Every finding on record at Covington Court Health and Rehabilitation Center

Number of residents sampled: Number of residents cited: Based on record review, observation and interview, the facility failed to ensure a Bilevel Positive Airway Pressure (BiPAP) mask [used to assist with breathing], and oxygen use was care planned for one (Resident #178) of two residents reviewed for oxygen. The findings include: Review of Resident #178's Active Orders with a start date of 03/01/2026, revealed Resident #178 had a Physician Order for BiPAP at bedtime and when napping. The physician order also indicated to administer oxygen at three to five liters per minute by nasal cannula, as needed for shortness of breath. Review of Resident #178's five-day Minimum Data Set (MDS) with an Assessment Reference Date of 03/03/2026, revealed that Resident #178 had a Brief interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The MDS also indicated that Resident #178 was on intermittent oxygen therapy and used a BiPAP on admission and while a resident at the facility. Review of a Care Plan reviewed on 03/01/2026, revealed the facility admitted Resident #178 on 02/28/2026 with diagnoses which included chronic obstructive pulmonary disease (COPD) with acute lower respiratory infection, and acute bronchitis [inflammation of the bronchioles] due to other specified organisms. The Care Plan did not indicate that Resident #178 used oxygen, or a BiPAP mask. On 03/09/2026 at 1:18 PM, this surveyor observed a BiPAP mask on a table in Resident #178's room uncovered. Resident #178 indicated that the BiPAP mask was always left uncovered. Resident #178 was on oxygen set at three liters by nasal cannula. The resident indicated they had been on oxygen since admission. During an interview on 03/11/2026 at 5:13 PM, MDS Coordinator #2 indicated she was responsible for updating the Care Plans. MDS Coordinator #2 indicated the information to update the Care Plans was received from the MDS and daily meetings. MDS Coordinator #2 stated the nurse managers will call me if they have changes that need to be added to the Care Plan. MDS Coordinator #2 confirmed that Resident #178 does not have oxygen Care Planned. MDS Coordinator #2 confirmed that oxygen was ordered on 02/28/2026 for Resident #178. MDS Coordinator #2 indicated that Licensed Practical Nurse (LPN) #3 in the medical records department documented the order for Resident #178's oxygen. During an interview on 03/11/2026 at 5:21 PM, LPN #3 indicated that she transcribed the order for Resident #178's oxygen on admission. She indicated that Resident #178 was admitted on [DATE]. LPN #3 indicated that she communicated what needed to be added to the Care Plan with MDS Coordinator #2 in the morning meeting that was held on 03/02/2026. During an interview on 03/12/2026 at 3:27 PM, the Administrator indicated that he did not have the documentation from the stand-up daily meeting on 03/02/2026.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined the facility failed to ensure oxygen was administered only when ordered by a physician to prevent potential respiratory complications for 1 (Resident #17) sampled resident reviewed for oxygen therapy. Findings include: A review of a facility policy titled, Verbal and Facsimile Orders, dated October 1, 2010, indicated, I.Verbal orders are those given to the nurse by the physician in person or be telephone, however, are not written by the physician in the medical record. a) Enter the verbal orders into the medical record.e) Follow through with orders by contacting the pharmacy and lab as appropriate . A review of the Face Sheet, indicated the facility admitted Resident #17 with diagnoses that included hypertensive chronic kidney disease; chronic kidney disease, stage 3; and generalized anxiety disorder. The annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/25/2024, revealed Resident #17 had special treatments procedures and programs which included oxygen therapy. A review of Resident #17's Care Plan, revealed there was no current use of the care plan due to no care plan being available for oxygen therapy. A review of the Physician Orders, revealed Resident #17 had no order for oxygen therapy. During an observation on 07/29/2024 at 11:58 AM, Resident #17 had a nasal cannula in place and an oxygen concentrator was in use. The oxygen rate setting was at two liters per minute. The oxygen tubing was wrapped around the leg of the over-the-bed table. Oxygen signage was present on the door frame outside of the room. During an observation on 07/30/2024 at 2:01 PM, Resident #17 was lying supine in bed. The oxygen concentrator was at the bedside with oxygen tubing inside a plastic bag and attached to the oxygen concentrator. During an interview on 07/31/2024 at 11:27 AM, the Assistant Director of Nursing (ADON) confirmed there was no order for Resident #17 to have oxygen therapy and no care plan was noted for the oxygen therapy. During an interview on 07/31/2024 at 1:45 PM, the Unit Manager reported that Resident #17 had been on oxygen. The unit manager brought the new order to the surveyor showing that oxygen therapy had been discontinued on 07/25/2024. On 07/31/2024 at 1:50 PM, the Unit Manager reported that the oxygen equipment and supplies had been removed from Resident #17's room. During an interview on 08/01/24 at 9:30 AM, the Minimum Data Set (MDS) Coordinator #2 stated the nurses can add interventions to the care plans, and that in the morning meetings, new orders and fall interventions were discussed to make sure they were placed on the care plans and to address any issues. During an interview on 08/01/2024 at 10:35 AM, the Director of Nursing (DON) confirmed the orders were reviewed each morning in the clinical meeting and new interventions were discussed. The DON stated that the Unit Manager should be adding the interventions to the care plans and that the charge nurses could also make changes and add to the care plan. When asked who was responsible for carrying out orders. The DON reported that when orders are discontinued, the nurse who took the order is responsible to remove any items from the resident's room that are no longer required.

Based on observations, interviews, record review, and policy review, it was determined that the facility failed to ensure dignity while dining for Resident #1 of 13 sampled residents. This failed practice had the potential to affect all sampled residents who are dependent while dining to maintain dignity. Findings include: A review of a facility policy titled, Resident/Rights dated 11/28/2016, under Respect and Dignity read in part .the resident has a right to be treated with respect and dignity including: the right to reside and receive services in the facility with reasonable accommodations of resident/guest preferences . Resident #1, diagnosis included Osteoarthritis, Pain, 2nd, and 3rd Spondylosis of Cervical Vertebra. The Resident is to always have on a cervical collar. The Minimum Data Set (MDS)- dated 01/25/2024, under section titled Cognitive Patterns listed a Brief Interview for Mental Status (BIMS) with a summary score of thirteen (13), which suggests a score of 13 to 15 the resident is cognitively intact. a. On 04/17/2024, at 8:35 AM to 9:35 AM the Surveyor observed Resident #1 lying in bed. The bedside table had dark substance under a bowl of oatmeal in liquid and a used spoon. The Resident had dried caked-liked consistency of oatmeal on the Resident's blouse, hands, and upper chest below her neck brace. In response to the question, does the facility help you with your breakfast? Resident #1 responded No, not unless I ask them several times. My right hand is not good, because I have Arthritis. I spill it all over me. Breakfast is my meal of the day, lunch, and night meal, I am unable to eat, because it takes too much out of me. Hospice will come in and clean me up and give me a bath. In response to the question, Did they offer a clothing protector when the nursing staff brought in breakfast? Resident responded, No, not today. b. In an interview on 4/18/2024, at 10:15 AM with LPN #1, in response to the question, can Resident #1 let her needs be known? LPN #1 responded, She is capable of letting staff know her needs, bedbound because of severe pain, has Arthritis, wears a neck brace and we never move her neck because of the pain. The Surveyor asked, is the Resident dependent for trays being served, and being fed meals? LPN #1 stated, Yes, she requires total care including tray set-ups and being fed by the nursing staff. In response to the question the Surveyor asked, does the facility provide protective covering or bibs during meals? LPN #1 responded, yes. c. In an interview on 4/18/2024, at 10:23 AM with Certified Nursing Assistant (CNA) #1, in response to the question, can Resident #1 let her needs be known? CNA #1 stated, She calls on the call light, and cannot get up. We come and help her when she calls us. The Surveyor asked, does the facility provide protective covering or Bibs for meals? CNA stated, yes. The surveyor asked, is the Resident dependent for trays being served, and being fed meals? CNA #1 responded, Yes, we set up trays for her meals, but she can feed herself. d. During the interview on 10:55 AM with the DON, and the Administrator, the surveyor asked were you aware that Resident #1 had dried cake-liked oatmeal on her blouse, hands, and upper chest below her neck brace, on 4/17/2024 for breakfast? The DON responded, I was not aware, been here one month and I am changing care for better outcomes.

Based on record review and interview, the facility failed to ensure that adequate visual supervision was provided by staff to prevent a severely cognitively impaired resident from eloping from the facility undetected for 1 (Resident #2) of 4 sampled residents. The situation resulted in a finding of Immediate Jeopardy, Past Non-compliance. The facility's Administrator was notified of the findings of Immediate Jeopardy on 8/17/23 at 12:41 PM. The findings include: Review of Resident #2 Significant Change Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/14/2023 noted a score of 4, on the Brief Interview for Mental Status (BIMS), which indicates severely impaired cognitive function. Review of Resident #2 care plan for Behavior Management with a start date of 2/6/23 noted the resident had exit seeking behaviors. The care plan for wandering with a start date of 1/14/2023, noted Resident #2 wanders and noted a monitoring device was placed on the resident, for exit seeking behavior. The care plan noted the resident should be in an area where frequent observation is possible, and staff to note which exits the resident favors (Main Entrance) for elopement from facility. Review of the physician orders dated 6/30/23 noted an order for an alarm bracelet at all times, on the right ankle, for safety. Staff to check for function every shift. A review of the Arkansas Department of Health and Human Services Division of Medical Services Office of Long Term Care form (DMS-762) dated 08/04/2023 noted that at 12:50 PM staff were not able to locate Resident #2. The resident was found off the facility premises and returned to the facility at 1:20 PM. The document noted another resident said Resident #2 went out the first door and the alarm did not go off and a visitor let resident #2 out the second door. Review of the nursing progress notes dated 8/04/2023 at 2:38 PM noted as a late entry, Resident #2 left the facility and had been found and was being transported back to the facility. Review of the nursing progress notes dated 8/04/2023 at 6:29 PM noted Resident #2 was last seen in the facility at 12:35 PM and eloped at 12:40 PM. Resident #2 was found at 1:20 PM by the local police department, who transported the resident back to the facility. Review of the nursing progress notes dated 8/04/2023 at 6:42 PM noted Resident #2 wandered out the front door and across the street to the bank. Resident #2 was picked up in a black car and taken to the police station at 12:40 PM, the police station notified the facility while the search was ongoing at 1:20 PM. On 8/17/2023 at 2:34 PM, in an interview with Certified Nurse's Assistant (CNA) #1 who stated resident #2 wore an alarm bracelet. On 8/17/2023 at 2:37 PM, in an interview with Registered Nurse (RN) #1 who stated resident #2 wore an alarm and ambulated with her walker. RN #1 stated Resident #2 was exit seeking, always looking through doors and staff had to keep an eye on her. On 8/17/2023 at 12:43 PM, in an interview with CNA #2 who stated Resident #2 was confused, wore an alarm, and the resident got out through the front door. On 8/17/2023 at 2:59 PM, in an interview with CNA #3 who stated Resident #2 wore an alarm and constantly circled the building. On 8/18/2023 at 9:01 AM, in an interview with the Financial Special Assistant who stated Resident #2 wore an alarm, was exit seeking every day all day, constantly pacing the halls. She stated she redirected Resident #2 from the front door just prior to the elopement incident and the alarm didn't go off. On 8/18/2023 at 9:13 AM, in an interview with the Maintenance Director who stated he tests the front door with an ankle bracelet once a week. He further stated there are testers for the ankle bracelet that is on the resident, which should be tested daily. He stated since the elopement the door is tested every day, and the control board to the door was replaced. On 08/18/2023 at 09:18 AM, in an interview with the Administrator who stated Resident #2 wore an alarm and was at risk for elopement. The Administrator confirmed he had observed Resident #1 exit seeking. Review of the facility Missing Resident Timeline dated 8/4/23 noted the outside temperature at the time of the resident elopement was 102 degrees and was sunny. The DMS-762 noted an in service on the elopement policy was completed with staff, Resident #2 was placed on one to one observation until transferred to a secured unit, staff was assigned to all exits with alarms until they were fixed, the door panel on the front door and the antenna were replaced and all ranges were tested and adjusted, a head count was completed, signs were placed on the facility doors reminding visitors not to open doors for people outside of their party. Notifications were made to the family, physician, law enforcement. The surveyor verified the plan of correction was completed. q. The facility Elopement and Wandering Residents Policy documented, . To identify those residents who wander so that appropriate interventions can be put in place in an effort to provide adequate supervision and safety . c Unsupervised activity outside the facility could lead to serious injury of a resident due to many hazards such as traffic, water, storms and hot/cold temperatures . the facility is equipped with door locks/ alarms to help avoid elopements .Tips for Prevention of Elopements: . d. Observe for aimless wandering . e. Involve the activities department in the prevention strategy . g. Review physical plant to be sure door alarms are working and that unauthorized areas are properly locked to prevent resident entry . h. Consider use of a Chain of Custody for High Risk Residents; develop a schedule for periodic checks on the resident .

Based on observation, interview, and record review the facility failed to ensure that a licensed administrator was responsible for the overall operation of the facility. The failed practice had the ability to affect all 124 residents who currently reside in the facility according to the census list which was provided by the Assistant Administrator on 7/10/23 at 11:04 AM. The findings are: On 7/10/23 at 10:45 AM the survey team entered the building and was greeted by Assistant Administrator. The surveyor asked for administrator and was told that the new administrator would be starting on Wednesday. The Assistant Administrator reported that she was in charge. When asked if she held a current license in the state of Arkansas, she stated, No, but its ok because we are within our 14 days. The surveyor then asked again, if there was anyone in the building who held a current administrator license. The Assistant Administrator affirmed, No. On 7/13/23 at approximately 2:00 PM the Assistant Administrator was asked to identify the last day the former Administrator was in charge. She stated, June 26th. The surveyor asked if the previous administrator provided a notice. The Assistant Administrator stated, no. The Assistant Administrator provided a copy of a letter she mailed to the Office of Long-Term Care on 6/26/23 noting the new Administrator would be assuming responsibility for the building as of 7/12/23. On 7/13/23 at approximately 2:45 PM Regional Nurse Consultant provided a copy of the NHS Management, LLC, Job Description, Job Title: Administrator. Qualifications: Must be a Licensed Nursing Home Administrator in good standing and/or meet all applicable federal state Licensure requirements.

Based on observation, record review and interview, the facility failed to ensure foods stored in the freezer, refrigerator and dry storage area were covered, sealed and dated to minimize the potential for food borne illness for residents who received meals from 1 of 1 kitchen; expired dairy products and food items were promptly removed / discarded on or before the expiration or use by date to prevent the growth of bacteria; dietary staff washed their hands between dirty and clean tasks and before handling clean equipment or food items to prevent potential for cross contamination for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 121 residents who receive meals from the kitchen (total census:124) as documented on a list provided by Dietary Supervisor. The findings are: 1. On [DATE] at 12:38 PM Dietary Employee (DE) #1 removed a carton of tomatoes from the refrigerator and placed it on the counter. She placed a cutting board on the counter. She transferred a few tomatoes inside a colander. She turned on the 3-compartment sink faucet and rinsed the tomatoes. After rinsing the tomatoes, she turned off the sink faucet and placed the colander on the counter. Without washing her hands, she removed gloves from the box and placed them on her hands, contaminating the gloves. She then placed tomatoes on the cutting board, cut and placed them into a pan to be served to the residents for lunch. 2. On [DATE] at 12:40 PM DE #2 turned on the hand washing sink faucet and washed her hands. She removed tissue and used them to turn off the faucet. She then used the same tissue papers to dry her hands, contaminating her hands. Without washing her hands, she picked up clean cups with her fingers inside the cups and placed them on the counter to be used in portioning ready-made pudding to be served to the residents for lunch. 3. On [DATE] at 12:46 PM DE #3 was on the tray line assisting with lunch meal. She went to the storage room, picked up a box of condiments and placed it on the counter. She removed condiments from the box, picked up cartons of supplements and placed them on the trays, contaminating her hands. Without washing her hands, she picked beverages glasses by their rims and placed them on the meal trays to be served to the residents for lunch. 4. On [DATE] at 12:58 PM DE #4 was wearing gloves on her hands when she opened a box of crispitos, contaminating the gloves. Without changing gloves and washing her hands, she removed crispitos from the box and placed them into deep fryer baskets to be fried and served to the residents for lunch. On [DATE] at 12:30 PM the Surveyor asked DE #4 what should you have done after touching dirty objects and before handling clean equipment and or food items. She stated, I should have removed the gloves and washed my hands. 5. On [DATE] at 1:00 PM DE#3 used a phone to announce that hall food cart was ready to be picked up, contaminated her hands. Without washing her hands, she picked up beverages glasses by their rims and placed them on the trays to be served to the residents for lunch. 6. On [DATE] at 3:34 PM DE#5 touched his mask. Without washing his hands, he picked up glasses by their rims and placed them on the trays. He poured water in the glasses to be served to the residents for supper. At 4:54 PM The Surveyor asked the DE #5 what should you have done after touching dirty objects and before handling clean equipment? He stated, I should have washed my hands. 7. On [DATE] at 3:35 PM DE #2 turned on the hand washing sink faucet and washed her hands. She removed tissue and used them to turn off the faucet. She then used the same tissue papers to dry her hands, contaminating her hands. Without washing her hands, she picked up a set of utensils by their tips and placed each set in an individual bag for the residents to be used in eating their supper meal. At 4:55 PM The Surveyor asked the DE #2 what should you have done after touching dirty objects and before handling clean equipment? She stated, Washed my hands. 8. On [DATE] at 3:36 PM DE#6 was wearing gloves on his hands when he removed bags of buns from the storage room and placed them on the counter, contaminating the gloves. Without changing gloves and washing his hands, he untied the bag of hamburger buns and emptied it into a pan. He then used his contaminated hands to separate the buns to be served to the residents for supper. 9. On [DATE] at 4:27 PM DE #1 took out a pan of hamburger patties from a pan of hot water on the stove and placed it on the counter. Without washing her hands, she picked up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. At 4:56 PM The Surveyor asked the DE #1 what should you have done after touching dirty objects and before handling clean equipment? She stated, I should have washed my hands. 10. On [DATE] at 4:48 PM DE#6 used a water hose to rinse off leftover foods from the blender bowl. He placed the bowl and blade in a dish rack and pushed it into the machine to wash. After the dish machine stopped. He removed gloves from the box and placed them on his hands, contaminating the gloves. He used the same gloved hands to pick up a clean blade and attached it to the base of the blender to be used in pureeing food items to be served to the residents on pureed diets. [DATE] 04:50 PM When DE #1 was about to place hamburger buns into the blender to puree. The Surveyor immediately stopped her and asked DE #6 what should you have done after touching dirty objects and before handling clean equipment? He stated, I should have changed gloves and washed my hands. 11. On [DATE] at 9:00 AM, The following food items were observed in the cabinet in the medication room at the Nurse's station between North [NAME] and South [NAME] There were no dates as of when the desserts were received. a. 7 cartons of vanilla pudding. b. 12 cartons of apple sauce. c. 19 cartons of strawberry Jell-o. d. 3 cartons of chocolate ice cream. e. A carton of frozen sugar free strawberry jello- in the freezer had expiration date of [DATE]. 12. The facility's policy titled, Frequency of hand washing. provided the Dietary Supervisor on [DATE] at 3:04 PM documented, Hands should be washed in the following situations. a. Every time an employee enters the kitchen, at the beginning of the shifts. b. after returning from break. c. After hands have touched anything unsanitary, i.e, garbage, soiled utensils or equipment, dirty dishes.

Based on interview and observation the facility failed to ensure that laundry was processed in a manner that minimized the risk cross contamination. The failed practice has the ability to affect all 124 residents whose clothing and linen are processed by the facility laundry according to the census list which was provided by the Assistant Administrator on 7/10/22 AT 11:04 AM. The findings are: On 7/13/23 at 8:13 AM this surveyor approached the laundry facility. Doors to the dirty side and clean side of the room were open to the outside. Multiple flies were observed on both sides of the facility, having landed on the clean linen. An oscillating fan observed to be covered in lint and dust. Upon entrance to the clean side of the facility the folding table observed to be against the wall. On top of the table is a personal drink cup, multiple clip boards, a mini refrigerator, an electric fan and snack items. Under the table, scattered on the floor there were approximately 10 tennis shoes of varying sizes and colors which are reported to be residents items which have no name. To the right of the table is an area of hanging clothes which are reported to be donations or unlabeled items which are available for residents in need. The items are uncovered. Underneath the clothing are two cardboard boxes located on the floor which contain additional donations. On a shelf located above the hanging items there are 15 to 20 heel boots which are piled to within 1 -2 inches of the ceiling. On 7/13/23 at 8:20 AM the surveyor asked laundry employee #1 what was important to consider when folding linen. She stated, how it should look, that it is put on the cart neatly so they can see how many they have. Employee did not identify keeping the items off her person or the floor. When asked what was important to remember when folding or hanging a resident's clothing laundry employee #1 stated, what rooms they go in, that they are put on the hanger right. Employee was observed to hold a folded piece of her clothing against her person and then placed it under her arm and then back against her person and then place on the hanging rack for delivery. On 7/14/23 at 9:10 AM the laundry supervisor was asked what steps were important when preventing cross contamination in the laundry. He stated, we keep it in bags and in barrels with the lids on them to keep it contained. During the folding process you keep it off yourself and the floor. When asked about the risk of work and personal items on the folding table supervisor stated, a drink could spill or the germs from the employee be transferred to the clothing.

