Every finding on record at Briarcliff Health Center of Greenville

Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to implement their abuse policy when CNA B and the ADON failed to report an allegation of abuse reported to them by Resident #2 regarding CNA A mistreating her and Resident #1 on 04/01/2026. This failure could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.Findings include: Record review of the facility's Abuse Investigation and Reporting policy, revised 10/15/2022, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, exploitation, neglect or injury of unknown source is reported, under the direct supervision of the Administrator will assign the investigation to an appropriate individual. 3. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury. 1. Record review of a face sheet dated 04/06/2026 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included closed fracture of the right patella (broken kneecap) and type 2 diabetes mellitus with hyperglycemia (insulin resistance leading to high blood sugars which result in nerve damage cause by prolonged high blood sugar levels). Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #2 required partial/moderate assistance with toileting, showering/bathing, and personal hygiene and supervision or touching assistance with eating. Record review of Resident #2's care plan revised 03/05/2026 indicated she had an ADL self-care performance deficit related to a right patella fracture, falls, lack or coordination, and weakness. Resident #2's care plan indicated she was independent with eating and required assistance with bathing, dressing, transferring, and toilet use. During an interview on 04/06/2026 at 10:38 AM, Resident #2 said there was a nurse who was very rude to her, and she had reported it to the head people. Resident #2 was unable to provide names of whom she reported it to. Resident #2 said she believed it was last Thursday (04/02/2026) or Friday (04/03/2026). Resident #2 said she asked CNA A for her breakfast tray, and she refused to give it to her. Resident #2 said CNA A told her she was her roommate's CNA, but not hers. Resident #2 said later a different nurse brought her tray. Resident #2 said later the same day CNA A asked her roommate if she wanted a shower and her roommate refused, and Resident #2 asked CNA A to change the sheets to her bed and CNA A refused. Resident #2 said she asked a different CNA who was her CNA because she needed her sheets changed, and they told her it was CNA A. Resident #2 said she returned to her room and was in her wheelchair when CNA A entered her room, and she could tell she was mad at her. CNA A did not speak to her and started changing the sheets on her bed and did not change the pillowcases or big blanket. Resident #2 said at that point she wanted to cry because she was asking herself what did I do to her for her to treat me this way. Resident #2 said then her roommate, Resident #1, asked CNA A to put her in bed, CNA A sighed loudly, did not speak to her, picked her roommate up by her brief, and almost dropped her when she picked her up to put her in the bed. Resident #2 said she could tell Resident #1 was scared. Resident #2 said she was frantic because she was afraid her roommate was going to be dropped on the floor, and she was unable to help her roommate. Resident #2 said CNA A adjusted her roommate in the bed and left the room without saying anything to either of them. Resident #2 said she told her roommate she needed to report CNA A for the way she had treated her, but her roommate did not want to report CNA A. Resident #2 said she told her roommate she was going to report CNA A for the way she had treated the both of them because she did not want her back in her room and she was not going to put up with abuse. Resident #2 said she reported what happened to the nurse, and she had not seen CNA A since the day of the incident. 2. Record review of a face sheet dated 04/06/2026 indicated Resident #1 was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic systolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and adult failure to thrive (a condition characterized by significant decline in physical and emotional well-being, often leading to weight loss, decreased appetite, and reduced functional abilities). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for transfers. Record review of Resident #1's care plan revised 04/01/2026 indicated she had an ADL self-care performance deficit related to muscle wasting and lack of coordination and required assistance with transferring. During an interview on 04/06/2026 at 2:31 PM, CNA B said last Wednesday (04/01/2026), when she checked on Resident #2 around 2 PM, she told her she was so glad to see her because CNA A had been very rude and mistreated them (Resident #2 and Resident #1). CNA B said Resident #2 told her CNA A did not want to give her her tray, change her sheets, give her a shower, and almost dropped Resident #1 when she transferred her to the bed. CNA B said she told Resident #2 she was going to get the ADON to report it to her. CNA B said she told the ADON, and the ADON went to talk to Resident #2. CNA B said she was not going to put up with any of the staff being abusive to the residents. CNA B said abuse should be reported to the nurse or the DON. During an interview on 04/06/2026 at 3:16 PM, the ADON said CNA B told her to talk to Resident #2 because Resident #2 told her the aide was rough with her roommate. Resident #2 reported to her that CNA A had been rough with her roommate, Resident #1, and felt like she threw her in the bed. The ADON said Resident #2 did not report CNA A mistreating her or anything about herself. The ADON said it was only about her roommate, Resident #1. The ADON said she asked Resident #1 if CNA A had hurt her, and Resident #1 did not say anything, just shook her head no. The ADON said allegations of abuse should be reported immediately to the Administrator. The ADON said she did not report the allegation made to the Administrator because she thought she had addressed the situation, and she was not going to schedule CNA A on Resident #1's and Resident #2's hall. The ADON said not reporting allegations of abuse placed the residents at risk for further abuse. During an interview on 04/06/2026 at 3:41 PM, the Administrator said she was just notified by the ADON of a statement Resident #2 made last week. The Administrator said the ADON told her Resident #2 reported to her CNA A was not polite, had an attitude, and sounded like Resident #1 was thrown into the bed by CNA A. The Administrator said the ADON asked Resident #1 what happened, and Resident #1told the ADON nothing happened. The Administrator said today (04/06/2026), she went to talk to Resident #2 and Resident #1. Resident #2 told her she saw CNA A pick up Resident #1 by the brief and throw her in the bed, and she asked CNA A for her breakfast tray and she did not give it to her. Resident #1 told her when CNA A went into the room, she had an attitude and did not speak to her. Resident #1 said CNA A picked her up to put her in the bed and almost dropped her. The Administrator said Resident #1 did not remember all the incident and told her whatever Resident #2 said happened was what happened. The Administrator said CNA A would be terminated because she had already been suspended a couple of weeks ago related to the way she talked to the residents and was educated on customer service. The Administrator said when Resident #2 made the allegations they should have been reported to her immediately. She said she expected all her staff to report allegations of abuse immediately so she could investigate the allegations made. The Administrator said she expected the staff to follow the facility's policy and any allegation of abuse be reported to her, the abuse coordinator. The Administrator said it was important for them to notify her so she could investigate and ensure the proper procedures were followed pending the investigation to protect the residents. The Administrator said not reporting abuse and neglect immediately could result in future issues with the residents and that employee. During an interview on 04/06/2026 at 4:52 PM, CNA A said she did not refuse to give Resident #2 her tray or give her a shower (on 04/01/2026). CNA A said she had not taken care of Resident #1 or Resident #2 in the past, and she did not know when Resident #2's shower days were. CNA A said when Resident #2 requested a shower she told her she did not know if it was her shower day that she would go check and give her one later, but she did not go back to give her a shower. CNA A said a different CNA gave her the shower later that day. CNA A said she did not remember if she had given Resident #2 her tray or if it was someone else. CNA A said she changed Resident #2's linens when she was asked to change them. CNA A said when she provided care to Resident #1 and Resident #2, she explained to both of them what she was doing. CNA A said other residents complained about her not talking enough to them. She said she was more closed off when she did not know the residents, but she tried to tell them what she was doing. CNA A said some of the residents reported her because she was not happy enough for them. CNA A said she was not rude or rough with Resident #1 or Resident #2. CNA A said when she transferred Resident #1 from her wheelchair to her bed, she did not use a gait belt. CNA A said she grabbed her from the back of her pants to transfer her into her bed. CNA A said she did not almost drop Resident #1. CNA A said Resident #1 did not get hurt and she was not rushing when she helped her. During an interview on 04/06/2026 at 5:28 PM, Resident #1 said she did not remember any CNAs transferring her inappropriately or mistreating her. During an interview on 04/06/2026 at 5:41 PM, the DON said she received complaints about CNA A's attitude from the residents, but it was more of customer service issues not any abuse allegations. The DON said verbal education was provided to CNA A on customer service. The DON said any allegation of abuse should be reported to the abuse coordinator, the Administrator, immediately. The DON said not reporting allegations of abuse immediately placed the residents at risk for further issues and for the same thing to happen to them. The DON said not following the facility's abuse policy placed the residents at risk for abuse.

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for abuse and neglect reporting. The facility failed to ensure CNA B and the ADON reported an allegation of abuse to the Administrator immediately when Resident #2 reported to them CNA A mistreated her and Resident #1 on 04/01/2026. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.Findings included: 1. Record review of a face sheet dated 04/06/2026 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included closed fracture of the right patella (broken kneecap) and type 2 diabetes mellitus with hyperglycemia (insulin resistance leading to high blood sugars which result in nerve damage cause by prolonged high blood sugar levels). Record review of Resident #2's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #2 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #2 required partial/moderate assistance with toileting, showering/bathing, and personal hygiene and supervision or touching assistance with eating. Record review of Resident #2's care plan revised 03/05/2026 indicated she had an ADL self-care performance deficit related to a right patella fracture, falls, lack or coordination, and weakness. Resident #2's care plan indicated she was independent with eating and required assistance with bathing, dressing, transferring, and toilet use. During an interview on 04/06/2026 at 10:38 AM, Resident #2 said there was a nurse who was very rude to her, and she had reported it to the head people. Resident #2 was unable to provide names of whom she reported it to. Resident #2 said she believed it was last Thursday (04/02/2026) or Friday (04/03/2026). Resident #2 said she asked CNA A for her breakfast tray, and she refused to give it to her. Resident #2 said CNA A told her she was her roommate's CNA, but not hers. Resident #2 said later a different nurse brought her tray. Resident #2 said later the same day CNA A asked her roommate if she wanted a shower and her roommate refused, and Resident #2 asked CNA A to change the sheets to her bed and CNA A refused. Resident #2 said she asked a different CNA who was her CNA because she needed her sheets changed, and they told her it was CNA A. Resident #2 said she returned to her room and was in her wheelchair when CNA A entered her room, and she could tell she was mad at her. CNA A did not speak to her and started changing the sheets on her bed and did not change the pillowcases or big blanket. Resident #2 said at that point she wanted to cry because she was asking herself what did I do to her for her to treat me this way. Resident #2 said then her roommate, Resident #1, asked CNA A to put her in bed, CNA A sighed loudly, did not speak to her, picked her roommate up by her brief, and almost dropped her when she picked her up to put her in the bed. Resident #2 said she could tell Resident #1 was scared. Resident #2 said she was frantic because she was afraid her roommate was going to be dropped on the floor, and she was unable to help her roommate. Resident #2 said CNA A adjusted her roommate in the bed and left the room without saying anything to either of them. Resident #2 said she told her roommate she needed to report CNA A for the way she had treated her, but her roommate did not want to report CNA A. Resident #2 said she told her roommate she was going to report CNA A for the way she had treated the both of them because she did not want her back in her room and she was not going to put up with abuse. Resident #2 said she reported what happened to the nurse, and she had not seen CNA A since the day of the incident. 2. Record review of a face sheet dated 04/06/2026 indicated Resident #1 was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic systolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and adult failure to thrive (a condition characterized by significant decline in physical and emotional well-being, often leading to weight loss, decreased appetite, and reduced functional abilities). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for transfers. Record review of Resident #1's care plan revised 04/01/2026 indicated she had an ADL self-care performance deficit related to muscle wasting and lack of coordination and required assistance with transferring. During an interview on 04/06/2026 at 2:31 PM, CNA B said last Wednesday (04/01/2026), when she checked on Resident #2 around 2 PM, she told her she was so glad to see her because CNA A had been very rude and mistreated them (Resident #2 and Resident #1). CNA B said Resident #2 told her CNA A did not want to give her her tray, change her sheets, give her a shower, and almost dropped Resident #1 when she transferred her to the bed. CNA B said she told Resident #2 she was going to get the ADON to report it to her. CNA B said she told the ADON, and the ADON went to talk to Resident #2. CNA B said she was not going to put up with any of the staff being abusive to the residents. CNA B said abuse should be reported to the nurse or the DON. During an interview on 04/06/2026 at 3:16 PM, the ADON said CNA B told her to talk to Resident #2 because Resident #2 told her the aide was rough with her roommate. Resident #2 reported to her that CNA A had been rough with her roommate, Resident #1, and felt like she threw her in the bed. The ADON said Resident #2 did not report CNA A mistreating her or anything about herself. The ADON said it was only about her roommate, Resident #1. The ADON said she asked Resident #1 if CNA A had hurt her, and Resident #1 did not say anything, just shook her head no. The ADON said allegations of abuse should be reported immediately to the Administrator. The ADON said she did not report the allegation made to the Administrator because she thought she had addressed the situation, and she was not going to schedule CNA A on Resident #1's and Resident #2's hall. The ADON said not reporting allegations of abuse placed the residents at risk for further abuse. During an interview on 04/06/2026 at 3:41 PM, the Administrator said she was just notified by the ADON of a statement Resident #2 made last week. The Administrator said the ADON told her Resident #2 reported to her CNA A was not polite, had an attitude, and sounded like Resident #1 was thrown into the bed by CNA A. The Administrator said the ADON asked Resident #1 what happened, and Resident #1told the ADON nothing happened. The Administrator said today (04/06/2026), she went to talk to Resident #2 and Resident #1. Resident #2 told her she saw CNA A pick up Resident #1 by the brief and throw her in the bed, and she asked CNA A for her breakfast tray and she did not give it to her. Resident #1 told her when CNA A went into the room, she had an attitude and did not speak to her. Resident #1 said CNA A picked her up to put her in the bed and almost dropped her. The Administrator said Resident #1 did not remember all the incident and told her whatever Resident #2 said happened was what happened. The Administrator said CNA A would be terminated because she had already been suspended a couple of weeks ago related to the way she talked to the residents and was educated on customer service. The Administrator said when Resident #2 made the allegations they should have been reported to her immediately. She said she expected all her staff to report allegations of abuse immediately so she could investigate the allegations made. The Administrator said she expected the staff to follow the facility's policy and any allegation of abuse be reported to her, the abuse coordinator. The Administrator said it was important for them to notify her so she could investigate and ensure the proper procedures were followed pending the investigation to protect the residents. The Administrator said not reporting abuse and neglect immediately could result in future issues with the residents and that employee. During an interview on 04/06/2026 at 4:52 PM, CNA A said she did not refuse to give Resident #2 her tray or give her a shower (on 04/01/2026). CNA A said she had not taken care of Resident #1 or Resident #2 in the past, and she did not know when Resident #2's shower days were. CNA A said when Resident #2 requested a shower she told her she did not know if it was her shower day that she would go check and give her one later, but she did not go back to give her a shower. CNA A said a different CNA gave her the shower later that day. CNA A said she did not remember if she had given Resident #2 her tray or if it was someone else. CNA A said she changed Resident #2's linens when she was asked to change them. CNA A said when she provided care to Resident #1 and Resident #2, she explained to both of them what she was doing. CNA A said other residents complained about her not talking enough to them. She said she was more closed off when she did not know the residents, but she tried to tell them what she was doing. CNA A said some of the residents reported her because she was not happy enough for them. CNA A said she was not rude or rough with Resident #1 or Resident #2. CNA A said when she transferred Resident #1 from her wheelchair to her bed, she did not use a gait belt. CNA A said she grabbed her from the back of her pants to transfer her into her bed. CNA A said she did not almost drop Resident #1. CNA A said Resident #1 did not get hurt and she was not rushing when she helped her. During an interview on 04/06/2026 at 5:28 PM, Resident #1 said she did not remember any CNAs transferring her inappropriately or mistreating her. During an interview on 04/06/2026 at 5:41 PM, the DON said she received complaints about CNA A's attitude from the residents, but it was more of customer service issues not any abuse allegations. The DON said verbal education was provided to CNA A on customer service. The DON said any allegation of abuse should be reported to the abuse coordinator, the Administrator, immediately. The DON said not reporting allegations of abuse immediately placed the residents at risk for further issues and for the same thing to happen to them. The DON said not following the facility's abuse policy placed the residents at risk for abuse. Record review of the facility's Abuse Investigation and Reporting policy, revised 10/15/2022, indicated, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Role of the Administrator: 1. If an incident or suspected incident of resident abuse, mistreatment, exploitation, neglect or injury of unknown source is reported, under the direct supervision of the Administrator will assign the investigation to an appropriate individual. 3. The Administrator will suspend immediately any employee who has been accused of resident abuse, pending the outcome of the investigation. 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but not later than:a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury.

Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure CNA A performed a proper transfer, when she grabbed Resident #1 from the pants to transfer her from her wheelchair to her bed and did not use a gait belt on 04/01/2026. This failure could place residents at risk for falls, injuries, and a decreased quality of life. Findings included: Record review of a face sheet dated 04/06/2026 indicated Resident #1 was an [AGE] year-old female originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included chronic systolic congestive heart failure (heart is unable to pump enough force to push enough blood into circulation) and adult failure to thrive (a condition characterized by significant decline in physical and emotional well-being, often leading to weight loss, decreased appetite, and reduced functional abilities). Record review of Resident #1's Comprehensive MDS assessment dated [DATE] indicated she was understood by others and understood others. The MDS assessment indicated Resident #1 had a BIMS score of 15, which indicated her cognition was intact. The MDS assessment indicated Resident #1 was dependent on staff for transfers. Record review of Resident #1's care plan revised 04/01/2026 indicated she had an ADL self-care performance deficit related to muscle wasting and lack of coordination and required assistance with transferring. The care plan did not address the type of equipment required to transfer Resident #1. During an interview on 04/06/2026 at 3:41 PM, the Administrator said Resident #1 told her CNA A picked her up to put her in the bed and almost dropped her. The Administrator said Resident #1 did not remember all the incident. During an interview on 04/06/2026 at 4:52 PM, CNA A said on 04/01/2026, when she transferred Resident #1 from her wheelchair to her bed, she did not use a gait belt. CNA A said she grabbed Resident #1 from the back of her pants to transfer her into her bed. CNA A said she did not almost drop Resident #1. CNA A said she should have used a gait belt when she transferred Resident #1 to her bed. CNA A said it was important to use a gait belt for transfers for the residents' safety. CNA A said not using a gait belt when transferring Resident #1 could have resulted in Resident # 1 getting hurt. CNA A said Resident #1 did not get hurt and she was not rushing when she helped her. During an interview on 04/06/2026 at 5:41 PM, the DON said Resident #1 required assistance of one person for transfers, and a gait belt should be used when transferring her. The DON said she was responsible for ensuring the CNAs were properly transferring the residents, and this was monitored by competencies she completed with the ADONs assistance. The DON said not using a gait belt during transfers placed the residents at risk for falls and injuries. During an interview on 04/06/2026 at 5:56 PM, the Administrator said she expected the staff to follow the policies and procedures and use a gait belt for one person transfers. The Administrator said nursing administration, the DON or designee, were responsible for ensuring the staff properly transferred the residents. The Administrator said if residents were not transferred properly it could result in an injury. Record review of the facility's policy titled, Safe Lifting and Movement of Residents, revised September 8, 2024, indicated, In order to protect the safety and well-being of staff and residents, and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents. 2. Manual lifting of residents shall be eliminated when feasible. You may need to utilize manual lifting in situations such as emergencies. 4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices as necessary.

Based on interview and record review the facility failed to ensure residents were free from significant medication errors for 1 of 6 residents (Resident #1) reviewed for significant medication errors, in that: The facility administered the incorrect insulin on 03/12/2026 based on a failed medication reconciliation upon Resident #1's readmission resulting in a low blood glucose reading of 35. The facility should have administered Insulin Glargine (a long acting medication use to treat diabetes mellitus and help regulate blood glucose levels) 12 units daily and incorrectly administered Tresiba (an ultra-long-acting insulin). The facility failed to ensure nursing staff were able to locate the emergency kit with glucagon medication (an emergency medication to treat severe hypoglycemia or low blood glucose level) to treat Resident #1's blood glucose level of 35 until the EMS team arrived to provide emergency intervention. An IJ was identified on 03/26/2026. The IJ Template was provided to the facility on [DATE] at 2:40 p.m. The IJ was removed on 03/27/2026 at 11:45 a.m. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure placed resident at risk for adverse side effects to include decrease in blood glucose levels resulting in increased confusion, loss of consciousness or life-threatening complications such as brain or organ damage or even death. Findings include: Record review of Resident #1's face sheet, dated 03/26/2026, revealed an [AGE] year-old male originally admitted [DATE] and discharged on 03/13/26 due to hypoglycemic episode with a blood glucose level of 35 and re-admitted on [DATE] after being treated for a hypoglycemia episode. Resident #1 was re-hospitalized on [DATE] after a fall and remained in the hospital during this survey. Diagnoses included Diabetes Type II (a chronic metabolic disorder where the body develops insulin resistance and cannot properly regulate blood sugar level), Chronic Obstructive Pulmonary Disease (a progressive lung disease that restricts airflow), dysphagia (difficulty swallowing), chronic kidney disease ( an irreversible loss of kidney function, preventing the kidneys from properly filtering the blood), atherosclerotic heart disease (heart disease involving the buildup of plaque, fat and cholesterol which narrows the blood vessels and restricts blood flow), atrial fibrillation (a heart rhythm disorder), gout (a painful form if inflammatory arthritis). Record review of Resident #1's Baseline Care Plan, revised 02/04/2026, revealed Resident #1 had diabetes mellitus and was receiving insulin. Record review of Resident #1's re-admission MDS, dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further of review of the readmission MDS dated [DATE] revealed Resident #1 presented with lower extremity range of motion impairment, required supervision with eating; maximum assistance with upper body dressing and bathing; and was dependent in bed mobility, transfers and lower body dressing. Record review of Resident #1's hospital discharge instructions, dated [DATE] revealed an order for 12 units Insulin Glargine (a long-acting insulin) one time a day and Insulin regular (a short acting insulin) to be administered via sliding scale before meals. Additional discharge instructions were to stop taking Insulin degludec (trade name Tresiba, an ultra-long-acting insulin) 40 units one time a day. Record review of Resident #1's March 2026 Medication Administration Record revealed the facility did not transcribe an order for 12 units Insulin Glargine (long-acting insulin) one time a day and Insulin Regular (short acting) to be administered via sliding scale. Record review of Resident #1's medication administration record for 03/01/2026-03/31/2026 revealed the facility failed to accurately reconcile Resident #1's hospital discharge instructions on readmission and continued with orders for Tresiba (Insulin) 40 units at the hours of sleep. On 03/12/2026 at the hour of sleep, Resident #1 had a blood glucose level of 135 and received 40 units of Tresiba (Insulin). At 5:10 a.m. on 03/13/2026, Resident #1 had a blood glucose level of 35. Record review of Resident #1's nursing progress noted dated 03/13/2026 revealed Resident #1 received nursing intervention for hypoglycemia (low blood sugar) to include dissolved sugar packets in water and juice until EMS arrived and administered Dextrose 50 (a concentrated carbohydrate solution used to treat severe hypoglycemia / low blood sugar) and transferred Resident #1 to the hospital. An interview with the responsible party was attempted on 03/26/26 at 11:45 a.m. and was unsuccessful. In an interview on 03/26/2026 at 11:45 a.m., LVN A stated she completed all of the admission assessments on 03/12/2026 on the re-admission of Resident #1 but did not review the hospital discharge medication list. LVN A stated that as time permits, two nurses split the admission process for new and re-admissions and the medication review for Resident #1's re-admission on [DATE] was completed by the charge nurse. In an interview on 03/26/26 at 12:05 p.m., LVN B revealed that he was the charge nurse when Resident #1 re-admitted on [DATE] and that he completed the medication reconciliation. LVN B acknowledged that he failed to accurately reconcile the medications and accurately transcribe the correct insulin orders. LVN #B stated he was notified of this transcription error on 03/17/2026 at 2:20 p.m. by the DON, at which time he received a written counseling related to transcription. LVN #B stated that this error could result in harm to the resident by lowering her blood sugar causing a hypoglycemic episode. In an interview on 03/26/26 at 12:23 p.m., RN C stated that she followed the physicians orders on 03/12/2026 when she checked Resident #1's blood sugar at the hours of sleep and administered 40 units of Tresiba (insulin). RN C stated she was aware that Resident #1 has re-admitted that day, but the re-admission and medication reconciliation was completed by the previous shift nurse. RN C stated that when she checked Resident #1's blood glucose level at 5:10 a.m., blood glucose level was at a low level of 35. RN C stated that Resident #1 was alert, about to sit upright and had no difficulty swallowing. RN C stated she administered sugar dissolved in peach juice and water until EMS arrived. RN C stated she was unable to locate the facility emergency kit with glucagon injection or gel. RN C stated she notified the physician, responsible party and DON of change of condition and subsequent hospital transfer. In an interview on 03/26/2026 at 1:10 p.m., the DON stated she was notified by RN C of the low blood sugar for Resident #1 and hospital transfer on 03/13/26 at approximately 5:30 a.m. The DON stated that glucagon gel and injection are available in the emergency kit which is located in the medication room, and that she was not sure why the floor staff were unable to locate it to administer to Resident #1. The DON was able to locate the emergency kit after searching for 45 minutes and surveyor confirmed that there was a tube of glucagon gel and one injection of glucagon in the emergency kit. The DON stated that while Resident #1 was hospitalized , they reviewed the hospital records, and it was confirmed that the LVN B failed to complete an accurate medication reconciliation when Resident #1 re-admitted on [DATE] which resulted in the low blood glucose level on the morning of 03/13/2026. The DON stated she met with LVN B and issued a written disciplinary action and provided Inservice and training on the importance of accurate transcription and medication reconciliation. The DON stated that she expects all nurses to complete the medication reconciliation for all admissions accurately and to ensure that transcription is done correctly. The DON stated that she expects all nursing staff to confirm the readmission orders with the physician and transcribe them to the EMR to ensure accurate medication administration. In an interview on 03/27/2026 at 11:08 a.m., the attending physician stated he did not recall exactly what Resident #1's admitting orders were but recalled he did ask the facility to continue / follow hospital orders and would evaluate the resident at next visit to the facility. The physician stated that he was the facility medical director and there were standing orders in place for the use of glucagon in the event of a low blood sugar reading as indicated. The physician stated he expects the nurses to accurately review the hospital discharge instructions and call him with accurate information when the orders are verified. The physician stated failure to accurately administer insulins could result in hyperglycemia (high blood glucose levels) or hypoglycemia (low blood glucose levels) that could cause harm to the residents. Record review of the facility policy named, Reconciliation of Medications on Admission, revised July 2025, revealed, Purpose: The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes and dosages upon admission or readmission to the facility. and, General Guidelines, 1. Medication reconciliation is the process of comparing pre-discharge medications to post-discharge medications by creating a list.to ensure that medications, routes and dosages have been communicated to the Attending Physician and care team. Record review of the facility policy named, Adverse Consequences and Medication Errors, revised April 2014, revealed, 5. A medication error is defined as .the administration of drugs which is not in accordance with professional standards and 6. Examples of medication errors include: a. Omission - a drug is ordered but not administered; and f. Wrong drug (e.g. vibramycin ordered, vancomycin given). This was determined to be an Immediate Jeopardy (IJ) on 03/26/2026 at 2:10 p.m. The Administrator and the DON were notified and provided the IJ Template on 03/26/2026 at 2:42 p.m., and a Plan of Removal was requested. The following Plan of Removal submitted by the facility was accepted on 03/27/2026 at 11:30 a.m. Tag Cited: F760 Alleged Issues:The facility failed to ensure Resident #1 was free from significant medication errors when the facility failed to administer Insulin Glargine medication according to hospital discharge instructions as ordered by the physician and failed to administer emergency medicine for low blood sugar due to staff not being able to locate the emergency medicine kit. Plan of Removal 1. Immediate ActionsThe Medical Director was notified by the DON on 03/26/2026 of the Immediate Jeopardy. Resident #1 was hospitalized at time of this survey and facility interventions were completed based on this identified concern. The DON completed a chart audit on all residents with a diagnosis of diabetes mellitus on 03/26/2026 to ensure all residents had orders in place for glucagon injection or gel as needed for low blood sugar and signs of hypoglycemia. A Glucagon Audit Sheet was implemented to be completed daily by charge nurse to ensure glucagon is available in the emergency kit. The tracker will be monitored by the DON or ADON daily in the clinical meeting Monday thru Friday. On Saturday and Sunday, the audit sheet will be monitored by the weekend supervisor or designee. The DON completed an audit on 03/27/2026 at 9:15 a.m. to confirm emergency glucagon orders were in place for all residents with a diagnosis of Diabetes Mellitus. The DON located the glucagon medication in the emergency kit in the medication room and re-labeled it with a large red paper to allow for it to be easily located. The DON implemented a policy that two nurses will review the medication reconciliation for all new admissions and readmissions. 2. Education An in-service was conducted with DON and ADON by the Regional Nurse director on 03/26/2026 at 2:00 p.m. in regard to the Diabetes protocol and the reconciliation of medications on all admissions. An in-service was conducted on 03/26/2026 from 2:45 p.m. - 4:00 p.m. by the DON for all full time and part time nurses on the importance of accuracy for medication reconciliation for new admissions and readmissions, the location of the emergency kit supply of glucagon and hypoglycemia / diabetes protocols. The DON/ADON will educate all new nursing staff of these same trainings before they are allowed to work. An in-service was conducted on 03/27/2026 at 5:50 a.m. by the DON for the Weekend Supervisor on reviewing the medication reconciliation for all new and re-admissions and the location of the emergency kit supply of glucagon. 3. Monitoring The DON or designee will monitor each new admissions physicians orders to ensure accurate transcription at the daily clinical meeting Monday thru Friday. The weekend supervisor or designee will monitor the physicians orders on Saturday and Sunday. The Regional Clinical Nurse will monitor to ensure the plan of removal education remains in place on the weekly Quality Improvement reviews. The Administrator will ensure the clinical meeting IDT members review the physician's orders for all new and re-admissions at the clinical meeting Monday-Friday and review the effectiveness of this system at the monthly QAPI meeting. 4. Administrator verified QAPI meeting was completed with a Performance Improvement Plan in place in conjunction with this Plan of Removal. The surveyor monitored completeness of POR criteria as evidenced by:Reviewed all training and education provided per POR to ensure 22 of 22 licensed nurses had completed the training and obtained verbal verification for all licensed staff in the facility on 03/27/2026 that training was received and understood. The surveyor ensured 22 of 22 licensed nurses were able to demonstrate the location of the emergency kit containing glucagon by observation or phone interview. Observed emergency kit with glucagon in the medication room with new red labels for easier identification.Observed chart audit of emergency kit for glucagon.Verified that two nurses will be checking new and re-admission orders thru interview for 22 of 22 licensed nurses.Observed sign in sheet for QAPI meeting held 03/27/2026 with Performance Improvement Plan. The Administrator was informed that the Immediate Jeopardy was removed on 03/27/2026 at 11:45 a.m. The facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation and interview the facility failed to ensure drugs and biological's used in the facility were labeled in accordance with currently accepted professional principles and the expiration date when applicable for 1 of 4 medication carts (A hall nurse medication cart) reviewed for labeling and storage, in that:The facility failed to label over the counter (OTC) eye drops with the name of the specific resident it was ordered for on [DATE].This failure could place residents who receive medications to have adverse reactions or cross contamination.Findings included:During an observation on [DATE] at 11:30 am, the medication cart for hall A had an OTC bottle of Sodium Chloride Hypertonicity ophthalmic solution 5% that was opened and unlabeled.During an interview on [DATE] at 11:40 am, LVN E said she was not sure what resident the eye drops belonged to. She said the nurses were responsible for labeling the OTC eyes drops with the residents name and date opened to ensure they were not used on multiple residents. She said the nurses should be checking their carts each shift and before administering any medication to ensure the medication was for the correct resident, not expired and labeled correctly. She said that labeling was to prevent cross contamination. During an interview on [DATE] at 11:44 am, the DON said that she and the ADON checked the medication carts periodically for unlabeled medications but there was not a set schedule. She said the pharmacist checked all the carts monthly and removed any medications that were unlabeled. She said that unlabeled eye drops could cause cross contamination and infections. During an interview on [DATE] at 10:47 am, the Administrator said that the nurses and pharmacists were responsible for ensuring all medications were labeled and stored correctly. She said the nurses should be checking the medication carts and other storage areas regularly and especially before administering any medication. She said that eye drops should be labeled with resident name and date opened to ensure single resident use to prevent chance of spreading infections. She said she expected the facility policies for medication storage, labeling and administration was always followed.Record review of a facility policy titled Labeling of Medication Containers dated 2001 indicated, . medications maintained in the facility are properly labeled in accordance with current state and federal guidelines and regulations .

