Every finding on record at Bishop Noa Home for Senior Citizens

Based on interview and record review the facility failed to report Payroll Based Journal (PBJ) information to CMS (Centers for Medicare and Medicaid) resulting in inaccurate reporting of staffing levels with the potential to affect all 69 residents.Findings include:Review of the CMS PBJ Staffing Data Report FY (fiscal year) Quarter 1 2026 (October 1- December 31) revealed the metric Failed to Submit Data for the Quarter, One Star Staffing Rating Excessively Low Weekend Staffing, No RN Hours, and Failed to have Licensed Nursing Coverage 24 Hours/Day.During an interview on 4/29/26 at 9:27 a.m., Resident Account Representative I reported, I am responsible for submitting the PBJ information to CMS.I did not submit the information for that quarter [October 1-December 31] .During an interview on 4/29/26 at 9:34 a.m., the Nursing Home Administrator (NHA) acknowledged the data for the PBJ report was not submitted for the first quarter [October 1- December 31].

Based on interview and record review, the facility failed to complete an annual performance review for three Certified Nurse's Aides (CNA's) out of five reviewed at least every 12 months.Findings include:Review of facility personnel records demonstrated the following:CNA C was hired on 10/11/22with no performance review since 3/11/25.CNA D was hired on 7/13/23 with no performance review since 9/30/23.CNA G was hired on 3/8/22 with no performance review since 9/21/23. During an interview on 4/29/26 at 8:12 a.m., Human Resource Manager H reported, Staff have annual performance reviews.During an interview on 4/29/26 at approximately 12:30 p.m., The Nursing Home Administrator (NHA) acknowledged the identified CNAs did not have annual performance evaluations.Review of Facility Assessment (FA) dated 3/26, read in part .Staff training/Education and Competencies.Annual performance evaluations for all staff. Annual evaluations are stored in personnel file.

Based on interview and record review, the facility failed to ensure four Certified Nurse Aides (CNA's) [ C D E and F] of five CNA's reviewed for competencies had the required yearly competency trainings, including demonstration in skills and techniques necessary to care for residents.Findings include:A review of facility staff personnel records revealed CNA C was hired10/11/22. CNA Cs personnel record did not demonstrate dated competency skills since 3/11/25.A review of facility staff personnel records revealed CNA D was hired on 7/13/23. CNA Ds personnel records did not demonstrate dated competency skills since 7/24/24.A review of facility staff personnel records revealed CNA E was hired on 5/21/24. CNA Es personnel records did not demonstrate dated competency skills since 5/21/24.A review of facility staff personnel records revealed CNA G was hired on 3/8/22. CNA Gs personnel records did not demonstrate dated competency skills since 6/11/24.During an interview on 4/29/26 at 8:12 a.m., Hurman Resource Manager H reported, The CNA's must have annual competency training.During an interview on 4/29/26 at approximately 12:30 p.m., The Nursing Home Administrator (NHA) acknowledged the identified CNAs did not have annual competency training.Review of Facility Assessment (FA) dated 3/26, read in part . Staff training/education and competencies.Annual evaluation of identified competencies for nurse aide staff. were required.

Based on observation, interview, and record review the facility failed to implement infection control program components as evidenced by the failure to:Perform appropriate hand hygiene during water pass,Ensure an ongoing, systematic collection and analysis of infection surveillance data,Properly don personal protective equipment (PPE) and ensure droplet precautions were implemented for Resident #27,Maintain a Resident catheter in a hygienic manner, andEnsure resident care equipment was maintained in a cleanable condition for use.These deficient practices resulted in the potential for the spread of infectious organisms and disease within the facility with the potential to affect all residents within the facility.Findings include:1. Hand Hygiene During Water Pass On 4/27/26 at 1:08 p.m., Certified Nurse Aide (CNA) A was observed entering resident room [ROOM NUMBER] with 2 clean water mugs and exiting the room moments later with two used (dirty) water mugs held in their bare hands. The used water mugs were placed on the second, lower shelf of a rolling cart. No hand hygiene was performed. CNA A then took two clean water mugs into room [ROOM NUMBER] where a Contact Precaution sign was posted outside of the room door which stated, Check with Nurse Before Entering, STOP, In Addition to Standard Precautions (checked was) . Hand hygiene before entering room and after leaving room, gown, gloves, and dedicated equipment. CNA A exited contact precaution room [ROOM NUMBER] with two used water mugs, picked up two clean water cups and took them into room [ROOM NUMBER] without the performance of hand hygiene. When asked about the presence of the Contact Precaution sign, CNA A stated, This isn't my hall and I don't know these residents very well. CNA A completed distribution of fresh, water mugs and removal of used/dirty water cups/mugs on the 100-hall without the performance of hand hygiene during the entire observation. During an interview on 4/28/26 at 11:44 a.m., when asked if water pass had ever been observed for compliance with hand hygiene policies and procedures, IP B said she had never watched staff passing water to facility residents in the facility. IP B stated, I would expect hand hygiene to be performed in between each room they enter. With the contact precaution room, they should use a Styrofoam cup instead and make sure they are using the proper precautions going in and out (of resident rooms). During an interview on 4/28/26 at 1:42 p.m., when asked about the absence of hand hygiene during water pass on 4/27/26, CNA A acknowledged hand hygiene had not been performed when going between resident rooms, including the contact precaution room [ROOM NUMBER], when passing fresh water and removing dirty water mugs/cups to the residents residing on the 100 Hall. Review of the cdc.gov/clean-hands/hcp/clinical-safety/index.html, dated February 27, 2024, accessed 4/28/26 4:10 PM revealed the following Recommendations: Know when to clean your hands: Immediately before touching a patient. After touching a patient or patient's surroundings. After contact with blood, body fluids, or contaminated surfaces. Immediately after glove removal. 2. Infection Control Surveillance and Tracking During review of the facilities Infection Control Program documentation on 4/28/26 at 11:01 a.m., Infection Preventionist (IP) B was asked to provide the April 2026 infection line listing and mapping. IP B stated, I haven't done my line listing for April 2026 yet. That is what I was working on today. I do the map (of facility infections) at the end of the month. Aprils' will be done at the end of the month. On 4/28/26 at approximately 11:05 a.m., Review of uncompiled April 2026 Resident infection surveillance data, with IP B, for Resident #12 (R12), included a completed McGeer's Criteria form, which revealed the infection was identified in March of 2026. During an interview after review of the documentation, IP B stated, [R12] was on an antibiotic in March (2026). This was a March Infection. IP B explained R12 had a Urinary Tract Infection (UTI) in March, and the McGeer's Criteria form had been completed for a UTI. IP B said the Electronic Medical Record (EMR) line listing involving R12's April 2026 antifungal concern was not completed because April was not completed yet. IP B stated, This was an error on my part. During an interview an 4/28/2026 at 11:11 a.m., when asked about why Resident #34 (R34) did not have infection surveillance documentation completed for review, including a McGeer's Criteria form, IP B stated, I put [R34] in the (EMR) dashboard but I don't have his paperwork filled out yet. R34 was present on the incomplete April 2026 EMR infection control line listing, but no criteria for the infection had been established. Review of the Infection Prevention and Control Program policy and procedure, dated 11/25, revealed the following, in part: .Objectives: The objectives of the Infection Prevention and Control Program Policies and Procedures are to .Provide surveillance that identifies possible communicable disease or infections that can spread from person to person in the facility . Responsibilities of the Infection Preventionist .4. Performs surveillance, including monitoring processes, data analysis and documentation . Surveillance tools are used for recognizing the occurrence of infections, recording their number and frequency, detecting outbreaks and epidemics, monitoring employee infections, and detecting unusual pathogens with infection control implications. Resident #27 (R27) On 4/27/26 at 2:07 PM, an observation was made of R27's room where signage was posted for transmission-based precautions (TBP) related to droplet precautions and the door was wide open. The signage outside of R27's door revealed TBP indicating staff should wear dedicated equipment including a gown, gloves, N-95 mask, and eye protection prior to entering. Review of R27's electronic medical record (EMR), revealed that R27 had contracted influenza A on 4/17/26. An observation was made on 4/28/26 at 12:00 PM, of R27's entrance door to her room which was wide open even though she was under droplet precautions. During an interview on 4/28/26 at 11:44 AM, the Director of Nursing (DON) and Infection Preventionist / RN A were both asked about droplet precautions and replied, We try and keep the door closed if it is safe. Both the DON and RN A agreed R27 was safe to have her door closed under droplet precautions. On 4/28/26 at 3:35 PM, an observation was made of Registered Nurse (RN) M donning PPE and entering R27's room without eye protection. RN M was interviewed after she exited R27's room and was asked why she did not have eye protection on and replied after reading the signage on the outside of R27's door, No, I guess I should have. An observation was made on 4/29/26 at 7:35 AM, of R27's entrance door to her room which was wide open and the signage indicated R27 was under droplet precautions. Review of policy titled, Transmission-based Precautions, dated 03/2025, read in part Policy: It is our policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' modes of transmission.DEFINITIONS.droplet precautions – refers to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucus membrane contact with respiratory secretions.11. Droplet Precautions.f. Based upon the pathogen or clinical syndrome, if there is risk of exposure of mucous membranes or substantial spraying of respiratory secretions is anticipated, gloves and gown as well as goggles (or face shield) should be worn.Recommendations for Personal Protective Equipment (PPE).droplet.Mask – [NAME] a mask upon entry into the patient room or cubicle.Type and Duration of Transmission-Based Precautions / Recommended for Selected Infections and Conditions.Infection/Condition.Influenza (pandemic), Precautions: Droplet. Resident #11 (R11) Review of R11's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on 3/24/25 with diagnoses that included: neurogenic bladder. The MDS Section H revealed R11 had an indwelling catheter [a flexible tube inserted into the bladder to continuously drain urine into an external bag]. During an observation on 4/27/26 at 2:12 p.m., R11, sat in his wheelchair and propelled the wheelchair with his feet down the hallway. R11's catheter bag dragged onto the floor at least two feet behind his wheelchair with urine visible in the catheter bag. Review of policy titled Indwelling Urinary Catheterization, Maintenance, and Care last revised 2/26, read in part .Monitor the foley catheter system.check that tubing and drainage bag are secure and in the proper position a. Ensure privacy of drainage bag.keep the collection bag below the level of the bladder and off of the floor. On 04/27/2026 at 4:29 PM while in the Station 2 Spa shower room the seat covering of a shower chair was observed with a hole in the seat, exposing the foam material below. Beige shower straps and black backrest pads were also observed hanging on the wall in this room. Certified Nursing Assistant (CNA) J stated these were used to assist with supporting residents during bathing. Two of the three large beige straps had coatings that were cracked and frayed around the holes that run up and down the straps. Two of the three smaller leather coated back supports had coatings that were cracked exposing the filler underneath the coating.

Based on interview and record review, the facility failed to respond to grievances for three Residents (#31, #43 and #52) of eight residents reviewed for grievances.Findings include:During a group meeting on 4/28/26 at 2:34 p.m., when queried about the facilities response to grievances R31, R43 and R52 reported the following:R31 reported, I have lost two pairs of jeans that were sent to the laundry quite some time ago (approximately 6 months) and I told the Activity Director (AD) L.I also lost a nightgown.R43 reported, The laundry lost a turquoise sweater, and it had been gone at least two months.I told the AD L.R52 reported, I wore a brand-new nightgown maybe three times and it had been gone since it went to the laundry.I didn't know the facility takes lost items and puts them on a table for all the residents to go through.Review of the grievance log did not reveal any grievances regarding missing clothing from R31, R43 or R52.During an interview on 4/28/26 at 4:28 p.m., ADL reported, When clothing goes missing I do not write up a grievance sheet about it.we don't do anything like that.R31's jeans had been missing for about 6 months, R43s sweater had been missing for over 2 months, and I really have not heard anything about R52's nightgown.I have not reported the missing items to the Nursing Home Administrator (NHA). The AD could not identify a process or procedure for missing items or a grievance procedure.During an interview on 4/28/26 at 4:40 p.m., the NHA reported, We don't have a form for missing items or a procedure for missing items.I have not heard about the missing items.there is a lack of communication regarding the missing clothing items. The NHA stated she would have expected staff to make her aware of any missing items. The NHA could not identify a process or procedure for missing items. Review of policy titled Missing Items last reviewed 4/25, read in part .To safeguard resident property to the extent possible to assure there is not misappropriation of resident property. Should an item be reported a missing, all efforts will be made to locate the item and/or provide restitution when warranted.A grievance policy was requested and was not provided by the facility prior to exit.

Based on observation, interview, and record review the facility failed to assess the risk of entrapment, review bed rail risks and benefits with the resident/resident representative and obtain consent and a physician order prior to the installation of bed rails for 1 Resident (#19) of 1 resident reviewed for bed rail safety. This deficient practice resulted in the potential for bed entrapment and risk of injury and death.Findings include:During an observation on 4/29/26 at 7:30 a.m., R19 was observed lying in bed. A breakfast tray was positioned on an overbed table but R19 was unable to eat independently. Bilateral quarter bed rails were present at the head of the bed on both the left (exit side) and the right (wall side) of the bed, with the head of the bed elevated to approximately 45 degrees. R19 did not respond visually or verbally to conversational questions.Review of R19's Minimum Data Set (MDS) assessment, dated 4/20/26, revealed R19 was admitted to the facility on [DATE] with active diagnoses that included the following, in part : stroke, heart failure, atrial fibrillation, aphasia, and hemiplegia (paralysis of one side of the body). Section B: Hearing, Speech, and Vision revealed R19 had No speech- absence of spoken words and was rarely/never understood and rarely /never understands when spoken to. R19's Cognitive Skills for Daily Decision Making were documented in Section: C as 3. Severely impaired - never/rarely made decision. Function Limitation in Range of Motion in Section: GG detailed bilateral upper extremity impairment, bilateral lower extremity impairment, with dependent (resident does none of the effort) assistance required for: eating, oral hygiene, toileting, shower/bathing, rolling left and right, sit to lying, lying to sitting, sit to stand, chair/bed-to-chair transfer, and toilet transfers. R19 used a wheelchair for mobility. Section P: Restraints and Alarms had no restraint or alarm use documented by R19.Review of R19's Medical Determination on 4/29/26 at 7:41 a.m., revealed R12 was unable to make their own medical decisions. Review of R19's Bed Mobility Care Plan on 4/29/26 at 7:52 a.m., revealed the following, in part: BED MOBILITY: The resident is dependent on 2 staff for bed mobility, repositioning and turning in bed. He can also have bed rails on his bed to improve bed mobility and repositioning. Date Initiated: 04/06/2026 Revision on: 04/06/2026.During an interview on 4/29/26 at 7:54 a.m., when asked about R19's ability to use the bilateral bed rails, Certified Nurse Aide (CNA) R confirmed she regularly provided care for R19 and stated R19 could grasp one side rail, because his right side was affected by a stroke and resulted in paralysis. During an interview on 4/29/26 at 8:11 a.m., when asked if there was a physician order in place for R19's bilateral bed rails, Registered Nurse Supervisor (RN) S stated, There should be. RN S said physical therapy evaluated residents for bed rails and made the order (for the bed rails) and maintenance then placed bed rails on the bed. When asked for R19's bed rail consent form, RN S stated, It (bed rail consent form) should be filed right here under consents in the R19's hard chart. RN S reviewed each document in R19's hard chart and Electronic Medical Record (EMR) and was unable to find a bed rail consent form for the bed rails in R19's complete medical record. RN S stated, I am not finding a (bed rail) consent (form). When asked if there was a physician order or signed consent for R19's bed rails, RN S confirmed no physician order was present for the bilateral bedrails in current physician orders, and stated, I am not finding a consent. During an observation on 4/29/26 at 8:38 a.m., during bed repositioning performed by CNA R and an unidentified CNA, R19 was able to use the right bed rail with his left hand, but use of the left, bed rail was only accomplished by staff placing his paralyzed hand onto the bedrail. Independent use or clasping of the left bed rail was not demonstrated by R19. During an interview on 4/29/26 at 12:19 p.m., the Nursing Home Administrator (NHA) and IP B were both asked for a copy of the facility bed rail policy. The NHA stated, We do not have a bed rail policy. A Restraints policy, updated 2/2026, was provided by the facility.During an interview with the NHA and Infection Preventionist (IP) B on 4/29/26 at approximately 12:30 p.m., the NHA again confirmed the absence of a Bed Rail policy. IP B reported review of R19's complete medical record and confirmed no bed rail assessment, physician order or consent was found for R19's bed rails.Review of the Restraints Policy and Procedure, updated 2/2026, revealed the following in part: . 'Physical Restraint' refers to any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body . 1. The resident must be assessed prior to the initiation of any form of device or medication which meets the criteria of a restraint and periodically reassessed as their needs change throughout their stay. 2. If a resident is admitted to the facility . the facility must conduct an assessment to determine the existence of medical symptoms that warrant the continued use of the restraint . 4. Document in the resident's medical record the medical symptom being treated, alternative interventions that were used to treat the identified medical treatment and were ineffective.5. The medical record must include a physician order for the specific type of restraint. 6. Consent for restraint use is obtained prior to use from the resident or responsible person and filed in the medical record. 8. If there are no medical symptoms identified that required treatment, the use of the restraint is prohibited.

