Every finding on record at Blountstown Health and Rehabilitation Center

Based on record review, staff interview, and policy review, the facility failed to administer the pneumonia vaccination in a timely manner to 1 of 5 sampled residents that consented to receive the vaccine. (Resident #18) The findings include:A review of Resident #18's medical record revealed that the resident was admitted to the facility on [DATE] and that the resident's representative consented for him to receive the pneumonia vaccine on 9/24/25. The record revealed the pneumonia vaccine had not been administered to Resident #18 as of 12/18/25. An interview was conducted with the facility's Infection Prevention Nurse on 12/18/25 at 9:54 AM. The Infection Prevention Nurse stated the resident's daughter did not want the pneumonia vaccine given until after the COVID-19 outbreak the facility had was over, which lasted until the end of October 2025. She did not administer the pneumonia vaccine in November 2025 because she was waiting on the influenza vaccines to arrive and did not like to give the vaccines at the same time. She confirmed the resident should have received the pneumonia vaccine by now. Review of the facility policy for Pneumococcal Vaccine (Series) revised 8/4/25 revealed each resident will be offered a pneumococcal immunization unless it is medically contraindicated or the resident has already been immunized. Following assessment for any medical contraindications, the immunization may be administered in accordance with physician-approved standing orders.

Based on record review, staff interview, and policy review, the facility failed to administer the COVID-19 vaccine in a timely manner to 1 of 5 sampled residents who consented to receive the vaccine. (Resident #18)The findings include: A review of Resident #18's medical record revealed the resident was admitted to the facility on [DATE] and the resident's representative consented for him to receive the COVID-19 vaccine on 9/24/25. The record revealed the COVID-19 vaccine had not been administered to Resident #18 as of 12/18/25. An interview was conducted with the facility's Infection Prevention Nurse on 12/18/25 at 9:54 AM. The Infection Prevention Nurse stated the resident's daughter did not want the COVID-19 vaccines given until after the COVID-19 outbreak the facility had was over, which lasted until the end of October 2025. She did not administer the COVID-19 vaccine in November 2025 because she was waiting on the influenza vaccines to arrive and did not like to give the vaccines at the same time. She confirmed the resident should have received the COVID-19 vaccine by now. Review of the COVID-19 Vaccination policy revised 12/8/25 revealed it is the policy of this facility to minimize the risk of acquiring, transmitting or experiencing complications form COVID-19 (SARS-CoV-2) by educating and offering our residents and staff the COVID-19 vaccine. COVID-19 vaccinations will be offered to residents when supplies are available, as per CDC and/or FDA guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this time period or refuses to receive the vaccine.

Based on record review, staff interview, and policy review, the facility failed to complete an annual comprehensive assessment (minimum data set) at least every 12 months for 1 of 23 sampled residents. (Resident #59) The findings include: On 12/17/25, a review of Resident #59's medical record revealed the resident's required annual minimum data set update dated 11/13/25 was incomplete. An interview was conducted with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator on 12/17/2025 at 2:51 PM. The DON stated the MDS coordinator was covering for the unit manager and herself and this caused the delay. The MDS Coordinator stated she reviews the dashboard for the MDS daily. The DON stated she did not know they were a month behind. Review of the facility policy for MDS Completion and Submission Timeframes (revised July 2017) revealed that the facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

Based on record review and staff interviews, the facility failed to ensure Minimum Data Set (MDS) Assessments were completed and transmitted within 14 days after a facility completed a resident's Quarterly MDS assessment for 2 of 23 MDS Assessments reviewed (Residents #73 and #10).The findings include:On 12/17/2025 at 2:37 PM, a review of the MDS Assessments for Resident #73 revealed the annual assessment was completed and submitted on 2-13-25. However, even though the required quarterly assessments were completed and submitted on 5-13-25 and 8-13-25, the current quarterly assessment dated [DATE] still shows in progress. Additionally, Resident #10's medical record review revealed that the current quarterly assessment dated [DATE] was in progress.On 12/17/2025 at 2:51 PM an interview with the MDS Coordinator and the Director of Nursing (DON) revealed these MDS Assessments are incomplete and are behind due to having to cover for the DON when they had some staffing shortages about a month ago. They usually do review the lists on a daily basis but could not because today was care plan day. They both confirmed the MDS assessment dated [DATE] is the oldest one not completed as of yet. Review of the MDS Completion ad Submission Timeframes Policy and Procedure revision date July 2017 revealed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes.

Based upon record review and interviews, the facility failed to obtain written consent prior to starting psychotropic medications for 2 of 5 residents reviewed. (Resident #3 and #54)The findings include:On 12/16/25 at 2:09 pm a record review was conducted for Resident #3 who was initially admitted to facility on 8/3/23, then discharged and re-admitted on [DATE] with diagnoses that include Parkinsonism, Chronic Kidney disease, Cellulitis, Type 2 Diabetes, Major Depressive disorder, and Unspecified Dementia. Amongst the current medications, orders for Duloxetine HCl Oral Capsule Delayed Release Sprinkle 30 ms by mouth two times a day for depression/anxiety and Cimetidine Oral Tablet 200 MG tablet by mouth in the morning for off label use for sexually inappropriate behavior. An additional record review was conducted for Resident #54, who was admitted on [DATE] with diagnoses including Psychophysiologic Insomnia and Major Depressive Disorder. Current medications include Sertraline HCl Oral Tablet 100 MG one time a day for depression and Trazadone 100 mg at bedtime for mood disorder initiated on 10/23/25 increased to 150 mg on 11/21/25. Upon further review, no psychotropic medication consent forms for Resident #3 or Resident #54 informing of the risk and benefits for psychotropic medication use prior to initiating treatment was present. An interview was conducted with the Unit Manager on 12/18/25 at 10:00 am, who stated that the consent forms are usually scanned into the computer system for each individual. When this was not found, she acknowledged she could not find that any of these forms had been completed. At 12:20 pm an interview was conducted with the Director of Nursing (DON), stating that the facility has an ongoing performance improvement plan (PIP) for antipsychotic and psychotropic monitoring. The PIP was initiated in February 2025 for psychotropic medications, ensuring orders have the correct diagnosis, behavior monitoring, gradual dose reductions, and side effects being documented in the medical record with the target date of June 2025. Per the DON she states, this PIP does not address the psychotropic medication informed consent forms.

Based on observation, interviews, and record reviews, the facility failed to acquire, receive, dispense, and administer an ordered anti-seizure medication for 1 of 1 residents reviewed. (Resident #39) The findings include: A record review of Resident #39 was conducted on 05/17/2023 at approximately 9:30 AM. Resident #39 was admitted on [DATE] with diagnoses of epilepsy, Alzheimer's disease, dementia, major depressive disorder, type 2 diabetes, atrial fibrillation, chronic kidney disease, anxiety disorder, and asthma. Resident #39 had an order for Carbamazepine 200 milligrams, one tablet by mouth to be given at bedtime. A review of the Medication Administration Record (MAR) for April 2023 revealed that Resident #39 did not receive this medication on 04/25/2023, 04/27/2023, and 04/30/2023. Progress notes entered by nursing staff on 04/25/2023, 04/27/2023, and 04/30/2023 revealed that the Carbamazepine tablets were not on hand. Review of Resident #39's care plan revealed she had a diagnosis of seizure disorder. The care plan interventions were to give the medications as ordered by the doctor. The Unavailable Medications policy (dated October 2022) states that the facility maintains a contract with a pharmacy provider to supply the facility with routine, as needed, and emergency medications. The policy further reads, The facility shall follow established procedures for ensuring residents have a sufficient supply of medications. The staff are to take immediate action when a medication is unavailable to include: 1. Determine the reason for unavailability, length of time to get the medication and what efforts have been attempted to obtain the medication. 2. Notify the physician of the inability to obtain the medication. An interview was conducted on 05/17/2023 at approximately 10:25 AM with the Director of Nursing (DON). The DON stated the facility medications are obtained from an outside pharmacy twice daily. The staff can obtain medications by fax, online, or by phone. The DON stated, We do have a local pharmacy, if we do not have the needed medications in our RX machine. The DON stated, The East Wing Unit Manager is responsible for making sure the medications are in the building. I was not aware that the resident did not receive her medications on the dates listed on the MAR. It is odd that she was able to receive them on two of those days (04/28/2023-04/29/2023) and then not again on the 30th. I will follow up with the pharmacy and the unit manager. The DON stated she would expect the facility medications to be ordered and escalated if the staff were not able to acquire them in time. The DON stated, I would expect a resident to receive her anti-seizure medication as ordered. Another interview was conducted with the DON at approximately 11:00 AM on 05/17/2023. The DON stated that approximately two months ago, the facility removed some medications from the RX List that were not used frequently. Carbamazepine was removed. The DON stated, I can get the pharmacy to add it for the future. The Carbamazepine was ordered by the staff, but it was not shipped on the 25th. Another nurse sent a handwritten communication to them. The Unit Manager was not notified. We normally see any missed medications in the 24-hour daily report. From now on, they will have to just notify me of any missing medications. An interview was conducted on 05/17/2023 at approximately 11:35 AM with the East Wing Unit Manager (UM). The UM stated she does risk management for the facility and supervises the certified nursing assistant (CNAs) and nurses. The UM stated, The facility has risk rounds, where events or issues that may have happened that night are looked at. Honestly, I had to have missed that medication (Carbamazepine). I was out for a few days. I don't even know if that was around during that timeframe or not. Normally, the staff would usually just tell me everything, most of the time. But they just didn't this time and I missed it.

