Every finding on record at Copper Ridge Care Center

Based on interview and record review the facility failed to ensure Physician ordered restorative nursing services (a program that helped residents maintain or improve their highest possible level of physical function) was provided to one out of 24 sampled residents (Resident 15). This failure had the potential for a decline in functional status and to negatively impact psychosocial well-being.Findings:A review of the facility's undated policy and procedure (P&P) titled, Restorative Nursing Program, indicated, residents would receive restorative nursing care as needed to maintain safety and independence in their functional ability. A review of Resident 15's admission Record, dated 7/15/25, indicated, Resident 15 was admitted to the facility on [DATE] with the diagnoses of muscle weakness and difficulty in walking (ambulation). Resident 15 was their own responsible party (decision maker). A review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 10/16/25, indicated that a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) assessment was conducted. Resident 15 scored a 14 out of 15, indicating good memory. The MDS indicated Resident 15 required staff supervision while ambulating. During an interview on 12/2/25 at 2:15 pm, Resident 15 stated, I'm done with my rehab [therapy that helped a person regain their independence], but I'm still here. Resident 15 denied receiving restorative nursing services and stated, I had it twice. During a review of the care plan (a detailed plan that included resident goals and resident care instructions) titled, RNA [Restorative Nurse Assistant] Program, dated 10/22/25, indicated, Resident 15 would receive assistance from the RNA to ambulate 50 to 100 feet three times a week or as tolerated. The care plan indicated, Resident 15's goal was to maintain strength and activity tolerance to prevent a decline in functional mobility. The care plan indicated Resident 15 required a four-wheeled walker (a metal frame on wheels that was used to assist with ambulation) and facility staff to stand by and assist as needed while ambulating. During an interview on 12/3/25 at 2:56 pm, Physical Therapist (PT) stated, when PT discharged the resident from the therapy program, we establish the RNA program with written instructions for what the RNA will do with the resident. PT confirmed, a referral to RNA program for Resident 15 was provided to the nursing department. A review of the Restorative Nursing Program Referral, dated 10/22/25, indicated, PT referred Resident 15 to the restorative nursing program for ambulation three times a week or as needed and required staff assistance with ambulation for safety. A review of the Physician's order, dated 10/22/25, indicated Resident 15 would receive restorative nursing services three times a week for ambulation. During a concurrent interview and record review on 12/3/25 at 3:04 pm, with RNA, Resident 15's RNA documentation (an untitled document that indicated what days of the week the resident received restorative nursing care), dated 10/21/25 through 12/1/25 was reviewed. RNA confirmed, the RNA documentation indicated that Resident 15 did not receive documented restorative nursing care from 10/22/25 to 11/10/25. RNA confirmed, the RNA documentation indicated, Resident 15 received restorative nursing services once between 11/11/25 and 11/17/25 and none from 11/18/25 to 11/24/25. RNA confirmed, the RNA documentation indicated, during the week of 11/25/25 to 12/1/25, Resident 15 was offered restorative nursing services twice, refused both times, and no other attempts were made. RNA stated, when documenting on the RNA form, we document the time or how many steps they take. Sometimes when we are short staffed, we are pulled onto the floor to work as a CNA [Certified Nurse Assistant]. RNA confirmed, on days that RNA was utilized as a CNA, residents did not receive restorative nursing care. During a concurrent interview and record review on 12/3/25 at 3:31 pm, with Director of Nursing (DON), Resident 15's RNA documentation, dated 10/21/25 through 12/1/25 was reviewed. DON stated, if the order indicated, ambulate the resident three times a week, they should ambulate three times a week. DON confirmed, Resident 15's RNA documentation indicated that Resident 15 did not receive Physician ordered restorative nursing care services.

Based on observation, interview, and record review, the facility failed to meet resident adaptive equipment needs for one of 24 residents (Resident 33) when Registered Nurse (RN) G was not aware of Resident 33's adaptive equipment needs and unable to provide information on where to find adaptive equipment for Resident 33 to meet his needs. This failure had the potential to affect Resident 33's ability to drink fluids independently. Findings:During a review of facility job description titled Job Description: Registered Nurse dated 2/2024, indicated RN was to, review nurses' notes to ensure they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to the care, and that such are provided in accordance with the resident's wishes, RN was to provide direct nursing care as necessary, RN was to report problem areas to the Director and assist in developing and implementing corrective action, RN was to keep the Director informed of the status of residents and other related matters through written/oral reports, and the RN was to recommend to the Director the equipment and supply needs of the department.During a record review of Resident 33's admission record, he was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (COPD - a condition involving constriction of the airways and difficulty or discomfort in breathing), muscle wasting (the decrease in muscle mass and size that occurs when protein breakdown exceeds muscle protein growth), dementia (a decline in memory, thinking, and other cognitive abilities that is severe enough to interfere with daily life), and dysphagia (difficulty swallowing).During an observation on 12/3/25 at 9:21 am, RN G was observed as he held Resident 33's black lid to his bedside water cup. RN G was observed as he taped clear desk tape over a sipping port on the lid. Family Member (FM) 1 walked up to the nursing station and asked, Where are we on my [Resident 33's] drinking cup? RN G replied to FM 1 that he was working on it. RN G held up the black lid with clear tape and asked FM 1, Will this work? FM 1 replied, I guess. During an observation and interview on 12/3/25 at 9:24 am, with FM 1, she stated that she had requested facility staff give Resident 33 a drinking cup with a lid that did not have a sipping port on it so that the water would not spill on Resident 33's shirt when he drank from the straw. RN G entered Resident 33's room, held up an adult sippy cup and asked FM 1 Will this work? FM 1 replied, I guess so. When RN G exited the room, FM 1 was observed to be upset and perplexed and stated, Are they really going to give him a sippy cup?During an interview on 12/3/25 at 9:40 am, with RN G and Director of Nursing (DON), RN G stated it was his first time being on this hall. RN G confirmed he had not made himself familiar with the residents and their needs on the hall prior to his shift. RN G confirmed he took Resident 33's black lid from his room up to the nursing station and further applied clear desk tape to the lid. RN G stated he was unfamiliar with the adaptive supplies the facility kept on hand. RN G stated he spoke to Assistant Director of Nursing (ADON) C, and they both agreed to put tape on the lid as a short term solution. RN G stated he did not know who else he could ask for help to locate an assistive device with a lid that did not leak. DON confirmed that RN G did not ask for help from her, and that facility expectation was for RN G to ask DON for help. During an interview with DON on 12/3/25 at 12:06 pm, DON stated facility expectation was for RN G to make himself familiar with the hall and residents he was assigned to at the start of his shift. DON stated RN G was expected to read the residents' recent progress notes. DON confirmed Resident 33 needed to be reassessed for a drinking device that fit his needs.

Based on interview and record review the facility failed to ensure that two of four Residents sampled (Resident 1 and Resident 2) had care plans (a document that outlines a patient's health care needs and the actions and interventions required to address them) for naloxone (a medication that rapidly reverses the effects of an opioid [a strong medication that blocks pain and poses a risk of death by overdose] overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]).These failures had the potential to result in delayed identification of and interventions for an opioid overdose for Resident 1 and Resident 2.Findings:Review of a facility policy titled, Care Plans, Comprehensive Person-Centered dated March 2022, indicated b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. And e. reflects currently recognized standards of practice for problem areas and conditions.Review of the admission record for Resident 1, indicated she was admitted to the facility on [DATE], with diagnoses including cancer. Review of Resident 1's Annual Minimum Data Set (MDS is a federally mandated assessment tool that measures the health status in nursing home residents) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/10/25 completed by the Social Services Assistant (SSA), indicated Resident 1 had a score of 8 out of 15 indicating she was not able to make her own decisions. Review of Resident 1's physician's orders (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) dated 11/15/25 indicated that Resident 1 had a prescription for naloxone.Review of Resident 1's care plan item titled Narcotic Black Box Care Plan (narcotic - a drug that relieves pain that can cause sleep or drowsiness) (black box - the highest level of safety alert for a prescription medication) (care plan - a written plan for any action to be taken by a nurse to help a patient achieve health goals, based on clinical judgement) dated 11/9/24 for her narcotic pain medication indicated that naloxone administration was not included in her care plan.Review of the admission record for Resident 2, indicated he was admitted to the facility on [DATE], with lumbar spondylosis (age-related wear and tear on the bones and discs of the lower back.)Review of Resident 2's Quarterly MDS, BIMS dated 8/21/25, completed by the SSA, indicated Resident 2 had a score of 13 out of 15 indicating he was able to make his own decisions.Review of Resident 2's physician's orders dated 8/12/25 indicated that Resident 2 had a prescription for naloxone.Review of Resident 2's care plan item titled Narcotic Black Box Care Plan dated 5/26/25 indicated that there was no intervention for administration of naloxone related to his narcotic pain medication.During an interview with the Assistant Director of Nursing (ADON) on 11/19/25 at 11:10 a.m. in her office, the ADON confirmed that if a resident has a physician's order for naloxone, then it should be included in their care plan.

Based on observation, interview, and record review, the facility failed to ensure that three of four residents sampled (Resident 1, Resident 2, and Resident 4) who had naloxone (a medication that rapidly reverses the effects of an opioid [a strong medication that blocks pain and poses a risk of death by overdose] overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]) prescribed had nurses competent on where their naloxone was stored.This failure had potential to result in delayed treatment of an opioid overdose and death for Resident 1, Resident 2, and Resident 4.Findings: Review of a facility policy titled Opioid Overdose Response (Naloxone) dated October 2023, indicated Naloxone Ordering and Administration 1. Opioid overdose-related deaths can be prevented when naloxone (e.g., Narcan [a brand name for naloxone]) is administered in a timely manner.During a concurrent observation and interview on 11/18/25 at 2:03 p.m. with Licensed Nurse (LN A), LN A was asked where Resident 1's naloxone was stored, LN A stated Probably in the top drawer on the med cart (medication cart - a wheeled cart used in healthcare to store medications, and supplies). Usually in the top left drawer. LN A could not find Resident 1's naloxone in her medication cart.During a concurrent observation and interview on 11/18/25 at 2:06 p.m. with LN A and the Director of Staff Development (DSD), the DSD joined LN A in looking for Resident 1's naloxone in LN A's medication cart. Neither LN A nor DSD could find Resident 1's naloxone in LN A's medication cart. DSD confirmed that Resident 1's naloxone was not in LN A's medication cart.During a concurrent observation and interview on 11/18/25 at 2:15 p.m. with LN B and DSD, LN B was asked where Resident 2's naloxone was stored, LN B did not respond. LN B and DSD searched LN B's medication cart but could not find it in the medication cart. The DSD confirmed Resident 2's naloxone was not in LN B's medication cart.During a concurrent observation and interview on 11/18/25 at 2:21 p.m. with LN C and DSD, LN C was asked where Resident 4's naloxone was stored, LN C stated, the naloxone should be in the narc drawer (narcotic drawer - a smaller, internal, separately locked drawer on a medication cart for storage of controlled substances such as morphine.) When LN C was asked where else Resident 4's naloxone might be stored, LN C stated, I'll have to find out.Review of the admission record for Resident 1, indicated she was admitted to the facility on [DATE], with diagnoses including cancer. Review of Resident 1's Annual Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home residents) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/10/25 completed by the Social Services Assistant (SSA), indicated Resident 1 had a score of 8 out of 15 indicating she was not able to make her own decisions. Review of Resident 1's physician's orders (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) dated 11/15/25 indicated that Resident 1 had a prescription for naloxone.Review of the admission record for Resident 2, indicated he was admitted to the facility on [DATE], with lumbar spondylosis (age-related wear and tear on the bones and discs of the lower back.)Review of Resident 2's Quarterly MDS, BIMS dated 8/21/25 completed by the SSA, indicated Resident 2 had a score of 13 out of 15 indicating he was able to make his own decisions.Review of Resident 2's physician's orders, dated 8/12/25 indicated that Resident 2 had a prescription for naloxone.Review of the admission record for Resident 4 indicated he was admitted to the facility on [DATE], with a break in a bone of his lower spine.Review of Resident 4's admission MDS, BIMS, dated 10/28/25 completed by the Minimum Data Set Nurse (MDS), indicated Resident 4 had a score of 11 out of 15 indicating moderate cognitive impairment.Review of Resident 4's physician's orders, dated 10/27/25 indicated that Resident 4 had a prescription for naloxone.During an interview on 11/19/25 at 11:10 a.m. with the Assistant Director of Nursing (ADON), the ADON indicated that facility nurses are expected to know where the naloxone is stored.

