Every finding on record at Citadel Post Acute

Based on clinical record review, staff interviews, facility documentation, policy review, and the State's Agency (SA) complaint tracking system, the facility failed to protect two residents (#3 and #9) right to be free from sexual abuse by other residents (#4 and #10). The deficient practice could result in residents being at risk for further abuse.Based on clinical record review, staff interviews, facility documentation, policy review, and the State's Agency (SA) complaint tracking system, the facility failed to protect two residents (#3 and #9) right to be free from sexual abuse by other residents (#4 and #10). The deficient practice could result in residents being at risk for further abuse.Findings include:-Regarding Resident #9 (Alleged Victim):Review of Resident #9's care plan initiated on October 25, 2018 revealed resident has impaired cognitive function related to dementia and memory loss.Resident #9 was admitted to the facility on [DATE] with a diagnosis that included Hypertension, Diabetes mellitus (DM), Arthritis, Non-Alzheimer's Dementia, Depression, and Schizophrenia.Review of Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8.0, moderately impaired and rejection of care, wandering and behavioral symptoms were not exhibited.Review of the Interdisciplinary Team (IDT) progress notes dated July 20, 2023 revealed resident was interviewed regarding a resident to resident contact. Resident reported that she felt safe in the facility, that no one touched her and that she would report it if something did happen. Resident was being monitored for her psychosocial well-being.Review of another MDS for significant change dated August 1, 2023 revealed a BIMS score of 5.0, severe impairment and behavioral symptoms not exhibited.-Regarding Resident #10 (Alleged Perpetrator):Resident #10 was admitted on [DATE] with a diagnosis that included diabetes mellitus (DM), hypertension and cerebrovascular accident (CVA).Review of admission MDS assessment dated [DATE] revealed a BIMs score of 7.0, severe impairment, and resident exhibited physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually).Review of care plan initiated on June 23, 2023 revealed a potential for a behavior problem related to cognitive decline. The interventions included to anticipate and meet needs, approach in a calm manner, and document behaviors and resident response to interventions.Review of nursing progress notes dated July 20, 2023 revealed the resident was seen touching another resident around the waistband. The residents were immediately separated, assessed, questioned, and educated. The provider and representative were notified. Resident #10 was placed on a one on one supervision, psych referral sent, and resident placed on change of condition monitoring.Review of another care plan initiated on July 20, 2023 revealed a potential to demonstrate inappropriate behaviors. The interventions dated July 20, 2023 included one on one staff observation, psych to evaluate and treat, and educating resident regarding being appropriate with others.Review of progress note dated July 21, 2023 revealed resident is on change of condition monitoring for inappropriate behaviors.On July 21, 2023, review of record revealed that Resident #10 was discharged to another facility.Review of facility's 5-day investigation report revealed that an interview was conducted with a certified nursing assistant (CNA/Staff #901). Staff #901 reported that she walked into the dining room where Resident #9 and Resident #10 were sitting in their wheelchair directly in front of each other. Staff stated that she thought she saw Resident #10's hands on Resident #9's lap and around her waistband. Staff #901 reported that while she was walking in, she observed Resident #9 pushed Resident #10's hand away and began to propel herself towards her lunch table. Staff #901 ensured the residents were safe and separated and she went to get help. The facility investigation concluded that abuse did not occur.-Regarding Resident #3 (Alleged Victim):Resident #3 was admitted to the facility on [DATE] with a diagnosis that included Hypertension, Urinary tract infection (UTI), Diabetes mellitus (DM), Non-Alzheimer's Dementia, Seizure disorder, and Depression.Review of significant change in status MDS assessment dated [DATE] revealed a BIMS score of 8.0, moderately impaired.Review of care plan initiated on April 30, 2024 revealed resident has an alteration in neurological status related to history of subarachnoid hemorrhage. The interventions included cueing and reorientation as needed.Another care plan initiated on April 24, 2024 revealed resident was at risk for impaired cognitive function/dementia or impaired thought processes related to unspecified dementia, and at risk for communication problem related to expressive aphasia.Review of nursing progress notes dated June 14, 2024 at 18:32 PM revealed Resident #3 was observed in a male resident's room. Resident was taken out of the room and brought back to her own room. Resident #3 was placed on a 15-minute checks. A skin check was completed and found no bruising, redness, swelling, discoloration, fluids or blood noted. The law enforcement was notified. Resident #3's emergency contacts were notified. And, Resident #3 was placed on psychosocial monitoring.Review of record, Skin Evaluation, dated June 14, 2024 revealed Resident's skin was intact, no redness, bruising, discoloration, swelling, abrasions, or skin tears noted. Resident's brief was clean and dry at time of assessment.Review of physician's progress notes dated June 14, 2024 revealed the provider was contacted by staff after Resident #3 was found in a male resident's room, both with pants down. Staff were unable to see if there was any penetration. The male resident initially denied that they were having sex at the time, but later reportedly stated that they have had sex before. The male resident also stated to staff that they were in a relationship. The staff notified the police and sexual crisis team. Furthermore, the progress note revealed that Resident #3 reported that she feels safe in the facility with staff, she is not the male resident's girlfriend, she did not want to have physical contact with the resident, however per staff camera review, Resident #3 independently wheeled herself from the cafeteria directly to the male resident's room. Resident #3 was unable to describe what happened in her own words. The progress note revealed that Resident #3 states yes when asked if she was in the male resident's room with her pants down. She endorses feeling scared while in his room. She agrees that she would like the male resident to stay away from her. According to the progress note, Resident #3 has the inability to properly weigh or retain information to make decisions and to verbally communicate said decisions. The situation has been confuted by the fact that it seems she sought out the male patient. After the incident, the staff have initiated a one on one on the male resident and a 15-minute checks on Resident #3.On June 15, 2024, a care plan for potential for a behavior problem related to poor impulse control, aphasia, seeks physical attention, resists care, history of striking out at caregivers and refusing medications was initiated. The interventions included 30-mimute checks, administer medications as ordered and monitor document for side effects and effectiveness, anticipate and meet resident's needs, caregivers to provide opportunity for positive interaction, attention, stop and talk with resident as passing by, document behaviors and resident response to interventions, discuss behavior, explain/reinforce why behavior is inappropriate, intervene as necessary to protect the rights and safety of others, remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause.Another review of physician's progress note dated June 18, 2024 revealed that the provider was informed about the event. He was informed about a resident wheeled herself into a male resident's room. The female resident was found standing with another male resident and their pants were down but it looked like they were trying to engage in a sexual intercourse but there was no penetration as per staff. Staff immediately intervened and appropriate actions have been taken including wheeling Resident #3 out of the male patient's room, calling the sexual crisis team, police etc. The provider met with Resident #3 in her room. Resident #3 was pleasant, not in any distress. Resident does not seem to be any more confused than her baseline. Provider notes revealed that Resident #3 was being followed by psych. It is really hard to assess her capacity because she does seem to have capacity when it comes to basic necessities like food, showers and other basic necessities but the provider doubt she has the capacity to understand or analyze any complex situations.Another review of record, Skin Evaluation, dated June 18, 2024 revealed Resident's has no new skin issues, skin is clean dry and intact.Review of quarterly MDS assessment dated [DATE] revealed a BIMS score of 4.0, severely impaired.Resident #3 was discharged out of the facility on August 22, 2024.-Regarding Resident #4 (Alleged Perpetrator):Resident #4 was admitted to the facility on [DATE] with a diagnosis that included Anxiety disorder, Depression, Schizophrenia, and Post Traumatic Stress Disorder (PTSD).Review of admission note dated March 7, 2024 revealed that Resident arrived to the facility, resident was able to stand and walk with walker and rolled in bed for skin assessment. Resident was alert and oriented times four, able to make his own needs.Review of the IDT progress note dated March 12, 2024 revealed that Resident follows staff members throughout the facility calling them terms outside of their name and potential to make accusatory statements. Staff initiated cares and pairs with a psych referral sent.Review of physician progress note dated March 13, 2024 revealed Since admission to the facility, has been noted to be verbally aggressive toward staff and sexually inappropriate. Staff reported resident was asking staff to sit on my lap and called a staff a fat ass. Staff additionally report he has a strong need to feel respected by others.Review of admission MDS assessment dated [DATE] revealed a BIMs score of 14.0, cognitively intact. Resident exhibited verbal behavioral symptoms directed towards othersReview of progress notes dated June 14, 2024 revealed that the resident was observed in his room with a female resident. The female resident was removed from the room. Resident #4 was placed on a one on one. The law enforcement was notified. Resident #4 did not want anyone notified. Resident will be monitored for psychosocial well-being.Review of progress note dated June 16, 2024 revealed resident is on change of condition monitoring and on a one on one with staff.Review of another nursing progress note dated June 17, 2024 revealed Resident inquired why there was an investigation going on and why he was not allowed to be around the other female resident.On June 18, 2024, review of nursing discharge summary progress note revealed resident was discharged to an assisted living.Review of the facility's 5-day investigation report dated June 21, 2024 revealed Resident #3 and Resident #4 were interviewed immediately following the incident on June 14, 2024. The investigation report revealed during an interview with Resident #3, Resident #3 denied having a relationship with Resident #4. Resident #3 reported nothing physical happened, she does not want Resident #4 touching her, she did not try and stop Resident #4, she was not scared during the interaction, she noted yes to feeling safe now and wants to remain in the facility, she does not want Resident #4 to get in trouble or to be punished, she knows what sex is , she denied penetration, she denied having her clothes off, she denied touching Resident #4, she denied spending time with Resident #4, she denied having been in Resident#4's room before, she smiled when asked if she was Resident #4's girlfriend, she denied being assaulted or raped, and she denied feeling scared to see or interact with Resident #4 again. The investigation report also revealed that Resident #3's affect was calm, smiling and happy. On the other hand, the investigation report revealed during an interview with Resident #4, Resident #4 reported that Resident #3 and him had been in the television room around 9:00 or 10:00 AM watching television, coloring and hugging each other. Resident #4 reported that later during the day, Resident #3 came to his room and Resident #3 grabbed his hand. Resident #4 also reported that they were watching television, necking, petting and kissing. Resident #4 reported that a CNA entered his room to deliver his dinner tray. Resident #4 reported that Resident #3 had pulled her own pants down. Resident #4 reported that it was the first time Resident #3 came to his room and that they did not have intercourse, and that their interaction was consensual. Resident #4 reported that Resident #3 can speak in sentences.Further review of facility's 5-day investigation report dated June 21, 2024 revealed an interview was conducted with a certified nursing assistant (CNA/Staff #700). Staff #700 reported that around 17:45-17:50 PM, while she was passing trays in one of the hallways and knocked on Resident #4's door, she heard Resident #4 say hold on. Staff #700 pushed the curtain just a little to set Resident #4's dinner tray down. Staff #700 reported that she noticed Resident #3 standing facing the wall and Resident #4 was behind Resident #3 with his pants down. Staff #700 saw Resident #4 doing a rocking motion but could not see where his penis was and when Resident #4 noticed Staff #700, Resident #4 pulled his pants up. Staff #700 called Staff #41, who was just outside the room to stand there while Staff #700 will get the nurse. Staff #700 reported that Resident #3 was safe when Staff #700 left Resident #3 in Resident #4's room. In addition, the facility's 5-day investigation report revealed an interview was conducted with another CNA/Staff #41 who reported that she saw Resident #3 standing by the bed and Resident #4 was next to her. Staff #41 waited until the nurse came. In addition, the facility 5-day investigation report revealed an interview was conducted with a Registered Nurse (RN/Staff #800). Staff #800 reported that when Staff #800 arrived in Resident #4's room, another nurse was already in Resident's #4's room. Staff #800 saw Resident #4 sitting in his wheelchair while Resident #3 was on the bed with her pants and briefs by her knees. Furthermore, another RN was interviewed during the facility's investigation and revealed that RN/Staff #900 reported that Staff #700 came to the desk and notified the nurse to go to Resident #4's room. Staff #900 reported that upon entering Resident #4's room, Staff #900 reported that he saw Resident #3 sitting on the edge of the bed with her brief down and Resident #4 was in his wheelchair. Staff #900 place a call to the administrator and left a message and then he called 911. After review of the facility's investigation report, the facility concluded that no abuse occurred.On July 16, 2025 at 09:10 AM, a call was placed to Staff #700 for an interview. Surveyor left a voice message.An interview was conducted on July 16, 2025 at 09:43 AM with CNA/Staff #41 in the conference room. Staff #41 stated that she works from 06:00 AM to 06:00 PM. When she comes to work, she will first check her assignment, she signs her initials in the assignment book so the staff knows that she is in the facility, she will then get report from the night shift CNA, then she will start getting her residents' vital signs, check everybody, pass ice water, get her residents up, and dress them up for breakfast which starts at 07:00 AM in the dining room. Her responsibility also includes cleaning her residents' rooms, changing their bed linens, and taking care of trash in their room. Regarding abuse, Staff #41 stated that abuse can be verbal, hitting is abuse, and if she witnessed an abuse, she reports it immediately to the administrator and her nurses because it has to be reported and she will not let abuse happen to somebody. Furthermore, Staff #41 stated that abuse is also touching someone inappropriately like trying to have sex. Staff #41 stated that there was one time, it happened a year ago in one of the halls, there was a female resident and Staff #41 forgot the male resident's name. She stated that she saw a CNA coming from the room while she was walking toward the room, and the CNA told her to stay with them by the door and watch them because the CNA stated that they were trying to do something. Staff #41 stated that she saw Resident #3 sitting in the male resident's bed, Resident #3's pants was above her thigh like she was trying to pull it up and the male resident was so mad because Staff #700 came in his room. Staff #41 saw the male resident in his wheelchair and the male resident asked her why she was standing there. Staff #41 stated that Resident #3 was laughing while sitting in the bed. Furthermore, Staff #41 stated that a male nurse came, the nurse still works at the facility, the nurse reported the incident and then the police came in the male resident's room on the same day. During the interview with Staff #41, she stated that she will report any abuse right away. Staff #41 also stated that she thinks that the residents were trying to have sex. Staff #41 stated that she took care of Resident #3 in the past and stated that Resident #3 was always in her wheelchair, Resident #3 requires total care, Resident #3 can't talk because sometimes Staff #41 tries talking to Resident #3 and she does not understand Resident #3. Staff #41 thinks that Resident #3 knows where she is at sometimes.A phone interview was conducted on July 16, 2025 at 10:22 AM with a Licensed Practical Nurse (LPN/Staff #105). Staff #105 stated that abuse is a violation of patient's rights, abuse can be sexual, financial, physical, and seclusion. Staff #105 stated that his responsibility when he witnessed an abuse is to separate the victim, separate as soon as he witnessed a physical contact or something that could lead to a physical contact which includes shouting, to prevent and deescalate the situation. Staff #105 stated that last year, a resident was found in a room, sexual abuse, he was the nurse of the male resident, the male resident was alert and oriented and was independent somehow. Staff #105 stated that the male resident was in bed 2, a CNA was passing meal trays, the door was closed, the CNA pulled the privacy curtain and found a female resident in the male resident's private space, the CNA saw two residents a male and a female, and the situation was awkward. Staff #105 stated that the female resident was known to wonder, the female resident could not make decision on her own, and the female resident was friendly and smiling. Staff #105 stated that after being informed of the incident, he rushed in his male resident's room, and when he arrived in the resident's room, he found a female resident leaning on the bed, her pants down, her face down on the bed, and the male resident was trying to adjust by pulling his pants. Staff #105 stated that Resident #4 stated to the staff to get out of his room, it was a private matter, the female resident was his girlfriend, and it was consensual. Staff #105 stated that as far as he knows, the female resident cannot give consent mentally based on her mental fit such as engaging in that kind of space. Staff #105 stated that her Power of Attorney (POA) was making all the decisions for her. Staff #105 stated that he informed the female resident that the room she was in was not her room. Staff #105 stated that the management was made aware of the incident, and the police came. In addition, Staff #105 stated that he remembered that as soon as he walked in the male resident's room, the male resident was trying to pull his pants, he became hostile, and Staff #105 asked the CNA to help the female resident get dress because the female resident was undress, her pants and briefs were down because the female resident was leaning towards the bed. Staff #105 stated that the female resident back was facing Staff #105. Furthermore, Staff #105 stated that the female resident needs assistance with mobility and cannot stand on her own and Staff #105 stated that he does not know why the female resident was leaning on the bed and the female resident's wheelchair was next to the bed. Staff #105 stated that the male resident refused a one on one with staff. The female resident was given a one on one with staff. And after the incident, the male resident was looking for the female resident. In the dining room, the male resident was heard saying hey baby come here, blowing kisses to the female resident, and that was why the male resident was assigned one on one. The male resident was eventually discharged out of the facility.An interview was conducted on July 16, 2025 at 11:26 AM with RN/Staff #900 in the conference room. Staff # 900 stated that his abuse training is done annually online and annually in person such as during in services. He stated that abuse is for instance a person was pushed, or was left in a chair. He stated that he remembered an incident but cannot give specifics. Staff #900 stated that the incident happened in one of the halls where one of the residents went in the wrong room. Staff #900 stated that a CNA came and got him and asked his help. Staff #900 stated that another nurse was at the room already when he arrived in the resident's room. Staff #900 stated that one female resident was sitting at the bed with her briefs at her knees as if one would go use a commode. He described the situation further as the female resident's briefs were across her thighs, one male resident sitting at the wheelchair, Staff #900 then contacted the executive director/Staff #16 about something going on inappropriately, the other nurse in the room asked him to call the police, but instead he called 911 to report about a sexual in nature situation going on.An interview was conducted on July 16, 2025 at 11:48 AM with the Director of Nursing (DON/Staff #70) in the conference room. The DON stated that abuse training is done upon hire, annually, and they have a lot of abuse training throughout the year. She stated that they discuss types of abuse, and suspected abuse is reported immediately to the abuse coordinator, DON, so residents can remain safe immediately. The DON stated that abuse can be sexual, verbal, and involuntary seclusion. She stated that sexual abuse is when somebody does not want to be touch, touching in sexual manner that is not wanted, if a resident does not want to be touch and then touch is sexual abuse. The DON stated that she submitted a sexual abuse 5-day investigation report regarding Resident #3 and Resident #4, she has to go back to check her email, and stated that she finds it odd that a State surveyor was asking a confirmation email regarding submission date of the report. The DON stated that she wrote the report and her conclusion involving Resident #3 and Resident #4 investigation was that no abuse occurred. Furthermore, the DON stated that it appeared that the residents being investigated were in the room together, appears that their pants were down, did not appear any intercourse took place, their staff responded immediately, and both residents denied any intercourse happened. The DON stated that Resident #3 was very complex, has expressive aphasia, sometimes Resident #3 can communicate better than others, Resident #3 knew where the DON office was located, Resident #3 knew her friends, Resident #3 has pseudobulbar which the DON explained and gave an example such as when laughing their sad and crying their happy. The DON stated that there was no psychosocial effect on both residents after the incident, and the residents were followed up every day by monitoring any change of condition. In addition, the DON stated that in the residents' progress notes has both residents were disappointed that they were separated. The DON stated that Resident #4 was placed on a one on one with staff, and even after Resident #4 was discharged , Resident #3 was visiting her office.On July 16, 2025 at 01:36 PM, a second phone call was placed to Staff #700 for an interview. There was no return call.An interview was conducted on July 17, 2025 at 11:49 AM with the administrator/Staff #16 in his office. The administrator stated that cameras are placed in common areas and outside. The camera records short amount of time but it deletes and it does not get saved. The cameras are based on movements. The administrator stated that there would be no footage to review for instance a last month's footage.An interview was conducted on July 18, 2025 at 10:34 AM with a CNA/Staff #124. Staff #124 stated that she works day shift from 6 AM to 6 PM. Regarding call lights, she answers calls that are flashing on top of the door, she does her every 2-hour rounds to check on her residents and sometimes a little bit earlier to see if her residents were okay. She stated that if she observes a resident going to another resident's room, she will talk to the resident, she will assist the residents to where they will go. When residents are in dining room, Staff #124 stated that there is two CNAs in the dining room, residents are never left alone, one CNA always stays while the other CNA takes the other residents back to their room, and there is always staff in the dining room. Regarding reporting abuse, she will call the administrator and report what she saw. For instance, if she witnessed a resident touching another resident inappropriately such as touching the boobs, thighs and legs and even grabbing, she will separate the residents because she considers it sexual abuse. Another instance is, if she finds a female resident in a male resident's room, she will separate the residents right away, she would take the female resident out of the room because there is another male resident in that room and she would not leave her in that room, and she will notify her nurse using her radio and also, she will notify the administrator which is the abuse coordinator. Staff #124 stated that if anything happened, the abuse coordinator will look at the camera footage in the hallway. Furthermore, Staff #124 stated that hitting someone's head and hands is a form of abuse, its physical abuse, and throwing items at resident is abuse, spitting is abuse, and grabbing a resident's private area is sexual abuse.On July 18, 2025 at 11:33 AM, Resident #9 was observed in her room sleeping.A follow up interview was conducted on July 18, 2025 at 11:39 AM with the DON in the conference room regarding Resident #3 and Resident #4. The DON stated that while looking at the provider's progress note dated June 18, 2024, the progress note revealed that there was no penetration as per staff, and when the staff entered the room the staff stated that they did not see any penetration, no erection and that is what the report revealed. Regarding camera footage review of the incident, the DON stated that Resident #3 entered Resident #4's room after coming from the dining room, and that she will check her notes regarding the camera footage time. In addition, the DON stated that if resident was assessed for behavioral symptoms on admission such as grabbing, kicking, the staff will create a baseline care plan, and the assessment of the resident is ongoing. After a week or so, if the behavior symptoms are exhibited towards staff, the staff might implement a case by case basis such as cares and pairs, and or get psych involved. The interventions such as cares and pairs and psych involvement will be documented in the care plan and progress notes. At 12:48 PM, regarding the allegation of abuse with Resident #3, the DON came back to the conference room and stated that she cannot find the exact time of the camera footage and she stated that it was just after dinner from the dining room.On July 18, 2025 at 3:02 PM, received the contact information from the administrator/Staff #16 for CNA/Staff #901. A call was placed to Staff #901 and was unable to make contact.A review of facility's policy titled, Abuse: Prevention of and Prohibition Against, with a revision/reviewed date of September 2024 revealed that it is the facility's policy that each resident has the right to be free from verbal, sexual, physical, and mental abuse.

