Every finding on record at Jacksonville SKLD Nur & Rehab

Based on interview and record review, the Facility failed to ensure a resident's wheelchair was properly secured in the transport van for 1 (R2) of 4 residents reviewed for accidents in the sample of 4. The surveyor confirmed by observation, interview, and record review that the deficiency practice occurred on 8/12/2025 and the deficient practice was corrected on 9/2/2025 prior to the start of the survey. Therefore the survey is Past Noncompliance.Findings Include:During the onsite survey, past noncompliance (PNC) was cited after the facility implemented actions to correct the noncompliance which included:1.Transportation vehicle was checked to ensure all safety mechanisms were properly functioning. Completed 8/12/2025.2.All transportation staff were trained on proper procedure for install of wheelchair and proper wheelchair to be used for transports, motor vehicle policy and first aid policy. Completed 2/20/2026.3.Transportation staff will log safety mechanisms in good working order and used properly for every transport, and complete vehicle inspection log daily. Started 8/13/2025 and ongoing.4.Maintenance Director or Designee will monitor vehicle safety mechanism weekly x 4 weeks. Completed on 9/2/2025.5. All new transportation staff in serviced on proper procedure for install of wheelchair upon hire prior to use of the vehicle. Completed 2/20/2026.6. Facility Administrator responsible for ensuring ongoing compliance.7.Facility Administrator responsible for reporting to QA Committee.The facility was able to demonstrate monitoring of the corrective action and sustained complianceR2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] and has a medical diagnosis of Type 2 Diabetes Mellitus, End Stage Renal Disease, Peripheral Vascular Disease, Intervertebral Disc Degeneration Lumbar Region, Fracture of First Lumbar Vertebra, Low Back Pain, Essential Tremor, and Acquired Absence of Left Leg Below Knee.R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact, uses a wheelchair, and needs partial/moderate assistance with chair/bed to chair transfers.R2's Care Plan Date Revised 8/19/2025 documents R2 is at risk for falls related to the diagnosis of acquired absence of left leg below the knee, essential tremor, diabetic retinopathy, Cerebral Vascular Accident, as well as medications taken.R2's Fall Risk assessment dated [DATE] documents R2 is a high fall risk.R2's Care Plan Date Revised 9/2/2025 documents R2 has an Activities of Daily Living (ADL) self-care performance deficit related to the diagnosis of unspecified sequalae of cerebral infarction. Interventions Date Initiated 3/5/2026 documents ambulation: does not ambulate and manual wheelchair for locomotion.R2's General Note dated 8/12/2025 at 12:35 PM documents resident went to appointment in small van with transportation, Upon returning her wheelchair tipped over backwards in van. Resident hit her head, small hematoma to back of head. Refused emergency room (ER) refused x-ray. States she has some back pain 4/10.The Facility's Fall Report dated 8/12/2025 documents Nursing Description: Hematoma to back of head, small. Some lower back pain. No injury seen to back. Resident Description: Chair tipped over and I was strapped in, brakes on too. Immediate Action Taken Description: resident returned to facility, vital signs (VS) taken, neuros started. Resident refused to go to ER to get check out. Complains of some back pain but x-ray refused. Notes 8/13/2025: During investigation, resident stated she was strapped in properly to the small van and wheelchair brakes were engaged during transport. Driver did not accelerate or engage brakes. Resident wheelchair tipped backwards and the resident did hit her back and head on the floor of the van. Root cause: improper positioning in wheelchair.R2's Lumbar Spine Computed Tomography (CT) Scan Without Contrast dated 9/30/2025 documents AcuteL1 compression fracture without retropulsion. Degenerative disc disease with ligamentous thickening and facet arthrosis. No high-grade degenerative stenosis is evident by CT.On 3/11/2026 at 8:52 AM R2 stated her wheelchair brakes were locked, and her wheelchair was securely strapped in and connected to the transport van by V5. R2 stated when V5 started to slowly accelerate, her wheelchair tipped backwards, and she hit her head and the top of her back on the van. R2 stated she refused to go to the hospital or have x rays done when this happened. R2 stated she continued to have back pain and the facility ordered an x-ray of her back and later ordered a CT scan. R2 stated she was told she had a fracture to her back.On 3/11/2026 at 1:00 PM V1, Administrator, stated R2 was securely buckled into the transport van and when the van driver started to accelerate, R2's wheelchair tipped backwards. V1 stated R2 was assessed in house and R2 refused to go to the local hospital for evaluation. V1 stated R2 complained of back pain after the incident and an X-ray was ordered, which had no acute findings. V1 stated the facility ordered a CT scan when R2 continued to have back pain. V1 stated R2's CT scan showed R2 had an L1 fracture.On 3/11/2026 at 1:07 PM V6, Maintenance Director, stated the transport van has a red lever on the straps that connects the wheelchair to the van. V6 stated the lever is pressed to loosen the straps to be able to remove them from the resident's wheelchair. V6 stated the facility is unsure if R2's foot may have hit the lever and loosen the straps that were securing R2's wheelchair to the van.On 3/11/2026 at 1:37pm V5, Transport CNA, stated R2 was securely strapped into the van and R2's wheelchair brakes were locked before she started to drive the van. V5 stated she is unsure how R2's wheelchair tipped backwards and R2 was still buckled and strapped to the van when R2's wheelchair tipped. V5 stated if a resident's foot would put pressure on the lever that is connected to the straps used to secure a wheelchair, it could loosen the straps.On 3/11/2026 at 2:11 PM V7, Medical Director, stated he was informed of R2's wheelchair tipping back while in the transport van and R2 refused medical treatment and to be sent to the hospital. On 3/12/2026 at 11:58 AM V20, Licensed Practical Nurse (LPN), stated she was the nurse working when R2's wheelchair tipped backwards in the transport van. V20 stated she was informed that R2's wheelchair tipped back, and she went to assess R2. V20 stated R2 was secured in the van with her wheelchair brakes locked. V20 stated she was informed that R2 had hit her head. V20 stated she assessed R2 and found a small hematoma to R2's head and R2 was complaining of a slight headache and back pain. V20 stated R2 refused to be sent to the local hospital for evaluation and refused an x-ray at that time.The Facility's Transportation Policy Date Revised 8/13/2025 documents It is the facility's responsibility that any resident being transported by the facility vehicle will have a safe and secure transport to and from the designated destination.

Based on interview and record review, the facility failed to prevent resident to resident abuse for 1 (R5) of 3 residents reviewed for abuse in a sample of 3. 1)R4's Undated Face Sheet documents R4 was admitted to the facility on [DATE] and had a medical diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Major Depressive Disorder, Alzheimer's Disease, and Dementia.R4's Minimum Date Set (MDS) dated [DATE] documents R4 is severely cognitively impaired. R4's Care Plan Date Initiated [DATE] documents R4 has behaviors related to makes accusatory statement, verbally aggressive toward others, misperceptions, jealous behaviors and R4 is at risk for alteration in psychosocial well-being related to Alzheimer's Disease, verbal behavioral symptoms toward others.2)R5's Undated Face Sheet documents R5 was admitted to the facility on [DATE] and has a medical diagnosis of Metabolic Encephalopathy, Anxiety Disorder, Dysphagia, Functional Quadriplegia, and Dementia.R5's MDS dated [DATE] documents R5 is severely cognitively impaired.R5's Care Plan Date Initiated [DATE] documents R5 has impaired cognitive function/dementia or impaired thought processes related to Dementia.R5's Care Plan Date Initiated [DATE] documents R5 has impaired cognitive function related to dementia. Interventions Date Initiated [DATE] documents reassure resident of safety.R5's Care Plan Date Initiated [DATE] documents R5 is at risk for alteration in psychosocial well-being related to conflicts with peers.The Facility's Initial Report Dated [DATE] at 12:00 PM documents Alleged Resident to resident physical altercation, residents immediately separated and assessed. Administrator immediately notified, investigation initiated, final report to follow. The Facility's Verification of Incident Investigation/Administrative Summary dated [DATE] at 12:00 pm documents: A comprehensive investigation was initiated and found that on [DATE] at approximately 1200 in the hallway, R4 observed R5 speaking with another female resident. Due to cognitive impairment and misperception, R4 believed R5 was her deceased husband 'cheating' on her. R4 became agitated and attempted to strike R5 on the left cheek, grazing him with fingertips. Staff member immediately separated resident and supervised to prevent any reoccurrence. Both residents were assessed with no injuries noted. Skin assessment completed immediately on R5 revealed no redness, bruising, swelling, or other injuries noted. No c/o pain observed or voiced. Upon interview of R5 with administrator, he could not remember incident. Interview with R4 on 9-6-25, she states that R5 is her husband, and he is cheating on her. R4 was evaluated at ER for change of condition and returned to facility. Upon return to facility, R4 was re-interviewed. During interview R4 admitted she mistook R5 for her husband. She states, R5 is not my deceased husband and I'm sorry. I thought he was for a minute.R4's Physical Aggression Initiated Report dated [DATE] at 12:00 PM documents Nursing Description: Resident rolled next to a male resident. This resident thought the male resident was her husband and that he was cheating on her. Resident made contact with male resident's left cheek. Resident Description: How dare he cheat!R5's Physical Aggression Received Report dated [DATE] at 12:00 pm documents Nursing Description: Resident was sitting in the lobby when another female resident rolled up next to him in her wheelchair and made contact with left cheek. Resident Description: She hit me.On [DATE] at 10:23 AM V1, Administrator, stated there was a recent incident where R4 thought that R5 was R4's deceased husband, and R4 thought R5 was cheating on her. V1 stated R4 made contact with R5 on R5's cheek. On [DATE] at 12:18 PM R4 didn't respond to questions asked by the Illinois Department of Public Health (IDPH) Surveyor. On [DATE] at 12:22 PM V8, Licensed Practice Nurse (LPN), stated R4 and R5 are confused. V8 stated R4 had a delusion that R5 was her husband and that he was cheating on her. V8 stated R4 slapped R5 on the cheek. On [DATE] at 12:42 PM R4 unable to clearly answer questions regarding incident from the IDPH Surveyor.On [DATE] at 12:50 PM V10, Certified Nursing Assistant (CNA), stated she was working on [DATE] when R4 hit R5 on R5's cheek. V10 stated R4 and R5 were up by the 2 nurse's stations and R5 was talking with another female resident. V10 stated R4 came up to R5 and tapped R5 on the cheek with her fingertips. V10 stated both R4 and R5 are confused and R4 thought R5 was her husband. On [DATE] at 2:52 PM V12, Social Services Director (SSD), stated R4 is very confused and thought R5 was her husband and hit R5 on the cheek when R4 thought R5 was cheating on her.The Facility's Abuse Policy Date Revised [DATE] documents Purpose: To provide guidance and procedures to the facility and staff to assure the residents remain to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility affirms the right of our residents to be free from abuse, neglect, exploitation, misappropriation of property, deprivation of goods and services by staff or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of residents.

Based on observation, interview and record review the facility failed to ensure a resident's low air loss mattress was working properly for 1 (R2) of 3 residents reviewed for safe, function, sanitary, comfortable environment in the sample of 3. R2's Undated Face Sheet documents R2 was admitted to the facility on [DATE] with a medical diagnosis of Thromboangitis Obliterans Buerger's Disease, Hyperlipidemia, Arthropathy, and Morbid Obesity. R2's Minimum Data Set, dated [DATE] documents R2 is cognitively intact, is dependent on staff for rolling left and right, and is always incontinent of bladder and bowel.R2's Care Plan with a focus area revision date of 12/9/2023 documents R2 is at risk for pain and R2 needs assistance with activities of daily living including bed mobility with two-person physical assistance required and pressure redistribution device.R2's Care Plan with a focus area revision date of 2/21/2024 documents R2 has the potential for impaired skin integrity related to decreased mobility, morbid obesity with interventions including a pressure redistribution support surface.R2's Physician Order dated 9/18/2024 at 11:30 AM documents low air loss mattress.On 7/17/2025 at 8:55 AM, R2 stated her low air loss mattress has not been working correctly and losing air for almost a week. R2 stated she informed staff of the mattress deflating on 7/10/2025, with V7, Maintenance Director, aware of the issue on 7/11/2025. R2 stated on 7/11/2025, her mattress was completely flat, and she was lying on the metal bed frame causing her severe pain in her back. R2 stated on 7/16/2025 V7, Maintenance Director, replaced the mattress pump to try to fix the air loss issues, however the mattress is still malfunctioning and deflating at times. R2 stated while the facility staff helped clean her up and change her on 7/16/2025, she could feel the bed frame on her hips as she rolled side to side which was painful. On 7/17/2025 at 9:09 AM R2's low air loss mattress pump beeped 3 times, flashed a red low-pressure light and then the alarm stopped. On 7/17/2025 at 9:10 AM R2's low air loss mattress pump beeped 3 times again, flashed a red low-pressure light and the alarm stopped.On 7/17/2025 at 9:11 AM R2's low air loss mattress pump started to beep continuously and with the red low-pressure light flashing. R2 stated she could feel the mattress starting to lose air at this time around her lower back and buttock area. On 7/17/2025 at 9:15 AM V3, Certified Nursing Assistant (CNA) and V4, CNA arrived in R2's room to address R2's mattress pump. V3, CNA, stated she does not know what is wrong with the mattress or pump, but knows it has not been functioning properly for a couple days and knows V7, Maintenance Director, has been made aware. V4, CNA, stated she has told V7, Maintenance Director several times that R2's bed is losing air and is not working as it should. V4, CNA, stated V7, Maintenance Director, replaced the pump on the mattress yesterday, 7/16/2025, and it is still alarming and not working correctly. On 7/17/2025 at 9:17 AM R2 stated she is starting to feel the bed frame underneath her buttock.On 7/17/2025 at 9:25 AM V5, Licensed Practical Nurse (LPN) stated she was made aware of R2's mattress losing air and not working properly on 7/16/2025 and was informed that V7, Maintenance Director, was aware of the mattress deflating. V5, LPN, stated she knows when R2's mattress deflates and starts to get flat; it causes R2 pain. On 7/17/2025 at 10:17 AM R2 stated once she laid the head of the bed down, the mattress started to inflate back up with air. R2 stated she cannot always lie flat due to pain in her back. On 7/17/2025 at 10:20 AM V3, CNA, stated V7, Maintenance Director, informed her that R2's mattress and pump are not working correctly, and a new mattress and pump have been ordered.On 7/17/2025 at 10:32 AM V2, Director of Nursing (DON), stated she was made aware of R2's mattress losing air on 7/16/2025 and is unsure what is wrong with it. V2, DON, stated V7, Maintenance Director, had replaced the pump for R2's mattress on 7/16/2025 and it is now working on and off. On 7/17/2025 at 10:37 AM V7, Maintenance Director, stated he was informed 2 days prior that R2's mattress was not functioning properly and losing air. V7, Maintenance Director, stated he replaced the mattress pump yesterday and the pump will work for a while, then will alarm and start to lose air. V7, Maintenance Director, stated R2 needs a new mattress and pump, which has been ordered, and a rental mattress is coming for R2.On 7/17/2025 at 10:56 AM V8, Social Services, stated she was made aware R2's mattress was losing air on 7/13/2025 and was informed by staff that a work order was in place for the mattress to be looked at.On 7/17/2025 at 11:06 AM V4, CNA, stated she was informed of R2's mattress beeping and losing air on 7/10/2025 and placed a work order that day. V4, CNA, stated the facility staff had to constantly adjust R2's mattress pump all weekend for the mattress to hold air. V3, CNA, stated she was also aware of R2's mattress losing air on 7/10/2025, and knew a work order was already in place for the mattress.On 7/17/2025 at 11:11 AM V1, Administrator, stated R2's mattress is working and functioning properly. On 7/17/2025 at 11:31 AM V7 Maintenance Director, brought a work order dated 7/16/2025 stating R2's mattress pump was beeping, and mattress was deflating. The Resident Rights for People in Long-Term Care Facilities document last revised 11/2018 documents Your facility must be safe, clean, comfortable, and homelike.

4. R39's admission Record, dated 6/5/25, documents R39 was admitted to the facility on [DATE] with Brown-Sequard Syndrome, Morbid Obesity, Cerebrovascular Disease affecting left non-dominant side, Hemiplegia/Hemiparesis, Arthropathy, Hypertension (HTN), Congestive Heart Failure (CHF), Cardiomegaly, Pulmonary Embolism (PE), Benign Prostatic Hyperplasia (BPH), and Gastro-Esophageal Reflux Disease (GERD). R39's Care Plan, dated 3/19/25, documents R39 has shortness of breath at times related to chronic bronchitis. R39 has asthma. Interventions: Inhalers as per MD order. It continues R39 is receiving medications with a black box warning. Medication type: Anticoagulant, Antihypertensive. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R39 has dx of GERD. Interventions: Give medications as ordered. R39's Minimum Data Set (MDS), dated [DATE], documents R39 is cognitively intact. On 6/2/25 at 10:53 AM, R39 has a medicine cup with an orange pill in it (stated for his constipation), Fluticasone inhaler, Generic Afrin Nasal Spray on his bedside table, R39 stated The nurse always comes in and leaves my medications in a cup on my table, and I take them on my own, she never stays and watches me take them. On 6/4/25 at 11:20 AM, R39 has his Fluticasone Inhaler and a medicine cup with 3 large round pills sitting on his bedside table. R39 stated These are my Tums; they give me some in a cup for when I need them. R39's Physician Order (PO), dated 10/28/24, documents Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (microgram)/Dose, 1 inhalation inhale orally every 12-hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Rinse mouth with water after use. Do not swallow the water. This order was updated on 6/4/25 as 1 inhalation inhale orally every 12 hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Unsupervised self-administration Rinse mouth with water after use. Do not swallow the water. R39's PO, dated 10/2/24, documents Senna-Plus Oral Tablet 8.6-50 MG, Give 1 tablet by mouth two times a day for Constipation. 5. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, HTN, Dementia, Major Depressive Disorder, BPH, Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has a diagnosis of hypertension. Interventions: Give antihypertensive medications as ordered, Obtain blood pressure readings per orders. It continues R44 is receiving medications with a black box warning. Medication type: antidepressant, antianxiety agent, nonopioid/opioid analgesic. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R44 is at risk for altered nutrition and hydration r/t recent illness, bladder cancer dx. Interventions: Medication per MD order. R44's MDS, dated [DATE], documents R44 has a moderate cognitive impairment. R44's PO, dated 2/25/25, documents Amlodipine Besylate Tablet 10 MG, Give 0.5 tablet by mouth one time a day for HTN. R44's PO, dated 2/14/25, documents D-Mannose Oral Capsule 500 MG. Give 1 capsule by mouth one time a day for supplementation. R44's PO, dated 1/17/25, documents Lactobacillus Capsule, Give 1 capsule by mouth in the morning for supplementation. R44's PO, dated 1/17/25, documents Cranberry Oral Tablet 500 MG, Give 500 mg by mouth one time a day for supplementation. On 6/4/25 at 11:05 AM, R44 seen sitting at nurse's desk waiting for lunch. R44 has a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. On 6/4/25 at 11:18 AM, V12, Licensed Practical Nurse (LPN), stated Some residents have an order for Self-Administration of a medication and we leave that medication in their room. When advised of R44's meds still sitting in a cup in his room, V12 stated I put (R44's) medications on his table and he leaned over to take them, I thought that he took them. That was totally my fault. On 6/4/25 at 11:45 AM, V12, LPN, seen giving R44 his medications that he did not take earlier. Amlodipine 0.5mg scheduled and was signed off as given at 6:00 AM, Cranberry tablet 500mg scheduled and was signed off as given at 6:00 AM, D-Mannose 500mg scheduled and was signed off as given at 6:00 AM, and Lactobacillus 1 capsule scheduled and was signed off as given at 6:00 AM. R44's General Note, dated 6/4/25 at 11:49 AM, documents Resident took morning meds at 11:45 today, MD (Medical Doctor) is aware. On 6/5/25 at 10:17 AM, R44 seen lying in bed, a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. R44 stated The nurse brought them in and set them on my table around 10:00 AM this morning and I have not taken them yet. On 6/5/25 at 10:25 AM, R44 was seen taking his cup of medications left at his bedside. 6. On 6/4/25 at 11:00 AM, R58 stated usually the nurse will bring in her medications and put them on her table and walk away, the only time they stay and watch her take it is if it is a controlled medication. R58's MDS, dated [DATE], documents R58 is cognitively intact. 7. On 6/4/25 at 11:15 AM, R70 stated some nurses do bring his meds in and will leave them on the bedside table for him to take and they don't watch to see if he takes them. R70 stated they are supposed to stay and watch me swallow them, but they don't. R70 stated this morning's meds were brought in and left on his table. R70's MDS, dated [DATE], documents R70 was cognitively intact. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the nurses to watch the residents take their medications and not to leave them with the resident to take on their own. They all know they are not supposed to do that. The facility's Medication Storage policy, dated 8/23/22, documented Purpose: To provide guidance to facility nursing staff on the proper storage of medication. Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. Policy Interpretation and Implementation: 1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls. Only persons authorized to prepare and administer medications may have access to locked medications. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date. 6. Hazardous drugs shall be clearly marked and stored separately from other medications. 7. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use. Unlocked medication carts are not left unattended. 8. Medications requiring refrigeration are stored in a refrigerator located in the drug room at the nurses' station or other secured location. Medications shall be stored separately from food and are labeled accordingly. 9. Over-the-counter medications shall be dated when opened, prior to use. 10. Schedule 11-V controlled medications are stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medications. 8. The Facility's Long-Term Care Facilities Application for Medicare and Medicaid, CMS 671, dated 6/2/25, documented there were 75 residing in the facility. Based on interview, observation, and record review the facility failed to date an open vial of Tuberculin that is used for all staff and residents, failed to date opened insulin administration pens, failed to date an open bottle of eye drops, failed to date an open bottle of liquid acetaminophen, failed to date an open vial of multi-dose insulin, and failed to properly dispense medications to residents by leaving them at the resident's bedside. This failure has the potential to affect all 75 residents in the facility. Findings include: 1. On 6/2/25 at 10:15 AM the facility's South unit medication room was checked with V21, Registered Nurse (RN). There was one medication refrigerator checked, and it contained an open tuberculin (TB) vial with no open date documented. The medication refrigerator contained 2 opened prefilled insulin pens with no open date or labeled with patient/resident name and 1 opened prefilled insulin pen with R9's name but no open date was documented on the insulin pen. R60's azelastine .05% eye drop bottle was open, approximately half full, and no open dated was documented on the bottle. V21 stated the TB vial and eye drop bottle should have been dated when it was opened. V21 also stated the insulin pens should have been stored in a bag labeled with the resident's name and dated when they were first used. 2. On 6/2/25 at 10:32 AM medication cart #1 on the Medicare unit was observed and it contained an undated open bottle of ciprofloxacin-dexamethasone 0.3-0.1% ear drops for R333 and 1 undated open bottle of liquid acetaminophen 160 mg/5ml. V21 stated both should have been dated when they were first opened, and that the acetaminophen is floor stock and used for all residents if they have an order for it. 3. On 6/2/25 at 10:40 AM medication cart#2 on the Medicare unit was inspected and it contained R77's undated opened multi-dose vial of Lantus insulin 100 units/ml. V12 LPN (Licensed Practical Nurse) stated the vial should be labeled with the date it was opened. On 6/5/25 at 9:35 AM V2, Director of Nursing, DON, stated the TB solution is used for all staff and residents to complete TB testing. V2 stated the TB vial should have been dated when it was opened and that all insulin medications and floor stock medications should be dated when they are opened.

4. On 06/02/25 at 11:53AM, during the noon meal V4, CNA removed a peanut butter and jelly sandwich from sandwich bag with V4's hands. V4 did not sanitize their hands or don gloves prior to removing the sandwich from bag. V4 then handed sandwich to R14. On 6/4/2025 at 2:30PM, V1, Administrator, stated she would expect staff to don gloves prior to handling food. 5. On 06/04/25 at 01:00 PM, a sign was posted outside R41's room that documents enhanced barrier precaution. V14 CNA and V15 CNA did not sanitize hands prior to donning gloves before entering R41's room. The enhanced barrier precaution sign documents everyone must: clean their hands, including before entering and when leaving the room. The facility policy Handwashing/Hand Hygiene, undated documents this facility considers hand hygiene the primary means to prevent the spread of infections. The policy documents use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: before and after direct care with residents, after removing gloves, before and after entering isolation precaution settings, before eating or handling food, before and after assisting a resident with meals. Based on observation, interview and record review, the facility failed to perform hand hygiene during passing meal trays, and failed to don Personal Protective Equipment for 8 of 8 residents (R2, R7, R14, R41, R55, R56, R71, R73) reviewed for infection control in a sample of 41. Findings include: 1. On 06/02/2025 at11:40 am, V16, Activity Director served meal trays to R2, R56 and R71 without benefit of hand hygiene in between serving each resident. 2. On 06/02/2025 at 11:40 AM, V25, Activity Assistant, served meal trays to R7 and R73 without benefit of hand hygiene in between each resident. On 06/05/2025 at 11:15 AM V16, Activity Director, stated that when she is passing meal trays, she washes her hand in between each resident. On 06/05/2025 at 11:15 AM, V25, Activity Assistant, stated that when she is passing meal trays, she washes her hand in between each resident. On 06/05/2025 at 11:15 AM, V26, Environmental Services Supervisor, stated that when she is passing meal trays, she washes her hand in between each resident. 3. On 06/04/2025 at 12:35 PM V5, Registered Nurse (RN), performed hand hygiene, gowned and gloved outside of R55's room. While gloved and gowned, V5 mixed the Ertapenem 1Gram, opened the Intra venous (IV) administration spike set, R55 wanted a blanket, and he took the blanket off of her bed and covered her up. He then spiked the IV Antibiotic bag with the administration spike set, primed the tubing and placed it in the IV pump. With the same gloved hands, he then opened the alcohol wipe package, swabbed the midline port, laid the alcohol wipe on top of the alcohol wipe package. He opened the normal saline flush package, and flushed R55's right midline IV access site, then took the used alcohol wipe, that was lying on the alcohol wipe package, cleansed the cap of the IV midline access and then screwed the IV administration line into the IV midline access without glove changes or benefit of hand hygiene. On 06/09/2025 at 09:53 AM V5, RN, stated that he should have changed gloves, performed hand hygiene and not reused the alcohol wipe when he was doing R55's IV. R55's Physicians order sheet, dated 06/02/2025, documented, IV antibiotics- Ertapenem Sodium Injection Solution Reconstituted 1 GM (Ertapenem Sodium) Use 1 gram intravenously one time a day for UTI for 5 Days. R55's Care plan, dated 6/2/2025 documented, Potential for infection (related to) IV Midline. The facility's policy, Handwashing/hand hygiene, undated, documented E. before and after handling an invasive device (e.g. urinary catheters, IV access sites). It continues, K. After contact with objects (e.g. medical equipment) in the immediate vicinity of the resident.

