Every finding on record at Exeter Center

Based on observation, interview, and record review, the facility failed to follow infection control policies and professional standards for hand hygiene, disinfection of equipment, enhanced barrier precaution (EBP), and urinary catheter maintenance for 1 of 1 resident reviewed for Transmission Based Precaution (TBP) and 2 of 2 residents reviewed for urinary catheter. (Resident identifiers are #8, #13, and #41.)Findings inclcude:Resident #8 Observation on 4/28/26 at approximately 9:48 a.m. of Resident #8 in his/her bed revealed that there was an urinary catheter bag on the floor next to the bed. Observation on 4/30/26 at approximately 8:19 a.m. of Resident #8 in his/her bed revealed that the urinary catheter bag was touching the edge of cushioned fall mat that was on the floor by Resident #8's bed. Interview on 4/30/26 at approximately 8:20 a.m. with Staff D (Licensed Nursing Assistant (LNA)) confirmed the above findings and further revealed that the urinary catheter bag should not be touching the fall mat or the floor. Observation on 4/30/26 at approximately 8:45 a.m. of Resident #8 in his/her bed revealed that the urinary catheter bag was on the edge of the cushioned fall mat by Resident #8's bed. Interview on 4/30/26 at approximately 9:42 a.m. With Staff M (RN) confirmed that the urinary catheter bag was on the edge of the cushioned fall mat and that the catheter should not be touching the fall mat or the floor. Interview on 4/30/26 at approximately 9:30 a.m. with Staff F (Market Lead Clinical Specialist) revealed that the facility followed Center for Disease Control (CDC) guidance for infection prevention. Review of CDC Guidelines for Prevention of Catheter Associated Urinary Tract Infections found at https://www.cdc.gov/infection-control/media/pdfs/Guideline-CAUTI-H.pdf revealed, .III. Proper Techniques for Urinary Catheter Maintenance . B. Maintain unobstructed urine flow.2. Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. Resident #13 Review on 4/28/26 of Resident #13's medical record revealed that Resident #13 had a physician's order for a urinary catheter for a medical diagnosis of neurogenic bladder. Further review of the medical record revealed a indwelling device care plan with an intervention for Enhanced Barrier Precautions (EBP). Observation on 4/28/26 at approximately 9:45 a.m. revealed that there was an EBP precautions sign outside Resident #13's room indicating that to wear gown and gloves (PPE) for high contact activities. Observation on 4/28/26 at approximately 11:50 a.m. revealed Staff F (RN) and an LNA entering Resident #13's room and repositioned Resident #13 while in bed. Further observation revealed that the two staff were wearing gloves and no gown. Interview on 4/28/026 at approximately 12:00 p.m. with Staff F (RN) confirmed the above observation. Staff F revealed that the Resident #13 was on EBP would require gloves and gown for high contact activities including repositioning in bed. Review of the facility's Procedure: Enhanced Barrier Precautions revealed, Enhanced barrier precautions applies to .indwelling medical devices (e.g urinary catheter .) . PPE use for these situations .During high contact care activities .Required PPE Gown, gloves prior to high contact activity. Resident #41 Review on 4/28/26 of Resident #41's active care plan for acute infection and at risk for sepsis related to gastrointestinal and positive Cryptosporidium antigen revealed an intervention for contact precautions. Review on 4/28/26 of Resident #41's Ova and Parasite (O&P) microscopic examination and Enzyme Immunoassay (EIA) antigen test report, dated 4/18/26, revealed a positive result for the Cryptosporidium antigen. Observation on 4/28/2026 at approximately 11:56 a.m. in Resident #41's room revealed a contact precaution sign was posted outside the room. The sign indicated staff, families, and visitors to clean their hands before entering and leaving the room (using hand sanitizer or soap and water), to wear a gown and gloves, and to clean and disinfect any shared equipment before using it with another patient. Further observation revealed Staff L (Phlebotomy Technician) was inside Resident #41's room seated in a chair with a black case (blood draw supplies), wearing gloves and a mask, and not wearing a gown. Staff L then obtained a gown from the PPE cart outside of Resident #41's room and donned it. Approximately a few minutes later, Staff L removed the gown, gloves, and mask, performed hand hygiene using the alcohol-based hand rub (ABHR), and exited the room carrying the black case without disinfecting it. Staff L did not wash their hands with soap and water after doffing PPE. Interview on 4/28/26 at approximately 12:00 p.m. with Staff L confirmed the above mentioned observations. Staff L revealed that they were in Resident #41's room to obtain a blood draw and that they did not have contact with Resident #41 prior to donning a gown. Staff L also revealed that the black case was storage for their blood draw supplies. Observation on 4/29/26 at approximately 9:30 a.m. with Staff J (Registered Nurse (RN)) during Resident #41's medication administration revealed Staff J donned a gown and gloves before entering Resident #41's room and brought in a non invasive vital signs monitor along with the resident's morning medications. Staff J obtained Resident #41's temperature using a handheld thermometer and measured blood pressure, heart rate, and oxygen saturation using the non invasive vital signs monitor. Staff J then administered the resident's morning medications. After completing the tasks, Staff J doffed the gown and gloves, performed hand hygiene with ABHR, exited the room with the vital signs monitor, placed the monitor outside Resident #41's room, went to the nurse's station to obtain a CaviWipes1 (tuberculocidal, bactericidal, virucidal, and fungicidal) disinfectant wipe, and returned to disinfect the vital signs monitor, its wires, its legs, and the handheld thermometer. Interview on 4/29/26 at approximately 9:50 a.m. with Staff J confirmed the above observations on 4/29/26. Staff J was unable to explain whether CaviWipes1 was an appropriate disinfectant for cleaning the vital signs monitor and the handheld thermometer. Interview on 4/30/26 at approximately 8:32 a.m. with Staff K (Infection Preventionist) revealed that Resident #41 was on contact precautions for Cryptosporidium. Staff K stated that public health had been contacted and advised the use of 3 percent hydrogen peroxide for disinfecting equipment. Staff K also confirmed that 3 percent hydrogen peroxide was available for this purpose. Interview further revealed that CaviWipes1 was not an appropriate disinfectant for the vital signs monitor and that handwashing with soap and water was the correct method of hand hygiene for Resident #41's Cryptosporidium infection. Review on 4/30/26 of the CDC website titled, Preventing Crypto [Cryptosporidiosis infection], dated 5/8/25, retrieved from: https://www.cdc.gov/cryptosporidium/prevention/index.html, revealed, .Practice Good Hygiene .Alcohol-based hand sanitizers are not effective against Crypto. Washing hands at key times with soap and water can help prevent infections. Note: When cleaning items and surfaces, no disinfectant is guaranteed to be completely effective against Crypto. However, hydrogen peroxide is more effective than standard bleach solutions . Review on 4/30/26 of the facility policy titled, Cleaning and Disinfecting, revision date 5/1/25, revealed, .Cleaning/Disinfecting rooms/surfaces according to specific (Transmission Based) precautions and by using an appropriate EPA-approved [Environmental Protection Agency] disinfectant for the organism involved . Review on 4/30/26 of the CDC website titled, Transmission-Based Precautions, dated 4/3/24, revealed, .Use Contact Precautions for patients with known or suspected infections that represent an increased risk for contact transmission .Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens . Review on 4/30/26 of the facility's policy titled, Transmission Based Precautions, revision date 5/1/25, revealed, .Staff will apply Transmission Based Precautions, in addition to standard Precautions, to patients who are known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2. The Center will use standard approached, as defined by the Centers for Disease Control and Prevention (CDC), for Transmission Based Precautions: Airborne, Contact, and Droplet Precautions. The category of Transmission Based Precautions will determine the type of personal protective equipment (PPE) to be used .Contact Precautions .Healthcare personnel caring for patients on Contact Precautions ear a gown and gloves in all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. 9.4 Donning PPE upon entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination .noroviruses and other intestinal tract pathogens .

Based on observation, interview, and record review, the facility failed to obtain laboratory services as ordered for 1 of 1 residents reviewed for anticoagulant in a final sample of 18 residents. (Resident identifier is #5.)Findings include:Review on 4/28/26 of Resident #5's medical record revealed a physician's orders for an International Normalized Ratio (INR) to be drawn on 4/27/26. Further review of the medical record under laboratory (lab) results revealed that there was no INR laboratory report on 4/27/26.Review on 4/29/26 of Resident #5's After-Hours Telehealth Consult note, dated 4/26/26, revealed that Resident #5's INR was subtherapeutic from lab results for 4/26/26 and that the provider ordered a repeat INR for 4/27/26.Interview on 4/29/26 at approximately 1:42 p.m. with Staff A (Licensed Practical Nurse) confirmed the above findings and that the INR was not completed as ordered.

Based on observation, interview, and record review, the facility failed to ensure that medication error rate remained below 5 percent for 4 of 34 opportunities of medication administration observed. (Resident identifiers are #41 and #46.)Findings include: Resident #46 Observation on 4/29/26 at approximately 8:45 a.m. with Staff A (Licensed Practical Nurse) during Resident #46's medication administration revealed that Staff A prepared Resident #46' scheduled morning medication and placed the oral medications in a medication cup that included one Over-The-Counter (OTC) Calcium with Vitamin D 600 mg-200 unit tablet, one Metoprolol Tartrate 12.5 milligram (mg) dose tablet, and one Digoxin 125 microgram (mcg) tablet. After preparing the medications, Staff A brought the medication cup, a 4% Lidocaine patch, and a cup of water to Resident #46's room. Staff A then obtained Resident #46's blood pressure and heart rate using a wrist blood pressure monitor, which showed a blood pressure of 117/65 and a heart rate of 59. Staff A handed Resident #46 the medication cup, and Resident #46 took the medications, including the above mentioned medications. Review on 4/29/26 at approximately 8:45 a.m. of Resident #46's Electronic Medication Administration Record (EMAR) with Staff A during Resident #46's medication administration revealed the following scheduled ordered morning medications on 4/29/26:Calcium with Vitamin D 600-400 (mg-unit) one time a day, there was no route indicated on the order;Digoxin 125 mcg by mouth one time a day every Monday, Wednesday, and Saturday for heart failure hold for heart rate less than 60; andMetoprolol Tartrate give 12.5mg by mouth every morning and at bedtime for hypertension Hold for systolic blood pressure (SBP) less than 100 mmHg (millimeters of mercury) and heart rate (HR) less than 60. Interview on 4/29/26 at approximately 9:00 a.m. with Staff A confirmed the above findings. Interview on 4/29/26 at approximately 1:21 p.m. with Staff J (Advanced Practice Registered Nurse) revealed that he/she reviewed Resident #46's above mentioned Metoprolol tartrate order and that the Metoprolol Tartrate should be held when the SBP was below 100 mmHg with a heart rate (HR) of 60 or greater; when the HR was below 60 with an SBP of 100 mmHg or greater; and when the SBP was below 100 mmHg and the HR was below 60. Resident #41 Review on 4/29/26 at approximately 9:08 a.m. of Resident #41's EMAR with Staff J (Registered Nurse) during Resident #41's medication administration revealed an order for Cetirizine Hydrochloride (HCl) 10 mg give one tablet by mouth twice a day. Observation on 4/29/26 at approximately 9:08 a.m. with Staff J during Resident #41's medication administration revealed Staff J prepared the scheduled morning medications and placed the oral medications into a medication cup. Staff J did not obtain the Cetirizine Hcl 10 mg tablet to place in the medication cup prior to completing the EMAR documentation, locking the medication cart, and proceeding to Resident #41's room to administer the medications. Interview on 4/29/26 at approximately 9:21 a.m. with Staff J confirmed he/she did not obtain the Cetirizine Hcl 10 mg tablet to place in the medication cup prior to clicking yes and completing the EMAR documentation for the morning medication including the Cetirizine Hcl 10 mg, locking the medication cart, and proceeding to Resident #41's room. Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration . Review on 4/30/26 of facility policy titled, Medication Administration General Guidelines, dated 01/26, revealed, Medications are administered in accordance with written orders of the prescriber .There were 34 opportunities of medication administration observed and 4 of the 34 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 11.76%.

