Every finding on record at Graham Hospital

Based on observation, interview, and record review the facility failed to implement physician ordered pressure relieving interventions to prevent the development of pressure ulcers and failed to initiate a pressure ulcer care plan as soon as a pressure ulcers were identified for one of one resident (R1) reviewed for pressure ulcers in the sample of 21. These failures resulted in R1 developing a stage two facility acquired pressure ulcer to the right gluteus and a stage four pressure ulcer to the right base of the big toe that required mechanical debridement. The facility's Skin Assessment, Wound Prevention, and Care Policy dated 4/2025 documents, (The facility) shall provide care, treatment, and services to: 1. Identify those at risk for skin breakdown. 2. Promote comfort and mobility. 3. Reduce or relieve pressure and maintain skin integrity. 4. Provide appropriate interventions to manage pressure ulcers and minimize infection. 5. Provide learning opportunities. Prevention of skin breakdown is primarily a nursing responsibility. The most effective means of preventing skin breakdown or relief of pressure on the skin, maintenance of adequate circulation, hydration, and an adequate diet. Staff should educate the patient and family regarding the importance of repositioning and proper way to change positions. Staff should remind patients to shift their weight every 15 minutes while sitting in a chair and to change position regularly. Staff should encourage patients to maintain or increase mobility or activity as appropriate. Staff should monitor the patient's frequency of repositioning. Patients who are dependent on the staff for repositioning: a. Reposition the patient every two hours as needed, depending on the patient's condition. Minimize shearing and friction on the skin when cleansing, providing care, or moving the patient. b. Use mechanical loading, support surfaces, and repositioning devices. 3. Preventative interventions for all patients at risk: b. Place a pillow under the patient's legs, suspending the heels, to decrease the pressure placed on the patient's heels. c. Encourage and assist with repositioning every two hours and as needed. f. Avoid layers of padding between patient's skin and relief surface. k. Evaluate and document preventative interventions. 5.Interventions shall be incorporated into the patient's plan of care, via automated process based on nursing evaluation. Nursing shall continue to evaluate and revise as the condition of the patient indicates. A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction. Stage Two Pressure Ulcer is partial loss of dermis presented as a shallow open ulcer with a red, pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. Stage Four Pressure Ulcer is full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (black or brown layer of dead tissue) may be present on some parts of the wound bed. Often include undermining and tunneling. Stage Four ulcers can extend into muscle and/or supporting structures make osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.R1's most recent MDS (Minimum Data Set) assessment dated [DATE] documents R1 was cognitively intact, was dependent on staff for toileting, rolling left and right, and personal hygiene, was at risk for developing pressure ulcers, had a stage II facility acquired pressure ulcer, and was on a turning-repositioning program.R1's Wound Clinic Notes dated 3/19/26 documents, Wound: Right Gluteus Pressure Injury. Primary Dressing Xeroform (Petroleum Based Dressing). Wound Measurements 4.2 cm (centimeters) by 5.0 cm by 0.1 cm. Stage Two. Date Acquired 7/29/25. Wound: Right Foot Pressure Ulcer. Date Acquired 10/20/25. Wound measurements 0.6 cm by 0.6 cm by 0.1 cm. Stage Four. Necrotic 67-100 percent. Eschar. Open wound debridement. Off-loading: Right Gluteus and Right Foot: (pressure relieving) cushion to wheelchair, turn and reposition every two hours, and heel protectors at all times. Primary Dressing Xeroform.R1's current Care Plan documents, Active 7/20/25 high risk for impaired skin integrity. This same Care Plan does not include pressure relieving interventions or interventions to address R1's current pressure ulcers to the right gluteus and right foot, or pressure relieving interventions to prevent pressure ulcers prior to R1's pressure ulcer development to the right gluteus or right foot.R1's Electronic Care Charting dated 3/30/26 from 7:00 AM through 1:12 PM, was documented as R1 remained in the same seated position in a chair for the entire time period. This same documentation indicated R1 did not refuse turning and repositioning during this timeframe.R1's Electronic Care Charting dated 3/31/26 from 7:00 AM through 10:58 AM, was documented again as R1 remained in the same seated position in a chair throughout the entire time period, with no documentation indicating R1 refused repositioning.On 3/30/26 from 10:30 AM through 12:50 PM and 3/31/26 from 10:15 AM through 1:15 PM, R1 was seated in a padded wheelchair in the dining room with bilateral heels resting on the wheelchair footrests. R1 was not wearing heel protector boots during these timeframes.On 3/31/26 at 1:30 PM R1 was lying in bed on her right side. R1 did not have on heel protector boots. V13 (Agency Registered Nurse) provided wound cares to R1's right gluteus pressure ulcer and R1's right base of the big toe pressure ulcer. R1's right gluteus pressure ulcer was pink, and dime sized. R1's pressure ulcer to the base of the right big toe was approximately 0.5 cm red and covered with a hardened yellow scab.On 3/30/26 at 10:15 AM R1 stated, The sores on my foot and butt are bedsores from lying in bed too long.On 3/31/26 at 11:10 AM V2 (Director of Nursing) stated, I know (R1) has a physician's order somewhere to be turned and re-positioned every two hours. Turning and repositioning every two hours is our (facility staff's) standard. (R1's) care plan does not include pressure relieving interventions to prevent pressure ulcers or current interventions to address (R1's) pressure ulcers. I have worked here since January 2026 and have not had time to update (R1's) care plan. (R1's) wounds to the right gluteus and right foot were caused by pressure.On 3/31/26 at 1:36 PM V17 (CNA/Certified Nursing Assistant) stated, (R1) is not on a turning and repositioning program. (R1) sits up all day long and then lies down later in the afternoon. (R1) does not wear heel protector boots throughout the day. We (the facility) only put (R1's) heel protectors on at night.On 3/31/26 at 2:30 PM V18 (Wound Nurse Practitioner) confirmed R1 has orders to be turned and repositioned every two hours and should be wearing heel protector boots at all times. V18 confirmed R1's wounds to the right gluteus and base of the right big toe were caused by pressure and were facility acquired.

Based on interview and record review the facility failed to ensure residents' comprehensive care plans were individualized to reflect each resident's specific needs, conditions, and preferences. This failure affects all 21 residents who reside at the facility. Findings include: The facility's Care Plan Policy revised 3/10/25 documents the individualized care plan is used to outline the care in which the patients shall receive during their stay. A plan of care which defines patient or family outcomes within a pre-established time frame, prompting continuity of care using interventions to meet expected outcomes. The documented plan of care is based on the patient's goals and time frames, settings, and services required to meet those goals. Goals need to be realistic, individualized, patient centered, measurable, dated, the care plan needs to be reviewed daily to determine if goals are being met. The facility's Patient/Resident Care Plan and Care Conference revised September 2025 documents Patients/residents shall have an individualized care plan. The resident care plan helps to provide quality patient/resident care. The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility. On 4/01/2026 at 9:40 AM, V2 (Director of Nursing) stated he is responsible for initiating and revising care plans for all residents in the facility. V2 reported he develops comprehensive care plans based on resident diagnoses and revises them as new diagnoses are identified. V2 further stated he does not have the capability within the facility's electronic medical record system to customize interventions for individual residents, and they plan to eventually switch to a new system better suited for long term care. V2 confirmed that all 21 residents currently residing in the facility do not have individualized interventions reflected in their care plans.

Based on observation, interview, and record review the facility failed to ensure sanitary conditions were maintained during food preparation and service to prevent cross-contamination and foodborne illness, in accordance with professional standards for food safety. This failure has the potential to affect all 21 residents who reside at the facility.Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility.On 03/30/2026 at 11:05 AM, V8 (Cook) was observed cleaning main food preparation areas with a wash rag while food on the steam table remained uncovered. The same wash rag was placed on the counter and subsequently used to clean a food thermometer between temperature checks of the food on the steam table. During continued observation, V8 was observed wiping sauce from the lasagna with her fingers onto the same wash rag used to clean the counters and thermometer. When checking hamburger temperatures, the initial holding temperature was 142 F, V8 stated the hamburgers would be returned to the steamer for reheating. V8 handled the pan using the same contaminated wash rag and placed the rag back on the counter. At no time during the observation did V8 perform hand hygiene or don gloves. V8 continued to use the same wash rag for cleaning surfaces and the thermometer throughout food handling activities.On 03/31/2026 at 8:10 AM, V11 (Dietary Supervisor) stated that staff are expected to perform hand hygiene and wear gloves when handling food. V11 further stated that thermometers should be cleaned between uses with an alcohol swab.On 03/31/2026 at 9:40 AM, V15 (Dietary Director) stated that if a wash rag is used for cleaning a thermometer, it should be clean and used for a single purpose only. V15 confirmed that V8 should have performed hand hygiene, worn gloves, and not used the same rag for multiple tasks. V15 further stated the facility does not have a policy or procedure to guide staff on proper techniques for obtaining food temperatures.

Facility failures resulted in two deficient practices.A. Based on interview and record review, the facility failed to establish and maintain an effective infection prevention and control program by failing to perform surveillance to track and monitor residents and staff illnesses and differentiating between resident facility-acquired and community acquired infections. This failure has the potential to affect all 21 residents residing in the facility.B. Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions while providing incontinent cares for one of 12 residents reviewed for infection control practices in the sample of 21.Findings include:A. The facility's Infection and Prevention Control Program Plan, dated March 2024, documents Policy: Based on current scientific knowledge, accepted practice guidelines, and applicable law and regulations, the hospital shall provide written policies and procedures related to Infection Control, surveillance and prevention for all departments of the organization. To assist in the prevention of the transmission of infections the entire staff is responsible for adhering to policies and procedures related to infection control. 6. Goals and Function: b. To conduct a surveillance program of infections with the Hospital through the collection and analysis of data that is meaningful in the prevention of the spread of infections. 7. Infection Control Professional: a. A Registered Nurse with knowledge of epidemiology practices, microbiology, and infectious disease, who has completed or shall complete a course in Infection control approved by the Center for Disease Control (CDC) and directs the Infection Control Program. c. Responsibilities: vii. Approves actions to prevent or control infection based on evaluation of surveillance reports of infections and of the infection potential among patients and hospital personnel. x. Coordinator of Employee Health to protect patients and employees. 8. Surveillance/Healthcare Acquired Infections and Healthcare Acquired Conditions: a. Total house surveillance is conducted and monitored weekly. Surveillance of infections, both community acquired, and healthcare acquired infections/conditions, is conducted to identify baseline information about the frequency and type of endemic infections in order to permit rapid identification of deviations from the baseline. 9. Reporting of Employee Health: a. All employee absences are reported to the Infection Control /Employee Health coordinator. This information is used to assess for potential areas of an outbreak. b. The Employee Health Report contains data that is pertinent to all immunization and vaccination compliance, exposures, employee illness, any other pertinent data and is given to the Director of Human Resources upon completion of new employee immunization completion and upon request. The facility's Infection Prevention Surveillance Policy, dated May 2024, documents Policy: Concurrent and retrospective review will be used to accomplish surveillance of the Hospital regarding infection disease in order to: 1. Identify- a. Unusual Pathogens, b. Any occurrence of hospital acquired infection, c. Hospital Acquired Infections that exceed the usual baseline levels, d. Clusters of Infections, and e. Epidemics. 2. Review and evaluate data trend analysis generated by surveillance activities. 3. Recommend and institute intervention strategies when appropriate to reduce the risk of future occurrence. 4. Monitor effectiveness of prevention or intervention strategies in reducing hospital acquired infection risk. 5. Sources of data shall be: a. Daily statistics report, b. census and bed availability report, c. diagnosis defining risk patient, d. isolation, e. elevated temperatures, f. respiratory difficulty, g. wounds, h. diarrhea, i. rash. 6. Microbiology and serological data: a. medical records, b. temperature records, c. progress notes, d. medication record, e. laboratory data, f. radiographic data. 8. Collected data shall be recorded and tabulated as to site, service, unit location, physician(s), risk factors, pathogens, and treatment. Sites of infections reported will be urinary tract, respiratory tract, (Eyes, Ears, Nose, Throat, Mouth, and Lower), circulatory (Systemic and localized), surgical wound, (superficial incision, deep incision, and organ/space), skin/soft tissue, reproductive tract, gastrointestinal tract, bone/joint and undetermined. The Investigation Protocol for Infection Surveillance, dated May 2024, documents Policy: The Hospital shall investigate infections and determine the following: Appropriate isolation is being employed, staff are observing isolation precautions, staff are employing appropriate work practice controls to prevent transmission, patients are on the proper antibiotic regimen for the pathogen per susceptibility, staff are well and have no contagious symptoms present. On 3/31/26 at 12:02 PM the facility's infection control surveillance logs were all reviewed from January 1st, 2026, through March 31st, 2026, and does not contain a tracking log of resident illnesses or employee illnesses, nor does it include whether residents' illness were facility or community acquired. On 3/31/26 at 12:20 PM, the V4 (Infection Control Nurse) who has held the position since July 2025, stated she has not been tracking employee illness since she has started the position. V4 stated, I was told to no longer track employee illnesses because we (the facility) are not allowed to ask why the staff called in. V4 verified, while an antibiotic tracking log is maintained for residents each month, it does not consistently specify whether a resident's infection was house-acquired or community acquired, nor does it include a comprehensive record of all resident illnesses other than infections that are being treated with an antibiotic. B. The facility's Enhanced Barrier Precautions policy dated 3/2025 documents, In addition to Standard Precautions, use of Enhanced Barrier Precautions for specified patients in the Skilled or Long Term area who have a colonized MDRO that they are not in contact isolations for, have an indwelling device, or have an acute or chronic wound. 3. Personal Protective Equipment: a. Gown and gloves are required to be worn when performing high contact cares for residents. These include dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs while assisting with toileting, device care, and wound care. A gown and gloves will be worn when working with patients who are in Enhanced Barrier Precautions while in their room or in the therapy gym. R1's current Physician's Orders documents an order to place R1 in Enhanced Barrier Precautions. These same orders document R1 has an indwelling urinary catheter and wounds to the right foot and right gluteus. On 03/30/2026 at 10:15 AM R1 had a sign located on her doorway that indicated R1 was placed in Enhanced Barrier Precautions. R1 was in bed lying on her right side. V5 (CNA/Certified Nursing Assistant) and V6 (CNA) were providing incontinent cares. R1 had a bowel movement in her adult brief. V5 and V6 had gloves on but did not have gowns on while providing R1's incontinent cares. On 3/30/26 at 10:30 AM both V5 and V6 verified they were not wearing gowns while providing incontinent cares for R1. V5 stated, We did not have time to put on gowns. On 3/30/26 at 2:00 PM V4 (Infection Control Nurse) stated all employees providing direct cares to any resident placed in Enhanced Barrier Precautions should be wearing gowns and gloves while providing direct cares.

Based on interview and record review, the facility failed to ensure the designated Infection Preventionist completed specialized Infection Prevention and Control (IPC) training prior to performing the role. This failure has the potential to affect all 21 residents residing in the facility. Findings include:The facility's CMS (Centers for Medicare and Medicaid Services) Form 671 dated 3/30/26 and signed by V1 (Administrator) documents 21 residents reside within the facility.The facility's Infection and Prevention Control Program Plan, dated March 2024, documents Policy: Based on current scientific knowledge, accepted practice guidelines, and applicable law and regulations, The hospital shall provide written policies and procedures related to Infection Control, surveillance and prevention for all departments of the organization. To assist in the prevention of the transmission of infections the entire staff is responsible for adhering to policies and procedures related to infection control. 7. Infection Control Professional: a. A Registered Nurse with knowledge of epidemiology practices, microbiology, and infectious disease, who has completed or shall complete a course in Infection control approved by the Center for Disease Control (CDC) and directs the Infection Control Program.On 3/31/26 at 12:07 PM V1 (Administrator) stated V4 (Infection Control Nurse) has not completed the Infection Prevention and Control training to her knowledge. V1 is unable to provide a certification of completion for Infection Prevention and Control for V4/Infection Preventionist. On 3/31/26 at 12:20 PM V4 (Infection Control Nurse) stated she has been the Infection Preventionist since July 2025 and has yet to complete the required Infection Preventionist training. V4 stated, I started to complete some of the infection control modules, but since I didn't complete them all I never received a certification of completion.

Based on observation, interview, and record review, the facility failed to ensure a resident's indwelling urinary catheter bag was covered to maintain the resident's dignity for one of one resident (R19) reviewed for dignity in a sample of 21.Findings include:The Illinois Long-Term Care Ombudsman Program Resident Rights Booklet, dated 11/18, documents Your rights to dignity and respect: Your facility must treat you with dignity and respect and must care for you in a manner that promotes your quality of life.R19's MDS (Minimum Data Set) Assessment, dated 3/26/26, documents R19 is severely cognitively impaired and has an indwelling catheter. R19's Physician Orders, dated 3/13/26, indicates R19 has an indwelling urinary catheter. On 3/30/26 at 10:27 AM R19 was sitting in her recliner in her room with the door open. R19's urinary catheter drainage bag was observed hanging on the side of R19's bed (facing the door) and was not covered by a dignity bag. The drainage bag was one fourth full of yellow urine. On 3/31/26 at 11:42 AM V1 (Administrator) stated R19's urinary catheter bag should be covered with a dignity bag if able to be seen from R19's room. V1 stated, I know we have the privacy bags to cover urinary catheter drainage bags. I am not sure why (R19) did not have a privacy bag covering her catheter bag.

Based on observation, interview, and record review the facility failed to accurately code the MDS (Minimum Data Set) Assessments for two of two residents (R5 and R8) reviewed for MDS Accuracy in the sample of 21. Findings Include: CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual Section P: Restraints and Alarms dated 10/2025 documents, 'Intent: The intent of this section is to record the frequency that the resident was restrained by any of the listed devices or an alarm was used, at any time day or night, during the seven-day look-back period. Assessors will evaluate whether or not a device meets the definition of a physical restraint or an alarm and code only the devices that meet the definitions in the appropriate categories. 1.R8's current Physician's Order dated 3/16/26 documents R8 utilizes bilateral upper side rails for positioning and bed mobility. R8's MDS assessment dated [DATE] documents R8 is cognitively intact and uses bedrails as a restraint daily. On 3/30/26 at 10:00 AM R8 stated she uses her side rails to position herself in bed. R8 stated her side rails do not restrain her. 2. R5's current Physician Orders dated 3/16/26 documents R5 utilizes bilateral upper side rails for positioning and bed mobility. R5's MDS Assessment (dated 3/18/26), documents R5 is moderately cognitively intact and uses side rails as a restraint daily. On 3/30/26 at 2:35 PM V2 (Director of Nursing) stated R5 and R8 use side rails for positioning. V2 stated R5 and R8's side rails are not being utilized as restraints. On 3/30/26 at 2:45 PM V10 (MDS Coordinator) stated, I have not received any formal training regarding coding section P Restraints of the MDS. I have been doing MDS Assessments since January 2026. (R5) and (R8) do not use side rails as restraints. (R5) and (R8's) Section P of their MDS Assessments are inappropriately coded.

