Every finding on record at Knox County Nursing Home

Based on interview and record review, the facility failed to provide adequate supervision and implement resident-specific fall prevention interventions to prevent accidents/injuries for two (R48 and R92) of six residents reviewed for accidents and supervision in the sample of 106. These failures resulted in actual harm to R92 after a fall forward from the wheelchair sustaining a laceration requiring sutures Findings include:R92's admission record documents R92's medical diagnoses including dementia, metabolic encephalopathy, cognitive communication deficit, unsteadiness on feet, muscle wasting and atrophy, abnormalities of gait and mobility, ataxia, osteoarthritis, and anemia.R92's Physical Therapy Evaluation and Plan of Treatment, dated 1/31/26, documents R92 used a manual wheelchair for mobility, was dependent for wheelchair mobility and transfers, demonstrated severe impaired routine decision-making, was unable to consistently follow commands, has impaired bilateral lower extremity range of motion, had diagnoses of unsteadiness on feet and lack of coordination, and had a Mobility Function Score of 1 (indicating complete dependence or substantial/maximal assistance).R92's Minimum Data Set (MDS) assessment, dated 5/27/26, documents R92 has severe cognitive impairment, required extensive assistance/dependence with mobility and activities of daily living, and used a wheelchair and was dependent with wheelchair mobility.R92's fall risk assessment, dated 5/27/26, documented R92 was at high risk for falls, had a history of falls, uses a wheelchair, had impaired gait, and overestimates or forgets limits. R92's current care plan documented R92 was at risk for falls and injuries related to unsteady balance, impaired mobility, and requires staff assistance with ADLs (activities of daily living) with a goal to minimize the risk for falls and injury by staff intervention. Interventions included escorting R92 back to R92's wing after meals, transferring R92 to a recliner after eating, increasing rounding, use of an anti-roll back wheelchair device, assistance with ADLs, completion of fall risk assessments, monitoring for unsteady gait and balance, and therapies as ordered. This same care plan documented R92 required assistance with his physical mobility needs, including being dependent for wheelchair mobility and R92's main mode of locomotion was, other person propelled wheelchair. There was no documentation of an intervention directing staff to utilize wheelchair footrests during transport or address the resident's behavior of placing his feet on the floor while being transported prior to 7/13/2026. The care plan was revised following the incident on 7/13/26 to require footrests while R92 was in the wheelchair.On 7/28/26 at 2:25 PM, V11, Certified Nursing Assistant, stated footrests should be applied to the wheelchair and residents' feet should be on them prior to pushing them in a wheelchair because you never know when a resident will put their feet down creating a risk for a resident to fall. If they put their feet down when pushed, they're going to fall. We are trained to do this to prevent falls from happening.On 7/29/26 at 10:25 AM, V12, Licensed Practical Nurse, stated R92 drags his feet a lot when he is pushed in his wheelchair and R92 did not have foot pedals on consistently prior to 7/13/26. V12 stated residents are not routinely assessed for the need for foot pedals, instead, it is determined what residents need them based on what is going on with them.On 7/29/26 at 1:32 PM, V13/R92's Power of Attorney, stated R92 had footrests for his wheelchair that were on at times and off at times prior to him falling on 7/13/26. V13 stated R92 was good at putting his feet down on the floor and stopping the wheelchair suddenly when he was being pushed. V13 stated, I'm not surprised the fall happened like that and he has very fragile skin.A progress note, dated 7/13/26, documented, R92 was being propelled in his wheelchair with staff assistance from the dining room back to the wing R92's room is on when R92 put his feet down on the ground and went forward in the wheelchair. The note further documented staff tried to catch R92 before he hit the floor, but they were unsuccessful and R92 had a left-hand injury with moderate amount of blood.The facility's incident report, dated 7/13/26, documented R92 was being transported from the dining room to R92's wing by staff in a manual wheelchair when R92 placed his feet on the floor, causing the wheelchair to stop abruptly. Staff attempted to prevent the fall from the wheelchair to the floor but were unsuccessful. R92 fell forward from the wheelchair, sustaining a left-hand injury with significant bleeding. Emergency Medical Services transported R49 to the emergency department for evaluation and treatment.A witness statement by V26, Certified Nursing Assistant (CNA), dated 7/13/26, documented, I, (V26), was wheeling (R92) back to his wing when (R92) put his feet down on to the ground, making the wheelchair come to a sudden stop. (R92) fell forward and I (V26) attempted to catch him but I was unsuccessful. R92 fell to ground and I (V26) immediately yelled for help.The facility's final report submitted to the State Agency documented R92's left hand injury required emergency department treatment consisting of steri-strips, tissue adhesive, and 10 sutures. This same report documented the care plan was updated following the incident to include an intervention for fall prevention to require wheelchair footrests for R92 when up in the wheelchair.R92's emergency department provider note, dated 7/13/26, documented R92 presented to the emergency department for a fall with a laceration to the hand. This same provider note documented R92 had a laceration to R92's dorsal left hand that was 7 cm (centimeters) in length by 7 mm (millimeters) in depth requiring extensive cleaning prior to complex closure with steri-strips around the wound, tissue adhesive to the steri-strips, and seven simple sutures.On 7/29/26 at 3:15 PM, V2, Director of Nursing, confirmed R92 should have had footrests on his wheelchair when V26, CNA, was propelling R92 in the wheelchair and if they were not. V2 further stated if the footrests were on then the fall could have been prevented.

Based on observation, interview and record review, the facility failed to monitor nephrostomy output for one of one resident (R18) reviewed for nephrostomy tubes, failed to wear appropriate Personal Protective Equipment and cleanse the urinary catheter during urinary catheter cares for one of six residents (R40), reviewed for urinary catheter care in a sample of 96. Findings include: 1. The facility policy, Care of Nephrostomy Tube, dated October 2010 directs staff, The purpose of this procedure is to provide guidelines for the care of the resident with a percutaneous nephrostomy tube. Empty drainage bag once per shift and as needed. Measure output as follows: every 8 hours. Measure output from the right and left kidneys separately. Record urinary and nephrostomy output separately. The following information should be recorded in the resident's medical record: Color, quantity and amount of drainage. R18's facility admission Record documents that R18 was admitted to the facility on [DATE] with the following diagnoses: Chronic Kidney Disease, Crossing Vessel and Stricture of Ureter, Acute Kidney Failure, HX: Urinary Tract Infection, Retention of Urine, History of Malignant Neoplasm of Bladder, Artificial Openings of Urinary Tract (Nephrostomy). R18's July 2025 Physician Order Sheet includes the following physician orders: Left Nephrostomy Tube Output Every Shift and Right Nephrostomy Tube Output Every Shift. R18's Care Plan, dated 5/13/25 includes the following Focus areas: (R18) has bilateral nephrostomy tubes related to obstructive and reflux uropathy due to crossing vessel and stricture of ureter. Also included are the following Interventions: Monitor and Document Output. R18's Medication Administration Records, dated September 2024 through January 2025, where facility nursing staff document nephrostomy tube output every 8 hours, contain numerous gaps in documentation to ensure staff were monitoring and recording output. On 7/30/25 at 9:30 A.M., V2/Director of Nurses (DON) confirmed the missing nurse documentation to verify staff were monitoring R18's nephrostomy output. At that time, V2/DON stated it was her expectation that facility staff monitor, and document nephrostomy output every 8 hours. 2.The facilities policy titled Enhanced Barrier Precautions, dated December 2024, documents, Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents. 1. Enhanced barrier precautions (EBPs) refer to infection prevention and control interventions designed to reduce the transmission of multi-drug-resistant organisms (MDROs) during high contact resident care activities. 2. Enhanced barrier precautions apply when: a. A resident is infected or colonized with a CDC-targeted MDRO, but does not have a wound or indwelling medical device, and does not have secretions or excretions that cannot be covered or contained, b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical devices, and does not have secretions or excretions that are unable to be covered or contained, and c. Contact precautions do not otherwise apply. 3. Contact precautions apply when: a. A resident is infected or colonized with any MDRO and has secretions or excretions that cannot be covered or contained, and b. A resident is NOT known to be infected or colonized with any MDRO, has a wound or indwelling medical device, and has secretions or excretions that cannot be covered or contained, or c. A resident is infected or colonized with any MDRO and there is a current investigation of a suspected or confirmed MDRO outbreak. 4. Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status. 5. Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies. Peripheral IV catheters are not considered an indwelling medical device for purposes of EBPs. 6. Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharges from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk of transmission of a pathogen. 7. EBPs employ targeted gown and glove use in addition to standard precautions during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). b. Personal protective equipment (PPE) is changed before caring for another resident. c. Face protection may be used if there is also a risk of splash or spray. 8. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include dressing; b. bathing/showering; c. providing hygiene or grooming; d. changing briefs or assisting with toileting; e. transferring; f. providing bed mobility; g. changing linens; h. prolonged, high-contact with items in the resident's room, with resident's equipment, or with resident's clothing or skin (e.g., in the shower room, therapy gym, or during restorative care); i. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and j. wound care (any skin opening requiring a dressing). The facilities Performance Skill #5.2 Providing Catheter Care, not dated, documents, Cleans tubing of catheter nearest meatus. Moves in only one direction, away from meatus. Uses a clean area of cloth for each stroke. R40's admission Record documents R40's date of admission to the facility was 4/4/11 and his diagnoses include Hemiplegia and Hemiparesis following unspecified Cerebrovascular Disease affecting right non-dominant side, Vascular Dementia Moderate with other Behavioral Disturbance, Urinary Tract Infection, Retention of Urine. R40's Minimum Data Set (MDS) assessment dated [DATE], documents that R40 has an indwelling urinary catheter. R40's Physician orders dated 6/14/24, documents that R40 has an order for 18 FR (French) with 10 cc (cubic centimeter) indwelling urinary catheter for Neuromuscular Dysfunction of Bladder related to Hemiplegia and Hemiparesis following Cerebrovascular Disease. R40's current care plan documents R40 is on Enhanced Barrier Precautions for Indwelling catheter and documents R40 has an Indwelling Catheter for Neuromuscular Dysfunction of Bladder, Hemiplegia following CVA (Cerebrovascular Accident). On 7/30/25 at 8:41 AM, R40 stated he has had a catheter for a while because he cannot urinate. On 7/30/2025 at 9:03 AM, V5 (Certified Nursing Assistant/CNA) observed providing indwelling urinary catheter care on R40. V5 (CNA) did not wear a gown during cares and did not cleanse down the urinary catheter. V5 (CNA) stated, I know what I did wrong, I should have worn a gown during his (R40) catheter care and you are right I did not wash down the catheter tubing. On 7/30/2025 at 12:00 PM V2 (Director of Nursing/DON) stated, I expect my staff to follow policy on catheter care by knocking on the door, telling the resident what they are going to do and put the appropriate PPE (Personal Protective Equipment) on prior to doing the care. V2 (DON) also stated, I have never seen a catheter care policy that states to cleanse the catheter tubing. On 7/31/2025 at 8:20 AM, V22 (Infection Preventionist) stated, If a resident has an indwelling urinary catheter, they should be wearing a gown and gloves with all cares except feeding.

Based on observation, interview, and record review the facility failed to serve all residents at a table at the same time for five (R9, R27, R32, R36 and R45) of 26 residents reviewed for residents' rights in a sample of 28. Findings include: Resident's Rights for People in Long-Term Care Facilities dated 3/2017 documents You have the right to safety and good care; your facility must provide services to keep your physical and mental health, and sense of satisfaction. Facility Routine Mealtimes Report, dated 04/01/2023, documents mealtimes of 7:30 am, 11:30 am and 4:30 pm. On 08/13/24 at 11:45 am to 12:40 pm, during the lunch hours in the Main Dining Room, meal trays and drinks were being passed. 1. On 08/13/24 at 11:45 am, three residents were eating their meal tray at the same table that R36 was sitting at. R36 did not have a meal tray. At 12:25 pm, R36 was served R36's meal tray and the resident's sitting at R36's table had already consumed their lunch meal. R36 stated that R36 was upset to have to wait as R36 feels they forgot her and R36's table mate's meals, and said that this happens all of the time. They have one staff member passing trays in no particular order with several tables that have residents eating, and others at the table waiting for their food. 34131 2. On 8/13/24 at 12:45 pm, R27's table mate was served the lunch meal tray. R27 was seated at the same table with his table mate, but R27 did not receive a meal tray. R27 sat by R27's self, for about ten minutes, before R27 was served the lunch meal tray. R27's table mate had already left the table. R27 stated, They don't have enough staff in the dining room. They always serve us late and it happens a lot. It was two hours one time to get a meal because people walked out, and they never called anyone in to replace them. It bothers me that they don't serve our whole table together, and I sit and watch them eat when I don't have my food. 3. On 8/13/24 at 12:47 pm, R9 was seated at a table with one table mate. R9's table mate received the lunch meal tray. Fifteen minutes later, R9 was served the lunch meal tray. 4. On 8/13/24 at 12:50 pm, R45 was seated at a table with a table mate. R45's table mate received the lunch meal tray, consumed the food, and walked out of the dining room before R45 got served R45's lunch meal tray. R45 stated They need more help in the dining room, and they always seem to serve the meals separate and not one table at a time. 5. On 8/14/24 at 9 am, R32 stated, We do not get served our meals at the same time if we are sitting at the same table. On 8/16/24 at 11:00 am, V1 (Administrator/ADM) stated that the residents don't have assigned seating, but some residents like to sit with the same people daily. Their dining room times are 7:30am, 11:30 am and 4:30 pm. At that same time, V1 stated We need to come up with something to get them served at the time they arrive, and especially if the table mate already has their food.

