Every finding on record at Azalea Trail Nursing and Rehabilitation Center

Based on observation, interview, and record review, the facility failed to provide an environment free of accident hazards for one (Resident #1) of three residents reviewed for oxygen use. The facility failed to securely store oxygen cylinder when in resident room on 7/27/26. This failure could place residents at risk of living in an unsafe environment. Findings included: 1. A record review of Resident #1's face sheet, dated 07/28/2026, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses of thrombocytopenia (a condition of low blood platelet count), pneumonia (infection that inflames the air sacs in one or both lungs), acute and chronic respiratory failure with hypoxia (low levels of oxygen in your body tissues), encephalopathy (altered brain function), sepsis (serious condition in which the body responds improperly to an infection), acute upper respiratory infection, Pain in left hip, chronic kidney disease, Dysphagia (trouble swallowing), and hypertension (high blood pressure). Review of Resident #1's MDS assessment, dated 6/25/2026, revealed the resident had a BIMS score of 4 which indicated severe cognitive impairment. The resident was coded as using oxygen therapy and required wheelchair for mobility assistance. Review of Resident #1 physician orders, dated 6/28/2026 to 7/28/2026 contained an order for oxygen at three liters via nasal cannula routinely at night from 10:00 p.m. to 6:00 a.m. Observation on 7/27/2026 at 10:26 a.m., Resident #1's room revealed Oxygen E-cylinder (middle sized metal portable container holding 680 liters of compressed medical gas at a full pressure of 2000 to 2200 psi) laying across on an extra bed in the room unsecured. Observation on 7/27/2026 at 11:23 a.m., Resident #1's room revealed Oxygen E-cylinder laying across on the extra bed in the room unsecured. Interview and observation on 7/27/2026 at 11:23 a.m., CNA A stated that Resident #1 used oxygen from concentrator while in bed, while oxygen cylinder were normally attached to the back wheelchairs in bags for use while up in wheelchairs. She stated that cylinder were not supposed to be stored in rooms or left on beds. She stated that when cylinder became empty, staff notified the nurse, who then came to replace the oxygen cylinder. During the interview, CNA A was observed to remove the empty oxygen cylinder from the extra bed in Resident #1 room. Interview conducted on 7/27/2026 at 11:00 a.m., RN B stated that residents utilized oxygen concentrators while in bed. She explained that residents used an oxygen cylinder secured in a black bag on the back of their wheelchairs when they were out in the facility. When an oxygen cylinder ran empty, the CNA notified the charge nurse, who replaced it with a fresh one from the Hall 3 closet rack. RN B stated that oxygen cylinders were never to be left on beds in resident rooms, and empty cylinders were always supposed to be removed from the rooms immediately and remain secured. Interview conducted on 7/28/2026 at 11:56 a.m., the DON stated that oxygen cylinder were to be changed by the nursing staff. The DON explained that oxygen cylinder in resident rooms were required to be secured either in a wheelchair bag or a rolling cart, and they were never supposed to be left loose in a room. The DON stated that any empty or extra oxygen cylinder had to be kept secured in a rack inside the oxygen closet, emphasizing that an oxygen cylinder should never be left unsecured in a resident room. Interview conducted on 7/28/2026 at 11:59 a.m., the Administrator stated that oxygen cylinder was stored securely in a rack inside the oxygen closet. The Administrator stated that when oxygen cylinder was in resident rooms, it was required to be kept in a oxygen bag on a wheelchair or secured in an oxygen rolling cart. The Administrator noted that no empty cylinders were ever to be left in a resident's rooms unsecured. A record review of the facility's policy dated 2002 titled LTC Compressed Gases, Safe Handling read: when tanks are stored, all tanks and cylinders should be stored in a cylinder cart or securely chained in a secure storage area. Never leave cylinders free-standing. All cylinders must be individually secured by separate chains.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 5 residents reviewed for care plans. (Resident #1) The facility failed to care plan the bed alarm being discontinued on 07/21/25 for Resident #1. The facility failed to care plan Resident #1's fall with major injuries on 08/06/25. These failures could place residents at risk of not having individual needs met and not receiving needed services. Findings included: Record review of a face sheet dated 11/19/25 indicated Resident #1 was an [AGE] year-old female admitted on [DATE] with left hip fracture.Record review of Resident #1's significant change MDS assessment dated [DATE] indicated her BIMS was 03 which indicated severely impaired cognitive level. She was dependent on staff for personal hygiene and required maximal assistance toileting. She had a fall in the past month and with fracture. Record review of Resident #1 physician's orders dated August 2025 indicated on 07/21/25 the bed alarm was discontinued. Record review of Resident #1 progress note dated on 08/06/25, the Resident #1 fell and was sent to the hospital Record review Resident #1 progress note dated 08/09/25, the Resident#1 was readmitted with diagnosis of a fractured right hip. Record review of Resident #1's care plan dated 07/30/25 did not address the bed alarm being discontinued on 7/21/25. Record review of Resident #1's care plan dated 08/14/25 in the electronic record did not address her fall on 08/06/25. During an interview on 11/19/25 at 11:00 a.m., the DON said the facility had slowly been discontinuing the use of bed alarms because the bed alarms were restraints and can be only used for certain diagnoses like seizures. She said the medical director does not use bed alarms. During an interview on 11/19/25 at 11:45 a.m., the Medical Director said he discontinued the bed alarms at all the facilities because they are restraints and do not prevent falls, most of the time the residents have already fallen. He said we were just checking on the residents more frequently; however he did not say a time frame. He said with Resident #1 the bed alarm would not have prevented her from falling. During an interview on 11/19/25 at 1:00 p.m., CNA A said she checks on Resident #1 frequently and said when she goes up and down the hall she would checks on all residents with high risk for falls frequently. She pointed to the doors that had stars and said those get frequent checks. She was unable to say a time those checks were done. She said the high fall risk residents had alarms, but they were discontinued by the medical director. During an interview on 11/19/25 at 2:00 p.m. the DON said the electronic record did not contain an update after the fall on 08/06/25. She said they would search for the acute care plan in a binder at the nurse's station. She said her expectation was for the care plan to be updated as required. During an interview and record review on 11/19/25 at 3:00 p.m., DON presented an acute care plan dated 08/06/25 and it contained a new approach of frequent visual checks to monitor Resident #1. The frequent visual checks did not indicate how often or when to check on the resident. She presented a bowel and bladder schedule and said they did not have anything else. She said the care plan did not contain information about discontinuing bed alarms. Record review of Restraint Free Environment dated 07/01/25 indicated . The care plan should be updated accordingly to include the development and implementation of interventions, to address any risks related to the use of the restraint. Record review of the Resident Alarms dated 07/01/25 indicated It is the policy of this facility to utilize resident alarms in limited circumstances, in accordance with the resident's needs. Implementation of interventions . d Interventions shall be communicated to all relevant staff, including frequency/ time frames and responsibility.

Based on observation, interview and record review, the facility failed to review and revise the person-centered care plan for 1 of 2 residents reviewed for care plans. (resident#13) The facility did not revise Residents #13's care plan to include her actual indwelling catheter. This failure could place residents at risk for decreased quality of care and life. Finding included: Record Review of a Matrix for providers (used to identify pertinent care categories) dated 11/2020 indicated Resident #13 did not have an indwelling Catheter. Record Review of an MDS dated [DATE] indicated Resident #13 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . MDS indicated Resident#13 was understood and understands others. Record Review of Resident #13 care plan dated 9/16/2021 indicated Resident#13 requires an intermittent catheterization R/T [CONDITION(S)]. Staff (Nursing)to assess urine, record the amount, type, color, odor, report [CONDITION(S)](acute confusion, urgency, frequency, bladder, spasms, nocturia ,burning, pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine ,blood in urine). There was a new order for indwelling catheter dated 9/13/2021. During an observation and interview on 11/15/2021 at 10:45 am with Resident#13 said, I am an [AGE] year-old female, had a hip replacement and Uterine Cancer. and now have a Foley catheter since 9/13/2021, I had had been doing self-catheters but had too many [CONDITION(S)] (Urinary Tract Infections). Observed urinary drainage bag covered and attached to her wheelchair. During an interview with the RN A on 11/17/2021 at 1:43 pm, she was asked who was responsible for updated the care plans, she said, I have to own up to no Care plan for Foley Catheter. She said she knew that Resident #13, had a Foley Catheter since 9/13/2021 but neglected to update the care plan to reflect. She said she knew that in order to change the MDS there had to be more than one significant change and totally forgot to change the care plan. During an interview with LVN B, on 11/17/2021 at 2:20 pm said that Resident #13 was under Urology/Oncology and on 9/13/2021 there was an order to insert a Foley Catheter to keep the catheter system a closed system to decrease the chances to increase [CONDITION(S)] (Urinary Tract Infections). The urology/oncology will support the need to have a Foley Catheter. During an interview and record review with the DON (Director of Nursing) on 11/17/2021 at 2:30 PM she showed surveyor all of the in/out catheters in her office she had ordered for Resident#13, and said this resident now has a Foley Catheter, she said she has had a Foley since 9/13/2021. During interview on 11/17/2021 at 2:30 pm with the DON, she agreed that the nurses and staff were to follow the policies set forth by the facility. Record review of the facility's Nursing Policy & Procedure Manual, 2003 GP UR 03-2.0 for Catheter Care stated: o Purpose o The purpose of this procedure is to prevent infection of the resident's urinary tract o Preparation o Review the resident's care plan and provide for any special needs of the residents o General Guidelines o Review the president's plan of care daily for changes

