Every finding on record at Jeff Davis Living Center, LLC

Based on record review, observation and interview, the facility failed to ensure that staff maintained appropriate infection control practices before, during, and after perineal care for 1 resident (#50) out of 6 residents (#3, #12, #13, #27, #50, #59) investigated for infection control in a total sample of 31 residents. Findings:A review of the facility's policy titled, Handwashing/Hand Hygiene with a review date of 01/05/2026, read in part: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections. Indications for Hand Hygiene: 1. Hand hygiene is indicated: c. after contact with body fluids, or contaminated surfaces; after touching the resident's environment; before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal. 5. The use of gloves does not replace hand washing/hand hygiene. A review of the facility's policy titled, Perineal Care, with a review date of 01/05/2026, read in part: Steps in Procedure: 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly.A review of the facility's policy titled, Bathroom, assisting a Resident to with a review date of 01/05/2026, read in part: Steps in Procedure: 1. Wash and dry your hands thoroughly. 17. If resident needs help in cleaning herself, put on gloves. 18. Remove and discard gloves. 19. Wash your hands. A review of Resident #50's electronic health record (EHR) revealed that she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, legal blindness, rheumatoid arthritis, muscle wasting and atrophy, and polyneuropathy.On 05/11/2026 at 9:00 am, an observation was made of S10CNA providing perineal care and removal and application of an adult incontinent brief on Resident #50. S10CNA removed Resident #50's soiled adult incontinent brief with no gloves on. S10CNA put the soiled adult incontinent brief in a trash bag and then put on gloves. S10CNA cleaned Resident #50's perineal area after she had a bowel movement. S10CNA then helped Resident #50 stand up and put a new adult incontinent brief. S10CNA did not remove her used gloves or perform hand hygiene prior to assisting the resident to put on a clean adult incontinent brief. S10CNA assisted Resident #50 back into her wheelchair, removed her gloves, and put them in the trash bag with the soiled adult incontinent brief. S10CNA did not wash her hands or apply hand sanitizer to her hands after she took off her gloves. S10CNA exited Resident #50's room with the trash bag in her hand, walked down the hall to a trash can, and threw the trash bag in the trash can. She did not perform hand hygiene after discarding the trash bag. S10CNA then walked into another resident's room. On 5/11/2026 at 9:15 am, an interview was conducted with S10CNA. S10CNA confirmed she did not wear gloves when she removed Resident #50's soiled adult incontinent brief. S10CNA also confirmed that she did not apply hand sanitizer or wash her hands after she removed her gloves. S10CNA confirmed that she did not change her gloves or wash her hands after cleaning the resident's perineal area after her bowel movement. S10CNA confirmed that she did not use hand sanitizer or wash hands after providing care to Resident #50 and before entering another resident's room. On 05/12/2026 at 10:30 am, an interview was conducted with S11ADON who was responsible for overseeing infection control at the facility. S11ADON confirmed all staff should wear gloves when removing soiled adult incontinent briefs from residents. S11ADON also confirmed that all staff should wash hands or apply hand sanitizer after removing gloves. S11ADON stated that all staff should wash hands or apply hand sanitize after resident care and before moving on to a different resident.

Based on observations, interviews, and policy review, the facility failed to maintain sanitary conditions in the kitchen by failing to ensure ceiling vents, ceiling tiles, kitchen utensils and the pots storage area in the kitchen remained free of a fluffy gray substance. The deficiency had the potential to affect 73 residents who consumed meals from the kitchen. Findings: Review of the facility's undated policy, titled, Kitchen Dust Control Policy revealed in part: Purpose: To maintain a clean, sanitary, and safe kitchen environment by preventing and controlling dust accumulation in all dietary and food preparation areas in accordance with infection control, sanitation, and state/federal regulations.Policy: To ensure that all kitchen and dietary areas remain free from excessive dust accumulation. Routine cleaning and environmental monitoring will be performed to reduce contamination risks and maintain food safety standards. Areas Included: ventilation covers and ceiling vents, shelving and carts. On 05/11/2026 at 08:40 a.m., an initial tour of the facility's kitchen with S4DM revealed the following: Moderate amounts of a gray fluffy substance on the ceiling vent and ceiling tiles above the food preparation area. -Small amounts of a gray fluffy substance on the storage rack which held pots, spoons, tongs and a whisk. On 05/11/2026 at 1:59 p.m., a follow up observation of the kitchen and an interview was conducted with S4DM who was responsible for the daily operations of the kitchen. S4DM confirmed the above observations of the ceiling vent, ceiling tile, and storage rack. She stated maintenance was responsible for cleaning the ceiling tile and ceiling vents, while dietary staff were responsible for cleaning the storage rack. S4DM further stated these areas should have been cleaned.

Based on record review and interview, the facility failed to develop a person-centered comprehensive plan of care to meet a resident's needs for 1 (#1) out of #26 sampled resident by failing to address the resident's risk for chemotherapy treatment. Findings: Review of Resident #1's EMR (electronic medical record) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, malignant neoplasm kidney, Schizophrenia, Bipolar disorder and anxiety.On 05/12/2026 at 12:10 p.m., an interview was conducted with Resident #1. She stated she started chemotherapy in February 2026 and was still receiving the chemotherapy at this time.Review of Resident #1's care plan revealed no evidence that the resident was receiving chemotherapy treatment. Further review of the entire care plan revealed no evidence that her receiving chemotherapy was addressed. On 05/13/2026 at 8:15 a.m., an interview was conducted with S3MDS. She reported she was responsible for updating the care plan for Resident #1. S3MDS confirmed Resident #1 was receiving chemotherapy. She confirmed that the resident's care plan did not address that Resident #1 was receiving cancer treatments. She further confirmed that the resident's care plan did not include interventions for receiving chemotherapy, but should have.

Based on record review and interview, the facility failed to ensure the accuracy of the Minimum Data Set (MDS) assessment related to chemotherapy for 1 (#1) out of 1 residents reviewed for chemotherapy. Findings: A review of Resident #1's EMR (electronic medical record) revealed an admission date of 01/15/2025, with diagnoses that included, but were not limited to, malignant neoplasm kidney, schizophrenia, bipolar disorder and anxiety. Further review of Resident #1's EMR revealed a physician progress note dated 02/23/2026, indicating Resident #1 was receiving chemotherapy. Review of Resident #1's comprehensive MDS assessment with an Assessment Reference Date (ARD) of 04/23/2026, revealed a BIMS (Brief Interview of Mental Status) of 11, indicating moderate cognitive impairment. Further review revealed cancer treatments, chemotherapy status was coded as none of the above. On 05/12/2026 at 12:10 p.m., an interview was conducted with Resident #1. The resident stated she had received radiation therapy in November 2025 and was currently receiving chemotherapy every couple of weeks.On 05/13/2026 at 8:15 a.m., a record review and an interview was conducted with S3MDS. She confirmed the resident received chemotherapy during the look back period of the MDS with an ARD date of 04/23/2026. S3MDS also confirmed the MDS did not indicate the resident was receiving cancer treatment of chemotherapy and should have.

Based on interviews and record review, the facility failed to ensure a grievance was initiated for an allegation of missing property for 1 (Resident #21) of 1 resident reviewed for grievances. Findings:A review of the facility's policy, Grievance/Complaints - Staff Responsibility Policy with a reviewed date of 01/05/2026, revealed in part should a staff member overhear or be the recipient of a complaint voiced by a resident, a residents representative, or another interested family member of a resident concerning the residents medical care, treatment, food, clothing, or behavior of other residents, etc., the staff member is encouraged to guide the resident or person acting on the residents behalf, as to how to file a written complaint with the facility. A review of Resident #21's clinical record revealed an admission date of 07/30/2021 with diagnoses that included chronic obstructive pulmonary disease, anemia, and type 2 diabetes mellitus. Review of Resident #21's Annual MDS (Minimum Data Set) dated 03/26/2026 revealed Resident #21 had a BIMS (Brief Interview of Mental Status) score of 9 indicating mildly impaired cognition. On 05/12/2026 at 4:15 p.m., an interview was conducted with Resident #21. Resident #21 stated he had $30 in his room in this bedside table. He went out on pass to a family gathering on a Sunday. On the following day, Monday, he noted that the $30 was missing from his bedside table. Resident #21 stated he went to the S1ADM and reported the money was missing.A review of the facility grievance log from 10/03/2025 to current (05/11/2026) failed to reveal any documented grievances or complaints filed by Resident #21, his family, or responsible parties regarding missing money. On 05/13/2026 at 3:24 p.m., an interview was conducted with S1ADM. He confirmed that Resident #21 came to him directly to voice a complaint of missing money from his room. S1ADM stated he did not believe the allegation of missing money was a grievance or a complaint because the resident appeared confused and then later stated never mind. S1ADM confirmed he did not initiate a written grievance or complaint and could not provide evidence that an investigation had been conducted or a resolution had been reached. S1ADM further stated that he, S2DON, and S5SSD were responsible for handling facility grievances. On 05/13/2026 at 3:35 p.m., a group interview was conducted with S2DON and S5SSD. Both confirmed they were aware Resident #21 voiced an allegation of missing money to S1ADM. Both agreed that an allegation of missing money should have been considered a complaint and/or grievance, and that a written grievance should have been initiated. Both further confirmed they were aware of Resident #21's complaint; however, neither initiated an official facility grievance investigation.

Based on observations and interview, the facility failed to ensure a safe, clean, and homelike environment for 1 (#50) out of 3 (#16, #50, and #66) residents investigated for environment by failing to ensure shower and shower chair were clean for Resident #50.Findings:A review of the facility's policy titled, Bath, Shower/ Tub, with a last review date of 01/05/2026, read in part: Steps in the Procedure. 9. Be sure the tub or shower is clean.A review of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, with a last review date of 01/05/2026, read in part: d. Reusable items are cleaned and disinfected or sterilized between residents. (1) Single resident-use items are cleaned/ disinfected between uses by a single resident.A review of the facility's housekeeping To Do List, read in part: Women's Hall To Do List. Room checks, Eating Tables, Dust, Move Furniture, Refrigerators, Over Head Lights, Baseboards, Mirrors, Faucets, Shelfs, Window Seals, Sinks, Floors, Showers, Walls. Review of Resident #50's electronic health record (EHR) revealed Resident #50 was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, legal blindness, dermatitis, rheumatoid arthritis, unsteadiness on feet, cognitive communication deficit and history of falls. A review of Resident #50's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Mental Status (MDS) score was 12, indicating her cognition was intact. On 05/12/2026 at 9:25 am, an interview and observation of Resident #50's bathroom and shower was made with S7CNA. The shower chair was observed to have dark patches of a black substance on the seat. The shower chair legs and rubber caps were observed to have a wet, velvety, film like black substance on them. The shower walls and floor of the shower were observed to have a black film like substance with small black circular patches that appeared as spots. S7CNA confirmed these observations. There were two wet washcloths observed on the shower floor. S7CNA confirmed the wash cloths were used to clean Resident #50, and they were now dirty. S7CNA stated she should have taken the dirty wet wash clothes to laundry and should not have left them on the shower floor. S7CNA stated she assisted Resident #50 with a shower this morning at approximately 8:15 am. S7CNA stated she observed the shower was dirty before she assisted Resident #50 with a shower. S7CNA stated that the shower should have be cleaned before she assisted Resident #50 with a shower. S7CNA wiped the leg of the shower chair with a wash cloth and chunks of black sooty sludgy like substance wiped off the chair and onto the wash cloth. An observation was made of a cup on Resident #50's sink in her bathroom. Resident #50 identified the cup as her sippy cup and stated she used the cup to rinse her mouth out every morning. The cup was clear plastic with a blue lid and a built in straw on the side of the cup. An observation of the cup revealed a black substance on the inside bottom of the cup as well as the inside bottom of the straw. There were small black circular patches that appeared as spots observed on the walls of the cup near the bottom. S7CNA confirmed these observations. S7CNA confirmed the cup was dirty and should have be cleaned.On 05/12/2026 at 9:30 am, an interview was conducted with S8CNAS who was responsible for supervising S7CNA. S8CNAS confirmed that showers should be clean before a resident is given a shower. S8CNAS observed Resident #50's sippy cup on her sink in her bathroom and confirmed it had a black substance on the inside bottom of the cup as well as the inside bottom of the straw. S8CNAS also confirmed there were small black circular patches that appeared as spots on the inside walls of the cup near the bottom. S8CNAS asked Resident #50 if she used the cup. Resident #50 stated yes she washed her mouth out with it every morning. S8CNAS picked up the cup and tilted it and a small pool of liquid moved at the bottom of the cup. S8CNAS threw the cup in the trash and told Resident #50 that the facility would buy her another cup because that one was dirty.On 05/12/2026 at 9:50 am, an interview was conducted with S6HKS. S6HKS confirmed that resident bathrooms and showers located inside resident bathrooms were to be cleaned daily and deep cleaned weekly by housekeeping.