Based on observation, interview, and record review the facility failed to develop and implement a restorative range of motion program for one of one resident (R6) reviewed for limitations in range of motion in the sample of 21.Findings include:The facility's Restorative Range of Motion Policy dated 2/2026 documents, The restorative Range of Motion program shall provide the patient with the assistance required to maintain and improve joint mobility and promote a greater sense of well-being, thus assisting in the prevention of contractures, pain, and edema. Objectives: 1.To maintain and improve range of motion to an extremity that has decreased ability and movement. 2. To prevent a decrease in patient mobility due to loss of ROM (Range of Motion). 3. To increase joint flexibility, thus leading to greater ease of ADLS (Activities of Daily Living) and transfers. A physician's order shall not be required for initial assessment of the Restorative Nurse Assistant program but shall be required for establishing treatment. The program shall be conducted by a Restorative Nurse on a one-to-one basis with the patient.R6's MDS (Minimum Data Set) assessment dated [DATE] documents R6 is severely cognitively impaired, has functional limitations in range of motion to one side of the upper extremity and one side of the lower extremity, is dependent on staff for ADLs (Activities of Daily Living), and receives no restorative nursing programs, including range of motion programs.R6's current Care Plan documents R6 has a diagnosis of CVA (Cardio-Vascular Accident) with Right Sided Sensory Deficit. This same Care Plan documents R6 has a problem of impaired mobility as evidenced by compromised ability to move, range-of-motion limitation, decreased muscle strength, impaired coordination, imposed restriction of movement, and reluctance to move. This same Care Plan does not include any restorative programs to address R6's impaired mobility.On 3/31/26 at 9:45 AM R6 was sitting in a wheelchair in his room. R6's right arm and right leg were flaccid. V13 (Agency Registered Nurse) stated, (R6) had a stroke and is unable to move his right arm or right leg.On 3/30/26 at 1:30 PM V14 (R6's Private Caregiver) stated, I am here almost every day to help take care of (R6) as a private sitter. I have never seen any staff do range of motion with (R6).On 3/30/26 at 3:44 PM V2 (Director of Nursing) stated, (R6) does not get any type of restoratives or range of motion exercises. We (the facility) do not have a restorative nurse that does assessments or establishes restorative programs for the residents.

Based on observation, interview, and record review, the facility failed to assess and identify entrapment risk associated with the use of side rails and document alternatives to side rails with outcomes prior to installing side rails for one of two residents (R5) reviewed for side rail use in a sample of 21.Findings include:The facility's Side Rails and Entrapment Policy, dated February 2026, documents, Policy: It is the policy of this facility to identify and reduce safety risks and hazards commonly associated with bed rail use. A duo-faceted approach shall be used to achieve sustainable quality outcomes, including 1) regular bed maintenance and 2) individual bed rail evaluations. In response to the requirement of providing for a safe, clean, comfortable, and homelike environment, the facility's regular preventative maintenance program shall include regular inspection of all bed systems (rails, frames and mattresses, and operation components) to ensure they are clean, comfortable, and safe. The facility shall also ensure individual resident bed rail evaluations are performed on a regular basis. Individual bed rail evaluations shall include data collection analysis and determination of potential alternatives to bed rail use. When bed rail(s) are deemed necessary and appropriate, the facility shall provide education to residents or resident's representative pertain to the risk and benefits of bed rail use. The facility's priority is to ensure safe and appropriate bed rail use. Purpose: The purpose of this policy is to assist resident representatives, physicians and facility staff to determine if resident use of side rails is safe and appropriate. The Interdisciplinary Team shall use data collected from regular bed inspections and induvial side rails assessments and evaluations to assist in care planning and positive resident outcomes. Definitions: Bed Rail: (also referred to as side rails, bed side rails, and safety rails are constructed of metal or rigid plastics and are available in various sizes including full length rails, half rails, and quarter rails to align with resident-specified needs. Bed rails may be positioned in various locations on the bed including upper or lower, either or both sides. No matter what the purpose for the use, bed rails and other bed accessories including transfer bars, trapeze, bed enclosures, although prescribed to include functional independence with bed mobility and transfers, may increase resident safety risk. Entanglement: TH estate of body or limb, being wrapped or twisted in any tubing, cords, cables and wires. Entrapment: The state of body or limb being caught, trapped or entangled such as in the space in or about the bed rail, mattress or bed frame. Procedure: 1. Resident Assessment: iv. Assessment of need for special equipment or accessories: 1. Assess resident to identify appropriate alternatives prior to installing bed rails or other bed mobility devices, 2. Assess resident for risk of entrapment from bed rails prior to installation, 3. Review risk and benefits with resident and representative. 2. This facility utilizes all alternative processes to minimize/eliminate the use of all physical side rails including bed rails, side rails and mobility enhancers. Staff shall implement alternatives prior to implementing a restraint.R5's Physician Order's, dated 3/30/26, documents the following, but not limited to diagnoses: Anxiety with Depression, History of Completed Stroke, General Weakness, Fall Downstairs, Strain of Left Elbow, and Neck Muscle Strain. These same Physician Orders document the following physician order Start date: 3/16/26-Bilateral Upper Rails. Reason for side Rail use: Positioning/Bed Mobility, get in and out of bed, and spatial awareness.R5's MDS (Minimum Data Set) Assessment, dated 3/18/26, documents R5 is moderately cognitively impaired, requires dependent assistance with rolling side to side and transfers, and uses side rails daily.R5's Medical Record does not include a side rail assessment to assess and identify entrapment risk associated with the use of side rails or documented alternatives tried prior to the implementation of side rails. On 3/30/26 at 10:15AM, R5's bed had bilateral quarter side rails in an upright position. On 3/30/26 at 2:30 PM V2 (Director of Nursing) verified R5 did have side rails and verified a bed rail assessment had not been completed along with documented alternatives prior to the implementation of side rails. V2 stated, We do not do side rail assessments or try alternatives prior to implementing the side rails on the skilled care unit.

Based on observation, interview and record review, the facility failed to use temperature testing strips to ensure dishes reach the required surface temperature during the rinse cycle in the dish machine, failed to ensure hanging light covers over the kitchen's fryer baskets were clean and free of debris and grime, and failed to complete and record cool down temperatures for prepared meats and leftover items that were prepared ahead and stored in the facility's refrigerator and freezer for future use. These failures have the potential to affect all 22 residents residing in the facility. Findings include: 1.) The facility's Washing and Storage of Dishes and Utensils policy, dated 4/2024, documents The dish machine water temperatures are as follows: Wash cycle: 150 to 165 degrees. Rinse cycle: 160 to 180 degrees. Final Rinse cycle: 180 to 195 degrees. If the proper temperatures are not met, the management team is notified. On 12/16/24 at 10:20 AM V5 (Dietary Manager) ran a temperature test cycle on the facility's dish machine. V5 stated the facility's dishwasher is a high temperature machine and has to reach a temperature of 185-200 degrees. V5 stated the kitchen staff check the temperature on this machine everyday by the gauge on the outside of the machine. V5 stated They record the temperature on the outside to ensure its correct. We do not use the test strips anymore or run anything through the cycle to check the surface temperature. We used to do that but have not used those in a while. I have a few strips, but staff do not use them. On 12/18/24 at 8:58 AM V11 (Director of Plant Operations) provided the facility's dishwasher manual. V11 stated They (dietary staff) should be checking the water cycle temperature with the strips they can run through the machine every day. The strips turn black when the water gets to the correct temperature. They should be checking that daily and I am not sure why they would've stopped. 2.) The facility's Patient [NAME] Cleaning Checklist dated 12/15/24-12/28/24, documents multiple areas in the kitchen that are to be cleaned by kitchen staff but does not include a cleaning schedule for lights located above the kitchen's fryer baskets. On 12/16/24 at 10:15 AM, two hanging lights with black metal grids over the bulbs, located under the kitchen's fryer hood, both were coated with grease and caked on grime containing small fuzzy hair like fibers and debris. Both lights hang directly over the fryer baskets used to prepare food. At this time V5 (Dietary Manager) stated the stove hood and fryer hood are cleaned by an outside cleaning company. On 12/17/24 at 11:20 AM, both lights above the kitchen's fryer baskets were noted to still contain caked on debris and hair like fuzz. On 12/17/24 at 11:25 AM, V5 confirmed the lights above fryer baskets are caked with debris and stated I am not sure who cleans the lights over the fryer. We (kitchen staff) usually come in and those things are just clean. On 12/18/24 at 8:58 AM V11 (Director of Plant Operations) stated The hood above the stove and the fryer are cleaned every four months by (a contracted cleaning company). The lights above the fryers are not a part of that cleaning process so I would say those would need cleaned by the (facility's) kitchen staff. 3.) The facility's Patient Food Services policy, dated 7/2024, documents Purpose: To assure proper and safe food handling, storage, delivery and preparation. This same policy documents Proper heating and cooling temperatures are followed using the HACCP (Hazard Analysis and Critical Control Point) procedure on the recipe. The facility's (undated) HACCP Cooling log documents Daily cooling log for hot potentially hazardous foods. From 135 degrees to 70 degrees within two hours and 70 degrees to 40 degrees or below in an additional four hours. Take corrective action immediately if food is not chilled from 135 degrees to 70 degrees within two hours. Take immediate corrective action if food is not chilled from 135 degrees to 40 degrees within the six-hour cooling process. This log documents blank areas for facility kitchen staff to record the date, time, food item, starting temperature, first reading (temperature) within two hours and second reading less than four hours from the first reading. On 12/16/24 at 10:10 AM, the facility's walk-in refrigerator and freezer contained several metal pans covered with aluminum foil and food labels including but not limited to Beef tamale pie, Taco meat, Chicken and wild rice soup, Meatloaf, Turkey, and Roast Beef. At this time V5 (Dietary Manager) stated they do not keep a cool down log for hot foods when placing them in a cooler or freezer. V5 stated The freezer food is mostly leftovers that we can make into pureed foods. When we cook a turkey, it will be cooked, placed in the cooler to cool down then sliced and placed in the freezer. We do not have any cool down logs to show the temperatures of these foods in the cooling process. I think we did that at one time, and it's been something that we went away from or stopped for some reason. Any leftovers or cooked items that are placed in the fridge or freezer do not have cool down logs. We don't do those and haven't for a while. The facility's Long Term Care Application for Medicare and Medicaid dated 12/16/24 and signed by V1 (Administrator) documents 22 residents reside in the facility.

Based on observation, interview, and record review the facility failed to develop and implement restorative programming for five of six residents (R5, R9, R11, R13, and R15) reviewed for limitations in range of motion in the sample of 21. Findings include: The facility's Restorative Activity Aide Job Description (undated) documents, The restorative aide will perform specialized restorative nursing and activities of daily living activities for residents, assess and documents the resident's response and assist the nursing staff as directed. Primary Duties and Responsibilities: 1. Is responsible to perform specific restorative nursing procedures. (Example: Exercises, ambulation, and assistance with ADLs (Activities of Daily Living), to residents as directed by the MDS (Minimum Data Set) Coordinator. 2. Is responsible to keep daily performance records on residents receiving restorative nursing procedures. Reporting to MDS Coordinator daily refused treatments, omitted treatments, or other adverse observations. 3. Is responsible to document weekly progress notes and present them to the MDS Coordinator for review. 9. Assists residents with range of motion exercises, walking, and other therapies as ordered. 1. R5's MDS (Minimum Data Set) Assessments dated 11-6-24 and 8-6-24 documents R5 is severely cognitively impaired, has an impairment in range of motion to one side of the lower extremity, and does not receive passive or active range of motion restorative programs or therapy. R5's current Impaired Mobility Care Plan documents, Outcome: (R5) will improve right knee range of motion through the next review date. Approach: (R5): Actively assist (R5) to perform ten repetitions of range of motion to both knees at least twice daily while sitting in wheelchair. R5's Restorative Active Range of Motion Program logs dated 10-1-24 through 12-18-24 documents, Problem: Impaired mobility due to Parkinsonism and past right hip fracture as evidenced by weakness, stiffness, and limited mobility. Approach: Actively assist (R5) to perform ten repetitions of range of motion to both knees at least twice daily while sitting in wheelchair. Stretch his right leg after range of motion by placing right heel on chair in front of him for five minutes. These same logs document R5 has not received range of motion as directed for 53 days between 10-1-24 through 12-18-24. On 12/16/24 at 11:03 AM V8 (R5's Family Member) stated, I visit (R5) every other day. I have never witnessed the staff do range of motion with (R5). (R5) fell and broke his femur in the past. I would like the staff to do range of motion with (R5) to help (R5) gain strength. 2. R11's MDS assessment dated [DATE] documents R11 is cognitively intact, has impairments in range of motion of both sides of the lower extremities, and does not receive passive or active range of motion restorative programs or therapy. R11's current Impaired Mobility Care Plan documents, Outcome: (R11) will maintain lower extremity range of motion to prevent hip and knee contractures through the next review date. Intervention: Perform range of motion to exercises eight to ten repetitions of range of motion to both shoulders, elbows, wrists, hips, knees, and ankles at least twice daily. R11's Restorative Active Range of Motion Program logs dated 10-1-24 through 12-18-24 documents, Problem: Impaired mobility due to arthritis, diabetes and neuropathy as evidenced by weakness, inability to stand, and limited mobility. Approach: Actively assist (R11) to perform eight to ten repetitions of range of motion to both shoulders, elbows, wrists, hips, knees, and ankles at least twice daily. These same program logs document R11 has not received range of motion as directed from 10-25-24 to 12-18-24. On 12/26/24 at 10:45 AM R11 was sitting in a high back padded wheelchair in the dining room. R11 stated, I do not get exercises daily. I cannot move my legs that well and cannot walk. 3. R15's current Diagnosis Report documents R15 has the diagnoses of abnormalities of gait and mobility, presence of a right artificial knee joint, and a fracture of the shaft of the humerus, left arm, and sequela. R15's MDS Assessments dated 7-9-24 and 10-8-24 document R15 is cognitively intact, has impairments in range of motion to one side of the upper extremity and to both sides of the lower extremities, and does not receive passive or active range of motion restorative programs or therapy. R15's current Care Plan does not include interventions to address R15's limitations in range of motion. On 12/17/24 at 08:35 AM R15 was sitting in a recliner in her room with a right sided walker at her right side and her left arm lying next to her left side. R15's left arm was flaccid. R15 stated, I had breast cancer and had my left breast and left lymph nodes in my left arm removed. I cannot lift my left arm. Staff do not do any exercises (range of motion) with me. On 12/17/24 at 2:00 PM V2 (Director of Nursing) stated, (R15) does not have a restorative range of motion plan or program to address her limitations in range of motion. (R5 and R11) are not receiving their range of motion programs twice daily. We (the facility) have not had a restorative aide to do restorative programs for quite some time. I hired a restorative aide (V14) and she quit while still in orientation. Restorative programs are lacking here (the facility). On 12/18/24 at 9:00 AM V1 (Administrator) stated, We (the facility) use the restorative aide job description as the policy for performing restorative programs. 31283 4. R9's current medical record documents R9's Diagnoses to include: Generalized Weakness, Gait Instability, Fall, Urinary Tract Infection and Osteoporosis. R9's Minimum Data Set Assessment (dated 11/13/24) documents the following: R9 requires substantial/maximal assistance putting on/taking off footwear; and requires partial/moderate assistance with shower/bathing, upper body dressing and lower body dressing. On 12/16/24 at 01:45 PM, V15 (R9's daughter) stated, They talked about starting some type of exercise program to maintain her mobility. I am not sure if they have started anything yet, but it has been discussed. R9's current Impaired Mobility care plan documents the following restorative programs in place: Walking and Dressing. R9's Restorative Program Logs for Dressing and Walking (dated 11/01/24 - 12/18/24) contain 42 days with no documentation of completion during this time frame. On 12/18/24 at 08:45 AM, V2 (Director of Nursing) stated that the facility currently has no restorative aide and confirmed R9's restorative programs have not been getting completed. 5. R13's medical record document R13's Diagnoses to include: History of CVA (Cerebrovascular Accident) with residual defect, Right Hemiplegia, Generalized Weakness, Vertigo and Balance Disorder. R13's Minimum Data Set Assessment (dated 10/16/24) documents the following: R13 has impairment on one side of her upper extremities and utilizes a walker. This same assessment documents R13 is dependent with toileting hygiene, lower body dressing and putting on/taking off footwear; and R13 requires substantial/maximal assistance with shower/bathing, upper body dressing and personal hygiene. On 12/16/24 at 09:40 AM, R13 was sitting upright in her recliner and stated she has weakness in her right arm after having a stroke. R13 stated, I have my good days and my bad days. I wish they would exercise me more. I was receiving therapy and after they said I was finished; I haven't done anything since. R13 stated staff does not assist her to complete any type of daily range of motion/restorative exercises. On 12/16/24 at 03:15 PM, V6 (Registered Nurse) stated R13 is not on any type of range of motion/restorative program, I think she was given exercises to do, and she does not do them. R9's current Impaired Mobility care plan documents the following restorative programs in place: Walking and Hygiene. R9's Restorative Program Logs for Personal Hygiene and Walking (dated 11/01/24 - 12/18/24) contain 42 days with no documentation of completion during this time frame. On 12/18/24 at 11:30 AM, V2 (Director of Nursing) stated R13's restorative exercises have not been getting completed, and V2 verified that R13 does not have any type of range of motion programming in place.

Based on interview and record review, the facility failed to refer a resident to the PASRR (Preadmission Screening and Resident Review) State Agency to obtain a Level II PASRR after experiencing a significant change in behavioral and psychiatric symptoms for one of one resident (R2) reviewed for Mental Illness in the sample of 21. Findings include: The facility's (PASSR) policy dated 9-5-24 documents, It is the responsibility of the Psychosocial Designee and/or designated staff to coordinate and ensure compliance with all PASRR federal, state, and local mandates including working with Illinois Maximus PASRR designated agency. The Psychosocial Designee or designated staff shall refer to the designated state agency any resident whose behavioral health condition had declined or worsened and is significantly changes from the most recent PASRR Level II evaluation. Residents with documented mental health condition and/or suspected of mental health conditions shall be referred to the state agency for determination of a mental health condition. This includes but is not limited to residents with recently updated behavioral health diagnosis status and residents show mental health screening assessment indicates a worsening or decline in mental health. R2's Progress Notes dated 11-28-24 document, (R2) complains of feeling there is dust all over her face. R2's Progress Notes dated 11-30-24 document, (R2) had to be reminded today that there was not dust in her ears and to stop picking at her fingernails and face. R2's Progress Notes dated 12-1-24 document, (R2) has to be reminded multiple times that there is not dust in her eyes, ears, or on her skin. Also had to remind (R2) to stop picking her fingernails and her face. (R2) complains that she feels closed in. R2's Progress Note dated 12-8-24 documents, (R2) stated there is dust everywhere. (R2) said the little fan that was going next to her was blowing dust everywhere. R2's Progress Note dated 12-11-24 documents, Spoke with (V10 R2's Family Member) in regards to order for Zyprexa and side effects. (V10) consents to Zyprexa. (V10) reported that when she visits, (R2) is adamant about dust everywhere and that (V10) has tried to show (R2) there is not dust on objects but (R2) gets upset and frustrated with family because they cannot see this dust. (V10) stated that (R2) believes she is having trouble breathing because there is dust on everything and that (R2) makes her take home candy and other things family brings her because there is dust on it. R2's Progress Notes dated 12-12-24 and 12-13-24 document R2 was complaining of having dust in her eyes. R2's Physician's Order dated 12-11-24 and signed by V7 (Physician) documents, Zyprexa (anti-psychotic medication) 2.5 mg (milligrams) daily for the diagnosis of Refractory Depression with Psychotic Symptoms. R2's Medical Record documents the most recent PASRR Level I screen was obtained on 2-2-23. R2's Medical Record does not include evidence of the facility referring R2 to the PASRR State Agency to obtain a Level II PASRR once R2 started exhibiting new behavioral symptoms on 11-30-24 and was ordered Zyprexa to treat the new diagnosis of Refractory Depression with Psychotic Symptoms on 12-11-24. On 12-16-24 at 2:30 PM V1 (Administrator) stated, I am responsible for requesting PASRR screenings. I have not requested a level II PASARR to be done for (R2) since (R2) started exhibiting new behaviors and was started on Zyprexa.

