Every finding on record at Carlyle Healthcare & SR Living

Based on interview and record review, the Facility failed to allow a resident visitation with a family member for 1 of 3 residents (R2) reviewed for resident rights in the sample of 7. Findings include: 1-R2's Face Sheet documents R2 was admitted to the Facility with diagnoses including type 2 diabetes, chronic obstructive pulmonary disease (COPD), and dementia. R2's Minimum Data Set (MDS) dated [DATE] documented R2 was severely cognitively impaired, required substantial assistance with transfer, and walking was not attempted due to medical condition or safety concern. R2's Care Plan initiated 3/25/26 documents, Resident does not have legal representation, but has designated responsible party, (V6, R2's Former Caregiver). R2's Facility admission Contract dated 4/1/26 documents V6 signed R2 into the Facility as his Responsible Party/Representative. R2's Order Summary Report documents 3/23/26 the order, LOA (Leave of Absence): May go out on therapeutic pass with medications. On 6/5/26 at 10:33 AM, V4, R2's Family, stated he told the Facility he was taking R2 out to get food, but the Facility would not allow him to go and said they would have to check with V6 who makes decisions for him, but not actually related to him. V4 stated he is in the process of trying to get guardianship of R2. On 6/5/26 at 11:40 AM, V1, Administrator, stated they have been having problems with V4, R2's Family, because he always says he is going to take R2 out of the Facility. V4 is not the POA (Power of Attorney), but we are in the process of getting a guardian for R2 because he is unable to make his own decisions. On 6/5/26 at 11:43 AM, V5, Social Services Director (SSD), stated R2 does not have a Healthcare POA. V6 is an ex of R2's family member who cared for R2 for three years before he was admitted to the Facility. V6 has been making decisions for R2, and she does not want V4 to take R2 out because she thinks V4 is trying to get R2's money. On 6/5/26 at 12:34 PM, R2 stated he likes V4, feels safe with V4, and would like to go on outing and live with V4. R2 thinks V4 is his decision maker. On 6/5/26 at 1:44 PM, V7, Ombudsman, stated the facility has not contacted her about R2 and his need for guardianship. If a resident is severely cognitively impaired and is admitted to the Facility without a healthcare POA, we would advise them to seek an emergency guardianship or Facility guardianship. If the resident says he would like to go out with V4, the Facility cannot stop him, and they have no say in the matter. The Facility's Notice of Resident Rights and Responsibilities Policy revised March 2017 documents, Should a resident be adjudicated incompetent or identified as lacking decision making capacity, the resident's representative (sponsor) shall act in behalf of the resident.

Based on interview and record review the facility failed to ensure residents remained free from abuse for one (R1) of three residents reviewed for abuse in the sample of 4. Findings include:R1's face sheet documents an admission date of 12/06/22 with diagnoses including: cerebral infarction due to thrombosis of unspecified precerebral artery, hypertensive heart disease with heart failure, asthma, chronic pain, major depressive disorder, chronic or unspecified gastric ulcer with hemorrhage, and cutaneous abscess of left axilla.R1's minimum data set (MDS) dated [DATE] documents a brief interview of mental status of 13 indicating cognitively intact. This same MDS documents: mobility devices; with walker and wheelchair both marked.R1's care plan documents a focus area dated 12/12/22 of anti-coagulant therapy: R1 takes medication to help keep my blood thinner to assist with decreasing my chances of blood clots. R1 has potential for side effects of this medication, gastrointestinal bleeding or increase chance of bruising.R1's progress note dated 08/30/25 at 2:03 PM documents: resident (R1) noted to be wheeling out of his room and states, He is on the floor! When asking who was on the floor, resident states that his roommate (R2) was on the floor. This resident states, that his roommate has been eating his snacks without permission. Resident states that when he confronted his roommate, that his roommate got out of his wheelchair and attempted to hit him. This resident (R1) states that he grabbed his roommate by the shirt d/t (do to) his roommate attempting to hit and his roommate fell to his bottom. Resident (R1) states that his roommate began kicking him in the lower legs. When this nurse entered the room, noted this resident and roommate verbally arguing and noted roommate balling up fists at this resident and yelling profanities. This nurse, a second nurse and a CNA (certified nursing assistant) were in the room and immediately separated residents. V1 called and roommate has been moved to another room. R1 has been assessed and noted to have large blue bruise to LLE (lower left extremity). Will continue to monitor for any type of emotional distress. Resident's (R1) affect has been per usual since incident occurred.R1's progress note dated 08/31/25 at 5:54 AM documents: shift follow up to resident to resident altercation. Resident (R1) noted with large bruising to LLE that is blue/purple to calf area all the way around. Area very tender. Will continue to monitor safety and needs.R1's progress note dated 09/01/25 at 8:44 AM documents: day 2 follow up from resident altercation. R2's face sheet documents admission date of 04/10/25 with diagnoses including: cerebral infarction, shortness of breath, major depressive disorder, type 2 diabetes mellitus with chronic kidney disease, chronic pain, functional dyspepsia, anxiety disorder, and acute cough.R2's MDS dated [DATE] documents a BIMS (Brief Interview for Mental Status) score of 15 indicating cognitively intact. This same MDS documents: mobility devices with wheelchair marked.R2's care plan documents a focus area of aggressive behavior: I (R2) can be aggressive towards others such as cussing at staff and yelling profanities dated 09/12/25 with interventions listed of: explain to me that this type of behavior is inappropriate, help me gain a quiet environment if I should need one but do not isolate me, remove me from my source of agitation, and spend one on one time with me to see what is bothering me dated 09/12/25.R2's progress note dated 08/30/25 at 2:03 PM documents: Resident's roommate (R1) wheeling down the hall and states that this resident (R2) is on the floor. Upon entering room, this resident (R2) was noted to be sitting on his bottom with his back against the wall. Resident (R2) states that he stood up and lost his balance, causing him to fall backwards. Denies hitting his head. During assessment of vitals, this resident (R2) noted to be balling up his fist in a threatening manner and shaking it at his roommate (R1). This resident (R2) noted to be yelling profanities at roommate (R1) as well as this nurse V6 (Registered Nurse), a second nurse and a CNA (V3) that were present. This resident (R2) assisted back to his w/c via two assist.On 01/09/26 at 3:33 PM V3 (Certified Nurse Aide (CNA)) stated, she was working when R1 and R2 had their incident, it was unwitnessed. V3 stated, she went in their room and R2 was on the floor. R1 stated, on her way to their room she passed R1 and he stated, come get your boy she didn't understand what that meant and when she entered the room is when she seen R2 on the floor. V3 stated, R1 stated R2 was trying to was trying to get into his snacks. V3 stated, R1 stated he got mad about it and R2 swung at him. R1 got pulled out of his chair and R2 kicked him. V3 stated, R2 told her that R1 pulled on his shirt and pulled him out of his chair and was starting to swing. V3 stated, R2 stated R1 pulled him by the shirt and he started kicking him (R1). V3 stated, It appeared R1's story lined up closer to what happened than R2's story because R2's shirt was torn and for a time after R1 had a bruise on his leg. V3 stated, she did not remember seeing the bruise on R1's leg prior to the incident but he is on blood thinners so it doesn't take much for him to bruise. V3 stated, they are both smokers and they had never prior to that day or since that day had any concerns with each other. V3 stated, both R1 and R2 are fairly chill so it was surprising that they had the incident, they had been roommates less than 24 hours. V3 stated, they moved R2 to a different room down at the other end of the hall immediately. V3 stated R1 and R2 had never had any concerns with any other residents before that day or since that day either.On 01/09/26 at 3:49 PM R1 stated, he does not have any problems with any residents at the facility including R2. When R1 was specifically asked if R2 kicked him, R1 stated, yes, he kicked me.On 01/09/26 at 3:24 PM R2 stated (when asked about the incident with R1), that was a long time ago, we are fine, we have no problems with each other.On 01/09/26 at 3:45 PM V4 (Registered Nurse) stated, she had never seen R1 or R2 have any concerns with each other or any other resident prior to that day or since that day.On 01/09/26 at 3:53 PM V1 (Administrator) stated, the incident with R1 and R2 was unwitnessed. V1 stated, they had moved R2 into R1's room on 08/29/25 at 10:43 AM and on 08/30/25 she received a call they had a resident to resident involving R1 and R2. V1 stated, she was shocked because they were both fairly laid back, both participated in smoking activity, and she had never seen either have any concerns with anyone. V1 stated, she thought they would get along great. V1 stated, she called the police and she came back to the facility and neither would say very much about it until the police arrived. V1 stated, R1 stated R2 went to grab my mixed nuts and R2 said he did not, he was just going over by the heater. V1 stated, R2 has weakness one his one side due to a stroke and so does R1. R1 also does not see too well. V1 stated, the only concerns they had previously with R2 was he had a few behaviors due to his blood sugar and he had some confusion, he had just been put on insulin on 08/25/25 and started accuchecks shortly after. R2 was sent out for evaluation. R2 returned with no new orders. V1 stated, R1 is on a blood thinner and is anemic, he is susceptible to bruising. V1 stated, at the time of the incident, R1 stated, he did not know if the bruising on his leg was from the kick or from something else. V1 stated, prior to the incident neither resident had had any issues with each other or any other resident.The facility policy dated 09/22 titled, Resident-to-Resident Altercations documents: all altercations, including those that may represent resident-to-resident abuse, are investigated and reported to the nursing supervisor, the director of nursing services and to the administrator. 4. if two residents are involved in an altercation, staff: separate the residents, and institute measures to calm the situation; identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation.

Based on interview and record review the failed to ensure allegations of physical abuse were reported immediately to the administrator of the facility and to the State Survey Agency for 1 of 3 residents (R55) reviewed for reporting of allegation of abuse in a sample of 57. Findings include: R55's Face Sheet, print date of 07/02/25, documented R55 has diagnoses of but not limited to dementia, paranoid schizophrenia, anxiety disorder due to known physiological condition. R55's Minimum Data Set (MDS), dated [DATE], documented R55 is severely cognitively impaired and requires substantial/maximal assistance with bed mobility. V2, Director of Nursing (DON) statement dated 06/22/25, documents V2, Director of Nursing, DON, received a phone call from agency nurse, V35, at 7:43 AM regarding a bruise/skin tear (ST) R55 received. The statement documented V35 stated that she had a gut feeling that the agency Certified Nursing Assistant (CNA), V31 gave resident the bruise/ST. That statement continued that V2 came into the facility and started investigation. The statement documented R55 had a Brief Interview of Mental Status (BIMS) of 99 and was alert to self only. The statement documented V2 assessed R55 and noted the bruise/ST, and R55 did not state she was harmed and did not show any emotional distress at that time. At that time, V2 asked V35 to contact V1, Administrator, and write a statement. The statement documents V35 did not contact V1 or write a statement. R55's Electronic Medical Record (EMR) was reviewed and there was no documentation that the Administrator and/or the State Survey Agency was notified of the allegation of abuse for R55. On 07/02/25 at 9:20 AM, V1, Administrator said with abuse she has to have it turned into the State Survey Agency within two hours and with a fall with major injury she has to have it reported within 24 hours. V1 said had she known about the incident with R55 and V31 she would have reported it immediately to the State Survey Agency. On 07/02/25 at 09:25 AM, V2 said V31 worked on the south hall on the night shift the night of the incident. She said after the incident regarding R55 and V31 the agency nurse, V35 called V2 on the phone while she was driving home and told her she had a gut feeling something happened with V31 and R55. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date of April 2021, documented 9. Investigate and report any allegations within time frames required by federal requirements. The facility's Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy, revised date of September 2022, documented Policy Statement All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. Policy Interpretation and Implementation Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. local/state ombudsman. It further documented 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interview and record review the facility failed to ensure residents were protected from potential further abuse, after an allegation of abuse. This failure affects 1 of 3 residents (R55) reviewed for abuse allegations in a sample of 57. Findings include: R55's Face Sheet, print date of 07/02/25, documented R55 has diagnoses of but not limited to dementia, paranoid schizophrenia, anxiety disorder due to known physiological condition. R55's Minimum Data Set (MDS), dated [DATE], documented R55 is severely cognitively impaired and requires substantial/maximal assistance with bed mobility. V2, Director of Nursing (DON) statement dated 06/22/25, documented V2, Director of Nursing, DON, received a phone call from agency nurse, V35, at 7:43 AM regarding a bruise/skin tear (ST) R55 received. The statement documented V35 stated that she had a gut feeling that the agency Certified Nursing Assistant (CNA), V31 gave resident the bruise/ST. That statement continued V2 came into the facility and started investigation. The statement documented R55 had a Brief Interview of Mental Status (BIMS) of 99 and was alert to self only. The statement documented V2 assessed R55 and noted the bruise/ST, and R55 did not state she was harmed and did not show any emotional distress at that time. At that time, V2 asked V35 to contact V1, Administrator, and write a statement. The statement documented V35 did not contact V1 or write a statement. The statement did not document if V31 was removed from resident care during the investigation. On 7/02/25, at 9:20 AM, V1 stated V31 worked the night shift that night and she stayed over for a double that day. V1 stated she worked the south hall on night shift and then worked a different hall on the day shift. V1 stated she finished her shift on days and then she didn't come back into the facility until the following Friday after the investigation was completed. On 7/2/25, at 9:25 AM, V2 stated V31 worked on the south hall on the night shift on the night of the incident. V2 stated after the incident regarding R55 and V31, the agency nurse, V35 called V2 on the phone while she was driving home and told her she had a gut feeling something happened with V31 and R55. V2 said she made sure V31 was moved to a different hall to work the day shift. She said she didn't feel like V31 was a threat to any of the other residents, so she let her stay and finish the shift. V2 said after she finished the shift, V321 didn't work back at the facility until the following Friday and the investigation had been completed. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised date of April 2021, documented 10. Protect residents from any further harm during investigations. The facility's Abuse, Neglect, Exploitation and Misappropriation - Reporting and Investigating policy, revised date of September 2022, documented 6. Any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on observation, interview, and record review, the Facility failed to adequately staff the dietary department to ensure meals are served in a timely manner for 4 of 5 residents (R1, R2, R4, R5) reviewed for food and nutrition services in the sample of 5. Findings include: 1. R1's Face Sheet documents R1 was admitted to the facility on [DATE] with diagnoses including heart failure and diabetes. R1's Minimum Data Set (MDS) dated [DATE] documented R1 was cognitively intact, required supervision with eating, and ambulated via wheelchair. R1's Physician Order dated 9/28/24 documents R1 is on a regular diet with no added sodium. R1's Grievance Form dated 12/27/24 documented, (R1) came to me about issues with not getting her dinner last night until late. On 1/7/25 at 11:43 AM, R1 stated everyone else was eating dinner, but she did not get served. She was supposed to get grilled cheese and soup, but they brought her something different which she did not like. She stated she then went back to her room and did not receive her grilled cheese and soup until around 7:00 PM. She stated, It is always late. It's supposed to start at 5:00 PM, and we are lucky if they start at 5:30 PM or a quarter 'til (6:00 PM). 2.R2's Face Sheet documents R2 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and blindness in right eye. R2's MDS dated [DATE] documented R2 was severely cognitively impaired and required substantial assistance with eating, bed mobility, and transfer. R2's Physician Order dated 7/27/16 documents R2 is on a regular diet. On 1/7/25 at 12:46 PM, V14, Licensed Practical Nurse (LPN), obtained a meal tray from the cart on the 200 Hall and delivered it to R2 in her room. This was one hour sixteen minutes after the lunch meal was scheduled to begin. 3.R4's Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes mellitus and pressure ulcers. R4's MDS dated [DATE] documented R4 was cognitively intact, required setup with eating, and was dependent with bed mobility and transfer. R4's Physician Order dated 10/25/24 documents R4 is on a mechanical soft diet. On 1/7/25 at 12:56 PM, V13, Certified Nursing Assistant (CNA), took a meal tray from the cart on the 200 Hall and delivered it to R4 in her room. V13 stated, We have good days (with timing) and bad days, but there usually aren't so many hall trays. There have been more (hall trays) with Covid, and it takes longer (to pass them). R4's tray was passed one hour and twenty-six minutes after the lunch meal was scheduled to begin. 4.R5's Face Sheet documents R5 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease and type 2 diabetes mellitus. R5's MDS dated [DATE] documented R5 was cognitively intact, required supervision with eating, and was dependent with bed mobility and transfer. R5's Physician Order dated 10/10/24 documents R5 is on a low concentrated sweets diet. On 1/7/25 at 1:05 PM, V13 took a meal tray from the cart on the 200 Hall and delivered it to R5 in her room. R5's tray was delivered one hour and thirty-five minutes after the lunch meal was scheduled to begin. On 1/7/25 at 8:55 AM, V4, Environmental Services and Dietary Supervisor, stated occasionally meals run late at supper. V1, Administrator, stated they have had some delays in meals with the recent snowfall and staff calling off work. On 1/7/25 at 9:20 AM, V11, Licensed Practical Nurse (LPN), stated sometimes there are delays in meals at the Facility. On 1/7/25 at 1:49 PM, V1 stated lunch was late today because three dietary employees that were scheduled to work called off. There was no cook or prep cook, so V4 had to do a lot of the work herself. On 1/7/25 at 2:40 PM, V1 stated she will be working with V4 to correct the issue. The Facility's Weekly Schedule for 1/5/25-1/11/25 documents five dietary staff were originally scheduled to be present during the lunch hour on 1/7/25 before the reported three call offs. The Facility's Mealtimes Posting documents lunch is served at 11:30 AM. The Facility's Frequency of Meals Policy revised 7/2017 documents, Each resident shall receive at least three (3) meals daily, at times comparable to typical mealtimes in the community, or in accordance with resident needs preferences, requests and the plan of care. The facility will serve at least three (3) meals or their equivalent daily at scheduled times.