Based on observations, interviews, and record review, the facility failed to ensure services provided meet nursing professional standards for medication administration by failing to ensure medications were not left at the bedside for 1 (#31) out of 31 sampled residents. Findings: On 05/13/2026 a review of the facility's policy titled, Administering Medications with a last reviewed date of 01/05/2026, read in part, Policy Statement: Medications are administered in a safe and timely manner. 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. Review of Resident #31's EHR (electronic health record) revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, dementia, bipolar disorder, major depression, blindness right eye, and anxiety. Review of Resident #31's most recent Quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) score was 06, indicating the resident's cognition was severely impaired. Review of Resident #31's MAR (Medication Administration Record) for May 2026 revealed S9LPN administered the resident's 8 a.m. (morning) medications on 05/11/2026. On 05/11/2026 at 10:03 a.m., an observation and an interview was conducted with Resident #31. A clear medicine cup containing pills/tablets was observed on Resident #31's bedside table. Resident #31 identified the clear medication cup on her bedside table as her morning medications, and stated the nurse left her morning medications on her bedside table for her to take when she woke up. Resident #31 further stated she could not remember the name of the pills or what they were for. On 05/11/2026 at 1:35 p.m., a record review was conducted and Resident #31 had not been assessed and approved for self-administration of medication. On 5/11/2026 at 10:06 a.m., an observation, interview and record review, were conducted with S9LPN. S9LPN confirmed she left the pills in the clear medication cup on Resident #31's bedside table at approximately 8:15 a.m. this morning (05/11/2026) for Resident #31 to take when she woke up. S9LPN identified the pills in the cup as: Famotidine 20 milligrams (mg), Namenda 5 mg, Citalopram 20 mg, Xanax 0.5 mg, Macrobid 100 mg, and Seroquel 25 mg stated she should have observed Resident #31 swallow the pills before leaving the room, and not leave the pills at the resident's bedside. S9LPN confirmed that Resident #31 was not able to self-administer medications. On 05/12/2026 at 2:00 p.m., an interview was conducted with S2DON. S2DON confirmed Resident #31 had not been evaluated and approved for self-administration of medications. S2DON stated S9LPN should not have left medications unattended at Resident #31's bedside.

Based on record review and interview, the facility failed to ensure a Registered Nurse (RN) provided services for 8 consecutive hours a day, 7 days a week and ensure the DON (Director of Nursing) did not serve as a charge nurse when the facility had an average daily census over 60 residents. Findings: Review of RN staffing timesheets from 10/01/2024-04/27/2025 revealed the RN did not work 8 consecutive hours the following dates: 11/10/2024 7.75 hours worked 11/23/2024 7.75 hours worked 12/31/2024 7.75 hours worked 01/03/2025 7.32 hours worked 01/28/2025 no RN hours worked 02/05/2025 6.75 hours worked 02/28/2025 7.92 hours worked 03/28/2025 7.88 hours worked 04/15/2025 5.75 hours worked On 04/28/2025 at 10:00 a.m., an interview was conducted with S2DON and S3RN. S2DON stated that on Saturday and Sunday the weekend RN is scheduled to work an 8 hour shift each day. S2DON stated that Monday through Friday, S3RN is scheduled to work an 8 hour shift each day. S2DON and S3RN reported that when S3RN is not present in the facility for her scheduled weekday 8 hour shift, S2DON serves as the RN. S3RN stated that she was off on 01/28/2025, and came to work late and did not work for the 8 hours on 02/05/2025 and 04/15/2025. S2DON stated she was present on those days and served as the RN, but is salaried and does not utilize the electronic clock in/out reporting system. On 04/28/2025 at 10:20 a.m., an interview, review of S3RN's time sheets, and review of the facility census was conducted with S4ACCT (Accounting). She confirmed on 01/28/2025 there was no RN hours worked by S3RN, and on 02/05/2025 and 04/15/2025 S3RN worked less than 8 hours. She stated on those dates S2DON was classified as working under the DON role. She confirmed the census on 01/28/2025 was 79, on 02/05/2025 was 79, and on 04/15/2025 was 74. S4ACCT stated it had been years since the facility census was below 60. On 04/28/2025 at 1:10 p.m., an interview and review of RN staffing time sheets from 10/01/2024-04/27/2025 was conducted with S4ACCT. She confirmed the RN hours did not meet the requirement of 8 consecutive hours on the above listed dates. On 04/28/2025 at 1:20 p.m., an interview was conducted with S2DON, with S1ADM (Administrator) present. S2DON acknowledged the provider did not meet the requirement when RN staff provided less than 8 consecutive hours worked. S2DON and S1ADM verbalized they were unaware that S2DON could not act dually as the RN and DON if the facility census was greater than 60. They acknowledged the facility census had been greater than 60 since October 2024 through April 2025.

Based on observations and interviews and record review, the facility failed to ensure a resident's plan of care was implemented for 1 (#41) out of 1 (#41) residents investigated for positioning out of a total sample of 32 residents. Findings: A review of Resident #41's Electronic Medical Record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses that included in part, cerebral infarction, cerebrovascular disease, and hemiplegia and hemiparesis. A review of Resident #41's Care Plan revealed a care plan intervention initiated on 10/11/2022 that read, staff instructed to check on resident's body alignment when passing by room and or after care and turning and repositioning her. Further review of the resident's care plan dated 08/15/2022 read in part .provide pressure reduction/relief mattress on bed. Assist positioning for comfort. Monitor frequently, at least every two hours for pressure redistribution and assist with repositioning as indicated. Review of the air mattress manufactures manual read in part .Note- this product is only one element of care in the prevention and treatment of pressure ulcers by medical professionals and skilled caregivers to assist in the treatment and prevention of pressure ulcers. This product is not designed to and cannot replace good caregiving practices and treatment, including but not limited to: frequent positioning. On 04/28/2025 at 10:00 a.m., an observation was made of Resident #41 in her room. Resident was observed lying on her back. Subsequent observation of the resident at 12:35 p.m., revealed the resident was lying on her back. On 04/28/2025 at 12:36 p.m., an interview was conducted with S8CNA/T (Certified Nursing Assistant/Transportation) who stated that she had not repositioned the resident. She confirmed the resident should have been repositioned every two hours. On 04/28/2025 at 12:37 p.m., an interview was conducted with S7LPN (Licensed Practical Nurse) who stated that she had not repositioned the resident, and the resident did not need to be repositioned because she was on an air mattress. On 04/28/2025 at 4:03 p.m., an interview was conducted with S6CNASUP (Certified Nursing Assistant Supervisor) who stated Resident #41 should have been repositioned every two hours. On 04/29/2025 at 9:30 a.m., an interview was conducted with S5TX (Treatment Nurse) stated Resident #41 should have been turned and repositioned every two hours.

Based on interview and record review, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the resident's status, for 1(#24) of 32 sampled residents Findings: A review of Resident #24's medical records revealed an admitted [DATE] with diagnoses which included but were not limited to Major Depressive Disorder and Bipolar Disorder. A review of Resident #24's Pre Admission Screening and Assessment Resident Review (PASRR) revealed a Level II determination that read, The individual has a serious mental illness and is recommended nursing home admission. A review of Resident #24's annual MDS with an ARD (Assessment Reference Date) of 02/06/2025 revealed the following: Section A1500 -Is the resident currently considered by the state Level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? The answer was coded 0 for no. On 04/29/2025 at 1:04 p.m., an interview and review of Resident #24's MDS was conducted with S2DON (Director of Nursing). She confirmed that the PASRR was incorrectly coded and did not reflect that the resident was considered by the state Level II PASRR process to have serious mental illness, and should have.

Based on observations, record review and interviews, the facility failed to implement policies and procedures for Enhanced Barrier Precautions (EBP) for 1 (#11) of 2 (#11, #27) residents sampled for wound care, with a total sample of 32 residents. Findings: Review of the facility's EBP policy revised on 03/2024 revealed the following, in part: EBP are used as in infection prevention and control intervention to reduce the transmission of multi-drug resistant organisms (MDROs) to residents. Review of the medical record for Resident #11 revealed an admitted [DATE] with diagnoses including peripheral vascular disease, and type 2 diabetes mellitus. Review of the March 2025 Physician's orders revealed an order dated 07/15/2024 which read in part enhanced barrier precautions. Further review revealed an order dated 03/26/2025, which read in part .venous stasis ulcer anterior right lateral lower leg: clean with normal saline, apply hydrofer blue dressing then cover. On 04/28/2025 at 10:20 a.m., an observation of wound care was conducted with S2DON (Director of Nursing) and S4TX (Treatment Nurse). Prior to S4TX beginning wound care, the resident was observed sitting in her recliner with her legs elevated. The resident had a brown colored covering over her chair that was visibly soiled. Further observation revealed the resident right lateral lower leg did not have a dressing, and the wound was exposed and resting on the brown colored soiled chair covering. A small amount of serosangenious fluid was observed on the wound. On 04/28/2025 at 10:30 a.m., an interview with S4TX confirmed she should have placed a protective barrier under the resident's right leg to prevent the open wound from touching the soiled chair covering. On 04/28/2025 at 10:30 a.m., S2DON confirmed that Resident #11 should have placed a protective barrier under her right leg, and the exposed wound should not have been touching the soiled chair covering.