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions were implemented and failed to ensure proper disposal of Personal Protective Equipment for four residents (R6, R11, R51, R150) of 28 residents reviewed for Infection Control in a sample of 28. Findings include: Enhanced Barrier Precautions Policy documents, Policy Interpretation and Implementation 1. Enhanced barrier precautions (EBP's) are used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MDRO's) to residents. 2. EBP's employ targeted gown and glove use during high contact resident care activities when precautions do not otherwise apply. A. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room). B. Personal protective equipment (PPE) is changed before caring for another resident. 3. Examples of high-contact resident care activities requiring the use of gown and gloves for the EBP's include: a. dressing; b. bathing/showering; c. transferring; d. providing hygiene; e. changing linens; f. changing briefs or assisting with toileting; g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and h. wound care (any skin opening requiring a dressing. 5. EBP's are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Personal Protective Equipment Policy documents, Gowns, Aprons, Lab Coats Policy Interpretation, and Implementation, dated 2001, documents, 7. Soiled gowns, aprons, and lab coats must be removed prior to leaving the work area and discarded into the appropriate receptacle located in the work area. 1. R11's Wound Consultation Note, dated 08/14/24, documents R11 has a Stage Four Pressure Wound of the Right Ear full thickness which measures 0.4 x 0.7 x not measurable (centimeters). R11's July 2024 Physician Order Sheet documents an order, dated 08/23/24, to administer J-Tube (Jejunostomy) enteral feedings six times a day for supplement and flush the J-Tube with 210 milliliters of water. On 08/13/24 2:16 pm, V5/Charge Nurse and V6/CNA/Certified Nursing Assistant were observed providing incontinence care to R11. V5 and V6 were not wearing gowns. V5 stated during an interview on 08/13/24 at 2:23 pm, We were in a hurry, we should have worn gowns. On 08/14/24 at 2:48 pm, V7/LPN entered R11's room and donned gloves, but no gown. Medication (Tylenol 325 milligram two tablets) were crushed prior to entering R11's room. V7 then gathered water and spoke with R11 before checking placement and residual of R11's J-Tube. V7 then flushed and administered the medication through R11's J-Tube. V7 did not wear a gown during the administration of R11's J-Tube medications. 2. R150's August 2024 Physician Order Sheet documents a diagnosis of Non-Pressure Chronic Ulcer of unspecified part of Lower Leg. R150's Wound Consultation Sheet, dated 8/14/24, documents R150 has a Non-Pressure Wound of the Right Lower Lateral Leg which is full thickness and measures 2.0 x 0.7 x 0.3 centimeters. On 08/13/24 at 12:13 pm, V8/LPN entered R150's room and performed glucose monitoring. V8 did not wear a gown. R150 was on a bedpan. V9/CNA and V10/CNA entered R150's room, removed R150's bedpan and used the mechanical lift to assist R150 to R150's electric wheelchair. V9 and V10 did not wear gowns while providing direct care and transferring R150. V8 returned on 8/13/24 at 12:21 pm and administered medication (insulin) to the left lower quadrant of R150's abdomen without wearing a gown. During interview on 08/13/24 at 12:25 pm, V8 does not know why R150 is on Enhanced Barrier Precautions but states that V8, V9 and V10 should have worn gowns. 50962 3. On 8/14/24 at 08:30 am, R6 stated that R6 has an area to the left heel that had originally started as a blister that opened and got infected. R6 is noted to have a bandage showing above the left sock and pressure boot to the left foot. On 08/15/24 at 10:40 am, V3 (Licensed Practical Nurse/LPN) provided wound care to R6 who is in Enhanced Barrier Precautions. V3 (LPN) removed V3's gloves and disposed of them in R6's room. V3 (LPN) then rolled up R6's soiled gown and carried it down the hallway to place it in a linen barrel in the shower room. 4. On 08/15/24 at 10:15 am, V3 (Licensed Practical Nurse/LPN) provided wound care to R51 who is in Enhanced Barrier Precautions for a coccyx wound. V3 walked out of R51's room with V3's gown and gloves on, walked up the hallway to the shower room, and then back to R51's room. V3 then removed and disposed of V3's contaminated gloves, rolled up the contaminated gown, and walked back up the hallway carrying the gown to a barrel in the shower room. On 8/15/24 at 10:30 am, V3 (LPN) stated that V3 should have removed and disposed of V3's gown and gloves in R51's room before exiting. On 08/15/24 11:14 am, V4 (Registered Nurse/ Infection Preventionist) stated that, Staff should have a linen barrel inside of the room to place contaminated gowns in after caring for residents on Enhanced Barriers, and if not available they should place the gown in a plastic trash bag and walk it down to linen barrel.

Based on observation, interview, and record review, the facility failed to provide sufficient staff to care for dependent residents. This failure has the potential to affect all 79 residents residing in the facility. Findings include: The facility Assessment, no date available, documents, Nursing, nutrition services, and housekeeping staffing is evaluated at the beginning of each shift and adjusted as needed to meet the care needs and acuity of the resident population. The facility's Resident Council Minutes/Report, dated 5/18/23, documents, The CNAs (Certified Nursing Assistants) should not be giving showers on Wing 1 when there is only one CNA. On 06/12/23 at 10:45 AM, V12 (R16's family) stated, (R16) was left in pool of urine, the bed, the mattress, and the sheets. This happened on 3rd shift 6/3/23 into 1st shift 6/4/23. (R16) is on a memory care unit. There are residents who wander all night long. They have one CNA and one nurse, but the nurse covers multiple halls on third shift. They set off the alarm to exit so that one CNA runs after them and leaves the floor unattended. So how is that CNA supposed to take care of residents turning and changing them as well as supervising the wandering resident on this locked hallway all by herself. On 06/13/23 at 10:00 AM, As a group when asked if there were staffing issues, R183, R43, R29, and R18 all stated yes. Then, when asked about call light response times they all laughed. R183 stated, There are times that we wait a quite a bit longer for our call lights to be answered, especially when they work short staffed. R43 stated, The call light wait times can be pretty long at times, but I try to tell myself over and over again to be patient. On 6/14/23 at 10:40 a.m., V6 CNA stated, We are supposed to have one CNA on 100 wing, two CNAs scheduled on 200 wing, and two CNAs on 300 wing. The nurse that works 200 wing also works 100 wing. So, we go with no nurse on our floor for a while at times. I've only worked with myself being the only CNA on the floor. If it's just one, I feel like it hurts the residents, and they don't get the care they should. There are residents that take two staff to turn and change. If the nurse isn't on the floor. Those residents can't be turned or changed. Luckily, with it being the dementia unit we really don't have to worry about call lights. If there was an emergency and no nurse was on the floor, I don't know what I would do if I couldn't leave the resident. We also have (R99) who wanders all through the night and attempts to go out the door. So, on top of everything else I have to make sure and supervise (R99) as well. On 6/04/23, I came in at 2:00 a.m. and the other CNA left at 2:00 a.m. The nurse was stuck on 100 wing for a long time. So, I was by myself. (R16) is a two assist to change her. I didn't have any help, so I wasn't able to change her that night. I know she was incontinent, but I couldn't safely change her by myself. On 06/14/23 at 11:55 AM, V7 (CNA) stated, There are times that we work short. I've came in and there's only been one CNA working on the hall. Depending on who is working will determine how much the CNA was or wasn't able to do on their own. A more inexperienced CNA may not be able to check and change everyone with it being just that one person. If there was an emergency on our hallway on third shift, the nurse was on the 100 hall, and I was all by myself I don't know what I would do if there was an emergency and I couldn't leave the resident. There are residents on this hall that require two people to change them. If it's just one CNA, you hope that the nurse is on the hall to help. On 06/14/23 at 11: 56 AM, V8 (CNA) stated, Staffing can be an issue at times. There's been one CNA on third shift when I've came in. With only one person there's times that there are more people wet and needing changed. It just depends on how much experience the CNA has. There are residents on our hall who require two of us to change them. On 06/14/23 at 12:06 PM, V9 (Licensed Practical Nurse), stated, We are short staffed here, both nurses and CNAs. When we are short all of the staff are stressed out and anxious trying to get double the work done. With working short things get missed and not done which affects the residents. A resident may not get changed timely or gotten up on time things like that. It's hard on us and the residents. I've worked third shift and covered both 100 and 200 hall. It's hard going back and forth and making sure everything is taken care of. If there's an emergency on one hall that means I'm going to be pulled from the other hall for a while. Then, if you throw in that there is only one CNA on this hallway that's even worse. With only one that means the nurse is the 2nd person for all of the two assist, but what about the time I'm on the other hall. Also, with doing more CNA work that's pulling me from the regular nurse duties. (R99) is a wanderer. It's scary when we are short and knowing you've got to keep an eye on her. She is exit seeking. We are so relieved the nights she may sleep through the night that's one less stressor on the nights we are short. On 6/15/23 at 9:30 a.m., V14 (CNA) stated, In the morning, if I'm alone I can't get the mechanical lifts up for their get up. I dress them and wait for day shift to get to the facility. There are a lot of two assist residents for get up. I just don't get them up when I'm alone. There is a few residents that I have difficulty with turning at time. When I'm doing rounds some of the resident end up being wet longer than they should. I have at least 21 residents that I have to change on rounds plus answer call lights, So, I'll change all of them on one side then head to the other side. When I'm done with the second side, the first side is wet, and I start all over again while I'm still trying to answer call lights as well. It's hard to get it done. The facility Staffing Assignment Daily, dated 6/03/23, documents that on 3rd shift one CNA is assigned to each hallway, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/04/23, documents that on 3rd shift one CNA each is assigned to 100 and 200 hall, two CNAs are assigned to 400 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/07/23, documents that on 3rd shift one CNA each is assigned to 100 and 200 hall, two CNAs are assigned to 400 hall until 2:00 a.m. when one CNA leaves, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/08/23, documents that on 3rd shift one CNA is assigned to each hallway until 2:00 a.m. when one of those CNAs is moved to 400 hall and another CNA comes in to work alone on 200 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/09/23, documents that on 3rd shift one CNA is assigned to each hallway until 2:00 a.m. when another CNA comes in to work 400 hall, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. The facility Staffing Assignment Daily, dated 6/10/23, documents that on 3rd shift one CNA is assigned to each hallway, one nurse is assigned to 100 and 200 hall, and one nurse on 400 hall. On 6/15/23 at 10:30 a.m., V17 (Social Services Director) stated, The resident complained about only one CNA on the floor during the resident council meeting because she felt like it wasn't safe since no other CNA was available if they were in the shower room. On 6/15/23 at 10:15 a.m. V11 (Human Resources) stated, I use the State calculator for the minimum staffing. However, I try to schedule two nurses, one works 100 and 200 hall and the other works 400 hall, and five CNAs, one on 100 hall, two on 200 hall, and two on 400 hall. With our staffing issues lately though sometimes it's only one CNA on 200 hall and one CNA on 400 hall. V11 confirmed the required minimum hours the facility was following for 3rd shift on 6/03, 6/04, 6/07, 6/08, 6/09, and 6/10/23 was two nurses and four CNAs. V11 also confirmed: 6/03 three CNAs were working, one for each hallway; 6/04 one CNA was working on 200 hall; 6/07 one CNA was working on 200 hall; 6/08 3.5 CNAs working with one on 200 hall; 6/09/23 3.5 CNAs working with one on 200 hall; three CNAs were working, one for each hallway. The Centers for Medicare and Medicaid (CMS) Resident's Census and Condition of Residents form 672, dated and signed by V13 (Minimum Data Set Coordinator) on 6/13/23, documents the following assistance required for residents: Dressing: 72 require one to two staff assist, 7 are dependent; Transferring: 61 require one to two staff assist, 12 are dependent; Toilet use: 72 require one to two staff assist, 7 are dependent. The 672 also documents that at the time of the survey 79 residents resided in the facility.

Based on interview and record review, the facility failed to provide incontinent care for one of three residents (R16) reviewed for bowel and bladder incontinence in the sample of 30. Findings include: The facility's Urinary Continence and Incontinence-Assessment and Management policy, dated 8/22, documents, Ensure that all residents, where possible, are toileted e.g., toilet incontinent residents (check/change per plan of care and as resident allows). R16's Care plan, dated 5/15/23, documents, R16 has alteration with elimination related to being frequently incontinent of bladder, frequently incontinent of bowels, requires staff assistance with ADLs (Activities of Daily Living). Intervention: Assist with toileting upon arising in AM, before/after meals, before going to bed and PRN (as needed). Bedside commode for toileting. Every two hours toileting; Clean peri-area with each incontinence episode. R16's ADL care plan, dated 1/19/23, documents, R16 has potential for changes with her ADL self care needs related to requires supervision to total assistance with her ADLs secondary to diagnoses: Alzheimer's disease, restlessness and agitation, Osteoarthritis, Delusional disorder. Interventions: Bed Mobility-Extensive assist with repositioning and turning in bed. On 06/12/23 at 10:45 AM, V12 (R16's family) stated, (R16) was left in pool of urine, the bed, the mattress and the sheets. This happened on 3rd shift 6/3/23 into 1st shift 6/4/23. (R16) is on a memory care unit. There are residents who wander all night long. They have one CNA (Certified Nursing Assistant) and one nurse, but the nurse covers multiple halls on third shift. They set off the alarm to exit, so that one CNA runs after them and leaves the floor unattended. So how is that CNA supposed to take care of residents turning and changing them as well as supervising the wandering resident on this locked hallway all by herself. (R16) is bedbound. She's not able to use her call light. The facility's Staffing Assignment Daily sheet dated 6/3-6/4/23, documents that one CNA and one nurse were assigned to work the 200 hall on 3rd shift. On 6/14/23 at 10:40 a.m., V6 CNA stated, On 6/4/23, I came in at 2:00 a.m. and the other CNA left at 2:00 a.m. The nurse was stuck on 100 wing for a long time. So, I was by myself. (R16) is a two assist to change her. I didn't have any help, so I wasn't able to change her that night. I knew she was incontinent, but I couldn't safely change her by myself.

