Every finding on record at Canton Oaks

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 7 resident (Resident #1 and Resident #2) reviewed for accidents and supervision. 1. The facility failed to ensure CNA A appropriately transferred Resident #1 who was identified as a two person assist for bed mobility. Resident #1 was assisted by CNA A for ADL care on [DATE]. CNA A rolled Resident #1 over in the bed, he fell and broke both hips. 2. The facility failed to ensure Resident #2, who could not bear weight and was identified as a Hoyer lift transfer, was transferred using a Hoyer lift. CNA C transferred Resident #2 using a stand and pivot transfer on [DATE]. Two days later an x ray report indicated the resident had a fractured hip. There was no other occurrence identified that could have caused the injury. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious harm, pain and serious injury. Findings include: 1. Record review of Resident #1's face sheet indicated a [AGE] year-old male who was last admitted to the facility on [DATE]. Resident #1 had diagnoses which included limitation of activities due to disability, abnormalities of gait and mobility, unspecified lack of coordination, a loss of bone density and muscle weakness. Record review of Resident #1's census report indicated his initial date of admission to the facility was [DATE]. Record review of Resident #1's Quarterly MDS, dated [DATE], indicated he had intact cognition with a BIMS( a score used to assess cognitive function in long term care settings) score of 14. Resident #1 was totally dependent of staff for toileting and hygiene. He was totally dependent of staff requiring the assist of two or more helpers for siting to laying and lying to sitting on the side of the bed. Record review of Resident #1 care plan with a problem of falls related to mobility. Approaches, dated [DATE], were to provide extensive assistance for transferring via a Hoyer lift. Resident #1 was identified with a problem of incontinence of bowel and bladder. An approach, dated [DATE], indicated to provide extensive assistance for toileting. A Problem start date of [DATE] indicated the resident fell /slid from his bed with fractures. Some of the interventions were to re-educate the resident was a two person assist with bed mobility, and peri care to help reduce the risk of falls/slides. The bed was to be in the lowest position. Record review of Resident #1's Resident Profile (a description of resident needs for aides to follow when providing care according to the DON) indicated his ADL status, dated [DATE], for toileting required the assistance of two people and his bed mobility was listed as extensive with the assistance of two people. Resident #1's transfer assistance indicated two people assist via Hoyer lift. Record review of Resident #1's nursing note, dated [DATE] at 10:19 p.m., indicated LVN B as called to Resident #1's room around 7:20 p.m. CNA A aid she was changing Resident #1 and he slid out of the bed while she had him roll unto his side. Resident #1 was yelling his hips were hurting. The resident was assessed. Two additional aides came in to assist with cleaning feces off the floor and covered the resident with a blanket. The staff were instructed not to move the resident and 911 was called. The resident was given fentanyl via nasal inhalation by EMS to relieve some pain so the resident could be moved to have the Hoyer sling placed under him. The resident left the facility with EMS at 7:42 p.m. The hospital was contacted at 10:20 p.m. and they stated Resident #1 had fractures in each hip. Record review of the facility's Provider Investigation Report indicated the incident occurred on [DATE] at 8:00 p.m. CNA A provided ADL care to Resident #1 alone and fell out of bed. Resident #1 was care planned for a two person assist. The nurse assessed Resident #1 and he was sent to the ER. The hospital called later in the evening to say Resident #1 suffered fractures to the right and left hips. Resident #1 was care planned for a two person assist for quite some time. All staff interviewed on the hall reported being aware of this and always ensured they had assistance when changing Resident #1. CNA A stated she provided care to Resident #1 in the past without assistance. She was aware of how to use the POC kiosk and where to find Resident #1's care plan. CNA A willfully chose to ignore the plan of care and make and independent decision to provide incontinent care to Resident #1 by herself and paced the resident at needless risk resulting in a fall. Record review of Resident #1's hospital records, dated [DATE], indicated he had a fall from his bed at the nursing home. His imaging demonstrated he sustained multiple orthopedic injuries which included right and left hip fractures. Review of the CT (imaging that uses x rays and computer technology to create detailed images of the inside of the body) of the pelvis on [DATE] at 11:24 p.m. indicated acute comminuted (fracture where bone breaks in three or more fragments) fracture of the left and right hips. Record review of Resident #1's computerized physician orders indicated he had an order, dated [DATE], for Tramadol 50mg every six hours PRN for bone density and structure disorders. He had an order dated [DATE] for alprazolam 0.25 mg for anxiety at bedtime and PRN. He had an order, dated [DATE], for hydrocodone/acetaminophen ,d+[DATE] 1 table for fracture, every 6 hours PRN. Record review CNA A's statement taken by the HR director on [DATE] at 12:00 p.m. indicated CNA A said she was scheduled to work until 7:00 p.m. on [DATE]. The statement indicated CNA A said around 7:30 p.m. she went into Resident #1's room to change him like she always changed him, and during the process she realized the whole bed was wet. She said she was standing on the far side of the bed next to the window. Resident #1 used the grab bar to turn away from her and hold on. CNA A said Resident #1 had neuropathy in his hands and feet. As she was changing him, she guessed his hand became weak. She saw his feet fall off the bed. She said Resident #1 fell off the other side of the bed, he started to yell that he was falling. CNA A said she was reaching for him to prevent his fall and hurt her back. She said he fell feet first onto the floor. She said she was yelling, and he was yelling, and the other CNA came into the room after he was already on the floor. Record review of a statement written by LVN B indicated on [DATE] when she entered the room Resident #1 was lying on the floor next to his bed that was in the high position. Resident #1's head was positioned towards the foot of the bed. Resident #1 was yelling it hurts, it hurts. The statement indicated 911 was called. Record review of Resident #1's nursing note, dated [DATE] at 2:02 a.m., indicated the resident was back from the hospital. He had a diagnosis of bilateral subtrochanteric femur fractures. PRN Tramadol 5mg was given. The medication was not effective. The resident was yelling out in pain. When asked if he would like to go back to the ER for further evaluation the resident refused. The nurse and aide tried to reposition the resident. The resident was unable to get comfortable. Record review of Resident #1's nursing notes, dated [DATE] at 11:24 a.m., indicated the resident was sent back to the hospital due to symptoms of severe anemia(lack of blood). Record review of Resident #1's nursing note, dated [DATE] at 2:55 p.m., indicated Resident returned from the hospital with a new order for alprazolam 0.25 mg as needed for sleep. Record review of Resident #1's nursing note, dated [DATE] at 12:55 a.m., indicated Resident #1 complained of discomfort when changed or repositioned. PRN pain medications were given. Record review of nursing note, dated [DATE] at 11:01 a.m., indicated new order to change hydrocodone /acetaminophen ,d+[DATE] every 6 hours routine medication. Record review of a nurse's note, dated [DATE] at11:23 a.m. indicated a new order to change to discontinue alprazolam 0.25 PRN and to start lorazepam 0.5 tablet for anxiety. Record a review of a nurses note, dated [DATE] at 2:59 p.m., indicated Resident #1 had 3 plus edemas noted. He complained of pain in the left ankle and foot. The physician was notified, and a new order was received to send him to the ER. Record review of Resident #1's nurses note, dated [DATE] at 2:05 p.m., indicated and a referral was received for hospice related to uncontrollable pain with symptoms of bilateral hip fracture and recent decline. Record review of a nurse's note, dated [DATE] at 2:13 a.m., indicated Resident #1 was admitted to hospice with a terminal diagnosis of systolic congestive heart failure (Heart failure where the left ventricle cannot pump blood efficiently) he had new orders for morphine 0.5 ml every two hours PRN as needed for pain, lorazepam 0.5 mg tablet take one every four hours PRN for anxiety. To discontinue the hydrocodone and began Hydrocodone acetaminophen ,d+[DATE] every 6 hours PRN. Acetaminophen 650 mg to administer one suppository rectally every 4 hours PRN for pain or temperature. During an interview on [DATE] at 1:50 p.m., the DON said Resident #1 was a 2 person assist with ADL care. She said it clearly stated in his plan of care documentation. She said Resident #1 did not have the ability to grip and hold on to the handrail on the bed. The DON said she was confused by CNA A's behaviors that day, CNA A's shift ended at 7:00 p.m. The DON said the other aides on the hall thought she already left for the day, instead she was in the room providing care to Resident #1 at about 7:30 p.m. She said CNA A was suspended and terminated, she did not work again after the incident. The DON said the fall caused Resident #1 to break both femurs. The DON said when the aide was providing care to him, she had the bed in the highest position when she rolled him. She said according to the aide and the resident interviews his legs fell off the side of the bed and he followed. The DON said Resident #1's legs hit the floor first. She said CNA A worked at the facility for 6 or 8 months, and the aides rotated different halls. The DON said that was not her first time working with Resident #1. During an interview on [DATE] at 2:20 p.m., Resident #1 said he remembered the incident when CNA A was in changing him and he rolled out of bed. He said she changed him in the past unassisted and he had no worries at first. He said the other staff always had two people to assist him. Resident #1 said she was by the window, and he was facing the door. He said his feet just slipped off the bed. He said he was in shock when he felt the rest of his body began to follow. He said he had been in pain ever since the fall. Resident #1 said since that time it was always two staff who provided care to him and he was fine. Resident #1 said the facility changed his pain medications, the pain was better, but he just felt like he would always be in pain. During an interview on [DATE] at 3:09 p.m., the Administrator said Resident #1 said CNA A changed him alone before. The Administrator said Resident #1 said CNA A was the only one who provided him care unassisted. During an interview on [DATE] at 3:26 p.m., the DON said the facility's Mitigation plan for Resident #1 was completed immediately. The DON said agency staff were in serviced as they came into work. She said in services began on [DATE] and were still on going for Agency and PRN staff. She said the staff were in-serviced on instructions for how to enter the plan of care information for the resident's profile. The DON said the resident profile was used by the CNAs to determine the level of care to provide to residents. She said in Mitigation plan they went back 2 weeks and monitored for trends and there were not any problems identified. She said they talked about accidents/incidents in morning meeting and made sure nothing was identified. The DON said each day she looked at the schedule to determine if they had new staff or staff that had not been in serviced. She said CNA A knew how to get in the Kiosk and she knew where the pocket worksheets were. The DON said there was a binder on the hall by the Kiosk with the resident profiles in it. She said the Mitigation plan included in services for aides and nurses. She said the aides had to do a return demonstration on the kiosk to show they knew how to use it correctly. During an interview on [DATE] at 4:20 p.m., CNA D said she was agency staff, but she worked at the facility often. She said she had taken care of Resident #1 in the past and it took two people to change him or transfer him. She said he had not gotten up since his fall. She said on the evening of [DATE] she was working down the hall. She said CNA A should have left the facility at 7:00 p.m. She said CNA A told them she was going to provide care to another resident and leave. CNA D said they did not know she was doing care with Resident #1 independently. CNA D said she heard hollering and CNA A was coming out of Resident #1's room hollering hysterically. She said prior to the incident CNA A did not ask for help. CNA D said Resident #1 was heavy, his body was stiff, and he was an extensive assist with care. She said it was on his care plan that he required two people. She said he could grab onto the bar and hold but she did not know how long he could hold. She had he had special utensils to assist him with eating, however he did have some issues with these hands. She said they were in serviced on providing care to him and other residents. She said she worked agency and always used the resident care plan/profiles so she was familiar with the resident care needs. During an interview on [DATE] at 5:15 p.m., the DON said initially Resident #1 came back from the hospital with Norco PRN every 6 hours for pain. She said the medications did not control his pain. The DON said he was sent out to the hospital on two different occasions since he came back from the broken femurs. She said the doctors would not work with them at the hospital for pain control. She said Resident #1 had several pain medication changes. She said they had talked to him and placed him on hospice services so he could receive some medications that would control his pain. She said the resident refused to have surgery at the hospital. He was basically bed fast before and did not see the need to undergo surgery. During a telephone interview on [DATE] at 1:52 p.m., CNA A said on [DATE] she had gone into Resident #1's room to provide incontinent care. She said she was supposed to leave at 7:00 p.m. but stayed to help the other aides out. CNA A said she was changing Resident #1 like she normally did, unassisted. She said when she started to change him, she realized the whole bed was wet. CNA A said she had to do an occupied bed change. She said it was something she did daily. She said when she was trying to roll the sheet to pull him back over his feet had neuropathy and they slid off the side of the bed. She said her first reaction was to grab, him, but he was not a little guy he weighed about 300 pounds, and she hurt her back. She said she would never ever intentionally hurt a resident. She said she saw him slip and she tried to catch him before he fell . CNA A said she did not know he was a two person assist. She was reminded she had taken an in service in [DATE] about using the kiosk and consulting with the plan of care/ resident provide regarding resident care needs. She said she did receive the in service. She said she thought it was okay to provide care to Resident #1 unassisted because she had seen other staff do so. She said she did not review his resident profile during the time she worked at the facility for about 6 months. During an interview on [DATE] at 1:50 p.m., the DON said Resident # 1 was a 2 person assist with ADL care. She said it clearly stated in his plan of care documentation and everywhere. She said Resident #1 did not have ability to grip and hold onto the bars on the side of the bed. The DON said she was confused by CNA A's behaviors that day, she was supposed to have gotten off work at 7:00 p.m., she said the other aides on hall thought she had already left for the day. She said she was in Resident #1's room around 7:30 p.m. providing care to him. The DON said the fall caused Resident to break both femurs. The DON said when the aide was providing care to him, she had the bed in the highest position when she rolled him. She said according to the aide and the resident interviews his feet fell off the side of the bed and his legs followed. She said CNA was terminated- and did not work again. He went over the side of the bed, so his legs hit first. She had worked at the facility for about 6 months, and didn't know if she worked that hall. Record review of CNA A's personnel file indicated a hire date of [DATE] and a CNA Competency check list which indicated competency on Resident Profile and care delivery. Record review of an in service, dated [DATE], on transfers indicated to check the profile of each resident prior to transfers to prevent injuries. Ask for help if a resident seems more confused than usual. Use a Hoyer for residents that list it on the profile under ADLS. The in service also included instructions for the Kiosk, instructions on selecting the resident profile for the most recent accurate care plan. CNA A signed the in service which indicated she had attended. Record review of CNA A's Suspension Pending Investigation form, dated [DATE], indicated the employee was changing Resident #1, and he fell out the bed which resulted in him going to the ER. The Employee said it was an accident, she did not mean for the resident to get hurt. The employee stated she injured herself trying to catch the resident. The form indicated she was too upset to sign the form. Record review of a Termination Form, with an effective date [DATE], indicated CNA A's last day to work was [DATE]. She was terminated due to a violation of rules and policy. Record review of the Mitigation Plan, dated [DATE], indicated the concern was a fall out of bed with major injury. The incident was reported to HHSC, an investigation was initiated, and the staff member was immediately suspended pending investigation, sent home and removed from the schedule on [DATE].Residents who required assistance with bed mobility have the potential to be affected. The current Residents were assessed by the DON/designated for appropriate amount of ADL assistance assigned to each resident for bed mobility, toileting, and to validate amount of assistance displayed in the resident profile. This was completed on [DATE]. Current residents with incident/accident reports for the past 14 days were reviewed by the DON and or designated to determine the root cause analysis of the fall, and validate that interventions were implemented as appropriate for root cause analysis. Daily review of incident/accidents in the daily clinical meeting Monday through Friday will be completed by [DATE] and ongoing Monday through Friday. Licensed nurses were re-educated on completing resident profiles upon admission and updating with any changes so that the profiles remained accurate with needed information to reflect the resident. The plan of care included the amount of assistance needed with ADLs and identified resident risks. CNAs were re- educated on following the designated amount of ADL assistance care plan in the resident profile. CNAs were educated on positioning with skills check off that was completed on [DATE]. Staff were educated on abuse, neglect, and exploitation completed on [DATE]. The facility administrator was responsible for the overall implementation of validation of this plan and the facility director was informed of this plan. Record review of the facility Provider Investigation Report, dated [DATE], indicated the Provider Action Taken Post-Investigation was conducted as needed QAPI with root cause analysis. A Mitigation plan was initiated to include but not limited to identifying all residents who had the potential to be harmed by this alleged deficient practice, residents were reassessed for accuracy. Licensed nurses were re-educated on completing resident profiles on admission. CNAs were educated on following designated amount of assistance and position with skills check offs completed. Record review of the facility's mediation plan indicated they conducted an in-service on abuse neglect the exportation on [DATE] for agency and facility staff. Record review of an in-service, dated [DATE], indicated nurses were in-service on point of care profile for residents. The in-service indicated to always use the care plan/resident profile to make determinations such as the number of staff, the extent of moderate, or minimum needed to give care. It indicated to never use less than what was listed in the plan of care. There were also directions on how to sign into the POC and it gave pictures with an example of navigating the system. Record review of the staff education/orientation on policies and procedures indicated the staff demonstrated competency in moving positioning and assisting residents. It appeared that all aides had competency check offs. Record review of the facility's plan of care/resident profiles indicated all resident profiles were evaluated to determine if they were correct. During an interview on [DATE] at 2:25 p.m., CNA E said she had been in serviced regarding using the profile sheet, how to access it in the kiosk, and making sure to provide care according to the resident plan of care. She said she provided care according to resident care plans/profile sheets. During an interview on [DATE] at 2:30 p.m., CNA/MA F said she did not provide resident care often, but she was aware Resident #1 was a two person assist with care. She said she had completed an in service on transferring and providing ADL care. She said they had a lot of agency staff who worked and had to have a way of letting them know how to take care of the residents. During an interview on [DATE] at 2:33 p.m. LVN G said she had worked at the facility for 3 weeks. She knew Resident #1 had broken his legs and was on hospice due to pain. She said Resident #1 received PRN morphine every two hours and he also had Ativan for anxiety. She said when they provided care to Resident #1 it was always two people and sometimes 3 people just to reposition him. She said she received an in servicing on the resident profile and how to put the information in the system. She said the aides were required to complete a return demonstration of how to access the information from the computer system and there was a book on each hall with the profile information in it. During a telephone interview on [DATE] at 5:38 a.m., RN H said she worked PRN and had been working at the facility for 4 years. She said she was in serviced about Resident #1. She said she as a nurse, they were educated on how to get on the plan of care in POC and how to put the information in the computer for the Plan of care. During a telephone interview on [DATE] at 5:41 a.m., RN I said she worked from 6p.m. to 6a.m. and had worked at the facility for [AGE] years. She said she had worked with Resident #1 and his ability to hold on was not dependable. She said Resident #1 could hold a little bit but did not have any grip strength. She said Resident #1 was a Hoyer transfer, and two persons for changing. RN I said they did check offs on the Kiosk, to make sure aides were able to access the level of care. She said nurses were educated on how put information into the POC and how to put in updates. During a telephone interview on [DATE] at 5:46 a.m., CNA J said she worked from 10 p.m. to 6 a.m. and had worked at the facility for 3 years. She said she worked all over the building. CNA J said Resident #1 had always been a two person assist. She said she had never gone in by herself to provide care to Resident #1 without help. She said Resident #1 could grab the bar and hold at times. She said he was two people go in because he is extensive assist with care. CNA J said she knew where the care plan/resident profile was, and she knew how to go to the Kiosk. She said they had a lot of agency staff that worked at the facility and she wanted to make agency staff were aware of how to provide the proper care to residents. 2. Record review of Resident #2's face sheet indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included muscle weakness and lack of coordination. Record review of Resident #2's quarterly MDS, dated [DATE], did not document a cognitive score on the BIMS. The resident was dependent on staff for all ADLs and required supervision with eating. Record review of Resident #2's computerized physician orders indicated to admit to hospice on [DATE]. An order, dated [DATE], indicated to transfer with the assistance of two people with Hoyer lift. The order indicated a diagnosis, dated [DATE], that indicated cognitive impairment moderate to severe. The order indicated an added diagnosis on [DATE] of contractures to ankles and feet. Record review of Resident #2's Resident Profile sheet indicated her ADL status on [DATE] was one person assist for bed mobility and two people assist with transfers via Hoyer lift. Record review of Resident #2's x-ray report, dated [DATE], indicated an acute hip fracture. Record review of Resident #2's nursing notes, dated [DATE] at 12:10 a.m., indicated Resident #2 had increased swelling to the leg. The resident showed discomfort possibly related to pain. The resident was unable to tell the nurse the area was hurting. Notified hospice awaiting call back. At 12:25 a.m. hospice called and gave an order for an x-ray of the right leg and three views of the ankle at 12:09 p.m. X-ray results showed right femur neck fracture. The family chose not to send the resident to the hospital and wanted the resident to remain in the facility with pain control per hospice orders. Record review of Resident #2's discharge summary indicated she expired on [DATE] while on hospice. Record review of a Provider Investigation report indicated on [DATE] Resident #2 was noted with edema that started in the lower right extremity and moved up the leg. The Hospice agency gave an order for an x ray due to a possible fracture. The Resident was assessed and treated for pain. Staff were interviewed for possible information related to the cause of the injury. Resident safe surveys were conducted on the hall and no concerns were reported. The staff were [NAME]-serviced on care planned transfer techniques/gait belt. Through the investigation process it was reported Resident #2 was transferred with a standing-pivot transfer on [DATE]. There was no fall or adverse reaction at that time, the resident was transferred safely to bed. The resident had a diagnosis of osteoporosis (decreased bone density, weakened and brittle bones) and osteopenia (lower than normal bone density) which could have contributed to the femoral neck fracture when she was transferred to bed. Resident #2 was care planned for a Hoyer transfer and while she could stand and bear weight, this could potentially be the cause of the injury. The provider actions taken were the DON/Designee would re-educate nursing staff regarding following the plan of care which included the expectation that non-compliance would not be tolerated. This education was initiated on [DATE]. A list of statements provided by the Administrator on [DATE] at 3:10 p.m. was titled Confidential Attorney Work Product. with no date. Statements indicated staff were interviewed regarding knowledge of an injury to Resident #2 and no staff had any knowledge. During an interview with CNA C, she said 2-or-3 days prior she had assisted Resident #2 with a stand and pivot transfer from her wheelchair to the bed. According to CNA C, there were no issues noted during the transfer. CNA C said she did not know Resident #2 was a two person assist. She said she asked CNA A and CNA A told her Resident #2 could bear weight. The same form indicated CNA A said she told CNA C the resident could bear weight, but they used a Hoyer to transfer her. Record review of CNA C's personnel file indicated a hire date of [DATE]. There was a skills verification, checklist and competency check offs that were completed by CNA C on [DATE]. The check off indicated she was competent on physical and body mechanics, and the use of a transfer belt. She was also competent on observation and documentation correctly on flow sheets in the kiosk as facility specific. During an interview on [DATE] at 3:09 p.m., the Administrator said CNA C had not worked with Resident #2 and she asked CNA A about the resident. CNA C said CNA A told her Resident # 2 could stand and pivot. He said she apparently did not use the kiosk or profile sheet. He said they had a Mitigation binder for that incident. During an interview on [DATE] at 1:00 p.m., the DON said CNA C did an improper transfer and they suspended her. She said they could not prove that was the reason why Resident #2 had the broken hip. The DON said Resident #2 had not had any falls or events that could have caused the hip fracture. However, they were going to allow CNA C to return to work with training. She had not come back to the facility. During a telephone interview on [DATE] at 1:52 p.m., CNA A said CNA C asked her about Resident #2. She said she thought CNA C had misunderstood what she had said. CNA A said she told CNA C, Resident #2 was a Hoyer lift transfer, but other staff transferred her by standing and pivoting. She said Resident #2 did not show any pain after the transfer. Record a review of a Mitigation plan, dated [DATE], indicated the facility received notice on [DATE] that Resident #2 had a fracture of the femur. Residents were being treated by the facility per physicians orders. Residents with a potential to be affected were residents who resided in the facility and required assistance with mechanical lift. The director of nurses/designee educated nursing staff on following the plan of care, which included the expectation that noncompliance was not tolerated. The education was initiated on [DATE] and staff not completing by [DATE] would receive training prior to working next shift. The education would be presented in the new hire packet on [DATE] all staff were in-service and reeducated regarding the use of gate belts. Attached was a copy of an in-service on an abuse and neglect. Attached was a copy of the facility's, gate belt procedures, and a copy of the facility's, geriatric patient assessment and treatment. Record a review of the in-service that was attached to the mitigation plan indicated staff were in-serviced beginning on [DATE] on transfers, to check the profile of each resident prior to transfers prevent injuries. Ask for help if the resident seems more confused than usual and may need more help. They were to use a Hoyer for residents that listed on their profile under ADLs. There were also instructions for the kiosk to check the residents name and how to follow the instructions in the POC. During a telephone interview on [DATE] at 5:38 a.m., RN H said she worked PRN and had been working at the facility for 4 years. She said she was in serviced about Resident #2. She said she as a nurse was educated on how to get on the plan of care in POC and how to put the information in the computer for the Plan of care. During an interview on [DATE] at 5:41 a.m., RN I said she worked from 6 p.m. to 6 a.m. and had worked at the [TRUNCATED]

