Every finding on record at Lake Forest Village by PureHealth

Based on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to accommodate Resident #1's needs when they did not ensure her call light was within reach for her to call for assistance. This failure could place residents at risk of not having access to receive necessary assistance, which could affect their dignity and well-being.Findings include: Record review of Resident #1's face sheet, dated [DATE], reflected a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had diagnoses which included: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial weakness and paralysis on left side due to stroke), aphasia (a communication disorder affecting speech due to brain injury), dysphasia (swallowing disorder), anoxic brain damage (brain damage due to lack of oxygen), chronic pain (long-standing pain), anxiety disorder (excessive fear or worry), and major depressive disorder (mood disorder characterized by intense sadness). Record review of Resident 1's significant change MDS assessment, dated [DATE], reflected the resident's BIMS score was 14, which indicated intact cognition. Section GG-Functional Abilities reflected Resident #1 required maximal assistance with most ADLs. Section I-Active Diagnoses reflected Resident #1 had hemiplegia or hemiparesis (weakness or paralysis). Record review of Resident 1's care plan, dated [DATE], reflected the resident had an ADL self-care performance deficit r/t paraplegic (impairment of motor or sensory function in lower extremities), post CVA affecting left side. Regarding bed mobility, interventions reflected Resident #1 was able to move up in bed, turn side to side, and sit on the side of the bed with cueing and x 1-2 assist from staff. In an observation and interview on [DATE] at 10:45 AM, Resident #1 was observed lying in bed using her electronic tablet. Resident #1 was dressed and well-groomed. Resident #1 was lying on her back with her head at a 45-degree angle, and she was unable to move her left arm. Resident #1 was able to use her right arm to reach for things within close proximity. Resident #1 used her tablet to express herself as she was unable to communicate verbally due to aphasia. Resident #1 used her tablet by typing out words to express to the state surveyor that she could not get help when needed, because her call light usually was not within reach, and when the door was closed staff could not see her waving for help if they happened to pass by. Resident #1 stated she would have to call her RP or wait for someone to come into the room. Resident #1 stated staff came in approximately every 2 hours, but sometimes she needed help before then, especially if they forgot to leave her essential items within reach on her bedside table. Resident #1 stated she was often frustrated and uncomfortable because of this. Observation of the room revealed Resident #1's call light was coming from the wall on the left side and was tucked behind the frame of the bed. Resident #1 did not have access to the call light, which directly notified the nurses. In an interview on [DATE] at 2:02 PM, CNA A revealed she worked at the facility for 2 months. She stated she worked with Resident #1, and the resident was able to use her right arm but could not turn completely without assistance. CNA A stated Resident #1 used the call light to get assistance and used her tablet to communicate with staff. CNA A stated it was important for Resident #1's call light to be clipped near her chest or on the bed sheet for easy access because the resident had limited mobility. CNA A stated she generally completed rounds every 2 hours to check on all residents, and she rounded more frequently on Resident #1 due to her condition. CNA A stated when she passed Resident #1's breakfast tray she recalled seeing her call light clipped to the sheet and within reach. She stated after breakfast, she repositioned Resident #1 and had to move the call light away from the resident, so it was possible she forgot to clip it back within reach of the resident. In an interview on [DATE] at 2:29 PM, RN B revealed she worked at the facility for 8 years. She stated she worked with Resident #1 and described the resident as being able to express her needs clearly. RN B stated Resident #1 used her tablet to type out what she needed, and she would bang on the table, wave at staff, or use the call light for assistance. RN B stated call lights should always be within the residents' reach and never tucked behind the bed. RN B stated she was not aware Resident #1's call light was behind her bed. She stated re-education would be completed with staff regarding call lights. In an interview on [DATE] at 2:35 PM, the DON stated Resident #1 was very expressive of her needs and was able to direct her care. The DON stated Resident #1 was unable to move one side of her body and was physically dependent on staff; however, she could move one of her arms and was able-bodied enough to reach and turn herself to a certain degree. The DON stated Resident #1 communicated her needs primarily through typing words or using sounds on her tablet, and she would bang, tap, wave, or use the call light to get staff's attention. She stated Resident #1 would also send a message to her RP through the tablet to communicate any needs, and the RP would then call the facility. The DON stated Resident #1 had multiple ways of getting help; however, the call light was still expected to be within the resident's reach when she was in bed. The DON stated the CNAs did rounds at least every two hours and as needed, and it was protocol for them to ensure the call lights were within reach before leaving the rooms. The DON stated the risk of not ensuring residents were able to reach their call lights could place them at risk of not receiving help when needed. In an interview on [DATE] at 2:51 PM, Resident #1's RP stated she had concerns staff sometimes forgot about the resident. The RP stated Resident #1 used the call light to get assistance and if she could not reach the call light, she would tap on the table or use sound on her tablet. The RP stated Resident #1's room was at the end of the hall, so staff did not always hear the tapping or sounds from the tablet if they were at the nurses' station, and she worried they would forget to check on her. The RP stated she visited Resident #1 often and would find the call light out of the resident's reach. She stated there was also a monitor in Resident #1's room and she could see when the resident needed help and was unable to reach her call light, so she would call the facility. The RP stated this concern had been addressed with the facility several times and it would only get better for a little while. Record review of the facility's Resident Rights policy, revised [DATE], reflected in part the following: Policy Statement: Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and ImplementationFederal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.communication with and access to people and services, both inside and outside the facility.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. Dietary staff failed to ensure the ice machine scooper was clean and sanitized. These deficient practices could place residents at risk for cross-contamination and foodborne illness.Findings included: Observation on 09/09/2025 from 9:10 AM to 9:45 AM in the facility's kitchen revealed: One wrapped bag of powdered sugar on the top shelf, labeled with a prep date of 09/02/25, with a use by date of 09/08/25. Three stainless steel containers of Mushrooms on the middle shelf in one of the refrigerators, labeled 09/04, with a use by date of 09/07. The Ice machine scooper bin was cracked and had a thick calcium buildup around the bottom. During an interview on 09/11/2025 at 1:00 PM, DD stated has been a DD, about 6 years. DD acknowledged the surveyor observations. The DD stated he is responsible to ensure for kitchen sanitation and proper storage of food products and the deficient practices were oversighted. DD stated the powdered sugar item appeared to be out of place based on where it was located by surveyor and DD, further one of staff probably picked it up and inadvertently put it down and went about doing something and forgot about it being there. DD stated the risk of all the concerns observed in the kitchen could result in residents getting sick. DD stated the risk of the concerns not being addressed could result in food-borne illnesses. DD stated if food items were not dated when they opened then they will not be able to know how long they will last. Items stored in the refrigerator must be dated upon receipt, unless they contain a manufacturer use by, sell by, best by date, or a date delivered. DD stated the fridge, and freezer should be checked daily for spoiled foods.During an interview on 09/11/2025 at 2:49 PM, the ADMIN stated oversaw all departments, and ensured residents were taken care of. The ADMIN stated the policy or procedure for storing food was, everything needed to be dated, and if opened it needed to have an open date and an expiration date. ADMIN stated the risk to residents, if the policy was not followed was, they could get sick from food borne illnesses. The ADMIN stated he expected staff to ensure they followed the policies and procedures of the facility kitchen policy, to protect residents and to deliver good care.Record review of the facility's Food-Supply Storage-Food and Nutrition Services Policy, dated 05/19/2025, indicated USE By/USE or Freeze By* (expiration date) -This is used on Time/temperature Control for Safety Foods (TCS). Safety phrasing will inform customers that these products should be consumed on or before the date listed on the package. The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. This date label is for perishable products with potential safety implications or material degradation of critical performance, such as nutrition. BEST If Used By/BEST If Used or Freeze By* - Quality phrasing will indicate to consumers that after the specified date, the product may not taste or perform as expected but is safe to use or consume. For example, the quality of the product taste or texture may have diminished slightly, or it may not have the full vitamin content indicated on the package. Best if used by/Best if Used or Freeze By dates such as sell by or best if used by, are not expiration dates. Refer to USDA guidance on Shelf-Stable Food Safety (www.fsis.usda.gov). Time/temperature control for safety food (TCS)-A food that requires time/temperature control for safety (TCS) to limit pathogenic microorganism growth or toxin formation. Leftovers-Food items prepared for service that were not served subsequently stored for use within seven days per Food Code. Check state regulations for more detail. 6. Storeroom layout:Foods that have been opened or prepared are placed in an enclosed container, dated, labeled, and stored properly.7. The items being prepared for the next meal do not have to be dated and labeled but must be covered. Once meal service is over, cover, date, and label trays of individually portioned items such as desserts, salads, glasses of juice, milk, and supplements.8. Use By and Freeze By (expiration) dates are checked on a regular basis; foods/fluids that have expired or are otherwise unsafe for use are discarded.9. In addition, once opened, all food items must be clearly labeled and dated. Time/temperature control for safety (TCS) foods must be used or discarded within 7 days of opening or preparation(including the day of preparation). Specific product categories follow USDA/FDA guidance, such as dairy products and deli meats 3 days, juices 7 days, frozen opened items 6 months to 12 months,Record review of the U.S. Food and Drug Administration (FDA ) Code (2022) revealed, Packaged Food shall be labeled as specified in law, including 21 CFR 101 Food Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306.

Based on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS for fiscal year 2025 for the first quarter (October 1, 2024, to December 31, 2024) reviewed for one of one facility administration reviewed.The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024.This failure could place all residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. Findings Included: Record review of the Casper3 PBJ report (CASPER Certification and Survey Enhanced Reporting) revealed the facility had four areas triggered on the FY Quarter 1 (October 1 - December 31) report. The areas were One Star Staffing Rating, which refers to (A quality rating system that gives each nursing home a rating of between 1 and 5 stars. Nursing homes with 5 stars are considered to have much above average quality and nursing homes with 1 star are considered to have quality much below average.) Excessively low Weekend Staffing, No RN hours, and Failed to have Licensed Nursing Coverage 24 hours/day. The report details no RN hours for every day in October 2024. It also details Failed to have Licensed Nursing Coverage 24 hours/day for every day in October 2024. During an interview on 09/11/2025 at 1:32 PM with the DON. The DON stated she has been here for 4 years at this facility as the DON. The DON stated was working during the month of October and there would have been no days without a working RN. The DON stated she was unaware of any issues and would pull the working schedule for the specified time. During an interview on 09/11/2025 at 2:00 PM HR stated has been the HR have been here for about a year and half. Does the facility use a vendor to submit information on behalf of the nursing home is still ultimately responsible for meeting all the requirements. I collect the data and send it up to corporate, and they send the information. HR stated so for 10/1/24 - 10/31/24 we just could not get anything even employee files from the previous owners.During an interview on 09/11/2025 at 2:52 PM The ADMIN stated he has been the ADMIN for approximately 11years. ADMIN stated they were aware the PBJ data had not been submitted for the quarter 1 to CMS. The ADMIN stated the facility had a change of ownership effective November 1, 2024. The previous company stated they would submit the PBJ data to CMS. ADMIN stated this has been an on-going issue with the previous owner. He stated that the corporate office enters the PBJ information. He stated that this was the only month with this error and was related to the change from one company to the new company and does not expect any issues in the future. The ADMIN stated their corporate offices were currently in the process of getting this rectified. Record review of PBJ data submission policy attempted / requested verbally on 09/09/2025 at 12:45 PM with the ADMIN. A follow up request via email was sent to the ADMIN & DON on 09/11/25 at 11:10 AM for PBJ Submission, Facility Assessment RN Hours / Staffing, and RN Coverage for the specified dates covering Quarter 1 (October 1 - December 31). The policy was not provided prior to the exit. Requested time sheets, and Punch Detail reports were requested from DON and ADMIN and were not provide prior to exit.

Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for four (Resident #7, Resident #9, resident #35, and Resident #37) of fifteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #7's care plan for diabetes, dated 08/25/2025, had appropriate interventions. 2. The facility failed to ensure Resident #7 was care planned for hypertension. 3. The facility failed to ensure Resident #9's care plan for diabetes, dated 08/25/2025, had appropriate interventions. 4. The facility failed to ensure Resident #35 was care planned for hypertension. 5. The facility failed to ensure Resident #37 was care planned for hyperlipidemia. These failures could place the residents at risk of not receiving the necessary care and services needed. Findings included: 1. Record review of Resident #7's Face Sheet, dated 09/10/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with type 2 diabetes mellitus (high blood sugar) and long-term use of insulin. Record review of Resident #7's Quarterly MDS Assessment, dated 06/08/2025, reflected the resident had moderate impairment (resident may need additional support and monitoring) in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #7's Comprehensive Care Plan, dated 08/25/2025, reflected that the interventions for the resident's diabetes were to check all body parts, licensed nurse to provide foot care, and ensure socks were dry. The care plan did not reflect that the resident was taking medications for diabetes, to have a dietary consult, to check the fasting blood sugar, and to monitor for signs and symptoms of hyperglycemia (high blood sugar) and hypoglycemia (low blood sugar). Record review of Resident #7's Physician Order, dated 08/27/2024, reflected Insulin Lispro Solution (man-made insulin to treat diabetes) 100 UNIT/ML. Inject subcutaneously (administer under the skin) before meals and at bedtime for DM2 (Type 2 diabetes: adult-onset diabetes). 2. Record review of Resident #7's Face Sheet, dated 09/10/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension (high blood pressure). The Face Sheet indicated to call MD's office and notify if systolic less than 110. Record review of Resident #7's Quarterly MDS Assessment, dated 06/08/2025, reflected the resident had moderate impairment in cognition with a BIMS score of 10. The Comprehensive MDS Assessment indicated the resident had hypertension for the last seven days. Record review of Resident #7's Comprehensive Care Plan on 09/10/2025 r reflected no care plan for hypertension. Record review of Resident #7's Physician Order, dated 12/04/2021, reflected Cozaar tablet (Losartan Potassium). Give 12.5 mg by mouth once a day for hypertension. 3. Record review of Resident #9's Face Sheet, dated 09/10/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed last 12/22/2023 with type 2 diabetes with diabetic neuropathy (nerve damage due to diabetes). Record review of Resident #9's Comprehensive MDS Assessment, dated 06/30/2025, reflected the resident had severe impairment (resident required significant assistance and support in daily life) in cognition with a BIMS score of 03. The Comprehensive MDS Assessment indicated the resident had diabetes mellitus. Record review of Resident #9's Comprehensive Care Plan, dated 08/25/2025, reflected that the interventions for the resident's diabetes were to observe the resident and family's ability to manage the treatment and to encourage resident to practice good general health practices. The care plan did not reflect that the resident was taking medications for diabetes, to have a dietary consult, to check the fasting blood sugar, and to monitor for signs and symptoms of hyperglycemia and hypoglycemia. Record review of Resident #9's Physician Order, dated 09/09/2025, reflected Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Lispro). Inject subcutaneously before meals for elevated A1C (test done to check the amount of sugar in the blood). Record review of Resident #9's Progress Notes, dated 08/16/2025, reflected Note Text: Humalog KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML . no insulin required; 141. Record review of Resident #9's Progress Notes, dated 08/21/2025, reflected Patient is stable . n/o received for insulin lispro 5U SQ before meals. 4. Record review of Resident #35's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with hypertension. Record review of Resident #35's Quarterly MDS Assessment, dated 08/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had hypertension. Record review of Resident #35's Comprehensive Care Plan on 09/10/2025 reflected no care plan for hypertension. Record review of Resident #35's Physician Order, dated 08/21/2021, reflected Lisinopril Oral Tablet 20 mg. Give 1 tablet by mouth once a day. 5. Record review of Resident #37's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted on the facility on 09/03/2025. The resident was diagnosed with hyperlipidemia (high cholesterol in the blood). Record review of Resident #37's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had hyperlipidemia. Record review of Resident #37's Comprehensive Care Plan on 09/10/2025 reflected no care plan for hyperlipidemia. Record review of resident #37's Physician order, dated 09/03/2025, reflected Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day for HLD (high density lipoprotein: good cholesterol). In an interview on 09/11/2025 at 7:18 AM, the MDS Coordinator stated she was responsible in doing the care plans of the residents. She said, without the care plans, the staff might not be in sync in terms of care. She said, she felt that if there was already an order and the staff were already doing the treatment, there was no need to put them in the care plan. She said, what should be in the care plan were what else needed to be done and if the resident was doing differently. She said, care plans were to guide care not covered in the orders. She said, do not see what referring back to the care plan will help. She said, she feels like checking the boxes was just to feel in the boxes. She said, if all the conditions of the residents were care planned, if could produce more than a 20-page care plan. In an interview on 09/11/2025 at 7:43 AM, the DON stated the care plan was the living document of what care were being done for the resident. She said the care plan complimented the orders and supplemented the care provided. She said the care plan should be person-centered and should contain the problem, the goals, and the interventions. She said the care plan should be tangible and specific. She said care plans also make it possible that all the providers taking care of the residents would be on the same page. She said if the resident was diabetic, the care plan should reflect that the resident was being checked for blood sugar and was taking insulin. She said if the resident was hypertensive, there should be a care plan for hypertension. She said the MDS Coordinator was mainly responsible in doing the care plan but she did help. She said she would coordinate with the MDS Coordinator to check and audit the care plans of the residents. In an interview on 09/11/2025 at 8:45 AM, the ADON stated care plans were done so the staff would know the care needed by the residents. She said if a resident had was diabetic, the care plan should indicate that the resident was on insulin therapy or receiving oral medications for diabetes. She said the intervention should also reflect that blood sugars were being checked. She said if the resident had hypertension and whatever else condition they had should be care planned. She said she was not that familiar with care plan and would coordinate with the DON and the MDS Coordinator about the issue. In an interview on 09/11/2025 at 2:50 PM, the Administrator asked, Are the residents not being cared for? Record review of facility's policy, Care Plans, Comprehensive Person-Centered Strategy, Delivery, Performance revised 08/2024 reflected Policy Statement: A comprehensive, person-centered care plan . is developed and implemented for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 10. Identifying problem areas and their causes and developing interventions that are targeted and meaningful . 9. Care plan interventions are chosen only after careful data gathering . 10. When . interventions address the underlying source(s) of the problem area(s).