Based on observation, interview, and record review, the facility failed to ensure that one of four residents sampled (Resident 1) was safe from a significant medication error when Licensed Nurse (LN D) crushed Resident 1's morphine sulfate (an opioid which blocks pain and poses the risk of death by morphine overdose [when a dose of an opioid is too high, and causes the person's breathing and heartbeat to slow down or stop]) extended release (a type of medication that is designed to release its ingredients slowly rather than all at once) and gave it to Resident 1.This failure had the potential to result in Resident 1 having a morphine overdose and dying.Findings:Review of the admission record for Resident 1, indicated she was admitted to the facility on [DATE], with diagnoses including cancer. Review of Resident 1's Annual Minimum Data Set (MDS - a federally mandated assessment tool that measures the health status in nursing home residents) Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 11/10/25 completed by the Social Services Assistant (SSA), indicated Resident 1 had a score of 8 out of 15 indicating she was not able to make her own decisions. Review of the facility's policy, titled Crushing Medications, dated October 2024, indicated, Medications shall be crushed only when it is appropriate and safe to do so, consistent with physician orders.Review of the facility's pharmacy policy, untitled, undated, indicated 'Medication Errors Due to Failure to Follow Manufactures Specifications or Accepted Professional Standards - The following situations in drug administration may be considered medication errors: Crushing Medications that should not be Crushed: Crushing tablets or capsules that the manufacturer states do not crush.'Review of an online document titled Medication Guide Morphine Sulfate Extended-Release Tablets, CII, dated March 2021 from Sun Pharma (the pharmaceutical manufacturer of Resident 1's morphine sulfate extended-release) indicated Swallow morphine sulfate extended-release tablets whole. Do not cut, break, chew, crush, dissolve, snort, or inject morphine sulfate extended-release tablets because this may cause you to overdose and die.During a concurrent observation and interview on 11/19/25 at 9:55 a.m. with Registered Nurse (RN E) at his medication cart (a wheeled cart used in healthcare to store, medications, and supplies) in his assigned hallway, RN E confirmed that Resident 1's current pack of Morphine Sulfate Tab 15 mg ER, last filled on 10/24/25 contained a pharmacy sticker label stating Swallow Whole. Do Not Chew Or Crush. Review of Resident 1's physician's orders (written instructions from a doctor detailing specific treatments, medications, or tests for a patient) dated 11/13/25 indicated that Resident 1 was prescribed Morphine Sulfate ER Oral Tablet Extended Release 15 (milligrams) MG Give two tablet four times a day for pain management.Review of Resident 1's record titled PACS- Medication Administration Record dated 11/15/25 indicated that LN D, administered morphine sulfate 15 mg two tablets at 4:00 p.m. to Resident 1.Review of Resident 1's record titled, Nurse's Note, dated 11/15/25 at 6:23 p.m. written by Licensed Nurse (LN D), indicated that LN D wrote Given morphine 30 mg ER crushed in yogurt.During a phone interview on 11/18/25 at 12:22 p.m. with Family Member (FM), FM stated that LN D did not know any better than to crush the morphine sulfate extended release and did not seem to care.During an interview on 11/19/25 at 11:10 a.m. with the Assistant Director of Nursing (ADON) in her office, ADON confirmed that Morphine Sulfate Extended Release should not be crushed.During an interview on 11/19/25 at 9:20 a.m. with the Administrator (ADM) in his office, the ADM acknowledged that LN D crushing Resident 1's Morphine Sulfate Extended Release was a medication error.

Based on interview, and record review, the facility failed to ensure that one of three sampled residents (Resident 1) received her intravenous (IV, a way to give fluids, medicine, nutrition, or blood directly into the blood stream through a vein) antibiotic called ceftriaxone (a medication used to treat bacterial infections) in a manner consistent with professional standards of practice and in accordance with the facility's policy to treat her urinary tract infection (infection of the kidneys and bladder) when: 1. Resident 1 did not receive her IV ceftriaxone until more than 4 hours after the physician ordered it. 2. The physician's order for the IV antibiotic ceftriaxone did not have an infusion rate (how fast an IV medication is given). These failures resulted in: 1. A delay in treatment of Resident 1's urinary tract infection. 2. The potential to infuse the ceftriaxone too fast or too slow to be effective or safe for Resident 1, and no way for nursing staff to document the rate the IV ceftriaxone was infused. Findings: Review of admission records for Resident 1 indicated she was admitted to the facility on [DATE], with diagnoses including weakness and paralysis on the left side of her body due to a stroke (loss of blood flow to a part of the brain), and atrial fibrillation (a-fib, an irregular and often very fast heartbeat that can cause poor blood flow). Review of Resident 1's admission Minimum Data Set (MDS, an assessment tool), dated 3/21/25, completed by Licensed Nurse (LN) B, indicated a BIMS (Brief Interview for Mental Status, an assessment to screen and identify memory, orientation, and judgement status of the resident), score of 7 out of 15, indicating severe cognitive impairment. A review of Resident 1's Physician's Orders for April 2025, indicated that on 4/22/25 at 5:17 pm, her physician had ordered IV ceftriaxone. The order had not contained the rate (over how many minutes) the IV infusion was to be given. During a review of Resident 1's April 2025 medication administration record (MAR), the MAR indicated that Resident 1 received the first dose of IV ceftriaxone on 4/23/25 at 8:00 am, nearly 15 hours later. During an interview on 6/12/25 at 8:03 am with Resident 1's Family Member (FM), the FM indicated that they were not sure if Resident 1's antibiotics were started when they should have been. Review of a facility policy titled, Administering Medications by IV dated October 2024, indicated, Document the following in the resident's medical record: 4. Total time infused. During a concurrent interview and record review on 6/11/25 at 2:35 pm, with the Director of Nursing (DON), the DON indicated that antibiotics should be given within 4 hours of the time the physician orders them. The DON confirmed that Resident 1's first dose of IV ceftriaxone was not given within 4 hours from the time her physician gave the order, and should have been. During a concurrent interview and record review on 6/12/25 at 10:25 am, with the DON, the DON confirmed the physicians order for Resident 1's IV ceftriaxone, had not inclued an infusion rate, and therefore, the order was incomplete.