Based on observation, interview, and record review, the facility failed to follow professional standards for medication administration for 1 of 5 residents observed for medication administration, follow physician's order for 1 of 5 residents reviewed for unnecessary medications, and obtain wound dressing orders for 1 of 1 resident reviewed for skin condition. (Resident identifiers are #8, #13, and #45.)Findings include:[NAME], P.A, [NAME], A.G., Stockhart, P.A., & Hall, A. (2021). Fundamentals of Nursing. Elsevier.Page 1262. Changing Dressings A Health care provider's order for wound care indicates the dressing type, the frequency of changing, and any solutions or ointments to be applied to the wound. Resident #13 Observation on 4/28/26 at approximately 9:37 a.m. of Resident #13 revealed that Resident #13's was in bed and his/her right hand had red drainage (blood-like) on the fingers. Further observation revealed that the red drainage (blood-like) came from an area on his/her right medial leg and that there was a dressing peeled back revealing red drainage. Interview on 4/28/26 at approximately 9:40 a.m. with Staff A (Licensed Practical Nurse) confirmed that Resident #13 was actively bleeding on the right medial leg and that it was blood on their fingers. Staff A revealed Resident #13 has a history of picking his/her skin. Review on 4/29/26 of Resident #13's medical record revealed an active diagnosis of excoriation (picking) and a care plan for risk of picking to provide wound care as ordered. Further review of Resident #13's medical record revealed no wound dressing order for the above mentioned wound dressing. Interview on 4/30/26 at approximately 9:40 a.m. with Staff M (Registered Nurse) revealed that there was no documentation of Resident #13 having a right medial leg wound and that Staff M was not made aware during report from the prior shift. Interview on 4/30/26 at approximately 9:42 a.m. with Staff D (Licensed Nursing Assistant) confirmed that Resident #13 had a right medial leg wound that was covered with a dressing. Interview on 4/30/26 at approximately 10:17 a.m. with Staff I (Advanced Practice Registered Nurse) revealed that he/she was unaware of any open areas for Resident #13 and that he/she would expect a phone call and for provider to provide an order for wound dressings including type of dressing, frequency of the dressing change and any ointments to be applied. Interview on 4/30/26 at approximately 11:46 a.m. with Staff B (Director of Nursing) confirmed that Resident #13's medical record contained no information regarding open area on Resident #13's right medial leg or notification to the provider for wound dressing orders. Review on 4/30/26 of the facility's policy: Skin Integrity and Wound Management with a revision date of 9/15/25, revealed, 6.2 Document newly identified skin/wound impairments as a change of condition; 6.3 Document skin/wound findings on the 24-hour report; .6.6.1 Document daily monitoring of ulcer/wound site with or without dressing 9. Notify physician/APP (advanced practice provider) to obtain orders. Standard: [NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th edition St. Louis, Missouri: Elsevier, 2021. Page 614 .It is essential to verify the accuracy of every medication you give to your patients with the patient's order. If the medication order is incomplete, incorrect, or inappropriate, or if there is a discrepancy between the original order and the information on the MAR [Medication Administration Record]. consult with the health care provider. Do not give a medication until you are certain that you can follow the seven rights of medication administration .Correct Administration .Use aseptic technique and proper procedures when handling and giving medications . Resident #45 Review on 4/29/26 revealed a physician's order dated 4/9/26 for Oxycodone HCI [Hydrochloride] oral tablet 5 mg [milligrams] Give 1 tablet by mouth every 4 hours as needed for pain level 8-10 for 14 days. Review on 4/29/26 of the Medication Administration Record (MAR) revealed that the Oxycodone 5 mg was administered outside of the ordered parameters on the following dates and at the documented pain levels: April 13, 2026 the Oxycodone was given for a pain level of 4. April 16, 2026 the Oxycodone was given for a pain level of 7. April 18, 2026 the Oxycodone was given for a pain level of 3. April 19, 2026 the Oxycodone was given for a pain level of 6. April 22, 2026 the Oxycodone was given for a pain level of 5. Interview on 4/30/26 at 8:54 a.m. with Staff B confirmed the above findings. Review on 4/30/26 of facility policy titled Medication Administration General Guidelines dated 01/26 revealed, 1. Medications are administered in accordance with written orders of the prescriber. Standards:[NAME], [NAME] A., and [NAME] [NAME]. Fundamentals of Nursing. 10th ed. St. Louis, Missouri: Mosby Elsevier, 2021, Chapter 31, Medication Administration, Page 618-619, .Administering Medications Through an Enteral Tube (Nasogastric Tube, G-tube [gastrostomy tube], J-tube [jejunostomy tube], or Small-Bore Feeding Tube .Steps .Before administration of enteral medications, verify placement of feeding tube according to agency policy and determine that tube is placed in the stomach or small intestine correctly .Check placement of feeding tube by observing gastric contents and checking pH of aspirate contents .Check for gastric residual volume . Resident #8 Observation on 4/29/26 at approximately 8:32 a.m. with Staff A (Licensed Practical Nurse) during Resident #8's medication administration revealed Staff A flushed the Resident #8's gastrostomy tube (G-tube) with water, administered 60 milliliters (mL) of Lactulose 10 gm/15 mL mixed with water, and then performed a post medication water flush of the G-tube. Staff A did not check or verify the placement or patency of Resident #8's G tube before flushing it or administering the Lactulose. Interview on 4/29/26 at approximately 9:00 a.m. with Staff A confirmed that he/she did not check Resident #8's G-tube placement and patency prior to administering the Lactulose. Review on 4/29/26 of Resident #8's April 2026 Medication Administration Record (MAR) revealed an order to administer Lactulose 10 gm/15mL give 60 mL via G-tube four times a day. Review on 4/29/26 of Resident #8's enteral feeding tube (G-tube) care plan, initiated date 11/22/22, revealed an intervention to check patency and placement of the G-tube daily, and before administering feedings and medications. Review on 4/30/26 of the facility's policy titled, Medication Administration Enteral Tubes, dated 1/26, revealed, PROCEDURES .8. Verify tube placement per facility protocol. 9. Check the patient's gastric contents for residual feeding. Return any residual volume to the stomach .14 .Administer liquid medication first . Review on 4/30/26 of the facility's policy titled, Enteral Feeding: Administration by pump, revision date 2/24/25, revealed, .8. Evaluate patient's abdomen for distention. 9. Evaluate tube and site for damage, leakage, or irritation . 10. Auscultate abdomen for bowel sounds. 11. Measure the external length of the tube from the point of entry into the skin to the end of the tube to verify placement. 12. Draw up 10-30 mL of air into syringe and connect to the end of the enteral tube. Inject air slowly into the tube, Pull back slowly and aspirate gastric contents. 13. Check gastric residual volume (GRV) .

Based on observation, interview and policy review, it was determined that the facility failed to ensure that food is stored in accordance with professional standards for food service safety for 1 out of 1 kitchen observed. Finding Include: Observation on 4/21/25 at approximately 8:20 a.m. in the kitchen with Staff A (Dietary Cook) revealed the following: A small dish of salad covered in plastic wrap without a preparation or use by date in the refrigerator; a clear container with tuna fish covered with plastic wrap, labeled tuna fish with a date of 4/14 (preparation date) in the refrigerator; a clear container with chicken salad covered in plastic wrap, labeled chicken salad with date of 4/13 (preparation date) in the refrigerator; a stainless steel bowl containing cubes of cooked potatoes uncovered without a preparation date; a plastic bag containing 7 thawed chicken breasts dated 4/15 (date pulled from the freezer) in the walk-in refrigerator; a case of cucumbers with 6 cucumbers that is leaking fluid, had black spots, and soft to touch in the walk-in refrigerator; a stainless steel pan containing thawed sliced deli ham dated 3/12 (date pulled from the freezer) in the walk-in refrigerator; and a stainless steel pan continuing thawed sliced salami dated 3/5 (date pulled from the freezer) in the walk-in refrigerator. Interview on 4/21/25 at approximately 8:30 a.m. with Staff A (Dietary Cook) confirmed the above findings. Review on 4/21/25 of the facility's policy titled Food Storage: Cold Foods, Revised 9/2017, revealed .Procedures 5. All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination . Review on 4/21/25 of the facility's policy titled Food Storage and Retention Guide,with no date, revealed .Ready-To-Eat/Prepared Foods .(Examples: leftovers, deli salads, cut produce .Refrigerator .Up to 7 days Day 1 is the day of preparation .Raw Meat/Poultry/Seafood: Fish, seafood, ground meat, and all poultry .Refrigerator .(Once Thawed) .1-2 days . Interview on 4/22/25 at approximately 11:00 a.m. with Staff B (Dietary Manager) confirmed the above policies. Standard: Review on 4/23/25 of the U.S. Food and Drug Administration Food Code, dated 2017, retrieved from https://www.fda.gov/food/FDA-food-code/food-code-2017 revealed the following: .Chapter 3 Food .3-305.11 Food Storage .Food shall be protected from contamination by storing the Food: .On-premises preparation .(D) A date marking system that meets the criteria stated in (A) and (B) of this section may include: (1) Using a method approved by the regulatory authority for refrigerated, ready-to-eat time/temperature control for safety food that is frequently rewrapped, such as lunchmeat or a roast, or for which date marking is impractical . (3) Marking the date or day the original container is opened in a food establishment, with a procedure to discard the food on or before the last date or day by which the food must be consumed on the premises, sold, or discarded .; or (4) Using calendar dates, days of the week, color-coded marks, or other effective marking methods .Products which are damaged, spoiled, or otherwise unfit for sale or use in a food establishment may become mistaken for safe and wholesome products and/or cause contamination of other foods . (5) Certain foodborne pathogens that are anaerobes or facultative anaerobes are able to multiply under either aerobic or anaerobic conditions. Therefore special controls are necessary to control their growth. Refrigerated storage temperatures of 5 C (41 F) may be adequate to prevent growth and/or toxin production of some pathogenic microorganisms .

Based on observation, interview, and record review, it was determined that the facility failed to ensure that open injectable medications were labeled in accordance with the manufacturer's instructions in 1 of 1 medication room observed. Findings Include: Observation on 4/21/25 at approximately 8:30 a.m. with Staff G (Licensed Practical Nurse) in the Chase Unit Medication Room revealed an open multi-dose vial of Tuberculin Purified Protein Derivative (Mantoux) without an open date or an open expiration date in the medication refrigerator. Interview on 4/21/25 at approximately 8:30 a.m. of Staff G confirmed the above findings. Review on 4/21/25 of the Tuberculin Purified Protein Derivative (Mantoux) manufacturer instructions revealed A vial .which has been entered and in use for 30 days should be discarded . Review on 4/21/25 of the facility policy titled Medications and Medication Labels dated 1/25 revealed PROCEDURES .2. Multi-dose vials shall be labeled to assure product integrity, considering the manufacturers' specifications .Nursing staff should document the date opened on multi-dose vials on the attached auxiliary label .

Based on record review and interview, it was determined that the facility failed to correctly code section M0300(Pressure Ulcers) on 2 of 15 resident Minimum Data Set (MDS) assessments reviewed in a final sample of 15 residents (Resident Identifier #20 and #54). Findings include: Resident #20 Review on 4/21/25 of Resident #20 admission note dated 3/26/25 revealed pressure area present on admission. Review on 4/21/25 of Resident #20's 5-day MDS with an Assessment Reference Date (ARD) of 3/30/25 revealed M0300 Current number of unhealed pressure B1 Number of stage 2 pressure ulcers was coded 1 and M0300 B2 Number of These Stage 2 pressure ulcers that were present on admission/entry or reentry was coded 0. Review on 4/22/25 of Resident #20's care plan revealed .actual pressure are [sic] on coccyx present upon admission . Interview on 4/22/25 at approximately 1:15 p.m. with Staff C (MDS Nurse) confirmed that Resident #2 has a Stage 2 pressure ulcer present on admission and the above MDS was coded incorrectly. 45419 Resident #54 Review on 4/22/25 of Resident #54's Hospital Discharge Summary, dated 11/12/24, revealed that Resident #54 had a Stage 2 pressure injury on the right heel. Review on 4/22/25 of Resident #54's admission note, dated 11/12/24, revealed that Resident #54 had a blister [Stage 2 pressure ulcer] on the right heel 4 cm (centimeter ) x (by) 2 cm. Review on 4/22/25 of Resident #54's 5-day MDS assessment with an ARD of 11/15/24 revealed that in Section M0100 Determination of Pressure Ulcer/Injury Risk was not coded for resident having pressure ulcer/injury. Further review revealed that Section M0210 Unhealed Pressure Ulcers/Injuries was coded 0, indicating not having one or more unhealed pressure ulcer. Interview on 4/23/25 at 10:20 a.m. with Staff C (MDS Coordinator) confirmed that Resident #54 had a Stage 2 pressure that was present on admission and that the above MDS was coded incorrectly.

Based on interview and record review, it was determined that the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 out of 4 residents reviewed for bowel management. A resident required hospitalization when his/her ordered bowel protocol was not followed (Resident Identifiers are #1 and #2). Findings include: Standards: [NAME], [NAME] A., and [NAME]. Fundamentals of Nursing. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders .The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Resident #1 Review on 5/30/24 of Resident #1's April 2024's Medication Administration Record (MAR) revealed the following physician's orders: Lactulose Oral Solution 10 grams (gm)/15 milliliters (ml), (Lactulose) Give 30 ml by mouth three times (3x) a day for Cirrhosis, Goal 3 Bowel Movements (BM) daily, may hold if greater than (>) 3 BM's, Start Date 4/18/24. Lactulose Oral Solution 10 gm/15 ml (Lactulose), Give 30 ml by mouth as needed for Cirrhosis daily if less than (<) 3 BM's a day, Start Date 4/18/24. Review on 5/30/24 of Resident #1's Licensed Nursing Assistant (LNA) Bowel Record from 4/17/24 through 4/29/24 revealed the following days that Resident #1 did not have 3 bowl movements: 4/17- no BM; 4/18- no BM; 4/19- 1 BM; 4/20- 2 BMs; 4/23- no BM; 4/24- no BM; 4/25- no BM; 4/26- no BM. Review on 5/30/2024 of Resident #1's MAR for the above dates revealed Lactulose had not been administered as needed when Resident #1 did not have 3 bowel movements daily. Review on 5/30/24 of Resident #1's progress noted, dated 4/26/24, revealed the following: Diagnosis and Plan, Unresponsive - Given patient medical history of Cirrhosis and no bowel movements in four days and changing condition with involuntary twitching and unresponsiveness, patient going to emergency room for evaluation as concerned for Encephalopathy. Interview on 5/30/24 at approximately 12:00 p.m. with Staff C (Registered Nurse) revealed that he/she did not track bowel movements separately from the LNAs, but documented on the Treatment Administration Record (TAR) what the LNAs told him/her. Interview on 5/30/24 at approximately 12:30 with Staff B (Nurse Practitioner) revealed he/she was not notified that Resident #1 did not have any BMs until the fourth day. Staff B stated he/she would've made changes to Resident #1's treatment if notified. Review on 5/30/24 of Resident #1's medical record revealed that Resident #1 had a diagnosis of Hepatic Failure without coma, Onset Date 1/27/24, Metabolic Encephalopathy, Onset Date 1/27/24 and Alcoholic Cirrhosis of Liver without Ascites, Onset Date 1/27/24. Further review of Resident #1's medical record revealed that Resident #1 required hospitalization on [DATE] for Altered Mental Status. Resident #2 Review on 5/30/24 of Resident #2's May 2024's MAR revealed the following physician's orders: Document the amount of BM's per shift, goal 3 BM's daily, Notify provider if goal is not met every shift, Start Date 5/24/24. Further review revealed Resident #2 did not meet the goals of 3 BM's on the following days: 5/26/24, 5/27/24, and 5/28/24. Lactulose Oral Solution 10 gm/15 ml (Lactulose), Give 30 ml by mouth two times a day for Constipation, hold once 3 BM's achieved for the day, Start Date of 1/20/24. Discontinue (D/C) Date of 5/28/24. Lactulose Oral Solution 10 gm/15 ml (Lactulose) Give 30 ml by mouth as needed for constipation, Start Date 1/20/24. Further review revealed the as needed dose was administered on 5/14/24. Review on 5/30/24 of Resident #2's LNA Bowel Record from 5/1/24 through 5/29/24 revealed that Resident #2 did not have 3 bowel movements on the following days: 5/1/24- 2 BMs, 5/2/24- 1 BM, 5/3/24- 2 BMs, 5/4/24- no BM, 5/5/24- 1 BM, 5/7/24- 1 BM, 5/8/24- 1 BM, 5/9/24- no BM, 5/10/24- 1 BM, 5/11/24- 1 BM, 5/12/24- 1 BM, 5/13/24- no BM, 5/14/24- 2 BMs, 5/15/24- 2 BMs, 5/16/24- 2 BMs, 5/17/24- 1 BM, 5/18/24- 1 BM, 5/19/24- 1 BM, 5/20/24- no BMs, 5/21/24- no BMs, 5/22/24- 2 BMs, 5/23/24- 2 BMs, 5/25/24- 2 BMs, 5/26/24- no BM, 5/27/24- 2 BMs, and 5/29/24- 2 BMs. Review on 5/30/24 of Resident #2's medical record revealed that Resident #2 had a diagnosis of Alcoholic Cirrhosis of Liver without Ascites, Onset Date 11/22/22. Interview on 5/30/24 at approximately 12:30 with Staff B revealed that Staff B was not notified that the above resident did not have 3 bowel movements a day on the above days. Review on 5/30/24 of the facility policy titled, NSG122 Change in Condition: Notification of, Revision Date 6/1/21 revealed: .Policy .A center must immediately inform the resident/patient (hereinafter patient), consult with the patient's physician, .where there is: . A need to alter treatment significantly (that is, a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment; .

