Every finding on record at Highland Manor of Elko Rehabilitation LLC

Based on interview, record review, and observation, the facility failed to ensure a resident's behavior to park a wheelchair in the middle of a fall mat was addressed through adequate supervision and environmental safeguards for 1 of 20 sampled residents (Resident #91). This deficient practice had the potential to result in an increased risk for falls, injury, or skin tears.Findings include:Resident #91Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, fracture neck left femur, and difficulty in walking.On 08/11/2026 at 8:40 AM, Resident #91 was observed asleep in bed with bilateral fall mats. The wheelchair was parked in the middle of the fall mat on the right side of the bed.On 08/12/2026 at 10:16 AM, Resident #91 was observed lying in bed with bilateral fall mats, and the wheelchair remained parked in the middle of the fall mat on the right side.Resident #91's Comprehensive Care Plan dated 05/19/2026, documented Resident #91 was a fall risk and staff would assist to providing the resident with a safe environment to reduce the risk for falls.On 08/12/2026 at 10:45 AM, a Certified Nursing Assistant (CNA) explained a fall risk resident would be identified via chart alert or yellow socks. The CNA reported interventions were care planned and updated through daily meetings when changes occurred. The CNA confirmed Resident #91 had bilateral fall mats and explained the wheelchair should have been placed at the bottom edge of the bed to avoid fall mat obstruction. The CNA explained parking the wheelchair in the center of the mat could cause skin tears or additional fall risk if the resident reached for it.On 08/12/2026 at 10:50 AM, a Licensed Practical Nurse (LPN) explained fall risk residents were identified during report and received care planned interventions, including fall mats. The LPN confirmed Resident #91 had bilateral fall mats and frequently attempted self transferring. The LPN verbalized the wheelchair was not to be placed on the fall mat because it created a hazard if residents attempted to self transfer. The LPN indicated awareness of Resident #91's consistent behavior to self transfer and leave the wheelchair in the middle of the right side fall mat.On 08/13/2026 at 11:40 AM, the Director of Nursing (DON) verbalized fall mats were used to prevent injury from falls. The DON explained parking a wheelchair on a fall mat created a hazard and directed staff to remove fall mats when a resident was out of bed and keep mats up until bedtime, particularly for residents known to self transfer.The facility policy titled Accidents and Supervision, reviewed 07/16/2026, documented the resident environment would remain as free of accident hazards as was possible. Identification of hazards and risks was the process in which the facility became aware of potential hazards in the resident's environment and the risk of the resident having an avoidable accident.Cross reference tag F657

Based on interview, record review and observation, the facility failed to ensure a resident's Comprehensive Care Plan was updated to include the resident's behavior of parking the wheelchair in the middle of a fall mat for 1 of 20 sampled residents (Resident #91). This deficient practice had the potential to result in an increased risk for falls, injury, or skin tears. Findings include:Resident #91Resident #91 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including unspecified dementia, fracture neck left femur, and difficulty in walking.On 08/11/2026 at 8:40 AM, Resident #91 was observed asleep in bed with bilateral fall mats. The resident's wheelchair was parked in the middle of the fall mat on the right side of the bed.On 08/12/2026 at 10:16 AM, Resident #91 was observed lying in bed with bilateral fall mats. The wheelchair remained parked in the middle of the fall mat on the resident's right side.Resident #91's Comprehensive Care Plan dated 05/19/2026, documented Resident #91 was a fall risk; however, lacked documentation of the resident's behavior to self transfer from the wheelchair to the bed, leaving the wheelchair parked in the middle of the fall mat.On 08/12/2026 at 10:45 AM, a Certified Nursing Assistant (CNA) explained a resident identified as a fall risk would have an alert in the chart or wear yellow socks. The CNA explained interventions were care planned for fall risk residents and changes were reported to the nurse, discussed in the daily meeting, and added to the care plan. The CNA confirmed Resident #91 was a fall risk and had bilateral fall mats. The CNA explained a wheelchair should have been placed at the bottom edge of the bed to avoid obstructing the fall mat.On 08/12/2026 at 10:50 AM, a Licensed Practical Nurse (LPN) verbalized fall risk residents were identified in report and care planned for interventions, including floor mats. The LPN explained Resident #91 frequently attempted self transferring and was reminded to use the call light. The LPN verbalized Resident #91 had bilateral fall mats and explained a wheelchair was not to be placed on the fall mat because it created additional danger. The LPN confirmed awareness of Resident #91's behavior to self transfer and leave the wheelchair against the bed in the middle of the right side fall mat and explained this behavior should have been added to the care plan.On 08/13/2026 at 11:40 AM, the Director of Nursing (DON) verbalized fall mats were used to protect residents from injury if they fell from bed. The DON explained a wheelchair should not be left in the middle of a fall mat because it created a hazard. The DON expected fall mats should be picked up when a resident was out of bed and remain up until bedtime, especially for residents who attempted self transferring. The DON confirmed Resident #91's care plan should have been updated, as the resident consistently self transferred and left the wheelchair in the middle of the fall mat and was a known fall risk.The facility policy titled Comprehensive Care Plans, reviewed 06/19/2026, documented all Care Assessment Areas triggered by the Minimum Data Set 3.0 (MDS) would be considered in the developing the plan of care. Other factors identified by the interdisciplinary team or in accordance with the residents' preferences would be also addressed in the plan of care. Resident specific interventions reflected the resident's needs. Cross reference tag F689

Based on record review, interview, and document review, the facility failed to ensure a written notice of the reason for transfer was provided to a resident and/or the resident's representative and the Office of State Long-Term Care Ombudsman (Ombudsman) and a written notice of the bed-hold policy and right to return to the facility was provided to the resident and/or the resident's representative for 1 of 20 sampled residents (Resident #105). This deficient practice had the potential to place residents at risk of being denied due process and losing the right to return to the facility following a transfer to an acute care hospital. Findings include:Resident #105 Resident #105 was admitted to the facility on [DATE], with diagnoses including end stage renal disease, type II diabetes mellitus with diabetic neuropathy, unspecified, other obesity not elsewhere classified, moderate protein calorie malnutrition, infection following a procedure, deep incisional surgical site, subsequent encounter, hypertensive chronic kidney disease with stage IV chronic kidney disease or end stage renal disease, and dependence on renal dialysis. A Nurses Note dated [DATE], documented Resident #105 was sitting in the dining room when a nurse went to assess the resident prior to attending dialysis and found the resident sitting with the resident's eyes closed. The resident was unresponsive and without a pulse. Cardiopulmonary resuscitation (CPR) was initiated, and emergency medical services (EMS) was called. EMS transferred Resident #105 to an acute care hospital. Resident #105's clinical record did not include documentation a written notice of transfer, including the reason for transfer, was completed and provided to the resident, the resident's representative, and/or the Ombudsman when the resident was transferred and admitted to an acute care hospital on [DATE]. Resident #105's clinical record did not include documentation the resident and/or the resident representative were provided with notification of the facility's bed hold policy and the right to return to the facility when the resident was transferred and admitted to an acute care hospital on [DATE]. On [DATE] at 11:40 AM, the Social Services Supervisor verbalized not being aware a copy of the notice of transfer needed to be sent to the resident representative when the resident was their own person and confirmed the letter was not sent to Resident #105's representative when the resident was found unresponsive and emergently transferred to an acute care hospital on [DATE]. On [DATE] at 11:45 AM, the Social Services Supervisor confirmed a copy of the facility's bed hold policy including the right to return to the facility was not sent to the resident and/or the resident representative when Resident #105 was transferred to an acute care hospital on [DATE]. The facility policy titled Bed Hold Notice, reviewed [DATE], documented in the event of emergency transfer of a resident, the facility would provide written notice of the facility's bed hold policies to the resident and/or representative within 24 hours. The facility kept a signed and dated copy of the bed hold notice information given to the resident and/or representative in the resident file and/or medical record.The facility policy titled Transfer and Discharge, reviewed [DATE], documented the facility's transfer/discharge notice was provided to the resident and resident's representative. The facility maintained evidence the notice was sent to the Ombudsman.

Based on interview, clinical record review, and document review, the facility failed to provide trauma-informed care and identify trauma triggers for 1 of 20 sampled residents (Resident #4) diagnosed with Post-Traumatic Stress Disorder (PTSD). This deficient practice placed Resident #4 at risk for re-traumatization. Findings include:Resident #4 Resident #4 was admitted to the facility on [DATE], with a diagnosis of PTSD. A Minimum Data Set (MDS) 3.0 assessment, Section I-Active Diagnoses, dated 07/28/2026 documented Resident #4's active diagnoses included PTSD. Resident #4's Progress Notes lacked documented evidence of behavioral monitoring for Resident #4 related to PTSD and did not document triggers related to the resident's history of trauma. Resident #4's clinical record did not include an assessment regarding Resident #4's history of trauma, diagnosis of PTSD, triggers related to the diagnosis, and behaviors to be monitored. including the Trauma Screening Interview form (TSI), The TSI was a tool used to quickly determine if an individual had been exposed to potentially traumatic events and to identify if the individual was experiencing acute or chronic traumatic stress symptoms. The TSI, Section C (Care Planning) instructed the individual completing the assessment to document the resident's specific triggers and describe the signs and/or symptoms the resident displayed when the resident experienced a triggering factor. Specific triggers with the potential to re-traumatize the resident and the signs and symptoms the resident may display was also documented on the TSI form. A facility document titled In-Service Education/Meeting Report revised October 2017, did not document a diagnosis of PTSD and did not include triggers or behaviors to be monitored. On 08/12/2026 at 3:11 PM, a Certified Nursing Assistant (CNA) verbalized CNAs reviewed each resident's In-Service Education/Meeting Reports (meeting reports) each shift. The meeting reports included information regarding resident care needs. The CNA confirmed when a resident had a diagnosis of PTSD, the diagnosis was included on the meeting report, as well as any triggers to avoid and behaviors to watch for. On 08/12/2026 at 3:17 PM, a Registered Nurse (RN) verbalized the nurse knew a resident had PTSD by reading the resident's care plan. When a resident was admitted to the facility with a diagnosis of PTSD and information regarding the resident's triggers, behaviors to be monitored and related care needs were not included in the sending facility's documentation the nurse asked Medical Records to request the documentation. On 08/12/2026 at 3:24 PM, the RN confirmed nurses and CNAs would not know what behaviors to monitor and triggers to avoid if the information was not documented in the nursing care plan and was not documented in the CNAs In-Service/Meeting Report On 08/12/2026 at 3:26 PM, the RN verbalized CNAs documented behaviors for residents on a generic form in the residents' electronic health record (EHR). The RN confirmed the form was not specific to a resident's individual needs and did not include or identify behaviors related to a resident's diagnosis of PTSD. On 08/12/2026 at 3:29 PM, the RN confirmed when information related to a resident's diagnosis of PTSD was not documented nurses would not know what behaviors to watch for and/or triggers to be avoided. This lack of information had the potential to result in increased anxiety, stress, and behaviors. The RN confirmed Resident #4's EHR did not include documentation regarding Resident #4's diagnosis of PTSD including triggers and behaviors. On 08/12/2026 at 3:56 PM, the Director of Nursing (DON) verbalized when a history of trauma was identified, the expectation was a trauma informed assessment would be completed and documented on a TSI form. The DON confirmed completed TSI forms were entered into the resident's clinical record. The DON verbalized when a resident had a diagnosis of PTSD CNAs were informed verbally of the resident's diagnosis, triggers to avoid, and behaviors to be monitored. The information was entered into the Kardex and was expected to include anything which would assist in the provision of care and/or anything which hindered resident care. The DON confirmed CNAs documented behaviors in the resident's EHR on an auto generated behavioral form and confirmed the form was a generic form used for all residents and could not be personalized. On 08/12/2025 at 4:05 PM, the DON confirmed Resident #4's EHR did not include a TSI. On 08/12/2026 at 4:12 PM, the DON explained the concern was when nurses and CNAs were not aware of a resident's diagnosis of PTSD, triggers to be avoided and the behaviors to be monitored, the resident had the potential to be emotionally taken back to when the trauma occurred. The DON confirmed Resident #4's EHR did not include the specific triggers and behaviors related to the resident's diagnosis of PTSD. The DON verbalized Resident #4's EHR should have included documentation regarding what the resident's trauma was related to and confirmed the documentation was not in Resident #4's EHR. The facility policy titled Trauma Informed Care, undated, documented the facility provided care and services to address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility used a multi-pronged approach to identify a resident's history of trauma. The facility identified triggers which could re-traumatize residents with a history of trauma. Trigger-specific interventions identified ways to decrease a resident's exposure to triggers, as well as identifying ways to mitigate or decrease the effect of the trigger on the resident. Cross reference with tag F656Complaint #2991102

Based on interview and document review, the facility failed to ensure staff, residents, and residents' families were provided education at least annually regarding the facility's antibiotic stewardship program according to facility policy. This deficient practice had the potential to result in suboptimal treatment of infections and lack of knowledgeable staff to follow the facility's antibiotic use protocols.Findings include: On 08/07/2025 at 8:46 AM, the Infection Preventionist (IP) verbalized the IP provided education to staff regarding the facility's antibiotic stewardship program when staff had questions. The IP verbalized the IP was unsure and would have to find out if education regarding antibiotic stewardship was provided to staff annually and how residents and residents' families/representatives were provided education related to antibiotic stewardship. On 08/07/2025 at 11:14 AM, the Regional Nurse Consultant (RNC) verbalized the RNC thought staff were provided education related to antibiotic stewardship during annual infection control training. The RNC denied all residents and residents' families were provided education regarding antibiotic stewardship annually. The RNC verbalized if a resident was not prescribed an antibiotic, it wouldn't make sense to educate the resident and the resident's family on antibiotic stewardship. On 08/07/2025 at 11:54 AM, the IP verbalized annual education provided to staff related to infection control included topics such as transmission-based precautions and enhanced barrier precautions. The IP denied the training included information related to the antibiotic stewardship program. The IP denied all staff, residents, and residents' families were provided annual education specific to antibiotic stewardship. On 08/07/2025 at 12:05 PM, the RNC affirmed the facility's policy documented the facility was supposed to provide education regarding antibiotic stewardship to staff, residents, and residents' families annually and confirmed the facility was not following the policy. The facility policy titled Antibiotic Stewardship Program, implemented 04/11/2025, documented an antibiotic stewardship program was to be implemented as part of the facility's overall infection prevention and control program. The purpose of the program was to optimize the treatment of infections while reducing adverse events associated with antibiotic use. Licensed nurses participated in the program through assessment of residents and following protocols as established by the program. Education regarding antibiotic stewardship was to be provided at least annually to facility staff, prescribing practitioners, residents, and families. Documentation related to the program was to be maintained by the IP. Documentation included but was not limited to antibiotic use protocols/algorithms and records related to education of physicians, staff, residents, and families.