Based on observation, interview, and record review, the facility failed to perform COVID-19 testing on staff with direct high-risk exposure to a COVID-19 positive resident. The facility also failed to implement their COVID-19 Response Plan to monitor residents at least daily for a fever to prevent the potential spread of COVID-19 virus. These failures had the potential to affect the 15 residents residing on the facility ICF (Intermediate Care Facility East wing). Findings include: The CDC's (Centers for Disease Control) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, dated 5/8/23, documents, Nursing homes: Responding to a newly identified SARS-CoV-2-infected HCP or resident: When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority. A single new case of SARS-CoV-2 infection in any HCP (Healthcare Professional) or resident should be evaluated to determine if others in the facility could have been exposed. The approach to an outbreak investigation could involve either contact tracing or a broad-based approach; however, a broad-based (e.g., unit, floor, or other specific area(s) of the facility) approach is preferred if all potential contacts cannot be identified or managed with contact tracing or if contact tracing fails to halt transmission. Perform testing for all residents and HCP identified as close contacts or on the affected unit(s) if using a broad-based approach, regardless of vaccination status. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 48 hours after the first negative test and, if negative, again 48 hours after the second negative test. This will typically be at day 1 (where day of exposure is day 0), day 3, and day 5. The facility's COVID-19 Response Plan, dated 7/31/23, documents, Increased emphasis on early identification and implementation of source control whenever possible will be expected: Evaluate and manage residents with symptoms of respiratory infection. Ask residents to report if they feel feverish or have symptoms of respiratory infection. Activity monitor all residents upon admission and at least daily for fever and respiratory symptoms (shortness of breath, new or change in cough, and sore throat). On 11/6/23 at 8:15 a.m., the hallway entrance to the ICF (Intermediate Care Facility East wing) had a sign announcing that the ICF had COVID-19 positive residents and staff. The facility's COVID-19 Positive Timeline, provided by V1 (Administrator) on 11/6/23, documents that the facility's COVID-19 outbreak began when R1 tested positive for COVID-19 on 10/21/23. The facility Nursing Monthly Schedule, dated 9/24-10/21/23, documents that for 48 hours prior to R1's COVID-19 positive test the following staff members took care of R1 and would have had direct exposure to her: V4 (RN-Registered Nurse), V5 (RN), V6 (RN), V7 (CNA-Certified Nursing Assistant), V8 (CNA), V9 (CNA), V10 (CNA), V11 (CNA), V12 (CNA), V13 (CNA), and V14 (RN). The facility ICF COVID-19 testing, provided on 11/6/23 by V3 (Infection Preventionist), documents that following R1's COVID-19 positive test on 10/21/23, the facility began testing staff who work on ICF and the residents who reside on ICF on 10/22/23. The testing also documents that following the facility's initial testing, testing was not done again for a week (10/30/23). R2's (R1's Roommate) Electronic vitals, dated 10/21-10/25/23, have no documentation of R2's temperature being checked during the timespan following R2's direct high-risk exposure to R1 while R1 was COVID-19 positive. R2's Discharge Summary, dated 10/25/23, documents, She tested positive for COVID-19 with minimal symptoms. Per hospital policy she needs airborne isolation. R3's electronic vitals, dated 10/21/23 to 11/6/23, document that R3's temperature was only obtained on the follow dates, during the facility outbreak, 10/24/23, 10/31/23, and 11/2/23. R4's Electronic Vitals, dated 10/21-11/6/23, document that R4's temperature was only obtained on the following dates, during the facility outbreak, 10/25/23, 11/1/23, 11/2/23, and 11/3/23. R5's Electronic Vitals, dated 10/21-11/6/23, document that R5's temperature was only obtained on the following dates, during the facility outbreak, 10/24/23, 11/1/23, and 11/6/23. On 11/6/23 8:20 a.m., V14 stated, We are tested weekly on Mondays. When (R1) tested positive (10/21/23), we were all tested that following Monday then weekly after that. V14 confirmed that he was directly exposed to R1, and he was not tested on day one, day three, and day five following his COVID-19 exposure to R1. On 11/6/23 at 11:00 a.m., V2 (Director of Nursing) stated, We started testing residents and staff the day after (R1) tested positive, and then we went to weekly. On 11/8/23 at 9:47 a.m., V11 stated, Since the outbreak has started, I've been tested a total of three times. I tested the Tuesday (10/24/23) after (R1) tested positive, and then weekly after that. On 11/6/23 at 2:10 p.m., V1 stated, Residents should be monitored for symptoms of COVID at least once a day, and with that they should be checking the resident's temperature. V1 confirmed that R2, R3, R4, and R5's temperatures were not being monitored on a daily basis. On 11/6/23 at 2:15 p.m., V3 stated, When (R1) tested positive (10/21/23) we started the immediate testing of all the residents and staff who may have had direct exposure to her in the last 48 hours. We tested within 24 hours. Then, on 10/25/23 (R2) tested positive because she was having symptoms. Once she tested positive, we started testing all the residents and the staff in that unit (ICF) weekly. We did not do the initial day 1, day 3, day 5 testing on those staff and residents who had direct exposure to (R1) initially. We didn't think we had to do that because we do PCR (Polymerase Chain Reaction COVID-19) testing and not antigen testing. All residents should be monitored for COVID-19 symptoms on a minimum of a daily basis, and that includes temperatures. The facility's ICF Daily Census, dated 11/6/23, documents that 15 residents (R1-R15) reside on this wing of the facility.

Based on record review and interview the facility failed to obtain a Preadmission Screening and Resident Review (PASRR) for one resident (R2) of one reviewed for PASRR in a total sample of 15. Findings Include: R2's PASRR dated 8/19/2022 documents Your Level 1 screen shows you have evidence of serious mental illness or intellectual/developmental disability (IDD). Further PASRR evaluation is not required because you meet criteria for an exempted hospital discharge. This means you may stay up to thirty (30) days in a Medicaid-certified nursing facility without further PASRR evaluation. R2's PASRR documents If you or your care provider think you need to stay longer than thirty (30) days, a nursing facility staff member must submit a new Level 1 screen to (Company). This must be complete by or before the 30th day stay after your admission to the nursing facility. On 2/1/23 at 10:00 A.M. V2 (Director of Nurses) stated We did not do another PASRR and we should have.

Based on interview and record review, the facility failed to track the progression of a pressure ulcer for one resident (R6) of three residents reviewed for pressure ulcers in a sample of 15. Findings include: The facility's Skin Assessment, Prevention and Care policy dated 5/2022 documents 2. Documentation including size, color, depth, tunneling present, exudates/drainage, pain association with the wound will be completed in the Electronic Health Record on the worklist. R6's medical record dated 8/25/22 documents Bottom wound pressure ulcer stage two. R6's medical record dated 9/7/22 documents Bottom wound pressure ulcer stage two R6's medical record does not document any measurements for her stage two pressure ulcer. R6's medical record documents R6 was discharged on [DATE] and returned 9/22/22. R6's re-admission skin assessment documents Left Upper buttocks shearing. On 02/01/23 at 2:20 PM, V3 (Minimum Data Set (MDS) Coordinator), stated The stage two pressure ulcer was found on 8/25/22 while she was here and still present when she was admitted downstairs on 9/7/22. It looks like she came back to us on 9/22/22 and at that time, the stage two had healed, and it was documented as shearing up until 11/27/22 when it is resolved. We didn't track (R6)'s wound measurements for her stage two pressure ulcer.

Based on observation, interview and record review, the facility failed to maintain the catheter drainage bag below the level of the bladder for one resident (R70) of five resident reviewed for catheters in a total sample of 15. Findings include: The facility's Indwelling Urinary Catheter policy dated 7/22 documents 8. When transporting patient, maintain position of drainage bag below the level of the patient's bladder. R70's physician order dated 2/2/23 documents Indwelling catheter for decubitus ulcer perineal area, incontinent patient. On 1/31/23 at 9:37 AM, V8 (Certified Nursing Assistant/CNA) stated I have to get (R70) ready for transportation to the wound clinic. On 1/31/23 at 9:39 AM, V2 (Director of Nursing/DON) entered the room and stated, I'll help you get (R70) ready. On 01/31/23 at 9:40 AM, V8 (CNA) observed preparing R70 for transportation to the wound clinic. V8 reached down, grabbed R70's catheter drainage bag and placed it on top of the resident's abdomen. V2 grabbed the catheter drainage bag and stated You can't do that. The bag has to be below the bladder. and hung the bag on the extension arm of the recliner where R70 is sitting. On 2/1/23 at 2:00 PM, V2 (DON) verified that the catheter drainage bag should not be raised above the level of the bladder and stated Yeah, I can't believe she did that. As soon as I saw her (V8 CNA) do that, I immediately grabbed it and placed it back down below the bladder.

Based on record and interview the facility failed to identify a specific diagnosis or behavior for psychotropic medication use for two residents (R2 and R10) and failed to limit an as needed psychotropic medication use to 14 days for one resident (R10) of 5 reviewed for unnecessary medication use in a total sample of 15. The Facility's Psychotropic Medication Use policy dated 4/2022 documents Residents of the facility who are prescribed a psychotropic medication will be monitored. The resident's need for the psychotropic medication will be monitored as wells as when the resident has received optional benefits from the medication and when the medication dose can be lowered or discontinued. The Facility's policy also documents Attending physicians must document that a psychotropic medication is necessary to treat a specific condition/behavior. Psychotropic medications include drugs from the following classes: hypnotics, antipsychotics, long and short-acting benzodiazepines, sedatives/anxiolytics and antidepressants. Behaviors for which these drugs are used must present a danger for others, interfere with staff's ability to provide care or cause the resident frightful distress due to paranoia, hallucinations or delusions. R2's Physician Order Sheet for January 2023 documents R2 takes Alprazolam 0.25 mg (Milligrams) twice daily for anxiety, Sertraline 100 mg daily for depression and Mirtazapine 7.5 mg daily for depression. R2's Medical Record does not include any listing of any identified behaviors for R2. On 2/1/23 at 11:00 AM V5 (Registered Nurse/RN) stated R2 did not have any behavior problems that she knew of. On 2/1/23 at 11:10 AM V6 (Certified Nurse Assistant/CNA) and V7 (CNA) both stated they were not aware of any behavior problems/behaviors to monitor with R2. On 2/2/23 at 8:00 A.M. V2 (Director of Nurses/DON) confirmed that R2 did not have any identified behaviors listed in her medical record for the use of the psychotropic medications. V2 stated (R2) shouldn't be on two antidepressants either. I don't know why she is. 41869 2. The facility's Psychotropic Medication Use policy dated 4/22, documents 3. Both the medical staff and nursing shall evaluate the effectiveness of PRN (as needed) orders for psychotropic drugs within 14 days to manage behavior. R10's medication orders dated 1/16/23 documents Alprazolam (Xanax) 0.25 milligrams (mg) by mouth at bedtime PRN for anxiety and Alprazolam (Xanax) 0.25 mg by mouth every eight hours as needed for anxiety. R10's medication administration record documents R10 received Alprazolam 0.25 mg on 1/25/23 and 1/31/23. R10's medical record does not include a diagnosis of anxiety or rationale for the PRN Xanax 0.25 mg to extend beyond 14 days. R10's medical record dated does not document an evaluation of the use of Xanax 0.25 mg for anxiety. On 02/01/23 at 01:12 PM, V2 (DON) stated (V9 Medical Director) won't write a stop date or rationale for the PRN psychotropics. The pharmacists has sent him notifications letting him know and I've sent him notification that we need a stop date or rationale for PRNs psychotropics, but he keeps putting indefinite on the orders without a rationale. He hasn't responded to any of my, or the pharmacists, notifications about it. This has been an ongoing issue with him.

Based on observation, record review and interview, the facility failed to protect a resident from mental abuse by a staff member, for one of two residents (R114) reviewed for abuse, in the sample of 15. This failure resulted in R114 experiencing episodes of crying, distress, fear of staff, and constipation. FINDINGS INCLUDE: The facility policy titled Abuse Prohibition and Reporting dated (revised) 12/20 directs staff, Each resident/resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. It is the policy of (facility) that all patients/residents have the right to be free from all types of abuse, corporal punishment and involuntary seclusion. Patients/residents will not be subjected to abuse by anyone, including, but not limited to, facility staff. R114's physician progress notes [REDACTED]. R114's care plan, dated 3/9/21 includes the following plan of care, Risk for Fear and Anxiety due to recent [PROCEDURE], evidenced by increased apprehension, feelings of helplessness, inadequacy. Implement an ambience of concern, openness and availability, provide emotional support. On 03/15/21 at 10:40 AM, R114 stated, I had an incident involving one of the CNAs (Certified Nursing Assistants). It was (V3/CNA). (V3/CNA) is big and looks scary. This happened last week at suppertime. (V3/CNA) brought my supper tray into me and didn't even talk to me. (V3/CNA) just slammed my tray down so hard, on this table here. It scared me to death. It made me cry. I don't know why (V3/CNA) was mad at me. Then (V3/CNA) picked up my purse and just threw it on my bed and then picked up that breathing thing (incentive spirometer) and just threw it on the bed. (V3/CNA) left the room and didn't even speak. I was so upset. I don't know why (V3/CNA) treated me like that. I didn't put my light on the rest of the night because I didn't want (V3/CNA) to come in here. I need help walking to the bathroom to have a bowel movement. But I didn't go the bathroom all night and then I became constipated. I told (V4/Registered Nurse/RN) that night about it and told (V4/RN) I didn't want (V3/CNA) to come back into my room and take care of me. Earlier, (V3/CNA) had mentioned that (V3/CNA) was going to be working the upcoming weekend and I told (V1/Administrator), when she came in to ask me about (the incident) that I did not want (V3/CNA) taking care of me again. I am afraid of (V3/CNA). I don't know when (V3/CNA) works again. I don't want (V3/CNA) in my room. During this time, R114 was crying, anxious and distressed. On 3/15/21 at 12:30 PM, V1/Administrator stated, (V6/Registered Nurse) came to me the next day (3/11/21) and told me that when (V5/Certified Occupational Therapy Assistant) was working with (R114) this morning, that (R114) began crying and was very distraught about an incident that occurred at supper time, the previous evening, with (V3/CNA). (R114) said that (V3/CNA) was very rude to her and frightened her and she was afraid of (V3/CNA). (R114) also told (V5/COTA) that she was afraid to put her call light on and ask for assistance the rest of the night. (R114) said she told (V4/RN) about the incident and (V4/RN) made (V3/CNA) go back into (R114's) room and apologize to her. (V4/RN) did not call me that night (3/10/21) and make me aware of the incident. I wasn't aware of it until the next day. (V3/CNA) worked the rest of the shift. When I became aware of the incident, I immediately suspended her and began an investigation. When I talked to (R114) she was still very upset and crying. She told me she was afraid of (V3/CNA). On 3/16/21 at 12:55 PM, V4/RN stated, I remember the incident between (R114) and (V3/CNA). It was on 3/10/21 around 5:30, at suppertime. I came on shift at 7:00 PM that night, and after I took Report, I went into (R114's) room to take her vital signs and introduce myself. (R114) was upset and crying. She said she thought (V3/CNA) was mad at her, that (V3/CNA) had handled her roughly. (R114) told me how (V3/CNA) slammed her supper tray down and picked up her personal belongings and threw them on the bed. (R114) said (V3/CNA) didn't speak to her at all and it made (R114) cry. I didn't think too much of it (the incident). When I saw (V3/CNA) later, I told her she needed to go into (R114's) room and make up with her. (V3/CNA) came back later and said she had gone back into (R114's) room and they had made up. I didn't report the incident to (V1/Administrator/Abuse Coordinator). I didn't send (V3/CNA) home. (V3/CNA) finished her shift. I know (V3/CNA) can look imposing and her tone is gruff, and her voice is rough. On 3/16/21 at 1:30 PM, V1/Administrator stated, We have fired (V3/CNA) for the incident involving (R114). I feel the situation was abuse. On 3/17/21 at 10:16 AM, V5/COTA stated, I was in (R114's) room the day after the incident involving (R114) and (V3/CNA), working with (R114). She was upset and began crying and told me that (V3/CNA) had treated her badly and that she was afraid of (V3/CNA). (R114) was also very upset because (V3/CNA) had said she would be back on Saturday (3/13/21) to take care of (R114). (R114) did not want (V3/CNA) back in her room. After I finished (R114's) treatment, I went to her nurse (V6/RN) and told her about the situation, and we both went to (V1's) office and told her. (R114) still talks about the incident, (R114) is still upset. On 3/17/21 at 10:30 AM, V6/Registered Nurse (RN) stated, (V5/COTA) came to me that morning (3/11/21) and told me about (R114) and what (V3/CNA) had done to her. I immediately went to (V1/Administrator) and told her. A review of V3/CNA's Employee File, documents V3/CNA's hire date as 12/09/19. This same file includes a Disciplinary Action form, dated 11/24/20 that documents, Employee (V3/CNA). Disciplinary Action: Verbal Reprimand. Reason for Disciplinary Action: Unsatisfactory work performance. Description of reasons for action: On 11/17/2020 when sitting at Nurse's Station, you were observed on your cell phone and throughout your Shift. Report wasn't taken for a half hour into your Shift. Computer Rounds weren't completed. When asked to provide care to a patient, you went the opposite way of the patient's room. Someone else had to assist the patient. The facility form, Long Term Care Facility-Serious Injury Incident Report, dated 3/15/21 documents, Final Report to Incident (of) 3/10/2021. Alleged Abuse. Resident Involved in Incident: (R114). (R114) is Interviewable, Able to make Informed Decisions, Alert and Oriented. Staff Involved in Incident: (V3/Certified Nursing Assistant). Detailed Incident Summary: This is a follow up to the alleged abuse report sent on 3/11/2021 involving patient (R114) and a CNA. On 3/11/21, a (Facility) employee (V5/COTA) reported to the Abuse Coordinator (V1/Administrator) an incident involving (R114) and (V3/CNA) that occurred on 3/10/2021 at suppertime causing (R114) to become scared. (R114) notified (V5/COTA) the morning of 3/11/2021. On 3/11/2021, (V3/CNA) was suspended pending investigation. (R114) stated during the interview that (V3/CNA) brought her dinner tray in and 'slapped' it onto her over bed table. She also stated CNA threw her purse and incentive spirometer onto her bed. Both items were sitting on patient's over bed table. Patient stated this caused her to become upset and she began to cry. After this incident, patient would not turn her call light on the rest of the evening causing her bathroom schedule to be interrupted. Patient said her feelings were hurt. (R114) did say the CNA came back to apologize and told her she would be working the weekend. (R114) informed me (V1/Administrator) she felt 'leery' about this CNA providing cares to her. (R114) was teary throughout the interview. Through Investigation, the determination was made that (R114) felt fearful of (V3/CNA) because of this incident. (V3's/CNA) employment has been terminated. The facility form, Termination of Service Form, dated 3/16/21 documents, (V3/CNA) was terminated for abuse to (R114). (V3/CNA) is not eligible for re-hire.

