Every finding on record at Good Samaritan Society - Westbrook

Based on observation, interview and document review the facility failed to provide surveillance and implement Transmission Based Precautions (TBP) for 7 of 7 residents (R6, R12, R16, R25, R29, R30 and R31) who were experiencing cold/respiratory signs and symptoms. The facility also failed to ensure nebulizer equipment was appropriately rinsed and dried after each use for 3 of 3 residents (R25, R29, and R30) and ensure appropriate cleaning and disinfection occurred for 1 of 1 multi-resident use whirlpool tub. This deficient practice had the ability to affect all 32 residents in the facility. Findings include: Whirlpool cleaning and disinfection: Observation on 3/18/26 at 10:10 a.m. with nursing assistant (NA)-A identified she prepared to disinfect the whirlpool tub by applying gloves, returned the bath chair into the tub, closed the door of the tub, and explained she liked to turn on the air jets for about 30 seconds at the beginning of the process to clear any debris that may have been in the bath. NA-A closed the drain, removed the belt attached to the chair and placed it into the well of the tub and the cushion remained attached on the seat of the bath chair. NA-A turned on the switch to fill the tub with the disinfectant (CID AL II) to the first level about 2 inches. The belt was immersed in the disinfectant, but the bath chair with a cutout in the seat, remained above the level of the disinfectant solution. She then took a long handled brush and using the disinfectant solution in the tub well brushed over the surfaces of the tub, back rest and top of chair cushion, but Failed to clean the bottom of the chair cushion. After brushing the tub surfaces , she picked up the belt and brushed over both sides of the belt, before placing it back into the solution in the bottom of the tub. She had given four baths this morning and this was her last one. At 10:16 a.m., NA-A reported she needed to wait 10 minutes to allow the disinfectant to remain on the tub surface to allow for disinfection. She set her watch alarm for 10 minutes, and began cleaning up the room, by taking out used linens, trash and supplies. She did not re-wet the surface of the tub which continued to dray as she went about her tasks. The directions posted on the back of the control area of the tub listed step by step directions, which included -lift the seat bottom off chair. Use the cleaning solution to scrub the tub, chair and underneath seat bottom. NA-A returned at 10:26 a.m., and stated the 10 minutes had elapsed, and she could now drain and rinse the tub which was the final step. NA-A was asked about cleaning of the tub chair cushion and replied she had scrubbed the top of the cushion, but she was not aware the cushion was removable and agreed she had not cleaned the bottom of the seat. She stated she had never removed the cushion from the frame to clean the underside. She removed the cushion which was clipped onto the frame of the chair and upon turning it over dried white residue was noted spotting the underside of the cushion. In addition a brown substance was noted along the edge of the opening in the seat cushion, which NA-A remarked it was probably feces as the resident had a bowel movement during her bath. NA-A reported she performed the cleaning according to the printed instructions between each bath, but since this was the last bath of the day she was following the disinfection procedure. She identified she had not removed the seat cushion between baths, and was not aware that it could be removed for cleaning. Observation and interview on 3/18/26 at 10:30 a.m. with the administrator who came to the tub room and observed the bath chair cushion, voiced agreement the chair cushion had not been cleaned appropriately, and she expected all components of the tub and chair to be cleaned and disinfected after each bath. She further stated it was likely other staff were also not aware the seat cushion was removable for cleaning and as a result would be implementing retraining. Review of the current, undated Advantage Seated Bathing System Cleaning and Disinfecting Process for Air Spa Series, Manufacturer's Guideline identified Staff were to: Turn off the blower and lift the seat bottom off the chair. Use the cleaning solution/disinfectant to scrub the tub, chair and underneath the seat bottom. Leave wet for 10 minutes, then open the tub drain and turn the blower on, turn the selector knob to Rinse and the control knob to on, and when clear water comes out of all outlets, turn the control knob off. Leave the blower on for 60 seconds to force the remaining water out of the airlines. Turn the blower off and use the shower wand to rinse the tub and chair. Review of the 12/2/24, Infection Prevention and Control Program Policy identified the program to prevent, identify, investigate, and report in the attempt to control infections and communicable diseases for residents, staff, and visitors in a facility. The program was to follow the nationally accepted standards, and guidelines for infection control. The program was to include an acceptable system to monitor and document infection control and prevention. The program was to be reviewed annually by the IP or designee, to ensure compliance. The IP utilizes surveillance data to identify outcomes, trends and patterns with results communicated to the QAPI committee. TBP Observation on 3/17/26 at 9:00a.m. during the initial tour, identified no residents were identified as being on Transmission-based precautions (TBP). Interview on 3/17/26 at 9:00a.m. with the director of nursing (DON during the entrance conference identified there were some resident with cold symptoms, but none had been placed on TBP. Observation and interview on 3/17/26 at 10:00a.m., of R6 in his room identified he/she showed signs and symptoms (S/S) of congestion and had a hoarse voice. Staff were entering and exiting the room with no Personal Protection Equipment (PPE) in use. Observation of R12 on 3/17/26 at 10:15 a.m. identified S/S including cough, congestion, and fever. The electronic medical record (MAR) identified the S/S had initiated on 3/8/26. Observation of R16 on 3/17/26 at 11:00 a.m. identified S/S including congestion and a hoarse voice. Observation of R25 on 3/17/26 at 11:15 a.m. identified S;/S including cough, congestion and shortness of breath (S.O.B.). The MAR identified the S/S had developed on 3/12/26. No precautions were in place, nor PPE in use by staff entering the room or caring for the resident. Observation/interview of R29 on 3/17/26 at 11:20 a.m. identified she had no S/.S, but she reported she had self isolated to avoid residents who were coughing and sneezing in the common areas of the facility. Observation/interview of R30 on 3/17/026 at 11:30 a.m., identified he had S/S including fever, cough and S.O.B. R30's medical record progress notes identified S/S had been noted on 3/13/26. Observation and interview on 3/17/26 at 11:45 a.m. of R31 identified she had developed a cough, complained of chest congestion and S.O.B. which the MAR progress note identified had begun on 3/8/26. There was no signage on any of the above resident's doors that identified the need to use TBP to prevent the potential spread of possible infectious disease. R31 Interview on 3/17/26 at 9:00 a.m., with the director of nursing (DON) identified the facility had no residents on transmission-based precautions for confirmed or suspected respiratory infections. R31's 2/9/26, comprehensive Minimum Data Set (MDS) assessment identified her cognition was moderately impaired, she was independent with transfers and toileting and required set up and clean up assistance with dressing. R31 required moderate assistance from staff with bathing. Observation and interview on 3/17/26 at 10:14 a.m., of R31 identified she had not been feeling well for a while, she was observed to be holding a Kleenex in her hand and coughing during the interview. She did not have any signage hanging on her room door to alert others that she had a potential infectious disease requiring transmission-based precautions. There was no personal protective equipment (PPE) available for staff to put on prior to entering her room. R31's 3/11/26, nursing progress note identified a fax was sent to the primary physician to notify him R31 has a very harsh cough. As needed, Mucinex and cough syrup was being administered. The physician responded with an order to start Tessalon capsules (an alternative to cough medicine). R31's nursing progress notes made no mention that she had been placed on isolation, advised to wear a mask when out of her room, that she had been tested for covid or influenza, or that monitoring had been set up. Review of R31's current medication orders identified she was to be administered Mucinex oral tablet extended release 800 milligrams (MG) every 12 hours as needed for cough and dextromethorphan-guaifenesin (cough syrup) 20 milliliters (ML) every 4 hours as needed for cough. In addition, R31's physician orders included testing at the facility for covid and influenza A & B as needed for s/s of respiratory infection. Interview and document review on 3/19/26 at 8:34 a.m., with the activity director identified R31 attended a happy hour (group activity held in the dining room with food and drinks) activity on 3/13/26 and the St Patrick's Day party on 3/17/26, with other residents and staff. Interview on 3/17/26, at 10:30 a.m., with the infection preventionist (IP) identified she would have expected nursing staff to place residents on precautions upon observation of respiratory infection signs and symptoms. Once the resident is placed on precautions, nursing should complete testing for Covid and Influenza. If the resident tested negative, they could leave their room if they are wearing a mask. The IP identified the facility has the supplies to test for Covid and influenza A & B at the facility, however, they do not have the ability to test for RSV (a highly contagious respiratory syncytial virus that can be dangerous for older adults) or any other respiratory infections. Review of R31's 3/17/26 nursing progress note identified she was tested for covid and influenza due to cough and chest congestion. R31 was placed on precautions until symptoms resolve, or 2 negative covid test results are obtained. R6's 3/2/26, accepted comprehensive Minimum Data Set (MDS) identified R6's cognition was severely impaired. R6 was independent with eating and required partial assistance from staff with bed mobility and transfers and required substantial assistance with personal hygiene and toileting. R6 had diagnoses of coronary artery disease, high cholesterol, osteoporosis, depression, dementia and Parkinson's disease. Observation on 3/17/26 at 11:05 a.m., identified R6 had a personal protective equipment (PPE) (gowns, gloves, mask) cart placed outside of his room with a transmission-based precautions (TBP) sign on his door, indicating anyone entering R6's room must wear surgical mask, perform hand hygiene, use eye protection and wear a gown. R6's medical record reviewed on 3/17/26, made no mention that he had been placed on precautions or why R6 had been tested for COVID and influenza A & B. There was also no indication in the medical record that a respiratory assessment had been completed, or monitoring had been set up at that time. R16's 2/23/26, accepted quarterly MDS identified R16's cognition was severely impaired. R16 was independent with eating, and needed substantial assistance from staff for personal hygiene, toileting, bed mobility, and transfers, and was dependent on staff for dressing. R16's had diagnoses of heart disease, arthritis, anxiety, depression, dementia, and Parkinson's disease. Observation and subsequent interview on 3/17/26 at 10:05 a.m., with licensed practical nurse (LPN)-A, identified she entered R16's room without donning PPE first and closed the door. LPN-A then came out of R16's room and reported she had just tested R16 for COVID and influenza. LPN-A gave no indication why she had not donned PPE prior to entering R16's room to test for COVID and influenza to rule out a potential infectious disease. Observation on 3/17/26 at 10:34 a.m., of R16 identified he was seated in the dining room at his table eating his breakfast. R16 was seated alone at the table with no mask visible. Observation on 3/17/26 at 11:03 a.m., of LPN-A identified she was directing nurse aide staff to place a PPE cart outside of R16's room. Staff acknowledged LPN-A's direction and reported they would need to go get R16 from the dining room. Interview on 3/17/26 at 11:06 a.m., with LPN-B identified R6 had a cough, and he was congested and R16 had respiratory symptoms as well. Their symptoms begin on 3/17/26, and both R6 and R16 were tested today. The results of both residents were negative, and they would be tested again in 2 days. Both were placed on TBP due to their respiratory symptoms. Observation on 3/17/26 at 11:12 a.m. through 11:17 a.m., of R16 identified he remained seated at the dining room table and was done eating breakfast and was now waiting for the noon meal. R16 remained unmasked. Staff are bringing other residents into the dining room for lunch. R16's table mate arrived and was seated at table next to R16 after R16 had been tested for respiratory system. Staff approached R16 unmasked and spoke to him. Staff then proceeded to wheel R16 out of the dining room without a mask and pushed him back to his room. R16 had a PPE cart outside of his room with a TBP sign on his door that indicated anyone entering the room must wear surgical mask, perform hand hygiene, use eye protection and gown. Interview on 3/17/26 at 11:19 a.m., with LPN-A reported she was unsure why staff took R16 out of his room for breakfast as she had tested R16 that morning for potential infectious respiratory disease after staff had reported to her that R16 had respiratory symptoms. She reported R16 should have stayed in his room. LPN-a did not indicate she had instructed staff to leave R16 in his room or if he was taken out of his room, staff were to ensure he wore a mask or seat him alone in the dining room to not expose residents near him. R16's medical record was reviewed on 3/17/26, and there was no mention he had been placed on TBP or why R16 had been tested for COVID and influenza A & B. There was also no mention R16 should wear a mask when out of his room, that a respiratory assessment had been completed, or monitoring had been set up. Further interview on 3/18/26 at 5:00 p.m., with LPN-A identified R6 had been at the desk after breakfast on 3/17/26 and was coughing. She had taken him back to his room and tested him for COVID and influenza. Staff had reported to her also that R16 sounded congested and that was why she had tested him. She revealed she did not complete a respiratory assessment on R6 or R16 and that was the reason there were no assessments in R6 or R16's medical record on 3/17/26. She did identify however, that she had some vitals documented on a piece of paper that she had not had time to enter the information into R6's or R16's charts yet, but she would be doing that today. She was unaware of any process for setting up specific monitoring for residents who displayed signs or symptoms of respiratory infection. Review of the 11/18/25, Infection Prevention and Control Program policy identified Transmission Based Precautions-specific measures would be used to protect residents, employees, visitors and other individuals from the spread of infection when the route of transmission is not interrupted by standard precautions alone. The type of precautions (i.e., airborne, contact, droplet) used depends on the potential for exposure, route of transmission, and infectious organism/pathogen or clinical syndrome if an organism is not yet identified. In addition, infection prevention and control education for residents/patients/clients, employees, visitors, and other individuals as appropriate for the healthcare setting. Nebulizer cleaning R29's 3/2/26, accepted quarterly MDS identified R29's cognition was intact. R29 was independent with eating and required substantial assistance from staff for personal hygiene, dressing, toileting, and transfers. R29 had diagnoses of heart failure, high blood pressure, depression, asthma, and chronic obstructive pulmonary disease. R29's Medication Administration record identified an order for DuoNeb Solution 0.5-2.5 milligrams/3 milliliter (mg/ml) inhaled medication, 1 inhalation, via a nebulizer machine one time a day in the morning. R30's 3/9/26, accepted comprehensive MDS identified R30's cognition was intact. R30 was independent with eating and required substantial assistance from staff for personal hygiene, dressing, toileting, and transfers. R30 had diagnoses of kidney insufficiency, Parkinson's disease, depression, and malnutrition. R30's current, March 2026, Medication Administration record identified a physician's order for Ipratropium-Albuterol inhalation solution, 0.5-2.5 mg/3ml 1 inhalation, four times a day. Observation on 3/17/26 at 9:24 a.m., of R29's and R30's shared room identified R29's nebulizer tee piece a handheld piece was still attached to the nebulizer machine sitting on bedside table next to her chair and had not been disconnected, rinsed, and left to air dry between use to remove residual medication. R30 had a nebulizer mask that was still attached to his nebulizer machine sitting on bedside table next to his chair that also had not been disconnected, rinsed, and left to air dry between use to remove residual medication. Observation and interview on 3/19/26 at 11:00 a.m., of R29's and R30's shared room identified R29's and R30's nebulizer mask were still attached to their nebulizer machines which were located on their bedside tables. R29 reported staff set up the machine for his/her use, and they would usually take their mask to the bathroom and rinse It out and bring it back sometime during the day, however, no staff had been into the room to do that yet. Later observation on 3/19/26 at 12:52 p.m., both R29 and R30 nebulizer mask were still attached to their nebulizer machines and remained on their bedside tables. Interview on 3/19/26 at 12:56 p.m., with director of nursing identified nebulizer attachments like a mask and handheld tee type was to be taken apart and rinsed after each use and left to air dry on a towel until the next use. R25's 2/2/26, accepted quarterly MDS identified R25's cognition was intact. She was independent with eating, needed partial assistance from staff for bed mobility, toileting and transfers, and needed substantial staff assistance for personal hygiene. R25 had diagnoses of high blood pressure, arthritis, anxiety, and chronic obstructive pulmonary disease. R25's current, March 2026, Medication Administration record identified a physician's order for Arformoterol Tartrate (a long-acting bronchodilator used to treat chronic bronchitis and emphysema) inhalation nebulization solution, 1 inhalation twice a day, morning and evening. Observation on 3/19/26 at 1:01 p.m., of R25's nebulizer machine which had a handheld tee piece device that was still attached to the machine located on the bedside table in her room that had not been disconnected, rinsed, and left to air dry between use to remove residual medication. Review of the 12/10/25, Nebulizer policy identified when a treatment was finished to clean the nebulizer after each use. Staff were to disconnect the tubing separate the nebulizer parts and wash with warm soapy water and rinse thoroughly, then place on paper towel to air dry until the next use.

Based on interview and document review, the facility failed to ensure the IP brought data forth measurable data to 1 of 1 Quality Assurance Performance Improvement (QAPI) committee. This had the potential to affect all 32 residents. Findings include: Review of the QAPI meeting minutes from the past four quarterly meeting minutes identified: 1). November 14,2025, (Quarter 4), Infection Control (IC) documentation included data of Monthly infection summary which included numbers and types of infections. The minutes identified numbers for the current month compared to the previous month with a comparison percentage, but no breakdown, analysis or discussion for an ongoing plan identified 2). September 16, 25. (Quarter 3), IC minutes documentation included a general goal of less than 7% compared to the current performance of 10.19%. There was no identified data included to identify what was included in the percentages. Analysis identified the plan to continue education regarding personal hygiene provided to residents, but there was no surveillance data or investigation into patterns or possible analysis of the data. 3). June 27, 2025, (Quarter 2), IC minutes documented number of resident infections with type listed, along with the percentage compared to the previous month. The goal identified a percentage, but there was no documentation to indicate analysis of root cause of infections, discussion as to potential interventions other than general comments to educate staff as needed. The report listed audits had been completed for 48-hour progress notes, but there was no identification of findings for the audits, or discussion regarding potential interventions with a plan identified. 4). January 26, 2026, (Quarter 1), IC minutes included goals for types of infections with comparison to previous month, but there was no tracking of potential source, or patterns identified. The minutes failed to include any discussion of data, with analysis of potential source, and determination of appropriate interventions to be initiated. Interview on 3/18/26 at 8:41 a.m. with the Infection Preventionist reported she had not been providing on-time infection control surveillance for residents and staff as her practice was to collect infection information place it in a folder on her desk and compile a report the week following the end of the month. She confirmed this practice did not allow her to analysis and develop a process for discussion of the findings at the QAPI meetings. She agreed that review of the Quarterly IC minutes did not include discussion of findings or development with documentation of a plan to go forward with the findings identified in her report. Interview on 3/18/26 at 11:00 a.m. with the administrator identified her expectation for the IP to provide evidence of surveillance, analysis and suggestions for discussion of a plan to monitor and prevent potential outbreak of infections in the facility. Review of the February 2024 Quality Assurance and Performance Improvement (QAPI) policy identified the facility was to have a QAPI plan to address resident's Quality of Life, and resident choices. The plan was to be developed according to details included in the Facility Assessment. The policy identified the QAPI program was to identify areas of high risk, high volume, and/or problem areas for improvement by identifying and correcting the areas of deficiency.The components to be included:1.) Tracking and measure of performance2.) Establish goals with thresholds for performance improvement.3.) Identify and prioritize areas of quality deficiencies.4.) Analyze causes of deficiencies.5.) Develop and implement corrective action plans.6.) Monitor and evaluate the action plan with revisions, as necessary.

