Every finding on record at Cedar Ridge Rehabilitation and Healthcare Center

Based on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three of eighteen residents (Resident #10, #37, and #81) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Residents #10, #37, and #81's rooms were in a position that was accessible to the residents on 03/30/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings included: Resident #10 Record review of Resident #10's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (insufficient oxygen in the brain causing stroke) and muscle weakness. Record review of Resident #10's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 02/20/2026, reflected the resident had a severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS (screening tool used to assess cognitive status) score of 00. The Comprehensive MDS Assessment indicated the resident was dependent on transfer, hygiene, shower, and dressing. Record review of Resident #10's Comprehensive Care Plan, dated 03/03/2026, reflected that the resident was at risk for falls and one of the interventions was to be sure the resident's call light was within reach. During an observation and interview on 03/30/2026 at 9:28 a.m. revealed Resident #10 was in his bed, awake. It was observed that his call light was tucked at the foot side of the bed. When asked where his call light was, the resident shrugged his shoulders. Resident #81 Record review of Resident #81's Face Sheet, dated 04/01/2025, reflected a [AGE] year-old female admitted on [DATE]. The resident was diagnosed with chronic pain (pain that persisted for a long period of time), anxiety (intense or excessive fear or worry), and lack of coordination. Record review of Resident #81's Comprehensive MDS Assessment, dated 03/10/2026, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated the resident was dependent for hygiene, dressing, transfer, and bed mobility. Record review of Resident #81's Comprehensive Care Plan, dated 03/10/2026, reflected the resident was at risk for falls and one of the interventions was to be sure the call light was within reach. During an observation and interview on 03/30/2026 at 9:31 a.m. revealed Resident #81 was sitting by her sink. It was observed that the resident's call light was behind the resident's headboard. When asked if she could reach her call light, the resident said it would be difficult for her to reach and pull the cord of the call light. She said even though she could walk, she was unable to pull the call light. During an observation and interview on 03/30/2026 at 9:37 a.m., LVN A said call lights were important for the residents because the residents used them to call the staff when they needed something or needed assistance. He said the residents might fall trying to get the call light or trying to do some activities that needed assistance. He went inside Resident #10's room and saw the call light stuck at the foot side of the bed. He pulled Resident #10's call light and placed it within reach. He then went to Resident #81's room and pulled the call light from behind the resident's headboard. He said Resident #81 could ambulate but if was she was having distress, it would be hard for her to pull the call light from behind the headboard. He said he would check also the call lights of the other residents. He said he would also remind the CNAs to make sure that the call lights were within reach of the residents before leaving the room. During an interview on 03/30/2026 at 11:59 a.m., CNA E said he did not notice that Resident #10 and Resident #81's call lights were not within their reach. He said the call lights were important for the residents because the call lights were what they used to call the staff if they needed something or were in distress. He said he would check if the call lights were within reach of the residents. Resident #37 Record review of Resident #37's Face Sheet, dated 04/01/2025, reflected an [AGE] year-old female admitted on [DATE]. The resident was diagnosed with muscle weakness, chest pain, and shortness of breath. Record review of Resident #37's Comprehensive MDS Assessment, dated 03/10/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 00. The Comprehensive MDS Assessment indicated that the resident needed assistance for hygiene, dressing, and transfer. Record review of Resident #37's Comprehensive Care Plan, dated 03/25/2026, reflected that the resident was at risk for falls and one of the interventions was to maintain the call light within reach. During an observation on 03/30/2026 at 9:50 a.m. revealed Resident #37 was in her bed with eyes closed. It was observed that her call light was on the floor. It was also observed that HK G was about to clean the resident's room. During an observation and interview on 03/30/2026 at 9:56 a.m., LVN B said call lights should always be within the reach of the residents because that was how they would call the staff if they needed something. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She went inside Resident's #37's room and saw the call light was already with the resident. She said somebody must have picked it up and placed it within reach of the resident. During an interview on 03/30/2026 at 10:00 a.m., HK G said she was the one who placed the call light where Resident #37 could reach it so she could call the staff if she needed help. She said it was on the floor when she started cleaning the resident's room. During an interview on 04/01/2026 at 9:18 a.m., the ADON said call lights were for dependent and independent residents. She said even though residents could ambulate, the call light should be in a place easily accessible because if independent residents were having distress, it would be hard for them if they needed to pull out their call lights. She said the staff should make sure that the call lights were with the residents or were easily accessible before they left the room. She said she would coordinate with the DON to do an in-service about call light placement. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said call lights were inside the residents' rooms so they can call the staff for assistance, for a glass of water, for pain medication, or because they needed to be changed. She said if the call lights were not within reach, their needs would not be met. She said call lights were for all residents, regardless of whether they were dependent or independent. She said all the staff were responsible for the call lights. She said the expectation was for the staff to scan the residents' rooms when they did their rounds and ensure the call lights were within reach of the residents before they left the room. She said the staff could also clip the call lights so they would not fall. She said she would educate the staff about the importance of call lights for the residents. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said call lights should always be within the reach of the residents. He said for some residents, the call lights were their sense of protection that if something happened to them, they could call the staff for help. He said the residents also used the call lights if they needed to be changed, or they needed pain medication. He said the residents might fall trying to get up and get what they needed. He said everybody was responsible for making sure the call lights were with the residents, whether the resident was independent or not. He said he would collaborate with the DON about the issue regarding call lights. Record review of facility's policy Answering the Call Light 2001 MED-PASS, Inc. revised September 2022 reflected Purpose: The purpose of this procedure is to ensure timely responses to the resident's requests and needs . General Guidelines . 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review, the facility failed to provide an activities program directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 85 of 85 residents.The facility's Activity Director was not a qualified therapeutic recreation specialist or an activities professional that met state licensing requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.Findings Include: Record review on 04/01/2026 at 9:00 AM, of the facility's Administrative and other licensed professional staff licensure audit, revealed the current Activity Director was not certified. Documents provided for the Activity Director included training certificates confirming the AD completed 3.5 hours of CEUs through Lifetime Wellness that were pre-approved NCCAP for Activity Directors and 7 hours of CEUs through [Employer] that were a 4-part series on Dementia Training over the last 12 months. Also included was a typed letter dated February 1, 2012, signed by ADM H stating, [AD] meets DADS NFR/LMC 19.702 guidelines for qualified activities professional. [AD] has worked in the [facility] social and recreational program since January 2006. [AD] has worked full time managing the [name of facility] activity program starting in February 2011.In an interview on 04/01/2026 at 11:18 AM, AD stated she has always used the letter from ADM as her certification to work as the Activity Director for the facility. AD stated she has worked for 24 years at this facility; 9.5 years as the office manager and assisted with the activities. AD stated that ADM talked her into doing activities only since she enjoyed it and wrote the letter on 2/01/12. AD stated that the letter was accepted in the past as proof of certification. AD stated she had not completed an accredited course for Activity Director, did not have a certification from a recognized accrediting body or licensure as an Occupational Therapist or Occupational Therapist Assistant. AD stated she was unaware of any addendums or changes to criteria for Activity Directors. AD stated she made sure she had more than enough CEUs each year.In an interview on 04/01/2026 at 12:05 PM, the Administrator stated that the AD has worked at the facility for over twenty years. The Administrator stated he had worked at the facility for almost a year and as far as he was aware all staff who were required to have certifications or licenses did and had accepted when the company stated current staff met criteria for their positions. The Administrator stated he felt the AD met the criteria for the position and was more than qualified based on her experience and longevity.Record review of [Employer] Job Description for Position Title: Activity Director, dated March 2017, revealed the AD reports to the Administrator of the facility. The Qualifications section revealed The requirements listed below are representative of the knowledge, skill and/or ability required.Minimum Qualifications:Freedom from illegal use of drugs.Freedom from use of and effects of drugs and alcohol in the workplaceAnyone found guilty by a court of law of abusing, neglecting or mistreating individuals in a health care related setting are ineligible for employment in the position.Education and/or Experience: Has two years of experience in a social or recreational program within the last five years (one of which was full-time in a residential activities program in a health care setting) or has completed a training program approved by the state.Certificates. Licenses, Registration: Certification as a Therapeutic Recreation Specialist desirable.Continuing Education: Attends in-service and educational programs and attends continuing education required for maintenance of professional certification or licensure.

Number of residents sampled: Number of residents cited: Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food storage, labeling, and dating. The facility failed to ensure all food items in the facility's kitchen were dated and discarded prior to their use-by date, were properly sealed, and failed to ensure the main ice machine was free of a brownish and blackish substance. These failures could place residents at risk for food contamination and food-borne illness. Finding included: During observation on 03/30/2026 between 9:10 AM and 9:45 AM in the facility's kitchen revealed: One large bag of marshmallows dated 03/19/26 with no visible expiration date. One large bag of crispy fried onions dated 03/10/26 with a use by date of 03/15/26. One large bag of graham crumbs dated 12/27/25 with no visible expiration date. One gallon bag of cherry cake mix not properly sealed and exposed to air contaminants. One gallon bag containing orange cake mix dated 03/27/26 with no visible expiration date. One 5-gallon bin containing [NAME] dated 02/11/26 with a use by date of 03/11/26. One 22-quart bin containing white beans dated 02/11/26 with a use by date of 03/11/26. One 22-quart bin containing Egg noodles dated 02/11/26 with a use by date of 03/11/26. One 22-quart bin containing Sweet Cornbread mix dated 02/08/26 with no visible expiration date One 5-gallon bin containing Blackeye peas One large bag of noodles dated 02/11/26 with a use by date of 03/11/26. One large bag of noodles dated 03/18/26 with a use by date of 03/23/26. One large bag of spaghetti noodles dated 03/03/26, with no visible expiration date was observed. One 20 lb. box of spaghetti pasta noodles not properly sealed and exposed to air contaminants. One 10 lb. bag of pancake mix not properly sealed and exposed to air contaminants. One large bag containing whole potatoes dated 03/27/26, with no visible expiration date was observed. One large bag of cooked beef patties was dated 03/23/26, with no visible expiration date was observed. One large bag containing cut potatoes was undated and revealed no expiration date. One large bag of premade salad opened, not properly sealed and exposed to air contaminants. One gallon pitcher of Vegetable soup dated 03/15/2026 and revealed no expiration date was observed. One large tray containing assorted sandwiches dated 02/27 and revealed no expiration date. Observation on 3/30/26 at 9:40 AM, the Main Ice Machine in the interior portion had brownish and blackish substance on the top portion of the ice bin. During an interview on 04/01/2026 at 10:40 AM DM stated he was the person overall responsible for ensuring the kitchen was meeting guidelines for food storage and kitchen sanitization. DM confirmed the surveyor observations and stated the listed items would be corrected. DM stated once items were opened, they should be properly sealed and dated. DM stated he was responsible for ensuring policy was followed. DM stated he and kitchen aide were responsible for labeling and making sure that the items were labeled properly. The DM stated the risk to residents if policy was not followed was a health risk to the residents. DM stated the items should be labeled, and the risk of the concerns not being addressed could result in food-borne illnesses. DM stated if food items were not dated when opened then they will not be able to know how long they will last. DM stated he will conduct a full in-service of food rotation and storage pertaining to what the proper procedures were dealing with food rotation and storage. The risk of serving foods that were past use by date or serving food that was not labeled or dated can cause food borne illness. During an interview on 04/01/2026 at 11:45 AM, ADM stated he oversaw all departments, and ensured residents were taken care of. ADM stated the DM made him aware of the concerns observed in the kitchen and had spoken with the DM. He stated that the issues could cause food contamination and this matter would be resolved. If items were expired, they do not want to serve them to residents. The ADM stated the risk of all these concerns observed in the kitchen could result in residents getting sick. The ADM said the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. He said the risk to residents if policy was not followed was that they could get sick from food borne illnesses. The ADM stated he would expect the DM to ensure that the kitchen followed all guidelines, including ensuring the food items were labeled properly in the kitchen. The ADM stated he expected staff to ensure they were following policies and procedures of the facility kitchen policy, to protect residents and to deliver good care. ADM stated if foods were not discarded properly, sanitized properly, or heated properly, there was the potential for foodborne illness. The ADM stated the risk of these concerns not being addressed could result in food contamination and residents becoming ill. Record review of the facility's Food Receiving and Storage Policy, dated March 2026, indicated 2. Food Labeling and Dating, to ensure proper food rotation and prevent use of expired products: All food must be dated upon delivery. Food removed from original packaging must be labeled with the product name and date.Prepared foods stored in refrigerators must include a use by date. Opened containers must be sealed or covered and dated. Expired foods must be immediately removed from storage areas. 4. Dry Storage Storage containers. Foods stored in bins must be removed from original packaging and placed in clean labeled binds or kept in the original packaging with proper labeling and dating. 5. Sanitation and Equipment Maintenance. Equipment will be cleaned regularly and sanitized as needed.Supervisors will conduct monthly inspections of refrigeration equipment including Door gaskets, Fans, Rust or corrosion, Condensation, and Mechanical issues. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for four of eighteen residents (Resident #5, #46, #67, and #82) reviewed for infection control. 1. The facility failed to ensure CNA F performed hand hygiene before assisting the ADON on Resident #5's wound care on 04/01/2026. 2. The facility failed to ensure MA D sanitized the blood pressure cuff while administering medications to Residents #46 and Resident #67 on 03/31/2026. 3. The facility failed to ensure CNA E performed hand hygiene and changed his gloves during Resident #82's incontinent care on 03/30/2026. These failures could place residents at risk of cross-contamination and development of infections.Findings included: 1. Record review of Resident #5's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with skin transplant status. Record review of Resident #5's Comprehensive MDS Assessment, dated 01/23/2026, reflected the resident had a moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had a skin transplant. Record review of Resident #5's Comprehensive Care Plan, dated 02/08/2026, reflected the resident had surgical skin graft to left lower leg/foot and one of the interventions was to keep incision clean and dry. Record review of Resident #5's Physician Order, dated 04/01/2026, reflected skin graft/surgical wound to left heel: cleanse with wound cleanser, pat dry. Apply collagen to wound bed and cover with ABD and wrap with kerlix. Secure with ace wrap. everyday shift for surgical wound AND as needed for soiled or dislodged dressing. During an observation on 04/01/2026 at 8:37 a.m. the ADON was about to do Resident # 5's wound care. Before doing wound care, she asked CNA F to help her. CNA F put on a gown and a pair of gloves. She did not wash or sanitize her hands. During an interview on 04/01/2026 at 9:10 a.m., CNA F said hands should be sanitized before putting on a gown and the gloves to prevent cross contamination and infection. She said she would remember the next time she would provide care to do hand hygiene. 2. Resident #46 Record review of Resident #46's Face Sheet, dated 04/01/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). Record review of Resident #46's Comprehensive MDS Assessment, dated 02/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated that the resident had hypertension. Record review of Resident #46's Comprehensive Care Plan, dated 03/02/2026, reflected that the resident had hypertension and one of the interventions was to give anti-hypertensive medications. Resident #67 Record review of Resident #67's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #67's Comprehensive MDS Assessment, dated 03/06/2026, reflected that the resident was cognitively intact with a BIMS score of 13. The Comprehensive MDS Assessment indicated that the resident had hypertension. Record review of Resident #67's Comprehensive Care Plan, dated 02/19/2026, reflected that the resident had hypertension and one of the interventions was to give anti-hypertensive medications. Record review of Resident #67's Physician Order, dated 11/21/2025, reflected Metoprolol Succinate ER Tablet Extended Release 24 Hour 50 MG Give 1 tablet by mouth one time a day for HTN related to ESSENTIAL (PRIMARY) HYPERTENSION (I10) HOLD for SBP<110, DBP<60 HR<60. During an observation on 03/31/2026 at 8:12 a.m. MA D was about to prepare Resident #46's medication. She picked up the blood pressure cuff from the top of the medication cart, put it on her wrist, went inside the resident's room, took the blood pressure cuff from her wrist, and placed it on Resident #46's arm. After the blood pressure reading was completed, she placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #46. She did not sanitize the blood pressure cuff. She then went to Resident #67's room to administer her medications. She picked up the blood pressure cuff, put it on her wrist again, went inside the resident's room, took the blood pressure cuff from her wrist, and placed it on Resident #67's arm. After the blood pressure reading was completed, MA D placed the blood pressure cuff on top of the medication cart, prepared the medications, and gave the medications to Residents #67. She did not sanitize the blood pressure. During an interview on 03/31/2026 at 8:49 a.m., MA D said she did take the blood pressures of the residents who had orders for anti-hypertensive medications, so she would know if she needed to hold medications or not. She said she would put the blood pressure cuff on her wrist before and after taking the blood pressure so she would not forget where she put it. She said she should have sanitized the blood pressure cuff between residents to prevent cross contamination and spread infection. She said one resident might have a skin issue and would be transferred to another resident because the blood pressure cuff was not sanitized. She said, on that note, she should also not put it on her wrist because she might have a skin infection and could transfer it to the residents or the other way around. 3. Record review of Resident #82's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body). Record review of Resident #82's Comprehensive MDS Assessment, dated 03/13/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #82's Comprehensive Care Plan, dated 03/11/2026, reflected that the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode. During an observation on 03/30/2026 at 11:47 a.m. revealed CNA E was about to do Resident #82's incontinent care. He went inside the resident's room and put on a pair of gloves. He did not wash his hands before putting on his gloves. He took the trash can and placed it near him. He did not change his gloves after touching the trash can and proceeded with incontinent care. He unfastened the brief and cleaned the resident's perineal area (area between the thighs) and then assisted the resident to roll to his side. He then pulled the soiled brief and threw it in the thrash can. He cleaned the resident's bottom and then pulled the soiled draw sheet. After cleaning the bottom, he took the new brief from the overbed table, placed it under the resident, and fixed it. He did not change his gloves after cleaning the bottom and rolling the soiled brief and draw sheet and before touching the new brief. During an interview on 03/30/2026 at 11:59 a.m., CNA E said he was supposed to change his gloves after touching the trash can, after cleaning Resident #82s' bottom, after rolling the soiled brief, and before touching the new brief to prevent using dirty gloves. He said hand hygiene should also be done before doing any care, like incontinent care to prevent cross contamination and urinary tract infection. During an interview on 04/01/2026 at 9:18 a.m., the ADON said hand hygiene should be done before doing any care and before putting on a pair of gloves to make sure the gloves that the staff would be using were clean. She said after touching the trash, the gloves should have been changed, after cleaning the bottom, the gloves should have been changed, after rolling the soiled draw sheet, the gloves should have been changed to avoid transfer of microorganisms to the new brief that could eventually cause infection. She said the blood pressure cuff should be sanitized after each use for the same reason. She said she would coordinate with the DON to do an in-service about hand hygiene and infection control During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said staff should do hand hygiene before, during, and after care. She said hand hygiene was the most effective way to prevent cross contamination that could possibly lead to infection. She said the gloves should have been changed after touching something soiled like the trash can, the resident's bottom, soiled brief, and soiled draw sheet to make sure there was no transfer of microorganisms to the new brief. She said the blood pressure cuff should be sanitized after every use for the same reason. She said the expectation was for the staff to be mindful that they would not be the cause of any infection. She said she would start an in-service about infection control. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said the expectation was for the staff to be mindful not to cause any kind of infection. He said he was not a clinician and would let the DON take the lead on the issue of infection control. Record review of the facility's policy Handwashing-Hand Hygiene Policy and Procedures revised October 2020 reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations . b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads . h. Before moving from a contaminated body site to a clean body site during resident care . i. After contact with a resident's intact skin . j. After contact with blood or bodily fluids . m. After removing gloves . Applying and Removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves. Record review of the facility's policy Fundamentals of Infection Control Precautions Infection Control Policy & Procedure Manual 2019 revised March 2024 reflected 6. Resident care equipment and articles . 3. Non-invasive resident care equipment is cleaned daily or as need between use. Record review of the facility's policy Perineal Care revised March 03, 2026, reflected Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 4. Wash hands and apply gloves.

Based on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for five of eighteen residents (Residents #1, #8, #18, #41, and #66) reviewed for medication storage. 1. The facility failed to ensure Resident #1 did not have a tube of zinc oxide inside his room on 03/30/2026. 2. The facility failed to ensure Resident #8 did not have a tube of zinc oxide and topical antibiotic ointment inside his room on 03/30/2026. 3. The facility failed to ensure Resident #18 did not have a tube of zinc oxide inside his room on 03/30/2026. 4. The facility failed to ensure Resident #41's eyedrops inside his room were not accessible to other residents on 03/30/2026. 5. The facility failed to ensure that Resident #66 did not have a tube of topical pain relief gel inside the room on 03/03/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.Findings included: 1. Record review of Resident #1's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with paraplegia (paralysis of the legs and lower part of the body). Record review of Resident #1's Comprehensive MDS Assessment, dated 02/06/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #1's Comprehensive Care Plan, dated 02/19/2026, reflected that the resident had incontinence and one of the interventions was incontinent care as needed and apply barrier cream. During an observation 03/30/2026 at 9:32 a.m. revealed Resident #1 was not inside his room. It was observed that a tube of zinc oxide (medicated cream used to prevent skin irritation) was on top of the resident's side table. 2. Record review of Resident #8's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with cerebral infarction (insufficient oxygen in the brain causing stroke). Record review of Resident #8's Comprehensive MDS Assessment, dated 01/24/2026, reflected that the resident had a moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident was incontinent for bowel. Record review of Resident #8's Comprehensive Care Plan, dated 03/11/2026, reflected that the resident had bowel incontinence and had the potential for pressure ulcers and one of the interventions was to keep clean and dry. Record review on 03/30/2026 of Resident #8's Physician Order reflected no order for a topical antibiotic ointment. Record review on 03/30/2026 of Resident #8's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 03/30/2026 at 9:36 a.m. it was revealed that Resident #8 was in his bed, awake. It was observed that a tube of zinc oxide and a cup with white cream were on top of the sink inside the room of the resident. It was also observed that a tube of an open topical antibiotic ointment was on the resident's side table. The resident said that the staff used the cream every time they changed him. He said he did not know what the topical antibiotic ointment was for because he did not have any skin infection. 3. Record review of Resident #18's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with anxiety (intense or excessive fear or worry) and dementia (a condition characterized by loss of memory and ability to reason). Record review of Resident #18's Comprehensive MDS Assessment, dated 02/27/2026, reflected that the resident had a severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated the resident was incontinent for bladder and bowel. Record review of Resident #18's Comprehensive Care Plan, dated 03/10/2026, reflected that the resident had bladder and bowel incontinence and one of the interventions was to clean peri-area with each incontinent episode. During an observation on 03/30/2026 at 9:48 a.m. revealed Resident #18 was not inside his room. It was observed that a tube of zinc oxide was on top of the sink inside his room. 4. Record review of Resident #66's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with legal blindness (vision impairment that affects central or peripheral vision or both) and dementia. Record review of Resident #66's Comprehensive MDS Assessment, dated 01/30/2026, reflected the resident had severe impairment in cognition with a BIMS score of 07. The Comprehensive MDS Assessment indicated that the resident received scheduled pain medication. Record review of Resident #66's Comprehensive Care Plan, dated 03/19/2026, reflected that the resident was at risk for pain and one of the interventions was to administer analgesia (pain relief medication) as per order. Record review on 03/30/2026 of Resident #66's Physician Order reflected that the resident did not have an order for topical pain relief gel. Record review on 04/01/2026 of Resident #66's Clinical Assessment Notes reflected no assessment for self-administration of medications or an assessment that the resident was competent to manage their own medications. During an observation and interview on 03/30/2026 at 9:32 a.m. Resident #66 was in his wheelchair inside his room. It was observed that a tube of topical pain relief gel was on top of the resident's table that was near the entrance of his room. The tube of topical pain relief gel was visible from the hallway. He said it was his pain medication, and it was always on his table so he would know where to get it in case he needed it. During an observation and interview on 03/30/2026 at 9:54 a.m., LVN A said barrier creams with zinc oxide should not be inside the rooms of the residents because confused residents might mistakenly consume them or use them inappropriately. He said the barrier creams should be somewhere not accessible to the residents. He said medications such as topical antibiotics and topical analgesic should not be inside the residents' rooms for the same reason. He said he did not notice the skin barriers with zinc oxide and the topical medications when he did his morning rounds. He went to Resident #66's room and saw the topical analgesic. He talked to Resident #66 and said he would put the topical analgesic inside his cart. He then went to Resident #8's room and saw the tube of zinc oxide, a cup with white cream on it, and the tube of topical antibiotics. He said, most probably, the white cream inside was also zinc oxide. He said Resident #8 did not have any skin issues, so he did not know why he had a topical antibiotic ointment inside his room. He then went to Resident #1 and Resident #18's rooms and took the barrier creams. He said he would also check the rooms of the other residents to see if they had any medications inside their rooms. He said he would check if Resident #66 needed the topical analgesic so he could request an order for it. He said he would also find out why Resident #8 had a topical antibiotic cream. 5. Record review of Resident #41's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with a lack of coordination. Record review of Resident #41's Comprehensive MDS Assessment, dated 02/11/2026, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had impaired eyes and used corrective lenses. Record review of Resident #41's Comprehensive Care Plan, dated 02/10/2026, reflected that the resident had limited physical mobility and one of the interventions was to re-evaluate safety. Record review of Resident #41's Self-Administration Safety Screen, dated 01/23/2025, reflected that the resident may self-administer his medication unsupervised. Record review of Resident #41's Physician Order, dated 07/14/2026, reflected Cyclosporine Emulsion 0.05 % Instill 1 drop in both eyes two times a day for dry eyes due to inflammation. During an observation on 03/30/2026 at 10:02 a.m. revealed Resident #41 was not inside his room. It was observed that a box of eyedrops were on top of his overbed table. Several eyedrops were also observed inside a plastic cup that was also on top of the overbed table. The eye drops were visible from the hallway. During an observation and interview on 03/30/2026 at 10:05 a.m., LVN C said Resident #41 could self-administer his medications. She said the issue was that eyedrops were accessible to other residents. She said other residents might go inside his room and might take some of the eyedrops and use them inappropriately. She said she would talk to the resident to find a way to secure the medications. During an interview on 04/01/2026 at 9:18 a.m., the ADON said barrier creams with zinc oxide is a form of topical medication because they were used to prevent skin breakdown and rashes. She said zinc oxide should not be left inside the rooms of the residents and within the reach of the residents because the creams had chemicals in them that could cause irritation and stomach upset. She said they should be inside the carts, and nurses should give the CNAs the creams in a cup when the CNAs needed to use the cream. She said the same with the topical analgesic and the topical antibiotic ointment. She said Resident #41's eye drops should not be within reach of other residents because they might use the eyedrops inappropriately. She said she would coordinate with the DON to do an in-service about medication storage. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said medications should not be inside the residents' rooms because the residents might use them inappropriately that could result in adverse reactions. She said skin barriers were applied topically and could be harmful when ingested. She said the same rationale applied to the eye drops found inside the room that were accessible to other residents. She said the expectation was for the staff to be vigilant when they entered the residents' room to check for any medications and for staff using the skin barriers to not leave the tubes within reach of the residents. She said she would start an in-service about medication storage. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said the expectation was for the staff to make sure there were no medications inside the residents' rooms the residents might consume them or use them on their eyes causing irritation. He said he was not a clinician and would let the DON take the lead on the issue. Record review of the facility's policy, Medication Administration revised March 05, 2026, reflected Purpose: To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice . General Standards . 1. Only individuals licensed or legally authorized in this state may prepare, administer, and document medications. Record review of the facility's policy Medication and Treatment Orders 2001 MED-PASS, Inc. revised July 2016 reflected Policy Statement: Orders for medications and treatments will be consistent with principles of safe and effective order writing . Policy Interpretation and Implementation . 1. Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state . Drug and biological orders must be recorded on the physician's order sheet in the resident's chart.

Based on observation, interview, and record review, the facility failed to ensure residents with wounds received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one of four residents (Resident #5) reviewed for quality of care. The facility failed to ensure that the interim ADON did not clean Resident #5's wound with the gauze used to clean the surrounding skin of the wound on 04/01/2026. This failure could place the residents with wounds at risk of infection.Findings included: Record review of Resident #5's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with skin transplant (a surgical procedure that involves taking healthy skin and moving it to cover damaged skin) status. Record review of Resident #5's Comprehensive MDS Assessment, dated 01/23/2026, reflected that the resident had a moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated that the resident had a skin transplant. Record review of Resident #5's Comprehensive Care Plan, dated 02/08/2026, reflected the resident had surgical skin graft (another term for skin transplant) to left lower leg/foot and one of the interventions was to keep incision clean and dry. Record review of Resident #5's Physician Order, dated 04/01/2026, reflected skin graft/surgical wound to left heel: cleanse with wound cleanser, pat dry. Apply collagen to wound bed and cover with ABD and wrap with kerlix (bandage used for wound care). Secure with ace wrap. Every day shift for surgical wound AND as needed for soiled or dislodged dressing. During an observation on 04/01/2026 at 8:37 a.m. revealed the ADON was about to do Resident # 5's wound care. She sanitized her hands, put on a pair of gloves, and sanitized the resident's overbed table. When the table was dry, she placed some gauze, some normal saline bullets, dressing, collagen sheet, kerlix, ace wrap, and some gloves on the table that she covered with wax paper. She sanitized her scissors, placed them on the table, and taped a plastic bag to the side of the table. She washed her hands and put on a gown and gloves. She took the ace wrap and kerlix off and then took the soiled dressing. She removed her gloves, sanitized her hands, and put on a new pair of gloves. She squeezed the normal saline bullet on a couple of gauzes and started to clean the resident's wound to his left heel. She started by cleaning the surrounding skin of the wound and used the same gauze to clean the inside of the wound. She did it twice. She took off her gloves, sanitized her hands, put on a pair of gloves, and proceeded with wound care. During an interview on 04/01/2026 at 9:12 p.m., the ADON said the gauze used to clean the skin surrounding the wound should not have been used to clean the inside of the wound because germs from the skin surrounding the wound would transfer to the wound itself. She said she was not aware she used the gauze to clean the surrounding skin of Resident #5's wound to clean the inside of the wound. She said she should have discarded the gauze used to clean the surrounding skin of the wound and got another gauze to clean the wound. She said the microorganism accumulated from the surrounding skin of the wound eventually was transferred to the wounds and could cause infections. She said she would be mindful the next time she would do wound care not to use soiled gauze to clean the inside of the wounds again. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said the gauze should be changed after every stroke and discarded. She said the gauze used to clean the surrounding skin was already soiled and should not be used to clean the inside of the wound. She said the goal was to clean the wound and not to contaminate it. She said if the same gauze was used, microorganisms might be introduced to the wound and could result in infection. She said the expectation was for the staff doing wound care to do the right procedure. She said she would do an in-service about proper techniques in wound care. She said the ADON went ahead and cleaned Resident #5's wound again. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said improper wound care could lead to infection. He said the expectation was to do wound care the right way according to wound care technique. He said he would coordinate with the DON about the issue. Record review of the facility's policy Skin Integrity, Prevention, and Treatment Program revised March 05, 2026, reflected Wound Care . c. Adheres to infection control best practices. Policy for wound care policy requested via email to the Administrator on 03/31/2026 and requested verbally to the Corporate Nurse on 04/01/2026 but was not provided prior to exit.

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for one of five direct staff (LVN C) reviewed for accident hazard. 1. The facility failed to ensure LVN C did not leave a container of germicidal wipes on top of her cart unattended on 03/30/2026. 2. The facility failed to ensure there were no germicidal wipes on the ledge of the nurse's station, unattended, on 03/30/2026. These failures could prevent the residents from having an environment that was free from toxic chemicals. Finding included: 1. During an observation on 03/30/2026 at 1:05 p.m. LVN C went inside a resident's room to administer medications. She closed the door while administering medications. She left a container of germicidal wipes (substance that destroys germs and microorganism) on top of a cart, unattended, until she finished administering medications. 2. During an observation on 03/30/2026 at 1:26 p.m. a container of germicidal wipes was observed sitting at the nurse's station ledge. It was observed that nobody was in the nurse's station and a resident was sitting near the nurse's station. During an observation and interview on 03/30/2026 at 1:28 p.m., LVN C said she forgot to put the container of germicidal wipes into the drawer of her cart when she went inside a resident's room to administer medications. She said she should have placed the germicidal wipes inside the cart before he closed the door to give medications because residents might be able to get hold of the wipes and use them to clean their faces and eyes that could result in irritations. She took the container of germicidal wipes and put it inside the last drawer of the cart she was using. She then saw the container of germicidal wipes on the ledge of the nurse's station. She took the container and placed it inside the medication room. During an interview on 04/01/2026 at 9:18 a.m., the ADON said the germicidal wipes should be stored inside the cart or the medication room and not where residents could access them. She said residents might pull some and use them to clean their eyes, skin, and private areas. She said it might cause irritation and toxicity if consumed. She said anything that indicated Keep out of reach of children. should be considered harmful because the facility had confused residents that may not know the outcome if the germicidal wipes were used. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said the containers of germicidal wipes should not be left on top of the cart or on the ledge of the nurse's station unattended because they have chemicals that could cause adverse effects if consumed or had contact with the skin, eyes, and mouth. She said the container of germicidal wipes was closed, but somebody could open it to pull some wipes with their bare hand. She said the wipes were handled with gloves on because they have chemicals on them to eliminate germs on surfaces. She said the containers should be inside the carts when staff were leaving their carts. She said she would start an in-service about not leaving any germicidal wipes, unattended, for resident safety. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said the containers of germicidal wipes should not be within reach of any residents because they might accidentally use them that could result in skin or eye irritation. He said he would collaborate with the DON and the Corporate Nurse regarding the issue. Record review of the facility's policy Safe Storage and Handling of Disinfectant Wipes and Chemical Agents undated, reflected Policy Statement: It is the policy of this facility to ensure that all disinfectant products, including but not limited to germicidal wipes are stored and handled in a manner that prevents resident access, minimizes exposure risk, and maintains a safe environment for residents, staff, and visitors . Purpose: To prevent accidental exposure, ingestion, skin irritation, or other adverse events associated with improper storage or use of disinfectant wipes and chemical agents . Policy Guidelines . Disinfectant wipes must not be left unattended . All chemical agents must be . Stored in secured compartments (locked carts, cabinets; or designated storage rooms) OR maintained under direct staff supervision at all times.

Based observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection for one of five residents (Resident #82) reviewed for incontinent care. The facility failed to ensure that CNA E performed the right technique during Resident #82's incontinent care on 03/30/2026. This failure could place the residents at risk of urinary tract infection.Findings included: Record review of Resident #82's Face Sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hemiplegia (paralysis of one side of the body). Record review of Resident #82's Comprehensive MDS Assessment, dated 03/13/2026, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated that the resident was frequently incontinent for bladder and bowel. Record review of Resident #82's Comprehensive Care Plan, dated 03/11/2026, reflected that the resident had incontinence and one of the interventions was to provide pericare (hygiene practices involved in cleaning the area between the thighs) after each incontinent episode. During an observation on 03/30/2026 at 11:47 a.m. revealed CNA E was about to do Resident #82's incontinent care. He put on a pair of gloves and started cleaning the sides and top of the resident's perineal area (area between the legs). He then pulled the skin of the shaft of the resident's penis and cleaned the shaft of the penis downward. With the same wipes he used to clean the shaft of the resident's penis, he cleaned the head of the penis touching the opening of the penis. He did it twice. During an interview on 03/30/2026 at 12:07 p.m., CNA E said he should not have used the wipes to clean the shaft of the penis to clean the head of the penis because the germ from the shaft could enter the opening of the penis and may cause urinary tract infection. During an interview on 04/01/2026 at 9:18 a.m., the ADON said wipes used to clean the shaft of the penis should not be used to clean the head of the penis because microorganisms (organism that is too small to be seen) from the shaft might enter the opening of the penis which was located on its tip. He said the head of the penis should be cleaned with clean wipes. She said she would coordinate with the Corporate Nurse or the DON to do an in-service about the right procedure during incontinent care. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said that using a soiled wipe to clean the head of the penis could result to urinary tract infection. She said the microorganisms from the shaft could eventually enter the opening of the penis. She said the expectation was for the staff to follow the right procedure in cleaning the penis. She said she would start an in-service about proper procedure in cleaning the penis and would let the DON know about the improper procedure of incontinent care. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said the expectation was for the staff to follow the proper technique of incontinent care to prevent any unwanted outcomes like urinary tract infections. He said he would collaborate with the DON and the Corporate Nurse regarding incontinent care. Record review of the facility's policy Perineal (area between the thighs) Care revised March 03, 2026, reflected Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . For a male resident . b. Wash perineal area starting with urethra (a tube where urine exits the body) and working outward.

Based on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals that met the needs of each resident for two of eighteen residents (Resident #33 and Resident #46) reviewed for pharmaceutical services. The facility failed to ensure LVN I did not leave Resident #33 and Resident #46's medications inside the cart on 03/31/2026, instead of administering their medications to them. This failure could place residents at risk of not receiving medications as ordered resulting in adverse effects such as worsening conditions and inadequate disease control.Findings included: Resident #33 Record review of Resident #33's Face Sheet, dated 04/01/2026, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with hypothyroidism (the thyroid gland does not produce enough thyroid hormones resulting in fatigue). Record review of Resident #33's Comprehensive MDS Assessment, dated 01/05/2026, reflected that the resident had severe impairment in cognition with a BIMS score of 05. The Comprehensive MDS Assessment indicated that the resident had hypothyroidism. Record review of Resident #33's Comprehensive Care Plan, dated 03/02/2026, reflected that the resident had hypothyroidism and the intervention was to administer medications as ordered. Record review of Resident #33's Physician's Order, dated 03/17/2025, reflected Levothyroxine Sodium Oral Tablet 25 MCG (Levothyroxine Sodium) Give 12.5 mcg by mouth in the morning for Hypothyroidism Give half tablet by mouth every day. Record review on 03/31/2026 of Resident #33's Progress Notes reflected no documentation why the medication was not administered.Record review on 03/31/2026 of Resident #33's eMAR reflected levothyroxine was not administered. Resident #46 Record review of Resident #46's Face Sheet, dated 04/01/2026, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with hypothyroidism. Record review of Resident #46's Comprehensive MDS Assessment, dated 02/10/2026, reflected the resident had severe impairment in cognition with a BIMS score of 06. The Comprehensive MDS Assessment indicated that the resident had hypothyroidism. Record review of Resident #46's Comprehensive Care Plan, dated 03/02/2026, reflected that the resident had hypothyroidism and the intervention was to administer medications as ordered. Record review of Resident #46's Physician's Order, dated 06/25/2025, reflected Levothyroxine Sodium Oral Tablet 88 MCG (Levothyroxine Sodium) Give 1 tablet by mouth in the morning for hypothyroidism recheck TSH in 6 weeks. Record review on 03/31/2026 of Resident #46's Progress Notes reflected no documentation why the medication was not administered.Record review on 03/31/2026 of Resident #46's eMAR reflected levothyroxine was not administered. During an observation on 03/31/2026 at 8:12 a.m. MA D was preparing medications. When she opened the first drawer of her cart, it was observed that there were two small cups with one pill each inside the drawer. During an observation and interview on 03/31/2026 at 8:49 a.m., MA D said the medications were left by the night nurse. She said the night nurse did not tell her anything about the medications. She said she did not know why it was left inside the cart. It was observed that the cups had Resident #33 and Resident #46's names on them. She took the cups and said she would show them to the DON. During an interview on 03/31/2026 at 3:12 p.m., Resident #33 just shrugged her shoulders when asked if she was given her early morning medication. During an interview on 03/31/2026 at 3:19 p.m., Resident #46 did not reply when asked about his early morning medication. During an interview on 04/01/2026 at 9:18 a.m., the ADON said there should be no medications that were already prepared inside the cart. She said the night nurse should have told the medication aide that she was not able to give the medications and if she could give them. She said the night nurse should have discarded the medications if the residents refused and documented it. She said if the residents were still sleeping, the night nurse should have revisited the resident to give the medications so that the residents would not miss any medications. She said another issue with this was that the MA could get confused or distracted and would be able to include the medications that were in the cups that were prepared before her shift. She said this could result to other residents taking medications that were not prescribed to them. During an interview on 04/01/2026 at 9:43 a.m., the Corporate Nurse said she already talked to LVN I about why there were medications left inside the cart with Resident #33 and Resident #46's names on them. According to the Corporate Nurse, one of the residents was still sleeping and the other one refused, that was why she placed the medications inside the cart and planned to go back to the said residents to administer the medications but forgot to do so. She said since it was a missed medication, the residents were assessed, and the NP and the responsible party were notified. During an interview on 04/01/2026 at 10:23 a.m., the Administrator said he was not a clinician and would let the Corporate Nurse and the DON take the lead on the issue. Record review of the facility's policy Medication Administration revised March 05, 2026, reflected Purpose: To ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice . During Medication Pass . Missed residents are followed up after completion of the medication pass . Refused, withheld, or rescheduled medications are documented appropriately on the MAR.