Based on observation, interview, and record review the facility failed to ensure a narcotic medication was stored and or consumed in a safe and secure manner for one Resident (#23) of seven residents reviewed for medication storage.Findings Include:Resident #23 (R23)On 4/29/26 at 7:30 AM, an observation was made of R23 lying in bed in her room. R23 had an empty medication cup on her floor upside down. R23 had a second medication cup on her bedside table with a small single round white pill inside. R23 was asked about the medication left in the cup and replied, I did not want to take it. I get all bound up if I take my oxycodone. R23 was asked if she was in any pain and what she would like to take for her pain and replied, My pain is at a 4 and I would like some Tylenol.During an interview on 4/29/26 at 7:35 AM, Licensed Practical Nurse (LPN) P was made aware R23 did not take her oxycodone and would like Tylenol instead. LPN P stated she did not dispense the oxycodone to R23, and rather indicated LPN Q had dispensed the oxycodone. LPN P reviewed the medication narcotic administration record which revealed LPN Q dispensed R23's oxycodone at 4:47 AM on 4/29/26.On 4/29/26 at 7:50 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if R23 had an order to self-administer medication or if medications should be left at the bedside and replied, I am not sure if she has an order to self-administer medications. The NHA agreed medications should not be left at the bedside and nurses are to ensure medications as consumed at the time they are dispensed.At 10:35 AM on 4/29/26, the NHA confirmed R23 did not have a physician order to self-administer medications.Review of policy titled, Medications Administration, dated 02/2026, read in part Policy: It is the policy of this facility to ensure medications are given as prescribed, safely, and in a timely manner, while observing Resident's rights.

Based on interview and record review, the facility failed to provide a bed hold notice for one Resident (#11) of four residents reviewed for hospitalization.Findings include:Resident #11 (R11)Review of R11's Minimum Data Set (MDS) assessment dated [DATE], revealed the most recent admission to the facility was on 3/24/25 with diagnoses that included: hip fracture.Review of Electronic Medical Record (EMR) revealed resident sustained a fall and was discharged to the hospital on 3/17/26. The EMR did not reveal a bed hold policy had been provided to the resident or responsible party.During an interview on 4/28/26 at 11:54 a.m., Resident Account Representative I reported, We do not give out the bed hold policy to residents that are on Medicaid when they go to the hospital.During an interview on 4/29/26 at 12:49 a.m., the Nursing Home Administrator (NHA) acknowledged a bed hold policy had not been given to the resident or responsible party.Review of policy titled Bed Holds and Readmission last reviewed 10/25, read in part .Bed hold information will be provided to the resident and/or responsible party within twenty-four hours of the temporary absence.

Based on observation, interview, and record review the facility failed to ensure an indwelling urinary catheter device was medically necessary and physician orders were in place for one Resident (#23) of two residents reviewed for catheters.Findings include:Resident #23 (R23)Review of R23's electronic medical record (EMR), revealed an admission to the facility on 4/17/26, with medical diagnoses including retention of urine and fracture of the right tibia.An observation was made on 4/27/26 at 2:52 PM, of R23 in her room with a urinary catheter bag hanging on the left side of her bed. R23 was asked why she had a urinary catheter and replied, I am not sure why. I suppose it is just for convenience.Review of R23's EMR revealed no physician order for the urinary catheter indicating size of tubing and balloon anchor to secure the catheter to the inside of the bladder.On 4/28/26 at 3:40 PM, an interview was conducted with Supervisor/Registered Nurse (RN) K who was asked about orders for indwelling urinary catheters and replied, It should have an order for balloon size and size of Foley tubing. I am not sure about measuring output.Review of R23's EMR, revealed physician orders dated 4/20/26 to change foley and obtain urine sample for UA (urinalysis) with C&S (culture and sensitivity), and on 4/25/26 a one time only order for catheter change after 24 hours of Fluconazole therapy. R23's progress notes lacked any documentation regarding removal or reinsertion of the urinary catheter which was completed on 4/20/26 and 4/25/26 per the April 2026 Treatment Administration Record (TAR).On 4/28/26 at 3:35 PM, an interview was conducted with RN M who was asked about adding orders for new admissions and replied, I am not sure about who adds the orders. The nursing supervisor usually adds the orders and double checks the orders added by nursing.During an interview on 4/28/26 at 3:45 PM, the Director of Nursing (DON) was asked if orders should be in place for residents that have indwelling urinary catheters and replied, Yes and there should be orders for balloon size and catheter size. The DON confirmed R23 had no orders for an indwelling urinary catheter and was not sure if hers was to be measured for output.On 4/29/26 at 10:30 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if the facility had a bladder scanner and why toilet training was not attempted for R23 and replied, Yes, we have a bladder scanner. We should have attempted to remove the urinary catheter after she arrived at the facility. The NHA was asked about physician orders and documentation regarding the changing of the indwelling urinary catheter and replied, Yes, there should be a physician's order and nursing should have documented changing the catheter and I am not sure if this was completed lacking the documentation.Review of policy titled, Indwelling Urinary Catheterization, Maintenance, and Care, dated 02/2026, read in part Policy: It is the policy of this facility to use indwelling urinary catheters only when medically necessary and provide catheter maintenance and care following evidence-based guidelines. Procedure, Straight or Indwelling Urinary Catheter Insertion.17. Document per facility protocol.Procedure for Discontinuing for Indwelling Urinary Catheter.Document per facility protocol.

This citation pertains to intake MI00152541 Based on interview and record review, the facility failed to provide adequate supervision for one Resident #1 (R1) of one resident reviewed for elopement. This deficient practice resulted in R1 leaving the facility unattended with the potential for fall and injury. Findings include: Resident #1 (R1) Review of Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with active diagnoses that included: Alzheimer's disease and dementia. Section C of the MDS revealed R1's cognitive skills for daily decision making were severely impaired. The MDS also indicated R1 rarely or never made decisions and was rarely or never understood. Review of a facility document titled R1-elopement 4/18/25 at 16:20 (4:21 p.m.) read in part, .at 16:20 resident stood up from the table and waved goodbye to everyone who was present, R1 then exited the dining room to the left. Resident proceeded down the hall an exited the facility at 1621 .resident exited the facility at 1621 (4:21 p.m.) and returned at 1634 (4:34 p.m.); elopement verified. During an interview on 4/30/25 at 9:56 a.m., Registered Nurse (RN) A reported R1 went all over the facility during the day, constantly wandered throughout the day, and tries to go out of the exit doors. During a follow-up interview at 10:25 a.m., RN A reported R1 tries to leave the facility and is not picky about which door R1 wants to exit. During a phone interview on 4/30/25 at 10:37 a.m., Licensed Practical Nurse (LPN) C reported R1 tries to exit the facility and wanders all over the facility. We constantly redirect [R1] away from the exit doors. LPN C stated she reported concerns over R1 eloping from the facility to a supervisor, but nothing has changed. LPN C stated I am very concerned about what could happen to [R1]. Review of a witness statement on 4/30/25 at approximately 11:15 a.m., revealed the following: (LPN B) said on 4/18/25 at around 16:20 (4:20 p.m.) the alarm for door 2 was going off. (LPN B) walked down to a room and met (Certified Nursing Assistant [CNA] F). (CNA F) didn't see anyone go out the door .a visitor, who does (R1's) hair said that (R1) was walking on the sidewalk in the parking lot. Then (RN D) and (CNA J) went running outside after (R1). During an interview on 4/30/25 at 11:24 a.m., LPN B reported the alarms went off on 4/18/25 when R1 eloped from the facility. LPN B stated they went to the front of the facility with CNA F and then went back to the nurse's station. LPN B stated they were going back to the nurse's station when a visitor told her R1 was out in the parking lot. LPN B said, I can't imagine how far (R1) could have gone down the street if the visitor had not told us.) Review of a witness statement on 4/30/25 at 1:00 p.m. revealed the following: (CNA F) said that on 4/18/25 door 2 was alarming. (CNA F) went to the door and looked outside, and didn't see anyone . (CNA F) told (LPN B) that she did not see anyone outside. During a phone interview on 4/30/25 at 1:12 p.m., CNA F was asked if she went outside to look for the resident. CNA F reported, I looked at the small parking lot and then went back inside the facility. I didn't look around the side of the facility or down the street. I really didn't know what to do. I was never trained about what to do if a resident elopes outside of the facility. During a phone interview on 4/30/25 at 1:27 p.m., CNA J stated he had worked on the day of the elopement. CNA J indicated he came out of the nurse's lounge and then a visitor came in and told the staff R1 was walking away from the facility. CNA J said, . then we ran outside to catch the resident. The resident was about half a block or so from the facility. During a phone interview on 4/30/25 at 1:36 p.m., RN D reported being in the purchasing office and did not hear the door alarm when it went off. RN D said, I went back to the nursing station area and a visitor told us they saw (R1) outside. I went outside and ran to the edge of the street as I didn't see (R1) in the parking lot. I looked down the street and (R1) was walking away from me. (R1) was easily redirected to return to the facility. It was quite a distance, so it took us several minutes to walk back into the facility. Review of policy titled, [Facility Name] Policy and Procedure Prevention of Wandering and Elopement last updated 4/24, read in part, .It is the policy of [Facility Name] to provide an environment that keeps residents safe and free of injury .Elopement is defined by the State Operations Manual as follows: when a resident leaves the premises or safe area without authorization .and/or any necessary supervision to do so. A resident who leaves a safe area may be at risk of (or has the potential to experience) heat or cold exposure, dehydration and/or other medical complication, drowning, or being struck by a motor vehicle.

Based on observation, interview and record review, the facility failed ensure personal protective equipment (PPE) was worn by staff as required when caring for 1 Resident (#21) of 3 residents, reviewed for Enhanced Barrier Precautions (EBP). This deficient practice resulted in the potential for infection, communicable disease and multi-drug resistant organism transmission. Findings include: Resident #21 (R21) Review of the Admission Record for R21 revealed an original admitted to the facility on [DATE] with diagnoses including: Amyotrophic Lateral Sclerosis (ALS-progressive and fatal neurological disorder). Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 1/21/25 revealed a Brief Interview for Mental Status (BIMS) score of 15/15 which indicated R21 was cognitively intact. Review of a facility Enhanced Barrier document on 3/6/25 at 9:04 AM., was noted on the outside wall/doorway of R21's room stating . CHECK WITH NURSE BEFORE ENTERING-STOP . In addition to Standard Precautions- High-Contact Resident Care Activities: ENHANCED BARRIER PRECAUTIONS (boxed checked) .(Activities on the sign were listed as follows) . Dressing, Bathing, Providing Hygiene, Caring for Devices (central lines, urinary catheters, feeding tubes, tracheostomy) . Transferring, Changing Linens, Toileting, Wound Care on the sign there were boxes with computerized images (a sink with water, a gown, gloves, a medical mask, stethoscope etc .) The boxes checked for R21's room were: Hand Hygiene, Gown and Gloves, and Not restricted to room . On 3/6/25 at 9:10 AM., 2 CNA staff were observed inside R21's room. CNA F was observed placing a Hoyer lift sling underneath R21 while lying in bed. CNA E walked into R21's room with a Hoyer lift which had been parked outside R21's room, near room [ROOM NUMBER]. CNA E did not sanitize the lift prior to entering R21's room. CNA F and CNA E were not wearing gowns, and CNA E was not wearing gloves. CNA F and CNA E proceeded to sit R21 up in her bed, adjust the lift sling, and CNA E moved the Hoyer into position to clip on the sling straps and attach them to the Hoyer lift with the help of CNA F. CNA F and CNA E adjusted R21 into the Hoyer lift and completed the transfer with the Hoyer lift from R21's bed into her electric wheelchair. CNA F and CNA E unclipped the sling from the Hoyer lift, and CNA E moved the Hoyer lift out of R21's bedroom into the hall and parked it near room [ROOM NUMBER]. CNA E did not wipe down the lift, perform hand hygiene or use hand sanitizer prior to exiting R21's room. CNA E re-entered R21's room and again, did not perform hand hygiene. On 3/6/25 at 9:23 AM., during an interview, CNA E acknowledged when transferring R21 both her and (CNA F) should have had sanitized the Hoyer lift before and after using it. CNA E confirmed all staff are required to perform hand hygiene either by use of soap and water for 20 seconds with the sink or use an approved hand sanitizer. CNA E acknowledged she did not follow proper infection control procedures. On 3/6/25 at 9:33 AM., during an interview, LPN H reported R21 was on EBP because she has a feeding tube. LPN H reported all staff providing care to R21 should use proper hand hygiene, gloves, and a gown. LPN H reported staff must wear a gown even if transferring to and from any equipment, bed to chair, shower, and toileting. LPN H reported resident shared equipment such as vital machines, lifts, and commonly touched surfaces should be wipes down with the sanitizing wipes, and after each use, and/or when visibly soiled. Review of R21's Physicians Orders dated 1/1/24 revealed: Change syringe for g-tube daily. Place date and time changed on new syringe when replacing every night shift for infection control . On 3/6/25 at 9:30 AM., during an interview, CNA F reported she should have been wearing a gown when doing morning care for R21. CNA F reported she was unsure exactly why the EBP was in place for R21, but thought it was because she (R21) had a feeding tube. CNA F reported she didn't think of putting on the gown, and she had not paid attention to the signage on the outside of the wall. CNA F reported she felt very bad that she didn't pay attention to the EBP sign and knows how important it is to protect the residents from possible infections. CNA F reported the facility has had many training's for the EBP protocol, but it had just slipped her mind today. CNA F stated I don't think I will ever forget to put it on again . CNA F stated that unfortunately sometimes mistakes were good, so that they learn from them, and they really give staff opportunities to improve.

