Every finding on record at Intersect Healthcare of Roscommon

Based on observation, interview and record review the facility failed to maintain general cleanliness and repair of the premises. This resulted in an increased potential for contamination and a possible decrease in satisfaction of living affecting all residents in the facility. Findings include:On 3/9/2026 at 4:17 PM there was an observed lack of hot water at the two hand sinks in the kitchen. The hand sink closest to the maintenance hallway was observed to have hot water at 81 degrees, and the hand sink on the other end of the kitchen closest to the dish machine room was observed at 80 degrees, as registered on a probe thermometer. On 3/9/2026 at 11:35 AM the dish machine room hand sink temperature was recorded at 82 degrees and the sink closest to the maintenance hall at 80 degrees, using a probe thermometer. During this observation, Maintenance Director G stated that the water heater was recently replaced and the mixing valve was turned down too low. According to the 2022 FDA Food Code section 5-202.12 Handwashing Sink, Installation. (A) A HANDWASHING SINK shall be equipped to provide water at a temperature of at least 29.4 C (85 F) through a mixing valve or combination faucet. On 03/10/2026 at 8:13 AM an observation in the Dietary Managers office just off of the hall to the kitchen revealed a ceiling vent cover and the ceiling around it with a buildup of dust and debris.

Based on observation, interview and record review, the facility failed to identify a change in bowel health for one Resident (#20) of one resident reviewed. This deficient practice resulted in the potential for constipation, intestinal blockage and discomfort.Findings include:Resident #20 (R20)Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/24/2025, revealed R20 was admitted to the facility on [DATE] and had diagnoses including end-stage renal disease, heart failure, right side hemiplegia, bilateral foot amputation, and diabetes. Further review of the MDS assessment revealed R20 received hemodialysis treatment, required supervision/touching assistance with transfers and scored 13 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the Resident was cognitively intact.On 3/10/2026 at 8:47 a.m., R20 was observed seated on the edge of his bed eating breakfast. R20 was not wearing a shirt and a dialysis access line was observed to be in place in his upper arm right. R20's meal tray contained one eight-ounce (240 milliliter) mug of coffee. No other fluids/drinks were visible on the meal tray or anywhere in R20's room. During an interview at the time of the observation, R20 was queried about his bowel habits and reported his last bowel movement was the other day. R20 could give no further information related to the frequency of his bowel movements.Review of R20's electronic medical record (EMR) revealed the following active order, dated 12/26/25, 1000 cc [cubic centimeter or milliliter] fluid restriction daily . four times a day every Mon [Monday], Wed [Wednesday}, Fri [Friday]. An additional active order, dated 12/27/2026, included a 1000 cc fluid restriction on Tuesday, Thursday, Saturday and Sunday. It was noted in review, R20 was on a daily 1000 cc fluid restriction.Review of R20's point of care documentation titled, Bowel Movements, revealed the Resident's last documented bowel movement was 3/5/2026 at 8:06 p.m. R20's bowel movements were documented as None, on the follow dates/times:3/06/2026 at 2:22 p.m. and 8:06 p.m.3/07/2026 at 11:29 p.m.3/08/2026 at 4:30 a.m. and 5:11 p.m.3/09/2026 at 4:14 a.m., 3:22 p.m. and 8:07 p.m.R20 had no documented bowel movement from 3/6/2025 at 8:06 p.m. to the time of review on 3/10/2026 at 10:46 a.m., which was determined to be more than four days without a bowel movement.Review of R20's March 2026 Medication Administration Record (MAR), revealed the following orders: MiraLax Oral Powder [laxative medication used to aid in passing stool)] 17 GM [gram] Scoop . Give 17 gram by mouth every 24 hours as needed for no BM [bowel movement] x 2 days/constipation. Start Dated: 11/15/2024 . No doses were documented as administered. Dulcolax Suppository [laxative medication used to stimulate bowel movements] 10 MG . Insert 1 suppository rectally every 24 hours as needed for if no bowel movement in 72 hours. Start Dated: 11/01/2022 . No doses were documented as administered.The March 2026 MAR for R20 documented oxycodone-acetaminophen (an opioid pain medication with a known side-effect of constipation) 5-325 MG four times daily was consistently administered.During an interview on 3/10/2026 at 12:18 p.m., Licensed Practical Nurse (LPN) A reported she was unaware R20 had no documented bowel movement since 3/05/2026 at 8:06 p.m. LPN A reported the night shift nurse usually passed along a list of residents requiring evaluation for bowel movements and the need to administer laxative medications per standing orders. LPN A reported she did not receive a list that morning indicating any residents were in need of intervention for bowel care. LPN H, present during the interview, reported she checked the lists from the previous shift and R20 was not listed.Further review of R20's EMR for March 5, 2026, through March 10, 2026, to include progress notes, evaluations and dialysis communication records, revealed no documentation of bowel movements, staff evaluation or resident assessment related to the Resident's bowel health or constipation. During an interview on 3/10/2026 at 1:47 p.m., the Director of Nursing (DON) confirmed there was no documented bowel movement for R20 since 3/5/2026 at 8:06 p.m. The DON reported LPN A alerted her about the situation following this Surveyor's inquiry. The DON reported she had just finished speaking with R20 who reported he had daily bowel movements, although not documented. The DON confirmed there was no documentation of staff inquiry regarding R20's documentation of the lack of bowel movements for more than four days and no initiation of standing orders for constipation. The DON said she was unsure how nursing overlooked the issue and any reported bowel movements by R20 should be documented.Review of facility, Standing Orders, provided by the Nursing Home Administrator (NHA) revealed the following: Bowel Protocol: If no BM after 2 days give 30 ml of MOM (non-dialysis patients only-Do not order MOM if dialysis patient). If no BM after 3 days give Dulcolax suppository. If no BM after 4 days five Fleets enema.

Based on observation, interview, and record review, the facility failed to ensure:(1) the correct dosage of medication was administered and(2) medication administration according to manufacturer recommendations for two Residents (R28 and R38) of three residents reviewed for medication administration. This deficient practice resulted in a medication error rate of 6.4% from 2 of 31 opportunities for error.Findings include:Resident #28 (R28) On 3/10/26 at 8:08 AM, Licensed Practical Nurse (LPN) A was observed administering medications to R28 who required medication administration through a gastrostomy tube (G-tube - a tube in the abdominal wall to provide direct access to the stomach for nutrition, fluids, and medication).LPN A added water to a 30 ml (milliliter) plastic medication cup containing a crushed medication tablet. The medication did not dissolve in the water and LPN A used a plastic spoon to stir the medication in the cup. When the medication was stirred in the 30 ml cup, the medication began spilling over the sides of the cup onto the bedside table. LPN A continued to stir the content of the cup with the medication spilling over the cup onto R28's bedside table until the medication tablet was dissolved. LPN A administered the remaining medication in the cup to R28. LPN A signed the medication on the Medication Administration Record (MAR) of R28 as administered despite R28 not receiving the prescribed amount of medication due to spillage of approximately 25% of the cup's content.During an interview with the Director of Nursing (DON) on 3/11/26 at 10:46 AM, the DON said if a nurse spilled medication, the nurse should dispose of the remainder of the medication and obtain new medication to ensure residents receive the correct dosage of medication.Resident #38 (R38)Registered Nurse (RN) B was observed preparing and administering medications to R38 on 3/11/26 at 7:19 AM. RN B removed a Toujeo Max SoloStar Subcutaneous Solution Pen (an insulin injection device) from the medication cart. RN B dialed the insulin pen to the prescribed 80 units of insulin without first priming the pen. The surveyor asked RN B about priming the pen with insulin before administering the 80 units of insulin. RN B said the insulin pen did not require priming. When RN B administered the insulin to R38, RN B injected the 80 units of insulin and immediately removed the pen without holding the injection button and maintaining the pen against the skin for a period of time to ensure the full dose of insulin was administered.During an interview with the DON on 3/11/26 at 10:46 AM, the DON said insulin pens need to be primed before adjusting to the prescribed amount of insulin. The DON said the injection button on an insulin pen should be held against a resident's skin after delivery of insulin but said she did not know how long to hold the pen against the skin.The manufacturer administration guidelines of the Toujeo Max SoloStar Subcutaneous Solution Pen (https://products.sanofi.us/Toujeo/Toujeo.pdf) provided the following instructions, in part: . Step 3: Do a safety test. Always do a safety test before each injection to: check your pen and the needle to make sure they are working properly. make sure that you get the correct insulin dose.3A Select 3 units by turning the dose selector until the dose pointer is at the mark between 2 and 4. 3B Press the injection button all the way in. When the insulin comes out of the needle tip, your pen is working correctly. Step 5: Inject dose.5D Keep the injection button held in and when you see 0 in the dose window, slowly count to 5. This will make sure you get your full dose. 5E After holding and slowly counting to 5, release the injection button. Then remove the needle from your skin.The policy General Dose Preparation and Medication Administration dated as revised 11/15/24 read, in part: .Verify each time a medication is administered that it is the correct medication, at the correct dose.Follow manufacturer medication administration guidelines.

Based on observation, interview, and record review, the facility failed to properly store medications in one medication cart of two medications carts reviewed for medication storage. Findings include:On 3/10/26 at 7:58 AM, Licensed Practical Nurse (LPN) A prepared 11 medications in a medication cup for Resident #15 (R15). LPN A placed the cup of medications on the overbed table in R15's room while she replaced a medication patch on R15's left upper posterior arm. After placing the medication patch, LPN A picked up the cup of medications from the overbed table to administer the medications. R15 told LPN A he didn't want the medications at that time. LPN A took the cup of medications back to the medication cart and placed the cup of medications in the top drawer of the medication cart.On 3/10/26 at 8:08 AM, Licensed Practical Nurse (LPN) A then proceeded to prepare seven medications for Resident #28 (R28), including a losartan tablet (medication to treat high blood pressure) obtained from a blister pack (a medication packaging system that holds individual doses of medication in separate compartments). LPN A left the medication cart and entered R28's room with the blister pack of losartan still atop the medication cart, unsecured and unattended. After administering the medications to R28, LPN A returned to the medication cart. The surveyor picked up the blister pack that contained 14 tablets of losartan and asked LPN A why the medication was left on the cart. LPN A said she forgot to secure the blister pack of medication back into the medication cart with the rest of R28's medications.The Director of Nursing (DON) was interviewed on 3/11/26 at 10:46 AM. The DON said nurses are expected to place blister packs of medication back into the medication cart when walking away from the cart. The DON agree it was unsafe to leave medications unsupervised and unattended atop the medication cart. The DON said if a nurse prepares medications and a resident does not want the medication after preparation the nurse should dispose of the medications and get a new supply of medications if the resident later decides to take the medication.The policy General Dose Preparation and Medication Administration dated as revised 11/15/24 read, in part: .Facility staff should not leave medications or chemicals unattended.Dispose of unused medication portions.The policy Storage and Expiration Dating of Medications and Biologicals dated as revised 6/30/25 read, in part: . Facility should ensure medications and biologicals that .have been contaminated .are stored separate from other medications util destroyed . Facility should ensure the medications and biologicals for each resident are stored in the containers in which they were originally received .

Based on observation, interview, and record review, the facility failed to provide barriers for resident care equipment and maintain infection control practices during medication administration for four Residents (#10, #15, #28, & #38) of seven residents reviewed for infection prevention and control.Findings include:Resident #10 (R10)R10 was admitted to the facility on [DATE]. A quarterly MDS (Minimum Data Set) assessment dated [DATE] documented R10 had chronic respiratory failure with hypoxia and required supplemental oxygen and a non-invasive ventilator (respiratory support device). On 3/9/26 at 2:05 PM, R10 was observed wearing a nasal cannula (an oxygen delivery device that provides supplemental oxygen through the nostrils) connected to an oxygen concentrator. An additional nasal cannula was connected to a portable oxygen tank on the back of R10's wheelchair. The nasal cannula on the portable oxygen tank was unbagged and lying across the back of R10's wheelchair without a barrier (a barrier is an item intended to prevent contamination of items and reduce the potential for transmission of infectious organisms).A BiPAP (a type of non-invasive ventilator used to support breathing) was observed unbagged and atop the nightstand next to the bed of R10 with the face portion of the mask resting directly against the nightstand without a barrier beneath it on the following dates and times:3/9/26 at 2:05 PM3/10/26 at 9:29 AM3/10/26 at 10:31 AM3/10/26 at 2:04 PM On 3/10/26 at 10:31 AM, R10 was asked about the cleaning of the BiPAP and tubing, and storage of the BiPAP mask and nasal cannula tubing. R10 said the nurses do not clean or change the BiPAP or mask and do not change or bag the nasal cannula when not in use. R10 said he was not supplied with a bag to put the BiPAP mask in when he is done using it.The Director of Nursing (DON), who also served as the facility's Infection Preventionist, was interviewed on 3/11/26 at 10:46 AM. The DON said BiPAP masks and nasal cannulas should be in a bag when not in use.Resident #15 (R15)R15 was admitted to the facility on [DATE] for aftercare following a surgical amputation.During an interview on 3/9/26 at 2:14 PM, R15 said he had finished his antibiotics and was scheduled to discharge from the facility the following day.Licensed Practical Nurse (LPN) A was observed administering medications on 3/10/26 at 7:58 AM. LPN A prepared 11 medications in a medication cup for R15. LPN A placed the cup containing the medications on R15's overbed table without a barrier beneath it while she replaced a medication patch. R15 said he did not want his medications at that time. LPN A took the medication cup from the overbed table and exited the room. LPN A placed the cup of medications on top of the medication cart without a barrier beneath it while she unlocked the medication cart. LPN A placed the cup of medications in the top drawer of the medication cart without a barrier beneath it. LPN A commenced preparing medications for other residents without cleaning or sanitizing the top of the medication cart where the cup of medications had been placed after being on the overbed table without a barrier in the room of R15.Resident #28 (R28) R28 was admitted to the facility on [DATE]. A quarterly MDS dated [DATE] documented R28 required a feeding tube for administration of nutrition, fluids, and medications.During medication administration with LPN A on 3/10/25 at 8:08 AM, LPN A entered R28's room with six clear plastic medication cups of crushed medication. LPN A placed the cups on the overbed table without a barrier beneath them. LPN A announced she did not have a measuring device in which to measure the feeding tube for placement prior to medication administration. LPN A picked up the medication cups from the overbed table, exited the room, and placed the medication cups on top of the medication cart without a barrier beneath them. LPN A unlocked the top drawer of the med cart and placed the medication cups in the cart without a barrier. LPN A obtained a measuring tape from another area of the facility and returned to the medication cart to obtain the six cups of medication for R28. LPN A did not clean or sanitize the top of the med cart or the drawer where she had stored the medication cups after the cups were on R28's overbed table without a barrier. When LPN A re-entered R28's room, she placed the six cups of medications back on top of the overbed table without a barrier beneath them.While in R28's room, a pen fell from the pocket of LPN A onto the floor. LPN A picked up the pen and placed it on R28's overbed table without a barrier beneath it. After administering medications to R28, LPN A picked up the pen and placed it back into her pocket without cleaning or sanitizing it.Resident #38 (R38)R38 was admitted to the facility on [DATE]. R38 had a diagnosis of diabetes and received insulin daily.Registered Nurse (RN) B was observed preparing and administering medications to R38 on 3/11/26 at 7:19 AM. RN B removed a Toujeo Max SoloStar Subcutaneous Solution Pen (an injection device to deliver insulin) from the medication cart. RN B placed a needle on the end of the pen without first cleansing the end of the injection pen.During the interview with the DON on 3/11/26 at 10:46 AM, the DON said nurses are expected to clean the ends of insulin pens with alcohol before applying needles to the pens. When asked the expectations regarding the use of barriers, the DON said, If something is set down and needs to leave the room or go back to the medication cart, nurses should use barriers. The DON agreed nurses should clean and sanitize medication carts when potentially infectious items are placed atop or within the cart. The manufacturer administration guidelines of the Toujeo Max SoloStar Subcutaneous Solution Pen (https://products.sanofi.us/Toujeo/Toujeo.pdf) provided the following instructions, in part: .Pull off the pen cap.Wipe the rubber seal with an alcohol swab. Step 2: Attach a new needle.The policy Medication Administered through Certain Routes of Administration dated as revised 11/15/24 read, in part: . Subcutaneous Injections [an injection between the skin and muscle - insulin is a subcutaneous injection] . swab vial with alcohol, let dry.The policy titled BIPAP-CPAP dated as last reviewed/revised June 2023 read, in part: .Store mask or nasal pillows [soft inserts that fit directly into the nostrils] in mesh bag or other approved storage container approved by the facility when not in use .The policy Oxygen Administration and Concentrator Policy dated as revised 6/23 read, in part: .keep delivery devices stored in a sanitary manner.The policy Storage and Expiration Dating of Medications and Biologicals dated as revised 6/30/25 read, in part: .Facility should ensure medications and biologicals that .have been contaminated .are stored separate from other medications until destroyed .Facility should ensure the medications and biologicals for each resident are stored in the containers in which they were originally received .