Based on observation, interview and record review, the facility failed to prevent mental abuse for 1 (R2) of 3 residents reviewed for abuse in the sample of 3. This failure resulted in R2 being tearful and expressing feelings including being upset and fearful of being kicked out of the facility. Findings include: R2's Minimum Data Set (MDS), dated [DATE] documents, she is alert and oriented, cognitively intact. R2's Undated Face Sheet, documents she was admitted to the facility on [DATE] with a diagnoses major depressive disorder and anxiety. V1, Administrator's typed stated, dated 12/9/2024 documents this is a statement regarding V6, CNA (Certified Nurse Aide) from 12/8/2024. A resident (R2) came to the ADON's (Assistant Director of Nurse's) office on 12/9/2024 and stated V6 was sleeping in her bed yesterday (12/8/2024.) The ADON came into the administrator's office and investigation was initiated immediately. Based on camera footage, V5 went into (R2's) room on 12/8/2024 at 5:11 AM, she did not leave that room until V7, LPN (Licensed Practical Nurse) went into resident's room at 6:47 AM to wake her up. Administrator, DON (Director of Nurses), ADON and HR (Human Resources) spoke to V7 on phone, and she stated that they were unable to find V6. They entered (R2's) room and found her to be sleeping. V8, LPN stated that V7 asked her to come with her to wake V6 up. Administrator logged into time clock and noted V6 clocked in at 5:11 AM on 12/8/2024. On 12/17/2024 at 11:03 AM, R2 was resident sitting up in her wheelchair in her room. R2 recalled CNA (V6) coming into her room early on Sunday (12/8/2024) and stated she was cold and needed to sleep. R2 stated she always sleeps in her recliner. V6 told R2 not to say a word because if she did, she would be fired and she would get kicked out of the facility. R2 was upset by this and felt it was a serious threat and she didn't want to get kicked out of the facility because she didn't have any place to go. R2 stated staff came into her room about an hour after (V6) had been sleeping and woke her up. She didn't talk to anyone about the CNA sleeping in her bed because she didn't want to get kicked out of the facility then when she spoke to her daughter (V5) on 12/9/2024 she was tearful and told her she's afraid she's going to get kicked out of the facility because a CNA slept in her bed and she was caught by staff but that she didn't tell on the CNA but she was afraid the CNA thinks she told staff she was sleeping in her bed. R2 stated she hopes that (V6) doesn't work at the facility anymore because she's afraid of what she will do to her if she thinks she told on her. On 12/17/2024 at 11:03 AM V8, Licensed Practical Nurse (LPN) stated she got to work on 12/8/2024 at approximately 5:30 AM and she was told V6 CNA was running late to work that day. At approximately 6:30 AM, V8 hadn't seen V6 and started looking for her. V6 stated she looked in R2's room and observed V6 sleeping in R2's bed. She attempted to wake V6 up, but she told her to get out. V6 then went and reported V6 was sleeping to another nurse V7, LPN. V8 and V7 went to R2's room and V6 woke up and went to work at approximately 6:45 AM. R2 was sitting up in her recliner in her room watching at that time and she wasn't crying or emotionally distressed. V8 stated she didn't report that R2 said not to say anything, or she'd get fired and R2 would get kicked out of the facility. V8 stated she didn't report the incident to management because she wasn't assigned to R2 that day. On 12/17/2024 at 12:23 PM V7, Registered Nurse (RN) she worked on 12/8/2024 day shift and was assigned to R2. V7 stated she knew V6 was running late but didn't know when she arrived to the facility. V6 stated staff couldn't find V6 and V8 reported to her that she found V6 sleeping in R2's bed. V7 and V8 went to R2's room and observed V6 was in fact sleeping in R2's bed. V7 stated she woke V6 up and stated she needed to get to work. V7 didn't report the sleeping incident to management on 12/8/2024. V1 called her on 12/9/2024 and they discussed the incident at that time. R2 wasn't upset on 12/8/2024 when V6 was sleeping in her bed, R2 actually laughed about it and didn't report that R2 told her not to say anything about her sleeping in her bed or she'd get fired and R2 would get kicked out of the facility. On 12/17/2024 at 12:45 PM V4, Social Services Assistant stated it was reported to her on 12/9/2024 that on 12/8/2024 V6 was found sleeping in R2's bed. V4 and V1 spoke to R2 about the incident on 12/9/2024 and V4 stated the resident got tearful during the interview and stated she didn't want anyone to get in trouble. V4 stated R2 didn't mention fear of being kicked out of the facility and V4 wasn't aware that R2 was fearful of being kicked out of the facility. V4 let R2 know V6 was terminated for sleeping in her bed and R2 understood she was safe at the facility. On 12/17/2024 at 1:30 PM V5, (family member) stated she went to see R2 in the afternoon on 12/9/2024 and as soon as she walked in the door R2 started to cry and shake and she told her that a CNA slept in her bed the day before and told her if she told anyone she would get fired and R2 would get kicked out of the facility. V5 stated R2 was very upset and shaking when she told her, and she could tell R2 was scared of the sleeping CNA V6. V5 spoke to the ADON and reported the incident immediately then she showered R2 in an attempt to calm her down. The Administrator spoke to her and R2 after the shower and that's when R2 told the Administrator that the CNA V6 slept in her bed the morning before, and she told her she'd get fired and R2 would be kicked out of the facility if she told on her for sleeping. V5 stated R2 told her that V6 threatened her, and she didn't feel safe at that time. On 12/17/2024 at 12:33 PM V6, CNA stated she worked at the facility day shift on 12/8/2024 and she had a rough night and that she was really cold and tired. V6 assisted R2 to the bathroom and R2 told her to lay in her bed and rest. V6 stated she thought she'd sit on R2's bed for a few minutes but she fell fast asleep. V7 and V8 woke her up, she didn't know how long she slept for. V6 went straight to work after being woke up and R2 was her usual cheerful self, she wasn't tearful or emotionally upset that day at all. V6 denied telling R2 not to tell staff she slept in her bed because she'd get fired and R2 would get kicked out of the facility. V6 stated she'd worked at the facility for over a year and R2 was like family to her, and she'd never say that to her. On 12/17/2024 at 10:30 AM, V3 stated she was aware a CNA was found sleeping in R2's on 12/9/2024 when R2's family member R5 reported it to her. An investigation was started immediately. V3 stated when she spoke to R5 on 12/9/2024 she stated R2 told her that if she said anything about R2 sleeping in her bed the CNA would be fired and she would be kicked out of the facility. When V3 spoke to R2 she was very upset and tearful stating she didn't want V6 to get in trouble and didn't mention the possibility of being kicked out of the facility. On 12/17/2024 at 2:11 PM V2 stated on 12/9/2024 sometime after morning meeting the R2, the ADON and V5, R2's family member entered V1, Administrator's office and stated V6 slept in R2's bed the morning before and that R2 didn't say anything because she didn't want to get V6 in trouble. V2 didn't recall who told her that R2 stated that V6 stated to her not to tell anyone that she was asleep in her room because she would get fired and R2 would get kicked out of the facility. R2 was tearful when she entered V1's office to speak to them. R2 has depression and her antidepressant medication was discontinued on 11/18/2024 due to swelling and was restarted due to being tearful and having more signs and symptoms of depression on 12/12/2024. On 12/17/2024 at 10:35 AM V1 stated R2, V3 and V5 entered her office on 12/9/2024 and R2 was tearful at that time and R2 stated V6 slept in her bed the morning before and that if she told anyone V6 would be fired, and she would be kicked out of the facility. R2 was visibly upset when she told V1 this but R2 had recently had some medication changes so that could have something to do with her being emotional. The facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 documents residents have the right to be free from abuse, this includes but is not limited to mental abuse.

Based on interview and record review, the Facility failed to establish an infection prevention and control program that reduces the risk of adverse events, including the development of antibiotic-resistant organisms, from unnecessary or inappropriate antibiotic use in 4 of 4 residents (R50, R74, R236, R237) reviewed for antibiotic stewardship in the sample of 46. Findings include: 1. The Facility's Infection Control Log for the month of June 2024 does not list a causative pathogen for R50's 6/1/24 urinary tract infection. R50's Urine Culture dated 5/31/24 documents, No Growth and (hand-written) Continue ABT (Antibiotic) r/t (related to) symptoms. R50's Physician Orders document 6/1/24 order for Augmentin ES (Extended Strength) (antibiotic) 600 milligrams (mg) - 42.9mg/5mL (milliliters) - give 5mL twice daily for 10 days starting 6/1/24. R50's Medication Administration Record (MAR) for June 2024 documents R50 received 13 of the 20 ordered doses of Augmentin ES. On 7/11/24 at 9:34 AM, V1, Administrator, stated R50 was sent to the hospital for unusual behavior and combativeness where he was started on an antibiotic. She stated his urine culture showed no microbial growth, but the antibiotic was continued in the Facility due to his symptoms. 2. The Facility's Infection Control Log does not list a causative pathogen for R74's 6/28/24 urinary tract infection. R74's 6/28/24 Physician Order documents 1g (gram) Ertapenem (antibiotic) to be given intravenously daily for 22 days starting 6/28/24. R74's MARs for June and July 2024 document R72 only received 8 of 22 doses of Ertapenem. On 7/11/24 at 8:30 AM, a culture for R74's 6/28/24 urinary tract infection was requested from V1, Administrator. On 7/11/24 at 9:34 AM, V1, Administrator, provided R74's Urine Culture from a previous course of antibiotics which started on 6/22/24. She stated the hospital does not communicate well with facility, and there was a lot of digging to try to find the culture. V1 was unable to provide a culture to justify the use of the antibiotic Ertapenem for R74's 6/28/24 urinary tract infection. 3. The Facility's Infection Control Log does not list a causative pathogen for R236's 5/24/24 urinary tract infection. R236's May 2024 Physician Orders document sulfamethoxazole 800mg - trimethoprim 160mg tablet twice daily by mouth for 7 days was discontinued on 5/31/24. There was no start date listed on the order. R236's MAR for the month of May 2024 documents R236 received all 14 ordered doses of sulfamethoxazole 800mg - trimethoprim (antibiotic) 160mg oral tablets. R236's 5/24/24 Urine Culture documents, Normal Genital Flora and (hand-written) Continue ABT due to symptomatic. On 7/11/24 at 9:34 AM, V1, Administrator, stated R236's antibiotic was also continued due to symptoms. 4-The Facility's Infection Control Log does not list a causative pathogen for R237's 5/8/24 urinary tract infection. R237's May 2024 Physician Orders document 500mg cephalexin (antibiotic) tablet by mouth three times daily for 7 days was discontinued on 5/15/24. There was no start date listed on the order. R237's MAR for the month of May 2024 documents R237 received 11 of the 21 ordered doses of cephalexin. On 7/11/24 at 8:30 AM, R237's Urine Culture from the 5/8/24 urinary tract infection was requested from V1, Administrator. On 7/11/24 at 9:34 AM, V1, Administrator, provided R237's Comprehensive Metabolic Panel (CMP) dated 5/7/24 and stated the antibiotic was continued due to elevated [NAME] Blood Cell (WBC) count. The CMP did not justify the use of the antibiotic cephalexin. On 7/12/24 at 9:20 AM, V1, Administrator, stated she expects staff to follow the Facility's Antibiotic Stewardship Policy and educate new hires on policies and (again) as needed. The Facility's Antibiotic Stewardship Policy revised 12/2016 documents, Antibiotics will be prescribed and administered to residents under the guidance of the facility's antibiotic stewardship program. When a resident is admitted from an emergency department, acute care facility, or other care facility, the admitting nurse will review discharge and transfer paperwork for correct antibiotic/anti-infective orders. When a culture and sensitivity (C&S) is ordered lab results and the current clinical situation will be communicated to the prescriber as soon as available to determine if antibiotic therapy should be started, continued, modified, or discontinued.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner that prevents foodborne illness. This has the potential to affect all 79 residents living in the Facility. Findings include: On 7/09/24 at 11:35 AM in the large dry storage room, there were two cardboard boxes containing hand sanitizer stored directly next to a bag of sugar and a bag of brown sugar. The top shelf on the large center storage rack had an insect bait trap stored directly next to a box of hot sauce. The second shelf from the top also had an insect bait trap stored next to several jars of poppy seed dressing. The top of the storage rack had scattered mouse droppings. On 7/9/24 at 11:50 AM, there was grease splattered on the backsplash behind the stovetop which was not in use. There was a black, burnt, crusty matter across the stovetop and inside the ovens. On 7/9/24 at 11:52 AM, the walk-in refrigerator held a box of sweet potatoes which were dated 6/19 in black marker. V6, Dietary Manager (DM), stated 6/19 was the delivery date and was unsure how staff would know which date to discard them. There were also eight boxes of cream cheese dated 7/1 in black marker that had been removed from original packaging and did not contain a date of expiration or date to discard them. On 7/9/24 at 11:55 AM, in the walk in freezer, there were two plastic bags containing pie crusts that were not labeled or dated. On 7/9/24 at 11:57 AM, next to the 3 compartment sink there was a rack holding various food service utensils. Above that rack, there was a significant amount of dust on the ceiling vent and food spattered on the wall. There was a meat slicer on the adjacent counter top that was covered in crumbs underneath its plastic cover. On 7/9/24 at 11:50 AM, in the standing refrigerator there were several jars of bouillon that were all dated upon delivery. One jar was opened and half empty and was not dated upon opening. V6, Dietary Manager (DM), stated they should be adding a new date when the product is opened. V23, [NAME] stated the jar should be dated upon opening so staff know when to throw it away. On 7/9/24 at 12:05 PM, in the small dry storage closet, there were large tubs containing oatmeal, sugar, flour and thickener. All were labeled with names, but none were dated. On 7/9/24 at 12:12 PM, the staff and resident refrigerator on the second floor next to dining room had a container of carry out food, a container of an unknown meat, half of a pizza in a cardboard box, cheese covered breadsticks in a cardboard box, pasta salad in a plastic storage container, a plastic container of store bought chef salad, and two submarine sandwiches from a chain restaurant. None of these were labeled with staff or resident names, and none of these were dated. There was a submarine sandwich from a gas station that was covered in mold and dated 12/23/23. There was a package of [NAME] jack cheese with a use by date of 1/28/24. There was a half empty container of broccoli cheddar soup with a use by date of 3/2/24. There was a bag of plums that were not dated, but were covered in mold. There was a bottled coffee beverage dated 2/23/24. The freezer had a previously opened can of soda that was not labeled or dated and was covered with a latex glove. On 7/9/24 at 1:15 PM, food temperatures were obtained from the second floor dining room steam table using a metal calibrated thermometer after the last resident tray was served. The green beans measured 113 Fahrenheit (F) and the two plastic containers of salad measured 69 F and 56 F. On 7/9/24 at 1:17 PM, V6, Dietary Manager (DM), stated, They didn't get it (green bean temperature) up enough when they brought more. She stated she will start working on cleaning up the resident and staff refrigerator right away. On 7/12/24 at 9:20 AM, V1, Administrator stated she expects staff to follow Facility policies. The Facility's Food Preparation and Service Policy revised 11/2022 documents Food and Nutrition Services employees prepare, distribute, and serve food in a manner that complies with safe food handling practices. The Policy documents the danger zone for food temperatures is greater than 41 Fahrenheit (F) and less than 135 F, and all fresh, frozen, or canned vegetables should be cooked to a minimum holding temperature of 135 F. The Facility's Food Receiving and Storage Policy revised 11/2022 documents food shall be received and stored in a manner that complies with safe food handling practices. It documents dry foods stored in bins are removed from their original packaging, and labeled and dated with a use by date. All foods in the refrigerator or freezer are covered, labeled and dated with a use by date. Refrigerated foods are monitored to ensure they are used before their use by date or discarded, including foods that belong to residents. Beverages are dated and discarded within 24 hours. The Policy also documents soaps, detergents, cleaning compounds and other similar substances are stored separately from food storage. The Facility's Long-Term Care Facility Application for Medicare and Medicaid (CMS 671) dated 7/8/24 documents there are 79 residents living in the Facility.

Based on interview, observation, and record review, the facility failed to store medications in a sanitary manner and failed to date an open multidose medication vial. This failure has the potential to affect all 21 residents residing in the dementia unit. Findings include: On 7/9/24 at 8:07 am the dementia unit medication storage room was entered with V17 RN (Registered Nurse). A large block of ice buildup was observed in and around the freezer at the top of the small medication refrigerator. The ice buildup was observed dripping onto the bottom of the refrigerator. One box containing a vial of abrysvo 120 mg (milligrams) vaccine for the prevention of respiratory syncytial virus was completely saturated with water. One box containing 3 bisacodyl (stool softner)10 mg suppositories was also completely saturated with water. This medication storage refrigerator also contained one opened multi-dose vial of tuberculin solution. There was no date listed on the vial to indicate when it was opened. On 7/9/24 at 8:15 AM, V17, RN stated that the suppositories, vial of abrysvo, and the tuberculin solution is used as needed for all residents of the unit. V17 stated that the medication refrigerator needs to be defrosted. On 7/15/24 at 8:50 AM, V1, Administrator stated she would expect the medication in the medication room refrigerator to be dated when opened and to be stored in a clean manner. On 7/15/24 at 8:52 AM, V2, DON (Director of Nursing) stated she would expect the medication in the vial to be dated when opened. The facility's Storage of Medications Policy, revision date of November 2020, documented the facility stores all drugs and biologicals in a safe, secure, and orderly manner. 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls. Only person authorized to prepare and administer medications have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation, interview, and record review the facility failed to provide complete incontinent care for 4 residents (R3, R17, R38, and R59) of 4 residents reviewed for incontinence in a sample of 46. Findings include: 1. R17's face sheet, print date 7/11/24, documented R17 has diagnoses of Alzheimer's disease, major depressive disorder, hypertension, macular degeneration, anxiety disorder, and osteoporosis. R17's MDS (Minimum Data Set), dated 4/5/24, documented that R17 is severely cognitively impaired, is always incontinent of urine, and is dependent on staff for all ADLS (Activities of Daily Living). On 7/9/24 at 9:20 am V12 CNA (Certified Nurse Assistant) and V16 CNA donned gloves without the benefit of hand hygiene and transferred R17 into bed. V12 and V16 then removed R17's urine-soaked incontinence brief and urine-soaked pants. R17's pants were visibly saturated throughout the buttock and hip regions. V12 then applied perineal cleanser to a disposable cloth and wiped R17's upper pubic region without the benefit of hand hygiene nor changing gloves. V12 then cleansed R17's inner labia with the same disposable cloth as was used to cleanse R17's upper pubic region. V12 did not fold the disposable cloth over nor get a new cloth prior to cleansing R17's inner labia region. V12 did not cleanse R17's outer labia nor inner thighs. V12 and V16 then rolled R17 onto her side and V12 cleansed R17's anal region and then rolled R17 onto her back. V12 did not cleanse R17's buttocks nor hips. V12 then pulled R17's blankets up over her with the same gloves as was used to cleanse R17's genitalia. V12 and V16 then removed their gloves and left R17's room without performing hand hygiene. 2. R3's face sheet, print date 7/11/24, documented R3 has diagnoses of Alzheimer's disease, urge incontinence, orthostatic hypotension, anxiety, and hypertension. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired and is dependent on staff for toileting hygiene needs and ADLS. On 7/9/24 at 9:55 am V12 CNA pushed R3 in his wheelchair from the dining room to his room. V12 and V16 donned gloves without the benefit of hand hygiene and transferred R3 onto his bedside commode. V12 and V16 then transferred R3 onto his bed and removed his disposable adult incontinence brief and pants. V16 then cleansed the tip of R3's penis with a disposable cloth. V16 did not perform hand hygiene nor change gloves prior to cleansing R3's penis. V16 did not cleanse the entire length of R3's penis, inner thighs, scrotum nor buttock. V16 did not retract R3's uncircumcised penis and cleanse the area. V12 and V16 then covered R3 up and removed their gloves. V12 and V16 did not perform hand hygiene prior to leaving R3's room. 3. R38's face sheet, print date 7/11/24, documented R38 has diagnoses of Alzheimer's disease, hypertension, bipolar disorder, anxiety, and depression. R38's MDS, dated [DATE], documented R38 is severely cognitively impaired and is dependent on staff for all toileting needs and ADLS. On 7/11/24 at 9:20 am V16 CNA pushed R38 in her reclining wheelchair from the dementia unit dining room into her room. V16 CNA and V21 CNA donned gloves without the benefit of hand hygiene. V16 placed a gait belt around R38's waist. V16 and V21 transferred R38 onto her bed and turned her her left side. V21 wet two washcloths with water and wiped R38's rectum and buttock. V21 did not apply perineal cleanser nor soap to the washcloths. R38 then had an extra-large bowel movement. V16 and V21 cleaned up the bowel movement with disposable cloths. V16 nor V21 cleansed R38's frontal labia region following her bowel movement. V16 then tossed R38's soiled bed pad onto the floor. V21 tossed the soiled washcloths onto the pad that was on the floor. V21 then picked the soiled linens up off the floor, placed them in a bag, and carried them down the hallway with the same gloves on. V16 removed her gloves and pushed R38 back into the dementia unit. V16 did not perform hand hygiene before leaving R38's room nor after leaving R38's room. V16 then proceeded to provide care and transfer other residents in dining room without performing hand hygiene. 4. R59's face sheet, print date 7/11/24, documented R59 has diagnoses of metabolic encephalopathy, dementia, Alzheimer's disease, depression, anxiety, hyperlipidemia, and bipolar disorder. R59's MDS, dated [DATE], documented R59 is severely cognitively impaired and requires substantial maximal assistance with toileting and ADL needs. On 7/11/24 at 9:42 am V21 CNA pushed R59 in her wheelchair from the dementia unit dining room to her bathroom. V21 and V16 donned gloves without the benefit of hand hygiene. V21 and V16 then placed a gait belt around R59's waist and transferred her onto the toilet. V16 stated that R59's adult incontinence brief was a little wet. V16 removed R59's wet brief. V16 and V21 then stood R59 up, V21 wiped R59's rectal and buttock area and then V16 placed a new adult brief on R59. Neither V16 nor V21 cleansed R59's frontal region including inner labia, labia, and inner thighs. V16 and V21 then removed their gloves and assisted R59 back to the dementia dining room. V16 and V21 did not perform hand hygiene before nor after leaving R59's room. On 7/15/24 at 8:47 AM, V1, Administrator and V2 DON stated that they would expect the CNAs to cleanse all resident areas potentially exposed to urine or feces. On 7/15/24 at 10:15 AM, V15, CNA stated that she washes the peri area, groin crease, thigh, private area, back of thighs, buttocks, and lower back of the resident when she provides incontinence care. On 7/15/24 at 10:25 AM, V9, CNA stated that when she provides incontinence care she washes the female resident's middle of the perineal area, the sides, and the buttocks. V9 stated that when she provides incontinence care for male residents she washes the penis, testicles, and buttock. 1.The Facility's Perineal Care Policy, revision date of February 2018, documented it is the purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Towels; 3. Washcloth; 4. Soap (or other authorized cleansing agent; and 5. Personal protective equipment (e.g., gowns, gloves, mask, etc., as needed). Steps in the procedure: 1. Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside stand within easy reach. 4. Fold the bedspread or blanket toward the foot of the bed. 5. Fold the sheet down to the lower part of the body. Cover the upper torso with a sheet. 6. Raise the gown or lower the pajamas. Avoid unnecessary exposure of the resident's body. 7. Put on gloves. 8. Ask the resident to bend his or her knees and put his or her feet flat on the mattress. Assist as necessary. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (1) Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area.) (2) Continue to wash the perineum moving from inside outward to the thighs. Rinse perineum thoroughly in same direction, using fresh water and a clean washcloth. (3) If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. (4) Gently dry perineum. c. Ask the resident to turn on her side with her top leg slightly bent, if able. d. Ask the resident to turn on her side with her top leg slightly bent, if able. e. Wash the rectal area thoroughly, wiping from the base of the labia towards and extending over the buttocks. f. Rinse and dry thoroughly. For a male resident. a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area starting with urethra and working outward. C. If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra down the catheter about 3 inches. Gently rinse and dry the area. d. Retract foreskin of the uncircumcised male. e. Wash and rinse urethral area using a circular motion. f. Continue to wash the perineal area including the penis, scrotum, and inner thighs. g. Thoroughly rinse perineal area in same order, using fresh water and clean washcloth. h. If the resident has an indwelling catheter, hold the tubing to one side and support the tubing against the leg to avoid traction or unnecessary movement of the catheter. i. Gently dry perineum following same sequence. j. Reposition foreskin of uncircumcised male. k. Ask the resident to turn on his side with his upper leg slightly bent, if able. l. Rinse washcloth and apply soap or skin cleansing agent. m. Wash and rinse the rectal area thoroughly, including the area under the scrotum, the anus, and the buttocks. n. Dry area thoroughly. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. 12. Reposition the bed covers. Make the resident comfortable. 12. Reposition the bed covers. Make the resident comfortable. 13. Place the call light within easy reach of the resident. 14. Clean wash basin and return to designated storage area. 15. Clean the bedside stand. 16. Wash and dry your hands thoroughly.