Based on observations, review of policy and procedure and interviews, the facility failed to store, distribute, and serve food in accordance with professional standards for food service safety by failing to follow appropriate food handling practices as evidenced by: 1. Failing to ensure staff present in the kitchen covered their facial hair. 2. Food storage: A. Refrigerated items: 1. A container of peaches not labeled with the date it had been prepared. 2. A bag of mozzarella cheese and cheddar cheese opened and not labeled with the date it had been opened or placed in a closed bag. 3. A container of ranch dressing with an expiration date of ,d+[DATE]. 4. A container of honey mustard with an expiration date of ,d+[DATE]. B. Dry Storage 1. One dented canned good in the dry storage room. C. Walk-in freezer: 1. One box of boneless chicken on the floor. 2. One box of hot dog buns on the floor. 3. No thermometer noted on the inside. 4. No record of daily temperatures. The total amount of residents that ate out of the kitchen was 74 residents. Findings: Review of the facility's policy, Food Storage, last reviewed on [DATE], revealed in part, the following, Policy Statement: Food storage area shall be maintained in a clean, safe, and sanitary manner . Policy Interpretation and Implementation: . 3. All food stored in walk-in refrigerators and freezers will be stored on shelves, racks, dollies, or other surfaces that facilitate thorough cleaning . 5. Prepared food stored in the refrigerator until service shall be dated with an expiration date. Such food will tightly sealed with plastic wrap, foil, or a lid . 9. Note: There is an accurate thermometer in each refrigerator and freezer and in storerooms used for perishable foods. 10. The food service manager, or his/her designee, will check refrigerators and freezers daily for proper temperatures. The food services manager will maintained record of such information. Review of the facility's policy, Refrigerators and Freezers, last reviewed on [DATE], revealed in part, the following, Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation and will observe food expirations guidelines. Policy Interpretation and Implementation: . 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures . 4. Food service supervisors or designated employees will check and record refrigerator and freezer temperatures daily . 8. Supervisors will be responsible for ensuring food items in pantry, refrigerators, and freezers are not expired . Review of the facility's policy, Food Services, last reviewed on [DATE], revealed in part, the following, Hair Nets: 15. Hair nets or caps and/or beard restraints are worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens . On [DATE] at 8:56 a.m., an initial tour of the facility's kitchen was conducted with S5DC (Dietary Cook). S7DA (Dietary Aide) was observed in the kitchen without facial hair covering in place. S5DC confirmed the above mentioned items were not labeled or dated and should have been, expired items should have been removed from the refrigerator and dented canned goods should not be stored in the dry storage room. On [DATE] at 9:50 a.m., continued initial tour of the facility's kitchen with S4DM (Dietary Manager). An observation was made of S7DA preparing food for lunch without facial hair covering in place. An observation was made of the walk-in freezer with S4DM. S4DM confirmed that there was not a thermometer inside the walk-in freezer and there was no record of daily temperatures for the walk-in freezer. S4DM confirmed all kitchen staff must wear a separate covering for facial hair. S4DM also confirmed all foods stored in the freezer must be labeled and dated, expired items should have been removed from the refrigerator, boxes containing food in it should not be on the floor in the freezer, and dented canned good items should not be stored in the dry storage room.

Based on interviews and record review, the facility failed to ensure the residents' assessment accurately reflected the status of 2 (# 53 and # 59) residents out of a total of 30 sampled residents by failing to ensure that: 1. Resident # 53 was coded correctly for anticoagulant use. 2. Resident # 59 was coded correctly for dialysis treatment. Findings 1. Review of Resident # 53's electronic health record revealed she was admitted to the facility on [DATE] with diagnoses that included, but were not limited to Anemia, Schizoaffective Disorder, Bipolar Disorder, Cardiac Pacemaker and Aphasia. Review of Resident # 53's Quarterly MDS (Minimum Data Set) assessment with an ARD (Assessment Reference Date) of 11/23/2023 revealed in Section N - High-Risk Drug Classes: Use and Indication Drug Class E. Anticoagulant (e.g., Warfarin, Heparin, or low-molecular weight Heparin) was checked for 1. Is taking. Review of Resident # 53's November 2023 physician's ordered revealed no orders for use of anticoagulants. On 03/11/2024 at 11:10 a.m., an interview was conducted with S11LPN (Licensed Practical Nurse). She verified that Resident # 53 was not on an anticoagulant. On 03/11/2024 at 11:41 a.m., an interview was conducted with S8MDS nurse and she confirmed the MDS assessment with an ARD of 11/23/2023 was coded to reflect Resident # 53 used the high risk medication of an anticoagulant. She reviewed the resident's electronic health record and confirmed the resident was on an antiplatelet and not anticoagulant. She confirmed Resident # 53 should not have been coded as using an anticoagulant in Section N of the quarterly MDS assessment dated [DATE]. 41868 2. Review of Resident #59's medical record revealed he admitted to the facility on [DATE] with diagnosis of End stage renal disease with dependence on renal dialysis. Review of Resident #59's physician orders effective on 09/08/2023 revealed: Dialysis every Tuesday, Thursday, and Saturday. Review of Resident #59's Dialysis Communication Forms revealed he had received Dialysis on 1/23/24, 1/25/24, and 1/27/24. Review of Resident #59's Significant Change MDS, with an ARD date of 01/29/2024 revealed Section O0110. Special treatments, Procedures, and Programs .Dialysis .B. while a resident, and within the last 14 days .was not checked. On 03/12/2024 at 12:00 p.m., an interview was conducted with S8MDS. She confirmed Resident #59 had received Dialysis during the assessment reference dates for his Significant Change MDS on 01/29/2024. She stated it should have been checked on his MDS that he had received Dialysis, and had been coded incorrectly.

Based on observations and interviews, the facility failed to ensure routine medications were disposed of when expired. The deficiency had the potential to affect a census of 77 residents. Findings: Review of the facility's policy on 03/12/2024, titled, Medication Labeling and Storage, with a policy revised date of February 2023, read in part: . 3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. On 03/12/2024 at 9:30 a.m., an observation of the facility's Hall A medication storage room was conducted with S9LPN (Licensed Practical Nurse). On 03/12/2024 at 9:58 a.m., an interview was conducted with S9LPN, who confirmed the following expired medications were present/identified in the residents' storage bins Phenergan 25mg (milligrams) suppository (6 suppositories) with an expiration date of 03/2023 Losartan K+ 50mg (30 tablets) with an expiration date of 01/31/2024 Amantadine 100mg (30 tablets) with an expiration date of 08/31/2022 Citalopram 20mg (30 tablets) with an expiration date of 02/28/2023 Trazadone 50mg (1/2 tablets) (30 1/2 tablets) with an expiration date of 12/31/2023 Famotidine 20mg (30 tablets) with an expiration date of 11/30/2023 Levothyroxine 100mcg (micrograms) (30 tablets) with an expiration date of 12/31/2023 Donepezil 10mg (30 tablets) with an expiration date of 01/31/2024 Meclizine 25mg (30 tablets) with an expiration date of 12/31/2023 Trazadone 50mg (1/2 tablets) (30 1/2 tablets) with an expiration date of 02/29/2024 Omeprazole 40mg (7 tablets) with an expiration date of 10/30/2023 Tamsulosin 0.4mg (30 capsules) with an expiration date of 01/31/2024 Glimepiride 2mg (29 tablets) with an expiration date of 05/31/2023 Amlodipine 10mg (8 tablets) with an expiration date of 01/31/2023 Lisinopril 10mg (30 tablets) with an expiration date of 04/30/2023 Meclizine 25mg (30 tablets) with an expiration date of 06/30/2023 Oxybutynin 5mg (9 tablets) with an expiration date of 03/31/2023 Lisinopril 20mg (14 tablets) expiration date of 12/31/2023 Preservision (30 capsules) with an expiration date of 12/31/2023 Preservision (5 capsules) with an expiration date of 07/31/2023 On 03/12/2024 at 10:10 a.m., a review of the facility's Hall B medication storage room with S10LPN, she observed the review of medications. S10LPN reported the medications are checked weekly for expired medications. S10LPN confirmed there were expired medication as listed below and should have discarded when they expired. Expired medications in residents' bins, identified in Hall B medication storage room: Influenza Vaccine vial (5milliliters (ml)) with an expiration date of 06/30/2023 Hydroxyzine 25mg (21 tablets) with an expiration date of 12/31/2022 Meclizine 25mg (30 tablets) with an expiration date of 12/31/2023 Bupropion 150mg (30 tablets) with an expiration date of 02/29/2024 Diltiazem 180mg (30 tablets) with an expiration date of 02/28/2023 Losartan K+(Potassium) 25mg (30 tablets) with an expiration date of 06/30/2023 Losartan K+ 25mg (30 tablets) with an expiration date of 05/31/2023 Tizanidine 2mg (30 tablets) with an expiration date of 11/30/2022 Amlodipine Besylate 5mg (30 tablets) with an expiration date of expired 05/31/2021 On 03/12/2024 at 10:15 a.m., an interview was conducted with S2DON (Director of Nursing), she reviewed the medication cards from the above list and confirmed a total of 663 pills, 5 ml's in a vial and 6 suppositories were expired and should have been discarded when the medications had expired.

Based on observation, interview, and record review, the facility failed to ensure menus met the nutritional needs of the residents and were followed as evidenced by kitchen staff failing to have knowledge of recipes to be followed when preparing pureed foods. This deficient practice had the potential to contribute to an unpleasant dining experience, decreased intake, altered nutritional needs and weight loss for the 3 residents who consumed pureed diets. Findings: On 03/12/2024 at 9:25 a.m., an observation was made of S6DC (Dietary Cook) preparing pureed lunch meals. S6DC prepared an unmeasured amount of ham by blending the pieces of ham into the blender and added an unmeasured amount of water. Next, S6DC was observed transferring an unmeasured amount of green bean casserole from the container to the blender and then added and unmeasured amount of water and blended all the ingredients. There were no recipe(s) present during the observed pureed lunch meal preparation by S6DC. On 03/12/2024 at 9:35 a.m., an interview was conducted with S6DC who confirmed she was one of the cooks at the facility and she often prepared puree meals. She stated there were 3 residents in the building that required pureed meals. She stated that she was never notified that she had to follow a recipe when preparing puree meals. She stated I just know how much food is needed for 3 puree residents. On 03/12/2024 at 9:40 a.m., an interview was conducted with S4DM. S4DM stated she had received recipes for puree diets and the recipes were currently kept are in a binder in her office. She confirmed that she and the dietary cooks had never followed recipes while preparing puree meals. She confirmed that they prepared puree meals for residents by eyeballing it. On 03/12/2024 at 9:45 a.m., a phone interview was conducted with S3RD (Registered Dietician). She stated that the menu for the therapeutic diets also came with a recipe. She confirmed that when the dietary cooks or dietary manager were preparing puree meals, a puree recipe should be followed to ensure the nutritional needs were met for the residents who consumed puree meals.