Based on observations, staff interviews, and admission packet review, the facility failed to ensure each resident bedroom was equipped with means for privacy for 2 of 18 sampled occupied resident rooms. (Rooms 605 A and 608 A) The findings include: Observations of occupied room [ROOM NUMBER] A were conducted on 5/16/23 at 8:57 AM and 5/16/23 at 1:15 PM. room [ROOM NUMBER] A was not equipped with a privacy curtain or curtain track. (Photographic evidence obtained.) Further observation of room [ROOM NUMBER] A was conducted in the presence of the Administrator on 5/16/23 at 3:15 PM. The Administrator stated room [ROOM NUMBER] A was once a private room and confirmed bed 605 A was not equipped with a privacy curtain or curtain track. Observations of occupied room [ROOM NUMBER] A were conducted on 5/15/23 at 2:00 PM and 5/17/23 at 9:58 AM. The privacy curtain near the doorway in room [ROOM NUMBER] A was about 2 feet too short in width to provide full visual privacy to the resident in room [ROOM NUMBER] A. (Photographic evidence obtained.) Further observation of room [ROOM NUMBER] A was conducted on 5/17/23 at 10:16 AM in the presence of the Environmental Director. He stated he was responsible for ensuring the privacy curtains provide residents with full visual privacy. The Environmental Director observed the curtain in room [ROOM NUMBER] A and confirmed the curtain was about 2 feet too short in width to provide full visual privacy. He stated the facility had no set process to check the curtains except during terminal cleans when a resident moves out or if the curtain is soiled. The resident admission packet states,The resident has the right to personal privacy and to confidentiality of your personal and clinical records. Personal privacy includes privacy in accommodations, medical treatment, payment for services, written and telephone communications, personal care, visits, and meetings of family and resident groups.

Based on observations, staff interviews and policy review, the facility failed to ensure proper storage of medications for 1 of 17 residents (#67) sampled. The findings include: On 12/13/21 at 12:58 PM, an observation was made of Resident #67. A medication cup containing a white pill and a disk inhaler was observed on the overbed table. The resident stated the white pill was a Tylenol used to treat mild pain, and the disk inhaler was Advairdiskus 250mcg/50mcg used to treat Asthma. There was no staff present in the room at the time of the observation. (photographic evidence obtained) A review of the facility policy LTC Facility Pharmacy Services and Procedures Manual revised 10/31/16 revealed next to item 3.3, Facility should ensure that all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. On 12/14/21 at 1:21 PM, an interview was conducted with Nurse A, a Registered Nurse (RN) who was assigned to Resident #67 on 12/13/21 during the day shift (7 AM to 7 PM). Nurse A stated, The resident was supposed to be taking the medication as I was exiting the room and did not make me aware that she did not take all of them. Nurse A continued, Normally I do stay with the resident until they complete their medications, but the resident was doing something else, so I was going to come back to her. Our policy is for us to stay with the resident while taking their medication, and I am not sure what pulled me away so that was my mistake. On 12/14/21 at 1:37 PM, an interview was conducted with the Director of Nursing who stated her expectation is for the nurse to stay with the resident while administering the medication and to take the medication with them when leaving the room.

Based on staff interview, and clinical record review the facility failed to develop a written care plan for pain after being triggered by Minimum Data Set (MDS) for 1 of 2 residents sampled for pain (#4). The findings include: A review of the admission MDS for Resident #4 dated 8/29/2020 was reviewed. Section J0400 indicated the resident was in pain constantly but that this did not affect sleep or day to day activities. J0600 indicated a pain intensity of an 8 (on a scale of 1 to 10). A review of the resident's care plan failed to reveal Pain as a concern. On 12/8/2020 at approximately 12:45 PM, the Director of Nursing (DON) was asked to provide a copy of all the current care plans for resident #4. The DON returned on 12/8/2020 about 1:15 PM, with the care plans which included a care plan for pain that had been initiated on 12/08/2020 by MDS Employee A, a Registered Nurse (RN). Employee A, RN MDS, was interviewed on 12/8/2020 at approximately 1:29 PM. She confirmed that pain had triggered on the resident's admission MDS in August but that a care plan for Pain had not been developed or initiated. She further confirmed that she had initiated a Pain care plan today (12/8/2020) after she had reviewed the resident chart. She was asked if she felt resident #4 had needed a care plan for pain prior to today, she stated yes, she definitely has pain.