Based on observation, interview and record review, the facility failed to ensure interventions to address fall prevention were implemented for two Residents (#5 & #6) of four residents reviewed for falls. Findings Include: Resident #5 (R5) Review of the care plan revealed R5 was identified on 11/21/23 at risk for accidents, injuries, and falls r/t (related to) hx (history) of falls with major injury, insomnia, heart failure, COPD (Chronic Obstructive Pulmonary disease) & emphysema with dependence on oxygen, impaired mobility and balance, generalized weakness, forgetfulness, impaired vision . Interventions on 11/21/23 included: Be sure my call light is within reach and encourage me to use it for assistance as needed. I need prompt response to all requests for assistance. Ensure that I am wearing non-skid footwear prior to assisting me with transfers and/or ambulation. Reduce my risk for falling by cleaning up spills or clutter from my floor, provide glare-free lighting, accessible working call light, bed set at height deemed appropriate by PT (Physical Therapy)/OT (Occupational Therapy)/Nurse (as applicable), my personal items within reach. Review fall risk factors on admission, quarterly, change of condition and with each fall. Review information on past falls and attempt to determine cause of falls. Record possible root cause(s) and remove any potential causes as applicable. On 11/27/23 R5's care plan was updated to include: Encourage me to participate in activities that promote exercise, physical activity for strengthening and maintain mobility. On 5/5/24 the care plan was updated with: Offer reminders with routine checks to use call light for assistance with mobility needs. O 8/14/24 R5's care plan was update to include 15-minute visual safety checks. Review of R5's progress notes revealed the following: Event occurred on 08/14/2024 3:30 AM. Heard yelling coming from (R5's) room. Upon arrival to room, (R5) observed on floor laying on right side between bed and bathroom. [NAME] noted to be tipped over to the left of resident. Small amount of blood noted on floor, (R5) yelling my leg! Right lower leg noted to have bone protruding through skin. Minimal bleeding noted on floor and to pant leg. No other injuries observed. Floor was noted clean and dry, resident had grip socks in place. Call light within reach, but (R5) did not use call light at time of occurrence. Physician and responsible party notified. R5's care plan was update on 8/14/24 to include 15-minute visual safety checks. R5 fell again on 10/4/24, where the progress notes at 3:41 AM indicated (R5) was assisted to the commode next to her bed in her room. CNA went back into assist (R5) back to bed and resident asked for a few more minutes. (R5) was attempting to wipe herself falling forward, she did use her call light for assistance at that time. (R5) was observed on the floor on her right-side walker was laying on its side above her. noted urine on floor, (R5) did not have footwear on. (R5) stated she went down on her right knee; (R5) denied hitting her head and she denied any pain. Head to Toe assessment was completed no noted injuries . The facility failed to ensure R5 was wearing non-skid footwear per her care plan prior to getting up to the commode. Review of the progress note dated 11/29/24 at 5:10 AM, revealed R5 was found on the floor in their room .sitting on floor on buttock with back to bed and feet toward bathroom door . Review of facility incident report's root cause analysis revealed the facility did not include an analysis for effectiveness of 15-minute safety checks. The EMR (electronic medical record) revealed the last documented 15-minute check was more than an hour before the fall occurred. 15-minute checks on the 11/29/24 were documented as follows 12:03 AM, 3:00 AM, 4:07 AM, 8:05 AM, 8:05 AM, 10:07 AM, 2:07 PM, 2:07 PM, 4:17 PM, 6:55 PM, 8:52 PM, and 11:00 PM. The documentation on the date of the incident revealed inconsistencies with completing and documenting the required 15-minute checks. Resident #6 (R6) R6 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, diabetes type II, generalized osteoarthritis, encephalopathy, motor and sensory neuropathy. R6 had a BIMS score of 15 indicating R6 was cognitively intact. R6's care plan implemented on 1/27/25, revealed : I am at risk for accidents, injuries, and falls r/t (related to) generalized weakness, diabetic neuropathy, Parkinsonism, impaired balance and mobility, Charcot-[NAME]-Tooth disease, and elevated ammonia levels. R6's care plan was updated on 3/5/25 post fall, to include: 15-minute visual safety checks with frequent reminders on call light use. R6's Current Care Record was updated to include: observe resident for visual safety check, offer frequent reminders on call light use every 15 minutes, charting Q2 hours. On 3/11/25, R6 was observed for a continuous period of 30 minutes revealed no staff completing the care planned 15-minute safety checks of R6, from 2:00 PM -2:30 PM. On 3/12/25 at 11:09 AM during an interview, the Director of Nursing (DON) stated the Q2 hour time frame for charting close supervision was to ensure staff were completing the 15-minute checks. When asked how the facility could ensure the checks were being completed if charting was only to be documented every 2 hours, the DON stated the documentation every two hours is the Certified Nursing Assistant's way of stating they had completed the 15-minute checks during that 2-hour time span. The DON explained the multiple exact times documented were due to staff charting at the end of their shifts and staff do not remember to change the time. When asked how the facility could determine 15-minute checks were being completed or if they were effective when staff are charting at the end of their shift, or only being required to chart in 2-hour increments, the DON did not provide an answer.

Based on observation, interview and record review, the facility failed to implement and maintain accurate and complete documentation for 15-minute safety checks for two Residents (#5 & #6) of two residents reviewed for documentation related to 15-minute safety checks. Findings include: Resident #5 (R5) Review of R5's Electronic Medical Record (EMR) revealed diagnoses including Chronic Obstructive Pulmonary Disease (COPD), dependence of supplemental oxygen, heart failure, Type II diabetes, presence of artificial eye, and legal blindness. R5 had a Brief Interview for Mental Status (BIMS) score of 15 indicating R5 was cognitively intact. R5 was identified as a fall risk on 11/21/23 as indicated during review of their care plan. R5's care plan was updated on 8/14/24 after a fall with injury, to include 15-minute visual safety checks due to cognitive impairment, failure to use call light consistently, and frequent attempts to ambulate unassisted. R5's Current Care Record was updated to 15-minute checks Q (every) 2 hours. A review of R5's EMR tasks for 15 minute checks revealed 133 days of missing 2-hour charting and/or several entries at the exact same time, on the same date, from August 2024 to February 2025. Staff did not properly document whether the checks were completed. Resident #6 (R6) R6 was admitted to the facility on [DATE] with diagnoses including Parkinsonism, diabetes type II, generalized osteoarthritis, encephalopathy, motor and sensory neuropathy. R6 had a BIMS score of 15 indicating R6 was cognitively intact. R6's care plan implemented on 1/27/25, revealed : I am at risk for accidents, injuries, and falls r/t (related to) generalized weakness, diabetic neuropathy, Parkinsonism, impaired balance and mobility, Charcot-[NAME]-Tooth disease, and elevated ammonia levels. R6's care plan was updated on 3/5/25 post fall, to include: 15-minute visual safety checks with frequent reminders on call light use. R6's Current Care Record was updated to include: observe resident for visual safety check, offer frequent reminders on call light use every 15 minutes, charting Q2 hours. Review of R6's EMR tasks for 15 minute checks from implementation date of 3/5/25 through 3/11/25 indicated 5 days of inconsistencies in completing the required 15-minute safety checks. On 3/11/25, R6 was observed for a continuous period of 30 minutes revealed no staff completing the care planned 15-minute safety checks of R6, from 2:00 PM -2:30 PM. On 3/12/25 at 11:09 AM during an interview, the Director of Nursing (DON) stated the Q2 hour time frame for charting close supervision was to ensure staff were completing the 15-minute checks. When asked how the facility could ensure the checks were being completed if charting was only to be documented every 2 hours, the DON stated the documentation every two hours is the Certified Nursing Assistant's way of stating they had completed the 15-minute checks during that 2-hour time span. The DON explained the multiple exact times documented were due to staff charting at the end of their shifts and staff do not remember to change the time. When asked how the facility could determine 15-minute checks were being completed or if they were effective when staff are charting at the end of their shift, or only being required to chart in 2-hour increments, the DON did not provide an answer.

Based on observation, interview, and record review, the facility failed to: (1) Ensure proper hand sanitizing during hall tray pass; (2) Ensure donning of proper personal protective equipment (PPE) in droplet precaution resident rooms and; (3) Ensure disinfection of an insulin pen prior to returning it to the medication storage cart during a facility influenza outbreak, (4) Ensure infection control practice was maintained for respiratory equipment, (5) Ensure opened containers of distilled water were dated for proper identification of expiration and discarding. These deficient practices resulted in the potential for transmission of infections and further spread of an influenza outbreak to all 36 facility residents and staff. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including: chronic obstructive pulmonary disease, and sleep apnea. R1 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. On 2/9/25 at 10:10 AM, R1 was observed in her room, lying in her bed resting, with a C-pap [continuous positive airway pressure] machine (a device for delivering oxygen during sleeping), and a gallon of distilled water that was opened on top of her nightstand undated. R1 also had oxygen tubing hanging off the back of her wheelchair without a protective covering. On 2/10/25 at 8:50 AM, an observation was made of R1 in her room lying in her bed resting and the gallon of distilled water remained undated on top of her nightstand. On 2/11/25 at 11:20 AM, an observation was made of R1 in her room lying in her bed resting and the gallon of distilled water remained undated on top of her nightstand. Resident #28 (R28) Review of R28's MDS assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including: chronic obstructive pulmonary disease, sleep apnea, diabetes mellitus, and hypertension. R28 scored a 15 of 15 on the BIMS assessment reflective of intact cognition. On 2/9/25 at 10:36 AM, R28's room was observed with a C-pap mask and machine located on top of his bedside dresser with tubing coiled up around the machine. The C-pap mask was not bagged and was sitting behind the machine. The mask surface designed to make contact with the resident's face was resting on the bedside dresser surface. R28's room also had an assembled nebulizer with oxygen tubing and a mouthpiece that was hanging off a second bedside dresser drawer handle. There was visible condensation observed inside the medication chamber and the nebulizer oxygen tubing was touching the floor. R28 had a bag hanging off the second dresser and in the bag was approximately 5 vials of used nebulizer solution. On 2/10/25 at 8:45 AM, R28 was observed resting in his bed with his c-pap on. R28's wheelchair was observed with oxygen tubing coiled up and not in a bag and the nasal cannula tips in contact with the wheelchair seat. R28's nebulizer remained hanging off the second bedside dresser drawer handle, assembled with condensation observed in the medication chamber. On 2/10/25 at 12:40 PM, meal tray pass on the 300-hall was observed. Certified Nurse Aide (CNA) J was observed entering room [ROOM NUMBER] to deliver a food tray. CNA J did not use hand hygiene after setting up the meal tray for an unidentified resident and exiting the room. CNA J returned to the food cart to retrieve salt and pepper and returned to room [ROOM NUMBER] to deliver the salt and pepper without performing hand hygiene. CNA J proceeded to get a second meal tray for room [ROOM NUMBER] off the food cart. CNA J delivered Resident #17 their tray and assisted by opening ketchup packets and exited the room without performing hand hygiene. On 2/10/25 at 12:50 PM, an interviewed was conducted with CNA J who was asked if she performed hand hygiene in between rooms [ROOM NUMBERS] and replied, I don't recall. I probably did not. I'm sorry. The facility was noted to be in an influenza outbreak during the time of the observations. On 2/11/25 at 10:00 AM, an interview was conducted with the Director of Nursing (DON) regarding the origin of the influenza outbreak. The DON replied, We had one CNA call in this past Sunday [2/9/25] with a cough who tested positive for influenza and then we sent out a resident on the 100-hall Sunday [2/9/25] whom we received information that they were positive for influenza. We began testing throughout the facility and then had two other residents down the 100-hall test positive for influenza. Today we added another resident down the 300-hall with influenza. 49397 On 2/11/25 at 8:10 AM, medication pass was observed with Registered Nurse (RN) F who entered room [ROOM NUMBER] under droplet precautions for Influenza A, wearing only a surgical mask. RN F administered insulin via pen injector, left room [ROOM NUMBER] and placed the insulin pen in the medication cart without cleaning the insulin pen, where it came into contact with insulin pens for other residents. On 2/11/25 at 8:25 AM, RN F was observed entering room [ROOM NUMBER] under droplet precautions for Influenza A, while only wearing a surgical mask and no eye protection. According to the Center for Disease Control (CDC) and Prevention's droplet precaution signage, everyone must Make sure their eyes, nose, and mouth are fully covered before room entry. The Center for Medicare & Medicaid Services require's insulin pens should be stored in a sanitary manner to prevent cross-contamination. A review of the CDC 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Last update: September 2024, located at https://www.cdc.gov/infection-control/media/pdfs/Guideline-Isolation-H.pdf, accessed on 2/21/25, revealed the following: I.B.3.a.ii. Indirect contact transmission. Indirect transmission involves the transfer of an infectious agent through a contaminated intermediate object or person. In the absence of a point-source outbreak, it is difficult to determine how indirect transmission occurs. However, extensive evidence cited in the Guideline for Hand Hygiene in Health Care Settings suggests that the contaminated hands of healthcare personnel are important contributors to indirect contact transmission 16. Examples of opportunities for indirect contact transmission include: Hands of healthcare personnel may transmit pathogens after touching an infected or colonized body site on one patient or a contaminated inanimate object, if hand hygiene is not performed before touching another patient.72, 73. Patient-care devices (e.g., electronic thermometers, glucose monitoring devices) may transmit pathogens if devices contaminated with blood or body fluids are shared between patients without cleaning and disinfecting between patients 74 75-77. (This would include single use patient care devices stored in the same area and that come into contact with patient care devices used for other residents. i.e. insulin pens are stored in the same area and come into contact with each other.) . Instruments that are inadequately cleaned between patients before disinfection or sterilization (e.g., endoscopes or surgical instruments)81-85 or that have manufacturing defects that interfere with the effectiveness of reprocessing 86, 87 may transmit bacterial and viral pathogens. . I.B.3.b. Droplet transmission. Droplet transmission is, technically, a form of contact transmission, and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. 49302 Resident #21 (R21) On 2/10/25 at 11:01 AM, signage was observed posted on R21's private door which read: DROPLET PRECAUTIONS. EVERYONE MUST: clean their hands, including before entering and when leaving the room. Make sure their eyes, nose and mouth are fully covered before room entry. Remove face protection before room exit. Review of R21's EMR revealed the following order: Droplet precautions r/t [related to] cough s/s [signs/symptoms] respiratory illness. On 2/10/25 at 12:52 PM, CNA G was observed delivering R21's lunch tray without eye protection. Upon exiting R21's room, CNA G did not change their surgical mask and continued delivering lunch trays on the unit, including residents without signs and symptoms of respiratory illness. On 2/11/25 at 11:43 AM, Housekeeper H was observed entering R21's room without eye protection. On 2/11/25 at 12:55 PM, CNA G was observed removing R21's lunch tray from the mobile meal cart and setting it on top of a storage bin filled with personal protective equipment (PPE) outside R21's room. CNA G donned a gown and gloves but entered the room without eye protection. On 2/11/25 at 12:57 PM, an interview was conducted with CNA G who confirmed R21 was on droplet precautions because they tested positive for influenza. When asked about the PPE requirements for droplet precaution rooms, CNA G stated, I have to put a gown and gloves on. When I leave the room, I have to take everything off, put it in the trash, and get a new mask. When asked if eye protection was a requirement in droplet precaution rooms, CNA G examined the signage posted on R21's door and stated, It looks like I should have had a [face] shield or goggles on. I didn't realize that . On 2/11/25 at 2:22 PM, an interview regarding facility infection control expectations was conducted with the DON who also served as the facility Infection Preventionist (IP). The DON confirmed residents with influenza are on droplet precautions and the signage posted on the door indicated eye protection is a PPE requirement upon entry. The DON indicated hand hygiene was expected to be performed between patient rooms and before/between handling meal trays. When asked about respiratory equipment expectations, the DON stated all equipment should be stored in protective bags when not in use and distilled water should be dated when opened. The DON verified nebulizers should be disassembled and cleaned between uses. Review of the facility policy titled, Standard and Transmission-Based Precautions, revised 2/25, read, in part: It is our policy to take appropriate precautions, including isolation, to prevent transmission of infectious agents. This policy specifies the different types of precautions, including when and how isolation should be used for a resident.The facility will use standard approaches, as defined by the CDC, for transmission-based precautions: airborne, contact, and droplet precautions. The category of transmission-based precautions will determine the type of personal protective equipment (PPE) to be used . Intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions (i.e. respiratory droplets that are generated by a resident who is coughing, sneezing, or talking) . Review of the facility policy titled, Nebulizer Therapy, revised 6/23, read, in part: .Care of Equipment: Disassemble parts after every treatment .store dry nebulizers [in] mesh bags, clear plastic bag or proper clean storage per the facility's preference . Review of the facility policy titled, BIPAP-CPAP (positive pressure breathing devices), revised 6/23, read, in part: Store mask or nasal pillows in mesh bag or other approved storage container approved by the facility when not in use . Review of the facility policy titled, Oxygen Administration and Concentrator Policy, revised 6/24, read, in part: .infection control measures include: keep delivery devices stored in a sanitary manner . Review of the facility policy titled, Hand Hygiene, revised 1/24, read, in part: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .Staff will perform hand hygiene when indicated, using proper technique consistent with accepted standards of practice .

Based on observation, interview, and record review, the facility failed to assess and monitor a resident's urostomy for complications, skin integrity, and proper function for one Resident (#238) of one resident reviewed for bowel and bladder. Findings include: Resident #238 (R238) A review of medical records indicated R238 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, history of malignant neoplasm of bladder, acquired absence of other parts of urinary tract, and chronic kidney disease stage 3. On 2/9/25 at 1:54 PM, R238 was interviewed and indicated they had a urostomy (a surgical procedure that creates an opening [stoma] in the abdomen to divert urine from the kidneys directly into a bag on the outside of the body) and was currently being treated for a urinary tract infection (UTI). R238 stated the urostomy had been present for about three years and they were accustomed to caring for it themselves. R238 stated facility staff had asked R238 to alert the facility if there were any changes noted to the urine or urostomy. R238 could not remember if the staff had ever assessed the urostomy upon admission or thereafter. R238 orders read in part: Follow-up with established nephrologist for dx (diagnosis): Chronic kidney disease, stage 3. Change Urostomy pouch and wafer (Size: 25 mm(millimeter)) twice weekly after showers and PRN (as needed) every night shift every Wed(Wednesday), Sun(Sunday) for urostomy cares AND as needed for if loose or soiled. Urostomy care q (every) shift every shift for urostomy care. Cipro oral tablet 500 Mg (Milligram) (Ciprofloxacin HCl antibiotic) Give 1 tablet by mouth two times a day for UTI for 20 Administrations which culture and sensitivity indicated UTI is susceptible. On 2/10/25 at 11:40 AM, R238 stated the facility had not performed their urostomy care since being admitted . On 2/10/25 at 1:08 PM, an interview was conducted with Registered Nurse (RN) D regarding urostomy care charting for R238. RN D stated that when they charted the urostomy care q shift that the resident does the urostomy care. RN D stated they checked to see if R238 had any issues, but RN D indicated they did not assess the urostomy themselves, before charting the urostomy care for 2/10/25 on the day shift. On 2/10/25 at 1:19 PM, while describing their urostomy care during a follow up interview, R238 stated they do not wash their hands prior to urostomy care self-performance. While conducting an interview on 2/10/25 at 1:52 PM, the Director of Nursing (DON) stated they do not have a policy for a urostomy. The DON stated if an order for urostomy care was in the chart it would be expected that the nurse evaluates the fit, color and amount of the urine, or any irritation at the site. R238's care plan dated 2/4/25, read in part: I have a urostomy r/t (related to) bladder cancer s/p (status post) cystectomy Change Urostomy pouch and wafer (Size: 25 mm Pouch Precut with 1 flex) twice weekly and PRN. Monitor for s/sx (signs/symptoms) of discomfort on urination and frequency. Record/report to MD (Doctor of Medicine) for s/sx UTI: pain, burning, no output, increased pulse, increased temp, urinary frequency, fever, chills, altered mental status, change in behavior, change in eating patterns. Urostomy output and care - Notify nurse if output is less than 250 cc (cubic centimeters) in 8 hours. Toilet use x 1 assist with toileting and urostomy care. I will perform my own urostomy care. Please assure I have adequate supplies available as I need. During a follow up interview with the DON on 2/11/25 at 10:30 AM, when asked if the facility had assessed R238's ability to care for the urostomy prior to care planning and that R238 would care for their own urostomy, the DON stated No. The DON was unaware R238 had admitted to not washing his hands prior to urostomy care. The DON acknowledged the facility should assess and educate R238, since R238 was admitted to the facility with a UTI, and was not washing his hands prior to urostomy care.

Based on observation, interview, and record review, the facility failed to appropriately store topical treatment medication for one Resident (#1) of twelve residents reviewed for medication storage. Findings include: Resident #1 (R1) Review of R1's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including obesity. R1 scored a 15 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. On 2/9/25 at 10:10 AM, R1 was observed in her room, lying in bed. R1 had a tube of Nystatin (an antifungal or anti-yeast cream) 100,000 units per 30 grams sitting on her nightstand. The topical cream order for application was completed two days ago according to the physician's order below. Review of R1's physician order, dated 12/1/24, read, Nystatin External Cream 100,000 units/gram, apply to vaginal folds topically every shift starting on the 1st and ending on the 7th every month for preventative skin care and candidiasis [fungal/yeast infection] prophylaxis. On 2/11/25 at 11:20 AM, R1 was observed in her room, lying in her bed resting. R1 had a tube of Nystatin cream 100,000 units per 30 grams sitting on her nightstand next to the left side of her bed. The topical cream order for application was completed four days ago according to the physician's order above. When asked about the cream, R1 replied, Sometimes when the nurses are busy the aides put the cream on me. On 2/11/25 at 11:40 AM, an interview was conducted with the Nursing Home Administrator (NHA) who was asked if treatment creams should be left at the bedside, if Certified Nurse Aides (CNAs) were able to administer treatments, and if R1 had a self-administration of medications assessment. The NHA replied, No, treatment creams are stored in the treatment carts, CNAs are not to administer treatments, and R1 does not have a self-administer medications safety assessment. Review of R1's physician orders, assessments, and care plan, had no interventions, orders, or assessment for self-administration of medications.