Based on observation, interview, and record review, the facility failed to document behaviors to warrant the initiation of an antipsychotic medication for one of one resident (R16) reviewed for antipsychotics in the sample of 30. Findings include: The facility's Antipsychotic Medication Use policy, dated 7/22, documents, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND: the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity; or behavioral interventions have been attempted and included in the plan of care, except in an emergency. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering; poor self-care; restlessness; impaired memory; mild anxiety; insomnia; inattention or indifference to surroundings; sadness or crying alone that is not related to depression or other psychiatric disorders; fidgeting; nervousness; or uncooperativeness. On 06/12/23 at 12:44 PM, R16 was alert sitting up in her high back reclining wheelchair. R16 was nonverbal and was not displaying any behaviors. R16's Physician's orders, dated 6/13/23, documents that R16 was started on Seroquel (antipsychotic) 25 mg (milligrams) by mouth twice a day for Anxiety (5/02/23). The orders also document that R16 is currently receiving Seroquel 25 mg by mouth daily. R16's Behavior note, dated 3/14/23 at 12:27 p.m., documents, R16 continues to yell and swear at staff when they attempt to speak with her or offer her food. Sits quietly when left alone at her table. R16's Behavior note, dated 3/14/23 at 2:33 p.m., documents, R16 observed crawling out of bed, attempted to place feet back into bed, R16 begins screaming/crying. R16 gotten up and toileted. Continues screaming/crying. Sitting at table at this time, when staff attempt to converse/calm her offering food/fluids R16 becomes upset and yelling at staff. R16's Behavior note, dated 3/15/23 at 2:48 a.m., documents, During repositioning R16, R16 called this nurse a n****r. R16 redirected with no effect. R16's Behavior note, dated 3/23/23 at 7:24 p.m., documents, R16 became agitated when nurse attempted to give eye drops, R16 grabbing at bottle and trying to put in her mouth. When nurse attempts to re-explain what is happening R16 gets even more agitated, cursing and threatening to kill nurse. Grabbing at nurses clothing. Repeatedly kicking feet off the side of footrests. R16's Behavior note, dated 4/3/23 at 1:18 p.m., documents, Staff attempted to lay R16 down after lunch. R16 became agitated, refused. Yelling/screaming/cursing/grabbing at staff. R16's Behavior note, dated 4/15/23 at 1:42 p.m., documents, R16 brought to dayroom at this time. Repeatedly crawling out of her bed. Toileted and repositioned without effect. Sitting at table fidgeting with clothing/blanket at this time. R16's Behavior note, dated 4/15/23 at 11:38 p.m., documents, R16 crawling out of bed at this time, when staff attempt to assist her to get repositioned, she begins screaming and grabbing. Swearing at staff/name calling. R16's Behavior note, dated 4/16/23 at 1:19 a.m., documents, R16 crawled out of her bed onto her floor mats. Incontinent of small amount of urine. Assisted back to bed with two staff and gait belt. Toileted and brought to dayroom for closer monitoring. R16's Communication with physician note, dated 5/2/23 at 10:21 a.m., documents, Situation: Physician faxed back stating that Ativan, Ambien, and valium are all benzodiazepines and would not help. He gave orders for Seroquel 25 mg BID (twice a day). R16's Communication with family note, dated 5/3/23 at 11:59 p.m., documents, Spoke with (V12 R16's family) per phone asking how R16 is sleeping. I assured her that she has been sleeping soundly since I got here at 10:00 PM. She is concerned that physician started R16 on Seroquel today and that it is causing her to be too sleepy as she slept through her supper. R16's Nurses' notes, dated 5/10/23 at 4:33 a.m., document, Behaviors: yelling out; resisting cares; restlessness. 1:1 ineffective. R16's Psychiatric Evaluation note, dated 5/11/23, documents, Type of Visit: Initial Psychiatric Evaluation. Chief Complaint: Establish care, initial evaluation of dementia with behaviors and insomnia. R16's Order Administration note, dated 5/14/23 at 7:27 a.m., documents, V12 didn't want R16 to have it (Seroquel) this AM due to family coming she didn't want her sleepy. R16's Nurses' notes, dated 5/17/23 at 12:43 p.m., documents, R16 was yelling out very loudly while CNA's (Certified Nursing Assistants) were getting R16 out of bed this morning. R16's Care plan, dated 6/5/23, documents, R16 has episodes of verbal and physical agitation towards staff. She will yell, curse, call them names and will become combative by hitting/grabbing when staff is trying to assist her related to Alzheimer's/dementia. R16's Care plan, dated 6/5/23, documents, R16 will resist care-will become combative, yell/cry out when staff, caregiver and family try to assist her related to anxiety, Alzheimer's Disease/Dementia. R16's Order Administration note, dated 5/28/23 at 10:32 a.m., documents, V12 wanted med (Seroquel) held this AM due to the med making her so sleepy. R16's Nurses' notes, dated 6/10/23 at 2:59 p.m., document, Note Text: Behaviors-Crawling out of bed and yelling out during cares. On 6/12/23 at 10:45 a.m., V12 (R16's family) stated, (R16) is now getting a sleeping pill, Seroquel, that knocks her out for the night. She sleeps through the night. The only behavior she has is attempting to get out of bed. That's why she is on the Seroquel so she will sleep through the night and not try to get out of bed. With only one staff member they get her up when she's trying to get out of bed. (R16) needs to sleep at night. She dangles her feet over the side of the bed, but when staff see her like that, they think she's trying to get up. On 6/14/23 at 2:45 p.m., V10 (Director of Nursing) stated, I've had the policy to have staff let me know if they are considering an antipsychotic. I was pretty irritated when I found out about (R16) getting started on Seroquel without consulting with me. In early May, I tried to explain to (V12) that (R16) shouldn't be on this type of medication. I felt like (R16) needed to be on a mood stabilizer and explained the risks. We agreed to (V12) contacting the physician about changing the antipsychotic. I never did hear anything back about it. Later in May, (V12) was unhappy with how lethargic (R16) was with the Seroquel twice a day so she had the morning dose discontinued. If she would just let us deal with her dementia and behaviors things would be fine, but she won't. I've tried to explain that (R16) should not be on the Seroquel. Antipsychotics should be the last resort. (V12) didn't even let us try anything non-pharmacological interventions before starting the Seroquel. (V12) demanded the physician start (R16) on the Seroquel. (R16) is the sweetest resident. She is so easy to take care of. The behaviors are aggression, hitting/pinching/biting staff, yelling at staff, and restless. (V12) was worried about her not getting any sleep at night. I didn't feel like the behaviors needed treated with an antipsychotic.

Based on interview and record review, the facility failed to immediately report an allegation of potential misappropriation of resident property to the Administrator and the State Survey Agency for one of three residents (R1) reviewed for Misappropriation in the sample of three. Findings include: The Facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated 4/2021, states, 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: The state licensing/certification agency responsible for surveying/licensing the facility; the resident's representative. R1's Detailed Incident Summary initially reported to the State Survey Agency on 5/17/22, states, On 5/17/22 at approximately 2:15 p.m., (V3/Housekeeper) reported to (V1/Administrator) an incident that occurred on 5/13/22. This same Incident Summary documents that V3 reported that V4 (Certified Nurse Aide/CNA) was seen eating out of a box of crackers that looked like R1's box of crackers. V3 also reported that R1's box of crackers were missing out of his room. On 5/27/22 at 1:30 p.m., V3 stated V3 had been assisting in moving R1 from one room to another and noticed his box of crackers behind the television area. V3 stated a couple of hours later, V3 observed V4 (CNA) eating from a box of crackers that looked just like R1's box of crackers. V3 stated she went to R1's room and R1's box of crackers were missing. V3 stated, I didn't want to get anyone in trouble over some crackers but the more I thought about it over the weekend, I thought it could lead to stealing more than crackers. V3 stated she reported the allegation of potential misappropriation of R1's crackers to V1(Administrator) on 5/17/22. V3 stated, I know I'm supposed to report any allegation like that right away, but I just hated to see anyone get in trouble, but in the end, I knew it was the right thing to do. I know I did it wrong. On 5/27/22 at 11:00 a.m., V2 (Director of Nursing) verified that V3 (Housekeeper) did not follow the facility policy and immediately notify the Administrator of an allegation of potential misappropriation of resident property. V2 stated the incident occurred with R1's crackers missing on 5/13/22 and V1 and V2 were not notified until the evening of 5/17/22. On 5/27/22 at 11:22 a.m., V1 (Administrator) stated V3 (Housekeeper) should have immediately notified V1 of the allegation that V4 was observed eating R1's crackers and that R1's crackers were missing. V1 stated the State Survey Agency should be notified immediately also, and in this case, no more than 24 hours after the allegation. V1 stated the State Survey agency wasn't notified until the evening of 5/17/22.

Based on observation, interview, and record review, the facility failed to date opened food, date food received or thawed, date thawed health shakes, clean the convection oven, ensure a covering for a food cart to keep food warm, and failed to wear a hair net in the kitchen. These failures have the potential to affect all 61 residents except R32 who is NPO (nothing by mouth). Findings include: Facility Food Receiving and Storage policy, revised 2017, documents, All foods stored in the refrigerator or freezer will be covered, labeled, and dated ('use by' date). Facility Sanitization policy, revised 2008, documents, The food service area shall be maintained in a clean and sanitary manner. All kitchens, kitchen areas and dining areas shall be kept clean. The Food Services Manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Facility Resident Council minutes, dated January 20, 2022, September 16, 2021, August 19, 2021, July 15, 2021, June 24, 2021, May 20, 2021, and April 22, 2021, document Resident Council complaints on cold food. On 4/26/22 at 10:15am, R25 verified there were complaints on cold food at the resident council meetings. On 4/26/22 between the hours of 10:00am and 11:00am, a tour of the kitchen was conducted with V5 Dietary Manager/DM. In the drink cooler there were four 64 fluid ounce apple juice containers opened and undated; 59 four fluid ounce containers of Ready care vanilla shakes no sugar added that had no expiration dates, no received dates, and no pull dates from the freezer. The outside of the Ready care vanilla shakes documents, Storage and handling- Store frozen. Thaw under refrigeration 40 degrees or below. After thawing, keep refrigerated. Use within 14 days after thawing. There was a note posted in the cooler hanging on a shelf that documents Put date on all liquids when opened. At that same time, V5 DM stated I posted the paper in the cooler because we have had a problem with staff dating things that are opened. It is a work in progress. V5 verified the apple juices had no open dates, and the vanilla shakes had no dates on them. The cooks' cooler had a five-pound sour cream container opened (half empty) and undated; a whole roast beef (no weight) in plastic packaging had no expiration date or pull date noted on the package. At that same time, V5 stated, I don't know when we had roast beef last, but I see no dates on the beef and the sour cream needs an open date. I will have to talk to staff. I have had a lot of things I have been working on getting fixed here. Facility single convection oven had a large amount of brown sticky substance on the sides and bottom of the oven. V5 stated, We use this oven every day and I have this on the list to be cleaned. I am working on getting staff to wipe up spills as they happen so cleaning is easier. Facility tall refrigerator had a four-pound butter tub that was half gone, undated, and had no expiration date; and a two- pound turkey breast package had no expiration date and no received date. A large metal tray storage cart was in the kitchen and was missing the door. At that same time, V5 stated, We need to do better with dating our product. The meal tray cart is used to serve meals to residents down the hallways that don't eat in the dining room. I fixed the cart once but the door fell off again and I haven't gotten it put back on the cart but it needs to be. The dry storage room had a room full of multiple canned goods, and multiple dry storage bags/containers of food that had no expiration dates or received dates. V5 verified that the dry storage canned goods and dry storage bags/containers of food had no expiration dates or received dates and should have. During the tour of the kitchen on 4/26/22 between the hours of 10:00am and 11:00am, V5 did not have V5's hair secured in a hair net. V5 had no hair on top of his head but V5 had hair on the sides and facial hair. V5 stated, I do not wear a hair net. Am I supposed to? I usually shave my head bald including the sides. Facility was unable to provide any daily cleaning sheets to document the kitchen appliances/areas were being cleaned. On 4/26/22 at 11:15am, V5 stated, I do not have the staff fill out daily cleaning sheets, they are to wipe down surfaces after and during meals, but the deep cleaning of the stove and ovens are done about once a month. I do not have anything to show you that was done. Resident Census and Conditions of Residents (Centers for Medicare and Medicaid/CMS 672) form dated 4/26/22, documents 61 residents reside in the facility.

