3. A review of the face sheet dated 6/9/2022 revealed Resident #25 was an [AGE] year-old female that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MDS dated [DATE] indicated Resident #25 was usually understood and usually understood others. Resident #25 had a BIMS of 06 which indicated a moderate cognitive impairment. The MDS also revealed inattention and disorganized thinking daily. No behaviors were noted on the MDS. Resident #25 required extensive assistance for ADLs. Review of the care plan for Resident # 25 dated 6/5/2020 revealed impaired cognition related to dementia with impaired decision-making, long-term memory loss and short-term memory loss. 4. A review of the face sheet dated 6/9/2022 revealed Resident #29 was a [AGE] year-old male that admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MDS dated [DATE] revealed Resident #29 was usually understood and usually understood others. The BIMS score for Resident #29 was 07 which indicated a moderate cognitive impairment. No behaviors were noted on the MDS. Review of the care plan dated 6/11/2021 revealed Resident #29 had impaired cognition with no behaviors. The care plan revealed Resident #29 was independent and in need of staff for meeting emotional, intellectual, physical, leisure and social needs related to personal choice. During an interview on 6/8/2022 at 10:30am CNA G revealed she reported sexually inappropriate behavior to the SW and DON in early March 2022. There was no documentation of her observations by CNA G. She stated Resident #29 was continually being inappropriate with Resident # 21, Resident #25 and Resident #61. CNA G stated Resident # 29 would rub the inner thigh of these residents, as well as hold their hands and rub their arms while making kissing noises with his mouth. CNA G stated Resident #29 would ask the ladies if they liked sex. CNA G stated she felt the need to report the behaviors because none of the ladies were cognitive enough to understand what was going on and give consent for his actions. CNA G stated no interventions that included the staff were made after she reported it for about 3 weeks and then Resident #29 was moved to the memory care unit. The memory care unit was compromised of male and female (28) residents. CNA G stated there was annual training on abuse and neglect for all staff. During an interview on 6/8/2022 at 10:45 am CNA H revealed Resident #29 liked to smoke, who needed to be encouraged to use the bathroom. Resident #29 responded to verbal cueing easily and was on the unit for wandering in and out of other resident's rooms. Resident #29 was friendly with the female residents. CNA H revealed that those females were gone now, except Resident #25. CNA H revealed Resident #29 had quite a few women he liked to blow kisses and pet on. CNA H participated in annual abuse and neglect training. During an interview and observation on 6/8/22 at 1:05 p.m. Resident #29 stated he had been a resident of the facility for about 1 year. Resident #29 believed he was put on the memory care unit about 2 months ago. Resident #29 stated he liked to hold hands with the female residents in dining room. Resident #29 stated he had blown kisses at and touched the legs of several females when he was outside of the memory care unit. Resident #29 stated he was looking for a woman friend. Resident #29 said that he understood what appropriate and inappropriate behavior was. Resident #29 stated he just stopped if the female staff told him to stop because he did not want any problems or to get into trouble. Resident #29 stated he got in a little trouble when he was outside of the memory care unit for being too friendly and touching female residents. Resident #29 stated staff did not always see when he was being inappropriate but when they did see it, they did correct him and he would stop. Resident #29 stated there were a few women on the memory care unit he would like to have as his woman friend. He stated he blew them kisses and held hands but did not touch legs or ask them for sex. During observations on 6/8/2022 at 1:05PM it was noted that staff were not monitoring Resident #29. Resident #29 was on both halls and in the dining room during observation. Resident #29 was mobile per self-propelled wheelchair. During a record review on 6/8/2022 at 1:15pm the progress notes made by the SW revealed a note from 3/4/2022 at 3:40pm: SW visited with res(ident) to discuss recent behaviors he has been observed displaying related to sexually inappropriate language towards female residents. SW explained that res. is not to physically touch any of the ladies stating you are not allowed to place your hands on any body part of any of the ladies. I understand that you may feel a little lonely and may be looking for companionship, but this is not the place. It is inappropriate to ask female residents about the relationship status or anything related to their sexually. I need you to stop this behavior now, because it can be considered sexual harassment, and could impact your continued stay here. Res verb understanding stating ok, I understand, this is just between you and I right? SW responded. for now, but if I am told that you are still being inappropriate, I will have to discuss with the administrator. Res verb understanding. During an interview on 6/8/2022 at 1:30 pm the DON stated she was unaware of any inappropriate behavior by Resident #29. The DON stated nothing had been reported to her about Resident #29 physically touching or making sexually inappropriate comments to any female residents. The DON read the note by the SW from 3/4/2022 regarding Resident #29 and stated she had no idea the note was in the chart and the SW no longer worked there. The DON stated had she been made aware she would have started an investigation for the incidents. The DON stated inappropriate behavior can be harmful psychologically to the residents. The DON stated the only behaviors she was aware of from Resident #29 was him holding hands with some of the female residents but nothing that was sexually inappropriate. The DON stated abuse of any kind cause depression, anxiety, and fearfulness to any resident effected by it. During an interview on 6/8/2022 at 1:45 pm the Administrator stated he was unaware of any inappropriate behavior by Resident #29. He stated he was the abuse prohibition coordinator, and nothing had been reported to him. He stated that he or the DON are the only abuse coordinators in the building and the staff knew to report to them immediately. The administrator stated if he was made aware of an allegation of abuse of any kind, he immediately investigated it and would report it to state if warranted. The administrator was made aware of the note the SW wrote on 3/4/2022 regarding Resident #29. The administrator stated abuse cause mental as well as physical harm to residents by making them withdrawn. During a phone interview on 6/8/2022 at 3:00pm, Resident #21's responsible party stated he had no concerns with Resident #21's care and nothing concerning or alarming had been reported to him. An interview was attempted on 6/8/2021 at 3:15pm with no answer or return call with the family representative of Resident # 61. During a telephone interview on 6/8/2022 at 3:30 pm Resident #25's family was called with no answer or returned call. During a telephone interview on 6/8/2022 at 3:35pm, Resident #29's family stated no calls had been made to her concerning any behaviors from the facility. The family asked if Resident #29 was misbehaving or was in trouble. She stated the facility only called her for money, they did not call her with care concerns because he was his own responsible party. During a telephone interview on 6/9/2022 at 3:45pm, the SW responsible for the SW note on 3/4/2022 called and stated she remembered the event well. The SW stated that on 3/4/2022 an employee came to her on their way out for the day and stated that Resident #29 was displaying some sexual behaviors that made her uncomfortable. The employee stated that Resident #29 asked a few different residents if they wanted to have sex with him while rubbing on their legs. SW stated she called Resident #29 into her office and spoke with him about his behavior. He stated he understood the behavior could not continue. SW stated this was late on a Friday and everyone was gone. The SW stated she did not think of the incident as abuse at the time. The SW stated she looked over and spoke with the resident he was inappropriate with and there was no evidence of harm. On Monday the SW reported the incident to the DON and asked what interventions would be best for his situation. SW stated the DON said just keep an eye on him. The SW stated she did keep an extra eye on him and did not notice any further behavior. The SW called the psychological service that the facility was using at the time and requested an evaluation related to his behavior. The SW stated that a counselor came out and spoke with Resident #29, however the facility was changing counseling services at this time and it was a few weeks before the other counseling service got him was able to assess Resident #29. The SW stated the DON wanted to get Resident #29 some medication to keep him from getting excited. The SW stated in the meantime the DON requested the MD start Resident #29 on some medication. The SW stated Resident #29 was started on [MEDICATION(S)] about 3 weeks after the incident of sexual inappropriateness. None of the observations were noted in Resident #29's file because The SW stated she was directed by the DON to just keep an eye on him. Resident #29 was on the memory care unit. The SW stated Resident #29 never tried to elope and was cognitively intact. The SW stated the facility staff would ask Resident #29 for assistance in translating for some of the Spanish only speaking residents. The SW ended by stating that some of the staff was intimidated by the DON and afraid of retaliation if they reported things to her, that is why she received the report on Resident #29. The SW stated her only role in the process when an abuse allegation was made was to investigate what she was directed by the administrator or DON to investigate. The SW stated she took yearly abuse and neglect courses. An undated facility policy titled Abuse and Neglect Prohibition Policy indicated, 'each resident has the right to be free from abuse, corporal punishment and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but no limited to, facility staff, other residents, consultants, or volunteers .All direct care staff have been trained to identify the three signs that might indicate abuse of residents. Staff can recognize physical changes, sudden changes in behavior or personality, and fear and anxiety All employees who suspect abuse at any time are to report it to their immediate supervisor. The immediate supervisor will report it to the DON who will report it to the abuse coordinator (the administrator). An immediate investigation will be instigated and the person responsible for this coordination of the investigation will be the abuse coordinator It is of utmost importance that the resident or residents suspected of being abused and all other residents be protected during the initial identification and investigation process. The facility will initiate immediate procedures to ensure that these residents are protected fully from any further harm or potential harm Inappropriate sexual behavior .must be addressed. The facility must document the behavior, conduct a resident assessment, as necessary, and incorporate in the care plan procedures to address the behavior and protect other residents from the inappropriate behavior.'

Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 4 (Resident #188, Resident #46, Resident #73, and Resident #58) of 5 residents reviewed for baseline care plans. The facility failed to ensure resident's baseline care plan accurately reflected the resident's goals and discharge planning and were shared with the resident and/or family. This failure could place newly admitted residents at risk of receiving inadequate care and services. Findings included: 1.Record review of the face sheet dated 6/9/2022 indicated that Resident #188 admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS for Resident #188 dated 6/13/2022 was incomplete with no BIMS information noted. Record review of MD orders for Resident #188 dated 06/09/2022 revealed orders for IV [MEDICATION(S)] 750mg in 250ml of normal saline for wound infection daily ordered 5/31/2022 and clean surgical wound to left foot apply with NS (normal saline) to wound bed, pat dry, apply green foam, apply wound vac at 125 mm HG continuous suction every Monday-Wednesday- Friday until healed dated 5/31/2022. Record review of care plan for Resident #188 initiated on 6/7/2022 revealed a problem listed as: The resident wishes to go home. The goal area of the care plan was left blank. No care plan was noted for IV medication or wound vac for wound care. During a record review of the admission assessment for Resident #188 with the start date of 5/31/2022 and the completion date of 6/1/2022 it was noted under the baseline care plan section that no discharge goals were selected. The discharge section under baseline care plan is blank. There was no indication of IV antibiotics or wound vac for wound care. During an interview on 6/6/2022 at 10:00am, Resident #188 stated she had been in the facility about 1 week and no one had talked with her about her discharge goals. Resident #188 was able to understand questions and was understood. Resident #188 stated she was waiting for someone to tell her how long she would have to be here and how long she would have to take IV medications. Resident #188 stated she asked LVN N on multiple occasions if she knew anything about her going home and LVN N always responded she did not know but would find out. Resident #188 stated she had not been involved with a care plan meeting and never received a copy of her baseline care plan. 2. Record review of the face sheet dated 6/9/2022 indicated that Resident #46 was an [AGE] year-old female that admitted on [DATE]. Resident #46 had the following Diagnosis: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #46 was understood and understood others. Resident #46 had a BIMS scored of 14 which indicated no memory problems or cognitive deficit noted. Record review of a care plan dated 06/01/2022 indicated Resident #46 wished to discharge to the community. The goal section of the care plan had no dates, milestones or abilities listed. There was no baseline care plan located in the file. During a record review of the admission assessment with the open date of 4/19/2022 and the closed date of 4/21/2022 the section on discharge planning was filled out incorrectly with all boxes being checked. This indicated that the resident wanted to discharge home, stay in the facility long term, and be transferred to another facility. No clear plan or goals were selected. During an interview on 6/6/2022 at 10:15am, Resident #46 revealed the desire to discharge to the community and stated she was told by the nursing staff the social worker would help her with discharge planning. Resident #46 stated no one asked her about discharge planning since her admit. Resident #46 stated she did not participate in a care plan meeting and was not given a copy or able to review her plan of care. 3. Record review of the face sheet dated 6/9/2022 indicated that Resident # 73 was admitted to the facility on [DATE] with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE] indicated Resident #73 was understood and understands. The BIMS for Resident #73 was 14, which indicated Resident #73 had no cognitive deficit. Resident #73 required supervision for ADLs and expected to be discharged back to the community per the MDS. During a record review of the admission assessment for Resident #73 with the open date of 5/21/2022 and the closed date of 5/21/2022 the section on discharge planning was filled out incorrectly with all boxes being checked. This indicated that the resident wanted to discharge home, stay in the facility long term, and be transferred to another facility. No clear discharge plan or goals are indicated. During an interview on 6/6/2022 at 11:16 am, Resident #73 stated he had not been informed of when he would discharge or what goals he needed to meet to discharge. Resident #73 stated no baseline care plan was completed with him present and no copy of the baseline care plan was given to him. 4. Record review of the face sheet dated 6/9/2022 indicated that Resident #58 was an [AGE] year-old female that admitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the MDS dated [DATE] indicated Resident #58 was understood and understood others. The MDS indicated Resident #58 had a BIMS of 02, which indicated cognitive impairment. The MDS from 6/8/2022 also indicated Resident # 58 was extensive to dependent for ADLs and had a discharge plan decided by the legal representative to stay in the facility long term. A record review of the care plans for Resident #58 indicated no care plan for discharge planning and no baseline care plan was created. During a record review of the admission assessment for Resident #58, dated 5/6/2022 opened and 5/10/2022 locked it was noted that the discharge section of the assessment was blank. During an interview on 6/7/2022 @ 2:13 pm the DON stated that it was the responsibility of the ADON or the charge nurse to complete the baseline care plan. The DON explained that the admission assessment had a section titled baseline care plan and the admitting nurse or the ADON completed this section. During an interview on 6/7/2022 @ 2:15pm RN O indicated the charge nurses completed a portion of the admission assessment that was labeled base line care plan. RN O stated she left the discharge section blank because that was a social worker function. RN O replied when asked who the social worker was .we don't have one at this time. RN O stated we haven't had a social worker for a few months now. RN O indicated she did not go over the information in the baseline care plan section with the resident or the family of the resident, stating she was unaware that she was required to do that. During an interview on 6/7/2022 @ 2:21 pm the DON stated she was unaware that the baseline care plans had to be reviewed with the resident or the family within the first two days of admission. The DON stated she would be responsible for ensuring that was completed and reviewed in the future and there was no one assigned to review baseline care plans with the residents presently. The DON stated it was the residents right to be a part of their care planning and discharge planning and it could lead to increased anxiety or depression and decreased outcomes if they are not given the information from the baseline care plan meeting. The DON stated there was no current policy for baseline care plans. The facility followed CMS guidelines.