Based on observation, interview, and record review, the facility failed to store medications being administered to residents in a safe, secure, and sanitary manner. The findings are: On 07/12/23 at 9:10 AM the Surveyor accompanied Licensed Practical Nurse (LPN) #5 to the medication room to look for two medications not found on the medication cart. LPN #5 looked through the cabinets in the medication room and commented, What a mess. She looked through the slot of the locked medication box and stated the potassium was in the waste bin. The surveyor asked how it got in the waste bin. LPN #5 answered, I couldn't tell you. Observed LPN #5 attempt to remove the medication from the waste bin. She stated, This is clean, as she attempted to reach in and get the medication which was out of her reach. She left the medication storage room and asked the Assistant Director of Nursing (ADON) to get a key to unlock the medication waste bin. On 07/12/23 at 9:37 AM the ADON returned to the medication room and unlocked the medication waste bin. LPN #5 reached in with ungloved hands and removed a tablet packaged in a clear plastic bag from the waste bin. The medication that was retrieved from the waste bin was then administered to Resident #110. 47912

Based on observation and interview, the facility failed to ensure pureed food items were blended to a smooth, lump free consistency to minimize the risk of choking or other complications for residents who required pureed diets for 2 of 2 meals observed. The failed practice had the potential to affect 9 residents who received pureed diets as documented on the List Dietary Supervisor provided by the Food Service Supervisor on 7/13/2023. The findings are: 1. On 07/13/2023 at 8:50 AM The pureed sausage served to the residents on pureed diets was runny and not formed. At 08:53 AM the Surveyor asked Dietary Supervisor to describe the consistency of the pureed food items served to the residents on pureed diets for breakfast. She stated, It was runny. I think they are afraid of making it too thick making sure they are smooth. 2. On 07/13/23 at 1:00 PM The following was observed during the noon meal observation in the dining room. a. The residents on pureed diets were served pureed dessert. The consistency was lumpy and not smooth. There were pieces of cherry visible in the mixture. b. The residents on pureed diets were served pureed bread. The consistency was gritty and not smooth. 3. On 07/13/2023 at 1:02 PM two certified Nursing Assistants (CNA) and the Activity Director were assisting residents at the same table. At 1:04 PM The Surveyor asked CNA#5 to describe the consistency of the pureed dessert served to the residents who required pureed diets. CN #5 stated, It was not smooth. CNA #6 stated, It has some chucks and the Activity Director stated, It's more of mechanical soft diets. Both CNA #5 and #6 stated, That's the word. 4. On 07/13/23 at 1:10 PM The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed dessert and pureed bread served to the residents on pureed diets. She stated, Pureed dessert was chunky,. Our blender did not blend it well. Pureed bread was a little gritty. They used the edge of the bread.4. On 07/13/23 at 1:10 PM The Surveyor asked the Dietary Supervisor to describe the consistency of the pureed dessert and pureed bread served to the residents on pureed diets. She stated, Pureed dessert was chucky, that was cherry. Our blender did not blend it well. Pureed bread was a little gritty. They used the edge of the bread.

Based on observation, record review, and interview, the facility failed to ensure residents' meals were consistently served at regularly scheduled times to provide residents with a dependable eating schedule for 2 of 2 meal services observed. The failed practice had the potential to affect all 121 residents who received meals from the kitchen (total census: 124), According to the list provided by the Dietary Supervisor dated 7/13/2023. The findings are: 1. On 07/11/2023 at 8:54 AM, the last resident was served breakfast in the dining room. This was a period of 1 hour and 54 minutes after the scheduled mealtime. 2. On 7/13/2023 at 8:50 AM, the last resident on the Northwest Hall was served breakfast. This was a period of 1 hour and 50 minutes after the scheduled mealtime. 4. The facility mealtime provided by the Dietary Supervisor dated 7/13/2023 documented, Breakfast .7 AM, Lunch .12 PM and Supper 5 PM

Based on observation and interview the facility failed to maintain a clean, well maintained, homelike environment. The failed practice has the ability to affect 6 of 6 sampled residents (R#9, #81, #79, #385, #55, #41) with rooms in need of cleaning or repair. The findings are: On 7/10/23 at 12:13 PM in room SE3, the wall adjacent to the middle and foot of the resident's bed is observed to have paint and plaster which is missing. The area is discolored ranging from white to tan to gray. The surface is rough to the touch. On 7/10/23 at 12:18 PM in room SE5, the wall adjacent to the head of the bed is observed to be patched and unpainted with a series of black marks and soiled areas. The wall behind the bed has paint and plaster missing. On 7/10/23 at 12:25 PM in room NE 21, the curtain which is adjacent to the resident's bed and at times protrudes over her bed rail contains a large stain, discoloring the fabric. On 7/10/23 at 2:49 PM in room SE10, the ceiling tile in front of the vent is observed to contain a large area covered with dust and debris. The wall adjacent to the side of the bed is observed to be missing paint and plaster with a series of black marks and soiled areas. The blind covering the window has multiple slats which are broken. 7/14/23 at 11:25 AM the surveyor asked the Maintenance Director if he was aware of the issues involving paint and missing plaster. The Maintenance Director stated he was aware of the issue and have been addressing the issue with paint and plexiglass panels. The Maintenance Director stated he was unaware of the issue with the blinds and stained curtain, that someone should have told him. A maintenance log is available at the nurse's station. 7/14/23 at 11:30 AM the administrator was asked for a policy concerning the maintenance of the physical plant. The consultant reports that one is not available.

Based on observation, record review and interview, the facility failed to ensure staff promptly assisted a resident who required assistance with incontinent care and failed to maintain privacy and dignity for 1 (Resident #51) of 3 (Residents #50, #51, and #103) sampled residents who required assistance with incontinent care on Southwest Hall and failed to ensure a catheter bag was covered to maintain dignity for one resident (Resident #110) of four (Residents #50, #51, #103, and #110) sampled residents who have an indwelling catheter. The findings are: 1. On 07/10/23 at 11:37 AM observed Resident #51 sitting up in a motorized chair in the room. The bed did not have sheets, was elevated, and had a strong odor of human waste. The surveyor asked Resident #51 why the bed was elevated so high and had no sheets. Resident # 51 answered, there has been a problem with flies because I have to have BM's [Bowel Movements] in bed and they don't want to change me or clean me up. a. On 07/11/23 at 3:08 PM the surveyor observed Resident # 51 lying naked and uncovered on his left side in bed facing the window with his backside facing the door. The Resident's head was approximately 3 inches off the bed, and there was no pillow. Resident #51's brief had been unfastened and a large bowel movement was visible on the resident's skin and brief. Three streaks of BM were smeared on the sheet beside Resident #51. The surveyor stepped out of the room and into the hallway to see four staff standing around nurse's desk. Certified Nursing Assistant (CNA) #7 went into Resident #51's room, spoke to the resident, and came back out of the resident's room to answer a call light at the opposite end of the hallway. No assistance was offered to Resident #51. The surveyor waited 3 minutes for a CNA to return. CNA #3 approached. The surveyor asked if she was going to help Resident # 51. CNA #3 replied, I just came on shift, I just got here. b. On 7/11/23 at 3:12 PM observed the DON in the hallway who accompanied the surveyor into Resident #51's room. Resident #51 was still lying exposed and uncovered on his side lying in human waste. The surveyor asked the DON if he was aware of the situation in Resident # 51's room. The DON answered Oh, I will get someone in to help clean him up. The DON walked out of the room to see CNA #7 and said, Not her. The DON walked to the nurse's desk and asked CNA #5 to help clean up Resident #51. c. On 07/11/23 at 3:14 PM CNA #7 and CNA #5 accompanied the DON and surveyor into Resident #51's room. Resident # 51 responded I'm glad you caught me like this, the flies are all over me. I've been begging for 30 minutes and waiting like this for someone to clean me up. Resident #51 started crying. The Surveyor counted 5 flies on Resident #51's body, two on his buttocks, two on his legs, and one on his right heel. d. On 07/12/23 at 11:14 AM observed Resident #51 lying flat on his bed with a wet washcloth on his forehead. The bed had no sheets, the resident was wearing no clothes, and his groin area was partially covered with a towel leaving his genitals partially exposed. Resident #51 stated, I don't feel well, my eyes hurt, and I'm real tired from yesterday. It was kind of testy. Resident #51 became tearful stating, I can't take it no more. When you can't make it talk to me. I don't want people to lose their jobs. I can discern a certain amount of hatred and discrimination from them. The room had a foul odor of human waste. e. On 07/12/23 at 1:20 PM observed Resident #51 lying flat in bed asleep, partially covered with a sheet. The surveyor counted three flies on the resident's feet and legs, and two on the bedside table. There was an open plastic pitcher containing urine on the bedside table, and a dried substance was observed on top of the bedside table. The room smelled of urine. f. On 07/12/23 at 3:30 PM the Surveyor asked the DON if it was an acceptable standard of practice, leaving a resident naked, uncovered, and lying on his side in feces with his brief undone, and flies crawling on skin. The DON answered, Absolutely not. The DON stated, I went in there, it looked like the window was cracked letting flies in. As far as the position and leaving the door open, that's another story. The surveyor asked who is responsible for care on the Southwest Hall. The DON answered, The CNA's assigned to the hall. The surveyor asked if it was standard practice to leave resident exposed in that position because of shift change. The DON answered, No, absolutely not. The surveyor asked the DON why this happened. The DON answered, Oh they are not supposed to go in there one at a time, it's care planned. But that doesn't excuse the whole incident. They don't want to be suspended on fake allegations of abuse. g. On 7/13/23 at approximately 9:30 AM observed the window in Resident #51's room, which revealed the screen was in place preventing the flies from entering the room through the window. 2. Resident #110 had a diagnosis of obstructive uropathy and an indwelling urinary catheter. a. On 07/10/23 at 12:59 PM observed Resident #110 sitting up in wheelchair in the dining room. The resident's catheter drainage bag was uncovered and in plain sight easily viewed by other residents, staff, and visitors in dining hall. b. On 07/11/23 at 3:17 PM observed Resident #110 lying in bed with his eyes closed. The door was open, and the catheter drainage bag was observed from outside the door in the hallway uncovered and in plain sight easily viewed by other residents, staff, and visitors passing by. c. On 7/12/23 at 03:30 PM the surveyor asked the DON who was responsible for maintaining catheter care and dignity. The DON replied, the nurses and CNAs assigned to the hall. The surveyor asked what the issue was with leaving catheter bags uncovered. The DON answered, It's a dignity issue. Their family or little kids could come in and you don't want to explain that.

Based on interview and record review, the facility failed to ensure resident funds were available on the same day of the request for 2 (Residents #20, #104) of 21 (Residents #2, #3, #5, #6, #7, #9, #11, #20, #44, #47, #51, #52, #55, #58, #67, #98, #103, #104, #110, #118, #333 ) sampled residents who relied on the facility to manage their personal funds. The findings are: On 07/10/2023 at 11:56 AM the Surveyor asked Resident #20 if the facility managed her money. The Resident stated, Yes. The Surveyor asked if money was available on request, including weekends. She stated, No. I can only get it Monday through Friday when the business office is open, and they never give me what I ask for. If I ask for my $30, they'll only give me $10 or $15. The Surveyor asked if she knew why she could not get her money. She stated, yes, they run out of money a lot. When the checks come in you have to wait in line and sometimes, they run out of money before you get to the door, so, they try to give you less to make it go farther. The Surveyor asked how long it took to receive the full amount requested. She stated, Two or three days, usually. On 07/10/2023 at 3:01 PM the Surveyor asked Resident #104 if the facility managed money for her. She stated, Yes. The Surveyor asked if money was available to her on request, including weekends. The Resident stated, No, never. The checks come in on the 3rd day of the month, sometimes I can't get it until the 5th, sometimes longer. The Surveyor asked if the facility had explained the reasoning behind this. She stated, they say they run out of money. They only get so much to give us and if residents want their money when it comes in, they run out. The Surveyor asked if the facility provided the amount that was requested when the resident asked. She stated, No, I can only get $5 to $10 at a time. The Surveyor asked if she was able to withdraw her personal funds from the facility on the weekend. She stated, No I don't think so. On 07/12/23 at 02:50 PM interview with the Financial Assistant who stated, resident funds were available to the residents in the evenings and on weekends, and further stated the residents can have access to funds when they want. She stated there is $50 available in the lock box after hours and weekends and the nurse manager has access to the funds. She stated if the resident wanted more money than what was available, she would, have to come up here and get them more. The Financial Assistant stated a receipt is completed, and the resident signs it when funds are dispersed. When asked if there were receipts for the weekend withdrawals, she stated, there are no receipts for the weekends, and stated she is not aware of any requests for funds on the weekend. On 07/12/23 at 3:32 PM the Surveyor asked the Financial Assistant if residents were able to withdraw their personal funds upon request. She stated, Yes. The Surveyor informed the Financial Assistant of resident statements that included the inability to withdraw the full amount they were entitled to. She stated, Well sometimes we run out, I'm only allowed $500 at a time, if we give $40 to everyone it doesn't go very far. The Surveyor asked if residents were being denied their funds when requested. She stated, No, I'm not saying that, just that sometimes I give them part of their money and then the rest a day or two later. The Surveyor asked why the facility did not have funds available to honor resident requests as required. She stated, The first of the month I'll have a line of people out the door wanting their money and $500 doesn't last long. Then I'll have to apply for another check, I'll have checks coming in every day at the start of the month. On 07/13/23 at 10:20 AM during the Resident Council meeting, Residents #38, #50, and #86 were in attendance. The Surveyor asked if the residents were aware that their personal funds were available to them after hours and on weekends. They stated they were not aware. On 07/13/23 at 10:32 AM the Surveyor made the Financial Assistant aware that the residents stated they were unaware that their funds were available on weekends or after hours. She stated, That's not true, we make sure it's discussed at resident council meetings. The Financial Assistant reviewed the Resident council Minutes and stated, It wasn't in the Minutes.

Based on observations, interview and record review, the facility failed to administer medications as ordered by the physician, and failed to accurately document the medications provided for 1 (Resident #106) of 11 (Residents #7, 9, 20, 44, 55, 67, 79, 98, 104, 118, 333) sampled residents that were administered medications by Licensed Practical Nurse (LPN)#1 and failed to provide appropriate hygiene care for for 1 (Resident #333) of 2 (Residents #5, 333) sampled residents. The findings are: 1. On 07/10/2023 at 3:11 PM Resident #106 stated he had not been receiving his afternoon medications. The surveyor asked if there were any specific medications, he was not receiving. He stated, none of the ones I'm supposed to get in the middle of the day. If I do get them, they add them to my morning dose so I'm getting twice as much as I'm supposed to at a time. I know I'm not getting my Gabapentin. I just want to get my medications when I'm supposed to get it. a. On 07/12/2023 at 1:10 PM the surveyor asked Resident #106 if he received his mid-day medications. The resident stated, no, I haven't gotten anything since the morning medication pass. b. A review of Resident #106 Physician Order Summary for July 2023 revealed the following orders for mid-day medications: Hydralazine four times daily for hypertension, with a start date of 3/24/23, citracal +D one time daily at noon for nutritional support, Juven one time daily at 11:00 AM for wound healing, and Gabapentin three times daily for neuropathy. c. On 7/12/23 at 1:10 PM review of Resident #106 Medication Administration Record (MAR) revealed LPN #1 documented the Hydralazine as given at 1:00 PM, Citracal +D was documented as given at 12:00 PM, Juven was documented as given at 11:00 AM, Gabapentin was documented as given at 12:00 PM. d. On 07/13/2023 at 10:50 AM observed the southeast hallway on which Resident #106's room was located. At 12:40 PM observed LPN #1 perform a medication pass on the southeast hallway. LPN #1 was not observed entering Resident #106's room. The midday medications for Resident #106 were not marked as administered. e. On 07/13/2023 at 2:23 PM observed LPN #1 seated at the nurse's station, documenting the midday medications as administered. f. On 07/13/2023 at 2:45 PM the Director of Nursing (DON) accompanied the Surveyor to the nurse's station where LPN #1 was seated. The Surveyor asked LPN #1 to navigate to Resident #106's MAR and identify if the four midday medications were documented as administered. She stated, Yes they are. The surveyor asked what time the medications were administered. She stated, This morning around 10:00 or 10:30 AM. The surveyor asked LPN #1 to clarify if she had administered the 11:00 AM, 12:00 PM, and 1:00 PM medications at that time. She stated, Yes, I've got 32 residents to pass medications to, so I have to give some of them early or late. The surveyor asked if she had administered two doses of Gabapentin at the same time. She stated, No I didn't give that. The surveyor asked LPN #1 to verify that the medications were documented as administered on Resident #106 MAR. She stated, Yes, it is. The surveyor asked LPN #1 if she documented the medication as given when it had not been. She stated, Yes, I got click happy when I was charting. It happens. The Surveyor asked if administering medications outside of the ordered times and erroneously documenting that medications were given was common practice. She stated, Yes. In all honesty, yes. It happens throughout the facility. There just aren't enough nurses. The Surveyor asked what the issue with this practice was. LPN#1 stated, The residents aren't getting their pain medications. The surveyor asked the DON if he was aware of this practice. He stated, No, not at all. The surveyor asked what a nurse should do if they felt they would not be able to administer resident medications as ordered. He said, report it to the Nurse Manager on the unit so they can get the information to us. 2. On 07/10/23 at 12:15 PM the surveyor interviewed Resident #333. The surveyor asked the resident if she was receiving adequate hygiene care. She stated, no, I have sores on my bottom and when the staff cleans me up, they just use toilet paper. The Surveyor asked if she knew why the staff was using toilet paper on an area with sores. Resident #333 stated, They don't have any wipes. They only give us one pack of wipes per week. If we're having stomach problems we can run out of wipes in a day or two, once we run out, they use toilet paper. I had a sore on my bottom when I was here before, but then I went to the hospital, and it almost healed up. Then I came back here and it's almost opening up again. The surveyor asked if the staff had offered to use an alternate method to clean her bottom. Resident #333 stated, Sometimes they will use washcloths, but they only have so many, and they use them up giving baths. The surveyor observed a partially used roll of toilet paper on the resident's bedside table. No cleansing agent to moisten the toilet paper was found nearby. a. On 07/11/23 at 9:15 AM the surveyor asked Resident #333 if the staff were continuing to use toilet paper to clean areas with skin breakdown. She stated, Yes. The surveyor asked if she had a bowel movement that morning. She stated, oh yeah, too many, my stomach is upset. The surveyor observed a roll of toilet paper on the resident's bedside table. b. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/11/23 documented under the heading Toilet use Resident #333 required .extensive assistance .two + persons physical assist . c. The Care Plan for Resident #333 dated 05/05/22 documented, .Potential for skin breakdown .Full skin evaluation with bath/shower .assess skin daily with routine care .turn and reposition per residents turning schedule . d. A Progress Note dated 07/11/23 documented as a late entry from 7/4/23, noted excoriation on the buttock. e. On 07/14/23 at 3:53 PM interviewed the DON related to using dry toilet paper on a resident with excoriation. The DON stated, Are they not using moist towels? The surveyor stated that the resident reported that toilet paper was being used and that rolls of toilet paper had been observed at the bedside. The DON stated, they shouldn't be doing that. 47661

Based on observation, interview, and record review, the facility failed to ensure oxygen flow rates were administered per physician orders, and humidifier bottles were present according to physician's order for 2 (Resident #3 and #51) of 11 (Residents #2, #3, #5, #9, #11, #44, #51, #52, #100, #106, & #333) sampled residents who received respiratory therapy. The findings are: 1. Resident #3 had diagnoses of chronic obstructive pulmonary disease, acute chronic respiratory failure with hypoxia. a. On 07/11/23 at 09:58 AM observed Resident #3 lying in bed with oxygen (O2) flow rate set at 1 Liter via nasal cannula. There was no humidifier bottle in place. The Resident stated, It should be set on 2. b. On 07/11/23 at 03:05 PM observed Resident #3 lying in bed with oxygen via nasal cannula connected to a concentrator with no humidifier bottle; the O2 flow rate setting was at less than 1.5 Liters. c. On 07/12/23 at 02:20 PM observed Resident #3 Lying in bed with eyes open receiving oxygen via nasal cannula. The O2 setting was at 1 Liter and there was no humidifier bottle. d. On 07/13/23 at 11:01 AM observed Resident # 3 lying in bed wearing O2 via nasal cannula attached to concentrator. The Flowmeter was set between 1 and 1.5 Liters. There was no humidifier bottle. e. On 07/12/23 at 3:35 PM the surveyor asked the Director of Nurses (DON) who was responsible for making sure O2 is at the right setting. The DON answered, nurses are responsible for the setting being correct. The surveyor asked the DON, what can happen if O2 settings are not at the right flow rate. The DON answered, worst case, death if it's too high, too low they can suffocate. The DON stated, nurses should be checking the settings every shift. If you have someone who fiddles with their settings, the nurse can ask the Certified Nursing Assistants (CNAs) to check and let them know. f. On 07/13/23 at 11:03 AM the Surveyor accompanied Licensed Practical Nurse (LPN) #4 to resident #3's room and asked her where the humidification bottle should be. She answered, It should be on the top right here if there is one The surveyor asked LPN #4 if Resident # 3 was supposed to have a humidifier bottle. She answered, It depends on who orders it. The surveyor asked LPN #4 what the O2 flow meter was set on. The LPN answered, it is on 1.5 on this one The surveyor asked what setting was ordered. LPN #4 answered, Probably 2-4. LPN#4 reviewed the orders and answered O2 at 2-4 per nasal cannula, as needed. The surveyor asked LPN #4 who was responsible for monitoring flow meter settings. LPN #4 answered, nurses are supposed to check it before we make our rounds. 2. On 07/10/23 at 11:37 AM Resident #51 was sitting up in motorized chair in room. The O2 Concentrator flow rate was set at 3.5 Liters and there was no humidifier bottle. a. On 07/12/23 at 11:14 PM observed Resident #51 lying in bed awake receiving oxygen. The O2 flow rate was at 3 Liters via nasal canula connected to O2 concentrator and there was no humidifier bottle. b. 07/13/23 at 08:44 AM observed Resident # 51 sitting on the side of bed eating breakfast. The O2 flow rate was set at 2 Liters via nasal cannula connected to concentrator and there was no humidifier bottle. c. On 07/14/23 at 08:29 AM observed Resident #51 lying in bed with O2 at 2 Liters via nasal cannula and there was no humidifier bottle. On 07/12/23 at 10:24 AM The Director of Nursing (DON) provided a document entitled, Nursing Procedure Manual .Policy Title: Oxygen Administration. Policy Number: NP.VI-58. Under section entitled Standard: Oxygen should be administered under orders of the attending physician . Under section entitled Process: Obtain physician's orders for the rate of flow and round of oxygen (i.e., by tank, concentrator, nasal cannula, or mask, etc.) .Fill the humidifier container to the correct level with distilled water and attach to oxygen unit; or use disposable humidifier .Cannulas and masks should be changed weekly .O2 cannula/mask should be stored in a plastic bag when not in use .