Based on observations, interviews, and record review, the facility failed to secure confidential medical records for three (Resident #16, Resident #21, and Resident #61) of eighteen residents reviewed for resident rights. The facility failed to ensure LVN I secured Resident #16, Resident #21, and Resident #61's medical information before leaving her cart on 09/10/2025. This failure could place the residents at risk of not having their medical information exposed to unauthorized individuals. Resident #16 Record review of Resident #16's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with infection and inflammatory reaction due to other internal joint prosthesis (artificial device that replaces a missing body part). Record review of Resident #16's Comprehensive MDS Assessment (assessment used to determine functional capabilities and health needs), dated 09/02/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needs little support) with a BIMS (screening tool used to assess cognitive status) score of 14. The Comprehensive MDS Assessment indicated the resident had an infection and inflammatory reaction due to other internal joint prosthesis. Record review of Resident #16's Comprehensive Care Plan, dated 09/09/2025, reflected the resident had infection to right shoulder and one of the interventions was to administer antibiotic as per MD orders. Record review of Resident #16's Physician Order, dated 08/29/2025, reflected Admit to skilled level of care (a level of care designed for individuals with complex medication that needed a high level of care) on 8/29/25. Record review of Resident #16's Physician Order, dated 08/30/2025, reflected Daptomycin (antibiotic used to treat bacterial infection) Intravenous Solution Reconstituted (Daptomycin). Use 300 mg intravenously one time a day for Post surgical right shoulder for 13 Days. Record review of Resident #16's Progress Notes, dated 09/01/2025, reflected Continue with IV (intravenous: administering fluids or medications directly into a vein) . transferred to . for skilled nursing care. Resident #21 Record review of Resident #21's Face Sheet, dated 09/09/2025, reflected an [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with acute kidney failure and retention of urine. Record review of Resident #21's Comprehensive MDS Assessment, dated 09/08/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had acute kidney failure (kidneys stop working) and retention of urine. Record review of Resident #21's Comprehensive Care Plan, dated 09/03/2025, reflected the resident had renal insufficiency (kidney unable to filter waste from the blood) and one the interventions was to monitor laboratory results. Record review of Resident #21's Physician Order, dated 09/02/2025, reflected Admit to skilled level of care on 9/2/25. Record review of Resident #21's Physician Order, dated 09/08/2025, reflected Culture, Urine | Automated Urine - UA one time only related to RETENTION OF URINE . ACUTE KIDNEY FAILURE. Record review of Resident #21's Physician Order, dated 09/09/2025, reflected Zinc oxide to perineum (area between the thighs) and buttocks, turn and reposition when in bed as needed every shift for Redness . Order Type: . TAR. Record review of Resident #21's Progress Notes, dated 09/08/2025, reflected New order . UA . Record review of Resident #21's Progress Notes, dated 09/10/2025, reflected Skin note: Zinc applied to perineum and buttock redness. Resident #61 Record review of Resident #61's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture (broken bone) to right foot. Record review of Resident #61's Comprehensive MDS Assessment, dated 09/09/2025, reflected the resident cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated the resident had a fracture related to fall. Record review of Resident #61's Comprehensive Care Plan, dated 4/12/2025, reflected had pain due to fracture to right foot and one of the interventions was to monitor was to administer analgesia (pain relief medication) as ordered. Record review of Resident #61's Physician Order, dated 09/04/2025, reflected Admit to skilled level of care on 9/4/25. Record review of Resident #61's Progress Notes, dated 09/05/2025, reflected Skilled Evaluation. An observation on 09/10/2025 at 6:52 AM revealed LVN I left her cart and went inside a resident's room. A piece of paper was on top of the cart that was parked in front of the nurses' station and was facing the hallway. On the piece of paper was some of Resident #16, #21, and #61's medical information. The piece of paper revealed that Resident #16 was on skilled nursing and needed urinalysis; Resident #21 was on skilled nursing, antibiotics, and to change the order of zinc in his TAR; and Resident #61 was on skilled nursing. During an observation and interview on 09/10/2025 at 7:02 AM, LVN I stated she always wrote what she needed to do for her shift on a piece of paper, so she had a brief summary of the things needed to monitor or accomplish. She said she would list who was on skilled nursing, any new orders, or which resident was on antibiotics. She said she would also write down their blood sugar. She said the numbers on the piece of paper were the residents' blood sugar. She said she was not sure if what she wrote was medical information. She said, she guessed she should have flipped the paper before she left her cart if it contained medical information. In an interview on 09/11/2025 at 7:43 AM, the DON stated if what was written on the piece of paper was medical information of the residents, then it should not be left unattended because some of the visitors were lay persons, and did not have an idea of what was written on the piece of paper, but some would be clinicians that would have a good idea of what was written. She said if confidential information were left unattended, unauthorized personnel could had access to them. She said she would do an in-service about confidentiality of records. In an interview on 09/11/2025 at 8:45 AM, the ADON stated the medical information of any resident should not be left unattended because they were confidential and could be a HIPAA violation. She said, before leaving the cart, the staff should have secured it somewhere so unauthorized individuals would not see them. She said visitors were not all lay persons, but others could be nurses, paramedics, or pharmacist that could clearly understand what was written on the paper. She said she would coordinate with the DON to do an in-service about privacy and confidentiality. Record review of the facility's policy entitled, Confidentiality of Information and Personal Privacy Strategy, Delivery, Performance revised 8/2024 reflected Policy Statement: Our facility will protect and safeguard resident confidentiality and personal privacy . 1. The facility will safeguard the personal privacy and confidentiality of all resident personal and medical records.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for five (Residents #4, #6, #32, #35, and #43) of twelve residents reviewed for infection control. 1. The facility failed to ensure CNA B wore a gown when she transferred Resident #4, who had a catheter, from bed to wheelchair on 09/09/2025. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene and changed their gloves after touching Resident #6's catheter tubing on 09/10/2025. 3. The facility failed to ensure CNA F performed hand hygiene and did not put gloves in her pocket when she assisted Resident #32 on 09/10/2025. 4. The facility failed to ensure LVN A wore a gown when she administered Resident #35's IV on 09/09/2025. 5. The facility failed to ensure PTA D and PT E wore a gown while assessing, repositioning, and trying to transfer Resident #43, who had a surgical wound, on 09/09/2025. These failures could place residents at risk of cross-contamination and development of infections. Findings included: 1. Review of Resident #4's Face Sheet, dated 09/09/2025, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder (the muscles and nerves that control the bladder do not work properly due to illness). Review of Resident #4's Comprehensive MDS Assessment, dated 06/20/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had an indwelling catheter (device that drains urine from the urinary bladder). Review of Resident #4's Comprehensive Care Plan, dated 09/09/2025, reflected the resident required enhanced barrier precaution. Record review of Resident #4's Physician Order, dated 10/10/2024, reflected CATHETER: 18 fr (French: unit of measurement for catheter sizes)with 10 cc balloon to dependent drainage. Change catheter PRN if dislodged or plugged and unable to clear with irrigation. Observation and interview on 09/09/2025 revealed Resident #4 was in her bed, awake. She stated she had the catheter since last year. It was also observed that there was sign outside the resident's door that EBP was required during transfer. Observation and interview on 09/09/2025 at 12:03 PM revealed CNA B was walking towards Resident #4's room. She said she would get the resident to eat lunch at the dining area. She went inside the room without wearing a gown. Observation on 09/09/2025 at 12:07 PM revealed there was no PPE cart inside Resident #4's room. Observation and interview on 09/09/2025 at 12:18 PM revealed Resident #4 was on her wheelchair waiting for her lunch in the dining area. She stated she was transferred to her wheelchair from her bed before lunch. She said the staff that transferred her did not have a gown during transfer. In an interview on 09/09/2025 at 12:39 PM, CNA B stated she did transfer Resident #4 from her bed to wheelchair to go to the dining area to eat lunch. She said she did not wear a gown when she transferred the resident. She said she should have worn a gown when she transferred the resident because there was an EBP sign on the resident's door that specified to wear a gown during transfer. She said her action could cause cross contamination and infection. 2. Record review of Resident #6's Face Sheet, dated 09/10/25, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with neuromuscular dysfunction of bladder. Record review of Resident #6's Comprehensive MDS Assessment, dated 07/13/2025, reflected the resident was cognitively intact with a BIMS score of 14. The Comprehensive MDS Assessment indicated that the resident had an indwelling catheter. Record review of Resident #6's Comprehensive Care Plan, dated 10/06/2025, reflected the resident had a catheter and one of the interventions was to monitor for signs and symptoms of UTI. Observation on 09/10/2025 at 10:26 AM revealed Resident #6 just came back from her shower and would be transferred to her bed via mechanical lift. It was observed that the resident had a catheter. CNA F and CNA G transferred the resident to her bed, and both started to detach the sling from the mechanical lift. CNA G hung the resident's catheter on the railing below the bed. Both CNAs changed their gloves, but CNA G did not sanitize her hands before putting on a new pair of gloves. They assisted the resident to roll on her right side. CNA F rolled the draw sheet along with the sling towards the center of the bed. While the resident was still on her right side, CNA F took off her gloves, sanitized her hands, put on a pair of gloves, and put the brief under the resident. After putting the brief under the resident, they assisted the resident to turn on the other side so CNA G could pull the draw sheet and the sling for the mechanical lift. While in the process of pulling the draw sheet and the sling, both CNAs touched the tubing of the catheter to adjust so the draw sheet and the sling could be pulled. After touching the tubing of the catheter, CNA F proceeded to fix the brief some more. She did not change her gloves after touching the tubing of the catheter. After pulling the draw sheet and the sling, CNA G changed her gloves but did not sanitize her hands before putting on the new pair of gloves. In an interview on 09/10/2025 at 10:40 AM, CNA F stated she thought the tubing of the catheter was clean because Resident #6 just came out of the shower. She said she guessed she should have changed her gloves because the tubing might still be dirty and could result in cross contamination and infection. In an interview on 09/10/2025 at 10:46 AM, CNA G stated she did change her gloves several times but did not sanitize her hands. She said it was important to sanitize the hands before putting on a new pair of gloves to ensure the hands were clean before touching the new pair of gloves. She said sanitizing the hands in between changing of gloves should be done to prevent infection. 3. Record review of Resident #32's Face Sheet, dated 09/11/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #32's Comprehensive MDS Assessment, dated 07/11/2025, reflected the resident had a severe impairment in cognition with a BIMS score of 03. The Quarterly MDS Assessment indicated the resident needed moderate assistance for toileting hygiene. Record review of Resident #32's Comprehensive Care Plan, dated 08/04/2025, reflected the resident had an ADL self-care performance deficit related to weakness and one of the interventions was to assist during transfer. Observation on 09/10/2025 at 8:40 AM revealed CNA F was ushering Resident #32 to her room. She said the resident wanted to go to the bathroom. Once inside the room, she pulled a pair of gloves from her pocket, put them on, and assisted the resident to transfer to the toilet bowl. She did not do hand hygiene before putting on a pair of gloves that she pulled from her pocket. After transferring the resident to the toilet bowl, she lowered the resident's pants and took the resident's brief that was already unfastened. She placed the brief in a plastic bag. She took off her gloves and said she would wait for the resident to be done inside the room. While waiting, she took some gloves from the box of gloves on the wall and put them inside her pocket. When the resident was done, she pulled a pair of gloves from her pockets, put them on, and put a new brief on the resident. In an interview on 09/10/2025 at 8:51 AM, CNA F stated she did put some gloves in her pocket, but she was not sure if her pocket was clean. She said she guessed her pocket was not clean because she would put her keys, and sometimes money in her pocket. She said she would not put gloves inside her pocket again and would just get them from the box to make sure she was using clean gloves. 4. Record review of Resident #35's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with infection following a procedure. Record review of Resident #35's Comprehensive MDS Assessment, dated 08/23/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated that the resident had a wound infection and was receiving antibiotics. Record review of Resident #35's Comprehensive Care Plan, dated 08/19/2025, reflected the resident required enhanced barrier protections related to infection to surgical wound. Record review of Resident #35's Physician Order, dated 08/20/2025, reflected Ceftriaxone Sodium Injection Solution Reconstituted 2 GM. Use 2 gram intravenously once daily. Record review of Resident #35's Physician Order, dated 08/19/2025, reflected IV-PICC Normal Saline Flush Solution 0.9 % 10 mL RUE every shift for patency (the tube was not blocked). Record review of Resident #35's Progress Note, dated 09/10/2025 reflected PICC line is patent. PICC dressing intact. Observation on 09/09/2025 at 11:45 AM revealed LVN A went inside the room to connect Resident #35's IV antibiotics. She did not wear a gown before going inside the room. A signage was posted on the resident's door that said to wear a gown for use of central line. Observation and interview on 09/09/2025 at 11:50 AM, revealed Resident #35 was in her bed receiving IV antibiotics. She said she had a surgical wound to the back of her neck that got infected and that was why she was getting an antibiotic. She said she did not notice if the nurse that connected the IV was wearing a gown or not and then she said she was not wearing the yellow gown. It was also observed that there was no PPE cart inside the resident's room. Observation and interview on 09/09/2025 at 11:55 AM, LVN A stated she would disconnect Resident #35's IV that she earlier connected. She went inside the room and went straight to the IV pole. She did not wear a gown before entering the room. When she was about to disconnect the IV, she saw that the IV antibiotics was not yet done. She said she would come back to check if the antibiotics was done. Observation and interview on 09/09/2025 at 12:13 PM, LVN A said she would disconnect Resident #35's IV antibiotics because it was done already. She went inside the room holding a saline syringe. Before she entered the room, LVN A was observed looking at the sign posted on the resident's door. After looking at the signage, she took a gown from the PPE cart and wore it before entering the room. She disconnected the IV and flushed it afterwards. In an interview on 09/09/2025 at 1:52 PM, LVN A stated she connected the IV antibiotics without a gown, went inside the room to disconnect the IV the first time and she also did not wear a gown. She said Resident #35 had an IV and that was why she was on EBP. She said the EBP was for residents with IV to prevent cross contamination and infection. 5. Record review of Resident #43's Face Sheet dated 09/10/2025, reflected a [AGE] year-old male admitted to the facility on [DATE]. The resident was diagnosed with presence of artificial knee joint. Record review of Resident #43's Comprehensive MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Comprehensive MDS Assessment indicated the resident had a joint replacement surgery. Record review of Resident #43's Comprehensive Care Plan, dated 09/09/2025, reflected the resident required enhance barrier precautions related to wound to right knee. Record review of Resident #43's Physician Order, dated 09/08/2025, reflected WOUND CARE: Surgical wound to Right knee- keep dressing clean dry and intact. Monitor for s/s of infection every shift for post-surgical. Record review of Resident #43's Physician Order, dated 09/08/2025, reflected PT . to evaluate . Observation and interview on 09/09/2025 at 9:16 AM revealed Resident #43 was in his bed, awake. It was observed that the resident had a bandage on his right knee. He said he just had surgery for a knee replacement. He said he was just admitted the day before. It was also observed that there was a sign outside the resident's door indicating that EBP was required during transfer. Observation on 09/09/2025 at 11:36 AM revealed PTA D and PT E went inside Resident #43's room. They both did not wear a gown. Observation and interview on 09/09/2025 at 11:39 AM revealed LVN A stood up because she said she could hear somebody in pain. She said it looked like it was coming from Resident#43's room. She opened the door and saw PTA D and PT E inside the room. PTA D was on the right side of the resident while PT E was on the left side. The resident was observed in a slant position and PT E was fixing the resident's bed linens. Both staff had gloves on and were holding the resident. LVN A said the physical therapist was assessing the resident. She said they were trying to get him up. She said she was not sure if they needed to wear a gown. In an interview on 09/09/2025 at 11:43 AM, PTA D stated they were assessing Resident #43 to see how far he could go. She said they were trying to sit him up and see if he could transfer to the wheelchair. In an interview on 09/09/2025 at 11:44 AM, PT E stated they were doing an initial assessment to evaluate Resident #43's condition and what were the resident's current capabilities. He said they were trying to transfer the resident and sit him up, but the resident was still in pain, so they were repositioning him back. He said he did not think he needed to wear a gown because the surgery site was wrapped, and they were wearing gloves. In an interview on 09/09/2025 at 12:36 PM, Resident #43 stated he was assessed by the physical therapists. He said they were trying to get him up or see how far he could go in terms of transferring. He said they tried to sit him up, one staff on his feet and the other on his back. In an interview on 09/11/2025 at 7:43 AM, the DON stated the gloves should not be placed inside the pockets because the pockets were not always clean. She said using gloves from the pocket was like using soiled gloves. She said the staff must do hand hygiene before putting on a pair of gloves because the gloves were porous, and drainage or contaminants could seep inside making the hands unclean. She said the staff should do hand hygiene before and after any care. She said the gloves should have been changed after touching the catheter tubing. She said when transferring a resident with a catheter, the staff should wear gloves and a gown because the resident was on EBP. She said it was tricky with therapy but if they were doing a high contact activity inside the room, like repositioning the resident with surgical wound, they should have worn a gown. She said she was not sure about administering antibiotics via IV because the staff was not touching the resident. She said the issues discussed could lead to cross contamination and probable infection. She said the expectation was for the staff to give the best care. She said another expectation was for the staff to communicate if they were not sure of what they were supposed to do. She said she would do an in-service pertaining to infection control focusing on all the issues discussed. She said she would closely monitor the staff with their compliance to the policy of infection control. In an interview on 09/11/2025 at 8:45 AM, the ADON stated staff must perform hand hygiene before doing any care so not to transfer any germs that they may have on their hands. She said staff must sanitize their hands before putting on a new pair of gloves because the gloves have small holes in them and fecal or wound drainage could seep inside the gloves rendering the hands dirty. She said the pocket was not a place to put the gloves because it was where the car keys, money, snacks, and dirty hands were. She said the pocket was not always clean. She said the gloves should have been changed when the tubing of the catheter was touched even if the resident just came out from the shower because it was a passage for urine. She said EBP should be worn during transfer of a resident with a catheter, repositioning, and bed mobility of a resident with a surgical wound and, IV use. She said the purpose of an EBP was to not carry any microorganism from one resident to another. She said EBP was used to prevent the spread of MDRO around the facility. She said the expectation was for the staff to be mindful and compliant with the policy of infection control. She said she would coordinate with the DON to do an in-service about infection control, and she would closely monitor the staff compliance since she was the IP. In an interview on 09/11/2025 at 2:50 PM, the Administrator stated will let the DON handle the issue of infection control. Record review of the facility's policy Handwashing/Hand Hygiene Strategy, Delivery, Performance revised 08/2024 reflected Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of infections . Policy Interpretation and Implementation . 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . 7. Use an alcohol-based hand rub . b. Before and after direct contact with residents . e. Before and after handling an invasive device (e.g., urinary catheters .). Record review of the facility's policy Enhanced Barrier Precaution undated reflected Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities . expand the use of PPE to donning of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands and clothing . Wounds include . unhealed surgical wounds . Indwelling medical device examples central line, urinary catheter . [NAME] Gloves and Gown . transfer a resident . Yes .Turn and Reposition or assist with bed mobility . Yes . Device care or use: central line . Yes.

