Every finding on record at Harmony Park at Wilson

Based on record review and staff interview, the facility failed to accurately code a Minimum Data Set (MDS) in the area of medications for 1 of 26 residents reviewed for MDS accuracy (Resident #8).Findings included:Resident #8 was admitted to the facility on [DATE] with diagnoses that included Type 2 diabetes mellitus.Review of physician orders revealed active orders for hypoglycemic medications (medication used to lower blood sugar) including Insulin Aspartame (rapid acting insulin) administered with meals ordered 5/8/2026 and Insulin Glargine (long-acting insulin) 20 units ordered 5/8/2026 to 5/11/2026 and 24 units ordered 5/11/2026 to 5/18/2026.Review of the Medication Administration Record (MAR) revealed Resident #8 received Insulin Aspartame 100 unit/ml subcutaneously with meals per sliding scale on 5/8/2026, 5/9/2026, 5/10/2026, 5/11/2026 and Insulin Glargine 20 units subcutaneously 5/8/2026, 5/9/2026 and 5/10/2026.The admission MDS dated [DATE] revealed, Resident #8 was coded as not receiving a hypoglycemic medication during the look-back period.On 6/4/2026 at 2:36 pm, an interview was conducted with the MDS Coordinator. The MDS Coordinator stated residents receiving insulin during the assessment look-back period should be coded on the MDS when a supporting diagnosis was documented in the medical record. The MDS Coordinator confirmed Resident #8 was receiving insulin during the assessment period. The MDS Coordinator stated that it was an error on her part and that MDS assessment should have been coded for Resident #8 receiving hypoglycemic medication (including insulin).On 6/4/2026 at 3:30 pm, an interview was conducted with the Administrator. The Administrator stated her expectation was that MDS assessments were completed accurately and reflected the residents' diagnoses, medications, treatments, and services received.

Based on observations and staff interviews, the facility failed to discard expired food items stored for use in 1 of 1 walk-in refrigerator and failed to serve a hot food item at a safe temperature range (at or above 135 degrees Fahrenheit) to prevent the potential for food borne illness for 1 of 1 meal observations. These practices had the potential to affect food served to residents. The findings included: 1. Observation on [DATE] at 10:47 AM of the walk-in refrigerator revealed 10 yogurt containers with an expiration date of [DATE] on the shelf. In an interview on [DATE] at 10:48 AM, the Dietary Manager (DM) said he had just put the yogurt containers on the shelf in order to take them to the halls for the residents but confirmed they were expired. He said normally the person putting away the delivery each week would check, and he (the DM) would double check dates throughout the week but just missed the yogurt. Observation on [DATE] at 3:10 PM of the walk-in refrigerator revealed two 5-pound tubs of sour cream and two 32 ounce containers of yogurt on the shelf. One tub of the sour cream had been open and used. The manufacturer's label on the sour cream read, Best if used by [DATE] and a label on the top with handwritten dates for the two tubs to be used [DATE] and [DATE]. The two 32-ounce tubs of yogurt were unopened with an expiration date [DATE] with a handwritten date of [DATE] on the lid. In an interview on [DATE] at 4:11 PM, the DM stated the sour cream had a best if used by date, which was not an expiration date, and the label date of [DATE] was the date it was opened. He said they were out of date and should have been removed. He said the handwritten date on the yogurt lid was the day it was delivered from the food distributor. He was not sure why the expiration date was not verified when the yogurt was delivered. 2. Observation on [DATE] at 12:17 PM revealed [NAME] #1 take the temperature of a pan of mashed potatoes on the steam table using a digital thermometer. The temperature of the potatoes was 111 degrees Fahrenheit (F). [NAME] #1 then stirred the mashed potatoes and took the temperature again. The temperature was 113 degrees F. In an interview on [DATE] at 12:18 PM, [NAME] #1 said the mashed potatoes should have maintained a temperature of at least 145 degrees F while on the steam table. In an interview on [DATE] at 12:19 PM, the DM told [NAME] #1 the mashed potatoes needed to be removed from the steam table and heated to temperature. In a continuous observation on [DATE] from 12:19 PM to 12:25 PM revealed [NAME] #1 begin to plate food items for service. The pan of mashed potatoes had not been removed from the steam table to reheat but had not been plated. Observation on [DATE] at 12:25 PM, [NAME] #1 scooped mashed potatoes onto a plate for service from the same pan. She continued to plate a puree diet plate and handed it to the dietary aide for service. After surveyor intervention, the plate was not served. The DM asked [NAME] #1 to get a spoon and stir the potatoes and retake the temperature. Observation on [DATE] at 12:26 PM, [NAME] #1 removed the pan of mashed potatoes from the steam table, stirred them, and retook the temperature, which read 122 degrees F. [NAME] #1 continued to stir the potatoes and at 12:27 PM, she retook the temperature, which read 127 degrees F. The DM got a large pot of boiling water to reheat the potatoes. Observation on [DATE] at 12:28 PM, [NAME] #1 stirred the mashed potatoes and took the temperature. The temperature was 141 degrees F. The mashed potatoes were returned to the steam table for service and service resumed. In an interview on [DATE] at 12:28 PM, [NAME] #1 said she did not remove the pan of mashed potatoes when it was not at holding temperature because she didn't think about it. In an interview on [DATE] at 1:10 PM, the DM said the mashed potatoes should have been removed from the tray line when the temperature was too low to be cooked longer before serving to the residents.

Based on record review and staff and resident interviews, the facility failed to protect a resident's right to be free from misappropriation of property leading to a suspected monetary loss of $3957.55. The deficient practice was for 1 of 3 residents reviewed for misappropriation of resident property (Resident #27). The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses including cognitive communication deficit and cerebral infarction (stroke). Resident #27's quarterly Minimum Data Set (MDS) dated [DATE] indicated he had intact cognition and had no behaviors. A Brief Interview of Mental Status assessment dated [DATE] indicated Resident #27 scored a 09, which indicated moderate cognitive impairment. The facility 24-hour Initial Report dated 5/31/24 documented an allegation that Resident #27 realized funds were missing from his bank account. The Administrator was notified on 5/31/24. The report noted the transactions appeared to have occurred over several months. It was noted Resident #27 had given his automatic teller machine (ATM) debit card to multiple people over time to buy drinks, snacks, and pizza in the past, but saw many additional unapproved withdrawals. There was no physical or mental harm noted. No alleged perpetrator was identified and the local police were notified. The facility Investigation Report dated 6/7/24 documented Resident #27 went to the bank and had three months of statements accessed and felt certain that there were expenditures that were not his. Some of the disputed charges were questionably his as they were from the vending machines he frequents in the facility. The Report noted that during a police interview with the resident, Resident #27 identified a staff member, Nurse Aide (NA) #3, and said he had given her his debit card to pick him up a sandwich at a local sandwich shop but could not remember the day. He said that after she got him a sandwich, he noticed his money was going faster. The Police Department stated they would contact her. NA #3 was suspended pending the results of the investigation. An addendum to the facility investigation dated 6/16/24 written by the Administrator noted the police had notified the facility that individuals had been identified using Resident #27's debit card without authorization and one of the individuals had been arrested. NA #3, who the resident identified to the police, did not appear to be involved as per the police investigation and was taken off of suspension. A police report by Police Officer #1 dated 6/24/24 noted there were three charges to Resident #27's debit card at ATMs on 4/22/24, 5/04/24, and 5/10/24, totaling $1709.00. Multiple other charges were noted in the report were made to various websites not used by Resident #27. Three individuals, NA #1, NA #2, and Individual #1 were identified in the investigation as having been the alleged perpetrators. Individual #1 was charged with identity theft and two counts of obtaining property under false pretenses. NA #2 was also charged with identity theft and six counts of obtaining property under false pretenses for purchases made online. The police report did not specify any charges or actions related to NA #1. In an interview on 3/12/25 at 9:03 AM, the Administrator said NA #1 and NA #2 were contracted NAs from a staffing agency, not facility employees. She said Individual #1 was related to NA #1 and NA #2. She said the total amount taken from Resident #27's bank account was $3957.55. In an interview on 03/12/25 at 9:40 AM, Resident #27 said his debit card went missing but he could not remember any details. He said the Administrator took care of everything for him and kept him informed of the investigation. He said the money had been replaced by the bank. He said he had a lock box and his nightstand drawer locked and he had the key but he preferred to keep his wallet with him at all times to maintain control of it. In an interview on 3/12/25 at 2:54 PM, Unit Manager #1 said she was the Unit Manager on Resident #27's unit. She said Resident #27 confided in her that more money than he spent was being taken out of his bank account. The Unit Manager said she helped Resident #27 obtain his bank statements and file fraud disputes. His bank statements showed multiple purchases that the resident denied making. Some of the websites were stores, and Resident #27 had not received any package deliveries at that time. She said on one occasion, a facility staff member took Resident #27 to run errands and had Individual #1 go with them. Resident #27 told her that Individual #1 helped him take money out of an ATM because he couldn't push the buttons and that Individual #1 punched in his personal identification number (PIN). She said Resident #27 was not distressed and he just wanted to find out what happened and get his money back. In an interview on 3/13/25 at 8:55 AM, the Administrator said neither the facility nor the staffing agency had current contact information for NA #2. Attempts to reach NA#1 were unsuccessful. Attempts to reach Police Officer #1 were unsuccessful during the survey. In an interview on 3/13/25 at 5:38 PM, the Administrator said the facility believed one of the NAs took Resident #27's debit card while working at the facility. They examined timecards for March, April, and May of 2024, and both NA #1 and NA #2 worked at the facility during that time period. She said as a result of the incident, the facility changed their policy on who can assist residents purchasing items and assisting resident with their money and directed staff to speak with the Social Worker, Activities Director, or the Business Office Manager. The policy said that no other staff may handle money or payment cards for the residents at any time. She said the facility sent out messages to all of the families and in-serviced all staff on the change of policy. In an interview on 3/13/25 at 8:09 PM, the Administrator said the facility created a plan of correction but had not completed the intended audits or monitored the corrections in the Quality Assurance committee as indicated in their plan.

Based on record review and staff interviews, the facility failed to report an allegation of misappropriation of resident property to the Department of Social Services (DSS). This deficient practice affected 1 of 3 residents reviewed for misappropriation (Residents #27). The findings included: The facility 24-hour Initial Report dated 5/31/24 completed by the Administrator documented an allegation that Resident #27 realized funds were missing from his bank account. The Administrator was notified on 5/31/24. The report noted the transactions appeared to have occurred over several months. It was noted Resident #27 had given his automatic teller machine (ATM) debit card to multiple people over time to buy drinks, snacks, and pizza in the past, but saw many additional unapproved withdrawals. There was no physical or mental harm noted. No alleged perpetrator was identified and the local police were notified. There was no documentation on the Initial Report that indicated DSS was notified. The Facility Investigation Report dated 6/7/24 completed by the Administrator documented the police were investigating and had suspects in the case. The Facility Investigation Report did not document that DSS was notified of the allegation. An addendum to the facility investigation dated 6/16/24 written by the Administrator noted the police had notified the facility that individuals had been identified using Resident #27's debit card without authorization and one of the individuals had been arrested. In an interview on 3/12/25 at 4:35 PM, the Administrator said she did not remember notifying DSS of the allegation and investigation related to the misappropriation of Resident #27's property, but would check with the Social Worker to see if she notified them. She said she was not aware that DSS had to be notified in addition to the state agency and the local police. In an interview on 3/12/25 at 5:03 PM, the Social Worker said she was involved in the investigation related to the misappropriation of Resident #27's property and DSS was not notified of the allegation.

Based on record review and staff interviews, the facility failed to ensure an updated Preadmission Screening and Resident Review (PASRR) was completed prior to admission for a resident diagnosed with psychosis and depression for 1 of 2 sampled residents reviewed for PASRR (Resident #32). The findings included: The North Carolina Department of Health and Human Services (NCDHHS) PASRR determination letter dated 09/30/2017 for Resident #32 revealed a level I screen and a PASRR number that remained valid for the individual's stay and no further PASRR screening was required unless a significant change occurred with the individual's status which suggested a diagnosis of mental illness. Resident #32 was admitted to the facility on [DATE] with diagnoses including psychosis not due to a substance or known physiological condition and depression. The admission Minimum Data Set (MDS) dated [DATE] indicated Resident #32 was cognitively intact, was not evaluated by Level II PASRR and determined to have a serious mental illness, and had diagnoses of depression and psychotic disorder. The MDS indicated she had not had any behaviors or rejection of care in the assessment period and had taken antipsychotic and antidepressant medications. In an interview on 3/13/25 at 2:57 PM, the Social Services Director said the social services office, which included herself and two assistants, were responsible for ensuring a PASRR was completed prior to admission. She said she did not realize Resident #32's PASRR had not been done since 2017. She had looked through the facility files upon surveyor request for a PASRR completed after that date, but because the hospital had not sent one, she was unable to find a more recent PASRR. She said the social services office should have made sure a Level 1 assessment was done if they did not receive one from the hospital. In an interview on 3/13/25 at 5:38 PM, the Administrator stated Resident #32 had a negative PASRR level I screen (a negative level I screen permits facility admission to proceed and ends the pre-screening process unless possible serious mental disorder or intellectual disability arises later) from 2017. She said the social services department was responsible for ensuring PASRR information was completed.