F761 Based on observation, interview, and record review, the facility failed to date and store over the counter medications being administered to residents in a manner following currently accepted professional principles in 1 (Central) of 5 (Northeast, Southeast, Central, Rehab S, Rehab N) medication carts used in the administration of prescribed medications in the facility. The findings are: On 07/12/23 at 7:10 AM the Surveyor inspected the medication cart while observing medication administration with Licensed Practical Nurse #5 (LPN#5). The Surveyor observed that two of the medications being administered, Acidophilus Probiotic and Sodium Chloride, were sourced from containers that had not been dated when opened. On 07/12/23 at 9:10 AM the Surveyor accompanied LPN#5 to the medication room to look for two medications not found on the medication cart, Finasteride and Potassium. LPN#5 looked through cabinets and commented, What a mess. They looked through the slot of the locked medication waste bin and commented, I see it. The Surveyor asked what they were referring to. They answered, The potassium. The Surveyor asked how it got in the waste bin. LPN#5 answered, I couldn't tell you. The LPN pulled up on one corner of the waste bin lid to remove the potassium. The opposite corner was locked. They stated, This is clean, as they attempted to reach in and get the medication which was out of their reach. They left the medication storage room and asked the Assistant Director of Nursing (ADON) to get a key to unlock the medication waste bin. On 07/12/23 at 9:37 AM the ADON returned to the medication room and unlocked the medication waste bin. LPN#5 reached in with ungloved hands and removed a tablet packaged in a clear plastic bag from the waste bin. The medication that was retrieved from the waste bin was then administered to Resident #110. A document titled Storage and Expiration of Medications, Biologicals, Syringes, and Needles was provided by the Clinical Liaison on 07/14/23 at 11:55 AM. It documented, .Once any medication or biological package is opened, Facility should manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened .

Based on observation and interview the facility failed to ensure the kitchen was free of pests and failed to ensure the room meal experience was free from pest for 4 (Resident #333, #104, #63 and#51) of 4 residents who had flies in their room or in their food items or their body during the noon meal in 1 of 1 facility. The failed practice had the potential to affect 121 residents who received food from the kitchen, according to the list provided by the Dietary Supervisor on 7/13/2023 at 9:49 A.M. The findings are: 1. On 07/10/23 at 12:08 PM the surveyor interviewed Resident #9 in their room. Three large black flies were flying around and landing on the resident. The resident was continually trying to dissuade the flies from landing on their face by waving their arms. 2. On 07/10/23 at 12:15 PM the surveyor interviewed Resident #333 in their room. The resident was lying in bed. There were six large black flies flying around the resident and crawling about the resident's bed and body. The Surveyor asked if they frequently had issues with flies or other pests. The resident stated, They're always in here. I've got a flyswatter somewhere, but I can't find it. 3. On 07/10/23 at 3:01 PM the Surveyor interviewed Resident #104 in their room. The resident had six large black flies crawling on or flying around their body. The Resident was attempting to chase them away by waving her arms. The surveyor asked if she frequently had pests in her room. She stated, Yes, drives me crazy. 4. On 07/12/23 at 11:47 AM There were 2 flies flying around the food preparation area. There was one on top of a can of thickener on the shelf above the food preparation counter. 5. On 07/12/23 at 4:29 PM There were 4 flies flying around the food preparation area. Showed them to the Dietary Supervisor and she shooed them away. 6. On 07/13/23 at 8:44 PM Resident # 51 was sitting on the side of bed eating breakfast. There were 2 flies on his food. There was a fly on his arms, lower legs, and feet. 7. On 07/12/2023 at 10:24 AM a pest control work order received by the Director of Nursing documented an Invoice dated 5/9/2023 documented, Service-related comment. Inspected all areas. No activity was noted during the inspection and or/service. No findings noted during service. Target Pest: Cockroaches, flies, -Large Equip. Mice. Application Method: Placement, crack and crevice, placement bait station, checking traps. Location Applied: Kitchen Area-Interior, Hallways-interior, kitchen area-interior, exterior area, storage area-interior, break room-interior, dining-interior, front door -introduction point, fire door-introduction, office area-interior, side door -interior, storage -area interior and kitchen area-interior. 10, An Invoice dated 6/14/2023. Service-related comment. Inspected and treated selected areas. Performed interior rodent service. Checked and reset all traps. Pest control company large fly program serviced; glue boards were 25 %. Glue board replaced. Performed exterior rodent service. Checked accessible and replaced bait as needed. Target Pest .Cockroaches. Application Method. Crack and Crevice . Location Applied. Kitchen area-interior. Target Pest: Flies- large. Application Method: Spot. Location applied: front door-introduction point, rear door-introduction point, Kitchen Area-Interior Dining room interior, Bathroom/locker, patient/guest room-Interior. 11. An Invoice dated 7/5/2023 documented, Service-related comment. Inspected and treated selected areas. Performed exterior rodent service. Checked accessible bait stations and replaced bait as needed. Performed interior rodent service. Checked and reset all traps. No rodent activity was noted during the inspection and/or service. Pest control company large fly program service. Glue board were 25 %full, glue board replaced. Pest activity found. No findings noted during service. Target Pest: Flies-Large equip, cockroaches. And mice Application Method: Checking traps, placement, crack and crevice, spot, and bait station. Location Applied: Kitchen area interior, Work floor interior, Near entry-introduction point, hallways-interior, Lounge/Bar-interior and exterior area.

Based on observation, record review and interview, the facility failed to ensure meals were served at temperatures that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. The failed practices had the potential to affect 24 residents who received their meal trays in their room, on Southeast Hall, 20 residents who receive trays in their room on North East Hall, 15 residents who receive trays in their room on North [NAME] hall, 10 residents who receive their meal trays in their room on South [NAME] Hall, and 10 residents who receive their meal trays in their room on Central Hall, as documented on a list provided by the Dietary Supervisor on 7/13/2023 at PM. The findings are: 1. On 07/10/2023 at 12:15 PM, The Surveyor asked resident #333 if she was satisfied with the quality of food in the facility. The resident stated, It's usually pretty good, but it's cold by the time it gets here. Th surveyor asked if cold food was a frequent occurrence. The resident stated, Yes, probably half the time. 2. 07/13/23 at 08:12 AM, an unheated cart that contained trays for breakfast was delivered to the South East Hall by the Certified Nursing Assistant #1. 07/13/23 at 08:20 AM immediately after the last resident received their tray in their room on the South East Hall The temperatures of the food items on a test tray from the cart were checked and read by the Dietary Supervisor with the following results: a. Milk 46 degrees Fahrenheit. b. Scrambled eggs 100 degrees Fahrenheit. c. Biscuit with gravy 102 degrees Fahrenheit. Sausage 110 degrees Fahrenheit. 2. 07/13/23 at 08:15 AM an unheated meal cart that contained trays for breakfast was delivered to the Northeast Hall by the Certified Nursing Assistant #1. On 07/13/23 at 08:38 AM immediately after the last resident was served in the room on the Northeast Hall the temperature of the food items on the test tray were checked and read by the Dietary Supervisor with the following results: a. Milk 46.6 degrees Fahrenheit. b. Scrambled eggs 108 degrees Fahrenheit. c. Sausage 93 degrees Fahrenheit. d. Biscuit with gravy 104 degrees Fahrenheit. 3. On 07/13/23 at 08:23 AM, an unheated cart that contained trays for breakfast was delivered to the Northwest by the Certified Nursing Assistant. On 07/13/23 at 08:50 AM, immediately after the last resident received their tray in the room on the Northwest, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Supervisor with the following results: a. Milk 51 degrees Fahrenheit. b. Scrambled eggs 100 degrees Fahrenheit. c. Ground sausage with gravy 95 degrees Fahrenheit. d. Pureed biscuit with gravy 113 degrees Fahrenheit. e. Pureed sausage 108.6 degrees Fahrenheit. 4. On 07/13/23 08:31 AM, an unheated cart that contained trays for breakfast was delivered to the Southwest by the Certified Nursing Assistant #4. At 8:44 AM, immediately after the last resident received their tray in the room on the Northwest, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Supervisor with the following results: a. Milk 45 degrees Fahrenheit. b. Scrambled eggs 104 degrees Fahrenheit. c. Sausage 91.4 degrees Fahrenheit. d. Pureed biscuit with gravy degrees Fahrenheit. 5. On 07/13/23 08:33 AM, an unheated cart that contained trays for breakfast was delivered to the Central Hall by the Certified Nursing Assistant #5. At 8:42 AM, immediately after the last resident received their tray in the room on the Northwest, the temperatures of the food items on a test tray from the cart were checked and read by Dietary Supervisor with the following results: a. Milk 44.6 degrees Fahrenheit. b. Scrambled eggs 112 degrees Fahrenheit. c. Sausage 97.8 degrees Fahrenheit.

Based on interview and record review the facility failed to ensure a refund was received by the resident or responsible party within 30 days from the date of discharge for 1 (Resident #234). The findings are: 1. On 07/11/23 at 11:40 AM a review of Resident #234 medical record revealed the resident was admitted on [DATE] with a diagnosis of vascular dementia, without behavior disturbance. a. A review of the Resident Account Audit reflected a deposit which was made by the resident/responsible party of Resident #234 to cover any charges not covered by the resident's Health Maintenance Organization (HMO) insurance. b. On 5/05/23 the resident and his responsible party were issued a Notice of Medicare Non-Coverage which stated, Your Medicare provider and/or health plan have determined that Medicare probably will not pay for your current skilled nursing services after the effective date indicated above. You may have to pay for any services you receive after the above date. c. On 5/8/23 the resident was discharged from the facility. d. On 7/12/23 at 10:00 AM the Business Office Manager provided a copy of the Resident Trust Check Request dated 6/14/23 payable to Social Security in the amount of $1,566.00. The purpose of expenditure was stated as, close account. e. On 7/12/23 at 10:15 AM the Financial Specialist provided a Request for Refund which was processed on 6/15/23. At that time a check in the amount of $1,000.00 was issued to Resident #234 responsible party. A letter from the Administrator accompanied the check and stated, Upon review of the above resident's account, we have determined that a refund is due. f. On 7/12/23 at 10:19 AM the surveyor asked the Financial Specialist if she was aware of the acceptable time frame for a resident refund after death or discharge. She stated, a normal refund would be done within 30 days, but we were holding this to see if his insurance paid for everything.

Based on observation, record review and interview, the facility failed to ensure devices were put into place to prevent worsening of contracture for 1 (Resident #11) of 5 (Residents #5, #11, #52, #55, and #76) sampled residents with contractures. The findings are: Resident #11 had diagnoses of chronic kidney disease, stage 5, and dialysis dependent. The admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 4/19/23 revealed the Resident had no impairment for Range of Motion (ROM)/ limitation on the upper and lower extremity. On 07/10/23 at 1:41 PM observed Resident #11 with a contracture of the left hand. Observed gauze wrapped in and around two fingers and inside the left-hand. The gauze was dirty. On 7/11/23 at 1:47 PM observed Resident #11 lying in bed awake. The left hand still has gauze in it and wrapped around two fingers. The gauze was dirty. On 0712/23 at 2:21 PM Resident #11was lying in bed with a rolled piece of gauze in the left hand, the resident's hand is dirty. Review of Resident #11 care plan with a start date of 5/4/23 noted the resident had potential for contractures and to use a carrot as ordered. Review of the physician order summary for the month of July 2023 failed to reveal an order for the use of a carrot for the left-hand contracture. On 07/13/23 at 1:30 PM the surveyor asked Licensed Practical Nurse (LPN) #1 if she knows how often Resident #11 left hand with contracture is cleaned. LPN #1 stated, I do not know when her left hand is cleaned. The surveyor asked who is responsible for cleaning the resident's hand with a contracture? LPN # 1 stated the Wound Care nurse is the one who cleans her left hand. The surveyor asked if she had seen the carrot for resident #11 left hand. The LPN #1 stated, I have never seen the carrot. On 7/13/23 at 2:23 PM the surveyor asked the Wound Care Nurse LPN # 2 how often do you clean, cut Resident #11 fingernails, and replace the gauze in her hand. LPN #2 stated, Sunday is nail care day. If the resident is a diabetic the podiatrist will cut them, if not a diabetic, the Certified Nursing Assistants (CNA's) can cut them. The surveyor asked LPN #2 do you clean the inside of Resident #11 hand and change the gauze or the carrot. LPN #2 said, yes, I try my best if resident will allow me to open her hand wide enough. Often, I can get the gauze in her left hand and try a flossing motion to clean. I have not seen a carrot. On 07/13/23 at 1:50 PM the surveyor asked the DON if he knew where Resident #11 carrot was. The DON stated, no, it is supposed to be in her left hand. The Surveyor asked the DON if he knew how often the gauze is removed, the left hand cleaned, and nails were cut. The DON stated, no, I do not know. The surveyor asked the DON if he knew there was no physicians order or anything in the care plan for Resident #11 care for her contracture. The DON stated, No, he did not know there was no order and felt the Wound Care nurse should have put one in. On 07/13/23 the surveyor asked the DON for a policy and procedure for contractures. The DON said, they do not have one. 47912 Based on observation, record review and interview, the facility failed to ensure nail care was regularly provided to maintain good hygiene and prevent potential injuries or infections for 2 (Residents #40 and #51) of 8 sampled residents (#3, #40, #50, #51, #86, #103, #110, and #385) who reside on the Southwest Hall & Rehabilitation Unit who required assistance with nail care. The findings are: 1. Resident #40 had diagnoses of Diabetes Mellitus, peripheral vascular disease, and wound infection on the right foot. a. On 07/11/23 at 2:54 PM observed Resident #40 sitting up in a wheelchair by the nurse's desk and activity room. The Residents fingernails, on both hands, were more than 1/4-inch-long past the fingertips with dark brown and black substance underneath the nailbeds. The thumbnail on the right hand was approximately 1/2 inch past the fingertip with medium brown substance underneath. b. On 07/12/23 at 2:15 PM observed Resident #40 sitting up in a wheelchair in the breezeway. The Residents fingernails remained long and with brown and black substance underneath the nails. The surveyor asked Resident #40 if he liked his nails that long. Resident #40 answered, no, they said they would trim them for me 2 or 3 days ago, but they haven't. My wife doesn't like them like this either. c. On 07/12/23 at 2:34 PM the Assistant Administrator accompanied the surveyor to observe Resident #40's fingernails and describe what she saw. The Assistant Administrator answered, they need to be cleaned. They are long and dirty and need manicured. The surveyor asked the Assistant Administrator who is responsible for nailcare. The Assistant Administrator answered, Certified Nursing Assistants (CNA's). The surveyor asked how often they should be trimmed. The Assistant Administrator answered, me personally, weekly but I guess it depends on the person and how fast their nails grow. d. On 07/12/23 at 2:40 PM the surveyor accompanied Licensed Practical Nurse (LPN) #4 to Resident #40. The surveyor asked LPN #4 to describe Resident #40's fingernails. LPN #4 answered, you know what, we need to wash these hands and clean these nails out. They are dirty, kind of long, and they do need nailcare. The surveyor asked LPN #4 who was responsible for Resident # 40's nail care. LPN #4 answered, He's diabetic so I will. Nurses have to do those. 2. Resident #51 had a diagnosis of chronic obstructive pulmonary disease, Diabetes Mellitus type 2, and morbid obesity due to excess calories. a. On 07/10/23 at 11:37 AM observed Resident #51 sitting up in his room in a motorized wheelchair. The resident's fingernails were observed to be more than 1/4 inch past the fingertips and had a brown substance underneath. b. On 07/11/23 at 3:14 PM observed Resident #51 lying in bed. The resident's fingernails remained approximately 1/4 - 1/2 inch in length past fingertips with light and dark brown substance underneath the nailbeds. c. On 07/12/23 at 11:14 AM observed Resident #51 lying on the bed with no sheets. Observed fingernails remained the same with brown substance visible underneath. d. On 07/13/23 at 8:44 AM observed Resident #51 sitting on the side of the bed eating breakfast. The resident's fingernails remain approximately 1/4 - 1/2 inch in length past fingertip with medium to dark brown substance underneath nailbeds. e. On 07/14/23 at 8:29 AM observed Resident #51 lying in bed. The resident's fingernails were approximately 1/4-1/2-inch past the fingertips, and uneven with medium brown substance underneath nailbeds. Resident #51 stated, I can't stand to have my nails long. f. On 07/12/23 at 3:30 PM the surveyor asked the Director of Nursing (DON) who is responsible for resident's nail care. The DON answered, nondiabetic, CNA's. If there's an oversight, the charge nurse, the unit manager, and then me. The surveyor asked the DON how often nail care is given. The DON answered, every shower. When shower days are scheduled, they should be checking fingernails. The surveyor asked who checks during showers. The DON answered, The CNA's. The Nurses do diabetics. The surveyor asked the DON what could happen if nail care isn't done or gets overlooked. The DON answered, If you have fecal material under fingernails, you could get horrible illnesses from e-coli. If you have jagged nails, you could tear your skin. It's also a dignity issue. g. On 07/14/23 at 8:30 AM the surveyor accompanied Nurse Assistant (NA)#1 into Resident #51's room and asked NA #1 to look at the resident's nails and describe what she saw. NA #1 answered, there's a little bit of dirt under them, but they really need to be clipped. The surveyor asked her to look at the other (left) hand and describe what she saw. The NA#1 answered, They are not as dirty but need to be clipped, but they are not super dirty. The surveyor asked NA #1 who is responsible for resident's nail care. The NA #1 answered if diabetic NA and CNAs can't do it, it must be done by nurses. If not diabetic we can get the ok from the nurses and file them, but we can't clip them. h. On 7/12/23 at 10:24 am the DON provided a policy for Nail Care, Policy Number: NP.I-42 effective October 1, 2010 which documented under section entitled .Purpose: Routine nail care helps reduce the potential for infection, prevents possible injuries and promotes a feeling of wellbeing . Under section entitled .Standard: Nail care is a routine part of grooming each day .