Based on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 7 residents (Resident #72) reviewed for infection control.The facility failed to ensure CNA D and CNA F followed contact precautions when incontinent care was provided to Resident #72 on 2/10/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.Findings included:Record review of an admission Record for Resident #72 dated 2/10/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of colostomy status (surgically created opening (stoma) connecting the colon to the abdominal wall, allowing waste to bypass a damaged or diseased part of the bowel), anorexia nervosa (an eating disorder that involves severe calorie restriction low body weight), and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #72 dated 12/19/2025 indicated she had moderate impairment in thinking with a BIMS score of 8. She was dependent on staff for toileting hygiene. She was always incontinent of urine/bowel. Record review of a care plan for Resident #72 dated 2/8/2025 indicated she was on isolation-contact isolation-based precaution MRSA with interventions included PPE defined by the CDC required before entering a contact precautions designated room is always gloves and a gown. Record review of active physician orders for Resident #72 dated 2/10/2026 indicated an order for contact isolation for MRSA in urine until antibiotic is finished, every shift with a start date of 2/8/2026.During an observation on 2/10/2026 at 10:50 AM, CNA D and CNA F were in the room of Resident #72. The resident's door had a sign for contact precautions and PPE in the hallway in a container that had gowns and gloves. Both staff entered the room, sanitized their hands, and applied gloves. Neither staff donned a gown during incontinent care that was provided.During an interview on 2/10/2026 at 10:59 am, CNA F said she had been employed at the facility since 2014. She said she worked D Hall where Resident #72 resided. When asked about the care she provided to Resident #72 if she should have done anything differently, she said the resident was on contact precautions and should have worn a gown. She said she had been off the past couple of days and when she last worked Resident #72 was not on contact precautions. She said she did not pay attention that the resident had a sign on her door along with PPE in a container in the hallway. She said there was a risk of infections if staff did not wear gowns if on contact precautions when care was provided.Record review of a competency skills check off on 10/25/2025 indicated CNA F was successful with donning PPE for contact precautions and incontinent care with a female resident.During an interview on 2/10/2026 at 1:22 pm, CNA D said she had been employed at the facility for 5 years. She said during the care provided to Resident #72 they should have worn a gown during care because the resident was on contact precautions and did not notice at the time the sign or PPE in the hallway. She said there was a risk of infections if staff did not wear gowns for residents who were on contact precautions.Record review of a competency skills check off on 10/2/2025 indicated CNA D was successful with donning PPE for contact precautions and incontinent care with a female resident.During an interview on 2/11/2026 at 10:34 am, the ADON said she was responsible for training staff on infection control on hire and yearly thereafter and as needed if issues arise. She said if a resident was on contact precautions the staff should wear a gown and gloves. She said residents could be at risk of infections if staff did not follow infection control practices.During an interview on 2/11/2026 at 10:38 am, the DON said she had been in the position since December 1, 2025. She said she along with the ADON was responsible for conducting in-services with the staff and competency evaluations. She said she was made aware of CNA D and CNA F who provided care to Resident #72 when they did not follow infection control measures. She said Resident #72 was on contact isolation for an infection in her urine and when staff provided care, they should wear a gown and gloves. She said she planned to provide 1:1 training with CNA D and CNA F. She said if staff did not follow infection control measures residents could be at risk for spreading infections.During an interview on 2/11/2026 at 10:42 am, the Administrator said the DON and ADON was responsible for training staff on infection control procedures and policies. She said residents who were on contact precautions staff should wear gowns and gloves when care was provided. She said if staff did not follow infection control measures, then residents could be at risk for infections. She said they planned to do more monitoring on pericare along with more frequent in-servicing.Record review of a facility policy titled Isolation-Categories of Transmission-Based Precautions revised March 20, 2025 indicated, .Contact Precautions 8. Staff and visitors wear disposable gown upon entering the room and remove before leaving the room

Based on observations, interviews, and record review, the facility failed to develop a person-centered comprehensive care plan to address medical needs for 1 of 5 residents (Resident #4) reviewed for comprehensive care plans.The facility failed to ensure Resident #4's comprehensive care plan was revised to reflect current transfer status of requiring a mechanical lift. This failure could place residents at increased risk of falls, injuries, and a decreased quality of life.Findings included:Record review of Resident #4's facility face sheet, dated 2/10/2026, indicated Resident #4 was a [AGE] year-old male, admitted [DATE], with diagnoses of cerebral infarction (stroke) and diabetes (increased glucose in the blood).Record review of Resident #4's quarterly MDS assessment, dated 01/29/2026, indicated Resident #4 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident #4's comprehensive care plan, revision date 02/05/2026, indicated Resident #4's comprehensive care plan did not reflect the current transfer status of requiring a mechanical lift on admission [DATE] or on revision date 02/05/2025.Record review on 02/10/2026 of Resident #4's order summary report revealed Resident #4 had an order written on 10/24/2025 for out of bed twice daily and as tolerated two times a day for pain. There was no order related to Resident #4's use of mechanical lift.During an interview on 02/10/2026 at 12:16 PM, CNA B said she had worked at the facility for 9 years and she does not look at a Kardex to find out what kind of transfer requirements are ordered for the residents. She relies on verbal reports from the other CNAs and charge nursesfor communication of correct lift requirements. CNA B said Resident #4 required a mechanical lift for transfers since he was dependent for all transfers. During an interview 02/11/2026 at 9:00 AM, MDS Nurse A said that there was no transfer status on Resident #4's admission care plan or his revised care plan and she would correct it to reflect two persons transfers with a mechanical lift. She said it appeared that the admission nurse clicked the transfer status but then deleted the transfer status, leaving it blank. She said not knowing proper transfer status could cause injuries if the correct transfer process was not followed. During an interview on 02/11/2026 at 9:15 AM, the DON said not having the correct transfer status on the care plan could cause injury if the staff were not aware of what was required for safety. During an interview on 02/11/2026 at 9:30 AM, the Administrator said not having the correct transfer status on the care plan could possibly cause injury to a resident if the staff was not aware of what transfer status was required.Record Review of a Facility policy dated 01/2025 titled:Care Plans, Comprehensive Person-Centered Policy StatementA comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.b. Describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment;(2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care.11.Asessments of residents are ongoing and care plans are revised as information about the residents and the residents' condition change.12.The interdisciplinary team reviews and updates the care plan

Based on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 2 of 20 residents reviewed for quality of care. (Resident # 4 and Resident # 64)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's # 4 and # 64.This failure could result in a loss of quality of life due to injuries.Findings included:1. Record review of Resident # 4's face sheet, dated 2/10/2026, indicated Resident # 4 was a [AGE] year-old male, admitted [DATE], with diagnoses of cerebral infarction (stroke) and diabetes (increased glucose in the blood).Record review of Resident # 4's quarterly MDS assessment, dated 01/29/2026, indicated Resident # 4 had a BIMS of 00 indicating severely impaired cognition, was dependent on staff for assistance with all ADLs, used a wheelchair, and had functional limitation of range of motion to both upper and lower extremities.Record review of Resident # 4's comprehensive care plan, revision date 02/05/2026, indicated Resident #4's care plan did not reflect the current transfer status of requiring a mechanical lift.Record review on 02/10/2026 of Resident # 4's order summary report dated 02/10/2026 revealed Resident # 4 had an order written on 10/24/2025 for out of bed twice daily and as tolerated two times a day for pain. There was no order related to Resident # 4's transfer status or use of mechanical lift.During an observation and interview on 02/09/2026 at 12:48 pm, Resident # 4 was sitting in a high back wheelchair in the hallway outside his room. Resident # 4 had a lift sling with straps faded in color, light pink for red, strap green or blue is white with light green stitching. CNA C said she had training on mechanical lift transfers and watching for rips and tear threads coming unsewn on the slings used for transfers. CNA C was not sure about the faded colors on the straps. She said she would ask her nurse about taking the sling out of service.During an observation on 02/10/2026 at 08:00 am, the same bleached mechanical sling was on Resident # 4's wheelchair ready for use.2. Record review of Resident # 64's face sheet revealed Resident # 64 was an [AGE] year-old female that admitted on [DATE] with a diagnosis of radiculopathy (pinched nerve in the spine). Record review of Resident # 64's admission MDS assessment dated [DATE] revealed Resident # 64 had a BIMS of 10 indicating moderate cognitive impairment and required maximum assistance with transfers. Record review of Resident # 64's comprehensive care plan dated 1/21/2026 revealed Resident # 64 had an ADL deficit and was dependent on staff for transfer. During an observation and interview on 2/9/2026 at 12:38 pm, Resident # 64 was observed in her room sitting in a wheelchair and had a lift sling under her. The sling's loops were frayed and torn. She said that she could stand but the facility must use a mechanical lift sometimes when she was weak. During an observation on 2/10/2026 at 9:15 am, Resident # 64 had a mechanical lift sling in her room that had frayed and torn loops. During an observation and interview on 2/10/2026 at 9:30 am, Resident # 64 was observed in the therapy room with no mechanical lift sling under her. She said she was strong this morning and they did not have to use the mechanical lift to get her up today. During an interview on 2/10/2026 at 9:48 am, CNA D said she was assigned to Resident # 64, and she required assistance x 1 for transfers. She said this morning she was good and stood up and transferred well but there were times in the afternoons that she was weaker, and a mechanical lift was used. She said before using a mechanical lift, the lift and sling were inspected for safety. The mechanical slings should be free of rips and tears and if they were not in good repair they should be given to the nurse and a new one obtained. She said using a frayed mechanical lift sling could cause a resident to fall and become injured. During an interview on 02/10/2026 at 8:15 am, Laundry Aide D said that she does not bleach the mechanical lift slings she washes them with colors and hangs them dry. She said she had received training to remove mechanical lift slings from service that were bleached. Laundry Aide D said she would remove lift slings that were ripped or torn. She said not removing damaged mechanical lift slings could cause injury to a resident if the lift sling broke.During an observation and interview on 02/10/2026 at 8:30 AM, the DON said she had worked at the facility for a couple of months. She said the staff are in-serviced on signs of wear and tear and to remove mechanical lift slings from service if they have rips, tears and coming unsewn. She said she was not aware of manufacturers' suggested practice of not bleaching. She said the lift sling used for Resident #4 would be removed from service and he would get a new lift sling. She said that using the faded lift sling could cause injury if it broke.During an interview on 02/10/2026 at 8:40 AM, the Administrator said the lift sling used for Resident #4 should be removed from service. She said they would have an in-service with staff. She said that using the faded lift sling could cause injury if it broke.During an interview on 02/10/2026 at 9:17 AM, the Housekeeping Supervisor said she would train all laundry staff on the care of the mechanical lift slings, including air dry and not use bleach. She said the lift sling that was used for Resident #4 could cause injury if it broke. Record Review of Facility policy dated 03/2025 Lifting Machine, using a Mechanical lift.The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting deviceGeneral Guidelines1.At least two (2) nursing assistants are needed to safely move a resident with a mechanical lift.2.Mechanical Lifts may be used for tasks that require:a. Lifting a resident from the floor.transferring a resident from bed to chair.c. Lateral transfers.lifting limbs.c. Toileting or bathing; [NAME]. Repositioning.Steps in the Procedure1.Before using a lifting device, assess the resident's current transfer ability utilizing the Kardex located in the electronic health system.2.The Therapy Screen 2.0 form will be completed upon admission and readmission, with MDS changes including IPA's, quarterly or significant change MDS and PRN to assess and determine transfer/mobility status.3.Prepare the environment:5.Make sure that all necessary equipment (slings, hooks, chains, straps and supports) is on hand and in good condition. Sling Care:1. Disinfect slings between residents (unless disposable).2. Discard any worn, frayed or ripped slings.Record Review of Manufacturer's recommendations accessed www.medline.com 02/11/2026Indicated: Always inspect slings prior to each use Signs of rips. tears. or frays indicate sling wear which 1s unsafe and could result 1n injury Signs of fading. bleached areas. or permanent wrinkles on the straps indicate improper laundering which is unsafe and could result in injury Any slings with signs of wear or improper laundering should be immediately removed from use.Always confirm compatibility between the connection style of the patient sling and the patient lift before use.Do not remove sling labels. If sling labels are removed or no longer legible. sling must be immediately removed from use.Frequency of laundering should follow facility guidelines, or when the sling is soiled. Refer to the sling's tag for laundering instructions and follow all wash instructions.

Based on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 5 (Resident #72) residents observed for incontinent care.CNA D and CNA F did not provide proper incontinent care for Resident #72 and wiped from the anal area toward the urethral area (back to front) on 2/10/2026.This failure could place residents at risk for bacterial infections from improper incontinent care.Findings include:Record review of an admission Record for Resident #72 dated 2/10/2026 indicated she admitted to the facility on [DATE] and was [AGE] years old with diagnosis of colostomy status (surgically created opening (stoma) connecting the colon to the abdominal wall, allowing waste to bypass a damaged or diseased part of the bowel), anorexia nervosa (an eating disorder that involves severe calorie restriction low body weight), and hypertension (high blood pressure).Record review of a Quarterly MDS Assessment for Resident #72 dated 12/19/2025 indicated she had moderate impairment in thinking with a BIMS score of 8. She was dependent on staff for toileting hygiene. She was always incontinent of urine/bowel. Record review of a care plan for Resident #72 dated 2/8/2025 indicated she was on prophylactic medications for recurrent UTIs.During an observation on 2/10/2026 at 10:50 a.m., CNA D and CNA F were in the room of Resident #72. Both staff entered the room, sanitized their hands, and applied gloves. CNA F opened the resident's brief and pulled it down between her thighs. Both staff removed their gloves and placed them in the trash. Both sanitized their hands and donned gloves. CNA F removed wipes from the package and wiped the resident's right inner thigh and placed the wipe in the trash; and then removed another wipe and wiped down the left inner thigh and placed it in the trash. CNA F removed a wipe and wiped down the middle of the vagina from front to back, removed her gloves, placed them in the trash, and sanitized her hands. CNA F donned gloves and the resident was rolled onto her right side. CNA F removed the soiled brief and placed them in the trash along with her gloves. CNA F sanitized her hands and donned gloves. CNA F removed wipes and wiped the residents left and right buttocks from front to back (from the resident's rectal area toward her back). CNA F then wiped the resident's rectal area down the middle from back to front toward the resident's urethra. She removed her gloves and placed them in the trash and sanitized her hands. She placed a clean brief under the resident's buttocks and secured it. Resident was repositioned in bed. Both staff removed their gloves and placed them in the trash and sanitized their hands.During an interview on 2/10/2026 at 10:59 am, CNA F said she had been employed at the facility since 2014. She said she worked D Hall where Resident #72 resided. When asked about the care she provided to Resident #72 if she should have done anything differently, she said she wiped her rectal area from back to front and was not thinking that she had wiped her incorrectly at that time. She said she had a skills check off about a month ago and had been trained on how to perform incontinent care to a female resident and knew to wipe from front to back. She said there was a risk for infections if staff did not wipe the correct way when care was provided to a female resident.Record review of a competency skills check off on 10/25/2025 indicated CNA F was successful with donning PPE or contact precautions and incontinent care with a female resident.During an interview on 2/10/2026 at 1:22 pm, CNA D said she had been employed at the facility for 5 years. She said her last competency skills check-off was November 2025. She said during the care provided to Resident #72; CNA F did not wipe the resident from front to back when she wiped her rectal area. She said there was a risk of UTI's and infections if staff did not wipe the correct way when care was provided. Record review of a competency skills check off on 10/2/2025 indicated CNA D was successful with donning ppe for contact precautions and incontinent care with a female resident.During an interview on 2/11/2026 at 10:34 am, the ADON said she was responsible for training staff on infection control on hire and yearly thereafter and as needed if issues arise. She said if staff provided incontinent care to a female resident, they should wipe from front to back. She said residents could be at risk for infections if staff did not follow infection control practices or did not wipe the resident properly.During an interview on 2/11/2026 at 10:38 am, the DON said she had been in the position since December 1, 2025. She said she along with the ADON was responsible for conducting in-services with the staff and competency evaluations. She said she was made aware of CNA D and CNA F who provided care to Resident #72 when they did not follow infection control measures. She said when incontinent care was provided to a female resident, they should wipe from front to back. She said she planned to provide 1:1 training with CNA D and CNA F. She said if staff did not follow infection control measures residents could be at risk for spreading infections. She said if staff did not wipe female residents correctly, they could cause the resident to develop UTI's or worsening infections. During an interview on 2/11/2026 at 10:42 am, the Administrator said the DON and ADON was responsible for training staff on infection control procedures and policies. She said if the staff provided incontinent care to a female resident, they should wipe from front to back. She said if staff did not follow infection control measures, then residents could be at risk for infections. She said they planned to do more monitoring on pericare along with more frequent in-servicing.Record review of a facility policy titled Perineal Care revised October 2010 indicated, .The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. 9. For a female resident: b. Wash perineal area, wiping from front to back .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that ensure accurate acquiring, receiving, dispensing and administering of medications for 2 of 6 residents (Residents # 27 and # 62) reviewed for pharmacy services. The facility failed to remove Resident # 27's expired lorazepam concentrate (anxiety medication) from the medication room refrigerator.The facility failed to remove Resident #62's expired ondansetron (nausea medication) from the medication cart.These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications, decreased quality of life, and hospitalization.Findings included:1. Record review of Resident #27's face sheet revealed Resident #27 was an [AGE] year-old female that admitted on [DATE] with a diagnosis of polyneuropathies (damage to multiple peripheral nerves).Record review of Resident #27's comprehensive care plan dated 2/20/2025 revealed Resident #27 used anti-anxiety medications and to administer medications as ordered.Record review of Resident #27's discontinued order report dated 8/11/2025 revealed Resident #27's lorazepam was discontinued. Record review of Resident #27's Quarterly MDS assessment dated [DATE] revealed Resident #27 had a BIMS of 07 indicating severe cognitive impairment.During an observation 2/10/2026 at 11:35 am, the lock box located in the main medication room refrigerator had a bottle for Lorazepam 2 milligrams/milliliter for Resident #27 that was opened on 4/03/2025 and per label was to be discarded after 90 days of opening. Record review of Resident #27's narcotic log sheet for lorazepam 2 milligrams/milliliter revealed the last dose was given 8/11/2025.2. Record review of Resident #62's face sheet revealed Resident #62 was a [AGE] year-old female that admitted on [DATE] with a diagnosis of traumatic subdural hemorrhage (collection of blood in the brain).Record review of Resident #62's comprehensive care plan dated 2/20/2025 revealed no problem with nausea addressed on current care plan. Record review of Resident #62's Quarterly MDS assessment dated [DATE] revealed Resident #62 had a BIMS of 04 indicating severe cognitive impairment. Record review of Resident #62's order summary report dated 2/10/2026 revealed Resident #62 had an active order for ondansetron 4 milligrams by mouth every 4 hours as needed for nausea or vomiting. Record review of Resident #62's medication administration reports for January 2026 and February 2026 revealed Resident #62 had not received ondansetron after expiration date.During an observation on 2/10/2026 at 11:30 am Resident #62 had a card of ondansetron 4 milligrams 1 tablet by mouth every 4 hours as needed that expired on 1/14/2026. During an interview on 2/10/2026 at 11:40 am, LVN E said that all the nurses were responsible for checking the medication carts and locked boxes as needed and should always check each medication before administering to ensure it was for the correct resident, not expired, and labeled correctly. She said that medications that were expired and discontinued should be removed for disposal. She said residents that receive expired medications could have poor effects because of decreased potency. She said she was not aware lorazepam concentrate was only good for 90 days after opening. During an interview on 2/10/2026 at 11:44 am, the DON said that she and the ADON checked the medication carts and lock boxes periodically for expired medications but there was not a set schedule. She said the pharmacist checked all the carts monthly and removed any medications that were expired. She said she was not aware lorazepam concentrate was only good for 90 days after opening and would educate all nurses on lorazepam concentrate. She said that expired medications could have decreased effectiveness. During an interview on 2/11/2026 at 10:47 am, the Administrator said that the nurses and pharmacists were responsible for ensuring all medications were discarded after expiration. She said the nurses should be checking the medication carts and other storage areas regularly and especially before administering any medication. She said any medication that was expired should be removed and discarded. She said medications that were expired could be ineffective. She said she expected the facility policies for medication storage, labeling and administration was always followed. Record review of a facility policy titled Administering Medications dated 2001 indicated, .11. The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi dose container, a date will be put on the container, 12. Vials labeled as single dose or single use are not used on multiple residents. Such vials are used only for one resident in a single procedure . Record review of a facility policy titled Storage of Medications dated 2001 indicated, .5.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed .

Based on interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) resident reviewed for infection control. The facility failed to immediately implement Enhanced Barrier Precautions (EBP) for Resident #1 when she admitted on [DATE]. These deficient practices placed residents at risk for cross contamination and spread of infection.Findings included:Record review of Resident # 1's EMR and face sheet dated 10/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/05/2025. Her diagnoses included: Right femur (thigh bone) fracture, sacral region (area of the back and buttocks) pressure ulcer, right buttock pressure ulcer, left buttock deep tissue injury, MRSA (Methicillin Resistant Staphylococcus Aureus, a type of bacteria that is resistant to many antibiotics), right lung cancer with lobectomy (removal of lobe of lung), post-operative anemia (blood loss after surgery), and Osteoporosis (a bone disorder where bones become thinner). Record review of Resident #1's admission MDS assessment dated [DATE] reflected that she was admitted from a short-term general hospital. The MDS report indicated she admitted with surgical wounds after hip replacement, an unstageable pressure ulcer to her right buttocks, a Stage 2 pressure ulcer to her sacrum and a deep tissue injury to her left buttock. She scored 15/15 on her BIMS which signified she was cognitively intact. Record review revealed resident required supervision in eating, maximum assistance in toileting, moderate assistance in upper body dressing and was dependent in lower body dressing, bathing, bed mobility and transfers. Record review of Resident #1's EMR Medication Administration Record dated August 2025 reflected Enhanced Barrier Precautions (EBP) were implemented on 08/12/2025, six days after admission. Record review of Resident #1's Order Summary Report printed 10/07/2025 revealed active order for EBP with start date of 08/12/2025, six days after admission. An interview on 10/08/2025 at 10:51 a.m. with LVN A revealed she believed EBP should be implemented on all residents with wounds, catheters, feeding tubes and urinary or respiratory infections. LVN A stated she would notify the DON if a resident did not have the proper PPE and signs available that reflected EBP. LVN A stated she was not the nurse who admitted Resident #1 and does not recall if EBP was utilized by staff prior to 08/12/2025. An interview on 10/08/2025 at 10:58 a.m. with NA E revealed she would only know if someone required PPE to be worn if there was a sign posted on the door. NA E stated she knows to wear PPE with feeding tube and catheters. NA E stated if the resident had wounds, she would only know if the nurse told her at start of shift.An interview on 10/08/2025 at 11:00 a.m. with NA C revealed she would notify the charge nurse if PPE was not available for residents who needed it. NA C stated that residents with a catheter, feeding tube and infections need EBP when she works with them. NA C stated she knows which residents have EBP needs because they have a sign on their door.An interview on 10/08/2025 at 11:03 a.m. with NA D revealed that she would wear PPE for residents who have the EBP sign posted on their door. NA D stated that she would ask the charge nurse if she did not know what the EBP need was for a particular resident. NA D stated she would not know that a resident required EBP if there was not a sign on his/her door.An interview on 10/08/2025 at 2:00 p.m. with LVN B revealed that she believed EBP was implemented on all residents who required PPE be utilized to prevent infection, contain infection and prevent spread of infection. LVN B stated that residents who had wounds would require EBP use by all staff during interactions. An interview on 10/08/2025 at 3:30 p.m. with the DON revealed that she expects nursing staff to implement EBP for all residents who have open wounds to prevent spread of infection. The DON stated she expects the admitting nurse and/or wound treatment nurse to identify EBP needs when the resident is admitted and to ensure appropriate signs are posted on the resident's door, PPE container is available at room entrance and orders obtained for EBP as needed. The DON stated she does not know why Resident #1 did not receive orders for EBP until six days after admission and acknowledged that she should have been under EBP since admission due to her wound care needs. The DON stated failures to ensure EBP were in place would place the resident at greater risk for increased infection and spread of infection due to poor infection control procedures.An interview on 10/08/2025 at 3:30 p.m. with the Administrator revealed that she expected nursing staff to follow all protocols and procedures for infection control for all residents. The Administrator stated that poor infection control could result in harm or injury to identified resident and other residents and increase the chance of spreading infection throughout the facility.Record review of policy and procedures for Infection Control titled, Infection Control Guidelines for All Nursing Procedures, Revised August 2021 revealed 2. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection.

Based on interviews and record reviews, the facility failed to maintain medical records on each resident in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #1) of 3 resident reviewed for resident records.The facility failed to reflect that Resident # 1 presented with alterations in skin integrity on daily Skilled Evaluation forms. This failure placed residents at risk of having inaccurate assessments to include those with alterations in skin integrity, that could lead to residents not receiving care as needed due to inaccurate medical records.The findings included: Record review of Resident # 1's EMR and face sheet dated 10/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/05/2025. Her diagnoses included: Right femur (thigh bone) fracture, sacral region (area of the back and buttock) pressure ulcer, right buttock pressure ulcer, left buttock deep tissue injury, MRSA (Methicillin Resistant Staphylococcus Aureus, a type of bacteria that is resistant to many antibiotics), right lung cancer with lobectomy (removal of lobe of lung), post-operative anemia (blood loss after surgery), and Osteoporosis (a bone disorder where bones become thinner). Record review of Resident #1's admission MDS assessment dated [DATE] reflected that she was admitted from a short-term general hospital. The MDS report indicated she admitted with surgical wounds after hip replacement, an unstageable pressure ulcer to her right buttocks, a Stage 2 pressure ulcer to her sacrum and a deep tissue injury to her left buttock. She scored 15/15 on her BIMS which signified she was cognitively intact. Record review revealed resident required supervision in eating, maximum assistance in toileting, moderate assistance in upper body dressing and was dependent in lower body dressing, bathing, bed mobility and transfers. Record review of Resident #1's nurse's Skilled Evaluation assessments dated 08/12/2025 (completed by LVN A), 08/21/25 (completed by LVN A) and 08/25/25 (completed by LVN B) revealed that no skin issues or surgical wounds were identified, and no isolation-Active Infectious Disease or Contact Isolation precautions were identified. An interview on 10/08/2025 at 10:51 a.m. with LVN A revealed skilled charting is done on all new admissions and on residents receiving skilled services. LVN A stated that there is a section on the skilled evaluation form to check off any skin concerns. LVN A stated she tries to be accurate when completing the evaluation form. An interview on 10/08/2025 at 2:00 p.m. with LVN B revealed that the skilled evaluation form should reflect the current conditions of each resident. LVN B stated that she does not measure the wounds herself, but that active skin concerns and infections should be checked off on the skilled evaluation note. An interview on 10/08/2025 at 2:40 p.m. with Tx Ns confirmed that Resident #1 did admit with right hip surgical sites with sutures and staples, and a sacral, right buttock pressure ulcer and a left buttock deep tissue injury. An interview on 10/08/2025 at 3:30 p.m. with the DON revealed that she expects nursing staff to accurately identify and code current skin issues and infection control concerns on the daily skilled charting for all residents. The DON stated that the facility had recently changed assessment forms as the Skilled Evaluation form was complicated and too long. The DON stated the failure to ensure accuracy of documentation could place the residents at risk for missed assessment that could result in harm to residents. An interview on 10/08/2025 at 3:30 p.m. with the Administrator revealed that she expected nursing staff to follow all protocols and procedures for accurate documentation for all residents. The Administrator stated that poor documentation reflects on the credibility of nursing care and facility overall. Record review of policy and procedures titled Charting and Documentation, Revised October 2021 revealed medical records should be complete and accurately document residents' medical condition.

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 3 residents (Resident #1) reviewed for pest control.The facility failed to ensure Resident #1's room remained free from ants. Resident #1 had ants in her bed on 07/27/25.This failure could place residents at risk of injury or infection related to ant bites, unsanitary environment, and decreased quality of life. Findings include: Record review of Resident #1’s face sheet, dated 7/28/25, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included lack of coordination, abnormal posture, abnormalities of gait and mobility. Record review of Resident #1’s admission MDS, dated [DATE], indicated she was cognitively intact with a BIMS score of 14. Resident #1 was dependent on staff for transfers. She required substantial to maximal assist with bed mobility with the helper doing more than half of the effort. Record review of Resident #1’s care plan, dated 6/9/25, indicated she was total dependent on staff for bed mobility, dressing, toilet use, transfers and walking. Record review of the facility’s Pest Control Chemical and Log Sheets indicated service was provided to the facility on 5/2/25, 6/2/25 and 7/2/25 treatment to all permissible areas for roaches, crickets, spiders, silver fish and ants. Record review of the facility insect report sheet indicated on 7/25/25 there were ants reported in Resident #1’s room. Record review of Resident #1’s nursing notes, dated 7/27/25 at 8:15 a.m., indicated Resident #1 was noted with medium bleeding from the perineal area and a small amount of blood on the upper tubing of her foley catheter. She was also noted with several small ants in her bed and over her thigh. The resident was sent to the hospital. Record review of Resident #1’s hospital records, dated 7/27/25, indicated the resident had blood in her urine and stool. She had a foley and a colostomy with blood in both. The EMS said the resident was laying in a bed that was covered with ants. The skin assessment indicated no rashes or lesions. During an observation on 7/28/25 at 9:20 a.m. Resident #1’s room showed it was clean there were no clothes in the closet, the smell of bug spray was noted. Observation of the room did not show any signs of ants, the bed had been stripped of everything including the mattress. During an observation on 7/28/25 at 9:23 a.m. the three rooms that share the same outside wall and courtyard as Resident #1’s room, did not show any signs of ants. There were no signs of ants inside or outside. Observations showed snacks in two of the rooms without any ants being visible. During an interview on 7/28/25 at 9:15 a.m. the Administrator said Resident #1 was sent to the hospital yesterday, 7/27/25 due to GI bleed. She said the staff reported they saw ants in Resident #1’s bed. The room was sprayed after she left. The Administrator said Resident #1 had a lot of snacks in her room, and the room was cleaned. During an observation and interview on 7/28/25 at 9:30 a.m., CNA A said she worked on 7/27/25 and was present when Resident #1 was sent out to the hospital. She said RN B called her to the room and Resident #1 was in bed. She said Resident #1 said she felt “tingly.” CNA A said Resident #1 could not get up unassisted and required a Hoyer for transfer. She said when RN B pulled the covers back, Resident #1 had ants on her. CNA A said it was not a lot of ants, just a few. She said she did not know if the resident had been bitten or not, she could not tell. She said the ants appeared to be coming from her back and coming from around her right thigh. She said she did not see any bites the resident said she felt “itchy,” but did not say she was bitten. CNA A said said Resident #1 used the A bed. She said the ants were mostly on Resident #1’s nightstand and on the handrail on the right side of the bed. Observation of Resident #1's room did not reveal any ants. CNA A said she pulled the sheets off the bed and the housekeeper cleaned and sprayed the room on 7/27/25. During an interview on 7/28/25 at 10:00 a.m. the Housekeeper stated she worked on 7/27/25. She said when she arrived in Resident #1’s room she saw one or two ants on the side rail. She said she disinfected the bed. She said a nurse brought in liquid to kill the ants. She said the family took the resident’s clothes. The Housekeeper said it was just a few ants. The Housekeeper said she did not see the resident; she only came in after she was gone and cleaned the room. During an observation and interview on 7/28/25 starting at 10:05 a.m., the Maintenance Director said someone told him on Friday, 7/25/25 Resident #1 had ants at the head of the bed. (He could not recall who, and interviews with staff did not reveal who.) He said he had gone into the room, looked, and did not see any ants. He had taken his flashlight and did a thorough search of Resident #1’s room. He said just to be on the safe side he went on the outside and around the perimeter of that hall and spayed. The Maintenance Director said he was not allowed to spray a room if a resident resided in it. He said he did not see any mounds or any live active ants on Friday, 7/25/25. He said he was told today there were ants in Resident #1’s room on 07/27/25. The Maintenance Director shined a flashlight on Resident #1's bed, wall, floor, nightstand and window seal and no ants were seen. Observation with the Maintenance Director of the outside perimeter of the E hall did not reveal any mounds, or live visible ant activity. He said when he sprayed, he usually spayed on the ground, and around the window unit. He used Ortho B-gone insect killer that was labeled for ants, roached, and spiders. He said he was told sometimes the ants made nests in the walls. He said they had a pest control company, and they came and treated the inside and the outside of the facility monthly. During a telephone interview on 7/28/25 at 10:46 a.m., RN B said she had gone into Resident #1’s room to administer medications. She said she had saw several ants and had pulled the covers back. She said there were several ants around Resident #1’s right thigh. She said there were more ants on the bed. RN B said it appeared the ants were coming from the night stand up the call light to the side rail of the bed. She said they took the snacks out of the way and cleaned the side rail. She said they were busy trying to get the ants off the resident, she was not sure if Resident #1 had any bites or not. RN B said she performed a skin assessment and there were some pinpoint red marks on the right thigh, but she was not sure if they were ant bites or not. She said Resident #1 said she felt “tingly” Resident #1 did not know if she was bitten or not. She said Resident #1 was sent to the hospital due to a possible GI bleed. RN B said Resident #1 had a pressure sore and the dressing was intact, and skin tears on her right arm with the dressing intact. She said there were no ants noted in those areas. RN B said CNA A and the weekend supervisor, RN C, were in the room to assist with getting Resident #1 ready to send to the hospital. During a telephone interview on 7/28/25 at 10:59 a.m., RN C said she was in the room with RN B to help Resident #1 and get her sent out to the hospital due to a possible GI bleed. She said she noticed ants on the bed on 7/27/25 and could see them moving around. She said she did notice ants were coming from the nightstand on the call light onto the bed. She said it appeared there were snacks on the nightstand. RN C said she saw ants on Resident #1’s feet and couple on her thigh. She said Resident #1 did not know the ants were there. She said Resident #1 said, “I feel prickly”. RN C said Resident #1 could not tell if she was being bitten or not. She said the ants were small and light brown. RN C said she would not have seen the ants if they were not moving. RN C said she could not see any bites and did not see any ants attached to Resident #1. She said housekeeping did most of the cleaning. RN C said she spayed, and CNA A packed up all the snacks and bagged the sheets. During an interview on 7/28/25 at 1:25 p.m., the hospital RN charge nurse said she was not aware Resident #1 had of any ant bites. She said Resident #1 had a lot of edema and it was hard to tell if she had any skin issues. She said the family was in the process of placing Resident #1 on hospice. She said she did not want to disturb the resident or family due to the resident’s current condition. During an observation and interview on 7/28/25 at 1:30 p.m. revealed Resident #1 was asleep in a hospital bed and did not awaken during the visit. There were several family members present. The family members said on 7/27/25 Resident #1 said she was bitten by ants. They said she mentioned the day before she thought there were ants in her bed. Observations were conducted during the interview of Resident #1’s left hand which had one small red area on her wrist and two small red areas on the top of her hand by her thumb that could have been ant bites. The family said they noted what they thought was a bite on her right inner arm. Observation of Resident #1’s right arm had an IV tapped and was not visible. Observation of Resident #1’s right thigh did not show any visible red marks. Resident #1 did not wake up during the visit. During an interview on 7/28/25 at 2:30 p.m., the Pest Control Technician said he was called out due to ants being found in Resident #1’s room on 7/27/25. He said he did a thorough inspection of the room and found one dead ant on the window seal of the room. He said he believed it was a sugar ant. He said they did not live in mounds but lived in a tree or were they had easy access to food. He said he put bait out and went to every room to include Resident #1’s room and put preventive measures in place. He said he came to the facility once a month and as needed for pest control issues. Record review of the facility’s Pest Control Policy, dated 9/22/23, indicated the facility shall maintain an effective pest control program. This facility maintains and on-going pest control program for insects and rodents.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections reviewed for 7 of 24 residents (Resident's#95, #203, #64, #20, #21, #74, #98) reviewed for infection control. 1. The facility failed to ensure CNA F, LVN C, and therapist E were following contact isolation for Resident #95 who had Clostridium difficile, also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis). 2. The facility failed to ensure the treatment nurse performed hand hygiene while performing wound care, and CNA B was following Enhanced Barrier Precautions (EBP) for Resident #203 who had wounds. 3. The facility failed to ensure CNA D changed gloves or performed hand hygiene while providing incontinent care for Resident #64. 4. The facility failed to ensure CMA S used proper hygiene while she administered medications to Resident #20, Resident #21, and Resident #74. 5. The facility failed to ensure CMA S washed her hands before and after administering eye drops to Resident #21. 6. The facility failed to ensure LVN A followed the enhanced barrier precautions for Resident #98 while she administered his IV medication through his PICC line. These deficient practices could place residents at risk for infection due to improper care practices. Findings included: 1.Record review of Resident #95's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the humerus (a fracture or break in the upper arm bone), Clostridium difficile, also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis {an inflammation of the colon}), diabetes, and high blood pressure. Record review of Resident #95's admission MDS assessment, dated 09/15/24, indicated Resident #95 understood and was understood by others. Resident #95 BIMS score was a 15 indicating her cognition was intact. The MDS indicated she needed assistance with toileting. The MDS indicated Resident #95 was frequently incontinent of bowel and bladder. Record review of Resident #95's comprehensive care plan revised on 09/30/24 did not indicate a care plan for C-Diff. Record review of Resident #95's Physician order dated 11/12/24 indicated: enteric (relating to the small intestine) contact isolation and transmission-based precaution for C-diff every shift. Record review of Resident #95's Physician order dated 11/12/24 indicated: Vancomycin HCl Oral Suspension 50 mg/ml Give 2.5 ml by mouth four times a day for C-diff for 7 days. Record review of Resident #95 Physician order dated 11/19/24 indicated: Fidaxomicin Oral Tablet 200 MG (Fidaxomicin) Give 1 tablet by mouth two times a day related to enterocolitis due to C-diff for 10 days. Record review of Resident #95's MAR (medication administration records) dated 11/12/24 through 11/18/24 revealed nurses were signing that Resident #95 received enteric contact isolation and transmission-based precautions for C-diff every shift. Record review of Resident #95's MAR dated 11/13/24 through 11/18/24 indicated Resident #95 received Vancomycin HCl Oral Suspension 50 mg/ml Give 2.5 ml by mouth four times. Record review of Resident #95's MAR with a start date of 11/20/24 indicated: Resident #95 received strict enteric contact isolation and transmission-based precautions for possible C-diff every shift. Record review of Resident #95's MAR with a start date of 11/20/24 indicated: Resident #95 received Fidaxomicin Oral Tablet 200 mg, give 1 tablet by mouth two times a day related to enterocolitis due to C-diff for 10 days. During an observation on 11/17/24 at 12:02 p.m., Resident #95 was sitting in her room in a wheelchair. Resident #95 had 2 signs posted outside her room door. The first sign indicated the use of enteric contact and said all staff who entered the room must wear PPE. The second sign was for EBP which indicated you must wear PPE when providing care. During an observation and interview on 11/17/24 at 4:39 p.m., LVN C went into Resident #95's room to answer the call light but did not put on any PPE. LVN C said the roommate wanted a cup and she did not have to put on PPE to answer the call light. The surveyor asked LVN C why Resident #95 was on contact precautions, and she said she had C-Diff. LVN C said she was only required to wear PPE if she was providing care to Resident #95. During an interview on 11/17/24 at 5:07 p.m. CNA F said she was the CNA for Resident #95. She said she had been in Resident #95's room without any PPE. She said she thought contact was just when you touched the resident. She said she was not sure why Resident #95 was in contact. During an observation on 11/18/24 at 8:45 a.m., Resident #95 was not in her room. No boxes or containers were noted in the room for linen or trash. Both contact and EBP signs remained outside Resident #95's door. During an observation on 11/18/24 at 9:07 a.m., a therapist was observed walking Resident #95 down the hallway. She did not have on any PPE. During an interview on 11/18/24 at 9:13 a.m., Therapist E said she was not aware Resident #95 had C-Diff. She said she was told by an unknown person that her C-Diff had resolved some time ago (unknown time). She said she had worked with Resident #95 during the previous week and did not wear PPE. She said if Resident #95 was on contact isolation, she should have worn her PPE. She said she thought the sign outside the door for contact and EBP was for her roommate because she had a wound. During an interview on 11/18/24 at 9:29 a.m., Resident #95 said the facility physician had cleared her from C-Diff about a week ago. She said then they started her back on antibiotics last week (unknown date) for loose stools, but she was under the impression that she would have loose stools often, for a while, but was no longer on contact isolation. She said when she knew she was in contact isolation, she still went wherever she wanted and did not wear any PPE. She said some staff wore PPE and others did not. She said they did tell her she could not use any resident's restroom, and no one could use hers. She said her last loose stool was the other day (unknown date). During an observation on 11/18/24 at 9:37 a.m., the DON went into Resident #95's room without applying PPE. When the DON was leaving the room, she saw the contact sign on the door and went back into the room and performed hand hygiene. She then went to the nurse's station and got a contact isolation sign. The DON went to Resident #95's room, applied her gown and gloves, and then placed the sign over her bed. During a phone interview on 11/18/24 at 10:42 a.m., the facility physician said he was treating Resident #95 for C-diff because she was showing symptoms. He said he expected her to be in contact isolation. During an interview on 11/19/2024 at 2:00 p.m., Laundry staff N said she was unaware of any resident who required isolation precautions. She said normally the laundry would be provided with an in-service to notify them of any residents requiring isolation precautions. She said when they did have a resident on isolation, she had a protective cover that she would use when the clothing arrived. She said she expected the clothing to come in a water-soluble bag and they would have been washed alone. 2. Record review of Resident #203's face sheet, dated 11/20/24 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the superior rim of the right pubis (a break in the pelvic area that's usually caused by a direct blow, such as from a fall or a motor vehicle accident), pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body), and dementia (decline in mental abilities that affects a person's daily life). Record review of Resident 203's admission MDS assessment, dated 08/13/24, indicated Resident #203 was understood and understood by others. Resident #203 BIMS score was a 04 indicating she was severely cognitively impaired. The MDS did not indicate Resident #203 had wounds. Record review of Resident #203's comprehensive care plan dated 08/16/24 and revised 09/12/24 indicated, she had potential/actual impairment to skin integrity related to fragile skin and a Stage 3(open wound) to her mid spine. The interventions were for staff to provide wound care as ordered. Record review of Resident 203's Physician order dated 10/31/24 revealed Resident #203 had the order to implement and maintain enhanced barrier precautions when performing high-contact care activities. Record review of Resident #203 Physician order dated 11/14/24 indicated: Cleanse Stage 3 pressure wound to mid-spine with NS, apply Calcium alginate, cover with a dry dressing on Monday, Wednesday, Friday, and as needed for soiling/dislodgement every day shift for Stage 3 pressure wound. Record review of Resident #203's comprehensive care plan dated 09/19/24 and revised 11/18/24 indicated, she was on EBP related to being at an increased risk of MDRO acquisition because of Stage 3 to her right upper back. The interventions were for staff to provide patient standard precautions using gowns and gloves during dressing, bathing, transferring, providing hygiene, changing linens, changing briefs, assisting with toileting, and while providing wound care. Post clear signage on the door or wall outside of the room indicating the type of precautions and required PPE and provide education to residents and visitors. During an observation on 11/17/24 at 12:08 p.m., an enhanced barrier sign was noted on Resident #203's door. During an observation and interview on 11/17/24 at 12:14 p.m., CNA B entered Resident #203's room. She went over to Resident #203's side pulled the curtain halfway, assisted her to put on her glasses, and then into the wheelchair, all without any PPE. CNA B said Resident #203 was not on any precautions, therefore she did not need to wear any PPE. She said the roommate, Resident #95, was on isolation for Shingles. She then said after looking at the door, she should have worn PPE (gown and gloves) when transferring Resident #203 into her chair for EBP. During an observation and interview on 11/17/24 at 12:14 p.m., the treatment nurse entered Resident #203's room to perform wound care. He explained what he was going to do and applied his gown and gloves. The treatment nurse removed the dirty dressing and then applied new gloves without hand hygiene. He then applied the wound dressing, removed his gloves and gown, and washed his hands. The treatment nurse said he was supposed to perform hand hygiene after he cleaned the wound and before he applied new gloves to prevent infection control issues. 3.Record review of Resident #64's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the superior rim of the right pubis (a break in the pelvic area that usually caused by a direct blow, such as from a fall or a motor vehicle accident), pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body), and dementia (decline in mental abilities that affects a person's daily life). Record review of Resident 64's quarterly MDS assessment, dated 10/01/24, indicated Resident #64 had memory deficient and severe cognitive impairment. The MDS indicated Resident #64 was dependent on staff for toileting. The MDS indicated Resident #64 was always incontinent of bowel and bladder. Record review of Resident #64's comprehensive care plan revised on 06/24/24 indicated she had bladder incontinence related to bladder spasms, and bowel incontinence related to the diagnosis of Alzheimer's. The interventions were for staff to provide incontinence care with each incontinent episode. During an observation on 11/18/24 at 1:53 p.m., CNA, D was providing incontinent care for Resident #64 who had an incontinent episode. She explained what she was going to do and provided hand hygiene and gloves. CNA D washed Resident #64's peri area and then turned her over touching her side without hand hygiene, then cleaned her buttock. CNA D then changed her gloves but did not perform hand hygiene. CNA D pulled up the covers and lowered the bed. During an interview on 11/18/24 at 2:06 p.m., CNA D said she should have changed her gloves and performed hand hygiene when going from dirty to clean or any time she changed her gloves. She said she forgot, but knew it was important to prevent cross-contamination. During an interview on 11/20/24 at 10:00 a.m., the DON said she expected staff to perform peri-care, wound care, and hand hygiene correctly to prevent infection. The DON said she and the ADON usually did peri-care and wound care checkoffs with staff on hire, annually, and as needed. The DON said she expected staff to follow contact and EBP precautions. She said she was aware Resident #95 was on contact isolation. She said she entered her room to pick something up off the floor. She said she used an alcohol-based sanitizer at first to clean her hands, but then went back into the room to wash her hands. She said she should have worn PPE when she entered Resident #95's room. The DON said she was unaware staff did not have any containers in the room for the linen and trash. She said Resident #95 had them in her room as of today (11/20/24). The DON said failure to follow contact isolation or EBP precautions, perform incontinent care, wound care, and hand hygiene properly could lead to infection issues. During an interview on 11/20/24 at 3:07 p.m., the Administrator said all staff was responsible for infection control issues. She said failure to do proper incontinent care, wound care, and hand hygiene or follow contact isolation or EBP precautions could lead to infection. 45810 4. Record review of Resident #20's face sheet dated 11/18/24 indicated she was an [AGE] year-old female who was readmitted to the facility on [DATE] with the diagnoses of Dementia, Diabetes Mellitus, heart failure, and high blood pressure. Record review of Resident #20's quarterly MDS dated [DATE] indicated he made himself understood and could understand others. The MDS also indicated he had a BIMS score of 10 which meant he had moderate cognitive impairment. During an observation on 11/17/24 at 3:57 PM, CMA S provided Resident #20 with his medications and failed to wash her hands or use hand sanitizer before or after administering the medications. 5. Record review of Resident #21's face sheet dated 11/20/24 indicated he was a [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses cerebral infarction (a disorder that causes disrupted blood flow to the brain), intellectual disabilities, depression, and high blood pressure. Record review of Resident #21's quarterly MDS date 08/15/24 indicated he usually made himself understood, he usually understood others, and he had a BIMS score of 10 which meant he had moderate cognitive impairment. Record review of Resident #21's care plan revised on 05/19/21 indicated he had an alteration in his neurological status with interventions to give his medications as ordered. The care plan also indicated he had impaired visual function related to glaucoma and the staff interventions were to give eye drops as ordered. Record review of Resident #21's order summary report dated 11/20/24 indicated he had an order for: Alphagan P Solution 0.15 % (Brimonidine Tartrate) Instill 1 drop in both eyes two times a day for GLAUCOMA with a start date of 02/21/2024. During an observation on 11/17/24 at 04:00 PM, CMA S administered Resident #21's oral medications without washing hands or using hand sanitizer before or after medication administration. CMA S then went to the medication cart and retrieved Resident #21's eye drops, Alphagan P Solution 0.15 % (Brimonidine Tartrate), put on gloves in the room and administered 1 drop to Resident #21's right and left eye. She gave Resident #21 a tissue, removed gloves, and returned to cart. CMA S did not use hand sanitizer or wash hands after administering the eye drops. 6. Record review of Resident #74's face sheet dated 11/18 24 indicated he was a [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses heart failure, atrial fibrillation (irregular and rapid heartbeat), and quadriplegia (paralysis that affects all 4 of a person's limbs). Record review of Resident #74's quarterly MDS dated [DATE] indicated he could understand others, made himself understood, and he had a BIMS score of 15 which meant he was mentally intact. During an observation on 11/17/24 at 04:12 PM, CMA S administered Resident #74'smedications without washing (his/her) hands or using hand sanitizer before or after administration of the medications. During an observation and interview on 11/17/24 at 04:15 PM, CMA S started to prepare next resident after Resident #74 and surveyor intervened. CMA S said hand hygiene and the use of hand sanitizer slipped her mind. She said she should have used hand sanitizer between medication administration for Resident #20, Resident #21, and Resident #74. CMA S said she should have washed hands before and after administering Resident #21's the eye drops. She said the failure placed a risk of spreading infection and disease. During an interview on 11/20/204 at 02:45 PM, the DON said she had completed a 1 on 1 in-service with the medication aides. She said she expected all CMAs to perform hand hygiene between each resident and to perform hand washing before and after eye drop administration. The DON said the failure placed a risk for residents to get infections. During an interview on 11/20/24 at 03:11 PM, the Administrator said her expectation was for the CMAs' hands to be washed prior to any type of care or eye drops given and afterwards. She said all nurses and CMAs should be performing hand hygiene between each resident. She said the failure placed the risk for infection. 7. Record review of Resident #98's face sheet, dated 11/20/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia (loss of memory), atrial fibrillation (a common type of irregular heartbeat), and high blood pressure Record review of Resident 98's 5-day MDS assessment, dated 10/22/24, indicated Resident #98 was understood by others and able to understand others. Resident #98 BIMS score was a 03 indicating he was severely cognitively impaired. The MDS indicated Resident #98 required extensive assistance with his ADLs. Record review of Resident #98's care plan revised on 11/17/24 indicated he was currently taking an IV medication, meropenem, through his PICC line for an infection. The care plan also indicated Resident #98 required enhanced barrier precautions as long as he continued to have the PICC line in place with interventions to wear a new gown and gloves while providing care. Record review of Resident #98's order summary report dated 11/20/24 indicated he had and order for: 1.Merrem Intravenous Solution Reconstituted 1 GM (Meropenem) Use 1 gram intravenously two times a day for surgical infection for 28 administrations with a start date of 11/08/2024 and an end date of 11/22/2024. 2.Nursing intervention: Implement and maintain enhanced barrier precautions when performing high contact care activities every shift with a start date of 10/28/2024 During an observation on 11/18/24 at 09:33 AM, LVN A used hand sanitizer and donned gloves but failed to don a gown. She administered Resident #98's IV medication. During an interview on 11/20/204 at 02:46 PM, the DON stated the expectation was for residents receiving IV therapy to be provided care using the proper PPE since they were at a heightened risk for infections, and she expected the nurses to provide extra precautions. The DON said the nurses, CNAs, and CMAs were expected to be aware of residents who needed enhanced barrier precautions, and the IV administration was an obvious reason for PPE to be worn. During an interview on 11/20/24 at 03:11 PM, the Administrator said she expected the nursing staff (nurse, CNA, and CMA) to be using PPE when providing care to anyone with the enhanced barrier precautions in place. The Administrator said the failure placed a risk for infection. Record review of the facility policy for Infection Control Guidelines for All Nursing Procedures revised August 2012 indicated: Purpose To provide guidelines for general infection control while caring for residents .I. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 2. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. 3. Employees must wash their hands for ten (10) to fifteen (15) seconds using antimicrobial or non antimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; b. When hands are visibly dirty or soiled with blood or other body fluids; Record review of the facility policy Implementation of Standard and Transmission-Based Precautions dated 3/2024 indicated: Policy Statement Infection control measures are implemented in attempts to prevent the spread of communicable diseases .Policy Implementation 2. The facility will incorporate Transmission-Based Precautions as second tier of basic infection control and used in addition to Standard Precautions for resident who are or maybe Infected, colonized with certain Infectious agents for which additional precautions are necessary to prevent infection transmission .Contact Precautions- (Transmission-Based Precautions or TSP) are used with a known infection thit It spread by direct or indirect contact with the resident or the resident's environment (e.g., [NAME]). Examples: a. Acute diarrhea; . 3. Enhanced Barrier Precautions (EBP)- Expand the use of PPE and refer to the use of gown and gloves during a high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing, MDROS may be indirectly transferred from resident-to-resident during these high-contact care activities. Record review of the facility policy titled, Clostridium Difficile, dated October 2018, indicated, Policy Statement: Measures are taken to prevent the occurrence of Clostridium difficile infections (CDI) among residents. Precautions are taken while caring for residents with C. difficile to prevent transmission to other residents. Policy Interpretation and Implementation: 1. Clostridium difficile infection is suspected in residents with acute, unexplained onset of diarrhea (three or more unformed stools within 24 hours) 5. Steps toward prevention and early intervention include: a. Ongoing surveillance or C-Diff; b. Increasing awareness of symptoms and risk factors among staff, residents, and visitors; c. Considering C. difficile in differential diagnoses, especially in residents with symptoms or risk factors; d. Frequent hand washing with soap and water by staff and residents; e. Wearing gloves when handling feces or articles contaminated with feces .9. Resident with diarrhea associated with C. difficile (i.e., residents who are colonized and symptomatic) are placed on Contact Precautions 10. Residents with diarrhea and suspected C-Diff are placed on Contact Precautions while awaiting laboratory results. Precautions: 12. Residents who are asymptomatic (diarrhea-free) for 48 hours can be removed from precautions. 13. Residents with C-Diff are placed in a private room if available. If a private room is not available, resident will be cohorted with a dedicated commode for each resident. 14. When caring for residents with C-Diff, staff is to maintain vigilant hand hygiene. Hand washing with soap and water is superior to ABHR for the mechanical removal of C. difficile spores from hands. 15. Enhanced infection control measures may be used on units with high rates of C. diff infection, in including a. Universal glove use; b. Enhanced environmental cleaning; c. Reduced sharing of or dedicated medical equipment; and D. staff cohorting.

