Every finding on record at Folsom Care Center

Based on observation, interview, and record review, the facility failed to ensure: 1. Medication storage rooms were kept secure when the automatic closing mechanism failed and the door was unlocked and accessible;2. Two of two medication storage room refrigerators were not monitored according to facility policy and procedure (P&P), and temperatures were not accurately documented;3. Emergency medications were not stored according to manufacturer specifications;4. Medication brought by family for Resident 69 was not labeled in accordance with facility P&P; and5. Medication carts were not kept locked and secure when unattended by nursing staff. These failures had the potential for diversion of medications, residents exposed to medications with unsafe or reduced potency, and incorrect or unsafe administration of medication from the absence of labeling on the container.Findings: 1. During a medication pass (med pass) observation on [DATE] at 8:22 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing two medications for Resident 103 including aspirin (a medication to prevent blood clots) EC (enteric coated, a special delayed release coating to prevent stomach irritation) 81 milligrams (mg, a unit of measurement), 1 tablet. During a concurrent observation and interview on [DATE] at 8:30 a.m. with LN 3, LN 3 looked in the medication cart and stated the aspirin was not available for administration but would check in the automated dispensing cabinet (ADC, a computerized, secure medication storage device located at the nursing station that allows for decentralized, automated storage, tracking, and dispensing of medications). LN 3 went into the medication storage room where the ADC was located, and when she was finished, she walked out without looking back to ensure the automatic closing mechanism shut and locked the door. When asked if the door had shut completely, LN 3 turned back and confirmed the door was ajar and shut it. During a second observation and interview on [DATE] at 9:39 a.m. with LN 3, LN 3 went back to the medication storage room with the ADC. LN 3 exited the room and the door again did not shut completely. LN 3 began to walk away and when it was brought to her attention that the door was unlocked, she turned around and went back to shut it. During a concurrent observation and interview on [DATE] at 11:17 a.m. with Head of Maintenance (HM), the HM was observed working on the automatic closing mechanism of the medication storage room that housed the ADC. The HM stated there was a problem with the closing mechanism and the lodge mechanism was not fitting with the door. The HM stated it appeared that someone had adjusted it in the past, but he needed to make additional adjustments for it to lock correctly. During a review of the facility's P&P titled, ID-1 Storage of Medications, dated 3/2018, the P&P indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 2. During a concurrent observation, interview, and record review on [DATE] at 10:08 a.m. with LN 11, the Sutter Station Medication Room Medication Refrigerator Daily Temperature Records were reviewed. LN 11 stated the refrigerator temperature was monitored by the morning and night nursing shifts. LN 11 reviewed the temperature records dated [DATE] to [DATE] and confirmed there were multiple shifts where nursing staff did not document that the temperature was monitored. A review of the Medication Refrigerator Daily Temperature Record (for the dates reviewed) indicated nursing staff did not monitor the temperature for 14 shifts. LN 11 stated staff possibly forgot to document on the log. A review of the refrigerator temperature for the day shift indicated nursing staff documented the temperature as 40 degrees Fahrenheit every single day. Two digital readouts on the exterior of the refrigerator were observed. LN 11 confirmed the digital readout nursing staff was recording read 4.0 C (Celsius). LN 11 stated she would do research to confirm that 4.0 C was the same as 40 degrees Fahrenheit (as documented by nursing staff). During a concurrent interview and record review on [DATE] at 10:37 a.m. with LN 11, the Natoma Station Medication Storage Room Medication Refrigerator Daily Temperature Records were reviewed. LN 11 confirmed multiple nursing shifts had not documented that the refrigerator temperature was routinely monitored and stated medications could be expired or lose potency if not monitored twice daily. A review of the Medication Refrigerator Daily Temperature Record (for the dates reviewed) indicated nursing staff did not monitor the temperature for 11 shifts. During a concurrent observation, interview, and record review on [DATE] at 11:05 a.m. with the Registered Nurse/Unit Manager (RN/UM), the Sutter Station Medication Storage Room Medication Refrigerator Daily Temperature Records were reviewed. The RN/UM confirmed the digital readout indicated 4.0 C and the day shift nursing staff had documented the temperatures as 40 degrees. The RN/UM stated 4.0 Celsius was different than 40 degrees Fahrenheit. During an interview and record review on [DATE] at 1:54 p.m. with LN 2, LN 2 reviewed the temperatures she had documented for the Sutter Station Medication Storage Room Refrigerator and confirmed she was documenting the 4.0 C digital readout as the temperature inside the refrigerator. LN 2 stated she thought 4.0 Celsius was the same as 40 degrees Fahrenheit. During an interview on [DATE] at 2:01 p.m. with the DON, the DON stated he had reviewed the medication storage room temperature monitoring logs and confirmed they were incomplete and incorrectly documented. The DON stated the digital centigrade readout that LN 2 was documenting was the temperature the refrigerator was set to be at. The DON stated every nursing shift was expected to document the refrigerator temperature three times a day, and at a minimum, twice a day. The DON stated it was important to do twice daily temperature monitoring to be able to correct deviations. During an interview on [DATE] at 10:46 a.m. with the CP, the CP stated nursing staff should be monitoring and documenting medication refrigerator temperatures twice a day. During a review of the facility's P&P titled, ID-1 Storage of Medications, dated 3/2018, the P&P indicated, Procedures. K. Medications requiring 'refrigeration'. are kept in a refrigerator with a thermometer to allow temperature monitoring. 3. During a concurrent interview and inspection on [DATE] at 10:12 a.m. with LN 11, the Sutter Medication Storage Room Refrigerator was inspected. The refrigerator had a clear glass door and inside was an E-Kit (a sealed box that contains emergency medications). The E-Kit was removed from the refrigerator and two clear glass vials lorazepam (a medication to treat severe seizures in an emergency) 2 milligrams/milliliter (mg/ml, a unit of measurement) were identified inside. The manufacturer's labeling on the vial indicated, Protect from light. LN 11 confirmed the manufacturer's labeling and stated the Sutter Medication Storage Room light always stayed on. LN 11 stated if the medication was exposed to light, it had the potential to lose potency and not be as effective when used in an emergency. During a concurrent interview and inspection on [DATE] at 10:37 a.m. with LN 11, the Natoma Station Medication Storage Refrigerator was inspected. The refrigerator was identical to the Sutter Station Medication Refrigerator with a clear glass door. Inside the refrigerator was an E-Kit that contained two clear glass vials lorazepam 2 mg/ml injectable. The manufacturer's labeling on the vials indicated, Protect from light. LN 11 confirmed the manufacturer's labeling and stated the light in the Natoma Station Medication Storage Room also stayed on at all times. During an interview on [DATE] at 2:06 p.m. with the DON, the DON confirmed the lorazepam in the refrigerated E-Kits needed to be protected from light. The DON stated exposure to light could potentially degrade the medication since the manufacturer had labeled it to be protected from light.During an interview on [DATE] at 10:48 a.m. with the CP, the CP stated if a light sensitive medication was not in a light protected vial, it needed to be in a light protective bag or in a drawer. The CP stated the lorazepam was not entirely protected from light and exposure to light increased the degradation of the medication. A review of the manufacturer's labeling for lorazepam 2 mg/ml injectable dated 2/2021 indicated, Store in a refrigerator. PROTECT FROM LIGHT. Use carton to protect contents from light. During a review of the facility's P&P titled, ID-1 Storage of Medications, dated 3/2018, the P&P indicated, Policy: Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. 4. During a concurrent interview and inspection on [DATE] at 10:39 a.m. with LN 11, the Natoma Station Medication Storage Refrigerator was inspected. Inside the refrigerator was a manufacturer's sample box of medication for Ozempic (a medication to treat diabetes) 2 mg/3 ml prefilled injectable pen with Resident 69's name written on it in black permanent marker. The box did not have any labeling on it to indicate where the medication was dispensed from, prescriber's name, or directions for use. LN 11 confirmed the finding and stated all medications that were delivered to the facility from the supplier pharmacy always had a pharmacy label on it. During a concurrent observation and interview on [DATE] at 10:43 a.m. with RN/UM, Resident 69's Ozempic was inspected. RN/UM confirmed the Ozempic did not have a label on it. He stated all medications stored in the facility for a specific resident needed a label on it because the label verified there was a physician's order for it, tells nursing staff which resident it was for, and what the dose was. During an interview on [DATE] at 2:07 p.m. with the DON, the DON stated Resident 69's family wanted to supply the Ozempic so they brought it into the facility. The DON stated if a medication was brought in by family for a resident, it needed to be sealed and have a pharmacy label or printed instructions on it from the physician on the package. During a review of the facility's P&P titled, IC-7 Medications Brought to the Facility by a Resident or Family Member, dated 3/2018, the P&P indicated, Procedures: A. Use of medications brought to the facility by a resident or family member on admission (i.e. not delivered directly from any pharmacy) is allowed only when the following conditions are met. 4. The medication container is clearly labeled in accordance with facility procedures for medication labeling and packaged in a manner consistent with facility guidelines for medications. 5. During a concurrent observation and interview on [DATE] at 8:32 a.m. with LN 13 at the Sutter Nursing Station, a medication cart was observed unlocked and unattended, accessible to residents passing by. LN 13 confirmed the med cart was unlocked and unattended. LN 13 confirmed she walked away from the cart without locking it and stated, I forgot. LN 13 stated they were not to leave med carts unlocked and unattended for safety reasons. She stated that locking the cart was essential to ensure its contents remained secure and inaccessible to residents. During an interview on [DATE] at 9:45 a.m. with the DON, the DON stated the med carts were to be kept locked when unattended to ensure the safety of the medications and the safety of the residents During a review of the facility's P&P titled, IIA-2 Medication Administration- General Guidelines, dated 3/2018, the P&P indicated, Procedures. B. Administration. 13. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse.

Based on observation, interview, and record review, the facility failed to ensure professional standards were followed when: Nursing staff did not wear appropriate personal protective equipment (PPE) while handling hazardous medication (medications that can cause serious effects including cancer, organ toxicity, fertility problems, genetic damage, and birth defects if not handled appropriately). Pain medication was not administered in accordance with the physician's order.An unclear PRN (as need) psychotropic medication order for Resident 11 was not clarified for indication for use prior to administration. These failures had the potential to result in worsening resident health conditions and unwanted exposure to hazardous medications leading to health complications. Findings: 1. During a medication pass observation on 4/21/26 at 7:50 a.m. with Licensed Nurse 2 (LN 2), LN 2 was observed preparing four medications for Resident 63 including mycophenolate mofetil (a medication to suppress the immune system) 500 milligrams (mg, a unit of measurement), two tablets. The pharmacy label affixed to the bubble pack indicated the medication was hazardous. LN 2 prepared the medications without wearing gloves or any other personal protective equipment. A review of Resident 63's medical record indicated a physician's order for mycophenolate mofetil 500 mg, give two tablets by mouth two times a day for immunosuppression related to sarcoidosis of lung (a rare disease where the immune system goes into overdrive, creating tiny, inflamed, solid lumps called granulomas in the lungs and lymph nodes), dated 3/14/25. During an interview on 4/21/26 at 1:27 p.m. with LN 2, LN 2 stated nursing staff were made aware of special handling requirements for hazardous medications by the pharmacy. LN 2 stated the pharmacy wrote it on the bubble pack, or it would be written in the directions on the pharmacy label. LN 2 stated the pharmacy would also place a sticker on the bubble pack to alert that the medication was hazardous. LN 2 stated she was not aware mycophenolate was a hazardous medication that required PPE and said, I just saw it right now. LN 2 stated it was important to wear gloves when handling hazardous medications, so it did not touch their hands or other things. During an interview on 4/22/26 at 1:47 p.m. with the Director of Nursing (DON), the DON stated hazardous medications included special instructions on the order. He stated nursing staff added the special instructions in the order or the pharmacist would identify it on the monthly review if it was not included. The DON stated a message would pop up for nursing staff in the E-MAR (electronic medication administration record). He stated nursing staff were expected to wear gloves when handling hazardous medication and it was important to do so for self-protection. The DON stated when the order for Resident 63 was discontinued the prior day, the special handling instructions for wearing gloves were not included. During a telephone interview on 4/23/26 at 10:40 a.m. with the Consultant Pharmacist (CP), the CP stated nursing staff were made aware of hazardous medications in the facility through education provided by the pharmacy as well as recommendations he made when reviewing resident drug regimens. The CP stated nursing staff should wear gloves during the preparation and administration of mycophenolate. 2. A review of Resident 86's medical record indicated she was admitted to the facility in December 2023 with diagnoses including osteoarthritis (a joint disease where the smooth, slippery cartilage cushioning the ends of bones breaks down) and spondylolisthesis (a spine condition where a backbone slips out of its proper position and moves forward, backward, or sideways over the bone below it). A review of Resident 86's physician's orders indicated an order for hydrocodone/acetaminophen (a potent opioid medication to treat pain) 5/325 mg, give one tablet by mouth every four hours as needed for severe pain (7-10) (pain scale of 0 to 10, with 10 being the highest level of pain), NTE (not to exceed) 3 grams of Tylenol in 24 hours from all sources, dated 9/3/25. A review of Resident 86's medication administration record (MAR) dated April 2026 indicated nursing staff administered hydrocodone/acetaminophen to Resident 86 for pain levels below parameters (specific, pre-determined safety rules that tell a nurse when it is appropriate to administer a dose of medication if a resident's pain level falls within a specified range) ordered by the physician on the following dates: 4/3/26 pain level 5, 4/4/26 pain level 5, 4/5/26 pain level 6, 4/5/26 pain level 5, 4/6/26 pain level 6, 4/9/26 pain level 6, 4/10/26 pain level 5, 4/11/26 pain level 0, 4/11/26 pain level 5 at 6:36 p.m. and again at 11:05 p.m., 4/12/26 pain level 6, 4/12/26 pain level 5, 4/13/26 pain level 6 at 3:40 a.m. and again at 1:12 p.m., 4/17/26 pain level 5, 4/18/26 pain level 5, 4/19/26 pain level 6, 4/19/26 pain level 5, 4/20/26 pain level 6 at 3:33 a.m. and again at 1:30 p.m., and 4/21/26 pain level 6 at 8:28 a.m. and again at 1:37 p.m. During a concurrent interview and record review on 4/22/26 at 2:43 p.m. with the DON, Resident 86's physician order for hydrocodone/acetaminophen was reviewed. The DON confirmed the order indicated to administer for pain level seven to 10. The DON stated Resident 86 had a physician's order for ibuprofen (a nonsteroidal anti-inflammatory medication to treat pain) indicated for moderate pain levels of five and six. He stated Resident 86 knew what she wanted and was insistent on it so nursing staff should have contacted the physician to update the parameters for the hydrocodone/acetaminophen order or administered ibuprofen when the resident reported pain levels five and six. 3. A review of Resident 11's medical record indicated he was admitted to the facility in March 2025 with diagnoses including dementia with other behavioral disturbance (globally referred to agitation including anxiety) and adjustment disorder with mixed disturbance of emotions and conduct (a condition where a person experiences both emotional distress such as anxiety, depression and behavioral issues such as aggression and acting out). A review of Resident 11's medical record indicated a physician's order for lorazepam (a medication to treat anxiety) 0.5 mg, give one tablet by mouth every four hours as needed for anxiety manifested by continuous shouting for 14 days and give two tablets by mouth every 4 hours as needed for severe anxiety manifested by continuous shouting for 14 days, dated 4/22/26. During a concurrent interview and record review on 4/24/26 at 12:57 p.m. with LN 1, Resident 11's lorazepam order was reviewed. LN 1 stated the order was unclear and should have been clarified. LN 1 stated the order was confusing for nursing staff who were not familiar with Resident 11's baseline mood. During a concurrent interview and record review on 4/24/26 at 1:37 p.m. with the DON, Resident 11's lorazepam order was reviewed. The DON confirmed the order was unclear and stated nursing staff should have clarified it. During a review of the facility's policy and procedure (P&P) titled, Section II: Medication Administration Preparation and General Guidelines IIA-2, dated 3/2018, the P&P indicated, Medication Administration-General Guidelines Policy: Medications are administered as prescribed in accordance with good nursing principals and practices. Procedures. B. Administration. 2. Medications are administered in accordance with written orders of the attending physician. 3. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current diagnoses or conditions, the nurse calls the provider pharmacy for clarification prior to the administration of the medication or if necessary contacts the prescriber for clarification.