Based on observation, interview, and record review, the facility failed to provide dining adaptive equipment for one Resident (#17) of three residents reviewed for dining assistive devices. Findings include: Resident #17 (R17) Review of R17's Minimum Data Set (MDS) assessment dated [DATE], revealed admission to the facility on [DATE], with diagnoses including ataxia (impaired coordination). R17 scored a 13 of 15 on the Brief Interview of Mental Status (BIMS) assessment reflective of intact cognition. On 2/9/25 at 1:02 PM, R17 was observed in his room, lying in his bed when his lunch tray was delivered. R17 sat upright in his bed and looked at his lunch meal. R17's meal tray and ticket were reviewed, and it was identified R17 did not get his adaptive equipment of built-up utensil handles on silverware. R17 was asked how often he does not receive the adaptive equipment and replied, It happens quite frequently. It seems like every other day. On 2/11/25 at 8:45 AM, R17's breakfast tray was observed in his room. R17 had one single red tube-like foam device laying on his tray which was not attached to any of the three pieces of silverware on R17's meal tray. On 2/11/25 at 12:50 PM, R17 was observed in his room, sitting on the side of his bed getting ready to eat his lunch. R17 received no built-up silverware as directed on the meal tray card and ticket. A single red tube-like foam device was observed laying on his tray and not attached to any of the three pieces of silverware on R17's meal tray. R17 was asked if he was able to place the single red tube-like foam device on any of the silverware and replied, I have a hard time gripping smaller things. I prefer the built-up silverware. Review of R17's Kardex, date printed 2/9/25, read in part, .Eating/Nutrition - Built up tubing on silverware for improved grip with self-feeding . Review of R17's care plan, dated 7/29/24, read in part, .Focus: I have an ADL (activities of daily living) Self Care Performance Deficit related to generalized weakness, right-sided hemiplegia (muscle weakness or partial paralysis on one side of the body) .Goal: To minimize decline in my current level of function in my ADLs through the review date .Interventions/Tasks .Eating: Set-up and offer assist as needed .Focus: I have the potential for a nutritional/hydration problem .Goal: My nutrition goal, while I am here, is to maintain my nutritional health and weight .Interventions/Tasks: Built up tubing on silverware for improved grip with self-feeding . On 2/10/25 at 1:45 PM, an interview was conducted with Registered Dietician (RD) I regarding R17's adaptive equipment requirements. RD I stated, R17 is supposed to have built-up silverware with every meal that should be applied to the silverware (by facility staff). I will ensure he receives the correct adaptive equipment on his tray and talk with the dietary staff. On 2/10/25 at 2:00 PM, the Nursing Home Administrator (NHA) was asked to provide a policy regarding adaptive equipment and again on 2/11/25 at 9:15 AM and no policy was provided prior to the exit of the survey.

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This deficient practice has the potential to result in a food borne illness among any and all 38 residents. Findings include: On 3/11/24 at approximately 11:55 AM, Cook C was observed to be preparing food for the noon meal. Cook C removed his gloves, lifted the lid to the 35 gallon garbage can, disposed of the gloves, removed two clean gloves from a box of gloves on the food serving line, and returned to prepare additional food. An interview with Cook C at this time who acknowledged that he didn't think to wash his hands prior to donning the clean gloves after contamination from the lid of the garbage can. The FDA Food Code 2017 states: 2-301.14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (E) After handling soiled EQUIPMENT or UTENSILS; P (F) During FOOD preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; P (I) After engaging in other activities that contaminate the hands. On 3/11/24 at approximately 10:15 AM, during the initial tour of the kitchen, a juice dispensing machine was observed on the counter in the kitchen. The machine had a direct connection with the potable water supply via a 3/8 flexible water line, plumbed from a 1/2 supply line located below the counter. No back flow prevention device was observed on the water line between the supply and the machine. At this time, an interview was conducted with Kitchen Manager (KM) A and learned the machine was installed by a food vendor with the facility leasing the machine. On the rear of the machine, near the water supply connection, a label informed the installer that proper back flow protection devices were required. At approximately 3:15 PM that same day, an interview was conducted with KM A who stated she had contacted the vendor with the information concerning the absent back flow prevention device. KM A stated the vendor informed A that it wasn't their (vendor's) responsibility to install the back flow prevention device. The FDA Food Code 2017 states: 5-202.14 Backflow Prevention Device, Design Standard. A backflow or backsiphonage prevention device installed on a water supply system shall meet American Society of Sanitary Engineering (A.S.S.E.) standards for construction, installation, maintenance, inspection, and testing for that specific application and type of device. P On 3/11/24 at approximately 10:15 AM, during the initial tour of the kitchen, an area of wall, near the dish washing area was observed to be poor condition, as evidenced by the absence of a cleanable material. It was observed that fiberglass reinforced plastic (FRP) panels were present throughout the area, with this localized area missing the panels. The floor in the same area, measuring approximately 2' x 2' was observed to have loose tiles and was depressed below the elevation of the surrounding floor. An interview with KM A at this time revealed that this condition of the wall and floor had occurred a few months ago due to a water leak in the housekeeping closet behind the wall and an obstruction in the sanitary sewer line below the floor. On 3/12/24 at approximately 10:45 AM, an interview was conducted with Maintenance Supervisor (MS) B who verified the condition and the time frame of a few months since the damage had occurred. MS B stated What is that material on the wall? referring to the FRP. When explained to MS B, he stated he would try and order it as soon as possible. The FDA Food Code 2017 states: 6-501.11 Repairing. PHYSICAL FACILITIES shall be maintained in good repair.

Based on observation and interview, the facility failed to maintain personal privacy for four Residents (R9, R11, R24, and R31) of 12 residents reviewed for privacy. This deficient practice resulted in the potential to cause feelings of embarrassment and humiliation. Findings include: Resident #31 (R31) Review of R31's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including dementia, mood disorder, depression, and urinary incontinence. Review of 31's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicative of moderate cognitive impairment. On 3/11/24 at 12:37 PM, an observation was conducted with R31 in her room. In R31's room on her nightstand was a small white in color device with a lens facing towards the wall. This surveyor viewed it as a device to face time family members during a voice call and to be able to view her. R31 was asked what it was and replied, Oh. That needs to be turned and pointed at me. R31 did not elaborate on the device and to what it was for. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. There was no signage posted on R31's door to indicate a camera was in use within the room. On 3/13/24 at 12:15 PM, an interview was conducted with R31 in her room and was asked about the device specifically and replied, It is from the hospital. They can see me. It has been here ever since I got here, and I don't know why. R31 was asked where she currently was and replied, In Roscommon at the nursing facility. Review of R31's care plan, dated 10/26/23, read in part, .I am at risk for accidents, injuries, and falls related to dementia .Interventions: Remote video monitor in my room for closer staff observation to allow for increased response to safety concerns and/or need for assistance . Review of R31's physician orders and scanned documents, revealed the lack of an order for remote video monitoring and lacked written family consent. Resident #24 (R24) Review of R24's EMR revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, depression, and alcohol dependence with alcohol induced persisting dementia. Review of R24's most recent MDS assessment dated [DATE] revealed a BIMS score of 11, indicative of moderate cognitive impairment. On 3/11/24 at 1:27 PM, an observation was made of R24 entering his room. While R24 was in his room an interview was conducted and during the interview he was observed to have the same device as R31 in his room on top of his nightstand. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. R24 was without concerns or complaints at that time. No signage which indicated a camera was in use was observed posted on R24's door. On 3/13/24 at 1:30 PM, an interview was conducted with R24 in his room and was asked about the device that was on his nightstand and replied, I am not sure how long it has been there. I do not know what it is for. R24 was then asked if he was aware, it was a visual and audio monitor and replied, I am not sure. Review of R24's care plan, dated 10/3/23, read in part, I have potential for altered mood state related to potential causes of: fatigue, discomfort, hunger/thirst, boredom, confusion .Interventions: Provide support/reassurance .Redirect from exit doors if demonstrating exit seeking behavior. Remote video monitor in my room for closer staff observation to allow for increased response to safety concerns and/or need for assistance. Date Initiated: 10/3/23 . Review of R24's physician orders and scanned documents, revealed the lack of an order for remote video monitoring by physician and lacked written family consent. Resident #11 (R11) Review of R11's EMR revealed initial admission to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, hypertension, depression, and alcohol dependence with alcohol induced persisting dementia. Review of R11's most recent MDS assessment dated [DATE] revealed a BIMS score of 00, indicative of severe cognitive impairment. On 3/11/24 at approximately 12:45 PM, an observation was made of R11 in her room and lying in her bed. R11 had a device just like R31 and R24 located in her room. R11's device was sitting on her sink counter pointing at her bed. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. R11 was unable to be interviewed regarding the device. No signage which indicated a camera was in use was observed posted on R11's door. On 3/13/24 at 12:23 PM, a review of R11's EMR was made. R11's care plan read in part, .[Resident's name] is at risk for accidents/falls/injuries related to Dementia, forgetful .Remote video monitor in my room for closer staff observation to allow for increased response to safety concerns and/or need for assistance. Date Initiated: 03/31/2023 .Staff to perform 15-minute visual safety checks. Date Initiated: 11/12/23 . Review of R11's progress note, dated 3/31/23, read in part, IDT Review Note .New intervention of a remote video monitor in room for closer staff observation to allow for increased response to safety concerns and/or need for assistance was recommended . On 3/12/24 at 11:35 AM, all three Residents (R31, R24, and R11) were observed on the video monitor screen which was unattended at the nurses' station in a high trafficked area, centrally located in the facility. There was no gate between the two open ends near the 100 and 200 halls for entering and exiting the area. On 3/12/24 at 2:30 PM, a request for a policy regarding the remote video monitoring was made to the Nursing Home Administrator (NHA). On 3/13/24 at 1:00 PM, the NHA confirmed that the facility does not have a policy for the remote video monitors/monitoring. The NHA stated that she felt the devices should be reassessed quarterly and/or with a change in condition. The NHA was unsure if reassessment was being completed and deferred to the Director of Nursing (DON). On 3/13/24 at 1:20 PM, an interview was conducted with the DON and was asked to provide documentation of family written consent for the four monitors and replied, I do not have any. The DON was asked about dignity and privacy and replied, Both are a risk to the residents. 49302 Resident #9 (R9): Review of R9's Electronic Medical Record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including congestive heart failure, bipolar disorder, panic disorder, and cognitive communication deficit. Review of R9's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 9, indicative of moderate cognitive impairment. On 3/12/24 at 9:30AM, R9 was observed sleeping in bed in his private room. A white [Brand Name] camera was observed on the bedside dresser, aimed at R9. A green light was observed next to the camera power switch reading, ON, indicating the unit was in use. On 3/12/24 at 9:32AM, R9 was observed on a [Brand Name] video monitor screen which was unattended at the nurse's station in a high traffick, central location within the facility. A review of a Nursing Progress note dated 1/25/24 at 9:01AM, read in part: .Remote video monitor placed in [R9's] room upon return from ED (emergency department) last night for closer staff supervision for safety d/t (due to) continued confusion and attempts to self transfer . On 3/12/24 at 1:16PM, an interview was conducted with R9 who was seated in his wheelchair facing the bedside table with the [Brand Name] camera facing him. R9 was unable to identify the camera or its purpose. R9 indicated no facility staff had explained what the device was or its purpose. When R9 was informed of the camera's video and audio features, he asked, So, they've [facility staff] been listening to me when I'm talking to myself, and I don't even know it? No signage which indicated a camera was in use was observed posted on R9's door. No orders or written consent for use of a video and/or audio monitoring system was located in R9's EMR. On 3/13/24 at 1:01PM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA verified the camera system was capable of both audio and video monitoring. When asked the purpose of the monitoring system the NHA stated, it's helpful for the staff to have video monitoring .if a resident gets up or down a lot, it helps keep extra eyes on them. The NHA was asked if the residents had knowledge of the devices in their rooms to which she replied, I don't know. The NHA was unsure if residents required a physician's order, or a consent for care planned intervention for use of the monitors. On 3/13/24 at 1:19PM, an interview was conducted with the Director of Nursing (DON) who estimated the first video monitor was implemented approximately a year ago. The DON verified there was no documentation of consent from a resident and/or resident representative, but the facility had recently acknowledged privacy and dignity concerns. The DON stated that in addition to viewing the monitors at the nurse's station, some night staff elect to carry the monitors on their medication carts to allow increased supervision. When questioned if unauthorized individuals (visitors, vendors, or other residents) could view the monitor at either the nurse's station or the medication cart, the DON said, Yes, that could easily happen. Review of [Brand Name] Full Color Pan and Tilt Video Monitor read, in part: IMPORTANT SAFETY INSTRUCTIONS . .This product is intended as an aid. It is not a substitute for responsible and proper adult supervision and should not be used as such . .This product is not intended for use as a medical monitor . Review of facility policy titled, Abuse, Neglect, and Exploitation, revised 6/22 read, in part: .Possible indicators of abuse include, but are not limited to: .evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the residents cognitive status . Review of the Michigan Penal Code, Act 328 of 1931 read, in part: 750.539d. Installation, placement, or use of device for observing, recording, transmitting, photographing or eavesdropping in private place. Sec. 539d. (1) Except as otherwise provided in this section, a person shall not do either of the following: (a) Install, place, or use in any private place, without the consent of the person or persons entitled to privacy in that place, any device for observing, recording, transmitting, photographing, or eavesdropping upon the sounds or events in that place .

Based on observation, interview, and record review, the facility failed to ensure a secured/locked medication cart and maintain clean and sanitary medication carts for two of two medication carts reviewed for medication storage and one of one medication rooms. This deficient practice had the potential for medications to be misappropriated, medication loss, and contamination. Findings include: On 3/12/24 at 8:20 AM, and inspection was conducted in the medication storage room and was found to have lorazepam [a scheduled IV medication] 2 mg (milligram) vials approximately three stored in the refrigerator in a plastic clear box with labeling on the outside and secured with a single plastic serial numbered device. The medication storage room refrigerator did not have a key lock on the outside of the door or key looking device affixed to the inside of the refrigerator so the lorazepam was easily accessible and removable to anyone that entered the medication storage room door. On 3/12/24 at 10:15 AM, an inspection was conducted of the medication cart for 100 hall and was found to have one loose pill tab of mirtazapine 15 mg (milligrams). Registered Nurse (RN) F verified and confirmed no loose pills should be in the cart. On 3/12/24 at 10:20 AM, an inspection was conducted of the medication cart for 300 hall and was found to have one loose pill 1/2 tab of carbidopa - levodopa 25 - 100 mg. Licensed Practical Nurse (LPN) G verified and confirmed that no loose pills should be left in the cart. On 3/12/24 at 10:25 AM, both RN F and LPN G were requested to go into the medication storage room, and both were asked about how controlled substance were to be locked and both responded, Double locked. Both RN F and LPN G were asked about the controlled substance in the refrigerator medication storage room both replied, We recently change pharmacy groups, and we were given a box and told to store it this way. We used to keep in in a locked key box. Yeah, I guess we need to change that. On 3/12/24 at approximately 12:30 PM, and interview was conducted with the Director of Nursing (DON) who was asked about the storage for controlled substances in the medication storage room and replied, Well it has a lock on it. The DON was asked if the same type of lock would be acceptable on the medication carts in the hall for the controlled substance medication box and replied, Well. No. We changed pharmacies within the last year, and we mentioned that, and they told us we could buy a new box or lock and we just never did. I guess we better get a lock or a box that will work to store the medication safely. The DON was asked about loose medications in the medication carts and replied, No. There should not be. They should be discarded. Review of policy titled, LTC [long term care] Facility's Pharmacy Services and Procedures Manual, dated 1/1/22, read in part, .Dispose of unused medication portions in accordance with Facility policy .Controlled Substances Storage: Facility should ensure that Schedule II-V controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility .Controlled Substances stored in the refrigerator must be in a separate container and double locked .

Based on observation, interview, and record review, the facility failed to store oxygen supplies per standards of practice and administer oxygen services per physician orders for one Resident (#30) of two residents reviewed for oxygen services. This deficient practice resulted in the potential for respiratory infection and hypoxia (below-normal level of blood oxygen) resulting in respiratory and/or medical decline. Findings include: Resident #30 (R30): During an initial tour of the facility on 3/11/24 at 10:50 AM, a CPAP (continuous positive airway pressure) machine was observed on R30's bedside nightstand. The CPAP hosing and facemask were in direct contact with the nightstand with no protective covering. On 3/11/24 at 10:51 AM, an interview was conducted with R30. R30 reported he had a concern regarding a connection piece on his CPAP machine because it had been damaged and was no longer functioning. Review of R30's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including obstructive sleep apnea (a disorder in which a person frequently stops breathing during sleep) and congestive heart failure. Review of R30's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. Review of R30's plan of care revealed the following focus: I have altered respiratory status r/t (related to) obstructive sleep apnea, CHF (congestive heart failure), morbid obesity, initiated 8/25/2022. An intervention initiated 8/25/2022 read, C-PAP at HS (at bedtime) with 2L (liters) O2 (oxygen)- Prior to each night: wipe mask with damp cloth adn (sic) rinse the humidifier and refill with sterile water. Observations on 3/12/24 at 2:22 PM and 3/13/24 at 10:09 were made of R30's CPAP hosing and facemask in direct contact with the nightstand with no protective covering. On 3/13/24 at 11:54 AM, during a follow-up interview, R30 reported the connection piece for oxygen tubing into the CPAP machine had been broken for approximately one week. R30 then pointed out he was not receiving supplemental oxygen per orders. R30 stated he reported the damaged piece to the facility but had not heard back regarding a replacement. R30 stated, It's probably important to have that [CPAP] fixed. On 3/13/24 at 12:21 PM, an interview was conducted with the Director of Nursing (DON) who confirmed R30's order for a CPAP with 2 liters of supplemental oxygen at bedtime. The DON was unaware about the broken connection piece stating, nobody communicated that to me. Review of facility policy titled BIPAP-CPAP reviewed 6/23 read, in part: .oxygen flow should be set according to sleep study results or most recent settings from the referring facility. Oxygen is bled into CPAP/BIPAP machines via oxygen concentrators or other oxygen delivery systems . .Store mask or nasal pillows in mesh bag or other approved storage container approved by the facility when not in use .