Based on record review and interview, the facility failed to ensure staff reported an allegation of mental abuse for one resident (R114) immediately to the Administrator and failed to remove the alleged perpetrator from the facility immediately, for one of two allegations of abuse reviewed in the sample of 15. FINDINGS INCLUDE: The facility policy titled Abuse Prohibition and Reporting dated (revised) 12/20 directs staff, All suspected incidents of abuse or perceived abuse will be immediately reported to the Abuse Coordinator/Clinical Supervisor and will be investigated. Protection to the resident must be provided during and after the investigation. The perpetrator will be immediately removed from direct patient/resident care. At no time will retaliation against the resident or reported be tolerated. The facility form, Long Term Care Facility-Serious Injury Incident Report, dated 3/15/21 documents, On 3/11/21, a (Facility) employee (V5/COTA) reported to the Abuse Coordinator(V1/Administrator) an incident involving (R114) and (V3/CNA) had occurred on 3/10/2021 at suppertime causing (R114) to become scared. On 3/15/21 at 12:30 PM, V1/Administrator stated, (V6/Registered Nurse/RN) came to me the next day (3/11/21) and told me that (R114) was very distraught about an incident that occurred at supper time, the previous evening, with (V3/CNA). (R114) said that (V3/CNA) was very rude to her and frightened her and she was afraid of (V3/CNA). (R114) said she told (V4/RN) about the incident and (V4/RN) made (V3/CNA) go back into (R114's) room and apologize to her. (V4/RN) did not call me that night (3/10/21) and make me aware of the incident. I wasn't aware of it until the next day. On 3/16/2021 at 12:55 PM, V4/RN stated, I remember the incident between (R114) and (V3/CNA). It was on 3/10/21 around 5:30, at suppertime. I came on shift at 7:00 PM that night, and after I took Report, I went into (R114's) room to take her vital signs and introduce myself. (R114) was upset and crying. She said she thought (V3/CNA) was mad at her, that (V3/CNA) had handled her roughly. (R114) told me how (V3/CNA) slammed her supper tray down and picked up her personal belongings and threw them on the bed. (R114) said (V3/CNA) didn't speak to her at all and it made (R114) cry. I didn't think too much of it (the incident). When I saw (V3/CNA) later, I told her she needed to go into (R114's) room and make up with her. (V3/CNA) came back later and said she had gone back into (R114's) room and they had made up. I didn't report the incident to (V1/Administrator/Abuse Coordinator). I didn't send (V3/CNA) home. (V3/CNA) finished her shift. I know (V3/CNA) can look imposing and her tone is gruff, and her voice is rough.

Based on observation, interview, and record review, the facility failed to document a complete side rail entrapment risk assessment, and failed to document alternatives attempted prior to the use of side rails for 12 of 12 residents (R1, R3, R5, R6, R12, R13, R14, R115, R165, R170, R172, R173) reviewed for accidents in the sample of 21. Findings include: On 5/28/19 at 11:23 a.m., R6's bed had bilateral half side rails in an upright position. On 5/28/19 at 1:51 p.m., R5's bed had bilateral half side rails in an upright position. On 5/28/19 at 1:25 p.m., R1's bed had bilateral half side rails in an upright position. On 5/28/19 at 11:35 a.m., R12's bed had bilateral half side rails in an upright position. On 5/28/19 at 10:30 am, R3's bed had bilateral half side rails in the upright position. On 5/28/19 at 11:28 a.m., R13's bed had half bilateral side rails on in the upright position. On 5/28/19 at 10:15 a.m., R14's bed had bilateral half side rails in the upright position. On 5/28/19 at 10:10 a.m., R115's bed had half bilateral side rails on in the upright position. On 05/28/19 at 10:00 AM, R165 was in bed and had bilateral upper side rails in the upright position. On 05/28/19 at 10:05 AM, R170's bed had bilateral upper side rails in the upright position. On 05/28/19 at 10:15 AM, R172's bed had bilateral upper side rails in the upright position. On 05/28/19 at 10:10 AM, R173 was resting in bed and had bilateral upper side rails in the upright position. R1, R3, R5, R6, R12, R13, R14, R115, R165, R170, R172, and R173's daily Side Rail Assessments only include the following risk factors for side rail entrapment: Intermittent Confusion, Constant Confusion, Agitation, Restlessness, [MEDICAL CONDITION], Prior Entrapment, Impulsive For Mobility, Medication (Side Effects), and High Risk Falls. V2 (Director of Nursing) stated R1, R3, R5, R6, R12, R13, R14, R115, R165, R170, R172, and R173's Side Rail Assessment does not document alternatives attempted prior to the use of side rails. On 5/30/19 at 9:30 a.m., V2 (Director of Nursing) stated that R1, R3, R5, R6, R12, R13, R14, R115, R165, R170, R172, and R173's Side Rail Entrapment Risk Assessments only include Intermittent Confusion, Constant Confusion, Agitation, Restlessness, [MEDICAL CONDITION], Prior Entrapment, Impulsive For Mobility, Medication (Side Effects), and High Risk Falls, and does not document alternatives attempted prior to the use of side rails.

Based on interview and record review the facility failed to follow their policy by immediately reporting abuse to the Administrator and removing an alleged perpetrator from resident contact. This failure resulted in Z1 (Agency Registered Nurse) continuing to work two additional shifts over a seven day period after she was initially witnessed verbally and mentally abusing R1. Z1 had two more witnessed abuse episodes, one towards R1 and one towards R4 before it was reported to the Abuse Coordinator. This failure has the potential to affect all residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on 8/17/17, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of the facility's abuse policy and procedure revision and staff in-service training. Findings include: The facility's current Abuse Prohibition policy (Revised July 2017) documents the following: It is the policy of (facility) to report any suspected cases of elder abuse or dependent adult abuse. This same policy documents, Training of all employees will include the following: (Computer Education) for new employee orientation and on-going annual training on all topics of abuse. This same policy also documents: All allegations of abuse must be reported to the Abuse Coordinator/Administrator immediately. An investigation should include but is not limited to identifying and interviewing all involved persons including the alleged victim, alleged perpetrator, witnesses and others who might have knowledge of the allegations, focusing the investigation on determining the form of abuse that is alleged, the extent and cause of the alleged abuse, and provide complete and thorough documentation of the investigation. This same policy also documents, Protection to the resident must be provided during and after the investigation. The perpetrator will be immediately removed from direct patient/resident care. Reports of all alleged incidents will be reported to the (State Agency) and the appropriate state licensing/registry agency. E4's (Registered Nurse) Written Witness Statement dated 7/25/17 documents that E4 witnessed Z1(Agency Registered Nurse) verbally and mentally abuse R1 on multiple occasions throughout the third shift hours (11:00 PM - 7:00 AM) on 7/18/17 and 7/24/17. This same statement also documents that E4 witnessed Z1 physically abuse R4 during the third shift hours (11:00 PM - 7:00 AM) on 7/24/17. R1's Investigation of Verbal Abuse Final Report dated 7/28/17 documents that on 7/25/17 at approximately 6:45 AM, E2 (Director of Nursing/Abuse Coordinator) was informed that Z1(Agency Registered Nurse) verbally abused R1 multiple times during third shift beginning at approximately 11:00 PM on 7/24/17 and continuing throughout the shift until approximately 7:00 AM on 7/25/17. This same report indicates that Z1 was terminated from the facility after E2's investigation was substantiated by confirming E3 (Certified Nursing Assistant), E4 (Registered Nurse) and R1's witness statements. On 8/9/17 at 3:30 PM, E4 (Registered Nurse) stated that E4 did not immediately report Z1's abusive actions that E4 witnessed on 7/18/17 and 7/24/17 to anyone. E4 then stated, I was trying to give her (Z1) the benefit of doubt. There were only two of us that night (7/18/18), so it would have been her word against mine. I should have reported it. E3's (Certified Nursing Assistant) Written Witness Statement dated 7/25/17 documents that E3 witnessed Z1 verbally and mentally abuse R1 on multiple occasions throughout the third shift hours (11:00 PM - 7:00 AM) on 7/24/17. This same statement also documents that E3 witnessed Z1 physically abuse R4 during the third shift hours on 7/24/17. On 8/10/17 at 8:58 AM, E3 stated that E3 did not immediately notify E2 (Director of Nursing/Abuse Coordinator) or E6 (Administrator) of Z1's abusive behavior. On 8/10/17 at 9:37 AM, E5 (House Supervisor) stated that the House Supervisor is the person in charge of the facility during the night shift hours and all staff are required to report any concerns that arise to the House Supervisor. E5 then stated that the House Supervisor is responsible for addressing any issues or concerns that are reported. E5 then stated that E3 came and talked to E5 on the early morning hours of 7/25/17 with concerns regarding Z1's abusive behavior towards R1. E5 then stated that since everything appeared to be ok when E5 rounded, E5 just reported the voiced concerns later in the morning once the day shift department heads arrived. E5 then stated, If there is a complaint/concern, I go and talk to the patient to see if the staff member needs removed and reassigned somewhere else. It never works out to leave them on the unit. I just reassign them, but I wasn't able to speak with (R1) because (R1) was asleep and everything seemed OK. E5 then verified that E5 did not immediately notify anyone of the concerns that E3 voiced regarding Z1 on 7/25/17. E5 stated, I didn't call (E2, Director of Nursing/Abuse Coordinator) because I was a little unclear of what truly went on. I only call if something physical occurs. Usually, I have to diffuse a situation when I arrive, but since everything was so calm when I was on the unit, I decided to wait and talk to (E2) when she arrived a few hours later. On 8/9/17 at 8:58 AM, E2 (Director of Nursing) stated that all of the allegations against Z1 were confirmed through witness statements from E3 (Certified Nursing Assistant), E4 (Registered Nurse) and R1. E2 then stated that Abuse Education and Training is assigned in a computer training system at a new employee's time of hire and then annually. E2 stated that Abuse Education was assigned at Z1's date of hire (5/30/17), but Z1 never completed the training. E2 also stated that E2 was unaware of any of Z1's behavior on 7/18/17, until first being notified on 7/25/17, and stated that E2 and E6 (Administrator) should have been immediately notified. E2 then stated that since E2 was not notified of Z1's abusive behavior on 7/18/17, the facility's abuse policy was not followed because an investigation was not conducted, Z1 was not removed from resident contact, and the State Agency was not notified. The facility's daily Staffing Assignment Sheets dated 7/18/17 - 7/24/17 document that Z1 worked third shift (11:00 PM - 7:00 AM) on the following days: 7/18/17, 7/21/17 and 7/24/17. The Immediate Jeopardy was identified at 9:15 AM on 8/17/17 to have begun on 7/18/17 when E4 witnessed Z1 verbally and mentally abusing R1 and did not immediately report the abuse to anyone . E1 (Chief Nursing Executive) and E2 (Director of Nursing) were notified of the Immediate Jeopardy at 9:15 AM on 8/17/17. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. E1 (Chief Nursing Executive) and E2 (Director of Nursing) will review the facility's current abuse policies and combine them into one to diminish the possibility or confusion on what constitutes abuse, who may report abuse, how to report abuse, what steps will be taken after a report, and consequences of failure to report. Upon approval of the policy by E1 and E2, all patient care and ancillary staff that may have occasion to be in patient care areas will be educated on the contents of the policy and the location of the policy on the employee computer system via an immediate email with read receipt (with policy attached) and mandatory employee meetings. For staff not immediately available by the due date or new to the facility, education on the contents of the policy and the location will be completed prior to the beginning of their shift. 2. Signage depicting who should report abuse, when it should be reported, and who it should be reported to will be created and posted at a minimum in all patient care areas, break rooms, and common areas. 3. New Employee education will be revised to include specific education on the facility's abuse policy and expectations as outlined, as well as the consequences of failure to report. 4. At a minimum, abuse education will be completed quarterly, and will be included in the facility's annual mandatory education requirements each fiscal year. 5. E3 (Certified Nursing Assistant) and E4 (Registered Nurse), who were identified as having had the opportunity to report abuse, were educated and counseled on possible future consequences if a failure to report occurrence is repeated.

Surveyor: Murphy, April M. Based on interview and record review, the facility failed to: immediately report episodes of verbal and mental abuse to the Administrator, investigate an allegation of abuse, immediately remove an alleged perpetrator from resident contact, and report to the State Agency. Z1 (Agency Registered Nurse) was witnessed by E4 (Registered Nurse) verbally and mentally abusing R1 several times on 7/18/17, yet E4 did not notify E6 (Administrator) or E2 (Abuse Coordinator). Z1 continued to work and have access to R1, was witnessed by E3 (Certified Nursing Assistant) and E4 again verbally and mentally abusing R1, and physically abusing R4 one week later. R1 and R4 are two of four residents reviewed for allegations of abuse in the sample of 17. This failure had the potential to affect all 17 residents residing on the skilled unit from 7/17/17 - 7/25/17. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/17/17, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of the facility's abuse policy and procedure revision and staff in-service training. Findings include: R1's Investigation of Verbal Abuse Final Report dated 7/28/17 documents that on 7/25/17 at approximately 6:45 AM, E2 (Director of Nursing/Abuse Coordinator) was informed that Z1(Agency Registered Nurse) verbally abused R1 multiple times during third shift beginning at approximately 11:00 PM on 7/24/17 and continuing throughout the shift until approximately 7:00 AM on 7/25/17. This same report indicates that Z1 was terminated from the facility after E2's investigation was substantiated by confirming E3 (Certified Nursing Assistant), E4 (Registered Nurse) and R1's witness statements. E4's (Registered Nurse) Written Witness Statement dated 7/25/17 documents that E4 witnessed Z1(local agency Registered Nurse) verbally and mentally abuse R1 on multiple occasions throughout the third shift hours (11:00 PM - 7:00 AM) on 7/18/17 and 7/24/17. This statement documents that E4 overheard Z1 call R1 a, p*ssy, and make other vulgar remarks about R1, instruct R1 not to turn on his call light anymore, threaten to withhold treatment if R1 did not apologize for his actions, and forced R1 to sleep with his door closed, although R1 requested that it be left open. This same statement also documents that E4 also witnessed Z1, man handling and physically abusing R4 during the third shift hours (11:00 PM - 7:00 AM) on 7/24/17. On 8/9/17 at 3:30 PM, E4 verified E4's Written Witness Statement dated 7/25/17 and stated that E4 did not immediately report Z1's abusive actions that E4 witnessed on 7/18/17 and 7/24/17 to anyone. E4 stated that E4 did not immediately report Z1's actions because, I was trying to give her (Z1) the benefit of doubt. There were only two of us working that night (7/18/17), so it would have been her word against mine. I should have reported it. E4 also stated that E4 felt that Z1 was verbally abusive and withheld care to R1 during the third shift hours on 7/18/17 and 7/24/17. E3's (Certified Nursing Assistant) Written Witness Statement dated 7/25/17 documents that E3 witnessed Z1 verbally and mentally abuse R1 on multiple occasions throughout the third shift hours (11:00 PM - 7:00 AM) on 7/24/17. This same statement also documents that E3 witnessed Z1 physically abuse R4 during the third shift hours on 7/24/17. On 8/10/17 at 8:58 AM, E3 verified E3's Written Witness Statement dated 7/25/17 and stated that Z1's abusive behavior lasted the entire duration of the shift (7/24/17 11:00 PM - 7:00 AM on 7/25/17). E3 also stated that E3 left the floor and went to talk to E5 (House Supervisor/Registered Nurse) at approximately 2:00 AM on 7/25/17 about Z1's abusive behavior, but did not immediately notify E2 (Director of Nursing/Abuse Coordinator) or E6 (Administrator). E3 then stated, (E5) told me to let someone know later in the morning. E3 then stated that E3 felt that Z1 was abusive to R1 and R4 on 7/25/17. E3 stated, (Z1) was very demeaning to (R1). I was very uncomfortable with (Z1's) behavior and her care towards the residents. She was neglectful (towards R1). (Z1) was not allowing the care (R1) needs and that is not OK. I could tell that (R1) was upset that night. I could hear it in his voice. He sounded defeated. E3 also stated that after R4's bed alarm sounded during the early morning hours on 7/25/17, Z1 entered R4's room, grabbed a hold of R4 and attempted to flip R4 back into bed. E3 stated, (Z1) was very aggressive and forced (R4). It terrified (R4) as (R4) started screaming and then (Z1) just started yelling at (R4). (R4) has dementia and is not able to follow directions. On 8/10/17 at 9:37 AM, E5 (House Supervisor) stated that the House Supervisor is the person in charge during the night shift hours and all staff are required to report any concerns that arise to the House Supervisor. E5 then stated that E3 came and talked to E5 on the early morning hours of 7/25/17, with concerns regarding Z1's abusive behavior towards R1. E5 stated that since everything appeared to be ok when E5 rounded, E5 just reported the voiced concerns later in the morning once the day shift department heads arrived. E5 then verified that E5 did not immediately notify anyone of the concerns that E3 voiced regarding Z1 on 7/25/17. E5 stated, I didn't call (E2, Director of Nursing/Abuse Coordinator) because I was a little unclear of what truly went on. I only call if something physical occurs. E5 then confirmed that Z1 was allowed to continue to work and completed Z1's shift as scheduled on 7/24/17. On 8/10/17 at 1:15 PM, Z1 stated that Z1 felt that it was unacceptable for R1 to talk to the staff the way he did. Z1 stated that R1 accused Z1 of being abusive and that R1 was, always on the call light. Z1 then stated that at one point while caring for R1, Z1 did tell R1 that R1 needed to apologize for the way he was speaking to the facility staff because he was being rude. On 8/9/17 at 8:58 AM, E2 (Director of Nursing) stated that all of the allegations against Z1 were confirmed through witness statements from E3 (Certified Nursing Assistant), E4 (Registered Nurse) and R1. E2 stated that E2 was unaware of any of Z1's behavior on 7/18/17, until first being notified on 7/25/17, and stated that E2 and E6 (Administrator) should have been immediately notified. E2 then stated that since E2 was not notified of Z1's abusive behavior on 7/18/17, an investigation was not conducted, the State Agency was not notified, Z1 was not removed from resident contact, continued to work and subsequently abused R1 and R4 on the third shift hours of 7/24/17. The facility's daily Staffing Assignment Sheets dated 7/18/17 - 7/24/17 document that Z1 worked third shift (11:00 PM - 7:00 AM) on the following days: 7/18/17, 7/21/17 and 7/24/17. The facility's daily census sheets dated 7/17/17 - 7/25/17 indicate the following residents resided on the facility's skilled unit where Z1 was assigned to work: R1 - R7, R9, and R11 - R19. The Immediate Jeopardy was identified at 9:15 AM on 8/17/17 to have begun on 7/18/17 when E4 witnessed Z1 verbally and mentally abusing R1 and did not immediately report the abuse to anyone . E1 (Chief Nursing Executive) and E2 (Director of Nursing) were notified of the Immediate Jeopardy at 9:15 AM on 8/17/17. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. E1 (Chief Nursing Executive) and E2 (Director of Nursing) will review the facility's current abuse policies and combine them into one to diminish the possibility or confusion on what constitutes abuse, who may report abuse, how to report abuse, what steps will be taken after a report, and consequences of failure to report. Upon approval of the policy by E1 and E2, all patient care and ancillary staff that may have occasion to be in patient care areas will be educated on the contents of the policy and the location of the policy on the employee computer system via an immediate email with read receipt (with policy attached) and mandatory employee meetings. For staff not immediately available by the due date or new to the facility, education on the contents of the policy and the location will be completed prior to the beginning of their shift. 2. Signage depicting who should report abuse, when it should be reported, and who it should be reported to will be created and posted at a minimum in all patient care areas, break rooms, and common areas. 3. New Employee education will be revised to include specific education on the facility's abuse policy and expectations as outlined, as well as the consequences of failure to report. 4. At a minimum, abuse education will be completed quarterly, and will be included in the facility's annual mandatory education requirements each fiscal year. 5. E3 (Certified Nursing Assistant) and E4 (Registered Nurse), who were identified as having had the opportunity to report abuse, were educated and counseled on possible future consequences if a failure to report occurrence is repeated.