Based on observation, interview, and record review the facility failed to remove soiled gloves, perform proper hand hygiene, and dispose of soiled linen properly for 5 of 5 residents (R3, R17, R38, R59, R42) reviewed for infection control in a sample of 46. 1. R17's face sheet, print date 7/11/24, documented R17 has diagnoses of Alzheimer's disease, major depressive disorder, hypertension, macular degeneration, anxiety disorder, and osteoporosis. R17's MDS (Minimum Data Set), dated 4/5/24, documented that R17 is severely cognitively impaired, is always incontinent of urine, and is dependent on staff for all ADLS (Activities of Daily Living). On 7/9/24 at 9:20 AM, V16, CNA (Certified Nurse Assistant) pushed R17 in her reclining wheelchair from the dementia unit dining room to her room. V12 CNA and V16 CNA donned gloves without the benefit of hand hygiene. V12 and V16 then transferred R17 into her bed and then removed R17's urine saturated disposable adult brief and her urine saturated pants. V12 then changed her gloves without performing hand hygiene and performed incontinence care on R17. V16 then removed her gloves and left the room without performing hand hygiene. V16 then returned to R17's room with a cloth pad. V16 donned gloves without performing hand hygiene and placed the cloth pad under R17. V12 then pulled R17's blankets up over her while wearing the same gloves that she had on when she performed incontinence care on R17. V12 and V16 then removed their gloves and left R17's room without performing hand hygiene. 2. R3's face sheet, print date 7/11/24, documented R3 has diagnoses of Alzheimer's disease, urge incontinence, orthostatic hypotension, anxiety, and hypertension. R3's MDS, dated [DATE], documented R3 is moderately cognitively impaired and is dependent on staff for toileting hygiene needs and ADLS. On 7/9/24 at 9:55 AM, V12, CNA and V16, CNA pushed R3 in his wheelchair from the dementia unit dining room into his room. V12 and V16 donned gloves without the benefit of hand hygiene. V12 and V16 transferred R3 onto his bedside commode and then onto his bed. V12 and V16 removed R3's disposable adult brief and pants. V16 performed perineal care on R3 without the benefit of hand hygiene nor did she change gloves. V12 placed soiled linens and R3's dirty clothes into a disposable bag. V12 removed her gloves and left the room with the bag of soiled linens. V12 did not perform hand hygiene before leaving R3's room nor immediately after leaving R3's room. 3. R38's face sheet, print date 7/11/24, documented R38 has diagnoses of Alzheimer's disease, hypertension, bipolar disorder, anxiety, and depression. R38's MDS, dated [DATE], documented R38 is severely cognitively impaired and is dependent on staff for all toileting needs and ADLS. On 7/11/24 at 9:20 AM, V16, CNA pushed R38 in her reclining wheelchair from the dementia unit dining room into her room. V16 CNA and V21 CNA donned gloves without the benefit of hand hygiene. V16 placed and gait belt around R38's waist. V16 and V21 transferred R38 into her bed onto her left side. V21 wet two washcloths with water and wiped R38's rectum and buttock. V21 did not apply perineal cleanser nor soap to the washcloths. R38 then had an extra-large bowel movement. V16 and V21 cleaned up the bowel movement with disposable cloths. V16 nor V21 cleansed R38's frontal labia region following her bowel movement. V16 then tossed R38's soiled bed pad onto the floor. V21 tossed the soiled washcloths onto the pad that was on the floor. V21 then picked the soiled linens up off the floor, placed them in a bag, and carried them down the hallway with the same gloves on. V16 removed her gloves and pushed R38 back into the dementia unit. V16 did not perform hand hygiene before leaving R38's room nor after leaving R38's room. V16 then proceeded to provide care and transfer other residents in dining room without performing hand hygiene. 4. R59's face sheet, print date 7/11/24, documented R59 has diagnoses of metabolic encephalopathy, dementia, Alzheimer's disease, depression, anxiety, hyperlipidemia, and bipolar disorder. R59's MDS, dated [DATE], documented R59 is severely cognitively impaired and requires substantial maximal assistance with toileting and ADL needs. On 7/11/24 at 9:42 AM, V21, CNA pushed R59 in her wheelchair from the dementia unit dining room to her bathroom. V21 and V16 donned gloves without the benefit of hand hygiene. V21 and V16 then placed a gait belt around R59's waist and transferred her onto the toilet. V16 stated that R59's adult incontinence brief was a little wet. V16 removed R59's wet brief. V16 and V21 then stood R59 up, V21 wiped R59's rectal and buttock area and then V16 placed a new adult brief on R59. Neither V16 nor V21 cleansed R59's frontal region including inner labia, labia, and inner thighs. V16 and V21 then removed their gloves and assisted R59 back to the dementia dining room. V16 and V21 did not perform hand hygiene before nor after leaving R59's room. On 7/15/24 at 8:47 AM, V1, Administrator and V2, DON stated that they would expect the CNAs to perform hand hygiene prior to, during, and after providing incontinence care. 40701 5. R42's MDS dated [DATE] documents R42 is frequently incontinent of urine, occasionally incontinent of bowel, and requires substantial/maximal assist from staff for toileting hygiene. R42's Care Plan Activity dated 5/27/2024 documents, Cleanse me after every incontinent episodes of urine or stool and Assist me with changing (briefs)/liners and assisting me with peri-care PRN (as needed). On 7/11/2024 at approximately 9:30 AM, R42 was observed to have been incontinent of bowel and bladder. V9, Certified Nursing Assistant (CNA) began by cleaning R42's buttocks of feces. When R42's buttocks was clean, using the same gloves and without the benefit of hand hygiene, V9 rolled R42, cleansed the frontal peri area, outer and inner labia, applied a clean brief and began changing R42 into clean clothing. V9 performed this whole incontinent care process without the benefit of hand hygiene or changing gloves. On 7/15/2024 at 10:15 AM, V15, CNA, stated she would clean a resident who had an incontinent episode from the front to the back, would use hand hygiene and change gloves in between clean and dirty areas. On 7/15/2024 at 10:25 AM, V9, CNA, stated she would change her gloves if they were dirty or visibly soiled. On 7/15/2024 at 10:35 AM, V1, Administrator stated she would expect staff to change gloves and perform hand hygiene between cleaning feces from a residents' buttocks prior to beginning to clean the area of urinary incontinence. The facility's Handwashing/Hand Hygiene policy, revision date August 2019, documented this facility considers hand hygiene the primary means to prevent the spread of infections. 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. It continues, 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Failures at this level required more than one deficient practice statement. A.) Based on observation, interview and record review, the facility failed to ensure the safety of residents who engage in cigarette smoking activities by failing to develop and implement personalized/individualized care plan interventions. These failures affect three of six residents (R2, R37, R73) reviewed for safety and supervision on the sample list of 46. B.) Based on observation, interview and record review, the facility failed to provide supervision to prevent falls for residents at risk for falls. This failure affects one of six residents (R42) reviewed for safety and supervision on the sample list of 46. Findings include: a.)1.) R73's Care Plan Activity Report dated 11/20/2023 documents, Cigarette Smoking- I am a smoke[er] and have expressed interest and desire to continue to smoke. I smoked prior to admission. Goals- I will remain safe while under the supervision of staff. Interventions include: Remind me that my staff will be supervising me during smoking and any related behaviors. Also, my noncompliance will be monitored and reported to my MD (Medical Doctor) and Family PRN (As needed). Staff will assist me to the smoking area and keep me safe from harm and will apply smoking apron PRN (as needed). Provide me a smoking apron to use during my smoking session and that my supplies must be kept at the nurse station to ensure my safety PRN. R73's Minimum Data Set (MDS) dated [DATE] documents R73 is cognitively intact. On 7/9/24 at 2:20 PM, R37 and R73 were observed outside in the designated smoking area. Neither R37 or R73 were wearing smoking aprons or being supervised. There were approximately 75-100 extinguished cigarettes butts littered all over the ground in the surrounding area. At this time, R37 told the surveyor he put a cigarette butt in the pocket of his flannel shirt, causing it to burn a hole in the pocket. R73 stated he put his lighter and a cigarette butt in the pocket of his jacket, causing a burn in his pocket. R73 also stated at this time that he keeps his lighter with him. During this conversation/observation, V4 (Nurse) walked up to the smoking area and educated both R37 and R73 there are supposed to return their lighters and extinguish the cigarettes in a provided receptacle. At this time, V4 stated she completes the smoking assessments for the residents and if the resident passes the assessment, they can smoke independently. V4 stated residents are not allowed to keep their lighters on their person. On 7/11/2024 at 10:04 AM, R73's coat pocket was observed with R73 and V4 present. The entire bottom (approximately 3 to 4 inches in length) of one of the pockets on R73's coat was missing. It had a charred (burnt) appearance above the hole. At this time, R73 stated it occurred a couple days ago. V2, Director of Nursing (DON) provided an electronic message dated 4/9/2024 documents, in part, Staff please make sure we are offering or encouraging the residents to put on a smoking vest when they are going outside to smoke to reduce the risk of burning themselves while smoking. a.)2.) R37's Care Plan Activity Report dated 3/24/2023 documents, Cigarette Smoking- I am a smoke[er] and have expressed interest and desire to continue to smoke. I smoked prior to admission. Goals- I will remain safe while under the supervision of staff. Interventions include: Remind me that my staff will be supervising me during smoking and any related behaviors. Also my noncompliance will be monitored and reported to my MD (Medical Doctor) and Family PRN (As needed). Staff will assist me to the smoking area and keep me safe from harm and will apply smoking apron as needed. Provide me a smoking apron to use during my smoking session and that my supplies must be kept at the nurse station to ensure my safety PRN. It also documents on 5/16/2023, I am allowed to go outside to smoke by myself. R37's MDS dated [DATE] documents R37 is moderately cognitively impaired. On 7/8/2024 at 2:21 PM, R37 stated he wears oxygen when he is in his room. R37 then stated, I'm going to smoke now in the [NAME] (covered shelter outside building). R37 stated he does not wear an apron, Because I am not sloppy. a.)3.) R2's Care Plan Activity dated 5/2/2024 documents, Provide me a smoking apron to use during my smoking session and that my supplies must be kept at the nurses' station to ensure my safety PRN. Remind me that my staff will be supervising me during smoking and any related behaviors. Also, my noncompliance will be monitored and reported to my MD and family PRN. R2's MDS dated [DATE] documents R2 is cognitively intact. On 7/9/2024 at 2:30 PM, R2 stated she keeps her lighter in her purse and does not wear a smoking apron. The Facility's Resident Smoking Policy dated October 2023, documents, This Facility has established and maintains safe resident smoking practices. It continues to document, Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) are noted on the care plan and all personnel caring for the resident shall be alerted to these issues. The Facility may impose smoking restrictions on a resident at any time if it determines that the resident cannot smoke safely with the available levels of support and supervision. Any resident with smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor, or volunteer worker at all times while smoking. Residents who have independent smoking privileges are permitted to keep cigarettes, electronic cigarettes, pipes, tobacco, and other smoking items in their possession. Only disposable safety lighters are permitted. All other forms of lighters, including matches, are prohibited. Residents without independent smoking privileges may not have or keep any smoking items, including cigarettes, tobacco, etc, except under direct supervision. b.) On 7/8/2024 at approximately 10:30 AM, R42 was located at the Nurses' station with a brace on her left foot. R42 was expressing signs of pain and stating, my foot. At this time, V24, Licensed Practical Nurse (LPN) stated R42 has a fractured ankle but V24 was unsure how it occurred. R42's MDS dated [DATE] documents R42 is severely cognitively impaired and requires substantial/maximal assistance with toilet transfers. R42's Care Plan Activity Report dated 5/27/2020 documents R42 has the potential for falls or injury from falls related to medications and history of falls, with a goal of having two or less falls on average per month. It further documents R42 requires one to two assist for transfers, as well as have a sensor pad at all times. R42's Accident/Incident Report dated 6/5/2024 documents R42 experienced a fall with no apparent injury due to not following care plan. It further documents R42's fall was unwitnessed after a Certified Nursing Assistant (CNA) left R42 on the toilet unattended and R42 attempted to stand/ambulate independently. It continues to document R42 has decreased safety awareness due to Dementia. R42's Fall Risk assessment dated [DATE] documents R42 has had 3 or more falls in the past 3 months and is a high fall risk. It further documents R42 was noted sitting on buttocks in front of toilet in her bathroom, after the Certified Nursing Assistant (CNA) assisted R42 to the toilet and left R42 unattended. It further documents R42 attempted to ambulate from the toilet into R42's bedroom independently without success. The CNA was instructed to never leave resident unattended on the toilet when they are a high fall risk and already uses a sensor pad (device to alert staff if a resident is transferring unassisted). R42's Progress Notes dated 6/10/2024 documents R42's doctor was updated regarding left foot swelling/bruising and an x-ray was ordered. R42's Progress Notes dated 6/10/2024 further documents R42 was sent to the local emergency room with a fractured left ankle. On 7/11/2024 at 11:00 AM, V22, Nurse consultant/former Director of Nursing (DON) stated she would expect staff to stay with/supervise a resident while they use the toilet, especially if they are a high fall risk. On 7/15/2024 at 10:15 AM, V15, CNA, stated R42 is a fall risk and V15 would stay in the bathroom with her while R42 is using the toilet. On 7/15/2024 at 10:25 AM, V9, CNA stated she was unsure if R42 is a fall risk, but states they usually are a fall risk if they have a sensor pad and a fall mat on the floor near their bed. The Facility's Strategies for Reducing the Risk of Falls Policy dated March 2018 documents, Elimination-Do not leave the resident unattended in the bathroom until the following have been established: Ability/compliance with call light use. Adequate sitting balance and postural stability. It continues, Staff Communication: Include resident fall risk category during shift report and team conference.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner which prevents potential contamination and food-borne illness. This has the potential to affect all 87 residents living in the facility. Findings include: 1. On 5/30/23 at 9:51 AM, the ice scoop was inside the ice machine in the second-floor dining room. There was a cooler on top of the ice machine that also had a scoop inside on the ice. On 5/30/23 at 11:34 AM, on the kitchen preparation counter, there was a clear container holding approximately 16 ounces of a white powdery substance that was labeled (Thickener) and was not dated. On 5/30/23 at 11:38 AM in the beverage refrigerator next to the prep counter, there was a 32-ounce bag of walnuts that had been opened and resealed but was not dated. There was a pitcher containing a red liquid that was labeled 4/23 and cranberry. There was a plastic gallon storage bag with a light tan colored creamy substance inside with no label or date. V5 (Dietary Aide) stated, I'm not even sure what that is. On 5/30/23 at 11:42 AM in the small storage closet there were four large, clear bins that were approximately three feet tall each. One contained a white powder and was not labeled or dated. The other three were labeled instant food thickener, oats, and sugar and were not dated. There was a plastic storage bag containing banana cake mix that had been opened but was not dated. On 5/30/23 at 11:45 AM in the walk-in refrigerator there was a container labeled chicken gravy dated 5/20 - 5/26. V4 (Dietary Manager) stated 5/26 is the date it should have been thrown out. I'll throw it out now. There was a container of an unknown substance that was not labeled or dated. V4 stated, That is pea salad, and it can come out since it's not labeled. There was a shallow pan containing a red liquid covered with plastic wrap labeled SB (gelatin) that was not dated. On 5/30/23 at 11:47 AM in the walk-in freezer, there was a pan with 3.5 pies that were covered with plastic wrap. None were labeled or dated. V4 (Dietary Manager) told V5 (Dietary Aide) to throw it out. There was a banana split in a container from a fast-food restaurant that was not labeled or dated. There was a plastic bag labeled diced potatoes that was not dated, and another plastic bag labeled salmon patties that was not dated. On 5/30/23 at 11:55 AM, V6 (Dietary Aide) was washing dishes in the three-compartment sink. V4 (Dietary Manager) stated, (Testing) is not done as often as we should. You probably know that since I had to go look for the strips. V4 placed the test strip into third part of the sink with the sanitizing solution. V4 pulled out the strip and compared it to the chart on the test strip tube. V4 stated, It looks like 10 ppm (parts per million) but should be in the 50-100 ppm range. I'm going to say I have the wrong strips or it's not right and I need to call the (maintenance) company about the chemicals. On 5/30/23 at 12:00 PM in the first-floor dining room V7 (Cook) pointed to the refrigerator, and stated, I don't feel like this is cold enough. V4 (Dietary Manager) read the dial on the thermometer inside and stated, It's not. It's 50 (degrees Fahrenheit). Everything in there is going to have to go. On 5/30/23 at 12:40 PM, V8 (Dietary Aide) took a can of cream of mushroom soup out of the cupboard on the first-floor dining room. V8 opened the can, poured contents in a bowl, and placed bowl in the microwave for 60 seconds. V8 began working on other tasks, then stopped microwave with 19 seconds remaining. V8 removed the bowl and gave to V4 (Dietary Manager) who served the bowl to R77. V4 or V8 did not check the temperature before serving to resident. 2. On 5/30/23 at 1:11 PM, obtained temperatures of food from the steam table using a metal calibrated thermometer on the first-floor dining room after the last resident tray was served. The pureed pork measured 98 degrees ( ) Fahrenheit (F). The mechanically altered pork measured 100 F. The pureed vegetables measured 99 F. The French fries measured 87 F. The Facility's Modified Diet List documents three residents were on Dental Soft (Mechanical Soft) Diets (R7, R43, R79) and 3 residents on Pureed Diets (R5, R11, R56). 3. On 6/1/23 at 12:08 PM V6 (Dietary Aide) was serving residents in the second-floor dining room. V6 pulled a dish towel out from her cleavage underneath her shirt with gloved hands and placed it on the side of her neck. V6 then placed the same towel in her pant pocket. V6 did not change gloves but resumed plating food at the steam table and delivered a plate to R79. On 6/1/23 at 9:58 AM, V1 (Administrator) stated she expects staff to follow food service policies. The Facility's Food Storage (Dry/Refrigerated/Frozen) Policy, 2011 Edition, documents, Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration. Keep potentially hazardous foods out of the temperature danger zone (41 F - 135 F, or per state specific regulations). Leftover contents of cans and prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers. Refrigerated storage guidelines to be followed: Set refrigerators to the proper temperature. The setting must ensure the internal temperature of the food is 41 F or lower. Wrap food properly. Never leave any food item uncovered and not labeled. Any food item at greater than 41 for an unknown duration of time, such as during opening of the kitchen, will be discarded immediately. The Facility's Steam Table Serving Temperatures for Hot and Cold Foods Policy, 2011 Edition, documents, Staff will follow the guidelines below when serving hot and cold beverages and food Foods will be served at the following temperatures to ensure a safe and appetizing experience. Meat, Casseroles: 135 F to 170 F. Vegetables, Potatoes: 135 F to 170 F. The Resident Census and Condition of Residents Form, (CMS 672), dated 5/30/2023 documents there are 87 residents living in the Facility.