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 3 of 19 residents (Resident #48, Resident #52, and Resident #56) reviewed for care plans. The facility failed to include Resident #48's discharge wishes and planning on the comprehensive care. The facility failed to include [MEDICATION(S)] (anticoagulant) and [MEDICATION(S)] (antianxiety) and sign/symptoms or side effect monitoring for anticoagulant (help prevent a blood clot from forming) and antianxiety (reduces anxiety) on Resident #52's comprehensive care plan. The facility failed to update Resident #56's functional status on her comprehensive care plan. These failures could affect residents by placing them at risk for not receiving care and services to meet their needs. Findings included: 1. Record review of the consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .), intellectual disability (Below average intelligence and set of life skills present before age 18), stage 2 chronic kidney disease (damage to your kidneys is still mild), [CONDITION(S)] (is a mental health condition that causes extreme mood swings), and difficulty walking. Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #48 was understood and understood others. The MDS revealed Resident #48 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #48 required supervision for ADLs except extensive assistance for bathing. The MDS revealed Resident #48 had active discharge planning to return to the community. Record review of the undated care plan revealed Resident #48 had ADL self-care performance deficit related to activity intolerance, fatigue, impaired balance, limited range of motion, and chronic pain. Intervention included supervision for ADLs and assist with sponge bath when shower cannot be tolerated. The care plan revealed Resident #48 had impaired communication as evidence by reduced ability to understood others and usually understood related to intellectual disability. Intervention included anticipate and meet needs, allow adequate time to respond, and speak on an adult level. The care plan revealed Resident #48 elected to remain at the facility for long term care. Intervention included assess mood quarterly and review discharge potential quarterly. The care plan did not address Resident #48 discharge planning to return to the community. During an observation and interview on 6/6/22 at 11:20 a.m., Resident #48 was lying in bed with a nasal cannula on her face. Resident #48 said she wanted to discharge to a group home because at one time she lived on her own. She said the facility currently did not have a social worker helping her with this discharge plan. She said a community social worker was helping her. 2. Record review of the consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The consolidated physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the MDS dated [DATE], completed by LVN AA, revealed Resident #52 was usually understood and usually understood others. The MDS revealed Resident #52 had a BIMS score of 15 which indicated intact cognition. The MDS revealed Resident #52 required limited assistance for ADLs. The MDS revealed Resident #52 received anticoagulant and antianxiety. Record review of the undated care plan revealed Resident #52 had ADL self-care deficit related to impaired cognition, debility (physical weakness, especially as a result of illness), and weakness. Intervention included extensive assist for bathing, limited assist for bed mobility and transfer, supervision for eating, and PT/OT evaluation and treatment. The care plan did not address Resident #52's prescribed anticoagulant and antianxiety. 3. Record review of resident #56's face sheet dated 6/9/22 revealed a [AGE] year-old female who was admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of resident #56's annual MDS dated [DATE], completed by LVN AA and LCSW BB, revealed the resident was unable to complete the BIMS. The MDS indicated the resident required extensive assistance of one person to physical assist for bed mobility, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene, and totally dependent on staff for bathing. The MDS indicated the resident required extensive assistance of two persons for transfers and walking in room or corridor were activities that did not occur. The MDS indicated that the resident used a wheelchair for mobility. Record review of Resident #56's care plan not dated, but facility provided to surveyor on 6/9/22, read in part: Problem: Resident #56 was able to independently walk around the unit, I am a very high fall risk, unable to recall to not get up without staff assistance. I have a bad habit of habitually stooping and bending to pick up items of the floor while I have and unsteady gait. Goal: Resident #56 will enjoy being with others and need the structure activities provide, attend/participate in activities of choice at least daily by next review date. Resident #56 is constantly on the move. Approach: All staff to converse with resident while providing care; Resident #56 requires supervision as well as some total anticipatory care per staff to assure my needs are met; Resident #56 is a high fall risk due to constantly stooping, bending, and picking up items off the floor; Resident is constantly attempting to walk, talk and at times invade others personal space. During an observation on 6/06/22 at 12:04 PM, observed Resident #56 in a reclined wheelchair and unable to feed self in the assisted dining area of the memory care unit. During an observation on 6/07/22 at 4:16 PM, observed Resident #56 in assisted dining area room in a reclined wheelchair. During an interview on 6/07/22 at 4:50 PM with LVN T, she said Resident #56 was wheelchair dependent. During an observation on 6/08/22 at 09:15 AM, observed CNA J push Resident #56 into the assisted dining room in the memory care unit with the wheelchair reclined back and she parked the wheelchair with the resident facing the back wall away from the other residents, who were watching a movie. During an interview on 6/08/22 at 10:06 AM with CNA J, she said Resident #56 sometimes has episodes of body spasms and the wheelchair she had was a special chair that therapy ordered to keep her from having the spasms or jumping out of the chair. She said the keep her wheelchair reclined to prevent spasms or the resident falling out of the chair. She said the resident could not walk, but she was able to walk a long time ago. During an interview on 6/8/22 at 9:03 a.m., CNA H said she had worked at the facility for 18-[AGE] years. She said there was several residents that required total assistance for transfers. She said she felt comfortable using the mechanical lift alone because I know what I am doing. She said she got assistance with the mechanical lift if needed. During an interview by phone on 6/8/22 at 1:37 p.m., the corporate MDS nurse stated she did not complete MDS assessments at the facility. She only comes on Monday and completes the assessments required to complete the MDS. The facility employees 3 prn nurses that come in when they can and work on MDSs to keep them up to date. The MDS nurses were responsible for completing and updating the care plans as they completed the MDS. Baseline care plans were the responsibility of the charge nurse. She stated MDS accuracy was important because the plan of care was created by the information coded on the MDS the plan of care was how the employees know what kind of care each resident needs. The corporate MDS nurse stated inaccurate assessments and care plans that are not complete or revised could negatively affect the care of the residents because the resident might not receive appropriate care, decreasing their quality of life. During an interview on 6/9/22 at 1:10 p.m., LVN H said she had been at the facility for [AGE] years and was a charge nurse. LVN H said she believed Resident #48 was PASSR positive. LVN H said she did not know Resident #48 very well but if she wanted to return to the community, she would notify the social worker or DON and write a progress note or 24-hour report to ensure all team members were informed. LVN H said the discharge planning information should be on the MDS then flows to the care plan. She said it was important for Resident #48's discharge wishes to be known because she may be depressed and want to go home. LVN H said Resident #56 talks some but not freely and did not walk. She said she did not know Resident #52 well but believed he was on an anticoagulant which should be monitored for falls and bleeding. LVN H said nursing staff should document accurately to ensure correct information is transferred to the care plan and MDS. She said currently the facility was using a corporate MDS coordinator and they were responsible for the care plan and MDSs. During an interview on 6/9/22 at 2:02 p.m., LVN L said she had been at the facility for [AGE] years and was a charge nurse. LVN L said Resident #48 was PASRR positive and was documented under the medical diagnosis. She said it should be on the MDS then placed on the care plan. She said it was important to monitor for behaviors, address them correctly, and receive appropriate services. LVN L said she did not know Resident #56 because she was on the secure unit. She said it was important to know the medication classes such as anticoagulants and antiplatelet to monitor lab values. She said Resident #52 was on an anticoagulant which required labs, monitor for bruising and blood in his urine. She said it should be documented in Resident #56 chart. LVN L said Resident #48 had not told her she wanted to return to the community. She said if she does then it should be on her care plan under discharge. She said we should all know this information to be on the same page. She said the MDS coordinator and social worker are responsible for discharge planning. During an interview on 6/9/22 at 2:54 p.m., the DON said she had been at the facility for [AGE] years. The DON said MDSs, and care plans should accurate show who the residents are. She said care plans are developed 48 hours from admission then done quarterly and if something happens in care plan meetings. She said the facility did not have a MDS nurse or social worker. She the corporate MDS was handling assessments. She said inaccurate assessments can affect the resident's care and cause wrong coding on the MDS. She said Resident #52 was on anticoagulants and signs and symptoms of bleeding should be monitored. She said Resident #56 no longer walked and only said a few words. She said if her care plan said she did, then it was not updated. The DON said Resident #48 wanted to return to the community and should be documented on her care plan and on her PASRR positive paperwork. She said Resident #48 was PASRR positive and should code on her MDS. She said all the information should be documented so everyone knowns and the social worker should have documented it. During an interview on 6/9/22 at 3:30 p.m., the administrator said the facility did not have a MDS coordinator or Social Worker for the last 30 days, so care plan and MDS may inaccurate. He said inaccurate care plans can affect quality of care. He said care plan lets the facility know resident and family wishes, special needs, and dietary requirements. On 6/8/22 at 3:35 p.m., a policy regarding comprehensive care plans was requested from the DON. The DON said the facility did not have one but followed CMS guidelines.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free from accident hazards as is possible in five of five resident halls. The facility failed to repair broken or missing outlet covers in 10 resident rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) among all five halls, even after a fire occurred in resident room 111 as a result of a broken outlet cover. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/3/2017. While the IJ was lowered on 11/5/2017, the facility remained out of compliance at a level of no actual harm but potential for more than minimal harm with a scope identified as widespread. This failure resulted in a fire in resident room 111 and could place 119 residents at risk of serious harm or death by electrical shock, smoke inhalation, or fire. Findings included: Review of a facility incident report provided by the DON on 11/3/2017 reflected the words (Facility name) Fire in the space provided for a name, a time of 4:57 p.m., and no date. The section marked Brief Description reflected Fire- fire alarmed on panel, staff looked at panel showed 100 hall, staff immediately grabbed fire extinguisher and ran searching each room, under bed, bathroom closet, and closing doors behind them. 111 room noted with smoke under the door. Staff from latter hall continued to search the last two rooms. Black smoke filling the hall, all residents cleared. Two residents removed from d/t both residents eat their meals in room. All cleared. Smoke thick all staff left hall except maintenance staff. EMS/fire department arrived, assessed the situation with orders to evacuate the front station. Staff immediately evacuated all residents-parking lot clear for all residents by three staff. Then fire marshal ordered to evacuate ABRI unit. All residents evacuated from ABRI unit. Staff from everywhere onsite to help, (names of nearby facilities listed here). EMS,(NAME)and White nurses, families. Headcount again people from out of nowhere in the nursing field came to help. Fire marshal, gave all clear for two, three and ABRI unit. Everyone helped the staff with bringing the residents back in the facility. All residents hydrated and given snack until trays were ready. All 100 hall staff and residents remained in the dining room, monitor closely. Other sister facilities continue to clean water from 100 hall, 15 staff or more. Facility began calling families to notify their loved ones were alright. Staff started with 10 hour firewatch. Review of a document dated 11/3/2017 and published by the local fire department reflected the following: Fire investigation determined the fire was unintentional and caused by an electrical short. The short started when a metal bed frame came in contact with a damaged cover plate of an electrical wall outlet, igniting bedding material and the mattress. During an interview on 11/3/2017 at 1:15 p.m., local fire department investigator stated that the fire appeared to be unintentional (not arson) and to have originated because a metal bed frame was pushed against the wall and damaged an outlet cover. The contact between the metal bed frame and the unprotected outlet probably caused an arcing condition, which ignited the bedding. He stated that there are black marks on the metal bed frame, and the outlet was burned inside and out. He stated that the fire fighters that responded to the fire did not tell the facility to occupy the section of the building, nor did they tell them not to occupy the affected portion. Instead, they left it to the facility's discretion, but recommended they get a restoration company in there as soon as possible because of the smoke and water damage. He stated the fire department did indicate that the rest of the building could be occupied with no issues. He stated the fire department also told the facility they must do a fire watch until they get their sprinkler system repaired, since it activated in response to the fire. Observation on 11/3/2017 at 2:45 p.m. revealed a closed door to room 111. A name plate outside the door had the names for Residents #1 and #2. Behind the closed door, the room was empty of people or belongings except for a bed frame. A hole approximately 5 feet by 4 feet could be seen on the corridor wall closest to the facility entrance with borders marked by black substance and apparent burn damage. The room smelled strongly of smoke. Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) conducted for Resident #1 on 10/5/2017 reflected a Brief Interview for Mental Status (BIMS) score of 12, indicating very little cognitive disability. Review of nurse's notes for Resident #1 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #2 on 8/4/2017 reflected a BIMS score of 4, indicating severe cognitive disability. Review of nurse's notes for Resident #2 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Observation on 11/3/2017 at 2:50 p.m. revealed that Resident #1 was wearing shorts and slippers with his legs exposed and a short sleeved shirt which exposed his arms. He was clean, dressed inn clean clothing, groomed, and free of odors. No injuries were observed on any exposed part of his skin. During an interview on 11/3/2017 at 2:50 p.m., Resident #1 stated that he got moved out of his room. He could not recall any incidents or accidents. When asked directly about a fire, he stated that there was a fire. He would not or could not answer whether he was in the room at the time of the fire. He stated he was not injured in any way during the fire. He stated he was evacuated into the back parking lot. He stated he was fine with the move to another room. Observation of Resident #2 on 11/3/2017 at 2:55 p.m. revealed that he was wearing sweatpants and a short-sleeved shirt. He was clean, dressed in clean clothing, groomed, and free of odors. No injuries of any kind were seen on his exposed skin. During an interview on 11/3/2017 at 2:55 p.m. Resident #2 stated when asked if he recalled any incidents or accidents recently, he did not answer with any clarity. Observation on 11/3/2017 at 3:05 p.m. revealed an electrical outlet in room 104 behind the headboard of bed B with no outlet cover and two cords plugged into it. No resident was observed in the room at this time. Observation on 11/3/2017 at 3:07 p.m. revealed an electrical outlet in resident room 109 behind the bedside table for bed A with a cracked plate cover. No resident was observed in the room at this time. During an interview on 11/3/2017 at 3:18 p.m., MD stated the fire started about 4:45 p.m. the day before. He stated the fire alarm went off, he checked the panel to see where the alarm was, and he went to hall 100 where he could see light smoke floating in the air. He yelled code red, and this is a fire, not a drill. He stated the door was closed to room 111, but he could see smoke coming from the bottom of the door. He stated the two residents who live in the room were in the dining area where dinner was expected. He stated there was one resident on that hall and two on the 200 hall. He stated the staff moved those residents out of the halls and toward the dining room. He stated that, in the meantime, the fire doors closed. He stated he called 911, and also the monitoring company they have for the fire alarms were notified and called the facility. He stated the entire building was evacuated. He stated that residents went out around the sidewalk from the dining room and out to the back parking lot. He stated that memory care, which consists of halls 400 and 500 in a locked unit, went out of the exit doors on the 400 hall. He stated the fire department told them to evacuate the entire building. He stated that he was up at the front of the building with the fire department. The fire department stated that the cause of the fire could have been two to three things: bad wiring, an overload of the circuit, or a manual crank bed on the A side touching the electrical outlet. He stated that, after the fire, the outlet plate was on the ground below the outlet and was broken. When asked about the fire department investigator's determination that the fire was caused by an electrical arc, he stated that this determination came later. He stated that the sprinklers came on. He stated he picked up the outlet but does not have it anymore. He stated that an outlet with a broken or missing plate cover could create a hazardous condition by having electrified metal exposed to any surface. He stated that a resident could touch it, or it could touch metal or cloth. He stated this is a fire hazard. He stated that he came to work on the morning of 11/3/2017 with a list of outlets that had missing or broken plates and required replacement. He stated he replaced all of those. When asked about the rooms on hall 100 that currently had missing plate covers, he stated they only had room 110 on the list of repairs. When asked how he could ensure that all the outlets had fully intact plate covers, he stated that the facility staff checked them all, and only room 110 needed a repaired plate cover. When asked how the system of checking all the outlets was effective if there are still missing plate covers in the facility, he stated that he did the work that was on the list. He stated that he does not think there are any more missing or broken outlet plates in the facility. During an interview on 11/3/2017 at 3:27 p.m., the ADM stated that the fire happened right at 5:00 p.m. He stated he had already left for the day, got the phone call about the fire, and u-turned to go back. He stated the fire was already out when he arrived. He stated they got all the residents out, and no one was hurt. He stated the residents living in room 111 were in the dining room at the time, and they are all thankful, because Resident #1 could have been very badly hurt or worse. He stated the fire department told him a bed had broken the outlet plate cover, and the fire had started when the metal from inside the outlet touched the metal of the bed frame. He stated that immediately all outlet plates were checked. He stated the DON assigned people to check the outlets in every room, and he believes it was nursing staff. He stated he doesn't know exactly who the DON assigned to which halls. When asked how the quality of these checks was assured, he stated they do quality of life rounds, and one of the things they do is making sure to check plugs. He stated he did not have any documentation of that specific check prior to the fire. He stated that educating staff on how to identify outlets in disrepair will be one of the in-services he does as a result of the fire. He stated the condition of a broken or missing outlet plate is definitely a hazard. He stated that if anyone stuck a finger in it, or anything metal touched it, it could cause electric shock or fire. He stated that wet floors nearby to the uncovered outlet could also be a hazard. He stated that the facility is currently doing fire watches. Review of face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #5 on 11/3/2017 reflected a BIMS score of 15, indicating no cognitive disability. Review of face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #6 on 8/9/2017 reflected a BIMS score of 3, indicating severe cognitive disability. Observation in resident room 114 on 11/3/2017 at 3:39 p.m. revealed that Resident #5 was sitting up in bed. His leg was amputated above the knee. He was clean, dressed in clean clothing, groomed, and free of odors. Observation at this time revealed that Resident #6 was sitting in his bed with his back against the wall. He was clean, dressed in clean clothing, groomed, and free of odors. He smiled and nodded in response to questions, but could not or would not participate in an interview. Further observation on 11/3/2017 at 3:39 p.m. revealed an electrical outlet in resident room 114 behind the headboard of bed B with no outlet cover and one cord plugged into it. During an interview on 11/3/2017 at 3:39 p.m., Resident #5 stated he did not know that there was no outlet plate cover on the outlet behind his bed. He granted permission for the area to be photographed and then asked to see the photographs. He stated he does not have the physical ability to see behind his bed. When viewing the photograph, he stated that the missing outlet plate was scary and asked who would be repairing it. When he was told that this is usually the job of the maintenance director or staff. He could not recall where he heard this. He stated that he feels as if his life is not important to the facility staff if they just let a hazard like this go unrepaired. He stated that he is a veteran, and that makes him feel terrible. Observation of resident room 209 on 11/3/2017 at 3:45 p.m. revealed no plate cover on the outlet into which the under-window air conditioner (AC) was plugged. Review of face sheet for Resident #8 reflected [AGE] year-old female and minutes of the facility on 12/13/2016 with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #8 on 10/23/2017 reflected a BIMS score of 12, indicating very little cognitive disability. During an interview in resident room 211 on 11/3/2017 at 3:48 p.m., Resident #8 stated she was evacuated the other day for a fire. She stated she was not hurt and feels fine. She stated she does not want to be in a fire. She stated she does not like that fact that there is no plate cover on the outlet under the air conditioner. She stated that did not seem safe. She stated she has always felt safe in the facility before. Observation of resident room 211 on 11/3/2017 at 3:48 p.m. revealed no plate cover on the outlet into which the AC was plugged. Observation of resident room 214 on 11/3/2017 at 3:51 p.m. revealed a cracked upper socket on the outlet behind bed A. Observation of resident room 304 on 11/3/2017 at 3:53 p.m. revealed no plate cover on the outlet into which the AC was plugged. A strip of black-spotted wallpaper had come loose from the wall and curled around into the outlet receptacle. A maroon curtain hung against the other side of the AC plug, touching and obscuring the open outlet receptacle. Observation of resident room 401 (in locked memory care unit) on 11/3/2017 at 4:06 p.m. revealed that the plate cover behind bed A was not flush with the wall or the sockets, and 1/4 to 1/2 inch gaps existed between the plate cover openings and the outlet receptacle. Observation of resident room 503 (in locked memory care unit) on 11/3/2017 at 3:56 p.m. revealed an outlet against bed B was placed had a broken plate cover, a broken upper socket, and a metal tongue protruding from the base of the upper socket. Observation of resident room 504 (in locked memory care unit) on 11/3/2017 at 3:58 p.m. revealed a cracked plate cover on the outlet into which the AC was plugged. During an interview on 11/3/2017 at 6:15 p.m., the RVP stated that she was the person in charge on the night of the fire. She stated that when she got to the facility, the fire was already out, and the fire marshal brought her into the office and talked to her. She clarified that she was not sure if it was the fire marshal or who it was from the fire department, but she got his card. She stated he had told her he looked for smoking paraphernalia and didn't see any. She stated he told her he didn't see where the outlet had been overloaded, but showed her where some wires had been frayed. She stated he showed her where the bed frame touched the outlet. He picked up the plate and showed it to her. It looked as if it had melted, but the sides were intact. She stated that the corporate vice president of nursing sent a message that they should check all the rooms. She stated that CNAs were sent out to check rooms. She brought everyone together to do two forms of checks: outlets in bedrooms and respiratory checks for residents. She stated the CNAs were told the beds need to be going the right way perpendicular to their lights. She stated she told them to look for broken outlet covers, missing outlet covers. She stated they did not check the 100 hallway until the fire department was done there. When asked if she felt CNAs were qualified or educated to perform these maintenance checks, she stated that at the time everyone was brought together as a team to do all the jobs such as cleaning up, removing water, and checking the other resident rooms. She stated that, in an ideal situation, the buildings would have their maintenance directors perform this task or call in maintenance directors from other buildings. She stated they did talk about what to look for when inspecting a room for outlets in bad repair. She stated she felt, at the time, that what they did was adequate to address the problem that created the fire. Review of facility work orders from (MONTH) (YEAR) to present reflected that they did not include orders for resident rooms 104, 109, 114, 209, 211, 214, 401, 503, or 504. Review of a document provided by the facility, dated 11/2/2017, and titled Performance Improvement Plan reflected the following: Observation/System/Problem- Broken and Missing outlet covers; Goal/Objective- The Staff will notify Maintenance immediately when any missing or broken outlet plates identified; Actions- The Department Heads will monitor daily during their assigned Quality of Life rounds to monitor for any missing or broken outlet plates and report back to Maintenance immediately for repairs; Responsible Party- Department Heads and/or Designee; Target Date- 11/2/17@1930; Comments- Focus Area on Rounds: Broken or Missing outlet plates will be discussed in QAPI Meeting for resolution. Attached to this document was a resident census list with notations by rooms where outlets were damaged or missing. Review of the list reflected that rooms 211 and 504 had been notated. According to the ADM, the page that listed hall 100 could not be found at the time the document was requested. Review of the United States Department of Labor Occupational Health and Safety regulations dated 2/13/1996 and titled Safety and Health Regulations for Construction reflected the following: All pull boxes, junction boxes, and fittings shall be provided with covers. The ADM and RVP were notified on 7:50 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the ADM and RVP on 11/03/17 at 9:57 p.m. The Plan of Removal was accepted by the Survey Team on 11/03/17 at 10:00 p.m. The facility's Plan of Removal was as follows: a. Maintenance men will round facility and check the condition of all outlets in each resident room. Completed - 11/3/2017. b. Maintenance men will replace and repair all outlet covers found to be missing or broken/cracked. Completed - 11/3/2017. c. Administrator and/or designee will begin to in-service direct care staff and housekeeping on how to detect when an outlet cover is in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. d. Administrator and/or designee will begin to in-service Dept heads when doing Quality of Life rounds to check all outlet covers to insure that they are in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. e. Maintenance Man will observe the condition of all outlets in resident rooms during his weekly preventative maintenance rounds and repair and/or replace any defective outlets and outlet covers. Target date 11/6/2017. f. Education will begin on 11/3/17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The survey team monitored the current plan of removal as follows: Observation and interviews on 11/3/2017 between 7:50 p.m. and 9:59 p.m. revealed three CNAs and one LVN verified their knowledge of the material contained in facility in-services presented that night. Observation revealed that outlet plate covers for all aforementioned rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) were replaced with intact plate covers or otherwise repaired. Review of nurse's notes for Residents #1-15 reflected checks on 11/3/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 14 staff members had signed an in-service dated 11/3/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 16 staff members had signed an in-service dated 11/3/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/4/2017 between 12:00 p.m. and 2:30 p.m. revealed 5 employees who all stated they had been in-serviced on the Immediate Jeopardy items prior on starting their shift. Observation of 15 rooms revealed that beds were positioned as should be, away from plugs and no outlet covers were cracked or missing. All department heads were present and busy correcting identified issues. The Administrator stated he has a total of 93 employees who need in-servicing and he hoped to have them all complete by tomorrow. Review of in-service documents reflected that 48 of 93 staff members had signed an in-service dated 11/4/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 52 of 93 staff members had signed an in-service dated 11/4/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/5/2017 at 2:20 p.m. and 4:30 p.m. revealed interviews were conducted with seven staff members not interviewed on 11/4/2017, and they each stated they had been in-serviced at the beginning of each shift (which was twice for 6 of the 7) and imparted a detailed understanding of the in-service material as well as the need for the in-service tasks. During an interview with the DON, she stated that several staff persons are PRN staff and live too far away to drive in for an in-service, so they will be trained at the beginning of their next shifts. Observation of 18 rooms revealed no broken or missing outlet plate covers and no further hazards. Review of nurse's notes for Residents #1-15 reflected continued checks on 11/4/2017 and 11/5/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 70 of 93 staff members had signed an in-service dated 11/5/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 67 of 93 staff members had signed an in-service dated 11/5/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. The Administrator was informed at 4:40 p.m. on 11/5/2017 that the Immediate Jeopardy was lowered. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm and a scope identified as widespread. Review of the facility census dated and provided by the Director of Nursing on 11/3/2017 reflected that 119 residents lived in the facility.