Based on observations, interviews, and record review, the facility failed to ensure that medications were stored properly in locked compartments for 4 (Resident #11, Resident #37, Resident #44, and Resident #60) of eighteen residents reviewed for medication storage, 1. The facility failed to ensure Resident #11's zinc oxide (medicated cream used to prevent skin irritation) was not left inside the resident's room on 09/09/2025. 2. The facility failed to ensure LVN A did not leave Resident #37's tramadol inside the resident's room for the resident to take unsupervised on 09/09/2025. 3. The facility failed to ensure Resident #44's zinc oxide was not left inside the resident's room on 09/09/2025. 4. The facility failed to ensure Resident #60's xeroform, petroleum dressing, and calcium alginate were not left inside the resident's room on 09/09/2025. These failures could place the residents at risk of accidental overdose or misuse of medications. Findings included: 1. Record review of Resident #11s Face Sheet, dated 09/10/2025, reflected an [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness. Record review of Resident #11's Comprehensive MDS Assessment, dated 07/24/2025, reflected the resident was cognitively intact with a BIMS score of 14.The Comprehensive MDS Assessment indicated the resident was incontinent for bowel and bladder and was at risk of developing pressure ulcers/injuries. Record review of Resident #11's Comprehensive Care Plan, dated 08/13/2025, reflected the resident had incontinence and one of the goals was for the resident to be free from skin breakdown. Record review of Resident #11's Physician Order on 09/09/2025 reflected no order for barrier cream. Observation on 09/09/2025 at 9:18 AM revealed Resident #11 was not inside the room. It was observed that a tube of zinc oxide was on the resident's side table. In an interview on 09/09/2025 at 12:39 PM, CNA B stated she did not notice that the zinc oxide was at Resident #11's side table when she did her morning round. She said she did not do the resident's incontinent care because the resident was already up. She said the zinc oxide should be inside the drawer of the resident's side table when not in use because the resident might consume it. She said it should be not within the reach of any resident for their safety. 2. Record review of Resident #37's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted on the facility on 09/03/2025. The resident was diagnosed with fracture to right femur and acute pain due to trauma. Record review of Resident #37's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had fracture and had acute pain. Record review of Resident #37's Comprehensive Care Plan, dated 09/04/2025, reflected the resident had acute pain related to fracture and one of the interventions was to monitor the effectiveness of the pain interventions. Record review of Resident #37's Physician Order, date 09/03/2025, reflected Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain. Observation and interview on 09/09/2025 at 9:21 AM revealed Resident #37 was in her bed, awake. It was observed that there was a small plastic cup, with one pill inside, on the resident's food tray. The resident took the cup and took the medication. She said the nurse left it there and told her to take the medication after she was done with breakfast. She said the medication was a tramadol. In an interview on 09/09/2025 at 1:52 PM, LVN A stated Resident #37 requested for a tramadol and she gave her one as her PRN. She said she should have made sure that the resident swallowed the tramadol before leaving the resident because the resident might not take them, throw them, or choke while taking them and no one would know. She said it was a controlled substance and a resident who was allergic to tramadol might get a hold of it. 3. Record review of Resident #44's Face Sheet, dated 09/10/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with muscle weakness and needed assistance for personal care. Record review of Resident #44's Quarterly MDS Assessment, dated 08/25/2025, reflected the resident was cognitively intact with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident was incontinent for bowel and bladder. Record review of Resident #44's Comprehensive Care Plan, dated 08/27/2025, reflected the resident had incontinence and one of the goals was for the resident to be free from skin breakdown. Record review of Resident #44's Physician Order on 09/09/2025 reflected no order for barrier cream. Observation and interview on 09/09/2025 at 9:14 AM revealed Resident #44 was in her bed, awake. It was observed that there was a tube of zinc oxide on the resident's side table. She said the aides use the cream after they clean her bottom. She said the tube of zinc oxide had always been on the table. In an interview on 09/09/2025 at 12:48 PM, CNA C stated she did not notice the tube of zinc oxide on Resident #44 side table when she did her round. She said the resident was done with her incontinent care when she came. She said when she did the resident's incontinent care, she saw the tube of zinc oxide at the resident's side table, and she did not know who left it there. She said she placed the zinc oxide inside the resident's side table drawer when she was done providing incontinent care. She said the resident might eat the cream and it could be harmful to the residents. 4. Record review of Resident #60's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with history of falling. Record review of Resident #60's Quarterly MDS Assessment, dated 08/08/2025, reflected the resident had severe impairment in cognition with a BIMS score of 04. The Quarterly MDS Assessment indicated the resident had a skin tear. Record review of Resident #60's Care Plan, dated 09/08/2025, reflected the resident had a skin tear and one of the interventions was to treat the skin tear. Record review of Resident #60's Physician Order, dated 09/04/2024, reflected WOUND CARE: skin tear to RUE and forearm cleanse with vashe solution, pat dry, apply oil emulsion dressing to wound bed and open skin flaps, then calcium alginate, wrap with kerlix and secure with tape every day shift every other day forskin tears. Observation on 09/09/2025 at 9:10 AM revealed Resident #60 was not inside the room. It was observed that there were several materials for wound care, such as xeroform, alginate dressing, petroleum dressing, on top of the resident's dresser. One of the packaging had an instruction Caution: The Packaging of This Product Contains Natural Rubber Latex Which May Cause Allergic Reactions. Observation and interview on 09/09/2025 at 12:20 PM, LVN A stated Resident #60 had a skin tear to his right arm. She said she did not know who left the wound care materials on top of the resident's dresser. She said it should be inside the cart or inside the resident's drawer. She said residents might get hold of them and consume them. She said the dressings were medicated dressing that were applied topically to facilitate healing of the wound but might have a different effect when ingested. She said residents might be allergic to them. She gathered the wound care materials and said she would put them in the cart. She said the wound care materials were also accessible to other residents and they could accidentally consume them as well. In an interview on 09/11/2025 at 7:43 AM, the DON stated zinc oxide, and the medicated dressing should not be within reach of the residents because of the possibility of the residents consuming it. She stated they may only present little risks when ingested but there was still a risk. She said the residents might be allergic to them when consumed or used differently. She said the zinc oxide should be stored along with the wound care materials inside the carts. She said the expectations were for the staff to always scan the residents' rooms to make sure they were not leaving the tubes of zinc oxide and materials for wound care. She said she would do an in-service about storing medications accordingly. In an interview on 09/11/2025 at 8:45 AM, the ADON stated the zinc oxide should be inside the drawer or somewhere the residents could not access them. She said the materials for wound care should be inside the cart and not left inside the room after wound care. She said confused residents might mistake them as something that could be eaten and could result in upset stomach. She said the expectation was for the staff to make sure no zinc oxide was placed where the residents could access them and the materials for wound care, which some of them were medicated, were stored in the cart when not in use. She said she would coordinate with the DON to do an in-service about medication storage. In an interview on 09/11/2025 at 2:50 PM, the Administrator stated according to SDS, a large quantity of zinc oxide was needed to be ingested before there would be an effect. Record review of the facility's policy, Medication Labeling and Storage Strategy Delivery Performance revised 08/2024 reflected Policy Statement: The facility stores all medications and biologicals in locked compartments . Medication Storage . 5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown and infection for one (Resident #44) of four residents reviewed for quality of care. The facility failed to ensure that LVN A did not use only one gauze to clean Resident #44's pressure ulcer to her sacrum (bone of the bottom) back and forth, and one gauze to pat dry the pressure ulcer as well as the surrounding skin on 09/09/2025. This failure could place the residents with pressure ulcers at risk for worsening of the existing pressure ulcers and infection. Findings included: Record review of Resident #44's Face Sheet, dated 09/10/2025, reflected an [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with a fracture to sacrum. Record review of Resident #44's Quarterly MDS Assessment, dated 08/25/2025, reflected the resident was cognitively intact (resident capable of normal cognition and needed little support) with a BIMS score of 13. The Quarterly MDS Assessment indicated that the resident had an unstageable pressure ulcer. Record review of Resident #44's Comprehensive Care Plan, dated 08/27/2025, reflected the resident had pressure ulcer to sacrum due to immobility one of the interventions was to administer treatment as ordered and monitor for effectiveness. Record review of Resident #44's Physician Order, dated 09/04/2025, reflected WOUND CARE: Clean sacral pressure ulcer with wound cleanser or NS and pat dry. Collagen powder alginate and border gauze qd and prn if soiled, saturated, or dislodged. Every day shift every 2 day(s) for sacral ulcer AND as needed for sacral ulcer prn saturated, soiled or dislodged. Observation on 09/09/2025 at 1:33 PM revealed LVN A was about to do Resident #44's wound care. She said the resident had a pressure ulcer to her sacrum and the treatment would be to clean with normal saline, collagen powder, and cover with a dressing. She sanitized her hands, put on a pair of gloves, sanitized the table, and waited for it to dry up. When the table was dry, she placed a blue pad on the table and put the gauze, powder alginate, gelling fiber silver dressing, and normal saline bullets on top of the pad. She then taped a plastic bag at the side of the table. She took off her gloves and sanitized her hands. She put on a gown and a pair of gloves, and closed the door using her foot. She told the resident to roll on her side, unfastened the brief and took off the old dressing. She took off her gloves, sanitized her hands, and put on a new pair of gloves. She squeezed the normal saline bullet on a couple of gauze and started to clean the resident's pressure ulcer to the resident's sacrum. She started by cleaning the pressure ulcer downward, but then with the same gauze, wiped the pressure ulcer upward. She used the same gauze to clean the pressure ulcer upward and downward four times. It was observed that the wet gauze touched the surrounding skin of the pressure ulcer. She then took some gauze and patted dry the wound and the surrounding skin of the wound. She took off her gloves, sanitized her hands, and put on a pair of gloves. She then put some collagen powder on the wound and covered it a dressing. In an interview on 09/09/2025 at 1:52 PM, LVN A stated the right procedure in cleaning the wound was to clean the wound from inside to outside and not to use the gauze that was already used again. She said she should have discarded the first gauze that she used to clean one wound and take another one to clean it. She said as if the microorganism accumulated from the first cleaning was introduced back to the wound. She said she should have cleaned and then discarded the gauze and then repeated. She said she would be mindful the next time she would do wound care not to use soiled gauze to clean the pressure ulcer and to clean from inside out to make sure the pressure ulcer would not be infected. In an interview on 09/11/2025 at 7:43 AM, the DON stated the gauze should be changed after every stroke and should not touch the pressure ulcer again. She said the soiled gauze should not go back and forth on the pressure ulcer because the goal was to clean the wound. She said if the same gauze was used, the microorganism might be introduced back to the pressure ulcer and could result in infection. She said the expectation was for the staff doing wound care to do the right procedure. She said she would do an in-service about proper technique in wound care. In an interview on 09/11/2025 at 8:45 AM, the ADON stated using the gauze used to clean the pressure ulcer again could lead to infection. She said the proper procedure in cleaning the wound be from inside out and then discard the gauze, get another gauze, clean the wound again, and then discard the gauze, and so on and so forth. She said if the same gauze just went back and forth, it would be as if the microorganisms was just trapped in the wound instead of washing it out. She said touching the surrounding skin with the gauze could introduce other bacteria from the surrounding skin to the wound. She said the expectation was to keep the bacteria out and not introduce germs from the surrounding skin. She said she would coordinate with the DON to do an in-service about wound care. In an interview on 09/11/2025 at 2:50 PM, the Administrator stated improper wound care could lead to infection. He said the expectation was to do wound care the right way according to wound care technique. He said they would do an in-service and check-offs. Record review of the facility's policy Wound Care 2001 MED-PASS, Inc. revised October 2010 reflected Purpose: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . 11. Cleanse wound and peri wound . Policy specific to not using the same gauze in cleaning the wound requested on 09/11/2025 at 12:39 PM via email but was not provided prior to exit.