Based on observation, interview, and record review, the facility failed to ensure: a) Staff donned appropriate personal protective equipment (PPE) for one (Resident #8) of five residents reviewed for Enhanced Barrier Precautions (EBP). b) Catheter care was performed in accordance with acceptable standards of practice for one (Resident #30) of one residents reviewed for urinary catheters. These deficient practices resulted in the potential for the development and transmission of communicable disease and infections. Findings Include: Resident #8 (R8): Review of R8's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including a non-pressure chronic ulcer of the left ankle, acquired absence of the right leg below the knee, and history of infectious and parasitic diseases. Review of R8's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicative of intact cognition. During an initial tour of the facility on 3/11/24 at 10:38AM, a sign was observed on the door of R8's room titled, Enhanced Barrier Precautions. The signage indicated: Everyone Must: Clean their hands, before entering and when leaving the room . .Providers and staff must also: Wear gloves and a gown for the following High-Contact Resident Care Activities: -Dressing -Bathing/Showering -Transferring -Changing Linens -Providing Hygiene -Changing briefs or assisting with toileting -Device care or use: central line, urinary catheter, feeding tube, tracheostomy -Wound Care: any skin opening requiring a dressing. On 3/11/24 at 10:38AM, an interview was conducted with R8 who verified she had an open wound on her left ankle. R8 stated that floor staff generally did not wear a gown when assisting her with personal cares. On 3/11/24 at 11:06AM, Certified Nursing Assistant (CNA) E was observed entering R8's without a gown or gloves. CNA E exited the room approximately 10 minutes later carrying soiled containments in a clear plastic bag. On 3/11/24 at approximately 11:16AM, an interview was conducted with CNA E. CNA E verified that R8 was on EBP. When asked the PPE expectations for EBP, CNA E stated, to wear gloves. After CNA E reviewed the signage posted on R8's door she stated, it looks like I was supposed to gown up. I didn't know that. Review of a Consultation Report with an Infectious Disease specialist on 12/18/23 read, in part: .she [R8] grew GBS [gram B Streptococcus] on 11/17 .she [R8] is certainly at risk for infection with size of open wound . Review of R8's EMR did not reveal orders for EBP. Review of facility policy titled, Enhanced Barrier Precautions revised 9/23 read, in part: .Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organisms] as well as those at increased risk of MDRO acquisition . .an order for enhanced barrier precautions will be obtained for residents with any of the following: Wounds (e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous status ulcers) and/or indwelling medical devices (e.g., central lines, hemodialysis catheters, urinary catheters, feeding tubes, tracheostomy/ventilator tubes). Resident #30 (R30): Review of R30's electronic medical record (EMR) revealed initial admission to the facility on [DATE] with diagnoses including urine retention prostatic hyperplasia (an enlargement of the prostate gland) with lower urinary tract symptoms. Review of R30's most recent Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicative of intact cognition. During initial tour of the facility on 3/11/24 at 10:50AM, a sign was observed on the door of R30's room titled, Enhanced Barrier Precautions. Review of R30's EMR did not reveal orders for EBP. On 3/12/24 at 11:12AM, R30 was observed walking with a four-wheel walker from the therapy gym to his private room (the length of two long hallways) with his urinary catheter tubing dragging on the floor. Three clinical staff recognized the tubing dragging the floor but made no attempts to secure it. On 3/12/24 at approximately 2:12PM, R30 was observed walking with a four-wheel walker in a common area with his urinary catheter tubing dragging on the floor. Review of R30's EMR revealed the following order with a start date of 10/19/23: Secure foley catheter with leg strap Q (every) shift. On 3/13/24 at 11:54AM, an interview was conducted with R30. R30 acknowledged his catheter tubing drags on the floor, quite a bit. R30 stated he has had UTIs (urinary tract infections) in the past requiring hospitalization s and had a concern regarding germs on the facility floor contaminating his catheter tubing and bag. Review of a hospitalization Admission History and Physical on 11/4/23 read, in part: Chief Complaint . In via EMS (emergency medical services) from [facility name] for fall today with no known injuries, blood in urine x3 days . Assessment/Plan . 1. Sepsis - likely secondary to urinary tract infection . Review of a hospitalization Summary on 2/11/24, read in part: .hospital course .1. Sepsis with organ dysfunction .likely secondary to urinary tract infection .patient noted to have blood clots plugging Foley catheter, like secondary to urinary tract infection . On 3/13/24 at 12:47AM, an interview was conducted with the Director of Nursing (DON). The DON confirmed that PPE expectations with EBP would be to wear both a gown and gloves during high-contact care. The DON stated she was concerned with the lack of gown donning when performing high-contact cares for vulnerable residents and re-education of the floor staff was necessary. The DON confirmed no EBP orders were placed in R8 or R30's EMR. The DON acknowledged a keeping catheter tubing off the floor is important and expected for infection prevention. Review of facility policy, Clinical Nursing Skills & Techniques 10th edition, read, in part: .Prevention of Catheter-Associated Urinary Tract Infection .secure indwelling catheters to prevent movement and pulling on the catheter .maintain a sterile, closed urinary drainage system .

Based on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety as evidenced by: 1. Failing to ensure food handling staff handled food serving utensils in a sanitary manner. 2. Failing to ensure food handling staff washed their hands after contamination. 3. Failing to remove expired food from the walk in cooler. 4. Failing to ensure the testing of the sanitizing chemical was conducted in accordance with directions. These deficient practices have the potential to result in food borne illness among any and all 35 residents of the facility. Findings include: 1. On [DATE] at approximately 12:05 PM Dietary Cook (DC) B was observed to drop a food scoop onto the floor, then reached down, picked up the scoop and placed it on the stainless steel counter where plate covers and other utensils were lying waiting to be used for the noon meal. The FDA Food Code 2017 states: ,d+[DATE].11 Equipment Food-Contact Surfaces and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be cleaned: (5) At any time during the operation when contamination may have occurred. 2. On [DATE] between 11:30 AM and 12:15 PM, observations were made in the kitchen during the preparation and service of the noon meal. Dietary Cook (DC) B was observed on four different occasions pulling the mask away from his face, touching his face, then returning to food preparation and food service. At 12:05 PM, DC B dropped a food scoop onto the floor, picked it up and failed to wash his hands before retuning to the work station to serve food. The FDA Food Code 2017 states: ,d+[DATE].14 When to Wash. FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S ,d+[DATE].12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES and: (A) After touching bare human body parts other than clean hands and clean, exposed portions of arms; 3. On [DATE] at approximately 11:15 AM, two half gallon containers of lemon juice were observed on the top shelf of the walk in refrigerator. Both containers had the expiration date of [DATE] stamped at the bottom of the plastic container. At 1:45 PM, an interview was conducted with Dietary Manager DM A, and asked about the containers of lemon juice. DM A stated the lemon juice was not used as a food product, rather, was used to clean the heated cooking surfaces in the kitchen. The FDA Food Code 2017 states: ,d+[DATE].11 Separation. POISONOUS OR TOXIC MATERIALS shall be stored so they can not contaminate FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLESERVICE and SINGLE-USE ARTICLES by: (A) Separating the POISONOUS OR TOXIC MATERIALS by spacing or partitioning; and (B) Locating the POISONOUS OR TOXIC MATERIALS in an area that is not above FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE or SINGLE-USE ARTICLES. This paragraph does not apply to EQUIPMENT and UTENSIL cleaners and SANITIZERS that are stored in WAREWASHING areas for availability and convenience if the materials are stored to prevent contamination of FOOD, EQUIPMENT, UTENSILS, LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES 4. On [DATE] at approximately 8:45 AM, DM A was requested to demonstrate that the wiping cloth buckets contained an approved concentration of sanitizer. DM A identified the sanitizer as a quaternary product, removed a strip of QT 40 test strip and held it in the solution for 5 seconds, as recorded by the second hand of a wrist watch. The result read by DM A was less than 150 PPM (parts per million). DM A was requested to conduct the test again, and held the strip in the solution for six seconds. An interview was conducted at this time with DM A and asked about the time period the strip was to be immersed into the solution. DM A responded it was to be ten seconds, which was correct pursuant to the package instructions. When told the strip was held for only five and six seconds, DM A stated I guess I count fast. The FDA Food Code 2017 states: ,d+[DATE].116 Warewashing Equipment, Determining Chemical Sanitizer Concentration. Concentration of the SANITIZING solution shall be accurately determined by using a test kit or other device.

This citation will have two components: A and B with individual deficiency practice statements. A. Based on observation, interview and record review, the facility failed to ensure proper disinfection of laundry when transmission based precaution (TBP) sourced laundry was present in the building. This included a laundry chemical which could not be demonstrated to disinfect TBP sourced linens, and a failure to implement a verification procedure to ensure proper levels of disinfectant chemicals were present during the washing process of TBP sourced linens. This deficient practice has the potential to result in transmission of TBP pathogens to all 35 residents. No TBP residents were identified in the facility. Findings include: On 4/5/23 at approximately 3:30 PM observations were made of the laundry department with Environmental Director (ED) C. It was learned the facility was not using a chlorinated bleach product to disinfect TBP sourced linens, rather, an oxygenated bleach product. An interview with ED C was conducted at this time and learned there had not been any concentration specified for an effective elimination of TBP pathogens, and the facility did not have any testing regiment to test the concentration of the product. It was further learned, by review of the container of oxygenated bleach, the active ingredient was an undefined peroxide agent. The container did not have an EPA (Environmental Protection Agency) approval number indicating its approval for TBP pathogens relative to concentration or contact time. A review of the facility policy Laundry with a date implemented 04/1720 (sic), and revised date of 12/20, Item 6 states: Laundry may be processed with hot or low-temperature processes: a. Hot water cycle: Wash with detergent in a water temperature of 160 degrees or above for at least 25 minutes. b. Low temperature cycle: wash with chemicals suitable for low temperature washing at the proper concentration. c. A 125 part-per-million (ppm) chlorine bleach rinse will be used to destroy microorganisms when applicable. ED C stated there was not a mechanism to ensure the washers held a water temperature of 160 F for 25 minutes, and did not have a process to test any chemical or know what concentration was acceptable. B. Based on interview and record review, the facility failed to develop a comprehensive Water Management Plan (WMP) to address the control and spread of Legionella bacteria in the facility water system, in accordance with QSO 17-30 Hospitals/CAHs/NH, Revised 7-6-2018. The facility failed to Develop and implement a water management program that considers the ASHRAE 188 (American Society of Heating, Refrigerating and Air-Conditioning Engineers) and the CDC (Centers for Disease Control) tool kit. The failure to develop a comprehensive Water Management Plan has the potential for the proliferation and transmission of Legionella in the circulating water of the building and the spread of Legionella infections in all 35 residents. Findings include: On 4/6/23 a review of the facility's WATER MANAGEMENT PROGRAM (dated 04/2017)(Revised Date 12/2020) document was conducted. This document were presented in its entirety as the facility's WMP for Legionella control. This document was a policy which defined the specific components of a water management plan including: creation of a water management team; conducting an annual risk assessment of the premise plumbing to identify where water born pathogens could grow and spread; creating control points and control measures which limit the growth and spread of water pathogens; testing protocols; and annual evaluation of the program's effectiveness. No specific parameters for the facility's WMP were identified. Absent from the facility's WMP documents were: 1. Identification of a water management team (WMT) comprised of current facility staff and others designated to assess and review the facility's water system for potential risks associated with water borne pathogens. 2. An assessment as to the locations of plumbing fixtures posing a risk for harborage and/or transmission of Legionella bacteria. 3. Specific Control measures at specific locations for the elimination/control of Legionella. 4. Specific measurable Critical limits within the control measures of areas within the building. 5. Defined monitoring of parameters, which were identified as control measures and their associated limits, to determine targeted interventions were present. 6. Documentation of any monitoring. 7. Review of data from defined monitoring documented to demonstrate interventions were either functional or requiring to be refined. On 4/06/23 at approximately 10:30 AM, an interview with Environmental Director (ED) C was conducted to review the WMP. ED C acknowledged the above components could not be located, no data collection had been located, and review of data to determine the efficacy of the entire Water Management program implementation had not been conducted.

Based on observation, interview and record review, the facility failed to provide a dignified experience related to toileting for one Resident (#19) of two residents reviewed for dignity. This deficient practice resulted in the potential for embarrassment and a sense of low self-worth. Findings include: An observation on 1/24/22 at 11:28 a.m., revealed Resident #19 self-propelling around his room in a wheelchair. During an interview at that time, Resident #19 reported he did not use the toilet in his bathroom instead, staff would use the lift to put him back to bed to use a bedpan when he needed it. When asked why he did not use the toilet, Resident #19 reported the lift used to transfer him did not fit in the bathroom. Resident #19 stated would rather use the toilet in the bathroom than the bed pan. An observation on 1/24/22 at 11:55 a.m., revealed Certified Nurse Aide (CNA) B and CNA C transferring Resident #19 from his wheelchair to the bed using a total mechanical lift. Further observation revealed CNA B assist Resident #19 to remove his pants and brief. CNA B then placed a bedpan with a plastic liner underneath the Resident lying in bed. CNA C provided Resident #24 with a hand held urine receptacle (urinal). After assisting Resident #19 to position the urinal, CNA C placed a blanket over Resident #19. CNA B provided Resident #19 with a call light and instructed the Resident to call when he was finished. Both CNA B and CNA C then left the room. During an interview at the time of the observation, a query was made as to why Resident #19 was transferred to the bed to use the bedpan and not transferred to the toilet in his bathroom. CNA B reported the total mechanical lift would not fit into the bathroom and the facility did not have the type of lift slings necessary for toilet use. CNA C stated Resident #19 was capable of using the toilet but the sit-to-stand lift used to transfer the Resident was out of order. CNA B stated the sit-to-stand lift had been out of operation for awhile and administration had been notified. CNA C stated the only reason Resident #19 had to use the bedpan was due to the sit-to-stand lift being out of order. A review of Resident #19's care plan revealed the following, in part: Focus: (Resident #19) has a ADL (activities of daily living) self-care performance deficit . Interventions: Toilet Use: (Resident #19) need 1 staff assist to assist him with toileting and occasional incontinence care.He uses a urinal when in bed. Date initiated: 2/9/17. Transfer: (Resident #19) needs x2 (two-person) assist with sit-to-stand lift. Date initiated: 2/9/17. During an interveiw on 1/25/22 at 12:00 p.m. Certified Occupational Therapy Assistant (COTA) G reported Resident #19's transfer status was to transfer using the sit-to-stand lift. A review of Resident #19's therapy records with COTA G revealed no record of a referral for a decline in function or evaluation for a change in transfer status for Resident #19 requiring the use of the total mechanical lift. During an interview on 1/25/22 at 2:00 p.m., the Nursing Home Administrator (NHA) reported the sit-to-stand lift had been evaluated by the durable medical equipment company on 11/29/21, after staff had reported it was not functioning correctly. The NHA reported the lift had been deemed safe and functional for use. The NHA reported the lift was older and slower than the facility's previous sit-to-stand lift but was functioning properly. The NHA reported the durable medical equipment company had education staff on the use of the lift after the evaluation on 11/29/21. During an interview on 1/26/22 at 9:45 a.m., the Director of Nursing (DON) reported she had not been aware staff were not using the sit-to-stand lift to transfer Resident #19 prior to this Surveyor's inquiry on 1/25/21. The DON reported staff had concerns the sit-to-stand lift was not functioning correctly a few weeks prior. The DON stated the durable medical equipment company had come to the facility to evaluate the sit-to-stand lift for malfunction and had found the lift was functioning properly. The DON reported the lift was slower to lower residents to a seated position than the facility's previous sit-to-stand lift but was functioning properly. When asked if she was aware Resident #19 was still being transferred to his bed to use the bedpan for toileting, the DON reported she was aware the Resident had been using the bedpan before the sit-to-stand lift was deemed to be operational. An observation with CNA F on 1/26/22 at 10:12 a.m., revealed a sit-to-stand lift positioned directly across from the doorway in the equipment storage room. Further observation revealed no service tag alerting staff the sit-to-stand lift was out of order and in need of service. In an interview at the time of the observation, CNA F stated the sit-to-stand lift was operational but staff did not like to use it due to the lift being slower than the facility's previous sit-to-stand lift. A review of the facility policy titled, Resident Rights, last reviewed 8/2021, revealed the following, in part: Policy Explanation and compliance Guidelines: 10. The facility will ensure that all staff members are educated on the rights of residents and the responsibility of the facility to properly care for its residents . Resident Rights: The resident has the right to a dignified existence, self-determination . 4. Respect and dignity: The resident has a right to be treated with respect and dignity, including: c. The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences .

This citation has two parts, A. and B.: A. Based on observation, interview and record review, the facility failed to ensure a fall prevention safety device was functioning properly for one Resident (#28) of three Residents reviewed for falls. This deficient practice resulted in the potential for falls and injury. B. Based on observation, interview and record review, the facility failed to safely perform a total lift transfer for one Resident (#130) of three residents reviewed for safety. This deficient practice resulted in the potential for falling out of the sling and the potential for injury. Findings include: A. Resident #28 On 1/25/22 at 8:09 a.m., Resident #28 was observed resting in bed. The wheelchair was noted to have an anti-rollback device attached to the wheelchair. The anti-rollback device was tested by this Surveyor. The wheelchair brakes were disengaged and the wheelchair was pushed backwards. The wheelchair moved backwards freely and the anti-rollback device failed to engage. A review of the care plan for Resident #28 .at risk for falls/accidents . read in part: .Focus . (Resident #28) is at risk for accidents/falls r/t (related to) Gait (walking)/balance problems, Hx (history): [CONDITION(S)], Unaware of safety needs, impulsive behaviors, generalized weakness, does not always wait for staff assistance, sits down abruptly in w/c (wheelchair) and on toilet seat, hx of [CONDITION(S)] (low blood pressure with position changes). Revised 10/30/20 .Interventions//Tasks . (Resident #28) has antirollbacks and antitippers on his wheelchair. Last revision 9/28/20 On 1/25/22 at 12:57 p.m., the Director of Nursing (DON) provided a fall investigation dated 10/30/21 which revealed Resident #28 was observed sitting on the floor between his bathroom and sink at approximately 11:35 a.m. Resident #28's w/c was positioned next to his bed with the seat positioned toward the head of the bed. Resident #28 stated he fell . Resident #28 self-transferred off the floor back to his bed. There was a scratch noted on Resident #28's right back. B. Resident #130 On 1/24/22 at 10:30 a.m., a total lift transfer was observed performed by Physical Therapy Assistant (PTA) I and Certified Nurse Aide (CNA) C for Resident #130. PTA I and CNA C placed the loops for the leg portion of the lift sling on different colored loops. One leg strap was placed on a green/blue colored loop and the other leg strap was placed on a purple loop. CNA C and PTA I failed to notice the loops were not on the same color and lifted Resident #130 from her bed and placed her in her wheelchair. The staff members were shown the concern of the leg straps being on different colored loops. CNA C stated she didn't realize the same-colored loops were supposed to be used all the way around the lift sling. On 1/26/22 at 11:26 a.m., during an interview, CNA F was asked to describe safe use of the lift slings and the purpose of the different colored loops. CNA F stated the arm loops should be on the same-colored loops and leg loops should be on the same-colored loops. CNA F stated this was to avoid having a resident fall out of the sling during a transfer. A review of (Brand Name) Lift Operation Manual, undated, read in part: .2. Match the corresponding colors on each side of the sling for an even lift of the patient .