Based on interview and record review, it was determined that the facility failed to provide sufficient staff to meet residents' needs in April 2024 and May 2024. Findings include: Review on 5/30/24 of the Facility Assessment revealed Consider the overall needs of your resident population based on your Facility Assessment, MDS [Minimum Data Set], Resident Population Profile and any additional source when indicating the number, average, range or ratio needed. Further review of the Facility Assessment revealed the following staffing levels for direct care staff: [NAME] - 1 Nurse [Registered Nurse (RN)/Licensed Practical Nurse (LPN)], 2 LNAs [Licensed Nurse Aide] day and eves, 1 Nurse, 1 LNA nights. [NAME] - 1 Nurse, 2 LNAs days and eves, 1 Nurse, 1 LNA nights. Review on 5/30/24 of the Daily Staffing Sheets from April 23, 2024 to May 30, 2024, revealed the following 6 shifts (over 4 days) in April and 22 shifts (over 16 days) in May with LNA/Certified Nursing Assistant (CNA) staffing that does not meet levels outlined in the Facility Assessment: 4/23/24 - Tuesday - Day shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 18 4/23/24 - Tuesday - Eve shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 23 4/24/24 - Wednesday - Day shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 4/24/24 - Wednesday - Eve shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 4/25/24 - Thursday - Day shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 19 4/30/24 - Tuesday - Day shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/1/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/1/24 - Wednesday - Eve Shift - [NAME] Hall - 1 LPN, 0 CNA - Unit census 19 5/2/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/3/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/3/24 - Friday - Night Shift - [NAME] Hall - 1 RN, 0 CNA - Unit census 19 5/4/24 - Saturday - Day Shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 19 5/5/24 - Sunday - Day Shift - [NAME] Hall - 1 RN, 1 CNA - Unit census 23 5/6/24 - Monday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/8/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/9/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/10/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 23 5/10/24 - Friday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/10/24 - Friday - Eve Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/11/24 - Saturday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/11/24 - Saturday - Eve Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/12/24 - Sunday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/15/24 - Wednesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/16/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/17/24 - Saturday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/2124 - Tuesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 5/21/24 - Tuesday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 25 5/30/24 - Thursday - Day Shift - [NAME] Hall - 1 LPN, 1 CNA - Unit census 19 Interview on 5/30/24 at approximately 1:00 p.m. with Staff A (Director of Nursing) confirmed the above findings. Interview on 5/30/24 at approximately 9:35 a.m. with Staff C (Anonymous) stated, LNA staffing is a very serious concern here. Residents get up between 7:00 a.m. and 8:00 a.m., and with one LNA on they're running around non-stop, sometimes not able to get a break. Nurses help LNAs when they can but have their own tasks to tend to. Interview on 5/30/24 at approximately 9:45 a.m. with Staff D (Anonymous) stated, The wait times for residents can be really long because there's not enough LNAs on. One LNA is not enough on any given unit. We need two LNAs on per unit. It seems Administration only considers census and not acuity when they schedule staff. Mealtimes can be challenging and there are delays in feeding residents. Some units have Residents that need lifts and that requires two staff that's hard to come by. Interview on 5/30/24 at approximately 10:00 a.m. with Staff E (Anonymous) and Staff F (Anonymous), stated, We all try to help each other out, but one LNA is not enough. We need two LNAs when we have residents with heavier loads. Interview on 5/30/24 at approximately 10:15 a.m. with Resident #4 on [NAME] Hall revealed, Days, evenings, and shift change is usually when we have the longest waits, varying sometimes from 10-15 minutes and up to 20-40 minutes, depending on staff call outs. There have been times when I use my call bell, but staff don't make it here before I soil myself (fecal matter). One LNA is not enough to provide care that everyone needs. Interview on 5/30/24 at approximately 10:30 a.m. with Resident #3 on Chase Unit stated, No, there's not enough staff, not enough aides. Sometimes when only one aide changes me in bed, I feel like I'm going to fall out of bed. The call bell waits vary, from 5 minutes up to 45 minutes. They could use at least two aides on the unit. Interview on 5/30/24 at approximately 10:45 a.m. with Resident #2 on [NAME] Hall stated, Only sometimes do they have enough staff, but not usually. Interview on 5/30/24 at approximately 11:15 a.m. with Staff G (Anonymous) stated, Ideally there should be two LNAs on [NAME] and [NAME] Halls. With only one LNA on a unit, it can be rough. Interview on 5/30/24 at approximately 12:30 p.m. with Resident #5 stated, I regularly attend Resident Council, and staffing here has been a chronic and considerable problem for many months on all shifts. They'll hire two staff, then two staff quit. They can never catch up. One LNA is absolutely not enough on any unit. One LNA is left running around trying to get people up in the mornings for breakfast, but sometimes they're only able to get half the residents ready for the meal, while the other half still in bed have to wait to eat.

Based on observation and interview, it was determined that the facility failed to prepare food in accordance with professional standards for food service safety and failed to ensure that staff were wearing proper hair restraints in the main kitchen. Findings include: Observation on 4/23/24 at 08:20 a.m., during the initial tour of the kitchen, revealed Staff E (Cook) serving scrambled eggs onto plates. Further observation revealed Staff E had facial hair and was not wearing a facial hair restraint. Interview on 04/23/24 at approximately 8:25 a.m. with Staff E confirmed that he/she did not wear a facial hair restraints when serving food. Review on 04/25/24 of the facility policy titled Staff Attire undated, revealed Procedures .1. All staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Review on 04/25/24 of Chapter 2 of the FDA (Food and Drug Administration) food code 2022 Management and Personnel document section 2-402 Hair Restraints 2-402.11 Effectiveness (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.

Based on record review and interview, it was determined that the facility failed to ensure medical records were accurate for 1 out of 2 residents reviewed for pressure ulcers in a final sample of 16 residents (Resident identifier is #43). Findings include: Review on 4/24/24 of Resident #43's current orders revealed an order dated 4/8/24 for wound care to left posterior thigh pressure area: Cleanse with NSS [normal saline] and apply [name brand] dressing every 3 days next treatment due 4/11/24 on 7-3 shift. Review on 4/24/24 of Resident #43's April 2024 Treatment Administration Record (TAR) revealed no wound care order or treatment documentation. Interview on 4/24/24 at approximately 11:15 a.m. with Staff A (Registered Nurse) confirmed that the treatment had not been added to the TAR. Review on 4/24/24 of Resident #43's Wound Evaluations listed the location as rear right thigh. Interview on 4/24/24 at approximately 11:30 a.m. with Staff B (Director of Nursing) confirmed above the findings and revealed that the above wound evaluations were done of the left right thigh, not the right thigh.

Based on observation, record review, and interview, it was determined that the facility failed to follow physician orders for 1 of 3 residents reviewed for falls in a final sample of 16 (Resident identifier is #18). Findings include: Review on 4/26/24 of professional nursing standard: Fundamentals of Nursing, [NAME], [NAME] A., and [NAME] [NAME]. 7th ed. St. Louis, Missouri: Mosby Elsevier, 2009 revealed: Page 336 - Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician ' s orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 4/23/24 at approximately 9:30 a.m. revealed a gauze border dressing without a date on his/her right elbow. Interview on 4/23/24 at approximately 9:30 a.m. with Resident #18 revealed the injury to his/her right elbow may have been a result of resident #18's recent fall. Review on 4/24/24 of Resident #18's orders, skin/wound assessments, change in condition (fall dated 4/16/24) report, treatment records, care plans, and progress notes had no documentation of right elbow injury. Interview on 4/25/24 at approximately 10:00 a.m. with Staff B (Director of Nursing) confirmed there was no documentation and no order for dressings. Interview on 4/25/24 at approximately 10:00 a.m. with Staff B confirmed above findings. Review on 4/25/24 of facility policy titled NSG236 Skin integrity and Wound Management with a revision date of 2/1/23 revealed . under section called Practice Standards .5. The nursing assistant will observe skin daily and report any changes or concerns to the nurse. 6. The nurse will: 6.1 Evaluate any reported or suspected skin changes or wounds. 6.2 Document newly identified skin/wound impairments as a change in condition.

Based on observation, interview, and record review, it was determined that the facility failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance for 2 residents in a census of 51 residents (Resident Identifiers are #6 and #26). Observation on 3/22/23 at 11:32 a.m. revealed that there were only 2 residents who resided on the [NAME] Unit. It was observed that the nurse's station was under repair and there were no facility staff scheduled to work on that unit. Staff from the [NAME] Unit were responsible for Resident #6 and Resident #26 on the [NAME] Unit. Both resident rooms were over 120 feet away from the nurse's station on the [NAME] Unit and could not be seen from the [NAME] Unit. Observation on 3/22/23 at 11:35 a.m. revealed that Resident #26 resided in room [ROOM NUMBER] which was approximately half way down the nursing unit. Interview with Resident #26 on 3/22/23 at 11:35 a.m. revealed that he/she enjoyed living on the unit because of how quiet it was. He/She stated that the staff check on him/her periodically. Resident #26 stated that he/she is very independent and mostly takes care of him/herself. Resident #26 stated that he/she would yell out for help until someone came if he/she fell . Observation on 3/23/23 at 8:35 a.m. revealed that Resident #6 resided in room [ROOM NUMBER] which was on the opposite side of the unit from Resident #26 and approximately half way down the nursing unit. Interview with Resident #6 revealed that he/she enjoyed living on the unit because of how quiet it was and that he/she had a private suite. Resident #6 stated that the staff will come down to visit during the day to see if everything was ok. Resident #6 stated that he/she takes care of him/herself and would walk to the nurse's station if he/she needed help. Interview on 3/23/23 at 10:34 a.m. with Staff D (Licensed Practical Nurse) on the [NAME] Unit, who stated that they make periodic rounds on the [NAME] Unit to make sure the residents were okay. Staff D stated both residents were independent and did not need much assistance. He/She stated that the call system does not ring to the nurse's station on the [NAME] Unit. When asked how a staff member would know if the residents on that unit needed help, Staff D stated that he/she would not know until a staff member went down to the unit during their periodic rounds. Interview on 3/23/23 at 1:40 p.m. with Staff E (Licensed Nursing Assistant) on the [NAME] Unit stated that staff will go to the [NAME] Unit during every meal. He/She stated that both residents were pretty independent. He/She said that he/she wouldn't know if someone from the [NAME] unit needed help if they fell or needed immediate assistance. Observation on 3/23/23 at 11:51 a.m. revealed that when Resident #26's call light was pressed, the audible sound could not be heard at the [NAME] Unit nurse's station. Review on 3/24/23 of the facility's policy titled Call Lights revised on 6/1/21 revealed, . All Genesis HealthCare patients will have a call light or alternative communication device with their reach at all times when unattended. Staff will respond to call lights and communication devices promptly . Purpose. To ensure safety and communication between staff and patients.

Based on observation, interview, and record review, it was determined that the facility failed to follow physicians' orders for 1 out of 28 medication administrations observed (Resident identifier is #102). Findings include: Standard: Potter, Patricia A., and Anne Griffin Perry. Fundamentals of Nursing. 7th edition St. Louis, Missouri: Mosby Elsevier, 2009. Page 336- Physicians' Orders The physician is responsible for directing medical treatment. Nurses follow physician's orders unless they believe the orders are in error or harm clients. Therefore you need to assess all orders, and if you find one to be erroneous or harmful, further clarification from the physician is necessary . Observation on 3/22/23 at approximately 8:45 a.m. with Staff B (Registered Nurse) revealed that Staff B dispensed two tablets of over the counter (OTC) Bisacodyl 5 milligram (mg) in a medication cup. Observation also revealed that Staff B administered the two tablets of OTC Bisacodyl 5 mg to Resident #102. Record review on 3/22/23 at approximately 8:45 a.m. during observation with Staff B revealed that Resident #102's Electronic Medication Administration Record (EMAR) had no order for two Bisacodyl 5 mg tablets to be given by mouth. The EMAR revealed an order for Dulcolax (brand name of Bisacodyl) 10 mg suppository to be given rectally as needed for constipation. Interview on 3/22/23 at approximately 8:50 a.m. with Staff B confirmed the above findings.