Based on observation, record review and interview the facility failed to identify a pressure sore for 1 of 3 residents (R41) reviewed for pressure sores in the sample of 41. Findings include: On 6/4/2025 at 12:43 PM, V11, Wound Nurse, was in R41's room performing R41's pressure ulcer dressing change. R41 was on right side facing window as V11 removed dressing from R41's sacrum. R41's pressure ulcer dressing was tan-light brown with foul smelling drainage. V11 cleansed R41's pressure ulcer with wound cleanser. R41's pressure ulcer was oblong with slough and eschar inside the wound bed, no granulation and the peri wound are red. V11 stated R41's pressure ulcer was facility acquired and at time the pressure ulcer was found to R41's sacrum the pressure ulcer was unstageable due to slouch and eschar. V11 packed puffed gauze in wound bed and covered with bordered gauze. R41's Care Plan, dated 8/25/2024, revised 3/26/2024 documents R41 has a potential for impaired skin integrity related to cognitive deficits, decreased sensation, Diabetes Mellitus, neuropathy, incontinence, edema. R41's Care Plan documents intervention dated 8/25/2021 observe skin integrity during am/pm care. R41's Care Plan intervention dated 8/25/2021 document notify physician promptly of skin breakdown. R41's wound assessment report dated 4/16/2025 documents new wound facility acquired on 4/12/2025. R41's wound assessment documents unstageable pressure ulcer length 2.50 Centimeters (CM) X 5.50 CM width depth .10cm. R41's wound assessment documents 100 % slough, epithelium exposed. R41's assessment documents peri wound fragile, erythema and mild odor. Assessment documents cleanse with antiseptic solution and hydrocolloid. R41's wound evaluation dated 6/4/2025 documents 0% granulation, 100% slough, exposed tissue epithelium, dermis, and subcutaneous. Periwound fragile, erythema no exudate. Documents clean wound with acetic acid daily and as needed. Documents primary treatment as Dakin's moistened fluffed gauze, skin prep surrounding tissue or peri wound bordered gauze. Evaluation documents wound size 4.00CM in length x3.50CM width and 2.80 depth. R41's Minimum Data Set (MDS) dated [DATE] documents R41 is severely cognitively impaired. R41's MDS documents R41 is dependent on staff for toileting, bathing, dressing, and personal hygiene. On 6/5/2025 at 12:50PM V11, Wound Nurse stated she would like to think pressure sore would have been found before unstageable. The facility policy Pressure Ulcer prevention, identification and treatment dated, revise 8/31/2023 documents the purpose is to provide guidelines that will assist nursing staff in prevention, identification, and appropriate treatment for pressure ulcers. The policy documents unstageable: Full thickness, tissue loss in which the base of ulcer is covered by slough (yellow, tan, gray, or brown) and/or eschar (tan, brown, or black) in the wound bed. The policy documents (when eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed, or the wound has been debrided.) The policy documents color identification red: pale pink to beefy red with or without healthy granulation tissue. Yellow: whitish yellow, creamy yellow, yellow-green or beige. Black: Black, stringy gray, or gray scab. The policy documents it is the responsibility of the Charge nurse/designee to care for pressure areas, and to provide treatments as ordered. The policy documents it is the responsibility of the Charge nurse/designee to measure and document on the pressure areas weekly. The policy documents it is the responsibility of the Charge nurse/designee to monitor healing progress and ensure appropriated treatment are in use. It is recommended that Director of Nursing (DON)/Designee make frequent pressure rounds with charge nurse. The policy documents it is the responsibility of the Certified Nursing Assistant to report any skin conditions to the charge nurse immediately upon identification.

Based on interview and record review, the facility failed to provide restorative services to prevent reduction in range of motion (ROM) for 1 of 4 residents (R58) reviewed for restorative therapy/Range of Motion (ROM) in the sample of 41. Findings include: R58's admission Record, dated 6/5/25, documents R58 was admitted to the facility on [DATE] with diagnoses of Polyneuropathy, Morbid Obesity, Buerger's Disease, Myiasis, Major Depressive Disorder, and Arthropathy. R58's Care Plan, dated 6/3/25, documents R58 Restorative: At risk for decline in their ability to complete bed mobility due to reduced physical function. Interventions: Assist R58 with completing bed mobility tasks with verbal cueing to participate to fullest potential. Provide R58 with verbal cues to use her side rails to assist in rolling in the bed. Provide R58 with hands on assist as needed. It continues R58 is a Long Term stay in Facility for Rehabilitation. R58's Minimum Data Set (MDS), dated [DATE], documents R58 is cognitively intact and is dependent on staff for toileting, dressing, and transfers. R58 is always incontinent of both bowel and bladder. On 6/2/25 at 10:00 AM, R58 stated I wish I could get PT (Physical Therapy) or some kind of therapy to work with me more. They said they were done with me and now, no one does anything with me. R58's Physician Order (PO), dated 3/27/25, documents PT to d/c (discharged ) from skilled PT interventions effective date 3-17-2025 due to max potential met. By (V19, Physical Therapist). R58's PO, dated 3/17/25, documents Patient to d/c from skilled OT (Occupational Therapy) interventions due to max potential met. R58's General Note, dated 4/21/25 at 10:09 AM, documents Seen by (physician). Resident is requesting more therapy even though she is at the maximum amount provided. Resident voiced understanding. The Therapy Department's Therapy to Nursing Recommendations dated 3/17/25, documents Therapy's Recommendation for R58 to continue to have Passive and Active ROM, Bed Mobility, and Transfers. On 6/4/25 at 2:10 PM, V19, Physical Therapist (PT), stated (R58) was discharged from therapy because she plateaued and was not improving. (R58) never wanted to get out of bed for PT to work with her with walking or anything like that. When we discharged (R58) we gave the nursing staff the Therapy to Nursing Recommendation form which told the nursing staff what we recommended after therapy. The problem here is there is no restorative staff here and they don't really work with the residents. I think that (R58) really needs ROM (range of motion) and exercises, especially since she doesn't do much on her own. On 6/4/25 at 2:15 PM, V20, Physical Therapy Assistant (PTA), stated We try to educate the staff on what the resident was working on in therapy. I know they are all licensed and should be educated and able to perform ROM and exercises with the residents. On 6/5/25 at 8:55 AM, V21, Registered Nurse (RN), stated We don't have any Restorative Aides here. The Certified Nursing Assistants (CNAs) are responsible for doing restorative care on the residents, but I don't think they are doing it. On 6/5/25 at 9:00 AM, V13 CNA, stated There are no restorative aides here. It is listed on the tasks list which residents need restorative care. R58's Tasks from her electronic health record, does not show any task related to ROM or exercises as recommended by therapy. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the staff to provide restorative therapy to the residents in need as recommended by therapy. We do not have specific restorative staff; however, all staff are trained to provide restorative care. The Facility's Restorative Program/Range of Motion policy, dated 2/3/22, documents in part Purpose: To provide resident with limited range of motion appropriate treatment and services to increase or prevent further decrease in range of motion. The facility protocol for ROM is ten repetitions daily, seven days a week for prevention of contractures. It is the responsibility of the nurse who completes the quarterly restorative assessment to identify resident's need for ROM exercise. It is the responsibility of the CNA to perform exercises as identified. It is the responsibility of the Care Plan Coordinator for addressing on the Care Plan.

Based on interview and record review the facility failed to implement an intervention to prevent falls for 1 of 4 residents (R41) reviewed for falls in the sample of 41 Findings include: 1. R41's Fall's Details report dated 5/2/2025 documents R41 was found on floor lying on stomach on mat beside bed. R41's report documents environmental conditions as bolsters were not clipped to bed. Report document R41 sustained a 3 centimeter (cm) long scratch to left cheek. R41's care plan dated 4/9/2021 documents R41 is at risk for falls r/t (related to) cognition deficit and history of fall with a fracture. Impaired mobility and lack of safety awareness due to diagnosis of dementia. R41's care plan documents the following interventions: 4/19/2025 bolster to bed for positioning. R41's Minimum Data Set, MDS, dated [DATE] documents R41 is severely cognitively impaired. On 6/5/2025 at 9:50AM, V1, Administrator stated the bolsters were loose and laying on the bed. The facility policy Accidents and Incidents dated revised 9/7/2023 documents the interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions.

Based on observation, interview, and record review, the facility failed to provide complete incontinent care and catheter care for 2 of 5 residents (R44, R58) reviewed for incontinence and catheter care in the sample of 41. Findings include: 1. R58's admission Record, dated 6/5/25, documents R58 was admitted to the facility on [DATE] with Diagnoses of Polyneuropathy, Morbid Obesity, Buerger's Disease, Myiasis, Major Depressive Disorder, and Arthropathy. R58's Care Plan, dated 4/2/25, documents R58's Self-Care Deficit as Evidenced by: Needs assistance with ADLs (Activities of Daily Living). Interventions: Toilet Use: Two-person physical assistance required. R58's Minimum Data Set (MDS), dated [DATE], documents R58 is cognitively intact and is dependent on staff for toileting. R58 is always incontinent of both bowel and bladder. On 6/4/25 at 12:50 PM, V13, Certified Nursing Assistant (CNA), and V10, CNA, provided incontinent care on R58. All supplies were on the bedside table, with a large pile of wash cloths that were wet from the restroom sink, and then placed on top of the bedside table. V10 sprayed a wet washcloth with peri-wash, wiped R58's right and left groins from top going down through R58's inner thigh, spread R58's labia and wiped downward front to back three times, then dried R58's groins and vaginal area. There was no wiping of R58's abdominal fold as she has Morbid Obesity. R58 was turned to her right side with V13 holding her while V10 sprayed a wet washcloth with peri-wash and wiped R58's left buttock down her posterior thigh, then dried. R58 rolled to her left side and V10 wiped R58's right buttock down her posterior thigh. V10 did not clean R58's anal area or between her buttocks. V10 applied cream to R58's right hip per R58's request, but there was no cream or moisture barrier applied to R58's groin, buttocks, peri-area, or skin folds. R58's Physician Order (PO), dated 11/5/24, documents Triad cream to buttocks and thighs. three times a day for MASD (moisture associated skin damage). R58's PO, dated 1/9/24, documents Skin Inspection / Nursing Weekly Assessment Thursday days. Every day shift every Thu (Thursday). R58's PO, dated 10/4/23, documents Interdry to breast and abdominal folds daily and PRN (as needed). Every day shift for rash and as needed daily PRN (as needed). 2. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with diagnoses of Cerebral Infarction, Hypertension (HTN), Dementia, Major Depressive Disorder, Benign Prostatic Hyperplasia (BPH), Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has impaired urinary elimination. Intervention: Supra pubic catheter as ordered. It continues R44 has a Self-Care Deficit. Interventions: Toilet Use- Requires one-person physical assistance with catheter care. It continues R44 is at High Risk for Urinary Tract Infection due to: Suprapubic Catheter. Interventions: Change catheter and drainage bag per MD (medical doctor) orders, empty catheter drainage collection bag QS (every shift), Enhanced Barrier Precautions, ensure catheter tubing and drainage bag are properly positioned to prevent urinary backflow or contamination, minimize catheter related injury, provide catheter / peri care QS, provide catheter irrigation as ordered, provide thorough perineal hygiene daily. R44's MDS, dated [DATE], documents R44 has a moderate cognitive impairment, requires substantial/maximal assistance for toileting. R44 has urinary catheter and is frequently incontinent of bowel. On 6/2/25 at 10:40 AM, R44 was lying in bed, suprapubic catheter in place, bag covered and hanging on his walker on the side of bed, dated 5/25/25. On 6/5/25 at 10:17 AM, R44 stated No one does any sort of catheter care on me. They change my bag and that is it. R44 showed his supra-pubic catheter coming out of his supra-pubic area, which appears dirty, and is draining a white substance into his incontinence brief and down his penis and scrotum. R44's PO, dated 11/1/24, documents Cleanse supra-pubic catheter site with Normal saline, apply TAO (topical antibiotic ointment) and T-drain sponge daily and PRN (as needed) until healed. Every day shift for drainage/redness at supra-pubic catheter site. This is documented as completed each day in the Treatment Administration Record (TAR). R44's PO, dated 9/18/24, documents Foley: Change Catheter Bag every 7 days and as needed when bag is soiled or Catheter Dislodged, and every night shift every 7 day(s) for catheter use. R44's PO, dated 9/18/24, documents Change Bag every 7 days and as needed every night shift every 7 day(s) for catheter use. R44's PO, dated 5/4/25, documents Suprapubic Cath care every shift. On 6/5/25 at 10:25 AM, R44's Catheter bag was seen dated 5/25/25. R44's Treatment Administration Record (TAR), dated June 2025, documents R44's catheter bag was changed on 5/28/25. The bag was due to be changed on 6/1/25 (every 7 days). On 6/5/25 at 10:30 AM, V22, CNA, brought in supplies to do catheter care on R44. V22 stated I have been here about a year, and I have never done catheter care on (R44), but I don't usually take care of (R44). V22 wet wash cloths in the sink and sprayed them with peri cleaner. V22 took R44's pants and incontinence brief off and stated His catheter does look dirty. It looks like it has been draining into his (incontinence brief). V22 provided incontinent care including wiping R44's penis and scrotum which had dried drainage from his supra-pubic site. R44 stated This was the first time that someone has cleaned my catheter like that. I used to have a leg strap to hold the catheter in place, but a nurse took it off and told me that I didn't need it. R44's catheter care was done with no TAO or T-drain sponge applied to his supra-pubic site. There was no securing of his catheter as it was fed through his pants leg. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the staff to perform complete incontinent care, including the cleaning of all areas. I would expect the staff to provide complete and timely catheter care, including site care, and bag changes as ordered. The Facility's Incontinence Care Policy, dated 5/1/22, documents in part All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Procedure: 8. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. 9. Apply protective skin lubricant and rub well into skin. The Facility's Indwelling Catheter Care Policy, dated 10/7/22, documents in part The facility shall maintain and care for foley catheters per the facility, following physician orders and adhering to facility infection control and best nursing practice standards. d. Empty the collection bag and perform indwelling catheter care at least every shift. Steps in the Procedure: 3. Fill the wash basin one-half (1/2) full of warm water. Place the wash basin on the bedside on the bedside stand within easy reach. 12. Use a clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to approximately four inches outward. 13. Secure catheter utilizing a leg band.

Based on interview, observation, and record review, the facility failed to administer resident medications at the correct time as ordered for 2 of 6 residents (R44, R39), reviewed for pharmacy services in the sample of 41. The Findings Include: 1. R44's admission Record, dated 6/5/25, documents R44 was admitted to the facility on [DATE] with Diagnosis of Cerebral Infarction, Hypertension (HTN), Dementia, Major Depressive Disorder, Benign Prostatic Hyperplasia (BPH), Uropathy, Malignant Neoplasm of Bladder, Wedge fracture of lumbar vertebra, and Malnutrition. R44's Care Plan, dated 5/26/25, documents R44 has a diagnosis of hypertension. Interventions: Give antihypertensive medications as ordered, Obtain blood pressure readings per orders. It continues R44 is receiving medications with a black box warning. Medication type: antidepressant, antianxiety agent, nonopioid/opioid analgesic. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R44 is at risk for altered nutrition and hydration related to recent illness, bladder cancer diagnosis. Interventions: Medication per MD (medical doctor) order. R44's Minimum Data Set (MDS), dated [DATE], documents R44 has a moderate cognitive impairment. R44's Physician Order (PO), dated 2/25/25, documents Amlodipine Besylate Tablet 10 MG (milligram), Give 0.5 tablet by mouth one time a day for HTN. R44's PO, dated 2/14/25, documents D-Mannose Oral Capsule 500 MG. Give 1 capsule by mouth one time a day for supplementation. R44's PO, dated 1/17/25, documents Lactobacillus Capsule, Give 1 capsule by mouth in the morning for supplementation. R44's PO, dated 1/17/25, documents Cranberry Oral Tablet 500 MG, Give 500 MG by mouth one time a day for supplementation. On 6/4/25 at 11:05 AM, R44 seen sitting at nurse's desk waiting for lunch. R44 has a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. On 6/4/25 at 11:18 AM, V12, Licensed Practical Nurse (LPN), stated Some residents have an order for Self-Administration of a medication and we leave that medication in their room. When advised of R44's meds still sitting in a cup in his room, V12 stated I put (R44's) medications on his table and he leaned over to take them, I thought that he took them. That was totally my fault. On 6/4/25 at 11:45 AM, V12, LPN, seen giving R44 his medications that he did not take earlier. Amlodipine 0.5 MG scheduled and was signed off as given at 6:00 AM, Cranberry tablet 500 MG scheduled and was signed off as given at 6:00 AM, D-Mannose 500 MG scheduled and was signed off as given at 6:00 AM, and Lactobacillus 1 capsule scheduled and was signed off as given at 6:00 AM. R44's General Note, dated 6/4/25 at 11:49 AM, documents Resident took morning meds at 11:45 today, MD (Medical Doctor) is aware. On 6/5/25 at 10:17 AM, R44 seen lying in bed, a medicine cup of medications (4 pills) sitting on his bedside table with a cup of water. R44 stated The nurse brought them in and set them on my table this morning and I have not taken them yet. On 6/5/25 at 10:25 AM, R44 was seen taking his cup of medications left at his bedside. 2. R39's admission Record, dated 6/5/25, documents R39 was admitted to the facility on [DATE] with Brown-Sequard Syndrome, Morbid Obesity, Cerebrovascular Disease affecting left non-dominant side, Hemiplegia/Hemiparesis, Arthropathy, HTN, Congestive Heart Failure (CHF), Cardiomegaly, Pulmonary Embolism (PE), BPH, and Gastro-Esophageal Reflux Disease (GERD). R39's Care Plan, dated 3/19/25, documents R39 has shortness of breath at times related to chronic bronchitis. R39 has asthma. Interventions: Inhalers as per MD order. It continues R39 is receiving medications with a black box warning. Medication type: Anticoagulant, Antihypertensive. Interventions: Administer medication as directed (correct time, dose, route, duration). It continues R39 has dx of GERD. Interventions: Give medications as ordered. R39's MDS, dated [DATE], documents R39 is cognitively intact. On 6/2/25 at 10:53 AM, R39 has a medicine cup with an orange pill in it (stated for his constipation), Fluticasone inhaler, Generic Afrin Nasal Spray on his bedside table, R39 stated The nurse always comes in and leaves my medications in a cup on my table, and I take them on my own, she never stays and watches me take them. On 6/4/25 at 11:20 AM, R39 has his Fluticasone Inhaler and a medicine cup with 3 large round pills sitting on his bedside table. R39 stated These are my Tums; they give me some in a cup for when I need them. R39's PO, dated 10/28/24, documents Advair Diskus Aerosol Powder Breath Activated 100-50 MCG (microgram)/Dose, 1 inhalation inhale orally every 12 hours for COPD (chronic obstructive pulmonary disease) related to other Pulmonary Embolism without Acute Cor pulmonale. Rinse mouth with water after use. Do not swallow the water. This order was updated on 6/4/25 as 1 inhalation inhale orally every 12 hours for COPD related to other Pulmonary Embolism without Acute Cor pulmonale. Unsupervised self-administration Rinse mouth with water after use. Do not swallow the water. R39's PO, dated 10/2/24, documents Senna-Plus Oral Tablet 8.6-50 MG, Give 1 tablet by mouth two times a day for Constipation. There was no order for the Generic Afrin Nasal Spray or Tums seen in R39's Physician Orders. On 6/5/25 at 3:20 PM, V1, Administrator, stated I would expect the nurses to watch the residents take their medications and not to leave them with the resident to take on their own. They all know they are not supposed to do that. The Facility's Medication Administration Policy/Procedure, dated 9/27/22, documents in part Medications will be administered safely to residents within the facility by Licensed Nurses at the specified time/timeframe, following the recommended administration method and will be documented as required. 9. Ensure medication has been swallowed before leaving. 10. Throw away used disposable supplies. 12. Chart the medication administered on the electronic medication administration record.

Based on interview and record review, the facility failed to have interventions in place to prevent a fall, for 1 of 3 (R2) residents, reviewed for falls in a sample of 4. This past non-compliance occurred from 2/19/2025 to 3/10/2025. Findings include: On 3/6/2025 at 11:15 AM, R2 was sitting up in his recliner, sleepy. Pad alarm was in place and call light was within reach. Easily awoken, there was a scabbed area to his chin but R2 has a full beard. Indwelling urinary catheter, was hanging on the side rail of the bed, below his recliner. R2 was asked what happened when he fell , he stated that he really didn't remember. He then stated that his sister was visiting him, he thought when he fell . He was asked if he fell in the morning or in the evening and he stated that he thought it was in the evening, but he really didn't remember. On 3/10/2025 at 10:00 AM, V4, Licensed Practical Nurse (LPN), stated that she was just getting her day started, it was right after shift change, when she heard R2 fall. She found R2 face down by his dresser. She continued to state that he did not have his alarms on, nor did he have his nonskid footwear on, and that he had on his regular socks. V4, also stated that he was up to his recliner prior to his fall. On 3/10/2025 at 3:45 PM, V5, LPN, stated that she didn't work on 2/19 but was there the night of 2/18, she stated that they do walking rounds and R2 wasn't having any behaviors. V5, LPN also stated that she doesn't remember him having an alarm pad on his bed or in his chair that night but also stated that it has been a long time ago. On 3/10/2025 at 12:50 PM V7, Certified Nurse Assistant (CNA), returned a call and stated that she did not recall if R2's pad alarm was in place that night while in bed or up to his recliner on 2/18. V7 stated that when there is a new fall intervention put in place, they are told in shift report of changes with residents. She continued to state that she did not recall if she was told that he required a pad alarm when in bed or when up to his recliner. On 3/6/25 at 2:00 PM, V8, CNA stated the pull tap alarms put in place need to be clipped on to the resident for it to function correctly. If they are not in place if they are dangling on the ground behind the wheelchair. V8 stated the alarm will blink when it needs a new battery. The pad chair alarms will typically show a green light when they are first applied to know it is turned on. On 3/6/25 at 2:05 PM, V6, CNA stated that the pull tab alarm needs to be attached to the resident in order for it to be effective and work. R2's Minimum Data Set, dated dated [DATE] documented that his cognition was severely impaired. R2's Fall risk Assessment, dated 2/12/2025, documented that he was a high risk for falls and that he was chair bound and /or assist with elimination. R2's Physician's orders dated 3/2025, documented diagnosis of Wedge Compression Fracture of T5-T6 and T11-T12, Lymphoid Leukemia and Neurocognitive Disorder with Lewy Bodies. It also documents an order on 2/18/2025 for Device: Alarm: To Bed and Chair as resident will allow. Check for placement and functioning every shift. R2's Care Plan, dated 2/8/2025, documented, Transfer: One person physical assistance required. R2's Care Plan, dated 2/11/2025, prior to a fall on 2/19/2025, documented, fall interventions of 2/11 Fall Mats, 2/11 Low bed, 2/18 Personal alarm at all times as resident will allow. It continues, Provide/Reinforce use of non-skid footwear. R2's Progress note, dated 2/19/2025 at 7:13 AM, documented, Resident found on floor in room face down near dresser. Laceration to chin and above left eye, hematomas started on forehead at this time. Right sided jaw pain and right shoulder pain. Wife notified, on call nurse aware, MD aware. Sent out for eval and treatment. Resident is alert x 4 at this time with paramedics. Unwitnessed fall and hit head. All paperwork sent with resident. R2's General Note, dated 2/19/2025 at 12:56 PM, documented, Resident returned from hospital. Closed comminuted fracture of right sided mandibular alveolar bone; Atypical syncope; chin laceration. Remove sutures in 5 days Ciprofloxacin 500 mg, 1 tab BID 14 days Potassium chloride 20 meq oral tab extended release po q day follow up with (Unknown Physician) within 1-2 days for worsening/continued problem. Call to schedule appointment. R2's Fall investigation with root cause analysis, dated 2/19/2025, documented, Type of incident: fall with injury. It continued, Pertinent Diagnosis: Neurocognitive Disorder with Lewy Bodies. Resident Status/Description of injuries (If Any): Laceration, mandibular FX. It continues, 78 y/o male who is non independent with ambulation. Resident got up to use the bathroom despite the indwelling catheter, became dizzy and fell . Laceration noted to chin and above left eye, right sided jaw pain, right shoulder pain. EMS was called to the facility and transported resident to (local hospital) for evaluation and treatment. (R2) returned from (local hospital) to the facility with sutures to close the laceration to chin. CT was negative for intracranial abnormality but did reveal an acute fracture of the right sided mandibular condyle. Resident returned to facility on 2/19/2025 and remains at baseline. Care Plan updated. Resident assessed for pain. Fall intervention updated and in place. It continues, Conclusion: IDT discussion on fall. Root cause: Bladder spasms. Upon investigation, resident recently returned to facility from hospitalization . During hospital stay, previous medications used to treat bladder spasms and hypotension had been discontinued. Intervention: Medication review. Problem Statement: Resident stood up to go to the restroom, got dizzy and fell forward. Why 1: bladder spasms, urge to void. Why 2: bladder spasms r/t indwelling foley cath. R2's Hospital record, dated 2/19/2025, documented, History of Present illness: Patient is a 78- year old male who presents emergency department after fall. According to the patient who resides in a nursing home currently and he reports that he blacked out and fell but this was witnessed. It continues, CT facial bones: It continues, .There is an acute comminuted and displaced fracture of the right mandibular condyle and there is right temporal mandibular dislocation. The right mandibular condyle is displaced medially and anteriorly with the jaw in a closed position. On 3/10/2025 at 2:55 PM, V2, Assistant Administrator, stated that they do not have a fall prevention policy. The facility's Policy, Accidents and Incidents, dated 9/7/2023, documented, 5. the Interdisciplinary Team (IDT) will conduct a thorough investigation of the accident/incident. Findings of the investigation, including root cause of the accident/incident and appropriate interventions will be indicated in the incident report and implemented. Prior to the survey date of 3/12/2025, the facility had taken the following actions to correct the noncompliance. 1. All staff inserviced on Fall interventions that need to be in place at all times and where to find this information. 2. House wide fall interventions audit and care plans reviewed. 3. Alarms were added to CNA task.