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of 4 residents reviewed for respiratory care.The facility failed to ensure Resident #1's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) and nebulizer mouthpiece (device used to deliver medication in a mist form through the mouth) was properly stored when not in use on 09/30/2025.This failure could place residents at risk of respiratory infection and not having their respiratory needs met.Findings include: Record review of Resident #1's Face Sheet, dated 09/30/2025, reflected the resident was a [AGE] year-old female who admitted on [DATE]. Resident #1 had diagnoses which included hypertension (elevated blood pressure) and COPD (chronic inflammatory lung disease that causes obstructed airflow from the lungs).Record review of Resident #1's MDS (tool used to measure health status) Discharge Assessment, dated 09/21/2025, reflected a BIMS (tool used to measure cognitive status) Assessment was not completed for resident #1. The staff assessment for mental status indicated Resident #1's cognition was moderately impaired with making decisions regarding tasks of daily life. Section I (Active Diagnoses) reflected Resident #1 was treated for COPD.Record review of Resident #1's Comprehensive Care Plan, dated 07/30/2025, reflected the resident had COPD related to smoking. One intervention was continuous oxygen via nasal cannula to keep oxygen saturation at 92% - 94%.Record review of Resident #1's Comprehensive Care Plan, dated 07/30/2025, reflected Resident is at risk for infection, due to non-compliance with nasal cannula use.Frequently removes nasal cannula and drops on the floor. Date initiated 06/20/2025. The intervention was Nursing will monitor for canula placement and if found on floor will be replaced immediately. Date Initiated: 06/20/2025.Record review of Resident #1's Physician's Order, dated 07/10/2025, reflected to administer oxygen at 2-5 LPM to maintain oxygen greater than 92% every shift for shortness of breath. Record review of Resident #1's Physician's Orders, dated 07/10/2025, reflected to administer Ipratropium-Albuterol (medication that makes it easier to breathe) Inhalation Solution 0.5-2.5 (3) MG/3 ML. Inhale 1 vial orally three times a day related to COPD with acute exacerbation (sudden worsening of symptoms in chronic conditions). During an observation and interview on 09/30/2025 at 11:22 AM, Resident #1's oxygen tubing was on the resident's bed unbagged. Resident #1's mouthpiece for administration of breathing treatments was on the resident's bedside table unbagged. Resident #1 was not in her room. CNA C was in the hall and stated the charge nurse was responsible for putting the mouthpiece in the bag after the medication was finished. CNA C stated Resident #1 placed the oxygen tubing on her bed until she returned from smoking and put it back in her nose. CNA C stated the mouthpiece used for breathing treatments should have been bagged to keep it clean, but she was not sure about the nasal cannula. During an interview on 09/30/2025 at 11:28 AM, Resident #1 stated a staff member came to get her for smoke breaks. Resident #1 stated she removed the oxygen tubing and placed it on her bed when she went to smoke. She stated the oxygen tubing was usually on the bed when she returned from smoking. Resident #1 stated she usually turned off the nebulizer machine herself and put the nebulizer mouthpiece on the bedside table. Resident #1 stated she had not been told to notify staff when she removed the nasal cannula or nebulizer mouthpiece.During an interview on 09/30/2025 at 11:36 AM, DON A stated the oxygen tubing and respiratory items should have been stored in a bag when not in use. She stated Resident #1 left her oxygen tubing on the bed when she went to smoke. She stated whoever administered medication should ensure the nebulizer mouthpiece was placed in a bag after the breathing treatment. She stated if left exposed, it should be replaced, and placed in a clean bag. DON A stated if respiratory items were dirty or contaminated, the risk to the resident was infection. She stated the facility would provide in-service training related to monitoring the resident to ensure respiratory items were stored in a bag when not in use. During a telephone interview on 10/02/2025 at 9:58 AM, LVN B stated the nasal cannula, and mouthpiece should have been stored in a bag. She stated Resident #1 had a breathing treatment three times daily. She stated sometimes Resident #1 turned off the nebulizer before completing a treatment, and placed the mouthpiece on the bedside table. LVN B stated it was important to monitor the resident and ensure the items were bagged for infection control. Record review of the facility's policy Administering Medications through a Small Volume (Handheld) Nebulizer, revised October 2010, reflected store in a plastic bag with the resident's name and date on it.Record review of the facility's policy Oxygen Administration and Oxygen Safety, revised 07/23/2025, did not reflect how to store oxygen tubing when not in use.

Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated to reflect a left heel wound on 06/01/2025. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #1's Face Sheet, dated 06/18/2025, reflected an [AGE] year-old male who initially admitted to the facility 04/29/2025 and re-admitted on [DATE]. Resident #1 had diagnoses which included chronic kidney disease stage 3 (kidneys do not function properly), heart failure (heart does not pump effectively), and pneumonia (infection in lung). Resident #1 was discharged home on [DATE]. Record review of Resident #1's Quarterly MDS (tool used to assess health needs and functional capabilities) Assessment, dated 05/17/2025, reflected the resident had severe impairment in cognition with a BIMS (tool used to assess cognitive function) score of 06. Record review of Resident #1's Physician Order, dated 06/01/2025, reflected to apply xeroform (non-adherent wound dressing that promotes healing) and a bordered gauze dressing to the resident's left heel. Record review of Resident #1's Comprehensive Care Plan, dated 05/07/2025, did not reflect a left heel wound. During an interview on 06/20/2025 at 3:20 PM, the Administrator stated it was important to update care plans so everyone knew what care to provide the residents. He stated if they were not updated, the resident might not receive the appropriate care. During an interview on 06/20/25 at 3:59 PM, the Wound Care Nurse stated she was responsible for adding or updating any skin related resident care plan. She stated it was important to include all the resident's needs in the care plan to monitor progress and follow through with meeting the needs. During an interview on 6/20/2025 at 4:15 PM, the MDS Coordinator stated it was important to update care plans so staff knew how to take care of the residents. She stated the nurses, ADON, DON, and MDS Coordinator added and updated residents' care plans. She stated the wound care nurse added or updated a care plan for any skin issues. She stated it was important to care plan any skin issue because of the risk for infection. During an interview on 06/20/2025 at 4:50 PM, the DON stated it was important for each resident to have a personalized plan of care. She stated Resident #1's wound should have been included in his care plan. She stated resident care would not be consistent if the care plan was not personalized and updated to reflect the resident's needs. Record review of the facility's policy, Care Plan, Comprehensive Person-Centered, reviewed 06/02/2025, reflected A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #1) of four residents reviewed for Care Plans. The facility failed to ensure Resident #1's history of falls were care planned. This failure could place the resident at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #1's Face Sheet, dated 04/30/25, reflected she was an [AGE] year-old female admitted on [DATE]. Relevant diagnoses included muscle weakness, lack of coordination, and dizziness. Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment, dated 04/15/25, reflected she had a BIMS score of 10 (moderate impairment). Resident required extensive assisted with ADL care. Record review of the facility's incident report and Resident #1's progress notes on 04/30/25, reflected the resident had an unwitnessed fall on 03/14/25, which resulted in no injuries. Record review of Resident #1's Quarterly Care Plan, dated 11/19/24, did not reflect a care plan for the resident's history of falls. In an interview on 04/30/25 at 11:00 AM, the ADON stated Resident #1 had a fall in March 2025 and she was considered at high risk for falls. She stated the resident should have been care planned for falls, but it was not done. She stated the DON at the time should have care planned the fall risk. She stated the ADON, the MDS nurse, and the DON were responsible for ensuring the resident was care planned as a fall risk. She stated the risk of not care planning the fall risk was it could impact the resident not having the proper precautions in place. In an interview on 04/30/25 at 11:15 AM, the MDS nurse stated Resident #1 had a fall on 03/14/25. She was considered a fall risk and all the residents at the facility were considered a fall risk. She stated based on the neurological report completed on 03/14/25, the resident should have been care planned for falls, but she was not. She stated the ADON, the DON, and herself were responsible for ensuring the residents care plans were updated and this resident's care plan should have been updated by the DON at the time. She stated the DON was no longer at the facility. She stated the risk of not care planning her fall could result in missed care to the resident. Record review of the facility's policy, Care Plans and CAAs (Care Area Assessments) (05/06/16) revealed It is the intent of Advanced Health Care Solutions to meet and abide by all State and Federal regulations that pertain to resident care plans and subsequent Care Area Assessments (CAAs) completion. The purpose of this guide is to ensure that an interdisciplinary (IDT) approach is utilized in addressing the Care Area Triggers (CATs) that were generated by the completion of the Minimum Data Set (MDS) in order to effectively address the Care Area Assessments (CAAs) and ultimately achieve the completion of an effective comprehensive plan of care for each resident.

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for three (Resident #29, Resident #73, and Resident #82) of eighteen residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #29, Resident #73, and Resident #82's rooms were in a position that was accessible to the resident on 01/14/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency. Findings included: Resident #29 Review of Resident #29's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female admitted on [DATE]. Resident #29 was diagnosed with muscle weakness and gait abnormalities. Review of Resident #29's Quarterly MDS Assessment, dated 12/24/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 00. The Quarterly MDS Assessment indicated that Resident #29 was dependent to staff for toileting hygiene, shower, dressing, and personal hygiene. Review of Resident #29's Comprehensive Care Plan, dated 11/18/2024, reflected the resident had an ADL self-care performance deficit and interventions included provide extensive assist for dressing, bed mobility, personal hygiene, and toilet use. Observation on 01/14/2025 at 9:40 AM revealed Resident #29 was in her bed, with her eyes closed. It was observed that the resident's call light was on the floor at the foot of the bed. Observation and interview on 01/14/2025 at 2:03 PM revealed resident #29 was in her bed, awake. When asked about what she used when she needed to call the staff, the resident did not answer. Resident #73 Review of Resident #73's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male admitted on [DATE]. Resident #73 was diagnosed with muscle weakness and lack of coordination. Review of Resident #73's Quarterly MDS Assessment, dated 10/28/2024, reflected the resident had a severe impairment in cognition with a BIMS score of 05. The Quarterly MDS Assessment indicated that Resident #73 required maximal assistance for toileting hygiene, dressing, bed mobility, and transfer. Review of Resident #73's Comprehensive Care Plan, dated 01/14/2025, reflected the resident had an ADL self-care performance deficit and interventions included provide maximal assistance for toileting hygiene, dressing, bed mobility, and transfer. Observation and interview with Resident #73 on 01/14/2025 at 9:45 AM revealed the resident in his bed, awake. It was observed the resident's call light was on the floor and stuck between the bed and the wall. When asked about his call light, the resident just shrugged his shoulders. Observation and interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated call lights were important for the residents because that was how they called the staff if they needed something or if they needed assistance. She said without the call lights, the residents might be upset or might fall if they tried to do things by themselves. She said the call lights were for independent and dependent residents. She went inside Resident's #29's room and pulled the call light from the floor and put it beside the resident. CNA A then went inside Resident # 73's room and saw the call light was stuck between the wall and the bed. She pulled the call light and put it beside the resident. She said she did not notice the call lights were not with Resident #29 and Resident #73 during her morning round that. Resident #82 Review of Resident #82's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male admitted on [DATE]. Resident #82 was diagnosed with muscle weakness and lack of coordination. Review of Resident #82's Quarterly MDS Assessment, dated 11/27/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated that Resident #82 required maximal assistance for toileting hygiene, shower, dressing, and personal hygiene. Review of Resident #82's Comprehensive Care Plan, dated 01/14/2025, reflected the resident had an ADL self-care performance deficit and interventions included provide maximal assistance for toileting hygiene, shower, dressing, and personal hygiene. Observation and interview with Resident #82 on 01/14/2025 at 9:34 AM revealed the resident was in his wheelchair, awake. It was observed that the resident's call light was hanging by the wall and coiled around where the call light was connected. He said he was transferred to the room the night before because his roommate tested positive for COVID-19. He said the staff did not place the call light near him. He said he could not reach the call light that was on the wall. He said he needed to go out of his room so he could call a staff because he needed something. Observation and interview with CNA B on 01/14/2025 at 10:20 AM, CNA B stated call lights should be with the residents at all times so they could call the staff when they needed something. She said the residents might fall trying to get the call light or trying to do some activities that needed assistance. she went inside Resident #82's room and saw the call light on the wall. She pulled the call light on the wall and placed it where the resident could reach it. She said she did not notice the call light was not with the resident during her morning rounds. In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated call lights were inside the residents' rooms for a reason. He said the residents used the call lights to call for assistance, a glass of water, pain medication, or because they needed to be changed. The DON said without the call lights, the residents would not be able to tell the staff what they needed and eventually their needs would not be met. The DON added when the residents could not reach their call lights, unfavorable incidents, like falls, could happen. The DON said all the staff were responsible for the call lights. The DON said the expectation was for the staff to scan the resident's room when they do their rounds and ensure the call lights were within reach of the residents before they leave the room. The DON said he would educate the staff about the importance of call lights for the residents and would include the issue on their IDT meeting. In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated call light should be with the residents at all times, whether independent or dependent. He said he was also responsible in checking if the call lights were with Resident #29, #73, and #82 because he was the nurse in-charged for their care. He said without the call lights, their needs would not be met. He said he would do his round and check if the call lights were with the residents. In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated call lights should be within the reach of the residents at all times. She said for some residents, the call light was their sense of protection that if something happened to them, they would be able to call the staff for help. She said the residents also use the call lights if they needed to be changed or they needed a pain medication. the Administrator said the residents might fall trying to get up and get what they needed. She said everybody was responsible in making sure the call lights were with the residents, whether the resident was independent or not. She said she would collaborate with the DON about the issue regarding call lights. Record review of facility's policy Resident Call System reviewed 03/28/2023 revealed Policy: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation . Policy Interpretation and Implementation . 1. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 6 (Rooms #1, #2, #3, #4, #5, and #6) of 10 resident rooms and the hallway floors reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, #5, and #6 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Findings included: An observation on 01/14/25 at 10:35 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. An observation on 01/14/25 at 10:39 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. The bottom of the bedside table had red stains on it. An observation on 01/14/25 at 10:42 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. An observation on 01/14/25 at 10:47 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. Inside the mini fridge revealed hairbrushes, a towel, and two sandwiches wrapped in white napkins. An observation on 01/14/25 at 10:50 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. An observation on 01/14/25 at 10:53 AM of the Resident room [ROOM NUMBER] reflected the air condition unit had vents filled with black and brown dirt-like debris. In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she would consider purchasing hand vacuums to assist with removing the dirt particles between the outer vents. She stated the risk of the area not being addressed could impact residents' respiratory system. In an interview on 01/16/25 at 10:10 AM, Housekeeper L stated she had been at the facility 1 year. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated housekeeping was responsible for cleaning the outside of the air condition units in the resident rooms. She stated she had a challenging time removing the dirt particles from between the vents, but she would meet with the house keeping supervisor to see how the units could be clean more thoroughly. She stated the risk of the air condition units not being thoroughly cleaned could impact residents' health. In an interview on 01/16/25 at 10:19 AM, Housekeeping Supervisor stated she had been at the facility nearly 3 years. She was shown pictures of the concerns observed in Resident Rooms #1, #2, #3, #4, #5, and #6. She stated she had met with the Administrator on 01/15/25 to solve how to clean the air condition units better. She stated the risk to the residents having the dirty air condition unit could impact their health. Review of the facility's policy on Homelike Environment (February 2021) revealed Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment;

Based on observations, interviews, and record reviews, the facility failed to ensure that residents' bed was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 4 (Resident #1, #5, #25, and #29) of 5 residents reviewed for physical restraints, The facility failed to obtain physician orders or a physician assessment as of 01/16/25 for Residents #1, #5, #25, and #29, for the usage of a scoop mattress prior to installing the mattress to assist in fall prevention. This failure could prevent residents from having an environment that was free from any physical or chemical restraints. Findings included: Resident #1 Record review of Resident #1's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included restlessness and irritation, and cerebral palsy (movement disorder). Record review of Resident #1's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, he had a Brief Interview for Mental Status (BIMS) score of 00, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #1's physician's orders, dated 01/14/25, reflected no physician's orders for a scoop or bolster mattress. Record review of Resident #1's Comprehensive Care plan, dated 01/15/25, reflected air mattress with boosters as an intervention for fall prevention. Resident #5 Record review of Resident #5's Face Sheet, dated 01/16/25, reflected she was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included repeated falls, muscle weakness, and lack of coordination. Record review of Resident #5's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 04, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #5's physician's orders, dated 01/15/25, reflected no physician's orders for a scoop or bolster mattress. Record review of Resident #5's Comprehensive Care plan, dated 0/18/24, reflected no scoop or bolster mattress as an intervention for fall prevention. Resident #25 Record review of Resident #25's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old male admitted on [DATE]. Relevant diagnoses included repeated adult failure to thrive, muscle weakness, and lack of coordination. Record review of Resident #25's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 06, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #25's physician's orders, dated 01/15/25, reflected no physician's orders for a scoop or bolster mattress. Record review of Resident #25's Comprehensive Care plan, dated 0/18/24, reflected no scoop or bolster mattress as an intervention for fall prevention. Resident #29 Record review of Resident #29's Face Sheet, dated 01/16/25, reflected he was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included seizures, muscle weakness, and lack of coordination. Record review of Resident #29's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected, she had a Brief Interview for Mental Status (BIMS) score of 00, (severe cognitive impairment) and for ADL care it reflected for transfers, toileting, and bathing and the resident was totally dependent for assistance. Record review of Resident #29's physician's orders, dated 01/14/25, reflected no physician's orders for a scoop or bolster mattress. Record review of Resident #29's Comprehensive Care plan, dated 0/18/24, reflected a scoop mattress as an intervention for fall prevention. Observations on 01/14/25 from 10:00 AM to 11:00 AM, revealed Residents #1, #5, #25, and #29 had a scoop or bolster mattress on their bed, which restricted their movement in bed. In an interview on 01/15/25 at 10:00 AM, LVN D and the DON were asked if Residents #1, #5, #25, and #29 had physicians' orders for a bolster and scoop mattress, and the DON stated he was not sure, but he would check. After checking, he stated the residents did not have physicians' orders, which would be required for the residents to have a scoop or bolster mattress. The DON stated the physician would need to complete an assessment to ensure that the scoop or bolster mattress would not injure or restrain the resident. The facility's policy Physical Restraints and Involuntary Seclusion (03/2023) reflected Patients/Residents have the right to be free from any physical restraint imposed for purposes of discipline or convenience and when not required to treat the patient's/resident's medical condition. Patients/Residents have the right to function at their highest practicable level in the least restrictive environment possible.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three (Resident #36, Resident #68, and Resident #79) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #36's care plan for catheter, dated 12/17/2024, had appropriate interventions. 2. The facility failed to ensure Resident #68's care plan for catheter, dated 10/02/2024, had appropriate interventions. 3. The facility failed to ensure Resident #79's care plan for catheter, dated 01/09/2025, had appropriate interventions. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: 1. Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with infection to surgical site to sacrum. Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Comprehensive MDS Assessment indicated the resident had skin problem to her surgical wound and had an indwelling catheter (device to drain the urine from the urinary bladder to a collection bag). Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected Resident #36's care plan for indwelling catheter related to skin breakdown on sacrum had only one intervention listed. The only intervention indicated was to check for kinks each shift. Record review of Resident #36's Physician Order, dated 09/05/2024, reflected Foley Catheter Care Q Shift and PRN. In an interview with Resident #36 on 01/14/2025 at 1:36 PM, Resident #36 stated she had a catheter but was removed the day before because she was having abdominal pain. She said she had the catheter because of her wound in her bottom. In an interview with the Wound Care Nurse on 01/15/2025 at 8:51 AM, the Wound Care Nurse stated Resident #36 had a wound to her sacrum that was present during her admission. She said she had a catheter to facilitate healing of the wound. 2. Record review of Resident #68's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #68 was diagnosed with urinary retention (the urinary bladder does not empty completely). Record review of Resident #68's Quarterly MDS Assessment, dated 01/03/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 11. The Quarterly MDS Assessment indicated the resident had an indwelling catheter. Record review of Resident #68's Comprehensive Care Plan, dated 10/02/2024, reflected Resident #68's care plan for indwelling catheter related to urinary retentions had only one intervention listed. The only intervention indicated was to monitor, record, and report signs and symptoms of urinary tract infection. Record review of Resident #68's Physician Order, dated 10/02/2024, reflected Foley Catheter Care Q Shift and PRN. Observation and interview with Resident #68 on 01/14/2025 at 11:05 AM revealed the resident was sitting in his recliner, awake. It was observed that he had a catheter hanging on his walker. He said he had the catheter because he had an issue with his bladder. Observation and interview with the MDS Coordinator on 01/15/2025 at 9:34 AM, the MDS Coordinator stated care plans were done so the staff would know the care needed by the residents. she said if a resident had a catheter, there should be a care plan for catheter. She said the care plan was comprised of problem areas, the goals, and the interventions. She said the interventions should address the underlying problem of the residents. She opened Resident #36's profile and saw the resident had orders for her catheter and was triggered in the MDS for indwelling catheter. When she opened the resident's care plan, she saw the indwelling catheter was listed as one of the problem list. She also saw that there was only one intervention listed. She said there should be more interventions listed like check for trauma, monitor for signs and symptoms of urinary tract infection related to the catheter, check for signs and symptoms of discomfort, monitor the color of the urine, and cover with privacy bag. After looking at Resident #36's care plan, she opened Resident #68's care plan and saw the same thing. She said she would update the care plans for both residents and would input the interventions for indwelling catheter. In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated every resident needed a thorough care plan to ensure the residents received the care needed. The DON said the care plan should be in place so the staff providing care would be on the same page and without the care plan, there could be confusion with the care of the residents. The DON said the care plan should reflect the resident's problem lists, the goals, and the interventions. He said a care plan would not be a care plan without appropriate interventions. He said, with indwelling catheters, staff should monitor for urinary tract infection, discomfort, distension of the bladder, cloudiness of the urine, and if there were blood in the urine. He said with only one intervention could be considered an incomplete care plan. He said the expectation was every care plan would be resident-centered and complete. He said he would coordinate with the MDS Coordinator to audit to the care plans of the residents. In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated all the care plans of the residents should have all the interventions needed by the residents. She said without the care plan, the staff would not know and understand what kind of care to provide. The Administrator concluded that the expectation was for the staff to ensure that the residents' care plan were complete and individualized. She said he would coordinate with the DON to make sure all the residents were care planned. 3. Record review of Resident #79's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #79 was diagnosed with urinary retention. Record review of Resident #79's Comprehensive MDS Assessment, dated 01/02/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter. Record review of Resident #79's Comprehensive Care Plan, dated 01/09/2025, reflected Resident #79's care plan for indwelling catheter related to history of malignant neoplasm of the prostate had only one intervention listed. The only intervention indicated was to monitor for signs and symptoms of discomfort on urination and frequency. Record review of Resident #79's Physician Order, dated 12/29/2024, reflected Foley Catheter Care Q Shift and PRN. Observation and interview with Resident #79 on 01/16/2025 at 9:02 AM revealed the resident was in the dining area finishing his breakfast. It was observed that the resident had a catheter leg bag secured to the right leg. When asked how long he had the catheter, the resident did not reply. In an interview with LVN D on 01/16/2025 at 9:12 AM, LVN D stated Resident #79 had a catheter because he had an issue with his prostate. She said before he goes out of his room, they would replace his catheter with leg strap because the resident had the tendency to drag his catheter. In an interview with the MDS Nurse on 01/16/2025 at 9:43 AM revealed the MDS Coordinator was advised that Resident #79 also only had one intervention for his indwelling catheter. She said she would check on it and update it accordingly. Record review of facility's policy, Care Plans, Comprehensive Person-Centered reviewed Jan. 2023 revealed Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident . 10. Identifying problem areas and their causes, and developing interventions that are targeted and meaningful . 11. Care plan interventions are chosen only after careful data gathering . a. When possible, interventions address the underlying source(s) of the problem area(s).

Based on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #16, #28, #40, and #38) of 14 residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #16's breathing mask for her nebulizer (machine that turns liquid medication into a mist breathed directly into the lungs) was properly stored when not in use on 01/14/2025. 2. The facility failed to ensure that Resident #28's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 01/14/2025. 3. The facility failed to ensure that Resident #40's nasal cannula was properly stored when not in use on 01/14/2025. 4. The facility failed to ensure that Resident #38's nebulizer mask (medication is inhaled through) was properly stored when not in use on 01/14/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #16's Face Sheet, dated 01/16/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #16 was diagnosed with anemia (low blood cells). Record review of Resident #16's Comprehensive MDS Assessment, dated 11/24/2024, reflected the resident had a score of 99 on her BIMS summary score suggesting that the resident was not able to complete the interview to determine the BIMS score. The Comprehensive MDS Assessment indicated the resident had anemia. Record review of Resident #16's Comprehensive Care Plan, dated 11/04/2024, reflected the resident tested positive for COVID on 01/25/2022 and one of the interventions was to observe for signs and symptoms of respiratory issues. Record review of Resident #16's Physician Orders, dated 11/02/2024, reflected Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for SOB ONE VIAL Q 4-7 HOURS. An observation on 01/14/2025 at 9:20 AM revealed Resident #16 was in her bed, awake. A nebulizer machine was observed beside the room's sink. Beside the nebulizer machine was a breathing mask that was not bagged. The part of the breathing mask that would touch the face when using was touching a bottle of sanitizer. Resident #16 did not respond when asked how long she had been using the breathing mask. In an interview with LVN C on 01/14/2025 at 11:33 AM, LVN C stated he was not sure for whom the breathing mask was. He opened the profiles of both residents occupying the room. He said the breathing mask was for Resident #16. He said the order was to administer as needed. He went inside the room and saw the unbagged breathing mask beside the room's sink. He said he did not notice during his rounds that the breathing mask was not inside a bag. He said it should be bagged to prevent cross contamination. He said the issue was not if the resident was using it or not, the breathing mask should be bagged. LVN C went to the storage room and took a new breathing mask and a plastic bag. In an interview with the DON on 01/15/2024 at 11:03 AM, the DON stated the breathing mask was supposed to be in a bag when the resident was not using it to prevent cross contamination and worsening of respiratory issues the resident might already had. He said the expectation was for the staff to be mindful and make sure the breathing was bagged when the resident was not using it. He said it did not matter if the order was daily or as needed, the breathing mask must be in a bag or do not leave a breathing mask inside the room and just get one if needed by the resident. He said he would conduct an in-service about respiratory care. In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated everything the residents were using should be kept clean to prevent infection. She said she would coordinate with the DON to educate and re-educate the nursing staff to bag the breathing mask if not in use. She said the DON will also in-service the staff about the respiratory care issue. 2. Review of Resident #28's Face Sheet, dated 01/16/2025, reflected the resident was a [AGE] year-old female admitted on [DATE]. Resident #28 had a diagnosis of chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident #28's Quarterly MDS Assessment, dated 07/05/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. The Quarterly MDS Assessment indicated the resident was on oxygen therapy while a resident of the facility. Review of Resident #28's Comprehensive Care Plan, dated 10/22/2024, reflected resident has oxygen therapy r/t ineffective gas exchange. Interventions included For residents who should be ambulatory, provide extension tubing or portable oxygen apparatus. Give medications as ordered by physician. Monitor/document side effects and effectiveness. Review of Resident #28's Physician Order, dated 04/24/2024, reflected O2 at 2 liters per minute via nasal cannula continuously. May titrate to 3-4 LPM to keep O2 sat >90% every shift. An observation on 01/14/2025 at 09:52 AM revealed Resident #28 lying in bed with her eyes closed. Resident #28's wheelchair was next to the bed with a portable oxygen cannister on the back of the wheelchair. Resident #28 was receiving oxygen at 2 LPM (rate of oxygen flow) via the nasal cannula tubing connected to the oxygen cannister on the wheelchair. The resident's oxygen concentrator was next to the head of the bed. The oxygen tubing connected to the concentrator was on the floor between the concentrator and the nightstand. The tubing was not bagged. 3. Review of Resident #40's Face Sheet, dated 01/16/25, reflected Resident #40 was a [AGE] year-old female admitted on [DATE]. Resident #40 had a diagnosis of chronic obstructive pulmonary disease. Review of Resident #40's Physician Orders, dated 09/09/24, reflected O2 at 2 liters per minute via nasal cannula PRN. May titrate to 2-4 LPM to keep 02 sats >92% as needed for Shortness of Breath, Wheezing, 02 sat less than 90%. Obtain vital signs BID two times a day document vs q shift. Review of Resident #40's Quarterly MDS Assessment, dated 11/01/2024, reflected resident had a moderate impairment in cognition with a BIMS score of 08. Section I reflected resident was treated for chronic obstructive pulmonary disease. Review of Resident #40's Comprehensive Care Plan, dated 11/02/2024, reflected resident has oxygen therapy. O2 at 2 liters per minute via nasal cannula PRN. May titrate to 3-4 LPM to keep O2 sats >90%. One intervention was monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry, Increased heart rate. An observation on 01/14/25 at 10:04 AM revealed an oxygen concentrator in Resident #40's room. The concentrator was next to a cabinet with drawers. Oxygen tubing was connected to the concentrator and placed in the top drawer of the cabinet. The oxygen tubing was not bagged. 4. Review of Resident #38's Face Sheet, dated 01/16/25, reflected Resident #38 was a [AGE] year-old male. Resident #38 admitted on [DATE] with asthma (chronic lung disease causing the airway to narrow and can make breathing difficult) and shortness of breath. Review of Resident #38's Quarterly MDS Assessment, dated 11/25/24, reflected Resident #38 had intact cognition with a BIMS score of 15. Section I reflected Resident #38 was treated for asthma and shortness of breath. Review of Resident #38's Comprehensive Care Plan, dated 10/23/24, reflected the resident has unspecified asthma. One intervention was to give nebulizer treatments as ordered. An observation on 01/14/25 at 8:45 am revealed a nebulizer on Resident #38's nightstand. The nebulizer mask was connected to the nebulizer and the mask was placed on top of the nebulizer. It was not stored in a bag. In an interview on 01/14/25 at 09:55 AM, LVN D stated the oxygen tubing should have been bagged to prevent contamination. She removed the tubing and stated she was going to get new oxygen tubing. In an interview on 1/14/25 at 09:58 AM, CNA F stated the oxygen tubing should have been stored in a bag to keep it clean. In an interview on 01/14/25 at 10:35 AM, the DON stated the oxygen tubing and nebulizer masks should have been stored in bags when not used to prevent contamination. The DON stated he was going to follow up with the nurses to be sure those were corrected. During an interview on 01/14/25 at 10:42 AM, LVN E stated all respiratory items should have been bagged when not in use to prevent contamination and infection. In an interview on 01/16/24 at 10:45 AM, the ADON stated respiratory items were to be stored in bags when residents were not using them. She stated she tells the nurses if oxygen tubing is found on the floor, throw it away and get new tubing. She said her expectation is for all oxygen tubing and nebulizer masks to be stored in bags at all times when not in use by a resident. She stated this was an important measure to prevent contamination of these items. After record review of the facility's policy for Oxygen Administration on 01/16/2025 at 10:44 AM, a policy for bagging the nasal cannula and breathing mask was verbally requested on 01/16/2025 at 10:54 AM but was not provided prior to exit.

Based on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure staff were wearing the appropriate hair and beard coverings. 2. The facility failed to ensure the food stored in the refrigerator and freezer were labeled with the date the product was received from the vendor. 3. The facility failed to ensure that the sugar and flour bins were cleaned. 4. The facility failed to ensure the ice scoop in the facility kitchen was cleaned. 5. The facility failed to ensure the food in the dry storage area was labeled with the product was received from the vendor. 6. The facility failed to ensure the food stored in the freezer was properly sealed from air-borne contaminants. 7. The facility failed to ensure foods being transported to resident rooms and the memory care unit were properly concealed from air-borne contaminants. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings included: Observations on 01/14/25 from 9:16 AM to 9:25 AM in the facility's only kitchen reflected: The ice scoop, hanging in a blue plastic holder, had a brownish substance and white stains along the bottom of the holder. One large tray containing three 2- pound packages of bologna and one 2-pound package of ham, located in the refrigerator, did not have the date the product was received from the vendor. One large plastic container of raw, chopped up celery, located in the refrigerator, did not have a date the product was received from the vendor. One large bag or frozen okra, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants. One bag of frozen waffles, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants. One small bag of an unknown frozen food substance, located in the freezer, was not labeled and did not have the date the product was received from the vendor. Two large boxes of cookie dough, located in the freezer, had a large tear in the bag, exposing the food to airborne contaminants. Two large white storage bins, containing sugar and flour, had dark dirt-like stains on the outside of the containers and dark dirt-like stains within the opening and inside walls of the containers. Two packages of hamburger buns, containing 12 buns each, located in the dry storage area was not labeled with the date the product was received from the vendor. Two packages of large tortillas, located in the dry storage area were not labeled with the date the product was received from the vendor. In an observation and interview on 01/16/25 at 10:05 AM, the Dietary Manager was observed preparing food in the kitchen and he was not wearing a beard guard. The DM was observed to have a beard approximately 1/2 inch in length. The DM stated a beard covering should be worn to prevent hair from falling into the food. In an observation on 01/15/25 at 11:45 AM, [NAME] S was observed in the kitchen area placing food trays on the serving steam table, and had no head covering on his head. His hair was approximately 1/2 inch in length. He was asked where his hair covering was, and he proceeded to grab one and placed it on her head, before going back to plating the food. A dining observation on 01/15/24 at 12:39 PM revealed Kitchen Aide B transporting the food cart to the Memory Care Unit. There were two trays sitting on top of the cart and one of them included a bowl of uncovered desert. The other tray included a bowl of uncovered desert and a bowl of uncovered green beans. Two residents were observed walking up to, and then standing over the cart and looking at the trays, before staff redirected them. An observation and interview on 01/15/25 at 01:25 PM revealed three food test trays, that were being observed and tasted by the Surveyor, being removed from the food transfer cart, and all three-desert bowls were uncovered. The DM stated the bowls should have been covered during the transfer from the kitchen to the residents to avoid any food contamination. The DM stated he completed in-services on properly transporting food, food storage, and kitchen sanitation. In an interview on 01/15/25 at 01:35 PM, the DM stated that he had been the DM for nearly 3 months. He stated he had cleaned the sugar and flour bins twice since being at the facility. He stated that the ice scoop holder should have been cleaned after every shift at night. He was shown pictures of the concerns observed in the kitchen area. He stated that he thought it was being cleaned but it was not. He stated he needed to check behind them again. He stated the risk to the resident of not addressing the issues mentioned was residents could get food poison. He was made aware that [NAME] S was observed placing food on the steam table and he was not wearing a head covering. The DM stated [NAME] S should have been wearing a head covering to prevent food contamination. In an interview on 01/15/25 at 02:05 PM, the Administrator was shown pictures of the concerns observed in the facility's only kitchen. She stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination. The Administrator was advised of the concern of food being transported to residents eating in their rooms and in the memory care unit without a cover, and she stated she would follow up with the DM to address the concerns. She stated the concerns observed could result in residents experiencing food contamination. An interview on 01/16/25 at 01:05 PM, Kitchen Aide B stated that she always transported the deserts desserts and other items that were in bowls, uncovered. She stated she never knew that it needed to be covered. She stated moving forward she would ensure all foods were covered properly when transporting food to residents. She stated the risk of not covering the food when transporting it, could result in germs being spread. Record Review of the facility's policy on Food Storage and Supplies dated October 2022, revealed, Foods shall be received and stored in a manner that complies with safe food handling practices. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). All items must be dated with the date that the food was delivered. The food service area shall be maintained in a clean and sanitary manner. All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy. Review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #36 and Resident #39) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA A and CNA B changed their gloves and performed hand hygiene while providing incontinent care to Resident #36 on 01/14/2025. 2. The facility failed to ensure CNA B performed hand hygiene while providing incontinent care to Resident #39 on 01/14/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Record review of Resident #36's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36 was diagnosed with personal history of urinary tract infections and cerebrovascular disease (reduction of blood flow to the brain). Record review of Resident #36's Quarterly MDS Assessment, dated 12/03/2024, reflected the resident had moderate impairment in cognition with a BIMS score of 12. The Quarterly MDS Assessment indicated the resident was incontinent for bowel and bladder. Record review of Resident #36's Comprehensive Care Plan, dated 12/17/2024, reflected the resident had actual impairment to ski integrity related to wound to sacrum and one of the interventions was to provide incontinent care as needed. Observation on 01/14/2025 at 9:54 AM revealed CNA A and CNA B were about to do incontinent care to Resident #36. Both CNAs washed their hands before putting on their gloves. CNA A went the resident's right side, while CNA B went to the resident's left side. CNA B unfastened the brief and pushed it between the resident's thighs. CNA A placed the wipes and the brief beside the resident's right leg. After placing the wipes and the brief beside the resident's right leg, CNA A put a plastic bag on the trash can. After putting the plastic bag on the trash can, CNA A proceeded with incontinent care without changing her gloves. CNA A cleaned the perineal (area between the legs) area using the front to back technique. After cleaning the perineal area, both CNAs assisted the resident to roll to her left side. CNA A cleaned the resident's bottom. After cleaning the resident's bottom, CNA A took the brief that was placed beside the resident's right leg and placed it under Resident #36. She did not change her gloves after cleaning the resident's bottom and before touching the new brief. The resident was rolled back, both CNA A fixed the brief. CNA B helped in fixing the brief. She did not change her gloves when she touched the soiled brief at the beginning of incontinent care. In an interview with CNA A on 01/14/2025 at 10:15 AM, CNA A stated she was not aware she did not change her gloves after placing a plastic bag on the trash can. Said she should have changed her gloves and sanitized her hands after touching the trash can because the trash was not only presumed dirty but was dirty. Said she also should have changed her gloves and sanitized her hands after cleaning the resident's bottom and before touching the new brief because whatever germs that she touched from the soiled bottom and soiled brief would eventually transfer to the new brief. Said her actions could cause transfer of germs and infection. She said she needed to be mindful with how she did incontinent care. In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she assisted CNA A with incontinent care for Resident #36. She said she unfastened the soiled brief and tucked it between the thighs of the resident. She said she also helped in fixing the brief when CNA A was done cleaning the resident. She said because she touched the soiled brief, she should have changed her gloves before touching the new brief because her gloves were already considered soiled. She said the resident could have urinary tract infection because the new brief would be considered dirty. 2. Record review of Resident #39's Face Sheet, dated 01/16/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 was diagnosed with cerebral infarction (stroke). Record review of Resident #39's Comprehensive MDS Assessment, dated 11/25/2024, reflected the resident had a moderate impairment in cognition with a BIMS score of 08. The Comprehensive MDS Assessment indicated the resident was always incontinent for bladder and bowel. Record review of Resident #39's Comprehensive Care Plan, dated 11/24/2024, reflected the resident had incontinence and one of the interventions was to provide pericare after each incontinent episode. Observation on 01/14/2025 at 10:32 AM revealed CNA B was about to do incontinent care for Resident #39. She washed her hands before putting on a pair of gloves. When she was about to prepare the brief and the wipes, she realized there was no wipes inside the room. She said she would go out to get some wipes. When CNA B returned inside the room, she put on a pair of gloves and proceeded with incontinent care. She did not wash her hands again or sanitize her hands before doing incontinent care. In an interview with CNA B on 01/14/2025 at 10:47 AM, CNA B stated she washed her hands when she first entered Resident #39's room. She said after washing her hands, she realized she did not have any wipes to use that was why she went out of the room. She said when she went back inside the room, she should have washed her hands again because she touched the door knobs and other things when she went out of the room. She said her hands were deemed dirty again when she touched the door knob and other things. She said hand washing was important to prevent infection. In an interview with the DON on 01/15/2025 at 11:03 AM, the DON stated hand hygiene was the most effective way to prevent cross contamination and infection. The DON said the staff should have washed her hands again when she went back into the room because the staff touched something else when she went out of the room. He said gloves should be changed after touching the trash can and the soiled brief to prevent transfer of microorganisms to any clean items. He said the rule of the thumb was, when you were in doubt, wash the hands and change the gloves. he said the expectations were staff would wash their hands before incontinent care and staff would wound change their gloves before touching anything clean. He said he would do and in-service about hand hygiene and infection control and would randomly monitor the staff doing direct care. He said the issue would also be included in their IDT meeting so everybody would know the issue and discuss the measures that could be implemented. In an interview with LVN C on 01/15/2025 at 11:20 AM, LVN C stated hands hygiene was included in all the procedures of any care. He said the staff should do hand hygiene before and after any care like incontinent care. He said gloves should be changed after touching the trash can and after cleaning the residents' bottom to prevent cross contamination and development of infection. He said he would remind the CNAs on his hall to wash their hands and change their gloves as appropriate. In an interview with the Administrator on 01/15/2025 at 11:39 AM, the Administrator stated not washing the hands before any care, not changing the gloves from soiled to clean could contribute to cross contamination and infection. She said the expectation was for the staff to follow the policy and procedures pertaining to infection control. She said she would coordinate with the DON on how to handle the issue about infection control and hand hygiene. Review of facility policy, Handwashing-Hand Hygiene Policy and Procedures revised 10-2020 revealed Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . 7. Use an alcohol-based hand rub . f. Before donning sterile gloves . h. Before moving from a contaminated body site to a clean body site during resident care . j. After contact with blood or bodily fluids . k. After handling used dressings, contaminated equipment, etc. Applying and removing Gloves . 1. Perform hand hygiene before and after applying non-sterile gloves. Review of facility policy, Perineal Care revised 04/16/2024 revealed Purpose: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation . Steps in the Procedure . 2. Wash and apply gloves . For a female resident . b. wash perineal area . 10. Remove gloves . 11. Wash and dry hands thoroughly.