Based on observation, interview, and record review the facility failed to provide sufficient supervision to prevent a fall with major injury for one of three residents (R1) reviewed for falls in a sample of three. This failure resulted in R1 walking without her walker or staff assistance causing R1 to fall sustaining a laceration to the forehead, a laceration to the right hand and a fracture to the right proximal phalanx of the little finger and a fracture to the base of the phalanx of the right ring finger. Findings include: A Falls and Fall Risk, Managing policy dated 3/2018 states, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. In addition, this policy states that conditions that may contribute to the risk of falls include [CONDITION(S)] or other cognitive impairment, functional impairments, and incontinence. This policy also instructs, The staff with input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. R1's Minimum Data Set (MDS ) assessment dated [DATE] documents R1 is severely cognitively impaired and requires limited assistance of one person for transfers, walking in R1 room and walking in the corridor; and requires extensive assistance of one person for toilet use and personal hygiene. R1's Fall risk assessment date 7/8/21 documents R1 is at high risk for falling because R1 has had previous falls, has multiple medical diagnoses, uses a mobility device such as a walker, exhibits a weak gait, and overestimates or forgets the limits of R1's abilities to ambulate safely. R1's care plan states under the focus of physical mobility needs that R1's, Ambulation: Requires supervision to limited assistance with one staff, walker. and Provide close supervision and watch for early signs of agitation or increasing anxiety and report. R1's care plan also documents that R1 is receiving Hospice services due to terminal prognosis secondary to diagnoses including Senile Degeneration of brain and Dementia. In addition, R1's care plan instructs, Increase supervision during times of wandering. This same plan includes a fall prevention intervention dated 10/1/2020 which instructs staff to supervise R1 with 15 minute visuals. R1's fall investigation final report dated 8/20/21 documents that on 8/17/21 at 10:02a.m. R1 had an unwitnessed fall in R1's room requiring hospitalization where R1 received sutures to a forehead laceration, sutures to a right palm laceration, and sustained a fracture to the fourth and fifth fingers of the right hand. This fall investigation documents that V10 (Housekeeper) heard R1 yelling and went to R1's room to find R1 on the floor, in the middle of R1's room, and bleeding from R1's head and hand. The investigation documents that V10 had last seen R1 in R1 room, in bed, at 9:20a.m. when V10 cleaned R1's room. This investigation also documents that V8 (Activity Aide) and V9 (Activity Aide) saw R1 walking in R1's room without R1's walker, at which that time, they gave R1 her walker and redirected R1 back to her bed. R1's fall investigation documents the root cause of the fall as, (R1) self-ambulated from bed to R1 window with her walker, then turned and walked toward the center of R1's room without her walker where R1 lost her balance and sat down on the floor bumping the left side of her forehead. Not wearing shoes, incontinent brief was soiled. The fall investigation documents that the intervention developed as a result of R1's 8/17/21 fall was, During 15 minute visuals staff educated to observe and anticipate resident's needs, make sure R1 has her walker within reach to remind R1 to use walker when/if R1 gets up, as R1 is forgetful of using walker at times. R1's hospital emergency room records dated 8/17/21 documents that as a result of R1's fall R1 required nine sutures to a laceration to R1's forehead, four sutures to R1's right hand laceration, and sustained a fracture to the base of the proximal phalanx of R1's right little finger and a fracture to the base of the proximal phalanx of R1's right ring finger. On 8/30/21 at 12:00p.m. R1 was seated in a wheelchair in the day room next to the nurse's station with her right hand elevated on a pillow and with folded wash cloths on the table in front of R1. V4 (Certified Nurse Aide/CNA) was in the day room providing supervision for residents seated in the day room, including R1. V4 stated that R1 was already on 15-minute visuals while R1 is in her room or her bed prior to R1's fall on 8/17/21. V4 stated that Normally we have (R1) sit up in the day room during the day so we can watch R1. On 8/31/21 at 9:48a.m. V8 (Activity Aide) stated that on 8/17/21 at 9:30a.m. she and V9 (Activity Aide) were walking down R1's hallway asking residents to attend an activity. V8 stated that R1 was standing at R1 door without her walker with no staff assisting R1. V8 stated that R1 was leaning down trying to fix something on the bottom of R1's roommates' bed. V8 stated, We told her she (R1) can't do that so she wouldn't fall. My coworker (V9) stayed at (R1's) side while I grabbed her walker which was by her closet next to the window. I grabbed the walker and brought it to (R1). Then (V9) directed (R1) to her bed. (R1) sat down on her bed. We thought (R1) would lay down on her bed but she was just sitting there with her walker next to her bed. She didn't lay down. V8 stated, Usually (R1) will sleep in her bed without someone in the room with her but when she wakes up, the nurses and CNAs will put (R1) up at the day room next to the nurse's desk to keep an eye on her. V8 stated that she has never seen R1 in her room by herself before stating, I normally see her in the day room. V8 stated, We told both the CNA and nurse that we saw R1 up walking by herself. The nurse was V6 (Registered Nurse) but I'm not sure about the CNA. They just said 'OK. We'll go down there.' On 8/31/21 at 10:06a.m. V7 (CNA) stated she was R1's CNA on 8/17/21 at the time of R1's fall. V7 stated that she had been making 15-minute visual checks on R1 while R1 was in her room in bed. V7 stated she was on a break at the time of R1's fall. V7 stated that when R1 gets up out of bed, staff take her to the day room across from the nurse's station to supervise her. V7 stated, We don't leave her alone in her room. We bring her to the day room. V7 stated the practice of keeping R1 in the day room while she is awake was started prior to R1's fall on 8/17/21. V7 stated, If we see (R1) up walking, we walk with her because she is confused. V7 stated that she documents R1's 15-minute visuals on R1's 15-minute checks sheet. R1's 15 Minutes Checks sheet dated 8/17/21 to 8/18/21 shows that V7 did document R1's 15-minute visual checks from 6:00a.m. to 9:45a.m. on 8/17/21, but the area next to the 9:45a.m. to 10:00a.m. visual check is blank. On 8/31/21 at 10:22a.m. V6 stated that she is R1's regular day shift nurse. V6 stated that R1 makes poor safety decisions and needs to be supervised when R1 is awake and out of bed. V6 stated, Once (R1) gets up from bed or from a nap, staff take (R1) to the day room for supervision, otherwise, she will wander into other residents rooms or try to pick things up off the floor, putting her at risk of falls. V6 stated that keeping R1 in the day room for supervision while R1 is awake has been in practice since before R1's fall on 8/17/21. V6 stated that she was not notified by V8 and V9 at 9:30a.m. on 8/17/21 that R1 was awake and walking around her room unattended. V6 stated that if she had been notified, she would have taken R1 to the day room for supervision. On 8/31/21 at 11:33a.m. V2 Director of Nurses stated, All staff, including ancillary staff such as housekeeping or activities, know that they should not leave residents such as (R1) unattended while up in their rooms and should tell their nurse or CNA right away. V2 stated that at the time of R1's fall on 8/17/21 at 10:02 a.m., V7, R1's CNA, was on her break but that any staff could have made R1's 15-minute visual check.

Based on interview and record review, the facility failed to ensure call lights were answered in a timely manner and resident needs were met for one of four residents (R3) reviewed for call lights in the sample of four. FINDINGS INCLUDE: The facility policy, Answering the Call Light, dated (revised) October 2010 directs staff, The purpose of this procedure is to respond to the resident's requests and needs. When the resident is in bed or confined to a chair, be sure the call light is within easy reach of the resident. Answer the resident's call light as soon as possible. The facility Resident Council Minutes/Report dated 4/22/21 document, Three residents stated the call light is not answered timely. The facility Resident Council Minutes/Report dated 5/20/21 document, Three of thirteen residents stated it is still taking too long for call lights to be answered. R3's current Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . This same document include the following physician orders: Toilet every two hours during waking hours and at least one time during the night. R3's current Incontinence Assessment, date 4/16/21 documents, Frequently incontinent, functional incontinence. (R3) states she has been incontinent of bladder for over a year prior to admission, wears (incontinence briefs). Requires extensive assist of two staff members. Keep touch call light in reach and assist to stand. R3's current Minimum Data Set Assessment, dated 4/16/21 documents that R3's BIMS (Brief Interview for Mental Status) is 15:15 (cognitively intact). This same assessment documents that R3 requires extensive assistance of two staff for transfers, mobility and toileting. R3's Care Plan, dated 1/20/21 documents that R3 is at risk for decline in her continent status. Interventions include: Keep call light within easy reach while in bed or room; remind her to call or ask for assistance when needing to use the restroom; Encourage her to use the restroom, bedpan or commode every two hours throughout the day and every four hours throughout the night; Provide support cares and give verbal cues to perform toileting tasks, encourage to empty bladder completely with each toilet use. Provide positive encouragement for all attempts. On 7/1/2021 at 10:20 A.M., R3 stated, Call light wait times can be terribly long. One, two hours, sometimes. Last Tuesday afternoon (June 29, 2021), I waited over two hours for my call light to be answered. I needed to use the bathroom badly. It was between first and second shift, so no one wanted to answer it (call light). I waited so long, I ended up (urinating) on myself. I was so embarrassed.

Based on observation, interview and record review, the facility failed to implement interventions to prevent further falls for two of four residents (R2 and R4) reviewed for falls, in a sample of four. FINDINGS INCLUDE: The facility policy, Managing Falls and Fall Risk, dated (revised) March 2018 directs staff, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. 1.) R2's current Physician Order Sheet, dated July 2021, documents that R2 was admitted to the facility on [DATE] with the following diagnoses: Muscle Weakness, Abnormalities of Gait and Mobility, Polyosteoathritis, Difficulty in Walking, and Fracture of the Left Femur. R2's Fall Risk Assessment, dated 4/15/2021 documents that R2 is at high risk for falling. R2's Minimum Data Set Assessment, dated 4/19/21 documents that R2 requires extensive assist of two staff members for transfers, ambulation and toileting. R2's current Care Plan, dated 12/12/2014 documents, (R2) is at risk for falls and injuries related to unsteady balance, impaired mobility, being on medications that increase her risk of falls and requires assistance with ADLs (activities of Daily Living). R2's last fall was 4/15/21. Interventions include: Have call light within reach and encourage to use when needing assistance. On 7/1/21 at 10:08 A.M., R2 was seated in a recliner, in her room, watching television. A hip adducer pillow was between R2's legs and a sign posted on R2's room directed staff, Hip Extension Precautions in place. R2's call light was pinned to R2's bed, across the room. At that time, R2 stated, You're supposed to push that button if you need help. I can't reach it now. You have to yell for help if you want something, or just sit and wait. On 7/1/2021 at 10:45 A.M., V3/Registered Nurse (RN) verified that R2 was unable to reach her call light to call for staff assistance. At that time, V3/RN also stated, (R2) is at high risk for falls. (R2) has fallen many times. 2.) R4's current Physician Order Sheet, dated July 2021 documents that R3 was admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease and [CONDITION(S)]. R4's Fall Risk Assessment, dated 6/12/21 documents that R4 is at high risk for falling. R4's current Minimum Data Set Assessment, dated 4/5/21 documents that R4 requires extensive assist of two staff member for transfers and toilet use. R4's current Care Plan, dated 3/29/21 documents, (R4) is at risk for falls and injures related to be ing new to facility, unsteady balance, impaired mobility, decreased safety awareness, requires assistance with ADLs (activities of Daily Living). R4 had falls on 4/25/21, 5/21/21 and 6/12/21. Interventions include: Have call light within reach and encourage to use when needing assistance. On 7/1/21 at 10:39 A.M., R4 was lying in a low bed, in a darkened room. R4's call light was laying on the floor, out of R4's reach. On 7/1/21 at 10:47 A.M., V3/Registered Nurse (RN) verified that R4 was unable to reach her call light to call for staff assistance. At that time, V3/RN stated, (R4) was at high risk for falls.

Based on observation, interview and record review, the facility failed to properly store controlled substance medications, ensure a medication cart was locked and date an open in use multi dose insulin vial. These failures have the potential to affect all 55 residents residing in the facility. Findings include: Facility Storage of Medication policy, revised April 2019, documents, Compartments containing drugs and biologicals are locked when not in use. Scheduled II-V controlled medications are stored in separately locked, permanently affixed compartments. Security access to controlled medication is separate from access to non-controlled medications. Facility Insulin Administration, revised September 2014, documents If opening a new vial, record expiration date and time on the vial (follow manufacturer recommendations for expiration after opening). On 02/10/21 at 10:38 AM, V5, Licensed Practical Nurse (LPN), unlocked the medication cart and pulled out the drawer containing the controlled substance medication storage box. When V5, LPN opened the drawer, the controlled substance storage box was already partially open and not locked. Drawer contained multiple medications labeled with a C (controlled) for multiple residents. V5, LPN, verified box contained schedule II-V controlled medication. On 02/10/21 at 10:43 AM V9, LPN, locked the medication cart and walked into a resident's room to administer medication. When V9, LPN, returned, she unlocked the medication cart and pulled out the drawer containing the controlled substance medication storage box. When V9, LPN pulled out the drawer, the controlled substance medication storage box was already partially open and not locked. Drawer contained multiple medications labeled with a C (controlled) for multiple residents. V9, LPN, verified box contained schedule II-V controlled medication. R18's multi dose insulin bottle was sitting in the top drawer of the medication cart with no expiration date. V9, LPN, verified the insulin bottle was in use and half empty and stated, The bottle is supposed to have a date on it. I'll be honest, I'm not sure when it was opened. On 02/10/21 at 10:49 AM, the medication cart on wing three was sitting behind nurses station. V10, LPN, unlocked the medication cart and pulled out the drawer containing the controlled substance medication lock box. When V10, LPN opened the drawer, the controlled substance storage box was already partially open and not locked. Drawer contained multiple medications labeled with a C (controlled) for multiple residents. V10, LPN, verified box contained schedule II-V controlled medication. On 2/10/21 at 10:53 AM, V10, LPN, unlocked a door to a room containing a medication cart. The medication cart was not locked. V10 pulled out the drawer containing the controlled substance medication storage box and the controlled substance storage box was already partially open and not locked. Drawer contained multiple medications labeled with a C (controlled) for multiple residents. V10, LPN, verified box contained schedule II-V controlled medication. 02/10/21 10:56 AM V11, Registered Nurse (RN) stated, Controlled substances should be under double lock. The expectation is that the controlled substance storage box in the medication carts should always be locked when not being directly accessed. On 2/11/21 at 9:23 AM, V2, Director of Nursing (DON) stated, The multi dose insulin vials should be labeled with the date and time of when the insulin is to expire from the date of first use. The Facility's CMS (Center for Medicare and Medicaid Services) 672, dated 2/8/21 signed by V12, Minimum Data Set (MDS) Coordinator, documents that 55 residents reside in the facility.