Based on observation, interview, and document review, the facility failed to ensure staff performed hand hygiene upon entering the food preparation area of the kitchen and kitchenettes, and sanitary food handling occurred during lunchtime meal service. This deficient practice had the potential to result in placing residents at risk for food-borne illnesses. Findings include: Hand Hygiene During an observation of lunch tray line, the following sequential events occurred without doffing gloves, performing hand hygiene, or donning clean gloves:-On 08/06/2025 at 11:18 AM, the dietary staff exited the food preparation area, entered the pantry, collected serving scoops, re-entered the food preparation area, placed the scoops into the hot hold station and began portioning food.-On 08/06/2025 at 11:45 AM, the dietary staff exited the food preparation area, entered the pantry, collected a bag of bread, collected a jar of peanut butter, collected a jar of jelly, re-entered the food preparation area, opened the bag of bread and laid out slices of bread on the counter, exited the food preparation area, entered the pantry, collected a spoon and knife, re-entered the food preparation area, picked up a slice of bread and slathered peanut butter onto the slice. On 08/06/2025 at 11:45 AM, the Dietary Supervisor (DS) verbalized the food preparation area was considered the main kitchen area where food was made. The pantry and dish-washing sections would not be considered food preparation areas. The DS explained when staff returned to the food preparation area, staff were expected to doff gloves, wash hands, and don new gloves in order to prevent the spread of bacteria. The DS confirmed the lack of hand hygiene during the lunch tray line. On 08/05/2025 at 12:31 PM, during an observation of lunchtime meal service in the locked memory care unit, a Certified Nursing Assistant (CNA) used an alcohol-based hand rub, entered a kitchenette, exited the kitchenette, and re-entered the kitchenette. The CNA did not wash the CNA's hands. On 08/05/2025 at 12:35 PM, during an observation of lunchtime meal service in the locked memory care unit, the CNA entered the kitchenette, opened two cupboards, collected pepper packets, and brought the pepper to a resident in the dining room. The CNA did not wash the CNA's hands. On 08/05/2025 at 1:41 PM, the CNA verbalized staff washed hands prior to serving meal trays during meal service; however, the CNA was unaware of a process related to hand hygiene upon entering the kitchenette. The CNA confirmed the CNA did not wash the CNA's hands upon entering the kitchenette and explained the lack of hand hygiene could pose an infection control risk when entering the kitchenettes. On 08/06/2025 at 1:44 PM, the DS verbalized staff were expected to wash hands upon entering the kitchenettes. The DS explained it would be ideal to have one staff in the dining area serving meal trays and one staff in the kitchenettes collecting additional requested items to limit cross contamination. On 08/06/2025 at 4:10 PM, the Director of Nursing (DON) explained staff should wash hands when entering the kitchenettes when staff hands were visibly soiled. The DON verbalized the facility did not have enough staff to consistently perform appropriate hand hygiene during meal service. The facility policy titled, Handwashing Guidelines for Dietary Employees, implemented 04/11/2025, documented dietary employees would clean their hands by handwashing every time an employee entered the kitchen. Sanitary Food Handling On 08/05/2025 at 12:14 PM, during an observation of lunchtime meal service in the locked memory care unit, the following events occurred:-The CNA held a tray of empty mugs to the CNA's torso coming in contact with the CNA's clothing. The CNA distributed the mugs amongst the residents in the dining room.-The CNA removed a tray from the meal cart and held the food tray to the CNA's torso, coming in contact with the CNA's clothing. The CNA placed the food tray in front of a seated resident in the dining room.-The CNA removed another tray from the meal cart and held the food tray to the CNA's torso. The edge of the food tray, hot plate, and bowl on the tray came in contact with the CNA's clothing. The CNA placed the food tray in front of another seated resident in the dining room. On 08/05/2025 at 1:41 PM, the CNA verbalized during meal service, staff should hold the tray up and away from the body as an infection control prevention due to items coming in contact with staff clothing potentially contaminated with bacteria. The CNA confirmed holding the trays against the CNA's torso and verbalized the action could affect all residents receiving the mugs and food. On 08/07/2025 at 10:34 AM, a Licensed Practical Nurse (LPN) verbalized staff were expected to hold meal trays away from the body to prevent contact with potentially contaminated staff clothing. On 08/07/2025 at 11:25 AM, the DON verbalized the DON expected staff to hold the trays away from staff clothing because contact with clothing presented an infection control risk.

Based on clinical record review, interview, and document review the facility failed to ensure 1 of 5 residents sampled for vaccines (Resident #69) was offered a 2024-2025 COVID-19 (Covid) vaccine after consenting to the vaccine. This deficient practice had the potential to result in severe illness and/or hospitalization from infection with Covid. Findings include: Resident #69 Resident #69 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, type two diabetes mellitus with diabetic neuropathy, unspecified and acute on chronic systolic (congestive) heart failure. Resident #69's clinical record included an informed consent for the Covid vaccine. A checkmark indicated the resident consented to the vaccine and the form was signed by the resident on 06/22/2025. The immunizations section of Resident #69's clinical record documented the resident last received a dose of the Covid vaccine on 10/11/2022. On 08/06/2025 at 4:42 PM, the Infection Preventionist (IP) explained the IP followed Centers for Disease Control and Prevention (CDC) guidelines when determining if a resident was up to date with the Covid vaccine. The IP verbalized Resident #69 last received a Covid vaccine in October of 2022 and needed a dose of the updated vaccine. The IP explained the IP had contacted the facility's contracted pharmacy and a local pharmacy in early 2025 and was unable to secure doses of the vaccine. The IP denied having documentation of contact with the pharmacy, purchase orders for the vaccine, and documentation of additional efforts to secure the vaccine for residents who wished to receive an updated dose. The CDC document titled Adult Immunization Schedule Notes, dated 07/02/2025, documented routine vaccination for people age [AGE] and older who were previously vaccinated before the 2024-2025 vaccine included:- Administer one dose of the 2024-2025 vaccine at least eight weeks after the most recent dose.- Administer a second dose of the 2024-2025 vaccine six months later. The facility policy titled Covid-19 Vaccination, implemented 04/11/2025, documented the facility minimized the risk of acquiring, transmitting, or experiencing complications from Covid-19 by educating and offering the Covid-19 vaccine to residents and staff. Up to date was defined as receiving a 2024-2025 updated Covid-19 vaccine, per CDC guidelines. The number of updated vaccine doses was based on age and vaccination history. Residents age [AGE] years and older were to receive two doses of any 2024-2025 Covid-19 vaccine, spaced six months apart. In case of lack of availability of the Covid-19 vaccine, or other issue with the availability leading to an inability to implement the Covid-19 vaccine program, the facility would demonstrate the vaccine had been ordered and a confirmation of the order indicating the vaccine had been shipped or the product was not available but would be shipped when supply was available.

Based on observation, clinical record review, interview, and document review, the facility failed to adhere to proper infection control protocols by 1) allowing a resident's catheter tubing to drag on the floor while the resident was seated in a wheelchair for 1 unsampled residents (Resident #4) and 2) failing to ensure reusable resident-care equipment was cleaned and disinfected after each use. This deficient practice had the potential to result in contamination of the catheter tubing, urinary tract infections, increased risk of other complications for the resident, and spread of infectious organisms throughout the facility. Findings include: Catheter Care Resident #4 was admitted to the facility on [DATE], with a diagnosis of other retention of urine. A physician's order dated 06/14/2025, documented urinary catheter size 16 French scale (Fr) with 10 cubic centimeters (cc) balloon. On 08/05/2025 at 4:46 PM, Resident #4 was in a wheelchair in the hallway outside the resident's room with the catheter drainage bag attached to the underside of the wheelchair. The resident's catheter tubing and privacy bag was in contact with the floor. On 08/05/2025 at 4:46 PM, a Certified Nursing Assistant (CNA) verbalized catheter tubing should not be in contact with the floor as it could spread bacteria to the residents. On 08/05/2025 at 4:46 PM, a Licensed Practical Nurse (LPN) explained catheter drainage bags were to be covered in a privacy bag and hung off of the bottom of the wheelchair. The LPN verbalized tubing should never drag on the floor because the tubing could tug and compromise the integrity of the catheter drainage bag, or the floor could introduce bacteria to the resident, potentially harming the resident. The LPN confirmed Resident #4's catheter tubing and privacy bag was in contact with the floor. On 08/06/2025 at 3:37 PM, the Director of Nursing (DON) verbalized catheter tubing should be secured to the leg. The DON explained catheter tubing should not be on the floor where the tube could pull on the catheter drainage bag. The facility policy titled, Catheter Care, implemented 04/11/2025, documented the facility would ensure residents with indwelling catheters received appropriate catheter care. Disinfecting of reusable resident-care equipment On 08/07/2025 at 7:55 AM, an LPN was passing medications in the dining room area of the memory care unit. The LPN placed a wrist cuff on a resident's right wrist to check the resident's Blood Pressure (BP). The LPN then returned to the medication cart and placed the cuff on top of the medication cart. The LPN did not disinfect the cuff. On 08/07/2025 at 8:01 AM, the LPN placed the cuff on a second resident's wrist to check the resident's BP. The LPN then removed the cuff, returned to the medication cart and placed the cuff on top of the medication cart. The LPN did not disinfect the cuff. On 08/07/2025 at 8:14 AM, the LPN grabbed the BP cuff and entered a resident's room. On 08/07/2025 at 8:17 AM, the LPN returned to the medication cart and placed the cuff on top of the cart. The LPN did not disinfect the cuff. On 08/07/2025 at 8:23 AM, the LPN verbalized staff should don gloves and use disinfectant wipes to clean shared equipment in between each resident. The LPN confirmed the LPN did not disinfect the BP cuff after each use during the morning medication pass as required. On 08/07/2025 at 8:46 AM, the Infection Preventionist verbalized shared resident-care equipment should be disinfected after each use to prevent spread of infections. Shared resident-care equipment included anything used for multiple residents such as glucometers and blood pressure cuffs. The facility policy titled Cleaning and Disinfection of Resident-Care Equipment, implemented 04/11/2025, documented resident-care equipment could be a source of indirect transmission of pathogens and would be cleaned and disinfected in accordance with Centers for Disease Control and Prevention (CDC) recommendations in order to break the chain of infection. Staff were to follow established infection control principles for cleaning and disinfecting reusable equipment. Multiple-resident use equipment was to be cleaned and disinfected after each use.

Based on interview, clinical record review, and document review, the facility failed to ensure a clinical record was complete for 1 of 18 sampled residents (Resident #5). This deficient practice had the potential for care provided to residents, resident response to care provided, and refusals of care to not be documented and available for review as necessary.Findings include: Resident #5 was admitted to the facility on [DATE], and readmitted on [DATE], with a primary diagnosis of acute on chronic diastolic heart failure. A Comprehensive Care Plan included a care plan revised 07/12/2025, documenting Resident #5 was married, and their spouse resided in the facility. Resident #5 would maintain meaningful connection with their spouse through regular visits and shared time. An intervention documented to encourage regular visits with the resident's spouse by arranging seating or walking assistance as needed. On 08/06/2025 at 10:27 AM, Resident #5 verbalized the resident had been married 50 years. Approximately one year prior, Resident #5's spouse moved into the locked memory care unit and Resident #5 moved into an unlocked unit of the skilled nursing facility. Resident #5 verbalized visiting the resident's spouse most days for lunch, dinner, and activities in the locked memory care unit. Resident #5 described struggling to leave the resident's spouse and had wanted to spend the night with their spouse in the past. Resident #5 explained if the resident lived in the same unit as the resident's spouse, the resident may feel more in control of and less worried about the care the resident's spouse was receiving. Resident #5 verbalized the facility did not inform the resident of the right to room with the resident's spouse. The resident explained the resident did not know it was an option. On 08/06/2025 at 12:49 PM, a Licensed Practical Nurse (LPN) verbalized Resident #5 was admitted to the adjoined assisted living facility prior to requesting movement to the skilled nursing facility in order to be closer to Resident #5's spouse. The LPN explained Resident #5 would often enjoy meals and participate in activities with the resident's spouse in the locked memory care unit of the facility. The LPN verbalized belief an oriented resident would not qualify nor want to reside in the locked memory care unit of the facility. The LPN verbalized being unsure whether Resident #5 was informed of the right to room with the resident's spouse. On 08/06/2025 at 12:58 PM, the Social Services Supervisor (SSS) verbalized residents were informed upon admission of the right to room with their spouse if both resided in the facility. Married couples had multiple options including to room together and to facilitate a private room for the resident to stay overnight periodically. Residents had the right to decide to room together. The SSS explained Resident #5 resided in the skilled nursing unit of the facility while the resident's spouse resided in the locked memory care unit. The SSS explained the SSS had previously spoken to Resident #5 about sharing a room with the resident's spouse and verbalized the conversation should be documented in the resident's health record. On 08/07/2025 at 8:13 AM, the SSS verbalized Resident #5's health record lacked documentation the resident was informed of the right to room with their spouse and lacked documentation the facility offered to accommodate a shared room for Resident #5 and their spouse. The facility policy titled, Resident Rights, implemented 04/11/2025, documented the facility would inform residents both orally and in writing of their rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Residents had the right to be treated wit respect and dignity, including the right to share a room with the resident's spouse when married residents live in the same facility and both spouses consent to the arrangement.