Based on observations, interviews, and record review, the facility failed to ensure that the residents were provided medications and/or biologicals and pharmaceutical services to meet their needs for one (Resident #37) of eight residents reviewed for pharmaceutical services. 1. The facility failed to ensure that Resident #37 was not self-administering her Tramadol without assessment on 09/09/2025. 2. The facility failed to ensure that there was no expired medication inside the medication cart since Resident #37's admission to the facility on [DATE]. These failures could place residents at risk of not receiving medications as ordered by the physician, for potential overdose, and adverse effects. Findings included: Record review of Resident #37's Face Sheet, dated 09/10/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. The resident was diagnosed with fracture to right femur, acute pain due to trauma, and hyperlipidemia (high cholesterol in the blood). Record review of Resident #37's Quarterly MDS Assessment, dated 09/09/2025, reflected the resident was cognitively intact with a BIMS score of 15. The Quarterly MDS Assessment indicated the resident had fracture and had acute pain. Record review of Resident #37's Comprehensive Care Plan, dated 09/04/2025, reflected the resident had acute pain related to fracture and one of the interventions was to monitor the effectiveness of the pain interventions. The care plan did not indicate that resident could self-administer her medications. The resident was not care planned did not for hyperlipidemia. Record review of Resident #37's Physician Order, date 09/03/2025, reflected Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 6 hours as needed for pain. Record review of Resident #37's Physician Order on 09/09/2025 reflected no order that the resident could self-administer her medications. Record review of Resident #37's Physician order, dated 09/03/2025, reflected Atorvastatin Calcium Oral Tablet 10 MG (Atorvastatin Calcium) Give 1 tablet by mouth one time a day for HLD. Record review of Resident #37's Clinical Assessment on 09/09/2025 reflected no assessment for self-administration of medications, no clear instructions for self-administrations, and no assessment that the resident was competent to manage her own medications. 1. Observation and interview on 09/09/2025 at 9:21 AM revealed Resident #37 was in her bed, awake. It was observed that there was a small plastic cup, with one pill inside, on the resident's food tray. The resident took the cup and took the medication. She said the nurse left it there and told her to take the medication after she was done with breakfast. She said the medication was a tramadol that she requested because she would go to therapy after breakfast, and most of the time, her body gets sore after therapy. She said she had a routine Tylenol, but it was not enough. She said as much as possible, she would not take tramadol, but her body was still sore from the last therapy session. In an interview on 09/09/2025 at 1:52 PM, LVN A stated Resident #37 requested for a tramadol and she gave her one as her PRN. She said she thought the resident took it. She said she should have made sure that the resident swallowed the tramadol before leaving the resident. She said the pills should not be left with the resident because the resident might not take them, throw them, or choke while taking them and no one would know. 2. Observation on 09/10/2025 at 11:05 AM revealed during inspection of the medication cart, one bottle of Atorvastatin for Resident #37 was dated 10/07/2024. Observation and interview on 09/10/2025 at 11:06 AM, MA J saw the bottle of medication and stated she did not know that the bottle was dated 10/07/2024. She said she administered Resident #37's atorvastatin earlier and took the medication from the resident's blister pack (a type of packaging in which a product is sealed in plastic, often with a cardboard backing). She said she noticed the bottle of medication but did not check for the expiration date of the bottles. She said if expired medications were used, it would be considered as a medication error. She said expired medications could be less effective or could have adverse reactions. She said she saw the bottle of medications but should have checked the dates of expiration. She said she did not know who placed the medications inside the cart. She took the bottle of medication and said she would discard it. In an interview on 09/10/2025 at 3:03 PM, MA K stated she remembered that there was a bottle of medication for Resident #37. She said the nurse put the bottle of medication in her cart but did not touch it because it was not in the system for her to give. MA K said she did not check the medications when they were placed in the cart. She said the resident had blister pack for atorvastatin and that is what she used when she administered the medication. She said there should be no expired medication inside the cart because it would not be good for the residents if they were given it accidentally. In an interview on 09/10/2025 at 3:09 PM, RN H stated she was the one who admitted Resident #37 on 09/03/2025 and she remembered that medications in bottles were handed to her by a family member. She said she placed the bottles of medications inside the medication cart. She said she was handed two bottles of medication in a plastic bag. She said she did not check the medications before placing them inside the medication cart. She said she was not aware that one of the medication bottles was dated 10/07/2024. She said she did notice that the bottle was old, and the words could not be read anymore, and that should have prompted her to check the expiration date. She said expired medications could be harmful to the residents depending on what kind of medication. In an interview on 09/11/2025 at 7:43 AM, the DON stated a staff should never leave the medications at the bedside for the resident to take later unsupervised. She said the staff must ensure the resident took the medications before leaving the room. She said the resident might not take the pills or hide the pills to avoid taking them. She said the residents could also overdose if they took the pills given with the hoarded pills. She said expired medications should not be inside the medication carts because if taken by the residents, it could result in reduced effectiveness of the medication to unfavorable side effects. She said some expired medications lose their potency, but some would be toxic. She said the bottle of medication should have been handed to her because the facility had an in-house pharmacy where they order the medications. She said the expectations were for the staff not to leave any medication inside the room for the residents to take unsupervised and for no expired medications in the medication cart. She said she would do an in-service pertaining to all the issues mentioned. In an interview on 09/11/2025 at 8:45 AM, the ADON stated medication should not be left with the residents because the resident might not take it, throw it, or hide it. She said the resident might take the medication that she hid with the one that was just given to her and could overdose from it. She said another concern would be someone else might take it, like a confused resident or a visitor. She said the staff should stay with the resident until the resident was done taking the medications. She said residents could take their own medications if they have an assessment that they were competent enough to take the medications by themselves and without supervision. She said expired medications should not be inside the cart for the basic reason that it was expired. She said the bottle of medication should have been inspected upon receiving it and before placing it inside the cart. She said she was not sure what would be the adverse effects of expired medication, and she would consult the provider regarding what could be the effect of the expired medication. She said she would coordinate with the DON to do an in-service about not leaving any medications with the residents and about expired medications. In an interview on 09/11/2025 at 2:50 PM, the Administrator stated the medication should not be left inside the room because a wrong resident could take the wrong dose. He said the staff should make sure that the medication was swallowed before going out of the room. He said the staff must make sure there were no expired medications in the cart. Record review of the facility's policy, Administering Medications Strategy Delivery Performance revised 08/2024 reflected Policy Statement: Medications are administered in a safe and timely manner, and as prescribed . Policy Interpretation and Implementation . 1. Only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so . 12. The expiration/beyond use date on the medication label is checked . 27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of eight residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's breathing mask (used to receive medications by breathing in mist through nose and mouth) used for nebulization (method of delivering medication by converting liquid medication into an inhalable mist) was properly stored when not in use on 07/08/2025. 2. The facility failed to ensure Resident #2's breathing mask was properly stored when not in use on 07/08/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met. Findings included: 1. Record review of Resident #1's Face Sheet, dated 07/08/2025, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with respiratory failure (condition where there is not enough oxygen in the body or too much carbon dioxide in the body) and pleural edema (collection of fluid around the lungs). Record review of Resident #1's Comprehensive MDS Assessment (assessment used to determine the functional capabilities and health needs of the residents), dated 06/11/2025, reflected the resident was cognitively intact (capable of normal cognition and needs little support) with a BIMS score (screening tool used to assess the cognitive status of the residents) of 15. The Comprehensive MDS Assessment indicated the resident had respiratory failure. Record review of Resident #1's Comprehensive Care Plan, dated 06/25/2025, reflected the resident had oxygen therapy and one of the interventions was to improve air exchange during nebulization treatment. Record review of Resident #1's Physician's Order, dated 06/06/2024, reflected Ipratropium-albuterol solution 0.5 mg-3 mg (3) MG/3ML 1 vial inhale orally three times a day for shortness of breath. Observation and interview on 07/08/2025 at 9:00 AM revealed Resident #1 was on her bed, awake. It was observed that the resident had a nebulization machine on her side table with a breathing mask attached to it. The breathing mask was not bagged and the inner part was touching the table. She said she had been using the breathing treatment for a while, and she said she might ask her doctor if she could not have it always because she was feeling much better. She said her nurse came to see her and to do the breathing treatment, but she said she did not want it. She said, if she was not mistaken, she had the breathing treatment last night or two nights prior. She said the nurses would come to put on the breathing treatment and would come back to take it off when it was done. She said the nurses would be the one taking it off and put it somewhere. She said her side table was too far for her and would be impossible for her to put her breathing mask on the table. There was no bag noted on the table. 2. Record review of Resident #2's Face Sheet, dated 07/07/2025, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. The resident was diagnosed with chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #2's Comprehensive MDS Assessment, dated 07/08/2025, reflected the resident had a severe impairment (requires significant assistance and support in daily life) in cognition with a BIMS score of 02. The Comprehensive MDS Assessment indicated the resident had chronic obstructive pulmonary disease. Record review of Resident #2's Comprehensive Care Plan, dated 07/07/2025, reflected the resident had nebulizers ordered and one of the interventions was to improve air exchange during nebulization treatment. Record review of Resident #2's Physician's Order, dated 07/07/2024, reflected Albuterol Sulfate Nebulization Solution (2.5 MG/3ML) 0.083% 3 milliliter inhale orally via nebulizer three times a day for Shortness of Breath. Observation on 07/08/2025 at 9:14 AM revealed Resident #2 was on his bed with eyes closed. It was observed that the resident had a nebulization machine on his side table with a breathing mask attached to it. The breathing mask was not bagged, and the inner part was touching the table and a box of tissue. There was no bag noted on the table. Observation and interview on 07/08/2025 at 9:37 AM with LVN A revealed she went to Resident #1's room earlier to administer the breathing treatment, but the resident refused. She said she did notice that the breathing mask was not bagged. She disconnected the breathing mask and told the resident that she would replace the breathing mask because it was exposed and was just sitting on the table. She went to Resident #2's room and saw the resident's breathing mask on the table. She disconnected it and said she would also get a replacement. She said she was the one who administered the Resident #2's breathing treatment, and should had come back to check if it was done. She said if the residents were not using the breathing masks, it should be inside a clean plastic bag to ensure cleanliness for the next use. She said whoever took off the breathing masks, should clean and bag them to prevent any respiratory infection. In an interview on 07/08/2025 at11:30 AM, the DON stated the breathing masks should be bagged and not left on top of the side table to ensure cleanliness and patency. She said cleanliness should be ensured to prevent respiratory infections or other issues related to respiration. She said the expectation was for whoever took the breathing mask off should clean it and store it properly. She said when the staff were checking on the residents or were doing their rounds, they needed to also check if the breathing masks were stored properly, and if not, they should replace them. She said the staff needed to monitor more on the residents who were presumed taking off their breathing mask by themselves once the breathing treatment was done. She said they needed to educate the residents, who were taking off the breathing mask by themselves, on the importance of bagging the breathing mask once the breathing treatment was done. She said she already started an in-service about bagging the breathing mask and said they would do better. In an interview on 07/08/2025 at 1:00 PM, the Administrator stated the breathing masks should be bagged to prevent infection. He said the DON would take care of the issue. Record review of the facility's policy RESPIRATORY TREATMENT, CARE AND SERVICES PROGRAM Nursing Policies and Procedures revised May 05,2023 revealed POLICY: The Facility ensures the safe, appropriate, and effective provision of respiratory treatment, care, and services in accordance with professional standards of practice . PROCEDURES . Infection control practices including standard and transmission-based precautions are . B. Handling of equipment, including cleaning, storage.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the resident's room for 1 of 4 (Resident #1) reviewed for pest control. The facility failed to keep an effective pest control program to ensure Resident #1's closet was free of ants. These failures could place residents at risk for insect bites, skin irritations, cross-contamination, and decreased quality of life. Findings included : A record review of Resident #1's factsheet dated 09/07/23 revealed she was a [AGE] year-old female initially admitted on [DATE], and again on 08/25/23 with diagnosis: fracture of the first lumbar, Parkinson's Disease. Chronic Kidney Disease, Acute Embolism and Thrombosis. Limited assistance with ADL not steady on her feet. MD note 8/29/23 at 1:40 p.m. Respiratory Infection is potentially a result of COVID-19. A record review of Resident #1's Admissions MDS assessment dated [DATE] revealed a BIMS score of 14 indicating resident's cognitive functions were intact. Resident #1 requires extensive assistance for ADL's and transfers X2 staff. A review of Resident #1's baseline care plan dated 08/25/23 revealed an initial diagnosis of pneumonia, antibiotics, occupational and physical therapy for strengthening and increased ADL functions. Resident #1 has sleep disturbances and limited physical mobility requiring staff to provide extensive assistance. A review of Provider investigation report written and completed by the administrator revealed the following: Review of Provider incident report 3613 revealed the incident occurred on 8/11/23 at 2:00pm. found to have 10 small pustules (blisters with white pus) in the underarm region of the right arm. Resident does not know when or how they occurred. Pustules viewed as possible ant bites. Resident was assessed and found to have 10 small white pustules to rt axilla (underarm) area. treatment provided to Resident #1 immediately in house. Once the provider learned of the incident the resident was immediately reviewed for further ant bites. The entire room was inspected for any further ants which no ants were present. All pertinent statements were gathered. The investigation confirms Resident 1 had ant bites. The investigation furthered revealed on 8/4/23 several ants were found in the closet of Resident 1 and on the clothing of Resident #1. At the time Resident 1 was not bit and had no issues. However, Resident 1 believes that ants may have been in her clothing at some point before all her clothing went to laundry for washing. Furthermore, the investigation revealed 7/27/23 the building perimeter was treated by [pest control company] for pest including ants as a preventative measure for combating pest. The investigation revealed on 8/4/23 when the ants were found all staff responded accordingly and treated the room with local pesticides until the Pest control contractor could treat on 8/17/23. Resident #1 was not harmed and did not complain of pain and itchiness. Family and physician were notified findings confirmed. After confirming the incident of the ant bites the facility performed a thorough sweep of the entire facility to ensure no further ants were present. The facility further ordered the pest control contractor to continue to spray a protective barrier on the outside of the building and treat any room that may present with ants, this was completed. The Housekeeping will continue to step up efforts of cleaning and reviewing of ants all times. The Nursing team was in-serviced on ensuring all ants/bugs are reported for treatment through TELS to ensure documentation is occurring of the incident. Resident #1 was fine and successfully discharged to her home with no further incidents of ants in the room (as she had completed her treatment at the facility). The physician and family were notified. Resident was readmitted for further therapy. A review of LVN K's statement dated 08/11/23 revealed On Friday, August 11, 2023, 4:39 PM, she reported to Administrator and the DON, the details of the incident (regarding ants ) involving Resident #1s She said on Monday 8/4/23 morning ants were noted in the closet of room. It was immediately reported to maintenance and treated. No ants were found on the person of Resident #1. Her clothes were sent to laundry. Resident #1 wheeled passed me Friday morning and I noticed a pustule on her right shoulder, she allowed me to examine her. I found 11 pustules. One on her shoulder and 10 in her right axilla under shoulder joint arm pit. There were no more found. She states she did not know they were there, that they do not itch or hurt. I have updated the provider and attempted to call her family with no response. I left a message. Family, MD, ADM, and ombudsman were notified. Record review of written statement dated 08/14/23 by CNA G, revealed The nurse was made aware by patients' (RP) that she had red bumps with pustules on right upper extremity and axilla. The nurse notified patients assigned nurse with (RP) present. Record review of written statement from CNA J dated 08/15/23 revealed upon opening the closet in room to gather clothing for Resident #1's shower on 08/04/23, she wrote I noticed a lot of ants on her clothing, inside closet wall and on floor. I then went to the nurse (LVN-K) and reported the ant problem who then contacted maintenance assistant to fix the ant problem, as I gathered all of her clothing to take to laundry to be rewashed. In an interview on 09/07/23 at 9:25 a.m. with RP of Resident#1 revealed that on 08/11/23 during a visit she observed pustules (small blister containing pus .) under Resident #1's armpit and requested a nurse to assess in order to rule out shingles, as this was her perception. The nurse immediately responded and assessed the skin and blisters. The RP stated the nurse determined the pustules were ant bites. The RP could not recall the aide's or nurse's name. The RP stated that there have been other incidents of ants in the building, however she was unaware of other residents obtaining ant