Based on observation, interview, and record review, the facility failed to provide goods and services necessary to avoid physical harm, mental harm, or mental anguish in five of five resident halls observed and reviewed. The facility failed to repair broken or missing outlet covers in 10 resident rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) among all five halls, even after a fire occurred in resident room [ROOM NUMBER] as a result of a broken outlet cover. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/3/2017. While the IJ was lowered on 11/5/2017, the facility remained out of compliance at a level of no actual harm but potential for more than minimal harm with a scope identified as widespread. This failure resulted in a fire in resident room [ROOM NUMBER] and could place 119 residents at risk of serious harm or death by electrical shock, smoke inhalation, or fire. Findings included: Review of a facility incident report provided by the DON on 11/3/2017 reflected the words (Facility name) Fire in the space provided for a name, a time of 4:57 p.m., and no date. The section marked Brief Description reflected Fire- fire alarmed on panel, staff looked at panel showed 100 hall, staff immediately grabbed fire extinguisher and ran searching each room, under bed, bathroom closet, and closing doors behind them. 111 room noted with smoke under the door. Staff from latter hall continued to search the last two rooms. Black smoke filling the hall, all residents cleared. Two residents removed from d/t both residents eat their meals in room. All cleared. Smoke thick all staff left hall except maintenance staff. EMS/fire department arrived, assessed the situation with orders to evacuate the front station. Staff immediately evacuated all residents-parking lot clear for all residents by three staff. Then fire marshal ordered to evacuate ABRI unit. All residents evacuated from ABRI unit. Staff from everywhere onsite to help, (names of nearby facilities listed here). EMS,(NAME)and White nurses, families. Headcount again people from out of nowhere in the nursing field came to help. Fire marshal, gave all clear for two, three and ABRI unit. Everyone helped the staff with bringing the residents back in the facility. All residents hydrated and given snack until trays were ready. All 100 hall staff and residents remained in the dining room, monitor closely. Other sister facilities continue to clean water from 100 hall, 15 staff or more. Facility began calling families to notify their loved ones were alright. Staff started with 10 hour firewatch. Review of a document dated 11/3/2017 and published by the local fire department reflected the following: Fire investigation determined the fire was unintentional and caused by an electrical short. The short started when a metal bed frame came in contact with a damaged cover plate of an electrical wall outlet, igniting bedding material and the mattress. During an interview on 11/3/2017 at 1:15 p.m., local fire department investigator stated that the fire appeared to be unintentional (not arson) and to have originated because a metal bed frame was pushed against the wall and damaged an outlet cover. The contact between the metal bed frame and the unprotected outlet probably caused an arcing condition, which ignited the bedding. He stated that there are black marks on the metal bed frame, and the outlet was burned inside and out. He stated that the fire fighters that responded to the fire did not tell the facility to occupy the section of the building, nor did they tell them not to occupy the affected portion. Instead, they left it to the facility's discretion, but recommended they get a restoration company in there as soon as possible because of the smoke and water damage. He stated the fire department did indicate that the rest of the building could be occupied with no issues. He stated the fire department also told the facility they must do a fire watch until they get their sprinkler system repaired, since it activated in response to the fire. Observation on 11/3/2017 at 2:45 p.m. revealed a closed door to room [ROOM NUMBER]. A name plate outside the door had the names for Residents #1 and #2. Behind the closed door, the room was empty of people or belongings except for a bed frame. A hole approximately 5 feet by 4 feet could be seen on the corridor wall closest to the facility entrance with borders marked by black substance and apparent burn damage. The room smelled strongly of smoke. Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) conducted for Resident #1 on 10/5/2017 reflected a Brief Interview for Mental Status (BIMS) score of 12, indicating very little cognitive disability. Review of nurse's notes for Resident #1 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #2 on 8/4/2017 reflected a BIMS score of 4, indicating severe cognitive disability. Review of nurse's notes for Resident #2 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Observation on 11/3/2017 at 2:50 p.m. revealed that Resident #1 was wearing shorts and slippers with his legs exposed and a short sleeved shirt which exposed his arms. He was clean, dressed inn clean clothing, groomed, and free of odors. No injuries were observed on any exposed part of his skin. During an interview on 11/3/2017 at 2:50 p.m., Resident #1 stated that he got moved out of his room. He could not recall any incidents or accidents. When asked directly about a fire, he stated that there was a fire. He would not or could not answer whether he was in the room at the time of the fire. He stated he was not injured in any way during the fire. He stated he was evacuated into the back parking lot. He stated he was fine with the move to another room. Observation of Resident #2 on 11/3/2017 at 2:55 p.m. revealed that he was wearing sweatpants and a short-sleeved shirt. He was clean, dressed in clean clothing, groomed, and free of odors. No injuries of any kind were seen on his exposed skin. During an interview on 11/3/2017 at 2:55 p.m. Resident #2 stated when asked if he recalled any incidents or accidents recently, he did not answer with any clarity. Observation on 11/3/2017 at 3:05 p.m. revealed an electrical outlet in room [ROOM NUMBER] behind the headboard of bed B with no outlet cover and two cords plugged into it. No resident was observed in the room at this time. Observation on 11/3/2017 at 3:07 p.m. revealed an electrical outlet in resident room [ROOM NUMBER] behind the bedside table for bed A with a cracked plate cover. No resident was observed in the room at this time. During an interview on 11/3/2017 at 3:18 p.m., MD stated the fire started about 4:45 p.m. the day before. He stated the fire alarm went off, he checked the panel to see where the alarm was, and he went to hall 100 where he could see light smoke floating in the air. He yelled code red, and this is a fire, not a drill. He stated the door was closed to room [ROOM NUMBER], but he could see smoke coming from the bottom of the door. He stated the two residents who live in the room were in the dining area where dinner was expected. He stated there was one resident on that hall and two on the 200 hall. He stated the staff moved those residents out of the halls and toward the dining room. He stated that, in the meantime, the fire doors closed. He stated he called 911, and also the monitoring company they have for the fire alarms were notified and called the facility. He stated the entire building was evacuated. He stated that residents went out around the sidewalk from the dining room and out to the back parking lot. He stated that memory care, which consists of halls 400 and 500 in a locked unit, went out of the exit doors on the 400 hall. He stated the fire department told them to evacuate the entire building. He stated that he was up at the front of the building with the fire department. The fire department stated that the cause of the fire could have been two to three things: bad wiring, an overload of the circuit, or a manual crank bed on the A side touching the electrical outlet. He stated that, after the fire, the outlet plate was on the ground below the outlet and was broken. When asked about the fire department investigator's determination that the fire was caused by an electrical arc, he stated that this determination came later. He stated that the sprinklers came on. He stated he picked up the outlet but does not have it anymore. He stated that an outlet with a broken or missing plate cover could create a hazardous condition by having electrified metal exposed to any surface. He stated that a resident could touch it, or it could touch metal or cloth. He stated this is a fire hazard. He stated that he came to work on the morning of 11/3/2017 with a list of outlets that had missing or broken plates and required replacement. He stated he replaced all of those. When asked about the rooms on hall 100 that currently had missing plate covers, he stated they only had room [ROOM NUMBER] on the list of repairs. When asked how he could ensure that all the outlets had fully intact plate covers, he stated that the facility staff checked them all, and only room [ROOM NUMBER] needed a repaired plate cover. When asked how the system of checking all the outlets was effective if there are still missing plate covers in the facility, he stated that he did the work that was on the list. He stated that he does not think there are any more missing or broken outlet plates in the facility. During an interview on 11/3/2017 at 3:27 p.m., the ADM stated that the fire happened right at 5:00 p.m. He stated he had already left for the day, got the phone call about the fire, and u-turned to go back. He stated the fire was already out when he arrived. He stated they got all the residents out, and no one was hurt. He stated the residents living in room [ROOM NUMBER] were in the dining room at the time, and they are all thankful, because Resident #1 could have been very badly hurt or worse. He stated the fire department told him a bed had broken the outlet plate cover, and the fire had started when the metal from inside the outlet touched the metal of the bed frame. He stated that immediately all outlet plates were checked. He stated the DON assigned people to check the outlets in every room, and he believes it was nursing staff. He stated he doesn't know exactly who the DON assigned to which halls. When asked how the quality of these checks was assured, he stated they do quality of life rounds, and one of the things they do is making sure to check plugs. He stated he did not have any documentation of that specific check prior to the fire. He stated that educating staff on how to identify outlets in disrepair will be one of the in-services he does as a result of the fire. He stated the condition of a broken or missing outlet plate is definitely a hazard. He stated that if anyone stuck a finger in it, or anything metal touched it, it could cause electric shock or fire. He stated that wet floors nearby to the uncovered outlet could also be a hazard. He stated that the facility is currently doing fire watches. Review of face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #5 on 11/3/2017 reflected a BIMS score of 15, indicating no cognitive disability. Review of face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #6 on 8/9/2017 reflected a BIMS score of 3, indicating severe cognitive disability. Observation in resident room [ROOM NUMBER] on 11/3/2017 at 3:39 p.m. revealed that Resident #5 was sitting up in bed. His leg was amputated above the knee. He was clean, dressed in clean clothing, groomed, and free of odors. Observation at this time revealed that Resident #6 was sitting in his bed with his back against the wall. He was clean, dressed in clean clothing, groomed, and free of odors. He smiled and nodded in response to questions, but could not or would not participate in an interview. Further observation on 11/3/2017 at 3:39 p.m. revealed an electrical outlet in resident room [ROOM NUMBER] behind the headboard of bed B with no outlet cover and one cord plugged into it. During an interview on 11/3/2017 at 3:39 p.m., Resident #5 stated he did not know that there was no outlet plate cover on the outlet behind his bed. He granted permission for the area to be photographed and then asked to see the photographs. He stated he does not have the physical ability to see behind his bed. When viewing the photograph, he stated that the missing outlet plate was scary and asked who would be repairing it. When he was told that this is usually the job of the maintenance director or staff. He could not recall where he heard this. He stated that he feels as if his life is not important to the facility staff if they just let a hazard like this go unrepaired. He stated that he is a veteran, and that makes him feel terrible. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:45 p.m. revealed no plate cover on the outlet into which the under-window air conditioner (AC) was plugged. Review of face sheet for Resident #8 reflected [AGE] year-old female and minutes of the facility on 12/13/2016 with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #8 on 10/23/2017 reflected a BIMS score of 12, indicating very little cognitive disability. During an interview in resident room [ROOM NUMBER] on 11/3/2017 at 3:48 p.m., Resident #8 stated she was evacuated the other day for a fire. She stated she was not hurt and feels fine. She stated she does not want to be in a fire. She stated she does not like that fact that there is no plate cover on the outlet under the air conditioner. She stated that did not seem safe. She stated she has always felt safe in the facility before. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:48 p.m. revealed no plate cover on the outlet into which the AC was plugged. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:51 p.m. revealed a cracked upper socket on the outlet behind bed A. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:53 p.m. revealed no plate cover on the outlet into which the AC was plugged. A strip of black-spotted wallpaper had come loose from the wall and curled around into the outlet receptacle. A maroon curtain hung against the other side of the AC plug, touching and obscuring the open outlet receptacle. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 4:06 p.m. revealed that the plate cover behind bed A was not flush with the wall or the sockets, and 1/4 to 1/2 inch gaps existed between the plate cover openings and the outlet receptacle. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 3:56 p.m. revealed an outlet against bed B was placed had a broken plate cover, a broken upper socket, and a metal tongue protruding from the base of the upper socket. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 3:58 p.m. revealed a cracked plate cover on the outlet into which the AC was plugged. During an interview on 11/3/2017 at 6:15 p.m., the RVP stated that she was the person in charge on the night of the fire. She stated that when she got to the facility, the fire was already out, and the fire marshal brought her into the office and talked to her. She clarified that she was not sure if it was the fire marshal or who it was from the fire department, but she got his card. She stated he had told her he looked for smoking paraphernalia and didn't see any. She stated he told her he didn't see where the outlet had been overloaded, but showed her where some wires had been frayed. She stated he showed her where the bed frame touched the outlet. He picked up the plate and showed it to her. It looked as if it had melted, but the sides were intact. She stated that the corporate vice president of nursing sent a message that they should check all the rooms. She stated that CNAs were sent out to check rooms. She brought everyone together to do two forms of checks: outlets in bedrooms and respiratory checks for residents. She stated the CNAs were told the beds need to be going the right way perpendicular to their lights. She stated she told them to look for broken outlet covers, missing outlet covers. She stated they did not check the 100 hallway until the fire department was done there. When asked if she felt CNAs were qualified or educated to perform these maintenance checks, she stated that at the time everyone was brought together as a team to do all the jobs such as cleaning up, removing water, and checking the other resident rooms. She stated that, in an ideal situation, the buildings would have their maintenance directors perform this task or call in maintenance directors from other buildings. She stated they did talk about what to look for when inspecting a room for outlets in bad repair. She stated she felt, at the time, that what they did was adequate to address the problem that created the fire. Review of facility work orders from (MONTH) (YEAR) to present reflected that they did not include orders for resident rooms 104, 109, 114, 209, 211, 214, 401, 503, or 504. Review of a document provided by the facility, dated 11/2/2017, and titled Performance Improvement Plan reflected the following: Observation/System/Problem- Broken and Missing outlet covers; Goal/Objective- The Staff will notify Maintenance immediately when any missing or broken outlet plates identified; Actions- The Department Heads will monitor daily during their assigned Quality of Life rounds to monitor for any missing or broken outlet plates and report back to Maintenance immediately for repairs; Responsible Party- Department Heads and/or Designee; Target Date- 11/2/17@1930; Comments- Focus Area on Rounds: Broken or Missing outlet plates will be discussed in QAPI Meeting for resolution. Attached to this document was a resident census list with notations by rooms where outlets were damaged or missing. Review of the list reflected that rooms [ROOM NUMBERS] had been notated. According to the ADM, the page that listed hall 100 could not be found at the time the document was requested. Review of the United States Department of Labor Occupational Health and Safety regulations dated 2/13/1996 and titled Safety and Health Regulations for Construction reflected the following: All pull boxes, junction boxes, and fittings shall be provided with covers. Review of undated facility policy titled Resident Behavior and Facility Practices Policy reflected the following: Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect, psychological harm related to an authorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish a pain to a resident; . No resident will be deprived of any individual of goods or services necessary to attain or maintain physical, mental and psychosocial well-being, including abuse facilitated or enabled by the use of technology . The facility has developed operational policies and procedures for screening and training employees for the protection of residence and for the prevention, identification, investigation, and reporting of abuse. The ADM and RVP were notified on 7:50 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the ADM and RVP on 11/03/17 at 9:57 p.m. The Plan of Removal was accepted by the Survey Team on 11/03/17 at 10:00 p.m. The facility's Plan of Removal was as follows: a. Maintenance men will round facility and check the condition of all outlets in each resident room. Completed - 11/3/2017. b. Maintenance men will replace and repair all outlet covers found to be missing or broken/cracked. Completed - 11/3/2017. c. Administrator and/or designee will begin to in-service direct care staff and housekeeping on how to detect when an outlet cover is in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. d. Administrator and/or designee will begin to in-service Dept heads when doing Quality of Life rounds to check all outlet covers to insure that they are in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. e. Maintenance Man will observe the condition of all outlets in resident rooms during his weekly preventative maintenance rounds and repair and/or replace any defective outlets and outlet covers. Target date 11/6/2017. f. Education will begin on 11/3/17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The survey team monitored the current plan of removal as follows: Observation and interviews on 11/3/2017 between 7:50 p.m. and 9:59 p.m. revealed three CNAs and one LVN verified their knowledge of the material contained in facility in-services presented that night. Observation revealed that outlet plate covers for all aforementioned rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) were replaced with intact plate covers or otherwise repaired. Review of nurse's notes for Residents #1-15 reflected checks on 11/3/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 14 staff members had signed an in-service dated 11/3/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 16 staff members had signed an in-service dated 11/3/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/4/2017 between 12:00 p.m. and 2:30 p.m. revealed 5 employees who all stated they had been in-serviced on the Immediate Jeopardy items prior on starting their shift. Observation of 15 rooms revealed that beds were positioned as should be, away from plugs and no outlet covers were cracked or missing. All department heads were present and busy correcting identified issues. The Administrator stated he has a total of 93 employees who need in-servicing and he hoped to have them all complete by tomorrow. Review of in-service documents reflected that 48 of 93 staff members had signed an in-service dated 11/4/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 52 of 93 staff members had signed an in-service dated 11/4/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/5/2017 at 2:20 p.m. and 4:30 p.m. revealed interviews were conducted with seven staff members not interviewed on 11/4/2017, and they each stated they had been in-serviced at the beginning of each shift (which was twice for 6 of the 7) and imparted a detailed understanding of the in-service material as well as the need for the in-service tasks. During an interview with the DON, she stated that several staff persons are PRN staff and live too far away to drive in for an in-service, so they will be trained at the beginning of their next shifts. Observation of 18 rooms revealed no broken or missing outlet plate covers and no further hazards. Review of nurse's notes for Residents #1-15 reflected continued checks on 11/4/2017 and 11/5/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 70 of 93 staff members had signed an in-service dated 11/5/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 67 of 93 staff members had signed an in-service dated 11/5/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. The Administrator was informed at 4:40 p.m. on 11/5/2017 that the Immediate Jeopardy was lowered. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm and a scope identified as widespread. Review of the facility census dated and provided by the Director of Nursing on 11/3/2017 reflected that 119 residents lived in the facility.