Based on observations, interviews, and record review, the facility failed to ensure each residents environment remained as free from accident hazards as possible for 1 (Resident #30) of 9 residents reviewed for environmental hazards. The facility failed to ensure Resident #30 did not have pointed scissors in his room on 01/14/2024. This failure could place the resident and other residents who came into the room at risk for injury. Review of Resident #30's Face Sheet, dated 01/16/25, reflected that resident was an [AGE] year-old male initially admitted on [DATE]. Resident #30 had a diagnosis of dysphagia (difficulty swallowing) following other cerebrovascular disease (condition that impacts blood vessels in the brain). Review of Resident #30's Quarterly MDS (tool to assess health and functional capabilities) Assessment, dated 01/13/2025, reflected that Resident #30 had impaired cognition with a BIMS score of 11. Section I did not reflect dementia or a mood disorder. Section I reflected Resident #30 had cognitive communication deficit and other abnormality of gait and mobility. Review of Resident #30's Comprehensive Care Plan, dated 12/06/2024, reflected Resident #30 had impaired thought processes. One intervention was COMMUNICATION: Use his preferred name. Identify yourself at each interaction. Face the resident when speaking and make eye contact. Reduce any distractions. Turn off TV, radio, close door etc. He understands consistent, simple, directive sentences. Provide the resident with necessary cues- stop and return if agitated. In an interview and observation on 01/14/25 at 09:40 AM, Resident #30 was lying in bed. Resident #30's wheelchair was parked close to the bed. Prior to leaving the room, surveyor bumped into the wheelchair and a pair of large scissors fell to the floor. The ends were not rounded. Resident #30's wheelchair had a piece of foam wrapped around the arms of the wheelchair. Resident #30 stated he kept the pair of scissors in the opening between the foam and arm of the wheelchair. Resident #30 stated at times he used the scissors to cut the sides of a soiled brief when he was in the restroom. The DON was in the hall at that time and notified of scissors in Resident #30's room. He stated he would take care of it. In an interview on 01/14/25 at 02:20 PM, RN G stated Resident #30 used the scissors to cut extra paper (old activity schedules) up for scratch paper. RN G pointed at a stack of letter size sheets that had been cut up into fourths for scratch paper. She stated the resident kept the scissors inside the foam piece that is wrapped around the arm of his wheelchair. While in the room, the resident agreed for RN G to assess his skin. RN G lowered his pants and assessed the skin around Resident #30's brief to ensure he had not caused any injury. Observation revealed there was no redness, scratches, or any injury on Resident #30's skin. RN G stated she had never heard Resident #30 used scissors to cut off his brief. RN G agreed an accident could result in the resident harming himself when using the scissors. In an interview on 01/14/25 at 02:28 PM, LVN E stated she had never heard Resident #30 used his scissors to cut the briefs on the sides to remove them. She stated she had thought it was ok for Resident #30 to use the scissors for activities. LVN E stated the scissors had been removed from the resident's room and given to her and she understood an accident could occur involving the resident or another resident who might have found the scissors. In an interview on 01/14/25 at 02:36 PM, the Activities Director stated she provided Resident #30 with a daily chronicle. She stated she had never seen him cutting the papers. The Activities Director stated she allowed residents to use scissors when she was observing them. She stated she made sure residents only used scissors with rounded edges. In an interview on 01/16/25 at 09:16 AM, the DON stated the facility did not have a policy about residents or family members bringing in personal items like scissors. The DON stated it posed a danger and was not safe for the resident to have the scissors in his room. He stated if staff sees something like that, it should be removed and documented. He stated it was important to educate family about the dangers and to care plan it. He said it was important for the resident to have rights, but there are other residents in the environment too. He stated it was important for staff to be diligent about safety awareness and any danger to residents and he will in-service them about it. The facility did not provide a policy about environmental hazards. In an interview on 01/16/25 at 09:16 AM, the DON stated there was not a facility policy regarding a resident or family member bringing sharp objects like scissors into a resident's room.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of six residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A provided appropriate supervision and care to Resident #1 who had advanced Alzheimer's and did not follow facility's Dementia Management Policy, subsequently CNA A redirected Resident #1 out of another resident's room inappropriately, which resulted in her falling backwards and sustaining a right femur (hip) fracture. Resident #1 required hospitalization and surgery to repair her hip fracture which increased her risk of heart attack, stroke, blood clot, pneumonia or death. The Noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM and ended on 06/22/23 at 11:30 AM. The facility had corrected the noncompliance before the survey began. This failure could place all residents at risk of not getting adequately trained staff to provide appropriate care to them which could result in hospitalization and surgical procedures increasing the resident's risk of heart attack, stroke, blood clots, pneumonia or death. The findings include: Record review of Resident #1's Order Summary Report, dated 06/24/23, revealed an 86-year- old female who was admitted to the facility on [DATE] with diagnoses which included Hypertension, Edema (puffiness around body tissues) , Gastro-intestinal reflux disease (stomach acid), protein-calorie malnutrition (inadequate food intake), and Alzheimer's disease with late onset . Resident #1 had orders for house shake dated 12/06/22. Record review of Resident #1's Quarterly MDS Assessment, dated 05/24/23, revealed she had a BIMS score of 2, which indicated severe cognitive impairment. The MDS also indicated the resident walked with supervision, walk and turn was not steady but able to stabilize without staff assistance and no upper or lower impairments and no use of mobility devices. Record review of Resident #1's Care Plans, dated 03/08/22, revealed, I have been evaluated as a wandering risk related to decreased safety awareness, confusion and wandering behavior .Goal: I will remain free of injuries associated with wandering behaviors . Interventions: Check my location frequently, encourage me to participate in activities, engage me in diversional activities when indicated, I will be evaluated every quarter for placement on the memory care unit, observe me for signs/symptoms of agitation, pacing, repetitive verbalizations of wanting to leave/go home, restlessness, report increased behaviors to nurses for further interventions, provide re-orientation as needed, re-evaluate continued need for memory care unit quarterly and as needed .revised date 02/23/23 uses anti-depressant and anti-psychotic medications .dated 06/24/22 The resident is at high risk for fall related to confusion, gait/balance problems, vision/hearing problems, wandering, rejects care .revised date 03/15/22. The resident has impaired cognitive function/dementia or impaired thought processes related to Alzheimer's, Dementia, difficulty making decisions, impaired decision making, long-term memory loss, short term memory loss Record review of Resident #1's Hospital Discharge Summary revealed on 06/22/23 [Resident #1] admitted .with dementia presenting after a fall and found to have a femoral hip fracture [broken hip] .discharge diagnosis Right Intertrochanteric hip fracture S/P and on 06/22/23 [Resident #1] had an orthopedic procedure: Cephalomedullary (implant device) nailing of right intertrochanteric hip fracture and on 06/26/23 resident discharged the hospital with orders to follow-up with orthopedic Doctor in two weeks and OT/PT .Assessment/Plan dated 06/22/23 by Attending Doctor I discussed risk, benefits, and alternatives of surgical intervention in the form of Cephalomedullary nailing with patient's son. Specifically discussed the risk of bleeding, infection, wound issues, nonunion, malunion, stiffness, arthrosis, poor mobilization, and need for further procedures. I also discussed the medical complications associated with surgery including heart attack, stroke, blood clot, pneumonia, and even death Record review of Resident #1's Provider Investigation Report written by the Administrator, dated 06/22/23, revealed on 06/21/23 at 6:30 PM Resident #1 fell , at 6:45 PM the resident was assessed by LVN C, and at 7:30 PM the resident was treated by LVN C. Description of the allegation: The resident had a fall on 06/21/23 and was sent to the hospital for X-ray and evaluation. The hospital reported positive X-ray for femur fracture investigation revealed video surveillance and incorrect redirection provided by CNA A on duty. On 06/22/23 Resident #1's fall was reported to HHSC. Actions: allegedly resulted in this fall. Assessment: Head to toe assessment done, neuro checks initiated, assisted the resident to a wheelchair and to her bed. 2 tabs of ibuprofen 200 mg . given for pain. The Nurse reported right leg sensitive to touch. The resident was sent out via 911 for X-ray and further evaluation. The hospital X-ray reported positive for femur fracture via nurse to nurse report. Provider Response: All staff Inservice on approaches, activities and interventions in response to behaviors of people with Alzheimer's and Dementia, abuse and neglect Inservice initiated, complete skin assessment completed on all residents on unit, alleged perpetrator suspended, police report initiated. Were other parties notified: Family, MD and NP, Corporate Support Team and Ombudsman. On 06/24/23 Investigation completed by State Surveyors, terminated alleged perpetrator - CNA A terminated and second CNA B witness. Completed a robust QA plan as a response to this incident, posttest given with dementia training, continue approaches, activities and interventions in response to behaviors of people with Alzheimer's and dementia education with all new hires and agency staff prior to working. Findings: Confirmed. Observation on 06/24/23 of the video footage, dated 06/21/23 at 6:40 PM, revealed Resident #1 was already in another resident's room when CNA A and CNA B walked into the room with another resident. CNA A and CNA B were telling Resident #1 to leave and go to her own room. CNA A's tone when speaking to Resident #1 was very stern in his attempt to re-direct Resident #1 out of the other resident's room by saying You need to go right now .this is not your room what do you need to get. CNA A was then seen getting within inches in front of Resident #1 and his left hand touched Resident #1's upper forearm. CNA A took two to three steps forward which caused Resident #1 to walk backwards and caused her to fall to the floor on her buttocks and against the hall exit door. Interview on 06/24/23 at 11:51 am, Resident #1's Family Member stated he received a call on 06/21/23 around 6:30 pm or 7:00 pm to go to the facility, because Resident #1 fell . He stated when he arrived he was told Resident #1 was walking towards a door and stopped and turned around to go back into the room and fell backwards, He stated the Administrator stated they had video of CNA A grabbing Resident #1 trying to get her to leave another resident's room and she fell . He stated they sent Resident #1 to the hospital and put a rod in her leg and the Administrator said she terminated CNA A after they looked at the video. He stated the next day on 06/22/23, Resident #1 had surgery and the Doctor had to put a steel rod with pins into her hip bone. He stated Resident #1 was currently doing fine and was able to stand up and walk 4 or 5 steps before having to be laid back down. He stated the hospital was discharging Resident #1 soon He stated CNA A should not have put his hands on his mother. He stated Resident #1 had not fallen in the past, but this facility did not need to be open because the staff were not qualified to work at this facility. He stated before Resident #1 fell on [DATE], she used to walk without a problem and socialized with everyone. Interview on 06/24/23 at 1:53 PM, the Administrator stated after she received the video from 06/21/23 from a family member and could see CNA A and CNA B entered a resident's room, and they attempted to redirect Resident #1 but the manner with how CNA A redirected Resident #1 was not in this facility's policy and procedure. She stated CNA A's actions caused Resident #1 to fall because she saw CNA A's left hand grab Resident #1's right hand and he let go and he did not believe he pushed her but Resident #1 was walking backwards and he was still trying to redirect her. She stated it was hard to tell if he pushed Resident #1 and after review of the video, they suspended CNA A and CNA B as of today, 06/24/23, they decided to terminate the two CNA's. She stated CNA A was being terminated for allegation of neglect with not following the policy of dementia training. CNA B was still suspended during this investigation but due to her response during the incident and she was not considered and alleged perpetrator. She stated CNA B should have intervened despite providing care to another resident because she heard Resident #1 and CNA A's interactions and had she tried to intervene Resident #'1 may not have fallen. She stated currently Resident #1 was still at the hospital with a femur [hip] fracture. Interview by telephone on 06/24/23 at 5:02 PM, CNA A stated Resident #1's fall was an unfortunate accident that happened on 06/21/23 around 7:45 PM. He stated he and CNA B were trying to put another resident to bed but Resident #1 was in the room and as Resident #1 walked out of the door she turned around. He stated he told Resident #1 To please go, you need to leave then Resident #1 said, she needed to get her stuff first and he said he responded with, [Resident #1] this is not your room, your stuff is in your room. He stated Resident #1 kind of backed up then she came up to him with her hands and stumbled back and fell up against the exit door. He stated Resident #1 fell against the door then slide down to the floor, then LVN D came down to assess Resident #1. He stated they transferred her to her bed, then Resident #1's family member arrived at the facility, and they explained what happened about her falling. He stated Resident #1 left the facility during the 8:00 PM hour. He stated he's had dementia care training over the year and a month ago by the corporate office representative and his last abuse/neglect in-service training was within the last month. He stated he did not touch Resident #1 or push her and she kind of came at him and tripped back and fell to the doorway. He stated redirecting a resident he would say Come on let me show you where your room was by showing them family pictures and every case was different and varied. He stated the staff should never ever jerk on the residents, should use verbal cues and get other staff involved. He stated he was suspended since last Thursday, 06/22/23 until further notice after looking through everything. He stated the Administrator told him to go home and they would get back with him . Interview on 06/24/23 at 2:32 PM, LVN C stated he was the charge nurse on 6/21/23 and around 6:45 PM or 7:00 PM he heard Resident #1 screaming and noticed she was in a sitting up position at the end of the hallway and her back was against the wall, by the exit door and resident's room door. He stated he asked CNA A what happened and was told Resident #1 was going to go back to her room and stopped, saying she needed to get something out of the room then put her hands on CNA A. He stated CNA A said he did not push Resident #1. He stated he assessed Resident #1 and she had right leg pain and could tell she was in a lot of pain, level was a 9 or 10. He stated she could move the left leg then they transferred her to her room. He stated he called Resident #1's family member who said he would give the information to a second family member because he was too far away. He stated he called Resident #1's doctor and an order for Ibuprofen was ordered and x-ray then Resident #1 was given Ibuprofen and was calm. He stated the second family member arrived at the facility and the resident appeared to be calm and not in pain but was in pain to touch, of her right leg, and was waiting for the X-ray tech to arrive, but they were taking too long. He stated around 8:20 PM he called 911 and the paramedics came around 8:30 PM and at 8:40 PM Resident #1 left the facility. He stated Resident #1 walked without assistance but was very confused. Interview on 06/24/23 at 5:41 PM, the DON stated on 06/21/23 she received a text at 7:16 PM from LVN C that Resident #1 fell , and he was currently trying to find out what happened, and the resident's Doctor had been called and Resident #1's family member was at the facility. She stated LVN C said he was pending getting an X-ray and had given Resident #1 Ibuprofen, then she received a text that Resident #1 was sent to the hospital around 8:40 PM. She stated Resident #1 fell in the hallway outside of another resident's door. She stated after she reviewed the video from 06/21/23 she could hear CNA A's tone when talking to Resident #1 was not right and it was hard for her to tell where Resident #1 and CNA A hands were. She stated she tried to look very carefully and did see forward movement but was not sure if hands were up and it was difficult for her to see what was going on in the video. She stated just based off of what they saw was enough for CNA A's dismissal. She stated she could not see if CNA A hit or made contact or not with Resident #1 but saw forward movement and both of CNA A hands were up. Interview on 06/24/23 at 6:44 PM, the DON stated CNA A should have approached Resident #1 calmly with a soft voice and relaxed demeaner and hands open by his side to be invited into Resident #1's space. She stated if he had experienced combativeness from Resident #1, he should have stepped back, or he could have distracted the resident with activity and if he noticed she was aggravated he needed to remove what was aggravating the resident until the resident was calm. She stated the biggest problem was CNA A should have had a calm demeanor and tone of voice. She stated since Resident #1's fall incident they were monitoring the staff interactions with the residents three times weekly. She stated the Administrator was also doing spot checks to look at how the staff engaged with the residents and with their tones when speaking and redirecting the residents. She stated monitoring would also include if the residents looked fearful and if a problem were identified they would immediately take action by removing the Alleged Perpetrator and suspend and investigate it further. She stated she would be doing random monitoring of the staff interactions with the residents three times weekly which included the weekends by herself, the Administrator and the Weekend Supervisor. The noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM to 06/22/23 at 11:30 AM. The Administrator was notified and provided with the IJ template on 07/12/23 at 3:06 PM. The facility had corrected the noncompliance before the survey began. Interview on 06/24/23 at 8:20 PM, the Administrator stated after they received notice from the hospital on 06/22/23 at 5:30 AM, about Resident #1's femur fracture, they requested the video footage from a family member and received it around 11:00 AM on 06/22/23 to review. She stated they suspended CNA A and CNA B on 06/22/23 around 11:30 AM and they had not returned to work since then and as of this day, 06/24/23, they were both terminated. Interview on 06/24/23 at 8:05 PM, the Corporate RDO (Regional Director of Operations) stated he reported this incident to HHSC around 7:00 PM on 6/22/23. Interview on 06/24/23 at 8:11 PM, the Administrator stated all staff which included CNA A were trained on 06/15/23 and 06/16/23 on Dementia care and Management, a week prior to this incident by their Corporate Educational liaison. She stated after Resident #1's fall, on 06/24/23, they in-serviced the staff on Dementia Care, Abuse and Neglect and had them complete comprehensive tests and continued to monitor the staff and did random checks weekly including the weekends of the staff for any discrepancies they needed to correct in their QA meetings and re-educate and remove staff if needed . Interviews on 06/24/23 between 12:32 PM to 3:58 PM, LVN C, CNA D, CNA E, LVN F, LVN G who worked the Weekend Shift stated they were re-trained on Dementia Care, Abuse/neglect and completed post-tests and discussed the techniques they used to re-direct the residents. Interviews on 07/12/23 between 12:20 PM to 3:33 PM, LVN H, LVN I, MA J, MA K, CNA L, LVN M, CNA N, CNA O, CNA P, CNA Q, CNA R, CNA S, LVN T who worked the Weekday shift revealed they were re-trained on Dementia Care and Abuse/neglect and completed post-tests and discussed the techniques they used to re-direct the residents. Record review of CNA A's training records revealed he was trained on abuse with a post test on 05/26/22, Dementia training 11/10/22 and his signatures were on the group trainings Dementia Basics/Sensory Changes/Behavior Management on 06/15/23, Memory Care Program Training on 04/26/23, Communicating with Non-Verbal and Dementia residents on 06/06/23. Record Review of CNA A's employee records were completed without any adverse actions noted until 06/22/23, a disciplinary Action Form revealed CNA A was suspended because The company is conducting an internal investigation in which I am Involved signed by CNA A. And on 06/24/23 another Disciplinary Action Form revealed, As part of our investigation related to intake #432324, CNA A will be terminated signed by Corporate RDO. Record review of CNA B's Employee Records were completed without any adverse actions noted until 06/22/23 a disciplinary Action Form revealed CNA B was suspended because the company is conducting an internal investigation in which I am Involved) . Record review of the, undated, staff roster revealed the facility had 81 employees. Record review of the In-service trainings dated 06/22/23, for all employee revealed 62 employee signatures on topic which included: approaches, activities and interventions in response to behaviors with Alzheimer's and Dementia - General - verbal anxiety - Repetitive calling out, yelling, screaming - verbal, abusive language - expression of display of sadness/depression - short attention span. Record review of the facility's Dementia policy, revised 06/22/23, revealed, Redirection: Introduce a favorite snack, introduce a favorite/familiar hobby/task, Introduce a meaningful activity, Introduce a change in environment or change or scenery (go to a quieter area, an area with familiar activity, or go outside, introduce an object, activity, prop, conversation, don't try to explain or reason, just talk and listen, don't try to correct .During redirection, always remember: Initiate the interaction by starting at a safe distance from the resident - remember sensory changes related to dementia affect all senses, including their field of vision. Approach the resident from the front (in their line of sight, but make sure to leave safe space so that resident doesn't become afraid or intimidated .never use any pushing/pulling motions, never raise you voice or use words that may seem harsh Record review of the facility's Fall Prevention Policy, dated Jan. 2023, revealed, Policy: All residents will be assessed for the risk of fall at the time of admission, on a quarterly basis, and upon significant change in condition thereafter .Definition: A fall can be defined as: when a resident is found on the floor .Procedure: 2. Residents identified at being at risk will have interventions identified in their plan of care to minimize falls The Noncompliance was identified as PNC. The IJ began on 06/21/23 at 6:40 PM and ended on 06/22/23 at 11:30 AM. The facility had corrected the noncompliance before the survey began. The facility failed to ensure CNA A provided appropriate supervision and care to Resident #1 who had advanced Alzheimer's and did not follow facility's Dementia Management Policy, subsequently CNA A redirected Resident #1 out of another resident's room inappropriately, which resulted in her falling backwards and sustaining a right femur (hip) fracture. Resident #1 required hospitalization and surgery to repair her hip fracture which increased her risk of heart attack, stroke, blood clot, pneumonia or death.