Based on interview and record review, the facility failed to provide a diet to met the needs of 1 of 17 residents reviewed for physician orders. (Resident #8) The facility failed to ensure Resident #8 received magic cup and yogurt with every meal as ordered by the physician. This failure could place residents at risk for not receiving appropriate treatment and services to meet their needs. Findings included: Record review of the physician order dated November 2021 indicated Resident #8 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with diagnoses including dysphagia (difficulty swallowing), type 2 diabetes, anorexia, and cerebral infarction (stroke). There was an order for yogurt and magic cup with every meal (7:00am, 12:00pm and 5:00pm) effective 10/08/20. Record Review of the revised care plan dated 8/25/21 indicated Resident #8 was at risk for malnutrition and weight loss due to dysphagia, DM, [CONDITION(S)], anorexia, poor oral intake. Goal: Resident will not exhibit signs of malnutrition or dehydration. Care plan did not address magic cup or yogurt. Record review of the annual MDS dated [DATE] indicated Resident #8 had a Brief Interview for Mental Status (BIMS) score of 1 which indicated she severely impaired. Record review of the progress note dated 10/08/20 indicated Resident #8 had a new order to please send yogurt and magic cup with all meals due to resident prefers these over meals prepared. RP was notified and ST aware of new order. Also, that a dietary communication was given to staff to make aware of new order. Record review of undated diet report printed on 11/17/21 indicated Resident #8 was to have a pureed diet with mechanical soft upon request. Please send yogurt and magic cup with every meal; 7am, 12pm and 5pm. During an observation of lunch meals on 11/15/21 and on 11/16/21 Resident #8 did not receive a magic cup or yogurt with lunch meal as ordered. During an interview on 11/17/21 at 10:51 a.m., DM said she only had two residents that she was to give magic cup with meals. DM said Resident #8 was not one of the residents who she put a magic cup on meal tray and was not aware Resident #8 had an order to receive magic cup and yogurt with each meal. DM said she kept the magic cups, and yogurts in kitchen and if staff request it then she gives it to them. DM acknowledge Resident #8 occasionally received yogurt, but it was not with every meal, only whenever staff requested it. DM said whenever a resident has a new order, or a change was made the nurses send her a communication note and verbally tell her . DM said she kept all communication notes in a binder, she did not have a communication note indicating Resident #8 was to receive magic cup and yogurt with every meal, the only communication note she had for Resident #8 was for pureed or mechanical soft diet changes. During an interview on 11/17/2 at DON said if Resident #8 had an order for magic cup and yogurt with every meal then she expected for Resident #8 to get items with every meal. She said she was not aware Resident #8 was not getting a magic cup and yogurt with every meal.

Based on observation, interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 2 of 17 residents reviewed for accuracy and completeness. (Resident #s 8 and 15) Resident #8's care plan inaccurately reflected she was taking an anticoagulant when she was not. Resident #15's care plan inaccurately reflected she had a foley catheter when she did not have one. These failures could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident 's health. Findings included: 1) Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There were no anticoagulant (AC) medication listed. Record review of Resident #8's annual MDS (minimum data set) dated 9/15/21 indicated in section N0410 that resident received no anticoagulant (ex: [MEDICATION(S)], [MEDICATION(S)], or low-molecular weight [MEDICATION(S)]). Record Review of the revised care plan dated 8/25/21 indicated Resident #8 received anticoagulant medication daily due to history of a stroke. Goal: Resident will have no sign and symptoms of active bleeding during the next 90 days. Approach: administer anticoagulant medication as ordered. During an interview on 11/17/21 at 10:36 am, DON said she reviewed Resident #8's clinical record and did not see a current order for an anticoagulant medication. She said Resident #8 had a current order for [MEDICATION(S)] (blood thinner) medication, which was an antiplatelet, but she was not sure why RN A put anticoagulant on Resident #8's care plan and asked instructed for surveyor get clarification from RN A. During an interview on 11/17/21 at 10:45 am RN A, said she was responsible for doing the car e plans and the MDS. She said Resident #8 was taking [MEDICATION(S)] (blood thinner) which was classified as an antiplatelet and not an anticoagulant (AC). RN A said she was aware Resident #8 was not taking an AC, she said she automatically added AC to all care plans of residents who were on a blood thinner. RN A said [MEDICATION(S)] medication was not considered an anticoagulant and that's why she marked 0 on MDS for anticoagulant. She said instead of putting AC on Resident #8's care plan she should have put antiplatelet which was accurate. 2) Record review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no order for foley catheter (F/C). Record review of the quarterly MDS dated [DATE] indicated in section H0100 -Bladder and Bowel that Resident #15 did not have a F/C. Record review of the revised care plan dated 9/17/21 indicated Resident #15 had frequent UTI's. Remains at risk for other infections. Resident currently has a F/C due to urinary retention, risk of skin breakdown, immobilization, and comfort for end-of-life care. During an observation on 11/15/21 and on 11/16/21 at 12:00 pm of Resident #15 revealed that she did not have a F/C. During an interview on 11/17/21 at 10:29am, LVN B said Resident #15 did not have a FC and has not had one in several months. During an interview on 11/17/21 at 10:33 am, DON said Resident #15 did not have a (Foley Catheter) F/C, but she did have one in the past. DON said Resident #15's FC was discharged /removed on 5/6/21. She said she did not know why Resident #15 care plan indicated she currently had a F/C. During an interview on 11/17/21 at 10:42 am RN A said she was not working at the time Resident #15's FC was discontinued; but she reviewed/revised Resident #15's CP on 9/17/21 and just overlooked it, and that she should have removed F/C off care plan but missed it. Record review of revised documentation policy dated 8/20/12 stated The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents, staff, and the public . The facility failed to properly store two oxygen cylinders. This failure could place residents at risk for an unsafe environment and injury. Findings included: During an observation on 11/15/2021 at 9:30 AM to 4:30 PM the DON's office door was opened. Against the back wall of the office standing on the floor were two (2) E-Cylinder oxygen tanks unsecured. Staff as well as residents were in and out of the DON's office. Multiple times during the day the DON's office door was opened and the DON was not in the office. During an observation on 11/16/2021 at 8:30 AM to 4:30 PM the DON's office door was opened. Against the back wall of the office standing on the floor were two (2) E-Cylinder oxygen tanks unsecured. Staff as well as residents were in and out of the DON's office. Multiple times during the day the DON's office door was opened and the DON was not in the office. During an observation on 11/17/2021 at 8:30 AM to 10:30 AM the DON's office door was opened. Against the back wall of the office standing on the floor were two (2) E-Cylinder oxygen tanks unsecured. The E-Cylinders were surrounded by cardboard boxes sitting on the floor. Staff as well as residents were in and out of the DON's office. Multiple times during the day the DON's office door was opened and the DON was not in the office . During an interview on 11/17/2021 at 10:08 AM the DON said the oxygen cylinders sitting there were empty, just waiting to get them serviced. The oxygen cylinders are unsecured. She said her office was a collection place for all things. Record review of an oxygen safety: storage requirements policy dated 2003 indicated . Cylinders shall not be stored within 20 feet of flammable materials. The storage area will be free of oil, grease, paper and other combustible materials Storage areas must be secure from unauthorized access and cylinders must be protected from tampering. Cylinders must be store in rack, bins or chained to ta wall or other appropriate secured structure to prevent them from falling or being knocked over. This includes cylinders considered to be empty . Cylinder storage areas shall have signs posted regarding appropriate safety precautions and shall be labeled with NO SMOKING and NO OPEN FLAMES signs . The cylinder storage area shall serve no other purpose and be kept clear of flammable debris

Based on observation and interview, the facility failed to prominently display in the facility written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The facility failed to display in writing procedures for applying for and using Medicare and Medicaid benefits. This failure could place the residents at risk for not receiving information regarding their rights as residents. Findings included: During an observation on 11/17/21 at 1:20 pm, the posting bulletin located Hall 2 by the copier machine and on Hall 3 outside the MDS office had no information on how to apply for Medicare and Medicaid benefits. During an observation and interview on 11/17/21 at 1:40 pm the Administrator said he was not aware to post a copy of how to apply for and use Medicare and Medicaid benefits and how to receive funds for previous payments covered by such benefits were required postings. He said the missing posting was included in the admission packets but was not aware he was to also post it. He said he was responsible for postings.

