Every finding on record at Henderson Health & Rehabilitation Center

Based on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 8 staff (CNA A, CNA B, LVN C and RN D) and 2 of 6 residents (Resident #2 and Resident #5 )reviewed for infection control.1.The facility failed to ensure CNA A followed infection control measures during dining service on 7/27/2026.2. The facility failed to ensure CNA B and LVN C followed EBP during direct care for Resident #2 on 7/28/2026.3. The facility failed to ensure RN D performed hand hygiene during urinary catheter care on 7/29/2026.These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices. Findings included: 1.During an observation on 7/27/2026 at 12:03 PM, CNA A applied gloves without sanitizing or handwashing and entered room [ROOM NUMBER] and pulled the resident up in bed, rearranged his linens, touched the resident's feet, set up his tray, and removed his gloves then left the room without hand hygiene. He then passed a meal tray to room [ROOM NUMBER] without hand hygiene. CNA A returned to the meal cart and removed a tray for room [ROOM NUMBER]. He entered room [ROOM NUMBER], pushed the bedside table to the resident, rearranged personal items, set up the meal and left the room without hand hygiene. During an interview on 7/27/2026 at 12:20 PM, CNA A said he had been trained on infection control measures. He said he realized he had not performed hand hygiene after he noticed he was being watched. CNA A said he should have sanitized between each resident interaction while serving meal trays. He said that poor hand hygiene could cause infections to spread. During an interview on 07/28/2026 at 11:45 AM, the DON stated she expected all staff to follow the CDC's recommendations for hand hygiene during care. She said the risk for the residents were infections if hand hygiene was not performed between each resident encounter. She said she would provide the facility's policy for hand hygiene for review and had already started an in-service for the staff. During an interview on 7/28/2026 at 12:00 PM, the Administrator said all staff were provided with education on infection control policies including handwashing. She stated staff should utilize hand hygiene while passing trays to residents, which includes sanitizing or washing hands after each tray was passed. She stated, moving forward, she expected all staff to follow the facility's infection control policy, and practice proper hand hygiene. 2. Record review of Resident #2's facility face sheet, dated 7/28/2026, indicated Resident #2 was a [AGE] year-old female, admitted [DATE], with diagnosis of seizures. Record review of Resident #2's quarterly MDS assessment, dated 6/10/2026, revealed a BIMS of 03 that indicated Resident #2 had severely impaired cognition. She was dependent on all ADL's, always incontinent of bowel and bladder and had a pressure ulcer. Record review of Resident #2's comprehensive care plan, revision date 7/13/2026, indicated Resident #2 had a pressure ulcer but did not address EBP. Record review of Resident #2's consolidated orders, dated 7/28/2026, indicated an order for wound care to pressure area of left foot but did not indicate need for EBP. During an interview and observation on 7/27/2026 at 10:14 am, during initial rounds Resident #2 had a dressing to her left foot. LVN C said Resident #2 had a pressure ulcer on her foot. There was no EBP sign outside her room. Resident #2 was unable to answer questions regarding EBP. During an observation on 7/28/2026 at 9:42 am, no EBP sign was posted outside resident's room. During an observation on 7/28/2026 at 9:43 am, CNA B and LVN C performed incontinent care to Resident #2. Resident #2 had a pressure ulcer and should be under EBP. Neither CNA B nor LVN C applied a gown prior to or while providing direct care to Resident #2. During an interview on 7/28/2026 at 10:01 am, CNA B said that residents with wounds and catheters should have a sign outside their room indicating EBP. She said that Resident #2 had a wound and should have an EBP sign and she should have applied a gown to provide care. She said she had not noticed that EBP was not in place and she had been trained on when to apply PPE for EBP. She said the sign was her visual aid to remind her to wear the gown and gloves. She said not following EBP could lead to the spread of infections. During an interview on 7/28/2026 at 10:03 am, LVN C said he was the charge nurse and was aware Resident #2 required EBP because of her wound. He said he did not see the sign on the door therefore provided direct care without a gown and gloves. He said the DON, wound nurse and nursing staff were responsible for ensuring that the signs were placed at the door. He said PPE was kept on the nurse's cart and the CNA carts. He said not following EBP could lead to the spread of infections. During an interview on 7/28/2026 at 10:05 am, the Treatment Nurse said she and the DON were the infection prevention nurses in the facility. She said that she had been providing wound care to Resident #2 and had missed that the EBP sign was not posted for staff to know the need for a gown and gloves during care. She said the DON normally put out the signs, and Resident #2 was missed. She said not following EBP could lead to infections spreading. During an interview on 07/29/2026 at 10:08 am, the DON said that she, along with the ADON and Treatment Nurse, were responsible for the oversight of the EBP program. She said that orders were reviewed daily to ensure precautions were put into place and was not sure how Resident #2 was overlooked. She said the staff should have followed the EBP program and wore gowns and gloves when providing care. She said the sign at the door was the staff's visual aid for remembering who needed EBP, but they also were all trained on what requires EBP and even if there was no sign should know to follow the EBP program. She said if staff were not following EBP infections could spread. During an interview on 7/29/2026 at 10:15 am, the Administrator said that nursing was responsible for the oversight of the EBP program. She said the DON, ADON, and Treatment Nurse were to review orders daily and put EBP in place when required. She said all staff were trained on EBP and should be following the facility policies and program to prevent the spread of infections. 3. Record review of a face sheet dated 7/29/2026 for Resident #5 indicated he admitted to the facility on [DATE] and was [AGE] years old with diagnoses of type 2 diabetes, BPH (enlarged prostate gland), and COPD (a group of lung diseases that affect breathing). Record review of active physician orders for Resident #5 dated 7/29/2026 indicated an order for the licensed nurse to provide suprapubic catheter (a tube inserted through the lower abdomen into the bladder to drain urine) care every shift that started on 2/2/2026. Record review of a Quarterly MDS Assessment for Resident #5 dated 5/5/2026 indicated he had severe impairment in thinking with a BIMS score of 3. He had an indwelling catheter that included a suprapubic catheter. Record review of a care plan for Resident #5 revised on 3/16/2026 indicated he had a suprapubic catheter and was at risk for urinary tract infections. Interventions included to provide urinary catheter care per facility practice. During an observation on 7/29/2026 at 10:05 am, RN D was in the room of Resident #5 to perform catheter care. RN D had supplies in a plastic bag and donned a gown in the hallway before entering the room. RN D placed a pillowcase on the overbed table for a barrier and placed her bag of supplies on it. She removed gloves from the plastic bag and donned (put on) without washing or sanitizing her hands. She removed the dressing noted to his suprapubic catheter insertion site and placed the dressing in the trash along with her gloves. She donned gloves without washing or sanitizing them. She cleaned the insertion site in a circular motion and cleaned down the tubing with wound cleanser and gauze. She placed the gauze in the trash and used a clean gauze to pat the area dry. She placed a split gauze sponge around the insertion site. She gathered the trash and exited the room wearing her gown and gloves and said she was taking out the trash. During an interview on 7/29/2026 at 10:19 am, RN D said she had been employed at the facility for 3 years. She said during the care provided to Resident #5 she should have sanitized her hands between gloves changes and should have washed her hands before care was provided. She said she should have changed her gloves when she changed tasks from touching dirty items to clean. She said she forgot to bring in the sanitizer and more gloves. She said there was a risk of residents getting infections. She said her last skills check-off was about 3 months ago. Record review of a Hand Hygiene Checklist dated 5/21/2026 for RN D indicated she used the correct technique with hand hygiene. During an interview 7/29/2026 at 11:08 am, the DON said she had been employed at the facility for 3 years and was one of the IPs for the facility. She said they trained staff quarterly on infection control measures. She said hand hygiene should be performed between clean and dirty tasks, which included sanitizing, before care was started, when it was completed, and when gloves were changed staff should sanitize or wash their hands. She said staff should not exit the rooms wearing PPE that included gown and gloves. She said PPE should be disposed of in the rooms. She said there could be a risk of transmission of microbes to residents. She said she planned to reeducate staff on infection control measures that included hand hygiene and PPE removal. During an interview on 7/29/2026 at 11:30 am, the Administrator said hand hygiene should be performed before care was performed and should not touch clean items with dirty gloves. She said staff should never leave the room wearing PPE that included a gown and gloves. She said there was a risk of infections passing on to other residents. She said going forward would continue education on infection control measures and proper techniques. Record review of the facility's policy titled Handwashing/Hand Hygiene, updated 01/2025 indicated, .This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections . all personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other, residents, and visitors; Hand hygiene is indicated: immediately before touching a resident, after touching a resident, after touching the residents' environment, immediately after glove removal. Record review of a facility policy titled Infection Prevention and Control Program, dated 3/26/2024, indicated, .This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines. 6.Enhanced Barrier Precautions EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing. EBP are indicated for residents with any of the following: a. Infection or colonization with an MDRO when Contact Precautions do not otherwise apply b. Wounds and/or indwelling medical devices (e.g., central lines, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status. During high-contact resident care activities: Dressing Bathing/showering Transferring Providing hygiene Changing linens Changing briefs or assisting with toileting Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator Wound care: any skin opening requiring a dressing Gloves and gowns prior to the high-contact care activity (Change PPE before caring for another resident) (Face protection may also be needed if performing activity with risk of splash or spray) .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen.The facility failed to date mayonnaise or jelly that was not in their original containers with a use by date.The facility failed to ensure a fan that was used to cool the kitchen was free of dust that was blowing toward the food prep tables.These failures could place residents at risk for food-borne illnesses. Findings included:During an observation on 7/27/2026 at 9:34 am, the walk-in cooler in the kitchen had twelve small cups of mayonnaise and a container of jelly that were removed from their original containers that did not have a use by date.During an observation and interview on 7/27/2026 at 9:50 am, there was a fan in the kitchen that was blowing toward the food prep tables that had dust on it. Dietary staff were observed in the kitchen buttering rolls at the food prep table. The DM said the kitchen staff cleaned the fan weekly, but it was not on a schedule. She said she did not realize the dust could blow on the food prep area. She said they placed the fan in the kitchen because it was hot and it helped to cool the kitchen area.During an interview on 7/28/2026 at 1:42 pm, the DM said the kitchen staff, and she checked the refrigerators and freezers to make sure items were labeled and dated daily. She said residents could get sick from eating foods that were not labeled with a use by date of seven days. She said the mayonnaise and jelly were discarded on 7/27/2206. She said she just overlooked them. She said she did an in-service with the kitchen staff yesterday (7/27/2026) and they removed the fan that could blow debris on the food. During an interview on 7/29/2026 at 11:20 am, the Administrator said she was made aware of the items in the kitchen that were not dated. She said they removed the fan from the kitchen. She said using a fan in the kitchen over the food prep area could blow dust on the food. She said if residents were given foods that did not indicate a use by date it could make someone sick.Record review of a facility policy titled Food Storage: Cold dated October 2019 indicated, .It is the center policy to ensure all Time/Temperature Control for Safety (TCS), frozen and refrigerator food items, will be appropriately stored in accordance with guidelines of the FDA Food Code. 5. The Dining Services Director/Cook(s) ensures that all food items are stored properly in covered containers, labeled, and dated and arranged in a manner to prevent cross contamination .Record review of a facility policy titled Cleaning and Sanitation revised 11/11/2024 indicated, .4.1.1 non-food contact surfaces; all surfaces that do not (or are intended to) contact food are considered non-food-contact surfaces. Examples include but are not limited to: floors, walls, ceilings, storage racks, tables, shelves, door surfaces, doorknobs or handles, dish machines, trash cans, mop buckets, etc .

Based on observation, interview, and record review, the facility failed to follow their policy to ensure safe and sanitary storage of residents' food items for 2 of 6 (Resident #40 and Resident #49) personal refrigerators reviewed for food safety.The facility failed to ensure the personal refrigerator for Resident #40 did not contain two half pints of milk that expired as of 7/24/2026.The facility failed to ensure the personal refrigerator for Resident #49 did not contain a paper plate with molded food on 7/27/2026 and 7/28/2026.These failures could place residents at risk for food borne illnesses.Findings include:1. Record review of a face sheet for Resident #40 dated 7/28/2026 indicated he admitted to the facility on [DATE] and he was [AGE] years old with diagnoses of hemiplegia affection left non-dominant side (paralyzed on the left side), Parkinson's disease (a disease that affects the nervous system that causes problems with body motions), and aphasia following cerebral infarction (difficulty speaking following a stroke).Record review of a Quarterly MDS Assessment for Resident #40 dated 6/19/2026 indicated he did not have any impairment in thinking with a BIMS score of 14. He required substantial/maximal assistance with personal hygiene.Record review of a care plan for Resident #40 revised 6/19/2026 indicated he had an ADL self-care performance deficit and was at risk of not having met needs in a timely manner. Interventions included providing shower, have, oral care, hair care, and nail care per schedule and when needed.During an observation and interview on 7/27/2026 at 10:20 am, Resident #40 was in bed awake and was non-verbal. He had a personal refrigerator with two half pints of milk dated 7/24/2026. Resident #40 nodded his head yes that the staff gave him items out of his refrigerator.During an observation on 7/28/2026 at 8:32 am, Resident #40 was in bed awake. His personal refrigerator still had two half pints of expired milk dated 7/24/2026.During an interview on 7/28/2026 at 1:52 pm, LVN F said they checked the personal refrigerators throughout the day for expired food and temperatures. She said she checked Resident #40's refrigerator that morning and he wanted a mountain dew soft drink. During an observation and interview on 7/28/2026 at 1:54 pm, LVN F looked inside Resident #40's personal refrigerator and said someone had an open soda left inside. She saw two pints of milk that were expired and said if Resident #40 drank them he could get sick and she discarded the milk in the trash. 2. Record review of a face sheet for Resident #49 dated 7/28/2026 indicated she was admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of cerebral infarction (stroke), dementia (a decline in thinking that can interfere with daily life), and hypotension (low blood pressure).Record review of a Significant Change MDS Assessment for Resident #49 dated 7/3/2026 indicated she had moderate impairment in thinking with a BIMS score of 12. She required setup or clean up assistance for personal hygiene. Record review of a care plan for Resident #49 revised 7/25/2025 indicated she had an ADL self-care performance deficit and was at risk of not having their needs met in a timely manner. Interventions included providing shower, shave, oral care, hair care, and nail care per schedule and when needed.During an observation and interview on 7/27/2026 at 10:47 am, Resident #49 was in bed awake. She had a personal refrigerator in the room that had a plate of food that was inside a bread bag that was molded. She was alert to person with confusion noted. She said the staff would give her items from her personal refrigerator.During an observation on 7/28/2026 at 8:35 am, Resident #49 was in bed awake. Her personal refrigerator still had a paper plate of molded food.During an observation and interview on 7/28/2026 at 2:02 pm, LVN H said the night shift checked the temperatures of the personal refrigerators but was not sure about the foods. She observed the personal refrigerator of Resident #49 and saw a paper plate of food that was in a bread bag and said it was old and needed to be thrown away. She said residents could get sick if they ate food that was old. During an interview on 7/29/2026 at 11:16 am, the DON said the ADON was the one that had been checking the personal refrigerators every other week and would check to see if they needed to be defrosted or needed old food removed. She said going forward she would have the ADON to check the personal refrigerators weekly for expired food items. She said residents could get sick from eating foods that were expired or old. She was not aware of the molded food that was observed in Resident #49's refrigerator.During an interview on 7/29/2026 at 11:23 am, the Administrator said she was made aware of the personal refrigerators that included expired milk and old food. She said going forward the Maintenance Supervisor would be responsible for checking the personal refrigerators daily for temperatures and expired or old food. She said if residents ate food items that were expired or old could make them ill.Record review of a facility policy titled Refrigerator-Personal revised 1/1/2026 indicated, .It is the policy of this home that residents' refrigerators will be checked weekly for cleanliness and remaining sanitary. 2. Housekeeping Supervisor/Facility Designee will monitor resident's refrigerator weekly. b. clean and remove expired food .

Based on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 2 of 6 residents reviewed for ADLs. (Resident #40 and Resident #49)The facility failed to clean/groom and trim Resident #40's fingernails that were long and had a dark, brown substance underneath them on 7/27/2026 and 7/28/2026.The facility failed to ensure Resident #49 did not have gray hair on her chin that was about a 1/2 inch in length on 7/28/2026.These failures could place residents at risk of poor hygiene and a decreased quality of life.Findings included:1. Record review of a face sheet for Resident #40 dated 7/28/2026 indicated he admitted on [DATE] and he was [AGE] years old. His diagnoses included hemiplegia affecting left non-dominant side (paralyzed on the left side), Parkinson's disease (a disease that affects the nervous system that causes problems with body motions), and aphasia following cerebral infarction (difficulty speaking following a stroke).Record review of a Quarterly MDS Assessment for Resident #40 dated 6/19/2026 indicated he did not have any impairment in thinking with a BIMS score of 14. He required substantial/maximal assistance with personal hygiene.Record review of a care plan for Resident #40 revised 6/19/2026 indicated he had an ADL self-care performance deficit and was at risk of not having met needs in a timely manner. Interventions included providing shower, have, oral care, hair care, and nail care per schedule and when needed.During an observation and interview on 7/27/2026 at 10:20 am, Resident #40 was in bed awake and shook his head yes/no to answer questions along with giving the thumbs up. His fingernails were long with a dark, brown substance underneath them. When he was questioned if he would allow the staff to trim or clean his nails, he nodded that it was ok for them to.During an observation on 7/27/2026 at 2:46 pm, Resident #40 was in bed awake. His fingernails were still long and dirty with a dark, brown-black substance underneath them.During an observation on 7/28/2026 at 8:32 am, Resident #40 was in bed awake. His fingernails were still long and dirty with a dark brown-black substance underneath them.During an observation on 7/28/2026 at 1:50 pm, Resident #40 was in bed awake. His fingernails were still long and dirty. A bag of linens was on his dresser and when asked if staff were going to give him a shower, he shook his head yes.During an observation on 7/28/2026 at 3:07 pm, Resident #40 was in bed awake, and said he had received a bed bath, but his fingernails were still long and dirty. During an observation and interview on 7/28/2026 at 3:12 pm, Agency CNA E said that day was her second time at the facility. She said she had just given Resident #40 a bed bath and during the care she provided incontinent care but did not clean his nails and was going to go back and check after she talked to the charge nurse. She said his nails were long and dirty. She said she would still feel dirty if she was left with long and dirty nails after she was given a bath. She said his nails needed to be clipped also.During an observation and interview on 7/28/2026 at 3:19 pm, LVN F said the nurses and the wound care nurse were responsible for clipping nails and the nurse aides cleaned them at every bath. She said nails were clipped once a week and as needed. She entered the room of Resident #40 and said his nails were long and dirty. She said she would feel bad if she was left with long and dirty nails. She said she would clean and trim them.2. Record review of a face sheet for Resident #49 dated 7/28/2026 indicated she was admitted to the facility on [DATE] and she was [AGE] years old with diagnoses of cerebral infarction (stroke), dementia (a decline in thinking that can interfere with daily life), and hypotension (low blood pressure).Record review of a Significant Change MDS Assessment for Resident #49 dated 7/3/2026 indicated she had moderate impairment in thinking with a BIMS score of 12. She required setup or clean up assistance for personal hygiene. Record review of a care plan for Resident #49 revised 7/25/2025 indicated she had an ADL self-care performance deficit and was at risk of not having their needs met in a timely manner. Interventions included providing shower, shave, oral care, hair care, and nail care per schedule and when needed.During an observation on 7/28/2026 at 8:35 am, Resident #49 was in bed awake. She had about 1/2 long gray hairs noted to her chin and neck area. She said she could feel the hair at times and did not like it on her face. During an interview on 7/28/2026 at 2:07 pm, CNA G said she gave Resident #49 a bed bath that day because she was not feeling well. She said Resident #49's shower days were Tuesdays, Thursdays, and Saturdays. She said she washed their hair, cleaned nails, and shaved the men and women's facial hair. She said she was going to shave Resident #49 that day, but she was sent out to the hospital for a change in condition. She said the last time she shaved Resident #49 was last Thursday (7/23/2026). She said she noticed Resident #49 had long gray facial hair on her chin. She said she would not like it if she was dependent on someone else to do it for her.During an interview on 7/29/2026 at 11:13 am, the DON said the licensed nurse oversaw nail care and the nurse aides could clean nails. She said if a resident was diabetic, then the nurses would need to oversee the nail care for that resident. She said nail care should be done on shower days and as needed. She said facial hair should be removed when the staff see it and should be checked daily during rounds. She said it would be hard to deal with if she had dirty or long nails or facial hair and would want that taken care of immediately. She said she would expect things to be done in a timely manner. She said going forward she would have the nurses check to ensure ADLs were completed and would discuss in the morning meetings. During an interview on 7/29/2026 at 11:26 am, the Administrator said the nurse aides were responsible for ADL care that should be done according to the residents' schedule. She said nail care and shaving should be done on the shower days. She said she would not like it if she was left with long and dirty nails or if she had facial hair that needed to be shaved.Record review of a facility policy titled Activities of Daily Living (ADL), Supporting dated 2001 indicated, .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. hygiene (bathing, dressing, grooming, and oral care) .