Based on observation, record review, and interview, the facility failed to meet the minimum requirement for RN (Registered Nurse) coverage. This has the potential to affect all 72 residents living at the facility. On 06/22/22 on the 7am to 7pm shift, it was observed that there were no RNs on duty at the facility. Nursing staff schedules for May 2022 and June 2022 documented the following days where there were no RNs scheduled to work on any shift: Monday 5/23/22, Friday 5/27/22, Wednesday 06/08/22, Friday 06/10/22, Tuesday 06/14/22, Friday 6/17/22, and Wednesday 06/22/22. On 06/22/22 at 08:30am, V1 (Administrator) acknowledged that the above referenced dates lacked RN coverage. V1 stated that V2 (Director of Nurses) was at work all of the above dates and was therefore available to provide skilled services such as IV (Intravenous) therapy. V1 stated the facility is always attempting to attract and retain nursing staff and has advertisements on multiple platforms toward this end. A Census and Conditions dated 06/21/22 documented a total of 72 residents living at the facility.

Based on observation, interview, and record review the facility failed to ensure interventions to prevent falls were appropriately implemented for 1 of 8 (R65) residents reviewed for falls in the sample of 43. This failure resulted in R65 falling out of bed sustaining a comminuted intra-articular fracture of distal femur. Findings Include: R65's facility face sheet dated 5/17/22 documents R65 was admitted to the facility on [DATE] with diagnoses that include acquired absence of right and left leg below the knee, heart failure, [CONDITION(S)], chronic pain, diabetes, and muscle spasms. R65's Minimum Data Set (MDS) dated [DATE] documents R65 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates R65 is cognitively intact. R65's MDS documents under section G that R65 requires assist of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. R65's fall risk assessments documents a score of 15 on 4/6/22 and a score of 20 on 4/10/22 which indicate R65 is at high risk of falls. R65's care plan with a revision date of 4/25/22 documents I have a potential for falls or injury from falls R/t (related to) the use of anti-psych (psychiatric) medications and my history of falls. Goals- I will have no injury from falls by: Long-term . 6/11/19 interventions are documented as; keep bed in lowest position, complete fall assessments as needed, assess area for hazards, invite and escort to planned activity, ensure glasses are clean, monitor for behaviors, ensure call light is in reach, monitor lab values, monitor diet, monitor for side effects, ensure adaptive equipment is being used properly, do medication review, and monitor for signs/symptoms of pain. 1/5/21 intervention is documented as R65 is to be transferred using a mechanical lift and assist of two staff. 4/11/21 intervention documents, 4/6/22 Fall; Noted fall resulting in fx (fracture) to L (left) femur. Resident (R65) was sent to ER (emergency room ) for eval (evaluation) cont. (continue) with brace to LLE (left lower extremity). Intervention: Fall mat to be beside bed, body pillow for proper positioning in bed . Under interventions the care plan documents 4/10/22 Fall: Noted fall with no apparent injuries noted. R65 is alert and able to make needs known. Intervention: Staff to ensure proper positioning in bed and MD (physician) to be updated regarding meds R/T (related to) increased confusion . On 5/11/22 at 11:36 AM, R65 stated she was asleep in her bed (on 4/6/22) and woke up when she hit the floor and heard a loud crunch. R65 stated she broke her femur and had broken the other leg in the exact same way before. R65 stated after she fell and broke the first leg the facility put a mat on the floor by her bed. When asked if the mat was on the floor when she fell the second time, R65 stated it was not. R65 was observed sitting in her wheelchair with bilateral below the knee amputations and a brace noted to her left lower extremity. R65's facility Accident report dated 9/8/21 documents at 5:10 AM, R65 rolled out of bed onto the floor. Under outcome, the report documents R65 had pain to her right kneecap, an abrasion to her right stump and on right side of head. Under contributing factors, the report documents bed in high position, no call light and motorized wheelchair parked right up against head of bed in front of AC unit. Under corrective actions taken the report documents Neuro's initiated, .X-ray coming out to x-ray right knee cap. MD (physician) updated with new orders to send to ER for Eval, (R65) was seen and x-ray obtained with results of FX (fracture) to R (right) femur with orders to cont. (continue) pain meds as ordered and refer to ortho (orthopedics) . Under measures to prevent recurrence the report documents Educate resident on keeping w/c (wheelchair) out of room when plugged in. Educate staff on keeping bed in lowest position and ensuring resident has call light within reach. R65's 9/8/21 right knee x-ray report documents under impression: 1. Acute mildly displaced transverse fracture involving the distal femur with associated hemarthrosis, 2. Diffuse osseous demineralization suggesting underlying osteopenia/[CONDITION(S)] . R65's hospital after visit summary dated 9/8/21 documents diagnosis as broken leg. R65's facility fall risk assessment dated [DATE] documents Noted fall with FX (fracture) noted to R (right) femur after x-ray done at ER. Staff to ensure bed is in lowest position and fall mat applied. Staff to ensure elder is properly positioned in bed. See goals. Elder was referred to ortho. Will monitor. R65's progress notes document the following: 4/6/22 at 3:10 AM documents, Note: (R65) was yelling and upon entering room (R65) was on right side in floor beside bed. (R65) stated, I rolled out of bed. (R65) stated that no injury (sic) and did not hit head. (R65) (mechanical lift) into recliner. ROM (range of motion), LOC (level of consciousness), and neuros WNL (within normal limits) for (R65). Fall mat placed beside bed. Resident encouraged to lay in the middle of the bed r/t (related to) resident is a double BKA (below knee [CONDITION(S)]) . 4/6/22 11:17 AM Note: Shift f/u (follow up) for fall. During assessment this morning resident was calm and sleeping in recliner with c/o (complaints of) little pain to left knee. About an hour later resident became tearful complaining of severe pain to left knee stating, I'm afraid it's broken. No warmth, bruising, redness or obvious signs of injury at site. Left knee slightly more swollen than right knee. Able to move left lower extremity. Noted large purple knot/hematoma on left forearm. Denies pain to arm, stated, I didn't even know it was there V17 (physician) was updated on complaints of pain to LFA (left forearm) and L (left) knee. New order for STAT X-ray to both sites . 4/6/2022 8:17 PM Note: 1:00 PM .Updated on x-ray results with N.O. (new order) to send to ER (emergency room ) for further imaging, eval (evaluation), and tx. (treatment). R65's facility accident report dated 4/6/22 documents at 2:40 AM under description, Resident rolled out of bed. Under Outcome: No apparent injury neuros started. Under Contributing factors: Resident mental (resident was sleeping). Under Corrective Actions Taken: Fall mat placed beside bed. Under measures to prevent recurrence: Fall mat beside bed. Bed in lowest position. Encourage resident to stay in the middle of the bed. R65's radiology report dated 4/6/22 documents an examination of pelvis, left hip, left femur, and left knee at 2:52 PM. Under clinical history the report documents, Trauma. fell from bed. Previous below-knee amputation. Under Impression the report documents, Comminuted intra-articular fracture of the distal femur. R65's hospital after visit summary dated 4/6/22 documents fall as the reason for visit and closed displaced fracture of distal epiphysis of left femur . On 05/13/22 at 11:56 AM, V14 (Certified Nursing Assistant/CNA) stated she was not working when R65 fell . V14 stated R65's fall interventions are a floor mat, bed in lowest position, and to ensure the call light is in reach. V14 stated the floor mat has been in place for a while and is not a new intervention. On 5/13/22 at 12:12 PM V19 (Licensed Practical Nurse/LPN) stated she was working the night R65 fell and fractured her leg in April of 2022. V19 stated R65 was in her bed and the facility staff heard her yelling. V19 stated when they entered R65's room she was on the floor. V19 stated R65 was laughing and stated she fell out of her bed. V19 stated she assessed R65 and R65 did not have any complaints. V19 stated she was off work the next day and when she came back, she was told R65 had started complaining of pain and was sent to the hospital for evaluation. When asked what interventions were put in prior to R65's fall, V19 stated she had a high/low bed and mats on the floor. When asked if that was all in place when R65 fell V19 stated it was. On 5/13/22 at 1:10 PM, R65 confirmed the mat was not on the floor when she fell out of the bed on 4/6/22. On 5/13/22 at 1:37 PM, V20 (CNA) stated she was working the night (4/6/22) R65 fell and fractured her leg. V20 stated she heard yelling and went to check on R65 and she was laying on the floor. V20 stated she moved the floor mat and the wheelchair and then got the mechanical lift and got R65 up and back into bed. When asked if R65 was laying on the floor mat when she found her, V2 stated, Umm, I want to say she was, but I can't quite remember because I have a bad memory. When asked if she was R65's CNA that night, V20 stated she was. When asked if she assisted R65 to bed that night V20 stated she couldn't remember. On 5/13/22 at 1:47 PM, V2 (Director of Nurses) stated she didn't think there was a mat on the floor when R65 fell on [DATE]. V2 stated R65 always refuses the mat. V2 stated she would expect the mat to be in place when R65 is in bed. On 5/13/22 at 2:38 PM, V21(MDS/Care plan Coordinator) stated on 4/6/22 when R65 fell and fractured her leg she received a call from the staff notifying her of the incident. V21 stated she was told the mat was not on the floor beside the bed when R65 fell . V21 stated R65 is not a fan of the fall mat and likes to sleep in her chair at times. V21 stated R65 is alert and oriented and her BIMS is always 15. V21 stated R65 would not be able to transfer herself or move the floor mat herself. On 5/18/22 at 8:30am, V17 (R65's Physician) stated a fall mat on the floor beside R65's bed may not have been 100% effective in preventing R65's fracture, but it would certainly have lowered the possibility of a fracture. V17 stated it is his expectation that the facility will consistently implement fall precautions. The facility Falls-Clinical Protocol dated March 2018 documents under Cause Identification 1. For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes within 24 hours of the fall Under Treatment/Management the protocol documents, 1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequence of falling. A. Frail elderly individuals are often at greater risk for serious adverse consequences of falls. B. Risks of serious adverse consequences can sometimes be minimized even if falls cannot be prevented.

Based on observation, interview, and record review, the facility failed to provide prescribed nutritional supplements and meals as ordered for 3 (R23, R24, R38) of 7 residents reviewed for nutritional services in the sample of 43. This failure resulted in R24 suffering a 7.95% weight loss over the past 3 months. Findings Include: 1. On 05/11/22 at 09:47 AM, R24 was observed in his room, sitting in his wheelchair. An interview with R24 revealed R24 was alert to person only. R24's current physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . R24 is documented as admitting to the facility on [DATE] from an Assisted Living Facility. Review of R24's weights in his Electronic Health Record documented the following entries: 146.4 lbs (pounds) - 11/03/2021 158.9 lbs -12/02/2021 149.7 lbs - 02/02/2022 149.8 lbs - 03/02/2022 141.9 lbs - 04/06/2022 137.8 lbs - 05/04/2022 When calculated, this shows R24 has had a 7.95% weight loss in the past 3 months. On 5/17/22 at 9:58 AM, V2 (Director of Nursing/DON) stated that R24 did not have a January 2022 weight documented. V2 confirmed R24 was present in the facility during January and is unsure why a weight was not obtained for that month. Review of R24's Physician Order's documents an active order with an original order date of 2/21/22 for House Supplement TID (three times a day). R24's dietary orders also include an order with a 1/5/22 original order date for Diet order changed to mechanical soft with nectar thick liquids and Monitor Weight stating to schedule every month on the 1st Wednesday at 5:00 AM - 5:00 PM with the original order date being 12/20/21. Review of V8's (Registered Dietitian/RD) most recent dietary note entry dated 4/13/22 documents R24's Ideal Body Weight is between 139-169 pounds. V8's entry stated she recommends continued diet therapy, continue supplements, 2cal (calorie) med pass 60 cc (cubic centimeter) tid (three times daily), encourage oral intake, with no weight decrease desired. Review of R24's Plan of Care documents a problem area with an effective date of 9/25/21 which stated, I am at risk for inadequate nourishment R/T (related to) my dx (diagnosis) of pain and SOB (shortness of breath). Interventions listed for this plan of care include: Provide my diet order TID and PRN (as needed); Monitor my intake of all meals. On 05/11/22 at 12:31 PM, R24 was served a meal tray of broccoli, ground chicken with mushroom sauce, buttered egg noodles, and glazed apple cake. Review of R24's meal ticket served with his tray documents bread and margarine should have also been included, which is not observed on the tray. Along with the bread and margarine, no house supplement was observed to be served with the meal. On 05/11/22 at 12:43 PM, V5 (Dietary Aide) stated bread and butter is listed on the diet tickets/menu for R24 today and acknowledged it was not served. V5 stated she has it in the cabinet and residents can ask for it if they want some. V5 stated house supplement drinks are served with meals by dietary or CNA (Certified Nursing Assistant) staff when serving trays. V5 acknowledges no house supplement drinks were served to anyone in the 2nd floor dining room during lunch time today, which includes R24. V5 confirmed the error and stated she will get the supplements served to residents. On 5/13/22 at 8:46 AM, V8 (RD) stated that house supplements are given to residents during meals by the kitchen staff. V8 stated that foods listed on resident's meal ticket should be served unless the resident specifically has requested not to receive that food. V8 stated that the lack of residents receiving house supplements or diets as ordered can be a factor with weight loss as those are just missed calories. V8 stated she would expect residents to be receiving house supplements along with foods listed on their diet card corresponding with their diet as prescribed. V8 stated when reviewing R24's food intake log which is completed by the CNA's, there are very few entries. V8 stated from 5/7/22 - 5/12/22 between all 3 meals served in a day, there are only 5 entries made in total for food intake percentages for R24. V8 stated intakes should be documented each meal. On 5/13/22 at 4:30 PM, V12 (Physician) stated that he would expect R24 to be receiving his diet and nutritional supplements as ordered. V12 stated he was aware R24 had experienced weight loss. V12 stated that R24 had previously had Covid, which seemed to take a declining toll on his health. V12 stated while the supplements may or may not provide R24 weight gain, V12 confirms he would expect them to be provided in an effort to prevent further loss. Review of R24's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) the score of 99, which indicates the resident was unable to complete the interview. Section G of the same MDS documents under the section titled eating that R24 required limited assistance of one-person physical assist. 2. R23's Face Sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R23's MDS dated on 3/26/2022 documented a BIMS score of 15, indicating he is cognitively intact. Section G of the same MDS under the section titled eating documents set up with one assist needed. Section K documents no swallowing disorder but has a weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] R23's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/11/22 at 12:54 PM, R23 did not get a house supplement or ice cream served for lunch as indicated on his menu card. R23 was served ice cream after surveyor asked V18 (Restorative Aide) if he should have ice cream served. On 5/11/2022 when surveyor asked V18 if (R23) was supposed to get ice cream and a house supplement served as indicated on the menu card, V18 asked (R23) if he would like the ice cream for lunch and R23 stated yes. V5 (Dietary Aide) stated (R23) should have been served ice cream and a house supplement as indicated on his menu card. V5 stated Yes if the diet card has to serve ice cream and house supplement it should be served with the meal. On 05/13/22 at 9:52 AM, V8 (RD) stated, if (R23's) menu card had house supplement three times a day, she would expect dietary staff to serve the supplement at all three meals. V8 also stated that if the diet card has ice cream on it, they should be serving the ice cream too. 3. R38's Resident Face Sheet documented diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Vitamin Deficiency, Immobility syndrome (paraplegic). Permanent [CONDITION(S)] fibrillation; Nonrheumatic aortic (valve) stenosis; Presence of cardiac pacemaker, and Chronic Kidney Disease. R38's MDS dated [DATE], documents a BIMS score of 15, indicating R38 is cognitively intact. Section G of this same MDS documents R38 requires limited assistance with eating by one staff member. Section K documents no swallowing disorder but has weight loss of 5% or more within the last month. R38's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/11/22 at 11:38 AM, R38 stated he has lost weight over the last 6 months. R38 also stated, the food does not taste good because it is often over cooked or undercooked. On 5/11/2022 at 12:30 PM and 5/12/2022 at 12:07 PM, R38 was eating lunch and did not have a house supplement served. R38's menu card did not have a house supplement listed. On 05/13/22 at 8:48 AM, R38 was eating breakfast and he still did not have a house supplement served or a house supplement listed on his menu card. On 5/13/2022 R38 stated, he does not get a house supplement. R38 also stated he was not aware he was supposed to be getting a house supplement with his meal. On 05/13/22 at 9:52 AM, V8 (RD) stated, (R38) should be getting a house supplement with his meals per the doctor's order written on 5/4/2022. On 05/13/22 at 11:25 AM, V1 (Administrator) stated, V2 (DON) sends the registered dietician's recommendations to the doctor to get them approved which is usually done within a few days. V1 also stated, usually in their morning meetings (V2) will let her know the dietary recommendations were approved, and she will update the resident's menu cards for the kitchen staff thereafter. V1 stated, she was not aware of (R38's) diet order for house supplement three times a day and she would check into this. V1 also stated, there is no policy on supplements.