Based on observation, interview, and record review, the facility failed to ensure proper inflation of the air mattress in 3 (R2, R4, and R5) of 3 residents in the sample of 8 reviewed for safety. This failure resulted in R2 being found on the floor from an unwitnessed fall and suffering a laceration on the right side of the head and several skin tears. Findings include: 1. R2's undated face sheet documented that R2 was admitted to the facility on [DATE] with diagnoses of Parkinson's, dementia, neurocognitive disorder with Lewy Bodies, cachexia, and hypotension. R2's Minimum Data Sheet (MDS), dated [DATE], documented that R2 has severe cognitive impairment. R2 requires use of a wheelchair and is always incontinent of bowel and bladder. R2's Care Plan, dated [DATE], documented that R2's problems include self-care deficit, impaired cognitive function due to dementia with Lewy bodies, is at a risk for falls and injuries related to balance problems, dementia, tremor, scoliosis, and medications. The interventions for the fall risk include encourage use of call light, keep call light within reach, keep environment clutter free, keep personal belongings within reach, and provide adequate lighting. On [DATE] low bed was added. On [DATE], the care plan was updated adding bolsters to the air mattress and bed reset by maintenance and reviewed for proper functioning. R2's progress notes, dated [DATE] at 9:30 PM, documents that R2 was noted to be on the floor bedside her bed on her right side tangled up in her blankets. R2 was curled up laying on right side. There was a laceration to right side of head approximately 1 cm, a skin tear to right elbow approximately 1 centimeter, a skin tear to right hand approximately 1 centimeter, a skin tear to right knee approximately 1 centimeter. All wounds cleansed and dressed. Resident denies pain and cannot state what happened. Range of motion intact. Fall was unwitnessed. Neurology checks initiated. R2's physician orders, dated [DATE], at 10:06 PM documents monitor, steri-strips to right knee and reinforce as needed. To clean right elbow with normal saline, dry, apply xeroform & dry dressing. To also monitor steri-strips to the back of right hand two times per day and reinforce as needed. To right side of head monitor steri-strips, cleanse two times per day and reinforce as necessary. R2's incident report, dated [DATE], documents on [DATE] that the root cause was air mattress deflation. Bed was reset and properly functioning. Request entered for maintenance to check properly. Bolsters added to bed. On [DATE] at 9:55 AM, R2 was sitting in a high back wheelchair in their room. A half dollar size light blue discoloration was visible to R2's right cheek. R2 also had multiple scabbed abrasions in varies sizes to her forehead. When asked what happened R2 replied that she didn't know. On [DATE] at 9:10 AM, V11 (CNA) was asked why R2 had bruising on her face and abrasions on her forehead, and V11 stated that she heard R2 fell out of bed a couple of weeks ago. On [DATE] at 9:20 AM, V12 (CNA) was asked about the bolster, and she stated that is a mattress to help her not roll out of bed. V12 stated that hospice had brought this and before that she had a plain air mattress. She stated that she heard the previous mattress deflated on one side. On [DATE] at 10:30 AM, phone interview performed with V9 (RN), V9 stated V9 was called to the room and R2 was lying on the floor. V9 stated that the mattress was deflating on one side. R2 was curled up on the blankets on one side of the floor. V9 stated that R2 liked to curl up on one side of the bed. R2 had not had issues with her mattress prior to this. V9 stated that at the top of the mattress there is a plug that can be unplugged for a need for cardiopulmonary resuscitation, (CPR). V9 stated that these plugs often become unplugged easily and this happens quite often. V9 added that a few times she has been called into rooms because the mattress is deflating. On [DATE] at 12:15 PM, interview with V14, Health Information Coordinator. She stated that she worked the floor last week and was aware of R2's fall. V14 stated that R2 doesn't try to transfer herself. Sometimes in bed she gets a little wiggly at times. Air mattresses are usually an inflation problem. They are pinching off the tubing if the bed is raised to high. Maintenance comes and checks it out. On [DATE] at 12:33 PM V13 (Maintenance Director) was asked about the air mattresses. He stated he has problems with them all the time. He stated that when they go bad, they order a new one. Many times, it is due to the resident's positioning with the head or the feet of the bed too high. V13 added that nine times out of ten, it is a pin hole in the mattress. The facility buys their own air mattresses, and they usually have a spare one lying around. They leak and deflate air. He is unaware of any specific care instructions. The process of V13 includes that he has a work order program in place called Tells.com. In Tells.com the staff put a work order in, and I address. I check the Tells system a minimum of three times per day. Most of the time the problem is fixed that day. Many times, the air mattress issue is from the positioning of the bed with the mattress. I had one time that a motor went bad. When asked if air mattresses have a maintenance or preventative program, he stated they do not. 2. R4's MDS dated [DATE], documents that R4 has some moderate cognitive impairment. On [DATE] at 11:15 AM, R4 was asked if she has problems with her mattress deflating, she replied that yes that this happens a lot. They don't do nothing. 3. R5's MDS dated [DATE] documented that he is cognitively intact. On [DATE] at 11:20 AM, R5 stated that the mattress deflates often. He stated it feels like you're lying on a bar. On [DATE] V1, Administrator, provided a daily census and indicated that R5 was interview able. On [DATE] at 2:45 pm V1, Administrator, stated they do not have a policy regarding air mattresses and do not perform assessments for residents utilizing air loss mattresses. V1 also stated that she is aware of the deflating of the mattresses and had started purchasing a different brand, but still has problems with these mattresses deflating. The air mattress manual provided by facility documents that it is indicted for the prevention and treatment of all stage pressure ulcers when used in conjunction with a comprehensive pressure ulcer management program. Included in the manual are entrapment guidelines stating that the use of bed rails is dependent on the setting as well as the facilities protocols. Proper patient assessment, monitoring, equipment uses, and maintenance are required to reduce entrapment risk. Make sure the air hoses are not kinked or tucked under the mattress. Also check to ensure the cardiopulmonary resuscitation, (CPR) valves are properly attached. It stated that after using for some time (approximately 3 months), clean the air filter cotton inside the enclosure base, steps as below: 1. Take out air filter cover and air filter cotton. 2. Wash air filter cotton with clean water, if the dirt sticks to the filter, soak the air filter cotton in the water. 3. Dry the air filter cotton then put it back to the air filter cover.

Based on interview and record review the facility failed to provide safety and supervision for 1 of 3 (R3) residents reviewed for falls. This failure resulted in R3 falling, obtaining a laceration to the head, sutures and experiencing pain. Findings include: R3's Care Plan documents 6/28/23, documents that (R3) has a Self-Care Deficit As Evidenced by: Needs assistance with Activities of Daily Living (ADLs). It also documents Bed Mobility and Dressing require - One person physical assist required. R3's Care Plan continues (R3) is at risk for falls and injuries related to (r/t) cognition deficit and history of fall with fx. I have impaired mobility and lack safety awareness due to (d/t) my diagnosis (dx) of dementia. R3's Minimum Data Set, dated dated [DATE], documents that R3 is dependent on staff for Lying to sitting on side of bed: The ability to move from lying on the back to sitting on the side of the bed and with no back support. R3's Progress Note, dated 8/1/2024 at 5:15 AM, documents Nursing Note Late Entry: Note Text: Upon entering residents' room the resident was sitting on floor by roommate's bedside with Nurse's Aide (V8) sitting beside the resident. Resident noted to have a Laceration to their center of their forehead. I cleaned the resident's injury and applied a band aide to injury. Notified Hospice Care Team who recommended resident be sent out to ED (emergency department) for further evaluation along with Physician (V9) recommending the same as above stated. Notified residents emergency contact (V10) and on call Nurse (V3), ADON who verbalized an understanding of situation. R3's Progress Notes, dated 8/1/2024 at 5:15 AM, documents Change of Condition / Transfer Late Entry: Note Text: (R3) was transferred on a gurney via ambulance to acute care hospital Sent To: (Local) Hospital Date: 8/1/2024 5:15 Sent From: (Facility) Unit: Unit [NAME] Reason(s) for Transfer: Trauma (fall-related or other) -- head injury MD notified of transfer. See Transfer Form for other details. R3's Progress Note, dated 8/1/2024 at 8:34 AM, documents Nursing Note Text: Resident returned from (local) Hospital per facility transport in wheelchair. R3's Progress Note, dated 8/1/2024 at 12:54 PM, documents Nursing Note Text: Resident wincing with movement to arm/hand. Resident received scheduled Tylenol, still wincing/frowning/guarding arm/hand when attempting movement. Call to Hospice, Spoke with (V11 Case Manager.) NEW ORDER: Tramadol 50 mg q 6 hours for pain. Call to (V10), informed of new order. R3's Incident Report, dated 8/1/2024, documents that R3 had fallen from sliding off the bed. It also documented V8's statement: 8/2/2024 I was getting the resident up for the day, I had her sitting on the side of the bed, with the bed elevated. I was standing in front of the resident facing her and I went to grab the bed remote, which was stuck. At that time, I tried to grab remote with both hands to get it uncaught and the resident fell . The Report Form-IDPH Notification form, dated 8/7/2024, documents Fall with Injury. A comprehensive investigation was Initiated and showed that (R3) 88 YO female, non-independent transfer, dx dementia. Resident was sitting on the side of the bed being dressed by the aid with the bed elevated. CNA was standing in front of the resident facing her and went to grab the bed remote, which was stuck. At this time CNA tried to grab the remote with both hands to get it uncaught and the resident fell . On 8/13/2024 at 11:10 AM V4, Licensed Practical Nurse (LPN) stated that R3 is the most pleasantly confused person. V4 stated that R3 is dependent on staff for care. On 8/13/2024 at 11:13 AM V6, Certified Nurse Assistant (CNA), stated that R3 is dependent on staff for care. V6 stated that R3 cannot sit on the side of the bed independently. V6 stated that you must be directly in front of R3. V6 stated that R3 is also a picker. V6 stated that R3 reaches for and picks at things randomly. V6 this is why you have to be focused on her. On 8/13/2024 at 11:16 AM V7, CNA, stated that R3 is dependent on staff for care. V7 stated that R3 cannot walk and requires assistance with transfers. V7 stated that R3 is not safe sitting on the side of the bed and cannot sit there independently. V7 stated that you have to be right in front of R3. V7 stated that R3 picks at stuff in the air, around her and reaches out randomly. V7 stated that you have to have your hands on R3. On 8/13/2024 at 3:44 PM V12, LPN, stated that when he entered the room R3 was on the floor sitting on buttocks by roommate beds. V12 stated that he assessed R3 and then made the appropriate calls. V12 stated that R3 went to the hospital by ambulance and returned with sutures to her head. V12 stated that he was informed by V8, CNA, that she was assisting R3 with getting dressed. V12 stated that V8 had R3 sitting on the side of the bed. V12 stated that he was informed that V8 tried to grab the remote and turned her back for just a second and R3 fell face first onto the floor. V12 stated that R3 is alert and oriented to self only and was unable to communicate what happened. V12 stated because of this it is challenging to know when R3 is in pain. V12 stated that when it happened R3 did wince and whimper. On 8/13/2024 at 6:00 PM V8, CNA, stated that she was getting R3 dressed. V8 stated that she raised R3's bed up and R3's feet were off the floor. V8 stated that she initially had her arm around R3 but then took it off R3 leaned to grab the bed remote and R3 fell face forward. V8 stated that it was her fault she (V8) had the bed to high. The facility did not provide a Fall Prevention policy.

Based on observation, interview, and record review, the facility failed to handle food in a manner that prevents potential contamination, failed to restrain hair and perform hand hygiene during food service. This failure potentially affects all 83 residents residing in the facility. Findings include: 1. On 6/13/24 at 8:15 AM V3, Certified Nurse Aide, CNA, was feeding R1 breakfast. V3 was holding the toast with her bare hand and trying to get R1 to take a bite. V3 put the toast down multiple times and then attempted again with her bare hands. 2. On 6/13/24 at 11:25 AM, the kitchen was entered to observe the noon meal preparation. V13, Dietary Aide, was wearing a head band with a ponytail. V16, Corporate Dietary Supervisor, was wearing a hairnet that is positioned in the middle of her head. V16 also had a long side bang that was not restrained in the hairnet as it is lying on the side of her face. Neither V13's or V16's hair were restrained. During meal preparation V13 was observed to be preparing the residents trays with silverware, the drinks, and side dishes, V12, Cook, would then place main course, and then V13 would place the tray onto the serving cart. V13 was observed to scratch her head and face multiple times without washing her hands in between. 3. On 6/13/24 at 12:18 PM, V2, Director of Nurses, was holding R13's bologna sandwich with her bare hands and tearing it in half. V2 then hands the half of sandwich to R13. V2 then went to R14 and picks up her grilled cheese and takes the crust off the sandwich. 4. On 6/13/24 at 12:25 PM, V17, CNA, was assisting R15 with her lunch. V17 with bare hands picked up the grilled cheese sandwich, dunked it into the tomato soup, and then fed it to V17. On 6/14/24 at 3:30 PM, V1, Administrator, stated all kitchen staff should be wearing hair nets, washing their hands when needed, and wearing gloves when appropriate. V1 further stated that staff should not be touching residents' food with their bare hands. The policy Hand Washing, dated 9/1/21, documents, 4. When to wash your hands, Wash your hands as often as possible. It is important to wash your hands: Before starting to work with food, utensils, or equipment. It continues, After touching skin, face or hair. The policy Staff Attire, dated 9/1/21, documents, All staff will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. The policy Meal Assistance, dated 2/17/20, documents, 3. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of foodborne illness, including personal hygiene practices and safe food handling. The facility supplied document, dated 6/17/24, documents that the facility had 83 residents living in the facility.

Based on interview, observation, and record review, the facility failed to provide Oxygen to residents that required oxygen for 2 of 5 residents (R26, R56), reviewed for respiratory care in the sample of 40. This failure resulted in R26 becoming cyanotic with a low oxygen saturation of 51%. The Findings Include: 1. R26's Face Sheet, undated, documents R26 was originally admitted to the facility on [DATE] with diagnosis of Motor Neuron Disease, Asthma, Chronic Obstructive Pulmonary Disease (COPD), Osteoporosis, Atherosclerotic Heart Disease (ASHD), Sleep Apnea, Chronic Inflammatory Demyelinating Polyneuritis, Arthropathy, Primary Lateral Sclerosis, Major Depressive disorder, Anxiety disorder, Hypertension, Pneumonia, Malignant neoplasm of bronchus and lung, Pulmonary embolism, Venous Thrombosis and Embolism, and Dependence on Supplemental Oxygen. R26's Care Plan, dated 8/26/20, documented that R26 has shortness of breath lying flat related and with exertion due to COPD. It continues to document that R26 has oxygen therapy related to Ineffective gas exchange. It continues, Interventions: Oxygen Settings: O2 via Nasal Cannula (NC) as per MD (Physician) orders, give medications as ordered by physician. Monitor/document side effects and effectiveness. It continues, (R26) has COPD, Asthma, sleep apnea, and recent acute episode of respiratory failure with hypoxia. She uses oxygen, inhaler, nebulizers, and positioning. Interventions: Give aerosol or bronchodilators as ordered. Monitor/document any side effects and effectiveness, head of bed elevated to 40 to 50 degrees or resident's preference or out of bed upright in a chair during episodes of difficulty breathing, monitor for s/sx (signs/symptoms) of acute respiratory insufficiency: Anxiety, confusion, restlessness, SOB at rest, cyanosis, somnolence, nebulizer treatments per MD orders, Oxygen Settings: O2 via 2 liters daily via nasal cannula. On 5/20/24 at 9:38 AM, R26 was sitting in her wheelchair in her room with her nasal cannula (NC) in her nose with no sound of oxygen (O2) coming out of it. The nasal cannula was hooked up to a portable tank hanging on the back of her wheelchair and was completely empty, with the needle on gauge seen all the way to the left side in red, indicating empty. R26 was asked if she could feel anything coming out of her nasal cannula, and she was unsure if there was anything or not. There was no humidifier attached to the oxygen concentrator. On 5/20/24 at 9:48 AM, V11, Registered Nurse (RN)/Hospice Nurse, was seen visiting R26 and stated (R26) is usually on between 2 to 5 Liters (L) /NC to keep her oxygen saturation above 89 to 90%. On 5/20/24 at 9:48 AM, V12, Licensed Practical Nurse (LPN), was notified about R26's O2 being off because the portable tank was empty. V12 confirmed that the portable tank was empty and attached R26's NC to the O2 concentrator sitting behind her. V12 obtained an oxygen saturation on R26 which read 88% and V12 increased the O2 to 2.5 L/NC with O2 saturation reading above 90% afterwards. On 5/21/24 at 10:28 AM, R26 was seen sitting in her wheelchair with her head down, difficult to arouse, shallow breathing, and her fingertips were bluish in color. R26's nasal cannula was in her nose and attached to the portable oxygen tank which was totally empty and had no oxygen coming out of the tank. The oxygen concentrator is behind her and is currently off with a nasal cannula attached and lying on the floor. V12, LPN, was notified and went in to assess R26. V12 stated Yes, the tank is empty. (R26) doesn't tolerate being off her oxygen that is why her fingers are blue. V12 took off R26's nasal cannula and grabbed the nasal cannula that was connected to the O2 concentrator lying on the floor and put it into R26's nose and turned on the oxygen at 4 liters/minute. V12 attached a pulse oximeter to R26 which showed an oxygen saturation of 51% and a heart rate at 96. After approximately five to ten minutes, R26's oxygen saturation went up to 88% and her heart rate went down to 88. V12 stated she was going to call the Hospice Nurse to tell her that R26 was without oxygen for a while and her oxygen saturations had dropped. On 5/21/24 at 10:45 AM, V2, Director of Nursing (DON), was notified of the incident involving R26 and stated Please tell me they didn't pick the nasal cannula off the floor and put it in her nose. We will be doing some in-services. On 5/21/24 at 10:50 AM, V1, Administrator, walked into the office where surveyors were sitting and stated, I already know (about R26 situation), and we are doing an audit right now. On 5/22/24 at 8:35 AM, V4, Assistant Director of Nursing (ADON), stated We all pitch in to bring residents back from the dining room to their room, but whatever staff brings the resident on oxygen back to their room, should be telling the nurse that the resident is back and needs their oxygen back on. On 5/22/24 at 8:45 AM, V25, RN, stated When a resident on oxygen comes back from the dining room, they should be switched over from the portable tank to the concentrator. The aids should tell the nurse that the resident is back in their room. On 5/22/24 at 8:48 AM, V26, CNA, stated I'm not supposed to touch the oxygen, so if I bring a resident on oxygen back, I go tell the nurse to switch it over. I'm not going to lie, there may be times when I'm busy and forget to tell the nurse. On 5/22/24 at 10:50 AM, V1, Administrator, stated, I would expect the staff to ensure that any resident getting transferred while on a portable oxygen tank, returns to their room and is switched over to the concentrator. I would expect the staff member doing the transfer to notify the nurse that the resident is back and then would expect the nurse to take care of the residents oxygen needs. R26's Physician Order (PO), dated 3/15/24, documents Change Nebulizer mask/HHN (high humidity nebulizer) & tubing weekly, place in bag when not in use (Change bag weekly). Every Sunday for Infection Control and as needed for Infection Control Visibly soiled or damaged. R26's PO, dated 3/15/24, documents Oxygen: Rinse and Replace Intake filter every week. Change oxygen tubing and humidifier weekly. Every night shift, every Sunday for Infection Control. R26's PO, dated 3/15/24, documents Oxygen at 2-5 LPM (liters per minute) via nasal cannula as needed for SOB (shortness of breath)/Wheezing. R26's PO, dated 3/15/24, documents Oxygen: Pulse Ox (O2 Sat) As Needed For Shortness of Breath / Wheezing. R26's PO, dated 5/21/24, documents Oxygen PRN: if in use, ensure portable tank is full and functioning properly prior to meals. Transfer to concentrator in room at HS (hours sleep). R26's PO, dated 5/21/24, documents Continuous oxygen at 2-5 LPM via nasal cannula. Every shift for Shortness of breath. R26's Nursing Note, dated 5/21/24 at 10:54 AM, documented, Call to hospice (company) to make aware of low SPO2. Resident was placed on concentrator and SPO2 increased to 89-90% on 4 L, heart rate 85-90. Resident was reevaluated 10 minutes later and SP02 was 93% HR 80s. Lowered O2 to 3L and SPO2 is now 94-97%. Left message and awaiting return call from (hospice). DON aware. On 5/22/24 at 10:50 AM, V1, Administrator, stated that the facility does not have a policy on transporting a resident while on oxygen. 42108 2. R56's Care Plan, dated 2/6/2024, documented, (R56) has DX (diagnosis) of COPD (Chronic Obstructive Pulmonary Disease). It continues, O2 via nasal cannula as ordered. R56's MDS, dated [DATE], documented that R56 was cognitively impaired, required oxygen, and required assistance with ADL's. R56's POS, dated 1/26/2024, documented, Oxygen at 2 LPM via Nasal cannula continuous. May wean to room air as tolerated every shift. It continued, dated 5/21/2024, Oxygen PRN: if in use, ensure portable tank is full and functioning properly prior to meals. Transfer to concentrator in room at HS. On 05/19/24 at 3:02 PM, R56 was sitting in her room in her wheelchair. R56's oxygen tank was empty. V23, R56's daughter, went and got R56 a full tank. On 5/19/24 at 3:05 PM, V23, R56's daughter, stated that they allow R56's tank to go empty in the dining room and take her (R56) to her room and do not refill the tank. V23 also stated that the tank is always empty, and she (V23) has to get her new ones everyday she visits. The facility's Oxygen Administration Procedure Policy, undated, documented, The purpose of this procedure is to provide guidelines for safe oxygen administration. Equipment and Supplies: The following equipment and supplies will be necessary when performing this procedure. 1. Portable oxygen cylinder. It continues, 3. Humidifier bottle. Assessment: Before administering oxygen, and while the resident is receiving oxygen therapy, assess for the following: 1. Signs or symptoms of Cyanosis. 2. Signs or symptoms of hypoxia. It continues, Steps in the Procedure: 5. Check the tubing connected to the oxygen cylinder to assure that is free of kinks. 6. Turn on the oxygen. It continues, 9. Check the mask, tank, humidifying jar, etc., to be sure they are in good working order and are securely fastened. Be sure there is water in the humidifying jar and that the water level is high enough that the water bubbles as oxygen flows through. Ensure the tubing and humidifying jar/container are dated. 10. Periodically re-check water level in humidifying jar.

Based on observation, interview, and record review, the facility failed to properly store medication and failed to label a Tuberculin vial and Insulin vials. This has the potential to affect all 83 residents living in the facility. Findings include: On 05/19/2024 at 10:29AM the facility's 100-Hall Medication Storage Room was inspected. The refrigerator located in the 100-Hall medication room contained the following: 1. One open and partially used multi dose vial of Tuberculin. The vial was in the refrigerator, no open date on the vial. The Tuberculin Purified Protein Derivative, (Mantoux), Tubersol package insert, dated April 2016, documents A vial of Tubersol which has been entered and in use for 30 days should be discarded. On 5/19/2024 at 10:30 AM the Medicare medication cart was inspected. The cart contained the following: 2. R8's open and partially used multi dose Lantus vial. No open date. 3. R71's open and partially used multi dose Gargling vial. No open date. 4. R37's open and partially used multi dose Humalog vial. No open date. 5. R182's open and partially used multi dose Lantus vial. No open date. On 5/19/2024 at 10:36 AM V6, Licensed Practical Nurse, (LPN), stated, that the Tuberculin (TB) is a stock medication. V6 stated, that the TB medication is a stock medication and used for all residents in the facility. V6 stated, that unless they have an allergy all residents get a TB shot at least yearly. V6 stated, that this would be the medication that would be used. V6 verified that the multi dose vial was open and in use. V6 stated, that she had not used the insulin pen as they are scheduled for evenings. V6 stated, that the pen once put in use should have the resident name on it and the open date. V6 stated, that the TB multi dose vial and the insulin pens have different expiration days once open. V6 stated that the expiration date decreases. V6 stated that the open date lets them know when that date is. On 5/22/24 at 9:08 AM V25, Registered Nurse, stated that when opening a new Tuberculin multi dose vial, an open date or expiration date is placed on the box. V25 stated that once opened the use by date shortens to 30 days. V25 stated that the date lets them know when the use by date ends. V25 states that when removing an insulin pen from the box and it is not individually labeled the nurse is to place the open date or expiration date on it. V25 stated that once the vial is open the use by date shortens and the date that is placed on the vial when open lets them know when that is. The facility's Medication Storage policy, dated 8/23/22, documents Policy: The facility stores all drugs and biologicals in a safe, secure, and orderly manner and in accordance with state and federal regulations. It also documents, POLICY INTERPRETATION AND IMPLEMENTATION 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers. 4. Drug containers that have missing, incomplete, improper, or incorrect labels shall be returned to the pharmacy for proper labeling before storing. Discontinued, outdated, or deteriorated drugs or biologicals shall be returned to the dispensing pharmacy or destroyed. 5. Medications shall be administered prior to the manufacturer's expiration date. The CMS Long Term Care Facility Application for Medicare and Medicaid dated 05/19/2024, documents, the facility's Census 83.