Based on interview and record review, the facility failed to ensure that residents were not abused. E4 (Registered Nurse) witnessed multiple episodes of verbal and mental abuse towards R1 by (Z1, Agency Registered Nurse), on two separate days, one week apart. E3 (Certified Nursing Assistant) and E4 also witnessed Z1 physically abuse R4. R1 and R4 are two of four residents reviewed for allegations of abuse in the sample of 17. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 8/17/17, the facility remains out of compliance at a Severity Level II. Additional time is needed to monitor the effectiveness of the facility's abuse policy and procedure revision and staff in-service training. Findings include: 1. R1's Investigation of Verbal Abuse Final Report dated 7/28/17 documents that on 7/25/17 at approximately 6:45 AM, E2 (Director of Nursing/Abuse Coordinator) was informed that Z1(Agency Registered Nurse) verbally abused R1 multiple times during third shift beginning at approximately 11:00 PM on 7/24/17 and continuing throughout the shift until approximately 7:00 AM on 7/25/17. This same report documents the following: The situation being reported was: (Z1) entered (R1's) room and proceeded to tell (R1), who at the time wanted some pain medication, that it wasn't time yet and then proceeded to say that (R1) was a p*ssy and comparing (R1) to (Z1's) own family members. (Z1) also told (R1), 'Do not put your call light on anymore tonight, I (Z1) will come in here and check on you.' (R1) had placed (R1's) call light on several more times after that and (Z1) proceeded to turn the call light off and not assess (R1's) needs. Again, (R1) asked for pain medication and (Z1) told (R1) that if he didn't apologize to (Z1) for his actions and treatment that (Z1) would not give him the pain medications. (R1) then apologized to (Z1) and (Z1) asked that (R1), 'say it like he meant it.' (R1) asked for his door to be left open and (Z1) stated to him, 'No. I want the door shut, you need to go to sleep.' (Z1) had then used very vulgar and foul language to describe (R1) to her co-workers right outside (R1's) room. Upon being interviewed, (R1) reports that, 'Every night (Z1) walks in here it is a yelling match. (Z1) is very unacceptable and vulgar.' (R1) confirmed all accounts made in the witness statements gathered. (R1) reports, '(Z1) should not be a nurse.' After witness statements were gathered, the alleged verbal abuse was confirmed by (R1). The facility then reviewed (Z1's) contract and contacted the agency that (Z1) work for to immediately terminate the contract between (Z1) and (the facility). E4's (Registered Nurse) Written Witness Statement dated 7/25/17 documents, Last night (7/25/17), (Z1) was verbally abusing (R1). Last Wednesday (7/18/17), there was another episode with (Z1) mistreating (R1). E4's same written witness statement documents the following occurred on 7/18/17: (R1) had turned his call light on to use the bathroom. (Z1) entered the room and I heard (Z1) tell him that she was all he had and that nobody else was working so he was going to have to deal with it. I knew that (R1) was a two assist, so I started to walk in (R1's) room to ask if (Z1) needed help, when (Z1) turned around and pushed me (E4) out of the room stating that she (Z1) told (R1) that she was the only one there and he could wait until the (day shift CNAs/Certified Nursing Assistants) arrive on the floor and he was able to go to the bathroom. 45 minutes later they (day shift CNAs) arrived on the floor and he was able to go to the bathroom. I also heard (Z1) yell at (R1), 'Don't tell me what to do. I tell you what to do. (R1) made some comment about paying for his hospital stay and paying her to do her job and (Z1) said, 'You don't pay my check and I don't work for (facility).' (R1) asked for his water. I could hear (Z1) telling him to grab it. (R1) said he has [MEDICAL CONDITION] and had difficulty reaching it. (Z1) told him that he was on the therapy floor and needed to do stuff for himself. (R1) told me that (Z1) put the cup just outside of his reach and left the room. I heard (R1) yell out that (Z1) tried to pour water down his throat and would not let him use the straw. I also heard (R1) tell (Z1) that the way (Z1) was treating (R1) was elder abuse and (Z1) laughed and said, 'report me'. E4's Written Witness Statement dated 7/25/17 documents the following occurred on 7/25/17: Tonight (R1) turned on his call light for pain pills and (Z1) entered his room. I could hear (Z1) yelling at (R1). (Z1) told (R1) that if he didn't apologize to her for the way he was talking to her that she would not help him. She started to walk out of his room and I could hear (R1) apologize to (Z1) and then I heard (Z1) say to (R1), 'Say it like you mean it.' (R1) apologized again and (Z1) turned around and re-entered the room and continued to help him. (R1) turned on his light at least five times in a row that I counted and (Z1) would turn around from her chair and slam the receiver on the call light system, shutting his light off and never entering his room to see what he wanted. (Z1) would make the comment that she was just in (R1's) room. Another incident from tonight I could hear (Z1) yelling from (R1's) room and said, 'Do not turn your call light on again tonight. I will come check on you.' Then (Z1) walked out of (R1's) room and started to shut his door. (R1) asked (Z1) to leave the door open and (Z1) said, 'No. I want the door shut and you need to go to sleep.' I waited until (Z1) went into another room and went in to check on (R1). He thanked me for coming in to check on him. Another time (Z1) was arguing with (R1) and called him an a**hole loud enough for him to hear and said that he could stick his straw up his a**. On 8/9/17 at 3:30 PM, E4 verified the above written witness statement and stated that 7/18/17 was the first time that E4 had ever seen Z1, act like that toward anybody. E4 then stated, (Z1's) behavior started at the beginning of the shift (11:00 PM on 7/24/17) and continued throughout the entire shift. (E3, Certified Nursing Assistant) was so upset that she left the floor approximately two hours into the shift and went and talked to (E5, House Supervisor/Registered Nurse). E4 then stated that E4 did not immediately report Z1's abusive actions that E4 witnessed on 7/18/17 and 7/24/17 to anyone. E4 stated that E4 did not immediately report Z1's actions because, I was trying to give her (Z1) the benefit of doubt. There were only two of us working that night (7/18/17), so it would have been her word against mine. I should have reported it. E4 also stated that E4 felt that Z1 was verbally abusive and withheld care to R1 on 7/18/17 and 7/25/17. E3's (Certified Nursing Assistant) Written Witness Statement dated 7/25/17 documents, (R1) had asked for pain medication and (Z1) said that it wasn't time yet and proceeded to say that (R1) was a p*ssy and that (Z1's) father who was a few years older than (R1) could tolerate and do more than (R1) could. Later, I assisted (R1) to the bedside commode. (Z1) told me that we needed to assist (R1) as a two-person assist just to make sure that we were covered because (R1) had made allegations that (Z1) was being abusive towards (R1) and threatened to call the elder abuse hotline on (Z1). When (R1) turned on the call light when he was finished with the commode, (Z1) made (R1) wait until (Z1) took (R1's) vitals before he could get cleaned up and transferred back to the chair. (R1) stated that he wanted to go back to the chair before (Z1) took his vitals and (Z1) said that she was getting his vitals first and asked him, 'Are we going to do this again tonight?' Later in the shift, I heard (Z1) tell (R1) not to put his call light on anymore tonight, that she would come check on him to see if he needed anything. (R1) had began to rebuke this when (Z1) stated that (R1) is not to turn on his light again, that she would be in to check on him and if he puts his call light on, (Z1) would just shut it off, in which (Z1) actually did. I was gathering items and placing them in the shower room at the end of the hall, when I could hear banging coming from the desk and upon further investigation, found it was (Z1) slamming the phone to our call light system down repeatedly to shut (R1's) light off. Several times during the night (R1) made comments to me about (Z1's) treatment of [REDACTED]. On 8/10/17 at 8:58 AM, E3 stated that Z1's abusive behavior lasted the entire duration of the shift (7/24/17 11:00 PM - 7:00 AM on 7/25/17). E3 then stated that E3 felt that Z1 was abusive to R1 on 7/25/17. E3 stated, (Z1) was very demeaning to (R1). I (E3) was very uncomfortable with (Z1's) behavior and her care towards the residents. She was neglectful (towards R1). (Z1) was not allowing the care (R1) needs and that is not OK. I could tell that (R1) was upset that night. I could hear it in his voice. He sounded defeated. R1's Brief Interview for Mental Status dated 8/11/17 documents a score of 14, indicating that R1 is cognitively intact. R1's Written Witness Statement (undated) documents the following: The third shift nurse, (Z1), has picked a fight with me every night she has been here. From the time she walks into this room, it is a screaming match. (Z1) should not be like that. That is unacceptable. (Z1) even told me that she wouldn't do anything for me, even care for me if I didn't apologize to her. She shouldn't be a nurse. On 8/9/17 at 11:00 AM, R1 verified the above written statement. R1 stated, There was one nurse, (Z1), that I got into a pushing match with. (Z1) put a cup of water in my face when I had a coughing spell, and I had to push it away. Every night, we (Z1 and R1) we got into a screaming contest. She was bull-headed and belligerent. One morning, she made a mistake and a few people overheard her and I think turned her in. She was running with a short fuse and I just kept quiet. She put on a hell of a show. She shouldn't be conducting herself like that. It was ongoing. She never missed a night. I called her abusive. It made me feel bad when she screamed and yelled at me. She wasn't very nice. She shouldn't treat people like that. On 8/10/17 at 1:15 PM, Z1 stated that Z1 felt that it was unacceptable for R1 to talk to the staff the way he did. Z1 stated that R1 accused Z1 of being abusive and that R1 was, always on the call light. Z1 then stated that at one point while caring for R1, Z1 did tell R1 that R1 needed to apologize for the way he was speaking to the facility staff because he was being rude. Z1 then verified that Z1's employment with the facility was terminated on 7/25/17. 2. R4's Brief Interview for Mental Status dated 8/2/17 documents a score of 7, indicating that R4 is cognitively impaired. E4's (Registered Nurse) Written Witness Statement dated 7/25/17 also documents that the following occurred on 7/25/17: (Z1) was also mean to (R4). (R4) was attempting to get out of bed and the bed alarm was sounding. (Z1) entered the room and I could hear (R4) screaming out so I entered the room to see (Z1) man handling (R4) attempting to keep (R4) from getting out of bed. (Z1) yelled, 'Knock it off' at (R4). (R4) being confused didn't understand (Z1). (Z1) continued to yell at (R4). On 8/9/17 at 3:30 PM, E4 verified the above written statement and stated that on 7/25/17, E4 entered R4's room to find Z1 holding one of Z1's arms around R4's back and the other arm around R4's leg. E4 stated, (R4) was trying to get out of bed and (Z1) was physically forcing (R4) to stay in bed. (Z1) was handling (R4) in an aggressive teeter-totter like motion, almost causing (R4) to fall. (Z1) then yelled at (R4). (R4) is confused, so (R4) didn't understand. Usually, if (R4) gets up at night, it is just to use the bathroom and once (R4) is toileted, she goes back to bed easily. E3's (Certified Nursing Assistant) Written Witness Statement dated 7/25/17 also documents, (R4) was another patient (Z1) was aggressive with. (R4) had set her bed alarm off because she needed to void. (Z1) tried to swing (R4) around on the other side of the bed man handling (R4) and almost sliding (R4) out of bed onto the floor, flung (R4) back up into bed to get her bottom off the edge and then flipped her back up on the side of the bed yelling at (R4) wanting to know what (R4) thought she was doing and wanting to know why she was trying to get out of bed. (R4) began to scream and started mumbling in a shouting manner. On 8/10/17 at 8:58 AM, E3 verified the above written statement and stated that after R4's bed alarm sounded during the early morning hours on 7/25/17, Z1 entered R4's room, grabbed a hold of R4 and attempted to flip R4 back into bed. E3 stated, (Z1) was very aggressive and forced (R4). It terrified (R4) as (R4) started screaming and then (Z1) just started yelling at (R4). (R4) has dementia and is not able to follow directions. E3 then stated that E3 felt that Z1 was abusive to R4 on 7/25/17. On 8/9/17 at 8:58 AM, E2 (Director of Nursing) stated that all of the allegations against Z1 were confirmed through witness statements from E3 (Certified Nursing Assistant), E4 (Registered Nurse) and R1. E2 stated that R4 is cognitively impaired and therefore was not a candidate to be interviewed regarding Z1's abusive behavior. The facility's daily Staffing Assignment Sheets dated 7/18/17 - 7/24/17 document that Z1 worked third shift (11:00 PM - 7:00 AM) on the facility's skilled unit on the following days: 7/18/17, 7/21/17 and 7/24/17. The Immediate Jeopardy was identified at 9:15 AM on 8/17/17 to have begun on 7/18/17 when E4 witnessed Z1 verbally and mentally abusing R1 and did not immediately report the abuse to anyone . E1 (Chief Nursing Executive) and E2 (Director of Nursing) were notified of the Immediate Jeopardy at 9:15 AM on 8/17/17. The surveyor confirmed through interview and record review that the facility took the following action to remove the Immediate Jeopardy: 1. E1 (Chief Nursing Executive) and E2 (Director of Nursing) will review the facility's current abuse policies and combine them into one to diminish the possibility or confusion on what constitutes abuse, who may report abuse, how to report abuse, what steps will be taken after a report, and consequences of failure to report. Upon approval of the policy by E1 and E2, all patient care and ancillary staff that may have occasion to be in patient care areas will be educated on the contents of the policy and the location of the policy on the employee computer system via an immediate email with read receipt (with policy attached) and mandatory employee meetings. For staff not immediately available by the due date or new to the facility, education on the contents of the policy and the location will be completed prior to the beginning of their shift. 2. Signage depicting who should report abuse, when it should be reported, and who it should be reported to will be created and posted at a minimum in all patient care areas, break rooms, and common areas. 3. New Employee education will be revised to include specific education on the facility's abuse policy and expectations as outlined, as well as the consequences of failure to report. 4. At a minimum, abuse education will be completed quarterly, and will be included in the facility's annual mandatory education requirements each fiscal year. 5. E3 (Certified Nursing Assistant) and E4 (Registered Nurse), who were identified as having had the opportunity to report abuse, were educated and counseled on possible future consequences if a failure to report occurrence is repeated.