The facility failed to adhere to infection control guidelines in the medication storage room. This deficient practice could compromise resident medication safety. Findings include, A medication room tour was conducted with the Director of Nursing (Staff # 24) and Licensed Practical Nurse (Staff #105) on February 19, 2025. The following were observed: -Medication room sink contained white, brown, and black unidentifiable debris in the basin. -The purple curtain covering the area under the sink has an unidentifiable light brownish substance in a non-uniform splash throughout the material. -A cardboard box with an array of medical supplies is stored directly underneath the black polyvinyl chloride (PVC pipe), under the sink, beside a stack of plastic rectangular small storage bins. The brown paneling affixed to the water faucet line has streaks of dark discolorations. Towards the paneling sink divider there is a grayish colored panel with a significant amount of dark colored discolorations. Toward the bottom of the gray panel, there is visible dry wall, which has some crumbling of the white substance onto the floor. - An orange tackle box, which was identified as emergency kit, was stored under the sink. - Additional paneling under the sink, in the area where the copper waterlines and the black PVC pipe with silver clamp located, has dark discolorations on the board. The area with the densest concentration of dark discolorations runs parallel to the PVC pipe. -A card box without flaps is stored under the sink, containing additional medical supplies. Inside the box is a plastic bin which contains items such as a remote, and a biohazard bag of badge clips. - In the corner of the sink counter is a BladderScan machine, which is streaked down the middle with a light color discoloration. Scanning Systems is written on the top green portion of the barcode label. The machine is walled by a cardboard box of resident medications, multiple blister packs, and a temperature scanner. -Under the stack of blister packs, the wall between the counter and wheeled cart, and on the side of the wheeled cart are splashes of a dried, crusted, and brown substance. - The Over the Counter Shelf area contains a bottle of Biotene Dry Mouth Oral Rinse, which has stains of dark and light brown dried substance on the bottle. -The LPN (Staff # 105) retrieved a lockbox from the top of the refrigerator. Once opened, the box included a glucometer, and a bottle of testing strips. The LPN and the surveyor both observed dried brown stains on the glucometer and the test strip bottle. -An expired dark bottle of Nystatin suspension 100,000 mg, was located on the shelf in the medication room. There is a build up of a yellow crusted solution beginning under the tamper proof cap, and protrudes down the sides of the bottle. There is a grayish fingerprint present on the third white label on the back. All three white labels are stained with a grayish substance. The bottle reaches close to the 2 of 6 measurement mark on the side of bottle. -The counter area in front of the storage containers, housing the red end caps, and clear vacutainers, has residual pieces of ,d+[DATE] inch transparent tape, with the borders stained with black substance. -An uncovered bin located on the floor, in the corner between the refrigerator and resident medication area, has a co-mingling of resident medications. Some of the medications are loose, some are enclosed in Ziploc bags, and others in personal belongings bags. There is also a biohazard bag with three medications inside, belonging to two different residents. An interview conducted with the DON on February 19, 2025 during the medication room observation beginning at 8:36 a.m., stated the cleanliness of the room and bottles is potentially an infection control issue. The DON further elaborated the expectation of the medication storage area, as all areas, is maintaining clean, organized, and sanitary conditions. The DON revealed that the current state of the medication storage room does not meet facility expectations. The DON stated that part of the process of keeping the area clean, is having the housekeeping staff (under the supervision of a licensed nurse), clean the area every morning. An interview conducted with the LPN (Staff # 105) during the morning medication room observation on February 19, 2025 beginning at 8:36 a.m. revealed that the stored glucometer failed to meet facility expectation of achieving the infection control goals. The LPN further elaborated that the unit was used by a resident that has now been discharged , however the meter and strips should have been cleaned and disinfected according to facility policy and manufacturer guidelines. The LPN explained that improper cleaning and disinfection of the glucometer can spread of disease. A panel discussion was held with members of the resident council conducted on [DATE] at approximately 11:10 a.m. The panel voiced significant contentment with the care they received at the facility. Regarding medication administration, the panel agreed that the staff are competent and have the utmost faith and trust that the staff properly handle their medications. An interview was conducted during medication pass with LPN (Staff # 161) on February 20, 2025 at approximately 9:00 a.m. The LPN explained that maintaining a clean, organized, and sanitized medication cart is important to decrease the risk of spreading pathogens. The LPN admitted the medication storage rooms also should have the expectations. The LPN explained that resident safety is one of the reasons for cleaning and sanitizing the glucometer after each resident use. The LPN voiced that leaving blood stains on the meter and test strips was against facility expectation, and can place the resident at risk for illness. An interview was conducted with the facility pharmacist (Staff # 300) on February 20, 2025 at 1:12 p.m. The pharmacist voiced that the expectation of medication carts and storage rooms are to be clean, sanitary, and orderly at all times. The pharmacist stated the co-mingling of used resident medications can increase the risk of cross-contamination, and becomes even more worrisome if a resident is discharged and takes a potentially contaminated medication home. The pharmacist continued that expectation is that resident home medications and discontinued medications are separated, secured, and handled properly as directed by facility policy in order to avoid cross contamination. The storage of a contaminated glucometer in the medication room, the pharmacist felt, was a violation of facility policy and health risk. The storage of resident medical supplies on the floor and under the sinks, the pharmacist explained, can cause contamination, which does not meet facility expectation. Stained and spills on medication bottles stored in clean areas with other medications, do not meet facility expectations either, according to the pharmacist. The 2024 Facility Assessment revealed their population averages 30 residents on Enhanced Barrier Precautions (EBP), and 7 residents on Transmission Based Precautions (TBP). The facility's Infection Control policy reflects a goal to decrease the risk of infection to residents and personnel. The facility's Medication Access and storage, E Kit Access policy dictates that storage areas are kept clean, well lit, and free of clutter.

Based on observations, interviews, clinical record review, facility documentation, and facility policy, the facility failed to ensure safeguards and systems were in place to control, and account for controlled medications in order to prevent loss, diversion or accidental exposure for three residents (#4, #329, and #330). This deficient practice could result in staff diversion of a resident's controlled medications. Findings include, -Resident # 4 was admitted to the facility on [DATE], with diagnoses that include anxiety, depression, unspecified dementia, and epilepsy. The consent form for treatment with psychotropic medications acceptance for resident was dated on November 15, 2017. Lorazepam 2 milligrams (mg) was ordered for as needed use for seizures on May 26, 2020. The care plan for anti-anxiety medication use for seizures was initiated on January 19, 2021. The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview Mental Status (BIMS) score of 3, indicated a significant impairment in cognition. A notice from the president of the facility's long-term care pharmacy dated February 20, 2025, revealed Lorazepam 2 milligrams (mg) Carpuject syringe was dispensed from the pharmacy on August 14, 2024. The Controlled Drug Receipt/Disposition Log form identified one pen syringe of Lorazepam Injection Prescription (Rx) # 2384163 was disposed of by two licensed staff members. The date of disposition is not recorded on the log. The Controlled Drug Receipt/Disposition Log form identified 30 milliliters of Lorazepam 2 mg solution Rx # 10286425 was disposed by two licensed staff members. The date of disposition is not recorded on the log. The Controlled Drug Receipt/Record/Disposition form confirmed 30 ml of Lorazepam 2mg/2 ml, Rx # 10286425 was received on July 25, 2024. The record fails to reflect the signature of nurse receiving the medication. No entries were recorded in the section for Disposition of Remaining Doses. No date or rationale was provided for the reason of the two signatures in the body of the form. The Controlled Drug Receipt/ Record/Disposition form confirmed a licensed nurse received the Lorazepam 2mg/ml, Rx # 2215224/001 on August 14, 2024. No entries were recorded in the section for Disposition of Remaining Doses. No date or rationale was provided for the reason of the two signatures in the body of the form. A Carpuject Syringe of Lorazepam 2 mg/1 ml belonging to the resident was observed with a break in the tamper seal integrity was observed in the narcotic refrigeration in the medication room with the Director of Nursing (DON/Staff # 24), and the Resource Licensed Practical Nurse (LPN/Staff # 105) on February 19, 2025 at 8:36 a.m. An interview was conducted with the DON and Resource LPN on February 19, 2025 at approximately 8:36 a.m. in the facility medication storage room. Both parties were unaware of the break in the tamper seal integrity and revealed the need to investigate the matter further, as this was not a facility expectation. An interview was conducted with the DON and Resource LPN on February 19, 2025 at approximately 2:50 p.m. revealed both parties agreed that the syringe with the tampered seal was disposed of properly. An interview with the facility's Registered Pharmacist (Staff # 300) on February 20, 2025 at 1:12 p.m. revealed that the intramuscular (IM) Carpujet injections requires its own injector and thus a special needle has to be available in order to use the syringe. The pharmacist stated that the Carpujet syringe system is used rarely, and that she would expect the nursing staff to not be well versed on its operation. The Pharmacist stated that if the integrity of the tamper seal was compromised it should have been reported according to facility policy immediately. -Resident # 329 was admitted to the facility on [DATE] with clinical diagnoses that included congested heart failure, dependence on supplemental oxygen, dementia, and hypotension (low blood pressure). A progress note dated December 8, 2024 identified the daughter as the resident's surrogate decision maker. The resident's inventory of personal effects with the admitted [DATE] does not reflect any medications either on admission or at discharge. The responsible party discharge section was signed, but not dated. There was no signature or date entered in the staff portion for inventory on discharge. The admission hospice orders dated December 23, 2024, revealed the resident was ordered Lorazepam .25 ml every four hours as an as needed comfort medication. The Controlled Drug Receipt/Record/Disposition Form for Rx # 10508766 Lorazepam 2mg/ml dispensed date of December 23, 2024, revealed two licensed staff members signed of on a 30 ml entry February 19, 2025 at 10:00 a.m. No entries were made in the disposition portion of the form. Documentation reflected the daughters wish to have the facility destroy the medication. The discharge MDS dated [DATE], revealed the resident was discharged home to hospice. The resident had a BIMS score of 15, indicating the resident was cognitively intact. The MDS does not reflect the resident use of anti-anxiety medication. The discharge summary and post discharge plan of care dated December 31, 2024 revealed that the resident received their personal belongings, and any remaining medications, as instructed by the provider order. An order dated December 31, 2024 revealed the resident was to be discharged with hospice with all remaining medications, including narcotics. A progress note dated December 31, 2024 revealed all discharge paperwork and all remaining medications went with resident along with all personal belongings. The Medication Administration Record (MAR) for December 2024, does not reflect the administration of any doses of the ordered Lorazepam to the resident. During the medication room observation on February 19, 2025 at 8:36 a.m. the DON could not explain the reason for the resident's Lorazepam ended up with other medications in the resident medication return box. The DON stated that not properly storing and securing controlled medications is against facility policy and has the potential for diversion. The DON, February 19, 2025, at approximately 2 pm. stated the resident's surrogate decision maker was contacted, and permission was granted for the facility to dispose of the controlled substance. An interview was conducted on February 20, 2025 at 10:42 a.m. with Resource LPN (Staff # 105) who revealed if a resident is admitted with home medications the nurse will tell the resident/family that the facility cannot use these, and the family can take it home. The inventory list is completed on admission and again at discharge. In a panel discussion conducted with the resident council on February 20, 2025 at 11:45, the participants stated on admission, if medications were bought with them, they are collected and sent back to their home with family members. During the discussion, no panel recipient was able to recall seeing or receiving a copy of their inventory sheets. An interview with the Pharmacist (Staff # 300) was conducted on February 20, 2025 at 1:12 p.m. The pharmacist is uncertain as to how the medication fell out of proper chain of custody. The Pharmacist explained that Lorazepam is a controlled substance, and strict adherence to chain of custody is of utmost importance for resident safety, and to prevent medication diversion. In addition, the pharmacist stated the medication are returned to the residents with an order, and if the medication does not go home with the resident, it is destroyed at the facility per protocol. -Resident # 330 was admitted to the facility on [DATE] for orthopedic aftercare following a leg fracture, with diagnoses of anxiety disorder, depression, insomnia, and unspecified dementia. The admission MDS dated [DATE] revealed the resident had a BIMS score of 11, which indicated moderate cognitive impairment. An order for Alprazolam .25 m, give two tablets twice a day was initiated on February 11, 2025 The care plan for anti-anxiety medication, initiated February 12, 2025, called for the consideration for reducing prescription therapy when clinically indicated. The MAR reflected the resident's refusal of the prescribed Alprazolam .25 mg one tablet for anxiety on February 20, 2025. An order dated February 12, 2025 revealed Alprazolam .25 mg to be held from February 12, 2025 to February 18, 2025. An order dated February 19, 2025 revealed Alprazolam .25 mg was reduced to one tablet every 12 hours for anxiety. The Controlled Drug Receipt/Record/Disposition form for Rx # 2498847 Alprazolam .25 mg tablet, dated February 11, 2025 at 11 p.m. through February 19, 2025 at 11:10 p.m. revealed the quantity dispensed as 18 which had a strike through to change the quantity to 9. The record reflects only one licensed signature is present on each line of the count. The record does not reflect a count being completed at morning shift change by 2 licensed nurses. The ending quantity count was recorded as 3 for February 19, 2025 at 11:10 p.m. The Controlled Drug Receipt/Record/Disposition form for Rx # 2498847 Alprazolam. 25 mg tablet, dated February 11, 2025 through February 20, 2025 revealed the quantity dispensed as 18 which had a strike through to change the quantity to 9. The directions from the previous log sheet are covered by a note stating Directions Changed, Refer to Chart. The record fails to reflect the date on which the change occurred. On February 20, 2025, the entry reflects two licensed signatures wasting 1. The documentation does not reflect if the 1 refers to the count by tablet or by blister (each blister contained 2 tablets). On February 20, 2025 at 8:50 a.m. the ending quantity count was recorded as 3. The ending count remained unchanged from February 19 - February 20, despite having a waste and no additions to the count. During medication pass observation (med pass) with LPN (Staff # 163) on February 20, 2025 at 8:18 a.m. the surveyor and LPN observed a break in the packaging integrity of the resident's Alprazolam .25 mg blister pack. Upon closer inspection, it was observed one tablet was missing from the compromised blister. During the narcotic log comparison to actual quantity on hand a discrepancy was detected, where there were 7 tablets present, but a total of 6 tablets were recorded. At the conclusion of the interview, all narcotics were returned and locked in a separate drawer so the Director of Nursing could be alerted. An interview was conducted with the LPN (Staff # 163) during med pass on February 20, 2025 at 8:18 a.m. The LPN was not aware of the break in blister integrity, and stated it would have been caught during a narcotic count and immediately reported to the Director of Nursing. The LPN voiced the importance of a two-person narcotic count, and understands her liability and responsibility for the medication cart and narcotic counts. Further discussion revealed the Lorazepam was counted by number of blisters instead of number of tablets, and in this case, each blister contained two tablets. The LPN confirmed the actual tablet count of seven did not match the narcotic count log count of 6. The nurse explained that the pharmacy quantity of 18 was changed to 9 to reflect the number of blisters. The LPN reviewed the chart and stated there was an order change which reduced the dose from 2 tablets to 1, so the extra tablet was not wasted according to policy. The LPN voiced incorrect narcotic counts is not a facility expectation and can be problematic. -Facility Written correspondence was initiated with the Arizona State Board of Pharmacy on February 20, 2025 at approximately 10:00 a.m. According to the State Board of Pharmacy, their duty is to regulate long-term care pharmacies, while the DEA office handles controlled substances issues the long-term care facilities. The board expects that when substances are delivered to the facility under a patient-specific order, intended for patient administration, it becomes the responsibility of the staff for safe and appropriate storage. In addition, the board requires the supplying pharmacy to record/ inventory all the way down to the specific total quantity level, instead of counting by number of blisters. An interview was conducted on February 20, 2025 at 1:12 p.m. with the Registered Pharmacist (Staff # 300). The pharmacist revealed the improper storage of controlled substances, and breaks in integrity of blister and tamper seals do not align with pharmacy and facility policy. The pharmacist was appreciative of the feedback and is making plans to further investigate and plan education/training for the staff. The facility's Medication Access and Storage, E kit access policy revealed Schedule IV controlled substances are stored separately from other medications in a locked drawer or compartment designated for that purpose. In addition, reconciliation of controlled medications is done at least every shift by the incoming and outgoing Licensed Nurses at change of shifts. The policy further instructs for discharged residents' narcotic medications are to be turned into the Director of Nursing for destruction. The policy also mandates that reconciliation of controlled medications are done at least every shift by the incoming and outgoing licensed nurses at change of shifts. The facility's Medication Destruction policy advises that discontinued medications and medications left in the facility after a resident's discharge, which do not qualify for return to the pharmacy for credit, are destroyed. It further revealed that controlled substances are retained in a securely locked area with restricted access until properly destroyed.