Based on observation, record review, and interviews with a resident and staff, the facility failed to provide double portions as ordered by the physician and to ensure a surgeon's recommendation for a high protein diet was implemented following a surgical amputation of the resident's foot for 1 of 6 residents reviewed for therapeutic diets (Resident #56). The findings included: a. Resident #56 admitted to the facility on [DATE]. Resident #56's comprehensive care plan initiated on 1/29/25 documented he had potential for a nutritional problem related to diagnoses of hypertension (high blood pressure), peripheral vascular disease, congestive heart failure, and type 2 diabetes mellitus, atherosclerotic heart disease, anticoagulant use, and a therapeutic diet. Interventions included to provide and serve his diet as ordered. Resident #56's physician's orders dated 1/30/25 noted he was to receive a diet of Controlled Carbohydrates and No Added Salt diet with double portions at breakfast. A significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #56 was cognitively intact, fed himself after staff set-up assistance with meals, and received a therapeutic diet. Review of the facility's Diet Order Report dated 3/12/25 recorded Resident #56 was to receive a double portions at breakfast. An observation on 3/13/25 at 8:48 AM revealed Resident #56 with his breakfast tray. His breakfast meal had one sausage patty, two pancakes, and a 4-ounce bowl of grits. The diet slip on his tray indicated he was to receive double portions with breakfast. Double portions were not observed. In an interview on 3/13/25 at 8:49 AM, Resident #56 said he received one patty of sausage, two pancakes, and a small bowl of grits. He said he ate the grits but did not want to eat any more of his breakfast because his family would be bringing him restaurant food. In an interview on 3/13/25 at 3:14 PM, the Registered Dietitian (RD) said that Resident #56 should have received a double portion of the breakfast foods as ordered because the calories would assist with wound healing. In an interview on 3/13/25 at 4:11 PM, the Dietary Manager (DM) said that a resident with a diet order for double portions should receive double portions of meats, starches, and vegetables. He said Resident #56 should have received two sausage patties and a larger bowl of grits. The DM stated that it was an oversight that Resident #56 did not receive double portions at breakfast. In an interview on 3/13/25 at 5:05 PM, the facility Nurse Practitioner (NP) said Resident #56 had an order for double portions for his wound healing. b. Resident #56 was admitted to the facility on [DATE] with diagnoses including non-pressure chronic ulcer of right foot, gangrene, peripheral vascular disease, osteomyelitis (an infection in the bone) of ankle and foot, hypertension (high blood pressure), congestive heart failure, atherosclerotic heart disease and type 2 diabetes mellitus with circulatory complications. A Wound Nurse Practitioner progress note dated 2/19/25 documented Resident #56 was scheduled to have part of his right foot amputated that day. A significant change Minimum Data Set (MDS) dated [DATE] indicated Resident #56 was cognitively intact, fed himself after staff set-up assistance with meals, he had a recent surgery which required skilled nursing care, received a therapeutic diet, and received anticoagulants (medications that thin the blood to prevent blood clots). Resident #56's handwritten surgical consultation note dated 2/26/25 indicated he had a right foot transmetatarsal (the front part of the foot including the toes) amputation for dry gangrene on 2/19/25. The note included orders for antibiotics and wound care. The handwritten note did not include recommendations regarding Resident #56's diet. Resident #56's typewritten surgical consultation report dated 2/26/25 noted the same information as was noted on the handwritten note. The typewritten report also included he should be eating a diet high in protein to aide in the healing of the surgery site. Resident #56's nursing progress notes written by Unit Manager #1 dated 2/26/25 noted his visit with the surgeon but did not address the surgeon's recommendation for a high protein diet. Resident #56's comprehensive care plan updated 3/01/25 documented he had potential for a nutritional problem related to diagnoses of hypertension, peripheral vascular disease, congestive heart failure, type 2 diabetes mellitus, atherosclerotic heart disease, anticoagulant use, and a therapeutic diet. Resident #56's laboratory results dated [DATE] noted his albumin level was 2.9 gm/dl (normal range 3.5 to 5.5, low albumin levels can affect wound healing). Resident #56's Registered Dietitian (RD) progress note dated 3/12/25 documented Resident #56's diet order was controlled carbohydrates, no added salt, and regular texture. The RD noted Resident #56's food intake was 0-100% in the 7 days prior. She noted he had a pressure ulcer on his right heel. The RD recommended a multivitamin daily to aid with skin integrity. Resident #56's February and March 2025 physician's orders did not reveal orders for a high protein diet or for protein supplements. Resident #56's February and March 2025 Medication Administration Records (MAR) did not contain entries for protein supplementation. In an interview on 3/13/25 at 8:49 AM, Resident #56 said he did not receive any protein supplements such as an additional cup of liquids with medications or a protein milkshake. In an interview on 3/12/25 at 2:54 PM, Unit Manager #1 reviewed Resident #56's orders and said he did not have any orders for a high protein diet or for protein supplements. She said when she reviewed the initial surgeon's consultation notes, she did not see the protein recommendation. She said she would check with medical records to see if there was another note from the physician. During a follow up interview on 3/13/25 at 10:26 AM, Unit Manager #1 stated when Resident #56 returned from his follow up visit with the surgeon on 2/26/25, she reviewed a handwritten progress note from the surgeon which did not include the recommendation for a high protein diet. During the interview, she reviewed the typewritten surgery consultation report dated 2/26/25 with the high protein diet recommendation. She said when a resident saw an outside consultant provider, the provider would sometimes send the facility two notes, a handwritten one done immediately while the resident was at the clinic and another one, usually when information was dictated, that would be faxed to the facility for the chart. The high protein diet recommendation was faxed over from the surgeon on 2/27/25 and she did not see it. She said the Medical Records Coordinator would receive any additional typewritten notes from a provider and upload the notes to the chart. She said she did not normally see the typewritten notes and said she did not know the notes could contain different or additional information. She said a high protein diet would help with Resident #56's wound healing but the recommendation was just missed because it was not on the original handwritten note. Unit Manager #1 reviewed Resident #56's physician orders and said there were no protein supplements ordered and there were no changes to his diet order since 1/30/25 when the double portions with breakfast was ordered. She said the facility had multiple supplements that could have been added to Resident #56's regimen but had not been ordered. In an interview on 3/13/25 at 3:14 PM, the RD said if diet changes were made at an outside consultant appointment, she would be made aware by nursing or when the report was put into the resident's clinical record. She said she had not reviewed the surgeon's progress notes from the 2/26/25 visit and was not sure if it was uploaded into the chart when she reviewed his chart on 3/12/25. She said she did not know about the recommendation for a high protein diet. She said she did not want to comment on Resident #56's specific case re: protein and if it was beneficial for him because she did not remember the details. She saw Resident #56 the day he went out for surgery but did not have another note until 3/12/25. In an interview on 3/13/25 at 4:08 PM, the Director of Nursing (DON) said Resident #56 received double portions of breakfast but she was not aware of the recommendation of a high protein diet from the surgeon. In an interview on 3/13/25 at 4:34 PM, Nurse Practitioner #1 said she was not aware of the recommendation from the surgeon until 3/13/25. She said having Resident #56 on a high protein diet would be a proactive intervention to aide in long-term wound healing. She indicated Resident #56 did not eat much of the facility food but that his family frequently brought in food for him which he ate. She added that the resident's albumin level had increased, indicating he was getting enough protein.

Based on observations, and staff interview the facility failed to keep kitchen equipment clean by failing to clean 1 of 1 plate warmer, 1 of 1 drink nozzle, 1 of 1 knife holder, and 1 of 1 steam table shelf observed. This practice has the potential for cross contamination of food served to residents. The findings included: a. Observations of the kitchen were conducted on 11/28/23 at 9:53 AM, 11/29/23 at 3:06 PM and on 11/30/23 at 8:29 AM the two cylinder well plate warmer was observed with dark black dried food particles inside each well. b. Observations of the kitchen conducted on 11/28/23 at 9:53 AM and 11/30/23 at 10:41AM, the drink gun nozzle was observed with a buildup of sticky liquid. c. Observations of the kitchen conducted on 11/29/23 at 3:06 PM and 11/30/23 at 8:29 AM revealed a buildup of dried food particles on top of the wall mounted knife holder. An observation of the kitchen was conducted with the Dietary Manger on 11/30/23 at 10:41 AM. The 5-foot steam table shelf was observed to have a buildup of dark sticky food debris. The plate warmer, drink gun nozzle and knife holder were observed in the same condition. During an interview with the Dietary Manager on 11/30/23 at 11:48 AM he stated he had one staff at night to deep clean the kitchen and he did not always check behind to see the work was completed. He indicated he had a cleaning schedule and it was not always posted. In an interview on 12/1/23 at 9:37 AM the Administrator stated dietary should have a daily cleaning schedule and follow it. She further indicated she expected staff to clean the affected areas.

Based on observations, record review, resident and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor the interventions the committee put into place following the complaint investigation surveys of [DATE] and [DATE] and the recertification and complaint investigation surveys of [DATE] and [DATE]. This was for five deficiencies recited on the current recertification and complaint investigation survey of [DATE] in the areas of: Accuracy of Assessments (F641), Care Plan Timing and Revision (F657), Food Procurement, Storage and Preparation (F812), Complete and Accurate Medical Records (842), and Proper Functioning of Call System (F919). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: a) F641: Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Gradual Dose Reduction, insulin administration, and antipsychotic medication for 3 of 26 sampled residents (Resident #57, Resident #61, and Resident #58). During a recertification and complaint investigation survey of [DATE] the facility inaccurately coded the use of insulin for a non-diabetic resident and an invasive mechanical ventilator on the MDS assessment. During a recertification and complaint investigation survey of [DATE], the facility failed to accurately assess the discharge location on the MDS assessment. b) F657: Based on record review and staff interviews, the facility failed to update a resident care plan to reflect the resident's current nutritional status for 1 of 26 residents whose care plans were reviewed (Resident #2). During a recertification and complaint investigation survey of [DATE] the facility failed to conduct a care plan meeting and invite the resident to the care plan meeting. During a recertification and complaint investigation survey of [DATE], the facility failed to conduct a care plan conference. c) F812: Based on observations, and staff interview the facility failed to keep kitchen equipment clean by failing to clean 1 of 1 plate warmer, 1 of 1 drink nozzle, 1 of 1 knife holder, and 1 of 1 steam table shelf observed. This practice has the potential for cross contamination of food served to residents. During a recertification and complaint investigation survey of [DATE] the facility failed to remove expired items from a nourishment refrigerator. During a recertification and complaint investigation survey of [DATE], the facility failed to date left over food items, remove expired food stored for use and clean a nourishment refrigerator located in the day room. d) F842: Based on the record review, staff interviews and Director of Nursing interview the facility failed to document complete and accurate information in the Medical Administration Record for one of twenty-six Residents (Resident #8) reviewed for accuracy of medical records. During a complaint investigation survey of [DATE] the facility failed to maintain accurate Medication Administration Records. During a complaint investigation survey of [DATE] the facility failed to maintain accurate Treatment Administration Records. e) F919: Based on observation, staff interviews, and resident interview, the facility failed to ensure a call light was functioning properly for one of one resident who required staff assistance for activities of daily living (Resident #33). During a recertification and complaint investigation survey of [DATE] the facility failed to ensure a call bell was working. An interview was conducted with the Administrator on [DATE] at 12:00 P.M. The Administrator revealed she was under the impression the plan of corrections were implemented. She also stated there has been complete change of administration staff to include the Director of Nursing and the Assistant Director of Nursing and she believed the transition of change caused a breakdown in the monitoring and audits that were in place previously. She stated the monthly Quality Assurance and Performance Improvement (QAPI) meetings have an agenda to ensure the QAA process is adhered to and monitored.

Based on record review and staff interviews, the facility failed to refer residents with a serious mental health diagnoses for a Preadmission Screening and Annual Resident Review (PASARR) level II screening for 2 of 4 residents reviewed for PASARR (Resident #51 and Resident #9). The findings included: 1. Resident #51 was admitted to the facility on [DATE] with diagnoses which included anxiety, depression, and schizoaffective disorder. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #51 had severe cognitive impairment and did not have a PASARR Level II. Resident #51 was coded for mental health diagnoses which included schizophrenia, anxiety, and depression and he was not coded for behaviors. During an interview with the Social Worker on 11/29/23 at 3:32 pm she revealed Resident #51's PASARR Level I notice dated 10/13/21 did not list schizophrenia on his list of diagnoses. The Social Worker stated she was not at the facility when Resident #51 was admitted , and she had not reviewed his PASARR information because the diagnosis was in place at the time of admission. She stated a level II review should have been sent due to the schizophrenia diagnosis not being listed on Resident #51's PASARR level I notice. Multiple attempts to interview the previous Social Worker on 11/29/23 at 4:43 pm, 11/30/23 at 12:05 pm, and 11/30/23 at 3:12 pm were unsuccessful. An interview with the Administrator was conducted on 12/01/23 at 9:56 am revealed the previous Social Worker was responsible to ensure Resident #51's PASARR level I was reviewed and referred for a PASARR level II screen if the schizoaffective disorder was not listed on the original PASARR level I notice upon admission. 2. Resident #9 was admitted to the facility on [DATE] with a diagnosis of stroke. Review of Resident #9's active diagnoses revealed a diagnosis of adjustment disorder with mixed anxiety and depressed mood was identified on 2/20/23. The Minimum Data Set (MDS) annual assessment dated [DATE] revealed Resident #9 did not have a PASARR level II. He was coded for a diagnosis of psychotic disorder and was not coded for behaviors. During an interview with the Social Worker on 11/29/23 at 3:32 pm she revealed Resident #9's PASARR Level I notice dated 5/29/17 did not have any mental health diagnoses listed. The Social Worker stated she was not at the facility when Resident #9's new diagnosis of adjustment disorder with mixed anxiety and depressed mood was identified, and she had not reviewed his PASARR information because the diagnosis was in place when she started. The Social Worker stated a level II review should have been sent due to the mental health diagnosis not being listed on Resident #9's PASARR level I notice. Multiple attempts to interview the previous Social Worker on 11/29/23 at 4:43 pm, 11/30/23 at 12:05 pm, and 11/30/23 at 3:12 pm were unsuccessful. An interview with the Administrator was conducted on 12/01/23 at 9:56 am revealed the previous Social Worker was responsible to ensure Resident #9's PASARR level I was reviewed and referred for a PASARR level II screen when the adjustment disorder with mixed anxiety and depressed mood was identified.