Based on interview and record review, the facility failed to ensure pain management is provided, consistent with professional standards of practice by failing to thoroughly assess, investigate, and adequately intervene when the resident reported increased pain to her left shoulder. The resident was later diagnosed with a left shoulder dislocation and humerus fracture for 1 (#2) of 5 (#1, #2, #3, #4, #5) sampled residents. Findings: Review of policy Pain Assessment and Management read in part, Purpose: the purpose of this procedure are to help the staff identify pain in the resident and to develop interventions that are consistent with the resident's goals and needs and that address the underlying cause of pain . Assessing Pain. 5. During the pain assessment gather the following information as indicated from the resident (or legal representative): c. Characteristics of pain: (1) Location of pain; (2) Intensity of pain (as measured on a standardized pain scale); (3) Characteristics of pain (e.g., aching burning, crushing, numbness, burning, etc.); (4) Pattern of pain (e.g., constant or intermittent); and (5) Frequency, timing and duration of pain; A review of Resident #2's record revealed an admitted [DATE]. The resident's diagnoses included: Cerebral infarction, Epilepsy, Hemiplegia and Hemiparesis following Non-Traumatic Subarachnoid Hemorrhage Affecting Left Side. A review of Resident #2's annual MDS (Minimum Data Set) assessment, dated 3/1/2023, revealed the resident had a BIMS (Brief Interview for Mental Status) score of 10 (moderately impaired). Resident did not reject care, she had responded Yes to the question regarding having pain, and that she had occasional, moderate pain in the last 5 days. A review of Resident #2's care plan revealed she was at risk for pain to left arm, left shoulder, left leg, left side pain (stroke side). Interventions included administer pain medication per MD (Medical Doctor) orders, monitor and document for effectiveness on MAR (Medication Administration Record), encourage resident to report or point at area of onset of pain to handle gently when moving or repositions left arm, (Resident #2) will hold arm up to chest when assisting with turning and or transferring, support left shoulder with pillows as needed/ as requested by resident A review of physician orders revealed the following orders: 10/12/2022 Acetaminophen 325mg (milligrams) give two by mouth every 4 hours as needed mild pain. 03/22/2023 Oxycodone HCL (narcotic) 5mg by mouth twice a day as needed for pain. 05/02/2023 an x-ray to left shoulder for c/o (complaints of) pain. Review of incident report completed on 05/03/2023 revealed the following: It was noted that on 05/02/2023 Resident #2 complained to her primary MD that was making rounds that her left shoulder had been hurting her. She reported that she has been having pain in that shoulder since her stroke, but she has noted an increase in pain in the area. She reported that it's been about three weeks since the pain has increased. S6MD ordered an x-ray of the left shoulder for 05/03/2023. X-ray results received and it showed the following: 3 views of the left shoulder show a non-displaced but minimally impacted humeral (upper arm bone) neck fracture with associated inferior dislocation of the humerus compared to the glenoid fossa. Impression: non-displaced impacted humeral neck fracture with associated shoulder dislocation as above. S6MD was notified of the results and has ordered a consultation with orthopaedics. After reviewing her nurses notes it appears that on 04/09/2023 Resident #2 went out on pass with her family for Easter Sunday and upon her returning she requested Oxycodone for pain. Prior to this she was requesting Tylenol for pain. It is noted that oxycodone is effective in relieving that pain. Resident #2's spouse was made aware of the x-ray results and was questioned if she has complained of an increase in pain to him on 04/09/2023 or if anything may have had happened while she was out on pass for the day or while transferring her to and from the car. Resident #2's spouse reported that she had a good day and that she was transferred with no problem that he knows of; that she did complain of shoulder pain but that was not uncommon because that this her stroke side and has had pain in that arm and shoulder since .Then she (Resident #2) remembered that on the night of 04/08/2023, somehow during the night her arm fell to the side of the bed A review of nurse's notes revealed the following: 04/09/2023 7:11 a.m. OOP (out on pass) with family 04/09/2023 5:19 p.m. returned from OOP 04/09/2023 5:30 p.m. Oxycodone 5mg given returned from OOP and c/o (complaints of) pain 04/10/2023 5:36 a.m. headache and neck pain Oxycodone given 04/10/2023 5:02 p.m. Oxycodone given at 5pm for left arm pain stated that her stroke arm and when she was in therapy PT lifted under her arm to transfer, arm elevated on pillow 04/11/2023 4:01pm oxycodone 5mg given left shoulder/arm pain 04/11/2023 5:05pm oxycodone was providing some relief 04/11/2023 10:17p.m. Informed by CNA (certified nursing assistant) when entering residents room, resident had CPAP (continuous positive airway pressure) sitting on stomach. When CNA asked why CPAP was removed resident stated CPAP was blowing air on her arm and it was causing pain to L (left) shoulder. When I entered residents room, CPAP was lying on residents stomach. I went on to inform resident she needs to let me know if she does not want CPAP on and proper documentation is needed. Resident was also informed that the air that is blowing from the CPAP mask cannot be stopped. CPAP was placed back on residents head and resident was re position so air was not hitting shoulder. Residents husband was notified about incident and that resident was removing CPAP when staff is leaving the room. Residents husband stated he will talk to wife in am. 05/01/2023 oxycodone 5mg for generalized pain 05/02/2023 acetaminophen 325mg for generalized body pain 05/02/2023 MD made rounds today with new orders noted for an x-ray to left shoulder for c/o pain 05/03/2023 oxycodone given for left shoulder pain 05/03/2023 xray results are left shoulder shows a nondisplaced but minimally Impacted humeral neck fracture associated with inferior dislocation of the humerus compared to the glenoid fossa. Impression: nondisplaced impacted humeral neck fracture with associated shoulder dislocation. Physician notified. Further review of the nurse's notes revealed there was no complete assessment of the resident's pain to include: location of pain, intensity of pain, characteristics of pain, pattern of pain, and frequency, timing and duration of pain A review of physical therapy notes revealed the following: 04/10/2023- pain 8/10, location- LUE (left upper extremity) 04/12/2023- pain at rest 8/10- location- LUE. Patient stated her LUE was hurting her to much today and she would want to skip therapy. 04/15/2023 refused therapy pain 8/10: location: lower back and LUE A review of Resident #2's MARs (medication administration record) revealed the following: March 2023 - resident was not administered Oxycodone for the entire month. April 2023- resident was administered oxycodone on April 7th, 9th, 10th, 11th, 13th, 14th, and 18th May 2023- resident was administered Oxycodone on May 1st, 3rd, 6th, and 7th June 2023- resident was administered Oxycodone on June 24th July 2023- resident was administered Oxycodone on July 9th, 12th, and 19th Further review of the March through July 2023 MARs revealed no complete assessment to include: location of pain, intensity of pain, characteristics of pain, pattern of pain, and frequency, timing and duration of pain On 7/19/2023 at 12:53 p.m., Resident #2 was observed and interviewed in her room with family and spouse noted at her bedside. Resident #2's spouse stated resident was bedridden, and unsure how the fracture occurred. Resident #2 stated her left arm was paralyzed from the stroke and sometimes it just fell . Her spouse reported that on 4/9/2023 that resident was out of the facility with him and she had complained right away that her left shoulder was hurting. She was not able to make the day with her due to her pain and asked to be brought back to the facility. When he brought her back, he stated that he told S3LPN that her left shoulder was hurting and that she needed pain medication. Resident #2 stated she remembered the night of 4/8/2023 she woke up to her left arm being stuck between the bed railing and mattress, she stated she jerked her arm out and did not notify staff about the incident. On 7/19/2023 at 1:20 p.m., an interview was conducted with S5PTA. She stated she has worked with the resident since admit. When the resident first came in with the stroke, she usually complained of pain and described the pain as, not shoulder pain, but more of a numbness and tingling pain to the left arm. She stated on Easter, the resident went out to her family's home. When she returned, they asked her How did it go this weekend? and the resident stated she had to come back because of her left arm pain. Resident #2 was on physical therapy workload during dates: 2/17/23-5/8/23. On 7/19/2023 at 1:32 p.m., an interview was conducted with S3LPN. She stated she was familiar with the resident. Resident was capable of making her wants and needs known since her BIMS was 10. She stated the resident having pain to the left side was not an uncommon pain for her to experience. When the resident had complaints of left shoulder pain, the resident never stated it was bad enough to her needing pain medication. S3LPN reported that the resident never made it seem like it was a severe pain and would just ask for pain medications which is not uncommon for her to do. On 7/19/2023 at 3:42 p.m., an interview was conducted with S6MD. He stated Resident #2 and her spouse were complaining of shoulder pain. Her spouse was said that her shoulder was hurting and that is what warranted him to order an x-ray to see what the cause was. He stated he was unsure if she had any type of shoulder pain prior to this and does not recall a nurse calling him to notify him of any shoulder pain. On 7/20/2023 10:02 a.m. interview was conducted with S2DON. She stated she assisted in completing the investigation report for Resident #2. S2DON stated that the nurses should have identified the new pain onset and location sooner and notified the physician. She stated that the physician would have ordered an x-ray sooner. On 7/20/2023 at 11:07 a.m., an additional interview was conducted with S3LPN. She stated when a resident complained of pain she only asked them where they were hurting and the pain level. She continued to say that when resident retuned on Easter with the family, the resident's spouse came to the front and said she was hurting and needed a pain pill. S3LPN stated she did not ask the resident specifically where she was hurting. S3LPN reviewed the policy and stated she had not follow the pain policy for assessing pain prior to administering the resident's pain medication. On 7/20/2023 at 11:28 a.m., a telephone interview was conducted with S4LPN. She said the night of 4/11/2023 Resident #2 complained that the air from the CPAP machine was making her left shoulder hurt. She stated that she had found it unusual that she was complaining of left shoulder pain and informed S2DON the following morning on 4/12/2023. However, she did not give her any pain medications that night. She stated did not follow the policy by asking the resident the intensity, characteristics, and pattern of her pain. On 7/20/2023 at 11:52 a.m., an additional interview was conducted with Resident #2. The resident stated staff ask her everyday if she is in pain and where the pain is located. Staff do not ask her any other questions about the pain. She stated that she had been telling the nurses that she was having left shoulder pain. On 7/20/23 at 12:09 p.m., an interview was conducted with S2DON. S2DON confirmed nursing staff had not conducted a full and thorough pain assessment per the facility's policy and therefore did not identify the increase in severity and location of the resident's pain.

Based on interview and record review, the facility failed to implement an antibiotic stewardship program to ensure antibiotic use was being monitored and trending was being performed for residents receiving antibiotics. Findings: Review of the facility's Antibiotic Stewardship Program Policy revealed in part: Tracking: Process measures: Collect, review and report types of antibiotics ordered. Who ordered the antibiotic (attending, on call physician or nurse practitioner), Review and track whether appropriate tests such as cultures were obtained prior to prescribing antibiotics, are cultures (C&S) results communicated as soon as possible and changes in antibiotic therapy during course of treatment. Review of the Antibiotic Stewardship binder on 02/07/2023 revealed the tracking and trending of infections and antibiotic use for the months November 2022, December 2022 and January 2023, were incomplete. The logs revealed the following: 1. November 2022 Infection Control Log revealed 11 reported infections. 3 did not have a date the physician was notified, and 5 did not have a stop date of the antibiotic. 2. December 2022 Infection Control Log revealed 19 reported infections. None of the reported infections had an antibiotic start or stop date, and 6 did not have a completed culture. 3. January 2023 Infection control log revealed 18 reported infections. None of the reported infections had an antibiotic start or stop date, and 1 did not have a completed culture. On 02/07/2023 at 10:45 a.m., an interview was conducted with S3ICP, she reported S2RN was responsible for the Antibiotic Stewardship Program including monitoring, tracking, trending and reporting. On 02/06/2023 at 3:10 p.m., an interview was conducted with S2RN (Registered Nurse). She confirmed she was responsible for keeping the Infection Control Log current and complete monthly for residents on antibiotics. She also confirmed the Infection Control Log for November 2022, December 2022 and January 2023 were incomplete. On 2/07/2023 at 1:30 p.m., an interview was conducted with S1DON (Director of Nursing). She reported the Antibiotic Stewardship Program was conducted by S2RN. She stated the procedure was for S2RN to receive a copy of physicians' orders daily for tracking and trending the use of antibiotics. S2RN was also responsible for completing the Infection Control Log daily with resident name, date doctor notified, date treatment began, date resolved, site of infection, infection related diagnosis, cultured, organism and antibiotic. She confirmed the Infection Control Log was incomplete for November 2022, December 2022 and January 2023.

Based on observation and interview, the provider failed to ensure dinnerware sanitization was achieved when dishwasher temperatures failed to reach the minimally required temperature and chemical used to sanitize dishware during the process failed to be delivered into the system. This deficient practice had the potential to effect 71 residents that consumed meals and/or beverage prepared and served from the facility kitchen. Findings: On 02/05/2023 at 8:35 a.m. a tour of the facility's kitchen was conducted. During this time, S4DA (Dietary Aid) was asked to demonstrate use of the dishwasher, including confirmation of the sterilization process by litmus paper test. S4DA initiated three consecutive wash cycles, all of which failed to reach the minimally required temperature of 120 degrees Fahrenheit. Additionally, S4DA attempted three chemical sterilization tests using litmus paper; all failed to register any color change, indicating sterilization had not been achieved. S4DA examined the small, clear hose used to deliver liquid sterilizing agent into the system and discovered it was completely occluded. On 02/05/2023 at 9:12 a.m., during an interview with S5DM (Dietary Manager), she acknowledged the dishwashing machine must reach a minimal temperature of 120 degrees Fahrenheit and an adequate, measured amount of sterilizing agent must be delivered during the process in order to achieve a proper wash cycle and ensure clean and sterilized dishware. She confirmed that the sterilization process was measured by litmus paper test with a minimal reading of 50 ppm (parts per million).