Based on observation, staff interviews, and policy review, the facility failed to ensure that medications in the medication storage room were stored appropriately and that expired medications were discarded or disposed of in accordance with professional standards. The deficient practice could result in the medications not being disposed of properly, and not being organized appropriately. Regarding medication storage During an observation of the medication storage room conducted with the Director of Nursing (DON/staff #101) on February 19, 2025 8:27 a.m, approximately 13 medication bubble packs were observed to be lying on the counter, along with 6 other boxes of medications, one COVID-19 test kit, a sharp container, a portable thermometer, and a glucometer. The medication bubble packs included: Dicyclomine caps 10 mg, Gabapentin caps 300 mg, Montelukast tabs 10 mg, Midorine tab 5 mg, Levothyroxine tabs 75 mcg, Benzonatate caps 100 mg, Atovastatin tabs 20 mg and Furosemide tabs 40 mg were stacked up on the counter. The 6 boxes of medications included: four boxes of Enoxaparin 40 mg per 0.4 ml, and one box of Albuterol 2.5 mg/3 ml, and one box of Ipratropium Bromide 0.5mg/ Albuterol Sulfate 3 mg. The medications were identified to belong to five previously discharged residents. There was no evidence of an organizational system or storage mechanism for discontinued medication storage. Further observation revealed a plastic bin on the floor next to the medication refrigerator. Inside the bin was an array of different medications that belonged to another five residents who had been discharged during 2024. The medications included: Clonidine tabs 0.1 mg, Nitroglycerine 0.4 sub tab, Memantine HCL 10 mg tabs, Cresemba 186 mg. One of the medicines, Cresemba, was stapled to a brown paper bag with a sticker that contained a handwritten note please send this med with the family home. Also, a bottle of Lorazepam, a schedule IV medication, was found in the bin with no evidence of a secondary lock. An interview was conducted following the medication room observation on February 19, 2025 at 8:36 a.m with the DON, who stated that the Pharmacy staff and team were responsible for conducting inventory and removing the discontinued medications. The DON explained that there are certain medical runners from the Pharmacy that bring in the medications and they could not pick up medications and that was the reason why medications were stacking up in the storage room. The DON also stated that she had a medication shredder machine in her office that she used to shred the medications of discharged residents that have been removed from the bubble packs. The DON stated that she had not destroyed the medications because it was safe and locked in the medication room. The DON also stated that she did not know why the bottle of Lorazepam ended up with the other medications in the plastic bin. She confirmed that the risk of not properly storing medication could result in other problems such as medication diversion. Regarding expired medications During an observation of the medication storage room conducted with the DON on February 19, 2025 at 8:50 a.m, two expired over the counter (OTC) medications were observed on a shelf above the medication room counter. The three boxes observed included: two boxes of Octreotide acetate injections 100 mcg/ml that expired January 2025 and one box of Nystatin suspension 100,000 mg that expired on February 6, 2025. An emergency box with expired medications inside was also identified under the sink. The DON stated that the staff are not using this emergency kit which is why they placed it under the sink. The DON identified and agreed that there are risks if nurses accidentally pull out this emergency kit during an emergency and that the risk of using the expired medications poses an extreme health outcome in the lives of the residents. The DON also stated that she is responsible for disposing expired medications and the medical storage room should not have any expired medications at all times. An interview was conducted on February 20, 2025 at 1:12 pm with a Registered Pharmacist (staff #300), who stated that Lorazepam and other controlled substances are stored in a secured locker and are typically destroyed by the nurses. The Pharmacist also stated that when a resident is discharged , narcotic medications are pulled out of the medication cart, and another nurse verifies that the amount matches and both the Pharmacist and the nurse sign off on the narcotic sheet. The narcotic log book stays with the medication bubble pack until the medication is destroyed and then the narcotic sheet is uploaded into the residents' record. The Pharmacist stated that the time to destroy the discharged residents' medications depends on the facility's policy and procedures. The facility policy titled, Medication Access and Storage, E Kit access, stated that all drugs and biological products must be stored in locked compartments under proper temperature controls, and the storage room should be kept clean, well lit, and free of clutter. Also, the policy stated for scheduled III & IV controlled medications are stored separately from other medications in a locked drawer or compartment designated for that purpose. Moreover, the policy stated that expired medications are immediately removed from the stock, disposed of according to procedures for medications destruction processes. Finally, the policy stated that discharged residents' medications shall be turned into the DON for proper destruction.

Based on observation, staff interview, and policy review, the facility failed to maintain a clean and sanitary kitchen; and, failed to ensure that expired food items were not available for resident use. The deficient practice could result in a potential for food borne illness. Findings include: An initial observation of the kitchen was conducted with kitchen manager (staff #35) on [DATE] at 8:30 a.m. The following expired food items were found in the refrigerator: -One open one-gallon container of [NAME] mayonnaise with an expiration date of [DATE]; -Open bag of lettuce with a use by date of [DATE]; and, - A 4-quart container of parmesan cheese with a use by date of [DATE]. A testing of four buckets of the sanitizer solution was conducted; and, three out of four buckets tested did not change the color of the test strip. An interview was conducted immediately following the observation with a kitchen staff who stated they had not changed the bucket sanitation fluids since earlier that morning. The kitchen manager stated that the expectations was that the sanitation buckets are at the required 200 ppm (parts per minute) at all times to prevent food borne illness and cross contamination of working surfaces for food and staff complete the logs following completion of their tasks. During an observation of puree food preparation was conducted with staff #199, #200, #35 and #221 on [DATE] at 11:05 a.m. Staff #199 prepared the main dish of goulash to what she stated was a pureed consistency; and that, the food was ready. She did not taste the food then placed the pureed goulash in a heating dish to be served to those with a puree diet. Staff #199 stated that she knew the goulash was in a pureed consistency just by looking at the food. The pureed goulash was tasted during the observation and reveled that the pureed goulash was thick and grainy, with large particles of food and did not have a smooth consistency. Staffs #221, #35 and #220 sampled the pureed goulash and staffs #221, #35 and #220 stated that the pureed goulash was not prepared at the required consistency. Staff #221 stated the risks of serving the pureed goulash could pose a risk for choking or aspiration for a resident with a puree diet. Review of the facility policy on General Food Preparation and Handling dated 2018 included that food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of harmful organisms and substances. The kitchen will be kept neat and orderly. The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. The facility policy on Employee Sanitary Practices revealed that all nutrition and food service employees will practice good personal hygiene and safe handling procedures.

Based on clinical record reviews, an observation, staff interviews, and review of facility policies, the facility failed to ensure that a blood pressure medication was administered as ordered for one resident (#6) and failed to ensure that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The deficient practice could result in residents not receiving medications as ordered by the physician and could result in increased risk of side effects. Findings include: Regarding the blood pressure medication -Resident #6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to hold the medication for a Systolic Blood Pressure (SBP) greater than 120 millimeters of mercury (mm Hg). A care plan initiated on December 11, 2021 for altered cardiovascular status included a goal that the resident would be free from signs and symptoms of complications of cardiac (heart) problems. Interventions included to administer medications as ordered and perform vital signs as ordered. Review of the admission Minimum Data Set (MDS) dated [DATE] revealed the resident scored a 5 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. A review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation conducted on December 21, 2021 at 8:30 am of medication administration for the resident, a Licensed Practical Nurse (LPN/staff #153) held the [MEDICATION(S)] for a blood pressure greater than 120 mm Hg. At that time, the LPN stated that the provider would need to contacted to clarify the order. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included a change in that it noted to hold the medication for a SBP less than 120 mm Hg rather than holding the medication for a SBP more than 120 mm Hg. During an interview with a LPN (staff #153) on December 22, 2021 at 1:08 pm, the LPN stated that the resident had an order to hold the medication if the SBP was greater than 120 mm Hg. The LPN stated that this did not seem correct as the resident had hypertension and the medication is used to treat hypertension. The LPN stated she held the medication on December 21 because the resident's blood pressure was outside of the ordered parameters. The LPN stated this would be documented and the provider would be notified. The LPN acknowledged that the medication had been given outside of the ordered parameter multiple times in December 2021, including on December 17 when the LPN had administered the medication. The LPN said that the medication should not have been given on that day and the provider should have been called to clarify the order at that time. The LPN did not recall why the medication was administered outside the ordered parameter. In an interview with the Director of Nursing (DON/staff #106) on December 22, 2021 at 1:20 pm, The DON stated that provider orders should be followed as written. The DON stated that the order for the resident was entered into the system incorrectly and that the staff should have contacted the provider for clarification to ensure the medication was administered correctly and as ordered. The DON stated that the resident needed the medication and that the hold parameters were entered backwards as it should have read to hold the medication when the SBP was less than 120 mm Hg, not to hold it when the SBP was more than 120 mm Hg. Review of the facility's policy regarding physician orders, revised May 2021, revealed a policy statement that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. A second policy statement included that the the facility will accurately implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A facility policy for the administration of drugs, dated August 2021, revealed a policy statement that medications shall be administered as prescribed by the attending physician. The policy included that medications must be administered in accordance with the written orders of the attending physician. Regarding orders for insulin and blood sugar monitoring -Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order included to notify the provider if the blood sugar is less than 60 or greater than 300 milligrams per deciliter (mg/dL). Review of the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The clinical record did not include documentation of notification to the provider when the resident's blood glucose was greater than 300 mg/dL. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This order was discontinued on December 10, 2021. Review of the MAR for December 2021 revealed that the resident had a blood sugar value of over 400 mg/dL on December 10, 2021. The correct dosage of insulin was provided. The clinical record did not include documentation that the resident's blood sugar had been rechecked in 60 minutes. There was no evidence that the provider had been notified. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for December 2021 revealed that the resident had a blood sugar value of over 400 mg/dL on December 11, 2021. The correct dosage of insulin was provided. The clinical record did not include documentation that the resident's blood sugar had been rechecked in 60 minutes. There was no evidence that the provider had been notified. An interview was conducted with a Registered Nurse (RN/staff #40) on December 22, 2021 at 12:02 pm. The RN stated that when caring for resident #1 there was a lot going on. The RN stated that on admission on December 9, 2021, she completed the resident's blood sugar and that it was high, but the resident was not as concerned about that as he was about his incontinence. The RN stated she contacted the Nurse Practitioner (NP/staff #154) via a phone call to discuss placement of a urinary catheter and the blood sugar. The RN stated that she remembered going back to check the blood sugar and that it is good to always check after one hour. The RN stated that it must have been an oversight not documenting the blood sugar or phone call to the provider. The RN stated that if something is not documented, it was not done. The RN stated that the working environment likely contributed to the lack of documentation as it was very busy. During an interview with a LPN (staff #153) on December 22, 2021 at 1:08 pm, the LPN said that they documented the blood sugar reading that was over 401 mg/dL on December 11, 2021 but did not recall rechecking or notifying the provider about the blood sugar reading. The LPN stated that if the blood sugar is greater than 401 mg/dL, the order is to recheck it in one hour after administering the insulin and if it is still elevated, notify the provider. The LPN said the repeat blood sugar and notification should be in the Electronic Health Record (EHR). -Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the MAR for December 2021 revealed that the resident's blood sugar values were greater than 401 mg/dL on more than 5 occasions. The blood sugar value ranged from 407 to 553 mg/dL. Several of these blood sugar readings were documented by a LPN (staff #129). The correct dosages of insulin were provided. The clinical record did not include documentation that the resident's blood sugar had been rechecked in 60 minutes. There was no evidence that the provider had been notified. During an interview with a LPN (staff #129) on December 22, 2021 at 11:10 am, the LPN said that if a resident's blood sugar reading is outside of the ordered parameter, the provider is notified. The LPN said that the notification is documented in the clinical record in either a skilled nursing note or a MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The LPN stated that when the order specifies that a recheck be done, it will be documented in the EHR. The LPN said that even if the follow-up blood sugar is stable, they would still touch base with the provider. The LPN said that if something is not documented, then it was not done and stated that they do not recall notifying the provider for the resident's elevated blood sugars. An interview was conducted on December 22, 2021 at 1:20 pm with the DON (staff #106). The DON stated that based on the order to notify the provider for a blood sugar of greater than 300, the provider should have been notified on December 9, 2021 for resident #1. The DON stated that the NP (staff #154) informed her that she was notified of the blood sugar and decided to address it the following day. The DON stated that the orders for both residents included that blood sugar should be rechecked in 60 minutes and if still elevated to notify the provider at that time. The DON stated that the rechecked blood sugar and notification to the provider should be documented in the medical record. The DON stated that there is no documentation in the medical record of the notification to the provider or the NP (staff #154) for blood sugar values for either of the residents. The DON said that the provider should definitely be notified of a blood sugar value over 500 mg/dL. Review of the facility's policy regarding physician orders, revised May 2021, revealed a policy statement that drugs shall be administered only upon the order of a person duly licensed and authorized to prescribe such drugs. A second policy statement included that the the facility will accurately implement physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#2) received adequate bathing. The sample size was 3 residents. The deficient practice could result in resident grooming and hygiene needs not being met. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An admission note dated November 8, 2021 included that the resident was incontinent of bowel and bladder. The resident's Activities of Daily Living (ADL) care plan, dated November 9, 2021, revealed the resident had a self- care performance deficit related to limited mobility. The goal included to improve and maintain the resident's current level of function. Interventions included praising all efforts of self-care, encourage discussing feeling about self-care deficit, and to encourage participation with each interaction. Review of the clinical record as well as the Certified Nursing Assistant (CNA) shower sheets from November 8 through November 15, 2021, revealed no documentation that the resident was offered, refused, or was provided any showers, bed baths, or any other form of bathing. The clinical record indicated that the resident was discharged from the facility on November 15, 2021. A Discharge Minimum Data Set (MDS) dated [DATE] included that the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating the resident was cognitively intact. The assessment included that the resident required extensive assistance for bed mobility and personal hygiene. The assessment indicated that bathing activity did not occur during the 7-day look-back period of the assessment. During an interview conducted on December 22, 2021 at 8:38 am with a CNA (staff #127), the CNA stated that during the month of November 2021 there were times where ADL care could not be completed for residents. The CNA stated that they were requested to stay late on several occasions to help and that they would try to capture any missing ADL care on the next day. The CNA stated that when ADL care is completed it is documented in the Electronic Health Record (EHR) and that bathing is documented on CNA shower sheets. The CNA did not recall caring for the resident. In an interview with a CNA (staff #139) on December 22, 2021 at 9:25 am, the CNA stated that all showers/baths are documented on paper shower sheets and in the EHR. The CNA stated that in November 2021, they had to stay late to complete tasks, but the CNA did not recall any ADL care being missed for the resident. During an interview conducted on December 22, 2021 at 10:55 am with a CNA (staff #147), the CNA stated that resident showers/baths are documented in the EHR, reported to the nurse, and documented on paper shower sheets. The CNA stated that if a resident refuses the shower/bath, they have the resident sign the shower sheet if they can to document the refusal. The CNA stated that in November 2021 there were occasions when residents did not get baths because the facility was short staffed. An interview was conducted on December 22, 2021 at 12:40 pm with the Assistant Director of Nursing (ADON/staff #82). The ADON stated that audits were completed in November 2021 for ADLs and that they did not recall any issues in care. The ADON stated that none of the staff informed them of any concerns related to residents not receiving showers/baths in November 2021. The ADON stated that the facility hired a staff member to perform showers once a week for every resident at a minimum. The ADON stated that the showers are documented on the shower sheets and that if it is not documented, it was not done. During an interview conducted on December 22, 2021 at 1:20 pm with the Director of Nursing (DON/staff #106), she stated that she was not the DON in November 2021 as she had only been the DON for three weeks. She stated that she does not know of any residents who did not receive showers/baths. Review of the facility's ADL policy, dated July 2021, included a policy statement that resident are given the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in accordance with the written plan of care. The policy included that if a resident is unable to carry out ADLS, the necessary services to maintain grooming will be provided by qualified staff. The policy included that bathing will be offered at least twice weekly, and as needed per resident request. The policy noted that ADL care provided will be documented accordingly.

Based on facility documentation, staff interviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure that multiple staff were tested for COVID-19 at the required frequency. The deficient practice could result in increased risk of COVID-19 transmission. Findings include: During the entrance conference conducted on 11/9/2021 at 9:30 a.m. with the administrator (staff #97) and the Assistant Director of Nursing (ADON/staff #39), they stated that there were currently 10 COVID-19 positive residents in the facility and two staff members who had tested positive for COVID-19. They stated that all of the cases were facility acquired. The ADON said that the residents and the staff were being tested twice weekly because they are on outbreak status which began in early October 2021. She said the testing was being conducted on Tuesdays and Fridays, and the as needed staff were tested on the day of their first shift for the week. The ADON later said that a week for the facility was being defined as Sunday through Saturday. Review of facility documentation revealed a surveillance line list showing that a staff member tested positive for COVID-19 on 10/5/2021. An additional staff member tested positive on 10/25/2021. The facility's staff COVID-19 testing documentation for October 2021 revealed the following: -A Registered Nurse (RN/staff #47) had only been tested on one occasion, 10/25. Punch detail revealed that the RN had worked shifts during the entire month of October. -A Certified Nursing Assistant (CNA/staff #53) had been tested on two occasions, 10/25 and 10/28. Punch detail revealed that the CNA had worked shifts during the entire month of October. -A CNA (staff #123) had been tested on only one occasion, 10/27. Punch detail revealed the CNA had worked shifts during the entire month of October. -A CNA (staff #149) had been tested on ,d+[DATE], 10/20, and 10/25. Punch detail revealed that the staff member had worked shifts during the entire month of October. An interview was conducted on 11/10/2021 at 8:58 a.m. with the ADON (staff #39). She stated that she conducts the COVID-19 testing but has help from other staff such as the unit manager/Licensed Practical Nurse (LPN/staff #4). She stated that they have the testing sheets to review to ensure that staff have been tested . She said this makes it easy to ensure that staff are being tested . During an interview on 11/10/2021 at 11:20 a.m. with the unit manager/LPN (staff #4), she said that she has a log that lists every staff member in the building. The list includes the date and the results of each test. She said that she had instituted this practice on 11/5/2021. She said the ADON and herself had tried to come up with an easier way to keep track of employee testing. She said that originally she did not want anything to do with keeping track of the employees who had received testing and she was not really sure how this was being done at the beginning of October 2021. She stated that the risks for not completing testing would include possibly spreading COVID-19 in the building which would be detrimental to some of the residents. The facility's COVID-19 staff testing requirements policy included that the facility will test residents and staff, including individuals providing services under arrangement and volunteers for COVID-19. The policy noted that the facility will conduct this testing based on parameters set forth by the Secretary. The policy noted that for outbreak testing, all staff and residents will be tested , regardless of vaccination status, every 3 to 7 days until testing identified no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidance, updated September 10, 2021, revealed that if healthcare-associated transmission is suspected or identified, facilities might consider expanding testing of staff and residents as determined by the distribution and number of cases throughout the facility and ability to identify close contacts. If an expanded testing approach is taken and testing identified additional infections, testing should be expanded more broadly. The guidance included that if possible, testing should be repeated every 3-7 days until no new cases are identified for at least 14 days.