Based on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 6 residents (Resident #1) reviewed for care plans. Resident #1's comprehensive care plan did not include a plan of care for wound care to her right foot, wound care consultation, impaired circulation, use of a bed cradle (device used to prevent bed linens from contacting the resident's feet), or the resident's resistance to care. These failures could result in care needs not being communicated to direct care staff. Findings included: A facility policy titled Comprehensive Care Plans, dated 2003, indicated the care plan must describe the following: *services/interventions that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being *problem statements to identify services that are required to maintain the resident's highest practicable physical, mental, and psychosocial well-being *Short- and long-term goals to identify reassessment parameters for the resident's maintenance of well-being, and *Evaluation of the interventions and goals to maintain the resident's well-being. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The most recent MDS assessment, dated 3/22/21, indicated Resident #1 had moderately impaired cognition, needed extensive assistance of one to two staff for most ADLs, and had application of dressings to feet. The most recent care plan, reviewed 3/19/21, indicated Resident #1 had problems including Alzheimer's disease, assistance with ADLs, nutritional status, falls, infection, diabetes, risk for pressure ulcers, pain, activities, and DNR code status. The care plan included a statement, dated 3/5/21, that Resident #1 was to have a wound care consult after Resident comes off skilled services. A statement dated 3/8/21 indicated Eschar to top of right second toe .treatment in progress. An undated statement indicated TOB (Tincture of [MEDICATION(S)], used skin sores and wounds to protest the area from irritation and infection) to right and left heels and toes twice a day.) The care plan did not include problems, goals or interventions for diabetic [CONDITION(S)], gangrenous tissue on the second and third toe of the right foot, use of a bed cradle, or refusal of care. Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] *4/2/21 - open area to right top of second toes, cleanse with normal saline, pat dry. Apply xeroform and secondary dressing daily *4/9/21 - utilize a foot cradle at all times while in bed. *4/12/21 - necrotic area to second and third toe, cleanse with normal saline, pat dry, pain with [MEDICATION(S)] daily A progress note dated 5/13/21 at 10:09 a.m., written by the ADON, indicated Resident #1's wound care appointment scheduled for 5/14/21 was cancelled at the request of the patient. During an interview on 6/4/21 at 3:30 p.m., the ADON said on 5/13/21 she had taken Resident #1 to the doctor when he placed the vascular stent (used to improve blood flow and circulation) in her right leg. The ADON said the physician told Resident #1 that the procedure had improved her circulation and that her toes would heal on their own. The ADON indicated Resident #1 said she did not want to go back to the wound care clinic and that they're not doing anything for me anyway. During an interview on 6/3/21 at 1:30 p.m., Resident #1 said she had been to get her toes looked at, and that Physician A had told her she had gangrene. Resident #1 said she had previously had a stent surgically placed in her leg to improve blood flow to her extremities. During an interview on 6/3/21 at 2:38 p.m. Physician A said Resident #1 had dry gangrene of the toes (unspecified) on her right foot. He said the gangrene was caused by poor circulation and complications of diabetes. Physician A said Resident #1 had gone to a couple of wound care appointments but then stopped going. Physician A said Resident #1 was capable of making her own medical decisions. During an interview on 6/7/21 at 2:09 p.m., the ADON said Resident #1's care plan did not address poor circulation, use of a bed, wound care consultation, gangrenous toes, or refusal of care. The ADON said all of those problems should have been included on the care plan, and she could not explain their absence. During a telephone interview on 6/7/21 at 3:14 p.m., RN B said she was the MDS coordinator and was responsible for updating care plans. RN B said the care plans had suffered over the past year due to the COVID-19 pandemic. RN B said she worked from home and came to the facility on e day a week. RN B said she had access to the electronic record at home, but that she did not check the orders every day. RN B said she went to the facility on Saturdays and would look at the treatments to see if there was anything that needed to be added. RN B said she was familiar with Resident #1 and I believe we have missed the mark on her. RN B said Resident #1's care plan should have been updated when she started having problems with her toes. RN B said the fact that she was not working at the facility made it hard to get information she needed to update the care plans. RN B said Resident #1 fell through the cracks. During an interview on 6/7/21 at 3:23 p.m., CNA D said she had taken care of Resident #1 about a month ago. CNA D said Resident #1's toes were sensitive and black. CNA D said Resident #1 had a bed cradle so nothing would touch her feet, but she did not like it. CNA D said Resident #1 would tell staff to leave her toes alone. CNA D said the nurses would usually let her know if anything was different about a resident's care, but if there was a question, they could access the care plan in the electronic record. During an interview on 6/7/21 at 3:45 p.m., CNA E said she usually gets a report at shift change, but if she had a question regarding a resident's care, she would look at the care plan for information. During an interview on 6/7/21 at 4:00 p.m., the administrator said RN B had been working from home since the pandemic started. The administrator said the system for getting resident care plans updated should include the MDS coordinator participating in a weekly nursing meeting where resident care issues were discussed. The administrator said RN B had not been attending those meetings since she had started working from home.

Based on observation, interview, and policy review, the facility failed to ensure staff removed gloves and completed hand hygiene after providing resident care. In addition, the facility failed to ensure staff removed personal protective equipment (PPE) per Center for Disease Control (CDC) guidelines. The deficient practice has the potential to contaminate anything the staff touch and could spread disease. Findings include: During an observation on 02/25/21 at 11:35 AM, Licensed Vocational Nurse (LVN)8 was seen doing an assessment by listening to the lungs of Resident (R)8 while wearing gloves. LVN8 then walked over to the medication cart, which was outside of the room, to get an [MEDICATION NAME] of medication for a breathing treatment. LVN8 did not remove the gloves or perform hand hygiene before getting the medication. During an observation on 02/25/21 at 11:50 AM, LVN8 was seen in R5's room completing a physical assessment. LVN8 walked to the medication cart and reached for the computer mouse to access the electronic medical record. LVN8 was wearing the same gloves that were worn during R5 assessment. During an interview on 02/25/21 at 11:55 AM, LVN8 was asked about not removing gloves and performing hand hygiene after completing resident assessments during the two observations. LVN8 stated, I should have taken the gloves off and performed hand washing before moving on to the medication cart. During an observation on 02/25/21 at 12:05 PM, Certified Nursing Assistant (CNA)9 was seen to doffing personal protective equipment (PPE) in the room of R6. CNA9 began with doffing gown, the hair cap, and the footies before taking off the gloves. During an interview on 02/25/21 at 12:10 PM, CNA9 was asked about doffing the gown, cap, and footies prior to taking off the gloves. CNA9 stated that she did take the gloves off last. CNA9 could not recall why that was the wrong sequence. CNA9 walked over to the wall near R6's room where the instructions were. The instructions indicated the gloves should be removed first due to being the most contaminated. CNA9 stated, I knew that. I forgot. During an interview on 02/25/21 at 12:20 PM, the Assistant Director of Nursing (ADON) was asked about the staff wearing gloves and not performing hand hygiene after providing resident care. The ADON stated, Staff should always take off their gloves and wash hands as they leave the resident. When asked about the sequence in which the CNA had doffed the PPE, the ADON stated, There are instructions hanging next to each of the doors that illustrate the sequence in which PPE should be doffed. It has also been in-serviced several times. The gloves come off first. Review of facility policy titled, Isolation Management, dated March 1, 2005, revealed . Remove gloves before leaving the resident's room and wash hands immediately with an antimicrobial or a waterless antiseptic agent .