Based on observation, interview and record review, the facility failed to complete daily skin checks for a resident at risk for developing pressure wounds and failed to ensure policies and procedures regarding hand hygiene were followed for one of one residents (R39), reviewed for pressure wounds, in a sample of 24 . Findings include: The facility policy, Prevention of Pressure Injuries, dated (revised) April 2020 directs staff, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. Conduct a comprehensive skin assessment upon admission, with each risk assessment, as indicated according to the resident's risk factors and prior to discharge. Skin Assessment: During the skin assessment, inspect presence of [DIAGNOSES REDACTED]; temperature of skin and soft tissue and [MEDICAL CONDITION]. The facility policy, Wound Care, dated (revised) October 2010 directs staff, The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Use disposable cloth to establish a clean field. Wash and dry hands. Position patient. Put on gloves. Loosen tape and remove dressing. Remove gloves. Wash and dry hands. Put on gloves. Clean wound. Apply treatments. Dress wounds. Remove gloves. Wash and dry hands. Reposition the bed covers. Make the resident comfortable. Place call light within easy reach of resident. R39's current Physician order [REDACTED]. This same document includes the following Physician orders: Skin assessment daily every evening shift. Cleanse sacral wound with Normal Saline, pat dry and apply Collagen to wound bed, cover with dressing. Change daily and PRN (as needed) until resolved. R39's current Braden Scale for Predicting Pressure Sore Risk, dated 9/9/2020 documents R39's risk as Moderate Risk. R39's current Care Plan, dated 3/18/2019 includes the following Focus Care areas: At risk for skin breakdown related to impaired mobility, incontinence, meal intakes vary, requires assistance with ADLs (Activities of Daily Living). This same document includes the following Interventions: Nurse to check and record skin daily. R39's Treatment Administration Record, dated December 2020 documents, Skin assessment daily, every evening shift, every Monday and Thursday and is signed by V8/Licensed Practical Nurse as being performed on 12/3/20 and 12/7/20. R39's Progress Notes, dated 12/8/2020 at 1:12 P.M. and signed by V7/Licensed Practical Nurse/Wound Nurse document, Skin check completed. Unstageable wound noted to sacral area. Area measures 2 CM (Centimeters) X 4 CM X UTD (Undetermined Depth). Small serous drainage noted. 100% yellow slough noted to wound bed. Surrounding skin is intact. On 2/8/2021 at 1:10 P.M., V5/Licensed Practical Nurse (LPN) and V6/Registered Nurse Supervisor prepared to perform pressure wound care for R39. V5/LPN performed hand hygiene, applied gloves and removed a soiled dressing from R39's sacral area. V5/LPN removed her soiled gloves, performed hand hygiene and reapplied clean gloves. V5/LPN cleansed the pressure wound with Normal saline, packed the wound with Collagen and applied a wound covering. Without removing her soiled gloves, performing hand hygiene or applying clean gloves, V5/LPN touched R39's shoulder, R39's bed clothes and R39's pillow while assisting V6/RN to reposition R39. At that time, V5/LPN verified she had not removed her soiled gloves or performed hand hygiene before touching R39. On 2/9/2021 at 12:30 P.M., V7/Licensed Practical Nurse/Wound Nurse stated, I am the facility wound nurse. I do wound care treatments every day and measure wounds weekly. I had been off sick during December. The day I came back to work, I did a skin assessment on (R39). She had an unstageable wound to her sacrum. I measured the wound and contacted her doctor and got a treatment for [REDACTED]. She was at risk for skin breakdown and had a daily skin assessment scheduled. A skin assessment is a nurse looking at a resident's skin to monitor it for rashes or pressure wounds, and then documenting it on the TAR (Treatment Administration Record). On 2/10/21 at 9:20 A.M., V8/Licensed Practical Nurse stated, I was (R39's) nurse the evening of December third and December seventh. (R39) was given a shower by the CNA (Certified Nursing Assistant) that night and the CNA gave me a shower sheet that said (R39) had no skin problems. I don't remember which CNA worked those nights. I didn't do an assessment of (R39's) skin, I just initialed the TAR. If a CNA reports an area, then I go look at it. On 2/10/21 at 12:25 P.M., V2/Director of Nurses stated, If a resident is at moderate risk for skin breakdown, they should have daily skin checks, performed by a nurse. A CNA is not qualified to do a skin assessment.

Based on observation, interview, and record review, the facility failed to check for jejunostomy tube (j-tube) and gastrostomy tube ([DEVICE]) placement prior to flushing and administering medications for one of two residents (R29) reviewed for feeding tubes in the sample of 24. Findings include: The facility's Confirming Placement of Feeding Tubes policy, dated 11/2018, documents The purpose of this procedure is to ensure proper placement of an existing feeding tube prior to administering enteral feedings or medication. This policy also documents, To confirm placement of an existing feeding tube at the bedside: 2. If a change in the incremental markings or tube length is observed, use additional method(s) to test whether the tube is properly positioned: a. Observe for symptoms of elevated gastric residual volume (GVR): (1) A sharp increase in residual volume may indicate that a small bowel tube has moved into the stomach; (2) Little to no residual volume may suggest that the tube has migrated from the stomach to the esophagus. b. Observe and check the pH of aspirate: (1) Fasting stomach contents will have a clear and colorless or grassy green and brown appearance. (2) Fluids from the pleural space may have a pale yellow, serous appearance. (3) Post-pyloric/small bowel contents can be bile stained, light to dark yellow or greenish-brown. (4) Fasting stomach acid will have a pH of 5 or less. (5) Fluid from the pleural space will have a pH of 7 or higher. (6) A pH of 5 or less suggests that the tube is placed in the stomach. However, a pH of 6 or greater is not definitive of placement outside the stomach. R29's current physician's orders [REDACTED]. Enteral Check J-tube placement before initiation of formula, medication administration, and flushing tube or at least every eight hours. Enteral feed order three times a day flush [DEVICE] with 90 milliliters of water every shift. R29's current care plan, dated 12/14/20, documents (R29) is NPO (nothing by mouth) and receives his nutrition via [DEVICE] feedings as ordered, secondary [MEDICAL CONDITION] with dysphagia (difficulty swallowing). 12/26/19 Hospital return with j-tube insertion, continue with [DEVICE] also, nourishment and medications are to be given via j-tube. This care plan lists an intervention to, Check tube placement as ordered. On 2/8/21 at 11:45 AM, V4 (Licensed Practical Nurse) accessed R29's J-tube site and aspirated with no residual. V4 then flushed the J-tube with water and administered medication per R29's physician's orders [REDACTED]. V4 then flushed the [DEVICE] with water per R29's medication orders. V4 did not use pH testing of residual or auscultate (listen) to check the enteral feeding tube placement. On 2/8/21 at 12:05 PM, V4 stated I always use aspiration to check for [DEVICE] and j-tube placement. I do not auscultate. That was the first time I have given (R29) medications today. On 2/10/21 at 9:02 AM, V2 (Director of Nursing) stated Our nurses should check placement prior to any enteral medication administration or feeding. They should all check via auscultation and then check for residual. We have it in our policy that we check the acidity of residual but we are having a hard time getting those test strips in. Without the test strips, auscultating is our way of checking placement. The staff all know that and know how to do it. They should always do both aspiration for residual and auscultation to check placement.

Based on observation, interview and record review the facility failed to ensure policies and procedures regarding hand hygiene were followed for one residents (R20) of 22 residents reviewed for infection control, in the sample of 24. FINDINGS INCLUDE: The facility policy, Personal Protective Equipment-Using Gloves, dated (revised) September 2010 directs staff, To guide the use of gloves. To prevent the spread of infection; To protect wounds from contamination; To protect hands from potentially infectious material; To prevent exposure to [MEDICAL CONDITION](Human Immunodeficiency Syndrome) and [MEDICAL CONDITION] viruses from blood or body fluids. The facility policy, Subcutaneous Injections, dated (revised) March 2011 directs staff, The purpose of this procedure is to provide guidelines for the administration of medication by subcutaneous injection. Perform hand antisepsis. Put on gloves. Slowly inject medication. Remove gloves and discard. Wash and dry hands. R20's current Physician order [REDACTED]. This same document includes the following Physician orders: Flasp Solution (Insulin [MEDICATION NAME]) Inject 7 Units subcutaneously in the afternoon. On 2/8/21 at 11:25 A.M., V5/Licensed Practical Nurse (LPN) prepared to administer Insulin for R20. V5/LPN set the Insulin pen to 7 Units, attached a needle to the barrel of the pen and entered R20's room. Without performing hand hygiene or applying gloves, V5/LPN swabbed R20's abdomen with an alcohol swab and injected 7 Units of Insulin. V5/LPN removed the needle from R20's abdomen, swabbed R20's abdomen with the same alcohol pad and left the room and returned to the Medication cart. At that time, V5/LPN verified she did not wear gloves while administering Insulin to R20.