Based on interview and record review the facility failed to safely transfer 1 of 2 residents (Resident #101) sampled for injury of unknown origin, from a total sample of 2 residents, resulting in a fracture of Resident #101's left tibia. Findings include: Resident #101 Review of a Face Sheet revealed Resident #101 was a [AGE] year old male, originally admitted to the facility on [DATE], with pertinent [DIAGNOSES REDACTED]. Minimum Data Set assessment, with reference date of 08/28/17, revealed Resident #101 was cognitively intact, scoring 15 out of 15 on the Brief Interview for Mental Status (BIMS). Resident #101 required total assistance from 2 staff for transfers and had severe bilateral lower extremity contractures. Review of CNA -ADL Tracking Form, dated 8/17, revealed that Resident #101 was a 2 person transfer and totally dependent on staff to move from wheelchair to bed. Review of an x-ray report from Medical Diagnostic Services, dated 08/21/17 at 11:18 P.M., revealed Resident #101 had an oblique and slightly spiral fracture of the mid and proximal shaft of the left tibia. During an interview on 10/18/17 at 2 P.M., Resident #101 stated that while being transferred from his wheelchair to his bed, on 08/21/17, two staff persons were transferring him, and his heel got caught on the bed or wheelchair. I heard my leg go snap. Resident #101 stated that he was immediately in terrible pain and yelled at staff to put down his leg. Resident #101 also stated that once staff put his left leg on the bed in a straight position, the pain got better. Resident #101 indicated that he did not feel that the staff were trying to hurt him intentionally but they were really in a rush. Review of a physician progress notes [REDACTED].#101 was seen for an oblique and slightly spiral fracture of his left tibia. Report of injury occurred when the aides were swinging patient into bed when his heel caught either the bed or wheelchair and he had instant pain. During an interview on 10/18/17 at 3:25 P.M., Assistant Director of Nursing (ADON) B indicated that she had not interviewed Resident #101 or staff after it was discovered that he (Resident #101) had a oblique spiral fracture to his left tibia. ADON B reported that she thought it was a spontaneous fracture and that I had no idea he (Resident #101) said anything about twisting his leg. ADON B also reported I can certainly see how that could happen when discussing Resident #101's heel being caught and then twisting his left leg. During an interview on 10/18/17 at 2:50 P.M., Certified Nurse Aide (CNA) F stated she did recall working the evening of 08/21/17; CNA F did not recall working with Resident #101 the evening of 08/21/17 and did not recall any specific instances when Resident # 101 had behaved in any way or said anything to her (CNA F) that would have made her believe that Resident #101 was in pain. Review of Daily Assignment Sheet, dated 08/21/17, revealed that CNA F and CNA J were scheduled to work 2nd shift on 08/21/17. During an interview on 10/19/17 at 2:10 P.M., Human Resources Director (HRD) C stated that CNA F and CNA J both worked their scheduled shifts the evening of 08/21/17. During an interview on 10/18/17 at 2:45 P.M., CNA J stated that Resident #101 had been complaining of leg pain for a good week and that she (CNA J) was told that it was nobody's fault (Resident #101's fractured leg). CNA J indicated that she did not recall anything out of the ordinary happening the evening of 08/21/17. Review of Daily Skilled Nurses's Notes, dated 08/12/17 to 08/21/17 at 1 A.M. revealed no progress notes that indicated Resident #101 was experiencing left leg pain. Review of Daily Skilled Nurse's Note dated 08/21/17 at 6:40 P.M., revealed that LPN I assessed Resident #101's leg and found area directly under knee red, painful to touch. During an interview on 10/18/17 at 3:25 P.M., Licensed Practical Nurse (LPN) I stated that on the evening of 08/21/17 the aide (CNA) came and told me that Resident #101 was having left leg pain and when LPN I assessed Resident #101, he was having more pain than usual. LPN I stated that she spoke with the physician and a left leg x-ray was ordered.

Based on observation, interview and record review the facility failed to consistently implement positioning every 2 hours, update the care plan and clarify treatment orders for pressure ulcers for 1 Resident (#6) of 2 residents reviewed for pressure ulcers from a total sample of 15 residents, resulting in preventable multiple pressure ulcers for Resident #6; 5 stage II pressure ulcers and one stage 3 pressure ulcers. Findings include: Review of Resident #6's face sheet (undated) revealed he was a [AGE] year old male admitted to the facility on [DATE] and had the following Diagnoses: [REDACTED]. Resident #6 was listed as his own responsible party. Review of Resident #6 Brief Interview of Mental Status dated 9/10/15 was 14/15 (normal cognition). On 9-22-15 at 4:30 PM, Resident #6 was observed in bed. Resident #6 said he did not know how he got the pressure ulcers and said he could not feel anything in the area where the pressure ulcers were located. Resident #6 said when the staff discovered the pressure ulcers they have encouraged him to decrease the amount of time he is up (sitting) but he is not sure how long he can remain out of bed. Review of Resident #6's weekly shower sheet dated 9/10/15 did not document any skin problems which contradicted the presence of pressure ulcers. Review of the Daily Skilled Nurse's Note for Resident #6 dated 9/11/15 at 11:00 AM did not indicate any skin problems. Note at 21:30 (9:30 PM) documented, skin issues on coccyx (no details on type, description of skin issues and any treatment of [REDACTED]. Review of the SBAR Communication Form for Resident #6 dated 9/11/15, (untimed) document, open areas on Buttocks, Scrotum. Things that make the condition or symptom worse are up in wheelchair. Things that make the condition or symptom better are turn q (every) 2 hours. Review of an Occurrence note for Resident #6 dated 9/11/15 at 21:00 (9:00 PM documented, resident note with open area on coccyx. cleansed and magic butt cream applied. educated on importance of turning Q (every) 2 hours (care plan or high risk pressure ulcers dated 6/10/14 documented Resident #6 was to be repositioned every 2 hour). Measurement for coccyx was 0 x 0 x 0 and documented as stage II. On page 3 of this document an entry for conclusion documented, Resident has 6 small open areas to buttock and scrotum. New orders to observe, cleanse and apply magic butt cream every shift. Resident is to be turned and repositioned every two hours. Resident is encouraged to lay down more often throughout the day and not to be upright in geri-chair. Air mattress functioning properly. The column for Root Cause documented, no fault. There was no size or staging of the other 5 ulcers. Review of the Pressure Ulcer Record for Resident #6 dated 9/11/15 documented Resident #6 had 6 pressure ulcers. One pressure ulcer was located on the left buttock and measured 2 cm x 1.5 cm x .3 cm and stage 3, Pressure ulcer 2 was located on the lower left buttock and measured 1 cm x 1 cm x 0.1 cm and was a stage II, Pressure ulcer 3 was located on the mid left buttock and measured 1 cm x 1 cm x 0.1 cm and was a stage II, pressure ulcer 4 was located on the right gluteal fold and measured 4 cm x 7 cm x 0.1 cm and was a stage II, Pressure ulcer 5 was located on the scrotum and measured 1.5 cm x .5 cm x 0.1 cm and was a stage II, Pressure ulcer 6 was located on the right buttock and measured 1.5 cm x 1 cm x 0.1 cm and was a stage II. All 6 pressure ulcers were measured and staged again on 9/15/15 and 9/24/15. All 6 pressure ulcer were still present and had slight decreases in size and remained the same stage. During an interview with Registered Nurse (RN) D on 9/23/15 at 11:12 AM, RN D said she did the initial and weekly wound measurements on Resident #6 and reviewed the pressure ulcer documentation she completed (see measurements and staging listed above). RN D was asked what was the root cause of Resident #6's pressure ulcers and RN D said, We do not do root cause analysis on pressure ulcers here. RN D was asked what do you think caused Resident #6's pressure ulcers and RN D said that moisture and too much time out of bed. Review of Resident #6's care plan for stages 2 and 3 pressure ulcers dated 9/11/15 did not document any interventions for reducing moisture or for a change in Resident #6 time out of bed. Resident #6's care plan for stage 2 and 3 pressure ulcers listed most of the approaches that were on the high risk for pressure ulcers care plan dated 6/10/15. RN D was asked to provide any documentation that Resident #6 had been seen by a physician or that the physician had reviewed Resident #6's pressure ulcer. There was no document to review by the end of the survey for any physician notes for Resident #6's pressure ulcer treatment. Review of Resident #6's Kardex did not indicate any amount of time or restrictions for out of bed, but documented wound dressing to buttock. However, there were no orders for any dressing to buttock wounds that could be located from the medical records. Resident #6's Kardex document he required the assistance of 2 people for bed mobility. Review of Physician Orders for Resident #6 dated 9/1/15 thru: 9/30/15 documented under treatments, Diaper: [MEDICATION NAME]: NYS CR (medicated cream) : Buttock/groin: apply topically (to skin) bid (twice a day) and prn (as need). Review of Resident #6's treatment record documented Resident #6 received Diaper; [MEDICATION NAME] NYS CR from 9/1/15 to 9/23/15 twice a day except on 9/11/15 in the AM and 9/22/15 in the PM. According to this document the staff documented that they provided treatment twice daily to the area that developed pressure ulcers. The facility did not provide any order or treatment record for the magic butt cream that was applied on Resident #6 as indicated in the Occurrence note dated 9/11/15. Review of the Guidelines For Unavoidable Wounds form for Resident #6 dated 9/11/15 documented multiple boxes on the form were checked however there was no signature in the Director of Clinical Service box and no signature in the Physician box. There was no conclusion or statement to indicate if the wounds were avoidable or unavoidable. Review of the facility policy for Unavoidable Pressure Ulcer dated, revision 6/1/15, documented, It is the policy of The Company that any resident who enters the facility without pressure ulcers does not develop pressure ulcer unless the individual's clinical condition demonstrates that they were unavoidable. (# )

Based upon observation, interview, and record review, three of five sampled resident's reviewed for antipsychotic drug use (residents # 4, 8, and 9) out of a total of fifteen sampled residents, failed to have drug regimens free from unnecessary drugs due to duplication of antipsychotic drug therapy, inadequate indication for use, inadequate monitoring of behavioral symptoms, or in the presence of adverse events which included involuntary abnormal movements and falls, resulting in the development of abnormal involuntary movements, falls, increased lethargy, and weight loss. Findings include: During the review of resident #4's medical record, his face sheet (undated) documented an admission to the facility on [DATE] with a readmission on July 12, 2015. Admission [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED]. Resident #4's [MEDICATION NAME] dosage was increased on 3/12/2015 to 150 mg by mouth twice daily, then again on April 1, 2015 to 200 mg by mouth twice daily, and then on April 20, 2015 to [MEDICATION NAME] 300 mg by mouth twice daily for increased aggressive behaviors towards staff member and other residents documented to justify these dosage increases. Resident #4's [MEDICATION NAME] dosage was decreased on May 1, 2015 and another atypical antipsychotic drug [MEDICATION NAME] ([MEDICATION NAME]) was started at a dosage of 0.5 mg by mouth twice a day. According to interdisciplinary progress notes dated May 13, 2015 the facility Behavior Management Team (BMT) reviewed resident #4's antipsychotic drug use and documented that [MEDICATION NAME] was started on 5/1/2015 since the drug works better per resident #4's spouse, with the goal to discontinue resident #4's [MEDICATION NAME]. On June 16, 2015, interdisciplinary progress notes documented that resident #4's [MEDICATION NAME] was decreased to 100 mg by mouth twice a day and his [MEDICATION NAME] was increased to 1 mg by mouth twice a day. Thus, resident #4 was being administered 200 mg of [MEDICATION NAME] daily along with 2 mg of [MEDICATION NAME]. According to hospital emergency room records dated July 8, 2015, resident #4 was admitted to the hospital with [REDACTED]. Resident #4 was observed to have fecal matter with blood clots and tested Hemoccult positive. A [DIAGNOSES REDACTED]. Hospital discharge medications dated July 12, 2015 included [MEDICATION NAME] ([MEDICATION NAME] 1 mg by mouth three times a day and [MEDICATION NAME] (Quetiapine) 300 mg by mouth twice a day which was continued by the facility upon readmission on July 12, 2015. Resident #4 was observed on September 24, 2015 at about 10:30 AM., walking up and down the locked unit hallway on his tip toes with yellow grippy socks on. He was observed at the exit doorway looking out as facility staff assisted him back into his bed. Resident #4 was observed to be hunched over, leaning forward as he walked on his tip toes, at high risk for falling. During an interview with the facility Assistant Director of Nursing (C) and Nursing Director (B) on September 25, 2015 in their office at 11:00 AM., it was unknown as to why resident #4's BMT goal as noted on May 13, 2015 was not followed through with. There was no explanation as to why resident #4's [MEDICATION NAME] and [MEDICATION NAME] dosages were increased to the present doses, and there was no clear data given to support the effectiveness of these two drugs being used together compared with just [MEDICATION NAME] being administered for resident #4's aggressive behaviors in the presence of AIMS (Abnormal Involuntary Movement) scores of 21 on July 30, 2015 which reveals extensive moderate involuntary movements which are an adverse effect of antipsychotic drugs. Thus, duplication of [MEDICATION NAME] and [MEDICATION NAME] as atypical antipsychotic agents used to prevent aggressive behaviors could not be supported either by existing published medical literature or behavior tracking tools by the facility to be any more effective than a single drug. ( ) According to the Face Sheet dated 7/23/15, Resident #8 was an [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The September 2015 Physician order [REDACTED]. Resident #8 was receiving the medication [MEDICATION NAME], 750 mg twice a day for the [MEDICAL CONDITION] disorder and the antipsychotic [MEDICATION NAME] 25 mg twice a day for dementia with behavioral disturbances. A review of the only Behavior Symptom Monitoring Flow Record showed a blank form with only the name, facility number, room number and physician for Resident #8. The areas for Behavior, Cause/Trigger, and Interventions were all blank. An interview with the Director of Nursing, B on 9/23/15 at 11:40 a.m. confirmed that there was no Care Plan for the specific targeted behaviors the [MEDICATION NAME] was supposed to be treating. She also confirmed that there was no individualized assessment of the relative risks versus benefits of the use of the antipsychotic medication which addressed the risk of use for a resident with [MEDICAL CONDITION] or addressed either specific targeted behaviors or the Federal Food and Drug Administration ' s (FDA) Black Box Warning which stated these medications (Antipsychotic medications) are not approved for the treatment of [REDACTED]. According to a progress note dated 8/13/15, Resident #8 experienced a [MEDICAL CONDITION] approximately 45 sec (seconds) - 1 min (minute) light twitching, drool, 0 resp (not responsive). The physician was notified and an order was written to check his [MEDICATION NAME] levels. There was no assessment of the possible role the antipsychotic medication he was taking could have in lowering the [MEDICAL CONDITION] threshold and making the [MEDICATION NAME] ineffective. A note written in the Interdisciplinary Progress Notes dated 9/21/15 stated res (resident) seen having twitching while in bed. [MEDICAL CONDITION] activity noted 0 (no) injuries. There was no documentation that the physician was notified of the [MEDICAL CONDITION] and again there was no assessment of the possible role the antipsychotic medication he was taking could have in lowering the [MEDICAL CONDITION] threshold and making the [MEDICATION NAME] ineffective. Additional information on the justification for use of the antipsychotic medication, monitoring of behaviors, and a risk versus benefit for the use of the antipsychotic medication was requested during the interview with the Director of Nursing, B on 9/23/15 at 11:40 a.m. but no other documentation was presented by the end of the survey. ( ) According to the Face Sheet dated 7/01/15, Resident #9 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The September 2015 Physician order [REDACTED]. A hospital transfer form dated 6/18/15 also included the [DIAGNOSES REDACTED]. There was no other mention of tardive dyskinesia in any of the physician's note, social service notes or on any Care Plan related to the use of antipsychotic medications. The Abnormal Involuntary Movement Scale completed on 6/22/15 showed 1s (minimal) movements in 9 of 10 areas and the AIMS dated 9/17/15 showed 1s in 5 of 10 areas but an interview with the Director of Nursing, B and the Assistant Director of Nursing C on 9/23/15 at 10:30 AM., confirmed that Resident #9 was probably not capable of following the directions for the completion of the AIMS test so the results would not likely be accurate. During the interview mentioned above, the Director of Nursing, B and the Assistant Director of Nursing C confirmed that there were only vague behaviors such as wander (in/out rooms), walk to point of exhaustion (never documented as happening), resistive and pushing from behind listed on the Behavior Symptom Monitoring Flow Record. They agreed that none of the above behaviors made the resident a danger to herself or others or met the criteria for delusions or hallucinations that were so distressing they impaired the resident's functioning. Resident #9 was observed in the locked dementia unit on 9/22/15 at 2:45 PM., for over a half hour and on 9/23/15 at 7:45 AM., for an hour during breakfast service. On the 22nd she spent her time sitting in the A hall Day Room on the couch. She had a very flat affect and did not respond to either this surveyor's greeting or questions or to either the nurse or activity aide on the unit when they spoke to her. The activity aide gave her two cookies on a napkin and she just looked at them and left them sitting on her lap the entire time. On 9/23/15, during breakfast, Resident #9 spent the entire hour walking in the hall. Again with a very flat affect and no response to anyone's greeting. She walked with a shuffling gait until she reached an obstacle i.e. a person, wall, medication cart etc. then would turn around and walk until she reached another obstacle. An aide gave her a biscuit and encouraged her to eat it but she just carried it at waist level and carried it up and down the hall with her the entire time. According to a progress note dated 8/22/15, Resident #9 noted at 8:00 PM., Resident on the floor in dining room facing doorway having [MEDICAL CONDITION] activity. Noted blood on right side of face. [MEDICAL CONDITION] lasted about 45 seconds when noted. Laceration R. (right) side above eye. The physician was notified and Resident #9 was sent to the emergency room for treatment. There was no documentation by either the physician or the pharmacist of the possible role the antipsychotic medication she was taking could have in lowering the [MEDICAL CONDITION] threshold and making the [MEDICATION NAME] ineffective. Additional information regarding the specific targeted behaviors, non-pharmacological interventions, and/or justification for the use of the antipsychotic medication were requested and no other documentation was presented by the end of the survey. ( )