Based on observations, interviews and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 4 (Resident #2, #3, #6 and #7) of 9 residents reviewed for infection control. The facility failed to cohort residents based upon COVID-19 status. Resident #6 and #7 contracted COVID-19 after being cohorted with roommates who were COVID-19 positive. Resident #7 expired 6 days after contracting COVID-19. Residents #2 and #3 were negative for COVID-19 but their roommates, Residents #1 and #4, were positive. An Immediate Jeopardy was identified on [DATE] at 2:12 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal. These failures placed residents, who resided on the Memory Care Unit, at risk of exposure to COVID-19, which could result in serious illness, hospitalization , and/or death. Findings included: In an interview on [DATE] at 9:33 AM, the DON, who was the Infection Control Preventionist, said the facility had a COVID-19 outbreak. She said the Memory Care Unit had a census of 18 and 15 were currently positive for COVID-19. She said the three residents on the Memory Care Unit that were not positive, Residents #2, #3, and #10, were encouraged to just stay in their rooms. Record Review of the facility's COVID-19 Outbreak Tracking dated [DATE], indicated the first COVID-19 positive case on the Memory Care Unit was on [DATE], Resident #9. On [DATE], Resident #4 tested positive. On [DATE], Resident #8 tested positive. On [DATE], Resident #5 tested positive. On [DATE], Resident #6 tested positive. Record Review of the facility census dated [DATE] indicated, the following COVID-19 negative residents resided on the Memory Care Unit, Resident #10 was in a private room, Residents #2 and #3 resided in the rooms with COVID-19 positive residents, Residents #1 and #4. Record Review of Resident #2's Admission Record dated [DATE] indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the facility's COVID-19 Outbreak Tracking dated [DATE], indicated Resident #2's roommate, Resident #4, tested positive for COVID-19 on [DATE]. Resident #2 was negative, as of [DATE]. Record Review of Resident #2's census record from [DATE] - [DATE] indicated Resident #2 remained roommates with Resident #4. Record Review of Resident #3's Admission Record dated [DATE] indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the facility's COVID-19 Outbreak Tracking dated [DATE], indicated Resident #3's roommate, Resident #1, tested positive for COVID-19 on [DATE]. Resident #3 was negative, as of [DATE]. In an observation and interview on [DATE] at 10:26 AM, on the Memory Care Unit, revealed Resident #2, who the facility identified as COVID-19 negative, was sitting in her wheelchair at the nurse's station. She wore a face mask. Other positive residents on the unit wandered around the nurse's station and hall without masks on. LVN A said Resident #2 was COVID-19 negative but could not be moved off the unit because she was a flight risk. She said Resident #2's roommate, Resident #4, was COVID-19 positive, and they resided in the same room. She said Resident #10 was negative but resided in a private room and did not come out of her room. She said Resident #3 was COVID-19 negative but resided in a room with a COVID-19 positive roommate, Resident #1. She said the staff were doing the best they could to try to keep residents separated and to encourage them to wear masks, but it was difficult on the unit with confused and wandering residents. She said ideally the residents, who were negative, would be kept apart from positive residents for infection control purposes. She said the first case of COVID-19 on the unit was Resident #9 on [DATE]. She said all the current residents were doing well and recovering. She said Resident #7 expired after contracting COVID-19, he did have a COVID-19 positive roommate, Resident #8, but was on hospice related his diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . She said Resident #7 was declining prior to contracting COVID-19 but the infection may have contributed to his passing because he stopped eating and drinking. Record Review of Resident #7's Admission Record dated [DATE] indicated the [AGE] year-old male resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . He was diagnosed with COVID-19 on [DATE] and expired, in the facility, on [DATE] (6 days later). His roommate was Resident #8. Record Review of Resident #7's Nurse's Note on [DATE] at 1:28 PM indicated a COVID test was completed, and the results were negative. Record Review of Resident #7's census record from [DATE] - [DATE] indicated he remained roommates with Resident #8, until Resident #7 expired on [DATE]. Record Review of Resident #7's Nurses' Note dated [DATE] 4:23 PM, the A COVID-19 test was done, the resident was positive. His responsible party was notified. Record Review of Resident #7's Nurse's Note dated [DATE] at 9:51 PM indicated the resident was mouth breathing and would not open his eyes even with tactile stimuli. The nurse placed a call to the resident's hospice agency and held all of his medications, food, and fluids. Record Review of Resident #7's Social Services Note dated [DATE] at 12:02 PM revealed the Social Worker was informed the resident had a decline. He was not eating or drinking. The charge nurse had spoken to the resident's guardian. The resident was on hospice. Record Review of Resident #7's Nurse's Note [DATE] 0:04 AM indicated the resident took his last breath and a call was placed to hospice. Record Review of the facility's COVID-19 Outbreak Tracking dated [DATE], indicated Resident #7's roommate, Resident #8, tested positive for COVID-19 on [DATE], two days before Resident #7. An observation on [DATE] at 10:35 AM, of the rooms on the Memory Care Unit, confirmed Resident #2 and #3, COVID-19 negative residents, remained assigned to rooms with COVID-19 positive residents (Residents #4 and #1). Resident #2 remained at the nurse's station in her wheelchair. Resident #2's roommate, Resident #4, was in bed in their shared room with no separation between the beds. Resident #3 was in her room, shared with Resident #1, and there was no barrier between their beds and the privacy curtain was not drawn. In an interview on [DATE] at 11:49 AM, the DON said the facility's policy was to not cohort COVID-19 positive residents with COVID-19 negative residents. She said she did not realize Residents #2 and #3 were being cohorted with COVID-19 positive roommates until today ([DATE]) when the Investigator began questioning the staff. She said the risk of COVID-19 transmission was high to the negative residents because they could contract COVID-19 from being cohorted with positive residents. She said so many residents began testing positive on the unit, it just did not compute that she had positive residents with negative residents. She said the negative residents should have been moved from the positive residents to prevent the spread of infection on the unit. She said Residents #2 and #3 were COVID-19 tested , once she realized they were cohorted with positive residents, and they both tested negative. She said room changes would be made today ([DATE]) to ensure Residents #2 and #3 were not in rooms with COVID-19 positive residents. Record Review of the facility's COVID-19 Infection Control and Mitigation Policy dated [DATE] indicated, under no circumstance should a COVID-positive resident be in the same room as a COVID-negative resident. If room isolation is not possible, such as for a dementia unit with wandering residents, try to set up smaller areas for wandering that reduces number of residents interacting and hence potential exposure and spread. In an interview on [DATE] at 11:07 AM, the Administrator said she contacted the RNC when the outbreak on the Memory Care Unit began. She said it was her understanding from the RNC to leave the residents cohorted on the unit. In an observation on [DATE] at 11:39, on the Memory Care Unit, revealed Resident #1 was in her wheelchair in the lobby by the nurse's station; she was not wearing her mask. Resident #2 remained in the lobby area in her wheelchair with her mask in place. Residents were wandering and intermingling. Resident #3 was in her room in bed. In an interview on [DATE] at 11:45 AM, LVN A said the COVID-19 positive, and COVID-19 negative residents had been cohorted since the outbreak started ([DATE]). She said there was a high risk of COVID-19 negative residents contracting COVID-19 from their roommates. In an interview on [DATE] at 1:56 PM, the Administrator said she called the corporate RNC on [DATE] to discuss the outbreak on the unit. She said she asked the RNC what to do about the positive and negative residents. She said the RNC told her the Memory Care Unit was different from the general population and the residents could stay where they were on the unit. She said the RNC said to try to do the best they could to keep the residents separated. She said the RNC did not say to move any of the positive or negative residents to different rooms. She said the RNC was at the facility on [DATE] and knew the residents on the unit were cohorted. In an interview on [DATE] at 2:05 PM, with the DON and Administrator, the DON said the facility would normally move a resident to a private room that tested positive for COVID-19, but because the RNC was a former State Surveyor, they felt she knew what to do, in regards, to the Memory Care Unit. She said, at the time of the outbreak on [DATE], the unit did not have enough available rooms to separate the residents, but the facility should have taken the negative residents out of the unit and provided, if needed, one on one supervision to keep them safe from elopement. The Administrator said today, [DATE], they were told by the Vice President of Clinical Operations they should not have cohorted the positive and negative residents on the unit and should have separated them. The Administrator said no curtain or other type of barrier was used in the rooms to separate negative residents from the positive residents. The Administrator was informed of the Immediate Jeopardy on [DATE] at 2:12 PM and was provided with the Immediate Jeopardy template. A Plan of Removal was also requested at that time. In a telephone interview on [DATE] at 2:13 PM, the RNC said the Administrator made her aware of the COVID-19 outbreak on the Memory Care Unit, but the Administrator misunderstood her instructions. She said the facility policy was to not cohort positive and negative residents. She said if she had known residents were cohorted, she and the team would have discussed what was best for the unit, to set up a separate space on the unit or move the negative residents off the unit. She said the risk of cohorting residents was that the negative residents could contract COVID-19 from being exposed to their roommates. She said she was at the facility on [DATE], but she did not go back to the Memory Care Unit and did not know or receive any information about residents with different COVID-19 statuses being cohorted together. In a confidential telephone interview on [DATE], a concerned party, said she was informed of the COVID-19 outbreak on the unit on [DATE], by LVN B. She said she asked LVN B how the facility was separating the positive and negative residents on the unit. She said LVN B told her they were just doing the best they could, and she if she had further questions to address them with the DON. She said she was very afraid all the residents would contract COVID-19 on the unit. She said she was very upset the facility was not following the infection control guidelines to prevent the spread of the infection. In an observation on [DATE] at 10:44 AM, on the Memory Care Unit, revealed Residents #2 and #3 (COVID-19 negative) were placed in private rooms. Resident #2 was in the lobby, sitting in her wheelchair. She did not have her mask on, five other COVID-19 positive residents were also in the lobby without masks on. In an interview on [DATE] at 10:47 AM, CNA C, who was working on the Memory Care Unit, said COVID-19 positive residents had been cohorted with negative residents on the unit since the outbreak. She said she did not feel that was good infection control practices, but she did not ask anyone about it. She said she believed positive and negative residents should be separated to prevent the spread of infection. She said she most of the residents wander all around, in and out of each other's rooms. She said the residents on the unit would not wear their mask. She said on Saturday ([DATE]), Resident #6 told her she was concerned she might contract COVID-19 from her roommate, who was coughing and had symptoms. She said Resident #6 was negative and her roommate, Resident #5 was positive. She said she also overheard Resident #6 discussing her concerns with her family on the phone. She said Residents #5 and #6 were still roommates. Record Review of Resident #6's Admission Record dated [DATE] indicated the [AGE] year-old female resident was admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She was roommates with Resident #5. Record Review of the facility's COVID-19 Outbreak Tracking dated [DATE], indicated Resident #6's roommate, Resident #5, tested positive for COVID-19 on [DATE], three days before Resident #6. Record Review of Resident #6's census record from [DATE] - [DATE] indicated she remained roommates with Resident #5. Record Review of Resident #6's quarterly MDS dated [DATE] indicated the resident was moderately cognitively impaired with a BIMS score of 9 (a score of ,d+[DATE] indicated moderate cognitive impairment). In an observation and interview on [DATE] at 10:49 AM revealed Resident #6 was in her room, her roommate, Resident #5, was also in the room. Resident #6 said she contracted COVID-19 from her roommate. She said she was concerned when her roommate became positive that she would contract COVID-19 because she remained in the room with her. She said positive residents also wandered in her room and roamed all over the unit. She said residents would not wear a mask. She said she was not having any signs or symptoms of COVID-19 at this time. In a telephone interview on [DATE] at 12:18 PM, the Medical Director said he was not aware of the cohorting of COVID-19 positive and negative residents on the Memory Care. He said residents should not have been cohorted due to the high risk of the spread of the infection. He said he had spoken to the Administrator and believed, as of [DATE], the facility had taken the appropriate actions to fix the problem and ensure this did not happen again. In a telephone interview on [DATE] at 1:59 PM, Resident #2's responsible party said the facility informed her of the COVID-19 outbreak. She said yesterday ([DATE]) the facility called her to let her know they were moving Resident #2 to another room because her roommate had tested positive for COVID-19 and the facility did not want Resident #2 to contract COVID-19. She said she was always concerned the resident might contract COVID-19, since the pandemic began, and with the resident's health conditions she was not sure how the resident would do if she contracted it. She said she resided out of state and was not able to come to the facility to visit the resident. In a telephone interview on [DATE] at 2:19 PM, the Medical Director's Nurse Practitioner said she was not aware residents who were COVID-19 negative were being cohorted with residents who were COVID-19 positive on the Memory Care Unit. She said she did know most of the residents on the unit were COVID-19 positive. She said she was not surprised the infection spread on the unit because everyone on the unit had been exposed and COVID-19 was so contagious. She said residents on the unit wandered and would not wear masks. She said Resident #7 was on hospice related to his cancer diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said COVID-19 may have played a part in his passing but she did not know how much he did not present with the classic respiratory symptoms. She said she would review his closed clinical record and provide more information. In an interview on [DATE] at 2:51 PM, LVN D said he did not think that COVID-19 positive and negative residents should be cohorted, but he never asked anyone about it. He said he could see the concern of moving wandering residents off the Memory Care Unit and the risk for elopement. He said on the Memory Care Unit it was impossible to isolate the residents because they wandered and would not wear masks. He said residents just being in the unit caused the spread of the infection because residents go in each other's rooms, touch things, and get together in groups. In a telephone interview on [DATE] at 3:09 PM, LVN B, who worked the Memory Care Unit, said she expressed serious concern to the DON when the first resident, Resident #9 tested positive ([DATE]) on the Memory Care Unit. She said Resident #9 should have been moved off the unit to try to stop the spread of the infection. She said Resident #9 could have been moved off the unit to the COVID-19 hall because the resident was not at risk for elopement because she was ill and not getting out of bed. She said she wanted to separate the positive and negative residents to try to contain the infection. She said she told the DON her concerns, but the DON said all the residents on the unit were exposed and going to get it anyway. She said the DON knew positive and negative residents were in the same room together on the unit. She said she called the Nurse Practitioner to discuss her concerns, she did not remember the date. She said the Nurse Practitioner knew the positive negative residents were cohorted on the unit. She said the Nurse Practitioner told her all the residents were going to get COVID-19 anyway because it was so contagious. She said the overall philosophy was that all the residents had been exposed and were going to get COVID-19 on the unit. She said no interventions were put in place to try to keep COVID-19 from spreading on the unit. She said the nurses and CNAs cleaned as much as they could. She said because it's a Memory Care unit, no matter how hard they tried they could not keep wandering residents from going in each other's rooms, or wear masks. She said positive residents were going up to negative residents and talking to them without masks on. She said one by one residents on the unit tested positive for COVID-19. She said she could not say whether or not Resident #7 expired from COVID-19, but it probably contributed to his decline. In a telephone interview on [DATE] at 3:29 PM, the Nurse Practitioner said she had reviewed Resident #7's closed clinical record and believed from the documentation in the record he expired from a pulmonary embolism (a blood clot to his lungs). She said COVID-19 could cause blood clots but usually after an extended illness and Resident #7's was a more rapid decline. She said she did not believe COVID-19 had a lot to do with his death but an autopsy would be the only way to know for sure. In an interview on [DATE] at 4:09 PM the DON said all the licensed nurses had been in-serviced regarding the policy on cohorting on [DATE]. She said all the licensed nurses would be in-serviced before working their shifts. She said she would work this weekend and in-service the weekend staff. She said the in-service would be on-going for new hires and any agency staff. The facility's POR (Plan of Removal) was accepted on [DATE] at 11:26 AM and reflected the following: Problem: Two residents on the secure unit were cohorted in their rooms with negative roommates. o Action Positive and negative residents were separated by licensed nurse under the direction of the Director of Nursing and isolated in accordance with CDC (Centers for Disease Control) protocols on [DATE]. o Families of negative residents were notified by DON on [DATE]. o Medical Director was notified by Administrator on [DATE]. o Both negative residents were tested by licensed nurse on [DATE] and remained negative. o Both negative residents will be monitored q shift x 72 hours by licensed nurse for signs and symptoms of COVID and this assessment will be documented in the electronic medical record. Problem: The facility was under the impression that due to the outbreak on the secured unit, COVID positive and negative residents could remain together. o Action on [DATE], Lead CCS (Corporate Clinical Specialist) in-serviced Director of Nursing, Administrator, Regional Director of Operations and Corporate Clinical Specialist on COVID policies and procedures to include proper cohorting and management of positive residents and negative roommates. o On [DATE], Director of Nursing, Regional Corporate Clinical Specialist (CCS) and LEAD CCS completed in-servicing with licensed nurses on COVID protocols to include proper cohorting and management of positive and negative residents. No licensed nurses will be allowed to work without receiving this in-service prior to reporting for duty. This in-service material will be incorporated into new hire orientation effective [DATE]. Currently the facility does not use agency staff, but in the event agency staff is needed, they will not be utilized until they have completed the required in-service. Monitoring o In order to monitor residents for potential risk, proper cohorting, and isolation/quarantine, the DON will review the status of all new admissions, PUI, and COVID-positive residents on a daily basis with lead CCS beginning [DATE]rd, 2022, for 30 days. Facility administrator will ensure that DON reviews residents with lead corporate nurse daily for 30 days. o The facility QA (Quality Assurance) Committee will meet weekly for the next eight weeks to review compliance. If no further concerns are noted, will continue to monitor as per routine facility QA Committee. Facility administrator will be responsible to ensure that meeting occurs weekly. The following interviews, and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Review of the facility's in-service and training records, COVID Protocols dated [DATE], indicated all the licensed nurses would be in-serviced on the proper cohorting of COVID-19 positive and negative residents. Positive and negative COVID-19 residents could not remain in the same room. The COVID-19 negative resident must be moved to a single room. Staff were to encourage residents to wear masks. Staff must make every effort to keep COVID-19 positive and negative residents separated, at all times. The DON and Administrator must be notified immediately of any new COVID-19 cases. Interviews were conducted with staff across multiple shifts, the shifts were 6:00 AM - 2:00 PM, 2:00 PM - 10:00 PM and 10:00 PM - 6:00 AM, on [DATE] from 10:55 AM through 4:30 PM, including, the Administrator, DON, MDS Coordinator, Medical Director and six LVNs, A, B, D, E, F, and G. They were able to verbalize the appropriate understanding of cohorting residents based upon COVID-19 status, and the plan of removal. Review of rapid testing results from [DATE] revealed Resident #2 and #3 tested negative for COVID-19. An Immediate Jeopardy was identified on [DATE] at 2:12 PM. While the Immediate Jeopardy was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on interviews and record reviews, the facility failed to implement policies and procedures that prohibit abuse for two (Residents #1 and #2) of five residents reviewed for abuse. 1. The facility failed to implement policy to protect Resident #1 from physical and verbal abuse. On 09/11/18 Resident #1 reported to multiple staff that CNA D slapped him twice on the face while assisting him with ADLs. CNA D was suspended pending investigation on 09/11/18, but was allowed to return to work on 09/14/18. CNA D was working in the facility on 07/31/19. 2. The facility failed to implement their abuse policy when a staff member alleged CNA W hit Resident #2 on the back of the head on 12/19/18. CNA W was not suspended during the abuse investigation, a thorough investigation of the allegation was not completed, and the social worker other than the abuse coordinator completed aspects of the investigation without being familiar with the process. An Immediate Jeopardy (IJ) was identified on 07/31/19. The IJ was removed on 08/05/19; however, the facility remained out of compliance at isolated of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical and verbal abuse, which could result in decreased self-esteem, reduced quality of life, injury, or decline in condition. Findings included: 1. Review of the facility's policy Abuse - Reportable Events revised 01/2018 reflected the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. The policy defines Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse included but not limited to, hitting, slapping, punching, and kicking. Under investigation .the abuse coordinator will review all aspects of the investigation as soon as possible, ensure that all reports are complete and appropriate authorities have been notified, complete the investigation and direct any disciplinary action required, complete the state provider investigation report (5 day report), review corrective action(s), inform the resident or his/her representative of the findings of the investigation and corrective action taken. Under protection .a. All residents will be immediately protected from harm Review of Resident #1's face sheet dated 07/31/19 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected he had [DIAGNOSES REDACTED]. He had a Brief Interview for Mental Status (BIMS) score of 11, which indicated he was moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting and hygiene. Resident #1 had no behaviors. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9, which indicated he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Resident #1's Comprehensive Care Plan reflected the following: Concern: Resident #1 had a history of [REDACTED]. Approaches included: administer medications at ordered by MD, document physically abusive behaviors and report to MD, remove resident from settings that seem to upset or exacerbate behaviors, be firm with resident and tell resident that behavior of hitting others is not acceptable and pysh consult as ordered. Concern: Resident #1 had behavioral health concerns related to refusing care and services including medications and [MEDICAL CONDITION] machine, He becomes easily agitated and verbally aggressive toward staff, he frequently displays verbally inappropriate comments towards staff placing him at risk for potential complications. (Start date of 01/02/17 and last reviewed 07/22/19) Approaches included: allow resident to actively participate in ADL care; if resident becomes verbally inappropriate, redirect and use buddy system of x2 assist during ADL care; if resident refuses ADL care attempt care again at a different time; notify MD if unable to redirect behaviors, psych referral as warranted; social services to counsel as warranted and staff to document behaviors as warranted. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9 indicating he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Provider Investigation Report signed by Previous Administrator on 09/17/18 reflected on 09/11/18 at 2:00 PM Resident #1 was alert and oriented x2-3. He reported before breakfast this morning he was joking with CNA D. He stated CNA D asked him, Do you want me to slap you? and then she slapped him on the face. According to the report, Resident #1 stated after CNA D said, Do you want me to slap you? he felt like he was no longer joking, but the CNA may have been. The report's Investigation summary revealed : CNA D was assisting Resident #1 with putting on his shirt before breakfast. While she was helping him Resident #1 started using foul language towards her. The CNA asked if he spoke like that to all the ladies. Resident #1 stated that he did not give a[***] The CNA then stated in a joking manner, Do you want me to slap you?. After the CNA asked the question she touched his face. At this point the resident slapped the CNA on her face. Thinking the resident was joking she asked him again if he wanted her to slap him and then touched his face. Resident #1 then said, You're full of[***] CNA D was under the impression that he was still joking. CNA D then transferred Resident #1 into his wheelchair and assisted him to the dining room. The resident did not say anything else about the situation. Towards the end of the 6a-2p shift he told the charge nurse that someone slapped him. Investigation findings were unconfirmed. Staff were in-serviced on abuse prevention and awareness. CNA D completed the abuse pre/post-test, and was in-serviced on burnout and customer service. Review of attachments to the Provider Investigation Report related to the incident involving Resident #1 and CNA D revealed the following notes written by the Previous Administrator: on 09/11/18 at approximately 1:50 pm I conducted an interview with Resident #1 regarding an alleged allegation of abuse. This resident stated that a CNA slapped him in the face 2 times. She asked him what caused the incident and he stated that he was not sure. He stated he was probably cussing at her but she slapped him. I asked the resident if he was hurt or if he felt like the employee was trying to hurt him. He stated I am not worried about her. I explained to him that we take these types of allegations or incidents serious and that my job was to protect our residents. I asked him if he felt comfortable with me bringing in CNA D and interviewing them together. Resident (#1) stated he did not care. I then called in the social worker as a witness and CNA (D) for an interview. 09/11/18 at 3:00 PM Resident (#1) came up to the administrator's office about the allegation that he made. (Resident #1) asked that I just forget that he said anything at all. I explained to him that I could not ignore this type of allegation. (Resident #1) sated I wish I would not have said anything I do not want her to loose her job. I then explained to him that he does not need to worry about her and that I have to make sure that all of the residents are safe including him I assisted the resident back to his room. 09/11/18 at 4:45 PM Resident (#1) stopped me in the hallway and asked if I really had to fire her. I explained to him that I need to investigate the incident and ensure that he and the other residents are safe. He again expressed that he wished I would just forget that he said anything that she should not loose her job. 09/11/18 at approximately 4:50 PM I contacted (Resident #1's) daughter to discuss the allegation he made. Review of attachments to the Provider Investigation Report related to the incident revealed a note dated 09/11/18 by social worker reflected Resident #1 made an allegation of abuse. He told his charge nurse that a CNA slapped him in the face and called him a bastard. Review of CNA D's undated Written Statement related to the incident between her and Resident #1 on 09/11/18 undated signed by CNA D reflected the following: On 09/11/18 at 7:30 AM, I was getting (Resident #1) ready for breakfast, I was changing his brief and he said the brief was crooked because that's the way I play with my balls.' I sat him at the edge of the bed to finish dressing him. He started cussing me, calling me a son of a [***] like he always does. I asked is that how you talked to ladies and he said he didn't give a[***] then in a joking way I asked him if he wanted me to slap him, and then I continued joking and touched his face. I thought he was still joking and he slapped me on the face, I said again do you want me to slap you and then again jokingly touched his face. Then he said 'you're full of[***]' I still thought he was joking around. Then I transferred him to his wheelchair and took him to the dining room for breakfast and he didn't say anything else. Just before the end of the shift I went to help change him and heard him tell the nurse he got slapped, I walked up to them and thought he was joking but that's when I noticed he was serious. Then me and the nurse went to the DON office. The statement was signed by CNA D. Review of Resident #1's Nurses' Note dated 09/11/18 at 7:45 PM by LVN [NAME] revealed Resident reported to charge nurse that CNA slapped and cursed resident. Charge Nurse made DON and Administrator aware. Charge nurse assessed patient no bruising or redness noted with no signs or symptoms distress or discomfort noted. No complaints or signs/symptoms of pain. Review of a facility conducted In-service dated 09/12/18 reflected CNA D was in-serviced on abuse and burnout along with other staff. Review of attachments to the Provider Investigation Report revealed on 09/18/18 (4 days after CNA D returned to work) CNA D completed an Abuse Prohibition Questionnaire but it was not scored. Observations and interviews on 07/31/19 at 1:05 PM and on 08/01/19 at 9:03 AM revealed Resident #1 was sitting in his wheelchair. Resident #1 revealed on 09/11/18 he was cursing at CNA D when she slapped him twice on the face with an open hand. He demonstrated he was slapped by CNA D with open hand on his face. He stated he was not joking around with CNA D. He stated he reported the incident to staff because it hurt when she slapped him. He stated CNA D no longer provided care to him after the incident but still worked at the facility. Interviews on 07/31/19 at 11:08 AM and 1:45 PM with CNA D revealed she was getting Resident #1 dressed when they started joking around with each other. When asked to give an example of Resident #1 joking with her she was unable to. She stated Resident #1 started cursing at her. She asked him, Do you talk to ladies that way. She said, Do you want me to slap you? and then she touched his face . She stated Resident #1 continued to curse her, calling her a [***] , and then he slapped her. CNA D stated she asked him a second time, Do you want me to slap you? and then touched his face . She stated Resident #1 didn't report the incident to the nurse until the end of her shift. She stated she was suspended for two or three days. CNA D stated the Previous Administrator told her not to do that again but the Previous Administrator did not elaborate on what she meant. She stated she took that as she should not have touched him. She kept stating it just happened during the interview. She stated she was not sure when she completed her witness statement, and it was either on 09/11/18 or when she returned to work. She reviewed her written statement and stated it happened as she wrote it down. An interview on 07/31/19 at 6:10 PM with LVN F revealed she had worked with resident for 2 years. She stated Resident #1 did not have a history of making false accusations against staff being abusive toward him. She described Resident #1 as rude and brash. She stated he would curse at staff when he was upset or did not want to do something. She stated if he liked the staff member he would joke with them. An interview on 07/31/19 at 2:18 PM with CNA H revealed she worked with Resident #1 regularly. She stated Resident #1 would curse at staff and call them a [***] if he was upset with them. She stated Resident #1 did not have a history of being accusatory of staff. An interview on 7/31/19 at 5:55 PM with CNA G revealed Resident #1 didn't have a history of making false accusations against staff. CNA G stated Resident #1 was an honest person. She stated if Resident #1 got mad or upset, he will curse at you. An interview on 07/31/19 at 2:45 PM with Social Worker revealed that her and the Previous Administrator interviewed Resident #1 on 09/11/18 about his allegations against CNA D. The Social Worker stated Resident #1 reported that CNA D slapped him. The Social Worker stated after Resident #1 made the initial allegation the Administrator asked him if she could bring CNA D in and interview them together. The Social Worker stated Resident #1 said he didn't care. The Social Worker stated Resident #1's story stayed the same while CNA D was in the room and since his initial allegation. He continued to allege that CNA D had slapped him. The Social Worker stated it was not the normal procedure to bring the alleged perpetrator and the resident together for an interview. She stated she felt this was an inappropriate way to investigate an allegation of abuse. She stated CNA D came in on one of the days she was suspended because she was wearing normal clothes not her work clothes. The Social Worker stated she believed CNA D slapped Resident #1 and recommended to the Administrator and the DON that CNA D be terminated. She stated she did not have this documented. An interview on 07/31/19 at 5:10 PM with the DON revealed she described Resident #1 as crude, and vulgar. The DON stated Resident #1 was touchy feely and would make sexual comments toward staff. She stated he was aware of what he was doing, and his dementia was mild. The DON stated on 09/11/18 he reported to LVN [NAME] that CNA D slapped him. The DON stated in an interview with CNA D, she stated, she was getting him dressed and he made the comment, I bet you want me, then patted her on the butt. The DON stated CNA D was suspended until the investigation was completed. She stated Resident #1 was upset after he learned CNA D was suspended. She stated Resident #1 went to the Administrator and recanted his allegations because he did not want her to lose her job. An interview on 07/31/19 at 4:45 PM with the Previous Administrator revealed she did not substantiate Resident #1's allegation of abuse that he was slapped because they were just joking around with each other. She stated Resident #1 stated he wasn't afraid and he felt safe around CNA D. She stated when Resident #1 found out CNA D was suspended he came back and changed his mind about the incident. He stated he wished he would have never mentioned that she had slapped him, and he didn't want her to lose her job. Review of the Previous Administrator's employee file revealed her last date working at the facility was on 07/23/19. An Interview on 07/31/19 at 1:23 PM the Interim Administrator stated she had only been working at the facility as the Administrator since last Wednesday (07/24/19). She stated if she had investigated this incident on 09/11/18 she would have terminated the employee after investigation due to the written statement showing CNA D asked Resident #1 if he wanted to be slapped twice and then CNA D admitted to touching his face two times. She stated Resident #1 reported he was slapped by CNA D. She would have to terminate the employee to protect the resident. She would have completed an employee counseling form showing CNA D was suspended pending investigation and terminated after investigation completed. 2. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to totally dependent in ADLs. Review of the facility's Provider Investigation Report dated 12/26/18 signed by Social Worker reflected on 12/19/18 CNA V asked CNA W to talk to Resident #2 to see what she wanted. Resident #2 was pointing to her pants. CNA W leaned over to look then pushed/hit Resident #2 in the back of the head. Resident #2 the said she hit me. CNA W walked away and laughed. Nurse assessed resident with no injury noted. The report's Investigation Summary section revealed CNA V reported to the DON and social worker that she took Resident #2 to the nurse's station from the dining room because resident had been yelling continuously, so a different CNA could talk to her. CNA V stated that the resident thought she was in school and wanted to talk to someone else. CNA W came over at CNA V's request, asked what was wrong, and the resident said look at this while pointing to her pants. CNA W then looked at the resident's pants from behind because resident was in the walkway to the nurse's station and CNA W could not get around the wheelchair. CNA W then leaned over resident's shoulder to look and her chest caused the resident to move slightly forward. The resident then yelled, Don't hit me. CNA W said, I did not hit you and then went back to her assignment. CNA V then took Resident #2 back to the dining room for lunch and came to the front office. Investigation findings were unconfirmed. An in-service was conducted regarding abuse prevention and awareness as well as communicating with residents. Review of the facility's in-service records revealed on 12/19/18 an in-service was conducted on Abuse/Neglect and Communication. The in-service record did not reflect CNA W participated in the in-service. Review of CNA W's employee file did not reflect any documentation of suspension on 12/19/18 related to the allegations made by CNA V. Review of CNA W's time card reflected she worked on 12/20/18 and 12/21/18 on the 6 AM to 2 PM shift. The Kiosk system showed CNA W provided care to residents on 12/21/18. Review of facility's daily sign in sheet for 12/21/18 revealed CNA W signed in showing she worked. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to total dependent in ADLs. In an interview on 08/01/19 at 12:20 PM CNA V stated on 12/19/18 she took Resident #2 out of the dining room during lunch due to yelling and screaming. She stated Resident #2 was upsetting the other residents so she pushed her in the wheelchair back to the nursing station. She stated she asked CNA W to ask Resident #2 what she wanted. She stated CNA W asked Resident #2 what she wanted and then she hit her in the back of the head. She stated Resident #2 screamed oh you hit me. She stated CNA W walked away. She stated she reported it to the Administrator, but CNA W was not suspended and returned back to work. She stated other staff had made reports about CNA W in the past but nothing had been done. When asked for details, CNA V would not respond. In an interview on 08/01/19 at 2:02 PM CNA W stated another CNA asked her to talk to Resident #2 who was brought to the nurse's station, so she did. She stated Resident #2 was pointing to her pants and said look at this. She stated the way Resident #2's wheelchair was positioned prevented her from going around to face Resident #2 so she leaned over the back of Resident #2 since she could not get around her since Resident #2 was blocking the entrance of nurse's station. She stated she could have pushed Resident #2 forward a little when she was trying to look at the resident's lap. She stated Resident #2 said she hit her. She stated she told Resident #2 that she did not hit her. She stated she walked away from Resident #2 and the other CN[NAME] She stated she went back to working on the hall to assist with passing out trays. She stated she was sent home on 12/19/18 and suspended for two days pending investigation by the Previous Administrator. In interviews on 08/01/19 at 1:44 PM and on 08/02/19 at 10:18 AM the Social Worker stated CNA V reported she witnessed CNA W hit Resident #2 on 12/19/18. She stated the Previous Administrator told CNA W she was suspended pending investigation and would be called once the investigation was completed. She stated her and the Administrator interviewed CNA W together and CNA W denied any abuse. CNA W stated she had leaned over Resident #2 to find out what Resident #2 was pointing to. The Social Worker stated she completed the provider investigation report, but was told the findings by the Administrator or the DON as being unconfirmed. She stated at one time she had looked up what each of the findings meant but could not recall specifically what it meant. She stated she was told by the Administrator or DON that CNA W was suspended pending investigation. She stated she sent to the Provider Investigation Report to the state on 12/26/19, but she did not know when investigation was actually completed. She stated she initially reported the allegations of abuse and neglect to the state with the previous Administration. She was not aware the abuse coordinator was supposed to complete the provider investigation reports and to report the allegation to the state initially. The Social Worker stated CNA W was working today on the 6 AM to 2 PM shift. In an interview on 08/02/19 at 10:45 AM the Interim Administrator stated she was not aware the Social Worker completed the provider investigation report on Resident #2 for the incident on 12/19/18. She stated it was the Administrator's responsibility as the Abuse Coordinator to complete the Provider Investigation Report, but the Social Worker might have been delegated to complete it. An Immediate Jeopardy was identified on 07/31/19. The Interim Administrator, Social Worker, ADON B, MDS Coordinator and Administrator in training were notified of the Immediate Jeopardy on 07/31/19 at 6:30 pm and provided the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/03/19 at 8:21 AM and reflected the following: 1. The facility will ensure all residents are free from abuse/neglect and exploitation. All staff will be educated on policies of abuse/neglect, exploitation and how to handle difficult residents and will complete a post-test following the in-service. PRN employees and Employees that are on vacation, or any employee who misses the in-service for whatever reason will be in-serviced prior to start of the next shift. No employee will be allowed to work until all in-services have been completed. Completion date- 8/5/2019 2. All residents who were provided care by this alleged perpetrator have the potential to be affected by this alleged deficient practice. 3. Immediate Action: The alleged perpetrator was suspended on 07/31/19 and was terminated on the morning of 8-1-19. The managers/department heads were in-serviced by the administrator on new procedure of using the Resident Safe Survey Questionnaire weekly and reporting their finding at the morning meeting. On 08/01/19 the questionnaire was used to interview all residents. Those residents that are unable to answer question have been assessed for unusual bruising or any signs of mistreatment. All concerns have been reported to the administrator for follow up. Medical Director- Spoke with Medical Director at 8:26 am on 08/01/19 and had a QA meeting he is in agreement with Plan of Removal 4. EDUCATION [NAME] All facility staff (all staff/all departments: Administrator, DON, ADON, licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Abuse - Reportable Events Policy attached to include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents The Administrator has assigned department managers to conduct the in-services. The in-services will continue each shift to ensure all staff have been educated on Abuse - Reportable Events Policy attached. Validation of understanding will be accomplished by administering a post test. Initiated: 07/31/19 Completion date: 08/05/19 The Administrator thoroughly reinvestigated the incidents that occurred. Employees who were determined to have not responded appropriately and per facility policy have been appropriately disciplined by the Administrator to include: Alleged Perpetrator #1 was suspended on 07/31/19 and terminated on 08/01/19 Initiated: 7/31/19 Completion date: 8/1/19 The self-report dated 12/19/2018 involving alleged Perpetrator #2 continues to be reinvestigated and the final disposition will be made 08/03/19. Perpetrator #2 was suspended on 08/01/19 pending investigation. B. All department heads have been in-serviced by the Administrator on a Resident Safe Survey Questionnaire. Please see policy that was revised by administrator initiated on 07/31/19. Residents who are unable to respond to safe survey questionnaire will be assessed by licensed nurse for signs of abuse/neglect. The abuse policy has been revised by the administrator to include the safe survey questionnaire on 8/2/2019 Initiated: 7/31/19 Completion date: 8/2/19 C. Facility will conduct a QA meeting on 8/1/19 to review the Plan of Removal, including the new policy for reviewing Safe Survey questionnaire revised by the administrator. Initiated: 7/31/19 Completion date: 8/1/19 D. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance, and dept heads), will be in-serviced on Freedom from Abuse/Neglect and Exploitation which will include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents Grievance process Employees will be in-serviced by the Administrator/ designee prior to working their first shift. Validation of understanding will be accomplished by administering a post test. Initiated: 8/1/19 Completion date: Ongoing 5. MONITOR [NAME] To ensure that all concerns/grievances are investigated and appropriately reported, Resident Safe Survey Questionnaires will be reviewed as well as any concerns brought up at the Morning Meeting. The Administrator will make a determination as to the need for follow up and investigation. The Administrator will begin an investigation immediately after the morning meeting to determine if further follow up or action is required. Initiated: 8/1/19 Completion date: Ongoing B. Facility Administrator will in-service all staff on grievance policy and procedure. Administrator to ensure concern forms are available and staff is aware of location. Initiated: 8/1/2019 Completion date: Ongoing C. After completion of investigation, the decision to return or not to return the alleged perpetrator to work will be reviewed by the ADM, DON, RDO, and RNC . Initiated: 8/1/19 Completion date: Ongoing D. Facility will continue in-service/education on Freedom from Abuse/Neglect and Exploitation as scheduled throughout the year and as needed. A post-test will be used for validation of understanding. Initiated: 7/31/2019 Completion date: Ongoing E. Facility will continue to report concerns and abuse allegations/investigations to the QA meeting monthly. Facility Administrator will review grievance log to ensure no potential abuse or neglect allegations are present that the facility failed to follow up on. Initiated and Completed: 8/1/2019 7. When an allegation of abuse or neglect is made, the facility administrator is responsible for all aspects of the investigation and follow up. The abuse policy has been revised by the Administrator to include: Protect the resident by immediately suspending any and all alleged perpetrators pending outcome of investigation The administrator will ensure the nurse head to toe assessment of the resident Interview the resident including description of events Interview any potential witnesses including other staff, visitors or residents Follow the new policy for safe surveys Review the medical record and care plan Review the employee file Report any allegation of abuse or neglect to HHSC following the guidelines outlined in the provider letter 19-17 Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents That A Nursing Facility Must Report to the Health and Human Services Commission (HHSC) Depending on outcome of the investigation, following steps may include: in servicing on specific topic, disciplinary action up to and including termination; or other actions as needed. The Social Services Director's only involvement will include Safe Surveys, or other secondary tasks as directed by the administrator. Social Services director in-serviced on her role in investigations on 8/2/2019. 8. The administrator reviewed all grievances and concern forms dating back to (MONTH) (YEAR) with the Social Services Director and in-serviced the Social Services Director on the process for completion and follow up on grievances and concern forms to include response to all grievances on 08/01/19. Any concerns noted by the administrator will be followed up on by 08/03/19. The facility's implementation of the Plan of Removal was verified through the following: Interviews on 08/03/19 with facility department heads (Activity Director, ADON B, BOM, Housekeeping/Laundry Manager, ADON A/Wound Nurse, Dietary Manager, Social Worker and MDS Coordinator C) revealed all were able to discuss types of abuse/neglect, knew to report any allegations of abuse/neglect/misappropriation immediately to the Administrator, who was the abuse coordinator, and the grievance process. The Social Worker knew her role was to report any allegation of abuse/neglect/misappropriation of property to the Administrator who was the abuse coordinator. The Social Worker stated she was to only do resident safe survey rounds. Interviews were conducted on 08/03/19 starting at 12:18 PM and continued through 08/05/19 with RN P, RN Q, LVN R, LVN S, and LVN T, regarding in-services which included freedom from abuse/neglect/misappropriation of property facility policy, reporting guidelines, how to deal with difficult residents, and grievance process. The staff members were able to: discuss types of abuse/neglect/misappropriation of property of residents, reporting guidelines, Administrator was the abuse coordinator, grievance process and approaches to use with difficult residents. Interviews were conducted on 08/03/19 through 08/05/19 with CNAs G, H, I, J, K, L and M, from all shifts, regarding in-services which included freedom from abuse/neglect/misappropriation of property facility policy, reporting guidelines, how to deal with difficult residents

Based on observation, interview, and record review, the facility failed to ensure residents were protected free from abuse for two (Residents #1 and #2) of 5 residents reviewed for abuse and neglect. 1. The facility failed to ensure residents were free from abuse. On 09/11/18 Resident #1 reported to multiple staff that CNA D slapped him twice on the face while assisting him with ADLs. CNA D admitted that she slapped the resident twice. CNA D was suspended pending investigation on 09/11/18, but was allowed to return to work on 09/14/18. CNA D was working in the facility on 07/31/19. 2. The facility failed to prevent abuse for Resident #2 when CNA W alleged to hit Resident #2 on the back of the head on 12/19/18. CNA W was not suspended during the abuse investigation, a thorough investigation of the allegation was not completed, and the social worker other than the abuse coordinator completed aspects of the investigation without being familiar with the process. An Immediate Jeopardy (IJ) was identified on 07/31/19. The IJ was removed on 08/05/19; however, the facility remained out of compliance at isolated of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical and verbal abuse, which could result in decreased self-esteem, reduced quality of life, injury, or decline in condition. Findings included: 1. Review of Resident #1's face sheet dated 07/31/19 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected he had [DIAGNOSES REDACTED]. He had a Brief Interview for Mental Status (BIMS) score of 11, which indicated he was moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting and hygiene. Resident #1 had no behaviors. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9, which indicated he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Resident #1's Comprehensive Care Plan reflected the following: Concern: Resident #1 had a history of [REDACTED]. Approaches included: administer medications at ordered by MD, document physically abusive behaviors and report to MD, remove resident from settings that seem to upset or exacerbate behaviors, be firm with resident and tell resident that behavior of hitting others is not acceptable and pysh consult as ordered. Concern: Resident #1 had behavioral health concerns related to refusing care and services including medications and [MEDICAL CONDITION] machine, He becomes easily agitated and verbally aggressive toward staff, he frequently displays verbally inappropriate comments towards staff placing him at risk for potential complications. (Start date of 01/02/17 and last reviewed 07/22/19) Approaches included: allow resident to actively participate in ADL care; if resident becomes verbally inappropriate, redirect and use buddy system of x2 assist during ADL care; if resident refuses ADL care attempt care again at a different time; notify MD if unable to redirect behaviors, psych referral as warranted; social services to counsel as warranted and staff to document behaviors as warranted. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9 indicating he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Provider Investigation Report signed by Previous Administrator on 09/17/18 reflected on 09/11/18 at 2:00 PM Resident #1 was alert and oriented x2-3. He reported before breakfast this morning he was joking with CNA D. He stated CNA D asked him, Do you want me to slap you? and then she slapped him on the face. According to the report, Resident #1 stated after CNA D said, Do you want me to slap you? he felt like he was no longer joking, but the CNA may have been. The report's Investigation summary revealed : CNA D was assisting Resident #1 with putting on his shirt before breakfast. While she was helping him Resident #1 started using foul language towards her. The CNA asked if he spoke like that to all the ladies. Resident #1 stated that he did not give a[***] The CNA then stated in a joking manner, Do you want me to slap you?. After the CNA asked the question she touched his face. At this point the resident slapped the CNA on her face. Thinking the resident was joking she asked him again if he wanted her to slap him and then touched his face. Resident #1 then said, You're full of[***] CNA D was under the impression that he was still joking. CNA D then transferred Resident #1 into his wheelchair and assisted him to the dining room. The resident did not say anything else about the situation. Towards the end of the 6a-2p shift he told the charge nurse that someone slapped him. Investigation findings were unconfirmed. Staff were in-serviced on abuse prevention and awareness. CNA D completed the abuse pre/post-test, and was in-serviced on burnout and customer service. Review of attachments to the Provider Investigation Report related to the incident involving Resident #1 and CNA D revealed the following notes written by the Previous Administrator: on 09/11/18 at approximately 1:50 pm I conducted an interview with Resident #1 regarding an alleged allegation of abuse. This resident stated that a CNA slapped him in the face 2 times. She asked him what caused the incident and he stated that he was not sure. He stated he was probably cussing at her but she slapped him. I asked the resident if he was hurt or if he felt like the employee was trying to hurt him. He stated I am not worried about her. I explained to him that we take these types of allegations or incidents serious and that my job was to protect our residents. I asked him if he felt comfortable with me bringing in CNA D and interviewing them together. Resident (#1) stated he did not care. I then called in the social worker as a witness and CNA (D) for an interview. 09/11/18 at 3:00 PM Resident (#1) came up to the administrator's office about the allegation that he made. (Resident #1) asked that I just forget that he said anything at all. I explained to him that I could not ignore this type of allegation. (Resident #1) sated I wish I would not have said anything I do not want her to loose her job. I then explained to him that he does not need to worry about her and that I have to make sure that all of the residents are safe including him I assisted the resident back to his room. 09/11/18 at 4:45 PM Resident (#1) stopped me in the hallway and asked if I really had to fire her. I explained to him that I need to investigate the incident and ensure that he and the other residents are safe. He again expressed that he wished I would just forget that he said anything that she should not loose her job. 09/11/18 at approximately 4:50 PM I contacted (Resident #1's) daughter to discuss the allegation he made. Review of attachments to the Provider Investigation Report related to the incident revealed a note dated 09/11/18 by social worker reflected Resident #1 made an allegation of abuse. He told his charge nurse that a CNA slapped him in the face and called him a bastard. Review of CNA D's undated Written Statement related to the incident between her and Resident #1 on 09/11/18 undated signed by CNA D reflected the following: On 09/11/18 at 7:30 AM, I was getting (Resident #1) ready for breakfast, I was changing his brief and he said the brief was crooked because that's the way I play with my balls.' I sat him at the edge of the bed to finish dressing him. He started cussing me, calling me a son of a [***] like he always does. I asked is that how you talked to ladies and he said he didn't give a[***] then in a joking way I asked him if he wanted me to slap him, and then I continued joking and touched his face. I thought he was still joking and he slapped me on the face, I said again do you want me to slap you and then again jokingly touched his face. Then he said 'you're full of[***]' I still thought he was joking around. Then I transferred him to his wheelchair and took him to the dining room for breakfast and he didn't say anything else. Just before the end of the shift I went to help change him and heard him tell the nurse he got slapped, I walked up to them and thought he was joking but that's when I noticed he was serious. Then me and the nurse went to the DON office. The statement was signed by CNA D. Review of Resident #1's Nurses' Note dated 09/11/18 at 7:45 PM by LVN [NAME] revealed Resident reported to charge nurse that CNA slapped and cursed resident. Charge Nurse made DON and Administrator aware. Charge nurse assessed patient no bruising or redness noted with no signs or symptoms distress or discomfort noted. No complaints or signs/symptoms of pain. Review of a facility conducted In-service dated 09/12/18 reflected CNA D was in-serviced on abuse and burnout along with other staff. Review of attachments to the Provider Investigation Report revealed on 09/18/18 (4 days after CNA D returned to work) CNA D completed an Abuse Prohibition Questionnaire but it was not scored. Observations and interviews on 07/31/19 at 1:05 PM and on 08/01/19 at 9:03 AM revealed Resident #1 was sitting in his wheelchair. Resident #1 revealed on 09/11/18 he was cursing at CNA D when she slapped him twice on the face with an open hand. He demonstrated he was slapped by CNA D with open hand on his face. He stated he was not joking around with CNA D. He stated he reported the incident to staff because it hurt when she slapped him. He stated CNA D no longer provided care to him after the incident but still worked at the facility. Interviews on 07/31/19 at 11:08 AM and 1:45 PM with CNA D revealed she was getting Resident #1 dressed when they started joking around with each other. When asked to give an example of Resident #1 joking with her she was unable to. She stated Resident #1 started cursing at her. She asked him, Do you talk to ladies that way. She said, Do you want me to slap you? and then she touched his face . She stated Resident #1 continued to curse her, calling her a [***] , and then he slapped her. CNA D stated she asked him a second time, Do you want me to slap you? and then touched his face . She stated Resident #1 didn't report the incident to the nurse until the end of her shift. She stated she was suspended for two or three days. CNA D stated the Previous Administrator told her not to do that again but the Previous Administrator did not elaborate on what she meant. She stated she took that as she should not have touched him. She kept stating it just happened during the interview. She stated she was not sure when she completed her witness statement, and it was either on 09/11/18 or when she returned to work. She reviewed her written statement and stated it happened as she wrote it down. An interview on 07/31/19 at 6:10 PM with LVN F revealed she had worked with resident for 2 years. She stated Resident #1 did not have a history of making false accusations against staff being abusive toward him. She described Resident #1 as rude and brash. She stated he would curse at staff when he was upset or did not want to do something. She stated if he liked the staff member he would joke with them. An interview on 07/31/19 at 2:18 PM with CNA H revealed she worked with Resident #1 regularly. She stated Resident #1 would curse at staff and call them a [***] if he was upset with them. She stated Resident #1 did not have a history of being accusatory of staff. An interview on 7/31/19 at 5:55 PM with CNA G revealed Resident #1 didn't have a history of making false accusations against staff. CNA G stated Resident #1 was an honest person. She stated if Resident #1 got mad or upset, he will curse at you. An interview on 07/31/19 at 2:45 PM with Social Worker revealed that her and the Previous Administrator interviewed Resident #1 on 09/11/18 about his allegations against CNA D. The Social Worker stated Resident #1 reported that CNA D slapped him. The Social Worker stated after Resident #1 made the initial allegation the Administrator asked him if she could bring CNA D in and interview them together. The Social Worker stated Resident #1 said he didn't care. The Social Worker stated Resident #1's story stayed the same while CNA D was in the room and since his initial allegation. He continued to allege that CNA D had slapped him. The Social Worker stated it was not the normal procedure to bring the alleged perpetrator and the resident together for an interview. She stated she felt this was an inappropriate way to investigate an allegation of abuse. She stated CNA D came in on one of the days she was suspended because she was wearing normal clothes not her work clothes. The Social Worker stated she believed CNA D slapped Resident #1 and recommended to the Administrator and the DON that CNA D be terminated. She stated she did not have this documented. An interview on 07/31/19 at 5:10 PM with the DON revealed she described Resident #1 as crude, and vulgar. The DON stated Resident #1 was touchy feely and would make sexual comments toward staff. She stated he was aware of what he was doing, and his dementia was mild. The DON stated on 09/11/18 he reported to LVN [NAME] that CNA D slapped him. The DON stated in an interview with CNA D, she stated, she was getting him dressed and he made the comment, I bet you want me, then patted her on the butt. The DON stated CNA D was suspended until the investigation was completed. She stated Resident #1 was upset after he learned CNA D was suspended. She stated Resident #1 went to the Administrator and recanted his allegations because he did not want her to lose her job. An interview on 07/31/19 at 4:45 PM with the Previous Administrator revealed she did not substantiate Resident #1's allegation of abuse that he was slapped because they were just joking around with each other. She stated Resident #1 stated he wasn't afraid and he felt safe around CNA D. She stated when Resident #1 found out CNA D was suspended he came back and changed his mind about the incident. He stated he wished he would have never mentioned that she had slapped him, and he didn't want her to lose her job. Review of the Previous Administrator's employee file revealed her last date working at the facility was on 07/23/19. An Interview on 07/31/19 at 1:23 PM the Interim Administrator stated she had only been working at the facility as the Administrator since last Wednesday (07/24/19). She stated if she had investigated this incident on 09/11/18 she would have terminated the employee after investigation due to the written statement showing CNA D asked Resident #1 if he wanted to be slapped twice and then CNA D admitted to touching his face two times. She stated Resident #1 reported he was slapped by CNA D. She would have to terminate the employee to protect the resident. She would have completed an employee counseling form showing CNA D was suspended pending investigation and terminated after investigation completed. 2. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to totally dependent in ADLs. Review of the facility's Provider Investigation Report dated 12/26/18 signed by Social Worker reflected on 12/19/18 CNA V asked CNA W to talk to Resident #2 to see what she wanted. Resident #2 was pointing to her pants. CNA W leaned over to look then pushed/hit Resident #2 in the back of the head. Resident #2 the said she hit me. CNA W walked away and laughed. Nurse assessed resident with no injury noted. The report's Investigation Summary section revealed CNA V reported to the DON and social worker that she took Resident #2 to the nurse's station from the dining room because resident had been yelling continuously, so a different CNA could talk to her. CNA V stated that the resident thought she was in school and wanted to talk to someone else. CNA W came over at CNA V's request, asked what was wrong, and the resident said look at this while pointing to her pants. CNA W then looked at the resident's pants from behind because resident was in the walkway to the nurse's station and CNA W could not get around the wheelchair. CNA W then leaned over resident's shoulder to look and her chest caused the resident to move slightly forward. The resident then yelled, Don't hit me. CNA W said, I did not hit you and then went back to her assignment. CNA V then took Resident #2 back to the dining room for lunch and came to the front office. Investigation findings were unconfirmed. An in-service was conducted regarding abuse prevention and awareness as well as communicating with residents. Review of the facility's in-service records revealed on 12/19/18 an in-service was conducted on Abuse/Neglect and Communication. The in-service record did not reflect CNA W participated in the in-service. Review of CNA W's employee file did not reflect any documentation of suspension on 12/19/18 related to the allegations made by CNA V. Review of CNA W's time card reflected she worked on 12/20/18 and 12/21/18 on the 6 AM to 2 PM shift. The Kiosk system showed CNA W provided care to residents on 12/21/18. Review of facility's daily sign in sheet for 12/21/18 revealed CNA W signed in showing she worked. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to total dependent in ADLs. In an interview on 08/01/19 at 12:20 PM CNA V stated on 12/19/18 she took Resident #2 out of the dining room during lunch due to yelling and screaming. She stated Resident #2 was upsetting the other residents so she pushed her in the wheelchair back to the nursing station. She stated she asked CNA W to ask Resident #2 what she wanted. She stated CNA W asked Resident #2 what she wanted and then she hit her in the back of the head. She stated Resident #2 screamed oh you hit me. She stated CNA W walked away. She stated she reported it to the Administrator, but CNA W was not suspended and returned back to work. She stated other staff had made reports about CNA W in the past but nothing had been done. When asked for details, CNA V would not respond. In an interview on 08/01/19 at 2:02 PM CNA W stated another CNA asked her to talk to Resident #2 who was brought to the nurse's station, so she did. She stated Resident #2 was pointing to her pants and said look at this. She stated the way Resident #2's wheelchair was positioned prevented her from going around to face Resident #2 so she leaned over the back of Resident #2 since she could not get around her since Resident #2 was blocking the entrance of nurse's station. She stated she could have pushed Resident #2 forward a little when she was trying to look at the resident's lap. She stated Resident #2 said she hit her. She stated she told Resident #2 that she did not hit her. She stated she walked away from Resident #2 and the other CN[NAME] She stated she went back to working on the hall to assist with passing out trays. She stated she was sent home on 12/19/18 and suspended for two days pending investigation by the Previous Administrator. In interviews on 08/01/19 at 1:44 PM and on 08/02/19 at 10:18 AM the Social Worker stated CNA V reported she witnessed CNA W hit Resident #2 on 12/19/18. She stated the Previous Administrator told CNA W she was suspended pending investigation and would be called once the investigation was completed. She stated her and the Administrator interviewed CNA W together and CNA W denied any abuse. CNA W stated she had leaned over Resident #2 to find out what Resident #2 was pointing to. The Social Worker stated she completed the provider investigation report, but was told the findings by the Administrator or the DON as being unconfirmed. She stated at one time she had looked up what each of the findings meant but could not recall specifically what it meant. She stated she was told by the Administrator or DON that CNA W was suspended pending investigation. She stated she sent to the Provider Investigation Report to the state on 12/26/19, but she did not know when investigation was actually completed. She stated she initially reported the allegations of abuse and neglect to the state with the previous Administration. She was not aware the abuse coordinator was supposed to complete the provider investigation reports and to report the allegation to the state initially. The Social Worker stated CNA W was working today on the 6 AM to 2 PM shift. In an interview on 08/02/19 at 10:45 AM the Interim Administrator stated she was not aware the Social Worker completed the provider investigation report on Resident #2 for the incident on 12/19/18. She stated it was the Administrator's responsibility as the Abuse Coordinator to complete the Provider Investigation Report, but the Social Worker might have been delegated to complete it. Review of the facility's policy Abuse - Reportable Events revised 01/2018 reflected the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. The policy defines Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse included but not limited to, hitting, slapping, punching, and kicking. Under investigation .the abuse coordinator will review all aspects of the investigation as soon as possible, ensure that all reports are complete and appropriate authorities have been notified, complete the investigation and direct any disciplinary action required, complete the state provider investigation report (5 day report), review corrective action(s), inform the resident or his/her representative of the findings of the investigation and corrective action taken. Under protection .a. All residents will be immediately protected from harm An Immediate Jeopardy was identified on 07/31/19. The Interim Administrator, Social Worker, ADON B, MDS Coordinator and Administrator in training were notified of the Immediate Jeopardy on 07/31/19 at 6:30 pm and provided the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/03/19 at 8:21 AM and reflected the following: 1. The facility will ensure all residents are free from abuse/neglect and exploitation. All staff will be educated on policies of abuse/neglect, exploitation and how to handle difficult residents and will complete a post-test following the in-service. PRN employees and Employees that are on vacation, or any employee who misses the in-service for whatever reason will be in-serviced prior to start of the next shift. No employee will be allowed to work until all in-services have been completed. Completion date- 8/5/2019 2. All residents who were provided care by this alleged perpetrator have the potential to be affected by this alleged deficient practice. 3. Immediate Action: The alleged perpetrator was suspended on 07/31/19 and was terminated on the morning of 8-1-19. The managers/department heads were in-serviced by the administrator on new procedure of using the Resident Safe Survey Questionnaire weekly and reporting their finding at the morning meeting. On 08/01/19 the questionnaire was used to interview all residents. Those residents that are unable to answer question have been assessed for unusual bruising or any signs of mistreatment. All concerns have been reported to the administrator for follow up. Medical Director- Spoke with Medical Director at 8:26 am on 08/01/19 and had a QA meeting he is in agreement with Plan of Removal 4. EDUCATION [NAME] All facility staff (all staff/all departments: Administrator, DON, ADON, licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Abuse - Reportable Events Policy attached to include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents The Administrator has assigned department managers to conduct the in-services. The in-services will continue each shift to ensure all staff have been educated on Abuse - Reportable Events Policy attached. Validation of understanding will be accomplished by administering a post test. Initiated: 07/31/19 Completion date: 08/05/19 The Administrator thoroughly reinvestigated the incidents that occurred. Employees who were determined to have not responded appropriately and per facility policy have been appropriately disciplined by the Administrator to include: Alleged Perpetrator #1 was suspended on 07/31/19 and terminated on 08/01/19 Initiated: 7/31/19 Completion date: 8/1/19 The self-report dated 12/19/2018 involving alleged Perpetrator #2 continues to be reinvestigated and the final disposition will be made 08/03/19. Perpetrator #2 was suspended on 08/01/19 pending investigation. B. All department heads have been in-serviced by the Administrator on a Resident Safe Survey Questionnaire. Please see policy that was revised by administrator initiated on 07/31/19. Residents who are unable to respond to safe survey questionnaire will be assessed by licensed nurse for signs of abuse/neglect. The abuse policy has been revised by the administrator to include the safe survey questionnaire on 8/2/2019 Initiated: 7/31/19 Completion date: 8/2/19 C. Facility will conduct a QA meeting on 8/1/19 to review the Plan of Removal, including the new policy for reviewing Safe Survey questionnaire revised by the administrator. Initiated: 7/31/19 Completion date: 8/1/19 D. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance, and dept heads), will be in-serviced on Freedom from Abuse/Neglect and Exploitation which will include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents Grievance process Employees will be in-serviced by the Administrator/ designee prior to working their first shift. Validation of understanding will be accomplished by administering a post test. Initiated: 8/1/19 Completion date: Ongoing 5. MONITOR [NAME] To ensure that all concerns/grievances are investigated and appropriately reported, Resident Safe Survey Questionnaires will be reviewed as well as any concerns brought up at the Morning Meeting. The Administrator will make a determination as to the need for follow up and investigation. The Administrator will begin an investigation immediately after the morning meeting to determine if further follow up or action is required. Initiated: 8/1/19 Completion date: Ongoing B. Facility Administrator will in-service all staff on grievance policy and procedure. Administrator to ensure concern forms are available and staff is aware of location. Initiated: 8/1/2019 Completion date: Ongoing C. After completion of investigation, the decision to return or not to return the alleged perpetrator to work will be reviewed by the ADM, DON, RDO, and RNC . Initiated: 8/1/19 Completion date: Ongoing D. Facility will continue in-service/education on Freedom from Abuse/Neglect and Exploitation as scheduled throughout the year and as needed. A post-test will be used for validation of understanding. Initiated: 7/31/2019 Completion date: Ongoing E. Facility will continue to report concerns and abuse allegations/investigations to the QA meeting monthly. Facility Administrator will review grievance log to ensure no potential abuse or neglect allegations are present that the facility failed to follow up on. Initiated and Completed: 8/1/2019 7. When an allegation of abuse or neglect is made, the facility administrator is responsible for all aspects of the investigation and follow up. The abuse policy has been revised by the Administrator to include: Protect the resident by immediately suspending any and all alleged perpetrators pending outcome of investigation The administrator will ensure the nurse head to toe assessment of the resident Interview the resident including description of events Interview any potential witnesses including other staff, visitors or residents Follow the new policy for safe surveys Review the medical record and care plan Review the employee file Report any allegation of abuse or neglect to HHSC following the guidelines outlined in the provider letter 19-17 Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents That A Nursing Facility Must Report to the Health and Human Services Commission (HHSC) Depending on outcome of the investigation, following steps may include: in servicing on specific topic, disciplinary action up to and including termination; or other actions as needed. The Social Services Director's only involvement will include Safe Surveys, or other secondary tasks as directed by the administrator. Social Services director in-serviced on her role in investigations on 8/2/2019. 8. The administrator reviewed all grievances and concern forms dating back to (MONTH) (YEAR) with the Social Services Director and in-serviced the Social Services Director on the process for completion and follow up on grievances and concern forms to include response to all grievances on 08/01/19. Any concerns noted by the administrator will be followed up on by 08/03/19. The facility's implementation of the Plan of Removal was verified through the following: Interviews on 08/03/19 with facility department heads (Activity Director, ADON B, BOM, Housekeeping/Laundry Manager, ADON A/Wound Nurse, Dietary Manager, Social Worker and MDS Coordinator C) revealed all were able to discuss types of abuse/neglect, knew to report any allegations of abuse/neglect/misappropriation immediately to the Administrator, who was the abuse coordinator, and the grievance process. The Social Worker knew her role was to report any allegation of abuse/neglect/misappropriation of property to the Administrator who was the abuse coordinator. The Social Worker stated she was to only do resident safe survey rounds. Interviews were conducted on 08/03/19 starting at 12:18 PM and continued through 08/05/19 with RN P, RN Q, LVN R, LVN S, and LVN T, regarding in-services which included freedom from abuse/neglect/misappropriation of property facility policy, reporting guidelines, how to deal with difficult residents, and grievance process. The staff members were able to: discuss types of abuse/neglect/misappropriation of property of residents, reporting guidelines, Administrator was the abuse coordinator, grievance process and approaches to use with difficult residents. Interviews were conducted on 08/03/19 through 08/05/19 with CNAs G, H, I, J, K, L and M, from all shifts, regarding in-services which included freedom from abuse/neglect/misappropriation of property facility policy, reporting guidelines, how to deal with dif