Based on observation, interview, and document review the facility failed to appropriately prepare unpasteurized eggs, monitor temperatures of food prior to serving, and to monitor the refrigerator and freezer temperatures to prevent food borne illnesses. Findings include: Observation and interview on 1/6/25 at 10:52 a.m., with the dietary manager (DM) during a tour of the kitchen, the DM identified the eggs located in the refrigerator in the prep area were unpasteurized. The DM reported that the facility cooked the unpasteurized eggs hard. She further reported she had forgotten to provide temperature monitoring sheets for the month of January, and temperatures had not been monitored and documented for the refrigerators and freezer. She confirmed that the refrigerator and freezer temperatures were to be monitored twice a day. Interview on 1/7/25 at 7:58 a.m., with the DM identified she ordered eggs through Sysco, and pasteurized eggs were not available at the time of the order. She stated she was aware that the unpasteurized eggs were to be cooked hard as they could not be served with a soft yoke. Review of the current facility menu identified eggs for breakfast: Week 1-Sunday scrambled eggs, Monday no eggs, Tuesday no eggs, Wednesday egg of choice, Thursday scrabbled eggs, Friday egg of choice, and Saturday no eggs. Week 2- Sunday cheesy eggs, Monday no eggs, Tuesday no eggs, Wednesday scrambled eggs, Thursday no eggs, Friday scrabbled eggs, and Saturday no eggs. Week 3-Sunday egg of choice, Monday cheese omelet, Tuesday no eggs, Wednesday scrambled eggs, Thursday cheese and egg casserole, Friday egg of choice, and Saturday no eggs. Week 4-Sunday egg and cheese sandwich, Monday no eggs, Tuesday scrambled eggs, Wednesday no eggs, Thursday egg of choice, Friday cheese omelet, and Saturday no eggs. Observation on 1/7/25 at 9:07 a.m., during medication pass, R5's plate was observed to have what looked like yellow egg yolk smeared on about 1/4 of the plate and on the plates raised edges. There were two other residents in the dining room eating scrabbled eggs with no indication of egg yolk on their plates. Interview on 1/8/25 at 7:47 a.m., with dietary cook (C)-A who identified residents can get their eggs scrabbled or over easy. If she made scrambled eggs, she used the liquid eggs from the carton and for the over easy eggs she used the eggs out of the refrigerator. She reported she was unaware if the eggs were pasteurized or unpasteurized. She revealed she had not received any education on the use of pasteurized or unpasteurized eggs and how to prepare them. She reported R27 had requested runny eggs this morning and she made them runny for her. She then revealed that R5, R25, and R26 also requested their eggs runny sometimes. She then said, she believed the eggs were unpasteurized and that they had been getting the unpasteurized eggs for a while now. She reported she was unaware unpasteurized eggs needed to be hard cooked and not served runny. Interview on 1/8/25 at 7:54 a.m., with the dietary assistant (DA)-B identified that he did not cook, and he had not had any training on handling unpasteurized eggs. He confirmed there were residents in the facility who liked their eggs runny or soft for breakfast. Interview on 1/8/25 at 8:13 a.m., with R5 identified she liked eggs, and she usually ordered them fried, but did occasionally like them soft but not runny. Interview on 1/8/25 at 8:16 a.m., with R26 identified he liked eggs. He was unable to tell how he liked or received his eggs. Interview on 1/8/25 at 8:20 a.m., with the director of nursing (DON) identified the dietary manager ordered the eggs for the facility. She reported that if the facility had unpasteurized eggs, she would expect the dietary staff to be trained on handling unpasteurized eggs. Interview on 1/8/25 at 8:24 a.m., with the administrator identified unpasteurized eggs should not be served runny and she would expect all dietary staff to know how to handle unpasteurized eggs. She was unaware that the facility had been getting unpasteurized eggs and stated the facility should only be ordering pasteurized eggs. She then picked up the phone and called the dietician and the dietician stated on speaker phone the only time the facility should use unpasteurized eggs was if it was for baking. The dietician further reported if unpasteurized eggs were to be used for breakfast that they had to be cooked hard and all staff should be trained on how to handle unpasteurized eggs. Interview on 1/8/25 at 8:39 a.m., with DM identified she was still unable to get pasteurized eggs and she had forgotten to tell C-A the unpasteurized eggs could only be served cooked hard. For residents who like them served soft she reported they were to explain to the resident that they could not make soft eggs at this time and offer to serve the eggs hard or scrabbled. She said when she went to order the pasteurized eggs from Sysco they were listed out of stock. She stated, I'm not going to try to pull the wool over your eyes or lie and confirmed she had not been monitoring the temperatures for the food, refrigerators, or freezer. She reported she knew the refrigerator and freezer were working and she had set a bad example for others. She confirmed she knew she was supposed to monitor and document but she just did not do it. She said she had let a lot of things go that she was supposed to do but she had been working 7 days a week for a very long time and she just let things go. She confirmed she had no temperature logs to provide for food monitoring, refrigerators, or freezer. Interview on 1/8/25 at 9:18 a.m., with the dietician identified she would expect staff to monitor and document food temperature prior to serving, in addition to monitoring refrigerator and freezer temperatures. She reported she was surprised that it had not been getting completed. She was unaware that anyone was having trouble getting pasteurized eggs. Interview on 1/8/25 at 9:35 a.m., with the Sysco customer care identified there had been a problem with obtaining pasteurized eggs at some warehouses. He revealed that his records showed pasteurized eggs were unavailable at time of the facilities November and December orders. Facilities are not allowed to use unpasteurized eggs and other facilities had been ordering liquid eggs. He was unsure why the pasteurized eggs were unavailable and said Sysco was at the mercy of what they could get in the warehouses, but it appeared to be resolved at this time. Interview on 1/8/25 at 10:12 a.m., with the administrator identified she had all the unpasteurized eggs removed from the building, she set up mandatory education for dietary staff prior to starting their shift and arranged for the dietician to come today to re-educate the dietary manager. Interview on 1/8/25 at 1:21 p.m., with the medical director identified he would expect the facility to be following policies and procedures for monitoring and documenting food temperatures, refrigerator, and freezer temperatures to prevent food borne illnesses. He further confirmed unpasteurized eggs should not be served soft or runny due to the risk of Salmonella illness. Review of 12/16/24, Food Temperature Monitoring policy identified food temperatures are to be taken and documented prior to each meal. Additionally, periodic temperatures should be taken during or at end of meal to ensure temperatures maintain acceptable ranges. Review of 5/7/24, Food-Supply Storage-Food and Nutrition policy identified all refrigerators and freezers in the nutrition department and dining room are recorded twice daily. Review of 3/11/24, Ordering-Food and Nutrition Service policy identified ordering food will be completed timely and can be completed by ordering through Food Samaritan NET Purchasing System (DSSI) or by ordering directly from the vendor. If questions or concerns staff should reach out by submitting question directly to [NAME] Service Portal, or by contacting National Campus. A policy for use of unpasteurized eggs was requested but not provided.

Based on observation, interview and document review the facility failed to have a current, ongoing, system of surveillance to identify potential outbreaks of infectious disease, ensure transmission based precautions were implemented timely, perform root cause analysis to identify patterns of illness in staff or residents, report an outbreak of Norovirus (highly contagious gastrointestinal (GI) virus that causes inflammation of the stomach and intestines), prohibit staff from returning to work until 72 hours from resolution of gastrointestinal symptoms occurred. and ensure 1 of 1 whirlpool tub was appropriately disinfected between resident use according to the manufacturer's directions. This had the potential to affect all 29 residents. Findings include: SURVEILLANCE/ POTENTIAL NOROVIRUS OUTBREAK Review of the September 2024 Monthly Infection Control Report identified 14 antibiotic orders utilized with 231 days of therapy. No staff/family/visitor documentation of illness was provided/identified in the document. Nine residents (R3, R5, R11, R17, R19, R24, R31, R182 and R183) were identified as having received antibiotics. 1 resident (R17) was identified as started on Paxlovid (antiviral medication used to treat COVID-19 symptoms). There was no documentation on the surveillance of a positive COVID diagnosis, date of initiation of S/S, transmission-based precautions (TBP) implemented, with start and stop dates, nor investigation into potential contacts or source of infection. Review of the October 2024, Monthly Infection Control Report identified 10 antibiotic orders utilized with 100 days of therapy. The report identified a COVID outbreak in the facility with 14 residents identified as COVID positive from September were carried over (R5, R9, R10, R14, R17, R22, R23, R24, R31, R133, R134, R185, R186 and R189). One resident (R31) was identified as having COVID and was also receiving an oral antibiotic without documented rational to support treatment for a bacterial infection. One resident was identified to be positive for Norovirus (R11) on 10/14/24, and 5 other residents (R1, R8, R17, R18, and R19) were listed as having GI symptoms on 10/21/24 through 10/26/24. Three residents, R2, R8, and R11, had documented urinary tract infections (UTI). The employee/children/family/visitor log for October 2024 identified 10 staff and/or their family members: 1) Nurse aide (NA)-C tested positive for COVID with onset of symptoms beginning 10/4/24 and returned to work when a negative COVID test was obtained on 10/9/24. 2) NA-D reported nausea and being sweaty on 10/11/24 and returned to work on 10/13/24. 3) Trained medication aide (TMA)-A reported nausea and vomiting on 10/13/24 and returned to work 10/15/24. 4) Licensed practical nurse (LPN)-B reported vomiting and diarrhea also on 10/13/24 and returned to work the next day on 10/14/24. 5) NA-E reported vomiting and diarrhea on 10/23/24 and 10/24/24 and returned to work on 10/31/24. 6) NA-F reported vomiting and diarrhea 10/15/24 through 10/16/24 and returned to work 10/18/24. 7) Unidentified staff (U)-A reported they along with their child had symptoms of fever, vomiting, and diarrhea. There was no notation if or when that staff reported back to work. 8) NA-G and their child reported vomiting and/or diarrhea on 10/16/24 and 10/17/24. NA-G returned to work on 10/20/24. It was noted some staff symptoms were documented as resolved, but not the date they resolved, or if staff had been prevented from returning to work for 72 hrs. after GI symptoms resolved. It is also not identified the infection preventionist correlated the possibility of staff being infected with Norovirus after R11 was formally diagnosed with the infection on 10/14/24, or the other residents, who had not been tested for potential Norovirus but had similar symptoms of potential outbreak had been noted. There was also no mention when TBP were implemented, or if any had occurred, or what type. Review of the November 2024, Monthly Infection Control Report identified 16 antibiotic orders utilized with 75 days of therapy. The report identified 1 resident (R7) admitted on a prophylactic antibiotic for history of UTI's. The record failed to contain any investigation into the continued need or rational for continued use of the antibiotic or if a time-out had been performed. 12 residents received antibiotics in November (R6, R7, R13, R15, R17, R18, R23, R24, R27, R187, R188, and R189). The employee/children/family/visitor log for November 2024 identified: 1) An unidentified staff (U)-B had s/s of a sore throat and cough on 11/13/24, tested negative for COVID and returned to work 11/15/24. 2) NA-I had GI Illness at work on 11/1/24 and went home. NA-I was noted as working less than part time, however, there was no notation to show if or when NA-I returned to work in November 2024. 3) LPN-C reported s/s of migraine on 11/15/24, but was not tested for COVID as they were positive for COVID infection in September 2024. 4) NA-C reported vomiting on 11/21/24, noted as symptom free and returned to work the next day on 11/22/24. 5) NA-J reported fever and vomiting on 11/21/24, and returned to work the next day on 11/25/24. 6) NA-G had an ill child from 11/12/24 through 11/14/24 and took to MD [doctor]. NA-G returned to work on 11/18/24. It was noted some staff symptoms were documented as resolved, but not the date they resolved, or if staff had been prevented from returning to work for 72 hrs. after GI symptoms resolved. It is also not identified the infection preventionist correlated the possibility of staff being infected with potential Norovirus. There was also no mention when TBP were implemented, or if any had occurred, or what type There was no surveillance performed during the month of December 2024 for residents or staff. Review of the 2024-2025 Norovirus Information for Long-term Care Facilities, located at https://www.health.state.mn.us/diseases/foodborne/outbreak/facility/ltcfnorotoolkit.pdf, identified Norovirus is transmitted through a fecal (stool)-oral route with symptoms of diarrhea, vomiting, nausea, abdominal pain, low grade fever, headache, and or body aches. Individuals generally become ill 12-48 hours after exposure (swallowing Norovirus). Infected individuals shed the virus in their stool and contaminate food, surfaces, and objects and can be shed in the stool for several weeks after recovery. Products used to clean Norovirus must say they are effective against Norovirus. Hand sanitizer does not work to kill the virus. Individuals should wash their hands for 20 seconds with soap and water. Individual cases of Norovirus are not reportable to the State, however, possible outbreaks or multiple cases with Norovirus-like symptoms must be reported. Documentation of possible outbreaks was to include: 1) Use the RESIDENT ILLNESS LOG and STAFF ILLNESS LOG to document illnesses among staff and residents/patients Contact managers of each unit, etc. as necessary to gather illness information. Send both ILLNESS LOGS back to MDH within 2 business days of reporting the suspected outbreak. Epidemiology staff will use this to assess A) which pathogen is causing the outbreak, B) the likely route of transmission, and C) whether additional prevention measures are needed. 2) Gather additional information List activities, events, etc., held during the week prior to the first illness (especially if food was served). Determine when and where there were any vomiting incidents or diarrheal accidents in the facility. If requested by MDH, provide a dietary menu (breakfast, lunch, and dinner). If requested by MDH, provide names and phone numbers for staff and/or residents (in rare cases, MDH may want to conduct interviews). 3) Collect a stool sample from three (3) residents and/or staff and send to MDH Laboratory for analysis (MDH will provide specimen collection kits; the testing is free of charge). If stools from residents or staff were sent to a clinical laboratory, notify MDH of any results. 4) Send both completed ILLNESS LOGS back to MDH between 1 and 2 weeks after the last illness. 5) IMPLEMENT OUTBREAK CONTROL MEASURES: Monitor for resident illness (record on RESIDENT ILLNESS LOG) and when possible, isolate residents while they are ill and for 72 hours after symptoms have stopped. Consider halting new admissions until the outbreak has ended. Exclude actively ill residents from games/activities where touching common items occurs (e.g., checkers, cards). Monitor for staff illness (record on STAFF ILLNESS LOG) and restrict ill staff/volunteers from patient care and food handling duties until 72 hours after their vomiting/diarrhea has ended. Interview and document review on 1/8/24 at 2:10 p.m., with the infection preventionist (IP) identified 1 resident (R11), began having gastrointestinal (GI) symptoms of vomiting and diarrhea on 10/10/24 which continued resulting in her being transferred to the Emergency Department (ED) on 10/14/24 where she was diagnosed with Norovirus and was hospitalized . Beginning on 10/11/24, the October Infection Summary identified staff members and residents who reported ill with symptoms of vomiting and diarrhea. The facility also experienced an outbreak of COVID which documented as beginning 9/21/24 and extending through October 2024 with 13 residents (R5, R9, R10, R14, R17, R22, R23, R24, R31, R 133, R 185, R 186, and R 189), who were identified as positive for COVID during that time. The IP logged the illness for R11 which was diagnoses as Norovirus but had not done further investigation to identify potential contacts or the potential source of the infection. She had not identified the possible correlation of R11 being diagnoses with Norovirus, and staff members and residents becoming ill with the same type of gastrointestinal (GI) symptoms. The IP identified that due to multiple residents being COVID positive residents were isolated in their rooms, and the facility was not having group activities or dining. Review of the logs for the 2-week period following 10/14/24 Norovirus diagnosis did not identify any additional residents or staff with symptoms of nausea, vomiting or diarrhea. The IP acknowledged there was no surveillance for December 2024. The IP reported she collected infection control data and prepared a summary report at the end of each month that was presented at the QAPI meetings. The IP received both electronic (if the documentation was completed correctly), and verbal notifications from the nursing staff when a resident had an infection, and/or there was a positive culture and sensitively result and/or when they were started on an antibiotic. The IP stated she had been on vacation and had not completed the December tracing information at the time of survey and agreed she had not performed daily, cumulative infection control surveillance. There was no mention of any staff member covering the IP duties while she was away from the facility. Review of the infection control logs for residents from September 2024 through November 2024, (December had not been completed), failed to document the resolution of the identified infection following the use of antibiotic treatment, nor was there investigation documented as to potential contacts, or sources of the infection. The employee logs of illness September 2024 through November 2024 (December not available), failed to investigate the potential illness and ensure the employees remained off duty for 48-72 hours following the resolution of signs and symptoms. WHIRLPOOL Observation on 1/8/25 at 9:16 a.m. with nursing assistant (NA)-B as she performed cleaning and disinfection of the Air Spa Advantage Bathing System. NA-B followed the manufacture's posted instructions for cleaning the tub, chair and cushions and rinsing surfaces, however, she failed to ensure the interior surfaces of the tub and chair remained wet for 10 minutes per the manufacturer's instructions. Interview on 1/8/25 at 10:00 a.m. with NA-B reported she had read the posted direction for cleaning and disinfecting the tub and noted the direction for the surface to remain wet for 10 minutes with the disinfectant but was not aware of how she could do that. She had not been trained to ensure surfaces remained wet with disinfectant and stated that was the way everyone did it. Interview on 1/8/25 at 1:25 p.m. with the medical director identified his expectation for infection control documentation to be complete and investigation into potential root cause, and or contact with other persons to be documented following an outbreak or infectious virus. He reported he would need to investigate the Infection Control process further as the medical director. Interview on 1/9/25 at 9:43 a.m., with the director of nursing (DON), reported she was not aware of any potential correlation between the resident diagnosed with Norovirus, and other residents and staff beginning to report similar symptoms. Her expectation was for the IP to report any potential contagious conditions to be investigated, interventions implemented, surveillance implemented with appropriate documentation by the IP. The DON was interviewed related to the jetted tub and confirmed her expectation for the jetted tub to be disinfected according to the manufacture's direction listed in the manual and the posted direction on the surface of the tub. She was unaware staff were not following the direction of ensuring a wet contact time of 10 minutes in order to appropriately disinfect the whirlpool tub time and would need to provide re-education to staff to correct the issue. Interview on 1/9/25 at 9:50 a.m., with the administrator reported she was not aware of the tub not being disinfected correctly and expected staff to follow the instructions as listed in the manual. She was also unaware of a possible correlation between other staff and resident illness and the resident that had been diagnosed with Norovirus. The IP had been on vacation and failed to identify anyone designated to cover infection control surveillance. The administrator would expect potential outbreaks to be reported to the State Agency. Review of the 12/2/24, policy Definitions of Infection-For Surveillance Purposes only identified the presence of new GI symptoms in a single resident could prompt increased surveillance for any additional residents with symptoms that could indicate additional cases or outbreak. If an outbreak was suspected stool specimens were to be collected and sent to the lab to determine the presence of Norovirus or other contagions. Norovirus Gastroenteritis-if laboratory confirmation is not available, an outbreak (two or more cases in a nursing home) due to Norovirus infection can be assumed present if: 1) vomiting in more than half of residents, 2.) incubation period of 24-48 hours. 3) duration of illness 12-60 hours. 3) No bacterial pathogen in a stool culture. There was no indication how the facility determined its qualifiers for potential outbreak based of standards of practice or quality. Review of the 12/2/24, Infection Prevention and Control Program Policy identified the program was to work to prevent, identify, investigate, and report in the attempt to control infections and communicable diseases for residents, staff, and visitors in a facility. The program was to follow the nationally accepted standards, and guidelines for infection control. The program was to include an acceptable system to monitor and document infection control and prevention. The program was to be reviewed annually by the IP or designee, to ensure compliance. The IP utilizes surveillance date to identify outcomes, trends and patterns with results communicated to the QAPI committee.