Based on observations, interviews with representatives from the State of Florida public health authority (Florida Department of Health (DOH)), facility staff interviews and record reviews, the facility failed to consistently follow DOH, Centers for Disease Control and Prevention (CDC), State Survey Agency, (Agency for Health Care Administration (AHCA)), the Florida Division of Emergency Management (DEM) and the Centers for Medicare and Medicaid (CMS) infection control orders, directives, recommendations and guidelines related to the Coronavirus Disease 2019 (COVID-19) pandemic. The Administration failed to implement appropriate isolation precautions and cohorting recommendations for both COV1D-19 infected residents and Persons Under Investigation (PUIs) to control or prevent the potential spread of COVID-19. The Administration failed to consistently deny entry to staff members with sore throats, coughs, and/or other possible COVID-19 symptoms and failed to consistently screen employees prior to the start of their shifts. The Administration also failed to provide adequate training to staff regarding personal protective equipment (PPE). These failures affected all 81 residents residing in the facility on [DATE] plus 2 additional COVID-19 infected residents who had been hospitalized (#12 & 13). The facility failures resulted in 23 residents, some from every wing in the facility, becoming infected with COVID-19 as of [DATE] (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 20, 21, 31, 33, 34, 35, 36, & 38). The facility census on [DATE] was 81. Individuals who are [AGE] years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing, and might require intensive care for the treatment of [REDACTED]. COVID-19 infection can lead to death. COVID-19 is a new disease, caused by a new coronavirus that has not previously been seen in humans. Currently, there is no vaccine and no approved treatment for [REDACTED]. The cumulative result of these administrative concerns led to a widespread finding of immediate jeopardy at a scope and severity of L. The Nursing Home Administrator was informed of the findings of immediate jeopardy on [DATE] at 3:15 PM. It was determined the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. The immediate jeopardy was determined to start on [DATE] and was ongoing. Cross reference F880. The findings include: On [DATE], The Office of the Governor issued Executive Order Number ,[DATE] directing the Florida Department of Health to issue a Public Health Emergency. The Executive Order documented, Coronavirus Disease 2019 (COVID-19) is a severe acute respiratory illness that can spread among humans through respiratory transmission and presents with symptoms similar to those of influenza. Section 2 directed the State Health Officer to take any action necessary to protect the public health. Section 3 directed the State Health Officer to follow the guidelines established by the CDC (Centers for Disease Control and Prevention) in establishing protocols to control the spread of COVID-19. Section 4 designated the Florida Department of Health as the lead state agency to coordinate emergency response activities among the various state agencies and local governments. Section 5 specified that all actions taken by the State Health Officer with respect to this emergency before the issuance of this Executive Order are ratified. Section 6 stated The Florida Department of Health will actively monitor, at a minimum, all persons meeting the definition of a Person Under Investigation (PUI) as defined by the CDC for COVID-19 for a period of at least 14 days. Active monitoring by the Florida Department of Health will include at least the following: A. Risk Assessment with 24 hours of learning an individual meets the criteria for a PUI and B. Twice daily temperature checks. Section 7 directed the Florida Department of Health, pursuant to its authority in section 381XXX , Florida Statutes, will ensure that all individuals meeting the CDC's definition of a PUI are isolated or quarantined for a period of 14 days or until the person tests negative for COVID-19. Section 8 directed Florida Department of Health to make its own determinations as to quarantine, isolation and other necessary public health interventions as permitted under Florida Law. Section 9 directs all agencies under the direction of the Governor to fully cooperate with the Florida Department of Health, and any representative thereof in furtherance of this Order. On [DATE], The Office of the Governor issued Executive Order Number ,[DATE] declaring a state of emergency for the entire State of Florida as a result of COVID-19. On [DATE], the Division of Emergency Management (DEM) Emergency Order No. ,[DATE] restricting entrance into residential health care facilities including nursing homes. The Order limited persons who were allowed to enter the facility and directed screening of all individuals seeking entry. The order documented, Individuals seeking entry to the facility under the above section 1 (includes staff) will not be allowed to enter if they meet any of the screening criteria listed below: a. Any person infected with COVID-19 who has not had 2 consecutive negative test results separated by 24 hours; b. Any person showing, presenting signs or symptoms of, or disclosing the presence of a respiratory infection, including cough, fever, shortness of breath or sore throat; c. Any person who has been in contact with any person(s) known to be infected with COVID-19, who has not yet tested negative for COVID-19 within the past 14 days; d. Any person who traveled through any airport within the past 14 days; or e. Any person who traveled on a cruise ship within the past 14 days. Part 5 of the Order stated, The following documentation must be kept for visitation within a facility: a. Individuals entering a facility subject to the screening criteria above may be screened using a standardized questionnaire or other form of documentation. b. The facility is required to maintain documentation of all non-resident individuals entering the facility. Documentation must include: 1. Name of the individual; 2. Date and time of entry; and 3. The documentation used by the facility to screen the individual showing the individual did not meet any of the enumerated screening criteria, including the screening employee's printed name and signature. The President declared a Nationwide emergency for COVID-19 on [DATE] and approved a major disaster declaration for Florida on [DATE]. On [DATE] the Agency for Health Care Administration (AHCA), the state survey agency, issued an Alert entitled, Residential and Long Term Care Facilities to Implement Universal Use of Facial Masks. The directive stated, Effective immediately staff of residential and long term care facilities are to implement universal use of facial masks while in the facility. All staff, essential healthcare visitors and anyone entering the facility are to don a face mask upon the start of their shift or visit and only change it once it becomes moist. It is important to keep hands away from the face mask and only touch the straps of the face mask. Gloves are to be worn when providing care to the resident. Continue to perform hand hygiene prior to donning gloves, after removing gloves, and anytime there is contact with the resident environment. Staff in a room with a patient with respiratory symptoms of unknown cause or a patient with known or suspected COVID-19 should adhere to Standard, Contact, and Droplet Precautions with eye protection. This includes wearing gown, gloves, N95 face mask (as fitted and available - if not available, at least a facial mask), and eye protection such as face shields or goggles. In addition to securing more gowns, gloves, and masks, facilities will need to immediately order the appropriate eye protection (I.e. face shields) since many do not have this on hand. In the event you are unable to acquire the necessary PPE, please notify your local emergency management agency. Facilities will need to educate their staff on the proper donning (putting on), doffing (taking off), and disposal of any PPE. Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of hospitalized Patients with COVID-19. 1. Administration's failure to implement appropriate isolation precautions and cohorting recommendations for both COV1D-19 infected residents and Persons Under Investigation (PUIs) to control or prevent the potential spread of COVID-19: On [DATE] at approximately 12:50 PM, during the entrance conference, the Nursing Home Administrator (NHA) and Director of Nursing (DON) identified the 400 hall as the isolation unit for COVID-19 infected residents. At about 1:50 PM the NHA and DON stated that the 500 Hall was designated as a monitoring area for hospital transfers and residents requiring observation. On [DATE] at approximately 11:20 AM the surveyor asked the DON to provide resident surveillance records and a comprehensive list containing all test data for all residents in the facility. The DON was unable to provide a comprehensive list of test information for all residents including which laboratory conducted the testing, what date the tests were obtained and what date the results were received, as many residents had been tested more than once and by different laboratories. However, she did provide a Line List (list of ill residents) for residents which had fields for resident name, age, sex, room number, date of onset, duration of illness, fever, cough, sore throat, runny nose, nasal congestion, chest congestion, shortness of breath, muscle aches, vomiting, diarrhea, pneumonia, x-ray results, hospitalization , death, COVID-19 and date of COVID-19 test, among others. The Line List did not contain all relevant information and in some cases contained inaccurate information. The list contained the names of 25 residents and two entries were whited out. The fields for age and duration of illness were not completed for any resident. Room numbers were not recorded for two residents (Resident #2 and #4). Date of onset was not recorded for seven residents (Residents #3, 8, 10, 13, 15, 33 and 34). Some of the asymptomatic roommates of positive residents were included on the list while others weren't. Resident #1's test result was documented as being obtained by the hospital when she hadn't been to the hospital. Similarly, the surveyor noticed that a resident who was known to be at the hospital (Resident #12), was not indicated to be at the hospital. The surveyor brought this to the DON's attention who stated that it was actually Resident #12, not Resident #1 who was at the hospital and said, I don't know what I did there. Further review of the Line List revealed Resident #7 was tested on [DATE] with a positive result on [DATE] but was recorded with a negative test result on the DON's undated census that was being used to track residents' COVID-19 status. The surveyor brought this to the DON's attention who stated that it was a mistake and Resident #7 is indeed positive. Resident #39's test date according to the Line List was listed as [DATE] while the DOH, who conducted that test, documented a [DATE] test date. Resident #35's test date was listed as [DATE] on the Line List whereas it was documented as [DATE] on the undated census the DON was using to record resident test results. Lastly, the Line List revealed Resident #43 on the 300 wing developed a fever and cough on [DATE] and was diagnosed with [REDACTED].#44 on the 300 wing developed a fever, cough and chest congestion on [DATE]. Both residents had roommates according to the census, however, neither roommate appeared on the Line List. And neither Resident #43 or #44's rooms were observed to have precautions in place during the facility tours. On [DATE] at approximately 12:40 PM a tour conducted of the isolation unit (400 Hall) with the DON which revealed that 4 of the rooms had COVID-19 infected (positive) residents (#2, 4, 5, 10), sharing a room with COVID-19 negative residents (#14, #30, #31 and #33) and one of the rooms had a PUI (#39) sharing a room with COVID-19 negative resident (#36). Also observed were three rooms that housed COVID-19 negative residents (#41, 37, 35, 42, 26 & 27) who had not been moved off the isolation unit despite being asymptomatic and receiving negative test results. When asked, the DON confirmed the negative test results and added that resident #26 and #27 were being moved off the hall so that their room can be used for a staff breakroom. The surveyor expressed concern to the DON again regarding the presentation of rooms on the isolation unit. The DON stated that designated staff working the hall know which residents are positive and which are negative and there aren't enough bins to setup separate isolation precaution stations outside each room so there are no signs or PPE stations setup outside each individual room. She also stated that she was trying to move the negative residents off the isolation. As the tour of the facility continued it was observed that 2 resident rooms, outside the dedicated isolation area, were noted to have COVID-19 Positive residents (511 & 602) and there were 5 rooms (504, 508, 511, 602, & 604) that housed residents who were PUIs. There was no signage indicating isolation or contact precautions, there was no PPE available for use and the doors leading into the rooms were found to be open. Review of the facility's policy, Novel [MEDICAL CONDITION] Prevention and Response Policy, with a [DATE] implementation date, revealed under Section 5(e)(i), Posting signs on the door or wall outside of the resident room that clearly describe the type of precautions needed and required PPE. Further review of the policy under Section 5(e)(ii) revealed, Make PPE, including facemask, eye protection, gowns, and gloves, available immediately outside of the resident's room. According to the CDC's webpage titled, Responding to Coronavirus (COVID-19) in Nursing Home, last reviewed on [DATE] and located at: https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for COVID-19 14 days after their last exposure (e.g. date their roommate was removed). 2. Administration failure to consistently deny entry to staff members with sore throats, coughs, and/or other possible COVID-19 symptoms: On [DATE] at approximately 12:50 PM, the joint DOH and AHCA team conducted an interview with the DON and NHA. The surveyor asked for confirmation of the current number of known cases. They stated that there's one positive resident, Resident #11, and two positive staff, Staff O, Activities, and Staff T, an RN. The surveyor asked for an explanation of events leading up to the identification of the first positive case, Resident #11. The NHA stated that resident (#11) had coded (required resuscitation) several times before she was transferred to the hospital on [DATE]. The DON stated that three nurses responded to the code events: RN X, , LPN JJ, and LPN KK. The DON stated that RN X and LPN KK both performed Cardiopulmonary Resuscitation (CPR). The surveyor asked about the status of each of the three staff involved and the NHA stated that RN X was at home self-isolating, LPN KK, who was pregnant, decided not to return to work after being informed of her COVID-19 exposure, and LPN JJ was currently working. The surveyor asked if designated staff were overseeing the employee screening at the door. The NHA stated that the staff that was there at the time, Dietary Staff RR, covers the screening booth from 08:00 AM to 5:00 PM and approximately nine other staff who are department heads have screening responsibilities when she's not there. The surveyor asked if any staff had failed the screening process due to fever or report of other symptoms and the NHA replied, No. The surveyor asked how many residents currently had respiratory symptoms. The DON responded one, Resident #1, who had an 80% oxygen saturation on room air and a fever of 101 degrees Fahrenheit. The surveyor asked the DON how frequently residents are being screened for symptoms and she stated once per 12-hour shift. On [DATE] a review was conducted of the staff screening materials from [DATE] through [DATE]. The records reflected that 20 staff from all departments within the facility including direct care, nursing, and housekeeping, presented for their shifts reporting coughs, fever, shortness of breath, headache, loss of taste or muscle ache, often a combination of several symptoms, and were nonetheless directed to report for service within the facility (Staff A, H, I, L, J, K, M, U, W, X, Y, Z, AA, BB, CC, DD, EE, FF, GG, & HH). One of these individuals, Staff U, a Licensed Practical Nurse (LPN), was sent home on [DATE] by representatives of Florida's Department of Health (DOH) after LPN U had served residents for approximately four (4) hours. Review of the facility's policy Coronavirus Surveillance implemented [DATE] revealed under Policy Explanation and Compliance Guidelines section 8 revealed The facility will refer to current CDC guidance for exposures that might warrant restricting asymptomatic staff from reporting to work. 3. Administration's failure to adhere to CDC guidance and AHCA and DOH staff recommendations to keep resident's doors closed: On [DATE] at approximately 12:40 PM, a joint DOH and AHCA visit was conducted at the facility with the following DOH staff: Calhoun & Liberty Counties Health Administrator (CHA), Epidemiologist and Long-Term Care Liaison. The team made observations of resident room doors throughout the building being left open. This included 6 of the 8 resident rooms on the 100 Hall; 5 of the 7 resident rooms on the 200 Hall; 9 of 11 resident rooms on the 300 Hall; and 7 of 8 rooms on the 600 Hall. On the 400 Hall, the Isolation unit, all resident room doors with exception of rooms [ROOM NUMBERS] were observed to be open. On [DATE] at 2:40 PM, a conference was conducted with the joint team and the facility DON and the facility Administrator. The team made recommendations which included keeping resident room doors closed throughout the facility to help contain the spread of COVID 19. On [DATE] at approximately 11:20 AM, the AHCA surveyor and facility DON conducted a tour of the facility which revealed that most doors on the 100 Hall were open, 6 out of 7 resident room doors on the 200 Hall were open, most resident room doors on the 300 Hall were open and 5 of the 10 rooms observed on the isolation unit (400 Hall) were documented as being open during the tour. The DON was reminded of guidance provided by DOH and the CDC to keep resident room doors closed. The next day, on [DATE] at approximately 11:00 AM, a tour of the facility revealed that the following resident rooms were observed with open doors: 103, 105, 109, 201, 202, 203, 205, 206, 207, 303, 305, 306, 307, 309, 310, and 311. A review of the Interim Infection Prevention and Control recommendations for patients with suspected for confirmed COVID-19 in Health Care Settings under Key Concepts retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html Isolate symptomatic patients as soon as possible. Set up separate, well-ventilated triage areas, place patients with suspected or confirmed COVID-19 in private rooms with the door closed. 4. Administration's failure to provide adequate training to staff regarding personal protective equipment (PPE): On [DATE] at approximately 1:50 PM, the surveyor observed Dietary Staff A in the kitchen rolling metal silverware in paper napkins. She had a surgical face mask around her neck and no gloves on. Dietary Staff A saw the surveyor and pulled her surgical face mask up over her nose and mouth. She then immediately resumed rolling silverware. Dietary Staff A did not perform hand hygiene before or after touching her surgical face mask. On [DATE] at approximately 1:50 PM, the surveyor immediately brought the identified concern to the NHA's attention. The NHA and the Certified Dietary Manager (CDM) re-educated Dietary Staff A on hand hygiene and facility policy regarding face masks. On [DATE], an observation was made of a housekeeping cart in use by Staff B, a Housekeeper, which did not visibly indicate it was designated for the isolation hall only. At approximately 2:15 PM, the surveyor asked Housekeeper B if there was a designated cart for the isolation hall. She replied, No. The surveyor asked if she used that same cart to clean other parts of the facility and she stated that she used it to clean the 600 Hall earlier that shift. The surveyor asked how often the mop solution is changed and Housekeeper B responded that the bucket is filled at the start of her shift and the mop heads stay in that same solution until the end of her shift when housekeeping launders them. At approximately 2:30 PM, the surveyor asked the Maintenance Director if there was a designated housekeeping cart for the isolation hall. He replied, As far as I know there isn't one. On [DATE], an observation was made in the isolation unit (400 hall) of the facility during which three bins were noted at the end of the hallway inside the double doors leading out to the East Wing Nurses' Station. The surveyor asked the DON, who was present, to explain the purpose for each bin. The DON stated that one was intended for trash, one for torn/soiled gowns to be discarded and one for gowns that are in good condition to be re-used. The surveyor questioned the practice of re-using disposable gowns that are not intended for repeat use. On [DATE] at approximately 12:55 PM, Staff V, a CNA, was observed exiting room [ROOM NUMBER]. The door to room [ROOM NUMBER] was open and had an airborne precaution sign posted on the door. CNA V did not remove the yellow gown or surgical face mask she was wearing before exiting room [ROOM NUMBER], which housed two COVID-19 infected residents. CNA V immediately walked across the hallway to enter room [ROOM NUMBER], which housed two COVID-19 negative residents, while wearing the same yellow gown and surgical face mask in place. room [ROOM NUMBER] also had an open door, and no droplet precaution sign was on the door. Before CNA V entered room [ROOM NUMBER] this surveyor stopped her. An interview with CNA V was immediately conducted. The surveyor asked why she was wearing the gown in the hallway after exiting a resident's room who was on airborne precautions. CNA V did not have an immediate answer. The surveyor advised of the CDC recommendation regarding not exiting an isolation room without first removing the PPE, especially when there are residents and staff in this area who have tested negative. The surveyor further communicated that staff should not enter the room of a resident, who has not yet tested positive, wearing soiled PPE. In response, CNA V stated, We did not know we were supposed to do all of that. At this time the surveyor then asked which staff members were caring for the residents who were positive, and which were caring for those who were negative. The surveyor expanded on the inquiry and asked if specific CNAs and nurses were caring for the positive residents and other staff members caring for those who were negative. CNA V replied, No, we care for all the residents back here. CNA V further stated, No one has told us. We did not know. The surveyor asked: Why are the doors on this hallway open? CNA V replied, We were not told to close them. The surveyor advised CNA V of the CDC and DOH recommendation that all doors on the hall should be closed. The staff later closed all the doors on the hallway. A review of the job description for the administrator that was electronically signed on [DATE] revealed the General Purpose of this position is To lead and direct the overall operations of the facility in accordance with customer needs, government regulations and company policies, with focus on maintaining excellent care for the residents . A review of the unsigned job description for the Director of Nursing (DON) revealed that the DON Performs specific functions outlined in the Job Description/Performance Appraisal, which includes, but is not limited to, assumes accountability for the development, organization and implementation of approved policies and procedures; Directs, evaluates and supervises all resident care to maintain compliance with state/federal regulations, as well as company standards, policies and procedures; Directs and implements nursing services, educational programs including, but not limited to, orientation, and in services for licensed and unlicensed nursing personnel.; Establish open lines of communication with consultants and consistently take follow-up action on recommendations; Observes infection control procedures related to the department: Identify safety hazards and initiates corrective action immediately.