Based on facility documentation, interviews, facility policy, and Centers for Disease Control (CDC) guidance, the facility failed to ensure that multiple staff members were screened for signs and symptoms of COVID-19 upon entry to the building. The deficient practice could increase the risk for transmission of COVID-19. Findings include: Review of the facility's employee COVID-19 screening logs for October 2021 revealed the following: -A Certified Nursing Assistant (CNA/staff #149) did not complete COVID-19 screening questions or provide a temperature for approximately 10 days. The punch detail for the CNA indicated the staff member worked those 10 days. -A Registered Nurse (RN/staff #47) did not complete COVID-19 screening questions or provide a temperature for more than 5 days. The punch detail for the RN indicated that the staff member worked on the days there was no completed screening. -A CNA (staff #123) did not complete COVID-19 screening questions or provide a temperature for over 10 days. The punch detail for the CNA indicated that the staff member worked on the days there was no completed screening. -A CNA (staff #138) did not complete COVID-19 screening questions or provide a temperature for more than 5 days. The punch detail for the CNA indicated that the staff member worked on the days there was no completed screening. Review of the facility's surveillance line list revealed that staff #138 tested positive for COVID-19 on 10/25/2021. During an interview on 11/10/2021 at 8:58 a.m. with the Assistant Director of Nursing (ADON/staff #39), she stated that a new Director of Nursing (DON) had been hired three weeks ago, but that was on vacation now. She stated that she ensures that staff complete COVID-19 screening prior to their shift. She said that she spoke to a few staff members and found out that not all of them could say that they completed the screening 100% of the time. She said that all staff complete the screening at the front of the building as this is where they punch in for work. She said that she did not know for sure, but hoped that staff were not clocking in for work without screening. She said that if staff do not complete screening, it changes the whole process of knowing if they are free from symptoms of COVID-19. She said that there isn't always a receptionist at the front desk to ensure the staff are screening and that it is on them at times to ensure they do this. She said that the risk of not screening would include that someone could come to work sick or symptomatic. She said this does not meet her expectations. An interview was conducted with the receptionist (staff #120) on 11/10/2021 at 10:29 a.m. She said she tries to make sure that every person who comes into the building is screened. She said that normally, if she is not at her desk, she tries to make sure that another staff member sits there so that anyone entering the building is screened. The facility's COVID-19 Symptom Assessment and Quarantine/Isolation policy included that it is the policy of the facility that any staff member entering the facility at any time will be screened for COVID-19 symptoms following current CDC, Center for Medicare/Medicaid Services (CMS), State and County specific guidelines. The policy included that screening will be conducted prior to entering resident care areas. The policy included that secondary symptom assessment will be completed for any staff with shortness of breath or cough, or two or more of any other symptoms. Screening questions and guidelines will be modified with any new CDC, CMS, State, and/or County specific guidelines. Review of the CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated September 10, 2021, revealed that a process is to be established to identify anyone entering the facility, regardless of their vaccination status, who may have symptoms of COVID-19 or who meet the criteria for exclusion from work or quarantine. The guidance included that options to do this could include individual screening on arrival at the facility.

Based on observations, staff interviews, facility posting, policy review, and the Center for Prevention and Disease Prevention (CDC) guidance, the facility failed to ensure infection control standards were maintained regarding personal protective equipment (PPE) and hand hygiene. The deficient practice could result in the spread of infections, including COVID-19 to residents and staff. Findings include: During an interview conducted with the Director of Nursing (DON/staff #49) on February 9, 2021 at 9:15 a.m., the DON stated that all residents in the facility were on contact/droplet isolation precautions related to the facility outbreak status. She stated that staff were to be wearing a mask and eye protection at all times. She stated that a medical mask was permitted in all areas except the COVID-19 designated unit which required a N95 mask. The DON stated hall 100 was long term and hall 200 and 300 were observation (including new admissions) units. She stated staff were required to don a gown and gloves before providing care to any resident and that for halls 100, 200, and 300, gowns were hung in the room and used for the shift by staff. The DON stated hall 400 was the designated COVID-19 unit and that staff were required to wear a N95 mask, eye protection, and a gown continuously on that unit. -On February 9, 2021 at 10:31 a.m., a transport staff (staff #155) was observed transporting a resident to their room on hall 200. Staff #155 was observed to be wearing a single layer cloth face covering and sunglasses. Staff #155 was observed to transport the resident into their room without donning a gown and gloves. The resident was on contact/droplet isolation precautions. Following the observation, an interview was conducted with staff #155. Staff #155 stated that he had not been instructed to wear eye protection or a different mask in the facility. Staff #155 also stated that he was not instructed to wear a gown or gloves in the resident's room. -During an observation conducted on February 9, 2021 at 11:50 a.m. on hall 100, staff were not observed to don gloves and a gown when delivering meal trays to three resident rooms, and coffee to one resident room. One staff member was observed to move a resident's belongings to make room to set the meal tray on the bedside table. Another staff member was not observed to perform hand hygiene between the delivery of meal trays to two different resident rooms. -On February 9, 2021 at 12:02 p.m., a Licensed Practical Nurse (LPN/staff #54) was observed standing at the medication cart wearing a cloth face covering on hall 200. At 12:06 p.m., the nurse was observed to enter a contact/droplet isolation room wearing the cloth face covering. An interview was conducted with the LPN (staff #54) following the observation. The LPN stated that she was wearing a cloth mask and that it had three layers and a mesh weave on the inside. Staff #54 stated that she had not discussed the use of a cloth mask with her supervisor and that she was not exactly sure what type of mask she was required to wear. She stated that she felt a cloth mask worked better than the medical masks. The LPN stated that they were supposed to wear PPE in the facility and that she did not know if a cloth face covering was considered PPE. -During an observation conducted on February 9, 2021 at 1:35 p.m., an x-ray technician was observed not wearing eye protection in the core area of the facility. In an interview conducted with the DON on February 10, 2021 at 8:15 a.m., the DON stated that the employees were expected to read the information on the COVID information board. Review of the COVID information board located in the entry hall between the lobby and resident care areas revealed: Frequently asked questions including: What do I wear for contact precautions? Answer: gown, mask, gloves, goggles. What do I wear for droplet precautions? Answer: mask and goggles, basically everyone in the facility is on droplet precautions. Remind people to wear their mask if it is not in place, follow isolation precautions and wash your hands frequently or use hand sanitizer. Reminder: We are still in outbreak status. In order to end it, we must have no new cases for 14 days. Every week we have been getting positive COVID results. This is due to the lack of diligence in wearing proper PPE by staff. Please wear your surgical masks and goggles at all times. Wear gowns when in residents' rooms and wash your hands or sanitize constantly. Facility PPE: eye covering, gown, mask. An interview was conducted on February 10, 2021 at 11:35 a.m. with the receptionist (staff #42). The receptionist stated that she screens everyone entering the facility for COVID-19 and ensures they are wearing the required PPE, a mask and eye protection. Staff #42 stated that only staff and essential workers (i.e., lab, x-ray, doctors) were allowed to come into the building. She stated that if the person entering the facility did not have on the required PPE, she would provide it to them. Staff #42 stated anyone entering the facility had to wear a medical mask and could not wear a cloth mask/face covering alone. She stated that they could cover the medical mask with a cloth covering if they wanted. Staff #42 also stated the required PPE was important to keep the staff/essential workers and the residents safe and to keep from spreading infection. An interview was conducted on February 10, 2021 at 11:46 a.m. with a Certified Nursing Assistant (CNA/staff #28). She stated that nurses and CNAs were required to wear a mask and eye protection when they entered the facility. She stated that she was educated by a nurse to wear a medical mask and that if she wanted to, she could wear a cloth mask over the medical mask. She stated that she was not sure if transport, lab, or x-ray was required to wear eye protection, but that they did have to wear a medical mask while in the facility. The CNA stated all residents were on contact/droplet precautions and to enter a resident's room, she was required to put on a gown and gloves. She stated that it would apply to anyone entering a resident room. The CNA stated if there were only two CNAs working, they would deliver the meal trays without donning a gown and gloves. The CNA stated she would don a gown and gloves if she needed to reposition a resident. She said when there are three CNAs working, they would don a gown and gloves to deliver meal trays. She further stated that they were supposed to don a gown and gloves to deliver meal trays. She also said she performs hand hygiene before entry and after exit from every resident room, and if she touched a resident's belongings. She stated that PPE was important so that they do not spread infection. An interview was conducted on February 10, 2021 at 12:15 p.m. with an LPN (staff #99). She stated that she needed to have her mask on to enter the facility and that she would don her eye protection at the nursing station at the start of her shift. The LPN stated that everyone entering the facility were required to wear a medical grade mask. She stated that a cloth face covering could be used over a medical grade mask but not in place of it. She stated that she worked hall 100 and that all of the residents were on contact/droplet isolation. She stated anyone entering the resident rooms were required to wear a gown and gloves. Staff #99 also stated that she would perform hand hygiene if she touched a resident's belongings. The LPN stated it was important to wear the proper PPE appropriately to prevent the transmission of infection. In an interview conducted with the Infection Preventionist (IP/staff #121) on February 10, 2021 at 1:44 p.m., the IP stated all residents were on contact/droplet isolation related to the facility's COVID-19 outbreak status. He stated that they were following the CDC guidance for PPE use. He stated all staff were expected to wear a mask and eye protection while in the facility and to wear a gown and gloves when in the resident rooms. The IP stated staff had been educated to wear a medical grade or higher mask and that a cloth mask/face covering was not PPE. He stated that no cloth masks/face coverings were permitted unless the staff member had a medical grade mask underneath. He stated that if transport entered the building with a resident, the transport staff should be wearing a mask and eye protection. The IP also stated that the transport person would not be required to don a gown or gloves if the transport person did not transfer or touch the resident while in the resident's room. He stated that sun glasses are not eye protection, and a cloth face covering was not considered PPE. He stated that the transport person should have been stopped at the reception desk and been given education and the appropriate PPE. The IP stated that for meal pass, if the staff member was just dropping off a meal tray and not providing resident care, the staff member would not necessarily need to don a gown or gloves. He stated that staff would need to do hand hygiene after each meal tray delivery. He stated that staff need to don a gown and gloves before touching the resident or the resident's belongings. The IP stated that it was important to wear the right PPE correctly and to perform hand hygiene to prevent transmission of COVID-19 to others, including residents and staff. During an interview conducted with the DON on February 10, 2021 at 2:43 p.m., the DON stated all persons entering the facility must be wearing a medical mask. She said eye protection was required after passing the double doors to enter the core area/nurses' station and was required while on resident halls. She stated that if a person in the facility was not wearing a medical grade mask and/or eye protection, they presented a risk to transmit COVID-19 to themselves and others. The DON stated that she would expect transport and x-ray personnel that entered the facility not wearing the required PPE to be stopped in the front lobby/reception area and be instructed to don or be given the correct PPE before entering further into the facility. She stated that staff would not need to don a gown and gloves to enter a resident room if they kept a distance of 6 feet from the resident and did not touch the resident or anything in the resident's room. She stated that a gown and gloves were required to be donned before touching a resident, a resident's belongings, or surfaces in the resident's room. The DON stated that she would like staff to have a habit of performing hand hygiene before and after entering a resident's room but that it was not a concern if they did not do hand hygiene after a resident room visit in which they did not touch anything in the room. The DON stated the transport staff would not need to don a gown and gloves to transport a resident into their room if they did not touch the resident or the surroundings. Regarding meal tray pass on all units except the COVID-19 unit, the DON stated one staff member should be outside of the resident's room to hand the meal tray to the staff wearing a gown and gloves inside the resident's room. She stated that staff should not be passing meal trays to the residents without wearing a gown and gloves. The DON also stated staff need to change their gown and gloves and perform hand hygiene between residents. Review of the facility's Infection Control and Prevention Policy: Emerging Infectious Disease (EID): Coronavirus disease 2019 (COVID-19) policy revised October 15, 2020 revealed the goal is to implement recommended appropriate infection control strategies, guidance and standards from the local, State and Federal agencies for an EID event. Include preparatory plans and actions to respond to the threat of the COVID-19, including but not limited to infection prevention and control practices in order to prevent transmission. Adhere to standard and transmission-based precautions. Standard precautions assume that every person is potentially infected or colonized with a pathogen that could be transmitted in the healthcare setting. Healthcare personnel (HCP) who enter the room of a patient with known or suspected COVID-19 should adhere to standard precautions and use a respirator or facemask, gown, gloves, and eye protection. Consider having HCP wear all recommended PPE (gown, gloves, eye protection, N-95 respirator or facemask) for the care of all residents, regardless of presence of symptoms. HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Implement universal masking throughout the facility, put on a facemask before entry into care area. Put on eye protection upon entry to the patient room or care area. Personal eyeglasses are not considered adequate eye protection. Put on clean, non-sterile gloves upon entry into the patient room or care area, remove and discard gloves when leaving the patient room or care area and immediately perform hand hygiene. Put on an isolation gown upon entry into the patient care area. Remove and discard the gown in a dedicated container before leaving the patient room or care area. Review of the CDC Preparing for COVID-19 in Nursing Homes updated November 20, 2020 revealed source control measures to be implemented included HCP should wear a facemask at all times while they are in the facility. Cloth face coverings should not be worn by HCP instead of a respirator or facemask if PPE is required. The guidance included reinforcing adherence to standard infection prevention and control measures including hand hygiene and selection and correct use of PPE. HCP should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a face shield that covers the front and sides of the face), gloves, and gown when caring for residents that are new admissions or readmissions whose COVID-19 status is unknown. Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The CDC Hand Hygiene Guidance stated HCP should use an alcohol-based hand rub or wash with soap and water immediately before touching a patient, after touching a patient or the patient's immediate environment, after contact with contaminated surfaces, and immediately after glove removal. Ensure that HCP perform hand hygiene with soap and water when hands are visibly soiled.

Based on county COVID-19 positivity rates, facility documentation, interviews, policy review, and the Centers for Medicare and Medicaid services (CMS) Interim Final Rule requirements, the facility failed to ensure one Registered Nurse (staff #33) was tested for COVID-19 at the required frequency. The deficient practice could lead to the spread of COVID-19. Findings include: Review of the county positivity rate applicable for the facility revealed the rate was greater than 10% for January 2021, which is considered a red classification. Since the county's positivity rate was in the red, the facility would need to test each staff member twice per week per the CMS Interim Final Rule requirements. During the entrance conference conducted with the Director of Nursing (DON/staff #49) on February 9, 2021 at 8:32 AM, the DON stated staff are being tested for COVID-19 twice a week according to the county positivity rate. Review of the facility's COVID-19 testing log revealed a Registered Nurse (RN/staff #33) was tested for COVID-19 on January 11, 18, and 25, 2021 and February 2, 2021. Review of staff #33 punch details revealed the RN worked on January 11, 12, and 13, 25, 26, and 30, 2021 and February 1, 2021. An interview was conducted on February 9, 2021 at 10:15 AM with staff #33. The RN stated that she only works on the COVID unit and that she gets tested for COVID-19 twice a week. An interview was conducted with facility's Infection Preventionist (IP/staff #121) on February 10, 2021 at 12:04 PM. The IP stated staff #33 works on Mondays, Tuesdays and Wednesdays. The IP stated staff #33 is tested for COVID-19 on Mondays and Wednesdays. Staff #121 confirmed staff #33 was did not have the second test for COVID-19 the week of January 11, 2021 and the week of January 25, 2021. Staff #121 stated staff #33 did not work Wednesday, January 27, 2021 and therefore was not tested for COVID-19. The IP stated staff #33 should have been tested for COVID-19 before starting her next shift. The IP stated that he was responsible for ensuring staff were tested twice a week for COVID-19 and that he missed staff #33 not having the second test for COVID-19. In another interview conducted with the IP on February 10, 2021 at 1:44 PM, the IP stated there was no shortage of COVID-19 testing supplies. The IP said staff were constantly being educated to get tested twice a week for COVID-19 because the county positivity rate was still in red. He said management is responsible for making sure staff get tested as required. He stated staff #33 should have been tested twice a week and that there could be a risk for transmission of infection. An interview was conducted with the DON (staff #49) on February 10, 2021 at 2:43 AM. The DON stated staff were to be tested twice a week according to the county positivity rate. The DON stated testing for COVID-19 is being conducted Monday to Sunday. Staff #49 said the IP was making sure all staff get tested and that the IP would notify staffing if any staff missed testing. Staff #49 said if someone refused testing or was not tested twice a week, the staff would be removed from the schedule until they got tested . The DON stated there is a risk for transmission of infection if staff do not get tested twice a week for COVID-19. The facility's policy titled Laboratory Services - Testing Requirements for Covid-19 revised September 15, 2020 revealed routine staff testing will be conducted based on the county positivity rates from the prior week. The policy stated that the facility will monitor the county positivity rate every other week (e.g., first and third Monday of every month) and adjust the frequency of performing staff testing according to the table. The table included staff will be tested twice a week for county positivity rate in the past week greater than 10%. Review of the CMS Interim Final Rule requirements revealed facilities are to test staff on a routine basis based on the extent of [MEDICAL CONDITION] in the community. The facility is to use their county positivity rate in the prior week as the trigger for staff testing frequency. A positivity rate greater than 10% required a minimum testing frequency of twice per week.