Based on observation, interview and record review, the facility failed to check the placement of an enteral tube before initiating a feeding, to monitor monthly and weekly weights, and to provide the correct amount of enteral feeding as per Dietician and Physicians orders for one tube fed resident with significant weight loss (R48) of one resident reviewed for enteral feeding in the sample of 43. This failure resulted in R48 losing a total of 30 pounds between 12/21/21 and 4/6/22. Findings include: A Face Sheet documented that R48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . (g tube.) R48's Care Plan with a review date of 4/13/22 documented a problem area, I am at risk for inadequate nourishment ., with a corresponding goal, I will maintain my weight between 135 pounds and 140 pounds, and intervention, Monitor my g tube feeding formula and ensure it is adequate and consult with Registered Dietician R48's May 2022 Physicians Order Sheet (POS) documented an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . NPO (Nothing by mouth). This POS did not document an order as to the frequency of weight monitoring. The same POS documented, Stage 2 pressure wound to the right buttock. On 05/11/22 at 8:51am, R48 was observed in her room. R48 appeared thin, with contracted limbs. R48 was alert but not oriented to person, place, or time, and most of her answers were unintelligible. An enteral feeding pump was infusing a trade name 1.2 calorie per ml enteral feeding supplement at a rate of 75 ml per hour into R48's g tube. On 05/11/22 at 10:33 am, V15 (Licensed Practical Nurse/LPN) was observed changing the tubing and initiating a new container of R48's enteral feeding. V15 turned off the pump and unhooked the pump tubing from the g tube port and removed the empty container of solution. V15 took a new tubing set up and inserted it into the new feeding solution container. V15 then hooked the tubing to the g tube port and restarted the pump, and the feeding began infusing. V15 did not check for g tube placement, either by auscultation or checking for residual gastric contents, prior restarting the feeding. A Gastric Tube Feeding Policy dated 8/29/17 documented, Aspirate the feeding catheter using a syringe to determine proper placement, (then) attach feeding solution tubing to gastric tube. On 05/12/22 at 03:05 PM, V15 stated g tube placement should be checked via auscultation and by aspirating residual gastric contents, Anytime you are getting ready to put anything into the g tube, either medications, or a feeding. R48's Weight Record documented the following weights: 12/22/21: 136 lb (pounds) 3/2/22: 114 lb 4/6/22:106 lb 5/4/22:112 lb There was no documentation of January and February 2022 weights. An Admission Nutrition assessment dated [DATE] documented, Current (admission) weight 135 lb. Ideal body weight 103-127 lb. Small (pressure) area to coccyx. (Receiving)(trade name enteral feeding) 1.2 calorie per ml 65ml per hour. Progress Notes authored by V8 (Registered Dietician/RD) documented the following: 12/20/21: December weight pending. (Receiving) (trade name enteral feeding solution) 1.2 calories, infuse 65ml per hour for an estimated 23 hours. Recommend current tube feeding. 1/12/22: December weight 136lb. Continue diet therapy. (January weight was not documented in this note). 2/25/22: December weight 136lb. Continue diet therapy. (February weight was not documented in this note). 3/21/22: March weight 132 pounds, December (2021) weight 136 pounds. Increase (feeding rate) to 75ml per hour. 4/27/22: Resident receiving (trade name enteral feeding) 1.2 calories infuse 75ml per hour. April weight 106 lb, December weight 136 lb. Noted weight loss. Tube feeding was increased to 75ml per hour on 3/21/22. Recommend continue tube feeding, weekly weights, no weight loss desired. On 05/13/22 at 9:15am, V8 stated R48 is to receive 75ml of a trade name 1.2 calorie per ml enteral feeding solution every hour via pump, for a total of 1725ml in a 23-hour period. V8 stated an hour off the feeding daily is calculated so as to allow for time in changing the tubing and feeding solution. V8 stated she is not sure why there is an 18 lb. discrepancy between the weight in her 3/21/22 progress note versus the 3/2/22 weight on the resident's weight log in the chart, nor any documentation of January and February weights. V8 stated she depends on getting accurate weights from the staff. V8 stated she was going to evaluate R48 later that day and get back with the surveyor. On 05/17/22 at 8:48am, V15 (LPN) stated the enteral feeding pump records the amount of solution infused, and this amount is to be recorded on the MAR (Medication Administration Record) every 12 hours (once per shift). R48's (MAR) documented the following daily totals for the enteral feeding solution: March 2022: 3/23/22: 1549ml 3/28/22: 1622ml 3/29/22: 1572ml April 2022: 4/19/22: 1699ml 4/20/22: 726ml on the 5am to 5pm shift; on the 5pm to 5am shift,Not collected. 4/21/22: 1295ml May 2022: 5/8/22: 1704ml 5/10/22: 1823ml 5/12/22: 1718ml On 05/13/22 at 9:15am, V8 stated she evaluated R48 on 12/20/21, 1/12/22, 2/25/22, 3/21/22, and 4/27/22. V8 said when she had evaluated R48 on 3/21/22, she was given R48's weight as 134lb, and increased the rate of R41's feeding from 65ml per hour to 75ml per hour to prevent further weight loss. V8 stated she evaluated R48 earlier today and recommended adding a trade name liquid protein supplement 30ml daily to prevent further weight loss. V8 stated the current feeding orders should be enough to meet R48's calorie requirements. V8 stated she cannot account for R48's weight loss except that she may have not taken R48's pressure wound into account when calculating R48's nutritional needs. V8 also stated R48 had Covid in February 2022, and she was not sure if the infection could have contributed to the weight loss. When V8 was shown the above referenced MAR, she stated she could not account for the wide variances in R48's enteral feeding intake. A Progress Note authored by V8 dated 5/13/22 documented, Current weight 112. No tube feeding problems noted in recent nursing notes. Noted weight loss, (but weight did) increase (from April 2022). Resident had Covid 19 mid-February 2022, possibly contributed to weight loss. (Receiving) (trade name enteral feeding supplement) 1.2 calories 75ml per hour, estimated 23 hours, equaling 2070 calories per day. Compared to nutritional needs, the resident is receiving adequate nutrition with both tube feeding products and rate. Recommend continued tube feeding, add Liquid Protein 30cc daily, no weight decrease is desired continued weight increase is beneficial. On 05/17/22 at 08:53am, V2 (Director of Nursing) confirmed that R48 has had a significant weight loss since admission. V2 stated she cannot account for R48's weight loss. V2 stated she is not sure why there is an 18lb discrepancy between the 3/2/22 and 3/21/22 weights. V2 stated she is not sure why R48's weight was not documented in January and February 2022. V2 stated she was unaware V8 had previously recommended weekly weights. V2 stated unless there is a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . V2 stated she is not sure what accounts for the variance in R48's intakes on the MAR as outlined above. V2 confirmed R48 should receive 1725cc of feeding in a 23-hour period. V2 confirmed the intakes are to be obtained from the feeding pump memory and documented on the MAR every 12 hours. V2 confirmed that R48 had Covid in February of 2022. V2 stated she seemed to recall R48 having a couple episodes of emesis during that time in which her feeding had to be shut off. V2 stated she would check for documentation of this in the nurses' notes. V2 stated R48 did not have episodes of loose stool during that time. V2 stated on occasion, staff will disconnect R48's feeding pump and leave it in her room in order to take her outside when the weather is nice. V2 stated staff do not switch on the battery feature so the pump can be taken outside. V2 stated she could perhaps in-service the nurses to leave the pump on and run it with the battery when R48 is taken outside. V2 stated perhaps the facility could begin monitoring R48's weight more frequently than monthly. V2 made no statements indicating she intended to investigate the varying intakes or weight documentation discrepancy. The facility was unable to present any documentation to show that R48 experienced episodes of emesis in February 2022. The facility also did not present any documentation as to R48 being taken outside without her feeding pump. On 05/18/22 at 8:52am, V17 (R48's Physician) verified the tube feeding order as per V2 and V8. V17 stated he has no explanation as to the varying intakes on the MAR as outlined above. V17 stated R48 is NPO, and her daily intakes should be fairly consistent to 1725ml. V17 stated the facility had kept him informed of R48's weight decline.V17 stated a tube fed resident generally will not sustain weight loss. V17 stated a Covid infection, nor a stage 2 pressure ulcer would increase metabolic demand enough to cause a 30lb weight loss. V17 stated his expectation is that the facility should switch the tube feeding pump to battery mode when taking R48 outside if at all possible. V17 stated R48's weight should have been monitored at least monthly, and when the significant weight loss was noted, increasing weight monitoring to weekly per V8's recommendation would have been helpful. V17 further stated the facility needs to investigate the cause of the varying intakes on the MAR. A Resident Weight Policy dated 10/26/17 documented, .Ongoing weights will be performed monthly and as needed per physician's recommendation which may be changed to daily or weekly depending upon condition change. The facility's goal is to address each individual case for potential interventions to stabilize weight status. The (facility) will follow regulations and report significant weight gain or loss. 5% (percent) in one month, 7.5% in 3 months, or 10% in 6 months.

Based on observation, record review and interview, the facility failed to ensure that proper food handling, sanitation and serving procedures were followed to prevent cross contamination. This has the potential to affect all residents in the facility. The Findings Include: On 5/11/22, at 9:30 AM, the gelatin salad in the walk-in refrigerator was left uncovered with no date or time of preparation. On 5/11/22, at 12:15 PM, V7 (Cook) took the temperature of the lunch menu items and the buttered noodles were 120 degrees Fahrenheit. V7 did not reheat the noodles prior to beginning of tray line. On 5/11/22 at 10:45AM, V6 (Cook) was observed to use gloved hands to assemble the commercial blender that would puree the food items and use those same gloved hands to pick up the meat, rip it up with her gloved hands and place in the machine. V6 then proceeded to operate the machine with the same gloved hands. When the proper consistency of the meat was reached, V6 then used her gloved hand to scrape the food from the blender bowl into the stainless-steel container to be used on the steam table of which it will be served. The Resident Census and Condition dated 5/11/22 documents 70 residents currently residing in the facility.

Based on observation, interview and record review, the facility failed to prepare meals as scheduled for puree diets for 6 (R9, R16, R21, R50, R57, R220) of 6 residents reviewed for diet adherence in a sample of 43. The Findings Include: On 5/11/22 at 12:15PM, V7 (Cook) was taking the temperature of the food items on the steam table and the pureed item was mashed potatoes. The menu for the day was documented as chicken with mushroom sauce, broccoli, and buttered noodles. The same menu (with recipe included) had directions indicated for residents receiving pureed diet to have pureed buttered noodles. V7 stated at this time that he doesn't generally puree the buttered noodles by preference, but that he would if a resident requested them. On 5/12/22 at 10:45 AM, V6 (Cook) was observed to be preparing the pureed items and stated that she had mashed potatoes for the lunch menu selection for the purees. The menu for today lists boneless pork chop, fried potatoes and onions, and mixed vegetables. The recipe book for that day's menu items indicated that residents who receive puree diet would receive the same food items. V6 stated that she just added garlic powder to the mashed potatoes for the residents who receive a pureed diet. On 5/12/22 at 2:00 PM, V1 (Administrator) stated that the residents with a pureed diet order should be receiving the same food as the regular consistency residents are receiving and following the diet spreadsheet. On 5/13/22 at 10:00 AM, V8 (Dietitian) stated that the facility should be pureeing the foods as the menu instructs.

Based on observation, interview, and record review, the facility failed to ensure expired stock medications were disposed of per current standards of practice for 15 (R2, R3, R4, R8, R12, R15, R24, R26, R30, R32, R44, R49, R56, R60, and R67) of 33 residents reviewed for medication storage in the sample of 43. Findings Include: On 05/11/22 at 03:22 PM, Medication Cart C located on the 2nd floor was reviewed with the following stock medication observations: 1. 1 bottle Ibuprofen 200 mg tablets, exp. 11/2021 2. 1 bottle Vitamin D 50,000 IU (International Units), exp. 7/2021 3. 1 bottle Naproxen Sodium 220 my, exp. 2/2022 4. 1 bottle Guaifenesin 200 my tab; exp. 11/2021 Review of additional stock medication bottles present in the medication cart revealed no additional bottles of the same medication present that were not expired which may have been available for use. On 5/11/22 at 3:30 PM, V4 (Registered Nurse/RN) stated she isn't sure who is assigned to clean out the medication cart regularly. V4 stated night shift nurses do this most of the time she believes, and then day shift does as they can. V4 was shown the expired medications for disposal. On 05/12/22 at 8:02 AM, V3 (RN) states that Medication Cart C serves Rooms BBB-CCC, with the exception of room AAA and all stock meds could potentially be used for the people in those rooms. Review of the Facility Matrix documents based on the room numbers assigned, Medication Cart C would serve R2, R3, R4, R8, R12, R15, R24, R26, R30, R32, R44, R49, R56, R60, and R67. Review of the facility policy titled Medication Therapy with a most recent revision date of 4/28/21 stated under the section titled Expired Medications, The outdated medications will be returned or destroyed following the discontinued med protocols.