bites. She said the staff immediately assessed her family, removed her from the room to inspect and spray. She said the resident was then showered to clean and treat the area that had blisters. The RP said the facility notifies family when there are pest concerns. The RP said resident was not aware of the blisters until she asked about the blisters. She said she observed ants in the closet in a corner at the time, but not near the resident. Observations on 09/07/23 at 2:28 p.m. of resident rooms, shower room, television room, nursing station, and dining room revealed no observation of ants, or any other insects. In an interview with Resident #1 on 09/07/23 at 2:30 p.m. she stated that she was bitten by ants and no other incidents have occurred. She said the area was healed and the staff took care of her. In an interview on 09/07/23 at 2:35 p.m. with LVN H she stated that she has not observed ants in Resident #1's room, however she was made aware by leadership that ants were in the building on 08/04/23. She said the resident leaves snacks out and staff are told to assess, and report concerns of ants. She said she was not aware of other incidents of ants recently. When ants are observed maintenance reports and treats. She has observed the pest control treating the facility often. In an interview with the DON on 09/07/23 at 3:30 p.m. revealed she was notified about the pustules on Resident #1 with LVN K by Resident #1. The DON said Resident #1 propelled to the nursing station and inquired about bumps on her body. She said reports and concerns about ants were reported afterwards. She said at that time she notified all staff about the pustules and possible insect bites in the resident's room. The DON said that the pustules were not confirmed as ant biters on the resident. The DON described Resident #1 had small bumps under her arm with blisters. The DON said the room was immediately inspected for pest by maintenance staff, and LVN-K completed a skin assessment on Resident #1 and treated pustules under her arm. The DON negated evidence of ant bites listed in the investigation report, maintaining the pustules were not determined to be from ant bites. DON said all staff was then educated via in service on assessing rooms for insects and notifying the nurse and maintenance immediately to complete and inspection. She said staff were further informed to conduct observations of each resident's room for ants and food that could lead to pest presence. The DON denied observing ants in the resident room and facility. In an interview with the maintenance assistance for the health care building on 09/07/23 at 3:36 p.m. He stated that he received TELS order (electronic maintenance orders system) to report to room for inspection of ants. He said upon arriving to Room, he observed approximately 10 small ants in the corner of the closet. He stated an inspection of her room and other resident rooms revealed no other observations of the ants. He reported to the lead maintenance assistant , who arrived and assisted with spraying and assessing. He said pest control visits weekly to spray the building. In an interview with the lead Maintenance assistant on 09/07/23 at 3:45 p.m. He said maintenance received pest control calls all the time about ants. He said their pest control contract was with a pest control company, and they visit weekly to inspect and assess, and if there are specific instances of ants, such as Resident #1's they will treat those rooms. He said once he reported to room, he observed ants in the closet, so he and the assistant maintenance sprayed and cleaned the ants out of the closet. He said an inspection of the resident room revealed no other observations or mounds of ants. He then inspected all resident rooms for ants, and there were none found. He said he has been working here as a maintenance assistant for [AGE] years and maintenance receive many calls about ants. He said the pest control company reported to the building the following day and treated the room. No ants upon the pest control company's arrival. In an interview with the administrator on 09/07/23 at 3:55 p.m. he stated that the receptionist submitted the TEL order, after receiving a report to inspect for insects. He said no ants were observed. He said they did not determine the pustules were from insect bites. He said unless we conducted a lab sample of the pustules, they would not be able to determine if the cause were from an insect. He said no staff reported observation of ants in the resident's room. He said the resident was confused and did not recognize the pustules it was the staff observation. He said the family and resident were not upset about the incident and had no complaints about the care provided and interventions the facility provided to Resident #1's . He said the pest control contractor inspects and assess weekly for pest and treat the property inside and outside, as well as target areas in rooms as reported in Resident #1's closet. He said the property has encountered pest including ants, due to the summer temperatures, which was why the pest control contractor treats and inspect weekly as they want to be vigilant in maintaining a safe environment free of insects. He stated that he could not prevent ants from entering the building other pest on property, however he has maintained regular preventative measures to deter incidents of possible ant bites. He has educated staff to keep watch for possible pest and removing snacks that are opened and exposed in all resident's rooms and clean up any crumbs that could provoke or invite pest. It should be noted that the facts in his provider report from his staff confirmed that ants were in the resident's closet. The administrator then stated that the surveyor was exaggerating findings to elevate the incident to deficient practice when he and his staff followed the necessary steps to maintain an environment free of pest in the building, despite acts of nature that he could not control, meaning the excessive heat outside. The maintenance Director was not interviewed as he was out on bereavement leave. Record review of Inservice with all staff at the facility was reviewed for investigation and reporting timely . Housekeeping and healthcare: 2023 Subject - Report ants and bugs for treatment through the TELS facility login is posted by computers at nurses' station for anyone to report. If ants are found in closets or drawers near clothing, make sure to shake out any clothing . Let your nurse know immediately so report to maintenance. If ants are found on a person, make sure to notify the nurse for assessment. If bites are found notify the administrator and the DON. A record review of facility maintenance log revealed ant observations on 08/30/23-Room and room [ROOM NUMBER] 08/29/23-office. 08/24/23 Bugs and ants' storage shed 08/17/23, Room outside of facility, room [ROOM NUMBER] bathroom, 08/22/23 room [ROOM NUMBER] ants and beetles 08/09/23 rooms [ROOM NUMBERS] Sugar ants 08/03/23 room [ROOM NUMBER], ants 07/22/23 room [ROOM NUMBER] around air condition unit window Record review of text messages (screenshot) attached to the PIR from the administrator to the maintenance assistant HHS revealed the following: do you know anything about ants in room from 8/4/23? Response No, I didn't go back to work until 7 Aug. did you see any ants when you went and sprayed on 7 Aug? Yes, there were a few in the corner of the closet. Only the closet? yes Thank you Record review of pest control contractor invoices dated 08/24/23, 08/11/23, 08/10/23, 07/20/23 revealed that pest control treatment was performed on site in resident's rooms, and outside areas of the buildings.

Based on observation, interviews and record reviews the facility failed to ensure food was stored, prepared, distributed and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerator, and freezer were stored and dated according to guidelines. The facility failed to ensure that staff was wearing the proper head coverings when serving food. The facility failed to ensure proper discarding of expired food stored in the refrigerator and freezer storage area. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings on [DATE] at 08:45 AM include: Four small bowls of garden salad was uncovered and unlabeled in the refrigerator. Seven small bowls of fruit salad was uncovered and unlabeled in the refrigerator. Two small Styrofoam containers of Caesar salad was unlabeled and undated in the refrigerator. Two large Styrofoam containers labeled Tuna plate was undated in the refrigerator. Three large pans of Coffee Cakes were uncovered, unsealed, and undated in the refrigerator. A One-gallon container of Fat Free Raspberry Vinaigrette Dressing with a date of ,d+[DATE] and no visible manufacturer expiration date in the refrigerator. Box of approximately 20 frozen beef patties unsealed in the freezer. Ten expired frozen Tilapia fillets with a Use by date of ,d+[DATE] One unsealed container of at least 12 frozen hashbrown patties. One large pitcher full of Iced Tea located in a standalone refrigerator was uncovered. Observation and interview with Cook B on [DATE] at 08:45 AM revealed Cook B was observed entering and exiting the facility's only kitchen, and she was observed cooking omelets for residents. Cook B was observed wearing a hairnet, but she had bangs in approximately 2 inches in length exposed. Cook B stated she was advised that it was okay to wear her hairnet like that, but she did not remember by who. She stated the risk of not covering her hair completely could result in her hair falling into the food and causing residents to get sick. Observation and interview with Cook L on [DATE] at 08:50 AM in the facility's only kitchen revealed him in the kitchen preparing food for lunch and he was not wearing a beard covering to cover his quarter inch in length beard. He stated the policy required him to wear a face covering, but he just did not have one on. He stated the risk of not covering his beard could result in hair falling into the food and residents could get sick. Interview with the Dietary Manager on [DATE] at 09:00 AM revealed he had been the Dietary Manager for the Facility's only kitchen for 4 months. He was advised of the two kitchen staffers who were not in compliance with head and face covering and he stated that the previous Dietary Manager allowed staff not to wear heading coverings appropriately and he is trying to change the culture. He stated the risk of staff not wearing their head and face coverings appropriately could result in air borne illnesses. He advised that he would in-service his staff on Employee Hygiene and Dress Code. Interview with Cook T on [DATE] at 10:23 AM revealed all cooks and diet aides were responsible for labeling and dating inventory as they are delivered. She advised they must put a name on it and that day's date on it., which includes can goods. She stated they use the first in and first out method, which means they use the oldest dated product first. She was shown pictures of the concerns and she stated that all staff were required to monitor for any of these concerns and correcting it, but the DM is overall responsible for ensuring that it is corrected. She stated whoever puts up the inventory must also check for expired foods and ensure all foods are sealed appropriately. She stated the risk of these issues not being resolved could result in spread of bacteria. Interview with Cook L on [DATE] at 10:30 AM revealed he and all cooks and diet aides are responsible for labeling and dating. He advised staff must label and put the date the shipment came in on the product. He was shown pictures of concerns referenced previously and he advised that everyone was responsible for ensuring these concerns do not happen and the Dietary Manager is overall responsible for monitoring and identifying any of the concerns mentioned. He stated the residents could get sick eating expired or contaminated foods. Interview with the Dietary Manager on [DATE] at 10:45 AM revealed he and all cooks are overall responsible for managing the food inventory, which included labeling and dating food as they come in, labeling and dating food as it is prepared, monitoring and disposing of expired foods, and ensuring all foods are properly sealed. He advised that he is still working with his staff to be more consistent in their daily responsibilities and he had to be more disciplined to check for consistency in being in complaint compliance. He stated he had already started in-services on the areas previously mentioned and will strategize on how to ensure this does not happen again. He stated the risk of not meeting these expectations could result in the spread of a food borne illness and residents getting ill. Interview on [DATE] at 11:30 PM with the Administrator revealed he was advised of the findings in the kitchen by his Dietary Manager, but he may not had known all the concerns, so he reviewed the pictures of all the concerns previously referenced. He stated that his Dietary Manager had only been at the facility for a few months, and he was still working on changing the culture in the kitchen because the previous Dietary Manager was a little relaxed with following compliance. He stated he thought his new DM would get it straightened out. He advised that he plans to complete more walk throughs to ensure they comply with guidelines. He was asked the risk of not adhering to any of the concerns presented and he stated that it could result in the residents getting ill. Review of the facility's policy and procedures on Food Storage, dated [DATE], revealed The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered Food Code Reference unlabeled food items section ,d+[DATE].17 (B) Except as specified in (E) -(G) of this section, refrigerated, READY-TO-EAT TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the FOOD shall be consumed on the PREMISES, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: Pf (1) The day the original container is opened in the FOOD ESTABLISHMENT shall be counted as Day 1; Pf and (2) The day or date marked by the FOOD ESTABLISHMENT may not exceed a manufacturer ' s use-by date if the manufacturer determined the use-by date based on FOOD safety. Food code reference beard restraints section ,d+[DATE].11 (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLESERVICE and SINGLE-USE ARTICLES. Review of the facility's policy and procedures on Employee Hygiene and Dress Code - Food and Nutrition Services, dated [DATE] revealed Hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, and assembling food or ingredients.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure the proper labeling and dating of all foods stored in the refrigerator, freezer, and dry food storage areas. 2. The facility failed to ensure proper discarding of expired food stored in the refrigerator storage area. 3. The facility failed to ensure that staff was wearing the proper head coverings when serving food. These failures could place residents at risk for food-borne and transmission-based illnesses. Findings included: Observation and interview on [DATE] at 9:10 AM with the Chef revealed he was in the kitchen area with no head covering on. The Chef was asked the standards for wearing the proper head coverings and he replied that all head coverings must always be worn to prevent cross contamination and prevent resident from getting ill. He stated that he was in a rush today because he was shorthanded, which was why he was not wearing a head covering. Observation and interview on [DATE] at 10:00 AM revealed that Cook B was not wearing the proper head covering while in the kitchen area and was observed wearing a skull cap over her head, she had a ponytail sticking out of the skull cap, without a hairnet on. She stated that she thought that it was acceptable. She was asked the risk of not wearing the proper head covering and she stated that residents can become ill. Observation and interview on [DATE] at 9:15 AM with the Chef revealed the walk-in refrigerator with three trays containing dishes of uncovered slices of cherry pies, two uncovered trays of garden salads, one uncovered tray of other dessert items and fruit cups on a cart. There was a tray of two whole cherry pies that were on a second cart uncovered. Observation on [DATE] at 9:15 AM of a container of Rosemary leaves ( herb used in cooking) with a Use by date of [DATE]. A large bag of coleslaw with a Use by date of [DATE]. A box of [NAME] lettuce with a Use by date of [DATE], a box of granny apples with a Use by date of [DATE] and a box of cucumbers with a Use by date of [DATE]. The Chef was asked about these items being uncovered and he stated that he had some staff called in this morning and he had not gotten around to covering the items. When he was asked about the dates on the boxes, he stated that the dates on the boxes are the stored date. Surveyor advised him that if this was the case, the items referenced would still be expired based on the items being perishable and the items being more than 30 days old. The Chef advised that he would be throwing away the items. He stated that the risk of not covering food properly and not discarding expired food, could result in residents getting a food borne illness. Interview on [DATE] at 1:30 PM with the Administrator revealed the Administrator was advised of the findings in the kitchen and the concerns that were observed. He stated that he was briefed by his Chef earlier today. He advised that he was advised of the improper dating of foods stored in the refrigerator, discarding of expired food, and staff not wearing the proper head coverings. He was asked the risk of not adhering to any of the concerns addressed and he stated that it could result in the residents getting ill. Review of the facility's policy and procedures on Food Storage, dated [DATE], revealed The product should not be consumed after the date on the package due to the product's perishable nature and the product should be disposed of. Foods that have been opened or prepared must be covered Review of the facility's policy and procedures on Employee Hygiene and Dress Code - Food and Nutrition Services, dated [DATE] revealed Hairnets or hair restraints and beard nets or beard restraints are used when cooking, preparing, and assembling food or ingredients.

Based on observation, interview, and record review the facility failed to maintain wheelchairs were in safe operating condition for 4 (Resident's #3, #5, #12 and #25) of 15 residents reviewed for wheelchair as an assistive device. The facility failed to properly maintain wheelchairs for Resident's #3, #5, #12 and #25. This failure placed residents at risk for skin tears and discomfort. Findings included: Observation on 05/05/22 at 7:45 am revealed Resident #3's both armrest on her wheelchair, the material on the top was cracked with the foam exposed on the edges. Observation on 05/05/22 at 7:46 am revealed Resident #25's both armrest on her wheelchair, the material on the top was cracked with the foam exposed on the edges. Observation on 05/05/22 at 7:48 am revealed Resident #5's left armrest on her wheelchair, the top of the material was cracked and the foam beneath was exposed. Observation on 05/05/22 at 7:50 am revealed Resident #12's both armrest on her wheelchair, the material on the top was cracked with the foam exposed on most of the surface. In an interview on 05/05/22 at 7:45 am with Resident #3, she stated she would like the armrest replaced because the armrest on the left had edges which could scratch her arm. She stated she had not told the staff about the needed repair. In an interview on 05/05/22 at 8:04 am with LVN A, she stated when a resident's wheelchair needed repair the staff would use the TELS system, the computer program used by staff to notify maintenance of needed repair or just tell maintenance they were on the unit a lot. In an interview on 05/05/22 at 8:06 am with LVN B, she stated when a resident's wheelchair needed repaired the staff would use the TELS system the computer program used by staff to notify maintenance of needed repair. In an interview on 05/05/22 at 8:10 am with MA C, she stated when a resident's wheelchair needed repaired the staff would use the TELS system the computer program used by staff to notify maintenance of needed repair. In an interview on 05/05/22 at 8:15 am with CNA D, she stated when a resident's wheelchair needed repaired the staff would use the TELS system the computer program used by staff to notify maintenance of needed repair. In an interview on 05/05/22 at 8:20 am with Maintenance Supervisor, he stated the staff let him know when a resident's wheelchair needed repair. He said they would let him know using the TELS system to notify maintenance of the needed repair. He stated maintenance personal were supposed to check resident's wheelchairs for needed repairs . He stated he was not aware that the resident's armrest pads needed to be replaced. In an interview on 05/05/22 at 9:30 am with Administrator, he stated staff can tell the person at the front desk or notify maintenance by using the TELS system, which would notify maintenance of the needed repair. A review of the facility's policy entitled Preventive Maintenance Program dated 03/30/22, indicated All Society locations will implement a preventive maintenance program designed to identify and make necessary .