Based on observation, interview, and record review, the facility failed to provide a safe environment in five of five resident halls. The facility failed to repair broken or missing outlet covers in 10 resident rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) among all five halls, even after a fire occurred in resident room 111 as a result of a broken outlet cover. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/3/2017. While the IJ was lowered on 11/5/2017, the facility remained out of compliance at a level of no actual harm but potential for more than minimal harm with a scope identified as widespread. This failure resulted in a fire in resident room 111 and could place 119 residents at risk of serious harm or death by electrical shock, smoke inhalation, or fire. Findings included: Review of a facility incident report provided by the DON on 11/3/2017 reflected the words (Facility name) Fire in the space provided for a name, a time of 4:57 p.m., and no date. The section marked Brief Description reflected Fire- fire alarmed on panel, staff looked at panel showed 100 hall, staff immediately grabbed fire extinguisher and ran searching each room, under bed, bathroom closet, and closing doors behind them. 111 room noted with smoke under the door. Staff from latter hall continued to search the last two rooms. Black smoke filling the hall, all residents cleared. Two residents removed from d/t both residents eat their meals in room. All cleared. Smoke thick all staff left hall except maintenance staff. EMS/fire department arrived, assessed the situation with orders to evacuate the front station. Staff immediately evacuated all residents-parking lot clear for all residents by three staff. Then fire marshal ordered to evacuate ABRI unit. All residents evacuated from ABRI unit. Staff from everywhere onsite to help, (names of nearby facilities listed here). EMS,(NAME)and White nurses, families. Headcount again people from out of nowhere in the nursing field came to help. Fire marshal, gave all clear for two, three and ABRI unit. Everyone helped the staff with bringing the residents back in the facility. All residents hydrated and given snack until trays were ready. All 100 hall staff and residents remained in the dining room, monitor closely. Other sister facilities continue to clean water from 100 hall, 15 staff or more. Facility began calling families to notify their loved ones were alright. Staff started with 10 hour firewatch. Review of a document dated 11/3/2017 and published by the local fire department reflected the following: Fire investigation determined the fire was unintentional and caused by an electrical short. The short started when a metal bed frame came in contact with a damaged cover plate of an electrical wall outlet, igniting bedding material and the mattress. During an interview on 11/3/2017 at 1:15 p.m., local fire department investigator stated that the fire appeared to be unintentional (not arson) and to have originated because a metal bed frame was pushed against the wall and damaged an outlet cover. The contact between the metal bed frame and the unprotected outlet probably caused an arcing condition, which ignited the bedding. He stated that there are black marks on the metal bed frame, and the outlet was burned inside and out. He stated that the fire fighters that responded to the fire did not tell the facility to occupy the section of the building, nor did they tell them not to occupy the affected portion. Instead, they left it to the facility's discretion, but recommended they get a restoration company in there as soon as possible because of the smoke and water damage. He stated the fire department did indicate that the rest of the building could be occupied with no issues. He stated the fire department also told the facility they must do a fire watch until they get their sprinkler system repaired, since it activated in response to the fire. Observation on 11/3/2017 at 2:45 p.m. revealed a closed door to room 111. A name plate outside the door had the names for Residents #1 and #2. Behind the closed door, the room was empty of people or belongings except for a bed frame. A hole approximately 5 feet by 4 feet could be seen on the corridor wall closest to the facility entrance with borders marked by black substance and apparent burn damage. The room smelled strongly of smoke. Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) conducted for Resident #1 on 10/5/2017 reflected a Brief Interview for Mental Status (BIMS) score of 12, indicating very little cognitive disability. Review of nurse's notes for Resident #1 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #2 on 8/4/2017 reflected a BIMS score of 4, indicating severe cognitive disability. Review of nurse's notes for Resident #2 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Observation on 11/3/2017 at 2:50 p.m. revealed that Resident #1 was wearing shorts and slippers with his legs exposed and a short sleeved shirt which exposed his arms. He was clean, dressed inn clean clothing, groomed, and free of odors. No injuries were observed on any exposed part of his skin. During an interview on 11/3/2017 at 2:50 p.m., Resident #1 stated that he got moved out of his room. He could not recall any incidents or accidents. When asked directly about a fire, he stated that there was a fire. He would not or could not answer whether he was in the room at the time of the fire. He stated he was not injured in any way during the fire. He stated he was evacuated into the back parking lot. He stated he was fine with the move to another room. Observation of Resident #2 on 11/3/2017 at 2:55 p.m. revealed that he was wearing sweatpants and a short-sleeved shirt. He was clean, dressed in clean clothing, groomed, and free of odors. No injuries of any kind were seen on his exposed skin. During an interview on 11/3/2017 at 2:55 p.m. Resident #2 stated when asked if he recalled any incidents or accidents recently, he did not answer with any clarity. Observation on 11/3/2017 at 3:05 p.m. revealed an electrical outlet in room 104 behind the headboard of bed B with no outlet cover and two cords plugged into it. No resident was observed in the room at this time. Observation on 11/3/2017 at 3:07 p.m. revealed an electrical outlet in resident room 109 behind the bedside table for bed A with a cracked plate cover. No resident was observed in the room at this time. During an interview on 11/3/2017 at 3:18 p.m., MD stated the fire started about 4:45 p.m. the day before. He stated the fire alarm went off, he checked the panel to see where the alarm was, and he went to hall 100 where he could see light smoke floating in the air. He yelled code red, and this is a fire, not a drill. He stated the door was closed to room 111, but he could see smoke coming from the bottom of the door. He stated the two residents who live in the room were in the dining area where dinner was expected. He stated there was one resident on that hall and two on the 200 hall. He stated the staff moved those residents out of the halls and toward the dining room. He stated that, in the meantime, the fire doors closed. He stated he called 911, and also the monitoring company they have for the fire alarms were notified and called the facility. He stated the entire building was evacuated. He stated that residents went out around the sidewalk from the dining room and out to the back parking lot. He stated that memory care, which consists of halls 400 and 500 in a locked unit, went out of the exit doors on the 400 hall. He stated the fire department told them to evacuate the entire building. He stated that he was up at the front of the building with the fire department. The fire department stated that the cause of the fire could have been two to three things: bad wiring, an overload of the circuit, or a manual crank bed on the A side touching the electrical outlet. He stated that, after the fire, the outlet plate was on the ground below the outlet and was broken. When asked about the fire department investigator's determination that the fire was caused by an electrical arc, he stated that this determination came later. He stated that the sprinklers came on. He stated he picked up the outlet but does not have it anymore. He stated that an outlet with a broken or missing plate cover could create a hazardous condition by having electrified metal exposed to any surface. He stated that a resident could touch it, or it could touch metal or cloth. He stated this is a fire hazard. He stated that he came to work on the morning of 11/3/2017 with a list of outlets that had missing or broken plates and required replacement. He stated he replaced all of those. When asked about the rooms on hall 100 that currently had missing plate covers, he stated they only had room 110 on the list of repairs. When asked how he could ensure that all the outlets had fully intact plate covers, he stated that the facility staff checked them all, and only room 110 needed a repaired plate cover. When asked how the system of checking all the outlets was effective if there are still missing plate covers in the facility, he stated that he did the work that was on the list. He stated that he does not think there are any more missing or broken outlet plates in the facility. During an interview on 11/3/2017 at 3:27 p.m., the ADM stated that the fire happened right at 5:00 p.m. He stated he had already left for the day, got the phone call about the fire, and u-turned to go back. He stated the fire was already out when he arrived. He stated they got all the residents out, and no one was hurt. He stated the residents living in room 111 were in the dining room at the time, and they are all thankful, because Resident #1 could have been very badly hurt or worse. He stated the fire department told him a bed had broken the outlet plate cover, and the fire had started when the metal from inside the outlet touched the metal of the bed frame. He stated that immediately all outlet plates were checked. He stated the DON assigned people to check the outlets in every room, and he believes it was nursing staff. He stated he doesn't know exactly who the DON assigned to which halls. When asked how the quality of these checks was assured, he stated they do quality of life rounds, and one of the things they do is making sure to check plugs. He stated he did not have any documentation of that specific check prior to the fire. He stated that educating staff on how to identify outlets in disrepair will be one of the in-services he does as a result of the fire. He stated the condition of a broken or missing outlet plate is definitely a hazard. He stated that if anyone stuck a finger in it, or anything metal touched it, it could cause electric shock or fire. He stated that wet floors nearby to the uncovered outlet could also be a hazard. He stated that the facility is currently doing fire watches. Review of face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #5 on 11/3/2017 reflected a BIMS score of 15, indicating no cognitive disability. Review of face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #6 on 8/9/2017 reflected a BIMS score of 3, indicating severe cognitive disability. Observation in resident room 114 on 11/3/2017 at 3:39 p.m. revealed that Resident #5 was sitting up in bed. His leg was amputated above the knee. He was clean, dressed in clean clothing, groomed, and free of odors. Observation at this time revealed that Resident #6 was sitting in his bed with his back against the wall. He was clean, dressed in clean clothing, groomed, and free of odors. He smiled and nodded in response to questions, but could not or would not participate in an interview. Further observation on 11/3/2017 at 3:39 p.m. revealed an electrical outlet in resident room 114 behind the headboard of bed B with no outlet cover and one cord plugged into it. During an interview on 11/3/2017 at 3:39 p.m., Resident #5 stated he did not know that there was no outlet plate cover on the outlet behind his bed. He granted permission for the area to be photographed and then asked to see the photographs. He stated he does not have the physical ability to see behind his bed. When viewing the photograph, he stated that the missing outlet plate was scary and asked who would be repairing it. When he was told that this is usually the job of the maintenance director or staff. He could not recall where he heard this. He stated that he feels as if his life is not important to the facility staff if they just let a hazard like this go unrepaired. He stated that he is a veteran, and that makes him feel terrible. Observation of resident room 209 on 11/3/2017 at 3:45 p.m. revealed no plate cover on the outlet into which the under-window air conditioner (AC) was plugged. Review of face sheet for Resident #8 reflected [AGE] year-old female and minutes of the facility on 12/13/2016 with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #8 on 10/23/2017 reflected a BIMS score of 12, indicating very little cognitive disability. During an interview in resident room 211 on 11/3/2017 at 3:48 p.m., Resident #8 stated she was evacuated the other day for a fire. She stated she was not hurt and feels fine. She stated she does not want to be in a fire. She stated she does not like that fact that there is no plate cover on the outlet under the air conditioner. She stated that did not seem safe. She stated she has always felt safe in the facility before. Observation of resident room 211 on 11/3/2017 at 3:48 p.m. revealed no plate cover on the outlet into which the AC was plugged. Observation of resident room 214 on 11/3/2017 at 3:51 p.m. revealed a cracked upper socket on the outlet behind bed A. Observation of resident room 304 on 11/3/2017 at 3:53 p.m. revealed no plate cover on the outlet into which the AC was plugged. A strip of black-spotted wallpaper had come loose from the wall and curled around into the outlet receptacle. A maroon curtain hung against the other side of the AC plug, touching and obscuring the open outlet receptacle. Observation of resident room 401 (in locked memory care unit) on 11/3/2017 at 4:06 p.m. revealed that the plate cover behind bed A was not flush with the wall or the sockets, and 1/4 to 1/2 inch gaps existed between the plate cover openings and the outlet receptacle. Observation of resident room 503 (in locked memory care unit) on 11/3/2017 at 3:56 p.m. revealed an outlet against bed B was placed had a broken plate cover, a broken upper socket, and a metal tongue protruding from the base of the upper socket. Observation of resident room 504 (in locked memory care unit) on 11/3/2017 at 3:58 p.m. revealed a cracked plate cover on the outlet into which the AC was plugged. During an interview on 11/3/2017 at 6:15 p.m., the RVP stated that she was the person in charge on the night of the fire. She stated that when she got to the facility, the fire was already out, and the fire marshal brought her into the office and talked to her. She clarified that she was not sure if it was the fire marshal or who it was from the fire department, but she got his card. She stated he had told her he looked for smoking paraphernalia and didn't see any. She stated he told her he didn't see where the outlet had been overloaded, but showed her where some wires had been frayed. She stated he showed her where the bed frame touched the outlet. He picked up the plate and showed it to her. It looked as if it had melted, but the sides were intact. She stated that the corporate vice president of nursing sent a message that they should check all the rooms. She stated that CNAs were sent out to check rooms. She brought everyone together to do two forms of checks: outlets in bedrooms and respiratory checks for residents. She stated the CNAs were told the beds need to be going the right way perpendicular to their lights. She stated she told them to look for broken outlet covers, missing outlet covers. She stated they did not check the 100 hallway until the fire department was done there. When asked if she felt CNAs were qualified or educated to perform these maintenance checks, she stated that at the time everyone was brought together as a team to do all the jobs such as cleaning up, removing water, and checking the other resident rooms. She stated that, in an ideal situation, the buildings would have their maintenance directors perform this task or call in maintenance directors from other buildings. She stated they did talk about what to look for when inspecting a room for outlets in bad repair. She stated she felt, at the time, that what they did was adequate to address the problem that created the fire. Review of facility work orders from (MONTH) (YEAR) to present reflected that they did not include orders for resident rooms 104, 109, 114, 209, 211, 214, 401, 503, or 504. Review of a document provided by the facility, dated 11/2/2017, and titled Performance Improvement Plan reflected the following: Observation/System/Problem- Broken and Missing outlet covers; Goal/Objective- The Staff will notify Maintenance immediately when any missing or broken outlet plates identified; Actions- The Department Heads will monitor daily during their assigned Quality of Life rounds to monitor for any missing or broken outlet plates and report back to Maintenance immediately for repairs; Responsible Party- Department Heads and/or Designee; Target Date- 11/2/17@1930; Comments- Focus Area on Rounds: Broken or Missing outlet plates will be discussed in QAPI Meeting for resolution. Attached to this document was a resident census list with notations by rooms where outlets were damaged or missing. Review of the list reflected that rooms 211 and 504 had been notated. According to the ADM, the page that listed hall 100 could not be found at the time the document was requested. Review of the United States Department of Labor Occupational Health and Safety regulations dated 2/13/1996 and titled Safety and Health Regulations for Construction reflected the following: All pull boxes, junction boxes, and fittings shall be provided with covers. The ADM and RVP were notified on 7:50 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the ADM and RVP on 11/03/17 at 9:57 p.m. The Plan of Removal was accepted by the Survey Team on 11/03/17 at 10:00 p.m. The facility's Plan of Removal was as follows: a. Maintenance men will round facility and check the condition of all outlets in each resident room. Completed - 11/3/2017. b. Maintenance men will replace and repair all outlet covers found to be missing or broken/cracked. Completed - 11/3/2017. c. Administrator and/or designee will begin to in-service direct care staff and housekeeping on how to detect when an outlet cover is in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. d. Administrator and/or designee will begin to in-service Dept heads when doing Quality of Life rounds to check all outlet covers to insure that they are in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. e. Maintenance Man will observe the condition of all outlets in resident rooms during his weekly preventative maintenance rounds and repair and/or replace any defective outlets and outlet covers. Target date 11/6/2017. f. Education will begin on 11/3/17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The survey team monitored the current plan of removal as follows: Observation and interviews on 11/3/2017 between 7:50 p.m. and 9:59 p.m. revealed three CNAs and one LVN verified their knowledge of the material contained in facility in-services presented that night. Observation revealed that outlet plate covers for all aforementioned rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) were replaced with intact plate covers or otherwise repaired. Review of nurse's notes for Residents #1-15 reflected checks on 11/3/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 14 staff members had signed an in-service dated 11/3/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 16 staff members had signed an in-service dated 11/3/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/4/2017 between 12:00 p.m. and 2:30 p.m. revealed 5 employees who all stated they had been in-serviced on the Immediate Jeopardy items prior on starting their shift. Observation of 15 rooms revealed that beds were positioned as should be, away from plugs and no outlet covers were cracked or missing. All department heads were present and busy correcting identified issues. The Administrator stated he has a total of 93 employees who need in-servicing and he hoped to have them all complete by tomorrow. Review of in-service documents reflected that 48 of 93 staff members had signed an in-service dated 11/4/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 52 of 93 staff members had signed an in-service dated 11/4/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/5/2017 at 2:20 p.m. and 4:30 p.m. revealed interviews were conducted with seven staff members not interviewed on 11/4/2017, and they each stated they had been in-serviced at the beginning of each shift (which was twice for 6 of the 7) and imparted a detailed understanding of the in-service material as well as the need for the in-service tasks. During an interview with the DON, she stated that several staff persons are PRN staff and live too far away to drive in for an in-service, so they will be trained at the beginning of their next shifts. Observation of 18 rooms revealed no broken or missing outlet plate covers and no further hazards. Review of nurse's notes for Residents #1-15 reflected continued checks on 11/4/2017 and 11/5/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 70 of 93 staff members had signed an in-service dated 11/5/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 67 of 93 staff members had signed an in-service dated 11/5/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. The Administrator was informed at 4:40 p.m. on 11/5/2017 that the Immediate Jeopardy was lowered. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm and a scope identified as widespread. Review of the facility census dated and provided by the Director of Nursing on 11/3/2017 reflected that 119 residents lived in the facility.

Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit the neglect of residents in five of five resident halls. The facility failed to repair broken or missing outlet covers in 10 resident rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) among all five halls, even after a fire occurred in resident room [ROOM NUMBER] as a result of a broken outlet cover. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 11/3/2017. While the IJ was lowered on 11/5/2017, the facility remained out of compliance at a level of no actual harm but potential for more than minimal harm with a scope identified as widespread. This failure resulted in a fire in resident room [ROOM NUMBER] and could place 119 residents at risk of serious harm or death by electrical shock, smoke inhalation, or fire. Findings included: Review of undated facility policy titled Resident Behavior and Facility Practices Policy reflected the following: Each resident has the right to be free from mental and physical abuse, corporal punishment, involuntary seclusion, unreasonable confinement, intimidation, neglect, psychological harm related to an authorized photos or willful infliction of injury or punishment with resulting physical or emotional harm, mental anguish a pain to a resident; . No resident will be deprived of any individual of goods or services necessary to attain or maintain physical, mental and psychosocial well-being, including abuse facilitated or enabled by the use of technology . The facility has developed operational policies and procedures for screening and training employees for the protection of residence and for the prevention, identification, investigation, and reporting of abuse. Review of a facility incident report provided by the DON on 11/3/2017 reflected the words (Facility name) Fire in the space provided for a name, a time of 4:57 p.m., and no date. The section marked Brief Description reflected Fire- fire alarmed on panel, staff looked at panel showed 100 hall, staff immediately grabbed fire extinguisher and ran searching each room, under bed, bathroom closet, and closing doors behind them. 111 room noted with smoke under the door. Staff from latter hall continued to search the last two rooms. Black smoke filling the hall, all residents cleared. Two residents removed from d/t both residents eat their meals in room. All cleared. Smoke thick all staff left hall except maintenance staff. EMS/fire department arrived, assessed the situation with orders to evacuate the front station. Staff immediately evacuated all residents-parking lot clear for all residents by three staff. Then fire marshal ordered to evacuate ABRI unit. All residents evacuated from ABRI unit. Staff from everywhere onsite to help, (names of nearby facilities listed here). EMS,(NAME)and White nurses, families. Headcount again people from out of nowhere in the nursing field came to help. Fire marshal, gave all clear for two, three and ABRI unit. Everyone helped the staff with bringing the residents back in the facility. All residents hydrated and given snack until trays were ready. All 100 hall staff and residents remained in the dining room, monitor closely. Other sister facilities continue to clean water from 100 hall, 15 staff or more. Facility began calling families to notify their loved ones were alright. Staff started with 10 hour firewatch. Review of a document dated 11/3/2017 and published by the local fire department reflected the following: Fire investigation determined the fire was unintentional and caused by an electrical short. The short started when a metal bed frame came in contact with a damaged cover plate of an electrical wall outlet, igniting bedding material and the mattress. During an interview on 11/3/2017 at 1:15 p.m., local fire department investigator stated that the fire appeared to be unintentional (not arson) and to have originated because a metal bed frame was pushed against the wall and damaged an outlet cover. The contact between the metal bed frame and the unprotected outlet probably caused an arcing condition, which ignited the bedding. He stated that there are black marks on the metal bed frame, and the outlet was burned inside and out. He stated that the fire fighters that responded to the fire did not tell the facility to occupy the section of the building, nor did they tell them not to occupy the affected portion. Instead, they left it to the facility's discretion, but recommended they get a restoration company in there as soon as possible because of the smoke and water damage. He stated the fire department did indicate that the rest of the building could be occupied with no issues. He stated the fire department also told the facility they must do a fire watch until they get their sprinkler system repaired, since it activated in response to the fire. Observation on 11/3/2017 at 2:45 p.m. revealed a closed door to room [ROOM NUMBER]. A name plate outside the door had the names for Residents #1 and #2. Behind the closed door, the room was empty of people or belongings except for a bed frame. A hole approximately 5 feet by 4 feet could be seen on the corridor wall closest to the facility entrance with borders marked by black substance and apparent burn damage. The room smelled strongly of smoke. Review of face sheet for Resident #1 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual Minimum Data Set (MDS) conducted for Resident #1 on 10/5/2017 reflected a Brief Interview for Mental Status (BIMS) score of 12, indicating very little cognitive disability. Review of nurse's notes for Resident #1 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Review of face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #2 on 8/4/2017 reflected a BIMS score of 4, indicating severe cognitive disability. Review of nurse's notes for Resident #2 reflected the following entry: 11/3/2017 zero signs or symptoms of respiratory distress noted. Observation on 11/3/2017 at 2:50 p.m. revealed that Resident #1 was wearing shorts and slippers with his legs exposed and a short sleeved shirt which exposed his arms. He was clean, dressed inn clean clothing, groomed, and free of odors. No injuries were observed on any exposed part of his skin. During an interview on 11/3/2017 at 2:50 p.m., Resident #1 stated that he got moved out of his room. He could not recall any incidents or accidents. When asked directly about a fire, he stated that there was a fire. He would not or could not answer whether he was in the room at the time of the fire. He stated he was not injured in any way during the fire. He stated he was evacuated into the back parking lot. He stated he was fine with the move to another room. Observation of Resident #2 on 11/3/2017 at 2:55 p.m. revealed that he was wearing sweatpants and a short-sleeved shirt. He was clean, dressed in clean clothing, groomed, and free of odors. No injuries of any kind were seen on his exposed skin. During an interview on 11/3/2017 at 2:55 p.m. Resident #2 stated when asked if he recalled any incidents or accidents recently, he did not answer with any clarity. Observation on 11/3/2017 at 3:05 p.m. revealed an electrical outlet in room [ROOM NUMBER] behind the headboard of bed B with no outlet cover and two cords plugged into it. No resident was observed in the room at this time. Observation on 11/3/2017 at 3:07 p.m. revealed an electrical outlet in resident room [ROOM NUMBER] behind the bedside table for bed A with a cracked plate cover. No resident was observed in the room at this time. During an interview on 11/3/2017 at 3:18 p.m., MD stated the fire started about 4:45 p.m. the day before. He stated the fire alarm went off, he checked the panel to see where the alarm was, and he went to hall 100 where he could see light smoke floating in the air. He yelled code red, and this is a fire, not a drill. He stated the door was closed to room [ROOM NUMBER], but he could see smoke coming from the bottom of the door. He stated the two residents who live in the room were in the dining area where dinner was expected. He stated there was one resident on that hall and two on the 200 hall. He stated the staff moved those residents out of the halls and toward the dining room. He stated that, in the meantime, the fire doors closed. He stated he called 911, and also the monitoring company they have for the fire alarms were notified and called the facility. He stated the entire building was evacuated. He stated that residents went out around the sidewalk from the dining room and out to the back parking lot. He stated that memory care, which consists of halls 400 and 500 in a locked unit, went out of the exit doors on the 400 hall. He stated the fire department told them to evacuate the entire building. He stated that he was up at the front of the building with the fire department. The fire department stated that the cause of the fire could have been two to three things: bad wiring, an overload of the circuit, or a manual crank bed on the A side touching the electrical outlet. He stated that, after the fire, the outlet plate was on the ground below the outlet and was broken. When asked about the fire department investigator's determination that the fire was caused by an electrical arc, he stated that this determination came later. He stated that the sprinklers came on. He stated he picked up the outlet but does not have it anymore. He stated that an outlet with a broken or missing plate cover could create a hazardous condition by having electrified metal exposed to any surface. He stated that a resident could touch it, or it could touch metal or cloth. He stated this is a fire hazard. He stated that he came to work on the morning of 11/3/2017 with a list of outlets that had missing or broken plates and required replacement. He stated he replaced all of those. When asked about the rooms on hall 100 that currently had missing plate covers, he stated they only had room [ROOM NUMBER] on the list of repairs. When asked how he could ensure that all the outlets had fully intact plate covers, he stated that the facility staff checked them all, and only room [ROOM NUMBER] needed a repaired plate cover. When asked how the system of checking all the outlets was effective if there are still missing plate covers in the facility, he stated that he did the work that was on the list. He stated that he does not think there are any more missing or broken outlet plates in the facility. During an interview on 11/3/2017 at 3:27 p.m., the ADM stated that the fire happened right at 5:00 p.m. He stated he had already left for the day, got the phone call about the fire, and u-turned to go back. He stated the fire was already out when he arrived. He stated they got all the residents out, and no one was hurt. He stated the residents living in room [ROOM NUMBER] were in the dining room at the time, and they are all thankful, because Resident #1 could have been very badly hurt or worse. He stated the fire department told him a bed had broken the outlet plate cover, and the fire had started when the metal from inside the outlet touched the metal of the bed frame. He stated that immediately all outlet plates were checked. He stated the DON assigned people to check the outlets in every room, and he believes it was nursing staff. He stated he doesn't know exactly who the DON assigned to which halls. When asked how the quality of these checks was assured, he stated they do quality of life rounds, and one of the things they do is making sure to check plugs. He stated he did not have any documentation of that specific check prior to the fire. He stated that educating staff on how to identify outlets in disrepair will be one of the in-services he does as a result of the fire. He stated the condition of a broken or missing outlet plate is definitely a hazard. He stated that if anyone stuck a finger in it, or anything metal touched it, it could cause electric shock or fire. He stated that wet floors nearby to the uncovered outlet could also be a hazard. He stated that the facility is currently doing fire watches. Review of face sheet for Resident #5 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #5 on 11/3/2017 reflected a BIMS score of 15, indicating no cognitive disability. Review of face sheet for Resident #6 reflected a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #6 on 8/9/2017 reflected a BIMS score of 3, indicating severe cognitive disability. Observation in resident room [ROOM NUMBER] on 11/3/2017 at 3:39 p.m. revealed that Resident #5 was sitting up in bed. His leg was amputated above the knee. He was clean, dressed in clean clothing, groomed, and free of odors. Observation at this time revealed that Resident #6 was sitting in his bed with his back against the wall. He was clean, dressed in clean clothing, groomed, and free of odors. He smiled and nodded in response to questions, but could not or would not participate in an interview. Further observation on 11/3/2017 at 3:39 p.m. revealed an electrical outlet in resident room [ROOM NUMBER] behind the headboard of bed B with no outlet cover and one cord plugged into it. During an interview on 11/3/2017 at 3:39 p.m., Resident #5 stated he did not know that there was no outlet plate cover on the outlet behind his bed. He granted permission for the area to be photographed and then asked to see the photographs. He stated he does not have the physical ability to see behind his bed. When viewing the photograph, he stated that the missing outlet plate was scary and asked who would be repairing it. When he was told that this is usually the job of the maintenance director or staff. He could not recall where he heard this. He stated that he feels as if his life is not important to the facility staff if they just let a hazard like this go unrepaired. He stated that he is a veteran, and that makes him feel terrible. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:45 p.m. revealed no plate cover on the outlet into which the under-window air conditioner (AC) was plugged. Review of face sheet for Resident #8 reflected [AGE] year-old female and minutes of the facility on 12/13/2016 with [DIAGNOSES REDACTED]. Review of annual MDS conducted for Resident #8 on 10/23/2017 reflected a BIMS score of 12, indicating very little cognitive disability. During an interview in resident room [ROOM NUMBER] on 11/3/2017 at 3:48 p.m., Resident #8 stated she was evacuated the other day for a fire. She stated she was not hurt and feels fine. She stated she does not want to be in a fire. She stated she does not like that fact that there is no plate cover on the outlet under the air conditioner. She stated that did not seem safe. She stated she has always felt safe in the facility before. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:48 p.m. revealed no plate cover on the outlet into which the AC was plugged. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:51 p.m. revealed a cracked upper socket on the outlet behind bed A. Observation of resident room [ROOM NUMBER] on 11/3/2017 at 3:53 p.m. revealed no plate cover on the outlet into which the AC was plugged. A strip of black-spotted wallpaper had come loose from the wall and curled around into the outlet receptacle. A maroon curtain hung against the other side of the AC plug, touching and obscuring the open outlet receptacle. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 4:06 p.m. revealed that the plate cover behind bed A was not flush with the wall or the sockets, and 1/4 to 1/2 inch gaps existed between the plate cover openings and the outlet receptacle. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 3:56 p.m. revealed an outlet against bed B was placed had a broken plate cover, a broken upper socket, and a metal tongue protruding from the base of the upper socket. Observation of resident room [ROOM NUMBER] (in locked memory care unit) on 11/3/2017 at 3:58 p.m. revealed a cracked plate cover on the outlet into which the AC was plugged. During an interview on 11/3/2017 at 6:15 p.m., the RVP stated that she was the person in charge on the night of the fire. She stated that when she got to the facility, the fire was already out, and the fire marshal brought her into the office and talked to her. She clarified that she was not sure if it was the fire marshal or who it was from the fire department, but she got his card. She stated he had told her he looked for smoking paraphernalia and didn't see any. She stated he told her he didn't see where the outlet had been overloaded, but showed her where some wires had been frayed. She stated he showed her where the bed frame touched the outlet. He picked up the plate and showed it to her. It looked as if it had melted, but the sides were intact. She stated that the corporate vice president of nursing sent a message that they should check all the rooms. She stated that CNAs were sent out to check rooms. She brought everyone together to do two forms of checks: outlets in bedrooms and respiratory checks for residents. She stated the CNAs were told the beds need to be going the right way perpendicular to their lights. She stated she told them to look for broken outlet covers, missing outlet covers. She stated they did not check the 100 hallway until the fire department was done there. When asked if she felt CNAs were qualified or educated to perform these maintenance checks, she stated that at the time everyone was brought together as a team to do all the jobs such as cleaning up, removing water, and checking the other resident rooms. She stated that, in an ideal situation, the buildings would have their maintenance directors perform this task or call in maintenance directors from other buildings. She stated they did talk about what to look for when inspecting a room for outlets in bad repair. She stated she felt, at the time, that what they did was adequate to address the problem that created the fire. Review of facility work orders from (MONTH) (YEAR) to present reflected that they did not include orders for resident rooms 104, 109, 114, 209, 211, 214, 401, 503, or 504. Review of a document provided by the facility, dated 11/2/2017, and titled Performance Improvement Plan reflected the following: Observation/System/Problem- Broken and Missing outlet covers; Goal/Objective- The Staff will notify Maintenance immediately when any missing or broken outlet plates identified; Actions- The Department Heads will monitor daily during their assigned Quality of Life rounds to monitor for any missing or broken outlet plates and report back to Maintenance immediately for repairs; Responsible Party- Department Heads and/or Designee; Target Date- 11/2/17@1930; Comments- Focus Area on Rounds: Broken or Missing outlet plates will be discussed in QAPI Meeting for resolution. Attached to this document was a resident census list with notations by rooms where outlets were damaged or missing. Review of the list reflected that rooms [ROOM NUMBERS] had been notated. According to the ADM, the page that listed hall 100 could not be found at the time the document was requested. Review of the United States Department of Labor Occupational Health and Safety regulations dated 2/13/1996 and titled Safety and Health Regulations for Construction reflected the following: All pull boxes, junction boxes, and fittings shall be provided with covers. The ADM and RVP were notified on 7:50 p.m. an Immediate Jeopardy situation had been identified due to above failures. The following Plan of Removal was submitted by the ADM and RVP on 11/03/17 at 9:57 p.m. The Plan of Removal was accepted by the Survey Team on 11/03/17 at 10:00 p.m. The facility's Plan of Removal was as follows: a. Maintenance men will round facility and check the condition of all outlets in each resident room. Completed - 11/3/2017. b. Maintenance men will replace and repair all outlet covers found to be missing or broken/cracked. Completed - 11/3/2017. c. Administrator and/or designee will begin to in-service direct care staff and housekeeping on how to detect when an outlet cover is in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. d. Administrator and/or designee will begin to in-service Dept heads when doing Quality of Life rounds to check all outlet covers to insure that they are in good working order and to insure that bed is in a perpendicular manner. If outlet cover is found to be defective they are to notify Maintenance Supervisor immediately to replace defective outlet cover. Target date for completion - 11/6/2017. e. Maintenance Man will observe the condition of all outlets in resident rooms during his weekly preventative maintenance rounds and repair and/or replace any defective outlets and outlet covers. Target date 11/6/2017. f. Education will begin on 11/3/17 and continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. The survey team monitored the current plan of removal as follows: Observation and interviews on 11/3/2017 between 7:50 p.m. and 9:59 p.m. revealed three CNAs and one LVN verified their knowledge of the material contained in facility in-services presented that night. Observation revealed that outlet plate covers for all aforementioned rooms (104, 109, 114, 209, 211, 214, 304, 401, 503, and 504) were replaced with intact plate covers or otherwise repaired. Review of nurse's notes for Residents #1-15 reflected checks on 11/3/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 14 staff members had signed an in-service dated 11/3/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 16 staff members had signed an in-service dated 11/3/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/4/2017 between 12:00 p.m. and 2:30 p.m. revealed 5 employees who all stated they had been in-serviced on the Immediate Jeopardy items prior on starting their shift. Observation of 15 rooms revealed that beds were positioned as should be, away from plugs and no outlet covers were cracked or missing. All department heads were present and busy correcting identified issues. The Administrator stated he has a total of 93 employees who need in-servicing and he hoped to have them all complete by tomorrow. Review of in-service documents reflected that 48 of 93 staff members had signed an in-service dated 11/4/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 52 of 93 staff members had signed an in-service dated 11/4/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. Observation and interviews on 11/5/2017 at 2:20 p.m. and 4:30 p.m. revealed interviews were conducted with seven staff members not interviewed on 11/4/2017, and they each stated they had been in-serviced at the beginning of each shift (which was twice for 6 of the 7) and imparted a detailed understanding of the in-service material as well as the need for the in-service tasks. During an interview with the DON, she stated that several staff persons are PRN staff and live too far away to drive in for an in-service, so they will be trained at the beginning of their next shifts. Observation of 18 rooms revealed no broken or missing outlet plate covers and no further hazards. Review of nurse's notes for Residents #1-15 reflected continued checks on 11/4/2017 and 11/5/2017 for signs or symptoms of respiratory distress for all 15. Review of in-service documents reflected that 70 of 93 staff members had signed an in-service dated 11/5/2017 on the following: To ensure that beds are in locked position and never pushed up against the wall, against a wall plug, or against any electrical outlet. Review of in-service documents further reflected that 67 of 93 staff members had signed an in-service dated 11/5/2017 on the following: How to detect when an outlet cover is in good working order. If outlet cover is found to be defective they are to notify maintenance supervisor immediately. The Administrator was informed at 4:40 p.m. on 11/5/2017 that the Immediate Jeopardy was lowered. However, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm and a scope identified as widespread. Review of the facility census dated and provided by the Director of Nursing on 11/3/2017 reflected that 119 residents lived in the facility.

