Every finding on record at Highland Oaks

Based on observation, interview and record review the facility failed to develop and implement a comprehensive water management program plan to detect and control legionella and water borne pathogens in the facility's water system. This failure had the potential to affect all 20 residents in the certified section. The findings include: The resident roster provided by the facility on December 8, 2025, during the survey entrance conference shows 20 residents in the certified section. 1.On December 9, 2025, at 3:10 PM, V2 (Director of Nursing) and V10 (Maintenance Director presented the facility's Water Management Program, a 3 page document. While reviewing the facility's water system diagram together, V10 pointed to the drinking fountain on the drawing and stated the facility does not even have a drinking fountain, yet it was included in the water management plan as a part of the water system description. Review of the water system description did not include if there were any areas of deadlines, areas of corrosion in the pipes, or any areas of stagnant water. On December 11, 2025, 10:35 AM, V2 provided an additional policy that V2 stated was part of the facility water management program plan. The document, undated, titled Infectious Disease-Legionella showed Operation and Maintenance.storing of water is recommended above 140 degrees F (Fahrenheit) to continuously kill the Legionella bacteria. The facility provided documentation for monitoring water temperatures for 2024, and 2025, that showed the temperatures of the water heaters both number 1 and number 2 did not ever exceed 140F. On December 9, 2025, at 3:35 PM, V10 stated he had worked in the facility for 10 years and they have never done any water testing, either of the municipal water supply or within the facility for pH level, presence of chlorine or other disinfectant, or presence of bacteria including legionella to validate the effectiveness of the facilities control measures. The facility's water management plan for control measures identified the drinking fountain, ice machines, kitchen appliances, and sinks, tubs, and showers as areas within the facility with potential for bacterial growth. The CDC (Center for Disease Control) Developing a Water Management program to reduce Legionella Growth and Spread in Buildings dated September 30, 2025, showed Because of the vulnerable population served, inpatient healthcare facilities should conduct routine testing for Legionella to validate their WMP. (Water Management Program). The Water Management Plan provided by V2 and V10, (3 page document) did not address the method to be used to validate the effectiveness of their water management program and did not address water testing. On December 9, 2025, during the infection control interview regarding the facility's surveillance activities, V2 (DON) identified an increase in the infection control rate to 6.18 % for the month of November 2025. V2 stated the increase was due to an increase in the number of residents who experienced pneumonia and respiratory infections in the month of November. V2 stated none of the residents were tested or sputum cultured to identify if there was a common organism present among the residents who became ill. The CDC (Center for Disease Control) Developing a Water Management program to reduce Legionella Growth and Spread in Buildings dated September 30, 2025, showed A healthcare facility's water management program to limit Legionella growth and spread should include the actions to take when a patient is diagnosed with Legionnaires' disease. include an investigation for Legionella in high risk residents who develop respiratory symptoms and have been in the facility for 10 consecutive days prior to the onset of symptoms. The Facility's Water Management Program did not include actions to take when a resident is diagnosed with Legionella disease or when high risk residents who have been in the facility for longer than 10 days develop symptoms of pneumonia and upper respiratory disease. The water management plan lacked an accurate description of the facility's water system, lacked effective monitoring methods for areas identified at risk for bacteria growth, lacked strategy for monitoring any water quality measures. The water management plan also failed to identify a plan for intervention in response to external risk factors, such a disruption in the facility's building water supply, changes in the municipal water supply, or construction, and failed to address internal risk factors such as biofilm, scale and sediment, water pressure changes and pH level and inadequate disinfection in accordance with CDC (Center for Disease Control) Developing a Water Management program to reduce Legionella Growth and Spread in Buildings dated September 30, 2025.

Based on observation, interview and record review the facility failed to properly evaluate and treat a resident who sustained a burn injury from coffee spill.This applies to 1 of 1 resident (R20) reviewed for quality of care in the sample of 12.The findings include:R20's Nursing Progress Note documented by V13 (Nurse) on December 6, 2025, at 10:30 PM, showed a notification time to the physician of 8:30 PM. The note showed that R20 sustained a burn on his thigh while drinking coffee at dinner due to R20's tremors. Additionally, the note also showed that V21 (Physician/Medical Director) gave an order to apply moisturizer, watch for open area, cover with gauze dressing if tender, and to notify the provider if it worsens.R20's Nursing Progress Note showed an edited note documented by V13 on December 6, 2025, at 10:33 PM that when assessing R20's left thigh at bedtime, R20's left thigh was noted with redness, warm to touch, and with areas of blister fluid-filled sacs. The same Progress Note also showed that R20's POA and Physician were notified.On December 10, 2025, at 2:45 PM, V13 (Nurse) said she applied regular facility house supplied lotion to R20's thigh on December 6, 2025, and she passed the information on in shift-to-shift report but did not create a treatment order flowsheet for nurses to document.On December 10, 2025, at 2:40 PM, V8 (Nurse) said he was R20's nurse on December 7, 2025, December 9, 2025, and December 10, 2025. V8 said he was made aware of the burn from a hot coffee spill on R20's left thigh. V8 also added that he was told to apply lotion to R20's thigh. V8 said he applied the regular facility house supply lotion to R20's thigh. V8 also said there was no treatment order to follow, just instructions from the nurses' shift to shift report, and there was no treatment order to document monitoring the skin condition or when to apply lotion. V8 also added that R20 had Parkinson's disease, feeds himself with regular utensils, and has always had hand tremors.Review of R20's Treatment Administration Record for December 2025 showed there was no Treatment Order and no documentation of R20's left thigh burn wound.On December 10, 2025, at 4:10 PM, V21 said the facility notified her on December 6, 2025, regarding R20 spilling coffee on his left thigh at dinner time. V21 said R20 sustained a mild second-degree burn based on the photo of R20's burn the facility sent to her. V21 added that the expected protocol for the facility is that hot coffee cups should be covered with lids. In addition, V21 said R20 had some tremors in his hands due to diagnosis of Parkinson's Disease and would have benefited from assistive devices to help with his tremors. V21 said she gave an order to apply moisturizer, monitor for open areas, drainage and cover the area with a dressing gauze. V21 also said the facility did not notify her of the change in R20's wound being reddened, painful to touch, warm, with blistered fluid filled sacs at bedtime on December 6, 2025. V21 said she attempted to see R20's burn on December 7, 2025, but did not evaluate R20's wound because he was asleep.The facility's undated Skin Care Policy showed Policy . Prevention of skin problems requires consistent, ongoing monitoring, as well as standardized management to reduce risks of skin breakdown.

Based on observation, interview and record review, the facility failed to notify the physician and failed to implement pressure ulcer interventions to prevent the development of facility acquired pressure ulcers for a resident at high risk for developing a pressure ulcer.This applies to 1 of 3 resident (R20) reviewed for pressure ulcers in the sample of 12.The findings include:R20's face sheet showed that R20 was admitted to the facility on [DATE]. R20 had multiple diagnoses, including Parkinson's Disease with dyskinesia and dementia. R20's Quarterly (MDS) Minimum Data Set, dated [DATE], showed R20 had severe cognitive impairment. The same MDS also showed that R20 was dependent on the facility staff for toileting, showering, required moderate assistance for personal hygiene, and touch assistance for bed mobility. R20's Pressure Ulcer Care Plan dated April 30, 2025, showed that R20 was at high risk for skin failure related to advanced age, limited mobility due to Parkinson's disease, incontinent episodes, history of pressure wounds to buttocks, and spending most of the daytime hours sitting in a recliner, watching TV. Interventions for the same Care Plan showed that nurses are to conduct skin inspection weekly and document in the Observation Flowsheet. The intervention also included that the CNA (Certified Nursing Assistants) should notify nurses of any sign of skin breakdown, redness, blisters, bruises, and discoloration noted during daily cares.R20's Nursing Progress Notes for November 1, 2025, to December 10, 2025, the Weekly Wound Flowsheets dated November 11, 2025, November 17, 2025, November 24, 2025, and December 9, 2025, were reviewed. R20's Nursing Progress Note documented by V12 (Nurse) dated November 11, 2025, and the Weekly Wound Flowsheet documented by V22 on November 11, 2025, both showed that R20's right buttock wound was an open wound measuring 0.5 cm x 0.5 cm and was identified by the facility on November 11, 2025. On November 10, 2025, at 1:53 PM, V2 (Director of Nursing) said the facility must have missed the Weekly Wound Flowsheet documentation for the week after November 24, 2025, and there was no documentation to be provided.R20's Weekly Wound Flowsheet dated December 9, 2025, showed that R20's pressure ulcer has deteriorated, and an additional pressure ulcer had been identified on R20's right lower buttock.On December 10, 2025, at 11:44 AM, V17, CNA was assisting R20 in the bathroom with toileting. A foam dressing dated December 9, 2025, was on R20's right buttocks, there was no dressing noted on the left buttock.On December 10, 2025, at 12:50 PM, V17 (MDS coordinator/Nurse) was assisting R20 in the bathroom for incontinence care. V17 removed the foam dressing on R20's right buttock and R20 had an area of red open pressure ulcer on the right upper buttock measuring 0.5 cm x 0.5 cm which was covered with a Vaseline gauze dressing. R20's right lower buttock had a pink intact skin area covered with a Vaseline gauze. R20's left buttock had an area of red pressure ulcer measuring 0.3 cm x 0.3 cm, which was not documented in R20's EMR (Electronic Medical Records). According to a review of R20's Physician Progress Note and the Nursing Progress Note documentation, there was no documentation that V21 (Physician/Medical Director) was notified of R20's buttock wound.On December 10, 2025, at 4:10 PM, V21 said she was not notified about R20 developing pressure ulcers on his buttocks until today and her expectation is that the facility should notify her of residents' change in condition such as the development of a pressure ulcer. V21 said she would have provided the facility the appropriate treatment and additional pressure relieve orders to help heal and prevent further deterioration of R20's buttocks pressure ulcer if she had been notified as soon as the facility identified R20's wound. R20's Nursing Progress Note documented by V22 (Nurse) on December 10, 2025, at 12:10 PM showed the facility notified V21 of R20's right buttock wound and obtained a treatment order. There was no mention of notifying V21 of R20's newly developed reddened area pressure injury on R20's left buttock in the note.The facility's undated Pressure Ulcer Policy showed Policy: The facility will ensure that a resident that enters the facility without pressure ulcers does not develop pressure ulcers unless the resident's clinical condition indicates that they were unavoidable. Procedure: . 2. At least weekly, an evaluation of the pressure ulcer will be documented. 3. MD [Medical Director] and POA [Power of Attorney] will be notified.