Based on observation and interview the facility failed to ensure that the staff follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness evidenced by staff not wearing a hairnet while in the kitchen serving area. Findings Review of the facility's policy titled, The Safe Food Handler, Work Attire Guidelines, that indicated hair restraints are worn when in a food-prep area. This can keep hair from falling into and onto the food-contact surfaces. On 05/17/2022 at 12:02 p.m., S8ADM was observed standing behind the food serving line holding a plate of food with no hairnet. S8ADM stated that he did not have a hairnet while he was fixing his own plate of food. S8ADM stated, I am the administrator and do not need to wear a hairnet; I was fixing my own plate. During an interview, on 05/17/2022 at 12:23 p.m., S1ICP (Infection Control Preventionist) stated that all staff were required to wear a hairnet while in the kitchen area including while serving food from the serving line. S1ICP reported it was the current facility policy for all staff to wear a hairnet at all times while in the kitchen area and serving line. In an interview, on 05/17/2022 02:10 p.m., with S9DM, she reported residents were served food that was left over from the serving line after all residents and staff were fed.

Based on observations, interviews and record reviews, the facility failed to properly maintain an infection prevention and control program designed to help prevent the development of COVID-19 by failing to: 1. follow the facility COVID-19 policy and procedure for quarantine after a 24 hour hospital admission, and COVID testing upon development of COVID-19 like symptoms for 1(#2) of 5 (#1 #2 #3 #4 #5) sample residents and 1 (# R1) random sampled resident. 2. don and doff appropriate PPE (Personal Protective Equipment) when entering and exiting an isolation room for 1(#2) of 5 (#1 #2 #3 #4 #5) sample residents and 1 (#R1) random sampled resident. Findings: 1. Review of the facility's policy titled New admissions and resident who leave the facility policy revealed in part: Residents who are NOT up to date with all recommended COVID-19 vaccine doses and are new admission/readmission will be placed in quarantine, even if they have a negative test upon admission, and will be tested as described in the testing section . Review of the facility's policy titled COVID TESTING POLICY revealed, in part, the following: Anyone with even mild symptoms of COVID-19 regardless of vaccination status, will receive a [CONDITION(S)] test as soon as possible. Residents who have signs or symptoms of COVID-19, regardless of vaccination status, must be tested immediately. While test results are pending, residents with signs or symptoms will be placed in transmission based precautions (TBP) in accordance with CMS/CDC guidance . Resident who left the facility for greater than 24 hours, regardless of vaccination status, will have two [CONDITION(S)] tests for SAR-COV-2 infection; immediately and or within 24 hours of admission/return and, if negative, again 5-7 days after . Review of the medical record for Resident # 2 revealed, the resident had a BIMS (brief Interview for Mental Status) of 12, she required extensive assistance with 1 person assistance for bed mobility, transfers, dressing, toileting, bathing and required a Hoyer Lift for transfers. She was out of the facility, 05/03/2022 to 05/05/2022, for hospital admission with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented evidence, the resident had been placed in quarantine, upon return to facility after a hospital admission of over 24 hours. Further review revealed no documentation Resident #2 had COVID-19 test performed when she developed COVID-19, like symptom, fever of 100.0. on 05/05/2022 at 4:50 p.m. COVID-19 testing was not performed until 05/06/2022 at 08:00 a.m. Review of the Nurse's Notes in part stated: Resident returned to the facility on [DATE] at 3:54 p.m. On 5/5/22 at 4:50 p.m., Resident #2 had a temperature of 100.0, was placed on [MEDICATION(S)] 500 mg daily for 7 days. On 5/11/22 at 7:02 a.m., resident's daughter notified facility, the daughter had tested positive for COVID-19, stating she had visited her mother on Sunday and Monday, testing positive Tuesday 5/10/22. Daughter stated her mother had a dry cough and oxygen saturation was 91 on room air (RA). Resident afebrile, no c/o (complaints), awaiting test Polymerase chain reaction (PCR) results from Monday. Further review revealed the resident was not placed in isolation when she returned from the hospital on 05/05/22 per policy. She was placed in quarantine on 05/11/22, after having been in close contact with her daughter, who tested positive for COVID-19 on 5/10/22. On 05/17/22 the resident's 3rd PCR test resulted negative and isolation was discontinued that morning. An observation on 05/16/2022 at 11:10 a.m., revealed Resident #2's door was open and the resident was lying in bed inside her room. A sign was noted on the door which stated in part: Contact Precautions: wash hands, gowns, gloves, bag linen, discard infectious trash in room. On 05/16/2022 at 11:15 a.m., an interview was conducted with S1ICP (Infection Control Preventionist), She confirmed Resident #2, had returned from the hospital on 05/05/22. She confirmed Resident #2 was unvaccinated. After returning to the facility, Resident #2's daughter later tested positive for COVID-19, and the resident was placed in isolation related to exposure. Resident #2 was tested for COVID-19 on 05/10/22, results - Not Detected. 2. On 05/16/22 at 11:25 a.m., an observation was made of S5CNA and S6CNA entering Resident's #2's room with a Hoyer Lift, without sanitizing their hands or donning the proper PPE (Personal Protective Equipment) prior to entering the resident's room. On 05/16/22 at 11:27 a.m., while with S1ICP, an observation was made as S1ICP knocked and opened the door to Resident #2's room. S5CNA and S6CNA, were observed in the room providing care, changing brief, to Resident #2, who was on Contact/Droplet Isolation. S1ICP, asked S5CNA if she knew she was to wear the appropriate PPE, S5CNA replied yes, there were no gowns in the door, so we just come in to care for the resident. On 05/16/22 at 11:30 a.m., during an interview with S6CNA, she confirmed she had been in Resident #2's room, who was on isolation, and entered the room without the appropriated PPE. On 05/16/22 at 11:35 a.m., during an interview with S5CNA, she confirmed she did not have a gown on while providing care for Resident #2, who was in isolation. She also confirmed for contact isolation she should have a gown, gloves, face shield and mask when providing care. On 05/16/22 at 11:51 a.m., an observation was made of S7HK (housekeeper), who exited Resident #2's room, with her PPE (gown, gloves, and mask) still on. She was observed removing the PPE while standing in the hallway and disposed of the PPE's in her housekeeping cart trash can. On 05/16/22 at 11:54 a.m., an interview was conducted with S7HK. She confirmed she exited the resident's room with all PPE still on, and should have removed and discarded them inside the resident's room. On 05/16/22 at 11:57 a.m., an interview with S1ICP, she confirmed the two CNA's, S5CNA and S6CNA, were in the room providing care to the Resident #2, who was on Contact/Droplet Isolation, while neither of the staff had on the appropriate PPE. S1ICP, confirmed Resident #2 was in isolation and anyone entering the room should have a gown, gloves, face mask and face shield in place before entering the room and remove all PPE, placing in red trash bag in room, prior to exiting the room of an isolation room. On 05/16/22 at 1:22 p.m., an interview was conducted with Resident #2, who stated she had been in isolation since her daughter found out she had COVID-19 and had been visiting her. She stated she had a few tests done but did not test positive for (COVID-19). She added that staff sometimes do not put on a gown or face shield prior to entering her room. On 05/17/22 12:25 at p.m., an interview was conducted with S1ICP. She confirmed the COVID-19 policy stated that residents with signs and symptoms of COVID-19, regardless of vaccination status, must be tested immediately and that Resident #2 should have been placed in isolation when she returned from the hospital. On 05/17/22 at 1:30 p.m., an interview and nurse's notes review was conducted with S2DON, S3RN, COVID-19 Nurse, and S1ICP. S2DON and S1ICP both confirmed that on 05/05/22, Resident #2 had returned to facility, from a hospital stay of greater than 24 hours, and that resident had a temperature of 100.0 after returning to the facility, which is one of the signs or symptoms of COVID-19. S1ICP, confirmed a COVID-19 test was not performed when Resident #2 developed a fever, as per the facility COVID Testing Policy. S1ICP, S2DON and S3RN, all three, confirmed Resident #2 was not COVID-19 vaccinated and should have been placed in quarantine; also confirmed Resident #2 was not placed on isolation upon return from the hospital, did have a fever, and should have been placed in Contact/Droplet Isolation with a COVID-19 test performed as per the facility COVID-19 Testing Policy. S3RN, confirmed the policy titled New admissions and resident who leave the facility policy revealed in part: that residents who are NOT up to date with all recommended COVID-19 vaccine doses and are new admission/readmission will be placed in quarantine, even if they have a negative test upon admission.