Based on interview and record review, the facility failed to administer the facility in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility did not test staff based on the facility's county positivity rate and allowed staff (54) to refuse mandatory testing for COVID-19 ([MEDICAL CONDITION] that is spread from person to person causing mild to severe respiratory symptoms). The county positive rate increased 9.7 percent in one month. The county's positivity's rate was 14.4 percent which required 2 times a week testing. Staff said that administration did not require them to test for COVID-19 if they were asymptomatic. The facility did not document required symptoms of COVID-19 during the screening process before staff entered the facility. The facility only documented staff's temperatures. The staff screening logs did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. An Immediate Jeopardy (IJ) situation was identified on 10/31/20. While the IJ was removed on 11/02/20, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete testing and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of developing COVID-19. Findings included: During an interview on 10/30/20 at 2:48 p.m., the administrator said they offered COVID-19 testing to all staff based on the facility's county COVID-19 positivity rate. He said the positivity rate was currently at 14.4% and they offered to test staff twice a week. He said staff refused to be tested if they were asymptomatic. He said he called the local public health district and there were no testing guidelines in place. He said the regulations clearly stated that if the local jurisdiction did not have testing guidelines, a staff member that refused testing and was asymptomatic, would be allowed to continue working. The administrator said if a staff member had symptoms and refused to test, they would be required to quarantine for 10 days at home. He said if a staff member refused COVID-19 testing, the staff member had to initial and write refused on their testing logs. The administrator said if he required asymptomatic staff to test for COVID-19 based on the county's positive rate, most of the staff would quit. He said staff member A notified the facility on 10/27/20 that she was having COVID-19 symptoms. The administrator said staff member A, who did not provide direct care, was tested on [DATE] and received her positive results on 10/29/20. A COVID-19 test dated 10/27/20, for staff member A, indicated she had a positive result. Staff screening logs for staff member A dated 10/16/20, 10/19/20, 10/20/20, and 10/21/20 indicated her temperature was documented. The screening logs for staff member A did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. A letter dated 11/02/20 from the local public health district addressed to the administrator indicated the local public health district did not have a policy for testing nursing facilities. The local public health district recommended the facility follow CMS, DSHS, HHSC, and CDC guidelines on testing. During an interview on 10/30/20 at 2:53 p.m., the DON said she contacted each staff member, based on the county's positive rate, and offered COVID-19 testing. She said staff told her that they did not want to be tested because they were asymptomatic. She said staff were allowed to refuse testing and were still allowed to work. The DON said she tested all new hires, any staff that were symptomatic, and any residents that were symptomatic for COVID-19. Daily staff COVID-19 screening logs dated 10/15/20 to 10/31/20 indicated staff's temperatures were documented. The screening logs did not address absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. A staff testing log dated 09/21/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 09/23/20 indicated the facility's county positivity rate was 4.7% and the facility's minimum testing frequency was once a month. A staff testing log dated 09/28/20 indicated a total of 49 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 09/30/20 indicated the facility's county positivity rate was 5.5% and the facility's minimum testing frequency was once a week. A staff testing log dated 10/06/20 indicated a total of 52 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/07/20 indicated the facility's county positivity rate was 5.9% and the facility's minimum testing frequency was once a week. A staff testing log dated 10/15/20 indicated a total of 54 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/21/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/23/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/28/20 indicated a total of 54 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/26/20 indicated the facility's county positivity rate was 14.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/30/20 (surveyor entered the facility on 10/30/20) indicated a total of 38 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/26/20 indicated the facility's county positivity rate was 14.4% and the facility's minimum testing frequency was twice a week. A list of staff tested for COVID-19, provided on 10/30/20 by the DON, indicated in the last 2 weeks, 2 staff were tested on [DATE], 4 staff were tested on [DATE], and one staff was tested on [DATE]. During an interview on 10/30/20 at 3:07 p.m., the social worker said she was offered COVID-19 testing twice a week by the facility. She said administration explained to her that if she was asymptomatic she could refuse testing and still be allowed to work. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. The social worker said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the social worker dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for the social worker did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:11 p.m., CNA E said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA E dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, 10/30/20, and 10/31/20 indicated her temperature was documented. The screening logs for CNA E did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:14 p.m., MA D said she was offered COVID-19 testing twice a week by the facility. She said administration explained to her that if she was asymptomatic she could refuse testing and still be allowed to work. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA D dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA D did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:17 p.m., LVN H said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN H dated 10/15/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN H did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:22 p.m., CNA K said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA K dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA K did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:28 p.m., CNA F said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA F dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA F did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:36 p.m., the director of rehab said he was offered COVID-19 testing twice a week by the facility. He said he refused the testing because he was asymptomatic. He said he initialed and wrote refused on the testing log. He said he was screened before his shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the director of rehab dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated his temperature was documented. The screening logs for the director of rehab did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:44 p.m., MA L said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA L dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA L did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 4:07 p.m., MA J said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA J dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA J did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 5:26 p.m., LVN B said she was offered COVID-19 testing twice a week by the facility. She said administration explained to her that if she was asymptomatic she could refuse testing and still be allowed to work. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN B dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN B did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 5:35 p.m., CNA C said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA C dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA C did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. The facility's testing policy for refusals dated 08/26/20 indicated .it is the policy of (the facility) to follow CMS guidelines (noted below) in the event of an employee refusing the CMS mandated testing. Refusal of testing facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing. Due to our local jurisdiction not having testing guidelines, if a facility employee who is asymptomatic refuses, testing, they will be allowed to continue working. If an employee is symptomatic and refuses testing, they will be required to quarantine at home until symptoms have subsided for 72 hours or until they have provided a negative PCR test . The HHS COVID-19 Response for Nursing Facilities (NF) dated 10/08/20 indicated .a NF must test all staff, including individuals providing services under arrangement and volunteers, for COVID-19. NF staff must be tested for COVID-19 if they have signs and symptoms of COVID-19; during outbreak conditions; routinely based on the county positivity rate for the county where the NF is located .a NF must check the county positivity at least every other week. A NF can use either the CMS-issued or locally-issued county positivity rate .a NF must develop policies and procedures for staff refusal of routine testing, outbreak testing, and testing because the person has signs or symptoms of COVID-19. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. A NF should consult its human resources and legal departments for guidance on staff refusal of routine testing. A NF's policies about an employee's individual position regarding testing should be based on the employee's reasons for declining and the facilities' policy on hiring and refusal of routine testing. A NF is not required to exclude an employee from work for refusal of routine testing. However, a NF must ensure that an employee's refusal of routine testing does not potentially endanger the health and safety of the residents or other staff. A NF must ensure ICP precautions are followed .the CDC and CMS recommend, (and the NF COVID-19 Response rules require), NFs screen all staff prior to entering the facility at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat (and other symptoms of COVID-19) . A CMS Memorandum dated 08/26/20 (QSO-20-38-NH) indicated .to enhance efforts to keep COVID-19 from entering and spreading through nursing home, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary .Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as a trigger for staff testing frequency .The facility should begin testing all staff at the frequency prescribed in the routine testing table based on the county positivity rate reported in the past week. Facilities should monitor their county positivity rate every other week and adjust the frequency of performing staff testing according to the table above .Facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing . The Centers for Disease Control (CDC) Overview of Testing for SAR-CoV-2 (COVID-19) dated 10/21/20 indicated .if you work in a nursing home, you will need testing if there is an outbreak in your facility, and repeat testing at regular intervals if your initial test result was negative until the outbreak is over; you will need serial testing based on your county percent test positivity rate; follow any additional guidance from public health officials and the Center for Medicare and Medicaid Services (CMS) . The Centers for Disease Control (CDC) Preparing for COVID-19 in Nursing Homes dated 06/25/20 indicated .screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 . The administrator was notified on 10/31/20 at 1:33 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 10/31/20. The facility's Plan of Removal was accepted on 10/31/20 at 8:29 p.m. and included: All staff members will be tested by Monday, November 2, 2020 at 11:59 p.m. In the event we are unable to reach a staff member by this time, that employee will not be allowed into the facility until they are able to be tested . If an employee tests negative and is presenting with no symptoms they will be allowed to work. If an employee test negative and has symptoms, they will immediately be given a PCR test and will not be allowed to return to work unless the PCR test is negative or until they have met the CDC return to work guidelines. In the event the county positivity rate is below 5%, staff will be tested 1 time per month. If the county positivity rate is between 5-10%, staff will be tested 1 time per week. If the county positivity rate is greater than 10%, staff will be tested twice per week. Our facilities plan for staffing amid numerous positive cases or refusals is as follows: (The facility) has entered into a contract with (staffing agency) to provide agency staff in the case of staff shortages. If (staffing agency) unable to provide our facility with staff, (the facility) will submit a STAR request to the state for staffing enhancements. Staff screening forms have been updated to identify symptoms and temperatures and a copy of that screening form is attached at the bottom of this form. Coronavirus Screening Form Name: _____________________________ Date: _____________ Temperature:________________ Part I: Questionnaire Please answer the following. Yes No Have you traveled to or from known COVID19 hot-spots in the past 14 days? Do you have a fever or chills? Do you have a cough? Do you have a sore throat? Are you experiencing shortness of breath or difficulty breathing? Are you experiencing muscle or body aches? Do you have a headache? Are you experiencing any new loss of taste or smell? Do you have congestion or a runny nose? Are you having any nausea, vomiting or diarrhea? Have you been in contact with someone with or under investigation for COVID-19? Part II: Comments Provide additional information, if you answered yes to any of the above. Travel history: Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: Part III: Action/Signature Visitation denied/work restricted: _______ No _______ Yes (exhibits criteria) Wishes to speak with Infection Preventionist: _______ No _______ Yes Signature: __________________________________ Date: ______________ Part IV: Follow Up Notes: Infection Preventionist Signature: _______________________ Date: _____________ On 11/02/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 11/02/20 at 1:44 p.m., staff were outside the facility being screened by the ADON with the new screening tool that included documentation of temperature, absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 11/02/20 at 1:50 p.m., the administrator said 48 staff had been tested for COVID-19 by the DON and all 48 tests were negative. He said they initiated testing on 10/31/20. He said the DON used the POC tests. The administrator said staff that have not been tested will not be allowed in the facility until they are tested . He said no staff have refused COVID-19 testing. The administrator said they initiated the use of the new screening tool for staff. He said he updated the facility's testing policy for refusals and it now indicated that if a staff member was symptomatic and refused testing, they would be required to quarantine at home for 10 days and could return to work if they were fever free for 72 hours and symptom free. The administrator said they would continue staff testing based on the county's positive rate. During an interview on 11/02/20 at 2:43 p.m., the DON said she was performing the POC COVID-19 tests on staff. She said she completed 51 tests and they all were negative. She said there were only a few staff left that had not been tested but they would be tested before they were allowed to work. She said the staff member that tested positive on 10/27/20 was not tested . She said she wrote the staff member's name on the outside of the testing card and when the card displayed the result, she took a picture and printed the picture. During an observation on 11/02/20 at 3:22 p.m., pictures and photocopied pictures of 51 staff tests with negative results were reviewed. A staff testing log was reviewed and indicated 14 staff were tested on [DATE], 4 staff were tested on [DATE], and 33 staff were tested on [DATE]. The log indicated all 51 staff tested negative. The facility's testing policy for refusals dated 08/26/20 was reviewed and updated. The policy indicated .if an employee is symptomatic and refuses testing, they will be required to quarantine at home for 10 days and may return to work only when symptoms have subsided and they have been fever free for 72 hours . Three nurses, the social worker, the housekeeping supervisor, a dietary aide, the activity director, one MA, and 3 CNAs said they were tested for COVID-19 by the facility and they had no concerns about testing based on the county's positive rate. They said they were using the new screening tool when they were screened for COVID-19 symptoms and fever before their shift. On 11/02/20 at 4:10 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete testing and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure testing parameters set forth by the Secretary of State related to COVID-19 (a virus that is spread from person to person causing mild to severe respiratory symptoms). The facility did not test staff based on the facility's county positivity rate for COVID 19 and allowed staff (54) to refuse COVID-19 testing. The county positive rate increased 9.7 percent in one month. The county's positivity's rate was 14.4 percent which required 2 times a week testing. Staff said that administration did not require them to test for COVID-19 if they were asymptomatic. An Immediate Jeopardy (IJ) situation was identified on 10/31/20. While the IJ was removed on 11/02/20, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete testing and evaluate the effectiveness of the corrective systems. This failure could place residents at risk of developing COVID-19. Findings included: During an interview on 10/30/20 at 2:48 p.m., the administrator said they offered COVID-19 testing to all staff based on the facility's county COVID-19 positivity rate. He said the positivity rate was currently at 14.4% and they offered to test staff twice a week. He said staff refused to be tested if they were asymptomatic. He said he called the local public health district and there were no testing guidelines in place. He said the regulations clearly stated that if the local jurisdiction did not have testing guidelines, a staff member that refused testing and was asymptomatic, would be allowed to continue working. The administrator said if a staff member had symptoms and refused to test, they would be required to quarantine for 10 days at home. He said if a staff member refused COVID-19 testing, the staff member had to initial and write refused on their testing logs. The administrator said if he required asymptomatic staff to test for COVID-19 based on the county's positive rate, most of the staff would quit. He said staff member A notified the facility on 10/27/20 that she was having COVID-19 symptoms. He said staff member A was last in the facility on 10/21/20 and exhibited no COVID-19 symptoms. He said staff member A was off work due to her daughter testing positive for COVID-19 on 10/24/20 and she was exposed to her daughter. The administrator said staff member A, who did not provide direct care, was tested on [DATE] and tested positive. He said staff member A was not tested at the facility and she received her positive results on 10/29/20. The administrator said staff member A would not return to work until she was asymptomatic for 10 days and fever free for 72 hours. A COVID-19 test dated 10/27/20, for staff member A, indicated she had a positive result. Staff screening logs for staff member A dated 10/16/20, 10/19/20, 10/20/20, and 10/21/20 indicated her temperature was documented. The screening logs for staff member A did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. A letter dated 11/02/20 from the local public health district addressed to the administrator indicated the local public health district did not have a policy for testing nursing facilities. The local public health district recommended the facility follow CMS, DSHS, HHSC, and CDC guidelines on testing. During an interview on 10/30/20 at 2:53 p.m., the DON said she contacted each staff member, based on the county's positive rate, and offered COVID-19 testing. She said staff told her that they did not want to be tested because they were asymptomatic. She said all staff were screened for COVID-19 symptoms before entering the facility. She said if a staff member presented with any symptoms, they were not allowed to enter the facility. She said staff were vigilant with self-monitoring when they were at work and not working. The DON said staff notified her if they had any COVID-19 symptoms, they were offered a COVID-19 test, or they were required to quarantine at home for 10 days. The DON said she tested all new hires, any staff that were symptomatic, and any residents that were symptomatic for COVID-19. Daily staff COVID-19 screening logs dated 10/15/20 to 10/31/20 indicated staff's temperatures were documented. The screening logs did not address absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 11/02/20 at 4:16 p.m., the DON said the facility received point of care (POC) testing kits in September 2020, but the negative control was not accurately displaying on the cartridge. She said it was not until 09/21/20 that the facility received instruction from the manufacturer regarding the inaccurate negative control and they began offering testing to staff on 09/21/20. A staff testing log dated 09/21/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 09/23/20 indicated the facility's county positivity rate was 4.7% and the facility's minimum testing frequency was once a month. A staff testing log dated 09/28/20 indicated a total of 49 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 09/30/20 indicated the facility's county positivity rate was 5.5% and the facility's minimum testing frequency was once a week. A staff testing log dated 10/06/20 indicated a total of 52 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/07/20 indicated the facility's county positivity rate was 5.9% and the facility's minimum testing frequency was once a week. A staff testing log dated 10/15/20 indicated a total of 54 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/21/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/23/20 indicated a total of 53 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/14/20 indicated the facility's county positivity rate was 10.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/28/20 indicated a total of 54 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/26/20 indicated the facility's county positivity rate was 14.4% and the facility's minimum testing frequency was twice a week. A staff testing log dated 10/30/20 (surveyor entered the facility on 10/30/20) indicated a total of 38 staff refused COVID-19 testing. CMS COVID-19 positivity rate data for the week ending 10/26/20 indicated the facility's county positivity rate was 14.4% and the facility's minimum testing frequency was twice a week. A list of staff tested for COVID-19, provided on 10/30/20 by the DON, indicated in the last 2 weeks, 2 staff were tested on [DATE], 4 staff were tested on [DATE], and one staff was tested on [DATE]. During an interview on 11/02/20 at 2:46 p.m., the administrator said 2 of the staff tested for COVID-19 were new hires, one staff was a hairdresser, and 3 staff had mild symptoms. He said those staff tested negative. He said staff member A was the only staff that tested positive. During an interview on 10/30/20 at 3:07 p.m., the social worker said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. The social worker said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the social worker dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for the social worker did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:11 p.m., CNA E said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA E dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, 10/30/20, and 10/31/20 indicated her temperature was documented. The screening logs for CNA E did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:14 p.m., MA D said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA D dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA D did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:17 p.m., LVN H said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN H dated 10/15/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN H did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:22 p.m., CNA K said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA K dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA K did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:28 p.m., CNA F said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA F dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA F did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:36 p.m., the director of rehab said he was offered COVID-19 testing twice a week by the facility. He said he refused the testing because he was asymptomatic. He said he initialed and wrote refused on the testing log. He said he was screened before his shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the director of rehab dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated his temperature was documented. The screening logs for the director of rehab did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 3:44 p.m., MA L said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA L dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA L did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 4:07 p.m., MA J said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA J dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA J did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 5:26 p.m., LVN B said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN B dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN B did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 10/30/20 at 5:35 p.m., CNA C said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA C dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA C did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. The facility's testing policy for refusals dated 08/26/20 indicated .it is the policy of [the facility] to follow CMS guidelines (noted below) in the event of an employee refusing the CMS mandated testing. Refusal of testing facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing. Due to our local jurisdiction not having testing guidelines, if a facility employee who is asymptomatic refuses, testing, they will be allowed to continue working. If an employee is symptomatic and refuses testing, they will be required to quarantine at home until symptoms have subsided for 72 hours or until they have provided a negative PCR test . The HHS COVID-19 Response for Nursing Facilities (NF) dated 10/08/20 indicated .a NF must test all staff, including individuals providing services under arrangement and volunteers, for COVID-19. NF staff must be tested for COVID-19 if they have signs and symptoms of COVID-19; during outbreak conditions; routinely based on the county positivity rate for the county where the NF is located .a NF must check the county positivity at least every other week. A NF can use either the CMS-issued or locally-issued county positivity rate .a NF must develop policies and procedures for staff refusal of routine testing, outbreak testing, and testing because the person has signs or symptoms of COVID-19. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. A NF should consult its human resources and legal departments for guidance on staff refusal of routine testing. A NF's policies about an employee's individual position regarding testing should be based on the employee's reasons for declining and the facilities' policy on hiring and refusal of routine testing. A NF is not required to exclude an employee from work for refusal of routine testing. However, a NF must ensure that an employee's refusal of routine testing does not potentially endanger the health and safety of the residents or other staff. A NF must ensure ICP precautions are followed .the CDC and CMS recommend, [and the NF COVID-19 Response rules require], NFs screen all staff prior to entering the facility at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat [and other symptoms of COVID-19] . A CMS Memorandum dated 08/26/20 (QSO-20-38-NH) indicated .to enhance efforts to keep COVID-19 from entering and spreading through nursing home, facilities are required to test residents and staff based on parameters and a frequency set forth by the HHS Secretary .Routine testing should be based on the extent of the virus in the community, therefore facilities should use their county positivity rate in the prior week as a trigger for staff testing frequency .The facility should begin testing all staff at the frequency prescribed in the routine testing table based on the county positivity rate reported in the past week. Facilities should monitor their county positivity rate every other week and adjust the frequency of performing staff testing according to the table above .Facilities must have procedures in place to address staff who refuse testing. Procedures should ensure that staff who have signs or symptoms of COVID-19 and refuse testing are prohibited from entering the building until the return to work criteria are met. If outbreak testing has been triggered and a staff member refuses testing, the staff member should be restricted from the building until the procedures for outbreak testing have been completed. The facility should follow its occupational health and local jurisdiction policies with respect to any asymptomatic staff who refuse routine testing . The Centers for Disease Control (CDC) Overview of Testing for SAR-CoV-2 (COVID-19) dated 10/21/20 indicated .if you work in a nursing home, you will need testing if there is an outbreak in your facility, and repeat testing at regular intervals if your initial test result was negative until the outbreak is over; you will need serial testing based on your county percent test positivity rate; follow any additional guidance from public health officials and the Center for Medicare and Medicaid Services (CMS) . The Centers for Disease Control (CDC) Preparing for COVID-19 in Nursing Homes dated 06/25/20 indicated .screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 . The administrator was notified on 10/31/20 at 1:33 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The IJ template was provided to the administrator by email on 10/31/20. The facility's Plan of Removal was accepted on 10/31/20 at 8:29 p.m. and included: All staff members will be tested by Monday, November 2, 2020 at 11:59p.m. In the event we are unable to reach a staff member by this time, that employee will not be allowed into the facility until they are able to be tested . If an employee tests negative and is presenting with no symptoms they will be allowed to work. If an employee test negative and has symptoms, they will immediately be given a PCR test and will not be allowed to return to work unless the PCR test is negative or until they have met the CDC return to work guidelines. In the event the county positivity rate is below 5%, staff will be tested 1 time per month. If the county positivity rate is between 5-10%, staff will be tested 1 time per week. If the county positivity rate is greater than 10%, staff will be tested twice per week. Our facilities plan for staffing amid numerous positive cases or refusals is as follows: [The facility] has entered into a contract with [staffing agency] to provide agency staff in the case of staff shortages. If [staffing agency] unable to provide our facility with staff, [the facility] will submit a STAR request to the state for staffing enhancements. Staff screening forms have been updated to identify symptoms and temperatures and a copy of that screening form is attached at the bottom of this form. Coronavirus Screening Form Name: _____________________________ Date: _____________ Temperature:________________ Part I: Questionnaire Please answer the following. Yes No Have you traveled to or from known COVID19 hot-spots in the past 14 days? Do you have a fever or chills? Do you have a cough? Do you have a sore throat? Are you experiencing shortness of breath or difficulty breathing? Are you experiencing muscle or body aches? Do you have a headache? Are you experiencing any new loss of taste or smell? Do you have congestion or a runny nose? Are you having any nausea, vomiting or diarrhea? Have you been in contact with someone with or under investigation for COVID-19? Part II: Comments Provide additional information, if you answered yes to any of the above. Travel history: Onset and duration of any symptoms: Duration & proximity of contact with anyone with or under investigation for COVID-19: Part III: Action/Signature Visitation denied/work restricted: _______ No _______ Yes (exhibits criteria) Wishes to speak with Infection Preventionist: _______ No _______ Yes Signature: ____________________________________________ Date: ______________ Part IV: Follow Up Notes: Infection Preventionist Signature: ___________________________________________ Date: ______________ On 11/02/20 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: During an observation on 11/02/20 at 1:44 p.m., staff were outside the facility being screened by the ADON with the new screening tool that included documentation of temperature, absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with or under investigation for COVID-19, and international travel in the last 14 days. During an interview on 11/02/20 at 1:50 p.m., the administrator said 48 staff had been tested for COVID-19 by the DON and all 48 tests were negative. He said they initiated testing on 10/31/20. He said the DON used the POC tests. The administrator said staff that have not been tested will not be allowed in the facility until they are tested . He said no staff have refused COVID-19 testing. The administrator said they initiated the use of the new screening tool for staff. He said he updated the facility's testing policy for refusals and it now indicated that if a staff member was symptomatic and refused testing, they would be required to quarantine at home for 10 days and could return to work if they were fever free for 72 hours and symptom free. The administrator said they would continue staffing testing based on the county's positive rate. During an interview on 11/02/20 at 2:43 p.m., the DON said she was performing the POC COVID-19 tests on staff. She said she completed 51 tests and they all were negative. She said there were only a few staff left that had not been tested but they would be tested before they were allowed to work. She said the staff member that tested positive on 10/27/20 was not tested . She said she wrote the staff member's name on the outside of the testing card and when the card displayed the result, she took a picture and printed the picture. During an observation on 11/02/20 at 3:22 p.m., pictures and photocopied pictures of 51 staff tests with negative results were reviewed. A staff testing log was reviewed and indicated 14 staff were tested on [DATE], 4 staff were tested on [DATE], and 33 staff were tested on [DATE]. The log indicated all 51 staff tested negative. The facility's testing policy for refusals dated 08/26/20 was reviewed and updated. The policy indicated .if an employee is symptomatic and refuses testing, they will be required to quarantine at home for 10 days and may return to work only when symptoms have subsided, and they have been fever free for 72 hours . Three nurses, the social worker, the housekeeping supervisor, a dietary aide, the activity director, one MA, and 3 CNAs said they were tested for COVID-19 by the facility and they had no concerns about testing based on the county's positive rate. They said they were using the new screening tool when they were screened for COVID-19 symptoms and fever before their shift. On 11/02/20 at 4:10 p.m., the administrator and DON were informed the IJ was removed; however, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as widespread due to the facility's need to complete testing and evaluate the effectiveness of the corrective systems.

Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to help prevent the development and transmission of communicable diseases was established and maintained for infection control related to COVID-19 ([MEDICAL CONDITION] that is spread from person to person causing mild to severe respiratory symptoms). The facility did not document required symptoms of COVID-19 during the screening process before staff entered the facility. The facility only documented staff's temperatures. The staff screening logs did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. This failure could place residents at risk of developing COVID-19, other infections and death. Findings included: The HHS COVID-19 Response for Nursing Facilities (NF) dated 10/08/20 indicated .the CDC and CMS recommend, (and the NF COVID-19 Response rules require), NFs screen all staff prior to entering the facility at the beginning of their shift for fever and symptoms consistent with COVID-19. Actively take their temperature and document absence of or shortness of breath, new or change in cough, sore throat (and other symptoms of COVID-19) . The Centers for Disease Control (CDC) Preparing for COVID-19 in Nursing Homes dated 06/25/20 indicated .screen all healthcare personnel (HCP) at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19 . The facility's Novel Coronavirus (COVID-19) prevention and response policy dated 03/11/20 indicated .monitor residents and employees for fever or respiratory symptoms . The facility's policy did not address screening documentation of COVID-19 symptoms for staff. Daily staff COVID-19 screening logs dated 10/15/20 to 10/31/20 indicated staff's temperatures were documented. The screening logs did not address absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:07 p.m., the social worker said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. The social worker said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the social worker dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for the social worker did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:11 p.m., CNA E said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA E dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, 10/30/20, and 10/31/20 indicated her temperature was documented. The screening logs for CNA E did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:14 p.m., MA D said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA D dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA D did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:17 p.m., LVN H said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN H dated 10/15/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN H did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:22 p.m., CNA K said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA K dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA K did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:28 p.m., CNA F said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA F dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/25/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA F did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:36 p.m., the director of rehab said he was offered COVID-19 testing twice a week by the facility. He said he refused the testing because he was asymptomatic. He said he initialed and wrote refused on the testing log. He said he was screened before his shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for the director of rehab dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated his temperature was documented. The screening logs for the director of rehab did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 3:44 p.m., MA L said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA L dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA L did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 4:07 p.m., MA J said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for MA J dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for MA J did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 5:26 p.m., LVN B said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for LVN B dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/23/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for LVN B did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 5:35 p.m., CNA C said she was offered COVID-19 testing twice a week by the facility. She said she refused the testing because she was asymptomatic. She said she initialed and wrote refused on the testing log. She said she was screened before her shift for temperature and symptoms of COVID-19 and allowed to enter the facility. Staff screening logs for CNA C dated 10/15/20, 10/16/20, 10/19/20, 10/20/20, 10/21/20, 10/22/20, 10/26/20, 10/27/20, 10/28/20, 10/29/20, and 10/30/20 indicated her temperature was documented. The screening logs for CNA C did not include absence of/or shortness of breath, difficulty breathing, new or change in cough, sore throat, chills, fatigue, muscle aches, headache, new loss of taste or smell, congestion, runny nose, nausea, vomiting, diarrhea, exposure to someone diagnosed with [REDACTED]. During an interview on 10/30/20 at 2:53 p.m., the DON said all staff were screened for temperature and asked about new or change in cough, shortness of breath, sore throat, and other symptoms of COVID-19 before entering the facility but they were only documenting staff's temperatures. She said if a staff member presented with any symptoms, they were not allowed to enter the facility. She said staff were vigilant with self-monitoring when they were at work and not working.