A. Based on observation, record review, and interview the facility failed to have in place and functioning a collaborative infection control program between housekeeping and nursing services to prevent the spread of Clostridium difficile infection for two sampled residents (R9, R19) with Clostridium difficile and residents (R2, R11, R13, R16, R17, R18, R19, R20, R26, R27) who had blood glucose monitoring. This involves one resident on the sample and eight residents on the supplemental sample. The facility failed to implement precautionary isolation infection procedures for one resident (R8) with diarrhea prior to definitive diagnostic tesing. R3 with an indwelling urinary catheter, R4 with [DIAGNOSES REDACTED]. The facility failed to effectively clean and disinfect environmental surfaces and resident equipment to control and prevent the spread of Clostridium difficile infection. The facility failed to analyze data related Clostridium difficile infection, identify trends and implement corrective action. The facility failed to demonstrate knowledge of and implementation of isolation precautions to prevent cross contamination and the spread of Clostridium difficile infection. Facility staff cross contaminated during direct care. These failures have the potential to impact all 32 residents on the unit. These failures resulted in an Immediate Jeopardy. While the immediacy was removed on 9/7/11, the facility remains out of compliance at a Severity Level 2. Additional time is needed to evaluate the implementation of revised policies and procedures, inservicing of staff and repair of mechanical equipment to determine the effectiveness of these changes. Findings include: Environmental Cleaning Lab report dated 8/14/11 and 8/18/11 document that R9 and R19, respectively tested positive for[DIAGNOSES REDACTED]icile (Clostridium Difficile). A 3M Environmental Control of Clostridium difficile Fact Sheet dated February 2009 provided by facility environmental staff states that [DIAGNOSES REDACTED]icile is a spore forming bacterium that can produce toxins causing disease in humans. [DIAGNOSES REDACTED]icile is present in feces and the major reservoirs of [DIAGNOSES REDACTED]icile are infected patients (both symptomatic and asymptomatic) and items or surfaces contaminated with feces. [DIAGNOSES REDACTED]icile spores are transferred to patients primarily via the hands of healthcare personnel who have direct contact with infected patients or who have touched a contaminated surface or item. This report continues stating that the ability of [DIAGNOSES REDACTED]icile to form spores allows the organism to survive in the environment for weeks or months. Lab report dated 2/28/11 documents that R1 was diagnosed with [REDACTED]. On 8/29/11 at 1:00 p.m. R1, R9, and R19 had Isolation signs hanging on the outside of their doors. There were unlabeled, undated cleaning wipes sitting on top of the isolation carts outside of R1, R9, and R19's rooms. These wipes were to be available to staff to disinfect environmental surfaces and equipment. At 1:55 p.m. on 8/29/11. E19 (Environmental Services Coordinator) verified (when questioned as to what cleaning solution was present in these wipes) that the cleaning buckets outside of R1, R9 and R19's room should have been labeled with the name of the chemical that was contained inside, a label that said 10 minute kill time and the date the cleaning solution should be changed out. E19 stated that he would label the buckets "right away." When E19 was asked how E19 was going to label the cleaning buckets without knowing what chemical they were mixed with, E19 stated "I guess I should dump the buckets." E19 stated that to kill[DIAGNOSES REDACTED]icile a 10% bleach solution with "3 ounces of bleach for 36 ounces of water" should be mixed. E19 was not aware that this would not be the correct dilution for a 1:10 chlorine solution need for environmental disinfection for[DIAGNOSES REDACTED]icile. E19 stated that for all other organisms that HB Quat Disinfectant Cleaner should be mixed and placed outside of residents doors. E19 verified that he was aware that R9 and R19 were in isolation due to[DIAGNOSES REDACTED]icile and that R1 was in isolation for MRSA. E19 immediately removed the unlabeled cleaning buckets at this time, leaving no cleaning solutions outside the isolation rooms.. Later on the same day, 8/29/11 at 3:45 p.m. R1, R9 and R19's rooms remained without a cleaning bucket of wipes outside their doors. E16 (Environmental Services Director) was notified at this time that E19 had stated at 1:55 p.m. (2 hours earlier) that the buckets for R1, R9, and R19 would be replaced with the appropriate cleaning solutions. E16 verified that a room with a resident that has[DIAGNOSES REDACTED]icile should have a 10% Bleach solution for cleaning and stated to mix that you would use 1 part bleach to 2 parts water. E16's one part bleach to two parts water was the second incorrect dilution given for a 1:10 bleach solution by Environmental Services Management personnel. E16 stated she would have cleaning buckets made for R1, R9 and R19. On 8/29/11 at 4:00 p.m. R1, R9 and R19's rooms remained without cleaning buckets outside their doors. E2 (Registered Nurse, Department Director for Extended Care Facility) was informed at the time of this observation that the proper solutions had not been outside the door at 1:00 p.m. and that at 1:55 p.m. E19 stated that the cleaning buckets would be replaced and at 3:45 p.m. E16 also stated that the cleaning buckets would be replaced. E2 confirmed that a 10% Bleach solution should be outside of R1's door and stated that she would have the cleaning buckets replaced. On 8/29/11 at 5:00 p.m., 5:40 p.m. and 6:10 p.m. (now more than five hours since the first observation) R1, R9 and R19 did not have cleaning buckets outside of their isolation rooms. On 8/29/11 at 5 p.m., Z2 (family member) discussed her concern regarding R8's diarrhea with E6 (Registered Nurse). On 8/30/11, R8's physician ordered that a stool culture for Clostridium difficile be obtained. The facility provided infection control policy for Clostridium Difficile dated as reviewed on 1/2011 states that contact precautions shall be used for patients with known or suspected Clostridium difficile associated disease. Isolation precautions were not initiated when R8 displayed symptoms of suspected Clostridium difficile infection and laboratory tests were ordered. On 08/31/11 E14 (Licensed Practical Nurse) verified that R8 was not placed in isolation precautions while her stool culture was pending, but should have been On 8/30/11 at 8:05 a.m. R1, R9 and R19 again did not have cleaning buckets outside of their isolation rooms. At 9:25 a.m. R1 had a bucket labeled with HB Quat outside of her MRSA isolation room while R9 and R19 did not have cleaning buckets outside of their[DIAGNOSES REDACTED]icile isolation rooms. On 8/30/11 at 9:30 a.m. two spray bottles of bleach were behind the nurses station labeled two parts bleach to ten parts water (another incorrect attempt at 1:10 dilution). On 8/30/11 at 1:05 p.m. E10 (Infectionist) and E11(Infection Control Director) stated that for a patient with[DIAGNOSES REDACTED] a bleach substance should be available in the patient's room for staff to clean with.. E11 stated that the HB Cleaning wipes are not acceptable to kill[DIAGNOSES REDACTED]. E11 stated that she was not aware that cleaning buckets had been placed outside of R9 and R19's room. E11 stated that nurses portable medication scanners are not to be taken into any patients room in isolation. The facility's policy for Clostridium Difficile from the Infection Control Department dated August 2011 documents to Remove gown and gloves before exiting room, ensure adequate cleaning and disinfection procedures of environmental surfaces and reusable devices, especially items likely to be contaminated with feces and surfaces that are touched frequently are performed. An Environmental Protection Agency registered sodium hypochlorite based disinfectant shall be used for environmental surface disinfection after cleaning in accordance with label instructions, generic sources of hypochlorite (household chlorine bleach) also may be appropriately diluted and used (diluted 1:10 with water). E16 (Environmental Service Supervisor) stated on 8/31/11 at 2 PM that the disinfectant used in the hospital for Clostridium Difficile (C-diff) and Influenza A infections is a solution of one part bleach to ten parts water, in accordance with Centers for Disease Control (CDC) Guidelines. E16 stated that these solutions are made by housekeeping staff for use in isolation rooms. E16 stated that the Housekeeping Supervisor (E19) oversees that housekeeping staff are mixing the solutions correctly. Interviews with Environmental Services Aides verified that there was still confusion as to where the cleaning solutions for disinfecting equipment was to be kept. On 8/31/11 at 9:20 a.m. E17 (Environmental Services Aide I) stated that to prepare a cleaning solution for a[DIAGNOSES REDACTED]icile room he would mix in a spray bottle 10% Bleach and 90% water . E 17 stated he would "put it someplace so it is available for the nurses to use it, maybe at the nurses station." On 8/31/11 at 10:45 a.m., when asked how the 10% bleach solution is made available for Nurses E20 (Environmental Services Aide II) replied that it is left in the housekeeping closets or on the housekeeper's carts and that the Nurses have to ask for it. On 9/1/11 at 10 AM, a spray bottle labeled " 1 Part Bleach to 10 parts Water " and " 10 Minute Kill Time " was sitting on a counter at the Extended Care nurses ' station. The bottle was filled to within one to two inches of the top, far above the volumetric graduations on the bottle. Glucose Monitoring and Patient Care Observations on 8/29/11, 8/30/11, and 9/1/11 verify that multiple staff including E14 (LPN)Licensed Practical Nurse, E15 (RN) Registered Nurse, E12 RN, E21 (CNA) Certified Nurse Aide, and E6 RN failed to practice good infection control technique when performing blood glucose monitoring and direct patient care. Information provided by the facility documents that ten residents (R2, R11, R13, R16, R17, R18, R19, R20, R26, and R27) all have orders for blood glucose monitoring. Facility staff utilize one glucometer for all glucose monitoring for these ten residents. On 8/29/11 at 11:23 a.m. E14 (Licensed Practical Nurse) performed a Blood Glucose Check on R2 in her room. E14 did not wash her hands with soap and water or sanitize her hands before or after performing R2's blood glucose check. E14 placed the glucose machine, glucose strip and four by four gauze on R2's bedside table; no clean field was prepared. E14 donned one glove prior to performing finger stick. E14 then left R2's room and obtained R2's Insulin in a syringe, E14 then re-entered R2's room to administer the injection and administered the injection without donning gloves. E14 then entered R16's room at 11:45 a.m. to perform a glucose check without cleaning the glucose monitoring machine or washing her hands between rooms. E14 placed the four by four, and the Glucose Monitoring Machine and strip on R16's bed. E14 donned one glove and performed the glucose check. E14 exited R16's room and entered R17's room at 11:55a.m. without washing hands or cleaning the Glucose Monitoring Machine. E14 placed the four by four, and Glucose monitoring machine and strip on R17's chair. E14 donned one glove and performed the glucose check. E14 then left R17's room to obtain R17's insulin injection. E14 re-entered R17's room without washing hands or donning gloves and administered R17's insulin injection. E14 left R17's room and placed the Glucose Monitoring Machine on the Nurses medication cart without cleaning it. On 8/29/11 at 4:20 p.m. E15 (Registered Nurse) entered R17's room to perform a glucose check. E15 placed the Glucose monitoring machine,strip and four by four on the bedside table without preparing and maintaining a clean field. After performing the glucose check E15 left R17's room and wiped the glucose monitoring machine with a HB Quat wipe for 3 seconds. E15 then entered R16's room at 4:25 p.m. to perform a glucose check. Supplies were placed on R16's bedside table without establishing or maintaining a clean work field. E15 left R16's room and cleaned the Glucose Monitoring Machine with an HB Quat cleaning wipe for 5 seconds. At 4:35 p.m. E15 entered R18's room and performed a glucose check. A sterile field was not established or maintained for the Glucose Monitoring supplies. E15 left R18's room and cleaned the Glucose monitoring machine with an HB Quat wipe. Continuing on 8/29/11 at 4:40 p.m. E15 entered R19's room. R19 had tested positive for[DIAGNOSES REDACTED] 8/18/11 and had Isolation supplies and a sign outside of her room. R19's isolation sign read contact precautions. E15 donned a gown and gloves and placed the blood glucose monitoring machine on R19's bedside table and a four by four and the glucose monitoring strip on the arm of the chair R19 was sitting in. E15 did not establish or maintain a clean field for the glucose monitoring supplies. E15 completed R19's glucose check and proceeded to leave the room to obtain R19's Insulin injection while wearing the protective gown she had donned. E15 placed the glucose monitoring machine that was used in R19's room on the nursing medication cart without cleaning it. E15 continued to stand outside of R19's room at the nurses medication cart in the same gown E15 had donned when she entered R19's room. E15 prepared R19's insulin injection while E7 (Licensed Practical Nurse) stood next to E15, brushing her gowned arm to while verifying the Insulin for R19. E15 re-entered the R19's room to administer the Insulin injection. E15 carried the portable medication scanner into R19's room to scan R19's armband. E15 left R19's room and cleaned the Glucose Monitoring Machine with an HB Quat cleaning wipe.(The 3M Environmental Control of Clostridium difficile Fact Sheet notes that "some strains of [DIAGNOSES REDACTED]icile may display increased levels of spore production when exposed to non-chlorine based cleansing agents). E15 placed the medication scanner back on the nurses medication cart without cleaning it. E15 later this same day performed a glucose check at 4:50 p.m.on R2. E15 did not establish or maintain a clean working field for the blood glucose monitoring supplies. On 8/30/11 at 9:25 a.m. E12 (Registered Nurse) placed a nursing portable medication scanner in her pocket, donned a gown and gloves and entered R19's isolation room to administer oral medications. E12 exited R19's room after scanning her armband and her medications with the medication scanner in her pocket. E12 walked to the nurses station and took the scanner that had been used in R19's room and cleaned it with a bleach spray bottle labeled 2 parts bleach/10 parts water. The facility's policy titled Blood Glucose Monitoring dated September 2010 documents to clean meter with hospital aseptic wipes between all patient contact. Clean test strip holder and lens gently with 10% bleach solution and to refer to operator's guide for further information. The (manufacturer's name) professional blood glucose management system manufacturer's instructions document Caution: do not use alcohol or any cleansers containing [MEDICATION NAME] or ammonia to clean the test strip holder and the lens area. The manufacturers recommendation document to wipe the test strip holder and base with a cotton swab dampened with a 10% bleach solution, dry the test strip holder with a soft cloth or lint-free tissue and to wipe the lens are with a cotton swab dampened with a 10% bleach solution. The recommendations then document to follow with a cotton swab dampened with water to remove residual bleach and to finish by drying the lens with a clean, soft, lint-free tissue. The Material Safety Data Sheet for 3M HB Quat documents ingredients as Alkyl (68% C12, 32% C14) [MEDICATION NAME] Ammonium chloride, Alkyl (60% C14, 30% C16, 5% C12, 5% C18) [MEDICATION NAME] Ammonium Chloride, Ethoxylated C12-C15 Alcohols and Ethyl Alcohol. The manufacturers patient instruction card for R9's central venous port documents that R9's central venous port was inserted on 6/29/11. The computerized lab report documented that R9 was positive for[DIAGNOSES REDACTED]icile ( Clostridium Difficile) on 8/14/11. On 9/1/11 at 9:45 a.m. E21 (Certified Nursing Assistant) answered R9's request to remove her from the bedpan. E21 donned gloves to clean up feces from R9 after removing the bedpan from under R9. E21 cleaned the bedpan with feces in it with water, removed old gloves and donned new gloves without washing hands. E21 proceeded to clean feces from R9's buttocks and peri area and remove dirty linens soiled with feces. E21 removed the linens dirtied with feces out from under R9, rolled them up and placed them on the foot of R9's bed on top of R9's comforter. E21 placed a clean gown on R9 while wearing the same gloves she had cleaned the feces with. E21 removed gloves, washed her hands with soap and water for less than 5 seconds then donned a new pair of gloves to apply a barrier creme to R9's buttocks. E21 removed her gloves and washed her hands again for less than 5 seconds and exited the room. On 9/1/11 at 10:10 a.m. E21 confirmed wearing the dirty gloves to place the clean hospital gown on R9. Admission forms dated 07/27/11 document that R3 has [DIAGNOSES REDACTED]. E21 entered R3 ' s room, donned gloves without first washing her hands, removed R3 ' s incontinent brief and washed R3 ' s labia and catheter. E21 cleansed bowel movement from R3 ' s rectal area, changed gloves without washing her hands and applied protective ointment to R3 ' s rectal area. At 10:50 a.m., on 09/01/11, E21 confirmed that she did not wash her hands prior to performing catheter care on R3. The Center for Disease Control documented in July 2000 that most transient organisms can be removed by 30 seconds of proper scrubbing with soap and water. On 8/29/11 at 4:20 PM, E6(Registered Professional Nurse) got a lancet and a blood glucose strip out of the medication cart and entered R13 ' s room. E6 did not wash her hands, donned gloves, placed the strips and lancet on an unclean chair seat. E6 did the finger stick and scraped the blood from the finger with the strip. E6 left the room, placed the strip into the glucose monitoring machine, removed her gloves and did not wash her hands. E6 did not clean the glucose monitoring machine after use. E6 dropped R13 ' s oral medication on the medication cart, picked it up with unclean hands and placed it in the medication cup and administered it to R13. E6 did not wash or sanitize her hands before leaving R13 ' s room. On 8/29/11 at 5:00 PM, E6 entered R14 ' s room, did not wash her hands, donned gloves and administered a [MEDICATION NAME] injection, recapped the needle, took off her gloves and did not wash or sanitize her hands before leaving the room. According to admission forms dated 08/14/11, R4 has [DIAGNOSES REDACTED]. On 08/30/11 at 12:50 p.m. E18 (Registered Nurse) performed pressure sore treatment to R4 ' s bilateral buttocks pressure sores. E18 failed to establish a clean field and did not cleanse R4 ' s over bed table prior to placing the dressings and supplies on it. R4 has a stage II pressure ulcer on her right buttock and another stage II pressure ulcer on her left buttock. E18 cross contaminated these two areas by using the same part of the same washcloth to cleanse both pressure sores. After E18 applied dressings to both pressure ulcers, without washing hands or changing gloves, E18 applied Aloe Vista protective ointment to R4 ' s peri-rectal area. On 8/29/11 at 4:15 p.m. E15 (Registered Nurse) donned a gown and gloves to administer eye drops to R1. R1 had a sign on the door that read contact isolation precautions for MRSA (Methicillin-Resistant Staphylococcus Aureus) in the urine. E15 set the eye drop bottle down on the overbed table, obtained a tissue and administered the eye drops to R1. E15 wiped R1's eye then placed the eye drop bottle back on the overbed table. E15 removed gown and gloves, washed her hands then picked up the eye drops from the overbed table, carried them out of the room and placed the eye drops in the computerized medication cart. On 8/30/11 at 8:09 a.m. E12 (Registered Nurse) entered R1's room to administer eye drops and opened the computerized medication cart to look for the bottle of eye drops. E12 could not find the eye drop bottle so she entered R1's room and found them in a basket in the room. R1's room had a contact isolation precaution on the outside of the door. Z3 stated on 8/30/11 at 12:30 p.m. that she is concerned that chairs in R1's room for visitors are being used as storage for R1's linens and pillows. Z3 stated "how do I know what dirty items staff has placed on (R1)'s chairs and that I am not at risk for getting MRSA myself. "When I asked the staff to stop using the chairs for (R1)'s items they obtained a folding chair for me to use when I visit. I am not going to sit in a folding chair for hours while I visit (R1)." Infection Control Policies/Procedures On 8/30/11 at 1:05 PM, E10 (Infectionist) stated that she was in charge of infection control for the entire hospital including the second floor extended care. E10 stated that she reviews laboratory results daily and decides whether the infection was hospital or community acquired. E10 stated that she keeps a log of organisms, site, patient location, history, patient origin, but she does not track antibiotic usage. E10 stated that at the present time she has two residents in isolation with[DIAGNOSES REDACTED]icile (R9, R19) and one resident in isolation for Methicillin Resistant Staphylococcus Aureus(Colonized) (R1). E10 stated that there are three residents with catheters and one resident with a Mediport. E10 stated that they use Standard Precautions to prevent spread of infections. E10 stated that Contact Isolation is used when a resident has[DIAGNOSES REDACTED]. A bleach solution is kept in the resident's room and soap and water is used to wash hands. No alcohol based hand gel is used for hand washing. E10 stated that Residents with MRSA are placed in isolation and retested twice after receiving antibiotic. E10 stated that she was unsure what solution is used to clean equipment and room, but staff can use alcohol based hand cleaner for hand washing. E10 stated that she was unaware of tubs of wipes sitting outside the isolation rooms. She did not know what solutions was in them. E10 stated that housekeeping takes care of this; they mix the solutions. E10 stated that she thinks they keep a " Johnny mop " in the room and use it to clean with. E10 stated that the medication scanners are not to be taken into isolation rooms. The patient information is to be entered into the computer manually to give the medications. The Infection Control Log documentation for 6/2011, 7/2011 and 8/2011 indicates that there were no residents on the extended care floor with[DIAGNOSES REDACTED]icile, the month of June and two patients on the hospital floors. In July there were five residents on the extended care with[DIAGNOSES REDACTED]. and one patient in the hospital part. In August there were four residents on the extended care floor with[DIAGNOSES REDACTED] and no patients on the hospital floors. On 8/31/11 at 3:00 PM, E2 (Unit Director) stated that she has not investigated or monitored isolation procedures regarding so many cases of[DIAGNOSES REDACTED] on her unit. E2 stated that she did not know if they were brought to the unit with infection or whether it was acquired. E2 stated that she has not had inservices for the staff regarding hand washing, cleaning of the equipment and cleaning the rooms with[DIAGNOSES REDACTED] since the increase of residents with[DIAGNOSES REDACTED]. Laundry Services During the general tour of the laundry with E 9 (Housekeeping Supervisor) and E2 (Extended Care Unit Director) at 10 AM on 8/31/11, E9 stated that all general linens are sent out of the hospital to a commercial laundry. E9 stated that only mops, housekeeping rags, patient personal laundry, foot protectors and Extended Care Unit privacy curtains are laundered in the facility's washing machine. E9 said that the washer has computerized settings for different items. E9 gave examples that personal clothing is run on setting # 12 with no bleach, while delicate microfiber mop heads used to clean all in-house nursing units are run on setting # 19 with no bleach. E9 stated that the washer functions are checked monthly by the facility's laundry chemical supplier. A chemical supplier technician Routine Preventive Maintenance report dated 7/20/11 indicated that the temperature of the wash water in the machine when tested was only 130 degrees Fahrenheit (F). E16 (Environmental Service Supervisor) stated at 2 PM on 8/31/11 that the facility's washer uses four chemicals: liquid laundry detergent, chlorinated de-stainer, fabric softener and concentrated laundry sour. E16 said that there are different water temperatures for different settings, and that the machine is equipped with a temperature button that can be pushed to determine the water temperature in the machine for that particular cycle. E16 presented a note at 2:30 PM on 8/31/11 that temperature readings for the washer had been taken earlier by staff for settings #12 and #19 with readings of only 98 degrees and 103 degrees, respectively. The facility's Immediate Jeopardy Abatement Plan presented 9/1/11 indicated under the topic of Linen Disinfection that a washing machine steam valve rebuild kit was on order and would be installed on arrival, with all linens to be sent to the outside contracted line service in the mean time. The Plan stated that all linens will be washed with bleach or at a temperature above 160 degrees F (per Centers for Disease Control (CDC) guidelines) to kill bacteria and spores for washer setting #19. E1 (Hospital Administrator) stated on 9/1/11 at 9:30 AM that maintenance staff discovered the preceding afternoon that low temperature readings were obtained for the washing machine because the machine's steam valve was not opening correctly or consistently to supply hot water at 180 degrees Fahrenheit. Whirlpool Tub Cleaning During the general tour of the Two East hall with E9 (Housekeeping Supervisor) and E2 (Extended Care Unit Director) in the whirlpool tub room on 8/31/11 at 10:40 AM, E30 (Certified Nurse Aide) stated that she cleans the tub in between patients by first spraying Bathroom Cleaner # 4 sanitizer on the walls and floor of the tub. E30 said that after five to ten minutes, she sprays off the sanitizer with hot water and wipes down the tub with bath soap. E30 said that finally she sprays off the soap and fills the tub for the next patient. E30 said that this procedure is what she does to clean the tub. E31 (Certified Nurse Aide) stated on 8/31/11 at 2:25 PM that after draining the whirlpool tub, she sprays the tub walls, floor and attached lift chair with Bathroom Cleaner #4 . E31 stated that after about five to ten minutes, she wipes the tub and chair down with a rag and sprays the tub with hot water. E31 said that she next hooks the spray hose to the whirlpool jet outlet and flushes it out. E31 said that finally she cleans the bottom of the tub with the disinfectant again where the water came out of the outlet, rinses it, and fills the tub for the next patient. E31 said that she was taught this cleaning procedure over [AGE] years ago when she started working at the hospital. The facility's Immediate Jeopardy Abatement Plan for F441 dated 9/1/11 stated under the Whirlpool Cleaning section: " A specific policy will be developed for Whirlpool Bath cleaning. " The Immediate Jeopardy was identified at 4 PM on 8/31/11 to have begun on 8/29/11 when the survey team observed breaches in infection control procedures for residents in isolation on the Extended Care Unit. E1 (Hospital Administrator) and E2 (Extended Care Unit Director) were notified of the Immediate Jeopardy on 8/31/11 at 4:45 PM. It was confirmed through interview, observation, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. The Infection Control Nurse completed an assessment of current policies to ensure adherence to F441 on 9/1/11. 2. All staff will receive re-education on Infection Control Policies, cleaning agents used for pathogens, signs and symptoms of potentially infectious pathogens including Methicillin Resistant Staphylococcus Aureus (MRSA) , [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE), Clostridium Difficile (C-diff) and [DIAGNOSES REDACTED] (TB); hand hygiene guidelines from Centers for Disease Control (CDC)/ World Health Organization (WHO), the revised policy for glucometer cleaning, the use of dedicated equipment in isolation rooms, the cleaning of whirlpools,and cleaning and care of medication scanners. The re-education of staff is to be completed by 9/7/11. 3. A specific policy will be developed for Whirlpool bath cleaning on 9/1/11. 4. Corrective action plans for each identified infection will be added to the Infection Control Log and reviewed with the Director of Extended Care. The analysis and surveillance of these findings will be presented to Quality Council, and the information will be shared with Environmental Services and Extended Care. 5. All hospital -laundered linens will be washed with appropriate concentration of bleach or at a temperature high enough to kill bacteria and spores (Cycle 19). A steam valve rebuild kit is on order and will be installed on arrival. All linens will be sent out to the contracted linen service until the valve is repaired. B. Based on record review, observation, and interview, the facility failed to have isolation procedures in place to discontinue isolation when the organism is colonized or contained for one of one residents (R1) reviewed with MRSA in the sample of ten. Findings include: According to the face sheet R1 was admitted to the facility on [DATE]. The POS (Physician order [REDACTED]. The computerized patient notes document that R1 was placed in isolation for MRSA (Methicillin-Resistant Staphylococcus Aureus) in the urine on 2/28/11 and is in a private room. R1 has been confined to her room for six months although she has a urinary catheter in her bladder to contain the spread of MRSA. R1 has been unable to attend activities or to wear her own clothing during this time period. On 8/29/11 at 4:15 p.m., 8/30/11 at 8:09 a.m. R1 was lying in the bed in her private room with a contact isolation sign on the door, wearing a hospital gown sleeping in her bed. On 8/30/11 at 12:30 p.m. Z3 (R1's niece) was visiting. R1 was sleeping during the visit in bed with a hospital gown on. On 8/31/11 at 8:10 a.m., 1:00 p.m. and 9/1/11 at 10:00 a.m. R1 was lying in her bed wearing her hospital gown. On 8/31/11 at 10:00 a.m. E2 (Unit Director) stated that residents in isolation do not wear their own clothes. E10 (Infection Control Coordinator) stated on 9/1/11 at 10:45 a.m. in response to why R1 was in contact isolation if R1's urine was contained in a urinary catheter bag, "I wondered that myself but the person i