Based on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three (Resident #30, Resident #1, and Resident #13) of six residents observed for infection control. CMA I failed to sanitize the blood pressure cuff before, after, or between care for Resident #30, Resident #1, and Resident #13. The failure could place residents at risk for infection. Findings included: Record review of Resident #30 annual face sheet, dated 05/04/22, reflected an admitted [DATE]. Resident #30's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1 annual face sheet, dated 05/04/22, reflected an admitted [DATE]. Resident #1's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13 annual face sheet, dated 05/04/22, reflected an admitted [DATE]. Resident #13's active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation on 05/04/22 at 7:15 AM revealed MA C at her medication cart outside Resident #30's room. MA C then obtained the blood pressure machine and entered Resident #30's room. MA C then applied the blood pressure cuff to Resident #30's wrist and obtained her blood pressure. MA C then removed the blood pressure cuff and returned to her med cart outside Resident #30's room, placed the blood pressure machine and cuff on the medication cart, and then reviewed information on the computer. MA C then gathered Resident #30's medication. MA C failed to sanitize the blood pressure cuff before or after care of Resident #30. Observation revealed MA C moving the medication cart to the room of Resident # 1. Observation on 05/04/22 at 07:33 AM revealed MA C at her medication cart outside Resident #1's room. MA C then obtained the blood pressure machine and entered Resident #1's room. MA C then applied the blood pressure cuff to Resident #1's wrist and obtained his blood pressure. MA C then removed the blood pressure cuff and returned to her med cart outside Resident #1's room, placed the blood pressure machine and cuff on the medication cart, and then reviewed information on the computer. MA C then gathered Resident #1's medication. MA C failed to sanitize the blood pressure cuff before or after care of Resident #1. Observation revealed MA C moving the medication cart to the room of Resident # 13. Observation on 05/04/22 at 07:46 AM revealed MA C at her medication cart outside Resident #13's room. MA C then obtained the blood pressure machine and entered Resident #13's room. MA C then applied the blood pressure cuff to Resident #13's wrist and obtained her blood pressure. MA C then removed the blood pressure cuff and returned to her med cart outside Resident #13's room, placed the blood pressure machine and cuff on the medication cart, and then reviewed information on the computer. MA C then gathered Resident #13's medication. MA C failed to sanitize the blood pressure cuff before or after care of Resident #13. Interview with MA C on 05/04/22 08:15 AM revealed MA C stated that she is supposed to clean blood pressure cuff after every patient. She stated that it can cause infection if they are not cleaned. She stated, she did not think about it as the reason for not cleaning the blood pressure cuff after each patient. MA C stated she did not clean the blood pressure cuff after every patient. Interview with DON on 5/04/22 11:30 AM DON stated staff should wipe the blood pressure cuff down after every patient. DON stated that herself, infection preventionist, and regional nurse have all trained on infection control at some point. The DON believed the MA was nervous as a possible reason the MA did not clean blood pressure cuff. DON stated that if the blood pressure cuffs are not cleaned, something can be transmitted .depending on what is on it. Record review of the facility's Vital Signs - Blood Pressure policy, dated 9/22/21 stated, 16 .Clean blood pressure cuff after each use following manufacturer's instructions . Record review of the facility's Vital Signs - Blood Pressure Clinical Skill checklist used for training, dated 9/22/21 stated, 15 .Also, clean blood pressure cuff after each use .

Based on observation, interview and record review, the facility failed to ensure residents received adequate monitoring and supervision to prevent elopement for 1 of 4 residents reviewed for accidents hazards/supervision. (Resident#1) The facility failed to properly supervise Resident #1 who was cognitively impaired and who wore a wander guard due to elopement behaviors. Resident #1 wandered out of the front door of the facility, and she was located 0.9 miles away from the facility. Law Enforcement was notified by someone in the neighborhood. An Immediate Jeopardy (IJ) was identified to have existed from 04/03/22 to 04/03/22 . The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the survey. This failure could place residents requiring supervision at risk for serious injury and death. The findings include: Record Review of Resident #1' face sheet revealed she was an [AGE] year-old female, admitted to the facility on [DATE]. Her diagnosis was Alzheimer's Disease, Dementia , Anxiety Disorders, and Muscle Weakness. Record Review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 3, signifying a severe cognitive impairment. MDS, Section G revealed that resident needed 1 person assist with ADLs of bed mobility, dressing, Toileting, and Personal Hygiene including bathing. Resident #1 was able to always ambulate steady, however she was not steady when moving from seated to standing position, turning around, Moving on and off the toilet, and Surface to Surface transfer. Resident #1 did not use any devices to ambulate. MDS Section I, revealed under neurological checked Alzheimer's Disease and Non-Alzheimer's Dementia. MDS, Section P Alarms, checked Wander/elopement alarm used daily. Record review of Resident#1's care plan, dated 03/23/21, revealed Resident #1 had potential for elopement and would leave the facility unattended. The care plan reflected, Elopement Risk Interventions included attempting Non-Pharmacological interventions such as, offering Resident #1 diversional activities including reading a cookbook or playing the piano when she was wandering or seemed uneasy. A wander guard was used to alert staff to resident movements. Checking the wander guard functionality every shift to ensure that it was operating properly. Educating families to use the sign in/sign out sheet at the nurses' stations. Ensuring exit alarms were working properly. Consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate. Further record review of Resident's #1s care plan revealed she was at risk for altered confusion when she was experiencing urinary tract infections. The facility would monitor/document/report to health care provider PRN for s/s [sign and symptoms] of [CONDITION(S)]'s. Record review of Resident #1's Care Plan, dated 02/14/2021 revealed Resident #1 has impaired cognitive function and disorganized thought processes r/t [related to] Alzheimer's disease e/b [evidenced by] rambling, nonsensical speech, confusion, and memory loss. The plan date of initiation was 04/01/2019. Interventions included in part: engage in simple structured activities .give direction .avoid demanding tasks .using photos of family to reminisce 'Behaviors to observe including inability to communicate basic needs on a daily basis, displaying symptoms of distress by frowning wandering, appearing upset, and grimacing, and not eloping and feeling safe in her environment. A review of resident records did not reveal that a Fall Assessment was formerly completed, however, LVN A stated that she assessed the resident through Neuro checks, injuries, and vitals. Resident Care plan addressed her elopement and wander guard Wander guard used to alert staff to residents' movements, revised 12/23/2021. Check wander guard functionality every shift to ensure wander guard is in working order initiated on 03/23/2021. Ensure that exit door alarms are in working order, Initiated 03/23/2021. Educate families to use the sign in/sign out sheet at nurses' station, initiated 03/23/2021. 'Consult with pharmacy, health care provider, etc. to consider dosage reduction when clinically appropriate, dated initiated, 03/23/2021. Record review of Resident #1's physician's order revealed an order for Personal Alarm .Wander-guard to alert staff to resident's movement and to assist staff in monitoring movement. Date initiated 03/23/2021, revision date of 12/23/2021. Record review of Resident#1's MAR, dated March 2022 and April 2022, revealed the wander guard was checked every shift,. The facility has 3 shifts, so the wander guard was tested a total of 3 times a day as ordered. LVN-A checked the wander guard on 04/03/2022. Record review of the Provider Investigation Report (PIR) dated 04/10/2022, revealed Resident#1 was missing and found by police on 04/03/2022. She had minimal functional ability, required special supervision, was independently ambulatory, could not make informed decisions, had a history of wandering and was wearing a working wander guard at the time of the elopement. Further, the facility concluded Resident #1 eloped through the front door and Resident #1 could not recall how she left the facility. The Provider Investigation Report reflected there were several family members entering and exiting the facility around the same time Resident #1 was assumed to have eloped and Resident#1 may have followed one of them out the door. The report further reflected all staff members were interviewed, and no one witnessed Resident#1 leaving the facility nor heard the wander guard alarm sound, even though it was found to be in working order at the beginning of the shift and upon her return to the facility. PIR placed resident on 15-minute observations, in-serviced all Health staff, Dietary Staff, Maintenance and Housekeeping on proper procedures for elopement to include adhering to responding to the door alarms immediately when heard. An elopement binder was implemented to include a face sheet of the resident and their means of locomotion. The receptionist was in serviced on the importance of bine familiar with Elopement notebook and those at risk of eloping from the Health Care Center. The facility has increased the frequency of elopement drills for the next few months to ensure all staff are thoroughly confident in the elopement procedures of the family. The staff were in-serviced and trained on importance of being familiar with and responding to the door alarms. The incident was documented in the incident of elopement in the progress note on 04/03/2022 at 2:30 PM, stating that This nurse as notified by CNA-D at approximately 1:25 PM' that Resident #1 was located by the law enforcement walking down the road. LVN-A, LVN-B, and CNA-D immediately went to the front of the of the facility and a police SUV was out front with Resident #1 in the front seat. An observation of the surrounding area from the facility to where Resident#1 on 04/04/2022 at 2:45 PM and 04/13/2022 at 10:40 AM awas found on 04/03/22 at 1::10 PM, revealed the resident would have walked through facility property passing housing leading up to a 4 way stop with traffic. The road was observed with several side ditches with run off drainage overflows, a bridge with a deep grassy wooded area, no sidewalks, and ongoing traffic with winding roads. The facility didn't know that the resident had left the facility, until RR notified them, and Officer V arrived with Resident #1. This was confirmed by RR. The distance from the facility to where the resident was located was driven by Administrator and based on information provided by the daughter and Officer V, Resident was found on Andrews Ave. A search of MAPS revealed that the distance from the facility to the located was 0.9 miles. In an observation and interview of Resident #1 on 04/4/2022 at 3:30 PM, revealed her lying in bed. She stated that she was doing fine, and that she was not hurt. I asked if she remembered leaving the facility, and said no. Then she asked me, was I hurt? I don't remember. An interview with the Administrator on 04/04/2022 at 3:30 PM revealed on the day of the incident Resident #1 left the building and he was not sure how she exited the building. He stated had two potential theories: 1. She may have exited the building with visitors of other families. 2. The wander guard system at the main entrance had a flaw that caused the system to not continue to operate as intended. The Maintenance Director, DON, and Administrator discovered when a resident approached the closed double door outfitted with the wander guard sensor the wander guard would operate as intended. However, as the resident passed through the door, the door would close behind the resident which then cut the frequency of the wander guard bracelet to the sensor tricking the system in believing the alarm had vanished therefore automatically shutting off the alarm. This action would then disengage the magnetic lock from the second/main double doors thus letting a resident through the secured door. The Administrator stated the facility believes on 4/3/2022 [Resident #1] exited the dining room during lunch time and made a right towards the exit door instead of a left towards the nurses' station/residential area and proceeded to the door where the alarm activated as intended. The administrator stated that the staff were occupied during time duties and did not hear the alarm activated [Resident #1] continued through the door which then cut the frequency to the alarm silencing the alarm and disengaging the magnetic locks which allowed [Resident #1] to exit healthcare into the main hallway at the entrance of the facility and eventually out the door, 04/03/2022. The Administrator stated the facility had removed the double doors that may have caused the sensor to flaw to prevent future interferences with the signal to the wander guard sensor. The Administrator stated the last observation of Resident #1 was during lunch in the dining room by CNA F at 12:00 PM to 1:10PM. The Administrator stated that he was not certain what route Resident #1 took that ended on [NAME] Avenue, however it was 81 degrees outside and an estimated 19-minute walk from the Health Care Center. The administrator stated that Resident #1 was Administrator stated his expectation was for all staff to be aware and listen for the alarms and respond timely to prevent resident incidence of this nature from occurring. He stated all staff were in-serviced on Elopement Procedures and the MD ordered labs for the resident. The Administrator stated Resident #1 was assessed fully upon her return to the facility. Resident #1 did not have any injuries When asked if the facility had video, he stated the facility did have video and he would follow up to see if he could view it to determine how the resident exited the building. He stated Resident #1 was returned to the facility by law enforcement at approximately 1:30 PM. He stated he did not have a police report number nor the officers name and contact information that transported Resident #1 back to the facility. He further stated that the officer contacted the facility and spoke with the receptionist at 1:10 PM about locating Resident #1 inquiring if they had a resident missing or by a specific name. The Receptionist was located east of the entrance of the facility. The Administrator stated the Receptionist did not recognize the name provided by the officer, nor was she notified of a resident missing from the facility at that time. The Administrator stated the resident was returned to the facility at 1:30 PM by the police. He stated the facility was unaware that Resident#1 was missing until they were notified by the police and the family. This was the only method of notification to the family. The Administrator stated the family member and LVN A confirmed the identity of Resident #1, then escorted her inside to complete a full assessment. An observation on 04/04/2022 at 3:45 PM the doors between the wander guard and the nursing station had been removed from the facility prior to survey Entrance. An observation on 04/04/2022 at 4:09 PM, revealed that the wander gaurd alarm system was working, and previously set to the highest frequency for sensitivity. In a record reveiw of facility records opn 04/04/2022, revealed that LVN-A had in-serviced all nursing staff, dietary staff, maintenance staff, administrative, security and housekeeping staff on elopement and responding to wander guard alarms immediately. LVN-A also in-serviced night shift nursing staff upon arrival to work 04/03/2022. Record Review of Resident #1's MAR revealed a physician's order on 04/03/2022 upon notification of the elopement 4/4/2022 for BMP, CBC, and UA with C&S if Indicated, orders entered, labs ordered, notified pt. [family member] of order. A review of Resident #1s Urinalysis labs revealed that date of testing as 04/05/2022 at 7:30 AM revealed Resident #1 was positive for Escherichia coli [CONDITION(S)]. In an observation and interview of Resident #2 at 5:00 PM on 04/04/2022 revealed him sitting in a high back clinical care recliner at the dining table. His wander guard was observed on his ankle. In an interview and observation of Resident #3 on 04/04/2022 at 5:30 PM, revealed ambulating down 200 hall of the facility in her wheel chair. Wander guard was observed on her ankle. Resident would not answer any questions. She was observed again at 7:15 PM sitting in wheelchair in her room. In an interview and observation of Resident #4 on 04/04 2022 at 5:45 PM, revealed resident sitting in his wheelchair in her room watching television. An Interview with the DON on 04/04/2022 at 5:14 PM revealed she doesn't know how Resident #1 exited the building on 04/03/2022. She said there are currently 4 residents with wander guards. She stated the wander guards were checked each shift with a sensor and then marked as working in the MAR. She stated a new one is applied right away if the current wander guard does not work. The DON stated they require a physician's order, and the resident must qualify to get one, such as a history of wandering or exit seeking, through an elopement assessment She stated she was surprised that no one noticed Resident#1 being gone, as she was always up and walking the halls, visiting other residents, or chatting at the nurse's station. The nursing staff were checking wander guard for correct operations during shifts. Staff are informed by care plans, MDS assessments, and medical orders of residents being an elopement risk and assessments are ongoing. When I asked the DON what the facility had done to prevent this indecent from occurring again, she stated that they are conducting census counts, more frequent rounds, removed the additional double doors between the wander guard alarm for clear signals, increased frequency of the alarm to its highest level, conducted elopement assessments, and elopement binder and training with housekeeping, laundry, heath staff, receptionist, and security staff. An interview with LVN C on 04/04/2022 at 5:40 PM, revealed she was not on duty the day of Resident #1's elopement. She stated she was the nurse working with Resident #1 today. She stated she has not observed Resident #1 attempt to leave the facility during her shift. She stated she has observed Resident #1 frequently confused and walking the halls wanting to help other residents. She stated she has asked Resident #1 what happened; however, she could not give a straight answer as she can't stay on task. She stated the resident had not told her that she walked out of the facility. She stated she does not know how the resident left the facility. LVN C stated Resident #1 has not been observed roaming with or attempting to leave nor near the wander guard alarm. She stated she has been in-serviced on elopement by the DON. She stated wander guards are checked each shift by the nurse. She stated monitoring has been ongoing during shifts for all staff on duty. She stated Resident #1 was doing well and there have been no concerns or behaviors of anxiety observed since the incident. She stated they have 4 residents with wander guards, and she was able to name the residents. An interview with LVN-E on 04/04/2022 at 6:55 PM, revealed she was not on duty the day Resident #1 eloped. She stated she has received in-service on elopement by DON. She stated residents' wander guards are checked every shift and if the wander guard was not working, it would be replaced as they have extra. She stated Resident #1 had been doing well and there have been no concerns. She stated they have 4 residents with wander guards, and she was able to name the residents. An interview with CNA-G on 04/04/2022 at 6:57 PM, revealed she does provide direct care to Resident #1 and has been employed for 1 month. She stated she has been working with Resident #1 and she has received elopement training from the DON. She stated the staff are expected to respond to wander guard alarms immediately when sounded. CNA-G stated they would notify the charge nurse of any concerns if a resident was attempting to elope or was missing. CNA-G stated Resident #1 has not been observed during her shift seeking exits. She stated she does monitor her location often when she works. In an interview with CNA-J on 04/04/2022 at 7:10 PM, she stated she provides care for residents on the 300 hall and part of the 100 hall. She stated she has been employed for 2 months. She stated she