Based on interviews and record reviews, the facility failed to have evidence that all alleged violations of abuse are thoroughly investigated and to prevent further potential abuse for two (Residents #1 and #2) of five residents reviewed for abuse. 1. The facility failed to have evidence residents were free from abuse. On 09/11/18 Resident #1 reported to multiple staff that CNA D slapped him twice on the face while assisting him with ADLs. CNA D admitted that she slapped the resident twice. CNA D was suspended pending investigation on 09/11/18, but was allowed to return to work on 09/14/18. CNA D was working in the facility on 07/31/19. 2. The facility failed to have evidence of a thorough investigation for Resident #2 when CNA W alleged to hit Resident #2 on the back of the head on 12/19/18. CNA W was not suspended during the abuse investigation, a thorough investigation of the allegation was not completed, and the social worker other than the abuse coordinator completed aspects of the investigation without being familiar with the process. An Immediate Jeopardy (IJ) was identified on 07/31/19. The IJ was removed on 08/05/19; however, the facility remained out of compliance at isolated of potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical and verbal abuse, which could result in decreased self-esteem, reduced quality of life, injury, or decline in condition. Findings included: 1. Review of Resident #1's face sheet dated 07/31/19 reflected he was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Review of Resident #1's Annual Minimum Data Set (MDS) assessment dated [DATE] reflected he had [DIAGNOSES REDACTED]. He had a Brief Interview for Mental Status (BIMS) score of 11, which indicated he was moderately cognitively impaired. Resident #1 required extensive assistance with bed mobility, transfers, dressing, toileting and hygiene. Resident #1 had no behaviors. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9, which indicated he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Resident #1's Comprehensive Care Plan reflected the following: Concern: Resident #1 had a history of [REDACTED]. Approaches included: administer medications at ordered by MD, document physically abusive behaviors and report to MD, remove resident from settings that seem to upset or exacerbate behaviors, be firm with resident and tell resident that behavior of hitting others is not acceptable and pysh consult as ordered. Concern: Resident #1 had behavioral health concerns related to refusing care and services including medications and [MEDICAL CONDITION] machine, He becomes easily agitated and verbally aggressive toward staff, he frequently displays verbally inappropriate comments towards staff placing him at risk for potential complications. (Start date of 01/02/17 and last reviewed 07/22/19) Approaches included: allow resident to actively participate in ADL care; if resident becomes verbally inappropriate, redirect and use buddy system of x2 assist during ADL care; if resident refuses ADL care attempt care again at a different time; notify MD if unable to redirect behaviors, psych referral as warranted; social services to counsel as warranted and staff to document behaviors as warranted. Review of Resident #1's Quarterly MDS assessment dated [DATE] reflected he had a BIMS of 9 indicating he was moderately cognitively impaired. Resident #1 had no behaviors. Review of Provider Investigation Report signed by Previous Administrator on 09/17/18 reflected on 09/11/18 at 2:00 PM Resident #1 was alert and oriented x2-3. He reported before breakfast this morning he was joking with CNA D. He stated CNA D asked him, Do you want me to slap you? and then she slapped him on the face. According to the report, Resident #1 stated after CNA D said, Do you want me to slap you? he felt like he was no longer joking, but the CNA may have been. The report's Investigation summary revealed : CNA D was assisting Resident #1 with putting on his shirt before breakfast. While she was helping him Resident #1 started using foul language towards her. The CNA asked if he spoke like that to all the ladies. Resident #1 stated that he did not give a[***] The CNA then stated in a joking manner, Do you want me to slap you?. After the CNA asked the question she touched his face. At this point the resident slapped the CNA on her face. Thinking the resident was joking she asked him again if he wanted her to slap him and then touched his face. Resident #1 then said, You're full of[***] CNA D was under the impression that he was still joking. CNA D then transferred Resident #1 into his wheelchair and assisted him to the dining room. The resident did not say anything else about the situation. Towards the end of the 6a-2p shift he told the charge nurse that someone slapped him. Investigation findings were unconfirmed. Staff were in-serviced on abuse prevention and awareness. CNA D completed the abuse pre/post-test, and was in-serviced on burnout and customer service. Review of attachments to the Provider Investigation Report related to the incident involving Resident #1 and CNA D revealed the following notes written by the Previous Administrator: on 09/11/18 at approximately 1:50 pm I conducted an interview with Resident #1 regarding an alleged allegation of abuse. This resident stated that a CNA slapped him in the face 2 times. She asked him what caused the incident and he stated that he was not sure. He stated he was probably cussing at her but she slapped him. I asked the resident if he was hurt or if he felt like the employee was trying to hurt him. He stated I am not worried about her. I explained to him that we take these types of allegations or incidents serious and that my job was to protect our residents. I asked him if he felt comfortable with me bringing in CNA D and interviewing them together. Resident (#1) stated he did not care. I then called in the social worker as a witness and CNA (D) for an interview. 09/11/18 at 3:00 PM Resident (#1) came up to the administrator's office about the allegation that he made. (Resident #1) asked that I just forget that he said anything at all. I explained to him that I could not ignore this type of allegation. (Resident #1) sated I wish I would not have said anything I do not want her to loose her job. I then explained to him that he does not need to worry about her and that I have to make sure that all of the residents are safe including him I assisted the resident back to his room. 09/11/18 at 4:45 PM Resident (#1) stopped me in the hallway and asked if I really had to fire her. I explained to him that I need to investigate the incident and ensure that he and the other residents are safe. He again expressed that he wished I would just forget that he said anything that she should not loose her job. 09/11/18 at approximately 4:50 PM I contacted (Resident #1's) daughter to discuss the allegation he made. Review of attachments to the Provider Investigation Report related to the incident revealed a note dated 09/11/18 by social worker reflected Resident #1 made an allegation of abuse. He told his charge nurse that a CNA slapped him in the face and called him a bastard. Review of CNA D's undated Written Statement related to the incident between her and Resident #1 on 09/11/18 undated signed by CNA D reflected the following: On 09/11/18 at 7:30 AM, I was getting (Resident #1) ready for breakfast, I was changing his brief and he said the brief was crooked because that's the way I play with my balls.' I sat him at the edge of the bed to finish dressing him. He started cussing me, calling me a son of a [***] like he always does. I asked is that how you talked to ladies and he said he didn't give a[***] then in a joking way I asked him if he wanted me to slap him, and then I continued joking and touched his face. I thought he was still joking and he slapped me on the face, I said again do you want me to slap you and then again jokingly touched his face. Then he said 'you're full of[***]' I still thought he was joking around. Then I transferred him to his wheelchair and took him to the dining room for breakfast and he didn't say anything else. Just before the end of the shift I went to help change him and heard him tell the nurse he got slapped, I walked up to them and thought he was joking but that's when I noticed he was serious. Then me and the nurse went to the DON office. The statement was signed by CNA D. Review of Resident #1's Nurses' Note dated 09/11/18 at 7:45 PM by LVN [NAME] revealed Resident reported to charge nurse that CNA slapped and cursed resident. Charge Nurse made DON and Administrator aware. Charge nurse assessed patient no bruising or redness noted with no signs or symptoms distress or discomfort noted. No complaints or signs/symptoms of pain. Review of a facility conducted In-service dated 09/12/18 reflected CNA D was in-serviced on abuse and burnout along with other staff. Review of attachments to the Provider Investigation Report revealed on 09/18/18 (4 days after CNA D returned to work) CNA D completed an Abuse Prohibition Questionnaire but it was not scored. Observations and interviews on 07/31/19 at 1:05 PM and on 08/01/19 at 9:03 AM revealed Resident #1 was sitting in his wheelchair. Resident #1 revealed on 09/11/18 he was cursing at CNA D when she slapped him twice on the face with an open hand. He demonstrated he was slapped by CNA D with open hand on his face. He stated he was not joking around with CNA D. He stated he reported the incident to staff because it hurt when she slapped him. He stated CNA D no longer provided care to him after the incident but still worked at the facility. Interviews on 07/31/19 at 11:08 AM and 1:45 PM with CNA D revealed she was getting Resident #1 dressed when they started joking around with each other. When asked to give an example of Resident #1 joking with her she was unable to. She stated Resident #1 started cursing at her. She asked him, Do you talk to ladies that way. She said, Do you want me to slap you? and then she touched his face . She stated Resident #1 continued to curse her, calling her a [***] , and then he slapped her. CNA D stated she asked him a second time, Do you want me to slap you? and then touched his face . She stated Resident #1 didn't report the incident to the nurse until the end of her shift. She stated she was suspended for two or three days. CNA D stated the Previous Administrator told her not to do that again but the Previous Administrator did not elaborate on what she meant. She stated she took that as she should not have touched him. She kept stating it just happened during the interview. She stated she was not sure when she completed her witness statement, and it was either on 09/11/18 or when she returned to work. She reviewed her written statement and stated it happened as she wrote it down. An interview on 07/31/19 at 6:10 PM with LVN F revealed she had worked with resident for 2 years. She stated Resident #1 did not have a history of making false accusations against staff being abusive toward him. She described Resident #1 as rude and brash. She stated he would curse at staff when he was upset or did not want to do something. She stated if he liked the staff member he would joke with them. An interview on 07/31/19 at 2:18 PM with CNA H revealed she worked with Resident #1 regularly. She stated Resident #1 would curse at staff and call them a [***] if he was upset with them. She stated Resident #1 did not have a history of being accusatory of staff. An interview on 7/31/19 at 5:55 PM with CNA G revealed Resident #1 didn't have a history of making false accusations against staff. CNA G stated Resident #1 was an honest person. She stated if Resident #1 got mad or upset, he will curse at you. An interview on 07/31/19 at 2:45 PM with Social Worker revealed that her and the Previous Administrator interviewed Resident #1 on 09/11/18 about his allegations against CNA D. The Social Worker stated Resident #1 reported that CNA D slapped him. The Social Worker stated after Resident #1 made the initial allegation the Administrator asked him if she could bring CNA D in and interview them together. The Social Worker stated Resident #1 said he didn't care. The Social Worker stated Resident #1's story stayed the same while CNA D was in the room and since his initial allegation. He continued to allege that CNA D had slapped him. The Social Worker stated it was not the normal procedure to bring the alleged perpetrator and the resident together for an interview. She stated she felt this was an inappropriate way to investigate an allegation of abuse. She stated CNA D came in on one of the days she was suspended because she was wearing normal clothes not her work clothes. The Social Worker stated she believed CNA D slapped Resident #1 and recommended to the Administrator and the DON that CNA D be terminated. She stated she did not have this documented. An interview on 07/31/19 at 5:10 PM with the DON revealed she described Resident #1 as crude, and vulgar. The DON stated Resident #1 was touchy feely and would make sexual comments toward staff. She stated he was aware of what he was doing, and his dementia was mild. The DON stated on 09/11/18 he reported to LVN [NAME] that CNA D slapped him. The DON stated in an interview with CNA D, she stated, she was getting him dressed and he made the comment, I bet you want me, then patted her on the butt. The DON stated CNA D was suspended until the investigation was completed. She stated Resident #1 was upset after he learned CNA D was suspended. She stated Resident #1 went to the Administrator and recanted his allegations because he did not want her to lose her job. An interview on 07/31/19 at 4:45 PM with the Previous Administrator revealed she did not substantiate Resident #1's allegation of abuse that he was slapped because they were just joking around with each other. She stated Resident #1 stated he wasn't afraid and he felt safe around CNA D. She stated when Resident #1 found out CNA D was suspended he came back and changed his mind about the incident. He stated he wished he would have never mentioned that she had slapped him, and he didn't want her to lose her job. Review of the Previous Administrator's employee file revealed her last date working at the facility was on 07/23/19. An Interview on 07/31/19 at 1:23 PM the Interim Administrator stated she had only been working at the facility as the Administrator since last Wednesday (07/24/19). She stated if she had investigated this incident on 09/11/18 she would have terminated the employee after investigation due to the written statement showing CNA D asked Resident #1 if he wanted to be slapped twice and then CNA D admitted to touching his face two times. She stated Resident #1 reported he was slapped by CNA D. She would have to terminate the employee to protect the resident. She would have completed an employee counseling form showing CNA D was suspended pending investigation and terminated after investigation completed. 2. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to totally dependent in ADLs. Review of the facility's Provider Investigation Report dated 12/26/18 signed by Social Worker reflected on 12/19/18 CNA V asked CNA W to talk to Resident #2 to see what she wanted. Resident #2 was pointing to her pants. CNA W leaned over to look then pushed/hit Resident #2 in the back of the head. Resident #2 the said she hit me. CNA W walked away and laughed. Nurse assessed resident with no injury noted. The report's Investigation Summary section revealed CNA V reported to the DON and social worker that she took Resident #2 to the nurse's station from the dining room because resident had been yelling continuously, so a different CNA could talk to her. CNA V stated that the resident thought she was in school and wanted to talk to someone else. CNA W came over at CNA V's request, asked what was wrong, and the resident said look at this while pointing to her pants. CNA W then looked at the resident's pants from behind because resident was in the walkway to the nurse's station and CNA W could not get around the wheelchair. CNA W then leaned over resident's shoulder to look and her chest caused the resident to move slightly forward. The resident then yelled, Don't hit me. CNA W said, I did not hit you and then went back to her assignment. CNA V then took Resident #2 back to the dining room for lunch and came to the front office. Investigation findings were unconfirmed. An in-service was conducted regarding abuse prevention and awareness as well as communicating with residents. Review of the facility's in-service records revealed on 12/19/18 an in-service was conducted on Abuse/Neglect and Communication. The in-service record did not reflect CNA W participated in the in-service. Review of CNA W's employee file did not reflect any documentation of suspension on 12/19/18 related to the allegations made by CNA V. Review of CNA W's time card reflected she worked on 12/20/18 and 12/21/18 on the 6 AM to 2 PM shift. The Kiosk system showed CNA W provided care to residents on 12/21/18. Review of facility's daily sign in sheet for 12/21/18 revealed CNA W signed in showing she worked. Review of Resident #2's quarterly MDS assessment dated [DATE] reflected she had [DIAGNOSES REDACTED]. Resident #2 was severely cognitively impaired in daily decision making. She was extensive to total dependent in ADLs. In an interview on 08/01/19 at 12:20 PM CNA V stated on 12/19/18 she took Resident #2 out of the dining room during lunch due to yelling and screaming. She stated Resident #2 was upsetting the other residents so she pushed her in the wheelchair back to the nursing station. She stated she asked CNA W to ask Resident #2 what she wanted. She stated CNA W asked Resident #2 what she wanted and then she hit her in the back of the head. She stated Resident #2 screamed oh you hit me. She stated CNA W walked away. She stated she reported it to the Administrator, but CNA W was not suspended and returned back to work. She stated other staff had made reports about CNA W in the past but nothing had been done. When asked for details, CNA V would not respond. In an interview on 08/01/19 at 2:02 PM CNA W stated another CNA asked her to talk to Resident #2 who was brought to the nurse's station, so she did. She stated Resident #2 was pointing to her pants and said look at this. She stated the way Resident #2's wheelchair was positioned prevented her from going around to face Resident #2 so she leaned over the back of Resident #2 since she could not get around her since Resident #2 was blocking the entrance of nurse's station. She stated she could have pushed Resident #2 forward a little when she was trying to look at the resident's lap. She stated Resident #2 said she hit her. She stated she told Resident #2 that she did not hit her. She stated she walked away from Resident #2 and the other CN[NAME] She stated she went back to working on the hall to assist with passing out trays. She stated she was sent home on 12/19/18 and suspended for two days pending investigation by the Previous Administrator. In interviews on 08/01/19 at 1:44 PM and on 08/02/19 at 10:18 AM the Social Worker stated CNA V reported she witnessed CNA W hit Resident #2 on 12/19/18. She stated the Previous Administrator told CNA W she was suspended pending investigation and would be called once the investigation was completed. She stated her and the Administrator interviewed CNA W together and CNA W denied any abuse. CNA W stated she had leaned over Resident #2 to find out what Resident #2 was pointing to. The Social Worker stated she completed the provider investigation report, but was told the findings by the Administrator or the DON as being unconfirmed. She stated at one time she had looked up what each of the findings meant but could not recall specifically what it meant. She stated she was told by the Administrator or DON that CNA W was suspended pending investigation. She stated she sent to the Provider Investigation Report to the state on 12/26/19, but she did not know when investigation was actually completed. She stated she initially reported the allegations of abuse and neglect to the state with the previous Administration. She was not aware the abuse coordinator was supposed to complete the provider investigation reports and to report the allegation to the state initially. The Social Worker stated CNA W was working today on the 6 AM to 2 PM shift. In an interview on 08/02/19 at 10:45 AM the Interim Administrator stated she was not aware the Social Worker completed the provider investigation report on Resident #2 for the incident on 12/19/18. She stated it was the Administrator's responsibility as the Abuse Coordinator to complete the Provider Investigation Report, but the Social Worker might have been delegated to complete it. Review of the facility's policy Abuse - Reportable Events revised 01/2018 reflected the responsibility of all facility staff to prohibit resident abuse or neglect in any form, and to report in accordance with the law any incident/event in which there is cause to believe a resident's physical or mental health or welfare has been or may be adversely affected by abuse or neglect caused by another person. The policy defines Abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Physical abuse included but not limited to, hitting, slapping, punching, and kicking. Under investigation .the abuse coordinator will review all aspects of the investigation as soon as possible, ensure that all reports are complete and appropriate authorities have been notified, complete the investigation and direct any disciplinary action required, complete the state provider investigation report (5 day report), review corrective action(s), inform the resident or his/her representative of the findings of the investigation and corrective action taken. Under protection .a. All residents will be immediately protected from harm An Immediate Jeopardy was identified on 07/31/19. The Interim Administrator, Social Worker, ADON B, MDS Coordinator and Administrator in training were notified of the Immediate Jeopardy on 07/31/19 at 6:30 pm and provided the IJ template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/03/19 at 8:21 AM and reflected the following: 1. The facility will ensure all residents are free from abuse/neglect and exploitation. All staff will be educated on policies of abuse/neglect, exploitation and how to handle difficult residents and will complete a post-test following the in-service. PRN employees and Employees that are on vacation, or any employee who misses the in-service for whatever reason will be in-serviced prior to start of the next shift. No employee will be allowed to work until all in-services have been completed. Completion date- 8/5/2019 2. All residents who were provided care by this alleged perpetrator have the potential to be affected by this alleged deficient practice. 3. Immediate Action: The alleged perpetrator was suspended on 07/31/19 and was terminated on the morning of 8-1-19. The managers/department heads were in-serviced by the administrator on new procedure of using the Resident Safe Survey Questionnaire weekly and reporting their finding at the morning meeting. On 08/01/19 the questionnaire was used to interview all residents. Those residents that are unable to answer question have been assessed for unusual bruising or any signs of mistreatment. All concerns have been reported to the administrator for follow up. Medical Director- Spoke with Medical Director at 8:26 am on 08/01/19 and had a QA meeting he is in agreement with Plan of Removal 4. EDUCATION [NAME] All facility staff (all staff/all departments: Administrator, DON, ADON, licensed nurses, certified nursing assistants, dietary, housekeeping, laundry, activity director, social worker, maintenance) are being in-serviced on Abuse - Reportable Events Policy attached to include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents The Administrator has assigned department managers to conduct the in-services. The in-services will continue each shift to ensure all staff have been educated on Abuse - Reportable Events Policy attached. Validation of understanding will be accomplished by administering a post test. Initiated: 07/31/19 Completion date: 08/05/19 The Administrator thoroughly reinvestigated the incidents that occurred. Employees who were determined to have not responded appropriately and per facility policy have been appropriately disciplined by the Administrator to include: Alleged Perpetrator #1 was suspended on 07/31/19 and terminated on 08/01/19 Initiated: 7/31/19 Completion date: 8/1/19 The self-report dated 12/19/2018 involving alleged Perpetrator #2 continues to be reinvestigated and the final disposition will be made 08/03/19. Perpetrator #2 was suspended on 08/01/19 pending investigation. B. All department heads have been in-serviced by the Administrator on a Resident Safe Survey Questionnaire. Please see policy that was revised by administrator initiated on 07/31/19. Residents who are unable to respond to safe survey questionnaire will be assessed by licensed nurse for signs of abuse/neglect. The abuse policy has been revised by the administrator to include the safe survey questionnaire on 8/2/2019 Initiated: 7/31/19 Completion date: 8/2/19 C. Facility will conduct a QA meeting on 8/1/19 to review the Plan of Removal, including the new policy for reviewing Safe Survey questionnaire revised by the administrator. Initiated: 7/31/19 Completion date: 8/1/19 D. All newly hired staff (licensed nurses, certified nurses assistants, medication aides, dietary, housekeeping, laundry, activity director, business office manager, social worker, maintenance, and dept heads), will be in-serviced on Freedom from Abuse/Neglect and Exploitation which will include: Abuse Definitions Freedom from Abuse Abuse Prevention Resident Rights Reporting Abuse Abuse Coordinator How to handle difficult residents Grievance process Employees will be in-serviced by the Administrator/ designee prior to working their first shift. Validation of understanding will be accomplished by administering a post test. Initiated: 8/1/19 Completion date: Ongoing 5. MONITOR [NAME] To ensure that all concerns/grievances are investigated and appropriately reported, Resident Safe Survey Questionnaires will be reviewed as well as any concerns brought up at the Morning Meeting. The Administrator will make a determination as to the need for follow up and investigation. The Administrator will begin an investigation immediately after the morning meeting to determine if further follow up or action is required. Initiated: 8/1/19 Completion date: Ongoing B. Facility Administrator will in-service all staff on grievance policy and procedure. Administrator to ensure concern forms are available and staff is aware of location. Initiated: 8/1/2019 Completion date: Ongoing C. After completion of investigation, the decision to return or not to return the alleged perpetrator to work will be reviewed by the ADM, DON, RDO, and RNC . Initiated: 8/1/19 Completion date: Ongoing D. Facility will continue in-service/education on Freedom from Abuse/Neglect and Exploitation as scheduled throughout the year and as needed. A post-test will be used for validation of understanding. Initiated: 7/31/2019 Completion date: Ongoing E. Facility will continue to report concerns and abuse allegations/investigations to the QA meeting monthly. Facility Administrator will review grievance log to ensure no potential abuse or neglect allegations are present that the facility failed to follow up on. Initiated and Completed: 8/1/2019 7. When an allegation of abuse or neglect is made, the facility administrator is responsible for all aspects of the investigation and follow up. The abuse policy has been revised by the Administrator to include: Protect the resident by immediately suspending any and all alleged perpetrators pending outcome of investigation The administrator will ensure the nurse head to toe assessment of the resident Interview the resident including description of events Interview any potential witnesses including other staff, visitors or residents Follow the new policy for safe surveys Review the medical record and care plan Review the employee file Report any allegation of abuse or neglect to HHSC following the guidelines outlined in the provider letter 19-17 Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents That A Nursing Facility Must Report to the Health and Human Services Commission (HHSC) Depending on outcome of the investigation, following steps may include: in servicing on specific topic, disciplinary action up to and including termination; or other actions as needed. The Social Services Director's only involvement will include Safe Surveys, or other secondary tasks as directed by the administrator. Social Services director in-serviced on her role in investigations on 8/2/2019. 8. The administrator reviewed all grievances and concern forms dating back to (MONTH) (YEAR) with the Social Services Director and in-serviced the Social Services Director on the process for completion and follow up on grievances and concern forms to include response to all grievances on 08/01/19. Any concerns noted by the administrator will be followed up on by 08/03/19. The facility's implementation of the Plan of Removal was verified through the following: Interviews on 08/03/19 with facility department heads (Activity Director, ADON B, BOM, Housekeeping/Laundry Manager, ADON A/Wound Nurse, Dietary Manager, Social Worker and MDS Coordinator C) revealed all were able to discuss types of abuse/neglect, knew to report any allegations of abuse/neglect/misappropriation immediately to the Administrator, who was the abuse coordinator, and the grievance process. The Social Worker knew her role was to report any allegation of abuse/neglect/misappropriation of property to the Administrator who was the abuse coordinator. The Social Worker stated she was to only do resident safe survey rounds. Interviews were conducted on 08/03/19 starting at 12:18 PM and continued through 08/05/19 with RN P, RN Q, LVN R, LVN S, and LVN T, regarding in-services which included freedom from abuse/neglect/misappropriation of property facility policy, reporting guidelines, how to deal with difficult residents, and grievance process. The staff members were able to: discuss types of abuse/neglect/misappropriation of property of residents, reporting guidelines, Administrator was the abuse coordinator, grievance process and approaches to use with difficult residents. Interviews were conducted on 08/03/19 through 08/05/19 with CNAs G, H, I, J, K, L and M, from all shifts, regarding in-services which included freedom from abuse/negl