Based on observation, interview, and record review the facility failed to ensure resident shared equipment was properly cleaned and sanitized. Findings include: On 3/4/25 at 4:10 PM., a sit to stand lift was observed parked outside of room [ROOM NUMBER]. The base of the lift (where residents plant their feet) was noted to be heavily soiled with dirt, debris and food crumbs. The padded knee area (where residents shins are pressed against for stability) beige in color was noted to be soiled with dried, crusted stuck on substances. The padded arms (beige in color) were also noted to be soiled with grime, the mechanical body of the lift had a heavy accumulation of dust and overall the sit to stand was noticeably soiled. On 3/5/25 at 9:19 AM., a Hoyer lift was observed near room [ROOM NUMBER]. There were blue pads located on the lift and base which were visibly soiled with dried crusted substances, dust and debris. A medication cart next to room [ROOM NUMBER] was observed with a pill crusher on it, which was heavily soiled with white crushed pill dust, dirt and grime in the crevasses. There was a brown dried substance on the sides of the pill crusher. On 3/05/25 at 9:24 AM, a sit to stand lift was observed near room [ROOM NUMBER]. The base of the lift was soiled with dust, debris and food crumbs. The padded handles which were beige in color were noticeably soiled with dirt and grime. In an interview on 3/5/25 at 9:30 AM., Licensed Practical Nurse (LPN) D reported Certified Nurse Aides (CNA's) and any staff using lifts and resident shared equipment (such as lifts, scales, vital machines) were responsible for sanitizing the shared equipment after each use, and when noticeably soiled. LPN D reported the sanitizing wipes were located in the medication storage room, or soiled linen rooms. LPN D reported the CNA's have to ask a nurse to get wipes from the medication storage rooms because they are locked. LPN D reported the soiled linen rooms were locked but the CNA's and most staff have the key codes to get into those rooms. LPN D reported she was rarely asked to get sanitizing wipes for anyone from the medication storage rooms. On 3/5/25 at 9:36 AM., a sit to stand lift was observed parked outside of room [ROOM NUMBER]. The base of the lift was noted to be heavily soiled with dirt, debris and food crumbs. The padded knee area beige in color was noted to be soiled with dried, crusted stuck on substances. The padded arms were also noted to be soiled with grime, the mechanical body of the lift had a heavy accumulation of dust and overall the sit to stand was noticeably soiled. On 3/5/25 at 10:34 AM., a sit to stand lift was observed near room [ROOM NUMBER]. The base of the lift was soiled with dust, debris and food crumbs. The padded handles which were beige in color were noticeably soiled with dirt and grime. On 3/5/25 at 2:28 PM., a sit to stand lift was observed parked outside of room [ROOM NUMBER]. The base of the lift was soiled with dirt, debris and food crumbs. The padded knee area was noted to be soiled with dried, crusted stuck on substances. The padded arms were also noted to be soiled with grime, and the overall sit to stand was noticeably soiled. On 3/5/25 at 2:34 PM., a sit to stand lift was observed parked outside of room [ROOM NUMBER]. The base of the lift was soiled with dirt, debris and food crumbs. The padded knee area was noted to be soiled with dried, crusted stuck on substances. The padded arms were also noted to be soiled with grime, and the overall sit to stand was noticeably soiled. On 3/5/25 at 2:31 PM., a sit to stand lift was observed in room [ROOM NUMBER] with the beige pads and base soiled. An unidentified staff member brought the lift out of room [ROOM NUMBER] and parked it outside the door. The unidentified staff member left the lift without cleaning it and/or using sanitizing wipes which were located in the bag on the lift. The base was observed soiled and the legs of the lift were visibly soiled with dust, and grime. The frame was observed soiled in various areas with dried stuck on substances and an overall soiled/dingy appearance with food crumbs on base. There were no sanitizing wiped observed in the resident's room and none were observed in bathroom or under bathroom vanity sink. On 3/5/25 at 3:15 PM., a Hoyer lift was observed near room [ROOM NUMBER]. The blue padded handle covers were noted to be soiled with dirt and grime. The legs/base of the lift were noted to have an accumulation of thick dust, and dried spillage on various areas of the base and legs of the Hoyer lift. On 3/6/25 at 9:25 AM., during an interview, Patient Care Aide (PCA) G reported staff are supposed to clean any resident shared equipment before and after use. PCA G reported the facility has purple wipes available for use and they are usually stored in the soiled linen rooms. PCA G reported it would be nice if they were closer to the equipment, or in bags attached to the equipment. PCA G reported she thought that would help staff who might forget about wiping the equipment after use if they are busy. On 3/6/25 at 10:11 AM., a sit to stand lift was observed near room [ROOM NUMBER]. The base of the lift was soiled with dust, debris and food crumbs. The padded handles which were beige in color were noticeably soiled with dirt and grime. On 3/6/25 at 10:20 AM., a sit to stand lift was observed near room [ROOM NUMBER]. The base of the lift was soiled with dust, debris and food crumbs. The padded handles which were beige in color were noticeably soiled with dirt and grime. On 3/6/25 at 10:25 AM., a sit to stand lift was observed near room [ROOM NUMBER]. The base of the lift was soiled with dust, debris and food crumbs. The padded handles which were beige in color were noticeably soiled with dirt and grime. Review of a facility Policy & Procedure-Cleaning and Disinfecting of Resident Share Equipment with a revision date of 6/2024 revealed: Policy- Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA (Occupational Safety Health Administration) Bloodborne Pathogens Standard Procedure:1. The following categories are used to distinguish the levels of sterilization/ disinfection necessary for items used in resident care: a. Critical items consist of items that carry a high risk of infection if contaminated with any microorganism. Objects that enter sterile tissue (e.g., urinary catheters) or the vascular system (e.g., intravenous catheters) are considered critical items and must be sterile. b. Semi-critical items consist of items that may come in contact with mucous membranes or non-intact skin (e.g., respiratory therapy equipment). Such devices should be free from all microorganisms, although small numbers of bacterial spores are permissible. (Note: Some items that may come in contact with non-intact skin for a brief period of time (e.g., hydrotherapy tanks, bed side rails) are usually considered non-critical surfaces and are disinfected with intermediate-level disinfectants.) c. Non-critical items are those that come in contact with intact skin but not mucous membranes. 1. Non-critical resident-care items include but limited to bedpans, blood pressure cuffs, walkers and computers. 2. Most non-critical reusable items can be decontaminated where they are used (as opposed to being transported to a central processing location). a. Reusable items are cleaned and disinfected or sterilized between residents. 1. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards. a. Single-use items are disposed of after a single use. 2. Critical and semi-critical items will be sterilized/disinfected in a central processing location and stored appropriately until use. Equipment to be processed will be labeled with at least the following information: a. That the equipment is contaminated, b. The address to which the equipment is to be shipped, c. The address from which the equipment was removed (including telephone number); d. The name of the person labeling the equipment; and e. The date and time the label was affixed to the equipment. 2. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. 3. Reusable resident care equipment will be decontaminated and or sterilized between residents according to manufacturers' instructions .

Based on observation, interview, and record review, the facility failed to ensure appropriate assessments, physician orders, and medical justification, for restraints that were in place for one Resident (R49) of one resident reviewed for restraints. Findings include: Resident #49 (R49) On 3/6/25 at 10:25 a.m., R49 was observed in a merry walker (a four wheeled walker with a seat and frame/crossbar locking the resident in the walker) ambulating down the hallway. R49's merry walker strap was observed attached to the back frame of the merry walker. R49 was observed attempting to enter another resident's room at the time and was redirected by staff. Review of R49's Electronic Medical Record (EMR) revealed admission to the facility on [DATE] with primary diagnoses of vascular dementia with agitation. A quarterly Minimum Data Set (MDS) assessment completed on 1/29/25 documented R49 as having short-term and long-term memory impairment with severely impaired cognitive skills for daily decision making. The MDS coded the use of a chair that prevents rising restraint less than daily for R49. There was no physician's orders for a merry walker. The Director of Nursing (DON) was interviewed on 3/6/25 at 10:51 a.m. The DON was asked about restraint assessments, physician orders and resident representative consent for the use of R49's merry walker. The DON confirmed R49 was first trialed and given a merry walker in November 2024 and that there was no resident representative consent signed until January 2025. The DON also stated that there was a delay in R49's care plan for the use of the merry walker, and R49 had no completed assessments. Review of the facility's Restraints and Seclusions policy dated 12/12/24 read, in part, It is the policy of this facility that each resident shall attain and maintain his/her highest practicable well-being in an environment that prohibits the use of restraints and seclusion for discipline, coercion, retaliation or convenience and limits restraint use to circumstances in which the resident has medical symptoms that warrant the use of restraints . The policy did not discuss how the facility will determine the need for a physical restraint, physician order, assessments, consents, or care plans.

Based on interview and record review, the facility failed to ensure a recapitulation of stay was completed for one Resident (#66) out of one resident reviewed for for discharge to the community. Findings Include: Resident #66 (R66) Review of R66's electronic medical record (EMR) revealed admission to the facility on [DATE] for surgical aftercare following an intestinal obstruction. R66 was discharged from the facility on 1/30/25 following a short-term rehabilitation stay. Review of R66's EMR revealed no discharge plan, recapitulation of stay, nor reconciliation of pre- and post-discharge medications. On 3/6/25 at 9:28 AM, an interview was conducted with Registered Nurse (RN) M regarding discharge expectations. RN M stated each discipline was supposed to include a discharge progress note in the EMR. RN M was unsure why R66 did not have the expected discharge summaries in their EMR. On 3/6/25 at 9:34 AM, an interview was conducted with Licensed Practical Nurse (LPN) H regarding the discharge process. LPN H stated facility staff were required to review medications with the resident and complete discharge progress notes by discipline in the EMR. On 3/6/25 at 9:42 AM, an interview was conducted with the Director of Nursing (DON) regarding R66's discharge process. The DON confirmed a discharge summary by discipline was expected and was unsure why R66 did not have such in their EMR. The DON stated an official recapitulation of stay was not part of the facility's discharge process. However, the regulation explicitly stated one was required for such a discharge. Review of the facility policy titled, Discharge/Transfer, reviewed 6/2024, read, in part: .nursing staff will provide education and information to prepare resident for discharge .resident will be provided with education regarding medications that are ordered by the physician on discharge .

Based on observation, interview, and record review, the facility failed to ensure sanitary storage and proper cleaning of respiratory equipment for one Resident (#59) of one resident reviewed for respiratory services. Findings include: Resident #59 (R59) Review of R59's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including obstructive sleep apnea and asthma. Review of R59's most recent Minimum Data Set (MDS) assessment, dated 1/8/25, revealed a Brief Interview for Mental Status (BIMS) score of 15/15, indicative of intact cognition. On 3/4/25 at 3:12 PM, a continuous positive airway pressure (CPAP) mask and tubing were observed placed on R59's dresser with no protective covering. Supplemental oxygen tubing, including the nasal cannula, was also observed attached to a concentrator near the dresser, in direct contact with the floor. On 3/5/25 at 11:53 AM, R59's CPAP mask and tubing were again observed on the dresser with no protective covering. The supplemental oxygen tubing and cannula continued to be in direct contact with the floor. When asked about cleaning expectations, R59 stated the respiratory equipment was supposed to be cleaned daily but staff did not routinely clean the respiratory equipment. On 3/6/25 on 9:57 AM, R59's CPAP mask and tubing was again observed on the dresser with no protective covering. The supplemental oxygen tubing and cannula continued to be in direct contact with the floor. Review of R59's EMR revealed the following order, initiated 5/3/24: .CPAP machine with oxygen concentrator 2.5 L/m [liters/minute] use as directed .Apply at bedtime, remove at AM [morning]. Clean machine per manufactures instructions. On 3/6/25 at 10:31 AM, an interview was conducted with Certified Nursing Assistant (CNA) O regarding respiratory equipment storage expectations. CNA O was unfamiliar with the facility's cleaning or storage policy. On 3/6/25 at 10:35 AM, an interview was conducted with Registered Nurse (RN) N regarding CPAP and oxygen equipment storage expectations. RN N indicated the CPAP hose was supposed to be cleaned with water after every use and then hung to dry. RN N was unaware of a policy regarding storage of respiratory equipment when not in use. When asked what the manufacturer instructions for the cleaning of R59's respiratory equipment per physician's orders meant, RN N was unaware. On 3/6/25 at 10:49 AM, an interview was conducted with the Director of Nursing (DON) regarding the facility's respiratory cleaning and storage policies. The DON stated the CPAP tubing should be cleaned after each use and more thoroughly one time per week, unless otherwise indicated in the physician's orders. After reviewing R59's orders, the DON stated, clean per manufacturer's instructions is unclear and floor staff would not have access to such information. The DON indicated both the CPAP mask and oxygen cannula in direct contact with the dresser and floor, respectively, was an infection control concern as it would increase the risk of respiratory illness. Review of the facility policy titled, CPAP Equipment Cleaning Instructions, reviewed 1/23/25, read, in part: It is the policy of [Facility Name] to promote a clean environment by reducing and/or eliminating the risk for infection through proper cleaning of the equipment being used . the CPAP equipment will be cleaned on a regular basis . Review of the facility policy titled, Cleaning Oxygen Concentrators and Changing Oxygen Accessories, reviewed 6/2019, read, in part: .all tubing will be placed in a plastic bag attached to oxygen system when not in use .

This citation pertains to Intake:MI00147670 Based on observation, interview, and record review, the facility failed to prevent the misappropriation of narcotic medication for one Resident (R1) of six residents reviewed for misappropriation. Findings include: Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE] with diagnoses including cancer, malignant neoplasm of unspecified ovary, malignant neoplasm of left kidney, cervical disc degeneration, and chronic pain. R1 scored a 7 of 15 on the Brief Interview for Mental Status (BIMS) assessment reflective of severe cognitive impairment. Review of R1's Medication Administration Record (MAR), revealed the following: Morphine Sulfate (concentrate) oral solution 100 mg/ml (milligrams/milliliter). Give 0.5 ml every hour as needed for hospice care patient for air hunger or moderate/severe pain .start date 10/4/24. Review of the Facility Reported Incident (FRI) submitted on 10/13/24 at 6:32 p.m. revealed the following: Incident Summary: Nurse noted morphine solution was discolored. Morphine set aside for pharmacy analysis. Doctor notified and new vial obtained immediately from back up. Resident does not appear to be in uncontrolled pain. No physical pain or mental anguish apparent outside of typical behavior for this resident. To protect residents the suspect nurse has been removed from the schedule. Review of Facility investigation report submitted on 10/21/24 at 12:19 p.m., read in part . I [Director of Nursing (DON)] was contacted by . RN [Registered Nurse E] supervisor via phone . (R1's) Morphine 100 mg/5 ml concentrate looked tampered with, the color is clear and should be blue . I updated administrator (Nursing Home Administrator [NHA]). (NHA) contacted and updated . (Local Police) of possible drug diversion . I arrived at (the facility). I and (RN F) removed the possibly tampered Morphine 100 mg/5 ml concentrate from the Narcotic box. I . inspected the Morphine contents with (RN F) and noted the concentration to be clear in color. I . DON inspected all other bottles of Morphine concentrate within the building . Resident (R1) was found to be without increase in pain and showing normal behavior for the resident at this time. Resident's (R1's) mother/DPOA (Durable Power of Attorney) was notified of the discrepancy, as well as (local) Public Safety was notified and updated . To protect residents, the suspect nurse, (Licensed Practical Nurse [LPN D]) was removed from schedule . camera footage was reviewed . from 10/11/24 at 7:00 p.m. through 10/13/24 at 7:00 a.m. Which revealed (LPN D) taking the morphine vial, syringes, and medication cups and going into the nurses lounge/bathroom or hall bathroom numerous times and then replacing the vial of morphine in the top drawer of the medication cart. (R1) is the only resident that has Morphine ordered on (unit). Her (R1's) medication administration record (MAR) was reviewed and no charting of receipt of Morphine was administered during the viewed hours of the camera footage. Suspect nurse (LPN D) had no need to obtain the Morphine bottle or syringes. Placement of the bottle and syringes in (LPN D's) pocket and in the top drawer of the medication cart, along with multiple trips to the bathroom, and tampered bottle, lead the facility to conclude that (LPN D), diverted medication. Following the viewed camera footage, (LPN) D was terminated. An attempt to reach (LPN) D by telephone was conducted on 12/17/24 at 3:52 p.m., no connection was made and unable to leave a voicemail. During an interview on 12/17/24 at 3:19 p.m., the NHA acknowledged the facility concluded LPN G diverted morphine. During an interview on 12/17/24 at 4:08 p.m., the DON acknowledged LPN G diverted morphine and stated, The vial of morphine was supposed to be blue and you could see it was clear .the video footage shows that (LPN G) took the vial of morphine out of the medication cart and placed it in her pocket . This Surveyor reviewed video footage received from the Facility and confirmed LPN G obtained a vial out of the medication cart and syringes and placed them in her pocket and then went into the nurses lounge or hallway bathroom and then returned to the medication cart and placed the vial back into the medication cart. Review of facility policy titled [Facility] Freedom from Abuse, Neglect, Mistreatment, Misappropriation or Exploitation last reviewed 5/24, read in part .any allegations or suspicions of abuse, neglect, or misappropriation of property .will be reviewed by the Quality Assurance and Performance Improvement (QAPI) committee for potential education improvements or policy changes.