Based on interview, observation, and record review, the facility failed to provide timely and complete incontinent care, including hand hygiene and glove changes for 5 of 5 (R23, R37, R48, R55, R180) reviewed for incontinence care in the sample of 40. The findings include: 1. R48's Face Sheet, undated, documented that R48 was admitted to the facility on [DATE] with the diagnosis of Brown-Sequard Syndrome, Hemiplegia and Hemiparesis, Intervertebral disc disorders with Myelopathy, Arthropathy, Morbid Obesity, Bronchitis, Hypertension (HTN), Heart Failure, and Benign Prostatic hyperplasia (BPH) with Urinary Tract symptoms. R48's Care Plan, dated 2/27/23, documented, (R48) has impaired urinary elimination related to (r/t) obstruction of urethra r/t BPH. (R48) was unable to use a urinal and will often place towels between my legs to urinate on. (R48) can make staff aware of my needs and when this has occurred. It continues, (R48) needs assist with his ADLs (Activities of Daily Living) r/t weakness, decreased endurance, diagnosis of Hemiparesis and obesity. Interventions: Transfer: (full body mechanical lift) required, Bed Mobility: Two-person assist for pulling resident up in bed; may require one or two-person assist for repositioning in bed depending on resident condition. Bathing: One-person physical assist required. It continues, (R48) has the potential for impaired skin integrity related to impaired mobility and decrease sensation resulting from hemiplegia. Interventions: Provide peri-care after each episode. R48's Minimum Data Set (MDS), dated [DATE], documented that R48 was cognitively intact and was dependent on staff for toileting, dressing, and transfers. R48 was always incontinent of both bowel and bladder. On 5/19/24 at 10:27 AM, R48 stated he uses a urinal at times but is also incontinent and has bowel movements (BM) in bed and will let the staff know with his call light. R48 stated that if it's during a mealtime, he has to sit in it a couple hours because the staff is in the dining rooms and assisting residents with eating. On 5/20/24 at 11:10 AM, R48 stated that he was incontinent of urine overnight while he was asleep. R48 stated that he woke up at 7:30 AM and was saturated in urine. R48 stated the staff came in asking him about breakfast, he told the Certified Nursing Assistants (CNAs) that he was wet, and they told R48 that they are doing breakfast right now, and that he will have to wait until after breakfast. R48 stated that the CNA then brought him his breakfast, and he had to eat his breakfast while saturated in urine. R48 stated that after breakfast, around 9:00 AM to 9:30 AM, the CNAs came in to get him up and take him to therapy, and that is when he finally got cleaned up. R48 stated that this happens a lot and that some staff will clean him up before he eats, and some will make you wait until after. R48 stated that it is Gross to sit in your urine while you eat. R48 stated that he has not been checked or cleaned up since the earlier time before therapy (9:00 to 9:30 AM) and that he is wet now and is waiting for lunch to be served. R48 stated that sitting in urine is gross, but sitting in your BM is not tolerable. On 5/20/24 at 11:50 AM, while this surveyor was observing from the hallway, R48 was heard telling V14, CNA, that he was wet and needed cleaned up, and V14 stated she will be back and left the room. R48 was delivered lunch shortly after and ate his lunch while saturated in urine. On 5/20/24 at 12:25 PM, R48 was still sitting in his wheelchair in his room, and had not been cleaned up yet. This Surveyor has been watching R48's room from the hallway and R48 has not been cleaned or checked. R48 stated he can use a urinal at times but when he goes to therapy, they put an incontinence brief on him, and he just goes in the brief. On 5/20/24 at 12:35 PM, V14, CNA, and V16, CNA, came in to assist R48 to bed via full body mechanical lift to get cleaned up. No hand hygiene was done as V14 donned gloves and began removing R48's pants, which were wet with urine. R48's incontinent brief was unfastened and appeared saturated with urine. R48 rolled to his left side, V14 used wet washcloths, sprayed the cloths with peri-cleaner, and then wiped R48's right buttock and anal area and did not dry the area. R48's skin appeared reddened, but no open sores noted. V14 tucked a new incontinent brief under R48, then changed her gloves with no hand hygiene completed in between glove changes. V14 applied moisture cream to R48's buttock and anal area. R48 was rolled back to his back and V14 wiped once under R48's abdominal roll, across his pubic area, once down left groin, once down right groin, around his penis, and around his scrotum but did not dry areas after being cleansed. R48 rolled to his right side and the soiled brief and pad were removed. R48's left buttock was not cleansed when he was on his right side. R48 was rolled back to his back side and onto the new brief. V16 provided powder to R48's abdominal roll, groins, and pubic area. Supplies were gathered, and both CNAs doffed their gloves with no hand hygiene done prior to leaving the room. Neither CNA did hand hygiene prior to or after resident care. 2. R55's Face Sheet, undated, documented that R55 was originally admitted to the facility on [DATE] with the diagnosis of Dysphagia, Congestive Heart Failure (CHF), Lumbar Spondylosis, Chronic Kidney Disease-stage 3, HTN, Urinary Tract Infections (UTI), and Osteoarthritis. R55's Care Plan, dated 10/16/23, documented, (R55) has a self-Care Deficit as evidenced by: Needs assistance with ADLs. Interventions: Toilet Use: Two-person physical assistance required, Transfer: Mechanical lift required with two staff assist. R55's MDS, dated [DATE], documented that R55 had a severe cognitive impairment and was dependent on staff for toileting, bathing, dressing, and transfers. R55 was always incontinent of both bowel and bladder. On 5/19/24 at 10:38 AM, V8, CNA, and V9, CNA, were seen getting R55 cleaned up and dressed for lunch. V8 did not do hand hygiene prior to donning gloves and caring for R55. V8 initially brought in a couple washcloths, ran the sink water in the restroom to get it warm, wet the washcloth and then placed it over the headboard. R55's pants were pulled down and her incontinent brief was unfastened and tucked between her legs. V8 wiped each groin once and once across pubic area, stopped and covered R55 up and left the room to get more washcloths without drying wet areas. V9 now entered to assist V8 and donned gloves with no hand hygiene done prior to. V8 came back with more towels and washcloths, donned gloves, again without doing any hand hygiene, put washcloths in a plastic bag, added water to bag, then added peri-wash to the cloths in the bag. V8 then wiped R55's pubic area and once down each groin again and did not dry the areas. V9 had to tell V8 to wipe down the middle of R55's vagina, so V8 got a wet washcloth and very minimally wiped once down the middle with no spreading of the labia nor was the areas dried. R55 was then rolled to her left side, and the incontinence brief was removed, which appeared saturated with urine. V8 wiped R55's buttocks and anal area without drying areas, and then with the same gloves on, walked to the restroom and opened the door to wet more washcloths in sink, then came out and changed her gloves, no hand hygiene was done. V8 donned gloves and wiped R55's anal area again with a wet wash cloth and did not dry the area. V8 then used the same gloves again to get a clean incontinence brief and bed pad, then doffed her gloves, and turned R55 to her right side. V9 then wiped R55's left buttock but did not dry it, fastened the incontinence brief, pulled R55's pants up. Both CNAs left R55's room without any hand hygiene completed. 42108 3. R37's Care Plan, dated 1/29/2024, documented, (R37) has Self-Care Deficit As Evidenced by: Needs assistance with ADLs (activities of daily living) r/t (related to) impaired mobility d/t (due to) recent illness. It continues, Personal Hygiene - One person physical assist required. R37's Minimum Data Set, dated dated [DATE], documented that R37 was cognitively intact and was dependent on staff for toileting. On 5/20/2024 at 10:21 AM, V17, Certified Nurse Assistant (CNA), performed incontinent care. R37 was incontinent of urine and bowel. V17 asked R37 to turn over. R37 turned on his left side. Using a wet washcloth, V17 wiped R37's anal area, but did not dry area. V17 then applied barrier cream to R37 buttocks without cleansing area. V17 then assisted R37 onto his right side and removed a heavily urine and bowel soiled pad. V17 then with a dry washcloth wiped the top of R37's left hip. V17 then applied clean gown and pulled a cover over R37. V17 gathered R37's soiled linen from the floor and left the room. V17 did not cleanse all areas of incontinence including R37's buttocks, penis, groin and peri area. 4. R180's Care Plan, dated 5/15/2024, documented, (R180) has Self-Care Deficit As Evidenced by: Needs assistance with ADLs Related to weakness, decreased mobility. It continues, Toilet Use: one person physical assistance required. R180's Skilled Care assessment, dated 5/19/2024, documented that R180 was alert and oriented to person, place, and time. It also documented that R180 was incontinent and requires assistance with toileting. On 5/20/2024 at 9:50 AM, V7, CNA, perform incontinent care. R180 was incontinent of bladder. V7 using a wet washcloth and peri wash spray cleansed R180's pubic area and down the right side of the outer labia. V7 then using a wet washcloth and peri wash cleansed down the front of R180's vaginal area. R180 lifted her buttocks off the bed and V7, using a wet washcloth and peri wash, wiped one swipe between the middle of R180's buttocks. All without benefit of drying the areas that were cleansed. V7 did not clean all areas of incontinence. V7 did not cleanse R180's groin, inner labia, entire outer labia, buttocks and inner thighs. On 5/22/2024 at 1:00 PM V1, Administrator, stated that she would expect the staff to clean all areas that urine and feces touch, buttocks, peri area, groin, vaginal, penis and scrotum. V1 stated that she would expect the staff to dispose of soiled linen in a bag. V1 stated that it is not appropriate to throw soiled linen on the floor. The facility's Perineal Care Competency 525, not dated, documented, 11. Female perineal care a. If resident is soiled with feces, place resident on side and dean perineum and rectal area. b. Change water and discard soiled linen appropriately. c. Change gloves d. Turn resident on her back e. Ask resident to separate her legs and flex knees. If she is unable to spread her legs and flex knees, the perineal area can be washed with the resident on the side with legs flexed. f. Use one gloved hand to stabilize and separate the labia, with other hand wash from front to back. Rinse and pat dry with towel. g. If resident is able to use bed pan place resident on bedpan and pour clean warm water or cleansing solution over the vulva and perineum. h. Dry the area well, remove bedpan, and position resident on back. 12. Male perineal care a. If resident is soiled with feces, place him on side and clean perineum and rectal area. b. Change water and discard soiled linen appropriately c. Change gloves d. Turn. resident on his back e. Ask resident to separate his legs and flex knees. If he is unable to spread his legs and flex knees, the perineal area can be washed with the resident on the side with legs flexed. f. Gently wash pubis and penis. If uncircumcised pull back foreskin and wash gently. Carefully dry and return foreskin to normal position. Make sure shaft of penis is dry. g. Ask resident to bend and separate knees. Help resident if required. Wash scrotum carefully. Rinse and pat dry. 13. Help position resident onto back. 14. Remove protective pad under buttocks, remove gloves. 15. Replace top bed linen. 16. Make resident comfortable. 17. Place call light in reach. 18. Document procedure in medical record. 32874 5. On 5/20/2024 at 11:07AM, V20, CNA and V21 CNA were providing incontinent care to R23 in her bed in her room. Both V20 and V21 CNAs both sanitized hands prior to donning gloves. A basin of soapy water sitting was on table at end of bed with bottle of peri wash oand a towel. V21 CNA stated he had put body soap in the water. V21 undid R23's adult diaper, R23 was dry. V20 CNA then took soapy wash cloth and went down left groin then right groin, R23 then started urinating in the diaper. So V20 then started the process over. V20, CNA then cleansed R23's left groin then right groin. V20 did separate and cleanse the labia. V20 did not rinse the soapy water off R23 nor did she dry R23. R23 was then rolled onto her side. V20 cleansed R23. V20 did not rinse soapy water off R23. V20 then dried R23's buttocks. R23's Minimum Data Set, dated dated [DATE], documented that R23 was dependent on staff for toileting. It also documented that R23 was frequently incontinent of urine. R23's Care plan, dated 4/25/2023, documented that R23 was incontinent of Bowel / Bladder. R23's care plan also documented an intervention, dated 4/25/2023, of clean peri-area with each incontinence episode. On 05/22/24 at 10:59 AM, V21, CNA, stated that if they use body soap and not the peri wash during incontinent care the resident should be rinsed. The facility incontinence care policy dated, revised 5/16/2022, documented, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinent care will be provided as required. The policy documents soap and water (peri wash) washcloth and towel, lotion (Vaseline.) The policy documents perform hand hygiene. apply gloves, wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and perform hand hygiene as required to prevent cross contamination. Apply protective skin lubrication and rub well into skin., perform hand hygiene.

Based on observation, interview and record review the facility failed to properly dispose of soiled linens, and cleanse hands between glove changes for 4 of 8 residents (R23, R48, R55 and R37) reviewed for infection control in the sample of 40. Findings include: 1. On 5/20/204 at 11:07AM, during incontinent care V20, Certified Nursing Assistant, (CNA), was providing incontinent care and R3 started, urinating, V20 removed gloves and donned new gloves. V20 did not sanitize hands prior to donning new gloves. R23's Minimum Data Set, (MDS), dated [DATE], documents, that R23 is dependent on staff for toileting. R23's MDS documents, that R23 is frequently incontinent of urine. R23's Care plan dated 04/25/2023, documents R23 is incontinent of Bowel/Bladder, related to Functional. R23's Care Plan documents, intervention dated 04/25/2023, to Clean peri-area with each incontinence episode. 44967 2. R48's Face Sheet, undated, documents R48 was admitted to the facility on [DATE] with the diagnosis of Brown-Sequard Syndrome, Hemiplegia and Hemiparesis, Intervertebral disc disorders with myelopathy, Arthropathy, Morbid Obesity, Bronchitis, Hypertension (HTN), Heart Failure, and Benign Prostatic hyperplasia (BPH) with Urinary Tract symptoms. R48's Care Plan, dated 2/27/23, documents R48 has impaired urinary elimination related to (r/t) obstruction of urethra r/t BPH. R48 is unable to use a urinal and will often place towels between my legs to urinate on. R48 can make staff aware of my needs and when this has occurred. It continues R48 needs assist with his Activities of Daily Living (ADLs) r/t weakness, decreased endurance, diagnosis of Hemiparesis and obesity. Interventions: Transfer: (full body mechanical lift) required, Bed Mobility: Two-person assist for pulling resident up in bed; may require one or two-person assist for repositioning in bed depending on resident condition. Bathing: One-person physical assist required. It continues R48 has the potential for impaired skin integrity related to impaired mobility and decrease sensation resulting from hemiplegia. Interventions: Provide peri-care after each episode, R48's Minimum Data Set (MDS), dated [DATE], documents R48 is cognitively intact and is dependent on staff for toileting, dressing, and transfers. R48 is always incontinent of both bowel and bladder. On 5/20/24 at 12:35 PM, V14, CNA, and V16, CNA, came in to assist R48 to bed via full body mechanical lift to get cleaned up. No hand hygiene was done as V14 donned gloves and began removing R48's pants, which were wet with urine. R48's incontinent brief was unfastened and appeared saturated with urine. R48 rolled to his left side, V14 used wet washcloths, sprayed the cloths with peri-cleaner, and then wiped R48's right buttock and anal area. R48's skin appeared reddened, but no open sore noted. V14 tucked a new incontinent brief under R48, then changed her gloves with no hand hygiene completed in between glove changes. V14 applied moisture cream to R48's buttock and anal area. R48 was rolled back to his back and V14 wiped once under R48's abdominal roll, across his pubic area, once down left groin, once down right groin, around his penis, and around his scrotum. R48 rolled to his right side and the soiled brief and pad were removed. There was no wiping of R48's left buttock when he was on his right side. R48 was rolled back to his back side and onto the new brief. V16 provided powder to R48's abdominal roll, groins, and pubic area. Supplies were gathered, and both CNAs doffed their gloves with no hand hygiene done prior to leaving the room. Neither CNA did hand hygiene prior to or after resident care. 3. R55's Face Sheet, undated, documents R55 was originally admitted to the facility on [DATE] with the diagnosis of Dysphagia, Congestive Heart Failure (CHF), Lumbar Spondylosis, Chronic Kidney Disease-stage 3, HTN, Urinary Tract Infections (UTI), and Osteoarthritis. R55's Care Plan, dated 10/16/23, documents R55 has a self-Care Deficit as evidenced by: Needs assistance with ADLs. Interventions: Toilet Use: Two-person physical assistance required, Transfer: Mechanical lift required with two staff assist. R55's MDS, dated [DATE], documents R55 has a severe cognitive impairment and is dependent on staff for toileting, bathing, dressing, and transfers. R55 is always incontinent of both bowel and bladder. On 5/19/24 at 10:38 AM, V8, CNA, and V9, CNA, was seen getting R55 cleaned up and dressed for lunch. V8 did not do hand hygiene prior to donning gloves and caring for R55. V8 initially brought in a couple washcloths, ran the sink water in the restroom to get it warm, wet the washcloth and then placed it over the headboard. R55's pants were pulled down and her incontinent brief was unfastened and tucked between her legs. V8 wiped each groin once and once across pubic area, stopped and covered R55 up and left the room to get more washcloths. V9 now entered to assist V8 and donned gloves with no hand hygiene done prior to. V8 came back with more towels and washcloths, donned gloves, again without doing any hand hygiene, put washcloths in a plastic bag, added water to bag, then added peri-wash to the cloths in the bag. V8 then wiped R55's pubic area and once down each groin again. V9 had to tell V8 to wipe down the middle of R55's vagina, so V8 got a wet washcloth and very minimally wiped once down the middle with no spreading of the labia. R55 was rolled to her left side, and the incontinence brief was removed, which appeared saturated. V8 wiped R55's buttocks and anal area, and then with the same gloves on, walked to the restroom and opened the door to wet more washcloths in sink, then came out and changed her gloves, no hand hygiene was done. V8 donned gloves and wiped R55's anal area again and use the same gloves again to get a clean incontinence brief and bed pad, then doffed her gloves, and turned R55 to her right side. V9 then wiped R55's left buttock, fastened the incontinence brief, pulled R55's pants up. Both CNAs left R55's room without any hand hygiene completed. 42108 4. R37's Care Plan, dated 01/29/2024, documents, R37 has Self-Care Deficit as Evidenced by: Needs assistance with ADLs, (Activities of Daily Living), r/t, (related to), impaired mobility d/t, (due to), recent illness. It also, documents, Personal Hygiene - One-person physical assist required. R37's Minimum Data Set, dated dated [DATE], documents, that R37 is cognitively intact and dependent on staff for toileting. On 05/20/2024, at 10:21AM observed V17, Certified Nurse Assistant, (CNA), perform incontinent care. R37 was incontinent of urine and bowel. V17 asked R37 to turn over. R37 turned on his left side. Using a wet washcloth, V17 wiped, R37's anal area and threw urine and feces soiled washcloth on floor beside the bed. V17 then applied barrier cream to R37 buttocks. V17 then assisted R37 onto his right side and removed a heavily urine and feces soiled pad and threw it on the floor. V17 then with a dry washcloth wiped the top of R37's left hip and threw it on the floor. V17 then applied clean gown and pulled cover over R37. V17 gathered R37's urine and feces soiled linen from the floor and left the room. The facility's Perineal Care Competency 525, not dated, documents 12. Male perineal care a. If resident is soiled with feces, place him on side and clean perineum and rectal area. b. Change water and discard soiled linen appropriately. The facility's Handwashing/Hand Hygiene policy, not dated, documents Policy Statement This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; g. Before handling clean or soiled dressings, gauze pads, etc.; h. Before moving from a contaminated body site to a clean body site during resident care; i. After contact with blood or bodily fluids; k. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; I. After removing gloves; 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. It also documents Applying and Removing Gloves l. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on interview, observation, and record review, the facility failed to provide adequate lighting for 1 of 3 residents (R63) reviewed for reasonable accommodations for residents in the sample of 40. The findings include: R63's Face Sheet, undated, documented that R63 was admitted to the facility on [DATE] with diagnosis of Polyneuropathy, Morbid obesity, Buerger's Disease, Myiasis, Major Depressive disorder, Arthropathy, restlessness and agitation. R63's Care Plan, dated 10/11/23, documented, R63 is focused on therapy and prefers to spend the majority of her free time resting in the comfort of her room involved in independent leisure pursuits. Interventions: Resident enjoys Reading scary books. It continues, 2/21/24 (R63) is at risk for falls related to (r/t) decreased mobility, History of Arthropathy, Polyneuropathy. Interventions: Provide adequate lighting, encourage use of call light, keep call light within reach, keep personal belongings within reach, provide verbal safety cues, provide/reinforce use of assistive devices: (Specify: Reacher, walker, cane, wheelchair, transfer pole, provide/reinforce use of non-skid footwear). R63's Minimum Data Set (MDS), dated [DATE], documented that R63 was cognitively intact and was dependent on staff for toileting, dressing, and transfers. R63 also required extensive assistance from staff for other Activities of Daily Living (ADLs). R63 was always incontinent of bowel and bladder. On 5/19/24 at 9:55 AM, R63's room appeared very dark and R63 stated the over bed lights in her room are burnt out. R63 stated that she told the maintenance man about it at least a month ago, and she was told that he was waiting on parts. On 5/20/24 at 1:10 PM, V18, Wound Nurse, is doing wound care for R63. V18 stated I need to buy a headlamp so I can see. It's dark in here. On 5/20/24 at 1:25 PM, While watching V18 provide wound care for R63, it appeared very dark in her room. R63 stated that she has no lights on her side of the room, her over the bed lights are out and that V19 Maintenance Director was aware and told her that parts are ordered to fix it. The only light in the room is one over the bed light on her roommate's (R19) bed and there is only one light bulb on there. R63 stated that at night, she has to use the television or her laptop computer for light or will just go to sleep because it's dark. On 5/20/24 at 1:30 PM, V19, Maintenance Director, stated that he was aware of R63's lights out and he has a work order to fix it. V19 stated that R63's lights over her head of bed uses three-foot Incandescence light bulbs and he is in the process of changing all over the bed lights to LED instead. V19 stated he is having trouble finding the correct size LED bulbs to go into the lights. When asked about just putting the regular bulbs back in until he can find the LED bulbs, V19 stated that he had to order them too, and they came in maybe a week or so ago, but he has been busy and hasn't had the time to put them in. V19 stated he will put them in immediately. This was brought up to V1, who followed up and made sure it was completed. On 5/20/24 at 2:50 PM, V1, Administrator, stated Yes, I would expect the maintenance man to replace light bulbs in resident's room when needed. The Maintenance Work Order, dated 4/26/24, documents 117 W has no working light above her bed. Stated it has been out for a week now. Priority: Critical. The facility's Resident Rights - Homelike Environment Policy, dated 7/18/22, documented, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting. 4. Comfortable and adequate lighting is provided in all areas of the facility to promote a safe, comfortable, and homelike environment. The lighting design emphasizes: a. Sufficient general lighting in resident-use areas; b. Task lighting as needed; c. Reduction in glare (through use of light filters, no wax floors); d. Even light levels; e. Maximum use of daylight; f. Night lighting to promote safety and independence; g. Dimming switches, where feasible.