Based on record review and staff interviews, the facility failed to obtain a Level II Preadmission Screening and Resident Review (PASRR) after the initial approval for nursing home placement expired for 2 of 4 residents reviewed for PASRR (Resident #57 and Resident #61). Findings included: 1. Resident #57 was admitted on [DATE]. His diagnoses included depression, and schizophrenia. Resident #57's Admission Minimum Data Set (MDS) assessment dated [DATE] indicated a Level II PASRR determination for intellectual disability. He was noted with severe cognitive impairment, and diagnoses included anxiety, depression, and schizophrenia. A Level II Preadmission Screening and Resident Review (PASRR) determination notice dated [DATE] indicated the determination had an expiration date of [DATE]. No further PASRR determination notices were discovered for Resident #57. Multiple attempts to interview the previous Social Worker (SW) on [DATE] at 4:43 pm, [DATE] at 12:05 pm, and [DATE] at 3:12 pm were unsuccessful. An interview with the SW was conducted on [DATE] at 11:02 AM. She explained she had been in this only been in this position for a few months. She had just been made aware of the expired PASRR determination and had not yet been set up to access the PASRR program to check for information. During an interview with the Administrator on [DATE] at 11:17 AM she stated the PASRR determination should be up to date. 2. Resident #61 had been readmitted on [DATE]. Her diagnoses included Cerebrovascular Accident (CVA) and anxiety. A Psychiatric Nurse Practitioner note regarding Resident #61 dated [DATE] included diagnoses of anxiety and schizoaffective disorder. A Level II Preadmission Screening and Resident Review (PASRR) determination notice dated [DATE] indicated the determination had an expiration date of [DATE]. No further PASRR determination notices were discovered. Resident #61's most recent annual Minimum Data Set (MDS) assessment dated [DATE] indicated she had a Level II PASRR determination for serious mental illness. She was noted with severe cognitive impairment, and diagnoses included anxiety, psychotic disorder, and schizophrenia. Multiple attempts to interview the previous Social Worker (SW) on [DATE] at 4:43 pm, [DATE] at 12:05 pm, and [DATE] at 3:12 pm were unsuccessful. An interview with the SW was conducted on [DATE] at 11:02 AM. She explained she had been in this only been in this position for a few months. She had just been made aware of the expired PASRR determination and had not yet been set up to access the PASRR program to check for information. During an interview with the Administrator on [DATE] at 11:17 AM she stated the PASRR determination should be up to date.

Based on observation, record review, resident interview, and staff interviews, the facility failed to provide a resident with a regular texture diet to reflect the active physician diet order for 1 of 4 residents reviewed for food (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included diabetes, end stage renal disease, and dependence on dialysis. Resident #2 was hospitalized on [DATE] and returned to the facility on [DATE]. Review of the discontinued/completed physician orders revealed Resident #2's prior diet order dated 7/26/23 was a controlled carbohydrates/no added salt diet, regular texture. The order was discontinued on 10/28/23 when he was hospitalized . A physician diet order dated 10/31/23 for a carbohydrate controlled no added salt diet, regular texture. The dietary communication slip dated 10/31/23 revealed the diet order sent to the dietary department for Resident #2 was for a carbohydrate controlled no added salt diet, regular texture. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #2 was cognitively intact. Resident #2 was not coded for a swallowing disorder and was not coded for a mechanically altered diet. During an interview on 11/28/23 at 10:47 am Resident #2 revealed he did not like the way the facility served the meat on his meal trays. He stated the meat tasted like sand and he could not tell what kind of meat he was eating because it was ground up so small. Resident #2 stated it made him sick to his stomach just to look at it. An observation on 11/29/23 at 8:55 am of Resident #2's breakfast meal tray revealed his breakfast meat was ground into small pieces. Resident #2's breakfast meal ticket on his meal tray was reviewed and the diet was listed as regular texture, but it was crossed out and soft was handwritten in place of regular texture on the meal ticket. An interview was conducted on 11/29/23 at 4:18 pm with the Dietary Manager who revealed the nursing department entered the physician order in the medical record and would give the dietary department the diet communication slip and he would enter the order into the meal ticket program. The Dietary Manager stated he wrote soft on the meal ticket because he thought Resident #2 was a mechanical soft diet. He stated he did not recall receiving the diet communication slip for Resident #2's regular texture diet and did not recall him being on a regular texture diet prior to his hospitalization . He stated he meant to talk to the nurse regarding the order, but he had forgotten. The Dietary Manager stated the diet communication slip for Resident #2 must have been missed. During an interview on 12/01/23 at 9:34 am the Unit Manager revealed when Resident #2 was readmitted to the facility on [DATE] his diet order was entered, and a diet communication slip was sent to the dietary department. An interview was conducted with the Administrator on 12/01/23 at 10:07 am who revealed the Dietary Manager was responsible to ensure the correct diet texture for Resident #2 was entered in the meal ticket system when the diet communication slip was received from the Unit Manager.

Based on observation, staff interviews, and resident interview, the facility failed to ensure a call light was functioning properly for 1 of 1 resident who required staff assistance for activities of daily living (Resident #33). The findings included: Resident #33 was admitted to the facility on [DATE]. Review of an admission Minimum Data Set assessment dated [DATE] documented Resident #33 had intact cognition. In an interview with Resident #33 during the initial tour of the facility on 11/28/23 at 9:30 AM he stated his call bell had never worked since his admission. He explained if he needed help, he would stand in his doorway and holler but would prefer to ring his call bell. He did not report the call bell was not working. On 11/28/23 at 10:30 AM an observation of the call bell in Resident #33's room revealed the call bell did not activate the light over his doorway and no sound was heard. The Director of Nursing was present during the observation. Several call lights in surrounding rooms on the hallway were checked and they were observed to produce sound and had a light over the doorway that was activated. In an interview with the facility Maintenance Director on 11/29/23 at 2:20 PM he stated he had no idea the call bell in Resident #33's room was broken. He stated when a repair was needed it was communicated on a work order slip. He reported that usually if there was something broken, if the nurse aide or nurse remembered to tell him when they passed him in the hallway and before they went off shift, he wrote it down on a slip of paper he carried in his pocket to remind him. He noted he had fixed the call bell in Resident #33's room after it was brought to his attention by the Director of Nursing on 11/28/23. He stated it wasn't the call bell cord in the room that was broken, it was a short in the electrical wiring leading to the light in the hallway above the doorway. In an interview with Nurse Aide #4 on 11/29/23 at 3:00 PM she stated she routinely cared for Resident #33. She noted she was not aware the call bell in his room was not working. She reported when Resident #33 needed something he would stand in his door and yell. She concluded had she known the call bell in his room was broken she would have written it in the book at the nurse's station and told the Maintenance Director when she passed him in the hallway. In an interview with Nurse Aide #5 on 11/29/23 at 3:10 PM she stated she normally cared for Resident #33 on her assignment for the past couple of months. She noted she did not know his call bell had not been working because he had been coming to his doorway and asking for help when he needed it. She reported the resident had never told her his call bell was broken. She stated she completed incontinent rounds every 2 hours and checked the resident frequently. She commented that when she was aware of a needed repair, she would write it in the book at the nurse's station and tell the Unit Manager. It was her understanding the Unit Manager then would tell the Maintenance Director. In an interview with the Unit Manager on B Hall on 11/29/23 at 3:20 PM she stated no one had informed her that the call bell in Resident #33's room had not been working since his admission. In an interview with the facility Administrator on 12/1/23 at 8:05 AM she stated she would expect staff to know when a call bell was not working and to complete a work order slip so that maintenance could fix it. She would also expect to be notified if it was not fixed after filing a work order. She stated she was not aware Resident #33's call bell had not been working since his admission to the facility.

Based on record review and staff interviews, the facility failed to notify the Ombudsman in writing of the residents transfer to the hospital for 2 of 4 residents reviewed for hospitalization (Resident #2 and Resident #86). The findings included: 1. Resident #2 was admitted to the facility on [DATE]. Review of the nursing progress note dated 10/28/23 at 16:21 revealed resident #2 was transferred to the hospital. Resident #2 was transferred to the hospital on 10/28/23 and returned to the facility on [DATE]. Record review of the progress notes revealed there was no documentation that the Ombudsman was notified of Resident #2's transfer to the hospital on 10/28/23. An interview was conducted on 11/29/23 at 4:05 pm with the Social Worker who revealed she was new to the position as of September 2023 and was not aware she was required to notify the Ombudsman of Resident #2's transfer to the hospital. The Social Worker stated she was trained by the previous Social Worker, but the Ombudsman notification of transfer was not included in the training she received. Attempts to interview the previous Social Worker on 11/29/23 at 4:43 pm, 11/30/23 at 12:03 pm, and 11/30/23 at 3:12 pm were unsuccessful. During an interview with the Administrator on 12/01/23 at 10:04 am she revealed the Social Worker was responsible to notify the Ombudsman of Resident #2's transfer to the hospital. The Administrator stated she was not aware that the Social Worker was not trained to notify the Ombudsman of resident transfers. 2. Resident #86 was admitted to the facility on [DATE]. The nursing progress note dated 9/22/23 at 2:40 am revealed Resident #86 was transferred to the hospital. Resident #86 was transferred to the hospital on 9/22/23 and returned to the facility on [DATE]. The nursing progress note dated 10/19/23 at 3:00 pm revealed Resident #86 was transferred to the hospital. Resident #86 was transferred to the hospital on 10/19/23 and she did not return to the facility. Review of Resident #86's progress notes revealed there was no documentation that the Ombudsman was notified of the transfers to the hospital on 9/22/23 or 10/19/23. An interview was conducted on 11/29/23 at 4:05 pm with the Social Worker who revealed she started at the facility in September 2023 and was new to the position. The Social Worker stated she was not aware she was required to notify the Ombudsman of Resident #86's transfers to the hospital. The Social Worker stated she was trained by the previous Social Worker, but the Ombudsman notification of transfer was not included in the training she received. Attempts to interview the previous Social Worker on 11/29/23 at 4:43 pm, 11/30/23 at 12:03 pm, and 11/30/23 at 3:12 pm were unsuccessful. During an interview with the Administrator on 12/01/23 at 10:04 am she revealed the Social Worker was responsible to notify the Ombudsman of Resident #86's transfers to the hospital. The Administrator stated she was not aware that the Social Worker was not trained to notify the Ombudsman of resident transfers.

Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for Gradual Dose Reduction, insulin administration, and antipsychotic medication for 3 of 26 sampled residents (Resident #57, Resident #61, and Resident #58). Findings included: 1. Resident #61 had been readmitted on [DATE]. Her diagnoses included Cerebrovascular Accident (CVA) and anxiety. A Psychiatric Nurse Practitioner note regarding Resident #61 dated 12/20/22 included diagnoses of anxiety and schizoaffective disorder. The consultant Pharmacist Recommendation to Physician form dated 4/7/23 included a note written by the physician dated 4/25/23 Patient stable at currant dosage, any attempted GDR might cause decompensation. Review of Resident #61's October and November 2023 Medication Administration Records were reviewed and revealed she received olanzapine (antipsychotic medication to treat the symptoms of schizophrenia) 7.5 milligrams twice daily. Resident #61's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] included diagnoses of anxiety, psychotic disorder, and schizophrenia. She received antipsychotic medication on a routine basis. No Gradual Dose Reduction (GDR) had been noted as attempted and no physician documentation of GDR as clinically contraindicated was noted. During an interview on 11/30/23 at 11:50 AM with the Corporate Consultant, she stated the MDS Nurses had access to pharmacy recommendations and physician documentation needed for information for the MDS assessments. She explained the MDS Nurses could look in the Medical Records department for forms not yet scanned into the system. She stated the MDS should be accurate and include correct information. On 11/30/23 at 12:05 PM an interview was conducted with MDS Nurse #1 and MDS Nurse #2. MDS Nurse #1 stated she reviewed physician notes and pharmacy records available in the electronic medical record. She stated she could check with medical records for things which were waiting to be scanned but clarified she would not look through the papers in there. 2. Resident #57 was admitted on [DATE]. His diagnoses included diabetes. Review of Resident #57's August 2023 Medication Administration Record revealed he received dulaglutide (a non-insulin diabetic medication) 0.75 milligram injection once weekly on Thursdays. Resident #57's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated he received one dose of insulin. On 11/30/23 at 11:50 AM an interview with the Corporate Consultant was conducted. She explained the MDS should be accurate and include the correct information. An interview was conducted on 11/30/23 at 12:07 PM with MDS Nurse #1. She stated the dulaglutide should not have been marked as insulin and this was an error. 45045 3. Resident #58 was admitted to the facility on [DATE] with diagnoses which included schizophrenia. A physician order dated 6/15/23 for Paliperidone Palmitate ER (an antipsychotic medication) prefilled syringe 234 milligrams (mg). Inject 234 mg one time a day every 28 days for antipsychotic. Review of the nursing progress notes revealed Resident #58 received the antipsychotic medication injection on the following dates 6/26/23, 7/25/23, 8/22/23, 9/18/23, and 10/17/23. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #58 was coded as an antipsychotic medication was not received. During an interview on 12/01/23 at 8:54 am with the MDS Nurse #1 who revealed she did not recall seeing nursing progress notes that the medication was administered. The MDS Nurse #1 stated Resident #58 should have been coded for an antipsychotic medication during the last assessment period. An interview was conducted on 12/01/23 at 8:58 am with the MDS Nurse #2 who revealed when she completed the assessment, she would review the medication administration record or nursing notes to confirm the medication was administered. The MDS Nurse #2 was unable to state how the antipsychotic medication was missed on the assessment for Resident #58. An interview was conducted on 12/01/23 10:46 am with the Director of Nursing (DON) who revealed the MDS Nurses were responsible to ensure Resident #58's antipsychotic medication was coded accurately. During an interview on 12/01/23 at 10:11 am with the Administrator revealed the MDS Nurse was responsible to accurately code Resident #58's medications. The Administrator stated if the MDS Nurse was uncertain if Resident #58's antipsychotic medication was administered she would expect the MDS Nurse to follow-up with the DON.

Based on observations, record review, and staff and resident interviews, the facility failed to provide care in a safe manner during a bed bath for a dependent resident (Resident #3) resulting in a head injury for 1 of 3 residents reviewed for accidents. Findings included: Resident #3 was admitted to the facility on [DATE] with diagnoses that included quadriplegia. His quarterly Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. He required total assistance from staff for bed mobility, hygiene, and bathing. He required two-person assistance for bathing. A Care Plan dated 8/2/22 focused on fall risk included a goal for Resident #3 to be free from falls for the review date. Interventions included keep call light within reach, anticipate the resident's needs, and follow fall protocol. Resident #3 ' s Care Guide indicated he required 1 person assistance for bathing and showering and turning and repositioning in bed. A facility incident report dated 8/26/22 indicated that Nurse Aide (NA) #2 was providing a bed bath and Resident #3 was on his left side. Resident #3 began shaking and stiffened his body causing him to jerk forward and roll off the bed. Resident #3 hit the right side of his head and complained of head and neck pain. Emergency Medical Services (EMS) was called, and Resident #3 was taken to the Emergency Department (ED). ED documentation dated 8/26/22 revealed Resident #3 was seen following a fall. Diagnoses included a laceration to the forehead and subarachnoid hemorrhage (head bleed). His blood thinner was discontinued, and a seizure medication was added. The laceration to his forehead was closed with skin glue. A nursing progress note dated 8/29/22 revealed Resident #3 was complaining of blurred vision and was sent to the ED. He returned 9/1/22. A Nurse Practitioner note dated 9/1/22 revealed Resident #3 had returned from the ED and a magnetic resonance imaging (MRI) indicated the head bleed had not worsened and the blurred vision was likely post-concussion syndrome. During an interview on 3/7/23 at 10:25 AM, Resident #3 revealed he had a fall while NA#2 was providing a bed bath. He indicated she rolled him to the side and did not pull him close enough to her and he rolled onto the floor. He did not state if he was shaking or jerking. He went to the ED and was diagnosed with a concussion and a cut to the forehead and was sent back to the facility. Resident #3 added on 3/8/23 at 9:00 AM that he returned to the ED on 8/29/22 due to blurred vision. He indicated he had a scan, and his bleed was stable. He was not admitted to the hospital. His nurse practitioner followed up for the blurred vision and he has an appointment with an optometrist. NA #2 could not be reached for interview. During an interview on 3/8/23 at 1:15 PM, the Director of Nursing (DON) indicated he did not work at the facility at the time of Resident #3's fall. He revealed staff should use the Care Guide to determine how much assistance residents needed for bed baths. Staff was provided ongoing education of falls and bed mobility. During an interview on 3/8/23 at 1:40 PM, the Administrator indicated she did not work at the facility at the time of Resident #3's fall. She revealed that falls were discussed in morning meetings. The interdisciplinary team looked for the root cause of the fall and discussed interventions. The administrator indicated that staff was provided ongoing fall education. During an interview on 3/8/23 at 1:45 PM, the [NAME] President revealed that fall education was provided to nursing staff monthly. Falls were discussed in Quality Assurance (QA) meetings monthly.

Based on observations, resident and staff interview, and record review, the facility failed to ensure a dependent resident could access the call light to request staff assistance for 1 of 5 residents reviewed for accommodation of needs (Resident #3). Findings included: Resident #3 was admitted to the facility on [DATE]. with diagnoses that included anxiety disorder. His annual Minimum Data Set (MDS) dated [DATE] indicated he was cognitively intact. He required total assistance by staff for bed mobility, hygiene, and bathing. A Care Plan dated 1/17/23 focused on fall risk included a goal for Resident #3 to be free from falls for the review date. Interventions included keep call light within reach and encourage resident to use it for assistance. An observation was made on 3/7/23 at 10:25 AM of Resident #3 lying in bed with his call light cord wrapped around the assist bar and the paddle call light (a flat button used for people with limited hand movement) hanging next to the bed. Resident #3 indicated he was not able to use the paddle call light in that location. An observation was made on 3/7/23 at 3:20 PM of Resident #3 in his wheelchair next to the bed. His paddle call light was on his bed. Resident #3 indicated he could not use the call light in that position. He could not reach his hand to the bed or move his chair to the bed. During an interview on 3/7/23 at 3:25 PM, Nurse Aide (NA) #1 indicated Resident #3 could use the paddle light if it was placed next to his hand. NA #1 observed Resident #3 and revealed the call light was not within reach. NA #1 indicated that he had just started his shift and he had not checked on Resident #3 since he had been there. The nurse aide moved the call light to Resident #3's arm rest and Resident #3 demonstrated use. During an interview on 3/8/23 at 9:00 AM, Resident #3 indicated his call light was frequently out of reach and he called out to get staff assistance. During an interview on 3/8/23 at 1:15 PM, the Director of Nursing (DON) indicated that Resident #3 was able to tell staff where he wanted his call light. The DON indicated call lights should be within reach. During an interview on 3/8/23 at 1:40 PM, the Administrator revealed she visited frequently and had not observed Resident #3 with his call light out of reach. She indicated that staff should ensure the residents' call lights were within reach.

Based on staff interviews and record review, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor these interventions that the committee put into place following the 8/19/22 recertification and complaint investigation survey. This was for a recited deficiency in the area of accidents (F689). This deficiency was cited again on the current complaint investigation survey. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAA program. Findings included: This tag is cross referenced to: F689: Based on observations, record review, and staff and resident interviews, the facility failed to provide care in a safe manner during a bed bath for a dependent resident (Resident #3) resulting in a head injury for 1 of 3 residents reviewed for accidents. During the recertification survey on 8/19/22, the facility was cited at F689 accidents and hazards for failing to implement fall inventions, failed to secure smoking materials, and failed to provide supervision for smoking. During an interview on 3/8/23 at 1:40 PM, the Administrator revealed falls were discussed at monthly QAA meetings. The facility provided ongoing training to staff regarding falls as part of the QAA improvement plan. During an interview on 3/8/23 at 1:45 PM, the [NAME] President revealed falls were an ongoing issue for QAA at the facility and the facility continued to work to prevent falls.

Based on medical record review and staff interviews the facility failed to carry out orders consistent with the physician's written order by failing to provide a daily dressing change for 1 of 1 residents reviewed (Resident #1) for dressing change. The findings included: Resident #1 was readmitted to the facility on [DATE] after hospitalization for altered mental status and sepsis secondary to UTI with diagnoses that included osteomyelitis of vertebra, sacral and sacrococcygeal region, acquired absences of left and right leg above knee, myocardial infarction, dysphagia, protein-calorie malnutrition, diabetes mellitus, major depressive disorder, osteoporosis, lymphedema, rheumatoid arthritis, and history of COVID-19. A review of the quarterly Minimum Data Set, dated dated dated [DATE] documented Resident #1 as cognitively intact and able to communicate her needs. She was assessed as having lower extremities impairment on both sides. A review of the physician's order for Resident #1, dated 11/24/22 revealed an order for left Above Knee Amputation (AKA) treatment: clean with Wound Cleanser (WC), pat dry, apply Santyl, cover with gauze, apply calcium alginate with silver, cover with an absorbent dressing and wrap with elastic gauze and Elastic Bandage for gentle compression daily and PRN (as needed) every day shift for wound care. A review of the Treatment Administration Record (TAR) for December 2022 conducted on 1/04/23 revealed an order for the left AKA dressing change as ordered. However, the dressing change was not documented as applied on 12/18/22. Further review of the December MAR revealed there was no documentation on 12/18/22 the dressing change had been provided. In an interview on 1/04/23 at 11:20 AM Nurse #1 revealed on Sunday, 12/18/22 there were 2 nurses on the hall. She indicated she was unable to provide any dressing changes, but she made sure all her residents received their medications. In an interview on 1/04/23 at 12:55 PM the Director of Nursing (DON) he indicated any resident with physician orders for a dressing change should receive their treatment as ordered. On 1/04/23 at 3:14 PM the Administrator indicated it a resident had an order for a daily dressing change she would expect staff to provide the dressing change as the physician ordered.