Based on observation, interview, and record review, the facility failed to implement an infection prevention and control program to prevent the hospitalization of one Resident (R205) and prevent the spread of infectious organisms for eight Residents (R16, R47, R42, R13, R205, R32, R31, and R33) of eight residents reviewed for infection prevention and control as evidenced by failure to: 1. Post isolation precaution signage timely for residents with indwelling medical devices and/or wounds. 2. Post isolation precautions procedures in accordance with facility policy and/or standards of practice for residents with known contagious illnesses. 3. Post appropriate Personal Protective Equipment (PPE) information for residents diagnosed with infectious illnesses. 4. Develop care plans for residents with known contagious, infectious illness. 5. Adhere to facility policy and standards of practice for placing residents with infectious, contagious illness in private rooms or cohorting residents with the same infection. 6. Ensure staff donned appropriate PPE when providing care to residents. 7. Adhere to policy and standards of practice for active daily surveillance of infections. 8. Correlate staff illness with resident infections. 9. Determine duration of isolation based on facility policy and accepted standards. This deficient practice resulted in harm when Resident #205 (R205) was hospitalized with Influenza A that resulted in acute respiratory failure and acute encephalopathy with hypoxia, bacterial pneumonia and septic shock. Findings include: During an observation on [DATE] at 12:16 p.m., Certified Nurse Aide (CNA) A wore a surgical mask with a face shield, gown, and gloves into Resident R47's room. Posted outside of R47's room was a sign that read: CHECK WITH NURSE BEFORE ENTERING - STOP: In addition to standard precautions: Droplet precautions (box was checked). Hand hygiene (before entering room and after leaving room), Gown, Gloves, Mask N95, Protective Eyewear (Face shield or goggles) and Dedicated equipment . boxes were checked as required Personal Protective Equipment (PPE) for entry into R47's room. CNA A exited R47's room wearing just a surgical mask at 12:21 p.m. On [DATE] at approximately 12:22 p.m., CNA A entered the room of R33, who was on droplet precautions for influenza, and roommate R9, who was not positive for influenza, wearing only a surgical mask. The room door was open and the privacy curtains between the roommates was not pulled closed. During an interview on [DATE] at 12:23 p.m., when asked what type of mask staff needed to wear into R47's droplet precaution room (shared with another resident), CNA A stated, A surgical mask. CNA A said they were unaware that they needed to wear an N95 mask into the droplet precaution rooms. When asked to review the droplet precaution signage posted on R47's and R33's room doors which had written instructions to wear an N95 mask into the room, CNA A looked at the signage and stated, I was not aware that we were supposed to wear N95 masks in the influenza positive rooms. I will do that from now on. During an interview on [DATE] at 12:46 p.m., the Director of Nursing (DON) was asked about the use of an N95 mask for both the Influenza A positive and negative roommates. The DON stated, They (facility staff) don't have to wear an N95 mask if they are in a shared room. When asked about the droplet precaution signs posted outside of the Influenza A positive residents' doors, the DON stated, If the sign says N95 mask then they should be wearing an N95 mask. I would have to ask Infection Preventionist (IP) E, and I would hope that she did not tell him otherwise. We put the signs up for a reason .I hope she (IP E) didn't tell them they didn't have to wear N95 masks in the influenza positive rooms . During an interview on [DATE] at 12:58 p.m., IP E reviewed the droplet precaution signage posted outside the room door of Residents positive for Influenza A. IP E said because it was an Influenza A outbreak a surgical mask would be appropriate. When asked if facility staff would be expected to follow the directions provided for proper PPE posted outside Influenza A positive Resident doors, IP E stated, I would have updated that sign if I had known it was wrong. When asked about allowing Residents who tested positive for Influenza A to stay in the room with a roommate who was not positive, IP E stated, (We are) trying to keep the curtain pulled. There should be a pulling of the curtains between the residents. If the curtain isn't pulled, I would have to look into that further . (the) curtain doesn't matter - we like to keep it pulled for an extra layer of protection. IP E confirmed R47 and R33 were two of the Residents who were positive for Influenza A. During an interview on [DATE] at 1:17 p.m., IP E reviewed the droplet precaution signage posted on the room doors of R47 and R33, who were both positive for Influenza A. IP E confirmed the sign indicated Droplet Precautions and Mask: N95 was marked with an X. IP E said the Influenza outbreak within the resident population was first identified on [DATE]th, 2024. IP E said they were not the person who had placed the isolation precaution signage on resident room doors as Influenza A spread within the facility. When asked if the same isolation precaution signage had been on the room doors of Residents positive for Influenza A since the beginning of the outbreak, IP E acknowledged she had not checked the room door isolation precaution signage on Residents positive for Influenza A, to ensure they were providing accurate PPE information to facility staff since [DATE]. During an observation on [DATE] at 8:01 a.m., CNA B was observed in Influenza A positive R42's room. The room door was open, the privacy curtain between the roommates was not pulled, and CNA B wore a gown, gloves, and surgical mask. No face shield or eye protection was present on CNA B's face as he provided personal care for R42. As CNA B exited R42's room, he wore only the surgical mask. When asked about the absence of a face shield or eye protection as instructed on the precaution signage posted at R42's room door entrance, CNA B said they normally would have worn a face shield, but they had forgotten. CNA B performed hand hygiene with alcohol-based hand rub located just outside R42's room door. CNA B's surgical facemask was positioned down below his nose, and CNA B used his bare hands four times to pull the front of the surgical mask up over his nose. CNA B said the surgical masks do not stay up on his nose because of facial hair. When asked where the surgical mask was removed and discarded after use in an Influenza A positive room, CNA B stated, I wait til I get to the nurses' station (approximately half-way down the resident hallway), and I'll remove my mask and get a new one (at the nurses' station). CNA B was observed to walk to the nurses' station with the contaminated surgical mask on his face, sanitize hands, get new mask from the box, remove the used, contaminated mask, and place a new mask on his face with potentially contaminated hands. During an interview on [DATE] at approximately 8:10 a.m., Registered Nurse (RN) F was asked to verify the PPE required, per the signage, for entry into R42's room. RN F confirmed R42 was positive for Influenza A and the droplet precaution signage instructed protective eyewear (face shield or goggles) were to be worn with a surgical mask. (All precaution signage on [DATE] had been changed from the previous days ([DATE]) observation which required an N95 mask.) Resident R21 During catheter care observation for R21 on [DATE] at 9:00 a.m., CNAs A and G entered the room wearing surgical masks, performed hand hygiene and donned gloves. Signage outside of R21's room door instructed staff to wear Enhanced Barrier Precaution PPE, including the following items: gown and gloves. CNA A and CNA G did not wear gowns for R21's catheter/peri care. Resident R17 During medication pass observation for R17 on [DATE] at 10:18 a.m., RN F administered six medications through R17's feeding tube while wearing gloves. RN F did not wear a gown in compliance with the facility's Enhanced Barrier Precaution policy and signage. Review of the Centers for Disease Control and Prevention (CDC), Enhanced Barrier Precautions signage, revealed the following: . Providers and Staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, Bathing/Showering, Transferring, Changing Linens, Providing Hygiene, changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy, Wound Care: any skin opening requiring a dressing . Review of the [Facility Name] PPE (personal protective equipment) Policy, dated ,d+[DATE], revealed the following, in part: POLICY: It is the policy of the [Facility Name] to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection through the proper use of PPE . Masks - Required when entering a room under droplet or airborne precautions, when staff have s/sx (symptoms) of respiratory illness and/or as directed by IP or designee . Eyewear - Goggles or Face shield, required when entering a room under droplet or airborne precautions, when there is the potential for blood or body fluids to splash into eyes and/or as directed by IP or designee. 4. A supply of PPE is maintained in designated areas. Employees who fail to use PPE as necessary may receive disciplinary action. 5. Visitors of residents who are under transmission-based precautions will be educated on and provided the proper PPE. Review of the [Facility Name] Transmission Based Precautions Policy, dated ,d+[DATE], revealed the following, in part: .In all instances of TBP: Signs will be posted outside the room that indicate type of precautions, PPE will be available outside resident room and trash can will be placed for easy disposal of PPE . DROPLET PRECAUTIONS: 1. Implemented for residents with suspected or confirmed infection with a microorganisms transmitted by droplets (large particle, greater than 5 microns in size) that are generated by coughing, sneezing, talking or performance of procedures, such as suctioning. 2. Examples of Infections requiring Droplet Precautions . Influenza . Resident Placement: a. Place in a private room, if possible. b. If private room is unavailable, may cohort with other residents with the same infection with the same microorganism. c. When unable to cohort, keep room divider curtain closed as able and maintain at least 3 feet of distance between the infected resident and other residents and visitors. d. An alarmed stop sign will be added to the room door to remind resident to stay in their room and to alert staff if the resident is leaving their room as needed. 4. Masks and Face shield: a. Must be worn in addition to gloves and gown. b. Must don a minimum of a surgical mask before entering room, higher grade mask (N95) may be required as directed. c. Goggles or face shield must be donned before entering room. 5. Resident Transport: a. Limited movement of resident from the room to essential purposes. b. If transport from room is necessary, place mask on resident and encourage respiratory hygiene/cough etiquette as within residents' ability to comprehend. ENHANCED BARRIER PRECAUTIONS: 1. Infection control interventions designed to reduce transmission of MDRPs that uses targeted gown and glove use during high contact resident cares. 2. May be indicated for: a. Residents with non-acute wounds (Pressure injuries) or indwelling medical devices, such as: central line, urinary catheter, feeding tube and tracheostomy, regardless of MDRO colonization status. b. Residents that are colonized with MDRO. 3. High-contact care activities: a. Dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs, or assisting with toilet/commode use, device care and wound care. 49310 On [DATE] at 11:00 a.m. a posting was observed on the building entrance door stating the facility was experiencing an outbreak of influenza A. The DON conveyed eight residents had been diagnosed with influenza A, and said the outbreak began on [DATE]. On [DATE] at 3:05 p.m., signage was observed posted outside the doors of Resident #21's (R21) room and Resident #31's (R31) room. A sign for EBP was posted on R21's door; the sign was not present when the room was initially observed during initial observation at 12:02 p.m. R31's door had a sign posted for Droplet Precautions that was not present when the room was observed during an initial tour at 12:02 p.m. On [DATE] at 3:15 p.m., the DON was asked regarding the posting on R21's door indicating EBP. The DON said R21 was on EBP due to having an indwelling urinary catheter. When asked why the sign wasn't posted until today, the DON said, It (the sign) should have been posted when (R21) was admitted but it (the sign) didn't get posted until today ([DATE]). The DON was asked why the sign appeared on R31's door. The DON said there had been a posting on R31's door for Droplet precautions due to Influenza A but they took it (the posting) down because they thought 7 days had elapsed since R31 tested positive for Influenza A. The DON stated, we realized today that the 7 days of precautions won't be over until tomorrow ([DATE]) so we put the sign back up. The DON was asked if R31 had resolution of symptoms or if R31 remained symptomatic. The DON replied that she would have to review the record to see. When asked if any residents had died or were hospitalized with influenza, the DON said there were no influenza-related deaths and one resident, Resident #205 (R205), went to the hospital with influenza-related illness. Review of R205's record revealed a laboratory-confirmed diagnosis of influenza A on [DATE]. A nurses note on [DATE] at 1:00 a.m. read, The resident was sent to [name of hospital]. Vital signs Blood pressure ,d+[DATE] Pulse 122 Temp 98.9 respirations are 40 oxygen is 88% @ (at) room air. The resident is non-responsive with sternal rub. R205 was admitted to the hospital with a primary diagnosis of Influenza A. Hospital Records documented R205 experienced hospitalization for acute respiratory failure and acute encephalopathy with hypoxia with bacterial pneumonia and septic shock in setting of Influenza A infection. R205 was readmitted back to the facility on comfort care measures on [DATE]. During an interview on [DATE] at 10:46 a.m., IP E was asked about the absence or delay in posting EBP and Droplet Precautions signs on the doors to resident rooms. IP E said, the nurses were taught but they aren't always getting the signs put up. When asked if she audited as part of IP duties to ensure postings were placed and accurate, and if she conducted any monitoring to ensure staff were adhering to precaution expectations, IP E replied, No. IP E reported there were eight laboratory-confirmed cases of influenza for residents, and three cases of staff influenza. Review of the facility infection log revealed the following residents had been diagnosed with Influenza A: Resident #13 (R13) diagnosed [DATE], R205 diagnosed [DATE], Resident #32 (R32) diagnosed [DATE], R31 diagnosed [DATE], R33 diagnosed [DATE], R16 diagnosed [DATE], R47 diagnosed [DATE], and R42 diagnosed [DATE]. IP E was asked why the residents who tested positive were not placed in private rooms or cohorted with the same illness. IP E stated, I don't know. I don't have a good answer to your question. IP E said the first identified case in the outbreak was Resident #13 (R13). IP E was asked regarding contact tracing or source investigation, correlation of illness or analysis to determine the initial source of the infectious organism. IP E said she had not attempted to determine the initial source. When asked the reason the illness was spreading to other hallways in the building, IP E shrugged her shoulders and said, I don't know. I assume from visitors. IP E was asked the expectation for the privacy curtains in the rooms and the door to the rooms being open for residents with Influenza. IP E said, the curtain should be pulled but we don't close the door due to safety concerns - but the curtain should always be pulled. IP E confirmed there were no care plans developed for residents with influenza nor were there any physicians' orders for the residents with Influenza to be placed in isolation. When asked how staff would know the appropriate interventions with no care plan, IP E shrugged and did not provide an answer. When asked how active daily surveillance was being conducted, IP E replied, It's not. IP E suggested the nurses were surveilling through resident observations. When asked if those observations included resident assessments such as obtaining vital signs, respiratory assessment, temperature, documenting signs or symptoms of influenza, or obtaining pulse oximetry, IP E stated, No. Just observing the residents. IP E was questioned regarding staff illnesses during and preceding the outbreak. IP E said there were three staff members who had influenza. IP E said staff who called off work with respiratory symptoms were tested for COVID-19, influenza, and Respiratry Syncytial Virus (a contagious viral infection of the respiratory tract that can cause severe lung infections). A list of employee call-offs from work for illnesses for the month of [DATE] through [DATE] was reviewed. According to the employee illness call-off log, Staff J, a Personal Care Attendant, called off work on [DATE] due to influenza. CNA K called off work on [DATE] due to Influenza A. CNA L called off work on [DATE] for Influenza. Staff M called off work due to Influenza on [DATE]. CNA N called off work on [DATE] due to having Influenza A. Staff O called off work on [DATE] due to Influenza A. A total of six staff members diagnosed with influenza were documented on the illness log from [DATE] through [DATE]. This information conflicted with the number reported by IP E as three employees. The employee call-off log for [DATE] included 23 employee call-offs for work. Six of the call-offs were for influenza. Fifteen of the 23 call-offs were employees experiencing one or more symptom of influenza but were not tested for Influenza. Two of the call-offs received testing for Influenza. IP E was asked why symptomatic employees weren't tested for influenza as IP E had previously told the surveyor they would have been. IP E stated, I can't force them to do that. When asked if the symptomatic staff members were encouraged to test or if education on influenza was provided, IP E replied, no. IP E confirmed she was not tracking symptom-resolution dates for employees. IP E said she was not tracking return to work dates for employees who called off work with confirmed influenza or symptoms of influenza and she was not tracking symptom-resolution for employees who were ill. IP E was asked why infection control documentation did not include correlation of illness between staff and residents. IP E did not provide an answer. IP E said, They (symptomatic staff or staff with diagnosed influenza) couldn't return to work until they were fever-free for 24 hours. When asked duration of isolation for residents diagnosed with Influenza, IP E stated, residents are on isolation for 7 days and are removed from isolation on day 8 unless their fever hasn't resolved. When asked if everyone who has the flu has a fever, IP E responded, yes. According to the Centers for Disease Control (CDC): Influenza can cause mild to severe illness, and at times can lead to death. People who have flu often feel some or all of these symptoms: fever* or feeling feverish/chills, cough, sore throat, runny or stuffy nose, muscle or body aches, headaches, fatigue, some people may have vomiting and diarrhea, *it's important to note that not everyone with flu will have a fever. Flu Symptoms & Complications | CDC According to the CDC Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities | CDC: Droplet Precautions should be implemented for residents with suspected or confirmed influenza for 7 days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer, while a resident is in a healthcare facility. Examples of Droplet Precautions include: placing ill residents in a private room. If a private room is not available, place (cohort) residents suspected of having influenza residents with one another. The guidance from CDC includes: Active surveillance for additional cases should be implemented as soon as possible once one case of laboratory-confirmed influenza. When 2 cases of laboratory-confirmed influenza are identified within 72 hours of each other in residents on the same unity, outbreak control measures should be implemented as soon as possible. The facility policy '[facility name] Policy and Procedure Prevention and Control of Seasonal Influenza' dated ,d+[DATE] read in part: It is the policy of [facility name] to provide for the residents, staff and visitors a safe and health environment by identifying, treating, and controlling the spread of Influenza in the facility. Droplet Precautions: 1. Droplet precautions will be implemented for residents with suspected or confirmed influenza for seven (7) days after illness onset or until 24 hours after the resolution of fever and respiratory symptoms, whichever is longer. 2. In some cases, droplet precautions may be applied for longer periods based on clinical judgment. 3. Residents with suspected or confirmed influenza will be placed in a private room or area, when possible. When a single resident room is not available, the IP and/or designee will assess the risks associated with other resident placement options (e.g., cohorting .) 5. Residents under droplet precautions will be discharged from care when clinically appropriate, not based on the period of potential virus shedding or recommended duration of droplet precautions.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety as evidenced by failing to ensure that potentially hazardous food was labeled, dated, and cooled according to facility policy and food code guidelines. This deficient practice had the potential to result in food borne illness among any or all the 57 residents in the facility. Findings include: During a tour of the facility dietary department with Dietary Manager (Staff H) on [DATE] at 11:06 AM, the following observations were made: In the reach-in refrigerator: - A container of ranch salad dressing was found with an expired use by date of [DATE]. - A zipper sealed gallon baggie housed 11 hard-boiled eggs without a preparation date, nor a use by date. Staff H stated he expected, If it is out of the original container, dates would be on the product. - A zipper sealed baggie with a type of meat (identified by Staff H due to lack of a label) had an expired use by date of [DATE]. - An unsealed, open to air, gallon baggie of hashbrowns (identified by Staff H) had no label, and no use by date. In the walk-in freezer there was a large bin with multiple zipper sealed bags of product. The bottom of the bin had debris and dried food particles. The bin contents included: - A partial bag of Fiesta corn mix which was not labeled with an opened date. There was a use by date as stamped by the manufacturer revealing the product had expired on [DATE]. - An unsealed, open to air, partial bag of frozen diced rutabaga did not have an opened date or a use by date. - An unsealed, open to air, partial bag of frozen brussel sprouts did not have an opened date or a use by date. The walk-in freezer also contained: - A large cardboard box with the top open exposing an open plastic bag with green beans. No date marking was evident. - A cart with several steam table pans of foods including one marked Ribbets with a use by date of ,d+[DATE]. - A large cardboard box with the top open exposing an open plastic bag of frozen uncooked chicken pieces. No date marking was evident. - A large plastic bin containing a variety of partially filled plastic bags of product out of the original manufacture's containers including: - 6 pancakes in an unsealed plastic bag. No date marking was evident. - Cinnamon rolls in a plastic bag. No date marking was evident. - French toast in several bags (one bag was open with exposed french toast). No date marking was evident. Staff H again explained he would expect all items out of the original manufacturer's containers to be labeled, dated when opened, and dated with a use by date. Approximately 20 unlabeled, uncovered small bowls of a tri-colored product were observed in the walk-in freezer. Staff H was asked to identify the product. He replied, I don't know. (It) looks like leftovers. He stated he would expect such items to be covered, labeled, and dated. On [DATE] at 11:45 AM, the cooling process was requested. Staff H indicated the cooling process was part of a daily sheet of paper filled out by the staff. The sheets were in multiple stacks of papers in Staff H's office. One sheet dated across the top [DATE] had a lower portion of the page labeled FOOD COOLING LOG filled in with Pepper Steak. The date on this portion was blank. The initial time was blank. The start temperature was blank. No follow up times were noted, only 70 and 39 were recorded. When asked about the process, Staff H replied, They (Dietary Staff) are not really capturing the data appropriately. The undated facility policy titled: Labeling and Dating of Food Items was received and read in part: .All foods taken out of the original packaging will be placed in a sealed container or bag to include the date the item was opened, the contents of the item, with a use by or discard date. All food items must be properly labeled, dated and stored using the FIFO (First In First Out) method. The undated facility policy titled: Cooling of Foods was received and read in part: .Cooling TCS (temperature control for safety) foods from 135F (Fahrenheit) to 41F or lower within 6 hours. Pathogens grow rapidly between 125F and 70F .Cool food from 135F to 70F within two hours. Then cool foods to 41F within the next four hours . Foods that are cooled for future service are to be monitored on the cooling record sheet . The FDA Food Code 2017 states: ,d+[DATE].14 Cooling. (A) Cooked TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cooled: (1) Within 2 hours from 57 C (135 F) to 21 C (70 F); and (2) Within a total of 6 hours from 57 C (135 F) to 5 C (41 F) or less The FDA Food Code 2017 states: ,d+[DATE].17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. (A) Except when PACKAGING FOOD using a REDUCED OXYGEN PACKAGING method as specified under S ,d+[DATE].12, and except as specified in (E) and (F) of this section, refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded when held at a temperature of 5 C (41 F) or less for a maximum of 7 days. The day of preparation shall be counted as Day 1.