Based on record review and interview, the facility failed to take actions to prevent the transmission of COVID-19 (Coronavirus 19) for 9 (#21, #27, #40, #42, #56, #62, #218, #219 and #318) of 9 sampled residents reviewed for COVID-19 infection control. This deficient practice had the likelihood to affect all residents residing in the facility. The facility failed to: 1. Ensure staff who had signs and symptoms of COVID-19 and/or test positive for COVID-19 were immediately removed from the workplace, and not allowed to work with COVID-19 negative residents. 2. Ensure that staff, who tested positive for COVID-19, did not return to work if they did not meet Return to Work Criteria; This failed practice resulted in an Immediate Jeopardy (IJ) on [DATE] at 7:00 AM when the provider allowed symptomatic and/or COVID-19 positive staff to provide care to COVID-19 negative residents. S4CNA (Certified Nursing Assistant) was symptomatic during the week prior to testing positive for COVID-19 on [DATE]. S4CNA continued to work through [DATE] and had contact with Resident #40 who tested positive on [DATE] and Resident #27 and Resident #318 who tested positive on [DATE] S1AD (Activity Director) was symptomatic on [DATE]. S1AD tested positive for COVID-19 on [DATE] and worked through [DATE] and had contact with Resident #218, who tested positive for COVID-19 on [DATE]. S5LPN (Licensed Practical Nurse) tested positive for COVID-19 on [DATE] and worked through [DATE]. S2CNA/VD (Certified Nursing Assistant/Van Driver) was symptomatic and tested positive for COVID-19 on [DATE]. She worked through [DATE] transporting residents. S2CNS/VD transported Resident #42 who tested positive for COVID-19 on [DATE]. S5LPN (Licensed Practical Nurse) tested positive for COVID-19 on [DATE] and worked through [DATE]. S6DG (Door Greeter/Screener) tested positive for COVID-10 on [DATE] and worked through [DATE]. S3LPN was symptomatic the morning of [DATE]. She tested positive for COVID-19 on [DATE] and worked [DATE] and had contact with Resident #219 who tested positive for COVID-19 on [DATE]. On [DATE] Resident #56 tested positive for COVID-19. On [DATE] Resident #62 tested positive for COVID-19. On [DATE] Resident #21 tested positive for COVID-19. On [DATE] 03:27 PM, S14Adm (Administrator) stated that he and S28MedDir (Medical Director) were aware that COVID-19 positive staff worked with COVID-19 negative residents. S14Adm stated that COVID-19 positive staff could continue to work if they were fever free and asymptomatic even if the facility was not in a staffing crisis. The administrator was notified of the Immediate Jeopardy on [DATE] at 11:05 a.m. The IJ was removed on [DATE] at 12:50 p.m., when the facility presented an acceptable POR (plan of removal), which by record review and interview, the survey team verified was in progress. This deficient practice continues at a potential for more than a minimal level of harm for the COVID-19 negative residents who reside in the nursing home. The POR read as follows: IJ Plan of Removal: Plan to Eliminate High Risk for COVID-19 Transmission 1. For the Recipients # 21, 27, 40, 42, 56, 62, 218, 219 ,318 who have suffered, or likely to suffer from COVID. All residents are free of symptoms of COVID as of [DATE]. All employees will be screened for COVID symptoms upon entrance into the facility and are free of COVID symptoms as of [DATE]. If an employee has signs and symptoms of COVID or test positive for COVID and are not at work they will remain at home x 5 day and notify their supervisor/DON immediately. If an employee is at work has symptoms of COVID they will be tested and sent home immediately x 5 days, then after 5 days they may return to work if symptoms are improving, and employee is fever free x 24 hrs without the use of fever reducing meds. 2. A QA will be performed by DON or designee every day to ensure all employees are completing a COVID screening form and if any employee has any signs or symptoms of COVID they will be sent home immediately. A QA will be performed by DON or designee to monitor residents for signs and symptoms of COVID. Signage was placed at the front entrance that if any employee has signs or symptoms of COVID they are not to enter the building and notify their supervisor immediately. An in-service was given to all employees concerning signs of COVID and return to work criteria on [DATE], through [DATE] to reach all employees. Questionnaire was administered to all employee's concerning signs of COVID and return to work criteria on ,d+[DATE], through [DATE] to reach all employees 3. Deficient practice was corrected on [DATE]. Findings: 1. Review of the facility's policy titled, Coronavirus Disease COVID-19- Surge Capacity Staffing read in part,.4 prioritizing exposed and symptomatic personnel for testing. When personnel are tested and found to be infected with [CONDITION(S)]-CoV-2 they are excluded from work until they meet all Return to work Criteria unless staffing shortages continue despite other mitigation strategies and certain criteria are met. Crisis Staffing Strategies . 4. if staff are allowed to work before meeting all return to work criteria, restricting them form contact with severely immunocompromised patients and prioritizing their duties in the following order: a. if not already done, allowing staff with suspected or confirmed COVID-19 to perform job duties where they do not interact with other, such as in telemedicine services. b. allow staff with confirmed COVID-19 to provide direct care only for resident with confirmed COVID-19, preferably in a cohort setting. c. allow staff with confirmed COVID-19 to provide direct care for residents with suspected COVID-19. d. as a last resort, allow staff with confirmed COVID-19 to provide direct care for residents without suspected or confirmed COVID-19. Review of the facility's policy titled, Managing Residents with Symptoms of COVID-19 read in part, Resident with known or suspected COVID-19 will need to be in isolation in a single room and if a shared bathroom then a bedside commode will be used. Residents with COVID-19 will be in a dedicated unit with dedicated HCP and remain there until a negative COVID-19 test is received or the resident has remained in isolation x14 days. dated [DATE] Review of the facility's policy titled, Preparing for COVID-19 in Nursing Homes read in part, HCP will be assigned to work only on the COVID-19 care unit when it is in use. Review of the facility's policy titled, Plan for staffing for COVID-10 unit read in part, If a resident test positive for COVID-19 virus they will be relocated to the back hall. The staff assigned to that hall will take care of resident/residents assigned to that hall only .The staff previously assigned will continue to care for the isolation residents only. dated [DATE]. Review of CDC (Centers for Disease Control) Recommendations titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Updated February 2, 2022 read in part, Evaluating and Managing Personnel and Residents: Identify Space in the Facility that Could be Dedicated to Monitor and Care for Residents with Confirmed [CONDITION(S)]-CoV-2 Infection: Determine the location of the COVID-19 care unit and create a staffing plan. The location of the COVID-19 care unit should ideally be physically separated from other rooms or units housing residents without confirmed [CONDITION(S)]-CoV-2 infection. 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 [CONDITION(S)]-CoV-2 infection . Review of the facility's logs of COVID-19 positive staff and PCR test (polymerase chain reaction test that detects the presence of the COVID-19 virus at the time of the test) results revealed: S4CNA tested positive on [DATE] S1AD tested positive on [DATE] S5LPN tested positive on [DATE] S2CNA/VD (Van Driver) tested positive on [DATE] S6DG tested positive on [DATE] S3LPN tested positive on [DATE] Further review of the facility's log of positive staff revealed S4CNA, S1AD, S5LPN, S2CNA, S2CNA/VD, S6DG, and S3LPN were not vaccinated. Review of the facility's logs of COVID-19 positive residents and PCR test results revealed: Resident #40 tested positive on [DATE] Resident #318 and Resident #27 tested positive on [DATE] Resident #218 tested positive on [DATE] Resident #42 tested positive on [DATE] Resident #219 and Resident #56 tested positive on [DATE] Resident #62 tested positive on [DATE] Resident #21 tested positive on [DATE] Review of the Ombudsman transfer logs [DATE] - February 2022 revealed Resident #218 expired on [DATE] in facility. Resident #219 expired in the facility on [DATE]. Both residents received Hospice Services and were COVID-19 positive and in isolation at the time of death. Review of the facility's Root Cause Analysis for [DATE] with PCR tests revealed: S4CNA was not vaccinated and tested positive for COVID-19 on [DATE]. Resident #40 was not vaccinated and tested positive for COVID-19 on [DATE]. On [DATE] six residents including Resident #27 were not feeling well and were tested for COVID-19. Resident #27 was unvaccinated and tested positive. Resident #318 also tested positive for COVID-19 on [DATE]. Review of S4CNA's time card revealed she worked: Tues [DATE] 5:47 am-2:22 pm (8 hours) Wed [DATE] 5:38 am-2:16 pm (8 hours) Thurs [DATE] 5:41 am-2:22 pm (8 hours) Fri [DATE] 5:44am-2:16 pm (8 hours) Mon [DATE] 5:37 am-2:16 pm (8.25 hours) Tues [DATE] 5:49 am-2:21 pm (8 hours) Wed [DATE] 5:42 am-2:16 pm (8 hours) Fri [DATE] 5:38 am-2:19 pm (8 hours) Sat [DATE] 5:42 am-2:18 pm (8 hours) Sun [DATE] 5:43 am-2:16 pm (8 hours) On [DATE] at 09:56 AM, S4CNA stated that she was feeling sick with sinus-like symptoms a week before testing positive for COVID-19 on [DATE]. S4CNA was tested during routine testing on Monday [DATE] and was negative, but she continued to work while having sinus-like symptoms. The following week her symptoms had gone away. S4CNA was tested again during routine testing on Monday [DATE] and was positive. S4CNA stated that after she was informed of her positive test result, she was told she had to stay at work and worked her regular shift assignment. S4CNA stated that S14Adm decided who was tested and that staff had to keep working even when they were positive and/or sick. S4CNA stated that she and other COVID positive staff did not quarantine for 5 days before returning to work. S4CNA then asked what the COVID guidelines were for quarantining positive employees because staff were upset about having to remain at work, working their regular shift sick and/or after testing COVID positive. S4CNA stated that she worked her regular schedule and regular assignment rooms ,d+[DATE] with no adjustments made with resident assignments while she was COVID positive. S4CNA stated she worked with both COVID negative and COVID positive residents on the hall during the latest outbreak in January because the COVID unit was closed. COVID positive residents were isolated in their rooms. Ambulatory COVID positive residents did not remain in their room, they were out and about around facility as their isolation protocols were not strictly enforced. Positive staff were not assigned to only positive residents. S4CNA stated it was a big mix of everything and it didn't matter if they were positive or negative; all they did was spread it around the building. S4CNA stated that staff were not told to do anything different to prevent the spread, just wear their KN95 mask when caring for COVID negative residents. S4CNA further stated during the time she was COVID positive she may have spread COVID-19 to other residents she was not assigned to because she assisted other CNAs on the hall and passed meal trays to all residents on the hall. S4CNA stated that when she was positive she passed a breakfast tray to Resident #318 and remembered being around Resident #27 and Resident #40. Review of Resident #318's clinical record revealed he was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #318's Admission MDS (Minimum Data Set) dated [DATE] revealed he had a BIMS (Brief Interview for Mental Status) score of 9, indicating his cognition was moderately intact. On [DATE] at 11:33 AM, an interview was conducted with Resident #318 who stated he was COVID positive and quarantined inside his room; he was not moved to the COVID unit. Resident #318 stated that staff went in his room with full PPE. Review of the facility's Root Cause Analysis for [DATE] with PCR results revealed: on [DATE] S1AD complained of chills with fever. Her rapid test was negative and she was sent home for the day. S1AD returned to work on [DATE] with no symptoms. Her PCR test was received on [DATE] and was positive. S1AD was not vaccinated. Review of S1AD's time card revealed she worked: Mon [DATE] 6:25 am-3:19 pm (8.25 hours) Tues [DATE] 6:26 am-3:23 pm (8.5 hours) Wed [DATE] 6:22 am-3:16 pm (8.5 hours) Thur [DATE] 6:32 am-3:18 pm (8.25 hours) Fri [DATE] 6:18 am-3:18 pm (8.50 hours) On [DATE] at 01:58 PM, an interview was conducted with S1AD. She stated that she was at home on Friday [DATE] with a fever of 101 degrees. She reported to the facility, got rapid tested on [DATE] and was negative. She further stated that she felt she was COVID positive at that time due to her symptoms and contracting COVID-19 a year prior. She stayed home Friday, Saturday and Sunday, had not had a fever since Saturday morning, and was feeling better through the weekend. She felt ok on Monday [DATE] and came in to work for routine testing as she normally would and worked her regular shift performing regular duties. On the early morning of Wednesday [DATE], S11DON informed her that her test from Monday [DATE] was positive. She told S11DON that she felt ok and could remain at work and mutually decided she could remain at work on [DATE]. S1AD stated that on [DATE] through the rest of [DATE], she provided scheduled activities as normal with residents in groups and 1 on 1 activities in resident rooms on her regularly scheduled work days while she was COVID positive. S1AD stated that staff were told in a meeting that they could work as long as they did not have COVID signs and symptoms. S1AD stated that S28HSKSup was back-up staff and would cover for her when she would go on vacation or if she could not work. She further stated that in room activities like crafts, books, puzzles, packets were available and could be utilized when she could not conduct activities. S1AD stated that she remembered providing activities for Resident #218 in January including entering his room to give him communion donated by a local church. S1AD stated she documented activity notes and would provide a copy. Review of Resident #218's clinical record revealed he was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #218 was unvaccinated and tested positive for COVID-19 on [DATE]. Review of [DATE] activity notes for Resident #218 revealed S1AD documented communion was brought to his room on [DATE], the day before S1AD became symptomatic. S1AD