Based on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 8/17/25 at approximately 4:00 p.m. when Resident #2 pushed her down and kicked her causing two skin tears and pain rated as a 10/10 on a numeric pain scale following the incident. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life.Findings included:1.Review of an admission Record for Resident #1 dated 9/16/2025 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of dementia (altered cognition), peripheral vascular disease (poor circulation in legs), and bilateral (both left and right sides) osteoarthritis of hip.Review of a quarterly MDS for Resident #1 dated 9/6/2025 indicated she had severely impaired thinking with a BIMS of 3. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #1 dated 2/1/24 indicated she resided in a secured unit related to cognitive impairment and elopement risk secondary to dementia. Review of the care plan for Resident #1 dated 4/15/24 indicated she had behavioral problem of rummaging in other residents' rooms and/or belongings. Appropriate interventions were in place including anticipating the resident's needs, intervening early, and providing as many daily care activity choices as possible for resident.Review of an admission Record for Resident #2 dated 9/16/25 indicated she was a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of dementia, cognitive communication deficit, and aphasia (communication disorder).Review of a quarterly MDS for Resident #2 dated 9/2/25 indicated a BIMS was not conducted due to the resident being rarely or never understood. She had exhibited difficulty focusing attention and being easily distracted. She had exhibited no verbal or aggressive physical behaviors directed toward others.Review of the care plan for Resident #2 dated 8/28/25 indicated she had a behavior problem as evidenced by potential for physical aggression if bathroom is used by another resident. Appropriate interventions were in place including intervening early when resident shows agitation by guiding away from source of distress, engaging calmy in conversation, or attempting over interventions, and if response is aggressive approach at a later time after ensuring resident's safety. Resident #2 had no aggressive behaviors identified in the care plan prior to 8/28/25.Review of an incident report titled Physical Aggression Initiated dated 8/17/25 by RN A indicated .staff stopped and removed [Resident #2] from another pt that was in her room. Staff witnessed pt pushing her. The same incident report indicated immediate action was taken in placing Resident #2 on 1-to-1 supervision and completing assessments and notifications to the family and providers for Resident #1.Review of an incident report titled Physical Aggression Received dated 8/17/25 by RN A indicated .Staff stopped other resident after she starting kicking this [Resident #1] after pushing her to the floor. the same incident report indicated Resident #1 was assessed for injuries and two new skin tears to her right arm were identified. Her level of pain on a PAINAD (observational pain scale) was assessed as 7/10 which indicated severe pain. Predisposing factors were identified as Resident #1 went into Resident #2's room.Review of a nurse's progress note dated 8/17/25 at 4:43 p.m. by RN A indicated .[Resident #1] received physical aggression from other patient.pt was assessed and Stat x-rays were ordered for R hip, pelvis, R femur (thigh bone), pain 10/10 after incident. Was witnessed by staff member, pt did not hit head, but hit right arm and caused two skin tears.Review of a provider progress note dated 8/18/25 indicated [Resident #1] has two skin tears on her RUE.X-rays were negative for fractures or dislocations. Neuro is intact.During an observation and interview on 9/16/25 at 10:30 a.m., Resident #2 was observed in a common sitting area, sitting on a couch. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #2 was not able to recall the altercation with Resident #1 due to her diagnosis of dementia.During an interview on 9/16/25 at 10:33 a.m., LVN B said she did not witness the altercation between Residents #1 and #2 and only knew of the incident through report. LVN B said Resident #2 had a history of getting into verbal altercations with any resident who went into her room. LVN B said the CNA was responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/16/25 at 10:43 a.m., CNA C said Resident #2 was known to be verbally aggressive toward residents who tried to enter her room. CNA C said she had not witnessed any physical aggression from Resident #2. CNA C said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an observation and interview on 9/16/25 at 3:00 p.m., Resident #1 was observed in self-propelling herself in a wheelchair in the hallway on the secured memory care unit. She appeared clean and well-groomed and she had no visible marks, bruises, or skin tears. Resident #1 was not able to recall the altercation with Resident #2 due to her diagnosis of dementia.During a telephone interview on 9/16/25 at 3:45 p.m., CNA D said she was working on the memory care unit the day of the altercation between Residents #1 and #2. CNA D said she was in the hallway talking to CNA E when Resident #1 walked by her stating she was going to the restroom. CNA D said Resident #1 and Resident #2 had a shared bathroom. CNA D said Resident #2 went into her own room approximately 1 to 2 minutes later. CNA D said they heard Resident #1 yell out. CNA D said CNA E ran down to Resident #2's room and opened the door. CNA D said she saw Resident #2 stepping toward the door to leave the room as CNA E was going in. CNA D said she heard CNA E tell the residents to stop fighting so she went and alerted RN A for assistance.During an interview on 9/17/25 at 9:00 a.m., LVN F said Resident #2 had exhibited verbal aggression towards residents who wandered into her room in the past. LVN F said Resident #2 had not exhibited any physical aggression towards residents. LVN F said CNAs were responsible for monitoring the residents and redirecting them from entering other residents' rooms.During an interview on 9/17/25 at 10:45 a.m., the DON said Resident #2 had no previous aggressive behavior noted. The DON said she believed the incident occurred because Resident #2 valued her personal space and considered the shared bathroom to be her personal space. The DON said Resident #2 was put on 1-to-1 observation immediately and referrals were sent to two inpatient behavioral health facilities. The DON said Resident #2 was also moved to a room with a private bathroom. The DON said staff were expected to intervene and redirect any resident wandering into other resident rooms.During an interview on 9/17/25 at 11:00 a.m., CNA E said she was assigned to work on the hall next to the secured unit on 8/17/25 and witnessed the resident-to-resident altercation between Residents #1 and #2. CNA E said she was on the secured unit talking to CNA D when Resident #1 passed by them and went into her room. CNA E said approximately 1 to 2 minutes later Resident #2 went into her own room, which shared a bathroom with Resident #1's room. CNA E said she heard Resident #1 hollering and ran down to Resident #2's room. CNA E said she saw Resident #2 push Resident #1 down on the floor by the bed, with both hands and kick her in the side. CNA E said Resident #2 was jumping back as she was coming into the room. CNA E said she told the residents to stop fighting and told Resident #2 to leave the room. CNA E said CNA D ran and alerted the charge nurse, RN A, who conducted the post incident assessments.During an interview on 9/17/25 at 11:10 a.m., the ADM said Resident #2 had displayed verbal aggression with other residents, but there had been no previous physically aggressive behavior. The ADM said following the altercation between Residents #1 and #2 the residents were immediately separated; Resident #2 was placed on 1-to-1 supervision and referred to behavioral health inpatient facility. The ADM said Resident #2's medications were adjusted, and she was moved to a room with a private bathroom and there had been no more incidents of physical aggression. Attempted interviews with RN A by telephone and text message on 9/17/25 at 11:34 a.m. Review of progress note dated 8/17/25 at 4:30 p.m. by the DON indicated Resident #2 was placed on 1-to-1 supervision immediately following altercation with Resident #1.Review of a progress note dated 8/17/25 at 5:24 p.m. by RN A indicated Resident #2 was tolerating 1-to-1 supervision well.Review of a nursing follow-up dated 8/18/25 at 5:46 a.m. by FNP indicated Resident #2's Olanzapine dose was increased from 2.5mg to 5mg nightly and she was put on one-to-one observation.Review of a psychiatric hospital Discharge summary dated [DATE] at 2:40 p.m. indicated Resident #2 was admitted to the facility on [DATE] at 4:32 p.m. and discharged on 8/27/25 with medication changes including discontinuing Olanzapine and starting Uzedy.Review of an admission record dated 9/16/25 indicated Resident #2 was admitted to the facility from a psychiatric hospital and assigned to room [ROOM NUMBER]-B.During an observation on 9/17/2025 at 11:30 am, Resident #2's room [ROOM NUMBER]-B revealed the room to have a private bathroom. Review of facility policy titled Policy and Procedures: Abuse, Neglect, and Exploitation revised on 9/6/24 indicated .Identifying, correcting, and intervening in situations in which abuse.is suspected or identified.by taking immediate action to correct any issues that can reduce the risk of further harm continuing or occurring.

Based on interview and record reviews, the facility failed to implement their policy to ensure the residents, or their responsible party, received education of the benefits and risks, or potential side effects of Covid -19(a severe acute respiratory syndrome ) immunizations, receipt of Covid-19 immunizations, or the residents did not receive the Covid-19 immunizations, due to medical contraindication, or refusal, for 74 of 74 residents living in the facility and 5 of 5 residents who were reviewed for immunizations (Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57) The facility failed to document, in Resident #11, Resident #35, Resident #52, Resident #56 and Resident #57 medical records, having had received education, whether by self or with their responsible party, of the benefits and risk, and potential side effects, of the Covid-19 immunization, receipt of the of the Covid-19 immunization, or having had not received the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. Findings included: Record review of a facility face sheet dated 5/14/25 for Resident #11 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain in right hip, altered mental status and repeated falls. Record review of a physician order summary report dated 5/14/25 for Resident #11 indicated that she had no orders for Covid vaccination. Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 11 and/or her representative was not offered the Covid-19 vaccine since 01/19/21 The document indicated no education given. Record review of a facility face sheet dated 5/14/25 for Resident #35 indicated that she was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: chronic pain, atrial fibrillation (rapid heart rate) and anorexia (no desire to eat). Record review of a physician order summary report dated 5/14/25 for Resident #35 indicated that she had no orders for Covid-19 vaccination. Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #35 and/or her representative was not offered the Covid vaccine on admission and the document indicated there was no education given to Resident #35. Record review of a facility face sheet dated 5/14/25 for Resident #52 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: anemia (low blood volume), atrial fibrillation (rapid heart rate) and anorexia (no desire to eat). Record review of a physician order summary report dated 5/14/25 for Resident #52 indicated that she had no orders for Covid-19 vaccination. Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #52 and/or her representative was not offered the Covid-19 vaccine since 01/03/21. The document indicated there was no education given to Resident #52 or a representative. Record review of a facility face sheet dated 5/14/25 for Resident #56 indicated that she was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: atrial fibrillation (rapid heart rate), weakness and chronic cough. Record review of a physician order summary report dated 5/14/25 for Resident #56 indicated that she had no orders for Covid-19 vaccination. Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident # 56 and/or her representative was not offered the Covid-19 vaccine since 07/22/22. The document indicated there was no education given to Resident #56 or a representative. Record review of a facility face sheet dated 5/14/25 for Resident #57 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: pain, weakness, and lack of coordination. Record review of a physician order summary report dated 5/14/25 for Resident #57 indicated that he had no orders for Covid-19 vaccination. Review of a document titled, immunization audit report dated 5/13/2025, revealed Resident #57 and/or her representative was not offered the Covid-19 vaccine. The document indicated there was no education given to Resident #57 or a representative. During an interview on 5/14/2025 at 8:45 am, the DON said she was the Infection Preventionist for the facility. The DON could not provide documentation of any resident (74 residents in the facility) education for Covid immunization refusals. DON said the facility had no form for declination to be used when the resident or representative refused and there was no refusal scanned into the electronic system for residents that indicated they had been education on benefits or risks of the covid vaccine. She said there was no documentation of education provide after refusal of Covid vaccination for any resident in the facility. The DON said she would be responsible going forward to ensure that residents were educated on immunizations and providing documentation. She said residents could be at risk of not knowing what they were refusing if they were not provided education. The DON said residents could be at risk of contracting infections, severe respiratory problems and even death if they were not properly educated and did not receive vaccinations. DON said they would be providing education and have consent/declination forms signed going forward. During an interview on 5/14/2025 at 9:00 am, the Administrator said there was no documentation of education provide after refusal of Covid vaccination for any of the 74 residents in the facility. She said the facility had not provided covid vaccinations or education on Covid vaccinations in the last two years due to no interest and refusal of the residents or families. The Administrator said the DON was responsible for immunizations and going forward residents will be provided education regarding benefits and risks. Administrator said that residents and families could possibly not have the knowledge to make informed decisions concerning covid vaccinations if risks and benefits were not provided. Record Review of a facility policy titled Infection Control Program dated 10-24-2022 indicated . COVID-19 Immunization : a. Residents and staff will have the opportunity to receive the COVID-19 vaccination, and change their decision based on current guidance. b. Residents and staff will be screened prior to offering the vaccination for prior immunization, medical precautions, and contraindications to determine candidacy for the vaccination. c. Education about the vaccine, risks, benefits, and potential side effects will be given to residents or resident representatives and staff prior to offering the vaccine. d. Documentation will reflect the education provided and details regarding whether or not the resident or staff received the vaccine.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 1 smoking area reviewed for smoking safety. The facility failed to ensure cigarette butts were not discarded into a regular trash can that also contained paper trash on 5/12/25 causing a fire hazard. The facility failed to ensure regular trash was not discarded into the red metal ashtray container on 5/12/25 causing a fire hazard. This failure could place residents at risk of injury, burns, and an unsafe smoking environment. Findings included: During an observation on 5/12/25 at 10:50 am a red metal ashtray container was observed with paper trash in it. A metal trash can was also observed in the smoking area with a clear plastic liner in it. Observation revealed that can was full of cigarette butts along with cigarette boxes and regular trash. During an interview on 5/13/25 at 1:50 pm DON said there was not one specific person responsible for emptying the ashtrays in the smoking area, but whoever took the residents out to smoke should be emptying the ashtrays into the ashtray container. DON said she would get with the maintenance man to correct this issue. During an interview on 5/13/25 at 2:00 pm Maintenance man said staff that take residents out to smoke should be emptying the ashtrays into the red metal can. He said there was no one specific person responsible for this. He said ashtrays should not be emptied into the regular trash can, due to it being a fire hazard. Maintenance man said it was also a fire hazard for regular trash to be emptied into the red metal can. Record review of a facility policy titled Smoking Policy dated 4/12/23 read: .It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees as related to smoking .

Based on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 1 of 12 residents (Resident #23) reviewed for ADL care. The facility failed to ensure Resident #23 had a shower and shave from 4/15/2025 to 5/08/2025. This failure could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity. Finding included: Record review of Resident # 23's facility face sheet revealed Resident #23 was a [AGE] year-old male and admitted on [DATE] with diagnosis of cerebral infarction (stroke). Record review of Resident 23's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderately impaired cognition, relied on staff for assistance with bathing and personal hygiene and was incontinent of bowel and bladder at times. Record review of Resident #23's comprehensive care plan dated 5/12/2025 revealed Resident #23 had an ADL self-care performance deficit and was at risk for not having their needs met in a timely manner and to provide shower, shave, oral care, hair care, and nail care per schedule and when needed. During an observation and interview on 5/12/2025 at 10:43 AM Resident # 23 had long facial hair and faint urine odor. He said he had not had a shower in a while, and no one has offered to shave him. He said the staff had changed him and cleaned his private area but that was all. He said he was not able to shave himself and needed help. Record review of an untitled and undated form listed Resident #23 for a shower on Wednesday and Saturday. Record review of POC (point of care) response history dated 5/12/2025 for bathing revealed Resident # 23's nurse aide response for bathing was recorded as not applicable from 4/15/2025 to 5/08/2025. There was no entry for shaving. During an interview on 5/13/2025 at 11:20 AM Resident # 23 was sitting in his room and clothes were different then yesterday and said the staff helped him change his clothes but did not get a shower and shave. He said he thought about it from yesterday's conversation and could not remember the last shower and shave he had. He said he would like a shower and shave at least 1-2 times a week. He said he didn't feel upset about not getting a shower but would like to be clean and free of odors. During an interview on 5/13/2025 at 11:30 am CNA A said that each resident had a shower schedule and Resident #23 was scheduled on the night shift for a shower. CNA A said there was a shower book at the nurses station for the nurse aides and nurses and once the task was complete then the CNA entered the task into the computer. CNA A said if the task was checked as not applicable then the task was not done . CNA A said she could not speak on why Resident #23 had not been receiving a shower and he had not voiced any concerns to her, but she would ensure he was showered and shaved today. CNA A said residents that don't receive proper ADL care like a shower and shave could feel bad or have skin changes. During an interview on 5/13/2025 at 11:35 am LVN C said she worked at the facility as needed as a charge nurse. She said she was to oversee resident care by the CNA's and observed their ADL care on her rounds. LVN C said she had noticed resident #23 had an odor on 5/12/25 but today 5/13/25 had clean clothes on and thought he had been showered. LVN C said that residents that don't receive ADL care like showers could have changes in skin and feel bad about not being clean. During an interview on 5/14/2025 at 9:39 am the DON said that ADL care was now overseen by the treatment nurse and the facility had a new treatment nurse as of this week due to the previous treatment nurse not completing her job duties. DON said there was no alert for when care was not provided, and the nurses and aides should be aware of care that needed to be completed. She said she was not sure why Resident #23 did not have a shower recorded since before 04/15/25 and felt that was an error in documentation. She said she expected all residents to receive their ADL care and by not providing ADL care residents could have an adverse outcome. During an interview on 5/14/2025 at 11:31 am the Administrator said all staff were responsible for ensuring resident's received ADL care and CNA's should be accurately recording ADL care and completing their job task as assigned. She said all staff made rounds and if they see something they should say something. She said she did not know why Resident #23 did not have a shower recorded since before 4/15/25 and felt it was a documentation error because she had seen him the shower room. Administrator said if ADL care was not provided it could affect resident skin and infection control and expected all staff to follow the ADL assignments and follow the residents care plan. Record review of a facility policy titled Activities of daily Living Care Guidelines dated 01/23/2016 revealed, .residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene .

Based on interview, observation and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 4 residents (Resident #12) reviewed for accuracy of assessments. The facility failed to accurately code the 04/30/25 MDS for an in-dwelling catheter (tube inserted into the bladder to drain urine) used for Resident #12. This failure could put residents at risk for lack of proper care and decreased quality of life. Findings included: Record review of a facility face sheet dated 5/14/25 for Resident #12 indicated he was a [AGE] year-old male admitted to the facility on [DATE] and subsequently readmitted on [DATE] with diagnosis of cerebrovascular disease (heart disease). Record review of a Comprehensive MDS assessment dated [DATE] for Resident #12 indicated he had a BIMS score of 12, which indicated moderately impaired cognition. Question H0100 did not indicate he had an indwelling catheter. Record review of a comprehensive care plan dated 3/13/25 for Resident #13 indicated that he had a urinary catheter. Record review of a physician's order summary report dated 5/14/25 for Resident #13 indicated he had the following physician's order dated 4/24/25: .Urinary catheter 24 FR 20 CC bulb to gravity (BSD). Change the catheter if it becomes occluded, to obtain a urine specimen, or if the closed system has become compromised . During an observation on 5/12/25 at 12:13 pm Resident #12 was observed lying in bed. He was observed to have a Foley catheter. During an interview on 5/14/25 at 11:00 am MDS Nurse was not receptive to questioning. During an interview on 5/14/25 at 11:15 am DON said the MDS nurse was responsible for MDS accuracy. She said MDS assessments were responsible for the payments to the facility. She said she did the care plans and nothing on the care plan was missed due to the MDS being inaccurately coded. She said going forward she would have a system of checks to ensure MDS assessments are coded correctly. During an interview on 5/14/25 at 11:35 am Administrator said if MDS assessments are coded incorrectly it could possibly cause payment issues. She said going forward there would be multiple reviews and meetings to discuss the residents to hopefully prevent this from happening. Record review of a facility policy titled MDS Completion dated 2/10/21 read: .According to federal regulations, the facility conducts initially and periodically a comprehensive, accurate and standardized assessment of each resident's functional capacity, using the RAI specified by the State .