Based on interview, record, and policy review, the facility failed to follow physician's orders and complete monitoring and adjustment of warfarin (also called Coumadin, a high-risk medication used to prevent blood clots by thinning the blood and has a significant risk for bleeding complications), for one of four residents sampled for warfarin use (Resident 1), when Licensed Nurse (LN) A incorrectly revised Resident 1's physician's order for a lab test for a prothrombin time and International Normalized Ratio (PT/INR, the laboratory testing parameter utilized to monitor warfarin therapy. The PT is the number of seconds required for the blood to clot, and the INR is the standardized ratio of the PT), and caused the order not to populate on to Resident 1's Electronic Health Record (EHR). This lapse in clinical oversight eliminated opportunities for timely intervention, which could have mitigated the risk of bleeding complications and prevented Resident 1 from enduring serious clinical harm which necessitated emergency treatments and a prolonged 12-day hospitalization . This had the potential to affect all residents who take warfarin. Findings: A review of the facility's policy titled, Anticoagulant [blood thinners] -Clinical Protocol revised November 2018, indicated, a. Assess for any signs or symptoms related to adverse drug reactions due to the medication alone or in combination with other medications. b. Assess for evidence or effects related to the subtherapeutic [less than expected result] or greater than therapeutic drug level related to that particular drug (for example, a resident with an above therapeutic level of an anticoagulation medication should be assessed for bleeding). In addition, the nurse shall assess and document/report the following: a. Current anticoagulation therapy (blood thinning), including drug and current dosage. b. Recent labs, including therapeutic dose monitoring . A review of National Library of Medicine (NIH, a nationally recognized professional resource for healthcare providers), at ncbi.nlm.nih.gov, dated January 2024, indicated; Severe adverse effects of warfarin include bleeding and significant hemorrhage (severe blood loss). Significant hemorrhage, examples of which include intracranial (brain) hemorrhage, gastrointestinal (stomach) bleeding, hematemesis (vomiting blood), intraocular (eye) bleeding, and hemarthrosis (bleeding in a joint), can occur at virtually any body site .Patients should undergo a risk assessment, with appropriate adjustments to their treatment plan made accordingly. Other adverse effects include nausea, vomiting, abdominal pain, bloating, flatulence (gas), and an altered sense of taste .Monitoring: Consistent monitoring of INR levels is essential for all patients receiving warfarin sodium therapy .Patients receiving treatment with warfarin should be closely monitored to ensure the safety and efficacy [desired result] of the medication. Periodic blood testing is recommended to assess the PT and INR .Routine assessment of INR is essential for patients receiving warfarin therapy. The INR of a healthy patient not on anticoagulation therapy is approximately 1.0. Therefore, a patient with an INR of 2.0 or 3.0 requires 2 or 3 times longer for their blood to clot .Most patients receiving warfarin have an INR goal of 2 to 3 .Close INR monitoring is strongly recommended for patients initiating warfarin therapy. This parameter requires more frequent monitoring after beginning a warfarin regimen .More frequent monitoring is necessary for patients with supratherapeutic or subtherapeutic INR to evaluate the safety and efficacy of treatment. Also, the patient's INR requires assessment when initiating, discontinuing, or changing doses .Patients also require close monitoring for signs and symptoms of active bleeding throughout their treatment. Close monitoring for signs and symptoms of bleeding, such as dark, tarry stools, nosebleeds, and hematomas (bruises), is necessary. Toxicity [poisonous]: Warfarin toxicity may be assessed by observing the signs and symptoms of bleeding, as well as the determination of a supratherapeutic INR level. The risk of bleeding is significantly greater for patients with an elevated INR, especially above 5.0. Nurses must recognize the signs of warfarin toxicity so they can alert the attending or prescribing clinician. Review of the facility's policy titled, Medication and Treatment Orders dated July 2016 indicated, 14. Orders for anti-coagulants will be prescribed only with appropriate clinical and laboratory monitoring. Review of admission records for Resident 1 indicated Resident 1 was admitted to the facility on [DATE], with diagnoses that included fracture of right femur (broken hip). A review of a Brief Interview for Mental Status screening (BIMS - an assessment tool used to screen and identify resident memory, orientation, and judgement problems), reflected that Resident 1 scored 12 out of 15, which indicated that she had good memory and ability to make decisions. A review of Resident 1's Physician's Orders, dated for the month of September 2024, was conducted and reflected the following: On 9/5/24, Resident 1's Attending Physician (AP), ordered warfarin 3.5 milligrams (mg, a unit of measure) to be given once a day and to check her PT/INR by lab testing, on 9/6/24. On 9/7/24, AP increased Resident 1's warfarin to 5 mg once a day and ordered to recheck her PT/INR on 9/9/24. On 9/9/24, AP increased Resident 1's warfarin to 7.5 mg once a day and ordered to recheck her PT/INR on 9/12/24. On 9/13/24, AP increased Resident 1's warfarin to 9 mg once a day and to recheck her PT/INR on 9/16/24. A review of Resident 1's PT/INR lab testing results for the months of September and October 2024, was conducted and reflected the following: On 9/6/24, the PT was 17 and the INR 1.4. On 9/9/24, the PT was 17.4 and the INR 1.4 On 9/12/24, the PT was 18.9 and the INR 1.6 There was no evidence that the PT/INR lab test was done on 9/16/24. On 9/30/24, a PT/INR was done and the results were too high for the laboratory equipment to analyze. On 10/1/24, a PT/INR was done and Resident 1's PT was greater than 120 and her INR was greater than 16 (a critical lab result). A review of Resident 1's Progress Notes for September and October 2024, was conducted and documentation reflected the following; On 9/28/24, Resident 1 had blood in her urine. On 9/29/24, at 5:55 AM, Resident 1 complained of nausea and vomiting, she didn ' t feel like eating, had not eaten much the night before, had mostly drank water that day and had only soup for dinner the night before. At 10:25 AM, Resident 1 complained of left abdomen pain, she had the urge to urinate and could not. Resident 1 had not eaten much and had only eaten one yogurt and half of a banana for breakfast. At 6:10 PM, Resident 1 had blood in her urine and was having difficulty urinating and pain in her left side. At 8:15 PM, a urine sample was collected from Resident 1 for a urinalysis (UA, a test done on urine to check for signs of infection), and the urine was bloody. A review was conducted of Resident 1's Lab Results Report for the UA dated 9/29/24 at 10:06 PM, and indicated, Unable to perform chemical analysis due to color interference caused by the grossly [extremely obvious just by looking at it] bloody specimen received. A review of Resident 1's Progress Notes dated 9/30/24, nursing documentation showed that at 8:51 AM, Resident 1 reported nausea and vomiting. At 9:01 AM, an order was obtained for a PT/INR to be done which was done at 12:53 PM. At 2:55 PM, lab called stated the PT/INR level was so high it could not be read. At 3:48 PM, the Physician's Assistant (PA) was notified and ordered Vitamin K (a medication that reverses the effects of too much warfarin and helps the blood clot), 1 Gram, hold warfarin for 3 days, and do a PT/INR daily for 3 days. At 5:09 PM, another UA was collected from Resident 1 and sent to the lab and the urine was noted by the nurse to be tinted red. A review of Resident 1's Lab Results Report dated 10/1/24, indicated a PT of greater than 120 seconds (PT greater than 27 is a critical value and indicates an increased risk of bleeding), and an INR of greater than 16 (INR greater than 5 is a critical value and indicates an increased risk of bleeding). A review of Resident 1's Progress Notes dated 10/1/24, reflected at 11:43 AM the nurse received a phone call with critical labs of an INR greater than 16. At 12:31 PM, a new order was obtained from the PA for Vitamin K 2.5 milligrams (mg, a unit of measure) by mouth one time. At 11:07 PM, Resident 1 stated she was nauseated and the Zofran (a medication for nausea), was not helping her. A review of Resident 1's Progress Notes dated 10/2/24 reflected at 1:02 PM, a nurse documented that the facility received a phone call from the lab reporting Resident 1's PT/INR was still critical with a PT greater than 120 and INR greater than 16. At 2:23 PM, nursing documentation reflected that Resident 1 requested to be sent to the hospital and was transferred to the hospital by ambulance at 2:25 PM. A review of Resident 1's, SNF/NF to Hospital Transfer Form dated 10/2/24 at 1:45 PM reflected that Resident 1 was on warfarin and her last INR was done on 10/2/24 and was critical at greater than 16. Under the GU/Urine [the urinary and bladder system] Evaluation the box blood in urine was checked. A review of Resident 1's hospital emergency room [ER] documentation, dated 10/2/24, reflected that the physician's preliminary concerns were that Resident 1 had a spontaneous retroperitoneal hematoma (internal bleeding around the kidneys), the high INR, acute kidney injury (a condition in which the kidneys suddenly can't filter waste from the blood), and possible sepsis (a life-threatening blood infection) related to a urinary tract infection (UTI, an infection of any part of the urinary system) and low urine output. A Computed Tomography scan (a CT scan is a medical imaging procedure that uses x-rays to make detailed images of the body), of Resident 1's abdomen and pelvis was done and indicated fluid that was suspicious for internal bleeding. A review of Resident 1's hospital History and Physical dated 10/2/24, reflected that Resident 1's lab testing at the ER showed a PT greater than 120 and an INR of greater than 12 (both critical). The physician documented that Resident 1 had, warfarin coagulopathy (a bleeding complication due to too much warfarin in the blood stream), which caused blood in her urine and internal bleeding around her kidneys and upper ureters (thin tubes that connect the kidneys to the bladder). Resident 1 was given Kcentra (a medication given for urgent reversal of warfarin overdose), and Vitamin K. A review of Resident 1's, Hospital Record Progress Notes dated 10/2/24, reflected diagnoses of internal bleeding around the kidneys, high INR, Acute Kidney Injury (AKI), metabolic acidosis (the buildup of acid in the body due to kidney disease or kidney failure), and diabetes insipidus (a condition that causes the body to make large amounts of urine and excessive thirst and causes the fluids in the body to be out of balance). During an interview on 11/26/24 at 2:50 PM, with the Medical Director (MD), the MD stated that when the warfarin dosage is being adjusted there should be PT/INR monitoring in about 2 days. During an interview on 11/26/24 at 3:09 PM, with PA, the PA indicated Resident 1's PT/INR lab test, that was ordered for 9/16/24, may have been missed due to the order being put in the wrong place in Resident 1's EHR. The PA indicated that her understanding was that there were two places lab orders could be within a resident's EHR. The PA indicated the Attending Physician (AP) hand writes the orders directly on the lab results report and faxes it back to the nurses. The nurses would then enter any new orders into the residents EHR. During an interview on 11/26/24 at 3:15 PM, with the Director of Nursing (DON), the DON stated that she was not sure what caused the PT/INR to not populate on Resident 1's EHR, after LN A revised the order. The DON confirmed that the order was not in Resident 1's EHR and the PT/INR was not done. The DON indicated she caught this 14 days later, after Resident 1 began having active bleeding, it was an oversight. During an interview on 12/5/24 at 2:51 PM, with the PA, the PA confirmed she saw Resident 1 on 9/25/24, and had not recognized that the PT/INR, that was to be done on 9/16/24, was missed. A review of Resident 1's Progress Notes dated 9/25/24, reflected that PA saw Resident 1 on 9/25/24 and made a note that Resident 1 was taking warfarin, but had not addressed that the PT/INR that was ordered by AP to be done on 9/16/24, had not been done. During an interview on 12/5/24 at 3:29 PM, with the DON, the DON stated that nurses enter physician's orders into the EHR LAB flow sheet, and from there every night a nurse runs a report for lab tests that are to be done for that day. The nurse then filled out lab requisition (request) form which indicated what lab tests were to be done each day. The DON stated that if the physician's orders do not make it on to the LAB flow sheet, the labs may not show up on the report thererfore, will not likely get done. During an interview on 12/6/24 at 11:36 AM, with the MD, the MD stated that acute retroperitoneal hemorrhage is very common complication when too much warfarin is taken and PT/INRs are too high. The MD stated that after a review the PT/INR lab results, a physician would be expected to give orders to the nurses that would include; when to get the next PT/INR, change or hold the warfarin dose, either verbally (in person or on the phone), or by handwritten orders directly on the lab result sheet and faxed to the nurse. The nurses would then enter the physician's order into the resident's EHR. During an interview on 12/11/24 at 9:05 AM, with Resident 1, Resident 1 indicated that the nurses had not listened to her when she told them she had been sick for days, so she asked to be sent to the hospital. Resident 1 stated, I was bleeding from my mouth, nose, and vagina, and it was very much a nightmare and I felt like I was dying. During an interview on 12/12/24 at 1:12 PM, with LN A, LN A indicated that Resident 1's PT/INR lab testing order that was to be done on 9/16/24, was on the wrong MAR. LN A indicated that there were MARs for medications and different MARs for Lab testing. LN A indicated that her intention was to move the PT/INR lab test order from the medication MAR to the lab MAR, and had not recognized that the order never made it to the lab MAR. LN A indicated that she does not know how that happened. During an interview on 12/12/24 at 3:59 PM, with the Assistant Director of Nursing (ADON), the ADON confirmed that nursing staff received training on the facility's EHR system upon hire and and when any changes to the system occur.

Based on observation, interview, and record review, the facility failed to ensure that Licensed Nurses administered medication in accordance with their Medication Administration Policy for one of four sampled residents (Resident 1), when 4 and a half Norco tablets (a narcotic pain pill), were found in a container in Resident 1 ' s room. This failure had the potential to lead to possible overdose (when a person takes more than the recommended amount of a medication which can lead to serious harm or death), drug diversion (the illegal distribution, or abuse of prescription drugs, or their use for purposes not intended by the prescriber), and possible exposure of other residents to potentially hazardous substances. Findings: Review of Resident 1 ' s Admission Record indicated that Resident 1 was admitted to the facility on [DATE] and had diagnoses which included anxiety disorder (worrying that interferes with daily activities) and major depressive disorder (sad mood or the loss of interest or pleasure in nearly all activities). Review of Resident 1 ' s care plan regarding mood dated 9/23/24 indicated that Resident 1 was at risk for poor impulse control. Review of the facility ' s policy titled, Administering Medications dated April 2023 indicated, Only persons licensed or permitted by this state to prepare, administer and document the administration of medication may do so and Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely. During a concurrent observation and interview, on 10/3/24, at 3:15 PM, Resident 1 stated that she found pain pills in her bed and kept them in a small, black, round container while she pointed to the container on her bedside table. Review of Resident 1 ' s Nurse ' s Notes dated 9/28/24 at 12:18 PM indicated that Resident 1 ' s nurse was notified by a Certified Nursing Assistant (CNA) that Resident 1 had put pills into a black, round container on her bedside table. The nurse went into the room and located the container in which 4 whole tablets and 1/2 tablet of Norco (a narcotic pain medication) 5/325 milligrams (mg - a unit of measure) were found. Review of Resident 1 ' s current Order Summary Report indicated that on 3/3/24, Resident 1 ' s physician ordered Norco 5/325 mg, to be given by mouth every 6 hours. On 8/2/24, Resident 1 ' s physician added Norco 5/325 mg to be given by mouth every 4 hours as needed (PRN). During an interview, on 10/30/24, at 2:52 PM, the Director of Nursing (DON) stated that her expectation for the facility ' s nurses when giving medications was that the nurses would stay throughout the patients taking the medications and if the nurses needed to leave the room before the patient took the medications, the nurses would take all the medications with them and destroy the medications and bring fresh medications when they returned to the patients ' rooms to complete medication administration.