Based on record review, observations, staff and Health Department interviews the facility failed to develop and implement facility policies for infection control as recommended by the Centers for Disease Control and Prevention (CDC) guidelines; the facility failed to implement current infection control measures as recommended by the CDC on all resident halls ( A Hall and B Hall), when the facility failed to have required PPE (N-95 masks, disinfectant wipes) available for staff on 3 of 4 isolation carts (A1-A10 cart and B1-B-24 cart); when 4 of 20 staff members (Nurse #1, Nurse Aide (NA) #2, Nurse Aide #1, and Housekeeper #1) failed to wear the required Personal Protective Equipment (PPE) when they entered into quarantined special droplet contact precaution rooms on 2 of 2 hallways; when 4 of 20 staff members (NA #2, NA#1, Housekeeper #1, and the Floor Technician #1) failed to remove PPE when they exited COVID-19 and quarantined special droplet contact precaution rooms on 2 of 2 hallways; when 6 of 20 staff members (Nurse #1, NA #1 and #2, Housekeeper #1, Floor Technician, and Director of Nursing) failed to disinfect eye protection when they exited Special Droplet Precaution rooms on 2 of 2 hallways; and when 2 of 20 staff (NA#2 and Nurse #1) failed to perform hand hygiene when leaving a special droplet precaution room on 1 of 1 hallway. The COVID-19 outbreak began on 8/4/2022 when Resident #13 tested positive for COVID-19. Two residents (Resident #47 and Resident #372) tested positive during the outbreak and were taken to the emergency room for evaluation with respiratory symptoms. There were 22 residents who were not up to date with the COVID-19 vaccination series residing at the facility. These system failures occurred during the COVID-19 pandemic, which caused a high likelihood of affecting all residents by placing them at increased risk for developing and transmitting COVID-19. Immediate jeopardy began on 8/15/2022 when facility staff were observed to be out of compliance with CDC recommendations regarding PPE availability, PPE use, removal of PPE, and disinfection of PPE when caring for residents on special droplet contact precautions. Immediate Jeopardy was removed as of 8/18/2022 when the facility implemented an acceptable credible allegation for Immediate Jeopardy removal. The facility remains out of compliance at a scope and severity level F (No actual harm with potential for more than minimal harm that is not immediate jeopardy) to ensure the facility completes all staff training and ensure monitoring systems put into place are effective. The finding included. The Centers for Disease Control and Prevention (CDC) guidance entitled Strategies for Optimizing the Supply of Eye Protection: COVID-19 last updated on 9/13/2021 read in part Disposable eye protection should be removed and discarded after use. Reusable eye protection should (be) cleaned and disinfected after each patient encounter. Review of the facility's policy titled Personal Protective Equipment last reviewed/revised on 6/27/2022 revealed the following statements: - Face protection: Change when heavily soiled or contaminated. The review of the facility's policy titled Novel Coronavirus Prevention and Response last updated 6/15/2022 and Personal Protective Equipment policy last updated 6/27/2022 revealed there was not a policy in place to address the CDC's recommendations to clean and disinfect eye protection after each patient encounter. The CDC guidelines entitled Responding to Coronavirus (COVID-19) in Nursing Homes last updated on 4/30/2022 read in part All recommended COVID-19 PPE should be worn during care of residents under observation, which includes use of N95 or higher-level respirator (or face masks if a respirator is not available), eye protection (goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown. The CDC guidelines recommends the following when the broad-based approach is utilized: - Perform testing for all residents and HCP on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later. - If no additional cases are identified during the broad-based testing, room restriction and full PPE use by HCP caring for residents who are not up to date with all recommended COVID-19 vaccine doses can be discontinued after 14 days and no further testing is indicated. Review of the facility Novel Coronavirus policies revealed they did not have a CDC recommended Broad-based approach policy or procedure. Review of the facility's policy titled Novel Coronavirus Prevention and Response last reviewed/revised on 6/15/2022 revealed the following statements: - Educate staff on proper use of personal protective equipment and application of standard, contact, droplet, and airborne precautions, including eye protection. - Make PPE, including facemask, eye protection, gowns, and gloves, available immediately outside of the resident's room. - Implement standard, contact, and droplet precautions. Wear gloves, gown, goggles/face shield, and a NIOSH-approved N95 or equivalent or higher-lever respirator upon entering room and when caring for the resident. - Housekeeping staff shall adhere to transmission-based precautions. A review of the facility's Covid-19 Outbreak 8/8/2022 Process Protocol in-service provided to the staff indicated the following statements: - All residents who tested positive are placed on quarantine and will be tested in 5 days and if negative will be taken off quarantine on day 7. - All residents who are not vaccinated or not fully vaccinated will also be on quarantine until 14 days from last positive. - Isolation stations have been set up on each hall and should be worn before entering a quarantine room. - Signs have been placed on resident doors who are positive and those on quarantine due to vaccination status. - All staff entering the facility will be screened and required to wear an N95 and eye shields. Review of staff vaccination matrix showed 4 staff with non-medical exemptions, 100% of staff are fully vaccinated and 33% of staff are up to date with vaccination. As of 8/16/2022, 5 staff have tested positive for COVID-19. Review of resident vaccination matrix showed 78% are fully vaccinated and 69% are up to date with the COVID-19 vaccinations. As of 8/16/2022, 18 residents have tested positive for COVID-19. Resident #372 tested positive for COVID-19 on 8/8/2022. A Nursing progress note dated 8/15/2022 read in part resident observed disoriented, wheezing heavily, and agitated. Resident oxygen saturation was 70% (normal oxygen saturation levels on room air are 90% and higher) on room air. Resident #372 was sent to the emergency roiagnom on [DATE] with a chief complaint of respiratory distress. In the emergency room , Resident #372 required six liters of oxygen to maintain an oxygenation saturation of 95%. Resident #372 had a previous hospitalization in July 2022 related to a stroke and heart failure during which hospice was discussed. During Resident #372's hospitalization on [DATE], her family elected for Resident #372 to be on comfort care and to remain in the hospital until she was stable. Resident #47 was diagnosed as COVID-19 positive on 8/12/2022. A Nursing progress note dated 8/13/2022 read in part resident has complaints of excruciating left sided pain along with cough and low-grade temperature. Oxygen saturation was 88% on room air. Resident returned to the facility on [DATE]. Hospital diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] An observation made during the initial facility tour on 8/15/2022 at 11:30 A.M revealed Hallway A had two isolation carts with Personal Protective Equipment (PPE). Room A1 - A10 were served by one isolation cart and rooms A11-A23 were served by a second isolation cart. An observation made on 8/15/2022 at 12:30 P.M. revealed the isolation cart utilized on Hallway A for rooms Room A1 - A10 had no N95 masks or disinfectant wipes on the cart. An observation made on 8/15/2022 at 2:50 P.M. revealed the two isolation carts utilized on Hallway B for Rooms B1 - B24 had no N95 masks or disinfectant wipes on the cart. On 8/16/2022 at 9:00 A.M. Hallway A had 12 rooms on special droplet contact precautions (A1-A10: 4 quarantined rooms, A11-A23: 2 quarantined rooms; A1-A10: 0 COVID-19 positive rooms, A11-A23: 6 positive COVID-19 rooms). Hallway B had 14 rooms on special droplet contact precautions (B1-B10: 5 quarantined room, B11-B24: 2 quarantined rooms; B1-B11-: 3 COVID-19 positive rooms, B11-B24: 4 positive COVID-19 rooms). An interview was conducted with the Infection Preventionist (IP) on 8/17/2022 at 9:39 A.M. The IP indicated on 8/8/2022, due to the current COVID-19 outbreak at the facility, the facility had looked into increasing the number of isolation carts on each hallway to prevent staff from walking so far with the increased number of special droplet contract precautions rooms due to the current outbreak. She indicated at this time, the additional isolation carts were sold out and they were looking into other choices for carts to increase the number of PPE stations available to staff. During the interview, the IP stated there was no shortage of PPE at the facility and she was unsure why the carts were not stocked with supplies. She further indicated staff were aware of where extra supplies were located and should have refilled the carts if there were no supplies. An observation on 8/15/2022 at 11:25 A.M. During a medication administration, Nurse #1 entered Resident #70 and Resident #45's room. There was a Special Droplet Contact Precautions sign posted on the residents' door that read: all healthcare personnel must wear a gown before entering room and remove before leaving, wear N95 or higher level respiratory before entering the room and remove after exiting. Protective eyewear (face shield or goggles), wear gloves when entering room and removed before leaving. Neither resident was positive for COVID-19 and neither resident was up to date with COVID-19 vaccination recommendations. Nurse #1 wore a N95 mask and goggles when she entered the room. Nurse #1 was asked about the isolation signage and the required PPE gear to enter Resident #70 and Resident #45's room. She indicated when a resident was not COVID-19 positive and was quarantined for not being up-to-to date on their COVID-19 vaccines, a gown was not required to be worn. Review of the assignment sheets dated 8/15/22 revealed Nurse #1 was scheduled to work with residents in special contact precaution rooms and residents not on precautions. An observation on 8/15/2022 at 1:00 P.M. revealed Nurse Aide (NA) #2 entered three different resident rooms (Resident #11 and Resident 28's room, Resident #59 and Resident #21's room, and Resident #9 and Resident #1's room) without following posted PPE signage before entering two of the three resident rooms with signage posted that read Special Droplet Contact Precautions. NA #2 did not perform hand hygiene, wear gloves, remove and replace his N95 mask, disinfect his eye protection, or don a gown for one of the two isolation rooms (Resident #11 and Resident #28's room). During the observation NA #2 entered Resident #9 and Resident#'1 room last after providing care to Resident #11, Resident #28, Resident #59 and Resident #21 who were placed on special droplet contact precautions during the COVID-19 outbreak for not being up to date with all recommended COVID-19 vaccines. An observation on 8/15/2022 at 2:56 P.M. revealed Resident #371's room had signage that read Special Droplet Contact Precautions. NA #1 entered Resident #371's room and wore a KN95 mask and goggles. NA #1 was observed to not clean her eye protections when she exited the room. During an interview, NA #1 indicated she had not read the signage posted on the door when she entered the room and was unaware, she needed to wear a N95 masks, gown, and googles when she entered the room. An observation on 8/16/2022 at 11:48 A.M. revealed Housekeeper #1 in a resident's room (Resident #3 and Resident #44) where a Special Droplet Contact Precautions signage was posted on the resident's door. Housekeeping Staff #1 was present in room performing housekeeping tasks and was observed not wearing gloves or a gown. The housekeeping staff then exited Resident #3 and Resident #44's room and entered another resident's room without changing her N95 mask. During an interview, the housekeeping staff indicated she should have read the signage posted on the door and followed the requirements listed by changing out her N95 mask, wearing gloves, and a gown. Review of the assignment sheets dated 8/16/22 revealed Housekeeper #1 was scheduled to work with residents in special contact precaution rooms and residents not on precautions. An observation was made on 8/16/2022 at 12:20 P.M. of a Floor Technician #1 assigned to rooms of residents that did and did not require special droplet precautions. During the observation, the Floor Technician #1 exited a room that had signage posted that read Special Droplet Contact Precautions and both residents (Resident #39 and Resident #38) had tested positive for COVID-19 during this facility outbreak. The Floor Technician #1 did not remove or replace his N95 mask and did not disinfect their eye protection. The Floor Technician #1 was stopped by a surveyor in the hallway. During the interview, the Floor Technician #1 indicated he was walking to the nurse's station to replace his mask and disinfect his googles. The Floor Technician #1 had to pass 7 resident rooms and an isolation cart, to arrive at the nurses' station. An observation on 8/16/2022 at 12:45 P.M. of the Director of Nursing (DON) exiting a resident's room (Resident #20). There was signage posted on the door that read Special Droplet Contact Precautions due to the resident not being up to date on their COVID-19 vaccine series. The DON was not observed to sanitize her goggles when she exited Resident #20's room. During an interview, the DON indicated she had been sanitizing her goggles when she exited isolation rooms; however, at this encounter her goggles were not sanitized. The DON further indicated the signs on the door did not say to sanitize goggles. The DON indicated the IP provided education to staff about following the posted signage on a resident's room when the resident was on isolation precautions. An observation was made on 8/16/2022 at 12:58 P.M. of Nurse #1 who was assigned to rooms of residents that did and did not require special droplet precautions. Nurse #1 wore a gown, N95 mask, and eye protections when she entered a residents' room (Resident #11 and Resident #28) with signage posted that read special droplet contact precautions with lunch meal trays. Nurse #1 set up Resident #11's meal tray, doffed her gown, washed her hands, came out of the room and applied a new N95 mask. Nurse #1 did not wear gloves during this encounter. During an interview, Nurse #1 indicated she forgot to apply gloves and perform hand hygiene when she entered and exited the residents' room An interview on 8/17/2022 at 9:39 A.M. with the Infection Preventionist (IP) indicated she does not get any COVID-19 updates herself. The information is provided to her by the facility's corporate office and the Administrators as changes are made to policies and procedures. The policy for COVID-19 was last updated on 6/15/2022 to reflect the CDC recommendations. She indicated she was unable to trace the sources for the COVID-19 outbreak that began on 8/4/2022. The facility made the decision to follow the CDC's recommended broad-based approach, which indicated to place both Covid positive and residents not up to date on Covid-19 vaccines on Special Droplet Contact Precautions. The IP indicated there was no shortage of available PPE, to include N95 masks and stated their corporate office was available for assistance with getting PPE supplies if needed. During the interview, the IP further stated staff should follow the guidance posted on the Special Droplet Contract Precautions signage and don a new N95 mask, after doffing the mask being worn, when they exited a room on contact precautions. The IP indicated staff were provided education during orientation on the donning/doffing process and to follow the guidance posted on each isolation sign. The IP further stated she was unaware the eye protection should be disinfected when leaving a special droplet contract precautions room. During the interview, the IP stated the management team worked together to correct staff that were not following the posted special droplet precaution signage immediately when a concern was identified. An interview was conducted on 8/15/2022 at 4:14 P.M. with the Administrator. During the interview, it was indicated N95 masks were to be changed every shift and there was nothing on the special droplet contact precautions signage to indicate eye protection had to be sanitized when exiting a contact room. The Administrator further indicated staff should follow the signage posted when determining what PPE to use prior to entering resident rooms. An interview on 8/17/2022 at 3:23 P.M. with the Administrator and DON revealed staff were monitored for signs and symptoms when they entered the building each shift. Residents were monitored each shift for signs and symptoms of Covid-19. During the interview the Administrator stated there is no specific policy to address the removal of PPE gear when exiting a contact room. On 8/17/2022 at 6:40 P.M., the facility's Administrator, Director of Nursing, and the facility's Regional Nurse Consultant were informed of the immediate jeopardy. The facility provided the following credible allegation of Immediate Jeopardy removal: Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance. Residents #373 and #47, residents in room(s) A5, A6, A7, A10, A14, A18 were at risk while the 22% of residents who are not fully vaccinated and 31% of residents who are not up to date with COVID-19 vaccinations were at a greater risk from the failure to adhere with correct and appropriate infection control processes as guided by the Centers for Disease Control (CDC) and Centers for Medicare and Medicaid Services (CMS). The facility will test residents identified at risk and those at a greater risk according to the testing cadence set forth by the Center for Disease Control (CDC) along with monitoring the resident's vital signs and signs and symptoms (i.e. fever, respiratory, body aches, chills, sore throat, nausea, vomiting) of COVID-19. Specify the Action the Facility will take to alter the process or system failure to Prevent a Serious Outcome from occurring or reoccurring and when the Action will be complete. The facility will take immediate action to educate and ensure all staff follow Centers for Disease Control (CDC) recommendations for Personal Protective Equipment (PPE) when caring for resident's placed on Special Droplet Contact Precautions. Staff will don when entering and doff when exiting appropriate PPE based on signage and discarding/sanitizing eye protection when exiting Special Droplet Contact Precaution rooms On 8/17/2022, the Administrator and Director of Nursing were educated by the Regional Director of Operations and the Regional Director of Clinical Services on the procedure of donning when entering and doffing when exiting appropriate Personal Protective Equipment (PPE) based on signage and discarding/sanitizing eye protection when exiting Special Droplet Contact Precaution rooms. This was to ensure that the Administrator and Director of Nursing could educate the Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admission Coordinator, Maintenance Director, Scheduler, Central Supply, MDS Coordinator, Staff Development and Wound Nurse) on the procedure and can monitor all staff for compliance. All staff currently in the facility, including contract staff or employees, have been re-educated on 8/17/22 on the proper procedures of donning when entering and doffing when exiting appropriate PPE based on signage and discarding/sanitizing eye protection when exiting Special Droplet Contact Precaution rooms by the Director of Nursing, Assistant Director of Nursing, Wound Nurse and Staff Development Coordinator On 8/17/22, the Administrator assigned training competency requirements and responsibilities of completion to the Staff Development Coordinator, Wound Nurse, Assistant Director of Nursing, Unit Manager, or Director of Nursing. Any staff members who were not in the facility on 8/17/22 will be in-serviced by phone and competency evaluated by return demonstration as they report for their next assigned shift by the Staff Development Coordinator, Wound Nurse, Assistant Director of Nursing, Unit Manager, or Director of Nursing. Effective 08/17/22, all staff are required to complete this training prior to working in the facility and were notified of the requirement by their Department Supervisor. Effective 8/17/22, the Administrator instructed the Staff Development Coordinator to utilize a master employee list to track completion of education. No staff will be allowed to work past 8/17/22 until education is completed. Education will also be included during orientation for newly hired staff. Effective 8/17/2022, the facility Interdisciplinary Team (Administrator, Director of Nursing, Assistant Director of Nursing, Social Worker, Activities Director, Business Office Manager, Admission Coordinator, Maintenance Director, Scheduler, Central Supply, MDS Coordinator, Staff Development and Wound Nurse) will perform facility observation and surveillance daily in the facility to ensure the procedures of donning when entering and doffing when exiting appropriate Personal Protective Equipment (PPE) based on signage and discarding/sanitizing eye protection when exiting Special Droplet Contact Precaution rooms is being followed. Additionally, the Administrator and Director of Nursing will monitor any areas of non-compliance and provide education and return demonstration with identified staff members. Effective 8/17/2022, the Administrator and Director of Nursing will be ultimately responsible to ensure implementation of plan of correction this alleged noncompliance. Date of correction action completion Immediate Jeopardy Removal date will be 8/18/2022. The facility's credible allegation of Immediate Jeopardy removal was validated on 8/19/2022. Review of in-service attendance sheets revealed staff had been in-serviced on the CDC recommendations for PPE for residents placed on special droplet contract precautions to include when to don and doff PPE, following signage requirements for PPE, sanitize eye protection, return demonstration for sanitize eye protection. Observations of Special Droplet Contact Precaution rooms revealed staff followed the posted signage when they entered and exited the isolation room. A review of facility records revealed daily monitoring and tracking for compliance had been completed. Interviews conducted revealed staff from all shifts and all disciplines had been in-serviced on Special Droplet Contact Precautions. IJ was removed on 8/18/2022.