Based on interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice, the comprehensive person-centered care plan, and choices for 42 of 42 (Residents #1 through #42) residents reviewed for infections. The facility failed to intervene and further prevent the spread of suspected norovirus by failing to following CDC guidelines: - proper hand hygiene - implement and maintain contact precautions for residents with gastrointestinal symptoms, residents with the infection remained in rooms with non sick residents - perform proper cleaning and decontamination of infected rooms - follow infection control procedures for laundry - have a system in place to evaluate employees returning to work (after calling in sick with nausea, vomiting and diarrhea. As a result, the facility experienced an outbreak of suspected norovirus beginning on 01/17/19 and affected up to 42 residents and 31 staff to date. An Immediate Jeopardy was identified on 01/25/19. While the Immediate Jeopardy was removed on 01/31/19, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration. Findings Included: 1. Review of line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected on 01/17/19, Resident #1 had symptoms of diarrhea and vomiting on the 10 pm to 6 am shift. Resident #2 had symptoms of diarrhea, vomiting and nausea with onset at 12:00 PM on 01/17/19. Both residents were on the secure unit. 2. Review of Resident #1's MDS quarterly assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse note dated 01/17/19 at 7:00 AM reflected, CNA reported that 10-6 CNA reported resident had vomited and diarrhea. Resident currently with loose stool. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was given report at the beginning of her shift from the night shift CNA that Resident #1 had vomiting and diarrhea overnight, but the night shift CNA did not tell the nurse. CNA I said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 01/29/19 at 11:40 AM with LVN O revealed the CNA (CNA I) on morning shift on 01/17/19 reported to her the CNA from the 10 PM to 6 AM shift had reported Resident #1 had diarrhea and vomiting along with loose stool on the night shift. She stated Resident #1 had no other symptoms since that incident. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #2's nurse's note dated 01/17/19 at 9:45 AM reflected, upon returning from break CNA reported resident vomited x1 .complained of stomach cramping, and at 12:00 PM, resident ate few bites at lunch then vomited. Removed from dining room cleaned up then placed in bed due to resident request. Resident placed on side HOB (head of bed) elevated. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was working on 01/17/19 on the 6 AM to 2 PM shift on the secure unit. She stated Resident #2 vomited in the common area after breakfast and told the nurse. She stated she took Resident #2 to the shower room to clean him up and give him a shower. She stated she cleaned the floor of the common area where he vomited with sanitizing wipes (not approved by CDC for norovirus). She stated at lunch, Resident #2 was sitting with Residents #5 and #32 at a table in the dining room of the secure unit. She stated Resident #2 had eaten a few bites of his lunch, which was a regular diet and then vomited. She stated the vomit was on him and on his plate. She stated the other aide cleaned up the table and took Residents #5 and #32's plates. She stated Resident #2 was taken back to his room. She stated Residents #5 and #32 were given new plates of food and were put back at the same table after the aide cleaned the table and got a new table cloth for the table. She stated Resident #2 had a roommate and stayed in the room with their roommate. Interview on 01/29/19 at 11:40 AM with LVN O revealed on 01/17/19 when she came back from break, she was told by the CNA I that Resident #2 had vomited. She stated Resident #2 was in the bathroom when she saw him and had a large, soft stool. She stated at lunch he was in the dining room and had a regular diet. She stated Resident #2 vomited after eating a few bites of food. She stated the vomit was on his plate and the table. She stated two other residents were eating with Resident #2. She stated one CNA took Resident #2 to go clean him up and another CNA cleaned up the table and got the other residents at the table new food after the table had been cleaned. She stated the two residents were put back at the table after it was cleaned up. She stated Resident #2 was put on a clear liquid diet after he vomited the second time. 3. Review of line listing revealed on 01/18/19 Resident #3 (on the secure unit) had vomiting and fever. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected she was an 81-year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She was incontinent of bowel and bladder. Review of Resident #3's nurse's note dated 01/18/19 at 6:25 PM revealed Resident #3 had emesis (vomiting), very large, volume estimated at 150 mL, yellow in color, mixed with some remnant of food. Ate poorly at dinner prior to emesis. Temperature 98.3 degrees .New order clear liquid diet x 24 hours and BRAT diet x 48 hours. Nursing continues to monitor. At 7:25 PM family member, son informed of the vomiting and the new order. Review of Resident #3's telephone order dated 01/18/19 reflected Resident #3 on clear liquid diet x 24 hours, BRAT diet x 48 hours due to vomiting (emesis x2). 4. Review of line listing revealed on 01/19/19 Resident #4 had symptoms of diarrhea and vomiting with onset between 1:30 to 7:30 PM. Resident #5 had nausea and vomiting with onset at 11:00 PM. Both Resident #4 and #5 were on the secure unit. Resident #6 (not on secure unit) had symptoms of diarrhea and vomiting. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was severely cognitively impaired. Review of Resident #5's nurse's note dated 01/18/19 at 11:00 PM revealed Resident #5 approached the nurse's station and reported vomiting. Emesis (vomiting) was witnessed in the resident's bathroom toilet. The resident denied continued nausea. There were no other documented episodes or new doctor orders. Review of Resident #6's nurse's note dated 01/20/19 at 7:30 AM revealed Resident #6 had emesis (vomiting) x2 and loose stools. There were no further episodes after 01/20/19. A Physician order [REDACTED].#6 was on a clear liquid diet, then BRAT diet due to emesis and loose stools. Review of Resident #6's line listing revealed on 01/20/19 Resident #7, Resident #8, Resident #9 and Resident #10 also had stomach virus symptoms. Resident #7 had symptoms of diarrhea and vomiting with onset at 6:30 AM. Resident #8 had symptoms of nausea on during the 10 PM to 6 AM shift. Resident #9 had diarrhea and vomiting. Resident #10 had diarrhea. 5. Review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was a 68-year- old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurse's note dated 01/20/19 at 8:00 AM revealed the resident reported emesis (vomiting) x 1 and loose stool. Vital signs were within normal limits. A new physician order [REDACTED]. Review of Resident #10's nurse's note dated 01/23/19 at 10:00 AM revealed an episode of diarrhea. A new order for a stat CBC/CMP and BRAT diet for 24 hours was received. Resident #10's nurse's note dated 01/23/19 at 3:15 PM revealed lab results returned CMP within normal limits. CBC had abnormal WBC of 10.8 9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). A new order for stool culture/parasite/[MEDICAL CONDITIONS] stat was obtained and family was notified. Resident #10's nurse's note dated 01/23/19 at 9:00 PM and on 01/24/19 at 2:30 AM revealed Resident #10's stool was not collected for stat order as the resident had no bowel movement. Review of Resident #10's nurse's note dated 01/24/19 at 10:10 AM revealed stool collected via collection vessel. No foul odor was noted; brown in color. The lab was notified for STAT pick up of sample. Review of Resident #10's stool culture lab collected 01/24/19 and results dated 01/26/19 reflected the resident was negative for salmonella, shigella, pathogenic e coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #10 had no lab test for norovirus. 6. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was incontinent of bowel and bladder. Review of Resident #17's nurse's note dated 01/20/19 at 2:30 PM revealed the resident began vomiting and experiencing loose stools. Vital signs were within normal limits. A new physician's orders [REDACTED]. The resident was cleaned in the shower room and taken to his bedroom. Bed rest was encouraged due to resident's statement, I feel a little weak. Review of Resident #17's SBAR communication form dated 01/21/19 reflected Resident #17 was lethargic, pale in color, and had vomiting and diarrhea. Resident #17's symptoms of nausea, vomiting and diarrhea started on 01/20/19 and resident continued to get weaker. The resident's daughter was concerned about his condition due to possible dehydration. Resident #17 was sent to the local hospital to evaluate and treat. Resident #17 returned to the facility from the hospital. Interview on 01/31/19 at 2:20 PM with CNA J revealed on 01/19/19 Resident #18 had large diarrhea stools. CNA J changed Resident #17 the first time about 10:30 AM in the shower room and it got on his pants, so he had to go home and change clothes. He stated at lunch time after 12:00 PM, Resident #18 had a second large episode of diarrhea. He stated Resident #18 was cleaned up with sanitizing wipes and the CNA cleaned the shower room with those wipes as well (sanitizing wipes not approved by CDC for norovirus). He bagged Resident #18's soiled clothes and put them in the soiled linen bin (not in biohazard bag). He stated on 01/19/19, Resident #25 also had multiple episodes of diarrhea and he informed the nurse. He stated he was feeling nauseous on his shift on 01/20/19 about 11:00 AM and stated Resident #18 was having symptoms at this time, too. He stated he knew he could not help Resident #17 because he felt nauseous and had an upset stomach. CNA J stated he started having vomiting and diarrhea about 11:00 AM or noon and informed the nurse immediately, but he could not leave until a replacement came due to staffing needs. He stated he did not have direct contact with residents after he vomited and had diarrhea. He was on the couch in the room at the end of the hall on hall 200 where it's a small common area for the residents. He stated he clocked out about 3:00 PM on 01/20/19. He stated he went to the emergency roiagnom on [DATE] and was dehydrated and given fluids. He stated his diarrhea lasted until 01/23/19 in the morning. Review of CNA J's timecard reflected on 01/20/19 he left at 3:08 PM. He returned to work on 01/24/19 at 9:37 am (was not symptom free of diarrhea for 48 hours before returning to work). Interview on 01/30/19 at 10:15 AM with the Weekend RN Supervisor revealed CNA J started having GI symptoms of nausea and vomiting on 01/20/19 and was not able to finish his shift. She stated Resident #18 had vomiting and diarrhea on 01/20/19 as well. She stated the residents were only on standard precautions and not contact isolation. She stated she thought it was, just a stomach bug going around, but had no idea it would turn into an outbreak. 7. Review of line listing on 01/21/19 Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 and Resident #18 had symptoms of vomiting and diarrhea. Resident #11 had diarrhea and nausea with onset on during the 10 PM to 6 AM shift. Resident #12 and Resident #14, Resident #15 and Resident #16 had vomiting. Resident #13 had diarrhea with onset at 12:00 PM on 01/21/19. Resident #18 had diarrhea and lethargy. Review of Resident #11's (roommate of Resident #3) annual MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's CMP dated 01/23/19 reflected his WBC count was 13.9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). Resident #11's stool culture results dated 01/25/19 revealed the resident was negative for salmonella, shigella, pathogenic e. coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #11 had no lab test for norovirus. Review of Resident #18's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's nurse's note dated 01/21/19 at 9:00 PM revealed Resident #18 was, having difficulty walking her leg appears to be giving out while standing having to assist with transfers. She is unable to walk this evening. A nurse's note dated 01/22/19 at 5:00 AM revealed Resident #17, had diarrhea x2. Continue to monitor. Review of Resident #18's SBAR communication form dated 01/22/19 reflected Resident #18 was lethargic, confused, had slurred speech, decreased appetite, diarrhea, nausea and vomiting. Resident #18 had emesis (vomiting) that morning and had loose stools starting 01/21/19 at 9:00 PM. There was no emesis that shift but continued to have loose stools all day. Her blood sugar was 137 at 4:00 PM and her 70 units of [MEDICATION NAME] was held. The nurse rechecked her blood sugar at 8:20 PM and obtained a reading of 114. The resident drank part of her soda at dinner and did not eat her broth. Staff was able to have the resident drink a little water that day. The family and physician was notified of changes. Resident #18 was sent to emergency room . Review of Resident #18's hospital records dated 01/23/19 at 12:00 AM reflected Resident #18 was admitted to the local hospital on [DATE] for altered mental status. Resident #18 was discharged from the local hospital on [DATE] and back to the facility. 8. Review of line listing on 01/22/19 Residents #19 and #20 had diarrhea. Residents #21 had vomiting and loss of appetite with onset at 7:00 AM. Resident #22 had diarrhea and vomiting with onset at 5:00 PM. Review of Resident #21's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's nurse's note dated 01/22/19 reflected the resident had vomit x1, clear liquid diet well tolerated. At 8:00 PM the resident had one episode of diarrhea. The 10 PM to 6 AM nurse notated at 3:30 AM that Resident #21 had an episode of vomiting and loose stool. Review of Resident #21's telephone physician order [REDACTED]. 9. Review of line listing on 01/23/19 Resident #23 had diarrhea and vomiting with onset at 6:30 AM. Resident #24 had diarrhea, nausea and vomiting with onset at 8:00 AM. Resident #25 had diarrhea and vomiting. Resident #10 had diarrhea. 10. Review of line listing on 01/24/19 Resident #26 had diarrhea, vomiting, nausea and loss of appetite with onset at 4:30 AM. Resident #27 had vomiting and loss of appetite with onset at 5:00 AM. Resident #28 had nausea and vomiting with onset at 12:00 PM. Residents #28, #29, #30 and #31 had diarrhea. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #26's nurse's note dated 01/24/19 at 4:30 AM reflected, .resident has had loose stools x2 and 1 episode of vomiting. Clear liquid diet x 24 hours; then BRAT diet x 24 hours; then resume previous diet as tolerated. The nurse's notes revealed no other episodes of vomiting or diarrhea. 11. Observation on 01/25/19 at 5:36 PM revealed Resident #31 and #26 were sitting in the dining room eating. Both residents were in the dining room with other residents who were non-symptomatic. Review of Resident #31's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's nurse's note dated 01/24/19 at 10:00 AM revealed Resident #31 had a loose stool that morning. At 2:30 PM a new order was received for clear liquid diet x 24 hours, then BRAT diet x 48 hours and then resume regular diet as tolerated. Resident #31 also had another loose stool. 12. Interview on 01/25/19 at 5:30 PM with RN M revealed she had the stomach bug on 01/23/19 with vomiting, and came back to work on 01/24/19 having had no symptoms since 01/23/19. She stated Resident #31 had diarrhea yesterday (01/24/19) on her shift but she was not aware of Resident #31 having any current symptoms. She stated Resident #31 was put on a clear liquid diet yesterday as well. Review of RN M's timesheet revealed she returned to work on 01/24/19 at 2:07 PM (not symptom free of vomiting for 48 hours per CDC guidelines). She did not work on 01/23/19. 13. Review of line listing on 01/25/19 Residents #32, #33, #34 and #35 had diarrhea. Resident #21 also had diarrhea. Review of Resident #21's nurse's note dated 01/25/19 reflected Resident #21 had diarrhea stool noted at the beginning of the10 PM to 6 AM shift. Resident sipping on (electrolyte sports drink). Staff states resident had diarrhea on 2 to 10 pm shift with complaint of abdominal pain voiced. 2:00 am resident had large loose stool x 1 and complaint of abdominal pain. Review of Resident #21's telephone physician order [REDACTED]. Review of Resident #21's telephone physician order [REDACTED]. (no symptoms for 48 hours) Interview on 01/25/19 at 7:10 PM with CNA F revealed Resident #35 had just vomited in her room and the CNA was going to clean it up. now. She stated Resident #35 had vomited before supper or she would have been in the dining room with the other residents. She stated she cleaned the vomit up using the purple sanitizing wipes used the sanitizing wipes to clean the surfaces where the vomit was. She cleaned up the resident. She stated they used standard precautions on the residents with any symptoms of the stomach virus. Review of Resident #35's nurse's note dated 01/25/19 reflected at 6:40 PM Resident #35, vomited x 1 in moderate amount, temperature 99.6 degrees. Review of Resident #35's physician order [REDACTED]. 14. Interview on 01/27/19 at 11:16 AM with CNA F revealed she had symptoms of diarrhea and nausea on 01/24/19 and returned to work on 01/25/19 for her 2 PM to 10 PM shift. She said her last episode of diarrhea was about 3:00 PM on 01/24/19. She stated they had an in-serviced about standard precautions and hand hygiene. She stated they could utilize handwashing or hand sanitizer when providing care to residents including residents with GI symptoms. Interview on 01/30/19 at 2:05 PM with RN W revealed she worked on 01/22/19 on the 6 AM to 2 PM shift. She stated that evening around 5 - 6 PM she felt a little nauseated before vomiting 3 - 4 times. She had frequent diarrhea about 5 - 6 times before bed. She called into work sick on 01/23/19 when symptoms of vomiting continued, twice, and she had three episodes of diarrhea. She called in sick on 01/24/19 with symptoms of continuing of vomiting in the morning and two episodes of diarrhea during the day. She returned to work on 01/25/19 and had two to three episodes of diarrhea at work. She told management she was feeling sick but did not tell them she was having diarrhea. 15. Review of the Intake Incident Worksheet # 0 reflected the State Survey Agency was notified of the illness outbreak on 01/23/19 at 3:06 PM (5 days later 01/18/19 after 3 residents had gastrointestinal symptoms) by the Social Worker. [MEDICAL CONDITION] infection had affected approximately 20 residents who had vomiting and diarrhea at that time, along with 11 staff who also had the [MEDICAL CONDITION] symptoms. The building was on a 24-hour quarantine until new residents did not show symptoms. The CDC Guideline for Norovirus, updated 06/01/18 retrieved on 01/26/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having direct contact with an infected person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not use hand sanitizer as a substitute for washing your hands with soap and water. Hand sanitizers aren't as effective as washing hands with soap and water at removing norovirus particles. You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in long-term care facilities where they may expose people to norovirus. You are most contagious when you have symptoms of norovirus illness, especially vomiting and during the first few days after you recover from norovirus illness. In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: .Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection .Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus .Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Remove and wash contaminated clothing or linens .Healthcare workers who have symptoms consistent with norovirus should be excluded from work .After someone vomits or has diarrhea, always thoroughly clean and disinfect the entire area immediately. Put on rubber or disposable gloves, and wipe the entire area with paper towels, then disinfect the area using a bleach-based household cleaner as directed on the product label. Leave the bleach disinfectant on the affected area for at least five minutes then clean the entire area again with soap and hot water. Finish by cleaning soiled laundry, taking out the trash, and washing your hands. You should use a chlorine bleach solution with a concentration of 1000 to 5000 ppm (5 to 25 tablespoons of household bleach (5% to 8%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA). Immediately remove and wash clothes or linens that may be contaminated with vomit or stool. You should handle soiled items carefully without agitating them, wear rubber or disposable gloves while handling soiled items and wash your hands after . and wash the items with detergent and hot water at the maximum available cycle length then machine dry them at the highest heat setting. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. 16. Interview on 01/29/19 at 3:54 PM with the local health department official revealed they were notified by the facility on 01/24/19 of residents and employees having a GI outbreak. He was told they had symptoms of diarrhea and vomiting. He provided the facility with a line listing template to complete for the residents, and the facility sent the completed form back to them on Thursday afternoon. He was told they were not isolating the residents but trying to keep the residents in their rooms. He told them the symptoms sounded like the norovirus and recommended the facility to test for the norovirus. He stated the local health department followed the CDC guidelines. Review of local health department official's email to Admin dated 01/25/19 at 11:16 am reflected the chief epidemiologist at the local health department .wants to wait through the weekend to see if there is an increase or decrease in cases throughout the facility before we make a visit. If you could keep us updated as cases pop up that would be greatly appreciated! Interview on 01/25/19 at 8:42 AM with ADON L revealed on 01/23/19 when the DON and other employees called in sick, they realized there was something going around. She stated she was responsible for the infection control books but had not updated it them in the last 10 days. She was not aware they had an outbreak. Interviews on 01/25/19 at 5:45 PM and 8:18 PM with the DON revealed the local health department had mentioned the illness in the facility could be the Norovirus. She stated they were using standard precautions including gloves, handwashing and sanitizing when providing care to residents. She stated they had cleaned the handrails in the facility and disinfected resident rooms. She stated she called in sick on 01/23/19 and had two episodes of vomiting between 3:00 AM to 7:00 AM, with the last episode at 7:00 AM on 01/23/19. She stated she returned to work on 01/24/19 at about 8:00 AM with no symptoms and was feeling better. She stated they did not become aware until Monday morning of residents having GI symptoms when they reviewed the 24-hour reports for over the weekend that a few residents had been sick during the weekend. She said they were not aware they had [MEDICAL CONDITION] going around. She stated she initiated verbal cues to staff for hand hygiene on Monday (01/21/19). She stated on Wednesday when she called in along with other employees, they realized they had more cases and it was spreading. She stated they could not separate residents with symptoms because they had no open resident rooms. She stated a couple of the residents who were tested were negative for [MEDICAL CONDITION] but had not tested for norovirus. She stated they had no idea where it was going to pop up next. She stated she had not looked up about the norovirus. Interview on 01/25/19 at 8:51 PM with the Admin revealed the facility in-serviced on 01/22/19 and 01/23/19 on hand hygiene. She stated they were following standard precautions and were unable to move residents since they had no unoccupied rooms. She stated more employees started calling in on Tuesday evening and Wednesday. She stated the local health department on 01/24/19 told them the gastrointestinal symptoms sounded like the norovirus, and in the afternoon had provided the local health department of the resident line listing. She stated the local health department was going to wait until 01/28/19 to monitor and see how it went over the weekend. She stated she asked employees when they returned if they felt better and did not ask them about their gastrointestinal symptoms. She had not read the CDC guidelines and was going by what the local health department. She encouraged employees to go to the doctor, but she could not make them go. She stated there were no changes made to laundry or disinfecting the rooms. Review of facility in-services reflected: Standard Precautions (instead of contact isolation per CDC guidelines) started 01/22/19 (01/18/19 had 3 residents with gastrointestinal symptoms0 Meal service and infection control for dietary staff - 01/23/19 17. Review of the employee line listing reflected 25 employees had called in sick with symptoms of diarrhea, nausea, vomiting and/or loss of appetite with start date of 01/19/19 to 01/25/19. Review of facility's policy Abuse - Reportable events revised (MONTH) (YEAR) reflected the definition of Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. Review of facility's policy Infection Control - Standard Precautions revised (MONTH) 2012 reflected staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. Under procedure .3. Hands: Hands shall be washed immediately and thoroughly if contaminated with blood or other bodily fluids. Hands shall be washed between each change of gloves. 4. Gowns: Gowns or aprons shall be worn if soiling with blood or body fluids is likely. Review of facility's policy Infection Control - Precautions - Categories and Notices revised date of (MONTH) (YEAR) reflected 4. In addition to standard precautions, contact precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or patient-care items in the resident's environment. A. Examples of infections requiring contact prec

Based on observations, interviews and record reviews, the facility failed to implement written policies and procedures to prevent neglect for forty-two residents (Residents #1 through #42) of forty-two residents review for neglect. The facility failed to intervene and further prevent the spread of suspected norovirus by failing to following CDC guidelines: - proper hand hygiene - implement and maintain contact precautions for residents with gastrointestinal symptoms, residents with the infection remained in rooms with non sick residents - perform proper cleaning and decontamination of infected rooms - follow infection control procedures for laundry - have a system in place to evaluate employees returning to work (after calling in sick with nausea, vomiting and diarrhea. As a result, the facility experienced an outbreak of suspected norovirus beginning on 01/17/19 and affected up to 42 residents and 31 staff to date. An Immediate Jeopardy was identified on 01/25/19. While the Immediate Jeopardy was removed on 01/31/19, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration. Findings Included: 1. Review of facility's policy Abuse - Reportable events revised (MONTH) (YEAR) reflected the definition of Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. Review of facility's policy Infection Control - Standard Precautions revised (MONTH) 2012 reflected staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. Under procedure .3. Hands: Hands shall be washed immediately and thoroughly if contaminated with blood or other bodily fluids. Hands shall be washed between each change of gloves. 4. Gowns: Gowns or aprons shall be worn if soiling with blood or body fluids is likely. Review of facility's policy Infection Control - Precautions - Categories and Notices revised date of (MONTH) (YEAR) reflected 4. In addition to standard precautions, contact precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or patient-care items in the resident's environment. A. Examples of infections requiring contact precautions include, but are not limited to: gastrointestinal infections or colonization with multidrug resistant bacteria .e. Signs - signs will be used to alert staff of the implementation of isolation precautions, while protecting the privacy of the resident. A sign instructing 'Please report to the nurses station before entering' should be placed at the doorway. Review of facility's policy Infection Control - Cleaning and Disinfecting Resident Care Items and Equipment revised (MONTH) 2012 reflected to clean and disinfect resident-care equipment including reusable items and durable medical equipment according to current CDC recommendations for disinfection . Review of facility's policy Linen handling revised (MONTH) 2012 reflected the staff will handle linens in a manner to prevent the spread of infection. Laundry that is deemed contaminated or at potential for contamination will be treated as follows: .2. Contaminated laundry shall be bagged or contained at the location where it was used .4. Contaminated laundry will be bagged in linen bags designated and recognized as bags for contaminated linen .6. Employees will wear a protective gown and gloves when handling contaminated linen. 7. Contaminated laundry will be washed according to the recommendations of the Centers for Disease Control. Review of line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected on 01/17/19, Resident #1 had symptoms of diarrhea and vomiting on the 10 pm to 6 am shift. Resident #2 had symptoms of diarrhea, vomiting and nausea with onset at 12:00 PM on 01/17/19. Both residents were on the secure unit. 2. Review of Resident #1's MDS quarterly assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse note dated 01/17/19 at 7:00 AM reflected, CNA reported that 10-6 CNA reported resident had vomited and diarrhea. Resident currently with loose stool. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was given report at the beginning of her shift from the night shift CNA that Resident #1 had vomiting and diarrhea overnight, but the night shift CNA did not tell the nurse. CNA I said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 01/29/19 at 11:40 AM with LVN O revealed the CNA (CNA I) on morning shift on 01/17/19 reported to her the CNA from the 10 PM to 6 AM shift had reported Resident #1 had diarrhea and vomiting along with loose stool on the night shift. She stated Resident #1 had no other symptoms since that incident. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #2's nurse's note dated 01/17/19 at 9:45 AM reflected, upon returning from break CNA reported resident vomited x1 .complained of stomach cramping, and at 12:00 PM, resident ate few bites at lunch then vomited. Removed from dining room cleaned up then placed in bed due to resident request. Resident placed on side HOB (head of bed) elevated. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was working on 01/17/19 on the 6 AM to 2 PM shift on the secure unit. She stated Resident #2 vomited in the common area after breakfast and told the nurse. She stated she took Resident #2 to the shower room to clean him up and give him a shower. She stated she cleaned the floor of the common area where he vomited with sanitizing wipes (not approved by CDC for norovirus). She stated at lunch, Resident #2 was sitting with Residents #5 and #32 at a table in the dining room of the secure unit. She stated Resident #2 had eaten a few bites of his lunch, which was a regular diet and then vomited. She stated the vomit was on him and on his plate. She stated the other aide cleaned up the table and took Residents #5 and #32's plates. She stated Resident #2 was taken back to his room. She stated Residents #5 and #32 were given new plates of food and were put back at the same table after the aide cleaned the table and got a new table cloth for the table. She stated Resident #2 had a roommate and stayed in the room with their roommate. Interview on 01/29/19 at 11:40 AM with LVN O revealed on 01/17/19 when she came back from break, she was told by the CNA I that Resident #2 had vomited. She stated Resident #2 was in the bathroom when she saw him and had a large, soft stool. She stated at lunch he was in the dining room and had a regular diet. She stated Resident #2 vomited after eating a few bites of food. She stated the vomit was on his plate and the table. She stated two other residents were eating with Resident #2. She stated one CNA took Resident #2 to go clean him up and another CNA cleaned up the table and got the other residents at the table new food after the table had been cleaned. She stated the two residents were put back at the table after it was cleaned up. She stated Resident #2 was put on a clear liquid diet after he vomited the second time. 3. Review of line listing revealed on 01/18/19 Resident #3 (on the secure unit) had vomiting and fever. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected she was an 81-year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She was incontinent of bowel and bladder. Review of Resident #3's nurse's note dated 01/18/19 at 6:25 PM revealed Resident #3 had emesis (vomiting), very large, volume estimated at 150 mL, yellow in color, mixed with some remnant of food. Ate poorly at dinner prior to emesis. Temperature 98.3 degrees .New order clear liquid diet x 24 hours and BRAT diet x 48 hours. Nursing continues to monitor. At 7:25 PM family member, son informed of the vomiting and the new order. Review of Resident #3's telephone order dated 01/18/19 reflected Resident #3 on clear liquid diet x 24 hours, BRAT diet x 48 hours due to vomiting (emesis x2). 4. Review of line listing revealed on 01/19/19 Resident #4 had symptoms of diarrhea and vomiting with onset between 1:30 to 7:30 PM. Resident #5 had nausea and vomiting with onset at 11:00 PM. Both Resident #4 and #5 were on the secure unit. Resident #6 (not on secure unit) had symptoms of diarrhea and vomiting. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was severely cognitively impaired. Review of Resident #5's nurse's note dated 01/18/19 at 11:00 PM revealed Resident #5 approached the nurse's station and reported vomiting. Emesis (vomiting) was witnessed in the resident's bathroom toilet. The resident denied continued nausea. There were no other documented episodes or new doctor orders. Review of Resident #6's nurse's note dated 01/20/19 at 7:30 AM revealed Resident #6 had emesis (vomiting) x2 and loose stools. There were no further episodes after 01/20/19. A Physician order [REDACTED].#6 was on a clear liquid diet, then BRAT diet due to emesis and loose stools. Review of Resident #6's line listing revealed on 01/20/19 Resident #7, Resident #8, Resident #9 and Resident #10 also had stomach virus symptoms. Resident #7 had symptoms of diarrhea and vomiting with onset at 6:30 AM. Resident #8 had symptoms of nausea on during the 10 PM to 6 AM shift. Resident #9 had diarrhea and vomiting. Resident #10 had diarrhea. 5. Review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was a 68-year- old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurse's note dated 01/20/19 at 8:00 AM revealed the resident reported emesis (vomiting) x 1 and loose stool. Vital signs were within normal limits. A new physician order [REDACTED]. Review of Resident #10's nurse's note dated 01/23/19 at 10:00 AM revealed an episode of diarrhea. A new order for a stat CBC/CMP and BRAT diet for 24 hours was received. Resident #10's nurse's note dated 01/23/19 at 3:15 PM revealed lab results returned CMP within normal limits. CBC had abnormal WBC of 10.8 9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). A new order for stool culture/parasite/[MEDICAL CONDITIONS] stat was obtained and family was notified. Resident #10's nurse's note dated 01/23/19 at 9:00 PM and on 01/24/19 at 2:30 AM revealed Resident #10's stool was not collected for stat order as the resident had no bowel movement. Review of Resident #10's nurse's note dated 01/24/19 at 10:10 AM revealed stool collected via collection vessel. No foul odor was noted; brown in color. The lab was notified for STAT pick up of sample. Review of Resident #10's stool culture lab collected 01/24/19 and results dated 01/26/19 reflected the resident was negative for salmonella, shigella, pathogenic e coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #10 had no lab test for norovirus. 6. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was incontinent of bowel and bladder. Review of Resident #17's nurse's note dated 01/20/19 at 2:30 PM revealed the resident began vomiting and experiencing loose stools. Vital signs were within normal limits. A new physician's orders [REDACTED]. The resident was cleaned in the shower room and taken to his bedroom. Bed rest was encouraged due to resident's statement, I feel a little weak. Review of Resident #17's SBAR communication form dated 01/21/19 reflected Resident #17 was lethargic, pale in color, and had vomiting and diarrhea. Resident #17's symptoms of nausea, vomiting and diarrhea started on 01/20/19 and resident continued to get weaker. The resident's daughter was concerned about his condition due to possible dehydration. Resident #17 was sent to the local hospital to evaluate and treat. Resident #17 returned to the facility from the hospital. Interview on 01/31/19 at 2:20 PM with CNA J revealed on 01/19/19 Resident #18 had large diarrhea stools. CNA J changed Resident #17 the first time about 10:30 AM in the shower room and it got on his pants, so he had to go home and change clothes. He stated at lunch time after 12:00 PM, Resident #18 had a second large episode of diarrhea. He stated Resident #18 was cleaned up with sanitizing wipes and the CNA cleaned the shower room with those wipes as well (sanitizing wipes not approved by CDC for norovirus). He bagged Resident #18's soiled clothes and put them in the soiled linen bin (not in biohazard bag). He stated on 01/19/19, Resident #25 also had multiple episodes of diarrhea and he informed the nurse. He stated he was feeling nauseous on his shift on 01/20/19 about 11:00 AM and stated Resident #18 was having symptoms at this time, too. He stated he knew he could not help Resident #17 because he felt nauseous and had an upset stomach. CNA J stated he started having vomiting and diarrhea about 11:00 AM or noon and informed the nurse immediately, but he could not leave until a replacement came due to staffing needs. He stated he did not have direct contact with residents after he vomited and had diarrhea. He was on the couch in the room at the end of the hall on hall 200 where it's a small common area for the residents. He stated he clocked out about 3:00 PM on 01/20/19. He stated he went to the emergency roiagnom on [DATE] and was dehydrated and given fluids. He stated his diarrhea lasted until 01/23/19 in the morning. Review of CNA J's timecard reflected on 01/20/19 he left at 3:08 PM. He returned to work on 01/24/19 at 9:37 am (was not symptom free of diarrhea for 48 hours before returning to work). Interview on 01/30/19 at 10:15 AM with the Weekend RN Supervisor revealed CNA J started having GI symptoms of nausea and vomiting on 01/20/19 and was not able to finish his shift. She stated Resident #18 had vomiting and diarrhea on 01/20/19 as well. She stated the residents were only on standard precautions and not contact isolation. She stated she thought it was, just a stomach bug going around, but had no idea it would turn into an outbreak. 7. Review of line listing on 01/21/19 Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 and Resident #18 had symptoms of vomiting and diarrhea. Resident #11 had diarrhea and nausea with onset on during the 10 PM to 6 AM shift. Resident #12 and Resident #14, Resident #15 and Resident #16 had vomiting. Resident #13 had diarrhea with onset at 12:00 PM on 01/21/19. Resident #18 had diarrhea and lethargy. Review of Resident #11's (roommate of Resident #3) annual MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's CMP dated 01/23/19 reflected his WBC count was 13.9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). Resident #11's stool culture results dated 01/25/19 revealed the resident was negative for salmonella, shigella, pathogenic e. coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #11 had no lab test for norovirus. Review of Resident #18's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's nurse's note dated 01/21/19 at 9:00 PM revealed Resident #18 was, having difficulty walking her leg appears to be giving out while standing having to assist with transfers. She is unable to walk this evening. A nurse's note dated 01/22/19 at 5:00 AM revealed Resident #17, had diarrhea x2. Continue to monitor. Review of Resident #18's SBAR communication form dated 01/22/19 reflected Resident #18 was lethargic, confused, had slurred speech, decreased appetite, diarrhea, nausea and vomiting. Resident #18 had emesis (vomiting) that morning and had loose stools starting 01/21/19 at 9:00 PM. There was no emesis that shift but continued to have loose stools all day. Her blood sugar was 137 at 4:00 PM and her 70 units of [MEDICATION NAME] was held. The nurse rechecked her blood sugar at 8:20 PM and obtained a reading of 114. The resident drank part of her soda at dinner and did not eat her broth. Staff was able to have the resident drink a little water that day. The family and physician was notified of changes. Resident #18 was sent to emergency room . Review of Resident #18's hospital records dated 01/23/19 at 12:00 AM reflected Resident #18 was admitted to the local hospital on [DATE] for altered mental status. Resident #18 was discharged from the local hospital on [DATE] and back to the facility. 8. Review of line listing on 01/22/19 Residents #19 and #20 had diarrhea. Residents #21 had vomiting and loss of appetite with onset at 7:00 AM. Resident #22 had diarrhea and vomiting with onset at 5:00 PM. Review of Resident #21's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's nurse's note dated 01/22/19 reflected the resident had vomit x1, clear liquid diet well tolerated. At 8:00 PM the resident had one episode of diarrhea. The 10 PM to 6 AM nurse notated at 3:30 AM that Resident #21 had an episode of vomiting and loose stool. Review of Resident #21's telephone physician order [REDACTED]. 9. Review of line listing on 01/23/19 Resident #23 had diarrhea and vomiting with onset at 6:30 AM. Resident #24 had diarrhea, nausea and vomiting with onset at 8:00 AM. Resident #25 had diarrhea and vomiting. Resident #10 had diarrhea. 10. Review of line listing on 01/24/19 Resident #26 had diarrhea, vomiting, nausea and loss of appetite with onset at 4:30 AM. Resident #27 had vomiting and loss of appetite with onset at 5:00 AM. Resident #28 had nausea and vomiting with onset at 12:00 PM. Residents #28, #29, #30 and #31 had diarrhea. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #26's nurse's note dated 01/24/19 at 4:30 AM reflected, .resident has had loose stools x2 and 1 episode of vomiting. Clear liquid diet x 24 hours; then BRAT diet x 24 hours; then resume previous diet as tolerated. The nurse's notes revealed no other episodes of vomiting or diarrhea. 11. Observation on 01/25/19 at 5:36 PM revealed Resident #31 and #26 were sitting in the dining room eating. Both residents were in the dining room with other residents who were non-symptomatic. Review of Resident #31's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's nurse's note dated 01/24/19 at 10:00 AM revealed Resident #31 had a loose stool that morning. At 2:30 PM a new order was received for clear liquid diet x 24 hours, then BRAT diet x 48 hours and then resume regular diet as tolerated. Resident #31 also had another loose stool. 12. Interview on 01/25/19 at 5:30 PM with RN M revealed she had the stomach bug on 01/23/19 with vomiting, and came back to work on 01/24/19 having had no symptoms since 01/23/19. She stated Resident #31 had diarrhea yesterday (01/24/19) on her shift but she was not aware of Resident #31 having any current symptoms. She stated Resident #31 was put on a clear liquid diet yesterday as well. Review of RN M's timesheet revealed she returned to work on 01/24/19 at 2:07 PM (not symptom free of vomiting for 48 hours per CDC guidelines). She did not work on 01/23/19. 13. Review of line listing on 01/25/19 Residents #32, #33, #34 and #35 had diarrhea. Resident #21 also had diarrhea. Review of Resident #21's nurse's note dated 01/25/19 reflected Resident #21 had diarrhea stool noted at the beginning of the10 PM to 6 AM shift. Resident sipping on (electrolyte sports drink). Staff states resident had diarrhea on 2 to 10 pm shift with complaint of abdominal pain voiced. 2:00 am resident had large loose stool x 1 and complaint of abdominal pain. Review of Resident #21's telephone physician order [REDACTED]. Review of Resident #21's telephone physician order [REDACTED]. (no symptoms for 48 hours) Interview on 01/25/19 at 7:10 PM with CNA F revealed Resident #35 had just vomited in her room and the CNA was going to clean it up. now. She stated Resident #35 had vomited before supper or she would have been in the dining room with the other residents. She stated she cleaned the vomit up using the purple sanitizing wipes used the sanitizing wipes to clean the surfaces where the vomit was. She cleaned up the resident. She stated they used standard precautions on the residents with any symptoms of the stomach virus. Review of Resident #35's nurse's note dated 01/25/19 reflected at 6:40 PM Resident #35, vomited x 1 in moderate amount, temperature 99.6 degrees. Review of Resident #35's physician order [REDACTED]. 14. Interview on 01/27/19 at 11:16 AM with CNA F revealed she had symptoms of diarrhea and nausea on 01/24/19 and returned to work on 01/25/19 for her 2 PM to 10 PM shift. She said her last episode of diarrhea was about 3:00 PM on 01/24/19. She stated they had an in-serviced about standard precautions and hand hygiene. She stated they could utilize handwashing or hand sanitizer when providing care to residents including residents with GI symptoms. Interview on 01/30/19 at 2:05 PM with RN W revealed she worked on 01/22/19 on the 6 AM to 2 PM shift. She stated that evening around 5 - 6 PM she felt a little nauseated before vomiting 3 - 4 times. She had frequent diarrhea about 5 - 6 times before bed. She called into work sick on 01/23/19 when symptoms of vomiting continued, twice, and she had three episodes of diarrhea. She called in sick on 01/24/19 with symptoms of continuing of vomiting in the morning and two episodes of diarrhea during the day. She returned to work on 01/25/19 and had two to three episodes of diarrhea at work. She told management she was feeling sick but did not tell them she was having diarrhea. 15. Review of the Intake Incident Worksheet # 0 reflected the State Survey Agency was notified of the illness outbreak on 01/23/19 at 3:06 PM (5 days later 01/18/19 after 3 residents had gastrointestinal symptoms) by the Social Worker. [MEDICAL CONDITION] infection had affected approximately 20 residents who had vomiting and diarrhea at that time, along with 11 staff who also had the [MEDICAL CONDITION] symptoms. The building was on a 24-hour quarantine until new residents did not show symptoms. The CDC Guideline for Norovirus, updated 06/01/18 retrieved on 01/26/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having direct contact with an infected person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not use hand sanitizer as a substitute for washing your hands with soap and water. Hand sanitizers aren't as effective as washing hands with soap and water at removing norovirus particles. You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in long-term care facilities where they may expose people to norovirus. You are most contagious when you have symptoms of norovirus illness, especially vomiting and during the first few days after you recover from norovirus illness. In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: .Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection .Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus .Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Remove and wash contaminated clothing or linens .Healthcare workers who have symptoms consistent with norovirus should be excluded from work .After someone vomits or has diarrhea, always thoroughly clean and disinfect the entire area immediately. Put on rubber or disposable gloves, and wipe the entire area with paper towels, then disinfect the area using a bleach-based household cleaner as directed on the product label. Leave the bleach disinfectant on the affected area for at least five minutes then clean the entire area again with soap and hot water. Finish by cleaning soiled laundry, taking out the trash, and washing your hands. You should use a chlorine bleach solution with a concentration of 1000 to 5000 ppm (5 to 25 tablespoons of household bleach (5% to 8%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA). Immediately remove and wash clothes or linens that may be contaminated with vomit or stool. You should handle soiled items carefully without agitating them, wear rubber or disposable gloves while handling soiled items and wash your hands after . and wash the items with detergent and hot water at the maximum available cycle length then machine dry them at the highest heat setting. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. 16. Interview on 01/29/19 at 3:54 PM with the local health department official revealed they were notified by the facility on 01/24/19 of residents and employees having a GI outbreak. He was told they had symptoms of diarrhea and vomiting. He provided the facility with a line listing template to complete for the residents, and the facility sent the completed form back to them on Thursday afternoon. He was told they were not isolating the residents but trying to keep the residents in their rooms. He told them the symptoms sounded like the norovirus and recommended the facility to test for the norovirus. He stated the local health department followed the CDC guidelines. Review of local health department official's email to Admin dated 01/25/19 at 11:16 am reflected the chief epidemiologist at the local health department .wants to wait through the weekend to see if there is an increase or decrease in cases throughout the facility before we make a visit. If you could keep us updated as cases pop up that would be greatly appreciated! Interview on 01/25/19 at 8:42 AM with ADON L revealed on 01/23/19 when the DON and other employees called in sick, they realized there was something going around. She stated she was responsible for the infection control books but had not updated it them in the last 10 days. She was not aware they had an outbreak. Interviews on 01/25/19 at 5:45 PM and 8:18 PM with the DON revealed the local health department had mentioned the illness in the facility could be the Norovirus. She stated they were using standard precautions including gloves, handwashing and sanitizing when providing care to residents. She stated they had cleaned the handrails in the facility and disinfected resident rooms. She stated she called in sick on 01/23/19 and had two episodes of vomiting between 3:00 AM to 7:00 AM, with the last episode at 7:00 AM on 01/23/19. She stated she returned to work on 01/24/19 at about 8:00 AM with no symptoms and was feeling better. She stated they did not become aware until Monday morning of residents having GI symptoms when they reviewed the 24-hour reports for over the weekend that a few residents had been sick during the weekend. She said they were not aware they had [MEDICAL CONDITION] going around. She stated she initiated verbal cues to staff for hand hygiene on Monday (01/21/19). She stated on Wednesday when she called in along with other employees, they realized they had more cases and it was spreading. She stated they could not separate residents with symptoms because they had no open resident rooms. She stated a couple of the residents who were tested were negative for [MEDICAL CONDITION] but had not tested for norovirus. She stated they had no idea where it was going to pop up next. She stated she had not looked up about the norovirus. Interview on 01/25/19 at 8:51 PM with the Admin revealed the facility in-serviced on 01/22/19 and 01/23/19 on hand hygiene. She stated they were following standard precautions and were unable to move residents since they