Based on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurate for the disposition of a resident at the time of discharge for 1 (Resident #102) of 23 sampled residents. Findings included: A facility policy titled Resident Assessments, revised 10/2023, indicated, 11. All persons who have completed any portion of the MDS resident assessment form must sign the document attesting to the accuracy of such information. An Admission Record indicated the facility admitted Resident #102 on 07/05/2024. According to the Admission Record, the resident had a medical history that included diagnoses of arthritis and type 2 diabetes mellitus. Per the Admission Record, Resident #102 discharged home on 07/27/2024. Resident #102's care plan included a focus are initiated 07/10/2024, that indicated the resident and their responsible party/family member indicated a preference for the resident to discharge home/community with family/friend support. Resident #102's Discharge Summary dated 07/26/2024, indicated the resident reached and maintained goals for a safe transition home with home health services. Resident #102's Progress Notes, dated 07/27/2024, indicated the resident discharged home on 07/27/2024. The discharge MDS, with an Assessment Reference Date (ARD) of 07/27/2024, indicated Resident #102 discharged to a short-term general hospital on 07/27/2024. During a concurrent record review and interview on 09/25/2024 at 12:29 PM, the MDS Coordinator reviewed Resident #102's discharge MDS dated [DATE] which indicated the resident discharged to the hospital. The MDS Coordinator stated that according to the resident's progress notes, Resident #102 discharged home. The MDS Coordinator stated the MDS was not coded accurately as it reflected the resident discharged to hospital. The MDS Coordinator stated it was coded in error. During an interview on 09/25/2024 at 1:29 PM, the Director of Nursing (DON) stated her expectations were for MDS assessments to be coded accurately. The DON stated accurate coding was important because it told the story of the resident. During an interview on 09/25/2024 at 1:45 PM, the Administrator stated he was aware of the MDS process, but he was not involved in the process. The Administrator stated he would expect MDS assessments to be coded accurately.

Based on observation, interview, and record review, the facility failed to ensure safe infection control practices were followed when staff did not properly wear a surgical mask (face covering) and a Certified Nurse Assistant (CNA) drank water while walking down a hallway that contained COVID-19 positive residents. This failure had the potential to spread COVID-19 to other residents, potentially leading to a decline in health status. Findings: A review of an undated document titled, Important Reminders, indicated, the Proper way to wear a mask, was for the mask to cover the nose, mouth, and chin. Important Reminders indicated, Personal food and drink was not allowed in hallways or at nurse ' s station. The image of a properly worn mask, that was included in the Important Reminders, included a person wearing a surgical mask. During an observation on 8/21/22 at 2:00 pm, located on Cherry Hall (the name of the unit that contained residents who tested positive for COVID-19), CNA B was observed walking down the entire length of Cherry Hall wearing a surgical mask that did not cover her nose. While CNA B walked down the hallway, CNA B was observed pulling the surgical mask below her chin and drinking water from a cup that had no lid, on three separate occasions. During an interview on 8/21/24 at 2:06 pm, CNA B stated, surgical masks were required to be worn by staff on Cherry Hall due to COVID-19 positive residents. CNA B confirmed, the surgical mask was not being worn properly and stated, it should have covered her nose and was not. CNA B was asked about removing mask from face to drink water while walking down Cherry Hall, and CNA B stated, unawareness that CNA B could not drink water while walking down Cherry Hall. During an observation on 8/21/24 at 2:33 pm, the facility ' s Treatment Nurse (TN, performed resident wound care treatments), had been observed standing at the nurse ' s station, located on Cherry Hall. TN was observed talking to Licensed Nurse (LN A) and two other staff members at the nurse ' s station. TN's surgical mask was not covering the nose for the entirety of the observation. TN was observed walking away from the nurse ' s station. After TN walked past a room with an open door, TN pulled the surgical mask up and covered TN ' s nose. The sign located outside of the room with an open door indicated, the resident was positive for COVID-19. During an interview on 8/21/24 at 3:10 pm, TN stated, surgical masks should cover the nose, mouth, and chin. TN was asked about the observation made while TN was at the nurse ' s station on Cherry Hall. TN confirmed, having a conversation with facility staff at the nurse ' s station and stated, the observation made, of TN wearing the surgical mask under her nose, was incorrect. During a concurrent observation and interview, on 8/21/24 at 3:45 pm, LN A was observed standing at the nurse ' s station on Cherry Hall. LN A ' s surgical mask was not covering the mouth or nose. Upon arrival to the nurse ' s station, LN A repositioned the surgical mask and covered up the mouth and nose. LN A confirmed, LN A ' s mouth and nose was not covered and should have been. LN A confirmed being present at the observation made earlier at 3:10 pm. LN A confirmed, while TN was at the nurse ' s station, TN ' s nose was not covered by the surgical mask. During an interview on 8/22/24 at 4:08 pm, Director of Staff Development (DSD, responsible for training staff and was also the CNA supervisor) stated, education had been provided to the facility staff regarding proper use of the surgical mask. DSD stated, the surgical mask should cover the nose, mouth, and chin. DSD stated, staff should not drink water in the hallways of the facility and stated, CNA B should have utilized the staff ' s breakroom. During a concurrent interview and record review on 8/22/24 at 12:38 pm, Infection Preventionist (IP), stated, on 8/7/24 an in-service training was provided to staff regarding infection control. IP stated, a properly worn surgical mask covered the nose, mouth, and chin. IP confirmed, facility staff were not permitted to eat or drink at the nurse ' s station or in the facility hallways.

Based on interview and record review, the facility failed to honor resident rights for one out of three sampled residents (Resident 1) when Resident 1's caregiver (CG) requested a nurse to be present at the care conference meeting (a group of medical professionals that met to discuss resident care and care planning with the resident, family members, or caregivers), and nursing was not notified of the request. This failure had the potential for Resident 1 and Resident 1's representatives to not be allowed to participate in resident care planning. Findings: A review of the facility's policy and procedure titled, Care Planning- Interdisciplinary Team, revised 3/1/22, indicated, the Interdisciplinary Team (IDT, a group of medical professions that meet to discuss resident care and care planning) was responsible for .the development of resident care plans and nursing was included in the IDT. A review of the undated Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart disease (heart problems that were caused by high blood pressure) and diabetes. Resident 1 was her own responsible party (made own decisions about heath care). During an interview on 5/14/24 at 12:27 pm, CG stated, CG had a conversation with the facility's social worker (SW) and requested nursing to be present at Resident 1's care conference meeting due to concerns of diabetes and bathroom assistance. During a concurrent record review and interview, on 5/31/24 at 9:29 am, with SW, Resident 1's Care Conference Meeting note, dated 4/22/24 was reviewed. SW confirmed a request had been made for nursing to be present at Resident 1's care conference meeting. SW stated, the Care Conference Meeting note indicated, the IDT team members present included the SW, physical therapy, and the occupational therapist. SW stated, Resident 1 was medically stable, and didn't require nursing to be present, and the care conference meeting was focused on care received from physical therapy and occupational therapy. SW confirmed, nursing should have been included in the care conference and was not. During an interview, on 5/31/24 at 10:26 am, Director of Nursing (DON) stated the SW had not informed DON there was a request made for nursing to be present at the care conference meeting and confirmed DON was not present at the care conference meeting that occurred on 4/22/24.

Based on interview and record review, the facility failed to provided one out of three sampled residents (Resident 2) with food that was served in a safe manner when Resident 2 was served a chef's salad that contained moldy cherry tomatoes. This failure had the potential for spoiled food to be eaten and could cause illness. Findings: A review of the facility's policy and procedure titled, Food and Nutrition Services, revised 10/1/17, indicated, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive, and it is served at a safe and appetizing temperature. A review of the undated Admissions Record, indicated, Resident 2 was admitted to the facility 5/3/24 with the diagnoses of depression (a sad mood) and atrial fibrillation (an irregular heartbeat that caused poor blood flow and had the potential to cause blood clots to form in the heart). Resident 2 was her own responsible party and made her own decisions. During an interview on 5/17/24 at 10:48 am, Resident 2 stated, she had been served moldy tomatoes. During an interview on 5/31/24 at 8:35 am, the facility's dietary manager in training/lead cook (DM) stated, Resident 2 had ordered a chef's salad and Resident 2 had sent back the chef's salad due to moldy cherry tomatoes. DM stated performing a visual inspection of the chef salad and confirmed, Resident 2 had been served a chef salad with moldy cherry tomatoes. During an interview on 5/31/24 at 11:38 am, Registered Dietician (RD) stated, RD was notified that Resident 2 had been served a chef salad with moldy cherry tomatoes and observed a photo of the moldy cherry tomatoes taken with Resident 2's cell phone. RD stated the expectancy was for staff to visually inspect food prior to serving it to the residents and stated, the chef salad should not have been served.

Based on interview and record review the facility failed to provide one out of three sampled residents (Resident 1) with outside services when a request was made for Resident 1 to be seen by her cardiologist (doctor that specialized in the heart) and a referral was not initiated. This had the potential for a decline in resident health status. Findings: A review of the facility's policy and procedure (P&P) titled, Referrals, revised 12/1/08, indicated Social Services or designee shall coordinate most resident referrals. The P&P indicated, Social Services or designee will document the referral in the resident's medical record. A review of the undated Admission Record, indicated, Resident 1 was admitted to the facility on [DATE] with the diagnoses of hypertensive heart disease (heart problems that were caused by high blood pressure) and diabetes. Resident 1 was her own responsible party (made own decisions about heath care). During an interview on 5/14/24 at 12:27 pm, Resident 1's care giver (CG) stated, during a care conference meeting (a group of medical professionals that met to discuss resident care and care planning with the resident, family members, or caregivers), the social worker (SW) had been informed that Resident 1 wanted to been seen by Resident 1's cardiologist. CG stated, Resident 1 had not been seen by the cardiologist and had concerns due to Resident 1's history of heart problems. During a concurrent interview and record review on 5/31/24 at 9:29 am, Resident 1's Care Conference Meeting note, dated 4/22/24 was reviewed with SW. SW stated, the Care Conference Meting note, indicated, the next step was to make a cardiology appointment for Resident 1. SW stated inability to find the documents that would be faxed to the cardiologist requesting an appointment for Resident 1 and confirmed there was no documentation in Resident 1's medical records that supported a referral had been made.