Based on interview and record review, the facility failed to ensure the physician ordered [CONDITION(S)] and [CONDITION(S)] and failed to schedule [CONDITION(S)] and [CONDITION(S)] appointments for 1 (Resident #1) of 3 (Resident ' s #1, #2, and #3) case mix residents following Resident #1 ' s recent hospital admission. The failed practice caused Resident #1 to miss three hemodialysis and one [CONDITION(S)] treatment and resulted in fluid overload and a life-threatening electrolyte imbalance requiring immediate treatment. The failed practice had the potential to cause more than minimal harm to 8 residents who had orders for [CONDITION(S)] appointments scheduled outside of the facility according to a list provided by the Director of Nursing (DON) on 08/01/2022 and resulted in a Past Non-compliance Immediate Jeopardy. The facility removed the Immediate Jeopardy and corrected the failed practice on 07/26/2022 prior to the survey. The Administrator was notified of the Past Immediate Jeopardy on 08/02/2022. The findings are: 1. Resident #1 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/19/2022 documented the resident scored 7 (1-7 indicates severely cognitively impaired) on a Brief Interview for Mental Status (BIMS) and received [CONDITION(S)], [CONDITION(S)], and hospice. a. The July 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Notify MD [Medical Doctor] Of Any Negative findings. Start Date: 7/14/2022 . Hemodialysis on Monday Wednesday & Friday at 1240 [12:40 PM] . Order Start Date: 7/15/2022 . The [CONDITION(S)] Treatments were initialed by Licensed Facility Staff on 7/15/2022, 7/18/2022, and 7/20/2022 and the Hemodialysis Orders were initialed by Licensed Facility Staff on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . b. The Renal Progress Note by [Nephrology Physician] documented, .Date of Service: 7/13/2022 .75 YO [year old] with past medical history of [MEDICAL RECORD OR PHYSICIAN ORDER] . and AKI [acute kidney injury] on CKD [chronic kidney [CONDITION(S)]] stage (4) .[CONDITION(S)] access - RIJ [right internal jugular] tunneled [CONDITION(S)] line. RUE [right upper extremity] AVF [arteriovenous fistula, nonfunctioning . Pt [patient] is on [CONDITION(S)] this am . Pt progressed to [CONDITION(S)] [[CONDITION(S)]]: IR [[MEDICATION(S)] radiology] placed new TDC [tunneled [CONDITION(S)] catheter] on 7/1 -Outpatient hemodialysis chair placement in progress, Orders faxed . c. The (Hospital) Discharge Summary documented, .Date of Admission: 6/22/2022 Date of Discharge: 7/13/2022 . Follow up with Onc [Oncology] to be scheduled . Follow up with nephro [Nephrology] to be scheduled . AKI [Acute Kidney Injury], now [CONDITION(S)] [[CONDITION(S)]] on HD [Hemodialysis] - continue HD as scheduled . MDS [[CONDITION(S)]]/[CONDITION(S)] - follow labs, transfuse prn [as needed] .Patient was admitted to LTAC [Long Term Acute Care] .[CONDITION(S)] chair outpatient has been arranged . d. The (Hospital) After Visit Summary documented, .Most recent update: 7/13/2022 . Your medications have changed . Follow up with [Facility] . Office visit established . Wednesday Aug [August] 17, 2022 . These forms had no documentation of ongoing hemodialysis or [CONDITION(S)] treatments. e. The Nursing Admission Note dated 7/13/2022 at 5:45 PM documented, .Resident arrived at 1600 [4:00 p.m.] XXX[AGE] year old white female . Arrived from [Hospital] . HX [History] of Chronic Renal Insufficiency . Lifeport noted to left upper chest . Signed by Licensed Practical Nurse (LPN #2). f. The Plan of Care with a start date of 7/14/2022 documented, .[CONDITION(S)]: Requires [CONDITION(S)] . I will not have any unresolved complications RT [related to] [CONDITION(S)] . Provide/Coordinate transportation to the [CONDITION(S)] center . g. The Nurse Practitioner Progress Notes documented, .Date of Service: July 14, 2022 . I am seeing [Resident #1] for a new admission visit to establish care . She tells me that she does not know when she had [CONDITION(S)] last or if she is to have [CONDITION(S)]. She does have a hemodialysis line to the left [MEDICATION(S)] and a port-a-cath . [CONDITION(S)] [[CONDITION(S)]] . on [CONDITION(S)], [CONDITION(S)] syndrome with [CONDITION(S)] . She is followed by nephrology and hem [hematology]/onc [oncology] . Assessment and Plan . I will order CBC [complete blood count] today. Follow up with hematology/oncology . [CONDITION(S)] . Followed by nephrology. Will need to clarify [CONDITION(S)] status . h. The Nursing Progress Note dated 7/15/2022 at 1:04 PM documented, .remains on skilled charting dx [diagnosis] wound infection [CONDITION(S)] also is doing [CONDITION(S)] three x [times] a week [CONDITION(S)] port present double lumen dressing dry and intact . also has [CONDITION(S)] to bilat [bilateral] lower ext [extremities] . Signed by Licensed Practical Nurse (LPN) #4. i. The Nursing Progress Note dated 07/20/22 at 6:13 PM documented, .At 3:00 pm res [resident's] son came to nurses' station to discuss residents HD [hemodialysis] schedule and also appointments with hemo [hematology] DR [doctor] re [regarding] abnormal labs. Son stated res is supposed to be having HD on Mon, Wed, and Fridays. Instructed res's son, this nurse would speak to [Nurse Practitioner] and contact [CONDITION(S)] center and hemo dr for appointment dates and times. After speaking to [Nurse Practitioner] new order was received to schedule nephrology follow up, follow up with [CONDITION(S)] center for HD appointments, schedule appointment with hematologist, and draw lab tomorrow. Contacted [CONDITION(S)] center to request a chair time, [CONDITION(S)] stated they had the Pt as no show, they would have to speak with [Nephrologist] before giving res a new appointment. After several minutes [[CONDITION(S)] Nurse] called this nurse back advising res be sent to ER [emergency room ] for eval [evaluation] prior to being allowed to come in for [CONDITION(S)]. At this time physician was on floor making rounds. Reported to him what was advised. After physician seen pt, no new orders were received. Instructed to cont [continue] previous order, draw lab in the am and report results. Res has showed no signs of distress this shift. No abnormal symptoms noted . Signed by LPN #3. j. The Nursing Progress Note dated 7/21/2022 at 2:46 PM documented, .New order to send to ER for eval for missed [CONDITION(S)] appts [appointments] and son called and she has appt in am 8 am for chemo at [Hospital] . k. The Nursing Progress note dated 7/21/2022 at 7:53 PM documented, .[Laboratory Facility] called with critical hemoglobin of 6.2 & platelets of 13. [Hospital] notified of results since resident is at hospital . l. The (Hospital) Record dated 7/21/2022 at 7:54 PM documented, .CKD [chronic kidney disease] . resulting in [CONDITION(S)] [[CONDITION(S)]] she was started on hemodialysis on 6/13/2022 .She is admitted with fatigue and weakness having missed [CONDITION(S)] for a week after discharge from LTAC [long term acute care] to (facility). Lab eval showed BUN [Blood urea nitrogen] 122, hemoglobin of 6.4, plt [platelet] 24,000, potassium of 6.3 .pulmonary vascular congestion with streaky bibasilar airspace disease which may represent pulmonary [CONDITION(S)]/volume overload .probable trace bilateral pleural effusions .admitted with weakness and fatigue with lab eval showing [CONDITION(S)] and [CONDITION(S)] and uremia. Pt seen and examined during hemodialysis for 2 hours without event for acute [CONDITION(S)] and requisite of pRBC [packed red blood cells] transfusion. Fluid removal of 2 liters. Plan for hemodialysis tomorrow .will send blood cultures . 7/24/2022 . [CONDITION(S)] - on hemodialysis Monday Wednesday and Friday. She missed - 3 treatments. Since admission, she dialyzed 3 days consecutive. The first treatment was short treatment 7/21/2022 for acute [CONDITION(S)] and pRBC .[CONDITION(S)] - multifactorial - transfusion dependent . she received 2 units of blood thus far during hospital course. She has evidence of iron overload. Continue [MEDICATION(S)] and recommendations of hematology . discharged [DATE] 1647 [4:47 p.m.] . m. On 8/1/2022 at 1:40 p.m., the Surveyor asked LPN #3, Why did [Resident #1] miss her [CONDITION(S)] appointments on 7/15/2022, 7/18/2022, and 7/21/2022? LPN #3 stated, I didn't take care of her when she was admitted . I can't answer that. The son came in at the end of day shift and he asked me when his mom was going to [CONDITION(S)]. In report it wasn't reported that a [CONDITION(S)] patient. The patient never said anything about [CONDITION(S)]. I didn't even know she had a port. the Surveyor asked LPN #3, Did [Resident #1] have any orders for [CONDITION(S)] or blood [CONDITION(S)]? LPN #3 stated, The Advanced Practice Nurse was asking how this got missed. They said an order was put, but it wasn't. You have to put in two different orders before it will pop up on MAR. We were doing weekly labs. It was never chemo, some kind of blood [CONDITION(S)]. The labs needed to be done weekly. The only encounter I had with [Resident #1] was on 7/20/2022. That was the only time I made contact with her. I didn't get any report about [CONDITION(S)]. I didn't see a [MEDICATION(S)]. The only time I knew about [CONDITION(S)] is when the son brought it to my attention. n. On 8/1/2022 at 2:01 p.m., the Surveyor asked LPN #4, Why did [Resident #1] miss her [CONDITION(S)] appointments on 7/15/2022, 7/18/2022, and 7/21/2022? LPN #4 stated, I don't remember. I remember looking at her port. We recently started doing Rehab overflow. A resident may be with us eight hours or twelve and then they are gone. We usually get new admissions when they come out of the hospital. I did not admit [Resident #1]. the Surveyor asked LPN #4, How did you know [Resident #1] was supposed to receive [CONDITION(S)] treatments? LPN #4 stated, It was passed on in report. I did an assessment on her. I will be really honest with you. I don't remember this little lady. Honestly, I don't remember asking, also doing [CONDITION(S)] three times a week. She had a double lumen. I don't remember seeing any order. I remember looking at port, usually temporary. I remember looking at the written report from the hospital. They didn't have a set chair time for [Resident #1]. She was a brand new [CONDITION(S)] patient. Just started [CONDITION(S)]. They will call us to set up a chair time. It usually takes a while. I would walk by one of my rooms and they would be already gone. These residents fall through the cracks. It is frustrating and not fair to the nursing staff. We are not getting the information that we need to take care of these people. We are not getting reports on some of these people. o. On 8/1/2022 at 2:30 p.m., the Surveyor asked LPN #1, Why did [Resident #1] miss her [CONDITION(S)] appointments on 7/15/2022, 7/18/2022, and 7/21/2022? LPN #1 stated, That I do not know. I knew that she was supposed to have [CONDITION(S)], but I didn't know what time. [Resident #1] never said anything to me and I didn't ask. I thought she was getting on 3-11 [3:00 PM to 11:00 PM] shift. p. On 8/1/2022 at 3:48 p.m., the Surveyor asked LPN #2, Did you get report from the hospital regarding [Resident #1] when she was admitted to the facility on [DATE]? LPN #2 stated, Yes, I took report on [Resident #1]. The Surveyor asked LPN #2, Did the Hospital Nurse tell you anything about [Resident #1] receiving hemodialysis or [CONDITION(S)] treatments? LPN #2 stated, No, she did not say anything about [CONDITION(S)] or those blood [CONDITION(S)] when giving me report. The Surveyor asked LPN #2, Did you receive any paperwork or hospital records indicating that [Resident #1] received hemodialysis or blood [CONDITION(S)]? LPN #2 stated, There were no orders in the [Hospital] discharge summary indicating that [Resident #1] was supposed to get [CONDITION(S)] or blood [CONDITION(S)]. The Surveyor asked LPN #2, When you did your admission assessment did you see a [CONDITION(S)] graft or catheter? LPN #2 stated, I did do a full assessment when [Resident #1] was admitted . I didn't know anything about that. The Surveyor asked LPN #2, In your notes you documented that [Resident #1] had a Lifeport? LPN #2 stated, Your right it does say Lifeport. It is like a port under the skin where you can administer medications. q. On 8/1/2022 at 4:32 p.m., the Surveyor asked the Nurse Practitioner (NP), Did you know if [Resident #1] was supposed to be receiving hemodialysis and [CONDITION(S)] treatments outside of the facility? The NP stated, [Resident #1] could not tell me anything about [CONDITION(S)]. She didn't know if she had [CONDITION(S)] or if she was going to start [CONDITION(S)]. [Resident #1] did have a port-a-cath and left [MEDICATION(S)]. So many variables to consider. The Surveyor asked the NP, Did you ever receive clarification from the facility nursing staff regarding [CONDITION(S)] treatments for [Resident #1]? The NP stated, No. r. On 8/2/2022 at 10:05 a.m., the Surveyor asked LPN #5, When did you receive all of the [Hospital] records for [Resident #1]? LPN #5 stated, On 7/14/2022. The Surveyor asked LPN #5, When did you receive [CONDITION(S)] and [CONDITION(S)] orders for [Resident #1]? LPN #5 stated, On 7/14/2022. The Surveyor asked LPN #5, Why did the facility licensed nurses not get these orders? LPN #5 stated, I'm not sure. I was told that we need to put these orders under appointments and [CONDITION(S)] so that they fire on the MAR. I have always been putting under vital signs. It should of been firing on the MAR. I don't know why the LPNs didn't see. I didn't know there was a [CONDITION(S)] category. I was told that they couldn't see it on the E-chart or the Orders unless I put under appointments and under [CONDITION(S)]. It still flags on the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility initiated corrective action immediately after the incident on 07/20/2022 by implementing the following: a.Inservice .7/27/2022 .[CONDITION(S)] Appointments .When ordering [CONDITION(S)], order type should be '[CONDITION(S)]'. A second order should be placed under 'Order Type', 'Appointments' . b. Instant Inservice - Nurses .If a resident is being moved from one hall to another, or from LTC [Long Term Care] to Rehab (or vice versa) please ensure you do a bedside report to prevent from missing anything in resident's care. Report should also be given to oncoming nurses for every single shift. Again, to prevent any delays in care . c. Inservice .7/27/2022 .If you are clicking something off of the MAR/TAR, please make sure the task has been/is being done. Appt. reminders, weekly summaries, etc. [etcetera] . d. Inservice .7/26/2022 .1. Discussed Clinical Meeting and going through orders for new admissions and ensuring they are coded and placed correctly, including follow ups and appointments. 2. Discussed following up with nurses on new admissions and ensuring when residents are moved that nurses give a report to new nurse. 3. Discussed following up on each new admission to ensure appointments/[CONDITION(S)] are happening without issue. Also monitoring for any issues or concerns with new admit that need addressed . e. 7/26/2022 . the facility staff interviewed 3 cognitively intact [CONDITION(S)] residents and placed information on Witness Statements. The [CONDITION(S)] residents stated that they would occasionally refuse [CONDITION(S)] when not feeling well and that the facility always provided transportation to [CONDITION(S)] facility . 3. The document provided by the Nurse Consultant on 8/2/2022 at 11:30 a.m. documented, [Resident #1] missed 3 [CONDITION(S)] appointments. After this was brought to our attention, we completed the following in-services and audit of all current residents on [CONDITION(S)] 1. Placing orders into AHT [American Health Tech] under appointments and [CONDITION(S)]. 2. In-service on giving report on admit and with transferring residents to another room. 3. In-service on reading and ensuring they sign off MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] 4. Nursing management in-serviced on clinical meeting and ensuring orders and follow up on new admission and appointments are completed. We then placed the following monitoring in place. 1. DON/Designee will monitor 2 times weekly to ensure [CONDITION(S)] orders are in AHT under appointments and [CONDITION(S)]. 2. Unit Manager/Admissions nurse will ensure nurse to nurse report is given on new admissions and when residents change rooms. 3. DON/ADON/Designee will monitor 3 residents 2 days a week, for inaccurate documentation. 4. DON/Designee during clinical meeting will monitor to ensure follow up with any clinical concerns new admission. 5. DON/Designee during clinical meeting will monitor to ensure appointments and orders are entered correctly in AHT . Signed by (Nurse Consultant).

Based on record review and interview, the facility failed to ensure residents and/or their representatives and the Ombudsman were provided in writing the reason for discharge or attempted discharge and the reasons for discharge were documented in the resident's record and appropriate placement was obtained prior to discharge for 1 of 1 (Resident #2) resident who was discharged to a homeless shelter and 1 of 1 (Resident #3) who the facility attempted to discharge to a homeless shelter. This failed practice resulted in actual harm to Resident #2 who was discharged to a homeless shelter without permission and had the potential to cause more than minimal harm to Resident #3 who the facility attempted to discharge to a homeless shelter. The findings are: 1. Resident #2 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] documented the resident scored 9 (,d+[DATE] indicates moderately cognitively impaired) on a Brief Interview for Mental Status (BIMS). 2. Resident #3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 5 Day MDS with an ARD of [DATE] documented the resident scored 11 (,d+[DATE] indicates moderately cognitively impaired) on a BIMS. a. On [DATE] at 10:56 AM, the Administrator was asked, Can you tell me about the discharge of [Resident #2] and attempted discharge of [Resident #3]? He stated, [Resident #3] he was admitted [DATE] for skilled services, then transferred to Long Term Care Medicaid pending. While waiting for Medicaid to approve he was positive for Covid, so we skilled him for Covid. After his skilled days were over, he still remained Medicaid pending. Medicaid denied due to he was too high functioning. He transfers self, toilets self, feeds self and he didn't pass the 703. We discussed with the Ombudsman about Assisted Living Facilities. The Ombudsman sent an e-mail with different options for placement. We got the list and took to [Resident #3] and he chose some places and sent the referrals out and he was denied. After that we went back and talked to him, and he said he was previously homeless. He told us about some family that lived out of state but didn't have contact information. We got on Facebook and hunted them down. The facility stated they were not in any shape to help him. Went back and talked to [Resident #3] and he said he was a veteran. We contacted the VA [Veterans]. There's an application process and they are familiar with him. We asked if there were any options for him and they said HUD [Housing and [NAME] Development] previously assisted him but there had been some negative issues between him and HUD, which made him ineligible for HUD assistance now. Talked to him again and the last conversation approximately 2 weeks ago and he said he had been to [Local Homeless Shelter] before and knew he could not stay here any longer. He was agreeable to go to [Local Homeless Shelter]. Our transport company took him because our facility van was broke down. When they went to drop him off, they said he couldn't stay there. [Transport] brought him back to facility where he remains at this time. This was 2 to 3 days ago. b. On [DATE] at 11:33 AM, the Administrator was asked, Did you issue [Resident #2] or [Resident #3] a 30 Day Discharge Notice? She stated, No I did not issue either one of them a 30 Day Discharge because we had discussed options, and both were agreeable to the plan. [Local Homeless Shelter] didn't accept [Resident #3]. The Administrator was asked, Was [Resident #2] taken to [Local Homeless Shelter] by the facility and dropped off? He stated, Yes she was. The Administrator was asked, If that was the plan should [Local Homeless Shelter] have been made aware of the transfers and make sure they would be accepted? He stated, Yes, they should have been notified. The Administrator was asked, [Resident #2] and [Resident #3] were discharged or attempted discharged due to Medicaid denial, is that correct? He stated, Yes, we did re-apply but they were denied after re-applying. c. On [DATE] at 11:42 AM, the Director of Nursing (DON) and the Regional Nurse Consultant were asked, What can you tell me about the discharge of [Resident #2] and attempted discharge of [Resident #3]? The Regional Nurse Consultant stated, I know Social Services was talking to [Resident #2's] family, but I don't recall what they discussed.? They were then asked, Was a 30 Day Discharge Notice given? The Regional Nurse Consultant stated, I'm not aware if 30 Day Discharge Notice was given or not. They were then asked, When are you supposed to issue a 30 Day Discharge Notice? The Regional Nurse Consultant stated, I know they have to have a safe discharge when you discharge them. I know Social Services was working on discharge plan for [Resident #3]. The DON stated, [Resident #3] is still here. [Local Homeless Shelter] would not take him. [Transport] driver said they don't take people in wheelchairs. They were then asked, Should there have been documentation in these resident's records regarding the discharge and the attempted discharge? They both stated, Yes there should have been. d. On [DATE] at 11:52 AM, the Social Service Director was asked, What can you tell me about the discharge of [Resident #2]? She stated, When she admitted , she admitted Medicaid pending. Then it was determined by DHS [Department of Human Services] that she was not eligible for Medicaid, but they did approve for 30 days. They base it on the physical ability of the resident. Our financial reached out to the son regarding the discharge and her inability to pay and her son told us that initially [Resident #2] stayed with her daughter and there were allegations that the resident had abused her grandchildren and she was removed from the home due to that. The son stated to us he had children and he couldn't take the risk. [Financial Specialist] mentioned her going to the homeless shelter and he said send her there because that's where she was to begin with. [Resident #2] agreed to go to [Local Homeless Shelter] and we took her down there with all her medications and her belongings, and that same day I get a call from the intake person that they couldn't take her, and I asked what the problem was, and he did not give me a definitive answer. He hung up the phone then called back requesting contact information and I didn't hear from him again after that. She was asked, Was [Local Homeless Shelter] notified prior to [Resident #2] being taken there? She stated, No they weren't. She was asked, Should a 30 Day Discharge Notice have been issued? She stated, Yes it should have. That's Standard Practice. Regarding [Resident #3] the Social Service Director stated, I had reached out to Ombudsman on [DATE] for assist [assistance] with finding housing for him. She sent me some information to help get him in Residential Care Facility and I sent out 6 or 7 and I got denial from one due to it was for strictly mental disabilities and never received anything from the others except still under evaluation. He was taken to [Local Homeless Shelter] on [DATE] and they didn't accept him. He was brought back here, and he remains here. e. On [DATE] at 12:31 PM, during a phone interview the Case Manager at [Local Homeless Shelter], was asked, Is [Resident #2] in your facility? She stated, [Resident #2] was brought over here on [DATE]. He was asked, Were you notified prior to her arrival? He stated, No, I was not. I called [Facility] and spoke with [Social Service Director] and asked what was going on and she told me her insurance ran out. We were not notified when they brought over [Resident #3] the other day and we didn't accept him. The Shelter Coordinator saw them bring him and refused to accept him. We had not received a prior call and he couldn't take care of his self. The only reason I accepted [Resident #2] was because they were already gone. When I saw her, she was in the building with a bag of medicine and in a wheelchair. She just kept on saying her family was in Pine Bluff. She did have discharge papers with her from the [Facility]. What I'm doing right now is what [Social Service Director] should have been doing. I'm trying to find placement for her closer to her son in White Hall. She's not getting Social Security because payee died and she's not cognitive enough that Social Security could talk to her. She did sit in here with me on the phone with Social Security and she was able to finally say one name that Social Security could verify it was her. When she was in my office, she told me she was 42 but she is actually 54. I have someone watching her or she could just be out on the streets of Fort Smith and not knowing where she was. He was asked, Have any other residents been brought to you without notification? He stated, Yes, a couple of days ago they tried to drop off another resident, but staff saw them and told them we couldn't take him. That was [Resident #3]. f. On [DATE] at 2:21 PM, [Transport] was asked, Did you transport [Resident #2] to [Local Homeless Shelter]? She stated, Yes I did. She was asked, Who asked you to take her? She stated, On [DATE] [Social Service Director] asked me to take her on ,d+[DATE] [2022]. I was on my way to [Local Homeless Shelter] at 11:52 AM. That's what time I let them know I was out of the facility with her. She hadn't had lunch here yet, so I stopped at [Fast Food] to let her eat and drink. She had a purse with her. She didn't have any money, so I paid for her lunch. She was not ambulatory, and she required a wheelchair She was asked, Could she take care of herself? She stated, I would say no, because she didn't improve while she was here. She was asked, Did you notify [Local Homeless Shelter] you were bringing her? She stated, No. She was asked, What were you told from here when you took her? She stated, I was told by [Social Service Director] to take her there and see if anyone could help her because we couldn't anymore. She was asked, Who did you speak to when you took her? She stated, There was a lady there, I don't know her name, but I told her I was from [Facility] and this lady didn't have anywhere to go. She just looked at me like I was crazy. The only thing on [Resident #2] is that I know they had reached out to her kids, and they wanted nothing to do with her. 3. The facility policy titled, Transfer, Discharge and Therapeutic Leaves (including AMA [Against Medical Advice]), provided by the Administrator on [DATE] at 11:31 AM documented, . PURPOSE: the resident/guest has the right to refuse involuntary transfer out of or discharge from the facility under certain circumstances. STANDARD: Transfer means the moving of a resident/guest from the facility to another legally responsible institutional setting. Discharge means the moving of a resident/guest to a non-institutional setting when the releasing facility ceases to be responsible for the resident/guest's care. According to federal regulations, the facility must permit each resident/guest to remain in the facility, and not transfer or discharge the resident/guest from the facility unless: . 5) The resident/guest has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. PROCESS: 1. Non Emergency Transfers or Discharges (Licensed Nurse should complete Discharge Summary) Non emergency transfers or discharges should be coordinated by the Social Service Designee. Arrangements for a safe discharge should be conducted by the clinical team prior to discharge. Procedures for non emergency transfer/discharge should include: a) Notify the resident/guest in writing, and if known, a family member or legal representative, 30 days in advance, of the transfer or discharge and the reasons for the transfer or discharge, according to the above reasons for transfer or discharge. b) Record the reasons for, and the effective date of transfer, or discharge, and the location to which the resident/guest is being transferred or discharged , in the medical record and on attached state specific forms. Give a copy of this notice to the resident/guest and his/her family, legal representative upon transfer or discharge. c) Provide orientation for the resident/guest to the new facility, when possible. Assist with transportation arrangements to the new facility and any other arrangements, as needed. d) Provide the resident/guest with a statement of the right to appeal the action to the state agency designated for such appeals, along with the name, address, and phone number for the State Long Term Care Ombudsman. f) Assist the resident/guest with such appeal, and Ombudsman representative consultations, as desired.