Based on interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #1) reviewed for enteral feeding. The facility failed to ensure Resident #1's tube feeding was stopped at 7:00 a.m. as ordered. Resident #1 received the tube feeding and water flushes via the pump for approximately an additional 6 and 1/2 hours resulting in an excess volume delivery of 1072mls Resident #1 began vomiting, was found cyanotic (when the skin, lips or nails turn a bluish color) and had an Sp02 ( oxygen saturation level -normal rage is 95-100%) of 52% and was transferred to the hospital where he was diagnosed with aspiration pneumonia ( when food or liquid is breathed into the airways or lungs) ,acute respiratory failure (a sudden life threatening condition where there's not enough oxygen or too much carbon dioxide in the body, which can be caused by aspiration) and required intubation in the intensive care unit. An Immediate Jeopardy (IJ) was identified on 7/22/24 at 4:26 p.m. While the IJ was removed on 7/23/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could affect residents receiving tube feedings by placing them at an increased risk of aspiration, fluid overload and death. Findings included: Record review of the face sheet for Resident #1 indicated he was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including HIV disease (human immunodeficiency virus) gastrostomy malfunction (malfunction of opening into the stomach from the abdominal wall, made surgically for the introduction of food) , dysphagia (difficulty or discomfort in swallowing) quadriplegia (paralysis of all four limbs) and unspecified protein-calorie malnutrition. Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and sometimes made himself understood. The MDS indicated Resident #1 was cognitively intact (BIMS of 15). The MDS indicated Resident #1 was dependent on staff for eating, toileting, showering, dressing the upper and lower body, putting on and taking off of footwear, and personal hygiene. The MDS indicated Resident #1 had an active diagnosis of quadriplegia. The MDS indicated Resident #1 had a feeding tube and a mechanically altered diet during the 7 days look back period. The MDS indicated Resident #1 had received 51% or more of his total calories through tube feeding and 501 cc/day or more of his fluid intake by tube feeding daily during the seven days look back period . Record review of the care plan, revised on 6/4/24, indicated Resident #1 received tube feedings related to dysphagia. The care plan interventions included, elevate the head of bed 30-45 degrees during feeding and one hour after; check residual if residual 150 ml or less reinsert volume into stomach and continue feeding-If greater than 150 ml hold feeding and notify physician; and monitor for signs/symptoms of tube feeding intolerance. Record review of the active physician order dated 2/21/24 revealed Resident #1 was to be administered enteral feeding (Enteral nutrition refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) with Jevity 1.5 at 90 cc/hr from 5:00 p.m. to 7:00 a.m. via pump per G-tube with a 75 cc water flush via the G-tube per hour. Record review of the active physician order dated 4/2/24 indicated Resident #1 was to be administered a mechanically altered diet with nectar thick liquids and chopped meats. Record review of the nursing progress note dated 7/18/24 at 2:30 p.m., for Resident #1 stated At 1356 (1:56 p.m.) this nurse was called into the resident's room by the charge nurse. Charge nurse reported that res. (Resident) had vomited and nurse realized she had not turned tube feed off at 7:00 a.m. When this nurse entered the room the resident appeared cyanotic and abd (abdomen) distended. This nurse immediately began suctioning and turned resident to the side when vomiting applied nonrebreather r/t (related to) Sp02 at 52 %. Residents 02 immediately began to increase. EMS arrived and pt 02 had increased to 92 % on 15 L. Resident was transferred to (hospital) . This note was written by ADON A. During an interview on 7/22/24 at 12:48 p.m., LVN A said she had taken care of Resident #1 on 7/18/24 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said normally she turned of Resident #1's tube feeding before breakfast. LVN A said she was very busy trying to get her finger sticks (blood sugar checks) and insulin administered, and she had people trying to get of bed. LVN A said she just forgot to turn off Resident #1's tube feeding. LVN A said she turned the pump off around 12:30 p.m., were her and CNA B went to perform incontinent care. LVN A said Resident #1 was still using the bathroom, so they (LVN A and CNA B) discontinued the care. LVN A said CNA B rounded on Resident #1 at approximately 1:30 to 1:45 p.m. LVN A said CNA B reported he was vomiting and didn't look right. LVN A said she went to the room and notified the ADON. LVN A said herself and the ADON suctioned him, called EMS. During an interview on 7/22/24 at 1:43 p.m., CNA B said she took care of Resident #1 on 7/18/24 on the 6:00 a.m. to 2:00 p.m. shift. CNA B said her partner working the hall with her had reported to her that Resident #1 had not wanted a breakfast tray. CNA B explained Resident #1 had a Tube feeding but was offered mechanically altered trays during the day. CNA B said she offered him a lunch tray but he declined it. CNA B said she told Resident #1 she would be back to pick up the tray and get him cleaned up. CNA B said when she returned at approximately 1:30 p.m. she was going to perform incontinent care but noticed the tube feeding was running. CNA B said she paused the Tube feeding before laying Resident #1 back because she had been taught to always ensure the tube feeding was paused before laying a resident with tube feeding back to perform incontinent care. CNA B said when she laid Resident #1 back and went to turn him on his side he started vomiting. CNA B said she then got LVN A and told her Resident #1 was vomiting. CNA B said LVN A said she had forgotten to turn off his Tube Feeding. During an interview on 7/22/24 at 2:00 p.m. LVN C said she was working on 7/18/24 but was the nurse for a different hall. LVN C said LVN A had not asked for any help or assistance until she was asked to retrieve oxygen for Resident #1 in the afternoon. LVN C said LVN A had not asked for any assistance before that time. LVN C said the nurses were good about helping each other and could not say why LVN A had not asked for help if she felt she needed it. LVN C said it was very important to ensure G-tube feedings were turned off at the ordered times because fluid could build up and increase a resident's risk of aspiration. During an interview on 7/22/24 at 2:20 p.m., LVN D said she was working on 7/18/24 but was the nurse for another floor. LVN D said LVN A never asked for help or assistance. LVN D said the facility was well staffed with 3 nurses, 5 nurse aids and 2 med aides. LVN D said there was not anything abnormal going on. LVN D said she could not say why LVN A had not ask for help as the everyone was worked as team. During an interview 7/22/24 at 2:31 p.m., the ADON said she was working on 7/18/24. The ADON said she received a text message from LVN A to come to Resident #1's room stat. Th ADON said she ran to the room and LVN A told me she realized when CNA B came to get her (LVNA) she had never turned off Resident #1's tube feeding. The ADON said Resident #1 was blue and his sat when she got in the room was 52 percent. The ADON said they continued intermittent suction and oxygen administration. The ADON said Resident #1 was still vomiting intermittently so she went to turn the resident on his side and noticed his abdomen was severely distended. The ADON said she also observed tube feeding was leaking from one of the three ports from the gastrostomy tube. The ADON said she opened the feed port in an attempt to aspirate contents, but the formula just came pouring out. The ADON said she sat a canister there to collect the feed pouring out of the port. The ADON said the canister collected somewhere between 400-500 mls of feed. The ADON said she continued to suction and provide oxygen and had gotten Resident #1's Spo2 up to 80 percent and by the time EMS arrived his Spo2 was up to 92 percent. The ADON said she had heard Resident #1's Sp02 had dropped again in the ambulance and that he was currently in the ICU intubated. The ADON said she questioned LVN A over the incident as to why she had not turned off the tube feeding. The ADON said LVN told her she just forgot and was trying to get her blood sugar checks and insulin administered. The ADON said she asked LVN A why she checked off the MAR that she had stopped the tube feeding for Resident #1 when she had not yet completed the task. The ADON said LVN A said she meant to turn it off and just forgot. The ADON said she told LVN A this is why you don't check/ sign something off before you have completed it. The ADON said had LVN A not checked off the task before the tube feeding was actually turned off it would have served as a reminder that the task had not been completed. The ADON said she sent LVN A home because she did not trust her mental state and knew she needed to be suspended . Record review of the hospital progress note dated 7/22/24 revealed Resident #1 was admitted to the hospital with diagnoses of acute respiratory failure and septic shock due to aspiration pneumonia and influenza b. The hospital progress note revealed Resident #1 was intubated but extubation would be attempted . Record review of the email from the Regional Dietitian to the DON, dated 7/23/24 stated If he [Resident #1] was on his current TF [tube feeding] and flushes for an additional 6.5 hours, this would have given him an extra: 585 cc of the TF formula and 487 cc of water from the flushes (total volume= 1072 cc). During an interview on 7/23/24 at 3:00 p.m., the Medical Director said he had to say that Resident #1 receiving his tube feeding for an additional 6 and half hours would increase his risk of aspiration. Record review of the facility policy and procedure dated 5/5/23, titled Nursing Policy and Procedures: Gastrostomy tubes, stated, .(2) The patient/resident that is fed by enteral methods receives appropriate treatment and services to restore oral eating skills and prevent complications of enteral feeding like aspiration pneumonia, diarrhea, vomiting, . complications: (1) Aspiration .(7) Death secondary to complications not addressed immediately. The Administrator was notified on 7/22/24 at 4:30 p.m. at that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided with the Immediate Jeopardy template on 7/22/24 at 4:43 p.m. The facility's Plan of Removal was accepted on 7/23/24 at 2:57 p.m., and included: Upon Resident #1's return or new admission of a resident that requires a tube feeding, the Director of Nursing/Designee will validate daily for 7 days that physician orders for tube feeding are being followed as written and continue to randomly validate weekly that physician orders for tube feeding are being followed as written. LVN A was suspended pending investigation on 7/18/24 and terminated post investigation on 7/22/24. The Director of Nursing/Designee will re-educate Licensed Nurses on 7/22/24 on following physician orders including start and stop times of tube feedings. The Director of Nursing/Designee will reeducate Licensed Nurses on 7/22/24 on assessing residents for complications related to tube feedings which includes the following: * Monitoring for nausea, vomiting, diarrhea and constipation * Gastric distention and bowel sounds * Monitoring for aspiration which may include adventitious breath sounds Licensed Nurses and Certified Nursing Assistants will be reeducated by the Director of Nursing/Designee by 7/23/24 on tube feeding management and prevention of tube feeding complications which includes: *Licensed Nurses may hold/pause feeding while ADL care is performed that requires the head of bed to be lowered *Certified Nursing Assistants will notify the licensed Nurse prior to performing ADL care that requires the head of the bed to be lowered to allow for the Licensed Nurse to pause/hold the feeding and resume the feeding once ADL care completed *Certified Nursing Assistants will not adjust the tube feeding, only licensed nurses Nursing Staff not receiving this education by 7/23/24 will receive prior to their next scheduled shift. The Director of Nursing/Designee will randomly interview a minimum of 3 nursing staff members weekly for 4 weeks to validate understanding and compliance with tube feeding management and prevention of tube feeding complications. Medical Director was notified of the incident and plan for improvement on 7/22/24. An Ad Hoc QAPI will be held on 7/22/24 to discuss the contents of this plan. On 7/23/24 the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of LVN A's employee file confirmed she was suspended 7/18/24 and terminated on 7/22/24. Interviews on 7/23/24 from 11:00 a.m. to 2:50 p.m., with licensed nurses (LVN C, LVN D, LVNE, RN F, LVN G) who had worked on 7/22/24 and 7/23/24 on all shifts (6:00 a.m. to 6:00 p.m.) confirmed they had received in-services over the importance ensuring physician orders were followed related to tube feedings, not documenting task was complete before the task was complete, and monitoring for complications of tube feeding. The nurses said it was very important to ensure tube feedings were started/stopped as ordered by the physician because residents could receive to little or too much feeding if orders were not followed. The nurses stated that receiving too much feeding could place a resident at greater risk of fluid overload and aspiration. The nurses stated they would monitor residents on tube feeding closely for complications including nausea, vomiting, diarrhea, constipation, abdominal distention, bowel sounds, and signs of symptoms of aspiration. The nurses reported they would notify the physician immediately if any complications were observed. The nurses said they would also ensure prompt response to CNA requesting a tube feeding being paused in order to provide care as licensed nurses were the only ones that should hold, pause, stop or restart tube feedings. Interviews on 7/23/24 from 11:00 a.m. to 2:50 p.m., with CNAs and MAs (MA H, MA I, MA J, MA K, CNA L, CNA M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, CNA T, CNA U, CNA V, CNA W, CNA B) that worked on 7/22/24 and 7/23/24 on all shifts (6:00 a.m. to 2:00 p.m., 2:00 p.m.-10:00 p.m. and 10:00 p.m. to 6:00 a.m.) The CNAs said they would ensure a resident they were caring for with tube feeding would have their head elevated at all times at 30 to 45 degrees. The MAs and CNAs said if the head of the bed needed to be lowered to provide care they would notify the nurse to pause, stop or disconnect the feeding. The MAs and CNAs voiced that only a licensed nurse could touch a feeding tube pump. They said after they provided the care they would raise the head of the bed to 30-45 degrees and notify the nurse so they (nurses) could resume the feeding. The CNAs and MAs said they would notify the nurse immediately if a tube feeding resident had any change of condition, such as vomiting, diarrhea, a hard stomach, changes in breathing or any sign or symptom outside the residents normal. Record review of the Ad Hoc QAPI sign in sheet dated 7/22/24 confirmed and AD hoc QAPI had been held. During an interview on 7/2324 at 3:00 p.m., the medical director confirmed he had been notified of the IJ and attended the Ad Hoc QAPI via phone. Record review of the daily monitoring tool dated July 2024, for physician orders adherence as written for peg tubes was completed. During an interview on 7/23/24 at 3:20 p.m., the DON said the daily monitoring tool for physician orders adherence as written for peg tubes, would be utilized upon Resident #1's return to the facility or in the event a new resident with tube feedings was admitted to the facility. The DON said she would validate for daily times one week and then randomly every week that physician orders for tube feeding were being followed as written. The DON also said she would randomly interview nurses and aides (at least three staff weekly) for 4 weeks to ensure understanding and compliance with tube feeding management and potential complications of tube feeding. The DON said no staff would be allowed to work until they have received all in-services. During an interview on 7/23/24 at 3:30 p.m., the administrator said no nursing staff member would be allowed to return to work until they had completed all in- services. On 7/23/24 at 3:32 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not Immediate Jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were accurately documented for 1 of 4 residents (Resident #1) reviewed for accurate medical records. LVN A failed to accurately document on Resident #1's medical record when she documented Resident #1's tube feeding had been discontinued at 7:00 a.m. on 7/18/24. This failure could place residents receiving tube feeding at risk of increased complications of tube feeding. Findings included: Record review of the face sheet for Resident #1 indicated he was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including HIV disease (human immunodeficiency virus) gastrostomy malfunction (malfunction of opening into the stomach from the abdominal wall, made surgically for the introduction of food) , dysphagia (difficulty or discomfort in swallowing) quadriplegia (paralysis of all four limbs) and unspecified protein-calorie malnutrition. Record review of the MDS dated [DATE] indicated Resident #1 sometimes understood others and sometimes made himself understood. The MDS indicated Resident #1 was cognitively intact (BIMS of 15). The MDS indicated Resident #1 was dependent on staff for eating, toileting, showering, dressing the upper and lower body, putting on and taking off of footwear, and personal hygiene. The MDS indicated Resident #1 had an active diagnosis of quadriplegia. The MDS indicated Resident #1 had a feeding tube and a mechanically altered diet during the 7 days look back period. The MDS indicated Resident #1 had received 51% or more of his total calories through tube feeding and 501 cc/day or more of his fluid intake by tube feeding daily during the seven days look back period. Record review of the care plan, revised on 6/4/24, indicated Resident #1 received tube feedings related to dysphagia. The care plan interventions included, elevate the head of bed 30-45 degrees during feeding and one hour after; check residual if residual 150 ml or less reinsert volume into stomach and continue feeding-If greater than 150 ml hold feeding and notify physician; and monitor for signs/symptoms of tube feeding intolerance. Record review of the active physician order dated 2/21/24 revealed Resident #1 was to be administered enteral feeding (Enteral nutrition refers to any method of feeding that uses the gastrointestinal (GI) tract to deliver nutrition and calories) with Jevity 1.5 at 90 cc/hr from 5:00 p.m. to 7:00 a.m. via pump per G-tube with a 75 cc water flush via the G-tube per hour. Record review of Resident #1's MAR for 7/18/24 indicated Resident #1's tube feeding had been stopped at 7:00 a.m. The MAR was electronically signed by LVN A. During an interview on 7/22/24 at 12:48 p.m., LVN A said she had taken care of Resident #1 on 7/18/24 on the 6:00 a.m. to 6:00 p.m. shift. LVN A said normally she turned off Resident #1's tube feeding before breakfast. LVN A said she was very busy trying to get her finger sticks and insulin administered and she had people trying to get out of bed. LVN A said she just forgot to turn off Resident #1's tube feeding. LVN A said she turned the pump off around 12:30 p.m., were her and CNA B went to perform incontinent care. LVN A said Resident #1 was still using the bathroom, so they (LVN A and CNA B) discontinued the care. LVN A said CNA B rounded on Resident #1 at approximately 1:30 to 1:45 p.m. LVN A said CNA B reported he was vomiting and didn't look right. LVN A said she went to the room and notified the ADON. LVN A said herself and the ADON suctioned him, called EMS. LVN A said she documented the tube feeding had been discontinued at 7:00 a.m. because she had intended to turn off the feed but just forgot. During an interview 7/22/24 at 2:31 p.m., the ADON said she was working on 7/18/24. The ADON said after Resident #1 was sent to the hospital she questioned LVN A about the incident and asked her why she had documented the tube feeding was discontinued at 7:00 a.m. The ADON said LVN A told her she documented the task was complete because she was going to do it and just forgot. The ADON said she told LVN A that was exactly why she should not have documented the tube feeding was discontinued because had she not documented it was done, the work log would have reminded her the task was not compete. During an interview on 7/22/24 at 2:05 p.m. The DON said LVN A should not have documented Resident #1's tube feeding was stopped at 7:00 a.m. if she had not completed the task. The DON said the way the orders were entered were to remind and ensure that nurses did not forget to start and stop the tube feeding at the ordered times. The DON said LVN A charting she had completed the task, when she had not was part of checks system to ensure nurses did not forget to perform important tasks, such as stopping the tube feeding for Resident #1. Record review of the facility policy and procedure , dated 5/23/23, titled Nursing policy and Procedures, Documentation Licensed Nursing, stated .documentation pertaining to patient/resident will be recorded in accordance with regulatory requirements .the qualified nursing staff notes the time and date and dosage of all medications and treatments at the time they are administered and initials the note on the medication/treatment record .if a scheduled medication is withheld or not given as ordered, the nurse documents this and lists the reason for the patient/ resident not receiving the medication .

47204 Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided Preadmission Screening and Resident Review (PASRR) Screenings for 2 of 10 residents (Residents #6 and #48) reviewed for PASRR. The facility failed to ensure Resident #6 and Resident #48 had accurate PASRR Level 1 Screenings which indicated diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs. Findings included: Record review of Resident #6's face sheet indicated she was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included Cerebrovascular Accident (a CVA or stroke), Diabetes Mellitus, and MELAS Syndrome (a rare genetic disorder primarily affecting the nervous system and muscles). Major Depression (a mental illness that can cause a depressed mood or loss of interest) and bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs) were added to Resident #6's list of diagnoses on 07/11/2019 and 07/19/2019. Record review of Resident #6's PASRR Level 1 Screening completed on 05/30/2019 indicated in section C0100 there was no evidence of this individual having mental illness. Further review of the medical records indicated there was no documentation of any actions taken to refer Resident #6 for further screening or evaluation after the facility identified Resident # 6 as having diagnoses of mental illness. Record review of Resident #6's physician's orders dated 06/05/2024indicated she was receiving antidepressant and antipsychotic medications for the treatment of Major Depression and bipolar disorder. Record review of Section I: Active Diagnoses of the Quarterly MDS assessment dated [DATE] indicated Resident #6 did not have a mental disorder of bipolar disorder. Section N of the same MDS assessment indicated Resident #6 received an antipsychotic medication all 7 days of the review. Record review of Section I: Active Diagnoses of the Quarterly MDS assessment dated [DATE] indicated Resident #6 did have a mental disorder of bipolar disorder. Section N of the same MDS assessment indicated Resident #6 had received an antipsychotic medication all 7 days of the review. Record review of Resident #6's PASRR Level 1 Screening completed on 05/30/2019 indicated in section C0100 there was no evidence of this individual having mental illness. Further review of the medical records indicated there was no action taken after the facility identified Resident # 6 as having diagnoses of mental illness. Record review of Resident #48's undated face sheet indicated she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder (feeling of dread, fear, and uneasiness), visual hallucinations (seeing things that are not there), and psychotic disorder with hallucinations (a mental disorder characterized by a disconnection from reality). Record review of the Comprehensive (admission) MDS assessment dated [DATE] in the section, Preadmission Screening and Resident Review, indicated Resident #48 did not have a serious mental illness. The MDS section I, Active Diagnoses, indicated Resident #48 had diagnoses of anxiety disorder and psychotic disorder. MDS section N indicated the resident received antipsychotic and antianxiety medications all 7 days of the review. Record review of the Comprehensive (quarterly) MDS assessment dated [DATE] in the section I, Active Diagnoses, indicated Resident #48 had diagnoses which included anxiety disorder and psychotic disorder. Section N indicated the resident received antipsychotic and antianxiety medications all 7 days of the review. Record review of the Comprehensive(annual) MDS Assessment, dated 08/12/2023, in section, Preadmission Screening and Resident Review, indicated Resident #48 did not have a serious mental illness. Section I, Active Diagnoses, indicated Resident #48 had diagnoses which included anxiety disorder and psychotic disorder. Section N indicated the resident received antidepressant and antianiety medications all 7 days of the review. Record review of the physician's orders dated June 2024 indicated an order dated 09/21/2023 for Resident #48 to receive buspirone (a medication for anxiety) for treatment of anxiety disorder three times a day and an order dated 12/18/2023 for Resident #48 to receive Risperdal (an antipsychotic medication) for treatment of psychotic disorder twice a day. Record review of Resident #48's PASRR Level 1 Screening completed on 08/03/2022 indicated in section C0100 this resident did not have evidence of having a mental illness. During an interview with MDS/LVN A on 06/05/2024 at 9:25 AM, she said she was responsible for tasks related to PASRR and MDS processes. She said she was hired in 2020 and was not aware a corrected Form 1012 to correct the original PASRR Level 1 had not been completed. She said she would contact the local authority and address it immediately. During an interview with the DON on 06/05/2024 at 09:50 AM, she said the MDS Nurses were responsible for MDs and PASRR tasks. She said she expected the PASRR tasks to be done correctly and timely. During an interview on 06/05/2024 at 10:45 AM MDS/LVN A said she would contact the local authority concerning the inaccurate PASRR and get it corrected. During an interview with MDS/RN on 06/05/2024 at 04:00 PM, she said she and MDS/LVN A use the Long-Term Care (LTC) User Guide for Preadmission Screening and Resident Review (PASRR) as their reference for PASRR associated tasks. She said a failure to notify the local authority of residents with diagnoses of mental illnesses could result in a resident not receiving services.

Based on interview and records review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 (Resident #1) residents reviewed for medication errors. The facility failed to administer Resident #1's crushed medication and instead administering Resident #1 half of her roommates crushed medications which included Clonidine (medication used to treat high blood pressure), Losartan (medication used to treat high blood pressure), Metoprolol Succinate ER (an extended release medication to treat high blood pressure, chest pain, and heart failure), and Norvasc (medication used to treat high blood pressure) and all of her own crushed medications resulting in Resident #1 being hospitalized . This failure resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 3:25 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy 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 could place residents at risk for harm or death relating to not receiving their ordered medication. Finding Include: 1. Record review of the face sheet dated [DATE] indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including hypotension, Alzheimer's disease, atrial fibrillation ((irregular, often rapid heart rate that commonly causes poor blood flow), chronic kidney disease, heart failure, dementia, and hypertension. Record review of the physician orders dated [DATE] through [DATE] indicated Resident #1 orders included Citalopram 10 milligrams (mg) (medication for depression) at bedtime starting [DATE], Donepezil 10mg (medication to treat Alzheimer's) at bedtime starting [DATE], Gabapentin 300mg (medication to treat neuropathy) at bedtime starting [DATE], Melatonin 3mg (medication to treat insomnia) at bedtime starting [DATE], Pravastatin 20mg (medication to treat high cholesterol) at bedtime starting [DATE], Allegra 180mg (medication to treat allergies) at bedtime starting [DATE], Memantine 10mg (medication to treat Alzheimer's) at bedtime starting [DATE], and Metoprolol Tartrate 25mg (medication to treat atrial fibrillation). Record review if the MDS dated [DATE] indicated Resident #1 understood others and was understood by others. The MDS indicated Resident #1 had a BIMS of 13 and was cognitively intact. The MDS indicated Resident #1 required extensive assistance with bed mobility, transferring, dressing, toileting, and personal hygiene. The MDS indicated Resident #1 required assistance with eating. Record review of the care plan last revised [DATE] indicted Resident #1 had and increased risk for injury related to hypertension with a goal of maintaining blood pressure range of ,d+[DATE] systolic and ,d+[DATE] diastolic. Record review of a nursing progress note dated [DATE] at 9:41 p.m. written by LVN A indicated she received a call from nursing management that there had been a medication error with Resident #1 receiving another resident's nighttime medication along with her own. The nursing progress note indicated LVN A assessed Resident #1 and found her with a blood pressure ,d+[DATE] and very lethargic. The nursing progress note indicated Resident #1 asked LVN A to just let her sleep. The nursing progress noted indicated LVN A attempted to call the physician with no answer. The nursing progress note indicated Resident #1 was transferred to the emergency room . Record review of the hospital records dated [DATE] through [DATE] indicated Resident #1 was admitted to the hospital with diagnoses of hypotension and medication overdose, accidental or unintentional. Record review of the Medication Error Investigation Worksheet dated [DATE] indicated Resident #1 had received approximately half of another resident's crushed bedtime medications along with her own crushed bedtime medications. The Medication Error Investigation Worksheet indicated the reasons for the error was failure to check medication administration record, failure to follow procedure, failure to identify patient, and misread order/dose. The Medication Error Investigation Worksheet indicated Resident #1 was assessed and sent to the emergency room due to decreased blood pressure. The Medication Error Investigation Worksheet indicated MA B was suspended pending investigation and staff were re-educated regarding medication administration policies and procedures. Record review of the Corrective Action Form dated [DATE] indicated MA B was suspended on [DATE]. The Corrective Action Form indicated the reason for suspension was dispensing wrong medication to Resident #1 resulting in the resident being sent to the hospital. Record review of the Termination Form dated [DATE] indicated MA B last worked on [DATE]. The Termination Form indicated MA B was terminated due to gross misconduct. During an interview on [DATE] at 8:58 a.m. MA B said she had crushed both Resident #1's and her roommate's bedtime medication and entered the room with both cups of medication. MA B said Resident #1 was not receiving blood pressure medication during this medication pass. MA B said she administered half of Resident #1's roommate's medication to Resident #1. MA B said when she realized what she was doing she panicked, then administered Resident #1 her correct medications. MA B said with the medications being crushed there was no way to determine how much of each medication that Resident #1 had received. MA B said she administered 2 other residents their medication following the error before contacting the DON. MA B said she asked to be relieved by another medication aide and left the building. MA B said she did not notify the charge nurse of the medication error, and that the DON made the notification of the medication error to the charge nurse. MA B said she should have prepared, crushed, and administered the resident's medication one at a time to prevent the medication error. During an interview on [DATE] at 10:11 a.m. the physician said he was notified of the medication error involving Resident #1. The physician said the medications Resident #1 received caused her blood pressure to drop significantly below her baseline. The physician said preparing one resident's medication at time cuts down on medication errors and the opportunity for errors. During an interview on [DATE] at 10:18 a.m. LVN C said staff should never prepare more than one resident's medication at a time. LVN C said preparing one resident's medication at a time prevented medication errors. LVN C said in the event of a medication error the Administrator, DON, physician, and family should be notified immediately and the resident should be assessed. LVN C said if the resident had an adverse reaction the physician should be notified and depending on the severity of the reaction the resident should be sent to the emergency room . During an interview on [DATE] at 10:21 a.m. MA D was able to name the 8 rights of medication administration. MA D said staff should not ever prepare more than one resident's medication at a time. MA D said preparing more than one resident's medication at a time could lead to a medication error. MA D said in the event of the medication error she would report to the charge nurse (her immediate supervisor) immediately. During an interview on [DATE] at 10:27 a.m. Resident #1 said she was doing well. Resident #1 said she had recently gotten out of the hospital and was feeling much better. Resident #1 said she had been hospitalized due to receiving the wrong medications. Resident #1 said it was scary. Resident #1 said things are better now. During an interview on [DATE] at 10:41 a.m. the DON said she expected staff to not pre-prepare medications and only prepare and administer on resident's medication at a time. The DON said MA B immediately suspended, and another MA took her place. The DON said MA B was eventually terminated due to the medication error. The DON said to prevent further medication errors nursing management was performing random audits, weekly medication cart checks, and random observations of medication pass. During an interview on [DATE] at 12:30 p.m. LVN A said on [DATE] she received a call from the DON regarding the medication error for Resident #1. LVN A said the DON told her Resident #1 had received approximately ,d+[DATE] a cup of crushed medication that were not her own including 4 blood pressure medications. LVN A said she could not confirm what medication Resident #1 actually received due to the medication being crushed. LVN A said an in-service was done following the incident regarding proper medication administration and not preparing/administering more than one resident's medication at a time. LVN A said if a medication error occurred it should be reported immediately. During an interview [DATE] at 12:42 p.m. MA E worked at the facility as a medication aide Monday through Friday 2:00 p.m.-10:00 p.m. and double weekends. MA E said they had recently received an in-service regarding medication administration. MA E said the in-service included not preparing/administering more than one resident's medication at a time and reporting a medication error immediately. MA E said the importance of not preparing/administering more than one resident's medication at a time was to prevent medication errors. During an observation of medication pass on [DATE] at 12:23 p.m. MA D checked medication against MAR to ensure right medication and dosage was given to the right resident. No issues noted during medication pass. No other medications were noted already prepared sitting in the medication cart and no other residents medication were prepared/administered at the same time. During interview on [DATE] at 11:15 a.m. the DON said the recent medication error was discussed in a QAA Committee Meeting on [DATE]. The DON said currently, she is and has been conducting unexpected spot checks of CMA's and nurses, during medication pass. She said going forward, the spot checks will continue, and she will be conducting weekly medication cart audits. She said she will be updating all competencies for CMA's first and then carry over to all nurses. All competencies will be repeated every 6 months. Any medication error, during times of completing competencies, will result in re-education with that staff member. She said egregious medications errors may result in disciplinary actions. Record review of the facility's Medical Management Program policy last revised [DATE] indicated, The facility implements a medication management program to meet the pharmaceutical needs of patients and residents, according to established standards of practice and regulatory requirements Authorized staff must understand The 8 Rights for administering medication: 1. The Right Patient/Resident, 2. The Right Drug, 3. The Right Dose, 4. The Right Time, 5. The Right Route, 6. The Right Charting, 7. The Right Results, 8. The Right Reason .medications supplies for an individual patient/resident are not administered to another patient/resident .The authorized staff member or licensed nurse will only prepare one resident's medications at a time. Pre-pouring medication is NOT an acceptable or safe practice . The Administrator was notified on [DATE] at 4:06 p.m. that an Immediate Jeopardy situation was identified due to the above failure. The Administrator was provided the Immediate Jeopardy template on [DATE] at 4:09 p.m. The facility's Plan of Removal was accepted on [DATE] at 3:07p.m. and included: The identified resident has returned to the facility and is at baseline with no further concerns. The identified employee was suspended on [DATE] pending the outcome of the investigation. All residents who reside in the facility and receive medications have the potential to be affected by the alleged deficient practice. The Facility Activity report and the 24- hour report for the past 24 hours was reviewed by the Director of Nursing/designee to validate that no change of condition was identified that could be the result of a medication error. There were none identified. Facility wide audit conducted of all non-crushable medications on [DATE] at 8:00 p.m. any non-crushable medications orders have been updated to read do no crush. Licensed Nurses and Certified Medication Aides were re-educated on Medication Administration including the 8 Rights for administering medication. Education included: that under no circumstances do we ever set up medication pass in advance, pull medications for med pass 1 resident at a time, performing the 3-way check, monitoring and reporting. The Right Patient/Resident The Right Drug The Right Dose The Right Time The Right Route The Right Charting The Right Results The Right Reason Medication administration competencies completed with Licensed nurses and Certified Medication Aides using the Medication Administration Competency tool from the staff education orientation policy and procedure manual. Competencies completed by the Director of Nursing/designee. This was completed on [DATE] at 8:00 PM. This Re-education and competencies began on [DATE] and will be completed on [DATE] at 8:00 PM. Anyone not receiving this re-education by this time will receive prior to next scheduled shift. This will be included in new hire orientation and for agency staff. The 24-hour report and the Facility Activity report will be reviewed in clinical morning meeting to identify any change of condition that may be related to a potential medication error. The resident will be assessed and physician notified for further direction. The Medical Director was notified on [DATE] at 4:09 PM by telephone of the Immediate Jeopardy and the contents. An Ad Hoc Quality Assurance Performance Improvement meeting was held on [DATE] at 5:06 PM to discuss the contents of this plan. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Record review of the Nursing Medication Administration competencies for licensed nurses dated [DATE] through [DATE] indicated all licensed nurse who had been observed for medication administration competencies had been checked off by the DON as performing medication administration competencies accurately with no issues. Record review of the Nursing Medication Administration competencies for the MAs dated [DATE] through [DATE] indicated all MAs who had been observed for medication administration competencies had been checked off by the DON as performing medication administration competencies accurately with no issues. Record review of the Pharmacy Services audits dated [DATE], [DATE], and [DATE] indicated medication cart audits were being performed to ensure the medication cart were locked when unattended, there were no preset/pre-prepared medications in or on top of the cart, there were no loose pills in the cart, the carts were free of expired products and medications, and all items were properly dated when opened. Record review of a random sample of 5 resident's medication orders indicated medications not to be crushed included special instruction in the physician orders included DO NOT CRUSH starting [DATE]. Interviews with staff on [DATE] between 9:08 a.m. and 10:36 a.m. (LVN F, MA G, LVN H, RN J, LVN K, LVN C, MA L, MA D, LVN M, LVN N, the MDS nurse, LVN P, MA E, LVN A, and the DON) were performed. During the interviews the staff were able to list the 8 rights of medication administration, said resident's medications should not be pre-prepared, and medications should be administered to one resident at a time. Record review of the QAPI meeting sign in-sheet dated [DATE] indicated the facility had held a QAPI meeting and all required attendees were in attendance including the Medical Director, Administrator, DON, ADON, Dietary supervisor, Maintenance Supervisor, SW, Nurse Assessment Coordinator, Staff Development Coordinator, Human Resources Manager, and Director of Rehab.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent injury for 1 of 1 resident reviewed for accidents. (Resident #48) The facility did not provide foot pedals to wheelchair prior to transport which resulted in Resident #48 getting a left ankle fracture. This failure could affect residents who required assistive devices when traveling in the facility van at risk for accidents. Findings included: Record review of physician orders dated 01/16/22 to 02/16/22 indicated Resident #48 was a [AGE] year-old male who admitted on [DATE] with diagnoses including dementia without behaviors, fracture to left ankle, depressive disorder, intellectual disability, severe obesity, and [CONDITION(S)] . Record review of revised care plan dated 1/27/22 indicated Resident #48 required extensive to total assist with most ADLs. Also, indicated Resident #48 had pain/discomfort and was at risk for injury from decrease in ADLs. Record review of provider investigation report dated 01/24/22 indicated the incident occurred on 1/18/.22. Description of Allegation: The Staff Transport Aide was propelling Resident #48 wheelchair out of exam area after Resident #48 was seen by doctor at the doctor's office. As the Transport Aide was crossing waiting area, Resident #48's foot caught on area rug in waiting area that was curled up. Resident #48 responded with ouch ;; nurse a doctor's office assessed resident. Resident #48 was returned to facility, later complained of increased discomfort. X-ray obtained with fracture to ankle discovered. Description of injury: Acute medial malleolus and distal fibula fractures without displacement seen. No joint dislocation. Soft tissue swelling noted. No comparison study: Resident #48 has long history of foot issues: [CONDITION(S)] to bilateral feet, type II diabetic and morbid obesity. Provider response: Ankle immobilized; comfort measures provided with analgesics for pain as well. Investigation Summary: Transport Aide did not attach footrests to wheelchair prior to transport. Record review of a nurse progress note dated 01/18/22 indicated while out at doctor appointment Resident #48 got his ankle caught under the wheelchair and complained of pain to left ankle. Resident #48 doctor was notified and gave order for Xray of left ankle. Record review of a nurse progress note dated 01/20/22 indicated Resident #48 complained of pain to lower left leg. [MEDICATION(S)] (pain medication) was delivered from pharmacy. Order was received to change [MEDICATION(S)] to 1-tab q6 hours prn for pain. Record review of Xray report dated 01/18/22 indicated Resident #48 had acute medial malleolus and distal fibula fractures. Record review of Orthopedic physician order dated 01/26/22 indicated Resident #48 was diagnosed with left fracture ankle. An order was written for walking boot to left lower extremity (prescription provided) obtain at a medical supply store. Remain non-weight bearing to left lower extremity; remove walking boot to check skin daily and to follow up with orthopedic doctor in a month. During an observation on 02/15/22 at 2:26 p.m., Resident #48 was sitting in the hall, he had a boot to left lower leg. During an interview on 02/15/22 at 1:30 p.m., the Administrator acknowledged Resident #48's fractured ankle was their fault, and the Transportation Aide should have attached foot pedal to wheelchair and did not know why she did not. During an interview on 02/15/22 at 3:59 p.m., the DON said she was on leave during the time of the incident regarding Resident #48's fractured ankle but acknowledged the Transportation Aide did not grab foot pedals for wheelchair and should have. During an interview on 02/16/22 at 1:39 p.m., the Transportation Aide said she took Resident #48 to his blood sugar appointment. She said normally he used an electric chair, but the van did not have room for his chair, so he was transported using a standard wheelchair. She acknowledged the incident and Resident #48 fractured ankle was her fault because she should have attached foot pedals to the wheelchair. Transportation Aide said they had a storage closet full of foot pedals. During an observation and interview on 02/16/22 at 1:44 p.m. the Transportation Aide went to a storage closet next to the vending machine. Located inside the storage closet was a box overflowing with foot pedals for wheelchairs. Transportation Aide said the foot pedals were easy to attach to wheelchairs and said she should have gotten a pair for Resident #48, but she did not think to get one. During an interview on 02/16/22 at 1:48 p.m., Resident #48 said whenever the incident happened, he was leaving a doctor's appointment and the Transportation Aide ran over his foot with the wheelchair. He said he knew immediately it was broken because he was in the worst pain. Resident #48 said he still had pain due to left ankle fracture when moving or with ankle being stable.