Based on observations, interview and record review, the facility failed to provide mechanical soft consistency diet per menu spreadsheet and facility policy guidance. This applies to 1 of 1 resident (R10) reviewed for dining in the sample of 13. The findings include:R10's face sheet included diagnoses of cerebral infarction due to embolism of right middle cerebral artery, dysphagia following cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, dysarthria following cerebral infarctionR10's diet order on POS (Physician Order Summary) included Mechanical Soft diet and Nectar Thick Liquid. R10's nutrition care plan (dated May 15, 2025) included that R10 is at risk for aspiration due to difficulty swallowing post stroke. Interventions for the same included (to serve) diet per Medical Doctor's order.1.Facility Fall/Winter menu for Monday, spreadsheet for December 08, 2025, included Sweet and Sour Pork Saute, [NAME] Rice, Sugar Snap Peas, Tropical Fruit.Menu spreadsheet for the lunch meal for December 08, 2025, included Tropical Fruit as the dessert. The same spreadsheet showed that residents on mechanical soft to receive 4 ounces of Tropical fruit salad with no pineapple and #16 scoop [2 ounces] of sugar snap peas. On December 08, 2025, at 12:33 PM, during the lunch meal service, V7 (Dietary Aide) was passing out desserts from a cart to the residents that were having their lunch. The desserts offered included Tropical fruit salad with pineapple, ice cream or cookie. When asked, V7 stated that residents on Regular and Mechanical soft diets can have Tropical fruit with the pineapple. R10 received Tropical fruit salad with pineapple and also sugar snap peas that were around 2 inches long, some of them with a hard stalk. R10 did not eat either the Tropical fruit salad with pineapple nor the sugar snap peas and stated that she is unable to chew them. On December 08, 2025, at 12:34 PM, V5 (Director of Dietary) stated that he did not see the Tropical fruit had pineapple in it. On relaying that the sugar snap peas had stalks on it, V5 stated that he will reach out to the dietitian as she usually changes the menu as needed. 2. On December 08, 2025, at around 10:00 AM, V5 stated that the facility is serving the residents choice for the meal of the month which included baked potato with toppings. V5 stated that he does not have a spreadsheet for the meal of the month but will follow scoop sizes and foods allowed based on the spreadsheet for these items served on other days.On December 08, 2025, at 12:22 PM, during lunch meal observations, R10 received baked potato with skin. R10 was noted to have occasional coughing and throat clearing while eating her meal. On December 08, 2025, at 12:32 PM, on enquiry whether residents on mechanical soft diet can have baked potato with skin, V5 stated that the facility's menu had shown baked potato for dinner on the same day. On review of the menu (week 5 day 3) for the dinner meal showed that residents on mechanical soft diet should be served baked potato without skin and V5 acknowledged the same. On December 08, 2025, at 2:13 PM, V9 (Dietitian) stated that the facility has a liberalized mechanical soft diet, and the speech therapist determines if the resident can tolerate foods/textures. V9 stated that the facility should follow the spreadsheet to serve diet consistencies as shown. V9 stated that if the vegetable is stringy and had a stalk it should not be served to residents on mechanical soft diets. Facility (undated) policy titled National Dysphagia Level 2: Mechanically altered Nutrition Therapy included that fresh, canned, or cooked pineapple to be avoided, and that vegetables allowed should be well cooked, less than 1/2 inch and should be easily mashed with a fork. Vegetables to be avoided included fibrous, non-tender, or rubbery cooked vegetables. Potatoes and starches to be avoided included potato skins and chips.

Based on observations, interview and record review the facility failed to maintain food safe temperatures at the steam table. This applies to 3 of 3 residents (R15, R19, R24) reviewed for pureed diets in the sample of 14. The findings include: Facility Fall/Winter menu for Monday, December 08, 2025, included Sweet and Sour Pork Saute, Sugar Snap Peas.On December 08, 2025, at 12:15 PM, the food temperatures were taken for the lunch meal. V5 (Director of Dietary) stated that meal service had started at 12:00 PM.The pureed sweet and sour pork showed 111.5 degrees Fahrenheit, and the pureed snap peas showed 122.5 degrees Fahrenheit. On December 08, 2025, at 12:23 PM, V6 (Cook) stated that he prepared the pureed items at around 10:00AM. On enquiry on how he prepared these items, V6 stated that he pureed the cooked sweet and sour pork and sugar snap peas respectively in a blender and had added a little hot water and thickener during the pureeing process. V6 stated that he then placed the items directly on the steam table. V6 stated that the hot water (in the steam table) may not have been hot enough to keep these pureed items warm. V6 added that he did not reheat the above pureed items.On December 08, 2025, at 2:13 PM, V9 (Dietitian) stated that the foods should be at minimum of 135 degrees Fahrenheit at the steam table. V9 stated that the pureed recipes should be followed during preparation of the same. Recipe for pureed Pork Saute Sweet and Sour showed as follows: Measure amount of cooked sweet and sour pork to be pureed in a food processor. Process until smooth in consistency. Pour into steam table pan coated with liquid food release. Keep hot for service. Critical Control Point: Hot foods held for later service must maintain internal temperature of 135 degrees Fahrenheit. Recipe for Pea's Sugar Snap Pureed Thick showed as follows: Remove portions to be pureed from the regular prepared vegetable. Place in food processor and process until fine in consistency. Gradually add food thickener and melted margarine to the vegetables while processing. Scrape down sides of processor with a rubber spatula and process for seconds. Heat. Critical Control Point: Within 2 hours, Reheat to a minimum internal temperature of 165 degrees Fahrenheit for a minimum of 15 seconds. Hot foods held for later service must maintain internal temperature of 135 degrees Fahrenheit. Facility (undated) Policy titled Safe Food Preparation and Handling included:Policy: Food will be prepared to conserve maximum nutrition value in a safe and sanitary environment.Procedure: The following safe food preparation and handling practices will be followed:6. Foods will be held at proper temperatures. Hot food will be a minimum of 135 degrees Fahrenheit and cold food will be a maximum of 41 degrees Fahrenheit. Facility diet order listing printed on December 8, 2025, showed that R15, R19, and R24 were on pureed diets.

Based on observation, interview, and record review the facility failed to properly label and store food in the refrigerator; ensure thermometers were inside the refrigerator; and ensure leftovers were properly cooled. This affects all residents residing in the facility. The findings include: The CMS 671 dated 8/29/24 showed there were 22 residents. On 8/27/24 at 8:59 AM, during a kitchen tour with V6 (Dietary Manager) there was a small refrigerator, under the steamer. The digital thermometer on the exterior of the refrigerator showed 37 degrees. There was no thermometer inside the refrigerator. V6 said the dietary staff use the digital reading from the exterior for the temperature logs. He said temperatures were monitored to ensure the quality of the food and prevent foodborne illness. There was a stand-up refrigerator with beverages inside. The external digital reading was 39 degrees. There was not a thermometer inside the refrigerator. At 9:03 AM, there was a Cooling Temperature Log affixed to the outside of the walk-in cooler. (The last documented items was Meatloaf on 5/20/24. This document's instructions showed, Record temperature every hour during the cooling cycle. Record corrective actions, if applicable. The food service manager will verify that the food service staff is cooling food properly by visually monitoring food service employees during the shift and reviewing, initially and dating this log daily.) Inside the walk-in cooler there was a metal container, covered with saran wrap, labeled Ham, 8/24/24. V6 said the ham was left over from Saturday. V6 said the ham should be entered on the cooling log. The surveyor and V6 exited the cooler and viewed the Cooling Temperature Log. V6 said the ham was not on the cooling log, but it should be. V6 said the cooling log is done to ensure food is safely cooled and prevent the risk of foodborne illness. Inside the walk-in cooler, was an uncovered, open, shelved cart. There were 5 trays of individual servings of tiramisu and 2 trays of salads. The trays were not covered. There was a tray of individual cups of ketchup that was uncovered. The residents were served the tiramisu and salads during the noon meal. On 8/28/24 at 9:30 AM, the small refrigerator under the steamer and the front refrigerator still did not have thermometers inside. The walk-in cooler had a tray with left over tiramisu (from yesterday) and individual servings of various salad dressings. These items were uncovered. At 10:02 AM, V6 said food stored in the refrigerator should be covered and labeled. V6 said food is covered to prevent cross-contamination. The surveyor accompanied V6 to the walk-in cooler and pointed out the left-over dessert and salad dressings. V6 replied, That shouldn't be like that. It was from yesterday; I will throw it out. V6 said he doesn't have a cover for the open storage rack (observed yesterday), but stated, We could probably put a bag over the cart until we serve the food. The facility's Spring/Summer 2024 Menu showed on Saturday (8/24/24) baked, glazed ham was served for lunch. The Menu showed Tuesday (8/28/24) was, Lunch Bunch: Village Pizza, salad, and dessert. The facility's Leftover Food Policy dated 2014 showed, Leftover food of adequate quality, appearance, and nutrient retention will be covered, labeled, dated, and used within 72 hours. Procedure: 1. Leftover food will be properly wrapped/covered, labeled, and dated. The product will be refrigerated immediately. 2. Using the two-stage cooling process, leftovers will be cooled to 70 degrees Fahrenheit within 2 hours and then down to less than or equal to 41 degrees within another 4 hours. 3. Cooked foods will be used within 48 hours or frozen for later use . The facility's Storage of Food and Supplies Policy dated 2014 showed, Food and supply storage areas shall be maintained in clean, safe, and sanitary manner. Procedure: .4. Prepared foods stored in the refrigerator until service will be covered, labeled, and dated with an expiration date. TCS (Time/Temperature Control for Safety) foods prepared on site must be labeled with the name of the food, the date it should be sold, consumed or discarded .7. Refrigerators and freezers will be equipped with an internal thermometer and monitored. Temperatures will be documented .