Based on interviews and record reviews, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #90, Resident #203, and Resident #8) out of 24 sampled residents whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #90's care plan was updated and accurate by not resolving the care plan for a PICC line and antibiotic administration that resident no longer had an order for. The facility failed to ensure Resident #203's care plan was updated by resolving her melatonin and rash in which she no longer had those orders. The facility failed to ensure Resident #8's care plan was updated by resolving her antibiotics and IV fluids in which she no longer had those orders. These failures could place residents at risk for not receiving the care and services to meet their needs. Findings include: 1.Record review of Resident #90's face sheet indicated he was a [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses fracture of femur (broken hip), stage 4 pressure ulcer, and dementia (thinking and social symptoms that interfere with daily functioning). Record review of Resident #90's quarterly MDS dated [DATE] indicated he was sometimes understood and sometimes understood others, and he had a BIMS score 7 of which meant he had severe cognitive impairment. The MDS also indicated he required maximal assistance with transfers and hygiene, total assistance with toileting, dressing, and bathing, and independent with eating. Record review of Resident #90's care plan initiated 06/14/24 and revised 09/23/24 indicated he was on IV Medications r/t an infection to his sacral wound with interventions that included: 1. If IV is infiltrated: stop infusion and thoroughly examine the site. 2. If the catheter appears to be lodged in the tissues, an attempt to aspirate any fluid remaining in the catheter can be made in order to lessen the amount of drug at the site. After removing the cannula, elevate the affected arm, notify the physician (for large infiltrations and extravasations), and apply cool compresses (warm, if [NAME] alkaloids are involved). 3. IV DRESSING: PICC line dressing change q week & prn. Observe dressing q shift. Change dressing and record observations of site. Monitor/document/report PRN. During an interview on 11/20/24 at 02:47 PM, the DON said her expectation was for the care plan to be accurate. She said the MDS nurse was responsible for ensuring care plans were accurate, but the DON updated and oversaw care plans as well. The DON said she expected the care plans to be revised within at least the week of the order change. She said the failure could prevent the resident care plan from being accurate. During an interview on 11/20/24 at 03:06 PM, the Administrator said her expectation was for the care plans to be resolved as they were finished with the care. She said the MDS nurse was responsible for ensuring the care plans were updated and accurate. The Administrator said the failure placed a risk for Resident #90 getting care that was not needed (getting IV medications that were not ordered). 45879 2.Record review of Resident #203's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the superior rim of the right pubis (a break in the pelvic area that usually caused by a direct blow, such as from a fall or a motor vehicle accident), pressure wounds (areas of damaged skin and tissue caused by sustained pressure that reduces blood flow to vulnerable areas of the body), and dementia (decline in mental abilities that affects a person's daily life). Record review of Resident #203's admission MDS assessment, dated 08/13/24, indicated Resident #203 was understood and usually understood by others. Resident #203's BIMS score was a 04 indicating she was severely cognitively impaired. The MDS indicated she required assistance with her activities of daily living. Record review of Resident #203's comprehensive care plan dated 08/08/24 indicated she was taking melatonin related to insomnia. The intervention was for staff to give medication as ordered. Record review of Resident #203's comprehensive care plan dated 08/08/24 indicated, she had a rash on the right side with a diagnosis of Shingles. The interventions were for staff to provide medication as ordered and for her to be in contact isolation. Record review of Resident #203's Physician order dated 11/01/24 through 11/20/24 did not indicate an order for a rash or diagnosis of shingles. Record review of Resident #203's Physician order dated 08/14/24 indicated all contact was discontinued for shingles. Record review of Resident #203's Physician order dated 11/01/24 through 11/20/24 did not indicate an order for melatonin. Record review of Resident #203's Physician order dated 09/10/24 indicated Melatonin was discontinued. 3.Record review of Resident #8's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Cerebral palsy also known as CP (a group of neurological disorders that affect a person's ability to move, balance, and maintain postured), depression (sadness), high blood pressure, seizures (a sudden burst of electrical activity in the brain), and Quadriplegia (a medical condition that causes partial or total loss of movement and sensation in all four limbs and the torso). Record review of Resident #8's admission MDS assessment, dated 09/24/24, indicated Resident #8 was sometimes understood and understood by others. Resident #8's BIMS score was a 03 indicating she was severely cognitively impaired. The MDS did indicate she was on antibiotics. Record review of Resident #8's comprehensive care plan revised on 10/07/24 indicated she was on antibiotic therapy related to chronic urinary tract infections. The intervention was for staff to give medication as ordered. Record review of Resident #8's comprehensive care plan revised on 10/25/24 indicated she was at risk for altered fluid balance related to hydration and sodium chloride solution. The intervention was for staff to give medication as ordered. Record review of Resident #8's physician's orders dated 11/01/24 through 11/20/24 did not indicate any orders for an antibiotic for a urinary tract infection. Record review of Resident #8's physician's orders dated 11/01/24 through 11/20/24 did not indicate any orders for IV sodium chloride 0.9%. During an interview on 11/20/24 at 10:22 a.m., MDS nurse #1 said she was responsible for the care plans for the long-term and private residents. She said the care plan was done so the staff would know how to care for the resident. She said she was made aware of the residents' changes in the morning meeting. She said she brought her computer to the morning meetings and updated any changes during the meeting. She said she was unaware she missed deleting Resident #90's PICC and antibiotics off his care plan. She said failure to update a care plan could cause staff not to know how to care for the residents. During an interview on 11/20/24 at 2:36 p.m., MDS nurse #2 said she was responsible for the Medicare resident's care plans She said care plans were done for staff to know the needs of the residents. She said she was made aware of changes or new orders in the morning meeting. She said she was new to this position and was learning. She said she was unaware she had not updated Resident #8 or Resident #203's, care plan. She said it was important to ensure the resident's care plan was updated with any new orders or changes. She said care plans should be done and or updated so that staff knew how to care for the resident. During an interview on 11/20/24 at 3:07 p.m., the Administrator said the MDS nurse was responsible for the care plans. She said the DON was the overseer of the care plans. She said if care plans were not done residents might receive something they do not need or not receive something they do need. Record review of the facility's policy titled, Care Plans and Comprehensive Person-Centered, dated December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition.

Based on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 4 of 24 residents (Residents #90, Resident #95, Resident #203, Resident #98) reviewed for care plans. 1.The facility failed to include Resident #90's diagnosis and interventions for the medication Eliquis Oral Tablet 2.5 MG (Apixaban) (an anticoagulant used for preventing coagulation of blood) in his comprehensive care plan. 2. The facility failed to ensure Resident #95's diagnosis of Clostridioides difficile also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis) and precautions was on her care plan. 3. The facility failed to ensure Resident #98's Eliquis (a medication used to reduce the risk of stroke and blood clots), and interventions was on his care plan. 4. The facility failed to ensure Resident #203's oxygen and interventions was on her care plan These failures could have placed residents at risk for not having their needs met. The findings included: 1.Record review of Resident #90's face sheet indicated he was a [AGE] year-old male who readmitted to the facility on [DATE] with the diagnoses fracture of femur (broken hip), stage 4 pressure ulcer, and dementia (thinking and social symptoms that interfere with daily functioning). Record review of Resident #90's quarterly MDS dated [DATE] indicated he was sometimes understood and sometimes understood others, and he had a BIMS score of 7 which meant he had severe cognitive impairment. The MDS also indicated he required maximal assistance with transfers and hygiene, total assistance with toileting, dressing, and bathing, and independent with eating. The MDS also indicated he takes an anticoagulant. Record review of Resident #90's order summary report dated 11/20/24 indicated he had an order for: 1.Eliquis Oral Tablet 2.5 MG (Apixaban) Give 1 tablet by mouth two times a day with a start date of 09/14/2024. The order summary did not indicate any monitoring for the side effects of the anticoagulant medication. During an interview on 11/20/24 at 2:47 p.m., the DON said her expectation was for the care plan to be accurate, especially medications like anticoagulants. She said the MDS nurse was responsible for ensuring care plans was accurate, but the DON updated and oversaw care plans as well. The DON said the failure placed Resident #90 at risk for not being monitored for the side effects of the medication as well as the tools to be put in place for awareness and focused monitoring or the anticoagulant. The DON said she expected the care plans to be revised within at least the week of the order change. She said the failure also could prevent the resident care plan from being accurate. During an interview on 11/20/24 at 3:06 p.m., the Administrator said her expectation was for all medications to be care planned and especially the anticoagulant. She said the MDS nurse was responsible for ensuring the care plans were updated and accurate. The Administrator said the failure placed a risk for the staff not knowing the resident was taking the medication and could cause bleeding, she assumed because she was not a nurse. 45879 2.Record review of Resident #95's face sheet, dated 11/20/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included fracture of the humerus (a fracture or break in the upper arm bone), Clostridioides difficile also known as C-diff (a very contagious bacterium that can cause diarrhea and colitis {an inflammation of the colon}), diabetes, and high blood pressure. Record review of Resident #95's admission MDS assessment, dated 09/15/24, indicated Resident #95 was understood and understood by others. Resident #95 BIMS score was a 15 indicating she was cognitively intact. The MDS indicated she needed assistance with toileting. The MDS indicated Resident #95 was frequently incontinent of bowel and bladder. Record review of Resident #95's Physician order dated 11/12/24 indicated: enteric contact isolation and transmission-based precaution for C-diff every shift. Record review of Resident #95's Physician order dated 11/12/24 indicated: Vancomycin HCl Oral Suspension 50 mg/ml Give 2.5 ml by mouth four times a day for C-diff for 7 days. 3.Record review of Resident #98's face sheet, dated 11/20/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia (loss of memory), atrial fibrillation (a common type of irregular heartbeat), and high blood pressure. Record review of Resident 98's 5-day MDS assessment, dated 10/22/24, indicated Resident #98 was understood and understood by others. Resident #98 BIMS score was a 03 indicating he was severely cognitively impaired. The MDS indicated Resident #98 required extensive assistance with his ADLs. The MDS indicated he had taken an anticoagulant medication. Record review of Resident 98's Physician order dated 10/17/24 indicated he had an order for Eliquis (Apixaban) 2.5 MG, give 1 tablet by mouth two times a day for diagnosis of atrial fibrillation. 4.Record review of Resident #205's face sheet, dated 11/20/24 indicated an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of congestive heart failure also known as CHF (a chronic condition that occurs when the heart can't pump enough blood to meet the body's needs), Atrial fibrillation also known as A Fib (is a heart condition that causes an irregular and rapid heartbeat in the upper chambers of the heart), stroke, high blood pressure and anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #205's admission MDS assessment, dated 09/15/24, indicated Resident #205 was usually understood and was usually understood by others. Resident #205's BIMS score was 03, which indicated she was severely cognitively impaired. The MDS indicated Resident #205 required assistance with dressing, personal hygiene, toileting, bathing, bed mobility, transfers, and set-up for eating. The MDS during the 7-day look-back period indicated Resident #205 was receiving oxygen. Record review of Resident #205 physician orders dated 09/12/24 indicated, Nasal Cannula Continuous at 1-3 liters per minute for congestive heart failure. During an interview on 11/20/24 at 10:22 a.m., MDS nurse #1 said she was responsible for the care plans for the long-term and private residents. She said the care plan was done so the staff would know how to care for the resident. She said she was made aware of the residents' changes in the morning meeting. She said she brought her computer to the morning meetings and updated any changes during the meeting. She said she was unaware of how she missed adding Resident #90's Eliquis to his care plan. She said failure to do a care plan could cause staff not to know how to care for the residents. During an interview on 11/20/24 at 2:36 p.m., MDS nurse#2 said she was responsible for the Medicare resident's care plans She said care plans were done for staff to know the needs of the residents. She said she was made aware of changes or new orders in the morning meeting. She said she was new to this position and was learning. She said she was unaware she had not updated Resident #98's, Resident #95's, or Resident #205's care plan. She said it was important to ensure the resident's care plan was updated with any new orders or changes. She said care plans should be done and or updated so that staff knew how to care for the resident. During an interview on 11/20/24 at 2:37 p.m., the DON said the MDS nurse was responsible for the care plans. She said the purpose of the care plans was to keep everyone informed of the resident's care She said they talked about the resident's changes during the morning meeting. She said she expected any changes to be done as soon as possible but no later than a week. She said she expected the care plans to be accurate to reflect the resident's care. During an interview on 11/20/24 at 3:07 p.m., the Administrator said the MDS nurse was responsible for the care plans. She said the DON was the overseer of the care plans. She said if care plans were not done residents might receive something they do not need or not receive something they do need. Record review of the facility's policy titled, Comprehensive Care Plan, dated December 2016 indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation:1. The Interdisciplinary Team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.8. The comprehensive, person-centered care plan will: a. Include measurable objectives and timeframes; b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being;13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 14. The Interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition.

Based on observations, interviews, and record reviews, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for 1 of 24 Residents (Resident #98) reviewed for accidents and hazards. The facility failed to ensure Resident #98's fall mat was beside his bed on 11/17/24, 11/18/24 and 11/19/24. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents. Findings included: 1.Record review of Resident #98's face sheet, dated 11/20/24 indicated he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included muscle weakness, dementia (loss of memory), atrial fibrillation (a common type of irregular heartbeat), and high blood pressure. Record review of Resident 98's 5-day MDS assessment, dated 10/22/24, indicated Resident #98 understood and was understood by others. Resident #98's BIMS score was a 03 indicating his cognition was severely impaired. The MDS indicated Resident #98 required extensive assistance with his ADLs including transfers and bed mobility. The MDS indicated he had a fall in the prior month. Record review of Resident #98's comprehensive care plan dated 11/13/24 indicated, he had an actual fall related to poor balance, and impaired mobility, and was at risk for further falls with injury. The intervention was for staff to apply a fall mat at the bedside. Record review of Resident 98's Physician order dated 11/13/24 indicated, he had an order for a fall mat at the bedside every shift. Record review of Resident 98's incident report dated 11/13/24 indicated he had a fall. The intervention was to place a fall mat beside his bed. During an observation on 11/17/24 at 11:35 a.m., Resident #98 was in bed with his eyes closed. No fall mat was noted beside his bed. During an observation on 11/18/24 at 4:35 p.m., Resident #98 was in his bed with no mat beside his bed. During an observation and interview on 11/19/24 at 9:00 a.m., LVN A went into Resident #98's room and verified he did not have a fall mat beside his bed. She then looked into his electronic chart and said Resident #98 had an order for a fall mat. She said Resident #98 had a fall the other day and they must have placed the fall mat as an intervention. She said fall mats were important to prevent falls or injuries from falling. During an interview on 11/20/24 at 2:37 p.m., the DON said Resident #98 was supposed to have a fall mat beside his bed because he had a fall and was at risk for further falls. She said all staff was responsible for ensuring the fall mat was beside his bed. She said if he did not have his fall mat down then he could fall and obtain an injury. During an interview on 11/20/24 at 3:07 p.m., the Administrator said if Resident #98 had an order for a fall mat to be beside his bed, then all staff were responsible for ensuring it was beside his bed. She said failure to have the fall mat could cause an injury from the fall. Record review of facility policy titled, Falls dated November 14, 2023, indicated, The Assessment: The Nursing Staff with physician's support will identify residents with a history of falls and risk factors for falling. a. The Staff Nurse will complete a Fall Risk Screening or equivalent form, on the resident upon admission, readmission, routine quarterly, annual, significant change MDS, and PRN. Treatment/Management: Based on the preceding assessment, the Nursing Staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. Monitoring and Follow-Up: The Nursing Staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling during the Standard of Care/High-Risk Management Meetings. If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed.

Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 24 residents (Resident #59) reviewed for ADL (activities of daily living) care. The facility failed to provide nail care by removing black material from under fingernails for dependent female Resident #59 on 11/17/2024,11/18/2024, and 11/19/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of the face sheet, dated 11/18/2024, revealed Resident #59 was a [AGE] year old female with diagnoses which included traumatic subdural hemorrhage without loss of consciousness, subsequent encounter (a medical situation where a patient has experienced a brain bleed (subdural hemorrhage) due to a head injury, but did not lose consciousness at the time of the injury, and was now being seen for follow-up care related to this condition), metabolic encephalopathy (a brain dysfunction caused by a chemical imbalance in the blood that affects the brain), cognitive communication deficit (difficulty with communication that's caused by a disruption in cognition). Record view of the quarterly MDS, dated [DATE], revealed Resident #59 had a BIMS of 03 indicating severe cognitive impairment. Resident #59 required assistance of two person for dressing, bathing, and personal hygiene ADLs, Resident #59 required assistance of two person for dressing, bathing, and personal hygiene ADLs. The MDS revealed Resident #59 did not reject care. Record review of care plan, with a revision date of 07/14/2024, indicated Resident #59 had an ADL self-care performance deficit. Goal: Resident #59 will improve current level of function in ADLs. Interventions: personal hygiene resident was totally dependent in personal hygiene. During an observation on 11/17/2024 at 9:48 a.m. Resident #59 was observed with black material under fingernails. During an observation on 11/18/2024 at 9:32 a.m. Resident #59 was observed with black material under fingernails. During an observation on 11/19/2024 at 9:35 a.m. Resident #59 was observed with black material under fingernails. During an interview on 11/19/2024 at 10:37 a.m., CNA O stated it was the CNAs responsibility to ensure the residents fingernails were clean during showers or when needed. CNA O stated it was important to keep resident fingernails clean to keep bacteria down. CNA O stated Resident #59 could put her hand in her mouth and the bacteria could get into her mouth and cause an infection. During an interview on 11/19/2024 at 10:43 a.m., CNA P stated it was her responsibility to clean the resident's fingernails during showers. CNA P stated it was important to keep resident fingernails clean to keep bacteria from getting into Resident #59 mouth when eating. CNA P stated if Resident #59 had feces under her fingernail it could make her sick. During an interview on 11/20/2024 at 2:20 p.m., the DON stated it was the CNAs who usually cleaned the resident's fingernails on bath days. The DON stated it was important to keep Resident #59's fingernails clean for infection control and dignity. The DON stated she would monitor by making frequent rounds on every shift and at mealtime. During an interview on 11/20/2024 at 2:37 p.m., the Administrator stated she expected the CNAs to do nail care every Sunday or when needed. The Administrator stated it was important to keep Resident # 59's fingernails clean to prevent contamination. The Administrator stated there could potentially be a risk to Resident #59 by putting dirty fingernails in her mouth. The Administrator stated the department heads would monitor by making rounds. Record review of the facility's undated policy titled Care of Fingernails/Toenails the purpose of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections.