Based on observation, interview and record review the facility failed to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the development and the transmission of disease and infection for 2 of 4 residents observed for blood sugar assessments and 1 of 4 residents observed for resident care interactions. LVN A used alcohol prep pads to disinfect the glucometer before and after resident blood sugars. CNA B and C did not wash or sanitize their hands when providing resident care. This failure could place residents who require blood sugars, assistance with ADLs, and Hoyer transfers at risk for infections. Findings included: 1. During observations of blood sugar checks on 02/10/20 at 11:40 AM and 11:45 AM, LVN A was noted to clean the glucometer before and after use with an alcohol prep pad. 2. During an observation on 02/11/20 at 02:10 PM, CNA B and C performed a Hoyer transfer from the wheelchair to the bed for Resident #33. The resident was positioned in bed by CNA C while CNA B worked the Hoyer control. CNA B removed the resident's socks and pants, she was noted to be sniffling and rubbed her nose with her hand. CNA B and C did not wash or sanitize their hands before or after resident care and they did not use gloves 3. During an observation on 02/11/20 at 02:15 PM, CNA C left Resident #33s room [ROOM NUMBER] without washing or sanitizing her hands. She pushed the Hoyer lift to the 100 hall and left it there. CNA C was then noted to enter to room [ROOM NUMBER] where she was touched Resident #41 with her bare hands. CNA C did not wash or sanitize her hands when exiting room [ROOM NUMBER] and before entering room [ROOM NUMBER]. During an interview on 02/10/20 at 11:37 AM, LVA A said she had to clean the glucometer, opened an alcohol prep pad and wiped down the glucometer. During an interview on 02/12/20 at 12:38 PM, the DON and ADON said that dispatch wipes are to be used for sanitizing the glucometers before and after use. The DON said that alcohol prep pads are not to be used, as they do not kill certain pathogens such [MEDICAL CONDITIONS]. The ADON said that the expectation is for dispatch wipes to be used and it was written this way in the glucometer policy and procedure. The DON said dispatch is the name of the wipes. During an interview on 02/11/20 at 02:17 PM, CNA B said she did not wash or sanitize her hands before performing resident care for Resident # 33, she said she should have. During an interview on 02/11/20 at 02:19 PM, CNA C said she did not wash or sanitize her hands before or after providing care for Resident #33. She said when she left room [ROOM NUMBER] she took the Hoyer lift to the 100 hall and went to room [ROOM NUMBER] where she was caring for Resident 41. CNA C said she did not wash or sanitize her hands between caring for Resident #33 and Resident #41. CNA C said she should have washed her hands before and after caring for each resident. During an interview on 02/12/20 at 09:52 AM, the DON said the CNAs should wash their hands before and after caring for each resident. She said the CNAs said they were nervous and did not wash their hands. She said the CNAs had never been through a survey and were nervous. A [MEDEQUIP] Use in Obtaining Blood Sugar Results procedure dated March 8,2012 indicated under #15. Clean glucometer with dispatch wipes and allow to dry. An undated policy and procedure for hand-washing indicated hand washing should be done before and after caring for each resident. During the exit conference on 02/12/20 at 01:25 PM, the facility was asked if they wished to provide any additional information. No additional information was provided.