Based on observation, interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently and to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 42 (Residents #1 through #42) of 42 residents and 31 of 31 employees reviewed for a communicable disease outbreak. 1. The Admin and DON failed to intervene and prevent the spread of suspected norovirus and facilitate the implementation of CDC guidelines in a timely manner. 2. The Admin and DON failed to notify the state until and local health department until 01/23/19 after the facility had 25 residents with current or had history of gastrointestinal symptoms from 01/17/19 to 01/23/19. 3. The Admin and DON failed to in-service facility staff on CDC guidelines and implement these CDC guidelines to prevent the spread of infection. 4. ADON L, the infection control nurse, failed to keep up-to-date infection tracking records which resulted in a delay in the identification of a widespread GI illness (norovirus) amongst residents and staff. As a result, the facility experienced an outbreak of suspected norovirus beginning on 01/17/19 and affected up to 42 residents and 31 staff to date. An Immediate Jeopardy was identified on 01/25/19. While the Immediate Jeopardy was removed on 01/31/19, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration. Findings Included: 1. Review of line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected on 01/17/19, Resident #1 had symptoms of diarrhea and vomiting on the 10 pm to 6 am shift. Resident #2 had symptoms of diarrhea, vomiting and nausea with onset at 12:00 PM on 01/17/19. Both residents were on the secure unit. 2. Review of Resident #1's MDS quarterly assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse note dated 01/17/19 at 7:00 AM reflected, CNA reported that 10-6 CNA reported resident had vomited and diarrhea. Resident currently with loose stool. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was given report at the beginning of her shift from the night shift CNA that Resident #1 had vomiting and diarrhea overnight, but the night shift CNA did not tell the nurse. CNA I said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 01/29/19 at 11:40 AM with LVN O revealed the CNA (CNA I) on morning shift on 01/17/19 reported to her the CNA from the 10 PM to 6 AM shift had reported Resident #1 had diarrhea and vomiting along with loose stool on the night shift. She stated Resident #1 had no other symptoms since that incident. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #2's nurse's note dated 01/17/19 at 9:45 AM reflected, upon returning from break CNA reported resident vomited x1 .complained of stomach cramping, and at 12:00 PM, resident ate few bites at lunch then vomited. Removed from dining room cleaned up then placed in bed due to resident request. Resident placed on side HOB (head of bed) elevated. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was working on 01/17/19 on the 6 AM to 2 PM shift on the secure unit. She stated Resident #2 vomited in the common area after breakfast and told the nurse. She stated she took Resident #2 to the shower room to clean him up and give him a shower. She stated she cleaned the floor of the common area where he vomited with sanitizing wipes (not approved by CDC for norovirus). She stated at lunch, Resident #2 was sitting with Residents #5 and #32 at a table in the dining room of the secure unit. She stated Resident #2 had eaten a few bites of his lunch, which was a regular diet and then vomited. She stated the vomit was on him and on his plate. She stated the other aide cleaned up the table and took Residents #5 and #32's plates. She stated Resident #2 was taken back to his room. She stated Residents #5 and #32 were given new plates of food and were put back at the same table after the aide cleaned the table and got a new table cloth for the table. She stated Resident #2 had a roommate and stayed in the room with their roommate. Interview on 01/29/19 at 11:40 AM with LVN O revealed on 01/17/19 when she came back from break, she was told by the CNA I that Resident #2 had vomited. She stated Resident #2 was in the bathroom when she saw him and had a large, soft stool. She stated at lunch he was in the dining room and had a regular diet. She stated Resident #2 vomited after eating a few bites of food. She stated the vomit was on his plate and the table. She stated two other residents were eating with Resident #2. She stated one CNA took Resident #2 to go clean him up and another CNA cleaned up the table and got the other residents at the table new food after the table had been cleaned. She stated the two residents were put back at the table after it was cleaned up. She stated Resident #2 was put on a clear liquid diet after he vomited the second time. 3. Review of line listing revealed on 01/18/19 Resident #3 (on the secure unit) had vomiting and fever. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected she was an 81-year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She was incontinent of bowel and bladder. Review of Resident #3's nurse's note dated 01/18/19 at 6:25 PM revealed Resident #3 had emesis (vomiting), very large, volume estimated at 150 mL, yellow in color, mixed with some remnant of food. Ate poorly at dinner prior to emesis. Temperature 98.3 degrees .New order clear liquid diet x 24 hours and BRAT diet x 48 hours. Nursing continues to monitor. At 7:25 PM family member, son informed of the vomiting and the new order. Review of Resident #3's telephone order dated 01/18/19 reflected Resident #3 on clear liquid diet x 24 hours, BRAT diet x 48 hours due to vomiting (emesis x2). 4. Review of line listing revealed on 01/19/19 Resident #4 had symptoms of diarrhea and vomiting with onset between 1:30 to 7:30 PM. Resident #5 had nausea and vomiting with onset at 11:00 PM. Both Resident #4 and #5 were on the secure unit. Resident #6 (not on secure unit) had symptoms of diarrhea and vomiting. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was severely cognitively impaired. Review of Resident #5's nurse's note dated 01/18/19 at 11:00 PM revealed Resident #5 approached the nurse's station and reported vomiting. Emesis (vomiting) was witnessed in the resident's bathroom toilet. The resident denied continued nausea. There were no other documented episodes or new doctor orders. Review of Resident #6's nurse's note dated 01/20/19 at 7:30 AM revealed Resident #6 had emesis (vomiting) x2 and loose stools. There were no further episodes after 01/20/19. A Physician order [REDACTED].#6 was on a clear liquid diet, then BRAT diet due to emesis and loose stools. Review of Resident #6's line listing revealed on 01/20/19 Resident #7, Resident #8, Resident #9 and Resident #10 also had stomach virus symptoms. Resident #7 had symptoms of diarrhea and vomiting with onset at 6:30 AM. Resident #8 had symptoms of nausea on during the 10 PM to 6 AM shift. Resident #9 had diarrhea and vomiting. Resident #10 had diarrhea. 5. Review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was a 68-year- old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurse's note dated 01/20/19 at 8:00 AM revealed the resident reported emesis (vomiting) x 1 and loose stool. Vital signs were within normal limits. A new physician order [REDACTED]. Review of Resident #10's nurse's note dated 01/23/19 at 10:00 AM revealed an episode of diarrhea. A new order for a stat CBC/CMP and BRAT diet for 24 hours was received. Resident #10's nurse's note dated 01/23/19 at 3:15 PM revealed lab results returned CMP within normal limits. CBC had abnormal WBC of 10.8 9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). A new order for stool culture/parasite/[MEDICAL CONDITIONS] stat was obtained and family was notified. Resident #10's nurse's note dated 01/23/19 at 9:00 PM and on 01/24/19 at 2:30 AM revealed Resident #10's stool was not collected for stat order as the resident had no bowel movement. Review of Resident #10's nurse's note dated 01/24/19 at 10:10 AM revealed stool collected via collection vessel. No foul odor was noted; brown in color. The lab was notified for STAT pick up of sample. Review of Resident #10's stool culture lab collected 01/24/19 and results dated 01/26/19 reflected the resident was negative for salmonella, shigella, pathogenic e coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #10 had no lab test for norovirus. 6. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was incontinent of bowel and bladder. Review of Resident #17's nurse's note dated 01/20/19 at 2:30 PM revealed the resident began vomiting and experiencing loose stools. Vital signs were within normal limits. A new physician's orders [REDACTED]. The resident was cleaned in the shower room and taken to his bedroom. Bed rest was encouraged due to resident's statement, I feel a little weak. Review of Resident #17's SBAR communication form dated 01/21/19 reflected Resident #17 was lethargic, pale in color, and had vomiting and diarrhea. Resident #17's symptoms of nausea, vomiting and diarrhea started on 01/20/19 and resident continued to get weaker. The resident's daughter was concerned about his condition due to possible dehydration. Resident #17 was sent to the local hospital to evaluate and treat. Resident #17 returned to the facility from the hospital. Interview on 01/31/19 at 2:20 PM with CNA J revealed on 01/19/19 Resident #18 had large diarrhea stools. CNA J changed Resident #17 the first time about 10:30 AM in the shower room and it got on his pants, so he had to go home and change clothes. He stated at lunch time after 12:00 PM, Resident #18 had a second large episode of diarrhea. He stated Resident #18 was cleaned up with sanitizing wipes and the CNA cleaned the shower room with those wipes as well (sanitizing wipes not approved by CDC for norovirus). He bagged Resident #18's soiled clothes and put them in the soiled linen bin (not in biohazard bag). He stated on 01/19/19, Resident #25 also had multiple episodes of diarrhea and he informed the nurse. He stated he was feeling nauseous on his shift on 01/20/19 about 11:00 AM and stated Resident #18 was having symptoms at this time, too. He stated he knew he could not help Resident #17 because he felt nauseous and had an upset stomach. CNA J stated he started having vomiting and diarrhea about 11:00 AM or noon and informed the nurse immediately, but he could not leave until a replacement came due to staffing needs. He stated he did not have direct contact with residents after he vomited and had diarrhea. He was on the couch in the room at the end of the hall on hall 200 where it's a small common area for the residents. He stated he clocked out about 3:00 PM on 01/20/19. He stated he went to the emergency roiagnom on [DATE] and was dehydrated and given fluids. He stated his diarrhea lasted until 01/23/19 in the morning. Review of CNA J's timecard reflected on 01/20/19 he left at 3:08 PM. He returned to work on 01/24/19 at 9:37 am (was not symptom free of diarrhea for 48 hours before returning to work). Interview on 01/30/19 at 10:15 AM with the Weekend RN Supervisor revealed CNA J started having GI symptoms of nausea and vomiting on 01/20/19 and was not able to finish his shift. She stated Resident #18 had vomiting and diarrhea on 01/20/19 as well. She stated the residents were only on standard precautions and not contact isolation. She stated she thought it was, just a stomach bug going around, but had no idea it would turn into an outbreak. 7. Review of line listing on 01/21/19 Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 and Resident #18 had symptoms of vomiting and diarrhea. Resident #11 had diarrhea and nausea with onset on during the 10 PM to 6 AM shift. Resident #12 and Resident #14, Resident #15 and Resident #16 had vomiting. Resident #13 had diarrhea with onset at 12:00 PM on 01/21/19. Resident #18 had diarrhea and lethargy. Review of Resident #11's (roommate of Resident #3) annual MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's CMP dated 01/23/19 reflected his WBC count was 13.9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). Resident #11's stool culture results dated 01/25/19 revealed the resident was negative for salmonella, shigella, pathogenic e. coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #11 had no lab test for norovirus. Review of Resident #18's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's nurse's note dated 01/21/19 at 9:00 PM revealed Resident #18 was, having difficulty walking her leg appears to be giving out while standing having to assist with transfers. She is unable to walk this evening. A nurse's note dated 01/22/19 at 5:00 AM revealed Resident #17, had diarrhea x2. Continue to monitor. Review of Resident #18's SBAR communication form dated 01/22/19 reflected Resident #18 was lethargic, confused, had slurred speech, decreased appetite, diarrhea, nausea and vomiting. Resident #18 had emesis (vomiting) that morning and had loose stools starting 01/21/19 at 9:00 PM. There was no emesis that shift but continued to have loose stools all day. Her blood sugar was 137 at 4:00 PM and her 70 units of [MEDICATION NAME] was held. The nurse rechecked her blood sugar at 8:20 PM and obtained a reading of 114. The resident drank part of her soda at dinner and did not eat her broth. Staff was able to have the resident drink a little water that day. The family and physician was notified of changes. Resident #18 was sent to emergency room . Review of Resident #18's hospital records dated 01/23/19 at 12:00 AM reflected Resident #18 was admitted to the local hospital on [DATE] for altered mental status. Resident #18 was discharged from the local hospital on [DATE] and back to the facility. 8. Review of line listing on 01/22/19 Residents #19 and #20 had diarrhea. Residents #21 had vomiting and loss of appetite with onset at 7:00 AM. Resident #22 had diarrhea and vomiting with onset at 5:00 PM. Review of Resident #21's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's nurse's note dated 01/22/19 reflected the resident had vomit x1, clear liquid diet well tolerated. At 8:00 PM the resident had one episode of diarrhea. The 10 PM to 6 AM nurse notated at 3:30 AM that Resident #21 had an episode of vomiting and loose stool. Review of Resident #21's telephone physician order [REDACTED]. 9. Review of line listing on 01/23/19 Resident #23 had diarrhea and vomiting with onset at 6:30 AM. Resident #24 had diarrhea, nausea and vomiting with onset at 8:00 AM. Resident #25 had diarrhea and vomiting. Resident #10 had diarrhea. 10. Review of line listing on 01/24/19 Resident #26 had diarrhea, vomiting, nausea and loss of appetite with onset at 4:30 AM. Resident #27 had vomiting and loss of appetite with onset at 5:00 AM. Resident #28 had nausea and vomiting with onset at 12:00 PM. Residents #28, #29, #30 and #31 had diarrhea. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #26's nurse's note dated 01/24/19 at 4:30 AM reflected, .resident has had loose stools x2 and 1 episode of vomiting. Clear liquid diet x 24 hours; then BRAT diet x 24 hours; then resume previous diet as tolerated. The nurse's notes revealed no other episodes of vomiting or diarrhea. 11. Observation on 01/25/19 at 5:36 PM revealed Resident #31 and #26 were sitting in the dining room eating. Both residents were in the dining room with other residents who were non-symptomatic. Review of Resident #31's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's nurse's note dated 01/24/19 at 10:00 AM revealed Resident #31 had a loose stool that morning. At 2:30 PM a new order was received for clear liquid diet x 24 hours, then BRAT diet x 48 hours and then resume regular diet as tolerated. Resident #31 also had another loose stool. 12. Interview on 01/25/19 at 5:30 PM with RN M revealed she had the stomach bug on 01/23/19 with vomiting, and came back to work on 01/24/19 having had no symptoms since 01/23/19. She stated Resident #31 had diarrhea yesterday (01/24/19) on her shift but she was not aware of Resident #31 having any current symptoms. She stated Resident #31 was put on a clear liquid diet yesterday as well. Review of RN M's timesheet revealed she returned to work on 01/24/19 at 2:07 PM (not symptom free of vomiting for 48 hours per CDC guidelines). She did not work on 01/23/19. 13. Review of line listing on 01/25/19 Residents #32, #33, #34 and #35 had diarrhea. Resident #21 also had diarrhea. Review of Resident #21's nurse's note dated 01/25/19 reflected Resident #21 had diarrhea stool noted at the beginning of the10 PM to 6 AM shift. Resident sipping on (electrolyte sports drink). Staff states resident had diarrhea on 2 to 10 pm shift with complaint of abdominal pain voiced. 2:00 am resident had large loose stool x 1 and complaint of abdominal pain. Review of Resident #21's telephone physician order [REDACTED]. Review of Resident #21's telephone physician order [REDACTED]. (no symptoms for 48 hours) Interview on 01/25/19 at 7:10 PM with CNA F revealed Resident #35 had just vomited in her room and the CNA was going to clean it up. now. She stated Resident #35 had vomited before supper or she would have been in the dining room with the other residents. She stated she cleaned the vomit up using the purple sanitizing wipes used the sanitizing wipes to clean the surfaces where the vomit was. She cleaned up the resident. She stated they used standard precautions on the residents with any symptoms of the stomach virus. Review of Resident #35's nurse's note dated 01/25/19 reflected at 6:40 PM Resident #35, vomited x 1 in moderate amount, temperature 99.6 degrees. Review of Resident #35's physician order [REDACTED]. 14. Interview on 01/27/19 at 11:16 AM with CNA F revealed she had symptoms of diarrhea and nausea on 01/24/19 and returned to work on 01/25/19 for her 2 PM to 10 PM shift. She said her last episode of diarrhea was about 3:00 PM on 01/24/19. She stated they had an in-serviced about standard precautions and hand hygiene. She stated they could utilize handwashing or hand sanitizer when providing care to residents including residents with GI symptoms. Interview on 01/30/19 at 2:05 PM with RN W revealed she worked on 01/22/19 on the 6 AM to 2 PM shift. She stated that evening around 5 - 6 PM she felt a little nauseated before vomiting 3 - 4 times. She had frequent diarrhea about 5 - 6 times before bed. She called into work sick on 01/23/19 when symptoms of vomiting continued, twice, and she had three episodes of diarrhea. She called in sick on 01/24/19 with symptoms of continuing of vomiting in the morning and two episodes of diarrhea during the day. She returned to work on 01/25/19 and had two to three episodes of diarrhea at work. She told management she was feeling sick but did not tell them she was having diarrhea. 15. Review of the Intake Incident Worksheet # 0 reflected the State Survey Agency was notified of the illness outbreak on 01/23/19 at 3:06 PM (5 days later 01/18/19 after 3 residents had gastrointestinal symptoms) by the Social Worker. [MEDICAL CONDITION] infection had affected approximately 20 residents who had vomiting and diarrhea at that time, along with 11 staff who also had the [MEDICAL CONDITION] symptoms. The building was on a 24-hour quarantine until new residents did not show symptoms. The CDC Guideline for Norovirus, updated 06/01/18 retrieved on 01/26/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having direct contact with an infected person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not use hand sanitizer as a substitute for washing your hands with soap and water. Hand sanitizers aren't as effective as washing hands with soap and water at removing norovirus particles. You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in long-term care facilities where they may expose people to norovirus. You are most contagious when you have symptoms of norovirus illness, especially vomiting and during the first few days after you recover from norovirus illness. In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: .Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection .Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus .Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Remove and wash contaminated clothing or linens .Healthcare workers who have symptoms consistent with norovirus should be excluded from work .After someone vomits or has diarrhea, always thoroughly clean and disinfect the entire area immediately. Put on rubber or disposable gloves, and wipe the entire area with paper towels, then disinfect the area using a bleach-based household cleaner as directed on the product label. Leave the bleach disinfectant on the affected area for at least five minutes then clean the entire area again with soap and hot water. Finish by cleaning soiled laundry, taking out the trash, and washing your hands. You should use a chlorine bleach solution with a concentration of 1000 to 5000 ppm (5 to 25 tablespoons of household bleach (5% to 8%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA). Immediately remove and wash clothes or linens that may be contaminated with vomit or stool. You should handle soiled items carefully without agitating them, wear rubber or disposable gloves while handling soiled items and wash your hands after . and wash the items with detergent and hot water at the maximum available cycle length then machine dry them at the highest heat setting. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. 16. Interview on 01/29/19 at 3:54 PM with the local health department official revealed they were notified by the facility on 01/24/19 of residents and employees having a GI outbreak. He was told they had symptoms of diarrhea and vomiting. He provided the facility with a line listing template to complete for the residents, and the facility sent the completed form back to them on Thursday afternoon. He was told they were not isolating the residents but trying to keep the residents in their rooms. He told them the symptoms sounded like the norovirus and recommended the facility to test for the norovirus. He stated the local health department followed the CDC guidelines. Review of local health department official's email to Admin dated 01/25/19 at 11:16 am reflected the chief epidemiologist at the local health department .wants to wait through the weekend to see if there is an increase or decrease in cases throughout the facility before we make a visit. If you could keep us updated as cases pop up that would be greatly appreciated! Interview on 01/25/19 at 8:42 AM with ADON L revealed on 01/23/19 when the DON and other employees called in sick, they realized there was something going around. She stated she was responsible for the infection control books but had not updated it them in the last 10 days. She was not aware they had an outbreak. Interviews on 01/25/19 at 5:45 PM and 8:18 PM with the DON revealed the local health department had mentioned the illness in the facility could be the Norovirus. She stated they were using standard precautions including gloves, handwashing and sanitizing when providing care to residents. She stated they had cleaned the handrails in the facility and disinfected resident rooms. She stated she called in sick on 01/23/19 and had two episodes of vomiting between 3:00 AM to 7:00 AM, with the last episode at 7:00 AM on 01/23/19. She stated she returned to work on 01/24/19 at about 8:00 AM with no symptoms and was feeling better. She stated they did not become aware until Monday morning of residents having GI symptoms when they reviewed the 24-hour reports for over the weekend that a few residents had been sick during the weekend. She said they were not aware they had [MEDICAL CONDITION] going around. She stated she initiated verbal cues to staff for hand hygiene on Monday (01/21/19). She stated on Wednesday when she called in along with other employees, they realized they had more cases and it was spreading. She stated they could not separate residents with symptoms because they had no open resident rooms. She stated a couple of the residents who were tested were negative for [MEDICAL CONDITION] but had not tested for norovirus. She stated they had no idea where it was going to pop up next. She stated she had not looked up about the norovirus. Interview on 01/25/19 at 8:51 PM with the Admin revealed the facility in-serviced on 01/22/19 and 01/23/19 on hand hygiene. She stated they were following standard precautions and were unable to move residents since they had no unoccupied rooms. She stated more employees started calling in on Tuesday evening and Wednesday. She stated the local health department on 01/24/19 told them the gastrointestinal symptoms sounded like the norovirus, and in the afternoon had provided the local health department of the resident line listing. She stated the local health department was going to wait until 01/28/19 to monitor and see how it went over the weekend. She stated she asked employees when they returned if they felt better and did not ask them about their gastrointestinal symptoms. She had not read the CDC guidelines and was going by what the local health department. She encouraged employees to go to the doctor, but she could not make them go. She stated there were no changes made to laundry or disinfecting the rooms. Review of facility in-services reflected: Standard Precautions (instead of contact isolation per CDC guidelines) started 01/22/19 (01/18/19 had 3 residents with gastrointestinal symptoms0 Meal service and infection control for dietary staff - 01/23/19 17. Review of the employee line listing reflected 25 employees had called in sick with symptoms of diarrhea, nausea, vomiting and/or loss of appetite with start date of 01/19/19 to 01/25/19. Review of facility's policy Abuse - Reportable events revised (MONTH) (YEAR) reflected the definition of Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. Review of facility's policy Infection Control - Standard Precautions revised (MONTH) 2012 reflected staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. Under procedure .3. Hands: Hands shall be washed immediately and thoroughly if contaminated with blood or other bodily fluids. Hands shall be washed between each change of gloves. 4. Gowns: Gowns or aprons shall be worn if soiling with blood or body fluids is likely. Review of facility's policy Infection Control - Precautions - Categories and Notices revised date of (MONTH) (YEAR) reflected 4. In addition to standard precautions, contact precautions must be implemented for residents known or suspecte

Based on observations, interviews and record reviews, the facility failed to ensure that residents were free from neglect for forty-two residents (Residents #1 through #42) of forty-two residents reviewed for neglect. The facility failed to intervene and further prevent the spread of suspected norovirus by failing to following CDC guidelines: - proper hand hygiene - implement and maintain contact precautions for residents with gastrointestinal symptoms, residents with the infection remained in rooms with non sick residents - perform proper cleaning and decontamination of infected rooms - follow infection control procedures for laundry - have a system in place to evaluate employees returning to work (after calling in sick with nausea, vomiting and diarrhea. As a result, the facility experienced an outbreak of suspected norovirus beginning on 01/17/19 and affected up to 42 residents and 31 staff to date. An Immediate Jeopardy was identified on 01/25/19. While the Immediate Jeopardy was removed on 01/31/19, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration. Findings Included: 1. Review of line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected on 01/17/19, Resident #1 had symptoms of diarrhea and vomiting on the 10 pm to 6 am shift. Resident #2 had symptoms of diarrhea, vomiting and nausea with onset at 12:00 PM on 01/17/19. Both residents were on the secure unit. 2. Review of Resident #1's MDS quarterly assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse note dated 01/17/19 at 7:00 AM reflected, CNA reported that 10-6 CNA reported resident had vomited and diarrhea. Resident currently with loose stool. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was given report at the beginning of her shift from the night shift CNA that Resident #1 had vomiting and diarrhea overnight, but the night shift CNA did not tell the nurse. CNA I said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 01/29/19 at 11:40 AM with LVN O revealed the CNA (CNA I) on morning shift on 01/17/19 reported to her the CNA from the 10 PM to 6 AM shift had reported Resident #1 had diarrhea and vomiting along with loose stool on the night shift. She stated Resident #1 had no other symptoms since that incident. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #2's nurse's note dated 01/17/19 at 9:45 AM reflected, upon returning from break CNA reported resident vomited x1 .complained of stomach cramping, and at 12:00 PM, resident ate few bites at lunch then vomited. Removed from dining room cleaned up then placed in bed due to resident request. Resident placed on side HOB (head of bed) elevated. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was working on 01/17/19 on the 6 AM to 2 PM shift on the secure unit. She stated Resident #2 vomited in the common area after breakfast and told the nurse. She stated she took Resident #2 to the shower room to clean him up and give him a shower. She stated she cleaned the floor of the common area where he vomited with sanitizing wipes (not approved by CDC for norovirus). She stated at lunch, Resident #2 was sitting with Residents #5 and #32 at a table in the dining room of the secure unit. She stated Resident #2 had eaten a few bites of his lunch, which was a regular diet and then vomited. She stated the vomit was on him and on his plate. She stated the other aide cleaned up the table and took Residents #5 and #32's plates. She stated Resident #2 was taken back to his room. She stated Residents #5 and #32 were given new plates of food and were put back at the same table after the aide cleaned the table and got a new table cloth for the table. She stated Resident #2 had a roommate and stayed in the room with their roommate. Interview on 01/29/19 at 11:40 AM with LVN O revealed on 01/17/19 when she came back from break, she was told by the CNA I that Resident #2 had vomited. She stated Resident #2 was in the bathroom when she saw him and had a large, soft stool. She stated at lunch he was in the dining room and had a regular diet. She stated Resident #2 vomited after eating a few bites of food. She stated the vomit was on his plate and the table. She stated two other residents were eating with Resident #2. She stated one CNA took Resident #2 to go clean him up and another CNA cleaned up the table and got the other residents at the table new food after the table had been cleaned. She stated the two residents were put back at the table after it was cleaned up. She stated Resident #2 was put on a clear liquid diet after he vomited the second time. 3. Review of line listing revealed on 01/18/19 Resident #3 (on the secure unit) had vomiting and fever. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected she was an 81-year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She was incontinent of bowel and bladder. Review of Resident #3's nurse's note dated 01/18/19 at 6:25 PM revealed Resident #3 had emesis (vomiting), very large, volume estimated at 150 mL, yellow in color, mixed with some remnant of food. Ate poorly at dinner prior to emesis. Temperature 98.3 degrees .New order clear liquid diet x 24 hours and BRAT diet x 48 hours. Nursing continues to monitor. At 7:25 PM family member, son informed of the vomiting and the new order. Review of Resident #3's telephone order dated 01/18/19 reflected Resident #3 on clear liquid diet x 24 hours, BRAT diet x 48 hours due to vomiting (emesis x2). 4. Review of line listing revealed on 01/19/19 Resident #4 had symptoms of diarrhea and vomiting with onset between 1:30 to 7:30 PM. Resident #5 had nausea and vomiting with onset at 11:00 PM. Both Resident #4 and #5 were on the secure unit. Resident #6 (not on secure unit) had symptoms of diarrhea and vomiting. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was severely cognitively impaired. Review of Resident #5's nurse's note dated 01/18/19 at 11:00 PM revealed Resident #5 approached the nurse's station and reported vomiting. Emesis (vomiting) was witnessed in the resident's bathroom toilet. The resident denied continued nausea. There were no other documented episodes or new doctor orders. Review of Resident #6's nurse's note dated 01/20/19 at 7:30 AM revealed Resident #6 had emesis (vomiting) x2 and loose stools. There were no further episodes after 01/20/19. A Physician order [REDACTED].#6 was on a clear liquid diet, then BRAT diet due to emesis and loose stools. Review of Resident #6's line listing revealed on 01/20/19 Resident #7, Resident #8, Resident #9 and Resident #10 also had stomach virus symptoms. Resident #7 had symptoms of diarrhea and vomiting with onset at 6:30 AM. Resident #8 had symptoms of nausea on during the 10 PM to 6 AM shift. Resident #9 had diarrhea and vomiting. Resident #10 had diarrhea. 5. Review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was a 68-year- old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurse's note dated 01/20/19 at 8:00 AM revealed the resident reported emesis (vomiting) x 1 and loose stool. Vital signs were within normal limits. A new physician order [REDACTED]. Review of Resident #10's nurse's note dated 01/23/19 at 10:00 AM revealed an episode of diarrhea. A new order for a stat CBC/CMP and BRAT diet for 24 hours was received. Resident #10's nurse's note dated 01/23/19 at 3:15 PM revealed lab results returned CMP within normal limits. CBC had abnormal WBC of 10.8 9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). A new order for stool culture/parasite/[MEDICAL CONDITIONS] stat was obtained and family was notified. Resident #10's nurse's note dated 01/23/19 at 9:00 PM and on 01/24/19 at 2:30 AM revealed Resident #10's stool was not collected for stat order as the resident had no bowel movement. Review of Resident #10's nurse's note dated 01/24/19 at 10:10 AM revealed stool collected via collection vessel. No foul odor was noted; brown in color. The lab was notified for STAT pick up of sample. Review of Resident #10's stool culture lab collected 01/24/19 and results dated 01/26/19 reflected the resident was negative for salmonella, shigella, pathogenic e coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #10 had no lab test for norovirus. 6. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was incontinent of bowel and bladder. Review of Resident #17's nurse's note dated 01/20/19 at 2:30 PM revealed the resident began vomiting and experiencing loose stools. Vital signs were within normal limits. A new physician's orders [REDACTED]. The resident was cleaned in the shower room and taken to his bedroom. Bed rest was encouraged due to resident's statement, I feel a little weak. Review of Resident #17's SBAR communication form dated 01/21/19 reflected Resident #17 was lethargic, pale in color, and had vomiting and diarrhea. Resident #17's symptoms of nausea, vomiting and diarrhea started on 01/20/19 and resident continued to get weaker. The resident's daughter was concerned about his condition due to possible dehydration. Resident #17 was sent to the local hospital to evaluate and treat. Resident #17 returned to the facility from the hospital. Interview on 01/31/19 at 2:20 PM with CNA J revealed on 01/19/19 Resident #18 had large diarrhea stools. CNA J changed Resident #17 the first time about 10:30 AM in the shower room and it got on his pants, so he had to go home and change clothes. He stated at lunch time after 12:00 PM, Resident #18 had a second large episode of diarrhea. He stated Resident #18 was cleaned up with sanitizing wipes and the CNA cleaned the shower room with those wipes as well (sanitizing wipes not approved by CDC for norovirus). He bagged Resident #18's soiled clothes and put them in the soiled linen bin (not in biohazard bag). He stated on 01/19/19, Resident #25 also had multiple episodes of diarrhea and he informed the nurse. He stated he was feeling nauseous on his shift on 01/20/19 about 11:00 AM and stated Resident #18 was having symptoms at this time, too. He stated he knew he could not help Resident #17 because he felt nauseous and had an upset stomach. CNA J stated he started having vomiting and diarrhea about 11:00 AM or noon and informed the nurse immediately, but he could not leave until a replacement came due to staffing needs. He stated he did not have direct contact with residents after he vomited and had diarrhea. He was on the couch in the room at the end of the hall on hall 200 where it's a small common area for the residents. He stated he clocked out about 3:00 PM on 01/20/19. He stated he went to the emergency roiagnom on [DATE] and was dehydrated and given fluids. He stated his diarrhea lasted until 01/23/19 in the morning. Review of CNA J's timecard reflected on 01/20/19 he left at 3:08 PM. He returned to work on 01/24/19 at 9:37 am (was not symptom free of diarrhea for 48 hours before returning to work). Interview on 01/30/19 at 10:15 AM with the Weekend RN Supervisor revealed CNA J started having GI symptoms of nausea and vomiting on 01/20/19 and was not able to finish his shift. She stated Resident #18 had vomiting and diarrhea on 01/20/19 as well. She stated the residents were only on standard precautions and not contact isolation. She stated she thought it was, just a stomach bug going around, but had no idea it would turn into an outbreak. 7. Review of line listing on 01/21/19 Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 and Resident #18 had symptoms of vomiting and diarrhea. Resident #11 had diarrhea and nausea with onset on during the 10 PM to 6 AM shift. Resident #12 and Resident #14, Resident #15 and Resident #16 had vomiting. Resident #13 had diarrhea with onset at 12:00 PM on 01/21/19. Resident #18 had diarrhea and lethargy. Review of Resident #11's (roommate of Resident #3) annual MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's CMP dated 01/23/19 reflected his WBC count was 13.9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). Resident #11's stool culture results dated 01/25/19 revealed the resident was negative for salmonella, shigella, pathogenic e. coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #11 had no lab test for norovirus. Review of Resident #18's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's nurse's note dated 01/21/19 at 9:00 PM revealed Resident #18 was, having difficulty walking her leg appears to be giving out while standing having to assist with transfers. She is unable to walk this evening. A nurse's note dated 01/22/19 at 5:00 AM revealed Resident #17, had diarrhea x2. Continue to monitor. Review of Resident #18's SBAR communication form dated 01/22/19 reflected Resident #18 was lethargic, confused, had slurred speech, decreased appetite, diarrhea, nausea and vomiting. Resident #18 had emesis (vomiting) that morning and had loose stools starting 01/21/19 at 9:00 PM. There was no emesis that shift but continued to have loose stools all day. Her blood sugar was 137 at 4:00 PM and her 70 units of [MEDICATION NAME] was held. The nurse rechecked her blood sugar at 8:20 PM and obtained a reading of 114. The resident drank part of her soda at dinner and did not eat her broth. Staff was able to have the resident drink a little water that day. The family and physician was notified of changes. Resident #18 was sent to emergency room . Review of Resident #18's hospital records dated 01/23/19 at 12:00 AM reflected Resident #18 was admitted to the local hospital on [DATE] for altered mental status. Resident #18 was discharged from the local hospital on [DATE] and back to the facility. 8. Review of line listing on 01/22/19 Residents #19 and #20 had diarrhea. Residents #21 had vomiting and loss of appetite with onset at 7:00 AM. Resident #22 had diarrhea and vomiting with onset at 5:00 PM. Review of Resident #21's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's nurse's note dated 01/22/19 reflected the resident had vomit x1, clear liquid diet well tolerated. At 8:00 PM the resident had one episode of diarrhea. The 10 PM to 6 AM nurse notated at 3:30 AM that Resident #21 had an episode of vomiting and loose stool. Review of Resident #21's telephone physician order [REDACTED]. 9. Review of line listing on 01/23/19 Resident #23 had diarrhea and vomiting with onset at 6:30 AM. Resident #24 had diarrhea, nausea and vomiting with onset at 8:00 AM. Resident #25 had diarrhea and vomiting. Resident #10 had diarrhea. 10. Review of line listing on 01/24/19 Resident #26 had diarrhea, vomiting, nausea and loss of appetite with onset at 4:30 AM. Resident #27 had vomiting and loss of appetite with onset at 5:00 AM. Resident #28 had nausea and vomiting with onset at 12:00 PM. Residents #28, #29, #30 and #31 had diarrhea. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #26's nurse's note dated 01/24/19 at 4:30 AM reflected, .resident has had loose stools x2 and 1 episode of vomiting. Clear liquid diet x 24 hours; then BRAT diet x 24 hours; then resume previous diet as tolerated. The nurse's notes revealed no other episodes of vomiting or diarrhea. 11. Observation on 01/25/19 at 5:36 PM revealed Resident #31 and #26 were sitting in the dining room eating. Both residents were in the dining room with other residents who were non-symptomatic. Review of Resident #31's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's nurse's note dated 01/24/19 at 10:00 AM revealed Resident #31 had a loose stool that morning. At 2:30 PM a new order was received for clear liquid diet x 24 hours, then BRAT diet x 48 hours and then resume regular diet as tolerated. Resident #31 also had another loose stool. 12. Interview on 01/25/19 at 5:30 PM with RN M revealed she had the stomach bug on 01/23/19 with vomiting, and came back to work on 01/24/19 having had no symptoms since 01/23/19. She stated Resident #31 had diarrhea yesterday (01/24/19) on her shift but she was not aware of Resident #31 having any current symptoms. She stated Resident #31 was put on a clear liquid diet yesterday as well. Review of RN M's timesheet revealed she returned to work on 01/24/19 at 2:07 PM (not symptom free of vomiting for 48 hours per CDC guidelines). She did not work on 01/23/19. 13. Review of line listing on 01/25/19 Residents #32, #33, #34 and #35 had diarrhea. Resident #21 also had diarrhea. Review of Resident #21's nurse's note dated 01/25/19 reflected Resident #21 had diarrhea stool noted at the beginning of the10 PM to 6 AM shift. Resident sipping on (electrolyte sports drink). Staff states resident had diarrhea on 2 to 10 pm shift with complaint of abdominal pain voiced. 2:00 am resident had large loose stool x 1 and complaint of abdominal pain. Review of Resident #21's telephone physician order [REDACTED]. Review of Resident #21's telephone physician order [REDACTED]. (no symptoms for 48 hours) Interview on 01/25/19 at 7:10 PM with CNA F revealed Resident #35 had just vomited in her room and the CNA was going to clean it up. now. She stated Resident #35 had vomited before supper or she would have been in the dining room with the other residents. She stated she cleaned the vomit up using the purple sanitizing wipes used the sanitizing wipes to clean the surfaces where the vomit was. She cleaned up the resident. She stated they used standard precautions on the residents with any symptoms of the stomach virus. Review of Resident #35's nurse's note dated 01/25/19 reflected at 6:40 PM Resident #35, vomited x 1 in moderate amount, temperature 99.6 degrees. Review of Resident #35's physician order [REDACTED]. 14. Interview on 01/27/19 at 11:16 AM with CNA F revealed she had symptoms of diarrhea and nausea on 01/24/19 and returned to work on 01/25/19 for her 2 PM to 10 PM shift. She said her last episode of diarrhea was about 3:00 PM on 01/24/19. She stated they had an in-serviced about standard precautions and hand hygiene. She stated they could utilize handwashing or hand sanitizer when providing care to residents including residents with GI symptoms. Interview on 01/30/19 at 2:05 PM with RN W revealed she worked on 01/22/19 on the 6 AM to 2 PM shift. She stated that evening around 5 - 6 PM she felt a little nauseated before vomiting 3 - 4 times. She had frequent diarrhea about 5 - 6 times before bed. She called into work sick on 01/23/19 when symptoms of vomiting continued, twice, and she had three episodes of diarrhea. She called in sick on 01/24/19 with symptoms of continuing of vomiting in the morning and two episodes of diarrhea during the day. She returned to work on 01/25/19 and had two to three episodes of diarrhea at work. She told management she was feeling sick but did not tell them she was having diarrhea. 15. Review of the Intake Incident Worksheet # 0 reflected the State Survey Agency was notified of the illness outbreak on 01/23/19 at 3:06 PM (5 days later 01/18/19 after 3 residents had gastrointestinal symptoms) by the Social Worker. [MEDICAL CONDITION] infection had affected approximately 20 residents who had vomiting and diarrhea at that time, along with 11 staff who also had the [MEDICAL CONDITION] symptoms. The building was on a 24-hour quarantine until new residents did not show symptoms. The CDC Guideline for Norovirus, updated 06/01/18 retrieved on 01/26/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having direct contact with an infected person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not use hand sanitizer as a substitute for washing your hands with soap and water. Hand sanitizers aren't as effective as washing hands with soap and water at removing norovirus particles. You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in long-term care facilities where they may expose people to norovirus. You are most contagious when you have symptoms of norovirus illness, especially vomiting and during the first few days after you recover from norovirus illness. In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: .Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection .Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus .Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Remove and wash contaminated clothing or linens .Healthcare workers who have symptoms consistent with norovirus should be excluded from work .After someone vomits or has diarrhea, always thoroughly clean and disinfect the entire area immediately. Put on rubber or disposable gloves, and wipe the entire area with paper towels, then disinfect the area using a bleach-based household cleaner as directed on the product label. Leave the bleach disinfectant on the affected area for at least five minutes then clean the entire area again with soap and hot water. Finish by cleaning soiled laundry, taking out the trash, and washing your hands. You should use a chlorine bleach solution with a concentration of 1000 to 5000 ppm (5 to 25 tablespoons of household bleach (5% to 8%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA). Immediately remove and wash clothes or linens that may be contaminated with vomit or stool. You should handle soiled items carefully without agitating them, wear rubber or disposable gloves while handling soiled items and wash your hands after . and wash the items with detergent and hot water at the maximum available cycle length then machine dry them at the highest heat setting. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. 16. Interview on 01/29/19 at 3:54 PM with the local health department official revealed they were notified by the facility on 01/24/19 of residents and employees having a GI outbreak. He was told they had symptoms of diarrhea and vomiting. He provided the facility with a line listing template to complete for the residents, and the facility sent the completed form back to them on Thursday afternoon. He was told they were not isolating the residents but trying to keep the residents in their rooms. He told them the symptoms sounded like the norovirus and recommended the facility to test for the norovirus. He stated the local health department followed the CDC guidelines. Review of local health department official's email to Admin dated 01/25/19 at 11:16 am reflected the chief epidemiologist at the local health department .wants to wait through the weekend to see if there is an increase or decrease in cases throughout the facility before we make a visit. If you could keep us updated as cases pop up that would be greatly appreciated! Interview on 01/25/19 at 8:42 AM with ADON L revealed on 01/23/19 when the DON and other employees called in sick, they realized there was something going around. She stated she was responsible for the infection control books but had not updated it them in the last 10 days. She was not aware they had an outbreak. Interviews on 01/25/19 at 5:45 PM and 8:18 PM with the DON revealed the local health department had mentioned the illness in the facility could be the Norovirus. She stated they were using standard precautions including gloves, handwashing and sanitizing when providing care to residents. She stated they had cleaned the handrails in the facility and disinfected resident rooms. She stated she called in sick on 01/23/19 and had two episodes of vomiting between 3:00 AM to 7:00 AM, with the last episode at 7:00 AM on 01/23/19. She stated she returned to work on 01/24/19 at about 8:00 AM with no symptoms and was feeling better. She stated they did not become aware until Monday morning of residents having GI symptoms when they reviewed the 24-hour reports for over the weekend that a few residents had been sick during the weekend. She said they were not aware they had [MEDICAL CONDITION] going around. She stated she initiated verbal cues to staff for hand hygiene on Monday (01/21/19). She stated on Wednesday when she called in along with other employees, they realized they had more cases and it was spreading. She stated they could not separate residents with symptoms because they had no open resident rooms. She stated a couple of the residents who were tested were negative for [MEDICAL CONDITION] but had not tested for norovirus. She stated they had no idea where it was going to pop up next. She stated she had not looked up about the norovirus. Interview on 01/25/19 at 8:51 PM with the Admin revealed the facility in-serviced on 01/22/19 and 01/23/19 on hand hygiene. She stated they were following standard precautions and were unable to move residents since they had no unoccupied rooms. She stated more employees started calling in on Tuesday evening and Wednesday. She stated the local health department on 01/24/19 told them the gastrointestinal symptoms sounded like the norovirus, and in the afternoon had provided the local health department of the resident line listing. She stated the local health department was going to wait until 01/28/19 to monitor and see how it went over the weekend. She stated she asked employees when they returned if they felt better and did not ask them about their gastrointestinal symptoms. She had not read the CDC guidelines and was going by what the local health department. She encouraged employees to go to the doctor, but she could not make them go. She stated there were no changes made to laundry or disinfecting the rooms. Review of facility in-services reflected: Standard Precautions (instead of contact isolation per CDC guidelines) started 01/22/19 (01/18/19 had 3 residents with gastrointestinal symptoms0 Meal service and infection control for dietary staff - 01/23/19 17. Review of the employee line listing reflected 25 employees had called in sick with symptoms of diarrhea, nausea, vomiting and/or loss of appetite with start date of 01/19/19 to 01/25/19. Review of facility's policy Abuse - Reportable events revised (MONTH) (YEAR) reflected the definition of Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. Review of facility's policy Infection Control - Standard Precautions revised (MONTH) 2012 reflected staff members will use standard precautions when providing resident care or when there is the potential of coming into contact with contaminated items. Under procedure .3. Hands: Hands shall be washed immediately and thoroughly if contaminated with blood or other bodily fluids. Hands shall be washed between each change of gloves. 4. Gowns: Gowns or aprons shall be worn if soiling with blood or body fluids is likely. Review of facility's policy Infection Control - Precautions - Categories and Notices revised date of (MONTH) (YEAR) reflected 4. In addition to standard precautions, contact precautions must be implemented for residents known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental services or patient-care items in the resident's environment. A. Examples of infections requiring contact precautions include, but are not limited to: gastrointestinal infections or coloni