Based on observation and interview the facility did not store cooking utensils in a sanitary manner when serving scoops were observed to be stored in a drawer containing dark colored water and food particles. The failure to maintain cleanliness in storage of serving utensils has the potential to cause the spread of food borne illness leading to adverse resident clinical outcomes. Findings: During a concurrent kitchen observation and interview, on 2/15/22 at 8:32 AM with the dietitian, three of four utensil drawers were observed to have food particulate matter within. One drawer was observed to have dark fluid accumulated in contact with food serving scoops. The dietitian commented that, This is unusual. I don't know how that got in there. We will change the location of the scoops so this doesn't happen again. As to the food particles the dietitian stated, It must have come during food prep. Remediation was instituted immediately. During a concurrent kitchen observation and interview, on 02/15/22 at 8:37 AM with the dietitian, a pie serving utensil and a spatula in a storage drawer were observed to have dried food particulate matter present. The dietitian removed the utensils and stated, They (staff) must not have seen that. They will be reminded to observe for that closely. The utensils were handed off to the kitchen assistant who acknowledged the presence of the food particles on the utensils and returned them to the dishwashing area to be cleaned.

Based on observation, interview, and record review, the facility failed to prevent the spread of infection when: 1. a staff member entered an isolation room of a resident who was under observation for exposure to the COVID-19 virus without donning (putting on) appropriate Personal Protective Equipment (PPE); 2. two of three pill cutters had not been cleaned between uses; 3. one of three glucometers (a device used to measure blood sugar) was not cleaned according to manufacturer's guidelines between uses. This failure had the potential to spread germs from resident to resident or staff which could have caused illness or outbreaks of infectious disease. Findings: 1. Review of the facility policy, titled, Care & Placement of Residents/Patients with Known or Suspected COVID-19, or Undiagnosed Respiratory Infection, undated, indicated that COVID-19 was most often transmitted from a person with close contact by way of respiratory droplets produced when an infected person coughed or sneezed, similar to how the flu and other respiratory germs spread. Residents who had potentially been exposed to COVID-19 were placed in designated areas called Yellow Zones or Units to be quarantined or isolated from other residents. All Yellow Zone residents were considered potentially contagious until that possibility was ruled out, and strict precautions were to be adhered to at all times. PPE to be used in the Yellow Zone included N95 respirators (masks), eye shields, disposable gowns, and gloves. In addition to an N95 and protective eyewear, staff were to don gowns and gloves upon entry into the room or at any time in the room when exposure to resident secretions was likely. Staff were to remove the PPE and discard it at the doorway prior to exiting the resident room, perform hand hygiene upon completion of contact with the resident, after doffing (removing) the PPE. During a concurrent observation and interview, on 2/15/22, at 8:15 AM, Housekeeper (HSK) delivered some clothing on hangers to room [ROOM NUMBER] and placed them in the closet. HSK wore an N95 mask and eye shield, but no isolation gown or gloves. HSK exited the room without sanitizing their hands. When asked, HSK confirmed they were not wearing a gown and gloves and didn't sanitize their hands, but normally would have. A review of the facility's policy titled Infection Prevention and Control Program revised 10/2018 indicated that the facility's policy was established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 2. During an observation on 2/14/22 at 9:00 AM LN 1 used a pill cutter to cut an oral medication and then replaced it back into her medication cart (medication cart 1), without cleaning it. Debris from the pill could be seen in the pill cutter. During a concurrent observation and interview of LN 3 with ADON on 2/14/22 at 10:45 AM 1 of 2 pill cutters on LN3's medication cart (medication cart 2), was observed to have white powdery debris inside. Both LN 3 and ADON stated that the pill cutter appeared dirty and had not been cleaned after prior use. ADON stated that it was her expectation that the multipatient use pill cutters be cleaned after each use with soap and water to avoid contamination between patients. During a concurrent observation and interview on 2/14/22 at 11:00 AM LN 1 and ADON opened the pill cutter from medication cart 1 and it was observed to have white powdery debris in it. Both LN 1 and ADON stated that the pill cutter was dirty and should have been cleaned after use. 3. During an observation on 2/15/22 LN 1 used a glucometer (device used by several patients to measure blood sugar), and was observed to wipe it with a bleach wipe for 30 seconds and then placed it back into the medication cart drawer. No dwell time (time a product must remain wet on a surface to kill all germs) was observed. During a review of the bleach wipe product used for this cleaning (PDI Sani-Cloth Bleach) the product directions indicate that a treated surface must remain visibly wet for a full 4 minutes. Use additional wipes if needed to assure continuous 4 minute wet contact time. During an interview on 2/15/22 at 1:00 PM with Infection Preventionist (IP), IP stated that all staff are trained to use bleach wipes from a packet and let sit for 10 minutes. IP stated that she believed the product would remain wet on the device for 10 minutes. A review of the bleach wipe packet product ([MEDICATION(S)] Micro-Kill Bleach) packet instructions indicate that a 30 second contact time is required to kill all bacteria and viruses the label except a 1 minute contact time is required to kill [MEDICATION(S)] and [MEDICATION(S)] (specific germs) and a 3 minute contact time is required to kill [CONDITION(S)] spores ( a germ that can spread rapidly in a nursing home setting and can cause significant illness and death.) During an interview with DON on 2/17/22 at 10:00 AM DON stated that obtaining standardized cleaning and disinfecting products during the pandemic had been difficult and acknowledged that staff could be confused when different products require different wet times and usage instructions.

Based on observation, record review and interview the facility failed to ensure that outdated drugs were removed from the medication storage room when an expired bag of medication was found in the medication refrigerator in the main medication storage area. This could have led to a resident receiving an ineffective dose of medication that had expired. During a concurrent observation and interview, on [DATE] at 10:20 am, in Medication Storage Room 1 with Assistant Director of Nursing (ADON), Pharmacist (Pharm), and pharmacy manager (Pharm Manager), a bag of [MEDICATION(S)] (a vaccine for [CONDITION(S)], a blood infection) 20 mcg/ml (microgram per milliliter) was noted to have an expiration date of ,d+[DATE]. ADON stated that this should have been removed, and did remove it immediately. Pharm stated that it was their job (contracted pharmacy vendor) to check for out dated medications monthly. Pharm and Pharm Manager were observed doing their February inspection of the medications. A review of the facility's policy entitled Storage of Medications revised [DATE], indicated that The facility stores all drugs and biologicals in a safe, secure and orderly manner, that nursing staff is responsible for maintaining medication storage and preparation areas in a clean safe, and sanitary manner, and that discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

Based on observation and interview the facility failed to maintain clean and sanitary conditions when: 1. Two clean utility room under-sink cabinets were observed to be soiled. 2. Two room fans were observed to have lint on the fan blades and wire cage of the fan. These failures created the potential for environmental contamination with bacteria, viruses and allergens, not facilitating a homelike environment that could lead to negative clinical outcomes. Findings: 1. During an initial tour of the Cherry wing and concurrent interview on 3/9/20 at 9:37 AM, the clean utility room was observed with Certified Nursing Assistant (CNA) 2. CNA 2 confirmed the area under the sink was soiled with a blackish brown substance and trash bags in a corrugated cardboard box were being stored. CNA 2 stated items should not be stored under the sink. During an observation and concurrent interview on 3/9/20 at 9:47 AM, CNA 2 returned to the clean utility room and removed the box of trash can liners that were being stored under the sink and stated she would notify housekeeping to clean under the sink. During an observation on 3/11/20 at 10:30 AM, the Peach wing clean utility room was observed. The under-sink cabinet, where items were being stored, was soiled with a blackish brown substance. 2. On 3/10/20 @ 10:30 AM during an observation of the facility utility rooms and physical therapy gym, two wall mounted room fans were observed to have dust accumulation on the fan blades and wire blade cover. The fan in the physical therapy room had a strand of dust, approximately 2 ½ inches long hanging from a fan blade. On 3/10/20 @ 10:40 AM CNA 3 was asked about the condition of the fan and stated, It looks kind of gross. Lint, yes. It needs to be cleaned. I will get housekeeping; they should have cleaned it. Shortly after, Housekeeper 2 entered the utility room and viewed the fan. I will take care of it right now was her response when viewing the condition of the fan. On 3/10/20 at 10:45 AM the fan in the physical therapy gym was called to the attention of staff. Physical Rehabilitation Aid acknowledged lint present on the fan. Housekeeping staff were summoned to clean the fan.

Based on observation, interview and record review, the facility failed to follow the standard of practice and manufacturer's recommendations for identifying expiration dates when it did not label blood sugar testing strips and solutions with the date they were opened, and when an expired bottle of [MEDICATION NAME] (a solution used to kill germs on skin) was not labeled with the date it was opened and was still in use. This failure had the potential to cause inaccurate blood sugar test results and insulin medication errors, and to ineffectively kill germs during wound care treatments, increasing the risk of infection. Findings: A review of a facility policy, titled, Storage of Medications, revised ,[DATE], indicated that all drugs and biologicals would be stored in a safe, secure and orderly manner. Nursing staff was responsible for maintaining medication storage in a clean, safe and sanitary manner. Outdated drugs or biologicals would be destroyed. Antiseptics, disinfectants and germicides used in any aspect of resident care must be clearly labeled with directions for use. During an observation of a Treatment Nurse's (TN) treatment cart, on [DATE] at 3:45 PM, a bottle of [MEDICATION NAME] solution had an expiration date of ,[DATE]. During an interview with TN, on [DATE] at 3:50 PM, she confirmed that the bottle did not have a date written on it for when it was first opened and that the expiration date from the manufacturer had expired. TN stated that staff routinely refill the expired bottle with solution from a larger bottle. She discarded the expired bottle and stated they would change their process to avoid potential infection control issues. During an observation of a medication cart on Cherry Wing, on [DATE] at 11:35 AM, the blood sugar device testing strips and control solution bottles (used to determine if the device is working accurately) were not labeled with the date when they were opened. The strips and solutions were in containers that identified the manufacturer. During an interview with a Licensed Nurse (LN) C, on [DATE] at 11:40 AM, she confirmed the bottles of test strips and control solutions were not labeled with the date they were opened. She stated that staff would use the expiration dates stamped on the bottles by the manufacturer to stop using those bottles. LN C was not aware of any other time frame after they were opened where they should be considered expired. During an interview with the Assistant Director of Nurses (ADON), on [DATE] 11:49 AM, she stated that staff go by the expiration date for test strips and solutions. A review of the manufacturer's recommendation for the blood sugar device test strips and control solution, on [DATE] at 11:58 AM, indicated they were good for 3 months after opening. During an observation of a medication cart in front of Apple Wing, on [DATE] at 12:25 PM, the blood sugar device testing strips and control solution bottles were not labeled with the date when they were opened. During an interview with LN D and ADON, on [DATE] at 12:16 PM, they stated they do not label the test strips or control solutions with the date they are first opened. When advised of the manufacturer's recommendations to stop using them within three months of being opened, they stated all the bottles would need to be labeled for staff to identify when three months had passed. During an interview with the Pharmacy Consultant, on [DATE] at 8:36 AM, she stated all medications used in patient care should be labeled with the date they are opened, including glucometer control solutions (used to verify accuracy of blood sugar testing devices).