Based on interview and record review, the facility failed to ensure four out of five sampled employee personnel records included annual performance evaluations (formal, written, mandated processes typically occurring annually and during probationary periods to assess skill, knowledge, and work habits).This failure had the potential to result in poorly trained and managed employees, decreased quality of care provided, and safety risks for a vulnerable population.Findings: During a concurrent interview and record review on 4/23/26 at 8:53 a.m. with the Director of Staff Development (DSD) and the Administrator (Adm), the Certified Nursing Assistants (CNAs) personnel records reviewed did not have a completed Annual Performance Evaluations (APE). The Adm stated the APE's had not been completed in a while. The Adm indicated the performance evaluations have not been on the facility's radar and the employee performance evaluations were not completed as required. The Adm stated the performance evaluations were used to ensure the staff perform up to current laws and regulations and maintain the staff skills for patient care. The Adm confirmed the DSD and the Admin conducted walking rounds, walked the halls and observed the CNAs, and if the DSD noticed a trend, then those issues were discussed during the staff in-services. The DSD stated, Performance evaluations are a great way to determine what in-services are needed to be taught throughout the facility.During an interview on 4/23/26 at 10:40 a.m. with the Director of Nursing (DON), the DON confirmed the performance evaluations were completed on the employees Anniversary Date of Hire (ADOH). The DON confirmed the performance evaluations have not been done for quite a while. The DON indicated the importance of the annual performance evaluation was used as a tool to know how the staff were doing, and the performance issues to identify, and if additional trainings were needed. The DON stated, The Unit Managers (UMs) on each station should do the performance evaluation for the staff in their units. The CNAs APE had not been done.During a concurrent interview and review on 4/23/26 at 12:30 p.m. with the DON, the DON reviewed the following employees' personnel files and confirmed the employee files did not have a completed APE for the following CNAs:CNA 3 - ADOH 7/1/25 (not due);CNA 5 - ADOH 1/23/25;CNA 6 - ADOH 1/23/25;CNA 7 - ADOH 1/3/24; andCNA 8 - ADOH 7/30/24 terminated 2/28/26. The DON indicated he had not done a performance evaluation in a long time, and stated, Some of the managers did not have a completed annual performance evaluation for quite some time now.During an interview on 4/23/26 at 1:52 p.m. with the UM, the UM indicated she had been in the facility for 11 years. The UM stated she personally had not had a performance evaluation in years. A request was made for Performance Evaluation policies and procedures, but none was provided by the end of survey.

Based on observation, interview, and record review, the facility failed to ensure: Nursing staff disposed of medication that was prepared but not administered in accordance with facility policy and procedure;Medications for destruction were disposed of in a manner that limited potential for diversionEmergency medications (E-kit) were replaced timely for a census of 84;Two of 2 randomly selected medication cart controlled drug sign-in/sign-out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart by the outgoing and incoming nurse during a shift change) were signed by the outgoing and incoming nursing shift. These failures resulted in the facility not having accurate accountability of controlled medications and potential for abuse or misuse of these medications, the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.1. During a medication pass (med pass) observation on 4/21/26 at 8 a.m. with Licensed Nurse 2 (LN 2), LN 2 was observed preparing medications for Resident 63, including metoprolol succinate (a medication to treat high blood pressure) ER (extended release) 25 milligrams (mg, a unit of measurement), one tablet. LN 2 reviewed Resident 63's vitals and stated she would not administer the metoprolol because his blood pressure fell below the parameters (specific, pre-determined safety rules that tell a nurse or caregiver to skip a dose of medication if a resident's vital signs or lab results are not in a safe range). During the same medication pass observation on 4/21/26 with LN 2, LN 2 placed the metoprolol tablet in a cup then placed the paper cup in the top drawer of the medication cart (med cart). LN 2 stated she would later dispose of it in a container in the medication storage room. During an interview on 4/21/26 at 8:47 a.m. with LN 3, LN 3 stated prepared medications that were not administered to the residents were to be disposed of right away and not at the end of a med pass. She stated it could be a slippery slope, and she did not want to hang onto refused pills and get them confused with other medications. During a concurrent interview and inspection on 4/21/26 at 10:01 a.m. with LN 2, LN 2's med cart was inspected. LN 2 opened her med cart and inside the drawer was the one white pill (from the med pass observation 2 hours earlier) in a cup still in right hand side of the med cart. LN 2 stated she collected dropped or refused doses of medication during med pass in the top drawer and disposed of them when she passed by the medication storage room that contained the drug disposal container. LN 2 pulled out a small drug destruction container located in the med cart and stated it was designated for the destruction of controlled substances. During a concurrent interview and inspection on 4/22/26 at 1:20 p.m. with LN 4, the Natoma 1 Med Cart was inspected. LN 4 stated if she was in the middle of med pass she would place noncontrolled medications that needed to be destructed in a paper cup in the drawer of the med cart and then dispose of them in the medication storage room at the end of her shift. LN 4 then removed a paper cup from the med cart and inside was eight tablets. LN 4 stated she could also use a drug destruction container that was located on the med cart but stated it filled up quickly so she saved the pills to destruct them in a larger container in the medication storage room. During an interview on 4/22/26 at 2:09 p.m. with the Director of Nursing (DON), the DON stated non-narcotic medications that were refused or dropped should have been placed in the drug destruction container inside the med cart. The DON stated nursing staff should have been disposing medication right away because if it is saved in the med cart it could potentially be administered to a resident by mistake. During a telephone interview on 4/23/26 at 10:29 a.m. with the Consultant Pharmacist (CP), the CP stated nursing staff were expected to destruct dropped or refused medication right then and there at the med cart using the drug destruction container located inside it. During a review of the facility's policy and procedure (P&P) titled, Preparation and General Guidelines, dated 3/2018, the P&P indicated, IIA-2 Medication Administration- General Guidelines. Procedures. A. Preparation. 4. Once the medication and dose have been confirmed, the medication is ready to be removed from the prescription packaging. b. If for any reason, once removed from the packaging, the resident refuses some or all of the medications, the refused medications are destroyed at the medication cart per facility procedures. C. Medications removed from the prescription packaging and refused by the resident are not kept (on the cart, in the nurse's pocket, in the medication room) for attempts at administering at a later time. 2. During a concurrent interview and inspection of the Sutter Medication Storage Room on 4/21/26 at 10:26 a.m. with LN 11, a large white plastic container with a blue pop-open lid was observed. Inside the container were hundreds of tablets, capsules, injectable vials with medication inside and unopened vials of medication for nebulization. The opening of the container was large enough to allow one to reach inside and either pull out or pour medication out. No other substance or liquid was mixed in the container, and the medications were in their original form. LN 11 confirmed the observation and stated the medications were retrievable. During an interview on 4/22/26 at 2:12 p.m. with the DON, the DON stated nursing staff were expected to add liquid of some kind, cat litter, or coffee grounds initially to start a new medication destruction container in the med storage room. The DON stated it was important for the container to have another substance in it to limit the potential for diversion. During a telephone interview on 4/23/26 at 10:32 a.m. with the CP, the CP stated the medication destruction containers located in the medication storage room were for nonnarcotic medications that were discontinued or not going home with a resident. CP confirmed that from a diversion standpoint, the opening of the container was large enough for medications to be easily removed if they were kept in there in their original form. During a review of the facility's P&P titled, IE-E Medication Destruction, dated 3/2018, the P&P indicated, Procedures. J. Unintentional Wasting of Medication Doses 2. If a single dose of medication is accidentally contaminated or is otherwise unusable, (dropped, spilled, touched, refused by the resident, etc.), the following policies and procedures will apply: a. Non-controlled drugs (prescription and non prescription) - single doses may be destroyed by the nurse preparing the dose for administration. Destruction is accomplished by discarding the crushed/capsule emptied medication dose in the 'medication waste/[branded product for drug destruction]/[branded product for drug destruction]' container on the cart.' 3. During a concurrent observation and interview on 4/21/26 at 10:56 a.m. in the Mill Station Medication Storage Room with Registered Nurse/Unit Manager (RN/UM), the Injectable/Sublingual/Nasal/Oral Suspension E-Kit was observed with a red plastic tie indicating it had been opened by nursing staff. Inside the E-Kit was a log. RN/UM opened the E-Kit and emergency kit log (a document completed by nursing staff whenever a medication is removed from the emergency supply) was dated 4/11/26, 10 days prior. RN/UM stated nursing staff were expected to reorder a used E-Kit right away. He confirmed it was expected that the E-Kit would have already been replaced and stated the timeline for replacing an opened E-Kit was 48 to 72 hours. RN/UM stated it was important used E-Kits were replaced timely to ensure nursing staff did not open them in need of medication only to find that the supply had been exhausted. During an interview on 4/22/26 at 1:57 p.m. with the DON, the DON stated nursing staff were expected to reorder an opened E-Kit immediately and it should be replaced within 72 hours. The DON stated nursing staff routinely check E-Kits to see if any had been opened and if they were, they were expected to reorder them. The DON stated he would rather have nursing staff reorder an E-Kit 20 times than to not have it replaced at all. During a telephone interview on 4/23/26 at 10:27 a.m. with the CP, the CP stated once an E-Kit was opened, nursing staff were expected to notify the pharmacy and reorder it. The CP stated the pharmacy was to replace the used E-Kit within three days. During a review of the facility's P&P titled, IC-3 Emergency Pharmacy Service and Emergency Kits, dated 3/2018, the P&P indicated, Procedures. Procedures. G. As soon as possible, the nurse records the medication use on the medication order form and notifies the pharmacy for replacement of the kit by transmitting the entire order for the resident and indicating that the first dose was used from the kit. The nurse flags the kid with a red color-coded lock to indicate need for replacement of kit. K. If exchanging kits, opened kits are replaced with sealed kits within 72 hours of opening. If replacing used medications, the replacement doses are added to the kit within 72 hours of opening. 4. During a concurrent interview and record review 4/21/26 at 1:54 p.m. with LN 12, the Floor Narcotic and Emergency Kit Release for the Mill Station Medication Cart was reviewed. LN 12 stated nursing staff were expected to document between shifts that they completed a narcotic count. LN 12 confirmed there were many shifts where nursing staff had not documented that the narcotic count was done. A review of the record, dated 2/1/26 to 4/21/26, indicated 95 missing signatures between nursing shift changes. During a concurrent interview and record review on 4/21/26 at 3:46 p.m. with LN 2, the Floor Narcotic and Emergency Kit Release for the Sutter Station Medication Cart was reviewed. LN 2 confirmed nursing staff were expected to count the narcotics between shift change and document the count was completed on the form. LN 2 confirmed there were missing signatures and stated sometimes nursing staff forgot to sign it. A review of the record, dated 2/1/26 to 4/21/26, indicated 37 missing signatures between nursing shift changes. During an interview on 4/22/26 at 2 p.m. with the DON, the DON stated nursing staff were expected to count and document on the shift-to-shift count sheet that the count was performed between shift change. During a review of the facility's P&P titled, ID-3 Controlled Medication Storage, dated 3/2018, the P&P indicated, Procedures. D. At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is documented on the controlled medication accountability record.