This citation pertains to MI# 089 Based on observation, interview and record review, the facility failed to prevent physical abuse in 1 (#101) of 4 sampled residents, from a total sample of 8, resulting in facility reporting that Resident #101 was pinned down in bed (physically restrained) by Certified Nurse Assistant (CNA)"C" and being yelled (verbal abuse) at, and then spat on (physical abuse) in the face. The Administrator was notified on 5/21/14 at 2:55 PM of the immediate jeopardy that was identified on 5/20/14 at 3:00 PM. The Immediate Jeopardy began on 5/6/2014 at 9:30 PM when Resident #101, who was cognitively impaired was physically pinned in his bed by CNA "C", while she yelled at him and spat in the resident's face. The facility provided a correction plan to remove but not correct the immediate jeopardy on 5/22/2014. The deficient practice continued at a potential for more than minimal harm, isolated related to the need to validate facility staff training and monitor their correction plan through their Quality Assurance Committee. Findings include: Record review of facility 'Resident Abuse' policy dated 1/2012 revealed it was inherent in the nature and dignity of each resident at the facility that he/she be afforded basis human rights, including the right to be free from abuse, neglect, mistreatment, and/or misappropriation of property. The management of the facility recognizes these rights and hereby establishes the following statements and policies and procedures to protect these rights and to establish a disciplinary policy, which results in the fair and timely treatment of [REDACTED]. Physical Abuse- physical contact intentionally (spitting) and restraining (pinning to the bed) act of physical retaliation in response to a physical attack. Verbal Abuse- yelling. Record review of facility investigation summary dated 5/8/14 revealed that Resident #101 was admitted on [DATE] and is disoriented to person, place and time and is unable to verbalize his needs. No BIM's (Brief Interview of Mental Status) score is available related to his inability to complete BIMs assessment. Resident #101 was noted to be unable to compete any of his activities of daily living is dependent upon staff. Resident #101 was noted to have [DIAGNOSES REDACTED]. The facility noted that on 5/6/14 at approximately 9:30 PM, 2 Certified Nurse Assistants (CNA) were assisting Resident #101 with his bedtime ADL's (Activities of Daily Living) and while assisting the resident from the bathroom to the bed the resident became combative and struck out. CNA "D" witnessed CNA "C" pinning Resident #101 to the bed and yelling at the resident. Resident #101 then spit at CNA "C" and CNA "C" then retaliated by spitting back at Resident #101 in the face. The facility investigation noted that CNA "C" was interviewed and admitted to spitting in Resident #101's face. Record review of Resident #101's Minimum (MDS) data set [DATE] revealed an [AGE] year old male with cognitive/decision making skills of 3 severely impaired. The resident was independent with ambulation and resided in the secured dementia unit within the facility. Record review of Resident #101's physician orders [REDACTED]. Physician orders [REDACTED]. record review of Resident #101's 'Behavior Symptom Monitoring' log dated 1/26/14 through 5/11/14 revealed that the resident had behaviors of anxious, combative, refuse medications, throw medications, resistive and pace halls. There was no behavior of spitting noted on the behavior log. The facility provided the State surveyor with 'behavior Monitoring' policy dated 1/2014 and 'Managing Behavior Problems of Residents with Dementia' which included dealing with aggressive behaviors where noted to rarely occur without reason, aggression maybe a defensive reaction to threatening intrusions upon personal space. The policy noted that staff should not be confrontational........not to corner the confused person, as this will heighten feelings of threat and alarm....not raise their voices....not to take personal offence at the assault or accusation...... Record review of Resident #101's 'Admission Data Collection' form dated 1/14/14 revealed that the resident had a history of [REDACTED]. Record review of Resident #101's 'Alzheimer's care plan dated 1/21/14 revealed that the resident had behavioral disturbances and interventions included attempting to orient the resident to the task at hand, use simple direct words, cues, and statements. Approach in a calm, positive reassuring way. Resident #101's Dementia care plan dated 1/21/14 revealed the resident was noted to have dementia with behaviors with physical aggression, irritability, forgetfulness, resistive to cares and striking out at others. Interventions included during cares interact with resident as appropriate, taking into consideration hearing difficulties. Document behaviors on behavior log. Approach and speak in a calm reassuring voice. If resident is restless, refuses or is combative with task at hand, leave alone and re-approach at a later time. Inform the nurse of behaviors. Intervene to ensure the safety of the resident and others. Watch for behavioral cues, body language, tone of voice, pacing etc. Keep safe distance behavior occurs. Record review of Certified Nurse Assistant (CNA) "C"s employee file revealed that the CNA's 'Employment Application' dated 6/24/13 noted CNA "C" was previously employed at the facility from February 2010 to October 2011 and was "let go". CNA "C" had disciplines for absences and tardiness noted in her file. Record review of CNA "C"s 'Job Description' form signed by the CNA on 7/2/13 revealed: Demonstrate positive customer service when performing the role of certified nurse aide with residents, family members, facility staff and medical staff. Demonstrate an awareness of and sensitivity for resident's rights in all interfaces with residents and family. Create and maintain an atmosphere of warmth, personal interest and positive emphasis, as well as a calm environment throughout the unit and shift. Ensure that all residents are treated fairly, with kindness, dignity, and respect. Must be able to relate to and work with the ill, disabled, elderly, emotionally upset, and at times, hostile residents. Must have patience, tact, a cheerful disposition and enthusiasm, as well as the willingness to handle difficult residents. Record review of facility investigation statements for CNA "C" revealed that CNA admitted to wrong doing of spitting and noted that she worked in a "nursing facility and not a psych ward, usually I can control it, but the spit was too much". Record review of Certified Nurse Assistant "D" who was assisting with the care of Resident #101 on 5/6/14 had written a statement: To whom it may concern, CNA "C" and I were putting Resident #101 to bed when he was doing the usual when we had him on the toilet. Resident#101 was kicking, hitting and yelling. We changed his clothes and cleaned him up. CNA "C" took Resident #101 to his bed, while I cleaned up the bathroom. CNA "D" wrote that she heard CNA "C" yelling at Resident #101 and turned to see CNA "C" had the resident pinned to the bed and the resident had spit at CNA "C". CNA "C" then spit in Resident #101's face and notice a large amount of spit on the left side of Resident #101's face. CNA "C" then yelled at CNA "D" to "Go ahead and report me and give them a reason to fire me". CNA "D" noted that she just stood there shocked and then informed the nurse of the incident. In an interview on 5/20 /14 at 3:05 PM with Certified Nurse Assistant (CNA) "D" revealed that she witnessed the incident on 5/6/14. CNA "D" stated that her co-worker CNA "C" was hot headed and could not keep her temper under control. CNA "D" stated that the secured dementia unit takes a special person/staff. CNA "D" stated that she had worked a couple of days with CNA "C" and her temper was building up and the nurses were telling her that she needed to calm down, keep attitude in check and if she could not she would be removed from the floor. CNA "D" stated that there had been abuse training and that she told the Director of Clinical Services/DON "B" that they needed to talk about having CNA "C" removed from the secure dementia unit and that the nurses were having CNA "C" take extra breaks because her attitude was so bad. CNA "D" stated that CNA "C" had stated to her, "I'm sick of the[***] I don't get paid enough to deal with his crap"; being very verbal about not liking her job and that management was aware of CNA "C"s behavior. CNA "D" stated that it was after dinner on 5/6/14 when both CNA "C" and CNA "D" were assisting Resident #101with bedtime care/toileting when CNA "C" was heard yelling at Resident #101, "Don't, Stop. Quit". CNA "D" stated that she looked from the bathroom door to see CNA "C" had Resident #101 pinned in the bed, he was lying face up and CNA "C" held both arms/hands down beside each side of his head and CNA "C" made a sucking sound, lugger sinus collection noise in her mouth and CNA "D" recalled that she saw CNA "C" spit "a large thick nasty lugger" onto Resident #101's left cheek. CNA "D" stated that she did not see any spit on CNA "C" but that CNA "C" claimed the resident spat in her mouth. CNA "D" heard CNA "C" stop what she was doing to suck up snot from her own sinuses and spit it on Resident #101. CNA "D" stated that CNA "C" then turned around and yelled at her at the top of her lungs (loudly) while still on top of Resident #101, "Go ahead and tell on me, give them a reason to fire me". CNA "D" stated that she left the room with CNA "C" who then went to lunch or break with the hall nurse License Practical Nurse (LPN) "F". CNA "D" stated that she went back and cleaned up Resident #101. She was not comfortable to report the abuse to LPN "F" because she was friends with CNA "C". CNA "D" stated that she reported the incident to the Registered Nurse "G" and the administrator. CNA "D" stated that CNA "C" did not show any remorse or regrets for what she did, and was proud of her spitting in his face. CNA "D" stated that if CNA "C" had been pulled off the secured dementia unit with her attitude it could have been avoided. Management knew about the attitude issue. In an interview on 5/21/14 at 4:21 PM, Licensed Practical Nurse (LPN) "F" revealed that CNA "C" had an attitude that night (5/6/14), would get frustrated and was real short tempered toward her. LPN "F" stated that she told CNA "C" that they needed to take a break but that CNA "C" did not want to. LPN "F" stated that RN "G" took care of the allegation. LPN "F" stated that she did not call the family or the police. LPN "F" stated that CNA "C" had a loud/outburst personality and that she wanted to get fired from the facility so she could get unemployment. In an interview on 5/21/14 at 12:10 PM, Registered Nurse "G" revealed that CNA "C" had a loud and outgoing howl, would report that she did all the work and her co-workers did little; but when you watched her she was always in the hallway while the others were in the rooms working with residents. RN "G" stated that she was notified by CNA "D" that she would get a call from the DON that CNA "C" just spat in Resident #101's face. RN "G" stated that she spoke with both CNAs and that according to the witness had heard CNA "C" clear her throat to gather spit with the intention of spitting on the resident. RN "G" stated that CNA "C" was ranting about wanting to get fired so she could collect unemployment. In an interview on 5/20/14 at 12:30 PM, Licensed Practical Nurse (LPN) "H" revealed that she had worked with CNA "C" and stated that the CNA can become agitated and upset stating, "I'm doing all the work" and runs around like she was working, but she was doing a lot of nothing. LPN "H" stated that she would have to say hey what are you doing and then re-direct her back to her tasks. The state surveyor asked LPN "H" about CNA "C" having a temper and the LPN stated that she had spoken to her about it before, pulled the CNA "C" aside to ask what was going on and send the CNA on breaks to get herself back together. LPN "H" stated that she worked over until 11:00 PM before and worked with CNA "C" and toward the end of the shift CNA "C" seemed more agitated and short with the residents. LPN "H" stated that CNA "C" would have good days and bad days with frequent call ins. LPN "H" stated that CNA "C" would say, "Why don't they just fire me". LPN "H" stated that CNA "C" had an attitude problem toward residents, staff and co-workers. LPN "H" stated that if she saw CNA "C" scheduled on the secured dementia unit that LPN "H" would change the assignment to another hall if there was another staff that was a better fit, someone who had more patience with the residents. In an interview on 5/21/14 at 1:50 PM , Manger/Licensed Practical Nurse (LPN) "E" was asked by state surveyor why CNA "C" was scheduled on secured dementia unit and was told it was the CNA's preference of where she wanted to work. Manger/Licensed Practical Nurse (LPN) "E" acknowledged that the residents on the secured dementia unit had behaviors, were compromised cognitively and not able to speak for themselves. In an interview on 5/21/14 at 11:55 AM, the Director of Clinical Services/DON "B" stated that none of the staff had come to her prior to the incident, but it had been brought to her attention that CNA "C" had a bad attitude. The Director of Clinical Services/DON "B" stated that nurses had reported maybe once or twice, but could not recall when, but just that the CNA had a bad attitude. The Director of Clinical Services/DON "B" stated, " CNA "C" wrote a statement of the incident and admitted to spitting in the residents face". In an interview on 5/21/14 at 4:00 PM with the Clinical Regional consultant "I" stated that he was aware of the facility's notification of immediate jeopardy and reviewed the incident with this state surveyor. The Clinical Regional consultant "I" acknowledged willful intent by CNA "C" by pinning Resident #101 to the bed (restrained) as defined by their policy, yelled at the resident (verbal abuse) as defined by their policy and sucked up saliva and spat (physical abuse) in the resident's face. Interviews done during the on-site investigation with 5 Certified Nurse Assistants (CNAs) that had worked with the CNA "C" revealed that she treated the residents as a task and not as a human person with needs. Interviews described CNA "C" as immature for her age, with mood swings, short tempered, easily frustrated and did not take the time to interact/socialize with the residents. The facility provided a correction plan to remove the immediate jeopardy on 5/22/2014 that outlined the following steps: 1. On 5/7/14 Resident #101 was assessed by the social worker and Director of clinical services and the primary care physician. 2. On 4/6/14 Certified Nurse Assistant "C" was suspended pending investigation and was terminated on 5/16/14. CNA "C" was last educated on Resident Abuse on 4/30/14. 3. On 5/6/14 staff re-education on Resident Abuse began and was completed on 5/8/14. An in-service of dealing with difficult behaviors began on 5/6/14 and was completed on 5/13/14. 4. On 5/7/14 (no time) 13 residents on the secured unit were assessed by the social worker and the director of clinical services for injury or distress. 5. (no date) The facility staff interviewed staff members who the felt were having "temper/attitude" issues. There were 3 staff members were identified and were removed from the resident care until re-educated on abuse and dealing with difficult behaviors. 6. On 5/21/14 Facility staff were re-educated on the 'Abuse' policy, dealing with difficult behaviors and reporting immediatelt to the administrator staff members who have 'temper/attitude' issues towards residents to prevent abuse. Staff that were not educated will be educated prior to their next scheduled shift. 7. The administrator will monitor staff knowledge of interventions to prevent abuse 3-5 times weekly for four weeks then weekly for four weeks then monthly. Areas of concern will be addressed immediately. Findings will be reported to the Quality Assurance/Performance Improvement Committee monthly. While the immediate jeopardy was removed on 5/22/14 at 4:50 PM, the facility remained out of compliance at an isolation with the potential for more than minimal harm that is not immediate jeopardy due to the facility's plan to complete, monitor and sustain their correction plan and reporting this to their Quality Assurance/Performance Improvement Committee. ( ) ( )