Based on observations, record review, physician interview and resident and staff interviews, the facility failed to 1.) implement fall interventions after a resident fell and sustained a laceration to his forehead for 1 of 18 residents reviewed for falls, (Resident #16); and 2.) failed to secure smoking materials and failed to supervise a resident while smoking for 1 of 3 residents reviewed for smoking. (Resident #27). Findings Included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses which included generalized muscle weakness, hypertension, Type II diabetes and [CONDITION(S)] disease. A review of Resident #16 ' s quarterly Minimum Data Set (MDS) dated [DATE] revealed he was cognitively intact and required extensive assistance for bed mobility and total dependence with one-person assist for bed transfer. The MDS also revealed he had no falls documented for the lookback period. A review of Resident #16 ' s care plan initiated on 02/23/22 revealed he was at high risk for falls related to his weakness, impaired mobility, cerebral infarction and attempted unassisted transfers. The interventions included Resident #16 would be free of falls through the next review date, ensure his call light was within reach and anticipate and meet his needs. A review of a nursing progress note dated 06/06/2022 at 3:50 am written by Nurse #12 read in part, informed by a nursing assistant (NA) that Resident #16 was observed on the floor during resident rounds. Nurse #12 ' s progress note revealed she went to his room and observed Resident #16 lying on the floor and requesting to get back in bed. Resident was assisted back to bed and observed in semi-fowlers position. Nurse #12 noted she performed an assessment of Resident #16 which revealed a bruise with minimal bleeding to the middle of his forehead about 1 inch in size with no signs and symptoms of any additional skin tears or bruising. Nurse #12 ' s progress notes also read, incident reported to Supervisory Staff, Medical Doctor and Family. A review of the hospital records dated 06/06/2022 read in part Resident #16 was seen in the Emergency Department (ED) after he fell and struck his head suffering a one-centimeter (cm) laceration to his right forehead. The laceration was repaired with skin bond. All x-rays and CT scans were negative with no acute fractures. A head cat scan (CT), a cervical spine CT, a pelvic x-ray and a chest x-ray was completed during this visit. The ED record also revealed Resident #16 was discharged back to the facility at 5:17 am. A review of the facility ' s fall incident reports for Resident #16 revealed no fall incident report was completed for on 06/06/22. A review of Resident #16 ' s care plan dated 2/23/22 revealed no additional falls interventions were added after his fall on 06/06/22. A phone interview was conducted with Nurse #12 on 08/18/22 at 3:35 pm. Nurse #12 stated she no longer worked at the facility but remembered Resident #16 ' s fall on 06/06/2022. Nurse #12 stated Emergency Medical Services (EMS) transported him to the hospital to be evaluated after his fall. Nurse #12 also stated she didn ' t notify the Administrator on call because she thought another staff person was going to do it. Nurse #12 stated she only worked at the facility for a couple of shifts, therefore, she was not aware of other staff members' names. Nurse #12 also stated she did not call a supervisory staff person because she thought someone else was going to do it. An interview with the Assistant Director of Nursing (ADON) on 08/18/22 at 4:01 pm revealed she was on call for the night of 06/05/2022 - 06/06/2022. The ADON stated she remembered Resident #16 but did not remember if she received a call from a nurse about a fall for him in the middle of the night on 06/06/2022. The ADON further stated she did not keep a log of the calls she received while being on call. A review of a nursing progress note dated 06/12/22 at 12:45 am by Nurse #7 read in part, this nurse was called to the resident ' s room at approximately 12:45 a.m. and observed Resident #16 lying on the floor with visible blood to his left cheek area. Nurse #7 ' s note continued with, the resident was assessed for injury. Resident #16 was alert and oriented. Emergency Medical Services (EMS) were contacted. The nursing note revealed first aid was rendered to Resident #16 ' s left cheek using aseptic technique. EMS left the facility with the resident at approximately 1:13 a.m. A review of the hospital records dated 06/12/2022 read in part Resident #16 was seen in the Emergency Department (ED) after he fell and struck his face sustaining a two (cm) laceration to the left upper cheek area and required 5 sutures. A head CT scan was performed during this visit and resulted negative. The ED record also revealed Resident #16 was discharged back to the facility at 5:00 am. A review of the facility ' s fall incident reports for Resident #16 revealed a fall report was completed on 06/12/22. The falls report revealed Resident #16 was oriented to person, place with some confusion stating to the staff that his mother was in his room telling him to get up and come on. A review of Resident #16 ' s care plan revised on 06/12/2022 revealed interventions were added to include Resident #16 ' s bed would remain in lowest position, fall mats would be placed on the left and right side of bed and staff would encourage him to use his call light and ask for assistance as needed. Several attempts were made to interview with Nurse #7 but were unsuccessful. Interview with the Corporate Consultant on 08/18/2022 at 2:06 pm revealed there were no additional interventions added to Resident #16 ' s care plan after his fall on 06/06/22. The Corporate Consultant also stated a fall incident report was not completed Resident #16 on 06/06/2022 and there were no additional interventions put into place to prevent another fall. Interview with the facility ' s Social Worker on 08/18/22 at 3:46 pm revealed there were not additional interventions added to Resident #16 ' s care plan after his fall on 06/06/22 because the Interdisciplinary Team (IDT) was unaware of the fall. The Social Worker stated a fall incident report was not completed for his fall on 06/06/22 which as a result did not alert the team of his fall. He further stated the facility ' s process when a fall occurs would be to complete a falls incident report which would send the IDT an alert indicating a fall had occurred. The Social Worker stated once the alert had been received, the IDT would have discussed it in morning stand-up meeting and placed the appropriate care plan interventions in place. The Social Worker further stated since a falls incident report was completed for Resident #16 ' s fall on 06/12/22, the IDT added care plan interventions to prevent further falls. Interview with the Administrator on 08/18/22 at 02:12 pm revealed there was not a falls incident report completed for Resident #16 ' s fall on 06/06/22. She stated if a report had been completed the information would have pulled over to our clinical morning meeting and collaboratively additional fall interventions would have been put into place. She further stated a root cause analysis (RCA) would have been completed and appropriate interventions and the care plan would have been updated. The Administrator stated there should have been additional interventions added to Resident #16 ' s care plan after his fall on 06/06/22 to prevent further falls. Interview with the Medical Director (MD) on 08/18/22 04:32 pm revealed he was aware of Resident #16 ' s fall on 06/06/22 and 06/12/22. The MD stated Resident #16 had multiple comorbidities and was very frail. The MD stated he assessed Resident #16 at the facility on 06/06/22 and on 06/15/22 after each of his falls at the facility. The MD also stated Resident #16 ' s health condition was challenging as he was occasionally confused. The MD further stated both of Resident #16 ' s falls could not be prevented due to his increased confusion and generalized weakness. 2. A review of the facility ' s smoking policy dated 11/01/2020 read in part, any resident who is deemed safe to smoke, will be supervised and will be allowed to smoke in designated smoking areas at designated times, and in accordance with his/her care plan. The policy also read Smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. Resident #27 was admitted to the facility on [DATE] with diagnoses which included dementia, [CONDITION(S)], hypertension and heart disease. A review of Resident #27 ' s admission Minimum Data Set (MDS) dated [DATE], section 1300, was coded as a user of tobacco. A review of Resident #27 ' s care plan dated 05/31/2022 revealed he was a smoker and was noncompliant with the facility ' s policy and had an intervention in place stating he would not smoke without staff supervision through the next review date. A review of Resident #27 ' s smoking assessments dated 02/17/2022, 05/17/2022 and 8/17/2022 revealed Resident #27 required supervision while smoking. Observation on 08/17/22 at 11:04 am revealed Resident #27 was outside in the facility ' s designated smoking area. Resident #27 removed a tobacco cigarette and a disposable lighter from his shirt pocket. He lit the cigarette and began smoking. Observation also revealed there was not a staff member present while Resident #27 was outside smoking. Interview with Resident #27 on 08/17/22 at 11:30 am revealed he always kept his tobacco cigarettes, electronic cigarettes and disposable lighter on his person. He stated the facility knew he kept his smoking materials with him and not at the nurse ' s station. Resident #27 did not have a roommate. Observation on 08/18/22 at 3:12 pm revealed Resident #27 smoking an electronic cigarette in the family room of the facility. Observation also revealed there was not a staff person in the family room and no oxygen was nearby Resident #27. This surveyor alerted the DON and the Administrator of this observation. Interview with the Director of Nursing (DON) on 08/17/2022 at 11:50 am revealed the facility had experienced Resident #27 smoking in his room numerous times, however, it usually involved his electronic cigarette. The DON also stated Resident #27 ' s family members would bring cigarettes and electronic cigarettes to the facility even though they knew it was against facility policy. The DON stated the facility had educated Resident #27 and his family on several occasions, however, Resident #27 still managed to have cigarettes and lighter. Interview with the Administrator on 08/19/2022 at 3:36 pm revealed Resident #27 should have been supervised while smoking per his smoking assessments and care plan.