Based on observation, interview, and record review, the facility had a 7.69% error rate when three medication errors out of 39 opportunities were observed during a medication pass for three of nine Residents (Residents 73, 84, and 103). This failure resulted in medications not given in accordance with the prescriber's order and potential to affect the residents' clinical conditions. 1. During a medication pass (med pass) observation on 4/21/26 at 8:22 a.m. with Licensed Nurse 3 (LN 3), LN 3 was observed preparing two medications for Resident 103 including aspirin (a medication to prevent blood clots) EC (enteric coated, a special delayed release coating to prevent stomach irritation) 81 milligrams (mg, a unit of measurement), 1 tablet. A review of Resident 103's physician's orders indicated an order for aspirin delayed release 81 mg, give one tablet by mouth two times a day for VTE (venous thromboembolism, dangerous blood clots that form in the veins) prophylaxis (prevention) for 30 days, dated 4/16/26. LN 3 looked in the medication cart and stated the aspirin was not available for administration but would check in the automated dispensing cabinet (ADC, a computerized, secure medication storage device located at the nursing station that allows for decentralized, automated storage, tracking, and dispensing of medications). LN 3 stated enteric coated aspirin was stocked in the ADC and the chewable aspirin was stocked in the facility's over the counter (OTC) drug supply. LN 3 went to the medication storage room where the ADC was located and logged into the ADC computer system. LN 3stated the medication was not available to be dispensed under Resident 103's profile and would need to contact the pharmacy to add it. During a concurrent interview and observation on 4/21/26 at 9:39 a.m. with LN 3, LN 3 checked Resident 103's profile in the ADC computer system and confirmed it was still not available to be dispensed. During an interview on 4/21/26 at 9:55 a.m. with LN 3, LN 3 stated the aspirin order for Resident 103 was still not showing up in the ADC computer system so she would call the pharmacy again. During a concurrent observation and interview on 4/21/26 at 10:40 a.m. (over 2 hours after the initial med pass observation) with LN 3, LN 3 was holding Resident 103's aspirin EC 81 mg tablet in a dispensed pouch from the ADC. She stated the medication order was now in the ADC and she went to administer the medication to Resident 103. During an interview on 4/22/26 at 1:47 p.m. with the Director of Nursing (DON), the DON stated aspirin EC 81 mg tablets were stocked in the facility's OTC drug supply located in the same room as the ADC. The DON stated LN 3 could have located it in one of the cabinets to administer to Resident 103. The DON stated the late administration of aspirin at 10:40 a.m. was a medication error. During a review of the facility's policy and procedure (P&P) titled, IC-1 Ordering and Receiving Medications from the Dispensing Pharmacy, dated 3/2018, the P&P indicated, Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. Procedures A. Ordering Medications from the Dispensing Pharmacy. 2. If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form, electronic transmission, or ordered by peeling the reorder strip from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows: a. Reorder medication three to four days in advance of need to assure an adequate supply is on hand. 2. During a med pass observation on 4/21/26 at 8:47 a.m. with LN 3, LN 3 was observed preparing 10 medications for Resident 73 including Multaq (a prescription medicine used to lower the chance of hospitalization for atrial fibrillation, an irregular, rapid heart rate caused by faulty electrical signals in the heart) 400 mg, 1 tablet. A review of Resident 73's physician's orders indicated an order for Multaq 400 mg, give one tablet by mouth two times a day for A-Fib (atrial fibrillation) with morning and evening meals. Hold for SBP (systolic blood pressure, a measurement of the maximum force of blood pushing against artery walls when the heart beats) below 110 and HR (heart rate) below 60, dated 3/30/26. During the same medication pass observation on 4/21/26 at 9:28 a.m.with LN 3, LN 3 entered Resident 73's room and administered all prepared medications. During a concurrent interview and record review on 4/22/26 at 8:40 a.m. with LN 3, LN 3 reviewed Resident 73's physician's order for Multaq and confirmed it indicated to administer with a meal. LN 3 stated the residents in her assigned hall received breakfast by 7:45 a.m. She stated if a med pass went late and a medication was ordered to be given with food she normally asked the resident if they still felt full before administering the medication. She stated if the resident reported that they did not feel full she would first offer a snack before administering the medication. LN 3 acknowledged the administration was approximately two hours after breakfast was served and stated she should have offered Resident 73 pudding or crackers when she administered the Multaq. LN 3 searched the internet to locate administration information for Multaq and stated the absorption and efficacy increased when it was given with a meal. A review of the manufacturer's labeling for Multaq, dated 6/2011, indicated, Absorption. bioavailability (the amount the body absorbs) of dronedarone (generic for Multaq) without food is low, about 4%. It increases to approximately 15% when dronedarone is administered with a high fat meal. During an interview on 4/22/26 at 2:40 p.m. with the DON, the DON stated he would consider medication administration up to an hour after a meal to be considered given with food. He stated if it had been over two hours nursing staff were expected to give something extra to the resident like a snack with the medication or a glass of milk. During a telephone interview on 4/23/26 at 10:24 a.m. with the Consultant Pharmacist (CP), the CP stated administration of Multaq with a meal helps with the absorption of the medication to be as stable as possible. CP stated if Multaq was not administered with food, the bioavailability could be affected. During a review of the facility's P&P titled, IIA-2 Medication Administration- General Guidelines, dated 3/2018, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. Procedures. B. Administration. 2. Medications are administered in accordance with written orders of the attending physician. 10. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered based on mealtimes. 3. During a medication pass observation on 4/23/26 at 8:24 a.m. with LN 1, LN 1 was observed preparing nine medications for Resident 84, including ferrous sulfate (a medication to treat low iron levels) 220 mg/5 ml elixir, 7 ml. A review of Resident 84's physician's orders indicated an order for ferrous sulfate elixir 220 mg/5 ml, give 7 ml via PEG-tube (percutaneous endoscopic gastrostomy, a soft, flexible tube placed directly into the stomach through a small, temporary abdominal incision to provide nutrition, liquids, and medication when someone cannot swallow or eat enough by mouth) one time a day for supplement, dated 1/23/26. During the same medication pass observation on 4/23/26 with LN1, LN 1 poured ferrous sulfate into a plastic medicine cup and stated she measured between the 5 ml and 10 ml graduation marks to estimate 7 ml. LN 1 then stated she should have used a syringe and went to the medication storage room to obtain one. LN 1 returned to the medication cart and used a luer lock syringe (a medical tool with a twist-and-lock tip that secures a needle or tubing in place) to measure the ferrous sulfate. LN 1 measured and squirted into a medicine cup 3 ml, 2 ml, and 2 ml to equal 7 ml. LN 1 stated she used the bottom of the two rings of the rubber stopper (the black tip of the plunger that creates an airtight seal and is used to read measurements) each time she drew up the ferrous sulfate to measure Resident 84's dose. A review of Medical Mathematics, an online textbook designed to prepare students to apply math concepts in health care settings, in the section titled, 5.6 Reading Syringes, the article indicated, Identify where the end of the plunger is. A. The liquid inside the syringe will take up space up to the edge of the plunger inside the syringe. This edge is what should be compared to the graduated measurements to determine how much liquid is inside the syringe. The plunger inside the syringe is large and usually shows two sharp edges where the rubber is touching the inside of the syringe barrel. The edge you are looking at is always going to be the edge close to the tip of the syringe, not the edge close to where your fingers are holding the flanges and plunger rod. (https://ecampusontario.pressbooks.pub/sccmedicalmath/chapter/reading-syringes/; accessed 4/28/26) During an interview on 4/23/26 at 9:04 a.m. with LN 1, LN 1 stated she was not aware she had incorrectly measured Resident 84's ferrous sulfate when she used the bottom ring and not the top ring of the rubber stopper. During a concurrent observation and interview on 4/23/26 at 11:30 a.m. with the DON and LN 1, LN 1 went to the medication storage room and retrieved a luer lock syringe (identical to the one she used to measure Resident 84's ferrous sulfate). LN 1 showed the DON the syringe and demonstrated how she had measured the medication using the bottom ring of rubber stopper instead of the top. The DON confirmed that was not the correct way to measure with the syringe. During a review of the facility's P&P titled, Section II: Medication Administration Preparation and General Guidelines IIA-2 Medication Administration- General Guidelines, dated 3/2018, the P&P indicated, Policy: Medications are administered as prescribed in accordance with good nursing principles and practices. Procedures A. Preparation. 2. An adequate supply of disposable containers and equipment. is maintained on the medication cart for the administration of medications.

Based on observation and interview, the facility failed to implement infection control and prevention practices when:1. Laundry Staff 1 (LS 1) reused a gown after handling soiled linens;2. Incentive spirometers (IS, a handheld device designed to encourage deep breathing) were not labeled for 3 out of 22 sampled residents (Resident 21, Resident 56, Resident 101). These failures increased the potential for the spread of infections among vulnerable residents.Findings: 1. During a concurrent observation and interview on 4/23/26 commencing at 9:36 a.m. with LS 1 in the laundry room, LS 1 was observed putting on gown and gloves and sorting soiled linens in separate bins, then LS 1 removed the gown [rolled into a ball] and placed it on the top of the shelf. LS 1 removed washed clothes from two washers and placed them in the dryers. LS 1 walked back to the shelf, took a previously used gown, put it on, put on a new pair of gloves, loaded soiled linens into two washers, and started the washing cycles. LS 1 stated that she reused the same gown throughout her eight (8) hour shift. LS 1 agreed the used gown was likely contaminated after the first use when handling soiled linens. During an interview on 4/24/26 at 11:43 a.m. with the Infection Prevention and Control Nurse (IPCN), the IPCN confirmed that she expected no reuse of gowns in the laundry room, as it increased the risk of cross-contamination and the spread of infection. During a review of the facility's policy and procedure (P&P) titled, Laundry Department, undated, the P&P indicated, Careful precautionary procedures must be followed by laundry personnel to prevent the spread of infectious diseases to other staff members, residents and visitors. All soiled linen is potentially infectious.Prior to sorting or handling of soiled linen, protective clothing with long sleeve gown is to be placed over uniform, gloves and mask are to be worn. Protective clothing is to be secured in the back and must be worn continually through the machine loading process. When all washers are full, remove gown, gloves and mask. Dispose of in the trash or washer as appropriate. 2. During a review of Resident 21's admission Record (AR), dated 4/24/26 (print date), the AR indicated that Resident 21 was admitted to the facility in March of 2026 with diagnoses which included chronic respiratory failure (breathing or gas exchange problems) and dependence on supplemental oxygen. During a review of Resident 56's AR, dated 4/24/26 (print date), the AR indicated that Resident 56 was readmitted to the facility in April of 2026 with diagnoses which included aftercare for surgery on the digestive system and dysphagia (difficulty swallowing). During a review of Resident 101's AR, dated 4/24/26 (print date), the AR indicated that Resident 101 was readmitted to the facility in April of 2026 with diagnoses which included pulmonary fibrosis (lung disease, scarring of lung tissue, shortness of breath) and multiple rib fractures. During an observation on 4/21/26 at 8:44 a.m. in Resident 101's room, two IS were observed unlabeled on the nightstand by Resident 101's bed. During an observation on 4/21/26 at 8:50 a.m. in Resident 56's room, an unlabeled IS was seen on the nightstand by Resident 56's bed. During an observation on 4/21/26 at 9:17 a.m. in Resident 21's room, an unlabeled IS was seen on the nightstand by Resident 21's bed. During a concurrent observation and interview on 4/23/26 commencing at 2:22 p.m. with the IPCN, the IPCN walked into Resident 21's, 56's, and 101's rooms and confirmed that all three residents had unlabeled IS at the bedside. The IPCN further stated that the IS were personal items and needed to be labeled. During an interview on 4/24/26 at 11:43 a.m. with the IPCN, the IPCN confirmed that not labeling IS increased the risk of cross-contamination (spread of infections). During a review of the facility's P&P titled Theft and Loss, revised 5/17, the P&P indicated, Personal articles, other than clothing, brought into the facility should be engraved with the resident's name on the article or other methods of identification.

Based on interview and record review, the facility failed to ensure informed consent was obtained prior to the administration of as needed (PRN) lorazepam (a psychotropic medication to treat anxiety) for one of 22 sampled residents (Resident 3). This failure increased the potential for Resident 3's Responsible Party (RP) to not be informed of the risks and benefits of the medication and possible alternatives.A review of Resident 3's medical record indicated he was admitted to the facility in October 2025 with diagnoses which included dementia, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), depression, and anxiety. A review of Resident 3's medical record indicated the following physician's orders for lorazepam:- Lorazepam 0.5 milligram (mg, a unit of measurement): Give 0.5 mg by mouth in the afternoon for anxiety manifested by restlessness related to anxiety disorder, dated 4/22/26- Lorazepam 0.5 mg: Give one tablet by mouth every 8 hours as needed for anxiety manifested by restlessness related to anxiety disorder for 14 days, dated 4/22/26 During a concurrent interview and record review on 4/23/26 at 5 p.m. with Licensed Nurse 1 (LN 1), Resident 3's informed consents were reviewed. LN 1 stated an informed consent was obtained from a resident or their RP before psychotropic medication was initiated. LN 1 stated sometimes multiple doses for the same medication were combined onto one consent. LN 1 reviewed Resident 3's consents and stated she only saw one obtained for the routine dose and not the PRN dose. During a concurrent interview and record review on 4/23/26 at 5:10 p.m. with the Director of Nursing (DON), Resident 3's informed consents were reviewed. The DON stated he looked but did not see a consent for Resident 3's as needed lorazepam order. The DON stated each order for Resident 3's lorazepam required its own form. During a review of the facility's policy and procedure (P&P) titled, Medication Management, dated 3/2018, the P&P indicated, Procedures.2. The resident is evaluated before initiating, withdrawing, or withholding medication(s), or using non-pharmacologic approaches. A. The extent of the evaluation will vary according to the resident's current condition but may include.6. Refusal of care and treatment, including the basis for declining it and the identification of pertinent alternatives.

Based on observation, record review, and interview, the facility failed to implement a care plan intervention for the use of eyeglasses for one of 22 sampled residents (Resident 8), when Resident 8's glasses were not applied.This failure had the potential to negatively affect Resident 8's communication needs and quality of life.Findings:A review of Resident 8's admission record indicated she was admitted in Fall 2021 with diagnoses which included a history of bed confinement status (inability to leave the bed due to illness, injury, or severe frailty), bilateral cataracts (where the natural, clear lens inside your eye becomes cloudy or foggy), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).During a review of Resident 8's Care Plan Report (CPR), dated [DATE], the CPR indicated, The resident has impaired visual function, with interventions that included environmental factors and use of glasses for visual support.During a review of Resident 8's Valuable List (VL), dated [DATE], the VL indicated two pair of eyeglasses were present on admission.During an observation on [DATE] at 9:57 a.m. in Resident 8's room, Resident 8 was found lying in the bed with eyes open without glasses in place. During an interview with Resident 8's Responsible Party (RP) on [DATE] at 9:16 a.m., the RP stated Resident 8 wore glasses and reported they had not observed Resident 8 wearing glasses during visits. The RP stated glasses were important to Resident 8's dignity and quality of care.During a concurrent observation and interview on [DATE] at 9:23 a.m. with Resident 8 in Resident 8's room, Resident 8 was found lying in the bed with eyes open without glasses in place. During a concurrent interview and record review on [DATE] at 10:37 a.m. with Certified Nursing Assistant (CNA) 9, Resident 8's Valuable List was reviewed. CNA 9 confirmed Resident 8 had two pair of glasses and stated she was expected Resident 8 to have glasses on to avoid eye injury.During a concurrent observation and interview on [DATE] at 10:43 a.m. with Unit Manager (UM) 1 in resident 8's room, Resident 8 was found lying in the bed with eyes open without glasses in place. UM 1 retrieved Resident 8's glasses from a drawer and confirmed the glasses frame was broken. UM 1 confirmed the RP had requested the glasses for Resident 8 to use and that glasses were important to assist with reading and recognition of caregivers. During an interview on [DATE] at 12:33 p.m. with CNA 4, CNA 4 stated residents had the right to wear glasses if requested by the RP.During an interview on [DATE] at 11:59 a.m. with the Social Services Director (SSD), the SSD stated residents' glasses were listed on a residents' VL and confirmed that Resident 8's broken glasses were expected to be reported to SSD.During an interview on [DATE] at 8:51 am. with CNA 9, CNA 9 indicated Resident 8's RP requested that Resident 8 wore glasses and the last time they saw Resident 8 with glasses on was 8 months ago. CNA 9 stated staff found out resident needs by referring to the care plan or family and that it was important for Resident 8 to wear the glasses, and stated, Even if we don't know if [Resident 8] can see, it is still important.she might like them for fashion and to look beautiful.During an interview on [DATE] at 8:51 am. with LN 8, LN 8 stated she has not seen Resident 8 wore glasses in the last three months. During an interview on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the DON stated glasses were expected to be worn, the care plan to be followed, and could cause unhappiness in a resident if they do not have their glasses.During a review of the facility's policy and procedure (P&P) titled, Federal Resident Rights, dated 2025, the P&P indicated, Respect and Dignity: you have the right to be treated with respect and dignity, including the right to.retain and use personal possessions.