Based on clinical record review, observations, interviews, facility policy and Centers for Disease Control (CDC) recommendations, the facility failed to implement proper infection prevention and control practices to prevent the development and transmission of infections including COVID-19. The facility census was 96 residents. The deficient practice could result in transmission of infection in the facility. Findings include: An entrance interview was conducted with the Director of Nursing (DON/staff #123) and the Administrator (staff #1) on November 30, 2020 at 8:42 a.m. They stated that the facility census includes 96 residents of which 27 have confirmed COVID-19. They said that they were in outbreak status and their first confirmed case was on October 13, 2020. The DON said that the 100 and 300 halls were identified as negative COVID-19 units, the 200 hall contained COVID-19 positive residents, residents who had recovered from COVID-19, COVID-19 negative residents, and residents suspected of having COVID-19. The 400 hall was dedicated as the COVID-19 positive unit. -Regarding gown use and isolation signage on rooms in the 200 hall: An observation of the 200 hall, was conducted on November 30, 2020 at 9:43 a.m. A staff member was observed exiting a resident room. The staff member was wearing Personal Protective Equipment (PPE) including an isolation gown, face shield, and facemask and did not remove or change any of the PPE when exiting from the room. A sign on the door indicated that both residents in the room were on contact and droplet isolation and that bed one would be off isolation on December 1 and bed two would be off of isolation on November 30. An observation was conducted on November 30, 2020 at 9:45 a.m. of the 200 hall. A staff member entered a resident room and was wearing eye protection, a facemask, and an isolation gown. The staff member was not observed to change any PPE before entering the room. There was a contact and droplet isolation precautions sign on the door but the sign did not indicate which bed was on isolation. On November 30, 2020 at 9:55 a.m., a Certified Nursing Assistant (CNA/staff #16) was observed exiting a resident room wearing a gown, eye protection, and a facemask. There was a sign on the door to the room indicating that the resident in bed two was on contact and droplet isolation and that this would end on November 26. The CNA sanitized her hands and then entered a second resident room without changing her remaining PPE. The second room had a sign on the door that indicated that both residents were on contact and droplet isolation but indicated that the residents were off of isolation on October 29. An interview was conducted with the CNA (staff #16) on November 30, 2020 at 10:00 a.m. She stated that she puts on her facemask and eye protection when she enters the building. She said she usually works the 200 hall and she puts on a gown prior to entering the unit. She stated that at the weekly meeting, the facility told them that two of the residents on the 200 hall had tested positive for COVID-19. She said that later they were told that all the residents were positive for COVID-19 except for one resident, but that he had been exposed. She said that she wears the same gown between all the residents she cares for on the 200 hall except for the one resident that was negative for COVID-19. She said for the COVID-19 negative resident, she takes off her gown and puts on a new gown, provides care, sanitizes her hands and then uses the new gown to care for other residents. Observations were conducted during the interview with the CNA (staff #16) of the room with the COVID-19 negative resident. The room with the COVID-19 negative resident was observed to contain two residents, there was a contact and droplet isolation sign outside the door but it did not indicate which bed was on isolation. There was nothing posted to indicate that additional precautions were needed for either resident. Further observations of the 200 hall revealed there was no specific signage on any resident door to indicate that additional precautions were required prior to entering the room. An interview was conducted on November 30, 2020 with the Infection Preventionist (IP/staff #34). He stated that the building is in COVID-19 outbreak status and as such all staff are aware that they need to wear all PPE including an isolation gown, gloves, facemasks, and eye protection when caring for any resident in the building. He stated that staff are made aware of this when they conduct daily huddle meetings and he keeps COVID-19 information on a board that is updated. He said that staff are expected to read the information on the board prior to working. He said that prior to the outbreak, staff would be made aware of who was on isolation precautions by a neon sign hanging outside the door. He said that new admissions were being placed in a 14-day quarantine and the sign outside their door would include a date that they could go off of isolation precautions. He stated that since the outbreak, these dates should have been erased because all the resident are on contact and droplet isolation. He said the dates on the doors would not be correct. He stated that the 200 hall is now a COVID positive unit due to the number of positive cases there. He stated that staff can use the same isolation gown to care for multiple residents but only if the residents are diagnosed with [REDACTED]. He said that the same gown could not be used between COVID-19 positive/recovered residents and residents that were negative for COVID-19 as this could cause COVID-19 negative residents to be exposed. He said that there were three COVID-19 negative residents on the 200 hall. He said that two residents had just tested positive for COVID-19 in the 200 hall on this date. Review of the facility's COVID-19 infection control and prevention policy revealed a goal to implement recommended appropriate infection control strategies from local, state, and federal agencies. The policy of the facility was to include preparatory plans and actions to respond to the threat of COVID-19. The policy included that due to the congregate nature and the resident population served nursing home populations are at high risk of being affected by respiratory pathogens like COVID-19. A strong infection prevention and control program is critical to protect both residents and staff. The policy included to educate staff, residents, and visitors about COVID-19 including current precautions being taken in the facility and actions they should take to protect themselves including the correct use of PPE. The policy noted that if extended use of gowns is implemented, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility. The policy noted that because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility wide depending on the situation) is recommended when even a single case among residents or staff is newly identified in the facility; this could also be considered when there is sustained transmission in the community. Review of the CDC guidance on Preparing for COVID-19 in Nursing Homes, updated November 20, 2020, revealed that if extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility. Because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or healthcare personnel is newly identified in the facility. Review of CDC guidance regarding Strategies for Optimizing the Supply of Isolation Gowns, updated October 9, 2020, revealed that risks to staff and resident safety must be carefully considered before implementing a gown reuse strategy. The guidance noted that consideration can be made to extend the use of isolation gowns such that the same gown is worn by the same staff member when interacting with more than one resident housed in the same location and known to be infected with the same infectious disease. For care of patients with suspected COVID-19, staff risk from re-use of cloth isolation gowns without laundering among one single staff caring for multiple patients using one gown or multiple staff sharing one gown is unclear. The goal of this strategy is to minimize exposures to staff and not necessarily prevent transmission between residents. The guidance further noted that reusable gowns should not be reused before laundering because reuse poses risk for possible transmission among patients and staff and this likely outweighs any potential benefits. -Regarding handling and storage of trash on the COVID-19 positive unit (400 hall): An observation was conducted on November 30, 2020 at 10:41 a.m. on the 400 hall, which housed COVID-19 positive residents. A door near the inside entrance to the unit had a posted sign that read temporary biohazard room. Inside of the room there were two red bins with lids open and the bins were too full to close the lids. One bin had a sharps container and at least two isolation gowns not contained on top of the visible closed top red bag in the bin. A second bin had two gloves not contained and sitting on top of the top visible closed red bag in the bin. In addition, there were at least three full, secured, red bags surrounding the bins that were being stored directly on the floor of the room. An interview was conducted on November 30, 2020 at 10:56 a.m. with a Registered Nurse (RN/staff #100) working on the 400 unit. She stated that this hall is a designated COVID-19 unit and all the residents on the unit are positive for COVID-19. She stated that the unit had designated times for laundry and trash pick-up and that the staff would call for additional pick up as needed. She stated that unit staff need to call for pick-up when trash bins were full. She stated that a trash bin should not be filled above the rim and the lid should be closed. She stated that no trash bags should be stored directly on the floor and that the bags should contain all of the trash. She stated that the housekeeping manager was in charge of emptying the bins and should be doing daily checks. She stated the housekeeping manager could only come on the COVID-19 unit at the end of the work day and that the unit staff had the responsibility to call when the bins were full. She stated they did not follow their policy regarding trash handling/storage. An interview was conducted on November 30, 2020 at 3:33 p.m. with the IP (staff #34). He stated that staff need to discard trash and linen into a bag. He stated that when the bag was full staff would take the bag out of the unit by the outside entrance. He stated that trash bins should not overflow, that trash needs to be contained within a liner and placed in a bin and not on the floor. He stated that if trash was not contained properly that staff did not meet expectations for handling/storing trash. He stated staff should have called maintenance to pick up the trash bins when they were full. He stated that trash that is not stored properly results in a risk of contamination of surroundings and surfaces and was not safe. An interview was conducted on November 30, 2020 at 5:31 p.m. with the DON (staff #123). She stated that if the trash is full, the staff should call to get it emptied. She stated that all items should be contained in the bag/liner and placed in a container. She stated that staff did not meet expectations regarding trash handling/storage and increased the risk for spread on infection. Review of the facility policy for waste disposal revealed that all garbage will be disposed of daily and as needed throughout the day. Prior to disposal, all waste shall be kept in a leak-proof, non-absorbent, fireproof containers that are kept covered. These containers are emptied as often as necessary throughout the day. Trash bags shall be sealed prior to removing them from the facility. The CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personal During the Coronavirus Disease 2019 (COVID-19) Pandemic guidance, dated November 4, 2020, states management of laundry, food service utensils, and medical waste should be performed in accordance with routine procedures. -Regarding staff re-use of resident dedicated gown(s) and staff sharing of resident dedicated gown for care of a resident co-infected with COVID-19 and [MEDICAL CONDITION] (C. diff.). Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. diff and COVID-19. Resident #1 was located in a room on the 400 hall. Review of the physician's orders revealed an order dated November 23, 2020 for [MEDICATION NAME] (an antibiotic) 125 milligram (mg) capsule by mouth every 6 hours for [DIAGNOSES REDACTED] for 28 days. A second order dated November 29, 2020 revealed the resident was on contact and droplet isolation precautions. An infection care plan dated November 25, 2020 revealed the resident had a confirmed COVID-19 case on November 13, 2020 (prior to admission) with a goal that included to minimize complications through supportive management of clinical signs and symptoms and management of pre-existing conditions. The interventions included to adhere to transmission-based precautions and to educate staff, residents, and any visitors of COVID-19 signs and symptoms and precautions. A second care plan dated November 30, 2020 revealed the resident had [DIAGNOSES REDACTED] with a goal that the resident would have no complications related to [DIAGNOSES REDACTED]. The interventions included: contact isolation, wear gowns and masks when changing contaminated linens and to place in a private room with contact isolation precautions. Review of the bowel movement report for November 23, 2020 indicated that the resident had both continence and incontinence of bowels and had a loose stool on this date. A nurse progress note dated November 25, 2020 revealed the resident had an active symptom of diarrhea and received education on [DIAGNOSES REDACTED] infection etiology, and reinforcement of infection control with hand washing. The noted included to continue [MEDICATION NAME] by mouth. The bowel movement report for November 29, 2020 indicated that the resident had a loose stool on this date. Review of a nurse progress noted dated November 29 and 30, 2020 revealed the resident had bowel incontinence and was toileted by staff. The notes included skilled treatments of isolation or quarantine for active infectious disease of [DIAGNOSES REDACTED] and COVID-19, contact precautions were maintained, and the resident was to continue on [MEDICATION NAME] by mouth. The Medication Administration Record [REDACTED]. Review of an interdisciplinary team note written by the DON (staff #123) dated November 30, 2020 at 3:54 p.m. revealed a focus that the resident had [DIAGNOSES REDACTED]. The noted stated per staff interviews the resident has had one putty like stool which was last night and that the resident had not had stools today and no bowel movement prior to that. The noted included that the provider would be notified and the facility would discontinue the isolation for now. An interview was conducted on November 30, 2020 at 10:56 a.m. with a RN (staff #100). She stated that her hall, hall 400, was the designated COVID-19 hall. She stated that all of the residents on this hall have active COVID-19. She stated that the resident had a secondary infection of [DIAGNOSES REDACTED]. She stated that staff wear the same gown the whole shift for care of all of the COVID-19 positive residents and additionally cover that gown with a second room gown to care for the resident with [DIAGNOSES REDACTED]. She stated that there should be three separate gowns in the room; one for the CNA, one for the Nurse, and one for Therapy. She stated that the staff would use their gown for the whole shift for working with that resident and would replace the gown if it got soiled. She stated that she had 2 CNAs and that they had assigned rooms. She stated that if the assigned CNA goes into the resident's room they would use the gown that was hanging in the room. She stated that if the CNA that was not assigned to the room were to go into the room he/she would bring a fresh gown for one use. An interview was conducted on November 30, 2020 at 11:12 a.m. with a CNA (staff #135). She stated that the resident had [DIAGNOSES REDACTED]. She stated that she did not have assigned rooms on the unit. She stated that she used the gown hung in the room when she gave care to the resident. She stated that when she enters the resident's room, she takes her continuous use gown off and puts on the gown hanging in the room to care for the resident. She stated there was only one gown hanging in the room and that everyone used that gown all shift and that the gown gets replaced each shift or when soiled. An observation of the resident's room at the time of the interview with staff #135 revealed a single resident in the room, a single gown hanging inside the room, a contact and droplet sign posted by the door, and nothing posted to indicate that additional precautions were needed for the resident. An interview was conducted on November 30, 2020 at 3:33 p.m. with the IP (staff #34). He stated that when caring for a resident with [DIAGNOSES REDACTED], staff should put on a new gown which is to be disposed of after a single use and the staff should wash their hands with soap and water after giving care to the resident. He stated that no gowns should be re-used with a resident that has [DIAGNOSES REDACTED] and that staff should not be sharing any gowns between them. He stated that if staff were sharing a gown if would increase the risk for transmission of infections and that if staff were reusing a gown used for a resident with [DIAGNOSES REDACTED] they could remove the gown incorrectly and risk contamination. He stated that he provides education in huddles, staff meetings, and ongoing updates on the COVID-19 education board. He stated that staff are expected to read the COVID-19 education board before starting their shift. An interview was conducted on November 30, 2020 at 3:37 p.m. with the DON (staff #123). She stated that she was not aware of any current residents on [DIAGNOSES REDACTED] precautions in the building. She later stated that the resident did have [DIAGNOSES REDACTED] and was on isolation precautions. She was interviewed again at 5:31 p.m. and she stated that when caring for a resident on [DIAGNOSES REDACTED] isolation precautions, the staff member could keep their gown on and care for the resident. She stated that when exiting the room, the staff member would be required to remove the gown and replace it with a clean gown. She said that a gown could not be used more than once for a resident with [DIAGNOSES REDACTED]. She said that staff members should not share gowns. She said that if a gown is reused after initial use, it could increase the risk of spreading [DIAGNOSES REDACTED] among residents and staff. Review of the facility's COVID-19 infection control policy revealed a section regarding strategies to optimize current PPE supply. The policy noted that if extended use of gowns is implemented as part of crisis strategies, the same gown should not be worn when caring for different residents unless it is for the care of residents with confirmed COVID-19 who are cohorted in the same area of the facility and these residents are not known to have any co-infections (e.g. [DIAGNOSES REDACTED]). Review of a facility policy on contact precautions for [DIAGNOSES REDACTED] infection revealed contact precautions will be used for specified patients known or suspected of being infected with [DIAGNOSES REDACTED]. This microorganism may be transmitted to patients by the contaminated hands or clothing of healthcare workers by contact with contaminated inanimate or environmental surfaces. The policy included to wear a gown when entering the room and to remove gown before leaving the resident's environment. The policy included to post contact precautions sign on patient's door and to place precaution/isolation cart outside of room. Review of CDC guidance regarding Strategies for Optimizing the Supply of Isolation Gowns, updated October 9, 2020, revealed that risks to staff and resident safety must be carefully considered before implementing a gown reuse strategy. The guidance noted that consideration can be made to extend the use of isolation gowns such that the same gown is worn by the same health care personnel when interacting with more than one resident housed in the same location and known to be infected with the same infectious disease. However, this can be considered only if there are no additional co-infectious [DIAGNOSES REDACTED]. diff) among patients. Review of the 2007 CDC guidelines for isolation precautions: preventing transmission of infectious agents in healthcare settings, last updated July 2019, revealed: [DIAGNOSES REDACTED] is a spore-forming gram-positive anaerobic bacillus. This pathogen is a major cause of health care associated diarrhea and has been responsible for many large outbreaks in healthcare settings that were extremely difficult to control. Important factors that contribute to healthcare-associated outbreaks include environmental contamination, persistence of spores for prolonged periods of time and hand carriage by healthcare personnel to other patients. Considering the greater morbidity, mortality, length of stay, and costs associated with [DIAGNOSES REDACTED] disease in both acute care and long-term care facilities, control of this pathogen is now even more important than previously. Healthcare personnel caring for patients on contact precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. -Regarding a mechanical lift: An observation was conducted at 9:41 a.m. on 11/30/2020 of a sit to stand mechanical lift in the 100 hall outside of a resident room. The lift was visibly soiled with debris that was on both foot placement areas and had a dry crusted area on the right handle of the lift. An interview was conducted with a CNA (staff #39) on 11/30/2020 at 10:10 a.m. She stated that resident care equipment is used every shift and that between each use, she uses bleach wipes to clean the equipment. During an observation on 11/30/2020 at 10:50 a.m., the mechanical lift had been moved to a different place in the 100 hall but continued to have debris on both foot placement areas and a dry crusted area to the right handle of the lift. There was also a smudge on the left side of the lift. In an interview with a CNA (staff #125) on 11/30/2020 at 11:05 a.m., she stated that all shared resident equipment should be wiped down with bleach wipes between uses. She stated that if a lift is not wiped down after use, infection could spread from resident to resident. She stated that sometimes the lifts are wiped down inside the resident's room. She said that when a CNA grabs a lift out of the hallway, they are relying on good faith that it had been cleaned by the previous staff who used it. She also said that if the lift was visibly dirty, it would be cleaned again prior to use. An interview was conducted with a CNA (staff #48) on 11/30/2020 at 3:00 p.m. She said that she works on the 100 hall and there are two mechanical lifts that are in use, one total lift and one sit to stand lift. She stated that there are about 10 different residents that require the use of the two lifts. She said that the sit to stand lift was used at least four times on this date. She stated that after the lift is used, the best practice is to clean it with bleach wipes before putting it back in the hallway and that once a lift is in the hallway, it is considered clean. She stated that if the lift is not disinfected, then it could spread germs from one resident to another. She demonstrated the use of the lift and during this demonstration, multiple areas of the lift that were visibly soiled would touch the resident's body including a smudge in the area near where a resident's knee would touch. The CNA observed this area. She said that the lift would not be considered dirty because it was in the hallway. She stated that she could see the debris on the bottom of the lift where the resident's feet would go, but said that the resident would be protected because they always wear socks while in the lift. An observation was conducted on 11/30/2020 at 4:15 a.m. The lift was in the 100 hall but was in a different location. It continued to be visibly soiled near the foot placement area, the area where a resident's knee would contact, and the right handle area. In an interview with the IP (staff #34) on 11/30/2020 at 4:52 p.m., he stated that there are two mechanical lifts in the 100 hall and they are constantly being used from resident to resident. He stated that the CNAs have been educated to clean them between each use with bleach wipes so that they remain clean and do not spread infection. He stated that after they are cleaned, they are stored in the hallway. He stated that a lift should never be soiled when in the hallway as it should be clean and ready for use. An interview was conducted with the DON (staff #123) on 11/30/2020 at 5:31 p.m. She stated that per the infection control policy, resident equipment that is shared between residents should be cleaned between uses. She said that if not cleaned, the equipment could spread infection. She stated that not cleaning mechanical lifts between resident use would not meet the expected standards for cleaning equipment in the facility. Review of the facility's infection control policy for general cleaning and maintenance of equipment revealed that it is the policy of the facility that all resident care equipment will be cleaned and decontaminated after each use and will be prepared for reuse by the same or another resident. The policy noted that equipment will be cleaned and decontaminated according to the manufacturer's recommendations.