does not have any residents with wander guards on her halls. CNA-J stated there was a list at the nursing station that could be accessed. She stated she was trained on elopement and told to check on residents and if a resident was observed attempting to exit to notify the nurse. When the alarm sounds, the staff were expected to stop what they are doing and go to the alarm area and search. Survey verified that everything had been corrected prior to entry on 04/04/2022, therfore, the facilities failure was determined to be past noncompliance. In an observation and interview of Resident #2 at 11:15 AM on 04/13/2022 revealed him sitting in a high back clinical care recliner in the TV room in front of the nurisng station. His wander guard was observed on his ankle. In an interview with Resident #1 on 04/13/2022 at 12:00 PM, she was sitting a the dining table talking with another resident. She was observed with her wander guard around her ankle. In an interview and observation of Resident #3 on 04/13/2022 at 12:15 PM, revealed she was sitting in her wheelchair in the dining room waiting to be served lunch. In an imnterview on 04/13/2022 at 11:00 AM, revealed resident #4 sitting in his wheelchair watching television in his room. Wander gaurd observed on his ankle. In in an interview on 04/13/2022 at 1:29 PM with Resident #1's Resident Representative, revealed on 04/03/2022 she received a call from another family member in [city name], stating that Resident #1 was located by law enforcement walking alone unsupervised. The Resident Representative stated the family member gave them the officer's number to contact. The Resident Representee contacted Officer V and learned that Resident #1 had left the facility and they were trying to locate her place of residence. The Resident Representee stated Officer V stated he conducted a property search after Resident #1 mentioned living in [city name] and found the family member. The Resident Representee stated she told Officer V that Resident #1 was a resident at [facility name]. She stated she asked Officer V where Resident #1 was located, and he said by homeowners in the neighborhood walking alone, and the homeowners called 911 for assistance. The Resident Representee stated she asked that Officer V transport Resident #1 to the facility and she would meet him to identify Resident #1. The Resident Representee stated she notified the facility about Resident #1 being found. The Resident Representee stated once the officer arrived at the facility Resident #1 was sitting in the passenger seat unharmed and smiling in a good mood. She stated Resident #1 was sunburned and was dressed in another resident's clothing and she looked raggedy. She stated that 3 nursing staff came out and assisted Resident #1 out of the vehicle and proceeded to assess Resident #1 for injuries. She stated Resident #1 did not have an injury and could not verbalize how she got out of the facility. An interview with MA on 04/13/2022 at 3:13 PM revealed she was the medication aide and was trained on elopement 04/06/2022 by DON. She stated all staff were trained to respond to the wander guard alarm when it sounds. She stated she would report any concerns of exiting behaviors, elopement, or door alarms to the charge nurse, then , are alarms to charge staff immediately and proceed to search for the resident. MA stated once the resident was found, communicate to the Health Care team, DON, and Administrator. team and maintain the resident's safety. She stated there had not been a resident that has eloped from the facility in her tenure at the facility. She stated Resident #1 has not revealed any information to her about how she eloped. When asked what could happen to a resident that wanders out of the facility with Alzheimer's, she stated the resident would be in danger and can have an accident and hurt themselves. MA sated that the Kardex, Care Plan informs all staff who are an elopement risk. The facility has a list at the nursing station with all wander guard and elopement residents. An interview with the MDS Nurse on 04/13/2022 at 4:25 PM revealed she has updated Resident #1 care plan for labs and [CONDITION(S)]'s for interventions. When asked if the IDT or care plan team had met to discuss with the Resident Representative (RR )some additional interventions for Resident #1 she stated they had met with the RR and as a team often. When a copy of the meetings was requested, she stated she would have to check for documentation. When asked if the team discussed any non-pharmacological interventions for staff to access during their shifts with Resident #1, she stated staff were able to access the Kardex (a medical-patient information system to inform staff of care. And see information about the resident such as encouraging her to read cookbooks or play the piano. An Interview with the ADM on 04/13/2022 at 4:35 PM revealed that he was not sure how many residents currently had orders for wander guards. When asked to identify what qualified residents for an order for a wander guard, he stated, at risk for elopement., by completing an elopement assessment. ADM stated that additional interventions that were put in place after Resident #1 returned were to in-service health staff to conduct routine shift census counts, increase the frequency of patient rounds, removed the additional double doors between the wander guard alarm for clear signals, increased frequency of the alarm to its highest level, conducted elopement assessments, and elopement binder and training with receptionist. He stated she had never attempted to elope before. He said it was plausible the alarm did not sound or that it was ignored by staff. He stated that the additional double doors between the hall and alarm possibly shut off the wander guard signal, preventing it from sounding. He said he can't rule out her going through a side door, although it was not likely. He stated he has not contacted law enforcement for a police report. He stated he has not checked video surveillance cameras on campus to see how she exited the facility on 04/03/2022. He stated he did not know the officer's name that returned Resident #1 to the facility; however, his receptionist stated the officer located Resident #1 0.9 miles away. He stated everyone was assuming she walked to the location, yet that has not been proven, because he has not spoken with law enforcement. When asked if he would like the officers name and number, he said no as it would not change the IJ. He further stated he does not agree that the incident was neglect, accidental, or problems with supervision, as she was not harmed, and no injuries were found. When asked if the IDT or care plan team had met to discuss with the RR some additional interventions for Resident #1 de stated he had met with the RR and stated that if the resident eloped again, she may have to locate a new placement. Administrator stated that the nurses are checking the wander guards every shift and to assure that it works at the door. They take the device to the door and test, then document. At night the Security guards are able to monitor the wander guards while they are on duty from 7am to 7p.m. Interview with LVN A on 04/16/22 at 10:30 AM revealed she does not know how Resident #1 got out of the facility. She said there are currently 4 residents with wander guards. She stated the wander guards were checked each shift with a device to determine functionality, then marked as working in the folder located at the nursing station. The documentation was located into locations. She stated if the wader guard was not working, then she would replace it with a working wander guard. LVN A stated she was Resident#1's nurse on the day of the incident. She checked the wander guard at the beginning of the shift. LVN A stated she completed the assessment on Resident#1 upon her arrival back to the facility and found no signs of injury or distress. She stated she assessed the resident along with the RR and she checked for dehydration, marks, and bruises. She stated she then contacted the MD for orders. She stated she in-serviced all staff in the facility including dining and housekeeping to assure that all staff were knowledgeable about elopement and alarms. She stated she was notified of Resident #1 missing when law enforcement returned her to the facility. LVN-A stated that the last person that saw Resident #1 was CNA-F in the dining room. LVN A' stated that REsident #1 had no injuries were found. An interview with LVN-B on 04/16/2022 at 10:37 AM, revealed the receptionist informed her the police called stating that one of the facility's residents was located. LVN-B stated she, LVN-A, and CNA-D rushed out to locate the resident. LVN B stated Resident #1 was sitting in the front seat of the police car. She stated they assisted Resident #1 out the vehicle and into the facility. She stated Resident #1 did not appear to be in distress and was in a normal state. LVN-B stated both she and LVN A assessed the resident and check for marks, bruises, dehydration, and mental distress. LVN-B stated on 04/03/2022, Resident #1 was last observed at approximately 11:50 AM. She stated she did not hear any alarms sounding in the building. LVN-B stated she checks wander guards every shift per protocol. She stated she has received an in-service on elopement on 04/03/2022 LVN-B stated when the alarm sounds all staff are to respond and check resident locations and report any concerns to nurse. LVN-B stated that she hasn't observed Resident #1 exit seeking on her shift since being employed. She stated that Resident #1 prefers to eat in the dining room. In an interview with CNA-F 04/16/2022 at 10:45 AM, revealed Resident #1 was last observed on 04/03/2022 at approximately 12:00 PM. She stated she was observed sitting at the lunch table in the dining room eating. She stated she did not see Resident #1 leaving the dining room or the facility. She stated she did not hear an alarm sound. She stated she has received an in-service on elopement, on 04/03/2022. She stated that all were expected to respond to alarms when they sound. Grab Census and search for all residents. all staff are to respond and check resident locations and report any concerns to the charge nurse. She stated that they are informed of residents with wander guards and elopement risk from care plans and Kardex. In an interview with Officer V on 04/16/2022 at 11:10 AM, revealed he had responded to a 911 call from a resident on [street name]. He stated when he responded to the location, homeowners stated that they observed Resident #1 walking down the sidewalk on [[NAME] Avenue], appearing to be confused and disoriented. Officer V stated he called the facility and asked if they had a resident missing and provided them with the resident's name, and the receptionist said no. Officer V stated he searched properties in [city name] and located a relative. Officer V stated he contacted the relative who stated that Resident #1 was a patient at the facility and provided contact information for the RR. Officer V stated he contacted RR and she met the officer at the facility with her relative. The officer stated he completed an information report with the report number 87. Record review of a facility in-service dated 04/03/2022 revealed the topic was exit alarms. The in-service reflected when exit alarms sounded the staff was to stop what they were doing and go towards door that alarm sounded at and search for the resident. All nurses were advised to continue wander guard device assessments every shift and maintain supervision and resident counts for safety. A review of the list of Residents with wander guards were reviewed. RR stated that this has never happened before and though they have assured her of measures put in place, she continues to have concerns about Resident #1's safety. A review of the facility policy titled Elopement-Rehab/Skilled, dated 01/12/2022, revealed, When a resident who needs supervision leaves the premises or safe areas without authorization (i.e., order for discharge or leave of abuse) and/or any necessary supervision to do so . POLICY The location will be responsible for maintaining a system that clearly defines the mechanism and procedures for monitoring residents at risk for elopement. These include identifying environmental hazards and resident risks; evaluating/analyzing hazards and risk; implementing interventions; and monitoring a/modifying interventions as needed. All residents will be assessed for risk of elopement through the re-admission and /or admission process, as needed. Each location will put measures in place to minimize the risk of elopement that are individualized to resident needs and identified on the care plan. When an elopement occurs, immediate efforts to locate the resident will be taken. All occurrences will be documented, and all follow up required by state and federal regulations will occurs. A Record Review of all 4 residents with wander guards were confirmed for physician orders, elopement risk, care plan, MDS, and progress notes.

Tag: F584 S/S= E Surveyor Name(s): [NAME] Based on observation, interview, and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary interior for resident's restrooms for one (Resident #25) of 10 reviewed for environment. The facility failed to ensure that resident #25's bathroom was cleaned daily and free of debris and discoloring of the toilet bowl. This failure could place residents at risk by contributing to feelings of dissatisfaction and low self-esteem. Findings Included: Review of Resident #25's current face sheet dated 01/21/2022, revealed that the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included anxiety disorder, [CONDITION(S)], dementia, history of falling, ataxia (Loss of coordination of voluntary muscle movements.) Review of Resident #25's psychiatric assessment dated [DATE], with LHP-E, AGNP, TX: AP 9, TXDEA, MH 37. The assessment revealed the following additional diagnosis F.42.3-Hoarding disorder, F41.1-Genarlized Anxiety disorder, F33.0-Majory Depression Disorder, G31.84-Mild Neurocognitive disorder. Review of resident #25's record review dated 01/12/2022, revealed resident fell in her bathroom floor while transferring from her toilet to wheelchair. Resident was transported to Medical City [NAME], where she was diagnosed with a fractured right hip. Resident #25's records dated 01/18/2022, revealed that resident returned to facility by ambulance post hospital stay. In an interview on 01/21/2022 at 12:20 PM with HKM-A revealed that housekeeping staff were cleaning the resident's rooms and restrooms daily with Virasept with a 4 minutes contact time and Peroxide Multi Surface and Disinfectant with a contact time of 5 minutes. Additionally, she added that she was also cleaning high touch areas, floors, and laundry. In an observation on 01/21/2022 at 1:25 PM revealed Resident #25's toilet had dark black stains all around the bowl, inside of the toilet. In addition, at the top of the water level in the bowl, there was a black substance collected and ringed around the inside of the toilet bowl. In an interview with CME-D on 01/21/2022 at 1:38 PM, she revealed she had been employed with the facility for 7 years. CME-D has worked with resident #25. She stated Resident #25 has had several falls, due to wanting to maintain her independence. She stated she assisted with CNA duties with residents when she is not performing medication administration to residents. She stated they currently didn't have enough housekeeping and laundry staff for the past month. She stated CNA's, nurses, and medication staff were disinfecting with purple bleach wipes in high touch areas such as, rails, doorknobs, medication carts, counters, and equipment when providing care to patients. CME-D stated that MD-B and HKM-A were assigned to clean resident rooms and restrooms daily during their staff shortage at the facility. In an interview with CNA-C on 01/21/2022 at 1:50 pm revealed she worked the first shift at the facility, and she has worked with Resident #25 to provide care frequently. All nursing staff have been trained to check on Resident #25 every hour to offer assistance with ADL's due to her frequent falls. CNA-C stated that she had provided care to resident #25 01/21/2022, and she observed the soiled toilet in her bathroom. She stated she notified the nurse on duty LVN-I and HKM-A as this is the protocol. She stated that HKM-A did not respond and clean the restroom. She also stated that resident #25 was not using her restroom currently due to her immobility from the fractured right hip. In an interview with LVN-I on 01/21/2022 at 2:10 PM revealed that she was employed as a LVN for 3 ½ years. She stated that the housekeeping staff are responsible for cleaning the resident bathrooms and rooms daily. She stated that she and CNA-C provided care to Resident #25 today and upon completing care she entered the restroom and observed the dirty toilet at 1:30 PM. She stated MD-B has asked for healthcare staff to help with cleaning. She stated that it is the nurse's responsibility to report concerns with cleaning to the HKM-A. LVN-I stated that she did not report the dirty toilet as she was attending to other residents. In an interview with the DON-G. on 01/21/2022 at 2:40 PM, revealed that the facility was short staffed in the housekeeping department. MD-B was the assigned supervisor of HKM-A at the time of the incident on 01/21/2022. The DON-G stated that MD-B has been assisting HKM-A with cleaning duties at the facility in the past month since they have been short staffed in the cleaning department. The DON-G denied that resident #25 toilet was dirty and described the dark black discoloring and black scratches observed were from the plumbing tools used to unclog the resident's toilet. She further stated that the resident has not complained about the toilet to the facility staff, and that changing the toilet out in the resident's room without her permission may cause emotional and psychological distress. As resident #25 has anxiety about items being touched or changed in her room. She stated that resident #25 was not using the restroom at this time, due to a fractured hip. DON-G stated that in the past resident #25 tell the staff that her room did not need cleaning and that the clutter was not a problem. DON-G stated the resident does not like change. She stated resident #25's resident representative would be able to communicate her Resident #25's history of not accepting change, when it comes to her room. In a second interview with HKM-A on 01/21/2022 at 3:10 PM, she stated that she had not cleaned the resident rooms and restroom today. She was asked if she had cleaned the resident's rooms and restrooms on 01/21/2022, and she stated that she had not. She was asked if she had cleaned the resident's rooms and restrooms this week and she stated that she was the only housekeeping staff on duty. She stated she was responsible for laundry and housekeeping until the facility hired new staff. The additional duties have limited her ability to clean all rooms and restrooms. She stated that her supervisor has asked nursing staff to assist her with cleaning duties. In an interview with the MD-B on 01/21/2022 at 3:30 PM, revealed that he has been working at the facility for over 9 years in the maintenance department. He stated that housekeeping staff should be cleaning all resident rooms and restrooms daily, and that nursing staff was asked to assist until staff can be hired. He further stated the dark colored substance in the toilet is due to the Plumbing Auger that is used to unstop clogged toilets. MD-B stated that the dark black stains inside of the toilet cannot be removed. He was asked to provide the work orders for the toilet in resident #25's room. MD-B returned after searching for the maintenance logs and stated that he did not have any work orders for the toilet in resident #25's room. He then stated that while in route back to the facility for this interview he directed his maintenance staff to replace the toilet in Resident #25's room, due to the black color in the toilet bowl. At that time, MD-G and surveyor jointly walked to Resident #25's room and observed a new toilet in the restroom. On 01/24/2022 at 7:32 AM, an interview with the RR-F, the resident representative for Resident #25 revealed that RR-F has seen the toilet on several occasions while visiting Resident #25, and she was happy to see that the toilet was changed out this past weekend, due to the stains in the toilet bowl. She stated changing the toilet while Resident #25 is not mobile was good. RR-F did not report the toilet to anyone, as she knew it was from the plumbing tool. RR-F stated that resident #25 would ambulate to use the toilet in the bathroom independently prior to her fracture. In an interview with ADM-H on 01/21/2022, revealed that he had received a picture of the toilet from staff, and agrees with the DON-G that the toilet is not soiled. The black stains are from plumbing tools. He urged me to continue to reach out and speak with RR-F for insight, as the resident has a history of anxiety that is associated with hoarding regarding her personal items in the room. A Review of the facilities Resident Rights policy; page 11, 16 (4) reflected, The resident has a right to a safe, clean, comfortable, and homelike environment.