Based on observation, interview, and record review, the facility failed to maintain a safe environment for one of 22 sampled residents (Resident 80), when wheelchair footrests were found in Resident 80's room walking pathway. This failure had the potential risk to result in accidents or injuries of Resident 80. Findings:A review of Resident 80's admission record indicated she was admitted in Spring 2026 with diagnoses which included history of falling, muscle weakness, abnormalities of gait and mobility (difficulty walking and moving around), lack of coordination, and osteoporosis (disease that makes bones weak, thin, and brittle, causing them to break easily).A review of Resident 80's Minimum Data Set (MDS- a federally mandated resident assessment tool), dated [DATE], the MDS indicated that Resident 80 had decision-making capacity, at risk for falls, and required a wheelchair, walker, and staff assistance for mobility.A review of Resident 80's Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 80 was a high risk for falls and included interventions to modify the environment and maintain floors free from clutter.A review of Resident 80's Progress Notes (PN), dated [DATE], the PN indicated Resident 80 had a recent fall and was found lying on the floor next to her bed while attempting to go to the bathroom.During a concurrent observation and interview on [DATE] at 9:47 a.m. with Resident 80 in Resident 80's room, wheelchair footrests were found lying on the floor directly within Resident 80's walking pathway to the restroom. Resident 80 stated she could get up and use the restroom independently when necessary.During a concurrent observation and interview on [DATE] at 9:50 a.m. with Licensed Nurse (LN) 7, LN 7 confirmed the wheelchair footrests were in Resident 80's walking pathway and stated they were not expected to be in front of the door and should have been placed under the table to prevent tripping accidents.During a concurrent observation and interview on [DATE] at 12:33 p.m. with Certified Nursing Assistant (CNA) 4, CNA 4 stated pathways should have been kept clear to reduce fall risk and pointed to multiple areas of a resident room which included the front of the bathroom door to identify intended walking paths that should have been unobstructed.During a concurrent observation and interview on [DATE] at 1:11 p.m. with LN 5, LN 5 stated pathways should have been kept clear to prevent falls and injury. During an interview on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the DON stated it was the expectation that obstructions should be moved and stored safely to avoid falls.During a request of the facility's Fall policy and procedure on [DATE] at 11:22 a.m., the facility was unable to provide a specific Fall Policy.During a review of the facility's policy and procedure (P&P) titled Resident Rights, dated 4/2017, the P&P indicated, Safe environment.residents have the right to a safe, clean and homelike environment.

Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 8) remained free from unnecessary medication, when Resident 8 was prescribed and administered with antibiotics (ABX, medications that treat bacterial infections) for prophylactic (preventative medical measure or medication designed to stop a disease, infection, or health condition before it occurs) for a urinary tract infection (UTI, an infection in the bladder/urinary tract).This failure had the potential for antibiotic resistance and infection.Findings:A review of Resident 8's admission record indicated she was admitted in Fall 2021 with diagnoses which included history of bed confinement status (inability to leave the bed due to illness, injury, or severe frailty), pressure ulcer (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities).A review of Resident 8's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated [DATE], the MDS indicated Resident 8 did not have the capacity to make decisions.During review of Resident 8's Care Plan Report (CPR), dated [DATE], the CPR indicated Resident 8 had the inability to communicate needs and included interventions: Monitor/record/report to MD for s/sx [signs and symptoms] of UTI [urinary tract infection: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns .for [Resident 8's] incontinence and urinary catheter [a hollow tube inserted into the bladder to drain or collect urine].A review or Resident 8's Order Summary Report (OSR, physician's orders), dated [DATE], the OSR indicated, Sulfamethoxazole-Trimethoprim (ABX)Tablet 800-160 MG Give 1 tablet via NG-Tube in the morning for UTI prophylaxis.A review of Resident 8's Progress Note (PN), dated [DATE], the PN indicated, [Resident 8] received antibiotics for UTI prevention although having Urine clear yellow in color. No urinary complaints.During a concurrent interview and record review on [DATE] at 9:37 a.m. with LN 4, Resident 8's medical record was reviewed. LN 4 confirmed Resident 8 received ABX for frequent UTI's. LN 4 was unable to find documented positive culture or UTI symptoms. LN 4 stated that Resident 4's ABX were a request from Resident 8's Responsible Party (RP) and KN 4 indicated having unneeded ABX can cause resistance especially if nothing was being treated. LN 4 further stated it was the expectation that staff or the antibiotic stewardship (management of antibiotic prescribing to ensure the right drug, dose, and duration were used only when necessary) was followed to avoid unnecessary ABX.During a concurrent interview and record review on [DATE] at 11:01 a.m. with the Infection Prevention and Control Nurse (IPCN), Resident 8's laboratory reports were reviewed. The IPCN confirmed Resident 8's most recent positive urine culture in 2021 and there were no documentation of a positive urine culture (UC) or symptoms supporting UTI. The IPCN further confirmed Resident 8's UC during Resident 8's recent hospital admission in [DATE] recommended recollection and repeat testing recommended should have been completed when readmitted . The IPCN confirmed that Resident 8's ABX had not met the facilities Antibiotic Stewardship program McGeer Criteria (standardized, evidence-based definitions used to identify infections in long-term care (LTC) facilities) and stated that Resident 8's ABX were unnecessary and caused a risk to family, staff, and the public being exposed to a resistant bug.During an interview on [DATE] at 11:10 a.m. with Unit Manager (UM) 2, UM 2 stated the expectation was that readmissions from the hospital be treated like a new admission and that Resident 8's UC should have been completed to avoid unnecessary treatment, resistance, kidney and other health issues especially for the elderly.can cause fungal infection causing women health issues. UM 2 further stated, We want to make sure our residents are not treated for what they are not needed based off our antibiotic stewardship.During an interview on [DATE] at 11:15 a.m. with the Director of Nursing (DON), the DON stated the expectation was that Resident 8's ABX were reviewed and that unnecessary ABX could create a super bug and could cause a risk to residents and other residents.During an interview on [DATE] at 2:43 p.m. with the Medical Director (MD), the MD confirmed that Resident 8's antibiotics had no indication, and the MD stated that although Resident 8's RP was educated there was no indication for the ABX.During a review of the facility's policy and procedure (P&P) titled, Infection Control Monitoring and Surveillance, undated, the P&P indicated, .will utilize the McGeer Criteria for Long Term Care Surveillance Updated 2012 and recommended by the Society for Healthcare epidemiology of America and other leading entities specializing in long term care epidemiology.

Based on interview and record review, the facility failed to ensure accurate records were maintained for one of 22 sampled residents (Resident 3) when the physician updated Resident 3's bisoprolol (medication to treat high blood pressure) order to remove hold parameters (specific, pre-determined safety rules that tell a nurse or caregiver to skip a dose of medication if a resident's vital signs or lab results are not in a safe range) for blood pressure medication and nursing staff did update Resident 3's medication order to reflect the change. This failure resulted in an inaccurate medication order for Resident 3 and had the potential for Resident 3 to not receive blood pressure lowering medicine when it was scheduled to be administered.Findings: A review of Resident 3's medical record indicated he was admitted to the facility in October 2025 with diagnosis including high blood pressure and atherosclerosis (the slow buildup of fats, cholesterol, and other substances inside artery walls, making them thick, stiff, and narrow). A review of Resident 3's medical record indicated a physician's order for bisoprolol 5 milligrams (mg, a unit of measurement), give 5 mg by mouth at bedtime for HTN (hypertension). Hold for SBP (systolic blood pressure, pressure in your arteries when your heart muscle squeezes and pumps blood out to the body) < 110, pulse < 60, dated 11/11/25. During a concurrent interview and record review on 4/23/26 at 3:12 p.m. with Licensed Nurse 1 (LN 1), Resident 3's order for bisoprolol was reviewed. LN 1 confirmed the order indicated hold parameters but the prompt in the computer system that directed nursing staff to measure and document blood pressure and pulse prior to administration had been removed. LN 1 reviewed Resident 3's medical record and stated the physician and removed the parameter to take Resident 3's blood pressure before administering bisoprolol because the resident's blood pressure had stabilized and no longer required daily monitoring. LN 1 reviewed Resident 3's medical record and stated it had been approximately four months since the physician removed the hold parameter, but it had not been updated on the medication order with the pharmacy. During an interview on 4/24/26 at 3:20 p.m. with the Director of Nursing (DON), the DON confirmed he had reviewed Resident 3's physician's order for bisoprolol and stated when an order was updated the facility was responsible for updating the order with the pharmacy. He stated the order for Resident 3's bisoprolol should have been updated with the pharmacy to reflect the removal of hold parameters but had not been. During a review of the facility's policy and procedure (P&P) titled, IC-1 Ordering and Receiving Medications from the Dispensing Pharmacy, dated 3/2018, the P&P indicated, Policy: Medications and related products are received from the dispensing pharmacy on a timely basis. Procedures A. Ordering Medications from the Dispensing Pharmacy. 2. If not automatically refilled by the pharmacy, repeat medications (refills) are written on a medication order form, electronic transmission, or ordered by peeling the reorder strip from the label and placing it in the appropriate area on the order form provided by the pharmacy for that purpose and ordered as follows. b. The nurse who reorders the medication is responsible for notifying the pharmacy of changes in directions for use or previous labeling errors. During a review of the facility's policy and procedure (P&P) titled, Medical Records for Residents, dated 9/2012, the P&P indicated, Procedure. 8. Medical records shall be current and kept in detail consistent with good medical and professional practice based on the services provided to each resident.

Based on the interview and record review, the facility failed to implement the antibiotic stewardship protocol when the physician was not notified that McGeer's criteria (standardized surveillance definitions used in long-term care facilities to detect infections) for diagnosis of urinary tract infection (UTI) were not met for one resident (Resident 53) in a census of 84. This failure increased the potential for Resident 53 to receive unnecessary antibiotics.Findings: During a review of Resident 53's admission Record (AR), dated 4/24/26 (print date), the AR indicated Resident 53 was admitted to the facility in April of 2026 with diagnoses which included ischemic heart disease (a condition where reduced blood flow to the heart muscle causes, or threatens to cause, tissue damage due to a lack of oxygen and nutrients) and coronary angioplasty (implants in the vessels of the heart). During a review of Resident 53's Medication Administration Record (MAR - a daily documentation record used by a licensed nurse to document medications and treatments given to a resident) for April 2026, the MAR indicated that Resident 53 was prescribed and received doxycycline (a broad-spectrum antibiotic) 100 mg (milligram, unit of mass) twice daily during 4/7/26 -4/10/26 for a total of 8 doses. During a concurrent interview and record review on 4/24/26 at 11:43 a.m. with the Infection Prevention and Control Nurse (IPCN), the facility's antibiotic stewardship program practices were reviewed, and the IPCN provided sample records of McGeer's criteria for Resident 53, completed for UTI on 4/7/26. The IPCN confirmed that the criteria for UTI were not met. The document did not contain the physician's acknowledgment of McGeer's criteria conclusions. The IPCN stated that she did not notify the physician of the McGeer's criteria outcomes. During an interview on 4/24/26 at 1:08 p.m. with the IPCN, the IPCN stated that if the physician was not notified and informed of the McGeer's criteria outcomes, the resident could be at a higher risk of receiving unnecessary antibiotics. During a review of the facility's policy and procedure (P&P) titled Antibiotic Stewardship Program, undated, the P&P indicated, . [The facility] has engaged in improving in the following action items.An antibiotic review process, also known as antibiotic time-out (ATO) for all antibiotics prescribed in the facility. ATOs prompt clinicians to reassess the ongoing need for a choice of an antibiotic when the clinical picture is clearer and more information available. ATO can be considered a stop order of an antibiotic when diagnostic test results or symptoms of resident do not support the diagnosis of infection.

Based on observation, interview, and record review, the facility failed to ensure 13 of 32 resident rooms (rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214) accommodated no more than four residents in each room.This failure had the potential to result in inadequate space for the provision of residents' care. Findings: During a review of a facility letter, dated 4/24/26, the letter indicated thirteen rooms would accommodate five residents each, with one shared bathroom. The letter further indicated, .Every resident has a reasonable amount of privacy as well as appropriate furnishings and storage in the noted rooms .the rooms have sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During an observation of the facility on 4/21/26 at 8:07 a.m., there were multiple rooms contained more than four residents. Rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214 were configured with a solid wall from floor to ceiling divided the space, with a shared bathroom and one exit door shared by five residents. Two beds were configured on one side of the wall and three beds were configured on the other side of the wall. Each bed had a privacy curtain to separate the residents. During a concurrent observation and interview on 4/24/26 at 10:42 a.m. with the Maintenance Supervisor (MS), measurements were taken of room [ROOM NUMBER]/110. The MS confirmed room [ROOM NUMBER] was configured with two beds and a shared bathroom; the measured living space per resident was 117.5 sq. ft. room [ROOM NUMBER] was configured with three beds; the measured living space per resident was 88 sq. ft. per resident. During an interview on 4/21/26 at 9:17 a.m. with Resident 86 (Res 86) in room [ROOM NUMBER], when asked if there was enough space, Res 86 stated she did not have problems with her space in her room and could move about easily. During an interview on 4/23/26 at 9:08 a.m. Resident 7 (Res 7) in room [ROOM NUMBER], Res 7 stated she maneuvered her wheelchair, got into the bathroom, or transferred in and out of bed with assistance and had no problems with her room space. During an interview on 4/23/26 at 10:08 a.m. with Licensed Nurse 5 (LN 5), LN 5 stated she provided care for rooms accommodating five residents. LN 5 stated there was sufficient space and maneuvered residents' beds and equipment. LN 5 stated space was adequate and assisted residents with wheelchairs and walkers. LN 5 stated there were no complaints from residents' families regarding the space. During an interview on 4/23/26 at 10:44 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated he was assigned to rooms accommodating five residents and he did not have issues and maneuvered residents and it was doable. The Department recommends granting a room waiver per the facility request.