Based on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #57) and 2 of 8 staff (CNA A and CNA B) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions and performed hand hygiene when providing incontinent care to Resident #57 on 5/12/2025. These failures could place residents at risk for cross contamination and infection. Findings included: Record review of Resident # 57's facility face sheet revealed Resident #57 was a [AGE] year-old male and admitted on [DATE] with diagnosis of cerebral infarction (stroke). Record review of Resident 57's Annual MDS assessment dated [DATE] revealed a BIMS score of 14 indicating intact cognition, relied on staff for all ADL's, was incontinent of bowel and bladder, and required a feeding tube. Record review of Resident #57's comprehensive care plan dated 3/17/2025 revealed Resident #57 was incontinent of bowel and bladder and dependent on staff for care and required EBP due to feeding tube and staff to wear a gown and gloves during high-contact resident care activities. Record review of nurse assistant skills review checklist dated 5/07/2024 revealed CNA B had been trained on infection control measures for EBP and hand hygiene. Record review of nurse assistant skills review checklist dated 5/08/2024 revealed CNA A had been trained on infection control measures for EBP and hand hygiene. During an observation on 5/13/2025 at 9:11 AM CNA A and CNA B provided incontinent care to Resident #57. Resident #57 had an EBP sign on his door indicating he required gloves and gown for direct care. Neither CNA applied a gown when providing incontinent care and personal care to Resident #57. During incontinent care both CNA's washed their hands and applied gloves prior to starting care. CNA B began care by cleaning Resident #57's front periarea with wipes. After care she continued to wear the soiled gloves while turning the resident. CNA A then cleaned the back periarea of Resident #57 of stool using wipes and then removed her gloves and applied new gloves without hand hygiene. CNA A then applied a clean pad and brief and applied skin barrier cream to Resident #57's buttocks. Resident #57 was then turned back to his right side and CNA B using the same soiled gloves from the beginning , placed clean linens, pad and brief. CNA B and CNA A then repositioned the resident and adjusted his linens and head of the bed with soiled gloves. CNA B gathered the soiled linen and left the room with soiled gloves on. During an interview on 5/13/2025 at 9:45 am CNA A said that she forgot Resident #57 required EBP and should have put on a gown and gloves before providing care. CNA A said she should have performed hand hygiene between glove changes and should not use soiled gloves to touch clean objects. CNA A said she had been trained on EBP and proper hand hygiene but was nervous. CNA A said by not following infection control measures infections could spread. During an interview on 5/13/2025 at 9:47 am CNA B said that she did not see the sign for EBP on the door and failed to put on proper PPE for Resident #57. CNA B said she should have removed her gloves and performed hand hygiene between dirty and clean task and before exiting the residents room. CNA B said by not following infection control measures infections could spread. During an interview on 5/14/2025 at 9:39 am the DON said that she was the now the infection prevention nurse and that all staff were responsible for following the facilities infection control policies. DON said the staff were trained on hire, annual and throughout the year on infection control measures like hand washing and EBP. DON said if staff were not following the infection control program, then infections could spread. During an interview on 5/14/2025 at 11:31 am the Administrator said the infection control program was the responsibility of the DON who was the infection prevention nurse. Administrator said all staff were trained on hire and throughout the year on infection control measures including EBP and hand hygiene. Administrator said if the infection control program measures were not followed by staff, infections could spread and expected all staff to follow the facilities infection control program. Record review of a facility policy titled Hand Hygiene dated 02/11/2022 indicated, .all staff will perform proper hand hygiene procedures to prevent the spread of infections;6a. the use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing gloves . Record review of a facility policy titled Infection Prevention and Control Program dated 11/6/24 indicated .6. Enhanced Barrier Precautions: EBP are used in conjunction with standard precautions and expand the use of gown and gloves during high contact resident care activities .

Based on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, 1 of 4 medication carts (hall two cart) reviewed for storage of medications. The facility failed to ensure LVN C kept the hall two medication cart secured and was unable to be accessed by unauthorized personnel or residents on 05/12/25. This failure could put residents at risk of unauthorized use of medication and accidental ingestions/use of an unprescribed medication. Findings included: During an observation on 5/12/2025 at 12:10 pm, medication cart for hall two was located at the nurses station and observed unlocked. During an observation on 5/12/2025 at 12:15 pm, a visitor and two unlicensed staff members (CNA's) passed by the unlocked medication cart located on hall two. During an observation on 5/12/2025 at 12:20 pm, two housekeepers passed by the unlocked medication cart located on hall two. During an observation on 5/12/2025 at 12:25pm, a resident passed by the unlocked medication cart located on hall two. During an observation and interview at 12:30 pm, LVN C returned to the unlocked medication cart and proceeded to lock the medication cart. LVN C said she had worked at the facility for two weeks and had been a nurse for about two years. She said that not locking the cart could cause a drug diversion if a visitor, resident, or unlicensed staff member entered the unlocked cart. LVN C said a confused resident might access medications and cause harm to themselves if medications that were not ordered for them were consumed. During an interview on 5/12/2025 at 12:35 pm, the Administrator said it was the responsibility of the DON or her designee to train and in-service the nursing staff on medication storage. The Administrator said that the medication cart should be locked while not attended and the unopened cart could cause harm if the cart was accessed by a confused resident. During an interview on 5/12/2025 at 2:00 pm, the DON said the medication carts should be always locked when unattended. She said there was a risk of harm if a resident entered the cart, and consumed medications. She said there was a risk of a drug diversion if visitors or unlicensed staff had access to medications. Record Review of a facility Medication Storage policy dated1/20/2021 Policy . It is the policy of this facility to ensure all medications housed on our premises will be stored, dated and labeled according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security .Policy Explanation and Compliance Guidelines 1. General Guidelines: a. All drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms) under proper temperature controls. b. Only authorized personnel will have access to the keys to locked compartments c. During a medication pass, medications must be under the direct observation of the person administering medications or locked in the medication storage area/cart.

Based on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #39) reviewed for accidents/hazards. The facility failed to remove worn and damaged mechanical lift slings from service on 5/12/25. This deficient practice place residents at risk of injuries. Findings included: Record review of a facility face sheet dated 5/12/25 for Resident #39 indicated that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including hypotension (low blood pressure) and muscle weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #39 indicated that he had a BIMS score of 15 which indicated that he had intact cognitive status. Resident #39 was dependent for transfers. Record review of a Comprehensive Care Plan dated 3/7/24 for Resident #39 indicated that he had an ADL self-care performance deficit and required 2 staff for transfers. During an observation on 5/12/25 at 9:27 am Resident #39 was observed being transferred by CNA E and LVN D using a mechanical lift. Mechanical lift sling loops were observed to be faded in color and the labels appeared to have been cut off of sling. During an interview on 5/12/25 at 3:15 pm CNA E said she would check for broken hooks or loops. CNA E said that broken hooks or loops would indicate wear and tear on the sling. She said she did not know to look for faded colors on loops. During an interview on 5/12/25 at 3:20 pm LVN E said nurses and CNAs check the slings before use and they look for signs of dry rotting, faded coloring. She said they have so many different kinds of lift pads that it's hard to notice the fading sometimes, because they are all different colors. During an interview on 5/12/25 at 3:30 pm Laundry Aide said she did not use bleach on the lift pads, and she hangs them to air dry. She said she looks for rips/tears and colors fading. Laundry Aide said she would notify the ADON if she noticed anything out of the ordinary and let them make the decision on whether to remove them from service. During an interview on 5/14/25 at 11:15 am DON said direct care staff using the slings were responsible to check them before use. She said faded or fraying slings could tear with any weight and cause accidents. She said she would be holding an in-service with all staff to ensure they knew to ensure the tag was on the sling and readable and the colors were bright and not faded. DON said she would also in-service laundry staff to ensure they did not use bleach or place slings in dryer. During an interview on 5/14/25 at 11:35 am Administrator said if lift sling loops are faded the sling would need to be replaced. She said direct care staff are responsible for checking before using on a resident, but it also goes up the chain as well, so ultimately administrative staff were also responsible. She said if staff cannot discern the loop colors, they may not use the correct hooks and it could lead to resident injury. Administrator said she would put a new system in place to check slings going forward. Record review of a facility policy titled Hydraulic Lift (Mechanical Lift) dated 9/13/24 indicated that policy did not address safety checks of lift slings. Record review of the manufacturer instruction for Medline full body slings undated indicated, .Full body slings are made of durable materials and are ideal for patient transferring and toileting activities. Always inspect slings prior to each use. Signs of color fading, bleached areas, indicate improper laundering which is unsafe and could result in injury. Any slings with signs of wear or improper laundering should be immediately removed from use .

Based on observation, interview, and record review, the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for 1 of 8 residents (Resident #2) in that: 1. Resident #2's window, window blinds, and floor around his bed were soiled with visible dust, dirt, debris, and smudges. 2. Resident #2's bed sheets and pillowcase had scattered brown stains on them. This failure placed residents residing in the facility at risk for a diminished quality of life and a diminished clean, homelike environment. The findings include: Review of Resident #2's undated face sheet revealed he was a [AGE] year-old male readmitted to the facility on [DATE] with a primary diagnosis hemiplegia and hemiparesis following cerebral infarction of left non-dominate side (weakness or paralysis on one side of the body) and secondary diagnoses of cognitive or emotional deficit and aphasia (impaired ability to comprehend or formulate language). Review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS score of 3 which indicated severe cognitive impairment and he required total assistance with oral hygiene, toileting hygiene, shower/bathing, lower body dressing, putting on/taking off footwear, and personal hygiene; he required maximum assistance for upper body dressing; he required setup and clean up assistance with eating. He was always incontinent of bowel and bladder. A comprehensive care plan revised on 10/03/24 indicated Resident #2 exhibited verbal and physical aggressive behaviors with interventions in place including approaching and speaking to resident in a calm manner, clearly explaining all daily care activities, and early intervention when resident behaviors were escalating. Resident #2 had a history of violent behaviors and had hit staff at the facility on multiple occasions. The same comprehensive care plan included a revision on 12/05/25 which indicated Resident #2 had an ADL self-care performance deficit related to contracture of left hand, limited range of motion in upper and lower extremities, and hemiplegia/hemiparesis. An observation on 3/24/25 at 11:36 AM of Resident #2's room revealed there were scattered brown stains on his sheets and pillowcase. The window in his room had green and brown smudges on the glass and the window blinds had an accumulation of dust on them. The floor around his bed had an accumulation of dirt and debris. During an interview on 3/24/25 at 11:36 AM, Resident #2 said facility staff did change his bed linens and clean his room, but not daily. During an interview on 3/24/25 at 11:45 AM Housekeeper C said all resident rooms were cleaned every day. She said the daily cleaning consisted of cleaning the restroom, wiping down all surfaces, sweeping and mopping the floors, and taking out the trash. She said she doesn't always clean behind resident beds or underneath them because she would need help to move the beds away from the wall. She said Resident #2 never exhibited any violent behaviors that interfered with housekeeping staff's ability to clean his room, and his room had already been cleaned today. An observation on 3/25/25 at 9:00 AM Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from previous observation. During an interview on 3/25/25 at 9:45 AM Housekeeper D said every resident room was cleaned daily and a daily cleaning included wiping down all surfaces, sweeping and mopping floors, and taking out the trash. Housekeeper C said she had enough time to complete all assigned duties and no resident behaviors had ever affected her ability to clean their rooms. During an interview on 3/25/25 at 10:05 AM, CNA E said the facility had been having problems running out of clean linens in the morning. She said sometimes she had to delay changing bed linens until laundry staff washed more linens. During an interview on 3/25/25 at 10:30 AM, EVS Manager said housekeepers were expected to clean each resident's room daily, which consisted of taking out the trash, wiping down all surfaces, and sweeping and mopping floors. She said, additionally, each housekeeper was assigned one room daily to be deep cleaned. She said a deep clean was cleaning everything in the room and it was also done for new resident admissions. She said CNAs were bringing soiled linens to the laundry room too late in the day to be washed and ready for the next morning, because laundry staff left at 2:00 PM. She said linens were provided late some days, but there was always clean linen available to accommodate resident needs. During an interview on 3/25/25 at 11:00 AM, the ADON said the facility had identified an issue with their laundry processing. The ADON said CNAs recently changed to a 12-hour shift, and left at 6:00 PM instead of 2:00 PM. She said CNAs were waiting until the end of their shift to bring linens to the laundry room and laundry staff left at 2:00 PM. The ADON said she wasn't satisfied with the quality of housekeeping services, and administration was in discussion with the company they were contracted with. An observation on 3/25/25 at 3:00 PM of Resident #2's room revealed what appeared to be the same soiled bed linens and pillowcase on his bed. The floor, window, and window blinds appeared to have not been cleaned from the initial observation. During an interview on 3/25/25 at 3:00 PM, Resident #2 said staff had helped him change his clothing that day, but his linens had not been changed in a few days. During an interview on 3/25/25 at 4:30 PM, the ADM said the facility had identified there was an issue with their laundry processing. She said CNAs were not emptying linen barrels early enough in the day to provide laundry staff time to wash them. The ADM said CNAs had been instructed to empty linen barrels earlier in the day. She said the facility always had clean linens available to accommodate resident needs. Review of a policy dated May 2003 titled Housekeeping Standards indicated the following: .The facility will provide a clean and sanitary living environment for the physical and emotional wellbeing of the resident . And .Daily cleaning schedules will be followed to provide a clean, safe, sanitary environment for residents, staff and visitors .

Based on interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 8 (Resident #1) reviewed for dignity in that: CNA A spoke to Resident #1 in a loud and harsh tone while attempting to assist the resident out of bed. This failure placed residents in the facility at risk of diminished quality of life, and loss of dignity and self-worth. Findings Include: Review of Resident #1's undated face sheet revealed he was a [AGE] year-old male admitted to the facility on [DATE] with a primary diagnosis of heart failure and secondary diagnoses of shoulder pain, low back pain, and muscle wasting (loss of muscle mass due to disuse or nerve problems). Review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 12 which indicated moderate cognitive impairment, and he required total assistance with toileting, putting on/taking off footwear; he required maximum assistance with showering/bathing and lower body dressing; he required moderate assistance with upper body dressing; he required setup assistance with personal and oral hygiene; he required no assistance eating. He was occasionally incontinent of bladder and frequently incontinent of bowel. A comprehensive care plan revised on 9/26/24 indicated Resident #1 had an ADL self-care performance deficit and Resident #1 did not always like to change his clothing daily or shower when scheduled. Interventions were in place to provide ADL care as needed, encouraging resident to participate to the fullest extent possible, and praising resident when attempts were made. A comprehensive care plan revised on 9/30/24 indicated Resident #1 had impaired cognition and was at risk for further decline related to encephalopathy (group of conditions that cause brain dysfunction) and dementia (altered cognition). Interventions were in place including explaining all procedures to resident and stopping and returning later if resident becomes agitated during care. During an interview on 3/24/25 at 12:21 PM, Resident #1 said CNA A came into his room and told him he needed to get up and out of bed. Resident #1 said he told CNA A he did not want to get up right then, and CNA A replied that he had to get up and then pulled his blanket off him. Resident #1 said the CNA attempted to assist him to his feet by pulling his legs over to the side of the bed and he told her again that he did not want to get up yet. Resident #1 said CNA A said, We don't play around here in loud and harsh voice and left the room. During an interview on 3/24/25 at 12:30 PM, Resident #3, who was Resident #1's roommate, said he remembered CNA A coming into their room on the morning of the incident. He said CNA A yelled at Resident #1 and told him he had to get out of bed. He said he did not remember CNA A pulling Resident #1 out of bed or jerking his leg. During an interview on 3/24/25 at 12:40 PM, Resident Representative said the facility notified him of the incident, and he accompanied Resident #1 to a meeting with the ADM. He said Resident #1 told the ADM he didn't think CNA A should be fired, but he did not want CNA A to be allowed in his room anymore. Attempted a telephone interview on 3/24/25 at 1:00 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup. During an interview on 3/24/25 at 3:10 PM, MA B said she went into Resident #1's room to check Resident #3's vital signs in preparation of a medication pass. MA B said she heard Resident #1 tell CNA A he did not want to get up and CNA A responded you need to get up or I'll get in trouble in a loud and harsh-sounding tone of voice. MA B said she left the room to get Resident #3's medication, and when she returned, Resident #1 was seated in his wheelchair dressing himself; CNA A was not in the room. During an interview on 3/25/25 at 11:00 AM, the DON said there was nothing in CNA A's background checks or job performance that indicated a risk to residents in the facility. She said CNA A was a large woman with a loud voice and she could have been intimidating to some residents, but there had been no previous allegations of mistreatment from any resident in the facility against CNA A. Second attempted telephone interview on 3/25/25 at 3:45 PM with CNA A. An automated voice recording indicated the correct number was reached and there was no voicemail box setup. During an interview on 3/25/25 at 4:00 PM, the ADM said CNA A had nothing in her background or job history that indicated a concern for resident safety. She said there had been no allegations of abuse or neglect against CNA A from any resident before this incident. She said CNA A was suspended while the facility investigated the allegation, and the decision was made to terminate CNA A based off MA B's witness statement. The ADM said CNA A was too direct and did not respect Resident #1's personal choice and that would not be tolerated at the facility. She said all CNAs were trained and expected to fully explain all care being provided and encourage residents to participate in care. Review of facility policy titled Promoting/Maintaining Resident Dignity last reviewed on 2/16/20 indicated all staff involved in providing resident care will promote and maintain resident dignity by .personal choices will be considered when providing care and services to meet the resident's needs and preferences . and .speak respectfully to residents .