documented she gave Resident #218 communion on [DATE], the day S1AD was notified she tested positive for COVID-19. On [DATE] at 01:04 PM, S8LPN IP stated that S1AD was the only staff employed in the activities department, was essential, and had to come to work even though she was COVID positive because there was no one else to cover S1AD's duties. Reviewed document presented by S8LPN/IP that read On [DATE] S1AD arrived at work and was screening station. Temperature was taken and result was 101.7. Employee was tested at that time and sent home. Employee returned to work on [DATE], fever and symptom free. Employee was tested that day due to this day being the assigned testing day for unvaccinated employees. On [DATE] results came back and employee was positive at this time but asymptomatic. Employee was allowed to continue to work under the Strategies to Mitigate Healthcare Personnel Staffing Strategies. On [DATE] at 02:24 PM, S30HSKSup confirmed that she was back-up staff for S1AD and stated she had provided activities for residents in the past when S1AD was on vacation. Review of the facility's log of COVID-19 positive staff and PCR test results revealed S5LPN was not vaccinated, asymptomatic, tested COVID-19 positive on [DATE] and continued to work. Review of S5LPN's time card and work schedule revealed she worked on Hall B: Mon [DATE] 5:44 am-1:58 pm (7.75 hours) Tues [DATE] 5:36am-1:54 pm (8 hours) Wed [DATE] 5:38am-5:56 pm (11.75 hours) Thurs [DATE] 5:48 am-6:05 pm (11.75 hours) On [DATE] at 10:43 AM, an interview was conducted with S5LPN who stated that she was COVID positive in January, but did not have any symptoms at any time. S5LPN stated that the facility's protocol was if you were COVID positive, but not feeling sick, you could work due the facility's staffing crisis. S5LPN stated that positive staff did not have to quarantine at home. S5LPN stated she worked her regular schedule and room assignments on Hall B and rooms located on Unit C (COVID Unit) after she found out she was COVID positive. S5LPN stated she took care of both positive and negative residents. She confirmed there was no adjustment or grouping of positive residents with positive staff. Review of the facility's log of COVID-19 positive staff and the facility's Root Cause Analysis for [DATE] with PCR test results revealed: S2CNA/VD was not vaccinated, had a fever and cough, and tested positive for COVID-19 on [DATE]. On [DATE] Resident #42 went for a prep exam at her surgeon's office. His office tested her and she had a positive COVID result. Review of S2CNA/VD's time card revealed she worked: Thurs [DATE] 7:11am-3:38 pm (8 hours) Fri [DATE] 6:35am-11:,d+[DATE]:,d+[DATE]:18pm (8.25 hours) Mon [DATE] 5:40 am-11:50am/12:14pm-5:23 am (11.25 hours) Tues [DATE] 7:56 am-4:53pm (8.50 hours) Review of the CNA work assignments for January (2022) revealed S2CNA/VD was assigned to transport residents on the days she worked. Review of the facility's transportation log revealed S2CNA transported Resident #42 on [DATE] and [DATE]. Review of Resident #42's clinical record revealed she was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #42's Significant Change MDS (Minimum Data Set) dated [DATE] revealed she had a BIMS (Brief Interview for Mental Status) score of 9, indicating her cognition was moderately intact. On [DATE] at 11:07 AM, an interview was conducted with Resident #42 who stated that a few days before she found out she was COVID positive she experienced hot flashes, felt confused and not like herself. She was in therapy room and could not remember where the bathroom was. She went to her doctor's appointment where they did a COVID test. When she returned to the facility, staff came and told her she was COVID positive and had to stay isolated in her room for 14 days. The resident further stated that staff told her they would not move her to the COVID unit because she was the only positive resident and would isolate in her room. Resident #42 stated it was a long 14 days for her not being able to leave her room. Review of the facility's log of COVID-19 positive staff revealed S6DG was not vaccinated, asymptomatic. She tested positive for COVID-19 on [DATE]. Review of S6DG's time card revealed she worked: Thurs [DATE] 9:35 am-2:13 pm (8.02 hours) Sat [DATE] 6:01 am -2:54 pm (8.5 hours) On [DATE] at 08:50 AM, S6DG stated she was responsible for screening staff and visitors. S6DG stated she tested positive for COVID in [DATE]. She called in sick a couple of days and did not come to work and returned to work when she was no longer symptomatic. Review of the facility's log of COVID-19 positive staff and the facility's Root Cause Analysis for February 2022 with PCR test results revealed: S3LPN was not vaccinated, tested positive for COVID-19 on [DATE] and returned to work on [DATE] with improving symptoms. Resident #219 and Resident #56 were tested on [DATE] with positive results received on [DATE]. Resident #219 passed away on [DATE]. Resident #62 was vaccinated, was coughing and feeling bad on [DATE]. His rapid test was positive. Resident #21 was tested on [DATE] because she was to be transported to another facility. Her result was positive. Review of S3LPN's time card and work assignment revealed she was assigned to Hall A and worked: Fri [DATE] 5:40 pm-6:13 pm (12 hours) Sat [DATE] 5:37 pm-6:13 pm (12.25 hours) Sun [DATE] 5:40 pm-6:10 am (12 hours) Wed [DATE] 5:43 am-6:14 am (12 hours) Review of resident records revealed Resident #219 and #21 resided on Hall A. Review of Resident #219's MAR (Medication Administration Record) for February 2022 revealed S3LPN administered medications to the resident on [DATE] (the day S3LPN tested positive) through [DATE]. Review of Resident #21's MAR February 2022 revealed S3LPN administered medications to the resident on [DATE] (the day S3LPN tested positive) through [DATE], on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. On [DATE] at 05:45 PM, an interview was conducted with S3LPN. S3LPN stated that she worked the night shift Sunday [DATE] and was tested for COVID on Monday morning [DATE] for routine testing. S3LPN stated that on Tuesday [DATE] at 11:00 am she was at home with a low grade fever of 99.0 and a headache. She then came to facility and requested a rapid COVID test which resulted positive within 15 minutes. She returned home and was off from work on her regular days off. Later that night on [DATE] she ran a fever. She stated that after taking medicine her fever did not come back. She returned to work on Friday [DATE] on the night shift (6a-6p) on Hall A which was her normal assignment and continued working her regularly scheduled days. When asked if staff have to quarantine for a certain number of days after testing positive she replied, staff can work if they are fever free for 48 hrs. When asked if she quarantined at home for a few days before coming back to work, she replied no, staff can work if they are fever free for 48 hrs. S3LPN stated that she was asymptomatic and had not used fever reducing medication 48 hours before her return, so she was allowed to work. S3LPN stated that she was not assigned to the COVID unit while she was COVID positive and denied any resident assignment changes or adjustments with her work schedule. S3LPN further stated that she had never worked on the COVID unit. She stated that Resident #21 resided on her assigned hall and she provided care to the resident before and after Resident #21 tested COVID positive up until the resident was discharged . Resident #21 was the only COVID positive resident she provided care to. S3LPN stated that she worked with COVID negative residents while she was COVID positive wearing a KN95 mask as she always has. S3LPN stated that there were no other precautions she had to take while taking care of COVID negative residents. S3LPN stated that she was not sure if any of the COVID negative residents were immunocompromised or if the residents had been COVID positive within the last 90 days. S3LPN stated she provided care to Resident #219 until the resident tested positive and was moved to the COVID unit. Review of Resident #56's clinical record revealed she was admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #56 Admission MDS dated [DATE] revealed she had a BIMS score of 15, indicating she was cognitively intact. On [DATE] at 11:20 AM, an interview was conducted with Resident #56 who stated she isolated in her room on Unit C when she was COVID positive. Review of staffing schedules [DATE] -February 2022 revealed no written assignments for the COVID unit. On [DATE] at 08:36 AM, S29MR stated she was responsible for tracking and trending positive residents and staff. Asymptomatic positive staff may continue work and do not need to quarantine for 5 days. She stated that positive staff were not re-assigned and stated those who provided direct resident care were allowed to work with negative residents. On [DATE] at 12:00 PM, S8LPN/IP (Licensed Practical Nurse/Infection Preventionist) stated that positive asymptomatic staff who did not have a fever could continue to work because the facility was in a staffing crisis. When asked about specific symptoms to determine who met criteria, she replied that as long as staff did not have a fever, they could work. She was not sure if that included other symptoms like a cough. On [DATE] at 02:12 PM, S11DON stated if any staff tests positive today, whether they have symptoms or not, they may be allowed to work if they wear a KN95 mask if S14Adm approved it. The decision to allow positive staff to work or not depends on what the S14Adm says as he made that call. On [DATE] at 01:21 PM, S8LPN/IP stated the COVID unit was opened on [DATE] and closed on [DATE]. On [DATE] at 03:17 PM, an interview was conducted with S11DON, S8LPN/IP and S13MDS. S8LPN/IP and S11DON stated they were aware that S4CNA, S1AD, S5LPN, S2CNA, S2CNA/VD, S6DG, and S3LPN were not vaccinated, tested positive for COVID and worked with COVID negative residents. S11DON stated that she consulted S14Adm regarding each of these staff on a case by case basis and S14Adm gave the ok for each employee to work as long as they were not symptomatic. S8LPN/IP stated she notified S28MedDir to inform him of the CDC guidelines allowing positive staff to work. On [DATE] at 03:27 PM, S14Adm stated that he was aware positive staff worked with COVID negative residents. He stated that CDC said they could allow positive staff to work if they were asymptomatic and fever free. He again stated he was aware that positive staff were working with negative residents. He further stated that the COVID tests could have been false positives so staff could work. Then he said that if staff were positive, fever free and asymptomatic they could still work. 2. Review of the facility's policy titled, Covid Policy read in part, HCP [Health Care Personnel] and residents with symptoms of COVID-19: Symptomatic HCP, regardless of vaccination status, should be restricted from work pending evaluation for [CONDITION(S)]-CoV2 infection. Review of the facility's policy titled, Policies to test employees for COVID-19 read in part, 4. If an employee has s/s (signs and symptoms) of COVID-19 (cough temp greater than 100.4) a test will be conducted and employee will [be] placed on leave until the results arrive. 5. If the employee has a negative result they may return to work. 6. If an employee has a positive result they will remain at home for 5 days and if then asymptomatic may return to work .8.If an employee test positive for COVID but, is asymptomatic they may return to work wear a N95 mask x5 days if vaccinated. 9. If an employee is positive for COVID and symptoms are improving employee may return to work and wear a N95 mask. Review of CDC (Centers for Disease Control) Recommendations titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Updated February 2, 2022 read in part, Evaluating and Managing Personnel and Residents: HCP (Health Care Providers) should not work while acutely ill, even if [CONDITION(S)]-CoV-2 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill . Review of CDC Recommendations titled, Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 Updated [DATE] read in part, Work Restriction for HCP who are not up to date with all recommended COVID-19 vaccine doses - Higher-risk: HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed [CONDITION(S)]-CoV-2 infection-- Option 1: Exclude from work. HCP can return to work after day 7 following the exposure (day 0) if a [CONDITION(S)] test6 is negative for [CONDITION(S)]-CoV-2 and HCP do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned return to work (e.g., in anticipation of testing delays). Option 2: Exclude from work. HCP can return to work after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare facilities could consider testing6 for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned return. In addition to Options above: Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for [CONDITION(S)]-CoV-2 infection. Any HCP who develop fever or symptoms consistent with COVID-19 should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing. On [DATE] at 04:34 PM, an interview and review of CDC Guidance Strategies to Mitigate Healthcare Personnel Staffing Shortages with S8LPN/IP who stated positive staff who worked did not quarantine for 5 days after testing positive or meet return to work criteria prior to returning. Positive staff worked with positive and negative residents. Staff work assignments were not rearranged where positive staff worked only with positive residents; staff worked their regular schedule and room assignments. Positive staff only wore a KN95 mask; they did not wear a N95 mask. There were no other precautions taken. Staff were not able to practice physical distancing because staff provided direct care. S8LPN/IP stated that all positive residents were not moved to the COVID unit; if the resident had a private room and bath they isolated in their own room. She was not sure if any of the residents on the hall, that positive staff were caring for, had been negative in the last 90 days. Vaccination statuses of residents and staff were not taken into consideration. S8LPN/IP confirmed the facility did not follow all steps as detailed in the Guidance Strategies to Mitigate Healthcare Personnel Staffing Shortages. On [DATE] at 11:27 AM, S11DON was present with S14Adm. S14Adm stated that the facility was never in a crisis. The facility met their minimum staffing numbers and he was able to get agency to cover needed shifts. On [DATE] at 03:51 PM, a phone interview was conducted with S28MedDir who stated that he was not aware of what a crisis staffing was nor was he aware of the information put out by the CDC regarding crisis staffing. S28MedDir stated that he was not involved in discussions regarding the staffing crisis or the decision to allow positive staff to work with negative residents