Based on interview and document review, the facility failed to develop an antibiotic stewardship program which included development of protocols and a system to monitor antibiotic use, to ensure appropriate antibiotics were utilized to prevent antibiotic resistance. This deficient practice had the potential to affect all 29 residents who resided in the facility. Findings include: Review of the September 2024, October 2024, and November 2024 infection control (IC) antibiotic stewardship identified the following information: Resident name, Medication prescribed, Classification of the drug, start date, end date, ordered days of therapy, actual days of therapy, Route, and abbreviation for infection without a legend to identify the infection abbreviations. The data for each report showed in: 1.) September 2024, 14 antibiotic orders with 231 days of therapy were included on the monthly IC report. Nine residents were identified as having received antibiotic therapy (R3, R5, R11, R17, R19, R24, R31, R182 and R183). 2.) October 2024, 10 antibiotic orders with 100 days of therapy. R31 was identified as receiving an ongoing oral antibiotic, but there was no identified rational, or documentation of a physician contact to identify and document the need for continued use. Three residents (R2, R8 and R11) were identified as on antibiotics for a urinary tract infection (UTI). 3.) November 2024, 16 antibiotic orders with 75 days of therapy were documented. R7 was admitted with physician orders for an antibiotic for a prophylactic antibiotic due to a history of UTIs. The record failed to identify any consult with the physician related to Antibiotic Stewardship, the continued need for the antibiotic, and any rational or investigation as to when it had been initiated, a stop date, or follow up testing indicated. R6, R7, R13, R15, R18, R23, R24, R27, R187, R188, and R189 also received antibiotic treatment in November 2024. There was no documentation of symptoms, a time out completed, or culture/sensitivity results with notification of the physician to identify if the appropriate medication was in use or should be changed or discontinued. There was also no indication staff had re-assessed the resident's following completion of therapy or notified their physicians to identify if symptoms had resolved or if there was a need to change the medication or continue medication for a specific period. Interview on 1/8/25 at 1:25 p.m. interview with Physician (MD)-A reported he was not certain when R7 had started taking an antibiotic for a diagnosis of recurrent UTI's. Upon review of his clinical record, he identified the original order was in October of 2023. He had not investigated the use of the antibiotic at the time of admission, nor was he aware of R7 having any symptoms of a urinary tract infection since she had been admitted to the facility. He further commented he did not recall being asked about continued need for the antibiotic and reported he was not aware of any investigation or referrals to urology or infectious disease related to the need for continued use of the antibiotic. MD-A stated he felt continued use of an antibiotic for an extended period should be investigated further and there should be an end date to assess the need for continuation of a medication. MD-A also voiced agreement this was an area the IP should be aware of and questioning the MD for rational for the need of continued use or if the medication was effective Interview and document review on 1/8/24 at 2:30 p.m., with the IP reported she had not performed timeouts or tracked the antibiotic use through to resolution to identify if the antibiotic was appropriate, or the need to alter or change therapy was identified. The IP stated she had been on vacation and had not completed the December tracing information at the time of survey and agreed she had not performed appropriate antibiotic stewardship. There was no mention of any staff member covering the IP duties while she was away from the facility. Interview on 1/9/25 at 9:43 a.m., with the director of nursing (DON), identified she would expect a thorough IC program to include appropriate antibiotic stewardship. She was unaware no one was assigned to monitor the program when the IP had been on vacation. Interview on 1/9/25 at 9:50 a.m., with the administrator identified she agreed antibiotic stewardship was lacking appropriate oversight. The IP had been on vacation and had failed to identify anyone designated to cover infection control surveillance while they were on vacation. Review of the 12/19/24 Antibiotic Stewardship-Rehab/Skilled policy identified staff were to follow Loeb's criteria for initiating antibiotics (which, when met, indicate that the resident likely has an infection and that an antibiotic might be indicated, even if the infection has not been confirmed by diagnostic testing).

Based on interview and document review, the facility failed to ensure 1 of 1 infection preventionist (IP) had appropriate training and oversight of the infection control (IC) program to management by performing current, daily cumulative infection control surveillance activities, maintain documentation of incidents, findings, and any corrective actions required, and ensure the IC program continued in her absence. Findings include: Refer to F880 and F881 Review of the September through December 2024 logs identified infection surveillance had not been tracked through to resolution, no tracking or trending had occurred, and December 2024 had not been performed. Interview on 1/8/25, at 2:10 p.m. with the IP identified she tracked staff illness with an illness/absence report, which was completed when a staff member called in due to illness of themselves or a child. The process was for the charge nurse to complete the form and provide a copy to the IP, director of nursing (DON), and office manager who completed the schedule. The IP reported she collected the forms and completed a report at the end of each month that was presented to the Quality Assurance (QA) committee. The IP reported she recalled R23 also being tested for Norovirus, but she had not included her on the log, and no initial clinical monitoring documentation had been completed. She stated she did not have an explanation for why this did not occur, but it was not on her log. The IP reported she had not been including documentation on surveillance or resolution of infections and when a resident had been admitted with orders for a prophylactic antibiotic she had not investigated or questioned the order. She identified completion of the IP training and provided a copy of her certificate, but stated she would like to receive additional education on how and what she needed to investigate and document, in addition to finding a format that included the necessary information. The reporting of infections and/or antibiotic use was received electronically if staff completed the documentation correctly. She also stated she was told by staff, or a note was left for her, for antibiotic use which she recorded on her log form. She made no follow-up to identify antibiotic stewardship had occurred, including antibiotic timeouts. The IP was unaware of the need to report potential Norovirus outbreak and had not correlated GI illness or put measures in place to prevent potential spread and ensured staff remained off work until 72 hours after symptoms subsided. Interview on 1/9/25 at 9:43 a.m., with the DON reported her expectation for the IP to correlate potential outbreak concerns related to staff and resident illness and investigate root cause with potential intervention. The DON identified there was a checklist that was supposed to be completed and sent to the IP and DON and she expected the IP to follow the facility policy and procedures about IC surveillance and documentation. She confirmed antibiotics should not be started until a culture was received and 48 hours after an antibiotic was started a time out was implemented with a form completed and sent to provider. She reported the physician was to review the appropriateness of the antibiotic and make the determination if it should continue or be changed. She confirmed R7 had been admitted on a prophylactic antibiotic and there was no documentation to indicate there had been an attempt to investigate need for continued use, or an attempt to implement alternate treatments. Interview on 1/9/25 at 9:50 a.m., with the administrator reported she was not aware of a possible correlation between the resident who was hospitalized with Norovirus and reported staff illness with the same symptoms. She reported she would expect staff or family illness to be investigated and staff is not allowed to return to work until the appropriate time follow resolution of symptoms. She stated she would expect documentation to be maintained to confirm this had taken place. She reported the IP had been on vacation and failed to identify anyone designated to cover infection control surveillance while the IP was on vacation. Review of the December 2, 2024, Infection Prevention and Control Program Policy identified the program was to work to prevent, identify, investigate, and report in the attempt to control infections and communicable diseases for residents, staff, and visitors in a facility. The program was to follow the nationally accepted standards, and guidelines for infection control. The program was to include an acceptable system to monitor and document infection control and prevention. The program was to be reviewed annually by the IP or designee, to ensure compliance. The IP utilizes surveillance date to identify outcomes, trends and patterns with results communicated to the QAPI committee.

Based on observation, interview and document review, the facility failed to update the provider following re-development of an unstageable pressure area for 1 of 1 resident (R2). Findings include: R2's 10/9/24, Annual Minimum Data Set (MDS) assessment identified her cognition was intact, she required extensive assistance from staff for activities of daily living (ADLs), and there were no skin issues identified. R2 had diagnoses of Neurocognitive disorder with Lewy Bodies, urge incontinence, major depressive disorder, anxiety disorder, neuromuscular dysfunction of bladder, osteoporosis, Parkinson's disease, and a history of falls. She was identified as at risk for pressure ulcers but had no unhealed pressure areas at the time of the assessment. R2 had a pressure relief mattress on her bed and her primary mode of transportation was a wheelchair. Observation and /interview on 1/6/25 at 1:30 p.m. with R2 who pulled up her right pant leg to show a Band-Aid covering the outer aspect of her ankle, and reported she had a sore there, but she did not recall when it had occurred or if she had injured the area. She reported staff put her stockings on over the bandage in the morning and took then off when she went to bed at night. The staff changed the band aid, but she wasn't certain how often they did that. Observation on 1/7/25 at 3:19 p.m., of licensed practical nurse (LPN)-A as she performed wound care to R2's right ankle. LPN-A cleansed the wound area with wound cleanser, applied skin prep to the surrounding area and allowed to dry. The wound had a light pink area surrounding a white, scabbed center area. R2 denied any pain or discomfort in the area. LPN-A applied a new Band Aid to the wound and dated and initialed the area. She reported R2 preferred to lie on her right side and interventions included repositioning and encouraging her to position off her right side. Interview on 1/7/25 at 3:25 p.m. with the director of nursing (DON), reported the medical record identified the wound was noted on 12/28/24, and described as the outer aspect red, and the center was pink with a small, scabbed area. She reported the source was unknown, but R2 had a history of reoccurrence of a right ankle wound. The DON reviewed the record and identified the last wound occurrence was in August of 2024. She reported the wound had healed, and remained healed until it was noted again on 12/28/24. A skin assessment was documented on 12/29/24, but there was no documentation the provider had been notified or orders received for a plan of treatment. She reported the record indicated staff were using skin prep on the area and covering with a band aid for protection. The DON reported she would have expected the provider to be notified of the reoccurrence, furthermore, the provider had made rounds on 12/31/24 with no record of the provider being updated of the reoccurrence of R2's ankle wound. The DON obtained measurements of the wound and reported, the size as .2 centimeters (cm) x .2 cm. on 1/9/25, with the area scabbed with no drainage present. Review of the April 26, 2024, Skin Assessment Pressure Ulcer Prevention and Documentation Requirements Policy identified the registered nurse (RN) was to complete a skin assessment to identify any skin issues. When an area was identified the RN was to record the type of wound, the degree of tissue damage, and the location of the wound, measurements, and the stage for a pressure area. The physician was to be notified of the resident condition and ulcer with orders for treatment documented.

Based on observation, interview and document review the facility failed to prevent potential accident hazards for 2 of 2 residents (R7 and R19) due to wandering behaviors into unsecured areas containing hazardous substances. Findings include: R7's, 12/17/24, Significant change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and wandered throughout the facility including into other resident spaces. R7 had diagnoses of cognitive communication deficit, Cerebrovascular disease affecting left side, anxiety disorder, dementia, and cerebral infarction and wandered within the facility 1-3 days weekly. R19's, 11/27/24, quarterly MDS identified she had severe cognitive impairment, demonstrated verbal and physical behaviors directed toward others, and wandered throughout the facility and into other resident spaces and wandered 1-3 days weekly. Observation on 1/8/25 at 7:33 a.m. noted the tub room door open with no staff in attendance or in the immediate area outside of the tub room. Inside the room located beside the whirlpool tub a white cabinet had both doors open displaying personal care products including Skin protectant cream; hand lotion; skin cleaner; brushes; combs; body spray; hair spray; body powder; deodorant; nail files; and an electric razor. A pair of scissors, tweezers and a nail clipper were on the top of the cabinet along with a large jug of Thera Sol and a spray bottle of Rapid Multi disinfectant cleaner. The items were within reach of a resident ambulating or seated in a wheelchair who could enter the room. The removable bath chair base was located on the floor on the other side of the tub and could present a fall risk to a resident on that side of the tub. At 7:35 a.m., R19 was observed transporting herself in her wheelchair as she proceeded into the tub room, looked around and moved toward the cabinet. Unidentified staff were noted to pass by the room and glance in, but failed to investigate what R19 was doing in the unsecured tub room, as they passed by. R19 moved toward the cabinet reaching her hand out, as she was mumbling but was not able to reach the cabinet due to surveyor standing in front of it. R19 continued to move around the room, bumping items with her wheelchair before turning and exiting the room transporting herself down the hall. No staff checked on R19 or questioned what she was doing in the open and unattended tub room. Interview on 1/8/25 at 7:45 a.m. with the administrator reported the tub room should not have been left open and unattended, and the cabinet containing personal care items, in addition to the cleaning products on top of the cabinet should have been secured. The administrator confirmed R19 had severe cognitive impairment and was not aware of safety issues that could have occurred with the items in and on the cabinet. 47497 Observation on 1/6/25 at 12:20 p.m., a room at the end of the 300-wing hallway across from a sitting area had an open door. Inside the room was a desk against the wall. The desk had 2 bottles labeled Drano (a toxic solution used for clogged drains), a cart next to the desk had 2 cans labeled WD-40 (a flammable solvent), on the bottom shelf of another utility cart was a box labeled [NAME] (a pest control solution), an aerosol can labeled Lysol (disinfectant spray), an aerosol can labeled [NAME]-Eye 123 Primer, and multiple hand held tools including drills, drill bits, and screw drivers. Interview on 1/6/25 at 12:44 p.m., with NA-(A) identified they do have 2 residents who wander. R7 likes to walk up and down the hallways and R19 likes to sit by the doors at the end of the 300-wing (across from the above mentioned room). They both have a diagnosis of dementia. Observation on 1/6/25 at 12:50 p.m., unsecured room containing chemicals remains open, no residents or staff were observed in the area during the observation. Interview on 1/6/25 at 12:50 p.m., with the administrator identified the door should always be locked. She agreed there are toxic chemicals in the room that need to always be secured for the safety of the residents and any children that may be visiting the facility. She further identified that the facility has residents with diagnosis of dementia that could be at risk. The maintenance director was unavailable for interview. Review of the undated Procurement and Storage of Equipment, Products, and Supplies policy identified the facility was to ensure that all chemicals and disinfectants are labeled and stored in a manner that eliminates risk of improper use, contamination, inhalation, skin contact or personal injury. Housekeeping products and supplies should not be stored in resident rooms or units. Store these items in a locked cabinet and/or storage rooms as appropriate.