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents # 20 and #52) reviewed for infection control practices. 1.LVN T failed to change her gloves after performing foley care on Resident #20 and touched clean surfaces. 2.CNA K failed to wash or sanitize her hands when changing gloves while performing foley catheter care for Resident #52. 3. CNA J and CNA K failed to wash or sanitize their hands after performing foley catheter care for Resident #52. These failures could place residents at risk of exposure to communicable diseases, cross-contamination and infections. 1. Record review of Resident #20's, undated, face sheet indicated an [AGE] year-old male who was admitted to the facility on 3/15/24. Record review of Resident #20's physician's orders, dated 4/16/24 , indicated Resident #20 had diagnoses which included: Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Cerebrovascular Disease (affects blood flow to the brain), flaccid neuropathic bladder (hyperstimulation of the nerves and muscles leading to urinary retention and the inability to fully empty the bladder) and Stage 3 pressure ulcer to the sacrum (an injury that breaks down the skin and underlying tissue). Record review of Resident #20's physician's order, dated 3/18/24, indicated: Urinary catheter 16 FR, 10cc, bulb to gravity. Record review of the admission MDS, dated [DATE], indicated Resident #20 had clear speech, was sometimes understood by others, and sometimes understood others. Resident #20 had a BIMS score of 6, which indicated severe cognitive impairment. The MDS indicated under H0300, Urinary Continence 9. Not rated, resident had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. Record review of the care plan, dated 3/21/24, indicated Resident #20 had impaired cognition with a risk for further decline. Resident #20 had a urinary catheter and was at risk for urinary tract infections and injury. Urinary catheter care was to be provided per facility practice. During an observation on 4/16/24 at 1:28 PM, LVN T and CNA V donned gowns and after washing their hands, donned gloves. LVN T performed foley care for Resident #20. CNA V assisted LVN T. LVN T performed foley care and did not change her gloves. She touched Resident #20's brief, blanket and bed side table with the same gloves. After covering Resident #20 and adjusting the bed side table she took off her gloves and washed her hands. During an interview on 04/16/24 01:38 PM, LVN T said she should have changed her gloves after the foley care when her gloves were dirty and before touching the resident's brief, blanket and bed side table. She said she was trained to change her gloves and clean her hands after foley care, and she did not because she was nervous. She said what she did was an infection control issue and could spread infection. During an interview on 4/17/24 at 12:02 PM, CNA W said it was important to take dirty gloves off before touching anything clean to prevent spreading germs. She said staff had to take off their dirty gloves, wash their hands and re-glove, if needed. She said it was an infection control issue to touch items or residents with dirty gloves. She said she was trained to remove her dirty gloves before touching anything clean and washing her hands to prevent infection. During an interview on 04/17/24 at 12:07 PM, LVN R said when doing foley or incontinent care it was an infection control issue to touch clean items when gloves were dirty. She said dirty gloves should be taken off immediately and hands washed before touching anything clean. She said anything could be spread by contact and could make the resident sick or sicker. During an interview on 4/17/24 at 12:14 PM, LVN S said dirty gloves should not touch clean items because that would be cross-contamination and could cause infection to the resident. She said dirty gloves should be swapped out for clean gloves, after hand washing during foley care. During an interview on 4/17/24 at 12:23 PM, ADON P said touching clean surfaces with dirty gloves could cause cross contamination of the clean area especially if someone else touched the dirty area with clean gloves or hands. She said the danger to the resident was infection, weight loss and an infection could require the resident to be on antibiotics. She said touching clean surfaces with dirty gloves was bad all the way around. During an interview on 4/17/24 at 1:11 PM, the DON said regarding foley care, a staff should never touch resident's items with dirty gloves. She said to do that was cross-contamination which could spread infection or cause infection. She said she expected staff to go by their training and change their gloves after a dirty procedure and perform hand hygiene. She said dirty gloves should be changed and hand hygiene performed before going to a clean area. During an interview on 4/17/24 at 1:41 PM, the ADM said she expected staff to follow best practices learned when obtaining their licensure. She said if a staff had dirty gloves on and touched a clean area it was cross-contamination and could cause infection. She said it was definitely an infection control issue and could cause a resident to become sick. Record review of a skills check off entitled Nursing Hand Hygiene, dated 10/16/23, indicated LVN T was competent in hand hygiene. Record review of a skills check off entitled Provides Catheter Care for Female, dated 8/8/23, indicated LVN T was competent in catheter care. 2. Record review of Resident #52's face sheet, dated 4/17/2024, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (unable to move the left side of his body), type 2 diabetes mellitus with hyperglycemia (high blood sugar) and obstructive and reflux uropathy (urine cannot drain through the urinary tract). Record review of Resident #52's care plan, dated 11/10/2021, indicated he had a urinary catheter related to obstructive uropathy with interventions to provide urinary catheter care per facility practice and to position the catheter bag and tubing below the level of the bladder. Record review of Resident #52's annual MDS, dated [DATE], indicated he was rarely/never understood, and a BIMS score that was not able to be obtained. He required total dependence with one-person physical assist with bed mobility, dressing, toilet use and personal hygiene. He was always incontinent of bowel. Bladder was not rated due to having a foley catheter in place. During an observation on 4/16/2024 at 3:12 PM in Resident #52's room revealed, CNA J and CNA K were present to provide foley catheter care. Both staff washed their hands in the assisted dining room before entering Resident #52's room. CNA J and CNA K stopped at linen cart in the hallway and applied gowns 2 doors down from Resident #52's room. CNA J and CNA K both knocked on the resident's door and entered the room. CNA J and CNA K sanitized their hands and donned gloves at the bedside. CNA J and CNA K positioned Resident #52 in supine position to perform his foley catheter care. CNA J doffed gloves and sanitized hands, CNA K doffed gloves and did not sanitize her hands and donned new gloves. CNA J removed the blanket from Resident #52 and placed the foley catheter bag and tubing on the bed next to his leg. CNA K placed a trash bag at the end of the bed. CNA J removed a wipe from the over the bed table and began cleaning around the foley catheter insertion site working in a downward motion. LVN E placed the wipes in the trash bag at the end of the bed. After CNA J completed the foley catheter care, CNA K repositioned Resident #52. CNA J, without changing gloves, took the foley catheter bag off the bed and positioned it under the mattress below bladder level. CNA J and CNA K pulled the resident up in bed without changing gloves, sanitizing or washing hands. CNA J and CNA K both doffed gloves and said skill complete without washing or sanitizing hands. CNA J then removed the trash bag at the end of the bed and placed it in the trash can in the resident's room. Both CNA J and CNA K stopped before exiting residents' room and doffed gowns then exited the room. Once in the hallway CNA J and CNA K said skill not complete we forgot to wash our hands and went over to the hand sanitizer station in the hallway and sanitized their hands. CNA J doffed clean gloves and re-entered residents' room and retrieved the trash bag from the trash can and walked down the hallway and disposed the trash bag in trash barrel. During an interview on 4/17/2024 at 3:31 PM, CNA K said she had been employed at the facility for about 1 year and 5 months., CAN K said she should have sanitized her hands when she doffed her gloves after positioning the resident. She said both CNA J and CNA K should have washed their hands after doffing gloves before they said, skill complete. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. During an interview on 4/17/2024 at 3:34 PM, CNA J said she had been employed at the facility for about 2 years. CNA J said she should not have gone back into the resident's room to retrieve the trash bag after she doffed her gown. She said CNA K should have sanitized her hands between glove changes after repositioning Resident #52. She said it was not the proper procedure for CNA K to have placed the trash bag on the end of the bed. She said residents could be at risk of an infection if they did not wash or sanitize their hands when changing their gloves. Record review of the Validation Checklist, dated 5/20/2023, for CNA K indicated she was trained and had demonstrated hand hygiene procedure in accordance with the facility's standard of practice. Record review of the Nursing Assistant Clinical Skills Checklist and Competency Evaluation, dated 8/16/2023, for CNA J indicated she was trained and had demonstrated hand hygiene procedure in accordance with the facility's standard of practice. Record review of the facility's policy titled Indwelling Foley Catheter Guidelines, dated 5/23/2014 and reviewed on 2/10/20, indicated: The facility shall identify and assess patients with an indwelling catheter or at risk for catheterization, provide appropriate treatment and services to prevent urinary tract infections and to achieve or maintain as much normal bladder function as possible, and ensure that indwelling catheters are medically necessary .Perform hand hygiene immediately before and after insertion or any manipulation of the catheter .Keep the collecting bag below the level of the bladder at all times. Record review of the facility's policy titled Hand Hygiene, dated 2/20/20, with a revised date of 2/11/2022, indicated: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility .The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves. Record review of the facility's policy titled Infection Control Guidelines dated 2/2007 with a revised date of 9/22/2015, indicated: The purpose for this policy is to reduce and prevent the spread of infections by the use of evidenced based techniques established infection control policies and procedures .Staff shall use hand hygiene when coming on duty, between patient contacts, after handling contaminated objects, after PPE removal, and before going off duty .Staff shall wash their hands with an antiseptic preparation before performing patient care procedures and when providing care to patients in isolation. Record Review of the facility's policy titled Infection Prevention and Control Program, dated 10/24/2022 and revised on 4/12/2023, indicated: This facility has established and maintains an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections as per accepted national standards and guidelines .Hand hygiene shall be performed in accordance with out facility's established hand hygiene procedures .All staff are expected to provide care consistent with infection control practices.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and residents received adequate supervision and assistance devices to prevent accidents for 2 of 6 residents (Residents #39 and #9) reviewed for accident hazards. 1. The facility failed to ensure Resident #39's shoulder seat belt was buckled prior to transport. Resident #39 slid out of the wheelchair to the floor when the facility transportation van stopped at a stop sign. 2. The facility failed to ensure CNA H and LVN I transferred Resident #9 safely when they tilted Resident #9's wheelchair back onto the anti-tip bars with all 4 wheelchair wheels not touching the floor and lowered Resident #9 into the wheelchair via mechanical lift. 3. The facility failed to ensure CNA H and LVN I ensured the mechanical lift legs were in the widest position while transferring Resident #9 from bed to her wheelchair. These failures could place residents at risk of falls which could result in injury and hospitalization . Findings include: 1. Record review of Resident #39's face sheet, dated 04/15/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included: end stage renal disease (kidney failure), pressure ulcer of sacral region stage 4 (full-thickness skin loss extends through the fascia with considerable tissue loss) and peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs). Record review of Resident #39's quarterly MDS assessment, dated 3/25/24, reflected Resident #39 was usually understood and usually understood others. Resident #39 had a BIMS score 12, which indicated moderate cognitive impairment. Resident #39 required x2 assistance for bed mobility, transfer, toilet use and x1 assistance for personal hygiene and bathing. Record review of Resident #39 care plan, dated 4/16/24, reflected he required pressure relieving/reducing devices on bed/chair. Resident #39 has an air mattress bed. Resident #39 required reposition frequently or more often as needed or requested. Interventions included to approach Resident #39 in a calm manner. Resident #39 requested to called by name, spoken to slowly, maintain eye contact, talked while care provided, allow time for a response and do not rush. During an interview and observation on 04/16/24 at 08:27 AM revealed Resident #39 was sitting in his bedroom in wheelchair. Resident #39 said, the day I slipped out of the seat, [Driver X] did not hook me up right. Resident #39 said [Driver X] was going 80 miles per hour down the highway, then he got on the brake and I slipped out of the wheelchair. Resident #39 said when he slipped out of his wheelchair, he hurt his wounds: on his knee, right arm and buttock. Resident #39 said after Driver X realized he had slipped out of his wheelchair, Driver X pulled over to a gas station to place him back in his wheelchair. Resident #39 said Driver X asked him if he was hurt, if he wanted to go to the emergency room or did he want to go back to the facility. Resident #39 said he told Driver X he was fine and he still wanted to go to his appointment. Resident #39 said Driver X did not drive fast he just got to where he was going. Resident #39 said Driver X strapped down his wheelchair, but he forgot to put his seat belt on. During an interview on 04/16/24 at 02:16 PM Resident #14 said she remembered the incident when Resident #39 slipped out of his wheelchair. Resident #14 said Driver X did not check Resident #39 before they left the facility. Resident #14 said Driver X put Resident #39 on the van and probably thought he had secured Resident #39, but evidently Resident #39 was not secured in the van. Resident #14 said Resident #39 was not in his chair good. Resident #14 said Driver X secured her and her wheelchair like he always did. Resident #14 said Driver X usually checked everyone before he left the facility. Resident #14 said it scared her when Resident #39 got out of his wheelchair. Resident #14 said Driver X did not drive fast. Resident #14 said she thought this was an accident and Resident #39 just was not in his wheelchair good. Resident #14 said she thought Resident #39 slid out of the chair and hit her wheelchair. Resident #14 said as soon as Driver X realized Resident #39 came out of his wheelchair, he immediately got off the highway and pulled over to the gas station. Resident #14 said Driver X checked on Resident #39 and got him back into his wheelchair. Resident #14 said she remembered Resident #39 said he was not hurt and he wanted to go to his appointment; after the incident. Resident #14 said after Driver X checked on Resident #39 and got him back in his chair they went to the doctor appointments, then back to the facility safely. During an interview on 04/17/24 at 08:52 AM, Driver Z said she was in-serviced and checked off on the transportation van on 4/08/24. Driver Z said, the process of loading a resident was, let the emergency brake down on the van. Secure the resident on the lift with a seat belt and lock the wheelchair before going up with the lift. Driver Z said there were 4 straps that went around the wheelchair and locked the wheelchair to secure. Driver Z said place the over the body seat belt over the resident prior to leaving the facility. Driver Z said she felt confident to transport the residents safely. During an interview on 04/17/24 at 09:53 AM, Driver X said he had two transports the morning of 4/1/24. Driver X said he secured Resident #14 in van first. Driver X said he thought he secured Resident #39's wheelchair and seat belt prior to departure from the facility. Driver X said, it does not make sense, why would I secure one resident and not the other one. Driver X said he felt like Resident #39 took the shoulder seat belt off his self. Driver X said they got to the four-way stop at the highway, then Resident #39 slid out of his wheelchair. Driver X said there were times when Resident #39 refused to wear his seat belt and said it made his stomach hurt and did not put it on tight, but Driver X would encourage Resident #39 he had to wear the seat belt. Driver X said in the past Resident #39 had refused to wear a seat belt and had taken off the seat belt during a previous transport. Driver X said he was terminated from the facility due to the incident. During an interview on 4/17/24 at 2:42 PM, the DON said Resident #39 went to an appointment and Driver X forgot to put the shoulder strap across Resident #39. The DON said Resident #39 and Driver X were on their way to an appointment and Driver X got on the brake at a stop sign and Resident #39 slid out of his wheelchair to the floor. The DON said Resident #39 denied injuries due to the fall and denied hitting his head. The DON said Resident #39 said he just fell on the floor. The DON said Driver X did not notify the facility or Police and left the scene. The DON said there were no residents in the van at the time of the accident. The DON said after the accident with the hit and run Driver X and other van drivers were in-serviced. The DON said the staff was in-serviced over if an incident or accident happened while out on transport staff were expected to call the facility to notify management and Police, if necessary. The DON said after the accident with Resident #39 the van drivers were in-serviced on safety precautions, following policy and procedures. The DON said Driver X was terminated after the incident with Resident #39. The DON said there was a failure because Driver X forgot or got distracted and did not place the seat belt on Resident #39. The DON said, the bottom-line Resident #39 should have had a seat belt on prior to leaving the facility. During an interview on 4/17/24 at 2:57 PM, the Administrator said Driver X returned to the facility from a transport with Resident #14 and Resident #39. The Administrator said Driver X notified management, he forgot to put Resident #39's shoulder strap on and the resident slid out of his wheelchair onto the floor of the van, due to Driver X stopped at a stop sign. The Administrator said Resident #39 had a lift pad between him and the seat and there was not a grip. The Administrator said Driver X pulled over to the gas station and checked to see if Resident #39 was injured, after Resident #39 denied injuries Driver X replaced Resident #39 back into his wheelchair. The Administrator said Driver X said he asked Resident #39 if he wanted to go back to the facility or emergency room . The Administrator said Driver X said Resident #39 refused and said he wanted to go to his appointment. The Administrator said Driver X assured the shoulder strap was secured and they went to appointments. The Administrator said when Resident #39 returned to the facility a nurse assessed him for injuries and Resident #39 said he was not injured. The Administrator said the nurse notified Resident #39's Physician and family of incident. The Administrator said x-rays were ordered and performed, no abnormal findings were noted. The Administrator said Resident #39 told staff his back hurt, but he had a history of back pain. The Administrator said Resident #39 had pain medication for back pain and the facility kept the pain controlled. The Administrator said staff checked on Resident #14 and got her statement of the incident. The Administrator said Resident #14's statement collaborated with Driver X's statement on the incident. The Administrator said the facility suspended Driver X while the investigation was pending. The Administrator said Driver X and three other staff members were certified to drive the facility van were in serviced on if an incident or accident happened while on a transport, they were to notify the facility as soon as possible or local police if necessary. The Administrator said the facility terminated Driver X, because the incident with Resident #39 and Driver X had incident in November 2023. The Administrator said Driver X was in facility van and was hit from behind. The Administrator said the driver of the car that hit the facility van ran and Driver X did not notify the facility or local police and left the scene to return to the facility. The Administrator said the facility in-serviced Driver X after an incident or accident to notify the facility, but he did not. The Administrator said her expectation was for Driver X to stop and notify the facility or 911 for assistance to ensure Resident #39 was able to be moved. The Administrator said Driver X did not have the credentials to make the decision to move Resident #39. The Administrator said Driver X admitted he felt rushed, Resident #39 was hard to deal with and he should have notified the facility of the incident when it happened. The Administrator said Driver X's defense for no notification to the facility was he was tried to make Resident #14 and Resident #39 to their appointments on time. The Administrator said the incident occurred and Driver X's failure could have caused more than potential harm to Resident #39. Record review of in-services and staff signatures dated 4/1/24, on Properly securing passenger for transport, loading and unloading passenger. Record review of van Orientation Checklists, dated on 4/1/24, for Driver X. These 3 record reviews moved up and documented in section 1 with the info about the van driver incident. (That is a quote of what they said.) Record review of the Maintenance Policy & Procedure Manual, dated 03/11/13, reflected . In order for our Residents to maintain the highest practical, physical, mental and psychological wellbeing it is the policy of this facility vehicle (Van) for residents who because of medical or special needs, require transportation. Record review of the, undated, Van driver job Description reflected .The overall purpose of the Van Driver position is to transport Facility Residents to prearranged physician and/ or dialysis appointments and/or to transport Residents on scheduled outings arranged by the Facility. Record review of Transportation Policy and Procedure for Center-Based Vehicle, dated 11/16/2023, reflected for our Residents to maintain the highest practical, physical, mental and psychological wellbeing it is the policy of this facility vehicle (Van) for residents who because of medical or special needs, require transportation. 2. Record review of Resident #9's face sheet, dated 4/16/2024, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included: type 2 diabetes mellitus with hyperglycemia (high blood sugar), unspecified fall and morbid obesity (severely overweight). Record review of Resident #9's quarterly MDS, dated [DATE], indicated Resident #9 had clear speech, sometimes made self-understood, and sometimes had the ability to understand others. Resident #9's BIMS was 10, which indicated mild cognitive impairment. Resident #9 was totally dependent with bed mobility, and transfers. Record review of Resident #9's care plan, dated 11/10/2021, indicated Resident #9 had an ADL self-care deficit with an intervention: Transfers: staff x 2 hoyer lift. Resident #9 had the potential for falls with interventions that included: Anticipate and meet the resident's needs .Follow facility fall protocol. During an observation on 4/15/2024 at 11:07 AM, CNA H and LVN I placed a lift sling under Resident #9 while she was lying in bed. CNA H pushed the Hoyer lift under the bed and CNA H and LVN I attached the straps of the sling onto the Hoyer lift bar. CNA H raised the Hoyer lift until Resident #9 was lifted off the bed. CNA H and LVN I turned the Hoyer lift without opening the Hoyer lift legs to the widest position until the Hoyer lift was facing the resident's wheelchair. LVN I then opened the Hoyer lift legs to the widest position and CNA H placed the wheelchair between the opened Hoyer lift legs. CNA H then braced her body against the wall in Resident #9's room and tilted the resident's wheelchair all the way back where it was on the anti-tip bars, all 4 wheels were off the floor and the back of the wheelchair was resting on CNA H's thighs. LVN I began lowering the Hoyer lift as CNA H was pulling the sling and Resident #9 to guide her placement in the wheel chair. Once Resident #9 was in the wheelchair CNA H then grabbed the wheelchair handles that were resting on her thighs and slowly pulled the wheelchair back into an upright position. CNA H and LVN I removed the sling straps from the Hoyer lift bar. During an attempted interview on 4/15/2024 at 11:35 AM revealed Resident #9 was not able to answer questions due to cognitive impairment. During an interview on 4/15/2024 at 11:22 AM, CNA H said she did not feel the transfer was a safe transfer. She said it was probably not the safest way to do the transfer. She said she should have gone and asked therapy to help with a safe transfer for the resident. She said the resident could have fallen out of the w/c on top of her on the floor and got hurt. During an interview on 4/15/2024 at 11:28 AM, LVN I said she did not feel like the transfer was a safe transfer. She said the legs on the Hoyer lift should have been opened when the resident was raised in the Hoyer lift. She said it was not safe when CNA H tipped the wheelchair all the way back on the anti-tip bars and braced herself against the wall with the wheelchair in her lap. She said she thought maybe the staff were trained in a new way that she was not aware of to transfer Resident #9. She said she should have stopped the transfer at that time. She said Resident #9 could have fallen on the floor or on top of the CNA H and either one of them could have been hurt. During an interview on 4/17/2024 at 10:51 AM, OT O said was is okay for the chair to be pulled back a little bit but once the anti-tip bars touch the floor that's where it should stop. She said the lift legs should have been opened earlier as soon as it was safe. She said if transfers were not performed correctly the resident was at risk of flipping back in the wheelchair and falling. During an interview on 4/17/2024 at 11:04 AM, PTA N said she had worked at the facility for 1 1/2 years. She said in this facility therapy did not usually do Hoyer lift transfers due to it not being a skilled task. She said in her opinion the lift legs should be open before the resident was connected to the Hoyer lift. She said the legs being opened stabilized the Hoyer lift and was safer for the resident. She said the anti-tippers on the back of wheelchairs were to keep the resident from tipping the chair backwards. She said the anti-tippers were not made to support the weight of a resident. She said the anti-tippers could break and cause harm or injury to the resident. During an interview on 4/17/2024 at 11:25 AM, ADON P said typically the Hoyer lift legs were closed while the Hoyer lift was under the bed, and prior to the resident being moved in the Hoyer lift, the Hoyer lift legs should be opened. She said no CNA should ever pull a resident back in the wheelchair to where only the anti-tipping bars were touching the floor. She said using Hoyer lifts or wheelchairs incorrectly could cause injury to the resident or staff. During an interview on 4/17/2024 at 11:32 AM, the DON said it depended on the space in a resident's room as to when the Hoyer lift legs were opened. She said if there was space, they should be opened as soon as the lift was pulled out from under the bed. She said it was not possible to open the legs of the lift while the lift was still under the bed. She said a resident's wheelchair should never be pulled back on the anti-tip bars while transferring a resident into the wheelchair. She said incorrectly done transfers could cause staff and residents to get hurt. During an interview on 04/17/24 at 11:48 AM, the Administrator said the lift legs should be opened as soon as there was enough space to open the legs. She said she did not see how it was possible for a wheelchair to be tipped back on the anti-tipping bars while transferring a resident. She said the anti-tip bars could break, and the resident could fall and get hurt. Record review of the facility's, undated, policy titled Hydraulic Lift (Hoyer Lift) reflected the purpose: to enable one individual to lift and move a resident safely, with as little effort as possible .open lift to the widest point and set brakes . 13. Position wheelchair and lock brakes. Swing resident's feet off bed. When resident has been lifted clear of bed, grasp bar and move to chair . 14. Push gently on knees as resident is being lowered into chair to correct position and maintain balance. Lower resident slowly. Record review of the, undated, manufacturer's instructions for the Span F600B mechanical lift reflected: The F600B is intended to be used for transfers of the patient in and out of bed, their wheelchair, to and from the commode, or any other type of surface. Page 13 of the manufacturer's instructions indicated: Operating Instructions .Preparation Before Lifting .Widen the base and disengage the [NAME] brakes.