Based on observation, interview, and record review, the facility failed to ensure a resident with moderate cognitive deficits who was identified as a potential risk for elopement did not exit the building unattended for 1 of 3 (R2) residents reviewed for elopement in the sample of 5. This past non-compliance occurred between 12/30/2023 and 1/2/2024. Findings include: R2's Care Plan, dated 10/12/22, documents that R2 has Potential Risk of Elopement due to Cognitive deficit and History of wandering. It also documents Identify any Patterns or Exacerbating Factors, Identify Individual factors which seem to calm, alleviate, or reduce behavior, Keep familiar items in residents living space, Monitor whereabouts regularly; Recognize any unsafe conditions or escalating patterns, Provide re-direction and Diversion as needed, Respond to any alarm activation promptly. R2's Minimum Data Set, dated dated [DATE], documents that R2 is moderately cognitively impaired. R2's Face Sheet, not dated, documents unspecified Dementia, Unspecified severity, with other behavioral disturbance as diagnosis. R2's Elopement Assessment, dated 10/19/2023, documents that R2 is not at risk for elopement. R2's Elopement Report, dated 12/30/2023, documents Resident was reported to be outside in street, was noted by staff that an ambulance driver was attempting to assist resident. Staff intervened and assisted resident back to facility. Resident reported he was attempting to go home, no c/o (complaints), no injuries noted. Was reported to (V1-Administrator) (on call), order to have wander guard applied, (V8) from Transport applied, called Wife (V9), left message to call facility. It also documents that resident description was that he wanted to go home, he was going to church street. R2's Progress Notes, dated 12/30/2023 at 9:00 AM documents Resident was reported to be outside in street, was noted by staff that an ambulance driver was attempting to assist resident. Staff intervened and assisted resident back to facility. Resident reported he was attempting to go home, no c/o, no injuries noted. was reported to (V1) (on call), order to have wander guard applied, (V8) from Transport applied, called Wife (V9), left message to call facility. On 1/10/2024 at 10:00 AM V5, Certified Nurse's Assistant (CNA), stated that she has been at the facility for about a month. V5 stated that she has worked with R2 and R2 requires assistance with all his care. V5 stated that he tries to help but is pretty much dependent on staff for care. V5 stated that R2 is confused. V5 stated that R2 is alert to name but that is it. V5 stated that this has been this way since she has been here. On 1/10/2024 at 10:05 AM V6, CNA, stated that he was here when R2 left the building. V6 stated that he was pushing a resident down the hall and heard the door alarm go off. V6 stated that he walked towards the door and saw R2 outside. V6 stated that he went outside and helped R2 back in. V6 stated that when he went out to get R2 he was where the parking lot meets the road and 2 EMTs (Emergency Medical Technicians) was with R2. V6 stated that R2 did not have any injuries and did not appear in distress. V6 stated that R2 said he wanted to go across the street to his family house. V6 stated that R2 is normally confused and wanders the building in his wheelchair. V6 stated that he has not seen him attempt to leave the building but is aware of R2 wandering. On 1/10/2024 at 10:10 AM V3, Licensed Practical Nurse, stated that she was at dining room passing medications. V3 stated that the door alarm went off. V3 stated that she was notified by V6 that R2 had went out the door and made it to the street. V3 stated that she did not see R2 out there herself, but this is what she was told. V3 stated that she assessed R2, and no injuries were noted. V3 stated that R2 has always been confused and made statements that he wants to leave and go home. V3 stated that she is not aware of him making any attempts to do so. V3 stated that R2 has sat next to the doors and never went out. V3 stated that R2 wanders through the building in his wheelchair. V3 stated that R2's wife comes in the evening and spends time with him. V3 stated that R2 wants to be home with her but is not aware of any attempts to leave. On 1/10/2024 at 10:26 AM, R2 stated that he went outside to go across the street. R2 stated that he didn't make it because some guys stopped him. R2 stated that he made it to the middle of the street. R2 stated that the guys were nice, but he wanted to go across the street to his family house. R2 stated that he does not know who the men were. R2 stated that when returning to the building he felt like he was in trouble and felt like a prisoner. On 1/10/2024 at 11:31 AM V4, EMT, stated that he and his partner were leaving the hospital across the street. V4 stated that he saw R2 in the wheelchair out in the street. V4 stated that R2 was moving the wheelchair. V4 stated that they turned on the emergency lights to stop traffic. V4 stated that he got out to help R2 back to the facility. V4 stated that he asked where he (R2) was going. V4 stated that R2 told him (V4) that he was going to the church across the street. V4 stated that he told him that it was not a church and that it was a hospital. V4 stated that he helped push R2 back towards the facility and at that time the staff came out and took R2 back into the facility. On 1/10/2024 at 12:03 AM V7, EMT, stated that he and his partner were coming from the hospital and saw R2 trying to go cross the street. V7 stated that R2 was pushing his wheelchair. V7 stated that the only thing that kept R2 from making it all the way across was that he was stuck on a piece of ice. V7 stated that they turned on the emergency lights to keep R2 from being hurt. V7 stated that R2 was on the black asphalt. On 1/10/2024 at 1:14 PM V1, Administrator, stated that R2 did not elope. When asked how did she come to this conclusion? V1 stated because R2 did not get hurt. On 1/11/2024 at 11:08 AM, V1 stated that she was aware that R2 made it to the middle of the street. V1 stated that she checked the area where R2 went out and it's an incline. V1 stated that this (elopement) occurred in a matter of 5 minutes. V1 stated that she has spoken to her corporate about it to see if there is something that can be done. The facility's Elopement and Missing Resident Policy, dated October 2009, located in the elopement binder's documents that it is standard policy to monitor and evaluate residents at risk for wandering and elopement. It also documents the Elopement Definition as elopement occurs when a resident leaves the premises or a safe area without authorization or staff notification and/or any necessary supervision to do so. The facility's Wandering/Elopement Policy, dated 10/18/22, documents that the facility will identify residents who are at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Prior to the survey date, the facility took the following actions to correct the deficient practice: 1. A Quality Assurance and Performance Improvement meeting was held on 1/2/24. In attendance - V2, Director of Nursing (DON), V8, Transportation Aide, V10, LPN, V11, Social Service Director, V12, Maintenance Director, V13, Asst. Maintenance Director, V14, Asst DON, and V15, Wound Nurse. The following was discussed. The resident was brought back into facility, elopement risk was reassessed, applied wander guard. The Resident was added to the elopement book. The door alarm volume/level checked, and volume increased. 2. Process/Steps to identify others having the potential to be impacted by the same deficient practice: All resident's elopement assessments were reviewed for accuracy. 1/2/24. 3. Measures put into place/systematic changes to ensure the deficient practice does not recur: Staff have been re-educated on 1/2/24 on elopement policy and procedure. Staff were educated on the elopement book and location. 4. Plan to monitor performance to ensure solutions are sustained: Admin or designee will monitor 5 days per week door alarm functionality and residents with wondergaurds will be monitored BID (twice daily) for placement and weekly on Fridays for wondergaurds function. Audits will be reviewed by the QA committee monthly to ensure continued compliance and will revise as needed to maintain compliance.

Based on observation, interview and record review the facility failed to provide adequate supervision to prevent falls for 1 of 4 residents (R2) reviewed for falls in the sample of 18. This failure resulted in R2's fall sustaining a subdural hematoma and later expiring from this injury. Findings include: R2's Electronic Medical Record (EMR) dated 6/2021, documents R2 was admitted to the facility on [DATE] with diagnosis to include [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] (CVA), Effusion Right Knee, [CONDITION(S)] and Collapse. R2's Minimum Data Set (MDS) dated [DATE] documents R2 has moderately impaired cognition, requires extensive assist of two persons for transfers and toileting. R2's Fall Risk assessment dated [DATE] documents at High Risk of Falling. R2's Care Plan documents a history of multiple falls. R2's Care Plan and Interventions in place prior to 5/27/21 fall, dated 4/6/21 documents, Focus: At risk for falls and injuries related to (r/t) CVA, medications, and history of multiple falls. Goals: Decrease risk of fall and/or minimize injuries from falls x 90 days. Interventions: Encourage use of call light, Date Initiated: 04/06/2021. Keep call light within reach, Date Initiated: 04/06/2021. Keep environment clutter free, Date Initiated: 04/06/2021. Keep personal belongings within reach, Date Initiated: 04/06/2021 Provide adequate lighting. The Care Plan has nothing to address R2's current needs for level of supervision. On 8/3/21 at 9:41 AM, V13, Licensed Practical Nurse (LPN), stated, (R2) spent a lot of time in bed. She did not have good safety awareness. (R2) was not strong enough to transfer on her own. She would occasionally try to get up by herself. She was able to use the call light. On 8/3/21 at 9:45 AM, V14, Certified Nurse Aide (CNA), stated, (R2) needed assist of 1 to 2 people for transfers, sometimes she would try to get up by herself. On 8/3/21 at 9:55 AM, V18, Physical Therapist (PT), stated, (R2) had a safety awareness deficit, she needed 1 person assist when out of bed. On 8/3/21 at 10:15 AM, V19, CNA, stated, (R2) needed 1 to 2 person assist with transfers and walking. She was known to get up and try to take herself to the bathroom. At times, she would turn the call light on but if staff did not get in there right away, she would try getting up with the walker. On 8/3/21 at 1:33 PM, V9, LPN, stated, For some reason, (R2) attempted to get up by herself. She was in bed; she was not in the wheelchair. Her wheelchair was next to the wall by her roommates' bed. It was not within her reach. When I went in, she was lying face down and really wasn't moving much. I was concerned about moving her, I rolled her over on her back. She had blood coming from her nose, her lip was busted up pretty bad. I called her doctor and called 911. She did not have her call light on. She needed assist of one to get up. It would be dangerous for her to be up by herself. R2's Progress Notes dated 5/27/21 at 9:30 PM, document, General Note Note Text: Author in hallway passing medication at approximately 9:00 PM on 5/27/2021 and heard noise from resident's room. Upon entering, author noted resident to be laying face down on floor and attempting to roll over. Author questioned resident for neck pain. Resident denied neck pain and voiced for someone to help her up off the floor. Author assisted resident over on back and advised that some assessment of skin would be needed. Author noted a deep laceration to upper lip with steady bleeding. Author noted a trickle of blood from left nare. Author noted slight bleeding evident on bridge of nose. Resident's pupils were noted to be equal, round, reactive and accommodating. Author advised resident it may be necessary to go to hospital for evaluation. Resident voiced disapproval with idea and requested only to be put in bed. Author left room to call doctor and following advisement of condition, doctor gave order to transport to local emergency room (ER) for evaluation and treatment. R2's Fall Investigation and Intervention report dated 5/27/21, documents, Incident description Author in hallway passing medication and heard noise in resident room, author entered and noted resident to be on floor face down, resident was attempting to self ambulate to the bathroom without requesting assistance. Immediate Action taken: vitals taken. Inquired to neck pain. resident denied neck pain, author assisted resident over to back and then assessed upper and lower extremity range of motion, author used pen light to check pupil status, author performed skin check, author contacted personal care physician (pcp) with request to send resident to ER for evaluation and treatment. Root cause: Resident was self ambulating to the toilet without assistance and fell to the floor. Intervention: Call don't fall sign in room. R2's Local ER report dated 5/27/21 documents include, Physical Exam: General: The patient is a [AGE] year old female that is alert and oriented, with significant facial trauma/swelling and bruising forehead, nose, around and specially at medial aspect both eyes, very swollen and bruised upper lip. Speech is normal and coherent. Medical Decision Making: 9:53 PM, Evaluated patient at bedside. Pending laboratory and radiology results. At 11:03 PM, Spoke with radiologist, discussed radiology results. Diffuse subarachnoid and subdural hemorrhage. Plan transfer patient to (Larger hospital) for further work up and treatment. R2's Computed Tomography of the Brain dated 5/27/21 documents, IMPRESSION: 1. There is subarachnoid hemorrhage along both frontal and temporal lobes greatest on right. 2. There is also subdural hemorrhage along the anterior falx and right frontoparietal the convexity. There may be some subdural hemorrhage along the inferior frontal lobes as well. No significant mass effect or midline shift. R2's Progress Notes dated 6/3/21 at 5:38 PM, document, Admission Notes Note Text: Resident readmitted from hospital via facility van in wheelchair (w/c). Resident alert with some confusion, complains of (c/o) discomfort to buttock being up in w/c and assisted to bed per 2 staff (max assist). Resident noted with severe bruising to face, bilateral knees, Left hand (edema), Left shoulder area, Left breast area, Right shoulder area, RAC (right antecubital), skin tear to LAC (left antecubital). Resident only wanted to go to bed, stated she was very tired. vital signs stable (VSS). R2's Progress Notes dated 6/7/21 at 6:20 PM document, Neurological Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) Weakness or [CONDITION(S)] Nursing observations, evaluation, and recommendations are: patient having difficulty swallowing, answering questions, increased pulse, poor posture, increased weakness Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: Recommendations: send to ER for evaluation and treatment. R2's Progress Notes dated 6/7/2021 at 6:44 PM, document, Change of Condition / Transfer Note Text: R2 was transferred on a gurney via ambulance to acute care hospital. MD (medical doctor) notified of transfer. R2's Progress Notes dated 6/7/2021 at 10:30 PM document, General Note Text: author called to check on status update on (R2). ER nurse advised that (R2) was being transferred to other hospital following head CT showing increased fluid and a midline shift. R2's CT report dated 6/7/21 documents, Right subdural hematoma on the right side now contains less acute bleeding however overall increase in size of 1.2 centimeters (cm) at the right frontal lobe compared to 0.6 cm previously subarachnoid blood products have significantly decreases from previous exam. R2's Hospital Admission History and Physical dated 6/8/21 documents, Impression and Plan: [AGE] year old lady with past medical history of hypertension, diabetes mellitus, [CONDITION(S)], [CONDITION(S)], [CONDITION(S)] patient presented to outlying hospital from her nursing home for increased confusion, repeat head CT as done at outlying hospital which showed increased midline shift. Patient was evaluated in the ER and being admitted to neurocritical care for further monitoring. R2's Death Certificate documents date of death [DATE]. Cause of death Subdural Hematoma due to fall with head injury. Date of injury 5/27/21. On 8/5/21 at 10:05 AM, V2, Director of Nurses (DON), was asked if she felt a call bell is an effective intervention for a resident who is a fall risk with impaired cognition, she stated, Interventions should be individualized depending on the resident. The facility Policy and Procedure for Fall Prevention dated 9/15/2019, documents, Purpose: To provide guidelines on preventing resident falls or injuries. Initial Screen: 1. Review hospital records for fall related information. 2. Interview family or resident for history of prior falls, frequency of falls. Common cause of falls. 3. Complete the fall assessment initially on admission, quarterly, and with a change of status. Initial Plan of Care: 1. Initiate risk reducing interventions. 2. Verify and obtain orders if needed. 3. Develop admission care plan. Resident Assessment: 1. Complete Minimum Data Set. 2. Complete Resident Assessment Protocol. Individualized Care Plan: 1. Identify Problem or need. 2. State measurable goal. 3. Specify target date. 4. List interventions. 5. Provide resident and family education as appropriate. Action Steps: 1. Provide ongoing risk reducing interventions. 2. Initiate physician orders as needed. 3. Identify and implement related care link interventions. 4. Provide ongoing evaluation of resident response to interventions. Quality Improvement Monitoring: 1. Shift to shift report. 2. 24 hour report. 3. Interdisciplinary Meeting. 4. Quality improvement process. Change of Status: 1. Review and discuss potential root cause of fall. 2. Complete follow-up event documentation as clinically indicated. 3. New or changes in current interventions will be discussed by the Interdisciplinary Team and the care plan will be updated accordingly.

Based on observation, interview and record review, the facility failed to implement an infection control program in accordance with CDC guidelines to prevent the spread of COVID-19. The facility failed to identify residents who have had prolonged exposure to positive COVID 19 staff and residents and implementing transmission based precautions, failed to implement screening procedures in accordance with CDC guidelines, failed to wear required personal protective equipment during a facility outbreak, failed to perform hand hygiene as required, and failed to post signage on the use of specific PPE for staff in locations where transmission precautions are required. This failure resulted in an Immediate Jeopardy which began on [DATE] when V6, Activity Aide, tested positive for COVID 19. At that time, the facility failed to implement an infection control system to identify residents and/or staff who may have had a prolonged exposure to V6 while V6 was working and then not implementing transmission-based precautions for those residents. As of [DATE] the facility has had 37 residents test positive for COVID 19 (R2 R3, R4, R5, R6, R7, R8,R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24 , R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, R35, R36, R37 and R38, with 10 residents (R2, R3, R4, R6, R11, R26, R27, R29, R30 and R34) expiring due to COVID-19. Due to the residents' ages, comorbidities and vulnerabilities, this failure has the potential to affect all 68 residents in the facility. The Immediate Jeopardy was identified on [DATE]. On [DATE], at 8:39 AM, V1, Administrator, V2, Director of Nurse (DON) and V3, Assistant Director of Nurse's (ADON), were notified of the Immediate Jeopardy. The surveyor confirmed through observations, record review and interview that the Immediate Jeopardy was removed on [DATE] but non-compliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of in-service training. Findings include: 1. On [DATE], a tour was conducted of the facility. The facility had identified the red zone as the area where all residents who tested positive for COVID-19 were residing. The yellow zone was an area where residents were currently in quarantine as persons under investigation for COVID-19. The facility undated Line List for COVID-19 Outbreaks in Long Term Care Facilities documents V6, Activity Aide, as the initial case of COVID-19 at the facility. The line lists documents V6 tested positive for COVID 19 on [DATE]. The line list documents that V6 had a temperature of 100.3 degrees Fahrenheit (F) and that V6 was unvaccinated. On [DATE] at 2:26 PM, V2, Director of Nursing (DON)/Infection Preventionist stated that V6 was the first employee to test positive for COVID 19 on [DATE]. V2 stated that V6 was not feeling well and came to the facility and a rapid COVID-19 test was completed in the parking lot of the facility. V2 stated V6 tested positive for COVID 19. V2 stated that V6 was placed off work for 10 days. V2 stated that V6 had worked the day before, [DATE]. V2 stated that she did not identify the areas in the facility where V6 worked and what residents V6 worked with but would assume V6 worked all areas of the building. V2 stated that all residents at the facility had a rapid COVID-19 test after V6 tested positive for COVID 19. On [DATE] at 1:40 PM, V6 stated she tested positive for COVID on [DATE]. V6 stated on the morning of [DATE] she woke up about 3:00 AM with a headache and felt hot. V6 stated she got up around 7:00 AM, dressed and called the V25, Activity Director. V6 stated she met V25 outside the back door and took her temperature and stated her temperature was 100.4 degrees F. V6 stated a nurse came out and did a rapid COVID 19 test and told her to go home. V6 stated the facility called and told her she was positive. V6 stated she returned to work on [DATE]. V6 stated that she has not been vaccinated. V6 stated that she did work at the facility on [DATE]. V6 stated on [DATE], the facility was running normal and she had group activities. V6 stated that no one from the facility asked her who she had close or prolonged contact with. V6 stated but she knows people she was around tested positive. On [DATE] at 2:31 PM V6 stated that on [DATE] during group activities that she did crafts which involved coloring, bingo and nails. The facility had no documentation regarding if the facility conducted surveillance to identify who V6 had prolonged contact with and potentially exposed to COVID 19 while she worked on [DATE]. The facility Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that V13, Certified Nurse's Aide, CNA, tested positive for COVID 19 on [DATE]. The line list documents that V13 was not vaccinated and had no symptoms. 0n [DATE] at 1:11 PM V2 stated that V13 had a rapid COVID-19 test on [DATE] and tested positive. V2 stated V13 was working the yellow zone (zone where residents who are quarantined for suspected or under investigation for COVID-19). The facility had no documentation regarding if the facility identified who V13 had prolonged contact with and potentially exposed to COVID 19 while he worked on [DATE]. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities document that V28, Registered Nurse, RN, tested positive for COVID on [DATE]. The line list documents that V28 was fully vaccinated. The line list does document that V28 had symptoms of cough, myalgia and loss of taste and smell. On [DATE] at 1:11 PM V2 stated that V28 had a rapid COVID 19 test prior to his shift on [DATE]. The facility Nurse's Schedule for [DATE] documents V28 worked 6:00 PM - 6:00 AM on ,d+[DATE], ,d+[DATE] and [DATE]. The nursing schedule does not document where V28 worked. The facility had no documentation regarding if the facility identified who V28 had prolonged contact with and potentially exposed to COVID 19. The facility Line List for COVID-19 Outbreaks in Long Term Care Facilities document that V3, Assistant Director of Nursing (ADON) tested positive for COVID 19 on [DATE]. The line list documents that V3 had symptoms of cough and myalgia. The line list documents that V3 fully vaccinated. On [DATE] at 1:30 PM, V3 stated that she did not feel well and had headache and the symptoms which started Saturday evening, [DATE]. V3 stated she came to the facility on [DATE] and went into the office and tested herself and stated she tested positive for COVID-19. V3 stated that she notified the health department and they stated her quarantine would be 10 days starting on that [DATE]. The facility had no documentation regarding if the facility identified who V3 had prolonged contact with and potentially exposed to COVID 19 while she worked on [DATE]. On [DATE], there was a sign posted inside the facility entryway prior to entering the facility that documents Attention all staff and visitors you must check in on electronic kiosk upon entry. On [DATE] at 1:59 PM V29, Human Resources Director stated that corporate can pull up a printout of people testing at the kiosk. The first question on the kiosk states Do you have any of the following symptoms sore throat, SOB (shortness of breath), cough, loss of taste/smell headache? V29 did a test demonstration and answered yes to the above question, and a warning with a stop sign shows on the screen and documents Stop please do not enter. V29 stated that the Kiosk will also send a warning to corporate. On [DATE] at 2:15 PM V1, Administrator presented a COVID screening flag email that he received based on test demonstration which included name, phone number and if resident or visitor the report documented the question and answer that triggered the report and temperature. The facility screening kiosk report dated [DATE] documents that V3 screened at the facility at 5:16 PM and completed screening, not reporting any symptoms. The facility screening kiosk report dated [DATE] documents that V3 completed screening at 10:12 AM and did not report any symptoms, although she noted she was experiencing symptoms at home the night before ([DATE]) and came to facility to test for COVID-19. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that on [DATE], R10, R11, R12 and R13 all tested positive for COVID-19, and the line list documents that R11 expired. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents V21, Certified Nurse's Aide (CNA) and V27, CNA, tested positive for COVID-19 on [DATE]. The Line List documents that V21 and V27 were unvaccinated. The line list does document that V27 had symptoms of cough and myalgia. The facility had no documentation regarding if the facility identified who V21 and V27 worked with and if they had prolonged contact with these residents to see who was potentially exposed to COVID 19. On [DATE] at 1:11PM V2 stated that both V21 and V27 were working the south hall which was a yellow zone. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that V17, Dietary Aide, tested positive for COVID based on test that was done on [DATE] and results came back [DATE]. On [DATE] at 1:30 PM, when asked if V17 had prolonged exposure with any employees or residents prior to testing positive for COVID-19, V3 stated, I am not sure. We do not do the kitchen schedules. V3 stated that V17 worked in the kitchen and took the food carts to the doors of the units. V3 stated V17 was fully vaccinated. The kitchen schedule documents that V17 was on duty from 5:30 AM-1:30 PM on ,d+[DATE], ,d+[DATE], and [DATE]. The Facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R14 and R15 tested positive for COVID-19 on [DATE] and both were fully vaccinated. The facility had no documentation that they attempted to identify who may have had prolonged close contact to V17, R14, R15 to see who was potentially exposed to COVID-19. On [DATE] at 9:45 AM, V2 stated that when V6 tested positive all residents had rapid COVID-19 tests and staff were tested by PCR (Polymerase Chain Reaction). V2 again confirmed she did not interview V6 or do any type of contact tracing to see who may have had prolonged exposure and implement isolation. V2 stated she did not do that for the 2 staff, V21 and V27, that currently tested positive on [DATE]. V2 stated that when the employees tested positive on ,d+[DATE] the facility conducted rapid tests again. On [DATE] at 3:20PM, V30, Medical Director stated he would expect the facility to identify residents with prolonged close contact for potential COVID 19 exposure to identify these persons and implement isolation procedures if needed. V30 stated if this not done, this could increase the spread of virus. V30 stated sounds like some holes as what is supposed to be happening at the facility. The Centers for Disease Control and Prevention's Website Interim Infection Prevention and Control Recommendation to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated [DATE], was reviewed. In the section entitled Evaluating and Managing Personnel and Residents, documented Have a plan for how to respond to HCP (Health Care Personnel) with [CONDITION(S)]-COV-2 infection who worked while ill (e.g., identifying exposed residents and co-workers and initiating an outbreak investigation in the unit or area of the building where they worked). The website documents Establish a process to ensure HCP (including consultant personnel and ancillary staff such as environmental and dietary services) entering the facility are assessed for symptoms of COVID-19 or close contact outside the facility to others with [CONDITION(S)]-CoV-2 infection and that they are practicing source control. The website documents Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which, prior to arrival at the facility, HCP report absence of fever and symptoms of COVID-19, absence of a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Centers for Disease Control and Prevention's website Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccination, updated on [DATE], documents Fully vaccinated inpatients and residents in healthcare settings should continue to quarantine following prolonged close contact (within 6 feet for a cumulative total of 15 minutes or more over a 24-hour period) with someone with [CONDITION(S)]-CoV-2 infection; outpatients should be cared for using recommended Transmission-Based Precautions. 2. R2's Face Sheet, dated [DATE] documents R2 has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 1:10 PM V2 stated that after R2 tested positive for COVID 19 on [DATE], the facility started testing all employees and residents and set up zones. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents that R2 tested positive for COVID-19 on [DATE], was fully vaccinated and expired at the hospital. R2's Death certificate dated [DATE] documents R2's cause of death as a) pulmonary [CONDITION(S)] b) COVID-19 (positive test/clinical). The facility had no documentation that they attempted to identify who may have had prolonged close contact to R2 to identify who was potentially exposed to COVID-19. 3. The facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities documents R21 tested positive for COVID-19 on [DATE] and R7, roommate, tested positive for COVID 19 on [DATE]. The facility had no documentation that they attempted to identify who may have had prolonged close contact to R7 and R21 to see who was potentially exposed to COVID-19. 4. On [DATE] at 2:02PM V4, CNA was in common area outside the large dining room putting face shield together. V4 was not wearing a face shield or goggles. 5. On [DATE] at 1:23 PM V5, Dietary manager was interviewed regarding COVID-19 policies. During this interview, V5 did not have a face shield or goggles on and did not attempt to get one during the interview. 6. On [DATE] at 1:26 PM, V26, Dietary Staff, was bringing a covered Styrofoam container to yellow zone door on west hall. V26 did not have a face shield or goggles on. When questioned V26 responded I work in the kitchen. 7. On [DATE] at 1:34 PM V7, CNA, and V8, RN were sitting at the desk in the yellow zone east hall next to the entrance of zippered red zone. V7 and V8 were not wearing face shields or goggles. V8 stated I was aware only needed when in rooms. At no time did V7 attempt to don a face shield. V7, without face shield or goggles, unzipped the curtain to the entrance of the red zone which has COVID 19 positive residents and entered. V7 left the zippered curtain to the entrance of the red zone unzipped ,d+[DATE] of way up leaving it opened. At that time, the surveyor questioned V8 as to why that area not closed/zipped. V8 stated That's is a good question and instructed V7, CNA to close the zippered curtain. On [DATE] at 1:37PM V3, ADON stated that the zippered curtain is always to be closed. 8. On [DATE] at 8:20 AM V22, Licensed Practical Nurse, LPN exited R25's room who currently resides in a room in the yellow zone. V22, while wearing a face shield and N95 mask, removed her gown and gloves but did not sanitize her hands after doffing her gloves. V22 walked down to the end of the hall and disposed of N95 and face shield and donned new ones. At no time during this process did V22 sanitize her hands. V22 then exited the facility at the end of the COVID unit through the double doors. 9. On [DATE] at 8:31 AM V23 CNA was wearing a face shield, gown, and N95 mask. V23 donned gloves but did not sanitize hands prior to donning gloves. V23 entered R12's room (who currently resides on the yellow zone). V23 exited R12's room and removed gown and gloves. V23 did not sanitize her hands after doffing gloves and exited the area through double doors. 10. On [DATE] at 8:39 AM V24 CNA and V25, Activity Director, were putting up signs for PPE usage outside of resident's room doors on the yellow zone unit. Prior to this, there was no signage instructing facility staff what type of PPE to utilize on the double doors which staff enter to get into the yellow zone. 11. On [DATE] at 2:10PM, V13 CNA entered the COVID unit from outside the building. V13 was wearing an N95 mask and face shield. V13 did not don a gown or gloves upon entry into the COVID 19 unit. V13 walked the length of the hallway then donned gown and gloves but did not sanitize hands prior to donning gloves. On [DATE] at 2:15 PM, V12, LPN on the COVID-19 unit stated that all staff are to wear full Personal Protective Equipment (PPE) while on the unit which includes gown, gloves, N95, and face shield. 12. On [DATE] at 9:37 AM, V19, Dietitian entered the conference room with only N95 mask on and asked surveyor if she could work in room with surveyor. When asked where her face shield/goggles were, V19 then stated she was going to work in the storeroom. V19 stated it would be too hard to wear a face shield all day. The facility PPE Guidelines and Scenarios, updated [DATE] documents In the event we have COVID in the facility, all staff will don an N95 mask and goggles/face shields on all units. 13.The Facility Midnight Census Report dated [DATE] documents a census of 68. The surveyors verified through observation, interview and record review; the facility took the following actions to remove the Immediate Jeopardy: 1). Immediate Actions take for residents identified: A) All residents are located on units appropriate to their COVID 19 status. (1) Residents who have tested positive for COVID 19 are located on secured units (Red Zones) with limited access and egress directly to outside the facility. These units are staffed, PPE in place, no visitation, no communal activity in accordance with CMS and CDC guidelines. Completed [DATE]. Overseeing Director of Clinical Excellence. (2) Residents who have met recovery criteria or who have been exposed but have not tested positive are located on a unit (Yellow Zone) which is in Quarantine/Observation and is separate from the well (COVID negative, without symptoms, tested negative) population and the COVID positive population. This unit is staffed, PPE in place, no visitation, no communal activity or dining in accordance with CMS and CDC guidelines. Completed [DATE]. Director of Clinical Excellence overseeing. (3) Residents who have continually tested negative, have not exhibited signs or symptoms of COVID 19 virus and have not had prolonged or high-risk exposures are located in a well section of the facility. These residents may have outdoor visitation all communal dining or activities have been halted until the facility has had 14 consecutive days without a new positive test of any resident or employee. B) The Director of Clinical Excellence (Corporate level RN) has directed re-education of staff with regard to proper PPE for each area/zone and hand hygiene. All facility staff have been re-educated. Completed [DATE]. C) All indoor visitation was stopped on [DATE]. All staff were immediately re-educated on the visitation policy regarding COVID-19 outbreak. The entire staff of the facility including Department heads have been re-educated on [DATE] and completed on [DATE] by the ADON overseen by the Director of Clinical Excellence. D) All residents are receiving meal service in their rooms. This was implemented on [DATE]. All staff including Department Heads were re-educated on COVID 19 policy regarding outbreaks initiated on [DATE] and completed [DATE] by the ADON and overseen by the Director of Clinical Excellence. E) The DON/Infection Preventionist was immediately re-educated on the infection control program and Strategies to Prevent COVID 19 policy on [DATE] by the Director of Clinical Excellence. F) All staff, including department heads were re-educated on the screening process ensuring they correctly answer the questions and do not continue to proceed past the lobby if they flag for symptoms. Education initiated on [DATE] and completed on [DATE] by the ADON and overseen by the Director of Clinical Excellence. G) Line Staff that are unable to be educated on [DATE] or [DATE] due to vacation etc. will be educated prior to their next shift on screening, visitation, isolation precautions, PPE and hand hygiene by the ADON. H)All contract/temporary staff and new employees will be educated by the ADON prior to working a shift on screening, visitation, isolation precautions, PPE and hand hygiene. 2) Identification of other residents who could potentially be affected: All residents residing in the facility have the potential to be affected. 3) Measures put in place/ System changes: A)The DON and Administrator have been re-educated on the facility COVID-19 policies related to an Outbreak on [DATE] by the Director of Clinical Excellence. This involves as above related to screening, visitation, isolation precautions, staff compliance with PPE and hand hygiene. B)Staff have been re-educated on the facility COVID-19 policies on [DATE] and completed on [DATE] by the ADON and overseen by the Director of Clinical Excellence. This includes isolation precautions, employee screening, visitation, PPE, dining, activities, and hand hygiene. C)The DON/Infection Preventionist was re-educated by the Director of Clinical Excellence on [DATE] on her role in monitoring and managing infection control program and surveillance. D)The facility has implemented a guideline on responding to a positive or presumed positive COVID 19 case. 4)How the corrective actions will be monitored: A)The Infection Preventionist or Designee will complete daily audits until outbreak is ended then 5 times a week times 6 weeks to ensure compliance with appropriate PPE, handwashing, isolation precautions, employee screening, resident dining, and visitation. B)The Director of Clinical Excellence will review compliance weekly on visits to ensure the facility is following policies on COVID-19 and the infection control program. This process will include immediate notification of new positive cases and that contact tracing is completed and appropriate interventions are implemented. 5)Date of Removal: [DATE]