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control and Protection (CDC) guidance for cohorting positive COVID-19 residents (R1, R2, R3, R4, R10, and R13) in a dedicated area and ensure dedicated staff were assigned to positive COVID residents, the facility also failed to utilize facility capacity, ensure COVID-19 positive residents remained isolated and droplet isolation protocols were followed, and failed to ensure adequate staffing to meet resident needs. These failures have the potential to affect all 78 residents residing in the facility. This failure resulted in an Immediate Jeopardy. While the immediacy was removed on [DATE], the facility remains out of compliance at Severity Level 2. The facility is still in the process of monitoring the effectiveness of utilizing supplemental agency staff, staff training and adherence to COVID-19 policies. Findings include: A CDC Strategies to Mitigate Healthcare Personnel Staffing Shortages, updated [DATE], documents, Healthcare facilities must be prepared for potential staffing shortages and have plans and processes in place to mitigate these, including communicating with HCP (Health Care Professionals) about actions the facility is taking to address shortages and maintain patient and HCP safety and providing resources to assist HCP with anxiety and stress. A CDC Recommendation for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic dated [DATE] states, As a measure to limit HCP (Healthcare Personnel) exposure and conserve PPE (personal protective equipment), facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection (COVID-19). Dedicated means that HCP are assigned to care only for these patients during their shifts. A CDC Preparing for COVID-19 in Nursing Homes guidance updated [DATE] documents, Given their congregate nature and resident population served (e.g., older adults often with underlying chronic medical conditions), nursing home populations are at risk of being affected by respiratory pathogens like COVID-19 and other pathogens. This guidance also states, As demonstrated by the COVID-19 pandemic, a strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). This policy further states, Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19, and Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. The facility's Coronavirus/COVID-19 policy and procedure, revised [DATE], documents: 3 .If a resident has symptoms place on droplet precautions in a private room. 5. Residents will be encouraged to stay in their rooms at all times. Except when leaving the room as necessary. At those times, the resident will be required to wear a face covering. Nursing: 2. Properly clean, disinfect and limit sharing of medical equipment between residents and areas of the facility .5. Residents will be encouraged to stay in their rooms at all times. Except when leaving the room as necessary. At those times, the resident will be required to wear a face covering. Face Covering/Mask Covering for Preventing Spread of COVID-19, revised [DATE], documents, 3. Facility must keep in communication with local coalitions, federal, state, and local public health regarding identification of and obtaining additional supplies .4. e) Cohorting staff and residents. The facility's COVID-19 Control Measure for LTC (long-term care) - with suspected or confirmed cases policy, revised [DATE], documents If patients have been screened and their testing is POSITIVE for COVID-19 OR if patients have signs/symptoms of a respiratory [MEDICAL CONDITION] infection: .Private Room or Cohort with another symptomatic/positive patient. Maintain Standard, Contact and Droplet Precautions (including eye protection). Consider that staff caring for positive or symptomatic patients do NOT care for negative or asymptomatic patients .Resident with confirmed COVID-19 or displaying respiratory symptoms should receive all services in room with door closed (meals, physical and occupational therapy, activities, and personal hygiene, etc.) .Ensure all residents wear a cloth face covering for source of control whenever they leave their room or are around others .Whenever a resident is outside their room, they should wear a cloth face covering or facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (6 feet rule) .Facilities: Follow IDPH (Illinois Department of Public Health) guidelines for reporting COVID-19 cases and outbreaks. Immediately inform the local health department and IDPH of symptomatic residents to determine if COVID-19 testing is indicated .Decrease staff rotation and cohort staff who work with symptomatic residents whenever possible .Identify additional isolation rooms limiting to single unit if possible .Residents that are suspected/confirmed to have COVID-19 or related symptoms, will be isolated on a separate wing (wing 2) that is subject to change depending on the number of residents affected and availability of rooms on that individual wing. RN Supervisors will work 12-hour shifts, with on RN to the isolated wing every 12 hours, providing all aspects of care to residents. An increase in nurses to the COVID-Wing will be determined based on caseload. COVID-Wing RN will not enter the facility as they normally would. The RN scheduled to work that wing will enter through the Wing exit door at the end of A-Hall . Any COVID-Wing staff will be required to wear an N95 (filtering facepiece respirator) at all times, and must don a face shield, gloves, gown, and shoe protection when in residents' room, or any patient care area where they might be within 6 feet of the residents. Maintenance will develop a method to attempt to create a negative air pressure in the resident rooms. They will also block the return air for the COVID-Wing .All meals to the COVID-Wing shall be on disposable items and thrown away after use. All items are to remain on the wing and disposed of separately from other materials from the unaffected wing .Nursing/Administration/Social Services: Non Nursing staff will deliver trays to resident rooms for all residents that are not at risk of chocking, or need assistance with feeding .Housekeeping Department: Staff will clean all frequently touched/high risk of contamination surfaces every 2 hours with a List N (products the EPA/Environmental Protection Agency expects will kill the coronavirus virus) approved disinfectant. They are to do this a minimum of every 2 hours. Activities Department: Staff will assist as a resource with meal times, cleaning, and any other task delegated by management, within their scope of practice, to ensure that we are meeting the resident's needs. Maintenance Department: Staff will assist with cleaning/disinfecting as needed .Dietary Department: Dietary will utilize covered carts to deliver meals by wing .Meal Times: all management and other ancillary staff will be assisting with meals and feeding residents (if qualified to do so) . Therapy Services: Therapy services provided on the COVID-Wing will be via (video service) telehealth from the specified therapy, and to be performed by the RN in the residents' rooms, and directed by the therapist/therapy assistant. On [DATE] at 10:35 am, during the facility tour, Wing 1 and Wing 2 were empty and all facility residents were being housed on Wing 3 and Wing 4. The facility did not have a designated COVID-19 unit set up and there were no barriers in place on Wing 3 and Wing 4. There were residents sitting in the common areas, at the nurse's station, and in the hallways. On [DATE] from 10:53 am through 11:05 am, Wing 3 had contact/droplet isolation signage on each resident's door on both A and B halls. The following resident doors were open with visual into the rooms; R1, R2, R6, R7, R9 through R11, and R16. On [DATE] from 11:45 am through 12:00 pm, Wing 4 had contact/droplet isolation signage on each resident's door on both A and B halls. The following resident doors were open with visual into the rooms; R3, R8, R27, R12, R13, R30, R31, and R33. R13's name was on the door but R13 was not in the room. On [DATE] the facility provided a list of residents who have tested positive for COVID-19 which includes the following residents in the order of Laboratory reported positives or rapid positive COVID-19 testing as: R5 on [DATE], R13, R29 and R30 on [DATE]; R31, R14, and R15 on [DATE]; R16, R3, R32, R33, and R27 on [DATE]; R34, R2, R21, and R20 on [DATE]; R17 on [DATE]; and R4 on [DATE]. 1. On [DATE] at 10:57 am, R1 and R6 shared a room with contact/droplet isolation signage on their open bedroom door. R1's Laboratory results document R1 was tested for COVID-19 on [DATE] and positive results were reported to the facility on [DATE]. R6's Laboratory results document R6 was tested for COVID-19 on [DATE] and negative results were reported to the facility on [DATE]. R6 was retested on [DATE] and positive results were reported to the facility on [DATE]. On [DATE] at 4:43 pm, V1 Administrator confirmed R1 and R6 remained in the same room after R1 tested positive for COVID-19. 2. On [DATE] at 10:59 am, R2 and R7 shared a room with contact/droplet isolation signage on their open bedroom door. R2's Laboratory results document R2 was tested for COVID-19 on [DATE] and positive results were reported to the facility on [DATE]. R7's Laboratory results document R7 was tested for COVID-19 on [DATE] and negative results were reported to the facility on [DATE]. R7 was retested on [DATE] and positive results were reported to the facility on [DATE]. On [DATE] at 4:43 pm, V1 Administrator confirmed R2 and R7 remained in the same room after R2 tested positive for COVID-19. 3. On [DATE] at 11:55 am, R3 and R8 shared a room with contact/droplet isolation signage on their open bedroom door. R3's EHR (Electronic Medical Record) documents that on [DATE] a rapid COVID test was performed on R3 with positive results for COVID-19. R3's Laboratory results document R3 was tested for COVID-19 on [DATE] and positive results were reported to the facility on [DATE]. R8's Laboratory results document R8 was tested for COVID-19 on [DATE] and negative results were reported to the facility on [DATE]. On [DATE] at 4:43 pm, V1 Administrator confirmed R3 and R8 remained in the same room after R3 tested positive for COVID-19. 4. On [DATE] at 11:04 am, R4 and R9 shared a room with contact/droplet isolation signage on their open bedroom door. R4's Electronic Medical Record documents on [DATE] a rapid test for COVID-19 was performed with positive results. R4's Laboratory results document R4 was tested for COVID-19 on [DATE] and positive results were reported to the facility on [DATE]. R9's Laboratory results document R9 was tested for COVID-19 on [DATE] and negative results were reported to the facility on [DATE]. On [DATE] at 4:43 pm, V1 Administrator confirmed R4 and R9 remained in the same room after R4 tested positive for COVID-19. 5. On [DATE] at 11:05 am, R10 and R11 shared a room with contact/droplet isolation signage on their open bedroom door. R10's Laboratory results document R10 tested positive for COVID-19 on [DATE] and [DATE]. R11's Laboratory results document R11 tested negative for COVID-19 on [DATE] and positive on [DATE]. On [DATE] at 4:43 pm, V1 Administrator confirmed R10 and R11 remained in the same room after R10 tested positive for COVID-19. 6. On [DATE] at 11:54 am, R12 and R13's names were on the contact/droplet isolation room door; however, R13 was not in the room. R12's EHR (Electronic Health Record) documents a rapid test was performed on [DATE] with positive results. Laboratory results document R12 tested positive for COVID-19 on [DATE]. R13's Laboratory results document R13 was tested for COVID-19 on [DATE], [DATE] and [DATE] and all results were positive for COVID-19. R13's EHR documents R13 expired on [DATE]. On [DATE] at 4:43 pm, V1 Administrator stated R12 and R13 were both positive for COVID-19 and R13 expired on [DATE] with a [DIAGNOSES REDACTED]. 7. On [DATE] at 10:53 am, R22's bedroom was across the hall from a COVID-19 positive resident's open door. R22 entered the hallway and was propelling her wheelchair in the hallway, by way of the handrail, with a bag of books in her lap. R22 stated she was going to the facility library, just outside of Wing 3 to return the bag of books, and maybe get some more to read. 8. On [DATE] at 11:00 am, R23 was sitting in her wheelchair, in the doorway of her room, without a face mask on. R23 was actively coughing into the hallway. On this same date, at 11:18 am, R23 propelled her wheelchair into the hallway using her feet and the hall handrail without a face mask on and continued to cough into the hallway. On [DATE] at 11:20 am, R9 exited her bedroom in her wheelchair and grasped the handrail and began pulling herself down the hallway towards R23. On [DATE] at 11:10 am, V6 LPN (Licensed Practical Nurse) stated R23 is symptomatic and is in contact/droplet isolation as precautionary measure and R9 has not tested positive for COVID-19. 9. On [DATE] at 11:45 am V9 Housekeeper stated We clean high touch areas daily and more frequently when we can. We do not work one hall. We work where they need us to. On [DATE] between 10:00 am and 3:00 pm there were no Housekeepers or Nursing Staff observed cleaning high tough surfaces. On [DATE] at 2:36 pm, V14 Environmental Services Director stated, I have two Housekeepers out due to COVID. Most of the time I have one Housekeeper per Wing. The Housekeepers are to sanitize the handrails and doorknobs daily. The CNA's wipe down the high touch areas as well. On [DATE] at 4:36 pm, V14 stated We do not have the capabilities to have negative pressure rooms or halls. We did talk about using barriers, but it won't do anything with the air and we haven't done it for this outbreak. 10. On [DATE] at 11:45 am, Dietary Staff brought the noon meal on plastic trays on a bakers cart to Wing 3 hall A and an enclosed cart with meal trays to Wing 3 hall B. The noon meal was delivered with regular dinnerware, glass ware, and silverware on a plastic tray. These dishes and trays were placed back on the bakers rack and enclosed cart and the Dietary staff picked them up from each hall and took them back to the kitchen to be washed. On [DATE] at 4:25 pm, V16 Dietary Supervisor stated, We have not been using disposable dishware here. V16 stated dietary loads the meal trays onto the baker racks and enclosed carts and take the carts to each Wing where the nursing staff then delivers to the residents. The Nursing staff reloads the carts with the dishware and dietary brings them back to the kitchen to be washed. 11. The facility diagnostic Laboratory Testing service documented positive resident results for the following residents and dates: R12 on [DATE], R14 on [DATE], R15 on [DATE], R31 on [DATE], R32 on [DATE], and R33 on [DATE]. The Progress Notes for R14, R15, and R31, dated [DATE], document R14, R15, and R31 were moved from the COVID unit on Wing 1 back into the general population of other residents. The Progress Notes for R32 and R33, dated [DATE], document R32 and R33 were moved from the COVID unit back into the general population of other residents. On [DATE] at 4:43 pm, V1 Administrator provided a list of COVID positive residents and stated there are only 10 residents currently in isolation for COVID-19 now because the others on the list have already finished their 14 days of quarantine. V1 stated R1, R2, R10, and R16 are the four residents on Wing 3 and R3, R4, R17, R18, R20 and R21 are the six residents on Wing 4 that are currently in isolation for COVID-19. V1 also stated the following residents, R12, R14, R15, R31, R32, and R33 are out of isolation because they have completed their 14 days of quarantine. When reviewed the testing results with V1, he stated, Yes, that is true. and confirmed R14, R15, and R31 should have remained in isolation until [DATE] and R12, R32, and R33 should have remained in isolation until [DATE] as they have not finished their 14 days of quarantine. On [DATE] at 10:45 am, V3 CNA stated all the residents are on Wings 3 and 4, there are positive residents rooming with negative residents and That doesn't seem right. It's been very difficult to know who has what. I think they should have all the positive residents on one hall. I went on vacation and came back and there were several more with COVID-19. V3 stated there are numerous staff that are out with COVID-19 and they need more help. On [DATE] at 11:10 am, V6 LPN (Licensed Practical Nurse) stated I am the only nurse working today on the 3 and 4 Wing. I have 78 residents. I have four CNA's on Wing 3 but that is unusual, most days I only have three. There are four CNA's on Wing 4 today. At 2:00 pm, V6 stated the residents are being tested weekly and the staff are being tested twice weekly. They are cohorting positive and negative residents together. I don't know what they are doing. On [DATE] at 11:20 am, V7 CNA stated, We got hit hard over the weekend. They closed Wing 1 about two weeks ago due to staffing and everything just exploded. We don't work the same hall every day, we work where they need us to. There are positive and negative residents sharing rooms on Wings 3 and 4. Each Wing has a community Women's and Men's bathroom and all the residents use these because they do not have bathrooms in their rooms. On [DATE] at 11:27 am, V8 CNA stated, They used to have Wing 1 open for the positive COVID residents but closed it because we don't have enough staff to work it. There are positive and negative residents on all the Wings now. On [DATE] at 12:10 pm, V10 LPN stated that R3 and R8 are in a room together. R3 is positive for COVID-19 and R8 is negative. On [DATE] at 12:20 pm, V11 SSD (Social Service Director) stated Wing 1 was our COVID unit but we closed it because we don't have enough staff to work it. All the residents live on Wings 3 and 4. On [DATE] at 2:50 pm, V13 CNA stated, We work where they need us to. On [DATE] at 4:43 pm, V1 Administrator stated, According to my current information, we have had six residents (R13, R34, R35, R37, R38 and R39) to date, that were COVID-19 positive at the time of their passing. The laboratory results for R13, R34, R35, R37, R38, and R39 document positive COVID-19 results were reported to the facility respectively on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. The EHR's (Electronic Health Records) for R13, R34, R35, R37, R38, and R29 respectively document these residents expired on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 12:45 pm, V2 DON (Director of Nursing) stated he tracks all the facility COVID-19 test results. V2 stated R5 was admitted on [DATE] from the local hospital with a hospital negative COVID-19 test dated [DATE]. V2 did confirm that he is unsure if R5 was exposed between [DATE] and [DATE] and (V2) did not feel it was necessary to retest R5 after her admission because she had just been tested . V2 stated the facility tested R5 on the facility's routine test date of [DATE] and received positive results on [DATE]. V2 stated R5 was the facility's first positive COVID resident for this outbreak and R5 was placed on the facility's COVID unit on Wing 1; however, due to staffing issues and too many positive COVID-19 residents, Wing 1 was closed and all the residents housed on Wing 1 were moved to Wings 3 and 4. V2 stated, We do the best we can to keep staff consistent on each Wing. Last week we did have three residents expire that were COVID positive. We are now back in Phase One of reopening because of our County rate being above 10%. We test all the residents weekly on Mondays and the staff twice weekly on Tuesdays and Fridays. We currently have one resident, R36 who goes to [MEDICAL TREATMENT] three times weekly, is being quarantined, and continues to test negative. On [DATE] at 12:19 pm, V2 stated, We probably could have done some things differently, but we thought what we were doing was correct. The Resident Census and Conditions of Residents, dated [DATE] by V1 Administrator, documents that there were 78 residents residing in the facility on [DATE]. The Immediate Jeopardy was identified on [DATE] at 10:00 am. The Immediate Jeopardy began on [DATE] when the facility began to move COVID positive residents from Wing 1, the dedicated COVID unit, to Wing 3 and Wing 4 with COVID negative residents. V1 Administrator was notified of the Immediate Jeopardy on [DATE] at 12:25 pm. The surveyor confirmed through observation, interview, and record review that the facility took the following actions to remove the Immediate Jeopardy: 1. On [DATE] V1 Administrator updated the facility COVID-19 policy and procedures and educated the staff. 2. On [DATE] V1 dedicated the facility's entire B hall on Wing 3 as the facility's COVID-19 unit and closed the double doors to the unit. On [DATE] V1 and management staff moved all of the positive COVID-19 residents to the dedicated COVID-19 unit and the residents who had not had COVID-19 were moved off of Hall B. On [DATE] V1 revised the Daily Assignment Sheets to allow for dedicated staff to work only the COVID-19 unit. On [DATE] at 9:15 am, V1 Administrator stated it was reported to him yesterday morning that R40 and R41 tested positive for COVID-19. V1 stated management are doing all the room moves for COVID-19 and R40 and R41 were not moved because (V1) didn't have the staff available to do it. V1 stated R40 and R41 would be moved today. On [DATE] at 9:19 am, 9:22 am, 9:26 am, 9:40 am, 9:47 am, 9:50 am, 9:53 am, and 10:05 am V19, V20, V21, V25, V26, V31, and V8 CNA's (Certified Nursing Assistants) respectively stated all the COVID-19 positive residents are residing on the COVID unit on the B hall of Wing 3; and V7, V31, and V8 CNA's go from A hall to B hall COVID unit to assist when needed. On [DATE] at 9:35 am, R40 and R41 were rooming together on Hall A of Wing 3, the non COVID-19 unit, amongst other residents. The laboratory results for R40, dated [DATE], document R40 tested positive for COVID-19. The laboratory results for R41, dated [DATE], document R41 tested positive for COVID-19. There also was no signage to their bedroom door. On [DATE] at 9:40 am, V31 CNA (Certified Nursing Assistant) stated R40 and R41 are in isolation because they tested positive for COVID-19 a few days ago and I think they are going to be moved to the COVID unit on B hall today. On [DATE] at 9:45 am, Hall B of Wing 3 has a plastic barrier up separating the first three rooms of the hall from the remainder of the hall. R43, R28, R46, R47, and R48 rooms are in front of the COVID-19 unit barrier on the B hall. On [DATE] at 9:57 am, V8 and V31 CNA's came from A hall, entered the B hall COVID unit, walked down to the end of the unit and entered R9's COVID room with V25 and V26 CNA's. V8 and V31 then exited the COVID unit and returned to work on the non COVID A hall. On [DATE] at 10:05 am, V25 CNA stated she is unsure if R28, R43, R46, R47, or R48 have had COVID-19. R43, R28, R46, R47, and R48's rooms are located next to the COVID barrier unit. On [DATE] at 10:30 am, V1 provided a list of residents in the facility who have not tested positive for COVID-19 and confirmed that R28 and R43 have not had COVID-19 and their rooms were on the same hall as the facility's COVID unit. 3. On [DATE] at 3:30 pm, V1 Administrator stated he would ensure all the COVID-19 residents were placed on the COVID unit and move the residents that have not had COVID-19 off the COVID-19 hall. V1 stated he would ensure the facility COVID-19 Staffing policy was updated, ensure dedicated staff were assigned to the COVID-19 unit, and educate all staff. V1 stated this will be completed by [DATE]. 4. On [DATE] V1 had obtained 2 new staffing agency contracts, which now gives them a total of 4 agencies to utilize. Staff are working 12 plus hours and working other shifts. Agency staff are being utilized to supplement facility staff to maintain adequate staffing levels. The Volunteer Network is in place and the facility, with help from LHD (Local Health Department), is adding more volunteers to this network as they identify them. Staffing levels are checked by the HR Director daily for minimum staffing needs and daily assignments are made from this. 5. On [DATE] The facility had a dedicated COVID-19 unit, with closed double doors at the entrance of the Wing 3 B hall and all positive COVID-19 residents were on this unit. R40 and R41 were moved to the COVID unit and R43, R46, R47, and R48 were moved off the COVID unit hall. R28 remained on the COVID-19 unit due to a rapid COVID-19 test with positive results on [DATE]. There were no positive COVID residents and negative residents rooming together currently. Staff stated they had been educated regarding the facility's updated COVID-19 policies and procedures. The Daily Assignment Sheet for [DATE], document dedicated staff for the COVID-19 unit. Due to all residents who have tested positive for COVID-19 not being housed on the dedicated COVID-19 wing and no dedicated staff caring for the COVID-19 positive residents, the abatement plan was not completely executed by the facility by [DATE] as documented by the facility. Based on observation, interview, and record review conducted [DATE] the facility completed all measures on the abatement plan, including cohorting all COVID positive residents in the dedicated COVID wing and having dedicated staff providing cares to the COVID-19 positive residents. Therefore, the immediacy was removed on [DATE] and the abatement plan could be approved on [DATE]. Completion Date: [DATE]