Based on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 18 residents (Resident # 28 and Resident # 42) reviewed for resident rights. 1. The facility failed to ensure Resident #28's dignity when dining while the Nurse Practitioner assessed the resident's foot callous at the dining room table while the resident was eating with other residents eating . 2. The facility failed to ensure Resident #42 had toilet paper, paper towels and soap in dispenser for personal hygiene use. These failures could place residents at risk for a decreased quality of life, decreased self-esteem and increase anxiety. Findings include: 1. Record review of Resident #28's face sheet, dated 04/17/2024, indicated an [AGE] year-old female who was admitted on [DATE]. Resident #28 had diagnoses which included Dementia with other behavioral disturbances (general term for loss of memory, language, problem solving and thinking was severe enough to interfere with daily life), Cognitive communication deficit (problems with communicating), Depression (loss of pleasure or interest in activities for long periods of time) and Anxiety (feeling of fear, dread, and uneasiness). Record review of the MDS Quarterly Assessment, dated 2/22/2024, indicated Resident #28 was sometimes understood and sometimes understood others. Resident #28 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #28 required supervision for most ADL's. Record review of Resident #28's care plan, revised on 11/6/2023, indicated Resident #28 was at risk for behavioral problems. There was an intervention to intervene as necessary to protect the rights and safety of others by removing resident to an alternative location when needed to protect the rights and safety of others. During an observation on 4/16/2024 at 12:18 p.m. revealed, Resident #28 was sitting at a table with all memory care residents in the dining area. The Nurse Practicioner was knelt beside Resident #28 assessing her right foot at the dinner table while other residents looked on. The Nurse Practitioner was spreading each toe out inspecting Resident #28 right foot and said she did not have a wound but a large callous. A resident to the right of Resident #28 was observing during the assessment while eating lunch. During an interview on 4/16/2024 at 12:30 p.m., the Nurse Practitioner said it was not usual practice for her to assess her residents while they were eating. She stated she usually had the resident return to their room, and it depended on the situation. The Nurse Practitioner said she was going to make a referral for the resident to see the podiatrist . There were approximately 10-12 residents in the dining room at the time of the assessment. During an interview on 4/17/2024 at 11:13 a.m., LVN D said it was not appropriate for a nurse, Nurse Practitioner or Physician to remove a resident's socks or shoes to assess their feet while at the dinner table. The resident could feel embarrassed. LVN D said he had not observed any staff assessing residents at mealtimes . During an interview on 4/17/2024 at 11:26 a.m., LVN E said it would be a dignity issue to assess a resident's feet while eating at the table with other residents. LVN E said she would offer to take the residents to their room to be assessed privately even on the memory unit. LVN E said if she observed a clinician such as a doctor or Nurse Practitioner performing an assessment in a public area, she would report to management. LVN E said a resident could feel humiliated . During an interview on 4/17/2024 at 11:34 a.m., the ADON said she would wait after the meal was completed to assess a resident. The ADON said she could see where assessing a resident while they were eating would make them feel uncomfortable. The ADON said she would check the resident's cognitive level. The ADON said it could make another resident wonder why they were performing an assessment at the table and may not want to observe. The ADON said she expected staff to perform assessments and care in a more private room area where other residents were not around. During an interview on 4/17/2024, the DON said it depended on where you were and if the resident wore shoes. The DON said the resident initiated the encounter with the Nurse Practitioner and allowed the Nurse Practitioner to observe her foot at the dining table while she was eating. The DON said she did not have an issue due to the resident having a mentation that allowed her to know what was going on. The DON said there was 100% confusion on the memory care unit. The DON said she would assume the Nurse Practitioner would explain to the family what was going on if the family came in the facility. The DON said Resident #28 was willing to allow the Nurse Practitioner to observe her at the time and stuck her foot up. The DON said all residents with memory issues should be treated with dignity and respect but that was not what happened, and she did not feel it was a dignity issue with Resident #28. During an interview on 4/17/2024, the ADM said resident's care was based on the resident's particular need. The ADM said the Nurse Practitioner making rounds should not have assessed the resident's feet during a meal. The ADM said the resident should have privacy when assessing a resident's skin or foot would not need to take place during their meal. The ADM said she would offer the resident go to another room, attempt to move resident to another area, or come back at another time if a resident offered to be assessed at the dining table. The ADM said she would redirect the resident and wait till after meal. The ADM said she would want to base care on the resident's memory needs. 2. Record review of Resident #42's face sheet, dated 4/17/2024, indicated Resident #42 was a [AGE] year-old female who was admitted on [DATE]. Resident #42 had diagnoses which included Hyperlipidemia (a condition in which there are high levels of fat particles in the blood), Dementia (general term for loss of memory, language, problem solving and thinking was severe enough to interfere with daily life), anxiety ((feeling of fear, dread, and uneasiness) and ulcerative (chronic) pancolitis with other complications (form of inflammatory bowel disease characterized by widespread inflammation affecting the entire colon). Record review of the MDS Optional State Assessment, dated 1/11/2024, indicated Resident #42 was usually understood and sometimes understood others. Resident #42 had a BIMS score of 3, which indicated severe cognitive impairment. Resident #42 required limited assistance with toileting. Record review of Resident #42's care plan, revised on 2/26/2024, indicated Resident #42 was at risk for behavioral problems and incontinence of bowel and bladder. There was an intervention to assess and anticipate resident's needs such as food, thirst, toileting needs, comfort level, body positioning and pain. During an observation on 4/15/2024 at 9:47 a.m., Resident #42 bathroom had a brown residue in the sink, no paper towels, no soap in the dispenser and no toilet paper. Resident #42 said when she urinated, she would drip dry and she said if she had a bowel movement, she would use paper towels from the dining room she collected during meals from her tray. Resident #42 pulled open her top drawer of her dresser cabinet and she showed napkins from her dining room tray she had stacked in her dresser drawer. Resident #42 said she ran her hands under water in her bathroom sink and did not use soap. Resident #42 said the facility never had soap in her bathroom . During an interview on 4/17/2024 at 9:25 a.m., CNA B said when she came in the morning, she would get the residents up for the day. CNA B said she would gather the resident's clothes and take them to the shower room for the residents with a scheduled shower. CNA B said she would get the residents ready for their day by changing their briefs if they were wet, performed perineal -care to freshen them up, brush hair, brush teeth, and wash their face. CNA B said there were residents who could go to the bathroom on their own. CNA B said the facility did not keep toilet paper in the resident's room because residents would wipe and clog the toilets. CNA B could not identify what the residents used to get clean after toileting. CNA B could not identify residents who washed their hands after leaving their bathroom. CNA B said residents who did not have proper hand hygiene would be at risk for infection if they got feces on their hands and then in their mouth. CNA B said she did touch doors and other objects the residents touched which could cause staff to become sick and affect others around her. CNA B said the staff checked the rooms to see if they needed to be cleaned and CNA B said she would take care of it if she could. CNA B said the residents did not use hand sanitizer while on the memory unit. During an interview on 4/17/2024 at 9:40 a.m., CNA A said she would get the residents up before breakfast and took them down to the shower room to get them cleaned up and dressed by brushing their teeth, washing their face and hands. CNA A said the residents did not have wash cloths or soap in their rooms. CNA A said everyone should have soap, but residents would put it in their hair. CNA A said the housekeeper supplied the toilet paper. CNA A said the housekeeper knew which resident rooms to put toilet paper in. CNA A said she checked the residents every 2 hours to ensure they were clean. CNA A said she was not sure how the residents were wiping because the residents must ask staff, and staff brought them wipes. CNA A said if a resident did not have access to toilet paper, soap and paper towels, it would be nasty, and they could get an infection. CNA A said not being cleaned properly could place the residents at risk for skin issues or cause their bottom to get red. CNA A said staff were at risk for infection if objects were touched by residents who had not washed their hands, then staff touched objects the residents touched. CNA A said the majority of the residents did need supplies in their room. During an interview on 4/17/2024 at 9:56 a.m., LVN E said residents started their day getting up and sitting in the main room or going to the shower room. LVN E said residents were scheduled for a shower, they would go to the shower room. LVN E said the staff performed morning care for all residents. LVN E said the evening shift would get up 6 residents to receive morning care. LVN E said there were certain residents who received paper towels and toilet paper. LVN E said she was not sure how the residents washed their hands. LVN E said she was unaware residents did not have soap in their dispenser and there was no way to determine who had washed their hands. LVN E said residents and other staff could get contaminated and become sick. LVN E said she expected resident's hands to be washed prior to meals and between meals as needed. During an interview on 4/17/2024 at 10:11 a.m., Hospitality Aid F said she was the housekeeper for Hall 3 and the Memory care unit. Hospitality Aid F said she went in the morning and emptied the trash out of the rooms and checked the paper towels, toilet paper and soap dispensers. Hospitality Aid F said she was instructed by her supervisor not to place paper towels and toilet paper on the memory unit due to residents clogging the toilets. Hospitality Aid F said Aides told her not to put soap in the dispenser in the resident's rooms. She said residents not washing their hands could contaminate other surfaces other residents and staff touched placing them at risk for infection. Hospitality Aide F said this was the resident's home and they should have access to toilet paper, paper towels and soap. During an interview on 4/17/2024 at 10:39 a.m., Hospitality Aide G said she was the supervisor for housekeeping. She said toilet paper and paper towels were not being placed in the resident's room. Hospitality Aid G said the residents were to use the dining room bathroom and shower room bathroom to wash their hands and use the bathroom. Hospitality Aide G said residents would put paper towels and toilet paper in their toilet. Hospitality Aide G said she was not sure which residents were independent with toileting. She said the facility was no longer putting soap in the dispensers in the resident's rooms on the memory hall due to residents putting soap on their face and hands. Hospitality Aide G said upper department heads made the decision not to put paper products in the resident's bathrooms and was told the staff would be responsible for washing and tending to the resident hygiene. Hospitality Aide G said handwashing was important for all residents and staff. During an interview on 4/17/2024 at 11:34 a.m., ADON P said residents on the memory care unit did not have toilet paper in their rooms due to residents stopping up toilets, sinks and stuffing paper towels in the sinks which caused water to overflow. ADON P said the staff on the unit were responsible for washing all the resident's hands in the morning before breakfast and changed residents to prepare them for the day. ADON P said the staff kept rounding and identified residents who needed to be changed. ADON P said she was not aware of who was washing and getting personal care completed after residents toileted. ADON P said she would not want residents using a sock or drip dry after toileting. During an interview on 4/17/2024 at 11:45 a.m., the DON said the facility staff talked about the toilet paper, paper towels in the past due to plumbing issues from resident's stuffing things in the toilet. The DON said the facility was going to take another look at the issue. The DON said she observed staff, and they made sure the residents had hand sanitizer. The DON said she discussed with staff to make more frequent rounds to make sure the residents were not taking off their brief and placing them in drawers or under the mattress. The DON said the facility needed to do a case-by-case evaluation. During an interview on 4/17/2024 at 1:14 PM, the ADM said the residents on the memory unit were taking paper towels and toilet paper and sticking them in their own orifices. The ADM said paper towels, toilet paper and soap were not in the rooms on the memory hall. The ADM said there was not a policy just concern for the well-being of the residents. The ADM said the facility had plumbing issues related to the residents on the memory unit stuffing paper towels and toilet paper down the sink. The ADM said the unit staff had access to the main bathroom on the hall and the shower room they could take residents to use during the day. The ADM said the hand sanitizers and soap were removed due to resident putting it in their drinks. The ADM said the facility was re-evaluating and seeking alternative options for residents to ensure proper hygiene was achieved. Record review of the facility policy, dated 2/16/2020, titled Promoting/Maintaining Resident Dignity, reflected . It is practice of the facility to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect . What is dignity .innate quality of being a human .a person's self-esteem .Process: 1. All staff members are involved in providing care to residents to promote and maintain resident dignity .2. During interactions with residents, staff must report, document and act upon information regarding a resident preference .6. Respond to request for assistance in a timely manner which include but not limited to responding to call lights, toileting/incontinence, and personal needs .12. Maintain resident privacy Record review of the facility's, undated and untitled, policy reflected Standard Bathroom Cleaning indicated .daily cleaning of the bathrooms, restrooms and tub-shower rooms help provide a sanitary environment, prevent odors, control infectious material, and prolong the useful life of the equipment .Procedure .empty and sanitize toilet, using bowl brush daily .add bowl cleaner one time per week, more if necessary

Based on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 6 (Resident #33) residents reviewed for environment. 1. The facility failed to ensure Resident #33's bathroom sink was free of brown substances. 2. The facility failed to ensure soiled briefs were removed from Resident #33's trash can. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth. Findings include: Record review of Resident #33's, undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #33 had diagnoses which included CVA (damage to the brain from interruption of its blood supply), hypertension (high blood pressure) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Record review Resident #33's quarterly MDS assessment, dated 02/14/2024, reflected Resident #33 had a BIMS of 02, which indicated severe cognitive impairment. Resident #33 had no behaviors, was frequently incontinent of bowel and bladder and was dependent on staff for personal hygiene and toileting. Record review of Resident #33's care plan indicated no care plans for behaviors. The care plan, dated 02/14/2024, indicated Resident #33 was frequently incontinent of bowel and bladder and required assistance of 1 staff member for incontinent care. During an observation on 04/15/2024 at 9:30 a.m. revealed the bathroom of Resident #33 was noted to have a brown foul-smelling substance smeared throughout the sink. There were no paper towels and no soap in the bathroom. There was a soiled brief in the trash can next to the toilet. The mirror was covered in a white film. During an observation on 04/16/2024 at 10:20 a.m. revealed the bathroom of Resident #33 continued to have a brown foul-smelling substance smeared throughout the sink. There were still no paper towels or soap in the bathroom. During an interview on 04/15/2024 at 10:00 a.m., the family member of Resident #33 stated the only complaint they had about Resident #33's care was the bathroom was always dirty and looked like a rundown truck stop bathroom. The family member stated there was rarely any soap or paper towels and she liked to wash Resident #33's hands prior to her eating meals. The family member of Resident #33 stated she was unsure if it was Resident #33 or the resident next door who shared the bathroom with her who was smearing what appeared to be feces on the lavatory and mirror. She stated she felt like housekeeping should be cleaning those areas more frequently for sanitation reasons. She also stated Resident #33 would have been devastated prior to her illness to have a bathroom in the state of filth her bathroom was currently in. During an interview on 04/17/2024 at 11:00 a.m., CNA A stated there were several resident rooms and bathrooms that needed to be deep cleaned. CNA A stated the housekeepers were supposed to come and clean all the rooms and bathrooms each day. She stated the housekeepers were supposed to come back multiple times per day and clean, but they usually only came once a day. CNA A stated over the last 7 days she worked, today was the first day staff ensured all the soap dispenses and toilet paper holders were full for all residents. CNA A stated she alerted housekeeping when she saw them when a room was in need of cleaning. During an interview on 04/17/2024 at 11:30 a.m., Housekeeper Y stated it was her job when she was assigned to the memory care unit to ensure all the rooms and bathrooms were cleaned daily. She stated she came back to the memory care after each meal and cleaned the dining rooms. She stated she was unaware of why no one had cleaned Resident #33's bathroom on 04/15/2024 and 04/16/2024. She stated it was the responsibility of the housekeeper working the memory care unit to make sure it was done. She stated the Housekeeping Supervisor had their own area to clean and was not always available to check behind the housekeeping staff. During an interview on 04/17/2024 at 12:45 p.m., the ADM stated she expected the housekeeping policy to be followed by all housekeepers in each area of the building. The ADM stated there were a few residents on the memory care unit that were not provided soap in their rooms but were encouraged by the staff to wash their hands in the shower room for safety of the residents. The ADM viewed Resident #33's bathroom and stated the condition of the Resident #33's bathroom was unacceptable. The ADM stated the IDT would brainstorm as a team on a way to ensure all residents had access to a clean restroom and ways to wash their hands after using the bathroom and before meals. Record review of the facility's, undated, policy titled Resident Room Cleaning indicated, Daily cleaning of the bathrooms, restrooms and tub-shower rooms helps to provide a sanitary environment, prevent odors, control infectious material, and prolong the useful life of the equipment, paint, and floor finish . Clean and dust all fixtures, use high duster on any hard-to-reach areas. Use cleanser on sink for any stains. Shine chrome with damp cloth and mild cleaning solution. Use glass cleaner on mirrors.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission and included the minimum healthcare information necessary to properly care for a resident for 2 of 7 residents (Resident #181 and Resident #182) reviewed for care plans. The facility failed to develop and implement a baseline care plan within 48 hours of admission for Residents #181 and #182. This failure could place residents at risk of not receiving care and services to meet their needs. Findings include: 1. Record review of Resident #181's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #181 had diagnoses which included traumatic subdural hematoma (bleeding fills the brain area very rapidly, compressing brain tissue), dementia (progressive disease that destroys memory and other important mental functions) and anxiety. Record review of an incomplete admission MDS assessment, dated 04/15/2024, reflected Resident #181 had a BIMS of 02, which indicated severe cognitive impairment. The discharge plan for Resident #181 was to remain in the facility long-term. Record review of the baseline care for Resident #181 reflected no baseline care plan was initiated prior to survey intervention. 2. Record review of Resident #182's, undated, face sheet reflected Resident #182 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #182had diagnoses which included dementia (progressive disease that destroys memory and other important mental functions), hypertension (high-blood pressure) and hypothyroidism (progressive disease that destroys memory and other important mental functions). Record review of an incomplete admission MDS assessment, dated 04/22/2024, reflected an incomplete MDS in progress. Record review of the baseline care plan for Resident #182 reflected no baseline care plan was initiated prior to survey intervention. During an interview on 04/17/2024 at 12:30 p.m., the DON stated the baseline care plan was an interdisciplinary team responsibility. The interdisciplinary team consisted of the Social Worker, Activities Department, the nurse, therapy and dietary department. The DON stated a meeting was to be scheduled by the Social Worker with the resident and their family and each department had a section to complete. The DON was not aware the baseline care plan was to be completed within 48 hours of admission. The DON stated the baseline care plans for Residents #181 and #182 were not completed until 04/16/2024 after surveyor intervention. The DON stated the facility completed an in-service about timeliness of the completion of baseline care plans on 04/12/2024 with all IDT members that included the timeline for completion of the baseline care plan. The DON stated the baseline care plan acted as a set of instructions to follow for the resident's care. The DON stated not having a baseline care plan would make it hard for staff to give accurate care to the individual needs of each resident. During an interview on 04/17/2024 at 12:45 p.m., the Administrator stated she expected the staff members to do their part to complete the baseline care plans. She felt baseline care plans were important information to help the staff care for each resident. The ADM stated it was hard to care for new residents without having an outline and the baseline care plan gave the staff an outline until the MDS was completed and the comprehensive care plan was created to guide resident care. Record review of an in-service, dated 04/12/2024, signed by the Dietary Manager, Activities Director, Social Worker, and therapy department indicated the facility must have a baseline care plan meeting within 48 hours of the admission of the resident and implement a baseline care plan for all newly admitted residents. Record review of the facility policy, dated 11/08/2026, titled Baseline Care Plan, indicated the baseline care plans are developed and implemented within 48 hours of a resident's new admission Baseline care plans are developed by the Registered Nurses and other healthcare team members.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 20 residents (Resident #20) reviewed for care plans. The facility failed to revise Resident #20's care plan to reflect his choice to be a DNR. This failure could place residents at risk for not receiving appropriate care and interventions to meet their current choices and needs. Findings include: Record review of Resident #20's, undated, face sheet indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Record review of Resident #20's physician's orders, dated [DATE] , indicated Resident #20 had diagnoses which included: Parkinson's Disease (a disorder of the nervous system that affects movement, often including tremors), Cerebrovascular Disease (affects blood flow to the brain) and dementia (persistent loss of intellectual functioning). Record review of Resident #20's physician's order, dated [DATE], indicated Resident #20 was a DNR. Record review of Resident #20's OOH-DNR indicated it was signed on [DATE] by Resident #20's family member. Record review of the care plan, dated [DATE], indicated Resident #20 had impaired cognition with a risk for further decline and indicated he was a full code. Resident has physician's orders that include a status of full code. The goal indicated staff would administer CPR if resident had an arrest. The interventions were to ensure the full code order was on the chart and begin CPR after absence of vital signs, call 911, notify physician, and notify family/responsible party. Record review of the admission MDS, dated [DATE], indicated Resident #20 had clear speech, was sometimes understood by others, and sometimes understood others. Resident #20 had a BIMS score of 6, which indicated severe cognitive impairment. He had inattention that was continuously present. Record review of the care plan on [DATE] at 11:05 AM indicated Resident #20 was full code. Record review of the physician's orders, dated [DATE], indicated Resident #20 was a DNR. The DNR was ordered by the physician on [DATE]. Record review of an OOH-DNR for Resident #20 was dated [DATE] . During an interview on [DATE] at 11:39 AM, MDS Q said the care plan was an IDT approach. She said different staff were responsible for the care plan in the different disciplines put different things in the care plan. She said the person responsible for the code status of a resident was the SW . During an interview and record review on [DATE] at 11:41 AM, the DON and the State Surveyor looked at Resident #20's care plan. The DON agreed the care plan indicated the resident was full code. She and she looked at his DNR, dated [DATE], and she stated she knew he was a DNR. She said his care plan should have been changed and updated to indicate he was a DNR, and it was not. She said his most recent care plan meeting was Wednesday [DATE] and the next day, [DATE] his family member came in and signed a DNR with the SW. She said the SW should have updated the care plan when she got the DNR paperwork. The SW and the DON reviewed the resident's physician's orders for a DNR, dated [DATE] and an OOH-DNR also dated [DATE]. She said the process was, whoever received the DNR paperwork should change the care plan. She said the SW did not change the care plan and it was her responsibility. She said ultimately, she was responsible for the care plan being updated to reflect the current status of Resident #20 because she was the DON. During an interview on [DATE] at 12:34 PM, the DON said the advance directive policy indicated the SW should document all DNR's. She said the SW knew it was her responsibility, and it was she who met with the family to discuss and complete the DNR. During an interview on [DATE] at 2:39 PM, the SW said she met with Resident #20's family to do the DNR on [DATE]. She said she was supposed to update the care plan but got busy and did not do it. She said it was her responsibility to update the care plan and she should have done it . During an interview on [DATE] at 12:07 PM, LVN R said the importance of code status on the care plan was for nurses to know whether or not to perform CPR on a resident. She said she would not want to do CPR if a resident was a DNR because it could cause a poor quality of life. She said you would certainly want to do CPR on a resident who had chosen a full code status. She said nurses had to know whether a resident was a full code or a DNR and their information had to be documented correctly. She said if staff did CPR on a resident who chose a DNR, that resident could end up on a tracheostomy (surgically created hole in the neck to allow air into the lungs) or life support. She said a DNR or a full code was the resident/family's choice to make. She said resident choices were very important. She said the SW was responsible for making sure the code status was documented correctly on the care plan. During an interview on [DATE] at 12:14 PM, LVN S said code status was important. She said if a resident was a DNR and they gave that resident CPR and revived them, they could be in a lot of trouble. She said if a resident was a full code and they thought the resident was a DNR, and did not try to revive them the resident could die. She said they had to be sure all information was in the care plan correctly. She said the residents choice was very important. She said the SW was responsible for making sure a resident's code status was correct in the care plan. During an interview on [DATE] at 12:23 PM, ADON P said the resident's code status on the care plan was how they determined whether or not to initiate CPR for a resident. She said it was very important for the information to be correct regarding the resident's choices. She said if a resident was a DNR and they did CPR, it could cause harm to the resident because they could have broken bones during CPR, caused a poor quality of life, caused the resident's family to be upset, not acknowledged the resident's wishes or their right to choose. ADON P said if it was the other way around, and a resident was a full code and did not get CPR, they could die. She said the family would be very upset if the facility did not try to save them. During an interview on [DATE] at 1:11 PM, the DON said she expected the SW or the licensed staff who received DNR paperwork to update the care plan. She said she thought Resident #20's care plan not being updated with the new DNR order was an oversite on the part of the SW. She said she expected the care plan to be updated with the resident's wishes regarding a full code or a DNR. The DON said it would be a big problem if a resident who was a DNR was given CPR because that was a dignity issue and not the resident's wishes. She said that could cause the resident depression and a poor quality of life. She said giving a DNR resident CPR would be the worst scenario ever. She said if you did not give CPR to a resident who was a full code it could cause a resident to die before they should and not attempting to save their life. She said that was playing with someone's life. She said if the wishes of the resident were not followed it could also cause the family to be grievous. During an interview on [DATE] at 1:41 PM, the ADM said she expected the care plan to be correct regarding a resident's code status. She said the SW was responsible for making sure the care plan was updated to reflect the correct code status. She said the SW's responsibility for the care plan was the code status. She said regarding Resident #20's incorrect care plan (which indicated he was a full code when he was a DNR) that could have caused him to get CPR when that was against his wishes and it could be a dignity issue. She said they had a code book that ADON P updated with new information and staff could look in the book to see who was a DNR and who was a full code. She said she did not know if Resident #20's code status was updated in the Code Book . She said if a resident was a full code and incorrectly marked as a DNR the resident could die when they should not have, and that could cause legal issues. She said resident choices were important. During an interview and record review on [DATE] at 1:46 PM, ADON P showed the State Surveyor the Code Book which included a DNR for Resident #20 and a copy of his OOH-DNR dated [DATE]. She said she put the information for Resident #20's code status in the Code Book but did not remember when. Record review of an Advance Directives/Advance Care Planning Policy, dated ,d+[DATE], revised ,d+[DATE], and ,d+[DATE], indicated: Policy It is the policy of this facility to recognize two fundamental rights of a person; the right to live and to continue treatment and the right to refuse or terminate unwanted treatment. This facility will honor a resident's wished and advanced directives pertaining to his/her own medical treatment, including wishes to withhold treatment . In the absence of the Social Worker the Administrator appoints a staff member to assume the responsibility for advance directives and advanced care planning. .8.Social Service communicates to a nursing a residents advanced directive/code status implementation or changes. Record review of the Comprehensive Care Plans Policy, dated [DATE], indicated: Policy It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. .3.The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. b. Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment .

Based on observation, interview, and record review the facility failed to ensure an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections were maintained for 4 of 6 residents reviewed for communicable disease (Resident #'s 41, 45, 54, and 74) and 1 of 12 months reviewed for infection control tracking and trending (January 2023). The facility failed to initiate transmission-based precautions with the onset of the diagnosis of shingles F(painful rash with blisters) for Resident #45. The facility failed to initiate transmission-based precautions with the onset of and ongoing of diarrhea for Resident #74. CNA C failed to change gloves and washing her hands during incontinent care and prior to exiting Resident #74's room. The facility failed to separate the linen from the rooms with communicable infections from the general linen for Resident #'s 45 and 74. The facility failed to test Resident #41 for Clostridium Difficile (Inflammation of the colon caused by bacteria) when he had chronic diarrhea. The facility failed to document tracking and trending of infection and antibiotic use for January of 2023. LVN F failed to remove soiled gloves after obtaining Resident #50's blood sugar and he failed to perform hand hygiene before donning clean gloves. The facility failed to ensure LVN D did not use a dirty cloth to clean Resident #54's catheter during catheter care. The Infection Preventionist allowed RN G to work with a temperature of 102.2. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of widespread with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for being exposed to shingles, and diarrhea related to clostridium difficile (bacteria causing diarrhea to life-threatening damage to the colon. Findings included: 1) Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. Record review of the consolidated physician's orders dated 02/01/2023 indicated Resident #45 was did not indicated contact isolation was ordered. Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023. Record review of the comprehensive care plan dated 11/09/2022 failed to indicate Resident #45 had shingles involving his face, and right eye. The comprehensive care plan did not address isolation precautions. Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understands. Resident #45 required large print to read. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Resident #45 was incontinent of bowel and bladder. Record review of Resident #45's February 2023 electronic medication record indicated he received Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023 after surveyor intervention. Record review of a nursing note dated 02/20/2023 at 10:12 a.m., LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye. Record review of a nursing note dated 02/20/2023 at 10:54 a.m., LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and check a HSV ig M level. Record review of a nursing note dated 02/20/2023 at 8:34 p.m., LVN M wrote monitoring for edema every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with labs ordered. Record review of a nursing note dated 02/21/2023 at 1:03 a.m., LVN M wrote right side of Resident #45's face/eye continues with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's son would like to see if the facility ophthalmologist could see resident #45 instead of having to be transferred out of the facility. Record review of a nursing note dated 02/22/2023 at 9:08 a.m., LVN O indicated Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes. During an observation on 02/27/2023 at 12:17 p.m., Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye is scabbed closed he could not open it on command. There were no isolation precautions posted on Resident #45's room. During an interview on 02/27/2023 at 12:26 p.m., CNA N said Resident #45 had not been on any isolation precautions. CNA N said she regularly cares for Resident #45 and has floated to other halls to help. CNA N said she had questioned the DON as to why Resident #45 was not on any type of isolation because CNA N said shingles were contagious. CNA N said she floated to work on other halls. CNA N said Resident #45 did not eat any of his noon meal because he was hurting from the shingles. During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation. The DON said the nurses did not make her aware of a case of shingles. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility eye physician had already made rounds around February 9th or the 10th. The DON said she had not contacted the mobile eye physician or the son with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles as missed because she said the nurse managers log the infections and review the orders in morning meeting. Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a tramadol 50 milligram tablet for pain. During an interview on 02/28/2023 at 3:11 p.m., LVN P said CNA N asked why Resident #45 was not on isolation if he had shingles. LVN P said she asked the DON to explain why Resident #45 was being treated for shingles why was he not on isolation. LVN P said the DON said Resident #45 should have been on isolation. LVN P said she had worked February 19, 2023, through February 23, 2023. LVN P said Resident #45's eye was much worse. LVN P said no one had contacted the physician for Resident #45's worsening shingles. LVN P said Resident #45 had not been on isolation for the shingles, but he should have been to prevent the spread to other residents. During an interview on 02/28/2023 at 3:26 p.m., the medical director said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The medical director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The medical director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. During an observation and interview on 02/28/2023 at 3:45 p.m., LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Resident #45 now had isolation signs and PPE outside of the room. Record review of a nurses note dated 02/28/2023 at 12:57 p.m., Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's son was notified of the appointment related to shingles to the right eye. Record review of a nurse note dated 02/28/2023 at 8:03 p.m., the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM result of 0.66 and the new order received from the physician for Clindamycin 300 mg one three times and day and discontinue the acyclovir. Record review of a nurse note dated 02/28/2022 at 8:21 p.m., the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. Record review of a nurse note dated 02/28/2023 at 11:08 p.m., LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs. During an interview on 02/28/2023 at 8:55 a.m., the DON said the nurses did not realize Resident #45 required isolation for the shingles. The DON said Resident #45 should have been placed on contact isolation. During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. The Interim Administrator said shingles should be isolated in so not to spread to other residents. Record review of Resident #45's March 2023 electronic medical record indicated he had Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. Record review of a nurse note dated 03/01/2023 at 1:24 a.m., LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on ofloxacin and gentamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face with warm compresses used. During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. Resident #45's isolation precautions remained removed. During an interview on 03/01/2023 at 2:57 p.m., the medical director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test (antibody test for an infection) was negative. The medical director said she would complete a PCR HSV and VSV, and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV (testing for Herpes simplex virus and varicella simplex virus) because the test would be the most accurate test according to CDC recommendation. Record review of a nurses note dated 03/01/2023 at 6:10 p.m., LVN G placed Resident #45 back on isolation precautions further pending laboratory results. Record review of a nurses note dated 03/01/2023 at 6:24 p.m., ADON wrote she notified the Resident #45's son of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab (laboratory test for herpes simplex and varicella zoster), and reinstate the isolation precautions. Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room . Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated: *If the shingles affects your eye the doctor may cover your eye with a bandage *Infections of the eye and the skin around the eye were other health problems to treat *To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox. *Do not touch or scratch your rashes, if you do wash your hand afterwards. 2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., the ADON did not document Resident #74 had a recent history of Clostridium Difficile (infection of the colon from bacteria), diarrhea, or isolation precautions needed for on-going symptoms. Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but did not mention Clostridium Difficile or the need for isolation precautions. Record review of an Admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understands. The MDS indicated Resident #74 BIMS score was a 13 indicating cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. Record review of the February 2023 electronic medical record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medical record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post Clostridium Difficile . Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified. Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., LVN F documented Resident #74 was administered Lomotil for diarrhea. Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated Resident #74 was post Clostridium Difficile. Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., LVN R documented Resident #74 was post clostridium difficile. Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post clostridium difficile. Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea. Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated Resident #74 continued to have been monitored for diarrhea none noted on this shift. Record review of a nurses note dated 02/25/2023 at 6:41 a.m., LVN T indicated Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. Record review of a nurses note dated 02/25/2023 at 6:43 p.m., LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. During an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. CNA C opened Resident #74's brief, then wiped down the left side of her groin, and then across Resident #74's abdomen. CNA C removed her gloves and applied new gloves. Then CNA C took a roll of trash bags and unrolled a bag for use with the same gloves on. CNA C removed gloves and washed her hands. She returned to Resident #74 applied new gloves then removed the soiled brief. CNA C touched the wipe bag and obtained more wipes to cleanse Resident #74's buttocks. CNA C dropped the new brief on the floor. CNA C removed her soiled gloves, opened Resident #74's door and exited the room without washing her hands. CNA C returned to the room with a new brief. CNA C then washed her hands and laid the new brief on top of soiled linen she had rolled up underneath Resident #74. CNA C touched the foot of the bed and moved the bed out to walk around the bed to provide care. CNA C then walked to end of the bed, moved the bed back against the wall and continued with the care. CNA C removed her gloves and donned more gloves applying a barrier cream to Resident #74's buttocks. Resident #74's room had no isolation signs posted or PPE (personal protective equipment). Record review of a nurses note dated 02/27/2023 at 5:55 p.m., LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. During an interview on 02/28/2023 at 7:47 a.m., CNA C said she made a lot of mistakes with incontinent care. CNA C said she should have closed Resident #74's blind, should have washed hands with glove changes. CNA C said Resident #74 has had diarrhea since she admitted . During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The housekeeping supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said Resident #74 had Clostridium Difficile in the recent past. The Medical Director said she was not notified Resident #74 had on-going diarrhea since admission. The Medical Director said Resident #74 could be a carrier of Clostridium Difficile. The medical director said Resident #74 could still be infectious up to 6 weeks and should have been isolated to prevent the spread of a potential reinfection. The Medical Director said she was unaware Resident #74 was the neighbor to a resident who had non-Hodgkin's lymphoma (cancer of lymphatic system) and recently had a stem cell transplant. Record review of a nurses note dated 02/28/2023 at 4:00 p.m., the Marketer QQ documented the medical director was notified of ongoing loose stool and ongoing since admission. The note indicated Marketer QQ notified the medical director of the negative C-diff lab test prior to admission on 01/20/2023 and Resident #74 having Lomotil as needed. The note indicated a new order was received for Imodium 2 mg three times daily until C-diff test returns negative. During an interview on 03/01/2023 at 10:58 a.m., LVN S said Resident #74's stool sample result was not back. During an observation on 03/01/2023 at 9:18 a.m., Resident #74 was in the therapy gym with other residents present. Resident #74's room had isolation precautions signs and PPE available. During an interview on 03/01/2023 at 11:17 a.m., LVN S said if Resident #74 does have clostridium difficile she was told the germ would be contained in her brief. LVN S agreed Resident #74 was incontinent of stool. During an interview on 03/01/2023 at 11:30 a.m., the occupational therapist assistant said she checked with LVN S and was advised Resident #74 although on isolation precautions could come to the gym for therapy. During an interview on 03/01/2023 at 11:36 a.m., the DON said Resident #74 should have not been allowed in the therapy gym increasing the risk to spread the communicable disease. During an observation on 03/02/2023 at 9:48 a.m., Resident #74's neighbor next door had a sign placed beside her entrance indicating she was now in enhanced barrier precautions. The sign indicated everyone must: *Clean hands before entering room *All personnel must wear gloves, gown, with high care activities such as dressing, bathing, showers, and transfers *Changing linen *Providing hygiene *Changing brief/toileting *Device care *Wound care. This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. The following Plan of Removal submitted by the facility was accepted on 03/03/23 at 1:21 p.m. and included the following: Immediate Action: *On 02/27/2023 Resident #45 was placed in contact isolation *On 02/28/2023 Resident #74 was placed in contact isolation *On 02/28/2023 Resident #45 was removed from contact isolation per physician's order, related to a negative Herpes Simplex IGM test on 02/21/2023, Medical Director ordered Acyclovir treatment which was administer per physician's order *On 03/01/2023 after Medical Director spoke to the survey team, the Medical Director ordered Resident #45 to be placed back in isolation, restart Acyclovir, and PCR (Polymerase chain reaction) testing for HSV (herpes simplex virus) and VZV (varicella-zoster virus). *On 03/01/2023 Resident #45 was placed back on contact isolation *On 02/28/2023 Regional Nurse Consultant completed an assessment of resident #74 to validate Resident had no negative outcome from alleged improper peri-care. Facility's plan to ensure compliance quickly: *On 02/28/2023 DON/designee began training on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens base on mode of transmission including linen handling, storage, and sanitation for residents with presumed or confirmed infections, with all staff on duty. This education was completed on 02/28/2023with 20 of 89 staff trained. On 03/01/2023 at 2:00 p.m., no staff will be allowed to work until his education was completed. *The DON/Designee was responsible for ensuring residents were placed on appropriate isolation precautions. *On 03/01/2023 the DON was provided 1:1 education on Transmission Based Precautions to guide the center on when and what precautions to take to prevent transmission of pathogens based on mode of transmission, on monitoring, tracking, trending of infections by Regional Nurse Consultant. *On 03/01/2023 an additional 8 staff were trained prior to working *Again, no staff would be allowed to work until the education had been completed *On 03/01/1023 DON/designee began performing Hand Hygiene Skills Validation with Nurse Assistants. The skill competencies were completed on 02/28/2023 at 10:00 p.m., with 19 of 89 staff trained. NO staff would be allowed to work until the skills competency was completed. *On 03/01/2023 DON/designee began performing Hand Hygiene Skills Validation with all staff with an additional 39 of 89 staff trained. *On 02/28/2023 DON/designee began performing Peri-Skills Validation with Nurse Assistants. The skills competencies were completed on 02/28/2023 at 10:00 p.m. with 11 of 29 Nurse Assistants trained. No Nurse Assistants would be allowed to work until the education was completed. *On 03/01/2023 DON/designee began performing Peri-Skills Validation with Nurse assistants with an additional 10 of 29 staff trained. *On 03/01/2023 housekeeping staff completed deep thorough cleaning/disinfection of resident #'s 45, 74, and 1 other identified resident's room. The cleaning included halls and common areas. Quality Assurance: *Medical Director was notified on 02/28/2023 at 8:00 p.m. of the Immediate Jeopardies. *On 03/01/2023 an Ad Hoc QAPI meeting was conducted to discuss identified issues and to develop plan for sustaining compliance. In-services Conducted: Transmission Based (Isolation) Precautions dated 10/24/2022 indicated it was the policy to take appropriate precautions to prevent transmission of pathogens, based on the pathogens' mode of transmission. For training and quick referencing purposes a summary of precautions was contained at the end of the policy. Airborne Precautions refer to actions taken to prevent or minimize the transmission of infectious agents/organisms that remain infections over long distances when suspended in air. Contact precautions refer to measures that were intended to prevent transmission of infectious agents which were spread by direct or indirect contact with the resident or the resident's environment. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Transmission-based precautions (aka Isolation Precautions) refer to actions implemented in addition to standard precautions that were based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Policy Explanation and Compliance Guidelines: 1.Facility staff will apply Transmission-Based Precautions, in addition to standard precautions, to residents who were known or suspected to be infected or colonized with certain infectious agents requiring additional controls to prevent transmission. 2.The facility would use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment to be used. 3.When implementing transmission-based precautions, the facility will consider the following: a. The identification of resident risk factors b. The provision of a private room . c. Cohorting . d. sharing a room with a roommate with limited risk factors. 4. Residents on transmission-based precautions should remain in their rooms except for medically necessary care. 5. High touch objects and environmental surfaces should be cleaned and disinfected with an EPA-registered disinfectant . 6. Prompt recognition of need Type and Duration of transmission-based precautions recommend for selected infections and conditions: Clostridioides difficile formerly Clostridium difficile requires contact precautions, for the duration of the illness and hand hygiene with soap and water. Herpes zoster (shingles) requires airborne (if disseminated), contact I if resident was immunocompromised, standard (if localized). Validation Checklist Hand Hygiene: *Necessary supplies present *Water turned on with clean, dry towel; temperature adjusted for comfort *Soap applied to hands *Hands rubbed together vigorously with antimicrobial soap *Friction applied to all surfaces of the hands and fingers *Hand hygiene activity continued for 20-30 seconds *Hands rinsed thoroughly under running water *Hands kept lower than level of wrist during procedure *No contact with the inside of the sink *Stood away from sink to prevent splashing of uniform/clothing *Hands dried thoroughly with paper towels *Clean, dry paper towels used to turn off faucet *Towels discarded into trash receptacles *Alcohol gel used as adjunct *Understands the use of gloves and when they were to be used *Appropriate use of alcohol-based products. Validation Checklist Perineal Care: *Reviewed plan of care *Gathered needed supplies *Summoned for assistance if needed *Knock and gained permission to enter resident's room *Identified self, explained the procedure, provided privacy and asked permission to proceed *Set up needed supplies on the bedside stand in easy reach *Positioned the bed at a comfortable working position *Washed hands correctly *Avoided over exposure of resident while placing linens in proper place *Filled wash basin half full of water *Donned appropriate personal protective equipment *Placed waterproof pad under resident if necessary *Followed correct procedure for removing fecal material *Performed correct procedure for female *Performed correct procedure for male *Followed infection control protocol *Placed call-light device within easy reach of the resident *Cleaned wash basin and returned to storage area *Cleaned bedside stand *Returned the door and blinds open if resident desired *Recorded/reported appropriate data *Maintained clean technique and observed any isolation precautions. Monitoring included: During Interviews on 03/03/2023 from 3:08 p.m. until 3:54 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently [TRUNCATED]