Based on observation, interview and record review the facility failed to implement interventions to prevent accidents, falls and elopements and failed to provide safe transfer techniques to prevent accidents for 5 of 8 residents (R23, R48, R69, R71) reviewed for resident care in the sample of 41. This failure resulted in R48 falling out of the wheelchair and sustaining hematomas to right and left chest and laceration to left elbow requiring hospitalization . Findings include: 1. R48's Electronic Medical Record (EMR) dated 5/24/21 documents diagnoses of [CONDITION(S)], Long Term (Current) Use of Anticoagulants, Acquired Absence of Right Leg Below the Knee and Abnormal Coagulation Profile and Presence of Prosthetic Heart Valve. R48's Minimum Data Set (MDS) dated [DATE], documents R48 is cognitively intact. On 5/20/21 at 3:10 PM, R48 stated, I was being transported to a doctor's appointment on 3/22/21 and the driver hit a curb, the driver did not lock my wheelchair or put a seat belt on me. R48 stated, I flew out of the wheelchair and hit my chest on something. The driver stopped but was unable to get me back into the wheelchair (w/c). R48 stated, The driver told me to just lay on the floor until they got to the doctor's office. When we got to the doctor's office the driver went into the building and came back out with 2 nurses. They helped the driver get me back into the w/c. R48 stated, The driver wanted to take me in the building for my doctor appointment, but the nurses told her, 'No, you need to take her to the hospital.' R48 stated, The driver was talking on the phone when she hit the curb. I didn't want to get her in trouble, so I didn't tell the facility she was on the phone. I just told them I saw the driver put the phone down. R48 stated, My wheelchair was not locked, and I did not have a seat belt on. R48's Hospital records dated 3/22/21 document A [AGE] year-old female with a history of mechanical valve on [MEDICATION(S)], w/c bound presenting to the emergency department and declared a trauma consult after a motor vehicle accident (MVA). Patient was an unrestrained passenger in a transport van when the van hit a curb along the road. Patient fell out of her wheelchair and complaining of left sided shoulder pain and chest wall pain as well as shoulder pain. No loss of consciousness (LOC). Patient is on [MEDICATION(S)]. Patient denies LOC, but does not remember the exact set of events, but was awake and alert on presentation and in vehicle per family member. Patient is complaining of left shoulder, left wrist and left chest wall and right shoulder pain. R48's Computerized Tomography Scan (CT) dated 3/22/21, documents, CT Chest Impression: 1. There is a large left breast hematoma with overlying skin thickening and with active bleeding. 2. There is a hematoma involving the soft tissue of the anterior right shoulder and anterior upper right chest wall with multiple foci of active bleeding. R48's Left forearm x-ray, dated 3/22/21, documents, Impression: Soft tissue swelling. R48's Left wrist x-ray, dated 3/22/21, documents, Impression: Soft tissue swelling. R48's Hospital History and Physical, dated 3/22/21, documents [AGE] year-old female with a history of aortic and mitral valve repairs with mechanical valves, on [MEDICATION(S)], admitted as trauma consult after a fall out of wheelchair in moving vehicle. Left elbow laceration repaired by emergency department staff with nylon suture. Left elbow contusion, left wrist contusion, left chest wall hematoma and swelling, right underarm and chest hematoma and ecchymosis. Large 10 X (by) 10 cm (centimeter) area of ecchymosis on bilateral superolateral breasts with no skin necrosis, tender to palpation. CT with bilateral chest hematomas, right with evidence of active bleeding. R48's Hospital Impression and Plan, dated 3/22/21, documents the following Trauma diagnoses: Head contusion, elbow contusion, elbow laceration, Left breast hematoma, and right shoulder hematoma. The facility's Verification of Incident Investigation/Administrative Summary, dated 3/22/2021 documents resident was on transport van when van hit a curb and caused resident to shift out of wheelchair. resident is an assist of 1 person. Transport van pulled over and assisted resident back into wheelchair. Resident had no initial need to go to the hospital. Upon arrival to scheduled MD appointment, resident began to complain of pain and was transported to the ER for evaluation and treatment. V18's (Former CNA/Driver) Witness Statement, dated 3/23/21 documents, I was driving the van down (street name) and I hit a curb and brought the van back on the road and then I looked in my mirror and the resident slid out of chair and was on the floor and so I was able to stop. I went and checked on the resident and she had a scrap on her ear and I looked at her whole body and nothing else was wrong and I asked the patient how she felt and she said she was having palpitations and we got the patient off the floor and put her in her chair and then went to the doctor office and she was telling the nurse she was having palpitations more and they told me to take her to the ER (emergency room ) and I called the Director of Nurses (DON) when I stopped, to let her know what was going on. The resident was sitting on her bottom and she just had a scrape on her ear and the chair was locked in place and the resident was sitting in her chair. On 5/25/21 at 8:25 AM, V2 Director of Nurses (DON) stated, I would expect residents to be secured in the transport van. I was not aware (R48)'s wheelchair was not secured on the transport van or that she did not have the seatbelt on. We did not find any of this out until the resident was readmitted back to the facility from the hospital on 3/24/21. At that time, we had received her hospital records and were able to interview (R48) and found out what really happened. The Certified Nurse Aide/Driver (V18) was terminated because she did not follow Policy and she lied. On 5/25/21 at 9:30 AM, V1, Administrator, stated, I did not know that the wheelchair and resident were not secured in the transport van until she was returned to the facility on [DATE] and we interviewed her and received the hospital records stating she was not restrained. On 5/25/21 at 12:50 PM, V24, R48's Physician, stated, I would expect the staff to secure to wheelchair and resident when transferring residents in the transport van. The facility policy and Procedure for Crest Fleet Safety Program, dated 2/2021, documents It is the policy to define guidelines regarding the purchase and use of company owned vehicles and to ensure that authorized drivers follow safe driving practice. The Policy and Procedures documents Purpose: To provide guidelines for the purchase or lease of company vehicles; assure compliance with applicable laws; promote safety of employees and maintenance of company owned vehicles. The Policy documented Driver safety regulations 1. The driver and all occupants are required to wear safety belts when the vehicle is in operation or while riding in a vehicle. The driver is responsible for ensuring passengers wear their safety belts. This policy documents 5. Cellular Telephones, Walkman's and Pagers. The following procedures apply to employees driving on company business who wish to use cellular telephones in the vehicle. A. External speaker and microphone must be included to allow hands-free operation. B. Phone number memory and programming capabilities are to be included. C. Drivers are to refrain from placing outgoing calls or responding to pagers while the vehicle is in motion. D. Incoming calls should be limited. The Policy documents If transferring is NOT feasible: Secure the wheelchair (facing forward) to the vehicle floor. Use all 4 crash-tested wheelchair securement straps. Use crash-tested 3-point seatbelts for the wheelchair-seated rider. Protect the wheelchair rider. VERY IMPORTANT Provide effective restraint for the wheelchair passenger. Use a crash-tested pelvic and shoulder belt. 2. R23's Care Plan, dated 5/24/2021, documents At risk for falls and injuries r/t (related to) Medical Factors: [CONDITION(S)], [CONDITION(S)], Cognitive Impairment, HX (history) of falls and Incontinence. The Care Plan documented the following Interventions: 1/12/18 Keep call light within reach; Nonskid pad to wheelchair; 5/24/2021 Provide/Reinforce use of assistive devices: Reacher (assistive device to reach objects and grab onto items); 10/21/2020 Soft touch call light to be utilized 10/6; 6/24/2020 Tab alarm when in chair (w/c & recliner) for safety. On 5/19/2021 at 11:15 AM R23 was sitting in wheelchair. R23 had no personal alarm on her wheelchair or on her person. R23's personal alarm was sitting on table next to closet. R23's Reacher was lying on the foot of the bed covered by two blankets. R23's call light is not a soft touch. On 5/19/2021 at 12:50 PM R23 was assisted to the toilet. R23's alarm was not attached to R23. When R23 stood from the wheelchair, R23's alarm did not sound. There was nonskid pad in R23's wheelchair. On 5/20/2021 from 10:30 AM to 1:10 PM, based upon 30-minute observations, R23's alarm box remained on table next to closet. R23 did not have an alarm on herself or the wheelchair. R23's Reacher was on the bed with 2 blankets on top of it. On 5/24/2020 at 10:30 PM R23 was sitting in her room in her wheelchair with eyes closed. R23 was leaning forward and to the left. R23's head was beneath her knees sliding forward in chair. R23's call light was attached to R23's bed behind her and not in reach. R23's bed alarm was not attached to R23 and was located on the table next to the chair. R23's reacher was located on the recliner behind the wheelchair. R23 had no nonstick pad in her chair. On 5/24/2020 at 10:35 AM, R23 stated that she wanted to lie down but could not call for help because she didn't have her call light. R23 stated that when she does have her call light, she does have problems with pushing the button. R23 stated that at times she can't push the button. R23 stated that when her Reacher is at the foot of her bed it's hard for her to find and she can't use it if she can't find it. On 5/24/2021 at 10:40 AM V13, CNA, stated that she was not aware of the reason why R23's chair alarm was not on her. V13 stated that R23 has removed the alarm in the past. V13 stated that she was not here when the alarm was removed and didn't know why it hasn't been in place since Wednesday of last week. V13 stated that R23 should have an alarm box on her chair and a tab connected to her shirt. V13 stated that R23 was supposed to have her call light and Reacher in reach to keep her from falling. V13 stated that R23 does not have a soft touch call light. On 5/24/2021 at 11:15 AM V2, Director of Nursing, stated that R23 is supposed to have an alarm to her wheelchair and to her shirt. V2 stated that the Reacher should be in reach and behind her or at the foot of her bed covered by blankets is not in reach. V2 stated that R23 is supposed to have a nonskid pad in her wheelchair and soft touch call light in R23's reach. V2 stated that when an intervention is put in place, she expects the staff to make sure they are in place. 3. R71's MDS dated [DATE], documents R71 requires a two staff assistance for transfers. It does not state in the MDS to use mechanical lift. R71's Care Plan, dated 5/5/21, documented R71 required two-person physical assistance required for transfers. R71's Care Plan does not document he uses a mechanical lift for transfers. On 05/19/21 at 12:05 PM, V4 and V5, CNAs, placed the mechanical lift sling under R71, secured the strap loops to the machine, raised R71 up over the bed, moved her over to the wheelchair, and lowered R71 down to the wheelchair. V4 and V5 failed to check the straps after raising R71 above the bed, failed to keep hands on R71 during lift, and failed to lock R71's wheelchair prior to the transfer. On 05/24/21 at 2:30 PM V20, Physical Therapist (PT), stated that (R71) has been transferred using a full body mechanical lift since admission. On 05/24/21 at 3:16 PM, V1, Administrator, was questioned regarding proper use of the mechanical lift. When asked if she would expect staff to make sure straps are secure prior to lifting resident, she responded yes. When asked if she would expect staff to lock the wheelchair, she responded yes. When asked if she would expect staff to keep hands on the resident during the mechanical lift, she responded yes. 4. R69's Care Plan, dated 3/23/21, documents impaired cognitive function/dementia or impaired thought processes related to Alzheimer and Dementia. R69's admission nursing assessment dated [DATE], documented moderately impaired decisions poor, supervision required and not to be considered an Elopement Risk Factors. On 5/19/21 at 9:45 AM, R69 was in her wheelchair. R69 propelled herself down the hall to the North-East exit door. R69 then used her left hand, placed it on the door below the door handle horizontal bar, then extended her right foot placed on the base, and was able to open the door. The door was not latching and therefore, R69 could open the door. R69 then used both hands and right foot to push the door open. At this time the door alarm sounded North-East Door, North-East Door. A housekeeper approached R69 and returned her back into the building. The terrain outside the exit door is approximately 20 feet of concrete with an adjacent high traffic road and area hospital. On 5/20/21 at 10:15AM, state surveyor brought to V1's Administrators attention, that the North-East exit door is not latching with the door jam. State Surveyor showed V1 that the horizontal door handle must be pulled hard to provide a secure seal and completely shut the door. Without the seal, the door is can easily be open with a hand or foot without using the door handle. At 10:20AM, V1 stated she was not aware and would immediately address the issue with the maintenance department. The Facility's policy and procedure, entitled Monitoring Wandering Resident, dated 9/15/19, documented, every effort will be made to prevent wandering episodes.