Based on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of admission for 5 of 5 residents reviewed for baseline care plans. (Resident #s 55, 70, 173, 174, and 175) * The facility did not have a baseline care developed and implemented within 48 hours after admission for Resident #s 55, 70, 173, 174, and 175. This failure could place newly admitted residents at risk for no continuity of care, no communication among nursing home staff, and decreased quality of life. Findings included: 1. Record review of a face sheet dated 02/16/22 indicated Resident #55 was a [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the EMR from 01/06/22 through 02/16/22 indicated Resident #55 had no baseline care plan. 2. Record review of a face sheet dated 02/16/22 indicated Resident #70 was a [AGE] year-old female admitted on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the EMR from 12/28/21 through 02/16/22 indicated Resident #70 had no baseline care plan. 3. Record review of a face sheet dated 02/16/22 indicated Resident #173 was a [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a hospital history and physical dated 01/13/22 indicated Resident #173 had head and neck cancer and a tube inserted through the skin directly into the stomach for feeding. Record review of the EMR from 01/24/22 through 02/16/22 indicated Resident #173 had no baseline care plan. 4. Record review of a face sheet dated 02/16/22 indicated Resident #174 was a [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the EMR from 02/01/22 through 02/16/22 indicated Resident #174 had no baseline care plan. 5. Record review of a face sheet dated 02/16/22 indicated Resident #175 was a [AGE] year-old male admitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a hospital discharge instruction dated 02/08/22 indicated Resident #175 was to have fluid restrictions of 1500 ml per day, a blood thinner medication daily for 24 days, salt tablets for 5 days, and blood sugar check 3 times daily and before bed with routine insulin and sliding scale insulin (insulin dosage based on the blood sugar level). Record review of the EMR from 02/08/22 through 02/16/22 indicated Resident #175 had no baseline care plan. During an interview on 02/16/22 at 09:48 a.m. the administrator said the SW was not available as she had been suspended on 02/14/22 for not performing her duties accordingly including completing and implementing baseline care plans within 48 hours after a resident admitted . During an interview on 02/16/22 at 02:15 p.m. the MR said baseline care plan information was not provided to the resident or family until 2 weeks after admission when the comprehensive care plan was due. During an interview on 02/16/22 at 02:23 p.m. the ADON said the baseline care plan was the responsibility of the SW. She said they were not done until the comprehensive was done 2 weeks later and a meeting with the family or resident was done at that time. She said they had no baseline care plans at this time provided to the resident or family within 48 hours after admission. Record review of a Social Services Policies and Procedures revised 10/01/20 indicated the following: Subject: Person-Centered Care Plan Policy: The resident has the right to be informed of and participate in treatment and the right to participate in the development and implementation of a person-centered plan of care. Social Services Staff will participate in the development of a baseline and or comprehensive care plan for each patient/resident. Procedures: 1. Social Services Staff will participate in the development of a baseline and or comprehensive care plan for each patient/resident according to the following time frames and facility procedures: 2. Baseline Care Plan: A. Develop and initiated within 48-hours of admission

Based on interview and record review, the facility failed to obtain from hospice the most recent plan of care specific to each patient and the Hospice medication information specific to each patient for 1 of 1 resident reviewed for hospice services. (Resident #14) The facility did not obtain Resident #14's most recent hospice plan of care from the resident's hospice provider. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident's health. Findings included: Record review of face sheet printed on 2/16/22 indicated Resident #14 was a [AGE] year-old female who was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, indicated Resident #14 admitted from home with Hospice. Record review of Resident #14's Hospice chart did not have current hospice notes., The most recent hospice comprehensive assessment and plan of care on chart was for benefit period dated 9/10/21 to 11/8/21. Record review of admission MDS dated [DATE] indicated Resident was receiving hospice services. Record review of quarterly MDS dated [DATE] and 11/17/21 both indicated Resident #14 was receiving hospice services. Record review of the clinical record for Resident #14 from 5/10/21 through 2/16/22 did not have current hospice paperwork. Record review of revised care plan dated 11/30/21 indicated Resident #14 required extensive to total assist with all ADLs. During an interview on 2/16/22 at 3:09 p.m., the ADON said she did not locate the current hospice notes and contacted the Hospice agency to request the needed missing paperwork. ADON acknowledged Resident #14's 1/8/22 to 3/8/22 benefit period hospice comprehensive assessment and plan of care paperwork and 11/9/21 to 1/7/22 benefit period Hospice comprehensive assessment and plan of care paperwork should had been in the chart and did not know who was responsible for making sure charts were current. During an interview on 2/16/22 at 3:56 p.m., with Administrator and Clinical Service Director they said in the past the DON was responsible for making sure the charts was current and up to date. Said the DON was a new hire and they had not determined at that time who would be responsible. Record review of hospice contract dated 9/12/11 indicated 3.2 Coordination of Services, b) Hospice shall provide the following information to nursing facility for each hospice patient: i) The most recent hospice plan of care specific to each hospice patient, ii) hospice election form and any advance directives specific to each hospice patient; iii) physician certification and recertification of the terminal illness specific to each hospice patient . Record review of revised health information management policies, and procedures dated 3/1/13 indicated The Health Information Management Department maintains all current clinical information in each resident/patient's clinical records. Procedures: 1) File all current information about patient/resident in the patient/resident's current in-house record.

Based on observation, interview, and record review, the facility failed to ensure CNAs demonstrated competency in techniques to care for 2 of 3 residents reviewed for incontinent care. (Resident #s 72 and 175). CNAs D and E did not use correct technique when providing incontinent care for Resident #72. CNA F did not pull back the foreskin and lift and clean the shaft of Resident #175's penis while performing incontinent care. This failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections. Findings included: 1.During an observation on 11/18/20 at 11:10 AM, CNAs D and E provided incontinent care for Resident # 72. CNA D unfastened brief and CNA E handed her an incontinent wipe. CNA D cleansed the resident's frontal areas with one disposable wipe, folding it over twice between wipes. She wiped the right groin, center labia, and left groin. She cleansed the labia without fully exposing the inner labia. Using the same soiled gloves CNA D turned the resident to her right side with assist from CNA E. CNA D rolled the wet brief under the resident's lower back and cleansed the left buttock and anal area folding the wipe once. CNA E handed her another wipe and she cleaned the left buttock and anal area again with the same process. CNA D removed the soiled brief and placed it in the discard bag. Using the same soiled gloves, CNA D placed a clean brief under the resident. Both CNAs then turned the resident to the opposite side and CNA E cleansed the resident's right buttock and anal area using one wipe folding it once. Using the same soiled gloves, CNA E pulled the brief through from under the resident. Using the same soiled gloves, both CNAs turned the resident to her back and both pulled up the brief and affixed the tabs on their respective sides. Using the same soiled gloves, they straightened the resident's gown and pulled her up in bed. They removed their gloves and sanitized their hands by reaching in their pockets for sanitizer. During an interview on 11/18/2020 at 11:20 AM, CNAs E and D indicated they would not have done anything differently when asked. CNA E said she thought she didn't need to change gloves because the resident wasn't dirty she was only wet. CNA D did not know what they might have done wrong or differently. Physician orders [REDACTED].#72 was an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] for Resident #72 indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting and personal hygiene. She required assistance of one staff with eating and she was incontinent of bowel and bladder. A care plan last revised on 10/21/20 indicated Resident #72 required extensive assistance from staff with ADLs to remain clean, dry, odor free, and well-groomed. The care plan indicated she had urinary incontinence related to impaired mobility and was at risk for urinary tract infection. The care plan indicated the resident was at risk for skin breakdown and was to be kept as clean and dry as possible and incontinence care was to be provided after each episode. The care plan indicated the resident was at risk for pressure ulcers and incontinence care was to be provided after each episode. A Perineal Care/Incontinent Care Policy, dated 2016, indicated .Wash labia majora .1) Separate labia to expose urethra meatus and vaginal orifice . Wash downward from pubic area toward rectum in one smooth stroke . An Infection Prevention and Control Policies and Procedures revised 09/11 indicated Subject: Hand Hygiene/Handwashing: Procedures: 1. Hand hygiene/hand washing is done: After: H. After removal of medical/surgical or utility gloves According to the World Health Organization's Glove Use Information Leaflet revised August 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal 2. During an observation on 11/18/20 at 9:20 AM, CNA F with gloved hands used one wipe to clean the penis and scrotum on Resident #175. She wiped from the base of the penis with a downward swipe to the scrotal sac. She did not lift the penis to clean underneath it, nor did she pull back the foreskin, clean around the head of the penis and replace the foreskin. Physician orders [REDACTED].#175 was a [AGE] year old male, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE], admission, indicated Resident #175 was on his 5-day admission. A care plan dated 11/05/20 indicated Resident #175 was incontinent of bowel and bladder. During an interview on 11/18/20 at 9:38 AM, CNA F said this was the way she does incontinent care every day, she said this is the way she was taught. During an interview on 11/18/20 at 12:10 PM, the DON said CNA F told her about the incontinent care and she said she should have pulled the foreskin back further. The DON said she was aware and would take care of it. A perineal care/incontinent care policy dated 2016 indicated .9 . 1) Gently grasp shaft of penis. If patient/resident is uncircumcised, retract foreskin. Apply cleanser as directed. Wash tip of penis at urethral meatus firs. Using circular motion, cleanse from meatus outward .3) return foreskin to its natural position. 4) wash shaft of penis with gently but downward [MEDICAL CONDITION]. Pay special attention to underlying surface of penis .

Based on observation, interview, and record review, the facility failed to ensure pharmaceutical services were provided for 2 of 3 nurse medication carts and 1 of 3 medication aide carts. Glucometer strips were not dated when opened. Expired medications were not removed from use. This failure could place residents at risk of not receiving the full therapeutic benefit of their medications. Findings included: 1. During an observation and interview of the Hall 200 nurses' medication cart with RN A on 11/18/2020 at 10:20 AM, the blood glucose strips were not dated when opened. RN A said she used 12-14 strips a day and she dated the package when she opened them, she said she did not open this bottle. She said the bottle had not been opened too long, she placed a date on the container when she thought it might have been opened. 2. During an observation and interview of the Hall 300 nurses' medication cart with LVN B on 11/18/20 at 10:30 AM, the following was noted: *blood glucose strips were not dated when opened; *[MEDICATION NAME] Flex Pen for Resident #22 had an open date of 10/17/20; *[MEDICATION NAME] Flex Pen for Resident #42 had open date of 10/03/20. LVN B said the insulins should have been discarded and the test strips should have been dated when opened. 3. During an observation and interview of the Hall 300 medication aide cart with MA C on 11/18/20 at 11:25 AM, the following was noted: *[MEDICATION NAME] 60 mg tablets (OTC) 5 tablets expired 8/20 and co-mingled with 2 tablets expiring 8/21. MA C said she did not know how that could have happened. A manufactures labeling on the blood glucose strips package indicated Use within 6 months after first opening or before expiration date. a manufactures labeling on the [MEDICATION NAME] Flex Pen indicated Discard 28 days after opening. A Pharmacy Services Policy for Medication Storage, dated 11/1/2017, indicated .6. Once any medication is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates of opened medications. 7. Once any multi-dose medication is opened, nursing will mark multi-dose products (e.g., inhalers, insulin, opthalmics, otics and the like) with the date opened and discard and replace after 28 days (or sooner if required by the manufacturer i.e. Mix Insulins) .12. Outdated, contaminated, or deteriorated medications .are immediately removed from stock, disposed of according to procedures for medication destruction .

Based on observation, interview, and record review, the facility failed to have an effective infection control program to prevent the development and transmission of disease and infection for 1 of 3 residents reviewed for incontinent care/peri care (Resident #72). CNAs D and E contaminated clean areas and did not thoroughly clean Resident #72 when providing incontinent care. This failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections. Findings included: During an observation on 11/18/20 at 11:10 AM, CNAs D and E provided incontinent care for Resident # 72. CNA D unfastened brief and CNA E handed her an incontinent wipe. CNA D cleansed the resident's frontal areas with one disposable wipe, folding it over twice between wipes. She wiped the right groin, center labia, and left groin. She cleansed the labia without fully exposing the inner labia. Using the same soiled gloves CNA D turned the resident to her right side with assist from CNA E. CNA D rolled the wet brief under the resident's lower back and cleansed the left buttock and anal area folding the wipe once. CNA E handed her another wipe and she cleaned the left buttock and anal area again with the same process. CNA D removed the soiled brief and placed it in the discard bag. Using the same soiled gloves, CNA D placed a clean brief under the resident. Both CNAs then turned the resident to the opposite side and CNA E cleansed the resident's right buttock and anal area using one wipe folding it once. Using the same soiled gloves, CNA E pulled the brief through from under the resident. Using the same soiled gloves, both CNAs turned the resident to her back and both pulled up the brief and affixed the tabs on their respective sides. Using the same soiled gloves, they straightened the resident's gown and pulled her up in bed. They removed their gloves and sanitized their hands by reaching in their pockets for sanitizer. During an interview on 11/18/2020 at 11:20 AM, CNAs D and E indicated they would not have done anything differently when asked. CNA E said she thought she didn't need to change gloves because the resident wasn't dirty she was only wet. CNA D did not know what they might have done wrong or differently. Physician orders [REDACTED].#72 was an [AGE] year-old female admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] for Resident #72 indicated the resident required extensive assistance of 2 staff with bed mobility, transfers, dressing, toileting and personal hygiene. She required assistance of one staff with eating. She was incontinent of bowel and bladder. A care plan last revised on 10/21/20 indicated Resident #72 required extensive assistance from staff with ADLs to remain clean, dry, odor free, and well-groomed. The care plan indicated she had urinary incontinence related to impaired mobility and was at risk for urinary tract infection. The care plan indicated the resident was at risk for skin breakdown and was to be kept clean and dry as possible and incontinence care was to be provided after each episode. The care plan indicated the resident was at risk for pressure ulcers and incontinence care was to be provided after each episode. A Perineal Care/Incontinent Care Policy, dated 2016, indicated .Wash labia majora .1) Separate labia to expose urethra meatus and vaginal orifice . Wash downward from pubic area toward rectum in one smooth stroke . An Infection Prevention and Control Policies and Procedures revised 09/11 indicated Subject: Hand Hygiene/Handwashing: Procedures: 1. Hand hygiene/hand washing is done: After: H. After removal of medical/surgical or utility gloves According to the World Health Organization's Glove Use Information Leaflet revised August 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal

Based on observation, interview, and record review, the facility failed to ensure the written plan of care was followed for 1 of 7 residents reviewed for physician orders. (Resident #1) The facility did not provide wound care for 7 days or weekly skin assessments for 3 weeks for Resident #1's right hip surgical incision. This failure could place residents at risk of skin breakdown, infection, and a decline in health. Findings included: A face sheet dated 09/04/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact, usually made her needs known, and usually understood others. She required extensive assistance with ADLs, was frequently incontinent of bowel and bladder. The MDS indicated Resident #1 had a surgical wound. The hospital discharge orders dated 08/19/19 indicated Resident #1 was to have daily wound and skin care. Physician orders [REDACTED].#1 did not include wound treatments or weekly skin assessments. A care plan dated 09/10/19 indicated Resident #1 had a surgical wound to her right hip and staff should monitor the area for increased breakdown, signs of infection, and perform wound treatment as ordered. Staff should perform weekly skin assessments and document findings in the resident's record. During an interview on 09/10/19 at 11:27 a.m., Resident #1 said she admitted to the facility after she had right hip surgery for [REDACTED]. She said a few weeks ago her dressing got wet during a shower and the incision became red and started draining. She said her physician assessed her and ordered her an antibiotic. She said she was already taking another antibiotic for a sore throat. Resident #1 said the incision cleared up and she went to a follow up appointment with her surgeon's physician assistant on 09/09/19 and had her staples removed. She said the physician's assistant said her incision looked good and placed steri strips over the incision. During an observation on 09/10/19 at 3:42 p.m., the DON assessed Resident #1's surgical incision to her right hip. The incision was covered from end to end with steri strips. There was no redness, drainage, or swelling to Resident #1's right hip incision. The DON measured Resident #1's incision to be approximately 12 cm long. A nursing progress note dated 08/21/19 at 3:31 a.m., completed by LVN A indicated Resident #1 arrived at the facility on 08/20/19 at approximately 5:15 p.m. Resident #1's skin was warm and dry, and the resident could voice her needs. The nursing note indicated to refer to admission observations for further assessment information. An admission observation report dated 08/21/19 at 4:43 a.m., completed by LVN A indicated Resident #1's skin was warm, dry, with no alterations in skin. The report indicated to refer to the separate skin assessment. An initial skin assessment dated [DATE] at 4:38 a.m., completed by LVN A was blank. The assessment indicated it was completed on 08/21/19 at 5:22 a.m. During an interview on 09/10/19 at 5:15 p.m., LVN A said she worked the evening of 08/20/19 when Resident #1 admitted to the facility. She said Resident #1 was agitated when she arrived and refused care. She said Resident #1 settled down after she received her PRN anxiety medication. LVN A said she did not remember if she performed an initial skin assessment of Resident #1 or looked at her surgical incision. She said an initial skin assessment should be completed on admission. She said she could not remember if Resident #1 admitted with wound care orders. LVN A said if a resident admitted with treatment orders, the orders should be entered during admission. She said she saw Resident #1's surgical incision twice since admission and that was about a week and a half ago. She said Resident #1's surgical incision had no redness or drainage when she saw it. She said Resident #1's treatments were performed on the day shift. A skilled nursing note dated 08/21/19 at 8:12 p.m. indicated Resident #1's skin was warm and dry with a surgical wound present. The note indicated wound treatment was completed. A skilled nursing note dated 08/23/19 at 8:29 a.m. indicated Resident #1's skin was warm and with no wound present. A skilled nursing note dated 08/23/19 at 11:33 a.m. indicated Resident #1's skin was warm and dry with a surgical wound present. The note indicated wound treatment was completed. A skilled nursing note dated 08/24/19 at 8:04 a.m. indicated Resident #1's skin was warm and dry with a surgical wound present to her right hip. The note indicated wound treatment was completed. A skilled nursing note dated 08/25/19 at 6:37 a.m. indicated Resident #1's skin was warm and dry with a surgical wound present to her right hip. The note indicated wound treatment was completed. A skilled nursing note dated 08/26/19 at 3:50 p.m. indicated Resident #1's skin was warm and dry with a surgical wound present to her right hip. The note indicated wound treatment was completed. A skilled nursing note dated 08/27/19 at 6:33 a.m. indicated Resident #1's skin was warm and dry with a surgical wound present to her right hip. The note indicated wound treatment was completed. A weekly skin assessment dated [DATE] for Resident #1 was not available. A skilled nursing note dated 08/28/19 at 7:24 a.m. indicated Resident #1's skin was warm and dry with a surgical wound present to her right hip. The note indicated wound treatment was completed. A nursing progress note dated 08/28/19 at 1:31 p.m. completed by LVN B indicated orders were received by Resident #1's physician to continue with current wound care that Resident #1 came from the hospital with that was already applied to the wound. Physician orders [REDACTED].#1 was ordered daily wound care to her right hip with normal saline, pat dry, apply xeroform with petroleum, and cover with a dressing. Resident #1 was ordered [MEDICATION NAME] 500 mg and [MEDICATION NAME] 180 mg for rhinitis. During an interview on 09/10/19 at 11:53 a.m., LVN B said Resident #1 admitted to the facility without surgical wound orders. She said Resident #1's physician came to the facility on [DATE] and she notified him that Resident #1 admitted without surgical wound orders. LVN B said Resident #1's physician assessed Resident #1 incision to her right hip and said to continue the same treatment that the hospital was performing. She said on 08/28/19, Resident #1's incision had no redness or drainage. She said she did not perform dressing changes before 08/28/19 because there were no orders. LVN B said she was off for the next 4 days and when she returned Resident #1's surgical site became red and her physician ordered her an antibiotic. She said if a resident admitted with wound orders, the orders should be entered upon admission. A nursing progress note dated 08/30/19 at 3:02 p.m. by an agency nurse indicated Resident #1's surgical incision was red, warm, and tender. Resident #1 complained of pain radiating down her leg. Resident #1's physician was notified by fax. During an interview on 09/10/19 at 3:58 p.m., LVN D said she was working with an agency nurse on 08/30/19 and the nurse notified her that Resident #1's surgical incision did not look good. She said the agency nurse said told her that Resident #'1s surgical incision looked red and infected. LVN D said she did not assess Resident #1, but she told the agency nurse she needed to document what the incision looked like. LVN D said she did not perform wound care on Resident #1. A physician progress notes [REDACTED].#1 had [MEDICAL CONDITION] to her surgical site that was red, warm, and tender. Resident #1 was currently taking [MEDICATION NAME] for pharyngitis and [MEDICATION NAME] ([MEDICATION NAME]) 300 mg would be added. Physician orders [REDACTED].#1 was ordered [MEDICATION NAME] 300 mg twice a day for 7 days for an infection following a procedure. A treatment administration record (TAR) dated (MONTH) 2019 for Resident #1 indicated right hip surgical wound treatments were completed on 08/28/19, 08/29/19, 08/30/19, and 08/31/19. The TAR indicated Resident #1 did not receive surgical wound treatments from 08/20/19 to 08/27/19. Physician orders [REDACTED].#1 indicated her right hip surgical orders were discontinued and to continue to monitor the surgical site. A treatment administration record (TAR) dated (MONTH) 2019 for Resident #1 indicated right hip surgical wound treatments were completed from 09/01/19 to 09/08/19. The TAR indicated on 09/09/19 Resident #1's wound treatment was completed at her orthopedic appointment. A weekly skin assessment dated [DATE] for Resident #1 was not available. A weekly skin assessment dated [DATE] at 2:55 p.m. for Resident #1, after surveyor intervention, indicated Resident #1 had a surgical incision to her right hip with steri strips. The assessment indicated there were no other skin impairments. During an interview on 09/10/19 at 4:03 p.m., RN C said Resident #1 did have a surgical incision, but she could not remember what it looked like. She said she may have performed wound care on Resident #1's incision but she could not remember when. She said if a resident admitted with wound orders, the orders should be entered upon admission. During an interview on 09/10/19 at 4:48 p.m., Resident #1's physician said he was notified about Resident #1's surgical incision becoming red and tender. He said he assessed the surgical site and it was not infected. He said Resident #1 had [MEDICAL CONDITION] around her surgical site and Resident #1 was already on [MEDICATION NAME] for pharyngitis and he added [MEDICATION NAME] for the [MEDICAL CONDITION]. He said the 2 antibiotics may have been overkill, but the [MEDICAL CONDITION] was caught early, and it cleared up. He said Resident #1's surgeon was happy, so he was happy. During an interview on 09/10/19 at 3:17 p.m., the DON said Resident #1 admitted to the facility with orders for daily wound care and the orders should have been entered upon admission. She said weekly skin assessment orders were standing orders that were entered by administrative nursing. She said it looked like Resident #1's weekly skin assessments orders were missed. She said all residents were supposed to receive weekly skin assessment orders. The DON said weekly skin assessments were to be performed every 7 days from admission. The facility's wound care policy last revised 06/01/15 indicated each resident should have a head to toe skin evaluation performed by a licensed nurse during the admission process. The documentation should include the pressure injuries, other wound areas, and skin conditions. Evaluation of wounds would be performed on admission, weekly, and on discovery. The policy indicated the clinician would follow specific physician orders [REDACTED]. The clinician should document all procedures performed and the resident's response.