Based on interview and record review, the facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least quarterly with the required committee members. This deficient practice resulted in the potential for ineffective coordination of medical care and delayed resolution of facility issues, placing all 57 residents in the facility at risk for quality care concerns. Findings include: During an interview on 3/20/24 at 8:40 AM, the Nursing Home Administrator (NHA) reviewed the QAPI policy and the attendance for the quarterly QAPI meetings. The QAPI meeting sign in sheets revealed: - 1/17/24 The NHA, Medical Director, Infection Preventionist, DON (Director of Nursing) and more than two others were present. - 10/12/23 The NHA, Medical Director, Infection Preventionist, DON and more than two others were present. - 7/13/23 The Medical Director, Infection Preventionist, DON and more than two others were present but the NHA (or other in a leadership role) was not present. - 4/13/23 The NHA, Infection Preventionist/DON and more than two others were present, but the Medical Director was not present. - 1/19/23 The NHA, Infection Preventionist, DON and more than two others were present, but the Medical Director was not present. The facility QAPI Program was reviewed and read in part: QAPI FRAMEWORK . The QAPI Committee will consist of the facility Administrator, Medical Director, Director of Nurses .

Based on observation, interview, and record review, the facility failed to maintain a medication error rate less than 5 percent when eight medication errors were observed out of 25 medication pass opportunities. This deficient practice resulted in a 32 percent medication error rate, the potential for medication to not be administered, and medications provided in a manner that was inconsistent with physician orders. Findings include: Resident R3 Medication pass was observed on 3/19/24 at 8:12 a.m., when Licensed Practical Nurse (LPN) D prepared medications for R3, including 17 grams of polyethylene glycol (a medication used in the management and treatment of constipation) mixed in a cup with water and a straw. LPN D entered R3's room and placed the small cup filled with the clear liquid on R3's over-bed table. Resident R3 was not offered, encouraged, or assisted to consume the polyethylene glycol, and no mention was made of the medication left on the over-bed table. During an interview on 3/19/24 at 8:23 a.m., LPN D was asked if R3 had been assessed as capable of self-administration of medications. LPN D stated, That is a good question. When asked if R3 was cognitively intact and able to make their own decisions, LPN D said R3 was not cognitively intact. LPN D reviewed R3's Electronic Medical Record (EMR) and said an assessment to determine R3's ability to self-administer medications was not found. During an interview on 3/19/24 at 8:28 a.m., the Director of Nursing (DON) was asked if R3 had an assessment to allow for self-administration of medications. The DON stated, No [they] do not. No residents are (able to) self-administer (medications) in the building at this time. Review of the Medication Self-Administration Policy, dated 3/2021, revealed the following, in part: These residents who request to self-administer medications will be assessed by a nurse and the assessment will be documented in the resident's EMR. The medication self-administration assessment along with the doctor's medical determination of the resident will determine whether the resident is appropriate to safely self-administer medications. Procedure: 1. Self-administration will be allowed only for those residents who . Have demonstrated minimal cognitive, visual, and physical abilities as determined by the nurse completing the assessment and the doctor's medical determination. Has a written physician's order allowing self-administration. Have a secure area for storage of medications so that other residents do not have access . 4. Nurse will document the medication taken by resident on the MAR, when resident informs the nurse of self-administration of a medication . Resident's care plan will reflect the self-administration of the medications. Resident R17 During an observation of medication pass on 3/19/24 at 10:18 a.m., Registered Nurse (RN) F crushed tablets and/or opened capsules in preparation of administration of R17's medications through an enteral feeding tube. The following medications were crushed and added to approximately 120 mL (milliliters) of apple juice: 1. Acetaminophen 325 mg (milligrams), 2 tablets. 2. Fexofenadine HCL (hydrochloride) 180 mg, one tablet. 3. Fluoxetine 20 mg, one capsule. 4. Januvia 50 mg, one tablet. 5. Lisinopril 2.5 mg, one tablet. 6. Multivitamin, one tablet. 7. Polyethylene glycol, 17 grams (powder) in a separate cup of apple juice. Medications one through six were crushed and/or opened and mixed with apple juice in a small, plastic cup, and the polyethylene glycol was mixed in another cup of apple juice and all medications were administered by pushed injection by RN D through R17's feeding tube on 3/19/24 at approximately 10:25 a.m. Review of R17's Physician Orders related to medication administration revealed the following, in part: May administer all medications as prescribed all together via G-tube (Gastronomy tube). Dilute in 120 mL of water. Administer via gravity two times a day related to amyotrophic lateral sclerosis (ALS diagnosis). Prescriber Written. Order Date: 3/19/24, Start Date: 3/19/24. During an interview on 3/20/24 at 11:11 a.m., the Director of Nursing (DON) was asked if the physician order specified gravity for the method of medication administration through R17's G-tube, could nursing staff administer medications by pushed injection into the feeding tube? The DON stated, It has to be gravity. When asked about the use of apple juice for the liquid used to dissolve the crushed medications, the DON stated, I would have to get an order (physician order) for apple juice for (R17). When asked if failure to gravity feed the medications, and the administration of the enteral medications in apple juice rather than the water in the physician order would be considered a medication error, the DON agreed each of those medications would be considered a medication administration error. Review of Medication Administered through an Enteral Tube policy, revision date April 2022, revealed the following, in part: .If the physician/prescriber and the interdisciplinary care team have evaluated the resident and determined that the administration of crushed medication as a single bolus outweighs the risk of administering the crushed medications individually, the physician/prescriber should . assure the bolus administration of crushed medications is addressed in the resident's care plan . Allow medications to flow down the medication syringe via gravity. Do not push medications through a tube. Flush after each dose with at least 15 mL of water .