This failure resulted in two deficient practice statements. 1. Based on observation, interview and record review, the facility failed to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to: 1) properly implement the extended use of eye protection by not providing each staff member with a dedicated eye protection (goggles or faceshield) per CDC Guidelines (Centers for Disease Control and Prevention) and failed to follow proper disinfection of the eye protection after use on R1; 2) follow proper resident cohorting (R1, R2) per CDC guidance; 3) ensure staff used approved N95 mask (particulate-filtering facepiece respirator that filters at least 95% of airborne particles), staff were fit-tested prior to use of an N95 mask and staff were trained to properly store and maintain a re-used N95 mask per CDC Guidelines and OSHA Guidelines; 4) ensure staff followed proper hand hygiene before exiting R3 and R4's room (contact and droplet isolation room). This had the potential to affect the remaining two residents, 25 nursing staff, seven housekeeping staff and three activity staff who did not test positive for COVID-19 (an infectious disease caused by a newly discovered coronavirus called [DIAGNOSES REDACTED]-CoV-2). At the time of survey, the facility had a total of 61 residents, 22 staff who tested positive for COVID-19 and there were 15 deaths among residents due to COVID-19.The facility was in a county which had sustained community transmission, especially in the nursing home setting. The Immediate Jeopardy began on 9/2/20 at 10:52am, when: 1) the facility failed to properly implement extended use of eye protection by not providing each staff member with a dedicated eye protector (goggles) per CDC Guidelines and failure to proper disinfection of the eye protection after use on R1. NA1 was observed to disinfect the used goggles with a Super Sani-cloth for 12 seconds instead of the two-minute dwell time; 2) the facility failed to ensure a resident (R1) who tested positive on 8/5/20 did not continue to share the same room with R2; 3) the facility failed to follow proper procedures for the limited reuse of a respirator, failed to ensure staff used CDC/OSHA approved N95 masks and staff were fit tested prior to the use of N95 mask; and 4) the facility failed to ensure staff observed proper hand hygiene prior to exiting R3 and R4's room (both residents were diagnosed of COVID-19) and were on contact and droplet precautions. The Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy on 9/3/20 at 12:57pm. The Immediacy was removed when the removal plan was accepted on 9/8/20 at 7:17pm and was verified as implemented on 9/10/20 at 2:10pm. Findings include: A. During the entrance interview on 9/2/20 at 10:30am, the Administrator stated that they have adequate PPE (personal protective equipment) supply. The Administrator stated We have no issues or problems with supplies. We have tons of supplies. The Administrator stated that they were not doing any PPE conservation strategy at that time. During observation on 9/2/20 at 10:45am, activity staff (E1) was wearing an N95 mask, gown, goggles and gloves when she entered room [ROOM NUMBER]. E1 passed out juice and dessert to R1 in room [ROOM NUMBER]. At 10:52am, E1 handed a pair of used goggles to nursing assistant (NA1) who was standing outside of the room. NA1 took one Super Sanicoth disinfecting wipe and wiped the goggles for 12 seconds, then placed them inside a plastic container and covered it with the lid, on top of the isolation cart. NA1 failed to ensure that the goggles remained wet for the recommended contact time. When asked how long the goggles should stay wet with the disinfectant, NA1 stated, I don't know. NA1 proceeded to check the label on the Super Sanicloth tub. Further observation revealed that there were two plastic containers for the goggles on top of the isolation cart that were not labeled, outside of R1's room. NA1 confirmed that the plastic container was where staff kept the shared protective eyewear after disinfection. Observations made during the tour of the South and Medicare Hall between 10:55am to 11:14am on 9/2/20, revealed two unlabeled plastic containers with goggles on top of isolation carts outside of R5's room and one unlabeled plastic container outside of R4's room. During an interview on 9/2/20 at 12:55pm, the Assistant Director of Nursing (ADON) stated that staff can share protective eyewear or goggles after it had been disinfected. During an interview with the Director of Nursing (DON) on 9/2/20 at 2:28pm, the DON stated Generally when they are leaving the isolation room, another staff outside the room will wear gloves, take goggles from the staff inside the room, take the wipe and clean before placing it in the container. When asked if they are dedicated for one healthcare personnel after it was disinfected, the DON stated They can share. During a follow-up interview with the DON at 11:00 am on 9/3/20, the DON stated that they were optimizing their supply of PPE. The DON stated The PPE we are trying to conserve like the goggles with the reuse because those kind of run back and forth. When asked about the disinfection of eye protection, the DON explained This person would be wearing gloves at that time. They are using the wipes to wipe them down based on the manufacturer's guidance for how long. Then they placed it back in the container. She repeated that staff could share the same goggles after disinfection. Review of facility's SRS-CoV-2 Detection Test Summary revealed 15 nursing staff and one housekeeping staff tested positive for COVID-19, from 7/20/20 to 8/21/20. Review of facility policy titled Protective Eyewear (Use) dated 9/15/19 revealed, Protective eyewear will be used per Standard Precautions, Droplet Precautions, and facility policy .It is the responsibility of the D.O.N./Infection Control Nurse to ensure that all staff are trained and educated regarding the appropriate use of protective eyewear .5. Put on masks, then put on eyewear, goggles or face shield per manufacturer's instructions .7. Dispose of or clean eyewear as applicable. The policy did not contain additional documentation on the steps for the extended use of eye protection. Review of facility's policy titled Cleaning Contaminated Equipment with revised date of 3/25/20 revealed, To provide staff with procedures for cleaning and disinfecting reusable resident equipment properly, in order to avoid cross contamination .10. Eye protection/goggles .Eye protection needs to be taken off immediately before/at the time of exiting a resident room and sanitized with EPA appropriate wipes prior to placing in the isolation set-up. Review of facility's policy titled Strategies to Prevent Coronavirus dated 6/15/20 revealed The facility will follow CDC guidelines to reduce the risk and prevent of COVID-19 .Provide the right supplies to ensure easy and correct use of PPE. Under Updates, revealed, The facility will use IDPH/CDC guidelines on testing and proper PPE. Review of CDC article titled Strategies for Optimizing the Supply of Eye Protection dated July 15, 2020 revealed under Implement extended use of eye protection revealed, Extended use of eye protection can be applied to disposable and reusable devices. Eye protection should be removed and reprocessed if it becomes visibly soiled or difficult to see through. If a disposable face shield is reprocessed, it should be dedicated to one HCP and reprocessed whenever it is visibly soiled or removed (e.g., when leaving the isolation area) prior to putting it back on . https://www.cdc.gov/coronavirus/2019-ncov/hcp/ppe-strategy/eye-protection.html Review of Super Sani-cloth Germicidal Disposable wipe user guide revealed under Description, Effective against 30 microorganisms in 2 minutes. Under General guidelines for use revealed, 3b. Unfold a clean wipe and thoroughly wet surface. 4. Allow treated surface to remain wet for two (2) minutes. Let air dry. https://pdihc.com/products/environment-of-care/super-sani-cloth-germicidal-disposable-wipe/ Review of EPA (United States Environmental Protection Agency) article titled List N: Disinfectants for Use Against [DIAGNOSES REDACTED]-CoV-2 (COVID-19) revealed under Follow the Label, When using an EPA-registered, follow the label directions for safe, effective use. Make sure to follow the contact time, which is the amount of time the surface should be visibly wet, listed in the table below. https://www.epa.gov/pesticide-registration/list-n-disinfectants-use-against-[DIAGNOSES REDACTED]-cov-2-covid-19 B. Review of R1's medical record on 9/2/20 revealed [DIAGNOSES REDACTED]. Per R1's census note dated 8/4/20 revealed that R1 was staying in room [ROOM NUMBER] until 8/12/20. Per [DIAGNOSES REDACTED]-CoV-2 ([MEDICAL CONDITION] that causes COVID-19) Detection Summary note dated 8/5/20, R1 was positive for COVID-19. Review of R1's progress notes did not provide evidence that R1 was transferred to a private room, or moved to cohort with other residents positive with COVID or transferred to a designated COVID unit or wing after becoming positive for COVID-19. Review of R2's medical record on 9/2/20 revealed [DIAGNOSES REDACTED]. R2 was [AGE] years old. Per R2's census note dated 8/4/20 indicated that R2 was staying in room [ROOM NUMBER] until 8/12/20. R1 and R2 shared the same room from 8/4/20 to 8/12/20. Review of R2's progress note dated 8/12/20 at 4:34am revealed, SPO2=81, applied oxygen. Per [DIAGNOSES REDACTED]-CoV-2 Detection Summary note dated 8/12/20, R2 was positive for COVID-19. R2's medical [DIAGNOSES REDACTED]. During an interview with the DON at 11:00am on 9/3/20, when asked about the cohorting of residents, the DON stated, When we would have one, we had that happen a couple of times on the West and we had moved both down since Medicare end up as designated COVID Hall, we moved them down or if we moved to the West Hall. But if one is negative there is a chance that one will be moved to the private room and the positive would stay in the current room. The DON confirmed that the negative resident will be moved to the private room. Review of facility policy on 9/4/20 titled Strategies to prevent Coronavirus, with revised date 6/15/20 revealed under updates, The Facility will refer to the Infection Control Policies: Standard Precautions CC8.17 or Transmission Based Precautions CC8.10 depending what type of resident room they are entering to ensure proper PPE. Review of facility policy on 9/3/20 titled Infection Control: Isolation Categories of Transmission-Based Precautions dated 9/15/19 revealed, Transmission Based Precaution shall be used when caring for residents who are documented or suspected to have communicable diseases or infections that can be transmitted to others .Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. Under Contact Precautions, it revealed, B. Resident Placement (1) Place the individual in a private room if it is not feasible to contain drainage, excretions, blood or body fluids (2) If a private room is not available, the Infection Control Coordinator will assess various risks associated with other resident placement options (e.g., cohorting). Under Droplet Precautions, it revealed, B. Resident Placement (1) Place the resident in a private room. (2) When the private room is not available, residents with the same infections with the same microorganism but with no other infection may be cohorted. Review of facility staff in-service on 9/4/20 titled COVID-19 with revision date of 4/16/20 and 4/17/20 revealed, If patients have been screened and their testing is positive for COVID-19 or if patients have signs/symptoms of a respiratory [MEDICAL CONDITION] infection: a) full vitals and pulse oximetry every 4 hours (Q4 hours) twice a shift b) Private room or cohort with another symptomatic or positive patient c) maintain standard, contact and droplet precautions (including eye protection). According to CDC article titled People with certain Medical Conditions updated Sept. 11, 2020 revealed under risk for severe illness increases with age, As you get older, your risk for severe illness from COVID-19 increases .Similarly, people in their 60s or 70s are in general, at higher risk for severe illness than people in their 50s. The greatest risk for severe illness from COVID-19 is among those aged 85 or older. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html According to CDC article titled People with Certain Medical Conditions updated Sept. 11, 2020 revealed, People of any age with the following conditions are at increased risk of severe illness from COVID-19: cancer .[MEDICAL CONDITION], serious heart conditions, such as heart failure, [MEDICAL CONDITION] or [MEDICAL CONDITION] . https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html According to a CDC article titled Preparing for COVID-19 in Nursing Homes updated June 25, 2020 revealed, Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19 .Have a plan for how residents in the facility who develop COVID-19 will be handled (e.g., transfer to single room, implement use of Transmission-Based Precautions, prioritize for testing, transfer to COVID-19 unit if positive) .Have a plan for how roommates, other residents, and HCP who may have been exposed to an individual with COVID-19 will be handled (e.g., monitor closely, avoid placing unexposed residents into a shared space with them) .Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility . https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html According to CDC article titled Responding to Coronavirus (COVID-19) in Nursing Homes updated April 30, 2020 under Response to Newly Identified [DIAGNOSES REDACTED]-CoV-2-infected HCP or residents revealed, If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to the designated COVID-19 care unit. Roommates of residents with COVID-19 should be considered exposed and potentially infected and, if at all possible, should not share rooms with other residents unless they remain asymptomatic and/or have tested negative for [DIAGNOSES REDACTED]-CoV-2 14 days after their last exposure (e.g., date their roommate was moved to the COVID-19 care unit). Exposed residents may be permitted to room share with other exposed residents if space is not available for them to remain in a single room. https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html C. During the entrance interview on 9/2/20 at approximately 10:45am, the Administrator was asked about the facility's personal protective equipment (PPE) inventory. The Administrator verbalized, We are lucky to have more than enough. Our corporate office sends us whatever we need. The Administrator added, And that's for all PPEs, gowns, N95masks, gloves When asked what the facility's PPE's operating capacity. The Administrator confirmed they were operating under normal standard of practice and reiterated they had enough PPE to operate otherwise. When specifically asked about the availability of their N95 masks, the Administrator stated they currently had tons of N95 masks. Later, during the unit tour, the Administrator showed a room converted into a storage room full of PPE supplies. The Administrator explained the room was for the PPE overflow and they had more in the main supply room. During the initial tour of all the units (Medicare, South and West wings) on 9/2/20 at approximately 11:15am, staff members were observed to use different types of N95masks as evidenced by different shapes, colors and mask markings. On 9/2/20 at 11:55am, the Assistant Director of Nursing (ADON) was asked about the above-mentioned observation. The ADON stated the facility had approximately four different types of N95 masks that were concurrently in use. When asked what type of N95 mask he had on, the ADON stated he could not remember the name but later provided the name of the N95 mask as Inovel 3000 Series N95. When ask if he was fit tested for this mask. The ADON confirmed that he was not. The ADON added that he was fit tested on a different type of N95 mask sometime during the early days of the pandemic however; he could not remember the name of that particular N95 mask. In a concurrent interview on 9/2/20 at approximately 2:20pm, with the Director of Nursing (DON), the ADON and the Administrator, the latter was asked about the N95 mask she had on. The Administrator's N95 mask was different from what the ADON and other staff members used on the floor. The Administrator showed the markings on her mask that reads Uniair San Huei SH3500 NIOSH N95 TC- 84A- 4313. When asked whether she was fit tested for the mask, the Administrator verbalized, No, I was not. When asked about the various N95 masks used on the floor. The Administrator confirmed staff members concurrently used four different N95 masks throughout the building. In addition to the two N95 masks mentioned above the facility also used the 3M8000 N95 mask and the Dasheng N95 respirator mask DTC3x. Of these masks, only 3M 8000 N95 was approved by the Centers for Disease Control and Prevention (CDC), the National Institute for Occupational Safety and Health (NIOSH); the National Personal Protective Technology Laboratory (NPPTL), the Food and Drug Administration (FDA) and the Occupational Safety and Health Administration (OSHA). When asked whether staff members were fit tested for the above-mentioned N95 masks. The Administrator confirmed staff members were not fit tested . The Administrator claimed staff were fit tested on ly once in May but for a different N95 mask. When asked what the facility's process was prior to the use of N95 masks. The DON stated that ideally a fit testing would be conducted prior to the use of any N95 masks. The DON explained they were often provided with different N95 masks and had difficulty fit testing staff upon receipt of the new ones. When asked what the facility's procedure for the use of N95 mask was. The ADON responded that each staff member was given one N95 mask and the mask was re-used for five working days. When asked if they had consulted with the N95 mask manufacturers regarding its proper reuse procedure. The Administrator stated they had not reached out to the manufacturers. When asked if staff were trained on how to properly store and re-use the N95 mask in order to maintain its integrity. The three did not provide an answer and there was no documented N95 mask re-use training provided prior to the survey's exit. It was clarified with the Administrator that the process of reusing the N95 mask contradicted to their prior claim of operating under normal standard of practice. The reusing of N95 mask fell under the surge capacity strata. An excerpt from the CDC's website reads, Because crisis capacity strategies are not compatible with US standards of care, crisis capacity strategies should only be implemented when there are known shortages of N95 Filtering Face Respirators (FFRs) and only after conventional and contingency strategies have been implemented. When asked about the aforementioned steps and strategies.The Administrator did not provide an answer. In a concurrent interview on 9/10/20 at approximately 11:30am with NA2 and NA3 both were asked whether they were fit tested for the N95 masks they previously used. NA2 responded, I do not think so. I know when this (referring to the pandemic) first started we were fit tested but that was for a different mask. When asked for the number of N95 masks they had used since then. NA3 responded, Three or four. Not sure but I know more than two. NA2 explained they were instructed to reuse the facemask for five working days. When asked what the process was. NA2 further explained that she kept her N95 mask on her workbag when she was not working and reused the mask every time she worked. NA2 added they would get a new mask after it was used for five days. When asked what training both received in proper storing and or maintaining the integrity of the N95. NA3 responded that they did not received any training specific to the aforementioned but rather on the proper sequence in putting on and taking off the PPE. Review of the facility's Respirator Fit Test Record dated 5/5/20 revealed some parts of the form were left blank. The missing sections included but were not limited to type of testing whether it was qualitative or quantitative, missing signatures of staff who completed the test, lacked the name and signature of the person who conducted the fit testing, and whether staff passed or failed the fit testing. Review of the facility's policy titled N95 Masks PPE Conservation/ Respirator revised on 4/21/20 under Procedure indicated When a N95 mask is being used, it will be used for patient care and stored in a paper bag when not in use. Each mask should be worn for a time period of three to five days after being issued to staff member. If the integrity of the N95 masks fails or becomes soiled, it should be returned to the facility Administrator or Director of Nursing to have a new mask fitted and issued. Staff are mandated by the company to wear N95 masks when providing patient care . According to the CDC, Respirators, when required to protect HCP from airborne contaminants such as some infectious agents, must be used in the context of a comprehensive, written respiratory protection program that meets the requirements of OSHA's Respiratory Protection standard external icon. The program should include medical evaluations, training, and fit testing . Retrieved on September 3, 2020 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html According to the CDC's Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Face piece Respirators in Healthcare Settings under Respirator Extended Use Recommendations revealed, Extended use is favored over reuse because it is expected to involve less touching of the respirator and therefore less risk of contact transmission. If extended use of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination (e.g., use of barriers to prevent droplet spray contamination) Further review of the same document under Respirator Reuse Recommendations revealed .Safe N95 reuse is affected by a number of variables that impact respirator function and contamination over time.(18, 19) However, manufacturers of N95 respirators may have specific guidance regarding reuse of their product .If reuse of N95 respirators is permitted, respiratory protection program administrators should ensure adherence to administrative and engineering controls to limit potential N95 respirator surface contamination .Healthcare facilities should develop clearly written procedures to advise staff to take the following steps to reduce contact transmission .Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses. To minimize potential cross-contamination, store respirators so that they do not touch each other and the person using the respirator is clearly identified. Storage containers should be disposed of or cleaned regularly .To reduce the chances of decreased protection caused by a loss of respirator functionality, respiratory protection program managers shouldconsult with the respirator manufacturer regarding the maximum number of donnings or uses they recommend for the N95 respirator model(s) used in that facility .Management should consider additional training and/or reminders for users to reinforce the need for proper respirator donning techniques including inspection of the device for physical damage (e.g., Are the straps stretched out so much that they no longer provide enough tension for the respirator to seal to the face? . Is the nosepiece or other fit enhancements broken? etc.). Healthcare facilities should provide staff clearly written procedures . www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html According to OSHA, .1910.134(c)(1) In any workplace where respirators are necessary to protect the health of the employee or whenever respirators are required by the employer, the employer shall establish and implement a written respiratory protection program with worksite-specific procedures .The employer shall include in the program the following provisions of this section, as applicable .1910.134(c)(1)(v) Procedures and schedules for cleaning, disinfecting, storing, inspecting, repairing, discarding, and otherwise maintaining respirators .If an employee is required to use a tight- fitting respirator at work, such as a surgical N95 mask, then the employee must be fit tested with the mask prior to use. Fit testing is done to be sure that the respirator's face piece fits the user's face, and must be assessed at least annually (note that Federal OSHA has waived annual fit-testing requirements during the COVID-19 pandemic, but initial fit testing is still required). Fit testing can be qualitative (recommended) or quantitative. In addition, fit tests should be performed: Whenever a different size, style, model or make of respirator is used. When any facial changes occur that could affect fit, such as significant weight fluctuation or dental work .Mask users can be fit tested in house by trained personnel (see do-it-yourself procedures below) or by an outside vendor, usually an expert in industrial hygiene or occupational safety. Retrieved from https://www.osha.gov/lawsregs/regulations/standardnumber/1910/1910.134 D. On 9/2/20 at approximately 11:15am, the Physical Therapy Aide (PTA) was observed to exit R3 and R4's room (both residents were on contact and droplet precautions due to COVID19) with gloves on. The PTA stood next to the isolation cart outside R3 and R4's room and quickly applied a small amount of alcohol gel on his gloved hands. It was further observed that the PTA had used two pairs of gloves (double gloved). The ADON who was nearby was informed about the observation and stopped the PTA from going to another room On 9/2/20 at approximately 11:55am, the ADON was asked about the observation. The ADON stated (Name of PTA) should have removed his gloves prior to exiting the isolation room. The ADON added that double gloving was not acceptable and it was not the facility's practice. In a concurrent interview with the Administrator, the DON and the ADON on 9/2/20 at approximately 2:35pm, the DON was asked about the above-mentioned observation. The DON concurred with the ADON's statement earlier that it was not the facility's policy to double glove. The DON further explained she expected staff to remove gloves and perform hand hygiene before exiting a resident's room whether it was an isolation room or not. On 9/9/20 at approximately 11:50am, the PTA was asked about the above-mentioned observation. The PTA stated, It's a misunderstanding. I misunderstood our gloving procedure. The PTA further stated that he should have removed his gloves prior to exiting the room and should have not donned two pairs of gloves. Review of the facility's Hand Hygiene policy revised 9/15/19 under Procedure indicated .5 Employees must wash their hands for fifteen (15) to twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after direct contact with residents .6.If hands are not visibly soiled, use Instant FOAM hand sanitizer .j. after removing gloves .7. Hand hygiene is always the final step after removing and disposing of personal protective equipment. 8. The use of gloves does not replace handwashing/hand hygiene . The Immediacy was accepted on 9/8/20 at 7:17pm and was verified 9/10/20 at 2:10pm that the facility implemented the following actions: 1) staff were educated on the new policies related to the use of disposable goggles and disposable N95 mask that included provisions to discard both PPE after each use and procedures when the facility would operate under surge capacity; 2) R2 was moved to another room; 3) staff were fit tested and used only N95 masks approved by CDC/OSHA; 4) staff were re-educated on proper hand washing, use of gloves and alcohol based hand rub; 5) management team were re-educated on following the CDC guidelines on proper cohorting of COVID-19 residents; and 6) educated staff in charge of PPE procurement on following the CDC guidelines on procuring approved PPEs. 2. Based on observation, interview and record review, the facility failed to prevent potential infection and transmission of COVID-19 by failing to ensure adherence to infection control practices to prevent the transmission of the Coronavirus (COVID-19) as evidenced by failure to perform hand hygiene after contact with an N95 mask and before handling clean linens. This could affect NA4 and two residents in South Hall who had not tested positive for COVID-19. Observations made during the tour in the South Hall at 10:55am on 9/2/20, noted that NA4 touched the front of his N95 and continued to walk the hallway. NA4 proceeded to take some clean towels and NA4 then touched the front of his N95 mask. NA4 walked back towards the South Hall and touched the front of his N95 mask for the third time. NA4 failed to perform hand hygiene after touching his N95 and before taking clean linens. During an interview with the DON on 9/2/20 at 2:28pm, when asked about her expectation from staff when they touched their N95 mask, the DON Wash their hands or use the hand sanitizer and if it (mask) is soiled, get a new mask. Review of facility's in-service policy titled Handwashing/ Mask Etiquette dated 3/31/20 revealed Hand Hygiene should be performed before putting on a mask, and after touching, adjusting or removing a mask. Review of facility's policy titled Handling Linen dated 9/15/19 revealed 10. Wash hands before contact with clean linen and after contact with soiled linen. According to a CDC article titled Using Personal Protective Equipment updated Aug. 19, 2020, under Respirator on/Respirator off revealed, Do not touch the front of the respirator during or after use. It may be contaminated. https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/fs-respirator-on-off.pdf According to a CDC article titled Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic updated July 15, 2020 revealed, Educate patients, visitors, and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth face covering. https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html According to a CDC article titled Appendix D - Linen and laundry management dated March 27, 2020 revealed, Sort, package, transport and store linens in a manner that prevents risk of contamination (TRUNCATED)

Based on interview, observation and record review, the facility failed to use a gait belt during resident transfer to prevent injury for one of eight residents (R3) reviewed for transfers in the sample of 32. This failure resulted in R3 having an injury with increased pain and a functional decline. Findings include: The facility's Use of a Gait Belt policy, dated 12/2017, documents, It is the policy of this facility that staff will help control and balance (by using a gait belt) residents who require assistance with ambulation and transfer. On 2/5/19 at 10:15 AM, R3 stated, I told (V15, Certified Nursing Assistant, CNA) to not transfer me without a gait belt. I was in my chair in my room. (V15) said, 'I'm just transferring you to bed.' I told her no, and before I knew it she lifted me by my arm. I screamed because it hurt. It took my breath away. I pulled the muscle under my right arm on the right side of my chest. (V15) told me, 'I'm sorry I hurt you.' R3's Assessment Scoring Report, dated 2/5/19, documents a BIMS (Brief Interview for Mental Status) score of 15 (cognitively intact). R3's Care plan, dated 12/24/18, documents that R3 has a self-care deficit and requires one to two person physical assistance for transfers. R3's Physical Therapist Progress note, dated 1/25/19, documents, Current Level of Function: Gait Tasks: Distances Surfaces: (R3) ambulates 132 feet on level surfaces and requiring stand by assistance to contact guard assist (contact due to unsteadiness) with front wheeled walker; Transfer: Sit to Stand: (R3) is able to safely transition from sit to stand requiring minimal to moderate assistance (26-75% assist). R3's Nurse's note, dated 1/28/19 at 9:11 AM, documents, Upon assessment, (R3) is noted to be teary eyed in her room. (R3) stated that she, 'was hurt during a transfer and it took her breath away.' R3's Nurse's notes, dated 1/28/19, documents, Called physician to request stronger pain medication due to (R3) complaining of pain that Tylenol is not controlling. R3's Physical Therapy Treatment note, dated 1/28/19, documents, Treatment withheld due to (R3) has severe pain right side, and feeling overwhelmed after her arm was pulled yesterday (1/27/19). (R3) states, 'I'm just mad. It's unnecessary. I feel like I'm going backwards.' (R3) reports it hurts to cough. R3's Occupational Therapy Daily Treatment Note, dated 1/28/19, documents, (R3) voiced complaints of excruciating pain on right [MEDICATION NAME] area. (R3's) pain currently, extremely limiting patient's ability to safely perform ADL (Activities of Daily Living) task and functional transfers at this time. Requested further evaluation of (R3's) area to be determined per medical doctor or x-ray to determine if other concerns/[DIAGNOSES REDACTED]. R3's Occupational Therapy Daily Treatment Note, dated 1/29/19, documents, (R3) complains of severe pain in right chest area which nursing is aware of and x-ray ordered. Therapist instructed patient in putting on/off shoes which patient required maximum assistance due to inability to tie her shoe and reach properly due to pain in (R3's) right side. Therapist instructed (R3) and CNAs to discontinue ambulating to the toilet with the use of a wheeled walker at this time until pain subsides and results from x-rays are given. On 2/5/19 at 11:20 AM, V12 (Registered Nurse) stated, (R3) told me someone picked her up by under her arms, and it hurt her under her arm. On 2/5/19 at 12:10 PM, V13 (CNA) stated that R3 told V13 about the incident of V15 not transferring R3 with a gait belt. V13 also stated, (R3) did get hurt from this because she couldn't even walk with her walker because it hurt so bad. On 2/6/19 at 9:45 AM, V11 (Occupation Therapist Assistant) stated, (R3) told me about the incident with (V15). (R3) didn't have time to react; (V15) just lifted her by her arms, and didn't use a gait belt. The staff plan was to use a gait belt transfer because she was working to discharge home with independent transfers. (R3) felt a sharp pain in her right side. I made a progress note of it that day. I actually had to change her status to only be a pivot transfer, no walking because of the pain. All of her activities were limited due to the pain. On 2/6/19 at 12:50 AM, V16 (R3's Physician) stated, Transferring a resident without a gait belt is common sense that they could cause a muscular injury when pulling on the resident. The shoulder, chest wall, and back could be injured. They should transfer a resident according to the facility's policy.

Based on observation, record review, and interview, the facility failed to accurately and timely assess and monitor changes in pressure ulcers for 1 of 4 residents (R2) reviewed for pressure ulcers in the sample of 17. This failure resulted in R2's pressure ulcer progressing / worsening from a Stage 2 to a Stage 3 Pressure Ulcer. Findings include: R2's Admission Braden Scale for predicting pressure ulcer risk, dated 3/4/14, was 11 (Score of 12 or less is high risk). R2's Admission Minimum Data Set (MDS), dated [DATE], documented R2 did not have pressure ulcers, but R2 was at High Risk for pressure ulcers. R2's MDS, dated [DATE], documented R2 requires extensive assistance, and two plus physical assistance for bed mobility and transfers. R2's Care Plan, dated 3/6/15, documented R2 has a pressure ulcer to coccyx that was facility acquired on 8/17/14. R2's Care Plan documented the pressure ulcer was to be assessed weekly. R2's skin condition report dated 4/17/15, documented R2 had a Stage 2 Pressure Ulcer on her coccyx. On 4/22/15 at 10:50 AM, in an observation with E5, Licensed Practical Nurse (LPN), a dressing was in place on R2's pressure ulcer on her coccyx. Additionally, it was observed the size of the ulcer did not match the measurements on the Pressure Ulcer Log, dated 4/17/15. The Pressure Ulcer Log documents that R2's coccyx pressure ulcer measured 1.0 centimeter (CM) in length X 0.5 CM width X 0.1 CM in depth, and is a stage 2. E5 stated that the night nurse does the dressing changes. On 4/22/15 at 12:40 PM, E3, LPN/ Wound Nurse measured the pressure ulcer. The pressure ulcer now measured 3.0 CM in length X 1.4 CM in width X 0.3 CM in depth. E3 stated that when she took the dressing off it was macerated, and draining. E3 stated she had not seen this wound since her last weekly measurement done on 4/17/15. E3 stated she does not do the daily dressing changes, as they are done by the night nurse and as needed by day nurse. E3 stated she had not been informed the wound had worsened. E3 stated she would complete a change of condition form and notify the physician. The Change of Condition Pressure Ulcer sheet, dated 4/22/15 at 3:00 PM, documents the ulcer is now a Stage 3 Ulcer. On 4/24/15 at 9:00 AM, E1, Administrator stated that the facility has already identified a problem in regards to staging of pressure ulcers on 4/8/15, and had been sent through Quality Assurance. E1 stated that E2, Director of Nursing had been at the facility doing training on the weekend of 4/18/15. On 4/24/15 at 9:00 AM, E2, stated that she would expect any nurse caring for R2 to reassess the wound and notify the physician if there is a change in the pressure ulcer. The facility's Skin Integrity Standard Procedure documented that dependant residents sitting or in bed may need a position change for tissue offloading every hour. The procedure documented that weekly head to toe assessment are to be done for all residents by licensed nurse with narrative documentation of findings. Weekly narrative documentation must include: description of skin tissue, color, turgor, rashes, bruising, skin tears, [MEDICAL CONDITION], incision lines, and any other skin related issues. The procedure documented that if skin integrity issues are identified post- admission to the facility the following documentation is required: wound specifics, size of the wound including length, width, and depth in centimeters, indicated if undermining or tunneling exists the depth must be measured, the amount of drainage, description of the wound bed, odor, signs/symptoms of infection, description of surrounding tissue, stage of the wound, notification on the 24 hour report indicating the skin condition, incident report completed for in house acquired stage III and/or IV. If the wound has shown no signs of improvement in 2-4 weeks reevaluate interventions and the plan of care.