Based on observation, interview and record review, the facility failed to ensure an accurate assessment to reflect the resident's status for 1 of 7 residents reviewed for assessments. (Resident #1) The facility did not do weekly skin assessments for 3 weeks for Resident #1. This failure could place residents at risk of not receiving needed care and services in accordance with individually assessed needs. Findings included: A face sheet dated 09/04/19 indicated Resident #1 was [AGE] years old, admitted on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #1 was cognitively intact, usually made her needs known, and usually understood others. She required extensive assistance with ADLs. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #1 had a surgical wound. A hospital discharge order dated 08/19/19 indicated Resident #1 was ordered daily wound and skin care. Physician orders [REDACTED].#1 did not include wound treatments or weekly skin assessments. A care plan dated 09/10/19 indicated Resident #1 had a surgical wound to her right hip and staff should monitor the area for increased breakdown, signs of infection, and perform wound treatment as ordered. Staff should perform weekly skin assessments and document findings in the resident's record. During an interview on 09/10/19 at 11:27 a.m., Resident #1 said she admitted to the facility after she had right hip surgery for [REDACTED]. She said a few weeks ago her dressing got wet during a shower and the incision became red and started draining. She said she went to a follow up appointment with her surgeon's physician assistant on 09/09/19 and had her staples removed. She said the physician's assistant said her incision looked good and placed steri strips over the incision. During an observation on 09/10/19 at 3:42 p.m., the DON assessed Resident #1's surgical incision to her right hip. The incision was covered from end to end with steri strips. There was no redness, drainage, or swelling to Resident #1's right hip incision. The DON measured Resident #1's incision to be approximately 12 cm long. A nursing progress note dated 08/21/19 at 3:31 a.m. completed by LVN A indicated Resident #1 arrived at the facility on 08/20/19 at approximately 5:15 p.m. Resident #1's skin was warm and dry, and the resident could voice her needs. The nursing note indicated to refer to admission observations for further assessment information. An admission observation report dated 08/21/19 at 4:43 a.m. completed by LVN A indicated Resident #1's skin was warm, dry, with no alterations in skin. The report indicated to refer to the separate skin assessment. An initial skin assessment dated [DATE] at 4:38 a.m. completed by LVN A was blank. The assessment indicated it was completed on 08/21/19 at 5:22 a.m. During an interview on 09/10/19 at 5:15 p.m., LVN A said she worked the evening of 08/20/19 when Resident #1 admitted to the facility. She said Resident #1 was agitated when she arrived and refused care. She said Resident #1 settled down after she received her PRN anxiety medication. LVN A said she did not remember if she performed an initial skin assessment of Resident #1 or looked at her surgical incision. She said an initial skin assessment should be completed on admission. She said she could not remember if Resident #1 admitted with wound care orders. LVN A said if a resident admitted with treatment orders, the orders should be entered during admission. She said she saw Resident #1's surgical incision twice since admission and that was about a week and a half ago. She said Resident #1's surgical incision had no redness or drainage when she saw it. She said Resident #1's treatments were performed on the day shift. A weekly skin assessment dated [DATE] for Resident #1 was not available. Physician orders [REDACTED].#1 was ordered daily wound care to her right hip with normal saline, pat dry, apply xeroform with petroleum, and cover with a dressing. Resident #1 was ordered [MEDICATION NAME] 500 mg and [MEDICATION NAME] 180 mg for rhinitis. During an interview on 09/10/19 at 11:53 a.m., LVN B said Resident #1 admitted to the facility without surgical wound orders. She said Resident #1's physician came to the facility on [DATE] and she notified him that Resident #1 admitted without surgical wound orders. LVN B said Resident #1's physician assessed Resident #1 incision to her right hip and said to continue the same treatment that the hospital was performing. She said on 08/28/19, Resident #1's incision had no redness or drainage. She said she did not perform dressing changes before 08/28/19 because there were no orders. LVN B said she was off for the next 4 days and when she returned Resident #1's surgical site became red and her physician ordered her an antibiotic. She said if a resident admitted with wound orders, the orders should be entered upon admission. She said Resident #1 had no skin assessments since admission but should have received weekly skin assessments. A nursing progress note dated 08/30/19 at 3:02 p.m. by an agency nurse indicated Resident #1's surgical incision was red, warm, and tender. Resident #1 complained of pain radiating down her leg. Resident #1's physician was notified by fax. During an interview on 09/10/19 at 3:58 p.m., LVN D said she was working with an agency nurse on 08/30/19 and the nurse notified her that Resident #1's surgical incision did not look good. She said the agency nurse said she told her that Resident #'1s surgical incision looked red and infected. LVN D said she did not assess Resident #1, but she told the agency nurse she needed to document what the incision looked like. LVN D said she did not perform wound care on Resident #1. A physician progress notes [REDACTED].#1 had [MEDICAL CONDITION] to her surgical site that was red, warm, and tender. Resident #1 was currently taking [MEDICATION NAME] for pharyngitis and [MEDICATION NAME] ([MEDICATION NAME]) 300 mg would be added. Physician orders [REDACTED].#1 was ordered [MEDICATION NAME] 300 mg twice a day for 7 days for an infection following a procedure. A weekly skin assessment dated [DATE] for Resident #1 was not available. Physician orders [REDACTED].#1, after surveyor intervention, indicated she was ordered weekly skin assessments by a licensed nurse. A weekly skin assessment dated [DATE] at 2:55 p.m. after surveyor intervention, indicated Resident #1 had a surgical incision to her right hip with steri strips. The assessment indicated there were no other skin impairments. During an interview on 09/10/19 at 4:48 p.m., Resident #1's physician said he was notified about Resident #1's surgical incision becoming red and tender. He said he assessed the surgical site and it was not infected. He said Resident #1 had [MEDICAL CONDITION] around her surgical site and Resident #1 was already on [MEDICATION NAME] for pharyngitis and he added [MEDICATION NAME] for the [MEDICAL CONDITION]. He said the 2 antibiotics may have been overkill, but the [MEDICAL CONDITION] was caught early, and it cleared up. He said Resident #1's surgeon was happy, so he was happy. During an interview on 09/10/19 at 3:17 p.m., the DON said Resident #1 admitted to the facility with orders for daily wound and skin care and the orders should have been entered upon admission. She said weekly skin assessment orders were standing orders that were entered by administrative nursing. She said it looked like Resident #1's weekly skin assessments orders were missed. She said all residents were supposed to receive weekly skin assessment orders. The DON said weekly skin assessments were to be performed every 7 days from admission. The facility's wound care policy last revised 06/01/15 indicated each resident should have a head to toe skin evaluation performed by a licensed nurse during the admission process. The documentation should include the pressure injuries, other wound areas, and skin conditions. Evaluation of wounds would be performed on admission, weekly, and on discovery. The policy indicated the clinician would follow specific physician orders [REDACTED]. The clinician should document all procedures performed and the resident's response.

Based on observation, interview and record review to the facility failed to determine an account of all controlled drugs is maintained and periodically reconciled for 1 of 6 residents reviewed for pharmacy services. (Resident #1) The facility did not conduct a narcotic reconciliation count to ensure all narcotics were accounted for. LVN A and MA B did not do a narcotic reconciliation count at the end of MA B's shift. This failure could place residents at risk of not receiving narcotic medications and a drug diversion in the facility. Findings included: A face sheet dated 07/23/19 indicated Resident #1 was [AGE] years old, admitted [DATE] and discharged on [DATE], with [DIAGNOSES REDACTED]. Physician orders [REDACTED].#1 was ordered [MEDICATION NAME] 10 milligram (mg) (treats pain) ½ tablet by mouth twice daily. An MDS dated [DATE] indicated the resident was moderately impaired cognitively and received a pain regimen. A care plan dated 04/16/19 indicated the resident had complaints of chronic pain related to arthritis. Intervention was to monitor for pain and administer medications as ordered. A nursing note dated 07/09/19 at 6:54 p.m. indicated resident had no respirations, no pulse, and no heartbeat. Hospice of East Texas was notified to pronounce. A narcotic count sheet dated 07/08/19 indicated Resident #1 had 8 pills of [MEDICATION NAME] 5 milligram (mg) tablets available. A controlled substance shift change sign off sheet dated 07/09/19 at 10:00 p.m. indicated MA B signed off as the off going staff and LVN A signed off as the oncoming staff for unit 200 medication cart. A controlled substance shift change sign off sheet dated 07/10/19 at 6:00 a.m. indicated LVN A signed off as the off going staff and MA B signed off as the oncoming staff for unit 200 medication cart. A written witness statement dated 07/10/19 by LVN A stated, MA B did not count the med cart with me before she went home . I am unaware of what happened to the [MEDICATION NAME]. MA B said she would count and correct it when she came back to work in the morning I knew the count was incorrect on the cart. A written witness statement dated 07/10/19 by MA B stated, I did not do a narcotic count before I left. During an interview on 07/23/19 at 8:38 a.m., the DON said Resident #1's [MEDICATION NAME] was reported missing on 07/10/19 and was unable to be located. The DON said the written statements by LVN A and MA B indicated they did not count. The DON said the facility is responsible to account for all narcotics to prevent a drug diversion. The DON said the facility policy stated all narcotics are to be counted at the end of each shift. The DON said LVN A and MA B did not follow the policy and resulted in Resident #1's [MEDICATION NAME] missing. The DON said all staff members, including LVN B and MA B, were in-serviced on the facility policy to ensure staff are conducting narcotic counts at the end of each shift change. The DON said LVN A and MA B were suspended and had a negative drug test. The DON said LVN A and MA B are still employed in the facility. The DON said LVN B was admitted to the hospital and was unavailable to be interviewed. During an interview on 07/23/19 at 8:46 a.m., the administrator said Resident #1's [MEDICATION NAME] was reported missing on 07/10/19 and was unable to be located. The administrator said both LVN A and MA B told her they did not do a narcotic count on 07/09/19, she said the facility policy stated all narcotics are to be counted at the end of each shift. She said the facility is responsible to account for all narcotics to prevent a drug diversion. The administrator said LVN A and MA B did not follow the policy and resulted in Resident #1's [MEDICATION NAME] missing. An attempt was made to contact MA B on 07/23/19 at 10:32 a.m., but it was unsuccessful. A facility narcotic count and inventory policy dated 07/01/16 indicated, At the end of every eight (8) - or twelve (12) hour shift the authorized staff member reporting on duty and the authorized staff member reporting off duty meet at the designated medication car or storage area to count Schedule II drugs.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen observed. The facility did not ensure dietary staff had hands-free trash cans for the kitchen. The facility did not remove out dated milk from the milk supply in the cooler. The facility did not maintain a closed the exit door. The facility did not ensure all foods were dated and labeled. The facility did not ensure the pans were clean and free from debris build up. Cook [NAME] made direct contact with food after contacting unclean items. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: 1. During an observation and interview in the kitchen on 05/06/19, the following was noted: *at 11:13 AM the lid was broken on the trash can at staff wash sink at the main serving door. The lid did not work by the foot pad. The staff had to use their hand to open the lid to the trash can. *at 11:15 AM There were three 1/2-pint 2% milk cartons with a best by date of 05/04/19 in the walk-in cooler. The DM said they should have been pulled and placed by the door for the milk man to pick-up. *at 11:20 AM The back-exit door was open to the outside. It was not closing properly or all the way. The DM slammed the door four times before it caught and remained closed. She said the exit door should always be kept closed to keep out insects and things. The trash can at the employees' wash sink by the back door was not opening with the foot pad. Staff had to use their hands to open the lid. The DM said there was not a hands-free trash can in the kitchen that could be used at this time without using a hand to open it. *at 11:27 AM In the walk-in cooler, the desserts for the lunch trays were on carts, not label or dated. The DM said the cook should had put the labels and date on the desserts. She said the cook had made the labels, but she just had not put them on the desserts before she pushed them into the cooler. 2. During observation and interview in the kitchen on 05/07/19, the following was noted: *at 10:48 AM sixteen (16) large flat cookie sheet pans had thick black build up on them and nine (9) muffin pans with black build up. *at 11:58 AM The tray line for lunch started. A small box fan was blowing into kitchen preparation area and the back of the fan was dirty with brown build up. *at 12:15 PM On the serving line, some plates and plate lids fell on to the floor. The DM and cook [NAME] picked up and placed the plate lids back onto serving line. Cook [NAME] reached and picked up a soiled lid to place on a resident's plate of food and surveyor intervened and told her not to use the lids that had fallen onto the floor and to get clean lids. Cook [NAME] used clean lids. The DM took the soiled lids to the dish washer. Cook [NAME] while wearing plastic gloves, touched soiled plate lids, the hall 300 and 400 food carts, the serving scoops/utensils, and then touched the food (croissants) on residents' plates. During an interview on 05/08/19 at 03:37 p.m., the administrator said she expected the kitchen to meet sanitary conditions.

Based on observation, interview, and record review, the facility failed to provide services in accordance with the written plan of care for 1 of 24 residents reviewed for physician orders. (Resident #68) The facility did not weigh daily and notify the physician of any weight changes as ordered for Resident #68. This failure could place residents at risk for not receiving appropriate treatment and services to meet their needs. Findings included: An undated face sheet indicated Resident #68 was a [AGE] year-old male, admitted on [DATE] with [DIAGNOSES REDACTED]. A physician order [REDACTED]. A care plan revised 05/07/19 for Resident #68 did not address monitoring daily weights. A vitals report sheet dated 04/08/19 to 05/08/19 indicated Resident #68 weighed 232.8 lbs. on 04/18/19, 233.2 lbs. on 04/19/19, 228.2 lbs. on 04/20/19, 230.8 lbs. on 04/24/19, 230.8 lbs. on 05/01/19, 244 lbs. on 05/08/19, and no other weights were recorded. During an interview on 05/08/19 at 01:25 p.m., the DON said the physician orders [REDACTED].#68 and the care plan should have addressed the daily weights. She said the weights were done according to new admission protocol and not according to Resident #68's physician orders. She said she did not know the reason the weights had not been done.

Based on observation, interview, and record review, the facility failed to ensure pureed foods were prepared in a form designed to meet individual needs for 1 of 1 lunch meal reviewed for food form and preparation. (lunch meal on 05/07/19) The pureed chicken salad on croissant, three bean salad, and oatmeal cookie with raisins served during the lunch meal on 05/07/19 were not pureed smooth without fibrous particles, clumps, lumps, or bits. This failure could place residents who received pureed diets at risk of consuming foods that could cause choking, decreased meal intake, and not having nutritional needs met. Findings included: During an observation on 05/07/19 at 12:41 p.m., the puree test tray included an oatmeal raisin cookie with a raisin clump, chicken salad and croissant with clumps and chunks of chicken, and a three-bean salad with bits present, not in puree consistency. During an interview on 05/07/19 at 12:45 p.m., the DM said they were trying to find new blades for the food processer. She said she and the dietician had discussed the food was not being pureed enough. During an interview on 05/07/19 at 4:00 p.m., the DM said the maintenance man came into the kitchen at 3:00 p.m. and sharpened the blades on the food processor. She said it made the puree food much better. The DM said the puree food should be of a pudding consistency. During an interview on 05/08/19 at 03:37 p.m., the administrator said the facility's food processer's blades had been dull, but the maintenance man had sharpened the blades and it was now working correctly. A nutrition policies and procedures for meal service dated 10/02/17 indicated 9. Prepare puree foods the consistency of pudding or mashed potatoes as per recipe. A standard house diet orders and abbreviations sheet revised 03/02/19 indicated (Puree) This is a texture modification of the regular diet. Specific recipes are used to promote adequate nutrients with pudding like consistency. An explanation of food consistencies sheet revised 02/26/19 indicated Pureed - Mashed with no lumps or bumps. Ideally all foods will be the consistency of pudding and/or moist mashed potatoes. The Puree diet does follow the foods given on a regular diet as closely as possible, however the main difference being food consistency to eliminate chewing completely and ease swallowing.

Based on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 1 resident reviewed for gastrostomy tubes ([DEVICE]). (Resident #28) RN A did not administer medications properly to Resident #28 via gastrostomy tube. This failure could place residents with a [DEVICE] at risk of abdominal discomfort, nausea, vomiting, aspiration, infection, and decreased quality of life. Findings included: Physician orders [REDACTED].#28 was a [AGE] year-old female, admitted on [DATE] with [DIAGNOSES REDACTED]. There was an order for [REDACTED]. During an observation of the medication pass on 5/7/19 at 11:45 a.m., RN A turned off Resident #28's tube feeding and left it connected to the [DEVICE]. RN A lowered Resident #28's bed flat and rolled her over on her side to observe her skin, rolled her to her back and she then raised the HOB up 30 degrees. RN A left the room to prepare the [MEDICATION NAME] liquid, she returned and pulled the medication up in a 60 ml syringe. RN A resumed Resident #28's feeding then she placed the tip of the syringe, using the side port of the [DEVICE] she pushed the medications down the [DEVICE] using the syringe plunger instead allowing the medication to flow via gravity. RN A then pulled up 30 ml of water, used the side port, and pushed the water in the [DEVICE] using the syringe plunger. RN A did not check placement or flush the [DEVICE] prior to administering the medication/water flush. During an interview on 5/7/19 at 11:46 a.m., RN A said she had checked placement earlier in the shift and it was patent. She said she always uses the side port to administer the [MEDICATION NAME] liquid. She said she knows the tube is in its place because of the continuous feeding. A Nutrition policies and procedures dated (YEAR) indicated . 2. Stop tube feeding and clamp and disconnect . 6. For gastrostomy tubes, verify placement by aspiration of stomach contents . A Gastrostomy tube flush/irrigation policy dated (YEAR) indicated .Flushing of the tube with thirty cc of water will be performed: . 2. Before and after administration of medication 4. Whenever feeding is interrupted . 8. Remove plunger from syringe. Attach syringe to gastrostomy tube .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to prevent the development and the transmission of disease and infections for 1 of 4 residents reviewed for incontinent care. (Residents # 23) * CNA C did not wash/sanitize her hands when changing gloves and touched clean items with soiled gloves. This failure could place residents who require incontinent care at risk for cross contamination. Findings included: The MDS dated [DATE] indicated Resident #23 was a [AGE] year-old female, she admitted on [DATE], she required extensive assistance of 2 staff members for bed mobility, toilet use, and personal hygiene, and she was always incontinent of bowel and bladder. During an observation and interview on 05/07/19 at 03:15 p.m., CNA C and B provided incontinent care to Resident #23. CNA C obtained clean wipes from the packet with the same gloved hand she used to clean the resident and did not sanitize/wash hands between glove changes. CNA C said she would not have done anything different. During an interview on 05/08/19 at 03:45 p.m., ADON D said staff should not use gloved hand used to clean the resident to obtain clean wipes from the package. She said they should already have wipes pulled from the package or use the second person to hand them the clean wipes. She said staff should clean their hands between glove changes. During an interview on 05/08/19 at 03:50 p.m., CNA C and B said they should not pull clean wipes from the package with gloved hand used to clean the resident. They said hands should be sanitized or washed when changing gloves. An Infection Prevention and Control Policies and Procedures revised 09/11 indicated Subject: Hand Hygiene/Handwashing: Procedures: 1. Hand hygiene/hand washing is done: After: H. After removal of medical/surgical or utility gloves According to the World Health Organization's Glove Use Information Leaflet revised (MONTH) 2009 The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal

Based on observation, interview, and record review, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection for the 4 of 4 residents reviewed for infection control. (Resident #s 69, 22, 66, and 8) CNA A did not don PPE when she entered and exited Resident #69's room which was in contact isolation. CNA A did not wash or sanitize her hands after exiting the room. LVN D did not wash or sanitize her hands or don gloves prior to touching Resident #22's medication and after she administered the medication. LVN B did not maintain infection control procedures while separating medication capsules for Resident #66. LVN L did not discard a pill found in Resident #22's room on the resident's floor. He touched the pill with his bare hands then placed it back in the medication bottle. LVN M did not sanitize Resident #8's table prior to placing clean wound care items on the table. LVN M did not wash or sanitize her hands in between glove changes while providing wound care. These failures could place the census of 90 residents at risk for infection, disease, and decreased quality of life. Findings included: 1. During on observation on 05/22/18 at 10:15 a.m., Resident #69 was on contact isolation for an infection in the urine. Personal protective equipment (PPE) was available outside of the room. During an observation on 05/22/18 at 12:50 p.m., CNA A was passing lunch trays on hall 100. CNA A went into Resident #69, an isolation room, and placed Resident #69's lunch tray on the over bed table. CNA A touched the over bed table and the end of the bed. She then came out of the room without washing or sanitizing her hands and continued passing lunch trays to the other residents on hall 100. She took the next tray to Resident #76 without washing or sanitizing her hands. During an interview on 05/22/18 at 11:52 a.m. CNA A said she was not going to lie. She said she did not wash or sanitize her hands after taking a food tray into Resident #69's room. She said she came out of the room and continued handing out the other trays on Hall 100 without washing or sanitizing her hands. She said she should have washed her hands to prevent cross contamination. 2. During an observation on 05/22/18 at 12:48 p.m., LVN D did not don gloves or wash her hands prior to touching Resident #22's medication. She administered the medication and pushed Resident #22 back to the dining room, all without washing or sanitizing her hands or wearing gloves. 3. During an observation on 05/23/18 at 9:03 a.m., LVN B prepared Resident #66's medications in a medication cup and took the medications into the therapy room to Resident #66. Resident #66 pulled the large potassium pill from the other medications in the cup and handed it to LVN B. LVN B accepted the potassium pill in her bare hand and broke it in half and handed it back to Resident #66. LVN B did not wash or sanitize her hands or wear gloves before touching the medication. A medication administration policy dated 07/01/2016 indicated .7 .H. When indicated, breaks a tablet for proper dosage by:1) washing hands. 2) Uses a pill splitter to avoid touching the tablet 3). If a pill splitter is unavailable, dons gloves and breaks tablet along score lines .N. Wash hands with soap and water or antiseptic gel and follow the same guidelines for administering medication to the next patient/resident. 4. During an observation on 05/22/18 at 10:40 a.m., Resident #88 was wearing glasses, but said she was almost blind and did things by feel. A round orange medication tablet was found on the floor beside the bed with an empty plastic medicine cup under the bed. Resident #88 did not know whether it was from last night or this morning and she could not tell what it was by touch. During an observation and interview on 05/22/18 at 10:58 a.m., LVN L tried to identify the tablet by checking the Resident #88's medications in the cart. He identified the pill as a chewable 81 mg aspirin tablet. He poured the medication from the aspirin bottle into his bare hand and then returned the tablet to the bottle and placed it in the medication cart. 5. During an observation and interview on 05/23/18 at 09:58 a.m., LVN M provided wound care to Resident #8. LVN M did not remove items and sanitize Resident #8's over bed table prior to placing wound care items. Resident #8 was assisted to turn to his left side and LVN adjusted the resident's indwelling urinary catheter. LVN M changed her gloves, but she did not sanitize her hands. The dressing was removed and the wound cleaned. LVN M changed gloves without sanitizing her hands again. A new dressing was applied. LVN M removed the remaining wound care supplies from the over bed table and did not sanitize the table top. LVN M said she would have only adjusted her table and not done anything different. An infection prevention and control policy and procedure dated 11/27/17 indicated hand hygiene/hand washing was the single most important measure to reduce the risks of transmitting microorganisms from one person to another. The Glove Use Information Leaflet by the World Health Organization revised (MONTH) 2009 indicated .The efficacy of gloves in preventing contamination of health-care workers' hands and helping to reduce transmission of pathogens in health care has been confirmed in several clinical studies. Nevertheless, health-care workers should be informed that gloves do not provide complete protection against hand contamination. Pathogens may gain access to the caregivers' hands via small defects in gloves or by contamination of the hands during glove removal. Hand hygiene by rubbing or washing remains the basic to guarantee hand decontamination after glove removal The CMS 672 dated 05/22/18 indicated a census of 90 residents.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection control program that provided a safe environment to prevent the development and transmission of disease and infection for 21 of 21 residents reviewed for infection control. (Residents # 1,2,3,4,5,6,7,8,9,10,11,12,13,14,16, 22,24,25,28,30, and 31) 1.The facility did not prevent and control outbreaks and cross-contamination of upper respiratory infections for Residents # 1,2,3,5,6,8,25,30,31,16,14,22,12,13,and 11. The facility did not separate residents with known URI symptoms from those who were symptom free, did not care plan the necessary measures to care for residents with URI symptoms, did not provide the timely antibiotic administration for Resident #1 who had URI symptoms, did not maintain accurate information to determine and prevent the spread of the URI within the facility, and did not utilize necessary airborne precautions to prevent the rapid spread of a URI to at least 15 residents. 2.The facility did not prevent and control cross-contamination of residents with conjunctivitis (pink eye). No special infection control measures were taken to prevent the resident to resident contamination. Residents # 9,4, 24, and 10 developed facility acquired pink eye. 3.The facility did not ensure proper incontinence care was provided to prevent urinary tract infections for Residents # 7, 8, and 28. Residents # 14, 22,12,13, and 11 died after experiencing symptoms of a facility acquired URI during [DATE]. Fifteen (15) residents developed facility acquired URI symptoms during September and [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 80 residents at risk for serious infections or death due to super-imposed infections in an already fragile population. Findings included: During an interview on [DATE] at 10:35 a.m., RN Q said no resident with respiratory issues were placed in isolation. She said neither the staff nor the residents with URI symptoms had been wearing masks. She said there had been multiple deaths of residents with URI symptoms, but some of those deaths were residents who were on hospice and had co-morbidities. She said they did not obtain cultures, take any special precautions, or isolate residents with pink eye. During an interview on [DATE] at 1:17 p.m., LVN T said there was no communication from administration to direct care staff. He said administration did not enforce any kind of preventative measures for residents with URI symptoms. He said staff was not told to wear masks and residents with URI symptoms were not told to wear masks. He said the facility had no management and had not received any special training or instruction to prevent the spread of the URIs or pink eye. 1.URIs An undated list provided by the infection control nurse indicated 3 residents had a current URI and were currently on antibiotics. Fifteen (15) residents had signs and symptoms of URI, but did not meet the criteria to be placed on the infection control log. Resident #1- current resident The face sheet dated [DATE] indicated Resident #1 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. The physician orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE], no culture was obtained, no chest x-ray was performed, she was given antibiotic, she was not placed in isolation, it was a Healthcare Acquired Infection (HAI), and there was no resolved date. The care plan dated [DATE] indicated Resident #1 had a potential for complications related to respiratory infection/pneumonia with interventions including administer antibiotic as prescribed. Nursing notes for Resident #1 indicated the following: *[DATE] at 11:17 a.m., she complained of a sore throat, had a non-productive cough, temperature of 97.4 degrees F, and had scattered crackles in her chest. The physician was informed of her condition; *[DATE] at 2:13 a.m. she was complaining of a sore throat, was given [MEDICATION NAME], and had a temperature of 97.8 degrees F. There was no assessment of her chest/lungs.; *from [DATE]-[DATE] she continued on antibiotic, had scattered crackles in her chest, continued with a non-productive cough, and had no fever.; *from [DATE] to [DATE] she had completed the antibiotic, continued with a non-productive cough,had scattered crackles in her chest, and had no fever.; *[DATE] at 7:35 p.m., she had a cough, was lethargic, and had a poor appetite. The note indicated she had a temperature at 12:00 p.m. of 100.0 degrees F and Tylenol was administered. A chest xray was done with results of improvement from previous films.; *[DATE] at 12:00 a.m., she continued with a non-productive cough, scattered crackles in her chest, and had no fever.; *[DATE] at 9:30 p.m., the physician was notified and ordered an antibiotic.; *[DATE] at 10:00 p.m., she had a fever of 100.0 degrees F and received Tylenol.; *[DATE] at 5:33 a.m., she complained of feeling discomfort and had a wet non-productive cough and chest congestion.; *[DATE] at 6:30 p.m., a new order was received for a second antibiotic.; *[DATE] at 12:15 p.m., she continued to be lethargic with a poor appetite. She was sweating heavily and complaining of pain all over. She continued on the 2 antibiotics and with no improvement. She was transferred to the hospital. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE] and [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given 2 different antibiotics, she was not placed in isolation, and she continued treatment. Nursing notes for Resident #1 indicated the following: *[DATE] at 1:54 p.m., she returned from the hospital. She continued to have a wet non-productive cough and scattered crackles in her chest.; *[DATE] at 10:14 a.m., she had a wet productive cough with off-white sputum, had scattered crackles in her chest, and had no fever.; *[DATE] at 5:57 p.m., the physician saw her and ordered a CBC and a chest xray.; *[DATE] at 11:55 p.m., she had scattered crackles in her chest and had no fever.; *[DATE] at 10:48 p.m., labs were reported to the physician. An order was received for [MEDICATION NAME] (antibiotic). Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (antibiotic) for acute lower respiratory infection. The [DATE] MARs indicated Resident #1 received the initial dose of [MEDICATION NAME] on [DATE] at 9:30 a.m., almost 36 hours later. Nursing notes with entry dated [DATE] at 6:56 p.m. indicated Resident #1 received an initial dose of a Z-Pak. Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (Z-Pak) (antibiotic) for acute lower respiratory infection. Nursing notes from [DATE]-[DATE] indicated Resident #1 continued on [MEDICATION NAME], completed the [MEDICATION NAME] (Z-Pak), had scattered crackles in her chest, had a non-productive cough, and had no fever. The current MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She had pneumonia in the last 7 days and had received antibiotics in the last 7 days. During an observation on [DATE] beginning at 11:07 a.m. Resident #1 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. Resident #2- Current Resident The face sheet dated [DATE] indicated Resident #2 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to Hall 200. Physician orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 had severely impaired cognition. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. Nursing notes dated [DATE] at 12:19 p.m. indicated Resident #2 had exit seeking behaviors and no documented respiratory issues. Physician orders [REDACTED].#2 was to begin [MEDICATION NAME] (antibiotic). Nursing notes for Resident #2 indicated the following: *[DATE] at 12:14 a.m., he had an initial dose of the antibiotic due to URI earlier in the shift, had no fever, and had a non-productive cough; *[DATE] - [DATE] he continued on the antibiotic with no adverse reaction and had signs and symptoms of URI. The undated care plan did not address Resident #2's respiratory symptoms. The Infection Control Log for [DATE] did not list Resident #2. During an observation on [DATE] beginning at 11:07 a.m., Resident #2 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 12:45 p.m., after surveyor intervention, Resident #2 was moved to room [ROOM NUMBER]A on Hall 300 and co-horted with Resident #3 who also exhibited respiratory signs and symptoms. Resident #3 - current resident The face sheet dated [DATE] indicated Resident #3 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to room [ROOM NUMBER]B on Hall 300. (Resident #2 was his roommate). Physician orders [REDACTED].#3 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #3 had severely impaired cognition; had no infections; had [DIAGNOSES REDACTED]. The undated care plan did not address Resident #3's respiratory symptoms. Nursing notes for Resident #3 indicated the following: *[DATE] at 12:24 a.m., he had a temperature of 101.1 degrees F, complained of abdominal pain, and no documented respiratory issues.; *[DATE] at 10:50 a.m., he was red faced, had audible wheezing, complained of shortness of breath, O2 sats of 94% on room air, but had audible grunting with each breath. He was sent to the hospital. Nursing notes for Resident #3 indicated on [DATE] at 3:18 p.m., he returned to the facility. The physician orders [REDACTED].#3 was to receive [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The Infection Control Log for [DATE] did not list Resident #3. Resident #5- current resident The face sheet dated [DATE] indicated Resident #5 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #5 was in room [ROOM NUMBER](the same room as Resident #6 who was exhibiting signs and symptoms of respiratory issues). The physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #5 had severely impaired cognition. Nursing notes for Resident #5 indicated the following: *on [DATE] at 8:30 p.m., she had a non-productive cough and was given PRN cough syrup; *on [DATE] at 8:13 p.m., a chest x-ray was done due to thick green sputum and low grade temperature. The x-ray showed pneumonia. An order was received for Bactrim DS (antibiotic). The undated care plan did not address the pneumonia. The Infection Control Log for [DATE] indicated Resident #5 had a URI with onset date of [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given an antibiotic, she was not placed in isolation, it was a facility acquired, and there was no resolved date. Nursing notes from [DATE]-[DATE] indicated Resident #5 had a non-productive cough, had few scattered crackles, and continued on the antibiotic. During an observation on [DATE] beginning at 11:07 a.m., Resident #5, on Hall 200, exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 11:28 a.m., hand sanitizer bottles were stationed at the nursing station and medication carts. Resident rooms were not supplied with hand sanitizer. Resident #6-current resident The face sheet dated [DATE] indicated Resident #6 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #6 was in room [ROOM NUMBER](the same room as Resident #5 who had a URI). The physician orders [REDACTED].#6 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #6 had severely impaired cognition. The undated care plan did not address the URI symptoms or approaches to take. Nursing notes from [DATE]-[DATE] had no documentation of any issues with coughing or congestion. The [DATE] MAR indicated Resident #6 had received [MEDICATION NAME] (cough syrup): *on [DATE],[DATE],[DATE],[DATE], [DATE], [DATE], and [DATE]. During an observation and interview on [DATE] at 11:07 a.m., Resident #6 exhibited coughing and congestion symptoms. She was not wearing a mask. She said she had been coughing for about a week and her roommate had been sick too. The Infection Control Log for [DATE] indicated Resident #6 was not listed. Resident #8 - current resident Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #8 was in room [ROOM NUMBER] (same room as Resident #7). A care plan, last revised [DATE], indicated Resident #8 required assistance with all activities of daily living (ADLs) and she experienced bladder incontinence related to decreased mobilization. The care plan did not address Resident #8's UTI or URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 understood others and usually made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #8 did not have recent infections. Nursing notes for Resident #8 indicated the following: *on[DATE] at 1:17 a.m. - moved to room [ROOM NUMBER]; *on [DATE] at 12:17 a.m. - new order for chest x-ray, Z-pak (antibiotic) for cough and congestion; *on [DATE] at 10:54 a.m. - awaiting pharmacy to deliver Z-pak; *on [DATE] at 8:56 a.m. - resident had cough with thick mucus; *on [DATE] at 9:49 p.m. - resident had wet lung sounds with rhonchi, hospice new order for [MEDICATION NAME] (antibiotic), [MEDICATION NAME], and [MEDICATION NAME] swish and swallow; *on [DATE] at 7:01 a.m. - initial dose of [MEDICATION NAME] given; *on[DATE] at 12:48 a.m. - New antibiotic [MEDICATION NAME] for upper respiratory infection (URI) given, and to continlue [MEDICATION NAME], and breathing treatment; *on [DATE] at 12:51 p.m. - continues with productive cough, continues with breathing treatment, [MEDICATION NAME], and [MEDICATION NAME], resident in dining room for lunch; and *on[DATE] at 3:19 a.m. - continued breathing treatment for [REDACTED]. During an observation on [DATE] at 1:21 p.m., CNA D and CNA E were seen entering and exiting Resident #8's room with no mask and did not perform hand hygiene before entering the room. During an interview on [DATE] at 1:32 p.m., CNA D said nobody from administration had told her to take any special precautions with residents with URI symptoms. She said residents with URI symptoms were allowed to go to the dining room. The infection control log for [DATE] indicated Resident #8 had an UTI with an onset date of [DATE], a culture date of [DATE], and the culture being ESBL positive. The infection control log indicated Resident #8 had an URI on [DATE] and began antibiotics. The infection control log for [DATE] indicated Resident #8 continued treatment for [REDACTED]. Resident #25-current resident The face sheet dated [DATE] indicated Resident #25 was an [AGE] year old male admitted on [DATE] to Hall 400. The physician orders [REDACTED].#25 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #25 was cognitively intact. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. The undated care plan did not address Resident #25's respiratory symptoms. During an observation and interview on [DATE] at 1:00 p.m., Resident #25 had a non-productive cough. He said he developed the cough after he came to the facility. He said he had taken an antibiotic for it. Nursing notes with an entry dated [DATE] at 5:03 p.m. indicated he had a non-productive cough and complained of shortness of breath. The physician was notified of his condition. The physician orders [REDACTED].#25 was to be placed on [MEDICATION NAME] Z-Pak (antibiotic) for symptoms of URI. Nursing notes for Resident #25 indicated the following: *on [DATE] at 1:30 a.m., he continued with a non-productive cough, had course breath sounds, and a temperature of 99.1 degrees F.; *on [DATE] at 11:51 p.m., a chest xray report read lung fields were clear without mass, infiltrate, congestion, or effusion.; *on [DATE] at 1:44 a.m., he had no cough or congestion and lung fields were clear; *on [DATE] at 11:04 a.m., he continued on the antibiotic with no adverse reaction but lung sounds were not assessed.; *on [DATE] at 2:16 p.m., he completed the antibiotic with no adverse reaction but lung sounds were not assessed. The Infection Control Log for [DATE] did not list Resident #25. During an observation on [DATE] beginning at 11:07 a.m., Resident #25 was in his room. He exhibited coughing and congestion symptoms, but was not wearing a mask. Resident #30 - current resident Physician orders [REDACTED].#30 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 was in room [ROOM NUMBER] (same room as Resident #31). A care plan dated [DATE] indicated Resident #30 required assistance with activities of daily living (ADLs). The care plan did not address Resident #30's URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 usually understood others and made her needs known. She required extensive assistance with ADLs and was incontinent of bowel and bladder. The MDS indicated Resident #30 did not have recent infections. Nursing notes for Resident #30 indicated the following: *on [DATE] at 2:37 p.m. - resident with scattered crackles in bilateral chest, nonproductive wet cough, chest x-ray ordered; *on [DATE] at 1:15 a.m. - chest x-ray was clear, resident in bed with no cough or congestion; *on [DATE] at 11:25 a.m. -in wheelchair in dining room for lunch, no cough noted; *on [DATE] at 1:50 p.m. - resident coughing up thick yellow phlegm, noted bilateral chest congestion, breathing treatment given, resident in bed; *on [DATE] at 9:13 a.m. - resident continued with cough and congestion, new order for antibiotic, [MEDICATION NAME], and breathing treatment as needed, nausea and vomiting at breakfast with semi productive tight cough noted; *on [DATE] at 11:09 p.m. - initial dose of antibiotic given for URI; *on [DATE] at 1:02 a.m. - Tylenol given for 100.0 temperature; *on [DATE] at 10:00 a.m. - resident in bed, oxygen saturation 93%, resident very slow to respond to verbal and tactile stimuli, skin warm with tenting, chest with bilateral congestion, productive cough with thick yellow phlegm, daughter requested resident be sent to ER; *on [DATE] at 5:28 p.m. - resident back in facility with [DIAGNOSES REDACTED]. *on[DATE] at 10:55 a.m. - resident in bed, chest with scattered crackles, wet nonproductive cough; and *on [DATE] at 2:51 p.m. - resident in bed, chest with scattered crackles, intermittent wet nonproductive cough, poor intake. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #30's room without masks and CNA G already had gloves on when she entered the room. Neither washed their hands before providing care to Resident #30. The infection control log for [DATE] indicated Resident #30 had a URI that was facility acquired on [DATE], an antibiotic was ordered, onset date was [DATE], and a chest x-ray was performed on [DATE]. The infection control log for [DATE] indicated Resident #30 continued treatment for [REDACTED]. Resident #30's roommate, Resident #31 had a URI on [DATE]. Resident #31 - current resident Physician orders [REDACTED].#31 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #31 was in room [ROOM NUMBER] (same room as Resident #30). A care plan dated [DATE] indicated Resident #31 was incontinent of bowel and bladder and required assistance with all activities of daily living (ADLs). The care plan did not address Resident #31's upper respiratory infection (URI). A Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 understood others and made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #31 was admitted with pneumonia and did not have recent infections. Nursing notes for Resident #31 indicated the following: *on [DATE] at 1:53 a.m. - no cough noted, chest x-ray performed on prior shift with noted right upper lobe atelectasis with mild cardiomegaly; *on [DATE] at 4:55 a.m. - resident sitting in wheelchair in dining room, nonproductive cough noted; *on [DATE] at 9:15 a.m. - resident in wheelchair for breakfast, chest with scattered crackles, productive cough with thick brown/yellow sputum, new order for antibiotic, assisted to bed after breakfast; *on [DATE] at 11:50 p.m. - resident resting in bed, nonproductive cough noted, continued with antibiotic and [MEDICATION NAME]; *on [DATE] at 10:23 a.m. - appetite and fluid intake poor, chest with scattered crackles, CNA assisted resident with breakfast, assisted back to bed, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 11:26 a.m. - resident in bed, chest with scattered crackles and nonproductive wet cough, poor appetite, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 10:10 a.m. - resident in dining room for breakfast, chest with scattered crackles and nonproductive wet cough, appetite poor, completed antibiotic; *on [DATE] at 1:26 p.m. - resident continued with intermittent wet nonproductive cough, continued with [MEDICATION NAME]; and *on [DATE] at 10:27 a.m. - chest with scattered crackles, continued with [MEDICATION NAME], intake poor. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #31's room without masks and CNA G already had gloves on when she entered the room. The infection control log dated [DATE] indicated Resident #31 had a URI on [DATE]. Resident #31's roommate, Resident #30, had a URI on [DATE]. Resident #16 - closed record Physician orders [REDACTED].#16 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #16 understood others and made her needs known. She required extensive assistance with activities of daily living (ADLs). She was occasionally incontinent of bowel and bladder. The MDS indicated Resident #16 did not have recent infections. A care plan last revised [DATE] indicated Resident #16 required assistance with ADLs. The care plan did not address Resident #16's upper respiratory infection (URI). Nursing notes for Resident #16 indicated the following: [DATE] at 1:25 a.m. - resident complained of sore throat, hoarse voice, and nonproductive cough, [DATE] at 4:41 a.m. - continued with hoarse voice, productive cough, and yellow phlegm, [MEDICATION NAME] minimally effective; [DATE] at 6:48 p.m. - continued with URI symptoms and new complaint of hip pain; [DATE] at 3:46 a.m. - resident to be sent to hospital for hip fracture. During a telephone interview on [DATE] at 4:21 p.m., Resident #16's daughter said Resident #16 had a URI days before she went to the hospital for a fractured hip. She said Resident #16 did not have to wear a mask while she had URI symptoms. Resident #16's daughter said Resident #16 was allowed to go to the dining room while showing URI symptoms. The daughter said staff did not wear masks while providing care to her mother when she exhibited URI symptoms. The infection control log for [DATE] did not include Resident #16's URI. Resident #14 - closed record Physician orders [REDACTED].#14 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #14 was a full code and experienced occasional bowel and bladder incontinence. The care plan did not address his URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #14 understood others and made his needs known. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was incontinent of bowel and bladder. The MDS indicated Resident #14 did not have a recent infection. Nursing notes for Resident #14 indicated the following: *on [DATE] at 5:46 a.m. - nasal congestion with runny nose of clear drainage and nonproductive cough; *on [DATE] at 10:01 a.m. - new order for [MEDICATION NAME] for congestion; *on [DATE] at 12:11 a.m. - new order for Z-Pak (antibiotic) and chest x-ray, continue [MEDICATION NAME] for congestion; *on [DATE] at 7:00 a.m. - resident in dining room, resident noted to be lethargic, slurred speech, and scant amount of yellow, blood tinged drainage from nose, resident assisted to bed, hospice notified of change of condition; *on [DATE] at 5:53 p.m. - physician in facility, received new order for [MEDICATION NAME] IM (antibiotic) *on [DATE] at 5:55 p.m. - hospice nurse in facility to discontinue all routine medications and start palliative care; *on [DATE] at 10:19 p.m. - resident in bed with absent blood pressure, heart rate, and respirations, time of death 10:38 p.m. The infection control log for [DATE] indicated Resident #14 had a facility acquired URI on [DATE]. Resident #22 - closed record Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #22 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #22 was a full code, was incontinent of bladder, and had difficulty made herself understood. Resident #22's pneumonia was not addressed on the care plan. A Minimum (MDS) data set [DATE] indicated Resident #22 usually understood others and sometimes made her needs known. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #22 did not have a recent infection. Nursing notes for Resident #22 indicated the following: *on [DATE] at 1:30 p.m. - new order for [MEDICATION NAME] related to congestion; *on [DATE] at 3:34 p.m. - resident with projectile vomiting, chest x-ray ordered; *on [DATE] at 6:22 p.m. - chest x-ray results received, bilateral lower lobe pneumonia, doctor notified; *on [DATE] at 5:52 p.m. - new order for [MEDICATION NAME] IM (antibiotic); *on [DATE] at 5:56 p.m. - initial dose of antibiotic given; *on [DATE] at 1:23 p.m. - resident's oxygen saturation dropped to 79%, applied nasal cannula and back up to 94%, no signs of acute distress at this time; and *on [DATE] at 12:00 p.m. - oxygen saturation 85% on room air, pulse was thread and rapid, temperature was 99.0, resident was responsive but lethargic, bilateral crackles and diminished lung sounds were noted, spouse requested resident be sent to local hospital, resident sent out via EMS. The infection control log dated [DATE] indicated Resident #22 had pneumonia with an onset date of [DATE]. A chest x-ray was performed [DATE] and an antibiotic was ordered. A local newspaper dated [DATE] indicated Resident #22 died in a local inpatient hospice on [DATE]. Resident #12-closed record The face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #12 (was in room [ROOM NUMBER], the same room as Resident #11 who died 1 week after Resident #12). The physician orders [REDACTED].#12 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #12 had severely impaired cognition. The undated care plan did not address the URI. Nursing notes for Resident #12 indicated the following: *[DATE] at 9:07 a.m., she had a new order for [MEDICATION NAME] (to prevent cough) four times a day for 7 days for congestion; *from [DATE]-[DATE], she continued with [MEDICATION NAME] and had an intermittent cough; *on [DATE] at 1:20 p.m., she had a non-productive cough with congestion; *on [DATE] at 8:39 p.m. (a late entry for 5:00 p.m.), the physician had seen her due to cough and congestion and provided orders for a complete blood count, chest xray, and Zpak (antibiotic) for URI. She had no fever; *on [DATE] at 12:46 a.m., she had a non-productive cough with congestion and waiting for the antibiotic to be delivered so it could be administered; *on [DATE] at 5:26 p.m., she had rapid breathing, diminished lung sounds, and O2 Sats of 83% on room air. She was sent to the hospital. The [DATE] MAR did not have any documentation the Z-pak was administered. A hospital History and Physical dated [DATE] indicated Resident #12 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Nursing notes for Resident #12 indicated the following: *on [DATE] at 7:52 p.m., she returned from the hospital on palliative care, had no fever, and O2 sats were 91%; *from [DATE]-[DATE], she continued on palliative care; O2 sats ,[DATE]%, non-productive cough, and crackles to all areas of her lungs. *on [DATE] at 5:22 p.m., she had worsening of her condition, developed throat congestion, and accumulation of fluid between the skin and connective tissue. Her family wanted her admitted to hospice; *on [DATE] at 9:42 p.m., the physician was notified of low O2 sats and labored breathing with restlessness; *on [DATE] at 1:33 a.m., she had crackles in both lungs, ,[DATE] second pauses between breaths, and O2 sats were now decreased to 78%; *on [DATE] at 10:27 a.m., she was admitted to hospice for [DIAGNOSES REDACTED]. *on [DATE] at 5:27 p.m.,