Based on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 24 residents (Resident #20 and Resident #74) reviewed for resident rights. The facility did not ensure Laundry Aide N knocked, introduced herself, and explained what she was doing prior to entering Resident #20's and Resident #74's room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth. Findings included: 1.Record review of the face sheet, dated 11/18/2024, revealed Resident #20 was a [AGE] year old female with diagnoses which included type 2 diabetes mellitus with diabetic neuropathy (diabetic neuropathy was a common and serious complication of type 2 diabetes that occurs when high blood sugar damages nerves over time), acute respiratory failure with hypoxia (a medical emergency where the lungs are unable to adequately provide oxygen to the blood, resulting in dangerously low oxygen levels in the body (hypoxia), and occurring rapidly or suddenly), unspecified diastolic (congestive) heart failure (occurs when the heart's left ventricle stiffens and can't fill properly with blood). Record view of the quarterly MDS assessment, dated 07/15/2024, revealed Resident #20 was usually able to make herself understood and understood others. The MDS assessment indicated Resident #20 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #20 required assistance with toileting, partial moderate assistance with personal hygiene, and supervision for eating. The MDS assessment did indicate the use of oxygen. Record review of care plan, with a revision date of 08/02/2024, indicated Resident #20 was dependent on staff for activities, cognitive stimulation, social interaction, and interventions included for all staff to converse with resident while providing care. During an observation and interview on 11/18/2024 at 11:00 a.m., Surveyor was in Resident #20's room and Laundry Aide N entered the room, went inside Resident #20's closet to place a clothing item, and exited the room. Laundry Aide N did not knock prior to entering the room, and she did not introduce herself. Laundry Aide N did not explain to Resident #20 what she was doing in her room or why she was going in her closet. Resident# 20 stated the staff did not ever knock before entering and she did not like it. 2. Record review of the face sheet, dated 11/18/2024, revealed Resident #74 was a [AGE] year-old male with diagnoses which included quadriplegia, unspecified (a diagnosis code for paralysis of all four limbs, including the arms and legs, and the chest and abdominal muscles), sick sinus syndrome (a heart condition that occurs when the heart's natural pacemaker, the sinoatrial (SA) node, was damaged and can't generate normal heartbeats), cervical radiculopathy (occurs when a nerve root in the neck was compressed or irritated). Record view of the quarterly MDS assessment, dated 09/15/2024, revealed Resident #74 was able to make himself understood and understood others. The MDS assessment indicated Resident #74 had a BIMS score of 15, which indicated his cognition was intact. Record review of care plan, with a revision date of 08/20/2024, indicated Resident #74 would maintain involvement in cognitive stimulation, social activities. Intervention: all staff will converse with resident while providing care. During an observation and interview on 11/18/2024 at 11:20 a.m., surveyor observed Laundry Aide N go into Resident # 74's room without knocking. Resident #74 stated he felt like it was disrespectful for the staff to enter into his room without knocking first. During an interview on 11/18/2023 at 11:33 a.m., Laundry Aide N stated when entering a resident's room, she was supposed to knock, introduce herself and let the resident know why she was in their room. Laundry Aide N stated she did not knock, identify herself, or let Resident #20 know what she was doing because she just forgot. Laundry Aide N stated it was important to knock, introduce herself, and let the residents know what she was doing in their room so they would not feel uncomfortable, for them to know who she was and that she was not a stranger, and to be respectful of the residents. During an interview on 11/20/2024 at 2:20 p.m., the DON stated the staff should knock before walking into a room and announce themselves. The DON stated she expected the staff to knock, introduce themselves, and explain what they were doing in the room. The DON stated it was important for the staff to let residents know what they are doing in their rooms to make them feel comfortable and safe. The DON stated she would in-service the staff. During an interview on 11/20/2024 at 2:37 p.m., the Administrator stated everybody was responsible for treating the residents with dignity and respect. The Administrator stated she expected the staff to knock, introduce themselves, and tell the residents what they were doing in their room. The Administrator stated it was important because the facility was their home. The Administrator stated she expected the staff to treat the residents with dignity and respect. Record review of the facility's policy titled, Quality of Life- Dignity, revised October 4, 2022, indicated residents' private space and property shall be respected at all times. Staff are to knock and request permission before entering residents' room

Based on observations and interviews, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 24 residents (Resident #65) reviewed for accommodation of needs. The facility treatment nurse failed to ensure Resident #65's call light was in reach for her to use when assistance was needed on 11/17/24-11/19/24. This failure could have placed resident at risk of having needs gone unmet. Findings Included: Record review or Resident #65's face sheet dated 11/25/24 indicated she was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the diagnoses Alzheimer's (a progressive disease that destroys memory and other mental functions), high blood pressure, history of falling, and anxiety (a mental health characterized by worry, anxiety, or fear). Record review of Resident #65's MDS dated [DATE] indicated she could usually understand others and usually made herself understood. The MDS also indicated she had a BIMS score of 5 which meant she had severe cognitive impairment. The MDS also indicated Resident #65 required substantial/maximal assistance with transfers and toileting, supervision with dressing, and independent with eating and hygiene. Record review of Resident #65's care plan initiated on 06/21/24 indicated she had self-care deficit with bathing, dressing, and feeding related to her Alzheimer's and Dementia diagnosis with interventions in place for the staff to provide assistance with ADLs as needed. The care plan also indicated, after a revision completed on 11/20/24 related to surveyor intervention, that resident would come to the doorway and yell for help without using the call light. During an observation and interview on 11/17/24 at 11:14 AM, Resident #65 was laying in her bed sometimes she pressed her call light and the staff would poke their head in and leave. Resident #65's call light was on the floor at the foot of the bed. During an observation on 11/18/24 at 08:34 AM, Resident #65 was in her bed asleep. Call light on the floor under the bed. During an observation and interview on 11/19/24 at 08:30 AM, Resident #65 was laying in her bed and said come on here i need help as this surveyor was at the door. The call light continued to be on the floor under the bed. Resident said, i can't find my rooter(referring to the call light) to call you for help but it was here before. LVN K came into the room and noted the call light was on the floor under Resident #65's bed. She said she should have had the call light within her reach to call for help when she needed to. She said all staff who entered the room were responsible for ensuring all resident call lights were in reach for use. LVN K said the failure placed a risk for Resident #65 not to get help when she needed. During an interview on 11/20/24 at 02:33 PM, the DON said her expectation was for Resident #65 to always have the call light in reach so that she could use it if she needed help. The DON said the failure placed a risk for the resident not having the access to care that she needed. She said all staff that go in the rooms were responsible for ensuring the call lights were in reach. During an interview on 11/20/24 at 03:03 PM, the Administrator said she expected the call lights to be in the reach of the residents, that way the resident could use it if needed. She said the CNAs were immediately responsible for ensuring the call lights were in reach, but the department heads were responsible as well during rounding of the halls. The Administrator said the failure placed a risk of the resident's needs not being met or possible injury. Record review of the facility policy Resident Call Light System revised 6/2023 indicated: Purpose The purpose of this procedure is to respond to the resident's requests and needs. Policy Implementation A call light system (audible and visual) is in place and operative in the facility. This system allows individual residents to access a system that notifies nursing that the resident has a need .General Guidelines .4. Ensure that the call light is easily reachable by the resident .

43047 Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development hospitalization s for 3 of 3 residents (Resident #'s 43, 391, and 20) reviewed for infection control practices related to hospitalized residents with urinary tract infections resulting from E coli, 3 of 6 facility staff members (CNA 's M,P, V) reviewed for infection control practices related to incontinent care and foley catheter care, the provision of antibiotic stewardship for 1 of 1 residents (Resident #191) receiving hospice services and tracking and trending of organisms causing 28 urinary tract infections in July 2023 and 19 urinary tract infections in August 2023. 1. Resident #43 was admitted to the hospital on 7/15/2023 with septic shock related to a urinary tract infection. 2. Resident #391 was admitted to the hospital on 8/05/2023 with a diagnosis of sepsis related to a urinary tract infection. 3. Resident #20 was admitted to the hospital on 8/22/2023 with a diagnosis of urinary tract infection. 4. The facility's tracking and trending of infections failed to identify urinary tract infectious organisms. The facility's tracking and trending of infections for the month of July 2023 indicated there were 28 urinary tract infections. The facility's tracking and trending of infections for the month of August 2023 indicated there were 19 urinary tract infections. 5. The facility failed to ensure the contacted hospice services were practicing antibiotic stewardship. 6. CNA M failed to clean the foley catheter tubing during foley catheter care for Resident #12 who currently had a urinary tract infection. 7. CNA P failed to provide appropriate incontinent care for Resident #66 who had a recent history of urinary tract infection. 8. The facility failed to ensure CNA V provided proper incontinent care to Resident #2. 9. The facility failed to ensure in-services were provided since May 2023 regarding hand hygiene, foley catheter care, and incontinent care. An Immediate Jeopardy (IJ) situation was identified on 9/20/2023 at 10:50 a.m. While the IJ was removed on 9/21/2023 at 2:22 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for infections, serious infections, and even death due to improper care practices. Findings included: 1. Record review of Resident #43's face sheet, dated 09/21/2023, indicated Resident #43 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COVID-19 (an infectious disease caused by a virus), urinary tract infection (an infection in any part of the urinary system), and sepsis (occurs when your body has a life-threatening response to an infection). Record review of annual MDS assessment, dated 12/7/2022, indicated Resident #43 made herself understood and usually understood others. The assessment indicated Resident #43's BIMS score was 3, which indicated her cognition was severely impaired. The assessment indicated Resident #43 required total dependence for toilet use. The assessment indicated Resident #43 was always incontinent of bladder and bowel. The assessment indicated Resident #43 did not have an UTI in the last 30 days of this assessment. Record review of Resident #43's care plan, revised on 08/16/2023, indicated Resident #43 returned from the hospital with a diagnosis of urinary tract infection and sepsis The care plan interventions included administer antibiotic therapy as prescribed, encourage fluids, encourage resident to void frequently and fully empty bladder and monitor laboratory results. Record review of Resident #43's hospital discharge summary dated 07/18/2023 revealed resolved septic shock and UTI. 2. Record review of Resident #391's face sheet, dated 09/21/2023, indicated Resident #391 was an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included unilateral (one side) primary osteoarthritis ( degeneration of joint cartilage and the underlying bone) to the right knee, urinary tract infection, and sepsis. Record review of annual MDS assessment, dated 07/28/2023, indicated Resident #391 made himself understood and understood others. The assessment indicated Resident #391's BIMS score was 9, which indicated his cognition was moderately impaired. The assessment indicated Resident #391 required limited assistance for toilet use. The assessment indicated Resident #391 was occasionally incontinent of bladder and always continent with bowel. The assessment indicated Resident #391 did not have an UTI in last 30 days of this assessment. Record review of Resident #391's care plan, revised on 08/14/2023, indicated Resident #391 had a urinary tract infection and was at risk for dehydration. The care plan interventions included administer antibiotic therapy as prescribed, monitor cognitive changes, and evaluate for urinary complaints. Record review of Resident #391's hospital discharge summary dated 08/11/2023 revealed urosepsis (caused by a bacterial infection that starts in the urinary tract and spreads to the blood). The hospital microbiology report dated 08/05/2023 revealed Escherichia coli (a bacteria that lives in the intestines). 3. Record review of Resident #20's face sheet, dated 09/21/2023, indicated Resident #20 was an [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included urinary tract infection. Record review of annual MDS assessment, dated 04/03/2023, indicated Resident #20 made herself understood and understood others. The assessment indicated Resident #20's BIMS score was 13, which indicated her cognition was intact. The assessment indicated Resident #20 required total dependence for toilet use. The assessment indicated Resident #20 was always incontinent of bladder and bowel. The assessment indicated Resident #20 did not have a UTI in last 30 days of this assessment. Record review of Resident #20's care plan, revised on 07/26/2023, indicated Resident #20 had a urinary tract infection. The care plan interventions included encourage adequate fluid intake, give antibiotic therapy as ordered and monitor/document/report to MD for s/sx of UTI. Record review of Resident #20's hospital discharge summary dated 08/26/2023 revealed UTI due to extended ESBL (enzymes that break down and destroy some commonly used antibiotics) producing Escherichia coli (a bacteria that lives in the intestines). 4. Record review of the undated tracking and trending infection log for July 2023 did not address the urinary tract infectious organisms. Record review of the undated tracking and trending infection log for August 2023 did not address the urinary tract infectious organisms. Record review of the facility's July 2023 monthly infection control data log revealed 28 residents who had a urinary tract infection. 15 of those residents had Escherichia coli and 5 of those 15 had Escherichia coli with ESBL. Record review of the facility's August 2023 monthly infection control data log revealed 9 residents who had a urinary tract infection. 9 of those residents had Escherichia coli and 3 of those 9 had Escherichia coli with ESBL. 5. Record review of the progress note dated 07/07/2023 indicated Resident #191 complained of burning with urination. The progress note indicated Resident #191 reported she did not urinate very much or very often. Record review of the physician's telephone order sheet dated 07/07/2023 indicated Resident #191 was prescribed cefdinir (antibiotic to treat UTI) 250 mg/5ml by mouth BID x 7 days for UTI. Record review of the facility's electronic charting system on 07/07/2023 did not reveal urinalysis or urine culture for Resident #191. During a telephone interview on 09/21/2023 at 12:47, the DON for the hospice company stated a urinalysis or urine culture was not done on Resident #191. The DON for the hospice company stated due to the resident being on hospice a urinalysis was not required. During an interview on 09/21/2023 at 3:18 p.m., the DON stated a UTI could not be treated without a urine. The DON stated a urinalysis had to be obtained prior to prescribing an antibiotic. The DON stated an antibiotic ordered for a hospice resident without a urinalysis was against the antibiotic stewardship. 6.Record review of a face sheet dated 9/20/2023 indicated Resident #12 was initially admitted [DATE] and readmitted on [DATE] with the diagnoses of urinary tract infection, shock (a life-threatening medical condition as a result of insufficient blood flow throughout the body. Shock often accompanies severe injury or illness), and acute kidney failure with tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure caused by a lack of blood and oxygen to the kidneys). Record review of the consolidated physician orders dated 9/20/2023 indicated as of 9/15/2023 Resident #12 was receiving Merrem (meropenem) 1 gram intravenously two times daily for 14 administrations ending on 9/23/2023. Record review of an annual MDS dated [DATE] indicated Resident #12 understands and was understood. The MDS indicated Resident #12's BIMS score was 8 indicating moderate cognitive impairment. Record review of Resident #12's MDS indicated she required extensive assistance of two staff with personal hygiene and toileting. Record review of the MDS indicated Resident #12 had an indwelling catheter. Record review of the comprehensive care plan dated 11/07/2019 and updated on 9/12/2023 indicated Resident #12 had a foley catheter related to urine retention and overactive bladder with a history of urinary tract infections. The care plan indicated Resident #12 was treated: 7/18/2023 with Levofloxacin 500 milligrams one tablet by mouth daily for 7 days related to UTI provider urologist 7/31/2023 with Bactrim DS one tablet by mouth twice daily for 7 days for UTI. 8/18/2023 Merrem 1 gram twice daily for 7 days for an UTI The interventions included was to change the foley catheter per the physician orders, check the catheter tubing for kinks with turning and repositioning and monitor/report symptoms of an UTI. Record review of the medication administration record dated July 2023 indicated Resident #12 received Levofloxacin 500 milligrams daily for 6 days for a urinary tract infection starting on 7/18/2023 and ending on 7/24/2023. Record review of a urinalysis culture and sensitivity report dated 7/25/2023 indicated Resident #12's urine had 50,000 - 100,000 Escherichia coli (E coli) organism colony count. Record review of the medication administration record dated July 2023 indicated on 7/31/2023 Resident #12 was administered Bactrim DS 800-160 milligrams one tablet twice daily for 10 days for a UTI. Record review of a UTI Screener Evaluation dated 7/31/2023 indicated Resident #12 had an indwelling foley catheter and had suprapubic pain. Record review of a urinalysis culture and sensitivity report dated 8/13/2023 indicated Resident #12's urine had 50,000 - 100,000 colony count of Escherichia coli (E coli) organism count. Record review of a medication administration record dated August 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily for 13 administrations. The intravenous meropenem was started on 8/19/2023 and ended on 8/24/2023 for a urinary tract infection. Record review of a medication administration record dated September 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily starting on 9/17/2023 and completing on 9/23/2023 for a urinary tract infection. During an interview on 9/18/2023 at 10:31 a.m., Resident #12 said she had her intravenous antibiotic therapy for repeat urinary tract infections. Resident #12 said the urologist said the urinary tract infections were caused from not cleaning her perineal area well. Resident #12 said she did not feel as though the staff provided her good catheter care. Resident #12 said she had to complete the antibiotics before he would do the surgery to give her a suprapubic catheter (a catheter placed directly in the bladder by entering the skin on the abdomen). During an observation on 9/20/2023 at 9:26 a.m., CNA M raised Resident #12's bed to an appropriate height, Resident #12's brief was opened, then she obtained the clean under pad. CNA M rolled the clean pad up and instructed Resident #12 to roll to her right while CNA M placed the rolled pad underneath the current pad. CNA N then had Resident #12 roll toward her left while removing the current pad. CNA M took Resident #12's foley catheter bag from the side of the bed and laid it up in the bed at Resident #12's feet. CNA M had not changed her gloves when she took a clean washcloth, placed the washcloth in the basin of clean water and sprayed the washcloth with perineal cleanser. CNA M then wiped Resident #12's perineal area from top to bottom 4 times using a different fold of the cloth with each wiping. Then CNA M obtained a clean bath towel and dried Resident #12's perineal area without changing her gloves. Then CNA M discarded the used washcloth in the dirty linen bag. Resident #12 was instructed to roll to her right then CNA M obtained a clean washcloth, moistened the towel in the basin of water and then sprayed perineal wash on the toweling. CNA M then cleansed Resident #12's buttocks, 4 times wiping away and folding the cloth each time. CNA M discarded the cloth in the dirty linen. CNA M then used the bath towel and dried Resident #12's buttocks. CNA M then obtained the barrier cream, squeezed the cream in her hand and applied the barrier cream using the same pair of gloves throughout the incontinent care process. CNA M applied Resident #12's clean brief. CNA M then changed her gloves and repositioned Resident #12. During an interview on 9/20/2023 at 9:26 a.m., CNA N said CNA M failed to clean the foley catheter tubing. CNA N said Resident #12 could get a urinary tract infection from not doing catheter care correctly. CNA M said she failed to clean the foley catheter tubing and she failed to change her gloves between clean and dirty when she provided incontinent care to Resident #12. CNA M said catheter care and incontinent care should be done correctly to prevent urinary tract infections. Record review of a Certified Nursing Assistant Competency Checklist indicated CNA M was evaluated on 6/03/2023 for perineal care-female (with/without a catheter). The evaluation indicated CNA M received a satisfactory (S) score. 7. Record review of a face sheet dated 9/21/2023 indicated Resident #66 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia, left hip fracture, urinary tract infection, and dehydration. Record review of an Annual MDS dated [DATE] indicated Resident #66 was usually understood and usually understood others. The MDS indicated Resident #66's BIMS score was 3 indicating severely impaired cognition. The MDS indicated Resident #66 required extensive assistance of one staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #66 was frequently incontinent of bowel and bladder. Record review of the comprehensive care plan dated 8/23/2023 and revised on 9/04/2023 indicated Resident #66 had a urinalysis with a culture and sensitivity completed on 8/14/2023 due to confusion and altered mental status. The care plan indicated on 8/21/2023 Resident #66 had another urinalysis with a culture and sensitivity due to altered mental status and increased confusion. The care plan indicated on 8/24/2023 the physician ordered Macrobid 2 capsules by mouth twice daily for 7 days for a urinary tract infection. The goal of the care plan included Resident #66 would not have signs or symptoms of infection. The interventions included administering the antibiotics as ordered, encouraged fluids, evaluate pain, evaluate urinary complaints, monitor for cognitive changes, and monitor laboratory results. Record review of a urinalysis dated 8/15/2023 indicated Resident #66 had 0-5 red blood cells (none seen), bacteria was many (none seen), mucous light (none seen), appearance cloudy (clear), and leukocyte esterase moderate (negative). There were no orders written on the laboratory sheet but was signed by the physician. Record review of a urinalysis with a culture dated 8/22/2023 indicated Resident #66 had a urinary tract infection with greater than 100,000 Raoultella Planticola (bacteria) organism. The order provided on the laboratory result was Macrobid 100 milligrams one capsule twice daily for 7 days. During an observation on 9/18/2023 at 2:36 p.m., Resident #66 was assisted to her bed by two staff using a gait belt. Resident #66 was assisted by CNA P to remove her pants. CNA P, with her gloves on, touched the clean wipes and the brief. Resident #66's brief was opened by CNA P. CNA P then used a wipe and wiped down on each side of Resident #66's perineal area. Then CNA P wiped one wipe down the middle. Resident #66 was assisted by CNA O to roll to the right and CNA P cleansed her buttocks using three wipes. CNA P then removed her gloves, washed her hands, reapplied gloves, and then attempted to apply the brief. During the application of the brief. The brief tabbed area tore. CNA P removed her gloves and washed her hands again. Resident #66 urinated again on the clean brief. CNA O was aware Resident #66 urinated on the clean brief. Upon CNA P's return to the bedside CNA O indicated to CNA P Resident #66 urinated again. CNA P applied the clean brief and Resident #66 was repositioned. During an interview on 9/18/2023 at 2:36 p.m., CNA O said she believed incontinent care went well with no mistakes. During an interview with CNA P she said she was nervous but she thought the incontinent care went well. When asked why she failed to provide Resident #66 incontinent care again after she urinated on her torn brief, she said she did not have any more wipes. CNAs O and P said Resident #66 could get a UTI or a rash from improper incontinent care. Record review of CNA P's Certified Nursing Assistant Competency Checklist dated 8/24/2023 indicated CNA P was evaluated for perineal care-female with and without a catheter. The evaluation indicated CNA P met the evaluation criteria with a satisfactory (s) skill level. 8. During an observation and interview on 09/20/2023 starting at 8:45 AM, CNA V provided incontinent care to Resident #2. CNA V unfastened Resident #2's dirty brief and removed it. CNA V wiped Resident #2's front perineal area with the same wipe twice in different areas. CNA V failed to use a new wipe when going to a different area. CNA V turned Resident #2 and wiped her buttocks and removed the dirty brief. CNA V removed her dirty gloves and applied new gloved. CNA V did not perform hand hygiene after removing her gloves. CNA V placed the new brief under Resident #2 and applied barrier cream to her buttocks. CNA V removed her gloves and applied clean gloves. CNA V did not perform hand hygiene after removing her gloves. CNA V finished applying the new brief. CNA V removed her gloves and gathered the bag with trash. CNA V repositioned Resident #2 in her bed. CNA V exited the room and disposed of the trash and washed her hands. CNA V said when providing perineal care, she was supposed to use a different wipe every time she wiped. CNA V said she did not realize she had wiped twice in different areas with the same wipe. CNA V said she should have performed hand hygiene after removing her gloves. CNA V said she got nervous and forgot to perform hand hygiene. CNA V said she had been checked off on incontinent care about a month ago. CNA V said the CNAs were responsible for providing proper incontinent care. CNA V said it was important to provide proper incontinent care and perform hand hygiene during incontinent care to prevent cross contamination and UTIs. During an interview on 09/21/2023 at 3:15 PM, LVN Q said the charge nurses were responsible for making sure the CNAs provided proper incontinent care. LVN Q said she monitored the CNAs by going in with them when they provided incontinent care at least once a shift. LVN Q said sometimes she had to prompt them to change their gloves, and she had to prompt them to completely clean the residents. LVN Q said it was important for the CNAs to provided proper incontinent care and perform hand hygiene to decrease UTIs and any kind of infections, and to make sure the residents were clean and did not have any skin breakdown. During an interview on 09/21/2023 at 3:34 PM, the ADON said as a team the nurses and department heads were responsible for making sure the CNAs were providing proper incontinent care and performing hand hygiene adequately while providing incontinent care. The ADON said skills check offs were performed by the DON yearly and in-services were done as needed. The ADON said the CNAs providing proper incontinent care was monitored by the skills check offs and random checks. The ADON said she had not noticed any issues with incontinent care. The ADON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to keep infections down and so the residents would not get a UTI. During an interview on 09/21/2023 at 4:01 PM, the DON said the nurse managers and herself were responsible for ensuring the CNAs were providing proper incontinent care and performing hand hygiene. The DON said this was monitored by the competency checks and random pop-ins on the CNAs while they were performing incontinent care. The DON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to prevent infection and UTIs. During an interview on 09/21/2023 at 4:19 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said the charge nurses and nurse managers were responsible for ensuring the CNAs provided proper incontinent care and performed hand hygiene. The Administrator said it was important for the CNAs to provide proper incontinent care and perform hand hygiene for cleanliness and to reduce infections. During an interview on 9/21/2023 at 11:52 a.m., the ADON said she expected incontinent care and catheter to be performed correctly. The ADON said when incontinent care and catheter care was not performed correctly the resident was at risk for a urinary tract infection. The ADON said she expected catheter care to include cleaning of the tubing. The ADON said changing of the gloves should occur as often as needed but no less than 3 times during the process. The ADON said when a resident urinated again after just receiving incontinent care, she expected the resident to receive incontinent care again. The ADON said she expected the CNAs to clean the labia to prevent bowel movement from being pressed inside the urethral area causing an infection. The ADON said she had been in-serviced on incontinent care male and female, foley catheter, she had been checked off on skills in this area. The ADON said she had been given the task of infection control now. The ADON said she was unsure of her role as of yet, but her role would include identifying the infectious organism. The ADON said identification of the organism was important to monitor for trends. During an interview on 9/21/2023 at 12:04 p.m., RN C (unit manager) said she had in-serviced CNAs on incontinent care, catheter care, and infection control. RN C said she had in serviced the DON and ADON on tracking and trending of infections, monitoring of organisms, and the importance of identification of the organism to in-service staff on hydration and cleanliness, and to perform skills checks on incontinent care. RN C said she expected the CNAs to not wipe the residents from back to front, to change gloves between dirty and clean, and to ensure the female labia were cleansed. During an interview on 9/21/2023 at 12:15 p.m., the DON said she had conducted in-services regarding catheter care, hand hygiene, incontinent care, and prevention of infections. The DON said she had been in-serviced by RN C on tracking and trending of the organism and the importance. The DON said the tracking and trending log for infections had a column now added for organism. The DON said the tracking of the organism would help to see a trend and to identify if a certain hall or staff member may factor in on the results. The DON said the team will meet weekly and discuss the bacteria in the infections and then implement interventions. The DON said prior to this, there had been no formal meetings to involve everyone. The DON said the infection preventionist would just look over the infections. The DON said she had in serviced the hospice provider and the medical director on the antibiotic stewardship. The DON said she in-serviced in May and had the staff checked off on their skills but was still unsure of the deficient practice at an IJ level. During an interview on 9/21/2023 at 12:27 p.m., the Administrator said she would be more involved in monitoring, competencies, and in-servicing for infection control. The Administrator said she would attend the weekly infection control meetings and ensure during the QA meetings the infections were also discussed. The Administrator said she believed the tracking and trending of the organisms could help not to spread infections. During an interview on 9/21/2023 at 12:29 p.m., the Assistant Administrator/Owner said she would be involved in looking over the infections, and in-services. The Assistant Administrator/Owner said she was present in the facility 7 days a week and she would be involved in the monitoring more so. The Administrator/Owner said the infections would also be discussed in the morning meeting. The Assistant Administrator said she had been more involved in the past, but her spouse had become ill over the summer, and she had spent half days away from the facility and the DON herself had suffered a loss which took her away from the facility, but she remained unsure why the in-service in May and the staff check offs failed to prevent the deficient practice. 9. Record review of the Physical and Psychosocial Changes-Nutrition and Hydration in-service was completed 12/09/2022. Record review of the Infection Control-Donning/Doffing, PPE and Handwashing in-service was completed on 01/02/2023. Record review of the Fresh ice water was to be passed every shift in-service was completed 01/06/2023. Record review of the Incontinent Care/UTI in-service was completed on 05/08/2023. Record review of the undated Antimicrobial Stewardship policy, indicated, the facility will establish a multidisciplinary antimicrobial stewardship program that defines and provides guidance for optimal antimicrobial use 3. The members of the antimicrobial stewardship program will develop, endorse, and adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines 4. The members of the antimicrobial stewardship program will meet at least quarterly to review collected date and facility trends, analyze performance, and develop action plans to improve antimicrobial date and facility trends, analyze performance and develop action plans to improve antimicrobial use. Essential date to review includes a. antimicrobial orders b. clinical documentation c. supplemental information from d. effective communication among nursing staff and between nurses and physicians/prescribers Record review of the undated Infection Control Program policy, indicated It is the policy of this facility to have an infection control program, which assures a clean, safe, and sanitary environment for the residents 1. The facility will have an infection control system which will monitor and identify concerns in the following areas: Provides definition of acquired and communicable diseases, A means of identification of risk for infection factors, A means of identification and tracking of infections in the facility, to prevent spread of infections, Protocols for identification and isolation of residents with infectious process, Education information process to assure the staff understands how to care for residents and contain the infectious process to prevent further spread, Education and refresher in-services on infection control and standard precautions, Screening of staff to assure a decrease in the odds of transmission of infectious processes in the community, Sanitization methods for use in showers, whirlpools and multiple use equipment 2. The Director of Nursing or Designee will review staff procedures observations of standard precaution, infection control and isolation procedures 4. Labs will be reviewed by DON and/or Designee 5. Infection control log will be maintained with documentation of Resident/type of infection/antibiotic/treatment, start date . Record review of the facility's policy effective date 06/09/2023, titled, Hand Hygiene, indicated, Policy It is the policy of this facility to sanitize/clean hands properly to prevent the spread of infection . https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447 A urinary tract infection (UTI) is an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract - the bladder and the urethra. Women are at greater risk of developing a UTI than are men. If an infection is limited to the bladder, it can be painful and annoying. But serious health problems can result if a UTI spreads to the kidneys. Health care providers often treat urinary tract infections with antibiotics. You can also take steps to lower the chance of getting a UTI in the first place. UTIs typically occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder. The urinary system is designed to keep out bacteria. But the defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract. The most common UTIs occur mainly in women and affect the bladder and urethra. o Infection of the bladder. This type of UTI is usually caused by Escherichia coli (E. coli). E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract. But sometimes other bacteria are the cause. When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, UTIs can cause serious health problems. Complications of a UTI may include: o Repeated infections, which means you have two or more UTIs within six months or three or more within a year. Women are especially prone to having repeated infections. o Permanent kidney damage from a kidney infection due to an untreated UTI. o Delivering a low birth weight or premature infant when a UTI occurs during pregnancy. o A narrowed urethra in men from having repeated infections of the urethra. o Sepsis, a potentially life-threatening complication of an infection. This is a risk especially if the infection travels up the urinary tract to the kidneys. Prevention These steps may help lower the risk of UTIs: o Drink plenty of liquids, especially water. Drinking water helps dilute the urine. That leads to urinating more often - allowing bacteria to be flushed from the urinary tract before an infection can begin. o Try cranberry juice. Studies that look into whether cranberry juice prevents UTIs aren't final. However, d [TRUNCATED]