Based on observations, staff interviews, facility documents, review of policies and procedures, and the Centers for Disease Control (CDC) guidelines, the facility failed to ensure that infection control standards were maintained. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Regarding Covid-19 positive symptomatic staff: Review of the staff screening log dated October 30, 2020 revealed a Licensed Practical Nurse (LPN/staff #130) had marked a yes response for having symptoms that included: sore throat, runny nose, or congestion, new loss of taste or smell, muscle pain, and headache. She also marked yes for having contact outside the facility with someone suspected of having, or diagnosed with [REDACTED]. The employee time card dated October 30, 2020 included that staff #130 punched in at 6:00 a.m. and punched out at 8:17 a.m. The staff schedule dated October 30, 2020 revealed staff #130 was assigned to the 300 hall. Review of the staff Surveillance Line Listing included staff #130 tested positive for Covid-19 via a polymerase chain reaction (PCR) test. There was no date of the positive result, no location information regarding where she had worked in the facility at the time she tested positive, no symptoms were recorded, and there was no clearance/return to work date listed on the form. An interview was conducted on November 10, 2020 at 11:15 a.m. with the LPN (staff #130). She stated that she tested positive for Covid-19 on October 26, 2020. She stated she came to work that day, but had to go home sick. The LPN stated that she came back to work on October 30, 2020 and worked on the 300 hall for a couple of hours. She stated that at that time the 300 hall was not a Covid-19 positive unit, and it was not closed off from the rest of the facility. The LPN stated she went home after a couple of hours because she was still too sick to work. She said her symptoms included a cough, headache, sore throat, body aches, chills, congestion, and loss of smell. The LPN stated she returned to the facility to work from sick leave on November 5, 2020 and that she has been working ever since. She stated that she still has a pretty bad cough and no sense of smell. On November 10, 2020 at 2:04 p.m., an interview was conducted with the Interim Director of Nursing (staff #171). She stated that symptomatic staff should not be working in the facility at all. She stated that having a Covid-19 positive/symptomatic staff member working with residents did not meet her expectation. Regarding proper donning of Personal Protective Equipment (PPE), handling of garbage and soiled linens: -During an observation conducted on the 100 hall on November 9, 2020 at 1:10 p.m., a Nursing Assistant (NA/staff #83) was observed assisting a resident in the bed farthest from the door with incontinence care in the resident's room. The curtain between the door and the resident's bed had been drawn for privacy. However, the door of the room had been left open. The NA's legs and feet were visible beneath the curtain, from the knees down. As she assisted the resident, the NA was observed to place the wet linens she had removed from the bed into a pile directly onto the floor. On three separate occasions as she bent over, her PPE/gown was observed to drag across the floor and through the wet linens. After several minutes, the NA was observed to place the wet linens into a plastic bag and place the bag onto the floor beside the resident's bed. The NA was then observed to take the plastic waste can liner out of the waste container, tie it, and place the garbage onto the floor next to the soiled linens. When she had completed her tasks, she came out from behind the curtain and walked towards the sink. The NA took off her gloves, placed them into the waste container next to the sink, and turned back to the sink to wash her hands. It was observed that the NA's gown had been tied at the neck but the tie at the waist had been left untied. After she dried her hands, she removed the gown and hung it back on the hook in the room. The NA retrieved the soiled linens and trash and exited the resident's room. She took the bags to the soiled linen room for disposal. An interview was conducted on November 9, 2020 at 1:15 p.m. with the NA (staff #83). She stated that her process for entering a resident's room to provide care included donning a gown upon entering the room. She stated that she ties the gown at the neck and waist, and then she dons gloves. She stated that she had received in-service education regarding how to properly don PPE, and that she had been instructed to tie the gown at the neck and waist and that she had performed a return demonstration in order to be checked off. The NA stated that if her gown became soiled or dragged on the floor during resident care, she would place the gown into the dirty laundry hamper and replace it with a clean gown. She stated that she did not know her gown was not tied or that the gown had dragged on the floor. She stated she would replace the soiled gown on the hook with a clean one. The NA stated that she had been instructed not to put soiled linens on the floor. The NA stated that she would not place the soiled linens on the floor, and that she did not remember placing them on the floor. She stated that she could not remember what was said about placing garbage onto the floor, but that she said she thought it was ok because it was in a plastic bag. -An observation was conducted on November 9, 2020 at 1:35 p.m. on the 100 hall. An occupational therapist (OT/staff #1) was observed entering a resident's room to assist a Certified Nursing Assistant (CNA/staff #19) with transferring a resident using a Hoyer lift. Upon entering the room, staff #1 donned a gown. The neck of the gown was already tied. Staff #1 slipped the gown onto his arms and over his head, but left the waist of the gown untied. As he assisted the resident with the transfer, the gown fell forward off of his shoulders and dragged across the Hoyer lift and over the floor. As he assisted the resident into the bed, his gown fell forward and onto the bed. Staff #1 was observed to pull the gown back onto his shoulders several times during resident care. He was then observed to doff the gown and hang it back onto the hook in the room. The CNA (staff #19) was observed to have her gown tied at the neck but not at the waist. As she assisted the resident with the transfer, her gown was observed to slip off her shoulders and touch the floor multiple times. An interview was conducted on November 9, 2020 at 1:45 p.m. with the OT (staff #1). He stated that his process for donning PPE included tying the gown at the neck and the waist. He stated he had received training on the proper way to don PPE through learning modules and yearly in-service training. He stated that he thought he had secured the gown properly. An interview was conducted on November 9, 2020 at 1:48 p.m. with staff #19. She stated that her process for donning PPE included putting on the gown first. She stated the gowns were kept in the residents' rooms on a hook inside the doorway. She stated that she kept her gown tied at the neck, so she could just slip it over her head and put her arms through the sleeves quickly. She stated she had not attended an in-service on the proper donning of PPE since June of 2020. The CNA stated that she did not noticed her gown had touched the floor, but that she would dispose of it and get a new gown. Regarding doffing gown and using disinfectant: Observations and an interview were conducted on Hall 400 (COVID-19 unit) on November 9, 2020 at 1:10 p.m. with the Infection Control Preventionist (ICP/staff #81). During the interview, a gown was observed wadded up and placed partially on top of a backpack on the 3rd shelve of a bookshelf located on the right wall in the charting station. Staff #81 stated the therapy room had been converted into the charting station for the nurses and that it was a clean area. He stated the nurses were supposed to remove their PPE and sanitize their hands prior to entering the area. When asked by the surveyor to find out who had wadded up the gown and left it on the shelf, the ICP identified a Registered Nurse (RN/staff #115) as the staff who had put the gown on the shelf. An interview was then conducted with the RN. Staff #115 stated that she had received training on donning and doffing PPE. She said that she had put the gown on the bookshelf. The RN stated that she was supposed to doff the gown and dispose of it in the soiled utility room before entering the charting room. She said she had worn the gown when providing care for the residents on the COVID-19 unit and that the gown could be contaminated. She then removed the gown, took the gown to the soiled utility room and returned to work. During this time, a speech therapist (staff #98) entered the charting station. She stated that staff are supposed to remove their gown before entering the charting area to keep the area clean. Staff #81 was asked about staff #115 sanitizing the area where the gown had been. Staff #81 instructed staff #115 to sanitize the area. When staff #115 returned, she sprayed Clorox Hydrogen Peroxide Cleaner Disinfectant on the third shelf and immediately wiped the area with a tissue from a Kleenex box. Staff #81 stated she was not sure of the contact time for the disinfectant or if it was okay to use a tissue to wipe the area. Staff #81 was asked about the staff #115 sanitizing the backpack. Staff #81 instructed staff #115 to spray the disinfectant directly onto the backpack. After spraying it on to the backpack, she immediately began wiping the backpack with tissue. An interview was conducted on November 10, 2020 at 1:02 p.m. with the Director of Nursing (DON/staff #171), who stated that staff #115 has been retrained on doffing PPE (gowns). She said, she needs to make sure staff know how to use disinfectants and that they should follow the manufacturer's instructions regarding contact time. She said that she did not think that using tissue to wipe an area being disinfected would be effective as the tissue absorbs the disinfectant. The CDC Sequence for donning and doffing PPE states the gown is to be folded or rolled into a bundle and discarded in a waste container. The facility policy, Infection Control and Prevention Policy, Emerging Infectious Diseases (EID): Coronavirus Disease 2019 (COVID-19), states to put on an isolation gown upon entry into the patient care area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. The Clorox Hydrogen Peroxide Cleaner Disinfectant instructions states to sanitize nonporous surfaces: spray 6 to 8 from surface until surface is thoroughly wet. Allow the product to remain wet for contact time listed on the label (one minute). Then wipe (wipe with a clean damp cloth or paper towel). To sanitize soft areas: spray 6 to 8 from surface. Spray until fabric is wet. Do not saturate. Let stand for 30 seconds. Allow to air dry. This product kills HIV-1, HBV, and HCV on pre-cleaned hard, nonporous surfaces/objects soiled with blood/body fluids in healthcare settings. Contact time: allow surface to remain wet for HBV, HCV, and HIV-1 for 30 seconds. The contact time for other bacteria [MEDICAL CONDITION] may differ. The Environmental Protection Agency (EPA) N List states Clorox Hydrogen Peroxide Cleaner Disinfectant contact time is 1 minute. Review of the facility's policy, Sanitizing Product Recommended Wet Time, states Clorox Healthcare Hydrogen Peroxide disinfectant contact time is 5 minutes. This product is to be used as a bactericidal and virucidal disinfectant. To clean, disinfect, and deodorize, nonporous surfaces; spray 6 to 8 from surface until surface is thoroughly wet. For disinfecting equipment which may have been exposed to COVID-19, allow surface to remain wet for 5 minutes, then wipe. This product is used within the facility to disinfect equipment and surfaces that may have come in contact with COVID containing droplets. Regarding disposing of trash and soiled linens: During the interview and observations conducted on November 9, 2020 with staff #81 on Hall 400 (COVID-19 unit), it was observed that the door to the soiled utility room was left open. There was a sign on the door that said, keep door closed. Staff #81 stated that the door is supposed to be closed. A glove turned inside out was observed laying on top of an empty black trash bag. He stated the glove looked as if it had been used and should have been put in the bin for trash. There was one gray bin with a lid that did not have a plastic liner (trash bag) and multiple used gloves were observed inside of the bin. There was a second gray bin that was overflowing with trash and the lid had been laid on top of the overflowing trash. Staff #81 said the lid should cover the trash and that the trash should be taken out when it is full. He said he would retrain the staff. Two fabric bags full of soiled linens and gowns were observed uncovered. One bag was overflowing. The fabric bag had a zipper running vertically from the bottom to the top of the bag. The zipper was unzipped, exposing soiled linen and gowns. Some of the linens and gowns were in clear plastic bags and some were not. Staff #81 stated that the soiled linens and gowns should be covered and the bag should be zipped up. During this time, a Certified Nursing Assistant (CNA/staff #155) was interviewed and stated that it is the responsibility of the CNAs to empty the trash before it is too full. She said the trash should be covered and the door to the soiled utility room should be closed to prevent odors and contamination from spreading. During the interview another CNA (staff #112) was observed entering the soiled utility room and putting a clear plastic bag of trash on top of the trash in the overflowing bin and placing the lid back on top of the overflowing trash. As the interview and observations on Hall 400 (COVID-19 unit) continued with staff #81, a small dark brown rectangle shaped plastic trash can was observed in the hallway on the right wall by the zipper wall that led to the center of the facility where the main nursing station was located. The trash can was full of gowns and one gown was hanging over the top and down the side of the trash can. Staff #81 stated that the staff were disposing of the gowns in the trash can, so they did not have to walk all the way back to the soiled utility room. He acknowledged that the soiled gowns were not bagged and there was not a lid for the trash can. He said the gowns were contaminated, should be covered, and moved the trash can into the soiled utility room. An interview was conducted on November 10, 2020 at 12:55 p.m. with a laundry staff (staff #169), who identified herself as the lead staff for laundry. She stated that soiled gowns and linens are to be stored in a bin with a covered lid to prevent infection from spreading. An interview was conducted on November 10, 2020 at 1:02 p.m. with the DON (staff #171), who stated that soiled linens/gowns and trash are to be stored in a bin and covered to decrease exposure of [MEDICAL CONDITION] to the environment. The facility's policy for laundry reviewed May 2017, states to place soiled linens in designated containers. Return soiled linen to the laundry in the designated non-permeable containers. Keep all doors leading from the soiled area closed when not in use. Soiled linen should be removed from residents' care area and placed in appropriate containers. Plastic can liners should be used to line soiled liner container. The CDC Appendix D - Linen and laundry management, Best practices for linen (and laundry) handling states to place soiled linen into a clearly labeled, leak-proof container (e.g., bag, bucket) in the patient care area. Do not transport soiled linen by hand outside the specific patient care area from where it was removed. Reprocess (i.e., clean and disinfect) the designated container for soiled linen after each use. If reusable linen bags are used inside the designated container, do not overfill them, tie them securely, and launder after each use. The facility's policy, Environmental Services, Waste Disposal, revised July 2018, states all garbage will be disposed of daily and as needed throughout the day. Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof containers that are kept covered. The CDC, Interim Infection Prevention and Control Recommendations for Healthcare Personal During the Coronavirus Disease 2019 (COVID-19) Pandemic, states management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Regarding donning PPE: During the interview conducted on Hall 400 (COVID-19 unit) with the ICP (staff #81) on November 9, 2020 at 3:15 p.m., three female staff and one male staff were observed wearing gowns with the back open. The tie around the waist area was either not tied or tied loosely, exposing their clothing. Staff #81 stated that staff would have to be retrained. An interview was conducted on November 10, 2020 at 1:02 p.m. with the DON (staff #171), who stated that when donning a gown, it should cover the arms and the ties at the top and bottom should be tied. She said, if the gown does not cover the back area and the staff's clothing is exposed, there is a risk of spreading COVID-19 to the staff and then to other residents. The CDC Sequence for donning and doffing PPE states the gown should fully cover the torso from neck to knees, arms to end of wrists, and wrap around the back, and fasten in the back of neck and the waist. Regarding screening staff: Review of the screening tool dated September 30, 2020, revealed a staff (name was not legible) had a temperature of 99.9 and that the staff was not medically assessed. Review of the screening tool dated October 1, 2020, revealed a case manager (staff #12) did not answer the question about GI symptoms. Review of facility Time Cards revealed staff #12 worked on October 1, 2020. Review of the screening tool dated October 4, 2020, revealed a LPN (staff #33) did not answer the screening questions. Review of facility Time Cards revealed staff #33 worked on October 4, 2020. Review of the screening tool dated November 2, 2020, revealed a physical therapy assistant (staff #150) answered yes to having shortness of breath and/or cough and yes to sore throat, runny nose, or congestion. It also revealed there was not a recommendation for an advanced screening by the DON, ICP, or designee. Review of facility Time Cards revealed that staff #150 worked on November 2, 2020. An interview was conducted on November 10, 2020 at 12:10 p.m. with the ICP (staff #81), who stated the prior DON was responsible for checking the screening tool. Staff #81 reviewed the screening tool dated September 30, 2020 and observed that one staff had a temperature of 99.9. He stated that 99.9 is a low-grade temperature and thought the staff should have been tested for [MEDICAL CONDITION], but did not know if the staff was tested because the name was not legible. He reviewed the screening tool dated October 1, 2020, revealing that staff #12 did not answer the GI question. Staff #81 stated staff #12 should not have been allowed to enter the facility. Staff #81 reviewed the screening tool dated October 4, 2020 regarding staff #33 not answering the screening questions and stated staff #33 should not have been allowed into the facility. He reviewed the screening tool dated November 2, 2020 and stated that it looked like staff #150 answered yes to the first two screening questions. The ICP stated staff #150 should have been medically assessed to determine if staff #150 could enter the facility. He also observed that screening tool indicated the staff #150 was not assessed. An interview was conducted on November 10, 2020 at 1:02 p.m. with the DON (staff #171), who stated that the DON or the Assistant Director of Nursing (ADON) reviews the screening tool daily. She stated that if a staff answers yes to one or more of the screening questions, she would need to assess the staff. The DON said she would document the assessment on the log where the screening tools are kept. She also said that if the questions are not answered, it increases the risk of spreading [MEDICAL CONDITION]. She acknowledged there were errors on the screening tool, and that she has made changes in the process since she arrived last week. She stated that a staff with a temperature of 99.9 should be assessed before entering the building because this is considered a low-grade temperature. The facility's policy, Guidance for Healthcare Personnel (HCP) Screening, Monitoring, and Work Restriction dated April 27, 2020, states upon entrance into the facility all staff must stop at the front desk. Staff will be screened by an employee. If staff answers yes to any question, staff is not to proceed any further than the front desk until staff has had an advanced screening by the supervisor. The CDC, Infection Prevention and Control Assessment Tool for Nursing Homes Preparing for COVID-19, states all HCP should self-monitor when they are not at work and be actively screened upon entering the facility. Ideally, this would occur at the entrance to the facility, before they begin their shift. Screening includes temperature check and asking about symptoms like subjective fever, new or worsening cough, difficulty breathing, chills, repeated shaking with chills, muscle pain, headache, sore throat, and new loss of taste or smell. If they have a fever of 100.0 F or higher or symptoms, they should be masked and sent home.

Based on county COVID-19 positivity rates, facility documentation, staff interviews, policy and procedures, and the Centers for Medicare & Medicaid Services (CMS) Interim Final Rule requirements, the facility failed to ensure staff were tested for COVID-19 at the required frequency. The deficient practice could lead to the spread of COVID-19. Findings include: Review of the county positivity rate applicable to the facility revealed the rates were between 5.3% and 6.5% October 26 through November 10, 2020. Per the CMS Interim Final Rule requirements, the facility would need to test each staff member once per week. The staff list provided by the facility (which did not include the Director of Nursing and Executive Director) revealed 172 names of staff. Review of the Surveillance Line List dated November 1 through 6, 2020 included: -One member of staff with a sample collected on November 1, returned with a positive result on November 4, 2020. -Ten residents and two staff with samples collected on November 3, returned with positive results on November 4, 2020. -One resident with a sample collected on November 5, returned with a positive result on November 6, 2020. Review of the Point of Care (POC) November 2, 2020 rapid [MEDICATION NAME] testing conducted in the facility included for 3 staff members, and on November 4, 2020 included for 49 staff. An interview was conducted with the Infection Control Preventionist (ICP/staff #81) on November 10, 2020 at 9:10 a.m. He stated that it was his responsibility to keep track of staff Covid-19 POC testing and test results. He stated that the facility utilizes a rapid [MEDICATION NAME] (nasal swab) testing for staff on Wednesdays. Staff #81 further stated that he keeps a record of the employees receiving testing with their results. The ICP stated that there were 172 staff employed at the facility, but that not all staff were considered active staff. He stated that many employees worked only part time and that others had not worked in the facility for over a month. He said that he concentrates testing on the active staff. He said that if staff receive testing outside the facility sometimes they will give him a paper copy of their test results and sometimes they will send him a text with their results. The ICP stated that it has been tough keeping track of all 172 employees. He stated that at this time his process includes recording only the results of the testing that occurred in the facility. He stated that he does not have a log of staff that have been tested elsewhere. He stated that he has no idea whether more than half of the staff have received weekly testing, or whether or not they may have tested positive elsewhere. He stated there were 52 employees that received testing on November 4, 2020. On November 10, 2020 at 10:05 a.m., an interview was conducted with the staffing coordinator (staff #152). She stated that she has about 170 staff in the facility and that all are actively working as either full time, part time, as-needed, or weekend staff. She stated that the ICP updates her when staff have tested positive for Covid-19. She stated that her priority is to know whether or not staff have tested positive so that she ensures staff that have tested positive are taken of the schedule. She stated she was not sure how many of the staff have met the requirement for weekly testing. Staff #152 said that some of the staff working in the facility might be Covid-19 positive and that no one would know because they were not tested . An interview was conducted on November 10, 2020 at 2:04 p.m. with the Interim Director of Nursing (staff #171). She stated based on the county positivity rate and the outbreak status in the facility, her expectation is that testing for COVID-19 be conducted weekly. She stated that staff who do not receive testing or who do not bring in their test results should not be on the schedule to work. She stated that the current status of staff COVID-19 testing did not meet her expectation. The facility's policy titled Laboratory Services - Testing Requirements for COVID-19 stated that it is the policy of the facility to provide or obtain laboratory services to meet the needs of its residents, including testing requirements for COVID-19. The policy stated that testing triggered by an outbreak is defined as a new COVID-19 infection in any healthcare personnel (HCP) or any new nursing home-onset COVID-19 infection in a resident. The policy stated for outbreak testing, all staff and residents should be tested , then all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 among staff or residents for a period of at least 14 days since the most recent positive result. The policy also included the facility will provide routine staff testing based on the county positivity rates from the prior week. The CMS Interim Final Rule (IFC) states to enhance efforts to keep COVID-19 from entering and spreading through nursing homes, facilities are required to test residents and staff based on parameters and frequency set forth by the Health and Human Services (HHS) Secretary. The IFC stated that for an outbreak (any new case that arises in the facility) all residents and staff that have previously tested negative should be retested every 3 days to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result.