Based on interview and record review, it was determined that the facility failed to ensure that a resident received an influenza vaccine after obtaining a consent to administer the influenza vaccine for 1 of 5 residents reviewed for immunizations (Resident identifier is #25). Findings include: Review on 3/24/23 of Resident #25's influenza vaccine consent form revealed that Resident #25 gave the facility permission to administer the appropriate influenza vaccination annually with a sign date of 3/8/23. Review on 3/24/23 of Resident #25's medical record revealed that Resident #25 did not receive an influenza vaccination after consenting on 3/8/23. Interview on 3/24/23 at approximately 11:45 a.m. with Staff A (Director of Nursing) confirmed the above findings. Review on 3/24/23 of the facility's policy titled, Influenza Immunization Program, revision date of 11/15/21, revealed Center will provide the opportunity to receive the appropriate influenza vaccine to patients .

Based on observation, interview, and record review, it was determined that the facility failed to ensure proper storage of expired medications for 2 of 2 medication carts observed (Resident identifiers are #25 and #38). Findings include: Chase front medication cart Observation on 3/22/23 at approximately 8:30 a.m. with Staff C (Registered Nurse) revealed that Resident #38's used Breo Ellipta 100-25 microgram/inhalation (mcg/inh) inhaler had an open date of 2/2/23 and a do not use after 3/15/23 date on the inhaler. Further observation of the Breo Ellipta 100-25 mcg/inh inhaler revealed a manufacturer's instruction to discard 6 weeks after the inhaler is opened, which would be 3/16/23. Review on 3/22/23 of Resident #38's March 2023 Electronic Medication Administration Record (EMAR) revealed an active order for Breo Ellipta 100-25 mcg/inh with a start date of 9/27/22. Further review of Resident #38's March 2023 EMAR revealed that Resident #38 received Breo Ellipta 100-25 mcg/inh on 3/17/23 to 3/21/22. Interview on 3/22/23 at approximately 8:30 a.m. with Staff C confirmed the above findings. Staff C stated that Resident #38's currently used the above mentioned Breo Ellipta 100-25 mcg/inh inhaler. [NAME] back medication cart Observation on 3/22/23 at approximately 9:00 a.m. with Staff D (Licensed Practical Nurse) revealed that Resident #25's Novolin 70/30 insulin vial had an open date of 2/1/23 and a do not use after 3/15/23 date on the vial. Further observation of Resident #25's Novolin 70/30 insulin vial revealed a pharmacy label to discard after 42 days after opening, which would be 3/15/23. Interview on 3/22/23 at approximately 9:00 a.m. with Staff D confirmed the above findings in the [NAME] back medication cart. Staff D stated that Resident #23's Novolin 70/30 insulin vial should have been removed from the medication cart and placed in the medication room in a return to pharmacy container. Review on 3/22/23 of Resident #25's EMAR revealed a current order for Novolin 70/30 insulin pen with a start date of 3/16/23. There was not a current order for a Novolin 70/30 insulin vial. Review on 3/22/23 the facility's pharmacy insulin storage recommendations, dated 2022, revealed .Novolin 70/30 do not refrigerate after opening and room temperature for 42 days. Review on 3/23/23 of the facility's policy titled, Disposal/Destruction of Expired or Discontinued Medication, revision date of 2/23/22, revealed .Facility should place all discontinued or out-dated medications in a designated, secure location which is solely for discontinued medications or marked to identify the medication are discontinued and subject to destruction .

Based on observation, interview, record review, manufacturer's instruction review, and policy review, it was determined that the facility failed to label opened medications with an opening date/open expiration date and failed to discard expired medications on 1 out of 3 medication carts, 1 out of 2 medication rooms, and 1 out of 1 refrigerator observed. Findings include: [NAME] Unit Observation on 5/4/22 at approximately 12:24 p.m. of the medication cart on [NAME] unit named Front revealed the following expired medications: [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #10's [MEDICATION(S)] Solution, date of opening 3/21/22, use by date 4/18/22. Resident #25's Wixela inhaler, no date of opening, no use by date. Resident #30's Artificial Tears Solution, no opening date, use by date 4/25/22. Resident #37's [MEDICATION(S)] Solution, date of opening 3/19/22, use by date 4/14/22. Resident #48's [MEDICATION(S)] Ophthalmic Eye Ointment, date of opening 3/26/22, labeled to discard after 28 days. Review on 5/4/22 of the manufacturer's instructions for Wixela inhaler revealed: .How should I store Winela Inhub? .Safely throw away Wixela Inhub in the trash 1 month after you open the foil pouch or when the counter reads 0, whichever comes first Interview on 5/4/22 with Staff D (Licensed Practical Nurse) confirmed the medications were expired and should have been removed from the medication cart. Chase Unit Observation on 5/4/22 at approximately 12:41 p.m. of the medication room refrigerator on Chase unit revealed the following expired medication: Resident #218's [MEDICATION(S)] IV Solution 100ml, expiration date 4/29/22 (8 IV solution bags) Interview on 5/4/22 with Staff E (Licensed Practical Nurse) confirmed the medication was expired. Review on 5/5/22 of the facility policy title, 5.3 Storage and Expiration Dating of Medications, Biologics, Revision Date 1/1/22 revealed: .PROCEDURE .4. Facility should ensure that medications and biological that: (1) have an expiration date on the label; (2) have been retained longer than recommended by manufacturer or supplier guidelines; or (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. 5. Once any medication or biological package is opened. Facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the primary medication container (vial, bottle, inhaler) when the medication has a shortened expiration date once opened. .5.4 When ophthalmic solutions and suspensions are opened the bottle should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened bottle Laboratory Refrigerator Observation on 5/5/22 at approximately 1:00 p.m. with Staff A (Minimum Data Set Coordinator/Infection Preventionist) in the Laboratory room revealed a Laboratory refrigerator with 2 opened Influenza vaccine 5 ml (milliter) multi dose vials. One vials had an opened date of 10/25/21 and the second vial was opened on 11/11/21. Review of the manufacturer's instruction revealed Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days. Interview on 5/5/22 at approximately 1:00 p.m. with Staff A confirmed the above findings in the Laboratory refrigerator.

Based on interview and record review, it was determined that the facility failed to ensure physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Resident identifier is #226) Findings include: Interview on 5/03/22 at approximately 11:06 a.m. with Resident #226 revealed that he/she had not received his/her [MEDICATION(S)] inhaler since admission to facility. Resident #226 stated he/she had notified staff of missed medication. Review on 5/4/22 of Resident #226's medical record revealed that Resident #226 was admitted to the facility on [DATE]. Review on 5/5/22 of Resident #226's hospital discharge medication list dated 4/30/22 revealed .Discharge Medication List .Continue These Medications .[MEDICATION(S)] ([MEDICATION(S)] Handihaler) 18mcg (micrograms)/Inhalation Inhaler Oral, Dose: 2 PUFFS INHALATION, Daily . Review on 5/5/22 of Resident #226's physician's admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of Resident # 226's April and May 2022 MAR (Medication Administration Record) revealed no order for [MEDICATION(S)] inhaler. Interview on 5/05/22 at approximately 11:10 a.m. with Staff F (Registered Nurse) confirmed above findings. Interview on 5/05/22 at approximately 1:50 p.m. with Staff G (Corporate Nurse Executive) confirmed that [MEDICATION(S)] inhaler order was missed on admission to facility.

Based on interview and record review, it was determined that the facility failed to ensure that resident or resident representative were inform of the Notice of Medicare Non-coverage (NOMNC) for 1 out of 3 residents reviewed (Resident identifier is #161) for Skilled Nursing Facility (SNF) Beneficiary Protection Notice (BPN) and the facility also failed to ensure that the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Notice (SNF ABN) was accurate and signed for 1 out of 3 residents (Resident identifier is #52) reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notice. Findings include: Resident #52 Review on 5/3/22 of the facility Beneficiary Notice- Residents discharged Within the Last Six Months form revealed that Resident #52 last covered day for skilled services was on 1/25/22 and Resident #52 remained at the facility. Review on 5/5/22 of Resident #52's SNF BPN review form revealed that Resident #52 skilled services start date was 12/28/21 and last covered day of skilled services was 1/25/22. Review on 5/5/22 of Resident #52's SNF ABN form CMS- 5 (2018) revealed that Resident #52's services begun on 1/26/22. Further review revealed that the estimated cost of services was not filled out on the SNF ABN notice. Review also revealed that the SNF ABN notice had no signature and date from Resident #52 or Resident #52's representative indicating receiving and understanding the notice. Review also revealed no documentation that Resident #52 or Resident #52's representative had declined to sign or obtain a copy of the SNF ABN Notice. Review on 5/5/22 of the facility's form titled Use to Document Telephonic Delivery of SNF ABN notice dated 1/21/22 and signed by Staff C (Clinical Reimbursement Coordinator) revealed that Resident #52's representative was contacted on 1/21/22 via telephone and was informed of the last Medicare covered day for Resident #52 was 1/25/22. Interview on 5/5/22 at approximately 12: 30 p.m. with Staff C confirmed the above findings. Staff C stated that the the SNF ABN notification can be done verbally or personally written and does not have to be both. Interview on 5/5/22 at approximately 1:00 p.m. with Staff B (Administrator) revealed that the facility utilized the CMS SNF ABN Chapter 30 for instructions in addressing SNF ABN notices. Staff B stated that Resident #52's representative did not want a copy of the SNF ABN notice. Resident #161 Review on 5/3/22 of the facility Beneficiary Notice- Residents discharged Within the Last Six Months form revealed that Resident #161 was discharged to home on 1/12/22. Review on 5/5/22 of Resident #52's SNF BPN review form revealed that Resident #52 skilled services start date was 10/18/21 and last covered day of skilled services was 1/12/22. Review on 5/5/22 of Resident #161's progress notes revealed no documentation that Resident #161 was provided a copy of the NOMNC. Interview on 5/5/22 at approximately 12:30 p.m. with Staff C revealed that Staff C was unable to provided a copy of Resident #161's NOMNC.

Based on observation, interview, and medical record review, it was determined that the facility failed to provide supervision/assistance at meals for 2 of 2 residents observed during dining. (Resident identifiers are #2 and #3.) Findings include: Resident #2 Observation on 2/8/22 at approximately 8:45 a.m. revealed Resident #2 was in bed eating from a breakfast tray in front of him/her on the bedside table. There was no staff present in the room. The head of the bed was up approximately 30 degrees and Resident #2 stated I'm choking. Staff A (Director of Nursing) entered the room and assisted Resident #2 as he/she began vomiting. Review on 2/8/22 of Resident #2's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 2/8/22 of Resident #2's nutrition assessment dated [DATE] revealed that Resident #2 is on a regular/liberalized diet with dysphagia puree. Review on 2/8/22 of Resident #2's care plan revised on 11/17//21 with a target date of 3/13/22 revealed the following: Focus [name omitted] is at risk for impaired swallowing related to [CONDITION(S)] disease. Goal [name omitted] will not experience episodes of choking X [times] 90 days. Interventions [name omitted] encourage [name omitted] to be out of bed for meals or sitting up on the side of the bed monitor for signs/symptoms of aspiration i.e. coughing, watery eyes, choking, moist sounding voice. Interview on 2/8/22 at approximately 11:45 a.m. with Staff D (Unit Manager) revealed that Resident #2 should be upright sitting at the side of the bed or in a chair for all meals. Resident #3 Observation on 2/8/22 at approximately 8:45 a.m. revealed Resident #3 was in bed with a breakfast tray in front of him/her on the bedside table. There was no staff present in the room. The head of the bed was up approximately 15 degrees and Resident #3 was observed feeding him/her self. Review on 2/8/22 of Resident #3's medical diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review on 2/8/22 of Resident #3's care plan revised on 10/9/21 with a target date of 1/17/22 revealed the following: Focus [name omitted] requires assistance for ADL care in bathing, grooming, personal hygiene, dressing, eating, bed mobility, transfer locomotion, toilting, related to: [CONDITION(S)] resulting in fatigue, activity intolerance, confusion, weakness. Interventions: One to One feed: setup on left side, cues to use left hand, cues to continue to eat. Date initiated: 1/29/22, created on: 1/29/22. Review on 2/8/22 of Resident #3's care plan revised on 10/22/21 with a target date of 1/17/22 revealed the following: Focus [name omitted] is at risk for impaired swallowing related to [CONDITION(S)] [[CONDITION(S)]]. Goal: [name omitted] will be free from signs/symptoms of aspiration over the next 90 days. Interventions: provide assistance during meals, encourage resident to perform chin tuck, encourage small sips/bites and cue as needed, encourage to chew and swallow each bite. Review on 2/8/22 of the faciliy policy titled Meal Service revised 6/1/21 revealed: Practice Standards: 3.2 When serving meals in the patient's room. 3.2.4 If the patient requires assistance with eating, do not deliver the tray until assistance can be provided. 3.2.5 If the patient requires assistance, sit next to the patient while assisting to eat or raise the bed to the caregiver's eye level.