Based on observation, interview, and document review, the facility failed to ensure it maintained an infection control and prevention program to provide a safe and sanitary environment when: 1. RNA (restorative nursing aide) 1 wore a wrist splint while providing care to residents; and 2. The portable vital signs machine had not been properly cleaned between residents. This had the potential to spread infection and communicable diseases between residents. Findings: 1. On 3/9/20 at 12:18 pm, RNA 1 was seen in the Assisted Dining Room wearing a wrist brace on her right hand, wrist, and forearm while feeding Resident 7. On 3/9/20 at 2:11 pm, RNA 1 was observed entering room [ROOM NUMBER] and closing the door. RNA 1 had used hand sanitizer to hands and brace before entering the room. During an interview on 3/10/20 at 9:58 am, RNA 1 said she works as an RNA not Certified Nursing Assistant. She said she can put her wrist splint in the washer and does so frequently. She also said she can take it off to wash her hands and it can be wiped down with alcohol. She said she does not change residents or shower them but only does RNA services like taking residents down to therapy room and helping them onto the bicycle. During an interview on 3/10/20 at 11:09 am, the infection control nurse (ICN) said portable equipment that is used for multiple residents, such as a vital sign machine, was cleaned between residents with bleach germicidal wipes. RNA 1's splint was discussed with ICN since RNA 1 was providing RNA services to more than one resident. ICN said she would expect RNA 1 to clean her splint between residents with a bleach germicidal wipe and would give her packets to keep in her pocket. 2. A review of a facility policy, titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised 10/2018, indicated that reusable items were to be cleaned and disinfected between residents. Reusable resident care equipment would be decontaminated between residents according to manufacturer's recommendations. During observation of the Plum Wing hallway, on 3/11/20 at 9:20 AM, a vital signs machine plugged into the wall by the medication cart was observed to have yellow-brown fluid, partially dried, and splattered around the base of the machine. During an observation of medication administration on Plum Wing, on 3/11/20 at 10:09 AM, a Licensed Nurse (LN A) did not wipe down the vital signs machine before or after she used it on Resident 19 and placed it in the hallway. During an interview with LN A, on 3/11/20 at 10:15 AM, she stated that each resident has their own blood pressure cuff that did not need to be wiped down between uses. LN A stated the vital signs machine should be wiped down between patients if soiled or if it contacts a resident. She stated she did not need to wipe down the entire machine at that time. During an interview on 3/11/20 at 3:22 PM, the Infection Control Nurse said the portable vital sign machine should be cleaned with a bleach wipe between residents. During concurrent observation and interview with the Director of Nurses (DON), on 3/11/20 at 3:24 PM, she confirmed that the vital signs machine on the Plum Wing was visibly dirty around the base and should have been cleaned. DON stated that the nurses and aides were responsible to clean the devices between patients. During an interview with LN B, 03/12/20 10:05 AM, she sated the vital sings machine should be cleaned between patients. She would wipe down any parts that were touched. LN B stated that if visibly soiled, she would clean the machine down to its base.

Based on observation, interview and document review, the facility failed to provide a safe and sanitary environment when: 1. Two sit-to-stand patient lifts were observed with visibly dirty foot sections. 2. The bathroom toilet shared by Residents 104 & 109, was visibly soiled with a brown substance. 3. A partially filled corrugated box of isolation gowns was stored on top of a clean linen cart, within approximately eight inches of the ceiling, in a clean utility room. These failures had the potential for cross-contamination of bacteria [MEDICAL CONDITION] between residents and to impede the function of the fire suspension sprinklers in the event of a fire. Findings: 1. Review of the facility's policy and procedure titled Cleaning and Disinfection of Resident-Care Items and Equipment, dated 10/1/18, indicated reusable items are cleaned and disinfected or sterilized between residents. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Manufacturer instructions provided by the facility for the sit-to-stand lifts, titled Disinfection, Cleaning and Maintenance, not dated, indicated Unless otherwise stated, before each and every use follow the cleaning, care and inspection procedures . The lift should be cleaned before it is used by another patient. ULINE Anti-Slip Tape application instructions, provided by the facility, not dated, indicated to keep tape surface clean. Use mild floor cleaners as directed. During an initial tour of the facility on 3/9/20 at 8:51 AM, a sit-to-stand patient lift was observed in the exit hallway on the Cherry wing with a visibly soiled foot section, with what looked like skin flakes. During an observation and concurrent interview on 3/09/20 at 9:34 AM with Certified Nursing Assistant (CNA) 1, a sit-to-stand lift was observed in the hallway, across from the nurse's station on the Cherry wing. CNA 1 confirmed the foot section of the lift was dirty. She stated the lifts were wiped down with bleach wipes between use and deep cleaned by housekeeping. CNA 1 stated the lift had been deep cleaned last week. She agreed the dirty foot section of the lift was an infection control issue and that she would deep clean the lift. CNA 1 stated it was difficult to clean the foot sections of the lifts, due to the anti-slip surface. During an observation and concurrent interview on 3/09/20 at 10:37 AM with Housekeeper (HSK) 1, a sit-to-stand lift was observed outside of room [ROOM NUMBER]. HSK 1 confirmed the foot section of the lift was dirty. She stated she was not sure if housekeeping cleaned the lifts and would need to check with her supervisor. During an observation and concurrent interview on 3/09/20 at 11:28 AM with Administrator (Admin), he confirmed the lift in the hallway outside of resident room [ROOM NUMBER] was dirty. During an interview on 3/12/20 at 8:20 AM with Assistant Director of Nursing (ADON) at the nurse's station on the Cherry wing, she stated staff were expected to clean the patient lifts between each use, using bleach wipes. ADON stated that maintenance staff were responsible for deep cleaning the lifts weekly and kept a cleaning log. Review of the facility's Resident Council Minutes, dated 4/9/19, indicated Hoyer & sit-to-stand wheels need to be cleaned clogged with excess hair. 2. Review of the facility's policy and procedure titled Cleaning and Disinfecting Residents' Rooms, dated 8/1/13, indicated environmental surfaces will be disinfected (or cleaned) on a regular basis .and when surfaces are visibly soiled. During an observation and concurrent interview on 3/09/20 at 10:33 AM, the bathroom in room [ROOM NUMBER], shared by Residents 104 and 109 was observed. The toilet and elevated toilet were not clean. A brown substance was smeared on the toilet seat and the toilet bowl was splattered with what appeared to be fecal material. There was no liner in trash can. HSK 1 confirmed the toilet and elevated seat were not clean. She stated the toilet had been used since she cleaned it earlier and confirmed the trash can should have had a liner. During an observation on 3/11/20 at 7:34 AM the bathroom in resident room [ROOM NUMBER] was observed. The sides of the toilet bowl were splattered with a brown substance that appeared to be fecal material. 3. Review of the facility's policy and procedure titled Receipt and Storage of Supplies and Equipment, dated 11/1/09, indicated .must be properly stored and labeled in accordance with current regulations. During an observation and concurrent interview on 3/09/20 at 9:37 AM the Cherry wing clean utility room was observed. A corrugated cardboard box with isolation gowns was observed on top of the clean linen cart, within approximately eight inches of the ceiling and a fire suppression sprinkler head. Certified Nursing Assistant (CNA) 2 confirmed the box was stored too close in proximity to the sprinkler head. She did not know the specific distance standard for storage of supplies in proximity to a sprinkler and stated she would need to ask someone. During an observation and concurrent interview on 3/09/20 at 9:47 AM, the Cherry wing clean utility room was observed. CNA 2 returned to the room and stated storage was supposed to be 18 from the ceiling. She removed the box of isolation gowns stored on top of the linen cart. Review of the National Fire Protection Agency (NFPA) Standard 13 for the installation of Sprinkler Systems 2019 indicated there needs to be a minimum clearance to storage of 18 inches between the top of storage and ceiling sprinkler.