Based on observation, interview, record review, and document review, the facility failed to ensure a physician's order for dialysis was obtained for 1 of 3 residents (Resident #1) prior to the resident receiving dialysis treatments. This deficient practice had the potential to result in the resident not being assessed and monitored appropriately before and after dialysis. The importance of pre and post dialysis monitoring and assessments was to ensure the resident did not have an adverse outcome associated with dialysis including hypotension, muscle spasms, abnormal heart rhythms, and electrolyte imbalances. Findings include: Resident #1 was admitted to the facility on [DATE], with diagnoses including end stage renal disease (ESRD), hyperkalemia, heart failure, unspecified, anemia in chronic kidney disease, and dependence on renal dialysis. Resident #1's Minimum Data Set (MDS) 3.0, section O0110, J1 and J2 documented yes for dialysis, and yes for hemodialysis. On 08/05/2025, Resident #1's Order Summary Report did not include an order for dialysis, including the type and location of the access port, assessment of the dialysis access port before and after dialysis, the resident's dialysis schedule the Nephrologist's name and phone number, the name and phone number of the dialysis center, transport arrangements, instructions for administering or holding specific medications prior to dialysis, assessing vital signs, and monitoring the resident for signs of an adverse reaction.On 08/06/2025 at 1:26 PM, the Director of Nursing (DON) confirmed Resident #1's clinical record did not include an order for dialysis. A facility policy titled Hemodialysis dated 04/11/2025, documented the facility ensured physician orders for dialysis were in place and included the following: -The type of access for dialysis such as a graft, arteriovenous shunt, or an external dialysis catheter. -The location of the dialysis access.-The resident's dialysis schedule. -The Nephrologist name and phone number. -The dialysis center's name and phone number. -Transportation to and from the dialysis center. -The administration or withholding of administration of any specific medication prior to dialysis treatments. -Fluid restrictions if ordered by the physician.

Based on observation, interview, clinical record review, and document review the facility failed to ensure the Garden Court Unit (memory care unit) was free from accident hazards when a broken planter box with exposed nails/staples was in an area accessible to 28 of 28 residents residing on the unit and when staff provided hand sanitizing wipes to residents in the dining area without adequate supervision and a resident placed the sanitizing wipe in the resident's mouth (Resident #47). This deficient practice had the potential to result in injuries to residents and staff.Findings include: On 08/06/2025 at approximately 11:55 AM, during an observation of the memory care unit, a wooden planter box was on top of an approximately three-foot tall, permanent structure in the common area. The structure divided the dining area from the activities area of the unit and was accessible to all residents. The bottom of the planter box had come away from the main portion of the box, leaving several exposed nails/staples. There were 18 residents present in the dining area. On 08/06/2025 at 12:59 PM, a Licensed Practical Nurse (LPN) verbalized examples of safety risks in the memory care unit included spilled liquids on the floor and items left out such as medications and lotions. The LPN explained staff had to be very careful not to leave anything out in the unit. The LPN confirmed exposed nails would be considered a safety risk as residents could get a skin tear, could cut the resident's arm, could get a hold of them and get hurt or hurt someone else. On 08/06/2025 at 1:05 PM, the LPN confirmed the planter box was broken, leaving exposed nails/staples, and verbalized the LPN was unsure how long it had been broken. On 08/07/2025 at 9:59 AM, the Director of Nursing (DON) verbalized staff were provided with annual training regarding care of residents with dementia and the training included topics such as different ways to approach residents, use of redirection when handling residents with behaviors and resident safety. The DON explained a safety hazard in memory care was any item residents may put in their mouth and anything sharp. Sharp items could be used as a weapon. The DON confirmed exposed nails/staples would be considered a safety hazard as a resident could be injured. Resident #47 Resident #47 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, cognitive communication deficit, and dysphagia following cerebral infarction. On 08/06/2025 at 7:29 AM, there were 14 residents seated in the dining room in the memory care unit, waiting for breakfast to be served. A Certified Nursing Assistant (CNA) had a container of Purell sanitizing wipes and handed one wipe to each resident and asked each resident to clean their hands with the wipes. A Daily Census Report dated 08/07/2025, documented the census for Garden Court for the day was 28 residents. On 08/07/2025 at 7:40 AM, there were 12 residents seated in the dining room in the memory care unit, waiting for breakfast to be served. On 08/07/2025 at 7:49 AM, a CNA was passing out Purell sanitizing wipes for residents to clean their hands. The CNA approached Resident #47 and placed a wipe on the resident's hands, which were resting on the resident's lap. The CNA asked Resident #47 to clean hands with the wipes and walked away. Resident #47 lifted the wipe and inspected the wipe before placing the wipe in the resident's mouth. The resident sucked on the wipe, then placed the wipe on the table in front of the resident. On 08/07/2025 7:51 AM, a review of the label on the wipes revealed the wipes were for external use only. Keep out of reach of children. If swallowed, get medical help right away or contact a poison control center. On 08/07/2025 at 8:49 AM, the CNA explained prior to each meal service, the CNA passed out sanitizing wipes for residents to wipe their hands prior to eating food. The sanitizing wipes remained with the residents until the residents had finished eating. The CNA verbalized Resident #47 would often mistakenly put things in the resident's mouth to eat, and the resident was not aware of things the resident could eat and the things the resident should not eat. When the resident was seated in the dining room, the resident had no awareness and would eat anything. The CNA verbalized placing a wipe with Resident #47 and asking the resident to clean their hands prior to walking away. The CNA confirmed not being aware the resident was placing sanitizing wipes in the resident's mouth and the CNA did not watch the resident after giving the resident a sanitizing wipe. The CNA explained the facility used Purell sanitizing wipes and the CNA would not leave children unsupervised with the wipes for fear children would eat the wipes and harm themselves. The CNA verbalized residents could harm their health if the sanitizing agent was in their mouths for consumption and confirmed the label on the Purell sanitizing wipes documented the sanitizing wipes were not safe for consumption and if consumed to contact poison control. On 08/07/2025 at 8:56 AM, the DON explained Resident #47 was placed in the memory care unit related to confusion, not being aware of self-safety awareness, severe memory loss, and dementia. Prior to each meal service in the memory care unit dining room, the CNAs were to pass out Purell sanitizing wipes for the residents to cleanse hands prior to eating a meal. The DON verbalized most residents were to be supervised by a CNA while wiping hands down and then take the wipe to throw away. The DON verbalized the Purell wipes were used because there were no harmful chemicals used that would jeopardize a resident's health and safety. The DON was unaware the label on the Purell wipes documented to call poison control if consumed and confirmed the wipes were not safe to leave a resident unsupervised with the wipes. The DON explained if consumed, such as Resident #47's incident, consequences to the resident's safety would include choking on the wipe, swallowing antibacterial chemicals, and risking the safety of the residents with the sanitizing wipes. A Nursing Progress Note dated 08/07/2025 at 9:25 AM, documented Resident #47 was reported to have inadvertently placed a sanitizing wipe in the resident's mouth, and the physician was notified and assessed the resident in person. The physician advised to monitor the resident each shift, for 72 hours. The staff needed to monitor the resident for oral irritation and altered mental status. The facility policy titled Accidents and Supervision, implemented on 04/11/2025, documented resident environmental areas were to remain as free of accident hazards as was possible. Each resident would receive adequate supervision and assistive devices to prevent accidents. The supervision would include identifying hazards and risks, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. Hazards were defined as elements of the resident environment which had the potential to cause injury or illness.

Based on clinical record review, interview, observation, and document review, the facility failed to ensure a resident maintained a dignified existence when a resident's catheter drainage bag was visible with urine while the resident was in the hallway and in a communal area of the facility for 1 unsampled residents (Resident #4). This deficient practice had the potential to result in avoidable psychosocial harm to the resident.Findings include: Resident #4 was admitted to the facility on [DATE], with a diagnosis of other retention of urine. A physician's order dated 06/14/2025, documented urinary catheter size 16 French scale (Fr) with 10 cubic centimeters (cc) balloon. On 08/05/2025 at 4:46 PM, Resident #4 was in a wheelchair in the hallway outside the resident's room with the catheter drainage bag attached to the underside of the wheelchair. The resident's catheter drainage bag was placed inside an open privacy bag allowing the urine to be visible to sight. On 08/05/2025 at 4:46 PM, a Certified Nursing Assistant (CNA) verbalized catheter drainage bags were expected to be placed in a closed privacy bag. The CNA verbalized CNAs were responsible for ensuring catheter drainage bags were maintained. On 08/05/2025 at 4:46 PM, a Licensed Practical Nurse (LPN) explained catheter drainage bags were to be covered in a privacy bag and hung off of the bottom of the wheelchair. The LPN confirmed Resident #4's privacy bag was open, exposing the catheter drainage bag. On 08/06/2025 at 3:37 PM, the Director of Nursing (DON) verbalized best practice required catheter drainage bags to be placed inside a closed privacy bag. The DON explained an exposed catheter drainage bag could embarrass or upset the resident. The facility policy titled, Catheter Care, implemented 04/11/2025, documented the facility would ensure residents with indwelling catheters received care to maintain dignity and privacy. Privacy bags would be available and catheter drainage bags would be covered at all times while in use. The facility policy titled, Resident Rights, implemented 04/11/2025, documented residents had the right to a dignified existence.

Based on document review and interview, the facility failed to ensure tracking and trending of infections and antibiotic use was accurately monitored and completed for July 2024 for 2 of 2 residents on an antibiotic and diagnosed with an infection (Resident #13 and #8). The deficient practice had the potential to affect the facility's entire resident census of 79. Findings include: Resident #13 Resident #13 was admitted to the facility on [DATE], with diagnoses including unspecified fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing. A physician order dated 07/01/2024, documented Ciprofloxacin Hydrochloride (HCI) oral tablet 750 milligrams (mg), give 750 mg by mouth two times a day for arm infection related to unspecified fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing. Resident #8 Resident #8 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including acute and chronic respiratory failure with hypoxia and other specified urinary incontinence. A physician order dated 07/13/2024, documented Doxycycline Hyclate oral tablet 100 mg give one tablet by mouth two times a day for elevated white blood cells (WBC) for five days. A physician order dated 07/14/2024, documented Amoxicillin oral capsule 500 mg, give two capsules by mouth two times a day for elevated WBC until 07/17/2024. On 07/16/2024, the Antibiotic Stewardship binder lacked identification of infections, antibiotic use, tracking, room mapping, and trending for July 2024. The facility lacked a Monthly Antibiotic /Infection Control Log for July 2024. On 07/16/2024 at 1:58 PM, the Infection Preventionist (IP)/Assistant Director of Nursing (ADON) could not produce a Monthly Antibiotic/Infection Control Log for July 2024, and confirmed the IP/ADON had not performed infection trending or tracking for the month of July 2024, for a total of 16 days. The IP/ADON explained the IP/ADON kept track of infections in handwritten notebooks throughout the month and confirmed the IP/ADON had not yet started an infection notebook for July 2024, because the IP/ADON had been on vacation for three days in July. The IP/ADON explained the person covering the IP/ADON did not have access to the Monthly Antibiotic/Infection Control Log and could not create or update the document with active infections and antibiotic use for July 2024, during the IP/ADON's absence. On 07/16/2024 at 3:01 PM, the IP/ADON explained the facility used Point Click Care (PCC) as the facility's electronic documentation system. PCC included a screening tool completed by nursing staff when an infection was suspected. The IP would see the information on the dash board in PCC, discuss the resident in the daily clinical meeting, and would document this in the handwritten notebook and then transfer the information to the Monthly Antibiotic/Infection Control Log at the end of each month. An infection map was to be used to locate each type of infection by resident room and was to be completed monthly. The IP confirmed a map for July 2024 had not yet been created and would only include residents who were taking an antibiotic, omitting residents with infections, not currently treated with antibiotics. The IP/ADON lacked an understanding of the difference between tracking infections and tracking antibiotics to treat infections. Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable. On 07/16/2024 at 1:30 PM, a Licensed Practical Nurse (LPN) explained Resident #40 was on contact precautions due to a wound cultured and positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). An Antimicrobial Susceptibility and Organism Identification Report with a collection date of 06/19/2024, and a reported date of 06/22/2024, documented a culture from Resident #40's right gluteal was positive for MRSA. On 07/16/2024 at 3:35 PM, the IP/ADON confirmed the lack of tracking infections for July 2024, placed the other residents at an increased risk of contracting a multi-drug resistant organism (MDRO) or other infections. On 07/16/2024 at 5:07 PM, during an interview with the Director of Nursing (DON) and in the presence of the IP/ADON, the DON confirmed the DON provided oversight of the IP/ADON. The DON confirmed MRSA was an MDRO. The DON verbalized the DON knew MRSA could be detrimental to immunocompromised residents. On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP/ADON was responsible for the execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program. The facility policy titled Antibiotic Stewardship, revised 01/31/2024, documented the facility would follow an Antibiotic Stewardship program which included the core elements as outlined by the CDC. The Infection Preventionist was the designated coordinator of the Infection Prevention and Control Program. The facility would track antibiotic use daily and would monitor for all adverse reactions/outcomes related to antibiotic therapy. A CDC document titled Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented the seven core elements of the ASP was as follows: -Leadership Commitment: Demonstrate and support safe and appropriate antibiotic use. -Accountability: Identify nursing, physician, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship. -Drug expertise: establish access to individuals with experience or training in antibiotic stewardship. -Action: Implement at least policy or practice to improve antibiotic use. -Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in the facility. -Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff. Cross-reference with tag F880 and F882