Based on observation, record review and interview, the facility failed to ensure a resident was promptly provided with toileting assistance, which resulted in an incontinent episode, after which the facility failed to ensure incontinent care and a bed linen change were promptly provided, to promote dignity and maintain self-esteem for 1 (Resident #11) of 39 (Residents #118, 119, 117, 109, 17, 70, 61, 24, 80, 65, 57, 51, 30, 9, 108, 43, 42, 84, 67, 11, 28, 217, 83, 95, 116, 5, 14, 3, 104, 100, 32, 52, 20, 29, 76, 54, 218, 19 and 13) sampled residents who required assistance with toileting. The failed practice resulted in actual psychosocial harm for Resident #11, who experienced humiliation and emotional distress related to delays in being assisted to the toilet and being left wet after an incontinent episode, and had the potential to cause more than minimal harm to 114 residents who required assistance with toileting, according to a list provided by the Administrator on 9/26/19. The facility failed to ensure a resident was dressed in properly fitting clothing and staff promptly adjusted the resident's clothing to avoid exposure of the resident's body when sitting in a common area, to maintain dignity for 1 (Resident #32) of 44 (Residents #118, 119, 117, 109, 17, 70, 61, 24, 80, 65, 57, 51, 30, 73, 10, 71, 467, 113, 9, 108, 43, 42, 84, 67, 11, 28, 217, 83, 95, 116, 5, 14, 3, 104, 100, 32, 52, 20, 29, 76, 54, 218, 19 and 13) sampled residents who required assistance with dressing. The failed practice had the potential to affect 116 residents who required assistance with toileting, according to a list provided by the Administrator on 9/26/19. The facility failed to ensure staff sat at eye level and did not stand over a resident while feeding her to promote dignity and convey respect for 1 (Resident #108) of 5 (Residents #108, 62, 84, 95 and 29) sampled residents who were dependent on staff for eating. The failed practice had the potential to affect 11 residents who were dependent on staff for eating, according to a list provided by the Administrator on 9/26/19. The facility failed to ensure signs that documented personal care information were either avoided entirely or were posted in areas where they could not be seen by other residents or visitors, to promote dignity and protect privacy for 1 (Resident #116) of 4 (Resident #83, 20, 80 and 116) sampled residents who were required to avoid straws when drinking liquids. The failed practice had the potential to affect 12 residents who were required to avoid the use of straws due to swallowing problems, as documented on a list provided by the Director of Nursing on 9/11/19. The findings are: 1. Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/19 documented the resident scored 15 (13 to 15 indicates cognitively intact) on a brief interview for mental status (BIMS), required extensive assistance of 2 plus persons for bed mobility and transfer, was totally dependent on 2 plus persons for toileting and bathing, was occasionally incontinent of bowel and bladder, and had functional limitation in range of motion to the upper and lower extremities on both sides. a. The Care Plan dated 9/9/19 documented, Incontinent Episodes of bladder and bowels .pericare after each incontinent episode .Disposable brief program. Potential for complications r/t (related to) [MEDICAL CONDITION] .Assist with mobility needs . Allow time for mobilization .Actual Contractures bilateral upper and lower extremities .Observe for pain during mobility .Turn/reposition every 2 hours and prn (as needed) . b. On 9/12/19 at 8:54 a.m., Resident #11 asked to speak to the surveyor. The resident was sitting on a bedside commode in his room, on the right side of his bed, with a privacy curtain pulled between him and his roommate, who was also in the room at the time. The sheet on the resident's bed had a tan to brown discoloration covering approximately half of the sheet, and there was a strong urine odor. The resident stated at around 6:15 a.m., he used his call-light and no one answered until approximately 6:50 a.m. He stated he had to go to the bathroom and was unable to wait and had an incontinent episode, which soaked his bed and clothing. At 6:50 a.m., Certified Nursing Assistant (CNA) #10 had answered the light and offered to change him and brought a clean brief, which was lying on the end of the bed, unused. He stated told the CNA he wanted to be assisted to get out of the bed, that he didn't want to be rolled around in urine. He stated the CNA replied she did not have time to get him up and that she could clean him up and offered a new brief. He was later assisted out of the bed to the bedside commode. He stated one CNA and a float CNA were not enough staff and, The CNA was doing all she could, and he was, upset by this happening. He stated, I am mentally with it, and a grown man, and let me tell you, it is embarrassing to piss yourself because you can't get anyone to come answer your call light and look at my bed! It is humiliating. Instead of getting me up, she got a diaper. I told her I wanted to get up. The resident's voice trembled and his eyes teared slightly as he described how this incident made him feel. c. On 9/12/19 at 9:01 a.m., the Director of Nursing (DON) was asked to accompany the surveyor to see Resident #11. The resident was asked to tell the DON what had happened. He described what he had reported to the surveyor earlier, and the DON stated, I will look into that. The resident stated, She wanted to change the sheet and put me in a diaper. I didn't want to be rolled around in that piss. I asked her to get me up, and she said she couldn't. I am a grown man, and it is humiliating. Would you want to lay there in piss like that? Would you not feel humiliated to piss yourself because no one came to answer your light for over 30 minutes? She stated, I understand, and nodded yes. The resident asked the DON, What do you think an appropriate response time is to answer a call light? Do you think 30 minutes is too long? Could you wait that long to go to the bathroom if you really needed to go? How long do you think it should take to answer? She stated, Five minutes or less. The resident agreed and stated, That is what I am saying; your CNA is overwhelmed. For 1 CNA, with an occasional one helping, is not enough help. I have had to wait as long as an hour in the past. The CNA told me she didn't have anyone to help get me up earlier this morning when I asked her to get me out of bed, and she didn't know where the other CNA was, and didn't have the time to find her to get me up. At 9:08 a.m., as the DON exited the resident's room, the surveyor asked her if she noticed the stains on the bedding and the odor of urine in the room. She stated, Yes. I will have that taken care of. d. On 9/12/19 at 9:20 a.m., the Staff Scheduler was asked, how many CNAs were on the Northwest (NW) Hall last night on 11 p.m. to 7 a.m. shift? She stated, One on Southwest and 1 on Northwest and a float for the entire long-term care building. The scheduler was asked where the float CNA was located. She stated, She stays at the front desk by Northeast Hall. She was asked how the other aides contacted her if they needed help. She stated, They can walk down and tell her or page overhead for her or call the front desk if she is there. e. On 9/12/19 at 9:27 a.m. and 10:58 a.m., the surveyor attempted twice to contact CNA #10 via telephone. There was no answer, and the surveyor left a message requesting a call back. As of 9/13/19, when the surveyors exited the building, there had been no response from the CN[NAME] f. On 9/12/19 at 9:28 a.m., the DON was asked if the resident and his bed had been cleaned up yet and she stated, Not until we get done passing trays (meal trays). Our policy is we don't clean up residents until all the trays are passed. The DON was asked who told her this and stated, The DON that trained me. It's always been this way. The DON was asked for the facility's policy or documentation of this. The DON was asked if she had notified the Administrator of the resident's allegation and she stated yes, she told him immediately. As of9/13/19, when the survey team exited the facility, no policy had been provided regarding delaying care until all meal trays were served. g. On 9/12/19 at 9:34 a.m., the Nursing Consultant was informed by the surveyor that the resident needed to be cleaned up. h. On 9/12/19 at 9:38 a.m., the Nursing Consultant reported the resident had been cleaned up and placed in his chair. i. On 9/12/19 at 10:31 a.m., the resident stated, I am good now, but it was very upsetting and frustrating as far as what happened. j. On 9/13/19 at 8:10 a.m., the DON provided a list of residents who were incontinent of bowel and bladder. Resident #11 was not documented as an incontinent resident on this list. k. The facility's written procedure for, Answering the Call Light, provided by the Administrator on 9/13/19 at 10:05 a.m., documented, .Purpose: Call lights serve as notice to the staff the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident. Standard: .If the staff member cannot provide what the resident desires, the appropriate personnel are notified . Process: . d) inform the charge nurse when a resident request cannot be met . f) If assistance is needed with the procedure, summon help by using the call light . The following record reviews and interviews were conducted related to call light response times as a result of Resident #11's verbalized concerns: 1.) The June, (MONTH) and (MONTH) 2019 Grievance Logs were reviewed with the following findings: There were grievances related to call light response times on 6/4/19, 7/23/19, 7/29/19, 7/30/19, 8/5/19 (two different complaints on this date), and 8/20/19. 2.) On 9/13/19 at 9:58 a.m., the Administrator, with the Regional Director present, was asked about monitoring of the call light issue related to the grievances filed in June, (MONTH) and August. The Administrator stated, .I didn't do a QA (Quality Assessment) on call lights or QAPI (Quality Assessment Performance Improvement) recently on this . We did some answering of timeliness on call lights on 4/19/19 with QA and resolved this a couple of months afterwards. We were using the Guardian Angel sheet . The Administrator was asked about documentation of any follow up monitoring of the call light issue, but was unable to provide any documentation. The Administrator stated the facility resolved any call light grievances after (MONTH) and (MONTH) 2019 with staff in-services. The Administrator was again asked about any monitoring related to call light wait times after the in-services were conducted and he stated, No, but we did do the Angel round sheets by department heads. The Administrator was asked for this documentation. The documentation provided by the Administrator consisted of blank rounds sheets which did not address call light response times. 3.) As of 9/13/19 when the survey team exited the facility, no documentation had been provided to indicate the facility had conducted monitoring of call light response times as a result of the repeated grievances in June, (MONTH) and (MONTH) 2019. 2. Resident #32 had [DIAGNOSES REDACTED]. The MDS with an ARD of 6/24/19 documented the resident scored 15 (13 to 15 indicates cognitively intact) on a BIMS, required extensive assistance of 2 plus persons for transfers, and required limited assistance of two plus persons for and dressing. a. On 9/9/19 at 1:04 p.m., the meal trays for the Southwest (SW) and NW halls were being delivered. Resident #32 was sitting in his wheelchair directly in front of and facing the nursing desk between the NW and SW halls. His shirt was pulled up and trousers slid down on the right side, exposing his abdomen and the right side of his hip, which were visible to anyone in the area. b. At 1:14 p.m., an unidentified female staff member approached the resident. She spoke with the resident, then obtained a towel and placed it over his lap, as per the residents' request, then assisted with adding hot sauce to the food on his tray. The towel covered the right side of the resident's hip area but the resident's abdomen on the right side was still exposed. c. At 1:20 p.m., the resident remained in the wheelchair near the nurse's desk, eating his lunch. The resident's abdomen/hip remained partially exposed on the right side. The resident was visiting with another male resident who was facing him. d. At 1:28 p.m., the MDS Coordinator visited with the resident for a few minutes, then at 1:39 p.m., as the MDS Coordinator began walking away, she was asked by the surveyor to look at Resident #32's right side. She stated, Oh. I will get that taken care of. The MDS Coordinator went to the resident and asked him if she could speak with him and adjusted his clothing to cover his right side and hip. 3. Resident #116 had [DIAGNOSES REDACTED]. The Admission MDS with an ARD of 8/12/19 documented the resident scored 10 (8-12 indicates moderately impaired) on a Brief Interview for Mental Status. a. On 9/9/19 at 12:02 p.m., the door to Resident #116 was closed. A typed sign was posted on the outside of the door which documented, No Straws. The surveyor took a photograph of the sign on the door at this time. At 2:37 p.m., LPN #1 was asked, why can't he have straws? The LPN stated, It was when he had thickened liquids, which have been discontinued. b. On 9/11/19 at 8:04 a.m., CNA #2 was asked why there was a No Straws sign on the resident's door and stated, He's getting therapy and there are some swallowing issues. c. On 9/11/19 at 8:17 a.m., the Rehabilitation Technician (RT) was asked, what do you do here? She stated, I help Physical Therapy, Occupational Therapy and Speech Therapy. The RT was asked why the No Straws sign was on the resident's door and stated, Let me gather some information and I'll get back with you At 8:21 a.m., the RT stated, My therapy boss says it's because he was recently upgraded to thin liquids. d. On 9/11/19 at 8:31 a.m., the Physical Therapist Team Leader was asked about the No Straws sign on the resident's door and stated, He (Resident #116) was upgraded from honey thick liquids on 8/5/19, to nectar thick liquids on 8/13/19, and to thin liquids on 9/3/19. e. On 9/12/19 a 8:26 a.m., the DON was asked if she was aware of the sign on the resident's door. She stated, Yes, but we have a contract for that; I will get it for you. At 10:32 a.m., the DON brought in page 16 of the Admission Agreement which documented, .You and your responsible party do authorize the Facility, it's employees, designees, and assigns to place above your bed in the Facility, sign noting the proper care and maintenance for you. The surveyor pointed out the No Straws sign was not posted above the bed, as per the written agreement. The DON stated, Yes, I know. 5. Resident #108 had [DIAGNOSES REDACTED]. The 5-day MDS with an ARD of 9/2/19 documented the resident scored 0 (0-7 indicates severely impaired) on a brief interview for mental status and required the assistance of one staff member with eating. a. On 9/9/19 at 1:15 p.m., the resident was in bed. The head of the bed was elevated to approximately 60 degrees, and CNA #1 was in the resident's room feeding the resident. The CNA was standing over the resident, not sitting at the resident's eye level. The surveyor took a photograph of the CNA standing over the resident at this time. At 1:30 p.m., CNA #1 was asked, why did (Resident #108) eat in her room? The CNA stated, She just came over from the rehab unit. The CNA was asked, are you supposed to stand while you are feeding a resident? The CNA stated, Technically, we are supposed to sit. b. On 9/12/19 at 8:25 a.m., the DON was asked if staff were supposed to stand over a resident while feeding them? The DON stated, No, staff should sit to feed.

Based on observation, record review and interview, the facility failed to ensure a resident was promptly provided with toileting assistance, which resulted in an incontinent episode, after which the facility failed to ensure incontinent care and a bed linen change were promptly provided, to maintain good hygiene and prevent odors for 1 (Resident #11) of 39 (Residents #118, 119, 117, 109, 17, 70, 61, 24, 80, 65, 57, 51, 30, 9, 108, 43, 42, 84, 67, 11, 28, 217, 83, 95, 116, 5, 14, 3, 104, 100, 32, 52, 20, 29, 76, 54, 218, 19 and 13) sampled residents who required assistance with toileting. The failed practice resulted in actual psychosocial harm for Resident #11, who experienced humiliation and emotional distress related to delays in being assisted to the toilet and being left wet after an incontinent episode, and had the potential to cause more than minimal harm to 114 residents who required assistance with toileting, according to a list provided by the Administrator on 9/26/19.The findings are: Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/19 documented the resident scored 15 (13 to 15 indicates cognitively intact) on a brief interview for mental status (BIMS), required extensive assistance of 2 plus persons for bed mobility and transfer, was totally dependent on 2 plus persons for toileting and bathing, was occasionally incontinent of bowel and bladder, and had functional limitation in range of motion to the upper and lower extremities on both sides. a. The Care Plan dated 9/9/19 documented, Incontinent Episodes of bladder and bowels .pericare after each incontinent episode .Disposable brief program. Potential for complications r/t (related to) [MEDICAL CONDITION] .Assist with mobility needs . Allow time for mobilization .Actual Contractures bilateral upper and lower extremities .Observe for pain during mobility .Turn/reposition every 2 hours and prn (as needed) . b. On 9/12/19 at 8:54 a.m., Resident #11 asked to speak to the surveyor. The resident was sitting on a bedside commode in his room, on the right side of his bed, with a privacy curtain pulled between him and his roommate, who was also in the room at the time. The sheet on the resident's bed had a tan to brown discoloration covering approximately half of the sheet, and there was a strong urine odor. The resident stated at around 6:15 a.m., he used his call-light and no one answered until approximately 6:50 a.m. He stated he had to go to the bathroom and was unable to wait and had an incontinent episode, which soaked his bed and clothing. At 6:50 a.m., Certified Nursing Assistant (CNA) #10 had answered the light and offered to change him and brought a clean brief, which was lying on the end of the bed, unused. He stated told the CNA he wanted to be assisted to get out of the bed, that he didn't want to be rolled around in urine. He stated the CNA replied she did not have time to get him up and that she could clean him up and offered a new brief. He was later assisted out of the bed to the bedside commode. He stated one CNA and a float CNA were not enough staff to cover the entire building, The CNA was doing all she could, and he was, upset by this happening. He stated, I am mentally with it, and a grown man, and let me tell you, it is embarrassing to piss yourself because you can't get anyone to come answer your call light and look at my bed! It is humiliating. Instead of getting me up, she got a diaper. I told her I wanted to get up. The resident's voice trembled and his eyes teared slightly as he described how this incident made him feel. c. On 9/12/19 at 9:01 a.m., the Director of Nursing (DON) was asked to accompany the surveyor to see Resident #11. The resident was asked to tell the DON what had happened. He described what he had reported to the surveyor earlier, and the DON stated, I will look into that. The resident stated, She wanted to change the sheet and put me in a diaper. I didn't want to be rolled around in that piss. I asked her to get me up, and she said she couldn't. I am a grown man, and it is humiliating. Would you want to lay there in piss like that? Would you not feel humiliated to piss yourself because no one came to answer your light for over 30 minutes? She stated, I understand, and nodded yes. The resident asked the DON, What do you think an appropriate response time is to answer a call light? Do you think 30 minutes is too long? Could you wait that long to go to the bathroom if you really needed to go? How long do you think it should take to answer? She stated, Five minutes or less. The resident agreed and stated, That is what I am saying; your CNA is overwhelmed. For 1 CNA, with an occasional one helping, is not enough help. I have had to wait as long as an hour in the past. The CNA told me she didn't have anyone to help get me up earlier this morning when I asked her to get me out of bed, and she didn't know where the other CNA was, and didn't have the time to find her to get me up. At 9:08 a.m., as the DON exited the resident's room, the surveyor asked her if she noticed the stains on the bedding and the odor of urine in the room. She stated, Yes. I will have that taken care of. d. On 9/12/19 at 9:20 a.m., the Staff Scheduler was asked, how many CNAs were on the Northwest (NW) Hall last night on 11 p.m. to 7 a.m. shift? She stated, One on Southwest and 1 on Northwest and a float for the entire long-term care building. The scheduler was asked where the float CNA was located. She stated, She stays at the front desk by Northeast Hall. She was asked how the other aides contacted her if they needed help. She stated, They can walk down and tell her or page overhead for her or call the front desk if she is there. e. On 9/12/19 at 9:27 a.m. and 10:58 a.m., the surveyor attempted twice to contact CNA #10 via telephone. There was no answer, and the surveyor left a message requesting a call back. As of 9/13/19, when the surveyors exited the building, there had been no response from the CN[NAME] f. On 9/12/19 at 9:28 a.m., the DON was asked if the resident and his bed had been cleaned up yet and she stated, Not until we get done passing trays (meal trays). Our policy is we don't clean up residents until all the trays are passed. The DON was asked who told her this and stated, The DON that trained me. It's always been this way. The DON was asked for the facility's policy or documentation of this. The DON was asked if she had notified the Administrator of the resident's allegation and she stated yes, she told him immediately. As of9/13/19, when the survey team exited the facility, no policy had been provided regarding delaying care until all meal trays were served. g. On 9/12/19 at 9:34 a.m., the Nursing Consultant was informed by the surveyor that the resident needed to be cleaned up. h. On 9/12/19 at 9:38 a.m., the Nursing Consultant reported the resident had been cleaned up and placed in his chair. i. On 9/12/19 at 10:31 a.m., the resident stated, I am good now, but it was very upsetting and frustrating as far as what happened. j. On 9/13/19 at 8:10 a.m., the DON provided a list of residents who were incontinent of bowel and bladder. Resident #11 was not documented as an incontinent resident on this list.