43047 Based on observations, interviews, and record reviews, the facility failed to ensure a resident who is incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 3 of 3 residents (Resident #43, #391, #20) reviewed for treatment of urinary tract infections and 3 of 4 residents (Resident #12, #66, and #2) reviewed for incontinent care. 1. Resident #43 was admitted to the hospital on 7/15/2023 with septic shock related to a urinary tract infection. 2. Resident #391 was admitted to the hospital on 8/05/2023 with a diagnosis of sepsis related to a urinary tract infection. 3. Resident #20 was admitted to the hospital on 8/22/2023 with a diagnosis of urinary tract infection. 4. CNA M failed to clean the foley catheter tubing during foley catheter care for Resident #12 who currently had a urinary tract infection. 5. CNA P failed to provide appropriate incontinent care for Resident #66 who had a recent history of urinary tract infection. 6. The facility failed to ensure CNA V provided proper incontinent care to Resident #2. 7. The facility failed to ensure in-services were provided since May 2023 regarding hand hygiene, foley catheter care, and incontinent care. An Immediate Jeopardy (IJ) situation was identified on 9/20/2023 at 10:50 a.m. While the IJ was removed on 9/21/2023 at 2:22 p.m., the facility remained out of compliance at a severity level of actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of the corrective systems. These deficient practices could place residents at risk for infections, serious infections, and even death due to improper care practices. Findings included: 1. Record review of Resident #43's face sheet, dated 09/21/2023, indicated Resident #43 was a [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included COVID-19 (an infectious disease caused by a virus), urinary tract infection (an infection in any part of the urinary system), and sepsis (occurs when your body has a life-threatening response to an infection). Record review of annual MDS assessment, dated 12/7/2022, indicated Resident #43 made herself understood and usually understood others. The assessment indicated Resident #43's BIMS score was 3, which indicated her cognition was severely impaired. The assessment indicated Resident #43 required total dependence for toilet use. The assessment indicated Resident #43 was always incontinent of bladder and bowel. The assessment indicated Resident #43 did not have an UTI in the last 30 days of this assessment. Record review of Resident #43's care plan, revised on 08/16/2023, indicated Resident #43 returned from the hospital with a diagnosis of urinary tract infection and sepsis The care plan interventions included administer antibiotic therapy as prescribed, encourage fluids, encourage resident to void frequently and fully empty bladder and monitor laboratory results. Record review of Resident #43's hospital discharge summary dated 07/18/2023 revealed resolved septic shock and UTI. 2. Record review of Resident #391's face sheet, dated 09/21/2023, indicated Resident #391 was an [AGE] year-old male, originally admitted to the facility on [DATE] with diagnoses which included unilateral (one side) primary osteoarthritis ( degeneration of joint cartilage and the underlying bone) to the right knee, urinary tract infection, and sepsis. Record review of annual MDS assessment, dated 07/28/2023, indicated Resident #391 made himself understood and understood others. The assessment indicated Resident #391's BIMS score was 9, which indicated his cognition was moderately impaired. The assessment indicated Resident #391 required limited assistance for toilet use. The assessment indicated Resident #391 was occasionally incontinent of bladder and always continent with bowel. The assessment indicated Resident #391 did not have an UTI in last 30 days of this assessment. Record review of Resident #391's care plan, revised on 08/14/2023, indicated Resident #391 had a urinary tract infection and was at risk for dehydration. The care plan interventions included administer antibiotic therapy as prescribed, monitor cognitive changes, and evaluate for urinary complaints. Record review of Resident #391's hospital discharge summary dated 08/11/2023 revealed urosepsis (caused by a bacterial infection that starts in the urinary tract and spreads to the blood). The hospital microbiology report dated 08/05/2023 revealed Escherichia coli (a bacteria that lives in the intestines). 3. Record review of Resident #20's face sheet, dated 09/21/2023, indicated Resident #20 was an [AGE] year-old female, originally admitted to the facility on [DATE] with diagnoses which included urinary tract infection. Record review of annual MDS assessment, dated 04/03/2023, indicated Resident #20 made herself understood and understood others. The assessment indicated Resident #20's BIMS score was 13, which indicated her cognition was intact. The assessment indicated Resident #20 required total dependence for toilet use. The assessment indicated Resident #20 was always incontinent of bladder and bowel. The assessment indicated Resident #20 did not have a UTI in last 30 days of this assessment. Record review of Resident #20's care plan, revised on 07/26/2023, indicated Resident #20 had a urinary tract infection. The care plan interventions included encourage adequate fluid intake, give antibiotic therapy as ordered and monitor/document/report to MD for s/sx of UTI. Record review of Resident #20's hospital discharge summary dated 08/26/2023 revealed UTI due to extended ESBL (enzymes that break down and destroy some commonly used antibiotics) producing Escherichia coli (a bacteria that lives in the intestines). 4. Record review of a face sheet dated 9/20/2023 indicated Resident #12 was initially admitted [DATE] and readmitted on [DATE] with the diagnoses of urinary tract infection, shock (a life-threatening medical condition as a result of insufficient blood flow throughout the body. Shock often accompanies severe injury or illness), and acute kidney failure with tubular necrosis (kidney disorder involving damage to the tubule cells of the kidneys, which can lead to acute kidney failure caused by a lack of blood and oxygen to the kidneys). Record review of the consolidated physician orders dated 9/20/2023 indicated as of 9/15/2023 Resident #12 was receiving Merrem (meropenem) 1 gram intravenously two times daily for 14 administrations ending on 9/23/2023. Record review of an annual MDS dated [DATE] indicated Resident #12 understands and was understood. The MDS indicated Resident #12's BIMS score was 8 indicating moderate cognitive impairment. Record review of Resident #12's MDS indicated she required extensive assistance of two staff with personal hygiene and toileting. Record review of the MDS indicated Resident #12 had an indwelling catheter. Record review of the comprehensive care plan dated 11/07/2019 and updated on 9/12/2023 indicated Resident #12 had a foley catheter related to urine retention and overactive bladder with a history of urinary tract infections. The care plan indicated Resident #12 was treated: 7/18/2023 with Levofloxacin 500 milligrams one tablet by mouth daily for 7 days related to UTI provider urologist 7/31/2023 with Bactrim DS one tablet by mouth twice daily for 7 days for UTI. 8/18/2023 Merrem 1 gram twice daily for 7 days for an UTI The interventions included was to change the foley catheter per the physician orders, check the catheter tubing for kinks with turning and repositioning and monitor/report symptoms of an UTI. Record review of the medication administration record dated July 2023 indicated Resident #12 received Levofloxacin 500 milligrams daily for 6 days for a urinary tract infection starting on 7/18/2023 and ending on 7/24/2023. Record review of a urinalysis culture and sensitivity report dated 7/25/2023 indicated Resident #12's urine had 50,000 - 100,000 Escherichia coli (E coli) organism colony count. Record review of the medication administration record dated July 2023 indicated on 7/31/2023 Resident #12 was administered Bactrim DS 800-160 milligrams one tablet twice daily for 10 days for a UTI. Record review of a UTI Screener Evaluation dated 7/31/2023 indicated Resident #12 had an indwelling foley catheter and had suprapubic pain. Record review of a urinalysis culture and sensitivity report dated 8/13/2023 indicated Resident #12's urine had 50,000 - 100,000 colony count of Escherichia coli (E coli) organism count. Record review of a medication administration record dated August 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily for 13 administrations. The intravenous meropenem was started on 8/19/2023 and ended on 8/24/2023 for a urinary tract infection. Record review of a medication administration record dated September 2023 indicated Resident #12 was administered Meropenem intravenously 1 gram twice daily starting on 9/17/2023 and completing on 9/23/2023 for a urinary tract infection. During an interview on 9/18/2023 at 10:31 a.m., Resident #12 said she had her intravenous antibiotic therapy for repeat urinary tract infections. Resident #12 said the urologist said the urinary tract infections were caused from not cleaning her perineal area well. Resident #12 said she did not feel as though the staff provided her good catheter care. Resident #12 said she had to complete the antibiotics before he would do the surgery to give her a suprapubic catheter (a catheter placed directly in the bladder by entering the skin on the abdomen). During an observation on 9/20/2023 at 9:26 a.m., CNA M raised Resident #12's bed to an appropriate height, Resident #12's brief was opened, then she obtained the clean under pad. CNA M rolled the clean pad up and instructed Resident #12 to roll to her right while CNA M placed the rolled pad underneath the current pad. CNA N then had Resident #12 roll toward her left while removing the current pad. CNA M took Resident #12's foley catheter bag from the side of the bed and laid it up in the bed at Resident #12's feet. CNA M had not changed her gloves when she took a clean washcloth, placed the washcloth in the basin of clean water and sprayed the washcloth with perineal cleanser. CNA M then wiped Resident #12's perineal area from top to bottom 4 times using a different fold of the cloth with each wiping. Then CNA M obtained a clean bath towel and dried Resident #12's perineal area without changing her gloves. Then CNA M discarded the used washcloth in the dirty linen bag. Resident #12 was instructed to roll to her right then CNA M obtained a clean washcloth, moistened the towel in the basin of water and then sprayed perineal wash on the toweling. CNA M then cleansed Resident #12's buttocks, 4 times wiping away and folding the cloth each time. CNA M discarded the cloth in the dirty linen. CNA M then used the bath towel and dried Resident #12's buttocks. CNA M then obtained the barrier cream, squeezed the cream in her hand and applied the barrier cream using the same pair of gloves throughout the incontinent care process. CNA M applied Resident #12's clean brief. CNA M then changed her gloves and repositioned Resident #12. During an interview on 9/20/2023 at 9:26 a.m., CNA N said CNA M failed to clean the foley catheter tubing. CNA N said Resident #12 could get a urinary tract infection from not doing catheter care correctly. CNA M said she failed to clean the foley catheter tubing and she failed to change her gloves between clean and dirty when she provided incontinent care to Resident #12. CNA M said catheter care and incontinent care should be done correctly to prevent urinary tract infections. Record review of a Certified Nursing Assistant Competency Checklist indicated CNA M was evaluated on 6/03/2023 for perineal care-female (with/without a catheter). The evaluation indicated CNA M received a satisfactory (S) score. 5. Record review of a face sheet dated 9/21/2023 indicated Resident #66 was an [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnoses of dementia, left hip fracture, urinary tract infection, and dehydration. Record review of an Annual MDS dated [DATE] indicated Resident #66 was usually understood and usually understood others. The MDS indicated Resident #66's BIMS score was 3 indicating severely impaired cognition. The MDS indicated Resident #66 required extensive assistance of one staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. The MDS indicated Resident #66 was frequently incontinent of bowel and bladder. Record review of the comprehensive care plan dated 8/23/2023 and revised on 9/04/2023 indicated Resident #66 had a urinalysis with a culture and sensitivity completed on 8/14/2023 due to confusion and altered mental status. The care plan indicated on 8/21/2023 Resident #66 had another urinalysis with a culture and sensitivity due to altered mental status and increased confusion. The care plan indicated on 8/24/2023 the physician ordered Macrobid 2 capsules by mouth twice daily for 7 days for a urinary tract infection. The goal of the care plan included Resident #66 would not have signs or symptoms of infection. The interventions included administering the antibiotics as ordered, encouraged fluids, evaluate pain, evaluate urinary complaints, monitor for cognitive changes, and monitor laboratory results. Record review of a urinalysis dated 8/15/2023 indicated Resident #66 had 0-5 red blood cells (none seen), bacteria was many (none seen), mucous light (none seen), appearance cloudy (clear), and leukocyte esterase moderate (negative). There were no orders written on the laboratory sheet but was signed by the physician. Record review of a urinalysis with a culture dated 8/22/2023 indicated Resident #66 had a urinary tract infection with greater than 100,000 Raoultella Planticola (bacteria) organism. The order provided on the laboratory result was Macrobid 100 milligrams one capsule twice daily for 7 days. During an observation on 9/18/2023 at 2:36 p.m., Resident #66 was assisted to her bed by two staff using a gait belt. Resident #66 was assisted by CNA P to remove her pants. CNA P, with her gloves on, touched the clean wipes and the brief. Resident #66's brief was opened by CNA P. CNA P then used a wipe and wiped down on each side of Resident #66's perineal area. Then CNA P wiped one wipe down the middle. Resident #66 was assisted by CNA O to roll to the right and CNA P cleansed her buttocks using three wipes. CNA P then removed her gloves, washed her hands, reapplied gloves, and then attempted to apply the brief. During the application of the brief. The brief tabbed area tore. CNA P removed her gloves and washed her hands again. Resident #66 urinated again on the clean brief. CNA O was aware Resident #66 urinated on the clean brief. Upon CNA P's return to the bedside CNA O indicated to CNA P Resident #66 urinated again. CNA P applied the clean brief and Resident #66 was repositioned. During an interview on 9/18/2023 at 2:36 p.m., CNA O said she believed incontinent care went well with no mistakes. During an interview with CNA P she said she was nervous but she thought the incontinent care went well. When asked why she failed to provide Resident #66 incontinent care again after she urinated on her torn brief, she said she did not have any more wipes. CNAs O and P said Resident #66 could get a UTI or a rash from improper incontinent care. Record review of CNA P's Certified Nursing Assistant Competency Checklist dated 8/24/2023 indicated CNA P was evaluated for perineal care-female with and without a catheter. The evaluation indicated CNA P met the evaluation criteria with a satisfactory (s) skill level. 6. During an observation and interview on 09/20/2023 starting at 8:45 AM, CNA V provided incontinent care to Resident #2. CNA V unfastened Resident #2's dirty brief and removed it. CNA V wiped Resident #2's front perineal area with the same wipe twice in different areas. CNA V failed to use a new wipe when going to a different area. CNA V turned Resident #2 and wiped her buttocks and removed the dirty brief. CNA V removed her dirty gloves and applied new gloved. CNA V did not perform hand hygiene after removing her gloves. CNA V placed the new brief under Resident #2 and applied barrier cream to her buttocks. CNA V removed her gloves and applied clean gloves. CNA V did not perform hand hygiene after removing her gloves. CNA V finished applying the new brief. CNA V removed her gloves and gathered the bag with trash. CNA V repositioned Resident #2 in her bed. CNA V exited the room and disposed of the trash and washed her hands. CNA V said when providing perineal care, she was supposed to use a different wipe every time she wiped. CNA V said she did not realize she had wiped twice in different areas with the same wipe. CNA V said she should have performed hand hygiene after removing her gloves. CNA V said she got nervous and forgot to perform hand hygiene. CNA V said she had been checked off on incontinent care about a month ago. CNA V said the CNAs were responsible for providing proper incontinent care. CNA V said it was important to provide proper incontinent care and perform hand hygiene during incontinent care to prevent cross contamination and UTIs. During an interview on 09/21/2023 at 3:15 PM, LVN Q said the charge nurses were responsible for making sure the CNAs provided proper incontinent care. LVN Q said she monitored the CNAs by going in with them when they provided incontinent care at least once a shift. LVN Q said sometimes she had to prompt them to change their gloves, and she had to prompt them to completely clean the residents. LVN Q said it was important for the CNAs to provided proper incontinent care and perform hand hygiene to decrease UTIs and any kind of infections, and to make sure the residents were clean and did not have any skin breakdown. During an interview on 09/21/2023 at 3:34 PM, the ADON said as a team the nurses and department heads were responsible for making sure the CNAs were providing proper incontinent care and performing hand hygiene adequately while providing incontinent care. The ADON said skills check offs were performed by the DON yearly and in-services were done as needed. The ADON said the CNAs providing proper incontinent care was monitored by the skills check offs and random checks. The ADON said she had not noticed any issues with incontinent care. The ADON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to keep infections down and so the residents would not get a UTI. During an interview on 09/21/2023 at 4:01 PM, the DON said the nurse managers and herself were responsible for ensuring the CNAs were providing proper incontinent care and performing hand hygiene. The DON said this was monitored by the competency checks and random pop-ins on the CNAs while they were performing incontinent care. The DON said it was important for the CNAs to provide proper incontinent care and perform hand hygiene to prevent infection and UTIs. During an interview on 09/21/2023 at 4:19 PM, the Administrator said she expected the CNAs to provide proper incontinent care and perform hand hygiene. The Administrator said the charge nurses and nurse managers were responsible for ensuring the CNAs provided proper incontinent care and performed hand hygiene. The Administrator said it was important for the CNAs to provide proper incontinent care and perform hand hygiene for cleanliness and to reduce infections. During an interview on 9/21/2023 at 11:52 a.m., the ADON said she expected incontinent care and catheter to be performed correctly. The ADON said when incontinent care and catheter care was not performed correctly the resident was at risk for a urinary tract infection. The ADON said she expected catheter care to include cleaning of the tubing. The ADON said changing of the gloves should occur as often as needed but no less than 3 times during the process. The ADON said when a resident urinated again after just receiving incontinent care, she expected the resident to receive incontinent care again. The ADON said she expected the CNAs to clean the labia to prevent bowel movement from being pressed inside the urethral area causing an infection. The ADON said she had been in-serviced on incontinent care male and female, foley catheter, she had been checked off on skills in this area. The ADON said she had been given the task of infection control now. The ADON said she was unsure of her role as of yet, but her role would include identifying the infectious organism. The ADON said identification of the organism was important to monitor for trends. During an interview on 9/21/2023 at 12:04 p.m., RN C (unit manager) said she had in-serviced CNAs on incontinent care, catheter care, and infection control. RN C said she had in serviced the DON and ADON on tracking and trending of infections, monitoring of organisms, and the importance of identification of the organism to in-service staff on hydration and cleanliness, and to perform skills checks on incontinent care. RN C said she expected the CNAs to not wipe the residents from back to front, to change gloves between dirty and clean, and to ensure the female labia were cleansed. During an interview on 9/21/2023 at 12:15 p.m., the DON said she had conducted in-services regarding catheter care, hand hygiene, incontinent care, and prevention of infections. The DON said she had been in-serviced by RN C on tracking and trending of the organism and the importance. The DON said the tracking and trending log for infections had a column now added for organism. The DON said the tracking of the organism would help to see a trend and to identify if a certain hall or staff member may factor in on the results. The DON said the team will meet weekly and discuss the bacteria in the infections and then implement interventions. The DON said prior to this, there had been no formal meetings to involve everyone. The DON said the infection preventionist would just look over the infections. The DON said she had in serviced the hospice provider and the medical director on the antibiotic stewardship. The DON said she in-serviced in May and had the staff checked off on their skills but was still unsure of the deficient practice at an IJ level. During an interview on 9/21/2023 at 12:27 p.m., the Administrator said she would be more involved in monitoring, competencies, and in-servicing for infection control. The Administrator said she would attend the weekly infection control meetings and ensure during the QA meetings the infections were also discussed. The Administrator said she believed the tracking and trending of the organisms could help not to spread infections. During an interview on 9/21/2023 at 12:29 p.m., the Assistant Administrator/Owner said she would be involved in looking over the infections, and in-services. The Assistant Administrator/Owner said she was present in the facility 7 days a week and she would be involved in the monitoring more so. The Administrator/Owner said the infections would also be discussed in the morning meeting. The Assistant Administrator said she had been more involved in the past, but her spouse had become ill over the summer, and she had spent half days away from the facility and the DON herself had suffered a loss which took her away from the facility, but she remained unsure why the in-service in May and the staff check offs failed to prevent the deficient practice. 7. Record review of the Infection Control-Donning/Doffing, PPE and Handwashing in-service was completed on 01/02/2023. Record review of the Incontinent Care/UTI in-service was completed on 05/08/2023. Record review of the undated Antimicrobial Stewardship policy, indicated, the facility will establish a multidisciplinary antimicrobial stewardship program that defines and provides guidance for optimal antimicrobial use 3. The members of the antimicrobial stewardship program will develop, endorse, and adopt established guidelines for use by facility staff for appropriate identification and assessment of infections and treatment guidelines 4. The members of the antimicrobial stewardship program will meet at least quarterly to review collected date and facility trends, analyze performance, and develop action plans to improve antimicrobial date and facility trends, analyze performance and develop action plans to improve antimicrobial use. Essential date to review includes a. antimicrobial orders b. clinical documentation c. supplemental information from d. effective communication among nursing staff and between nurses and physicians/prescribers Record review of the undated Infection Control Program policy, indicated It is the policy of this facility to have an infection control program, which assures a clean, safe, and sanitary environment for the residents 1. The facility will have an infection control system which will monitor and identify concerns in the following areas: Provides definition of acquired and communicable diseases, A means of identification of risk for infection factors, A means of identification and tracking of infections in the facility, to prevent spread of infections, Protocols for identification and isolation of residents with infectious process, Education information process to assure the staff understands how to care for residents and contain the infectious process to prevent further spread, Education and refresher in-services on infection control and standard precautions, Screening of staff to assure a decrease in the odds of transmission of infectious processes in the community, Sanitization methods for use in showers, whirlpools and multiple use equipment 2. The Director of Nursing or Designee will review staff procedures observations of standard precaution, infection control and isolation procedures 4. Labs will be reviewed by DON and/or Designee 5. Infection control log will be maintained with documentation of Resident/type of infection/antibiotic/treatment, start date . Record review of the facility's policy effective date 06/09/2023, titled, Hand Hygiene, indicated, Policy It is the policy of this facility to sanitize/clean hands properly to prevent the spread of infection . https://www.mayoclinic.org/diseases-conditions/urinary-tract-infection/symptoms-causes/syc-20353447 A urinary tract infection (UTI) is an infection in any part of the urinary system. The urinary system includes the kidneys, ureters, bladder and urethra. Most infections involve the lower urinary tract - the bladder and the urethra. Women are at greater risk of developing a UTI than are men. If an infection is limited to the bladder, it can be painful and annoying. But serious health problems can result if a UTI spreads to the kidneys. Health care providers often treat urinary tract infections with antibiotics. You can also take steps to lower the chance of getting a UTI in the first place. UTIs typically occur when bacteria enter the urinary tract through the urethra and begin to spread in the bladder. The urinary system is designed to keep out bacteria. But the defenses sometimes fail. When that happens, bacteria may take hold and grow into a full-blown infection in the urinary tract. The most common UTIs occur mainly in women and affect the bladder and urethra. o Infection of the bladder. This type of UTI is usually caused by Escherichia coli (E. coli). E. coli is a type of bacteria commonly found in the gastrointestinal (GI) tract. But sometimes other bacteria are the cause. When treated promptly and properly, lower urinary tract infections rarely lead to complications. But left untreated, UTIs can cause serious health problems. Complications of a UTI may include: o Repeated infections, which means you have two or more UTIs within six months or three or more within a year. Women are especially prone to having repeated infections. o Permanent kidney damage from a kidney infection due to an untreated UTI. o Delivering a low birth weight or premature infant when a UTI occurs during pregnancy. o A narrowed urethra in men from having repeated infections of the urethra. o Sepsis, a potentially life-threatening complication of an infection. This is a risk especially if the infection travels up the urinary tract to the kidneys. Prevention These steps may help lower the risk of UTIs: o Drink plenty of liquids, especially water. Drinking water helps dilute the urine. That leads to urinating more often - allowing bacteria to be flushed from the urinary tract before an infection can begin. o Try cranberry juice. Studies that look into whether cranberry juice prevents UTIs aren't final. However, drinking cranberry juice is likely not harmful. o Wipe from front to back. Do this after urinating and after a bowel movement. It helps prevent the spread of bacteria from the anus to the vagina and urethra. https://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf Record review of Urinary Tract Infection (Catheter-Associated Urinary Tract Infection (CAUTI) and Non-Catheter-Associated Urinary Tract Infection (UTI) events Urinary tract infections (UTIs) are the fifth most common type of healthcare-associated infection, with an estimated 62,700 UTIs in acute care hospitals in 2015. UTIs additionally account for more than 9.5% of infections reported by acute care hospitals1 . Virtually all healthcare associated UTIs are caused by instrumentation of the urinary tract. Approximately 12%-16% of adult hospital inpatients will have an indwelling urinary catheter (IUC) at some time during their hospitalization , and each day the indwelling urinary catheter remains, a patient has a 3%-7% increased risk of acquiring a catheter-associated urinary tract infection (CAUTI).2-3 CAUTI can lead to such complications as prostatitis, epididymitis, and orchitis in males, and cystitis, pyelonephritis, gram-negative bacteremia, endocarditis, vertebral osteomyelitis, septic arthritis, endophthalmitis, and meningitis in patients. Complications associated with CAUTI cause discomfort to the patient, prolonged hospital stay, and increased cost and mortality4 . It has been estimated that each year, more than 13,000 deaths are associated with UTIs.5 . https://www.ncbi.nlm.nih.gov/books/NBK436013/ Record review of Complicated Urinary Tract Infections: Urinary tract infections (UTIs) are among the most common presenting causes of sepsis in hospitals. Some are simple UTIs that can be managed with outpatient antibiotics and lead to almost universally good outcomes. However, complicated urinary tract infections may lead to florid urosepsis, which can be fatal. Several risk factors can complicate urinary tract infections and lead to treatment failure, repeat infections, or significant morbidity and mortality. It is vitally important to determine if the patient's infection may have resulted from one of these risk factors and whether the episode is likely to resolve with first-line antibiotics. Complicated urinary tract infections are those that present with greater morbidity, carry a higher risk of treatment failure, and typically require longer antibiotic courses, frequently requiring additional workup. Complicated urinary tract infections include those that occur: in males, in pregnant females (including asymptomatic bacteriuria), as a result of obstruction, hydronephrosis, renal tract calculi, or colovesical fistula, in immunocompromised patients or the elderly, due to atypical organisms, after instrumentation, involve urinary catheters, in renal transplant patients, in patients with impaired renal function, after prostatectomies or radiotherapy. Additionally, urinary tract i [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 1 of 9 residents reviewed for accident hazards (Resident #1). CNA B did not ensure Resident #1's safety belt was fastened during transport to [CONDITION(S)]. Resident #1 fell out of his wheelchair during transport and sustained a fracture to his left orbital (the bony cavity around the eyeball). This failure could place dependent residents at risk for injury and hospitalization . Findings included: Record review of the physician order summary report indicated Resident #1 was [AGE] years old readmitted to the facility on [DATE] with diagnosis including history of stroke, type 2 diabetes, high blood pressure, heart failure, and [CONDITION(S)]. Record review of the MDS dated [DATE] indicated Resident #1 usually made himself understood and usually understood others. The MDS indicated Resident #1 had moderate cognitive impairment (BIMS of 12). The MDS indicated he had no behavior of rejecting care. The MDS indicated Resident #1 was totally dependent on staff for transfers, locomotion in his wheelchair, dressing, eating, toilet use, personal hygiene and bathing. The MDS indicated he required extensive assistance with bed mobility. The MDS indicated Resident #1 had impairment on one side of the body to both the upper extremity and lower extremity. The MDS indicated Resident #1 had an active diagnosis of [CONDITION(S)], TIA or stroke. The MDS indicated Resident #1 had no fall history in the last six months. The MDS indicated Resident #1 had received anticoagulant therapy daily during the 7 day look back period. The MDS indicated Resident #1 had received [CONDITION(S)] during the 14 day look back period. Record review of the care plan revised on 10/21/21 indicated Resident #1 was at risk for falls, had limited physical mobility, had a self-care deficit and received [CONDITION(S)] at an outpatient [CONDITION(S)] center every Monday, Wednesday and Friday. The care plan interventions included assist with ambulation and transfers; reposition as necessary in wheelchair using Hoyer sling; evaluate resident's ability to perform ADLs/IADLs and encourage resident to go for scheduled [CONDITION(S)] appointments. During an interview on 10/23/21 at 3:30 p.m., the DON said on 10/22/21 he received a call from CNA B at approximately 12:00 p.m. He said CNA B told him that while she was on her way to the [CONDITION(S)] center with Resident #1, she had to hit the brakes. He said CNA B said when she hit her breaks Resident #1 slid out of his wheelchair and into the floor of the transport van. The DON said CNA B told him she had not fastened the lap belt and shoulder strap. The DON said CNA B could not say why she had not strapped the lap belt and shoulder strap. The DON said CNA B said she knew she was supposed to make sure that both the lap belt and shoulder strap were secured but she just forgot. The DON said he immediately assessed Resident #1. The DON said Resident #1 was able to tell him he fell out of the wheelchair and hit his head on the back of the driver seat. The DON said Resident #1 had no complaints of pain to his head and his neurological exam was normal. He said Resident #1 initially stated he had a little pain to his right hip but once the DON assisted him back into his wheelchair and palpated the right hip area Resident #1 said he no longer had the pain to the right hip. The DON said he phoned the [CONDITION(S)] center to notify them of the incident and ensure they could continue neurological checks every 15 minutes. The DON said Resident #1 was then transported to [CONDITION(S)]. The DON said he then notified Resident #1's representative. The DON said the representative requested he be evaluated in the emergency department due to Resident #1's anticoagulant therapy. The DON said he then notified the physician who agreed evaluation should be performed in the emergency department. The DON contacted the [CONDITION(S)] center and explained [CONDITION(S)] would have to be stopped so Resident #1 could be transported to the emergency room . He said Resident #1 was evaluated in the emergency department and was found to have a fractured orbital. He said Resident #1 was sent back to the facility late on 10/22/21. The DON said Resident #1 would not have had the ability to brace himself during the fall as he had left sided paralysis. The DON said he verified that CNA B had been trained over the facility's transportation policy and procedure before being allowed to transport residents. He said CNA B was in-serviced over safe transports after the incident. The DON said there were 2 other transport aides that worked at the facility, transportation aide A and transportation aide C. The DON said he reported the incident to the Administrator right away. The DON said to his knowledge there was not a system in place, other than initial training to ensure transportation aids secured residents for transport properly. He said since the incident, himself and the Administrator were working on a check system. Record review of the hospital CT of the maxillo facial for Resident #1 dated 10/22/21 (related to the jaws and face) indicated he had a minimal nondisplaced fracture in the medial wall of the left orbit. During an interview on 10/23/21 at 3:35 p.m., Resident #1's representative said she was notified on 10/22/21 at 12:06 p.m., that Resident #1 had fallen out of his wheelchair when the transport personnel had to hit her brakes suddenly on the way to [CONDITION(S)]. She said Resident #1 told her he hit his head on the back of the drivers' seat. She said Resident #1 told her that CNA B was a good driver and had taken him to [CONDITION(S)] many times. The Resident representative said Resident #1 went to the hospital and at first the hospital was concerned he had a brain bleed. She said the hospital later ruled that out and found he had a fracture to bone around his eye. She said Resident #1 returned to the facility at around 10:00 p.m. During an interview on 10/23/21 at 3:42 p.m., CNA B said while she was transporting Resident #1 to [CONDITION(S)] on 10/22/21, she had to hit her brakes at a red light. CNA B said after she hit her brakes, she heard Resident #1 moan, and looked down and he was in the floor. CNA became tearful and said, I always make sure that wheelchair is secured properly in the van, I don't know how I didn't check to make sure the lap and shoulder belt were fastened. She explained there was a lap belt and shoulder belt that keep Resident #1 secure in the wheelchair once the wheelchair itself has been secured. She said it must have slipped her mind to check that the lap and shoulder belt were secured. CNA B said she had been trained on transportation safety and knew the belts needed to be secured. CNA B tearfully said she had been trained again after the incident and would never make that mistake again. CNA B said she immediately called the DON after the incident. During an observation on 10/23/21 at 4:00 p.m., Resident #1 was laying in his bed. Resident #1 had slight swelling to his left eye. Resident #1 said he wasn't in any pain at the moment, that the facility had given him a pain pill. Resident #1 said he just fell out of his wheelchair yesterday when CNA B had to hit her brakes. Resident #1 said he could not remember if his safety belt was on. Resident #1 said CNA B usually checked his seatbelt. During an interview on 10/23/21 at 4:23 p.m., transportation aide A said her primary job was housekeeping supervisor, but she had also helped with transportation at the facility for the last 6 years. Transportation aide A said when she transported a resident who was wheelchair dependent it was important to ensure the wheelchair was secured to the van. She said it was important to ensure the lap belt and shoulder straps were secured. Transportation aide A said these things were important because a resident could become injured if they were not done and done properly. Transportation aid A said she had been trained on transportation safety and learned how to properly secure the resident for transport before she started work as a transportation aid. During an interview on 10/23/21 at 4:32 p.m., transportation aide B said his primary job at the facility was transportation. Transportation aide B said he had worked at the facility for the last year. Transportation aide B said when he transported a resident who was wheelchair dependent it was important to ensure the wheelchair was secured to the van. He said it was important to ensure the lap belt and shoulder straps were secured. Transportation aide B said these things were important because a resident could become injured if they were not done and done properly. Transportation aid B said he had been trained on transportation safety and learned how to properly secure the resident for transport before he started work as a transportation aide. During an interview on 10/23/21 at 4:47 p.m., the Administrator said CNA B had been trained over proper wheelchair and resident securement before working as a transportation aide. She said after the incident CNA B was re-in-serviced. The Administrator said she reported the incident to the state when they called the hospital to check on Resident #1 and learned he had sustained a fractured orbital. The Administrator said she was also informed at that time, the hospital was planned to obtain additional imaging to rule out a brain bleed. The Administrator said Resident #1 returned to the facility at approximately 10:00 p.m. after the hospital had ruled out the presence of a brain bleed. The Administrator said it was extremely important to ensure residents were safely secured before transport to avoid situations like this. The Administrator said CNA B, nor any other transportation aide had ever had incident like this occur. The Administrator said in the past there had been no system to ensure transportation aides had properly secured the wheelchair and resident before transport, other than the training they had received. The Administrator said after the incident with Resident #1 she was working with the DON to ensure there was a check system in place so that CNA B's mistake was not repeated. Record review of the facility policy and procedure titled, Transportation Policy and Procedures, dated 4/23/19, stated .ensure the wheelchair seatbelt is secure .Securing the Rider- Rider has lap/shoulder belt system recommended for their use. Lap belt is positioned over the pelvic bone (not abdomen). Lap belt is inside the armrests, between the side panels and the seat cushion. Lap belt is snug. Shoulder belt is not under the rider's arm where it would cross the rib cage. Shoulder belt is adjusted to achieve firm but comfortable tension. Lap belt and shoulder belt lie flat against the body (not twisted) .Driver must ensure that all passengers are wearing a seat belt.