Based on observation, interview and record review the facility's Administrator and Director of Nurses failed to ensure that facility staff were trained and implemented the facility's current policies and procedures for infection control for 2 of 2 residents with [MEDICAL CONDITION](Resident #s 5 and 13) and 3 of 4 diabetic residents (Resident #s21, 29 and 30) requiring blood glucose fingerstick testing when: A.) Confused and occasionally incontinent Residents #5 and #13 were on contact isolation for [MEDICAL CONDITIONS] (a highly transmittable infection of the gastro-intestinal (GI) tract transmitted through contact with contaminated surfaces that causes severe diarrhea) were allowed to attend group activities and meals in the dinning area with other confused residents, use a shared restroom and staff wheeled biohazard linen and waste through the resident occupied hallways at the end of each shift. B.) 1 of 2 licensed staff (LVN L) failed to disinfect the glucometer machine in between finger sticks for blood specimens during observation of 3 of 4 resident finger sticks (Residents #21, #29 and #30). This deficient practice could affect residents residing on 300 Hall, residents eating in the secure unit dining area or attending activities as a result of cross-contamination and the potential spread of [MEDICAL CONDITION] or other infectious bacteria involving 75 residents.(29 requiring BGFS and 46 on Secure Unit) Findings included: Review of the facility ' s undated policy and procedure titled " Contact Precautions " reflected the following: To prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident ' s environment and does not warrant standard precautions. Procedure: 1. Two large trash containers are placed in the room and lined with red plastic polyethylene bags; one is labeled trash and the other is labeled laundry. 2. Used linen must be double bagged. 3. All items taken into the room for the use of the resident are to be disposable or left in the room until the resident is discharged out of isolation. 4. Staff entering the room should wear a gown and gloves for all interactions that may involve contact with the resident or potential contact with areas in the resident ' s room. Procedures that may require gown, gloves and mask: a. Bathing b. Incontinent care c. Repositioning d. Transferring 5. All items needed in the room for resident care are taken in by the nursing staff. Clean items removed from the room carefully with an antiseptic/antibacterial agent. 6. The garbage and linen is removed from the room at the end of each shift and placed in another bag immediately outside the door, tied securely, marked and discarded as medical waste/laundry. Observation on the secured unit (specialized, locked unit for residents with confusion, behaviors and exit seeking tendencies) on 9/14/10 at 9:00 AM revealed a three drawer, portable, plastic storage bin outside Resident #5 and Resident #13 ' s room semi-private room. There was a sign posted to contact the nurse before entering the room. The door to the room was open. Resident #13 was not in the room. Resident #5 was lying in the second bed. There were two isolation barrels at the foot of Resident #5 ' s bed. The room had one private bathroom with a commode and a sink. In an interview on 9/14/10 at 9:00 AM Licensed Vocational Nurse (LVN) A stated that Resident #5 and #13 were on isolation for [MEDICAL CONDITION]. She stated that Resident #5 had completed antibiotics but was still having diarrhea. She stated that she was not sure about Resident #13 but that he was recently admitted to the facility with [MEDICAL CONDITION] and the two residents were placed in the same room because of the same infection. Observation on 9/14/10 at 11:30 AM revealed Resident #5 and Resident #13 sitting in wheelchairs in the secured unit dining room. Two unidentified Residents were also sitting at the table next to Resident #5 and #13. In an interview on 9/14/10 at 12:20 PM LVN H stated that Resident #5 and Resident #13 had [MEDICAL CONDITION] and were on Contact Isolation. She stated that Resident #5 was incontinent at night and sometimes during the day and was also confused at times. LVN H stated that Resident #5 had been on antibiotics for [MEDICAL CONDITION] and they were waiting to retest him. She stated that Resident #13 was also positive for [MEDICAL CONDITION]. Observation on 9/15/10 at 8:00 AM revealed Resident #13 and Resident #5 eating breakfast in the common dining room on the secure unit. Two unidentified Residents were sitting at the same table. Resident #13 and #5 had paper and plastic wear from the kitchen. Observation on 9/15/10 at 8:27 AM revealed Resident #5 was in the restroom in his semi-private room. Two biohazard barrels were at the foot of Resident #5 ' s bed. The toilet flushed and Resident #5 immediately exited the restroom. No running water was heard from the restroom sink. LVN F entered the room without a gown or mask. She stated that they were not necessary when just entering the room. LVN F stated that Resident #13 was waiting for his turn to use the restroom. After Resident #5 exited the restroom LVN F wheeled Resident #13 over to the restroom door and assisted him onto the commode. (The restroom had not been disinfected between use by Resident #5 and Resident #13). In an interview on 9/15/10 at 8:30 AM LVN F stated that it was Resident #5 on isolation, not Resident #13. In an interview on 9/16/10 at 10:15 AM LVN F stated that with contact isolation for [MEDICAL CONDITION], gloves and gown should be worn if there is likely to be contact with the feces. She stated that Resident #5 had completed his antibiotics for [MEDICAL CONDITION] but was still on isolation until he had a negative stool culture. She stated that Resident #13 should not have used the restroom after Resident #5. She stated that she had never emptied the biohazard barrels in their room but she thought that they were to be put into another bag before being taken out of the room. In an interview on 9/16/10 at 3:00 PM Certified Nurses Aide (CNA) D stated that when entering the room of a resident on contact isolation staff only needed to use gloves, gown and mask when contact will be made with the resident, such as taking the resident to the restroom. In the room were two barrels; one for dirty linen and one for trash. She stated that the dirty linen and trash barrels were taken out at the end of each shift. She stated that she wheeled the barrels out the dining room door on the secure unit (where she pointed with her finger) (through the dining room tables where residents are served at mealtime) and around to the biohazard area where she removed the trash bag. She stated that she wheeled the linen and trash barrel through the door, cut across the 300 hall to the laundry building and leaves the barrels for the laundry staff. She stated that both Resident #5 and #13 were confused and incontinent of bowel and bladder. She stated that they were taken to the restroom at times and shared the same restroom. CNA D also stated that both residents came out of their room to participate in group activities. Observation on 9/16/10 at 11:40 AM revealed Resident #13 sitting in the common dining area near the nurses' station at a table with two unidentified Residents. He was using regular dinnerware. Observation on 9/16/10 at 2:50 PM revealed Resident #13 sitting at a table in the main dining room on the secure unit participating in activities. Resident #5 was not in his room. Observation on 9/17/10 at 5:15 AM revealed Resident #13 had been moved to a private room. Observation on 9/17/10 at 12:20 PM revealed Resident #13 sitting in the secure unit dining room near the nurses' station, at a table with two unidentified Residents. He was eating his noon meal with regular dinnerware from the kitchen. A.) Review of the admission orders [REDACTED]. He was to receive [MEDICATION NAME] (antibiotic) 500 mg three times a day for 12 days. The administration of [MEDICATION NAME] was initialed as administered three times a day from 8/12/10 through 8/23/10. Review of the Admission Data Summary dated 8/11/10 reflected Resident #13 had a [DIAGNOSES REDACTED]. He had long term and short term memory problems and his decision making skills and judgment were moderately impaired. Resident #13 was incontinent of bowel and occasionally incontinent of urine. He gets out of bed unassisted and wanders about the hallway. Review of Resident #13's nurses' notes reflected the following: 8/12/10-He was on contact isolation for [MEDICAL CONDITION]. He was assisted by one staff member for toileting and provided incontinent care. 8/13/10-He was on contact isolation for [MEDICAL CONDITION]. He had diarrhea stool two times. 8/14/10-He was on [MEDICAL CONDITION] precautions. He was up ambulatory to the restroom with the assistance of staff. 8/15/10-He was incontinent and used an adult brief but still used the toilet. He ambulated to the commode without assistance. He was on [MEDICAL CONDITION] precautions. 8/17/10-He was up to the restroom without assistance. 8/18/10-He was up in the hallway and to the dining area. He continued on contact isolation. 8/19/10-He was uncooperative at dinner time. He had a formed stool and remained on contact isolation for [MEDICAL CONDITION]. 8/20/10-He was up ambulating in the hallway. He was incontinent of bowel and bladder but gets up without assistance to use the commode. 8/22/10-Resident #13 was up propelling himself in her wheelchair around the secure unit. He remained on contact isolation for [MEDICAL CONDITION]. 8/23/10 through 8/26/10-On follow up for [MEDICAL CONDITION] with contact isolation still in effect. 8/28/10-He had a large, odd smelling, diarrhea stool. 'Foul smelling bowel movement noted. No loose stools after two loose stools noted'. Resident #13 gets up to the bathroom, removes wet incontinent brief and leaves it on the floor. 9/2/10-He gets combative with staff when redirected to ask for assistance. 9/4/10-He was alert but confused. He was up in his wheelchair in the dining room for meals and watching television. 9/5/10-He propels his wheelchair through the hallways on his own. 9/6/10, 9/9/10 and 9/13/10-Resident #13 attends group activities and events. 9/8/10-He was alert but confused. 9/11/10-He was watching television in the dinning area. 9/12/10-He participated in morning church activity. 9/12/10 and 9/14/10-He was incontinent of bowel and bladder. 9/15/10-Resident #13 was toileted with assistance and had a medium bowel movement (character of the stool was not documented). Review of the bowel and bladder shift chart from 8/12/10 through 9/16/10 reflected Resident #13 had one diarrhea stool in that time frame which was on 9/16/10. Diarrhea stool was not logged on the bowel and bladder chart for 8/28/10 as it was noted in the nurses' notes. In an interview on 9/16/10 at 12:10 PM CNA C stated that Resident #13 had a "slimy bowel movement all over himself this morning" and the isolation barrels from the room were taken to the biohazard trash and to the laundry. She stated that the CNAs wheel the barrels down the hall to the laundry building and the biohazard trash off of the 300 hall. In an interview on 12:15 PM CNA B stated that the isolation barrels from Resident #5 and #13's room were taken to the laundry and biohazard area off the 300 hall at the end of the shift. In an interview on 9/16/10 at 10:00 AM CNA G stated that Resident #13 was currently having foul smelling, loose stool. Review of the Life Enrichment assessment dated [DATE] reflected Resident #13 was confused, had multifactorial [MEDICAL CONDITION] and had an altered mental status. Resident #13 was mobile in a wheelchair and wandered. He had [MEDICAL CONDITION] and attended some out-of-room activities. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #13 had short term memory problems. He was not able to recall the current season, location of his room, staff faces or names or that he was in a nursing home. He required extensive assistance of one staff member for transfers, dressing, toilet use and personal hygiene. He was able to wheel himself in his wheelchair; incontinent of bowel and bladder. Dementia was checked as a current disease and [MEDICAL CONDITION] was checked for infections. He participated in activities from 1/3 to 2/3 of the time and he resided on the Alzheimer's special care unit. Review of the MDS dated [DATE] reflected Resident #13 had short term memory problems. He was not able to recall the current season, location of his room, staff faces or names or that he was in a nursing home. He required extensive assistance of two staff for transfers and extensive assistance of one staff for dressing, eating, toileting and personal hygiene. He was able to wheel himself in his wheelchair; incontinent of bowel and bladder. [MEDICAL CONDITION] was checked for infections and he participated in activities from 1/3 to 2/3 of the time. Review of hospital progress notes dated 8/10/10 reflected Resident #13 had three loose bowel movements over night; possible [MEDICAL CONDITION]; empiric [MEDICATION NAME]. Hospital progress notes dated 8/11/10 reflected Resident #13 continued to have diarrhea. Stool cultures were positive for [MEDICAL CONDITION] and he was placed on contact precautions and [MEDICATION NAME]. Review of the facility's physician's progress notes dated 8/12/10 reflected Resident #13's chart was reviewed. He had dementia and [MEDICAL CONDITION] and was receiving [MEDICATION NAME]. Review of the care plan dated 8/18/10 reflected Resident #13 was incontinent of bowel and bladder. He was admitted with [MEDICAL CONDITION]. Care planned approaches in there entirety included the following: a. Medicate as ordered. Monitor and record response. b. Wear gowns when soiling of clothing with infectious material was likely c. Obtain stool cultures as ordered. d. Isolation as ordered. e. Wear gloves for contact with stool. Wash hands well after removing gloves. There were no physician's orders to place Resident #13 on contact isolation or to recheck his stool for [MEDICAL CONDITION] following treatment. There were no stool cultures available for review. In an interview on 9/16/10 at 10:00 AM CNA G stated that she had worked at the facility for seven years. She stated that Resident #13 had [MEDICAL CONDITION] and Resident #5 had [MEDICAL CONDITION] "at one point" and they were on contact isolation. She stated that when a resident is on contact isolation and contact is to be made with the resident a gown, mask and gloves should be worn. CNA G stated that both Resident #13 and #5 were toileted but they also have incontinent episodes. CNA G stated that the biohazard barrels in the room were taken out at the end of each shift. She stated that she wheels the barrels down the hall with the lids on. She stated that the trash barrel was taken to the biohazard waste outside the facility and the biohazard laundry barrel was taken to the laundry and clean barrels were picked up. B.) Review of the face sheet for Resident #5 reflected he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Admission history and physical dated 6/1/10 reflected Resident #5 was admitted to the hospital due to abdominal distention. He had a history of [REDACTED]. Resident #5 was Demented, minimally retarded and had a history of [REDACTED]. Review of the hospital history and physical dated 6/3/10 reflected Resident #5 had increased abdominal distention and was complaining of the same abdominal pain as before (on 6/1/10). Tests revealed that Resident #5 did not have a bowel obstruction. However he did have significant bladder distention secondary to possible bladder outlet obstruction. After decompression of the bladder he had multiple bowel movements. A stool culture was ordered for [MEDICAL CONDITION]. An inpatient hospital progress note dated 6/22/10 reflected Resident #5 was having profuse watery diarrhea. [MEDICAL CONDITION] studies turned out to be positive and he was started on oral [MEDICATION NAME] (antibiotic). Review physician ' s orders dated 8/1/10 reflected Resident #5 was ordered Milk of Magnesia for constipation as needed. On 8/2/10 he was ordered a stool culture for [MEDICAL CONDITION]. On 8/5/10 Resident #5 was ordered [MEDICATION NAME] three times a day for 14 days and yogurt with each meal. On 8/20/10 Resident #5 was ordered [MEDICATION NAME] every six hours for 14 days to treat [MEDICAL CONDITION]. On 8/30/10 Resident was ordered to have a culture for [MEDICAL CONDITION] done on 9/15/10. Review of facility progress notes dated 8/4/10 reflected Resident #5 was reportedly having loose stool. Progress notes dated 8/6/10 reflected Resident #5 was positive for [MEDICAL CONDITION] ...recurrent. Review of nurses' notes for Resident #5 from 7/29/10 through 9/9/10 reflected the following: 7/29/10-Resident #5 was combative. 7/30/10-He had an elevated temperature and was noted to have loose stool. 8/1/10-He refused breakfast and lunch; ate very little at supper and had two diarrhea stools. 8/2/10-Resident #5 was having louse stools. A stool culture for [MEDICAL CONDITION] was ordered. He complained of stomach pain that was relieved following a bowel movement. His stool was loose. 8/3/10-Resident #5 refused dinner. 8/4/10-He had foul smelling diarrhea two times. 8/5/10-Resident #5 ' s lab results returned positive for [MEDICAL CONDITION]. New orders were received. 8/6/10-Resident #5 received his initial dose of [MEDICATION NAME] 500 mg to be given three times a day for 14 days. He was provided incontinent care with soap and water. Contact isolation precautions observed. He had two episodes of yellowish, foul smelling, loose stool. 8/7/10-Resident #5 had a small, odorous, formed stool. He was combative toward staff. 8/8/10-Resident #5 eats very little at breakfast and lunch. He had one medium sized loose stool. He was incontinent of bowel and bladder and was provided incontinent care as needed. 8/9/10-Resident 35 was assisted to the restroom for a large, foul smelling loose stool. 8/10/10-Resident #5 continued to have brown, foul smelling, slimy stool. He was later incontinent of a large pasty stool and incontinent care was provided. 8/11/10-Resident #5 continues to have loose stool. 8/12/10-Resident #5 remains on contact isolation for [MEDICAL CONDITION]. 8/13/10-He had two diarrhea stools. Incontinent care was provided with soap and water. All needs are anticipated by staff. 8/14/10-[MEDICAL CONDITION] precautions continue. He remains on antibiotics and has loose, odorous stool. He propels himself in his wheelchair throughout the dinning area and hallways. He participates quietly in activities with other residents. 8/15/10-Resident #5 is alert but confused. He is up for meals and activities. He is watching television in the dinning room. He propels himself through out the unit in his wheelchair. Resident #5 is incontinent of bowel and bladder. 8/16/10 through 8/19/10-He had no bowel movements noted. He finished his antibiotic for [MEDICAL CONDITION] and remained on contact isolation. 8/20/10-Resident #5 continues to have loose stools. His physician was notified and new orders were received to start [MEDICATION NAME] (antibiotic) every six hours for 14 days. 8/21/10-Contact precautions continue for [MEDICAL CONDITION]. Resident #5 is watching television in the dinning area. 8/23/10-Resident #5 had loose foul smelling stool. He was incontinent of bowel and bladder. 8/24/10-Resident #5 remains on contact isolation and attends activities. 8/25/10-He continues to have loose stool. He remains on contact isolation. 8/26/10-He continues with loose, stringy, stool. He refused his shower and was cursing at the staff. 8/28/10-Resident #5 was angry and verbally inappropriate with staff. He walked down the entire 400 hall trying to go home. Later he was propelling himself in his wheelchair down the hallway. 8/29/10-Resident #5 propels himself in his wheelchair throughout the unit and watches television in the dinning area. 8/30/10-Resident #5 continues to have watery diarrhea. Received a new order to recheck stool for [MEDICAL CONDITION] on 9/15/10. 8/31/10-Contact isolation continues to be in effect. 9/2/10-Resident #5 continues with loose stool. He is incontinent of bowel and bladder. 