Based on observation, interview, and record review, the facility failed to: 1) implement appropriate source control during a COVID-19 outbreak to control the transmission; 2) follow transmission-based precautions (TBP); 3) properly utilize Personal Protective Equipment (PPE); 4) maintain social distancing during a group activity; 5) properly store medical supplies and linens. These deficient practices resulted in Immediate Jeopardy which began when the first of three residents was found to be COVID-19 positive on 1/25/22. Data as of the exit conference on 2/2/2022 at 4 p.m. showed three residents and 17 staff were identified as COVID-19 positive by the week of 1/6/2022. According to CDC's {Center for Disease Control and Prevention} COVID-19 Data Tracker The facility's community transmission rate was 34.12% (reflected the last seven days ending January 28, 2022), which indicated high community transmission. The Immediate Jeopardy was identified on 2/1/22; the Nursing Home Administrator (NHA) was notified on 2/1/22 at 9:30 a.m. and an Abatement Plan was requested at that time and soon after approved. The Immediate Jeopardy was removed on 2/1/22 following verification the Abatement Plan was implemented to limit the continued spread of COVID-19 with proper source control. Following the removal of immediacy on 2/1/22, deficient practice continued at widespread potential for more than minimal harm level. Findings include: During entrance to the facility on [DATE] at 6 p.m., a sign was posted to the exterior door which read, PLEASE BE ADVISED: MULTIPLE CASES OF COVID-19 HAVE BEEN IDENTIFIED WITHIN THIS FACILITY IN THE LAST 14 DAYS. During entrance screening in the facility's vestibule, Registered Nurse (RN) O wore a surgical mask with tenting noted bilaterally (cheeks) which indicated the mask had a poor fit. On 1/31/22 at 6:54 p.m., Licensed Practical Nurse (LPN) K who was in front of the nurses' desk, had on a surgical mask that had tenting bilaterally and slipped down to the edge of the nose. LPN K touched the front of the mask twice while attempting to reposition it higher on the face without the performance of hand hygiene. When asked why staff were not wearing N95 masks since the facility was experiencing an outbreak, LPN O said because staff were shown a memo which indicated they were not approved by the FDA (Food and Drug Administration). On 1/31/22 at 7:08 a.m., an unidentified staff member was observed walking down the hallway on Station 1 Area (resident care area) with a surgical mask below the nose. On 1/31/22 at 7:34 p.m., Resident #27's doorway contained a CDC's Droplet Precautions sign which specified the following: EVERYONE MUST: Clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. A three drawer bin was positioned to the left side of the door frame in the hallway. The door was completely opened, and Resident #27 was sitting directly in front of the television with their back to the doorway. On 1/31/22 at approximately 7:40 p.m., RN X was asked why Resident #27 was in Droplet Precautions. RN X said the roommate tested positive for COVID-19 and indicated Resident #27 was unvaccinated for COVID-19. On 1/31/22 at approximately 7:45 p.m., Resident #27 walked out of the room, touched this Surveyor's right arm, and proceeded to walk down the hall to the nurses' desk. No facial covering was worn by Resident #27 when they left the room. An unidentified Certified Nurse Aide (CNA) escorted Resident #27 back to the room. The same CNA stopped outside Resident #27's door and donned a yellow gown, clear gloves, and a face shield (already wearing goggles and a surgical mask). No hand hygiene was performed prior to donning the PPE. During an interview on 2/1/22 at 7:15 a.m., the NHA and the Director of Nursing (DON) informed the survey team a second resident (Resident #38) was transferred to the hospital and tested positive for COVID-19 on 2/1/22. When asked about this Surveyor's observation of Resident #27's departure from the room on 1/31/22 at 7:45 p.m. without wearing any source control, who's room was directly across from Resident #38's room, the DON said all residents within the facility were care planned not to wear masks. The DON confirmed Resident #27's wandering posed a risk for COVID-19 transmission. During an interview on 2/1/22 at 7:49 a.m., the DON indicated the first staff person (Staff L), who last worked on Station One on 1/7/22, tested positive for COVID-19 and was unvaccinated. The DON provided COVID-19 surveillance data beginning January 7, 2022, which showed the following residents and staff positivity: Week One- two staff Week Two- seven staff Week Three-one resident and five staff Week Four-two residents and two staff When asked about contract tracing, the DON said that it was no longer performed and indicated all positive staff worked facility-wide and indicated the positive residents were located on more than one hallway. During an interview on 2/1/22 at 8:11 a.m., the DON was asked if the facility added a higher level of source control with the continuation of the outbreak over several weeks. The DON confirmed staff were expected to wear surgical masks and eye protection. When asked why facility staff were not wearing the available N95 masks which had a higher level of respiratory protection, the DON replied, We have plenty of N95s. We didn't put everyone in N95s because they were not all fit tested . The DON confirmed the N95 mask provided a higher level of protection than the surgical mask in preventing the transmission of COVID-19. The DON said the facility currently had 6 out of 47 residents who were not vaccinated. Regarding Resident #27's unvaccinated status and wandering behavior, the DON confirmed there existed a concern for possible transmission since residents were not wearing masks. When the NHA and DON were informed of the total number of cumulative staff and resident who were positive for COVID-19 since the second week of January (2022), the DON responded, That many? I lost track. During an observation on 2/1/22 at 9:28 a.m., Staff N repeatedly touched (four separate times) the exhalation valve on the front of the N95 mask without the performance of hand hygiene. When asked what the purpose of the exhalation valve was, Staff N responded, No, (I don't know), could you educate me? During an activity observation on 2/1/22 at 3:23 p.m., in the main dining room, approximately ten residents were seated shoulder to shoulder at square tables which were pushed together to form one long rectangle shaped table. Two staff were present, who were wearing N95 masks, with only two residents wearing surgical masks. No social distancing was observed to provide six feet separation. The activity was Crazy Eights (card game). During an interview immediately following the observation on 2/1/22 at 3:29 p.m., the DON was asked to observe the group activity in the main dining room. The DON confirmed social distancing was not in place. During an interview on 2/1/22 at 4:17 p.m., Activity Director (Staff) V said the tables were pushed together for the Crazy Eights activity and confirmed social distancing was not observed by both residents and staff. During an observation on 2/2/22 at 7:09 a.m., outside the main dining room towards the chapel, a posted sign read, COVID-19 SOCIAL DISTANCING Stay Apart 6ft.(feet) /2 m (meters) Between you and other people. During an observation on 2/2/22 at 7:16 a.m., Resident #27's isolation supply cart contained the following items which were placed directly on top: a Styrofoam cup (no lid) with was half-full of a clear liquid which appeared to be water, an assistive device used to pull up socks, and a stack of white linens. Registered Nurse (RN) Q confirmed the items should not have been stored on top of Resident #27's isolation cart and indicated the assistive device did not even belong to Resident #27. RN Q explained the items stored placed a risk for cross-contamination. During an interview on 2/2/22 at 8:16 a.m., the DON confirmed the exhalation mask worn earlier by Staff N should not have been used since the valve did not provide protection from COVID-19 transmission. When asked about transmission-based precautions for the two remaining residents (Resident #47 and Resident #27) not indicating gown usage, the DON confirmed a contact sign needed to be added. When asked about hand hygiene with donning PPE, the DON confirmed hand hygiene needed to be performed prior to gown and/or glove placement. References Review of the facility's policy and procedure Transmission-Based Precautions (Isolation) revised 3/21, read in part, Based on CDC definitions, three types of Transmission-Based Precautions (airborne, droplet and contact) have been established. In addition to Standard Precautions, implement Contact and Droplet Precautions for an individual documented or suspected to be infected with microorganisms transmitted by multi-route transmission that can be generated by the individual coughing, sneezing, talking, touching .examples of infections .COVID-19. Enhanced Barrier Precautions .For Novel .Per CDC Guidelines . Review from the CDC Types of Masks and Respirators Summary of Recent Changes https://www.cdc.gov/coronavirus/2019, updated 1/28/22, read in part, To protect yourself and others from COVID-19, CDC continues to recommend that you wear the most protective mask you can that fits well and that you will wear consistently . Some masks and respirators offer higher levels of protection than others, . It is most important to wear a well-fitting mask or respirator correctly that is comfortable for you and that provides good protection. While all masks and respirators provide some level of protection, properly fitting respirators provide the highest level of protection. Wearing a highly protective mask or respirator may be most important for certain higher risk situations, or by some people at increased risk for severe disease . Review of CMS (Centers for Medicare & Medicaid Services) Memorandum Reference: QSO-20-39-NH, revised 11/12/2021, read in part, physical distancing at least six feet between people, in accordance with CDC guidance .Communal Activities .The safest approach is for everyone, regardless of vaccination status, to wear a face covering or mask while in communal areas of the facility . Review of the facility's policy and procedure Hand Washing/Hand Hygiene dated 1/2020, read in part, Use an alcohol-based hand rub .; or alternately, soap . and water for the following situations: .After handling .contaminated equipment . Before and after entering isolation precaution setting . Review of CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Setting page 51, read in part, Full coverage of the arms and body front, from neck to the mid-thigh or below will ensure that clothing and exposed upper body areas are protected. Several gown sizes should be available in a healthcare facility to ensure appropriate coverage for staff members . During an observation and interview on 1/31/22 at 7:00 p.m., RN E was observed near the nurses' station, near the entrance to the resident living area. RN E wore a surgical mask with a visible gap (allowing passage of air) on the left side of her face. RN E confirmed that all staff were wearing surgical masks, in combination with eye protection on all halls in the facility, except for wearing an N95 mask (and gown, gloves, and eye protection) in COVID-19 quarantine rooms. RN E said they (facility staff) do not wear KN95 masks because they are not approved by the FDA, and they did not wear N95 masks even though they were in the midst of a COVID-19 outbreak. On 2/2/2022 at 7:27 a.m., an observation revealed a Droplet Precaution sign posted next to Resident #47's door. Patient Care Assistant (PCA) D was observed standing inside Resident #47's room holding a bag of garbage while wearing an N95 mask, goggles, gloves and a yellow protective gown. Further observation revealed PCA Ds yellow protective gown had not been secured by tying the gown around the neck and the waist. PCA Ds gown was open in the back and draping down her shoulders, exposing her clothing. During an interview immediately following the observation, PCA D reported the purpose of wearing the gown was to protect her clothing while caring for the Resident #47. PCA D reported the gowns do not fit her properly and she was unable to tie the gowns in the back. PCA D stated she had not alerted administration the gowns did not cover her appropriately nor sought out any other options. PCA D reported she had cared for all fourteen residents on the second wing, including Resident #47, throughout the night. PCA D stated droplet precautions were being used in the care of Resident #47 due to his exposure to a roommate who had tested positive for Covid-19 on 2/1/2022. The facility Abatement Plan was accepted on 2/1/22 to include: 1. Facility identified 16 positive staff over last three weeks and two positive residents. Facility failed to implement additional source control with use of available N95 masks. 1. Due to the current outbreak, all staff have changed over from surgical masks to N95s. Completion date 02/01/2022 2. Moving forward, upon identification of an outbreak, facility will require all staff to use the highest level mask available, when in the presence of residents (care areas, activity areas, etc.) Completion date 02/01/2022 2. Non-adherence to proper surgical mask use (resident and staff). 1. Staff will be educated on the proper use and fit needed of source control masks. Education Began 02/01/2022 Completion date 02/11/2022 2. Staff will be educated on the need to perform hand hygiene upon touching their mask. Education Began 02/01/2022 Completion date 02/11/2022 3. If tolerated, residents in transmission based precautions will be required to wear a mask when out of their rooms. All residents will be offered surgical masks during outbreak periods. Completion date 02/01/2022 3. Non-adherence to hand hygiene with PPE use. 1. All staff will be educated on proper hand-hygiene techniques. Education Began 02/01/2022 Completion date 02/01/2022 4. Failure to maintain TBP for one resident during quarantine with COVID-19 exposure. 1. A stop-sign alarm has been installed on the room doors of the two residents who are in transmission based precautions. Completion date 02/01/2022 2. Moving forward, residents unable to understand transmission based precautions or wear a mask will be quarantined to their room and a stop-sign alarm will be installed to alert staff to the resident leaving the room. Completion date 02/01/2022. The Administrator or designee will be responsible for implementing this abatement plan to its completion.

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a fall with major injury, resulting in harm, for one Resident (#1) of three residents reviewed for falls. This deficient practice resulted in an avoidable fall with fracture and increased pain. Findings include: Review of the Minimum Data Set (MDS) assessment, dated 3/28/18, revealed Resident #1 is [AGE] years old, and was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 required extensive, two-person assist with transfers, dressing, hygiene, and toileting. Resident #1 scored 3/15 on the Brief Interview for Mental Status (BIMS) reflective of severe cognitive impairment. Review of a Fall report, dated 6/7/18, revealed the following, in part: Observed on floor, Location: resident's room bathroom, Activity At The Time: transferring, Injury: no apparent injury moves all extremities c/o (complaints of) pain MD (physician) notified xray order obtained, Possible Cause: Resident was left alone in the bathroom ., Teaching Done: Staff educated (sic) provided, careplan was not followed correctly, Time of Incident: 13:15 (1:15 p.m.) . On 6/20/18 at 10:40 a.m. Registered Nurse (RN) A, Certified Nurse Aides (CNA) C and D assisted Resident #1 in repositioning from her right side, to left side in bed. RN A said Resident #1 was currently bed fast (stayed in bed) due to the injury (lumbar L3 compression fracture). On 6/20/18 at 11:00 a.m. Certified Nurse Aide (CNA) C confirmed she was providing care for Resident #1 on 6/7/18 at the time of the above fall. CNA C stated, I left (Resident #1) on the toilet to go and help (another CNA), and when I came back (Resident #1) was on the floor. When asked if Resident #1 was able to be left alone in the bathroom, CNA C confirmed she was unaware of the ADL Care Plan approach/intervention to not leave Resident #1 alone in the bathroom. CNA C stated, I did not read the Kardex (CENA Assignment Card) for (Resident #1) that day . Review of Resident #1's ADL Care Plan with revisions, with the Director of Nursing (DON) on 6/20/18 at 2:00 p.m. found Do not leave alone in bathroom was added to the ADL Care Plan on 4/4/2018 at 1:53 p.m., and discontinued, with revision, on 6/12/18 to Do not leave alone in bathroom if the resident would use the bathroom. Currently using the bed pan r/t (related to) fracture. Review of Resident #1's CENA ASSIGNMENT CARD, printed 6/5/18, revealed the following ADL approaches (interventions), in part: All Nursing Staff: Do not leave alone in bathroom .transfer with assist of one using a gait belt and FWW (front wheeled walked) . Review of the facility CENA Orientation Check List, dated 3/2018 included the following, in part: KARDEX/Careplan: Kept in closet, If noticed it is incorrect, let nurse know, Follow care plan/kardex. Review of a 6/8/18 Employee Action Notice for CNA C revealed the following, in part: Resident (#1) was left alone in bathroom when careplan/kardex specifically states do not leave alone in bathroom leading to preventable fall .The careplan/kardex must be followed at all times for all residents, no exceptions . Review of the facility undated Investigation Summary, read, in part: Summary of Investigation: Resident (#1) fell while ambulating into her room from the bathroom [ROOM NUMBER]/7/18 .Resident had complaints of back pain .Resident began complaining of pain to hip on 6/10/18 .CT scan of lumbar spine showed mild acute appearing compression deformity involving the superior endplate of L3 with approximately 15% maximal loss of height and mild retropulsion .Conclusion: Resident fell on her way back to her room from her bathroom. She was left alone in the bathroom .The resident's care plan states, do not leave alone in bathroom. resident sustained [REDACTED]. Review of Resident #1's, 6/10/18 Emergency Department report read, in part: Clinical Impression: The primary encounter [DIAGNOSES REDACTED]. Nursing Progress Note, Pain assessment scores included the following, in part: 6/1/18 - 6/6/18: No pain (0) 6/7/18 15:26 (3:26 p.m.): Total Pain Score 5 6/8/18 12:54 (12:54 p.m.): Total Pain Score 4 6/9/18 16:48 (4:48 p.m.): Total Pain Score 7 6/10/18 10:21 (10:21 a.m.): Total Pain Score 8 6/11/18 12:01 (12:01 p.m.): Total Pain Score 9 Resident #1 continued to report pain levels between 2 to 8, through 6/20/18 (date of abbreviated survey). Review of 6/10/18 12:56 (12:56 p.m.) Progress Note read, in part: .stating back pain; aides report resident (#1) very painful with cares; rigid, guarding, SOB (short of breath) grimacing, moaning with movement .resident refused to bear weight on either leg when they (CNA's) attempted to stand her .any attempt to reposition or align LLE (left lower extremity) elicits pain response . Review of Resident #1's Medication Administration Record [REDACTED] Physician order [REDACTED]. Physician order [REDACTED]. DC' d on 6/19/18. Physician order [REDACTED]. Physician order [REDACTED]. Administration of this medication between 6/7/18 - 6/18/18 occurred daily, with Resident #1 receiving from one dose, up to four doses on 6/12/18. Physician order [REDACTED].#1 beginning on 6/19/18. During an interview on 6/20/18 at 2:52 p.m. the DON confirmed CNA C did not follow Resident #1's care plan by leaving Resident #1 alone in her bathroom, resulting in an avoidable fall with fracture. The DON also confirmed Resident #1 did have complaints of pain following the fall. When asked about Resident #1's post-fall pain, the DON stated, Her (Resident #1's) pain patch was increased .They (Physician) gave us [MEDICATION NAME] (for Resident #1) .

- BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO DEVELOP AND PROVIDE INTERVENTIONS TO ENSURE EFFECTIVE SUPERVISION, FAILED TO RECOGNIZE SAFETY FACTORS THAT CONTRIBUTED TO REPEATED FALLS, AND FAILED TO REVISE THE PLAN OF CARE TO REDUCE THE LIKELIHOOD OF ANOTHER FALL FOR ONE NONAMBULATORY RESIDENT (#3) WITH SEVERE COGNITIVE IMPAIRMENT WHO WAS IDENTIFIED AS HAVING RISK FACTORS FOR FALLING, OF SEVEN RESIDENTS REVIEWED FOR FALLS IN THE TOTAL SAMPLE OF 16 RESIDENTS. RESIDENT #3 WAS KNOWN TO BE AT HIGH RISK FOR FALLING RELATED TO HISTORY OF MULTIPLE FALLS, BEHAVIORS RELATED TO DISABLING ASSISTIVE ALARMING DEVICES, SEVERELY IMPAIRED COGNITION, IMPULSIVENESS WHEN NEEDING TO TOILET AND LIMITED MOBILITY. DURING A MONTH'S PERIOD OF TIME SPECIFICALLY, 4/8/13 THROUGH 5/8/13, RESIDENT #3 HAD FOUR FALLS, ALL OCCURRING DURING THE EVENING HOURS, WITH THE LAST FALL OCCURRING ON 5/8/13 AT 5:30 A.M., RESULTING IN A FRACTURED PELVIS. AT THE TIME OF THE SURVEY, RESIDENT #3'S CARE PLAN WAS NOT REVISED TO ADDRESS THESE RISK FACTORS PLACING RESIDENT #3 IN IMMEDIATE JEOPARDY TO HER HEALTH AND SAFETY. ON 5/16/13 AT 9:25 A.M., THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY THAT WAS IDENTIFIED ON 5/15/13 AND BEGAN ON 4/21/13 WHEN THE FACILITY FAILED TO DETERMINE THE ROOT CAUSE OF RESIDENT #3'S SECOND FALL, FAILED TO REVISE THE RESIDENT'S PLAN OF CARE AND IMPLEMENT INTERVENTIONS TO MITIGATE RESIDENT #3'S RISK AND CONTRIBUTING FACTORS ASSOCIATED WITH HER FALLING. ON 5/16/13 AT 1:40 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THROUGH OBSERVATION AND RECORD REVIEW THE FOLLOWING: - FACILITY'S REASSESSMENT OF RESIDENT #3 HAD IDENTIFIED ALL FALL RISK FACTORS WHICH INCLUDED THE FOLLOWING: RESIDENT #3 HAS ONE LEG SHORTER THAN THE OTHER, HAS NO SENSE OF TIME DUE TO COGNITIVE IMPAIRMENT, HAS POOR DECISION MAKING SKILLS, PROPELS SELF IN WHEELCHAIR AND MOVES VERY QUICKLY, RECENT MEDICATION CHANGES, POOR HISTORIAN AND ANSWERS IN THE MOMENT AND IS EXPERIENCING URINARY URGENCY. - PHYSICIAN ORDER [REDACTED]. - OBSERVED STAFF PROVIDING SAFETY CHECKS EVERY 30 MINUTE ON RESIDENT #3 FOR HER SAFETY AND TOILETING NEEDS. - THERAPY REASSESSED RESIDENT #3'S TRANSFER STATUS AND ABILITIES. - OBSERVED THE INITIATION OF ACTIVITY LOG TO DOCUMENT RESIDENT #3'S SLEEP, SAFETY, AND TOILETING BEHAVIORS. - RESIDENT #3'S CARE PLAN REVISED WITH INTERVENTIONS, GOALS, STRENGTHS AND WEAKNESS BASED ON IDENTIFIED RISK FACTORS. - THE FACILITY HAD BEGUN TO REASSESS ALL RESIDENTS' FALL RISK FACTORS TO DEVELOP INDIVIDUALIZED CARE PLANS FOR THESE RESIDENTS. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT AN ISOLATED LEVEL WITH NO ACTUAL HARM BUT WITH A POTENTIAL FOR MORE THAN MINIMAL HARM, DUE TO: - CONTINUATION OF THE FACILITY'S QUALITY ASSURANCE PROGRAM TO REVIEW ALL CURRENT RESIDENTS' CARE PLANS ENSURING APPROPRIATE INTERVENTIONS ARE DOCUMENTED AND MONITORED TO ENSURE ACCURATE IMPLEMENTATION. - VALIDATION BY THE STATE AGENCY OF FACILITY'S ABILITY TO MAINTAIN SUBSTANTIAL COMPLIANCE WITH PROVIDING ADEQUATE SUPERVISION AND SAFE ENVIRONMENT TO PREVENT AN ACCIDENT. FINDINGS INCLUDE: THE MEDICAL RECORD FACE SHEET (NOT DATED) FOR RESIDENT #3 REVEALED SHE IS AN [AGE] year OLD WOMAN WHO WAS REadmitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. THE MINIMUM DATA SET (MDS) assessment dated [DATE], REVEALED RESIDENT #3 HAD SEVERE COGNITIVE IMPAIRMENT WITH A BRIEF INTERVIEW OF MENTAL STATUS (BIMS) SCORE OF 3/15, AND NEEDED EXTENSIVE ASSISTANCE OF TWO WITH TRANSFERS. THIS MDS ASSESSMENT SHOWED RESIDENT #3 HAD NOT AMBULATED IN HER ROOM OR CORRIDOR DURING THE ASSESSMENT REVIEW PERIOD. FURTHERMORE, RESIDENT #3 HAD TWO FALLS DURING THIS REVIEW PERIOD, WHILE THE PRIOR MDS assessment dated [DATE], SHOWED SHE HAD NO FALLS DURING THAT REVIEW PERIOD. IN ADDITION, THE MDS assessment dated [DATE] REVEALED RESIDENT #3 HAD FREQUENT URINARY INCONTINENCE. THE FACILITY'S "CARE PLAN" FOR RESIDENT #3 TITLED "PROBLEM: AT RISK FOR FALLS" DATED 11/23/2011 READ, "RELATED TO: RESIDENT IS IMPULSIVE ESPECIALLY WHEN NEEDING TO TOILET". THE "APPROACH" INTERVENTIONS INCLUDED: -(NURSE/NURSE AIDE) MAGNETIC ALARM TO BED AND WHEELCHAIR -(NURSE/NURSE AIDE) SENTRY ALARM WHEN IN BED AND CHAIR -(NURSE/NURSE AIDE) ALARMED SAFETY BELT TO WHEELCHAIR -(NURSE/NURSE AIDE) TAG ALARM NEXT TO WALL SIDE OF BED -(NURSE) NURSE WILL DISCUSS WITH MAINTENANCE ACCESS KEY EASY AVAILABLE FOR STAFF -(NURSE) WILL ASSESS LAP VELCRO SEAT BELT, WHAT CAN BE DONE SO IT WILL SOUND WHEN SHE REMOVES IT -(NURSE AIDE) DO NOT LEAVE UNATTENDED WHEN TOILETING. A REVIEW OF A REPORT (UNTITLED) PROVIDED BY THE FACILITY FOR RESIDENT #3 REVEALED ON 4/8/13, RESIDENT #3 HAD A FALL AT 9:20 P.M. THE "CONCLUSION" OF THE FALL REPORT READ, "...RESIDENT (#3) REMOVED ALARMS BETWEEN THE TIME SHE WAS PUT TO BED BY NURSE AND THE TIME SHE WAS FOUND KNEELING ON THE MAT BY HER BED." THERE WAS NO EVIDENCE THE FACILITY IDENTIFIED FACTORS THAT MAY HAVE CONTRIBUTED TO THIS FALL. THE FACILITY ALSO FAILED TO REVISE RESIDENT #3'S "FALL" CARE PLAN, TO ADDRESS STAFF SUPERVISION RELATED TO RESIDENT #3 REMOVING ALARMS. THIRTEEN DAYS AFTER RESIDENT #3 WAS FOUND KNEELING ON THE FLOOR NEXT TO HER BED, RESIDENT #3 fell AGAIN. A FACILITY PRODUCED REPORT (UNTITLED) REVEALED ON 4/21/13 AT 9:40 P.M., RESIDENT #3 HAD A FALL ATTEMPTING TO SELF TOILET. THE REPORT READ, "(RESIDENT #3) WAS FOUND ON THE FLOOR ON HER KNEES. SHE STATED SHE WAS GOING TO THE BR (BATHROOM). DIPSTICK WAS NEGATIVE, LAST TOILETED 2000 (8:00 P.M.)... SHE (RESIDENT #3) WAS FOUND IN HER BR BY HERSELF 4/18/13, HAD TAKEN OFF HER LAP VELCRO SEAT BELT OF WHICH DID NOT SOUND THEN. DOOR TO BR WAS LOCKED FROM INSIDE, SELF TOILETING... SHE GOT OFF THE TOILET AND UNLOCKED DOOR... WILL DISCUSS WITH MAINTENANCE ON HOW TO KEEP A BR KEY EASILY AVAILABLE TO STAFF." THE FACILITY FAILED TO IDENTIFY CONTRIBUTING FACTORS FOR THESE FALLS, SPECIFICALLY RELATED TO RESIDENT #3'S URGENCY TO URINATE WITH ATTEMPTS TO SELF TOILET AND THE ISSUES OF RESIDENT #3 DISABLING THE ALARMS AND LOCKING HERSELF IN THE BATHROOM. THE CARE PLAN IN THE SECTION TITLED "APPROACH" ADDED, "MOVING TAG ALARM NEXT TO WALL SIDE OF BED". THIS INTERVENTION DID NOT ADDRESS THE FACT RESIDENT #3 REMOVED HER VELCRO SEAT BELT ALARM; THEREFORE, WAS NOT AN EFFECTIVE INTERVENTION. SIX DAYS AFTER RESIDENT #3 fell WHILE ATTEMPTING TO SELF TOILET, SHE fell AGAIN. HOWEVER, THIS TIME, THE CAUSE IS UNKNOWN. A FACILITY PRODUCED REPORT (UNTITLED) REVEALED RESIDENT #3 HAD FALLEN ON 4/27/13 AT 8:20 P.M. IN HER ROOM. THE REPORT READ, "SHE HAD UNHOOKED HER MAGNETIC ALARM AND HER BED ALARM WAS ON THE FLOOR MAT, TURNED ON, BUT BARELY AUDIBLE...". THE "CONCLUSIONS" READ, "RESIDENT CONTINUES TO BE A RISK FOR FALLS D/T (DUE TO) HER DECLINED LEVEL OF COGNITION. SHE IS ABLE TO FIGURE OUT HOW TO TAKE ALARMS OFF, RESIDENT HAS A H/O (HISTORY OF) FALLS AND IS RESTLESS...". THE FACILITY FAILED TO DETERMINE THE CONTRIBUTING RISK FACTORS FOR THE FALL AND FAILED TO IMPLEMENT ACTIONS TO PREVENT THE RISK OF ANOTHER FALL. ELEVEN DAYS AFTER RESIDENT #3 DISABLED THE ASSISTIVE DEVICE INTENDED TO ALERT FACILITY STAFF SHE WAS IN MOTION, SHE fell WHILE ATTEMPTING TO SELF TOILET AND FRACTURED HER PELVIS. AN "INCIDENT REPORT" DATED 5/8/13 AT 5:30 A.M., REVEALED RESIDENT #3 HAD A FALL IN ANOTHER RESIDENT'S BATHROOM WHILE ATTEMPTING TO INDEPENDENTLY TOILET. THIS INCIDENT REPORT REVEALED, IN THE SECTION TITLED "ACTIONS", A LUNG ASSESSMENT WAS PERFORMED AND A "DIPSTICK" TEST WAS DONE ON THE URINE (NURSING NOTES DATED 5/14/13, REVEALED NEGATIVE RESULTS) AND DEPARTMENT HEADS WERE NOTIFIED OF THE FALL. THE FACILITY FAILED TO ANALYZE THE FALL IN A TIMELY MANNER OR DETERMINE CONTRIBUTING FACTORS; FURTHERMORE, THE FACILITY FAILED TO UPDATE THE "FALLS" CARE PLAN WITH PREVENTIVE MEASURES FOR RESIDENT #3. AN X-RAY REPORT (MOBILE X-RAY) DATED 5/10/13, INDICATED RESIDENT #3 HAD AN X-RAY RELATED TO "PAIN IN LT (LEFT) HIP POST TRAUMA". THE RESULT OF THE X-RAY READ: "IMPRESSIONS: LEFT SUPERIOR PUBIC RAMI FRACTURE, AGE UNDETERMINED." AN ADDITIONAL X-RAY (PERFORMED AT THE HOSPITAL) DATED 5/10/13, TITLED "FINAL XR (X-RAY) HIP 2 VIEWS UNILATERAL LEFT" READ, "HISTORY: PAIN. INJURY TWO DAYS AGO WITH FALL... IMPRESSION: SUSPECT NEW NONDISPLACED PELVIC FRACTURE." IN AN INTERVIEW WITH REGISTERED NURSE (RN) "B" ON 5/15/13 AT 9:30 A.M., SHE REVEALED THAT RESIDENT #3 CONTINUES TO SELF TRANSFER TO TOILET. RN "B" REVEALED SHE (RESIDENT #3) WAS FOUND ON 5/15/13 JUST PRIOR TO 9:30 A.M. ON THE TOILET WITHOUT FACILITY STAFF ASSISTANCE. ON 5/14/13 AT 3:30 P.M., AN INTERVIEW WITH THE DIRECTOR OF NURSING (DON) REVEALED THAT RESIDENT #3 HAS THREE TYPES OF ALARMS IN PLACE: A PRESSURE SENSITIVE ALARM, A MAGNETIC ALARM, AND A VELCRO SEAT BELT ALARM. THE DON STATED RESIDENT #3 CAN REMOVE THESE ALARMS AND THEY ARE INEFFECTIVE. THIS SURVEYOR ASKED WHY THE FACILITY CONTINUED WITH THESE ALARMS AND ASKED WHAT ADDITIONAL MEASURES THE FACILITY IMPLEMENTED TO ENSURE RESIDENT #3 WAS ADEQUATELY SUPERVISED. THE DON STATED THEY (THE FACILITY) WERE LOOKING AT ALL ALARM USE IN GENERAL, AND THE DON DID NOT DESCRIBE ANY ADDITIONAL MEASURES IMPLEMENTED TO KEEP RESIDENT #3 ADEQUATELY SUPERVISED. IN A FOLLOW UP INTERVIEW ON 5/15/13 AT 11:35 A.M. WITH THE DON, ALL INCIDENTS INVOLVING RESIDENT #3 WERE REVIEWED. CONCERNING THE INCIDENT ON 4/8/13 WHERE RESIDENT #3 LOCKED HERSELF IN THE BATHROOM, THE DON STATED THE CORRECTIVE ACTION WAS TO MOUNT A KEY OUTSIDE THE BATHROOM DOOR. WHEN ASKED BY THIS SURVEYOR IF THIS WAS DONE, SHE STATED, "NO... IT'S BEEN A MONTH SINCE SHE LOCKED HERSELF IN THE BATHROOM..." THIS SURVEYOR AND THE DON REVIEWED RESIDENT #3'S OTHER FALLS, SPECIFICALLY THOSE ON 4/21/13, 4/27/13 & THE FALL ON 5/8/13 RESULTING IN A FRACTURED PELVIS. THE DON CONFIRMED THE CONTRIBUTING FACTORS FOR THESE FALLS WERE NOT IDENTIFIED AND CORRECTIVE MEASURES TO ENSURE ADEQUATE SUPERVISION FOR RESIDENT #3 WERE NOT IMPLEMENTED. THE DON STATED THE ATTENDING PHYSICIAN DISCONTINUED THE URISPAS MEDICATION (AN ANTISPASMODIC BLADDER MEDICATION) IN MARCH 2013, AND THIS MAY HAVE CONTRIBUTED TO THE RESIDENT'S INCREASED URGENCY TO URINATE. THE DON STATED STAFF DID NOT ASSESS THE EFFECTS OF THIS MEDICATION CHANGE AT THE TIME OF ITS DISCONTINUATION, BUT THE DON NOW BELIEVES THIS CHANGE IN MEDICATION WAS A CONTRIBUTING FACTOR TO THE FALLS. DURING AN INTERVIEW ON 5/16/13 AT 12:10 P.M. WITH THE NURSING HOME ADMINISTRATOR (NHA) AND THE DON, THE NHA STATED THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR RESIDENT #3. THE NHA SAID THEY KNEW RESIDENT #3 VERY WELL STATING, "(RESIDENT #3) IS FAMILY AND WE IGNORED THESE SUBTLE CHANGES THAT WERE OCCURRING... WE JUST DIDN'T NOTICE THE CHANGES AND WE BECAME COMPLACENT... WE REALLY DID." THE NHA STATED, "ALL THREE OF THESE FALLS (4/21/13, 4/27/13 & 5/8/13) WERE RELATED TO TOILETING AND WE DID NOT ADDRESS THIS IN ANY WAY... WE MISSED IT. BUT... WE WILL FIX IT!" ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION AND ASSISTIVE DEVICES FOR TWO RESIDENTS (#21 & #23) OUT OF FOUR RESIDENTS REVIEWED FOR FALLS FROM A TOTAL POPULATION OF 77. THIS FAILURE RESULTED IN MULTIPLE FALLS FOR RESIDENT #21 AND THE POTENTIAL FOR FALLS WITH INJURY FOR RESIDENT #23. FINDINGS INCLUDE: REVIEW OF RESIDENT #21'S ADMISSION RECORD ON 03/08/12 REVEALED SHE IS A [AGE] year-old FEMALE admitted to the facility on [DATE]. HER [DIAGNOSES REDACTED]. A REVIEW OF THE CARE PLAN TITLED "AT RISK FOR FALLS" AND DATED 05/04/11, LIST APPROACHES WITH THE SAME DATE (05/04/11) AS "NURSE AIDE -- SENTRY ALARM TO BED, CHAIR AND WHEELCHAIR", AND ON 11/28/11, "ALL STAFF -- FLOOR MAT WHEN RESIDENT IS IN BED." THESE INTERVENTIONS ARE LISTED ON THE CERTIFIED NURSE AIDES (CNA) ASSIGNMENT CARD AS WELL. A REVIEW OF THE FACILITY'S "FALL TEAM" INVESTIGATION SUMMARY DATED 02/29/12, REVEALED RESIDENT #21'S RECENT FALL HISTORY. RESIDENT #21 fell on [DATE] AT 2000 (8:00 P.M.) "...RES. WAS ON FLOOR... FLOOR MAT WAS NOT IN PLACE NEXT TO THE BED... REDNESS NOTED TO BILATERAL KNEES. TYLENOL WAS GIVEN FOR RIGHT KNEE PAIN..." ON 02/26/12 AT 1500 (3:00 P.M.), "RES OBSERVED ON FLOOR IN HER ROOM. NOT WITNESSED, BUT POSSIBLY TRIED TO GET UP WITH OUT ASSISTANCE. SUSTAINED A SKIN TEAR TO LEFT ELBOW... ALARM WAS IN PLACE, BUT WAS NOT TURNED ON." AN INTERVIEW WAS CONDUCTED WITH FAMILY MEMBER (FM) #1 ON 03/08/12 AT 5:05 P.M. FM #1 STATED SHE RECEIVED A PHONE CALL FROM THE FACILITY ON "FRIDAY" (02/24/12) AT 8:30 P.M., AND WAS TOLD "MY MOM (RESIDENT #21) HAD FALLEN, I CAN REMEMBER ASKING THE NURSE IF HER MAT WAS DOWN AND SHE (UNIDENTIFIED NURSE) REPLIED 'I DON'T THINK SO.' THERE HAVE BEEN OTHER TIMES WHEN HER ALARM ISN'T TURNED ON WHEN WE'VE COME IN TO VISIT." AN INTERVIEW WAS CONDUCTED WITH REGISTERED NURSE (RN) "A" ON 03/08/12 AT 5:45 P.M. RN "A" CONFIRMED THE DOCUMENTATION WAS FACTUAL AND THAT STAFF HAVE BEEN REEDUCATED AND DISCIPLINED FOR THEIR ACTIONS. A REVIEW OF RESIDENT #23'S CLINICAL RECORD TOOK PLACE DURING THE ABBREVIATED SURVEY ON 03/08/12. THE ADMISSION RECORD REVEALED SHE IS AN [AGE] year-old FEMALE readmitted TO THE FACILITY IN AUGUST 2011. HER [DIAGNOSES REDACTED]. A REVIEW OF THE FACILITY'S INCIDENT REPORT REVEALS, ON 02/02/12 AT 9:00 A.M., RESIDENT #23 WAS FOUND ON THE FLOOR IN HER BATHROOM. SHE SUSTAINED "BRUISING TO LEFT FOREHEAD WITH LARGE BUMP." A REVIEW OF THE FACILITY'S "FALL TEAM" INVESTIGATION SUMMARY DATED 02/06/12, REVEALED RESIDENT #23'S FALL HISTORY INCLUDING A FALL ON 01/31/12. THE SUMMARY NOTED FALLS BEGAN WITH THE ONSET OF A URINARY TRACT INFECTION (UTI) AND A CHANGE IN MEDICATIONS. THE INTERVENTIONS LISTED "BLOOD PRESSURE MONITORING, PAIN ASSESSMENT... TAG AND BED ALARM PLACED, WHICH WILL BE RE-EVALUATED ONCE SHE IS STABLE." A REVIEW OF RESIDENT #23'S "AT RISK FOR FALLS" CARE PLAN DATED 09/01/11, LISTS INTERVENTIONS ON 01/23/12, "NURSES -- DISCUSS WITH RST (RESIDENT) AND FAMILY USE OF BED ALARM UNTIL STABLE." ON 02/02/12, "NURSES -- TAG ALARM WHEN IN WHEELCHAIR AND BED". THE CNA ASSIGNMENT CARD LISTS THE VERY SAME INTERVENTIONS. AN OBSERVATION AND INTERVIEW WAS CONDUCTED ON 03/08/12 AT 4:54 P.M. RESIDENT #23 WAS SITTING IN HER WHEELCHAIR IN HER ROOM, SHE WAS VISITING WITH HER COUSIN (FM #2). THE SENTRY ALARM WAS ON HER WHEELCHAIR AND WAS OBSERVED TO BE TURNED ON. THE TAG ALARM WAS ATTACHED TO THE BACK OF THE WHEELCHAIR, BUT NOT ATTACHED TO RESIDENT #23'S CLOTHING. FM #2 STATED, "THE NURSE TOOK IT OFF WHEN WE WERE HAVING COFFEE, SHE DIDN'T PUT IT BACK ON, SHE SHOULD BE HOOKED UP AGAIN." THIS SURVEYOR OBTAINED THE CNA ASSIGNMENT CARD FORM INSIDE RESIDENT #23'S CLOSET DOOR AND VERIFIED THE INTERVENTION INITIATED ON 02/02/12, "TAG ALARM WHEN IN WHEELCHAIR AND BED." AT 5:07 P.M. ON 03/08/12, LPN (LICENSED PRACTICAL NURSE) "D" VERIFIED THE TAG ALARM WAS NOT ATTACHED TO RESIDENT #23. LPN "D" STATED, "I TOOK IT OFF WHEN (FM #2) AND (RESIDENT #23) WERE HAVING COFFEE, IT WAS BEEPING EVERY TIME SHE MOVED." LPN "D" WAS ASKED IF THE CARE PLAN ALLOWED THE TAG ALARM TO BE OFF WHEN FAMILY WAS VISITING AND SHE REPLIED "NO", AS SHE WAS OBSERVED RE-ATTACHING THE ALARM TO RESIDENT #23'S CLOTHING. ( )