Based on observation, record review and interview, the facility failed to ensure the Quality Assessment and Assurance (QAA) Committee conducted ongoing monitoring of a corrective action plan after identifying quality deficiencies related to call light response times, to ensure the in-servicing of staff was sufficient to correct the problems and failed to identify and intervene to correct issues with adequate staffing levels, which resulted in failure to ensure a resident was promptly provided with toileting assistance and, after experiencing an incontinent episode, was promptly provided with incontinent care and a bed linen change for 1 (Resident #11) of 39 (Residents #118, 119, 117, 109, 17, 70, 61, 24, 80, 65, 57, 51, 30, 9, 108, 43, 42, 84, 67, 11, 28, 217, 83, 95, 116, 5, 14, 3, 104, 100, 32, 52, 20, 29, 76, 54, 218, 19 and 13) sampled residents who required assistance with toileting. The failed practice resulted in actual psychosocial harm for Resident #11, who experienced humiliation and emotional distress related to a delay in being assisted to the toilet and being left wet after an incontinent episode, and had the potential to cause more than minimal harm to 114 residents who required assistance with toileting, according to a list provided by the Administrator on 9/26/19. The findings are: 1. On 9/9/19 at 11:25 a.m., Resident #72, who resided on the Northwest (NW) Hall, stated, Several residents are bedridden. One CNA (Certified Nursing Assistant) can't take care of all of these residents. There are 2 aides and 1 float here. The Administration needs to look into this. 2. Resident #11 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/30/19 documented the resident scored 15 (13 to 15 indicates cognitively intact) on a brief interview for mental status (BIMS), required extensive assistance of 2 plus persons for bed mobility and transfer, was totally dependent on 2 plus persons for toileting and bathing, was occasionally incontinent of bowel and bladder, and had functional limitation in range of motion to the upper and lower extremities on both sides. a. The Care Plan dated 9/9/19 documented, Incontinent Episodes of bladder and bowels .pericare after each incontinent episode .Disposable brief program. Potential for complications r/t (related to)[MEDICAL CONDITION] .Assist with mobility needs . Allow time for mobilization .Actual Contractures bilateral upper and lower extremities .Observe for pain during mobility .Turn/reposition every 2 hours and prn (as needed) . b. On 9/12/19 at 8:54 a.m., Resident #11 asked to speak to the surveyor. The resident was sitting on a bedside commode in his room, on the right side of his bed, with a privacy curtain pulled between him and his roommate, who was also in the room at the time. The sheet on the resident's bed had a tan to brown discoloration covering approximately half of the sheet, and there was a strong urine odor. The resident stated at around 6:15 a.m., he used his call-light and no one answered until approximately 6:50 a.m. He stated he had to go to the bathroom and was unable to wait and had an incontinent episode, which soaked his bed and clothing. At 6:50 a.m., Certified Nursing Assistant (CNA) #10 had answered the light and offered to change him and brought a clean brief, which was lying on the end of the bed, unused. He stated told the CNA he wanted to be assisted to get out of the bed, that he didn't want to be rolled around in urine. He stated the CNA replied she did not have time to get him up and that she could clean him up and offered a new brief. He was later assisted out of the bed to the bedside commode. He stated one CNA and a float CNA were not enough staff and, The CNA was doing all she could, and he was, upset by this happening. He stated, I am mentally with it, and a grown man, and let me tell you, it is embarrassing to piss yourself because you can't get anyone to come answer your call light and look at my bed! It is humiliating. Instead of getting me up, she got a diaper. I told her I wanted to get up. The resident's voice trembled and his eyes teared slightly as he described how this incident made him feel. c. On 9/12/19 at 9:01 a.m., the Director of Nursing (DON) was asked to accompany the surveyor to see Resident #11. The resident was asked to tell the DON what had happened. He described what he had reported to the surveyor earlier, and the DON stated, I will look into that. The resident stated, She wanted to change the sheet and put me in a diaper. I didn't want to be rolled around in that piss. I asked her to get me up, and she said she couldn't. I am a grown man, and it is humiliating. Would you want to lay there in piss like that? Would you not feel humiliated to piss yourself because no one came to answer your light for over 30 minutes? She stated, I understand, and nodded yes. The resident asked the DON, What do you think an appropriate response time is to answer a call light? Do you think 30 minutes is too long? Could you wait that long to go to the bathroom if you really needed to go? How long do you think it should take to answer? She stated, Five minutes or less. The resident agreed and stated, That is what I am saying; your CNA is overwhelmed. For 1 CNA, with an occasional one helping, is not enough help. I have had to wait as long as an hour in the past. The CNA told me she didn't have anyone to help get me up earlier this morning when I asked her to get me out of bed, and she didn't know where the other CNA was, and didn't have the time to find her to get me up. At 9:08 a.m., as the DON exited the resident's room, the surveyor asked her if she noticed the stains on the bedding and the odor of urine in the room. She stated, Yes. I will have that taken care of. d. On 9/12/19 at 9:20 a.m., the Staff Scheduler was asked, how many CNAs were on the Northwest (NW) Hall last night on 11 p.m. to 7 a.m. shift? She stated, One on Southwest and 1 on Northwest and a float for the entire long-term care building. The scheduler was asked where the float CNA was located. She stated, She stays at the front desk by Northeast Hall. She was asked how the other aides contacted her if they needed help. She stated, They can walk down and tell her or page overhead for her or call the front desk if she is there. The scheduler was asked for the staffing and census information for the previous night. The sign-in sheet provided by the scheduler for the 9/11/19 to 9/12/19 (11:00 p.m. to 7:00 a.m. shift) documented CNA #11 was assigned to the NW Hall, CNA #10 was assigned to the Southwest (SW) Hall and CNA #12 was assigned as a float for the building. The census information documented there were 17 residents on SW Hall and 20 residents on NW Hall. The scheduler was asked if the Administrator had spoken with her about staffing for the residents on the long-term care halls, related to acuity / care needs. She stated, He just told me to work on where to place the staffing. She was asked if the schedule had been addressed to ensure adequate staff for the long-term care halls (NW and SW), which included a bariatric resident over 600 pounds (lbs), heavy care residents, and total care residents, with only 1 CNA assigned per hall on the 9/11/19 night shift. She stated, I am doing what I can with what I was able and allowed to do. I have been told not to pull from the rehab unit. I have spoken with the nurses and CNAs and told the nurses that they are to help with the residents. e. On 9/12/19 at 9:27 a.m. and 10:58 a.m., the surveyor attempted twice to contact CNA #10 via telephone. There was no answer, and the surveyor left a message requesting a call back. As of 9/13/19, when the surveyors exited the building, there had been no response from the CN[NAME] f. On 9/12/19 at 9:28 a.m., the DON was asked if the resident and his bed had been cleaned up yet and she stated, Not until we get done passing trays (meal trays). Our policy is we don't clean up residents until all the trays are passed. The DON was asked who told her this and stated, The DON that trained me. It's always been this way. The DON was asked for the facility's policy or documentation of this. The DON was asked if she had notified the Administrator of the resident's allegation and she stated yes, she told him immediately. As of9/13/19, when the survey team exited the facility, no policy had been provided regarding delaying care until all meal trays were served. g. On 9/12/19 at 9:34 a.m., the Nursing Consultant was informed by the surveyor that the resident needed to be cleaned up. h. On 9/12/19 at 9:38 a.m., the Nursing Consultant reported the resident had been cleaned up and placed in his chair. i. On 9/12/19 at 10:31 a.m., the resident stated, I am good now, but it was very upsetting and frustrating as far as what happened. j. On 9/13/19 at 8:10 a.m., the DON provided a list of residents who were incontinent of bowel and bladder. Resident #11 was not documented as an incontinent resident on this list. k. The facility's written procedure for, Answering the Call Light, provided by the Administrator on 9/13/19 at 10:05 a.m., documented, .Purpose: Call lights serve as notice to the staff the resident has a need or request. Prompt answering of call lights provides a sense of security to the resident. Standard: .If the staff member cannot provide what the resident desires, the appropriate personnel are notified . Process: . d) inform the charge nurse when a resident request cannot be met . f) If assistance is needed with the procedure, summon help by using the call light . The following record reviews and interviews were conducted related to call light response times and staffing levels, as a result of Resident #11's verbalized concerns: 1.) The June, (MONTH) and (MONTH) 2019 Grievance Logs were reviewed with the following findings: There were grievances related to call light response times on 6/4/19, 7/23/19, 7/29/19, 7/30/19, 8/5/19 (two different complaints on this date), and 8/20/19. 2.) On 9/13/19 at 9:58 a.m., the Administrator, with the Regional Director present, was asked about monitoring of the call light issue related to the grievances filed in June, (MONTH) and (MONTH) and the facility's practices with regard to staff assignments. The Administrator stated, I listen to my staff and let them take care of the staffing deployment / scheduling. I don't know about the staffing on individual halls. That is a nursing role . I didn't do a QA (Quality Assessment) on call lights or QAPI (Quality Assessment Performance Improvement) recently on this . We did some answering of timeliness on call lights on 4/19/19 with QA and resolved this a couple of months afterwards. We were using the Guardian Angel sheet . The Administrator was asked about documentation of any follow up monitoring of the call light issues but was unable to provide any documentation. The Administrator stated the facility resolved any call light grievances after (MONTH) and (MONTH) 2019 with staff in-services. When asked if the QAA Committee or Interdisciplinary Team (IDT) looked for a root cause of the issues with call light wait times. He stated, No. We dealt with each grievance individually. The Administrator was asked if anyone was evaluating repeat grievances to look at the 'big picture' or root causes of those concerns. He stated, No, no one was really looking at the big picture or root cause. The Administrator was again asked about any monitoring related to call light wait times after the in-services were conducted and he stated, No, but we did do the Angel round sheets by department heads. The Administrator was asked for this documentation. The documentation provided by the Administrator consisted of blank rounds sheets which did not address call light response times. 3.) The State Minimum Staffing forms and the 9/11/19 and 9/12/19 staffing sign-in sheets and assignments provided by Licensed Practical Nurse (LPN) #5 documented the following: The Daily Staffing Log documented on 9/11/19, the facility had a census of 124 residents and on 9/12/19, a census of 125 residents. The assignments were as follows: Southwest (SW) Hall census = 17 residents. Day shift 2 CNAs/NAs; Evening shift 2 CNAs/NAs; Night shift 1 CN[NAME] Northwest (NW) Hall census = 20 residents. Day shift 2 CNAs/NAs; Evening shift 2 CNAs/NAs; Night shift 1 CN[NAME] Southeast (SE) Hall census = 27 residents. Day shift 2 CNAs/NAs; Evening shift 2 CNAs/NAs; Night shift 2 CNAs. Northeast (NE) Hall census = 22 residents. Day shift 3 CNAs/NAs; Evening shift 2 CNAs/NAs; Night shift 2 CNAs. Central hall census: 9 residents. Day shift 2 CNAs/NAs; Evening shift 2 CNAs/NAs; Night shift 1 CN[NAME] 4). On 9/12/19 at 11:46 p.m., LPN #6 (employed with the facility for [AGE] years) was interviewed via telephone and stated, Before tonight we had 1 CNA on each hall on the Southwest and Northwest Halls, 2 CNAs on the front 2 halls and a float. The float staff stays in the north halls usually . 5.) On 9/12/19 at 11:52 p.m., CNA #8 was interviewed via telephone and stated, Before tonight, the facility staffed with 1 CNA each on the NW and SW hall and a float over all of the long-term care units . The CNA stated staff had no pagers or other method to let other staff know they need help except to yell or go find the other staff member to assist them. 6). On 9/12/19 at 11:58 p.m., CNA #9 (employed with the facility for 1 month) was interviewed via telephone and verified there was method of notifying the other CNAs for assistance other than going and trying to find another staff member when assistance was needed. 7). On 9/13/19 at 8:20 a.m., there was a strong odor of urine throughout the entire length of the Southeast Hall. Breakfast trays were being passed. 8). On 9/13/19 at 10:14 a.m., the DON (employed as DON for 1 year) was asked who was responsible to ensure the residents' acuity / care needs were met. The DON stated, I have little to do with staffing/scheduling, other than the scheduler comes to me for call-ins. The LPN Scheduler deploys the staff. I am aware of the acuity / care needs of the residents, but I am not aware of the staff scheduling or how / where she schedules the staff. The DON was asked who the scheduler's supervisor was and who was responsible for oversight to ensure all residents' needs were being met. She stated, The scheduler does that; the Administrator is our supervisor. The DON was asked how long the scheduler had been working in this position and what training she had received. The DON stated, She has worked as scheduler about 6 weeks to a couple of months. She worked here before that, so she knows the residents. The prior scheduler worked with her for a few days, then we sent her out to observe and work with our sister home for a couple days. The DON denied having any documentation of this training. The DON was asked how she, as the DON, ensured all residents' needs were met and that staffing was adequate, since the facility had a relatively new scheduler. She stated, I monitor and walk around and look. We also look at the grievances. She was asked if there had been any negative outcomes, such as incontinence episodes or falls / accidents in the last 3 months as a result of staffing issues. She denied any knowledge of this, other than when it was identified by the surveyor on 9/11/19 with Resident #11. 9.) The facility's Staffing and Delegation of Nursing Care Duties Policy, provided by the Nurse Consultant on 9/13/19 at 8:05 a.m., documented, I. Department Organization: . Director of Nursing - manages nursing department . III. Staffing levels are determined by the needs of the resident/guests(s). This should include such factors as acuity, facility size, facility layout. The facility will have a system of determining appropriate staffing levels so call offs can be replaced. This will be monitored by the DON or designee daily . 10). The facility's Quality Assurance/Quality Assurance Performance Improvement (QAPI) policy, provided by the Administrator on 9/13/19, documented, Policy: Our purpose is to provide excellent quality resident/guest services. Quality is defined as meeting or exceeding the needs, expectations and requirements of the resident/guest cost effectively while maintaining good resident/guest outcomes and perceptions of resident/guest care. IV. Feedback, Data Systems and Monitoring: . e. Dashboard for individual performance improvement projects are used to communicate progress and outcomes of individual QAPI projects . iii. Logs - QAPI lead is responsible for keeping logs up to date. VI. Systematic Analysis and Systematic Action . c. The QAPI Committee monitors progress to ensure that interventions or actions are implemented and effective in making and sustaining improvements . i. The QAPI Committee monitors the process according to predetermined time frames, observing if the changes in the process resulted in the desired outcome . ii. If the changes to the process have not resulted in the goal of PIP (Performance Improvement Project), further changes are made and monitoring of the process takes place again . iii. Once the PIP goals have been met, the PIP will be placed on a permanent tracking log for ongoing (but less frequent) measurement, to assure the PIP doesn't get 'forgotten' . 11.) As of 9/13/19 when the survey team exited the facility, no documentation had been provided to indicate the facility had conducted monitoring of call light response times as a result of the repeated grievances in June, (MONTH) and (MONTH) 2019.