Based on observation, interview, and record review, the facility failed to maintain an Infection Control Program designed to help prevent the transmission of disease and infection; maintain a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, and visitors; follow accepted national standards; follow a system of surveillance designed to identify possible communicable diseases or infections before they could spread to other persons in the facility; follow standard and transmission-based precautions to prevent spread of infections for forty-two residents (Residents #1 to #42) of forty-two residents for infection and 31 of 31 staff members and contact precautions and for two (Resident #43 and #44) of three residents observed for incontinence care. 1. The facility failed to intervene and further prevent the spread of suspected norovirus by failing to following CDC guidelines: - proper hand hygiene - implement and maintain contact precautions for residents with gastrointestinal symptoms, residents with the infection remained in rooms with non sick residents - perform proper cleaning and decontamination of infected rooms - follow infection control procedures for laundry - have a system in place to evaluate employees returning to work (after calling in sick with nausea, vomiting and diarrhea. As a result, the facility experienced an outbreak of suspected norovirus beginning on 01/17/19 and affected up to 42 residents and 31 staff to date. An Immediate Jeopardy was identified on 01/25/19. While the Immediate Jeopardy was removed on 01/31/19, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to facility continuation of in-servicing and monitoring the plan of removal. These failures placed the residents residing in the facility at risk for the development of GI outbreak and related complications including dehydration. 2. CNA D failed to appropriate hand hygiene procedures during or after incontinence care for Resident #43. 3. CNA [NAME] failed to utilize appropriate hand hygiene during and after incontinence care for Resident #44. These failures could affect the residents by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings Included: 1. Review of line listing (A line listing allows information about time, person, and place to be organized and reviewed quickly during an outbreak investigation) for residents reflected on 01/17/19, Resident #1 had symptoms of diarrhea and vomiting on the 10 pm to 6 am shift. Resident #2 had symptoms of diarrhea, vomiting and nausea with onset at 12:00 PM on 01/17/19. Both residents were on the secure unit. 2. Review of Resident #1's MDS quarterly assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Nurse note dated 01/17/19 at 7:00 AM reflected, CNA reported that 10-6 CNA reported resident had vomited and diarrhea. Resident currently with loose stool. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was given report at the beginning of her shift from the night shift CNA that Resident #1 had vomiting and diarrhea overnight, but the night shift CNA did not tell the nurse. CNA I said she told her charge nurse. She was unaware of Resident #1 having any more symptoms on her shift. Interview on 01/29/19 at 11:40 AM with LVN O revealed the CNA (CNA I) on morning shift on 01/17/19 reported to her the CNA from the 10 PM to 6 AM shift had reported Resident #1 had diarrhea and vomiting along with loose stool on the night shift. She stated Resident #1 had no other symptoms since that incident. 2. Review of Resident #2's Annual MDS assessment dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #2's nurse's note dated 01/17/19 at 9:45 AM reflected, upon returning from break CNA reported resident vomited x1 .complained of stomach cramping, and at 12:00 PM, resident ate few bites at lunch then vomited. Removed from dining room cleaned up then placed in bed due to resident request. Resident placed on side HOB (head of bed) elevated. Interview on 01/29/19 at 1:45 PM with CNA I revealed she was working on 01/17/19 on the 6 AM to 2 PM shift on the secure unit. She stated Resident #2 vomited in the common area after breakfast and told the nurse. She stated she took Resident #2 to the shower room to clean him up and give him a shower. She stated she cleaned the floor of the common area where he vomited with sanitizing wipes (not approved by CDC for norovirus). She stated at lunch, Resident #2 was sitting with Residents #5 and #32 at a table in the dining room of the secure unit. She stated Resident #2 had eaten a few bites of his lunch, which was a regular diet and then vomited. She stated the vomit was on him and on his plate. She stated the other aide cleaned up the table and took Residents #5 and #32's plates. She stated Resident #2 was taken back to his room. She stated Residents #5 and #32 were given new plates of food and were put back at the same table after the aide cleaned the table and got a new table cloth for the table. She stated Resident #2 had a roommate and stayed in the room with their roommate. Interview on 01/29/19 at 11:40 AM with LVN O revealed on 01/17/19 when she came back from break, she was told by the CNA I that Resident #2 had vomited. She stated Resident #2 was in the bathroom when she saw him and had a large, soft stool. She stated at lunch he was in the dining room and had a regular diet. She stated Resident #2 vomited after eating a few bites of food. She stated the vomit was on his plate and the table. She stated two other residents were eating with Resident #2. She stated one CNA took Resident #2 to go clean him up and another CNA cleaned up the table and got the other residents at the table new food after the table had been cleaned. She stated the two residents were put back at the table after it was cleaned up. She stated Resident #2 was put on a clear liquid diet after he vomited the second time. 3. Review of line listing revealed on 01/18/19 Resident #3 (on the secure unit) had vomiting and fever. Review of Resident #3's quarterly MDS assessment dated [DATE] reflected she was an 81-year- old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was severely cognitively impaired. She was incontinent of bowel and bladder. Review of Resident #3's nurse's note dated 01/18/19 at 6:25 PM revealed Resident #3 had emesis (vomiting), very large, volume estimated at 150 mL, yellow in color, mixed with some remnant of food. Ate poorly at dinner prior to emesis. Temperature 98.3 degrees .New order clear liquid diet x 24 hours and BRAT diet x 48 hours. Nursing continues to monitor. At 7:25 PM family member, son informed of the vomiting and the new order. Review of Resident #3's telephone order dated 01/18/19 reflected Resident #3 on clear liquid diet x 24 hours, BRAT diet x 48 hours due to vomiting (emesis x2). 4. Review of line listing revealed on 01/19/19 Resident #4 had symptoms of diarrhea and vomiting with onset between 1:30 to 7:30 PM. Resident #5 had nausea and vomiting with onset at 11:00 PM. Both Resident #4 and #5 were on the secure unit. Resident #6 (not on secure unit) had symptoms of diarrhea and vomiting. Review of Resident #5's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #5 was severely cognitively impaired. Review of Resident #5's nurse's note dated 01/18/19 at 11:00 PM revealed Resident #5 approached the nurse's station and reported vomiting. Emesis (vomiting) was witnessed in the resident's bathroom toilet. The resident denied continued nausea. There were no other documented episodes or new doctor orders. Review of Resident #6's nurse's note dated 01/20/19 at 7:30 AM revealed Resident #6 had emesis (vomiting) x2 and loose stools. There were no further episodes after 01/20/19. A Physician order [REDACTED].#6 was on a clear liquid diet, then BRAT diet due to emesis and loose stools. Review of Resident #6's line listing revealed on 01/20/19 Resident #7, Resident #8, Resident #9 and Resident #10 also had stomach virus symptoms. Resident #7 had symptoms of diarrhea and vomiting with onset at 6:30 AM. Resident #8 had symptoms of nausea on during the 10 PM to 6 AM shift. Resident #9 had diarrhea and vomiting. Resident #10 had diarrhea. 5. Review of Resident #10's quarterly MDS assessment dated [DATE] reflected he was a 68-year- old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #10's nurse's note dated 01/20/19 at 8:00 AM revealed the resident reported emesis (vomiting) x 1 and loose stool. Vital signs were within normal limits. A new physician order [REDACTED]. Review of Resident #10's nurse's note dated 01/23/19 at 10:00 AM revealed an episode of diarrhea. A new order for a stat CBC/CMP and BRAT diet for 24 hours was received. Resident #10's nurse's note dated 01/23/19 at 3:15 PM revealed lab results returned CMP within normal limits. CBC had abnormal WBC of 10.8 9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). A new order for stool culture/parasite/[MEDICAL CONDITIONS] stat was obtained and family was notified. Resident #10's nurse's note dated 01/23/19 at 9:00 PM and on 01/24/19 at 2:30 AM revealed Resident #10's stool was not collected for stat order as the resident had no bowel movement. Review of Resident #10's nurse's note dated 01/24/19 at 10:10 AM revealed stool collected via collection vessel. No foul odor was noted; brown in color. The lab was notified for STAT pick up of sample. Review of Resident #10's stool culture lab collected 01/24/19 and results dated 01/26/19 reflected the resident was negative for salmonella, shigella, pathogenic e coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #10 had no lab test for norovirus. 6. Review of Resident #17's quarterly MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was incontinent of bowel and bladder. Review of Resident #17's nurse's note dated 01/20/19 at 2:30 PM revealed the resident began vomiting and experiencing loose stools. Vital signs were within normal limits. A new physician's orders [REDACTED]. The resident was cleaned in the shower room and taken to his bedroom. Bed rest was encouraged due to resident's statement, I feel a little weak. Review of Resident #17's SBAR communication form dated 01/21/19 reflected Resident #17 was lethargic, pale in color, and had vomiting and diarrhea. Resident #17's symptoms of nausea, vomiting and diarrhea started on 01/20/19 and resident continued to get weaker. The resident's daughter was concerned about his condition due to possible dehydration. Resident #17 was sent to the local hospital to evaluate and treat. Resident #17 returned to the facility from the hospital. Interview on 01/31/19 at 2:20 PM with CNA J revealed on 01/19/19 Resident #18 had large diarrhea stools. CNA J changed Resident #17 the first time about 10:30 AM in the shower room and it got on his pants, so he had to go home and change clothes. He stated at lunch time after 12:00 PM, Resident #18 had a second large episode of diarrhea. He stated Resident #18 was cleaned up with sanitizing wipes and the CNA cleaned the shower room with those wipes as well (sanitizing wipes not approved by CDC for norovirus). He bagged Resident #18's soiled clothes and put them in the soiled linen bin (not in biohazard bag). He stated on 01/19/19, Resident #25 also had multiple episodes of diarrhea and he informed the nurse. He stated he was feeling nauseous on his shift on 01/20/19 about 11:00 AM and stated Resident #18 was having symptoms at this time, too. He stated he knew he could not help Resident #17 because he felt nauseous and had an upset stomach. CNA J stated he started having vomiting and diarrhea about 11:00 AM or noon and informed the nurse immediately, but he could not leave until a replacement came due to staffing needs. He stated he did not have direct contact with residents after he vomited and had diarrhea. He was on the couch in the room at the end of the hall on hall 200 where it's a small common area for the residents. He stated he clocked out about 3:00 PM on 01/20/19. He stated he went to the emergency roiagnom on [DATE] and was dehydrated and given fluids. He stated his diarrhea lasted until 01/23/19 in the morning. Review of CNA J's timecard reflected on 01/20/19 he left at 3:08 PM. He returned to work on 01/24/19 at 9:37 am (was not symptom free of diarrhea for 48 hours before returning to work). Interview on 01/30/19 at 10:15 AM with the Weekend RN Supervisor revealed CNA J started having GI symptoms of nausea and vomiting on 01/20/19 and was not able to finish his shift. She stated Resident #18 had vomiting and diarrhea on 01/20/19 as well. She stated the residents were only on standard precautions and not contact isolation. She stated she thought it was, just a stomach bug going around, but had no idea it would turn into an outbreak. 7. Review of line listing on 01/21/19 Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16 and Resident #18 had symptoms of vomiting and diarrhea. Resident #11 had diarrhea and nausea with onset on during the 10 PM to 6 AM shift. Resident #12 and Resident #14, Resident #15 and Resident #16 had vomiting. Resident #13 had diarrhea with onset at 12:00 PM on 01/21/19. Resident #18 had diarrhea and lethargy. Review of Resident #11's (roommate of Resident #3) annual MDS assessment dated [DATE] reflected he was an [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #11's CMP dated 01/23/19 reflected his WBC count was 13.9 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter (4.5 to 11.0 × 109/L)). Resident #11's stool culture results dated 01/25/19 revealed the resident was negative for salmonella, shigella, pathogenic e. coli and shiga toxins type 1 or 2 and campylobacter [MEDICATION NAME] by EIA. Resident #11 had no lab test for norovirus. Review of Resident #18's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #18's nurse's note dated 01/21/19 at 9:00 PM revealed Resident #18 was, having difficulty walking her leg appears to be giving out while standing having to assist with transfers. She is unable to walk this evening. A nurse's note dated 01/22/19 at 5:00 AM revealed Resident #17, had diarrhea x2. Continue to monitor. Review of Resident #18's SBAR communication form dated 01/22/19 reflected Resident #18 was lethargic, confused, had slurred speech, decreased appetite, diarrhea, nausea and vomiting. Resident #18 had emesis (vomiting) that morning and had loose stools starting 01/21/19 at 9:00 PM. There was no emesis that shift but continued to have loose stools all day. Her blood sugar was 137 at 4:00 PM and her 70 units of [MEDICATION NAME] was held. The nurse rechecked her blood sugar at 8:20 PM and obtained a reading of 114. The resident drank part of her soda at dinner and did not eat her broth. Staff was able to have the resident drink a little water that day. The family and physician was notified of changes. Resident #18 was sent to emergency room . Review of Resident #18's hospital records dated 01/23/19 at 12:00 AM reflected Resident #18 was admitted to the local hospital on [DATE] for altered mental status. Resident #18 was discharged from the local hospital on [DATE] and back to the facility. 8. Review of line listing on 01/22/19 Residents #19 and #20 had diarrhea. Residents #21 had vomiting and loss of appetite with onset at 7:00 AM. Resident #22 had diarrhea and vomiting with onset at 5:00 PM. Review of Resident #21's admission MDS assessment dated [DATE] reflected she was a [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #21's nurse's note dated 01/22/19 reflected the resident had vomit x1, clear liquid diet well tolerated. At 8:00 PM the resident had one episode of diarrhea. The 10 PM to 6 AM nurse notated at 3:30 AM that Resident #21 had an episode of vomiting and loose stool. Review of Resident #21's telephone physician order [REDACTED]. 9. Review of line listing on 01/23/19 Resident #23 had diarrhea and vomiting with onset at 6:30 AM. Resident #24 had diarrhea, nausea and vomiting with onset at 8:00 AM. Resident #25 had diarrhea and vomiting. Resident #10 had diarrhea. 10. Review of line listing on 01/24/19 Resident #26 had diarrhea, vomiting, nausea and loss of appetite with onset at 4:30 AM. Resident #27 had vomiting and loss of appetite with onset at 5:00 AM. Resident #28 had nausea and vomiting with onset at 12:00 PM. Residents #28, #29, #30 and #31 had diarrhea. Review of Resident #26's quarterly MDS assessment dated [DATE] reflected he was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was severely cognitively impaired. Review of Resident #26's nurse's note dated 01/24/19 at 4:30 AM reflected, .resident has had loose stools x2 and 1 episode of vomiting. Clear liquid diet x 24 hours; then BRAT diet x 24 hours; then resume previous diet as tolerated. The nurse's notes revealed no other episodes of vomiting or diarrhea. 11. Observation on 01/25/19 at 5:36 PM revealed Resident #31 and #26 were sitting in the dining room eating. Both residents were in the dining room with other residents who were non-symptomatic. Review of Resident #31's quarterly MDS assessment dated [DATE] reflected she was an [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #31's nurse's note dated 01/24/19 at 10:00 AM revealed Resident #31 had a loose stool that morning. At 2:30 PM a new order was received for clear liquid diet x 24 hours, then BRAT diet x 48 hours and then resume regular diet as tolerated. Resident #31 also had another loose stool. 12. Interview on 01/25/19 at 5:30 PM with RN M revealed she had the stomach bug on 01/23/19 with vomiting, and came back to work on 01/24/19 having had no symptoms since 01/23/19. She stated Resident #31 had diarrhea yesterday (01/24/19) on her shift but she was not aware of Resident #31 having any current symptoms. She stated Resident #31 was put on a clear liquid diet yesterday as well. Review of RN M's timesheet revealed she returned to work on 01/24/19 at 2:07 PM (not symptom free of vomiting for 48 hours per CDC guidelines). She did not work on 01/23/19. 13. Review of line listing on 01/25/19 Residents #32, #33, #34 and #35 had diarrhea. Resident #21 also had diarrhea. Review of Resident #21's nurse's note dated 01/25/19 reflected Resident #21 had diarrhea stool noted at the beginning of the10 PM to 6 AM shift. Resident sipping on (electrolyte sports drink). Staff states resident had diarrhea on 2 to 10 pm shift with complaint of abdominal pain voiced. 2:00 am resident had large loose stool x 1 and complaint of abdominal pain. Review of Resident #21's telephone physician order [REDACTED]. Review of Resident #21's telephone physician order [REDACTED]. (no symptoms for 48 hours) Interview on 01/25/19 at 7:10 PM with CNA F revealed Resident #35 had just vomited in her room and the CNA was going to clean it up. now. She stated Resident #35 had vomited before supper or she would have been in the dining room with the other residents. She stated she cleaned the vomit up using the purple sanitizing wipes used the sanitizing wipes to clean the surfaces where the vomit was. She cleaned up the resident. She stated they used standard precautions on the residents with any symptoms of the stomach virus. Review of Resident #35's nurse's note dated 01/25/19 reflected at 6:40 PM Resident #35, vomited x 1 in moderate amount, temperature 99.6 degrees. Review of Resident #35's physician order [REDACTED]. 14. Interview on 01/27/19 at 11:16 AM with CNA F revealed she had symptoms of diarrhea and nausea on 01/24/19 and returned to work on 01/25/19 for her 2 PM to 10 PM shift. She said her last episode of diarrhea was about 3:00 PM on 01/24/19. She stated they had an in-serviced about standard precautions and hand hygiene. She stated they could utilize handwashing or hand sanitizer when providing care to residents including residents with GI symptoms. Interview on 01/30/19 at 2:05 PM with RN W revealed she worked on 01/22/19 on the 6 AM to 2 PM shift. She stated that evening around 5 - 6 PM she felt a little nauseated before vomiting 3 - 4 times. She had frequent diarrhea about 5 - 6 times before bed. She called into work sick on 01/23/19 when symptoms of vomiting continued, twice, and she had three episodes of diarrhea. She called in sick on 01/24/19 with symptoms of continuing of vomiting in the morning and two episodes of diarrhea during the day. She returned to work on 01/25/19 and had two to three episodes of diarrhea at work. She told management she was feeling sick but did not tell them she was having diarrhea. 15. Review of the Intake Incident Worksheet # 0 reflected the State Survey Agency was notified of the illness outbreak on 01/23/19 at 3:06 PM (5 days later 01/18/19 after 3 residents had gastrointestinal symptoms) by the Social Worker. [MEDICAL CONDITION] infection had affected approximately 20 residents who had vomiting and diarrhea at that time, along with 11 staff who also had the [MEDICAL CONDITION] symptoms. The building was on a 24-hour quarantine until new residents did not show symptoms. The CDC Guideline for Norovirus, updated 06/01/18 retrieved on 01/26/19, reflected the following from https://www.cdc.gov/norovirus/: People with norovirus illness can shed billions of norovirus particles. And only a few virus particles can make other people sick. You can get norovirus from having direct contact with an infected person, consuming contaminated food or water or touching contaminated surfaces and putting you unwashed hands in your mouth. Norovirus Symptoms The most common symptoms include nausea, vomiting, diarrhea and stomach pain. Wash your hands thoroughly with soap and water, especially after using the toilet or changing diapers, always before eating, preparing, or handling food, and before giving yourself or someone else medicine. Norovirus can be found in your vomit or poop even before you start feeling sick. [MEDICAL CONDITION] can stay in your poop for 2 weeks or more after you feel better. It is important to continue washing your hands often during this time. You can use alcohol-based hand sanitizers in addition to hand washing. But, you should not use hand sanitizer as a substitute for washing your hands with soap and water. Hand sanitizers aren't as effective as washing hands with soap and water at removing norovirus particles. You should not prepare food for others or provide healthcare while you are sick and for at least 2 days (48 hours) after symptoms stop. This also applies to sick workers in long-term care facilities where they may expose people to norovirus. You are most contagious when you have symptoms of norovirus illness, especially vomiting and during the first few days after you recover from norovirus illness. In a healthcare facility, patients with suspected norovirus may be placed in private rooms or share rooms with other patients with the same infection. Additional prevention measures in healthcare facilities can decrease the chance of coming in contact with noroviruses: .Follow hand-hygiene guidelines, and carefully washing of hands with soap and water after contact with patients with norovirus infection .Use gowns and gloves when in contact with, or caring for patients who are symptomatic with norovirus .Routinely clean and disinfect high touch patient surfaces and equipment with an Environmental Protection Agency-approved product with a label claim for norovirus .Remove and wash contaminated clothing or linens .Healthcare workers who have symptoms consistent with norovirus should be excluded from work .After someone vomits or has diarrhea, always thoroughly clean and disinfect the entire area immediately. Put on rubber or disposable gloves, and wipe the entire area with paper towels, then disinfect the area using a bleach-based household cleaner as directed on the product label. Leave the bleach disinfectant on the affected area for at least five minutes then clean the entire area again with soap and hot water. Finish by cleaning soiled laundry, taking out the trash, and washing your hands. You should use a chlorine bleach solution with a concentration of 1000 to 5000 ppm (5 to 25 tablespoons of household bleach (5% to 8%) per gallon of water) or other disinfectant registered as effective against norovirus by the Environmental Protection Agency (EPA). Immediately remove and wash clothes or linens that may be contaminated with vomit or stool. You should handle soiled items carefully without agitating them, wear rubber or disposable gloves while handling soiled items and wash your hands after . and wash the items with detergent and hot water at the maximum available cycle length then machine dry them at the highest heat setting. Consider submitting stool specimens as early as possible during a suspected norovirus gastroenteritis outbreak and ideally from individuals during the acute phase of illness (within 2-3 days of onset). It is suggested that healthcare facilities consult with state or local public health authorities regarding the types of and number of specimens to obtain for testing. 16. Interview on 01/29/19 at 3:54 PM with the local health department official revealed they were notified by the facility on 01/24/19 of residents and employees having a GI outbreak. He was told they had symptoms of diarrhea and vomiting. He provided the facility with a line listing template to complete for the residents, and the facility sent the completed form back to them on Thursday afternoon. He was told they were not isolating the residents but trying to keep the residents in their rooms. He told them the symptoms sounded like the norovirus and recommended the facility to test for the norovirus. He stated the local health department followed the CDC guidelines. Review of local health department official's email to Admin dated 01/25/19 at 11:16 am reflected the chief epidemiologist at the local health department .wants to wait through the weekend to see if there is an increase or decrease in cases throughout the facility before we make a visit. If you could keep us updated as cases pop up that would be greatly appreciated! Interview on 01/25/19 at 8:42 AM with ADON L revealed on 01/23/19 when the DON and other employees called in sick, they realized there was something going around. She stated she was responsible for the infection control books but had not updated it them in the last 10 days. She was not aware they had an outbreak. Interviews on 01/25/19 at 5:45 PM and 8:18 PM with the DON revealed the local health department had mentioned the illness in the facility could be the Norovirus. She stated they were using standard precautions including gloves, handwashing and sanitizing when providing care to residents. She stated they had cleaned the handrails in the facility and disinfected resident rooms. She stated she called in sick on 01/23/19 and had two episodes of vomiting between 3:00 AM to 7:00 AM, with the last episode at 7:00 AM on 01/23/19. She stated she returned to work on 01/24/19 at about 8:00 AM with no symptoms and was feeling better. She stated they did not become aware until Monday morning of residents having GI symptoms when they reviewed the 24-hour reports for over the weekend that a few residents had been sick during the weekend. She said they were not aware they had [MEDICAL CONDITION] going around. She stated she initiated verbal cues to staff for hand hygiene on Monday (01/21/19). She stated on Wednesday when she called in along with other employees, they realized they had more cases and it was spreading. She stated they could not separate residents with symptoms because they had no open resident rooms. She stated a couple of the residents who were tested were negative for [MEDICAL CONDITION] but had not tested for norovirus. She stated they had no idea where it was going to pop up next. She stated she had not looked up about the norovirus. Interview on 01/25/19 at 8:51 PM with the Admin revealed the facility in-serviced on 01/22/19 and 01/23/19 on hand hygiene. She stated they were following standard precautions and were unable to move residents since they had no unoccupied rooms. She stated more employees started calling in on Tuesday evening and Wednesday. She stated the local health department on 01/24/19 told them the gastrointestinal symptoms sounded like the norovirus, and in the afternoon had provided the local health department of the resident line listing. She stated the local health department was going to wait until 01/28/19 to monitor and see how it went over the weekend. She stated she asked employees when they returned if they felt better and did not ask them about their gastrointestinal symptoms. She had not read the CDC guidelines and was going by what the local health department. She encouraged employees to go to the doctor, but she could not make them go. She stated there were no changes made to laundry or disinfecting the rooms. Review of facility in-services reflected: Standard Precautions (instead of contact isolation per CDC guidelines) started 01/22/19 (01/18/19 had 3 residents with gastrointestinal symptoms0 Meal service and infection control for dietary staff - 01/23/19 17. Review of the employee line listing reflected 25 employees had called in sick with symptoms of diarrhea, nausea, vomiting and/or loss of appetite with start date of 01/19/19 to 01/25/19. Review of facility's policy Abuse - Reportable events revised (MONTH) (YEAR) reflected the definition of Neglect: the failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain or mental illness. Review of facility's policy Infection Control - Standard Precautions revised (MONTH) 2012 r

Based on observation, interview and record review, the facility failed to ensure the necessary care and services were provided to attain or maintain the highest practicable physical well-being, in accordance with the comprehensive assessment and plan of care for one (Resident #1) of four residents reviewed with treatments for pressure ulcers, stasis ulcers and/or diabetic ulcers. Resident #1 was not administered pain medication prior to receiving wound care resulting in the resident grimacing, wincing/flinching, taking deep breaths, sucking in air through his clenched teeth and making fists with his hands. The wound doctor and LVN A did not respond to Resident #1 other than telling the resident to hold still. Resident #1 received a pain pill 20 minutes into the treatment. This failure to provide Resident #1 with pain medication prior to a dressing change and treatment resulted in the resident enduring pain until surveyor intervention. This failure could affect the seven residents identified with wound treatments, including Resident #1, and were at risk for unrelieved pain, which could result in a decline in their psychosocial and physical well-being. Findings included: During observation rounds conducted with the DON from 8:30 a.m. to 9:30 a.m. on 07/18/13, Resident #1 was identified as being alert and interviewable with wounds on his feet. The DON stated he had stents placed for circulation in his lower extremities either in December 2012 or January 2013 due to [MEDICAL CONDITION]. The DON added Resident #1 recently had a sleep study done because he was sleeping in the wheelchair all day. The DON said on his return trip to the facility on [DATE], Resident #1 was taken to the hospital due to complaints of pain in his feet. The DON stated Resident #1 was seen weekly (on Thursdays) by the wound doctor and was given PRN pain medication prior to the wound doctor's treatments. At that time, Resident #1 was observed sitting in a wheelchair in the dining room involved in an activity. The undated Resident Admission Record for Resident #1, a [AGE] year-old male, reflected a current admission date of [DATE] with a latest return date (to the facility) of 01/14/13. [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] reflected Resident #1 required the extensive assistance of two persons plus with transfers and the extensive assistance of one person with dressing and toileting. The Brief Interview for Mental Status reflected the resident scored 14 out of 15, which indicated he was not cognitively impaired. The MDS assessment reflected Resident #1 had two venous/arterial ulcers present, but did not indicate there was any application of dressings to the resident's feet. Review of Resident #1's Admission Care Plan dated 05/11/12 revealed the following: "Pain Goal: Resident will be as comfortable as possible Monitor pain ...Administer pain medications as ordered" "Cognitive Loss Goal: Resident will be as alert and oriented as comfortable ...Explain what you intend to do while providing care Anticipate needs and observe for non-verbal cues" Resident #1's acute plan of care dated 03/05/13 reflected the following: Open Wound - Infected Bilateral Lower Extremities Approach "...Monitor for ...pain and report to physician." This care plan was marked "resolved." Resident #1's acute plan of care dated 08/10/12 and was reviewed as recently as 07/10/13 reflected the following: Open Wound of right foot Approach "...Monitor for s/s of ...pain and report to physician." Review of all of Resident #1's care plans provided to the surveyor, which ranged from 05/11/12 through 07/10/13, revealed pain was not identified as a problem, but only an approach, despite infected vascular ulcers and a [DIAGNOSES REDACTED]. Resident #1's consolidated physician orders [REDACTED]. On 07/18/13 at 3:50 p.m., Resident #1 was observed sitting in the wheelchair with his feet and lower legs hanging down in a dependent position. The wound doctor, who was treating the open vascular ulcers on the resident's feet, was removing the soiled compression dressings from both of the resident's feet. The wound doctor then began cleaning the ulcers with normal saline. The vascular ulcers appeared very tender to touch as the resident was moving slightly in the wheelchair, grimacing, wincing/flinching, taking deep breaths and sucking in air through his clenched teeth. The ulcers had light bleeding with [MEDICAL CONDITION] and inflammation, some maceration (tissue softened by fluid) and slough (soft, dead tissue). The wound doctor stated firmly to the resident to "Be still. Don't move." Resident #1 apologized, stating, "It hurts," and continued taking deep breaths as well as wincing and sucking air in through his clenched teeth while the wound doctor continued with the treatment. Resident #1's hands were clenched in fists on the arm rests. The wound doctor never slowed with the treatment, never checking for the resident's reaction to the treatment. The surveyor asked the resident, "Are you hurting?" And Resident #1 responded, "Yeah," and continued to shift his weight in the wheelchair, wincing and taking deep breaths. The resident's feet were in a dependent position throughout the process. LVN A asked Resident #1, "How are you doing?" twice. The surveyor told Resident #1, "I think (LVN A) is asking if you need something for pain." The resident looked surprised, nodded his head and said, "Yes. Yes. I'd like a pain pill." LVN A left and returned at 4:10 p.m. (20 minutes since the wound doctor began). The LVN handed Resident #1 the pain medication. Following the completion of the treatment to the resident's right leg, Resident #1 complained of pain in his right great toe. Neither LVN A nor the wound doctor acknowledged Resident #1. When the wound doctor finished wrapping the resident's left leg, Resident #1 complained again, saying his right great toe hurt. Resident #1 touched his toe, stating, "It's cold and sore." Neither the wound doctor nor LVN A questioned Resident #1, asked for the level of pain or responded to him. Resident #1's PRN MAR for July 2013 reflected the medication [MEDICATION NAME] 10/325 mg, one tablet, was documented as being administered on 07/04/13 (Thursday), 07/08/13 (Monday) and 07/09/13 (Tuesday) and 07/18/13 (the date the surveyor intervened). There was nothing to indicate Resident #1 received PRN [MEDICATION NAME] on 07/11/13, a Thursday, when the wound doctor would have changed the resident's dressings. No [MEDICATION NAME] was documented as being given for pain. Review of Resident #1's Medications Flowsheet for July 2013 revealed one time when the resident had pain, which was on 07/18/13 when the surveyor intervened. Resident #1's Pain Management Flow Sheet for July 2013 reflected the following: two entries: one for 07/04/13 and one for 07/18/13. The Flow Sheet indicated the pain scale used was numeric and the pain rating on 07/04/13 was an eight. For the resident's Pain After Intervention, the pain was rated as 2/10 on 07/04/13. The Pain Management Flow Sheet did not indicate a pain assessment was conducted before or after for 07/08/13 or 07/09/13. The Flow Sheet indicated the pain scale used was numeric and the pain rating on 07/18/13 was an eight, and there was no rating of the resident's pain after being given pain medication. Review of Resident #1's PRN Medication Flowsheet for June 2013 revealed he was administered [MEDICATION NAME] 325 mg, two tabs on 06/26/13 and [MEDICATION NAME] 10/325 mg, one tab on 06/26/13. Resident #1's Medications Flowsheet for June 2013 reflected the resident only had pain on 06/27/13. Pain was marked "no" on 06/26/13. Resident #1's Pain Management Flowsheet for June 2013 reflected the resident was assessed for pain on 06/27/13, but not on 06/26/13. On 07/18/13 at approximately 5:00 PM, the surveyor spoke with the DON and the Administrator in regard to the observation of Resident #1's wound care and the resident not having been medicated prior to the wound care doctor's dressing change and treatment. The surveyor told them it was apparent Resident #1 was in pain during the procedure, and the resident did not seem to realize he could have pain medication. The DON and the Administrator appeared surprised Resident #1 was not administered pain medication prior to his dressing change/treatment and would follow-up with the wound doctor and facility staff. On 07/18/13 at approximately at 8:20 a.m., the DON informed the surveyor there were seven residents in the facility, including Resident #1, with pressure ulcers, stasis ulcers and/or diabetic ulcers.