Based on interview and document review the facility failed to ensure that consultant pharmacist reviews were completed monthly for 3 of 5 residents (R10, R19, and R21) reviewed for unnecessary medications. Findings include: R21's 10/30/24, quarterly Minimum Data Set (MDS) assessment identified R21 had severe cognitive impairment, and had behaviors of wandering, exit seeking, and verbal and physical agitation toward staff. She required extensive assistance with activities of daily living (ADLs). R21 ambulated using a 4 wheeled walker with assistance of staff and was seen by therapies. She had pain due to a pelvic fracture because of a fall and received both scheduled pharmacological and non-pharmacological pain interventions. R21 had diagnoses of Alzheimer's disease, major depressive disorder, pain in her feet, dementia, anxiety disorder, and adult personality disorder with behaviors. R21 received scheduled medications including an antipsychotic, antidepressant, and antianxiety. Safety measures were identified due to attempts to self-transfer and repeated falls. R21's monthly consulting pharmacist reviews between July through December 2024, identified there had been no documented pharmacist review completed for the months of November and December 2024. 47497 R19's 11/27/24, quarterly Minimum Data Set (MDS) assessment identified her cognition was severely impaired, she required extensive assistance with activities of daily life (ADL's) and had verbal and physical behaviors directed towards others, rejected care and at times wandered throughout the facility. R19 had diagnosis of dementia, aphasia, anxiety, and depression and was taking psychotropic medications for depression and anxiety. R19's monthly consulting pharmacist reviews between July through December 2024, identified there had been no documented pharmacist review completed for the months of November and December of 2024. 39988 R10's 12/23/24, quarterly Minimum Data Set (MDS) assessment identified R10's cognition was intact. R10 had some verbal behaviors directed towards others and required extensive to total assistance with cares. Daily he received insulin, an anticoagulant, diuretic, antidepressant, and antipsychotic medication. The assessment identified diagnoses of hypertension, diabetes, hyperlipidemia, stroke, bilateral weakness, seizure disorder, and depression. R10's monthly consulting pharmacist reviews between July through December 2024, identified there had been no documented pharmacist review completed for the months of November and December 2024. Interview on 1/8/24 at 10:12 a.m., with administrator identified that the facility had concerns with the consulting pharmacist, and she had reached out to national campus who was also working with the pharmacist. The facility had trouble getting pharmacy reviews completed timely and they had discussed switching back to Thrifty White. She believed that the reviews had been completed but the facility did not have a copy in house of the review. Not being provided the reviews consistently was a problem for being able to communicate the recommendations to the provider. The facility was consistently calling the pharmacy and asking for the information. Additionally, she reported that she had tried to reach out to the pharmacist however, the pharmacist was out ill and unavailable. The pharmacist was unavailable for interview. There was no pharmacy contract provided during the survey.

Based on interview and document review the facility failed to investigate and/or document the justification for a prophylactic antibiotic for 1 of 1 resident (R7). Findings include: R7's 12/17/24, Significant change Minimum Data Set (MDS) assessment identified she had severe cognitive impairment and wandered throughout the facility including into other resident spaces. R7 had diagnoses of cognitive communication deficit, Cerebrovascular disease affecting left side, anxiety disorder, vascular dementia, and cerebral infarction. R7 was frequently incontinent of bowel and bladder and required staff assistance for toileting. R7 was admitted in November of 2024, with orders for Macrobid (antibiotic)Capsule 100 milligrams (mg) by mouth (PO) daily (QD) with the diagnosis of chronic urinary tract infection (UTI). A urine test was completed 11/13/24 with negative results, and no culture and sensitivity was completed. There was no documentation to support the reason for the urine test, or any signs and symptoms (S/S) the resident had displayed. The preadmission assessment dated [DATE] by the MD, contained documentation R7 was receiving Macrobid 100 mg PO QD at 8:00 p.m., but there was no identified start or stop date, nor rational identifying a reason for prophylactic use of an antibiotic. R7's current undated care plan identified she had bowel and bladder incontinence related to vascular dementia, weakness, hallucinations, confusion, was at risk for falls, and low blood pressure. R7 had a history of frequent UTI's. Interventions included encouraging fluids during the morning and afternoon, monitor for S/S of UTI's, and offer toileting/repositioning Q 3 hours (H). There was no mention of R7 receiving a prophylactic antibiotic. Interview on 1/6/25 at 4:42 p.m. with licensed practical nurse (LPN)-B reported R7 was currently receiving a prophylactic antibiotic Macrobid 100 mg PO Q HS for chronic UTI's, with an original order date of 11/6/24 and no end date ordered. Interview on 1/7/25 at 11:14 a.m., with nursing assistant (NA)-A reported she was aware of the S/S of a UTI and would immediately report them to the charge nurse. She reported she had frequently assisted R7 with toileting and was not aware of any S/S of a UTI. Interview on 1/7/25 at 3:43 p.m. with the director of nursing (DON) identified R7 had been admitted with an order for a prophylactic antibiotic for recurrent UTI's. She was not aware of any evaluation for the need to continue the prophylactic antibiotic, or investigation taking place to identify the need for R7 to remain on the antibiotic. Interview on 1/8/25 at 1:25 p.m. with R7's primary provider (medical director) reported he was not certain when R7 had initially been started on Macrobid for a diagnosis of recurrent UTI's, but it had been prior to admission to the facility. The MD reviewed R7's clinic record and reported the original order was dated October of 2023 and she had been receiving the medication since that time. He had not investigated the continued need for the antibiotic at the time of admission, nor had R7 experienced any identified S/S of a UTI since time of admission. R7 had been admitted from an Assisted Living situation and was likely receiving better personal care currently than she had been able to provide for herself in her previous living situation. He was not aware of any previous referral to urology or infectious diseases and the continued use of the prophylactic antibiotic would need to be investigated further. The MD noted continued use justification should be brought forward for discussion with the MD if criteria was not met. Interview with the Infection Preventionist on 1/8/25 at 2:31 p.m. identified she was aware R7 was receiving a prophylactic antibiotic, but she had not identified this as an area of concern to investigate further under antibiotic stewardship criteria. A policy for unnecessary medications, and/or use of prophylactic antibiotic use was requested but not provided by the end of the survey period.

Based on interview and document review, the facility failed to submit accurate and/or complete data for staffing information at least quarterly or more often, including information for agency and contract staff, based on payroll and other verifiable and auditable data during 1 of 1 quarter reviewed (Quarter 3) in Federal Fiscal Year 2023, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. The facility also failed to have a policy for PBJ that instructed how and when staff were to submit data and run verification reports to ensure data submitted was complete and accurate. This has the potential to affect all 34 residents residing in the facility. Findings include: Review of the Payroll Based Journal Report (PBJ) [NAME] Report 1705D for Quarter 3, 2023 (April 1 through June 30), identified the facility triggered for failing to have licensed nursing coverage 24 hours per day. The following dates were triggered for review: 4/2/23, 4/16/23, 5/7/23, 6/10/23, 6/18/23, 6/20/23, 6/25/23, 6/26/23, and 6/28/23. Review of the nursing timecard punches for the infraction dates identified above on the 1705D identified the facility did have licensed staff who worked, therefore the data submitted was inaccurate and nor not complete. Interview on 12/06/23 at 10:18 a.m., with the adminsitrator identified that they in fact had licensed staff on for the dates indicated but the previous administrator did not enter the PBJ information correctly. There was no policy related to PBJ entries provided by the end of the survey.

Based on interview and document review, the facility failed to ensure 4 of 5 (R3, R4, R12 and R24) residents were appropriately vaccinated against pneumococcal disease upon admission and/or offered updated vaccination per Centers for Disease Control (CDC) vaccination recommendations. Findings include: Review of the current CDC pneumococcal guidelines located at https://www.cdc .gov/vaccines/vpd/pneumo/hcp/pneumo-vaccine-timing.html, identified for adults [AGE] years of age or older, staff were to offer and/or provide based off previous vaccination status as shown below: a) If NO history of vaccination, offer and/or provide: aa) the PCV-20 OR bb) PCV-15 followed by PPSV-23 at least 1 year later. b) For PPSV-23 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PPSV-23 OR bb) PCV-15 at least 1 year after prior PPSV-23 c) For PCV-13 vaccine ONLY (at any age): aa) PCV-20 at least 1 year after prior PCV13 OR bb) PPSV-23 at least 1 year after prior PCV13 d) For PCV-13 vaccine (at any age) AND PPSV-23 BEFORE [AGE] years: aa) PCV-20 at least 5 years after last pneumococcal vaccine dose OR bb) PPSV-23 at least 5 years after last pneumococcal vaccine dose e) Received PCV-13 at Any Age AND PPSV-23 AFTER Age [AGE] years: aa) Use shared clinical decision-making to decide whether to administer PCV-20. If so, the dose of PCV-20 should be administered at least 5 years after the last pneumococcal vaccine. Review of 4 sampled residents for vaccinations identified: 1) R3 was [AGE] years old and was admitted on May of 2023. R3 received PPSV-23 on 10/13/04 and PCV-13 on 8/12/16. There was no documentation to support R3 had been offered the PCV-20 to ensure she was updated with current CDC guidance for vaccines. 2) R4 was [AGE] years old and was admitted on October of 2015. R4 received PPSV-23 on 12/11/04 and 9/20/11 and PCV-13 on 6/03/17. There was no documentation to support R4 had been offered the PCV-20 to ensure she was updated with current CDC guidance for vaccines. 3) R12 was [AGE] years old and was admitted on January of 2023. R12 received PPSV-23 on 11/21/06, 3/3/11 and 8/18/14. R12 received PCV-13 on 10/08/15. There was no documentation to support R12 had been offered the PCV-20 to ensure she was updated with the current CDC guidance for vaccines. 4) R24 was [AGE] years old and was admitted on January of 2023. R24 received PCV-13 on 12/03/15 and 5/22/17. There was no documentation to support R24 had been offered the PCV-20 to ensure she was updated with the current CDC guidance for vaccines. Interview on 12/06/23 at 10:21 a.m., with licensed practical nurse (LPN-B) who is the facility Infection Preventionist (IP) confirmed residents was not offered and/or administered PCV-20 and lacked a declination of refusal for vaccine upon admission to the facility. Review of September 2023, Immunizations/Vaccinations for Residents, Pneumococcal, Influenza, COVID-19, Other, AL, R/S, LTC, HBS policy identified pneumococcal immunizations would be offered according to CDC recommendations upon admission and per CDC guidelines for eligibility. Review of October 2023, Infection Prevention and Control Program, All Service Lines policy identified facility would promote the facility immunization program ensuring residents were provided education including the risk and benefits, administration, and declination of immunizations in accordance with current standards of practice.

Based on interview, and record review the facility failed to have an appropriate diagnosis and target behavior for the use of an antipsychotic medication for 1 of 5 residents reviewed (R21). Findings include: R21's 10/11/23, annual Minimum Data Set (MDS) assessment identified R21's cognition was severely impaired, he felt down, depressed, or hopeless 2 of 6 days per week, and had diagnoses of anxiety disorder and depression. R21 was taking a anti-psychotic on a routine basis and also took an anti-depressant. The assessment lacked identification of any target behaviors in order to determine efficacy of medication therapy. R21's December 2023, Medication Administration Record (MAR) printed 12/5/23, identified R21 was administered quetiapine fumarate (anti-psychotic) 25 mg tablet two times a day for mood related to anxiety. R21's undated care plan printed on 12/5/23, identified R21 was taking antipsychotic medication for anxiety with behaviors with interventions to consult with pharmacy and health care provider to consider a dosage reduction when appropriate and to monitor for possible side effects. There was no mention what behavior specifics R21 exhibited to indicate if staff would be aware to identify medication efficacy or the need to alter treatment. Review of R21's nurse practitioner (NP) progress note on 8/11/22, identified a plan of care to continue with quetiapine two times a day and Ativan as needed because the improvement in his anxiety outweighs the risk of memory loss and falls. On 3/30/23, the NP identified a diagnosis of anxiety and paranoia. At the time of survey the facility had not yet updated R21's medical record to include the added diagnosis of paranoia. Interview on 12/05/23 at 10:48 a.m., with director of nursing (DON) identified R21 was placed on quetiapine while in the hospital for aggressive and violent behavior. She agreed the diagnosis was incorrect and nursing should have clarified the reason for the medication with the physician in order to establish a baseline. Review of the facility provided Psychotropic Medication Policy identified residents would not be given psychotropic medication unless they were necessary to treat a specific condition as diagnosed and documented in the clinical record.

Based on observation, interview and document review, the facility failed to ensure 1 of 2 E-kits (emergency kit) did not have expired medication and also ensure staff removed expired medications from the medication carts. E-Kit Observation, interview, and document review on 12/4/23 at 7:16 p.m. with registered nurse (RN)-A in the medication room identified a locked emergency medication container. The E-kit medication list on back of the E-kit listed four packages, one tablet of tramadol 50 milligram pills, that had expired on 10/18/23. Review of E-kit log sheet indicated the local pharmacy last checked the E-kit on 10/20/23. RN-A stated E-kit medications were checked and replaced by the pharmacy for expired medication during their monthly visits. Interview on 12/05/23 at 1:11 p.m., with local licensed pharmacist (RPh)-A identified they agreed the E-kit had expired medication. It was last checked in October of 2023. Her expectation was the E-Kit would be checked monthly for expired medication, however, the facility should be ensuring the security tab was in fact intact to identify potential diversion as soon as possible. Review of March 2023, Medication: Acquisition Receiving, Dispensing and Storage policy indicated all medications would be packaged and labeled in accordance with state pharmacy regulations and controlled medications would be reconciled through receipt and disposition by the licensed pharmacist. Medication Cart Observation on 12/06/23 at 7:36 a.m., of the facility medication cart identified 1 OTC (over the counter) bottle of Tylenol tablets that expired on February 2023. In addition, R3 had a bottle of omeprazole 40 mg (milligram) capsules had expired on 1/18/23. R3 also had OTC calcitriol which expired on 2/25/23, 37 remaining Folic acid tablets which expired on 4/05/23, 57 furosemide tablets that had expired on 7/19/23, and 100 tablets of vitamin B 12, which expired from the manufacturer on 10/17/23. Interview on 12/06/23 at 8:40 a.m., with LPN-A identified OTC medications that were expired should not be kept with medications that were in use. The facility's common practice was for those medications to be removed from the cart and replaced when reported off to another staff. LPN-A agreed medications that had expired should be removed from the cart as to not inadvertently administer those medications to a resident. Interview on 12/06/23 at 11:22 a.m., with the interim DON identified she would expect the medication cart to be check routinely for outdated medications and remove those medications when discovered as part of the medication administration process for administration. Review of the March 2023, Medications: Acquisitions Receiving Dispensing and Storage policy identified the facility staff will check and dispose expired medications in accordance with state pharmacy regulations.

Based on observation, interview, and document review, the facility failed to ensure comfortable warm water temperatures were maintained for 12 of 29 residents ( R1, R3, R4, R5, R11, R13, R17, R18, R19, R21, R25, and R181) who resided on the 100-wing. Findings include: Interview on 2/13/23 at 1:34 p.m., with R19 identified the water was too cold for bathing or washing up. R19 revealed she gets a bath 2 times a week. The water in her room was always cold. Everybody knows about it . they just tell us our rooms are at the end of the hall and there is nothing they could do about it. Observation on 2/13/23 at 2:29 p.m., in R19's room identified the hot water tap in bathroom had been turned on to its fullest extent. The hot water was allowed to run for 3 minutes and remained cold to the touch. Observation and Interview on 2/13/23 at 3:08 p.m., with R13 identified when she would use the bathroom sink in her room to wash up in the morning and had been unable to get any hot water. R13 had notified the staff at the facility several times. Staff had told her the water heater was on the other side of the building and there was nothing they could do to fix it. The hot water was then turned on and allowed to run approximately 4-5 minutes and remained cold to touch. Interview on 2/14/23 at 1:59 p.m., with nursing assistant (NA)-A identified she typically had to turn on the hot water in all resident rooms on the 100 wing for several minutes prior to using it as it never gets hot. NA-A revealed when water temps failed to get warm enough for comfort, she would either only wet a small corner of the washcloth to wash up the residents, or she had used a product called Peri-Wash spray that used little to no water instead. NA-A reported the lack of hot water down that wing approximately two months ago to the maintenance director (MD) and was told that a ticket was in to have the hot water problem fixed, however she was unsure of any outcome as the water remained well below comfortable temperatures for resident bathing. Interview on 2/14/23 at 2:57 p.m., with NA-B identified she was under the impression the water down the 100-wing failed to get warm enough for bathing because the hot water heater was on the opposite side of the building from the 100-wing. Interview on 2/14/23 at 3:02 p.m., with NA-C indicated the resident rooms on the 100-wing of the facility require a longer run time to get hot water. NA-C revealed she had told residents she was sorry she had been unable to get the water any warmer and if she had been able to fix it herself .she would. Observation and interview on 2/14/23 at 3:26 p.m., maintenance director (MD) identified 2 rooms were checked for appropriate water temperatures. R19's room hot water temperature was 80.7 degrees Fahrenheit (F). R18's room hot water temperature was 88.7 degrees F. The MD indicated the facility had trouble getting the water temperature to an acceptable range for the residents on the 100-wing. The MD revealed when she had been completing her routine hot water temperature audits, she would turn on the hot water in each room and lets it run awhile. She would then go back to the first room she had turned the water on and started checking temperatures so the hot water had time to warm up. Facility policy was to have hot water temperatures between 105-110 degrees within a minute or two of turning the hot water on. Review of the 1/6/23, Logbook Documentation indicated hot water temperature ranges for tap water was to be within 110 degrees to 115 degrees F, however, the logged temperatures identified that the hot water in the 100 wing resident rooms was between 53.6 degrees and 101 degrees. Interview on 2/14/23 at 3:45 p.m., with the administrator identified hot water temperature was to be maintained at acceptable ranges for comfort and safety between 105 F and 110 F.