II. Based on observation, interview, and record review, the facility failed to implement infection control measures to prevent and/or contain Covid-19 as evidenced by 1. Failure to provide adequate resident supervision to ensure Covid-19 positive residents remain within the designated Covid-19 isolation areas and away from Covid negative residents. 2. Failure to ensure residents testing positive and/or developed symptoms of [CONDITION(S)] CoV-2 (Covid-19) were isolated per current standards of practice to prevent the spread of Covid-19. 3. Failure to ensure proper use of PPE (Personal Protective Equipment), hand hygiene, and prevention of cross contamination according to current standards of practice. 4. Failure to ensure disinfectants used to treat non-porous surfaces for Covid-19 were utilized per manufacturer guidelines. These systemic failures have resulted in 54 residents (R1, R3, R4, R5, R6, R7, R8, R9, R11, R15, R17, R18, R19, R20, R22, R24, R25, R26, R27, R29, R31, R32, R35, R36, R38, R39, R40, R41, R42, R43, R44, R45, R48, R49, R50, R51, R52, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62, R63, R64, R65, R66, R67, R68, and R69) testing positive for Covid-19, with death being the result for 3 of these residents (R11, R36, and R66) who were confirmed positive for Covid-19. These failures have the potential to affect all 74 residents residing in the facility and resulted in an Immediate Jeopardy (IJ) to their health and safety. These failures resulted in an Immediate Jeopardy (IJ) which began on [DATE] when a Covid-19 positive resident (R6) was observed wandering in the vicinity of Covid-19 negative residents. Twenty-six facility residents subsequently tested positive for Covid-19 and the facility failed to safely separate residents based on Covid-19 status. R11 expired from Covid-19 on [DATE]. R36 expired from Covid-19 on [DATE]. R66 expired for Covid-19 on [DATE]. Fifty-four residents tested positive for COVID-19 and 3 residents (R11, R36 and R66) expired from COVID-19 and/or complications from COVID-19. Due to these residents' comorbidities and vulnerability, these failures increased their risk for severe illness from COVID-19 and possible death for all 74 residents living in the facility. The facility was notified of the Immediate Jeopardy on [DATE] at 11:37 AM with V1 (Administrator) present. The surveyors confirmed by observations, record review, and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at level two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings Include: On [DATE] at 11:00 AM, V2 (Director of Nursing/DON) stated, the document titled Census Detail Report dated [DATE] documents the current census as 74, and the information on it is correct including room numbers. On [DATE] at 10:20 AM, V1 (Administrator) stated, there are currently 40 positive residents in the facility. Staff are supposed to wear N95 and eye protection when in the facility. They currently do not have a Covid-19 unit, the positive residents are located on all the halls with Transmission Based Precaution signage outside their room. Staff should be donning PPE and performing hand hygiene after exiting a room that houses a Covid-19 positive resident. On [DATE] at 11:30 AM, V1 (Administrator) stated, V2 (DON) has a line list with the resident's names and date of positive test for Covid-19. On [DATE] at 9:12 AM, V1 (Administrator) stated the Line List is the updated list of the residents that have tested positive for Covid-19 with their test dates. On [DATE] the untitled, undated document, referred to as the line list documents the resident's name and date of positive test for Covid-19. The Line list documents on [DATE] three residents (R6, R7, and R11) tested positive for Covid-19. On [DATE] one resident (R8) tested positive for Covid-19. On [DATE] two residents (R5 and R52) tested positive for Covid-19. On [DATE] twenty-six residents (R1, R4, R9, R24, R25, R31, R35, R36, R38, R39, R41, R43, R48, R49, R50, R53, R54, R55, R56, R57, R58, R59, R60, R61, R62, and R63 tested positive for Covid-19. On [DATE] one resident (R64) tested positive for Covid-19. On [DATE] one resident (R18) tested positive for Covid-19. On [DATE] eight residents (R15, R26, R32, R42, R44, R45, R65, and R66) tested positive for Covid-19. On [DATE] eight residents (R3, R17, R19, R20, R22, R40, R51 and R67) tested positive for Covid-19. On [DATE] two residents (R27 and R68) tested positive for Covid-19. On [DATE] one resident (R69) tested positive for Covid-19. On [DATE] one resident (R29) tested positive for Covid-19. Of these residents, three residents (R8, R17 and R18) were hospitalized and three residents (R11, R36 and R66) expired. The State Death Certificate for R11 documents date of death as [DATE] and Cause of Death: a. Covid-19, b. Heart Failure, c. Hypertensive Heart Disease. Approximate interval between onset and death for a. Covid -19 is documented as: Days, (for b. and c. it is documented as Years). The State Death Certificate for R36 documents date of death as [DATE] and Cause of Death: a. Acute Respiratory Failure, b. [CONDITION(S)] Covid-19 Pneumonia. The approximate interval between onset and death for both a. and b. is documented as 1 week. The State Death Certificate for R66 documents date of death as [DATE] and Cause of Death: a. Novel Corona Covid-19 Virus Infection Virus Infection, b. Dementia, c. Hypertensive Heart Disease. The approximate interval between onset and death for a. is documented as Days and both b. and c. is documented as Years. R8's Electronic Medical Record's progress note documents R8 was sent to the hospital on [DATE] after complaints of not feeling well and having a fever of 102 degrees Fahrenheit that was not reduced with Tylenol. R8 was diagnosed at hospital with Covid-19. R17's Electronic Medical Record's progress note documents R17 was sent to the hospital on [DATE] with complaints of congestion, severe cough and minimal secretions. R17 tested positive for Covid-19 at the hospital and returned to the facility with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R18's Electronic Medical Record Census detail documents R18 was sent to the hospital on [DATE]. R18's progress note documents R18 had complaints of shortness of breath and cough. R18's hospital records document R18 tested positive for Covid-19 at the hospital and returned to the facility, after a six-day hospital stay, with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 1. On [DATE] at 8:35 AM, R1 was alert and oriented to person, place, time, and purpose. R1 stated R1 has not been vaccinated for Covid as R1 has chronic health conditions which render R1 a non-candidate. R1's Medical Record listed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 11:40 AM, R6 was observed ambulating alone in the second-floor hall in front of R1's room. R6 was not wearing a mask. R6 did not verbally respond to the surveyor. V10 (Certified Nursing Assistant) was observed coming down the hall and intercepting R6, taking R6's arm and slowly guiding R6 back to R6's room as R6 was somewhat resistive. V10 was not wearing a gown, stating she did not have time to don one when she saw R6 in the hall. V10 stated R6 is on isolation due to being Covid positive. V10 stated R6 is confused, and staff have difficulty keeping R6 in R6's room. An isolation supply bag was observed on R6's door, and isolation linen and trash barrels were observed within the room. R6's Medical Record documented a [DATE] diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] R6's Nursing Progress Notes documented the following: [DATE]: Left message for (family member) regarding (R6) testing positive for Covid 19. [DATE]: Evening Assessment: Resident alert and oriented to self with much confusion. Refused to stay in room - attempted some wandering into other residents' room. Isolation precautions related to positive Covid (status) attempted. [DATE]: Occasional non-productive cough, continues on isolation precautions, frequent reminders to stay in room required as resident has attempted to exit room several times. [DATE]: Evening Assessment: Isolation precautions continue related to Covid. Resident is alert with confusion. (R6) Attempted to wander (the) hall per usual. R6's Minimum Data Set, dated dated dated [DATE] documented a Brief Interview for Mental Status Score of 99, indicating R6 is so severely cognitively impaired the test questions could not be asked. On [DATE] at V2 (Director of Nurses) stated when R6 was placed on isolation on [DATE], V2 anticipated having difficulty keeping R6 in R6's room. V2 stated consideration was given for either providing R6 with one-to-one staff supervision or placing R6 on the South Hall quarantine unit, where there are positive and presumed positive residents. 2A.) On [DATE] at 12:22 PM, R50 and R51 were observed residing in the same room with no barrier or any Transmission Based Precautions in between the residents. The Facility Line List documents R50 tested positive for Covid-19 on [DATE] and R51 tested negative. The Facility Census Detail Reports dated [DATE], [DATE], [DATE], and [DATE] document R50 and R51 are roommates. On [DATE] at 12:40 PM R50 and R51 were observed still residing together in the same room with no Transmission Based Precautions between the residents. The Facility Line List documents R51 tested positive for Covid-19 on [DATE]. On [DATE] at 8:00 AM, V2 (Director of Nursing) stated V2 said on [DATE] at around 6:30 PM the residents were rapid tested and R51 tested positive for Covid-19. On [DATE] at 8:00 AM, V2 (Director of Nursing) stated all residents that had not previously tested positive for Covid-19 were tested on [DATE], [DATE], [DATE] by rapid tests at the facility. On [DATE] R50 tested positive and R51 tested negative for Covid-19. On [DATE] at 10:50 AM, V21 (Social Service Director) stated the test results from [DATE] showed that R51 was also positive for Covid-19. Both residents remained roommates from the time that R50 was known to be Covid-19 positive from test results of [DATE] through [DATE]. 2B.) On [DATE] at 10:30 AM, R32 and R33 were observed residing in the same room with no barrier or Transmission Based Precautions in place between the residents. The Facility Line List documents R32 tested positive for Covid-19 on [DATE]. The Facility Census Detail Report dated [DATE] documents R32 and R33 are roommates. On [DATE] at 11:00 AM, V2 (Director of Nursing) stated all residents that had not previously tested positive for Covid-19 were tested on [DATE] by rapid tests at the facility. R32 tested positive and R33 tested negative for Covid-19. R32 and R33 were separated on [DATE]. 2C.) On [DATE] at 11:25 AM and on [DATE] at 1:05 PM, R61 and R71 were observed residing in the same room with no Transmission Based Precautions between the residents. The Facility Line List documents R61 tested positive for Covid-19 on [DATE]. The Facility Census Detail Report dated [DATE] documents R61 and R71 are roommates. On [DATE] at 11:00 AM, V2 (Director of Nursing) stated all residents that had not previously tested positive for Covid-19 were tested on [DATE] by rapid tests at the facility. R61 tested positive and R71 tested negative for Covid-19. The Facility Bed Census dated [DATE], [DATE], and [DATE] document R61 and R71 were roommates. The Facility Census Detail Report dated [DATE] document R61 and R71 were roommates. R71's Electronic Health Record's Progress notes documents: on [DATE] at 1:13 AM, R71 had complaints of increased shortness of breath, inspiratory and expiratory wheezes, a productive cough and pain with breathing. On [DATE] at 10:26 AM R71's Progress Notes document: continue monitoring of R71 due to roommate (R61) positive for Covid-19, wheezing bilaterally, an occasional cough and congestion present. On [DATE] at 2:19 PM R71's Progress Notes document: R71 has a fever of 100.8 degrees Fahrenheit, has complaints of chest pain, back pain and pain radiating down left arm. R71's Covid-19 rapid test is negative. Orders are given for R71 to be sent to the emergency room for evaluation. On [DATE] at 10:43 PM, R71's progress notes document R71 continues on isolation due to R71's roommate (R61) has tested positive for Covid-19. R71's lungs are clear. R71 has an occasional cough and congestion present. On [DATE] R71's progress note documents: R71 is noted with a wet productive cough, lungs are coarse, and complaints of chest hurting when coughing. The Facility Bed Census dated [DATE] documents: R71 returned from the hospital to R71's previous room. The Facility Bed Census dated [DATE] documents R61 and R71 are roommates. 2D.) On [DATE] at 11:22 AM, R26 and R27 were observed residing in the same room with no barrier or Transmission Based Precautions in place between the residents. On [DATE] at 12:52 PM, R26 was observed and heard coughing multiple times, while roommate R27 stated I don't feel well. The Facility Line List documents R26 tested positive for Covid-19 on [DATE]. The Facility Census Detail Report dated [DATE] documents R26 and R27 are roommates. On [DATE] at 11:00 AM, V2 (Director of Nursing) stated all residents that had not previously tested positive for Covid-19 were tested on [DATE] by rapid tests at the facility, R26 tested positive and R27 tested negative for Covid-19. On [DATE] at 10:00 AM, R26 and R27 were observed still residing in the same room with no Transmission Based Precautions in place between the residents. The Facility Census Detail Report dated [DATE] documents R26 and R27 were roommates. R26 and R27 were separated on [DATE]. The Facility Line List documents R27 tested positive for Covid-19 on [DATE] via a rapid test. 2E.) On [DATE] at 10:05 AM, R20 and R21 were observed residing in the same room with no Transmission Based Precautions in place between the roommates. The Facility Line List documents R20 tested positive for Covid-19 on [DATE] and R21 tested negative for Covid-19. On [DATE] at 11:00 AM, V2 (Director of Nursing) stated all residents that had not previously tested positive for Covid-19 were tested on [DATE] by rapid tests at the facility, R20 tested positive and R21 tested negative for Covid-19. On [DATE] at 12:25 PM, R20 and R21 were observed residing in the same room with no Transmission Based Precautions in place between the roommates. On [DATE] at 12:25 PM V36 (Certified Nurse Aide) stated, she was not sure if R21 or R20 would be separated since R20 tested positive for Covid-19 and R21 is still negative for Covid-19. V36 (CNA) stated, V21 (Social Services) would have that information. The Facility Census Detail Report dated [DATE] documents R20 and R21 are roommates. On [DATE] at 3:00 PM, R20 would not answer when spoken to. R20 had a brown tinged sputum accumulating on R20's shirt while coughing, while residing with a covid-19 negative roommate (R21). There were no Transmission Based Precautions in place between the roommates. On [DATE] at 4:10 PM, R20 (Covid-19 positive) and R21 (Covid-19 negative) were observed still residing in the same room with no Transmission Based Precautions in place between the roommates. On [DATE] at 4:00 PM, V21 (Social Services) stated, R20 did test positive in the testing done on [DATE] at approximately 6:30 PM. She believes R20 and R21 might be separated and R21 moved over to the wing that they are going to make into the Covid-19 negative unit later this evening. She believes they are going to move the residents that have not tested positive for Covid-19 to the empty hall just past the business offices, the 100 hall. V21 stated, R23 is also Covid-19 negative. R23 is on the hall after the locked doors which does contain all Covid-19 positive residents, but R23 is on transmission-based precautions for something besides Covid-19, therefore she is unaware if they are going to move R23 or not. 3.) On [DATE] at 1:33 PM V2 (DON/the Infection Preventionist) said that all staff get fit tested for the N95 masks in use. V2 stated staff are to wear N95 masks and eye coverings when inside the facility. V2 stated proper N95 mask placement includes wearing one strap higher and one strap around the neck to make a secure fit and tight seal. You should see the mask move in and out when you breathe. V2 said she retrained the staff last week. On [DATE] at 1:33 PM during the interview with V2 (DON), two staff were observed walking between surveyors and V2 (DON) with masks improperly worn. V31 (Housekeeping) had the second strap of the N95, in front of the N95 hanging loose, and V29 (CNA/Transportation) had the bottom strap of the N95 completely cut off. V2 did not address it at that time. On [DATE] at 10:25 AM, V31 (Housekeeping) and V29 (CNA/Transportation) were observed walking down the hall with their N95 incorrectly. V31 (Housekeeping) had the bottom strap of his N95 hanging down in front of his N95 with the strap hanging below his chin and V29 (CNA/Transportation) had completely removed the bottom strap of her N95, causing neither N95 not to fit securely. On [DATE] at 10:27 AM, V31 (Housekeeping) was observed entering R15's (Covid-19 positive) room wearing his mask with the bottom strap hanging loose in front of the N95, not creating a tight fit. On [DATE] at 1:33 PM, V10 (Certified Nurse Aide) was observed not wearing her N95 correctly, both straps were at the bottom of her neck with the mask fitting very loosely. V10 had to keep pulling it up with her hands, touching the front of it. V10 had just exited R4's room, a Covid-19 positive resident. V10 (CNA) then touched the wall, a table sitting in the hallway and a trash bag never performing hand hygiene after touching the front of her N95 or before touching any of the other items. On [DATE] at 12:55 PM, V10 (CNA) was seated at a table in the hallway with her mask pulled down below her nose. V10 did not pull up her mask immediately when surveyor began speaking with her. On [DATE] at 1:30 PM, V10 was observed going in and out of resident rooms collecting disposable plates from lunch for disposal. V10 was observed not changing her N95 mask while going in and out of resident rooms or cover the N95 mask with surgical masks. V10 said that she was not sure which rooms were Covid positive and which rooms were not and indicated that she was confused about how to remove the disposable dishes from the resident rooms properly. V10 (CNA) stated, there had been some infection control training, but so many residents became Covid positive in such a short time, it has been confusing. On [DATE] at 1:33 PM, V10 (Certified Nurse Aide) stated she does not always put a gown on when she enters the resident's rooms. If there is a gown already hanging there, she will put it on. V10 (Certified Nurse Aide) stated she is only going in and grabbing their dishes from lunch. V10 (Certified Nurse Aide) stated she does not know which rooms have Covid-19 positive residents and which ones do not. On [DATE] at 11:00 AM, V24 (CNA) was wearing her N95 appropriately with the bottom strap hanging down in front below her chin, not making a seal prior to entering R4's room (Covid-19 positive) and after exiting R4's room. V24 (CNA) then walked down the hall and enter R20's (Covid-19 negative) room. On [DATE] at 12:36 PM, V19 (Activity Director) entered R44's room, a Covid-19 positive resident. V19 did not exchange her N95 mask upon exiting the room, on a hallway that contain both Covid-19 positive and negative rooms. V19 did not use a surgical mask to cover the N95 mask when in R44's room. On [DATE] at 3:40 PM, V19 (Activity Director) donned PPE and brought activity items (puzzles, magazines, and a deck of cards) into R48's, a Covid-19 positive resident and R49's, a Covid-19 positive resident, room. V19 doffed all but N95 mask upon exit from room. V19 (Activity Director) did not use a surgical mask to cover the N95. Signage present on R48 and R49's door that read: Contact/Droplet Precautions. On [DATE] at 12:25 PM, V27 (Speech Language pathologist) was observed in R30's room (Covid-19 positive) wearing his N95 with the bottom strap hanging down in front under his chin not creating a seal. V27 (Speech Language Pathologist) left R30's room and entered R34's room (Covid-19 negative) then started doing therapy with R34. V27 never secured his N95 properly between rooms, allowing it to hang loosely. On [DATE] at 3:05 PM, R35's door had a used gown that had been worn into a Covid-19 positive room, rolled vertically with the top approximately eight inches tucked into the infection control supply kit hanging over the door and the rest of the gown hanging over the lower half of the infection control supply kit touching the clean PPE stored in the infection control supply holder, contaminating the items in the holder. Then on [DATE] at 3:35 PM, V19 (Activity Director) was pushing her cart and supplies down the hall to do one to one activities with the residents. She stopped her cart in front of a room. V19 walked down to the infection control supplies kit hanging on R35's door and pulled some gloves out of one of the pockets and two gowns out of another pocket. V19 walked back to her cart and laid the gloves and gowns on top of her supplies. On [DATE] at 11:20 AM, V30 (Dietary) went into R24 (Covid-19 positive) and R25's (Covid-19 positive) room with a N95 and gloves on. V30 obtained their drink orders and came out to the beverage cart in the hallway. V30 prepared the chosen beverages and went back into R24 and R25's room to deliver the drinks. While making the drinks, V30 touched the cooler, drink pitchers, the cart, and handle on the coffee dispenser. V30 then entered R26 (Covid-19 positive) and R27's (Covid-19 negative) room getting their drink orders and coming back out into the hallway to prepare the drinks. V30 then entered R28 and R29's room (Covid-19 negative residents) getting their drink orders, coming back out to the drink cart, preparing the drinks, and taking the drinks back into their room. V30 then entered R32 (Covid-19 negative) and R33's (Covid-19 positive) room, obtained their drink order, came out to the cart, prepared their drinks and took them into their room for them. V30 then entered R13 and R14's room (both Covid-19 negative residents) obtained their drink orders, came out to the cart, prepared their drinks and took the drinks into their room. V30 did not perform any hand hygiene or PPE change between any of the rooms (some housing Covid-19 positive residents and some housing Covid-19 negative residents), between touching the items on the beverage cart, or before taking the drinks back into the resident's rooms. All rooms housing Covid-19 positive residents had signage present to indicate Contact/Droplet Precautions and that PPE should be worn when entering the room and hand hygiene should be performed after doffing PPE. V30 then took the beverage cart, with soda and juices still on it (that had been touched with the same gloves that she went into the Covid-19 positive rooms with) to the dining room and left unattended next to a refrigerator. On [DATE] at 12:50 PM, V27 (Speech Language Pathologist/SLP) was observed in R34's room, sitting within two feet of R34 (Covid-19 negative), with his N95 on with the bottom strap not in place, hanging below his chin, and not forming a seal. V27 had just left R52's (Covid-19 positive) room, without securing his N95 or any N95 change. On [DATE] at 1:10 PM V28 (Physical Therapy Aide/PTA) was performing therapy with R32 (Covid-19 positive) in his room wearing her N95 the with the bottom strap hanging loose in front of the N95, under her chin, not forming a seal. On [DATE] at 9:45 AM, V29 (CNA/transportation) was assisting moving Covid negative residents to the new negative hall wearing her N95 with the bottom strap cut off, causing the N95 not to have a seal. On [DATE], at 12:20 PM, V26 (Activities Assistant) entered the room of R38 (Covid positive) at 12:20 PM. R38 had signage for Contact/Droplet Precautions outside of R38's door. R38 was heard repeatedly coughing during this time was not wearing a mask when V26 was in R38's room. The facility's Line List documents that R38 tested positive for Covid-19 on [DATE]. Immediately after, on [DATE] at 1:00 PM, V26 entered the room of R12, who was Covid-19 negative when tested on [DATE]. Then, on [DATE] at 1:05 PM, V26 entered the room of R2, who had also tested negative on [DATE]. On [DATE] at 1:20 PM, V26 entered the room of R31, who had tested positive for Covid-19 on [DATE] as documented on the facility's Line List. There was signage for Contact/Droplet Precautions outside of R31's door. R31 was heard repeatedly coughing during this time and was not wearing a mask when V26 was inside of R31's room. On [DATE] during V26's visits with R38, R12, R2, and R31, V26 used a rolling chair that she brought inside each of these 4 rooms during 1:1 activity sessions and had a cart full of activity items that she left outside of each room. During visits to these residents' rooms, V26 used the same N95 without a surgical mask cover. V26 did not sanitize the rolling chair between resident rooms or dispose of her mask and obtain a new N95 mask prior to each resident visit. V26 sat less than 3 feet from R38, R12, R2, and R31 during the length of these activities and was not observed to ask residents to use their masks. On [DATE] at 1:30 PM, on the second floor, R39 walked out from behind the plastic entry of R39's room, without a mask, holding R39's large drinking cup and loudly said that she needed something to drink. The facility Line List documents that R39 tested Covid-19 positive on [DATE]. There was signage outside of R39's room for Contact/Droplet Precautions. V26 rushed down the hall to verbally encourage R39 to return to the chair inside of R39's room. V26 took R39's contaminated cup without wearing gloves and told R39 she would get ice and a beverage. V26 stopped near the surveyor on her walk to the ice chest and stated, I'm so confused. I don't know what to do! Was that the right thing to do? V26 said that she was frustrated and unsure of how to avoid cross contamination. V26 walked to the ice chest with the contaminated plastic cup and touched the ice scoop, the lid to open the ice chest, and the refrigerator door, all while touching the plastic cup she received from the Covid-19 positive resident. V26 used hand sanitizer from a wall dispenser after handing the cup and canned beverage to R39 through the plastic at the door. V26 potentially contaminated the ice scoop, the lid to the ice chest, and the refrigerator door handle. On [DATE] at 10:10 AM, V24 (CNA) was wearing her N95 with the second strap in front, below her chin, not creating a seal prior to entering R29's (Covid-19 negative) room. On [DATE] at 10:35 AM, V31 (Housekeeping) was observed in R27's room, a Covid-19 positive resident. V31 left R27's room with his contaminated PPE on, walked down the hall to the supply closet, touched the door handle and supplies in the closet, then walked back down the hall to his cart, touching his cart, never doffing his PPE or performing hand hygiene. 4.) On [DATE] at 11:15 AM, V31 (Housekeeping) stated he does not know the names of the cleaners he uses but knows where the bottles are. V31 does not know the contact times for the cleaners either. He just wipes the items off, mops the floor, and when it is dry, he moves the sign to the next room. V31 stated, he guesses the contact time would be a minute or two. V31 walked down to the closet and picked up the cleaner. V31 stated, the cleaner he wipes items off with is Brand name cleaner A and the cleaner he uses on the floor is Brand name cleaner B. V31 stated, he changes gloves between rooms, but he has not been told when to change his gown and he does not change his mask. Brand name cleaner A has a contact time of 10 minutes, (the United States Environmental Protection Agency Pesticide Registration, Disinfectants for Coronavirus (Covid-19)). Brand name cleaner B is not an EPA N listed cleaner, from the United States Environmental Protection Agency Pesticide Registration, Disinfectants for Coronavirus (Covid-19) www.epa.gov/listN. On [DATE] at 11:50 AM, V40 (technical service representative) stated, Brand name cleaner B is neutral cleaner and is not approved by the EPA as a N listed cleaner. On [DATE] at 2:45 PM, V15 (Environmental Services Supervisor) stated, he is the housekeeping, laundry, and dining supervisor. V15 stated, that staff should be donning PPE, including a gown, gloves, eye protection and N95 when going into any resident's room that is Covid-19 positive or have any transmission-based precautions. The PPE should be doffed upon exiting the room. The PPE should be changed between every room and disposed of after each use. Staff should not walk down the hallway with PPE on after exiting from a Covid-19 positive resident's room. N95's should be worn with the top strap higher up on the back of the head and the bottom strap lower on the back of the head, closer to the neck, so that the N95 makes a seal. The N95 should be changed between rooms or a surgical mask put over the N95 and the surgical mask doffed upon exiting the resident's room. The staff receive ongoing training from him when he notices an issue and receive monthly training from V17 (RN/staff development). The disinfectants that should be used are: Germicidal bleach cleaner (EPA ,d+[DATE]), Brand name cleaner C, bleach (EPA ,d+[DATE]), Brand name cleaner B, Brand name cleaner A, and Bleach Germicidal wipes (EPA ,d+[DATE]). The Facility Policy titled, Infection Control dated [DATE], with a revision date of [DATE] states, .IV. ENVIRONMENT: Housekeeping procedures will be conducted in keeping with the infection control procedures to reduce the spread of infections. 2. Surfaces are cleaned with a disinfectant/germicidal solution mixed per manufacturer's instructions 8. Hallway handrails, doorknobs, etc. are wiped with a disinfectant and maybe followed up with a disinfectant spray. A Covid 19 Policy dated [DATE] documented, Human Coronavirus is most commonly spread from an infected person to others through .Air by coughing and sneezing .close personal contact .(and/or) Touching an object or surface with the virus on it ,,If a resident shows symptoms (of Covid), (Begin) droplet precautions, (and)(move) them to an isolated room . Any resident who has tested positive will quarantine for 14 days .During this time, each resident will be watched and supported for any additional emotional needs. The Facility policy titled, Subject Coronavirus (Covid 19) dated [DATE] with a revision date of [DATE] states, Policy: A new respiratory illness - Coronavirus (Covid-19) is spreading globally and there have been instances of COVID-19 community spread in the United States. This facility will join general strategies recommended by the Center for Disease Control (CDC), federal, state and local health institutes to prevent the spread of COVID-19 in Long Term Care Facilities. Transmission - Human coronaviruses most commonly spread from an infected person to other through: air by coughing and sneezing, close personal contact, such as touching or shaking hands, touching an object or surface with the virus on it, then touching our mouth, nose, or eyes before washing your hands .Symptoms - Clinical features are fever or sign/symptoms of lower respiratory illnesses. May include: Fever, Cough, Shortness of breath, Sore throat, Chills or shaking, Muscle Pain/extreme weakness, Headaches, Loss of taste or smell, Human coronaviruses can sometimes cause lower-respiratory tract illnesses, such as pneumonia or [CONDITION(S)]. Facility Approaches: Monitor residents at least once per nurse shift for fever or respiratory symptoms. Assessments and vital signs will [TRUNCATED]