9/3/10-The last dose of [MEDICATION NAME] was administered for [MEDICAL CONDITION]. 9/5/10-Resident #5 was noted with loose stool. He was up in his wheelchair. Later in the day, he took all of his belongings and put them in the hallway. 9/6/10-He attends group events. 9/8/10-He had increased anger with the staff. Confusion was noted. Review of bowel and bladder documentation from 8/3/10 through 9/16/10 reflected Resident #5 had a total of seven diarrhea stools, the latest documented on 8/14/10 (this documentation was inconsistent with nurses' notes). The bowel and bladder documentation also reflected Resident #5's bowel movements were as infrequent as every 10 days. Review of Medication Administration Records (MAR) dated 8/10 and 9/10 reflected Resident #5 had not been administered medication for constipation. Review of the quarterly MDS dated [DATE] reflected Resident #5 was cognitively impaired. He wandered and was resistant to care. He propelled his wheelchair without assistance. He was incontinent of bowel and bladder most of the time. Review of the acute care plan dated 8/6/10 reflected Resident #5 was positive for [MEDICAL CONDITION]. Care plan approaches reflected to provide medications as ordered; incontinent care after each incontinent episode; ensure proper hygiene and hand washing practices and maintain isolation procedures per protocol. The care plan dated 6/9/10 reflected Resident #5 had impaired cognition, short term and long term memory problems due to Dementia and unpredictable behaviors. Review of the infection control log for 8/10 reflected Resident #5 was cleared of his [MEDICAL CONDITION] infection on 9/10/10. The infection control log for 9/10 reflected neither Resident #5 nor Resident #13 had been cleared for [MEDICAL CONDITION]. Also located in the infection control log was an undated document titled preventing the spread of illness related to Multi-Drug Resistant Organisms such as [MEDICAL CONDITION]. If a resident has diarrhea due to [MEDICAL CONDITION], large numbers of organisms will be released from the intestines into the environment and may be transferred to other residents. Contact precautions include: hand washing, providing the resident with his own toileting facilities. [MEDICAL CONDITION] can survive on surfaces in the environment for up to six months. In an interview on 9/15/10 at 2:30 PM the Assistant Director of Nurses (ADON) stated that a stool sample had not yet been collected for culture for Resident #5. She stated that until a resident with [MEDICAL CONDITION] had a negative stool sample they were still considered positive for [MEDICAL CONDITION]. In an interview on 9/17/10 at 9:10 AM the Director of Nurses (DON) stated that she could not find documentation to support that Resident #5 was cleared of [MEDICAL CONDITION] on 9/10/10. In an interview on 9/16/10 at 10:40 AM the ADON stated that contact isolation depends on the care being provided as to whether staff used gloves, gowns or masks. Staff should always wash there hands. [MEDICAL CONDITION] is spread by not washing hands and through contact with surfaces such as a doorknob. She stated that if a resident is continent and washes their hands after using the restroom, it was all right for them to come out of their rooms. She further stated that Resident #5 and #13 were continent and had been educated on hand washing. Review of a staff inservice dated 6/30/10, presented by the DON regarding [MEDICAL CONDITION] reflected the following: Procedure: 1. Contact isolation is used. 2. Thorough hand washing after caring for each resident. 3. A private room may be needed in special circumstances. 4. Gowns are indicated when potential for soiling of clothing with feces is likely. 5. Gloves must be worn when touching fecal material is anticipated. 6. Disinfect any visible fecal contamination. 7. Contain all fecal soiling. 8. Disinfect items which may be fecally contaminated after each use, i.e. commode. In an interview on 9/16/10 at 2:05 PM Resident #5's physician stated that isolation of residents with [MEDICAL CONDITION] depended on the resident's cognitive ability and their ability to follow directions. He stated that isolation for a resident in the secured unit would be different than in the normal resident population. He stated that in the normal population, if the resident is continent and can be taught to wash their hands after using the restroom they may not need to be isolated from the rest of the population. The physician stated that when a resident is cognitively impaired they may not understand or recall the need for hand washing and could carry the infectious organism to other residents in the nursing facility. He stated that two residents with [MEDICAL CONDITION] may be placed in the same room however they should not be using the same commode unless it is thoroughly disinfected between the residents. In an interview on 9/16/10 at 10:47 AM the ADON stated that their policy for contact isolation would have to be revisited. She stated that there was really no way to say that Resident #5 and Resident #13 washed their hands after using the restroom. She stated that they are both incontinent at times and used the restroom at other times. She stated that the organism can then be carried out to the dining room table or to anything the two residents touch. In an interview on 9/16/10 at 4:35 PM the administrator stated that the facility has begun inservicing their staff on infection control. C.) Review of the facility policy and procedure titled 'Cleaning and Disinfecting Blood Glucose Meter' dated 3/2010 reflected the following: PURPOSE: To assist healthcare staff in the cleaning and disinfecting of blood glucose meters between each resident test to avoid cross-contamination infection control issues as stated per CDC guidelines. PROCEDURE: To Clean/disinfect the outside of the meter 1. The following Germicidal products are also acceptable disinfectants for use on meters: *Super Sani-Cloth Germicidal Disposable Wipe 2. This product is a pre-moistened towelette. To use this product, remove a wipe from container and follow product label instructions to clean & disinfect the meter. Take extreme care not to get liquid in the battery compartment, test strip and key code ports of the meter. 3. Allow the meter to dry before re-using the meter to perform the next test. With all the recommended meter disinfecting methods, it is important the meter be completely dry before testing a resident's glucose level. When to use a Mixed Bleach Solution 4. If the Disposable Super Sani Cloth Wipe is not available. Then use the following guidelines to disinfect: * To disinfect the meter, dilute 1 milliliter (ml) of household bleach (5%-6% sodium hypochlorite solution-household bleach) in 9 ml of water to achieve a 1:10 dilution (nine parts water to 1 part bleach). Final concentration of 0.5%-0.6% sodium hypochlorite. * The solution can then be used to dampen a paper towel (do not saturate the towel). * Then use the dampened paper towel to thoroughly wipe down the meter. * DATE THE BOTTLE. THE SOLUTION IS ONLY GOOD FOR 24 HOURS FROM THE POINT THE BLEACH & WATER IS MIXED. * Secure the bottle-so residents do not have access. 5. If the resident is symptomatic [DIAGNOSES REDACTED]icile-the 1:10 bleach dilution is used on all devices. Special Notes: It is preferable to use the sani-cloth as the continued use of the bleach solution will corrode the machine and make it non-functional. Except in [MEDICAL CONDITION] situations. Patient Preparation Procedure 1. The glucose meter should have been clean/disinfected per above listed process prior to using the meter... 11. Apply at least one glove to a hand and obtain a sani-cloth from the container with the gloved hand. Wipe the meter down front, back, sides, etc. Once wiped down (clean/disinfected) place it on a second disposable towel. Observations on 9/13/10 between 11:20 AM and 11:40 AM revealed LVN L obtaining finger sticks for the following diabetics on 200 Hall: 1. At 11:20 AM after washing her hands and applying gloves, LVN L went into Resident #21's room and obtained a finger stick for blood glucose level using a glucometer. Then went back out to the medication cart to check orders for insulin. She did not clean or disinfect the glucometer. No insulin was required. 2. She continued to Resident #29 and took the same glucometer into Resident #29's room and obtained a finger stick. Resident #29 required insulin. She placed the glucometer on the medication cart and proceeded to draw up Resident #29's insulin per protocol having LVN J verify the amount drawn up prior to administering the insulin. LVN L washed her hands. 3. She proceeded to push the medication cart to Resident #30's room, applied gloves and took the same glucometer into Resident #30's room and obtained a finger stick. Then went back out to the medication cart to check orders for insulin. She did not clean or disinfect the glucometer. LVN L did not clean or disinfect the glucometer or surfaces where the meter was placed between residents. In an interview on 9/15/10 at 11:40 AM LVN L stated she would use alcohol to clean the machine in between residents but she forgot to do it. LVN J did not prompt LVN L to clean the glucometer between residents. Review of the manufacturer's recommendations (no date) reflected the following: Clean the outside of the meter with a lint-free cloth. Dampen with soapy water or [MEDICATION NAME] alcohol (70%-85%) To disinfect the meter, dilute 1 ml of household bleach (5%-6% sodium hypochlorite solution) in 9 ml of water. This is a 1:10 dilution. The final concentration is 0.5-0.6% sodium hypochlorite. Do not clean inside the battery compartment or test strip port. The facility CMS form 672, dated 9/14/10 reflected a census of 122 residents. 29 residents receive finger sticks. Observation on initial tour reflected 46 residents resided on the secure unit. Observations on 9/13/10 between 11:20 AM and 11:40 AM revealed LVN L obtaining finger sticks for diabetics on 200 Hall. She did not clean or disinfect the glucometer or surfaces between residents. (Refer to F 441) In an interview on 9/15/10 at 11:40 AM LVN L stated she would use alcohol to clean the machine in between residents but she forgot to do it. The facility CMS form 672, dated 9/14/10 reflected a census of 122 residents; 29 residents received fingersticks. Observation on initial tour reflected 46 residents resided on the secure unit; 2 secure unit residents had a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection when the facility failed to implement contact isolation for 2 of 10 sampled residents (Resident #5 and #13) reviewed for infection and 1 of 2 licensed staff Licensed Vocational Nurse (LVN ) L failed to disinfect the glucometer machine in between finger sticks during observation of 3 of 4 resident's finger sticks (Residents #21, #29 and #30). Confused and occasionally incontinent Residents #5 and #13 were on contact isolation for Clostridium Difficile (C-diff) (a highly transmittable infection of the gastro-intestinal (GI) tract transmitted through contact with contaminated surfaces that causes severe diarrhea). The facility allowed Resident #5 and #13 to attend group activities and meals in the general community dinning area with other confused residents, use a shared restroom and staff wheeled biohazard linen and waste through the hallways at the end of each shift. This deficient practice could cause the cross-contamination and/or spread of infectious disease in an elderly and immunocompromised population of 122 residents. Finding included: A.) Review of the admission orders [REDACTED]. He was to receive [MEDICATION NAME] (antibiotic) 500 mg three times a day for 12 days. The administration of [MEDICATION NAME] was initialed as administered three times a day from 8/12/10 through 8/23/10. Review of the Admission Data Summary dated 8/11/10 reflected Resident #13 had a [DIAGNOSES REDACTED]. He had long term and short term memory problems and his decision making skills and judgment were moderately impaired. Resident #13 was incontinent of bowel and occasionally incontinent of urine. He gets out of bed unassisted and wanders about the hallway. Observation on the secured unit (specialized, locked unit for residents with confusion, behaviors and exit seeking tendencies) on 9/14/10 at 9:00 AM revealed a three drawer, portable, plastic storage bin outside Resident #5 and Resident #13 ' s semi-private room. There was a sign posted to contact the nurse before entering the room. The door to the room was open. Resident #13 was not in the room. Resident #5 was lying in the second bed. There were two isolation barrels at the foot of Resident #5 ' s bed. The room had one private restroom with a commode and a sink. In an interview on 9/14/10 at 9:00 AM LVN A stated that Resident #5 and #13 were on isolation for[DIAGNOSES REDACTED]. She stated that Resident #5 had completed antibiotics but was still having diarrhea. She stated that she was not sure about Resident #13 but that he was recently admitted to the facility with[DIAGNOSES REDACTED] and the two residents were placed in the same room because of the same infection. Observation on 9/14/10 at 11:30 AM revealed Resident #5 and Resident #13 sitting in wheelchairs in the secured unit dining room. Two unidentified Residents were also sitting at the table next to Resident #5 and #13. In an interview on 9/14/10 at 12:20 PM LVN H stated that Resident #5 and Resident #13 had[DIAGNOSES REDACTED] and were on Contact Isolation. She stated that Resident #5 was incontinent at night and sometimes during the day and was also confused at times. LVN H stated that Resident #5 had been on antibiotics for[DIAGNOSES REDACTED] and they were waiting to retest him. She stated that Resident #13 was also positive for[DIAGNOSES REDACTED]. Observation on 9/15/10 at 8:00 AM revealed Resident #13 and Resident #5 eating breakfast in the common dining room on the secure unit. Two unidentified Residents were sitting at the same table. Resident #13 and #5 had paper and plastic wear from the kitchen. Observation on 9/15/10 at 8:27 AM revealed Resident #5 was in the restroom in his semi-private room. Two biohazard barrels were at the foot of Resident #5 ' s bed. The toilet flushed and Resident #5 immediately exited the restroom. No running water was heard from the restroom sink. LVN F entered the room without a gown or mask. She stated that they were not necessary when just entering the room. LVN F stated that Resident #13 was waiting for his turn to use the restroom. After Resident #5 exited the restroom LVN F wheeled Resident #13 over to the restroom door and assisted him onto the commode. (The restroom had not been disinfected between use by Resident #5 and Resident #13). In an interview on 9/15/10 at 8:30 AM LVN F stated that it was Resident #5 on isolation, not Resident #13. In an interview on 9/16/10 at 10:15 AM LVN F stated that with contact isolation for[DIAGNOSES REDACTED], gloves and gown should be worn if there is likely to be contact with the feces. She stated that Resident #5 had completed his antibiotics for[DIAGNOSES REDACTED] but was still on isolation until he had a negative stool culture. She stated that Resident #13 should not have used the restroom after Resident #5. She stated that she had never emptied the biohazard barrels in their room but she thought that they were to be put into another bag before being taken out of the room. In an interview on 9/16/10 at 3:00 PM Certified Nurses Aide (CNA) D stated that when entering the room of a resident on contact isolation staff only needed to use gloves, gown and mask when contact will be made with the resident, such as taking the resident to the restroom. In the room were two barrels; one for dirty linen and one for trash. She stated that the dirty linen and trash barrels were taken out at the end of each shift. She stated that she wheeled the barrels out the dining room door on the secure unit (where she pointed with her finger) (through the dining room tables where residents are served at mealtime) and around to the biohazard area where she removed the trash bag. She stated that she wheeled the linen and trash barrel through the door, cut across the 300 hall to the laundry building and leaves the barrels for the laundry staff. She stated that both Resident #5 and #13 were confused and incontinent of bowel and bladder. She stated that they were taken to the restroom at times and shared the same restroom. CNA D also stated that both residents came out of their room to participate in group activities. Observation on 9/16/10 at 11:40 AM revealed Resident #13 sitting in the common dining area near the nurses' station at a table with two unidentified Residents. He was using regular dinnerware. Observation on 9/16/10 at 2:50 PM revealed Resident #13 sitting at a table in the main dining room on the secure unit participating in activities. Resident #5 was not in his room. Observation on 9/17/10 at 5:15 AM revealed Resident #13 had been moved to a private room. Observation on 9/17/10 at 12:20 PM revealed Resident #13 sitting in the secure unit dining room near the nurses' station, at a table with two unidentified Residents. He was eating his noon meal with regular dinnerware from the kitchen. Review of Resident #13's nurses' notes reflected the following: 8/12/10-He was on contact isolation for[DIAGNOSES REDACTED]. He was assisted by one staff member for toileting and provided incontinent care. 8/13/10-He was on contact isolation for[DIAGNOSES REDACTED]. He had diarrhea stool two times. 8/14/10-He was on[DIAGNOSES REDACTED] precautions. He was up ambulatory to the restroom with the assistance of staff. 8/15/10-He was incontinent and used an adult brief but still used the toilet. He ambulated to the commode without assistance. He was on[DIAGNOSES REDACTED] precautions. 8/17/10-He was up to the restroom without assistance. 8/18/10-He was up in the hallway and to the dining area. He continued on contact isolation. 8/19/10-He was uncooperative at dinner time. He had a formed stool and remained on contact isolation for[DIAGNOSES REDACTED]. 8/20/10-He was up ambulating in the hallway. He was incontinent of bowel and bladder but gets up without assistance to use the commode. 8/22/10-Resident #13 was up propelling himself in his wheelchair around the secure unit. He remained on contact isolation for[DIAGNOSES REDACTED]. 8/23/10 through 8/26/10-On follow up for[DIAGNOSES REDACTED] with contact isolation still in effect. 8/28/10-He had a large, odd smelling, diarrhea stool. 'Foul smelling bowel movement noted. No loose stools after two loose stools noted'. Resident #13 gets up to the bathroom, removes wet incontinent brief and leaves it on the floor. 9/2/10-He gets combative with staff when redirected to ask for assistance. 9/4/10-He was alert but confused. He was up in his wheelchair in the dining room for meals and watching television. 9/5/10-He propels his wheelchair through the hallways on his own. 9/6/10, 9/9/10 and 9/13/10-Resident #13 attends group activities and events. 9/8/10-He was alert but confused. 9/11/10-He was watching television in the dinning area. 9/12/10-He participated in morning church activity. 9/12/10 and 9/14/10-He was incontinent of bowel and bladder. 