Based on interview and doument review, the facility failed to protect resident medication from misappropriation of resident propertyby securing away from unauthorized use when 1 of 1 staff (licensed practical nurse (LPN)- A) diverted medication from a discharged resident (R180) for personal use. Findings include: Review of the 12/29/22 at 8:35 a.m., State Agency (SA) report identified an allegation of licensed practical nurse (LPN)-A, taking a dose of Zofran (nausea medication) belonging to R180 during the night shift on 12/28/22. R180 had been discharged on [DATE], and the medication had been stored in a plastic bag, unsecured from access by staff in the medication room pending destruction. The SA report identified LPN-A had not been feeling well during her scheduled shift and she had taken 1 Zofran (a medication used to treat nausea and vomiting) from the plastic bag. LPN-A reported during the shift report on 12/28/22 at 6:00 a.m., she had taken one Zofran tablet from the bag of medication which was to be destroyed for R180 as she felt ill during work. R180's signed physician orders identified an order dated 9/26/22 for Zofran 4 milligrams (mg) by mouth (PO) every (Q) 8 hours (H) as needed (PRN) for nausea. R180's physician orders for discharge did not include the Zofran, and the medication was placed in a plastic bag stored in the medication room for destruction. Interview on 2/14/23 at 2:17 p.m., with the social services designee (SSD) reported she received report of the incident from trained medication aide (TMA)-A during the morning of 12/28/22 when she had come to work. The SSD reported TMA-A had come to her and reported during shift report at 6:00 a.m., LPN-A stated she was not feeling well, was not able to find someone to complete her shift, and had taken a Zofan that was in the medication room for destruction. The SSD reported she had been told by TMA- A, LPN-A stated she had a personal prescription for Zofran at home, but did not have any with her at work, so she had taken one of the pills to enable her to finish her shift. The administrator was not available at the time, so the incident was reported to the director of nursing (DON)-B. DON-B and SSD interviewed TMA-A, reviewed the video recording of the medication room for 12/28/22 night shift, but did not observe LPN-A taking the medication. LPN-A was contacted via phone by administrator-B and admitted she had taken one Zofran pill from the plastic bag containing R180's medication. The SSD reported following the facility investigation and consultation with the Corporate Human Resources (HR) department administrator-B had submitted a report to the SA. The corporate HR made the decision to file a report to the Board of Nursing, and issue a final written action to LPN-A in addition to providing re-education. The SSD reported HR advised administrator-B a report to law enforcement was not necessary because R180 had been discharged on [DATE], the incident did not take place until 12/28/22, and the medication was no longer R180's personal property since it was to be destroyed. Interview on 2/14/23 at 3:08 p.m., with TMA-A reported at shift report on 12/28/22 at about 6 a.m., LPN-A reported she had been ill during her overnight shift, there was no one available to cover her shift and she had recalled there was Zofran in the medication room from a resident that had been discharged . TMA-A reported LPN-A stated she could not leave as she was the only nurse on duty, she had a personal prescription for Zofran, but did not have any with her, so she had taken one of the Zofran pills. TMA-A reported she knew this was wrong and she had reported the incident to the SSD who stated she would report the incident to the administrator and DON. Interview on 2/14/23 at 6:00 p.m., with LPN-A reported she had worked the overnight shift on 12/28/22 and had become ill. LPN-A reported she had a history of gastric issues and had developed nausea, vomiting and diarrhea. LPN-A reported she had contacted DON-B and the infection preventionist but neither of them were available to replace her shift. LPN-A reported she remembered seeing the bag containing the Zofran in a bag of medications to be destroyed in the medication room. LPN-A reported she was aware that it was not acceptable to take the medication, but since the resident had been discharged , and the medication was to be destroyed, she felt it was ok to take one of the Zofran tablets. LPN-A had a personal prescription for the medication, but did not have any with her and she knew she had to get through her shift and so she had taken one of the Zofran pills from the bag to be destroyed. LPN-A reported she finished her shift and had mentioned she had taken the Zofran from the medication room during report. Later that morning LPN-A reported she received a phone call from DON-B and the SSD and when questioned had admitted she had taken the one Zofran pill and why she had done so. She was informed the incident had to be reported to the SA and she would need to meet with administrator-B and HR. LPN-A reported she had a meeting with administrator who reviewed the facility policy on medication destruction and diversion of medications, and issued her a written warning. The nurse consultant was also involved, and she was informed the incident had been reported to the Board of Nursing. LPN-A reported education was provided to all nursing staff on the policies for medication destruction and drug diversion. LPN-A stated she was aware taking the medication was wrong, but she felt she had no other option due to the situation of needing to be able to finish her shift. R180 was not able to be reached for interview on 2/14/22 at 3:00 p.m. or 2/17/22 at 10:30 a.m. Interview on 2/17/23 at 10:00 a.m. with DON-A reported she was just starting in her position as DON at the time of the incident and did not recall a lot of the investigation, but agreed it was drug diversion to take a medication that had been prescribed for a resident She was aware taking a medication was reportable to the SA and reported the steps in the investigation process. The facility policy was provided. Review of the August 11, 2020 Drug Diversion policy identified diversion as the removal of drugs for the employee or others use and included on or off the facility premises. If the investigation revealed suspicion the notifications were to include the facility administrator, the SA, law enforcement and other designated agencies in accordance with state law of a medication diversion. This is viewed as misappropriation of resident property.

Based on interview and document review, the facility failed to follow their policy to report an allegation of a crime (drug diversion) to the State Agency (SA) and law enforcement in a timely manner for 1 of 1 resident (R180). Findings include: Review of the 12/29/22 at 8:35 a.m., State Agency (SA) report identified an allegation of licensed practical nurse (LPN)-A, taking a dose of Zofran (nausea medication) belonging to R180 during the night shift on 12/28/22. R180 had been discharged on [DATE], and the medication had been stored in a plastic bag, unsecured from access by staff in the medication room pending destruction. The SA report identified LPN-A had not been feeling well during her scheduled shift and she had taken 1 Zofran (a medication used to treat nausea and vomiting) from the plastic bag. LPN-A reported during the shift report on 12/28/22 at 6:00 a.m., she had taken one Zofran tablet from the bag of medication which was to be destroyed for R180 as she felt ill during work. R180's signed physician orders identified an order dated 9/26/22 for Zofran 4 milligrams (mg) by mouth (PO) every (Q) 8 hours (H) as needed (PRN) for nausea. R180's physician orders for discharge did not include the Zofran, and the medication was placed in a plastic bag stored in the medication room for destruction. Interview on 2/14/23 at 2:17 p.m., with the social services designee (SSD) reported she received report of the incident from trained medication aide (TMA)-A during the morning of 12/28/22 when she had come to work. The SSD reported TMA-A had come to her and reported during shift report at 6:00 a.m., LPN-A stated she was not feeling well, was not able to find someone to complete her shift, and had taken a Zofan that was in the medication room for destruction. The SSD reported she had been told by TMA- A, LPN-A stated she had a personal prescription for Zofran at home, but did not have any with her at work, so she had taken one of the pills to enable her to finish her shift. The administrator was not available at the time, so the incident was reported to the director of nursing (DON)-B. DON-B and SSD interviewed TMA-A, reviewed the video recording of the medication room for 12/28/22 night shift, but did not observe LPN-A taking the medication. LPN-A was contacted via phone by administrator-B and admitted she had taken one Zofran pill from the plastic bag containing R180's medication. The SSD reported following the facility investigation and consultation with the Corporate Human Resources (HR) department administrator-B had submitted a report to the SA. The corporate HR made the decision to file a report to the Board of Nursing, and issue a final written action to LPN-A in addition to providing re-education. The SSD reported HR advised administrator-B a report to law enforcement was not necessary because R180 had been discharged on [DATE], the incident did not take place until 12/28/22, and the medication was no longer R180's personal property since it was to be destroyed. Interview on 2/14/23 at 3:08 p.m., with TMA-A reported at shift report on 12/28/22 at about 6 a.m., LPN-A reported she had been ill during her overnight shift, there was no one available to cover her shift and she had recalled there was Zofran in the medication room from a resident that had been discharged . TMA-A reported LPN-A stated she could not leave as she was the only nurse on duty, she had a personal prescription for Zofran, but did not have any with her, so she had taken one of the Zofran pills. TMA-A reported she knew this was wrong and she had reported the incident to the SSD who stated she would report the incident to the administrator and DON. Interview on 2/14/23 at 6:00 p.m., with LPN-A reported she had worked the overnight shift on 12/28/22 and had become ill. LPN-A reported she had a history of gastric issues and had developed nausea, vomiting and diarrhea. LPN-A reported she had contacted DON-B and the infection preventionist but neither of them were available to replace her shift. LPN-A reported she remembered seeing the bag containing the Zofran in a bag of medications to be destroyed in the medication room. LPN-A reported she was aware that it was not acceptable to take the medication, but since the resident had been discharged , and the medication was to be destroyed, she felt it was ok to take one of the Zofran tablets. LPN-A had a personal prescription for the medication, but did not have any with her and she knew she had to get through her shift and so she had taken one of the Zofran pills from the bag to be destroyed. LPN-A reported she finished her shift and had mentioned she had taken the Zofran from the medication room during report. Later that morning LPN-A reported she received a phone call from DON-B and the SSD and when questioned had admitted she had taken the one Zofran pill and why she had done so. She was informed the incident had to be reported to the SA and she would need to meet with administrator-B and HR. LPN-A reported she had a meeting with administrator who reviewed the facility policy on medication destruction and diversion of medications, and issued her a written warning. The nurse consultant was also involved, and she was informed the incident had been reported to the Board of Nursing. LPN-A reported education was provided to all nursing staff on the policies for medication destruction and drug diversion. LPN-A stated she was aware taking the medication was wrong, but she felt she had no other option due to the situation of needing to be able to finish her shift. R180 was not able to be reached for interview on 2/14/22 at 3:00 p.m. or 2/17/22 at 10:30 a.m. Interview on 2/17/23 at 10:00 a.m. with DON-A reported she was just starting in her position as DON at the time of the incident and did not recall a lot of the investigation, but agreed it was drug diversion to take a medication that had been prescribed for a resident She was aware taking a medication was reportable to the SA and reported the steps in the investigation process. The facility policy was provided. Review of the August 11, 2020 Drug Diversion policy identified diversion as the removal of drugs for the employee or others use and included on or off the facility premises. If the investigation revealed suspicion the notifications were to include the facility administrator, the SA, law enforcement and other designated agencies in accordance with state law of a medication diversion. This is viewed as misappropriation of resident property.

Based on interview and record review, the facility failed to appropriately assess and implement interventions to ensure residents were free from resident to resident abuse for 4 of 4 residents (R8, R9, R178 and R179). Findings include: Review of the 1/24/22, report to the State Agency (SA) identified R178 was wheeling himself past R5 in front of the nursing station when R5 hit R 178 on his right arm just below his shoulder with the back of her hand. R 178 continued past R5 without stopping. The 1/31/22 5 day investigation report identified R5 was looking for a man who ripped her off and is a crook. R 178 was in his wheelchair going past R5 who was in her wheelchair heading the opposite direction toward the dining room. R5 stuck her hand out and made contact with R178's right upper arm. R178 said ouch and pulled his arm back. R178 continued down the hall and did not stop. Interview with R178 after the incident reported he was wheeling past R5 and she had swatted him on his arm. R178 commented the area was going to be purple tomorrow. A skin observation completed by the charge nurse on 1/24/22 and repeated on 1/25/22. There was no documentation in the medical record of further investigation or review by the interdisciplinary team (IDT) into the root cause of R5 striking R178. the facility identified both residents were being kept separated as best as possible by staff. R8 was checked for a urinary tract infection (UTI) which came back negative and was scheduled to have a special visit with her primary doctor on 2/8/22 to review her mood and behavior. Review of the 1/24/22 at 4:15 p.m. facility incident report for R178 identified R8 had struck out at R178 and contacted his right upper arm. R178's right upper arm was checked and there was no sign of bruising or injury noted. R178 reported it had hurt right away but not anymore. There was no update to the care plan or interventions added on how staff were to provide for R178's safety and preventing further potential abuse. Review of the 9/13/22 initial report to the SA identified R8 and R9 were both seated in their wheelchairs by the nursing station. R9 stated that R8 had slapped his outer thing on his left leg then grabbed his pant leg and wouldn't let go. R9 reported it did not hurt, did not traumatize him and he was not upset. The 9/20/22 5 day investigation identified R5 was upset when she was in the dining room and had verbally threatened to hit dietary aide (DA)-A and was yelling and swearing. R5 had refused to leave the dining room and nursing assistant (NA)-B returned later and were able to transport R5 from the dining room. Both R8 and R9 were by the nursing station when NA-B returned to the area and observed R8 holding onto R9's pants. NA- B immediately separated R8 and R9 and R8 was taken to a quiet area and given a doll which she could put to sleep. When interviewed R9 reported he had gone to the nursing station to have someone help him find something and reported he was not hurt or traumatized. R9 denied any fear of being out of his room or of R8, and stated, she just gets ornery sometimes. Action taken to prevent reoccurrence was Education/communication to staff regarding offering non-pharmacological interventions listed in R8's care plan or from the intervention cabinet when R8 was worked up, had high anxiety or was over stimulated. There was no mention of interventions put into place or how staff were to prevent further potential abuse. Review of the 11/4/22, initial report to the SA identified R8 and R179 were heard bickering in the dining room by the administrator ( previous administrator)-B. Upon arrival at the dining room R8 and R179 were about 3 feet apart and the administrator attempted to remove R8 from the dining room, and as she was being moved she attempted to kick R179, but was not close enough to make contact. As R8 was being moved away she attempted to strike the administrator. R179 received a bruise and a scratch on her left arm and elbow. The 11/11/22 5 day investigation identified staff failed to separate R8 and R179 when R8 became agitated. R8 became agitated and began yelling at a staff member calling her names. R179 stepped in and told R8 not to say those types of tings to that staff member as R179 liked that staff member. the staff member walked away as that was usually effective in calming R8. Immediate intervention was to separate the 2 residents from each other. Staff education was provided via On Shift to separate the residents if R8 was becoming agitated with another resident. Education was required to all staff for Dementia Care: Challenging Behaviors and Direct Care Staff, R8's care plan was updated and placed at the nursing station for all staff to review and sign. R8's, 9/23/22 annual Minimum Data Set (MDS) assessment identified severe cognitive impairment, behaviors of physical symptoms directed toward others occurred 4-6 days during the assessment period, verbal behavior directed toward others occurred 1-3 days, and other behavior symptoms not directed toward other occurred 4-6 days. For activities of daily living (ADLs) R8 required Extensive assistance from 2 staff persons for bed mobility, transfers, dressing, and toileting. One staff assistance was needed for personal hygiene and locomotion on/off the unit and was not able to ambulate. R8 was always incontinent of bladder and frequently incontinent of bowel. R8 had diagnosis including non-traumatic brain dysfunction, hypertension, arthritis, dementia, anxiety disorder, and depression. R8 received scheduled pain, anxiety, and psychotropic medications. R8's undated care plan identified she had impaired thought process, was monitored for increased confusion or forgetfulness and had limited physical mobility. R8 was evaluated by Occupational therapy and used a low-scoot chair. R8 had increased anxiety at times and was repetitive and over stimulated by residents. Interventions included redirection by offering to watch TV in her room, reading, organizing belongings, hold her cat or doll, offer a book to read or coffee. If a resident to resident altercation occurred, staff were to separate the residents, keep all residents safe and offer non-pharmacological interventions. If combative with cares, staff were to leave R8 in a safe position and re-approach later. R9's, 10/14/22, annual MDS identified R9 had moderate cognitive impairment, had no identified behaviors, and required Extensive assistance of 2 staff for bed mobility, 1 person assist with transfers, locomotion on/off the unit, dressing, toileting and personal hygiene. R9 required limited assistance of one staff for walking in his room, and supervision for walking in the hall. R9 had diagnosis of medically complex conditions, Coronary artery disease, hypertension, hyperlipidemia, and Parkinson's disease. R9's undated care plan identified he had limited physical mobility, weakness, bilateral leg pain and Parkinson's disease. R9 needed assist of 1 staff with a gait belt for mobility. Staff were to protect resident from potential abuse. R9 was receiving a restorative program and received an antipsychotic for adjustment disorder and an antidepressant for depressed mood with monitoring for potential side effects. R178's, 11/29/21, admission MDS identified moderate cognitive impairment, ADLs were independent to supervision with all areas and R178 used a walker and wheelchair for mobility. R178 had a history of falls prior to admit, and diagnosis which included coronary artery disease, weakness, hypertension, and malignant neoplasm of prostate. R178's undated care plan identified he had limited physical mobility related to (R/T) a history of a motor vehicle accident (MVA) with a sternal fracture, weakness and used a w/c for locomotion, and was able to ambulate independently. Staff were to protect all residents from potential allegations of resident abuse, neglect, exploitation or mistreatment. The care plan identified R178 required assistance from one staff for ADLS. R178 had a psychosocial well-being deficit evidenced by calling staff servants. Non-pharmacological interventions included 1:1, playing cards, puzzles, and he received antidepressant medication R/T a diagnosis of anxiety. Mood and behavior identified R178 was short tempered with staff, made negative comments towards staff, mocked other residents, and had been being physically aggressive. Interventions included for staff to intervene as necessary to protect the rights and safety of others and approach/speak in a calm manner, divert attention, remove him from the situation and take to alternate location as needed. R178 had a history of physical aggression with other residents. that was noted when he was in an over stimulated environment and R178 had decreased patience. If a resident to resident altercation occurred staff were to separate the residents, keep all residents safe, and offer non-pharmacological interventions included in care plan. There were no interventions included to identify an individualized approach with regard to the altercation with R8. R179's, 12/13/22. discharge with return anticipated MDS identified her cognition was intact, she had moderate to severe depression, behaviors included delusions, and she required extensive assistance of 2 staff for bed mobility, and the assistance of one staff for transfers, locomotion on/off the unit, dressing, toileting, and personal hygiene. R179 had diagnosis of osteoarthritis of knee, heart failure, hypertension, arthritis, vision issues, morbid obesity and major depressive disorder, and occasional pain. R179 had been on isolation due to COVID-19 and was paranoid of facility staff. R179's, 10/20/22, Care Area Assessment (CAA) identified cognitive loss/dementia, had disorganized thinking at times and would ramble and have irrelevant conversations due to her paranoia of facility staff. R179's, undated care plan identified she was able to verbally communicate her needs, had limited physical mobility and was at risk for falls R/T incontinence, medication use, weakness, congestive heart failure, and depression. R179 had an ADL self-care performance deficit and utilized a w/c for locomotion, and required an EZ stand lift for transfers. Behaviors were paranoia, being rude to bullying other residents, refusing to talk about mental health, many negative comments towards staff/belittles and degrades staff, and was rude to residents. Intervene as necessary to protect the rights and safety of others. Remove from situation and take to alternate location as needed. There was no mention of interventions specific to altercations with R8 or other residents. Interview on 2/13/23 at 6:15 p.m., with the SSD reported R8 had dementia with behavioral disturbances and became physically aggressive with cares. She reported there were not specific triggers or persons that R8 targeted but it seemed to be a situational response when she was agitated, or there was something not as she thought it should be. She reported R8 became over-stimulated around other residents or if there were loud activities going on. R8 calmed down if staff were able to bring her to the lounge across from the nursing station and give her something to read, or take her to the living room and give her a baby doll to hold and put to sleep. The SSD reported R8 had received orders for a new pain medication ( Fentanyl patch) that had been started the previous week and staff had noticed R8's mood had improved and she had decreased behavior. The SSD reported facility staff had received education on an annual basis on abuse, vulnerable adults, and reporting in addition to dementia training that was provided after the incident in November 2022. She reported staff were aware of R8's behavior and agitation directed toward other residents and staff and attempted to position R8 in a quieter area and supervise to keep other residents from getting too close, especially if R8 was agitated. Interview on 2/14/23 at 2:53 p.m., with nursing assistant (NA)-A reported R8 required total assistance from two staff for all ADLS and more recently had needed to be assisted with eating. NA-A reported R8 did seem more calm since the new medication had been started, but she continued to have verbal and physical aggression toward staff and other residents. She reported the immediate intervention when R8 became agitated toward another resident was to separate them, and take R8 to the living room and give her a doll to hold, or a book to read. She reported R8 was allowed to sleep in if she didn't want to get up, and 30 minutes prior to personal cares being provided R8 was given an antianxiety medication which helped with the aggressive behavior directed toward staff. NA-A reported R8 liked her alone time and spent a lot of time sitting in the living room reading or watching TV. NA-A reported she had received education on abuse, rights, reporting and dementia training within the last year, and the dementia training was provided in November 2022. Interview on 2/16/23 at 8:30 a.m., with the DON reported she was new in her positron and just learning about the need to review and revise care plans and interventions. She reported her expectations for staff to follow the facility abuse and neglect policy for keeping all residents safe, and when an incident did take place it was to be reviewed by the management team, discussion to attempt to determine the cause, review of interventions in place, and care planing of any new interventions added.