Based on observation, clinical record review, interview, and document review the facility failed to ensure 1) Enhanced Barrier Precautions (EBP) were implemented for 2 of 7 sampled residents (Resident #58 and #69), 2) the facility peformed active infection surveillance for July 2024, 3) a Licensed Practical Nurse (LPN) performed hand hygiene between residents while administering medications and 4) a resident on contact precautions did not share a room with another resident who did not have the same infection with the same microorganism, did not have meals in a shared dining room, and staff understood the Personal Protective Equipment (PPE) requirements when entering a room with contact precuation signage in place for 1 of 18 sampled residents (Resident #40). Findings include: Enhanced Barrier Precautions Resident #58 Resident #58 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, type II diabetes mellitus without complications, benign prostatic hyperplasia without lower urinary tract symptoms, and acute on chronic respiratory failure with hypoxia. A physician order dated 04/25/2024, documented 16 French 10 cubic centimeters (cc) Foley catheter as needed related to neuromuscular dysfunction of bladder, unspecified. Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, apraxia, dysarthria and anarthria, and pressure ulcer of sacral region, Stage III. A physician order dated 07/10/2024, documented the following for wound treatment: -cleanse coccyx with wound cleaner, pat dry, apply hydrogel to wound bed and cover with foam dressing. Monitor for any signs or symptoms of infection, notify provider with any concerns. Every day shift Monday, Wednesday, Saturday related to pressure ulcer of sacral region, Stage III. Resident #69's Care Plan, last reviewed 06/03/2024, documented the resident's care was to be provided using EBP protocol. On 07/15/2024 at 5:35 PM, during a facility tour, Resident #69 and Resident #58's rooms did not have an EBP sign on the resident's room door or on the wall outside of each door. Both rooms lacked a PPE cart outside the room doors. On 07/16/2024 at 1:54 PM, the IP/ADON explained any resident receiving wound care should have EBP and confirmed Resident #69 received wound care three times weekly. On 07/16/2024 at 2:42 PM, Resident #69 and #58's rooms did not have EBP signage on the room door or a PPE cart outside the rooms. On 07/16/2024 at 2:47 PM, the IP/ADON explained each resident on EBP should have a sign on the door indicating EBP in use and what PPE to wear. The IP/ADON verbalized all residents with an indwelling catheter would be placed on EBP and confirmed Resident #58 had an indwelling catheter. On 07/16/2024 at 3:15 PM, the IP/ADON communicated the facility used the Centers for Disease Control (CDC) signage for resident precautions. EBP would include residents with a Foley catheter, an ostomy, and a wound requiring a dressing change. The IP/ADON explained the purpose of using the EBP was to protect the resident from possible transmission of infection and to protect staff from carrying the infection on staff clothing. On 07/16/2024 at 5:07 PM, the Director of Nursing (DON) explained infection precautions were based on the provider's recommendations and the CDC recommendations for EBP, PPE, and isolation. The DON communicated the infection control program was intended to prevent the spread of infection and prevent cross-contamination between the staff and residents and the IP was responsible for the program. The DON expected staff to don/doff gowns and gloves during care of resident's on EBP. On 07/18/2024 at 8:39 AM, the IP/ADON confirmed the facility followed the CDC guidance for infection control. The IP/ADON confirmed the facility did not follow CDC standards with the lack of EBP signage and PPE carts at the point of care for Resident #58 and #69. The facility policy titled Infection Control, revised 01/31/2024, documented all residents with known or suspected infectious conditions would be cared for using the most appropriate nursing care for the benefit and safety of the resident concerned, the other residents in the facility, and employee safety. A Centers for Medicare and Medicaid memo titled Quality, Safety, and Oversight (QSO)-24-08-Nursing Homes (NH), dated 03/20/2024, documented EBP recommendations included the use of EBP for residents with chronic wounds or indwelling medical devices during high-contact resident care activities regardless of the multidrug-resistant organism status, in addition to residents who had an infection or colonization with a CDC-targeted other epidemiologically important [NAME] Drug Restistant Organisms (MDROs). Staff should be aware of which residents require the use of EBP prior to providing high-contact care. It was critical to ensure staff had awareness of the facility's expectations about hand hygiene and gown/glove use and access to appropriate supplies. This was accomplished by the following: Surveillance On 07/16/2024 at 1:58 PM, the Antibiotic Stewardship binder did not include infections, antibiotic use, tracking, room mapping, or trending for July 2024. The IP/ADON could not produce a Monthly Antibiotic/Infection Control Log for July 2024 and confirmed the IP/ADON had not yet performed infection trending or tracking for the month of July because the IP had been on vacation. The IP/ADON explained the IP/ADON kept track of infections in handwritten notebooks throughout the month and confirmed the IP/ADON had not yet started an infection notebook for July 2024 and could not produce the June 2024 notebook. On 07/16/2024 at 3:01 PM, the IP/ADON explained the facility used Point Click Care (PCC) as the facility's electronic documentation system. PCC included a screening tool completed by nursing staff when an infection was suspected. The IP/ADON would see the information on the dash board in PCC, discuss the resident in the daily clinical meeting, would document the discussion in the handwritten notebook, and transfer the information to the Monthly Antibiotic/Infection Control Log at the end of each month. An infection map was used to locate each type of infection by resident room and was completed monthly. The IP/ADON confirmed a map for July 2024 had not yet been created and would only include residents who were taking an antibiotic, omitting residents with infections not currently treated with antibiotics, including a wound infection of Methicillin Resistant Staphylococcus Aureus (MRSA). The IP/ADON explained the IP/ADON would not know if an infection was currently contained or spreading throughout the facility as there was not a current infection map for July 2024. On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP/ADON was responsible for oversight and execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program. A job description titled Assistant Director of Nursing, documented the primary responsibilities of the ADON included supervision of the infection control and antibiotic stewardship program. Specific duties included completion of the weekly Infection Control Report, review numbers of infections and isolations to determine areas of concern, monitor completion of weekly measurements and documentation of wounds, and monitor/ensure compliance of standard precautions, the vaccine program, bloodborne pathogens, and CDC guidelines for isolation/treatment of infections. 49557 Hand Hygiene During Medication Pass On 07/17/2024, during the medication pass from 4:11 PM through 4:24 PM, an LPN administered medications to five residents and did not perform hand hygiene prior to preparing medication for each resident, prior to administering medication to each resident, or after administering medication to each resident. On 07/17/2024 at 4:25 PM, the Licensed Practical Nurse (LPN) confirmed the LPN did not perform hand hygiene prior to medication preparation and administration or after medication administration. The LPN explained hand hygiene was required to be performed between each resident. On 07/18/2024 at 9:06 AM, the DON explained hand hygiene was required to be performed by staff prior to any initiation of care with a resident. The DON confirmed hand hygiene was required to be performed during medication pass, prior to and after each resident interaction. The facility policy titled Infection Control, revised 01/31/2024, documented hand washing was the foundation of controlling infectious disease. Personnel were to wash hands when between residents. Contact Precautions On 07/15/2024 at 1:12 PM, room [ROOM NUMBER] had a sign on the door indicating contact precautions were in place. The sign stated everyone must perform hand hygiene before entering and when leaving the room, providers/staff must put on gloves and a gown before entering the room. A PPE cart was located outside the door, in the hallway. The placard on the wall outside the room indicated the room belonged to Resident #40 and Resident #26. Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, stage five and type two diabetes mellitus with diabetic chronic kidney disease. Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable. On 07/16/2024 at 8:31 AM, Resident #26 explained the contact precaution sign on the resident's door was intended for Resident #40 due to wounds on Resident #40's legs. Resident #26 denied staff regularly wore a gown or gloves while providing care to Resident #26. On 07/16/2024 at 9:16 AM, a Certified Nursing Assistant (CNA)1 entered room [ROOM NUMBER]. The CNA1 was not wearing a gown or gloves. On 07/16/2024 at 9:48 AM, a CNA2 explained the sign on the door of room [ROOM NUMBER] was in place because Resident #40 had a wound on the resident's hip. The CNA2 further explained the sign was intended to notify staff to don a gown when providing care to Resident #40 if the care required physical contact with the resident. The CNA2 verbalized a gown was not required when providing care to Resident #26. On 07/16/2024 at 1:30 PM, an LPN explained staff received infection control training quarterly. The LPN confirmed the training covered the topics of EBP and transmission-based precautions (TBP). The LPN explained staff knew a resident was on EBP or TBP by a sign on the resident's door. The LPN verbalized the sign would instruct staff on what PPE was required and when staff was required to wear it. The LPN explained Resident #40 was on contact precautions due to a wound cultured and positive for Methicillin-Resistant Staphylococcus Aureus (MRSA). The sign meant staff were required to don a gown and gloves for hands on care for Resident #40 such as showers, transfers, and changing the resident's clothing. A gown and gloves were not required when staff were only walking in the room. The LPN explained the intent of using a gown and gloves when providing care to Resident #40 was to prevent the transfer of MRSA onto staff clothing which could then be transferred to other residents. An Antimicrobial Susceptibility and Organism Identification Report with a collection date of 06/19/2024, and a reported date of 06/22/2024, documented a culture from Resident #40's right gluteal was positive for MRSA. Resident #40's Care Plan included a focus of MRSA: The resident had MRSA to a stage four pressure injury to right gluteal. The date initiated was 07/01/2024, and was revised on 07/15/2024. Interventions included: -Contact Precautions. Wear gown and masks when changing contaminated linens. Place soiled linens in marked biohazard. Bag linens and close bag tightly before taking to laundry. -Mask/face shield to be worn during procedures with risk of splashes or droplet contamination of bodily fluids. -Observe standard precautions for infection control. -Open wounds should be kept covered, rather than open to air. -Resident areas to be thoroughly cleaned using disinfectants. -Resident care equipment to be appropriately cleaned, disinfected or sterilized according to facility protocol. A progress note dated 06/23/2024, documented Resident #40's dressing on the resident's right glute was saturated and coming off. A progress note dated 06/27/2024, documented Resident #40's dressing on the resident's right gluteal was saturated and coming off. A progress note dated 07/01/2024, documented Resident #40 was on MRSA precautions. A progress note dated 07/01/2024, documented Resident #40's wound culture came back positive for MRSA. A progress note dated 07/04/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off. A progress note dated 07/05/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off. A progress note dated 07/11/2024, documented Resident #40's dressing on the resident's right glute was coming off. Progress notes dated from 06/23/2024 through 07/14/2024, documented Resident #40 was in the shared dining room for meals. On 07/16/2024 at 3:01 PM, the Minimum Data Set (MDS) Coordinator explained the MDS Coordinator updated residents' care plans based on interviews with the residents, meetings held with the interdisciplinary team (IDT), and clinical record review. The MDS Coordinator confirmed Resident #40's care plan included an intervention for contact precautions due to MRSA. The MDS Coordinator explained this intervention was added to Resident #40's care plan by the MDS Coordinator after the MDS Coordinator read a progress note in the resident's clinical record. The progress note indicated a lab result came back showing the resident was positive for MRSA. The MDS Coordinator explained adding the intervention to the care plan would give floor staff access to see the resident was positive for MRSA and the interventions needing to be implemented. The MDS Coordinator then verbalized the IP/ADON would be responsible to place precaution signage on the resident's door and a PPE cart in the hall. On 07/16/2024 at 3:15 PM, the IP/ADON explained the IP/ADON and/or the physician were able to make decisions on when to place residents on TBP or EBP. The IP/ADON used resident symptoms to guide the decision on which precautions were appropriate and if a resident had a wound the facility was culturing it would be more of a contact thing. The IP/ADON verbalized the facility used and followed CDC signage when placing a resident on TBP. The IP/ADON explained contact precautions were used when contact was how a possible contaminant was spread, staff were to wear a gown and gloves when providing care. The IP/ADON explained if a resident was on contact precautions due to a wound, and the wound was covered with a dressing, staff were not required to wear PPE if the care being provided did not include contact with the resident. The IP/ADON explained examples of when EBP was used were when residents had ostomies, catheters, and any wound requiring a dressing change. EBP was used to protect residents from possible transmission of infection and protected staff so the infection was not carried on clothing. With EBP, care such as showering, transfers, and anything with close contact required staff to wear a gown and gloves. The IP/ADON verbalized contact precautions and EBP were similar and it depended on if the infected area was covered or not. The IP/ADON explained the facility had one resident on contact precautions and the resident was allowed to come out of the resident's room and eat meals in the shared dining room because the resident's wound was covered. The IP/ADON confirmed the resident the IP/ADON was referring to was Resident #40. On 07/16/2024 at 3:21 PM, the IP/ADON retrieved a copy of the CDC signage the facility used for EBP and contact precautions and placed them side by side. The IP/ADON confirmed the sign for EBP instructed staff to don a gown and gloves prior to high-contact care activities. The IP/ADON confirmed the contact precautions sign instructed staff to don a gown and gloves prior to room entry and the sign did not specify PPE was only required for direct contact with the resident. The IP/ADON explained Resident #40 was previously on EBP. The resident was later placed on contact precautions after a culture of the resident's wound was positive for MRSA. The IP/ADON believed the wound culture result was received on 06/29/2024. The intent of placing Resident #40 on contact precautions was so staff would know the resident had an infection with the potential to spread. On 07/16/2024 at 3:35 PM, the IP/ADON provided a copy of the facility's TBP policy. The IP/ADON confirmed the policy stated residents on contact precautions were to be placed in a private room. The IP/ADON confirmed Resident #40 was not in a private room. The IP/ADON confirmed Resident #40's roommate, Resident #26, had a dialysis port in the resident's right upper chest. The IP/ADON confirmed placing Resident #26 in a shared room with Resident #40 put Resident #26 at an increased risk of contracting an MDRO. On 07/16/2024 at 5:07 PM, during an interview with the DON and in the presence of the IP/ADON, the DON confirmed the DON provided oversight of the IP/ADON. The DON confirmed MRSA was an MDRO. The DON explained the intent of TBP was to prevent the spread of infections. The facility followed CDC and physician recommendations when deciding to place residents on TBP. The DON verbalized it was the DON's understanding if staff entered a resident's room with contact precautions in place, and did not come into contact with the resident, staff would not be required to don PPE. The DON verbalized the DON knew MRSA could be detrimental to immunocompromised residents. The DON verbalized it was questionable whether a resident on contact precautions should be in a shared room. The DON confirmed the facility's policy stated to place a resident on contact precautions in a private room or with a resident with the same infection with the same microorganism. The DON confirmed Resident #40 had dressings described as saturated prior to 07/15/2024. On 07/17/2024 at 7:07 AM, Resident #26 was observed to have been moved to another room. Resident #40 remained in room [ROOM NUMBER], a CDC contact precautions sign remained on the door, and a PPE cart remained in the hall near the resident's doorway. The facility policy titled Infection Control, revised 01/31/2024, documented residents who were diagnosed as having an infectious disease or condition which did not warrant strict isolation procedures were to be restricted to the residents' rooms if the infection could not be contained. Activities were to be controlled such as going to the dining room and visitors to the room were to be limited. The purpose of isolation techniques was to protect the resident and personnel from infection and to halt the spread of infectious agents. The facility policy titled Categories of Transmission-Based Precautions, revised 01/2024, documented it was the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. Transmission-based precautions would be implemented, in addition to standard precautions, and were based upon the means of transmission in order to prevent or control infections. Contact precautions were implemented for residents known to be infected or colonized with organisms which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions included but were not limited to skin or wound infections or colonization with MDROs. Residents were to be placed in a private room or placed with a resident with the same infection with the same microorganism. Gloves were to be worn upon entering the room if contact with the resident or potentially contaminated surfaces was possible. Staff were to wear a gown when entering the room if it was anticipated staff would have substantial contact with the resident, the resident's environment, or items in the resident's room. Gowns were required if the resident had wound drainage not contained by a dressing. The facility policy did not follow CDC guidance regarding gown and glove usage when entering resident rooms with contact precautions in place. The CDC document titled Management of Multidrug-Resistant Organisms in Healthcare Settings (2006), updated 10/2022, documented recommendations for MDRO prevention in long-term care facilities included using contact precautions in addition to standard precautions for those residents whose infected secretions or drainage could not be contained. Contact precautions were intended to prevent transmission of infectious agents which were transmitted by direct or indirect contact with the resident or the resident's environment. Recommendations for resident placement included placing residents with MDROs in single-resident rooms or cohorting residents with the same MDRO when a single room was not available. A single resident room was preferred for residents who require contact precautions. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions which may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning a gown and gloves upon room entry and discarding before exiting the resident room was done to contain pathogens. The CDC document titled Transmission-Based Precautions, dated 04/03/2024, documented contact precautions were to be used for residents with known or suspected infections which represented an increased risk for contact transmission. Transport and movement of residents outside of the resident's room was to be limited to medically-necessary purposes. When transport or movement was necessary, infected or colonized areas of the resident's body were to be covered and staff were to don clean PPE to handle the resident at the transport location. A CDC document titled Implementation of PPE Use in Nursing Homes to Prevent Spread of MDROs, dated 07/12/2022, described EBP as an infection control intervention designed to reduce transmission of MDROs in nursing homes. EBP involved gown and glove use during high contact resident care areas for residents known to be colonized or infected with an MDRO, as well as those at increased risk of acquiring MDROs, such as residents with wounds or indwelling medical devices. Effective EBP implementation required staff training on PPE and the availability of PPE and hand hygiene supplies at the point of care. Cross reference with tag F698, F726, F881, and F882