Based on interview and record review, it was determined that the facility failed to prevent a fall from a mechanical lift that resulted in injury for 1 resident in a final survey sample of 8 residents who had falls and also needed equipment repairs. (Resident identifier is #1.) Findings include: Review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that on 1/8/19 at approximately 1:30 p.m., Resident #1 was being transferred using a mechanical lift and .while in the mechanical lift during a transfer from bed to chair, apparently a bolt became loose LNA's (Licensed Nursing Assistants) heard a 'crack' and the patient fell to the floor . Review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, also revealed that Resident #1 was sent to the hospital and was treated for [REDACTED]. Review on 2/27/19 of Resident #1's nurses notes revealed that Resident #1 had a fall on 1/8/19 and was sent to the hospital where they were treated for [REDACTED]. The nurses notes revealed that Resident #1 returned to the facility on [DATE]. The notes also revealed that Resident #1 is oriented to self only. Further review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that the facility did an investigation and found that .the locking nut on the mechanical lift was missing. It was identified that the screw was loose by the 3-11 shift (on 1/7/19.) Interview on 2/27/19 at approximately 3:00 p.m. with Staff A (Director of Nursing) and Staff B (Administrator) revealed that when the 3-11 shift staff, on 1/7/19, realized that the lift was broken, they put a sign on it that read Broken, Do Not Use, and removed the battery so that no staff would use it. Further review on 2/27/19 of the Facility Report to the Long Term Care Ombudsman Program dated 1/11/19, revealed that .the 11-7 LNA noted that the sign was on the lift indicating that it was 'broken' (pronoun for the LNA) identified that the battery was missing, (pronoun for the LNA) replaced it and reviewed all the functions of the lift and stated 'it worked' (pronoun for the LNA) removed the 'broken' sign. During the 7-3 shift (on 1/8/19) the LNAs attached the lift and sling appropriately, and subsequently lifted the patient according to protocol. However, the LNAs reported hearing a 'crack' while the patient was in the sling and the housing holding the patient slide (sic) out causing the housing and patient in the sling to fall to the floor . Review on 2/27/19 of the Facility Policy Titled Lock-Out/Tag-Out revised (MONTH) (YEAR), revealed that .All employees are responsible for complying with the requirements of the lock out/ tag-out procedures. Employees must never start, energize or use a piece of equipment locked/tagged for servicing or maintenance .When a tag is attached to any energy device, it must not be removed without authorization of the authorized person responsible for it . It also revealed that .In the case of a shift change when a lock-out/tag-out device is in use, specific procedures must be utilized to insure the continuity of the lock and tag-out protection, including the provision for the orderly transfer of lock-out and tag-out protection between off-going and oncoming employees . Interview on 2/27/19 at approximately 11:15 a.m. with Staff A revealed that at the time of Resident #1's incident, the Lock out cards were kept in the maintenance room, and not at the nurses station, so they were not as readily available to staff. Interview on 2/27/19 at approximately 3:00 p.m. with Staff A and Staff B confirmed that the mechanical lift was not used by any other residents, besides Resident #1, after the broken sign was removed on 1/8/19. Staff A also confirmed that the information regarding the broken mechanical lift was not passed on in the shift reports.