Based on record review and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to prevent and control the spread of COVID-19. This deficient practice affected 9 (#21, #27, #40, #42, #56, #62, #218, #219 and #318) of 9 sampled residents reviewed for COVID-19 infection control, and had the potential to affect all 75 residents residing in the facility. The facility's administration failed to have a system in place to: 1. Ensure staff who have signs and symptoms of COVID-19 and/or test positive for COVID-19 are immediately removed from the workplace; 2. Ensure that staff, who tested positive for COVID-19, do not return to work if they have not met Return to Work Criteria; and 3. Ensure policies and procedures coincide with current CDC (Centers for Disease Control) recommendations for return to work. This failed practice resulted in an Immediate Jeopardy (IJ) on 1/3/22 at 7:00 AM when the provider allowed symptomatic and/or COVID-19 positive staff to provide care to COVID-19 negative residents. S4CNA (Certified Nursing Assistant) was symptomatic during the week prior to testing positive for COVID-19 on 1/3/22. S4CNA continued to work through 1/9/22 and had contact with Resident #40 who tested positive on 1/3-22 and Resident #27 and Resident #318 who tested positive on 1/6/22 S1AD (Activity Director) was symptomatic on 1/7/22. S1AD tested positive for COVID-19 on 1/11/22 and worked through 1/14/22 and had contact with Resident #218, who tested positive for COVID-19 on 1/10/22. S5LPN (Licensed Practical Nurse) tested positive for COVID-19 on 1/17/22 and worked through 1/20/22. S2CNA/VD (Certified Nursing Assistant/Van Driver) was symptomatic and tested positive for COVID-19 on 1/24/22. She worked through 1/25/22 transporting residents. S2CNS/VD transported Resident #42 who tested positive for COVID-19 on 1/28/22. S5LPN (Licensed Practical Nurse) tested positive for COVID-19 on 1/17/22 and worked through 1/20/22. S6DG (Door Greeter/Screener) tested positive for COVID-10 on 1/24/22 and worked through 1/29/22. S3LPN was symptomatic the morning of 2/1/22. She tested positive for COVID-19 on 2/1/22 and worked 2/6/22 and had contact with Resident #219 who tested positive for COVID-19 on 2/7/22. On 2/7/22 Resident #56 tested positive for COVID-19. On 2/9/22 Resident #62 tested positive for COVID-19. On 2/17/22 Resident #21 tested positive for COVID-19. The administrator was notified of the Immediate Jeopardy on 03/17/2022 at 11:05 a.m. The IJ was removed on 03/21/2022 at 12:50 p.m., when the facility presented an acceptable POR (plan of removal), which by record review and interview, the survey team verified was in progress. This deficient practice continues at a potential for more than a minimal level of harm for the COVID-19 negative residents who reside in the nursing home. The POR read as follows: 1. For the Recipients #s 21, 27, 40, 42, 56, 62, 218, 219,318 who have suffered, or likely to suffer from COVID. All residents are free of symptoms of COVID as of 2/17/22 and All employee are free of symptoms of COVID as of 2/1/22. All employees will be screened for COVID symptoms upon entrance into the facility and are free of COVID symptoms as of 3/20/22. If an employee has signs and symptoms of COVID or test positive for COVID and are not at work, they will remain at home x 5 day and notify their supervisor/DON immediately. If an employee is at work has symptoms of COVID they will be tested and sent home immediately x 5 days, then after 5 days they may return to work if symptoms are improving, and employee is fever free x 24 hrs without the use of fever reducing meds. 2. DON met with Administrator and Owner regarding facility following policies and procedures of COVID as appropriate through CMS/CDC. Medical Director will be notified of all new policies/updates for COVID. All COVID policies were reviewed on 3/18/22-3/20/22 for compliance with CMS with COVID committee meeting and approving policies or revising policies. COVID committee consist of but not limited to ADM, DON, COVID nurse, Infection Control nurse, MDS. COVID nurse or designee will ensure all COVID policies are up to date and followed. As appropriate policies and procedures will be implemented for positive COVID cases under the direction of the DON. COVID nurse or designee will check CMS/CDC guidelines daily for updates and or changes. If noncompliance is noted within staff, then COVID nurse or designee will speak with DON/ADM Concerning disciplinary action needed. A disciplinary action may a verbal warning/education up to be not limited to termination. A QA will be performed by DON or designee on staff being in-service on all updates through CMS/CDC and staff compliance. Staff will be in-service monthly by administration with next in-service being 4/12/22 on new occurrences with COVID and as changes becomes available with policies and procedures per cms/cdc. 3. Deficient practice was corrected on 3/20/22. Findings: Cross reference F880. Review of the facility's policy titled, Policies to test employees for COVID-19 read in part, 4. If an employee has s/s (signs and symptoms) of COVID-19 (cough temp greater than 100.4) a test will be conducted and employee will [be] placed on leave until the results arrive. 5. If the employee has a negative result they may return to work. 6. If an employee has a positive result they will remain at home for 5 days and if then asymptomatic may return to work .8.If an employee test positive for COVID but, is asymptomatic they may return to work wear a N95 mask x5 days if vaccinated. 9. If an employee is positive for COVID and symptoms are improving employee may return to work and wear a N95 mask. Review of CDC (Centers for Disease Control) Recommendations titled, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes Updated February 2, 2022 read in part, Evaluating and Managing Personnel and Residents: HCP (Health Care Providers) should not work while acutely ill, even if [CONDITION(S)]-CoV-2 testing is negative, in order to minimize the risk of transmission of other infectious pathogens, including respiratory pathogens such as influenza. Implement sick leave policies that are non-punitive, flexible, and consistent with public health policies that support HCP to stay home when ill . Review of CDC Recommendations titled, Interim Guidance for Managing Healthcare Personnel with [CONDITION(S)]-CoV-2 Infection or Exposure to [CONDITION(S)]-CoV-2 Updated January 21, 2022 read in part, Work Restriction for HCP who are not up to date with all recommended COVID-19 vaccine doses - Higher-risk: HCP who had prolonged close contact with a patient, visitor, or HCP with confirmed [CONDITION(S)]-CoV-2 infection-- Option 1: o Exclude from work. HCP can return to work after day 7 following the exposure (day 0) if a [CONDITION(S)] test6 is negative for [CONDITION(S)]-CoV-2 and HCP do not develop symptoms. The specimen should be collected and tested within 48 hours before the time of planned return to work (e.g., in anticipation of testing delays). Option 2: o Exclude from work. HCP can return to work after day 10 following the exposure (day 0) if they do not develop symptoms. Although the residual risk of infection is low, healthcare facilities could consider testing6 for [CONDITION(S)]-CoV-2 within 48 hours before the time of planned return. In addition to Options above: o Follow all recommended infection prevention and control practices, including wearing well-fitting source control, monitoring themselves for fever or symptoms consistent with COVID-19, and not reporting to work when ill or if testing positive for [CONDITION(S)]-CoV-2 infection. o Any HCP who develop fever or symptoms consistent with COVID-19 should immediately contact their established point of contact (e.g., occupational health program) to arrange for medical evaluation and testing. Review of CDC guidelines Strategies to Mitigate Healthcare Personnel Staffing Shortages Updated January 21, 2022 read in part, CDC's mitigation strategies offer a continuum of options for addressing staffing shortages. Contingency, followed by crisis capacity, strategies augment conventional strategies and are meant to be considered and implemented sequentially (i.e., implementing contingency strategies before crisis strategies). Allowing HCP with [CONDITION(S)]-CoV-2 infection or higher-risk exposures to return to work before meeting the conventional criteria could result in healthcare-associated [CONDITION(S)]-CoV-2 transmission. Review of staffing shortage documentation provided by S11DON read, When staffing shortages are anticipated, the administrator in collaboration with the Director of Nursing, will use contingency/crisis capacity strategies to ensure staff needs are met. S11 DON stated On January 1, 2022 we as a facility activated the Strategies to Mitigate Healthcare Personnel Staffing Shortages. On February 14, 2022 our facility deactivated the Strategies to Mitigate Healthcare Personnel Staffing Shortages d/t no staffing crisis at that time. Review of State Staffing Pattern Forms from 12/26/21 through 2/19/22 completed by S14Adm, revealed minimum staffing requirements were met. Review of the facility's Root Cause Analysis December 2021 through February 2022 and Facility Assessment for 2022 revealed no documentation regarding a staffing crisis. Review of the facility's full list of employees with hire and terminations revealed: In 2021 the facility lost 10 PRN CNAs; 2 part time CNAs; 1 full time RN, 1 part time RN, 1 full time ADON, 4 PRN LPNs; 3 full time LPNs and 2 part time LPNs. In 2021 the facility hired 4 PRN CNAs; 9 full time CNAs; 6 full time LPNs, and 2 part time CNAs In 2022 the facility hired 1 part time CNA, 2 full time CNAs, and 1 full time RN. The facility had no terminations in 2022. On 03/14/22 at 12:00 PM, S8LPN/IP stated that positive asymptomatic staff who did not have a fever could continue to work because the facility was in a staffing crisis. When asked about specific symptoms to determine who met criteria, she replied that as long as staff did not have a fever, they could work. She was not sure if that included other symptoms like a cough. On 03/14/22 at 02:12 PM, S11DON (Director of Nurses) stated as of now facility is not in staff crisis, but if any staff tests positive today, whether they have symptoms or not, they may be allowed to work if they wear a KN95 mask if S14Adm (Administrator) approved it. The decision to allow positive staff to work or not depends on what the S14Adm said as he made that call. On 03/16/22 at 03:17 PM, an interview was conducted with S11DON, S8LPN/IP (Infection Preventionist) and S13MDS. S11DON and S8LPN/IP stated they were aware that S4CNA (Certified Nursing Assistant), S1AD, S5LPN, S2CNA, S2CNA/VD (Van Driver), S6DG (Door Greeter), and S3LPN were not vaccinated, tested positive for COVID and worked with COVID negative residents. S11DON stated that she consulted S14Adm regarding each of these staff on a case by case basis and S14Adm gave the ok for each employee to work as long as they were not symptomatic. S8LPN/IP stated she notified S28MedDir (Medical Director) to inform him of the CDC guidelines allowing positive staff to work. On 03/16/22 at 03:27 PM, S14Adm stated that he was aware positive staff worked with COVID negative residents. He stated at first that they were not in a staffing crisis then said they were in a staffing crisis (contradicting himself) and that the entire country was in a crisis. He stated that CDC said they could allow positive staff to work if they were asymptomatic and fever free. He again stated he was aware that positive staff were working with negative residents. He further stated that the COVID tests could have been false positives so staff could work. Then he said that if staff were positive, fever free and asymptomatic they could still work even if the facility was not in a staffing crisis. If he can't meet his minimum staffing hours staff will work positive and he considered that to be a staffing crisis. He stated that S28MedDir was aware that COVID positive staff were working with COVID negative residents. On 03/17/22 10:42 AM, an interview was conducted with S8LPN/IP and S11DON. S11DON and S8LPN/IP stated that S3LPN called on her days off insisting she was fine and able to work. S11DON stated that she he had staff available to cover S3LPN's shift but S3LPN wanted to work so they let her. S2CNA/VD was sick the week before testing positive on 1/24/22 and confirmed S2CNA/VD returned to work on 1/25/22. S8LPN/IP and S11DON insisted that since S2CNA/VD was sick the week before and stayed home that S2CNA/VD did not need to stay out 5 days after testing COVID positive. S8LPN/IP and S11DON confirmed that S4CNA, S1AD, S5LPN, S2CNA, S2CNA/VD, S6DG, and S3LPN did not quarantine at home for 5 days after testing COVID positive. On 03/17/22 at 11:27 AM, S11DON was present with S14Adm. S14Adm stated that the facility was never in a crisis. The facility met their minimum staffing numbers and he was able to get agency to cover needed shifts. On 03/17/22 at 03:51 PM, a phone interview was conducted with S28MedDir who stated that he was not aware of what a crisis staffing was nor was he aware of the information put out by the CDC regarding crisis staffing. S28MedDir stated that he was not involved in discussions regarding the staffing crisis or the decision to allow positive staff to work with negative residents. S28MedDir further stated that he was not aware the facility was allowing COVID positive staff to work with COVID negative residents. On 03/21/22 at 08:08 AM, an interview and review of the facility's policies was conducted with S8LPN/IP and S11DON. S11DON confirmed the facility's policy, Policy to test employees for COVID-19 was contradictory and confirmed staff should have isolated for 5 days after testing positive. S8LPN/IP and S11DON reviewed the facility's policy, Coronavirus Disease COVID-19- Surge Capacity Staffing and stated that S14Adm had the policy, they were not aware of this policy, nor read the policy. S8LPN/IP and S11DON confirmed the policy was not followed.