Based on observation, interview and document review the facility failed to ensure hand washing was performed between the passing of resident beverages, touching residents and in between assisting two residents with eating. Findings include: On 07/15/2024 at 4:55 PM, in preparation for dinner in the 600 hall dining room, a Certified Nursing Assistant (CNA) completed the following sequential tasks without performing hand hygiene between tasks: -The CNA assisted a resident to a dining room seat, patted the seat, and touched the resident's oxygen tubing to reposition the tubing. -Retrieved three glasses and filled with ice and water then served to residents. -Pushed a resident in a wheel chair to a table. -Touched a resident's shoulder. -Entered the satellite pantry, retrieved a coffee pot and mug, poured the cup of coffee, served it to the resident and put the coffee pot back in the satellite pantry. -Retrieved six glasses and filled them with ice and then water. Served water glasses to residents, embraced a resident with a full hug. -Poured two more glasses of water, served, retrieved towels and began placing on residents as bibs. -Put left arm around a resident while talking to the resident. -Placed a right hand on a resident's chest while talking to the resident. -Put a towel bib on a resident. -Retrieved residents from the television area and pushed one resident in a wheel chair to a dining table. -Embraced a resident with a full hug. -Retrieved mugs and placed two mugs in front of two residents, entered the satellite pantry, retrieved a coffee pot and poured for two residents. -Reentered the satellite pantry, retrieved a pitcher of a milky beverage and poured for two residents. -Reentered the satellite pantry, retrieved juice from fridge and placed pitchers of juice on the counter. -Readjusted a resident's towel bib, repositioned the resident's glasses on their face and placed CNA's right hand on the left knee of the resident. -Touched a resident's right arm and back with the CNA's left hand. On 07/15/2024 at 5:16 PM, the CNA washed their hands. On 07/15/2024 at 5:16 PM, the CNA recalled using hand sanitizer before assisting residents to the dining room, serving residents, and assisting residents with set-up. The CNA confirmed the CNA did not perform hand hygiene to include hand sanitizer between touching each resident. The CNA verbalized the CNA did not have to wash hands when touching residents, such as giving hugs. The CNA verbalized the CNA's preference was to wash hands when handling the cups. On 07/15/2024 at 5:24 PM, the CNA explained the CNA double checked and confirmed the CNA can use only hand sanitizer when serving cups up to a handful of times to include filling ice and water cups and touching residents. 49557 On 07/15/2024 at 5:49 PM, while seating between two residents in the 400 hall dining room, a CNA2 completed the following sequential tasks without performing hand hygiene between tasks: -Provided feeding assistance to a resident. -Assisted a second resident with cleaning up a small amount of food the resident dropped on the table and on the resident's clothing, then provided feeding assistance to the same resident. -Provided feeding assistance to the first resident. -Provided feeding assistance to the second resident. On 07/15/2024 at 5:58 PM, the CNA2 confirmed the CNA2 did not perform hand hygiene between assisting each resident with eating. The CNA2 explained hand hygiene was required to be performed prior to providing feeding assistance for residents and in between each resident. On 07/18/2024 at 9:06 AM, the Director of Nursing (DON) explained hand hygiene was required to be performed by staff prior to any initiation of resident care. The DON confirmed hand hygiene was required to be performed prior to and after meals or contact with each resident. The facility policy titled Infection Control, revised 01/31/2024, documented hand washing was the foundation of controlling infectious disease. Staff were to perform hand washing when between residents. The facility policy titled Handwashing Procedure, adopted 08/2019, documented when to wash hands: every time you enter the satellite pantry, after touching clothes, face, body or hair, after handling soiled equipment, and after engaging in any activity which would contaminate hands. Hand antiseptic may be used after washing hands and was not to be used as a substitute for handwashing.

Based on observation, interview, clinical record review, and document review, the facility failed to 1) ensure the Infection Preventionist (IP) had the education and competency to demonstrate the tracking and trending of infections was accurately completed and monitored with the potential to affect the facility's entire resident census of 79, 2) retain education and training when the Infection Preventionist did not demonstrate competency in the implementation of the Antibiotic Stewardship Program (ASP) and infection surveillance (lack of competency in medication differentiation, inaccurate infection control log, lack of infection surveillance), and 3) demonstrate understanding of contact precautions and following of the Center for Disease Control (CDC) guidance related to the implementation of contact precautions for 1 of 18 sampled residents (Resident #40). Findings include: Education/Competency On 07/16/2024 at 1:58 PM, the Antibiotic Stewardship binder did not include infections, antibiotic use, tracking, room mapping, or trending for July 2024. The Infection Preventionist (IP)/Assistant Director of Nursing (ADON) could not produce a Monthly Antibiotic/Infection Control Log for July and confirmed the IP/ADON had not yet performed infection trending or tracking for the month of July 2024, because the IP/ADON had been on vacation for three days in July. The IP/ADON explained the IP/ADON usually kept track of infections in handwritten notebooks throughout the month and confirmed the IP/ADON had not yet started an infection notebook for July 2024. On 07/16/2024 at 3:01 PM, the IP/ADON explained an infection map was to be used to locate each type of infection by resident room and was to be completed monthly to identify trends. The IP/ADON explained the infection tracking and mapping occurred at the end of the month and would not have a current infection or antibiotic resident list. The IP/ADON confirmed a map for July 2024, had not yet been created and would only include residents who were taking an antibiotic, thus omitting residents with infections not currently treated with antibiotics. ASP On 07/16/2024, the Antibiotic Stewardship binder lacked identification of infections, antibiotic use, tracking, room mapping, and trending for July 2024. On 07/16/2024, in the afternoon, the IP/ADON was asked to produce a list of all residents currently on antibiotics. On 07/16/2024 at 2:37 PM, the IP/ADON produced an Order Listing Report dated 07/16/2024 and printed at 2:06 PM, which was generated from the facility's electronic documentation system. The report listed five residents who were supposed to be prescribed antibiotics, however only two of the residents were on an antibiotic, two residents were on an antifungal medication, and one resident was on an anti-viral medication. The IP/ADON confirmed the provided list was accurate and complete to include all residents currently on an antibiotic. The IP/ADON lacked the understanding of the difference between an antibiotic medication, an antifungal medication, and an antiviral medication. On 07/16/2024 at 3:01 PM, the IP/ADON verbalized the IP/ADON had not been tracking infections not associated with an antibiotic prescription and did not include those infections on the facility mapping to trend infection spread. The IP/ADON explained the IP/ADON would not know if an infection was currently contained or spreading throughout the facility as there was not a current infection map for July 2024. The IP/ADON explained the daily stand up meeting members would discuss any new infections or suspected infections but did not document the data or map the rooms to ascertain infection spread throughout the facility. The IP/ADON confirmed the lack of surveillance of infections and antibiotics for July 2024. On 07/18/2024 at 9:10 AM, the Administrator confirmed the IP was responsible for the execution of the Infection Control and Prevention Program and the Antibiotic Stewardship program. The Administrator confirmed the lack of an IP job description and explained the role was considered a nursing role of the ADON. A job description titled Assistant Director of Nursing, documented the primary responsibilities of the ADON included supervision of the infection control and antibiotic stewardship program. Specific duties included completion of the weekly Infection Control Report, reviewed numbers of infections and isolations to determine areas of concern, monitor completion of weekly measurements and documentation of wounds, and monitor/ensure compliance of standard precautions, the vaccine program, bloodborne pathogens, and CDC guidelines for isolation/treatment of infections. The facility policy titled Antibiotic Stewardship, revised 01/31/2024, documented the facility would follow an Antibiotic Stewardship program which included the core elements as outlined by the CDC. The Infection Preventionist was the designated coordinator of the Infection Prevention and Control Program. The facility would track antibiotic use daily and would monitor for all adverse reactions/outcomes related to antibiotic therapy. A CDC document titled Core Elements of Antibiotic Stewardship for Nursing Homes, dated 03/18/2024, documented the seven core elements of the ASP was as follows: -Leadership Commitment: Demonstrate and support safe and appropriate antibiotic use. -Accountability: Identify nursing, physician, and pharmacy leads responsible for promoting and overseeing antibiotic stewardship. -Drug expertise: establish access to individuals with experience or training in antibiotic stewardship. -Action: Implement at least policy or practice to improve antibiotic use. -Tracking: Monitor at least one process measure of antibiotic use and at least one outcome from antibiotic use in the facility. -Reporting: Provide regular feedback on antibiotic use and resistance to prescribing clinicians, nursing staff, and other relevant staff. Cross-reference with tag F880, F881, and F883 49557 Contact Precautions On 07/15/2024 at 1:12 PM, room [ROOM NUMBER] had a CDC sign on the door indicating contact precautions were in place. The sign stated everyone must perform hand hygiene before entering and when leaving the room, providers/staff must put on gloves and a gown before entering the room. A Personal Protective Equipment (PPE) cart was located outside the door, in the hallway. The placard on the wall outside the room indicated the room belonged to Resident #40 and Resident #26. Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable. Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, stage five and type two diabetes mellitus with diabetic chronic kidney disease. On 07/16/2024 at 8:31 AM, Resident #26 explained the contact precaution sign on the resident's door was intended for Resident #40 due to wounds on Resident #40's legs. Resident #26 denied staff regularly wore a gown or gloves while providing care to Resident #26. On 07/16/2024 at 3:15 PM, the IP/ADON explained the IP/ADON and/or the physician were able to make decisions on when to place residents on TBP or EBP. The IP used resident symptoms to guide the decision on which precautions were appropriate and if a resident had a wound the facility was culturing it would be more of a contact thing. The IP/ADON verbalized the facility used and followed CDC signage when placing a resident on TBP. The IP/ADON explained if a resident was on contact precautions due to a wound, and the wound was covered with a dressing, staff were not required to wear PPE if the care being provided did not include contact with the resident. The IP/ADON verbalized contact precautions and EBP were similar and it depended on if the infected area was covered or not. On 07/16/2024 at 3:21 PM, the IP/ADON retrieved a copy of the CDC signage the facility used for EBP and contact precautions and placed them side by side. The IP/ADON confirmed the sign for EBP instructed staff to don a gown and gloves prior to high-contact care activities. The IP/ADON confirmed the contact precautions sign instructed staff to don a gown and gloves prior to room entering the room and sign did not specify PPE was only required for direct contact with the resident. The IP/ADON explained Resident #40 was previously on EBP and was later placed on contact precautions when a culture of the resident's wound was positive for MRSA. The IP/ADON believed the culture result was received on 06/29/2024, and the intent of placing Resident #40 on contact precautions was so staff would know the resident had an infection with the potential to spread. On 07/16/2024 at 3:35 PM, the IP/ADON provided a copy of the facility's TBP policy. The IP/ADON confirmed the policy stated residents on contact precautions were to be placed in a private room. The IP/ADON confirmed Resident #40 was not in a private room. A Job Description: Assistant Director of Nursing, signed and dated by the IP/ADON on 06/26/2023, documented the IP/ADON was responsible to monitor and ensure compliance with CDC guidelines for isolation/treatment of infections. The facility policy titled Categories of Transmission-Based Precautions, revised 01/2024, documented it was the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. Transmission-based precautions would be implemented, in addition to standard precautions, and were based upon the means of transmission in order to prevent or control infections. Contact precautions were implemented for residents known to be infected or colonized with organisms which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions included but were not limited to skin or wound infections or colonization with MDROs. Residents were to be placed in a private room or placed with a resident with the same infection with the same microorganism. The CDC document titled Management of Multidrug-Resistant Organisms in Healthcare Settings (2006), updated 10/2022, documented recommendations for MDRO prevention in long-term care facilities included using contact precautions in addition to standard precautions for those residents whose infected secretions or drainage could not be contained. Recommendations for resident placement included placing residents with MDROs in single-resident rooms or cohorting residents with the same MDRO when a single room was not available. A single resident room was preferred for residents who require contact precautions. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions which may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning a gown and gloves upon room entry and discarding before exiting the resident room was done to contain pathogens. The CDC document titled Transmission-Based Precautions, dated 04/03/2024, documented contact precautions were to be used for residents with known or suspected infections which represented an increased risk for contact transmission. The CDC document titled Frequently Asked Questions about Enhanced Barrier Precautions in Nursing Homes, dated 06/28/2024, documented EBP differed from contact precautions as contact precautions required the use of a gown and gloves on every entry into a resident's room, regardless of the level of care being provided to the resident.