Based on interview and document review, the facility failed to complete an appropriate discharge summary for 2 of 2 residents (R26 and R180) who were discharged to the community. Findings include: R26's 12/1/22, discharge Minimum Data Set (MDS) identified R26 had been independent with bed mobility, transfers, and toileting. R26 also required staff supervision when walking and was frequently incontinent of urine and occasionally incontinent of bowel. R26's 12/1/22, facility discharge summary identified pertinent medical diagnoses. It also had sections for hearing, vision and cognition which were blank. Staff noted mood and behavior as happy to be going, and Activities of Daily Living noted walker. Staff also noted resident's patterns of bladder and bowel were ambulates to the bathroom. The discharge summary lacked any mention of course of illness, treatment, pertinent labs or consultations. R26's discharge summary also included a section giving direction for the licensed nurse to complete a recapitulation of resident's stay including diagnosis, course of illness, treatment or therapy, pertinent lab, radiology and consultation results. A final summary of the resident's status to include the resident's strengths, goals, life history and preferences as reflected in the MDS. 34083 R180's 12/1/22, Discharge return not anticipated MDS identified R180 had moderate cognitive impairment and required limited assistance for toileting, supervision for all other Activities of Daily Living (ADL), and was able to ambulate independently in her room. R180 had diagnoses of osteoporosis, beeding of her brain stem, enlarged heart, abnormalities of gait and mobility, and hemiplegia( paralysis on 1/2 of the body). R180's 12/1/22 at 10:30 a.m., discharge summary identified diagnoses that were present on admission, with a space for final diagnosis to be completed by the physician with signature and date were left blank. The section identified as resident strengths and goals were also not completed on the discharge summary. Interview on 2/16/23 at 9:29 a.m., with the director of nursing (DON) indicated R26's discharge summary was missing a large amount of information that she would have expected to be included. The DON agreed R26's discharge summary did not include a recapitulation of care. Review of the 12/22/22, Discharge Planning Policy with a check list attached indicated a Discharge/Therapeutic Leave Instructions Progress Note and a Discharge Summary should have been completed in the medical record, however, there was no mention of a recapitulation of resident's stay.

Based on observation, interview and document review, the facility failed to administer medication according to manufactures guidelines and physician's orders for 2 of 31 observations, resulting in a 6.4% medication error rate. Findings include: Observation and interview on 2/16/23 at 7:57 a.m., of R10's medication pass with trained medication aide (TMA)-A who gathered his morning medications identified TMA-A administered his omeprazole (blocks stomach acid) and his albuterol inhaler. R10's inhaler label had an expiration date of 2/1/23 and was last used on 2/9/23. TMA-A reported R10's omeprazole was to administered before meals, but due to busy medication pass times, it would commonly end up being given with or immediately after R10 had his meal. TMA-A agreed R10's Albuterol inhaler label should have been verified as part of the 5 rights of medication administration and identified prior to administration. R10's current, undated physicians orders identified R10 had an order for omeprazole 20 milligrams (MG) by mouth (PO) twice daily (BID) to be taken before meals (ac) and Albuterol Sulfate 90 microgram (MCG) inhaler, 1 puff PO every 4 hours as needed (PRN). Interview on 2/16/23 at 8:38 a.m., with the DON identified she expected medications were to be administered according to the signed doctor's orders and discarded per manufacturer's instructions. The medication cart had been last checked by the Pharmacist on 1/25/23 and the TMA completed a check on 1/29/23. The DON was not certain how the inhaler was missed when both the consultant pharmacist and a TMA had checked the cart for outdated medications. The DON was aware medications such as omeprazole was being administered with meals rather than as order by the physician or indicated per manufacturer's guidelines. Review of the August 24, 2022, Administration Including Scheduling and Medication Aides policy identified medication was to be administered correctly and in a timely manner. The 5 Rights of Medication administration were to be followed for medication administration.

Based on observation, interview and document review, the facility failed to comprehensively assess and implement pressure ulcer interventions consistently for 1 of 1 resident (R21) identified at risk for pressure ulcers. R21 developed a pressure ulcer after admission to the facility which progressed to a stage four pressure ulcer resulting in actual harm. Findings include: Pressure Ulcer stages defined by the Minnimum Data Set (MDS) per Center Medicare/Medicaid Services: Stage I pressure ulcer (An observable, pressure-related alteration of intact skin, whose indicators as compared to adjacent or opposite area on the body may include changes in one or more of the following parameters: skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching); and/or a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues.) Stage II pressure ulcers (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) also present as an intact or open/ ruptured blister.) Stage III pressure ulcers (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling.) Stage IV pressure ulcer (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling.) Unstageable pressure ulcer: (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) R21's admission Minimum Data Set (MDS) assessment dated [DATE], identified she was admitted with heart failure, high blood pressure, generalized [MEDICAL CONDITION] (swelling), and long term use of anticoagulants (blood thinner). R21's cognition was intact, and required extensive assistance of staff for activities of daily living (ADL), bed mobility, transfers, locomotion on/off unit, and required limited assistance for walking in her room with a walker. R21's initial skin assessment indicated she was not at risk for pressure ulcers and had no pressure ulcers. R21's 9/17/18, Significant Change Assessment indicated she was at risk of developing pressure ulcers. A positioning assessment dated [DATE] indicated R21 required assistance of 1-2 persons for bed mobility, and was now incontinent of bowel and bladder. R21's next assessment dated [DATE] (significant change), identified R21 needed assistance of 1-2 for bed mobility, incontinent of bowel an bladder, decline in transfers with a risk for development of pressure areas. The skin assessment did not identify any pressure ulcers. The Care Area Assessment triggered for pressure ulcers, but there were no measures identified or implemented for R21. R21's 2/7/19 MDS assessment, (completed as a significant change with change/increase in level of care-transfers and toileting in addition to a pressure ulcer), identified intact cognition, unable to ambulate, utilized a wheelchair (W/C) with staff assistance for transport, was at risk for skin breakdown and had a facility acquired stage four pressure area on her right buttock. R21 required staff assistance with bed mobility, was no longer able to stand and/or ambulate and required transfer with the EZ stand lift. R21's Care Plan updated 2/27/19 listed limited physical mobility related to weakness, [MEDICAL CONDITION] and endocarditis. The interventions included education to use call light, uses wheelchair for locomotion, assistance of 1 staff as needed and 1-2 staff for bed mobility and repositioning, use EZ stand lift. The care plan also identified potential skin impairment with the interventions of keep skin clean and dry, weekly skin observation, stage 4 pressure area to the right buttock, Reposition/offer toileting every 2 hours, use wedge in bed and ROHO cushion in W/C, air mattress on bed, and up for meals only. Care Plan History, dated 1/23/19 identified wound on right buttock, and offer toileting/repositioning every 3 hours while awake. R21 was observed on 4/9/19 at 12:03 p.m. with a wound vac hanging from the back of her chair and the tubing extended to her right hip. R21 indicated staff did not reposition her on a regular basis and she usually remained lying on her left side other than when she got up for meals and Bingo. During the observation, R21 stated she was up at least 3 times daily for her meals and Bingo which was held two times weekly. In addition she was up in her chair to go to her wound clinic appointments every Monday. R21 stated she wasn't certain how often staff came into her room, but didn't think it was more than once unless she turned on her light and requested to be turned. During an observation at 12:40 p.m. on 4/9/19, R21's family member (FM)-A was in attendance and said he visited just about every day and R21 was usually lying on her left side when he came. (R21 was observed lying on her left side in the same position until 1:40 p.m. when staff returned and transferred her from the bed to her W/C so she could attend bingo.) R21 was interviewed on 4/09/19 at 12:24 p.m. and stated she had a wound on her buttock since around (MONTH) and that it had developed in the facility. Stated that prior to that time, she could shift herself alittle in her chair, but she was dependent on staff for repositioning when they came in or if she called for them to reposition her. R21 confirmed she was not on a repositioning schedule until after she developed her wound. During interview with nursing assistant (NA)-A on 4/9/19 at 12:51 p.m., she stated R21 requires extensive assistance with all ADLs and doesn't usually c/o pain but she does have difficulty moving her left leg. NA-A said R21 was gotten up for meals, bingo and exercises and except for those times she remained in bed being repositioned Q2-3 hours and PRN. During interview on 4/9/19 at 3:20 p.m. the DON stated the nursing staff had noticed the area on R21's right buttock on (MONTH) 6, 2019 with findings of a 1.0 cm (centimeter) x 1.0 cm area of sacral [MEDICAL CONDITION] above the area with surrounding skin reddened but not opened. A 1/3/19 the skin assessment listed the area as 2 cm x 2 cm round and very hard but there was no redness or warmth . Progress note documentation indicated on 1/6/19 the nursing staff had noticed redness, and [DIAGNOSES REDACTED]. As a result, a wound assessment was completed, the provider was updated, and orders were received to use a barrier cream twice daily. During observation on 4/15/19 at 12:51 p.m. NA-A transported R21 to her room, transferred her into bed with the use of the EZ stand (a mechanical lift) positioned her on her back, covered her with a blanket and left the room. At 2:11 p.m. R21 was in her bed lying on her back. R21 stated staff would return and help her reposition onto her side, but there was no specific times that they did this and they would come if she turned on her call light and asked them to reposition her. R21 was observed on 4/16/19 at 8:30 a.m. in the dining room eating breakfast and at 9:15 a.m. she was in bed lying on her left side with wedge positioned behind her. At 10:15 a.m. her position was unchanged. At 11:15 a.m. R21 remained in same position and stated staff would be coming soon to get her up for the noon meal, over 3 hours since R21 was repositioned. At 1:15 p.m. R21 stated she had gotten up for lunch and was again lying in bed positioned on her left side with the wedge pillow behind her. Observation of R21's wound vac dressing change was completed on 4/17/19 at 10:00 a.m. by registered nurse (RN)-A and licensed practical nurse (LPN)-A. RN-A described the wound located on R21's right buttock as the wound base. The area was observed to be beefy red in color and there was a clean return when irrigated with saline. R21 denied pain with touch. RN-A stated the wound measurement, described using clock detail included: 1.8 centimeter(cm) at 12:00 o'clock x 2.1 cm at 3:00 o'clock x 2.1 cm at 6:00 o'clock x 1.9 cm at 9:00 o'clock. There was a lip on the outer edge of the wound which extended from 9:00 to 12:00 o'clock, and was 2.0 cm in width. There was also a 3 cm tunneled area that was packed with [MEDICATION NAME]. R21 stated she had no control over her left leg and wasn't able to move it. RN- A completed packing of the wound with the wound vac foam and then applied the barrier film and hooked up the wound vac. Facility skin observation notes identified the following: 1/3/19, R21 was first observed to have a 2x2 round, very hard, non- reddened, not warm to touch-with some indentations. Barrier cream was applied with the intervention to monitor. There was no turning or repositioning schedule identified, and R21 indicated she was spending most of her day up in her w/c. 1/6/19 Wound Assessment: identified suspected deep tissue injury, partial thickness loss, deterioration of wound-evidenced by the new area. Modifications to treatment were repositioning/turning (no frequency listed), wound treatment. The area was continuing to deteriorate as evidenced by the wound margins or surrounding skin, sacral [MEDICAL CONDITION] above the area, with the surrounding skin is reddened, but not open. Physician notification and documentation included continue with current plan of treatment (barrier cream twice daily and as needed to area). A comment was included on the form: Staff educated to reposition off the area and watch for shearing. 1/14/19 Wound RN Assessment: identified R21's area as a pressure ulcer that was not present on admission, stage 2. Deterioration evidenced by increase in size. Modifications were repositioning/turning; moisture/incontinence protection; friction/shear management; and wound treatment and to follow up on nursing home rounds. 1/22/19: Wound RN Assessment: Deterioration of wound, area of maceration related to a dressing that was on the wound. (MD update to continue with current plan). 1/30/19: deterioration of wound evidenced by: area has increased in size with increased drainage and odor. Will be seen on rounds 1/31/19. Using ABD pad for increased drainage. Documentation indicated the MD saw R21 on rounds 1/31/19 and made a referral to the wound clinic. 1/31/19: Physician order [REDACTED]. MD note, does appear infected. Will obtain wound nurse consult and continue aggressive wound cares. 2/4/19: Wound nurse document: Stage 4 Pressure Ulcer right buttock. Orders: received Review of R21's wound data collection documents included: 1.) 1/6/19 initial data collection on wound: 1.0 cm(L) x 1.0 cm(W) x 0.1 cm(D) and evaluation of the ulcer is no signs (S) /symptoms(S) of infection, does have increased sacral [MEDICAL CONDITION] just above the area. Surrounding skin: sacral [MEDICAL CONDITION] above the area, surrounding skin is reddened but not open. Treatment: barrier cream applied, Fax sent to clinic to update provider and orders to use barrier cream twice a day (BID) and as needed (PRN) to the area. Suspected deep tissue injury with partial thickness loss. Staff educated to reposition off the area and to watch for shearing. 2.) 1/14/19 Right buttock wound identified as pressure ulcer not present on admission: 2.9 cm(L) x 1.5 cm(W) x 0.1 cm(D). Treatment: barrier cream to the area. Comments will follow up on rounds with provider on 1/15/19. Deterioration of wound-evidenced by increase in size. 3.) 1/18/19 Site listed as coccyx, but indicated same site: S/S of infection at this time Treatment: Barrier cream and repositioning as resident allows. 4.) 1/20/19 Right Buttock 2.8 cm (L) x 4.4 cm(W). Identification comments: granulation tissue around wound, mid wound yellow-white slough, with areas of necrotic tissue. Tissue surrounding the dressing, pink in color, blanches, No dressing on prior, applied non adherent pad with [MEDICATION NAME] covering due to drainage. 1/21/19 area is red and has drainage, 5.) 1/22/19: Comment: there was a dressing on the area, that was saturated with serous fluid causing maceration to the area. Educated staff on the area and current treatment. 6.) 1/26/19 Good tissue around area does have some hard area surrounding ulcer. Bloody drainage from wound bed. Resident c/o aching when sitting on it. 1/27/19: increased redness surrounding wound, [DIAGNOSES REDACTED], odor to wound with wound covered in slough. 1/29/19: Copious amounts of bloody drainage noted, surrounding tissue reddened. R/T odors, reddened, worsened-started on antibiotic. Resident states pain is worse when pressure applied, resident repositioned off of pressure area. Note on form that unable to assess wound edges r/t dressing. Surrounding tissue rd and slightly macerated. Dressing calcium alginate to wound bed, covered with ABD. Resident repositioned at least every 3 hours, changed ABD r/t copious amounts of drainage, monitor pain. 1/30/19: area has increased in size with increased drainage and odor will be seen on rounds 1/31/19. 7.) 2/4/19: Seen in wound clinic 4.6 cm(L) x 5.0 cm(W) x 4 cm(D) treatment of [REDACTED]. Set up by wound nurse. Wound was also debrided by wound nurse . 8.) 2/11/19 seen by wound nurse: Continuing same treatment and next appointment scheduled for 2/18/19; 2/19/19: 3 cm(L) x 4 cm(W) x 4.5 cm(D), treatment changed to medi honey with gauze in wound bed covered with ABD pad, Scheduled to see wound nurse weekly and orders received for wound vac to area. 9.) 2/26/2019 4 cm(L) x 3 cm(W) x 3.5 cm(D) 10.) 3/6/19 3.5 cm(L) x 3.0 cm (W) x 2.0 cm(D) 11.) 3/13/19 2.0 cm(L) x 3.5 cm(W) and wound vac in place with dressing changes Mon/Wed/Fri. No tunneling noted in wound bed. 12.) 3/20/19 2.0 cm(L) x 2.5 cm(W) x 1.5 cm(D) continues with wound vac. 13.) 3/27/19 2.0 cm(L) x 1.8 cm(W) x 2. 5cm(D), It was noted during wound dressing change to have white shinning area about 9-12 o'clock. [MEDICATION NAME] wound dressing was placed over the area with wound vac placed. A call was placed to wound clinic to update. 14.) 4/3/19 1.6 cm(L) x 1.6 cm(W) Lip area noted from 7-12 o'clock area, 4/10/19: 1.9 cm(L) x 2.) cm(L)-lip/tunnel area 9-12 o'clock area, 4/17/19: 1.7 cm(L) x 1.5 cm(W) same areas of tunneling wound vac with [MEDICATION NAME] dressing to lip area. During an interview with LPN-A and NA-B on 4/15/19 at 2:13 p.m. confirmed R21 was not put on a turning and repositioning schedule until after development of the pressure area on her right buttock. Prior to development of this area she had been calling and requesting staff to toilet and reposition her when she wanted it done. LPN-A and NA-B voiced the reason for not having R21 on a positioning schedule was they felt she was able to shift herself adequately in her bed and W/C. They stated the initial impression of R21's wound was that it was possibly a boil because it was hard and developed quickly. The area was seen on 1/3/19 by the nurse practioner (NP) for nursing home rounds but there was no comment addressing R21's wound. The provider was updated on 1/7/19 of the changes/deterioration along with the increased sacral [MEDICAL CONDITION] and agreed to the use of barrier cream two times daily and PRN. Then on 1/8/19 the area was noted to have opened and the provider was again notified of this along with R21's weight gain. During an interview with RN-A on 4/15/19 at 2:27 p.m. she stated R21 had episodes of increase/decrease of fluid retention which included sacral [MEDICAL CONDITION] and that she also has a funny way she sits in her w/c with her body angled and this could have caused her right buttock to be in contact with the chair. R21 was receiving therapies but there was no documentation addressing seating assessments or concerns. According to the EMR (electronic medical record) the last day R21 was ambulated was on 12/14/18 following which she had experienced decline with weight fluctuations and [MEDICAL CONDITION]. During a subsequent interview on 4/17/19 at 8:57 a.m. LPN-A said when the red, hardened area appeared on R21's right hip it had a boil like appearance. At that time R21 was able to stand for transfers with staff assistance and was ambulating with staff. In addition prior to development of this area there was no indication of a problem with pressure from chair that had been noted. R21 was utilizing an EZ stand lift for transfers occasionally in and out of bed when her legs were weak or she was tired. Therapy was discontinued around the end of (MONTH) 1/21/19 and the reason was due to her plateau and at that time staff were utilizing the EZ stand due to complaints of left hip pain. During interview on 4/17/19 at 9:26 a.m., the medical doctor (MD) stated he observed R21's wound was not located over the usual pressure point on her hip but was located in the midline sacral area, between the pelvic tuberosities. He further stated R21 has a history of heart issues and impaired circulation and as a result of this would have decreased circulation to the area. He said he couldn't say if the area could have been prevented but he felt the severity could have been avoided. The provider voiced that he didn't feel R21 would have been able to reposition herself adequately to relieve pressure to her buttock area and since she didn't have pain until the area became infected, in his opinion the severity of the wound could have been avoided by repositioning and off loading. During an interview on 4/17/19 at 1:28 p.m. with the DON, she indicated the only skin assessment completed was the Braden scale assessment and a positioning assessment which would have been done on admission and readmission, but she was not aware of any additional assessments completed for R21. Changes were made in R21's care plan with repositioning changing from 3 hours to 2 hours after development of her wound. The positioning assessment and evaluation was completed at the time of admission on 8/3/18 and was not repeated until following hospitalization on [DATE]. Although R21 declined in physical ability and needed increase assistance with ADL's, transfer and bed mobility. The facility had not comprehensively assessed R21 risk factors to determine appropriate interventions to decrease her risk for PU development. As a result R21's pressure ulcer progressed from no pressure ulcer on admission to a stage 4, resulting in actual harm. Review of the facility Procedure Mobility Support and Positioning with a revision date of (MONTH) (YEAR): Purpose- to position those residents unable to position/reposition independently in a manner which prevents formation of contractures, provides comfort and maintains skin integrity. To provide proper body alignment for residents in wheelchairs. Policy and Guidelines Routine Practice with a most recent revision date of (MONTH) (YEAR) Purpose: To ensue that care plans are resident-centered and specific to the unique needs of each resident and do not include expected routine practices. Policy Care plans should reflect resident-centered items that are unique to that resident's care. Exceptions to routine practice related to medical needs, personal preference and/or resident choice will be reflected on the care plan.