Based on observation, interview, and record review, the facility failed to develop and implement their policies and procedures to prohibit neglect for 21 of 21 residents reviewed for neglect. (Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 22, 24, 25, 28, 30, and 31) The facility did not implement infection control measures to prevent: 1. Residents #1, 2,3,5,6,7,8,25,30,31,16, 14,22,12,13, and 11 from acquiring an upper respiratory infection (URI); 2. Residents #4,9,24, and 10 from acquiring pink eye ([MEDICAL CONDITION]); and 3. Residents # 7,8,and 28 from acquiring a urinary tract infection [MEDICAL CONDITION]. Residents # 14,22,12, 13, and 11 died after experiencing symptoms of a facility acquired URI during [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 80 residents at risk for serious infections or death due to super-imposed infections in an already fragile population. Findings included: During an interview on [DATE] at 10:35 a.m., RN Q said no resident with respiratory issues were placed in isolation. She said neither the staff nor the residents with URI symptoms had been wearing masks. She said there had been multiple deaths of residents with URI symptoms, but some of those deaths were residents who were on hospice and had co-morbidities. She said they did not obtain cultures, take any special precautions, or isolate residents with pink eye. During an interview on [DATE] at 1:17 p.m., LVN T said there was no communication from administration to direct care staff. He said administration did not enforce any kind of preventative measures for residents with URI symptoms. He said staff was not told to wear masks and residents with URI symptoms were not told to wear masks. He said the facility had no management and had not received any special training or instruction to prevent the spread of the URIs or pink eye. 1.URIs An undated list provided by the infection control nurse indicated 3 residents had a current URI and were currently on antibiotics. Fifteen (15) residents had signs and symptoms of URI, but did not meet the criteria to be placed on the infection control log. Resident #1- current resident The face sheet dated [DATE] indicated Resident #1 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. The physician orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE], no culture was obtained, no chest x-ray was performed, she was given antibiotic, she was not placed in isolation, it was a Healthcare Acquired Infection (HAI), and there was no resolved date. The care plan dated [DATE] indicated Resident #1 had a potential for complications related to respiratory infection/pneumonia with interventions including administer antibiotic as prescribed. Nursing notes for Resident #1 indicated the following: *[DATE] at 11:17 a.m., she complained of a sore throat, had a non-productive cough, temperature of 97.4 degrees F, and had scattered crackles in her chest. The physician was informed of her condition; *[DATE] at 2:13 a.m. she was complaining of a sore throat, was given [MEDICATION NAME], and had a temperature of 97.8 degrees F. There was no assessment of her chest/lungs.; *from [DATE]-[DATE] she continued on antibiotic, had scattered crackles in her chest, continued with a non-productive cough, and had no fever.; *from [DATE] to [DATE] she had completed the antibiotic, continued with a non-productive cough,had scattered crackles in her chest, and had no fever.; *[DATE] at 7:35 p.m., she had a cough, was lethargic, and had a poor appetite. The note indicated she had a temperature at 12:00 p.m. of 100.0 degrees F and Tylenol was administered. A chest xray was done with results of improvement from previous films.; *[DATE] at 12:00 a.m., she continued with a non-productive cough, scattered crackles in her chest, and had no fever.; *[DATE] at 9:30 p.m., the physician was notified and ordered an antibiotic.; *[DATE] at 10:00 p.m., she had a fever of 100.0 degrees F and received Tylenol.; *[DATE] at 5:33 a.m., she complained of feeling discomfort and had a wet non-productive cough and chest congestion.; *[DATE] at 6:30 p.m., a new order was received for a second antibiotic.; *[DATE] at 12:15 p.m., she continued to be lethargic with a poor appetite. She was sweating heavily and complaining of pain all over. She continued on the 2 antibiotics and with no improvement. She was transferred to the hospital. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE] and [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given 2 different antibiotics, she was not placed in isolation, and she continued treatment. Nursing notes for Resident #1 indicated the following: *[DATE] at 1:54 p.m., she returned from the hospital. She continued to have a wet non-productive cough and scattered crackles in her chest.; *[DATE] at 10:14 a.m., she had a wet productive cough with off-white sputum, had scattered crackles in her chest, and had no fever.; *[DATE] at 5:57 p.m., the physician saw her and ordered a CBC and a chest xray.; *[DATE] at 11:55 p.m., she had scattered crackles in her chest and had no fever.; *[DATE] at 10:48 p.m., labs were reported to the physician. An order was received for [MEDICATION NAME] (antibiotic). Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (antibiotic) for acute lower respiratory infection. The [DATE] MARs indicated Resident #1 received the initial dose of [MEDICATION NAME] on [DATE] at 9:30 a.m., almost 36 hours later. Nursing notes with entry dated [DATE] at 6:56 p.m. indicated Resident #1 received an initial dose of a Z-Pak. Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (Z-Pak) (antibiotic) for acute lower respiratory infection. Nursing notes from [DATE]-[DATE] indicated Resident #1 continued on [MEDICATION NAME], completed the [MEDICATION NAME] (Z-Pak), had scattered crackles in her chest, had a non-productive cough, and had no fever. The current MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She had pneumonia in the last 7 days and had received antibiotics in the last 7 days. During an observation on [DATE] beginning at 11:07 a.m. Resident #1 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. Resident #2- Current Resident The face sheet dated [DATE] indicated Resident #2 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to Hall 200. Physician orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 had severely impaired cognition. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. Nursing notes dated [DATE] at 12:19 p.m. indicated Resident #2 had exit seeking behaviors and no documented respiratory issues. Physician orders [REDACTED].#2 was to begin [MEDICATION NAME] (antibiotic). Nursing notes for Resident #2 indicated the following: *[DATE] at 12:14 a.m., he had an initial dose of the antibiotic due to URI earlier in the shift, had no fever, and had a non-productive cough; *[DATE] - [DATE] he continued on the antibiotic with no adverse reaction and had signs and symptoms of URI. The undated care plan did not address Resident #2 ' s respiratory symptoms. The Infection Control Log for [DATE] did not list Resident #2. During an observation on [DATE] beginning at 11:07 a.m., Resident #2 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 12:45 p.m., after surveyor intervention, Resident #2 was moved to room [ROOM NUMBER]A on Hall 300 and co-horted with Resident #3 who also exhibited respiratory signs and symptoms. Resident #3 - current resident The face sheet dated [DATE] indicated Resident #3 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to room [ROOM NUMBER]B on Hall 300. (Resident #2 was his roommate). Physician orders [REDACTED].#3 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #3 had severely impaired cognition; had no infections; had [DIAGNOSES REDACTED]. The undated care plan did not address Resident #3 ' s respiratory symptoms. Nursing notes for Resident #3 indicated the following: *[DATE] at 12:24 a.m., he had a temperature of 101.1 degrees F, complained of abdominal pain, and no documented respiratory issues.; *[DATE] at 10:50 a.m., he was red faced, had audible wheezing, complained of shortness of breath, O2 sats of 94% on room air, but had audible grunting with each breath. He was sent to the hospital. Nursing notes for Resident #3 indicated on [DATE] at 3:18 p.m., he returned to the facility. The physician orders [REDACTED].#3 was to receive [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The Infection Control Log for [DATE] did not list Resident #3. Resident #5- current resident The face sheet dated [DATE] indicated Resident #5 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #5 was in room [ROOM NUMBER](the same room as Resident #6 who was exhibiting signs and symptoms of respiratory issues). The physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #5 had severely impaired cognition. Nursing notes for Resident #5 indicated the following: *on [DATE] at 8:30 p.m., she had a non-productive cough and was given PRN cough syrup; *on [DATE] at 8:13 p.m., a chest x-ray was done due to thick green sputum and low grade temperature. The x-ray showed pneumonia. An order was received for Bactrim DS (antibiotic). The undated care plan did not address the pneumonia. The Infection Control Log for [DATE] indicated Resident #5 had a URI with onset date of [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given an antibiotic, she was not placed in isolation, it was a facility acquired, and there was no resolved date. Nursing notes from [DATE]-[DATE] indicated Resident #5 had a non-productive cough, had few scattered crackles, and continued on the antibiotic. During an observation on [DATE] beginning at 11:07 a.m., Resident #5, on Hall 200, exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 11:28 a.m., hand sanitizer bottles were stationed at the nursing station and medication carts. Resident rooms were not supplied with hand sanitizer. Resident #6-current resident The face sheet dated [DATE] indicated Resident #6 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #6 was in room [ROOM NUMBER](the same room as Resident #5 who had a URI). The physician orders [REDACTED].#6 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #6 had severely impaired cognition. The undated care plan did not address the URI symptoms or approaches to take. Nursing notes from [DATE]-[DATE] had no documentation of any issues with coughing or congestion. The [DATE] MAR indicated [REDACTED] *on [DATE],[DATE],[DATE],[DATE], [DATE], [DATE], and [DATE]. During an observation and interview on [DATE] at 11:07 a.m., Resident #6 exhibited coughing and congestion symptoms. She was not wearing a mask. She said she had been coughing for about a week and her roommate had been sick too. The Infection Control Log for [DATE] indicated Resident #6 was not listed. Resident #8 - current resident Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #8 was in room [ROOM NUMBER] (same room as Resident #7). A care plan, last revised [DATE], indicated Resident #8 required assistance with all activities of daily living (ADLs) and she experienced bladder incontinence related to decreased mobilization. The care plan did not address Resident #8 ' s UTI or URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 understood others and usually made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #8 did not have recent infections. Nursing notes for Resident #8 indicated the following: *on[DATE] at 1:17 a.m. - moved to room [ROOM NUMBER]; *on [DATE] at 12:17 a.m. - new order for chest x-ray, Z-pak (antibiotic) for cough and congestion; *on [DATE] at 10:54 a.m. - awaiting pharmacy to deliver Z-pak; *on [DATE] at 8:56 a.m. - resident had cough with thick mucus; *on [DATE] at 9:49 p.m. - resident had wet lung sounds with rhonchi, hospice new order for [MEDICATION NAME] (antibiotic), [MEDICATION NAME], and [MEDICATION NAME] swish and swallow; *on [DATE] at 7:01 a.m. - initial dose of [MEDICATION NAME] given; *on[DATE] at 12:48 a.m. - New antibiotic [MEDICATION NAME] for upper respiratory infection (URI) given, and to continlue [MEDICATION NAME], and breathing treatment; *on [DATE] at 12:51 p.m. - continues with productive cough, continues with breathing treatment, [MEDICATION NAME], and [MEDICATION NAME], resident in dining room for lunch; and *on[DATE] at 3:19 a.m. - continued breathing treatment for [REDACTED]. During an observation on [DATE] at 1:21 p.m., CNA D and CNA E were seen entering and exiting Resident #8 ' s room with no mask and did not perform hand hygiene before entering the room. During an interview on [DATE] at 1:32 p.m., CNA D said nobody from administration had told her to take any special precautions with residents with URI symptoms. She said residents with URI symptoms were allowed to go to the dining room. The infection control log for [DATE] indicated Resident #8 had an UTI with an onset date of [DATE], a culture date of [DATE], and the culture being ESBL positive. The infection control log indicated Resident #8 had an URI on [DATE] and began antibiotics. The infection control log for [DATE] indicated Resident #8 continued treatment for [REDACTED]. Resident #25-current resident The face sheet dated [DATE] indicated Resident #25 was an [AGE] year old male admitted on [DATE] to Hall 400. The physician orders [REDACTED].#25 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #25 was cognitively intact. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. The undated care plan did not address Resident #25 ' s respiratory symptoms. During an observation and interview on [DATE] at 1:00 p.m., Resident #25 had a non-productive cough. He said he developed the cough after he came to the facility. He said he had taken an antibiotic for it. Nursing notes with an entry dated [DATE] at 5:03 p.m. indicated he had a non-productive cough and complained of shortness of breath. The physician was notified of his condition. The physician orders [REDACTED].#25 was to be placed on [MEDICATION NAME] Z-Pak (antibiotic) for symptoms of URI. Nursing notes for Resident #25 indicated the following: *on [DATE] at 1:30 a.m., he continued with a non-productive cough, had course breath sounds, and a temperature of 99.1 degrees F.; *on [DATE] at 11:51 p.m., a chest xray report read lung fields were clear without mass, infiltrate, congestion, or effusion.; *on [DATE] at 1:44 a.m., he had no cough or congestion and lung fields were clear; *on [DATE] at 11:04 a.m., he continued on the antibiotic with no adverse reaction but lung sounds were not assessed.; *on [DATE] at 2:16 p.m., he completed the antibiotic with no adverse reaction but lung sounds were not assessed. The Infection Control Log for [DATE] did not list Resident #25. During an observation on [DATE] beginning at 11:07 a.m., Resident #25 was in his room. He exhibited coughing and congestion symptoms, but was not wearing a mask. Resident #30 - current resident Physician orders [REDACTED].#30 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 was in room [ROOM NUMBER] (same room as Resident #31). A care plan dated [DATE] indicated Resident #30 required assistance with activities of daily living (ADLs). The care plan did not address Resident #30 ' s URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 usually understood others and made her needs known. She required extensive assistance with ADLs and was incontinent of bowel and bladder. The MDS indicated Resident #30 did not have recent infections. Nursing notes for Resident #30 indicated the following: *on [DATE] at 2:37 p.m. - resident with scattered crackles in bilateral chest, nonproductive wet cough, chest x-ray ordered; *on [DATE] at 1:15 a.m. - chest x-ray was clear, resident in bed with no cough or congestion; *on [DATE] at 11:25 a.m. -in wheelchair in dining room for lunch, no cough noted; *on [DATE] at 1:50 p.m. - resident coughing up thick yellow phlegm, noted bilateral chest congestion, breathing treatment given, resident in bed; *on [DATE] at 9:13 a.m. - resident continued with cough and congestion, new order for antibiotic, [MEDICATION NAME], and breathing treatment as needed, nausea and vomiting at breakfast with semi productive tight cough noted; *on [DATE] at 11:09 p.m. - initial dose of antibiotic given for URI; *on [DATE] at 1:02 a.m. - Tylenol given for 100.0 temperature; *on [DATE] at 10:00 a.m. - resident in bed, oxygen saturation 93%, resident very slow to respond to verbal and tactile stimuli, skin warm with tenting, chest with bilateral congestion, productive cough with thick yellow phlegm, daughter requested resident be sent to ER; *on [DATE] at 5:28 p.m. - resident back in facility with [DIAGNOSES REDACTED]. *on[DATE] at 10:55 a.m. - resident in bed, chest with scattered crackles, wet nonproductive cough; and *on [DATE] at 2:51 p.m. - resident in bed, chest with scattered crackles, intermittent wet nonproductive cough, poor intake. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #30 ' s room without masks and CNA G already had gloves on when she entered the room. Neither washed their hands before providing care to Resident #30. The infection control log for [DATE] indicated Resident #30 had a URI that was facility acquired on [DATE], an antibiotic was ordered, onset date was [DATE], and a chest x-ray was performed on [DATE]. The infection control log for [DATE] indicated Resident #30 continued treatment for [REDACTED]. Resident #30 ' s roommate, Resident #31 had a URI on [DATE]. Resident #31 - current resident Physician orders [REDACTED].#31 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #31 was in room [ROOM NUMBER] (same room as Resident #30). A care plan dated [DATE] indicated Resident #31 was incontinent of bowel and bladder and required assistance with all activities of daily living (ADLs). The care plan did not address Resident #31 ' s upper respiratory infection (URI). A Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 understood others and made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #31 was admitted with pneumonia and did not have recent infections. Nursing notes for Resident #31 indicated the following: *on [DATE] at 1:53 a.m. - no cough noted, chest x-ray performed on prior shift with noted right upper lobe atelectasis with mild cardiomegaly; *on [DATE] at 4:55 a.m. - resident sitting in wheelchair in dining room, nonproductive cough noted; *on [DATE] at 9:15 a.m. - resident in wheelchair for breakfast, chest with scattered crackles, productive cough with thick brown/yellow sputum, new order for antibiotic, assisted to bed after breakfast; *on [DATE] at 11:50 p.m. - resident resting in bed, nonproductive cough noted, continued with antibiotic and [MEDICATION NAME]; *on [DATE] at 10:23 a.m. - appetite and fluid intake poor, chest with scattered crackles, CNA assisted resident with breakfast, assisted back to bed, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 11:26 a.m. - resident in bed, chest with scattered crackles and nonproductive wet cough, poor appetite, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 10:10 a.m. - resident in dining room for breakfast, chest with scattered crackles and nonproductive wet cough, appetite poor, completed antibiotic; *on [DATE] at 1:26 p.m. - resident continued with intermittent wet nonproductive cough, continued with [MEDICATION NAME]; and *on [DATE] at 10:27 a.m. - chest with scattered crackles, continued with [MEDICATION NAME], intake poor. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #31 ' s room without masks and CNA G already had gloves on when she entered the room. The infection control log dated [DATE] indicated Resident #31 had a URI on [DATE]. Resident #31 ' s roommate, Resident #30, had a URI on [DATE]. Resident #16 - closed record Physician orders [REDACTED].#16 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #16 understood others and made her needs known. She required extensive assistance with activities of daily living (ADLs). She was occasionally incontinent of bowel and bladder. The MDS indicated Resident #16 did not have recent infections. A care plan last revised [DATE] indicated Resident #16 required assistance with ADLs. The care plan did not address Resident #16 ' s upper respiratory infection (URI). Nursing notes for Resident #16 indicated the following: [DATE] at 1:25 a.m. - resident complained of sore throat, hoarse voice, and nonproductive cough, [DATE] at 4:41 a.m. - continued with hoarse voice, productive cough, and yellow phlegm, [MEDICATION NAME] minimally effective; [DATE] at 6:48 p.m. - continued with URI symptoms and new complaint of hip pain; [DATE] at 3:46 a.m. - resident to be sent to hospital for [MEDICAL CONDITION]. During a telephone interview on [DATE] at 4:21 p.m., Resident #16 ' s daughter said Resident #16 had a URI days before she went to the hospital for a [MEDICAL CONDITION]. She said Resident #16 did not have to wear a mask while she had URI symptoms. Resident #16 ' s daughter said Resident #16 was allowed to go to the dining room while showing URI symptoms. The daughter said staff did not wear masks while providing care to her mother when she exhibited URI symptoms. The infection control log for [DATE] did not include Resident #16 ' s URI. Resident #14 - closed record Physician orders [REDACTED].#14 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #14 was a full code and experienced occasional bowel and bladder incontinence. The care plan did not address his URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #14 understood others and made his needs known. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was incontinent of bowel and bladder. The MDS indicated Resident #14 did not have a recent infection. Nursing notes for Resident #14 indicated the following: *on [DATE] at 5:46 a.m. - nasal congestion with runny nose of clear drainage and nonproductive cough; *on [DATE] at 10:01 a.m. - new order for [MEDICATION NAME] for congestion; *on [DATE] at 12:11 a.m. - new order for Z-Pak (antibiotic) and chest x-ray, continue [MEDICATION NAME] for congestion; *on [DATE] at 7:00 a.m. - resident in dining room, resident noted to be lethargic, slurred speech, and scant amount of yellow, blood tinged drainage from nose, resident assisted to bed, hospice notified of change of condition; *on [DATE] at 5:53 p.m. - physician in facility, received new order for [MEDICATION NAME] IM (antibiotic) *on [DATE] at 5:55 p.m. - hospice nurse in facility to discontinue all routine medications and start palliative care; *on [DATE] at 10:19 p.m. - resident in bed with absent blood pressure, heart rate, and respirations, time of death 10:38 p.m. The infection control log for [DATE] indicated Resident #14 had a facility acquired URI on [DATE]. Resident #22 - closed record Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #22 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #22 was a full code, was incontinent of bladder, and had difficulty made herself understood. Resident #22 ' s pneumonia was not addressed on the care plan. A Minimum (MDS) data set [DATE] indicated Resident #22 usually understood others and sometimes made her needs known. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #22 did not have a recent infection. Nursing notes for Resident #22 indicated the following: *on [DATE] at 1:30 p.m. - new order for [MEDICATION NAME] related to congestion; *on [DATE] at 3:34 p.m. - resident with projectile vomiting, chest x-ray ordered; *on [DATE] at 6:22 p.m. - chest x-ray results received, bilateral lower lobe pneumonia, doctor notified; *on [DATE] at 5:52 p.m. - new order for [MEDICATION NAME] IM (antibiotic); *on [DATE] at 5:56 p.m. - initial dose of antibiotic given; *on [DATE] at 1:23 p.m. - resident ' s oxygen saturation dropped to 79%, applied nasal cannula and back up to 94%, no signs of acute distress at this time; and *on [DATE] at 12:00 p.m. - oxygen saturation 85% on room air, pulse was thread and rapid, temperature was 99.0, resident was responsive but lethargic, bilateral crackles and diminished lung sounds were noted, spouse requested resident be sent to local hospital, resident sent out via EMS. The infection control log dated [DATE] indicated Resident #22 had pneumonia with an onset date of [DATE]. A chest x-ray was performed [DATE] and an antibiotic was ordered. A local newspaper dated [DATE] indicated Resident #22 died in a local inpatient hospice on [DATE]. Resident #12-closed record The face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #12 (was in room [ROOM NUMBER], the same room as Resident #11 who died 1 week after Resident #12). The physician orders [REDACTED].#12 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #12 had severely impaired cognition. The undated care plan did not address the URI. Nursing notes for Resident #12 indicated the following: *[DATE] at 9:07 a.m., she had a new order for [MEDICATION NAME] (to prevent cough) four times a day for 7 days for congestion; *from [DATE]-[DATE], she continued with [MEDICATION NAME] and had an intermittent cough; *on [DATE] at 1:20 p.m., she had a non-productive cough with congestion; *on [DATE] at 8:39 p.m. (a late entry for 5:00 p.m.), the physician had seen her due to cough and congestion and provided orders for a complete blood count, chest xray, and Zpak (antibiotic) for URI. She had no fever; *on [DATE] at 12:46 a.m., she had a non-productive cough with congestion and waiting for the antibiotic to be delivered so it could be administered; *on [DATE] at 5:26 p.m., she had rapid breathing, diminished lung sounds, and O2 Sats of 83% on room air. She was sent to the hospital. The [DATE] MAR indicated [REDACTED]. A hospital History and Physical dated [DATE] indicated Resident #12 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Nursing notes for Resident #12 indicated the following: *on [DATE] at 7:52 p.m., she returned from the hospital on palliative care, had no fever, and O2 sats were 91%; *from [DATE]-[DATE], she continued on palliative care; O2 sats ,[DATE]%, non-productive cough, and crackles to all areas of her lungs. *on [DATE] at 5:22 p.m., she had worsening of her condition, developed throat congestion, and accumulation of fluid between the skin and connective tissue. Her family wanted her admitted to hospice; *on [DATE] at 9:42 p.m., the physician was notified of low O2 sats and labored breathing with restlessness; *on [DATE] at 1:33 a.m., she had crackles in both lungs, ,[DATE] second pauses between breaths, and O2 sats were now decreased to 78%; *on [DATE] at 10:27 a.m., she was admitted to hospice for [DIAGNOSES REDACTED]. *on [DATE] at 5:27 p.m., hospice pronounced her deceased . The Infection Control Log for [DATE] indicated Resident #12 had a [MEDICAL CONDITION]/pneumonia with onset date of [DATE], there was no culture obtained, a chest xray was obtained on [DATE], she was given an antibiotic, she was placed in isolation on [DATE], it was not a facility acquired infection, and there was no resolved date. Resident #13-closed record Physician orders [REDACTED].#13 was [AGE] years old, admitted on [DATE], and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Resident #13 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #13 required limited assistance with bathing and was limited in her ability to walk. The care plan did not address her upper respiratory infection (URI) or pneumonia. A Minimum Data Set ((MDS) dated [DATE]

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit neglect for 21 of 21 residents reviewed for neglect. (Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 22, 24, 25, 28, 30, and 31) The facility did not implement infection control measures to prevent: 1. Residents #1, 2,3,5,6,7,8,25,30,31,16, 14,22,12,13, and 11 from acquiring an upper respiratory infection (URI); 2. Residents #4,9,24, and 10 from acquiring pink eye ([MEDICAL CONDITION]); and 3. Residents # 7,8,and 28 from acquiring a urinary tract infection [MEDICAL CONDITION]. Residents # 14,22,12, 13, and 11 died after experiencing symptoms of a facility acquired URI during [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 80 residents at risk for serious infections or death due to super-imposed infections in an already fragile population. Findings included: The Abuse,Neglect and Misappropriation Policy, last revised [DATE], included, . The facility's Leadership prohibits neglect, .will implement appropriate and necessary guidelines, which prohibit .neglect . All new and current employees receive continuous education, training and reinforcement that identifies all aspects of abuse prohibition . The Infection Control Policy, last revised ,[DATE], required the staff to wash hands, . Before working with each patient/resident, before handling clean equipment, and after completing activities with each patient/resident .with soap and water. This policy also included instructions for residents to be placed in transmission based isolation when, . body fluids cannot be controlled, residents are not compliant with hygienic measures, or where the control of body fluids is not possible or hygiene is poor. The policy indicated, All types of transmission based isolation are used in conjunction with standard precautions . During an interview on [DATE] at 10:35 a.m., RN Q said no resident with respiratory issues were placed in isolation. She said neither the staff nor the residents with URI symptoms had been wearing masks. She said there had been multiple deaths of residents with URI symptoms, but some of those deaths were residents who were on hospice and had co-morbidities. She said they did not obtain cultures, take any special precautions, or isolate residents with pink eye. During an interview on [DATE] at 1:17 p.m., LVN T said there was no communication from administration to direct care staff. He said administration did not enforce any kind of preventative measures for residents with URI symptoms. He said staff was not told to wear masks and residents with URI symptoms were not told to wear masks. He said the facility had no management and had not received any special training or instruction to prevent the spread of the URIs or pink eye. 1.URIs An undated list provided by the infection control nurse indicated 3 residents had a current URI and were currently on antibiotics. Fifteen (15) residents had signs and symptoms of URI, but did not meet the criteria to be placed on the infection control log. Resident #1- current resident The face sheet dated [DATE] indicated Resident #1 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. The physician orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE], no culture was obtained, no chest x-ray was performed, she was given antibiotic, she was not placed in isolation, it was a Healthcare Acquired Infection (HAI), and there was no resolved date. The care plan dated [DATE] indicated Resident #1 had a potential for complications related to respiratory infection/pneumonia with interventions including administer antibiotic as prescribed. Nursing notes for Resident #1 indicated the following: *[DATE] at 11:17 a.m., she complained of a sore throat, had a non-productive cough, temperature of 97.4 degrees F, and had scattered crackles in her chest. The physician was informed of her condition; *[DATE] at 2:13 a.m. she was complaining of a sore throat, was given [MEDICATION NAME], and had a temperature of 97.8 degrees F. There was no assessment of her chest/lungs.; *from [DATE]-[DATE] she continued on antibiotic, had scattered crackles in her chest, continued with a non-productive cough, and had no fever.; *from [DATE] to [DATE] she had completed the antibiotic, continued with a non-productive cough,had scattered crackles in her chest, and had no fever.; *[DATE] at 7:35 p.m., she had a cough, was lethargic, and had a poor appetite. The note indicated she had a temperature at 12:00 p.m. of 100.0 degrees F and Tylenol was administered. A chest xray was done with results of improvement from previous films.; *[DATE] at 12:00 a.m., she continued with a non-productive cough, scattered crackles in her chest, and had no fever.; *[DATE] at 9:30 p.m., the physician was notified and ordered an antibiotic.; *[DATE] at 10:00 p.m., she had a fever of 100.0 degrees F and received Tylenol.; *[DATE] at 5:33 a.m., she complained of feeling discomfort and had a wet non-productive cough and chest congestion.; *[DATE] at 6:30 p.m., a new order was received for a second antibiotic.; *[DATE] at 12:15 p.m., she continued to be lethargic with a poor appetite. She was sweating heavily and complaining of pain all over. She continued on the 2 antibiotics and with no improvement. She was transferred to the hospital. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE] and [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given 2 different antibiotics, she was not placed in isolation, and she continued treatment. Nursing notes for Resident #1 indicated the following: *[DATE] at 1:54 p.m., she returned from the hospital. She continued to have a wet non-productive cough and scattered crackles in her chest.; *[DATE] at 10:14 a.m., she had a wet productive cough with off-white sputum, had scattered crackles in her chest, and had no fever.; *[DATE] at 5:57 p.m., the physician saw her and ordered a CBC and a chest xray.; *[DATE] at 11:55 p.m., she had scattered crackles in her chest and had no fever.; *[DATE] at 10:48 p.m., labs were reported to the physician. An order was received for [MEDICATION NAME] (antibiotic). Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (antibiotic) for acute lower respiratory infection. The [DATE] MARs indicated Resident #1 received the initial dose of [MEDICATION NAME] on [DATE] at 9:30 a.m., almost 36 hours later. Nursing notes with entry dated [DATE] at 6:56 p.m. indicated Resident #1 received an initial dose of a Z-Pak. Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (Z-Pak) (antibiotic) for acute lower respiratory infection. Nursing notes from [DATE]-[DATE] indicated Resident #1 continued on [MEDICATION NAME], completed the [MEDICATION NAME] (Z-Pak), had scattered crackles in her chest, had a non-productive cough, and had no fever. The current MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She had pneumonia in the last 7 days and had received antibiotics in the last 7 days. During an observation on [DATE] beginning at 11:07 a.m. Resident #1 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. Resident #2- Current Resident The face sheet dated [DATE] indicated Resident #2 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to Hall 200. Physician orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 had severely impaired cognition. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. Nursing notes dated [DATE] at 12:19 p.m. indicated Resident #2 had exit seeking behaviors and no documented respiratory issues. Physician orders [REDACTED].#2 was to begin [MEDICATION NAME] (antibiotic). Nursing notes for Resident #2 indicated the following: *[DATE] at 12:14 a.m., he had an initial dose of the antibiotic due to URI earlier in the shift, had no fever, and had a non-productive cough; *[DATE] - [DATE] he continued on the antibiotic with no adverse reaction and had signs and symptoms of URI. The undated care plan did not address Resident #2 ' s respiratory symptoms. The Infection Control Log for [DATE] did not list Resident #2. During an observation on [DATE] beginning at 11:07 a.m., Resident #2 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 12:45 p.m., after surveyor intervention, Resident #2 was moved to room [ROOM NUMBER]A on Hall 300 and co-horted with Resident #3 who also exhibited respiratory signs and symptoms. Resident #3 - current resident The face sheet dated [DATE] indicated Resident #3 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to room [ROOM NUMBER]B on Hall 300. (Resident #2 was his roommate). Physician orders [REDACTED].#3 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #3 had severely impaired cognition; had no infections; had [DIAGNOSES REDACTED]. The undated care plan did not address Resident #3 ' s respiratory symptoms. Nursing notes for Resident #3 indicated the following: *[DATE] at 12:24 a.m., he had a temperature of 101.1 degrees F, complained of abdominal pain, and no documented respiratory issues.; *[DATE] at 10:50 a.m., he was red faced, had audible wheezing, complained of shortness of breath, O2 sats of 94% on room air, but had audible grunting with each breath. He was sent to the hospital. Nursing notes for Resident #3 indicated on [DATE] at 3:18 p.m., he returned to the facility. The physician orders [REDACTED].#3 was to receive [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The Infection Control Log for [DATE] did not list Resident #3. Resident #5- current resident The face sheet dated [DATE] indicated Resident #5 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #5 was in room [ROOM NUMBER](the same room as Resident #6 who was exhibiting signs and symptoms of respiratory issues). The physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #5 had severely impaired cognition. Nursing notes for Resident #5 indicated the following: *on [DATE] at 8:30 p.m., she had a non-productive cough and was given PRN cough syrup; *on [DATE] at 8:13 p.m., a chest x-ray was done due to thick green sputum and low grade temperature. The x-ray showed pneumonia. An order was received for Bactrim DS (antibiotic). The undated care plan did not address the pneumonia. The Infection Control Log for [DATE] indicated Resident #5 had a URI with onset date of [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given an antibiotic, she was not placed in isolation, it was a facility acquired, and there was no resolved date. Nursing notes from [DATE]-[DATE] indicated Resident #5 had a non-productive cough, had few scattered crackles, and continued on the antibiotic. During an observation on [DATE] beginning at 11:07 a.m., Resident #5, on Hall 200, exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 11:28 a.m., hand sanitizer bottles were stationed at the nursing station and medication carts. Resident rooms were not supplied with hand sanitizer. Resident #6-current resident The face sheet dated [DATE] indicated Resident #6 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #6 was in room [ROOM NUMBER](the same room as Resident #5 who had a URI). The physician orders [REDACTED].#6 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #6 had severely impaired cognition. The undated care plan did not address the URI symptoms or approaches to take. Nursing notes from [DATE]-[DATE] had no documentation of any issues with coughing or congestion. The [DATE] MAR indicated [REDACTED] *on [DATE],[DATE],[DATE],[DATE], [DATE], [DATE], and [DATE]. During an observation and interview on [DATE] at 11:07 a.m., Resident #6 exhibited coughing and congestion symptoms. She was not wearing a mask. She said she had been coughing for about a week and her roommate had been sick too. The Infection Control Log for [DATE] indicated Resident #6 was not listed. Resident #8 - current resident Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #8 was in room [ROOM NUMBER] (same room as Resident #7). A care plan, last revised [DATE], indicated Resident #8 required assistance with all activities of daily living (ADLs) and she experienced bladder incontinence related to decreased mobilization. The care plan did not address Resident #8 ' s UTI or URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 understood others and usually made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #8 did not have recent infections. Nursing notes for Resident #8 indicated the following: *on[DATE] at 1:17 a.m. - moved to room [ROOM NUMBER]; *on [DATE] at 12:17 a.m. - new order for chest x-ray, Z-pak (antibiotic) for cough and congestion; *on [DATE] at 10:54 a.m. - awaiting pharmacy to deliver Z-pak; *on [DATE] at 8:56 a.m. - resident had cough with thick mucus; *on [DATE] at 9:49 p.m. - resident had wet lung sounds with rhonchi, hospice new order for [MEDICATION NAME] (antibiotic), [MEDICATION NAME], and [MEDICATION NAME] swish and swallow; *on [DATE] at 7:01 a.m. - initial dose of [MEDICATION NAME] given; *on[DATE] at 12:48 a.m. - New antibiotic [MEDICATION NAME] for upper respiratory infection (URI) given, and to continlue [MEDICATION NAME], and breathing treatment; *on [DATE] at 12:51 p.m. - continues with productive cough, continues with breathing treatment, [MEDICATION NAME], and [MEDICATION NAME], resident in dining room for lunch; and *on[DATE] at 3:19 a.m. - continued breathing treatment for [REDACTED]. During an observation on [DATE] at 1:21 p.m., CNA D and CNA E were seen entering and exiting Resident #8 ' s room with no mask and did not perform hand hygiene before entering the room. During an interview on [DATE] at 1:32 p.m., CNA D said nobody from administration had told her to take any special precautions with residents with URI symptoms. She said residents with URI symptoms were allowed to go to the dining room. The infection control log for [DATE] indicated Resident #8 had an UTI with an onset date of [DATE], a culture date of [DATE], and the culture being ESBL positive. The infection control log indicated Resident #8 had an URI on [DATE] and began antibiotics. The infection control log for [DATE] indicated Resident #8 continued treatment for [REDACTED]. Resident #25-current resident The face sheet dated [DATE] indicated Resident #25 was an [AGE] year old male admitted on [DATE] to Hall 400. The physician orders [REDACTED].#25 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #25 was cognitively intact. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. The undated care plan did not address Resident #25 ' s respiratory symptoms. During an observation and interview on [DATE] at 1:00 p.m., Resident #25 had a non-productive cough. He said he developed the cough after he came to the facility. He said he had taken an antibiotic for it. Nursing notes with an entry dated [DATE] at 5:03 p.m. indicated he had a non-productive cough and complained of shortness of breath. The physician was notified of his condition. The physician orders [REDACTED].#25 was to be placed on [MEDICATION NAME] Z-Pak (antibiotic) for symptoms of URI. Nursing notes for Resident #25 indicated the following: *on [DATE] at 1:30 a.m., he continued with a non-productive cough, had course breath sounds, and a temperature of 99.1 degrees F.; *on [DATE] at 11:51 p.m., a chest xray report read lung fields were clear without mass, infiltrate, congestion, or effusion.; *on [DATE] at 1:44 a.m., he had no cough or congestion and lung fields were clear; *on [DATE] at 11:04 a.m., he continued on the antibiotic with no adverse reaction but lung sounds were not assessed.; *on [DATE] at 2:16 p.m., he completed the antibiotic with no adverse reaction but lung sounds were not assessed. The Infection Control Log for [DATE] did not list Resident #25. During an observation on [DATE] beginning at 11:07 a.m., Resident #25 was in his room. He exhibited coughing and congestion symptoms, but was not wearing a mask. Resident #30 - current resident Physician orders [REDACTED].#30 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 was in room [ROOM NUMBER] (same room as Resident #31). A care plan dated [DATE] indicated Resident #30 required assistance with activities of daily living (ADLs). The care plan did not address Resident #30 ' s URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 usually understood others and made her needs known. She required extensive assistance with ADLs and was incontinent of bowel and bladder. The MDS indicated Resident #30 did not have recent infections. Nursing notes for Resident #30 indicated the following: *on [DATE] at 2:37 p.m. - resident with scattered crackles in bilateral chest, nonproductive wet cough, chest x-ray ordered; *on [DATE] at 1:15 a.m. - chest x-ray was clear, resident in bed with no cough or congestion; *on [DATE] at 11:25 a.m. -in wheelchair in dining room for lunch, no cough noted; *on [DATE] at 1:50 p.m. - resident coughing up thick yellow phlegm, noted bilateral chest congestion, breathing treatment given, resident in bed; *on [DATE] at 9:13 a.m. - resident continued with cough and congestion, new order for antibiotic, [MEDICATION NAME], and breathing treatment as needed, nausea and vomiting at breakfast with semi productive tight cough noted; *on [DATE] at 11:09 p.m. - initial dose of antibiotic given for URI; *on [DATE] at 1:02 a.m. - Tylenol given for 100.0 temperature; *on [DATE] at 10:00 a.m. - resident in bed, oxygen saturation 93%, resident very slow to respond to verbal and tactile stimuli, skin warm with tenting, chest with bilateral congestion, productive cough with thick yellow phlegm, daughter requested resident be sent to ER; *on [DATE] at 5:28 p.m. - resident back in facility with [DIAGNOSES REDACTED]. *on[DATE] at 10:55 a.m. - resident in bed, chest with scattered crackles, wet nonproductive cough; and *on [DATE] at 2:51 p.m. - resident in bed, chest with scattered crackles, intermittent wet nonproductive cough, poor intake. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #30 ' s room without masks and CNA G already had gloves on when she entered the room. Neither washed their hands before providing care to Resident #30. The infection control log for [DATE] indicated Resident #30 had a URI that was facility acquired on [DATE], an antibiotic was ordered, onset date was [DATE], and a chest x-ray was performed on [DATE]. The infection control log for [DATE] indicated Resident #30 continued treatment for [REDACTED]. Resident #30 ' s roommate, Resident #31 had a URI on [DATE]. Resident #31 - current resident Physician orders [REDACTED].#31 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #31 was in room [ROOM NUMBER] (same room as Resident #30). A care plan dated [DATE] indicated Resident #31 was incontinent of bowel and bladder and required assistance with all activities of daily living (ADLs). The care plan did not address Resident #31 ' s upper respiratory infection (URI). A Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 understood others and made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #31 was admitted with pneumonia and did not have recent infections. Nursing notes for Resident #31 indicated the following: *on [DATE] at 1:53 a.m. - no cough noted, chest x-ray performed on prior shift with noted right upper lobe atelectasis with mild cardiomegaly; *on [DATE] at 4:55 a.m. - resident sitting in wheelchair in dining room, nonproductive cough noted; *on [DATE] at 9:15 a.m. - resident in wheelchair for breakfast, chest with scattered crackles, productive cough with thick brown/yellow sputum, new order for antibiotic, assisted to bed after breakfast; *on [DATE] at 11:50 p.m. - resident resting in bed, nonproductive cough noted, continued with antibiotic and [MEDICATION NAME]; *on [DATE] at 10:23 a.m. - appetite and fluid intake poor, chest with scattered crackles, CNA assisted resident with breakfast, assisted back to bed, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 11:26 a.m. - resident in bed, chest with scattered crackles and nonproductive wet cough, poor appetite, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 10:10 a.m. - resident in dining room for breakfast, chest with scattered crackles and nonproductive wet cough, appetite poor, completed antibiotic; *on [DATE] at 1:26 p.m. - resident continued with intermittent wet nonproductive cough, continued with [MEDICATION NAME]; and *on [DATE] at 10:27 a.m. - chest with scattered crackles, continued with [MEDICATION NAME], intake poor. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #31 ' s room without masks and CNA G already had gloves on when she entered the room. The infection control log dated [DATE] indicated Resident #31 had a URI on [DATE]. Resident #31 ' s roommate, Resident #30, had a URI on [DATE]. Resident #16 - closed record Physician orders [REDACTED].#16 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #16 understood others and made her needs known. She required extensive assistance with activities of daily living (ADLs). She was occasionally incontinent of bowel and bladder. The MDS indicated Resident #16 did not have recent infections. A care plan last revised [DATE] indicated Resident #16 required assistance with ADLs. The care plan did not address Resident #16 ' s upper respiratory infection (URI). Nursing notes for Resident #16 indicated the following: [DATE] at 1:25 a.m. - resident complained of sore throat, hoarse voice, and nonproductive cough, [DATE] at 4:41 a.m. - continued with hoarse voice, productive cough, and yellow phlegm, [MEDICATION NAME] minimally effective; [DATE] at 6:48 p.m. - continued with URI symptoms and new complaint of hip pain; [DATE] at 3:46 a.m. - resident to be sent to hospital for [MEDICAL CONDITION]. During a telephone interview on [DATE] at 4:21 p.m., Resident #16 ' s daughter said Resident #16 had a URI days before she went to the hospital for a [MEDICAL CONDITION]. She said Resident #16 did not have to wear a mask while she had URI symptoms. Resident #16 ' s daughter said Resident #16 was allowed to go to the dining room while showing URI symptoms. The daughter said staff did not wear masks while providing care to her mother when she exhibited URI symptoms. The infection control log for [DATE] did not include Resident #16 ' s URI. Resident #14 - closed record Physician orders [REDACTED].#14 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #14 was a full code and experienced occasional bowel and bladder incontinence. The care plan did not address his URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #14 understood others and made his needs known. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was incontinent of bowel and bladder. The MDS indicated Resident #14 did not have a recent infection. Nursing notes for Resident #14 indicated the following: *on [DATE] at 5:46 a.m. - nasal congestion with runny nose of clear drainage and nonproductive cough; *on [DATE] at 10:01 a.m. - new order for [MEDICATION NAME] for congestion; *on [DATE] at 12:11 a.m. - new order for Z-Pak (antibiotic) and chest x-ray, continue [MEDICATION NAME] for congestion; *on [DATE] at 7:00 a.m. - resident in dining room, resident noted to be lethargic, slurred speech, and scant amount of yellow, blood tinged drainage from nose, resident assisted to bed, hospice notified of change of condition; *on [DATE] at 5:53 p.m. - physician in facility, received new order for [MEDICATION NAME] IM (antibiotic) *on [DATE] at 5:55 p.m. - hospice nurse in facility to discontinue all routine medications and start palliative care; *on [DATE] at 10:19 p.m. - resident in bed with absent blood pressure, heart rate, and respirations, time of death 10:38 p.m. The infection control log for [DATE] indicated Resident #14 had a facility acquired URI on [DATE]. Resident #22 - closed record Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #22 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #22 was a full code, was incontinent of bladder, and had difficulty made herself understood. Resident #22 ' s pneumonia was not addressed on the care plan. A Minimum (MDS) data set [DATE] indicated Resident #22 usually understood others and sometimes made her needs known. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #22 did not have a recent infection. Nursing notes for Resident #22 indicated the following: *on [DATE] at 1:30 p.m. - new order for [MEDICATION NAME] related to congestion; *on [DATE] at 3:34 p.m. - resident with projectile vomiting, chest x-ray ordered; *on [DATE] at 6:22 p.m. - chest x-ray results received, bilateral lower lobe pneumonia, doctor notified; *on [DATE] at 5:52 p.m. - new order for [MEDICATION NAME] IM (antibiotic); *on [DATE] at 5:56 p.m. - initial dose of antibiotic given; *on [DATE] at 1:23 p.m. - resident ' s oxygen saturation dropped to 79%, applied nasal cannula and back up to 94%, no signs of acute distress at this time; and *on [DATE] at 12:00 p.m. - oxygen saturation 85% on room air, pulse was thread and rapid, temperature was 99.0, resident was responsive but lethargic, bilateral crackles and diminished lung sounds were noted, spouse requested resident be sent to local hospital, resident sent out via EMS. The infection control log dated [DATE] indicated Resident #22 had pneumonia with an onset date of [DATE]. A chest x-ray was performed [DATE] and an antibiotic was ordered. A local newspaper dated [DATE] indicated Resident #22 died in a local inpatient hospice on [DATE]. Resident #12-closed record The face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #12 (was in room [ROOM NUMBER], the same room as Resident #11 who died 1 week after Resident #12). The physician orders [REDACTED].#12 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #12 had severely impaired cognition. The undated care plan did not address the URI. Nursing notes for Resident #12 indicated the following: *[DATE] at 9:07 a.m., she had a new order for [MEDICATION NAME] (to prevent cough) four times a day for 7 days for congestion; *from [DATE]-[DATE], she continued with [MEDICATION NAME] and had an intermittent cough; *on [DATE] at 1:20 p.m., she had a non-productive cough with congestion; *on [DATE] at 8:39 p.m. (a late entry for 5:00 p.m.), the physician had seen her due to cough and congestion and provided orders for a complete blood count, chest xray, and Zpak (antibiotic) for URI. She had no fever; *on [DATE] at 12:46 a.m., she had a non-productive cough with congestion and waiting for the antibiotic to be delivered so it could be administered; *on [DATE] at 5:26 p.m., she had rapid breathing, diminished lung sounds, and O2 Sats of 83% on room air. She was sent to the hospital. The [DATE] MAR indicated [REDACTED]. A hospital History and Physical dated [DATE] indicated Resident #12 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Nursing notes for Resident #12 indicated the following: *on [DATE] at 7:52 p.m., she returned from the hospital on palliative care, had no fever, and O2 sats were 91%; *from [DATE]-[DATE], she continued on palliative care; O2 sats ,[DATE]%, non-productive cough, and crackles to all areas of her lungs. *on [DATE] at 5:22 p.m., she had worsening of her condition, developed throat congestion, and accumulation of fluid between the skin and connective tissue. Her family wanted her admitted to hospice; *on [DATE] at 9:42 p.m., the physician was notified of low O2 sats and labored breathing with restlessness; *on [DATE] at 1:33 a.m., she had crackles in both lungs, ,[DATE] second pauses between breaths, and O2 sats were now