Based on observation, interview and record review the facility neglected to re-evaluate the need for isolation precautions for six months for one of two residents (R1) reviewed for isolation in a sample of ten. During this six months of isolation, R1 was denied the opportunity to wear her own clothing, deprived of meaningful activities, and experienced a 15% weight loss. Findings include: According to the face sheet R1 was admitted to the facility on [DATE]. The POS (Physician order [REDACTED]. The computerized patient notes document that R1 was placed in isolation [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) in the urine on 2/28/11 and is in a private room. R1 has been confined to her room for six months although she has a urinary catheter in her bladder to contain the spread [MEDICAL CONDITION]. R1 has been unable to attend activities or to wear her own clothing during this time period. On 8/29/11 at 4:15 p.m., 8/30/11 at 8:09 a.m. R1 was lying in the bed in her private room with a contact isolation sign on the door, wearing a hospital gown sleeping in her bed. On 8/30/11 at 12:30 p.m. Z3 (R1's niece) was visiting. R1 was sleeping during the visit in bed with a hospital gown on. On 8/31/11 at 8:10 a.m., 1:00 p.m. and 9/1/11 at 10:00 a.m. R1 was lying in her bed wearing her hospital gown. On 8/31/11 at 10:00 a.m. E2 (Unit Director) stated that residents in isolation do not wear their own clothes. Z3 stated on 8/30/11 at 12:30 p.m. that R1 enjoyed going to bingo and church services before being placed in isolation/ Z3 states she feels that the staff do not even try to talk to R1 "they walk in, introduce themselves, state what they are doing and walk away sometimes while in mid sentence. The other day a nurse was talking to (R1) as she was walking out of the room and I made her turn around and come back and face (R1) so she could hear." E10 (Infection Control Coordinator) stated on 9/1/11 at 10:45 a.m. in response to why R1 was in contact isolation if R1's urine was contained in a urinary catheter bag, "I wondered that myself but the person in this position before me put (R1) in contact isolation and nursing would take her out of isolation." E5 (Activity Director) stated on 9/1/11 at 9:30 a.m. that she does activities with R1 three times a week, but due to her contact isolation precautions R1 can't be taken out of her room. E2 (Unit Director) stated on 9/1/11 at 11:00 a.m. that R1 liked to go to church and sit in the dining room before she was put in contact isolation. When asked why R1 is still in isolation of [MEDICAL CONDITION] is contained in the urinary catheter bag E2 stated "infection control decides when to take residents out of isolation." During this same time period of isolation, facility staff neglected to evaluate R1's nutritional status and the potential detrimental affect isolation had on R1's nutritional well being. In a Dietary Assessment Form dated 1-18-08 (verified by E2 , Extended Care Unit Director on 9/1/11 at 9:10 a.m. as the most recent dietary assessment), it is documented that R1 has no recorded likes and dislikes mashed potatoes. The RD (Registered Dietician) documented on this dietary assessment that R1 weighed 122 Lbs (pounds) and has an ideal weight of 130 Lbs. R1 has documented weights on a computerized medical flowsheet between the months of 3/2011-8/2011 (months which coincide with R1's isolation). In March of 2011 R1 weighed 119 Lbs (Pounds), April 2011 weighing 110 Lbs, May 2011 weighing 108 Lbs, June 2011 weighing 101 Lbs, and July and August weighing 100 pounds. R1 had a 19 Lb weight loss = 15% in a six month time frame. In Ancillary Services Progress notes the dietary aide documented on 3/3/11 that R1 weighed 119 Lbs and had intakes of 25%-75%. The dietary notes do not indicate if the poor intakes are of liquid, food or a combination. R1 was on a general diet with Dietary Supplements at lunch and supper. The Dietary Aide noted on 4/28/11 a weight of 110 Lbs and on a Mechanical Soft diet with ground meat. R1's oral intake was averaging 50%. The Dietary Aides notes do not address that R1 had a 9 Lb (7.5%) weight loss in one month. The Dietary Aide documented a goal to maintain good eating habits and to maintain weight. The Dietary Aide did not refer R1 to the Registered Dietician or Physician for further evaluation. The dietary notes do not include a plan or new interventions to prevent continued weight loss. According to the computerized flowsheet R1 weighed 108 Lbs in May and lost an additional 7 Lbs (6%) by June 2011 weighing 101 Lbs. The Dietary Aide did not document a note in May. The Dietary Aide's notes on 6/30/11 and 7/21/11 document "no new weight", oral intake of 0-25%, on mechanical soft diet, and "will follow". The Dietary Aide did not address R1's continued weight loss or refer R1 for further evaluation from the Physician or Registered Dietician. The dietary notes do not include a plan or new interventions to prevent continued weight loss. Although the computerized flow sheet documented an August weight of 100 Lbs for R1, the Dietary Aide noted for R1 on 8/31/11 "no new weight:, on mechanical soft diet with an oral intake of 0-50%, no new labs, "will follow". The dietary notes continued to not include a plan or new interventions to prevent continued weight loss. R1's care plan originally dated 2/1/11 and updated 3/31/11 documents as a problem to serve a mechanical soft diet due to [MEDICAL CONDITION] and to place all food in cups, and leaves 25% most of the time. R1's goal last revised 5/2/11 is to tolerate consistency of foods served and eat at least 50% without evidence or complaint of choking. R1's approaches dated 2/1/11 are to monitor /record percentage of meal consumed and supplement taken, cut food into small bites and give reminder to eat slow, place food in cups in front of her and tell her what she has in front of her and monitor/record the weight monthly and notify the physician of 5% weight loss in one month or 10% in 180 days. On 5/4/11 updates to approaches were documented that read to increase Ensure to TID (three times a day) for poor intake and wound healing, let her try some finger foods but staff to feed her and that family will bring in tippy cup for water. Documented under comments on R1's care plan on 8/1/11 it is documented "#100 an arrow pointing downward" with "refuses meals a lot" written. A weight loss care plan with goals and approaches was not documented. R1's MDS (Minimum Data Set) dated 8-1-11 documented under Section D-Mood for poor appetite a 1 for symptom presence and symptom frequency was 1-6 days. The MDS section G-Functional status documented extensive assist of one person with eating. Section K-Swallowing/Nutritional Status of R1's MDS documented a weight loss of 5% or more in the last month or loss of 10% or more in 6 months. In the computerized patient assessment form beginning 6/30/11 through 8/11/11 it is documented throughout that R1 has Stage I bilateral red buttocks and Peri area. It is also documented on 7/1/11 that R1 is assisted with dining. On 7/6/11 it is documented that R1 is a total feed. It is also documented that on 7/6/11 at 2130 that Z3 (Niece of R1) called and asked if anyone had checked R1's mouth as she had sores in her mouth. Oral exam shows a lot of food under R1's dentures, top gums are very red with numerous small blister areas. On 7/8/11 it is documented that R1 is assisted with dining. The computerized assessment forms vary for assistance needed to feed R1 from Total feed to assistance dated 6/30/11 ending with self feed on 8/10/11. On 8/30/11 at 12:30 p.m. Z3 stated that the facility does not pay attention to R1's likes and dislikes. Z3 stated that R1 loves Salmon but when the facility's kitchen does serve it the salmon is dark in color and dry. Z3 states she has told the facility about the food and the preferences and nothing is done about it. Z3 stated that at lunch on 8/30/11 R1 had eaten 1 bite of each of her pineapple, potatoes, chicken and noodles and tomato soup also taking just a couple sips of her supplement. E2 (Registered Nurse, Department director, Extended Care Facility) stated that the facility monitors weight loss by obtaining weekly weights, providing supplements and creating a weight loss care plan. E2 stated she was not aware of R1's 15% weight loss and that it should have been care planned but was not. E2 also verified that R1 should have been placed on weekly weights but was left on monthly weights which are obtained the 5th of every month. E2 stated that the Dietary Aides had access to all of R1's weights and should have asked for assistance from the staff if the Dietary Aides could not find R1's weights.