Based on interview and document review, the facility staff failed to immediately report to the administrator and to the state agency observed abuse of a resident (R1) by a nursing assistant (NA) resulting in bruises. In addition, facility staff failed to report immediately to the administrator and state agency bruises of suspicious nature (arms, wrists and legs) for two of three (R1 and R2) residents reviewed. The failure of several facility staff to report observed rough treatment to R1 placed all 38 residents of the facility at risk for abuse. Therefore, an immediate jeopardy to resident safety existed. The findings include: This deficient practice resulted in immediate jeopardy. The immediate jeopardy was identified on November 1, 2013 and began on September 11, 2013 when multiple staff failed to report rough treatment to R1 that resulted in injuries that were first identified on September 11, 2013. The administrator and director of nursing (DON) were notified of the immediate jeopardy on November 1, 2013, at 12:50 p.m. The immediate jeopardy had the potential to affect all 38 residents residing at the facility. The immediate jeopardy was removed on November 4, 2013, at 1:31 p.m., after the facilities removal plan was implemented and evaluated. The facility developed a plan to ensure staff immediately reported possible mistreatment or abuse. On November 1, 2013, at 4:30 p.m., the facility had an emergency and immediate in-service highlighting the importance to report allegations of abuse and neglect to the immediate supervisor, how the allegations will be investigated, the definitions of abuse/neglect and a detailed overview of abuse/neglect policy and procedures. Employees that were unable to attend the in-service received the in-service content before the start of their shift. A list of staff who completed the in-service was kept to ensure all staff received the information prior to working their assigned shift. The DON and administrator conducted monitoring rounds on all shifts on November 2, 3 and 4, 2013, to ensure the charge nurses were effectively managing, supervising and communicating with staff. A video monitoring system is used and viewed weekly for three months to ensure charge nurses are entering resident rooms and monitoring staff. To continue compliance, the facility will monitor abuse and neglect by randomly interviewing three staff members each month for six months to ensure all allegations of abuse and neglect are being reported and that reports are acted on consistent with the facility's policy and procedures. Additional training will be provided to the charge nurses regarding appropriate steps to take when allegations of abuse are reported. The facility will provide mandatory education regarding abuse/neglect annually for current staff. New employees will be required to receive the training prior to working in their job capacity. The scope and severity was lowered to isolated actual harm that was not an immediate jeopardy. On October 8, 2013, nursing assistant (NA)-A expressed in a resignation questionnaire that she had witnessed a resident (R1) with behavioral issues be held down by a coworker (NA-B). NA-A documented that she and "many other staff members" had complained and nothing was done. R1's medical record revealed that R1 returned to the facility on [DATE], following hospitalization for a [MEDICAL CONDITIONS]. On August 12, 2013, documentation by the social worker in the Interdisciplinary Assessments and Summary Reviews identified R1 had a significant change in status due to left side weakness and that the resident was wheelchair bound since her return from the hospital. The documentation also identified R1 had become combative with staff since her return from the hospital. On August 12, 2013, the nursing narrative note in the Interdisciplinary Assessments and Summary Review identified R1 required assistance of one with dressing and personal hygiene and assistance of two staff with toileting and bed mobility. The resident was also identified to require the use of a mechanical device for transfers. The documentation identified the residents skin was intact, and that the residents skin is checked daily with cares and that a weekly skin inspection is done by a licensed nurse on bath day. The documentation also identified the resident had exhibited behaviors of occasional hitting and kicking staff with cares. R1's record revealed that on September 1, 2013, at 2:00 p.m., the licensed practical nurse (LPN)-A documented the resident had a reddish brown (bruise) areas on the top of her right foot and back of the great toe, and of the right armpit area. There were no measurements or further description of the injuries. On September 2, 2013, at 7:15 a.m., LPN-A documented a skin inspection was done, and that the brown coloration of the right great toe was fading. The documentation identified the arm pit area continued to be "dark" with small yellow around the edges. On September 8, 2013, at 9:15 p.m., LPN-B documented the resident had a bruise to the right arm biceps that extended almost the full length of the residents upper arm. There was no description or measurement of the bruise. On September 9, 2013, at 6:45 a.m., the weekly skin inspection by LPN-A identified the resident had a fading bruise of the right upper arm and right great toe. The resident also had a healed skin tear of the top of the right hand and knuckle. On September 11, 2013, at 2:30 a.m., LPN-C documented in the Interdisciplinary Progress Notes R1 had an old faded bruise on the backside of her right knee. The LPN documented the area was greenish on the outside with some purplish red in the inside measuring 8.5 centimeters (cm) by 3.5 cm. LPN-C also completed a Incident Details report that was reviewed and signed off by the director of nurses (DON) on September 14, 2013. On September 14, 2013, at 4:30 a.m., LPN-D documented in the Interdisciplinary Progress Notes R1 had a red area of the inner lower right leg that measured four cm. On September 16, 2013, at 7:20 a.m., LPN-A documented in the weekly skin inspection note that R1's brownish red (bruise) area of the right great toe, armpit and biceps had resolved and that the area on the residents right lower leg and ankle remained brownish in color. The documentation also identified the resident's left arm/hand grayish color had improved. On September 30, 2013, at 6:30 a.m., LPN-A documented R1 had a bruise that measured seven cm on the right lower arm. LPN-A completed a Incident Details report that LPN identified the bruise was due to combative behaviors. The DON signed the report on October 8, 2013. On October 8, 2013, after receiving the resignation questionnaire from NA-A, an Incident Details report was completed by the social worker (SW). The report identified "possible abuse to resident (R1) by another coworker (NA-B)". On October 8, 2013, following the report of possible abuse, R1 was assessed by registered nurse (RN)-A and the following bruises were observed: Left upper outer arm, multiple bruises consistent with hand prints Right posterior arm large bruise brown/purple top of forearm to underneath arm solid bruise Reddened area tip of nose Right shin bruise, 1 centimeter (cm) x 1.3 cm upper middle - reddish purple Left posterior lower leg, 6.6 x 6.7 cm fading purple bruise Left posterior upper leg 1 x 2 cm brownish bruise Right posterior upper leg 2.1 x 2 cm brownish bruise Right hip 1 x 1 cm greenish bruise Right lower abdomen 0.4 x 0.5 cm greenish brown bruise Left posterior knee 4.9 x 2 cm purple brown bruise Left shoulder blade small scratch Left inner biceps 2.7 x 2.2 cm yellow green purple bruise Left upper arm 3.4 x 3.2 cm yellow outside purple inside bruise and a 1.7 x 1.1 cm brown bruise above the previous one Left upper outer arm 3 x 2 cm brownish purple bruise, and Left posterior upper arm 3.2 x 1.4 cm purple green bruise. On interview during the onsite investigation on October 22, 2013, NA-D stated R1's left side was not as strong as her right side. NA-D oriented on the night shift with NA-B on September 2 and 3, 2013. NA-D observed NA-B hold R1 on her left side by holding R1's right arm with her hands and R1's right leg with her knees pressed on top of R1's leg and knee. NA-D stated NA-B held R1 with her hands so tight that NA-B's knuckles turned white. NA-D stated there were marks left on R1's right arm and leg when NA-B let go and that R1 had bruises on her arms and legs where NA-B held R1 down. NA-D stated she did not work with NA-B after orientation, but was concerned about the amount of bruises that R1 had. After her orientation NA-D reported to LPN-C and LPN-D that she thought NA-B was rough and was informed "ya, she can be stern." NA-D stated she asked LPN-D (date unknown) about the bruises on R1's right arm (Interdisciplinary Notes identified bruises to the right arm on September 8 and 30, 2013). NA-D stated LPN-D was aware NA-B held R1 down, "how could she not", as R1's right arm was "so bruised." NA-D stated LPN-D contributed R1's bruising to R1 doing it to herself. On interview with NA-A on October 30, 2013, NA-A stated she completed the evening/night shift rounds on one occasion with NA-B. NA-A was the evening worker and NA-B came to work the night shift. NA-A stated that immediately upon entering R1's room, NA-B physically put her knees on top of R1's legs and her arms on R1's arms. NA-A stated she was a fairly new employee, but had never seen R1 handled this way. NA-A was concerned and asked NA-C if she had witnessed this. NA-C responded that she had and that she had already reported the treatment to the charge nurse LPN-D. NA-A stated R1 did strike out with cares if not informed what cares were going to be done and if R1 was not given enough time. NA-A stated R1 had constant bruises on her arms and legs and thought the bruises on R1's legs were peculiar as R1 could not move her legs. NA-A stated R1 was angry when she was held down, that R1 seemed frustrated, would swear at NA-B and then R1 gave a "big sigh" and "gave up." NA-A also stated R1's bruises were a "harsh - ugly color" and had bruises on her arms, forearms, legs and thighs. NA-A stated she did not report as she thought the nurses were aware, "how could they not." On interview with NA-C on October 31, 2013, NA-C stated she worked one night in September 2013 with NA-B(exact date unknown by NA-C; schedule identified on September 24, 2013, NA-C and NA-B worked the night shift). NA-C stated NA-B immediately held R1 down by putting her knee on R1's right knee and her hands around R1's forearms. NA-C stated she attempted at the time to intervene by telling NA-B "whoa, hold on, I don't think you need to hold her down so hard." NA-C stated R1 seemed afraid and R1 stated to NA-B "you are the devil, I can see it in your eyes." NA-C also stated R1 would say "Ouch, Ouch." NA-B responded to R1 "and you wonder why you are always bruised." NA-C stated R1's bed was at mid height so that NA-B would be able to put her knee on R1's right knee. NA-C stated R1's left side was weaker so R1's right side was held down harder. NA-C stated she reported to LPN-D, on the same night that she witnessed NA-B holding R1 down, that she thought NA-B was being more "rough" than she needed to be with R1. NA-C felt LPN-D ignored her and that LPN-D already knew that R1 was held down by NA-B. NA-C stated that since R1's [MEDICAL CONDITION], R1 was combative if not informed what cares were going to be done. NA-C stated NA-B did not explain cares, but immediately held R1 down. NA-C stated R1 had bruises on her arms and legs where NA-B held her down. On interview with LPN-D on October 22, 2013, LPN-D verified NA-C reported on the night that she worked with NA-B that NA-B was "rough" with R1. LPN-D verified she did not inquire what "rough" was, nor did she report the allegation of abuse immediately to the administrator or to the state agency. R1 was not interviewed at the time of the site visit. On interview with the director of nurses (DON) on October 22, 2013, it was verified LPN-D had not reported to the administrator or to the state agency the allegation of "rough" treatment for [REDACTED]. The DON verified there were no reports to the administrator or to the state agency of the numerous occurrences of bruising on R 1 that was documented by LPN-A, LPN-B and LPN-C from August 2013 through October 8, 2013. R2 's record was reviewed and revealed that on September 20, 2013, at 7:30 a.m., the resident was observed by LPN-C to have a purple blue bruise on the right wrist that measured 3 cm x 3 cm, a purple blue bruise on the left wrist that measured 6 cm x 3 cm and a purple blue bruise on her right back calf that measured 4 cm x 3 cm. The bruises of both wrists were of suspicious nature and were found in the morning. R2 is a [AGE] year old alert and oriented resident with [DIAGNOSES REDACTED]. R2 was continent of bladder with occasional incontinence of bowel. R2 required total assistance of staff for activities of daily (ADL) skills which included transfers and bed mobility. R2 was also identified with a bedtime of 9:00 p.m. On interview with R2 on November 1, 2013, R2 stated some staff treat her better than others. R2 stated at bedtime and during the night some staff are "rough" when they transfer her out of bed and put into the wheelchair to go to the bathroom. R2 stated they (unable to name) grab her wrists and under the arms and "pull". R2 stated she did not complain as "they handle you rougher if you do." so, "I just holler." R2 also stated that sometimes she is taken to the bathroom and is left there to sit for a long time. On interview with the director of nurses (DON) on October 22, 2013, the DON verified there were no reports to the administrator or to the state agency of the wrist bruising on R2 that was documented by LPN-C on September 20, 2013.