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 21 of 21 residents reviewed for quality of care. (Residents # 1,2,3,4,5,6,7,8,9,10,11,12,13,14,16, 22,24,25,28,30, and 31) 1.The facility did not prevent and control outbreaks and cross-contamination of upper respiratory infections for Residents # 1,2,3,5,6,8,25,30,31,16,14,22,12,13,and 11. The facility did not separate residents with known URI symptoms from those who were symptom free, did not care plan the necessary measures to care for residents with URI symptoms, did not provide the timely antibiotic administration for Resident #1 who had URI symptoms, did not maintain accurate information to determine and prevent the spread of the URI within the facility, and did not utilize necessary airborne precautions to prevent the rapid spread of a URI to at least 15 residents. 2.The facility did not prevent and control cross-contamination of residents with [MEDICAL CONDITION] (pink eye). No special infection control measures were taken to prevent the resident to resident contamination. Residents # 9,4, 24, and 10 developed facility acquired pink eye. 3.The facility did not ensure proper incontinence care was provided to prevent urinary tract infections for Residents # 7, 8, and 28. Residents # 14,22,12,13, and 11 died after experiencing symptoms of a facility acquired URI during [DATE]. Fifteen (15) residents developed facility acquired URI symptoms during September and [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 80 residents at risk for serious infections or death due to super-imposed infections in an already fragile population. Findings included: During an interview on [DATE] at 10:35 a.m., RN Q said no resident with respiratory issues were placed in isolation. She said neither the staff nor the residents with URI symptoms had been wearing masks. She said there had been multiple deaths of residents with URI symptoms, but some of those deaths were residents who were on hospice and had co-morbidities. She said they did not obtain cultures, take any special precautions, or isolate residents with pink eye. During an interview on [DATE] at 1:17 p.m., LVN T said there was no communication from administration to direct care staff. He said administration did not enforce any kind of preventative measures for residents with URI symptoms. He said staff was not told to wear masks and residents with URI symptoms were not told to wear masks. He said the facility had no management and had not received any special training or instruction to prevent the spread of the URIs or pink eye. 1.URIs An undated list provided by the infection control nurse indicated 3 residents had a current URI and were currently on antibiotics. Fifteen (15) residents had signs and symptoms of URI, but did not meet the criteria to be placed on the infection control log. Resident #1- current resident The face sheet dated [DATE] indicated Resident #1 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. The physician orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE], no culture was obtained, no chest x-ray was performed, she was given antibiotic, she was not placed in isolation, it was a Healthcare Acquired Infection (HAI), and there was no resolved date. The care plan dated [DATE] indicated Resident #1 had a potential for complications related to respiratory infection/pneumonia with interventions including administer antibiotic as prescribed. Nursing notes for Resident #1 indicated the following: *[DATE] at 11:17 a.m., she complained of a sore throat, had a non-productive cough, temperature of 97.4 degrees F, and had scattered crackles in her chest. The physician was informed of her condition; *[DATE] at 2:13 a.m. she was complaining of a sore throat, was given [MEDICATION NAME], and had a temperature of 97.8 degrees F. There was no assessment of her chest/lungs.; *from [DATE]-[DATE] she continued on antibiotic, had scattered crackles in her chest, continued with a non-productive cough, and had no fever.; *from [DATE] to [DATE] she had completed the antibiotic, continued with a non-productive cough,had scattered crackles in her chest, and had no fever.; *[DATE] at 7:35 p.m., she had a cough, was lethargic, and had a poor appetite. The note indicated she had a temperature at 12:00 p.m. of 100.0 degrees F and Tylenol was administered. A chest xray was done with results of improvement from previous films.; *[DATE] at 12:00 a.m., she continued with a non-productive cough, scattered crackles in her chest, and had no fever.; *[DATE] at 9:30 p.m., the physician was notified and ordered an antibiotic.; *[DATE] at 10:00 p.m., she had a fever of 100.0 degrees F and received Tylenol.; *[DATE] at 5:33 a.m., she complained of feeling discomfort and had a wet non-productive cough and chest congestion.; *[DATE] at 6:30 p.m., a new order was received for a second antibiotic.; *[DATE] at 12:15 p.m., she continued to be lethargic with a poor appetite. She was sweating heavily and complaining of pain all over. She continued on the 2 antibiotics and with no improvement. She was transferred to the hospital. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE] and [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given 2 different antibiotics, she was not placed in isolation, and she continued treatment. Nursing notes for Resident #1 indicated the following: *[DATE] at 1:54 p.m., she returned from the hospital. She continued to have a wet non-productive cough and scattered crackles in her chest.; *[DATE] at 10:14 a.m., she had a wet productive cough with off-white sputum, had scattered crackles in her chest, and had no fever.; *[DATE] at 5:57 p.m., the physician saw her and ordered a CBC and a chest xray.; *[DATE] at 11:55 p.m., she had scattered crackles in her chest and had no fever.; *[DATE] at 10:48 p.m., labs were reported to the physician. An order was received for [MEDICATION NAME] (antibiotic). Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (antibiotic) for acute lower respiratory infection. The [DATE] MARs indicated Resident #1 received the initial dose of [MEDICATION NAME] on [DATE] at 9:30 a.m., almost 36 hours later. Nursing notes with entry dated [DATE] at 6:56 p.m. indicated Resident #1 received an initial dose of a Z-Pak. Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (Z-Pak) (antibiotic) for acute lower respiratory infection. Nursing notes from [DATE]-[DATE] indicated Resident #1 continued on [MEDICATION NAME], completed the [MEDICATION NAME] (Z-Pak), had scattered crackles in her chest, had a non-productive cough, and had no fever. The current MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She had pneumonia in the last 7 days and had received antibiotics in the last 7 days. During an observation on [DATE] beginning at 11:07 a.m. Resident #1 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. Resident #2- Current Resident The face sheet dated [DATE] indicated Resident #2 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to Hall 200. Physician orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 had severely impaired cognition. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. Nursing notes dated [DATE] at 12:19 p.m. indicated Resident #2 had exit seeking behaviors and no documented respiratory issues. Physician orders [REDACTED].#2 was to begin [MEDICATION NAME] (antibiotic). Nursing notes for Resident #2 indicated the following: *[DATE] at 12:14 a.m., he had an initial dose of the antibiotic due to URI earlier in the shift, had no fever, and had a non-productive cough; *[DATE] - [DATE] he continued on the antibiotic with no adverse reaction and had signs and symptoms of URI. The undated care plan did not address Resident #2's respiratory symptoms. The Infection Control Log for [DATE] did not list Resident #2. During an observation on [DATE] beginning at 11:07 a.m., Resident #2 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 12:45 p.m., after surveyor intervention, Resident #2 was moved to room [ROOM NUMBER]A on Hall 300 and co-horted with Resident #3 who also exhibited respiratory signs and symptoms. Resident #3 - current resident The face sheet dated [DATE] indicated Resident #3 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to room [ROOM NUMBER]B on Hall 300. (Resident #2 was his roommate). Physician orders [REDACTED].#3 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #3 had severely impaired cognition; had no infections; had [DIAGNOSES REDACTED]. The undated care plan did not address Resident #3's respiratory symptoms. Nursing notes for Resident #3 indicated the following: *[DATE] at 12:24 a.m., he had a temperature of 101.1 degrees F, complained of abdominal pain, and no documented respiratory issues.; *[DATE] at 10:50 a.m., he was red faced, had audible wheezing, complained of shortness of breath, O2 sats of 94% on room air, but had audible grunting with each breath. He was sent to the hospital. Nursing notes for Resident #3 indicated on [DATE] at 3:18 p.m., he returned to the facility. The physician orders [REDACTED].#3 was to receive [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The Infection Control Log for [DATE] did not list Resident #3. Resident #5- current resident The face sheet dated [DATE] indicated Resident #5 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #5 was in room [ROOM NUMBER](the same room as Resident #6 who was exhibiting signs and symptoms of respiratory issues). The physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #5 had severely impaired cognition. Nursing notes for Resident #5 indicated the following: *on [DATE] at 8:30 p.m., she had a non-productive cough and was given PRN cough syrup; *on [DATE] at 8:13 p.m., a chest x-ray was done due to thick green sputum and low grade temperature. The x-ray showed pneumonia. An order was received for Bactrim DS (antibiotic). The undated care plan did not address the pneumonia. The Infection Control Log for [DATE] indicated Resident #5 had a URI with onset date of [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given an antibiotic, she was not placed in isolation, it was a facility acquired, and there was no resolved date. Nursing notes from [DATE]-[DATE] indicated Resident #5 had a non-productive cough, had few scattered crackles, and continued on the antibiotic. During an observation on [DATE] beginning at 11:07 a.m., Resident #5, on Hall 200, exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 11:28 a.m., hand sanitizer bottles were stationed at the nursing station and medication carts. Resident rooms were not supplied with hand sanitizer. Resident #6-current resident The face sheet dated [DATE] indicated Resident #6 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #6 was in room [ROOM NUMBER](the same room as Resident #5 who had a URI). The physician orders [REDACTED].#6 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #6 had severely impaired cognition. The undated care plan did not address the URI symptoms or approaches to take. Nursing notes from [DATE]-[DATE] had no documentation of any issues with coughing or congestion. The [DATE] MAR indicated [REDACTED] *on [DATE],[DATE],[DATE],[DATE], [DATE], [DATE], and [DATE]. During an observation and interview on [DATE] at 11:07 a.m., Resident #6 exhibited coughing and congestion symptoms. She was not wearing a mask. She said she had been coughing for about a week and her roommate had been sick too. The Infection Control Log for [DATE] indicated Resident #6 was not listed. Resident #8 - current resident Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #8 was in room [ROOM NUMBER] (same room as Resident #7). A care plan, last revised [DATE], indicated Resident #8 required assistance with all activities of daily living (ADLs) and she experienced bladder incontinence related to decreased mobilization. The care plan did not address Resident #8's UTI or URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 understood others and usually made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #8 did not have recent infections. Nursing notes for Resident #8 indicated the following: *on[DATE] at 1:17 a.m. - moved to room [ROOM NUMBER]; *on [DATE] at 12:17 a.m. - new order for chest x-ray, Z-pak (antibiotic) for cough and congestion; *on [DATE] at 10:54 a.m. - awaiting pharmacy to deliver Z-pak; *on [DATE] at 8:56 a.m. - resident had cough with thick mucus; *on [DATE] at 9:49 p.m. - resident had wet lung sounds with rhonchi, hospice new order for [MEDICATION NAME] (antibiotic), [MEDICATION NAME], and [MEDICATION NAME] swish and swallow; *on [DATE] at 7:01 a.m. - initial dose of [MEDICATION NAME] given; *on[DATE] at 12:48 a.m. - New antibiotic [MEDICATION NAME] for upper respiratory infection (URI) given, and to continlue [MEDICATION NAME], and breathing treatment; *on [DATE] at 12:51 p.m. - continues with productive cough, continues with breathing treatment, [MEDICATION NAME], and [MEDICATION NAME], resident in dining room for lunch; and *on[DATE] at 3:19 a.m. - continued breathing treatment for [REDACTED]. During an observation on [DATE] at 1:21 p.m., CNA D and CNA E were seen entering and exiting Resident #8's room with no mask and did not perform hand hygiene before entering the room. During an interview on [DATE] at 1:32 p.m., CNA D said nobody from administration had told her to take any special precautions with residents with URI symptoms. She said residents with URI symptoms were allowed to go to the dining room. The infection control log for [DATE] indicated Resident #8 had an UTI with an onset date of [DATE], a culture date of [DATE], and the culture being ESBL positive. The infection control log indicated Resident #8 had an URI on [DATE] and began antibiotics. The infection control log for [DATE] indicated Resident #8 continued treatment for [REDACTED]. Resident #25-current resident The face sheet dated [DATE] indicated Resident #25 was an [AGE] year old male admitted on [DATE] to Hall 400. The physician orders [REDACTED].#25 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #25 was cognitively intact. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. The undated care plan did not address Resident #25's respiratory symptoms. During an observation and interview on [DATE] at 1:00 p.m., Resident #25 had a non-productive cough. He said he developed the cough after he came to the facility. He said he had taken an antibiotic for it. Nursing notes with an entry dated [DATE] at 5:03 p.m. indicated he had a non-productive cough and complained of shortness of breath. The physician was notified of his condition. The physician orders [REDACTED].#25 was to be placed on [MEDICATION NAME] Z-Pak (antibiotic) for symptoms of URI. Nursing notes for Resident #25 indicated the following: *on [DATE] at 1:30 a.m., he continued with a non-productive cough, had course breath sounds, and a temperature of 99.1 degrees F.; *on [DATE] at 11:51 p.m., a chest xray report read lung fields were clear without mass, infiltrate, congestion, or effusion.; *on [DATE] at 1:44 a.m., he had no cough or congestion and lung fields were clear; *on [DATE] at 11:04 a.m., he continued on the antibiotic with no adverse reaction but lung sounds were not assessed.; *on [DATE] at 2:16 p.m., he completed the antibiotic with no adverse reaction but lung sounds were not assessed. The Infection Control Log for [DATE] did not list Resident #25. During an observation on [DATE] beginning at 11:07 a.m., Resident #25 was in his room. He exhibited coughing and congestion symptoms, but was not wearing a mask. Resident #30 - current resident Physician orders [REDACTED].#30 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 was in room [ROOM NUMBER] (same room as Resident #31). A care plan dated [DATE] indicated Resident #30 required assistance with activities of daily living (ADLs). The care plan did not address Resident #30's URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 usually understood others and made her needs known. She required extensive assistance with ADLs and was incontinent of bowel and bladder. The MDS indicated Resident #30 did not have recent infections. Nursing notes for Resident #30 indicated the following: *on [DATE] at 2:37 p.m. - resident with scattered crackles in bilateral chest, nonproductive wet cough, chest x-ray ordered; *on [DATE] at 1:15 a.m. - chest x-ray was clear, resident in bed with no cough or congestion; *on [DATE] at 11:25 a.m. -in wheelchair in dining room for lunch, no cough noted; *on [DATE] at 1:50 p.m. - resident coughing up thick yellow phlegm, noted bilateral chest congestion, breathing treatment given, resident in bed; *on [DATE] at 9:13 a.m. - resident continued with cough and congestion, new order for antibiotic, [MEDICATION NAME], and breathing treatment as needed, nausea and vomiting at breakfast with semi productive tight cough noted; *on [DATE] at 11:09 p.m. - initial dose of antibiotic given for URI; *on [DATE] at 1:02 a.m. - Tylenol given for 100.0 temperature; *on [DATE] at 10:00 a.m. - resident in bed, oxygen saturation 93%, resident very slow to respond to verbal and tactile stimuli, skin warm with tenting, chest with bilateral congestion, productive cough with thick yellow phlegm, daughter requested resident be sent to ER; *on [DATE] at 5:28 p.m. - resident back in facility with [DIAGNOSES REDACTED]. *on[DATE] at 10:55 a.m. - resident in bed, chest with scattered crackles, wet nonproductive cough; and *on [DATE] at 2:51 p.m. - resident in bed, chest with scattered crackles, intermittent wet nonproductive cough, poor intake. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #30's room without masks and CNA G already had gloves on when she entered the room. Neither washed their hands before providing care to Resident #30. The infection control log for [DATE] indicated Resident #30 had a URI that was facility acquired on [DATE], an antibiotic was ordered, onset date was [DATE], and a chest x-ray was performed on [DATE]. The infection control log for [DATE] indicated Resident #30 continued treatment for [REDACTED]. Resident #30's roommate, Resident #31 had a URI on [DATE]. Resident #31 - current resident Physician orders [REDACTED].#31 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #31 was in room [ROOM NUMBER] (same room as Resident #30). A care plan dated [DATE] indicated Resident #31 was incontinent of bowel and bladder and required assistance with all activities of daily living (ADLs). The care plan did not address Resident #31's upper respiratory infection (URI). A Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 understood others and made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #31 was admitted with pneumonia and did not have recent infections. Nursing notes for Resident #31 indicated the following: *on [DATE] at 1:53 a.m. - no cough noted, chest x-ray performed on prior shift with noted right upper lobe atelectasis with mild cardiomegaly; *on [DATE] at 4:55 a.m. - resident sitting in wheelchair in dining room, nonproductive cough noted; *on [DATE] at 9:15 a.m. - resident in wheelchair for breakfast, chest with scattered crackles, productive cough with thick brown/yellow sputum, new order for antibiotic, assisted to bed after breakfast; *on [DATE] at 11:50 p.m. - resident resting in bed, nonproductive cough noted, continued with antibiotic and [MEDICATION NAME]; *on [DATE] at 10:23 a.m. - appetite and fluid intake poor, chest with scattered crackles, CNA assisted resident with breakfast, assisted back to bed, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 11:26 a.m. - resident in bed, chest with scattered crackles and nonproductive wet cough, poor appetite, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 10:10 a.m. - resident in dining room for breakfast, chest with scattered crackles and nonproductive wet cough, appetite poor, completed antibiotic; *on [DATE] at 1:26 p.m. - resident continued with intermittent wet nonproductive cough, continued with [MEDICATION NAME]; and *on [DATE] at 10:27 a.m. - chest with scattered crackles, continued with [MEDICATION NAME], intake poor. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #31's room without masks and CNA G already had gloves on when she entered the room. The infection control log dated [DATE] indicated Resident #31 had a URI on [DATE]. Resident #31's roommate, Resident #30, had a URI on [DATE]. Resident #16 - closed record Physician orders [REDACTED].#16 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #16 understood others and made her needs known. She required extensive assistance with activities of daily living (ADLs). She was occasionally incontinent of bowel and bladder. The MDS indicated Resident #16 did not have recent infections. A care plan last revised [DATE] indicated Resident #16 required assistance with ADLs. The care plan did not address Resident #16's upper respiratory infection (URI). Nursing notes for Resident #16 indicated the following: [DATE] at 1:25 a.m. - resident complained of sore throat, hoarse voice, and nonproductive cough, [DATE] at 4:41 a.m. - continued with hoarse voice, productive cough, and yellow phlegm, [MEDICATION NAME] minimally effective; [DATE] at 6:48 p.m. - continued with URI symptoms and new complaint of hip pain; [DATE] at 3:46 a.m. - resident to be sent to hospital for [MEDICAL CONDITION]. During a telephone interview on [DATE] at 4:21 p.m., Resident #16's daughter said Resident #16 had a URI days before she went to the hospital for a [MEDICAL CONDITION]. She said Resident #16 did not have to wear a mask while she had URI symptoms. Resident #16's daughter said Resident #16 was allowed to go to the dining room while showing URI symptoms. The daughter said staff did not wear masks while providing care to her mother when she exhibited URI symptoms. The infection control log for [DATE] did not include Resident #16's URI. Resident #14 - closed record Physician orders [REDACTED].#14 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #14 was a full code and experienced occasional bowel and bladder incontinence. The care plan did not address his URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #14 understood others and made his needs known. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was incontinent of bowel and bladder. The MDS indicated Resident #14 did not have a recent infection. Nursing notes for Resident #14 indicated the following: *on [DATE] at 5:46 a.m. - nasal congestion with runny nose of clear drainage and nonproductive cough; *on [DATE] at 10:01 a.m. - new order for [MEDICATION NAME] for congestion; *on [DATE] at 12:11 a.m. - new order for Z-Pak (antibiotic) and chest x-ray, continue [MEDICATION NAME] for congestion; *on [DATE] at 7:00 a.m. - resident in dining room, resident noted to be lethargic, slurred speech, and scant amount of yellow, blood tinged drainage from nose, resident assisted to bed, hospice notified of change of condition; *on [DATE] at 5:53 p.m. - physician in facility, received new order for [MEDICATION NAME] IM (antibiotic) *on [DATE] at 5:55 p.m. - hospice nurse in facility to discontinue all routine medications and start palliative care; *on [DATE] at 10:19 p.m. - resident in bed with absent blood pressure, heart rate, and respirations, time of death 10:38 p.m. The infection control log for [DATE] indicated Resident #14 had a facility acquired URI on [DATE]. Resident #22 - closed record Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #22 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #22 was a full code, was incontinent of bladder, and had difficulty made herself understood. Resident #22's pneumonia was not addressed on the care plan. A Minimum (MDS) data set [DATE] indicated Resident #22 usually understood others and sometimes made her needs known. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #22 did not have a recent infection. Nursing notes for Resident #22 indicated the following: *on [DATE] at 1:30 p.m. - new order for [MEDICATION NAME] related to congestion; *on [DATE] at 3:34 p.m. - resident with projectile vomiting, chest x-ray ordered; *on [DATE] at 6:22 p.m. - chest x-ray results received, bilateral lower lobe pneumonia, doctor notified; *on [DATE] at 5:52 p.m. - new order for [MEDICATION NAME] IM (antibiotic); *on [DATE] at 5:56 p.m. - initial dose of antibiotic given; *on [DATE] at 1:23 p.m. - resident's oxygen saturation dropped to 79%, applied nasal cannula and back up to 94%, no signs of acute distress at this time; and *on [DATE] at 12:00 p.m. - oxygen saturation 85% on room air, pulse was thread and rapid, temperature was 99.0, resident was responsive but lethargic, bilateral crackles and diminished lung sounds were noted, spouse requested resident be sent to local hospital, resident sent out via EMS. The infection control log dated [DATE] indicated Resident #22 had pneumonia with an onset date of [DATE]. A chest x-ray was performed [DATE] and an antibiotic was ordered. A local newspaper dated [DATE] indicated Resident #22 died in a local inpatient hospice on [DATE]. Resident #12-closed record The face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #12 (was in room [ROOM NUMBER], the same room as Resident #11 who died 1 week after Resident #12). The physician orders [REDACTED].#12 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #12 had severely impaired cognition. The undated care plan did not address the URI. Nursing notes for Resident #12 indicated the following: *[DATE] at 9:07 a.m., she had a new order for [MEDICATION NAME] (to prevent cough) four times a day for 7 days for congestion; *from [DATE]-[DATE], she continued with [MEDICATION NAME] and had an intermittent cough; *on [DATE] at 1:20 p.m., she had a non-productive cough with congestion; *on [DATE] at 8:39 p.m. (a late entry for 5:00 p.m.), the physician had seen her due to cough and congestion and provided orders for a complete blood count, chest xray, and Zpak (antibiotic) for URI. She had no fever; *on [DATE] at 12:46 a.m., she had a non-productive cough with congestion and waiting for the antibiotic to be delivered so it could be administered; *on [DATE] at 5:26 p.m., she had rapid breathing, diminished lung sounds, and O2 Sats of 83% on room air. She was sent to the hospital. The [DATE] MAR indicated [REDACTED]. A hospital History and Physical dated [DATE] indicated Resident #12 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. Nursing notes for Resident #12 indicated the following: *on [DATE] at 7:52 p.m., she returned from the hospital on palliative care, had no fever, and O2 sats were 91%; *from [DATE]-[DATE], she continued on palliative care; O2 sats ,[DATE]%, non-productive cough, and crackles to all areas of her lungs. *on [DATE] at 5:22 p.m., she had worsening of her condition, developed throat congestion, and accumulation of fluid between the skin and connective tissue. Her family wanted her admitted to hospice; *on [DATE] at 9:42 p.m., the physician was notified of low O2 sats and labored breathing with restlessness; *on [DATE] at 1:33 a.m., she had crackles in both lungs, ,[DATE] second pauses between breaths, and O2 sats were now decreased to 78%; *on [DATE] at 10:27 a.m., she was admitted to hospice for [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the administrator and infection control nurse failed to ensure the facility ' s resources were utilized effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 21 of 21 residents reviewed for quality of care, neglect, and infection control. (Residents #1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 22, 24, 25, 28, 30, and 31) The administrator failed to: *ensure the nursing staff had the leadership of a Director of Nurses (DON); *supervise the staff to ensure the infection control policies were implemented; *monitor to ensure resident to resident infections were documented: *supervise to ensure the infection control nurse implemented infection control procedures to prevent the acquisition and spread of infections; *Ensure the staff were trained on appropriate infection control techniques to utilize. The infection control nurse, in the absence of a DON, did not: *supervise the direct care staff to prevent and control outbreaks and cross-contamination of upper respiratory infections for Residents # 1,2,3,5,6,8,25,30,31,16,14,22,12,13,and 11. *direct the nursing staff to separate residents with known URI symptoms from those who were symptom free; *supervise and train the direct care staff to ensure necessary measures were taken to care for residents with URI symptoms and [MEDICAL CONDITION]. (Residents #1, 2,3,5,6,7,8,25,30,31,16,14,22,12,13, and 11developed facility acquired URI symptoms and Residents # 9, 4, 24, and 10 developed facility acquired pink eye) * maintain accurate information to determine and prevent the spread of infections within the facility; and *ensure necessary precautions to prevent the rapid airborne spread of a URI to at least 15 residents. *ensure the CNAs used the proper methods to prevent contamination of clean areas during incontinence care.