Based on clinical record review, staff interviews and policy review, the facility failed to ensure medications were administered in accordance with professional standards of practice for 1 sampled resident (#65). The deficient practice could place residents at risk for increased complications related to infections. Findings include: Resident #65 was admitted to the facility on (MONTH) 10, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 11, 2019 included the resident had an infection related to intra-abdominal abscess and is on intravenous (IV) antibiotics. An intervention was to administer antibiotic per MD orders. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 10, 2019 revealed a score of 15 on the Brief Interview for Mental Status, which indicated the resident was cognitively intact. The MDS also noted that resident #65 was on IV antibiotics. Review of the physician orders [REDACTED]. -[MEDICATION NAME] Solution (antibiotic) 2.25 gm/50 ml, use 2.25 ml IV every 6 hours for intra-abdominal infection (administration time was midnight, 6 a.m., 12 p.m. and 6 p.m.) with a start date of (MONTH) 10, 2019 and a stop date of (MONTH) 25, 2019. -Caspofungin Acetate Solution (antibiotic) reconstituted 50 mg, use 50 mg IV one time a day for intra-abdominal infection (administration time was 5 p.m.), with a start date of (MONTH) 10, 2019 and a stop date of (MONTH) 25, 2019. -Sodium Chloride Solution (used for hydration), use 1000 ml IV every evening shift for supplement x1 liter bolus daily started on (MONTH) 11, 2019 with no stop date. Review of the (MONTH) and (MONTH) 2019 IV Medication Administration Records (MARs) for [MEDICATION NAME] revealed the following missing doses: (MONTH) 13 at 6 p.m., (MONTH) 14 at 12 p. m., (MONTH) 15 at 6 p.m., (MONTH) 17 at 12 p.m., (MONTH) 19 at 12 a.m., (MONTH) 20 at 6 p. m., (MONTH) 21 at 6 a.m., (MONTH) 22 at 6 p.m., (MONTH) 28 at 12 pm., (MONTH) 29 at 12 a. m., (MONTH) 30 at 12 a.m. and 6 a.m., (MONTH) 2 at 6 p. m., (MONTH) 3 at 6 a.m. and 6 p. m., (MONTH) 6 at 6 p. m., (MONTH) 8 at 12 a. m., (MONTH) 13 at 6 p.m., (MONTH) 15 at 12 a.m., (MONTH) 16 at 12 p.m. and 6 p.m., (MONTH) 17 at 12 a.m., 6 a.m. and at 6 p.m., (MONTH) 18, 19 and 20 at 6 p. m., (MONTH) 21 at 12 a.m. and 6 p.m., (MONTH) 22 at 12 p.m., and (MONTH) 24 at 12 p.m. Review of the IV MARs regarding Caspofungin Acetate revealed missing doses on (MONTH) 13, 15, 20, 21 and 22, 2019 and (MONTH) 2, 3, 6, 13, 16, 17, 18, 19, 20 and 21 at 5 p.m. Review of the IV MARs regarding the sodium chloride solution revealed missing doses on (MONTH) 20, and on (MONTH) 6, 13, 17, 21 and 27. Further review of the clinical record including the nurses progress notes revealed no documentation as to why the IV medications were not administered and there was no documentation the physician was notified that the IV medications were not administered. There was also no documentation that the resident refused the IV medications. An interview was conducted with a Licensed Practical Nurse (LPN/staff #141) on (MONTH) 2, 2019 at 10:23 a.m. The LPN stated the IV MAR lists the medications that are due. She stated that when she administers medication she signs for it and if the medication is not given, she documents the reason why. She said they can't leave the MAR blank, and they have to notify the provider if any IV antibiotics are not given and should document it in the progress notes. An interview was conducted with a LPN (staff #110) on (MONTH) 2, 2019 at 10:41 a.m. The LPN stated that the IV medications which are due, will show up on the IV MAR. She stated when she administers a medication she documents it in the electronic MAR. She said if the medication is not administered, she documents that it was not given and the system will ask the reason why it was not given. She stated that she also notifies the provider if an IV medication was not given. The LPN stated that they cannot hold medication without notifying the provider. She said that she would document that the provider was notified in the IV MAR under the progress note section. Staff #110 stated they cannot leave holes in the MAR documentation regarding medications. An interview was conducted with the Director of Nursing (DON/staff #171) on (MONTH) 3, 2019 at 10:56 a.m. The DON stated that she expects the nurses to sign for medications in the IV MAR in a timely manner and if for some reason the medication is not given, they should document it in the IV MAR and the nurses progress notes. She stated the physician has to be notified and it should be documented. The DON also stated that resident #65 tends to go out of the facility in her electric wheelchair for extended hours, and in that event she expects the physician should have been notified and the IV medications should have been adjusted, so they could be administered when she came back to the facility. She stated the nurses should have documented the reason why the medications were not administered. The facility's policy for Administration of Medication included that medications shall be administered in accordance with the written orders of the attending physician. The policy included that if a medication is withheld, refused or given other than at the scheduled time, the documentation will be reflected in the clinical record. The policy also stated that the documentation should include documenting the refusal of the medication or the attempt, and any concerns.

Based on observations, staff interview and policy review, the facility failed to implement infection control procedures for the handling of clean and soiled clothing and linens. The deficient practice could result in the spread of infection. Findings include: An observation was conducted on (MONTH) 3, 2019 at 8:25 a.m., of the facility's laundry services. At this time, a laundry staff member (staff #84) was in the clean laundry area. In the clean laundry area was a cart which was piled with clean resident clothing. On top of the clean resident clothing was staff #84's lunch bag and a paper plate with a wrapped burrito. Staff #84 was observed transferring the burrito from the paper plate into her lunch bag and then put the lunch bag on a shelf by the wall. Staff #84 stated that the pile of laundry that she had her food on was clean laundry and she shouldn't have food on top of the clean laundry. During another observation conducted on (MONTH) 3, 2019 at 9:14 a.m., staff #84 was observed with gloves on and had on a cotton patient gown with sleeves that came above her elbows. Staff #84 then pulled a red isolation bin to the washing machine and took a yellow bag out and placed it in the washer. She then tore the yellow bag open and removed all of the soiled clothing and linens. During this process, her arms were exposed from the elbows to her wrists and they were touching the soiled laundry. After this, staff #84 proceeded to untie her gown with the dirty gloves on. As she was trying to untie the gown, she touched the back of her neck and her clothing with the dirty gloves. Once the gown was untied, she removed it and put it in the washer and then removed the dirty gloves and washed her hands. Staff #84 stated that her arms above the wrist were touching the dirty isolation laundry and that dirty isolation laundry should always be handled with gloves and should not be touching bare skin. An interview was conducted on (MONTH) 3, 2019, at 10:35 a.m. with the Director of Nursing (DON/ staff #171), who stated the laundry staff member should have been wearing a yellow gown that has full sleeves when sorting and loading the dirty laundry, so that the dirty clothes are not touching the skin. Review of a policy titled, Infection Prevention and Control Program revealed to implement infection control measures to prevent the spread of communicable diseases and conditions. Standard precautions including contact precautions include putting gloves on immediately before anticipated contact with non-intact skin or blood and other body fluids or when touching surfaces soiled with blood or other body fluids. Remove gloves when the specific task is completed and wash hands immediately. The policy also stated to wear gowns when it is anticipated that there would be contact with blood or other body fluids or soiled surfaces. For linens, the policy stated that all contaminated linens should be handled appropriately whether their source was an isolation room or non-isolation room. All linens should be handled as if it were highly infectious. Healthcare workers play an important role in reducing the potential for transmission of infectious microorganisms.

Based on observation, clinical record review, interviews and policy review, the facility failed to ensure that one resident (#196) was assessed to determine clinical appropriateness to self administer medications. The deficient practice could result in medications not being taken as ordered, possible complications as a result of an inability to follow directions and unsafe storage of medications. The facility census was 103 residents. Findings include: Resident #196 was admitted to the facility on (MONTH) 19, 2019, with [DIAGNOSES REDACTED]. A care plan dated (MONTH) 19, 2019 included the resident was at risk for impaired thought processes related to end stage liver disease. The goal was for the resident to maintain the current level of cognitive function. Interventions included to face the resident when speaking, reduce distractions, use simple directive sentences, and provide the resident with necessary cues. Review of the admission Minimum Data Set assessment dated (MONTH) 26, 2019, revealed a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. An observation was conducted on (MONTH) 30, 2019 at 9:30 a.m., of the resident in her room. At this time, a small cup containing four pills was observed on the resident's bedside table. The resident stated that she was planning on taking the pills soon, but had not gotten around to it yet. Review of the physician's orders [REDACTED]. Review of the clinical record revealed no evidence that an assessment for self administration of medications was completed. An interview was conducted with a registered nurse (RN/staff #27) on (MONTH) 1, 2019 at 12:26 p.m. He said in order for a resident to self-administer medication, an assessment for safety would need to be completed, and there needs to be a physician's orders [REDACTED]. An interview was conducted with a RN (staff #110) on (MONTH) 1, 2019 at 12:40 p.m. She said there would need to be a physician's orders [REDACTED]. She said the resident would need to be observed for safety of self administration, and there would need to be some type of secure storage in the resident's room, if the resident planned to keep the medications at the bedside. An interview was conducted on (MONTH) 1, 2019 at 2:08 p.m., with the Director of Nursing (DON/staff #171). She said if a resident wanted to self administer medication, they would need a physician's orders [REDACTED]. She said the resident would receive education and would provide a demonstration of how to self-administer, as well as when to administer and have an understanding of side effects and risks and/or benefits. She said the medications could be stored at the bedside with a lockbox and a key in the resident's possession. During a follow-up interview at 2:39 p.m. on (MONTH) 1, 2019, staff #171 stated her expectation is that when nurses administer medications to residents, they will observe the residents actually taking the medications. Review of the facility's policy for self administration of medications revealed that if a resident wished to self administer medication, the interdisciplinary team would assess and periodically re-evaluate the resident based on change in the resident's status. The resident's cognitive, communication, visual, and physical ability to carry out this responsibility would be evaluated. If a resident was a candidate for self administration of medications, this would be indicated in the chart. The resident would receive instruction from the nurse regarding proper administration of medication.

Based on observation, clinical record reviews, staff interviews and policy review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of 2 residents (#3 and #76). The deficient practice could affect continuity of care. The census was 103 residents. Findings include: -Resident #3 was admitted to the facility on (MONTH) 21, (YEAR), with [DIAGNOSES REDACTED]. A care plan included the resident had a [MEDICATION NAME] and used a Foley urinary drainage bag overnight. Review of the quarterly MDS assessment dated (MONTH) 24, 2019, revealed documentation that the resident had an indwelling catheter and an ostomy. However, during an observation of the resident on (MONTH) 1, 2019 at 10:17 a.m., the resident was observed to have a [MEDICATION NAME], but did not have an indwelling catheter. An interview was conducted with the MDS coordinator (staff #41) on (MONTH) 1, 2019 at 10:26 a.m. She stated that to code the portion of the MDS assessment that referred to indwelling catheters and ostomies, she would review the nurse aide documentation, nursing notes, physician's orders [REDACTED]. She said the documentation on the MDS assessment for an indwelling catheter was a mistake, because resident #3 only had a [MEDICATION NAME]. -Resident #76 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of a wound assessment dated (MONTH) 15, 2019, revealed the resident had a stage 3 pressure ulcer on the right heel. The assessment stated the wound was facility acquired. However, review of the quarterly MDS assessment dated (MONTH) 20, 2019, revealed the resident had a stage 3 pressure ulcer that was present on admission. An interview was conducted with the MDS coordinator (staff #41) on (MONTH) 1, 2019 at 10:26 a.m. She said that to code the portion of the MDS assessment related to wounds, she would review physician's orders [REDACTED]. She said if a wound was present on admission, it would be documented in the wound rounds. She said the wound on the right heel of resident #76 was facility acquired. She said that she planned to file a correction for the MDS assessment for resident #76. An interview was conducted on (MONTH) 1, 2019 at 2:08 p.m., with the Director of Nursing (DON/staff #171). She said she expected that the chart would be thoroughly reviewed and any data that needed to be captured would be included in the MDS assessment. The facility's policy for accuracy of assessments stated that the MDS assessment should accurately reflect the resident's status. Each individual who completed a portion of the assessment must sign and certify accuracy of that portion of the assessment.

Based observations, clinical record reviews, interviews and policy review, the facility failed to provide pain management according to professional standards of practice for 2 residents (#195 and #397). The deficient practice could result in residents experiencing unrelieved pain and the potential for decline. Findings include: -Resident #195 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A care plan was initiated on (MONTH) 15, 2019, for acute pain related to surgery [MEDICAL CONDITION]. The goal was that the resident would voice a level of comfort, with interventions to evaluate the effectiveness of pain interventions, monitor and record pain characteristics, and notify the physician if interventions were unsuccessful. Review of the admission Minimum Data Set (MDS) assessment dated (MONTH) 22, 2019, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The assessment also stated the resident had received scheduled and as needed (PRN) pain medication, and that the resident experienced frequent pain. Review of the physician's orders [REDACTED]. During an interview with the resident on (MONTH) 30, 2019 at 9:00 a.m., she stated that she had waited one time for pain medication for almost 2 hours. She said at that time her pain had been around a 7 or 8 and that she had been crying. She said this had only occurred once, and normally she did not have to wait that long for pain medication. Another interview was conducted with the resident on (MONTH) 2, 2019 at 9:54 a.m. She said that she had just requested pain medication, because she was beginning to feel some discomfort. A follow up interview was conducted with the resident at 10:42 a.m. She said no one had come to address her pain yet. She said, I am doing ok, the pain is not too intense. An interview was conducted with a registered nurse (RN/staff #110) on (MONTH) 2, 2019 at 10:55 a.m. She stated that she was the nurse for resident #195. She said that she had not received any reports recently of the resident being in pain. An interview was conducted with a Certified Nursing Assistant (CNA/staff #103) on (MONTH) 2, 2019 at 10:56 a.m. She said that she was the one who had answered the resident's call light, and the resident had requested pain medication. She said she went to tell the resident's nurse, but the nurse was talking to another nurse. She said the resident had turned her call light on again, and another staff member had answered the light. She said she thought that maybe the resident had requested pain medication again and the other staff member had taken care of it. She said that she meant to go back and tell the nurse later about the resident's pain, but it had slipped her mind. Review of the Medication Administration Record [REDACTED]. A follow up interview was conducted with the resident's nurse (staff #110) on (MONTH) 2, 2019 at 1:08 p.m. She said that she normally tries to respond to a resident's request for pain medication within 15 minutes. She said sometimes she has to finish preparing and administering medication for another resident before she can respond to a resident's request, but it usually does not take more than 15 minutes. She said pain management was a top priority. An interview was conducted with the Director of Nursing (DON/staff #171) on (MONTH) 3, 2019 at 8:49 a.m. She said when a resident reports pain to staff, her expectation is that staff notify the nurse and the nurse addresses the pain as quickly as possible. She said if the nurse was preparing medications for another resident, the nurse should finish administering the medications before preparing pain medications for another resident, in order to avoid errors. -Resident #397 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to a Pain Management Review dated 9/29/19, the resident was interviewable and stated that she had pain now, and experienced pain daily or several times a day, and had back pain, neck pain and pain related to recent femur surgery. Per the assessment, the resident described the pain as aching/sharp and that physical activity and turning and repositioning made the pain worse. Non drug approaches included that cold packs helped to relieve pain and medication used in the past was [MEDICATION NAME], and that her pain had been managed well over the last three months. A care plan dated 9/29/19 revealed the resident has acute/chronic pain. The goal included to voice a level of comfort through the review date. Interventions included the resident was able to call for assistance when in pain, reposition self, ask for medication, tell you how much pain is experienced and tell you what increases or alleviates pain. The interventions also included to monitor pain characteristics, severity, location, onset, duration, aggravating factors and relieving factors, monitor/record/report to nurse any signs/symptoms of non-verbal pain, pain assessment every shift and to reposition for comfort. Review of the physician's orders [REDACTED]. Review of the (MONTH) 2019 Medication Administration Record [REDACTED]. For each administration, the documentation included that the medication was effective. An interview was conducted with resident #397 on 9/30/19 at 11:30 a.m. The resident stated that her pain was not being controlled since admission. The resident stated they were giving her pain medicine, but it was not helping. The resident stated she told the nurses and they told her that she would have to wait for the physician to come in for different pain medication. Further review of the (MONTH) 2019 MAR indicated [REDACTED]. There was no clinical record documentation that the physician/nurse practitioner had been called regarding the resident's ongoing pain. According to the (MONTH) 2019 MAR, the resident was given [MEDICATION NAME]/[MEDICATION NAME] 7.5-325 mg, two tablets at 1 a.m. for a pain level of 5 and at 5:03 a.m. for a pain level of 5. Another interview with resident #397 was conducted on 10/1/19 at 10:00 a.m. and she stated that her physician had come in to see her and was changing the pain medication. Review of the physician orders [REDACTED]. An interview with a licensed practical nurse (LPN/staff #69) was conducted on 10/2/19 at 11:17 a.m. Staff #69 said when the nurses call the physicians on-call in the evening, they will not change the pain medication orders and are told to wait until the regular physician sees the resident. She stated not everyone documents that in the record. During an interview with a LPN (staff #34) on 10/3/19 at 9:15 a.m., he stated that he has called physicians and they don't want to change the pain medication and have been told to wait until the attending physician comes in to see the resident. He said they tell the residents that they must wait for their physician to see them. An interview with the Director of Nursing (DON/staff #171) was conducted on 10/3/19 at 9:33 a.m. Staff #171 stated her expectation is that if a resident's pain medication is not effective, the resident's physician should be called. Staff #171 said if the physician does not change the medication or respond to the information that the medication was ineffective, the nurse should call her and she will call the Medical Director. Staff #171 said that she expects the nurses to document calls to the physicians. Staff #171 stated that she had no information regarding resident #397's pain medication not being effective. Another interview was conducted with resident #397 on 10/3/19 at 9:57 a.m. The resident was lying in bed with two ice packs on both of her knees, as she said she was having pain. The resident confirmed that on 9/30/19 she was in pain and the pain medication was ineffective and that she was told by the nurses that she would have to wait until her physician came in to see her regarding a change in pain medication. A review of the facility's Pain Management policy and procedure revised in (MONTH) (YEAR) revealed to provide an environment and programs that assist each resident to maintain their highest practicable physical, mental and psychosocial well being. Residents are provided and receive the care and services needed according to established practice guidelines. Resident's pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. Further the policy included to consult physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures.