Based on record review and interview, the facility failed to identify, implement interventions, and evaluate those interventions for 2 (R3, and R4) of 2 residents on the sample of 7. This failure resulted in R4 having a decline in mental and physical status with weight loss and dehydration which resulted in hospitalization . A urinary tract infection was not identified for R3 which resulted in increased behaviors and discharge from the facility. The findings include: 1. R4 was admitted to the facility on [DATE] with diagnoses, in part, of anxiety, hypertension, falls, pneumonia, and [DIAGNOSES REDACTED] (a form of [DIAGNOSES REDACTED]). The Minimum (MDS) data set [DATE] identified R4 as able to make herself understood and usually understands others. R4 has communication problems due to hearing and vision deficits. R4 requires extensive assistance of staff for all activities of daily living except eating. R4 received an order on [DATE] by Z1, Physician, [MEDICATION NAME] 0.25 mg (milligrams) every 6 hours as needed and on [DATE][MEDICATION NAME] mg at bedtime as needed. On [DATE], Z3 ordered [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 1 mg three times per day as needed, [MEDICATION NAME] 50 mg daily, continue the [MEDICATION NAME] 0.25 mg every 6 hours as needed, and [MEDICATION NAME] ,[DATE] 1 tablet every 4 hours as needed. Z3 stated on [DATE] that R4 was "very agitated" and the [DIAGNOSES REDACTED]. The "Geriatric Dosage Handbook" 12th edition noted the sedation incidence for [MEDICATION NAME] (Quetiapine)is "Moderate/High". The "U.S.Boxed Warning" states "Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at increased risk of death compared to placebo. Quetiapine is not approved for this indication". [MEDICATION NAME] is classified as an atypical antipsychotic with use for "treatment of [REDACTED]. Under "Drug Interactions" it was noted that [MEDICATION NAME] "may enhance the sedative effects of other CNS depressants" such as antidepressants, narcotic [MEDICATION NAME] and other sedative agents. The care plan dated [DATE] identified as a problem that R4 is at risk for dehydration with the goal of "will have no S/S (signs/symptoms) of dehydration or nutritional alteration". The approaches include, in part, "measure and record daily intake, report poor fluid intake amounts to physician and registered dietitian". The care plan also identified as problems for R4 as severe hearing loss and visual impairment. On the care plan under the problem "Impaired Communication D/T (due to) severe hearing loss/absence of useful hearing". The care plan documents "Will continue on lowest effective dose of [MEDICAL CONDITION] meds" as a "goal". There are no behaviors identified on the care plan or approaches for intervention. There is no documentation on the care plan regarding R4's husbands death . E3, Licensed Practical Nurse, stated on [DATE] that R4's husband had also been a resident at the facility and had "passed". The "Care Plan/Behavior Tracking Record" for April, 2011 only identifies "Yells out randomly" as the "Problem Statement". Interventions include: "1:1 as needed; assist res to activities of int (interest); ask res if hungry, pain toilet". There are no [MEDICAL CONDITION] medications listed. There is no behavior tracking sheet for March. E2, Director of Nursing, confirmed on [DATE] that there no [MEDICAL CONDITION] drug assessment completed for R4 and only documented the [MEDICAL CONDITION] medications under "Psychosocial Notes". The psychosocial notes only lists the medications ordered. The nurses notes for March documented that R4 was able to feed herself, could wheel herself about the facility in her wheelchair, able to make her needs known by reading lips and large print, and was alert. There are several notations of R4 "hollering out". R4's husband passed away at the facility on [DATE] as confirmed by E2 on [DATE]. On [DATE] the nurses notes documented R4 was "weeping et (and) talking about her husband, given PRN (as needed) [MEDICATION NAME] for anxiety (at) this time". There is no mention in the nurses notes on [DATE] that R4's husband passed away. On [DATE] the nurses notes documents "Does speak of (husband) dying. Says "He was a good man". On [DATE] the nurses notes documents "Res. very teary talking about deceased husband. She states "No one wants me". The physician was called regarding an antidepressant. On [DATE] R4 was noted in the nurses notes that she was "hollering out all NOC (night)". At 7:20 AM the nurses notes document that R4 was yelling out and other residents were "agitated due to her behavior". The physician was called and orders for [MEDICATION NAME], and [MEDICATION NAME] were given. [MEDICATION NAME] was also started on [DATE] and the [MEDICATION NAME] was continued. E4, Social Service Director, stated on [DATE] that she does total the behaviors on the behavior tracking sheet and that is put with the chart. E4 stated the Certified Nurse Aides mark the behavior on the sheet and the nurses chart in the nurses notes. E4 stated the physician look through the chart to see behaviors. E4 stated the physician and the nurses decide when a medication will be changed. On [DATE] the order was changed to [MEDICATION NAME] 0.25 mg twice a day as needed and decrease [MEDICATION NAME] 5 mg as needed for sleep. The April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] Z4, Psychiatrist, discontinued the [MEDICATION NAME], and added [MEDICATION NAME] 0.5 mg three times per day but did not discontinue the [MEDICATION NAME] 1 mg three times per day as needed. The nurses note dated [DATE] documented R4 was very tired and refused her supplement. On [DATE] the [MEDICATION NAME] was held as R4 was slow to respond. On ,[DATE] the physician was notified of a weight loss. On [DATE] R4 was very lethargic and refused her breakfast. On [DATE] at 9:30 PM the nurses notes stated [MEDICATION NAME] and [MEDICATION NAME] given and R4 "settled down shortly (after) wards". On [DATE] R4 was noted to be "very sleepy" with her arms hanging over the side of the wheelchair but did take AM meds. Intake was poor. On [DATE] Z4, Psychiatrist, was at the facility and discontinued [MEDICATION NAME] and [MEDICATION NAME]. The "Weight Record" dated [DATE] documented a weight of 121.3 pounds. On [DATE] the weight was 114.5 and on [DATE] the weight was 105.2 pounds for a significant weight loss of 13.3% in a one month period. The "intake and output sheet" documented fluid intake well below estimated fluid needs of ,[DATE] cc's per day for the month of April. E2, Director of Nursing, stated on [DATE] that [MEDICATION NAME] 180 cc's twice a day was not added into the intake and output record, however, this would have only increased the fluid intake enough on [DATE] to meet her fluid needs. On [DATE] R4's blood urea nitrogen (BUN) was 8 mg (milligrams)/dL (decaliter) with normal at ,[DATE] mg/dL. The creatinine were documented at 0.6 mg/dL with normal at 0XXX,[DATE].2 mg/dL. On [DATE] the BUN was 43 and creatinine was 0.9. R4's blood pressure was documented only in the nurses notes on [DATE] at ,[DATE]; on [DATE] at ,[DATE] and on [DATE] at ,[DATE]. On [DATE] at 10:30 AM, Z4, Psychiatrist was faxed regarding R4's condition according to the nurses notes. The note also states the family was contacted about "possible comfort measures" such as no hospital, labs, intravenous fluids and use of a geriatric chair. The family member stated they would discuss it with other family members and call them back. The nurses notes states Z4 faxed back and told staff to contact R4's primary care physician and Z1, primary care physician, was sent a fax. The nurses note dated [DATE] at 9:45 PM noted that Z5, Physician Assistant for Z1, stated "They pt info (information) on res (resident) that we faxed on her chart but NNO (no new orders) @ (at) this time". There was no documentation that the family was contacted again by the facility or that the family called the facility. There were no other nurses notes documented until [DATE] at 10:00 AM. The fax sheet sent to Z1 on [DATE] at 10:50 AM by E3, Licensed Practical Nurse, noted "Had to put her in (geriatric chair) for positioning; she is see physc (physician) he was there over weekend; took some of her meds away; gave her [MEDICATION NAME] 0.5; contacted physc. about condition also her daughter and talked to her about comfort measures. She is not eating or drinking; pocketed her food yesterday morning; daughter will call nursing home back about comfort measures". Z2, physician assistant, stated on the written note at 1:13 PM on [DATE] "noted. please keep us informed". The nurses notes dated [DATE] at 10:00 AM noted R4 was "very lethargic" and her breakfast eggs had to be removed due to pocketing of the food. The note stated E3 had to hold her head in an "upward position. Cradle her" to get her to take her medications. At 10:30 AM a family member, Z6, came to the facility to visit R4. The nurses note states Z6 came back to the nurses station and stated "She's dehydrated, How long has she been like this". The power of attorney was called and requested to send R4 to the hospital. Z1's office was called and orders to send R4 to the hospital were given. E3, Licensed Practical Nurse, stated on 5/ 24 /11 that she did have to cradle R4's head to get her to take her meds on [DATE] morning. E3 stated they were using a geriatric chair as R4 could not hold herself up and her arms kept falling off the wheelchair arms. E3 stated R4 was not eating or drinking well. E3 confirmed that she had only contacted the physician on [DATE] regarding R4's decline in condition. E3 confirmed that she did not call the family on [DATE] regarding R4's condition. E3 stated the sister of R4 came to the facility and she directed her to E2's office after the sister stated R4 was dehydrated. E3 stated she took the fax with her to show her the physician had been contacted. Z2, Physician Assistant for Z1, Physician, stated on [DATE] that the physician office was contacted on [DATE] by the facility regarding R4. Z2 stated she only saw what the facility reported on the fax dated [DATE] and confirmed that no information regarding blood pressure, intake and output, weight loss or specific medication changes was given. Z2 stated she can only go on what they (the facility staff) tell her. Z2 stated on [DATE] that R4 was not on hospice and the facility "definitely" should have called on [DATE] and notified the physicians office when the nurse noted on [DATE] that R4 could not sit up, pocketed her breakfast food, and had to cradle her head to give her medications. Z2 confirmed that when R4 was admitted to the hospital and the BUN (blood urea Nitrogen) indicated severe dehydration. Z3, Physician, stated on [DATE] that he saw R4 when she was admitted to the hospital only. Z3 confirmed that R4 was dehydrated on admission to the hospital and the dehydration was "severe". Z3 stated R4 also had pressure sores to the sacrum and on her foot when she was admitted . Z3 stated that R4's [DIAGNOSES REDACTED]. Z3 stated that if the families wishes regarding comfort measures had not been determined then the facility should have called or acted sooner regarding R4's decline in condition. Z3 stated if the facility was noticing decreased intake and dehydration they should have called the physician. Z3 stated "A call earlier would have been helpful". R4 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. According to the "Personal history and physical examination [REDACTED]. The BUN was noted to be elevated at 141 (,[DATE]) and creatinine of 2.6 (0XXX,[DATE].2). Sores were noted on the sacrum and bilateral feet. Medication changes were noted and "some medication changes may account for altered status". R4 was discharged back to the facility on comfort measures on [DATE]. R4 expired on [DATE] 2. R3 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, dementia with behavioral disturbances, depression and anxiety. R3 was assessed on the [DATE] Minimum Data Set as usually understanding and being understood by others. There were no behavioral symptoms identified on the assessment. The care plan dated [DATE] identified "Res (resident) becomes combative at times with AM care". On [DATE] the statement "Phys (physical) aggressiveness displayed towards others". On [DATE] R3 was started on [MEDICATION NAME] 50 mg (milligrams) every morning and [MEDICATION NAME] 0.5 mg twice a day. On [DATE] [MEDICATION NAME] was added at 50 mg every evening due to agitation and paranoia. The progress note dated [DATE] by Z4, Psychiatrist, noted R3 was agitated and paranoid of her roommates behavior. Z4 documented R3 was recently widowed in the last few months and questioned why she was at the facility. On [DATE] [MEDICATION NAME] was increased to 50 mg three times per day. On [DATE] the [MEDICATION NAME] was increased to 50 mg twice a day and 100 mg in the evening. [MEDICATION NAME] was increased to 100 mg every morning. The progress note dated [DATE] by Z4 noted that R3 "continues to voice paranoid ideation as well as extremely unhappy and upset about being here at the facility". The "Geriatric Dosage Handbook" 12th edition noted the sedation incidence for [MEDICATION NAME] (Quetiapine)is "Moderate/High". The "U.S.Boxed Warning" states "Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at increased risk of death compared to placebo. Quetiapine is not approved for this indication". [MEDICATION NAME] is classified as an atypical antipsychotic with use for "treatment of [REDACTED]. The "Care Plan/Behavior Tracking Record" for May, 2011 identified the behavior problem as "Depression-tearfulness", "Res. (resident) wakes up forgetful-doesn't recall where she is or events", "Res. becomes combative with AM (morning) care", and "Exit seeking". None of the behavior tracking sheets identify any frequency of any of the identified behaviors for May. The nurses notes from [DATE] thru [DATE] do not identify any behaviors. On [DATE] the "Resident Incident Report" documented R3 was observed striking her roommate on the back at 10:30 PM. The incident report documented the family was notified on [DATE] at 5:20 AM. The nurses notes dated [DATE] at 10:30 PM noted staff heard R3 yelling at her roommate and found her hitting the roommate on the back. R3 was agitated and combative to staff. R3 was "yelling et (and) wanting everyone to get out of her house". Z4, Psychiatrist, was notified and ordered [MEDICATION NAME] 1 mg intramuscularly and to check with a hospital for a psychiatric admission. There were no beds available. The nurses notes states the family was contacted and a message left. Z9, primary care physician for R3, was notified and ordered a geriatric chair with a tray for R3's safety. R3 was put in the chair until 12:30 AM on [DATE]. At 5:20 AM on [DATE] E1, Administrator, was notified of the incident. At 5:20 AM the nurses notes states the power of attorney was "informed of need to obtain alternate placement due to aggression and combativeness to roommate". There was one incident of kicking and hitting at staff at 6:00 AM on [DATE] documented and again on [DATE] at 6:30 AM during AM care. E1, Administrator, documented on [DATE] regarding the incident. E1 documented that the family called at 5:20 AM and was told they needed to come to the facility to discuss the situation and R3's behavior. The family stated they had a funeral to attend and was not sure when they could be there. E1 documented "stated needed to be here by noon, that we needed to discuss possibility of placing resident in other facility due to her aggression to other resident". E1 informed the family that the facility would call for possible bed openings at other facilities. E1 documented that E4, Social Service Director was contacted and told the family had "asked for help" placing R3 in another facility. E4's noted dated [DATE] noted the incident and called Z8, Power of Attorney for R3, at 8:00 AM "about possible home replacement". The note states Z8 gave verbal consent but then at 10:24 AM rescinded her consent after she talked to the ombudsman. The family contacted another facility and transferred R3 to the facility on [DATE]. E1, Administrator, confirmed on [DATE] that she did write the note. E1 stated she didn't feel R3's discharge was an involuntary discharge as the family had decided to move R3. E1 confirmed that R3 did not receive involuntary discharge notification. E2, Director of Nursing, stated on [DATE] that R3 didn't fit at the facility as she was combative and aggressive. E2 stated R3 had progressively gotten worse. E2 stated the family was unwilling to cooperate and choose to take R3 to another facility. E2 stated on [DATE] that R3 was discharged due to hitting her roommate. E2 stated it was unusual for R3 to hit another resident. E2 stated she was unsure if any labs had been done. E2 stated R3 was very combative with staff and no one could take care of her. E2 stated she did not know how they could keep R3 at the facility if she was harming others. E2 stated it was the family's decision to move her. E2 confirmed that R3 did not receive involuntary discharge notification. E4, Social Service Director, stated on [DATE] that the [DATE] incident was the first time R3 had hit another resident. Mostly the combative behavior occurred when she woke up and forgot where she was. E4 stated she had talked to the family about helping them find another facility for R3. E4 stated she did talk to the ombudsman who informed her that a written notification had to go out prior to discharge. Z8, family of R3, confirmed on [DATE] that they were told they needed to find another place for R3 to go due to her behaviors. Z8 confirmed that no written discharge notification was given to her. Z7, Administrator at new facility, stated she was aware R3 had hit another resident at the facility however, she had been informed this was not normal behavior for R3 to hit other residents. Z7 stated due to this they had ordered a complete medical work up for R3 and found R3 had a urinary tract infection. Z7 stated there has been no problems with R3 at the facility.

Based on record review and interview, the facility failed to provide adequate monitoring with indications for use, diagnoses, behavioral tracking and interventions for 2 (R3, and R4) of 4 residents reviewed for medication in a sample of 7. This failure resulted in a decline in condition, and hospitalization for change in mental status and dehydration for R4. The findings include: 1. R4 was admitted to the facility on [DATE] with diagnoses, in part, of anxiety, hypertension, falls, pneumonia, and [DIAGNOSES REDACTED] (a form of [DIAGNOSES REDACTED]). The Minimum (MDS) data set [DATE] identified R4 as able to make herself understood and usually understands others. R4 has communication problems due to hearing and vision deficits. R4 requires extensive assistance of staff for all activities of daily living except eating. R4 received an order on [DATE] by Z1, Physician, [MEDICATION NAME] 0.25 mg (milligrams) every 6 hours as needed and on [DATE][MEDICATION NAME] mg at bedtime as needed. On [DATE], Z3 ordered [MEDICATION NAME] 10 mg daily, [MEDICATION NAME] 1 mg three times per day as needed, [MEDICATION NAME] 50 mg daily, continue the [MEDICATION NAME] 0.25 mg every 6 hours as needed, and [MEDICATION NAME] ,[DATE] 1 tablet every 4 hours as needed. Z3 stated on [DATE] that R4 was "very agitated" and the [DIAGNOSES REDACTED]. The "Geriatric Dosage Handbook" 12th edition noted the sedation incidence for [MEDICATION NAME] (Quetiapine)is "Moderate/High". The "U.S.Boxed Warning" states "Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at increased risk of death compared to placebo. Quetiapine is not approved for this indication". [MEDICATION NAME] is classified as an atypical antipsychotic with use for "treatment of [REDACTED]. Under "Drug Interactions" it was noted that [MEDICATION NAME] "may enhance the sedative effects of other CNS depressants" such as antidepressants, narcotic [MEDICATION NAME] and other sedative agents. On the care plan under the problem "Impaired Communication D/T (due to) severe hearing loss/absence of useful hearing". The care plan documents "Will continue on lowest effective dose of [MEDICAL CONDITION] meds" as a "goal". There are no behaviors identified on the care plan or approaches for intervention. The "Care Plan/Behavior Tracking Record" for April, 2011 only identifies "Yells out randomly" as the "Problem Statement". Interventions include: "1:1 as needed; assist res to activities of int (interest); ask res if hungry, pain toilet". There are no [MEDICAL CONDITION] medications listed. There is no behavior tracking sheet for March. E2, Director of Nursing, confirmed in an interview on [DATE] that there no [MEDICAL CONDITION] drug assessment completed for R4 and only documented the [MEDICAL CONDITION] medications under "Psychosocial Notes". The psychosocial notes only lists the medications ordered. The nurses notes for March documented that R4 was able to feed herself, could wheel herself about the facility in her wheelchair, able to make her needs known by reading lips and large print, and was alert. There are several notations of R4 "hollering out". R4's husband passed away at the facility on [DATE] as confirmed by E2 on [DATE]. On [DATE] the nurses notes documented R4 was "weeping et (and) talking about her husband, given PRN (as needed) [MEDICATION NAME] for anxiety (at) this time". There is no mention in the nurses notes on [DATE] that R4's husband passed away. On [DATE] the nurses notes documents "Does speak of (husband) dying. Says "He was a good man". On [DATE] the nurses notes documents "Res. very teary talking about deceased husband. She states "No one wants me". The physician was called regarding an antidepressant. On [DATE] R4 was noted in the nurses notes that she was "hollering out all NOC (night)". At 7:20 AM the nurses notes document that R4 was yelling out and other residents were "agitated due to her behavior". The physician was called and orders for [MEDICATION NAME], and [MEDICATION NAME] were given. [MEDICATION NAME] was also started on [DATE] and the [MEDICATION NAME] was continued. E4, Social Service Director, stated on [DATE] that she does total the behaviors on the behavior tracking sheet and that is put with the chart. E4 stated the Certified Nurse Aides mark the behavior on the sheet and the nurses chart in the nurses notes. E4 stated the physician looks through the chart to see behaviors. E4 stated the physician and the nurses decide when a medication will be changed. On [DATE] the order was changed to [MEDICATION NAME] 0.25 mg twice a day as needed and decrease [MEDICATION NAME] 5 mg as needed for sleep. The April Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On [DATE] Z4, Psychiatrist, discontinued the [MEDICATION NAME], and added [MEDICATION NAME] 0.5 mg three times per day but did not discontinue the [MEDICATION NAME] 1 mg three times per day as needed. The nurses note dated [DATE] documented R4 was very tired and refused her supplement. On [DATE] the [MEDICATION NAME] was held as R4 was slow to respond. On ,[DATE] the physician was notified of a weight loss. On [DATE] R4 was very lethargic and refused her breakfast. On [DATE] at 9:30 PM the nurses notes stated [MEDICATION NAME] and [MEDICATION NAME] given and R4 "settled down shortly (after) wards". On [DATE] R4 was noted to be "very sleepy" with her arms hanging over the side of the wheelchair but did take AM meds. Intake was poor. On [DATE] Z4, Psychiatrist, was at the facility and discontinued [MEDICATION NAME] and [MEDICATION NAME]. The "Weight Record" dated [DATE] documented a weight of 121.3 pounds. On [DATE] the weight was 114.5 and on [DATE] the weight was 105.2 pounds for a significant weight loss of 13.3% in a one month period. The "intake and output sheet" documented fluid intake well below estimated fluid needs of ,[DATE] cc's per day for the month of April. R4's blood pressure was documented only in the nurses notes on [DATE] at ,[DATE]; on [DATE] at ,[DATE] and on [DATE] at ,[DATE]. On [DATE] at 10:30 AM, Z4, Psychiatrist was faxed regarding R4's condition according to the nurses notes. The note also states the family was contacted about "possible comfort measures" such as no hospital, labs, intravenous fluids and use of a geriatric chair. R4 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. According to the "Personal history and physical examination [REDACTED]. The BUN was noted to be elevated at 141 (,[DATE]) and creatinine of 2.6 (0XXX,[DATE].2). Sores were noted on the sacrum and bilateral feet. Medication changes were noted and "some medication changes may account for altered status". R4 was discharged back to the facility on comfort measures on [DATE]. R4 expired on [DATE] 2. R3 was admitted to the facility on [DATE] with diagnoses, in part, of Alzheimer's, dementia with behavioral disturbances, depression and anxiety. R3 was assessed on the [DATE] Minimum Data Set as usually understanding and being understood by others. There were no behavioral symptoms identified on the assessment. The care plan dated [DATE] identified "Res (resident) becomes combative at times with AM care". On [DATE] the statement "Phys (physical) aggressiveness displayed towards others". On [DATE] R3 was started on [MEDICATION NAME] 50 mg (milligrams) every morning and [MEDICATION NAME] 0.5 mg twice a day. On [DATE] [MEDICATION NAME] was added at 50 mg every evening due to agitation and paranoia. The progress note dated [DATE] by Z4, Psychiatrist, noted R3 was agitated and paranoid of her roommates behavior. Z4 documented R3 was recently widowed in the last few months and questioned why she was at the facility. On [DATE] [MEDICATION NAME] was increased to 50 mg three times per day. On [DATE] the [MEDICATION NAME] was increased to 50 mg twice a day and 100 mg in the evening. [MEDICATION NAME] was increased to 100 mg every morning. The progress note dated [DATE] by Z4 noted that R3 "continues to voice paranoid ideation as well as extremely unhappy and upset about being here at the facility". The "Geriatric Dosage Handbook" 12th edition noted the sedation incidence for [MEDICATION NAME] (Quetiapine)is "Moderate/High". The "U.S.Boxed Warning" states "Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at increased risk of death compared to placebo. Quetiapine is not approved for this indication". [MEDICATION NAME] is classified as an atypical antipsychotic with use for "treatment of [REDACTED]. Under "Drug Interactions" it was noted that [MEDICATION NAME] "may enhance the sedative effects of other CNS depressants" such as antidepressants, narcotic [MEDICATION NAME] and other sedative agents. The "Care Plan/Behavior Tracking Record" for May, 2011 identified the behavior problem as "Depression-tearfulness", "Res. (resident) wakes up forgetful-doesn't recall where she is or events", "Res. becomes combative with AM (morning) care", and "Exit seeking". None of the behavior tracking sheets identify any frequency of any of the identified behaviors for May. The nurses notes from [DATE] thru [DATE] do not identify any behaviors. On [DATE] the "Resident Incident Report" documented R3 was observed striking her roommate on the back at 10:30 PM. Z4, Psychiatrist, was notified and ordered [MEDICATION NAME] 1 mg intramuscularly and to check with a hospital for a psychiatric admission. At 5:20 AM the nurses notes states the power of attorney was "informed of need to obtain alternate placement due to aggression and combativeness to roommate". There was one incident of kicking and hitting at staff at 6:00 AM on [DATE] documented and again on [DATE] at 6:30 AM during AM care. The family contacted another facility and transferred R3 to the facility on [DATE]. E2, Director of Nursing, stated on [DATE] that R3 didn't fit at the facility as she was combative and aggressive. E2 stated R3 had progressively gotten worse. E2 stated the family was unwilling to cooperate and choose to take R3 to another facility. E2 stated on [DATE] that R3 was discharged due to hitting her roommate. E2 stated it was unusual for R3 to hit another resident. E2 stated she was unsure if any labs had been done. E2 stated R3 was very combative with staff and no one could take care of her. E2 stated she did not know how they could keep R3 at the facility if she was harming others. E4, Social Service Director, stated on [DATE] that the [DATE] incident was the first time R3 had hit another resident. Mostly the combative behavior occurred when she woke up and forgot where she was. E4, Social Service Director, stated on [DATE] that she does total the behaviors on the behavior tracking sheet and that is put with the chart. E4 stated the Certified Nurse Aides mark the behavior on the sheet and the nurses chart in the nurses notes. E4 stated the physician looks thru the chart to see behaviors. E4 stated the physician and the nurses decide when a medication will be changed. Z7, Administrator at new facility, stated she was aware R3 had hit another resident at the facility however, she had been informed this was not normal behavior for R3 to hit other residents. Z7 stated due to this they had ordered a complete medical work up for R3 and found R3 had a urinary tract infection. Z7 stated there has been no problems with R3 at the facility.