Based on observations, interviews with representatives from the State of Florida public health authority (Florida Department of Health/(DOH)), facility staff interviews and record reviews, the facility failed to consistently follow DOH, Centers for Disease Control and Prevention (CDC), State Survey Agency (Agency for Health Care Administration/(AHCA)), the Florida Division of Emergency Management (DEM) and the Centers for Medicare and Medicaid (CMS) infection control orders, directives, recommendations and guidelines related to the Coronavirus Disease 2019 (COVID-19) pandemic. The facility failed to implement appropriate isolation precautions and cohorting recommendations for both COV1D-19 infected residents and Persons Under Investigation (PUIs) to control or prevent the potential spread of COVID-19. Four COV1D-19 infected residents (#2, 4, 5 and 10) were sharing a room with COVID-19 negative roommates (#14, #30, #31 and #33), and Resident #39 a PUI was sharing a room with COVID-19 negative resident (#36). The facility failed to ensure that staff were consistently screened prior to facility entry. The facility failed to consistently deny entry to staff members with sore throats, coughs, and/or other possible COVID-19 symptoms. The facility failed to store housekeeping chemicals in properly labeled containers with clear instructions for use. This failure affected all 81 residents residing in the facility on [DATE] plus 2 additional COVID-19 infected resident who had been hospitalized (#12 & 13). The facility failures resulted in 23 residents, some from every wing in the facility, becoming infected with COVID-19 as of [DATE] (#1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 20, 21, 31, 33, 34, 35, 36, and 38). The facility census on [DATE] was 81. Individuals who are [AGE] years and older, those with chronic underlying medical conditions, and those living in nursing homes are at high risk for developing serious complications from COVID-19 illness. Individuals who are infected could develop serious disease with difficulty breathing and might require intensive care for the treatment of [REDACTED]. COVID-19 infection can lead to death. COVID-19 is a new disease, caused by a new coronavirus that has not previously been seen in humans. Currently, there is no vaccine and no approved treatment for [REDACTED]. The cumulative result of these infection control concerns led to a widespread finding of immediate jeopardy at a scope and severity of L. The Nursing Home Administrator and Director of Nursing were informed of the findings of immediate jeopardy on [DATE] at 3:15 PM (CST). The immediate jeopardy was determined to start on [DATE] when the facility failed to follow Centers for Disease Control and Prevention (CDC) guidelines related to the COVID-19 pandemic regarding the use of designated isolation housekeeping carts and designated staff for residents suspected or confirmed of having COVID-19. It was determined the provider's non-compliance caused, or was likely to cause, serious injury, harm, impairment or death to residents. Facility staff also failed to perform hand hygiene and wear PPE (face mask) when appropriate. The immediate jeopardy was ongoing. Cross reference F835. The findings include: On [DATE], The Office of the Governor issued Executive Order Number ,[DATE] directing the Florida Department of Health to issue a Public Health Emergency. The Executive Order documented, Coronavirus Disease 2019 (COVID-19) is a severe acute respiratory illness that can spread among humans through respiratory transmission and presents with symptoms similar to those of influenza. Section 2 directed the State Health Officer to take any action necessary to protect the public health. Section 3 directed the State Health Officer to follow the guidelines established by the CDC (Centers for Disease Control and Prevention) in establishing protocols to control the spread of COVID-19. Section 4 designated the Florida Department of Health as the lead state agency to coordinate emergency response activities among the various state agencies and local governments. Section 5 specified that all actions taken by the State Health Officer with respect to this emergency before the issuance of this Executive Order are ratified. Section 6 stated The Florida Department of Health will actively monitor, at a minimum, all persons meeting the definition of a Person Under Investigation (PUI) as defined by the CDC for COVID-19 for a period of at least 14 days. Active monitoring by the Florida Department of Health will include at least the following: A. Risk Assessment with 24 hours of learning an individual meets the criteria for a PUI and B. Twice daily temperature checks. Section 7 directed the Florida Department of Health, pursuant to its authority in section 381XXX , Florida Statutes, will ensure that all individuals meeting the CDC's definition of a PUI are isolated or quarantined for a period of 14 days or until the person tests negative for COVID-19. Section 8 directed Florida Department of Health to make its own determinations as to quarantine, isolation and other necessary public health interventions as permitted under Florida Law. Section 9 directs all agencies under the direction of the Governor to fully cooperate with the Florida Department of Health, and any representative thereof in furtherance of this Order. On [DATE], The Office of the Governor issued Executive Order Number ,[DATE] declaring a state of emergency for the entire State of Florida as a result of COVID-19. On [DATE], the Division of Emergency Management (DEM) Emergency Order No. ,[DATE] restricting entrance into residential health care facilities including nursing homes was issued. The Order limited persons who were allowed to enter the facility and directed screening of all individuals seeking entry. The order documented, Individuals seeking entry to the facility under the above section 1 (includes staff) will not be allowed to enter if they meet any of the screening criteria listed below: a. Any person infected with COVID-19 who has not had 2 consecutive negative test results separated by 24 hours; b. Any person showing, presenting signs or symptoms of, or disclosing the presence of a respiratory infection, including cough, fever, shortness of breath or sore throat; c. Any person who has been in contact with any person(s) known to be infected with COVID-19, who has not yet tested negative for COVID-19 within the past 14 days; d. Any person who traveled through any airport within the past 14 days; or e. Any person who traveled on a cruise ship within the past 14 days. Part 5 of the Order stated, The following documentation must be kept for visitation within a facility: a. Individuals entering a facility subject to the screening criteria above may be screened using a standardized questionnaire or other form of documentation. b. The facility is required to maintain documentation of all non-resident individuals entering the facility. Documentation must include: 1. Name of the individual; 2. Date and time of entry; and 3. The documentation used by the facility to screen the individual showing the individual did not meet any of the enumerated screening criteria, including the screening employee's printed name and signature. The President declared a Nationwide emergency for COVID-19 on [DATE] and approved a major disaster declaration for Florida on [DATE]. On [DATE] the Agency for Health Care Administration (AHCA), the state survey agency, issued an Alert entitled, Residential and Long-Term Care Facilities to Implement Universal Use of Facial Masks. The directive stated, Effective immediately staff of residential and long-term care facilities are to implement universal use of facial masks while in the facility. All staff, essential healthcare visitors and anyone entering the facility are to don a face mask upon the start of their shift or visit and only change it once it becomes moist. It is important to keep hands away from the face mask and only touch the straps of the face mask. Gloves are to be worn when providing care to the resident. Continue to perform hand hygiene prior to donning gloves, after removing gloves, and anytime there is contact with the resident environment. Staff in a room with a patient with respiratory symptoms of unknown cause or a patient with known or suspected COVID-19 should adhere to Standard, Contact, and Droplet Precautions with eye protection. This includes wearing gown, gloves, N95 face mask (as fitted and available - if not available, at least a facial mask), and eye protection such as face shields or goggles. In addition to securing more gowns, gloves, and masks, facilities will need to immediately order the appropriate eye protection (I.e. face shields) since many do not have this on hand. In the event you are unable to acquire the necessary PPE, please notify your local emergency management agency. Facilities will need to educate their staff on the proper donning (putting on), doffing (taking off), and disposal of any PPE. Information about the recommended duration of Transmission-Based Precautions is available in the Interim Guidance for Discontinuation of Transmission-Based Precautions and Disposition of hospitalized Patients with COVID-19. According to an interview with the DOH Nursing Director who oversees Calhoun and Liberty Counties, on [DATE] at 2:52 PM, she was notified by phone of the facility's first positive COVID-19 case (Resident #11) on [DATE] by the Bay County Health Department (BCHD). The DOH Nursing Director stated that the local hospital, which received Resident #11 and tested for COVID-19 on [DATE], contacted the BCHD on [DATE] to report the positive result it received on [DATE]. The DOH Nursing Director then immediately called the facility's Director of Nursing (DON) on [DATE] to notify her of the positive test result and obtain a list of anyone in the building who was known to be in close contact with Resident #11 recently. The DOH Nursing Director stated that she felt like the facility was going to need some help and didn't believe the facility had a real grasp of the severity of the situation, so she submitted a mission request for staffing to the local Emergency Operations Center (EOC) on [DATE]. The EOC was able to send two teams of infection control experts to assist. A Florida Division of Emergency Management (DEM) contracted Strike Team consisting of four Registered Nurses (RNs) and ten Certified Nursing Assistants (CNAs) who made daily visits from [DATE] to [DATE]. A United States Department of Veterans Affairs (VA) team consisting of one doctor, one Registered Nurse (RN), two Licensed Practical Nurses (LPNs) and one nursing assistant made daily visits to the facility from [DATE] to [DATE]. The Calhoun County Health Department contacted the Agency for Health Care Administration (AHCA) to request a joint on-site facility visit be conducted on [DATE] to complete an infection control assessment and epidemiological investigation. At the time of the joint visit, the facility had a total of three positive cases: one resident (Resident #11) and two staff (Staff O and T) who had direct contact with the resident. On [DATE] through [DATE] AHCA surveyors made a second onsite visit to the facility. In the time between the surveyors' first and second visits, the facility had five more staff (Staff N, P, Q, R and S) and 12 more residents (Resident #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10) test positive for COVID-19, two of which were in the hospital (Resident #12 and #13). During the time between the surveyors' 2nd and 4th visits, one staff (Staff U) and five more residents tested positive (Resident #15, #33, #35, #36 and #37). AHCA was informed by the DOH Nursing Director that five additional residents (Resident #16, #20, # 21, #34 and #38) and two staff (Staff V and W) tested positive for COVID-19 since the surveyors exited the facility on [DATE]. On [DATE] at approximately 12:40 PM, a joint AHCA visit was conducted at the facility with the following DOH staff: Calhoun & Liberty Counties Health Administrator (CHA), Epidemiologist and Long-Term Care Liaison. On [DATE] at approximately 12:50 PM, the joint team conducted an interview with the DON and Nursing Home Administrator (NHA). The surveyor asked for confirmation of the current number of known cases. They stated that there's one positive resident, Resident #11, and two positive staff, Staff O, Activities, and Staff T, a RN. The surveyor asked for an explanation of events leading up to the identification of the first positive case, Resident #11. The NHA stated that the resident (#11) had coded (required resuscitation) several times before she was transferred to the hospital on [DATE]. The DON stated that three nurses responded to the code events: Staff X, an RN, Staff JJ, an LPN, and Staff KK, an LPN. The DON stated that RN X and LPN KK both performed Cardiopulmonary Resuscitation (CPR). The surveyor asked about the status of each of the three staff involved and the NHA stated that RN X was at home self-isolating, LPN KK, who was pregnant, decided not to return to work after being informed of her COVID-19 exposure, and LPN JJ was currently working. The Nursing Home Administrator (NHA) and Director of Nursing (DON) identified the 400 hall as the isolation unit for COVID-19 infected residents and the 500 Hall was designated as a monitoring area for hospital transfers and residents requiring observation. The surveyor asked if designated staff were overseeing the employee screening at the door. The NHA stated that the staff that was there at the time, Staff RR, Dietary, covers the screening booth from 8:00 AM to 5:00 PM and approximately nine other staff who are department heads have screening responsibilities when she's not there. The surveyor asked if any staff had failed the screening process due to fever or report of other symptoms and the NHA replied, No. The surveyor asked how many residents currently had respiratory symptoms. The DON responded one, Resident #1, who had an 80% oxygen saturation on room air and a fever of 101 degrees Fahrenheit. The surveyor asked the DON how frequently residents are being screened for symptoms and she stated once per 12-hour shift. The following observations and interviews were obtained during the [DATE] joint visit: Six of the eight resident room doors on the 100 Hall were open and one resident was seated in a wheelchair in the hall with no facial covering. Five of the seven resident room doors on the 200 Hall were open. Nine of the eleven resident room doors on the 300 Hall were open and three residents were seated in wheelchairs in the hall with no facial coverings. On [DATE] at approximately 1:50 PM, the surveyor observed Staff A, Dietary, in the kitchen rolling metal silverware in paper napkins. She had a surgical face mask around her neck and no gloves on. Staff A observed the surveyor and pulled her surgical face mask up over her nose and mouth. She then immediately resumed rolling silverware. Staff A did not perform hand hygiene before or after touching her surgical face mask. On [DATE] at approximately 1:50 PM, the surveyor immediately brought the identified concern to the NHA's attention. The NHA and the Certified Dietary Manager (CDM) who was sitting in her office in the kitchen re-educated Staff A on hand hygiene and facility policy regarding face masks. The NHA and CDM also stated that Staff A was instructed to wash all of the rolled silverware and then re-roll it. According to the NHA, as of today all staff are required to wear N95 face masks while in the building, whereas prior to today they were required to wear surgical face masks at all times. Review of the facility's, Prevent COVID-19 Start of Shift Employee Screening Log, dated [DATE], revealed Staff A documented having a cough that week. 400 Hall Isolation Unit: All resident room doors except rooms [ROOM NUMBERS] were open. There was a housekeeping cart in use by Staff B, a Housekeeper, which did not visibly indicate it was designated for the isolation hall only. At approximately 2:15 PM, the surveyor asked Housekeeper B if there was a designated cart for the isolation hall. She replied, No. The surveyor asked if she used that same cart to clean other parts of the facility and she stated that she used it to clean the 600 Hall earlier that shift. The surveyor asked how often the mop solution is changed and Housekeeper B responded that the bucket is filled at the start of her shift and the mop heads stay in that same solution until the end of her shift when housekeeping launders them. At approximately 2:30 PM, the surveyor asked the Maintenance Director if there was a designated housekeeping cart for the isolation hall. He replied, As far as I know there isn't one. There was an open meal cart on the isolation hall that contained reusable trays and cups. There was a shared stethoscope hanging on the side of the medication cart in the hallway. There were three bins at the end of the hallway inside the double doors leading out to the East Wing Nurses' Station. At approximately 2:20 PM, the surveyor asked the DON who was present to explain the purpose for each bin. She stated that one was intended for trash, one for torn/soiled gowns to be discarded and one for gowns that are in good condition to be re-used. The surveyor questioned the practice of re-using disposable gowns that are not intended for repeat use. Observation of areas outside the isolation hall: On [DATE] at approximately 1:50 PM during the tour with the NHA and DON the team was informed that the 500 Hall designated as a monitoring area for hospital transfers and residents requiring observation. Four of 11 bedrooms on the 500 Hall were vacant and the hall contained all private rooms. Seven of eight resident room doors on the 600 Hall were open and three residents were seated in wheelchairs in the hall with no facial coverings. On [DATE] at 2:40 PM an end of day conference was conducted during which the joint team made recommendations including, but not limited to, keeping bedroom doors closed throughout the facility, assigning designated and seasoned nurses to provide all care needs to residents on isolation, not re-using disposable gowns, changing mop solution more frequently, and using all disposable items for meal service as well as disposable vital sign equipment on the isolation unit. While onsite, the Epidemiologist tested three residents, which included the roommate of the first confirmed case (Resident #14) and two symptomatic residents who shared a room on that same hall (Resident #1 and #12). On [DATE] the facility conducted COVID-19 testing that included all residents and the majority of staff. The results were returned from [DATE] to [DATE]. On [DATE] at approximately 11:20 AM the AHCA surveyor returned to the facility. At that time the surveyor asked the DON to provide resident surveillance records and a comprehensive list containing all test data for all residents in the facility. The DON was unable to provide a comprehensive list of test information for all residents including which laboratory conducted the testing, what date the tests were obtained and what date the results were received, as many residents had been tested more than once and by different laboratories. However, she did provide a Line List for Residents, a tool used to track all individuals being monitored for or meeting the case definition for the outbreak illness, which had fields for resident name, age, sex, room number, date of onset, duration of illness, fever, cough, sore throat, runny nose, nasal congestion, chest congestion, shortness of breath, muscle aches, vomiting, diarrhea, pneumonia, x-ray results, hospitalization , death, COVID-19 and date of COVID-19 test, among others. The line list did not contain all relevant information and in some cases contained inaccurate information. The list contained the names of 25 residents and two entries were whited out. The fields for age and duration of illness were not completed for any resident. Room numbers were not recorded for two residents (Resident #2 and #4). Date of onset was not recorded for seven residents (Resident #3, #8, #10, #13, #15, #33 and #34). Some of the asymptomatic roommates of positive residents were included on the list while others weren't. Resident #1's test result was documented as being obtained by the hospital when she hadn't been to the hospital. Similarly, the surveyor noticed that a resident who was known to be at the hospital (Resident #12), was not indicated to be at the hospital. The surveyor brought this to the DON's attention who stated that it was actually Resident #12, not Resident #1 who was at the hospital and said, I don't know what I did there. Further review of the line list revealed Resident #7 was tested on [DATE] with a positive result on [DATE] but was recorded with a negative test result on the DON's undated census that was being used to track residents' COVID-19 status. The surveyor brought this to the DON's attention who stated that it was a mistake and Resident #7 is indeed positive. Resident #39's test date according to the line list was listed as [DATE] which DOH, who conducted that test, documented a [DATE] test date. Resident #35's test date was listed as [DATE] on the line list whereas it was documented as [DATE] on the undated census the DON was also using to record resident test results. Lastly, the line list revealed Resident #43, on the 300 Hall, developed a fever and cough on [DATE] and was diagnosed with [REDACTED].#44, also on the 300 Hall, developed a fever, cough and chest congestion on [DATE]. Both residents had current roommates, however, neither of the roommates appeared on the line list. Neither of the resident's rooms were observed to have precautions in place during the facility tours on [DATE] and [DATE]. On [DATE] at approximately 11:35 AM, a tour of the facility was conducted with the DON. Most doors on the 100 Hall were open, including Resident #18's which had a sign stating, See Nurse Before Entering, on the door as well as biohazard bags, gowns and gloves posted outside the room. The surveyor asked the DON about the status of Resident #18. The DON stated that she was the former roommate of a COVID-19 positive resident, Resident #6, who was moved to the isolation hall (the 400 Hall). Resident #40 was seated in his wheelchair at the end of the 100 Hall looking out the exterior doors. Resident #40 wore no facial covering. The DON who was with the surveyor at that time provided no redirection to the resident. At this time the DON stated that the resident takes his face mask off and doesn't stay in his room. A few minutes later, a VA staff donning full PPE came along and pushed the resident in his wheelchair back to his room, which ended up being on the 300 Hall on the opposite side of the West Wing. Six out of seven resident room doors on the 200 Hall were open, including Resident #17's, which had a, See Nurse Before Entering, sign on the door as well as a hanging [MEDICATION NAME] containing trash bags, gowns and gloves. The surveyor asked the DON about the status of Resident #17. The DON stated that she was the former roommate of a COVID-19 positive resident, Resident #5, who was moved to the isolation hall (400 Hall). Most resident room doors on the 300 Hall were open, including Resident #16's, which had a, See Nurse Before Entering, sign on the door as well as a hanging [MEDICATION NAME] containing biohazard bags, gowns and gloves. The surveyor asked the DON about the status of Resident #16. The DON stated that she is the former roommate of Resident #20 who developed symptoms today including a low-grade fever, diarrhea and chills and was moved to the 500 Hall. She continued that Resident #16 was placed on contact precautions in the existing room. At this time the surveyor reiterated to the DON the importance of keeping resident room doors throughout the facility closed. The DON stated that, The FEMA doctor said it's okay. A resident was seated in a wheelchair in the 300 hallway with no facial covering. The DON stated that N95 face masks have been worn by staff at the recommendation of FEMA since [DATE] with the development of additional positive cases. At approximately 12:00 PM, four staff wearing N95 face masks and gowns (one also donned gloves) were observed to be gathered around the East Wing Nurses' Station (Personal Care Assistant (PCA) L, CNA M, Restorative CNA Z and CNA MM). The surveyor asked the four staff if any of them currently had symptoms or had experienced any in the last week. All four staff replied, No. Review of the facility's, Prevent COVID-19 Start of Shift Employee Screening Log, revealed that in fact three of the four staff had documented having symptoms in the last week. PCA L documented a sore throat and muscle pain on [DATE] and a sore throat on [DATE], CNA M documented new shortness of breath or difficulty breathing, a cough, and muscle pain on [DATE], and Restorative CNA Z documented a headache on [DATE]. On [DATE] at approximately 12:40 PM, the following was observed immediately outside the double doors leading into the 400 Hall (isolation unit): A, Staging Area, sign was posted on the wall over a cart, a red biohazardous waste bin with an unsecured lid had discarded PPE hanging out over the rim. Also posted on the double doors leading into the isolation unit were a sign that read, Anyone Entering This Hall Must Be Wearing: Mask (N95), Gown, Gloves, and, Stop. Do not enter. Only staff working this hall. Just on the other side of the double doors inside the isolation unit were two more red bins with a, Place soiled and/or compromised gowns here for disposal *may also be used to dispose of used gloves, etc. sign posted. The other bin was for soiled linen. The DON and surveyor toured the hall together and the DON provided the COVID-19 status of each of the rooms as follows: The door was open to the room which housed Resident #41 and Resident #37. The DON stated that both the residents tested negative for COVID-19. Review of an undated census that the DON had recorded test results on revealed both residents were tested by the facility on [DATE] which came back negative on [DATE]. The door was open to the room which housed Resident #6 and Resident #8. The DON stated that both residents tested positive. The door was open to the room which housed Resident #10 and Resident #14. The DON stated that Resident #10 tested positive for COVID-19 and Resident #14's test was pending. However, review of the DON's Line List for Residents dated [DATE] to [DATE] revealed Resident #14 was tested by the DOH on [DATE] and in an e-mail dated [DATE] at 4:08 PM, the DOH Nursing Director confirmed that Resident #14's negative test result was received on [DATE]. Review of the facility's census dated [DATE] revealed that Resident #10 was moved into this room on [DATE]. At this time the surveyor asked the DON why she would move a symptomatic resident (Resident #10) in with a resident who just tested negative (Resident #14). The DON stated that Resident #14 had developed symptoms since her negative test result was obtained, however review of the DON's Line List for Residents revealed Resident #14 had no symptoms documented. Further review of the line list revealed Resident #10 was tested on [DATE] by the DOH with a positive result. An e-mail on [DATE] at 3:16 PM from the DOH Nursing Director revealed that Resident #10's test was sent to the lab on [DATE], but it leaked, so the DOH re-tested the resident on [DATE] which came back positive on [DATE]. The DON failed to maintain complete and accurate surveillance records and the facility placed Resident #14, who was on Hospice and already a high risk, at an even greater risk of exposure by cohorting a confirmed negative (Resident #14) and symptomatic resident (Resident #10) in a room together. The door was open to the room which housed Resident #39, who occupied the A bed, and Resident #36, who occupied the B bed. The DON stated that both residents tested negative. Review of the DON's Line List for Residents dated [DATE] to [DATE] revealed Resident #39 had a 99.7 degree Fahrenheit temperature, cough, and chest congestion with a symptom onset date of [DATE]. The line list had no documented symptoms for Resident #36. Further review of the line list revealed Resident #39 was tested by DOH on [DATE] with a negative result, but the date the result was received wasn't recorded. On [DATE] at 5:20 PM the DOH Nursing Director verified that DOH administered the test on [DATE] and received the negative result on [DATE]. Review of an undated census that the DON was recording test results on revealed Resident #36 was tested on [DATE] with a negative result, but the date the results were received was not documented. An e-mail on [DATE] at 7:49 PM from the DOH Nursing Director revealed that the test obtained by the DOH on [DATE] leaked, so they re-tested the resident on [DATE], which had a negative result on [DATE]. The DON failed to maintain complete and accurate surveillance records requiring the surveyor to obtain records from outside the facility and failed to separate a symptomatic (Resident #39) and an asymptomatic (Resident #36) resident, both of whom had negative results and were housed on the isolation unit. The next room housed Resident #2 and Resident #31. The DON stated that Resident #2 tested positive and Resident #31 tested negative. She stated that Resident #31 was being moved to a different room on the isolation unit today, [DATE]. Review of the DOH lab slips revealed both residents were tested on [DATE] with results obtained on [DATE]. The room across the hall housed Resident #35 and Resident #42. The DON stated that both residents tested negative. Review of the facility's test results revealed neither resident had been tested by the facility. Review of the DON's Line List for Residents dated [DATE] to [DATE] revealed Resident #35 was tested by DOH on [DATE] with a negative result, but the date the results were received was not documented. Review of an undated census that the DON was recording test results on revealed Resident #35 was tested by DOH on [DATE] with a negative result, but the date the results were received was not documented. In an e-mail on [DATE] at 5:20 PM, the DOH Nursing Director verified that Resident #35 was test by DOH on [DATE] with a negative result on [DATE]. Review of the undated census the DON was recording test results on revealed Resident #42 was tested on [DATE] with a negative result received on [DATE]. The accuracy of this information could not be verified as Resident #42's name did not appear on the batch test report provided by the facility for tests administered on [DATE]. The door was open to the room which housed Resident #9 and Resident #1. The DON stated that both residents tested positive. Resident #9 was receiving oxygen via a nasal cannula and neither resident was wearing a face mask. Review of the facility's test results revealed Resident #9 was tested by the facility on [DATE] with a positive result, but the date the results were received was not indicated. Review of the DON's Line List for Residents dated [DATE] to [DATE] indicated the results were received on [DATE]. Resident #1 was tested by DOH on [DATE] with a positive result received on [DATE]. The room across the hall which housed Resident #30 and Resident #5. The DON stated that Resident #30 tested negative and Resident #5 tested positive. The surveyor expressed concern to the DON regarding a negative and positive roommate sharing a room. The DON stated that she was, figuring out where to move her (Resident #30). Review of the DON's Line List of Residents revealed Resident #5 developed a 100.7 degree Fahrenheit fever on [DATE]. Further review revealed no symptoms were (TRUNCATED)