Surveyor: Mouton-Tedder, Melan Based on observation, interview, and record review, the facility did not maintain an infection prevention program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 residents reviewed for incontinent care (Resident #s 31 and 51) * CNA F did not use universal precautions while providing Resident #31 with incontinent care. * CNA D touched clean items with soiled gloves during Resident #51's incontinent care. This failure could place residents who required incontinent care at risk for cross contamination. Findings included: 1. During an observation and interview on 02/19/19 at 09:45 AM CNA F provided incontinent care on Resident #31. CNA F did not wash her hands when she entered the resident room. She donned gloves. The resident's brief was opened, and the resident was turned to her left side. The dirty brief was rolled under the resident and a clean brief was placed. CNA F opened a package of barrier cream, applied cream to the resident's buttocks, and without changing gloves she rolled the resident on her back. The front of the dirty brief was tucked out of the way. Without changing gloves, the CNA took the washcloth to the bathroom and wet it. She came back and cleaned the resident with the washcloth without folding the washcloth over down one groin, then the other groin, then without opening the labia cleaned down the center. Without changing gloves, she removed the dirty brief, situated the clean brief, and closed the brief. Without changing gloves, CNA F pulled up the resident covers and adjusted the bed. CNA F then gathered up dirty linen and trash, removed the soiled gloves, tied the bags closed, and exited the room without washing her hands. She said she would not have done anything different. 2. During an observation on 02/20/19 at 09:30 AM, CNAs D and E provided incontinent care for Resident #51. Both washed their hands and gloved. CNA D provided care to the resident's front peri-area. Without changing gloves, CNA D covered the resident with her sheet. Both CNAs then changed gloves and sanitized their hands. The resident was turned onto her right side and CNA D removed the soiled brief and provided care to the resident's anal area. Using the same soiled gloves CNA D rolled the used incontinence pad under the resident, placed a clean incontinence pad, and placed a clean brief under the resident. Without changing gloves, the CNA D helped turn the resident to the opposite side and CNA E removed the old incontinence pad and pulled through the clean items. Using the same soiled gloves CNA D pulled the brief up through the resident's legs and affixed the tabs. Both CNAs then changed gloves and sanitized their hands. During an interview on 02/20/19 at 09:45 AM CNAD said they are supposed to change their gloves after they clean the front area, after they clean the back area, and when they are finished with care. She said she did not realize she had not changed her gloves after cleansing the back area before touching the clean items. She said she was nervous and should have put barrier cream on the resident also. A Perineal Care procedure revised 02/20/12 indicated Procedure: 2. Perform handwashing 6. Put on disposable gloves. 7. For female perineal care: .b. Using the washcloth and soap, wash the mons pubis, rinse and dry c. Moisten the washcloth with water and soap and separate the labia with the thumb and finger of the non-dominant hand and wash down the center of the genitalia from front to back, then down each side of the genitalia from front to back using a different part of the washcloth with water and soap. f. apply moisture barrier ointment as needed. g. wash hands h. change gloves before touching clean items An undated Policy and Procedure for Hand-Washing indicated: .Hand washing should be done at the following times: b. before and after caring for each resident. c. Before applying gloves and after removing gloves

Based on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of one resident reviewed for feeding tubes (Resident #18). LVN A failed to check placement and gastric residual volume of Resident #18's [DEVICE] (a tube inserted through the abdomen that delivers nutrition/medications/fluids directly to the stomach) prior to administering medications. The facility failed to have a physician order [REDACTED]. This failure could affect residents with a [DEVICE] by placing them at risk of abdominal discomfort, nausea, vomiting, aspiration, infection, and decreased quality of life. Findings included: An MDS assessment dated [DATE] indicated Resident #18 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired and received nutrition and medications via [DEVICE]. A care plan dated 10/09/18 indicated Resident #18 .requires all nutrition, fluids and medications via [DEVICE]. due [MEDICAL CONDITION].Interventions .Check for tube placement and patency of feeding tube per protocol. A handwritten addendum dated 12/11/18 said may have puree pleasure feedings and that Pleasure feedings are for pleasure, not to maintain nutrition - per ST (speech therapist). A physician order [REDACTED].#18 did not have any orders to check G- tube placement or residual. The report did not indicate when to notify the physician. During an observation on 02/19/19 at 03:10 p.m., LVN A crushed [MEDICATION NAME] 50mg and diluted it with approximately 10-15 cc of water. LVN A entered Resident #18's room, stopped the continuous feeding, and placed the 60-cc piston syringe in the end of the [DEVICE]. LVN A poured 30 cc of water into the tube, followed by the medication, and an additional 30 cc of water, he then resumed the continuous feeding. LVN A did not check for placement or residual prior to administering the medications. During an interview on 02/19/19 at 03:25 p.m., LVN A said could not think of anything he would have done differently. During an interview on 02/20/19 at 09:00 a.m., LVN B said placement and residual are checked every shift. She said placement is checked by insertion of air while auscultating. She said physician orders [REDACTED]. During an interview on 02/20/19 at 03:05 p.m., LVN C said when she administers medications she checks [DEVICE] placement by inserting about 30 cc of air into the [DEVICE] while auscultating. LVN C said she also checks for residual. She said there are usually orders to call the physician if residual is greater than a certain amount, she would have to check resident's orders as to the amount. During an interview on 02/20/19 at 03:45 p.m., the ADON said the physician usually orders placement checks for [DEVICE]s and residual checks according to their personal specifications when they wish to be called. The ADON said after checking the orders for Resident #18, no [DEVICE] placement or residual assessment orders had been written, she said this was an omission. She said the normal is for the nurse to check placement by inserting 30 cc of air and auscultating. She said there was a policy to address checking for placement and residual and she would provide a copy to the surveyor. An undated Enteral Medication Administration Policy/Procedure indicated 6. Check placement of the tube by aspiration of contents or auscultation.

Based on observation, interview, and record review, the facility failed to ensure nurse aides demonstrated competency in techniques necessary to care for residents' needs as identified through resident assessments and described in the plan of care for 1 of 3 residents reviewed for incontinent care. (Resident # 31). CNA F did not use universal precautions and did not use proper technique during incontinent care for Resident #31. This failure could place residents who require incontinent care at risk for infection and a decreased quality of life. Findings included: An MDS dated [DATE] indicated Resident #31 was an [AGE] year-old female admitted on [DATE] with [DIAGNOSES REDACTED]. She required extensive assistance of 1-2 persons with transfers and toileting, she was always incontinent of bladder, and she was always incontinent of bowel. A care plan dated 01/16/19 indicated Resident #31 was incontinent of bladder and bowel, and required extensive assistance of 1-2 persons with transfers, toileting, bathing, dressing, grooming, hygiene, and mobility. During an observation and interview on 02/19/19 at 09:45 a.m., CNA F provided incontinent care for Resident #31. CNA F entered the residents room and placed on gloves, she did not wash her hands. CNA F rolled the soiled brief under the resident and a clean brief was placed. CNA F opened a package of barrier cream, applied cream to the resident's buttocks, and rolled the resident on her back. CNA F took a washcloth to the bathroom and wet it, returned and wiped the residents vaginal area she did not rotate the washcloth and she did not separate Resident #31 labia and thoroughly clean her vagina. CNA F removed the dirty brief, situated the clean brief, adjusted the bed and the resident covers all while wearing the same pair of soiled gloves. CNA F gathered all supplies, removed the soiled gloves and left the residents room, she did not wash her hands. CNA F said she would not have done anything different. During an interview on 02/21/19 at 10:20 a.m. the ADON said staff were to sanitize hands between glove changes and clean residents using appropriate technique. A Perineal Care procedure revised 02/20/12 indicated Procedure: 2. Perform handwashing 6. Put on disposable gloves. 7. For female perineal care: .b. Using the washcloth and soap, wash the mons pubis, rinse and dry c. Moisten the washcloth with water and soap and separate the labia with the thumb and finger of the non-dominant hand and wash down the center of the genitalia from front to back, then down each side of the genitalia from front to back using a different part of the washcloth with water and soap. f. apply moisture barrier ointment as needed. g. wash hands h. change gloves before touching clean items