Based on observation, record review and interview, the facility failed to ensure an effective Infection Control Program was established that would facilitate prompt identification, isolation and prevention of the potential spread of Clostridium difficile (C-diff) infections, as evidenced by: failure to ensure contact isolation precautions for[DIAGNOSES REDACTED] (including cohorting of residents with[DIAGNOSES REDACTED], staff utilization of personal protective equipment (PPE), utilization of dedicated equipment and supplies and proper disinfection of any equipment / supplies removed from the residents' rooms) were initiated, were consistently followed and were maintained until the infection was resolved for residents who tested positive for[DIAGNOSES REDACTED] to prevent potential spread to other residents for 5 of 5 (Residents #2, #3, #5, #6 and #7) case mix residents who had positive[DIAGNOSES REDACTED] cultures in the past 3 months; failure to ensure housekeeping staff was informed of any residents who were[DIAGNOSES REDACTED] positive and that the appropriate disinfection procedures and products were consistently utilized when cleaning the rooms of residents with[DIAGNOSES REDACTED] to prevent the potential spread of[DIAGNOSES REDACTED] throughout the facility; and, failure to ensure[DIAGNOSES REDACTED] infections were accurately documented, tracked and trended on the Infection Control Long, to enable detection of any patterns of infection and facilitate the evaluation of procedures and staff practices that might contribute to the spread of infection for 3 of 3 months reviewed. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents 2, #3, #5, #6 and #7, who had positive[DIAGNOSES REDACTED] cultures and were not isolated and treated promptly to prevent potential complications of colitis, sepsis and possible death, and had the potential to expose all 130 residents who resided in the facility to potential[DIAGNOSES REDACTED] infection, according to the Resident List received from the Nurse Consultant on 7/5/16 at 9:45 a.m., including 18 residents who were diagnosed with [REDACTED]. The facility was notified of the Immediate Jeopardy condition on 7/5/16 at 5:00 p.m. The findings are: 1. The Center for Disease Control (CDC) web site at http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a10 documented, How can Clostridium difficile infection be prevented in hospitals and other healthcare settings? .Use Contact Precautions: for patients with known or suspected Clostridium difficile infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with Clostridium difficile infection. Use gloves when entering patients' rooms and during patient care . Perform Hand Hygiene after removing gloves . Use gowns when entering patients' rooms and during patient care. Continue these precautions until diarrhea ceases. Because Clostridium difficile-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g. (for example), household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against Clostridium difficile spores.) Hypochlorite-based disinfectants may be most effective in preventing Clostridium difficile transmission in units with high endemic rates of Clostridium difficile infection . Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings . 2. The facility's policy titled, Fact Sheets - Clostridium difficile, MRSA (Methicillin-Resistant Staphylococcus aureus), VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]), documented, Clostridium difficile . Precautions: Contact while having diarrhea. Room considerations: Infected residents should be placed in private rooms or cohorted . Discontinue Precautions: When diarrhea ceases (less than 3 episodes in 24 hours) . [DIAGNOSES REDACTED]icile is a spore-forming organism, environmental contamination frequently occurs . Because there are no EPA-registered products that are specific for inactivating Clostridium difficile spores, CDC recommends use of hypochlorite- based products for disinfection of environmental surfaces . 3. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/16 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status BIMS), required extensive assistance with toilet use, had an ostomy and had Clostridium Difficile. Failure to promptly initiate isolation precautions and treatment for [REDACTED].>a. A physician's orders [REDACTED]. change (every) 3 days . b. The New Bowel Report Roster documented the following entries from 6/4/16 through 6/7/16: 1.) 6/4/16 8:41 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 2.) 6/5/16 4:07 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 3.) 6/5/16 8:22 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 6/6/16 2:44 p.m. Size: Medium . Consistency: Soft Formed . 5.) 6/6/16 9:56 p.m. Size: Large . Consistency: Soft Formed . 6.) 6/7/16 5:37 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 7.) 6/7/16 1:12 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . c. A Laboratory Report dated 6/9/16 documented, .Collected: 6/7/16 9:00 p.m. Reported: 6/9/16 10:30 p.m. Stool type: Semi-solid .[DIAGNOSES REDACTED]icile/Epi . Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second is for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak . d. Departmental Notes dated 6/8/16 at 5:22 a.m. documented, Colostomy . change . Resident was found lying in bed with eyes closed and colostomy bag pulled off . e. The New Bowel Report Roster documented the following entries from the afternoon of 6/8/16 through the evening of 6/11/16: 1.) 6/8/16 2:18 p.m.Size: Medium . Consistency: Soft Formed . 2.) 6/8/16 at 9:30 p.m.Size: Small . Consistency: Soft Formed . 3.) 6/9/16 4:02 a.m. Size: Small . Consistency: Soft Formed . 4.) 6/9/16 1:32 p.m. Size: Medium . Consistency: Soft Formed . 5.) 6/9/16 6:44 p.m. Size: Medium . Consistency: Soft Formed . 6.) 6/10/16 10:45 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 7.) 6/11/16 4:03 a.m. Size: Large . Consistency: Soft Formed . 8.) 6/11/16 2:18 p.m. Size: Medium . Consistency: Soft Formed . 9.) 6/11/16 7:10 p.m. Size: Large . Consistency: Soft Formed . Consistency: Watery Liquid - Nurse Notified . 10.) 6/11/16 8:24 p.m. Size: Extra Large . Consistency: Soft Formed . Consistency: Watery Liquid - Nurse Notified . f. A physician's orders [REDACTED]. for 10 days. This was a period of 2 days after the resident's[DIAGNOSES REDACTED] cultures were determined by the lab provider to be positive. The June 2016 Medication Administration Record (MAR) documented the [MEDICATION NAME] was initiated on 6/12/16 at 9:00 a.m. and was administered three times daily at 9:00 a.m., 1:00 p.m. and 5:00 p.m. through 6/21/16 at 1:00 p.m., instead of every 8 hours as ordered by the physician. g. The New Bowel Report Roster entries dated 6/12/16 through 6/24/16 documented the resident had 0 to 2 soft formed stools per day. h. Departmental Notes dated 6/25/16 at 10:15 a.m. documented, Resident has stool that has the appearance of[DIAGNOSES REDACTED]. Notified (Advanced Practice Nurse). New order received for[DIAGNOSES REDACTED] (culture) . i. A New Bowel Report Roster entry dated 6/26/16 at 10:58 a.m. documented, Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . j. A New Bowel Report Roster entry dated 6/27/16 at 10:43 p.m. documented, .Size: Medium . Consistency: Soft Formed . k. A Laboratory Report dated 6/28/16 documented, .Collected: 6/26/16 10:30 a.m. Reported: 6/28/16 2:05 a.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak . A form titled New Bowel Report Roster documented, 6/28/16 3:54 a.m. Size: Large . Consistency: Soft Formed . l. Departmental Notes dated 6/28/16 at 3:57 a.m. documented, Call received from (laboratory), stool sample positive for[DIAGNOSES REDACTED] . APN notified. The note did not document the method by which the APN was notified, and there was no documentation of new orders for treatment of [REDACTED]. m. New Bowel Report Roster entries dated 6/28/16 through 6/19/16 documented the following: 1.) 6/28/16 9:50 a.m. Size: Large . Consistency: Soft Formed . 2.) 6/28/16 3:13 p.m. Size: Medium . Consistency: Soft Formed . 3.) 6/28/16 9:28 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . 4.) 6/29/16 12:30 a.m. Size: Medium . Consistency: Soft Formed . n. Departmental Notes dated 6/29/16 at 9:29 a.m. and electronically signed by LPN #4 documented, Received[DIAGNOSES REDACTED] (culture) stating that resident is positive for[DIAGNOSES REDACTED]. Notified (Advance Practice Nurse). New orders for [MEDICATION NAME] . On 7/8/16 at 9:20 a.m., LPN # 4 was asked, Was (Resident #5) in isolation in June 2016? LPN # 4 stated, No, I was told it was contained. o. New Bowel Report Roster entries dated 6/29/16 through 6/30/16 documented the following: 1.) 6/29/16 9:57 a.m. Size: Extra Large . Consistency: Soft Formed . 2.) 6/29/16 9:14 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 3.) 6/30/16 12:41 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . There were no further stools documented until 7/5/16 at 7:55 p.m. p. On 7/5/16 at 10:30 a.m., during initial rounds, the resident was in a wheelchair in his room. There was no isolation sign on the door, no personal protective equipment (gowns, gloves, etc.) outside the room and no isolation containers in the resident's room for contaminated items. q. On 7/5/16 at 1:40 p.m., a visitor was propelling the resident down the hallway from the end of the hall toward the nursing station. Certified Nurse Assistant (CNA #2) was in the hallway and asked the resident where he was going. The resident stated, Outside. r. On 7/5/16 at 2:45 p.m., CNAs #2 and #6 stated they worked on the hall where Resident #5 resided. CNAs #2 and #6 were asked, Are any residents in isolation on this hall? CNAs #2 and #6 stated, Kind of. CNA ##2 also stated (Resident #5) in (room number) - they didn't put him in isolation 'cause it's contained. CNAs #2 and #6 were asked, What's contained? CNA #2 stated, C diff, but he has a colostomy bag. CNAs #2 and #6 were asked, Do you wear gowns and gloves when emptying the colostomy? CNAs #2 and 6 stated, No, only gloves. s. The facility listing of Residents on Contact Isolation provided by Nurse Consultant on 7/8/16 at 11:45 a.m. documented isolation precautions were initiated for Resident #5 on 7/5/16, a period of approximately 26 days after the initial[DIAGNOSES REDACTED] positive lab results were received by the facility. t. On 7/8/16 at 1:30 p.m., the Assistant Director of Nursing (ADON), Director of Nursing (DON) and Nurse Consultant were asked, When was the resident first diagnosed with [REDACTED]. The ADON was asked, Did you isolate the resident? The ADON stated, No. The ADON was asked, Why not? The ADON stated, Contained in the colostomy bag. The ADON was asked, Do they always stay stuck? The ADON stated, No. The ADON was asked, Does someone have to change his colostomy bag? The ADON stated, Yes. The ADON was asked, If someone has to change the resident's colostomy bag or empty it, and they don't know he has[DIAGNOSES REDACTED], and they are not wearing PPE (Personal Protective Equipment) because the resident is not in isolation, what's going to happen? The ADON stated, It might spread. The ADON was asked, Did the resident have another positive culture for[DIAGNOSES REDACTED]? The ADON stated, 6/28/16. The ADON was asked, Did you isolate the resident? The ADON stated, No. The ADON was asked, Same reason why not? The ADON stated, Yes. 4. Failure to utilize dedicated equipment / supplies and/or properly disinfect any items removed from the resident's room during an active[DIAGNOSES REDACTED] infection: a. The July 2016 Physician order [REDACTED]. 4/22/16: .Suspected Deep Tissue Injury left heel, clean with saline, place Xeroform on heel, ABD (abdominal pad), and wrap with kerlix. Change dressing Monday, Wednesday, and Friday . 6/9/16: .Interval Code: (Monday, Wednesday, Friday) . Stage 3 Left ischial wound, clean with saline and place silver alginate dressing on wound. Cover with a foam dressing. Change dressing on Wednesday and Friday . 6/23/16: . Stage 2 distal right ischial wound clean with saline, place silver alginate on wound, covers with a foam dressing. Change (Monday, Wednesday, Friday) . b. On 7/6/16 at 10:50 a.m., the Treatment Nurse set up wound care supplies on a tray that was on top of the Treatment Cart. The Treatment Nurse put on a gown and gloves prior to entering the isolation room and carried the tray into the resident's room. The Treatment Nurse placed the tray on the over bed table with no barrier between the table top and the tray. After providing wound care, the Treatment Nurse removed her gown and gloves and lifted up the lid of the trash can with her hand, to place the gown and gloves into the overflowing trash can. The Treatment Nurse did not wash her hands prior to picking up the tray with wound care supplies and exiting the room. The Treatment Nurse exited the room with the tray that had scissors and a magic marker on it and placed the tray on the top of the Treatment cart, opened the cart with her unwashed hands, removed a sani-wipe from a container in the second drawer of the cart and cleaned the scissors with the sani-wipe. The Treatment Nurse then stated I have to go get bleach water to wipe off the tray and I forgot to wash my hands. The Treatment Nurse pulled the drawer with gowns open and removed a gown. The Treatment Nurse put a gown on, entered the room, went to the bathroom and washed her hands. The Treatment Nurse removed the gown and pushed it into the overflowing trash can, between the lid and the can, and left the room. The Treatment Nurse parked her treatment cart and went to the kitchen for bleach and a cup, went to the Northwest nursing station, then back to kitchen for a container to mix bleach with water. The Treatment Nurse poured one cup of bleach and 8 cups of water into the container and returned the bleach to the kitchen. The Treatment Nurse took the cleaning solution to her treatment cart, put on gloves, and used a washcloth placed in the cleaning solution to clean the scissors, magic marker, and the top and bottom of the tray. The Treatment Nurse was asked, Are you done cleaning? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, Did you clean the top of the treatment cart where you sat the tray? The Treatment Nurse stated, No. The Treatment Nurse also failed to clean the PPE cart drawer that she opened, the treatment cart drawer pull where she opened it to get out sani-wipes and the treatment cart lock handle. c. On 7/6/16 at 1:45 p.m., the Treatment Nurse was asked, for Resident #5's isolation room, if a step pedal trash can was in use. The Treatment Nurse stated, Trash can with a lid. The Treatment Nurse was asked, Did the lid seal the trash can? The Treatment Nurse stated, No, because I kept sticking stuff into it under the lid. 5. Resident #6 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/2/16 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the BIMS, required extensive assistance of two-plus persons for toilet use, was frequently incontinent of bowel and had no Clostridium Difficile. a. New Bowel Report Roster entries dated 6/23/16 documented the following: 1.) 6/23/16 1:41 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/23/16 9:42 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . b. The Departmental Notes dated 6/23/16 at 10:26 a.m. documented, New orders . [DIAGNOSES REDACTED] on stool for loose stools with odor . Samples collected . c. A physician's orders [REDACTED]. (Verbal Order) (Advanced Practice Nurse #1) / (Licensed Practical Nurse (LPN) #3). d. A Laboratory Report dated 6/25/16 documented, .Collected: 6/23/16 10:18 a.m. Reported: 6/25/16 1:47 p.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak . Called + (positive) [DIAGNOSES REDACTED] to (LPN #7) (at) 1:40 a.m. 6/25/16 . 1.) On 7/5/16 at 3:26 p.m., LPN #7 was asked, Did the lab notify you of the positive[DIAGNOSES REDACTED] results on 6/25/16 for (Resident #6)? LPN #7 stated, Yes, and I notified the nurse that was taking care of him (LPN #2). 2.) On 7/6/16 at 6:50 a.m., LPN # 2 was asked, On 6/25/16, the lab notified (LPN #7) of positive[DIAGNOSES REDACTED], and she says she informed you. Do you recall that? LPN #2 stated, Yes. LPN #2 was asked, What did you do? LPN # 2 stated, I called the doctor. LPN #2 was asked, Can you show me where that is charted? At 6:55 a.m., LPN #2 left to go to the computer to print Departmental Notes. At 6:57 a.m., LPN #2 returned and stated, The only thing I see in the notes was the weekly summary. I will tell you on the call they told me to put it (lab report) on the list and the APN (Advanced Practice Nurse) would address it in the morning. LPN #2 was asked, Do you recall who you talked to? LPN #2 stated, I believe it was (Physician #1) that night. When they do that, I don't chart because there is no resolution for that. LPN #2 was asked, You knew the resident was positive for[DIAGNOSES REDACTED]? LPN #2 stated, Yes. LPN # 2 was asked, Did you start isolation? LPN # 2 stated, No, I didn't. LPN # 2 was asked, Should the resident have been in isolation? LPN # 2 stated, Yes. e. New Bowel Report Roster entries dated 6/25/16 through 6/28/16 documented the following: 1.) 6/25/16 10:13 p.m. Size: Extra Large . Consistency: Soft Formed . 2.) 6/26/16 6:04 a.m. Size: Medium . Consistency: Soft Formed . 3.) 6/26/16 9:09 a.m. Size: Large . Consistency: Soft Formed . 4.) 6/27/16 8:32 p.m. Size: Large . Consistency: Soft Formed. Consistency: Watery Liquid - Nurse Notified . 5.) 6/28/16 2:38 p.m. Size: Large . Consistency: Soft Formed . f. A physician's orders [REDACTED]. times 14 days .C. diff. This was a period of 3 days after the positive[DIAGNOSES REDACTED] results were available to the facility. g. A New Bowel Report Roster entry dated 6/29/16 at 1:35 a.m. documented, .Size: Medium . Consistency: Soft Formed . h. A Departmental Note dated 6/29/16 at 10:14 a.m. documented, New order for [MEDICATION NAME] (every) 8 hours for[DIAGNOSES REDACTED] left at front nurses station dated 6/28/16. Order found on 6/29/16 . i. New Bowel Report Roster entries dated 6/29/16 through 7/5/16 documented the following: 1.) 6/29/16 9:15 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/29/16 11:46 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 3.) 6/30/16 1:58 p.m. Size: Medium . Consistency: Soft Formed . 4.) 7/2/16 10:52 a.m. Size: Large . Consistency Watery Liquid - Nurse Notified . 5.) 7/2/16 7:54 p.m. Size: Large . Consistency: Soft Formed . 6.) 7/3/16 9:51 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 7.) 7/3/16 9:42 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 8.) 7/4/16 6:16 a.m. Size: Large . Consistency: Soft Formed . 9.) 7/4/16 10:14 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 10.) 7/4/16 10:33 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 11.) 7/5/16 10:33 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . j. On 7/5/16 at 11:27 a.m., during initial rounds, Certified Nurse Assistants (CNAs) #4 and #5 were present in the resident's room and stated they were cleaning the resident. The resident's room smelled of stool and had a foul odor. CNAs #4 and #5 were not wearing gowns or gloves at this time. 1.) At 2:35 p.m., CNA #4 was asked, Any residents on isolation on this hall (hall on which Resident #6 resided)? CNA # 4 stated, No. CNA #4 was asked, Is (Resident #6) in isolation? CNA #4 stated, No. CNA #4 was asked, Is he having diarrhea? CNA #4 stated, Yes, he had a couple today. CNA #4 was asked, What were you doing when I made rounds? CNA #4 stated, Cleaning him up. CNA #4 was asked, Why? CNA #4 stated, Cause he had loose stools. CNA #4 was asked, Were you wearing a gown and gloves? CNA #4 stated, No, just gloves. 2.) On 7/5/16 at 2:40 p.m., CNA #5 was asked, Any residents on isolation on this hall (hall on which Resident # 6 resided)? CNA #5 stated, (Resident # 6) is supposed to be in isolation; he has loose bowels. CNA #5 was asked, Why (is he) supposed to be? CNA #5 stated, Cause of the loose stools, but there are no kits. CNA #5 was asked, Kits? CNA #5 stated, No gown or glove containers - he has[DIAGNOSES REDACTED]. CNA #5 was asked, You've been caring for him today? CNA #5 stated, Yes, I've cleaned him up. CNA #5 was asked, Did you have on a gown and gloves? CNA #5 stated, Gloves, but no gowns. k. On 7/5/16 at 11:40 a.m., the resident stated, Right now, I have a contagious bowel problem . The resident was asked, What kind of contagious bowel problem? The resident stated, C-diff. There was no isolation sign on the door, no personal protective equipment outside the room and no isolation containers in the resident's room for contaminated items. l. On 7/5/16 at 2:43 p.m., LPN #3, the charge assigned to Resident #6, was asked, Any residents on your halls in isolation? LPN #3 stated, We do have two people with[DIAGNOSES REDACTED], but they are not in isolation, (Resident #2) and (Resident #6). LPN #3 was asked, Why are they not in isolation? LPN #3 stated, They are contained in their room. They don't leave their rooms. LPN #3 was asked, Do they have roommates? LPN #3 stated, Yes. LPN #3 was asked, Do their roommates have [DIAGNOSES REDACTED]? LPN #3 stated, No. m. The facility listing of Residents in Contact Isolation, provided by the Nurse Consultant on 7/8/16 at 11:45 a.m. documented isolation was started for Resident #6 on 7/5/16. 6. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/3/16 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the BIMS, required extensive assistance of two-plus persons for toilet use, was frequently incontinent of bowel and had no Clostridium Difficile. a. New Bowel Report Roster entries dated 6/27/16 and 6/28/16 documented as follows: 1.) 6/27/16 8:31 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/28/16 1:46 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 3.) 6/28/16 2:28 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . b. Departmental Notes dated 6/28/16 at 2:08 a.m. and electronically signed by LPN #1 documented, Resident complaint of diarrhea . Resident having loose stools that is red blood tinged. (Physician) notified . c. A physician's orders [REDACTED]. d. New Bowel Report Roster entries dated 6/28/16 through 6/30/16 documented the following: 1.) 6/28/16 5:28 p.m. Size: Large . Consistency: Soft Formed . 2.) 6/29/16 1:29 a.m. Size: Large . Consistency: Soft Formed . 3.) 6/29/16 9:25 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 6/29/16 11:44 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 5.) 6/30/16 1:55 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 6.) 6/30/16 9:19 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . e. A Laboratory Report dated 6/30/16 documented, .Collected: 6/30/16 4:00 a.m. Reported: 6/30/16 9:33 p.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak .[DIAGNOSES REDACTED] called to (LPN #2) (at) 9:33 p.m. on 6/30/16 . On 7/6/16 at 6:50 a.m., LPN # 2 was asked, On 6/30/16, do you recall being notified of (Resident #2's) positive[DIAGNOSES REDACTED]? LPN # 2 stated I do not. f. New Bowel Report Roster entries dated 7/1/16 and 7/2/16 documented as follows: 1.) 7/1/16 2:15 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 2.) 7/1/16 1:07 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . 3.) 7/1/16 9:30 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 7/2/16 1:33 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 5.) 7/2/16 2:47 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 6.) 7/2/16 6:25 p.m. Size: Medium . Consistency: Soft formed . g. The Departmental Notes dated 7/2/16 at 1:42 a.m. and electronically signed by LPN #1 documented, Positive [DIAGNOSES REDACTED] stool culture obtained on previous shift on (7/1/16). No new orders at this time . Addendum: 7/2/16 7:09 a.m. New orders received from (Advanced Practice Nurse # 1) for [MEDICATION NAME] 500 (milligrams) . This was a period of 2 days after the positive[DIAGNOSES REDACTED] results were available to the facility. On 7/6/16 at 6:35 a.m., LPN #1 was asked, The [MEDICATION NAME] order, did you call the physician to get this order? LPN # 1 stated, No, I worked the 11:00 p.m. to 7:00 a.m. shift and I checked the APN (Advanced Practice Nurse) clipboard, and there was nothing on the clipboard regarding antibiotics, but when I checked it again before I left at 7:00 a.m. on 7/2/16, the APN had been in and wrote an order for [REDACTED].#1 was asked, You knew the [MEDICATION NAME] was to treat[DIAGNOSES REDACTED]? LPN #1 stated, Yes. LPN #1 was asked, Did you place the resident in isolation? LPN #1 stated, I told (LPN #3) the day shift charge nurse, because I was going home. LPN #1 was asked, Was the resident in isolation on 7/4/16 when you worked 11:00 p.m. to 7:00 a.m.? LPN #1 stated, No. LPN #1 was asked, If a resident has[DIAGNOSES REDACTED] shouldn't they be isolated? LPN #1 stated, That was my understanding. LPN #1 was asked, Do you know why the resident was not on isolation? LPN #1 stated, It's hard for me on night shift to have access to the barrels and isolation supplies. h. New Bowel Report Roster entries dated 7/3/16 and 7/4/16 documented as follows: 1.) 7/3/16 2:40 p.m. Size: Large . Consistency: Soft Formed . 2.) 7/3/16 9:37 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 3.) 7/4/16 2:47 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 4.) 7/4/16 1:56 p.m. Size: Medium . Consistency: Soft Formed . i. On 7/5/16 at 11:28 a.m., during initial rounds, the resident was not in his room. No isolation sign was on the door, no personal protective equipment (PPE) was present outside the entrance to the room, and no isolation containers were present in the resident's room. j. On 7/5/16 at 12:12 p.m., the resident was in a wheelchair in the main dining room. k. On 7/5/16 at 2:35 p.m., CNA #4 was asked, Any residents on isolation on this hall (hall on which Resident #2 resided)? CNA # 4 stated, No. l. On 7/5/16 at 2:40 p.m., CNA #5 was asked, Any residents on isolation on this hall (hall on which Resident #2 resided)? CNA # 5 stated, (Resident #6) is supposed to be in isolation; he has loose bowels. m. On 7/5/16 at 2:43 p.m., LPN #3, the charge nurse for Resident #2, was asked, Any residents on your halls in isolation? LPN #3 stated, We do have two people with[DIAGNOSES REDACTED], but they are not in isolation, (Resident #2) and (Resident #6). LPN #3 was asked, Why are they not in isolation? LPN #3 stated, They are contained in their room. They don't leave their rooms. LPN #3 was asked, Do they have roommates? LPN #3 stated, Yes. LPN #3 was asked, Do their roommates have [DIAGNOSES REDACTED]? LPN #3 stated, No. n. The facility listing of Residents in Contact Isolation, provided by the Nurse Consultant on 7/8/16 at 11:45 a.m. documented isolation was started for Resident