Based on observation, interview, and record review, the facility failed to ensure 11 of 32 resident rooms (rooms 300, 301, 302, 303, 304, 305, 306, 307, 308, 309, and 310) met the minimum requirement of 80 square feet (sq. ft.) per resident.This failure had the potential to result in inadequate space for the provision of residents' care.Findings: During a review of a facility letter, dated 4/24/26, the letter indicated 11 rooms measured less than 80 sq. ft. per resident. The letter further indicated, Each resident will have a reasonable amount of privacy as well as appropriate furnishings and storage space .the rooms provide sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During an observation of room [ROOM NUMBER] on 4/23/26 at 10:32 a.m., staff assisted a resident using a walker in the room. Both the staff member and resident had adequate space to maneuver without complaints. During an interview on 4/23/26 at 10:44 a.m. with Certified Nursing Assistant 3 (CNA 3), CNA 3 stated he was assigned to rooms 300-310. CNA 3 stated he did not have issues and maneuvered residents or their equipment. CNA 3 stated he could not remember any incidents of family or residents complaining about space. During an interview on 4/23/26 at 3:45 p.m. with Licensed Nurse 5 (LN 5), LN 5 stated she oversaw staff assigned to rooms 300-310. LN 5 stated she had not received complaints from residents or family members about room space. LN 5 stated there was enough space for residents to get to the bathroom either using their walkers or wheelchairs. During a concurrent observation and interview on 4/24/26 at 10:32 a.m. with the Maintenance Supervisor (MS), measurements were taken of room [ROOM NUMBER]. The MS confirmed room [ROOM NUMBER] was configured to accommodate two beds; the measured living space per resident was 72.5 sq. ft. During an interview on 4/24/26 at 11 a.m. with Administrator (ADM), the ADM stated he had not received complaints from residents or family about space in rooms 300-310. The Department recommends granting a room waiver per the facility request.

Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 2) was free from abuse when Resident 1 pushed Resident 2 and caused him to fall.This failure had the potential to cause physical harm to Resident 2.Findings:Resident 1 was admitted to the facility in July of 2024 with diagnoses that included degenerative disorders of the nervous system (memory loss, cognitive decline-relating to the mental processes of thinking, knowing, learning, and understanding) and dementia (decline in memory function).A review of Resident 1's Minimum Data Set (MDS, a standardized assessment tool used in nursing homes), dated 1/13/26, indicated Resident 1 had a Brief Interview for Mental Status (BIMS) score of 11, which indicated Resident 1 had moderate cognitive impairment.Resident 2 was admitted to the facility in October with a diagnosis of Alzheimer's disease (severe memory loss, cognitive decline) and dementia (a decline in memory function). A review of Resident 2's Minimum Data Set (MDS), a standardized assessment tool used in nursing homes), dated 1/5/26, indicated Resident 2 had a Brief Interview for Mental Status (BIMS) score of 3, indicating Resident 3 had severe cognitive impairment.During an interview on 4/1/26 at 1:30 p.m., with the Director of Nursing (DON), the DON stated that Resident 2 is a wanderer and when he went near Resident 1 she shoved him down to the ground.During an interview on 4/1/26 at 2 p.m., with Resident 1, Resident 1 stated that she did not like Resident 2 and wants him to stay away from her and that was why she pushed him.A review of Resident 1's progress note, dated 3/22/26 at 10:15 p.m., The resident (Resident 1) pushed another resident (Resident 2) to the floor. This altercation was unwitnessed. The resident stated that she is tired of him [Resident 2] going into her room so she pushed him as hard as she could and she hopes that he learned his lesson.During an interview on 4/1/26 at 4:05 p.m. with the Administrator, the Administrator indicated that Resident 2's wandering could be a danger to himself and others because he does not understand boundaries and gets physically too close to others, which can be an annoyance.During a review of the facility's policy and procedure (P&P) titled, Abuse Prevention and the Reporting of Alleged Abuse and Suspicions of Crime, revised 10/17, the P&P indicated, Each resident has the right to be free of abandonment, abduction, isolation, fiduciary neglect, verbal, sexual, physical, mental abuse, corporal punishment and involuntary seclusion. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents.

Based on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) were free from abuse, when:1. Resident 2 swung her right arm and hit Resident 1's stomach; and2. Resident 4 hit Resident 3's shoulder while Resident 3 was in bed.These failures had the potential to negatively impact Resident 1 and Resident 2's psychosocial well-being.Findings:1. A review of Resident 1's admission Record, dated 3/7/26, indicated Resident 1 was admitted to the facility in 2025 with diagnoses including dementia (a progressive state of decline in mental abilities) and adjustment disorder with depressed mood (a short-term mental health condition when an individual struggles to cope with stress, resulting in low mood, sadness, and feelings of hopelessness).A review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool), dated 12/5/25, indicated Resident 1's Brief Interview of Mental Status (BIMS, an assessment test) score was 14 out of 15 with no memory impairment.A review of Resident 1's care plan, dated 3/3/26, indicated Resident 1 had a trauma related to being a victim of resident-to-resident abuse.A review of Resident 2's admission Record, dated 3/7/26, indicated Resident 2 was admitted to the facility in 2025 with diagnoses including anxiety (feeling of fear, dread, or uneasiness often caused by stress), dementia, and adjustment disorder with depressed mood.A review of Resident 2's MDS, dated 1/23/26, indicated Resident 2's BIMS score was zero out of 15 with severe memory impairment.A review of Resident 2's care plan, dated 3/3/26, indicated Resident 2 had a history of harm to others, poor impulse control, and hit another resident.A review of Resident 1's and Resident 2's progress notes, dated 3/2/26, indicated at 3:05 p.m., there was a resident-to-resident altercation in the hallway. The notes further indicated Resident 1 and Resident 2 were walking in opposite direction; when Resident 2 put her arm out and hit Resident 1 in the stomach.During an interview on 3/23/26 at 1:14 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 stated Resident 1 was walking one way in the hallway and Resident 2 walking the opposite direction, when she witnessed Resident 2 approached Resident 1, swung her right arm and hit Resident 1's stomach. During an interview on 3/23/26 at 1:30 p.m. with Resident 1 inside her room, Resident 1 stated another resident hit her on the stomach and she was in pain at the time the incident happened.2. A review of Resident 3's admission Record, dated 3/20/26, indicated Resident 3 was admitted to the facility in 2025 with diagnoses including Parkinson's disease (a progressive disease of the nervous system marked by tremor, muscular rigidity, and slow, imprecise movements), dementia, Alzheimer's disease (a disease characterized by a progressive decline in mental abilities), and depression (a chronic mental disorder with loss of interest and energy in activities).A review of Resident 3's MDS, dated 2/9/26, indicated Resident 3's BIMS score was 11 out of 15 with moderate memory impairment.A review of Resident 3's care plan, dated 3/17/26, indicated Resident 3 had trauma related to being victim of resident-to-resident altercation.A review of Resident 4's admission Record, dated 3/20/26, indicated Resident 4 was admitted to the facility in 2025 with diagnoses including Alzheimer's disease, dementia, depression, and anxiety.A review of Resident 4's MDS, dated 1/9/26, indicated Resident 4's BIMS score was three out of 15 with severe memory impairment.A review of Resident 3's progress note, dated 3/17/26, indicated Resident 3 was involved with a resident-to-resident altercation witnessed by staff. The note further indicated Resident 3 was hit on his left shoulder.A review of Resident 4's progress note, dated 3/17/26, indicated Resident 4 was involved with a resident-to-resident altercation witnessed by staff. The note further indicted Resident 4 was witnessed by staff hitting his roommate's left shoulder.During an interview on 3/23/26 at 12:53 p.m. with CNA 1, CNA 1 stated Resident 3 was yelling, when CNA 1 came inside the room and witnessed Resident 4 hitting Resident 3 twice on the left shoulder. During an interview on 3/23/26 at 2:39 p.m. with the Director of Nursing (DON), DON stated residents had the right to be free from abuse. DON confirmed Resident 2 hit Resident 1's stomach in the hallway and Resident 4 hit Resident 3's left shoulder while Resident 3 was in bed.A review of the facility's policy titled, Abuse Prevention and The Reporting of Alleged Abuse and [Suspicion] of Crime, dated 10/17, indicated, To ensure that residents' rights are protected by providing a method for the prevention of any type of resident abuse.

Based on interview and record review the facility failed to provide adequate supervision to ensure a safe environment for one of two sampled residents (Resident 2) when Resident 1, who had a history of wandering and touching residents was witnessed to touch Resident 2 in the groin area. This failure had the potential to cause physical and emotional distress to Resident 2.Findings:A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility in 2020 with diagnoses that included Traumatic Brain Injury (an injury to the brain that can range in severity from mild to severe) and Dementia (a decline in memory function). A review of Resident 1's, Minimum Data Set (MDS - an assessment tool used to guide care) Cognitive (having full understanding) Patterns, dated 7/10/25, indicated Resident 1 had a Brief Interview for Mental Status (a tool to assess a person's full understanding) score of 12 out of 15 which indicated Resident 1 had some understanding. A review of Resident 1's, MDS Section E - Behavior under physical behavior symptoms directed at others (hitting, kicking, pushing, scratching, grabbing, abusing others sexually) indicated a score of 1 which indicated the behavior had occurred before. A review of Resident's 1's Care Plan, initiated date of 7/8/24, indicated that the resident has a behavior problem entering personal space of others making them feel uncomfortable. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility in 2024 with a diagnosis that included Chronic Obstructive Pulmonary Disease (an ongoing inflammation and narrowing of the airways, making it difficult to breathe). A review of Resident 2's, MDS, Cognitive Patterns, dated 7/17/25, indicated Resident 2 had a Brief Interview for Mental Status score of 4 out of 15 which indicated Resident 2 did not have full understanding. A review of Resident 2's Progress Notes, dated 9/8/25 at 1:13 p.m., indicated that Resident 2 admitted that Resident 1 touched her vagina. During an interview with the Director of Nursing (DON) on 9/24/25 at 10:17 a.m., the DON stated, Resident 1 was witnessed by a staff member touching Resident 2 on the groin. The DON further stated, Resident 1 has a history of going into other resident's personal space and inappropriate touching. During an interview with the Housekeeper (HK) on 9/24/25 at 11:13 a.m., the HK stated they had witnessed Resident 1 touching Resident 2 on the groin area. During an interview with the DON on 9/24/25 at 12:43 p.m., the DON stated, This shouldn't have occurred, and he should have been watched more closely. The DON further stated, He should have been monitored more closely since it has occurred before. A review of the facility policy titled, Resident Rights dated 4/2017 indicated, To be free from mental and physical abuse.

Based on observation, interview, and record review, the facility failed to ensure one of 24 sampled residents (Resident 16) was provided assistance with nail care when Resident 16 was observed with long untrimmed nails with a brown substance underneath. These findings had the potential for increased infections, shame, discomfort, and feelings of frustration for Resident 16. Findings: A review of Resident 16's admission record indicated Resident 16 was readmitted to the facility in 2021 with diagnoses which included major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety disorder (a condition of excessive worry, fear, and nervousness that can interfere with daily life), dementia (a progressive state of decline in mental abilities), hepatitis C (a viral infection of the liver that leads to illness and can be spread by contact with the contaminated blood), nail dystrophy (a group of conditions that cause abnormal changes in the structure, appearance, and growth of the nails), and other nail disorders. A review of Resident 16's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/21/25, indicated that Resident 16 has severe cognitive impairment and needed assistance with personal hygiene and dressing. A review of Resident 16's care plans indicated a care plan titled The resident has an ADL [Activities of Daily Living] self-care performance deficit r/t [related to] Dementia, Limited ROM [Range of Motion], initiated on 12/13/24 and revised on 2/5/25. The care plan indicated, The resident is totally dependent on staff for personal hygiene and oral care. During a concurrent observation and interview on 2/11/25 at 9:58 a.m. with Resident 16 in her wheelchair by her bedside, Resident 16 was observed with long discolored nails with a brown substance underneath. Resident 16 stated that she would like to get her nails trimmed. During a concurrent observation and interview on 2/14/25 at 8:39 a.m. with the Nursing Assistant (NA 1) and Unit Manager (UM 2) in Resident 16's room, Resident 16 was observed in her wheelchair at her bedside with long discolored nails with a brown substance underneath. NA 1 and UM 2 confirmed that the nails were long and had a brown substance underneath. NA 1 described nails as being 1 centimeter or longer, and she stated that nails could be cleaned with a wooden stick and filed down to the appropriate length. She also stated that she provided nail care whenever she sees that the nails are dirty. In an interview on 2/14/25 at 8:50 a.m. with Certified Nursing Assistant (CNA 2), CNA 2 confirmed that Resident 16 had long nails with a brown substance underneath and she planned on fixing it. She was not able to state the last time Resident 16 received nail care. In an interview on 2/14/25 at 11:21 a.m. the Director of Nursing (DON) stated that residents' nails should be clean and trimmed. DON also agreed that given Resident 16's medical condition her nail care should be more rigorous. The facility's policy on nail care was requested but was not received.