A. Based on observation, interview and record review, the facility failed to provide services that meet professional standards of quality by administering a gastrostomy tube feeding late when the Registered Nurse was unable to measure the tube feeding and failed to give the correct dosage of medication during this same observation for one of one residents (R4) receiving gastrostomy tube feedings in the sample of ten. R4 suffered mental and physical anguish when her tube feeding was two and one half hours late. R4 required two doses of anti-anxiety medications following this delayed feeding episode. Findings include: On 8/29/11 at 5:05 PM, E6 (RN) spent 45 minutes trying to measure 300 milliliters of Ensure Plus which was to be administered through R4's gastrostomy tube. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. E6 was unable to read the measurement lines indicated on the medication cups. E6 left the cart unlocked with the keys laying on top while she went to the nursing desk and made an unsuccessful phone call trying to get a clear cup so she could see the pre-measured lines. E6 returned to the med cart, tried again to read the measurement lines; staring at the cups for approximately five minutes. E6 asked E7, Licensed Practical Nurse to show her the line, but E6 was still unable to see the line. E6 left the medication cart a second time to make yet another phone call trying to get a clear cup to measure the 300 ml of feeding. The medication cart remained in the hallway approximately fifteen feet away with the medication cart unlocked with one drawer of oral medications standing open, the keys to the cart and the narcotics drawer laying on top of the cart. On 8/29/11 at 5:45 PM, E6 RN finally returned to the unlocked medication cart and poured the Ensure Plus into the two medication cups 150 ml lines. E6 again asked E7 to look to make sure she measured correctly. By now, it is one hour and 45 minutes past the time, the tube feeding is to be administered. E6 proceeded to pour 25 milliliters (ml) of liquid Tylenol into a medication cup. This measured amount was incorrect as the physician's orders [REDACTED]. dose of Tylenol was 20 ml.. E6 went into R4's room and began measuring 120 milliliters water for flush. Instead of proceeding with tube feeding and medication administration, E6 dumped the water, left the room, and went to the nurses desk to make another phone call. Once again the medication cart in the hallway was left unlocked with the keys and Tylenol still sitting on top. E6 then left the nurses desk after making the phone call and went down the hall and around the corner leaving the medication cart. At 5:50 PM, E2 (Unit Director) walked by the medication cart. E2 was told that the medication cart was unlocked with keys on top, the length of time and the problems E6 RN was having trying to administer R4's gastrostomy feeding and medication. E2 waited for E6's return. E2 gave E6 the medication cart keys from the top of the cart and told her to keep them in her pocket and to keep the cart locked. E2 then walked into R4's bathroom to get water for the flush leaving the medication cart unlocked. At 5:55 PM, E7 (Licensed Practical Nurse) brought the medication cart into R4's room and told E6 that E2 wanted her at the desk, that she (R7) was going to take over the medication pass. R4 stated to E7, "please feed me. I'm going to pass out from hunger. I was supposed to eat at 4:00 PM. My stomach is growling and hurting. I have never went this long without eating. I am so tired and need to go to bed, but I have to stay up and walk or sit up for thirty minutes after I eat." R4's color was grey. R4 was gasping when she spoke. R4 was crying when she complained of being hungry and weak. E7 left the room to get a stethoscope to listen for placement. E7 returned to the room, checked the order, checked placement and measured the water for flushing. At 6:10 PM, E7 started administering the feeding that E6 had poured (now two hours and ten minutes late). E7 could not find an order for [REDACTED]. E7 gave the Tylenol 25 ml that E6 had poured into the medication cup. E7 had no way of knowing what medication was in the medication cup. E7 did not check the amount of medication in the cup prior to administering it. The correct amount was 20 ml. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The Ensure Plus 300 milliliters was given again at 8:20 PM (two hours after the ordered 4:00 PM feeding which was given at 6:20 PM. According to Clinical Nursing Skills Nursing Process Mode Basic to Advanced Skills, Third Edition, Sandra F. Smith, RN MS and Donna J. Duell, RN MS, Chapter 15 Medication Administration, Safety Procedures: When you administer drugs, you must follow certain safety rules, which are also known as "The Five Rights." These rules must be carried out each time you give a drug to a patient. The Five Rights: 1. Right medication (compare drug card, medication sheet three times, with label on drug container. Know action, dosage, and method of administration. Know side effects of drug.) 2. Right patient, check the patient's identaband and door number. 3. Right time. 4. Right method of administration 5. Right amount. (check all calculations of divided doses with another nurse. Check [MEDICATION NAME], insulin and IV [MEDICATION NAME] doses with another nurse.) If you prepare a medication, you must also give it to the patient and chart it after the patient has taken the required dosage. Medication Safety Measures: Take medication tray or cart to patient's room. Keep all medications in locked carts or cupboards. Keep narcotics in double-locked cabinets. B. Based on observation, interview, and record review the facility used improper technique and the wrong medication when flushing a central line venous catheter for one of one residents (R9) with a central venous catheter on the sample of ten. Findings include: On 8/29/11 at 12:15 p.m. E18 (Registered Nurse) prepared R9's implanted venous access port for an intravenous antibiotic to be infused. E18 obtained a 10 ml (milliliter) needleless syringe of 0.9% Sodium Chloride to flush the two lumens on R9's venous access port. E18 unclamped the lumen, wiped the lumen port with an alcohol swab once, then attached the syringe to a lumen and attempted to pull back on the plunger of the syringe to elicit a back flush of blood. E18 was unable to elicit the back flush of blood and began forcefully pushing and pulling on the plunger of the syringe of Sodium Chloride. E18 continued to forcefully push and pull the syringe to elicit the blood return 10-12 times before eliciting a small amount of blood then forcefully flushing the 10 ml of sodium chloride through the lumen. The lumen of the venous access port was then left with air bubbles in it and not re clamped before detaching the syringe. E18 then attached the antibiotic infusing and began administering it through a pump. At completion of the antibiotic infusion E18 disconnected the intravenous infusion and flushed with 10 ml 0.9% Sodium Chloride. The facility's Central Venous Catheter Policy and Protocol Grid dated 6/2010 documented under the heading Practice Guidelines that a physicians order is required to start utilizing catheter. The Central Venous Catheter Protocol grid documented to wipe port with alcohol times two, utilize the push pause method for flushing and flush with 5 ml of [MEDICATION NAME] flush after each use. The facility's Needle Access, withdrawal of blood, injection of medication and [MEDICATION NAME] of implanted venous access ports dated 1987 and revised 9/03 documented to unclamp the lumen and withdraw 5 ml of blood, clamp tubing remove syringe and discard. If blood does not return have patient turn to side and cough gently, then attempt withdrawal. If blood still does not return after several attempts and position changes, notify physician. The manufacturer's instructions for the central venous catheter documented after each infusion of medication to flush with 10 ml sterile normal saline then 5 ml [MEDICATION NAME] saline. On 8/29/11 at 2:20 p.m. when asked to provide documentation of an order to use the central venous catheter E13 (Registered Nurse) and E14 (Licensed Practical Nurse) were unable to locate a physicians order. On 8/30/11 at 4:30 p.m. E18 stated "I was told to flush the central venous catheters with saline to get away from using so much [MEDICATION NAME]." E18 then verified after looking at the facility's policy that she was too forceful in flushing and should have used [MEDICATION NAME]. C. Based on observation, interview, and record review facility staff left the medication cart unlocked or unattended with the medication cart keys on top of the cart multiple times. This practice had the potential to affect six of ten residents (R1-R4, R8, R9) on the sample and twelve residents (R13, R14, R16-R20, R28-R32) on the supplemental sample. Findings Include: On 8/29/11 during medication pass starting at 11:35 a.m. and ending at 11:55 a.m. E14 (Licensed Practical Nurse) distributed medications from a wheeled computerized medication cart to R2, R16 and R17 failing to lock the medication cart when entering each individual's room. The unlocked medication cart was left in the hallway unattended. On 8/29/11 during medication pass starting at 4:05 p.m. and ending at 4:50 p.m. E15 (Registered Nurse) distributed medications from a wheeled computerized medication cart to R1, R2, R16-R19 failing to lock the medication cart when entering each individual's room. The unlocked cart was left in the hallway. On 8/29/11 from 4:00 PM to 4:20 PM a ring of keys were sitting on top of E6's, Registered Nurse's, (RN) medication cart unattended at the acute care side of the second floor nursing desk. E6 was seated at the nurses desk with the medication cart to her back at the end of the nursing desk. E6 stated that the keys were probably placed there by the respiratory therapist because the keys were for the medication cart and the storage cabinet for the respiratory medication. E6 removed the keys from the top of the medication cart and placed them in a unlocked drawer at the nurses desk. On 8/29/11 at 4:20 PM, E6 (RN) entered R13's room to administer a fingerstick to check the blood glucose level, leaving the medication administration cart in the hallway unlocked and unattended with the computerized Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s room. E6 did the finger stick and scrapped the blood from the finger onto the strip, returned to the hallway to the unlocked medication cart, placed the strip into the glucose monitoring meter, removed her gloves and did not wash her hands. E6 dropped the oral medication onto the cart, picked it up with unclean hands, placed the medication in the medication cup, returned to R13's room and administered the medication leaving the medication cart in the hallway unlocked. On 8/29/11 at 5:00 PM E6 administered [MEDICATION NAME] to R14, leaving the medication cart in the hallway unlocked and unattended, recapped the needle and placed it on top of the medication cart in a plastic glass. According to Clinical Nursing Skills Nursing Process Mode Basic to Advanced Skills, Third Edition, Sandra F. Smith, RN MS and Donna J. Duell, RN MS, Chapter 15 Medication Administration, Safety Procedures:...Medication Safety Measures: Take medication tray or cart to patient's room. Keep all medications in locked carts or cupboards. Keep narcotics in double-locked cabinets. Information provided by the facility indicates that R1-R4, R8, R9, R13, R14, R16-R20 and R28-R32 all have medications stored in these medication carts.

Based on observation, interview, and record review, the facility failed to provide tube feedings to meet nutritional requirements, failed to follow facility policy regarding water flushes, and failed to provide the correct tube feeding formula as ordered by physician and in a timely manner for one of one residents (R4) requiring gastrostomy tube feedings on the sample of 10. R4 lost 6% of her body weight during her two week stay in the facility and displayed signs of physical and mental anguish when her tube feeding was delayed for over two hours. Findings include: Admission forms state that R4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 08/29/11 at 11:30 a.m., E23 (Licensed Practical Nurse) administered a tube feeding to R4. E23 administered 300 cc (cubic centimeters) of Ensure muscle formula with 60 cc water flush before and after the formula and 40 cc water added to thin formula during the administration (total water 160 cc). The label on the can of Ensure muscle states that it is 247 cc and provides 250 calories per can. So, each 300 cc feeding would provide 303.6 calories. The Dietary note dated 08/15/11 is not signed, but on 08/30/11 E25 (Registered Dietitian) stated this note was written by E24 (Registered Dietitian) who is currently off and E25 is filling in for E24. This Dietary note of 08/15/11 states that R4 receives nothing orally and is receiving gastrostomy tube feedings of [MEDICATION NAME] with fiber 300 cc at 7:00 a.m., 11:00 a.m., 4:00 p.m. and 8:00 p.m. with 60 cc of water flush before and after each [MEDICATION NAME] feeding. This note states that R4 requires 1791 calories, 72 grams of protein and 1800 cc of free fluid daily, but that her current feedings only provided 1272 calories, 56 grams of protein, and 1008 cc of fluid daily. It was recommended that R4's current feeding be changed to Ensure plus, which would provide 1800 calories and 65 grams of protein daily. In a dietary note dated 08/22/11, E25 states that R4 remains NPO (nothing by mouth) and continues with feedings of [MEDICATION NAME] with fiber 300 cc four times daily, which provides only 71% of R4's needed calories, 77% of protein needs and 56% of fluid needs. E25 notes that R4 [MEDICATION NAME] level is low at 2.8, and her (R4) blood count indicates her hemoglobin of 9.4, hematocrit of 30 and red blood count of 2.84 are all low. E25 recommends that staff obtain a new weight for R4, get a pre-[MEDICATION NAME] lab test, and that R4's tube feeding formula be changed to Ensure plus "to more fully provide calorie needs." According to physician's orders R4's tube feeding was changed to Ensure plus on 08/25/11. This is 10 days after the Registered Dietitian made the first recommendation. On 08/31/11 at 10:15 a.m., E13 (Registered Nurse- charge nurse) stated that the Registered Dietitian recommendations are given to the charge nurse who call the physician regarding the recommendation and receives the physician's orders. E13 stated that she did not know why the recommendations of 08/15/11 and 08/22/11 were not addressed until 08/25/11. The computerized weight records document that R4 weighed 132 pounds on 08/14/11, and 124 pounds on 08/29/11. This weight loss of 8 pounds - 6% was confirmed by E2 (Extended Care Facility Unit Director) on 08/29/11 at 3:50 p.m. On 08/28/11, E25 writes that R4's laboratory report of 08/25/11 shows R4's [MEDICATION NAME] level remains low at 2.7, hemoglobin at 9.2, and hematocrit low at 29. E25's note states that R4 requires 780 cc of water flushes daily for adequate hydration, and again recommends a new weight be taken. On 08/29/11 at 3:35 p.m., R4's tube feeding formula which had just been sent up from the dietary department was Ensure muscle formula. E2 verified that Ensure muscle did not the contain the same nutrition and calories as Ensure plus and called for Ensure plus to be sent up for R4. On 08/30/11 at 9:55 a.m., E25 stated that R4 should be receiving Ensure plus for her tube feeding formula and that it was in stock on 08/28/11, but was not sure what was sent up on 08/29/11. E25 confirmed Ensure muscle does not have the same calories and nutrition as Ensure plus. On 08/30/11 at 10:35 a.m., E25 documents that Ensure plus is no longer available and to substitute Ensure clinical strength revigor 300 cc four times daily to provide the same calories and protein as Ensure plus. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On 08/29/11 at 11:50 a.m., E23 verified that nurses do not document R4's water flushes on the medication administration form or on the nurses notes. The facility policy for Insertion/Maintenance of Gastrostomy Tube dated 11/85 and last revised on 06/10 states patients receiving [MEDICATION NAME] enteral feedings are to have the gastrostomy tube irrigated according to physician's orders every four hours and/ or before and after the feeding. This policy also instructs nurses to maintain an intake and output record. The physician orders for R4 included no order for water flushes. According to the Intake and Output records, out of forty-seven shifts, between 08/15/11 to 08/30/11, the nurses failed to document water flush amounts for forty -three shifts. On 08/31/11 at 10:15 a.m., E13 (Registered Nurse - charge nurse) verified there are no physician orders for tube feeding water flushes. E13 stated that when a resident receives gastrostomy tube feedings, the Registered Dietitian calculates the residents daily fluid needs and the nurse calculates the amount and times of flushes depending on feeding and medication administration times. The form documenting fluid requirement calculations for R4 dated 08/15/11 states that R4's water flush amount is calculated at 30 cc of four flushes daily for a total of 120 cc of flushes. This form documents that the 30 cc flush amount would be divided by 2 resulting in 15 cc before and after medication administration. To the side of these calculations is written 60 cc before and 60 cc after. A second form for R4's fluid requirement calculation dated 08/30/11 was completed by E13. this form indicates that R4 requires 792 cc and has seven flush times daily. this form indicates nurses should administer 114 cc of water flushes 57 cc before and after medication administration. On 08/31/11 at 10:15 a.m., E13 stated that she completed a new form on 08/30/11 be cause none had been done since R4's tube feedings had changed on 08/25/11. E13 verified that the intake records are incomplete and there is no record of the actual amount of water flushes R4 received. R4 ' s current physician's order sheet dated 8/1/11 - 8/31/11 documented that R4 was ordered Ensure Plus 300 milliliters at 7:00 AM, 11:00 AM, 4:00 PM and 8:00 PM to be given per gastrostomy tube. Tylenol 80 mg/ 2.5 ml (650 mg/20 ml) every 6 hours per [DEVICE] was to be given at 4:00 PM. On 8/29/11 at 5:05 p.m. E6, Registered Nurse(RN) started to set up the 4:00 PM feeding and water flush. E6 placed two bottles of feeding on top of the medication cart along with two blue plastic cups with milliliter markings on the inside of the cup. E6 stated that she was going to fill both cups up to the 150 ml line to make 300 ml. E6 looked at the cups for a long time, then went to the nurses desk near a light and stared at the cups for approximately 5 minutes. E6 called on the phone trying to find some clear cups so she could see the markings. E6 spent from 5:05 PM until 6:00 PM back and forth from the medication cart to the nursing desk, on the phone and finally down the hallway around the corner. At this time E2 (Unit Director) was told about the situation. E2 sent E7(Licensed Practical Nurse) to take over R4 ' s tube feeding. E7 told R4 that she would be giving her the feeding. R4 was gasping and stated " please feed me, my stomach is hurting. I am so weak from not eating, I feel like I am going to pass out. " E7 left R4's room to get a stethoscope, came back and checked placement, checked orders and got water for the flush. R4 started crying, stated " I have never went this long without feeding. I have to sit up for thirty minutes or walk after my feeding, but I am too weak, I need to go to bed. " At 6:00 PM, R4 ' s color was grey. R4 was gasping and holding her stomach while complaining that her stomach was hurting. At 6:20 PM, E7 finished giving the tube feeding. On 08/30/11 at 1:00 p.m., R4 stated that a new nurse had problems with her (R4) tube feeding last evening (08/29/11) R4 said that she had "never had to wait that long." She said that she "felt weak," " was hungry," her "stomach growled." R4 said, "thought I was going to pass out." R4 said she had to "have a nerve pill twice last night", stating she "couldn't get to sleep." The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED].

Based on observation, interview and record review the facility failed to monitor, assess, and implement interventions to avoid weight loss for one of three residents (R1) reviewed for weight loss in a sample of ten. R1 had a 15% weight loss in six months. Findings include: The POS (Physician order [REDACTED]. The computerized Medical Patient Notes dated 2/28/11 document R1 has been in isolation [MEDICAL CONDITION] ([MEDICAL CONDITION]-Resistant Staphylococcus Aureus) since 2/28/11. In a Dietary Assessment Form dated 1-18-08 (verified by E2 , Extended Care Unit Director on 9/1/11 at 9:10 a.m. as the most recent dietary assessment), it is documented that R1 has no recorded likes and dislikes mashed potatoes. The RD (Registered Dietician) documented on this dietary assessment that R1 weighed 122 Lbs (pounds) and has an ideal weight of 130 Lbs. R1 has documented weights on a computerized medical flowsheet between the months of 3/2011-8/2011. In March of 2011 R1 weighed 119 Lbs (Pounds), April 2011 weighing 110 Lbs, May 2011 weighing 108 Lbs, June 2011 weighing 101 Lbs, and July and August weighing 100 pounds. R1 had a 19 Lb weight loss = 15% in a six month time frame. In Ancillary Services Progress notes the dietary aide documented on 3/3/11 that R1 weighed 119 Lbs and had intakes of 25%-75%. The dietary notes do not indicate if the poor intakes are of liquid, food or a combination. R1 was on a general diet with Dietary Supplements at lunch and supper. The Dietary Aide noted on 4/28/11 a weight of 110 Lbs and on a Mechanical Soft diet with ground meat. R1's oral intake was averaging 50%. The Dietary Aides notes do not address that R1 had a 9 Lb (7.5%) weight loss in one month. The Dietary Aide documented a goal to maintain good eating habits and to maintain weight. The Dietary Aide did not refer R1 to the Registered Dietician or Physician for further evaluation. The dietary notes do not include a plan or new interventions to prevent continued weight loss. According to the computerized flowsheet R1 weighed 108 Lbs in May and lost an additional 7 Lbs (6%) by June 2011 weighing 101 Lbs. The Dietary Aide did not document a note in May. The Dietary Aide's notes on 6/30/11 and 7/21/11 document "no new weight", oral intake of 0-25%, on mechanical soft diet, and "will follow". The Dietary Aide did not address R1's continued weight loss or refer R1 for further evaluation from the Physician or Registered Dietician. The dietary notes do not include a plan or new interventions to prevent continued weight loss. Although the computerized flow sheet documented an August weight of 100 Lbs for R1, the Dietary Aide noted for R1 on 8/31/11 "no new weight:, on mechanical soft diet with an oral intake of 0-50%, no new labs, "will follow". The dietary notes continued to not include a plan or new interventions to prevent continued weight loss. R1's care plan originally dated 2/1/11 and updated 3/31/11 documents as a problem to serve a mechanical soft diet due to [MEDICAL CONDITION] and to place all food in cups, and leaves 25% most of the time. R1's goal last revised 5/2/11 is to tolerate consistency of foods served and eat at least 50% without evidence or complaint of choking. R1's approaches dated 2/1/11 are to monitor /record percentage of meal consumed and supplement taken, cut food into small bites and give reminder to eat slow, place food in cups in front of her and tell her what she has in front of her and monitor/record the weight monthly and notify the physician of 5% weight loss in one month or 10% in 180 days. On 5/4/11 updates to approaches were documented that read to increase Ensure to TID (three times a day) for poor intake and wound healing, let her try some finger foods but staff to feed her and that family will bring in tippy cup for water. Documented under comments on R1's care plan on 8/1/11 it is documented "#100 an arrow pointing downward" with "refuses meals a lot" written. A weight loss care plan with goals and approaches was not documented. R1's MDS (Minimum Data Set) dated 8-1-11 documented under Section D-Mood for poor appetite a 1 for symptom presence and symptom frequency was 1-6 days. The MDS section G-Functional status documented extensive assist of one person with eating. Section K-Swallowing/Nutritional Status of R1's MDS documented a weight loss of 5% or more in the last month or loss of 10% or more in 6 months. In the computerized patient assessment form beginning 6/30/11 through 8/11/11 it is documented throughout that R1 has Stage I bilateral red buttocks and Peri area. It is also documented on 7/1/11 that R1 is assisted with dining. On 7/6/11 it is documented that R1 is a total feed. It is also documented that on 7/6/11 at 2130 that Z3 (Niece of R1) called and asked if anyone had checked R1's mouth as she had sores in her mouth. Oral exam shows a lot of food under R1's dentures, top gums are very red with numerous small blister areas. On 7/8/11 it is documented that R1 is assisted with dining. The computerized assessment forms vary for assistance needed to feed R1 from Total feed to assistance dated 6/30/11 ending with self feed on 8/10/11. On 8/30/11 at 12:30 p.m. Z3 stated that the facility does not pay attention to R1's likes and dislikes. Z3 stated that R1 loves Salmon but when the facility's kitchen does serve it the salmon is dark in color and dry. Z3 states she has told the facility about the food and the preferences and nothing is done about it. Z3 stated that at lunch on 8/30/11 R1 had eaten 1 bite of each of her pineapple, potatoes, chicken and noodles and tomato soup also taking just a couple sips of her supplement. E2 (Registered Nurse, Department director, Extended Care Facility) stated that the facility monitors weight loss by obtaining weekly weights, providing supplements and creating a weight loss care plan. E2 stated she was not aware of R1's 15% weight loss and that it should have been care planned but was not. E2 also verified that R1 should have been placed on weekly weights but was left on monthly weights which are obtained the 5th of every month. E2 stated that the Dietary Aides had access to all of R1's weights and should have asked for assistance from the staff if the Dietary Aides could not find R1's weights.