Based on observation, interview, clinical record review and document review the facility failed to ensure 1) the Director of Nursing (DON) had the knowledge necessary to correctly implement contact precautions for a resident with known infection with a Multi-Drug Resistant Organism (MDRO), and 2) the DON had the knowledge and skills necessary to access resident records and navigate the Electronic Medical Record (EMR) after the facility underwent a change of ownership with a new EMR program. This lack of knowledge had the potential to effect the entire census of 79. Findings include: On 07/15/2024 at 1:12 PM, room [ROOM NUMBER] had a Centers for Disease Control (CDC) sign on the door indicating contact precautions were in place. The sign stated everyone must perform hand hygiene before entering and when leaving the room, providers/staff must put on gloves and a gown before entering the room. A Personal Protective Equipment (PPE) cart was located outside the door, in the hallway. The placard on the wall outside the room indicated the room belonged to Resident #26 and Resident #40. Resident #26 Resident #26 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including chronic kidney disease, stage five and type two diabetes mellitus with diabetic chronic kidney disease. Resident #40 Resident #40 was admitted to the facility on [DATE], with diagnoses including Parkinson's disease without dyskinesia, without mention of fluctuations, and pressure ulcer of right buttock, unstageable. On 07/16/2024 at 8:31 AM, Resident #26 explained the contact precaution sign on the resident's door was intended for Resident #40 due to wounds on Resident #40's legs. Resident #26 denied staff regularly wore a gown or gloves while providing care to Resident #26. A progress note dated 06/23/2024, documented Resident #40's dressing on the resident's right glute was saturated and coming off. A progress note dated 06/27/2024, documented Resident #40's dressing on the resident's right gluteal was saturated and coming off. A progress note dated 07/01/2024, documented Resident #40 was on MRSA precautions. A progress note dated 07/01/2024, documented Resident #40's wound culture came back positive for MRSA. A progress note dated 07/04/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off. A progress note dated 07/05/2024, documented Resident #40's dressing on the resident's right glute was saturated and falling off. A progress note dated 07/11/2024, documented Resident #40's dressing on the resident's right glute was coming off. A Census List, printed by the facility on 07/18/2024, indicated Resident #26 was moved into room [ROOM NUMBER] on 10/15/2023. A Census List, printed by the facility on 07/18/2024, indicated Resident #40 was moved into room [ROOM NUMBER] on 05/22/2024. On 07/16/2024 at 5:07 PM, during an interview with the DON and in the presence of the IP, the DON explained the intent of Transmission-Based Precautions (TBP) was to prevent the spread of infections. The facility followed CDC and physician recommendations when deciding to place residents on TBP. The DON verbalized it was the DON's understanding if staff entered the resident's room with contact precautions in place and did not come into contact with the resident, staff would not be required to don PPE. The DON confirmed Methicillin-Resistant Staphylococcus Aureus (MRSA) was an MDRO. The DON verbalized the DON knew MRSA could be detrimental to immunocompromised residents. The DON verbalized it was questionable whether a resident on contact precautions should be in a shared room. The DON confirmed the facility's policy stated to place a resident on contact precautions in a private room or with a resident with the same infection with the same microorganism. The DON confirmed Resident #40 had dressings described as saturated prior to 07/15/2024. A Job Description: Director of Nursing Services, signed and dated by the DON on 06/21/2024, documented the primary purpose of the DON position was to ensure the highest quality of resident care was maintained at all times. The DON was responsible for managing all clinical systems of the facility and participating as the lead committee member for those systems including but not limited to the infection prevention and control program. The DON was responsible to ensure all staff followed best standards of practice. The facility policy titled Categories of Transmission-Based Precautions, revised 01/2024, documented it was the policy of the facility to follow nationally recognized standards and guidelines for transmission-based (isolation) precautions. TBP would be implemented, in addition to standard precautions, and were based upon the means of transmission in order to prevent or control infections. Contact precautions were implemented for residents known to be infected or colonized with organisms which could be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Examples of infections requiring contact precautions included but were not limited to skin or wound infections or colonization with MDROs. Residents were to be placed in a private room or placed with a resident with the same infection with the same microorganism. Gloves were to be worn upon entering the room if contact with the resident or potentially contaminated surfaces was possible. Staff were to wear a gown when entering the room if it was anticipated staff would have substantial contact with the resident, the resident's environment, or items in the resident's room. Gowns were required if the resident had wound drainage not contained by a dressing. The facility policy did not follow CDC guidance regarding gown and glove usage when entering resident rooms with contact precautions in place. The CDC document titled Management of Multidrug-Resistant Organisms in Healthcare Settings (2006), updated 10/2022, documented recommendations for MDRO prevention in long-term care facilities included using contact precautions in addition to standard precautions for those residents whose infected secretions or drainage could not be contained. Contact precautions were intended to prevent transmission of infectious agents which were transmitted by direct or indirect contact with the resident or the resident's environment. Recommendations for resident placement included placing residents with MDROs in single-resident rooms or cohorting residents with the same MDRO when a single room was not available. A single resident room was preferred for residents who require contact precautions. Healthcare personnel caring for residents on contact precautions should wear a gown and gloves for all interactions which may involve contact with the resident or potentially contaminated areas in the resident's environment. Donning a gown and gloves upon room entry and discarding before exiting the resident room was done to contain pathogens. The CDC document titled Transmission-Based Precautions, dated 04/03/2024, documented TBP was a second tier of basic infection control and was to be used in addition to standard precautions for residents who may be infected or colonized with certain infectious agents for which additional precautions were needed to prevent infection transmission. Contact precautions were to be used for residents with known or suspected infections which represented an increased risk for contact transmission. In long-term care settings, room placement decisions were made while balancing risks to other residents. PPE was to be used appropriately including gloves and a gown. A gown and gloves were to be worn for all interactions which may involve contact with the resident or the resident's environment. Donning PPE upon room entry and properly discarding before exiting the room was done to contain pathogens. Cross reference with tag F880 50210 On 07/17/2024 at 3:31 PM, during an interview with the DON and in the presence of the Regional Nurse Consultant, the DON verbalized the DON was not familiar with the facility's fall protocol to include the reference to interdisciplinary team minutes and did not know where to look to find them. The DON left the interview to ask the Assistant DON. Upon return, the DON verbalized being unsure how to access a resident's MAR. Once the MAR was accessed, the DON was not sure how to interpret a checkmark on a resident's MAR for side effect monitoring. The DON confirmed being unable to see whether side effects were exhibited for the resident per the MAR but did not know where to look for documentation of the side effects. The DON left to ask the Assistant DON. Upon return, the DON explained the DON's EMR training was informal and minimal. The facility's DON job description signed by the DON on 06/21/2024, documented the DON was accountable for directing all clinical services of the facility and overseeing nursing staff training upon hire and ongoing in-service education programs.

Based on interview, clinical record review, and document review, the facility failed to ensure a resident's fall with major injury, resulting in a fracture and incurred at the facility, was reported to the State Agency (Resident #132). The deficient practice could allow a fall with major injury to not be investigated for potential abuse or neglect and not be reported to the State Agency (SA). Findings include: Resident #132 Resident #132 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including nondisplaced oblique fracture of shaft of left femur, subsequent encounter for closed fracture with routine healing, muscle weakness (generalized), stiffness of unspecified joint, not elsewhere classified, and repeated falls. The facility Resident Matrix (identified care areas), printed on 07/15/2024, documented Resident #132 had a fall with major injury. A Nursing Progress Note dated 07/03/2024, documented a Certified Nursing Assistant (CNA) heard a loud noise from Resident #132's room. The CNA entered the resident's room and discovered the resident on the floor and the resident's bed was in the highest position. A nurse was retrieved to complete an assessment of the resident. The resident had obtained a skin tear and was complaining of left hip and leg pain. The left leg appeared to be rotated out. As a result, the resident was transferred to the emergency room . A Nursing Progress Note dated 07/03/2024, documented the resident had a distal femur fracture and was being flown to a larger hospital for treatment. Hospital Records dated 07/03/2024, documented the resident was admitted to the hospital secondary to a ground level fall. The resident had broken their femur and required further admission to the hospital with evaluation and management. The resident had a history of being a poor historian and mild cognitive impairment. Hospital Records dated 07/09/2024, documented the resident was admitted to the surgical floor for a femur fracture. The resident was to be discharged on [DATE], requiring appointments for surgical orthopedic aftercare. A Nursing Progress Note dated 07/11/2024, documented a fall review was completed as a result of the resident falling in their room on 07/03/2024. The resident was found on the floor in the room with the bed in an elevated position. A nursing assessment was completed to include the resident's left leg and hip appearing to be rotated outward. The resident was transferred to the hospital for evaluation and then flown to another hospital for an evaluation and surgery on the left hip. On 07/17/2024 at 2:16 PM, the Administrator explained Resident #132 had a remote to be able to control the height of the bed and it was assumed the resident had positioned the bed in the highest position on their own. The resident had fallen out of the bed, in the middle of the night, while the bed was in the highest position. As a result, the resident had to be transferred to the hospital for a fractured femur and had to have surgery to repair the fracture. The Administrator explained Resident #132's fall with major injury was not reported to the State Agency because there was no indication abuse or neglect had occurred on behalf of the facility. The Administrator verbalized abuse investigations were reported to the State Agency and the Administrator had conducted a facility investigation as a result of the fall. The facility policy titled Abuse Prohibition and Reporting (Elder Justice Act), last revised 07/13/2023, documented if a resident had an event resulting in serious bodily injury, a report would be made to the State Agency, the Ombudsman's office and law enforcement. The report would be made the State Agency no later than two hours after the incident.

Based on observation, interview, record review and document review the facility failed to ensure a resident's call light was not draped over an oxygen concentrator and out of reach of the resident for 1 of 18 sampled residents (Resident #53). Findings include: Resident #53 Resident #53 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, with agitation, muscle weakness, generalized, and anxiety disorder. Resident #53's Care Plan initiated on 04/18/2024, and revised on 07/15/2024, documented the resident was at risk for falls related to generalized muscle weakness, history of falls, incontinence, and dementia. Interventions included to encourage the resident to call for assistance before getting out of bed or transferring and was an extensive one person assist with stand pivot transfers. On 07/15/2024 at 1:25 PM, Resident #53 was in bed trying to straighten the bed blankets over the resident's legs with the call light draped over the running oxygen concentrator. The resident was not able to reach the call light. On 07/15/2024 at 1:30 PM, a Certified Nursing Assistant (CNA) entered the room and could not initially find the resident's call light device. The CNA found the call light device draped over the oxygen concentrator and attached the call light device to the resident's blanket. The CNA confirmed the resident could not reach the call light while it was draped over the oxygen concentrator and would have to yell for help. The CNA explained Resident #53 knew how to use the call light device. On 07/17/2024 at 3:29 PM, a Licensed Practical Nurse (LPN) explained Resident #53 was able to use the call light device when needed. The LPN explained the resident would be unable to reach the call light if it were draped over the oxygen concentrator. The facility policy titled Responding to Resident Needs, revised 10/2010, documented the primary means for a resident to communicate their need for staff assistance was via the call light. When the resident was in bed or confined to a chair be sure the call light was within easy reach of the resident.

Based on observation, interview, and document review, the facility failed to ensure 1) a comprehensive care plan was updated to reflect the assessed wound staging for a Stage III pressure ulcer (Resident #69) and 2) a comprehensive care plan for a resident with a history of falls was updated when new interventions were implemented (Resident #31) for 2 of 18 sampled residents. Findings include: Pressure Ulcer Resident #69 Resident #69 was admitted to the facility on [DATE], with diagnoses including cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery, apraxia, dysarthria and anarthria, and pressure ulcer of sacral region, Stage III. An Orders Administration Note dated 06/24/2024, documented the wound care nurse performed wound care to the resident's coccyx wound. A Nursing Progress Note dated 06/24/2024, documented the coccyx dressing was clean, dry, and intact (CDI). A physician order dated 06/24/2024, documented cleanse coccyx with wound cleaner, pat dry, apply anacept and collagen to wound bed and cover with foam dressing. Monitor for signs/symptoms of infections, notify provider with any concerns. Every day shift every Monday, Wednesday, and Saturday. A Wound Weekly Observation Tool dated 07/08/2024, documented the resident had a Stage III coccyx wound that had a moderate amount of serosanguinous drainage and required wound care treatment. The definition of a Stage III wound was documented as full thickness tissue loss and included undermining and tunneling. The document indicated under the Observation/Data section the wound originated on the coccyx and was present on 06/23/2024. A physician order dated 07/10/2024, documented Treatment: Cleanse coccyx area with wound cleaner, pat dry, apply hydrogel to wound bed and cover with foam dressing. Every day shift every Monday, Wednesday, Saturday related to pressure ulcer of sacral region, Stage III. Resident #69's Skin Care Plan initiated on 05/06/2024, and revised on 05/15/2024, lacked documented evidence the would was identified as a Stage III pressure ulcer. The Care Plan lacked an update or revision for the coccyx wound assessed as a Stage III wound. On 07/17/2024 at 4:18 PM, the Minimum Data Set (MDS) Coordinator explained the coccyx wound had started as blisters and had been initially staged as a II by the Wound Care Nurse on 06/23/2024. The MDS Coordinator confirmed a wound staging, restaging, and resolution should be updated to the Care Plan. The MDS Coordinator confirmed Resident #69's wound care staging was performed by the Wound Care Nurse as a Stage III on 07/08/2024, and was not updated on the Care Plan to accurately reflect the current wound stage assessment and care. On 07/17/2024 at 4:46 PM, the Director of Nursing (DON) confirmed Resident #69's wound was assessed as a Stage III by the Wound Care Nurse on 07/08/2024. The DON confirmed the wound care order and care plan did not match and was not accurate to the resident's current wound assessment or treatment. 50210 Resident #31 Resident #31 was admitted to the facility on [DATE], with diagnoses including unspecified dementia severe with anxiety, hypertension, unspecified severe protein-calorie malnutrition, and muscle weakness. On 07/16/2024 at 9:21 AM, Resident #31's bed was in low position, and a floor mat was on the left side of the bed. On 07/16/2024 at 3:36 PM, Resident #31's bed was in low position, and a floor mat was on the left side of the bed. On 07/17/2024 at 9:12 AM, Resident #31's bed was in low position, and a floor mat was on the left side of the bed. Resident #31's progress notes related to falls documented the following: -On 04/19/2024 at 11:45 PM, Resident #31 was found sitting on the floor mat in front of their bed playing with dolls. -On 04/23/2024 at 3:45 PM, Resident #31 was found on floor mat next to the bed. The bed was in low position. -On 04/26/2024 at 8:10 AM, the Fall Committee met to review the recent fall. The Care Plan was reviewed, the bed was in low position and floor mats were used to help reduce risk of fall-related injuries. -On 05/05/2024 at 3:23 PM, Resident #31 was found on the floor mat next to the bed. The bed was in low position. -On 05/12/2024 at 5:38 PM, Resident #31 was found on the floor mat next to the bed. The bed was in low position. -On 06/10/2024 at 2:30 PM, Resident #31 was found on the floor, floor mat in place, and the bed was in low position. -On 06/29/2024 at 3:52 PM, Resident #31 was found lying on the floor mat on the left side of the bed, and the bed was in low position. On 07/17/2024 at 9:33 AM, a Certified Nursing Assistant (CNA) verbalized Resident #31 often fell when the resident was put to bed but did not want to go to bed and attempted to get up without assistance. Since the last fall, the facility implemented the following interventions: -asking the resident if they were ready to go to bed. -laying down floor mats. -putting the bed in the lowest position. -ensuring the resident was in the center of the bed. -putting dolls on the bed so the resident did not need to reach for them. -putting pillows at the resident's back. -rounding on the resident more often. On 07/17/2024 at 9:54 AM, a Registered Nurse (RN) verbalized Resident #31 tended to fall out of bed when napping around 2:00 PM to 4:00 PM. The resident would get up without asking for assistance. The RN explained the facility implemented interventions to prevent injury when the resident did fall. These included floor mats, lower bed, waking the resident earlier, and rounding more often. Resident #31's Care Plan with a focus initiated 04/25/2024, and last revised on 07/02/2024, documented Resident #31 was at risk for falling and fall-related injuries relative to hypertension, diabetes, generalized muscle weakness, and medications. The Care Plan did not include interventions related to floor mats or the bed in a low position. On 07/17/2024 at 3:31 PM, the DON verbalized the DON was not familiar with the facility's fall protocol. After discussing with the MDS Coordinator, the DON confirmed if a resident used floor mats and the bed was in low position, both should be documented as interventions on the care plan. The facility policy titled Care Plan Policy, revised 06/01/2022, documented the facility would develop and implement a Comprehensive Person-Centered Care Plan appropriate for each resident and would include measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the resident's comprehensive assessment.