Based on observation, record review, and interview the facility failed to implement facility policy and procedure, failed to maintain an infection control program to prevent the neglect of residents in regard to respiratory infections that rose to the level of immediate jeopardy. The facility to identify a cluster of upper respiratory infections contributing to the hospitalization of 6 residents. (Resident identifiers are #3, #6, #10, #11, #14, and #15), 2 with co-morbidities expired. (Resident #10 and Resident #15.) Findings include: Observation on entry into the facility on [DATE] revealed no sign was posted stating to all visitors that a suspected outbreak was within the facility. Sign was observed posted on [DATE] after Immediate Jeopardy had been called on [DATE]. During the entry interview on [DATE] with Staff B (DON), Staff B was asked if their had been any "....outbreaks of illness since the last survey." Staff B then asked what did I mean by an outbreak. After clarifying the definition of an outbreak, Staff B indicated the facility had not had an outbreak. The team then asked to see the line listings for June, July, and [DATE]. Staff B also stated that the person responsible for the Infection Control program was Staff K (IP) who was out sick during the survey. Review with Staff B of the line listings immediately after tour on [DATE] that morning revealed that 21 residents had been affected by an URI in [DATE]. When Staff B was asked about a cluster of URI's (Upper Respiratory Infections) listed for the middle of July, Staff B stated that they were across the hall from each other, "....why would that be an outbreak?" Review of line listing revealed that two of three units had greater than three residents with respiratory infection. Facility policy (see below) defines "Occurrence of three or more cases of the same infections over a specified length of time on the same unit" as an outbreak. During the above interview Staff B was asked if they had contacted Public Health about the above increase in URI's. Staff B stated that they had not. On [DATE] at about 1 p.m. confirmation was received by Public Health that no outbreak of any kind had been reported to them. Staff B reported on the morning of [DATE] that Public Health was notified [DATE] after immediate jeopardy had been called. Review of policy and procedure under outbreak management states "...Incidence of multiple similar infections must be promptly identified and appropriately handled." The policy's document control measures include maintain line listing of identified cases and submit daily progress reports to the health department. Review on [DATE]-[DATE] of the Infection Control Program with Staff B (DON) and Staff C (RDCO (Regional Director of Clinical Operations)) showed detailed line listings of infections from [DATE]-[DATE] but the facility failed to maintain a current line listing; 4 sampled residents (Resident #3, Resident #10, Resident #11, and Resident #14) were not on the line listing and 2 sampled residents (Resident #6 and Resident #15), and 1 out of sample resident were not placed on the line listing timely. Policies and Procedures: Review on [DATE] and [DATE] of the facility's Infection Control Manual entitled "SunBridge Healthcare Corporation: Infection Control Manual" with an effective date of [DATE] stated; "Section 1: INFECTION CONTROL COMMITTEE" Standard: The Infection Control Committee oversees activities conducted to prevent and control infections in residents and personnel. Purpose: ? To control and prevent infections for residents and employees. ? To collect data related to infections occurring within the center (sic). ? To promote adequate infection control practices in all departments. ? To ensure that appropriate supplies and equipment are available for use by personnel. ? The surveillance of infection control practices within the center." "Structure: The Infection Control Committee is responsible for; ? The reporting, investigation, control and prevention of infections." "The Infection Control Committee meets monthly and follows an agenda of topics related to center infection control practices. The agenda is forwarded to the committee members at least 1 week before each meeting." "Page 2, Minutes of the meetings are maintained which include; ? Member attendance ? Surveillance data analysis and trend reports ? Recommendations and actions to improve infection control practices throughout the center" "The Infection Preventionist (IP) reports committee activity to the Performance Improvement Committee quarterly." "Minutes: Topics to be included in the meetings should be but are not limited to the following: ? Nosocomial Infections (acquired (sic) after admission) ? Any trending related to the occurrence of infections ? Antibiotic use ? Any quality improvement plans for monitoring, evaluating and prevention/control of spread of infection." "Page 1, Section 2: Infection Preventionist The Infection Preventionist (IP) ? Is responsible for the quality of resident care relative to infection control practices ? Works under the direction of, and reports to, the Performance Improvement Committee" "This program [MEDICATION NAME] (sic) is based on CDC and APIC standards of practice in infection control. The Infection Preventionist must have copies of, and become familiar with, the state and local requirements; i.e. TB testing, outbreak notification, etc. With the understanding that an effective Infection Control Program requires the cooperation of the entire staff, the IP coordinates and facilitates surveillance and control activities with all departments." "Infection Preventionist duties Include (sic): ? Surveillance to identify infections in residents and employees and to identify clusters in a timely manner ? Maintain the Infection Control Line Listing on each unit and a center date file. ? Analyze infection related data and track trends within the center and report appropriate information to state and local authorities ? Identify infection control issues and make recommendations for corrective actions ? Conduct outbreak investigations and initiate control measures ? Chair the Infection Control Committee and prepares (sic) the agenda for meetings" "Page 1, Section 8: Infection Surveillance Surveillance provides the foundation for the prevention and control of infections by providing systematic observation of the occurrence and distribution of center acquired infections among the residents. This includes: ? Data collection, collation and analysis. ? Dissemination of information to those who can take action." "There are two types of surveillance (process and outcome): 1. Process Surveillance Process surveillance reviews practices directly related to resident care in order to indentify (sic) whether the practices comply with established prevention and control procedures and policies based on recognized guidelines. 2. Outcome Surveillance In contrast to process surveillance, outcome surveillance is designed to identify and report evidence of an infection. The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections" "SURVEILLANCE PROCEDURES Infection surveillance procedures that include all residents in the center. ? Monitoring and evaluation of appropriate antibiotic use (Line list, pharmacy orders, MD orders) ? Data collection: line list, Res. Inf. (Resident Infections), Report, PI forms, checklists, Floor plan to assess for trends/. ? Monthly evaluation of surveillance findings - Data analysis (Infection Control Log)" "Page 2, SURVEILLANCE ACTIVITY Any resident who exhibits signs and symptoms of infection should be monitored for a suspected infection. ? The Infection Preventionist (IP) is notified of suspected infection(s) by the charge nurse and/or through review of the 24-hour report ? The Charge Nurse completes the Resident Infection Report and documents pertinent information the Line listing." "Page 1, Section 9: OUTBREAK MANAGEMENT Outbreaks of communicable diseases may occur in the resident population for a variety of reasons. Incidence of multiple similar infections must be promptly identified and appropriately handled. Proactive management is essential to limit the impact on the residents, staff and visitors. The definitions below do not necessarily coincide with the reporting parameters outlined by state and local regulators." (Note: State and Local guidelines for reporting, were not in the Infection Control Manual section as directed per their policy.) "An outbreak is typically one or more of the following: ? One case of an infection that is highly communicable ? Trends that are 10% higher than the historical rate of infection for the center that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or ? Occurrence of three or more cases of the same infections over a specified length of time on the same unit or other defined areas." "The Infection Practitioner: ? Notify the medical director of the concern ? Contact the local and state department of public health per regulations. ? Document control measures as necessary o Receive surveillance information and tabulate data o Maintain line listing of identified cases o Submit daily progress reports to the health department o Initiate the Communicable Disease Report Card system o Forward Communicable Disease Report Cards to the health department" "Page 2, Actions are Implemented: ? The Licensed nurse evaluates suspected contacts and notifies the attending physician. ? The attending physician/physician extender should visit the resident within 24 hours after being notified of the condition ? Contacts are cultured as directed by o The health department and/or o Medical director and/or attending physician. ? Symptomatic residents and employees are considered potentially infectious o Cultures are obtained o Appropriate precautions are maintained. ? Call an emergency meeting ot (sic) the Infection Control Committee to determine active control measures o Implement appropriate precautions o Discuss possible hold on admissions to the facility until 4 days after the last reported case or as authorized by health department or state regulations o Discontinue group activities, as indicated o Limit visitors if indicate (sic) i.e. influenza in the community o Assign nursing personnel to same resident groups for the duration of the outbreak" "Nursing Measures: Nursing personnel must remain diligent in controlling the outbreak ? Notify the DNS of symptomatic residents ? Provide infection surveillance data in a timely manner ? Obtain laboratory specimens as directed ? Initiate precautions as directed or as necessary ? Practice good hygiene and good hand washing ? Evaluate linen and precaution supplies ? Report any symptoms of illness to their supervisors." "The Medical Director: ? Oversee the management of the outbreak ? Work with the attending physicians and health department to determine the need for laboratory specimens o Based on symptoms and condition o Obtaining throat specimens for [MEDICAL CONDITION] culture in an influenza outbreak o In the event of an influenza A outbreak, determining the need for Amanatadine (sic) therapy ? Determine the need for follow-up specimen and discontinuing precautions ? Determine when precautions may be discontinued o After 3 negative stool specimens have been obtained 24 hours apart o 48 hours after the discontinuance of anti-microbial medication o For Salmonella, if no nit-microbials were given, obtain the first specimen as soon as symptoms subsides" "Section 12: Infection Data Collection & Analysis An important aspect of Infection Control in any center is Data Collection. This section is designed to assist the Infection Control Coordinator with: ? Data collection ? Collation of the data ? Data analysis" "Data collection includes reviewing the line list and Resident Infection Reports and entering the pertinent data onto the Infection control log. This is an Excel file designed to assist you in managing data and funneling it to various graphs. These graphs will make it easier to analyze trends such as Infection rates, Infection types and location, etc." "Analysis of the data from the Infection control Log is uses (sic) to prepare reports to the QA committee such as; ? Infection rates which are calculated based on the number of infections that meet the McGeer (sic) Criteria, no (sic) the total number of reported conditions. ? Chronic vs. Acute infections ? Trends and outbreaks" Resident #10. Record review revealed that Resident #10 was a long term care resident who resided in the facility since [DATE]. This resident had multiple co-morbidities including [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD (Assessment Reference Date) of [DATE] revealed that this resident was cognitively aware with a BIMS (Brief Interview for Mental Status) score of 15, no behavior issues coded, and required no assistance with eating or drinking. Resident #10 had no documented evidence, in the medical record, of lacking the capacity to make health care decisions. Review of the nurses notes for [DATE]- [DATE] revealed that Resident #10 developed a drop in O2 (Oxygen) levels and a cough with complaint stating, "...doesn't feel well" on [DATE]. Review of the MAR indicated [REDACTED]. Review of the nurses note dated [DATE] on the ,[DATE] shift revealed, "Res. (resident) noted (symbol for with) (symbol for increased) SOB/cough (shortness of breath). SAT (saturation) 80% room air. Applied O2 @ 2 L (liters) via n/c (nasal cannula) however, sats cont. (continued) to hover in mid 80's. N.O. (new order) for O2 ,[DATE]-L via nc....LS (lung sounds)-very dim (diminished) from bases to mid lobes.....meals in room per request." Review of the very next nurses note entry dated [DATE] on the ,[DATE] shift revealed, "Pt (patient medicated) X 2 on tylenol (sic) 650 mg (milligrams) @ 1530 and again @ 21:30 for (symbol for increased) temps of 100.3 and 100.1 respectively..." Review of the ,[DATE] (shift began at 11 p.m. [DATE]) nurses notes for [DATE] revealed, "Res. noted to be diaphoretic and c/o (complaint of) being hot. Also c/o cough. Temp 99.6. Tylenol given..." On [DATE] the ,[DATE] shift note written by Staff D (RN) read, "Resident states that (pronoun omitted) would like to go to the hospital. Resident on O2 via n/c - O2 sats 88% -89%. resident c/o SOB. MD notified. CXR (Chest X-ray) ordered...." Interview with Staff D on [DATE] at 12:05 p.m. revealed that Staff D was Resident #10's nurse on the ,[DATE] shift on [DATE]. Staff D stated that on [DATE] during the ,[DATE] shift, Staff D had called the primary care physician (Staff E), given Staff E the vital signs, and took an order for [REDACTED]. During an interview with Staff E (PCP/ Medical Director) on [DATE] at 8:15 a.m. Staff E stated that he was "surprised" that this resident had asked to go to the hospital. Staff E went on to say that Staff E did not realize there had been "....this many cases (of upper respiratory infections)..." Staff E went on to explain that the policy "not written" in this facility was to send those that wanted to go to the hospital, "right away..." Staff E stated that he, "did not realize" that Resident #10 had asked to go to the hospital on [DATE] during the ,[DATE] shift. Review of the nurses notes for the ,[DATE] shift on [DATE] revealed, "...had hard time holding on to (pronoun omitted) drinks, keeps on spilling it due to (pronoun omitted) hands being somewhat shaky...able to eat supper (symbol for with) some assistance in drinking. V/S (vital signs) ,[DATE] 90% on 3 LPM (liters per minute) 88 (pulse), 20 (respirations) 99.2 po (oral temp) occ (occasional) nonproductive cough noted." On [DATE] at 0300 the nurses notes by Staff F (LPN) read, "Resident noted to be in respiratory distress, labored breathing, diaphoretic, audible rattles in lungs both upon auscultation and listening. O2 sats on 3 L continue to be below 85....Called doctor @ 0315 he advised that (resident) be sent to the E.D.(emergency department) Patient left @ 0350 to hospital." On [DATE] at 0830 the nurses note by Staff F read, "DPOA informed of resident's condition @ 0350." Review on [DATE]-[DATE] of the Infection Control Program with Staff B and Staff C (RDCO (Regional Director of Clinical Operations)) revealed that Resident #10 had not been put on the up-dated line listing since the resident had "[MEDICAL CONDITION], not an (URI) infection." Interview with Staff C (RDCO) on [DATE] in the afternoon confirmed that Resident #10 was not added to the July line listing until [DATE]. Staff C stated that the facility chose [DATE] as the start date for the infection on the line listing but did not add Resident #10's name to the listing until 35 days later. Resident #10 was added under the "URI (Upper Respiratory Infection)" section to the [DATE] up-dated line listing. The [DATE] date of the initial infection was 20 days before this resident was sent to the emergency roiagnom on [DATE]. Review of the hospital "emergency room Visit Notes" for [DATE] for Resident #10 revealed under the section REVIEW OF SYSTEMS, "....patient is unresponsive to verbal stimuli." Under the section PHYSICAL EXAM, "Patient in severe distress. Distress appears respiratory." Under the section PROGRESS AND PROCEDURES, "The patient required critical care due to the acute impairment of vital organ systems (respiratory) and a high probability of imminent and life threatening deterioration." Under the section LABS X-RAYS AND EKG, "Chest X-ray: Marked [MEDICAL CONDITION] present. Infiltrate in the right lower lobe. Consistent with pneumonia......" Review of the hospital "History & Physical Report" for [DATE] for Resident #10 revealed under the section HISTORY OF PRESENT ILLNESS, "....The nurse at the nursing home (Staff F) stated that (Staff F) noticed that yesterday (resident) started to have mental status change. (Resident) was not aware. (Resident) was acting different 'spacey' and just no (sic) (resident's self). It was noted this evening that (resident) was in frank respiratory distress was unable to maintain saturations, and not feeling well. The patient was sent here to the emergency department for evaluation. No history can be obtained from the patient due to (resident's) profound obtundness (sic). Conversation was had with DPOA and is not aware of any recent changes or illnesses." Further review under the section GENERAL revealed, "(Resident) is not responding to both deep painful or noxious stimuli. (Resident) did not move with ABG's (arterial blood gases) nor with multiple repeated blood draw attempts." Review of the Assessment and Plan section of the "History & Physical Report" for [DATE] revealed that this resident was initially assessed in Acute [MEDICAL CONDITION], had signs and symptoms of [MEDICAL CONDITION], and had Right Lower Lobe Pneumonia. This resident had been placed in PCU and treated with [MEDICATION NAME] and IV antibiotics. Review of the hospital "Death Summary Report" for [DATE] for Resident #10 revealed under the section Hospital Course, "....Prior to arrival the patient was placed on [MEDICAL CONDITION]. Upon arrival the resident was obtunded." Later on in the paragraph it stated that the resident, "....was trialed (sic) on [MEDICAL CONDITION] for approximately 4 hours.....The patient remained obtunded." The report stated that Resident #10 died within 24 hours of admission to the hospital. During a confidential family interview of an out of sample resident on [DATE] around lunch time this family member stated that their mother got "Very sick" with an upper respiratory infection somewhere between ,[DATE]-[DATE]. "We thought that she was not going to make it." They stated, "...they were going to send her to the hospital but her doctor (Staff E) did an X-ray and treated her with antibiotics..." in the facility. This family member stated that "Many were so sick....Residents and Staff.....we were lucky (referring to the fact that the mother did not die)." Observation on [DATE] in the afternoon of Staff H (LNA) leaving the day shift from the Phillips Unit showed Staff H coughing heavily. When Staff H was seen in the morning of [DATE] entering the Phillips unit, this surveyor asked how Staff H was feeling. Staff H replied, "Much better. I have had pneumonia. Went back to the doctor, yesterday. This is my second round of antibiotics." Later that afternoon Staff H was observed in the Phillips unit hallway comforting a resident by kissing them on the cheek. Once the facility contacted the Division of Public Health on [DATE] in the early evening, they forwarded a letter to the facility to help prevent further spread of infection by offering several recommendations which are as followed: "-Suspend all communal activities. This includes dining room use by any affected residents and staff, parties, entertainers, and any visitors traveling between resident rooms." "-Restrict new admissions to affected unit(s). If transmission to other units/floors/wings occurs, BIDC (Bureau of Infectious Disease Control) will determine whether all admissions to the facility should be restricted." "Staff in affected units should not "float" to other units. Restrict well staff and residents from visiting or walking through the affected unit/floor/wing." "Staff caring for ill residents should follow contact and droplet precautions using surgical masks, gowns, and gloves." In an interview with Staff B (DON) and Staff C (RDCO) on [DATE] in the afternoon they stated that there had been no investigation or tracking of any ill staff until today [DATE]. Staff B and Staff C were, "...making phone calls now to those who had called out (in July and August) ..." They stated that they were trying to find out how many and who had a respiratory infection. Interview with Staff B (DON) and Staff C (RDCO) on [DATE] at 9:15 a.m. confirmed that Public Health had not been notified and "...should have been called in July." Staff C thought that at least when "3% (were affected) they should have been notified." Both Staff B and Staff C acknowledged that there were inaccuracies in the line listings with some residents having been left off entirely. In an interview on [DATE] after lunch Staff B and Staff C said that the facility had not been closed to admissions, not closed to visitors, therapy continued, and that the units were not closed. In interviews on [DATE] in the afternoon, with the department heads, it was confirmed that neither activities, Rehab therapy room, or any the dining rooms were closed during July or August. Laundry and Housekeeping were not informed of any special precautions instituted for a respiratory outbreak in July or [DATE]. Resident #3. Observation on [DATE] in the afternoon and subsequent interview with Staff I (Unit Manager) at the time of the observation revealed that Resident #3 had a Precaution Cart with PPE in front of the Resident #3's room. This cart had not been observed, nor PPE observed utilized for Resident #3 either [DATE] or [DATE]. Staff I stated that the cart had been put out this morning because of Public Health recommendations given last night. Staff I confirmed that Resident #3 had not been on "precautions" for the respiratory infection before [DATE]. Resident #6 During the initial tour of the Phillips Unit with Staff B (DON) on [DATE], Staff B stated Resident #6 had an URI (upper respiratory infection) about a month ago and had been using oxygen via the nasal canula as needed since then. Medical record review was done during survey for Resident #6. Review of the physician note for Resident #6 dated [DATE] reads "Patient with URI (upper respiratory infection) sx (symptoms) today and for past three days. complained cough. no fever. no SOB (shortness of breath). + (positive) URI sx throughout facility this week... ." Further review of the medical record reveals Resident #6 was hospitalized from [DATE] - [DATE] for acute [MEDICAL CONDITION] and returned to the facility on [DATE]. The admission nursing note for [DATE] states "Resident admitted from ... hospital ...[DIAGNOSES REDACTED]." Review of the line listing for facility infections for the month of [DATE] reveals Resident #6 was added to the line listing on [DATE] two days after return from the hospital to the facility and 13 days from the onset of an upper respiratory infection on [DATE]. Resident #6 was diagnosed at the hospital with a primary [DIAGNOSES REDACTED]. But the facility line listing has Resident #6 only noted as having a respiratory infection. Resident #14. On review of Resident #14's nurses noted dated [DATE] at 2 p.m. it states "02 sat (oxygen saturation) 92% - abnormal lung sounds - congested cough remains alert & verbal - notified (physician) of change in condition he ordered a CXR (chest X-ray) - T (temperature) 101.8 Tylenol 325 mg 2 tabs at 2 p.m. -daughter updated on all." Nursing note dated [DATE], ,[DATE] "Result of chest X Ray slight infiltrate in the right lower lobe. MD (medical doctor) ordered Z-pak ([MEDICATION NAME]/antibiotic treatment) this shift 2 tabs 250 m.g for total of first dose 500 mg will cont (continue) Z-pak x 4 days at 250 mg per day." Nursing note dated [DATE], ,[DATE] "Resident was found by me in bed at about 0545, with labored breathing, diaphoresis, and purplish color on (resident) lips. Sat (saturation) on RA(room air) was 74 Res (resident) put on 2 L (liters) O2 (oxygen). Sat (saturation) on 2 L (liters) 02 (oxygen) 91....Sats checked periodically ranged form ,[DATE]. Resident continued to appear in distress and was transported to hospital at 0715..." Hospital notes state "...Pt (patient) arrived at 1200 noon on stretcher from ER (emergency room )....(Resident #14) asked several times if (resident) had pneumonia...Pt (patient) wearing 02 (oxygen) 3 L (liters) n/c (nasal cannula). Congested nonproductive cough. Lungs diminished throughout bilaterally..." On review of the facility's [DATE] line listing, and infection control report, which was given to surveyor by Staff B (Director of Nursing) on [DATE] at 11 a.m. Resident #14 had not been placed on either report. Resident #15. On review of nurses notes dated [DATE]- ,[DATE] shift "(increased) lethargy in AM, asleep in W/C (wheelchair), assisted (with) breakfast and resident refused to eat, temp (temperature) 99.3 PO (by mouth), ...resident refused to drink and fluids at this time...LS (lung sounds) diminished, minimal cough...MD (medical doctor) notified of resident temp (and) lethargy..." Nursing note dated [DATE], ,[DATE] "...This nurse (checked) resident - face slightly flushed - T 100.4 degrees PO Tylenol 650 mg given PO @ 0245. Cool cloth placed on forehead - occasional congested cough noted..." Nursing note dated [DATE], ,[DATE] "...Cont (continue) (with) cold like symptoms, frequent, moist, non-prod(productive) cough..." Nursing note dated [DATE], ,[DATE] "Resident temp 101.2 at give tyl (Tylenol) 650 mg....Resident noted to be coughing this a.m., give cough syrup this a.m. (with) good effect." Nursing note dated [DATE], ,[DATE] "Resident's daughter in at 1050 and expressed concern re (regarding) temp (increased temperature) and cough...call made to MD (medical doctor) re: (regarding) daughter's concerns, received order for CXR (chest X ray) & UA C+S (urinary analysis culture and sensitivity)..." Nursing note dated [DATE] at 1500 "X-ray results = modest (right) lower lobe infiltrate, call made to MD, received new order for antibiotic tx (treatment)..." On [DATE] the Radiology Report from the CXR states "Conclusion: Modest right lower lobe infiltrate. The findings are worse than [DATE]." Nursing note dated [DATE], ,[DATE] Resident seen by MD this morning who noted pulse /\ 160 Temp(temperature) 98.5 B.P. (blood pressure) ,[DATE] 02 (oxygen) sat (saturation) 94 degrees call to 911 (secondary to) MD order to send to E.R.(emergency room )..." Hospital note dated [DATE] states "...As per the daughter at the bedside, she has been having a cough for nearly one to two weeks. She developed fever and was started on an antibiotic yesterday. Today she was found to be [MEDICAL CONDITION] around ,[DATE]..." On review of the facility's 2011 July line listing, and infection control report, which was given to surveyor by Staff B (Director of Nursing) on [DATE] at 11 a.m. Resident #15 was not placed on the lists until [DATE] 3 days after signs and symptoms were present before being placed onto the infection control program. Resident #3 Review of the significant change MDS assessment form dated [DATE] for Resident #3 reveals, at section I2000, a [DIAGNOSES REDACTED]. Review of the Facility's Resident Infection Report for Resident #3 dated [DATE] reveals Resident #3 had contracted a Respiratory Tract Infection as evidenced by meeting at least 3 of the McGeer's Criteria for Infections in Long Term Care Facilities. Review of the line listing from [DATE] reveals no documented evidence showing Resident #3 was added to either the [DATE] or the [DATE] line listings for a Respiratory infection. Resident #11 Review of the Nurses notes dated [DATE], for the ,[DATE] shift reveals oxygen therapy utilized for Resident #11 in the following entry: "Addendum: Resident Falling (sic) asleep in w/c (wheel chair) before going to lunch. O2 Sats-88%. Gave 2L O2 via N/C (nasal cannula)-O2 Sats increased to 95%. Resident unable to stay awake to eat lunch. Went to bed after lunch. Notified MD. MD unable to arouse resident. New order to transport to hospital (proper name omitted). VS: ,[DATE] - 84 (heart rate) - 20 (respiration rate) - 95% on 2 L (2 liters of oxygen) via n/c (nasal cannula). Resident transported via stretcher at 1435 (2:35 p.m.). Family notified." On [DATE], during the initial tour of the Facility, it was observed that Resident #11 (who was out of the facility at that time.) had an oxygen concentrator in her room with oxygen tubing attached that was dated as last replaced on [DATE]. Review of the Entry record MDS dated [DATE] reveals that Resident #11 was readmitted from Hospital to the Facility, on this date.