Based on observation, interview, and record review, the facility failed to ensure each residents' drug regimen was free of unnecessary drugs for 1 of 3 residents reviewed for medications. (Resident #3) The facility did not monitor Resident #3 for side effects/adverse reactions for the use of anticoagulant (blood-thinning) and antiplatelet (reduce blood clot) medications. The failure could place 14 residents who received anticoagulant or antiplatelet medications at risk of bleeding or adverse side effects. Findings included: Physician orders [REDACTED].#3 was 72 admitted on [DATE], readmitted [DATE] with [DIAGNOSES REDACTED]. An MDS 5/18/18 indicated Resident #3 understood others, made himself understood, and was independent with his ADLs. A care plan dated 5/30/18 indicated Resident #3 received an anticoagulant medication daily, making him at risk for complications. Interventions included: Administer [MEDICATION NAME] 150 mg two times daily and [MEDICATION NAME] 75 miligram (mg) daily; monitor laboratory panel work and notify physician of all laboratory results, observe for signs of bleeding, and protect from trauma as much as possible. A CBC (complete blood count) laboratory panel dated 7/9/18 indicated the following: *RBC (red blood cells)- 3.41 (normal-4.5-6.3); his previous laboratory - (5/18/18)- RBC 4.51 *HCT (hematocrit) - 27.8 (normal-41.0-51.0); previous (5/18/18)- 33.4 *HGB (hemoglobin)- 9.1 (normal 14.0-18.0); previous (5/18/18)- 10.5. The laboratory results did not have a physician signature on it, but only a fax date. The (MONTH) (YEAR) MAR indicated [REDACTED] *[MEDICATION NAME] (blood thinner) 150 mg at 7:00 a.m. and 7:00 p.m., it was listed for hypertension. *[MEDICATION NAME] ([MEDICATION NAME]) 75 mg (antiplatelet) once daily for high blood pressure and *aspirin 81 mg daily for high blood pressure. During an observation on 8/1/18 at 9:15 a.m., Resident #3 was standing in the hallway outside of his room. His left elbow was bleeding. He said he bled easily and was going to let the nurse know he needed a bandage. During an observation and interview on 8/1/18 at 10:07 a.m., Resident #3 was in his room and had a large Band-Aid type dressing on his elbow. He said he was not sure if he took a blood thinner medication. Resident #3 said he bled a lot over the least little bump and it was hard to get the bleeding to stop. He raised his left arm, and blood ran down the back of his arm from the bandaged area. Resident #3 had two small bandages to his left leg and a couple of small bandages on his right arm. He had a few scabs on his face from shaving. During an interview on 8/1/18 at 2:30 p.m., the DON said she reviewed the pharmacy recommendations for Resident #3. She said in (MONTH) (YEAR) there were no variables for Resident #3, and when the consultant came in (MONTH) (YEAR), Resident #3 was in the behavioral hospital, and a drug regimen was done for him in (MONTH) (YEAR). During an interview on 8/1/18 at 3:40 p.m., the consultant pharmacist said he did not have his notes, but if Resident #3 was receiving [MEDICATION NAME], and aspirin he would have written a letter to the physician regarding the rational for all blood thinning/antiplatelet medications. He said the medications together could cause issues and bleeding was a big indicator of possible complications. The consultant pharmacist said he did not review Resident #3's medications in (MONTH) (YEAR) due to his hospitalization . During an interview on 8/1/18 at 3:30 p.m., Resident #3's physician said after reviewing Resident #3's laboratory panels for 7/9/18 and his medications ([MEDICATION NAME], and aspirin), the medications could be the cause of the resident's declining weight change and decreased laboratory values. Resident #3's physician stated, Discontinue [MEDICATION NAME] 75 mg and aspirin 81 mg. During an interview on 8/1/18 at 4:00 p.m., the DON said 14 residents received anticoagulant medications.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of ants in 3 of 3 resident rooms reviewed for pests. (Resident room #'s 104, 106 and 405) The facility did not ensure ants were kept out of resident room [ROOM NUMBER]. Resident #1 received ant bites while lying in her bed. Residents # 2 and #4 complained of having ants in their rooms [ROOM NUMBERS]. The facility did not ensure the grounds were free of active ant beds. There were a few small active ant beds outside the grounds area of Halls 400 and 300. A large fire ant bed was noted near the exhaust fan from the commercial dryer on Hall 300 This failure could place 36 residents who resided on Halls 100 and 400 at risk of ant stings, pain and decreased quality of life. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 had clear comprehension, understood others and made herself understood. She required extensive to total assistance with her ADLs. Resident #1 required extensive assistance by two staff for bed mobility. A nursing note dated 7/14/18 at 6:30 a.m., indicated Resident #1 had red raised areas to her lower right and left eye, also blister like areas on the left bend of her elbow. During an interview on 8/1/18 at 4:05 p.m., the DON said the 7/14/18 nursing note regarding Resident #1's blisters, was an incorrect date and the nurse was coming in to correct her error. The DON said it was for 8/1/18, she said she was aware of the these areas, per the LVN but no one had told her about any ants. The incident/accident log for (MONTH) (YEAR) did not reflect any residents with ant bites. A physician progress notes [REDACTED].#1 said she had multiple ant blisters that appeared to be fire ant bites. The physician ordered Resident #1 a [MEDICATION NAME] (steroid) dose pack. During an observation and interview on 8/1/18 at 9:20 a.m., Resident #1 was in a Geri-chair, with a Hoyer lift pad beneath her sitting in the hallway. She had 2 inflamed red pustules on the left side of her neck. She said she had ants in her bed last night that had come through her window. Resident #1 had approximately 20-30 additional red inflamed pustules to her left inner arm (antecubital) area. Her arm was flaccid, and 2-3 pustules were noted on the fingers of her left hand. During an observation on 8/1/18 at 10:07 a.m., on Hall 400, in Resident #1's room, the resident's bed was pushed up against the wall, next to the window. During an interview on 8/1/18 at 2:00 p.m., CNA B said she had seen ants in Resident #1's bed a couple of weeks ago. She said she notified housekeeping when she saw them. During an interview on 8/1/18 at 2:10 p.m., the maintenance man said he treated Resident #1's room a couple of weeks ago for ants, and again earlier this morning, for ants. He said he was notified by a CNA who worked the 6 a.m.- 2 p.m. shift, there were ants in Resident #1's room. 2. During an interview on 8/1/18 at 9:30 a.m., Resident #2 said he had seen ants in his room and in his bed. Resident #2 said he asked staff to not push his bed next to the window ledge because of seeing ants in the past. Resident #2's bed/ mattress was against the window ledge. An MDS dated [DATE] indicated Resident #2 had clear comprehension, understood others and made himself understood. He required extensive to total assistance with all of his ADLs. Resident #1 was dependent of staff for his bed mobility. 3. During an interview on 8/1/18 at 9:35 a.m. Resident #4 was lying in bed, with her bed next to the window. She said she had seen ants on her window in the past, but not recently. She said she stayed in bed and did not get up often due to her [MEDICAL CONDITION] arthritis. The DON provided a list of interviewable residents dated 8/1/18 and Resident #4 was included on the list. During an observation on 8/1/18 at 10:30 a.m., there were a few small active ant beds outside the grounds area of Halls 400 and 300. A large fire ant bed was noted near the exhaust fan from the commercial dryer on Hall 300 and approximately 30 feet from Resident #1's window. During an interview on 8/1/18 at 11:40 a.m., Housekeeper A said she had seen ants in a resident's room on Hall 400 a couple of weeks, but not in the last few days. During an interview on 8/1/18 at 4:10 p.m., the administrator said the facility exterminator had treated the inside and outside building a week ago. A pest control policy dated 5/1/18 said .it was the policy of the facility to maintain an effective pest control program that eradicated and contained common household pests and rodents . The CMS 672 dated 8/1/18 indicated 4 residents were in bed and 32 residents were in a chair all or most of the time.

Based on interview and record review, the facility failed to establish an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for the facility. The facility did not have an antibiotic stewardship program. This failure could place the census of 50 residents at risk for unnecessary antibiotic use and increased infections that were resistant to antibiotics. Findings included: The facility Infection Control Policy Manual was dated 2003 and revised 2009. It did not address an Antibiotic Stewardship Program. During an interview on 02/28/18 at 03:02 p.m., the ADON said they did not have the Antibiotic Stewardship started yet. The DON said she thought the program was not supposed to start until 2019. The CMS 672 form dated 02/27/18 indicated a census of 50 residents.

Based on interview and record review, the facility failed to ensure written notice regarding changes in services was provided for 2 of 3 residents reviewed for notification of Medicare non-coverage. (Resident #s 6 and 45) The facility did not provide Resident #s 6 and 45 prior written notice of discharge from Medicare services. This failure could place the 9 residents who currently received Medicare Benefits at risk of not being informed of their rights to appeal Medicare services. Findings included: The Notice of Medicare Non-Coverage letter for Resident #6 indicated there was no end date of services and Resident #6 signed the letter on 1/31/18. The Notice of Medicare Non-Coverage letter for Resident #45 indicated there was no end date of services and Resident #45 signed the letter on 12/07/17. During an interview on 03/01/18 at 03:31 p.m., the SW said she filled out the Notice of Medicare Non-Coverage letter and had the residents to sign it. She said she had access to the information as to the ending date of covered services. She said she did not realize there was no end of services date on the forms for Resident #s 6 and 45. The CMS 672 form dated 02/27/18 indicated 9 residents were Medicare currently received Medicare Benefits.