Based on observation and staff interview, the facility failed to provide a safe and homelike environment by failing to maintain the building in 4 of 56 resident rooms (411, 401, 402 and 310), 1 of 2 shower rooms (west shower room), the main hallway and the ceiling over 1 of 2 nurses' stations (east wing nurses' station). The findings include: On 5/19/19 at 4:41 PM, observation of room [ROOM NUMBER] was conducted. In the bathroom, the door casing to the right as you entered was observed to be rusted approximately 1 foot along the casing and there was some scuffing/gouging to the wall. On 5/19/19 at 5:26 PM, observation of room [ROOM NUMBER] was conducted. There was rust on the door casings in the bathroom and there were scuff marks/gouges on wall in bathroom as well. On 5/20/19 at 10:52 AM, observation of room [ROOM NUMBER] was conducted. There was an area where the wall met the ceiling behind the resident bed closest to the door that was observed to have water damage. There was a stained ringed area and the wallpaper was peeling from the wall in a long bubble approximately 6 inches in length. On 05/22/19 at 9:08 AM Registered Nurse D was asked to accompany the surveyors to view the areas of concern. At that time, she agreed that the rusted areas posed a risk of injury and infection for residents entering the bathroom and that the gouges and scuffs on the wall should be reported to maintenance for repair and it was not the expectation for the walls to remain in that state. She also agreed that the area in room [ROOM NUMBER] appeared to be water damage and that it should be fixed. A tour of the facility was conducted with the Administrator on 5/22/19 at 9:33 AM. During the tour a hole was observed in the sheet rock near the baseboard in room [ROOM NUMBER]. The Administrator stated she was not aware of the hole in the wall. Peeling popcorn from the ceiling and a vent with a missing grate was observed in the hall near medical records. The Administrator stated she was not aware of the missing grate on the vent. (Photographic evidence obtained). She stated each department head was assigned a hall for rounds daily with random rooms checks and they were to bring concerns to the morning meeting or fix them. On 5/21/2019 at approximately 3:36PM, an observation of the ceiling near the east wing nurses' station revealed exposed sheetrock around a sprinkler head that appeared wet. Staff C was at the nurses' station at that time and stated the ceiling did leak, and had leaked the day before and seemed to leak whenever the generator came on. An observation of the west wing shower room was conducted on 5/21/19 at 12:10 PM. Rust was observed to be surrounding the door to the bathroom located in the shower room, the ceiling was patched with black tape, the last shower stall had missing floor tile, several wooden baseboards were covered in a black speckled substance, a vent had rust and the wallpaper on the wall in the hall near the entrance was peeling. An interview was conducted at this time with an anonymous employee. The employee stated they believed the black areas in the shower room were mold and had been there for about 3 years. The employee stated the areas were cleaned, but did not come off and some residents had voiced complaints. The employee stated this has been reported to Administration for about 2 years. (Photographic evidence obtained) An interview was conducted with the Administrator on 5/21/19 at 1:21 PM. The Administrator stated the Vice President of resident council told her about the shower room in (MONTH) 2019. She presented the problem to corporate and maintenance scrubbed and cleaned the areas. She called and got a quote for repairs and corporate had placed it on the capital expense report for 2019. A group interview was conducted with 5 members of the resident council on 5/21/19 at 2:10 PM. 2 members of the council stated they had concerns about mold in the shower room.