Based on observation, interview, and record review, the facility failed to implement infection control and preventive practices when: 1. There was no infection control and preventive practices training provided by the Infection Prevention nurse (IP, who specializes in preventing and controlling infections in healthcare settings) during a norovirus outbreak (a very contagious virus that causes stomach inflammation, vomiting, diarrhea, and stomach cramps); 2. Resident 335's urinary catheter (a hollow tube inserted into the bladder (a hollow organ of the lower stomach that holds urine before it leaves the body) drainage bag (a bag that collects urine) was found on the floor; 3. Resident 335's intravenous (IV- a needle or tube inserted into a vein) tubing was not dated; and, 4. Licensed Nurse (LN) placed a dirty pillow under Resident 335's leg. These failures decreased the facility's ability to ensure infection would not spread among residents for a census of 83. Findings: 1. During a review of the facility's infection prevention and control program (IPCP, a set of policies and procedures implemented within a healthcare setting to minimize the spread of infections among patients, staff, and visitors) on 2/14/25 at 10:25 a.m., the facility's antibiotic stewarship program (ASP, a set of practices that ensure antibiotics are used appropriately) was reviewed. During a review of the facility's monthly infection control report: under Healthcare Associated Infection (HAI, infections that develop while receiving medical care), on 2/14/25 at 10:28 a.m., the HAI report indicated, norovirus outbreak line list for the month of December 2024, 15 residents were listed to have gastro-intestinal (G.I.) infection symptoms like nausea (a feeling of sickness or discomfort in the stomach), vomiting, and diarrhea (stools are loose and watery). During a review of the facility's document submitted by the IP nurse to the local health department dated 1/6/25 at 4:42 p.m., the report indicated, gastrointestinal (G.I.) outbreak summary information. The local health department in its response confirmed it had received the norovirus outbreak report submitted by the facility. The facility's training binder was reviewed on 2/14/25 at 10:15 a.m. The review did not show any documentation that preventive practices training and/or in-services about norovirus outbreak was implemented. During a concurrent interview and record review on 2/14/25 at 10:25 a.m., with the IP Nurse, the facility's norovirus outbreak line list for the month of December 2024 and the monthly infection control report were reviewed. The IP nurse confirmed that in the line list, 15 residents have had norovirus-like symptoms of nausea, vomiting and diarrhea. The IP nurse was unable to show proof a norovirus in-service/training was provided during the outbreak to help protect both patients and healthcare workers from the spread of the infectious disease. The IP nurse stated she should have provided and documented the training but she did not. During an interview and record review on 2/14/25 at 11:19 a.m., with the Director of Staff Development (DSD), the monthly infection control report and the facility training binder were reviewed. The DSD confirmed the facility had a norovirus outbreak for the month of December 2024 but there was no norovirus training implemented to ensure the health and safety of the residents. During an interview on 2/14/25 at 11:32 with the Director of Nursing (DON), the DON confirmed the norovirus outbreak and stated when there was an outbreak, an infecton prevention and control training should have been provided to ensure the health and safety of the residents. During a review of the facility's undated policy and procedure (P/P) titled, Infection Control Plan, the P/P indicated, .Work with the in-service director in educating staff on infection control, methods, programs and procedures . During a review of the facility's undated Infection Preventionist position summary: it indicated, the IP is accountable for decreasing the incidence and transmission of infectious disease between patients, staff, visitors and community . Essential duties and responsibilities included: .Authority and responsibility for ensuring appropriate intervention and education occurs with staff, volunteers and medical staff when healthcare infection trends, outbreaks or non-compliance to infection control are identified . 2. A review of Resident 335's admission record indicated admission to the facility in January 2025 with diagnoses which included retention of urine (a condition that prevents urine from leaving the bladder). A review of Reident 335's medical records indicated the following: -An Order Summary Report dated 2/5/25 indicated orders for the provision of urinary catheter with drainage bag. -A care plan initiated on 2/7/25 indicated, The resident has .Catheter due to urinary retention .Position .away from entrance room door .Check tubing for kinks each shift During an observation in room [ROOM NUMBER]-B, on 2/12/25 at 11:40 a.m., Resident 335's urinary catheter drainage bag was found on the floor, on the right side of the bed facing the entrance room door, and not properly hung from the bed rail with use of the drainage bag hook. During a concurrent observation and interview on 02/12/25 at 11:49 a.m. with LN 1, LN 1 agreed to go to Resident 335's room as requested. LN 1 acknowledged that the urinary catheter drainage bag was on the floor. LN 1 confirmed that the drainage bag should not be on the floor, but that the drainage bag hook should be properly hung on the bed rail so that the drainage bag is positioned off the floor. LN 1 stated that by having the drainage bag on the floor could cause a potential infection control issue, and tripping hazard, which could lead to urine being spilled on the floor. An interview on 2/13/25 at 10:30 a.m. in the DSD's office, the DSD provided a copy of the new hire Certified Nursing Assistant (CNA) Skills Checklist which did not include checkoffs for urinary catheter care and catheter drainage bag positioning. DSD stated that it was important for staff to follow infection control prevention practices to avoid a potential illness outbreak between vulnerable residents. DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD conducted a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives or syllabus (an outline of what is taught) associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to urinary catheter care and urinary catheter drainage bag positioning. 3. A review of Reident 335's admission record indicated diagnoses which included Bacteremia (a condition where bacteria is present in the blood). A review of Resident 335's medical records indicated the following: -An Order Summary Report dated 2/13/25 indicated orders for the provision of Cefazolin (an antibiotic used to treat serious bacterial infections) Sodium 2 gram IV two times a day. -A care plan initiated on 2/7/25 indicated, The resident is on IV medications Cefazolin .The resident will not have any complications related to IV therapy . During a concurrent observation and interview on 2/12/25 at 12:35 p.m. with Unit Manager (UM) in Resident 335's room, UM was observed hanging Resident 335's IV medication Cefazolin. UM stated that Resident 335 has this medication scheduled to receive at 12 noon and at 12 midnight every day. UM spiked the new medication bag with the previously hung IV tubing noted on IV pole. UM hung the IV medication with the tubing, gave medication to Resident 335's IV site for infusion, and was prepared to leave the room. UM did not notice that the previous IV tubing did not have a label. UM did not use a new IV tubing for infusion, and did not label the IV tubing with the current date and time when hung. UM acknowledged that the IV tubing was not labeled with a date and time, and stated that no label was required for IV tubing per facility policy. During an interview on 2/13/25 at 10:30 a.m. in the Director of Staff Development's (DSD) office, the DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD did a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives of what was taught associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to IV tubing or IV tubing labeling. 4. During a concurrent observation and interview on 2/12/25 at 12:53 p.m. with LN 1 in Resident 335's room, it was noted that bed A (the roommate) was not occupied, the resident was discharged earlier in day, bed room area was not cleaned yet; as observation indicated that no linen was on bed, container of sanitizing wipes with discharged resident's name was left on dresser, and room area was not prepared for the next potential admission. LN 1 was observed taking a dirty pillow from bed A, placed a clean pillow case on the dirty pillow, and then positioned that pillow under Resident 335's right leg. LN 1 did not clean or sanitize the pillow before use on Resident 335. LN 1 acknowledged that the pillow was taken from bed A, and stated that bed A room area had been cleaned by housekeeping, and that the pillow used from bed A was clean. During an interview on 02/12/25 at 12:56 p.m. with Housekeeper (HK) in room [ROOM NUMBER]-A. HK stated that bed A had not been cleaned by housekeeping yet. HK stated that when a resident is discharged , the CNA strips the bed and remove a resident's personal items so that housekeeping can do a deep cleaning (terminal cleaning) of the bed, chair, wheelchair, dresser, floors, walls, and curtains. HK acknowledged that discharged resident's container of sanitizing wipes were left on dresser, and stated anything that the CNA forgot to remove, housekeeping would remove as part of the deep cleaning process. An interview on 2/13/25 at 10:30 a.m. in the Director of Staff Development's (DSD) office, the DSD provided a copy of the new hire CNA Skills Checklist which did not include checkoffs for cleaning items/pillows before resident use. DSD stated that it was important for staff to follow infection control prevention practices to avoid a potential illness outbreak between vulnerable residents. DSD provided a copy of the Competency/Procedure LN Checklist with checkoffs being done by the Director of Nursing (DON). The DSD did a three-way telephone call with the DON on 2/13/25 at 10:40 a.m. for an interview to discuss the Competency/Procedure LN Checklist. The DON stated that there are no objectives or syllabus (an outline of what is taught) associated with the Competency/Procedure LN Checklist. DON acknowledged that there is no LN checkoffs related to cleaning items/pillows before resident use. A follow up interview on 2/14/25 at 8:50 a.m. in the DON's office, the DON stated that the expectation of an LN is to follow infection control prevention practices by making sure that labels are placed on IV tubing with date and time hung, that dirty items/pillows are cleaned before use on a resident, and that urinary catheter drainage bags are hung properly from resident's bed frame and not touching the floor. DON stated that the facility does not have a urinary catheter policy and procedure (P&P), that had been requested, but that LNs follow the Lippincott Manual of Nursing Practice, Ninth Edition, related to urinary catheter care and catheter drainage bag positioning. An interview on 2/14/25 at 9:25 a.m. in the IP's office, the IP presented the past 4 months of facility's In-Service/Training/Seminar Records for staff which did not include inservices related to cleaning items/pillows before resident use, or urinary catheter care and urinary drainage bag positioning. IPN stated did not know enough about IV tubing to make a comment due to a certification as a LVN. IP stated that it was important for staff to follow infection control prevention practices to keep everyone safe from germs and illness. A review of the facility's Lippincott Manual of Nursing Practice, Ninth Edition, chapter General Procedures and Treatment Modalities, indicated, Maintaining a closed drainage system .2. Maintain unobstructed urine flow .c. Keep the bag off the floor . A review of the facility's Pharmacy Intravenous Therapy Services Manual, dated 10/2020, Section 6, titled: N. I.V. TUBING indicated, .2. I.V. tubings shall be dated and timed when hung . A review of the facility's Infection Control Manual, dated 10/25/24, Section 6, titled, Housekeeping Department, indicated, Procedure for Cleaning .3. Terminal cleaning of a resident room must include: Cleaning . Decontamination .; Cleaning Routines .In certain areas, housekeeping will not be responsible for the care of specific .These items may be the responsibility of the nursing services personnel, . A review of the facility's Infection Control Plan Policy, undated, indicated, .Work with the In-service Director in educating staff on infection control methods, programs and procedures; . 50282

Based on observation, interview, and record review, the facility failed to ensure 13 of 32 resident rooms (rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214) accommodated no more than four residents in each room. This failure had the potential to result in inadequate space for the provision of care. Findings: During a review of facility letter, dated 2/11/25, the letter indicated thirteen rooms would accommodate five residents each, with one shared bathroom. The letter further indicated, .Every resident has a reasonable amount of privacy as well as appropriate furnishings and storage in the noted rooms .the rooms have sufficient space for nursing staff to provide care and for residents to ambulate and use assistive devices. During a tour of the facility on 2/11/25 at 8:07 a.m., multiple observations of rooms containing more than four residents per room were made. Rooms 100/102, 101/103, 104/106, 105/107, 108/110, 112/114, 200/202, 201/203, 204/206, 205/207, 208/210, 209/211, and 212/214 were configured with a solid wall from floor to ceiling dividing the space, with a shared bathroom and one exit door shared by five residents. Two beds were configured on one side of the wall and three beds were configured on the other side of the wall. Each bed had a privacy curtain to separate the residents. During a concurrent observation and interview on 2/13/25 at 9:50 a.m. with Maintenance Supervisor (MS) and Assistant Administrator (AA), measurements were taken of room [ROOM NUMBER]/110. room [ROOM NUMBER] was configured with two beds and a shared bathroom; the measured living space per resident was 117.5 sq. ft. room [ROOM NUMBER] was configured with three beds; the measured living space per resident was 88 sq. ft. per resident. During an interview on 2/11/25 at 12:09 p.m. with Resident 32 (Res 32) in room [ROOM NUMBER], when asked if there was enough space, Res 32 stated, I brought a lot of stuff with me .I have a lot of clothes .I make it work. Res 32 indicated she had adequate space in her room and could move about easily. During an interview on 2/13/25 at 3:21 p.m. with Resident 10 (Res 10) in room [ROOM NUMBER], Res 10 indicated the room had plenty of space. Res 10 further indicated she never had an issue with maneuvering in her wheelchair, getting into the bathroom, or transferring in and out of bed. During an interview on 2/13/25 at 3:51 p.m. with Certified Nursing Assistant 1 (CNA 1), CNA 1 stated she was frequently assigned to rooms accommodating five residents. CNA 1 further stated she did not have issues with maneuvering residents. CNA 1 stated everything is accessible; she sometimes needed to move a bed temporarily for hoyer lifts, but it was still doable. During an interview on 02/13/25 at 03:51 p.m. with Licensed Nurse 3 (LN 3), LN 3 stated she had been assigned to provide care for rooms accommodating five residents frequently. LN 3 stated there was sufficient space for maneuvering five residents' beds and equipment. LN 3 further stated there is adequate space to assist residents with wheelchairs and walkers to the shared bathroom. LN 3 stated there were no complaints from residents' families regarding the space. The Department recommends granting a room waiver per the facility request.