Based on observation, resident and staff interview and record review, the facility failed to provide nail care for one resident (Resident # 37) and toileting assistance for two residents (Resident #34 and Resident #5), for 3 of 23 residents reviewed for Activities of Daily Living (ADLs)which resulted in residents having incontinent episodes and one resident was pi off and one resident did not like it. Findings included: 1.A review of the medical record revealed Resident #5 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) dated [DATE] indicated Resident # 5 was cognitively intact and needed extensive assistance for activities of daily living (ADL) care with the help of one person. The MDS noted Resident #5 was frequently incontinent for bowel and bladder and used a bedpan. In an interview on 4/14/2021 at 11:12 PM, NA #4 stated she did not think the facility had enough staff for her to address all her resident ' s needs. NA #4 indicated there were three residents she was not able to provide morning care for, including incontinent care on the morning of 4/14/2021, because she did not have help. In an interview on 4/16/2021 at 4:45 PM, Resident #5 stated a week before, he turned on his call bell at 9:00 PM because he needed to use the bedpan. Resident #5 stated an NA came into his room and turned the call bell off and said she would be back. The Resident stated he told her he needed to use the bedpan. Resident #5 noted an NA came in at 11:05 PM to help him get onto the bed pan. Resident #5 said it made him feel pi off and he reported it to the nurse. 2.The medical record revealed Resident #34 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set, dated dated dated [DATE] assessed Resident #34 as cognitively intact and needed total assistance for the activities of daily living (ADLs) of bath and toilet use with the help of one person. The Care Area Assessment noted a focus of ADL care and indicated a care plan would be initiated. There was no care plan for ADLs. On 4/16/2021 at 4:10 PM, Resident #34 was interviewed and stated he often waited 30 minutes for assistance to the bedpan and had waited 50 minutes. Resident #34 stated he could not always wait and would have an accident, he stated I don ' t like it, but I still have to wait. Resident #34 indicated the longer wait was mostly at night. 3. A review of the medical record revealed Resident #37 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) The Annual Minimum Data Set (MDS) dated [DATE] noted Resident #37 to be moderately impaired for cognition and needed extensive to total assistance for all ADL care with the help of one person. The MDS noted no rejection of care. The Care Area Assessment indicated a focus of ADL care and this area went to care plan. The care plan dated 7/23/2019 indicated Resident #37 had a self-care deficit for ADLs related to past Stroke and [CONDITION(S)]. Interventions included honor the resident ' s preference for bathing/showering. The resident is dependent on staff for personal hygiene and oral care. On 4/12/2021 at 9:30 AM, Resident #37 was observed lying in bed with clean fingernails extending approximately ¼ inch longer than his fingertip. Resident #37 did not speak clearly but could shake his head for yes and no and could shape words with his mouth. When asked if he liked his fingernails long Resident #37 shook his head to indicate no. When asked if he would like his fingernails trimmed, the Resident nodded his head to indicate yes. On 4/13/2021 at 10:00 AM, Resident #37 was observed in bed asleep and his fingernails appeared to be the same length as the day before. Resident #37 was observed with the same long nails on the afternoon of 4/13 and the morning of 4/14/2021. On 4/13/2021 at 1:30 PM, NA #10 stated he shaved residents and trimmed nails when there was enough staff. NA #10 stated if someone calls out the tasks change from extra care to what is necessary. NA #10 also noted that he may not have the same assignment two days in a row, so a resident that he did not get to shave on his assignment one day, may not be on his assignment the next day, or even the following day, and some residents don ' t want female NAs to do shaving or nail care. In an interview on 4/14/2021 at 2:30 PM, Nursing Assistant (NA) #2 stated she had Resident #37 on her assignment that day and she had given him a bath but did not trim his nails. Upon being told that Resident #37 had indicated on 4/12/2021 that he wanted his nails trimmed, NA #2 stated she did not have Resident #37 on her assignment on 4/12/2021. The Director of Nursing (DON), upon seeing Resident #37 ' s nails on 4/14/2021 at 2:35 PM, stated nail care was part of ADL care and Resident #37 ' s nails would be trimmed. On 4/15/2021 at 9:10 AM, NA #7 indicated that nail care was part of ADL care. In an interview on 4/15/2021 at 9:55 AM, NA #1 stated hair care, oral and nail care were part of ADL care. NA #1 stated she had trouble completing her work when there was not enough staff. On 4/15/2021, the Director of Nursing stated he knew there was a lot of work to do and he expected good care to be given to all residents.

Based on observations, staff and resident interviews and record review, the facility failed to maintain sufficient staffing resulting in nail care not being provided (Resident #37), and toileting assistance was not provided (Resident #34 and Resident #5) resulting in residents having incontinent episodes and one resident was pi off and one resident did not like it. Findings included: This tag is cross referenced to F677. Based on observation, staff and resident interview and record review, the facility failed to provide nail care for one resident (Resident # 37) and toileting assistance for two residents (Resident #34 and Resident #5) for residents reviewed for Activities of Daily Living (ADLs),resulting in residents having incontinent episodes and one resident was pi off and one resident did not like it. In an interview on 4/16/2021 at 7:52 AM, NA #6 stated even though her name was on the schedule for 4/13/2021 for the 11PM to 7AM shift, she did not work. NA #6 stated she was off that night. NA #6 stated the facility was often short of staff and even though she usually managed to get her work done, it was difficult. The facility Scheduler was interviewed on 4/16/2021 at 10:32 AM and stated there was not enough staff and she schedules regular staff as much as possible and then uses agency staff. The Scheduler stated the weekends were a problem because staff called out and she had to scramble to find someone to work. When asked specifically about 4/14/2021 on the 11PM to 7AM shift, the Scheduler stated there were only two NAs for the entire facility of 63 residents. On 4/16/2021 at 3:05 PM, NA #8 was interviewed and stated there was not enough staff. NA #8 indicated she would stay late, if she had to, to get her work done. In an interview on 4/15/2021, the Director of Nursing (DON) stated he had been hired in March. The DON stated he knew there was a lot to work on and he was trying his best to find staff. The DON stated it would be good to not depend on agency nurses, and his expectation was that good care be given to all residents.