Based on resident interviews, staff interviews and record review, the facility failed to ensure adequate staffing to provide restorative nursing services for 9 of the 28 sampled residents who were currently in the restorative nursing program (#6, #24, #35, #40, #41, #43, #50, #52, #74). The findings include: There were 28 residents on restorative case load at the time of the survey, based on a list of restorative residents provided by the facility upon request. An interview was conducted with Resident #24 on 5/20/19 at 10:05 AM. He stated the staff did restorative exercises with his hands once in a while when the restorative aide was not get pulled to work the floor. Review of the annual minimum data set (MDS) assessment for Resident #24, with an assessment reference date (ARD) of 2/28/19, indicated the resident had no cognitive impairment. Review of the Restorative Referral form for Resident #24 revealed the resident was to participate in restorative for bilateral arm exercises. He was scheduled for bicep curls, shoulder press and punches, 15 repetitions each for 3 sets with 3 pound wrist weights. Restorative records in (MONTH) show the exercises were offered 4 out of 31 days, and to date in (MONTH) 8 out of 20 days. An interview was conducted with Resident #6 on 5/22/19 at 1:35 PM. Resident #6 stated the facility staff did not do any exercises with her. Review of a quarterly MDS assessment for Resident #6, with an ARD of 2/8/19, indicated the resident had no cognitive impairment. Review of the Restorative Referral form for Resident #6 revealed the resident was to receive ambulation exercises. An interview was conducted with Resident #40 on 5/22/19 at 1:40 PM. Resident #40 stated the facility staff previously did exercises with her, but had not recently and she did not know why they stopped. Review of an annual MDS for Resident #40, with an ARD of 4/1/19, indicated the resident had no cognitive impairment. Review of the Restorative Referral form for Resident #40 revealed the resident was to participate in restorative for bilateral arm exercises with a 2 pound weight. Review of the Restorative Referral form for Resident #50 revealed the resident was to participate in restorative daily for lower extremity strength and ambulation; however, there was no documentation the resident had participated in any restorative activities for the year of 2019. Staff were asked to find this information and were unable to do so. On 5/22/19 at 1:27 PM an interview was conducted with Resident #52. She was identified on a list of residents currently receiving restorative services. When asked about restorative services she said she had no idea what the surveyor was talking about. The surveyor asked about various exercises that a restorative program might cover and she stated that she was not aware of receiving such services. A review of Resident #52's Quarterly Minimum Dataset from 4/11/2019 was conducted which revealed a Brief Interview for Mental Status score of 13, indicating she is Interviewable. A review of the Restorative Referral form for Resident #52 revealed the resident was to participate in restorative for lower extremity strength and range of motion (ROM) and ambulation exercises. On 5/22/19 at 1:37 PM an interview was conducted with Resident #35. She was identified on a list of residents currently receiving restorative services. When asked about restorative services, she stated that the restorative nursing assistant was amazing. She stated that the facility was short staffed and had to keep pulling him away from his restorative duties to work a regular nursing assistant assignment. She stated that she only gets restorative services a time or two a week for that reason. A review was conducted of resident #35's Quarterly Minimum Dataset from 3/21/2019 which revealed a Brief Interview for Mental Status score of 15, indicating she is Interviewable. Review of the Restorative Referral form for Resident #74 revealed the resident was to participate in restorative daily for lower extremity strength and ambulation; however, review of restorative documentation showed that in (MONTH) 2019. A review of Restorative Care Flow record revealed that in May, restorative services were refused 5/1, 5/6, 5/7 and completed on 5/2 and 5/8. The rest of the month was blank. (MONTH) - Staff were not able to locate documentation for this month. (MONTH) - restorative services was documented as done on 3/19 only. The rest of the month is blank. A review was conducted of the Restorative Referral form for Resident #43 which revealed that exercises to be performed for restorative were: Compensatory swallow strategies: Sit up 90 degrees, Take small bites/sips, Alternate bites/sips, SLOW and small bites to avoid acid reflux. A review of the Restorative Care Flow record revealed no documentation. Staff were not able to produce any records when asked to do so. A review was conducted of the Restorative Referral form for Resident #41 which revealed that exercises to be performed for restorative included Range of Motion to bilateral (both) lower extremities, 3 sets of 10 repetition with 2 pound ankle weights and green theraband (tension resistance). Ambulation (walking) with wheeled walker as tolerated up to 100 feet or to and from dining room. A review of the Restorative Care Flow record revealed only documentation from (MONTH) 2019. It was documented that ambulation and ROM was completed 2/25/2019. The rest of the form was blank. An interview was conducted with the restorative certified nursing assistant (CNA) on 5/21/19 at 10:21 AM. He stated if he had to work the floor, restorative was not getting done. He provided documentation of restorative care for Resident #24 for the month of (MONTH) 2019. The documentation indicated the restorative CNA was pulled to work the floor or go on transit with another resident on 5/13/19, 5/14/19 and 5/17/19. He stated the residents' assigned CNAs did not complete the restorative exercises if he was not working restorative. Further interview was conducted with the restorative CNA on 5/22/19 at 1:32 PM. He stated his supervisor was the director of nursing and he had been assigned the restorative program since (MONTH) 2019. He stated the scheduler would pull him to work the floor as necessary to cover staff call-ins and that his supervisor was aware he was working the floor instead of completing restorative. He stated almost every week he is pulled to work the floor instead of doing restorative. An interview was conducted with the director of nursing (DON) on 5/22/19 at 1:51 PM. The DON stated about once or twice a week the restorative aide was pulled to work on the floor and the CNAs for those residents on restorative were then responsible for providing the restorative care, but confirmed the facility was not able to provide any documentation to support the CNAs were completing restorative care when the restorative aide was pulled to work the floor for the 28 residents indicated to require restorative care. She stated there was no formal process to ensure resident's requiring restorative care received the care when the restorative aide worked the floor. An interview was conducted on 5/22/19 at 2:03 PM with employee G, a certified nursing assistant who worked the 7-3 shift. She stated no one had informed her that she had to complete restorative exercises for residents when the restorative aide was pulled to work the floor. An interview was conducted on 5/22/19 at 2:04 PM with employee H, a certified nursing assistant who normally worked a 7a-7p shift. Employee H stated no one had informed her she had to complete restorative exercises for residents when the restorative aide was pulled to work the floor. On 5/22/19 at 2:03 PM an interview was conducted with Certified Nursing Assistant (CNA) [NAME] and F. At that time they stated that no one told them to complete restorative services when the restorative certified nursing assistant was pulled to the floor, they would figure it our on their own. CNA [NAME] stated that they would document in CNA electronic charting. However, when she attempted to show the surveyor how this would be done she was unable to do so. Then Nurse K contradicted her and said that the restorative CNA maintained separate documentation to which they did not have access.