Based on observation, interview, and record review the facility failed to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This failure resulted in R14 experiencing excessive pain and distress due to unrelieved coughing for multiple days. Findings include: R14's Electronic Health Record documents R14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Minimum Data Set (MDS) Section C: Cognitive Patterns, dated 1/1/22 documents a Brief Interview of Mental Status (BIMS) score of 13, which indicates R14 is cognitively intact. R14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . O2 above 90% - IF<90 and O2 not available sent to ED (Emergency Department). R14's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 1/11/22 at 11:10 AM, R14 appeared distressed; R14 had R14's arms wrapped around self, with a slight rocking back and forth. R14's eyes were tearful, and R14's face was red and grimacing. R14 had a frequent deep, hoarse sounding cough. R14's cough could be heard down the hallway. On 1/11/22 at 11:10 AM, R14 stated, R14 has a bad cough and that R14 has had it for approximately a week now. R14 stated, the cough makes R14's chest and back hurt really bad. R14 said R14 just wants to lay there and cry it hurts so bad. This cough is just awful. R14 said R14 does not know what is wrong with R14, they have not told R14. R14 stated R14 does not see a doctor very often. R14 then stated, R14 had a fever for about a day or so R14 believes. R14 was told R14 was going to get a chest X-ray, but R14 never had one. On 1/11/22 at 11:05 AM, R13's (R14's Roommate) who was alert to person, place and time stated, R13 cannot get any sleep because everything is too loud at night, between peoples' TVs and everyone coughing. R13 said R13 knows R13's roommate (R14) cannot help that (R14) is coughing all the time, and all night, because (R14) is sick. R13 stated, but it keeps (R13) awake. On 1/11/22 at 11:15 AM, V24 (Certified Nurse Aide/CNA) stated, R14 has been coughing, R14 sounds pretty bad at times. On 1/11/22 at 1:45 PM, V36 (CNA) stated, she has heard R14 coughing, sometimes it sounds harsh. On 1/11/22 at 2:30 PM, R14 could be heard from the hallway coughing. On 1/12/22 at 10:10 AM, R14 could be heard coughing from the hallway. On 1/12/22 at 10:10 AM, R14 stated, this cough is still awful, it makes my back and lungs hurt awfully. On 1/31/22 at 2:05 PM, R14 stated, they (the nurses) did not ask R14 everyday if R14 would like anything for the cough. R14 did not always ask for anything because, R14 just felt too bad and was too miserable to care. R14 also gets tired of feeling like R14 has to fight with them to get any pain medication. If it hurts and they know it, why can't R14 just have R14's pain medication? R14 thought V43 (Attending Physician) wrote R14 a script for pain medication. R14's electronic Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . R14's Electronic Medical Record documents from 1/05/22 through 1/15/22, R14's vital signs were obtained on one occasion (1/10/22 at 1:24 PM) and not every 4 hours as ordered on 1/5/22. On 1/4/22 at 3:50 AM, a progress note by V38 (Licensed Practical Nurse/LPN) for R14 documents: Resident with cold like symptoms; scratchy throat, redness of b/l (Bilateral) eyes, low grade temp, will continue to monitor. No other progress notes for R14 from 1/4/22 through 1/12/22 addresses these symptoms. The next progress note to address these symptoms again for R14 was on 1/13/22 at 7:18 PM, which documents, R14 remains alert and oriented x 3 with occasional forgetfulness noted, respirations even and non-labored, continues to have a non-productive cough that is harsh at times with relief from PRN Tussin given, lung sounds diminished in lower bases, no other signs or symptoms of distress noted. On 1/12/22 at 2:55 PM, V17 (Registered Nurse/RN) stated, she does not see where R14 received any Tussin or Acetaminophen on the 11th or yet today (1/12/22) for R14's cough. R14 does have a bad cough, and R14 should have received some. V17 (RN) stated, she is unaware of why R14 did not receive any. V17 stated, she does not see any other progress notes, besides the one on 1/4/22, that describes any monitoring of R14's respiratory symptoms. On 1/12/22 at 2:55 PM, V18 (Human Resources Generalist) stated, (R14) does have a bad cough, and said she has heard (R14) coughing. On 1/18/22 at 1:33 PM, V17 (RN) stated the 1/5/22 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 2/1/22 at 11:47 AM, V42 (Advanced Practiced Nurse/APN) stated, she did not see R14 on 1/5/22, there was a standing order put in for the Covid-19 protocol which was for any resident showing signs and symptoms of Covid-19, which was the Tylenol 650 mg (Every 4 Hours) PRN (As Needed), Mucinex 600 mg BID (Twice Daily) x 10 days, Robitussin 5 ml (milliliters) every 4 hours PRN, [MEDICATION(S)] 90 MCG (Micrograms) 2 puffs every 4 hours PRN x 10 days, Vitamin C 500 mg BID x 10 days and VS (vital signs) every four hours. During the time the facility had several Covid-19 positive residents in a short time frame, she was in close contact with V19 (LPN) on who has tested positive and who had symptoms. R14 still had a cough and some breathing issues around 1/19/22, so an X-ray was ordered. V43 (Attending Physician) saw R14 on the 1/21/22. Facility Policy titled Subject: Medication Therapy (Therapy) dated 04/24/2014 with a revised date of 04/28/2021 states: Time Frame: .Administration of PRN or As Needed Medication 1. PRN medication are allowed as follows: . b. If the resident is showing signs of need, the LN (Licensed Nurse) may confer with resident on availability and need. Note body language or actions.5. Documentation will be completed after administering medication in EMAR including, reason for Administration, Dosage, Response or any medication effects.

Based on interview, and record review, the facility failed to provide required supervision during toileting for 1 (R3) of 3 residents reviewed for falls in the sample of 3. This failure resulted in R3 falling from the toilet and sustaining a lip laceration requiring sutures, impacted tooth into the gum, pain management, and emergency medical evaluation and treatment. Findings Include: Review of R3's Clinical Record documents, among other diagnoses, a [DIAGNOSES REDACTED]. According to the National Institute of Neurologic Disorders and Stroke (https://www.ninds.nih.gov/Disorders/Patient-Caregiver-Education/Fact-Sheets/Progressive-Supranuclear-Palsy-Fact-Sheet), [DIAGNOSES REDACTED] (PSP) is an uncommon brain disorder that affects movement, control of walking (gait) and balance, speech, swallowing, vision, mood and behavior, and thinking. The disease results from damage to nerve cells in the brain. The disorder's long name indicates that the disease worsens (progressive) and causes weakness (palsy) by damaging certain parts of the brain above nerve cell clusters called nuclei (supranuclear). A Facility Policy titled, Fall Risk Assessment with a review date of 8/29/17 documents, Each resident will be assessed to determine his or her risk of falling. Residents who score 10 or above of the Fall Risk Assessment are high risk for falls will be reviewed for interventions to reduce their risk. R3's Fall Risk Assessment completed 1/6/20 documents a score of 13, indicating she is high risk. Review of R3's Plan of Care documents a focus area with an effective date of 1/8/19 stating, Falls: I have a potential for falls or injury from falls R/T (related to) unsteady gait and poor balance. An intervention related to the fall focus area includes, Staff were educated on not leaving the resident on the toilet by self, with an effective date of 3/21/19. R3's Plan of Care also includes a focus area of, Restorative Transfer Program: I have impaired transfers due to weakness and poor balance R/T Progressive Supranuclear Ophthalmoplegia. R3's MDS (Minimum Data Set) dated 1/10/20 documents R3 is cognitively intact. R3's functional status for toilet use, which includes the defined area of how the resident uses the toilet room, and transfers on/off toilet is scored as 3 (Extensive assistance), 2 (One-person physical assist). The same MDS documents in all sections of G0300 which identifies R3's Balance during transitions and walking including moving on and off toilet, as a 2 (Not Steady, only able to stabilize with staff assistance. An Accident report dated 3/19/19 regarding R3 documents R3 was noted lying on the bathroom floor in her room. Corrective Actions Taken is documented as: Educated staff not to leave resident on toilet without observation due to spastic movements. Witnesses on this report include V3 (Certified Nurse Assistant/CNA). A serious injury incident report submitted to the state regulatory agency documents that on 1/19/20 at 6:15 AM, R3 was assisted to the toilet for AM care. A CNA determined that V3, stepped out of the bathroom area where R3 was, and into the bedroom space. R3 fell from the toilet resulting in a laceration to her upper lip and discoloration to her nose. R3 was transported to the local ED (emergency department) for evaluation and treatment via ambulance. Progress Notes dated 1/19/20 documents as reported in the serious injury report submitted to the state regulation agency that R3 sustained a fall on 1/19/20 at 6:15 AM from the toilet. The note made by V4 (Licensed Practical Nurse/LPN) documents upon initial evaluation a laceration to R3's upper lip with discoloration to her nose was noted. V4 documents R3's VS (Vital Signs) as being BP (Blood Pressure) 184/104, Pulse 81, Temperature 97.1 degrees Fahrenheit, Respirations 18, and her pupils being equal and reactive to light and accommodation. V4 goes on to document at 6:30 AM V11 (On call Physician) returned his call and was notified of R3's fall and status with orders given to send her to the ED. V4 documents the local ambulance service was notified of need to transfer at 6:35 AM, with the ambulance arriving at 6:45 AM for transfer. V4 documents R3 returned to the facility at 12:45PM on 1/19/20. The ED Note dated 1/19/20 documents R3 presented to the ED after She was reportedly sitting on the toilet and fell forward striking her face. Pt. (patient) has limited use of her upper extremities and would be unlikely to guard self during the fall. Pt. communicates using Yes/No boards. She indicates that she has a ha (headache), facial pain, mouth pain. She denies all other complaints. Physical Exam document R3 has a 3 cm (centimeter) laceration upper mid lip, left front tooth impacted into gums with base visible. Skin documents [DIAGNOSES REDACTED] to midface, along with Psychiatric documents R3 as being tearful. The ED Note documents a CT (computed tomography) of the cervical spine, facial bones, and head all without contrast were complete with no significant findings in relation to the injury noted. [DIAGNOSES REDACTED]. Spoke with V10 (Dentist). He advised that tooth is not likely salvageable. To f/u (follow up) with dentist as outpatient this week. In addition to R3's current physician orders, ED discharge orders included [MEDICATION NAME] 250 mg (milligrams) / 5 ml (milliliters), take 10 ml three times a day for 10 days, and [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg by mouth every 8 hours as needed for pain for 3 days. Under the category of laceration repair: upper interior lip, 3 cm long by 4 cm deep, repair method sutures. Review of R3's current Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. On 1/24/20 at 9:25 AM, V3 states she has worked at the facility approximately 6 years and is familiar with the residents. V3 states on 1/19/20, she responded to R3's call light and was getting her up to get dressed and ready for breakfast. V3 describes R3 as not being confused and able to make needs known. V3 states she had sat R3 on the toilet in R3's room and turned on the water to help R3 initiate urination. V3 states she waited for a short amount of time, and R3 had yet to urinate, but communicated no when asked if she was done. V3 states she instructed R3 that she was going to start getting her roommate ready and would be right back in to check on her. V3 states she exited the bathroom and began tending to the roommate within R3's room. V3 states a couple minutes later, she turned around to see R3 in process of falling forward and witnessed her hit her head directly on the floor. V3 states she notified the nurse and R3 was sent to the ER as she was bleeding from her mouth. V3 states she does not recall R3 as having a history of falls. V3 states once R3 fell she stated, I lost my balance. V3 states R3 is verbal for small phrases only and uses a communication board also. V3 states R3 walks with assistance in her room and uses a wheelchair for transport to the dining room. On 1/24/20 at 10:24 AM, R3 did not verbally respond when spoken to, although making eye contact. The Yes/No communication board observed on bedside table was utilized in which R3 demonstrated she is cognitively intact, being alert and oriented to person place and time. R3 was asked: Do you recall falling? - yes Do you fall frequently? - no Have you fallen in the past? - yes Do staff usually stay by you when you use the restroom? - yes Was a staff member by you when you recently fell ? - yes Was she directly by you where she could have prevented the fall? - no Did you experience pain with your fall? - yes Are they giving you pain medication since your fall/controlling your pain? - yes Do you have sutures to your lip? - yes Are you in pain now? - no Were you scared when you fell ? - yes Are you happy with your care at the facility? - yes Did you lose your balance causing you to fall on 1/19/20? - yes Do staff keep your call light within your reach for use? - yes Are you able to eat ok with your lip/dental injury? - yes On 1/24/20 at 11:55 AM, V9 (Nurse Practitioner) states she is the representative for V8 who is R3's Primary Care Physician. V9 states she is familiar with R3 and saw her on 1/23/20 at the facility. V9 states based on R3's previous history of falls, [DIAGNOSES REDACTED]. When read the fall care plan intervention of staff not leaving R3 on the toilet by herself, V9 states she would find that to be an appropriate intervention, which should have been maintained. V9 acknowledges given staff's immediate presence while on the toilet 1/19/20, R3's fall and injuries would have been avoidable. On 1/24/20 at 2:00 PM, V1 (Administrator) states after reviewing R3's Clinical Record and fall history, she is in agreement and acknowledges that R3 should have had staff present at the time of her fall, while on the toilet on 1/19/20. V1 states she just hadn't recalled R3 having a fall in 3/2019 with the intervention of having staff present during toileting being initiated. On 1/24/20 at 1:02 PM V2 (Director of Nursing) states V5 (Family Member) did not want a follow up dental appointment made for R3. V2 states the tooth is still intact currently, with R3 having no complaints of pain.