Based on observation, interview, and record review, the facility failed to establish and implement an effective infection control program to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection for a census of 90 when: 1. The facility did not ensure resident's personal care equipment was sanitized effectively between resident use and the facility used single resident-use items for multiple residents. 2. The facility failed to ensure linens were handled, transported, processed, and stored to prevent contamination and the transmission of infection. 3. Clean supplies were stored in the soiled utility rooms where the hopper (bedpan emptying basin) system was located. 4. The facility did not ensure the staff practiced nursing care in accordance with the nationally recognized infection control guidelines when: a. Staff applied a contaminated oxygen cannula, which had been picked up from the floor, on Random Resident 21's face; b. Staff did not perform hand hygiene between resident care. 5. The facility did not have a system to manage two possible gastrointestinal outbreaks (a sudden increase in the incidence of vomiting and diarrhea), which included identification, investigation, control, reporting, and monitoring. The possible outbreaks occurred in August and October of 2011. Resident 12 was not placed on contact precautions for highly transmissible bacteria in her urine, and no care plan was established for Resident 14 when a[DIAGNOSES REDACTED] infection (Clostridium difficile, a bowel bacteria causing diarrhea) was confirmed by laboratory testing. 6. The facility's Infection Control Plan did not reflect the current nationally recognized infection control guidelines per the Centers for Disease Control and Prevention (CDC), local health agency, and the State agency. On 10/7/11 at 12:25 p.m. the Department determined Immediate Jeopardy of residents in the facility related to the systemic failure of the facility to develop, implement, and maintain an Infection Control Plan that met current standards of practice. The specific list of deficiencies included: The improper re-use of disposable equipment, the use of outdated and malfunctioning sanitizing equipment, the lack of staff training, the lack of current laundry procedures, the lack of oversight at both the supervisory and administrative levels, and lack of reporting of possible outbreaks to appropriate agencies. These deficiencies put all residents in the facility at risk of becoming infected with communicable diseases (disease capable of being transmitted to others). The Department Team met with the Administrator and facility management staff to advise of the Immediate Jeopardy. The Immediate Jeopardy was abated on 10/11/11 at 4 p.m. with the Administrator as the result of acceptance and implementation of the facility's plan of correction. The correction included discontinuing the use of single-use resident care equipment for multiple residents, in-servicing of staff on sterilization of appropriate resident care items, implementation of updated laundry procedures to prevent the spread of infection, notification of the County Health Department about the the 13 residents with gastrointestinal symptoms, and utilization of an Infection Prevention Consultant to in-service staff regarding current infection control guidelines. The new scope and severity level is an F. Findings: 1. During the Initial Tour on 10/4/11 at 7:30 a.m. emesis basins storing residents' toothbrushes were noted in several rooms throughout the building. (An emesis basin is a kidney shaped dish, approximately 3 inches by 6 inches intended for a resident to vomit in, but also used to store resident toiletries.) During the Environmental Tour with the Housekeeping Supervisor (HS) on 10/6/11 at 10:20 a.m., a square metal washing tub was observed in a small room located on a hall with resident rooms. Multiple plastic patient care items, including emesis basins, bathing tubs, urinals, bed pans and commode buckets (pails that collect human waste from a portable toilet that can be used at the bedside) were located on the floor beside the machine, and on shelves above the machine. The HS reported the personal care items were dirty and the machine was a sanitizing machine used to clean them. She demonstrated how it operated by donning gloves, turning on the water, and filling the machine with water. She placed the dirty plastic items that had been on the floor into the water. The items were nested and were not completely submerged, preventing complete contact with the water. She then reported she would wait 30 minutes, remove the items from the machine, and then dry them and place them in the "clean" closet across the hall from the closet with the machine. A hand-washing sink was observed next to the sanitizing machine in the dirty closet. The sink had gloves and an electrical cord stored around and in the sink. The soap dispenser was empty and there was no towel dispenser. The HS did not wash her hands after loading the sanitizer with the dirty personal care items and removing her gloves. During the observation of the sanitizing process on 10/6/11 at 10:20 a.m. a sign was observed on the walls of both the "clean" closet and the sanitizing closet. The sign indicated "STERILIZATION is accomplished by submersion in boiling water for a minimum of thirty minutes" and directed staff to light burner with match, and turn off gas when through. The directions also indicated the tub was to be wiped out with a damp cloth when the sanitizing process was complete. The directions were most recently revised December 31,1982. There were no directions to provide monitoring to assure the temperature reached the boiling point, or any sanitation chemicals use during the process or after the process was completed. The machine was observed to be all electric. In an interview with the HS on 10/6/11 at approximately 10:20 a.m. she reported she did not use the sink next to the sanitizing machine, she would wash her hands at the sink next to the nurses' station, approximately 80 feet down the hall. During an observation of the "clean" storage closet on 10/6/11 at 10:45 a.m. several plastic bed pans were observed to have a brown film and a dried brown fluid on them. In a concurrent interview with the HS on 10/6/11 at 10:45 a.m. she looked at the items in the "clean" closet and agreed they were dirty. She reported the sanitation process was nearly finished and she demonstrated how she would remove the items from the sanitizing machine. She reported she had never monitored the temperature of the water of the sanitizing machine and was unaware of how hot the water needed to be to ensure the items placed in the machine were actually being sanitized by the process. She reported the plastic care items for all residents throughout the facility were brought to this machine for sanitizing and then placed in the "clean" closet across the hall, to be used for any resident throughout the facility as needed. At the Department's request she tested the water temperature of the sanitizing machine and reported it had reached 118? F. She reported she normally would just feel the side of the machine and it always felt as hot as it did during the observation. She did not remove the visibly soiled patient care equipment from the "clean" closet. During the interview the Department informed the HS the water temperature had not become sufficiently hot to clean the personal care equipment, and she should consider the items in the "clean" closet to be contaminated. This represented an inadequate cleaning of co-mingled patient care items that had the potential to lead to fecal-oral transmission of disease. In an interview with the HS on 10/6/11 at approximately 10:50 a.m. she reported she was unaware of any written policies on how the existing sanitizing machine operated. In a telephone interview with a representative of the manufacturer of the disposable bed pans observed in the "clean" closet on 10/6/11 at 12 p.m. she reported the disposable plastic patient use items were not intended to be used by multiple patients and were not constructed of materials that could be successfully sanitized. During an observation of the "clean" closet on 10/6/11 at 2 p.m., the visibly dirty bedpans were observed to still be in the closet, available for resident use. In an interview with Licensed Nurse 8 (LN 8) on 10/6/11 at 2 p.m. she reported all patient care items used throughout the entire facility were stored in the single "clean" closet located across from the sanitizing machine closet. In an interview with Certified Nursing Assistant 7 (CNA 7) on 10/6/11 at 2:10 p.m. she stated, "I get clean emesis basins in this closet ("clean" closet). Housekeeping cleans these things. At my other job we threw these out they were just for 1 patient due to infection control." In a concurrent interview with the Director of Staff Development (DSD) on 10/6/11 at 2:10 p.m. she observed the "sanitizer" contained a combination of wash basins, emesis basins, commode buckets, urinals and bedpans, and stated, "That's cross contamination" In an interview with the Administrator on 10/6/11 at 4:45 p.m., he reported the housekeeping staff were expected to put all new plastic patient care items through the sanitizing machine prior to storing them in the "clean" storage closet. In an interview with the Administrator on 10/7/11 at 9:30 a.m. he reported some of the plastic items used for patient care were meant to be sanitized, but the emesis basins, bathing tubs and bed pans were single patient use only, and he had been unaware the staff were trying to sanitize them for multiple-patient use. He reported the current HS had been responsible for performing the sanitation process for the past year. He was unable to locate any manufacturer guidelines for the proper use of the sanitizing machine. He further reported the HS had not brought it to his attention the Department had identified concerns with the sanitation process, and he had not been providing any oversight to her performance. In an interview with the Maintenance Supervisor (MS) on 10/7/11 at 3:10 p.m. he reported he had worked at the facility for approximately 4 years and had not performed any testing or maintenance on the sanitizing machine during that time, as it was "something the housekeepers deal with." This represented a systemic failure to establish a sanitation process that incorporated current standards of practice, an ongoing maintenance and monitoring system to ensure proper functioning of the machine, staff training, as well as administration oversight of the supervisory staff. 2. During an observation of the laundry processes on 10/6/11 at 3 p.m. Housekeeper 1 (H1) was observed bringing the dirty laundry to the laundry room to begin washing. She pushed a large bin filled with dirty laundry through the facility. A cover placed over the bin was cracked and worn and exposed the dirty laundry it was meant to contain. At the laundry room when she donned plastic gloves and an apron. The gloves came to her wrist and the apron did not cover her arms or shoulders. She sorted the laundry and loaded the washers with the dirty laundry, allowing the laundry to touch her arms. Once the washers were loaded she closed the doors and set the controls to begin the laundry. She returned to the dirty linen cart and removed the plastic-covered dirty pillows and sprayed them with a sanitizing solution, using the dirty hamper lid as a surface to place the pillow. After spraying one side of the pillow with sanitizer, she flipped the pillow over and placed the newly cleaned side on the dirty hamper. When both sides of the pillow had been sprayed with sanitizer she placed the pillows on top of the washers for storage. She then removed her gloves and the dirty apron and immediately proceeded to the dryer to remove the cleaned and dried laundry without washing her hands. A hand washing sink was not observed in the laundry room. This represented on ongoing opportunity for the spread of pathogens through cross-contamination throughout the laundry process. The AMDA (formerly known as the American Medical Directors Association) publication, "Common Infections in the Long-Term Care Setting Clinical Practice Guidelines, 2011" provided the following infection control guidelines: -Employee Education. One of the most important roles of the infection prevention practitioner is to provide employee education about infection prevention practices. Such education should be extended to all employees, including housekeeping, laundry, and maintenance staff. -Contact with contaminated surfaces and objects and shared equipment also may be a mode of transmission of infectious agents in LTC (Long Term Care) facilities. The risk of contact with contaminated surfaces and the spread of infectious agents can be further reduced by the diligent, consistent use of cleaners and disinfectants. In a translated interview with H1 on 10/6/11 at 3:15 p.m., she reported it was not her practice to sanitize the washer doors and controls after she had touched them with her dirty gloves, nor was it her practice to wash her hands before handling clean laundry. She reported she was aware the laundry machines were considered the dirty side of the room, but reported it was where she usually placed the sanitized pillows. In a concurrent interview with the HS on 10/6/11 at 3:15 p.m. she reviewed the information binders she had in the laundry room and reported she was unaware of any policies and procedures for the appropriate handling of the laundry process. She reported she did not have any records documenting the training of her staff. She was unaware the staff was expected to wash hands after handling dirty laundry and was not aware the pillows had been contaminated by being placed on the dirty hamper lid, or on top of the washer. In an interview with the Administrator on 10/6/11 at 3:45 p.m. he reported the facility did have policies and procedures for the handling of laundry and was unaware the HS was not familiar with the facility's policies for handling dirty laundry. Review of the facility's undated policy and procedure titled, "Laundry Service -Soiled Laundry and Linen Pick Up (Operational Procedures) did not include hand hygiene, use of personal protective equipment (PPE), the separation of a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items, staff training of the laundry service procedures, and preventive maintenance of laundry equipment and ongoing monitoring of the effectiveness of the laundry processes. Review of "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 2003, indicated on page 99, that "A laundry facility...partitioned into two separate areas - a "dirty" area for receiving and handling the soiled laundry and a "clean" area for processing the washed items...Laundry workers should wear appropriate personal protective equipment (e.g., gloves and protective garments) while sorting soiled fabrics and textiles. Laundry equipment should be used and maintained according to the manufacturer's instructions to prevent microbial contamination of the system...Laundry areas should have handwashing facilities readily available to workers." In an interview with the Administrator on 10/7/11 at 9:30 a.m. he reported he had received no reports from the provider of the chemicals used in the laundry process verifying the dispensation system of the chemicals was working properly to ensure adequate sanitation chemicals were being added to the wash at the temperatures recommended by the manufacturer. The facility's type-written, undated policy for "Laundry Service" directed the staff to keep soiled laundry covered at all times, and prohibited clean laundry being stored with dirty laundry. The policy contained no information on minimizing the risk of cross-contamination by washing hands after handling dirty laundry, or proper use of sanitizing agents. The policy did not identify if the laundry was being sanitized through the use of sufficiently hot water temperatures, hot dryer temperatures, or through chemical disinfectants. The policy contained no information on the monitoring of the temperatures, or chemical distribution systems to ensure they were working properly. This represented a systemic failure to handle, store, process, and transport linen to prevent the spread of infection when facility staff did not have the means to wash their hands, access to policies and procedures to ensure they understood proper laundry techniques, evidence of ongoing training to ensure they understood how they were to perform their duties to reduce the risk of cross-contamination, or administration oversight to ensure policies and procedures reflecting the current professional standards of practice were initiated, implemented, and monitored for compliance. 3a. During the Environmental Tour on 10/7/11 beginning at 9 a.m., a utility room located next to the Medicare nursing station was observed to contain both dirty and clean items, with no clear distinction between a clean and a dirty side of the rooms. The utility room was observed to have garbage can liners and urinary catheters (tubes inserted into the urethra to allow for the elimination of urine) wedged between the counter and the hopper (a flushable basin used to rinse out garments with heavy vomit or fecal contamination). A mattress overlay was observed folded and placed in the sink. The entire area located under the sink was completely filled with pressure mattress machines. When the contaminated items were pointed out by the Department, the MS picked them up from the floor and placed them on the counter. In a concurrent interview with the MS on 10/7/11 at approximately 9 a.m. he reported the staff did use the hopper. He reported dirty items were not stored in the building, but were taken directly outside for cleaning, and the mattress overlay was presumed clean. He acknowledged the sink was considered a dirty area and the staff should have not tried to store the mattress overlay in the sink. He also reported the area under the sink was not meant for storage. 3b. During the Environmental Tour with the MS on 10/6/11 at approximately 9:10 a.m. a hopper room was observed across from Resident room [ROOM NUMBER]. Two bedside commodes were located in the hopper room. One of the bedside commodes was labeled with a patient name and room number. There was no clear designation of a clean and dirty side of the hopper room In a concurrent interview with MS on 10/6/11 at approximately 9:10 a.m., he reported the labeled bedside commode was used by a resident in a nearby room and the staff stored the commode in the hopper room during the day, but would put it back in the resident's room in the evening when the resident went to bed. During a facility observation on 10/7/11 at 5:05 p.m. with the DSD in attendance, the hopper room was observed to have the labeled bedside commode stored in the hopper room. The DSD also observed the patient's equipment was stored next to the hopper and reported patient equipment stored in the hopper room should be considered dirty. During a facility observation on 10/8/11 at 3:10 p.m. the hopper room was observed to have the labeled bedside commode stored in the room. In a concurrent interview with CNA 1 on 10/8/11 at 3:10 p.m. she reported she removed the labeled bedside commode from the hopper room each night and placed in the appropriate resident's room. She reported she did not sanitize the commode before taking it to the resident, she assumed the day shift had done it when they placed it in the hopper room in the morning. She also reported she frequently used the hopper for its intended purpose. 4a. During the Initial Tour of the facility on 10/4/11 at 7:50 a.m. the oxygen cannula for Random Resident 21 was observed to be on the floor. During an observation of Random Resident 21 on 10/4/11 at 8:12 a.m. the oxygen cannula was on her face. LN 7 was at the resident's bedside and stated the oxygen "was on her when I came in." In an interview on 10/4/11 8:15 a.m. with CNA 8 he stated he had found the oxygen cannula on the floor and had put it on the resident. CNA 8 stated he had not cleaned the cannula or replaced it prior to placing it on the resident. 4b. During Medication Pass observation on 10/5/11 starting at 8 a.m. LN 2 was observed giving medications to 3 residents. LN 2 was observed continuously and did not wash or sanitize her hands once between administration of medication to 3 residents. During Medication Pass observation on 10/6/11 at 8:40 a.m. LN 1 was observed giving medications to a random resident, but not washing her hands before passing medications to the next resident. Review of CDC Guide for Hand Hygiene in Healthcare Settings, 10/25/02 revealed,"Indications for handwashing and hand antisepsis, Decontaminate hands before having direct contact with patients. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient)." During an interview with LN 2 on 10/5/11 at 11:20 a.m. LN 2 stated she was aware that she "didn't wash my hands or use sanitizer after each resident." During the document review on 10/7/11 at 2:30 p.m., the facility's policy and procedure titled "Hand Hygiene" dated 2009 did not reflect performance of hand hygiene before and after resident contact, as well as before and after glove use. On 10/7/11 at 2:45 p.m., the document titled "MMWR (Morbidity and Mortality Weekly Report: Guideline for Hand Hygiene in Health-Care Settings" dated 2002 was reviewed. On page 32, the document indicated, "Decontaminate hands before having direct contact with patients...Decontaminate hands after contact with a patient's intact skin...Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled...Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care...Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient...Decontaminate hands after removing gloves. 5. The facility did not identify, investigate, control or report a possible gastrointestinal outbreak in the facility in August, 2011 affecting 26 residents, and failed to maintain a record of residents, symptoms, dates, and corrective actions related to an infectious outbreak. During an interview with the Activity Director (AD) on 10/6/11 at 11:30 a.m. AD stated there had not been a meeting of the Resident Council meeting held in August because, "residents were sick with the flu or something" and group activities and meals had been cancelled until it was resolved. In an interview with the Director of Nurses (DON) on 10/6/11 at 11:35 a.m. she stated some residents had "Diarrhea and vomiting episodes for 24 hours, then it stopped. It was sporadic." The DON stated she did not know the dates of the episode or the number of residents effected, and the facility had not conducted an investigation to determine the source of the illness. The DON stated each resident's physician was contacted and made aware of the resident's symptoms and communal dining and group activities were stopped. The DON stated an outbreak of an illness was when "A number of residents had the same symptoms for more than 24 hours." The DON stated the residents had not been placed on contact precautions to prevent transmission during their illness and that lab testing had not been conducted for any of the residents to determine the organism responsible for their symptoms. She stated the occurrence had not been reported to either the county public health department nor to the Department. The DON's statement the occurrence was not an outbreak directly contradicted facility Infection Control (IC) policy. At the request of the Department, on 10/6/11, the DON compiled a list of 21 current residents who had loose stools or emesis, or both symptoms, between 8/19/11 and 8/23/11. The census during those dates was between 82 and 85. The list had been prepared from a computer report for all patients who were prescribed medications for nausea and vomiting on overlapping dates. During an interview with the DON on 10/7/11 at 8:55 a.m. she stated group activities and group dining had been stopped on 8/19/11 when resident symptoms had started, and they were restarted again on 8/29/11. The DON stated employee illnesses had not been reported or tracked during August or currently. At the request of the Department on 10/7/11, the Assistant Director of Nurse (ADON) prepared a report of 5 additional residents discharged from the facility as the previous report had only included current active residents. The ADON prepared a second list of residents who had also experienced vomiting and/or diarrhea while in the facility between 8/19/11 and 8/24/11. The combination of both reports revealed a total of 26 residents were affected by vomiting and/or diarrhea, or 30-31% of the resident population. The GI outbreak affected residents on each of the 3 nursing stations. Two of the 26 residents reportedly affected by the GI outbreak in August 2011 experienced more significant symptoms: >Review of the clinical record for Random Resident 22 showed the following: Random Resident 22 was an [AGE] year old woman, originally admitted to the facility on [DATE] and most recently readmitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] described the resident as continent of bowel and bladder and having full cognitive capacity. The resident was described as needing staff supervision for most Activities of Daily Living (ADL's) and transfers. Her weight recorded on 3/18/11 was 97 pounds. A "Condition Change Form" dated 8/21/11 recorded at 7:30 p.m. nausea and 'lo grade' temperature of 100.2, without emesis. Other nursing documentation recorded that she started having diarrhea on 8/21/11 at 4:51 p.m. and had 10 "watery liquid" stools between that time and when she was transferred to the General Acute Care Hospital (GACH). A document faxed to the resident ' s physician, dated 8/22/11, records "Resid(ent) having flu sx (symptoms) - n/v (nausea and vomiting) and loose stools /c (with) lo grade temp(erature) sx (symptoms) began 8/21/11 in the evening. Resid(ent) conts /c (continues with) flu sx (symptoms) today." A nurse ' s note dated 8/23/11 at 4 p.m. records "Had epi(sode) of large loose BM. Appears weak and fatigued ...drank glass of soda 120 cc, complained of stomach ache ... color appears pale ...temperature 99.2, pulse 102 ...unable to hear (bowel sounds)." The resident was transferred to the Emergency Department of the local General Acute Care Hospital (GACH) at 8 p.m. on 8/23/11. >Review of the clinical record for Random Resident 3 showed the following: Resident 3 was an [AGE] year old readmitted to the facility 1/30/09 with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. There was no evidence in the clinical record that stool samples were sent to the lab for identification of the cause of the gastrointestinal distress. Resident 3's monthly weights were documented. July 2011 the resident weighed 169 pounds. In August 2011 the recorded weight was 172 pounds. In September 2011 the recorded weight was 162 pounds. These numbers show a 6 pound weight loss from July to September and a 10 pound loss (5.8 %) in the month during which the gastrointestinal illness occurred. In an interview with the Minimum Data Set Coordinator (MDSC) on 10/5/11 at 2 p.m., she stated that Resident 3 had lost weight because she had been diagnosed with [REDACTED]. In addition to the outbreak of viral gastroenteritis that occurred in August, the facility had another ongoing, previously unrecognized outbreak just preceding and continuing at the time of the survey. Review of the documented Bowel Movement Roster for all facility residents between 9/30/11 to 10/6/11 showed 13 residents had experienced at least 1 diarrhea episode, which had been reported to a nurse, during that 7 day period. In an interview with the DON on 10/7/11 at 10 a.m. she stated she had not had a chance to review the bowel report and she was not aware 13 residents had been documented as having at least 1 watery stool (events that had been reported to a nurse, during the prior 7 day from 9/30/11 to 10/6/11). The facility had taken no action to track these occurrences, assess the source of the infections or otherwise explore the residents' symptoms. The facility had no documentation to show they had attempted to reduce transmission between residents and staff members or to otherwise contain these illnesses. The facility had no documentation to show that the facility had reported these illnesses to the state or county health departments, as is required by regulation. >Resident 14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The clinical record for Resident 14 included the following information: -A 9/16/11 lab result indicating Resident 14 was infected with[DIAGNOSES REDACTED]icile, a gastro-intestinal bacteria that causes diarrhea. -A 9/17/10 physician order [REDACTED]. -There was no care plan to address Resident 14's infection, course of treatment, or infection control precautions that should have been initiated at the time the Resident tested positive for[DIAGNOSES REDACTED]icile. In an interview with the DON on 10/11/11 at 3 p.m. she reported it was her expectation the nursing staff would have prepared a care plan for Resident 14 to address the resident's active infection. She reported the care plan should have identified he was taking antibiotics and to monitor for side effects, as well as to use contact precautions. She reviewed Resident 14's clinical record and verified the care plan had not been written. >Resident 12 was an [AGE] year old admitted to the facility on [DATE] after a fall with fracture and a hip replacement. Her [DIAGNOSES REDACTED]. Review of the clinical record for Resident 12 revealed: -A laboratory report dated 7/15/11 a urine culture final report indicating an infection ">1000,000 Proteus mirabilis, ESBL (extended spectrum beta lactamases) Unusual resistance: Highly transmissible." -There was no order for infection control precautions. In an interview and record review with LN 5 on 10/6/11 at 2:30 p.m., LN 5 stated if the resident was on any infection control precautions, it would be recorded in the nurse's notes. There was no evidence infection precautions were in place when the record was reviewed with LN 5. Review of the Centers For Disease Control (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings included in section I.C.1. "Epidemiologically important organisms. Any infectious agents transmitted in healthcare setting may, under defined conditions, become targeted for control because they are epidemiologically important...In determining what constitutes an "epidemiologically important organism", the following characteristics apply:...Resistance to first-line therapies (e.g...ESBL producing organisms)." Review of the facility's undated Infection Control policies revealed: "Outbreaks of Infection in the Facility. Identification and notification Whenever symptoms of infection, such as vomiting and diarrhea, elevated temperature with respiratory symptoms, or elevated temperature with myalgia, anorexia, prostration are present in more than 3 residents in any unit, the following procedures will be carried out. a. The DON and other department heads will be notified. b. All congregate activities will be suspended for 48 hrs. or until no new symptomatic residents within the facility for 48