Based on observation, interview and document review, the facility failed to ensure a post-fall assessment protocol was followed for 1 of 23 sampled residents (Resident #12); pain medication was provided to a resident who complained of severe chest pain for 1 of 23 sampled residents (Resident #4); and a physician was notified immediately when a resident complained of chest pain for 1 of 23 sampled residents (Resident #4). Findings include: Resident #12 Resident #12 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #12's medical record revealed the resident was found by a Certified Nursing Assistant (CNA) on the ground on 7/11/15 at 5:21 PM. The resident was assessed by the Registered Nurse (RN) with vital signs and neurological check, range of motion normal. The resident reported she hit her head and her head and ribs hurt. The nursing note indicated the resident spouse was called, Director of Nursing (DON) notified, and the event was placed in the physician and DON folder. At 6:00 PM, Resident #12's blood pressure (BP) was 117/78 and heart rate (HR) was 80. At 6:30 PM, BP was 110/85 and HR 81. At 7:00 PM, BP 79/60 and HR 80. The BP was rechecked by the Apprentice Nurse (A-RN) who confirmed the BP and notified the RN who instructed the A-RN to repeat the BP in 30 minutes. The A-RN documentation at 7:30 PM, indicated the resident was awake, smiling and able to state name. The resident was not able to answer orientation questions of place or time. The resident denied pain. At 7:30 PM, BP was documented as 119/64 and HR was 77. At 8:00 PM, the A-RN documented the resident was less responsive than previous checked. Resident complained of pain in her head and ribs. The vital signs were normal and the RN was notified. At 8:15 PM, the RN attempted to perform an assessment of the resident indicating the CNA and A-RN had noted the resident was not acting her normal self. The resident was found in bed with eyes closed. The RN note indicated the resident was difficult to arouse. Resident was asked to state name several times and responded in a soft voice. Multiple other neurological changes were documented after which the on call Nurse Practitioner was notified and the resident was transferred to the emergency room at 8:42 PM. Resident #12's nursing notes documented the resident returned to the facility on [DATE] at 1:30 AM. The resident BP was 98/64 and HR 81. The resident was identified to have a cough and was unable to recall place; all other neurological assessments were normal. Multiple right rib fractures were identified at the emergency room . On 8/20/15 at 7:30 AM, the DON reported to be in charge of the post fall program. The DON explained when a resident falls and a head injury is involved the expectation is for staff to perform neurological checks every 15 minutes for one hour and then every four hours for 24 hours. After reviewing Resident #12's medical record, the DON acknowledged the facility failed to follow post fall assessment protocol and notification of the health care provider at the time of the incident. Facility Policy Number: 3.06 titled Emergency Care Procedure, Falls documented the following, If a head injury has occurred with loss of consciousness, notify physician immediately for orders to transfer to emergency room . Resident #4 Resident #4 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #4's clinical record revealed a Nursing Progress Noted dated 1/31/15 at 9:55 PM, that documented the resident was complaining of chest pain. The note did not indicate the attending physician was notified. On 2/1/15 at 1:31 PM, a Nursing Progress Note documented the resident complained of chest pain at 9:30 AM. According to the notes, the vital signs were within normal limits. The progress note revealed at 11:50 AM, the resident manifested the chest pain was with a pain scale of 10 over 10 (10/10). The vital signs were obtained with a blood pressure of 98/68, heart rate 101 beats per minute, respirations 24 per minute and oxygen saturation of 78 % to 79 %. Oxygen was administered with a mask (the type of mask was not specified) at 8 liters per minute and the oxygen saturation increased to 87% after 10 minutes. The progress note revealed the resident verbalized the pain was in the left shoulder and ear. According to the progress note, the Physician was called at 12:15 PM. The Physician returned the call at 12:30 PM, and gave instructions to transport the resident to an acute care facility if the pain persisted. The progress note documented the Emergency Medical Services (EMS) was called at 12:45 PM, because the pain did not relieve and paramedics arrived at 12:50 PM to transport the resident to an acute care facility. The record lacked documented evidence pain medication was provided to the resident and the reasons why the attending Physician was not called at the onset time of the chest pain. On 8/19/15 at 3:50 PM, the Director of Nursing (DON) explained Resident #4 always wanted to go to a hospital reason why the notification to the Physician and the transfer to an emergency room were delayed. After review the clinical record, the DON confirmed the resident was complaining of chest pain since 1/31/15 at 9:30 PM and the Physician was not notified. The DON also confirmed the resident was complaining of severe chest pain for more than three hours and medications were not provided. The DON acknowledged the Physician should have been notified immediately and pain medication administered. On 8/20/15 at 11:50 AM, a Licensed Practical Nurse explained in the event a resident complained of chest pain, the vital signs would be obtained, checking for arrhythmia, shortness of breath or perspirations If that symptoms were not present, the resident will be monitory. If the pain persisted and symptoms were present, the physician would be notified to request instructions. The LPN was not aware the Physician had to be notified immediately in the event of a chest pain. Review of the Medication Administration Record [REDACTED]. Facility policy entitled Emergency Care Procedure, revised on May 2014, documented: .K. Acute Coronary: Signs and Symptoms: 1. Chest pain: steady, not relieved by rest or [MEDICATION NAME]; pain may radiate widely, may produce arrhythmia, [MEDICAL CONDITION], shock or cardiac failure. 3. Drop in blood pressure. 4. Dyspnea. 6. Anxiety and restlessness. 7. [MEDICAL CONDITIONS]. Treatment: 1. Obtain vitals. 2. Notify doctor immediately 3. Transport to hospital.

Based on record review, interview and document review, the facility failed to ensure the Quality Assurance (QA) Committee met quarterly to identify areas of concern as well as to recommend, implement, monitor, and evaluate changes; ensure issues regarding residents' weight loss and assessments were addressed as previously identified; and ensure the physician participated in the QA Committee meetings. Findings include: On 8/20/15 at 10:20 AM, the facility Administrator indicated he was the Director of the Quality Assurance (QA)/Quality Improvement Committee. The Administrator further indicated the committee met on a regular basis and included a physician member. The Administrator was asked to provide supporting documents to confirm quarterly Quality Assurance Committee meetings and members included a participating physician. The Administrator provided three QA meeting sign in reports dated 10/7/14, 11/25/14 and 4/22/15. None of the three sheets contained the signature of the physician committee member. The administrator indicated the physician was busy and did not have time to attend the meeting so he would call him and inform him of the meeting. During the interview with the administrator, multiple concerns currently identified by the survey team regarding weight loss and assessments by the registered dietician were discussed. These concerns were previously cited and there was a lack of evidence steps had been taken to correct these issues. On 8/20/15 at 12:25 PM, the physician indicated he was an independent contractor and he had not been contacted regarding Quality Assurance issues. The physician acknowledged participating in Discharge team planning and attending one Quality meeting when he first started working at this facility. The physician produced a copy of the Quality Indicator report from Center for Medicare and Medicaid Services (CMS) off-site report form for the previous year survey. Facility Policy titled Quality Assurance Committee (Revised 12/02) documented the QA Committed is utilized to evaluate the effectiveness of past and present actions taken to remedy deficiencies. The committee shall include a Medical Director. The Committee shall meet quarterly to identify areas of concern as well as to recommend, implement, monitor and evaluate changes. Quality Assurance audits shall be done during the quarter and will be reviewed at each quarterly meeting. Minutes of the meeting shall be typed and signed by all committee members. The facility shall have a QA Log available for review. The Quality Assurance Director failed to produce a QA Log for review.

Based on record review, document review and interview the facility failed to ensure a Registered Dietician Assessment for significant weight changes was performed on 1 of 23 sampled residents (Resident #21) and 7 unsampled residents (Resident #24, #25, #26, #27, #28, #29, and #30); a physician was notified for resident significant weight loss for 1 of 23 sampled residents (Resident #21). Resident #21 Resident #21 was originally admitted to the facility on [DATE], readmitted on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. The vitals taken from 1/1/15 to 8/19/15, documented the resident had the following weights: -169 lbs (pounds) on 1/30/15 -151 lbs on 3/6/15 -142 lbs on 5/1/15 -146 lbs on 7/9/15 The above-mentioned weights indicated the resident had 10.65% weight loss in one month (from 1/30/15 to 3/6/15), 15.97% weight loss in three months (from 1/30/15 to 5/1/15), and 13.60% weight loss in six months (from 1/30/15 to 7/9/15). The resident's medical record lacked documented evidence the physician was notified and the Registered Dietician (RD) made an assessment to address the weight loss. On 8/20/15 at 9:45 AM, the Director of Nursing (DON) confirmed the findings and revealed an RD assessment should be done at least monthly when weight loss was identified and the Interdisciplinary Team (IDT) should also address the weight loss. The nurses were expected to fill out an Incident Report titled Unplanned Weight Loss and should notify the physician about the weight loss. On 8/20/15 at 12:35 PM, a Registered Nurse (RN) indicated the nurses should notify the physician when weight loss was identified. Resident #24 On 12/23/14, Resident #24 was admitted with acute, ill-defined [MEDICAL CONDITION] disease, senile dementia, and adult failure to thrive. The facility's weight variance report, dated 7/13/15, identified a 3 month significant gain of 19 pounds. The resident had documented weights of 127 pounds on 4/7/15 and 146 pounds on 7/10/15. The last quarterly nutritional note was dated 6/23/15. Resident #24's medical record lacked documented evidence of a monthly and/or significant weight gain evaluation as of 8/20/15. Resident #25 On 5/13/15, Resident #25 was admitted with [MEDICAL CONDITION], diabetes mellitus II, [MEDICAL CONDITION] reflux, and aggressive behavior disorder. The facility's weight variance report, dated 7/13/15, identified a 1 month significant gain of 17 pounds. The resident had documented weights of 168 pounds on 6/12/15 and 183.6 pounds on 6/15/15. The last nutritional note was dated 6/29/15. The 6/29/15 note indicated to re-weigh the resident, continue weekly weights, and continue the same plan until the resident was reweighed. Resident #25's medical record lacked documented evidence of weekly weights as recommended. Subsequent weights documented were 186 on 7/10/15 and 182 on 8/7/15. Resident #25's medical record lacked documented evidence of a monthly and/or significant weight gain evaluation as of 8/20/15. Resident #26 On 5/28/15, Resident #26 was admitted with unspecified dysphagia, diabetes mellitus II, and [MEDICAL CONDITION] reflux. The facility's weight variance report, dated 7/13/15, identified a 1 month significant loss of 9 pounds. The resident had documented weights of 179 pounds on 6/12/15 and 170 pounds on 7/10/15. The resident's documented weight was 166 on 7/17/15. The only nutritional note was dated 7/30/15. On 8/7/15, the resident's documented weight was 158. Resident #26's medical record lacked documented evidence of a nutritional evaluation at admission and a continued significant weight loss evaluation as of 8/20/15. Resident #27 On 9/2/14, Resident #27 was admitted with dementia, protein-calorie malnutrition, abnormal weight loss, and [MEDICAL CONDITION] reflux. The facility's weight variance report, dated 7/13/15, identified a 3 month significant gain of 10 pounds. The resident had documented weights of 128 pounds on 4/7/15 and 138 pounds on 7/10/15. The last nutritional note was dated 3/11/15. The 3/11/15 note recommended weekly weights. Resident #27's medical record lacked documented evidence of weekly weights as recommended. Resident #27's medical record lacked documented evidence of a monthly and/or significant weight gain evaluation as of 8/20/15. Resident #28 On 6/3/15, Resident #28 was admitted with dementia, [MEDICAL CONDITIONS], and [DIAGNOSES REDACTED]. The facility's weight variance report, dated 7/13/15, identified a 1 month significant gain of 11 pounds. The resident had documented weights of 124 pounds on 6/12/15 and 135 pounds on 7/10/15. Resident #28's medical record lacked documented evidence of a nutritional evaluation at admission and a monthly and/or significant weight gain evaluation as of 8/20/15. Resident #29 On 3/20/15, Resident #29 was admitted with senile dementia, [DIAGNOSES REDACTED], hypo-osmolality/[MEDICAL CONDITION], and [MEDICAL CONDITION]. The facility's weight variance report, dated 7/13/15, identified a 1 month and a 3 month significant gain of 11 and 25 pounds respectively. The resident had documented weights of 147.2 on 4/15/15, 162 pounds on 6/12/15, and 173 pounds on 7/10/15. The last nutritional note was dated 6/23/15. Resident #29's medical record lacked documented evidence of a monthly and/or significant weight gain evaluation as of 8/20/15. Resident #30 On 5/14/15, Resident #30 was admitted with senile dementia, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], pressure ulcer buttocks. The facility's weight variance report, dated 7/13/15, identified a 1 month significant gain of 8 pounds. The resident had documented weights of 143.8 pounds on 5/14/15, 156 pounds on 6/12/15, 164 pounds on 7/10/15, and 175 pounds on 8/7/15. Despite a weight gain of over 30 pounds over 3 months, Resident #30's medical record lacked documented evidence of both a nutritional evaluation at admission and a monthly and/or significant weight gain evaluation/plan as of 8/18/15. The Dietitian first entered a note on the evening of 8/18/15. On 8/19/15 in the morning, the Administrator indicated the facility provided its Dietitian with a 30 day termination notice for failure to perform job responsibilities on 8/17/15. On 8/19/15 in the late morning, the Dietitian was contacted and a voice message was left regarding nutritional assessments of residents. The Dietitian was identified in the voice mail prompt. The Dietitian did not return the call. On 8/20/15 at 10:45 AM, the Dietary Manager explained the facility's significant weight gain/loss report process where weights were gathered monthly with a resident's ideal body weight range, whether or not a resident had a weight gain/loss, and how much the gain/loss was for 1 month, 3 months, and 6 months where applicable. The Dietary Manager communicated by e-mail with the contracted Dietitian regarding the weight gain/loss reports. The Dietitian was expected to respond within a couple days with recommendations and/or changes to the nutritional plan. The Dietary Manager provided documented proof the reports were sent regularly. The Dietary Manager indicated the facility did not receive a reply from the Dietitian regarding any of the significant weight gain/loss residents for the report dated 7/13/15. The Dietary Manager was asked to check Residents #24 through #30 for any additional nutritional assessments/notes which may have been entered, and none were identified. On 8/20/15 at 12:45 PM, the Director of Nursing indicated the facility was replacing the Dietitian as of the next week. The facility hired its Registered Dietitian (RD) on 8/1/12. The current contract between the facility and its Dietitian documented: .2. Complete required assessments on residents with special needs.Consultation to (name of facility) healthcare team (nursing, food service, physical and activity services and other disciplines as necessary) regarding diet and nutritional problems.6. Provide the Administrator, FSS (Food Services Supervisor) and DON (Director of Nursing), with routine exit interview, verbal and written reports, which include(s) information concerning residents, nutritional interventions and food service activities and recommendations.11. Emergency phone/on-line consultations whenever required. The RD signed a Job Responsibilities list on 10/24/14. The responsibilities included the following: The RD will chart on the following residents monthly: -Weight LOSS at 30 days (5%), 90 days (7.5%) and 180 days (10%). -Admissions; -Readmissions; -Annuals; -Significant Changes; -As needed per DON (Director of Nursing), ADM (Administrator) or FSS (Food Service Supervisor); -Weight GAIN at 30 days (5%), 90 days (7.5%) and 180 days (10%) if time permits. The RD should attach a progress note to the Food Service Supervisor's Nutritional Observations for all Admissions, Readmissions, Annuals and Significant Changes. The RD should review and/or add calculations for BMI (Body Mass Index), IBW (Ideal Body Weight), IBWR, and nutritional needs to all observations completed by the FSS. The RD is an important part of the facility team! It's important that if questions arise about a resident's weight or diet, the RD should seek clarification from the Director of Nursing or Food Service Supervisor prior to charting. Negative charting should be avoided. The RD's progress note should include the following information: -Reason for note (i.e., monthly review of Wt (weight) loss/Monthly TF (tube feeding) review or monthly review of Stage II PU (pressure ulcers), etc. -Resident's current weight and wt. history. -Resident's diet, supplements and PO intake, if applicable. -Review of meds (medications)/labs (laboratory tests)/skin issues. -RD's assessment and recommendations. If a diet changes recommended, the RD should complete a Diet Change Recommendation form. If a resident on weekly weights has a significant loss, the Food Service Supervisor will contact the Consulting RD. The RD will fax the facility a recommendation if necessary. According to the facility's Weight Management Protocol (undated) on page 40, .11. The food service supervisor/consultant dietitian calculates the calorie, protein, and fluid needs for each resident at least upon admission, annually, and upon significant changes in weight or when pressure sores occur. According to the facility's Guidelines For Unplanned Weight Loss (undated) on page 43, for significant unplanned loss of 5% in 1 month, or 7.5% in 3 months, or 10% in 6 months, .The consultant dietitian will re-calculate nutrient needs, including calorie, protein, and fluid and will evaluate need for high calorie/high protein or high protein supplement and vitamin/mineral supplementation. The M.D. will be notified of recommendations for need of diet prescription changes.The consultant dietitian will review with the food service supervisor the comparison of the actual intake with the calculated needs.The consultant dietitian will interview the resident for updated food preferences and attempt to cater to the resident's preferences. For continued significant weight loss, .The nursing staff will re-weigh the resident to verify accuracy of weight. The nursing staff will document unplanned weight change, per significant loss guidelines. The consultant dietitian will re-calculate nutrient needs, including calorie, protein, and fluid and evaluate the need for vitamin/mineral supplementation. The facility's policy titled Weight Monitoring dated 3/4, documented: .Procedure: .4. Licensed Staff will notify the physician of the following: A. 5% gain or loss in a 30-day period. B. 7 1/2% gain or loss in a 3-month period. C. 10% gain or loss in a 6-month period. .Notification to the physician must be documented, and also whether or not new orders were received. .6. RD to review weight loss/gains on monthly bases, and make recommendations to physicians as necessary.

Based on clinical record review and interview, the facility failed to obtain clarification of a pain medication order for a resident (Resident #1); ensure the physician was notified after a resident refused medications (Resident #12) and ensure the physician was notified of laboratory test results with a change in medical condition of a resident (Resident #20). Findings include: Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. The order lacked direction for determining when to give 1 [MEDICATION NAME] 20mg tablet or 2 [MEDICATION NAME] 20mg tablets. The Medications Administration History dated 8/20/14 to 9/10/1, indicated the resident received [MEDICATION NAME] from 8/26/14 through 9/8/14. On 9/10/14 at 12:20 PM, Resident #1 explained the nursing staff gave her different forms of pain medication and she was unaware of how the nursing staff determined when to give her 1 or 2 pain tablets. She explained she would ask for more than one tablet if she was in really bad pain or the staff would decide for her how many tablets to give her. On 9/10/14 at 3:30 PM, the Director of Nursing (DON) reported the standing orders for pain medication usually provide instructions when to give 1 or 2 tablets and the nursing staff usually ask the residents how many tablets they want. The DON confirmed the [MEDICATION NAME] order should have 'special instructions' that are written on the Medication Administration History to indicate one tablet to be given for mild to moderate pain and two tablets to be given for moderate to severe pain. The DON stated "I know I had them clarify the order." After looking through the Standing Orders notebook; the DON confirmed an order clarification had not be located. Resident #12 A) Resident #12 was admitted to the facility on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The Medications Administration History dated August 2014 and September 2014, indicated Resident #12 refused the [MEDICATION NAME] nasal spray from 8/8/14 to 8/11/14, and from 9/1/14 to 9/9/14. The resident's clinical record lacked documented evidence the physician was notified of the resident's refusal of the medication. On 9/10/14 at 10:30 AM, a Registered Nurse (RN) confirmed the findings; and at 5:15 PM, the Director of Nursing (DON) acknowledged the physician should be notified after three refusals of the medication. On 9/11/14 at 3:45 PM, the Director of Consulting Services indicated the physician should be notified if the resident refused the medication on a regular basis so the physician would either discontinue or change the order. The facility's policy titled "Pharmaceutical Procedures" dated February 2013, documented: "...E. Written procedures for the administration of drugs and biologicals should include the following instructions: ...3. Documentation of refusal of medications shall be done in such a way as to explain why the medication was not given: a. Resident refused dose (if this situation occurs routinely, physician is to be notified)..." B) The physician's orders [REDACTED]. The physician's orders [REDACTED]. Resident #12's clinical record documented the resident had no BM from 8/22/14 to 8/26/14, or a total of five days. The Resident Monitoring Administration History dated August 2014, indicated Resident #12 received the following medications for constipation: -MOM 30 cc on 8/26/14 at 5:03 AM (after four days of no BM) -[MEDICATION NAME] suppository 10 mg on 8/27/14 at 4:09 AM (after five days of no BM) On 9/10/14 at 2:45 PM, an RN confirmed the findings and verbalized the resident should have received MOM on 8/25/14, and if not effective, [MEDICATION NAME] suppository should be given on 8/26/14. The RN acknowledged the physician's orders [REDACTED]. On 9/10/14 at 5:16 PM, the DON confirmed the administration of MOM and [MEDICATION NAME] suppository to Resident #12 on 8/26/14 and 8/27/14 were not in accordance with the physician's orders [REDACTED]. Resident #20 Resident #20 was admitted on [DATE] and re-admitted on [DATE], with [DIAGNOSES REDACTED]. diff) [MEDICAL CONDITION]. Resident #20's History and Physical dated 3/20/14, documented: "Today patient is c/o (complaining of) severe diarrhea with some abdominal cramping... Checks stools for c.diff. Patient has been tx (treated) with abx (antibiotics), but one of the abx was [MEDICATION NAME]. Will continue to monitor". Resident #20's clinical record revealed a laboratory stool test report dated 3/22/14, that documented the result of the test was positive for [DIAGNOSES REDACTED] GDH [MEDICATION NAME] and toxin A and B. The clinical record lacked documented evidence the attending physician was notified of the test result. Resident #20's vital signs documentation revealed the resident had loose stools on 3/18/14, 3/19/14, 3/20/14 and 3/25/14. Nursing progress notes documented: - "03/21/2014 01:17 PM... she still having loose stools but they are getting better". - "03/23/2014 09:32 PM (name of the resident) vomited about 1/2 hour after taking her HS (before bed) medications. She stated she was nauseated also". - "03/24/2014 12:30 PM Residents bowel sounds are active x 4 (times four) quads (quadrants), reports frequent BM's (bowel movements) today". - "03/25/2014 05:33 AM (name of the resident) stated she was walking to the bathroom and felt weak and just couldn't stay on her feet and just held onto the door jamb and lowered herself to the floor. The CNA (Certified Nursing Assistant) was walking past her room and noticed she needed help... 'Since I've been having this darn loose stools, it's just making me so weak. I just couldn't stand and so I just lowered myself to the floor' ". - "03/28/2014 04:12 PM At lunch time noted was having difficulty staying awake. Noted she was pale, twitching, low grade temp (temperature) 99.9 VVS (sic). Stated she did not feel right". - 03/29/14 5:45 AM Entered res (resident) room, she was in BR (bathroom) had had incontinent loose stool from bed into bathroom. She was pale/gray, weak, shaky, placed on toilet with max assist, was unable to stand per self. BP (blood pressure) 205/91, very sob and dyspnic (sic). LS (lung sounds) dimished (sic) t/o, Sp02 (saturation of peripheral Oxygen) 85 %... ambulance arrived for transportation to (acute facility name) ER (emergency room ) for evaluation and treatment". Resident #20's clinical record lacked documented evidence the attending physician was notified about the recurrent loose stools and changes in the resident's health status. Review of physician orders [REDACTED]. diff [MEDICAL CONDITION] after the infection was detected through the stool test reported on 3/22/14. The record indicated the antibiotic therapy to treat the [DIAGNOSES REDACTED] infection was initiated when the resident came back from the acute care hospital on [DATE], nine days after the facility received the positive laboratory for [DIAGNOSES REDACTED]. Review of the facility Infection Control Surveillance information for the month of March 2014, lacked documented evidence Resident #20's [MEDICAL CONDITION] infection was detected. There was no evidence treatment orders or infection control and prevention measures were implemented. On 9/11/14 at 4:14 AM, the Director of Nursing (DON) who was also the facility staff member designated as the Infection Preventionist, explained if a resident is having loose stools and the nurses suspected it was caused by a [MEDICAL CONDITION] infection such as [DIAGNOSES REDACTED], the resident should be placed in transmission based precautions and the physician notified. The DON added if the physician ordered a laboratory test and the result came back positive for [DIAGNOSES REDACTED], the resident would continue in transmission based precaution status until clear from the infection. The DON indicated nurses must report any diarrhea, positive laboratory cultures and other issues related to infection control. The DON acknowledged the physician and the DON were not notified about Resident #20's recurrent episodes of diarrhea and positive [DIAGNOSES REDACTED] laboratory test results and as a consequence, the resident was not treated with the appropriate medication. The acute care facility Emergency Department record dated 3/29/14, documented the resident was admitted with a chief complaint of diarrhea and fever. The record revealed the resident had continuous diarrhea, positive stool for [DIAGNOSES REDACTED] and altered laboratory values including white blood cell count 17.9 (normal range 4.8-10.2), blood urea nitrogen 32 (normal range 7-18) and [MEDICATION NAME] 2.8 (normal range 3.4-5.0). Facility policy entitled Change in a Resident's Condition, revised on February 2005, read: "Purpose: Our facility promptly notify... his or her attending physician of changes in the resident's condition and / or status. "1. The nurse will notify the resident's attending physician when... b. There is a significant change in the resident's physical, mental, or psychosocial status". Complaint #NV 580