A. Based on observation, interview and record review, the facility failed to assess, identify causative factors contributing to falls including medications, implement interventions based on identified hazards, and monitor and modify those interventions when injuries continued for 7 of 13 residents (R2, R4, R9, R14, R15, R16, and R17) in the sample of 20 residents who had a history of [REDACTED]. Findings include: 1. R14's physician's orders [REDACTED]. The Minimum Data Set, ((MDS) dated [DATE], documents R14 is moderately impaired with cognition and decision making, has behavior problems, has unsteady balance during ambulation and requires assistance. The MDS documents R14 requires extensive assistance with transfers and all activities of daily living, and has functional limitation in range of motion for both lower extremities. The Fall Assessment, dated 6/27/11, assesses R14 as a high risk for falls. On 6/28/11, at 10:30 AM, R14 was observed to be extremely anxious and moving about repeatedly in his recliner, trying to rise. At 12:00 PM, during lunch, a visitor was trying to feed R14, and the visitor had to repeatedly redirect R14 to stay in his chair for the meal. R14 kept trying to rise and walk. R14 was confused and anxious. On 7/07/11, at 9:05 AM, R14 was observed in a reclined chair in the day area. He was extremely restless, with multiple bruises and skin tears to both upper extremities. R14's feet were hanging off of the footrest, and he was moving consistently in the chair, displaying symptoms of akathisia (the inability to remain in a sitting position with motor restlessness and a feeling of muscular quivering, as defined by Stedman's Medical Dictionary, 24th edition) . At 1:00 PM, R14 was fully reclined and awake in the recliner in the day area. No staff was sitting next to him. A sensor pad was in place to the recliner. R14 was wearing regular socks. The Incident/Accident Report, dated 1/16/11, at 9:00 AM documents R14 was alert with confusion, requires supervision of staff for ambulating in his room, and does not use the call light for assistance. The Report documents R14 was barefoot and ambulated independently in his room when he returned to his bed, and attempted to sit on the bed, when he slid to the floor with no apparent injury. The Report of the fall of 1/16/11 does not report if R14's fall was witnessed, or if a safety alarm was in place or sounding. Interventions are listed as; place R14 on the "Falling Star Program", send to the emergency department for 3 plus edema to lower extremities, and medication change. The Incident/Accident Report, dated 1/20/11, at 8:15 PM documents the door to R14's room was closed and when the nurse entered the room, R14 was sitting on the floor with no apparent injury. The Fall Investigation Form, dated 1/20/11, reports R14 lost his balance and had slipped in urine with bare feet. The Investigation reports R14 had been experiencing increased confusion, difficulty in taking steps, lower extremity edema, and was unable to comprehend simple commands. The Investigation documents R14 is on multiple "high risk" psychotropic medications; Depakote, Invega, and Seroquel XR; the diuretic, Furosemide; and the hypnotic, Zolpidem. The Report and Investigation does not document if a safety pressure alarm was in place or sounding. Interventions are listed as; "Encourage resident to use call light-staff to assist, continue the Falling Star Program and medication review-Namenda and Aricept discontinued." The Fall Investigation Form dated 2/24/11, at 8:10 PM, documents R14 was again discovered barefoot on the floor of his room. The Form documents the sensor pad alarm was intact, but does not document if it was sounding. High risk medications listed are; Depakote, Tramadol for pain, and the hypnotic, Zolpidem. Interventions are listed as; "Ensure non-skid socks are on, and provide night light or leave the bathroom light on at night." No mention is made of increasing supervision for R14 to prevent further falls. The Incident/Accident Report, dated 3/28/11, at 7:45 PM, documents R14 was discovered laying on his left side on the floor of his room. R14 had a skin tear to his left elbow, with redness to the left knee and left side. R14 was noted shaking, moaning and grimacing. The report documents staff had been in resident's room providing care at 7:15 PM. R14 was transferred into a recliner via a mechanical lift to provide supervision, and an X-ray was ordered by the physician. The Report documents when R14 was reassessed, he was unable to tolerate range of motion to his left lower extremity. R14 was sent out the hospital where he was admitted and treated for [REDACTED]. The Report of the 3/28/11 fall does not identify if R14 had a sensor pad alarm, or if it was sounding at the time of the fall. The Report does state R14's call light was on, which prompted the staff to check on him. The Report documents, "Resident (R14) does get up at night and wanders in his room, or will come out in hallway. Resident will keep his door shut. If staff opens it, resident will get up and close it. Resident has been counseled several times about leaving the door open. Resident has decreased safety awareness, and does not always wear foot wear. Does not use call light for assist." No interventions were listed on the the investigation. R14's Care Plan for falls, dated 4/11/11, documents, "Potential for falls or injury from falls related to use of anti-psychotic medication and history of falls." Interventions in place per R14's Care Plan to prevent falls are listed, in part; "Maintain high-low bed to aide with transfers and with positioning and to decrease falls, assess area for safety hazards, sensor pad alarm in bed and in wheelchair to alert staff, observe behaviors and report to nurse or physician, monitor for side effects of antipsychotic medications (Seroquel and Invega), ensure has proper footwear on to transfer with, do visual checks every 15 minutes to ensure safety, ensure (R14) is in great room and kept in view, apply bed bolsters to bed to ensure safety and aide with positioning as cognitively unaware of own safety, ensure non-skid socks or shoes on to help prevent falls." R14's Care Plan continues to note falls on 4/16/11 from the wheelchair, 5/02/11 and 5/03/11 falls from bed, 5/24/11 fall from the recliner in the great room, and fall from bed on 7/01/11. The Consultation Report from the pharmacy, dated 3/17/11, documents R14 is taking the hypnotic, Zolpidem 10 mg at bedtime, and documents, "The recommended maximum daily dose threshold for this medication when used to treat insomnia in the elderly as outlined in F329 is 5 mg. There is a risk in elderly and/or debilitated persons towards the development of over sedation, dizziness, confusion, and/or ataxia when sedative/hypnotic agents are used at the greater recommended maximum safe dose." Z1, Physician signed as accepted this recommendation on 4/13/11, after the fall of 3/28/11. The pharmacy Consultation Report, dated 6/14/11, recommends Z1 consider a gradual dose reduction of the antipsychotic Invega. The Report documents R14 is also taking the antipsychotic Seroquel and Depakote. The physician orders [REDACTED]. On 7/11/11, at 4:00 PM, E2, Director of Nursing, (DON), confirmed R14 is a very difficult case, and it would be difficult for the facility to provide 1: 1 observation to prevent falls at all times. E2 reported R14 can be very combative at times. E2 confirmed the potential side effect of akathisia from R14's current multiple psychotropic medications had not been assessed or addressed as a possible contributing factor related to R14's multiple behaviors and numerous falls. 2. R2's physician's orders [REDACTED]. The MDS, dated , 5/09/11, documents R2 is moderately impaired with cognition and decision making, requires extensive assistance for balance, bed mobility, transfers, ambulation, and has no limitations with range of motion. The Fall Risk Assessment, dated 3/23/11, assesses R2 as a high risk for falls. On 6/28/11, at 12:05 PM, R2 was in a reclined geriatric chair, talking incoherently and being fed lunch in her room. R2 had a bed in low position, 1/2 siderails at the head of the bed and bolsters along the end of the bed to prevent falls from bed. At 1:27 PM, 2:15 PM, and 2:55 PM, R2 was asleep in the reclined geriatric chair, with a sensor pad alarm attached to the chair. A wedge cushion was in the reclined geriatric chair. On 6/29/11, at 9:05 AM, R2 was asleep in the geriatric chair in the day area. At 9:15 AM, 9:40 AM, and 10:40 PM, R2 remained asleep in the geriatric chair. At 11:00 AM, R2 was transferred with a gait belt to the toilet with the assist of two staff. R2's balance was unsteady, but she was able to bear weight. At 11:05 AM, R2 was transferred back to the reclined geriatric chair. R2 repeatedly kept trying to lean forward in the chair to get up,but was unable to rise from the chair. On 6/30/11, at 1:05 PM, R2 was reclined in the geriatric chair in the day area. R2 was very restless and was repeatedly leaning forward in the chair. R2 was mumbling incoherently. E13, LPN, stated at that time, "She (R2) is only laid down in the evenings. She is up in the day room during the day. Some days she'll sleep. Some days she's restless." A review of the physician's orders [REDACTED]. The POS documents an order for [REDACTED]. A review of the Incident/Accident Report, dated 4/20/11, at 5:30 PM, documents R2 was sitting in the recliner in the day area and slid over the armrest onto the floor. The Fall Investigation Form, dated 4/20/11, documents R2 as "restless and very anxious frequently. Has constant movement most of the time. Moves about sideways, attempts to turn upside down while sitting in recliner. Has decreased safety awareness. Sensor pad was intact, but did not sound as was bunched up in padding in recliner." The intervention listed for this fall was to have Occupational Therapy to evaluate for positioning. The sensor pad alarm is not addressed. R2's potential for akathisia from her psychotropic medications is not addressed. The Accident Report, dated 5/18/11, at 3:00 PM, documents finding R2 sitting on the floor with a fading purple bruise noted to her right thigh. The corrective actions taken to prevent recurrence are the sensor pad was checked to see if it was functional, and to make sure sensor pad is in correct placement and functioning properly, and a medication review would be done 5/19/11. The Pharmacy Consult reports for review of numerous falls, dated 4/27/11, 4/29/11, 5/19/11, documents the use of Acetaminophen with Diphenhydramine to be re-evaluated for R2 as it is not recommended for use in the elderly. On 5/20/11, E2, DON documented on the Consultation Report of 5/19/11 that the physician declined recommendation on 4/28/11 to discontinue Diphenhydramine. On 6/14/11, the pharmacist reviewed three more falls for R2 and recommended to discontinue the Diphenhydramine use for R2, without success. There is no rationale provided by Z1 for the continuation of the Diphenhydramine. A review of the Accident Report for 6/14/11 and 6/19/11 document R2 was noted on the floor with the sensor pad alarms failing to sound. The measure to prevent recurrence is to ensure sensor pads are working and replace as needed. R2 was on 15 minute checks. The Psychiatric Consult from Z3, dated 1/12/11, documents Seroquel was tried for R2 in January 2011 when she was hospitalized , and was too sedating. Risperdal was then tried but "made akathisia worse." R2 was started on Zyprexa to assist R2 "to calm down and sit down." R2's Care Plan, updated 6/26/11, documents R2 has the "potential for falls or injury from falls related to use of anti-psychotic and anti-anxiety medication and history of falls, cognitive impairment, and is unaware of physical limitations." All of R2's numerous falls are addressed. One intervention listed is, "ensure sensor pad is used and working properly." The observation documentation forms for R2 for June and July 2011 show R2 is on a 30 minute observation schedule presently, and continues to be found on the floor. On 6/30/11, at 1:20 PM, E2, DON was interviewed regarding her numerous falls. E2 reported R2 has never been placed on a 1:1 observation to prevent falls. E2 reported, "I'm running out of ideas." The facility's policy and procedure for falls documents, in part, "When a resident continues to fall, involve the charge nurse in a thorough look at medications and [DIAGNOSES REDACTED]. A follow up note and reassessment must continue until the problem of falling has been resolved." 3. The Facility "Incident/Accident Report" documents that R4 experienced the following injuries: "1/15/11, 7:00 PM, Found 8 centimeter (cm) by 6 cm bruise to left wrist by Certified Nurses Aide (CNA). Unaware of when of how this occurred. Resident currently receives aspirin therapy. Residents skin is very thin and fragile. The wrist blood pressure cuff and pressure of it caused bruising to occur to wrist". The only potential causative factor which the Facility considered was the wrist blood pressure cuff. The corrective action for this injury is "geriatric sleeves on at all times - remove to lotion legs and arms. 3/16/11, 5:15 AM, Noted 1.5 cm skin tear to right outer lower leg. Area cleansed with normal saline. Steri-strips applied with triple antibiotic ointment and dressing. Resident's skin is very thin and appears translucent. Resident wears padded boots that cover lower extremities up to just below the knees. The boots have self adhering fabric straps to assist with keeping boots closed. The skin tear is noted to be just at the top of the self adhering fabric straps. The strap rubbed against residents skin causing area". The only potential causative factor which the Facility considered was the self adhering fabric strap. The corrective actions for this injury is "educate staff to skin concerns and needs. 4/11/11, 6:00 AM, When assisting resident out of bed 1.5 cm skin tear noted just above leg protector. Area was just above the padded boot resident was wearing. The boot has straps that have self adhering fabric. The self adhering fabric strap possibly rubbed leg causing area. The resident wears either long socks or leg protectors under boot. The sock had slid down some allowing strap to make contact with skin". The potential causative factor which the Facility identified is the self adhering fabric from the strap of the padded boots. The corrective action for this injury is "offer extra fluids twice a day to hydrate, monitor transfers and pending longer leg protectors". E2, Director of Nurses, stated on 6/28/11 at 4:20 PM, that the Facility had tried to obtain a different style of leg protectors for R4 but, have been unable to locate any. "4/16/11, 1:15 AM, Certified Nurses Aide (CNA) was turning resident over for bed checks and noticed blood. Right lower extremity below knee outside, 3.9 cm skin tear. Staff unable to determine for sure how incident occurred. However, the skin tear is positioned just above the Velcro strap of where leg boot/protector closes. Velcro edge possibly rubbed residents leg causing area. Resident unable to verbalize how incident occurred". The corrective action for this injury documents "Re-educate staff on transfer techniques. Use turn sheet for turning and positioning. 4/30/11, 2:45 PM, 2 cm by 2 cm skin tear noted while transferring to wheelchair. Resident was noted to receive a skin tear to right elbow while being transferred into wheelchair. Resident did not have long sleeves on shirt. Her elbow had rubbed the sides of the wheelchair as she was being lowered. The material of the mechanical lift pad is rough for her fragile skin". The documented corrective action for this injury is "long sleeves or geriatric sleeves. 5/4/11, 6:10 PM, CNA's reported a 3.5 cm by 4.0 cm red abrasion/scratch on right side of residents back. Denies pain. Will monitor. Resident was noted to have a scratch with an abrasion to right scapula area. Resident unable to recall how incident occurred. Staff noted area while changing residents shirt. Resident possibly rubbed area against the mechanical lift pad. Mechanical lift pad is a netted material and residents skin is very fragile". The corrective action for this injury is documented as "ensure proper position of mechanical lift pad. Lotion skin. 5/29/11, 6:00 AM, when doing morning care, CNA noted 0.8 cm by 3 cm skin tear to left forearm. Skin is very thin and fragile. Staff is unsure if edge of cloth incontinent pad may have rubbed her arm causing skin tear. No rough edges were noted to cloth incontinent pad. Geriatric sleeves had been changed for washing". The corrective action for this incident is "geriatric sleeves on at all times. Assess padding on mechanical lift. 6/22/11, 11 cm by 10.5 cm dark purple bruise noted to right upper shin while treatment nurse was applying lotion to bilateral lower extremities. Area is located above padded boots. Resident may have bumped shin against another residents wheelchair leg while being placed at table. Resident currently has children's aspirin and Naprosyn 375 milligrams orally, twice a day, which are both part of resident medications regimen and are contributing factors regarding bruising". The corrective action for this bruise documents "use caution with appropriate transfers. Continue leg protectors and padded leg boots". On 7/7/11, at 10:30 AM, E2, Director of Nursing, stated that the Facility had attempted to locate a different style of padded leg boots for R4 but, could not find any. E3, Quality Control Nurse, stated that the Facility did not know what other type of boot they could use for R4. E2 stated that they did not interview staff every time that R4 experienced an injury of unknown injury - they only interviewed staff concerning the incident which occurred on 4/16/11. R4 has diagnoses, in part, of Alzheimer's, Depression, Diabetes Mellitus and Arthritis. R4's most recent Minimum Data Set (MDS), dated [DATE], shows that she has short and long term memory problems, is moderately independent in cognitive skills for daily decision making and is dependent on staff for transfers and all activities of daily living. R4's plan of care, dated 6/13/11, shows that she is at moderate risk for skin breakdown, utilizes a pressure relieving pad and mattress, and heel-elbow protectors. 4. R15, has diagnoses, in part of Persistent Mental Disorder, Congestive Heart Failure and Dizziness. R15's most recent MDS shows that she has short and long term memory problems, modified independence in daily decision making and is totally dependent for transfers and all activities of daily living. R15's most recent plan of care, dated 5/9/11, documents that she utilizes 1/4 siderails for turning and positioning, and bilateral bed bolsters due to a history of falls and decreased safety awareness. R15's Facility "Incident/Accident Report", documents the following: "1/3/11, 3:30 AM, Noted 8 cm by 7 cm bruise to top of right wrist. Resident is unable to state how she may have obtained area. Has decreased safety awareness due to decreased cognition. Resident does move about while in bed. No environmental hazards noted". The corrective action for this injury is "Coumadin decreased. 2/2/11, 1:30 PM, Resident was attempting to get out of bed by herself. She was found on the floor sitting on her buttocks with the sensor pad in hand, sitting between her bed and the wall. Sensor pad was being held by resident so did not sound. No apparent injury". The corrective action for this incident is "bilateral bed bolsters. Room change closer to nurses station. 2/7/11, 5:50 AM, Resident was noted sitting on floor with pillows and blankets under her. No apparent injury. Staff had not gotten to room to get resident up for the day and resident became restless and began to move about. Resident attempts to sit up on side of bed and then to stand. No apparent injury". The corrective action for this incident is "change mattress. 2/9/11, 5:30 AM, staff member noted sensor pad sounding, went into the resident's room and noted her laying on her left side next to her bed. Sensor pad in place. Resident had scooted between side rail and bed bolster and slid off to the floor. Resident was unable to discuss how incident occurred due to her cognitive status. Resident gets agitated and begins moving. No apparent injuries". The corrective action for this incident is "assess mattress. Assess for routine pain medication and medicate as indicated. 2/26/11, 6:35 PM, CNA noted resident on the floor with her back against the bed and feet towards the wall in a sitting position. Left wrist has red area. She was sitting in a yellow liquid and feces on the floor". The corrective action for this incident is "1) assist to bathroom prior to putting to bed. 2) sensor pad replaced. 3) keep up until a later time". The investigation does not document if R15's sensor pad was in place and sounding. The investigation does not document when R15 was last toileted prior to the incident. 5/8/11, 7:10 PM, Alarm sounded. Entered room. Noted resident sitting on right side of the bed on the floor. E15 was holding onto the bedrail with her right hand. The bed bolsters had shifted down on the bed and a gap was noted between the bed bolsters and the side rails. Resident probably began sliding off the side of the bed due to paper incontinent pad on the bed. Resident had been calm prior to incident and laying still. No apparent injuries". The corrective action for this incident documents "1) adjust bilateral bed bolsters. 2) continue fall mats beside the bed". 5. The accident report and investigation from 6/24/10 for R16 documented that he was sitting on the bedside commode and fell . It documented that R16 acknowledged that he hit his head when he fell and denied blacking out. It identified that R16 required extensive assist of 2 staff for transfers and toileting. The accident report and investigation also documented the interventions for staff to assist with transfers and to counsel resident to wait for staff to assist. On 7/7/11 at 10:00 AM, Certified Nurse's Aid (CNA) E9, acknowledged that R16 required assist of 2 staff with the use of a gait belt to transfer to the bedside commode and that he should not be left alone on the bedside commode. 6. R17's Incident/Accident Report, dated 6/8/10, documented he was found in the shower room at 11:40 PM sitting on the floor. The Report documented the interventions to address this fall as "Ensure sensor pad working, visual checks, and Restorative Ambulation Program". R17's care plan documented R17's sensor pad was initiated on 5/12/10. The Report did not indicate if the sensor pad alarm sounded to notified the facility staff that R17 was up and ambulating independently. R17's Incident/Accident Report Form, dated 9/26/10 at 1:00 PM, documented he was sitting in the Alzheimer's unit Activity Area and he attempted to get up and ambulate by himself. The wheelchair slid out from under him and he fell to his buttocks. The Report documented the intervention to address this fall as "Assist res (resident) into stationary chair/recliner after meals, PROM (Passive Range Of Motion) to BLE (Bilateral Lower Extremities) daily, Restorative Walking Program, Do med reviewed to (decrease) episodes of anxiety and pain management, council family that outings may cause episodes of anxiety and (increased) confusion." R17's care plan, revised on 10/17/10, documented "Up in personal recliner with two staff and use of SSS (Sit-to-stand) device PRN (as needed) as (R17) is uncooperative and at times does not understand task PRN." R17's Incident/Accident Report Form, dated 10/29/10 at 6:30 PM, documented "Staff states res (resident) was being assisted from rocking chair into his w/c (wheelchair). w/c was sitting close to rocking chair. Resident was noted to keep trying to get up from rocking chair. CNA attempted to transfer resident from rocking chair into w/c. Res did not scoot feet over far enough during transfer to be in front of w/c to sit in seat. Res sat on w/c arm and arm of rocking chair. Rocking chair moved (rocked forward) and CNA stated she lowered resident to floor. Gait belt was on. " R17's Minimum Data Set, dated dated [DATE], documented he required assistance of two staff persons for transfers although during this incident, one CNA attempted to transfer R17 to his wheelchair. R17's Incident/Accident Report Form, dated 12/9/10, documented "Res. will not leave recliner reclined. Staff noted resident leaning in recliner (forward) towards front. As staff attempted to get to resident to prevent event, res fell forward onto elbows and knees onto floor." The Report interventions documented "(Anti-skid pad) in w/c to help prevent cushion from sliding out of w/c". The interventions did not address him falling out of the recliner. R17's care plan was updated on 12/15/10 and documented "Monitor and supervise with objects to keep in view." R17's Incident/Accident Report Form, dated 12/26/10, documented "Res was up in his w/c. He was noted to begin scooting his buttocks to the edge of his w/c seat and slid off onto w/c pedals and floor. The w/c cushion remained on seat of w/c." The interventions listed on the report documented "(Anti-skin pad) in w/c, monitor positioning while in w/c, ensure res in in staff's view when in w/c." There were no new progressive interventions to address this fall. R17's Incident/Accident Report Form, dated 12/29/10, documented "Staff states res was noted leaning forward in w/c in sec. 23. Staff attempted to reach res to assist in repositioning res to sit back in chair but res slid of w/c seat onto foot pedals." Although staff were present for this fall, the interventions documented on the report were "15 minute checks, cont (Anti-skid pad) in w/c". R17's care plan documented 15 minute checks had been implemented by staff on 6/18/10, at least six months prior. R17's Incident/Accident Report Form, dated 2/18/11 at 1:45 PM, documented "Res had been sitting up in recliner. Staff noted sensor pad sounding. Attempting to reach resident to prevent incident, was unable in time and sat on floor. He had transferred self from recliner and attempted to sit on chair that was by resident. Chair rolled and res lost balance sitting on floor." The interventions documented "F/U (Follow-up) lab to check progress of [DIAGNOSES REDACTED], assess environment for safety." R17's care plan intervention, dated 9/2/10, documented "Assess Environment for Safety issues and to Ensure Safety PRN". This was implemented at least four months prior and was not a new intervention. This interventions was implemented at that time due to R17 attempted to transfer himself to a wheeled stool and the stool rolled away. 7. R9's Minimum Data Set (MDS), dated [DATE], documented she required extensive assistance of one staff with bed mobility. R9's MDS dated [DATE] documented she was alert and oriented. R9's Incident/Accident Report, dated 1/14/11, documented "Is very particular regarding positioning of pillows to her back. Is unable to lay on her back so requests to be positioned on side. CNA had placed pillow as res had requested. Res places head very close to the bed rail and often is noted holding onto rails so as to not roll back onto back. Staff states they had noted res yelling. Entering res room res was noted to have slid off bed with cloth incontinent pad and paper incontinent pad under res on floor. Res left arm was still holding side rail." The Report's interventions documented "Ensure proper pillow positioning so does not cause res to turn and be too close to bed edge." On 6/30/11, at 10:00 AM, during an interview with R9, she stated staff had placed her too close to the edge of the bed on 1/14/11. She said she made a slight move and rolled off the bed. B. Based on observation, interview and record review, the facility failed to store chemicals in a secured area not accessible to cognitively impaired, mobile residents. This deficient practice affected two of two residents (R14, R17) who were mobile and cognitively impaired in the sample of 20 and 15 residents (R32, R39, R40, R41, R42, R43, R44, R45, R46, R47, R48, R49, R50, R51 and R52) in the supplemental sample. The facility failed to ensure electrical cords have only one device connected to them to prevent potential overloading of electrical circuits. This deficient practice affected one resident (R4) in the sample of 20 and one resident (R22) in the supplemental sample. Findings include: 1. R17's Incident/Accident Report Form dated 5/19/11, at 8:50 AM, documented "Due to cognitive status resident has decreased safety awareness. Does not perceive things as really are. Will put anything in his mouth. Staff states they had been wiping the tables off with the (Bleach) Wipes. Suddenly they heard a sensor pad alarm sound and went immediately to respond. In the meantime, another CNA brought this resident to the table after being toileted. Before staff could retrieve the wipes, this resident had grabbed hold of them and stuck them in his mouth and began chewing on them. " The Measure to Prevent Recurrence documented "Counsel staff on safety and env (environmental) hazards, place res at table only after surface cleaning accomplished. Monitor/remove env. hazards when leaving work area, locks changed on kitchenette door." 2. On 6/30/11, at 4:35 PM, and again on 7/1/11, at 9:54 AM, in the unlocked first floor shower room, in the unlocked cabinet on the bottom shelf, there was a spray bottle of WEX-CIDE 128 germicidal solution. The Material Safety Data Sheet (MSDS) for WEX-CIDE 128 documented the following health hazards "Causes eye damage. Harmful if swallowed". The MSDS documented the Emergency and First Aid Procedures as "In case of contact, immediately flush eyes or skin with plenty of water for at least 15 minutes. For eyes, call a physician. Remove and wash contaminated clothing before reusing. If swallowed, drink promptly a large quantity of water, avoid alcohol and call a physician." The facility's Census Report indicating residents who are cognitively impaired and mobile, dated 7/12/11, documented R42, R43 and R44 reside on the first floor and would have access to the 1st floor shower room. 3. On 6/30/11, at 4:40 PM, and again on 7/1/11, at 9:57 AM, in the unlocked 1st floor Spa Room located on the Alzheimer's unit, the following chemicals were located in an unlocked cabinet: a spray bottle of WEX-CIDE 128, a gallon container of Cid-A-L II a disinfectant/cleaner/detergent, a gallon container of Turbo Clean predisinfectant and detergent, and a spray bottle of BioMatic odor eliminator. The MSDS for the Cid-A-L II documented the following health hazard data "Effects of Exposure: -Eyes: Contact causes irritation and chemical burns. -Skin: Prolonged or repeated contact may cause irritation. -Inhalation: Vapor may cause drowsiness, naus