Based on staff interviews, physician interview, Nurse Practitioner interview, record review and facility audit, the facility: A. failed to administer a [DIAGNOSES REDACTED] screening on admission and to follow facility policy for 1 of 1 sampled resident (Resident #18) with a positive protein derivative (PPD) test and chest x-ray results indicating that [DIAGNOSES REDACTED] could not be excluded at the time; B. failed to administer a [DIAGNOSES REDACTED] screening on admission for 7 (Resident #3,#10,#11,#15,#17,#21,#23) of 25 sampled residents and for 8 (Resident #26,#27,#28,#29,#20,#31,#32,#33) residents identified per the requested audit by the facility completed on 06/29/10; C. failed to administer annual [DIAGNOSES REDACTED] screening for 3 (Resident #2,#6,#7) of 25 sampled residents and for 6 (Residents #34, #35, #36, #37, #38, #39) residents identified per the requested audit by the facility completed on 06/29/10; D. failed to administer [DIAGNOSES REDACTED] skin test for 5 (Nurse Aide #1, Nurse #2,#3,#4,#8) of 9 employees identified by the facility to have had contact, prior to isolation being initiated, with a resident who had a positive PPD and chest x-ray results indicating that [DIAGNOSES REDACTED] could not be excluded at the time Immediate Jeopardy began on 06/18/10. The facility administrator was notified of the Immediate Jeopardy on 06/30/10 at 10:10 AM. Immediate Jeopardy was removed on 07/01/10 at 4:55 PM when the facility provided a credible allegation of compliance. The facility remained out of compliance at a lower scope and severity at a level E (a pattern deficiency that constitutes no actual harm with potential for more than minimal harm that is not immediate jeopardy.) The facility remained out of compliance to ensure completion of in-servicing and to monitor implementation of the corrective action. Findings include: The facility "Infection Control Policy and Procedure" manual, dated 08/2007, read in part: 1. Screening New Admissions or Readmissions: a. The facility will screen referrals for admission and readmission for information regarding exposure to, or symptoms of, TB ([DIAGNOSES REDACTED]) and will check results of recent (within 12 months) [MEDICATION NAME] skin tests (TST), blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED] (BAMT) or chest x-rays (CXR) b. Any resident without documented negative TST, BAMT or CXR within the previous 12 months will receive a baseline (two step) TST or (one step) BAMT upon admission. If the first TST is negative, a follow up TST will be administered 1 to 3 weeks after the initial test is read. The BAMT is a one-step test. c. If the BAMT or either TST is positive, the nursing staff will contact the physician to obtain orders for a CXR and the physician will assess the resident prior to admission for possible active TB. g. Screening of new admissions or readmissions for [DIAGNOSES REDACTED] infection and disease will be in compliance with State regulations. 2. Handling Residents Suspected to Have Active TB: a. The nursing staff and or physician will immediately report to the Infection Control Coordinator the name of any resident with suspected active TB. b.The infection Control Coordinator will initiate airborne isolation precautions and ensure appropriate TB infection control until the case is clinically confirmed or denied. c. Nursing staff will place an appropriate mask over the mouth and nose of any resident having, or suspected of having, active TB, and will arrange for prompt transfer to an acute care hospital. d. The resident with suspected TB will remain under airborne isolation precautions in a room separate from other residents and visitors with the door closed until the resident is transferred. 1 A. Resident #18 was admitted to the facility on [DATE]. The cumulative [DIAGNOSES REDACTED]. Review of the resident's medical record found no documentation of a PPD (TST) being administered to the resident on 06/18/10 or 06/19/10. review of the resident's medical record revealed [REDACTED]. Review of the record of Resident #23, identified at the roommate of Resident #18, revealed the resident had been admitted on [DATE], [DIAGNOSES REDACTED]. Review of Resident #18 progress notes indicated that he was seen by the Nurse Practitioner (NP) on 06/22/10. The information documented in the history section of the visit indicated that the resident had a biopsy of a mass in the right lung and the result of the biopsy was prominent chronic inflammation with fibrosis. In the section, titled examination, the NP indicated that the resident appeared ill, cachectic and was lying in bed with the head of the bed elevated almost 90 degrees. In the section, titled plan for hypoxemia, the NP documented that the resident was a very complex pulmonary patient. The NP's notes indicated that the resident would have a chest x-ray, blood work, a PPD. If the PPD was positive then the resident was to have acid fast sputum cultures times 6 and to obtain sputum for TB culture. An interview, on 06/30/10 at 4:10 PM, was conducted with the NP. She stated that she saw the resident on 06/22/10, that he had just come out of the hospital and she was reviewing his case. She indicated that the resident looked very ill, had an oxygen saturation of 90% on room air, a slight fever and complained of pain. The NP relayed that with the resident's limited history and diagnoses, she ordered labs, chest x-ray, PPD test and a sputum test if the PPD was positive. Review of the Medication Administration Record (MAR), for the month of June 2010, revealed that the resident received a PPD on 06/22/10. Review of the chest x-ray report completed on 06/23/10 indicated the reason for the chest x-ray was to rule out TB. The impression of the x-ray report read in part: "Moderate right lower lobe and slight left lower lobe infiltrates and probable effusions. [DIAGNOSES REDACTED] cannot be excluded until these processes have resolved." A notation was hand written in the lower right hand corner of the x-ray results, which read in part: "(name of physician) notified of results. faxed report. on isolation." Review of the nursing notes, dated 06/23/10 at 10:05 PM, read in part: "Orders received to put patient in isolation and start TB precautions. Repeat PPD on patient in A bed. Notify (name) NP in the A.M. (morning) so that she can do sputum test. Staff will also need PPD test if in close contact with patient." The nursing note continued and indicated that the resident was moved to another room at 11:00 PM An interview was conducted on 06/29/10 at 3:50 PM with Nurse #1. Nurse #1 confirmed that she was the nurse working the evening of 06/23/10. She indicated that she received the x-ray report that evening, called the physician with the results. She stated that the physician asked what the results of the PPD was. Nurse #1 relayed that she told the physician that the PPD was just given the day before and it was not due to be read. She indicated that the physician advised her to go look at the PPD that if PPD was reactive it could be showing this soon after the administration. Nurse #1 stated she went to the resident's room, checked the PPD, it was positive and relayed the information. She indicated that she received orders to place the resident in isolation. She indicated she called the Director of Nursing (DON). Review of the nursing notes, dated 06/23/10 and 06/25/10 through 06/28/10, revealed that the resident had a productive cough. An interview was conducted on 06/28/10 at 10:45 AM with the DON. The DON stated that she received a call from the nurse on the evening of 06/23/10 regarding the resident's chest x-ray and positive PPD. She relayed she instructed the staff to place the resident in isolation and intended to send the resident out the next morning. The DON indicated she spoke with the resident's physician the morning of 06/24/10 and the physician stated he would call the pulmonologist regarding the [MEDICATION NAME] the resident had while in the hospital. She stated that the resident's physician relayed that he had spoken with the pulmonologist and the pulmonologist did not think there was a problem regarding TB. The DON relayed that after getting that information, she decided to keep the resident in isolation at the facility until the report was received from the pulmonologist. When asked if the facility had obtained the sputum cultures, the DON stated that they had not due to the fact that they were awaiting the information from the pulmonologist. When asked if the resident's room was a regular resident room or an airborne isolation room, she indicated that the room was a regular resident room, but that the resident was the only resident in the room and was on isolation. On 06/28/10 at 11:15 AM, the DON presented an unsigned statement, dated 06/24/10, from the resident's physician. The statement read: "(name) resident continues to appear very ill. We were concerned about the remote possibility of TB. We have placed a ppd and it looks like it might be positive. We are researching his ppd history as I tried to get the information from the patient but I don't think it is reliable. He did have a [MEDICATION NAME] on June 2, three weeks ago. I called the doctor who did the [MEDICATION NAME], (physician name) and learned the acid fast stains (on the [MEDICATION NAME] washings) were negative and is the preliminary TB culture. He feels and I feel that his chance of being communicable at this point is zero. Just to leave no stone unturned we will check two more sputums for acid fast stain." The resident's physician confirmed the statement on 07/01/10 at 10:35 AM. On 06/29/10 at 11:40 AM the DON, in the presence of two surveyors, approached and confirmed with the resident's physician that he had spoken with the pulmonologist and was waiting for the biopsy results from the [MEDICATION NAME] with regards to the status of the resident. The DON relayed to the physician at this time the orders were still in place on the chart for the acid fast sputum tests, the orders needed to be cancelled and no sputum specimens had been collected. The physician indicated that the orders were to remain as written. He relayed that he wanted the test results that he ordered to rely on and not just the information from the other physicians. On 06/29/10 at 4:00 PM the DON relayed there was some miscommunication regarding the collection of the sputum specimens. The DON revealed that she was under the impression they were waiting on the pulmonologist to get back to them and therefore had not collected the sputum specimens. She indicated that she should have gone with the policy and sent the resident out of the facility. The DON stated that she when she received the call on 06/23/10 that it was her plan to send the resident out the next morning; but, after the conversation with the physician on 06/24/10 decided to await the biopsy results. An interview was conducted on 06/30/10 at 7:45 AM with the DON. She relayed that the ADON (Assistant Director of Nursing), who had been at the facility when she (DON) was hired, left in May, had not kept up with the Infection Control Programs nor the status of resident issues, and had let the program fall through the cracks. The DON indicated that she had a new ADON in place for the past two weeks and had assigned the infection control to her. The DON stated the present ADON was in the process of trying to catch up the infection control program. She relayed that she and the administrator were looking at staff members who would be able to manage the program on an ongoing basis. When asked how the facility reviewed the trends of infections in the facility, the DON stated that it was done quarterly. She relayed that the facility did a clinical meeting daily, had a system to identify residents on antibiotics, on which hall so they can monitor the types of infections and this information was updated each shift. The DON indicated that the information was not recorded permanently but did help on a day to day basis. When asked about the Quality Assurance process for infection control, the DON stated that she used the 24 hour reports to gather the information. She indicated that was not the best way but the infection control program would get better once the facility had a staff member permanently assigned to follow the infection control status of all of the residents and to maintain records. On 06/29/10 at 3:00 PM, a request was made to the DON to obtain the [MEDICATION NAME] report from the hospital. Review of the [MEDICATION NAME] report performed on 06/02/10 read in part: "1. Copious mucoid secretions in the all three lobes of the right lung, suctioned and washed clear. 2. Incidental right lower lobe mass, biopsied." Review of the hospital records, dated 06/02/10, for the acid fast bacilli cultures and stains report on the [MEDICATION NAME] washings from both lungs indicated no acid fast bacilli seen. On 06/29/10 at 4:25 PM an interview was conducted with Nurse #2. She stated that a PPD should be given on the day the resident was admitted . Nurse #2 indicated that it was not probably done in the first few hours because of assessments that needed to be done, medications, etcetera (etc) but within the day of admission. On 06/29/10 at 4:30 PM an interview was conducted with Nurse #1. She stated that a PPD should be given on the day of admission. On 06/29/10 at 4:45 PM, the DON identified an undated, unsigned paper attached to the back of Resident #18's chart as a list of conditions that the physician maintains on the residents. The paper was headed with Resident 18's name and in the list of conditions read in part: "PPD status unknown." On 06/29/10 at 5:30PM a request was made to the administrator and the DON for a 100 percent audit of the residents' and staffs' PPD status. On 06/30/10 at 7:40 AM an interview was conducted with Nurse #3. Nurse #3 confirmed that she was the nurse who admitted Resident #18 on 06/18/10. She indicated that she received report from the hospital and did the resident admission assessment for the nurse in charge of the resident. Nurse #3 revealed when she did the admission assessment for a nurse in charge of the resident then the charge nurse would have been the one responsible to give the PPD. Nurse #3 stated she would give a PPD on the day the patient was admitted if the resident were her patient. On 06/30/10 at 8:30 AM an interview was conducted with the Wound Nurse. She indicated that a PPD should be done on the day of admission. The Wound Nurse relayed the nurse admitting the resident would place the PPD on the MARS for the next shift nurse to administer. On 06/30/10 at 9:00 AM, the DON presented a sputum culture report for Resident #18 that read in part: "Moderate normal respiratory flora." On 07/01/10 at 12:30 PM, the DON presented a sputum culture report for Resident #18 that read in part: "Moderate normal respiratory flora." 2 B: The facility failed to administer a PPD on admission for 7 of 25 sampled residents (Resident #3,#10,#11,#15,#17,#21, #23) and 8 (Resident #26,#27,#28,#29,#20,#31,#32,#33) residents identified per the facility audit that had been requested and completed on 06/29/10; 2a. Resident #3 was admitted to the facility on [DATE]. There was no documentation that the resident had received a PPD. Per the facility documentation the resident received a PPD on 06/29/10. 2b. Resident #10 was admitted to the facility on [DATE]. Review of the resident's MAR revealed the resident was given a PPD on 03/02/10 and was not read. The documentation also revealed the resident was given a PPD on 03/09/10 and was not read. Per the facility documentation the resident received a PPD on 06/29/10. 2c. Resident #11 was admitted to the facility on [DATE]. Per facility documentation the resident received a PPD on 06/29/10. 2d. Resident #15 was admitted to the facility on [DATE]. Review of the resident's MAR revealed that resident was given the first step PPD on 04/26/10. 2e. Resident #17 was admitted to the facility on [DATE]. Per the facility documentation the resident received a PPD on 06/29/10. 2f. Resident #21 was admitted to the facility on [DATE]. Per the facility documentation the resident received a PPD on 06/29/10. 2g. Resident #23 was admitted to the facility on [DATE]. Review of the resident's MAR revealed that resident was given a PPD on 06/23/10. 2g. Review of the audit information presented by the facility revealed Resident #26 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2h. Review of the audit information presented by the facility revealed Resident #27 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2i. Review of the audit information presented by the facility revealed Resident #28 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2j. Review of the audit information presented by the facility revealed Resident #29 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2k. Review of the audit information presented by the facility Resident #30 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2l. Review of the audit information presented by the facility revealed Resident #31 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2m. Review of the audit information presented by the facility revealed Resident #32 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 2n. Review of the audit information presented by the facility revealed Resident #33 was admitted to the facility on [DATE] and received a PPD on 06/29/10. 3 C: failed to administer an annual PPD for 3 (Resident #2,#6,#7) of 25 sampled residents and 6 (Residents #34, #35, #36, #37, #38, #39) residents identified per the facility audit that had been requested and completed on 06/29/10; 3a. Resident #2's due date for the annual PPD was 04/01/10. Per the facility documentation the resident received her annual PPD on 06/29/10. 3b. Resident #6's due date for the annual PPD was 04/23/10. Per the facility documentation the resident received her annual PPD on 06/29/10. 3c. Resident #7's due date for the annual PPD was 04/23/10. Per the facility documentation the resident received his annual PPD on 06/29/10. 3d. Per facility documentation, Resident #34's due date for the annual PPD was 06/26/10 and received his annual PPD on 06/29/10. 3e. Per facility documentation, Resident #35's due date for the annual PPD was 01/13/10 and received her annual PPD on 06/29/10. 3f. Per facility documentation, Resident #36's due date for the annual PPD was 03/06/10 and received his annual PPD on 06/29/10. 3g. Per facility documentation, Resident #37's due date for the annual PPD was 04/23/10 and received her annual PPD on 06/29/10. 3h. Per facility documentation, Resident #38's due date for the annual PPD was 05/10/10 and received his annual PPD on 06/29/10. 3i. Per facility documentation, Resident #39's due date for the annual PPD was 10/23/09 and received his annual PPD on 06/29/10. 4 D: failed to administer a PPD for 5 (Nurse Aide #1, Nurse #2,#3,#4,#8) of 9 employees identified by the facility to have had contact, prior to isolation being initiated, with a resident who had a positive PPD and chest x-ray results indicating that [DIAGNOSES REDACTED] could not be excluded at the time. 4a. Per facility documentation Nurse Aide # 1, who had been assigned to the resident between 06/18/10 and 06/22/10, was given a PPD on 06/29/10. 4b. Per facility documentation Nurse #2, who had been assigned to the resident between 06/18/10 and 06/22/10, was given a PPD on 06/29/10. 4c. Per facility documentation Nurse #3, who had been assigned to the resident between 06/18/10 and 06/22/10, was given a PPD on 06/29/10. 4d. Per facility documentation Nurse #4, who had been assigned to the resident between 06/18/10 and 06/22/10, was given a PPD on 06/29/10. 4e. Per facility documentation Nurse #8, who had been assigned to the resident between 06/18/10 and 06/22/10, was given a PPD on 06/29/10. The facility administrator was notified of the Immediate Jeopardy on 06/30/10 at 10:10 AM. Immediate Jeopardy was removed on 07/01/10 at 4:55 PM when the credible allegation of compliance was validated. A. Corrective action taken for the affected resident. 1. For resident #18, following the positive PPD (Purified Protein Derivative) of 6/22/10 and read on 6/23/10. per protocol, a chest X-ray was obtained to rule out TB. Due to infiltrates, active TB could not be ruled out. As a precautionary measure the resident was relocated to a private room with isolation precautions and the physician was notified of the X-ray results. Orders were obtained for sputum culture on 6/23/10. Negative results were received on 6/29/2010. 2. Regarding resident #23, on 6/23/10 PPD test was conducted. On 6/26/10 it was read as negative. 3. Resident # 23's room was deep cleaned with Virex TB, which is a tuberculocide, following the manufacturer's directions. This was accomplished immediately following the transfer of resident #18 to a private room. Further, PPD testing of all staff of record that cared for resident #18 since admission was initiated on 6/24/10. B. Corrective action taken for those residents having the potential to be affected by the deficient practice. 1.On 6/29/10 a 100% audit of all in-house residents PPD test records was conducted. This was completed by 2 MDS R.N. coordinators, 1 R.N. nursing supervisor, 1 licensed R.N. and the Director of Medical Records. In the case of all in-house resident, PPD status was brought current the same day, 6/29/10. Beginning on the morning of 7/1/2010, spot checking was initiated for any possible reactions. Final results will be documented after the 48 and 72 hour incubation period. 2. In the case of employees, a 100% audit of employee health records was conducted by the Social Services Director and the Director of Business Development. The employee health file of each employee was reviewed for the recorded test date of last PPD. A list of those employees identified as not having a current PPD or chest x-ray in the last 12-months was compiled. For these employees PPD testing was immediately initiated on 6/29/2010. 3. For all in-house residents and employees who had a positive PPD, chest X-rays will be obtained. The two MDS R.N. Coordinators have been designated to oversee the follow-up of the testing results described above to determine if any further testing or other interventions are necessary per infection control guidelines. Further, they have been designated to oversee the infection control program and compliance with infection control guidelines of the facility. Final results will be documented after the 48 and 72 hour incubation period. 3. Measures Implemented and/or Systemic Changes Made to ensure that deficient practices will not reoccur. 1. On 6/30/10 a general in-service was conducted for facility staff regarding general infection control guidelines included but limited to; 1) hand-washing, 2) linen handling, 3) isolation, 4) TB testing, 5) deep cleaning, 6) location of infection control guidelines. Further, the general orientation program will cover infection control guidelines. 2. In-service education for licensed nursing staff will be conducted regarding TST ([MEDICATION NAME] Skin Test) for residents and employees commencing on 7/1/10 and being completed by 7/6/2010. Any licensed nursing staff member having not been in-services by July 6, 2010 will be in-serviced prior to the start of their next shift by that shift's supervisor. All new hires will receive in-service training on the infection control program/guidelines by infection control nurses (MDS R.N. Coordinators), ADON, DON and/or shift nurse supervisor. 3. On a daily basis each shift nursing supervisors will validate that TST was performed on all admissions, upon admission, not to exceed 24-hours. The TST daily audit log will be completed by the nurse supervisors. The Director of Nursing (DON) will review and validate 20% of new admissions weekly for compliance with TST. 4. The TST Monthly Audit Log will be completed by the infection control nurses (MDS R.N. coordinators) to maintain compliance of annual TST for both residents and employees. 4.How the facility plans to monitor its performance to assure ongoing compliance is sustained. 1. Compliance with TST above will be reviewed in facility clinical meetings. The Clinical meetings are held daily, Monday thru Friday following the daily Stand-up meeting. The weekend TST log review will occur at the Monday Clinical meeting. The TST review will occur daily for the month of July, 2010, weekly for the month of August 2010, monthly in September, 2010, and quarterly for the last quarter of the calendar year 2010. 2. The above listed audits will be reviewed at the monthly QA meeting for recommendations. The audits will be presented to the QA committee for a minimum of 3 months or until a non-compliance rate of 1% or less is achieved. 3. Infection control tracking logs will be reviewed at the monthly QA meeting for trending. For any identified trending concerns (i.e. increased number of UTI's, educational needs, communicable disease issues, etc), a plan of corrective action will be formulated by the committee and implemented by the Administrator, DON and infection control nurses. This will be an ongoing process because it is an integral part of our QA meeting charge. 4. The infection control policies and procedures have been reviewed and approved as of this date by the Medical Director, Administrator and Director of Nursing. No revisions are required at this time. The policies and procedures include, but are not limited to, recognition, prevention and surveillance of communicable diseases. The infection control policies and procedures will be reviewed annually and revised as needed. The credible allegation was validated by reviewing the in-service materials presented to 69 staff members on 06/30/10 at 2:30 PM. Review of the 100% chart audit of the resident's TB screening status. Interviews conducted with the nursing staff about timeframe for administration of PPD, reading the results of a PPD test, steps when PPD read positive, identification of the Infection Control Nurse, and the type of isolation for a resident with TB. Interviews were conducted with the housekeeping staff with regards of how to clean a room occupied by a resident with suspected TB and what product would be used.