Based on observation, staff interview and policy review, the facility failed to ensure residents were appropriately assessed prior to allowing residents to self-administer medications for 2 of 14 observed residents (# 7 and # 40) . The findings include: On 5/20/2019 at approximately 8:40 AM, upon entering the room of Resident #7, it was observed that the resident was holding a small cup with several pills and capsules in it with no facility staff present. Resident # 7 stated that the nurse had given her morning medication but had left before she finished taking them all and the cup she was holding was what was left of them. On 5/20/2019 at approximately 8:50 AM, upon entering the room of Resident # 40, it was observed that the resident had an unlabeled clear cup containing a red liquid on the bedside table with no facility staff present. Resident # 40 stated that the cup contained medication that was mixed in a liquid that the nurse had left for her to drink. On 5/21/2019 at approximately 3:30 PM, an interview with the Director of Nursing revealed that no residents in the facility had been assessed to self-administer medication and that there should never be times when a resident is left with medication without a nurse present. On 5/21/2019 at approximately 4:00 PM, upon reviewing the facility's policy and procedure for medication administration, it was noted that the nurse was to remain with the resident until all medications have been taken. Review of Recommendations to Enhance Accuracy of Administration of Medications published by The National Coordinating Council for Medication Error Reporting and Prevention showed that the following checks were to be performed with medication administration: the right medication, in the right dose, to the right person, by the right route, using the right dosage form, at the right time, for the right reason, with the right response, with both the desired effect and potential adverse effects in mind, and with the right patient education and documentation. Leaving residents to take medications unsupervised does not ensure all the appropriate medication rights.