Based on observation, record review, and interview the facility failed to implement facility policy and procedure, failed to maintain an infection control program, failed to maintain a current line listing, and failed to prevent the transmission of respiratory infections that rose to the level of immediate jeopardy. The facility failed to identify a cluster of upper respiratory tract infections contributing to the hospitalization of 6 residents. (Resident identifiers are #3, #6, #10, #11, #14, and #15), 2 with co-morbidities expired. (Resident #10 and Resident #15.) Findings include: Observation on entry into the facility on [DATE] revealed no sign was posted stating to all visitors that a suspected outbreak was within the facility. Sign was observed posted on [DATE] after Immediate Jeopardy had been called on [DATE]. During the entry interview on [DATE] with Staff B (DON), Staff B was asked if their had been any "....outbreaks of illness since the last survey." Staff B then asked what did I mean by an outbreak. After clarifying the definition of an outbreak, Staff B indicated the facility had not had an outbreak. The team then asked to see the line listings for June, July, and [DATE]. Staff B also stated that the person responsible for the Infection Control program and reporting to the QA committee was Staff K (IP) who was out sick during the survey. Review with Staff B of the line listings immediately after tour on [DATE] that morning revealed that 21 residents had been affected by an URI (Upper Respiratory Infection) in [DATE]. When Staff B was asked about a cluster of URI's listed for the middle of July, Staff B stated that they were across the hall from each other, "....why would that be an outbreak?" Review of line listing revealed that two of three units had greater than three residents with respiratory infection. Facility policy (see below) defines "Occurrence of three or more cases of the same infections over a specified length of time on the same unit" as an outbreak. During the above interview Staff B was asked if they had contacted Public Health about the above increase in URI's. Staff B stated that they had not. On [DATE] at about 1 p.m. confirmation was received by Public Health that no outbreak of any kind had been reported to them. Staff B reported on the morning of [DATE] that Public Heath was notified [DATE] after immediate jeopardy had been called. Review of policy and procedure under outbreak management states "...Incidence of multiple similar infections must be promptly identified and appropriately handled." The policy's document control measures include maintain line listing of identified cases and submit daily progress reports to the health department. Review on [DATE]-[DATE] of the Infection Control Program with Staff B (DON) and Staff C (RDCO (Regional Director of Clinical Operations)) showed detailed line listings of infections from [DATE]-[DATE] but the facility failed to maintain a current line listing; 4 sampled residents (Resident #3, Resident #10, Resident #11, and Resident #14) were not on the line listing and 2 sampled residents (Resident #6 and Resident #15), and 1 out of sample resident were not placed on the line listing timely. Policies and Procedures: Review on [DATE] and [DATE] of the facility's Infection Control Manual entitled "SunBridge Healthcare Corporation: Infection Control Manual" with an effective date of [DATE] stated; "Section 1: INFECTION CONTROL COMMITTEE" Standard: The Infection Control Committee oversees activities conducted to prevent and control infections in residents and personnel. Purpose: ? To control and prevent infections for residents and employees. ? To collect data related to infections occurring within the cener (sic). ? To promote adequate infection control practices in all departments. ? To ensure that appropriate supplies and equipment are available for use by personnel. ? The surveillance of infection control practices within the center." "Structure: The Infection Control Committee is responsible for; ? The reporting, investigation, control and prevention of infections." "The Infection Control Committee meets monthly and follows an agenda of topics related to center infection control practices. The agenda is forwarded to the committee members at least 1 week before each meeting." "Page 2, Minutes of the meetings are maintained which include; ? Member attendance ? Surveillance data analysis and trend reports ? Recommendations and actions to improve infection control practices throughout the center" "The Infection Preventionist (IP) reports committee activity to the Performance Improvement Committee quarterly." "Minutes: Topics to be included in the meetings should be but are not limited to the following: ? Nosocomial Infections (aquired (sic) after admission) ? Any trending related to the occurrence of infections ? Antibiotic use ? Any quality improvement plans for monitoring, evaluating and prevention/control of spread of infection." "Page 1, Section 2: Infection Preventionist The Infection Preventionist (IP) ? Is responsible for the quality of resident care relative to infection control practices ? Works under the direction of, and reports to, the Performance Improvement Committee" "This program [MEDICATION NAME] (sic) is based on CDC and APIC standards of practice in infection control. The Infection Preventionist must have copies of, and become familiar with, the state and local requirements; i.e. TB testing, outbreak notification, etc. With the understanding that an effective Infection Control Program requires the cooperation of the entire staff, the IP coordinates and facilitates surveillance and control activities with all departments." "Infection Preventionist duties Include: ? Surveillance to identify infections in residents and employees and to identify clusters in a timely manner ? Maintain the Infection Control Line Listing on each unit and a center date file. ? Analyze infection related data and track trends within the center and report appropriate information to state and local authorities ? Identify infection control issues and make recommendations for corrective actions ? Conduct outbreak investigations and initiate control measures ? Chair the Infection Control Committee and prepares the agenda for meetings" "Page 1, Section 8: Infection Surveillance Surveillance provides the foundation for the prevention and control of infections by providing systematic observation of the occurrence and distribution of center acquired infections among the residents. This includes: ? Data collection, collation and analysis. ? Dissemination of information to those who can take action." "There are two types of surveillance (process and outcome): 1. Process Surveillance Process surveillance reviews practices directly related to resident care in order to indentify (sic) whether the practices comply with established prevention and control procedures and policies based on recognized guidelines. 2. Outcome Surveillance In contrast to process surveillance, outcome surveillance is designed to identify and report evidence of an infection. The outcome surveillance process consists of collecting/documenting data on individual cases and comparing the collected data to standard written definitions (criteria) of infections" "SURVEILLANCE PROCEDURES Infection surveillance procedures that include all residents in the center. ? Monitoring and evaluation of appropriate antibiotic use (Line list, pharmacy orders, MD orders) ? Data collection: line list, Res. Inf. Report, PI forms, checklists, Floor plan to assess for trends/clusters ? Monthly evaluation of surveillance findings - Data analysis (Infection Control Log)" "Page 2, SURVEILLANCE ACTIVITY Any resident who exhibit signs and symptoms of infection should be monitored for a suspected infection. ? The Infection Preventionist (IP) is notified of suspected infections(s) by the charge nurse and/or through review of the 24-hour report ? The Charge Nurse completes the Resident Infection Report and documents pertinent information the the Line listing." "Page 1, Section 9: OUTBREAK MANAGEMENT Outbreaks of communicable diseases may occur in the resident population for a variety of reasons. Incidence of multiple similar infections must be promptly identified and appropriately handled. Proactive management is essential to limit the impact on the residents, staff and visitors. The definitions below do not necessarily coincide with the reporting parameters outlined by state and local regulators." (Note: State and Local guidelines for reporting, were not in the Infection Control Manual section as directed per their policy.) "An outbreak is typically one or more of the following: ? One case of an infection that is highly communicable ? Trends that are 10% higher than the historical rate of infection for the center that may reflect an outbreak or seasonal variation and therefore warrant further investigation; or ? Occurrence of three or more case of the same infections over a specified length of time on the same unit or other defined areas." "The Infection Practitioner: ? Notify the medical director of the concern ? Contact the local and state department of public health per regulations. ? Document control measures as necessary O Receive surveillance information and tabulate data O Maintain line listing of identified cases O Submit daily progress reports to the health department o Initiate the Communicable Disease Report Card system o Forward Communicable Disease Report Cards to the health department" "Page 2, Actions are Implemented: ? The Licensed nurse evaluates suspected contacts and notifies the attending physician. ? The attending physician/physician extender should visit the resident within 24 hours after being notified of the condition ? Contacts are cultured as directed by o The health department and/or o Medical director and/or attending physician. ? Symptomatic residents and employees are considered potentially infectious o Cultures are obtained o Appropriate precautions are maintained. ? Call an emergency meeting ot (sic) the Infection Control Committee to determine active control measures o Implement appropriate precautions o Discuss possible hold on admissions to the facility until 4 days after the last reported case or as authorized by health department or state regulations o Discontinue group activities, as indicated o Limit visitors if indicate i.e. influenza in the community o Assign nursing personnel to same resident groups for the duration of the outbreak" "Nursing Measures: Nursing personnel must remain diligent in controlling the outbreak ? Notify the DNS of symptomatic residents ? Provide infection surveillance data in a timely manner ? Obtain laboratory specimens as directed ? Initiate precautions as directed or as necessary ? Practice good hygiene and good hand washing ? Evaluate linen and precaution supplies ? Report any symptoms of illness to their supervisors." "The Medical Director: ? Oversee the management of the outbreak ? Work with the attending physicians and health department to determine the need for laboratory specimens o Based on symptoms and condition o Obtaining throat specimens for viral culture in an influenza outbreak o In the event of an influenza A outbreak, determining the need for Amanatadine (sic) therapy ? Determine the need for follow-up specimen and discontinuing precautions ? Determine when precautions may be discontinued o After 3 negative stool specimens have been obtained 24 hours apart o 48 hours after the discontinuance of anti-microbial medication o For Salmonella, if no nit-microbials were given, obtain the first specimen as soon as symptoms subsides" "Section 12: Infection Data Collection & Analysis An important aspect of Infection Control in any center is Data Collection. This section is designed to assist the Infection Control Coordinator with: ? Data collection ? Collation of the data ? Data analysis" "Data collection includes reviewing the line list and Resident Infection Reports and entering the pertinent data onto the Infection control log. This is an Excel file designed to assist you in managing data and funneling it to various graphs. These graphs will make it easier to analyze trends such as Infection rates, Infection types and location, etc." "Analysis of the data from the Infection control Log is uses (sic) to prepare reports to the QA committee such as; ? Infection rates which are calculated based on the number of infections that meet the McGeer (sic) Criteria, no (sic) the total number of reported conditions. ? Chronic vs. Acute infections ? Trends and outbreaks" Resident #10. Record review revealed that Resident #10 was a long term care resident who resided in the facility since [DATE]. This resident had multiple co-morbidities including [DIAGNOSES REDACTED]. Review of the quarterly MDS with an ARD (Assessment Reference Date) of [DATE] revealed that this resident was cognitively aware with a BIMS (Brief Interview for Mental Status) score of 15, no behavior issues coded, and required no assistance with eating or drinking. Resident #10 had no documented evidence, in the medical record, of lacking the capacity to make health care decisions. Review of the nurses notes for [DATE]-[DATE] revealed that Resident #10 developed a drop in O2 (Oxygen) levels and a cough with complaint stating, "...doesn't feel well" on [DATE]. Review of the MAR revealed both Tylenol and [MEDICATION NAME] were ordered and administered for this middle period in July. Review of the nurses note dated [DATE] on the ,[DATE] shift revealed, "Res. (resident) noted (symbol for with) (symbol for increased) SOB/cough (shortness of breath). SAT (saturation) 80% room air. Applied O2 @ 2 L (liters) via n/c (nasal cannula) however, sats cont. (continued) to hover in mid 80's. N.O. (new order) for O2 ,[DATE] L via nc....LS (lung sounds)-very dim (diminished) from bases to mid lobes.....meals in room per request." Review of the very next nurses note entry dated [DATE] on the ,[DATE] shift revealed, "Pt (patient medicated) X 2 on tylenol (sic) 650 mg (milligrams) @ 1530 and again @ 21:30 for (symbol for increased) temps of 100.3 and 100.1 respectively..." Review of the ,[DATE] (shift began at 11 p.m. [DATE]) nurses notes for [DATE] revealed, "Res. noted to be diaphoretic and c/o (complaint of) being hot. Also c/o cough. Temp 99.6. Tylenol given..." On [DATE] the ,[DATE] shift note written by Staff D (RN) read, "Resident states that (pronoun omitted) would like to go to the hospital. Resident on O2 via n/c - O2 sats 88% -89%. resident c/o SOB. MD notified. CXR (Chest X-ray) ordered...." Interview with Staff D on [DATE] at 12:05 p.m. revealed that Staff D was Resident #10's nurse on the ,[DATE] on [DATE]. Staff D stated that on [DATE] during the ,[DATE] shift, Staff D had called the primary care physician (Staff E), given Staff E the vital signs, and took an order for [REDACTED]. During an interview with Staff E (PCP/ Medical Director) on [DATE] at 8:15 a.m. Staff E stated that he was "surprised" that this resident had asked to go to the hospital. Staff E went on to say that Staff E did not realize there had been "....this many cases (of upper respiratory infections)..." Staff E went on to explain that the policy "not written" in this facility was to send those that wanted to go to the hospital, "right away..." Staff E stated that he, "did not realize" that Resident #10 had asked to go to the hospital on [DATE] during the ,[DATE] shift. Review of the nurses notes for the ,[DATE] shift on [DATE] revealed, "...had hard time holding on to (pronoun omitted) drinks, keeps on spilling it due to (pronoun omitted) hands being somewhat