Based on observation, interview and record review, the facility failed to ensure staff wore appropriate PPE (personal protective equipment) in enhanced barrier precaution rooms when providing direct care for residents and failed to prevent cross-contamination during personal cares for 3 of 5 residents (R19, R16, and R14) reviewed for infection control in the sample of 14. The findings include: 1. R19's face sheet, provided by the facility on 8/29/24, showed she had diagnoses including muscular dystrophy, dysphagia (difficulty swallowing), protein-calorie malnutrition, gastro-esophageal reflux disease, and gastrostomy status (a g-tube). R19's ADL care plan initiated on 6/28/24 showed she is limited in her ability to transfer herself due to deconditioning/weakness related to muscular dystrophy and anemia. R19's Nutritional Status care plan initiated on 6/28/24 showed she has a g-tube and is on Enhanced Barrier Precautions: Follow instructions outside of resident's door. On 8/27/24 at 9:57 AM, V9 went into R19's room with surveyor. V5 (CNA) had her arms around R19's waist, putting a gait belt around R19. V5 secured the gait belt and assisted R19 with transferring from her bed to her wheelchair and then from her wheelchair to her recliner. R19 was not feeling well on 8/27/24 and V5 had both hands on R19's gait belt. V5's arms were touching R19 on her sides and her back during the transfers. V5 did not have a gown or gloves on during the transfers. A sign on R19's doorway showed she was on enhanced barrier precautions and staff should Wear gloves and a gown for the following high-contact resident care activities .Transferring . On 8/28/24 at 11:55 AM, V11 (Social Services) was observed in R19's room. V11 did not have a gown or gloves on. V11 was sitting on R19's unmade bed, talking to R19, who was sitting in her recliner. 2. R16's face sheet, provided by the facility on 8/29/24 showed he had diagnoses including vascular dementia with anxiety, and a personal history of stroke. R16's care plan initiated on 7/7/22, showed he needed assistance with ADLs (activities of daily living) due to cognitive loss, weakness, limited mobility, deconditioning, activity intolerance related to CHF (congestive heart failure), pain, and limited range of motion. On 8/27/24 at 9:42 AM, R16 was sitting in his wheelchair, propelling himself into his bathroom. V12 (Certified Nursing Assistant-CNA) was passing by R16's room and asked him where he was going. R16 said he was going in to use the bathroom. V12 asked R16 to hold on a minute and he would go get someone to assist him. V12 propelled R16 back out of the bathroom and told him he would be right back. V12 walked down the hall and came right back with V10 CNA. V10 entered R16's room without performing hand hygiene or donning PPE (personal protective equipment). The sign on R16's doorway showed Enhanced Barrier Precautions- Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and Staff Must Also Wear gloves and a gown for the following High-Contact Resident Care Activities .Dressing .Transferring .Changing briefs or assisting with toileting . V10 closed the door to R16's room and walked back out after a couple of minutes. At 9:48 AM, V10 returned to R16's room because the call light had been activated. V10 entered R16's room without performing hand hygiene or donning PPE. This surveyor knocked on the door and entered R16's room. V10 was observed cleaning R16 after he had a bowel movement. V10 did not have a gown on, only gloves. At 9:50 AM, V9 (Registered Nurse-RN) said R16 was on enhanced barrier precautions due to a wound on his right toe. V9 said staff only need to put PPE on when coming in contact with the affected area. On 8/28/24 at 12:16 PM, V13 (RN/Infection Preventionist) said enhanced barrier precautions involves modified contact precautions for anyone with an indwelling device or wound. V13 said the expectation is that staff would don gown and gloves if providing high-contact direct care. V13 said staff should be putting on a gown and gloves when providing toileting care, adding, We are trying to protect him from being exposed to anything he might come in contact within his environment. V13 said even though the wound is on his foot, staff should be donning a gown and gloves. V13 said when transferring a resident, if they are requiring extensive assist, then a gown is needed along with gloves. V13 said It is probably not appropriate for staff to be sitting on R19's bed because that is her environment. On 8/29/24 at 9:06 AM, V11 (Social Services) said she should not have sat on R19's bed to prevent cross-contamination, especially since her bed was not made, because she (R19) is on enhanced barrier precautions. The facility's policy and procedure titled Enhanced Barrier Precautions (EBP), with a review date of May 2024, showed 1. It is well-known that residents residing in congregate long-term care settings are at increased risk of becoming colonized and/or infected with MDROs (Multidrug-resistant organisms). 2. MDROs present significant infection control obstacles in their treatment and prevention of transmission. 3 Understanding that transmission can occur from colonized residents, Enhanced Barrier Precautions (EBP) is a measure to mitigate the spread to un-affected residents .5. EBP also applies to residents living in a long-term care setting who have indwelling devices (such as urinary catheters) or chronic wounds. These residents are at increased risk during high-contact cares due to potential transfer of MDROs to or from a staff's hands/clothing. a. Regardless of MDRO status, any residents with indwelling devices or chronic wounds will have EBP during the duration of the device or wound. The policy showed When a resident is known to be colonized with an MDRO or has an indwelling device/chronic wound: a. A sign will be placed outside their door, along with a PPE cart. i. This sign will list the cares requiring EBP .c. ABHR (alcohol-based hand rub) will be made available in the room for hand hygiene before, between, and after cares .e. High contact cares requiring gown, glove use include .iii. Transferring .v. Changing linens. vi. Toileting/changing briefs. 20042 3. On 8/27/24 at 9:38 AM, R14 was in bed while V4 CNA (Certified Nursing Assistant) was providing morning care. R14's night gown, incontinence pad, and wet washcloths were on the floor next to his bed. V4 did not have any gloves on, picked up the dirty linen and placed it in a pile on the floor in front of the armoire. V4 used hand sanitizer then put R14's tennis shoes on. V4 put a round pad on R14's left lower leg. V4 raised the head of bed and then lowered his bed. V4 did not have gloves on and picked up the pile of dirty linen from the floor and carried it out of the room. On 8/28/24 at 1:35 PM, V2 DON (Director of Nursing) stated, the soiled/dirty linen should not go on the floor. You don't know what is on it and then it will get on the floor and can go all over. It is cross contamination. It is absolutely an infection control problem. The Face Sheet dated 8/29/25 for R14 showed medical diagnoses including left sided hemiplegia, psoriasis, vascular dementia, mild cognitive impairment, peripheral vascular disease, atherosclerotic heart disease, cerebral infarction, pulmonary hypertension, hypokalemia, occlusion of right carotid artery, osteoarthritis, mononeuropathy of left lower limb, Vitamin D deficiency, gastroesophageal reflux disease, hypertension, dysphagia, hyperlipidemia, weakness, and sick sinus syndrome. The MDS (Minimum Data Set) dated 7/17/24 for R14 showed dependence for toileting hygiene and lower body dressing; substantial/maximal assistance for upper body dressing and personal hygiene. Incontinence of bowel and bladder. The facility's Incontinence Care policy (8/29/24) showed thorough perineal care, as detailed below, is to be peformed during AM cares and HS cares. The policy did not state where dirty/soiled linen should go to prevent cross contamination when care is provided.

Based on interview and record review the facility failed to prevent the diversion of a resident's controlled substance medication. This applies to 1 of 3 residents (R1) reviewed for misappropriation of resident property in the sample of 3. The finding include. R1's Controlled Drug Receipt / Record / Disposition (commonly referred to as a count sheet or controlled substance count sheet) showed the facility received, on R1's behalf, 120 tablets of 50 milligram (mg) tramadol, a schedule IV narcotic pain medication. The count sheets showed the tablets were delivered on 5/13/24 and were dispensed in four separate punch cards, each card containing 30 tablets of tramadol. R1's count sheet showed each individual punch card was delivered with its own accompanying count sheet (4 punch cards, 4 count sheets). The first dose of the first punch card of tramadol, from the delivery on 5/13/24, was dispensed on 5/16/24 at 11:59 AM. The final dose of the first card was given on 5/26/24 at 12:25 PM. The second punch card was started on 5/26/24 at 9:00 PM and the final dose of this card was given 6/5/24 at 11:40 AM. The third punch card was started 6/5/24 at 9:00 PM and completed on 6/15/24 at 5:01 AM (this completes 90 tablets of 120 tablets delivered on 5/13/24). Following the completion of R1's third card of tramadol, the next dose given was on 6/15/24 at 11:50 AM. The dose given on 6/15/24 at 11:50 AM was from a new delivery of 120 tablets of tramadol, which was delivered to the facility on [DATE]. (The fourth card of tramadol delivered on 5/13/24 was not accounted for.) On 8/14/24 at 12:30 PM, V2 (Director of Nursing) stated the facility was not able to account for R1's missing card of tramadol delivered on 5/13/24. V2 stated the only explanation for this missing tramadol punch card is theft. V2 stated tramadol is double locked and only the nurses on duty have access to the controlled substances. V2 stated the medications maintained by the facility are the resident's property. V2 said controlled substances are the most likely medications to be diverted for either financial gain or personal use. On 8/14/24 at 9:52 AM, V1 (Administrator) stated the facility was not able to locate R1's missing card of tramadol. V1 stated it appears a nurse took R1's count sheet and his punch card of tramadol. V1 stated the medications are the resident's property. The facility's Abuse and Neglect Prevention Protocol Policy showed, Misappropriation of resident property means using a resident's cash, clothing, or personal possessions without authorization by the resident or the resident's authorized representative .

Based on interview and record review the facility failed to implement policies to identify and prevent the diversion of controlled substances. This applies to 1 of 3 residents (R1) reviewed for controlled substances in the sample of 3. The findings include: R1's Controlled Drug Receipt / Record / Disposition (commonly referred to as a count sheet or controlled substance count sheet) showed the facility received, on R1's behalf, 120 tablets of 50 milligram (mg) tramadol, a schedule IV narcotic pain medication. The count sheets showed the tablets were delivered on 5/13/24 and were dispensed in four separate punch cards, each card containing 30 tablets of tramadol. R1's count sheet showed each individual punch card was delivered with its own accompanying count sheet (4 punch cards, 4 count sheets). The first dose of the first punch card of tramadol, from the delivery on 5/13/24, was dispensed on 5/16/24 at 11:59 AM. The final dose of the first card was given on 5/26/24 at 12:25 PM. The second punch card was started on 5/26/24 at 9:00 PM and the final dose of this card was given 6/5/24 at 11:40 AM. The third punch card was started 6/5/24 at 9:00 PM and completed on 6/15/24 at 5:01 AM (this completes 90 tablets of 120 tablets delivered on 5/13/24). Following the completion of R1's third card of tramadol, the next dose given was on 6/15/24 at 11:50 AM. The dose given on 6/15/24 at 11:50 AM was from a new delivery of 120 tablets of tramadol, which was delivered to the facility on [DATE]. (The fourth card of tramadol delivered on 5/13/24 was not accounted for.) On 8/14/24 at 9:24 AM, V4 (Licensed Practical Nurse) stated, At the time, we did not have a process in place to prevent a nurse from taking the card (narcotic punch card) and the sheet. I have heard of that being an issue at other facilities . On 8/14/24 at 9:52 AM, V1 (Administrator) stated the theft of a resident's controlled substance was first identified on or about 7/17/24 for R100, a resident in a licensed only (private pay) bed. V1 stated, during the investigation, other instances of missing controlled substances were identified, including R1's missing tramadol. (R1's missing tramadol was not discovered for at least one month and not until an investigation was initiated.) V1 stated she was not aware card counting (A method of accounting for all the controlled substance cards from one shift to the next). On 8/14/24 at 12:30 PM, V2 (Director of Nursing) stated the only explanation for the missing tramadol is theft. V2 stated it appears the nurse who stole R1's tramadol took the count sheet and the entire card of medication. V2 stated she was not aware nurses taking the count sheet and the punch card was a relatively method for individuals to divert controlled substances. V2 stated, at the time of the theft, the facility did not have policies and procedures in place to prevent or identify the theft of an entire punch card and count sheet. The facility's Controlled Substances Accountability Policy (7/19/24) showed, .The facility will have safeguards in place in order to prevent loss, diversion or accidental exposure .

Based on observation, interview, and record review, the facility failed to follow physician orders to apply a hand splint to a resident at risk for contractures. This applies to 1 of 2 residents (R15) reviewed for mobility and range of motion in the sample of 10. The findings include: The EMR (Electronic Medical Record) showed R15 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia (paralysis) and hemiparesis of the left side, dementia, and hypertension. R15's MDS (Minimum Data Set) dated July 19, 2023, showed R15 had moderate cognitive impairment, and R15 required extensive assistance from facility staff for bed mobility, dressing, and personal hygiene. The MDS continued to show R15 had a functional limitation in range of motion impairment of the upper extremity on one side. R15's ADL (Activity of Daily Living) care plan dated April 25, 2023, showed, I need assistance with my ADLs due to cognitive loss related to dementia, weakness/pain/limited mobility/deconditioning related to recent stroke with left sided weakness, osteoarthritis, neuropathy. I have some vision loss in me left eye. I am right handed. I cannot move my left arm/leg. The care plan continued to show multiple interventions dated July 5, 2023, including Left hand splint on per physician orders. R15's Physician Order Report showed an order dated July 5, 2023, for a resting hand splint to left hand splint, on in the morning and off at bedtime. On July 24, 2023, at 12:14 PM, R15 was sitting in his wheelchair, eating lunch in the dining room. R15's left arm was resting on his wheelchair arm, and R15 did not have a splint on his left hand. During the entire lunch service, R15 was not observed able to move his left arm or hand. On July 26, 2023, at 10:41 AM, R15 was sitting in his wheelchair in the activity room. R15's arm was resting on his lap, and R15's fingers were flexed. R15 did not have a splint on his left hand. On July 26, 2023, at 11:16 AM, V4 (CNA/Certified Nursing Assistant) said [R15] does not have a hand splint that I know of. I do not put a hand splint on him during the day. On July 26, 2023, at 11:19 AM, V5 (LPN/Licensed Practical Nurse) said he was not sure if R15 had a splint. On July 26, 2023, at 12:12 PM, V6 (Occupational Therapist) said R15's hand splint was recommended from therapy for positioning and to prevent a contracture. V6 continued to say R15's left upper extremity is flaccid with no active movement. V6 said without the left hand splint, R15's wrist and fingers are at risk for contractures. V6 continued to say R15's splint should be applied in in the morning when he is up in his wheelchair and then removed at nighttime. V6 said R15 does not need his splint removed during meals because he is unable to use his left hand to feed himself. V6 said facility staff should be reporting to therapy if R15 refuses to wear his splint, but she has not been told he had refused to wear his splint. V6 continued to say R15 always allows V6 to apply his splint. On July 26, 2023, at 1:54 PM, V2 (DON/Director of Nursing) said R15 has an order for a left hand splint, and it should be applied in the morning and left on throughout the day and taken off at night. V2 continued to say it is the CNA's task to apply R15's splint. V2 said the expectation is facility staff are applying R15's hand splint.

Based on interview and record review, the facility failed to follow their policy to offer the COVID-19 vaccine to residents. This applies to 2 of 5 residents (R10 and R15) reviewed for immunizations in the sample of 10. The findings include: 1. The EMR (Electronic Medical Record) showed R10 was admitted to the facility on [DATE], with multiple diagnoses including poliomyelitis, Parkinson's disease, and hypertension. The MDS (Minimum Data Set) dated July 12, 2023, showed R10 had moderate cognitive impairment. R10's COVID-19 care plan dated April 18, 2023, showed I am at risk for infection related to COVID-19 pandemic. The care plan continued to show multiple interventions dated April 18, 2023, including, COVID-19 vaccination per facility protocol. R10's Preventative Health Care Report showed R10 received COVID-19 vaccines on March 4, 2021, March 24, 2021, and December 21, 2021. The report did not show R10 had received an updated COVID-19 vaccine and R10 was not up to date with COVID-19 vaccinations. The facility does not have documentation to show R10 or R10's resident representative was offered the updated COVID-19 vaccine. 2. The EMR showed R15 was admitted to the facility on [DATE], with multiple diagnoses including stroke with hemiplegia (paralysis) and hemiparesis of the left side, dementia, and hypertension. R15's MDS dated [DATE], showed R15 had moderate cognitive impairment. R15's COVID-19 care plan dated April 25, 2023, showed I am at risk for infection related to COVID-19 pandemic. The care plan continued to show multiple interventions dated April 25, 2023, including, COVID-19 vaccination per facility protocol. R15's Preventative Health Care Report showed R15 received COVID-19 vaccines on March 24, 2021, April 15, 2021, and October 15, 2021. The report did not show R15 had received an updated COVID-19 vaccine and R15 was not up to date with COVID-19 vaccinations. The facility does not have documentation to show R15 or R15's resident representative was offered the updated COVID-19 vaccine. On July 26, 2023, at 1:09 PM, V2 (DON/Director of Nursing said, R10 and R15 had not been offered the updated COVID-19 vaccine because the facility was waiting to see if more residents needed the updated COVID-19 vaccine. V2 continued to say the facility usually offers the COVID-19 vaccine in the fall. The facility's policy titled, COVID-19 Infection Prevention and Control Policy, updated on July 18, 2023, showed, Policy Statement: COVID-19 is a respiratory illness (caused by the coronavirus) that is primarily transmitted from person to person via droplets generated by coughing and sneezing. Elderly individuals are at an increased risk of becoming infected due to compromised immunity and comorbidities . COVID-19 Vaccine- Policy: COVID-19 vaccines available in the United States are effective at protecting people from getting seriously ill, being hospitalized , and dying. As with other vaccine-preventable diseases, are protected best from COVID-19 when you stay up to date with the recommended vaccinations, including recommended boosters. For further guidance on current vaccine recommendations refer the CDC (Centers for Disease Control and Prevention): Stay Up-To-Date with COVID-19 Vaccines Including Boosters . COVID-19 Vaccine (Resident): The residents in this facility will be offered and provided the COVID-19 vaccine upon admission, and as requested . Documentation related to the resident's COVID-19 vaccine will be documented in the resident's electronic medical chart . The CDC website (https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html) titled COVID-19: Stay Up to Date with Vaccines, updated July 17, 2023, showed for everyone aged six years and older is up to date when they receive one updated COVID-19 vaccine. The website continued to show the updated vaccine became available September 2, 2022 for people aged [AGE] years and older.

Based on observation, interview, and record review, the facility failed to follow standards of infection control practices with regards to donning of personal protective equipment (PPE), placement of door signage/isolation bin and hand hygiene during provision of care. This applies to 4 of 4 residents (R5, R24, R26 and R28) reviewed for infection control practices in a sample of 12. The findings include: 1. On 5/4/21 at 08:30 AM, V7 CNA (Certified Nursing Assistant) walked in to R5's room without isolation gown or gloves. The signage at R5's door showed: Stop: Contact precautions (in addition to standard precautions). Everyone must: clean hands when entering and leaving room. And, Gown and Glove at the door. There was no isolation bin outside of R5's room. Review of R5's EHR (Electronic Health Record) showed R5 was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R5's POS (Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The sign outside R5's room showed contact isolation precautions. R5's MDS (Minimum Data Sets) dated 2/3/21 showed R5 required extensive assistance of one person assist with toilet use. 2. On 5/3/21 at 10:20 AM, the signage at R28's door showed: Stop: Contact precautions (in addition to standard precautions). Everyone must: clean hands when entering and leaving room. And, Gown and Glove at the door. There was no isolation bin outside of R28's room. Review of R28's EHR showed R28 was readmitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R28's POS showed an order dated 12/1/20 for contact isolation for ESBL in the urine. The sign outside R28's room showed contact isolation precautions. R28's MDS (Minimum Data Sets) dated 3/12/21 showed R28 required extensive assistance of one person assist with toilet use. R28's current care plan shows R28 is placed on contact isolation precaution per facility protocol. Follow instructions outside of resident's door. On 5/5/21 at 10:55 AM, V3 DON (Director of Nursing) stated she expects nursing staff to wear PPE prior to entering contact isolation room. V3 stated PPE is kept in three door compartment. The PPE should be kept outside the room. 3. On May 4, 2021 at 11:40 AM, V5 LPN (Licensed Practical Nurse) gathered supplies to perform R24's blood sugar check. V5 put on gloves without hand hygiene, picked up R24's insulin pen, cleaned off the the end with an alcohol wipe and put the needle on to the pen. V5 set the pen to deliver the scheduled amount of insulin ordered by the physician. V5 removed her gloves, did not perform hand hygiene, picked up the supplies needed and entered R24's room. V5 explained to R24 that she was there to check his blood sugar and put on gloves without hand hygiene. V5 cleaned finger with alcohol pad, pricked his finger, wiped away first drop of blood with cotton ball, and applied next drop onto the test strip. Once the results registered, V5 while still wearing the same gloves used to obtain blood sample, lifted R24's shirt and administered his insulin into his right lower abdomen. Before leaving the room, V5 removed her gloves, gathered used supplies, went out to the medication cart, and removed R24's eye drops from his drawer without washing hands. R24's EMR (Electronic Medical Record) shows R24 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R24's MDS dated [DATE] shows R24 was cognitively intact and required limited one staff assistance for ADLs (Activities of Daily Living) R24's POS shows R24 receives [MEDICATION(S)] insulin pen, 100 unit/ ml (milliliter), give 5 units subcutaneous, twice a day. Hold if blood sugar is less than 60. Notify physician if blood sugar less then 60 or equal to or greater than 300. Facility provided policy titled Blood Glucose Monitoring dated January 20, 2015 shows step four of procedure is to wash hands and don gloves after sample is obtained, equipment should be disposed. Facility provided policy titled. Injectable Medication Administration dated September 13, 2017 shows that injectable medications are administered as prescribed inaccordance with good nursing principals and practices. On May 5, 2021 V3 DON stated hands should be washed and gloves donned before sample is collected and after sample is collected nurse should doff the gloves and use hand sanitizer. I have to check the policy about wearing gloves when injecting a medication. 4. On May 3, 2021 at 10:11 AM during initial interviews, R26 was sitting up in wheelchair eating breakfast. V5 (LPN) entered room to pass medications without wearing PPE. There was no transmission based precaution sign on the room door and no isolation cart outside the room. Facility provided matrix shows R26 was positive for [CONDITION(S)] (Mulitdrug Resistant Organism). R26 was positive for ESBL ( Extended Spectrum Beta-Lactamases) in her urine. On May 4, 2021 at 8:53 AM R26 was asleep in bed and lights were off. There was no transmission based precaution sign on the door. V7 CNA (Certified Nurse Assistant) stated R26 is not feeling well today. On May 5, 2021 at 09:27 AM, R26 was in bed having just finished her breakfast. V6 RN (Registered Nurse) was standing at R26's bedside with her hand resting on the upper side rail of the bed. V6 was not wearing any gloves or PPE other than face mask. There is an isolation cart inside the room, and sign on bathroom door said Contact isolation. Bathroom Assist, Pericare, Clean Bathroom R26 stated she has a urinary tract infection and it is giving her hallucinations. R26's EMR shows R26 has multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's MDS dated [DATE] shows R26 was cognitively intact. R26 required two staff extensive assistance for bed mobility, total dependence of two staff for transfers from one surface to another, extensive one staff assistance for dressing and personal hygiene, and is totally dependent on one staff assistance for toileting. R26's POS shows physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . R26's care plan dated March 24, 2021 was updated on April 29, 2021 to address R26's urine culture positive for ESBL and contact precautions per facility protocol. Facility provided policy titled Infection Prevention and Control Manual Transmission-Based Precautions dated 2019 shows the purpose of contact isolation is to prevent the transmission of infections that are spread by direct (person to person) or indirect contact with the resident or environment. Contact precautions require the use of appropriate PPE including gown and gloves upon entering the room or making contact with the resident or resident's environment. Gloves should also be worn when handling items potentially contaminated by [CONDITION(S)]'s (Multidrug Resistant Organism). This may include such items as bedside tables, over-bed tray tables, bed rails, bathroom fixtures, television and bed controls, suctions, and oxygen tubing.

Based on observation, interview, and record review the facility failed to safely transfer a resident using a gait belt. This applies to 1 of 12 residents (R37) reviewed for safety in the sample of 12. The findings include: On (MONTH) 24, (YEAR) at 9:10 AM, V4 (Certified Nursing Assistant) assisted R37 to transfer from his wheelchair to his bed. Without using a gait belt, V4 held on to the back of R37's pants, hooked her left arm under R37's right arm and pulled up on R37 as R37 pulled up on 1/4 side rail attached to his bed. At 9:20 AM, V4 was asked when staff should use a gait belt with a resident. V4 stated, Gait belts are used for ambulation. Sometimes for transfers depending on how long they can stand and how much assistance they need. R37's care plan dated (MONTH) 11, (YEAR) states, Transfers - I am able to come to stand using my wheeled walker and a rocking motion to get up from sitting position, and might need minimal to moderate assist to come to stand. The interventions include: Stand pivot 1 assist with gait belt. A facility document entitled Counseling Statement dated (MONTH) 25, (YEAR) states, Transferring a resident without a gait belt in an unsafe practice. This could result in an injury to you and/or the resident. The undated facility policy entitled Transfer/Gait/Safety Belt Application states, Purpose: To assist the nursing staff by allowing a secure hold on the resident and To help residents feel more secure by preventing falls and injuries.

Based on observation, interview, and record review, the facility failed to show a specific [DIAGNOSES REDACTED]. This applies to 6 of 10 (R2, R3, R8-R11) reviewed for psychoactive medications in a sample of 12. The findings include: 1. On September 11, 2017 at 12:15 PM, R3 was eating lunch in the dining room with her son, conversing with her son and staff, and enjoying her meal. R3 was exhibiting no psychotic behaviors and appeared pleasantly confused during conversations. R3 was then taken to her room and sat with her family. R3 pleasantly spoke with her family and requested the use of the bathroom. On September 12, 2017 12:20 PM, R3 was eating lunch in the dining room and appeared pleasantly confused and was not exhibiting any behaviors. No psychotic signs or symptoms were observed. On September 14, 2018 at 11:49 AM, E3 (Licensed Practical Nurse), stated R3's behaviors include agitation and exit seeking which are usually triggered by her family visitors leaving and R3 searching for them. E3 stated R3 then begins seeking the facility exit and, when trying to redirect R3, R3 may shake her fist at staff. E3 stated if R3 is unredirectable, staff attempt to walk R3 around however sometimes R3 needs an as needed medication to reduce her anxiety. Physician order [REDACTED]. The POS shows R3's medications include quetiapine (Antipsychotic medication) 25 mg (milligrams) twice daily for dementia with behavioral disturbance, [MEDICATION NAME] (Antidepressant medication) 100 mg at bedtime for dementia with behavioral disturbance, [MEDICATION NAME] (Antidepressant medication) 45 mg at bedtime, and [MEDICATION NAME] (Antianxiety medication) 1mg every six hours as needed for anxiety disorder, and [MEDICATION NAME] (Antidepressant medication) 75 mg every morning. The POS shows R3's identified target behaviors for monitoring include agitation, self transferring, and wandering. [MEDICAL CONDITION] care plan, dated August 22, 2017, shows R3 struggled with anxiety and depression as well as [MEDICAL CONDITION]. The care plan also shows R3 wanders at times and calls for her late husband. Psychiatry note, dated August 28, 2017, shows R3's [DIAGNOSES REDACTED]. Unspecified [MEDICAL CONDITION]. Anxiety disorder. The progress note shows R3 had no signs or symptoms suggestive [MEDICAL CONDITION] hypomania or [MEDICAL CONDITION] and no evidence of delusions or perceptual disturbances. R3's clinical record fails to show any specific [DIAGNOSES REDACTED]. 2. POS, dated September 13, 2017, shows R2's [DIAGNOSES REDACTED]. The POS shows R2's medications include [MEDICATION NAME] (Antidepressant medication) 75 mg once a day, [MEDICATION NAME] (Antidepressant medication) 75 mg at bedtime as needed, and [MEDICATION NAME] (Antianxiety medication) 1 mg sublingual every three hours as needed for [MEDICAL CONDITION] with behavioral disturbance. The POS shows R2's identified target behaviors for monitoring include crying, resisting care, and self transferring. [MEDICAL CONDITION] care plan, dated July 11, 2017, shows R2 experienced depression most of her life, has dementia with behavior disturbance, mood disorder, and difficulty sleeping. On September 11 and 12, 2017, R2 was observed as alert, conversing with staff, and no anxiety or signs or symptoms of [MEDICAL CONDITION] were noted. Psychiatric progress note, dated June 24, 2016, shows R2's psychiatric care was transferred to R2's primary care physician. Physician note, dated September 24, 2016, show R2's [DIAGNOSES REDACTED]. Primary care physician note, dated December 2, 2016, shows R2's [DIAGNOSES REDACTED]. Primary care physician note, dated February 17, 2017, shows R2's [DIAGNOSES REDACTED]. No references to psychoses are mentioned in any of the psychiatrist or primary care physician notes. R2's clinical record fails to show any specific [DIAGNOSES REDACTED]. 3. POS, dated September 13, 2017, shows R8's [DIAGNOSES REDACTED]. The POS shows R8's medications include [MEDICATION NAME] oxalate (Antidepressant medication) 20 mg for major [MEDICAL CONDITION], [MEDICATION NAME] (Antianxiety medication) 0.25 mg every evening for unspecified dementia with behavioral disturbance, quetiapine 50 mg at bedtime for unspecified dementia with behavioral disturbance, and [MEDICATION NAME] 0.5 mg twice a day as needed for agitation/anxiety. The POS shows R8's targeted behaviors for monitoring include agitation and striking out at staff. [MEDICAL CONDITION] care plan, dated December 12, 2017 shows R8 was often irritable, resistive, even combative, and agitated when struggling with having a bowel movement. Psychiatric progress note, dated August 28, 2017, shows R8 had no signs or symptoms suggestive of mania, hypomania or [MEDICAL CONDITION], delusions, or perceptual disturbances. R8's clinical record fails to show any specific [DIAGNOSES REDACTED]. 4. POS, dated September 14, 2017, shows R9's [DIAGNOSES REDACTED]. The POS shows R9's medications include quetiapine (Antipsychotic medication) 75 mg once every morning, and 25 mg every noon and evening, for [MEDICAL CONDITION] with behavioral disturbance, [MEDICATION NAME] (Antianxiety medication) 1 mg twice a day and an additional 1 mg at noon as needed for [MEDICAL CONDITION] with behavioral disturbance, [MEDICATION NAME] (Antidepressant medication) 25 mg for major [MEDICAL CONDITION], [MEDICATION NAME] (Central nervous system agent) 20-10 mg twice a day for [MEDICAL CONDITION] with behavioral disturbance, [MEDICATION NAME] 50 mg at bedtime. The POS shows R9's targeted behaviors for monitoring include agitation, chanting, and crying. [MEDICAL CONDITION] care plan, dated July 11, 2017, shows R9 paranoia is described as other residents or staff do not like R9 and that other residents get more attention that R9. [MEDICAL CONDITION] progress note, dated August 28, 2017, shows R9 had no signs or symptoms suggestive of mania, hypomania, [MEDICAL CONDITION], delusions or perceptual disturbances. R9's clinical record fails to show any specific [DIAGNOSES REDACTED]. 5) R10's physician's orders [REDACTED]. R10 was also prescribed [MEDICAL CONDITION] medications; [MEDICATION NAME] (Antianxiety medication) 1 milligram (mg) tablet every morning and Quetiapine (Antipsychotic medication) 37.5 mg every morning and Quetiapine 50 mg every night. R10's Psychiatry Note dated July 21, 2017 showed: Staff reports no new behavioral issues. R10 has been stable with her with mood and behaviors. R10's sleep and appetite were fine. No verbal outburst or physical aggression. No symptoms suggestive of major [MEDICAL CONDITION] (MDD), mania, hypomania or [MEDICAL CONDITION]. R10 is compliant with her [MEDICAL CONDITION] with no side effects. R10's Axis I: Major neuro-cognitive disorder due to multiple etiologies with behavioral disturbances-stable. Anxiety disorder NOS. R10's Care Plan for [MEDICAL CONDITION] Drug Use with start date of March 2, 2016 shows the following: [MEDICAL CONDITION] Drug Use: R10 takes [MEDICATION NAME] and Quetiapine. R10 has [DIAGNOSES REDACTED]. R10 exhibits poor insight and judgment, illogical thought process with history of becoming very confused, anxious, and will ask the same questions over and over to different staff. R10's Care Plan Goals with targeted date of November 6, 2017: To be prescribed lowest dose of all medications as evidence by ability to obtain sleep 7-8 hours per night and staff being able to provide needed care every shift. R10's Treatment Administration History: Targeted Behavior from June 2017 through present showed monitored for agitation, crying and delusions (no specific behavior described as to what delusions R10 exhibits). On September 14, 2017 at 11:34 AM, E3 (Nurse) stated R10 displays agitation only when she's being showered or given bath. R10 displayed tearful or crying episode only the first few months after R10 was admitted to the facility. Basically R10 is pleasant and cooperative in general and likes to chat one on one. R10 sometimes believe that she's a nurse but has no auditory or visual hallucinations. 6) R11's physician's orders [REDACTED]. R11 was also prescribed [MEDICAL CONDITION] medications; [MEDICATION NAME] (Antidepressant medication) 50 mg tablet every night, [MEDICATION NAME] (Antipsychotic medication) 0.25 mg tablet (given 1/2 tablet=0.125 mg every night and [MEDICATION NAME] (Antianxiety medication) 0.5 mg twice a day and at bedtime as needed. R11's Psychiatry Note dated July 21, 2017 showed: Staff reports no new behavioral tissues. R11 has been stable with her with mood and behaviors. R11's sleep and appetite are fine. No verbal outburst or physical aggression. No symptoms suggestive of major [MEDICAL CONDITION] (MDD), mania, hypomania or [MEDICAL CONDITION]. R11 is compliant with her [MEDICAL CONDITION] with no side effects. R11's Axis I: Major neuro-cognitive disorder due to multiple etiologies with behavioral disturbances-stable. Anxiety disorder NOS. R11's Care Plan for [MEDICAL CONDITION] Drug Use with start date of December 12, 2013 shows the following: [MEDICAL CONDITION] Medication Use: R11 has [DIAGNOSES REDACTED]. R10 receives anti-anxiety, anti-psychotic and anti depressant medications for combativeness during provisions of care, striking out at others, irritability, agitation and difficulty sleeping. R11's Care Plan Goals with targeted date of November 13, 2017: To be prescribed lowest dose of all medications as evidence by ability to obtain sleep 7-8 hours per night and staff being able to provide needed care every shift. R11's Treatment Administration History: Targeted Behavior from June 2017 through present showed monitored for agitation, screaming/yelling, striking out at staff and resistive to care. On September 14, 2017 at 11:34 AM, E3 (Nurse) gave the following statement: Most times R11 is humming/singing in German language in the hallway. Sometimes she (R11) yells for no reason, resistive during activities of daily living (ADL) care, need encouragements to take medication. Staffs are not really sure what R11 yells at when she's agitated because it's in German language. R11 does not display auditory or visual hallucinations. From September 11 through September 13, 2017 multiple observations were made of R10 and R11, both residents were noted calm and did not display any psychotic symptoms. Both R10 and R11 had no specific [DIAGNOSES REDACTED]. Facility's Policy for the use of [MEDICAL CONDITION] Medications dated 02/24/2017 showed: The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED].

Based on observation, interview and record review, the facility failed to ensure that staff cleaned peri-area during the provision of incontinence/toileting care to residents who required extensive assistance with incontinence care/toileting. This applies to 3 of 7 residents (R1, R4, R5) reviewed for incontinence/toileting care in the sample of 12. The findings include: 1) R4's care plan dated September 10, 2017 showed: Indwelling catheter for [MEDICAL CONDITION]. On September 11, 2017 at 3:35 PM, E8 (Certified Nursing Assistant/CNA) provided toileting care to R4. When R4 was finished with toileting, E8 proceeded to clean R4's buttocks then applied new incontinence brief. E8 did not clean R4's peri-area (inner/outer labia, urethra, and groins) and indwelling catheter site and tube. 2) R5's care plan dated April 10, 2017 showed: Indwelling catheter related to [DIAGNOSES REDACTED]. On September 12, 2017 at 2:00 PM, E7 (CNA) toileted R5. After R5 was finished with toileting, E7 cleaned R5's buttocks and catheter tube but did not clean peri-area (groins and penis). 3) R1's care plan dated July 24, 2017 showed: Urinary incontinence/[MEDICAL CONDITION]. Minimum Data Set (MDS) dated [DATE] showed that R1 is incontinent of bowel and bladder. On September 12, 2017 at 2:00 PM, E6 (CNA) rendered incontinence care to R1 who had a bowel movement. E6 cleaned R1's buttocks with wet wipes then proceeded to apply new incontinence brief without cleaning R1's peri-area (groins and penis). On September 14, 2017, at 12:45 PM, E4 (Nurse) stated, when providing incontinence care staff must clean resident's genitalia to remove urine and fecal matter to prevent odor and skin breakdown. E4 also stated, for male residents staff should clean the shaft of the penis as well as the tip of the penis (urethral opening) with wet wipes or soap and water to prevent infection or UTI. R1's, R4's and R5's most recent MDS showed that these residents needed extensive assistance with toileting and hygiene and are incontinent with bowel and bladder. Facility's Policy for Incontinence Care dated September 22, 2015 showed: Purpose: 1) To ensure optimal care of the residents. 2) To prevent skin breakdown. 3) To ensure incontinent residents are given care to maintain dignity and prevent odors. 4) To prevent infection.

Based on observation, record review, and interview, the facility failed to follow their policy for hand hygiene. The facility also failed to keep oxygen and nebulizer equipment clean and free from contamination. This failure affects 5 (R3, R5, R7, R8, R9) residents reviewed for hand hygiene in a sample of 13 and for 1 (R15) resident in the supplemental sample. Findings include: 1). On August 9, 2016 at 12:54 PM, E6 (Certified Nursing Assistant-CNA) assisted R8 to the bathroom. R8's incontinence brief had fecal material in it. E6 removed R8's soiled incontinence brief with her ungloved right hand. E6 did not wash or sanitize her hands after removing the soiled incontinence brief. E6 then adjusted R8's shoes touching the soles of the shoes. E6 did not wash or sanitize her hands before putting on a new pair of gloves. E6 wiped R8's groin, pubic, buttocks and rectal areas. E6 removed her gloves but did not wash or sanitize her hands. E6 then touched R8's incontinence brief and pants to adjust and pull up, held R8's hand to assist in walking, touched the call light and oxygen tubing. E6 then washed her hands. 2). On August 9, 2016 at 2:03 PM, E11 (CNA) assisted R7 to the commode for toileting. E11 wiped R7's pubic, buttocks and rectal area. A smear of fecal material was seen when rectal area was wiped. E11 removed her gloves but did not wash or sanitize her hands. E11 pulled up R7's incontinence brief and pants and assisted R7 to the wheelchair. E11 touched the wheelchairs handle to reposition it and then wash her hands. 3). R9 is a [AGE] year old female whose face sheet documents the following Diagnoses: [REDACTED]. R9's MDS (Minimum Data Set) with Assessment Reference Date June 22, 2016 documents that she requires extensive assistance, two person physical assistance for toilet use. On August 10, 2014 at 1:42pm, E4 (Certified Nursing Assistant, CNA) performed incontinence care for R9. After cleansing R9 with disposable wipes, E4 removed her gloves and placed a new adult brief on R9 without performing hand hygiene. E4 stated it is the facility's policy to place the brief without hand hygiene. E4 stated I'm getting rid of this (dirty brief) then I'm washing my hands. 4). R5's face sheet documents [DIAGNOSES REDACTED]. R5's MDS documents that she requires extensive assistance, one person physical assist with toilet use and personal hygiene. On August 10, 2016, E7 provided incontinence care to R5. E7 placed R5 on a mechanical lift and placed her on the toilet. After R5 voided, E7 wiped her with disposable wipes, removed his gloves then placed a new adult brief between her legs and fastened it without performing hand washing. E7 then put the wet disposable diaper in the garbage bag and held the bag in his hand. E7 then used hand sanitizer while the dirty bag was in his hand. E7 stated it is the facility's policy not to use gloves when applying new adult brief. E7 stated I know she is clean and I know the brief is clean. But E7 didn't clean his hands. On August 10, 2016 at 3:30pm, E2 (Director of Nursing) stated that if the brief is clean and the resident is cleaned, staff could take their gloves off, but apply hand sanitizer and can put the brief on without gloves. The facility's policy for Hand Hygiene documents: Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn, immediately after gloves are removed; and when otherwise indicated to avoid transfer of microorganisms to other residents, personnel, equipment and /or environment. Specific examples include but are not limited to: before and after providing personal cares for resident, after removing gloves. 5). On August 9, 2016 during tour of the facility which started at 10:00am, along with E5 (Registered Nurse/RN), R15 had a nebulizer mask on top of her night stand and not protected in any type casing. The mask was not dated as to when it was given. E5 stated it should be dated. There was a bag attached to the night stand. E5 lifted the bag which was dated July 28, 2016. R3 had oxygen tubing hanging off his oxygen tank. The nasal cannula was against the back side of the oxygen tank. R8's nasal cannula was hanging against the side of the machine, there was a black bag attached to the machine, but the oxygen tubing was not in the bag. E6 (CNA/Certified Nursing Assistant) stated Every time we get her up, we store it (oxygen tubing) in the bag.

Based on observation, record review and interview the facility failed to follow their policy for medication administration. This failure resulted in an 8 percent medication error rate. There were a total of 25 opportunities with 2 errors. This applies to 2 of 4 residents (R8,R16) observed during medication pass. Findings include: 1). R8's MAR and POS documents the following order: [MEDICATION NAME] ([MEDICATION NAME]) spray, insert 2 sprays into each nostril daily (Class- Nasal agents-systemic) On August 10, 2016 at 7:40am, E13 (Registered Nurse) administered the [MEDICATION NAME] to R8. R8 was sitting in her wheelchair. E13 did not instruct R8 to hold her head back or maintain position. E13 also did not wipe away excess drainage/medication from R8's nose. E13 did not hold one nostril(or instruct R8 to hold one nostril) while spraying the [MEDICATION NAME]. The facility's policy documented: Position resident properly -if able to hold head back, being up in chair will be sufficient -if unable to hold head back, administer medication in bed -if able, instruct resident to maintain position for up to 2 minutes to assist medication to flow into sinuses. -wipe away any drainage or excess medication immediately. 2). R16's Medication Administration Record (MAR) and physician's orders [REDACTED].>Chronic [MEDICAL CONDITION] with recent Acute [MEDICAL CONDITION] [MEDICATION NAME] Aerosol 80-4.5, inhale 2 puffs by mouth twice daily On August 10, 2016 at 8:00am, E12 (Licensed Practical Nurse) administered the [MEDICATION NAME] to R16. E12 administered one puff, shook the inhaler and administered the second puff. The facility's policy for Inhaler Administration documented: Wait 1 minute if more than 1 puff is ordered for inhalers. On August 12, 2016 at 9:47am (2 days after Medication observation), E2 (Director of Nursing) stated to the survey team, I just changed one thing. I changed our medication policy. E2 then presented (On August 12, 2016) a print out for [MEDICATION NAME] which documents: Close one nostril and put tip of spray nozzle in other nostril. Put just to the tip into your nose. Aim slightly away from center of nose. While sniffing gently, press down on spray nozzle once or twice according to dosing instructions. E13 did not follow any of the above documented steps. E13 also did not instruct R8 to sniff gently while pressing down on the spray nozzle. This policy change was also made after medication administration observation. E2 also stated she changed the facility's policy for inhalers (August 12, 2016). E2 stated she changed the policy so we don't have to wait a minute between puffs for inhalers. E2 was asked when was the policy changed. E2 stated I changed it last night (which was after the medication administration observation and the facility providing the above documented policy). The facility's policy in effect at the time of medication administration observation documented that the nurses are required to wait 1 minute between puffs, which did not occur. The policy change occurred after the facility was informed that on August 10, 2016 E12 did not follow their policy for medication administration.

Based on observation, interview and record review, the facility failed to sanitize work surfaces after food contact, sanitize pots and pans at the correct sanitizer concentration, and utilize food-grade equipment to prevent foodborne illness. This has the potential to affect all 48 residents in the facility. The findings include: On the July 6, 2015, the Facility Resident Census and Condition Form (CMS 672) showed that there were 48 residents in the facility. On July 6, 2015 at 10:15 AM, laundry baskets were located on the bottom shelves of the freezer holding frozen wrapped meat products for storage. On July 6, 2015 at 10:20 AM E3 (Cook) was panning fish for lunch with no sanitation bucket for swabbing present. E3 continued to prepare items for lunch with no sanitation bucket utilized to sanitize food preparation area between tasks. E3 stated she should have had a sanitizer bucket available however she had not had time to prepare one that morning. On July 7, 2015 at 10:10 AM E3 had no sanitation bucket available at her work station when she prepared and placed ground meat for lunch at the stove and preparation table areas. E3 then pureed meat servings for lunch service. After finishing the tasks E3 moved on to other lunch tasks without utilizing a sanitation bucket to swab the food contact areas. E3 stated she should have had a sanitation bucket but she had not needed to sanitize anything since she was on break. On July 7, 2015 at 10:35 AM E4 (Dishwasher) utilized the three compartment sink to wash, rinse and sanitize pots and pans. E4 then utilized a test strip to measure the chemical sanitizer in the third sink which showed the sanitizer concentration to be less than 150 ppm (parts per million). E5 (Director of Dining Services) confirmed the sanitizer concentration was less than 150 ppm. E5 stated the chemical solution was more than two hours old and directed E4 to replace the solution with a new solution. E4 removed the wet pots and pans from the drying area, which had been sanitized in the inadequate concentration, and stacked them wet on the pot and pan rack. On July 7, 2014 at 3:45 PM, E1 (Administrator) confirmed the laundry baskets in the freezer were not food grade quality and will be replaced. Facility policy and procedure Sanitizer Buckets, dated September 5, 2014, shows, Buckets of sanitizer will be available for using washcloths to sanitize work areas as needed. Facility policy and procedure Sanitizer - Three-Compartment Sink, dated August 1, 2010, shows, The three compartment sink must use the following instructions and sequence for proper sanitation of dishes. 1) Wash. 2) Rinse. 3) Sanitize, 50 ppm chlorine or 200 ppm Quat at room temperature water (about 75 degrees Fahrenheit). Test sanitizer ppm every time sink is changed and record. Check or change sanitizer often. Air Dry clean items before storage or use. Facility chemical sanitizer manufacturer information, undated, shows chemical concentration of 150-400 ppm is to be utilized to sanitize hard nonporous food contact surfaces.

Based on record review and interview the facility failed to notify the physician to obtain medical evaluation and treatment in a timely manner for one resident who exhibited a significant change in condition. This applies to one of three residents in the sample reviewed for significant change. Findings include: Review of MDS (minimum data set) dated 4/15/15 shows R1 is [AGE] years old with severely impaired cognition (BIMS = 3), requires extensive hands on assist for most activities of daily living and is frequently incontinent of both bladder and bowel. Diagnosis' include hypertension, [MEDICAL CONDITION], diabetes, stroke, and [MEDICAL CONDITION]. E1 (assistant director of nursing) stated on 6/3/15 at 12:50pm R1 has been a resident in facility for about 6 months and has had episodes of getting very upset, refusing care and medication at times. This can be a fairly regular occurrence, said E1. Staff has found leaving R1 for a while (30 minutes or so) and then re-approaching him has been a successful method of getting R1 to be compliant. However this approach did not work on 6/1/15-6/2/15. E1 stated around 1:30pm on 6/1/15, after having eaten only 25% of his lunch and drinking very little, R1 sat down in the recliner in the facility living room and that is when the situation began to decline. We tried to get him up around 4:00pm but he refused. He refused to eat or drink anything for supper and was still refusing his medications. (R1) stayed in the chair all night. We made multiple attempts to get him up. At 10:40am the next morning (6/2/15) the physician was notified and gave orders to transfer R1 to the hospital. E1 confirmed R1 remained in the chair and did not eat, drink or receive incontinence care from 6/1/15 about 1:30pm until 6/2/15 at 10:30am (when R1 was taken to the hospital), about 21 hours. E1 also stated R1's behavior began to decline significantly on 5/31/15. Nurse's note dated 5/31/15 states R1's refused all medications today despite multiple attempts, approaches, and techniques. Angry and resistive to care. Refused to go to the bathroom before supper. Refusing to eat at meals when angry. Ate <10% at breakfast and <50% at lunch, despite alternatives being offered.yelling at staff. Did not eat any supper. Review of nurse's notes along with E1 show there was no nursing documentation for the day shift on 6/1/15. The evening note for 6/1/15 states R1 remained in the recliner for the entire shift. Continued to be angry, resistive of care, combative, agitated and abusive. Refused to have his Attends changed despite multiple attempts , approaches,,, . R1 attempted to hit and kick several staff. Staff could not provide the necessary care. E1 stated she would consider R1's behaviors beginning on 5/31/15 and into the next 2 days as a significant change in condition. E1 said the physician was not notified until 6/2/15 at 10:40am. E1 said staff thought they kept attempting different approaches as usual, in hopes of getting him to cooperate. Review of facility policy and procedure for Change of Condition states the purpose of this policy is to ensure appropriate care is being given. The facility must immediately inform the resident's physician when there is a significant change in the resident's physical, mental or psychosocial status. E1 also stated that the physician was not informed of R1's multiple refusals of medications for the past 3 days. Review of policy on Administration of Drugs (under G) states Residents refusing medications shall be brought to the attention of the attending physician. E3 (administrator) stated on 6/4/15 at 3:10pm that this policy will be revised to be revised to include specific time frames. E3 also stated R1 is being readmitted from the hospital today, around supper time. Review of MARs (medication administration) show R1 receives medication for high blood pressure, [MEDICAL CONDITION], diabetes and depression. The MARS for the last several days of May and for June 1 and 2, show R1 these medications in addition to other random refusals during the entire month of May. E1 stated she assumes the nurse informed the physician of the refusals when he came to visit R1 on 5/26/15. E1 stated there was no documentation of such, however.

Based on record review and interview the facility failed to conduct a thorough investigation of bruises of unknown origin to rule out possible abuse. This applies to two of three residents (R3 and R5) in the sample of 12 residents. The findings include: 1. The facility identified R3 has cognition impairment per her 9/3/14 Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score of '00.' R3's 9/3/14 section 'G' showed she is totally dependent on staff for her activities of daily living. R3's 6/18/14 nurses notes and an incident report showed a Certified Nurse Aide (CNA) when giving shower noticed a 2.5 cm x 1.7 cm bruise to top of left fore head. R3's 6/18/14 incident showed, she may have struck her head on the total mechanical lift bar or struck the radiator during turn out in bed. There were no documented staff or other interviews to gather information to determine the cause of the bruise to rule out abuse. R3 also per her 8/18/14 nurses notes and incident report she sustained four small bruises (total area 11 cm x 2.5 cm) to her right upper forearm. It was noted on 8/18/14 incident report 'other cause' section 'family here for birthday celebration and may have tried to reposition R3 by holding on to her arm and creating the bruise.' There is no documentation to show if the facility conducted staff and or other interviews to rule out possible abuse. On 9/4/14 at 2:00 PM E2 (Director of Nurses - DON) stated she did not think of ruling out abuse with her investigation of bruises or injuries of unknown origin. 2. R5's 6/4/14 MDS documents R5 to be rarely understood per her BIMS. R5 is not on any blood thinning medications nor is there a [DIAGNOSES REDACTED]. The nursing notes dated 7/31/14 at 10:10 PM documents R5 was noted with a large reddish/purple bruise to her right axilla, right medial upper arm measuring 13 cm x 8 cm. The bruise extends to the right breast and measures 16 cm x 15.4 cm and is noted to be swollen and tender with guarding to the area. There is continued documentation from 8/1/14 through 8/3/14 of the bruised area and resident showing signs and symptoms of pain, guarding the area. R5's 9/2/14 incident investigation section 'other cause' documented the occurrence is possibly related to readjusting / boosting R5 in her wheelchair. There are no employee or others interviews with this investigation. There was no thorough investigation to rule out possible abuse. On 9/4/14 at 8:50 AM, E2, stated there was no further investigation done on this. E2 also stated she interviewed the CNAs, but it was not documented and stated she felt comfortable the bruising / injury occurred during repositioning of R5 and never considered abuse at that time. On 9/4/14 at 9:20 AM, E3 (Social Services), stated she was the abuse coordinator in the facility, but she, E2 and E1 (Administrator) all worked together on abuse. E3 stated she was not involved with the investigation of R5's injury of unknown origin but she did speak with E2 about it and E2 felt the bruising occurred during repositioning. E3 was asked if she felt R5 was at risk for abuse and she stated, " Why, because she can't communicate for herself? " E3 then stated, " I guess she would be, I never thought about that. " R5's care plan with a problem start date of 9/4/2013 and a goal date of 9/8/2014 documents R5 to have a cognitive loss, dementia and unable to communicate verbally but does not have her at risk for abuse. There is also no update of the care plan with transferring / repositioning of R5 in regards to her recent injury and fragile status during repositioning and transferring.