Based on observation, record review and interview, the facility's nursing administration failed to promptly identify and take measures to correct the lack of an effective Infection Control Program to address the prompt identification, isolation and prevention of the potential spread of [MEDICAL CONDITIONS] infections, as evidenced by: failure to ensure contact isolation precautions for [MEDICAL CONDITION] (including cohorting of residents with [MEDICAL CONDITION], staff utilization of personal protective equipment (PPE), utilization of dedicated equipment and supplies and proper disinfection of any equipment / supplies removed from the residents' rooms) were initiated, were consistently followed and were maintained until the infection was resolved for residents who tested positive for [MEDICAL CONDITION] to prevent potential spread to other residents for 5 of 5 (Residents #2, #3, #5, #6 and #7) case mix residents who had positive [MEDICAL CONDITION] cultures in the past 3 months; failure to ensure housekeeping staff was informed of any residents who were [MEDICAL CONDITION] positive and that the appropriate disinfection procedures and products were consistently utilized when cleaning the rooms of residents with [MEDICAL CONDITION] to prevent the potential spread of [MEDICAL CONDITION] throughout the facility; and, failure to ensure [MEDICAL CONDITION] infections were accurately documented, tracked and trended on the Infection Control Long, to enable detection of any patterns of infection and facilitate the evaluation of procedures and staff practices that might contribute to the spread of infection for 2 of 3 months reviewed. The failed practices resulted in Immediate Jeopardy, which caused or could have caused serious harm, injury or death to Residents 2, #3, #5, #6 and #7, who had positive [MEDICAL CONDITION] cultures and were not isolated and treated promptly to prevent potential complications of [MEDICAL CONDITIONS] and possible death, and had the potential to expose all 130 residents who resided in the facility to potential [MEDICAL CONDITION] infection, according to the Resident List received from the Nurse Consultant on 7/5/16 at 9:45 a.m., including 18 residents who were diagnosed with [REDACTED]. The facility was notified of the Immediate Jeopardy condition on 7/5/16 at 5:00 p.m. The findings are: 1. The Director of Nursing Job Description, provided by the Administrator on 7/6/16, documented .Essential Job Functions: A. Administrative Functions: 1. Plan, develop, organize, implement, evaluate and direct the Nursing Service Department, it's programs and activities . B. Nursing Care Functions . 4. Monitor resident's treatment and medications to ensure residents are receiving proper care . C. Staff Training and Development Functions . 5. Ensure that all nursing services personnel attend and participate in . Infection Control and Standard Precautions training programs . 2. The Assistant Director of Nursing Job Description, provided by the Administrator on 7/6/16, documented, .Essential Job Functions: A. Administrative Functions: 1. Perform all duties outlined in Director of Nursing (job) description in absence of DON. 2. Participate with the Director of Nursing in planning, organizing, and directing Nursing Services . 8. Conduct daily compliance rounds . D. Staff Training and Development Functions . 5. Ensure that all nursing services personnel attend and participate in . Infection Control and Standard Precautions training programs . 3. The Center for Disease Control (CDC) web site at http://www.cdc.gov/HAI/organisms/cdiff/Cdiff_faqs_HCP.html#a10 documented, How can [MEDICAL CONDITION] infection be prevented in hospitals and other healthcare settings? .Use Contact Precautions: for patients with known or suspected [MEDICAL CONDITION] infection: Place these patients in private rooms. If private rooms are not available, these patients can be placed in rooms (cohorted) with other patients with [MEDICAL CONDITION] infection. Use gloves when entering patients' rooms and during patient care . Perform Hand Hygiene after removing gloves . Use gowns when entering patients' rooms and during patient care. Continue these precautions until diarrhea ceases. Because [MEDICAL CONDITION]-infected patients continue to shed organism for a number of days following cessation of diarrhea, some institutions routinely continue isolation for either several days beyond symptom resolution or until discharge, depending upon the type of setting and average length of stay. Implement an environmental cleaning and disinfection strategy: Ensure adequate cleaning and disinfection of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently. Consider using an Environmental Protection Agency (EPA)-registered disinfectant with a sporicidal claim for environmental surface disinfection after cleaning in accordance with label instructions; generic sources of hypochlorite (e.g. (for example), household chlorine bleach) also may be appropriately diluted and used. (Note: Standard EPA-registered hospital disinfectants are not effective against [MEDICAL CONDITION] spores.) Hypochlorite-based disinfectants may be most effective in preventing [MEDICAL CONDITION] transmission in units with high endemic rates of [MEDICAL CONDITION] infection . Recommended infection control practices in long term care and home health settings are similar to those practices taken in traditional health-care settings . 4. The facility's policy titled, Fact Sheets - [MEDICAL CONDITIONS] ([MEDICAL CONDITION]-Resistant Staphylococcus aureus), VRE ([MEDICATION NAME]-Resistant [MEDICATION NAME]), documented, [MEDICAL CONDITION] . Precautions: Contact while having diarrhea. Room considerations: Infected residents should be placed in private rooms or cohorted . Discontinue Precautions: When diarrhea ceases (less than 3 episodes in 24 hours) . [DIAGNOSES REDACTED]icile is a spore-forming organism, environmental contamination frequently occurs . Because there are no EPA-registered products that are specific for inactivating [MEDICAL CONDITION] spores, CDC recommends use of hypochlorite- based products for disinfection of environmental surfaces . 5. Resident #5 had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/30/16 documented the resident scored 10 (8 - 12 indicates moderately impaired) on the Brief Interview for Mental Status BIMS), required extensive assistance with toilet use, had an ostomy and had [MEDICAL CONDITION]. Failure to promptly initiate isolation precautions and treatment for [REDACTED].>a. A physician's orders [REDACTED]. change (every) 3 days . b. The New Bowel Report Roster documented the following entries from 6/4/16 through 6/7/16: 1.) 6/4/16 8:41 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 2.) 6/5/16 4:07 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 3.) 6/5/16 8:22 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 6/6/16 2:44 p.m. Size: Medium . Consistency: Soft Formed . 5.) 6/6/16 9:56 p.m. Size: Large . Consistency: Soft Formed . 6.) 6/7/16 5:37 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 7.) 6/7/16 1:12 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . c. A Laboratory Report dated 6/9/16 documented, .Collected: 6/7/16 9:00 p.m. Reported: 6/9/16 10:30 p.m. Stool type: Semi-solid .[DIAGNOSES REDACTED]icile/Epi . Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second is for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak . d. Departmental Notes dated 6/8/16 at 5:22 a.m. documented, [MEDICAL CONDITION] . change . Resident was found lying in bed with eyes closed and [MEDICAL CONDITION] bag pulled off . e. The New Bowel Report Roster documented the following entries from the afternoon of 6/8/16 through the evening of 6/11/16: 1.) 6/8/16 2:18 p.m.Size: Medium . Consistency: Soft Formed . 2.) 6/8/16 at 9:30 p.m.Size: Small . Consistency: Soft Formed . 3.) 6/9/16 4:02 a.m. Size: Small . Consistency: Soft Formed . 4.) 6/9/16 1:32 p.m. Size: Medium . Consistency: Soft Formed . 5.) 6/9/16 6:44 p.m. Size: Medium . Consistency: Soft Formed . 6.) 6/10/16 10:45 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 7.) 6/11/16 4:03 a.m. Size: Large . Consistency: Soft Formed . 8.) 6/11/16 2:18 p.m. Size: Medium . Consistency: Soft Formed . 9.) 6/11/16 7:10 p.m. Size: Large . Consistency: Soft Formed . Consistency: Watery Liquid - Nurse Notified . 10.) 6/11/16 8:24 p.m. Size: Extra Large . Consistency: Soft Formed . Consistency: Watery Liquid - Nurse Notified . f. A physician's orders [REDACTED]. for 10 days. This was a period of 2 days after the resident's [MEDICAL CONDITION] cultures were determined by the lab provider to be positive. The June 2016 Medication Administration Record [REDACTED]. g. The New Bowel Report Roster entries dated 6/12/16 through 6/24/16 documented the resident had 0 to 2 soft formed stools per day. h. Departmental Notes dated 6/25/16 at 10:15 a.m. documented, Resident has stool that has the appearance of[DIAGNOSES REDACTED]. Notified (Advanced Practice Nurse). New order received for[DIAGNOSES REDACTED] (culture) . i. A New Bowel Report Roster entry dated 6/26/16 at 10:58 a.m. documented, Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . j. A New Bowel Report Roster entry dated 6/27/16 at 10:43 p.m. documented, .Size: Medium . Consistency: Soft Formed . k. A Laboratory Report dated 6/28/16 documented, .Collected: 6/26/16 10:30 a.m. Reported: 6/28/16 2:05 a.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of a 027-NAP1-BI outbreak . A form titled New Bowel Report Roster documented, 6/28/16 3:54 a.m. Size: Large . Consistency: Soft Formed . l. Departmental Notes dated 6/28/16 at 3:57 a.m. documented, Call received from (laboratory), stool sample positive for[DIAGNOSES REDACTED] . APN notified. The note did not document the method by which the APN was notified, and there was no documentation of new orders for treatment of [REDACTED]. m. New Bowel Report Roster entries dated 6/28/16 through 6/19/16 documented the following: 1.) 6/28/16 9:50 a.m. Size: Large . Consistency: Soft Formed . 2.) 6/28/16 3:13 p.m. Size: Medium . Consistency: Soft Formed . 3.) 6/28/16 9:28 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . 4.) 6/29/16 12:30 a.m. Size: Medium . Consistency: Soft Formed . n. Departmental Notes dated 6/29/16 at 9:29 a.m. and electronically signed by LPN #4 documented, Received[DIAGNOSES REDACTED] (culture) stating that resident is positive for[DIAGNOSES REDACTED]. Notified (Advance Practice Nurse). New orders for [MEDICATION NAME] . On 7/8/16 at 9:20 a.m., LPN # 4 was asked, Was (Resident #5) in isolation in June 2016? LPN # 4 stated, No, I was told it was contained. o. New Bowel Report Roster entries dated 6/29/16 through 6/30/16 documented the following: 1.) 6/29/16 9:57 a.m. Size: Extra Large . Consistency: Soft Formed . 2.) 6/29/16 9:14 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 3.) 6/30/16 12:41 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . There were no further stools documented until 7/5/16 at 7:55 p.m. p. On 7/5/16 at 10:30 a.m., during initial rounds, the resident was in a wheelchair in his room. There was no isolation sign on the door, no personal protective equipment (gowns, gloves, etc.) outside the room and no isolation containers in the resident's room for contaminated items. q. On 7/5/16 at 1:40 p.m., a visitor was propelling the resident down the hallway from the end of the hall toward the nursing station. Certified Nurse Assistant (CNA #2) was in the hallway and asked the resident where he was going. The resident stated, Outside. r. On 7/5/16 at 2:45 p.m., CNAs #2 and #6 stated they worked on the hall where Resident #5 resided. CNAs #2 and #6 were asked, Are any residents in isolation on this hall? CNAs #2 and #6 stated, Kind of. CNA ##2 also stated (Resident #5) in (room number) - they didn't put him in isolation 'cause it's contained. CNAs #2 and #6 were asked, What's contained? CNA #2 stated, C diff, but he has a [MEDICAL CONDITION] bag. CNAs #2 and #6 were asked, Do you wear gowns and gloves when emptying the [MEDICAL CONDITION]? CNAs #2 and 6 stated, No, only gloves. s. The facility listing of Residents on Contact Isolation provided by Nurse Consultant on 7/8/16 at 11:45 a.m. documented isolation precautions were initiated for Resident #5 on 7/5/16, a period of approximately 26 days after the initial [MEDICAL CONDITION] positive lab results were received by the facility. t. On 7/8/16 at 1:30 p.m., the Assistant Director of Nursing (ADON), Director of Nursing (DON) and Nurse Consultant were asked, When was the resident first diagnosed with [REDACTED]. The ADON was asked, Did you isolate the resident? The ADON stated, No. The ADON was asked, Why not? The ADON stated, Contained in the [MEDICAL CONDITION] bag. The ADON was asked, Do they always stay stuck? The ADON stated, No. The ADON was asked, Does someone have to change his [MEDICAL CONDITION] bag? The ADON stated, Yes. The ADON was asked, If someone has to change the resident's [MEDICAL CONDITION] bag or empty it, and they don't know he has[DIAGNOSES REDACTED], and they are not wearing PPE (Personal Protective Equipment) because the resident is not in isolation, what's going to happen? The ADON stated, It might spread. The ADON was asked, Did the resident have another positive culture for[DIAGNOSES REDACTED]? The ADON stated, 6/28/16. The ADON was asked, Did you isolate the resident? The ADON stated, No. The ADON was asked, Same reason why not? The ADON stated, Yes. 6. Failure to utilize dedicated equipment / supplies and/or properly disinfect any items removed from the resident's room during an active [MEDICAL CONDITION] infection: a. The July 2016 Physician order [REDACTED]. 4/22/16: .Suspected Deep Tissue Injury left heel, clean with saline, place Xeroform on heel, ABD (abdominal pad), and wrap with kerlix. Change dressing Monday, Wednesday, and Friday . 6/9/16: .Interval Code: (Monday, Wednesday, Friday) . Stage 3 Left ischial wound, clean with saline and place silver alginate dressing on wound. Cover with a foam dressing. Change dressing on Wednesday and Friday . 6/23/16: . Stage 2 distal right ischial wound clean with saline, place silver alginate on wound, covers with a foam dressing. Change (Monday, Wednesday, Friday) . b. On 7/6/16 at 10:50 a.m., the Treatment Nurse set up wound care supplies on a tray that was on top of the Treatment Cart. The Treatment Nurse put on a gown and gloves prior to entering the isolation room and carried the tray into the resident's room. The Treatment Nurse placed the tray on the over bed table with no barrier between the table top and the tray. After providing wound care, the Treatment Nurse removed her gown and gloves and lifted up the lid of the trash can with her hand, to place the gown and gloves into the overflowing trash can. The Treatment Nurse did not wash her hands prior to picking up the tray with wound care supplies and exiting the room. The Treatment Nurse exited the room with the tray that had scissors and a magic marker on it and placed the tray on the top of the Treatment cart, opened the cart with her unwashed hands, removed a sani-wipe from a container in the second drawer of the cart and cleaned the scissors with the sani-wipe. The Treatment Nurse then stated I have to go get bleach water to wipe off the tray and I forgot to wash my hands. The Treatment Nurse pulled the drawer with gowns open and removed a gown. The Treatment Nurse put a gown on, entered the room, went to the bathroom and washed her hands. The Treatment Nurse removed the gown and pushed it into the overflowing trash can, between the lid and the can, and left the room. The Treatment Nurse parked her treatment cart and went to the kitchen for bleach and a cup, went to the Northwest nursing station, then back to kitchen for a container to mix bleach with water. The Treatment Nurse poured one cup of bleach and 8 cups of water into the container and returned the bleach to the kitchen. The Treatment Nurse took the cleaning solution to her treatment cart, put on gloves, and used a washcloth placed in the cleaning solution to clean the scissors, magic marker, and the top and bottom of the tray. The Treatment Nurse was asked, Are you done cleaning? The Treatment Nurse stated, Yes. The Treatment Nurse was asked, Did you clean the top of the treatment cart where you sat the tray? The Treatment Nurse stated, No. The Treatment Nurse also failed to clean the PPE cart drawer that she opened, the treatment cart drawer pull where she opened it to get out sani-wipes and the treatment cart lock handle. c. On 7/6/16 at 1:45 p.m., the Treatment Nurse was asked, for Resident #5's isolation room, if a step pedal trash can was in use. The Treatment Nurse stated, Trash can with a lid. The Treatment Nurse was asked, Did the lid seal the trash can? The Treatment Nurse stated, No, because I kept sticking stuff into it under the lid. 7. Resident #6 had a [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 6/2/16 documented the resident scored 14 (13 - 15 indicates cognitively intact) on the BIMS, required extensive assistance of two-plus persons for toilet use, was frequently incontinent of bowel and had no [MEDICAL CONDITION]. a. New Bowel Report Roster entries dated 6/23/16 documented the following: 1.) 6/23/16 1:41 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/23/16 9:42 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . b. The Departmental Notes dated 6/23/16 at 10:26 a.m. documented, New orders . [DIAGNOSES REDACTED] on stool for loose stools with odor . Samples collected . c. A physician's orders [REDACTED]. (Verbal Order) (Advanced Practice Nurse #1) / (Licensed Practical Nurse (LPN) #3). d. A Laboratory Report dated 6/25/16 documented, .Collected: 6/23/16 10:18 a.m. Reported: 6/25/16 1:47 p.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of an 027-NAP1-BI outbreak . Called + (positive) [DIAGNOSES REDACTED] to (LPN #7) (at) 1:40 a.m. 6/25/16 . 1.) On 7/5/16 at 3:26 p.m., LPN #7 was asked, Did the lab notify you of the positive [MEDICAL CONDITION] results on 6/25/16 for (Resident #6)? LPN #7 stated, Yes, and I notified the nurse that was taking care of him (LPN #2). 2.) On 7/6/16 at 6:50 a.m., LPN # 2 was asked, On 6/25/16, the lab notified (LPN #7) of positive [MEDICAL CONDITION], and she says she informed you. Do you recall that? LPN #2 stated, Yes. LPN #2 was asked, What did you do? LPN # 2 stated, I called the doctor. LPN #2 was asked, Can you show me where that is charted? At 6:55 a.m., LPN #2 left to go to the computer to print Departmental Notes. At 6:57 a.m., LPN #2 returned and stated, The only thing I see in the notes was the weekly summary. I will tell you on the call they told me to put it (lab report) on the list and the APN (Advanced Practice Nurse) would address it in the morning. LPN #2 was asked, Do you recall who you talked to? LPN #2 stated, I believe it was (Physician #1) that night. When they do that, I don't chart because there is no resolution for that. LPN #2 was asked, You knew the resident was positive for [MEDICAL CONDITION]? LPN #2 stated, Yes. LPN # 2 was asked, Did you start isolation? LPN # 2 stated, No, I didn't. LPN # 2 was asked, Should the resident have been in isolation? LPN # 2 stated, Yes. e. New Bowel Report Roster entries dated 6/25/16 through 6/28/16 documented the following: 1.) 6/25/16 10:13 p.m. Size: Extra Large . Consistency: Soft Formed . 2.) 6/26/16 6:04 a.m. Size: Medium . Consistency: Soft Formed . 3.) 6/26/16 9:09 a.m. Size: Large . Consistency: Soft Formed . 4.) 6/27/16 8:32 p.m. Size: Large . Consistency: Soft Formed. Consistency: Watery Liquid - Nurse Notified . 5.) 6/28/16 2:38 p.m. Size: Large . Consistency: Soft Formed . f. A physician's orders [REDACTED]. times 14 days .C. diff. This was a period of 3 days after the positive [MEDICAL CONDITION] results were available to the facility. g. A New Bowel Report Roster entry dated 6/29/16 at 1:35 a.m. documented, .Size: Medium . Consistency: Soft Formed . h. A Departmental Note dated 6/29/16 at 10:14 a.m. documented, New order for [MEDICATION NAME] (every) 8 hours for [MEDICAL CONDITION] left at front nurses station dated 6/28/16. Order found on 6/29/16 . i. New Bowel Report Roster entries dated 6/29/16 through 7/5/16 documented the following: 1.) 6/29/16 9:15 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/29/16 11:46 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 3.) 6/30/16 1:58 p.m. Size: Medium . Consistency: Soft Formed . 4.) 7/2/16 10:52 a.m. Size: Large . Consistency Watery Liquid - Nurse Notified . 5.) 7/2/16 7:54 p.m. Size: Large . Consistency: Soft Formed . 6.) 7/3/16 9:51 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 7.) 7/3/16 9:42 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 8.) 7/4/16 6:16 a.m. Size: Large . Consistency: Soft Formed . 9.) 7/4/16 10:14 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 10.) 7/4/16 10:33 p.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 11.) 7/5/16 10:33 a.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . j. On 7/5/16 at 11:27 a.m., during initial rounds, Certified Nurse Assistants (CNAs) #4 and #5 were present in the resident's room and stated they were cleaning the resident. The resident's room smelled of stool and had a foul odor. CNAs #4 and #5 were not wearing gowns or gloves at this time. 1.) At 2:35 p.m., CNA #4 was asked, Any residents on isolation on this hall (hall on which Resident #6 resided)? CNA # 4 stated, No. CNA #4 was asked, Is (Resident #6) in isolation? CNA #4 stated, No. CNA #4 was asked, Is he having diarrhea? CNA #4 stated, Yes, he had a couple today. CNA #4 was asked, What were you doing when I made rounds? CNA #4 stated, Cleaning him up. CNA #4 was asked, Why? CNA #4 stated, Cause he had loose stools. CNA #4 was asked, Were you wearing a gown and gloves? CNA #4 stated, No, just gloves. 2.) On 7/5/16 at 2:40 p.m., CNA #5 was asked, Any residents on isolation on this hall (hall on which Resident # 6 resided)? CNA #5 stated, (Resident # 6) is supposed to be in isolation; he has loose bowels. CNA #5 was asked, Why (is he) supposed to be? CNA #5 stated, Cause of the loose stools, but there are no kits. CNA #5 was asked, Kits? CNA #5 stated, No gown or glove containers - he has [MEDICAL CONDITION]. CNA #5 was asked, You've been caring for him today? CNA #5 stated, Yes, I've cleaned him up. CNA #5 was asked, Did you have on a gown and gloves? CNA #5 stated, Gloves, but no gowns. k. On 7/5/16 at 11:40 a.m., the resident stated, Right now, I have a contagious bowel problem . The resident was asked, What kind of contagious bowel problem? The resident stated, [MEDICAL CONDITION]. There was no isolation sign on the door, no personal protective equipment outside the room and no isolation containers in the resident's room for contaminated items. l. On 7/5/16 at 2:43 p.m., LPN #3, the charge assigned to Resident #6, was asked, Any residents on your halls in isolation? LPN #3 stated, We do have two people with [MEDICAL CONDITION], but they are not in isolation, (Resident #2) and (Resident #6). LPN #3 was asked, Why are they not in isolation? LPN #3 stated, They are contained in their room. They don't leave their rooms. LPN #3 was asked, Do they have roommates? LPN #3 stated, Yes. LPN #3 was asked, Do their roommates have [DIAGNOSES REDACTED]? LPN #3 stated, No. m. The facility listing of Residents in Contact Isolation, provided by the Nurse Consultant on 7/8/16 at 11:45 a.m. documented isolation was started for Resident #6 on 7/5/16. 8. Resident #2 had [DIAGNOSES REDACTED]. The Quarterly MDS with an ARD of 4/3/16 documented the resident scored 15 (13 - 15 indicates cognitively intact) on the BIMS, required extensive assistance of two-plus persons for toilet use, was frequently incontinent of bowel and had no [MEDICAL CONDITION]. a. New Bowel Report Roster entries dated 6/27/16 and 6/28/16 documented as follows: 1.) 6/27/16 8:31 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 2.) 6/28/16 1:46 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 3.) 6/28/16 2:28 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . b. Departmental Notes dated 6/28/16 at 2:08 a.m. and electronically signed by LPN #1 documented, Resident complaint of diarrhea . Resident having loose stools that is red blood tinged. (Physician) notified . c. A physician's orders [REDACTED]. d. New Bowel Report Roster entries dated 6/28/16 through 6/30/16 documented the following: 1.) 6/28/16 5:28 p.m. Size: Large . Consistency: Soft Formed . 2.) 6/29/16 1:29 a.m. Size: Large . Consistency: Soft Formed . 3.) 6/29/16 9:25 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 6/29/16 11:44 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 5.) 6/30/16 1:55 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 6.) 6/30/16 9:19 p.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . e. A Laboratory Report dated 6/30/16 documented, .Collected: 6/30/16 4:00 a.m. Reported: 6/30/16 9:33 p.m. Stool type: Liquid .[DIAGNOSES REDACTED]icile/Epi, Xpert Positive/Positive . There are two results for this test. The first is for toxin producing [DIAGNOSES REDACTED]icile, the second it for presumptive identification of epidemic strain 027-NAP1-BI. Format is [DIAGNOSES REDACTED] result/epidemic strain result. The epidemic strain 027-NAP1-BI is known to produce a higher number of spores and toxins and has been identified as a cause of hospital outbreaks worldwide. The identification of a presumptive positive or negative Epi 027-NAP1-BI may aid in the identification of possible sources of a 027-NAP1-BI outbreak .[DIAGNOSES REDACTED] called to (LPN #2) (at) 9:33 p.m. on 6/30/16 . On 7/6/16 at 6:50 a.m., LPN # 2 was asked, On 6/30/16, do you recall being notified of (Resident #2's) positive [MEDICAL CONDITION]? LPN # 2 stated I do not. f. New Bowel Report Roster entries dated 7/1/16 and 7/2/16 documented as follows: 1.) 7/1/16 2:15 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 2.) 7/1/16 1:07 p.m. Size: Small . Consistency: Watery Liquid - Nurse Notified . 3.) 7/1/16 9:30 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 4.) 7/2/16 1:33 a.m. Size: Large . Consistency: Watery Liquid - Nurse Notified . 5.) 7/2/16 2:47 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 6.) 7/2/16 6:25 p.m. Size: Medium . Consistency: Soft formed . g. The Departmental Notes dated 7/2/16 at 1:42 a.m. and electronically signed by LPN #1 documented, Positive [DIAGNOSES REDACTED] stool culture obtained on previous shift on (7/1/16). No new orders at this time . Addendum: 7/2/16 7:09 a.m. New orders received from (Advanced Practice Nurse # 1) for [MEDICATION NAME] 500 (milligrams) . This was a period of 2 days after the positive [MEDICAL CONDITION] results were available to the facility. On 7/6/16 at 6:35 a.m., LPN #1 was asked, The [MEDICATION NAME] order, did you call the physician to get this order? LPN # 1 stated, No, I worked the 11:00 p.m. to 7:00 a.m. shift and I checked the APN (Advanced Practice Nurse) clipboard, and there was nothing on the clipboard regarding antibiotics, but when I checked it again before I left at 7:00 a.m. on 7/2/16, the APN had been in and wrote an order for [REDACTED].#1 stated, Yes. LPN #1 was asked, Did you place the resident in isolation? LPN #1 stated, I told (LPN #3) the day shift charge nurse, because I was going home. LPN #1 was asked, Was the resident in isolation on 7/4/16 when you worked 11:00 p.m. to 7:00 a.m.? LPN #1 stated, No. LPN #1 was asked, If a resident has [MEDICAL CONDITION] shouldn't they be isolated? LPN #1 stated, That was my understanding. LPN #1 was asked, Do you know why the resident was not on isolation? LPN #1 stated, It's hard for me on night shift to have access to the barrels and isolation supplies. h. New Bowel Report Roster entries dated 7/3/16 and 7/4/16 documented as follows: 1.) 7/3/16 2:40 p.m. Size: Large . Consistency: Soft Formed . 2.) 7/3/16 9:37 p.m. Size: Extra Large . Consistency: Watery Liquid - Nurse Notified . 3.) 7/4/16 2:47 a.m. Size: Medium . Consistency: Watery Liquid - Nurse Notified . 4.) 7/4/16 1:56 p.m. Size: Medium . Consistency: Soft Formed . i. On 7/5/16 at 11:28 a.m., during initial rounds, the resident was not in his room. No isolation sign was on the door, no personal protective equipment (PPE) was present out