BASED ON OBSERVATION, INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO SUPERVISE ONE (#1) RESIDENT OF FIVE SAMPLED COGNITIVELY IMPAIRED RESIDENTS IDENTIFIED FOR ELOPEMENT RISKS FROM THE TOTAL FACILITY POPULATION OF EIGHTY-THREE. THE FACILITY'S DEFICIENT PRACTICE RESULTED IN RESIDENT #1 LEAVING AN OUTDOOR FENCED COURTYARD THROUGH AN UNALARMED GATE AND BEING FOUND BY A STAFF MEMBER APPROXIMATELY TEN MINUTES LATER ACROSS THE STREET, IN THE DRIVEWAY OF AN APARTMENT COMPLEX, PLACING RESIDENT #1 IN IMMEDIATE JEOPARDY TO HIS HEALTH AND SAFETY. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON 6/11/12 AT 12:00 P.M. THE IMMEDIATE JEOPARDY BEGAN ON 6/7/12 AT APPROXIMATELY 7:04 P.M. WHEN RESIDENT #1, A COGNITIVELY IMPAIRED RESIDENT WHO HAD BEEN ASSESSED TO BE AT RISK FOR ELOPEMENT, EFFECTIVELY WALKED OFF THE GROUNDS AND AWAY FROM THE FACILITY THROUGH AN UNALARMED GATE WHILE A GROUP OF SIXTEEN COGNITIVELY IMPAIRED RESIDENTS IDENTIFIED FOR ELOPEMENT RISKS, WERE LEFT UNSUPERVISED BY CERTIFIED NURSE AIDE (CNA) "B" IN AN OUTSIDE FENCED COURTYARD AREA LOCATED OFF THE FACILITY'S SECURED UNIT. RESIDENT #1 LEFT THE FENCED AREA THROUGH AN UNALARMED GATE LOCATED AT THE REAR OF THE FENCED COURTYARD, WALKED AROUND THE FENCED AREA, TO THE FRONT OF THE FACILITY, LEFT THE FACILITY GROUNDS AND WAS FOUND APPROXIMATELY TEN MINUTES LATER BY REGISTERED NURSE (RN) "A" ACROSS THE STREET FROM THE FACILITY IN THE DRIVEWAY OF AN APARTMENT COMPLEX. THE ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON 6/11/12 AT 12:05 P.M. AND A WRITTEN PLAN FOR REMOVAL OF THE IMMEDIATE JEOPARDY WAS REQUESTED. ON 6/11/12 AT 1:00 P.M., THE IMMEDIATE JEOPARDY WAS REMOVED WHEN THIS SURVEYOR VERIFIED THE FOLLOWING: - CNA "B" WAS SUSPENDED IMMEDIATELY FOLLOWING THE INCIDENT AND THEN WAS TERMINATED ON 6/11/12. A REVIEW OF CNA "B'S" PERSONNEL FILE VERIFIED THE SUSPENSION AND TERMINATION. - ON 6/7/12 AT APPROXIMATELY 8:00 P.M., TEMPORARY ALARMS WERE INSTALLED ON THE TWO GATES OF THE SECURED UNIT'S FENCED COURTYARD. ON 6/8/12 AT 1:00 P.M., THE TEMPORARY ALARMS WERE REPLACED WITH A PERMANENT ALARM SYSTEM. OBSERVATIONS OF THE PERMANENT ALARMS PLACED ON THE TWO GATES OCCURRED ON 6/11/12 AT 12:30 P.M. AS EACH GATE (EAST GATE AND SOUTH GATE) WAS OPENED, AN ALARM SOUNDED WITH CNA "F" COMING OUT OF THE SECURED UNIT, RESPONDING TO THE FIRST tested SOUTH GATE ALARM. - ALL SECURED UNIT STAFF WERE TRAINED ON THE NEW "GUIDELINES FOR COURT YARD USE ON SECURED UNIT" (6/8/12). ON 6/11/12, INTERVIEWS WERE CONDUCTED WITH RN "A", LICENSED PRACTICAL NURSE (LPN) "E", CNA "C", CNA "D", CNA "F" AND CNA "G", AT 9:00 A.M., 10:15 A.M., 10:30 A.M., 12:00 P.M., 1:50 P.M. AND 2:00 P.M. RESPECTIVELY. ALL THE STAFF INTERVIEWED SAID THEY HAD BEEN TRAINED IN THE NEW COURTYARD GUIDELINES. - IMMEDIATELY AFTER THE 6/7/12 INCIDENT, RESIDENTS HAVE NOT USED THE COURTYARD AREA OFF THE SECURED UNIT. DURING A 6/11/12, 8:45 A.M. INTERVIEW WITH THE ADMINISTRATOR, SHE EXPLAINED THE COURTYARD WOULD NOT BE USED UNTIL THE FACILITY'S QUALITY ASSURANCE (QA) COMMITTEE WAS SATISFIED WITH THE FACILITY'S PLAN OF CORRECTION. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE CONTINUES AT A PATTERN LEVEL WITH THE POTENTIAL FOR MORE THAN MINIMAL HARM TO THE ADDITIONAL FOUR COGNITIVELY IMPAIRED, INDEPENDENTLY AMBULATORY RESIDENTS (#2, #3, #4 AND #5) WHO WERE ASSESSED TO BE ELOPEMENT RISKS AND WHO WERE ALSO IN THE FENCED COURTYARD AT THE TIME RESIDENT #1 LEFT THE AREA. THE DEFICIENT PRACTICE WILL CONTINUE PENDING VERIFICATION BY THE STATE AGENCY OF THE FOLLOWING ACTION NEEDED TO BE MADE BY THE FACILITY: - TO TRAIN ALL STAFF IN THE NEW "GUIDELINES FOR COURT YARD USE ON SECURED UNIT" (6/8/12). - TO COMPLETE A FACT FINDING FACILITY SURVEY PROCESS WITH ALL STAFF TO IDENTIFY THEIR KNOWLEDGE LEVEL OF THE SECURE UNIT POPULATION, RESIDENT SPECIALITY CARE NEEDS AND REQUIRED SUPERVISION. THE AREAS OF CONCERN IDENTIFIED THROUGH THE PROCESS WILL BE PRESENTED TO THE ADMINISTRATOR AND AN ACTION PLAN WILL BE DEVELOPED AND MONITORED THROUGH THE FACILITY'S QA SYSTEM. - TO CONDUCT DAILY FUNCTION CHECKS OF THE COURTYARD GATE ALARM SYSTEM TO ENSURE PROPER WORKING ORDER. THESE DAILY CHECKS WILL BE CONDUCTED UNTIL THE QA COMMITTEE IS SATISFIED WITH THE OUTCOME OF THE CHECKS. - TO PRESENT TO THE ADMINISTRATOR, STAFF COMPETENCY TESTING RESULTS, FACT FINDING RESULTS OF THE DOOR ALARM AND GATE SYSTEMS CHECKS WITH A SUMMARY OF THE REVIEWS BEING PRESENTED TO THE MONTHLY QA COMMITTEE FOR AT LEAST THE NEXT THREE MONTHS. - TO ASSESS ALL RESIDENTS TO DETERMINE IF THEY HAVE BEEN EVALUATED FOR POTENTIAL ELOPEMENT RISKS. FINDINGS INCLUDE: THE FACILITY'S 6/8/12 INVESTIGATION REPORT SHOWED ON 6/7/12 AT APPROXIMATELY 7:03 P.M., RN "A" WAS IN HER CAR IN THE FRONT FACILITY PARKING LOT LEAVING THE FACILITY, WHEN SHE NOTICED RESIDENT #1 WANDERING IN THE PARKING LOT OF THE APARTMENT COMPLEX LOCATED ACROSS THE STREET FROM THE FRONT OF THE FACILITY. THE REPORT DOCUMENTED RN "A" IMMEDIATELY CALLED ON HER CELL PHONE INTO THE FACILITY AND REQUESTED A RESIDENT HEAD COUNT AS SHE REDIRECTED RESIDENT #1 BACK INTO THE FACILITY THROUGH THE FRONT DOOR. THE REPORT SHOWED RESIDENT #1 WAS UNINJURED AND HAD NO CHANGES IN HIS ABILITY TO PERFORM HIS ACTIVITIES OF DAILY LIVING. THE FACILITY INITIATED RESIDENT HEAD COUNT, PER THE FACILITY REPORT, SHOWED RESIDENT #1 WAS THE ONLY RESIDENT NOT IN THE BUILDING AT THE TIME OF THE HEAD COUNT. RESIDENT #1'S CLINICAL CHART FACE SHEET SHOWED HE WAS admitted INto the facility on [DATE] AND IS [AGE] years OLD. THE FACE SHEET DOCUMENTED RESIDENT #1'S [DIAGNOSES REDACTED]. THE 3/27/12 MINIMUM DATA SET (MDS) ASSESSMENT SHOWED RESIDENT #1'S COGNITION AS SEVERELY IMPAIRED, HIS LACK OF SAFETY AWARENESS, AND BOTH SHORT AND LONG TERM MEMORY PROBLEMS. THE 5/18/12 CARE PLAN DOCUMENTED RESIDENT #1'S ELOPEMENT RISK AND EXIT SEEKING BEHAVIORS. ELOPEMENT PREVENTION INTERVENTIONS INCLUDED RESIDENT #1 WEARING A "WANDERGUARD BRACELET" ON THE ANKLE AND STAFF CHECKING IT EACH SHIFT. THE MDS ASSESSMENT AND CARE PLAN DOCUMENTED RESIDENT #1'S ABILITY TO TRANSFER AND AMBULATE INDEPENDENTLY. ON 6/11/12 AT 9:30 A.M., RESIDENT #1 WAS OBSERVED SITTING IN A CHAIR IN THE RESIDENT LOUNGE AREA BOUNCING HIS BABY DOLL ON HIS KNEE AS HE TALKED TO IT. RESIDENT #1 WAS OBSERVED ON 6/11/12 AT 9:45 A.M., WALKING UPRIGHT AND AT A STEADY PACE, CARRYING HIS BABY DOLL, MOVING FROM THE RESIDENT LOUNGE AREA ACROSS THE HALL TO THE RESIDENT DINING AREA OF THE SECURED UNIT. AS HE PASSED THE SURVEYOR, HE SAID 'HELLO', SMILED AND KEPT WALKING. THE SURVEYOR DID NOT INTERVIEW RESIDENT #1 ABOUT HIS ELOPEMENT BECAUSE THE CONVERSATION MAY HAVE TRIGGERED HIS URGES TO ATTEMPT TO LEAVE THE FACILITY. AN OBSERVATION OF THE FENCED COURTYARD AND POSSIBLE ROUTE OF RESIDENT #1 WAS CONDUCTED WITH THE DIRECTOR OF NURSING (DON) ON 6/11/12 AT 9:15 A.M. THE SECURED UNIT'S ALARMED EXIT DOOR OPENS OUT INTO THE FENCED COURTYARD. THE NORTH OR FRONT, THE EAST AND THE SOUTH SIDES OF THE COURTYARD ARE FENCED WITH THE NORTH AND SOUTH SIDE FENCES ATTACHED TO THE FACILITY. TWO GATES WERE OBSERVED, ONE ON THE EAST FENCE AND ONE ON THE SOUTH FENCE. THE DON EXPLAINED THE POSSIBLE ROUTE RESIDENT #1 HAD TAKEN. THE ROUTE MEASURED APPROXIMATELY 200 PACES FROM THE SOUTH GATE, AROUND TO THE FRONT OF THE FACILITY, ACROSS THE ROAD TO THE DRIVEWAY OF THE APARTMENT COMPLEX. RN "A" WAS INTERVIEWED ON 6/11/12 AT 9:00 A.M. RN "A" SAID THE FACILITY'S REPORT WAS CORRECT. RN "A" EXPLAINED, AFTER SHE REDIRECTED RESIDENT #1 BACK INTO THE FACILITY AND DETERMINED HE HAD NO INJURIES, RN "A" ESCORTED HIM BACK TO THE UNIT AND RESIDENT #1 SHOWED HER HOW HE HAD LEFT THE FENCED COURTYARD. RN "A" STATED, RESIDENT #1 SHOWED HER HOW HE LIFTED THE LATCH ON THE SOUTH GATE AND WALKED OUT. RN "A" STATED RESIDENT #1 DID NOT RECONSTRUCT HIS ROUTE TO THE APARTMENT COMPLEX. RN "A" STATED HER IMMEDIATE INVESTIGATION INTO THE INCIDENT FOUND THAT CNA "B" WAS SUPERVISING THE RESIDENTS IN THE COURTYARD AFTER DINNER AND HAD LEFT THEM UNATTENDED GOING BACK INTO THE SECURED UNIT. WHEN ASKED IF CNA "B" GAVE AN EXPLANATION AS TO WHY SHE LEFT THE RESIDENTS UNSUPERVISED IN THE COURTYARD, RN "A" SAID, "(CNA "B") NEVER GAVE A REASON..." INTERVIEWS WERE CONDUCTED WITH CNA "C" AND CNA "D" ON 6/11/12 AT 10:30 A.M. AND 12:00 P.M. RESPECTIVELY. THEY STATED THE REPORT WAS CORRECT. CNA "C" EXPLAINED SHE HAD BEEN THE STAFF THAT TOOK THE RESIDENTS INTO THE COURTYARD AT APPROXIMATELY 6:00 P.M. CNA "C" SAID CNA "B" HAD RELIEVED HER FOR LUNCH BUT WASN'T SURE OF THE TIME. CNA "D" STATED HE WAS AWARE OF CNA "B" SUPERVISING THE RESIDENTS IN THE COURTYARD. CNA "D" EXPLAINED HE WAS IN THE SECURED UNIT BECAUSE SOME OF THE RESIDENTS CHOSE TO STAY INSIDE. CNA "D" SAID, HE CAME OUT OF A ROOM AND SAW CNA "B" BACK IN THE BUILDING, WALKING DOWN THE HALL AWAY FROM THE EXIT DOOR TO THE COURTYARD. CNA "D" STATED HE TOLD HER SHE NEEDED TO GET BACK OUTSIDE WITH THE RESIDENTS. CNA "D" SAID SHORTLY AFTER HE DIRECTED CNA "B" TO GO BACK INTO THE COURTYARD, HE HEARD THE CODE "L" FOR MISSING RESIDENTS. BOTH CNA "C" AND CNA "D" STATED THEY PARTICIPATED IN CONDUCTING A RESIDENT HEAD COUNT AND FOUND RESIDENT #1 MISSING. CNA "D" SAID RN "A" ESCORTED RESIDENT #1 BACK TO THE SECURED UNIT. CNA "C" SAID, RESIDENT #1 CONTINUED HIS EXIT SEEKING BEHAVIOR UNTIL HE WENT TO BED FOR THE NIGHT. CNA "C" SAID AFTER HIS ELOPEMENT, SHE PERFORMED THE 1:1 SUPERVISION OF RESIDENT #1. DURING THE INTERVIEWS WITH RN "A", CNA "C" AND CNA "D", THEY STATED STAFF KNOW YOU DO NOT LEAVE RESIDENTS UNATTENDED IN THE COURTYARD. CNA "C" EXPLAINED, "THESE ARE HIGH RISK RESIDENTS DOWN HERE (SECURED UNIT)... YOU DO NOT LEAVE THEM UNSUPERVISED OUT THERE (COURTYARD), WE ALL KNOW THAT... I DON'T KNOW WHAT (CNA "B") WAS THINKING..." AN INTERVIEW WAS CONDUCTED WITH THE ADMINISTRATOR AND THE DON ON 6/11/12 AT 3:15 P.M. WHEN ASKED IF CNA "B" GAVE ANY REASON FOR LEAVING THE RESIDENTS UNSUPERVISED IN THE COURTYARD, THE DON SAID, SHE DID NOT GIVE A REASON BUT STATED SHE KNEW THE RESIDENTS WERE TO BE SUPERVISED AT ALL TIMES WHILE IN THE COURTYARD. DURING THE INTERVIEW, THE ADMINISTRATOR AND THE DON CONFIRMED THEIR UNDERSTANDING OF THE DEFICIENT PRACTICE. ( )