Based on observation, interview and record review, the facility failed to ensure a resident had the right to be free from neglect for one (Resident #1) of five residents reviewed for neglect to address [MEDICAL CONDITION]. RN A was aware of sucical remarks and failed to implement interventions for Resident #1 that expressed [MEDICAL CONDITION] from midnight ([DATE]) till 7:00 AM ([DATE]). The following morning, Resident #1 was found with oxygen tubing wrapped around her neck. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. These failures could affect the 26 residents, who resided on the E Hall, by placing them at risk for neglect, serious harm and death. Findings included: The admission MDS, dated [DATE], for Resident #1 reflected a [AGE] year- old-female with an admission date of [DATE] with a BIMS score of 15 which indicated she was cognitively intact. She required limited assistance with ADLs. Resident #1's active [DIAGNOSES REDACTED]. The facility's interdisciplinary care plan dated [DATE], revealed Resident #1 required monitoring for behavioral issues such as anxiety, mood stability and follow-up as needed for confusion and yelling out. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] (Friday) at 2000 (8:00 PM), reflected, . Resident yelling loudly, I want to go home. I am going to hang myself, cut myself with knife or scissors. Talked with res. (resident) and she is very confused but keeps saying she wants to go home and she knows she is dying. Resident did not express any plans to harm herself. She called her daughter-in-law that I also spoke to. She told me to send her out if (Physician D) if that is what is needed. Called (Physician D) he wanted to order, n/o: [MEDICATION NAME] 10 mg. IM X1 now. To call him back if not successful in calming her down. He told me to tell the family they needed to pick a Hospice co. and set-up meeting to admit res to hospice. Family was under the impress res. was already on Hospice. Explained she wasn't. Family is to make some arrangements today to talk with Hospice. Resident #1's Physician order, dated [DATE] at 2000 (8:00 PM) reflected [MEDICATION NAME] 10mg IM x 1 now. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] at 9:00 PM, documented Resident #1 had no new episodes or behaviors noted. RN notes at 12:00 AM (Midnight [DATE]) that Resident #1 had no behaviors noted. There were no additional notes completed by RN A. The next Daily Skilled Nursing Notes, were dated [DATE] (Saturday) at 07:15 AM and competed by RN B, documented went to assess resident at this time, Resident noted to be very lethargic and had nasal cannula wrapped snuggly around neck about ,[DATE] times, this nurse quickly un-wrapped cannula tubing from around neck. Blood sugar checked d/t (due to) lethargy BS (blood sugar) was 41 with a recheck to confirm. (Physician D) made aware n/o (new order) noted to give [MEDICATION NAME] 1 mg. (milligram) IM (intramuscular) X1 (times one) dose and sent to ER. At 8:00 AM, RN B documented she had notified RN C, the week-end supervisor and informed her of incident. Review of the facility's Transfer Form for Resident #1, dated [DATE], reflected, Residents Information: .DX: [MEDICAL CONDITIONS]BS this A.M. 42 [MEDICATION NAME] 1 mg IM 1x time. Nasal Cannula wrapped 3x (three times) around neck. Hx (history): URI (upper respiratory infection), CAD ([MEDICAL CONDITION]), Depression cyst to coccyx . An interview with RN A on [DATE] at 6:39 PM revealed she had worked on [DATE] from 6:00 PM till 6:00 AM. She stated Resident #1 had been yelling out for hours I want to go home; I don't want to die here. She stated she was agitated and restless. She knew she was dying. She stated her family was visiting earlier and she had told them if you leave me here, I am going to kill myself. RN revealed she did not notify the DON or Administrator that Resident #1 had made comments that she was going to kill herself, hang herself or cut herself with a knife or scissors. She stated she did not initiate the suicide protocol because she did not think Resident #1 had a plan and she could not harm herself. I did not have anyone monitor one-on-one with her because she did not have a plan. Per documentation of Daily Skilled Nursing Notes reflected no entries after midnight. An interview with CNA E on [DATE] at 2:30 PM revealed she had worked the ,[DATE] shift on [DATE] and was assigned to care for Resident #1. She stated the resident was crying out I have to get out of here; God knows I have been patient. CNA E revealed RN A came in to work around 6:00 PM and Resident #1 was still yelling about wanting to go home. She stated RN A did not inform her Resident #1 had made any comments that she wanted to harm herself. She was not told to sit one-on-one with Resident #1. An interview with CNA F on [DATE] at 8:31 PM revealed RN A stated that Resident #1 made a statement that she wanted to kill herself, but she did not have a plan. He was not told to sit her one-on-one with Resident #1. CNA F stated he only did routine rounds no other interventions were implemented [MEDICAL CONDITION]. An interview with the Medical Director on [DATE] at 12:30 PM confirmed RN A had consulted with him regarding Resident #1's comments and behavior. He stated Resident #1 was not a candidate to transfer to a psychiatric unit or another hospital stay. She knew she was dying and wanted to go home. She was having a mental health crisis so he ordered medication to help calm her down. An interview with RN G on [DATE] at 2:32 PM revealed he had worked Friday, [DATE], on the 10PM -6AM shift. He stated RN A did not inform him about Resident #1 making statements that she wanted to harm herself, and she did not ask for assistance with Resident #1's care nor did she ask the CNAs assigned on his hall to help with Resident #1's care. An interview with RN B on [DATE] at 8:45 AM revealed she worked on [DATE] from 6:00 AM till 6:00 PM. She stated when she received shift change report from RN A, she was told Resident #1 had been upset with her family and told them if they left her in the facility that she was going to kill herself; she did not want to die in the facility, and she wanted to die at home. She stated as she entered the resident's room, she saw the oxygen tubing wrapped around her neck two to three times. She yelled for RN A to come help her. She removed the tubing from around her neck. She noticed Resident #1 was lethargic. She checked her blood sugar and it was low. She called Physician D and was given an order to send Resident #1 to the emergency room . She notified RN C, the week-end supervisor of the incident. Review of RN C's Daily Skilled Nursing Notes, dated [DATE] at 8:05 AM, reflected she had called and notified DON of Resident #1 wrapping her oxygen tubing around her neck before Resident #1 was sent to ER for low BS. At 8:30 AM, RN C documented she had called and spoke with resident's son . We discussed the fact that although the tubing was not tight enough to cut off her air supply it was a big concern regarding her mental health. An interview with RN C on [DATE] at 4:05 PM confirmed she worked on Saturday, [DATE], as the week-end supervisor. She was informed by RN B of Resident #1 was found with her oxygen tubing wrapped around her neck and she had been sent to the hospital for low blood sugar. She stated she went back and read the nurses notes from [DATE] and [DATE]. At that time, she called the DON and informed her of the incident. The DON informed her to notify the hospital that she had wrapped the oxygen tubing around her neck, and she wanted a mental health evaluation done before she was readmitted to the facility. An interview with the DON on [DATE] at 1:00 PM revealed RN C called her on Saturday, [DATE], after Resident #1 had wrapped the oxygen tubing around her neck. RN C read the documentation where Resident #1 stated she was going to hang herself, cut herself with a knife or scissors. The DON informed RN C to notify the hospital of the suicide threats and inform them she needed a mental health evaluation. RN C called her back and informed her Resident #1 had been admitted to the hospital related to her abnormal labs, but not to the psychiatric unit. The DON stated she felt since Resident #1 was admitted to the hospital that everything had been taken care of and no further actions needed to be done. During a subsequent interview with DON on [DATE] at 5:18 PM, she was asked what had been done in response to the Resident #1 making suicide threats and an attempt. She stated she thought the issue was resolved since Resident #1 was admitted to the hospital. She was asked if an incident occurred, what steps had been taken to prevent this from happening again. She stated the facility had not done in-servicing on their suicidal protocol and there had been no counseling for RN A. She stated there has not been any training on the suicide protocol since she started to work in 2008. She stated the facility had an incident report related to the suicide threats or the oxygen tubing wrapped around her neck. An interview with the Administrator on [DATE] at 12:24 PM revealed the DON had called her on Saturday, [DATE], and she was informed of Resident #1's oxygen tubing being wrapped around her neck. Resident #1 should have been placed on one-on-one Friday night ([DATE]) until a psychiatric evaluation was done or until she was no longer in danger. She stated she had instructed the DON to discipline RN A since she did not place the resident on one-one and did not follow the suicide protocol and if any resident makes suicide statements that the facility needed to ensure their safety. She stated by the time Monday ([DATE]) came, she thought the issue had been resolved because Resident #1 was admitted to the hospital. Review of the facility's Suicide Protocol, dated ,[DATE], and reflected the Procedures included the following: (1) Risk factors for residents may include, but are not limited to: (a) Making statements about helplessness, hopelessness, worthlessness, uselessness . (c) Threatening suicide or to harm oneself in some way .(e) Having a well thought out and do-able plan and access to lethal means . (2) When the interdisciplinary team considers a resident as a possible suicide risk, additional screening occurs that includes asking the resident the following questions: (a) Have you thought about killing yourself? Are you thinking about it right now? (b) Are these thoughts persistent and uncontrollable? (c) Do you have a plan on how to kill yourself? (d) Have you the means to carry out this plan? (e) Do you intend to carry out this plan? (4) If there appears to be no immediate danger (for example, there is no evidence of available lethal means), the team member may: (a) Express caring and concern for the resident, (b) Enlist the support of the resident's family, caregivers and significant others to engage the patient and actively listen to his or her expressed concerns . (d) Offer continuous care to provide a suicide watch until the crisis subsides . On [DATE] at 3:36 PM, the Administrator, Assistant Administrator and the DON were notified of IJ had been identified and a plan of removal was requested at that time. Interview with the Administrator on [DATE] at 9:00 AM, revealed the IJ came about related to the RN A not following the facility's policy on suicide protocol. Review of the plan of removal, accepted on [DATE] at 1:12 PM, reflected the following: --Background information: RN A failed to notify Administrator or DON. RN A, also did not initiate a 1:1 supervision and also failed to follow facility suicide policy. RN A failed to notify CNA E, CNA E who was assigned to Resident #1 about the statements resident had made and did not ask CNA E to provide 1:1 supervision of Resident #1. RN A also did not notify or get assistance from any other staff members in the facility. Resident expired at facility on [DATE] at 0008 while on Palliative Care per family request. --Implementation of Changes: All employees upon new hire and annually will be trained on our suicide policy and given a post test. As soon the Administrator, DON, or designee is notified of a suicide threat, that individual will come to the facility and assess situation, review documentation, and ensure that the facility policy and protocol was followed. The social worker will continue to initial social history to identify any risk of suicide. Charge nurses will continue to assess residents upon admission using Resident Data Collection Tool which assess mood. All new admissions, prn residents that have been identified at risk will be referred to DR H for mental health screen. --Monitoring: The DON, Administrator, ADON or designee will monitor compliance of the suicide policy by reviewing the suicide competency test of a score of 80 or additional training until a score of 80 is reached. The Resident Data Collection will be reviewed within 24 hours of admission by the DON, ADON or designee for monitoring for potential risk of suicide. All incident reports will be monitored in daily morning meeting, and the week-end nurse will monitor the incident reports on the week-end. The social worker will notify the Administrator or DON immediately of any resident potential risk of suicide upon completion of the initial Social Service Assessment or Minimum Data Set section D, resident mood interview. --On [DATE], the Social Worker performed safe rounds and interviews the 26 residents that resided on the E hall. If they had any care concerns, staff treatment, and if there needs were being met. --On [DATE], the Social Worker conducted Minimum Data Set section D, resident mood interview with the 26 residents that resided on the E hall. --On [DATE] at 2:30 AM, nurses were in-serviced suicide protocol and on [DATE] at 7:30 AM, staff were in-serviced on the Suicide Protocol by the ADON. Evidence of attendance was determined by a sign off sheet for each staff members that were scheduled to work. On [DATE] the facility had a mandatory all staff in-service on suicide Protocol. Evidence of attendance was determined using a payroll roaster check off. --RN A was terminated on [DATE] for violation of company rules employee violated company policy and procedure, by not ensuring the safety of a resident who made a threat of suicide, who had a plan, and was found the next morning by the oncoming nurse with her oxygen tubing wrapped around her neck. --The DON received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and for falling to counsel RN A, for not following suicide policy. --The Administrator received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and employee counseling was done regarding suicide policy. On [DATE] at 1:12 PM, Administrator, Assistant Administrator, DON and ADON were notified the IJ was removed. While the IJ was removed on [DATE]. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. On [DATE]-[DATE], six licensed nurses, dietary staff, laundry staff and three CNA's, representing staff from all three shifts and week-end staffs were interviewed regarding the in-services and training they received on the facility's Suicide Protocol. They were each able to explain what actions to take if a resident made a verbal threat to harm self, who to notify of the verbal threat to harm self, completion of Suicide risk assessment and incident report and 1:1 monitoring. The staffs were RN A,RN B, RN C, RN G, CNA E , CNA F, CNA K, LVN I. LVN J, and Laundry Aid L. Dietary Aid M. In an interview with the Administrator on [DATE] at 9:00 AM revealed 26 residents resided on E Hall where RN A was assigned.