Based on observation, interview and record review, the facility failed to provide a safe, sanitary environment to help prevent the development and transmission of disease and infection for a census of 88 when: 1. Laundry staff failed to sanitize their hands after handling soiled laundry, before walking through a closed door and down the hallway to reach a handwashing sink at the nurse's station; 2. One of 11 sampled residents (28) was not placed on contact precautions during an active bowel infection; 3. A licensed nurse contaminated her gloved hands prior to administering eye drops to 1 random resident; 4. A CNA transferred an uncovered commode bucket from a resident bathroom through the hallway, against facility policy; 5. Residents were served meals in their room while 1 random resident was being toileted and an open bedpan containing urine was carried through the room while meal trays were uncovered; 6. The facility did not ensure all staff had received infection control training as required by the plan of correction; and 7. There was no evidence of daily monitoring of staff infection control practices as required by the plan of correction. Findings: 1. During an observation of the laundry process, with the HS in attendance on 11/30/11 at 10:30 a.m., H 2 was observed starting a load of dirty laundry. Once the washer was started H 2 removed her gown and gloves and exited the laundry room through the dirty side doorway to wash her hands at the nurses station. H 2 did not sanitize her hands or the door knob prior to leaving the laundry room to use the sink at the nurse station. The facility's October 2011 policy titled, "Laundry Department" directed the laundry staff "When all washers are full, remove gown, gloves, and mask...Use sanitizing solution on hands then go to the ... Nurses Station to wash hands thoroughly." In an interview with the HS on 11/30/11 at 11:10 a.m. she verified the laundry staff had not followed the laundry policy when she left the dirty side of the laundry room without sanitizing her hands. 2. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 28's clinical records reviewed the following: -A Bowel Movement Roster dated 11/4/11 indicated Resident 28 had 4 loose watery stools. - A Nurses Progress Note dated 11/5/11 indicated Resident 28 had two episodes of loose stools. -A Physician order [REDACTED]. -A Bowel Movement Roster dated 11/6/11 indicated Resident 28 had 5 loose stools. -A Nurses Progress Note dated 11/7/11 at 3:30 p.m., indicated Resident 28's stool specimen was positive for[DIAGNOSES REDACTED]icile. -A Bowel Movement Roster dated 11/7/11 indicated Resident 28 had 3 loose stools. -A Nurses Progress Note dated 11/8/11 at 12 noon, indicated Resident 28 was on contact isolation (prevented method to reduce the spread of disease). -A Physician order [REDACTED]. Review of the AMDA (American Medical Directors Association) Clinical Practice Guidelines for Long Term Care Facilities dated 2011 indicated it was essential, caregivers should use appropriate contact precautions for all cases of infectious diarrhea ( loose stools) to prevent or minimize outbreaks, and risks to others. Review of the Centers for Disease Control and Prevention '2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings' indicated ...".Considering the greater morbidity, mortality, length of stay, and costs associated with [DIAGNOSES REDACTED]icile disease in both acute care and long term care facilities, control of this pathogen is now even more important than previously. Prevention of transmission focuses on syndromic (symptoms) application of Contact Precautions for patients with diarrhea, accurate identification of patients, environmental issues, and consistent hand hygiene." In an interview with the DON on 11/30/11 at 8:30 a.m., she verified, after reviewing Resident 28's nurses progress notes, the first time Resident 28 was documented as being on contact isolation was on 11/8/11. She also stated the monitoring documentation was done only in the nurses notes. In an interview with the DSD on 11/30/11 at 8:55 a.m., she stated the facility's policy was to place residents who were exhibiting symptoms of infections immediately on contact isolation until further investigation. She also stated the licensed staff were supposed to document in the nurses notes every shift that the resident was on contact isolation. 3. Random Resident 35 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During the Medication Pass observation on 11/29/11 at 2:15 p.m., LN 4 contaminated her gloved hand by pulling Random Resident 35's privacy curtain with the gloved hand prior to administering the resident's eye drops. Review of the Centers for Disease Control and Prevention document titled "MMWR (Morbidity and Mortality Weekly Report): Guideline for Hand Hygiene in Health-Care Settings" dated 2002. On page 32, the document indicated, "Decontaminate hands after contact with inanimate objects....Decontaminate hands before having direct contact with patients. In an interview with LN 4 on 11/30/11 at 2:45 p.m. she verified she had pulled Random Resident 35's curtain with her gloved hand prior to giving the resident her eye drops. She stated "I shouldn't have done that". 4. During the Initial Tour of the facility on 11/29/11 at 9:23 a.m., an unlabeled commode bucket was observed on the floor in the bathroom shared by residents in rooms [ROOM NUMBERS]. Two used tissues were observed to be inside the bucket. During an observation on 11/30/11 at 8:28 a.m. CNA 2 was carrying an uncovered commode bucket past the Natoma nurse's station. CNA 2 exited the building through the door near the laundry and placed the bucket outside, then he returned to the building. During an interview with CNA 2 on 11/30/11 at 8:29 a.m. he stated "I took the bucket from the bathroom of room [ROOM NUMBER], it wasn't used by anyone so I took it out. We are supposed to cover them in bags when they leave resident rooms, clean or dirty." CNA 2 confirmed he had not covered the commode bucket. During an observation with CNA 2 at 11/30/11 starting at 8:29 a.m. in the bathroom for room [ROOM NUMBER], he demonstrated where plastic bags were kept in resident bathrooms for staff to wrap used commode buckets and bedpans in before taking them out of the room. CNA 2 was observed reaching into the trash can, moving aside the plastic bag and agitating contaminated waste, to reach under the bag for the supply of unused trash bags. The process of reaching under a bathroom trash bag to obtain care supplies presented an opportunity for infectious organisms to be carried around the building on staffs' clothing and forearms. In an interview with the DSD on 11/30/11 at 11:12 a.m. she stated "If any commode leaves the room it should be covered and taken to the dirty utility room. Staff should not have an uncovered commode" bucket outside of resident rooms. When the DSD described the procedures for transporting commode buckets, she stated plastic bags to cover commode buckets were kept "In the bathroom trash cans" in resident rooms. 5. During an observation on 11/30/11 at 12:25 p.m. CNA 9 was observed pulling the privacy curtain for Random Resident 34 and staying with the resident. During an observation on 11/30/11 at 12:30 p.m. CNA 10 spoke to CNA 9 then brought a lunch tray to Random Resident 23, in the bed next to Random Resident 34, CNA 10 passed the closed curtain and Random Resident 23 began to eat. During an observation on 11/30/11 at 12:32 p.m. CNA 9 partially opened the privacy curtain for Random Resident 34, and CNA 10 brought the lunch tray to Random Resident 34, as CNA 9 exited the privacy curtain carrying an uncovered bedpan containing urine, into the bathroom, then CNA 9 was observed carrying the bedpan, wrapped in a clear plastic bag, into the utility room. During an interview on 11/30/11 at 12:35 p.m. in the utility room, CNA 9 stated the resident had urinated. CNA 9 stated "I had the curtains closed so (CNA 10) should have waited to bring the lunch tray. I am aware that trays should not be in the room until toileting was completed." During an interview on 11/30/11 at 12:40 p.m. CNA 10 stated food "could be contaminated with bacteria" if trays were brought into a room during resident toileting. CNA 10 stated "but the roommate wanted to eat." 6. Review of facility training records titled Emesis Basin Cleaning dated 10/25/11 revealed the time of training was left blank, there was no indication of the length of training. The names and signatures of 27 CNAs from the nursing department were listed on the sign-in section of the record. Review of facility training records titled Disinfection of Bedpans and Urinals and Bedside Commodes dated 10/25/11 revealed the time of training was left blank, there was no indication of the length of training. The names and signatures of 28 CNAs from the nursing department were listed on the sign-in section of the record. During an interview with the DSD on 11/30/11 starting at 10:45 a.m. she stated all CNA's had been trained in the revised infection control procedures related to disinfecting resident care supplies. When asked how many CNAs were employed in the nursing department the DSD was unable to give an accurate number. After obtaining a list from administration at 11:12 a.m. DSD stated there were 49 CNAs she was responsible for supervising in the nursing department. The DSD was not able to demonstrate that all CNA staff had attended training. 7. Review of the survey plan of correction included under the monitoring process for infection control the following statement: "DON and DSD to monitor hand washing technique during daily performance of nursing duties and/or observation rounds." During an interview on 11/30/11 at 11:20 a.m. the DSD stated she had no evidence monitoring of staff handwashing practices had occurred daily. The DSD stated "I remind them about handwashing every day." The DSD stated during her monitoring "No staff had failed to demonstrate proper handwashing."