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 6 residents reviewed changes of condition. (Resident #'s 41, 45 and 74) The facility failed to obtain a PCR HSV and VZV lab when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. The facility failed to obtain a stool culture when Resident #74 had on-going diarrhea since admission on 01/24/2023. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision, dehydration, and/or loss of life. Findings included: 1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023. Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions. Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2022, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023. Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye. Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection). Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered. Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility. Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes. During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye. During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles. During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen. Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye. Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye. During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles. During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir. Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023. During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go. Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs. During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used. During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies. On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation. Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions. Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room . Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated: *If the shingles affects your eye the doctor may cover your eye with a bandage *Infections of the eye and the skin around the eye were other health problems to treat *To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox. *Do not touch or scratch your rashes, if you do wash your hand afterwards. 2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. Record review of an Admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms. Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions. Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff. Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified. Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea. Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff. Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff. Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea. Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified. Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders. Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness. Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days. Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician. During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief. Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician. Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile. Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days. Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following: 9. An accident resulting in injury to the resident that potentially requires physician's intervention 10. An emergency response situation that requires EMS involvement 11. A significant change in the physical, mental, or psychosocial status of the resident. 12. The need to significantly alter the resident's treatment. 13. A decision to transfer or discharge the resident to another facility. 14. A change in room or roommate assignment. 15. A change in resident rights under Federal or State law, including changes to items and services included under State plans. 16. The facility's Medical Director will be contacted if the attending or admitting physician cannot be contacted and/or does not respond timely. Record review of a Provision of Quality-of-Care policy dated 01/24/2023 indicated based on comprehensive assessments, the facility will ensure that residents receive treatments and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. 1. Each resident will be provided care and services to attain or maintain his/her highest practicable physical, mental, and psychosocial well-being. 4. Qualified persons will provide the care and treatment in accordance with professional standards of practice, the resident's care plan and the resident's choices. 6. Policies and procedures will reflect current professional standards of practice. a. All employees are responsible for following established policies and procedures. B. Violations of policies and procedures will result in disciplinary action up to and including termination. This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 03/03/2023 at 1:21 p.m. and indicated the following: Immediate action: On 02/27/2023 Stool culture was obtained and sent to lab for Resident #74. On 02/28/2023 DON RN completed a Hydration assessment on Resident #74. On 03/01/2023 Regional Registered Dietician completed a Nutritional assessment on Resident #74 with no new recommendations. On 02/28/2023 Social Services/Designee obtained an Ophthalmology consult for Resident #45 for 03/03/23 related to worsening symptomatic Shingles. On 02/28/2023 ADON LVN completed rounds and identified 1 other resident with diarrhea who is in a private room and was placed on isolation precautions on 02/28/2023. DON RN completed a hydration assessment on this resident and notified the Physician 02/28/2023 regarding on-going diarrhea and hydration assessment. On 02/28/2023 stool culture was obtained and sent to lab for the one other identified resident. On 03/01/2023 Regional Registered Dietician completed a review on the 1 other resident in the center who was experiencing diarrhea, an identified as having the potential to be affected by this alleged practice with no recommendations. Facilities plan to ensure compliance quickly On 03/03/2023 DON Designee began training on Provision of Quality of Care to ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice. This education will be completed on 03/03/2023. No staff will be allowed to work until this education is completed. Quality Assurance Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies. On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance In-services: *Provision of Quality Care: The facility will ensure that residents receive treatment and care by qualified persons in accordance with professional standards of practice, the comprehensive person-centered care plans, and the resident's choice. During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition. Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries. Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return. Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff. Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher. During an interview on 03/03/2023 at 11:00 a.m., the DON said she expected nurses to monitor for changes of condition and then act on the physician's orders. The DON said a resident could have their needs not met. On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate threat with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review the facility failed to immediately consult with the resident's physician when there was significant change in the resident's physical, mental, or psychosocial status for 2 of 6 residents reviewed for notification of changes. (Resident #'s 45 and 74) The facility failed to notify the resident's physician when Resident #45 had worsening symptomatic shingles (painful rash with blisters) covering his right eye lid. The facility failed to notify the resident's physician when Resident #74 had diarrhea since admission on 01/24/2023. An Immediate Jeopardy (IJ) situation was identified on 02/28/2023 at 4:47 p.m. While the IJ was removed on the 03/03/2023 at 1:21 p.m., the facility remained out of compliance at an actual harm with a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of their physicians not being aware of the resident conditions and delay treatments for the residents' conditions of loss of vision and/or loss of life. Findings included: 1)Record review of a face sheet dated 03/02/2023 indicated Resident #45 was an [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of heart failure, depression, malnutrition, and high blood pressure. Record review of the most recent Significant change MDS dated [DATE] indicated Resident #45 was usually understood and usually understood others. The MDS indicated Resident #45's BIMS score was 11 indicating he had moderately impaired cognition. The MDS indicated during the assessment period Resident #45 did not reject care. The MDS indicated Resident #45 required extensive assistance of one staff with bed mobility, dressing, toilet use, personal hygiene, and with bathing Resident #45 required total assistance of one staff member. Record review of the consolidated physician's orders dated 03/01/2023 indicated Resident #45 had Acyclovir 800 milligrams 5 times daily for 5 days for possible shingles(painful rash with blisters) started on 03/01/2023. Resident #45 had Clindamycin 300 milligrams three times a day for cellulitis (potentially serious bacterial skin infection) x 7 days started on 02/28/2023 and Doxycycline Monohydrate 100 mg twice a day for cellulitis until 03/07/2023. Resident #45 was also ordered Gentamicin Sulfate Ophthalmic ointment 0.3% 1 application in right eye two times a day for infection x 7 days to start on 02/28/2023. Record review of the comprehensive care plan dated 11/09/2022 revealed it did not address that Resident #45 had shingles involving his face and right eye. The comprehensive care plan did not address isolation precautions. Record review of Resident #45's February 2023 electronic medication administration record indicated these medications were ordered and administered medications: Acyclovir 800 milligrams one tablet three times a day for shingles for 7 days started on 02/20/2023 and completed on 02/27/2023. Resident #45 was ordered Ofloxacin Ophthalmic Solution 0.3% one drop to the right eye 4 times daily for 5 days starting on 02/20/2023. Acyclovir 800 milligrams was restarted on 02/28/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days started on 2/27/2023, and Doxycycline 100 milligram give one tablet twice daily for 7 days started on 02/28/2023. Record review of Resident #45's March 2023 electronic medication record indicated these medications were ordered and administered: Gentamicin Sulfate Ophthalmic Ointment 0.3% instill one application in the right eye two times a day for 7 days starting on 03/01/2023, Ofloxacin Ophthalmic Solution 0.3% instill one drop in right eye at bedtime for 7 days starting on 02/27/2023; Doxycycline monohydrate 100 milligrams one capsule twice daily for cellulitis until 03/07/2023; and Clindamycin 300 mg one capsule by moth three times a day for cellulitis for 7 days; and Acyclovir 800 milligrams one tablet by mouth 5 times a day for 5 days for possible shingles starting on 03/01/2023. Record review of a nursing note dated 02/20/2023 at 10:12 a.m., indicated LVN G wrote the physician was notified regarding Resident #45's redness, swelling, and matter to his right eye. Record review of a nursing note dated 02/20/2023 at 10:54 a.m., indicated LVN G wrote he received new orders for Acyclovir 800 milligrams three times a day for 7 days, ofloxacin 0.3% one drop in right eye four times a day for 5 days, appointment with an ophthalmologist and to check a HSV ig M level (anti-body test to indicate a current or recent infection). Record review of a nursing note dated 02/20/2023 at 8:34 p.m., indicated LVN M wrote monitoring for edema (swelling) every day and night shift, with the right side of Resident #45's face/eye with edema with the MD aware with laboratory test ordered. Record review of a nursing note dated 02/21/2023 at 1:03 a.m., indicated LVN M wrote that the right side of Resident #45's face/eye continued with edema and redness, and Resident #45 denied pain. LVN M noted Resident #45's family member would like to see if the facility ophthalmologist could see Resident #45 instead of having to be transferred out of the facility. Record review of a nursing note dated 02/22/2023 at 9:08 a.m., indicated LVN O wrote that Resident #45 continued the Acyclovir eye drops to his eye every night, continued to assess for pain, discomfort, and changes. During an observation on 02/27/2023 at 12:17 p.m. revealed, Resident #45 was lying in his bed. He had scabbing appearing areas to his right eye and forehead. Resident #45's right eye was scabbed closed, and he could not open it when requested Resident #45 said he did not know what was on his face and eye. During an interview on 02/27/2023 at 12:26 p.m., CNA N said she was told Resident #45 had shingles (painful rash with blisters) and not been on any isolation precautions. CNA N said she regularly careds for Resident #45 and had floated to other halls to help. CNA N said she had questioned the DON today as to why Resident #45 was not on any type of isolation because she said shingles were contagious. CNA N said Resident #45 did not eat his noon meal because he was hurting from the shingles. During an interview on 02/27/2023 at 8:55 a.m., the DON said the nurses had not realized Resident #45 required isolation due to shingles being a contagious communicable disease. The DON said the nurses did not make her aware of Resident #45 having shingles when the symptoms started. The DON said Resident #45 should have been placed on contact isolation. The DON said the risk for unvaccinated and residents who had not had chicken pox as a child were at risk of having shingles. The DON said she was unaware Resident #45 had an order to see an ophthalmologist related to his right eye. The DON said they facility's eye physician had already made rounds around February 9th or the 10th 2023. The DON said she had not contacted the mobile eye physician or the family member with a plan to have Resident #45's right eye examined. The DON said shingles in the eye could result in vision loss for Resident #45. The DON said she was the infection preventionist for the building. The DON said she was unsure how Resident #45's infection of the shingles was missed because she said the nurse managers log the infections and review the orders in morning meeting. The DON said the physician should be notified immediately when symptoms occur or worsen. Record review of a nurses note written by LVN P dated 02/28/2023 at 12:57 p.m., revealed Resident #45 had an appointment scheduled for March 2, 2023, at 3:15 p.m. The note indicated Resident #45's family member was notified of the appointment related to shingles to the right eye. Record review of a nurse note dated 02/28/2023 at 1:06 p.m., indicated Resident #45 was administered a Tramadol 50 milligram tablet for pain to his right eye. During an interview on 02/28/2023 at 3:11 p.m., LVN P said she had worked February 19, 2023, through February 23, 2023 and had observed Resident #45 during that time period. LVN P said Resident #45's eye was much worse than when she last saw the eye on February 23, 2023. LVN P said the medical record did not indicate any one had contacted the physician for Resident #45's worsening shingles. During an interview on 02/28/2023 at 3:26 p.m., the Medical Director said she was #45's physician and she said she was unaware of Resident #45's right eye condition with shingles covering the entire eye lid and the right eye would not open. The Medical Director said she was unaware Resident #45 had not seen an eye specialist related to the shingles to the right side of the face and eye. The Medical Director said she expected the facility to obtain an appointment promptly due to the risk of blindness with ocular shingles. During an observation and interview on 02/28/2023 at 3:45 p.m., revealed LVN P applied a warm compress to Resident #45's right eye. LVN P asked Resident #45 to open his right eye, and he could not open the eye at all. Resident #45 said his right eye was hurting and LVN P immediately stopped and said she would administer a pain medication. LVN P said she would notify the physician. Record review of a nurse note dated 02/28/2023 at 8:03 p.m., indicated the ADON wrote Resident #45's family was notified of the lab results of the Herpes Simplex IgM (antibody test of recent or current infection) result of 0.66 and a new order was received from the physician for Clindamycin 300 mg one three times and day and discontinue the Acyclovir. Record review of a medication administration record dated February 2023 indicated Clindamycin 300 mg was administered on 02/28/2023. During an interview on 02/28/2023 9:57 a.m., the responsible party for Resident #45 said he was never told officially Resident #45 had shingles (painful rash with blisters). Resident #45's responsible party said he asked if the mobile eye doctor could see Resident #45 but he definitely would have had him sent to another local eye physician if Resident #45 needed to go. Record review of a nurse note dated 02/28/2022 at 8:21 p.m., indicated the DON wrote Resident #45's isolation was discontinued for shingle precautions and indicated Resident #45 had a new diagnosis of cellulitis and with a new medication ordered. The new order was Clindamycin 300 mg one capsule three times a day for 7 days. Record review of a nurse note dated 02/28/2023 at 11:08 p.m., indicated LVN B wrote Resident #45 was administered gentamycin eye drops. LVN B wrote Resident #45 face was red and swollen with blisters and scabs. During an interview on 02/28/2023 at 10:07 a.m., the Interim Administrator said she was unaware of Resident #45 having shingles. Record review of a nurse note dated 03/01/2023 at 1:24 a.m., indicated LVN B documented Resident #45 had a diagnosis of cellulitis, day 2 of isolation, acyclovir was discontinued, day 2 of 7 on Ofloxacin and G entamicin eye drops, day 3 of 7 on doxycycline with no adverse reactions. The note indicated Resident #45 had redness, swelling, and scabs to his face and a warm compress was used. During an interview on 03/01/2023 at 8:34 a.m., the Regional Corporate Nurse said after digging deeper the lab result for an IgM level (antibody level detecting recent or new infection) was 0.66 which was negative. The Regional Corporate Nurse said Resident #45 was negative for shingles but was being treated for cellulitis. During an observation and interview on 03/01/2023 at 9:18 a.m., Resident #45 said his right eye was hurting. Resident #45 had a very minimal opening between his eye lids and there was yellow stingy material in the opening. During an interview on 03/01/2023 at 2:57 p.m., the Medical Director indicated initially Resident #45's rash appeared to be shingles. The medical director indicated the IgM test was negative for antibodies. On 02/20/2023. The medical director said she would complete a PCR HSV and VSV (recommended testing for diagnosing of shingles), and place Resident #45 back on isolation. The medical director said she would order a PCR HSV and VSV because the test would be the most accurate test for diagnosing shingles according to CDC recommendation. Record review of a nurses note dated 03/01/2023 at 6:24 p.m., indicated the ADON wrote she notified the Resident #45's family member on of the new orders to restart Acyclovir 800 milligrams five times daily x 5 days, PCR HSV and VZV lab, and reinstate the isolation precautions. Record review of an incident report dated 03/02/2023 at 3:30 p.m., indicated Resident #45 slid from his wheelchair to the floor. The ADON wrote there were no injuries noted but Resident #45 was sent to the emergency room . Record review of an After Visit Summary dated 03/02/2023 indicated Resident #45 was provided instructions related to shingles and minor head injury. The summary indicated his diagnoses included an unspecified fall, facial contusion, and herpes zoster (shingles). The educational material included in the Visit Summary report indicated: *If the shingles affects your eye the doctor may cover your eye with a bandage *Infections of the eye and the skin around the eye were other health problems to treat *To prevent the shingles do not share towels, go swimming, or play contact sports with people who have shingles if you never had chicken pox. *Do not touch or scratch your rashes, if you do wash your hand afterwards. 2) Record review of a face sheet dated 03/02/2023 indicated Resident #74 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of spondylolisthesis (disorder of which a bone vertebra slips forward onto the bone below), eating disorder, and high blood pressure. Record review of an Admission MDS dated [DATE] indicated Resident #74 was usually understood and usually understood others. The MDS indicated Resident #74 BIMS score was a 13 indicating she was cognitively intact. The MDS indicated Resident #74 required extensive assistance of one staff with bed mobility, transfers, locomotion, toilet use, personal hygiene, and bathing. The MDS indicated Resident #74 was frequently incontinent of bowel and was not on a toileting plan. Record review of a Baseline care plan dated 01/24/2023 at 8:39 a.m., indicated the ADON did not document Resident #74 had a recent history of Clostridium Difficile from the physicians history and physical (inflammation of the colon cause by bacteria), diarrhea, or isolation precautions needed for on-going symptoms. Record review of the comprehensive care plan dated 02/07/2023 indicated Resident #74 was at risk for Covid 19 infection but the care plan did not mention Clostridium Difficile or the need for isolation precautions. Record review of the February 2023 electronic medication record indicated Resident #74 received Colestipol 1 gram twice daily for treating diarrhea since 01/24/2023, lactobacillus capsule one capsule by mouth twice daily, and Lomotil 2.5-0.025 milligrams one tablet every 6 hours as needed for diarrhea since 01/24/2023. The electronic medication record indicated Resident #74 had 8 doses in the month of February and two doses were unknown if effective. Record review of a nursing progress note dated 01/24/2023 documented by LVN T indicated Resident #74 was post C-diff. Record review of a nursing progress note dated 01/31/2023 at 1:22 a.m., indicated LVN V administered Lomotil for diarrhea, but the medication was ineffective. The note did not indicate the physician was notified. Record review of a nursing progress note dated 01/31/2023 at 12:24 p.m., indicated LVN F documented Resident #74 was administered Lomotil for diarrhea. Record review of a skilled nurses note dated 02/01/2023 at 12:48 a.m., indicated LVN T documented Resident #74 was post C-diff. Record review of a progress note dated 02/01/2023 at 1:30 a.m., indicated Resident #74 was administered Lomotil for diarrhea by LVN M. Record review of a nursing note dated 02/03/2023 at 5:40 a.m., LVN T documented an administration of Lomotil for diarrhea was provided to Resident #74. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. Record review of a nurses note dated 02/04/2023 at 3:32 a.m., indicated LVN R documented Resident #74 was post C-diff. Record review of a nurses note dated 02/06/2023 at 8:37 a.m., indicated LVN S documented Resident #74 was post C-diff. Record review of a nurses note dated 02/06/2023 at 11:18 p.m., LVN T documented Resident #74 required the administration of Lomotil for diarrhea. Record review of a nurses note dated 02/07/2023 at 11:40 p.m., LVN T documented Resident #74 required Lomotil administration related to diarrhea. Record review of a nurses note dated 02/15/2023 at 9:42 p.m., LVN T documented Resident #74 required administration of Lomotil for diarrhea. Record review of a nurses note dated 02/24/2023 at 12:54 a.m., indicated LVN PP documented Resident #74 continued to have been monitored for diarrhea none on this shift. The note failed to indicate the physician was notified. Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN T documented that Resident #74 had 3 diarrhea bowel movements with Lomotil given and effective at present. The note indicated Resident #74's peri area was very red. LVN T indicated she notified the physician and was waiting on orders. Record review of a nurses note dated 02/25/2023 at 8:59 a.m., indicated LVN D apply Nystatin ointment to Resident #74's inner thighs and buttocks for redness. Record review of a nurses note dated 02/25/2023 at 6:41 a.m., indicated LVN D received a new order for Nystatin ointment and zinc oxide twice daily for 30 days. Record review of a nurses note dated 02/25/2023 at 6:43 p.m., indicated LVN B documented Resident #74 required Lomotil for diarrhea and the medication was effective. The note did not reflect LVN B notified the physician. During an interview an observation on 02/27/2023 at 10:08 a.m., Resident #74 said her brief needed changing due to having a very large diarrhea bowel movement. Resident #74 said she thought she should return to the hospital due to her continuous diarrhea since she left the hospital. Resident #74 was assisted to activate her call light for assistance. CNA C answered the call light and left the room. CNA C returned with bed linen and incontinent care supplies. CNA C washed her hands then initiated care to Resident #74. LVN F said Resident #74 has had diarrhea since admission. LVN F said he had been trying to obtain a stool sample but the stool was so loose the bowel movement absorbed in the brief. Record review of the physician's orders dated February 2023 did not reveal a stool specimen was ordered by the physician. Record review of a nurses note dated 02/27/2023 at 5:55 p.m., indicated LVN F documented Resident #74 made the statement she thought she needed to return to the hospital due to the ongoing diarrhea. LVN F documented he informed Resident #74 he had a stool sample waiting for pickup. During an interview on 02/28/2023 at 7:51 a.m., the Housekeeping Supervisor said she was unaware there were residents with possible Clostridium Difficile. The Housekeeping Supervisor said for Clostridium Difficile there was a special tablet to add to the water for cleaning of these rooms. The housekeeping supervisor said she was also unaware of Resident #74 or Resident #45 having communicable disease processes requiring special laundry procedures. The housekeeping supervisor said when the laundry receives linen in the yellow bags the laundry personnel would be alerted to wash this linen separate from the general linen. During an interview on 02/28/2023 at 3:26 p.m., the physician for Resident #74 said Resident #74 had Clostridium Difficile in the recent past. The physician said she was not notified Resident #74 had on-going diarrhea since admission. The physician said Resident #74 could be a carrier of Clostridium Difficile. Record review of a hydration assessment completed by the DON dated 02/28/2023 indicated Resident #74 had poor skin turgor, had more than a 3-pound weight loss in a month, and was at risk due to diarrhea/vomiting occurred in the last 7 days. Record review of a Notification Policy dated 07/13/2015 and revised on 02/12/2023 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP, and responsible party. The facility will immediately inform the resident; consult with the resident's physician; and if known, the resident's legal representative or appropriate family members of the following: 1. An accident resulting in injury to the resident that potentially requires physician's intervention 2. An emergency response situation that requires EMS involvement 3. A significant change in the physical, mental, or psychosocial status of the resident. 4. The need to significantly alter the resident's treatment. 5. A decision to transfer or discharge the resident to another facility. 6. A change in room or roommate assignment. 7. A change in resident rights under Federal or State law, including changes to items and services included under State plans. 8. The facility's Medical Director will be contacted if the attending or admitting physician can not be contacted and/or does not respond timely. This was determined to be an Immediate Jeopardy (IJ) situation on 02/28/2023 at 4:47 p.m. The Interim Administrator and the Regional Corporate Nurse was notified. The Administrator was provided with the IJ template on 02/28/2023 at 4:58 p.m. and requested a Plan of Removal (POR). The Plan of Removal (POR) was accepted on 03/02/2023 at 4:22 p.m. and indicated the following: Immediate action: *On 02/28/2023 the physician was notified of Resident #74's on-going diarrhea *On 02/28/2023 the physician was notified of Resident #45's worsening symptoms of shingles. Facilities plan to ensure compliance quickly: *On 02/28/2023 DON/designee began training on notification of change in condition policy which provides guidance on when to communicate acute changes in status to physician and the need to significantly alter the resident's treatment with all licensed nurses on duty to include post-tests. This education was completed on 02/28/2023 at 10:00 p.m. with 11 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed. *On 03/01/2023 an additional 6 of 34 (total 17) licensed nurses were trained prior to working. *Again, no licensed nurse will be allowed to work until this education has been completed *On 03/01/2023 DON/designee began training on Clinical Documentation Guidelines which provides direction to the healthcare team on documentation and communication with the resident's progress and current treatment with all licensed nurse on duty. This education was completed on 03/01/2023 at 2:00 p.m. with 7 of 34 licensed nurses trained. No licensed nurse will be allowed to work until this education is completed. *On 03/01/2023 an additional 6 of 34 (13 total) licensed nurses were trained prior to working *Again, no licensed nurse will be allowed to work until this education has been completed. Quality Assurance *The Medical Director was notified on 02/28/2023 at 08:00 p.m., of the Immediate Jeopardies. On 03/01/2023 An Ad Hoc QAPI meeting was conducted to discuss identified issues, and to develop plan for sustaining compliance Monitoring included: During Interviews on 03/03/2023 from 3:08 p.m. until 1:21 p.m., the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview with the DON stated she was in-serviced on her role as Director of Nurses and Infection Preventionist. She was in-serviced on documentation of changes of condition requirements, notification of the responsible party and physicians, and following up on changes of condition to ensure all care needs were met. Interviews with 2 RNs: DON and RN KK (6am-6pm); 4 nurses LVN L (6a-6p), LVN A (6a-6p), LVN F (6a-6p), LVN B (6p-6a), ADON (all shifts), Tx nurse (all shifts) in-serviced on transmission-based precautions, notification of the physician and family of acute changes such as accidents, illness, transfers, emergencies, and injuries. Record review of Resident #74's laboratory PCR HSV and VSV pending taking 5-7 days for return. Record review of Resident #74's stool culture dated 2/27/2023 indicated a negative result for C-diff. Record review of Resident #45's ophthalmologist appointment dated 03/02/2023 at 3:15 p.m. but he slid from his wheelchair preparing to leave the facility. The facility working with a local EMS ambulance to take Resident #45 to the ophthalmologist on a stretcher. In-services: Record review of an in-service dated 03/03/3023 used the Notification of Changes policy with a revision date of 02/12/2021 indicated the policy was to provide guidance on when to communicate acute changes in status to MD, NP and /responsible party. The facility will immediately inform the resident: consult with the resident's physician; and if known, notify the resident's legal representative or appropriate family member(s) of the following: 3. A significant change in the physical, mental, or psychosocial status of the resident. 5. The facility documents resident assessment (s), interventions, physician and family notification (s) on SBAR, Nurse Progress Notes or Telephone Order Form (physician /family notice) as appropriate. During an interview on 03/03/2023 at 11:15 a.m., the Interim Administrator said she expected the physician to be notified off all changes of condition. On 03/03/2023 at 5:22 p.m. the Interim Administrator was informed the IJ was removed: however, the facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to provide care, consistent with professional standards of practice and based on a comprehensive assessment to prevent the development of pressure injuries for 1 of 1 resident reviewed for pressure injuries. (Resident #20) The facility did not implement interventions to prevent Resident #20 from developing 2 facility acquired stage 2 pressure injuries. The facility ordered Resident #20 a customized wheelchair on 11/15/17 after identifying the wheelchair was placing the resident at risk for developing pressure injuries; however, interventions were not implemented while the resident's wheelchair was ordered. Resident #2 developed 2 avoidable pressure injuries on 12/09/17. The resident received the customized wheelchair 12/15/17 after she developed the avoidable pressure injuries. This failure could place 2 residents with pressure injuries at risk for development of new pressure injuries and the decline in existing pressure injuries. Findings included: Physician orders [REDACTED].#20 admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #20 was cognitively intact, had clear speech was understood and could understand. The MDS indicated Resident #20 required extensive 1 person assistance with bed mobility and she was independent with transfers. The resident was noted to require a wheelchair for mobility with supervision and set up help only with locomotion on and off the unit. The MDS also indicated Resident #20 was at risk for pressure injuries with no pressure injuries present at the time of this assessment. It was indicated Resident #20 had 2 venous/arterial ulcers. A care plan with a review date of 11/02/17 indicated Resident #20 had a focus of pressure injury risk. A goal was the resident would be free of preventable breakdown. A telephone order dated 12/09/17 indicated a new order for Resident #20; clean both wounds (right and left upper legs) with normal saline, apply collagen to wound bed, cover with calcium alginate and dry dressing every 8 hours as needed. A Pressure Ulcer (Baseline Care Plan) dated 12/12/17 indicated Resident #20 had a stage 2 pressure injury on her right posterior thigh (back of the thigh). An approach was the resident was assessed for a new wheelchair. Interventions included 12/12/17 collagen and dry dressing every day, and 1/9/17 discontinue collagen and start [MEDICATION NAME] and dry dressing every day. A Pressure Ulcer (Baseline Care Plan) dated 12/12/17 indicated Resident #20 had a stage 2 pressure injury to the left posterior thigh. An approach was the resident was assessed for a new wheelchair. Interventions included 12/12/17 collagen and dry dressing every day, 12/19/17 discontinue collagen and start [MEDICATION NAME] every day, and 1/9/18 discontinue [MEDICATION NAME] and start collagen and dry dressing every day. A nursing note dated 12/12/17 indicated Resident #20 acquired a stage 2 pressure injury on her right posterior thigh measuring 2.0 cm x 1.5 cm x 0.1 cm and a stage 2 on her left posterior thigh measuring 0.6 cm x 1.7 cm x 0.1cm. There was no tunneling or undermining present in either wound. The most recent Braden Scale dated 12/28/17 indicated Resident #20 was at moderate risk for the development of pressure injuries. Weekly skin assessments identified 12/12/17 by the treatment nurse for Resident #20's Stage 2 pressure injury to the right posterior thigh indicated the following measurments: *12/12/17 - 2.0 cm x 1.50 cm x 0.1 cm; *12/19/17 - 1.3 cm x 1.4 cm x0.1 cm; *12/26/17 - 1.5 cm x 1.0 cm x 0.1 cm; *01/02/18- 1.60x0.80x0.10; and *01/09/18 - 1.50 x1.30x0.10. Weekly skin assessments identified 12/12/17 by the treatment nurse for Resident #20's Stage 2 pressure injury to the left posterior thigh indicated the following measurments: *12/12/17 -Stage 2 pressure injury on her measuring 0.7 cm x 1.5 cm x 0.1 cm; *12/19/17 Stage 2, 1.20x2.80x0.10; *12/26/17 Stage 2, 1.00x2.20x0.10; *01/02/18 Stage 2, 0.80x1.50x0.10; and *01/09/18 Stage 2, 0.90x2.20x0.10. During an interview on 01/19/18 at 10:24 a.m., the COTA/Director of Therapy department said the previous wheelchair Resident #20 used off and on since her admission did not provide pressure relieve to the back of her thighs due to the height of the wheelchair. The COTA/Director of Therapy said the resident's previous wheelchair seat was too high up and the foot rest would not come up high enough causing the resident to sit forward with her bottom toward the middle of the wheelchair seat. She said this caused pressure to Resident #20's thighs. The COTA/Therapy Director said a custom built wheelchair was ordered by therapy on 11/15/17 and the resident received the wheelchair on 12/15/17. During an observation and interview on 01/10/18 at 1:36 p.m., the treatment nurse said Resident #20 propelled her previous wheelchair with her feet. She said the previous wheelchair was too tall for Resident #20 causing the resident to slump down causing pressure to the back of the thighs and the stage 2 pressure sores developed. The treatment nurse said the facility ordered a new wheelchair and a cushion was special made for the resident. Resident #20 said the previous wheelchair was too tall and she had to scoot down in her wheelchair in order to put her foot on the floor causing the pressure injuries on the back of her thighs. The treatment nurse measured the pressure injuries as follows: * On the back of right thigh below the buttock - 1.9 cm x 1 cm x 0.1 cm * On the back of the left thigh below buttock - 0.8 cm x 2.1 cm x 0.1 cm. During an interview on 01/12/18 at 4:57 p.m., the DON said Resident #20 had problems with positioning in her wheelchair so the facility replaced the wheelchair. According to the National Pressure Ulcer Advisory Panel (NPUAP) website, http://www.npuap.org/resources/educational-and-clinical-resources, accessed 01/23/18, the following was indicated: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. The CMS 672 dated 01/09/18 indicated 2 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide care, based on a comprehensive assessment to prevent pressure injuries from developing for 1 of 5 residents reviewed for pressure injuries. (Resident #13) The facility did not identify and accurately assess 2 pressure injuries on Resident #13's left buttock, did not provide turning and repostioning for Resident #13, and did not provide pressure redistribution cushion for the resident's wheelchair. Resident #13 developed 2 avoidable facility acquired stage 2 pressure injuries that were not identified and provided treatment until surveyor intervention. This failure contributed to the development of new pressure injuries for Resident # 13. This failure could place 69 residents who received preventive skin care at risk for the development of new or worsening pressure injuries. Findings included: Physician orders [REDACTED].#13 was admitted [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment dated [DATE] indicated Resident #13 required extensive assistance of 2 staff for bed mobility, transferring, and toileting. The resident was incontinent of bowel and bladder. The resident did not have a pressure injury and was at risk for developing a pressure injury. The resident did not have skin problems identified. A Braden scale assessment dated [DATE] indicated Resident #13 was a mild risk for developing a pressure injury. A Care Plan dated 2/14/17 indicated Resident #13 had a skin shear of the left buttock, self-inflicted by scratching. Interventions included 1. Monitor for redness, [MEDICAL CONDITION] and drainage 2. Document size and progress with treatment weekly until healed. 3. Provide treatment as ordered. 4. Notify physician of any changes in appearance related to infection. 6. Turn and reposition every 2 H (off load per self). An admission Non-Pressure Skin Condition report dated 2/14/17 completed by LVN E (wound care nurse) indicated Resident #13 had a shear/abrasion on her right and left buttock from scratching. The wound was described as bright red with [MEDICATION NAME] tissue in the wound bed. The skin report did not provide measurements. No pressure injuries were identified on this assessment. The report indicated barrier cream was applied upon admission. A Non-Pressure Skin Condition report dated 2/21/17 completed by LVN E (treatment nurse) indicated Resident #13 had an abrasion on her right and left buttock from scratching. The report indicated barrier cream encouraged. The skin report did not provide measurements, or color/condition of the shear/abrasion. No pressure injuries were identified on this assessment. During an observation and interview 2/27/17 at 9:37 a.m., CNA H said yes when asked if Resident #13 had skin breakdown and said she had a sore on her buttock when she readmitted on [DATE], they were treating it with protective barrier cream and checked her frequently for incontinent care. She indicated the resident could turn herself. Resident #13 was sitting in a wheelchair waiting to go to therapy. The wheelchair did not have a pressure reducing cushion. Resident #13 said she had sores on her bottom. She indicated the sores had been on her bottom since admission. During an interview on 2/27/17 at 12:20 p.m., Resident #13 was lying in bed on her back with the head of bed elevated 45 degrees. She said she was unable to turn herself in bed or get up to the bathroom without assistance. She said staff changed her brief when she was wet but she was not turned off her back except while receiving incontinent care. During an interview and observation of incontinent care on 2/28/17 at 9:03 a.m., CNA F requested Resident #13 turn over to her side and Resident responded she could not turn off her back without help and the sheet needed to be removed from her feet. Two pressure injuries were on Resident #13's left buttock. The skin surrounding both wounds was intact and surrounding skin was discolored with a purple undertone. CNA F said an unnamed nurse told her to put barrier cream on the two open wounds when the resident readmitted about 2 weeks ago. CNA F applied barrier cream to the pressure injuries after incontinent care and placed the resident back on her back. CNA F said the areas were open when she worked 3 days ago. During an interview on 2/28/17 at 12:55 p.m., LVN G said she was notified by CNA F Resident #13's buttocks were red about 2 weeks ago. LVN G said she assessed the resident, but did not identify any skin breakdown. LVN G said she told CNA F to put barrier cream on the red area. LVN G said she did not document her assessment and could not recall the exact date. During an interview on 2/28/17 at 9:25 a.m., LVN E (wound care nurse) said Resident #13 did not have pressure injuries she had abrasions/shears on her left and right buttocks. LVN E said she did not have orders to treat any wounds on Resident #13's buttocks. She said she did not measure the abrasions/shears on Resident #13's buttock when she completed the skin assessment on 2/14/17 and 2/21/17. During an observation and interview on 2/28/17 at 9:49 a.m. (after surveyor intervention), the DON assessed Resident #13's two open pressure injuries on her left buttock. The DON said the two open wounds were pressure injuries and she was unable to determine staging until wounds were cleansed. The DON indicated the resident was not on a turning and repositioning program every 2 hours and the resident did not have a pressure reducing cushion in the wheelchair. The DON said the physician would be notified about the pressure injuries. She said she expected staff to report new or open wounds, assess, measure, and document findings. During an observation and interview on 2/28/17 at 9:57 a.m. (after surveyor intervention) LVN E cleansed and measured the two pressure injuries on Resident #13's buttock. She did not measure the depth for the 2 pressure injuries due to yellow slough (dead tissue) covering the wound beds. After LVN E cleaned the pressure injuries the wound bed could not be seen due to the slough. The pressure injury on the upper middle left buttock nearest the tailbone measured 0.5cm x 0.5cm with yellow slough. The pressure injury on her left medial buttock below the first wound measured 0.5cm x 0.3 cm with yellow slough. The DON said because both areas were open they were both unstageable but would be at least a stage 2. LVN E said they had a standing order and would begin treatment with hydrogel silver wound gel that would help debride the slough and refer the resident to the wound care physician. A Care Plan dated 2/28/17 after surveyor intervention indicated Resident #13 now has an unstageable pressure ulcer to left proximal buttock R/T coverage of slough 30% to wound bed, . Interventions included: 1. Keep clean and dry. 2. Treatment as ordered-Notify MD if TX is ineffective after 2 wks. 3. Off Load Wound .7. Turn and reposition every 2 hours .10. Skin assessment every day .Clean area with NS, Apply hydrogel silver wound gel, cover with dry dressing everyday (qd) and PRN .Mosiac roho cushion to wheelchair qd. A Care Plan dated 2/28/17 after surveyor intervention indicated Resident #13 now has an unstageable pressure ulcer to left distal buttock R/T coverage of slough 30% to wound bed, . Interventions included: 1. Keep clean and dry. 2. Treatment as ordered-Notify MD if TX is ineffective after 2 wks. 3. Off Load Wound .7. Turn and reposition every 2 hours .10. Skin assessment every day .Clean area with NS, Apply hydrogel silver wound gel, cover with dry drsg. every day and PRN .Mosiac roho cushion to wheelchair qd. During an observation and interview on 3/1/17 at 10:10 a.m. (after surveyor intervention), Resident #13 was evaluated by the wound care physician. The wound care physician said the pressure injury on Resident #13's left upper medial buttock was a stage 2 and measured 0.8cm x 0.8 cm x 0.1 cm and the left lower medial buttock was a stage 2 and measured 0.6 cm x 0.7 cm x 0.1 cm. Both pressure injuries were free of slough. A Skin Management policy with a revision date of 2/1/14 indicated A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a boney prominence, as a result of pressure or in combination with shear . Plan of Care: 7. the initial plan of care is completed by the licensed nurse for patients with pressure ulcers. The goal of the care plan may include but not be limited to: promoting the prevention of pressure ulcer development, promoting the healing of pressure ulcer that are present .8. An At Risk for Skin Breakdown care plan is implemented by the licensed nurse for patients with a score of 18 or less on the Braden Scale or as clinically indicated .Implement /Ongoing Strategy 1. The Braden Scale is completed on admission and then weekly times four .2. A weekly skin evaluation is completed by the licensed nurse or wound care nurse .3. A daily skin evaluation is completed by the licensed nurse or wound nurse for those patients with pressure ulcers . 7. Nursing assistants will notify the licensed nurse of skin observations . Evaluate .3. If new skin alteration of any type are identified through skin observation or skin evaluation/assessments the physician and family is notified. Physician orders [REDACTED]. The website, www.npuap.org/resources, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. The CMS Form 672 dated 2/27/17 indicated 69 residents received preventive skin care.