BASED ON INTERVIEW AND RECORD REVIEW, THE FACILITY FAILED TO IDENTIFY AND INVESTIGATE NINE (#2, #4, #8, #9, #10, #11, #12, #13 AND #14) RESIDENTS WHO WERE HAVING SYMPTOMS WHICH MET INFECTION CONTROL CRITERIA FOR SURVEILLANCE PURPOSES RELATED TO POSSIBLE GASTROINTESTINAL INFECTION (MULTIPLE EPISODES OF LOOSE STOOL) RESULTING IN AN IMMEDIATE JEOPARDY FOR RESIDENTS (#2, #4, #8, #9, #10, #11, #12, #13 AND #14) AND IN THE SUBSEQUENT DEATH OF RESIDENT #9 AND FAILED TO MAINTAIN AN INFECTION CONTROL PROGRAM TO HELP PREVENT THE DEVELOPMENT AND TRANSMISSION OF INFECTION FOR 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 AND #14) OF 14 RESIDENTS WHO WERE REVIEWED FOR INFECTION CONTROL PLACING ALL 87 FACILITY RESIDENT AT THE POTENTIAL FOR DEVELOPMENT AND TRANSMISSION OF AN INFECTION. THE IMMEDIATE JEOPARDY WAS IDENTIFIED ON [DATE] AT 8:11 A.M. THE IMMEDIATE JEOPARDY BEGAN ON [DATE] WHEN RESIDENT #9 HAD A SECOND LOOSE STOOL IN A 24-HOUR PERIOD. THE FACILITY ADMINISTRATOR WAS NOTIFIED OF THE IMMEDIATE JEOPARDY ON [DATE] AT 4:35 P.M. THE IMMEDIATE JEOPARDY WAS REMOVED ON [DATE] AT 5:35 P.M., WHEN THE FACILITY ADMINISTRATOR AND DIRECTOR OF NURSING DID THE FOLLOWING: * NOTIFIED THE EIGHT (#2, #4, #8, #10, #11, #12, #13 AND #14) RESIDENTS' PHYSICIANS OF THE LOOSE STOOL CONCERN; * IMPLEMENTED PHYSICIAN ORDERS [REDACTED]. * MOVED THESE RESIDENTS TO PRIVATE ROOMS OR IN ROOMS WITH OTHER RESIDENTS EXPERIENCING LOOSE STOOLS; * PROVIDED PERSONAL PROTECTIVE EQUIPMENT FOR THE FACILITY STAFF TO DECREASE THE RISK OF SPREADING A POTENTIAL HARMFUL INFECTION; * PROVIDED EDUCATION REGARDING[DIAGNOSES REDACTED]ICILE (CLOSTRIDIUM DIFFICILE) POLICY TO LICENSED STAFF; AND * RE-EDUCATE THE INFECTION CONTROL NURSE, DIRECTOR OF NURSING AND UNIT MANAGERS ON THE INFECTION CONTROL PROGRAM. ALTHOUGH THE IMMEDIATE JEOPARDY WAS REMOVED, THE FACILITY'S DEFICIENT PRACTICE WAS NOT CORRECTED AND CONTINUES AT WIDESPREAD LEVEL, WITH THE POTENTIAL FOR MORE THAN MINIMUM HARM PENDING THE FACILITY'S SUSTAINED ABILITY TO: * IDENTIFY, INVESTIGATE, CONTROL AND PREVENT INFECTION IN THE FACILITY; * IMPLEMENT APPROPRIATE INFECTION CONTROL POLICY AND PROCEDURES; * MAINTAIN A RECORD OF INFECTION INCIDENTS AND CORRECTIVE ACTIONS RELATED TO INFECTION; AND, VERIFICATION BY THE STATE AGENCY. FINDINGS INCLUDE: A REVIEW OF THE COMPLAINT INTAKE DONE ON [DATE] AT 8:11 A.M. READS, "...ON [DATE], THE RESIDENT (#9) STARTED EXPERIENCING DIAREAHA (SIC). THE FAMILY INFORMED NURSING STAFF WHO INFORMED THE PHYSICIAN. THE PHYSICIAN SAID HE DID NOT THINK IT WAS ANYTHING TO WORRY ABOUT AND STARTED THE RESIDENT ON ANTI-DIARREAH (SIC) MEDICATION. THE RESIDENT WAS NEVER tested FOR TOXINS WHILE AT THE FACILITY. THE RESIDENT WAS discharged HOME AND ACCORDING TO FACILITY DISCHARGE DIRECTIONS, CONTINUED ON ANTI-DIARREAH (SIC) MEDICATIONS. THE RESIDENT WAS TRANSFERRED TO THE HOSPITAL AND died on [DATE], FROM[DIAGNOSES REDACTED] COLITIS. SHE DEVELOPED SEVERE SEPSIS AND COULD NOT SURVIVE THE INFECTION...". AT THE WEBSITE, WWW.MEDICINENET.COM/CLOSTRIDIUM_DIFFICILE_COLITIS/ARTICLE, A PUBLICATION TITLED "CLOSTRIDIUM DIFFICILE COLITIS (ANTIBIOTIC-ASSOCIATED COLITIS...C DIFFICILE,[DIAGNOSES REDACTED]...)" READS, "...ANTIBIOTIC-ASSOCIATED (C. DIFFICILE) COLITIS IS AN INFECTION OF THE COLON CAUSED BY [DIAGNOSES REDACTED]ICILE THAT OCCURS PRIMARILY AMONG INDIVIDUALS WHO HAVE BEEN USING ANTIBIOTICS... [DIAGNOSES REDACTED]ICILE SPORES ARE FOUND FREQUENTLY IN HOSPITALS, NURSING HOMES, EXTENDED CARE FACILITIES AND THEY CAN BE FOUND ON BEDPANS, FURNITURE, TOILET SEATS, LINENS, TELEPHONES, STETHOSCOPES, FINGERNAILS, RINGS (JEWELRY), FLOORS... A HISTORY OF ANTIBIOTIC USE IS IMPORTANT IN THE [DIAGNOSES REDACTED]. PATIENTS TAKING ANTIBIOTICS (OR RECENTLY HAVING TAKEN ANTIBIOTICS) WHO DEVELOP ABDOMINAL PAIN, CRAMPS AND DIARRHEA ARE USUALLY tested FOR [DIAGNOSES REDACTED]ICILE INFECTION. HOWEVER, DOCTORS DO NOT ALWAYS WAIT FOR THE APPEARANCE OF DIARRHEA TO START TESTING FOR [DIAGNOSES REDACTED]ICILE SINCE IN RARE INSTANCES [DIAGNOSES REDACTED]ICILE CAN CAUSE ABDOMINAL PAIN AND TENDERNESS WITHOUT DIARRHEA..." AT THE WEBSITE, WWW.MAYOCLINIC.COM/HEALTH/C-DIFFICILE, INFORMATION REGARDING CLOSTRIDIUM DIFFICILE IS FOUND IN THE LINK TITLED "DISEASE/CONDITION". THIS INFORMATION READS, "...SOME PEOPLE WHO HAVE [DIAGNOSES REDACTED]ICILE NEVER BECOME SICK, THOUGH THEY CAN STILL SPREAD THE INFECTION... BUT SIGNS AND SYMPTOMS MAY NOT APPEAR FOR WEEKS OR EVEN MONTHS AFTERWARD... [DIAGNOSES REDACTED]ICILE BACTERIA ARE PASSED IN FECES AND SPREAD TO FOOD, SURFACES AND OBJECTS WHEN PEOPLE WHO ARE INFECTED DON'T WASH THEIR HANDS THOROUGHLY. THE BACTERIA PRODUCE HARDY SPORES THAT CAN PERSIST IN A ROOM FOR WEEKS OR MONTHS... ALTHOUGH PEOPLE...WITH NO KNOWN RISK FACTORS HAVE GOTTEN SICK FROM [DIAGNOSES REDACTED]ICILE, YOUR RISK IS GREATEST IF YOU... HAVE A SERIOUS UNDERLYING ILLNESS OR A WEAKENED IMMUNE SYSTEM AS A RESULT OF A MEDICAL CONDITION OR TREATMENT, HAVE HAD ABDOMINAL SURGERY OR A GASTROINTESTINAL PROCEDURE, HAVE A COLON DISEASE SUCH AS INFLAMMATORY BOWEL DISEASE OR [DIAGNOSES REDACTED]...COMPLICATIONS OF [DIAGNOSES REDACTED]ICILE INCLUDE...DEHYDRATION...KIDNEY FAILURE... BOWEL PERFORATION... DEATH. EVEN MILD TO MODERATE [DIAGNOSES REDACTED]ICILE INFECTION CAN QUICKLY PROGRESS TO A FATAL DISEASE IF NOT TREATED PROMPTLY... TO HELP PREVENT THE SPREAD OF [DIAGNOSES REDACTED]ICILE, HOSPITAL AND OTHER HEALTH CARE FACILITIES FOLLOW STRICT INFECTION-CONTROL GUIDELINES... PREVENTIVE MEASURES INCLUDE: HAND WASHING...CONTACT PRECAUTIONS...THOROUGH CLEANING...AVOID UNNECESSARY USE OF ANTIBIOTICS..." A REVIEW OF RESIDENT #9'S CLOSED CLINICAL RECORD WAS DONE ON [DATE]. THE FACE SHEET IN THIS RECORD REFLECTS RESIDENT #9 WAS A [AGE] year-old FEMALE WHO WAS admitted to the facility on [DATE] FROM A HOSPITAL WHERE SHE RECEIVED SERVICES DUE TO AN ANKLE FRACTURE AND WAS TREATED WITH ANTIBIOTICS FOR A URINARY TRACT AND RESPIRATORY RELATED INFECTIONS. A FORM TITLED "CARE MANAGEMENT SUMMARY" DATED [DATE], REFLECTS RESIDENT #9 WAS INCONTINENT OF BOWEL AND BLADDER. THE "TREATMENT RECORD" IN RESIDENT #9'S CLINICAL RECORD DOCUMENTS RESIDENT #9 EXPERIENCED LOOSE STOOLS ON [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]. A FORM TITLED "CARE TRACK" DATED [DATE] AT 3:35 P.M. READS, "...C/O (COMPLAINED OF) SLIGHT STOMACH DISCOMFORT. BSX4 (BOWEL SOUNDS IN FOUR QUADRANTS), ABD (ABDOMEN) SOFT AND TENDER, X2 (TWO TIMES) LOOSE STOOLS....". THE "INTERDISCIPLINARY DISCHARGE SUMMARY" DATED [DATE] REFLECTS NO INFORMATION REGARDING STATUS/CONDITION OF STOOLS OR STOMACH COMFORT OR PLANS FOR FOLLOW-UP CONSULTATION. THE PROGRESS NOTES DATED [DATE] AT 3:45 P.M., REFLECTS RESIDENT #9 WAS discharged HOME. A REVIEW OF A HOSPITAL HISTORY AND PHYSICAL REPORT DATED [DATE] READS, "REASON FOR ADMISSION: UNCONSCIOUS WITH SEVERE DIARRHEA. HISTORY OF PRESENT ILLNESS: THE PATIENT (RESIDENT #9) IS A [AGE] year-old FEMALE...HAD ANKLE FRACTURE RECENTLY...SHE WAS IN THE NURSING HOME UNTIL [DATE]. THE PATIENT DEVELOPED DIARRHEA ,[DATE] DAYS BEFORE LEAVING THE NURSING HOME. THE DIARRHEA WAS CONTINUOUS AND SEVERE. THE PATIENT WENT HOME AND STILL HAD THE DIARRHEA. NO FURTHER WORKUP DONE THAT TIME. THE PATIENT, 3 DAYS AGO, STARTED TO HAVE LOSS OF HER APPETITE. SHE STARTED TO BE LETHARGIC. TODAY THE PATIENT BECAME COMPLETELY UNCONSCIOUS... SHE HAS SEVERE SEPSIS..." THE DISCHARGE SUMMARY FROM THIS HOSPITAL STAY DATED [DATE] OF RESIDENT #9 READS, "ADMITTING Diagnoses: [REDACTED]. DIFF COLITIS... THE PATIENT WAS admitted TO THE CCU (CRITICAL CARE UNIT), WAS STARTED ON AGGRESSIVE IV FLUID REPLACEMENT AND EMPIRIC ANTIBIOTICS. DUE TO THE PATIENT'S SEVERE RENAL DYSFUNCTION IN ADDITION TO ELEVATED WHITE COUNT AND HER SEVERE DEHYDRATION, IT WAS SURMISED THAT THE PATIENT WOULD NEED TO UNDERGO A POSSIBLE TOTAL COLECTOMY TO BE ABLE TO HAVE ANY POSSIBLE IMPROVEMENT IN HER CURRENT SYMPTOMS. HOWEVER, THE NEED FOR SURGERY WAS DISCUSSED WITH THE FAMILY AND IT WAS NOTED THAT THE PATIENT MOST LIKELY WILL NOT SURVIVE SURGERY... THE PATIENT WAS PRONOUNCED DEAD... AT APPROXIMATELY 12:55 A.M. ON [DATE]...". AN INTERVIEW AND REVIEW OF INFECTION CONTROL PROGRAM/RECORDS WAS DONE ON [DATE] FROM 10:50 A.M. UNTIL 1:30 P.M. WITH THE INFECTION CONTROL NURSE (ICN). THE ICN STATED SHE BEGAN IN THE ROLE OF INFECTION PREVENTIONIST IN MARCH OF 2011 AND WAS AWAY FROM THIS DUTY BETWEEN THE DATES OF [DATE] AND [DATE]. THE ICN STATED SHE WAS NOT AWARE OF WHO IN THE FACILITY FILLS THIS ROLE IN HER ABSENCE. AT 11:20 A.M., THE DIRECTOR OF NURSING (DON) JOINED IN THE REVIEW OF THE INFECTION CONTROL PROGRAM AND INTERVIEW WITH THE ICN. WHEN THEY WERE ASKED IF THEY WERE KNOWLEDGEABLE OF THE FEDERAL REQUIREMENTS UNDER TAG 441 FOR LONG TERM CARE FACILITIES, BOTH THE ICN AND DON REPLIED "NO". DURING THE INTERVIEW, THE ICN STATED SHE FIRST BECOMES AWARE OF A RESIDENT WHO IS REPORTED TO HAVE AN INFECTION WHEN A NURSE WRITES ON A FORM TITLED "MONTHLY LINE LISTING REPORT" THAT A RESIDENT HAS BEEN STARTED ON AN ANTIBIOTIC. THE ICN STATED FROM THIS INFORMATION, SHE INITIATES A FORM TITLED "INFECTION SURVEILLANCE WORKSHEET". THE ICN STATED THE "MONTHLY LINE LISTING REPORTS" ARE KEPT AT THE NURSES STATION FOR ONGOING USE BY THE NURSING STAFF. THE DON WAS THEN ASKED WHO AT THE FACILITY PERFORMS THE ROLE OF THE INFECTION PREVENTIONIST IN THE ABSENCE OF THE ICN, SPECIFICALLY OBSERVING THE ENVIRONMENT/STAFF FOR SAFE/APPROPRIATE INFECTION CONTROL PRACTICES AS PART OF SURVEILLANCE. THE DON REPLIED THAT THE FACILITY PERFORMS "OBSERVATION/SAFETY CHECKS". WHEN ASKED TO DEMONSTRATE WHEN THE LAST ONE WAS PERFORMED, THE DON PRESENTED A DOCUMENT DATED [DATE]. THE DON ALSO STATED THE NURSING MANAGEMENT TEAM REVIEWS THE FACILITY'S "24-HOUR REPORT" EACH MORNING FOR AREAS OF CONCERN AND WILL TAKE ACTION/FOLLOW-UP WITH WHAT IS WRITTEN BY THE NURSING STAFF REGARDING RESIDENT ISSUES. DURING THE REVIEW OF INFECTION CONTROL PROGRAM/DOCUMENTS AND INTERVIEW WITH THE ICN AND DON DONE ON [DATE], THE "MONTHLY LINE LISTING REPORTS" AND "INFECTION SURVEILLANCE WORKSHEETS" FOR JUNE AND JULY OF 2011 WERE REVIEWED. JUNE'S "MONTHLY LINE LISTING REPORT" SHOWS THAT RESIDENT #9 WAS NOT RECORDED ON THIS REPORT AS HAVING SYMPTOMS OF AN INFECTION. AN INTERVIEW WITH LICENSED PRACTICAL NURSE (LPN) (H) WAS DONE ON [DATE] AT 2:50 P.M. LPN (H) VERIFIED SHE WROTE THE NOTE IN RESIDENT #9'S RECORD ON THE FORM TITLED "CARE TRACK" DATED [DATE] AT 3:35 P.M. WHICH READS, "...C/O (COMPLAINED OF) SLIGHT STOMACH DISCOMFORT. BSX4 (BOWEL SOUNDS IN FOUR QUADRANTS), ABD (ABDOMEN) SOFT AND TENDER, X2 (TWO TIMES) LOOSE STOOLS....". THE "TREATMENT RECORD" IN RESIDENT #9'S CLINICAL RECORD DOCUMENTING RESIDENT #9'S LOOSE STOOLS ON [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE] WAS SHOWN TO LPN (H). LPN (H) STATED SHE WAS NOT AWARE THAT RESIDENT #9 HAD SO MANY INSTANCES OF LOOSE STOOLS. SHE WENT ON TO EXPLAIN THAT CERTIFIED NURSE AIDES DOCUMENT RESIDENT BOWEL INFORMATION ON THE TREATMENT RECORD AND THAT IF SHE HAD BEEN MADE AWARE OF THE FREQUENCY OF RESIDENT #9'S STOOLING, SHE WOULD HAVE NOTIFIED THE PHYSICIAN. LPN (H) DID HOWEVER SHOW EVIDENCE THE NURSING MANAGEMENT TEAM WAS NOTIFIED VIA THEIR 24 HOUR REPORT THAT RESIDENT #9 HAD TWO EPISODES OF LOOSE STOOL ON [DATE]. A REVIEW OF RESIDENT #9'S MEDICAL RECORD SHOWS THIS RESIDENT WAS discharged HOME ON [DATE] WITHOUT THE FACILITY RECOGNIZING SHE HAD A GREATER THAN ONE WEEK TREND OF LOOSE STOOLS AND WITHOUT INFORMING THE PHYSICIAN. A TELEPHONE INTERVIEW WITH RESIDENT #9'S PHYSICIAN DONE ON [DATE] AT 9:00 A.M. VERIFIED HE WAS NOT INFORMED OF RESIDENT #9'S MULTIPLE LOOSE STOOLS. THE PHYSICIAN STATED IF HE HAD BEEN INFORMED, HE WOULD HAVE ORDERED A STOOL CULTURE FOR[DIAGNOSES REDACTED]ICILE. CONTINUED REVIEW OF JUNE'S "MONTHLY LINE LISTING REPORTS" SHOWED THAT RESIDENT #8 WAS TREATED WITH AN ANTIBIOTIC ON [DATE] FOR PNEUMONIA. DURING THIS REVIEW/INTERVIEW, THE ICN STATED RESIDENT #8 DISPLAYED SYMPTOMS OF A GASTROINTESTINAL (GI) INFECTION AND A PHYSICIAN ORDER [REDACTED]. A REVIEW OF THE LABORATORY REPORT SHOWS THAT A SAMPLE WAS NOT COLLECTED UNTIL [DATE] WITH A "NEGATIVE" RESULT REPORTED ON [DATE]. A REVIEW OF RESIDENT #8'S "TREATMENT RECORD" SHOWS SHE HAD "LARGE TO EXTRA LARGE" LOOSE STOOLS ON [DATE], [DATE], [DATE], [DATE], [DATE] AND [DATE]. THE "TREATMENT RECORD" SHOWS RESIDENT #8 DID NOT HAVE A LOOSE STOOL ON [DATE]. THE NURSES NOTES IN RESIDENT #8'S CLINICAL RECORD DATED [DATE], READS, "RESIDENT HAVING EPISODES OF LOOSE STOOLS, GREEN IN COLOR... [MEDICATION NAME] (ANTI-DIARRHEA) GIVEN...". IT WAS LEARNED DURING THE INTERVIEW WITH THE ICN THAT THE EPISODES OF MULTIPLE LOOSE STOOLS WHICH RESIDENT #8 EXPERIENCED WAS NOT WRITTEN ON THE MONTHLY LINE LISTING OR SURVEILLANCE WORKSHEET BECAUSE THE SINGLE SPECIMEN tested FOR[DIAGNOSES REDACTED] WAS NEGATIVE. A REVIEW OF THE INFECTION SURVEILLANCE POLICY TITLED "INFECTION CRITERIA 8.2.3" DATED ,[DATE] READS, "GASTROINTESTINAL TRACT INFECTION, ONE (1) OF THE FOLLOWING CRITERIA MUST BE MET: 1. TWO (2) OR MORE LOOSE OR WATER STOOLS ABOVE WHAT IS NORMAL FOR RESIDENT/PATIENT IN A 24 HOUR PERIOD...." THE ICN STATED RESIDENT #8 WAS PLACED IN ISOLATION WHEN THE SYMPTOMS STARTED IN JUNE, BUT THE ISOLATION WAS DISCONTINUED WHEN THE[DIAGNOSES REDACTED] TEST RETURNED NEGATIVE ON [DATE]. WHEN THE ICN WAS ASKED TO DEMONSTRATE WHAT INFECTION CONTROL SURVEILLANCE ACTION WAS TAKEN DURING THE TIME OF THIS INCIDENT TO PREVENT THE SPREAD OF A POSSIBLE CONTAGIOUS INFECTION, THE ICN WAS UNABLE TO. A REVIEW OF JULY'S "MONTHLY LINE LISTINGS REPORTS" AND "INFECTION SURVEILLANCE WORKSHEETS" SHOWED AS OF [DATE], THERE WERE 14 RESIDENTS IDENTIFIED ON JULY'S LINE LISTING REPORT AND ONLY TEN SURVEILLANCE WORKSHEETS WERE INITIATED. OF THESE TEN SURVEILLANCE WORKSHEETS INDICATING RESIDENTS WHO WERE REPORTED AS HAVING AN INFECTION, FOUR RESIDENTS (#1, #2, #3 AND #4) REFLECT HAVING HAD AN ONSET OF SYMPTOMS ALL OCCURRING AS OF [DATE] AND WERE ALL diagnosed /treated for [REDACTED]. THESE FOUR RESIDENTS LIVE ON THREE OF THE FOUR HALLWAYS IN THE FACILITY. WHEN THE DON WAS ASKED TO DEMONSTRATE WHAT SURVEILLANCE WAS DONE TO ENSURE SAFE INFECTION CONTROL PRACTICES WERE BEING ADHERED TO AS A RESULT OF THESE FOUR RESIDENTS DEVELOPING SYMPTOMS AT THE SAME TIME, SHE WAS UNABLE TO. CONTINUED REVIEW OF JULY'S "MONTHLY LINE LISTING REPORTS" REFLECTS RESIDENT #5 BEGAN TREATMENT WITH KEFLEX, AN ANTIBIOTIC AS OF [DATE]. THIS LINE LISTING REPORT INDICATES IT WAS A "NOSOCOMIAL" CLASS OF INFECTION, MEANING, RESIDENT #5 DEVELOPED THE INFECTION WHILE UNDER THE CARE OF THE FACILITY. THE INFECTION SURVEILLANCE WORKSHEET FOR THIS INFECTION INDICATES RESIDENT #5 WAS diagnosed with [REDACTED]. THE ONLY SYMPTOM IDENTIFIED ON THIS DOCUMENT FOR CRITERIA TO TREAT WITH AN ANTIBIOTIC WAS "REDNESS/EDEMA". THE INFECTION SURVEILLANCE POLICY TITLED "INFECTION CRITERIA 8.2.2" DATED ,[DATE] READS, "ONE (1) OF THE FOLLOWING CRITERIA MUST BE MET: 1. PUS PRESENT AT WOUND, SKIN, OR SOFT TISSUE 2. MUST HAVE FOUR (4) OR MORE OF THE FOLLOWING SIGNS & SYMPTOMS..." DURING THE INTERVIEW WITH THE ICN, IT WAS LEARNED THAT RESIDENT #5 DID NOT HAVE PUS PRESENT AND DID NOT MEET CRITERIA FOR TREATMENT WITH AN ANTIBIOTIC PER THEIR FACILITY POLICY. IN ADDITION, THE ICN PROVIDED NO DOCUMENTATION OF PHYSICIAN NOTIFICATION REGARDING FURTHER JUSTIFICATION FOR ANTIMICROBIAL TREATMENT. JULY'S "MONTHLY LINE LISTING REPORTS" ALSO REFLECT THAT RESIDENTS #6 AND #7 DEVELOPED SOME TYPE OF AN INFECTION ON [DATE], WITH ONE OF THEM BEING LISTED AS A NOSOCOMIAL. HOWEVER, THERE WERE NO SURVEILLANCE WORKSHEETS INITIATED TO REFLECT WHAT SYMPTOMS THESE RESIDENTS WERE DISPLAYING, OR WHERE THE SITE OF INFECTION WAS LOCATED. DURING THE INTERVIEW WITH THE ICN, SHE STATED BOTH OF THESE RESIDENTS HAD "SKIN INFECTIONS". WHEN AGAIN ASKED WHAT OBSERVATIONS/ACTION WAS TAKEN BY THE FACILITY TO ENSURE SAFE INFECTION CONTROL PRACTICES WERE BEING DONE, SINCE BOTH THESE RESIDENTS WERE REPORTED AS DEVELOPING SYMPTOMS AT THE SAME TIME, AND THEY LIVE IN ROOMS NEXT TO ONE ANOTHER, THE ICN REPLIED, "NONE". DURING AN INTERVIEW WITH THE DON ON [DATE] AT 3:15 P.M., SHE WAS ASKED IF SHE KNEW IF ANY RESIDENT IS CURRENTLY EXPERIENCING LOOSE/DIARRHEA LIKE STOOLS. SHE REPLIED SHE DOES NOT KNOW AND WOULD CONDUCT A RECORD REVIEW. AT 3:50 P.M., THE DON AND ICN STATED THE FACILITY CURRENTLY HAS SEVEN RESIDENTS WHO HAVE HAD LOOSE/DIARRHEA LIKE STOOLS WITHIN THE LAST TWO DAYS. PER THE DON AND ICN; 1. RESIDENT #2 - "HAS HAD 2 LOOSE STOOLS", STARTED ON ANTIBIOTIC ON [DATE]. 2. RESIDENT #4 - "HAVING LOOSE STOOLS ON [DATE], [DATE], [DATE]", STARTED ON ANTIBIOTIC ON [DATE]. 3. RESIDENT #10 - "RESIDENT WITH HISTORY OF IRRITABLE BOWEL SYNDROME, HAS HAD TWO LOOSE STOOLS YESTERDAY". 4. RESIDENT #11 - "HAS HISTORY OF GASTROPARESIS, HAS HAD A COUPLE OF LOOSE STOOLS". 5. RESIDENT #12 - "HAS HISTORY OF DIVERTICULITIS, HAS HAD THREE LOOSE STOOLS ON [DATE], [DATE], [DATE]". 6. RESIDENT #13 - "HAS THREE EPISODES OF LOOSE STOOLS ON [DATE], [DATE] AND [DATE]. THIS IS A CHANGE OF CONDITION. MOST STOOLS HAVE BEEN FORMED AND SOFT." 7. RESIDENT #14 - "ALWAYS HAS LOOSE STOOLS - IS ON MULTIPLE CATHARTICS." THE FACILITY FAILED TO PROVIDE ADEQUATE ORIENTATION OF THE INFECTION CONTROL PROGRAM REQUIREMENTS FOR THE FACILITY DESIGNATED INFECTION CONTROL NURSE AND FAILED TO PROVIDE FOR THE EXECUTION OF THIS RESPONSIBILITY ON AN ONGOING BASIS. THE FACILITY FAILED TO IDENTIFY, INVESTIGATE, DOCUMENT SURVEILLANCE OF AND TRY TO CONTAIN AN OUTBREAK OF GASTROINTESTINAL ILLNESS AMONG RESIDENTS WHO WERE AT RISK FOR AND WHO DEVELOPED SYMPTOMS OF A CONTAGIOUS AND POTENTIALLY FATAL GASTROINTESTINAL INFECTION. THE FACILITY FAILED TO IMPLEMENT A FACILITY WIDE INFECTION CONTROL/SURVEILLANCE PROGRAM THAT INCLUDES THE IDENTIFICATION AND INVESTIGATION OF INFECTIONS, ENSURES THE APPROPRIATE USE OF ANTIBIOTICS, AND HELPS TO PREVENT THE DEVELOPMENT OF/AND TRANSMISSION OF INFECTIONS. ( )