Based on observation, interview and record review, the facility failed to implement written policies and procedures that prevented neglect for one (Resident #1) of five residents reviewed for neglect to address [MEDICAL CONDITION]. RN A failed to recognize Resident #1's suicide intent and failed to monitor the resident throughout the night to ensure the resident did not have the means to follow through with suicide. As a result, the following morning, Resident #1 was found with oxygen tubing wrapped around her neck. The resident was also experiencing low blood sugar. The resident was sent to the emergency room . An IJ was identified on [DATE]. While the IJ was removed on [DATE] the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. These failures could affect the 26 residents, who resided on the E Hall, by placing them at risk for neglect, serious harm and death. Findings included: The facility's Abuse Policy dated [DATE] reflected Neglect . The failure to provide or services including medical services that is necessary to avoid physical or emotional harm, pain, or mental illness. Policy . (4) Identification of possible incidents or allegation which warrant investigation. (6) Investigation of incident and allegations. Investigation . The Director of Nursing, the Assistance Administrator will be responsible for coordinating the investigation of all allegations of abuse, neglect or exploitation. Review of the facility's Suicide Protocol, dated ,[DATE], reflected the Procedures included the following: (1) Risk factors for residents may include, but are not limited to: (a) Making statements about helplessness, hopelessness, worthlessness, uselessness . (c) Threatening suicide or to harm oneself in some way .(e) Having a well thought out and do-able plan and access to lethal means . (2) When the interdisciplinary team considers a resident as a possible suicide risk, additional screening occurs that includes asking the resident the following questions: (a) Have you thought about killing yourself? Are you thinking about it right now? (b) Are these thoughts persistent and uncontrollable? (c) Do you have a plan on how to kill yourself? (d) Have you the means to carry out this plan? (e) Do you intend to carry out this plan? (4) If there appears to be no immediate danger (for example, there is no evidence of available lethal means), the team member may: (a) Express caring and concern for the resident, (b) Enlist the support of the resident's family, caregivers and significant others to engage the patient and actively listen to his or her expressed concerns . (d) Offer continuous care to provide a suicide watch until the crisis subsides . The admission MDS, dated [DATE], for Resident #1 reflected a [AGE] year- old-female with an admission date of [DATE] with a BIMS score of 15 which indicated she was cognitively intact. She required limited assistance with ADLs. Resident #1's active [DIAGNOSES REDACTED]. The facility's interdisciplinary care plan dated [DATE], revealed Resident #1 required monitoring for behavioral issues such as anxiety, mood stability and follow-up as needed for confusion and yelling out. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] (Friday) at 2000 (8:00 PM), reflected, . Resident yelling loudly, I want to go home. I am going to hang myself, cut myself with knife or scissors. Talked with res. (resident) and she is very confused but keeps saying she wants to go home and she knows she is dying. Resident did not express any plans to harm herself. She called her daughter-in-law that I also spoke to. She told me to send her out if (Physician D) if that is what is needed. Called (Physician D) he wanted to order, n/o: [MEDICATION NAME] 10 mg. IM X1 now. To call him back if not successful in calming her down. He told me to tell the family they needed to pick a Hospice co. and set-up meeting to admit res to hospice. Family was under the impress res. was already on Hospice. Explained she wasn't. Family is to make some arrangements today to talk with Hospice. Resident #1's Physician order, dated [DATE] at 2000 (8:00 PM) reflected [MEDICATION NAME] 10mg IM x 1 now. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] at 9:00 PM, documented Resident #1 had no new episodes or behaviors noted. RN notes at 12:00 AM (Midnight [DATE]) that Resident #1 had no behaviors noted. There were no additional notes completed by RN A. The next Daily Skilled Nursing Notes, were dated [DATE] (Saturday) at 07:15 AM and competed by RN B, documented went to assess resident at this time, Resident noted to be very lethargic and had nasal cannula wrapped snuggly around neck about ,[DATE] times, this nurse quickly un-wrapped cannula tubing from around neck. Blood sugar checked d/t (due to) lethargy BS (blood sugar) was 41 with a recheck to confirm. (Physician D) made aware n/o (new order) noted to give [MEDICATION NAME] 1 mg. (milligram) IM (intramuscular) X1 (times one) dose and sent to ER. At 8:00 AM, RN B documented she had notified RN C, the week-end supervisor and informed her of incident. Review of the facility's Transfer Form for Resident #1, dated [DATE], reflected, Residents Information: .DX: [MEDICAL CONDITIONS]BS this A.M. 42 [MEDICATION NAME] 1 mg IM 1x time. Nasal Cannula wrapped 3x (three times) around neck. Hx (history): URI (upper respiratory infection), CAD ([MEDICAL CONDITION]), Depression cyst to coccyx . An interview with RN A on [DATE] at 6:39 PM revealed she had worked on [DATE] from 6:00 PM till 6:00 AM. She stated Resident #1 had been yelling out for hours I want to go home; I don't want to die here. She stated she was agitated and restless. She knew she was dying. She stated her family was visiting earlier and she had told them if you leave me here, I am going to kill myself. RN revealed she did not notify the DON or Administrator that Resident #1 had made comments that she was going to kill herself, hang herself or cut herself with a knife or scissors. She stated she did not initiate the suicide protocol because she did not think Resident #1 had a plan and she could not harm herself. She stated she did not have anyone monitor one-on-one with her because she did not have a plan. An interview with CNA E on [DATE] at 2:30 PM revealed she had worked the ,[DATE] shift on [DATE] and was assigned to care for Resident #1. She stated the resident was crying out I have to get out of here; God knows I have been patient. CNA E revealed RN A came in to work around 6:00 PM and Resident #1 was still yelling about wanting to go home. She stated RN A did not inform her Resident #1 had made any comments that she wanted to harm herself. She was not told to sit one-on-one with Resident #1. An interview with CNA F on [DATE] at 8:31 PM revealed RN A stated that Resident #1 made a statement that she wanted to kill herself, but she did not have a plan. He was not told to sit her one-on-one with Resident #1. An interview with the Medical Director on [DATE] at 12:30 PM confirmed RN A had consulted with him regarding Resident #1's comments and behavior. He stated Resident #1 was not a candidate to transfer to a psychiatric unit or another hospital stay. She knew she was dying and wanted to go home. She was having a mental health crisis so he ordered medication to help calm her down. An interview with RN G on [DATE] at 2:32 PM revealed he had worked Friday, [DATE], on the 10PM -6AM shift. He stated RN A did not inform him about Resident #1 making statements that she wanted to harm herself, and she did not ask for assistance with Resident #1's care nor did she ask the CNAs assigned on his hall to help with Resident #1's care. An interview with RN B on [DATE] at 8:45 AM revealed she worked on [DATE] from 6:00 AM till 6:00 PM. She stated when she received shift change report from RN A, she was told Resident #1 had been upset with her family and told them if they left her in the facility that she was going to kill herself; she did not want to die in the facility, and she wanted to die at home. She stated as she entered the resident's room, she saw the oxygen tubing wrapped around her neck two to three times. She yelled for RN A to come help her. She removed the tubing from around her neck. She noticed Resident #1 was lethargic. She checked her blood sugar and it was low. She called Physician D and was given an order to send Resident #1 to the emergency room . She notified RN C, the week-end supervisor of the incident. Review of RN C's Daily Skilled Nursing Notes, dated [DATE] at 8:05 AM, reflected she had called and notified DON of Resident #1 wrapping her oxygen tubing around her neck before Resident #1 was sent to ER for low BS. At 8:30 AM, RN C documented she had called and spoke with resident's son . We discussed the fact that although the tubing was not tight enough to cut off her air supply it was a big concern regarding her mental health. An interview with RN C on [DATE] at 4:05 PM confirmed she worked on Saturday, [DATE], as the week-end supervisor. She was informed by RN B of Resident #1 was found with her oxygen tubing wrapped around her neck and she had been sent to the hospital for low blood sugar. She stated she went back and read the nurses notes from [DATE] and [DATE]. At that time, she called the DON and informed her of the incident. The DON informed her to notify the hospital that she had wrapped the oxygen tubing around her neck, and she wanted a mental health evaluation done before she was readmitted to the facility. An interview with the DON on [DATE] at 1:00 PM revealed RN C called her on Saturday, [DATE], after Resident #1 had wrapped the oxygen tubing around her neck. RN C read the documentation where Resident #1 stated she was going to hang herself, cut herself with a knife or scissors. The DON informed RN C to notify the hospital of the suicide threats and inform them she needed a mental health evaluation. RN C called her back and informed her Resident #1 had been admitted to the hospital related to her abnormal labs, but not to the psychiatric unit. The DON stated she felt since Resident #1 was admitted to the hospital that everything had been taken care of and no further actions needed to be done. During a subsequent interview with DON on [DATE] at 5:18 PM, she was asked what had been done in response to the Resident #1 making suicide threats and an attempt. She stated she thought the issue was resolved since Resident #1 was admitted to the hospital. She was asked if an incident occurred, what steps had been taken to prevent this from happening again. She stated the facility had not done in-servicing on their suicidal protocol and there had been no counseling for RN A. She stated there has not been any training on the suicide protocol since she started to work in 2008. She stated the facility had an incident report related to the suicide threats or the oxygen tubing wrapped around her neck. An interview with the Administrator on [DATE] at 12:24 PM revealed the DON had called her on Saturday, [DATE], and she was informed of Resident #1's oxygen tubing being wrapped around her neck. Resident #1 should have been placed on one-on-one Friday night ([DATE]) until a psychiatric evaluation was done or until she was no longer in danger. She stated she had instructed the DON to discipline RN A since she did not place the resident on one-one and did not follow the suicide protocol and if any resident makes suicide statements that the facility needed to ensure their safety. She stated by the time Monday ([DATE]) came, she thought the issue had been resolved because Resident #1 was admitted to the hospital. On [DATE] at 3:36 PM, the Administrator, Assistant Administrator and the DON were notified of IJ had been identified and a plan of removal was requested at that time. Interview with the Administrator on [DATE] at 9:00 AM, revealed the IJ came about related to the RN A not following the facility's policy on suicide protocol. Review of the plan of removal, accepted on [DATE] at 1:12 PM, reflected the following: --Background information: RN A failed to notify Administrator or DON. RN A, also did not initiate a 1:1 supervision and also failed to follow facility suicide policy. RN A failed to notify CNA E, CNA E who was assigned to Resident #1 about the statements resident had made and did not ask CNA E to provide 1:1 supervision of Resident #1. RN A also did not notify or get assistance from any other staff members in the facility. Resident expired at facility on [DATE] at 0008 while on Palliative Care per family request. --Implementation of Changes: All employees upon new hire and annually will be trained on our suicide policy and given a post test. As soon the Administrator, DON, or designee is notified of a suicide threat, that individual will come to the facility and assess situation, review documentation, and ensure that the facility policy and protocol was followed. The social worker will continue to initial social history to identify any risk of suicide. Charge nurses will continue to assess residents upon admission using Resident Data Collection Tool which assess mood. All new admissions, prn residents that have been identified at risk will be referred to DR H for mental health screen. --Monitoring: The DON, Administrator, ADON or designee will monitor compliance of the suicide policy by reviewing the suicide competency test of a score of 80 or additional training until a score of 80 is reached. The Resident Data Collection will be reviewed within 24 hours of admission by the DON, ADON or designee for monitoring for potential risk of suicide. All incident reports will be monitored in daily morning meeting, and the week-end nurse will monitor the incident reports on the week-end. The social worker will notify the Administrator or DON immediately of any resident potential risk of suicide upon completion of the initial Social Service Assessment or Minimum Data Set section D, resident mood interview. --On [DATE], the Social Worker performed safe rounds and interviews the 26 residents that resided on the E hall. If they had any care concerns, staff treatment, and if there needs were being met. --On [DATE], the Social Worker conducted Minimum Data Set section D, resident mood interview with the 26 residents that resided on the E hall. --On [DATE] at 2:30 AM, nurses were in-serviced suicide protocol and on [DATE] at 7:30 AM, staff were in-serviced on the Suicide Protocol by the ADON. Evidence of attendance was determined by a sign off sheet for each staff members that were scheduled to work. On [DATE] the facility had a mandatory all staff in-service on suicide Protocol. Evidence of attendance was determined using a payroll roaster check off. --RN A was terminated on [DATE] for violation of company rules employee violated company policy and procedure, by not ensuring the safety of a resident who made a threat of suicide, who had a plan, and was found the next morning by the oncoming nurse with her oxygen tubing wrapped around her neck. --The DON received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and for falling to counsel RN A, for not following suicide policy. --The Administrator received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and employee counseling was done regarding suicide policy. On [DATE] at 1:12 PM, Administrator, Assistant Administrator, DON and ADON were notified the IJ was removed. While the IJ was removed on [DATE]. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. In an interview with the Administrator on [DATE] at 9:00 AM revealed 26 residents resided on E Hall where RN A was assigned.

Based on interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical well-being consistent with the resident's comprehensive assessment and plan of care, for one Resident (Resident #1) of five residents reviewed for behaviors. RN A failed to implement interventions for Resident #1 that expressed [MEDICAL CONDITION] from midnight ([DATE]) till 7:00 AM ([DATE]). The following morning, Resident #1 was found with oxygen tubing wrapped around her neck. An IJ was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. These failures could affect the 26 residents, who resided on the E Hall, by placing them at risk for neglect, serious harm and death. Findings included: The admission MDS, dated [DATE], for Resident #1 reflected a [AGE] year- old-female with an admission date of [DATE] with a BIMS score of 15 which indicated she was cognitively intact. She required limited assistance with ADLs. Resident #1's active [DIAGNOSES REDACTED]. The facility's interdisciplinary care plan dated [DATE], revealed Resident #1 required monitoring for behavioral issues such as anxiety, mood stability and follow-up as needed for confusion and yelling out. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] (Friday) at 2000 (8:00 PM), reflected, . Resident yelling loudly, I want to go home. I am going to hang myself, cut myself with knife or scissors. Talked with res. (resident) and she is very confused but keeps saying she wants to go home and she knows she is dying. Resident did not express any plans to harm herself. She called her daughter-in-law that I also spoke to. She told me to send her out if (Physician D) if that is what is needed. Called (Physician D) he wanted to order, n/o: [MEDICATION NAME] 10 mg. IM X1 now. To call him back if not successful in calming her down. He told me to tell the family they needed to pick a Hospice co. and set-up meeting to admit res to hospice. Family was under the impress res. was already on Hospice. Explained she wasn't. Family is to make some arrangements today to talk with Hospice. Resident #1's Physician order, dated [DATE] at 2000 (8:00 PM) reflected [MEDICATION NAME] 10mg IM x 1 now. Review of RN A's Daily Skilled Nursing Notes, dated [DATE] at 9:00 PM, documented Resident #1 had no new episodes or behaviors noted. RN notes at 12:00 AM (Midnight [DATE]) that Resident #1 had no behaviors noted. There were no additional notes completed by RN A. The next Daily Skilled Nursing Notes, were dated [DATE] (Saturday) at 07:15 AM and competed by RN B, documented went to assess resident at this time, Resident noted to be very lethargic and had nasal cannula wrapped snuggly around neck about ,[DATE] times, this nurse quickly un-wrapped cannula tubing from around neck. Blood sugar checked d/t (due to) lethargy BS (blood sugar) was 41 with a recheck to confirm. (Physician D) made aware n/o (new order) noted to give [MEDICATION NAME] 1 mg. (milligram) IM (intramuscular) X1 (times one) dose and sent to ER. At 8:00 AM, RN B documented she had notified RN C, the week-end supervisor and informed her of incident. Review of the facility's Transfer Form for Resident #1, dated [DATE], reflected, Residents Information: .DX: [MEDICAL CONDITIONS]BS this A.M. 42 [MEDICATION NAME] 1 mg IM 1x time. Nasal Cannula wrapped 3x (three times) around neck. Hx (history): URI (upper respiratory infection), CAD ([MEDICAL CONDITION]), Depression cyst to coccyx . An interview with RN A on [DATE] at 6:39 PM revealed she had worked on [DATE] from 6:00 PM till 6:00 AM. She stated Resident #1 had been yelling out for hours I want to go home; I don't want to die here. She stated she was agitated and restless. She knew she was dying. She stated her family was visiting earlier and she had told them if you leave me here, I am going to kill myself. RN revealed she did not notify the DON or Administrator that Resident #1 had made comments that she was going to kill herself, hang herself or cut herself with a knife or scissors. She stated she did not initiate the suicide protocol because she did not think Resident #1 had a plan and she could not harm herself. I did not have anyone monitor one-on-one with her because she did not have a plan. Per documentation of Daily Skilled Nursing Notes reflected no entries after midnight. An interview with CNA E on [DATE] at 2:30 PM revealed she had worked the ,[DATE] shift on [DATE] and was assigned to care for Resident #1. She stated the resident was crying out I have to get out of here; God knows I have been patient. CNA E revealed RN A came in to work around 6:00 PM and Resident #1 was still yelling about wanting to go home. She stated RN A did not inform her Resident #1 had made any comments that she wanted to harm herself. She was not told to sit one-on-one with Resident #1. An interview with CNA F on [DATE] at 8:31 PM revealed RN A stated that Resident #1 made a statement that she wanted to kill herself, but she did not have a plan. He was not told to sit her one-on-one with Resident #1. CNA F stated he only did routine rounds no other interventions were implemented [MEDICAL CONDITION]. An interview with the Medical Director on [DATE] at 12:30 PM confirmed RN A had consulted with him regarding Resident #1's comments and behavior. He stated Resident #1 was not a candidate to transfer to a psychiatric unit or another hospital stay. She knew she was dying and wanted to go home. She was having a mental health crisis so he ordered medication to help calm her down. An interview with RN G on [DATE] at 2:32 PM revealed he had worked Friday, [DATE], on the 10PM -6AM shift. He stated RN A did not inform him about Resident #1 making statements that she wanted to harm herself, and she did not ask for assistance with Resident #1's care nor did she ask the CNAs assigned on his hall to help with Resident #1's care. An interview with RN B on [DATE] at 8:45 AM revealed she worked on [DATE] from 6:00 AM till 6:00 PM. She stated when she received shift change report from RN A, she was told Resident #1 had been upset with her family and told them if they left her in the facility that she was going to kill herself; she did not want to die in the facility, and she wanted to die at home. She stated as she entered the resident's room, she saw the oxygen tubing wrapped around her neck two to three times. She yelled for RN A to come help her. She removed the tubing from around her neck. She noticed Resident #1 was lethargic. She checked her blood sugar and it was low. She called Physician D and was given an order to send Resident #1 to the emergency room . She notified RN C, the week-end supervisor of the incident. Review of RN C's Daily Skilled Nursing Notes, dated [DATE] at 8:05 AM, reflected she had called and notified DON of Resident #1 wrapping her oxygen tubing around her neck before Resident #1 was sent to ER for low BS. At 8:30 AM, RN C documented she had called and spoke with resident's son . We discussed the fact that although the tubing was not tight enough to cut off her air supply it was a big concern regarding her mental health. An interview with RN C on [DATE] at 4:05 PM confirmed she worked on Saturday, [DATE], as the week-end supervisor. She was informed by RN B of Resident #1 was found with her oxygen tubing wrapped around her neck and she had been sent to the hospital for low blood sugar. She stated she went back and read the nurses notes from [DATE] and [DATE]. At that time, she called the DON and informed her of the incident. The DON informed her to notify the hospital that she had wrapped the oxygen tubing around her neck, and she wanted a mental health evaluation done before she was readmitted to the facility. An interview with the DON on [DATE] at 1:00 PM revealed RN C called her on Saturday, [DATE], after Resident #1 had wrapped the oxygen tubing around her neck. RN C read the documentation where Resident #1 stated she was going to hang herself, cut herself with a knife or scissors. The DON informed RN C to notify the hospital of the suicide threats and inform them she needed a mental health evaluation. RN C called her back and informed her Resident #1 had been admitted to the hospital related to her abnormal labs, but not to the psychiatric unit. The DON stated she felt since Resident #1 was admitted to the hospital that everything had been taken care of and no further actions needed to be done. During a subsequent interview with DON on [DATE] at 5:18 PM, she was asked what had been done in response to the Resident #1 making suicide threats and an attempt. She stated she thought the issue was resolved since Resident #1 was admitted to the hospital. She was asked if an incident occurred, what steps had been taken to prevent this from happening again. She stated the facility had not done in-servicing on their suicidal protocol and there had been no counseling for RN A. She stated there has not been any training on the suicide protocol since she started to work in 2008. She stated the facility had an incident report related to the suicide threats or the oxygen tubing wrapped around her neck. An interview with the Administrator on [DATE] at 12:24 PM revealed the DON had called her on Saturday, [DATE], and she was informed of Resident #1's oxygen tubing being wrapped around her neck. Resident #1 should have been placed on one-on-one Friday night ([DATE]) until a psychiatric evaluation was done or until she was no longer in danger. She stated she had instructed the DON to discipline RN A since she did not place the resident on one-one and did not follow the suicide protocol and if any resident makes suicide statements that the facility needed to ensure their safety. She stated by the time Monday ([DATE]) came, she thought the issue had been resolved because Resident #1 was admitted to the hospital. Review of the facility's Suicide Protocol, dated ,[DATE], and reflected the Procedures included the following: (1) Risk factors for residents may include, but are not limited to: (a) Making statements about helplessness, hopelessness, worthlessness, uselessness . (c) Threatening suicide or to harm oneself in some way .(e) Having a well thought out and do-able plan and access to lethal means . (2) When the interdisciplinary team considers a resident as a possible suicide risk, additional screening occurs that includes asking the resident the following questions: (a) Have you thought about killing yourself? Are you thinking about it right now? (b) Are these thoughts persistent and uncontrollable? (c) Do you have a plan on how to kill yourself? (d) Have you the means to carry out this plan? (e) Do you intend to carry out this plan? (4) If there appears to be no immediate danger (for example, there is no evidence of available lethal means), the team member may: (a) Express caring and concern for the resident, (b) Enlist the support of the resident's family, caregivers and significant others to engage the patient and actively listen to his or her expressed concerns . (d) Offer continuous care to provide a suicide watch until the crisis subsides . On [DATE] at 3:36 PM, the Administrator, Assistant Administrator and the DON were notified of IJ had been identified and a plan of removal was requested at that time. Interview with the Administrator on [DATE] at 9:00 AM, revealed the IJ came about related to the RN A not following the facility's policy on suicide protocol. Review of the plan of removal, accepted on [DATE] at 1:12 PM, reflected the following: --Background information: RN A failed to notify Administrator or DON. RN A, also did not initiate a 1:1 supervision and also failed to follow facility suicide policy. RN A failed to notify CNA E, CNA E who was assigned to Resident #1 about the statements resident had made and did not ask CNA E to provide 1:1 supervision of Resident #1. RN A also did not notify or get assistance from any other staff members in the facility. Resident expired at facility on [DATE] at 0008 while on Palliative Care per family request. --Implementation of Changes: All employees upon new hire and annually will be trained on our suicide policy and given a post test. As soon the Administrator, DON, or designee is notified of a suicide threat, that individual will come to the facility and assess situation, review documentation, and ensure that the facility policy and protocol was followed. The social worker will continue to initial social history to identify any risk of suicide. Charge nurses will continue to assess residents upon admission using Resident Data Collection Tool which assess mood. All new admissions, prn residents that have been identified at risk will be referred to DR H for mental health screen. --Monitoring: The DON, Administrator, ADON or designee will monitor compliance of the suicide policy by reviewing the suicide competency test of a score of 80 or additional training until a score of 80 is reached. The Resident Data Collection will be reviewed within 24 hours of admission by the DON, ADON or designee for monitoring for potential risk of suicide. All incident reports will be monitored in daily morning meeting, and the week-end nurse will monitor the incident reports on the week-end. The social worker will notify the Administrator or DON immediately of any resident potential risk of suicide upon completion of the initial Social Service Assessment or Minimum Data Set section D, resident mood interview. --On [DATE], the Social Worker performed safe rounds and interviews the 26 residents that resided on the E hall. If they had any care concerns, staff treatment, and if there needs were being met. --On [DATE], the Social Worker conducted Minimum Data Set section D, resident mood interview with the 26 residents that resided on the E hall. --On [DATE] at 2:30 AM, nurses were in-serviced suicide protocol and on [DATE] at 7:30 AM, staff were in-serviced on the Suicide Protocol by the ADON. Evidence of attendance was determined by a sign off sheet for each staff members that were scheduled to work. On [DATE] the facility had a mandatory all staff in-service on suicide Protocol. Evidence of attendance was determined using a payroll roaster check off. --RN A was terminated on [DATE] for violation of company rules employee violated company policy and procedure, by not ensuring the safety of a resident who made a threat of suicide, who had a plan, and was found the next morning by the oncoming nurse with her oxygen tubing wrapped around her neck. --The DON received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and for falling to counsel RN A, for not following suicide policy. --The Administrator received a disciplinary Action on [DATE] for failing to follow-up after being made aware that suicide comments were made by a resident to ensure suicide policy was followed and employee counseling was done regarding suicide policy. On [DATE] at 1:12 PM, Administrator, Assistant Administrator, DON and ADON were notified the IJ was removed. While the IJ was removed on [DATE]. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and a scope pattern due to the facility requiring more time to train all staff and monitor their plan of removal. On [DATE]-[DATE], six licensed nurses, dietary staff, laundry staff and three CNA's, representing staff from all three shifts and week-end staffs were interviewed regarding the in-services and training they received on the facility's Suicide Protocol. They were each able to explain what actions to take if a resident made a verbal threat to harm self, who to notify of the verbal threat to harm self, completion of Suicide risk assessment and incident report and 1:1 monitoring. The staffs were RN A,RN B, RN C, RN G, CNA E , CNA F, CNA K, LVN I. LVN J, and Laundry Aid L. Dietary Aid M. In an interview with the Administrator on [DATE] at 9:00 AM revealed 26 residents resided on E Hall where RN A was assigned.