Based on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for six (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5 and Resident #6) of six residents reviewed for infection control. The facility failed to screen Residents #1, #2 #3, #4, #5 and #6 three times a day for signs and symptoms of COVID-19 per CDC guidelines and physician orders. This failure placed residents at risk for spread of infection. Findings included: 1. Review of Resident #1's MDS assessment, dated 11/23/20, revealed she was an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of Resident #1's consolidated physician's orders [REDACTED]. Review of Resident #1's eMAR, that reflected the same order as the physician consolidated orders, for the dates of 11/01/20 through 11/30/20 revealed Resident #1 was not monitored every shift on the following days: - 11/12/20 evening shift did not conduct COVID-19 monitoring - 11/19/20 evening and night shift did not conduct COVID-19 monitoring - 11/25/20 evening shift did not conduct COVID-19 monitoring Review of Resident #1 COVID-19 (Novel Coronavirus) Screening V14 revealed the screening form was completed once a day, starting on 11/10/20. Review of Resident #1's EMR for 11/01/20 through 11/30/20 revealed she was not screened for signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. 2. Review of Resident #2 MDS assessment, dated 10/27/20, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]., [MEDICAL CONDITION] due to known psychological condition, and [MEDICAL CONDITION] with lower urinary tract symptoms. Review of the facility's Positive Covid Testing Tracking Log, undated, revealed the following: - 11/23/20 Resident #2 tested positive for COVID-19 Review of Resident #2's consolidated physician orders [REDACTED]. START DATE: 11/23/20; no indication for order. Review of Resident #2 TAR for November 2020, reflected the same order as the physician consolidated orders, revealed Resident #2 was not monitored every shift on the following days: - 11/11/20 evening shift did not conduct COVID-19 monitoring. - 11/19/20 night shift did not conduct COVID-19 monitoring. - 11/23/20 evening shift did not conduct COVID-19 monitoring. Review of Resident #2 TAR for the month of November 2020, reflected the same order as his physician consolidated orders, revealed he was not monitored every 4 hours on the following days: - 11/25/20 he was not monitored at 4:00 AM. - 11/26/20 he was not monitored at 4:00 PM. - 11/30/20 he was not monitored at 4:00 PM. Review of Resident #2's COVID-19 (Novel Coronavirus) Screening V14 form revealed the form was completed once a day, starting on 11/10/20 and the last day it was completed was 11/23/20. Review of Resident #2's Clinical Monitoring Tool was completed twice a day, starting on 11/23/20, on all days except the following: - 11/27/20 the form was not completed. - 11/29/20 the form was completed once. - Review of Resident #2's EMR for 11/01/20 through 11/ 30/20 revealed he was not screened for signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. 3. Review of Resident #3's MDS assessment, dated 11/06/20, revealed she was as [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. region, and age-related [MEDICAL CONDITION] without current pathological fracture. Review of Resident #3's consolidated physician orders [REDACTED]. Review of Resident #3 TAR for November 2020, reflected the same order as the physician consolidated orders, revealed Resident #3 was not monitored every shift on the following days: - 11/04/20 evening shift did not conduct COVID-19 monitoring. - 11/11/20 night shift did not conduct COVID-19 monitoring. - 11/12/20 night shift did not conduct COVID-19 monitoring. - 11/26/20 evening shift did not conduct COVID-19 monitoring. Review of Resident #3's COVID-19 (Novel Coronavirus) Screening V14 revealed that this form was completed once a day, starting on 11/10/20, and the last day it was completed was 12/01/20. Review of Resident #3's EMR for 11/01/20 through 11/ 30/20 revealed he was not screened for signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. 4. Review of Resident #4's MDS assessment, dated 11/29/20, revealed she was [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the facility's Positive Covid Testing Tracking Log, undated, revealed the following: - 11/16/20 Resident #4 tested positive for COVID-19 Review of Resident #4's consolidated physician orders [REDACTED]. Review of Resident #4 TAR for the month of November 2020, reflected the same order as the physician consolidated orders, revealed Resident #4 was not monitored every shift on the follow days: - 11/11/20 night shift did not conduct COVID-19 monitoring. - 11/12/20 evening and night shift did not conduct COVID-19 monitoring. - 11/18/10 night shift did not conduct COVID-19 monitoring. - 11/22/20 day shift did not conduct COVID-19 monitoring. - 11/24/20 evening shift did not conduct COVID-19 monitoring. Review of Resident #4's COVID-19 (Novel Coronavirus) Screening V14 revealed that this form was completed once a day, starting on 11/10/20 and the last day it was completed was 11/16/20. Review of Resident #4's Clinical Monitoring Tool was completed twice a day starting on 11/16/20 on all days except the following: - 11/18/20 the form was not completed. - 11/19/20 the form was not completed. - 11/20/20 the form was completed once. - 11/23/20 the form was completed once. Review of Resident #4's EMR for 11/01/20 through 11/ 30/20 revealed he was not screened for the signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. 5. Review of Resident #5 MDS assessment, dated 11/19/20, revealed he was an [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #5's consolidated physician orders [REDACTED]. Review of Resident #5's TAR for November 2020, reflected the same order as the physician consolidated orders, revealed Resident #5 vitals were not taken every shift for COVID-19 monitoring on the following days: - 11/12/20 evening and night shift did not take his vitals. - 11/19/20 evening and night shift did not take his vitals. - 11/25/20 evening shift did not take his vitals Review of Resident #5's EMR for 11/01/20 through 11/ 30/20 revealed he was not screened for the signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. 6. Review of Resident #6's MDS assessment, dated 11/19/20, revealed he was a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Review of Resident #6's nurse's notes from 11/01/20 through 12/01/20 revealed he tested positive for COVID-19 on 11/15/20. Review of Resident #6's consolidated physician orders [REDACTED]. Review of Resident #6 TAR for November 2020, reflected the same order as the physician consolidated orders, revealed Resident #6 did not have his vitals taken every shift on the following days: - 11/12/20 evening shift and night shift did not take his vitals. - 11/18/20 evening shift did not take his vitals. - 11/22/20 day shift did not take his vitals. - 11/24/20 evening shift did not take his vitals. Review of Resident #6's Clinical Monitoring Tool was completed twice a day, starting on 11/14/20, on all days except the following: - 11/16/20 the form was completed once. - 11/17/20 the form was completed once. - 11/18/20 the form was not completed. - 11/19/20 the form was not completed. - 11/20/20 the form was not completed. - 11/23/20 the form was completed once. - 11/24/20 the form was not completed. - 11/25/20 the form was not completed. - 11/27/20 the form was completed once. - 11/28/20 the form was completed once. Review of Resident #6's EMR for 11/01/20 through 11/30/20 revealed he was not screened for the signs and symptoms of a respiratory infection, such as cough, shortness of breath, or sore throat; signs or symptoms of COVID-19, including chills, cough, shortness of breath or difficulty breathing, fatigue, muscle or body aches, headache, new loss of taste or smell, sore throat, congestion or runny nose, nausea or vomiting, or diarrhea; related to COVID-19, three times a day. In an interview on 12/01/20 at 9:01 AM with Charge Nurse A revealed staff checked the vital signs and lung sounds every shift of all residents who resided at the facility. In an interview on 12/01/20 at 12:25 PM with LVN B revealed staff screened residents for signs and symptoms of COVID-19 at least once per day and vital signs were taken once per shift. He stated the DON and he would audit the residents' TARs to ensure the checks were being done every shift and that the facility was trying to develop a better system but with the current change in management and the recent outbreak it has been more difficult to manage. He stated he shared the responsibility of these checks with the new DON. He stated he knew there had been some inconsistencies since they began utilizing agency and their (agency) ability to use the EMR. LVN B did confirm the blanks on the Resident TAR and stated he was aware that there was nurse who was recently terminated, for failing to do her job on the COVID unit with additional reasons as well. In an interview on 12/01/20 at 12:43 PM with the Interim DON revealed all residents in the building were screened daily and those residents that were positive for COVID-19 were screened twice a day using the clinical monitoring tool. She stated the COVID-19 positive residents were screened twice a day, since the staff on the (COVID) unit worked 12-hour shifts. She stated resident who were not COVID-19 positive were screened daily with the COVID19 Daily Screening form. She stated vitals were to be taken every 8 hours. She stated she had known other facilities that would have COVID-19 signs and symptoms pulled up on the residents MAR/TARs and it required the staff to answer yes or no to every symptom, but she had not seen that monitoring tool at this facility. Interim DON, did confirm that the resident had physician orders [REDACTED]. The facility did not provide a relevant policy in regard to screening/monitoring of resident for signs and symptoms of COVID. Review of the CDC's Preparing for COVID-19 in Nursing Homes revealed; Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. (Accessed from and retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html).

Based on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of three residents observed for infection control. CNA C failed to use PPE when entering a room where Resident #1 and #2 were in contact isolation. This failure could place residents at risk of infection. Findings included: Review of a list of residents provided by Nurse Manager F revealed Residents #1 and #2 had a positive stool culture for the Norovirus. The list further reflected Resident #1 had a symptom onset date of 03/08/20 at 8:00 AM and Resident #2 had a symptom onset date of 03/07/20. Review of Resident #1's care plan initiated on 03/11/20 reflected the resident had an alteration in gastrointestinal status norovirus as evidenced by diarrhea and vomiting, ceased 03/08/20. Interventions included keeping the resident in her room for 48 hours following the end of symptoms for her and her roommate. Review of Resident #1's clinical record revealed there was no evidence of the last norovirus symptom documented. Review of Resident #2's care plan initiated on 03/11/20 reflected the resident had diarrhea related to possible norovirus. Interventions included monitor/document for any precipitating factors and prevent factors which increases risk of episodes or diarrhea, resident will remain in room for 48 hours following last episode of vomiting or diarrhea; last episode 03/10/20 AM shift and teach resident/family hand washing practice. Observation on 03/11/20 at 9:19 AM revealed PPE outside of Resident #1 and #2's room. CNA C was observed walking into the room without using any PPE and sat on Resident #1's bed and began to set up her tablet on her wheelchair as she repositioned her. CNA C then pushed Resident #1 down the hallway. CNA C was asked if Resident #1 was still in isolation and CNA C stated the resident had not had an episode in three days. The resident was observed being pushed back into her room by another staff member. CNA C was not wearing any PPE as she left the room. Interview on 03/11/20 at 12:36 PM with CNA C revealed Resident #1 had not had a norovirus episode since Monday (03/09/20) so she thought it was safe to go in without PPE. Interview on 03/11/20 at 4:22 PM with CNA D revealed she had been working with Resident #1 for the past two days and she had not had an episode of diarrhea or vomiting but her roommate, Resident #2, had an episode of diarrhea yesterday (03/10/20) and they were continuing to use PPE as they entered the room. Interview on 03/11/20 at 11:48 AM with LVN B revealed there were still two rooms that were on contact isolation. She stated it had been 48 hours since Resident #1 had any symptoms, but PPE should still be used in the room because Resident #2 was still showing symptoms of [MEDICAL CONDITION]. Interview on 03/11/20 at 12:17 PM with the NP revealed they had been made aware of the facility having a norovirus outbreak and they were told to get a stool sample of residents that were having more than three episodes. The residents were put on contact isolation and could be taken off after at least two days of the last episode. Interview on 03/11/20 at 12:47 PM with Nurse Manager F revealed they were following CDC guidelines and standard precautions were to be used for the norovirus and PPE was to be worn only if the staff were providing care. Interview on 03/11/20 at 4:37 PM with Physician E revealed residents were put on contact isolation as precautions and could be taken off after 48 of having no symptoms. He stated the norovirus was spread through contact only and it was not likely that Resident #1 would become re-infected nor could she spread it because of her physical condition. He further stated he would personally use PPE in the room since Resident #2 was still having symptoms. Review of the facility's Contact Precautions policy and procedure revised December 2019 reflected the following: .Procedure 1. Contact precautions will be used in addition to standard precautions for residents/patients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. .3. Gloves Wear gloves whenever touching the resident's/patient's intact skin or surfaces and articles in close proximity to the resident/patient. Wear gloves for all direct care (changing clothing, toileting, bathing, etc.) Don gloves upon entry into room/unit

Based on observation, interview, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to label, date, and seal/close food in the reach-in freezer, reach-in refrigerator and walk-in refrigerator. This failure could affect residents by causing food-borne illnesses and contamination. Findings included: Observation of the two-door reach-in freezer on 01/28/20 at 9:19 AM revealed one unmarked plastic zipper bag of raw chicken, approximately two pounds, not dated and not labeled. Observation of the single door reach-in refrigerator on 01/28/20 at 9:21 AM revealed one 32-ounces carton of raw liquid whole eggs approximately one-quarter full, unsealed and not dated. Observation of the walk-in refrigerator revealed on 01/28/20 at 9:25 AM revealed one metal, rectangle, deep-dish pan of a pale-brown, mushy food. The pan was unlabeled but was dated 12/3. The pan was full but the Dietary Manager was unable to readily identify the product. She eventually determined it was Sauerkraut and asked staff when it was place in the refrigerator. Staff were unable to identify when it was placed in the refrigerator. An interview on 01/28/20 at 9:30 AM with the Dietary Manager revealed staff should have labeled/dated the chicken pieces before placing them in the freezer. The left-over carton of eggs should have been sealed with a use-by-date or discarded immediately. Staff should have labeled the pan of sauerkraut and dated it correctly. Staff should always label/date/seal open food items before placing them in the refrigerator or freezer. Review of the facility's Food and Nutrition Policy and Procedure; Date Marking policy, dated July 2018, reflected: .2. When food has been opened but remains in storage, employees: a. Ensure foods opened at the location are clearly date-marked for: 1) The date/time the original container is opened. 2) The date or day by which the food shall be consumed on the premises, sold or discarded. The U.S. Food and Drug Administration Food Code dated 2017 reflected, 3-302.12 Food Storage Containers, Identified with Common Name of Food. Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety.