Every finding on record at Holland Home Breton Rehabilitation & Living Centre

Based on observation, interview, and record review the facility failed to consistently use dignified terms for residents and ensure consistent dignified dining experiences for 10 (Residents #3, 19, 15, 42, 44, 6, 29, 38, 25, & 28) of 45 residents reviewed for dignity resulting in the potential for feelings of shame, embarrassment, and/or decreased meal enjoyment.Findings includeResident #3:Review of Resident #3's admission record, dated 4/30/26, indicated she was an [AGE] year old female with a pertinent diagnosis of dementia (decline in cognitive function).Review of Resident #3's brief interview for mental status, dated 2/26/26, was scored zero which reflected severe cognitive impairment. Review of Resident #3's activity of daily living care plan included an intervention, revised 9/2/25, which stated, EATING: The resident needs total feeding assistance (a level of care where a resident requires complete help with the entire eating/drinking process due to physical, cognitive, or medical impairments).During an observation and interview on 4/29/26 at 8:17 AM, Certified Nurse Aide (CNA) Y was in the hallway just outside of Resident #3's room and stated Resident #3 was a feeder and there were other feeders in the dining room who needed assistance. Resident #3 was inside her room, with the door open, and within hearing distance. Resident #3 was confused and unable to answer questions regarding how the term feeder made her feel. Note: Feeders is an undignified term that refers to residents who require staff assistance with their meals. Resident #19 and #15:Review of Resident #19's self-care care plan included an intervention, revised 4/28/26, that stated, EATING: (Resident #19) requires assistance by one staff to eat.Review of Resident #19's brief interview for mental status, dated 3/30/26, was scored zero which reflected severe cognitive impairment.Review of Resident #15's self-care care plan included an intervention, revised 2/20/26, that stated, EATING: I am usually able to eat independently with set up, and hands on assistance at times.Review of Resident #15's brief interview for mental status, dated 3/13/26, was scored 8 which reflected moderate cognitive impairment.During observations and interviews on 04/30/2026 starting at 8:16 AM, CNA Y was delivering and assisting residents during breakfast service and stated She is a feeder to Registered Nurse X in the hallway just outside of Resident #19's room and Resident #15's room. Residents #19 and #15 were in their rooms, with the doors open, and within hearing distance. On 04/30/2026 at 8:23 AM, CNA Y was observed providing total dining assistance for Resident #19 in her room. On 04/30/2026 at 8:26 AM CNA E was observed providing total dining assistance for Resident #15 in her room. Both Residents #19 and Resident #15 presented with confusion and were unable to answer questions related to how the term feeder made them feel.During an interview on 04/30/2026 at 9:21 AM, CNA Y reported feeder was the term she had used to describe residents who required eating and drinking assistance from staff. CNA Y reported previously she had not known another term to use instead of feeder.Residents #42, #44, #6, #29, #38, #25, & #28:Review of Residents #42, #44, #6, #29, #38, and #25's admission records all had a date of 4/30/26 and a diagnosis of dementia. Review of Resident #28's admission record, dated 4/30/26, included a diagnosis of mild cognitive impairment.During an observation on 04/30/2026 at 8:34 AM, Residents #42, #44, #6, #29, #38, #25, & #28 were in the activity/dining room across from the nurse's station. All 7 residents appeared to be cognitively impaired and received either meal supervision, total dining assistance, or partial dining assistance from staff. All 7 residents were served their meals (plates, bowls, cups, utensils, napkins, condiments, etc.) on trays on top of the dining tables and their meals remained on the trays for the duration of the meal.During an interview on 04/30/2026 at 8:57 AM, Dining Services Manager (DSM) CC reported the residents (which included Residents #42, #44, #6, #29, #38, #25, & #28) in the activity room/dining room who were served meals on trays needed more attention and feeding assistance. DSM CC reported there was no set reason for meals to be served on trays in the dining room and was not aware of any resident group that had voiced a preference to have their meals remain on trays in the dining room.During an interview on 04/30/2026 at 8:59 AM, Director of Nursing (DON) B reported the residents (which included Residents #42, #44, #6, #29, #38, #25, & #28) eating breakfast in the activity/dining room, located across from the nurses' station, needed direct supervision or hands on meal assistance. DON B reported there was no facility/resident group he was aware of that had agreed upon a preference/desire to have their meals served on trays in the dining room. Review of the facility's Resident Rights policy, revised 4/2021, stated, Upon admission, residents will be informed of their rights, including-but not limited to-the right to a dignified existence .Review of the facility's Meal Delivery policy, revised 2/2025, stated, A defined meal delivery service is followed to ensure delivery of.a dignified dining atmosphere and necessary assistance to promote nutritional health .Review of the Pioneer Network's (A group that advocates for positive culture change for care of elderly residents) resource paper, The Food and Dining Side of the Culture Change Movement: Identifying Barriers and Potential Solutions to furthering Innovation in Nursing Homes, dated 1/28/2010, stated, As part of a dignified dining experience, forward-thinking pioneers questioned, and then simply stopped.serving food on trays. What is also becoming a former long term care practice is referring to those needing assistance or to be fed as feeders. Harm was not meant by these ideas, but they have contributed to putting the task, and the goal of efficiency before the person.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive care plan was revised to reflect an increased need for assistance for transfers in 1 resident (Resident #6) of 12 residents reviewed for care plans, resulting in the potential for injury and falls.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, repeated falls, unsteadiness on feet, weakness, and difficulty walking. Review of a Significant Change in Status Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/7/26 revealed the Functional Abilities revealed that Resident #6 required substantial/maximal (staff does more than half of the effort) assistance to stand and for all transfers.Review of Resident #6's Care Plan revealed, I have a self-care deficit related to deconditioning, debility, and dementia as evidenced by needs assistance with daily cares and mobility. I require assistance with all my ADLs (activities of daily living) Date initiated: 8/27/25. Revision on: 11/7/25. Goal: (Resident #6) will receive max to total staff assistance to meet her ADL needs. Date initiated: 2/6/26. Revision on: 3/25/26. Interventions: 1/4 enabler rails to HOB (head of bed) for bed mobility, transfers. Date initiated: 8/27/25 .One person assist for transfers, mod-max assist (staff does 50% or more of effort) for bed mobility (rolling from side to side). Date initiated 2/24/26. Revision on: 3/13/26. Toilet Use: Max assist . Dated initiated: 8/27/25. Revision on: 3/13/26. The revisions on 3/13/26 were for an increased assistance level with bed mobility and toilet use but did not include 2-person assistance for bed to chair transfers. The care plan did not include personalized interventions related to Resident #6's inconsistent functional abilities.Review of Resident #6's Kardex (care guide for direct care staff) revealed, .Mobility: 1 assist for transfers .ADL's: Assist .Special instructions: .Fall risk, No socks, only tubi (compression stocking). During an observation on 04/28/2026 at 10:11 AM in Resident #6's room. Certified Nursing Assistant (CNA) D entered the room and prepared to transfer Resident #6 from bed to wheelchair. CNA D placed the wheelchair at the bedside, wrapped a gait belt (used to assist in transferring a resident with limited abilities) around Resident #6's waist and lifted Resident #6 up and sat her in the wheelchair. In an interview on 04/28/2026 at 10:26 AM, Registered Nurse (RN) L reported that Resident #6 did not stand well at all and it takes 2 people to transfer her. During an observation on 04/28/2026 at 10:30 AM in Resident #6's bathroom, RN L was observed lifting Resident #6 up and off the toilet, CNA D quickly pulled the resident's pants up and RN L sat Resident #6 down in her wheelchair. Resident #6's legs were bent during the transfer and she did not bear weight on her feet. In an interview on 04/30/2026 at 7:52 AM, RN L reported that Resident #6 did not stand well or bear weight, but staff was able to do a one person transfer due to Resident #6 being light weight. RN L reported that she was able to revise care plans and was expected to communicate to Nurse Manager (NM) F if a resident declined in their ability to transfer. During an observation on 04/29/2026 at 7:10 AM in Resident #6's room, CNA M entered the room to get the resident out of bed for breakfast. CNA M sat the resident up onto the side of the bed, put her arms underneath Resident #6's arms and wrapped them around the resident's back, then lifted her up and placed her in the wheelchair next to the bed. CNA M did not cue Resident #6 before the transfer, did not use a gait belt and/or enabler bar for the transfer and Resident #6 was not wearing any socks.In an interview on 04/29/2026 at 7:37 AM, CNA M reported that she had forgotten to use a gait belt. CNA M stated, (Resident #6) recently started to not stand on her legs.before she was able to help more. In an interview on 04/29/2026 at 12:39 PM, Physical Therapist (PT) V reported that Resident #6 was doing therapy to get stronger but was not motivated to participate. PT V reported that Resident #6 was a max (maximum) assist, which meant that 2 staff needed to do 75% of the effort to transfer. PT V reported that Resident #6 was at a high risk for falling, required 2 people, a gait belt, non-skid socks, and a wheelchair close by for all transfers. Review of Resident #6's Physical Therapy Notes dated 4/21/26 revealed, .Sit to stand transfer training with walker in the front 5x (five times), Max A (maximum assistance) of 2 person required.increased challenge with tasks.Review of Resident #6's Physical Therapy Notes dated 4/15/26 revealed, .Sit to stand transfer training with walker in the front 8x, Max A of 2 person required.required extra time to process new information.Review of Resident #6's Physical Therapy Notes dated 4/8/26 revealed, .Sit to stand transfer training with walker in the front 10x, Max A of 2 person required.required extra time to process new information.Review of Resident #6's Physical Therapy Notes dated 3/23/26 (first visit) revealed, .seen for functional transfer training including sit to stand, bed mobility including supine to sit, sit to supine, chair transfer with RW (rolling walker) with cue for hand placement, weight shift and sequencing. Pt (patient) required max A of 2 to dep (dependent) for all functional transfers and mobility.In an interview on 04/30/2026 at 8:57 AM, NM F reported that Resident #6's functional abilities fluctuated; on good days Resident #6 was able to transfer with one-person assistance and other days she required two-person assistance. NM F reported that a significant change in Resident #6's condition was identified about a month ago and therapy services were started. NM F reported that the therapy department normally communicated with the nursing staff when there were recommendations about transfer status and then the resident's care plan should be updated. NM F was not sure if she had received any communication from therapy recently regarding Resident #6.

Based on observation, interview, and record review, the facility failed to ensure safe transfers were performed and the comprehensive care plan was updated with therapy recommendations in 1 resident (Resident #6) of 3 residents reviewed for accidents/falls, resulting in the potential for injury and falls due to unsafe transfers.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, stage 4 pressure ulcer of sacral region (coccyx, tailbone area), repeated falls, unsteadiness on feet, weakness, and difficulty walking. Review of a Significant Change in Status Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 3/7/26 revealed the Functional Abilities revealed that Resident #6 required substantial/maximal (staff does more than half of the effort) assistance to stand and for all transfers.Review of Resident #6's Fall Risk Evaluation dated 4/15/26 revealed, .If the score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan.1-2 falls in the past 3 months.Disoriented x 3 at all times.Chairbound/incontinent.Fall Risk Score: 17.Review of Resident #6's Care Plan revealed, I have a self-care deficit related to deconditioning, debility, and dementia as evidenced by needs assistance with daily cares and mobility. I require assistance with all my ADLs (activities of daily living) Date initiated: 8/27/25. Revision on: 11/7/25. Goal: (Resident #6) will receive max to total staff assistance to meet her ADL needs. Date initiated: 2/6/26. Revision on: 3/25/26. Interventions: 1/4 enabler rails to HOB (head of bed) for bed mobility, transfers. Date initiated: 8/27/25. Up daily in high back wheelchair, foot buddy across leg rests. Date initiated: 3/13/26.One person assist for transfers, mod-max assist for bed mobility (rolling from side to side). Date initiated 2/24/26. Revision on: 3/13/26. Toilet Use: Max assist . Dated initiated: 8/27/25. Revision on: 3/13/26. The revisions on 3/13/26 were for an increased assistance level with bed mobility and toilet use but did not include 2-person assistance for bed to chair transfers. The care plan did not include personalized interventions related to Resident #6's inconsistent functional abilities.Review of Resident #6's Kardex (care guide for direct care staff) revealed, .Mobility: 1 assist for transfers .ADL's: Assist .Special instructions: .Fall risk, No socks, only tubi (compression stocking). During an observation on 04/28/2026 at 10:11 AM in Resident #6's room. Certified Nursing Assistant (CNA) D entered the room and prepared to transfer Resident #6 from bed to wheelchair. CNA D placed the wheelchair at the bedside, wrapped a gait belt (used to assist in transferring a resident with limited abilities) around Resident #6's waist and lifted Resident #6 up and sat her in the wheelchair. CNA D did not cue Resident #6 to place her feet on the floor or to stand. Resident #6 was wearing thick gray socks with very minimal grip on the bottom. Resident #6's feet slid across the floor, and she did not bear any weight.In an interview on 04/28/2026 at 10:26 AM, Registered Nurse (RN) L reported that Resident #6 did not stand well at all and it took 2 people to transfer her. During an observation on 04/28/2026 at 10:30 AM in Resident #6's bathroom, Nurse Manager (NM) F and CNA D were with the resident as she was sitting on the toilet. RN L entered the bathroom and NM F exited the room. RN L was observed lifting Resident #6 up and off the toilet, CNA D quickly pulled the resident's pants up and RN L sat Resident #6 down in her wheelchair. Resident #6's legs were bent during the transfer and she did not bear weight on her feet. In an interview on 04/30/2026 at 7:52 AM, RN L reported that Resident #6 did not stand well or bear weight, but staff were able to do a one person transfer due to Resident #6 being light weight. RN L reported that she was able to revise care plans and was expected to communicate to NM F if a resident declined in ability to transfer. RN L reported that Resident #6's transfer status had not changed recently.During an observation on 04/29/2026 at 7:10 AM in Resident #6's room, CNA M entered the room to get the resident out of bed for breakfast. CNA M sat the resident up onto the side of the bed, put her arms underneath Resident #6's arms and wrapped them around the resident's back, then lifted her up and placed her in the wheelchair next to the bed. CNA M did not cue Resident #6 before the transfer, did not use a gait belt and/or enabler bar for the transfer and Resident #6 was not wearing any socks.In an interview on 04/29/2026 at 7:37 AM, CNA M reported that she had forgotten to use a gait belt. CNA M stated, (Resident #6) recently started to not stand on her legs.before she was able to help more. In an interview on 04/29/2026 at 12:39 PM, Physical Therapist (PT) V reported that Resident #6 was doing therapy to get stronger but was not motivated to participate. PT V reported that Resident #6 was a max (maximum) assist, which meant that 2 staff needed to do 75% of the effort to transfer. PT V reported that Resident #6 was at a high risk for falling, required 2 people, a gait belt, non-skid socks, and a wheelchair close by for all transfers. PT V reported that Resident #6 was able to make the motion for walking but did not bear weight on her legs.Review of Resident #6's Physical Therapy Notes dated 4/21/26 revealed, .Sit to stand transfer training with walker in the front 5x (five times), Max A (maximum assistance) of 2 person required.increased challenge with tasks.Review of Resident #6's Physical Therapy Notes dated 4/15/26 revealed, .Sit to stand transfer training with walker in the front 8x, Max A of 2 person required.required extra time to process new information.Review of Resident #6's Physical Therapy Notes dated 4/8/26 revealed, .Sit to stand transfer training with walker in the front 10x, Max A of 2 person required.required extra time to process new information.Review of Resident #6's Physical Therapy Notes dated 3/23/26 (first visit) revealed, .seen for functional transfer training including sit to stand, bed mobility including supine (lying on back) to sit, sit to supine, chair transfer with RW (rolling walker) with cue for hand placement, weight shift and sequencing. Pt (patient) required max A of 2 to dep (dependent) for all functional transfers and mobility.In an interview on 04/29/2026 at 1:24 PM, Director of Nursing (DON) B reported that staff were expected to use a gait belt with all transfers. DON B reported that he was not aware that Resident #6 was not bearing weight during transfers.In an interview on 04/30/2026 at 8:57 AM, NM F reported that Resident #6's functional abilities fluctuated; on good days Resident #6 was able to transfer with one-person assistance and other days she required two-person assistance. NM F reported that a significant change in Resident #6's condition was identified about a month ago and therapy services were started. NM F reported that the therapy department normally communicated with the nursing staff when there were recommendations about transfer status and then the resident's care plan should be updated. NM F was not sure if she had received any communication from therapy recently regarding Resident #6, but that direct care staff had not reported any need for further assistance. NM F reported that direct care staff should be cueing Resident #6 before attempting to transfer and if the resident is not bearing weight, then they need to get a second person.

Based on observation, interview, and record review, the facility failed to effectively implement Enhanced Barrier Precautions (EBP) per facility policy and Centers for Disease Control and Prevention (CDC) guidance, in 1 resident (Resident #6) of 12 residents reviewed for infection control, resulting in the potential for cross-contamination and the development and spread of infection to a vulnerable population.Findings include:Resident #6Review of an admission Record revealed Resident #6 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia, stage 4 pressure ulcer of sacral region (coccyx, tailbone area).Review of Resident #6's current Care Plan revealed, .I have an Indwelling Catheter: due to urinary retention and stage 4 pressure ulcer.Review of Resident #6's current Physician Orders revealed, Indwelling urinary catheter.d/t (due to) wound contamination. During an observation on 04/28/2026 at 10:11 AM in Resident #6's room. Certified Nursing Assistant (CNA) D entered the room and prepared to transfer Resident #6 from bed to wheelchair. CNA D did not put a gown or gloves on. CNA D lifted Resident #6 up and sat her in the wheelchair. There was a sign outside of Resident #6's room indicating to use EBP with all high contact activities including transferring, providing hygiene, changing briefs or assisting with toileting, catheter care or use, and wound care.During an observation on 04/28/2026 at 10:30 AM in Resident #6's bathroom, Nurse Manager (NM) F and CNA D were with the resident as she was sitting on the toilet. NM F and CNA D were not wearing gowns, but CNA D was wearing gloves. RN L entered the bathroom and NM F exited the room. RN L was not wearing a gown. RN L was observed lifting Resident #6 up and off the toilet, CNA D quickly pulled her pants up and RN L sat Resident #6 down in her wheelchair. CNA D removed her gloves and pushed Resident #6 in her wheelchair, out of the bathroom. CNA D did not perform hand hygiene. CNA D placed a footrest on the resident's wheelchair and clipped the chair alarm to the resident's shirt. CNA D wheeled Resident #6 out into the hall, stopped and used hand sanitizer and proceeded down the hall. In an interview on 04/30/2026 at 7:52 AM, RN L reported that it was only required to wear a gown when working directly with Resident #6's catheter and/or wounds.During an observation on 04/29/2026 at 7:03 AM in Resident #6's room Director of Nursing (DON) B was completing wound care. A stage 4 pressure wound was observed on Resident #6's coccyx (upper buttocks, tailbone area), multiple wounds were observed on the resident's legs and feet, and a urinary catheter was in place.During an observation on 04/29/2026 at 7:10 AM in Resident #6's room, CNA M entered the room and put a gown and gloves on. CNA M changed Resident #6's urinary catheter bag to a day-time bag that strapped to her leg, cleansed the resident's genitals, groin and buttocks, and applied a clean brief. CNA M then retrieved clothes from Resident #6's dresser and got her dressed. CNA M still had the same gloves on. Then CNA M sat the resident up onto the side of the bed, put her arms underneath Resident #6's arms and wrapped them around the resident's back, then lifted her up and placed her in the wheelchair next to the bed. When CNA M put socks on Resident #6's feet, a large wound bandage rolled up and almost fell off; CNA M reattached the bandage using her soiled gloves. CNA M then took care of the linens and removed her gloves but did not perform hand hygiene. CNA M applied the foot pedals and a foot pad to Resident #6's wheelchair, clipped the chair alarm to the resident's shirt and wheeled her out into the hallway. CNA M took her gown off in the hallway, put it in a bin and used the hand sanitizer in the hallway. CNA M did not change gloves after providing incontinence care, touched surfaces in the resident's room, and did not remove her gown prior to exiting Resident #6's room.In an interview on 04/29/2026 at 7:37 AM, CNA M reported that she did not take her gloves off until after Resident #6 was in her wheelchair and that she should have discarded the gown in the resident's bathroom.In an interview on 04/29/2026 at 1:24 PM, DON B reported that staff were expected to wear a gown and gloves prior to providing any direct care to Resident #6, including incontinence care and transfers.Review of the facility policy Categories of Transmission Based Precautions dated July 2025 revealed, .Implement Enhanced Barrier Precautions: 1. For SNF (skilled nursing facility) residents with chronic wounds or indwelling devices. 4. High contact activities include: dressing, bathing/showering, providing hygiene, transferring, toileting/changing briefs, changing linens, device care or use (such as catheters), wound care for chronic wounds. 5. [NAME] (put on) gloves and gown prior to performing high contact activities. 7. Remove and discard gloves, gown and mask prior to exiting room; perform hand hygiene.Review of the CDC (Centers for Medicare & Medicaid Services) Center for Clinical Standards and Quality/Quality, Safety & Oversight Group Memorandum (Ref: QSO-24-08-NH) with an effective Date of April 1, 2024 revealed, .The new guidance related to EBP is being incorporated into F-880 Infection Prevention and Control .GUIDANCE Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) that employs targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO's to staff hands and clothing. EBP are indicated for residents with any of the following: .Wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO .For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, .Wound care: any skin opening requiring a dressing .

Based on observation, interview, and record review the facility failed to ensure urinary catheter equipment was consistently maintained in a secured and sanitary manner for 1 (Resident #36) of 2 residents reviewed for urinary catheter care, resulting in discomfort and pain at the urinary catheter insertion site and the potential for further catheter-associated urinary tract infections. Findings include: Review of Resident #36's most recent brief interview for mental status score, dated 2/6/25, was scored a 15 out of 15 suggesting Resident #36 was cognitively intact. Review of Resident #36's urology (branch of medicine focusing on the urinary system) consult note, dated 3/25/24, noted that Resident #36's primary diagnosis was Urinary retention and noted Resident #36 had an Atonic bladder (bladder (organ that holds urine) muscles don't fully contract) and an indwelling urethral catheter (tube inserted in the bladder through the penis to allow urine to flow). During observations and interview on 03/24/25 at 09:42 AM, upon entering Resident #36's (R36) room there was a sign on the door that indicated this resident was on enhanced barrier precautions (Enhanced barrier precautions are infection control interventions designed to reduce the spread of multidrug-resistant organisms). R36 was awake laying on his back in bed and a urinary catheter tube traveled down the side of the bed, from his right leg (catheter tubing was secured to the right leg by a white fabric strap), and down to the urinary catheter urine collection bag that was resting flat directly on the floor with the tube emptying spigot side up. R36 reported the catheter bag was often (R36 couldn't quantify exactly how many times) on the floor and it wasn't unusual to for the urinary catheter bag to be directly touching the floor. The urinary catheter bag was on the floor to the bottom left area of the bed which was closest to the entry door. R36 reported he had a recent urinary tract infection and received antibiotics to address it. R36 confirmed the catheter bag was directly on the facility floor; there was no barrier between the catheter bag and the floor. At 09:49 AM, Registered Nurse F entered R36's room, provided medication to the resident, and left the room. The urinary catheter bag remained on the floor unprotected with no barrier as the staff had not picked it up off the floor during the visit to R36's room. During observations and interview on 03/24/25 at 01:13 PM, Resident #36 (R36) and his urinary catheter tubing and bag were in nearly the same position they were at during the previous observation at 03/24/25 at 09:42 AM. The catheter bag was still laying directly on the facility floor with no barrier between the catheter bag and the floor. There was no device or bag affixed to the bed or near the bed to keep the catheter bag off the floor and to prevent potential tension in the urinary catheter tubing. As R36 turned himself independently from side to side in his bed the urinary catheter bag raised up off the floor and then back to resting on the floor flat again. During an interview on 03/25/25 at 12:38 PM, Certified Nurse Aide G reported urinary catheter bags should not be directly on the floor and there should be a barrier, such as a designated pad or the catheter bag be placed in the catheter holding bag that hangs from the bed frame, between the urinary catheter bag and the floor. During an interview on 03/25/25 at 03:41 PM, Director of Nursing (DON) B reported resident's urinary catheter bags, while laying in bed, should be placed in a privacy bag that hangs from the bed frame, in a plastic basin bin, or on a soaking pad that would create a barrier between the catheter bag and the floor. DON B confirmed Resident #36's urinary catheter bag should never be directly on the facility floor with no barrier. During an interview on 03/26/25 at 08:16 AM, Resident #36 (R36) showed his leg strap that held the urinary catheter tubing and reported when he moved in bed and the catheter bag was on the floor it would tug at his penis and stated it hurt. R36 reported the pain it caused was a 5 out of 10 (on a scale of zero being no pain and 10 being the highest level of pain). R36 confirmed this discomfort at times still occurred while the catheter tubing was secured to his leg with a leg strap and when the catheter bag was on the floor. R36 reported the leg strap often rides down his leg which would cause tension. R36 reported there were times staff placed his urinary catheter bag on a pad on the floor but the bag would end up directly on the floor as it moved as he moved in bed. R36 reported at times when the catheter was puling on his penis causing pain and the catheter bag was on the floor he would grab the tubing and pull it to give the tubing some slack to alleviate the discomfort. Review of R36's progress note, dated 3/12/25 at 9:24 PM, stated, CNA (certified nursing aide) mentioned to this writer around 21:30 (9:30 PM) that resident (Resident #36) has bloody urine in his bag when emptying it .resident (Resident #36) mentioned that when the tubing on the top is not positioned properly or the band that it tends to slide down and then ends up pulling . Review of Resident #36's Infection Report, dated 3/12/2025, indicated, Time of Onset 9:30 PM .Acquired Where? Facility .Infection Type CAUTI (Catheter-associated Urinary Tract Infection) .Observed with gross hematuria (blood in urine) in catheter collection bag and drainage around meatus (opening of the urethra where urine exits) with c/o (complaint of) doscomfort (discomfort) at site as well. UTI (urinary tract infection) monitor started, CBC (Complete Blood Count; lab) showed elevated WBCs (white blood cells). UA (urine analysis) collected which also demonstrated abnormal values. C&S (culture and sensitivity; lab test to identify bacteria and determine susceptibility to antibiotics) returned with e coli (escherichia coli; bacteria) and kleb. p (Klebsiella pneumoniae; bacteria), macrobid (antibiotic) started as both organisms sensitive .Symptoms - Urinary Tract .gross hematuria, Urinary Catheter specimen culture with at least 10^5 cfu/ml (colony-forming unit per milliliter) of any organism(s) .Purulent (pus) discharge from around the catheter or acute pain, swelling, or tenderness of the testes, epididymis (coiled tube inside the scrotum), or prostate (small gland below the bladder in men) .Comments ABX (antibiotics) completed. Review of the Physician orders indicated Macrobid (antibiotic) was given Twice a Day x (for) 7 days For UTI (urinary tract infection) started on 3/16/25 with the last dose on 3/23/25. Review of Resident #36's urinary care plan, start date of 3/4/24, stated, (Resident #36) utilizes an indwelling catheter use secondary to urinary retention during hospitalization , also has dx (diagnosis) of benign prostatic hyperplasia (condition that the prostate grows larger than usual). Trial voiding (urinating without the catheter) failed prior to discharge from hospital. He (R36) has the potential for urinary tract infection r/t (related to) catheterization .secure catheter on leg to avoid tension .Enhanced barrier precautions with ADLs (activities of daily living) and cath (catheter) care . Review of Resident #36's Care Area Assessment Summary, dated 2/6/25, stated, .He (Resident #36) does require one person assistance for catheter care. Review of the facility's Catheter -Usage and Care policy, date last reviewed 03/2018, stated, Catheter-Associated Urinary Tract Infection (CAUTI) .In order to prevent a catheter-associated urinary tract infection (CAUTI) .do not allow catheter tubing, bag or spigot to touch the floor .bag comes in different lengths and extension tubing can be added/cut to size to avoid tension at the catheter insertion site. Review of the Centers for Disease Control and Prevention's Summary of Recommendations Guideline for Prevention of Catheter-Associated Urinary Tract Infections, dated 2009 and viewable at https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html, stated, .Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor.

Based on observation, interview, and record review the facility failed to develop a person-centered comprehensive care plan for 2 (Resident #31 and Resident #38) of 12 residents reviewed for comprehensive care plans, resulting in the potential for unmet care needs. Findings include: Resident # 31 Review of an Admission Record revealed Resident #31 had pertinent diagnoses which included: Dementia, depression, and chronic obstructive pulmonary disease (COPD, a disease of the lungs that causes breathlessness and coughing). During an observation on 3/12/24 at 9:53 AM., Resident #31 was sitting in the recliner chair in her room sleeping wearing the oxygen nasal cannula (tubing connected to an oxygen machine and applied to the face with oxygen delivery into the nose) correctly with the oxygen concentrator running at 2 liters of oxygen per minute. During an observation on 3/12/24 at 12:19 PM., Resident #31 was sitting in her wheelchair in the dining room with an oxygen tank on the back of her wheelchair, nasal cannula tubing present in the bag on the back of the wheelchair. Resident #31 did not have oxygen tank turned on, nor was the nasal cannula applied to Resident #31's face. Review of Resident #31's physician orders revealed .Oxygen 1-2 liters/min Via nasal canula Q (every) shift. OK to Wean as able. - every shift ordered start date of 11/27/2023 . Lorazepam 0.5mg tablet oral by mouth Q week on bath/shower day for anxiety . Review of Resident #31's Care Plan revealed no care plan for oxygen use and no care plan related to anti-anxiety medication use prior to shower. During an observation on 3/13/24 at 9:45 AM., Resident #31 was sitting in her recliner chair in her room with her oxygen nasal cannula on her face and the oxygen concentrator running at 2 liters per minute. Resident #31 was sleeping. During an observation on 3/13/24 at 12:33 PM., Resident #31 was sitting in her wheelchair and was pushed down the hallway towards her room, Resident #31 had the oxygen nasal cannula in place on her face. The oxygen tank on the back of Resident #31's wheelchair was turned on and set to 2 liters/minute. During an interview on 3/13/24 at 12:56 PM, Licensed Practical Nurse (LPN) T reported that Resident #31 should wear her oxygen continuously at 1 to 2 liter/per minute. LPN T reported that Resident #31 can remove her nasal cannula herself. During an observation on 3/13/24 at 2:47 PM., Resident #31 was sitting in her wheelchair in her room. Resident #31 was not wearing her oxygen nasal cannula. Resident #31's oxygen nasal cannula was laying on her over the bed table beside her. The oxygen concentrator was running at 2 liters/minute. During an observation on 3/14/24 at 9:19 AM., Resident #31 was sitting in her recliner chair in her room with her oxygen nasal cannula on her face and the oxygen concentrator running at 2 liters per minute. Resident #31 was sleeping. During an interview on 3/14/24 at 9:34 AM., LPN U reported that Resident #31 has an order to wear her oxygen at 1-2 liters continuously. During an interview on 3/14/24 at 10:47 AM., Registered Nurse/Nurse Manager (RN/NM) M reported that care plans should be specific to each resident. RN/NM M reported that Resident #31 should have a care plan regarding oxygen use and the use of anti-anxiety medications prior to showers. During an interview on 3/14/24 at 11:12 AM., Director of Nursing (DON) B reported that his expectation was that a care plan be in place for any resident using oxygen. DON B reported he noticed yesterday Resident #31 did not have a care plan for oxygen use in place and created one. During an interview on 3/14/24 at 12:00 PM., LPN U reported that Resident #31 should have an anti-anxiety medication on the mornings her shower is scheduled to ease Resident #31's anxiety before her shower is given. LPN U reported that Resident #31's scheduled shower day was Tuesday. During an interview on 3/14/24 at 12:14 PM., Certified Nurse Assistant (CNA) L reported that Resident #31 had to have medicine for her anxiety before her shower is given. CNA L reported that Resident #31's scheduled shower day was Tuesday. Review of Medication Administration Record for Resident #31 revealed that administration of Lorazepam 0.5mg was done on Tuesday 3/12/24 at 06:00 AM. Resident #38 Review of an Admission Record revealed Resident #38 had pertinent diagnoses which included: Dementia, diabetes mellitus (a disease that results in elevated blood sugar and low insulin production), and lymphedema (a disease that results in swelling of the legs and/or arms). Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 12/21/23 revealed a Brief Interview for Mental Status (BIMS) score of 6/15 which indicated Resident #38 was severely cognitively impaired. During an observation on 3/12/24 at 9:39 AM., Resident #38 was sitting in her wheelchair in her room, and it was noted that both legs appeared to be wrapped with dressing material. Review of Physician Orders for Resident #38 revealed . wound care Right lower extremity-1 area noted lower medial shin and 2nd area noted lateral upper shin near knee): cleanse with NS (normal saline) pat dry, apply hydro-cellular Foam Dressing; - every 72 hours (Q (every) 3 days) for wound . started on 3/1/24 .check dressing to (Right lower extremity) Q shift, change PRN if soiled or off,- Topical Every Shift . started 2/29/24 . Review of Care Plan for Resident #38 revealed no care plan related to wound care. During an interview on 3/13/24 at 12:59 PM., RN/NM M reported that Resident #38 does have wound care on her right leg, and it was scheduled to be changed on 3/14/24. RN/NM M reported that care plans were created by departments. RN/NM M reported that the nurse managers and the director of nursing were responsible for the nursing care plan creations for residents. RN/NM M reported that wound care should be a care plan created by nursing. During an interview on 3/14/24 at 11:12 AM., Director of Nursing (DON) B reported that his expectation was that a care plan be in place for any resident who needed wound care. DON B reported that Resident #38 did not have a care plan in place for wound care.

Based on observation, interviews, and record review, the facility failed to ensure that professional standards of nursing practice were followed during medication administration for 1 (Resident #249) of 16 sampled residents reviewed for professional standards of nursing care resulting in the potential for worsening of health conditions. Findings include: Resident #249 Review of an Admission Record revealed Resident #249, was originally admitted to the facility on [DATE] with pertinent diagnoses which included unsteadiness on feet. During an observation and interview on 3/13/24 at 8:26 AM, Licensed Practical Nurse (LPN) U entered Resident #249's room to assess his vital signs. LPN U then exited Resident #249's room and walked over to her medication cart, opened the cart, and grabbed a cup of medications from a drawer. LPN U reported that she had prepared Resident #249's medications earlier in the morning, but when she went to his room to administer the medications, Resident #249 had other staff assisting him so she placed his medications in the cart and moved on to administer medications for someone else. LPN U reported that she thought she could prepare Resident #249's medications prior to administering them because Resident #249 was alert and oriented. LPN U reported that was not aware if the facility had a policy on if nurses were allowed to prepare medications prior to the time that the medications were to be administered. LPN U confirmed that it was not best practice to prepare medications prior to the time that they would be administered as this would be against the rights of medication administration, and could lead to medication errors. During an interview on 3/14/24 at 8:17 AM, Director of Nursing (DON) B reported that it was the facility expectation that nurses did not prepare medications prior to the time that they would be administering the medications. DON B reported that nurses should be checking to see if the resident is available for medication administration before preparing the medications. Review of the facility's Medication Administration policy, last revised 1/2020 revealed, Policy: Medications are administered safely as prescribed in accordance with state and federal guidelines . Administration . 4. Medications are administered at the time they are prepared and by the resident aide who prepared them .

Based on observations, interviews, and record review, the facility failed to ensure a positioning device was consistently used and applied accurately for 1 (Resident #22) of 2 residents reviewed for positioning, resulting in the potential for decreased range of motion and related complications, skin breakdown, contractures (hardening of the muscles, tendons, and other tissues) and pain. Findings include: Resident #22 Review of a Face Sheet revealed Resident #22 was a female, with pertinent diagnoses which included: hemiplegia following cerebral infarction (muscle weakness or partial paralysis following a stroke) affecting right dominant side. Review of Resident #22's current Care Plan revealed a focus of (Resident #22) has a self care deficit related to right sided weakness, secondary to Acute CVA (stroke). She requires assistance with all ADL's (activities of daily living) . with care planned interventions which included Arm rest (brand name omitted) cushion on armrest of wheelchair for right upper extremity (arm) when in the wheelchair with a start date of 11/11/22. During an observation on 3/12/24 at 1:49 PM, noted Resident #22 was seated in her room in her wheelchair. There was an arm rest cushion affixed to the right arm of the wheelchair. Resident #22's right arm was not placed in the cushion; rather, her right arm was bent at the elbow and resting across her abdomen with her right hand underneath her left elbow. During an observation and interview on 3/13/24 beginning at 1:30 PM, noted Resident #22 was seated in her room in her wheelchair. There was an arm rest cushion affixed to the right arm of the wheelchair with Resident #22's arm resting in the cushion. There was a velco strap that was part of the cushion that was applied across Resident #22's right forearm to keep her arm in place on the cushion. The arm rest cushion and Resident #22's right arm had slid around to the outer side of the arm rest of the wheelchair and Resident #22 was leaning slightly to the right. Licensed Practical Nurse (LPN) T, who was in the hallway outside Resident #22's room, was queried about Resident #22's positioning at that moment and about the purpose of the cushion. LPN T looked at Resident #22 in the wheelchair and reported Resident #22's arm rest cushion was on backwards, such that the longer lip of the cushion was on the inner side (next to Resident #22) instead of on the outer side of the armrest which was why the cushion and Resident #22's arm had slid outward. LPN T reported that therapy had worked with Resident #22 because the resident tended to pull her arm close to her body and never straighten it. LPN T reported that the arm rest cushion was supposed to be used every time Resident #22 was in her wheelchair to help keep her arm straight. In an interview on 3/14/24 at 10:46 AM, Therapy Manager (TM) GG reported Resident #22 had limited range of motion of her right arm following a stroke, and that she couldn't move the arm and it was tight. TM GG reported the purpose of the positioning cushion (referred to by TM GG as a lateral arm support cushion) for Resident #22 was to position her arm to prevent further contracture, assist with skin integrity, and reduce potential of pain when staff were performing ADLs (such as dressing the resident). TM GG demonstrated proper application of the cushion to the wheelchair arm and reported that the longer flap of the cushion needed to be on the outer side of the arm of the wheelchair to prevent the device from slipping away from the chair. TM GG reported if the longer flap of the cushion was on the inner side of the armrest of the wheelchair, it was applied improperly.

Based on observation and interview the facility failed to maintain air conditioners to be free from the accumulation of dust and debris in seven of eleven air conditioners assessed for cleanliness. This resulted in an increased risk of poor air quality and an increased risk of adding particulate matter to the air in the following rooms. Findings Include: During a tour of the facility, at 1:10 PM on 1/23/23, observation of resident room [ROOM NUMBER] found an air conditioner unit mounted on the far side wall. Observation of the unit found excessive accumulation of black spots and dusty debris. When asked how often these get cleaned, Housekeeping Manager Z stated that facilities would take care of that, and I am not sure of their schedule. During an interview with Facilities Manager AA, at 1:28 PM at 1/23/23, it was found that the wall mounted air conditioner units should have the filters cleaned and a vendor service the units twice a year. During a tour of the 200 hall, at 1:32 PM on 1/23/23, it was observed that both wall mounted units, in resident rooms [ROOM NUMBERS], were found with accumulation of debris inside the fan portion of the unit. During a tour of the facility, starting at 2:39 PM on 1/23/23, the following resident rooms were found with excessive accumulation of debris and black spotting on the inside of the wall mounted air conditioner units: 102, 111, 112, 113, 207, 214, and 215. An interview with Facilities BB, at 2:52 PM on 1/23/23, found that the wall mounted air conditioner units typically don't get deep cleaned until we do a deep clean of the room and the resident has moved out.

Based on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive, person-centered care plan for 2 of 2 residents (Residents #38 and #26) reviewed for care plans, resulting in Resident #38's fall mats not being implemented to prevent injury from falls and Resident #26 not having a care plan developed for the treatment of peripheral vascular disease. Findings include: Resident #38 Review of an Admission Record revealed Resident #38 was a male with pertinent diagnoses which included pertinent diagnoses of dementia with severe anxiety, spinal stenosis, low back pain, lumbago with sciatica, right side, pain in right shoulder, pain in left shoulder, pain in right wrist, repeated falls, weakness, unsteadiness on feet, and glaucoma (nerve connecting the eye to the brain is damaged causing blindness). Review of a Minimum Data Set (MDS) assessment for Resident #38, with a reference date of 12/29/22 revealed a Brief Interview for Mental Status (BIMS) score of 10 out of 15 which indicated Resident #38 was cognitively moderately cognitively impaired. Review of current Care Plan for Resident #38, dated 7/13/22, revealed, .(Resident #38) is at risk for falls and injury r/t (related to) impaired mobility and symptoms of dementia . with the intervention .remain free of injury secondary to falls .Floor mats at bedside. Bilaterally . Review of Care Guide dated 1/25/23, revealed, .Falls, Safety, Alarms, SR .Fall Risk .Floor mats on both sides of bed when res (resident) in bed . During an observation on 1/25/23 08:38 AM, observed Resident #38 lying in his bed finishing his breakfast. Observed no bilateral fall mats at the bedside or side rails to assist with mobility. In an interview on 1/25/23 at 8:40 AM, Registered Nurse (RN) J reported when a resident had interventions the nurse was able to review the treatment care record as they were located there. Bilateral fall mats next to bed was not observed in the treatment care record. RN J reported the care plan would have the interventions. Reviewed the falls care plan and the intervention, bilateral fall mats next bed was there. Proceeded to Resident #38's room and RN J reported the bilateral fall mats were not in place next to Resident #38's bed. RN J' reported the fall intervention was important to be in place for the safety of the resident, in case he fell while attempting to get out of bed, to prevent injury. Review of 100 Hall Nurses Report dated 1/25/23, revealed, no intervention documented for bilateral fall mats next to Resident #38's bed. In an interview on 01/25/23 at 8:48 AM, Certified Nursing Assistant (CNA) K reported to find out what interventions or precautions were in place for a resident, the care guide, which is located at the central nurse's desk, would inform the nursing staff of what interventions were needed to care for the resident. CNA K reported when staff signed in for their shift, they received a printed care guide for the group of residents they were responsible for during the shift. In an interview on 01/25/23 at 12:23 PM, CNA E reported the staff would sign in on the schedule which shows you the group assignment for the day. The nurse has the care guide for your assigned group printed out already for you. Reviewing the care guide, you can see what the resident needs for diet, mobility, need for transfers, falls/safety and any special instructions. Review of ID Notes dated 12/15/22 at 5:55 PM, Resident #38 revealed, .Was Care Planned reviewed: Yes .Care plan revisions: Added floor mats to bilateral sides of bed, to prevent injury .Resident and wife agree with current plan of action, to add floor mats at the bedside . In an interview on 01/25/23 at 1:47 PM, Director of Nursing (DON) B reported the expectation would be staff would review the care guide and ensure the fall interventions were in place. DON B reported the care plan and care guide should be a mirror and the interventions implemented at the bedside. Review of policy, Fall Program: Prevention & Management revised 6/2020, revealed, .Following each fall, residents are assessed and care plans are reviewed and revised as needed .4. Initiate or revise the certified nurse aide (CAN) care guide to include all current fall risk prevention interventions . 46999 Resident #26 Review of a Face Sheet revealed Resident #26 was admitted to the facility on [DATE] with pertinent diagnoses which included: venous insufficiency (improper functioning of the vein valves in the leg, causing swelling and skin changes) and peripheral vascular disease (a condition in which narrowed blood vessels reduce blood flow to the limbs). During an observation on 1/24/23 at 11:14am, Resident #26 was seen sitting in a recliner with bilateral lower legs wrapped and protective sleeves in place. Review of Resident #26's Care Plan revealed no problems, goals or care approaches related to peripheral vascular disease, venous insufficiency or treatments in place for lower legs. In an interview on 1/25/23 at 11:31am, Registered Nurse (RN) J reported Resident #26 received dressing changes to bilateral lower legs every 3 days prior to 1/22/23, when the physician changed the order to dressing changes every other day. RN J reported the resident currently had no open areas on either lower leg but previously had wounds. Review of Resident #26's Physician Orders revealed four orders related to peripheral vascular disease to include: 1. R (right) moist/exudating (draining) areas of lower anterior (front) and posterior (back) ankle; cleanse with normal saline, apply xerofoam dressing (made up of a petrolatum blend on fine mesh gauze), ABD pad (used to absorb discharges from heavily draining wounds), secure with kling (gauze wrap) and tape, every other day for venous stasis ulcer (wound caused by vein and blood flow issues). Start date 1/22/23. 2. Tubagrip (a wrap that provides continuous support for the management of swelling) to bilateral legs knee to foot on during day off at night. Start date 1/16/23. 3. Furosemide (used to reduce extra fluid in the body) 20 mg tablet for HTN (high blood pressure)/Edema (swelling caused by too much fluid trapped in the body's tissues). Start date 11/23/22. 4. Elevate feet in bed. Start date 8/23/22. In an interview on 1/25/23 at 11:43am, Unit Manager Registered Nurse (RN) Y confirmed that Resident #26 did not have a care plan related to her diagnosis of peripheral vascular disease or venous insufficiency. Unit Manager RN Y reviewed current and past care plans and stated, There is not a care plan for those issues. Unit Manager RN Y reported the care plan should include Resident #26's diagnoses of venous insufficiency and peripheral vascular disease along with the prescribed treatments, to avoid a potential worsening of her skin condition, such as weeping of the skin and vascular ulcers. 41027 In an interview on 1/25/23 at 12:40 P.M., DON reported Resident #26 admitted several months ago with venous wounds, but that the resident currently had no open wounds. DON reported that Resident #25 had stasis dermatitis (inflammatory skin changes caused by chronic edema due to poor circulation and blood pooling) on her lower legs as a result of her peripheral vascular disease. During an observation and interview on 1/25/23 at 12:49 P.M. Resident #26 was sitting in her recliner in her room. Both of Resident #26's lower legs were observed with thick gauze bandaging and tubigrip extending from toes to the knees. DON removed the bandages, which included a stretch gauze wrap, multiple ABD pads, and Xeroform dressings. The skin on Resident #26's right lower leg and foot was observed red, shiny, and fragile, with clear fluid drainage. The skin on Resident #26's left lower leg was observed red and shiny. DON reported that Resident #26 should have a care plan that included her peripheral vascular disease, along with the stasis dermatitis and stated, .especially with her having the ongoing treatments in place . The care plan (see Chapter 18) is a map for nursing care and demonstrates your accountability for patient care. By making accurate nursing diagnoses, your subsequent care plan communicates a patient's health care problems to other professionals and ensures that you select relevant and appropriate nursing interventions. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 16159-16161). Elsevier Health Sciences. Kindle Edition. A well-planned, comprehensive nursing care plan reduces the risk for incomplete, incorrect, or inaccurate care. As a patient's problems and status change, so does the plan. A nursing care plan is a guideline for coordinating nursing care, promoting continuity of care, and listing outcome criteria to be used later in evaluation (see Chapter 20). The plan of care communicates nursing care priorities to nurses and other health care providers. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations 16878-16882). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 1 (Resident #11) of 14 residents reviewed for quality of care, resulting in the failure of nursing staff to notify the physician following insulin being held and the potential for the worsening of a condition and a delay in treatment. Findings include: According to Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition, The health care provider (physician or advanced practice nurse) is responsible for directing medical treatment. Nurses follow health care providers' orders unless they believe that the orders are in error, violate agency policy, or are harmful to the patient. Resident #11 Review of a Face Sheet revealed Resident #11 was a male, with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #11, with a reference date of 7/22/21 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated Resident #11 was moderately cognitively impaired. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Contact MD (medical doctor/physician) with a Start Date of 01/05/21 and End Date 08/12/21. Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Contact MD with a Start Date of 08/12/21 and End Date N/A. Review of a Resident #11's Medication Records for 07/2021, 08/2021, 09/2021 revealed scheduled administration times for the Insulin [MEDICATION(S)] were 9:00 A.M. (0900), 1:00 P.M. (1300), and 6:00 P.M. (1800). Further review of Resident #11's Medication Record for 07/2021 revealed the Insulin [MEDICATION(S)] was not administered on 7/9/21 at 0900 due to BS (blood sugar) 95; 7/25/21 at 0900 due to BS 90; 7/25/21 at 1800 due to (no reason documented); 7/27/21 at 1800 due to Resident did not want eat after the gathering held at (location name omitted) for an employee retiring, follow MAR (medication administration record) did not inject Novolog 7 Units SubQ (subcutaneous) he did not consume any dinner. Review of Resident #11's nursing progress notes revealed no documentation or evidence that MD was contacted on 7/9/21, 7/25/21, or 7/27/21, to notify that ordered insulin was held or that further physician instruction was obtained. Further review of Resident #11's Medication Record for 08/2021 revealed the Insulin [MEDICATION(S)] was not administered on 8/11/21 at 1800 due to (no reason documented) and on 8/12/21 at 0900 due to BS <100. Review of Resident #11's nursing progress notes revealed no documentation or evidence that MD was contacted on 8/11/21 or 8/12/21 to notify that ordered insulin was held or that further physician instruction was obtained. Further review of Resident #11's Medication Record for 09/2021 revealed the Insulin [MEDICATION(S)] was not administered on 9/18/21 at 0900 due to bs 90; 9/24/21 at 1300 due to Res was very lethargic and did not want to eat lunch. BS at 1330 was 132. CN (charge nurse) held 1300 Novolog. Review of Resident #11's nursing progress notes revealed no documentation or evidence that MD was contacted on 9/18/21 or 9/24/21 to notify that ordered insulin was held or that further physician instruction was obtained. In an interview on 10/05/21 at 2:35 P.M., Registered Nurse (RN) C reported physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . RN C reported when a physician is called, the conversation is documented in the nurses progress notes (also called ID notes). In an interview on 10/05/21 at 3:25 P.M., RN H reported nursing standard of practice is to call the doctor when a medication is held. RN H reported if the doctor was notified, it would be documented in the nurses notes. In an interview on 10/05/21 at 3:33 P.M., Licensed Practical Nurse (LPN) M reported if insulin was held for a resident, the physician should be called because there might be more orders the physician would want to add such as recheck blood sugar later. LPN M reported when a physician is called it should be documented in the progress notes. In an interview on 10/06/21 at 9:04 A.M., Director of Nursing (DON) B reported nurses follow the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . DON B reported when the insulin was held for Resident #11 when he did not eat his meals (referring to 7/27/21 and 9/24/21), the physician should have been called because the order did not specify what to do in that situation. DON B reported when the nurse contacts the physician, it should be documented in the progress notes to prove that it was done.

Based on observation, interview and record review, the facility failed to implement interventions to prevent skin breakdown for residents at risk for pressure ulcers, for 1 of 16 residents (Resident #1) reviewed for pressure ulcer prevention, resulting in the potential for the development of an avoidable pressure ulcer, infection, and overall deterioration in health status. Findings include: Review of a Face Sheet revealed Resident #1 was originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Minimum Data Set (MDS) assessment for Resident #1, with a reference date of 7/1/2021 revealed a Staff Assessment for Mental Status indicating that Resident #1 was severely impaired. Review of the Functional Status revealed Resident #1 required extensive assistance of 2 persons for mobility in bed. Review of Resident #1's Braden Scale (for predicting pressure sore risk) dated 9/21/2021 indicated Resident #1 was at high risk, with a score of 11. Review of Resident #1's Skin Care Plan revealed, Start: 03/16/2020 (Resident #1) is at risk for impaired skin r/t (related to) decreased mobility, activity, poor PO (by mouth) intake, incontinence .8/23/21: new onset PI (pressure injury) to left buttocks: 8/31/21 resolved .INTERVENTIONS: observe skin daily with cares and report any changes such as redness, open areas, Start: 03/16/2020 .Skin barrier to peri (privates) area and buttocks PRN (as needed), Start: 03/24/2020, Resolved: 10/06/2021. Avoid episodes of prolonged presence of moisture such as incontinent episode, Start: 03/24/2020 .lay down between meals alternate sides, Start: 8/24/2021. Calazinc barrier cream to buttocks and sacrum Q (every) shift and after care, Start: 10/06/2021. Elevate feet in bed, Start: 10/06/2021. Review of Resident #1's End of Life Care Plan revealed, At risk for pain/discomfort, terminal restlessness, unavoidable skin break down, falls, unavoidable weight loss; Start: 6/28/2021. INTERVENTIONS: .Turn and reposition frequently for resident comfort .Start: 6/28/2021 . Incontinence care every 2 hours and PRN, Start: 6/28/2021 .(A) Start: 06/28/2021 .Apply protective ointment to buttocks and peri-area Q (every) shift and PRN. Start: 06/28/2021 . During an observation on 10/04/21 at 10:18 A.M. Resident #1 was lying on her back in her bed with the head of the bed (HOB) at approximately 30 degrees and her feet lying directly on the surface of the bed. There were no pillows or wedges observed to assist in repositioning. During an observation on 10/04/21 at 10:45 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her feet lying directly on the surface of the bed. During an observation on 10/05/21 at 08:07 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her feet lying directly on the surface of the bed. Certified Nursing Assistant (CNA) O entered the room to feed Resident #1 her breakfast and stated, yes, I did her cares this morning .around 6:30 A.M. During an observation on 10/05/21 at 08:54 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. During an observation on 10/05/21 at 10:09 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. During an observation on 10/05/21 at 10:25 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. During an observation on 10/05/21 at 10:32 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. During an observation on 10/05/21 at 11:00 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. During an observation on 10/05/21 at 11:29 A.M. Resident #1 was lying on her back in her bed with the HOB at approximately 30 degrees and her heels lying directly on the surface of the bed. CNA O and CNA V in the room to get Resident #1 up into her chair. Resident #1's incontinence brief was observed to be wet with urine. Resident #1's skin on her buttocks was observed to have a bright red area over the gluteal cleft (bottom of spine where the buttocks split), and deep wrinkled skin in the area that the incontinence brief was covering. Resident #1's front periarea (private area) was not washed during incontinence care and there was no application of protective ointment (protection from moisture). Resident #1's elbows were observed bright pink and with indented skin (from pressure) covering the elbow. During an interview on 10/05/21 at 11:45 A.M., CNA O reported that Resident #1 does not normally have redness on her elbows. CNA O reported that Resident #1 does not have a protective cream in her room and stated, we don't use it on her .but if she starts getting red we would get a topical from the nurse to use . During an interview on 10/6/21 at 9:10 A.M., Director of Nursing (DON) reported that frequent turning, repositioning and application of skin protectant products were standard interventions for prevention of pressure ulcers. Review of a facility policy Skin Care Program last revised 2/2018 revised, .Residents with impaired skin integrity will receive the necessary care and treatment to promote healing, prevent infection, and prevent further impairment . D. Inspection and Care - Certified Nurse Aides (CNAs) .2. The CNA will clean skin by using a mild cleansing agent and warm water, applying a moisture barrier after cleansing. 3. Residents will be repositioned in bed and when sitting in chair based on individual needs .II. Prevention of Impaired Skin Integrity: A. Interventions - Nurses 1. The nurse will implement the use of appropriate pressure-reducing devices, including, but not limited to .b. pillows or wedges to keep bony prominences (e.g., knees and ankles) from direct contact with each other c. devices to relieve pressure on the heels Review of Fundamentals of Nursing (Potter and Perry) 9th edition revealed, The presence and duration of moisture on the skin increases the risk of ulcer formation. Moisture reduces the resistance of the skin to other physical factors such as pressure and/ or shear force. Prolonged moisture softens skin, making it more susceptible to damage. Immobilized patients who are unable to perform their own hygiene needs depend on nurses to keep the skin dry and intact. Skin moisture originates from wound drainage, excessive perspiration, and fecal or urinary incontinence. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.

Based on interview and record review, the facility failed to ensure that a resident who required an antibiotic was prescribed the appropriate antibiotic for 1 of 13 residents (Resident #23) reviewed for antibiotic use, resulting in inappropriate antibiotic utilization and the potential for antibiotic resistance. Findings include: Review of a Face Sheet revealed Resident #23 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Progress Note dated 6/8/21 revealed, (Physician) notified of negative chest x-ray and positive UA (urinalysis); verbal order received for [MEDICATION(S)] (antibiotic) 1 tab po BID x7 days (by mouth twice a day for 7 days). Indicating the medication was ordered prior to the culture and susceptibility report. Review of Resident #23's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Twice a day for [CONDITION(S)] (Urinary Tract Infection) Review of Resident #23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #23's Laboratory Fax Report-Urinalysis with a faxed date of 6/8/21 revealed (Urine) Collected 06/08/21 PENDING ORDERS .URINE CULTURE AND SUSCEPTIBILITY . Indicating the culture results were not received prior to the start of the antibiotic. Review of Resident #23's Progress Note dated 6/10/21 revealed, .C and S (culture and susceptibility) results in showing ESBL (infection) in urine and resistive to [MEDICATION(S)] .new orders to dc [MEDICATION(S)] and start [MEDICATION(S)] (antibiotic) . Review of Resident #23's Laboratory Fax Report-Urine Cultures with a faxed date of 6/10/21 revealed that the urine sample that was collected on 6/7/21 was positive and the urinary tract infection was resistant to [MEDICATION(S)]. [MEDICATION(S)] would not effectively treat the infection. Review of Resident #23's June Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Twice a day for [CONDITION(S)]. Review of Resident #23's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. until 6/17/21. Review of Resident #23's Laboratory Fax Report dated 6/29/21 revealed a hand written note at the bottom of the page (Resident #23) has [CONDITION(S)] per (hospital name omitted) tx (treatment) [MEDICATION(S)] 250 mg q 12 hr x 7 days (every 12 hours for 7 days) .(Nurse Practitioner) notified . Review of Resident #23's June/July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Every 12 hours x 7 days for [CONDITION(S)] . Review of Resident #23's June and July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. (total of 7 doses administered). Review of Resident #23's (Urine Culture) collected on 6/29/21 and resulted on 7/2/21 revealed Resident #23's Urinary Tract Infection was resistant to [MEDICATION(S)]. Review of Resident #23's Progress Note (ID note) dated 7/3/21 revealed, (Received) call from (hospital name omitted) with notification ABX (antibiotic) needs to be changed. Informed nurse culture results obtained today, [MEDICATION(S)] already d/c'd (discontinued) and [MEDICATION(S)] 100mg po BID x 7 days ordered (by mouth twice a day for 7 days) . Review of Resident #23's Progress Note dated 7/3/21 revealed, (Nurse Practitioner) in today and discussed recent findings regarding resident. (Nurse Practitioner) located most recent urinary culture in which (residents) current ABX [MEDICATION(S)], is resistant to E.Coli . Review of Resident #23's July Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .Every 12 hours for [CONDITION(S)]. Review of Resident #23's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M.) until 7/10/21. During an interview on 10/6/21 at 9:10 A.M. Director of Nursing (DON) B reported that the facility's antibiotic stewardship policy is applied for Urinary Tract Infections. DON B reported that the facility staff ensure the correct antibiotic is ordered by using the culture and susceptibility results. During an interview on 10/6/21 at 12:10 P.M., Nurse Manager (NM) X reported that if a resident is having symptoms of a urinary tract infection an antibiotic is started. When the culture results return the antibiotic is changed if needed. Review of Resident #23's Temperatures for the month of June revealed no temperatures greater than 98.6 degrees. Indicating resident #23 was afebrile. Review of Resident #23's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . He is not in acute distress .He is not ill-appearing or toxic appearing .Patient noted to have leukocytosis, recommend additional work-up for this including checking a chest x-ray as well as urinalysis. Concern patient's worsening confusion may be related to possible infection. Check [CONDITION(S)] monitor x3 days. Recheck lab work in the morning .Pending results of urinalysis and chest x-ray may need antibiotic therapy . No documentation that resident had Gross hematuria, Acute costovertebral angle pain or tenderness, Suprapubic pain, New/increased incontinence, New/increased urgency, New/increased frequency, Acute dysuria or acute pain, swelling or tenderness of testes, epididymis or prostate. Review of the facility policy URINARY TRACT INFECTIONS-INDICATIONS TO TREAT last reviewed January 2019 revealed, Policy Urinary tract infections will be identified and treated according to current standards of practice. Procedure Definition of Infection In accordance with McGeer criteria and the Centers for Disease Control and Prevention (CDC), three important conditions apply to the identification of infections: All symptoms must be new or acutely worse. This is important as many residents have chronic conditions that are not associated with infection. Noninfectious causes of signs and symptoms should always be considered prior to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A. Clinical evidence that may suggest a [CONDITION(S)] for residents without a catheter. Both criteria (1) and (2) must be present : 1. One of the following - a. Acute dysuria or acute pain, swelling or tenderness of testes, epididymis or prostate b. Fever or leukocytosis AND at least one of the following (or in the absence of leukocytosis, then at least 2 of the following) i. Gross hematuria ii. Acute costovertebral angle pain or tenderness iii. Suprapubic pain iv. New/increased incontinence v. New/increased urgency vi. New/increased frequency . Review of Fundamentals of Nursing (Potter and Perry) revealed, collect body fluids and secretions suspected of containing infectious organisms for culture and sensitivity tests. After a specimen is sent to a laboratory, the laboratory technologist identifies the microorganisms growing in the culture. Additional test results indicate antibiotics to which the organisms are resistant or sensitive. Sensitivity reports determine which antibiotics used in treatment are effective and need to be ordered for treatment. Potter, Patricia A.; Perry, Anne Griffin; Stockert, Patricia; Hall, Amy. Fundamentals of Nursing - E-Book (Kindle Locations - ). Elsevier Health Sciences. Kindle Edition.

Based on observation, interview, and record review, the facility failed to properly label, date, and store medications and biologicals in 3 out of 3 medication carts resulting in the potential for decreased efficacy of medications and the exacerbation of medical conditions. Findings include: Review of the facility form Medication Expiration Dates revealed, Eye drops in multi-dose packaging .Expiration date 28 days after opening or expiration date if sooner .[MEDICATION NAME] .Expiration 90 days after removal from foil. Review of the manufacturer guidelines for Assure Platinum Test Strips last revised 12/14 revealed, When you first open the bottle, write the date on the bottle label. Use the test strips within 3 months of first opening the bottle. https://www.arkrayusa.com/diabetes-management/sites/arkrayusa.com.diabetes-management/files/AssurePlatinum_QAQCManual_6368-04.pdf Review of the The International Pharmacopoeia - Ninth Edition, 2019 revealed, Multidose ophthalmic drop preparations may be used for up to 4 weeks after the container is initially opened. http://apps.who.int/phint/2017/index.html#p/home During an observation on 11/19/19 at 09:45 [NAME]M., The 200 Unit Medication Cart contained an opened (unsealed) [MEDICATION NAME] inhaler with no open date written on the inhaler. During an interview on 11/19/19 at 09:45 [NAME]M., Licensed Practical Nurse (LPN) K reported that the date the inhaler is opened should be written on the inhaler. During an observation on 11/19/19 at 09:54 [NAME]M., The 300 Unit Medication Cart contained an opened (unsealed) container of Assure Prism Glucose Testing Strips with no open date written on the container. The 300 Unit Medication Cart contained 2 opened (unsealed) vial of Refresh Tears dated 10/16, an opened (unsealed) vial of [MEDICATION NAME] Eye Drops dated 10/3, an opened (unsealed) vial of [MEDICATION NAME] Eye Drops dated 10/16, an opened (unsealed) vial of [MEDICATION NAME] Eye Drops dated 10/18, and an opened (unsealed) vial of [MEDICATION NAME] Eye Drops dated 10/19. During an interview on 11/19/19 at 09:50 [NAME]M., Registered Nurse (RN) J reported that the date the container is opened should be written on the Glucose Testing Strips. During an observation on 11/21/19 at 10:22 [NAME]M., The 100 Unit Medication Cart contained an opened (unsealed) vial of [MEDICATION NAME] Eye Drops with no date, an opened (unsealed) vial of Refresh Tears dated 7/22/19, and an opened (unsealed) vial of Refresh Tears dated 10/17. During an interview on 11/21/19 at 10:34 [NAME]M., RN J reported that all eye drops are to be disposed of after 28 days when the vial is unsealed.

Based on interview and record review, the facility failed to review and revise a comprehensive, individualized plan of care for 2 of 16 residents (Resident #14 and #27) reviewed for care plans, resulting in the potential for impaired physical, mental, and psychosocial well-being. Findings include: Review of the facility policy CARE PLAN, COMPREHENSIVE last reviewed 1/2017 revealed, 11. Resident care plan documentation a. Review and update the care plan as needed. See EMR manual for procedure. Review of a facility policy FALLS PROGRAM: PREVENTION & MANAGEMENT last reviewed (MONTH) (YEAR) revealed, Following each fall, residents are assessed and care plans are reviewed and revised as needed .2. Following each fall incident, the nurse manager/designee will: .b. Review changes to the care plan made by charge nurse and ensure that interventions have been added to CNA care guide. Review of Fundamentals of Nursing (Potter and Perry) 8th edition revealed, Review and modification enable you to provide timely nursing interventions to best meet the patient's needs .It is necessary to revises related factors and the patient's goals, outcomes, and priories. Date any revisions. Revise specific interventions that correspond to the new nursing [DIAGNOSES REDACTED]. Potter, P. [NAME], Perry, [NAME] G., Stockert, P. [NAME], & Hall, [NAME] (2014). Fundamentals of Nursing (8th ed.). St. Louis: Mosby. p. 257-258 Resident #14 Review of a Face Sheet revealed Resident #14 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #14, with a reference date of 9/3/19 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated Resident #14 was severely cognitively impaired. Review of Resident #14's Incident report dated 10/13/19 at 7:45 P.M. revealed, (Resident #14) lying on Lt (left) side next to W/C (wheelchair) at DR (dining room) .Root Cause: resident attempting to enter kitchen, leaning forward from wc to open door, slipped out from wheelchair-Was Care plan reviewed: yes-Care plan revisions: Dycem added to wheelchair. Review of Resident #14's Care Plan revealed, (Resident #14) is at risk for injury r/t (related to) falls and self transferring to his knees from low bed position secondary to impaired mobility, lack of safety awareness, weakness, AMS (Altered Mental Status), Dementia .(Resident #14) is anticipated to experience falls in facility r/t unpredictability (sic)/impulsiveness and lack of safety awareness Start Date: 06/01/2018 .Keep personal items and call light within reach of resident Start Date: 06/01/2018 Keep room and environment free of barriers and clutter. (Resident #14) room is arranged so personal items in reach while sitting in WC. Start Date: 06/01/2018 Resident to sit up and stand slowly to avoid orthostatic [MEDICAL CONDITION] Start Date: 06/01/2018 Offer toileting every 2 hours during awake hours. (Resident #14) not to be left alone while sitting on toilet. Start Date: 06/11/2018 Grey impact mat on floor next to (Resident #14) bed at HS, to be removed in am Start Date: 09/10/2018 Motion sensor light in bathroom Start Date: 09/10/2018 Alarm's to (Resident #14) wheelchair, sensor pad alarm in wheelchair, dysem (sic) over alarm. Tab alarm to bathroom door. Start Date: 12/05/2018 Motion sensor alarm, placed on dresser or tray table at HS, leave on AAT. Door to (Resident #14) room to be closed when he is not in room. Nurse has receiver on med cart. CN to ensure motion sensor alarm positioned appropriately (sic) at HS. (Resident #14) has demonstrated ability to turn off bed alarms if in place. Start Date: 09/28/2018 Attempt to keep (Resident #14) in sight of CN in afternoon and evenings. Redirect (Resident #14) out of other residents rooms, offer diversional activities, i.e. cleaning side rails, snack, acitviitties (sic) when (Resident #14) demonstrates desire to enter other residents rooms. Start Date: 08/22/2019. The care plan was not updated following the fall on 10/13/19. During an interview on 11/21/19 at 12:03 P.M., Nurse Manager (NM) F reported that nurse managers update care plans with new interventions as needed. During an interview on 11/21/19 at 12:12 P.M., UM I reported that Resident #14 is a resident under her care. UM reported that Resident #14's care plan was not updated after the fall. UM reported that care plans should be updated after every fall. Resident #27 Review of a Face Sheet revealed Resident #27 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 9/24/2019 revealed a Staff Assessment for Mental Status, which indicated Resident #27 was cognitively severely impaired. Review of Resident #27's Care Plan revealed, Problem: At risk for falls/injury r/t (related to) dependency on staff for transfers, dementia with poor safety awareness and remote history of falls Start Date: 09/30/2017 . Approach: Keep personal items and call light within reach of resident Start Date: 09/30/2017. Keep room and environment free of barriers and clutter Start Date: 09/30/2017. Tab alarm to wheelchair, per family request. Start Date: 12/22/2017 .Low bed with impact mats on both sides of bed Start Date: 05/21/2018. Fall prevention alarm to bed. (Resident #27) demonstrates desire to move independently in bed while she is there. We anticipate that she will try to exit her bed Start Date: 06/26/2018. Dycem to be placed in WC under cushion. Start Date: 10/01/2018. Do not leave alone in room while awake in WC Start Date: 11/15/2018. Offer rest periods if (Resident #27) presenting fatigue. Start Date: 01/16/2019 30 minute check Start Date: 06/24/2019 Resolved Date: 07/09/2019. Wing mattress on bed. Start Date: 08/30/2019. Bed Sensor alarm to be place on bed near resident's shoulders Start Date: 09/26/2019. Leave area around resident's bed clear from furniture. Floor mats should be in place next to bed. Start Date: 09/26/2019. Provide rest periods in bed when res is sleepy before and after lunch as needed. Start Date: 11/21/2019. Review of Fall Incident Report dated 1/16/19 at 2:55 P.M. revealed, (Resident #27) observed on floor in MDR (main dining room), on right side, rt (right) arm and rt (right) leg, legs outstretched out, WC (wheelchair) next to resident. Resident holding right hand to forehead. Lacerations, 2, on right forehead, measuring 1.5 -2 cm each. abrasion above right eyebrow, abrasion below right eye .Care plan revisions: resident to be transferred to her room after noon meal, offered rest period. Review of Care Plan updates following Resident #27's fall on 1/16/19 revealed, Offer rest periods if (Resident #27) presenting fatigue. Start Date: 01/16/2019. The care plan did not include after noon meal. Review of Fall Incident Report dated 3/8/19 at 4:03 [NAME]M. revealed, (Resident #27) observed with top half of right side of body on the mat on the floor beside the bed with hips and legs on the bed .bed alarm sounded .Care plan revisions: Care plan continues to be effective .Bed alarm in place and sounding appropriately at time of incident. No changes to care plan. Review of Fall Incident Report dated 3/20/19 at 2:30 P.M. revealed, (Resident #27) laying down in bed with head on the floor towards the right side .Head laying on the floor and rest of the body in bed. How was staff alerted to the fall? Staff was checking on resident .At this incident resident had repositioned herself in bed, was observed with body in bed, head out of bed, resting on floor. Resident had not moved self off of bed sensor alarm, alarm not activated .Care plan revisions: no changes to care plan. Review of Fall Incident Report dated 3/24/19 at 3:00 P.M. revealed, observed (Resident #27) lower half of her body was still in her bed and her upper half of body was leaning out of her bed, head on the fall mat .bed alarm was sounding .Care plan revisions: larger/bariatric bed provided to resident. Review of Care Plan indicated that it was not updated following Resident #27's fall on 3/24/19. Review of Fall Incident Report dated 3/30/19 at 2:50 P.M. revealed, (Resident #27) was in room on the right side of bed on the floor .Resident was in the prone position with right arm under chest. How was staff alerted to the fall? the sound of the bed alarm .Root Cause: Resident is lain down each afternoon, after noon meal, for rest period. Resident consistently demonstrates fatigue in afternoons. Resident does not sleep long, less than 2 hours. Due to cognitive deficits resident unable to state desire to get up out of bed or to use call light. Resident had demonstrated ability to reposition self in bed, and has experienced falling from bed in past .Care plan revisions: resident nap time less than 1 1/2 hrs in afternoons. Review of Care Plan indicated that it was not updated following Resident #27's fall on 3/30/19. During an interview on 11/21/19 at 11:47 [NAME]M., Director of Nursing (DON) B reported that Resident #27's falls on 3/8/19, 3/20/19, 3/24/19 and 3/30/19, all occurred while the resident was in bed with fall interventions (bed alarm, fall mats and furniture cleared away from bed) in place, therefore the care plan was not revised at that time. Review of Fall Incident Report dated 6/22/19 at 10:45 [NAME]M. revealed, (Resident #27) was observed on activity room floor, in front of wheelchair, wheelchair turned over, tab alarm sounding .Was root cause of fall determined: resident was observed on security camera sleeping in wheelchair, leaning forward and falling from chair Root Cause: resident sleeping in chair Care plan revisions: 30 minute checks for resident put in place. Resident's currently daily schedule includes laying down in her bed after lunch. If resident presents tires, she will be encouraged to lay down and rest in the mornings. Review of Care Plan updates following Resident #27's fall on 6/22/19 indicated 30 minute checks in place from 6/24/19-7/9/19, but did not include a care plan intervention for laying down and resting in the morning. During an interview on 11/21/19 at 2:29 P.M., Certified Nursing Assistant (CNA) G reported that Resident #27 has not had any falls while she has been caring for her, just leaning out of bed. CNA G reported that for fall prevention, she would lay Resident #27 down if she started to fall asleep in her wheelchair and that there was not a specific amount of time that Resident #27 should nap for. Review of Fall Incident Report dated 8/27/19 at 5:00 [NAME]M. revealed, (Resident #27) laying on rt side, rt shoulder and rt side of her head was touching matt and floor knees and legs were still in bed. How was staff alerted to the fall? alarm sounding .Care plan revisions: change mattress to wing mattress. Review of Fall Incident Report dated 9/26/19 at 2:35 P.M. revealed, (Resident #27) was observed by staff during rounds hanging out of her bed .head was lying on the mat as her butt and legs were still in the bed .Was root cause of fall determined: no. Root Cause: Resident moves independently at times in bed and w/c. Due to her level of dementia we are unable to determine if she has a goal with her moving .Care plan revisions: Care plan changes to place bed sensor near resident's shoulders. Care plan also adjusted to prevent injuries with falls. Furniture is also not to be placed directly next to or near bed so if resident does get out of her bed she won't get hurt on furniture. Review of Care Plan updates following Resident #27's fall on 9/26/19 revealed, Bed Sensor alarm to be place on bed near resident's shoulders Start Date: 09/26/2019. Leave area around resident's bed clear from furniture. Floor mats should be in place next to bed. Start Date: 09/26/2019. During an interview on 11/21/19 at 2:40 P.M., CNA L reported that Resident #27 didn't have any falls, just rolled out of bed. CNA L reported that she places Resident #27's bed alarm directly under Resident #27's buttocks when she is in bed. CNA L reported that if Resident #27 is lying down when she starts her shift at 2:30 P.M., that she would get Resident #27 out of bed before supper.

Based on observation, interview, and record review, the facility failed to ensure resident received care in accordance with professional standards by transcribing a telephone physician's orders [REDACTED].#52) reviewed for quality of care, resulting in an inaccurate record and the potential of a delay in treatment. Findings include: Resident #52 Review of a Face Sheet revealed Resident #52 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #52, with a reference date of 8/26/19, revealed a Brief Interview for Mental Status (BIMS) score was not entered indicating Resident #52 was unable to complete the interview. Review of facility policy Physician order [REDACTED].Policy: A licensed physician order [REDACTED].Procedure: A .2. All orders will be documented in the resident's medical record. B. SNF only 1. Telephone or verbal orders from the physician shall be signed by the licensed nurse receiving the orders .4. The physician will review orders during each visit . Review of Resident #52's Interdisciplinary Notes dated 08/26/19 13:43:31, revealed, .Order received from (facility physician) to sent (sic) to ER . During an interview on 11/21/19 at 10:03 AM, DON B stated, I don't see an order for [REDACTED]. But she did not write out the telephone order. During an interview on 11/21/19 at 10:39 AM Nurse Manager F stated, (Resident #52) was sent to the ER and I took the telephone order from the physician. I should have wrote the order and did not.

Based on observation, interview and record review the facility failed to provide adequate supervision and effectively implement and revise care plans to prevent falls for 1 of 4 residents (resident #27) reviewed for falls, resulting in continued falls and the potential for a fall with major injury. Findings include: Review of a facility policy FALLS PROGRAM: PREVENTION & MANAGEMENT last reviewed (MONTH) (YEAR) revealed, Following each fall, residents are assessed and care plans are reviewed and revised as needed. A fall is an unintentional change in a resident's position, with the resident coming to rest on the ground, floor, or the next lower surface .[NAME] Assessment and Interventions .2. Fall prevention interventions should be initiated as soon as possible based on assessment, observation, and clinical judgment. 3. Initiate/update the Fall Risk Care Plan, including goals and interventions as needed .C. Post Fall Procedures/Management .2. Following each fall incident, the nurse manager/designee will: .b. Review changes to the care plan made by charge nurse and ensure that interventions have been added to CNA care guide. Resident #27 Review of a Face Sheet revealed Resident #27 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #27, with a reference date of 9/24/2019 revealed a Staff Assessment for Mental Status, which indicated Resident #27 was cognitively severely impaired. Review of Resident #27's Care Plan revealed, Problem: At risk for falls / injury r/t dependency on staff for transfers, dementia with poor safety awareness and remote history of falls Start Date: 09/30/2017 . Approach (intervention): Keep personal items and call light within reach of resident Start Date: 09/30/2017 Keep room and environment free of barriers and clutter Start Date: 09/30/2017 Tab alarm to wheelchair, per family request. Start Date: 12/22/2017 .Low bed with impact mats on both sides of bed Start Date: 05/21/2018 Fall prevention alarm to bed. (Resident #27) demonstrates desire to move independently in bed while she is there. We anticipate that she will try to exit her bed Start Date: 06/26/2018 Dycem to be placed in WC under cushion. Start Date: 10/01/2018 Do not leave alone in room while awake in WC (wheelchair) Start Date: 11/15/2018 Offer rest periods if (Resident #27) presenting fatigue. Start Date: 01/16/2019 30 minute check Start Date: 06/24/2019 Resolved Date: 07/09/2019 Wing mattress on bed. Start Date: 08/30/2019 Bed Sensor alarm to be place on bed near resident's shoulders Start Date: 09/26/2019 Leave area around resident's bed clear from furniture. Floor mats should be in place next to bed. Start Date: 09/26/2019. Provide rest periods in bed when res is sleepy before and after lunch as needed. Start Date: 11/21/2019. During an observation on 11/19/19 at 10:34 [NAME]M., Resident #27 lying in her bed with her eyes open looking around the room, with the head of the bed was observed at 45 degrees with pillows on both sides of her upper body. Resident #27 did not respond to being greeted by this surveyor. Resident #27's call light was observed out of her sight, attached to the left hand rail on the other side of the pillow. Resident #27's water was observed out of her reach, on the tray table against the wall towards the foot of the bed. During an observation on 11/19/19 at 2:41 P.M., Resident #27 observed in her bed, with the head of bed at approximately 40 degrees with her eyes open, restless and moving around in bed. During an observation on 11/20/19 at 2:23 P.M., Resident #27 observed in her wheelchair in the main dining room, looking out the window, fidgeting in her chair and talking non-sensical. Review of Fall Incident Report dated 1/16/19 at 2:55 P.M. revealed, (Resident #27) observed on floor in MDR (main dining room), on right side, rt (right) arm and rt (right) leg, legs outstretched out, WC (wheelchair) next to resident. Resident holding right hand to forehead. Lacerations, 2, on right forehead, measuring 1.5 -2 cm each. abrasion above right eyebrow, abrasion below right eye .Care plan revisions: resident to be transferred to her room after noon meal, offered rest period. Review of Fall Incident Report dated 3/8/19 at 4:03 [NAME]M. revealed, (Resident #27) observed with top half of right side of body on the mat on the floor beside the bed with hips and legs on the bed .bed alarm sounded .Care plan revisions: Care plan continues to be effective .Bed alarm in place and sounding appropriately at time of incident. No changes to care plan. Review of Fall Incident Report dated 3/20/19 at 2:30 P.M. revealed, (Resident #27) laying down in bed with head on the floor towards the right side .Head laying on the floor and rest of the body in bed. How was staff alerted to the fall? Staff was checking on resident .At this incident resident had repositioned herself in bed, was observed with body in bed, head out of bed, resting on floor. Resident had not moved self off of bed sensor alarm, alarm not activated .Care plan revisions: no changes to care plan. Review of Fall Incident Report dated 3/24/19 at 3:00 P.M. revealed, observed (Resident #27) lower half of her body was still in her bed and her upper half of body was leaning out of her bed, head on the fall mat .bed alarm was sounding .Care plan revisions: larger/bariatric bed provided to resident. Review of Care Plan indicated that it was not updated following Resident #27's fall on 3/24/19. Review of Fall Incident Reportdated 3/30/19 at 2:50 P.M. revealed, (Resident #27) was in room on the right side of bed on the floor .Resident was in the prone position with right arm under chest. How was staff alerted to the fall? the sound of the bed alarm .Root Cause: Resident is lain down each afternoon, after noon meal, for rest period. Resident consistently demonstrates fatigue in afternoons. Resident does not sleep long, less than 2 hours. Due to cognitive deficits resident unable to state desire to get up out of bed or to use call light. Resident had demonstrated ability to reposition self in bed, and has experienced falling from bed in past .Care plan revisions: resident nap time less than 1 1/2 hrs in afternoons. Review of Care Plan indicated that it was not updated following Resident #27's fall on 3/30/19. During an interview on 11/21/19 at 2:29 P.M., Certified Nursing Assistant (CNA) G reported that Resident #27 has not had any falls while she has been caring for her, just leaning out of bed. CNA G reported that for fall prevention, she would lay Resident #27 down if she started to fall asleep in her wheelchair and that there was not a specific amount of time that Resident #27 should nap for. During an interview on 11/21/19 at 11:47 [NAME]M., Director of Nursing (DON) B reported that Resident #27's falls on 3/8/19, 3/20/19, 3/24/19 and 3/30/19, all occurred while the resident was in bed with fall interventions (bed alarm, fall mats and furniture cleared away from bed) already in place, therefore the care plan was not revised at that time. Review of Fall Incident Report dated 6/22/19 at 10:45 [NAME]M. revealed, (Resident #27) was observed on activity room floor, in front of wheelchair, wheelchair turned over, tab alarm sounding .Was root cause of fall determined: resident was observed on security camera sleeping in wheelchair, leaning forward and falling from chair Root Cause: resident sleeping in chair Care plan revisions: 30 minute checks for resident put in place. Resident's currently daily schedule includes laying down in her bed after lunch. If resident presents tires, she will be encouraged to lay down and rest in the mornings. Review of Care Plan updates following Resident #27's fall on 6/22/19 indicated 30 minute checks in place from 6/24/19-7/9/19, care plan intervention not indicated for laying down and resting in the morning noted at that time. Review of Fall Incident Report dated 8/27/19 at 5:00 [NAME]M. revealed, (Resident #27) laying on rt side, rt shoulder and rt side of her head was touching matt and floor knees and legs were still in bed. How was staff alerted to the fall? alarm sounding .Care plan revisions: change mattress to wing mattress. Review of Fall Incident Report dated 9/26/19 at 2:35 P.M. revealed, (Resident #27) was observed by staff during rounds hanging out of her bed .head was lying on the mat as her butt and legs were still in the bed .Was root cause of fall determined: no. Root Cause: Resident moves independently at times in bed and w/c. Due to her level of dementia we are unable to determine if she has a goal with her moving .Care plan revisions: Care plan changes to place bed sensor near resident's shoulders. Care plan also adjusted to prevent injuries with falls. Furniture is also not to be placed directly next to or near bed so if resident does get out of her bed she won't get hurt on furniture. Review of Care Plan updates following Resident #27's fall on 9/26/19 revealed, Bed Sensor alarm to be place on bed near resident's shoulders Start Date: 09/26/2019 Leave area around resident's bed clear from furniture. Floor mats should be in place next to bed. Start Date: 09/26/2019. During an interview on 11/21/19 at 2:40 P.M., CNA L reported that Resident #27 didn't have any falls, just rolled out of bed. CNA L reported that she places Resident #27's bed alarm directly under Resident #27's buttocks when she is in bed. CNA L reported that if Resident #27 is lying down when she starts her shift at 2:30 P.M., that she would get Resident #27 out of bed before supper.

Based on observation, interview, and record review, the facility failed to fully develop and implement a policy regarding use and storage of foods brought to 1 (Resident #23) of 1 sampled resident, by family along with facility supplied foods, to ensure safe storage and consumption, resulting in the potential for persihable foods to be held beyond their discard date, increasing the risk of contamination and food borne illness. Findings include: Review of facility FOOD - USE & STORAGE FROM OUTSIDE OF FACILITY Date Last Reviewed: (MONTH) (YEAR), revealed, Policy: Food brought in by family or other visitors is permitted. It must be handled properly for safe and sanity storage and consumption .2. If the prepared food is not served immediately to the resident, the food must be stored in a container with a tight-fitting lid, clearly labeled with the resident's name and room number, the date the food was brought in to the resident, and also the use-by-date .6. Education on safe food handling will be provided to family, residents, and visitors who may provide foods or fluids to residents of the facility, including: a. proper food handling to prevent foodborne illness b. requirements for covered containers or secure wrapping c. proper labeling and dating of each item d. leftover foods will be used within 3 days or discarded . Review of facility REFRIGERATOR - RESIDENT, PERSONAL Revised Date : (MONTH) (YEAR) revealed, POLICY Permission for placement of a refrigerator will be assessed and determined on an individual basis. PR[NAME]EDURES: .2. a. Staff ability to monitor for safe operating temperature . 3. Director of nursing or executive director/designee will notify the resident and/or resident representative of the determination and staff's responsibility to dispose of any undated or expired items .5. Regularly scheduled refrigerator checks will be completed by staff .In the skilled nursing facility (SNF), the refrigerators will be checked daily. 6. Checks will include a. temperature (refrigerators must be 41 degrees or less; freezers must be cold enough to keep foods frozen solid to touch); b. food containment and quality c. disposal of any outdated food items d. cleaning e. checking for ice build-up . Review of facility Food Storage Chart dated, (YEAR), revealed, Expiration dates printed by the manufacturer apply until the product is opened .Once opened, use these time limits unless the manufacturer's date is earlier. Add the time in this chart to the date of opening/preparation to determine expiration. Dry Storage: Bread and Rolls-if not dated by the manufacturer, add a sticker with an expiration date +3 days after deliver. According to Manufacturer's Expiration Dates: +2 months for Peanut Butter. Refrigerated Storage: Use Manufacturer's Exp Date: +1 month: .Jams, jellies .Freezer Storage: Use Manufacturer's Exp Date: +3 months: Any food stored frozen, unless manufacturer's date is sooner. Review of a Face Sheet revealed Resident #23 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #23 was cognitively intact. Further review of MDS indicated Resident #23 required extensive assistance of 1 person for weight-bearing support for transfers and walking in room. Review of a Face Sheet revealed Resident #23 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #23, with a reference date of [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #23 was cognitively intact. Further review of MDS indicated Resident #23 required extensive assistance of 1 person for weight-bearing support for transfers and walking in room. During an observation on [DATE] at 1:10 PM Resident # 23's ceramic mug on bedside table held both wrapped and unwrapped chocolate candy. The unwrapped candy had melted chocolate with liquid in the bottom of the mug. Observed resident's personal refrigerator/freezer with 7 facility bowls of ice cream covered in clear wrap undated and with 4 bowls having freezer burn on contents. Also in freezer were 2 cartons of outside cartons of ice cream. Cartons did have stickers or dating. In the refrigerator were 1-opened bottle of pop partially gone, 1-opened Malted Milk, 1-restaurant disposable cup with lid with dark liquid, 2-opened water bottles, 1-opened bag of donuts, 3-restaurant to-go containers with food, 1-opened plastic jar of peanut butter, 1-opened glass jar of jelly, 3-small containers of fruit, and 10-small boxes of liquid supplement all items in personal freezer/refrigerator of food brought from outside source. On front of refrigerator was taped Food Storage Chart. Observed on [DATE] at 9:05 AM Resident #23 with a cinnamon roll in glass container brought from outside source next to bed and not dated. Personal refrigerator freezer contained the same food and beverage items as the day ([DATE]) before as did the refrigerator. On front of refrigerator was taped Food Storage Chart. The ceramic mug on bedside table with unwrapped chocolate candy candy had melted chocolate with liquid in the bottom of the mug. Observed on [DATE] at 3:15 PM, Resident #23's ceramic mug on bedside table contained unwrapped chocolate candy. The candy had melted with liquid in the bottom of the mug. Personal refrigerator/freezer contained the same food and beverage items as the day ([DATE]) before as did the refrigerator. On front of refrigerator was taped Food Storage Chart. Observed on [DATE] at 8:45 AM Resident #23's ceramic mug on bedside table contained unwrapped chocolate candy. The chocolate had melted with liquid in the bottom of the mug. Personal freezer contained 1-carton of outside sourced carton of ice cream with no open date or sticker. Refrigerator contained Malted Milk, and 1-name-brand peanut butter, with no open date. On table next to resident's chair was a brought from home cinnamon roll from day before, [DATE], in glass container with blue lid and not dated. During an interview on [DATE] 09:49 AM DON B stated, Food brought in from outside should be dated when put into refrigerator. (Resident #23) was upset when I told him and his spouse they were responsible for keeping it clean and items dated. Having the refrigerator gives him a feeling of normalcy. Night shift nurses keep record every night of temp on TAR (Treatment Administration Record ). The night nurses are to be checking dates and dispose of items. If items are not dated they should be disposed of. If food brought from home and sitting out all day it should be taken care of by staff. The candy in the ceramic mug should be thrown out. Ice cream is typically what (Resident #23) gets for night time snack. Anything opened should be dated and disposed. The resident's personal refrigerator and freezer should be maintained by staff according to policy. Review of Resident #23's Physician order [REDACTED].start date [DATE], .Night shift to clean fridge & freezer nightly, QD NSHFT (every day night shift) follow FOOD STORAGE CHART (taped to fridge) for expiration of items - For refrigerator/freezer protocol; .start date [DATE] Check fridge temp nightly. - 1 Every Day; . QD TCHECK (every day temperature check) . Review of Resident #23's Treatment Administration Record (TAR) dated [DATE]-[DATE], revealed, Check fridge temp nightly .Night shift to clean fridge & freezer nightly, follow FOOD STORAGE CHART (TAPED TO FRIDGE) for expiration of items - for refrigerator/freezer protocol; Diagnosis/Reason = refrigerator/freezer protocol; . Further review of Resident #23's TARs indicated that each nurse assigned to Resident #23 verified with their documented initials they had followed physician orders [REDACTED].

This citation has deficiency practice statements (DPS), A and B DPS A Based on observation, interview, and record review, the facility failed to maintain effective infection control practices per the standard of infection control and facility policy for 1 of 18 residents (Resident #6) reviewed for care and in the resident dining room, resulting in the potential for the spread of infection and cross-contamination. Findings include: Resident #6 Review of the Pericare and Catheter Care Checklist (no date), reflected Preparation: .Female: Separate the labia, beginning in the center - clean downward from front to back with one stroke - repeat cleaning out from the center - using a new quarter of the washcloth each time. Repeat as needed Review of a Detailed Summary revealed Resident #6 was a [AGE] year-old male, currently admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment for Resident #6, with a reference date of 4/3/18, revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #6 was cognitively intact. During an observation on 10/23/18 at 12:18 PM, Resident #6 was up in the wheelchair he was on 2 litters oxygen via nasal cannula from an oxygen concentrator, the oxygen tubing on the back of the wheelchair was wrapped around the handles of the back of the wheelchair and the nasal cannula was laying on the floor between the chair, Resident #6 was moving the wheelchair back and forth a short distance dragging the tubing. Certified Nursing Assistant (CNA) F entered the room, cleaned her hands, noted the oxygen tank on the back of the wheelchair was empty, left the room and returned, moving the tubing that was wrapped around the handle which picked the nasal cannula off the floor. CNA F replace the oxygen tank rolled the tubing onto one handle of wheelchair, and placed the nasal cannula onto Resident #6. During and interview on 10/24/18 at 2:21 PM, CNA F reported that she did not notice the oxygen tubing was on the floor or she would have replaced the tubing. Review of the policy titled Hand Hygiene last reviewed 1/2018 revealed: All employees/volunteers shall follow the establishedhand hygiene procedure to reduce the spread of infection and disease within the facilities/care units .Employees and volunteers will use alcohol-based hand rub or soap and water to clean their hands in the following circumstances: After contact with inanimate objects in the immediate vicinity of the resident wash with only soap and water in the following circumstances when hands are obviously soiled Alcohol based hand rub may be used to cleanse hands between resident contacts when feeding residents in the dining room During a dining observation and interview on 10/23/18 at 12:33 p.m., residents were observed in the dining and staff was serving their meals. Certified Nursing Assistant (CNA) Z was observed standing with hands on hips, serving a tray to a resident at the dining table, then wiping hands on clothing, walked into the kitchen after opening the door to grab another plate to serve. No hand hygiene was observed. While in the kitchen, the Dietary Aide (DA) G was observed grabbing her Styrofoam cup from the employee drink stand with her gloves on, took a sip of her drink, then opened the kitchen door to grab a cart with condiments on it to bring back to the kitchen. DA G then went to the walk in cooler with the same gloves on and took the cart in the cooler with deserts on it and took it to the dining room and served residents desert with the same gloves on. DA G reported that it was wrong for her to wear the same gloves to do the above. DPS B Based on observation and interview it was observed that the facility failed to 1. Properly store and protect clean linens in two of three clean linens rooms observed for cleanliness; and 2. Properly store food supplements for medication pass in one of one nourishment room. This resulted in an increased chance for waste water to contaminate supplies and linens, which affects all residents who use linens in the 100 and 300 halls as well as all residents who use dietary aids during medication pass. Findings include: During a tour of the facility at 1:18 PM on 10/24/18 it was observed that tuffs of dust and debris were found underneath the clean linen rack located in the closet on the 300 hall. No bottom barrier was observed to protect the clean linens on the bottom shelf from coming into contact with dust, debris, or waste water from mopping. During a tour of the facility at 1:30 PM on 10/24/18 an interview with Housekeeping supervisor FF, found that, As long as its kept clean in the linen rooms I didn't think I needed a bottom barrier (under the bottom shelving). An observation of the 300 hall clean linen room, with Housekeeping Supervisor FF found that the back half of the closet was being missed during cleaning. Observation of the 100 Hall clean linen room at 2:20 PM on 10/24/18, was found to have drywall dust and debris on the floor of the closet. During a tour of the facility at 2:00 PM on 10/24/18 it was observed that three flats of shake supplements, one case of applesauce, and a box of disposable cups, were all found stored under the sink of the Nourishment room. When asked if these were supposed to be stored under the sink, Housekeeping Supervisor FF stated, Nothing is supposed to be stored under the sink.

Based on observation, interview, and record review, the facility failed to make prompt efforts to resolve the grievance in 1 of 1 resident (Resident #5) reviewed for grievances, resulting in a belief that her concerns do not matter, and a disruption in her chosen daily routine. Findings include: Review of an Admission Record revealed Resident #5 was an [AGE] year old female who originally admitted the the facility on 7/24/13 with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 10/2/18 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of section B, Hearing, Speech, and Vision revealed Resident #5's ability to hear was Adequate. Review of section G, Functional Status revealed Resident #5 required extensive assistance with 2 staff members for transfers and was totally dependent on staff for locomotion on and off her unit. Review of a Dementia care plan dated 1/31/18 revealed, Goal: (Resident #5) will function at her highest practical ability, will continue to make independent choices such as .wake/sleep schedule. In an interview on 10/23/18 at 9:28 AM, Resident # 5 stated, My roommate (Resident #54) is up all night watching TV and rustling papers. I wish she would sleep at night. she's sleeping right now. It keeps me up. In an interview on 10/25/18 at 8:42 AM, Social Worker (SW) D stated (Resident #5) did complain about it in her care conference a while ago. We talked with the team who follows her room mate and they talked with her roommate and her family about turning her TV off once she's asleep. The kardex was changed, and I followed up with (Resident #5) afterward and she said it was better. SW D reported that they did not fill out a resident concern form for this complaint, they just addressed it in the care conference and in her own follow up. Review of a policy titled, Grievance/Complaint reviewed (MONTH) (YEAR), revealed, .Complaints and grievances can address care and treatment that has or has not been provided; the behavior of staff and of other residents; and other concerns regarding their skilled nursing facility. Voice grievances are not limited to a formal, write, grievance process but may include a resident's verbalized complaint to facility staff . Procedure .2. All staff members are responsible for: b. communicating complaints and grievances, either verbal or written, to their supervisor. (A Registry of Complaint Form may be used for this purpose) Review of Interdisciplinary Notes dated 10/10/18 revealed, Quarterly Care conference conducted on Wednesday, 10/3 Resident's current status and health discussed. Plan of Care reviewed, copy offered to resident. Changes in ADL (activities of daily living), mood/behavior or activities noted this quarter: No significant changes this quarter . (Resident #5) said that her roommates television was left on at night and keeping her awake. Passed on to her roommates care team to address with staff. Checked with (Resident #5) today, and she said that it was better . Review of Interdisciplinary Notes dated 10/11/18 revealed, Late entry for 1:1 visit yesterday with (Resident #5) to follow up on concerns. (Resident #5) had stated that her roommates television was being left on late at night after her roommate was asleep, and that this was keeping (Resident #5) awake. Concerns relayed to roommates care team, and staff notified to shut television off if roommate is asleep. (Resident #5) stated that it has no longer been a problem . Review of the Certified Nurse Aide (CNA) kardex for Resident #5 and Resident # 54 revealed no indication to staff to turn Resident # 54's TV off at night when she is asleep. In an interview on 10/25/18 at 8:59 AM, Resident #5 reported that she slept okay last night after her roommate's TV was turned off. She keeps it on full blast. Resident # 5 reported it was turned off at approximately 1:00 a.m. Resident # 5 reported that this has been an ongoing issue. She stated, I've told people. They don't care. I'd like to go to sleep around 9:00 p.m. In an interview on 10/25/18 at 9:15 AM, CNA Z stated, I know (Resident # 5) well. She does tell me about her roommate's TV being loud. It happens at night, but she tells me in the morning, so there's not much I can do about it. I pass it on to the nurse, I'm sure they're handling it. In an interview on 10/25/18 at 9:28 AM, Registered Nurse (RN) B reported that she is the nurse manager for Resident #5. RN B stated, (Resident #5) complained about it to us in a care conference. We researched it, and it resolved. This surveyor asked how it was researched and what was discovered. RN B stated, We did a sleep study on them, and we found that they were both sleeping through the night. We followed up afterward and (Resident # 5) said it was better. And she hasn't complained since. (Resident #5) had some other things going on medically and emotionally at that time. In an interview on 10/25/18 at 9:37 AM, RN B provided the sleep study and stated, Actually, we just did the sleep study on the roommate. Review of a (Facility) Sleep Log revealed, Resident: (Resident # 54) Monitoring dates: 10/8/18-10/12/18. The log indicated Resident # 54 was not asleep until 11:00 p.m. on 10/8/18, 12:00 a.m. on 10/9/18, 1:00 a.m. on 10/10/18, 12:00 a.m. on 10/11/18, and 1:00 a.m. on 10/12/18. The log did not indicate what Resident # 54 was doing while awake or if her TV was on. The log did not indicate if her roommate, Resident #5 was asleep or awake. In an interview on 10/25/18 at 9:41 AM, RN I reported that she knows Resident #5 well and she works with her often. RN I stated, (CNA Z) told me just now about the TV issue, I haven't heard about it before. My intention is just to tell the night nurse so she can look into it. Maybe I'll talk with (Resident # 54) today to see. Resident # 54 Review of an Admission Record revealed Resident # 54 was an [AGE] year old female who originally admitted the the facility on 5/3/18 with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) assessment with a reference date of 8/7/18 revealed a Brief Interview of Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of section B, Hearing, Speech, and Vision revealed Resident # 54's ability to hear was Adequate. Review of section G, Functional Status revealed Resident # 54 required limited assistance with 1 staff member for transfers and for locomotion on and off her unit. In an observation and interview on 10/24/18 at 9:48 AM, Resident # 54 was in bed which is up against one wall of the room. Her TV is on a piece of furniture that is up against the opposite wall of her room. Discussed breakfast, meals, and daily routine. Resident # 54 seemed hard of hearing as this surveyor had to repeat multiple questions during the interview. Resident # 54 stated, I like to sleep in a bit. But I sleep well at night too. In an interview on 10/25/18 at 9:47 AM, SW E reported that she is the social worker for Resident # 54. SW E reported she recalled hearing about the concern of Resident # 5 with her roommate's loud television. SW E stated, I do recall hearing about that concern, but I'll have to rack my brain. I think there was a sleep study done, but I can't remember all that came from it other than (Resident # 5) said it had improved. On 10/25/18 at 9:52 AM, This surveyor called the daughter of the Resident # 54. The voicemail box was full. In an interview on 10/25/18 at 9:56 AM, Resident # 54 stated, Oh, yes, I do enjoy watching TV at night. This surveyor asked if she has a hard time hearing. Resident #54 responded, What? This surveyor repeated the question. Resident #54 stated, Oh, (laughed) well yes, especially right now because my ears are so filled up. I have an appointment with an ear nose throat doctor this month, I think. Why is it too loud? This surveyor asked Resident # 54 if anyone has talked to her about the volume of the TV. Well, I keep the TV as quiet as I can, but the second shift nurse does get on me about that, because she says she can hear it clear out into the hall. I can't hardly believe that, but I could be wrong. See, I can hear you because you're right up by my face. But my TV is across the room while I'm in bed. This surveyor was crouched next to Resident # 54 while she sat in her recliner, and had to repeat multiple sentences during the interview. In an interview on 10/25/18 at 10:30 AM, RN W reported she is the nurse manager for Resident # 54. RN W stated, She doesn't have a hard time hearing, that I know of. Then again, I'm beginning to think I probably speak loudly in every room I go into these days. Yes, her daughter set up the appointment with an Ear Nose Throat (ENT) doctor for [DATE]th. I guess (Resident # 54) had tubes put in her ears a while back and she felt that one was coming out. The sleep study showed no issues with (Resident # 54) sleeping. SW E stated, There was no place on the sleep log about the TV, so that wasn't addressed. I seem to recall the other issue was a question of (Resident # 54) being up around her room at night. According to Resident # 54's daughter, she's never had trouble sleeping. (Resident #5) tends to perseverate on a concern that happened one time according to her care team. Review of the current Mood State, Cognitive Loss/Dementia care plans for Resident # 5 revealed no mention of a behavior of perseverating on a concern after it has been resolved.

Based on observation, interview, and record review, the facility failed to: 1.) implement infection control practices per policy and procedure and standards of practice to prevent the spread of infection for 10 of 15 sampled residents (Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, Resident #15, Resident #16, Resident #17, Resident #18, and Resident #19) and 14 supplemental residents who all exhibited signs and symptoms of Norovirus (highly contagious [MEDICAL CONDITION]) and, 2.) implement transmission based precautions to protect all residents from the spread of infections, resulting in an Immediate Jeopardy when on 12/30/17 residents began having signs and symptoms of a gastrointestinal illness and no transmission based precautions were implemented per facility policy. On 1/2/18, Norovirus was confirmed by laboratory testing and facility staff still did not place residents in transmission based precautions, did not notify the health department of a communicable disease as required, and did not perform the necessary cleaning to prevent or diminish the spread of infection. This deficient practice resulted in 25 of the 55 facility residents being diagnosed as positive for Norovirus and placed all residents, staff and visitors at risk for serious harm, injury and/or death. Findings include: Review of the facility policy titled Infection Control - Norovirus Outbreak dated January 2018 with a previous revised date of December 2017 reflected, (Name of Facility) will follow established procedures in the case of a suspected norovirus outbreak in order to facilitate the necessary treatment of [REDACTED]. A case of norovirus illness is defined as an acute onset of vomiting and/or diarrhea as evidenced by watery, non-bloody stools; abdominal cramps; nausea; and fever. 2. Identification of [MEDICAL CONDITION] can be done from stool specimens within 48 - 72 hours after the onset of symptoms .4. Residents who have symptoms consistent with norovirus gastroenteritis should be placed on contact precautions and in a single occupancy room. 5. The nurse/designee will notify: a. the director of nursing/designee, b. resident representative, c. physician, d. medical director, e. facility services, f. staffing resources, g. dietary services, h. (Name of) County Health Department. 6. If a single occupancy room is not available, symptomatic residents should be separated from asymptomatic residents. 7. The Nurse/designee should follow transmission-based precautions . Review of the facility policy titled Transmission-Based Precautions, Initiating dated August 1997 with a last revised date of November 2017 reflected, Transmission precautions are implemented when there is reason to believe that a resident has an infectious or communicable disease. The least restrictive approach necessary for resident protection will be utilized and for only as long as necessary .2. The executive director/designee, director of nursing, infection control coordinator, HFA response nurse, or medical director has the authority to initiate transmission precautions and actions to control infections within the facility as needed, including: a. Notifying the health department of reportable diseases, as appropriate, b. Obtaining laboratory specimens, c. Restricting admissions, d. Restricting visitation. 3. The nurse will implement transmission precautions by: .c. Placing the appropriate precaution sign on the door of the resident's room alerting staff and visitors of the specific transmission precautions (i.e., Contact, Droplet, and Airborne Precaution signs) .j. Documenting actions in the resident's medical record. 4. The nurse will obtain a physician order to discontinue the transmission precautions when it is evident that the resident no longer has an infectious disease . Review of the facility policy titled Transmission-Based Precautions, Visitation dated October 2002 last revised on November 2017 for review reflected, Guidelines for visitation are implemented to prevent the spread of infections and communicable diseases within the facility and to and from the community .Signs may be posted at the visitor entrances to: a. Indicate specific illness and/or outbreak of illness .4. Visitors should be discouraged from visiting when they have infectious conditions (i.e. upper respiratory infection, influenza, gastroenteritis, or unexplained rashes). Review of the facility policy titled Hand Hygiene dated August 1997 and last revised on August 2017 reflected, Employees and volunteers will wash only with soap and water in the following circumstances: .e. When contact is made with [DIAGNOSES REDACTED]icile or norovirus diagnosed resident or his/her environment .3. Hand washing will be performed in the following manner: f. Wash/scrub top and bottom of hands, between the fingers, around rings and around the wrists for 15 seconds. Rub fingertips into the palm of the hand to clean the fingernail . An onsite survey began on 1/8/18 and upon entrance, the Nursing Home Administrator (NHA) reported the unit doors that separated resident care units were closed because of an illness in the facility. The NHA deferred to the Director of Nursing (DON) for further explanation. DON B reported that some facility residents were afflicted with Norovirus but that necessary precautions were in place. During the initial review of the facility on 1/8/18, surveyors observed the following: - No contact precaution signage was posted in resident care areas. - Caregivers displayed universal precautions, not contact precautions - Residents that required assistance with meals were gathered together in an assistive dining area for a meal. - DON B reported the facility was using cleaning agents, but the ones used were ineffective against the Norovirus Review of an email received by the facility on 1/8/18 at 11:06 AM, from the County Health Department revealed a document titled, Guidelines for the Control of a Suspected or Confirmed Outbreak of [MEDICAL CONDITION] Gastroenteritis in a Nursing Home. The directives in this document included: Residents: 1. Isolate ill residents from others by confining them to their rooms .keep all residents in their rooms and serve meals in rooms. 2. Cohort (group) ill individuals together down the same hall, wing, or unit . 3. Discontinue group activities where ill and well residents would be together (e.g. Meals, parties, BINGO .) .postponed until the outbreak is over. Staff: 4. Minimize the flow of staff between sick and well residents. Staff should be assigned to work with either well or sick residents, but should not care for both groups. Housekeeping: 9. For outbreaks use bleach for disinfection . The document titled Healthcare/Hospital/Nursing Home Facilities provided by the County Health Department was reviewed which included the cleaning and management of a Norovirus outbreak but not limited to: medical equipment, laundry, carpets, ice machines .The document gave direction for the use of protective equipment when cleaning (for Norovirus such as the use of gloves, masks, eye protection, face shield, gowns and protective clothing). Review of the document titled Infection Control Report summarized the time line of the outbreak as follows: - 12/30/17, Resident #10 (300 hall) had loose stool and emesis (vomiting). - 1/1/18, Resident #11 (300 hall) displayed loose stools and emesis, was admitted to the hospital on [DATE], and was diagnosed with [REDACTED]. - 1/1/18, Resident #12 (300 hall) presented with emesis and had watery stools from her ostomy. - 1/2/18, the following Residents had signs and symptoms of Norovirus: Resident #13, (200 hall), Resident #14 (300 hall), Resident #15 (100 hall), Resident #16 (100 hall), and Resident #17 (100 hall) During an observation on 1/8/18 at 12:21 PM, Facility Staff E and Certified Nursing Assistant (CNA) F were noted to assist Resident #15, Resident #20, Resident #21 and Resident #22 with lunch at the same table. At 12:52 PM on 1/8/18, Resident #9, Resident #18 and Resident #19 were observed to be served lunch and assisted with lunch by 2 staff members, while seated at the same table in the Day Room/Assisted Dining Room. During an observation on 1/8/18 at 1:11 PM, CNA G opened a straw for Resident #9 and placed it in a milk carton. CNA G touched the end of the straw several times with bare hands, then placed the straw to Resident #9's mouth. On 1/8/18 at 1:13 PM, as CNA G was scooping food onto a feeding utensil, Resident #9's straw rubbed against CNA G's arm/uniform. CNA G proceeded to give Resident #9 a drink using the straw. On 01/8/18 at 12:18 PM, Secretary E was observed exiting the Day Room/Assisted Dining Room. Upon returning to the Day Room/Assisted Dining Room, Secretary E performed hand hygiene with soap and water for approximately 10 seconds, facility policy indicates washing for at least 15 seconds. Review of a document provided by DON B on 1/8/18, reflected that the names of Resident #15, Resident #18, and Resident #19 were highlighted. During an interview on 1/9/18 at 9:11 AM, DON B reported that the highlighted names reflected residents that had been symptomatic and had been isolated to their rooms. The names of Resident #9, Resident #20, Resident #21 and Resident #22 were not highlighted, which indicated that they were not symptomatic. The above residents, both symptomatic and not symptomatic, were dining at the same tables, which was inconsistent with the directive from the Health Department that well and sick residents should not take meals together. On 1/9/18 at 11:58 AM, four residents were observed seated at the same table in the Day Room/Assisted Dining Room. DON B was notified of the observation, at which time DON B advised staff to return each resident to their room. In an interview on 1/9/18 at 12:30 PM, DON B reported that the Main Dining Room and Beauty Shop were closed, and all group activities had been suspended on the evening of 1/5/18. Resident #10 Review of the facility Face Sheet reflected that Resident #10 was a [AGE] year old male, re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Note dated 12/29/17 at 4:22 AM, Licensed Nurse (LN) M documented, .resident with several large volume emesis (vomiting) as well as loose stools . Review of the Interdisciplinary Note dated 12/30/17 at 2:26 AM, LN R documented that the resident had emesis. Review of the Interdisciplinary Note dated 12/30/17 at 1:58 PM, LN Q documented, .Loose stool reported throughout shift .This nurse suggested to the Res. (resident) that he stay in his room for the remainder of the day to avoid spreading germs in case he is contagious. Res. refused this suggestion and proceeded to wheel himself to exercise class at 0945 (9:45 AM). Later on it was again suggested to the res. that he should stay in his room and the res. again refused, wheeling himself into the hall to attend Bingo. Review of the Interdisciplinary Note dated 12/30/17 at 8:58 PM, LN O documented that the resident had diarrhea two times during the shift. Review of the Interdisciplinary Note dated 12/31/17 at 4:35 AM, LN R documented that the resident had two loose stools during the shift. Review of the Interdisciplinary Note dated 12/31/17 at 1:01 PM, LN Q documented that the resident had loose stool one time. Review of the Interdisciplinary Note dated 12/31/17 at 10:21 PM, LN O documented that the resident had diarrhea. Loose stools and/or emesis continued to be documented on 1/1/18, 1/2/18, 1/4/18, 1/5/18, 1/6/18, 1/7/18 and 1/8/18. Review of a laboratory test reflected that Resident #10 had a positive fecal test result for Norovirus G2 on 1/4/18 at 10:50 PM. Review of the Treatment Record (TAR) for January 2018 reflected, Res (resident) to remain in room until GI (gastrointestinal) sx (symptoms) absent x 24 hrs. (for 24 hours). encourage and assist resident with handwashing, discourage visitors . The order had a start date of 1/4/18 (6 days after the onset of Norovirus symptoms) and an end date of 1/15/18. The TAR also reflected a contradictory note of, Contact Isolation secondary to: GI sx (loose stools) continue until: symptom free x 3 days or cleared by MD . The order had a start date of 1/9/18 (11 days after the onset of Norovirus symptoms) and an end date of 1/11/18. Resident #12 Review of the Face Sheet reflected that Resident #12 was a [AGE] year old female, admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Note dated 1/1/18 at 11:36 PM, revealed Licensed Practical Nurse (LPN) I documented that the resident complained of nausea after supper time, around 6:00 PM. Review of the Interdisciplinary Note dated 1/2/18 at 6:53 AM, revealed Licensed Nurse (LN) M documented that the resident had a small emesis on the evening shift, and output from the resident's [MEDICAL CONDITION] had been increased and more watery. Review of a laboratory test result reflected that Resident #12 had a positive feces test result for Norovirus G2 on 1/2/18 at 10:20 AM. Review of the Interdisciplinary Note dated 1/2/18 at 3:44 PM revealed, LN K documented that the resident continued with watery stool in her [MEDICAL CONDITION]. Review of the Interdisciplinary Note dated 1/2/18 at 11:47 PM revealed LPN I documented that the resident was in contact isolation. Review of the Interdisciplinary Note dated 1/3/18 at 9:51 AM revealed Registered Dietician (RD) documented, .Resident's nurse reports resident is off isolation . Review of the Interdisciplinary Note dated 1/4/18 at 7:13 AM, revealed LN M documented that the resident continued to have increased, watery output from her [MEDICAL CONDITION]. Review of the Interdisciplinary Note dated 1/4/18 at 10:00 AM revealed LN L documented that the resident still had watery stools. Review of the Interdisciplinary Note dated 1/5/18 at 11:47 AM revealed Registered Nurse (RN) J documented that the resident had one loose stool. Review of the Interdisciplinary Note dated 1/6/18 at 4:52 PM revealed, LN K documented that the resident continued to have watery stool in the [MEDICAL CONDITION] bag. Review of the Interdisciplinary Note dated 1/7/18 at 2:58 PM revealed, LN K documented that the resident continued to have watery stool from her [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. Resident #14 Review of the facility Face Sheet reflected that Resident #14 was a [AGE] year old male, readmitted to the facility 12/3/14, with [DIAGNOSES REDACTED]. Review of the Interdisciplinary Note dated 1/2/18 at 6:59 AM revealed, LN M documented that the resident had a large emesis and loose stool. Review of the Interdisciplinary Note dated 1/3/18 at 1:34 PM revealed, DON B documented, Res no longer exhibiting sx of gastroenteritis x 24 hrs. Testing for norovirus not completed as sx had subsided .At this time will discontinue isolation precautions. Review of the Interdisciplinary Note dated 1/4/18 at 2:33 AM and 4:41 AM reflected that the resident had emesis. Review of a laboratory test result reflected that Resident #14 had a positive feces test result for Norovirus G2 on 1/4/18 at 12:15 PM. Review of the Interdisciplinary Note dated on 1/6/18 at 5:21 AM revealed emesis was documented by LN M. Review of the Interdisciplinary Note dated 1/7/18 at 2:39 PM revealed, LN K documented that the resident had an extra large emesis and loose stool at 8:30 AM as well as a temperature of 100.3 degrees. Review of bowel documentation reflected that Resident #14 had loose stool documented on 1/8/18 at 4:11 AM. Review of the Interdisciplinary Note by LN K on 1/10/18 at 11:15 AM reflected that the resident remained on contact isolation. Review of the Interdisciplinary Note dated 1/10/18 at 4:43 PM revealed, DON B documented that isolation was discontinued due to the resident not being symptomatic for greater than 72 hours (last loose stool documented on 1/8/18, 48 hours previously). Review of the Medication Administration Record [REDACTED]. to remain in room until GI sx absent x 24 hrs. encourage and assist with handwashing, discourage visitors . A TAR order with a start date of 1/9/18 (7 days after the onset of Norovirus signs and symptoms) and an end date of 1/10/18 reflected, Contact isolation secondary to: GI illness continue until cleared by MD or symptom free x 3 days . In an interview on 1/22/18 at 5:48 PM, DON B reported that a single episode (of vomiting, loose stool or diarrhea) was enough for the facility to place a resident in contact isolation. If there was a single episode, DON B reported that the staff would monitor for 48 hours. If there were no further symptoms, contact precautions were discontinued. DON B further reported that if there were multiple episodes of symptoms, the residents were kept in isolation until they were symptom free for 72 hours. DON B reported that on 1/8/18, the facility implemented having residents remain in isolation for 72 hours after symptoms subsided. Resident #14 A Medication Administration observation and interview was conducted on 1/9/18, between 7 and 9 AM on the 300 Hall. Registered Nurse (RN) J reported that Resident #14 was on contact precautions. Resident #14 was observed to be receiving nutrition via pump through a feeding tube. RN J was observed wearing gloves during the suspending of the pump tube feeding and then administration of medication through the feeding tube for Resident #14. RN J was not observed donning a gown while administering the medication and flushing the feeding tube of Resident #14. Resident #11 According to a facility face sheet, Resident #11 was a [AGE] year old male readmitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Review of Resident #11's Interdisciplinary Notes from 1/01/18 at 00:32:15, Licensed Nurse (LN) revealed, Resident continues projectile emesis and diarrhea for several times during (3-11 shift.) Notified Dr. on call around 1750 Review of Resident #11's Interdisciplinary Notes from 1/01/18 at 15:49:08, revealed LN Q documented that, Res. experienced a change in health status demonstrated by several instances of liquid diarrhea, accompanied with vomiting Review of Resident #11's, Resident Transfer to Emergency Department Information sheet revealed that Resident #11 was transferred to the hospital on [DATE]. The reason for the transfer revealed that Resident #11 was having the following symptoms, emesis, loose stools, wet breath sounds, [MEDICAL CONDITIONS] and tachypena with a temperature of 100.2 degrees. According to the hospital Progress Note on 1/3/18 at 9:21 AM, Resident #11 had been diagnosed with [REDACTED]. The record revealed Resident #11 had not been tested for Norovirus while in the hospital. Review of Resident #11's Interdisciplinary Notes from 1/8/18 at 23:48:45 revealed, Licensed Nurse (LN) Y admitted Resident #11 to room [ROOM NUMBER]-1 at 3:00 pm from the hospital. Resident #11 admitted with resp failure, and acute [MEDICAL CONDITION]. Resident #11 was alert and oriented to person, place, time and situation. LS (lung sounds) right lung has coarse lung sounds and left lung is CTA (clear to auscultation). Resident SOB (short of breath) or cough at this time. HR (heart rate) and rhythm is regular. Skin turgor is good. Bowel sounds active x 4 quad. Abdomen is distended, soft, and non tender. Review of the Interdisciplinary Notes for Resident #11 revealed the following: -On 1/10/18 at 16:46:41, Director of Nursing (DON) B documented that, Contact isolation dc'd as roommate (Resident #14) no longer having sx (symptoms). Resident #11 has also remained free of sx. -On 1/15/18 at 07:13:40 LN M documented that, cna (Certified Nurses Aide) reports resident had a larger, watery loose BM (Bowl movement) early this am. resident placed on contact isolation, staff to obtain stool for Norovirus, VS q shift until s/sx resolve. -On 1/15/18 at 09:26:17, DON B documented that, Resident with onset of GI sx this AM (single loose stool). Private room is available on 200 hall, will move resident this AM. Staff instructed to gown and glove resident for move to 209. -On 1/16/18 at 13:26:13, LN V revealed, resident in contact isolation d/t previous loose stools. no loose stools noted this shift. -On 1/17/18 at 04:26:31, LN U documented that, Res remains in bed sleeping well at N(NAME) with contact isolation D/T Norovirus positive, no GI S/Sx noted. VSS. Will continue to monitor. Review of a laboratory test result reflected that Resident #11 had a positive feces test result for Norovirus G2 on 1/16/18 at 1820. Review of the Interdisciplinary Notes for Resident #11 revealed the following: -On 1/17/18 at 15:50:07, LN V documented that, resident in contact isolation d/t [MEDICAL CONDITION] positive. alert with some forgetfulness. one loose stool noted today. no c/o nausea. -On 1/18/18 at 03:33:50, LN Udocumented that, Res remains in bed sleeping well at N(NAME) with contact isolation D/T secondary having loose BM, stool specimen taken for Norovirus. VSS. Will continue to monitor. -On 1/18/18 at 11:10:48 LN V documented that, resident on contact isolation d/t [MEDICAL CONDITION]. resident had episode of loose stools, no nausea or emesis noted. -On 1/20/18 at 06:26:55, LN M documented that (Original Note dated 1/20/18 at 03:04) resident continues on contact isolation re: loose stools. On [MEDICATION NAME], not displaying any respiratory s/sx. VS stable, afebrile. CNA reports resident one loose stool this shift. -On 1/20/18 at 16:19:33, LN N documented that, Resident #11 is currently on Contact Isolation for Loose Stools. He did present with loose stools in am. Denies Nausea. No vomiting noted or reported . -On 1/21/18 at 06:06:07, LN Mdocumented that, resident continues on contact for loose stools, vs stable,, denies nausea. CNA reports one medium loose stool overnight. -On 1/21/18 at 16:50:37, LN Ndocumented that, Resident #11 is currently on Contact Isolation for Norovirus. Loose stool this shift. Denies Nausea. No vomiting noted or reported -On 1/22/18 at 06:52:31, LN M documented that, resident continues in contact isolation for Norovirus. Resident denies nausea. No loose stools or emesis this shift. An interview and record review was conducted on 1/17/18 at approximately 2:00 pm with Director of Nursing (DON) B. DON B stated that Resident #11 readmitted to the facility on [DATE]. DON B provided a copy of the facility's updated timeline of illness. The timeline reflected that the hospital attributed Resident #11's diarrhea to the Coronavirus (upper respiratory virus). The timeline also reflected that the day after Resident #11 was sent to the hospital on [DATE], the roommate Resident #14 started to have emesis and loose stools and Resident #12 had a confirmed lab test (1/3/18) for the Norovirus. When asked if anyone from the facility notified the hospital regarding the confirmed Norovirus breakout, the DON B stated, I know I didn't. During a subsequent interview on 1/22/18 at approximately 5:45 PM the DON B stated that no one from the facility notified the hospital that Resident #11's roommate had also had a confirmed [DIAGNOSES REDACTED]. Resident #13 According to a facility face sheet, Resident #13 was a [AGE] year old female admitted into the facility on [DATE] with the Diagnoses: [REDACTED]. Review of the Interdisciplinary Notes for Resident #13 revealed the following: -On 1/02/18 at 06:00:03, Licensed Nurse (LN) U documented that, Res had loose BM and moderate BMx2 and moderate indigested at 0130, VSS. IRP Pepto Bismol 30 ml PO given at 0140. Res stated I feel much better after I throw up. -On 1/2/18 at 10:15:46, LN V documented that, no loose bm or emesis noted on this shift. denies nausea, states I didn't eat to much for breakfast. c/o feeling achy today. resident remained in room today. -On 1/2/18 at 22:07:21, LN W documented that, Held stool softner for loose stools. -On 1/3/18 at 23:06:47, LN X documented that, Writer did not administer senna to resident. Due to diarrhea 1.2.18, and loose stools today. -On 1/4/18 at 12:17:28, LN V documented that, resident had one loose stools today, no emesis, no c/o nausea. During an interview on 1/22/17 at approximately 5:30, DON B was asked for the lab results for Resident #13. DON B stated they did not have a lab (result) for Resident #13. Supplemental Residents #24-37 The following Residents were confirmed to have Norovirus G2 after their stools were tested in a lab. Resident #24 on 1/04/18 at 0330. Resident #25 on 1/06/18 at 1435. Resident #26 on 1/06/18 at 1435. Resident #27 on 1/06/18 at 1935. Resident #28 on 1/06/18 at 1450. Resident #29 on 1/06/18 at 1450. Resident #30 on 1/06/18 at 1445. Resident #31 on 1/06/18 at 1440. Resident #32 on 1/06/18 at 0805. Resident #33 on 1/06/18 at 1445. Resident #34 on 1/07/18 at 1550. Resident #35 on 1/09/18 at 1000. Resident #36 on 1/09/18 at 1140. Resident #37 on 1/12/18 at 2210. In an interview on 1/16/18 at approximately 9:00 AM, DON B advised the Survey team that the facility had an outbreak of Influenza A and that 3 residents were exhibiting signs and symptoms and the facility had droplet precautions in place. On 1/22/18, DON B provided a copy of the current list of influenza precautions in place for the now 7 residents affected. DON B provided a copy of the staff illness log for December 2017 and January 2018. The logs reflected that from 12/10/17 - 1/22/18, twenty-five (25) staff members called in with at least one or more of the following symptoms: nausea, vomiting or diarrhea. The logs reflected that 13 staff members called in with at least one or more of the following influenza symptoms: fever, chills, muscle aches, cough, congestion, runny nose, headache, and fatigue. In an interview on 1/22/18 at approximately 5:45 PM, DON B stated, No, not yet when asked if the facility had conducted an investigation related to the outbreaks that could be reviewed. There was no infection control investigation made available for review prior to the exit of this survey. On 1/9/18 at 3:22 PM, the NHA was notified of the Immediate Jeopardy (IJ) due to the facilities failure to implement established interventions to provide care for and prevent the spread of signs and symptoms of Norovirus which began on 12/30/17, to residents, staff and visitors. A written plan for removal of the IJ, dated 1/17/18 and accepted on 1/17/18 follows: 1. On 1/8/18 at 10:50 am, Director of Nursing/Infection Control Nurse (DON) B notified the County Health Department of a Norovirus outbreak throughout facility. 2. On 1/8/18 at 11:06 am, the health department emailed recommendations on cleaning and treatment for [REDACTED]. DON B gave this direction to Dining Service Manager. 3. On 1/8/18, Corporate Quality, Development & Training Department Registered Nurse arrived at facility, reviewed education plan using materials provided from Michigan Department of Community Health with DON B & NHA. DON B & NHA were able to verbalize understanding of materials and provide demonstration of education for staff to Corporate Quality, Development & Training Dept RN. Corporate Quality, Development & Training Dept RN worked with staff to ensure sufficient PPE supplies were available. 4. On 1/8/18 at 12:56 pm, DON B communicated the health department recommondations for the cleaning process to Housekeeping Supervisors and housekeeping staff and provided bleach wipes with instructions on use. 5. On 1/8/18, the Housekeeping Supervisor provided additional instruction to housekeeping staff on the cleaning process and observed staff for compliance. Audits were initiated by Housekeeping Supervisor for compliance with education. 6. On 1/8/18, the Housekeeping Supervisor ordered replacement privacy curtains for resident rooms, following existing process that curtains be changed when isolation is discontinued. 7. On 1/9/18, in-service education for facility services/housekeeping/laundry/floor care & Maintenance staff was conducted by Corporate Housekeeping Supervisor and Regulatory Compliance Manager for Facility Services regarding norovirus and cleaning instructions, isolation sequence cleaning instruction, contact isolation, PPE education and validated by observation by Corporate Housekeeping Supervisor & Regulatory Compliance Manager for Facility Services. Audits for compliance initiated by Housekeeping Supervisor. 8. On the afternoon of 1/8/18, the decision was made by the NHA to hold on accepting admissions, this was communicated verbally by NHA to VP of Operations &(NAME)Home Central Intake Department. No new residents were admitted to BRLC since the afternoon of 1/8/18. 9. On 1/9/18, implementation of maintaining 72 hours of contact isolation after resident asymptomatic initiated per the health department recommendations. 10. On 1/9/18, the facility implemented process that employees who were absent from work with norovirus like symptoms (vomiting, diarrhea etc) would be removed from the schedule until 72 hours after resolution of symptoms. This information was also communicated to corporate staffing & scheduling by DON B and reinforced by the NHA. 11. On 1/8/18, DON B provided additional instruction to staff regarding proper infection control processes based on the health department information. DON & NHA began disinfecting main dining room, activity room, and other hard surfaces such as door knobs in & out of dining areas & common areas, restrooms. 12. Beginning on 1/9/18, additional Staff education started using the health department Norovirus Fact Sheet including contact isolation precaution details, necessity of using soap & water for hand washing, and the process for call in's related to any norovirus like symptoms by DON B and the NHA. Audits initiated by Quality Training & Development RN. By the end of day, 41 staff members were educated by either DON B or the NHA on above information, across all departments, prior to the start of their shift. No staff who had direct contact with residents would work their shift without first being in-serviced by DON B or the NHA. 13. On 1/9/18, dining carts were cleaned using bleach cleaner and process implemented to continue disinfecting with each use. Nursing Unit ice machine - external parts were cleaned using bleach wipes. 14. On 1/10/18, the internal mechanism of Nursing Unit ice machine (which is a closed system) was sanitized by HVAC technician (TRUNCATED)

This citation pertains to MI 732: Based on interview and record review, the facility failed to prevent a significant medication error for 1 (Resident #5) of 1 reviewed for medication errors, from a total sample of 9 residents, resulting in Resident #5 not receiving a prescribed medication and requiring hospitalization . Findings include: Review of the Face Sheet and Minimum Data Set ((MDS) dated [DATE], reflected that Resident #5 was a [AGE] year old male, admitted to the facility on [DATE] and most recently re-admitted on [DATE], with [DIAGNOSES REDACTED]. Hospital discharge instructions, dated 6/30/17, reflected that Resident #5 was to take [MEDICATION NAME] (a medication used to treat high blood pressure and to prevent chest pain) 100 milligrams (mg) by mouth once daily. Review of the facility's physician's orders [REDACTED]. The start date for the medication was listed as 6/1/18. Review of the Medication Administration Record [REDACTED]. Resident #5 did not receive the [MEDICATION NAME] in the facility from the date of admission (6/30/17) through the date he was sent to the hospital (7/7/17). Review of vital signs reflected a documented pulse of 112 beats per minute on 7/7/17 at 4:00 PM. Review of interdisciplinary notes reflected a note on 7/7/17 at 4:30 PM that the resident complained of left lower extremity (LLE) (left leg) pain, rated 6 out of 10. The note further reflected that the resident experienced [MEDICAL CONDITION] The nurse practitioner was contacted and ordered an electrocardiogram (EKG) (a test that records electrical activity of the heart) and a venous doppler (an ultrasound test that measures blood flow and checks for blood clots) of the LLE. A Cardiology Report document for a date of service of 7/7/17 reflected that the resident had sinus [MEDICAL CONDITION](elevated heart rate), a heart rate of 117 beats per minute, left anterior fascicular block and a complete right bundle branch block (a heart block). A progress note on 7/7/17 at 8:45 PM, reflected that the on-call physician was contacted at 5:50 PM on 7/7/17 and ordered the resident be sent to the emergency room for evaluation. A hospital clinical summary dated 7/9/17, reflected [DIAGNOSES REDACTED].[MEDICAL CONDITION] related to not having beta blocker medication recently . During a telephone interview on 12/27/17 at 3:24 PM, Registered Nurse (RN) H was unable to recall if she had put the orders in the computer or if she had double checked them. RN H stated that somehow the computer entered the start date for [MEDICATION NAME] as 2018 rather than 2017, and it was not caught. RN H stated she thought the computer had an alert, but it did not pop up. During a telephone interview on 12/27/17 at 3:42 PM, Licensed Practical Nurse (LPN) G stated she was unsure if she was the nurse that entered the medication orders into the computer or if she was the nurse that double checked them. LPN G reported that when putting medication orders in the computer, the start date normally populated for that day. If the medication had already been given that day, the nurse would manually change the start date for the next day. In an interview on 12/28/17 at 11:53 AM, Director of Nursing (DON) B reported that at the time the error occurred, one nurse would enter admission orders [REDACTED]. DON B further reported that the facility tried to have third shift review the orders as well by comparing hospital orders with the orders in the facility's system. DON B stated as far as he knew, the third shift review had been completed. DON B stated that the system did not flag a warning for the [MEDICATION NAME] since the start date was less than 365 days in the future. The medication never populated to the MAR indicated [REDACTED].

This citation pertains to Intake Number MI 394. Based on interviews and records review, the facility failed to safely transfer 1 of 3 sampled residents (#101) resulting in a left tibia (medial lower leg bone) fracture. Findings include: According to the Profile Face Sheet (no date), Resident #101 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the CNA guide sheet dated 02-10-11, Resident #101 was to be transferred with a two person assist and a mechanical lift. The Accident/Incident Report dated 02-10-11 at 4:50 pm documented Resident #101 complained of left ankle pain after being caught in between the mechanical lift and the recliner. During an interview on 03-03-11 at 11:25 am, RN #1 stated Resident #101 was being pushed by a CNA on her way to dinner when Resident #101 stated her left ankle hurt. RN #1 stated as the CNA was getting Resident #101 up out of her recliner chair in her room, the CNA pushed the wrong button, up instead of down, and caught Resident #101's leg in the mechanical lift. During an interview on 03-03-11 at 10:00 am, Resident #101 stated while the CNA was getting her up out of her recliner, she was not paying attention and was talking to someone else in the room. Resident #101 stated as the CNA was pushing the button to raise instead of lower her legs and her left leg was caught between the leg guards of the mechanical lift. Resident #101 stated she tried to tell the CNA to stop but she wasn't paying attention. Resident #101 stated she had to scream to get the CNA's attention to stop pushing the button. The Nurse's Notes dated 02-11-11 documented Resident #101's left ankle was swollen and an x-ray was ordered. According to the left ankle x-ray dated 02-12-11, Resident #101 had a fracture of the left tibia (medial bone of the lower leg). During an interview on 03-03-11 at 9:30 am, the DON (Director of Nursing) stated Resident #101's CNA did not use a two person assist in transferring Resident #101 when Resident #101 injured her leg. The DON stated he was not aware Resident #`101's CNA did not use a two person assist with Transferring Resident #101 until 02-14-11. During the investigation, the CNA that transferred Resident #101 causing the injury on 02-10-11 was unable to be contacted for an interview and no longer worked at the facility. ( )