Based on review of facility documentation, staff interviews and manufacturer's recommendations, the facility failed to ensure corrective action was implemented after performing a control solution test on one blood glucose monitor, when the results were outside of the recommended ranges. The deficient practice could result in inaccurate blood glucose readings. Findings include: Review of the Quality Control Record for (MONTH) 2019 for the glucometer on the 200 hall revealed sections to document that the glucometer was tested daily. This form included sections to document the normal control range and the test result and the high control range and the test result. Further review of this form revealed the control solution test for the glucometer was done on (MONTH) 2. The normal control range on the Control Record was 85-106 milligrams per deciliter (mg/dL). However, the result of the normal control test was documented at 134 mg/dL, which was outside of the normal control range. There was no evidence of any corrective action which was taken as a result of the control solution test result being outside of the normal parameters. According to the directions on the control solution bottle, the normal control range was 85-106 mg/dl. Review of the Medication Administration Record [REDACTED]. An interview was conducted on (MONTH) 2, 2019 at 10:42 a.m. with the 200 hall nurse (Licensed Practical Nurse/staff #141). She stated the blood glucose monitor control testing is completed by the night shift nurses. She stated that she had taken the blood sugars of eight residents that morning. An interview was conducted on (MONTH) 3, 2019 at 8:33 a.m., with the Director of Nursing (DON/staff #171). She stated that she expects the nurses to perform the control solution test on the blood glucose monitors correctly and make sure they are in the normal range. The DON said if the glucose monitor results are not in range, the nurses are expected to retest the monitor and discard it if it is still malfunctioning. Review of the manufacturer's user instruction manual for performing a control solution test revealed the control range should fall between the guidelines on the control solution bottle. The policy included that the monitor should not be used if the control solution result is out of range.

Based on clinical reviews, staff interviews, facility documentation, and review of facility policy, the facility failed to provide care and services to prevent the development of multiple pressure ulcers for one resident (#12) and failed to ensure wound treatment orders were obtained for one resident (#116). Findings include: -Resident #12 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed an admission nursing assessment dated [DATE], that documented the resident had an unstageable wound on the right lateral ankle. On this same assessment on the body diagram, it was noted that there was an open wound to the left lateral ankle. Physician admission orders [REDACTED]. A Braden scale for predicting pressure sore risk dated August 4, 2013, documented the resident was at high risk for the development of pressure ulcers. The Minimum Data Set (MDS) assessment dated [DATE], documented that the resident had a pressure ulcer on the left ankle. Per MDS staff, this documentation was incorrect, as the pressure ulcer was on the right ankle. The care plan for skin integrity and pressure ulcers dated August 4, 2013, identified the resident was at risk for skin breakdown related to immobility. The care plan noted that the resident was admitted with an unstageable pressure ulcer on the left ankle (per staff the pressure ulcer was to the right ankle). Interventions included to complete weekly skin checks, assist as needed to reposition/shift weight to relieve pressure, minimize pressure over bony prominence's, position with pillows to maintain body alignment, body pillow to offload left side and notify nurse of any new areas of skin breakdown, redness, blisters or discoloration noted during care. Further review of the clinical record revealed there was a lack of documentation in August 2013 of any preventative measures implemented, as identified in the above care plan, in order to help prevent the development of pressure ulcers. Review of the Weekly Skin assessment for August 29, revealed no documentation of any pressure ulcers to the left foot/ankle or knee. Regarding the left lateral ankle: Review of the Weekly Skin assessment for September 5, 2013, revealed no documentation of any pressure ulcers to the left ankle. However, according to the Pressure Ulcer Status Record, an unstageable pressure ulcer to the left lateral ankle was first identified on September 6, 2013. The wound measured 2.5 centimeters (cm) by 2 cm, with 100 percent purple tissue. The next skin assessment was completed six days later on September 12, 2013. Per the Weekly Skin assessment, the resident had an open wound to the left lateral ankle. However, there was no clinical record documentation regarding the size of the wound, nor any description of the wound. Nursing notes completed by the wound nurse dated September 16, 2013, documented the left lateral ankle was being treated for [REDACTED]. The note included a physician's orders [REDACTED]. Again, there was no clinical record documentation regarding the size or description of the wound since September 6. An initial wound consultation was completed on September 17, 2013, by the physician. The wound was described as unstageable, with yellow and black exudate and slough. The wound measured 3.0 cm by 2.5 cm. The note also documented under etiology that it was due to "Trauma? Pressure ?" The note further included that the plan was to offload with the use of foam/air boots. The next wound assessment was completed on September 24, 2013. The wound physician note documented that there was an unstageable pressure ulcer to the left lateral ankle with yellow exudate and slough, and measured 2.5 cm by 2.0 cm by 0.1 cm depth. The plan included to offload with foam/air boots. Continued review of the clinical record revealed that there was a lack of documentation in September 2013 that the foam/air boots were consistently utilized. Per the wound physician note dated October 1, 2013, the wound had improved, but remained unstageable with yellow slough and red granulation tissue. The wound measured 2.5 cm by 1.5 cm by 0.1 cm depth. Again, the plan included to offload with foam/air boots and to follow up in two weeks. A physician's orders [REDACTED]. The next pressure ulcer assessment was not completed until eleven days later on October 12, 2013, by the wound nurse. The pressure ulcer had increased in size measuring 2.6 cm by 1.7 cm and was described as unstageable, with 100 percent yellow slough. The note also documented the wound had improved, despite the wound now having 100 percent yellow slough, compared to the physician note from October 1, which noted the presence of slough and red granulation tissue. Further review of the pressure ulcer documentation included that the left lateral ankle was assessed at least weekly from October 12, through October 25, 2013. The wound care physician notes continued to reflect to offload with foam/air boots. Review of the October 2013 TAR (Treatment Administration Record) revealed the following documentation: Use body pillow to offload left side due to left lateral ankle wound. According to the TAR, staff initialed each day, on each shift that the body pillow was being utilized from October 6 through October 28. An observation was conducted on October 28, 2013 at 9:30 a.m., of the resident in his room, sitting in a Geri chair which was reclined, with the foot rest in the up position. The resident's left leg was observed to be off of the foot rest and wedged between the seat cushion and the metal frame of the arm rest. The resident's left ankle was pressed against the metal leg of the chair, which coincided with the location of the left lateral ankle pressure ulcer. There were no pillows, body pillow or foam/air boots or any other devices used to offload the left leg/foot. The wound nurse was present during this observation and searched the resident's room for the body pillow and none was found. She acknowledged that the resident's left leg was pressing against the metal where his ankle wound was located. She was also aware of the order for the body pillow and of the TAR documentation of its use. The foam/air boots were found in the resident's bathroom, however, they were soiled and needed to be cleaned. Another observation was conducted on October 28, 2013 at approximately 3 p.m. The resident was in his room in the Geri chair. His left leg was off of the foot rest and was leaning against the metal frame. No body pillow was in place to offload the left side. An interview was conducted on October 28, 2013, with a Licensed Practical Nurse (LPN). She stated that she had no knowledge of this resident having a body pillow. At this time, the TAR was reviewed with this staff member, showing that staff were initialing the body pillow was being used. She responded that she knew nothing about a body pillow. Interviews were conducted on October 28, 2013, with two different certified nursing assistants (CNA). Both CNAs stated that they had no knowledge of this resident having a body pillow. On October 29, 2013, an observation of the left lateral ankle wound was conducted with the wound nurse and the wound physician. The wound measured 2.0 cm by 1.8 cm and the depth was unstageable, with 25 percent red granulation tissue, and 75 percent slough and yellow exudate. Regarding the left lateral knee: Review of the Weekly Skin assessments for September 5 and 12, revealed no documentation of a wound to the left lateral knee. The next weekly skin assessment was not completed until October 3, 2013. There was no documentation of any wound to the left lateral knee. According to the Pressure Ulcer Status Record dated October 6, 2013, the resident now had a new open wound to the left lateral knee which was unstageable and measured 2.1 cm by 1.1 cm. The documentation did not include any description of the wound. A physician's orders [REDACTED]. Review of the Pressure Ulcer Status Record dated October 12, 2013, revealed the resident had an open wound to the left lateral knee that was unstageable and measured 1.8 cm by 1.8 cm by 0.1 depth. The note included a depth of the wound, despite documentation that the wound had 100 percent yellow slough. The wound physician note dated October 15, 2013, included the wound remained unstageable with yellow slough and had red granulation tissue. Measurements were 1.8 cm by 1.8 cm. The plan included pillows to offload the knee. The Pressure Ulcer Status Record dated October 18, 2013, documented that the left lateral knee had improved, but remained unstageable. The wound measured 1.9 cm by 1.5 cm by 0.1 cm in depth and had 20 percent granulation tissue and 80 percent slough. The left lateral knee was assessed on October 22, and 25, and was described as unstageable, with 50 percent slough. Review of the October 2013 TAR revealed the following documentation: Use body pillow to offload left side due to left knee wound. According to the documentation, staff initialed each day, on each shift that the body pillow was being utilized from October 6 through October 28. On October 28, 2013 at 9:30 a.m., an observation was conducted of the resident in his room, sitting in a Geri chair which was reclined, with the foot rest in the up position. The resident's left leg was observed to be off of the foot rest and wedged between the seat cushion and the metal frame of the arm rest. The resident's left knee was pressed up against the metal leg of the chair, which coincided with the location of the left lateral knee pressure ulcer. There were no pillows, body pillows or any other devices used to offload the left leg/knee area. The wound nurse was present during this observation and searched the resident's room for the body pillow and none was found. She acknowledged that the resident's left knee was pressing against the metal where his left lateral knee wound was located. She was also aware of the order for the body pillow and of the TAR documentation of its use. Another observation was conducted on October 28, 2013 at approximately 3 p.m. The resident was in his room in the Geri chair. His left leg was off of the foot rest and was leaning against the metal frame. No body pillow was in place to offload the left side. An interview was conducted on October 28, 2013, with a Licensed Practical Nurse (LPN). She stated that she had no knowledge of this resident having a body pillow. At this time, the TAR was reviewed with this staff member, showing that staff were initialing the body pillow was being used. She responded that she knew nothing about a body pillow. Interviews were conducted on October 28, 2013, with two different certified nursing assistants (CNA). Both CNAs stated that they had no knowledge of this resident having a body pillow. A wound observation was conducted on October 29, 2013, with the wound physician and the wound nurse present. The wound was observed to have red granulation tissue and a minimal amount of yellow slough. The wound measured 1.5 cm by 1.4 cm by 0.1 cm in depth. Regarding the left lateral foot: Review of the Weekly Skin assessment for September 5 and 12, revealed no documentation of a wound to the left lateral foot. There were no skin assessments completed for the remaining weeks in September. A wound physician note dated October 1, 2013, now documented that the resident had a dry black blister to the left dorsal foot area that measured 2.7 by 2.8 by 0.1 cm. The plan included for the use of foam/air boots. A Weekly Skin assessment dated [DATE], had no documentation of a left lateral/dorsal foot wound. The next wound assessment was not completed until eleven days later on October 12, 2013. According to the Pressure Ulcer Status Record, the resident had an unstageable pressure ulcer to the left lateral foot, which was 100 percent black eschar and measured 2 cm by 1.5 cm. Further review of the wound assessment documentation from October 18 through 25, revealed the pressure ulcer continued to have 100 percent black eschar. The plan included for the use of foam/air boots. Review of clinical record documentation revealed there was a lack of evidence that the foam/air boots were being utilized consistently, per the physician's plan of treatment. On October 28, 2013 at 9:30 a.m., an observation was conducted of the resident in his room, sitting in a Geri chair which was reclined, with the foot rest in the up position. The resident's left leg was observed to be off of the foot rest and wedged between the seat cushion and the metal frame of the arm rest. There were no pillows or body pillows or any other devices used to offload the left leg/foot. The resident was not observed wearing the foam/air boots. A wound observation was conducted on October 29, 2013, with the wound physician and wound nurse present. The left lateral foot pressure ulcer measured 1.9 cm by 1.3 cm, with black eschar present. At this time, the wound nurse clarified that the left dorsal foot wound was the same wound as the left lateral foot. During an interview, the unit manager stated that the wound nurse does an initial skin check on top of the one done by the resident's nurse upon admission and that the nurses are responsible for completing the weekly skin checks. An interview was conducted with the Assistant Director of Nursing (ADON) on October 29, 2013 at 11:00 a.m. The ADON stated that one of the reasons for the resident's pressure ulcers was due to difficulty with positioning, secondary to contractures to his lower extremities. The ADON was unable to explain why weekly skin checks were not done, why there was a lack of documentation regarding repositioning and use of the foam/air boots, why the body pillow was not able to be located, and why there was a lack of documentation of the use of pillows for offloading. A review of a facility policy related to Weekly Skin Assessments included they were to be completed on a weekly basis and that a licensed professional searches for areas of skin that differ from surrounding tissue and include the results on the Weekly Skin Integrity Data Collection Form. The policy further included that the Weekly Pressure Ulcer Status Records and nursing progress notes are also used for weekly assessments for existing wounds. -Resident #116 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Pressure Ulcer care plan revealed that on July 27, 2013, the resident was care planned as having pressure ulcers on her bilateral heels; right heel, unstageable, and left heel stage one. The approaches included: complete weekly skin check, float heels when in bed, minimize pressure over bony prominences, and observe effectiveness of response to treatments as ordered by physician. Review of the Initial Data Collection Tool/Nursing Service dated July 27, 2013, revealed no documented evidence of any pressure ulcers. Review of the Braden Scale for predicting pressure sore risk dated August 3, 2013, revealed a score of 16 which is considered at risk. Review of the Weekly Skin Integrity Data Collection sheet dated August 3, 2013, revealed that the left heel was red, soft, and mushy. Review of the Pressure Ulcer Status Record dated August 17, 2013, revealed a new unstageable pressure ulcer on the left Achilles measuring 1.8 cm by 2 cm, 100 percent black. Review of the Pressure Ulcer Status Record dated August 17, 2013, revealed a new unstageable pressure ulcer on the right heel measuring 1.2 cm by 1.7 cm, 100 percent black eschar. Review of the clinical records revealed no documented evidence of a treatment order for the two unstageable heel pressure ulcers. Review of the Treatment Record for August, 2013, revealed that [MEDICATION NAME] was applied to bilateral heels daily beginning on August 20, 2013. Review of the Pressure Ulcer Status Record dated August 26, 2013, revealed that the bilateral heel pressure ulcers were resolved. An interview was conducted with the wound nurse on October 28, 2013. The wound nurse stated that there should have been an order for [REDACTED]. Review of the facility's policy on physician's orders [REDACTED]. Review of the facility's policy on Treatment Orders revealed "...Treatment orders are written per facility policy...If a resident has multiple wound site, a complete and separate treatment order must be written for each site..."

Based on observations, staff interviews, reviews of a closed clinical record, review of hospital records, facility policy and procedures and other facility documentation, the facility failed to ensure adequate safety measures were implemented for one resident (#320), and as a result the resident sustained [REDACTED].#s 85 and 81) while smoking. The sample size for falls was one of residents and the sample size for smoking was two of four residents. Findings include: Issue regarding supervision: -Resident #320 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was totally dependent on staff for her activities of daily living (ADL's) and required one staff for physical assistance for bed mobility, transfer and eating. Section V. of the MDS Resident Assessment Protocol Summary documented that the resident was at risk for falls and directed staff to proceed to the development of a care plan. Further clinical record review revealed an updated care plan on August 20, 2010, which included that the resident required supervision and that the resident was at risk for falls. The resident was to have a low bed with a floor mat, hip protectors, and an alarm to her bed and wheelchair. Review of the social service progress notes dated August 20, 2010, documented that the resident required extensive need for assistance with her ADL's, with one to two person assistance with transfers. A clinical record review revealed nurse's notes with documentation dated October 14, 2010, that included a registered nurse (RN) was called to the resident's room by a certified nursing assistant (CNA/Staff #3) and the resident was found on her back, on the floor with her legs still up on the bed. Additional documentation revealed the resident was assessed for injuries, the physician was called, x-rays of her hip were ordered. Additional facility documentation review revealed subsequent written documentation, by staff #3, on October 15, 2010 at 12:36 p.m. that included that staff #3 had brought the resident a room tray at 6:30 to 6:40 p.m. The staff member documented she put the head of the bed up and placed the over bed tray table across the resident. Staff #3 stated that she stayed with the resident for a few minutes and then she left the room, leaving the tray in front of her." The staff further documented that she had not put the mat on the floor. Continued record review revealed a physician's telephone order dated October 14, 2010, to include stat x-ray of right hip and pelvis related to pain. Additional documentation revealed a final radiology report dated October 15, 2010, with findings of acute mildly displaced femoral neck fracture. In an interview was conducted on August 2, 2011, at 10:40 a.m., with staff #3 stated that she went back into the room about 7:50 p.m., to make her last rounds before leaving at 8:00 p.m., she entered the room and found the resident on the floor and immediately called the nurse to the room. Staff #3 additionally stated that she was making her final rounds for her shift and she had been in a hurry. She stated she had not placed the floor mat next to the resident's bed, because the over bed table was in front of the resident. In an interview conducted on August 2, 2011, Director of Nursing stated that CNAs should review the care plan and make sure they were providing the residents ' care as needed. Review of the "Managing Incidents and Falls" included, " ...High risk residents were to be identified and ensure that complete assessments and care planning are communicated to appropriate staff through orientation, in-services, staff meetings, shift reports ... " Issue regarding supervision and smoking: -Resident #85 was readmitted on [DATE], with [DIAGNOSES REDACTED]. On July 27, 2011 at 12:45 p.m., the resident was observed to exit the facility onto the designated smoking patio, unsupervised. At this time, the resident motioned to this surveyor that he wanted a cigarette. Although the resident was not provided with a cigarette, the resident made several more attempts, both verbally and with gestures, indicating that he wanted to smoke a cigarette. A review of the resident's clinical record revealed multiple social service progress notes and an activity progress note that included that the resident was alert, oriented, forgetful, and that he was able to make his needs known. The entries also included that the resident required assistance with activities of daily living and that he enjoyed smoking outside with his peers. A continued review of the clinical record revealed a Smoking Safety Assessment, dated December 28, 2010, March 21, and June 20, 2011. The smoking assessment included the following questions and answers, " ...Does resident attempt to keep smoking paraphernalia on self or in room? Yes ...Is resident non-complaint with smoking regulations in the facility? Yes ... " The smoking assessment plan section included, " ...Resident has demonstrated ability to safely smoke cigarettes without supervision. No ...Resident exhibits poor safety awareness when smoking and interventions must be place to promote smoking safety. Yes ... " The assessment also included multiple suggestions of intervention options, such as staff in attendance during all smoking times, a smoking apron, use of a cigarette holder, staff assistance to hold cigarette, occupational therapy intervention and social services intervention concerning compliance with smoking policies. An interview was conducted on July 27, 2011, with the Administrator, who acknowledged that based on the smoking assessment the resident was not safe to smoke independently. The Administrator stated that although the facility did not have a supervised smoking policy, the unit secretary would occasionally go outside with the resident when he smoked but acknowledged that it was not routine practice. -Resident #81 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was a known smoker. In a review of the clinical record, and specifically a smoking safety assessment dated [DATE], there was no clear cut determination in the assessment that the resident could safely smoke cigarettes without supervision. During multiple random observations throughout the survey the resident was observed to be smoking without supervision. During multiple interviews with administrative staff on July 27, 2011, the staff stated that the facility did not provide supervised smoking. In addition, staff concurred that the resident assessment for this resident did not clearly define the resident to be a safe smoker without supervision. A facility policy titled, Smoking, included, " ...The following procedure is intended to provide a smoke-free and safe environment for all residents, staff and visitors." The policy also included, "...A resident's ability to handle smoking material will be evaluated by the multidisciplinary team initially and quarterly using the smoking safety assessment. Each resident will be classified in one of the following categories ...Resident allowed to smoke unsupervised ...Resident allowed to smoke only with supervision ..."