Based on observation, interview, and record review, the facility failed to follow the Centers for Disease Control and Prevention (CDC) guidance for performing COVID-19 testing to R36 based on the county level of positivity rate being above ten percent, ensure COVID-19 test results were received within 48 hours, and failed to have a policy addressing residents and staff who refuse testing for COVID-19. These failures have the potential to affect all 78 residents residing in the facility. Findings include: The CDC Interim [DIAGNOSES REDACTED]-CoV-2 Testing Guidelines for Nursing Home Residents and Healthcare Personnel, updated 10/16/20, documents, Testing practices should aim for rapid turnaround times (e.g., less than 24 hours) in order to facilitate effective interventions .After initially performing [MEDICAL CONDITION] testing of all residents in response to an outbreak, CDC recommends repeat testing to ensure there are no new infections among residents .Continue repeat [MEDICAL CONDITION] testing of all previously negative residents, generally every 3 days to 7 days, until the testing identifies no new cases of [DIAGNOSES REDACTED]-CoV-2 infection among residents or HCP (Health Care Professional) for a period of at least 14 days since the most recent positive result .CDC suggests directing repeat rounds of testing to residents who leave and return to the facility (e.g., for outpatient [MEDICAL TREATMENT]) or have known exposure to a case (e.g., roommates of cases or those cared for by a HCP with a confirmed [DIAGNOSES REDACTED]-CoV-2 infection). CMS (Centers for Medicare and Medicaid Services) Memo, dated 8/26/20, documents, Routine testing should be based on the extent of [MEDICAL CONDITION] in the community, therefore facilities should use their county positivity rate in the prior week as the trigger for staff testing frequency. The CMS table 2 documents County positivity rates greater than 10 percent are to perform COVID-19 testing twice weekly. If the 48- hour turn-around time cannot be met due to .inability of laboratories to process tests within 48 hours, the facility should have documentation of its efforts to obtain quick turnaround test results with the identified laboratory or laboratories and contact with the local and state health departments .Facilities may consider testing asymptomatic residents who leave the facility frequently, such as for [MEDICAL TREATMENT] or [MEDICAL CONDITION]. This Memo also documents, Facilities must have procedures in place to address staff who refuse testing .Facilities must have procedures in place to address residents who refuse testing. The facility's Coronavirus/COVID-19 policy and procedures, revised 7/24/20, and COVID-19 Control Measures policy and procedures, revised 5/21/20, do not include a facility COVID-19 testing plan, and does not address resident or staff refusals of COVID-19 testing. The facility was unable to provide a Testing plan for COVID-19. The facility's County Positivity Rate is as follows with week ending dates of: 11/4/20 at 10.1%, 11/11/20 at 13.7%, and 11/18/20 at 15.4%. 1. On 11/17/20 between 9:30 am and 3:00 pm, COVID-19 testing was being performed on staff in an office near the entrance of the facility. On 12/1/20 at 9:30 am, V22 RN (Registered Nurse) Supervisor was in an office performing staff COVID-19 testing. V22 stated she has been assisting with the facility COVID-19 testing for staff and residents. V22 stated, I am doing testing of staff today. Staff are tested twice a week on Tuesdays and Fridays and the residents are only tested weekly and I have not been instructed to do anything differently. V22 stated the tests are collected, laboratory comes and picks up the samples around 3:00 pm on the test days, and then it usually takes a couple of days before we get results. It can take longer than 48 hours to get results. On 11/17/20 at 12:45 pm, V2 DON (Director of Nursing) stated the facility has been using the same diagnostic laboratory for their COVID-19 tests that they use for other laboratory services and have not had any problems. V2 stated after we collect COVID-19 test from staff and residents the laboratory picks them up and we get results within a few days. On 11/17/20 at 10:45 am, 11:20 am, 11:27 am, 11:45 am, 12:10 pm, 12:20pm , 2:00 pm, 2:30 pm, 2:36 pm, V5 CNA (Certified Nursing Assistant), V7 CNA, V8 CNA, V9 Housekeeper, V10 LPN (Licensed Practical Nurse)/Treatment Nurse, V11 SSD (Social Service Director), V6 LPN, V12 AD (Activity Director), and V14 Environmental Services Director respectively stated Staff are tested twice weekly and residents weekly. The facility's testing Laboratory COVID-19 Testing Spreadsheets document COVID-19 test collection dates and result reporting to the facility from October through November 2020. These spreadsheets confirm staff are being tested twice weekly and residents are being tested on a weekly basis with a greater than 48 hour turn around for results. The Laboratory COVID-19 Testing Spreadsheets for Staff document collection dates and reported dates for the following staff as: V34 Laundry Aid collected on 11/4/20 with positive results reported on 11/8/20; V35 Housekeeper collected on 11/4/10 with positive results reported on 11/9/20; V36 second shift CNA (Certified Nursing Assistant) collected on 11/11/20 with positive results reported on 11/14/20; V37 Activity Aid and V38 third shift CNA collected on 11/12/20 with positive results reported on 11/15/20; V31 first shift CNA and V32 third shift CNA collected on 11/16/20 with positive results reported on 11/19/20; V13 second shift CNA collected on 11/17/20 with positive results reported on 11/22/20; V33 first shift CNA collected on 11/17/20 with positive results reported on 11/23/20; and V11 SSD (Social Service Director) collected on 11/17/20 with positive results reported on 11/24/20. The Laboratory COVID-19 Testing Spreadsheets for Residents document collection dates and reported dates to the facility for the following residents as: R1, R2, R3, and R4 as collected on 11/10/20 with positive results reported on 11/13/20; R5 collected on 10/26/20 with positive results reported on 10/29/20; R6 and R7 collected on 11/16/20 with positive results reported on 11/19/20; R10 collected on 11/10/20 with positive results reported on 11/13/20; R11 collected on 11/16/20 with positive results reported on 11/19/20; R12 collected on 11/10/20 with positive results reported on 11/13/20; R13 collected on 11/10/20 with positive results reported on 11/13/20. 2. On 11/17/20 at 1:30 pm, R36 was lying in her bed with a mask on. R36 stated she goes out to [MEDICAL TREATMENT] on Monday, Wednesday, and Fridays. R36 stated the facility tests her for COVID every week and so far so good. R36's EHR (Electronic Health Record) documents R36 leaves the facility three times a week for [MEDICAL TREATMENT], on Monday, Wednesday, and Friday. The facility's Laboratory COVID-19 Testing Spreadsheets document R36 was tested for COVID-19 weekly on 10/26/20, 11/5/20, 11/10/20, and 11/16/20 with positive results reported to the facility on [DATE]. On 11/17/20 at 12:45 pm, V2 DON (Director of Nursing) stated R36 goes out to [MEDICAL TREATMENT] three times a week, is tested in the facility for COVID-19 weekly and continues to test negative. 3. On 11/17/20 at 11:02 am, R28 was lying in bed with her eyes closed and contact/droplet signage to her open bedroom door. The facility's diagnostic Laboratory COVID-19 Testing Spreadsheets, dated October through November 2020, indicate R28 has not been tested for COVID-19. R28's EHR (Electronic Health Record) documents R28 has not been tested for COVID-19. On 11/17/20 at 10:00 am, V1 Administrator stated no staff have refused to be tested ; however, R28's family refused to allow the facility to test (R28) for COVID-19. The Resident Census and Conditions of Residents, dated 11/27/20 by V1 Administrator, documents that there were 78 residents residing in the facility on 11/17/20.

Based on observation, interview, and record review the facility failed to implement a fall intervention for one of three residents (R1) reviewed for falls with injury in the sample of three. Findings include: The facility's Falls and Fall Risk Managing policy dated 03/2018 documents, The staff will implement a resident-centered fall prevention plan to reduce specific risk factors of falls for each resident at risk or with a history of falls. R1's Incident Report dated 7-9-20 documents, (R1) found laying face down on the floor beside her bed. (R1) has a bleeding laceration and hematoma to her outer right eyebrow, a bloody nose, and abrasions to her right cheek bone and right knee. Intervention: Add two floor mats. R1's current Care Plan documents, Risks for falls and injuries will be minimized with staff intervention through next review. 7-9-20 Fall Intervention: Add two floor mats. On 9-23-20 at 9:40 AM and 10:05 AM, R1 was lying in her bed. At these times, R1's right side floor mat was leaning up against her wall and unplugged from the alarm. R1's left floor mat was on the floor and unplugged from the alarm. On 9-23-20 at 9:45 AM, V3 (Certified Nursing Assistant/CNA) stated, (R1) should have floor mats on both sides of her bed at all times when (R1) is in bed. (R1's) floor mats should be plugged into the alarm at all times. On 9-23-20 at 10:00 AM, V4 (CNA) stated, (R1) should have fall mats on both sides of her bed at all times when she is in bed. The floor mats should always be plugged into the alarm. (R1's) fall mat on the right side of the bed should be on the floor and not leaning against the wall. (R1's) floor mats are not plugged into the alarm and should be.

Based on observation, interview and record review, the facility failed to count controlled substances per facility policy for one of four residents (R4) reviewed for controlled substances in a sample of four. Findings include: The facility's Controlled Substances policy dated (MONTH) 2012 documents Nursing staff must count controlled medications at the end of each shift. The nurse coming on duty and the nurse going off duty must make the count together. They must document and report any discrepancies to the Director of Nursing Services. On 9-24-19 at 2:20 pm, V6 and V7 (LPNs/Licensed Practical Nurse) were counting controlled substances at their change of shift. R4 had three bottles of [MEDICATION NAME] 50 mg (milligram) tablets from a non facility pharmacy. R4's three bottles of [MEDICATION NAME] were taped shut. V7 (LPN) broke thru the tape, opened each bottle and counted the pills inside. When asked how long the bottles had been taped shut, V7 stated they had been that way as long as she could remember. V7 indicated the bottles should not have been taped shut so staff could count all the pills inside. R4's Controlled Substances Proof of Use form documents the three bottles of [MEDICATION NAME] were received on 4-16-19. On 9-25-19 at 1:40 pm, V2 (DON/Director of Nursing) stated R4's three bottles of [MEDICATION NAME] came from an outside pharmacy and the bottles were not sealed shut when they arrived at the facility. V2 stated since the bottles of [MEDICATION NAME] were not sealed, nursing staff should never have taped them shut and should have opened and counted all the pills in the bottles at every narcotic count nursing staff performed. R4's POS (Physician order [REDACTED].