Based on observation, interview, and record review, the facility failed to have an effective infection control program to ensure a safe, sanitary environment for residents, staff, and visitors, and prevent and control the transmission of disease and infection by failing to: 1a. Ensure contact isolation procedures were in place for [DIAGNOSES REDACTED] (a gastrointestinal illness caused by a highly contagious, infectious bacteria (Clostridium difficile, [DIAGNOSES REDACTED]), according to facility policy and nationally recognized infection control standards, which required immediate contact precautions, separation of non-ill residents from those who were potentially contagious or contagious, strict hand washing with soap and water and the use of gowns and gloves when in contact with these residents. Resident 10 in room [ROOM NUMBER] had symptoms (diarrhea, sweats, and temperature) of [DIAGNOSES REDACTED], and was not immediately put on contact isolation precautions. The roommate of Resident 10, who did not have any symptoms of [DIAGNOSES REDACTED] was not moved immediately to a non-infectious room when the facility became aware of Resident 10's potentially contagious infection. This failure placed residents, staff, and visitors at risk for exposure to [DIAGNOSES REDACTED] infection. 1b. Ensure Housekeeping services effectively cleaned, disinfected, and sanitized the resident care environment, using infection prevention practices and cleaning/disinfectant agents, in accordance with nationally recognized infection control standards and manufacturers' recommendations for effective sanitization. Toilet water was used to clean bathrooms and resident care equipment, staff did not use proper hand hygiene after cleaning a room where the resident had a resistant and highly contagious infection. Staff were not aware of the proper use of disinfectants used for cleaning resident rooms and equipment. This resulted in the risk for residents, staff, and visitors to become infected with [DIAGNOSES REDACTED] which causes diarrhea, fever, and abdominal cramping and can rapidly lead to significant adverse outcomes. 1c. Ensure accurate identification of the source of infection for [DIAGNOSES REDACTED] when the Infection Monitoring Record (IMR, a log which tracks all residents with potential infections or infections at the facility) incorrectly identified a resident's [DIAGNOSES REDACTED] infection as being community acquired rather than facility acquired. Failure to have accurate information for the source of infection had the potential to result in a delay into the investigation, cause, and prevention of resident infections, placing residents, staff, and visitors at risk for infection. 2. Ensure two Laboratory Technicians (LT E and LT M) followed infection control and proper hand hygiene practices before and after contact with residents, in accordance with facility policy and nationally recognized infection control standards. This failure had the potential for the spread of blood borne pathogens and infectious diseases. 3. Ensure Resident room [ROOM NUMBER], shared by Residents 28 and 29, was clean when dust was observed directly on the residents' personal items, beds, and medical equipment. This failure had the potential for the spread of infection. 4. Ensure sanitary storage of resident care supplies, equipment and food items when Storage Room A was observed to contain resident care supplies, equipment, and food items stored with employees' personal items and food in the same area, and clean items were stored in direct contact with trash. This failure resulted in contamination of clean items and had the potential for food borne illness and the spread of infection. 5. Ensure sanitary storage of clean linen when Storage Room B contained clean linen stored with dirty equipment and employees' personal items. This failure had the potential for the spread of infectious diseases. 6. Ensure a sanitary shower room for residents when soiled, used gloves were observed on the floor of a shower room which was available for resident use. This failure had the potential for the spread of infectious diseases. Due to the facility's failure to ensure a sanitary resident care environment, an effective infection control program, that residents, staff, and visitors were safe from cross-contamination and not at risk for exposure of infectious diseases, an Immediate Jeopardy (IJ) was declared on 10/22/14 at 3:20 pm with the Administrator, Director of Nurses (DON), Infection Control Nurse (ICN) and the Environmental Supervisor (ES). On 10/24/14 at 11:30 am, the IJ was abated in the presence of the Administrator and the DON, when the facility provided evidence of implementation of a corrective action plan. Findings: A facility policy, dated 10/09, titled, "Handwashing/Hand Hygiene" instructed, "5. Employees must wash their hands for ten to fifteen seconds using ... soap and water under the following conditions: a. Before and after direct contact with residents; c. After contact with blood ... ; d. After removing gloves; g. When there is likely exposure to spores (part of bacteria that are extremely resistant and easily transmissible, example[DIAGNOSES REDACTED] ... ). (Note: Alcohol-based hand rubs are inactive against spores. For effective mechanical removal of spores, wash hands for 30 - 60 seconds with soap and water.) 8. The use of gloves does not replace handwashing/hand hygiene." A facility policy, dated 10/09, titled, "Isolation - Categories of Transmission-Based Precautions" instructed, "... three types of transmission-based precautions (airborne, droplet and contact) have been established. Page two: Contact Precautions, In addition to standard precautions, implement Contact Precautions for residents known or suspected to be infected ... with microorganisms (germs) that can be transmitted by direct contact with the environmental surfaces or resident-care items in the resident's environment. Examples of infections requiring Contact Precautions include, ... Diarrhea associated with[DIAGNOSES REDACTED]. Page three, Resident Placement; Place the individual in a private room ... . The infection control coordinator will assess various risk associated with other resident placement options (room sharing). Gown; in addition to wearing gloves wear a gown for all interactions that may involve contact with the resident or potentially contaminated items in the resident's room. Page four, Signs: Use color coded signs and/or other measures to alert staff. Place an orange sign at the doorway instructing visitors to report to the nurse's station before entering the room. An undated policy titled, Policy for Clostridium difficile Infections, instructed: "institute contact precautions for residents... , hand washing with soap and water. [DIAGNOSES REDACTED] is a spore and can survive in the environment in its spore state for months, and can contaminate the environment. [DIAGNOSES REDACTED] is shed in feces, any surface, item, or medical device that becomes contaminated with feces can act as a sources for the spores, and therefore, be involved in infection transmission. Ensure that personnel allow appropriate germicide contact time. The following items should be cleaned at least daily or more if often if indicated: The resident's bed, all furniture, commodes, bathrooms (including sink, floor, and toilet), frequently touched surfaces such as light switches, door knobs, call bell, ... and medical equipment. Consistency with recommended cleaning and disinfection procedures should be routinely monitored." 1a. On 10/20/14 at 4:30 pm, during an observation and interview with Resident 10, an alert and oriented resident, he stated he had diarrhea (loose stools) for five or six days. Resident 10 stated his temperature was elevated and he had been having night sweats. Resident 10 stated the physician had seen him in the morning and had ordered a stool sample to check if he had an infection. Resident 10 also shared a room with Resident 33. The room which was occupied by both Residents 10 and 33, was a standard room and did not have any signs or indications of contact precautions or isolation in place. On 10/20/14 at 5:15 pm, Resident 10's record was reviewed concurrently with the Infection Control Nurse (ICN), and indicated that Resident 10 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. On 10/17/14, the Nurse Practitioner (NP) Progress Note indicated Resident 10 had diarrhea. On 10/19/14, a physical therapist documented Resident 10 had diarrhea for three days. On 10/20/14 at 10:50 am, the NP ordered a stool specimen to check for[DIAGNOSES REDACTED]. The order was entered into the computer system and noted by the nurse in charge on 10/20/14 at 1:30 pm. A review of Resident 33's record indicated he was admitted to the facility on [DATE], for treatment after a stroke. Resident 33's record did not indicate he had symptoms of diarrhea. On 10/21/14 at 5:40 pm, the ICN stated she had become aware of Resident 10's diarrhea that morning and possibility that he could have [DIAGNOSES REDACTED]. She stated Resident 10's symptoms should have been reported to her sooner and investigated on 10/17/14, when the NP indicated in the progress note about his complaints of having diarrhea. The ICN stated Resident 10 should have been on contact precautions and not sharing a room with another resident, until the appropriate lab test had been completed (a stool sample test), and the results of the test were known if Resident 10 was contagious, and had a potentially infectious illness. The ICN stated Resident 10 needed to be on Contact Precautions, and his roommate needed to be moved to another room to prevent the possible spread of [DIAGNOSES REDACTED]. 1b. room [ROOM NUMBER] was observed, occupied by Resident 3, a resident with a [DIAGNOSES REDACTED]. diff to other residents. On 10/22/14 from 1:10 pm to 1:28 pm, Housekeeper (HSK) K was observed cleaning room [ROOM NUMBER]. HSK K entered Resident 3's room wearing a protective gown and gloves, carrying one cleaning cloth, and entered the bathroom and flushed the toilet. She then reached under her protective gown and took a can of disinfectant spray (End-Bac) out of her pants pocket and sprayed the top and legs of the commode (a portable toilet) with End-Bac, then reached under her protective gown and put it back into her pants pocket, and wiped the commode with the cleaning cloth. She then dried the commode with paper towels and rinsed the cleaning cloth in the toilet bowl water. HSK K then proceeded to wipe down the wall next to the toilet with the cleaning cloth that had been wet with toilet water. She then reached under her protective gown, removed the End-Bac and sprayed the toilet, then returned the End-Bac to her pants pocket. She then wiped the toilet lid and rim with the cleaning cloth, rinsed the cleaning cloth in the toilet bowl water again, wiped the wall above the toilet, and then the top of the commode again, then rinsed the cleaning cloth in the toilet water, and exited the bathroom holding the cleaning cloth. HSK K then reached under her protective gown, removed End-Bac and sprayed the resident room sink area, and wiped the sink with paper towels while holding the cleaning cloth. HSK K dropped the cleaning cloth into the trash. She then dropped the End-Bac can on the floor, picked it up, reached under the protective gown and put it back in her pants pocket, and stated, "You didn't see that" to the observing surveyor. At 1:25 pm, HSK K continued to clean room [ROOM NUMBER], and was observed concurrently with the Environmental Supervisor (ES). HSK K mopped the floor of room [ROOM NUMBER], put the soiled mop cloth in a bag, and removed the protective gown and gloves. HSK K went to the housekeeping cart, wrote information on a clip board, and started to leave with the cart to continue with her work in the facility. Because HSK K was going to continue with her work without using proper hand hygiene and possibly expose residents to germs, the surveyor asked ES (HSK K's supervisor) if HSK K should wash her hands before she continued to work. ES then instructed HSK K to wash her hands before she continued to work. HSK K then questioned ES as to how she should wash her hands and stated she thought her hands were clean because she had worn gloves when she had cleaned room [ROOM NUMBER]. ES instructed her again to wash her hands. HSK K went to the sink in room [ROOM NUMBER], put soap on her dry hands and briefly (five seconds) rubbed her hands together. She then rinsed her hand for five seconds, turned off the water with her hand, and then dried her hands with a paper towel. HSK K confirmed the observations of how she had cleaned room [ROOM NUMBER]'s bathroom and sink area. ES then stated to HSK K, "you should never use toilet water to rinse or clean." HSK K said she thought she "could use the toilet water to rinse the cleaning cloth because the toilet had been cleaned." HSK K stated she had worked full time at the facility in the housekeeping department for six years. During an extensive interview on 10/22/14 at 1:30 pm, ES stated HSK K did not follow the facility's procedure for cleaning an isolation room and did not use proper hand washing, and she should not have used toilet water to rinse her cleaning cloth. ES stated he monitored the housekeeping staff by observing resident rooms before and after they were cleaned. ES stated he did not directly observe the housekeeping staff when they cleaned resident rooms. ES stated the housekeeping department staff were not reviewed or evaluated for competency of the duties they performed, and he had not been aware of how HSK K had been cleaning the residents' rooms. ES stated there was not a written procedure instructing the housekeeping staff how to use the different cleaning chemicals and when to use them. ES stated there was an inservice over a year ago to tell staff about Virasept (type of disinfectant used in isolation rooms) when it was first introduced to the facility. He also stated he has reminded staff at meetings about the chemicals they clean with. ES stated the following regarding the disinfectants the facility used: Virasept was used specifically for contact precautions (isolation rooms), including [DIAGNOSES REDACTED], and surfaces needed to be wet with Virasept for 10 min to be effective. Oasis Pro 20 Premium was used as a floor cleaner and the floor surface needed to remain wet for five minutes. Comet with Bleach was used to clean non-isolation rooms and surfaces needed to remain wet for 10 minutes to be effective. A concurrent review with ES of the manufacturer's recommendations for Virasept, Comet with Bleach, and Oasis Pro 20 Premium verified the above information as follows: A review of the manufacturer's recommendations for the use of Virasept (used to clean [DIAGNOSES REDACTED] rooms) instructed to apply by spray or cloth, and surfaces must remain wet for 10 minutes to be effective to kill spores (for [DIAGNOSES REDACTED]). A review of the manufacturer's recommendations for the use of Comet with Bleach instructed to apply by spray or cloth, and surfaces must remain wet for 10 minutes to be effective against bacteria. A review of the manufacturer's recommendations for the use of Oasis Pro 20 Premium instructed to apply by spray, mop or cloth, and surfaces must remain wet for 5 minutes to be effective against bacteria. A facility policy, dated 8/2010, titled, "Cleaning and Disinfecting of Environmental Surfaces," instructed, "5. Manufacturers' instruction will be followed for proper use of disinfecting products including: ...recommendation use-dilution... ." (ensuring sufficient concentration and wet surface times). On 10/22/14 at 3:20 pm, HSK L stated she works full time and transferred from the facility's laundry department to the housekeeping department two months ago. HSK L stated she had not had any specific training from the housekeeping department on how to clean an isolation room (a room with a resident who has a contagious illness and special precautions and procedures that are required to ensure the infection does not spread to other residents and staff). HSK L stated she had received training four years ago, when she was first hired, but the chemicals she used to clean resident rooms had changed. HSK L stated she now used a bleach premixed solution to clean resident rooms, and sometimes sprayed with a disinfectant spray, End-bac spray, and then used a floor disinfectant, Oasis Pro 20 to mop with. She stated she had not cleaned an isolation room for months, and knew she was to use another cleaner, Virasept, for that purpose. HSK L stated when she used either the bleach solution, End-bac spray, or Virasept, the surfaces she cleaned would stay wet with the disinfectant/cleaners for "four to five minutes." She stated she did not know how long the disinfectants and/or cleaners she used should stay wet on the surfaces to which she applied them. HSK L's statement of how to clean a room did not adhere to the requirements as stated in the manufacturer's guidelines, specifically the requirement that surfaces must be wet for 10 minutes to kill bacteria when using Virasept or Comet with Bleach. During an interview on 10/22/14 at 2:40 pm, House Keeper/Janitor (HSK J) stated she had worked at the facility for 8 years and was currently full time and assigned to clean all rooms on the Cherry Wing, including rooms with residents on isolation who have been diagnosed with [REDACTED]. She stated that she uses a special cleaner called Virasept in the isolation rooms for residents with[DIAGNOSES REDACTED]. She stated that she does not spray the Virasept directly on surfaces except the toilet, that she moistens a rag with water and sprays the Virasept on to the moistened towel. She stated floors were cleaned with a mop using the Virasept. HSK J stated that drying time for the Virasept was "five minutes or less." During an interview on 10/22/14 at 3 pm, ES stated that the Virasept product was to be sprayed directly on surfaces. He confirmed that the manufacturer's guidelines for effective use of Virasept requires a moist surface with the product and ten minutes of drying time and that rags used should not be dampened by water. On 10/22/14 at 3:20 pm, HSK L was asked about how she used cleaning products. She stated that she uses Virasept for [DIAGNOSES REDACTED] rooms and that she did not know how long to leave the product on the surfaces that she cleans, including rooms with [DIAGNOSES REDACTED]. HSK L's statement of how to clean a room did not adhere to the requirements as stated in the manufacturer's guidelines, specifically the requirement that surfaces must be wet for 10 minutes to kill bacteria when using Virasept. Due to the facility's failure to ensure a safe, sanitary environment, effective infection control practices, and protect residents from the threat of cross-contamination and risk for exposure to infection(s), an Immediate Jeopardy (IJ) was declared on 10/22/14 at 3:20 pm, with the Administrator, Director of Nurses (DON), Infection Control Nurse (ICN) and the Environmental Supervisor (ES). On 10/22/14 at 6:54 pm, the facility provided an acceptable corrective action plan which included proper cleaning/sanitization of all rooms that had previously not been properly cleaned including isolation rooms, inservicing of staff in the proper cleaning procedures, review of infection control policies, proper cleaning of housekeeping carts and equipment to be completed by noon on 10/24/14. 1c. On 10/22/14, a list of the residents who had a [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]. A document that was "numbered IMR" was received on 10/23/14 at 3:43 pm from the ICN and indicated 22 residents had either community acquired (came to the facility with[DIAGNOSES REDACTED] or developed the infection within 2 days after admission) or facility acquired[DIAGNOSES REDACTED] (developed symptoms after 48 hours at the facility) in the last six months. A random selection of a resident, Resident 21, from the "numbered IMR" was reviewed concurrently with the ICN and the DON. Resident 21 was originally admitted to the facility on [DATE] with pneumonia, developed complications of bleeding and went back to the hospital on [DATE]. Resident 21 was readmitted to the facility on [DATE]. A review of the 9/22 and 10/5/14 facility documentation did not indicate Resident 21 had diarrhea. The nurses notes indicated on 10/10/14, Resident 21 had developed diarrhea and possible symptoms of [DIAGNOSES REDACTED], and was put on isolation precautions. On 10/11/14, laboratory testing confirmed that Resident 21 had a [DIAGNOSES REDACTED] infection, and treatment was ordered. Resident 21 had developed a facility acquired [DIAGNOSES REDACTED] infection, five days after her re-admission to the facility. A concurrent review of the October 2014 IMR with the ICN and the DON indicated Resident 21 had community acquired [DIAGNOSES REDACTED] and did not obtain her [DIAGNOSES REDACTED] infection at the facility. On 10/23/14 at 5 pm, the ICN acknowledged the above findings and stated the October 2014 IMR information was not accurate, and did not reflect that Resident 21 had developed a facility acquired [DIAGNOSES REDACTED] infection. The ICN stated the IMR's are reviewed by the Quality Assurance Committee and at the Safety Meeting monthly. She stated she indicated on the monthly IMR if the residents had community acquired or facility acquired infections. On 10/23/14, the survey team identified further deficient infection control practices at the facility based upon the above information. The incorrect identification of the source of a resident's infection as community acquired rather than facility acquired had the potential to result in a delay into the investigation, cause, and prevention of resident infections, placing residents, staff, and visitors at risk for infection. On 10/23/14, an addendum was added by the Administrator to the facility's 10/22/14 corrective action plan for the immediate jeopardy which included review of the IMR for accuracy for the previous six months. On 10/24/14 at 11:30 am, the IJ was abated in the presence of the Administrator and the DON, when the facility provided evidence of implementation of the corrective action plan. 2a. On 10/27/14 starting at 9:11 am, Laboratory Technician (LT) M was observed wearing disposable gloves, drawing two tubes of Resident 31's blood for a laboratory test. After Resident 31's blood was obtained, LT M wrote on the tubes while in room, then walked through the facility to another area, wearing the same gloves and carrying the tubes of blood. With a contaminated gloved hand, LT M unlocked a door and entered a small room, the electrical room, which had a laboratory cart containing supplies. LT M placed the two lab tubes which contained Resident 31's blood in a bin, directly next to clean supplies used to draw blood. LT M removed her gloves, then with her bare hands, put Resident 31's lab tubes in a plastic bag which was very full and contained other tubes of blood and papers. LT M then left the room and on the way to Resident 32's room, touched her hair and nose. She put on a pair of gloves, and entered the room. LT M then removed her gloves and put on a tourniquet and wiped Resident 32's skin with a alcohol wipe, put on gloves and attempted to obtain Resident 32's blood. After a failed attempt, LT M removed her gloves and then used an alcohol based sanitizer to clean her hands. On 10/27/14 at 9:30, LT M acknowledged she had put lab tubes which contained blood on top of clean lab supplies. She also acknowledged she had not cleaned her hands after drawing blood from Resident 31, and before the attempted blood draw from Resident 32. LT M stated she has been told the resident sinks are for their use and not to use them. She stated she relied on using hand sanitizer to clean her hands and was not aware the facility policy was to wash hands with soap and water after an invasive procedure or wearing gloves. 2b. During an observation on 10/27/14 at 8:50 am of the Pear Wing, the following was observed. LT E was pushing a cart containing laboratory supplies. LT E was seen collecting supplies together from the cart. LT E was writing with a pen and using her cell phone. LT E proceeded into room [ROOM NUMBER]. LT E did not change her gloves or wash her hands. LT E drew the blood of the resident in room [ROOM NUMBER], left the room and returned to the cart. LT E threw away the disposable equipment in the receptacles on her cart. LT E took her pen and wrote with the same gloves on. After finishing her tasks, LT E proceeded down the hall to the Apple wing. LT E then removed her gloves and used hand sanitizer. In an interview conducted on 10/27/14 at 9:10 am, LT E confirmed that she had not changed her gloves prior to or after the lab draw in room [ROOM NUMBER], nor had she washed her hands prior to or after drawing the blood in room [ROOM NUMBER]. When asked what the procedure was for drawing blood, LT E stated, "I don't know. Why don't you tell me?" In another interview conducted at 9:30 am, LT E stated that she was told by her boss that she "was not to use the resident sinks to wash her hands because those are their personal sinks." 3. During an observation on 10/20/14 at 9:40 am, room [ROOM NUMBER] (occupied by Resident 28 and 29) was observed with the Director of Nurses (DON). A thick layer of dust was observed on both residents' bed head boards, the lights above the beds, bedside tables, pictures on a cork board above the beds, on a walker, the top of a oxygen concentrator (a machine which pulls oxygen from the air through two filters into the machine and delivers oxygen through a tube (cannula) by nose or mask to the resident), and the window sill. Both residents had many personal items in the room, and there was dust on the surfaces of many of the personal resident items. The DON acknowledged the above findings and stated room [ROOM NUMBER] needed to be cleaned. 4. On 10/21/14 at 1 pm, during an observation of the Cherry Wing (Storage Room A) clean utility room, conducted with the Director of Staff Development (DSD, responsible for training nursing assistants)/ICN, the following was observed: On the counter, two open boxes of pastries, resident snacks stored next to the pastries, two open water bottles, two partially filled coffee cups, an open can of soda, and used cups; Slings (used to transfer residents with a lift) on a hook at the end of the room with an open trash can below the slings which was overflowing and the ends of the slings (four to five inches) were in contact with the trash; A window sill, located over the sink, had a basket containing crackers, peanut butter, and bananas; The cabinets under the counter contained both resident supplies (boxes of tissue, bed pan covers, and fall alarms) and employees' personal items, including an open can of soda; Medication cups were stored on top of the refrigerator; and A coffee maker and a coffee can were stored on the counter by resident supplies, for employee use. On 10/21/14 at 2:15 pm, the (DSD/ICN) verified the above findings and stated the clean utility room was for resident care items only, and the pastries, coffee, and open drinks should not be in the clean utility room. 5. During an observation conducted on 10/20/14 at 10:35 am of the Cherry Wing (Storage Room A) clean utility room, the following was observed: a) The door to the clean room was propped open with a rubber door stop, allowing access to this room by staff, residents, and visitors; b) The linen cart was uncovered on the northwest wall of the room; c) Two automatic blood pressure machines with their electric cords going from the machines across the floor, up and through the clean laundry cart, across and lying on linen, to access plugs on the northwest wall; and d) A coat rack on the south wall between the refrigerator and the doorway. During an interview conducted on 10/20/14 at 10:45 am, LVN A stated the electric cords from the blood pressure machines would pose an infection risk, because these machines were in and out of resident rooms and the cords would be considered dirty because of their frequent contact with the floor. LVN A also stated that the door should not have been propped open because this was a clean room containing linens and patient nourishment items. Visitors and residents would have access if the door was open and this could result in possible contamination of the area, food, and clean linens. During an interview on 10/21/14 at 2 pm in the Cherry Wing Storage Room A, the DSD/ICN stated that the linen was relocated to this room with the kitchen area because visitors were accessing the linen carts in the hallway. DSD/ICN also stated that the door should have been kept shut to ensure a clean room environment and that there should not have been a coat rack in this room. During the above interview, an unidentified certified nursing assistant (CNA) entered this room and walked past the linen cart. The CNA's long hair (not tied back) touched the linen as she walked past the cart. 6. During an environmental tour with the Maintenance Supervisor (MS) on 10/22/14 at 11 am, the shower room in Peach Wing, which was available for use, was observed to have soiled, used gloves on the floor next to the yellow barrel containing soiled linens. This had the potential to lead to cross contamination and expose residents to infectious material. In a concurrent interview with the MS on 10/22/14 at 11 am, he stated dirty gloves should not be left on the floor and should be disposed of properly.