BASED ON INTERVIEWS AND RECORD REVIEW, THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION FOR ONE RESIDENT (#1) OF FOUR RESIDENTS REVIEWED FOR FALLS FROM A TOTAL OF 80 RESIDENTS IN THE FACILITY. THIS FAILURE RESULTED IN RESIDENT #1 SUSTAINING A FALL WITH INJURY AND REQUIRING SURGICAL REPAIR OF A LEFT HUMERAL (ARM) FRACTURE. FINDINGS INCLUDE: REVIEW OF RESIDENT #1'S MEDICAL FILE REVEALED ON HER FACE SHEET, THAT SHE IS AN [AGE] year OLD WOMAN admitted to the facility on [DATE], WITH [DIAGNOSES REDACTED]. AN X-RAY OF HER LEFT SHOULDER, DATED 11/7/11, ALSO READ "COMMINUTED FRACTURE INVOLVING THE HEAD AND NECK OF THE HUMERUS." admission orders [REDACTED]. UPON ADMISSION ON 11/23/11, THE FACILITY HAD IMPLEMENTED CARE PLANS FOR SELF CARE DEFICIT AND AT RISK FOR FALLS. INTERVENTIONS INCLUDED A MAGNETIC ALARM TO BED AND WHEELCHAIR. ON 11/28/11, THE SELF CARE DEFICIT CARE PLAN WAS UPDATED WITH THE INTERVENTION TRANSFER WITH ASSIST OF TWO AND GAIT BELT. THIS SPECIFIC INTERVENTION WAS ALSO FOUND ON THE CNA (CERTIFIED NURSE AIDE) ASSIGNMENT CARD, OTHERWISE KNOWN AS THE KARDEX. REVIEW OF NURSES NOTES DATED 11/30/11 REVEALED THAT AT 11:00 A.M., RESIDENT #1 ATTEMPTED TO TRANSFER HERSELF OFF THE TOILET AND fell . SHE COMPLAINED OF RIGHT HIP PAIN. THE PHYSICIAN WAS NOTIFIED AND ORDERS WERE RECEIVED FOR X-RAYS OF HER LEFT HUMERUS, LEFT ANKLE, LEFT HIP AND RIGHT HIP. THE X-RAY REPORT FOR HER LEFT HUMERUS DATED 11/30/11, READ "A FRACTURE OF THE PROXIMAL HUMERUS IS IDENTIFIED. SUPERIOR LATERAL DISPLACEMENT OF THE DISTAL FRACTURE FRAGMENT IS NOTED. THIS IS DIFFERENT CONFIGURATION WHEN COMPARED TO THE PRIOR STUDY." AN ORTHOPEDIC CONSULTATION WAS ORDERED. THE ORTHOPEDIC CONSULTATION OFFICE VISIT REPORT DATED 12/2/11, READ "THIS [AGE] year OLD PATIENT IS A RESIDENT (OF FACILITY). A WEEK AND ONE-HALF AGO SHE fell DOWN AND BROKE HER HIP AND SHOULDER. (PHYSICIAN'S NAME) FIXED HER HIP. THE SHOULDER WAS NOT MUCH DISPLACED AT THAT TIME, HOWEVER SHE HAD A NEW FALL AND NOW IT IS DISPLACED. SHE CAME TO MY OFFICE THIS MORNING, I SAW THE DISPLACEMENT. I ALSO NOTED THAT HER INR WAS 8.9 WHICH IS KIND OF HIGH, SO FOR THESE TWO PROBLEMS I DECIDED TO ADMIT HER." DISCHARGE SUMMARY NOTE BY THIS SAME PHYSICIAN DATED 12/8/11, REVEALED THAT A LEFT HUMERAL HEMIARTHROPLASTY FOR FRACTURE WAS PERFORMED ON 12/7/11. AN INCIDENT REPORT DATED 12/1/11, REVEALED "ALARM WAS NOT ATTACHED TO RESIDENT WHILE ON TOILET, AND STAFF DID NOT STAY WITH RESIDENT WHILE TOILETING." THE FALL RISK CARE PLAN WAS UPDATED ON 12/1/11 TO INCLUDE, "DO NOT LEAVE UNATTENDED WHEN TOILETING." WITNESS STATEMENTS OBTAINED DURING THE FACILITY'S INVESTIGATION INCLUDED A STATEMENT FROM CNA 'E' WHICH READ IN PART, "I TOOK HER IN THE BATHROOM...STEPPED OUT FOR A FEW SECONDS...I FOUND HER ON THE FLOOR." CNA 'D' WROTE IN PART, "(CNA 'E') SAID TO ME I PUT (RESIDENT #1) IN THE BATHROOM...WHILE I WAS WALKING (ANOTHER RESIDENT) I HEARD A THUMP AND YELL. I SAID (CNA 'E') I THINK SOMETHING HAPPENED. (CNA 'E') WENT INTO (RESIDENT #1'S) BATHROOM AND FOUND HER ON THE FLOOR." REGISTERED NURSE (RN) 'A' WROTE IN PART, "(RESIDENT #1) WAS TAKEN TO THE BATHROOM ASSISTED THERE BY (CNA 'E'). SHE WAS LEFT ON THE TOILET FOR NO MORE THAN A MINUTE WHILE (CNA 'E') WAS GOING TO ASSIST ANOTHER RESIDENT AND RESIDENT (#1) ATTEMPTED TO GET UP ON HER OWN OFF OF THE TOILET. RESIDENT IS ALARMED BUT ALARM WAS NOT PUT ON HER WHILE ON THE TOILET. (CNA 'E') REENTERED THE ROOM TO FIND RESIDENT SITTING ON THE FLOOR...DUE TO RECENT FALL WITH FRACTURES TO LEFT HIP THAT WAS REPAIRED AND LEFT HUMEROUS THAT WAS NOT REPAIRED AND DUE TO RESIDENTS NON COMPLIANCE WITH WEARING OF SLING TO LEFT ARM, MD WAS CONTACTED AND ORDERS RECEIVED FOR X-RAYS...." DURING AN INTERVIEW WITH RN 'A' ON 1/4/12 AT 10:15 AM, SHE STATED, "ONE OF THE AIDES TRANSFERRED HER TO THE TOILET AND THEN LEFT HER ON THE TOILET ALONE. THE AIDE DID NOT ATTACH THE ALARM. SHE SHOULD HAVE STAYED WITH HER. SHE'S WORKED HERE LONGER THAN I HAVE; SHE SHOULD HAVE KNOWN NOT TO TRANSFER HER BY HERSELF, THEN LEAVE HER ALONE." CNA 'D' WAS INTERVIEWED ON 1/4/12 AT 10:38 AM. SHE STATED, "I WAS WALKING ANOTHER RESIDENT. (CNA 'E') MET ME IN THE HALL AND TOLD ME THAT SHE HAD PUT (RESIDENT #1) ON THE TOILET. SHE NO SOONER SAID IT THAN I HEARD A THUD. (CNA 'E') WENT IN TO CHECK AND (RESIDENT #1) WAS ON THE FLOOR. (CNA 'E') SHOULDN'T HAVE TRANSFERRED HER ALONE OR LEFT HER ALONE IN THE BATHROOM. (RESIDENT #1) WAS A TWO-PERSON TRANSFER WITH AN ALARM. (CNA 'E') KNEW BETTER." LICENSED PRACTICAL NURSE (LPN) 'C' STATED ON 1/4/12 AT 10:30 AM, "(RESIDENT #1) WAS ALARMED (WAS CARE-PLANNED TO HAVE AN ALARM) SO SHE SHOULDN'T HAVE BEEN LEFT ALONE---THAT'S A GIVEN." CNA 'E' WAS INTERVIEWED BY TELEPHONE CALL ON 1/4/12 AT 10:44 AM. SHE CONFIRMED SHE HAD PUT RESIDENT #1 ON THE TOILET WITHOUT ASSISTANCE FROM OTHER STAFF AND LEFT HER ON THE TOILET ALONE FOR A SHORT TIME. SHE ALSO REPORTED, "THERE'S NOT ENOUGH HELP THERE. IT WAS CRAZY WITH CALL LIGHTS. THE NURSES DON'T HELP US. I DIDN'T EVEN KNOW (RESIDENT #1). FOR MONTHS, WE NEVER HAD REPORT. I DIDN'T EVEN KNOW IF WE HAD A NEW RESIDENT. THERE'S A KARDEX IN THE RESIDENT'S CLOSETS. I HAD BEEN WORKING ON THE OTHER SIDE; WE SWITCHED HALLS EVERY WEEK. THAT WAS PRETTY MUCH THE FIRST TIME I TOOK CARE OF HER. I TRANSFERRED HER FROM HER WHEELCHAIR TO THE TOILET. I DIDN'T SEE AN ALARM ON HER." A RESIDENT CARE FLOW RECORD FOR RESIDENT #1 FOR THE MONTH OF NOVEMBER 2011, SHOWED THAT CNA 'E' HAD CARED FOR HER ON 11/27/11 AND 11/29/11 BEFORE HER FALL ON 11/30/11. HER INITIALS WERE VERIFIED BY THE DIRECTOR OF NURSING (DON) ON 1/5/12 AT 10:45 AM. THE DON WAS ASKED IF THE AIDE SHOULD HAVE KNOWN THAT A RESIDENT CARE PLANNED TO HAVE AN ALARM, SHOULD NOT BE LEFT ALONE ON THE TOILET. SHE STATED, "YES, SHE SHOULD HAVE KNOWN." OBSERVATIONS OF THE FOUR SAMPLED RESIDENT'S ROOMS SHOWED THAT THEIR CLOSETS ALL CONTAINED A KARDEX WITH THE CARE PLANS AND INTERVENTIONS FOR THE CNAS TO REFER TO IN PROVIDING CARE TO THEM. IT WAS DETERMINED THE FACILITY FAILED TO PROVIDE ADEQUATE SUPERVISION TO RESIDENT #1, WHO WAS CARE PLANNED TO HAVE AN ALARM ON IN BED AND WHEELCHAIR, BY LEAVING HER ALONE ON THE TOILET, RESULTING IN RESIDENT #1 SUSTAINING A FALL WITH FRACTURE TO HER LEFT HUMERUS. ( )