Based on observation, interview and record review, the facility failed to conduct a root cause analysis of fall data, identify trends and patterns related to falls and provide individualized approaches based on this information to prevent further falls for R9 (one of five residents on the selected sample with falls) out of a total sample of twenty-four. This failure resulted in R9 falling ten times in six months and sustained a fracture of the right hip. The facility also failed to have an antibacterial disinfectant spray locked up. This deficient practice has the potential to affect one of 24 residents (R12) on the sample, identified as being ambulatory and confused. Findings include: 1. The Physician order [REDACTED]. The Drug Information Handbook for Nursing 2007 documents that all of these medications have the same adverse side effects of dizziness, lethargy, confusion, postural hypotension and somnolence. The Minimum (MDS) data set [DATE] documents that R9's cognition is severely impaired, has short and long term memory loss and chronic confusion. The Care Area Assessment Summary documents that R9 Falls care area triggered and falls were care planned on 2/10/11 and 2/26/11. The incident investigation reports dated 10/2/10, 10/11/10, 10/17/10, 10/17/10, and 2/10/11 document that R9 fell in his room unwitnessed. Four of these were on the evening shift and one was on the night shift. The fall of 10/2/10 documents bruising to the knees. The other falls document no injuries. The fall incident of 10/2/11 documents that the bed was in low position, add mattress alarm to bed. The fall incident report of 10/11/10 documents to add fall mats. The rest of the recommended steps to prevent recurrence on the incident reports document to continue with these approaches and answer call lights timely(R9's cognition is severely impaired not aware to use call light). There are no patterns identified and steps recommended for increased supervision at the time and location of the falls. According to the incident investigation reports, on 10/18/10 at 7:30 PM, R9 fell in the hallway from the wheelchair while Certified Nurse Assistant was pushing wheelchair. R9 fell to the floor on his hands and knees and complained that his heels hurt. On 11/27/11 at 8:10 PM, R9 fell from the recliner in the dayroom unwitnessed. Seat alarm was flashing but not sounding. No apparent injuries. On 12/21/11 at 3:10 AM, R9 fell from the recliner in the day room. No apparent injuries. On 2/10/11 at 10:00 PM R9 fell in his room unwitnessed. No apparent injuries. On 2/26/11, R9 fell out of the wheelchair in the dayroom onto his right side, three centimeter skin tear to right side. Six steri strips applied, no complaints of pain. The recommended steps to prevent recurrence are to continue with alarms. On 6/15/11 at 3:00 PM, E2 stated that she is in the process of developing a new fall protocol to assure that new individual approaches are added at the time of the fall and that all falls are reviewed to identify the root cause of the fall and identify trends and patterns to prevent further falls. E2 stated that she was not working here when R9 fell fracturing his hip, therefore she does not know when or how it happened. E2 stated that the nurses notes document that R9 was complaining of pain on 3/5/11, but there are no incident reports that indicate that R9 fell on this date. R9 was transported to the hospital where they x rayed and found a right hip fracture requiring surgery. E2 stated that the nursing notes or the incident investigation do not document any falls or complaints of pain after the fall of 2/26/11 until 3/5/11 when R9 complained of pain in his right leg. The care plan dated 10/13/10 and updated 1/4/11, 3/30/11 and 5/28/11 documents that R9 is at risk for falls and potential for injury due to dementia and poor safety awareness. The approach dated 2/10/11: If (R9) is restless provide activity. On 4/23/11 the approach is: apply a self releasing seat belt. The safety measures with a start date of 3/24/11 - mattress alarm to bed,self release seat belt to wheelchair, chair pad alarm for w/c or recliner and fall mats next to bed. Low Bed were discontinued on 4/24/11. This care plan for R9's risk for falls does not provide individualized approaches to prevent further falls. It does not identify psychotropic medication as a possible contributing factor to the falls. 2. On June 13, 2011, at 10:15 a.m., the door to the Soiled Utility Room on Wing 4 was not in the locked position, making it possible to open the door without punching in the code on the keypad lock. A quart-size spray bottle of Zep Antibacterial Disinfectant and Cleaner was sitting next to a bucket of sudsy water. E28, Activity Director, verified the disinfectant spray and that the door was not locked at this time. The Material Safety Data Sheet for Zep Antibacterial Disinfectant and Cleaner includes the following first aid measures: Eye Contact -- "Immediately flush eyes with running water for at least 15 minutes, keeping eyelids open. Get medical attention immediately." Inhalation -- "If not breathing, give artificial respiration. If breathing is difficult, give oxygen. Get medical attention." Ingestion -- "Do not induce vomiting unless directed to do so by medical personnel. If affected person is conscious, give plenty of water to drink. Get medical attention immediately." On June 16, 2011, at 10:00 a.m., E2, Director of Nurses, said that on Wing 4 there is only R12, who is both confused and independently mobile and therefore could be affected by the problem found.

Based on observation, interview and record review, the facility failed to provide justification for duplicate antipsychotic medications, failed to decrease or discontinue antipsychotics in the presence of abnormal involuntary movements and adverse side effects: confusion, drowsiness and lethargy for R20, R9(two of eight residents (R9, R20) on the selected sample receiving antipsychotic medication in the sample of 24. This failure resulte in R20 developing abnormal involuntary movements of the muscles of the face, mouth, trunk and lower extremities. R9 developed adverse side effects of the [MEDICAL CONDITION] medications, drowsiness, lethargy and confusion and inability to stay awake, to eat or ambulate. Findings include: 1. The current physician's orders [REDACTED]. On 6/13/2011 at 12:45 PM, Z4 stated that R9 was admitted to this facility from a hospital based geriatric psychiatric unit where he was sent from the previous nursing home for uncooperative behavior. Z4(wife) stated that the Z5 (Psychiatrist) at the hospital placed him on [MEDICAL CONDITION] medications that caused him to continually sleep and not eat. Z4 stated that R9 lost 18 pounds while at the hospital. Z4 stated that this same psychiatrist is still treating R9 at this facility. Z4 stated that R9 was ambulating and eating independantly when he came to the nursing home on 9/30/10. R9 was weak and unstable with ambulation due to the side effects of the medications. Z4 stated that R9 has fallen twelve times, one time sustaining a fracture. Z4 stated that she and her daughter assist R9 to ambulate every day at noon but for the last two weeks, R9 can't stay awake or concentrate enough to stand and walk. Some days, R9 can't stay awake to eat. Z4 stated that R9 is capable of feeding himself when he is not drowsy from the medication. Z4 stated that R9 resists care, doesn't like to be told what to do. Z4 stated that it takes patience and re-approaching R9 to get him to let you give him cares. The current physician's orders [REDACTED]. mg daily). R9 receives [MEDICATION NAME] 0.5 mg every eight hours either Intramuscular or by mouth as needed, [MEDICATION NAME] 5 mg every eight hours Intramuscular or by mouth as needed, [MEDICATION NAME] 25 mg as needed, [MEDICATION NAME] 0.5 mg Intramuscular every twelve hours as needed (Extrapyramidal Symptoms.) On 6/13/11 at 12:30 PM, R9 was sleeping while seated in a recliner with Z4 seated by his side. R9 did not arouse when Z4 tried to wake him to tell him she was leaving. R9 remained asleep in the recliner until 3:30PM when two staff awakened him long enough to transfer him to the wheelchair and push him to the end of the hallway to the assisted dining area on the unit. R9 remained in the wheelchair in the hallway asleep until he was pushed into the dining room at 4:30 PM. On 6/15/11 at 7:45 AM, R9 was seated at the dining table in his wheelchair. R9's eyes were closed. E30(Certified Nurse Aid) was seated between R9 and another resident. The food was served at 7:47 AM. E30 tried to awaken R9, but couldn't. About five minutes later, E30 touched R9 on the shoulder and called his name three times and placed the fork of food in his mouth. R9 closed his eyes again and went back to sleep. Each time E30 gave R9 a fork full of food, she had to touch his shoulder and call his name over and over to get him to respond. This continued until approximately fifty percent of the scrambled eggs and sausage was consumed. R9 coughed twice after large bites of food was given to him while he was not fully awake. R9 did not fully awaken during the meal. On 6/15/11 at 11:30 AM, R9 was sleeping and hard to arouse when Z4 was feeding him lunch. Z4 had to continually awaken R9 and keep encouraging him to eat. R9 ate approximately sixty per cent of his meal before falling asleep and not responding to Z4's encouragement to eat. The Drug Information Handbook for Nursing 2007 documents that the two antipsychotics, the anticonvulsant(unlabeled use: to control agitation, aggression in patients with dementia), antidepressant, antianxiety and [MEDICATION NAME]([MEDICATION NAME] inhibitor used to treat mild to moderate dementia) all have similar adverse side effects of somnolence, sedation, dizziness, headache, [MEDICAL CONDITION], fatigue, confusion and agitation. It documents that [MEDICATION NAME] may increase the risk of antipsychotic-related extrapyramidal symptoms(EPS). According to this same handbook for Nursing, [MEDICATION NAME](antipsychotic): Warning/Precautions May be sedating, use with caution in disorders where Central Nervous System depression is a feature. [MEDICAL CONDITION] dysmotility and aspiration have been associated with antipsychotic use - use with caution in patients at risk of pneumonia (i.e. [MEDICAL CONDITION].) May cause extrapyramidal symptoms, including pseudoparkinsonism, acute dystonic reaction, akathisia and tardive dyskinesia (risk of these reactions is high relative to other neuroleptics.) [MEDICATION NAME] inhibitors([MEDICATION NAME]) may increase the risk of antipsychotic-related EPS. [MEDICATION NAME] may increase the effects of [MEDICATION NAME]. Adverse Reactions: Central Nervous System: Restlessness, anxiety, extrapyramidal symptoms, dystonic reactions, pseudoparkinsonism signs and symptoms, tardive dyskinesia, [DIAGNOSES REDACTED], altered central temperature regulation, akathisia, [MEDICAL CONDITION], euphoria, agitation, drowsiness, depression, lethargy, headache, confusion and [MEDICAL CONDITION]. Overdosage/Toxicology: Symptoms of overdose include deep sleep, [DIAGNOSES REDACTED], agitation, [MEDICAL CONDITION] and extrapyramidal symptoms. Treatment is supportive and symptomatic. [MEDICATION NAME](antipsychotic) documents most of the same adverse reactions as [MEDICATION NAME]. It also has a black box warning that Patients with dementia-related behavioral disorders treated with atypical antipsychotics are at an increased risk of [MEDICAL CONDITION] adverse events and death compared to placebo. [MEDICATION NAME] is not approved for this indication. According to the Antipsychotic medication Guidelines found in the Appendix/Obra Guidelines for long ter care in this same handbook for nursing and in the State Operations Manual guidelines, the resident must receive adequate monitoring for significant side effects such as tardive dyskinesia(irreversible movements of the face, tongue, trunk and upper and lower extremities) postural [MEDICAL CONDITION], cognitive-behavioral impairment, akathisia and parkinsonism. "The selection of an antipsychotic agent should be based on the side effect profile since all antipsychotic agents are equally effective at equivalent doses. Coadministration of two or more antipsychotics does not have any pharmacological basis or clinical advantage and increases the potential for side effects." The approaches documented on R9's [MEDICAL CONDITION] Medication care plan dated 3/30/11 document to note any side effects from medicines in chart and notify doctor. It does not list specific side effects to monitor for such as lethargy, postural [MEDICAL CONDITION](sitting and standing blood pressure). There is no documentation in the record to indicate that this monitoring is being done. On 6/14/11 at 3:30 PM, E2(Director of Nurses verified that postural [MEDICAL CONDITION] blood pressure monitoring was not being done. 2. The current physician's orders [REDACTED]. R20 is receiving [MEDICATION NAME] 37.5mg every evening since 10/16/10, [MEDICATION NAME] 0.25mg every other day and [MEDICATION NAME] 0.5mg daily since 5/14/10 along with [MEDICATION NAME] 125mg three times a day on 5/18/10, [MEDICATION NAME] 3 mg([MEDICATION NAME] Inhibitor to treat mild to moderate Alzheimer's dementia) twice a day and [MEDICATION NAME] 0.5mg three times a days started on 5/14/10. There is no documentation from the physician in R 20's record justifying the need for two antipsychotics and why the continued use of the drug and the dose of the drug is clinically appropriate. According to the Drug Information Handbook for Nursing 2007 Appendix/OBRA Guidlines for long-term care, "Selection of an antipsychotic agent should be based on the side effect profile since all antipsychotic agents are equally effective aqt ezuivalent doses. Coadministration of two or more antipsychotics does not have any pharmacological basis or clinical advantage and increases the potential for side effects." The Mental Health PAS screening dated 8/24/06 documents that the evidence does not support severe mental illness as a primary issue. There is no documentation in the record to indicate a history of [MEDICAL CONDITION]. On 6/15/11 at 2:30 PM, E2 (Director of Nurses) stated that she didn't know where the [DIAGNOSES REDACTED]. The Behavior Monitoring Sheets document no behaviors for February 2011, March 2011 and April 2011. On 6/15/11 at 2:00PM, R20 was in her room sitting on her bed. R20 had movements of the face, mouth, trunk and lower extremities while sitting on the bed. R20 held one hand with the other trying to keep them still. R20 stated that she has had these uncontrollable movements for approximately four months. R20 stated that she cannot control them no matter how hard she tries. R20 stated that it is embarrassing. R 20 stated that she doesn't know what causes her extremities to move continuously. R20 stated that she takes a lot of medicine, but she doesn't know what the medicine is prescribed to treat. R20 stated that she would prefer to live at home, but that is not possible because she needs help with activities of daily living. The Abnormal Involuntary Movement Scale(AIMS) dated 11/23/10 documents that R20 had zero movements of the face, mouth, trunk and lower extremities. The Abnormal Involuntary Movement Scale dated 2/16/11 documents that R20 has moderate movements of the face, mouth trunk and lower extremities. There is no documentation in the record to indicate that the facility followed the directions of the AIMS test and notified the physician of these abnormal movements at their onset. The Abnormal Involuntary Movement Scale directions directs to notify the physician of any abnormal involuntary movements if found, so the physician can evaluate the medication and reduce or discontinue the medication before the movements become irreversible(Tardive Dyskinesia). On 6/15/11 at 2:30 PM, E2 stated that the physician was not notified of the abnormal involuntary movements on 2/16/11. E2 stated that the physician did not provide any clinical justification for the need for two antipsychotic medications for R20 or R9 or why the continued use of the drug and the dose of the drug is clinically appropriate. According to the Information Handbook for Nursing 2007, [MEDICATION NAME] has the same adverse reactions and carries the same black box warning as [MEDICATION NAME] listed in example one. The adverse reactions of [MEDICATION NAME] is listed in example one.