Based on observations, record review and staff interviews, the facility failed to provide treatment and services to prevent further decrease in range of motion for 1 of 2 residents reviewed with limited range of motion (resident # 23). The findings include: Observations of Resident #23 were conducted on 5/20/19 at 10:51 AM and 3:51 PM and on 5/21/19 at 11:51 AM and 3:23 PM. The resident was in bed and observed with no splint or other orthotic device in use. Review of the medical record for Resident #23 revealed a [DIAGNOSES REDACTED]. The resident's quarterly minimum data set (MDS) assessment, with an assessment reference date of 2/28/19, revealed the resident had functional limitation in range of motion to the left upper extremity. There was a restorative referral, dated 5/10/19, that showed the resident was to wear a palm guard 4-6 hours daily. An interview was conducted with the west wing unit manager on 5/21/19 at 3:27 PM. She stated nursing had not received a referral for restorative services from therapy. An interview was conducted with the director of nursing (DON) on 5/21/19 at 3:32 PM. The DON stated the therapy department did not communicate the restorative plan to the nursing staff, so the resident was not picked up for restorative.

Based on staff interviews, review of a cost estimate and review of documented plans for quality improvement, the facility failed to develop and implement appropriate plans of action to address identified quality deficiencies related to environmental/maintenance concerns. The findings included: An observation of the west wing shower room was conducted on 5/21/19 at 12:10 PM. Rust was observed to be surrounding the door to the bathroom located in the shower room, the ceiling was patched with black tape, the last shower stall had missing floor tile, several wooden baseboards were covered in a black speckled substance, a vent had rust and the wallpaper on the wall in the hall near the entrance was peeling. An interview was conducted at this time with an anonymous employee. The employee stated they believed the black areas in the shower room were mold and had been there for about 3 years. The employee stated the areas were cleaned, but did not come off and some residents had voiced complaints. The employee stated this has been reported to Administration for about 2 years. (Photographic evidence obtained). Staff L, a registered nurse and unit manager, was identified as being responsible for maintaining records of meetings and progress of the Quality Assurance Process Improvement (QAPI) committee. During an interview on 5/22/2019 at approximately 3:00pm with staff L and the facility administrator, staff L acknowledged that maintenance issues were identified in the QAPI committee and a plan was developed with an initiation date of 5/4/2018. Staff L confirmed that target completion dates were not included in the plan and that repairs have not been completed more than one year later. Specific issues identified were related to repairing and painting walls, ceiling repairs, repairing door jams, and issues with exterior walls. Staff L also stated that the committee had identified concerns with mildew in the west wing shower room. An interview was conducted with the Administrator on 5/21/19 at 1:21 PM. The Administrator stated the Vice President of resident council told her about the shower room in (MONTH) 2019. She presented the problem to corporate and maintenance scrubbed and cleaned the areas. She called and got a quote for repairs and corporate had placed it on the capital expense report for 2019. A copy of the repair cost estimate was provided. The administration was unable to produce any evidence that the cost was approved, a contractor had been hired or that repair work had begun. (Cross reference F584).

Based on observations, staff interview and policy review, the facility failed to ensure staff follow infection control policies to prevent contamination of catheters for 1 of 2 residents reviewed with catheters. (resident #2) The findings include: Observations of resident #2 were conducted on 5/20/19 at 11:43 AM, 3:54 AM and on 5/21/19 at 9:15 AM, 11:55 AM. The resident was in bed and the catheter bag was on the floor during the observations (photographic evidence obtained). An interview was conducted with the west wing unit manager on 5/22/19 at 8:50 AM. The unit manager observed the catheter bag touching the floor and confirmed the bag should not be touching the floor. Review of the facility policy for urinary catheter care (revised (MONTH) 2014) revealed infection control guidelines to be sure the catheter tubing and drainage bag are kept off the floor.

Based on record review and staff interview, the facility failed to notify a resident's representative in writing when a transfer to the hospital occurred for 1 of 1 resident sampled. (#7) The Findings: Review of the medical record for resident #7 indicated the resident was admitted to the facility on [DATE] and was transferred to the hospital on [DATE] due to an emergent change in medical conidition. Resident #7 was re-admitted to the facility on [DATE]. Further review of resident #7's medical record failed to reveal any evidence that proper written notification to the resident's representative for his transfer to the hospital was made. An interview was conducted with the Social Services Director on 05/23/18 at 2:49PM. She stated that they were not sending notification of transfer to the resident representative or the Ombudsman due to them being informed that this was no longer necessary. She also stated that their Quality Assurance Committee had started a corrective action plan on 5/3/2018 to address the need to start sending these notices to the Ombudsman again; however, the plan did not include notification of the resident representative. She stated that transfer logs would now be sent to the Ombudsman by the fourth of each month per the action plan.

Based on observation, interview, and record review, the facility failed to implement the plan of care for 1 of 3 residents sampled for accidents, #8. Findings include: Resident #8's medical record was reviewed for falls. On 11/12/2016, the resident was found on the floor next to his wheelchair in the bathroom. On 12/4/2016, the resident was found on the bathroom floor again with wheelchair nearby. On 12/13/2016, the resident fell trying to transfer himself from his chair to wheelchair without assistance. The resident's care plan revealed a plan in place for anti-roll backs to his wheelchair at all times due to being at high risk for falls. Resident #8 was observed on 1/23/2017 at 10:50 AM and again at 3:17 PM to be sitting in his wheelchair without anti-roll backs in place. On 1/24/2017 at 09:15 AM and again at 11:15 AM, the resident was observed to be sitting in his wheelchair without anti-roll backs in place. An interview was conducted with Licensed Practical Nurse A on 1/24/2017 at 10:34 AM. She confirmed the resident was a fall risk and frequently tried to get up without assistance. When asked what kind of interventions were in place for the resident, she stated, We put anti-roll backs to his wheelchair. An interview was conducted with Certified Nursing Aid B on 1/24/2017 at 10:45 AM. She confirmed the resident was at risk for falls. She stated he had anti-roll backs to his wheelchair for fall prevention. On 1/24/2017 at 11:15 AM, the surveyor and the Director of Nursing (DON) went to the resident who was sitting in the hallway in his wheelchair. The DON confirmed there were no anti-roll backs in place. (Photographic evidence was obtained)

Based on observation, staff interview, and record review, the facility failed to ensure implementation of interventions necessary to decrease the risk for falls for 1 of 3 residents sampled for accidents, #8. Findings include: Resident #8's medical record was reviewed for falls. On 11/12/2016, the resident was found on the floor next to his wheelchair in the bathroom. On 12/4/2016, the resident was found on the bathroom floor again with wheelchair nearby. On 12/13/2016, the resident fell trying to transfer himself from his chair to wheelchair without assistance. The resident's care plan revealed a plan in place for anti-roll backs to his wheelchair at all times due to being at high risk for falls. The resident had a physician order [REDACTED]. Resident #8 was observed on 1/23/2017 at 10:50 AM and again at 3:17 PM to be sitting in his wheelchair without anti-roll backs in place. On 1/24/2017 at 09:15 AM and again at 11:15 AM, the resident was observed to be sitting in his wheelchair without anti-roll backs in place. An interview was conducted with Licensed Practical Nurse A on 1/24/2017 at 10:34 AM. She confirmed the resident was a fall risk and frequently tried to get up without assistance. When asked what kind of interventions were in place for the resident, she stated, We put anti-roll backs to his wheelchair. An interview was conducted with Certified Nursing Aid B on 1/24/2017 at 10:45 AM. She confirmed the resident was at risk for falls. She stated he had anti-roll backs to his wheelchair for fall prevention. On 1/24/2017 at 11:15 AM, the surveyor and the Director of Nursing (DON) went to the resident who was sitting in the hallway in his wheelchair. The DON confirmed there were no anti-roll backs in place. (Photographic evidence was obtained)