shaky...able to eat supper (symbol for with) some assistance in drinking. V/S (vital signs) ,[DATE] 90% on 3 LPM (liters per minute) 88 (pulse), 20 (respirations) 99.2 po (oral temp) occ (occasional) nonproductive cough noted." On [DATE] at 0300 the nurses notes by Staff F (LPN) read, "Resident noted to be in respiratory distress, labored breathing, diaphoretic, audible rattles in lungs both upon auscultation and listening. O2 sats on 3 L continue to be below 85....Called doctor @ 0315 he advised that (resident) be sent to the E.D. (emergency department) Patient left @ 0350 to hospital." On [DATE] at 0830 the nurses note by Staff F read, "DPOA informed of resident's condition @ 0350." Review on [DATE]-[DATE] of the Infection Control Program with Staff B and Staff C (RDCO (Regional Director of Clinical Operations)) revealed that Resident #10 had not been put on the up-dated line listing since the resident had "CHF, not an (URI) infection." Interview with Staff C (RDCO) on [DATE] in the afternoon confirmed that Resident #10 was not added to the July line listing until [DATE]. Staff C stated that the facility chose [DATE] as the start date for the infection on the line listing but did not add Resident #10's name to the listing until 35 days later. Resident #10 was added under the "URI (Upper Respiratory Infection)" section to the [DATE] up-dated line listing. The [DATE] date of the initial infection was 20 days before this resident was sent to the emergency roiagnom on [DATE]. Review of the hospital "emergency room Visit Notes" for [DATE] for Resident #10 revealed under the section REVIEW OF SYSTEMS, "....patient is unresponsive to verbal stimuli." Under the section PHYSICAL EXAM, "Patient in severe distress. Distress appears respiratory." Under the section PROGRESS AND PROCEDURES, "The patient required critical care due to the acute impairment of vital organ systems (respiratory) and a high probability of imminent and life threatening deterioration." Under the section LABS X-RAYS AND EKG, "Chest X-ray: Marked congestive heart failure present. Infiltrate in the right lower lobe. Consistent with pneumonia......" Review of the hospital "History & Physical Report" for [DATE] for Resident #10 revealed under the section HISTORY OF PRESENT ILLNESS, "....The nurse at the nursing home (Staff F) stated that (Staff F) noticed that yesterday (resident) started to have mental status change. (Resident) was not aware. (Resident) was acting different 'spacey' and just no (sic) (resident's self). It was noted this evening that (resident) was in frank respiratory distress was unable to maintain saturations, and not feeling well. The patient was sent here to the emergency department for evaluation. No history can be obtained from the patient due to (resident's) profound obtundness (sic). Conversation was had with DPOA and is not aware of any recent changes or illnesses." Further review under the section GENERAL revealed, "(Resident) is not responding to both deep painful or noxious stimuli. (Resident) did not move with ABG's (arterial blood gases) nor with multiple repeated blood draw attempts." Review of the Assessment and Plan section of the "History & Physical Report" for [DATE] revealed that this resident was initially assessed in Acute Renal Failure, had signs and symptoms of CHF, and had Right Lower Lobe Pneumonia. This resident had been placed in PCU and treated with [MEDICATION NAME] and IV antibiotics. Review of the hospital "Death Summary Report" for [DATE] for Resident #10 revealed under the section Hospital Course, "....Prior to arrival the patient was placed on BIPAP. Upon arrival the resident was obtunded." Later on in the paragraph it stated that the resident, "....was trialed (sic) on BIPAP for approximately 4 hours.....The patient remained obtunded." The report stated that Resident #10 died within 24 hours of admission to the hospital. During a confidential family interview of an out of sample resident on [DATE] around lunch time this family member stated that their mother got "Very sick" with an upper respiratory infection somewhere between ,[DATE]-[DATE]. "We thought that she was not going to make it." They stated, "...they were going to send her to the hospital but her doctor (Staff E) did an X-ray and treated her with antibiotics..." in the facility. This family member stated that that "Many were so sick....Residents and Staff.....we were lucky (referring to the fact that the mother did not die)." Observation on [DATE] in the afternoon of Staff H (LNA) leaving the day shift from the Phillips unit showed Staff H coughing heavily. When Staff H was seen in the morning of [DATE] entering the Phillips unit, this surveyor asked how Staff H was feeling. Staff H replied, "Much better. I have had pneumonia. Went back to the doctor, yesterday. This is my second round of antibiotics." Later that afternoon Staff H was observed in the Phillips Unit hallway comforting a resident by kissing them on the cheek. Once the division of public health was contacted on [DATE] in the early evening, they forwarded a letter to the facility to help prevent further spread of infection by offering several recommendations which are as followed: "-Suspend all communal activities. This includes dining room use by any affected residents and staff, parties, entertainers, and any visitors traveling between resident rooms." "-Restrict new admissions to affected unit(s). If transmission to other units/floors/wings occurs, BIDC (Bureau of Infectious Disease Control) will determine whether all admissions to the facility should be restricted." "Staff in affected units should not "float" to other units. Restrict well staff and residents from visiting or walking through the affected unit/floor/wing." "Staff caring for ill residents should follow contact and droplet precautions using surgical masks, gowns, and gloves." In an interview with Staff B (DON) and Staff C (RDCO) on [DATE] in the afternoon they stated that there had been no investigation or tracking of any ill staff until today, [DATE]. Staff B and Staff C were, "...making phone calls, now, to those who had called out (in July and August) ..." they stated that they were trying to find out how many and who had a respiratory infection. Interview with Staff B (DON) and Staff C (RDCO) on [DATE] at 9:15 a.m. confirmed that Public Health had not been notified and "...should have been called in July." Staff C thought that at least when "3% (were affected) they should have been notified." Both Staff B and Staff C acknowledged that there were inaccuracies in the line listings with some residents having been left off entirely. In an interview on [DATE] after lunch Staff B and Staff C said that the facility had not been closed to admissions, not closed to visitors, therapy continued, and that the units were not closed. In interviews on [DATE] in the afternoon, with the department heads, it was confirmed that neither activities, Rehab therapy room, or any of the dining room's were closed during July or August. Laundry and Housekeeping were not informed of any special precautions instituted for a respiratory outbreak in July or [DATE]. Resident #3. Observation on [DATE] in the afternoon and subsequent interview with Staff I (Unit Manager) at the time of the observation revealed that Resident #3 had a Precaution Cart with PPE in front of the Resident #3's room. This cart had not been observed, nor PPE observed utilized for Resident #3 either [DATE] or [DATE]. Staff I stated that the cart had been put out this morning because of Public Health recommendations given last night. Staff I confirmed that Resident #3 had not been on "precautions" for the respiratory infection before [DATE]. Resident #6 During the initial tour of the Phillips Unit with Staff B (DON) on [DATE], Staff B stated Resident #6 had an URI (upper respiratory infection) about a month ago and had been using oxygen via the nasal canula since then as needed. Medical record review was done during survey for Resident #6. Review of the physician note for Resident #6 dated [DATE] reads "Patient with URI (upper respiratory infection) sx (symptoms) today and for past three days. complained cough. no fever. no SOB (shortness of breath). + (positive) URI sx throughout facility this week... ." Further review of the medical record reveals Resident #6 was hospitalized from [DATE] - [DATE] due to acute respiratory failure. Review of the history and physical report dated [DATE] under "History of Present Illness" reads "The patient has severe dementia and most of the history is obtained from the nursing home records, the ... (nursing home facility) nurse, the son who is the DPOA and present at bedside, and the emergency room physician., The patient is an [AGE] year-old ... with a past medical history significant for COPD (chronic obstructive pulmonary disease) exacerbation, ... who presented to ...hospital for hypoxia and fever. The patient of note was seen at ...hospital in the middle of May for shortness of breath. At that time, ...(patient) was treated for [REDACTED]. The patient was apparently in her usual state of health and was on room air earlier today until ...(patient) developed shortness of breath. ...(Patient) was given an [MEDICATION NAME] treatment initially. An O2 saturation at that time was taken and it revealed that the patient was saturating 85% on room air. ...(Patient) was also found to have a fever with a temperature of 101.8 (degrees). ...(Patient) was immediately put on 2 liters oxygen via nasal cannula and later on received another nebulizer respiratory treatment. ...(Patient) had no response to this. Due to the persistence of ...(patient's) symptoms, the patient was brought to the emergency room hence leading to this subsequent admission. Upon arrival to the emergency, the patient was noted to be dyspneic with respiratory rate from ,[DATE]. ...(Patient) was initially started on oxygen via nasal cannula. However, owing to ...(Patients) persistent dyspnea, she was started on noninvasive positive pressure ventilation." Continued review of this same "History and Physical Report" reveals under "Assessment and Plan" on page 3 reads "This is an [AGE] year-old ... with a past medical history significant for chronic obstructive pulmonary disease with recent treatment for [REDACTED]. who presents to ...hospital for acute respiratory failure. 1. Acute respiratory failure: The patient will be admitted to the intensive care unit. The patient had been started on noninvasive positive-pressure ventilation. Multiple attempts have been made to obtain an arterial blood gas; however, this has been unsuccessful. We will reattempt this later today. ...(Patient) appears to be tolerating the BiPAP well and is oxygenating nicely. ...(Patients') work of breathing has significantly decreased since having been started on noninvasive positive-pressure ventilation. Blood cultures x 2 (times 2) will be obtained. ...(Patients') fever is concerning for a possible pneumonic process. It was reported to me that several people at the nursing home have been sick lately. In this light, we will cover her empirically with [MEDICATION NAME] and [MEDICATION NAME], ... . I will also obtain sputum culture, urine legionella [MEDICATION NAME], and strep pneumococcal [MEDICATION NAME]. We will start ...(patient) on nebulized respiratory treatments and intravenous steroids. We will give her mild intravenous fluid hydration today and repeat a chest x-ray tomorrow, ... ." The hospital discharge summary dated [DATE] states under discharge [DIAGNOSES REDACTED]. Urinary tract infection ([DIAGNOSES REDACTED]). 2. Acute respiratory failure on bilevel positive airway pressure (BiPAP), also on bilevel positive airway pressure (BiPAP) on admission, probably due to chronic pulmonary disease (COPD) exacerbation." Under this same hospital discharge summary in the section entitled "Hospital Course is written " This is an [AGE] year-old ...(patient) who came with a history of fever and hypoxia. The patient has a history of COPD, initially suspected a COPD exacerbation and pneumonia. ..(Patient) had blood cultures and urine cultures done. Initially ... (patient) was admitted ...on BiPAP but ...turned around quickly, but ...(patient) continued to need oxygen to saturate more than 90%. ...(Patient) had a chest x-ray done which was read as chronic interstitial lung disease without definite evidence of acute process. ...(Patient) was treated with IV antibiotics for a possible pneumonia or urinary tract infection. ...blood cultures came negative. ...urine culture came positive for [DIAGNOSES REDACTED] pneumonia which is sensitive to [MEDICATION NAME]. Upon discharge we will discharge on [MEDICATION NAME]." Resident #6 returned to the facility on [DATE]. The admission nursing note of [DATE] reads "Resident admitted from ... hospital ...[DIAGNOSES REDACTED]." No mention is made in this nursing note of the urinary tract infection which is listed as the primary [DIAGNOSES REDACTED]. Review of the line listing for facility infections reveals Resident #6 was added to the facility line listing for a respiratory infection on [DATE] which was two days after this resident returned from the hospital and 13 days from the onset of illness as documented on the [DATE] physician's note described above. Resident #6 was diagnosed at the hospital with a primary [DIAGNOSES REDACTED]. But the facility line listing has Resident #6 only noted as having a respiratory infection. Resident #3 Review of the significant change MDS assessment form dated [DATE] for Resident #3 reveals, at section I2000, a [DIAGNOSES REDACTED]. Review of the Facility's Resident Infection Report for Resident #3 dated [DATE] reveals Resident #3 had contracted a Respiratory Tract Infection as evidenced by meeting at least 3 of the McGeer's Criteria for Infections in Long Term Care Facilities. Review of the line listing from [DATE] reveals no documented evidence showing Resident #3 was added to either the [DATE] or the [DATE] line listings for a Respiratory infection. Resident #11: Review of the Nurses notes dated [DATE], for the ,[DATE] shift reveals oxygen therapy utilized for Resident #11 in the following entry: "Resident appears tired O2 Sat (percent of oxygen saturation in the blood) ,[DATE](%)-answering appropriately to Nurse Manager but earlier confusion noted, O2 (oxygen) on at 2L (2 liters/minute)..." Review of the Nurses notes dated [DATE], for the ,[DATE] shift reveals oxygen therapy utilized for Resident #11 in the following entry: "Addendum: Resident Falling (sic) asleep in w/c (wheel chair) before going to lunch. O2 Sats-88%. Gave 2L O2 via N/C (nasal cannula)-O2 Sats increased to 95%. Resident unable to stay awake to eat lunch. Went to bed after lunch. Notified MD. MD unable to arouse resident. New order to transport to hospital (name omitted). VS: ,[DATE] - 84 (heart rate) - 20 (respiration rate) - 95% on 2 L (2 liters of oxygen) via n/c (nasal cannula). Resident transported via stretcher at 1435 (2:35 p.m.). Family notified." On [DATE], during the initial tour of the Facility, it was observed that Resident #11 (who was out of the facility at that time.) had an oxygen concentrator in her room with oxygen tubing attached that was dated as last replaced on [DATE]. Review of the Entry record MDS dated [DATE] reveals that Resident #11 was readmitted from (hospital) to the Facility, on this date. Resident #14. On review of Resident #14's nurses noted dated [DATE] at 2 p.m. it states "02 sat (oxygen saturation) 92% - abnormal lung sounds - congested cough remains alert & verbal - notified (physician) of change in condition he ordered a CXR (chest X-ray) - T (temperature) 101.8