Based on interview and document review, the facility failed to ensure staff implemented the Abuse and Neglect Policy and report immediately to the administrator and the state agency allegations of rough treatment and failed to report bruises of unknown source to the administrator for two of two (R1 and R2) residents in the sample. The facility's failure to implement the abuse and neglect policy and procedures of reporting and investigating allegations of rough handling of residents had the potential to affect all 38 residents in the facility. Therefore, an immediate jeopardy to resident safety existed. The findings include: This deficient practice resulted in immediate jeopardy. The immediate jeopardy was identified on November 1, 2013 and began on September 11, 2013 when multiple staff failed to report rough treatment to R1 that resulted in injuries that were first identified on September 11, 2013. The administrator and director of nursing (DON) were notified of the immediate jeopardy on November 1, 2013, at 12:50 p.m. The immediate jeopardy had the potential to affect all 38 residents residing at the facility. The immediate jeopardy was removed on November 4, 2013, at 1:31 p.m., after the facilities removal plan was implemented and evaluated. The facility developed a plan to ensure staff immediately reported possible mistreatment or abuse. On November 1, 2013, at 4:30 p.m., the facility had an emergency and immediate in-service highlighting the importance to report allegations of abuse and neglect to the immediate supervisor, how the allegations will be investigated, the definitions of abuse/neglect and a detailed overview of abuse/neglect policy and procedures. Employees that were unable to attend the in-service received the in-service content before the start of their shift. A list of staff who completed the in-service was kept to ensure all staff received the information prior to working their assigned shift. The DON and administrator conducted monitoring rounds on all shifts on November 2, 3 and 4, 2013, to ensure the charge nurses were effectively managing, supervising and communicating with staff. A video monitoring system is used and viewed weekly for three months to ensure charge nurses are entering resident rooms and monitoring staff. To continue compliance, the facility will monitor abuse and neglect by randomly interviewing three staff members each month for six months to ensure all allegations of abuse and neglect are being reported and that reports are acted on consistent with the facility's policy and procedures. Additional training will be provided to the charge nurses regarding appropriate steps to take when allegations of abuse are reported. The facility will provide mandatory education regarding abuse/neglect annually for current staff. New employees will be required to receive the training prior to working in their job capacity. The scope and severity was lowered to no actual harm with potential for more than minimal harm that was not immediate jeopardy and was widespread. The facility's Abuse and Neglect Policy revised September 2013, identified the purpose of the policy was to assure that staff are knowledgeable regarding the reporting and investigative process of abuse and neglect allegations in the center. The policy identified "Alleged or suspected violations involving any mistreatment, neglect or abuse including injuries of unknown origin will be reported immediately to the administrator and to other officials in accordance with state law, including the state survey and certification agency." On October 8, 2013, nursing assistant (NA)-A provided a written statement in a resignation questionnaire that she witnessed a resident (R1) with behavioral issues be held down by a coworker (NA-B) and that many other staff members had complained and nothing had been done. After this information was received, on October 8, 2013, the social worker (SW) completed an Incident Details report and on October 8, 2013, registered nurse (RN)-A assessed R1 and observed the following bruises: Left upper outer arm, multiple bruises consistent with hand prints Right posterior arm large bruise brown/purple top of forearm to underneath arm solid bruise Reddened area tip of nose Right shin bruise, 1 centimeter (cm) x 1.3 cm upper middle - reddish purple Left posterior lower leg, 6.6 x 6.7 cm fading purple bruise Left posterior upper leg 1 x 2 cm brownish bruise Right posterior upper leg 2.1 x 2 cm brownish bruise Right hip 1 x 1 cm greenish bruise Right lower abdomen 0.4 x 0.5 cm greenish brown bruise Left posterior knee 4.9 x 2 cm purple brown bruise Left shoulder blade small scratch Left inner biceps 2.7 x 2.2 cm yellow green purple bruise Left upper arm 3.4 x 3.2 cm yellow outside purple inside bruise and a 1.7 x 1.1 cm brown bruise above the previous one Left upper outer arm 3 x 2 cm brownish purple bruise, and Left posterior upper arm 3.2 x 1.4 cm purple green bruise. R1's record review revealed documented entries in the Interdisciplinary Notes and documented weekly skin inspections by the licensed practical nurses (LPN) of bruising on the resident's upper and lower extremities from August 26, 2013, through October 8, 2013. There was no documentation that identified the administrator was notified immediately of the bruises or that the state agency was notified of the bruises. R1's record was reviewed and revealed that on August 26, 2013, the resident was identified with a reddened/purple area on the outer aspect of her left heel. On September 1, 2013, at 2:00 p.m., the licensed practical nurse (LPN)-A documented the resident had a reddish brown (bruise) areas on the top of her right foot and back of the great toe, and of the right armpit area. There were no measurements or further description of the injuries. On September 2, 2013, at 7:15 a.m., LPN-A documented a skin inspection was done, and that the brown coloration of the right great toe was fading. The documentation identified the arm pit area continued to be "dark" with small yellow around the edges. On September 8, 2013, at 9:15 p.m., LPN-B documented the resident had a bruise to the right arm biceps that extended almost the full length of the residents upper arm. There was no description or measurement of the bruise. On September 9, 2013, at 6:45 a.m., the weekly skin inspection by LPN-A identified the resident had a fading bruise of the right upper arm and right great toe. The resident also had a healed skin tear of the top of the right hand and knuckle. On September 11, 2013, at 2:30 a.m., LPN-C documented in the Interdisciplinary Progress Notes R1 had an old faded bruise on the backside of her right knee. The LPN documented the area was greenish on the outside with some purplish red in the inside measuring 8.5 centimeters (cm) by 3.5 cm. LPN-C also completed a Incident Details report that was reviewed and signed off by the director of nurses (DON) on September 14, 2013. On September 14, 2013, at 4:30 a.m., LPN-D documented in the Interdisciplinary Progress Notes R1 had a red area of the inner lower right leg that measured four cm. On September 16, 2013, at 7:20 a.m., LPN-A documented in the weekly skin inspection note that R1's brownish red (bruise) area of the right great toe, armpit and biceps had resolved and that the area on the residents right lower leg and ankle remained brownish in color. The documentation also identified the resident's left arm/hand grayish color had improved. On September 30, 2013, at 6:30 a.m., LPN-A documented R1 had a bruise that measured seven cm on the right lower arm. LPN-A completed a Incident Details report that LPN identified the bruise was due to combative behaviors. The DON signed the report on October 8, 2013. On interview during the onsite investigation on October 22, 2013, NA-D stated R1's left side was not as strong as her right side. NA-D oriented on the night shift with NA-B on September 2 and 3, 2013. NA-D observed NA-B hold R1 on her left side by holding R1's right arm with her hands and R1's right leg with her knees pressed on top of R1's leg and knee. NA-D stated NA-B held R1 with her hands so tight that NA-B's knuckles turned white. NA-D stated there were marks left on R1's right arm and leg when NA-B let go and that R1 had bruises on her arms and legs where NA-B held R1 down. NA-D stated she did not work with NA-B after orientation, but was concerned about the amount of bruises that R1 had. After her orientation NA-D reported to LPN-C and LPN-D that she thought NA-B was rough and was informed "ya, she can be stern." NA-D stated she asked LPN-D (date unknown) about the bruises on R1's right arm (Interdisciplinary Notes identified bruises to the right arm on September 8 and 30, 2013). NA-D stated LPN-D was aware NA-B held R1 down, "how could she not", as R1's right arm was "so bruised." NA-D stated LPN-D contributed R1's bruising to R1 doing it to herself. On interview with NA-A on October 30, 2013, NA-A stated she completed the evening/night shift rounds on one occasion with NA-B. NA-A was the evening worker and NA-B came to work the night shift. NA-A stated that immediately upon entering R1's room, NA-B physically put her knees on top of R1's legs and her arms on R1's arms. NA-A stated she was a fairly new employee, but had never seen R1 handled this way. NA-A was concerned and asked NA-C if she had witnessed this. NA-C responded that she had and that she had already reported the treatment to the charge nurse LPN-D. NA-A stated R1 did strike out with cares if not informed what cares were going to be done and if R1 was not given enough time. NA-A stated R1 had constant bruises on her arms and legs and thought the bruises on R1's legs were peculiar as R1 could not move her legs. NA-A stated R1 was angry when she was held down, that R1 seemed frustrated, would swear at NA-B and then R1 gave a "big sigh" and "gave up." NA-A also stated R1's bruises were "harsh - ugly color" and had bruises on her arms, forearms, legs and thighs. NA-A stated she did not report as she thought the nurses were aware, "how could they not." On interview with NA-C on October 31, 2013, NA-C stated she worked one night in September with NA-B(exact date unknown by NA-C; schedule identified on September 24, 2013, NA-C and NA-B worked the night shift). NA-C stated NA-B immediately held R1 down by putting her knee on R1's right knee and her hands around R1's forearms. NA-C stated she attempted at the time to intervene by telling NA-B "whoa, hold on, I don't think you need to hold her down so hard." NA-C stated R1 seemed afraid and R1 stated to NA-B "you are the devil, I can see it in your eyes." NA-C also stated R1 would say "Ouch, Ouch." NA-B responded to R1 "and you wonder why you are always bruised." NA-C stated R1's bed was at mid height so that NA-B would be able to put her knee on R1's right knee. NA-C stated R1's left side was weaker so R1's right side was held down harder. NA-C stated she reported to LPN-D, on the same night that she witnessed NA-B holding R1 down, that she thought NA-B was being more "rough" than she needed to be with R1. NA-C felt LPN-D ignored her and that LPN-D already knew that R1 was held down by NA-B. NA-C stated that since R1's [MEDICAL CONDITION], R1 was combative if not informed what cares were going to be done. NA-C stated NA-B did not explain cares, but immediately held R1 down. NA-C stated R1 had bruises on her arms and legs where NA-B held her down. On interview with LPN-D on October 22, 2013, LPN-D verified NA-C reported on the night that she worked with NA-B that NA-B was "rough" with R1. LPN-D verified she did not inquire what "rough" was, nor did she report the allegation of abuse immediately to the administrator or to the state agency. R2's record was reviewed and revealed that on September 20, 2013, at 7:30 a.m., the resident was observed to have a purple blue bruise on the right wrist that measured 3 cm x 3 cm, a purple blue bruise on the left wrist that measured 6 cm x 3 cm and a purple blue bruise on her right back calf that measured 4 cm x 3 cm. Although a Incident Detail report was completed on September 20, 2013, by LPN-C, there was no immediate report to the administrator or to the state agency of the bruises.

Based on interview and document review, the facility failed to ensure one of one resident (R1) who exhibited combative behaviors was not physically abused when the resident was restrained during incontinent cares. This failure resulted in harm for resident (R1) who sustained bruises of the arms, legs and thighs. The findings include: On October 8, 2013, nursing assistant (NA)-A expressed in a resignation questionnaire that she had witnessed a resident (R1) with behavioral issues be held down by a coworker (NA-B). NA-A documented that she and "many other staff members" had complained and nothing was done. R1's medical record revealed that R1 returned to the facility on [DATE], following hospitalization for a [MEDICAL CONDITIONS]. On August 12, 2013, documentation by the social worker in the Interdisciplinary Assessments and Summary Reviews identified R1 had a significant change in status due to left side weakness and that the resident was wheelchair bound since her return from the hospital. The documentation also identified R1 had become combative with staff since her return from the hospital. On August 12, 2013, the nursing narrative note in the Interdisciplinary Assessments and Summary Review identified R1 required assistance of one with dressing and personal hygiene and assistance of two staff with toileting and bed mobility. The resident was also identified to require the use of a mechanical device for transfers. The documentation identified the residents skin was intact, and that the residents skin is checked daily with cares and that a weekly skin inspection is done by a licensed nurse on bath day. The documentation also identified the resident had exhibited behaviors of occasional hitting and kicking staff with cares. On interview during the onsite investigation on October 22, 2013, NA-D stated R1's left side was not as strong as her right side. NA-D oriented on the night shift with NA-B on September 2 and 3, 2013. NA-D observed NA-B hold R1 on her left side by holding R1's right arm with her hands and R1's right leg with her knees pressed on top of R1's leg and knee. NA-D stated NA-B held R1 with her hands so tight that NA-B's knuckles turned white. NA-D stated there were marks left on R1's right arm and leg when NA-B let go and that R1 had bruises on her arms and legs where NA-B held R1 down. NA-D stated she did not work with NA-B after orientation, but was concerned about the amount of bruises that R1 had. After her orientation NA-D reported to LPN-C and LPN-D that she thought NA-B was rough and was informed "ya, she can be stern." NA-D stated she asked LPN-D (date unknown) about the bruises on R1's right arm (Interdisciplinary Notes identified bruises to the right arm on September 8 and 30, 2013). NA-D stated LPN-D was aware NA-B held R1 down, "how could she not", as R1's right arm was "so bruised." NA-D stated LPN-D contributed R1's bruising to R1 doing it to herself. On interview with NA-A on October 30, 2013, NA-A stated she completed the evening/night shift rounds on one occasion with NA-B. NA-A was the evening worker and NA-B came to work the night shift. NA-A stated that immediately upon entering R1's room, NA-B physically put her knees on top of R1's legs and her arms on R1's arms. NA-A stated she was a fairly new employee, but had never seen R1 handled this way. NA-A was concerned and asked NA-C if she had witnessed this. NA-C responded that she had and that she had already reported the treatment to the charge nurse LPN-D. NA-A stated R1 did strike out with cares if not informed what cares were going to be done and if R1 was not given enough time. NA-A stated R1 had constant bruises on her arms and legs and thought the bruises on R1's legs were peculiar as R1 could not move her legs. NA-A stated R1 was angry when she was held down, that R1 seemed frustrated, would swear at NA-B and then R1 gave a "big sigh" and "gave up." NA-A also stated R1's bruises were a "harsh - ugly color" and had bruises on her arms, forearms, legs and thighs. NA-A stated she did not report as she thought the nurses were aware, "how could they not." On interview with NA-C on October 31, 2013, NA-C stated she worked one night in September 2013 with NA-B(exact date unknown by NA-C; schedule identified on September 24, 2013, NA-C and NA-B worked the night shift). NA-C stated NA-B immediately held R1 down by putting her knee on R1's right knee and her hands around R1's forearms. NA-C stated she attempted at the time to intervene by telling NA-B "whoa, hold on, I don't think you need to hold her down so hard." NA-C stated R1 seemed afraid and R1 stated to NA-B "you are the devil, I can see it in your eyes." NA-C also stated R1 would say "Ouch, Ouch." NA-B responded to R1 "and you wonder why you are always bruised." NA-C stated R1's bed was at mid height so that NA-B would be able to put her knee on R1's right knee. NA-C stated R1's left side was weaker so R1's right side was held down harder. NA-C stated she reported to LPN-D, on the same night that she witnessed NA-B holding R1 down, that she thought NA-B was being more "rough" than she needed to be with R1. NA-C felt LPN-D ignored her and that LPN-D already knew that R1 was held down by NA-B. NA-C stated that since R1's [MEDICAL CONDITION], R1 was combative if not informed what cares were going to be done. NA-C stated NA-B did not explain cares, but immediately held R1 down. NA-C stated R1 had bruises on her arms and legs where NA-B held her down. On interview with LPN-D on October 22, 2013, LPN-D verified NA-C reported on the night that she worked with NA-B that NA-B was "rough" with R1. LPN-D verified she did not inquire what "rough" was, nor did she report the allegation of abuse immediately to the administrator or to the state agency. R1's record revealed that on September 1, 2013, at 2:00 p.m., the licensed practical nurse (LPN)-A documented the resident had a reddish brown (bruise) areas on the top of her right foot and back of the great toe, and of the right armpit area. There were no measurements or further description of the injuries. On September 2, 2013, at 7:15 a.m., LPN-A documented a skin inspection was done, and that the brown coloration of the right great toe was fading. The documentation identified the arm pit area continued to be "dark" with small yellow around the edges. On September 8, 2013, at 9:15 p.m., LPN-B documented the resident had a bruise to the right arm biceps that extended almost the full length of the residents upper arm. There was no description or measurement of the bruise. On September 9, 2013, at 6:45 a.m., the weekly skin inspection by LPN-A identified the resident had a fading bruise of the right upper arm and right great toe. The resident also had a healed skin tear of the top of the right hand and knuckle. On September 11, 2013, at 2:30 a.m., LPN-C documented in the Interdisciplinary Progress Notes R1 had an old faded bruise on the backside of her right knee. The LPN documented the area was greenish on the outside with some purplish red in the inside measuring 8.5 centimeters (cm) by 3.5 cm. LPN-C also completed a Incident Details report that was reviewed and signed off by the director of nurses (DON) on September 14, 2013. On September 14, 2013, at 4:30 a.m., LPN-D documented in the Interdisciplinary Progress Notes R1 had a red area of the inner lower right leg that measured four cm. On September 16, 2013, at 7:20 a.m., LPN-A documented in the weekly skin inspection note that R1's brownish red (bruise) area of the right great toe, armpit and biceps had resolved and that the area on the residents right lower leg and ankle remained brownish in color. The documentation also identified the resident's left arm/hand grayish color had improved. On September 30, 2013, at 6:30 a.m., LPN-A documented R1 had a bruise that measured seven cm on the right lower arm. LPN-A completed a Incident Details report that LPN identified the bruise was due to combative behaviors. The DON signed the report on October 8, 2013. On October 8, 2013, after receiving the resignation questionnaire from NA-A, an Incident Details report was completed by the social worker (SW). The report identified "possible abuse to resident (R1) by another coworker (NA-B)". On October 8, 2013, following the report of possible abuse, R1 was assessed by registered nurse (RN)-A and the following bruises were observed: Left upper outer arm, multiple bruises consistent with hand prints Right posterior arm large bruise brown/purple top of forearm to underneath arm solid bruise Reddened area tip of nose Right shin bruise, 1 centimeter (cm) x 1.3 cm upper middle - reddish purple Left posterior lower leg, 6.6 x 6.7 cm fading purple bruise Left posterior upper leg 1 x 2 cm brownish bruise Right posterior upper leg 2.1 x 2 cm brownish bruise Right hip 1 x 1 cm greenish bruise Right lower abdomen 0.4 x 0.5 cm greenish brown bruise Left posterior knee 4.9 x 2 cm purple brown bruise Left shoulder blade small scratch Left inner biceps 2.7 x 2.2 cm yellow green purple bruise Left upper arm 3.4 x 3.2 cm yellow outside purple inside bruise and a 1.7 x 1.1 cm brown bruise above the previous one Left upper outer arm 3 x 2 cm brownish purple bruise, and Left posterior upper arm 3.2 x 1.4 cm purple green bruise. R1 was not interviewed at the time of the site visit.