9/15/10-Resident #13 was toileted with assistance and had a medium bowel movement (character of the stool was not documented). Review of the bowel and bladder shift chart from 8/12/10 through 9/16/10 reflected Resident #13 had one diarrhea stool in that time frame which was on 9/16/10. Diarrhea stool was not logged on the bowel and bladder chart for 8/28/10 as it was noted in the nurses' notes. In an interview on 9/16/10 at 12:10 PM CNA C stated that Resident #13 had a "slimy bowel movement all over himself this morning" and the isolation barrels from the room were taken to the biohazard trash and to the laundry. She stated that the CNAs wheel the barrels down the hall to the laundry building and the biohazard trash off of the 300 hall. In an interview on 12:15 PM CNA B stated that the isolation barrels from Resident #5 and #13's room were taken to the laundry and biohazard area off the 300 hall at the end of the shift. In an interview on 9/16/10 at 10:00 AM CNA G stated that Resident #13 was currently having foul smelling, loose stool. Review of the Life Enrichment assessment dated [DATE] reflected Resident #13 was confused, had multifactorial Delirium and had an altered mental status. Resident #13 was mobile in a wheelchair and wandered. He had[DIAGNOSES REDACTED] and attended some out-of-room activities. Review of the Minimum Data Set ((MDS) dated [DATE] reflected Resident #13 had short term memory problems. He was not able to recall the current season, location of his room, staff faces or names or that he was in a nursing home. He required extensive assistance of one staff member for transfers, dressing, toilet use and personal hygiene. He was able to wheel himself in his wheelchair; incontinent of bowel and bladder. Dementia was checked as a current disease and[DIAGNOSES REDACTED] was checked for infections. He participated in activities from 1/3 to 2/3 of the time and he resided on the Alzheimer's special care unit. Review of the MDS dated [DATE] reflected Resident #13 had short term memory problems. He was not able to recall the current season, location of his room, staff faces or names or that he was in a nursing home. He required extensive assistance of two staff for transfers and extensive assistance of one staff for dressing, eating, toileting and personal hygiene. He was able to wheel himself in his wheelchair; incontinent of bowel and bladder. [DIAGNOSES REDACTED] was checked for infections and he participated in activities from 1/3 to 2/3 of the time. Review of hospital progress notes dated 8/10/10 reflected Resident #13 had three loose bowel movements over night; possible[DIAGNOSES REDACTED]; empiric [MEDICATION NAME]. Hospital progress notes dated 8/11/10 reflected Resident #13 continued to have diarrhea. Stool cultures were positive for[DIAGNOSES REDACTED] and he was placed on contact precautions and [MEDICATION NAME]. Review of the facility's physician's progress notes dated 8/12/10 reflected Resident #13's chart was reviewed. He had dementia and[DIAGNOSES REDACTED] and was receiving [MEDICATION NAME]. Review of the care plan dated 8/18/10 reflected Resident #13 was incontinent of bowel and bladder. He was admitted with[DIAGNOSES REDACTED]. Care planned approaches in there entirety included the following: a. Medicate as ordered. Monitor and record response. b. Wear gowns when soiling of clothing with infectious material was likely c. Obtain stool cultures as ordered. d. Isolation as ordered. e. Wear gloves for contact with stool. Wash hands well after removing gloves. There were no physician's orders to place Resident #13 on contact isolation or to recheck his stool for[DIAGNOSES REDACTED] following treatment. There were no stool cultures available for review. In an interview on 9/16/10 at 10:00 AM CNA G stated that she had worked at the facility for seven years. She stated that Resident #13 had[DIAGNOSES REDACTED] and Resident #5 had[DIAGNOSES REDACTED] "at one point" and they were on contact isolation. She stated that when a resident is on contact isolation and contact is to be made with the resident a gown, mask and gloves should be worn. CNA G stated that both Resident #13 and #5 were toileted but they also have incontinent episodes. CNA G stated that the biohazard barrels in the room were taken out at the end of each shift. She stated that she wheels the barrels down the hall with the lids on. She stated that the trash barrel was taken to the biohazard waste outside the facility and the biohazard laundry barrel was taken to the laundry and clean barrels were picked up. B.) Review of the face sheet for Resident #5 reflected he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the hospital Admission history and physical dated 6/1/10 reflected Resident #5 was admitted to the hospital due to abdominal distention. He had a history of [REDACTED]. Resident #5 was Demented, minimally retarded and had a history of [REDACTED]. Review of the hospital history and physical dated 6/3/10 reflected Resident #5 had increased abdominal distention and was complaining of the same abdominal pain as before (on 6/1/10). Tests revealed that Resident #5 did not have a bowel obstruction. However he did have significant bladder distention secondary to possible bladder outlet obstruction. After decompression of the bladder he had multiple bowel movements. A stool culture was ordered for[DIAGNOSES REDACTED]. An inpatient hospital progress note dated 6/22/10 reflected Resident #5 was having profuse watery diarrhea. [DIAGNOSES REDACTED] studies turned out to be positive and he was started on oral [MEDICATION NAME] (antibiotic). Review physician ' s orders dated 8/1/10 reflected Resident #5 was ordered Milk of Magnesia for constipation as needed. On 8/2/10 he was ordered a stool culture for[DIAGNOSES REDACTED]. On 8/5/10 Resident #5 was ordered [MEDICATION NAME] three times a day for 14 days and yogurt with each meal. On 8/20/10 Resident #5 was ordered [MEDICATION NAME] every six hours for 14 days to treat[DIAGNOSES REDACTED]. On 8/30/10 Resident was ordered to have a culture for[DIAGNOSES REDACTED] done on 9/15/10. Review of facility progress notes dated 8/4/10 reflected Resident #5 was reportedly having loose stool. Progress notes dated 8/6/10 reflected Resident #5 was positive for[DIAGNOSES REDACTED] ...recurrent. Review of nurses' notes for Resident #5 from 7/29/10 through 9/9/10 reflected the following: 7/29/10-Resident #5 was combative. 7/30/10-He had an elevated temperature and was noted to have loose stool. 8/1/10-He refused breakfast and lunch; ate very little at supper and had two diarrhea stools. 8/2/10-Resident #5 was having loose stools. A stool culture for[DIAGNOSES REDACTED] was ordered. He complained of stomach pain that was relieved following a bowel movement. His stool was loose. 8/3/10-Resident #5 refused dinner. 8/4/10-He had foul smelling diarrhea two times. 8/5/10-Resident #5 ' s lab results returned positive for[DIAGNOSES REDACTED]. New orders were received. 8/6/10-Resident #5 received his initial dose of [MEDICATION NAME] 500 mg to be given three times a day for 14 days. He was provided incontinent care with soap and water. Contact isolation precautions observed. He had two episodes of yellowish, foul smelling, loose stool. 8/7/10-Resident #5 had a small, odorous, formed stool. He was combative toward staff. 8/8/10-Resident #5 eats very little at breakfast and lunch. He had one medium sized loose stool. He was incontinent of bowel and bladder and was provided incontinent care as needed. 8/9/10-Resident #5 was assisted to the restroom for a large, foul smelling loose stool. 8/10/10-Resident #5 continued to have brown, foul smelling, slimy stool. He was later incontinent of a large pasty stool and incontinent care was provided. 8/11/10-Resident #5 continues to have loose stool. 8/12/10-Resident #5 remains on contact isolation for[DIAGNOSES REDACTED]. 8/13/10-He had two diarrhea stools. Incontinent care was provided with soap and water. All needs are anticipated by staff. 8/14/10-C-diff precautions continue. He remains on antibiotics and has loose, odorous stool. He propels himself in his wheelchair throughout the dinning area and hallways. He participates quietly in activities with other residents. 8/15/10-Resident #5 is alert but confused. He is up for meals and activities. He is watching television in the dinning room. He propels himself through out the unit in his wheelchair. Resident #5 is incontinent of bowel and bladder. 8/16/10 through 8/19/10-He had no bowel movements noted. He finished his antibiotic for[DIAGNOSES REDACTED] and remained on contact isolation. 8/20/10-Resident #5 continues to have loose stools. His physician was notified and new orders were received to start [MEDICATION NAME] (antibiotic) every six hours for 14 days. 8/21/10-Contact precautions continue for[DIAGNOSES REDACTED]. Resident #5 is watching television in the dinning area. 8/23/10-Resident #5 had loose foul smelling stool. He was incontinent of bowel and bladder. 8/24/10-Resident #5 remains on contact isolation and attends activities. 8/25/10-He continues to have loose stool. He remains on contact isolation. 8/26/10-He continues with loose, stringy, stool. He refused his shower and was cursing at the staff. 8/28/10-Resident #5 was angry and verbally inappropriate with staff. He walked down the entire 400 hall trying to go home. Later he was propelling himself in his wheelchair down the hallway. 8/29/10-Resident #5 propels himself in his wheelchair throughout the unit and watches television in the dinning area. 8/30/10-Resident #5 continues to have watery diarrhea. Received a new order to recheck stool for[DIAGNOSES REDACTED] on 9/15/10. 8/31/10-Contact isolation continues to be in effect. 9/2/10-Resident #5 continues with loose stool. He is incontinent of bowel and bladder. 9/3/10-The last dose of [MEDICATION NAME] was administered for[DIAGNOSES REDACTED]. 9/5/10-Resident #5 was noted with loose stool. He was up in his wheelchair. Later in the day, he took all of his belongings and put them in the hallway. 9/6/10-He attends group events. 9/8/10-He had increased anger with the staff. Confusion was noted. Review of bowel and bladder documentation from 8/3/10 through 9/16/10 reflected Resident #5 had a total of seven diarrhea stools, the latest documented on 8/14/10 (this documentation was inconsistent with nurses' notes). The bowel and bladder documentation also reflected Resident #5's bowel movements were as infrequent as every 10 days. Review of Medication Administration Records (MAR) dated 8/10 and 9/10 reflected Resident #5 had not been administered medication for constipation. Review of the quarterly MDS dated [DATE] reflected Resident #5 was cognitively impaired. He wandered and was resistant to care. He propelled his wheelchair without assistance. He was incontinent of bowel and bladder most of the time. Review of the acute care plan dated 8/6/10 reflected Resident #5 was positive for[DIAGNOSES REDACTED]. Care plan approaches reflected to provide medications as ordered; incontinent care after each incontinent episode; ensure proper hygiene and hand washing practices and maintain isolation procedures per protocol. The care plan dated 6/9/10 reflected Resident #5 had impaired cognition, short term and long term memory problems due to Dementia and unpredictable behaviors. Review of the infection control log for 8/10 reflected Resident #5 was cleared of his[DIAGNOSES REDACTED] infection on 9/10/10. The infection control log for 9/10 reflected neither Resident #5 nor Resident #13 had been cleared for[DIAGNOSES REDACTED]. Also located in the infection control log was an undated document titled preventing the spread of illness related to Multi-Drug Resistant Organisms such as[DIAGNOSES REDACTED]. If a resident has diarrhea due to[DIAGNOSES REDACTED], large numbers of organisms will be released from the intestines into the environment and may be transferred to other residents. Contact precautions include: hand washing, providing the resident with his own toileting facilities. [DIAGNOSES REDACTED] can survive on surfaces in the environment for up to six months. In an interview on 9/15/10 at 2:30 PM the Assistant Director of Nurses (ADON) stated that a stool sample had not yet been collected for culture for Resident #5. She stated that until a resident with[DIAGNOSES REDACTED] had a negative stool sample they were still considered positive for[DIAGNOSES REDACTED]. In an interview on 9/17/10 at 9:10 AM the Director of Nurses (DON) stated that she could not find documentation to support that Resident #5 was cleared of[DIAGNOSES REDACTED] on 9/10/10. In an interview on 9/16/10 at 10:40 AM the ADON stated that contact isolation depends on the care being provided as to whether staff used gloves, gowns or masks. Staff should always wash there hands. [DIAGNOSES REDACTED] is spread by not washing hands and through contact with surfaces such as a doorknob. She stated that if a resident is continent and washes their hands after using the restroom, it was all right for them to come out of their rooms. She further stated that Resident #5 and #13 were continent and had been educated on hand washing. In an interview on 9/16/10 at 2:05 PM Resident #5's physician stated that isolation of residents with[DIAGNOSES REDACTED] depended on the resident's cognitive ability and their ability to follow directions. He stated that isolation for a resident in the secured unit would be different than in the normal resident population. He stated that in the normal population, if the resident is continent and can be taught to wash their hands after using the restroom they may not need to be isolated from the rest of the population. The physician stated that when a resident is cognitively impaired they may not understand or recall the need for hand washing and could carry the infectious organism to other residents in the nursing facility. He stated that two residents with[DIAGNOSES REDACTED] may be placed in the same room however they should not be using the same commode unless it is thoroughly disinfected between the residents. In an interview on 9/16/10 at 10:47 AM the ADON stated that their policy for contact isolation would have to be revisited. She stated that there was really no way to say that Resident #5 and Resident #13 washed their hands after using the restroom. She stated that they are both incontinent at times and used the restroom at other times. She stated that the organism can then be carried out to the dining room table or to anything the two residents touch. In an interview on 9/16/10 at 4:35 PM the administrator stated that the facility has begun inservicing their staff on infection control. Review of the facility's undated policy and procedure titled "Contact Precautions" reflected the following: To prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or the resident's environment and does not warrant standard precautions. Procedure: 1. Two large trash containers are placed in the room and lined with red plastic polyethylene bags; one is labeled trash and the other is labeled laundry. 2. Used linen must be double bagged. 3. All items taken into the room for the use of the resident are to be disposable or left in the room until the resident is discharged out of isolation. 4. Staff entering the room should wear a gown and gloves for all interactions that may involve contact with the resident or potential contact with areas in the resident's room. Procedures that may require gown, gloves and mask: a. Bathing b. Incontinent care c. Repositioning d. Transferring 5. All items needed in the room for resident care are taken in by the nursing staff. Clean items removed from the room carefully with an antiseptic/antibacterial agent. 6. The garbage and linen is removed from the room at the end of each shift and placed in another bag immediately outside the door, tied securely, marked and discarded as medical waste/laundry. Review of a staff inservice dated 6/30/10, presented by the DON regarding[DIAGNOSES REDACTED] reflected the following: Procedure: 1. Contact isolation is used. 2. Thorough hand washing after caring for each resident. 3. A private room may be needed in special circumstances. 4. Gowns are indicated when potential for soiling of clothing with feces is likely. 5. Gloves must be worn when touching fecal material is anticipated. 6. Disinfect any visible fecal contamination. 7. Contain all fecal soiling. 8. Disinfect items which may be fecally contaminated after each use, i.e. commode. C.) Observations on 9/13/10 between 11:20 AM and 11:40 AM revealed LVN L obtaining finger sticks for the following diabetics on 200 Hall: 1. At 11:20 AM after washing her hands and applying gloves, LVN L went into Resident #21's room and obtained a finger stick for blood glucose level using a glucometer; Then went back out to the medication cart to check orders for insulin. She did not clean or disinfect the glucometer. No insulin was required. 2. She continued to Resident #29 and took the same glucometer into Resident #29's room and obtained a finger stick blood specimen. Resident #29 required insulin. She placed the glucometer on the medication cart and proceeded to draw up Resident #29's insulin per protocol having LVN J verify the amount of insulin drawn up prior to administering the insulin. LVN L washed her hands. 3. She (LVN L) proceeded to push the medication cart to Resident #30's room, applied gloves and took the same glucometer into Resident #30's room and obtained a finger stick for blood specimen; Then went back out to the medication cart to check orders for insulin. She did not clean or disinfect the glucometer machine. LVN L did not clean or disinfect the glucometer or surfaces where the meter was placed between resident use. In an interview on 9/15/10 at 11:40 AM LVN L stated she would use alcohol to clean the machine in-between residents but she forgot to do it. LVN J did not prompt LVN L to clean the glucometer between resident use for obtaining blood specimens to test for blood glucose levels. Review of the facility policy and procedure titled 'Cleaning and Disinfecting Blood Glucose Meter' dated 3/2010 reflected the following: PURPOSE: To assist healthcare staff in the cleaning and disinfecting of blood glucose meters between each resident test to avoid cross-contamination infection control issues as stated per CDC guidelines. PROCEDURE: To Clean/disinfect the outside of the meter 1. The following Germicidal products are also acceptable disinfectants for use on meters: *Super Sani-Cloth Germicidal Disposable Wipe 2. This product is a pre-moistened towelette. To use this product, remove a wipe from container and follow product label instructions to clean & disinfect the meter. Take extreme care not to get liquid in the battery compartment, test strip and key code ports of the meter. 3. Allow the meter to dry before re-using the meter to perform the next test. With all the recommended meter disinfecting methods, it is important the meter be completely dry before testing a resident's glucose level. When to use a Mixed Bleach Solution 4. If the Disposable Super Sani Cloth Wipe is not available. Then use the following guidelines to disinfect: * To disinfect the meter, dilute 1 milliliter (ml) of household bleach (5%-6% sodium hypochlorite solution-household bleach) in 9 ml of water to achieve a 1:10 dilution (nine parts water to 1 part bleach). Final concentration of 0.5%-0.6% sodium hypochlorite. * The solution can then be used to dampen a paper towel (do not saturate the towel). * Then use the dampened paper towel to thoroughly wipe down the meter. * DATE THE BOTTLE. THE SOLUTION IS ONLY GOOD FOR 24 HOURS FROM THE POINT THE BLEACH & WATER IS MIXED. * Secure the bottle-so residents do not have access. 5. If the resident is symptomatic [DIAGNOSES REDACTED]icile-the 1:10 bleach dilution is used on all devices. Special Notes: It is preferable to use the sani-cloth as the continued use of the bleach solution will corrode the machine and make it non-functional. Except in[DIAGNOSES REDACTED] situations. Patient Preparation Procedure 1. The glucose meter should have been clean/disinfected per above listed process prior to using the meter... 11. Apply at least one glove to a hand and obtain a sani-cloth from the container with the gloved hand. Wipe the meter down front, back, sides, etc. Once wiped down (clean/disinfected) place it on a second disposable towel. Review of the manufacturer's recommendations (no date) reflected the following: Clean the outside of the meter with a lint-free cloth. Dampen with soapy water or [MEDICATION NAME] alcohol (70%-85%) To disinfect the meter, dilute 1 ml of household bleach (5%-6% sodium hypochlorite solution) in 9 ml of water. This is a 1:10 dilution. The final concentration is 0.5-0.6% sodium hypochlorite. Do not clean inside the battery compartment or test strip port. The facility CMS form 672, dated 9/14/10 reflected a census of 122 residents; 29 residents received fingersticks for blood glucose testing. Observation on initial tour reflected 46 residents resided on the secure unit; 2 secure unit residents had a [DIAGNOSES REDACTED].