(Residents # 7, 8, and 28);and Residents # 14,22,12,13, and 11 died after experiencing symptoms of a facility acquired URI during [DATE]. Fifteen (15) residents developed facility acquired URI symptoms during September and [DATE]. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility ' s need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: During an interview on [DATE] at 11:25 a.m., the administrator said the infection control nurse was in charge of the infection control program. She said the DON was responsible for overseeing all aspects of nursing; however, they currently had no DON. During an interview on [DATE] at 11:26 a.m., the infection control nurse said she was the one who was in charge of the infection control program and had not put any special measures in place to prevent the spread of URIs and pink eye. During an interview on [DATE] at 11:27 a.m., the ADON said the infection control nurse was in charge of the infection control program and she was not involved in decisions regarding resident procedures to prevent infections. During an interview on [DATE] at 10:35 a.m., RN Q said no resident with respiratory issues were placed in isolation. She said neither the staff nor the residents with URI symptoms had been wearing masks. She said there had been multiple deaths of residents with URI symptoms, but some of those deaths were residents who were on hospice and had co-morbidities. She said they did not obtain cultures, take any special precautions, or isolate residents with pink eye. During an interview on [DATE] at 1:17 p.m., LVN T said there was no communication from administration to direct care staff. He said administration did not enforce any kind of preventative measures for residents with URI symptoms. He said staff was not told to wear masks and residents with URI symptoms were not told to wear masks. He said the facility had no management and had not received any special training or instruction to prevent the spread of the URIs or pink eye. 1.URIs An undated list provided by the infection control nurse indicated 3 residents had a current URI and were currently on antibiotics. Fifteen (15) residents had signs and symptoms of URI, but did not meet the criteria to be placed on the infection control log. Resident #1- current resident The face sheet dated [DATE] indicated Resident #1 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. The physician orders [REDACTED].#1 had [DIAGNOSES REDACTED]. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE], no culture was obtained, no chest x-ray was performed, she was given antibiotic, she was not placed in isolation, it was a Healthcare Acquired Infection (HAI), and there was no resolved date. The care plan dated [DATE] indicated Resident #1 had a potential for complications related to respiratory infection/pneumonia with interventions including administer antibiotic as prescribed. Nursing notes for Resident #1 indicated the following: *[DATE] at 11:17 a.m., she complained of a sore throat, had a non-productive cough, temperature of 97.4 degrees F, and had scattered crackles in her chest. The physician was informed of her condition; *[DATE] at 2:13 a.m. she was complaining of a sore throat, was given [MEDICATION NAME], and had a temperature of 97.8 degrees F. There was no assessment of her chest/lungs.; *from [DATE]-[DATE] she continued on antibiotic, had scattered crackles in her chest, continued with a non-productive cough, and had no fever.; *from [DATE] to [DATE] she had completed the antibiotic, continued with a non-productive cough,had scattered crackles in her chest, and had no fever.; *[DATE] at 7:35 p.m., she had a cough, was lethargic, and had a poor appetite. The note indicated she had a temperature at 12:00 p.m. of 100.0 degrees F and Tylenol was administered. A chest xray was done with results of improvement from previous films.; *[DATE] at 12:00 a.m., she continued with a non-productive cough, scattered crackles in her chest, and had no fever.; *[DATE] at 9:30 p.m., the physician was notified and ordered an antibiotic.; *[DATE] at 10:00 p.m., she had a fever of 100.0 degrees F and received Tylenol.; *[DATE] at 5:33 a.m., she complained of feeling discomfort and had a wet non-productive cough and chest congestion.; *[DATE] at 6:30 p.m., a new order was received for a second antibiotic.; *[DATE] at 12:15 p.m., she continued to be lethargic with a poor appetite. She was sweating heavily and complaining of pain all over. She continued on the 2 antibiotics and with no improvement. She was transferred to the hospital. The Infection Control Log for [DATE] indicated Resident #1 had a URI with onset date of [DATE] and [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given 2 different antibiotics, she was not placed in isolation, and she continued treatment. Nursing notes for Resident #1 indicated the following: *[DATE] at 1:54 p.m., she returned from the hospital. She continued to have a wet non-productive cough and scattered crackles in her chest.; *[DATE] at 10:14 a.m., she had a wet productive cough with off-white sputum, had scattered crackles in her chest, and had no fever.; *[DATE] at 5:57 p.m., the physician saw her and ordered a CBC and a chest xray.; *[DATE] at 11:55 p.m., she had scattered crackles in her chest and had no fever.; *[DATE] at 10:48 p.m., labs were reported to the physician. An order was received for [MEDICATION NAME] (antibiotic). Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (antibiotic) for acute lower respiratory infection. The [DATE] MARs indicated Resident #1 received the initial dose of [MEDICATION NAME] on [DATE] at 9:30 a.m., almost 36 hours later. Nursing notes with entry dated [DATE] at 6:56 p.m. indicated Resident #1 received an initial dose of a Z-Pak. Physician orders [REDACTED].#1 was to receive [MEDICATION NAME] (Z-Pak) (antibiotic) for acute lower respiratory infection. Nursing notes from [DATE]-[DATE] indicated Resident #1 continued on [MEDICATION NAME], completed the [MEDICATION NAME] (Z-Pak), had scattered crackles in her chest, had a non-productive cough, and had no fever. The current MDS dated [DATE] indicated Resident #1 had severely impaired cognition. She had pneumonia in the last 7 days and had received antibiotics in the last 7 days. During an observation on [DATE] beginning at 11:07 a.m. Resident #1 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. Resident #2- Current Resident The face sheet dated [DATE] indicated Resident #2 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to Hall 200. Physician orders [REDACTED].#2 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #2 had severely impaired cognition. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. Nursing notes dated [DATE] at 12:19 p.m. indicated Resident #2 had exit seeking behaviors and no documented respiratory issues. Physician orders [REDACTED].#2 was to begin [MEDICATION NAME] (antibiotic). Nursing notes for Resident #2 indicated the following: *[DATE] at 12:14 a.m., he had an initial dose of the antibiotic due to URI earlier in the shift, had no fever, and had a non-productive cough; *[DATE] - [DATE] he continued on the antibiotic with no adverse reaction and had signs and symptoms of URI. The undated care plan did not address Resident #2's respiratory symptoms. The Infection Control Log for [DATE] did not list Resident #2. During an observation on [DATE] beginning at 11:07 a.m., Resident #2 on Hall 200 exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 12:45 p.m., after surveyor intervention, Resident #2 was moved to room [ROOM NUMBER]A on Hall 300 and co-horted with Resident #3 who also exhibited respiratory signs and symptoms. Resident #3 - current resident The face sheet dated [DATE] indicated Resident #3 was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] to room [ROOM NUMBER]B on Hall 300. (Resident #2 was his roommate). Physician orders [REDACTED].#3 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #3 had severely impaired cognition; had no infections; had [DIAGNOSES REDACTED]. The undated care plan did not address Resident #3's respiratory symptoms. Nursing notes for Resident #3 indicated the following: *[DATE] at 12:24 a.m., he had a temperature of 101.1 degrees F, complained of abdominal pain, and no documented respiratory issues.; *[DATE] at 10:50 a.m., he was red faced, had audible wheezing, complained of shortness of breath, O2 sats of 94% on room air, but had audible grunting with each breath. He was sent to the hospital. Nursing notes for Resident #3 indicated on [DATE] at 3:18 p.m., he returned to the facility. The physician orders [REDACTED].#3 was to receive [MEDICATION NAME] and [MEDICATION NAME] (antibiotics). The Infection Control Log for [DATE] did not list Resident #3. Resident #5- current resident The face sheet dated [DATE] indicated Resident #5 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #5 was in room [ROOM NUMBER](the same room as Resident #6 who was exhibiting signs and symptoms of respiratory issues). The physician orders [REDACTED].#5 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #5 had severely impaired cognition. Nursing notes for Resident #5 indicated the following: *on [DATE] at 8:30 p.m., she had a non-productive cough and was given PRN cough syrup; *on [DATE] at 8:13 p.m., a chest x-ray was done due to thick green sputum and low grade temperature. The x-ray showed pneumonia. An order was received for Bactrim DS (antibiotic). The undated care plan did not address the pneumonia. The Infection Control Log for [DATE] indicated Resident #5 had a URI with onset date of [DATE], there was no culture obtained, a chest x-ray was obtained on [DATE], she was given an antibiotic, she was not placed in isolation, it was a facility acquired, and there was no resolved date. Nursing notes from [DATE]-[DATE] indicated Resident #5 had a non-productive cough, had few scattered crackles, and continued on the antibiotic. During an observation on [DATE] beginning at 11:07 a.m., Resident #5, on Hall 200, exhibited coughing and congestion symptoms, but was not wearing a mask with several other residents in the immediate vicinity. During an observation on [DATE] at 11:28 a.m., hand sanitizer bottles were stationed at the nursing station and medication carts. Resident rooms were not supplied with hand sanitizer. Resident #6-current resident The face sheet dated [DATE] indicated Resident #6 was an [AGE] year old female admitted on [DATE] and readmitted on [DATE] to Hall 200. Resident #6 was in room [ROOM NUMBER](the same room as Resident #5 who had a URI). The physician orders [REDACTED].#6 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #6 had severely impaired cognition. The undated care plan did not address the URI symptoms or approaches to take. Nursing notes from [DATE]-[DATE] had no documentation of any issues with coughing or congestion. The [DATE] MAR indicated [REDACTED] *on [DATE],[DATE],[DATE],[DATE], [DATE], [DATE], and [DATE]. During an observation and interview on [DATE] at 11:07 a.m., Resident #6 exhibited coughing and congestion symptoms. She was not wearing a mask. She said she had been coughing for about a week and her roommate had been sick too. The Infection Control Log for [DATE] indicated Resident #6 was not listed. Resident #8 - current resident Physician orders [REDACTED].#8 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #8 was in room [ROOM NUMBER] (same room as Resident #7). A care plan, last revised [DATE], indicated Resident #8 required assistance with all activities of daily living (ADLs) and she experienced bladder incontinence related to decreased mobilization. The care plan did not address Resident #8's UTI or URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #8 understood others and usually made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #8 did not have recent infections. Nursing notes for Resident #8 indicated the following: *on[DATE] at 1:17 a.m. - moved to room [ROOM NUMBER]; *on [DATE] at 12:17 a.m. - new order for chest x-ray, Z-pak (antibiotic) for cough and congestion; *on [DATE] at 10:54 a.m. - awaiting pharmacy to deliver Z-pak; *on [DATE] at 8:56 a.m. - resident had cough with thick mucus; *on [DATE] at 9:49 p.m. - resident had wet lung sounds with rhonchi, hospice new order for [MEDICATION NAME] (antibiotic), [MEDICATION NAME], and [MEDICATION NAME] swish and swallow; *on [DATE] at 7:01 a.m. - initial dose of [MEDICATION NAME] given; *on[DATE] at 12:48 a.m. - New antibiotic [MEDICATION NAME] for upper respiratory infection (URI) given, and to continlue [MEDICATION NAME], and breathing treatment; *on [DATE] at 12:51 p.m. - continues with productive cough, continues with breathing treatment, [MEDICATION NAME], and [MEDICATION NAME], resident in dining room for lunch; and *on[DATE] at 3:19 a.m. - continued breathing treatment for [REDACTED]. During an observation on [DATE] at 1:21 p.m., CNA D and CNA E were seen entering and exiting Resident #8's room with no mask and did not perform hand hygiene before entering the room. During an interview on [DATE] at 1:32 p.m., CNA D said nobody from administration had told her to take any special precautions with residents with URI symptoms. She said residents with URI symptoms were allowed to go to the dining room. The infection control log for [DATE] indicated Resident #8 had an UTI with an onset date of [DATE], a culture date of [DATE], and the culture being ESBL positive. The infection control log indicated Resident #8 had an URI on [DATE] and began antibiotics. The infection control log for [DATE] indicated Resident #8 continued treatment for [REDACTED]. Resident #25-current resident The face sheet dated [DATE] indicated Resident #25 was an [AGE] year old male admitted on [DATE] to Hall 400. The physician orders [REDACTED].#25 had [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #25 was cognitively intact. He had no infections in the last 7 days and had received no antibiotics in the last 7 days. The undated care plan did not address Resident #25's respiratory symptoms. During an observation and interview on [DATE] at 1:00 p.m., Resident #25 had a non-productive cough. He said he developed the cough after he came to the facility. He said he had taken an antibiotic for it. Nursing notes with an entry dated [DATE] at 5:03 p.m. indicated he had a non-productive cough and complained of shortness of breath. The physician was notified of his condition. The physician orders [REDACTED].#25 was to be placed on [MEDICATION NAME] Z-Pak (antibiotic) for symptoms of URI. Nursing notes for Resident #25 indicated the following: *on [DATE] at 1:30 a.m., he continued with a non-productive cough, had course breath sounds, and a temperature of 99.1 degrees F.; *on [DATE] at 11:51 p.m., a chest xray report read lung fields were clear without mass, infiltrate, congestion, or effusion.; *on [DATE] at 1:44 a.m., he had no cough or congestion and lung fields were clear; *on [DATE] at 11:04 a.m., he continued on the antibiotic with no adverse reaction but lung sounds were not assessed.; *on [DATE] at 2:16 p.m., he completed the antibiotic with no adverse reaction but lung sounds were not assessed. The Infection Control Log for [DATE] did not list Resident #25. During an observation on [DATE] beginning at 11:07 a.m., Resident #25 was in his room. He exhibited coughing and congestion symptoms, but was not wearing a mask. Resident #30 - current resident Physician orders [REDACTED].#30 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #30 was in room [ROOM NUMBER] (same room as Resident #31). A care plan dated [DATE] indicated Resident #30 required assistance with activities of daily living (ADLs). The care plan did not address Resident #30's URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #30 usually understood others and made her needs known. She required extensive assistance with ADLs and was incontinent of bowel and bladder. The MDS indicated Resident #30 did not have recent infections. Nursing notes for Resident #30 indicated the following: *on [DATE] at 2:37 p.m. - resident with scattered crackles in bilateral chest, nonproductive wet cough, chest x-ray ordered; *on [DATE] at 1:15 a.m. - chest x-ray was clear, resident in bed with no cough or congestion; *on [DATE] at 11:25 a.m. -in wheelchair in dining room for lunch, no cough noted; *on [DATE] at 1:50 p.m. - resident coughing up thick yellow phlegm, noted bilateral chest congestion, breathing treatment given, resident in bed; *on [DATE] at 9:13 a.m. - resident continued with cough and congestion, new order for antibiotic, [MEDICATION NAME], and breathing treatment as needed, nausea and vomiting at breakfast with semi productive tight cough noted; *on [DATE] at 11:09 p.m. - initial dose of antibiotic given for URI; *on [DATE] at 1:02 a.m. - Tylenol given for 100.0 temperature; *on [DATE] at 10:00 a.m. - resident in bed, oxygen saturation 93%, resident very slow to respond to verbal and tactile stimuli, skin warm with tenting, chest with bilateral congestion, productive cough with thick yellow phlegm, daughter requested resident be sent to ER; *on [DATE] at 5:28 p.m. - resident back in facility with [DIAGNOSES REDACTED]. *on[DATE] at 10:55 a.m. - resident in bed, chest with scattered crackles, wet nonproductive cough; and *on [DATE] at 2:51 p.m. - resident in bed, chest with scattered crackles, intermittent wet nonproductive cough, poor intake. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #30's room without masks and CNA G already had gloves on when she entered the room. Neither washed their hands before providing care to Resident #30. The infection control log for [DATE] indicated Resident #30 had a URI that was facility acquired on [DATE], an antibiotic was ordered, onset date was [DATE], and a chest x-ray was performed on [DATE]. The infection control log for [DATE] indicated Resident #30 continued treatment for [REDACTED]. Resident #30's roommate, Resident #31 had a URI on [DATE]. Resident #31 - current resident Physician orders [REDACTED].#31 was [AGE] years old and admitted on [DATE]. Her [DIAGNOSES REDACTED]. Resident #31 was in room [ROOM NUMBER] (same room as Resident #30). A care plan dated [DATE] indicated Resident #31 was incontinent of bowel and bladder and required assistance with all activities of daily living (ADLs). The care plan did not address Resident #31's upper respiratory infection (URI). A Minimum Data Set ((MDS) dated [DATE] indicated Resident #31 understood others and made her needs known. She required extensive assistance with transfers, dressing, toilet use, and personal hygiene. She was frequently incontinent of bowel and bladder. The MDS indicated Resident #31 was admitted with pneumonia and did not have recent infections. Nursing notes for Resident #31 indicated the following: *on [DATE] at 1:53 a.m. - no cough noted, chest x-ray performed on prior shift with noted right upper lobe atelectasis with mild cardiomegaly; *on [DATE] at 4:55 a.m. - resident sitting in wheelchair in dining room, nonproductive cough noted; *on [DATE] at 9:15 a.m. - resident in wheelchair for breakfast, chest with scattered crackles, productive cough with thick brown/yellow sputum, new order for antibiotic, assisted to bed after breakfast; *on [DATE] at 11:50 p.m. - resident resting in bed, nonproductive cough noted, continued with antibiotic and [MEDICATION NAME]; *on [DATE] at 10:23 a.m. - appetite and fluid intake poor, chest with scattered crackles, CNA assisted resident with breakfast, assisted back to bed, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 11:26 a.m. - resident in bed, chest with scattered crackles and nonproductive wet cough, poor appetite, continue antibiotic and [MEDICATION NAME]; *on [DATE] at 10:10 a.m. - resident in dining room for breakfast, chest with scattered crackles and nonproductive wet cough, appetite poor, completed antibiotic; *on [DATE] at 1:26 p.m. - resident continued with intermittent wet nonproductive cough, continued with [MEDICATION NAME]; and *on [DATE] at 10:27 a.m. - chest with scattered crackles, continued with [MEDICATION NAME], intake poor. During an observation on [DATE] at 1:38 p.m., CNA G and CNA F went into Resident #31's room without masks and CNA G already had gloves on when she entered the room. The infection control log dated [DATE] indicated Resident #31 had a URI on [DATE]. Resident #31's roommate, Resident #30, had a URI on [DATE]. Resident #16 - closed record Physician orders [REDACTED].#16 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #16 understood others and made her needs known. She required extensive assistance with activities of daily living (ADLs). She was occasionally incontinent of bowel and bladder. The MDS indicated Resident #16 did not have recent infections. A care plan last revised [DATE] indicated Resident #16 required assistance with ADLs. The care plan did not address Resident #16's upper respiratory infection (URI). Nursing notes for Resident #16 indicated the following: [DATE] at 1:25 a.m. - resident complained of sore throat, hoarse voice, and nonproductive cough, [DATE] at 4:41 a.m. - continued with hoarse voice, productive cough, and yellow phlegm, [MEDICATION NAME] minimally effective; [DATE] at 6:48 p.m. - continued with URI symptoms and new complaint of hip pain; [DATE] at 3:46 a.m. - resident to be sent to hospital for [MEDICAL CONDITION]. During a telephone interview on [DATE] at 4:21 p.m., Resident #16's daughter said Resident #16 had a URI days before she went to the hospital for a [MEDICAL CONDITION]. She said Resident #16 did not have to wear a mask while she had URI symptoms. Resident #16's daughter said Resident #16 was allowed to go to the dining room while showing URI symptoms. The daughter said staff did not wear masks while providing care to her mother when she exhibited URI symptoms. The infection control log for [DATE] did not include Resident #16's URI. Resident #14 - closed record Physician orders [REDACTED].#14 was [AGE] years old, admitted on [DATE], and died in the facility on [DATE]. His [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated Resident #14 was a full code and experienced occasional bowel and bladder incontinence. The care plan did not address his URI. A Minimum Data Set ((MDS) dated [DATE] indicated Resident #14 understood others and made his needs known. He required extensive assistance with bed mobility, transfers, dressing, toilet use, and personal hygiene. He was incontinent of bowel and bladder. The MDS indicated Resident #14 did not have a recent infection. Nursing notes for Resident #14 indicated the following: *on [DATE] at 5:46 a.m. - nasal congestion with runny nose of clear drainage and nonproductive cough; *on [DATE] at 10:01 a.m. - new order for [MEDICATION NAME] for congestion; *on [DATE] at 12:11 a.m. - new order for Z-Pak (antibiotic) and chest x-ray, continue [MEDICATION NAME] for congestion; *on [DATE] at 7:00 a.m. - resident in dining room, resident noted to be lethargic, slurred speech, and scant amount of yellow, blood tinged drainage from nose, resident assisted to bed, hospice notified of change of condition; *on [DATE] at 5:53 p.m. - physician in facility, received new order for [MEDICATION NAME] IM (antibiotic) *on [DATE] at 5:55 p.m. - hospice nurse in facility to discontinue all routine medications and start palliative care; *on [DATE] at 10:19 p.m. - resident in bed with absent blood pressure, heart rate, and respirations, time of death 10:38 p.m. The infection control log for [DATE] indicated Resident #14 had a facility acquired URI on [DATE]. Resident #22 - closed record Physician orders [REDACTED].#22 was [AGE] years old, admitted on [DATE], and discharged to a local hospital on [DATE]. Her [DIAGNOSES REDACTED]. Resident #22 was in room [ROOM NUMBER]. A care plan dated [DATE] indicated Resident #22 was a full code, was incontinent of bladder, and had difficulty made herself understood. Resident #22's pneumonia was not addressed on the care plan. A Minimum (MDS) data set [DATE] indicated Resident #22 usually understood others and sometimes made her needs known. She required extensive assistance with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene. She was incontinent of bowel and bladder. The MDS indicated Resident #22 did not have a recent infection. Nursing notes for Resident #22 indicated the following: *on [DATE] at 1:30 p.m. - new order for [MEDICATION NAME] related to congestion; *on [DATE] at 3:34 p.m. - resident with projectile vomiting, chest x-ray ordered; *on [DATE] at 6:22 p.m. - chest x-ray results received, bilateral lower lobe pneumonia, doctor notified; *on [DATE] at 5:52 p.m. - new order for [MEDICATION NAME] IM (antibiotic); *on [DATE] at 5:56 p.m. - initial dose of antibiotic given; *on [DATE] at 1:23 p.m. - resident's oxygen saturation dropped to 79%, applied nasal cannula and back up to 94%, no signs of acute distress at this time; and *on [DATE] at 12:00 p.m. - oxygen saturation 85% on room air, pulse was thread and rapid, temperature was 99.0, resident was responsive but lethargic, bilateral crackles and diminished lung sounds were noted, spouse requested resident be sent to local hospital, resident sent out via EMS. The infection control log dated [DATE] indicated Resident #22 had pneumonia with an onset date of [DATE]. A chest x-ray was performed [DATE] and an antibiotic was ordered. A local newspaper dated [DATE] indicated Resident #22 died in a local inpatient hospice on [DATE]. Resident #12-closed record The face sheet dated [DATE] indicated Resident #12 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE]. Resident #12 (was in room [ROOM NUMBER], the same room as Resident #11 who died 1 week after Resident #12). The physician orders [REDACTED].#12 had a [DIAGNOSES REDACTED]. The current MDS dated [DATE] indicated Resident #12 had severely impaired cognition. The undated care plan did not address the URI. Nursing notes for Resident #12 indicated the following: *[DATE] at 9:07 a.m., she had a new order for [MEDICATION NAME] (to prevent cough) four times a day for 7 days for congestion; *from [DATE]-[DATE], she continued with [MEDICATION NAME] and had an intermittent cough; *on [DATE] at 1:20 p.m., she had a non-productive cough with congestion; *on [DATE] at 8:39 p.m. (a late entry for 5:00 p.m.), the physician had seen her due to cough and congestion and provided orders for a complete blood count, chest xray, and Zpak (antibiotic) for URI. She had no fever; *on [DATE] at 12:46 a.m., she had a non-productive cough with congestion and waiting for the antibiotic to be delivered so it could be administered; *on [DATE] at 5:26 p.m., she had rapid breathing, diminished lung sounds, and O2 Sats of 83% on room air. She was sent to the hospital. The [DATE] MAR indicated [REDACTED]